Romiplostim (Nplate) earned a new indication from the Food and Drug Administration, allowing for earlier usage in adult patients with immune thrombocytopenia (ITP) who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy.

Olivier Le Moal/Getty Images

The new indication is for newly diagnosed and persistent adult patients.

Romiplostim is already approved for the treatment of pediatric patients aged 1 year and older who have had ITP for at least 6 months and had an insufficient response to other treatments, as well as for adults patients with chronic ITP who had insufficient response to other therapies.

The latest approval is based on positive results from a single-arm, phase 2 trial in adults with ITP who had an insufficient response to first-line treatment. The study met its primary endpoint – platelet response (50 x 10⁹/L or greater). The median number of months with platelet response was 11 months during a 12-month treatment period. The median time to first platelet response was just over 2 weeks.

Adverse events of at least 5% incidence in patients taking romiplostim with an ITP duration up to 12 months included bronchitis, sinusitis, vomiting, arthralgia, myalgia, headache, dizziness, diarrhea, upper respiratory tract infection, cough, nausea, and oropharyngeal pain. There was a 2% incidence of thrombocytosis among adults with an ITP duration up to 12 months.

mschneider@mdedge.com

Romiplostim (Nplate) earned a new indication from the Food and Drug Administration, allowing for earlier usage in adult patients with immune thrombocytopenia (ITP) who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy.

Olivier Le Moal/Getty Images

The new indication is for newly diagnosed and persistent adult patients.

Romiplostim is already approved for the treatment of pediatric patients aged 1 year and older who have had ITP for at least 6 months and had an insufficient response to other treatments, as well as for adults patients with chronic ITP who had insufficient response to other therapies.

The latest approval is based on positive results from a single-arm, phase 2 trial in adults with ITP who had an insufficient response to first-line treatment. The study met its primary endpoint – platelet response (50 x 10⁹/L or greater). The median number of months with platelet response was 11 months during a 12-month treatment period. The median time to first platelet response was just over 2 weeks.

Adverse events of at least 5% incidence in patients taking romiplostim with an ITP duration up to 12 months included bronchitis, sinusitis, vomiting, arthralgia, myalgia, headache, dizziness, diarrhea, upper respiratory tract infection, cough, nausea, and oropharyngeal pain. There was a 2% incidence of thrombocytosis among adults with an ITP duration up to 12 months.

mschneider@mdedge.com

Romiplostim (Nplate) earned a new indication from the Food and Drug Administration, allowing for earlier usage in adult patients with immune thrombocytopenia (ITP) who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy.

Olivier Le Moal/Getty Images

The new indication is for newly diagnosed and persistent adult patients.

Romiplostim is already approved for the treatment of pediatric patients aged 1 year and older who have had ITP for at least 6 months and had an insufficient response to other treatments, as well as for adults patients with chronic ITP who had insufficient response to other therapies.

The latest approval is based on positive results from a single-arm, phase 2 trial in adults with ITP who had an insufficient response to first-line treatment. The study met its primary endpoint – platelet response (50 x 10⁹/L or greater). The median number of months with platelet response was 11 months during a 12-month treatment period. The median time to first platelet response was just over 2 weeks.

Adverse events of at least 5% incidence in patients taking romiplostim with an ITP duration up to 12 months included bronchitis, sinusitis, vomiting, arthralgia, myalgia, headache, dizziness, diarrhea, upper respiratory tract infection, cough, nausea, and oropharyngeal pain. There was a 2% incidence of thrombocytosis among adults with an ITP duration up to 12 months.

mschneider@mdedge.com

MADRID – For the treatment of chronic thromboembolic pulmonary hypertension (CTEPH), balloon pulmonary angioplasty (BPA) is more effective than riociguat for reducing pulmonary vascular resistance (PVR) and improving functional class, according to a multicenter trial presented at the annual congress of the European Respiratory Congress.

Both therapies are widely used in the treatment of CTEPH, but this is the first controlled trial in which they were directly compared, according to Xavier Jaïs, MD, of the Pulmonology Service, Kremlin-Bicêtre Hospital, University of Paris-Sud.

In this randomized trial, called RACE, newly diagnosed and previously untreated patients with nonoperable CTEPH were enrolled. The key eligibility criteria included PVR greater than 320 dynes/sec per cm^–5 and a pulmonary capillary wedge pressure of 15 mm Hg or less.

The patients were randomized to BPA or riociguat and followed for 26 weeks. The primary endpoint was relative change in PVR from baseline. The 6-minute walk distance, change in functional class, time to clinical worsening and safety were among secondary endpoints.

As calculated by geometric mean from baseline, PVR was reduced by nearly 60% in the BPA group and by 32% in the riociguat group, providing a 40% (P less than .0001) relative advantage of BPA.

Although there was a small relative advantage in the 6-minute walk distance for the BPA group at the end of the study, it did not reach statistical significant. However, 88% of those randomized to BPA versus 49% of those treated with riociguat (P less than .0001) improved by at least one WHO class by the end of the study.

Clinical worsening events over the course of the trial were uncommon. All three of these events occurred in the riociguat group, but the difference was not significant.

The end-of-study reduction in brain natriuretic peptide, which was another secondary endpoint, was 67% greater in the BPA group (P less than .0001).

There was a safety cost for the greater efficacy of BPA. This included a higher proportion of patients in the BPA group with at least one serious adverse event (50% vs. 26%) and at least one serious treatment-related adverse event (14% vs. 9%). No patient in either arm discontinued therapy because of treatment-related adverse events, and there were no deaths over the course of the study in either arm.

The study has included a 6-month extension to allow patients symptomatic on their originally assigned therapy to switch to the opposite treatment. Results of the extension are not yet available, but Dr. Jaïs said that these data might provide insight about which therapy to start first.

“It was very important to do this trial,” according to the ERS-invited discussant, Martin Kolb, MD, of the Firestone Institute of Respiratory Health, McMaster University, Hamilton, Ont. The most recent World Symposium on Pulmonary Hypertension identified BPA and medical therapy as reasonable choices in inoperable CTEPH, but Dr. Kolb said there has been an unmet need for comparative data.

“This was a very strong study that demonstrated a powerful impact for both interventions on pulmonary vascular resistance,” Dr. Kolb said, adding that, although BPA proved to be more effective, clinicians consider the greater risk of adverse events. He believes further work needs to be done in identifying the best candidates for each and to explore hybrid approaches.

“What do you think about doing these sequentially so that you lower the pressure first with medical therapy and then go in with the balloon?” Dr. Kolb asked Dr. Jaïs during a discussion that followed presentation of the RACE results.

Dr. Jaïs conceded this point, noting that the treatments have different targets and might be complementary.

“We plan to do a study like this in the future,” Dr. Jaïs said.

Dr. Jaïs reported no potential conflicts of interest.

MADRID – For the treatment of chronic thromboembolic pulmonary hypertension (CTEPH), balloon pulmonary angioplasty (BPA) is more effective than riociguat for reducing pulmonary vascular resistance (PVR) and improving functional class, according to a multicenter trial presented at the annual congress of the European Respiratory Congress.

Both therapies are widely used in the treatment of CTEPH, but this is the first controlled trial in which they were directly compared, according to Xavier Jaïs, MD, of the Pulmonology Service, Kremlin-Bicêtre Hospital, University of Paris-Sud.

In this randomized trial, called RACE, newly diagnosed and previously untreated patients with nonoperable CTEPH were enrolled. The key eligibility criteria included PVR greater than 320 dynes/sec per cm^–5 and a pulmonary capillary wedge pressure of 15 mm Hg or less.

The patients were randomized to BPA or riociguat and followed for 26 weeks. The primary endpoint was relative change in PVR from baseline. The 6-minute walk distance, change in functional class, time to clinical worsening and safety were among secondary endpoints.

As calculated by geometric mean from baseline, PVR was reduced by nearly 60% in the BPA group and by 32% in the riociguat group, providing a 40% (P less than .0001) relative advantage of BPA.

Although there was a small relative advantage in the 6-minute walk distance for the BPA group at the end of the study, it did not reach statistical significant. However, 88% of those randomized to BPA versus 49% of those treated with riociguat (P less than .0001) improved by at least one WHO class by the end of the study.

Clinical worsening events over the course of the trial were uncommon. All three of these events occurred in the riociguat group, but the difference was not significant.

The end-of-study reduction in brain natriuretic peptide, which was another secondary endpoint, was 67% greater in the BPA group (P less than .0001).

There was a safety cost for the greater efficacy of BPA. This included a higher proportion of patients in the BPA group with at least one serious adverse event (50% vs. 26%) and at least one serious treatment-related adverse event (14% vs. 9%). No patient in either arm discontinued therapy because of treatment-related adverse events, and there were no deaths over the course of the study in either arm.

The study has included a 6-month extension to allow patients symptomatic on their originally assigned therapy to switch to the opposite treatment. Results of the extension are not yet available, but Dr. Jaïs said that these data might provide insight about which therapy to start first.

“It was very important to do this trial,” according to the ERS-invited discussant, Martin Kolb, MD, of the Firestone Institute of Respiratory Health, McMaster University, Hamilton, Ont. The most recent World Symposium on Pulmonary Hypertension identified BPA and medical therapy as reasonable choices in inoperable CTEPH, but Dr. Kolb said there has been an unmet need for comparative data.

“This was a very strong study that demonstrated a powerful impact for both interventions on pulmonary vascular resistance,” Dr. Kolb said, adding that, although BPA proved to be more effective, clinicians consider the greater risk of adverse events. He believes further work needs to be done in identifying the best candidates for each and to explore hybrid approaches.

“What do you think about doing these sequentially so that you lower the pressure first with medical therapy and then go in with the balloon?” Dr. Kolb asked Dr. Jaïs during a discussion that followed presentation of the RACE results.

Dr. Jaïs conceded this point, noting that the treatments have different targets and might be complementary.

“We plan to do a study like this in the future,” Dr. Jaïs said.

Dr. Jaïs reported no potential conflicts of interest.

MADRID – For the treatment of chronic thromboembolic pulmonary hypertension (CTEPH), balloon pulmonary angioplasty (BPA) is more effective than riociguat for reducing pulmonary vascular resistance (PVR) and improving functional class, according to a multicenter trial presented at the annual congress of the European Respiratory Congress.

Both therapies are widely used in the treatment of CTEPH, but this is the first controlled trial in which they were directly compared, according to Xavier Jaïs, MD, of the Pulmonology Service, Kremlin-Bicêtre Hospital, University of Paris-Sud.

In this randomized trial, called RACE, newly diagnosed and previously untreated patients with nonoperable CTEPH were enrolled. The key eligibility criteria included PVR greater than 320 dynes/sec per cm^–5 and a pulmonary capillary wedge pressure of 15 mm Hg or less.

The patients were randomized to BPA or riociguat and followed for 26 weeks. The primary endpoint was relative change in PVR from baseline. The 6-minute walk distance, change in functional class, time to clinical worsening and safety were among secondary endpoints.

As calculated by geometric mean from baseline, PVR was reduced by nearly 60% in the BPA group and by 32% in the riociguat group, providing a 40% (P less than .0001) relative advantage of BPA.

Although there was a small relative advantage in the 6-minute walk distance for the BPA group at the end of the study, it did not reach statistical significant. However, 88% of those randomized to BPA versus 49% of those treated with riociguat (P less than .0001) improved by at least one WHO class by the end of the study.

Clinical worsening events over the course of the trial were uncommon. All three of these events occurred in the riociguat group, but the difference was not significant.

The end-of-study reduction in brain natriuretic peptide, which was another secondary endpoint, was 67% greater in the BPA group (P less than .0001).

There was a safety cost for the greater efficacy of BPA. This included a higher proportion of patients in the BPA group with at least one serious adverse event (50% vs. 26%) and at least one serious treatment-related adverse event (14% vs. 9%). No patient in either arm discontinued therapy because of treatment-related adverse events, and there were no deaths over the course of the study in either arm.

The study has included a 6-month extension to allow patients symptomatic on their originally assigned therapy to switch to the opposite treatment. Results of the extension are not yet available, but Dr. Jaïs said that these data might provide insight about which therapy to start first.

“It was very important to do this trial,” according to the ERS-invited discussant, Martin Kolb, MD, of the Firestone Institute of Respiratory Health, McMaster University, Hamilton, Ont. The most recent World Symposium on Pulmonary Hypertension identified BPA and medical therapy as reasonable choices in inoperable CTEPH, but Dr. Kolb said there has been an unmet need for comparative data.

“This was a very strong study that demonstrated a powerful impact for both interventions on pulmonary vascular resistance,” Dr. Kolb said, adding that, although BPA proved to be more effective, clinicians consider the greater risk of adverse events. He believes further work needs to be done in identifying the best candidates for each and to explore hybrid approaches.

“What do you think about doing these sequentially so that you lower the pressure first with medical therapy and then go in with the balloon?” Dr. Kolb asked Dr. Jaïs during a discussion that followed presentation of the RACE results.

Dr. Jaïs conceded this point, noting that the treatments have different targets and might be complementary.

“We plan to do a study like this in the future,” Dr. Jaïs said.

Dr. Jaïs reported no potential conflicts of interest.

BARCELONA – Obesity, more so than having a poor lifestyle, significantly raised the odds of developing type 2 diabetes, independent of individuals’ genetic susceptibility, according to data from a Danish population-based, case-cohort study.

In fact, having a body mass index (BMI) of more than 30 kg/m2 was linked with a 480% risk of incident type 2 diabetes, compared with being of normal weight (BMI, 18.5-24.9 kg/m2). The 95% confidence interval was 5.16-6.55. Being overweight (BMI, 25-29.9 kg/m2) also carried a 100% increased risk of type 2 diabetes (hazard ratio, 2.37; 95% CI, 2.15-2.62).

Having an unfavorable lifestyle – which was defined as having no or only one of several healthy-living characteristics, from not smoking and moderating alcohol use to eating a well-balanced, nutritious diet and exercising regularly – increased the risk of diabetes by 18%, compared with having a favorable lifestyle (HR, 1.18; 95% CI, 1.06-1.30).

Individuals with a high genetic risk score (GRS) had a 100% increased risk of developing the disease versus those with a low GRS (HR, 2.0; 95% CI, 1.1-1.3).

“High genetic risk, obesity, and [an] unfavorable lifestyle increase the individual-level risk of incident type 2 diabetes,” Hermina Jakupovic and associates reported in a poster presentation at the annual meeting of the European Association for the Study of Diabetes. Their results suggest that “the effect of obesity on type 2 diabetes risk is dominant over other risk factors, highlighting the importance of weight management in type 2 diabetes prevention.”

Ms. Jakupovic, a PhD student at the Novo Nordisk Foundation Center for Basic Metabolic Research at the University of Copenhagen, and coauthors examined data on 9,555 participants of the Diet, Cancer, and Health cohort, a large, prospective study that has been running since the early 1990s.

Around half of the study sample were women and the mean age was 52 years. Just over one-fifth (22.8%) were obese, 43% were overweight, and the remaining 35.2% were of normal weight. A quarter (25.4%) had an unfavorable lifestyle, 40% a favorable lifestyle, and the remainder an “intermediate” lifestyle. Over a follow-up of almost 15 years, nearly half (49.5%) developed type 2 diabetes.

Genetic risk was assessed by a GRS comprising 193 genetic variants known to be strongly associated with type 2 diabetes, Ms. Jakupovic explained, adding that, using the GRS, patients were categorized into being at low (the lowest 20%), intermediate (middle 60%) and high risk (top 20%) of type 2 diabetes.

Considering individuals’ GRS and lifestyle score together showed an increasing risk of developing type 2 diabetes from the low GRS/favorable-lifestyle category (HR, 1.0; reference) upward to the high GRS/unfavorable lifestyle (HR, 2.22; 95% CI, 1.76-2.81).

The Diet, Cancer, and Health cohort is supported by the Danish Cancer Society. The Novo Nordisk Foundation Center for Basic Metabolic Research is an independent research center at the University of Copenhagen partially funded by an unrestricted donation from the Novo Nordisk Foundation. Ms. Jakupovic and associates are funded either directly or indirectly by the Novo Nordisk Foundation.

SOURCE: Jakupovic H et al. EASD 2019, Abstract 376.

BARCELONA – Obesity, more so than having a poor lifestyle, significantly raised the odds of developing type 2 diabetes, independent of individuals’ genetic susceptibility, according to data from a Danish population-based, case-cohort study.

In fact, having a body mass index (BMI) of more than 30 kg/m2 was linked with a 480% risk of incident type 2 diabetes, compared with being of normal weight (BMI, 18.5-24.9 kg/m2). The 95% confidence interval was 5.16-6.55. Being overweight (BMI, 25-29.9 kg/m2) also carried a 100% increased risk of type 2 diabetes (hazard ratio, 2.37; 95% CI, 2.15-2.62).

Having an unfavorable lifestyle – which was defined as having no or only one of several healthy-living characteristics, from not smoking and moderating alcohol use to eating a well-balanced, nutritious diet and exercising regularly – increased the risk of diabetes by 18%, compared with having a favorable lifestyle (HR, 1.18; 95% CI, 1.06-1.30).

Individuals with a high genetic risk score (GRS) had a 100% increased risk of developing the disease versus those with a low GRS (HR, 2.0; 95% CI, 1.1-1.3).

“High genetic risk, obesity, and [an] unfavorable lifestyle increase the individual-level risk of incident type 2 diabetes,” Hermina Jakupovic and associates reported in a poster presentation at the annual meeting of the European Association for the Study of Diabetes. Their results suggest that “the effect of obesity on type 2 diabetes risk is dominant over other risk factors, highlighting the importance of weight management in type 2 diabetes prevention.”

Ms. Jakupovic, a PhD student at the Novo Nordisk Foundation Center for Basic Metabolic Research at the University of Copenhagen, and coauthors examined data on 9,555 participants of the Diet, Cancer, and Health cohort, a large, prospective study that has been running since the early 1990s.

Around half of the study sample were women and the mean age was 52 years. Just over one-fifth (22.8%) were obese, 43% were overweight, and the remaining 35.2% were of normal weight. A quarter (25.4%) had an unfavorable lifestyle, 40% a favorable lifestyle, and the remainder an “intermediate” lifestyle. Over a follow-up of almost 15 years, nearly half (49.5%) developed type 2 diabetes.

Genetic risk was assessed by a GRS comprising 193 genetic variants known to be strongly associated with type 2 diabetes, Ms. Jakupovic explained, adding that, using the GRS, patients were categorized into being at low (the lowest 20%), intermediate (middle 60%) and high risk (top 20%) of type 2 diabetes.

Considering individuals’ GRS and lifestyle score together showed an increasing risk of developing type 2 diabetes from the low GRS/favorable-lifestyle category (HR, 1.0; reference) upward to the high GRS/unfavorable lifestyle (HR, 2.22; 95% CI, 1.76-2.81).

The Diet, Cancer, and Health cohort is supported by the Danish Cancer Society. The Novo Nordisk Foundation Center for Basic Metabolic Research is an independent research center at the University of Copenhagen partially funded by an unrestricted donation from the Novo Nordisk Foundation. Ms. Jakupovic and associates are funded either directly or indirectly by the Novo Nordisk Foundation.

SOURCE: Jakupovic H et al. EASD 2019, Abstract 376.

BARCELONA – Obesity, more so than having a poor lifestyle, significantly raised the odds of developing type 2 diabetes, independent of individuals’ genetic susceptibility, according to data from a Danish population-based, case-cohort study.

In fact, having a body mass index (BMI) of more than 30 kg/m2 was linked with a 480% risk of incident type 2 diabetes, compared with being of normal weight (BMI, 18.5-24.9 kg/m2). The 95% confidence interval was 5.16-6.55. Being overweight (BMI, 25-29.9 kg/m2) also carried a 100% increased risk of type 2 diabetes (hazard ratio, 2.37; 95% CI, 2.15-2.62).

Having an unfavorable lifestyle – which was defined as having no or only one of several healthy-living characteristics, from not smoking and moderating alcohol use to eating a well-balanced, nutritious diet and exercising regularly – increased the risk of diabetes by 18%, compared with having a favorable lifestyle (HR, 1.18; 95% CI, 1.06-1.30).

Individuals with a high genetic risk score (GRS) had a 100% increased risk of developing the disease versus those with a low GRS (HR, 2.0; 95% CI, 1.1-1.3).

“High genetic risk, obesity, and [an] unfavorable lifestyle increase the individual-level risk of incident type 2 diabetes,” Hermina Jakupovic and associates reported in a poster presentation at the annual meeting of the European Association for the Study of Diabetes. Their results suggest that “the effect of obesity on type 2 diabetes risk is dominant over other risk factors, highlighting the importance of weight management in type 2 diabetes prevention.”

Ms. Jakupovic, a PhD student at the Novo Nordisk Foundation Center for Basic Metabolic Research at the University of Copenhagen, and coauthors examined data on 9,555 participants of the Diet, Cancer, and Health cohort, a large, prospective study that has been running since the early 1990s.

Around half of the study sample were women and the mean age was 52 years. Just over one-fifth (22.8%) were obese, 43% were overweight, and the remaining 35.2% were of normal weight. A quarter (25.4%) had an unfavorable lifestyle, 40% a favorable lifestyle, and the remainder an “intermediate” lifestyle. Over a follow-up of almost 15 years, nearly half (49.5%) developed type 2 diabetes.

Genetic risk was assessed by a GRS comprising 193 genetic variants known to be strongly associated with type 2 diabetes, Ms. Jakupovic explained, adding that, using the GRS, patients were categorized into being at low (the lowest 20%), intermediate (middle 60%) and high risk (top 20%) of type 2 diabetes.

Considering individuals’ GRS and lifestyle score together showed an increasing risk of developing type 2 diabetes from the low GRS/favorable-lifestyle category (HR, 1.0; reference) upward to the high GRS/unfavorable lifestyle (HR, 2.22; 95% CI, 1.76-2.81).

The Diet, Cancer, and Health cohort is supported by the Danish Cancer Society. The Novo Nordisk Foundation Center for Basic Metabolic Research is an independent research center at the University of Copenhagen partially funded by an unrestricted donation from the Novo Nordisk Foundation. Ms. Jakupovic and associates are funded either directly or indirectly by the Novo Nordisk Foundation.

SOURCE: Jakupovic H et al. EASD 2019, Abstract 376.

Patients with type 1 diabetes who used a closed-loop insulin delivery system spent a greater percentage of time in their target blood glucose range, compared with patients using a sensor-augmented insulin pump.

The significant, between-group, mean-adjusted difference of 11 percentage points between the two groups translated into the closed-loop patients spending an additional 2.6 hr/day in the target range of 70-180 mg/dL, Susan A. Brown, MD, and colleagues wrote in the New England Journal of Medicine.

Most of the benefit occurred in the early morning hours, at 5 am, when 89% of patients using the closed-loop system remained in the target range, compared with 62% of those using the pump system, said Dr. Brown of the University of Virginia, Charlottesville, and colleagues.

The randomized study comprised 168 patients with a mean age of 33 years, although the age range was wide (14-71 years). The patients had a mean disease duration of 16 years. Their baseline glycated hemoglobin level ranged between 5.4% and 10.6%. At enrollment, 79% of patients used insulin pumps, and 21% used multiple daily insulin injections; 70% were using continuous glucose monitoring, of whom 86% were using pumps. Patients in both groups had follow-up visits at 2, 6, 13, and 26 weeks.

There were no dropouts in this study – 100% of clinical and telephone follow-ups were completed.

During the 6-month trial, the mean percentage of time spent in the glucose target range rose from 61% at baseline to 71% in the closed-loop group, but remained unchanged at 59% in the pump group. The difference became apparent very early in the study and remained consistent over its course.

“The mean percentage of time that the glucose level was in the target range was 70% in the closed-loop group and 59% in the control [pump] group during the daytime (6 a.m. to midnight) and 76% and 59%, respectively, during the nighttime (midnight to 6 am) ... and the greatest differences in the mean glucose level occurred at 5 a.m. and 6 a.m. [139 mg/dL in the closed-loop group vs. 166 mg/dL in the control group at both time points]. This diurnal pattern is a result of the increased aggressiveness of the algorithm to meet a lower glucose target during the second half of the night,” the authors noted.

The closed-loop system was also better than the pump system on all secondary endpoints, including the following:
 

• Glycated hemoglobin at 26 weeks: mean difference, –0.33 percentage points.
• Percentage of time with glucose higher than 180 mg/dL: mean difference, –10 percentage points (a difference of 2.4 hr/day).
• Percentage of time with glucose less than 70 mg/dL: mean difference, –0.88 percentage points (a difference of 13 min/day).

The other secondary endpoints – mean glucose level and mean glycated hemoglobin level – were also significantly better in those using the closed-loop system.

The benefits “consistently favored the closed-loop system across a broad range of baseline characteristics, including age, sex, body mass index, income, educational level, insulin pump or infection use, previous use of continuous glucose monitor, and glycated hemoglobin,” the authors said.

There were 17 adverse events in 16 patients in the closed-loop group, and 2 events in 2 patients in the pump group, but no incidents of severe hypoglycemia. One person in the closed-loop system experienced ketoacidosis because of a failure in the pump infusion set. There were 13 hyperglycemic or ketosis episodes in 12 patients in the closed-loop group, and 2 in 2 patients the pump group, but none of them met the criteria for diabetic ketoacidosis. All of these episodes were deemed related to infusion set failures.

There were three serious adverse events in the closed-loop group, and none related to the device. Blood ketones exceeding 1 mmol/L occurred in 11 closed-loop patients and 8 pump patients.

The results should be interpreted with consideration of potential group bias, the authors noted. “In our trial, 70% of the patients were using a continuous glucose monitor, and 79% were using an insulin pump at the time of enrollment, percentages that are substantially higher than the reported usage in the general population of type 1 diabetes. These data may reflect an interest in and willingness to use a closed-loop system among patients who were already using devices as part of diabetes management.”

Dr. Brown reported receiving grant support from Tandem Diabetes Care, Dexcom, and Roche Diagnostics. Other authors reported a range of support from numerous pharmaceutical and medical technology companies. Several reported patents on diabetes-related devices.

SOURCE: Brown SA et al. New Engl J Med. 2019 Oct 16. doi: 10.1056/NEJMoa1907863.

Patients with type 1 diabetes who used a closed-loop insulin delivery system spent a greater percentage of time in their target blood glucose range, compared with patients using a sensor-augmented insulin pump.

The significant, between-group, mean-adjusted difference of 11 percentage points between the two groups translated into the closed-loop patients spending an additional 2.6 hr/day in the target range of 70-180 mg/dL, Susan A. Brown, MD, and colleagues wrote in the New England Journal of Medicine.

Most of the benefit occurred in the early morning hours, at 5 am, when 89% of patients using the closed-loop system remained in the target range, compared with 62% of those using the pump system, said Dr. Brown of the University of Virginia, Charlottesville, and colleagues.

The randomized study comprised 168 patients with a mean age of 33 years, although the age range was wide (14-71 years). The patients had a mean disease duration of 16 years. Their baseline glycated hemoglobin level ranged between 5.4% and 10.6%. At enrollment, 79% of patients used insulin pumps, and 21% used multiple daily insulin injections; 70% were using continuous glucose monitoring, of whom 86% were using pumps. Patients in both groups had follow-up visits at 2, 6, 13, and 26 weeks.

There were no dropouts in this study – 100% of clinical and telephone follow-ups were completed.

During the 6-month trial, the mean percentage of time spent in the glucose target range rose from 61% at baseline to 71% in the closed-loop group, but remained unchanged at 59% in the pump group. The difference became apparent very early in the study and remained consistent over its course.

“The mean percentage of time that the glucose level was in the target range was 70% in the closed-loop group and 59% in the control [pump] group during the daytime (6 a.m. to midnight) and 76% and 59%, respectively, during the nighttime (midnight to 6 am) ... and the greatest differences in the mean glucose level occurred at 5 a.m. and 6 a.m. [139 mg/dL in the closed-loop group vs. 166 mg/dL in the control group at both time points]. This diurnal pattern is a result of the increased aggressiveness of the algorithm to meet a lower glucose target during the second half of the night,” the authors noted.

The closed-loop system was also better than the pump system on all secondary endpoints, including the following:
 

• Glycated hemoglobin at 26 weeks: mean difference, –0.33 percentage points.
• Percentage of time with glucose higher than 180 mg/dL: mean difference, –10 percentage points (a difference of 2.4 hr/day).
• Percentage of time with glucose less than 70 mg/dL: mean difference, –0.88 percentage points (a difference of 13 min/day).

The other secondary endpoints – mean glucose level and mean glycated hemoglobin level – were also significantly better in those using the closed-loop system.

The benefits “consistently favored the closed-loop system across a broad range of baseline characteristics, including age, sex, body mass index, income, educational level, insulin pump or infection use, previous use of continuous glucose monitor, and glycated hemoglobin,” the authors said.

There were 17 adverse events in 16 patients in the closed-loop group, and 2 events in 2 patients in the pump group, but no incidents of severe hypoglycemia. One person in the closed-loop system experienced ketoacidosis because of a failure in the pump infusion set. There were 13 hyperglycemic or ketosis episodes in 12 patients in the closed-loop group, and 2 in 2 patients the pump group, but none of them met the criteria for diabetic ketoacidosis. All of these episodes were deemed related to infusion set failures.

There were three serious adverse events in the closed-loop group, and none related to the device. Blood ketones exceeding 1 mmol/L occurred in 11 closed-loop patients and 8 pump patients.

The results should be interpreted with consideration of potential group bias, the authors noted. “In our trial, 70% of the patients were using a continuous glucose monitor, and 79% were using an insulin pump at the time of enrollment, percentages that are substantially higher than the reported usage in the general population of type 1 diabetes. These data may reflect an interest in and willingness to use a closed-loop system among patients who were already using devices as part of diabetes management.”

Dr. Brown reported receiving grant support from Tandem Diabetes Care, Dexcom, and Roche Diagnostics. Other authors reported a range of support from numerous pharmaceutical and medical technology companies. Several reported patents on diabetes-related devices.

SOURCE: Brown SA et al. New Engl J Med. 2019 Oct 16. doi: 10.1056/NEJMoa1907863.

Patients with type 1 diabetes who used a closed-loop insulin delivery system spent a greater percentage of time in their target blood glucose range, compared with patients using a sensor-augmented insulin pump.

The significant, between-group, mean-adjusted difference of 11 percentage points between the two groups translated into the closed-loop patients spending an additional 2.6 hr/day in the target range of 70-180 mg/dL, Susan A. Brown, MD, and colleagues wrote in the New England Journal of Medicine.

Most of the benefit occurred in the early morning hours, at 5 am, when 89% of patients using the closed-loop system remained in the target range, compared with 62% of those using the pump system, said Dr. Brown of the University of Virginia, Charlottesville, and colleagues.

The randomized study comprised 168 patients with a mean age of 33 years, although the age range was wide (14-71 years). The patients had a mean disease duration of 16 years. Their baseline glycated hemoglobin level ranged between 5.4% and 10.6%. At enrollment, 79% of patients used insulin pumps, and 21% used multiple daily insulin injections; 70% were using continuous glucose monitoring, of whom 86% were using pumps. Patients in both groups had follow-up visits at 2, 6, 13, and 26 weeks.

There were no dropouts in this study – 100% of clinical and telephone follow-ups were completed.

During the 6-month trial, the mean percentage of time spent in the glucose target range rose from 61% at baseline to 71% in the closed-loop group, but remained unchanged at 59% in the pump group. The difference became apparent very early in the study and remained consistent over its course.

“The mean percentage of time that the glucose level was in the target range was 70% in the closed-loop group and 59% in the control [pump] group during the daytime (6 a.m. to midnight) and 76% and 59%, respectively, during the nighttime (midnight to 6 am) ... and the greatest differences in the mean glucose level occurred at 5 a.m. and 6 a.m. [139 mg/dL in the closed-loop group vs. 166 mg/dL in the control group at both time points]. This diurnal pattern is a result of the increased aggressiveness of the algorithm to meet a lower glucose target during the second half of the night,” the authors noted.

The closed-loop system was also better than the pump system on all secondary endpoints, including the following:
 

• Glycated hemoglobin at 26 weeks: mean difference, –0.33 percentage points.
• Percentage of time with glucose higher than 180 mg/dL: mean difference, –10 percentage points (a difference of 2.4 hr/day).
• Percentage of time with glucose less than 70 mg/dL: mean difference, –0.88 percentage points (a difference of 13 min/day).

The other secondary endpoints – mean glucose level and mean glycated hemoglobin level – were also significantly better in those using the closed-loop system.

The benefits “consistently favored the closed-loop system across a broad range of baseline characteristics, including age, sex, body mass index, income, educational level, insulin pump or infection use, previous use of continuous glucose monitor, and glycated hemoglobin,” the authors said.

There were 17 adverse events in 16 patients in the closed-loop group, and 2 events in 2 patients in the pump group, but no incidents of severe hypoglycemia. One person in the closed-loop system experienced ketoacidosis because of a failure in the pump infusion set. There were 13 hyperglycemic or ketosis episodes in 12 patients in the closed-loop group, and 2 in 2 patients the pump group, but none of them met the criteria for diabetic ketoacidosis. All of these episodes were deemed related to infusion set failures.

There were three serious adverse events in the closed-loop group, and none related to the device. Blood ketones exceeding 1 mmol/L occurred in 11 closed-loop patients and 8 pump patients.

The results should be interpreted with consideration of potential group bias, the authors noted. “In our trial, 70% of the patients were using a continuous glucose monitor, and 79% were using an insulin pump at the time of enrollment, percentages that are substantially higher than the reported usage in the general population of type 1 diabetes. These data may reflect an interest in and willingness to use a closed-loop system among patients who were already using devices as part of diabetes management.”

Dr. Brown reported receiving grant support from Tandem Diabetes Care, Dexcom, and Roche Diagnostics. Other authors reported a range of support from numerous pharmaceutical and medical technology companies. Several reported patents on diabetes-related devices.

SOURCE: Brown SA et al. New Engl J Med. 2019 Oct 16. doi: 10.1056/NEJMoa1907863.

AUSTIN, TEX. – Patients with suspected myasthenia gravis are more likely to have positive repetitive nerve stimulation (RNS) findings if they undergo testing in an inpatient setting, are seropositive, or are classified as Myasthenia Gravis Foundation of America (MGFA) Class III or higher, according to research presented at the annual meeting of the American Association of Neuromuscular and Electrodiagnostic Medicine.

Low-frequency RNS is a common test that neurologists perform to evaluate a patient for myasthenia gravis. The effects of various clinical factors on the diagnostic yield of this test are unknown, however.

Myasthenia gravis is “mostly a clinical diagnosis,” study first author Tingting Hua, a medical student at the University of Missouri in Columbia, said in an interview. “RNS is just one of the helpful diagnostic tests for it. If we can find out in what kind of populations of patients this test is more helpful, maybe that would help cut down unnecessary tests in patients for whom it’s not necessarily helpful.”

Ms. Hua and her colleagues conducted research to assess the effects of clinical, serologic, and demographic factors on the diagnostic yield of RNS. They retrospectively analyzed patients with an established diagnosis of myasthenia gravis and at least 1 year of follow-up. The variables that the investigators examined were demographic characteristics, MGFA class, RNS study results, antibody test results, thymoma status, and treatments received.

Ms. Hua and her colleagues included 65 patients in their analysis. Thirty-one patients were female. Fifty-five patients were white, eight were black, and two were categorized as “unknown.” Of this population, 32 patients (49.2%) were in MGFA Class I, 14 (21.5%) were in MGFA Class IIa, 13 (20.0%) were in MGFA Class IIb, and the remaining 6 (9.2%) were in MGFA Classes IIIa through V. Twenty-seven patients (42%) had positive RNS studies. Twenty-one patients (32%) were seropositive for myasthenia gravis antibodies.

Eleven patients underwent RNS in an inpatient setting, and 54 were tested in an outpatient setting. Acetylcholine receptor (AChR) binding antibody titer ranged from 0.12 nmol/L to 118 nmol/L. The RNS results were significantly more likely to be positive for seropositive patients, compared with seronegative patients. Patients with MGFA Class III or higher also had higher likelihood of positive RNS results, compared with patients in lower classes. Finally, the diagnostic yield was highest for patients with MGFA Class III or higher who were tested in an inpatient setting.

The study was supported by a Missouri School of Medicine Summer Research Fellowship.

egreb@mdedge.com

SOURCE: Hua T et al. AANEM 2019, Abstract 9.

AUSTIN, TEX. – Patients with suspected myasthenia gravis are more likely to have positive repetitive nerve stimulation (RNS) findings if they undergo testing in an inpatient setting, are seropositive, or are classified as Myasthenia Gravis Foundation of America (MGFA) Class III or higher, according to research presented at the annual meeting of the American Association of Neuromuscular and Electrodiagnostic Medicine.

Low-frequency RNS is a common test that neurologists perform to evaluate a patient for myasthenia gravis. The effects of various clinical factors on the diagnostic yield of this test are unknown, however.

Myasthenia gravis is “mostly a clinical diagnosis,” study first author Tingting Hua, a medical student at the University of Missouri in Columbia, said in an interview. “RNS is just one of the helpful diagnostic tests for it. If we can find out in what kind of populations of patients this test is more helpful, maybe that would help cut down unnecessary tests in patients for whom it’s not necessarily helpful.”

Ms. Hua and her colleagues conducted research to assess the effects of clinical, serologic, and demographic factors on the diagnostic yield of RNS. They retrospectively analyzed patients with an established diagnosis of myasthenia gravis and at least 1 year of follow-up. The variables that the investigators examined were demographic characteristics, MGFA class, RNS study results, antibody test results, thymoma status, and treatments received.

Ms. Hua and her colleagues included 65 patients in their analysis. Thirty-one patients were female. Fifty-five patients were white, eight were black, and two were categorized as “unknown.” Of this population, 32 patients (49.2%) were in MGFA Class I, 14 (21.5%) were in MGFA Class IIa, 13 (20.0%) were in MGFA Class IIb, and the remaining 6 (9.2%) were in MGFA Classes IIIa through V. Twenty-seven patients (42%) had positive RNS studies. Twenty-one patients (32%) were seropositive for myasthenia gravis antibodies.

Eleven patients underwent RNS in an inpatient setting, and 54 were tested in an outpatient setting. Acetylcholine receptor (AChR) binding antibody titer ranged from 0.12 nmol/L to 118 nmol/L. The RNS results were significantly more likely to be positive for seropositive patients, compared with seronegative patients. Patients with MGFA Class III or higher also had higher likelihood of positive RNS results, compared with patients in lower classes. Finally, the diagnostic yield was highest for patients with MGFA Class III or higher who were tested in an inpatient setting.

The study was supported by a Missouri School of Medicine Summer Research Fellowship.

egreb@mdedge.com

SOURCE: Hua T et al. AANEM 2019, Abstract 9.

AUSTIN, TEX. – Patients with suspected myasthenia gravis are more likely to have positive repetitive nerve stimulation (RNS) findings if they undergo testing in an inpatient setting, are seropositive, or are classified as Myasthenia Gravis Foundation of America (MGFA) Class III or higher, according to research presented at the annual meeting of the American Association of Neuromuscular and Electrodiagnostic Medicine.

Low-frequency RNS is a common test that neurologists perform to evaluate a patient for myasthenia gravis. The effects of various clinical factors on the diagnostic yield of this test are unknown, however.

Myasthenia gravis is “mostly a clinical diagnosis,” study first author Tingting Hua, a medical student at the University of Missouri in Columbia, said in an interview. “RNS is just one of the helpful diagnostic tests for it. If we can find out in what kind of populations of patients this test is more helpful, maybe that would help cut down unnecessary tests in patients for whom it’s not necessarily helpful.”

Ms. Hua and her colleagues conducted research to assess the effects of clinical, serologic, and demographic factors on the diagnostic yield of RNS. They retrospectively analyzed patients with an established diagnosis of myasthenia gravis and at least 1 year of follow-up. The variables that the investigators examined were demographic characteristics, MGFA class, RNS study results, antibody test results, thymoma status, and treatments received.

Ms. Hua and her colleagues included 65 patients in their analysis. Thirty-one patients were female. Fifty-five patients were white, eight were black, and two were categorized as “unknown.” Of this population, 32 patients (49.2%) were in MGFA Class I, 14 (21.5%) were in MGFA Class IIa, 13 (20.0%) were in MGFA Class IIb, and the remaining 6 (9.2%) were in MGFA Classes IIIa through V. Twenty-seven patients (42%) had positive RNS studies. Twenty-one patients (32%) were seropositive for myasthenia gravis antibodies.

Eleven patients underwent RNS in an inpatient setting, and 54 were tested in an outpatient setting. Acetylcholine receptor (AChR) binding antibody titer ranged from 0.12 nmol/L to 118 nmol/L. The RNS results were significantly more likely to be positive for seropositive patients, compared with seronegative patients. Patients with MGFA Class III or higher also had higher likelihood of positive RNS results, compared with patients in lower classes. Finally, the diagnostic yield was highest for patients with MGFA Class III or higher who were tested in an inpatient setting.

The study was supported by a Missouri School of Medicine Summer Research Fellowship.

egreb@mdedge.com

SOURCE: Hua T et al. AANEM 2019, Abstract 9.

AUSTIN, TEX. – During a 3-year period, 5.7% of patients referred to an electromyography laboratory returned for at least one additional electrodiagnostic study, according to research presented at the annual meeting of the American Association of Neuromuscular and Electrodiagnostic Medicine. A preliminary analysis suggests that repeat testing for the same indication does not change symptom or disease management in about one-third of cases.

Jake Remaly/MDedge News

Physicians may request repeat electrodiagnostic studies to monitor previous, new, or progressing symptoms in the same or different body segments. “While the utility of [electrodiagnostic] studies for clinical care has been established, testing is associated with some patient risk, time, and cost,” the researchers wrote. “To date, there have been no known studies investigating the utility of repeat [electrodiagnostic] testing in the outpatient setting.”

To study referral patterns and outcomes following repeat electrodiagnostic testing, Aimee K. Boegle, MD, PhD, an instructor in neurology at Beth Israel Deaconess Medical Center in Boston, and colleagues examined all outpatient electromyography and nerve conduction studies performed between 2015 and 2017 in the neurology department at their institution. The investigators excluded patients who underwent inpatient electrodiagnostic studies from their analysis.

Approximately 4,800 patients underwent electrodiagnostic testing, 276 of whom underwent testing more than once.

Among patients who underwent two studies, 55% were referred by a different physician for the second study. Median neuropathy was the most common referring and final diagnosis among patients who underwent repeat electrodiagnostic testing, Dr. Boegle said. This finding was not surprising because carpal tunnel syndrome is among the most common reasons for referral overall.

Median neuropathy was the referring diagnosis in 31% and the final diagnosis in 30%, cervical radiculopathy in 15% and 14%, ulnar neuropathy in 14% and 17%, lumbosacral radiculopathy in 12% and 10%, and polyneuropathy in 8% and 10%.

The neurology and orthopedics departments made the most referrals for repeat electrodiagnostic studies (49.4% and 29.3%, respectively), followed by primary care physicians/internal medicine (13%).

About 24% of the returning patients underwent testing for the same indication as their initial referral.

A preliminary analysis of 26 patients who underwent a repeat study for the same indication found no change in treatment in 34%. When a study prompted intervention, a conservative course of management such as a splint or physical therapy was used in 42%. About 8% received a pharmacologic intervention, such as a medication change or steroid injections. Another 8% received a surgical intervention and about 8% received further work-up.

The researchers had no relevant disclosures.
 

jremaly@mdedge.com

SOURCE: Boegle AK et al. AANEM 2019, Abstract 85.

AUSTIN, TEX. – During a 3-year period, 5.7% of patients referred to an electromyography laboratory returned for at least one additional electrodiagnostic study, according to research presented at the annual meeting of the American Association of Neuromuscular and Electrodiagnostic Medicine. A preliminary analysis suggests that repeat testing for the same indication does not change symptom or disease management in about one-third of cases.

Jake Remaly/MDedge News

Physicians may request repeat electrodiagnostic studies to monitor previous, new, or progressing symptoms in the same or different body segments. “While the utility of [electrodiagnostic] studies for clinical care has been established, testing is associated with some patient risk, time, and cost,” the researchers wrote. “To date, there have been no known studies investigating the utility of repeat [electrodiagnostic] testing in the outpatient setting.”

To study referral patterns and outcomes following repeat electrodiagnostic testing, Aimee K. Boegle, MD, PhD, an instructor in neurology at Beth Israel Deaconess Medical Center in Boston, and colleagues examined all outpatient electromyography and nerve conduction studies performed between 2015 and 2017 in the neurology department at their institution. The investigators excluded patients who underwent inpatient electrodiagnostic studies from their analysis.

Approximately 4,800 patients underwent electrodiagnostic testing, 276 of whom underwent testing more than once.

Among patients who underwent two studies, 55% were referred by a different physician for the second study. Median neuropathy was the most common referring and final diagnosis among patients who underwent repeat electrodiagnostic testing, Dr. Boegle said. This finding was not surprising because carpal tunnel syndrome is among the most common reasons for referral overall.

Median neuropathy was the referring diagnosis in 31% and the final diagnosis in 30%, cervical radiculopathy in 15% and 14%, ulnar neuropathy in 14% and 17%, lumbosacral radiculopathy in 12% and 10%, and polyneuropathy in 8% and 10%.

The neurology and orthopedics departments made the most referrals for repeat electrodiagnostic studies (49.4% and 29.3%, respectively), followed by primary care physicians/internal medicine (13%).

About 24% of the returning patients underwent testing for the same indication as their initial referral.

A preliminary analysis of 26 patients who underwent a repeat study for the same indication found no change in treatment in 34%. When a study prompted intervention, a conservative course of management such as a splint or physical therapy was used in 42%. About 8% received a pharmacologic intervention, such as a medication change or steroid injections. Another 8% received a surgical intervention and about 8% received further work-up.

The researchers had no relevant disclosures.
 

jremaly@mdedge.com

SOURCE: Boegle AK et al. AANEM 2019, Abstract 85.

AUSTIN, TEX. – During a 3-year period, 5.7% of patients referred to an electromyography laboratory returned for at least one additional electrodiagnostic study, according to research presented at the annual meeting of the American Association of Neuromuscular and Electrodiagnostic Medicine. A preliminary analysis suggests that repeat testing for the same indication does not change symptom or disease management in about one-third of cases.

Jake Remaly/MDedge News

Physicians may request repeat electrodiagnostic studies to monitor previous, new, or progressing symptoms in the same or different body segments. “While the utility of [electrodiagnostic] studies for clinical care has been established, testing is associated with some patient risk, time, and cost,” the researchers wrote. “To date, there have been no known studies investigating the utility of repeat [electrodiagnostic] testing in the outpatient setting.”

To study referral patterns and outcomes following repeat electrodiagnostic testing, Aimee K. Boegle, MD, PhD, an instructor in neurology at Beth Israel Deaconess Medical Center in Boston, and colleagues examined all outpatient electromyography and nerve conduction studies performed between 2015 and 2017 in the neurology department at their institution. The investigators excluded patients who underwent inpatient electrodiagnostic studies from their analysis.

Approximately 4,800 patients underwent electrodiagnostic testing, 276 of whom underwent testing more than once.

Among patients who underwent two studies, 55% were referred by a different physician for the second study. Median neuropathy was the most common referring and final diagnosis among patients who underwent repeat electrodiagnostic testing, Dr. Boegle said. This finding was not surprising because carpal tunnel syndrome is among the most common reasons for referral overall.

Median neuropathy was the referring diagnosis in 31% and the final diagnosis in 30%, cervical radiculopathy in 15% and 14%, ulnar neuropathy in 14% and 17%, lumbosacral radiculopathy in 12% and 10%, and polyneuropathy in 8% and 10%.

The neurology and orthopedics departments made the most referrals for repeat electrodiagnostic studies (49.4% and 29.3%, respectively), followed by primary care physicians/internal medicine (13%).

About 24% of the returning patients underwent testing for the same indication as their initial referral.

A preliminary analysis of 26 patients who underwent a repeat study for the same indication found no change in treatment in 34%. When a study prompted intervention, a conservative course of management such as a splint or physical therapy was used in 42%. About 8% received a pharmacologic intervention, such as a medication change or steroid injections. Another 8% received a surgical intervention and about 8% received further work-up.

The researchers had no relevant disclosures.
 

jremaly@mdedge.com

SOURCE: Boegle AK et al. AANEM 2019, Abstract 85.

MADRID – A placebo-controlled trial has confirmed that amoxicillin/clavulanate is beneficial for resolution of acute exacerbations in nonsevere bronchiectasis while also demonstrating a greater relative effect than azithromycin, based on data presented at the annual congress of the European Respiratory Society.

“We now have robust data with which to support our guidelines,” reported Vikas Goyal, MD, of the Children’s Health Clinical Unit, University of Queensland, Brisbane, Australia.

The study addresses a knowledge gap. Antibiotics are already recommended by many guidelines for treatment of acute exacerbations in children with bronchiectasis, but Dr. Goyal said that no controlled trials have ever been performed in this age group to confirm superiority to placebo.

In this multicenter study, called BEST-1, 197 children with bronchiectasis were randomized at the start of an exacerbation to placebo, 45 mg/kg per day of amoxicillin/clavulanate, or 5 mg/kg per day of azithromycin. To maintain blinding, patients in the active treatment groups received a dummy for the opposite antibiotic while patients on placebo received dummies for both active agents.

For the primary outcome, 65% of children randomized to amoxicillin/clavulanate had resolution of their exacerbation by day 14 versus 61% of those randomized to azithromycin and 43% of those randomized to placebo. On the basis of relative risk for reaching this end point, the outcome was superior to placebo for amoxicillin/clavulanate (RR, 1.5; P = .015).

Although the relative risk for azithromycin (RR, 1.4; P = .042) was only slightly lower, it did not reach a prespecified level of significance set at P = .025. Dr. Goyal did report that the resolution rate at 14 days in the placebo group was “higher than expected.”

In this trial, 53% of the 154 children who were tested for respiratory viruses with nasal swabs on day 1 of the exacerbation were found to have respiratory viruses. Of these viruses, rhinovirus was the most common, according to Dr. Goyal, whose data were published just prior to his presentation (Lancet Respir Med. 2019;7:791-801).

The median durations of the exacerbations were 7 days, 8 days, and 10 days for those treated with amoxicillin/clavulanate, azithromycin, and placebo, respectively. The difference between amoxicillin/clavulanate and placebo, but not that between azithromycin and placebo, reached statistical significance, Dr. Goyal said.

There were no between group differences in the time to next exacerbation.

In discussing limitations of this study, Dr. Goyal pointed out that the optimal doses of amoxicillin/clavulanate or azithromycin have never been established for the treatment of exacerbations in children with bronchiectasis. He noted that some infectious disease specialists have advocated higher doses of both than those employed in this trial, but dose-ranging studies have never been conducted in this age group.

In this study, adverse events were less common on azithromycin than amoxicillin/clavulanate (21% vs. 30%), but none were severe, according to Dr. Goyal. He said treatment with azithromycin was associated with increased macrolide-resistant bacteria.

On the basis of these data, Dr. Goyal concluded that amoxicillin/clavulanate should remain, as already specified in some guidelines, the standard first-line therapy for nonsevere exacerbations in nonhospitalized children with bronchiectasis. He recommended reserving azithromycin as an alternative therapy.

Dr. Goyal reports no potential conflicts of interest.

SOURCE: Goyal V et al. Lancet Respir Med. 2019;7:791-801.

MADRID – A placebo-controlled trial has confirmed that amoxicillin/clavulanate is beneficial for resolution of acute exacerbations in nonsevere bronchiectasis while also demonstrating a greater relative effect than azithromycin, based on data presented at the annual congress of the European Respiratory Society.

“We now have robust data with which to support our guidelines,” reported Vikas Goyal, MD, of the Children’s Health Clinical Unit, University of Queensland, Brisbane, Australia.

The study addresses a knowledge gap. Antibiotics are already recommended by many guidelines for treatment of acute exacerbations in children with bronchiectasis, but Dr. Goyal said that no controlled trials have ever been performed in this age group to confirm superiority to placebo.

In this multicenter study, called BEST-1, 197 children with bronchiectasis were randomized at the start of an exacerbation to placebo, 45 mg/kg per day of amoxicillin/clavulanate, or 5 mg/kg per day of azithromycin. To maintain blinding, patients in the active treatment groups received a dummy for the opposite antibiotic while patients on placebo received dummies for both active agents.

For the primary outcome, 65% of children randomized to amoxicillin/clavulanate had resolution of their exacerbation by day 14 versus 61% of those randomized to azithromycin and 43% of those randomized to placebo. On the basis of relative risk for reaching this end point, the outcome was superior to placebo for amoxicillin/clavulanate (RR, 1.5; P = .015).

Although the relative risk for azithromycin (RR, 1.4; P = .042) was only slightly lower, it did not reach a prespecified level of significance set at P = .025. Dr. Goyal did report that the resolution rate at 14 days in the placebo group was “higher than expected.”

In this trial, 53% of the 154 children who were tested for respiratory viruses with nasal swabs on day 1 of the exacerbation were found to have respiratory viruses. Of these viruses, rhinovirus was the most common, according to Dr. Goyal, whose data were published just prior to his presentation (Lancet Respir Med. 2019;7:791-801).

The median durations of the exacerbations were 7 days, 8 days, and 10 days for those treated with amoxicillin/clavulanate, azithromycin, and placebo, respectively. The difference between amoxicillin/clavulanate and placebo, but not that between azithromycin and placebo, reached statistical significance, Dr. Goyal said.

There were no between group differences in the time to next exacerbation.

In discussing limitations of this study, Dr. Goyal pointed out that the optimal doses of amoxicillin/clavulanate or azithromycin have never been established for the treatment of exacerbations in children with bronchiectasis. He noted that some infectious disease specialists have advocated higher doses of both than those employed in this trial, but dose-ranging studies have never been conducted in this age group.

In this study, adverse events were less common on azithromycin than amoxicillin/clavulanate (21% vs. 30%), but none were severe, according to Dr. Goyal. He said treatment with azithromycin was associated with increased macrolide-resistant bacteria.

On the basis of these data, Dr. Goyal concluded that amoxicillin/clavulanate should remain, as already specified in some guidelines, the standard first-line therapy for nonsevere exacerbations in nonhospitalized children with bronchiectasis. He recommended reserving azithromycin as an alternative therapy.

Dr. Goyal reports no potential conflicts of interest.

SOURCE: Goyal V et al. Lancet Respir Med. 2019;7:791-801.

MADRID – A placebo-controlled trial has confirmed that amoxicillin/clavulanate is beneficial for resolution of acute exacerbations in nonsevere bronchiectasis while also demonstrating a greater relative effect than azithromycin, based on data presented at the annual congress of the European Respiratory Society.

“We now have robust data with which to support our guidelines,” reported Vikas Goyal, MD, of the Children’s Health Clinical Unit, University of Queensland, Brisbane, Australia.

The study addresses a knowledge gap. Antibiotics are already recommended by many guidelines for treatment of acute exacerbations in children with bronchiectasis, but Dr. Goyal said that no controlled trials have ever been performed in this age group to confirm superiority to placebo.

In this multicenter study, called BEST-1, 197 children with bronchiectasis were randomized at the start of an exacerbation to placebo, 45 mg/kg per day of amoxicillin/clavulanate, or 5 mg/kg per day of azithromycin. To maintain blinding, patients in the active treatment groups received a dummy for the opposite antibiotic while patients on placebo received dummies for both active agents.

For the primary outcome, 65% of children randomized to amoxicillin/clavulanate had resolution of their exacerbation by day 14 versus 61% of those randomized to azithromycin and 43% of those randomized to placebo. On the basis of relative risk for reaching this end point, the outcome was superior to placebo for amoxicillin/clavulanate (RR, 1.5; P = .015).

Although the relative risk for azithromycin (RR, 1.4; P = .042) was only slightly lower, it did not reach a prespecified level of significance set at P = .025. Dr. Goyal did report that the resolution rate at 14 days in the placebo group was “higher than expected.”

In this trial, 53% of the 154 children who were tested for respiratory viruses with nasal swabs on day 1 of the exacerbation were found to have respiratory viruses. Of these viruses, rhinovirus was the most common, according to Dr. Goyal, whose data were published just prior to his presentation (Lancet Respir Med. 2019;7:791-801).

The median durations of the exacerbations were 7 days, 8 days, and 10 days for those treated with amoxicillin/clavulanate, azithromycin, and placebo, respectively. The difference between amoxicillin/clavulanate and placebo, but not that between azithromycin and placebo, reached statistical significance, Dr. Goyal said.

There were no between group differences in the time to next exacerbation.

In discussing limitations of this study, Dr. Goyal pointed out that the optimal doses of amoxicillin/clavulanate or azithromycin have never been established for the treatment of exacerbations in children with bronchiectasis. He noted that some infectious disease specialists have advocated higher doses of both than those employed in this trial, but dose-ranging studies have never been conducted in this age group.

In this study, adverse events were less common on azithromycin than amoxicillin/clavulanate (21% vs. 30%), but none were severe, according to Dr. Goyal. He said treatment with azithromycin was associated with increased macrolide-resistant bacteria.

On the basis of these data, Dr. Goyal concluded that amoxicillin/clavulanate should remain, as already specified in some guidelines, the standard first-line therapy for nonsevere exacerbations in nonhospitalized children with bronchiectasis. He recommended reserving azithromycin as an alternative therapy.

Dr. Goyal reports no potential conflicts of interest.

SOURCE: Goyal V et al. Lancet Respir Med. 2019;7:791-801.

Read the full Cutis article, “Quality of Life in Patients With Atopic Dermatitis.”

Read the full Cutis article, “Quality of Life in Patients With Atopic Dermatitis.”

Read the full Cutis article, “Quality of Life in Patients With Atopic Dermatitis.”

SEATTLE – While current treatments for actinic keratosis include variations on light therapy and strategies such as field cancerization, the nitrogen tank in the corner of the office is likely to stay, David Pariser, MD, said during a presentation at the annual Coastal Dermatology Symposium.

“My personal view is that, no matter how good other treatments are eventually going to be, we’re never going to give that up,” Dr. Pariser, professor of dermatology at Eastern Virginia Medical School, Norfolk, said at the meeting, jointly presented by the University of Louisville and Global Academy for Medical Education.

During the presentation, he emphasized that it isn’t always clear which actinic keratosis (AK) should be treated and which can be left alone, since most AKs don’t progress to squamous cell carcinoma (SCC). “We know that most squamous cell carcinomas arise near AKs, and many of them have histologic evidence” of AK/SCC continuum at the periphery, he said. Sun protection reduces the incidence of AKs and the incidence of nonmelanoma skin cancer, “so it’s a logical conclusion that treating AKs reduces the development of SCCs, but there are no data to show that.”

Generally, treatment decisions are made based on the presence of symptoms, location, or appearance; if the area is irritated; or there is a progressive or unusual appearance, especially if hyperkeratotic. Physician or patient concerns about cancer can prompt treatment, as should a history of multiple skin cancers or the presence of immunosuppression, he said.

Treatment options include cryosurgery, surgery, topical agents, and photodynamic therapy (PDT); Dr. Pariser focused on the latter because it is a special interest of his.

Field cancerization is based on the idea that a broad area of cells may be at risk for developing into SCC, rather than just individual AKs. Treatment with methyl 5-aminolevulinate (MAL) can reveal the extent of a problem. In some patients, “you can see a lot of fluorescence in areas that look reasonably clinically normal. So this is a piece of evidence of this field cancerization, that maybe we shouldn’t be treating individual AKs, but larger areas,” Dr. Pariser said.

With PDT, there has been some debate about how long to leave the photosensitizer on the skin before applying the light. The longer it remains, the more it spreads to nerves, which can lead to pain during the procedure. A clinical trial comparing 1-, 2-, and 3-hour wait times showed no difference in efficacy. “So 1 hour is what I do for AKs, that’s it,” Dr. Pariser said.

There are two Food and Drug Administration–approved PDT systems, a blue-light system combined with aminolevulinic acid (ALA) and a newer red-light system combined with a nanoemulsion of ALA 7.8% and a proprietary 635-nm red LED light. The nanoemulsion has the theoretical advantage in that it can penetrate more deeply into the epidermis, though this isn’t really an issue when treating AKs, according to Dr. Pariser.

A study comparing nanoemulsion of ALA, compared with a MAL cream, found the nanoemulsion to be superior in achieving complete clearance of all lesions at 12 weeks (78.2% vs. 64.2%; P less than .05). Both treatments achieved best efficacy with LED lamps, and the proprietary red light may reduce pain by allowing use of lower light intensity (Br J Dermatol. 2012 Jan; 166[1]:137-46).

Another study, Dr. Pariser said, looked at whether occlusion during drug incubation improves outcomes of blue light ALA-PDT (J Drugs Dermatol. 2012;11[12]:1483-9). Patients underwent split occlusion on the upper extremities before undergoing blue-light treatment. The median clearance rate of AKs at 8 weeks was higher with occlusion, compared with the nonoccluded areas (75% vs. 47%; P = .006), and at 12 weeks, after a second treatment (89% vs. 70%; P = .00029). There was a higher efficacy with a 3-hour incubation period, compared with studies using a 2-hour incubation period.

Application of heat can also boost success rates by increasing the synthesis of the photoactive agent, Dr. Pariser said. One study found that a simple heating pad applied to the area treated with ALA-PDT and blue light led to an 88% reduction in lesions at 8 and 24 weeks, compared with a reduction of 71% at 8 weeks and 68% at 24 weeks without heat (P less than .0001). “So if you want to give PDT a little extra oomph, add occlusion and heat,” he commented.

He also pointed out the availability of a new 4% 5-fluorouracil cream that contains peanut oil, which has similar efficacy to 5% 5-fluorouracil cream but has been associated with less pruritus, stinging/burning, edema, crusting, scaling/dryness, erosion, and erythema (J Drugs Dermatol. 2016 Oct 1;15[10]: 1218-24).

Dr. Pariser is an investigator and consultant for DUSA/Sun Pharma, Photocure, LEO Pharma, and Biofrontera. This publication and Global Academy for Medical Education are owned by the same parent company.

SEATTLE – While current treatments for actinic keratosis include variations on light therapy and strategies such as field cancerization, the nitrogen tank in the corner of the office is likely to stay, David Pariser, MD, said during a presentation at the annual Coastal Dermatology Symposium.

“My personal view is that, no matter how good other treatments are eventually going to be, we’re never going to give that up,” Dr. Pariser, professor of dermatology at Eastern Virginia Medical School, Norfolk, said at the meeting, jointly presented by the University of Louisville and Global Academy for Medical Education.

During the presentation, he emphasized that it isn’t always clear which actinic keratosis (AK) should be treated and which can be left alone, since most AKs don’t progress to squamous cell carcinoma (SCC). “We know that most squamous cell carcinomas arise near AKs, and many of them have histologic evidence” of AK/SCC continuum at the periphery, he said. Sun protection reduces the incidence of AKs and the incidence of nonmelanoma skin cancer, “so it’s a logical conclusion that treating AKs reduces the development of SCCs, but there are no data to show that.”

Generally, treatment decisions are made based on the presence of symptoms, location, or appearance; if the area is irritated; or there is a progressive or unusual appearance, especially if hyperkeratotic. Physician or patient concerns about cancer can prompt treatment, as should a history of multiple skin cancers or the presence of immunosuppression, he said.

Treatment options include cryosurgery, surgery, topical agents, and photodynamic therapy (PDT); Dr. Pariser focused on the latter because it is a special interest of his.

Field cancerization is based on the idea that a broad area of cells may be at risk for developing into SCC, rather than just individual AKs. Treatment with methyl 5-aminolevulinate (MAL) can reveal the extent of a problem. In some patients, “you can see a lot of fluorescence in areas that look reasonably clinically normal. So this is a piece of evidence of this field cancerization, that maybe we shouldn’t be treating individual AKs, but larger areas,” Dr. Pariser said.

With PDT, there has been some debate about how long to leave the photosensitizer on the skin before applying the light. The longer it remains, the more it spreads to nerves, which can lead to pain during the procedure. A clinical trial comparing 1-, 2-, and 3-hour wait times showed no difference in efficacy. “So 1 hour is what I do for AKs, that’s it,” Dr. Pariser said.

There are two Food and Drug Administration–approved PDT systems, a blue-light system combined with aminolevulinic acid (ALA) and a newer red-light system combined with a nanoemulsion of ALA 7.8% and a proprietary 635-nm red LED light. The nanoemulsion has the theoretical advantage in that it can penetrate more deeply into the epidermis, though this isn’t really an issue when treating AKs, according to Dr. Pariser.

A study comparing nanoemulsion of ALA, compared with a MAL cream, found the nanoemulsion to be superior in achieving complete clearance of all lesions at 12 weeks (78.2% vs. 64.2%; P less than .05). Both treatments achieved best efficacy with LED lamps, and the proprietary red light may reduce pain by allowing use of lower light intensity (Br J Dermatol. 2012 Jan; 166[1]:137-46).

Another study, Dr. Pariser said, looked at whether occlusion during drug incubation improves outcomes of blue light ALA-PDT (J Drugs Dermatol. 2012;11[12]:1483-9). Patients underwent split occlusion on the upper extremities before undergoing blue-light treatment. The median clearance rate of AKs at 8 weeks was higher with occlusion, compared with the nonoccluded areas (75% vs. 47%; P = .006), and at 12 weeks, after a second treatment (89% vs. 70%; P = .00029). There was a higher efficacy with a 3-hour incubation period, compared with studies using a 2-hour incubation period.

Application of heat can also boost success rates by increasing the synthesis of the photoactive agent, Dr. Pariser said. One study found that a simple heating pad applied to the area treated with ALA-PDT and blue light led to an 88% reduction in lesions at 8 and 24 weeks, compared with a reduction of 71% at 8 weeks and 68% at 24 weeks without heat (P less than .0001). “So if you want to give PDT a little extra oomph, add occlusion and heat,” he commented.

He also pointed out the availability of a new 4% 5-fluorouracil cream that contains peanut oil, which has similar efficacy to 5% 5-fluorouracil cream but has been associated with less pruritus, stinging/burning, edema, crusting, scaling/dryness, erosion, and erythema (J Drugs Dermatol. 2016 Oct 1;15[10]: 1218-24).

Dr. Pariser is an investigator and consultant for DUSA/Sun Pharma, Photocure, LEO Pharma, and Biofrontera. This publication and Global Academy for Medical Education are owned by the same parent company.

SEATTLE – While current treatments for actinic keratosis include variations on light therapy and strategies such as field cancerization, the nitrogen tank in the corner of the office is likely to stay, David Pariser, MD, said during a presentation at the annual Coastal Dermatology Symposium.

“My personal view is that, no matter how good other treatments are eventually going to be, we’re never going to give that up,” Dr. Pariser, professor of dermatology at Eastern Virginia Medical School, Norfolk, said at the meeting, jointly presented by the University of Louisville and Global Academy for Medical Education.

During the presentation, he emphasized that it isn’t always clear which actinic keratosis (AK) should be treated and which can be left alone, since most AKs don’t progress to squamous cell carcinoma (SCC). “We know that most squamous cell carcinomas arise near AKs, and many of them have histologic evidence” of AK/SCC continuum at the periphery, he said. Sun protection reduces the incidence of AKs and the incidence of nonmelanoma skin cancer, “so it’s a logical conclusion that treating AKs reduces the development of SCCs, but there are no data to show that.”

Generally, treatment decisions are made based on the presence of symptoms, location, or appearance; if the area is irritated; or there is a progressive or unusual appearance, especially if hyperkeratotic. Physician or patient concerns about cancer can prompt treatment, as should a history of multiple skin cancers or the presence of immunosuppression, he said.

Treatment options include cryosurgery, surgery, topical agents, and photodynamic therapy (PDT); Dr. Pariser focused on the latter because it is a special interest of his.

Field cancerization is based on the idea that a broad area of cells may be at risk for developing into SCC, rather than just individual AKs. Treatment with methyl 5-aminolevulinate (MAL) can reveal the extent of a problem. In some patients, “you can see a lot of fluorescence in areas that look reasonably clinically normal. So this is a piece of evidence of this field cancerization, that maybe we shouldn’t be treating individual AKs, but larger areas,” Dr. Pariser said.

With PDT, there has been some debate about how long to leave the photosensitizer on the skin before applying the light. The longer it remains, the more it spreads to nerves, which can lead to pain during the procedure. A clinical trial comparing 1-, 2-, and 3-hour wait times showed no difference in efficacy. “So 1 hour is what I do for AKs, that’s it,” Dr. Pariser said.

There are two Food and Drug Administration–approved PDT systems, a blue-light system combined with aminolevulinic acid (ALA) and a newer red-light system combined with a nanoemulsion of ALA 7.8% and a proprietary 635-nm red LED light. The nanoemulsion has the theoretical advantage in that it can penetrate more deeply into the epidermis, though this isn’t really an issue when treating AKs, according to Dr. Pariser.

A study comparing nanoemulsion of ALA, compared with a MAL cream, found the nanoemulsion to be superior in achieving complete clearance of all lesions at 12 weeks (78.2% vs. 64.2%; P less than .05). Both treatments achieved best efficacy with LED lamps, and the proprietary red light may reduce pain by allowing use of lower light intensity (Br J Dermatol. 2012 Jan; 166[1]:137-46).

Another study, Dr. Pariser said, looked at whether occlusion during drug incubation improves outcomes of blue light ALA-PDT (J Drugs Dermatol. 2012;11[12]:1483-9). Patients underwent split occlusion on the upper extremities before undergoing blue-light treatment. The median clearance rate of AKs at 8 weeks was higher with occlusion, compared with the nonoccluded areas (75% vs. 47%; P = .006), and at 12 weeks, after a second treatment (89% vs. 70%; P = .00029). There was a higher efficacy with a 3-hour incubation period, compared with studies using a 2-hour incubation period.

Application of heat can also boost success rates by increasing the synthesis of the photoactive agent, Dr. Pariser said. One study found that a simple heating pad applied to the area treated with ALA-PDT and blue light led to an 88% reduction in lesions at 8 and 24 weeks, compared with a reduction of 71% at 8 weeks and 68% at 24 weeks without heat (P less than .0001). “So if you want to give PDT a little extra oomph, add occlusion and heat,” he commented.

He also pointed out the availability of a new 4% 5-fluorouracil cream that contains peanut oil, which has similar efficacy to 5% 5-fluorouracil cream but has been associated with less pruritus, stinging/burning, edema, crusting, scaling/dryness, erosion, and erythema (J Drugs Dermatol. 2016 Oct 1;15[10]: 1218-24).

Dr. Pariser is an investigator and consultant for DUSA/Sun Pharma, Photocure, LEO Pharma, and Biofrontera. This publication and Global Academy for Medical Education are owned by the same parent company.

About 100,000 people in America have sickle cell disease. Of those, an estimated 27 people have undergone experimental gene therapy using conventional vectors—virus-based vehicles for delivering “therapeutic genes.” Now National Institutes of Health researchers have taken the vector idea and revved it up, bringing the possibility of curing sickle cell disease a bit closer.

With gene therapy, doctors add a normal copy of the β-globin gene to the patient’s hematopoietic stem cells, then reinfuse the modified stem cells into the patient to produce normal disc-shaped red blood cells. In animal studies, the new vector was up to 10 times more efficient at incorporating corrective genes into bone marrow stem cells with a carrying capacity of up to 6 times greater viral load than current vectors. The new vectors also can be produced in much higher amounts, saving time and lowering costs.

The researchers call it a “forward-oriented” vector because it changes the usual direction of how gene sequences in globin-containing vectors are read: from right to left. That backward orientation—globin-containing vectors are the only therapeutic vectors in clinical development that use it—the researchers say, “has remained unchallenged for decades despite its negative impacts on efficiency.”

The right-to-left orientation was dictated by the need to prevent the loss of a key molecular component, intron 2, by RNA splicing during the vector preparation. The redesigned forward-reading method crucially leaves intron 2 intact and makes the gene-translation approach less complicated, says John Tisdale, MD, chief of the Cellular and Molecular Therapeutic Branch at the National Heart, Lung, and Blood Institute, who, with Naoya Uchida, MD, PhD, came up with the idea.

In testing, the new vectors also proved longer lasting, remaining in place 4 years after transplantation.

National Institutes of Health is working to accelerate research and development through the Cure Sickle Cell Initiative, launched by NHLBI in 2018 to identify and support the most promising genetic therapies for the more than 20 million people worldwide who have sickle cell disease. NIH holds the patent for the new vector, which still will need clinical testing in humans. Clinical trials are actively enrolling.

About 100,000 people in America have sickle cell disease. Of those, an estimated 27 people have undergone experimental gene therapy using conventional vectors—virus-based vehicles for delivering “therapeutic genes.” Now National Institutes of Health researchers have taken the vector idea and revved it up, bringing the possibility of curing sickle cell disease a bit closer.

With gene therapy, doctors add a normal copy of the β-globin gene to the patient’s hematopoietic stem cells, then reinfuse the modified stem cells into the patient to produce normal disc-shaped red blood cells. In animal studies, the new vector was up to 10 times more efficient at incorporating corrective genes into bone marrow stem cells with a carrying capacity of up to 6 times greater viral load than current vectors. The new vectors also can be produced in much higher amounts, saving time and lowering costs.

The researchers call it a “forward-oriented” vector because it changes the usual direction of how gene sequences in globin-containing vectors are read: from right to left. That backward orientation—globin-containing vectors are the only therapeutic vectors in clinical development that use it—the researchers say, “has remained unchallenged for decades despite its negative impacts on efficiency.”

The right-to-left orientation was dictated by the need to prevent the loss of a key molecular component, intron 2, by RNA splicing during the vector preparation. The redesigned forward-reading method crucially leaves intron 2 intact and makes the gene-translation approach less complicated, says John Tisdale, MD, chief of the Cellular and Molecular Therapeutic Branch at the National Heart, Lung, and Blood Institute, who, with Naoya Uchida, MD, PhD, came up with the idea.

In testing, the new vectors also proved longer lasting, remaining in place 4 years after transplantation.

National Institutes of Health is working to accelerate research and development through the Cure Sickle Cell Initiative, launched by NHLBI in 2018 to identify and support the most promising genetic therapies for the more than 20 million people worldwide who have sickle cell disease. NIH holds the patent for the new vector, which still will need clinical testing in humans. Clinical trials are actively enrolling.

About 100,000 people in America have sickle cell disease. Of those, an estimated 27 people have undergone experimental gene therapy using conventional vectors—virus-based vehicles for delivering “therapeutic genes.” Now National Institutes of Health researchers have taken the vector idea and revved it up, bringing the possibility of curing sickle cell disease a bit closer.

With gene therapy, doctors add a normal copy of the β-globin gene to the patient’s hematopoietic stem cells, then reinfuse the modified stem cells into the patient to produce normal disc-shaped red blood cells. In animal studies, the new vector was up to 10 times more efficient at incorporating corrective genes into bone marrow stem cells with a carrying capacity of up to 6 times greater viral load than current vectors. The new vectors also can be produced in much higher amounts, saving time and lowering costs.

The researchers call it a “forward-oriented” vector because it changes the usual direction of how gene sequences in globin-containing vectors are read: from right to left. That backward orientation—globin-containing vectors are the only therapeutic vectors in clinical development that use it—the researchers say, “has remained unchallenged for decades despite its negative impacts on efficiency.”

The right-to-left orientation was dictated by the need to prevent the loss of a key molecular component, intron 2, by RNA splicing during the vector preparation. The redesigned forward-reading method crucially leaves intron 2 intact and makes the gene-translation approach less complicated, says John Tisdale, MD, chief of the Cellular and Molecular Therapeutic Branch at the National Heart, Lung, and Blood Institute, who, with Naoya Uchida, MD, PhD, came up with the idea.

In testing, the new vectors also proved longer lasting, remaining in place 4 years after transplantation.

National Institutes of Health is working to accelerate research and development through the Cure Sickle Cell Initiative, launched by NHLBI in 2018 to identify and support the most promising genetic therapies for the more than 20 million people worldwide who have sickle cell disease. NIH holds the patent for the new vector, which still will need clinical testing in humans. Clinical trials are actively enrolling.