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Yale ASH 2022 Highlights: Classical Hematology

February 21, 2023

February 17, 2023

Hosted by: Dr. Robert Bona

Presentations by: Drs. Layla Van Doren, George Goshua, and Anish Sharda

ID
9534

Transcript

  • 00:03All right. Good afternoon, everybody,
  • 00:06and welcome to the classical
  • 00:08hematology review of the American
  • 00:10Society of Hematology meeting in 2022.
  • 00:13Thank you for joining us.
  • 00:16My name is Robert Bona.
  • 00:17I work here at Yale in the section of
  • 00:20hematology and I'm very excited and happy
  • 00:22to introduce our three speakers today.
  • 00:25I will be brief with their introductions
  • 00:27since I don't want to take away
  • 00:29time from the important things that
  • 00:30they're going to talk with us about.
  • 00:32Lila van Doren. We'll begin our discussion.
  • 00:34Lila joined.
  • 00:35All three of our faculty actually
  • 00:37have joined the classical hematology
  • 00:39program at Yale this academic year.
  • 00:41And Lila joined us from Columbia and
  • 00:43she brings a wealth of experience
  • 00:45and knowledge with her.
  • 00:47And at Yale she is going to be
  • 00:49focusing on sickle cell diseases and
  • 00:52iron disorders of iron hemostasis
  • 00:54in particular iron homeostasis in
  • 00:56particular in the area of of Women's Health.
  • 01:00Doctor Gashua,
  • 01:02Yale fellow.
  • 01:03And graduate of the Harvard Public
  • 01:05School of Health is focusing his work
  • 01:08research work here at Yale on decision
  • 01:11science analysis and hematologic disorders.
  • 01:14And Annie Sharda joined us from the
  • 01:16Beth Israel Deaconess Medical Center.
  • 01:17He has a active laboratory program
  • 01:20looking at endothelial function and
  • 01:23in particular the expression and
  • 01:25secretion of von Willebrand factor.
  • 01:28So again,
  • 01:28we're,
  • 01:29I'm very excited to to to have them
  • 01:31present their work to us today or their.
  • 01:34Their review of some of the ash.
  • 01:37Up hot abstracts and please put
  • 01:40your questions in the chat room
  • 01:43or in the Q&A and we'll get to
  • 01:46those at the end of the session.
  • 01:47Each of our presenters will present
  • 01:49for about 15 minutes and then
  • 01:52we'll take questions at the end.
  • 01:54So without further ado,
  • 01:55Doctor Van Dorn,
  • 01:57would you like to get us started?
  • 02:00Share my screen. And. There we go.
  • 02:06OK, these are my disclosures. All right.
  • 02:09These are the two abstracts that
  • 02:11I'm going to be discussing today,
  • 02:12so we'll just jump into it.
  • 02:14The first abstract is focused on
  • 02:16inherited thrombophilia and pregnancy,
  • 02:18anticoagulation and thrombophilia testing.
  • 02:22So I wanted to start out with the case first.
  • 02:24It's a 38 year old patient who presents
  • 02:27for evaluation at 8 weeks gestation.
  • 02:29She's the history of three miscarriages
  • 02:31in the first trimester anti phospholipid
  • 02:34antibody testing was previously negative but
  • 02:36she was found to be positive for Factor 5,
  • 02:39Leiden heterozygous mutation.
  • 02:41And the question is would you recommend
  • 02:44anticoagulation during pregnancy for this
  • 02:46patient to increase her chance of live birth?
  • 02:49So the background is that studies
  • 02:51have shown an association.
  • 02:53Between recurrent miscarriage and inherited
  • 02:55thrombophilia for women with a PLS,
  • 02:58we know that the use of heparin or low
  • 03:00molecular weight heparin and combined
  • 03:01with low dose aspirin is an effective
  • 03:04treatment for recurrent miscarriage.
  • 03:06And the thought about the role of
  • 03:08thrombophilia recurrent miscarriage
  • 03:10is that it can be explained partially
  • 03:12by the concept of thrombosis of the
  • 03:15microvasculature of the placenta.
  • 03:16And so it is thought that anticoagulant
  • 03:18therapy might reduce miscarriages and
  • 03:21adverse pregnancy outcomes in patients
  • 03:23with inherited thrombophilia as well.
  • 03:25However,
  • 03:25there's a lack of solid
  • 03:27evidence for this practice.
  • 03:29And so in 2010 a study was published,
  • 03:33a life study that was a randomized
  • 03:36placebo-controlled study investigating
  • 03:37whether aspirin plus low molecular
  • 03:40weight heparin or aspirin alone
  • 03:43combined oh compared to placebo
  • 03:44would improve the live birth.
  • 03:46Among 364 women,
  • 03:47so there were three different arms
  • 03:49and what this study showed was
  • 03:51that there was no difference in
  • 03:53the live birth rates between the
  • 03:55study groups with the relative risk
  • 03:57of 1.03 and in patient specific.
  • 04:00Thrombophilia,
  • 04:00there was also no difference,
  • 04:02although the number of patients
  • 04:04in the study with an inherited
  • 04:07thrombophilia were was very low and so.
  • 04:10Which brings us to the a life two study,
  • 04:12the first abstract,
  • 04:14which was a late breaking abstract
  • 04:16at ASH in December 2022,
  • 04:18and it was ten years in the making.
  • 04:20So the objective of the A life two
  • 04:23study was specifically to evaluate
  • 04:25the efficacy of low molecular weight
  • 04:27heparin and women with an inherited
  • 04:30thrombophilia with recurrent miscarriage.
  • 04:31And so the way this study was
  • 04:33designed is that patients who had a
  • 04:36history of two or more miscarriages
  • 04:38with an inherited thrombophilia,
  • 04:40no more than seven weeks gestational
  • 04:42age could be enrolled.
  • 04:43They were randomized 1 to one to
  • 04:45receive either a low molecular weight
  • 04:47heparin and those are the different
  • 04:49ones that that were used in the study
  • 04:51plus the standard of pregnancy care
  • 04:53or a standard of pregnancy care alone.
  • 04:56The outcomes was the primary efficacy
  • 04:58outcome was the live birth rate,
  • 05:00secondary efficacy.
  • 05:01This miscarriage or adverse
  • 05:03obstetric outcomes and then safety
  • 05:05was looked at as well.
  • 05:06And so these are the
  • 05:07characteristics of the patients.
  • 05:09The mean age was 33 and
  • 05:11the majority of patients
  • 05:13actually had three or more miscarriages.
  • 05:16The most common inherited thrombophilia
  • 05:18was the factor 5 Leiden heterozygous
  • 05:20followed by prothrombin gene mutation,
  • 05:22heterozygous protein ESTA efficiency
  • 05:24and then a mix of antithrombin combined
  • 05:28thrombophilias and then protein C deficiency.
  • 05:32And the outcome of the study was that there
  • 05:34was no difference between the standard of
  • 05:37care and low molecular weight heparin plus
  • 05:39standard of care in the live birth rate.
  • 05:42So the odds ratio was 1.04 when
  • 05:44this was adjusted for age.
  • 05:46So less than or greater than
  • 05:48or equal to 36 years old,
  • 05:50the number of miscarriages or the center.
  • 05:52So if the patient was treated at a
  • 05:54tertiary center or a non tertiary center,
  • 05:56or by country UK versus the Netherlands,
  • 05:59there was still no difference
  • 06:01between the live birth rate.
  • 06:02In the different arms.
  • 06:05In terms of the differences
  • 06:07in adverse effects,
  • 06:08there were more adverse effects in patients
  • 06:10receiving low molecular weight heparin,
  • 06:12such as easy bruising,
  • 06:14skin reactions,
  • 06:15that injection site and minor bleeding.
  • 06:18And so the conclusions of this study
  • 06:20was that low molecular weight heparin
  • 06:22did not result in a higher life birth
  • 06:25rate in women who had greater than
  • 06:27or equal to two pregnancy losses and
  • 06:30confirmed inherited thrombophilia.
  • 06:31And the recommendation is to not use
  • 06:33low molecular weight heparin in women
  • 06:35with recurrent pregnancy loss and
  • 06:37confirmed inherited thrombophilias
  • 06:39to prevent pregnancy loss.
  • 06:41And so this also speaks to,
  • 06:44not against,
  • 06:45the routine testing for inherited
  • 06:48thrombophilia in women with
  • 06:50recurrent pregnancy loss.
  • 06:52So that is the first abstract.
  • 06:54The second abstract will focus on
  • 06:56sickle cell disease, diarrhea,
  • 06:58and diminished ovarian reserve.
  • 07:01So second case,
  • 07:02a patient comes to you 12 years old.
  • 07:05She has a history of avascular necrosis
  • 07:08and very rare vasal clusive crises
  • 07:10she presents for initial visit.
  • 07:12During the visit you discussed
  • 07:14the importance of hydroxyurea as
  • 07:16a disease modifying therapy.
  • 07:18She notes that her previous provider
  • 07:20told her she does not require hydroxyurea
  • 07:22therapy due to infrequent basal,
  • 07:24occlusive crises.
  • 07:25But furthermore,
  • 07:26most concern for her is a Facebook,
  • 07:29Facebook group that she's a part of
  • 07:31recommends not taking it for those
  • 07:33who desire to have children in the
  • 07:34future as it leads to infertility.
  • 07:36So there is quite a bit of evidence for
  • 07:40hydroxyurea and fertility in males.
  • 07:42We know that it leads to lower sperm counts.
  • 07:45Which improves with cessation of hydroxyurea.
  • 07:48But we don't have a lot of data
  • 07:50available for the use of hydroxyurea
  • 07:52and diminished ovarian reserve in in
  • 07:54female patients with sickle cell disease.
  • 07:57And so from the evidence that we do have,
  • 07:59we do know that patients with sickle
  • 08:01cell disease have a higher rate of
  • 08:04diminished ovarian reserve compared
  • 08:05to those who are age and age,
  • 08:07race and sex match to to patients
  • 08:10with sickle cell disease,
  • 08:12there is much more of a sharper
  • 08:14trajectory of decline.
  • 08:15Of diminished ovarian reserve.
  • 08:17And the thought is that this is and
  • 08:20it was a theory again it had not
  • 08:22previously been proven.
  • 08:23The thought is that this is related to
  • 08:26hemolysis and anemia based occlusion.
  • 08:28Basically any organ that can be
  • 08:30affected by sickle cell disease,
  • 08:32which is every organ in the body,
  • 08:33the ovaries included, can.
  • 08:35This can all lead to
  • 08:37diminished ovarian reserve.
  • 08:39And one thing that we don't know
  • 08:41is that is hydroxy hydroxyurea,
  • 08:43is it a friend or a foe?
  • 08:45So we know that hydroxyurea causes.
  • 08:48Reduction and disease severity.
  • 08:50So in theory it should be preventing this
  • 08:53accelerated age-related loss of eggs,
  • 08:56but does it actually also contribute to
  • 08:59the accelerated age-related loss of eggs?
  • 09:02And that is the question that
  • 09:04we don't know the answer to.
  • 09:06And so this study was actually
  • 09:08this is a background study.
  • 09:10So this was done from the MULTICENTRIC
  • 09:13study of hydroxyurea and it was
  • 09:16the pivotal trial that showed the
  • 09:18benefits of hydroxyurea in patients
  • 09:21to present to prevent organ damage.
  • 09:23And what this shows here is that
  • 09:25you can see at every age level
  • 09:28starting from 20 to 25,
  • 09:30we see that there's an age associated decline
  • 09:33in the AM H level which is a marker of.
  • 09:36Administration ovarian reserve when the MH
  • 09:38level is less than 1.1 nanograms per ML.
  • 09:41This contributes to the definition
  • 09:42of diminished ovarian reserve.
  • 09:44The dark lines here are the median
  • 09:46age control match ADH levels and
  • 09:48the the the Gray boxes here these
  • 09:50are patients with sickle cell.
  • 09:52So we see even at age 20 to 25 years old,
  • 09:56there is lower a MH levels compared
  • 09:59to the controls and it's not until
  • 10:01age 40 to 46 where we see that
  • 10:04the controls as well as patients.
  • 10:06Sickle cell disease both have
  • 10:09AMH levels of less than 1.1.
  • 10:13And so we what do we know?
  • 10:15We know that patients with sickle cell
  • 10:18have higher rates of diminished ovarian
  • 10:20reserve at least starting 25 to 30 years old.
  • 10:23The relationship between diminished
  • 10:24ovarian reserve and pregnancy
  • 10:26outcomes and live births in sickle
  • 10:27cell does require further study
  • 10:29because that doesn't answer the
  • 10:30question we don't have an answer to.
  • 10:32But the data regarding venata toxicity
  • 10:34in women with sickle cell disease who
  • 10:37are taking hydroxyurea is limited,
  • 10:39and it's thought that hydroxyurea
  • 10:41use might be a surrogate.
  • 10:43The disease severity rather than
  • 10:45the hydroxyurea itself causing
  • 10:47diminished ovarian reserve.
  • 10:49And so this is an next abstract and
  • 10:52their study aimed to assess this
  • 10:55does hydroxyurea and does basal
  • 10:58occlusive crises cause diminished
  • 11:01ovarian follicle density?
  • 11:03And in girls and young females
  • 11:06with sickle cell disease?
  • 11:07And so this study,
  • 11:09it was designed 88 patients with
  • 11:11hemoglobin s s genotype underwent
  • 11:13ovarian tissue cryopreservation
  • 11:15prior to stem cell transplant.
  • 11:17Ovarian tissue was evaluated
  • 11:19histologically by two independent
  • 11:22investigators and the primary
  • 11:23outcome was ovarian follicle density
  • 11:26and here are the characteristics.
  • 11:28So most of the patients had
  • 11:30not reached puberty.
  • 11:31Puberty of 45% were treated with hydroxyurea
  • 11:34with a median dose of 23 milligrams.
  • 11:37It's per kilogram and the
  • 11:39vast majority of patients did
  • 11:41report vasal clusive crisis.
  • 11:43Of those patients who had vasoactive crisis,
  • 11:4649% were on hydroxyurea.
  • 11:4894% of patients receive pack red
  • 11:51blood cell transfusion at some point
  • 11:53with the median applied units of 22.
  • 11:56And so the outcome of the study showed
  • 11:58that the follicle density was similar
  • 12:00in the hydroxyurea group compared to
  • 12:02those without hydroxyurea exposure.
  • 12:04But for the first time,
  • 12:06a study did show that the follicle density
  • 12:08was significantly higher in patients
  • 12:10who did not have vasal occlusive crisis.
  • 12:12And so this suggests that it's
  • 12:15actually the disease itself rather
  • 12:17than hydroxyurea that is leading
  • 12:19to diminished ovarian reserve.
  • 12:21And so the conclusions of this
  • 12:23study as as I said,
  • 12:25were the hydroxyurea exposure did not
  • 12:27appear to reduce cortical follicle density
  • 12:30in females with sickle cell disease.
  • 12:32And for the first time,
  • 12:33the study could show an influence
  • 12:35of VOC on ovarian follicle density,
  • 12:38possibly related to reduced blood flow and
  • 12:40all the effects of sickle cell disease.
  • 12:42What we don't know is what.
  • 12:46What the?
  • 12:47Ovarian follicle density would look
  • 12:49like in a patient who has been on
  • 12:52hydroxyurea for a much longer duration,
  • 12:55because the median age of the patients
  • 12:58in this study was nine years old.
  • 13:01And the evidence that we have for
  • 13:03diminished ovarian reserve and
  • 13:04patients with sickle cell really
  • 13:06starts at age between 20 and 25,
  • 13:08that multicenter study of hydroxyurea
  • 13:10that I showed you previously.
  • 13:14And lastly, longitudinal data are
  • 13:16needed to evaluate if genotype and
  • 13:19severity of disease accelerate
  • 13:21diminished ovarian reserve.
  • 13:22Thank you and that's it.
  • 13:30It is a pleasure to follow Doctor Vandoren,
  • 13:33and so I will take over the screen sharing.
  • 13:39Beautiful. Good afternoon, everyone.
  • 13:42Thank you for joining.
  • 13:43My name is George Joshua.
  • 13:44I am an assistant professor of
  • 13:47medicine and hematology here at Yale,
  • 13:48and I'm the Pi for a quantitative
  • 13:52decision sign and some lab.
  • 13:55So without further ado,
  • 13:56let's talk about 3 hard hitting abstracts.
  • 13:59I have no disclosures.
  • 14:01The first, we're gonna go and talk
  • 14:03through cold gluten and disease
  • 14:05and immune thrombocytopenia.
  • 14:07We're going to start with all of these,
  • 14:09by the way, our orals,
  • 14:11one of them is a plenary,
  • 14:12as I'll point out in the next talk.
  • 14:14And the last talk will be focused on
  • 14:17a phenomenal study actually done by
  • 14:19a trainee from the Cleveland Clinic.
  • 14:22So talking about patient reported
  • 14:24outcomes 1st and septima abuse and our
  • 14:26patients with cold agglutinin disease.
  • 14:28And so this is the schematic for
  • 14:31cadenza and this is a trial that
  • 14:35focused on transfusion independent
  • 14:37individuals with cold agglutinin disease.
  • 14:41You can see part A and Part B.
  • 14:42Part A has been reported on
  • 14:45previously at this year's Ash,
  • 14:47Alexander Roth and colleagues
  • 14:48reported on Part B,
  • 14:49and so that that is what I'll focus on.
  • 14:52But for anchoring,
  • 14:55part A was a double-blind period of
  • 14:58randomization to sitemap versus placebo.
  • 15:01You see that there's a screening
  • 15:03observation period there of six
  • 15:04weeks leading into that study.
  • 15:06And Part B was then the continuation
  • 15:08of the open label phase component
  • 15:11of patients who are on similar map
  • 15:13on similar mab and patients who are
  • 15:15on placebo going to similar map.
  • 15:17So in the open label extension,
  • 15:19Part B,
  • 15:19all of those patients who completed
  • 15:21part A were eligible then to receive
  • 15:23biweekly doses and this was weight
  • 15:25based as you can see in front of you.
  • 15:27What we'll focus on in the next slide
  • 15:29will be the patient reported outcome
  • 15:30endpoints and there are five of them.
  • 15:34And so the objective here again is to
  • 15:36look at transfusion independent patients.
  • 15:38This is cadenza trial as opposed to
  • 15:41transfusion dependent called gluten
  • 15:42disease patients that would be cardinal.
  • 15:44And the follow up here is immediate
  • 15:46treatment over 99 weeks and the
  • 15:48patient reported outcomes are you
  • 15:49can see them in front of you here,
  • 15:51the facet fatigue, the PGS,
  • 15:53the PG,
  • 15:54I see the 12 item SF12 and I noted
  • 15:56for specific reasons that you'll
  • 15:57see on the next slide what that
  • 16:00includes both physical and mental
  • 16:02component scores and finally
  • 16:03the euroqol visual analog scale.
  • 16:07And here are the baselines and the patient
  • 16:11sample sizes and the mean effects.
  • 16:14And in the right column here I put for
  • 16:16you what the investigators reported
  • 16:18as clinically important changes that
  • 16:19were derived in private prior studies.
  • 16:21So we can actually interpret what
  • 16:24is cleanly clinically meaningful or
  • 16:26potentially clinically meaningful.
  • 16:27So the mean age of these patients
  • 16:30was 6780% of them were women and
  • 16:33you can see the facet fatigue score
  • 16:35with an improvement of 8.8.
  • 16:37Right in the middle there,
  • 16:38with the standard error of 2.1,
  • 16:39you'll note a reported clinically
  • 16:41important change which is
  • 16:43available here is more than five.
  • 16:45You have to think about that in the
  • 16:48context of the standard error now,
  • 16:50the SF 12,
  • 16:51the physical and the mental
  • 16:53cognitive scores as well.
  • 16:54Hit above the report of clinically
  • 16:57important changes with statement lab
  • 16:59use and you'll see an added about 4.9
  • 17:02points for the physical component,
  • 17:044.0 points for the mental component.
  • 17:07And the last piece within the rows you
  • 17:10see the EQ visual analog score scale
  • 17:12again and add an improvement there,
  • 17:15but there is not a study that has
  • 17:17derived invalidated a reported
  • 17:19clinically important change here.
  • 17:21And so that is that's why I put
  • 17:22that as a non applicable.
  • 17:24Now if you look at PGI S&P GIC,
  • 17:27you can see too that for the pgis
  • 17:3031% there was a 31% improvement
  • 17:32in the proportion of patients
  • 17:35reporting nor mild fatigue.
  • 17:36So it more patients by the conclusion of
  • 17:39the study reported no or mild fatigue
  • 17:42and the delta there was from about
  • 17:45mid 40s to mid 70s percentage wise.
  • 17:48And finally the PGIC by the end of
  • 17:51the study 71 of the patients who were
  • 17:53reporting a positive change from the
  • 17:55baseline from where they had started from.
  • 17:57So take home.
  • 17:59So the condenser part BPRO data it
  • 18:02appears that September map demonstrate
  • 18:04can demonstrate benefits that are
  • 18:07associated with its use specifically on
  • 18:09fatigue and overall quality of life.
  • 18:11The benefits appear to maintain for
  • 18:13more than one year and mentioned
  • 18:15median follow up in 99 weeks.
  • 18:17And and this is important patients
  • 18:19previously previously treated with
  • 18:21placebo did demonstrate a brisk
  • 18:24PR O improvement in Part B.
  • 18:26So these are the patients who went from.
  • 18:27Cebu to sitemap so they are able
  • 18:29to catch up to the patients who
  • 18:31had been on sitemap before.
  • 18:35Moving to a plenary,
  • 18:37this is Edgar Tigard and ITP Egard Tiger mod.
  • 18:41Is an IG1 FC fragment and a natural
  • 18:44ligand for the neonatal FC receptor.
  • 18:47It's engineered to competitively
  • 18:49bind to FCRN with a high affinity and
  • 18:52prevent the recycling of endogenous IG,
  • 18:54but it doesn't affect albumin.
  • 18:56This drug has been improved in
  • 18:58myasthenia gravis and here I present
  • 19:00to you the results from advanced 4
  • 19:02which is a phase three multicenter,
  • 19:03double-blind, placebo-controlled RCT.
  • 19:06In patients with immune thrombocytopenia,
  • 19:09generally speaking when we think about
  • 19:11pathogenic autoantibodies and ITP,
  • 19:13we think about increased platelet
  • 19:14clearance as one of the mechanisms
  • 19:16in inhibiting platelet production
  • 19:18and impacting platelet function.
  • 19:19You see all of those listed in a
  • 19:21schematic to the left and then on
  • 19:23the right the the schematic for the
  • 19:26recycling of your endogenous IG and
  • 19:30where F guys taking mod is is acting.
  • 19:35Now for this RCT,
  • 19:36you had to have been an adult,
  • 19:39so at least 18 years of age and to have
  • 19:41chronic or persistent ITP and as a reminder,
  • 19:44chronic ITP,
  • 19:44ITP of duration at 12 months or more,
  • 19:47persistent is 3 to 3 to 12 months.
  • 19:50You have to have two platelet counts
  • 19:52of less than 30,000 during the
  • 19:54screening period and the screening
  • 19:56period lasted 2 weeks for this trial.
  • 19:57And you had to have been on at least
  • 20:00two ITP treatments or one prior
  • 20:02treatment and one concurrent treatment.
  • 20:04Those are the eligibility criteria,
  • 20:06an important point for this trial
  • 20:08that's not listed on the slide because
  • 20:10it was an eligibility criteria.
  • 20:12But once the trial started,
  • 20:13these patients needed to be maintained
  • 20:15on the same dosing of whatever they
  • 20:18were on previously for their IT.
  • 20:20Be without those escalations.
  • 20:22So the treatment period was 24 weeks
  • 20:24and patients were randomized 2 to
  • 20:26one to Edgar Sigma 10 milligrams per
  • 20:29kilogram intravenously versus placebo.
  • 20:31And there was a period as you can see
  • 20:34in front of you here where you could
  • 20:37have those adjustments of I've got taken mod.
  • 20:40At the end of the trial,
  • 20:41as we'll talk about,
  • 20:42there's a follow-up period and more
  • 20:44than 90% went on to enroll in the
  • 20:47Open label extension called Advanced
  • 20:49Plus that is in its early phases now.
  • 20:52These are the baseline characteristics
  • 20:54for these patients.
  • 20:55You can see that they match
  • 20:57up reasonably well.
  • 20:58In particular,
  • 20:59I'll point out The Who bleeding scores
  • 21:02pretty similar across the board patients
  • 21:05with three or more prior ITP therapies,
  • 21:08patients that we technically think
  • 21:09of as quote UN quote refractory.
  • 21:12That's how the trial referred to them
  • 21:14as well and that's about 6 to 7 out
  • 21:17of 10 patients in both arms and to
  • 21:20the concurrent ITP therapy types.
  • 21:22Baseline being utilized, steroids,
  • 21:24tipra,
  • 21:24is,
  • 21:25and other immune suppressants
  • 21:26all reasonably nicely matched,
  • 21:28and so here in this case,
  • 21:30you can see that this random allocation
  • 21:33has probably served its purpose
  • 21:35of controlling for confounding.
  • 21:37The endpoints here are the
  • 21:39here's the primary endpoint and
  • 21:41also key secondary endpoints all
  • 21:42to say that all platelets specific
  • 21:45secondary endpoints were met.
  • 21:46The primary endpoint was the proportion
  • 21:49of patients with a sustained count
  • 21:51response and as typical in ITP literature,
  • 21:53this was defined as a platelet count
  • 21:56of 50,000 or more and in this case on
  • 21:58at least four out of 6 clinic visits
  • 22:01during the conclusion of this period,
  • 22:03in this case weeks 19 through 24,
  • 22:06of course in the absence of ITP.
  • 22:07Others and then key secondary endpoints
  • 22:09include cumulative weeks of Disease Control,
  • 22:11so just the number of weeks
  • 22:13of Disease Control,
  • 22:14something called sustained
  • 22:15platelet count response.
  • 22:17And the durable sustained platelet count
  • 22:19response which is just extending that
  • 22:21risk exposure period out to week 17.
  • 22:24And so there's a significance on the
  • 22:26platelet count and all of these the
  • 22:28take homes from this plenary abstract
  • 22:30whereas that lowering total IG levels
  • 22:32by targeting the neonatal FC receptor
  • 22:34appears to demonstrate statistically
  • 22:35significant improvements in primary
  • 22:37and secondary platelet endpoints.
  • 22:39The drug also appears to be well tolerated
  • 22:42without new safety signals that did not
  • 22:44have an opportunity to include that here.
  • 22:47But most adverse adverse events were
  • 22:49reported as quote mild to moderate.
  • 22:51And finally the open label extension
  • 22:54period is ongoing currently.
  • 22:56Now to wrap up this little portion with
  • 22:58a third abstract from the Cleveland
  • 23:01Clinic of 300 plus consecutive patients
  • 23:04treated with splenectomy for a variety
  • 23:06of different immune cytopenias.
  • 23:08So the investigators here wanted to
  • 23:10identify whether they could isolate
  • 23:12risk factors that could potentially
  • 23:14predict response to splenectomy and
  • 23:16adult patients with immune cytopenias.
  • 23:18On the right,
  • 23:19you see a schematic of total splenectomy
  • 23:22cases that they reviewed over the
  • 23:23course of 20 years from 2000 to 2020.
  • 23:26And here you had 1800 patients.
  • 23:28There was a bunch of patients excluded
  • 23:30as they were trying to hone in on
  • 23:32cytopenias and then ultimately
  • 23:33on immune cytopenias.
  • 23:35And at the very bottom I circled
  • 23:36for urine red.
  • 23:37You can see what the diagnosis
  • 23:39were that they considered ITP,
  • 23:41autoimmune hemolytic anemia,
  • 23:42Evans syndrome and autoimmune neutropenia,
  • 23:44neutropenia in general.
  • 23:46This was a retrospective study,
  • 23:49339 patients and the majority were
  • 23:53ITP and autoimmune hemolytic anemia.
  • 23:55Their results are are a little bit
  • 23:57remarkable even for the fact that
  • 23:59this is retrospective study and here
  • 24:01you can see ITP autoimmune hemolytic
  • 24:03anemia and autoimmune neutropenia
  • 24:05at the very least being presented
  • 24:07and simple pie charts for having
  • 24:09complete versus partial versus no
  • 24:11responses to splenectomy.
  • 24:13And at the bottom you actually also see how
  • 24:15fast those responses occurred in weeks.
  • 24:17The overall response for all patients
  • 24:20with 74% complete response rate of
  • 24:2286 and a partial response of 14%.
  • 24:25In these patients,
  • 24:27but perhaps the bigger take home
  • 24:29point was the following.
  • 24:31And one out of five cases there
  • 24:33was a discordant diagnosis from
  • 24:35pre to post operation on the left.
  • 24:37In the left column you see
  • 24:39the splenectomy indication.
  • 24:40In the middle you see what the
  • 24:42actual postoperative pathologic
  • 24:44diagnosis was and the frequency of this
  • 24:46occurring in total to be exactly was 19%.
  • 24:49So 19% of patients were discordant
  • 24:51from pre to post operative
  • 24:53diagnosis again in these 300.
  • 24:56Ask consecutively treated patients
  • 24:57over the course of 2000 to 2020
  • 25:00twenty years in the Cleveland Clinic.
  • 25:02And to wrap up with one final take
  • 25:05home is the investigators did try
  • 25:07to isolate the risk factors that
  • 25:10could predict response versus not
  • 25:13predict response and these are being
  • 25:15parsed out further as I understand
  • 25:17in the actual manuscript that's
  • 25:18being written up and probably
  • 25:20published in the next 6 to 12 months.
  • 25:21But the big take home points here,
  • 25:23most of these are crossing
  • 25:25your odds ratio of 1,
  • 25:27but you'll see that young age in particular
  • 25:30age less than 40 years seem to predict.
  • 25:33Their response to splenectomy as
  • 25:34well as primary ITP also seemed to
  • 25:37predict for favorable response to
  • 25:39splenectomy on the converse side of it,
  • 25:42requiring multiple therapies predicted
  • 25:44for poor response to splenectomy.
  • 25:47So take homes.
  • 25:48From the studies that splenectomy
  • 25:49remains a valuable option,
  • 25:51specifically in patients whose values
  • 25:53and preferences align with surgery.
  • 25:55And there's a surprisingly high proportion,
  • 25:58one out of five that had an added value of
  • 26:02the diagnostic component in their course.
  • 26:06And so with that,
  • 26:08I want to say thank you and I'm going
  • 26:10to transition over to Doctor Sharda.
  • 26:20Thank you, George.
  • 26:24I have nothing to disclose as well.
  • 26:26I will mostly be concentrating on
  • 26:30some abstracts, interesting abstracts
  • 26:32in the thrombosis realm and mostly
  • 26:36cancer associated thrombosis.
  • 26:38The first one is the the catheter three
  • 26:41study which was a prospective study of
  • 26:44apixaban for central venous catheter,
  • 26:47associated upper extremity,
  • 26:49venous thromboembolism and cancer patients.
  • 26:52And this was, this comes from at
  • 26:55least three senators in Canada.
  • 26:58So this was a a multi center
  • 27:02prospective cohort study.
  • 27:07In patients with CVC associated upper
  • 27:11extremity DVT they were treated with.
  • 27:15On a low molecular weight heparin
  • 27:17dalteparin in their case for seven days
  • 27:20followed by a full dose of apixaban for
  • 27:2211 weeks and and and the patients were
  • 27:25followed for for at least 12 weeks.
  • 27:28The inclusion criteria was all adults
  • 27:31with with active malignancy and
  • 27:34and clinically significant that is
  • 27:36symptomatic upper extremity DVT in
  • 27:39association with the counter a CVC
  • 27:41and the main exclusion criteria were.
  • 27:44Patients with active bleeding or clip
  • 27:47bits less than 75 or a need for dual
  • 27:51antiplatelet therapy as well as most
  • 27:53of the patients with hematologic
  • 27:56malignancies or planned for stem cell
  • 27:58transplant as well as pulmonary embolism
  • 28:01with only with hemodynamic instability.
  • 28:08The primary outcome was catheter survival
  • 28:11at three months and the secondary
  • 28:14outcomes were any types of symptomatic
  • 28:17recurrent venous thromboembolism as
  • 28:20well as bleeding both major as well
  • 28:23as clinically relevant non major
  • 28:25bleeds and deaths from any causes.
  • 28:27Umm, so here on the the
  • 28:33patients demographics here,
  • 28:35the 70 patients from 3 senators
  • 28:38majority were female, about 60%.
  • 28:40Median age 62.
  • 28:44The diagnostic modality used
  • 28:46in most patients were Doppler
  • 28:49ultrasounds and as you can see
  • 28:51these are symptomatic events.
  • 28:52So almost 75% of the patients
  • 28:55actually have proximal upper
  • 28:57extremity DVT involving subclavian,
  • 29:00at least subclavian veins.
  • 29:05And this is perhaps slightly
  • 29:06different from our practice,
  • 29:08so about 80% of the patients.
  • 29:09So these were mostly outpatient.
  • 29:12The patients being treated outpatients
  • 29:14and and about 80% of them had picks
  • 29:17and only 20% had portacaths and as
  • 29:20you can see the type of cancer about
  • 29:23a third were breast and a third were
  • 29:26colon and the remaining were others.
  • 29:28So coming to the primary outcome,
  • 29:30so catheter survival so adds 12 weeks,
  • 29:3440 patients had so which is about 5760%
  • 29:39had catheter still present and functioning.
  • 29:45But if you can see the reason for removal
  • 29:49actually most of the patients who had
  • 29:52it removed was because of end of the
  • 29:55therapeutic need which is about 20.
  • 29:57One patients or 30% and then a minor
  • 30:00proportion of the patients with
  • 30:02with other reasons which is you know
  • 30:05infection or two patients died and
  • 30:07there were no recurrent events and so.
  • 30:11If you consider.
  • 30:14Or exclude the end of therapeutic needs.
  • 30:16The the catheter survival was
  • 30:18almost 100% with the pixman therapy.
  • 30:22The safety outcomes only one patient
  • 30:24had a recurrent DVT and the same arm,
  • 30:27and even in this patient the the line
  • 30:30was not removed and was a functional.
  • 30:33There were twelve bleeds,
  • 30:36six major and six minor bleeds
  • 30:40and most happened within the first
  • 30:43two months of of treatment.
  • 30:45There were two deaths and they were
  • 30:47both delayed and and cancer related.
  • 30:51So limitations of course it's a single
  • 30:55arm and most of the patients were
  • 30:58outpatients and so perhaps not as ill
  • 31:01and with the limited follow but but
  • 31:03I I guess for our our practice many
  • 31:06of these or most of these patients
  • 31:09actually had picks our patient
  • 31:11as compared to a Porter cats.
  • 31:13So the conclusions were that the
  • 31:16pixabaj should promise in treating
  • 31:18central venous catheter associated
  • 31:21upper extremity DVT.
  • 31:22And the observed bleeding rates
  • 31:25were lower than as previously
  • 31:27described with rivaroxaban.
  • 31:30And so here are the the other two studies.
  • 31:35Done previously by the same group.
  • 31:36So the first one was the catheter
  • 31:39study which was low molecular
  • 31:41weight heparin followed by widening
  • 31:43the antagonist and then the more
  • 31:45recent one was a catheter 2 which
  • 31:48was River rockband without a lead
  • 31:50in with the loonie weight heparin.
  • 31:52And here as you can see there are
  • 31:54a lot more bleeds and then the the
  • 31:57the current bonus the dalteparin
  • 31:58followed by Pixar ban with perhaps
  • 32:01with less Pittsburgh.
  • 32:02I think the most important point is that in.
  • 32:05In most of these patients,
  • 32:07despite proximal and symptomatic
  • 32:10upper extremity DVT's are the lines
  • 32:14were not removed and and were not
  • 32:18associated with infusion failure and
  • 32:20and the lines were were were able
  • 32:22to be saved with anticoagulation.
  • 32:27So coming to the second one which
  • 32:30is abstract #519 and
  • 32:35the title of the abstract is only
  • 32:37dynamics of C reactive protein to
  • 32:39predict risk of venous thromboembolism
  • 32:41in patients with cancer treated
  • 32:43with immune checkpoint inhibitors.
  • 32:45And this comes from Austria, Vienna,
  • 32:49Austria. So just to be quick,
  • 32:54because I'm an embolism.
  • 32:57Is being recognized as a major complication
  • 33:01of immune checkpoint inhibitor therapy.
  • 33:04The rates have been described as
  • 33:06high as 25% but the the prothrombin
  • 33:09prothrombotic effect is the these
  • 33:12immune checkpoint inhibitors as
  • 33:14well as the the the risk factors are
  • 33:18unclear because the risk factors,
  • 33:20the traditional risk factors and the
  • 33:22scoring system such as the KORANA score,
  • 33:24they do not function as well.
  • 33:27In the setting of checkpoint inhibitors.
  • 33:31So basically the goal of the study was
  • 33:33to explore early dynamics of systemic
  • 33:35CRP levels after initiation of the immune
  • 33:38checkpoint habits for prediction of
  • 33:40venous thromboembolism in these patients.
  • 33:44And why CRP?
  • 33:47Because CRP has been shown to be a
  • 33:51predictor of poorer outcome or higher
  • 33:54designed CRP as well as a CRP response.
  • 33:58CRP Flair has been associated with
  • 34:01poor outcomes in these patients.
  • 34:03And and it's well recognized that the
  • 34:07developer systemic antitumoral immune
  • 34:09response associated with a major
  • 34:12inflammatory response in which CRP
  • 34:14has been shown to be a major marker.
  • 34:18Umm. So the methods.
  • 34:21So this was a retrospective cohort
  • 34:24study of about 405 patients.
  • 34:26These were patients with cancer
  • 34:30treated in in in Med UNI Vienna.
  • 34:35The.
  • 34:37The follow-up was at least for the
  • 34:39duration of IC ICI therapy until
  • 34:42subsequent anti cancer therapy
  • 34:44death or a maximum of three months
  • 34:47of the last cycle of the immune
  • 34:50checkpoint inhibitor therapy and
  • 34:52and the endpoints were DTE.
  • 34:57That were mostly pulmonary embolism and DVT,
  • 35:00but also recorded for splanchnic,
  • 35:02venous thrombosis,
  • 35:04catheter related thrombosis
  • 35:06and other other events.
  • 35:09In terms of the CRP dynamics,
  • 35:11the CRP was measured at baseline
  • 35:14that is within the four weeks,
  • 35:16within four weeks prior to
  • 35:18institution of this therapy and then
  • 35:21it was longitudinally monitored
  • 35:23for the first three months after
  • 35:26the initiation of the therapy.
  • 35:28And for the purpose of this study
  • 35:30this the the CRP dynamics were
  • 35:33defined either as CRP flare which
  • 35:36is increase in the CRP by by.
  • 35:39At least 2.5 fold over the baseline
  • 35:43or a CRP response which was 50%
  • 35:46relative decrease from the baseline.
  • 35:50Um.
  • 35:53So the most important in terms of the
  • 35:57cohort demographics is that most of
  • 35:59the patients were staged for malignancies.
  • 36:04Of of a variety of types,
  • 36:07mostly therapies where are cancers
  • 36:10known to be known to respond to to
  • 36:14immune checkpoint inhibitors and then
  • 36:17many of the patients had received or
  • 36:20seen multiple lines of therapies.
  • 36:24The the median follow up for the
  • 36:27study for was about 8.5 months.
  • 36:31Umm, so, so defining CRP flare.
  • 36:36So among the 405 patients,
  • 36:4070% had a CRP flare,
  • 36:41which is again a rise in CRP of greater
  • 36:45than 2.5 folds over the baseline.
  • 36:49And then there, so let me so in
  • 36:55terms of the different a definition,
  • 36:58so basically some 78 to 80% had the
  • 37:03CRP flare and then about a third had
  • 37:06CRP response which is drop in CRP.
  • 37:11Either after a flare or in about um.
  • 37:1714% of the patients without a flare
  • 37:19to to less than 50% of the baseline
  • 37:23and then about 1/3 of the patients
  • 37:26did not or were non responders which,
  • 37:28which is their CRP,
  • 37:31did not reduce to 50% of the baseline.
  • 37:37And then based on the CRP dynamics,
  • 37:41the the the authors found that the risk
  • 37:44of DVT E the cumulative risk of DVT
  • 37:48was about 3.5 fold in in patients who
  • 37:53had a CRP flare irrespective of of.
  • 38:00A response or not?
  • 38:04More importantly,
  • 38:05they also found that the the risk of
  • 38:08DVT was associated with an increase
  • 38:11mortality according to the CRP flare.
  • 38:14So the hazard ratio for death after VE
  • 38:17Justed for cancer type was about 3.5
  • 38:20fold in patients with CRV CRV flare
  • 38:23and then adjusted for the stage of
  • 38:26the cancer was 3.21 fold again. Um.
  • 38:35In patients with with their CRP flare.
  • 38:40So the conclusions were that's the early
  • 38:44dynamics of systemic CRP levels are
  • 38:47associated with the risk of VTE during
  • 38:50immune checkpoint inhibitor therapy and
  • 38:53the highest risk of DVT was observed
  • 38:56in patients with early CRP flare after
  • 39:00ICI initiation and then the lowest risk
  • 39:04was in patients where the CRP drop.
  • 39:08Dropped below 50% with no prior flare,
  • 39:10but this was a very small proportion
  • 39:14of patients about 12 to 14%.
  • 39:16And then they also found a potential risk,
  • 39:19a link between immune checkpoint inhibitor
  • 39:22induced systemic inflammatory response
  • 39:24and risk of CTE in in addition to an
  • 39:28independent association of of Vt with
  • 39:30mortality in patients who have a CRP flair.
  • 39:34So I think with this I'll end.
  • 39:44Well, that's great.
  • 39:45Thank you all for those
  • 39:46great presentations.
  • 39:47So thanks so much.
  • 39:49I if people have questions,
  • 39:51please put them in the Q&A or
  • 39:53the chat and while we're waiting
  • 39:55for them to come in perhaps
  • 39:58some I can start with a few.
  • 40:02If Doctor Van Doren is still on,
  • 40:04and I know she might have
  • 40:05had to go into clinic,
  • 40:06looks like she did step off.
  • 40:07So George, I I have a question for you.
  • 40:11In the study with Subtitle MIB
  • 40:15and cold agglutinin disease,
  • 40:17you noted that there was an increase
  • 40:20in patient reported outcomes.
  • 40:23Quality of life improved despite
  • 40:25the fact that these individuals
  • 40:28did not require blood transfusions.
  • 40:30Could you postulate on why they
  • 40:32may have had this improvement?
  • 40:34In the way they felt without having
  • 40:36a need for blood transfusion.
  • 40:39Thank you, Bob. Such a great question.
  • 40:42There's a thud in the
  • 40:44hemolytic community in general,
  • 40:46both in autoimmune hemolytic anemia and PNH
  • 40:48and other disorders where we see hemolysis,
  • 40:50that quality of life is affected by the
  • 40:53hemolysis independent of hemoglobin as well,
  • 40:55in addition to hemoglobin drops and
  • 40:58low hemoglobin hemoglobin levels.
  • 41:00The idea being that in
  • 41:02a chronically hemolytic,
  • 41:03in a chronic hemolytic stage,
  • 41:05you have an underlying degree
  • 41:06of inflammation.
  • 41:07At least that's the theory that's
  • 41:09being posited that's contributing
  • 41:10perhaps to this fatigue and
  • 41:11the idea being that if we can.
  • 41:13Shut down the hemolysis or maybe let's
  • 41:16say decrease it with ages like symbolab,
  • 41:20the monoclonal C1S antibody for cold
  • 41:23agglutinin disease or anti C3 and C5
  • 41:26therapies for example in pH that we
  • 41:28can further improve quality of life.
  • 41:30And I think this also underscores
  • 41:32too that umm, you know,
  • 41:34we we focus a lot in the past on
  • 41:36these hard outcomes which are of
  • 41:38course important like hemoglobin,
  • 41:39but there's an additional component
  • 41:42to quality of life.
  • 41:43Beyond that now that is difficult
  • 41:45to capture and I think that the
  • 41:47investigators could have done a
  • 41:48better job honestly with similar
  • 41:50map and in fact most of phase three
  • 41:52investigations currently looking
  • 41:53at quality of life use patient
  • 41:56reported outcomes which is good.
  • 41:58But most of the times they're not
  • 42:00validated externally validated.
  • 42:01And the one for sure surefire
  • 42:04way to robustly look at these,
  • 42:06although that takes a little bit
  • 42:09more money and effort is to actually
  • 42:11measure quality of life directly.
  • 42:14With direct patient interviews,
  • 42:15that that's a conversation for another time.
  • 42:18But that's a conversation I have had
  • 42:20with colleagues in the BMT space
  • 42:22and other spaces who want to truly
  • 42:23capture the quality of life beyond,
  • 42:25let's say like just the questionnaire stuff,
  • 42:2712 or whatever it is.
  • 42:29That's great. Thanks, George.
  • 42:30I wonder if some of that could
  • 42:32be applied to individuals who
  • 42:34have non transfusion dependent
  • 42:36thalassemia as well who have fatigue.
  • 42:38That's really fascinating. Yeah.
  • 42:41Anish, I I have a question for you if I may.
  • 42:43So the the last abstract you presented
  • 42:46with CRP and immune checkpoint inhibitors.
  • 42:49You know, obviously if we were
  • 42:53to intervene with prophylaxis,
  • 42:55measuring CRP's would be.
  • 42:59It would be too late in a sense,
  • 43:01so you couldn't measure the
  • 43:04CRP and then intervene with.
  • 43:07With anticoagulant because
  • 43:08it would be after the fact.
  • 43:10So my question is,
  • 43:11are the CRP changes similar
  • 43:13from cycle to cycle?
  • 43:15So can you use a cycle of CRP and
  • 43:18anticipate that in the next cycle
  • 43:20of immune checkpoint inhibitors
  • 43:22that change in CRP will be the same?
  • 43:28I think it's a very good question.
  • 43:32You know, if the majority of the patients,
  • 43:35about 7080% had a CRP flare and so my.
  • 43:43And and so and.
  • 43:45These were the group with.
  • 43:47With irrespective of whether
  • 43:50they had a response,
  • 43:52you know and you know they halved their
  • 43:56CRP irrespective of that they were
  • 43:59they were at high risk for for events and so.
  • 44:03Although it's a very interesting observation,
  • 44:08and you know this question comes,
  • 44:10it's coming up more and more.
  • 44:13It's it's again you know 80% of the of the
  • 44:16patients who are at risk and so it's it's.
  • 44:19It's again a major, it's a.
  • 44:24It I think the this whole,
  • 44:26this whole, you know,
  • 44:28CRP as a marker of inflammatory response.
  • 44:33As a marker for VTE in these patients
  • 44:36in this group will have to be refined
  • 44:38a little more just because you know
  • 44:41they're just the 80% eighty 85% of
  • 44:43the patients are at they're claiming
  • 44:46or at high risk which does not really
  • 44:48help us that much if I didn't answer
  • 44:52your question directly but that's
  • 44:53what came to my mind and like you
  • 44:55know again yes it's interesting but
  • 44:56it's you know you're you're telling
  • 44:58me that most of the patients are
  • 45:00at high risk so so you know
  • 45:03so there's a.
  • 45:03Question that came in the chat,
  • 45:05the question and answer extending
  • 45:07this and the the question was are
  • 45:10there recommendations that do CRP
  • 45:13levels prior to immunotherapy and
  • 45:15then monitor them on a monthly
  • 45:17basis and is there any role at
  • 45:19this point for prophylaxis and the
  • 45:21individual asking us about aspirin?
  • 45:24I think this was
  • 45:24a question that was asked at the
  • 45:27meeting as well and and there are none.
  • 45:30I'm not sure that our, you know,
  • 45:33what the European practice is,
  • 45:34but I don't think that it's been,
  • 45:36you know, done. It's such a.
  • 45:39Such a, you know, such a nonspecific,
  • 45:43you know, test among everything else
  • 45:45that has been happening and being done.
  • 45:47And I'm I'm not sure that
  • 45:50it's being routinely done. So.
  • 45:54The question of prophylaxis,
  • 45:56I think that there are.
  • 45:58There are um I, I,
  • 46:02I it's it's hypothesis hypothesis
  • 46:04generating and it's I wonder if
  • 46:06it's you know if these group of
  • 46:09patients should be separately sort
  • 46:11of included in all the prophylaxis
  • 46:13trials that are that are being
  • 46:15you know undertaken and and and
  • 46:18perhaps a more correlation you know.
  • 46:22Those those types of studies be done
  • 46:23including CRP and other markers.
  • 46:25Yeah, this is fascinating.
  • 46:26A lot of area for research for sure.
  • 46:29I'm George, I I had a
  • 46:31question for you as well.
  • 46:33In your study where or in the study
  • 46:36you reviewed where a splenectomy was
  • 46:40performed for immune cytopenias,
  • 46:42you noted that I think about 20% of the
  • 46:44patients and new diagnosis was made.
  • 46:46So an additional diagnosis as
  • 46:49presumably potentially A cause
  • 46:51for the immune cytopenia and I'm
  • 46:54wondering if the dates what the
  • 46:56dates of the of the study?
  • 46:59We're done.
  • 46:59And in particular I'm thinking
  • 47:01that with modern techniques of
  • 47:03flow cytometry and molecular
  • 47:05studies on the peripheral blood,
  • 47:07would we still expect to see that
  • 47:10high rate of an additional diagnosis
  • 47:12made before a splenectomy is done?
  • 47:15It's such a good question, Bob.
  • 47:17This abstract I think caught
  • 47:19a lot of people off guard,
  • 47:20especially because and of course
  • 47:22all of these are oralists,
  • 47:23but especially because this
  • 47:25was a retrospective analysis.
  • 47:26So usually don't expect such a hard hitting.
  • 47:29Opponent because again these
  • 47:31are consecutively treated
  • 47:32patients with splenectomy.
  • 47:34The years were 2002, 2020,
  • 47:36the median follow up they did not report on,
  • 47:38but as I was in touch with investigators
  • 47:40they noted that they're tabulating
  • 47:42it as they're putting together
  • 47:43their manuscript now because I was
  • 47:45curious you know how many years
  • 47:46since also what was not reported
  • 47:49and what they're looking at and the
  • 47:52question that had asked was are these
  • 47:54diagnostic changes and they were,
  • 47:56I should just clarify too that
  • 47:57investigators are calling them changes.
  • 47:59So not only the fact was
  • 48:02that initial indication not.
  • 48:05They're calling the initial
  • 48:06indication is incorrect,
  • 48:07meaning that the entire diagnosis
  • 48:09was switched to the postoperative
  • 48:11diagnosis as opposed to being added on,
  • 48:13which is interesting.
  • 48:14And so when I asked about.
  • 48:17Whether this was time variant or not,
  • 48:18meaning that like let's say in the 2000s,
  • 48:212005 period,
  • 48:22is that where we're catching all of
  • 48:24those 20% or is it mostly kind of
  • 48:25kind of the same across the board?
  • 48:28They weren't able to answer that
  • 48:29question only to say that it
  • 48:31appeared that there is not like
  • 48:33a huge spike in the early data,
  • 48:35although it might be a little bit
  • 48:37less moving forward it seems like,
  • 48:39and we'll see what the manuscript shows.
  • 48:40I won't speculate beyond that,
  • 48:42but it seems like these misdiagnoses
  • 48:44may still be happening.
  • 48:45And again,
  • 48:46I mean the Cleveland Clinic
  • 48:47is a fantastic health system.
  • 48:48And so if this is indeed accurate
  • 48:50and if this is what they ultimately
  • 48:52end up reporting,
  • 48:53I think this is something that we all
  • 48:54have to pay attention to because if
  • 48:56this is happening in the Cleveland Clinic,
  • 48:58then I don't think we're immune to that
  • 49:00either here at Yale or anywhere else.
  • 49:01Yeah, that's really fascinating, George.
  • 49:03So diseases that are really truly
  • 49:05isolated to the spleen at least
  • 49:08by our current techniques to
  • 49:09to discover them in the blood,
  • 49:10yeah, that's that is fascinating.
  • 49:13And Anish and if I may,
  • 49:15your catheter ohso so another.
  • 49:18So another question came in,
  • 49:19this is for you Anish.
  • 49:21So many factors affect the CRP
  • 49:23level and how do you know the CRP
  • 49:26elevation is due to the immune
  • 49:28checkpoint inhibitor or infection?
  • 49:31That developed afterwards perhaps.
  • 49:33Yeah, it's a very good question.
  • 49:34I mean it's just such a nonspecific
  • 49:36marker but but there's something
  • 49:38about it because you know it's a,
  • 49:39it's a significant rise and it's a
  • 49:42although it's a retrospectively done study,
  • 49:44but it's a cohort and.
  • 49:49And there there is clearly a pattern that
  • 49:52has been previously recognized as well.
  • 49:55So one of the citations
  • 49:57that had looked into CRP,
  • 49:59I don't know how you know well they
  • 50:01they can adjust for other things.
  • 50:03I mean these are patients with
  • 50:05systemic you know metastatic
  • 50:06malignancies and but they even
  • 50:09previously when when they had reported.
  • 50:15CRP Flair and and mortality or poor
  • 50:18outcomes they they they it was a similar
  • 50:21kind of dynamic so that it had been
  • 50:25recognized and and so it's a good question,
  • 50:28but it's such a such a nonspecific marker.
  • 50:31OK, thank you. And George,
  • 50:34if we can go back to you for a minute,
  • 50:35the the the amide trial.
  • 50:41Fascinating drug.
  • 50:42And I assume that there is a
  • 50:44potential that this could be used
  • 50:47in any autoimmune disease where
  • 50:49IG is felt to be the culprit.
  • 50:51Is that how you're thinking
  • 50:52about this as well?
  • 50:54Well, I'll say that's how the
  • 50:55pharmaceutical company is thinking about it.
  • 50:58Because I've had a I've had
  • 51:00a conversation with them.
  • 51:02Yeah. So it was approved this,
  • 51:05this drug was approved for my
  • 51:07senior Gravis just last year.
  • 51:08They're looking at it and they
  • 51:10have obviously, as I presented,
  • 51:11have looked at it and ITP.
  • 51:12But I know that they're really
  • 51:14excited about the whole host of neuro
  • 51:17autoimmune disorders that are out there.
  • 51:19And if it works and if it's successful,
  • 51:22you can make an argument that
  • 51:25this kind of mechanism could then
  • 51:27theoretically help with any disease
  • 51:29that has this pathologic auto antibody.
  • 51:32Component or at least it's worth
  • 51:34testing in any disease like that,
  • 51:36especially if they ultimately go on
  • 51:38to prove that the safety profile
  • 51:39is what they claim it to be.
  • 51:41Because as we've seen with other drugs,
  • 51:43even phase two or phase three studies
  • 51:44sometimes are not enough, right.
  • 51:46When you post marketing surveillance
  • 51:47phase four studies to really see
  • 51:49an effect across rare diseases,
  • 51:50presumably they're going to be
  • 51:51looking at a lot of rare diseases,
  • 51:53this autoimmune, neurological space.
  • 51:56So yeah,
  • 51:57I think there's a good amount
  • 51:58of excitement with it.
  • 51:58I'm curious to see what happens
  • 52:01going forward, but.
  • 52:02I do expect that we're going to
  • 52:03see a dozen plus trials within next
  • 52:0610 years in a bunch of autoimmune
  • 52:08mediated disorders with this mechanism.
  • 52:12And then presumably since B cells and plasma
  • 52:14cells are not being affected directly,
  • 52:16the immunosuppression will be
  • 52:18less than with the drug that.
  • 52:21Causes apoptosis or death of B cells present
  • 52:24really good. That's a really good
  • 52:26.1 that I hadn't actually discussed
  • 52:27with with the pharmaceutical company,
  • 52:29but one that makes a lot of sense to me.
  • 52:33The data will tell us, I think.
  • 52:34I think so too. Yeah,
  • 52:36it would be nice, right?
  • 52:37Often we're hoping that this is
  • 52:39going to be like the next big thing.
  • 52:41Hopefully that ends up actually
  • 52:42being the case here. We'll see.
  • 52:45A doctor Sharda question about
  • 52:46the catheter study, if I may.
  • 52:48I noted that in the catheter three study,
  • 52:51the authors used a low molecular
  • 52:54weight heparin for a week and
  • 52:56then transition to a doac.
  • 52:58Pixabay and that in in the,
  • 53:00in the case of that study,
  • 53:02do you think that's necessary it
  • 53:05seems like that's excessive treatment
  • 53:07quote excessive compared to that?
  • 53:10I was
  • 53:10also surprised to see that.
  • 53:11But I think that to increase
  • 53:14their recruitment they did that.
  • 53:16I think most of us have a bias to I I
  • 53:20know many people tell me like you know,
  • 53:23you want your patient to cool off like with
  • 53:25a heparin and then you know do something.
  • 53:27But it, it's strange, you know,
  • 53:28this is something that someone would do
  • 53:30with say the bigger trend, you know,
  • 53:32because that's what the originally
  • 53:34studies were kind of designed.
  • 53:36But I think this was also to
  • 53:39increase the recruitment.
  • 53:41And so they allowed like 7 days
  • 53:43of of and they made a protocol,
  • 53:45I mean everyone's treated about
  • 53:47seven days of of of Dalteparin,
  • 53:49Romario heparin followed by Pixar lamp,
  • 53:51whereas it didn't do it for rivaroxaban.
  • 53:54OK. And so you don't think the the
  • 53:57issue was people had cancer therefore
  • 53:59they might need a heparin like drug
  • 54:02before they get switched to a doac?
  • 54:04No, I think this is this was done rather
  • 54:06quickly and this was done after you know,
  • 54:08Adobe Saban and others already.
  • 54:11I guess you know, you know the
  • 54:14data was already out there. So
  • 54:15OK great. I think the most most
  • 54:18I think the conclude, the interesting
  • 54:19thing was and this often comes up,
  • 54:21which is what to do with the line I I
  • 54:25liked the fact that these were real
  • 54:28like symptomatic proximal events.
  • 54:30I mean 3/4 of them had subclavian
  • 54:33involves actually many had pulmonary
  • 54:35embolisms to and they were able to save
  • 54:39like like if you combine especially.
  • 54:42The, the the Warfarin trial is from
  • 54:452003 four or something like that
  • 54:46I think it was published in 2006.
  • 54:48But at least if you combine the
  • 54:51rivaroxaban and apixaban you can see
  • 54:53that you know the lines can be can
  • 54:55be saved without really recurrence
  • 54:57or symptoms or post traumatic
  • 55:00syndrome and can be used very safely.
  • 55:03So that's I think is pretty good
  • 55:05data to have.
  • 55:07Just one follow-up question to
  • 55:09you and then we'll we'll end
  • 55:10and there may not be data here.
  • 55:12But so if if you had a patient
  • 55:13who had a symptomatic line
  • 55:15associated thrombus and cancer,
  • 55:17would you start at all with a
  • 55:20low molecular weight heparin
  • 55:21or would you just begin with a
  • 55:24dull ache apixaban, let's say
  • 55:26I would just begin with the,
  • 55:28with the, with the doc.
  • 55:29I mean I was following the
  • 55:30River Rock Seban thing as it is
  • 55:32and now we've been using them,
  • 55:33you know, kind of interchangeably.
  • 55:36So I definitely would just,
  • 55:37you know, pick in the.
  • 55:39Great. OK. Thank you. Well.
  • 55:42And the hour is almost up.
  • 55:43I'd like to thank our speakers.
  • 55:45I these are really great abstracts
  • 55:47you chose to present and they're
  • 55:49some of them are clearly going to be
  • 55:51practice changing I think for all
  • 55:53of us and we're all excited about.
  • 55:55Seeing these new drugs and development
  • 55:57and new ideas brought forth.
  • 55:59So thank you both very much and thank
  • 56:03you to the participants who are here.
  • 56:05We really enjoyed having you
  • 56:07and I hope everyone has a nice
  • 56:09rest of the day and weekend.
  • 56:11Bye, bye now.