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Background Varoglutamstat (formerly PQ912) is a small molecule that inhibits the activity of the glutaminyl cyclase to reduce the level of pyroglutamate-A-beta (pGluAB42). Recent studies confirm that pGluAB42 is a particular amyloid form that is highly synaptotoxic and plays a significant role in the development of AD. Methods This paper describes the design and methodology behind the phase 2b VIVIAD-trial in AD. The aim of this study is to evaluate varoglutamstat in a state-of-the-art designed, placebo-controlled, double-blind, randomized clinical trial for safety and tolerability, efficacy on cognition, and effects on brain activity and AD biomarkers. In addition to its main purpose, the trial will explore potential associations between novel and established biomarkers and their individual and composite relation to disease characteristics. Results To be expected early 2023 Conclusion This state of the art phase 2b study will yield important results for the field with respect to trial methodology and for the treatment of AD with a small molecule directed against pyroglutamate-A-beta. Trial registration ClinicalTrials.gov Identifier: NCT04498650

To investigate acute changes in biochemical markers of bone and cartilage turnover in response to moderate intensity exercise with and without joint impact in healthy human subjects. A randomized, cross-over, exploratory, clinical study was conducted. Twenty healthy subjects with no history of joint trauma completed 30 min interventions of standardized moderate intensity cycling and running as well as a resting intervention 1 week apart. Blood samples were taken immediately before, four times after exercise and again the next day. Urine was sampled, before, after and the next day. On the day of rest, samples were taken at timepoints similar to the days of exercise. Markers of type I (CTX-I), II (C2M, CTX-II) and VI (C6M) collagen degradation, cartilage oligomeric matrix protein (COMP) and procollagen C-2 (PRO-C2) was measured. Trial registration number: NCT04542655, 02 September 2020, retrospectively registered. CTX-I was different from cycling (4.2%, 95%CI: 0.4–8.0%, p = 0.03) and resting (6.8%, 95%CI: 2.9–10.7%, p = 0.001) after running and the mean change in COMP was different from cycling (10.3%, 95%CI: 1.1–19.5%, p = 0.03), but not from resting (8.6%, 95%CI: − 0.7–17.8%, p = 0.07) after running. Overall, changes in other biomarkers were not different between interventions. In this exploratory study, running, but not cycling, at a moderate intensity and duration induced acute changes in biomarkers of bone and cartilage extra-cellular matrix turnover.

Objective To assess pain outcomes and cartilage thickness change in a subgroup at risk (SAR) of further progression in the FORWARD trial of knee osteoarthritis patients treated with sprifermin. Methods Patients were randomised 1:1:1:1:1 to: sprifermin 100 µg every 6 months (q6mo), 100 µg q12mo, 30 µg q6mo, 30 µg q12mo, or placebo for 18 months. SAR was defined as baseline medial or lateral minimum joint-space width (mJSW) 1.5–3.5 mm and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score 40–90 units. Follow-up to 3 years was included in the analysis. Treatment benefit was explored by repeated measures, linear dose-effect trends by timepoint. Results The SAR comprised 161 (29%) of 549 patients. Mean difference (95% CI) in WOMAC pain at year 3 for sprifermin 100 µg q6mo vs placebo SAR was -8.75 (-22.42, 4.92) for SAR vs 0.97 (-6.22, 8.16) for the intent-to-treat population. SAR placebo patients lost more cartilage over 2 years than the modified ITT (mITT) placebo arm (mean change from baseline, mm [SD]: -0.05 [0.10] vs -0.02 [0.07]). Net total femorotibial joint thickness gain with sprifermin 100 µg q6mo (adjusted mean difference from placebo [95% CI] was similar in the SAR and in the mITT group: 0.06 [0.01, 0.11] vs 0.05 [0.03, 0.07]). Conclusions Selection for low mJSW and moderate-to-high pain at baseline resulted in more rapid disease progression and demonstrated translation of structure modification (with maintained net benefit on total cartilage thickness) into symptomatic benefit. This subgroup may represent a target population for future trials. Clinical trial registration : NCT01919164.

Background: Menopause is associated with detrimental changes in turnover of bone and cartilage and a variety of symptoms with negative impact on the quality of life. Naturally occurring isoflavones from Radix Pueraria lobata, Kudzu root, may possess chondroprotective and symptom-relieving properties, but efficacy and safety of dosing and dose frequencies required for pharmacological action is unclear.Purpose: This clinical trial evaluates the efficacy on bone and cartilage turnover, menopausal symptoms, and safety of five dose regimens of Kudzu root extract administered either once, twice or three times daily in women with at least mild menopausal symptoms.Materials and Methods: Fifty postmenopausal women were randomized equally into five different dose regimen groups of Kudzu root extract in a four-week, parallel group, open-label, single-center, exploratory study design. Biomarkers CTX-I and CTX-II reflecting bone and cartilage degradation, respectively, were assessed in blood samples and 24-h urine samples. Change from baseline in the Menopause Rating Scale (MRS) and subscales was evaluated. Safety endpoints were frequency of adverse events, changes in hematology and safety chemistry data, vital signs and electrocardiogram.Results: Fifty women (Age 54.2 years, SD: 2.9) were randomized. After 4 weeks of treatment, biomarkers of bone resorption and cartilage degradation were statistically significantly reduced from baseline levels in the group receiving two capsules three times a day, serum/urine CTX-I (−18.4%, 95% CI: −8.1 to −27.5, p = 0.001/−34.2%, 95% CI: −21.6 to −44.7, p < 0.0001), urine CTX-II (−17.4% 95% CI: −2.5 to −30.0, p = 0.02). The observed effects were consistent across study groups but appeared to favour three times daily dosing. Four weeks of treatment led to statistically significant reductions in the MRS Total Score (p < 0.0001–0.03) in four out of five treatment groups. Kudzu root extract was well tolerated in all dose regimens, and no serious adverse events were reported.Conclusion: The results indicate that Kudzu extract may possess beneficial effects on bone and cartilage health and may be a promising natural alternative to existing treatments for menopausal symptoms. Kudzu root extract was well tolerated for short-term treatment of mild to severe menopausal symptoms in women in all tested doses and dose frequencies.

ObjectiveThe FORWARD (FGF-18 Osteoarthritis Randomized Trial with Administration of Repeated Doses) trial assessed efficacy and safety of the potential disease-modifying osteoarthritis drug (DMOAD) sprifermin in patients with knee osteoarthritis. Here, we report 5-year efficacy and safety results.MethodsPatients were randomised to intra-articular sprifermin 100 µg or 30 µg every 6 months (q6mo) or 12 months, or placebo, for 18 months. The primary analysis was at year 2, with follow-up at years 3, 4 and 5. Additional post hoc exploratory analyses were conducted in patients with baseline minimum radiographic joint space width 1.5–3.5 mm and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain 40–90, a subgroup at risk (SAR) of progression.Results378 (69%) patients completed the 5-year follow-up. A significant dose-response in total femorotibial joint cartilage thickness with sprifermin (trend test, pConclusionIn the longest DMOAD trial reported to date, sprifermin maintained long-term structural modification of articular cartilage over 3.5 years post-treatment. Potential translation to clinical benefit was observed in the SAR.Trial registration numberNCT01919164

The heterogeneous nature of osteoarthritis (OA) and the need to subtype patients is widely accepted in the field. The biomarker CRPM, a metabolite of C-reactive protein (CRP), is released to the circulation during inflammation. Blood CRPM levels have shown to be associated with disease activity and response to treatment in rheumatoid arthritis (RA). We investigated the level of blood CRPM in OA compared to RA using data from two phase III knee OA and two RA studies (N = 1591). Moreover, the association between CRPM levels and radiographic progression was investigated. The mean CRPM levels were significantly lower in OA (8.5 [95% CI 8.3–8.8] ng/mL, n = 781) compared to the RA patients (12.8 [9.5–16.0] ng/mL, n = 60); however, a significant subset of OA patients (31%) had CRPM levels (≥ 9 ng/mL) comparable to RA. Furthermore, OA patients (n = 152) with CRPM levels ≥ 9 ng/mL were more likely to develop contra-lateral knee OA assessed by X-ray over a two-year follow-up period with an odds ratio of 2.2 [1.0–4.7]. These data suggest that CRPM is a blood-based biochemical marker for early identification OA patients with an inflammatory phenotype.

Purpose Osteoarthritis Research Society International (OARSI) Expert Consensus Guidelines recommend topical non-steroidal anti-inflammatory drugs as first-line medications for osteoarthritis (OA) knee pain, but several voluminous daily applications are required to achieve efficacy. There is a need to develop new and improved topical analgesics with a faster onset, longer duration of action, and the requirement to apply less gel. This trial investigated the safety and efficacy of a new 3.06% diclofenac gel (AMZ001) in subjects with knee OA. Methods In total, 444 subjects (AMZ001 twice daily (BID) [n = 121], AMZ001 once daily (QD) + placebo QD [n = 121], placebo BID [n = 121], or Voltaren 1% 4-times daily [n = 81]) were enrolled. All except Voltaren 1% (single-blinded) were applied topically in a double-blind manner for a total of 4-weeks. The primary endpoint was the change from baseline to week 4 in the WOMAC pain sub-score in the target knee. Secondary and exploratory endpoints included additional efficacy measures (WOMAC total score, WOMAC function and stiffness sub-scores, WOMAC pain weight-bearing and non-weight-bearing sub-scores, ICOAP, chair-stand test, OMERACT-OARSI responder rate, PGA, WPAI, EQ-5D, rescue medication use, satisfaction questionnaire) and safety. Results Treatment with AMZ001 QD was effective at reducing WOMAC pain sub-scores vs placebo (estimated treatment difference [ETD]: −4.61 [95% confidence interval (CI): −9.09, −0.12]; p = 0.0440); however, BID application was not (ETD: −3.76 [95% CI: −8.21, 0.68]; p = 0.0969). For several secondary endpoints, changes from baseline to week 4 conferred nominally statistically significant improvements in favor of AMZ001 vs placebo, including PGA score (AMZ001 BID vs placebo, ETD: −0.61 [95% CI: −1.11, −0.11]; p = 0.0162; AMZ001 QD vs placebo, ETD: −0.63 [95% CI: −1.13, −0.13]; p = 0.0134), WPAI overall work impairment score (AMZ001 QD vs placebo, ETD: −10.44 [95% CI: −20.84, −0.04]; p = 0.0492), and EQ-5D VAS score (AMZ001 BID vs placebo, ETD: 4.70 [95% CI: 0.55, 8.85]; p = 0.0264). Post-hoc analysis excluding 11–14 subjects per group with pain scores that decreased between screening and baseline suggests a consistent effect of both AMZ001 QD (ETD: −5.84 [95% CI: −10.71, −0.97]; p = 0.0189) and BID (ETD: −5.35 [95% CI: −10.16, −0.54]; p = 0.0292) in reducing WOMAC pain sub-scores vs placebo. In general, treatment satisfaction was high, as measured by the satisfaction questionnaire. The frequency and incidence of adverse events (AEs) was greatest in the placebo group. Most AEs (>99%) were of mild or moderate severity. There were no serious AEs. There were no notable effects of any treatment on vital signs, ECGs, physical examination findings, or other laboratory assessments. Conclusions Treatment with AMZ001 BID for 4 weeks improved WOMAC pain sub-scores; however, only QD application conferred nominally statistically significant improvements vs placebo. AMZ001 was generally well tolerated.

Summary Objective To propose a standardized model for exercise-induced cartilage turnover and investigate residual levels and dynamics of biomarker serum ARGS (sARGS) in primary osteoarthritis (OA) patients and a supportive group of young healthy subjects. Method The trial is a randomized, cross-over, exploratory study with interventions of exercise and inactivity. 20 subjects with knee OA, as well as 20 young healthy subjects (mean age 25.7 years (range; 19–30), 50% male), underwent cycling, running and resting interventions on separate days one week apart. Blood samples were taken at baseline, immediately, 1, 2, 3 and 24 h after activity start. sARGS was measured by sandwich ELISA. Results Intraclass correlation between visits were 0.97 and 0.77 for the OA and healthy group, respectively. An acute drop in sARGS in response to high-intensity exercise was observed in both groups. Minute acute sARGS increase was observed in OA subjects in response to moderate intensity running and cycling, which normalized within 24 h. In healthy subjects an acute drop in sARGS was seen immediately after running, but not cycling, and no other changes were observed. A negative correlation between baseline Kellgren-Lawrence (KL) grade and baseline sARGS (r = −0.69, p = 0.002) in OA was found. A negative correlation between age and sARGS was found in healthy subjects (r = −0.67, p = Conclusion sARGS sensitivity to physical activity is considered low and sARGS is a reproducible and stable marker. Minute acute increases in sARGS were observed in the hours following moderate intensity exercise.

Background:In osteoarthritis (OA), response to different interventions could be more pronounced in different endotypes of cartilage turnover. Data from UK biobank suggest that an endotype of low cartilage repair is associated with structural progression in osteoarthritis (OA)[1]. Sprifermin a truncated and recombinant FGF18 have been shown to induce chondrocyte proliferation and cartilage formation in in vitro settings[2–4]. Efficacy on cartilage thickness in OA was recently demonstrated in the FORWARD study[5].Objectives:We investigated markers of cartilage formation (serum PRO-C2) and degradation (urine CTX-II), to assess profiles indicative of chondrocyte metabolic activity would be associated with both structural and symptomatic responses to sprifermin.Methods:Serum and urine from participants of the FORWARD study, a phase II clinical trial testing the efficacy of intra-articular (IA) sprifermin, were collected throughout the study. Clinical data recorded at baseline, year 2 and year 3 follow-up were used, including cartilage thickness and WOMAC. All available baseline samples of the placebo and treatment arms were assessed for serum PRO-C2 and urinary CTX-II. Patients were separated into dichotomized groups based on 33, 50 or 66 percentiles cut-points and two-year treatment responses were compared in a prospective-retrospective statistical design manner.Results:Patients with low baseline PRO-C2 (Conclusion:We noticed that low baseline PRO-C2 and CTX-II indicative for low metabolic activity of chondrocytes were associated with improved symptomatic outcome and slightly increased cartilage thickness compared to high metabolic activity. The parallelism between PRO-C2 and CTX-II point towards the existence of a low cartilage repair endotype and might reflect a subgroup of patients with higher sensitivity towards interventions - an effect that was maintained over three years.References:[1]Tachmazidou I, et al. ”Identification of new therapeutic targets for osteoarthritis through genome-wide analyses of UK Biobank data.” Nat Genet 2019;51:230–6.[2]Gigout A, et al. ”Sprifermin (rhFGF18) enables proliferation of chondrocytes producing a hyaline cartilage matrix”. Osteoarthr Cartil. 2017;25.[3]Reker D et al. “Sprifermin (rhFGF18) modulates extracellular matrix turnover in cartilage explants ex vivo”. J Transl Med. 2017;15.[4]Luo Y et al. ”A Novel High Sensitivity Type II Collagen Blood-Based Biomarker, PRO-C2, for Assessment of Cartilage Formation”. Int J Mol Sci 2018;19:3485.[5]Hochberg MC et al. “Effect of Intra-Articular Sprifermin vs Placebo on Femorotibial Joint Cartilage Thickness in Patients With Osteoarthritis”. JAMA. 2019; Oct 8;322(14).Disclosure of Interests:Hans Gühring Employee of: Merck KGaA, Anne-Christine Bay-Jensen Shareholder of: Nordic Bioscience A/S, Employee of: Full time employee at Nordic Bioscience A/S., Flavie Moreau Employee of: Merck KGaA, Jeppe Ragnar Andersen Shareholder of: Nordic Bioscience A/S., Employee of: Full time employee of Nordic Bioscience., Asger Reinstrup Bihlet Shareholder of: Nordic Bioscience A/S., Morten Karsdal Shareholder of: Nordic Bioscience A/S., Employee of: Full time employee at Nordic Bioscience A/S.

Objectives Clinical trials of new disease-modifying treatments for osteoarthritis should demonstrate a positive effect on a functional outcome or reduction in joint failure in order to be considered successful. Total joint replacement (TJR) surgery may be considered as joint failure, but great variation in the incidence of TJR complicates its use as a study endpoint. Factors predicting elevated risk of TJR could potentially be used to enrich such outcome-trials. Methods Using cumulative data from two phase three clinical trials with urine samples from 1255 knee OA patients followed for two years, we assessed the value of a series of baseline clinical variables including the uCTX-II biomarker, as predictors of joint-space narrowing, Kellgren-Lawrence-grade progression, and total joint replacement. Results A prediction-model incorporating age, sex, BMI, CTX-II and KL-grade predicted TJR within the two-year period with an AUC of 0.75 (95% CI: 0.72–0.77). The participants with a cumulative KL-grade between knees of 5, 6, or 7 had a more than 3 times higher risk of TJR in the study period compared to lower (HR: 3.03, 95% CI: 1.54 to 5.96, p = 0.001). Age was associated with increased TJR risk (per 5 years of age: HR: 1.28, 95% CI: 1.03–3.79, p = 0.05). Baseline u-CTX-II was associated with elevated risk of radiographic progression in terms of both JSN and KL-grade. Conclusions A composite model combining baseline age, sex, BMI, u-CTX-II and KL-grade was able to acceptably predict TJR during a two-year period. In the absence of baseline radiographic OA severity, u-CTX-II independently contributed to prediction of TJR. Baseline urine CTX-II was associated with risk of radiographic progression.

Background Osteoarthritis (OA) can lead to joint failure and ultimately total joint replacement (TJR). Identifying risk-factors of developing joint failure is of interest for clinicians and researchers. Currently late-stage clinical trial design for evaluating new treatments in OA is evolving with the possible utilization of accelerated approval pathways. This may require outcome studies with longer duration, in which joint failures may qualify as an endpoint. However, TJRs are relatively rare events and are known to be biased by doctor/patient interactions as well as local practice guidelines, and consequently, there is a need for objective non-invasive measures, such as soluble biomarkers (BM), to enrich the population for this outcome. BM may act as important tools in investigating the association between biochemical/pathological processes and risk of joint failure. Degradation of collagens type I and II are known to be involved in OA disease progression, and the biomarkers CTX-I (C-telopeptide of crosslinked collagen type I), a marker of bone degradation, and CTX-II (C-telopeptide of crosslinked collagen type II), a marker of cartilage degradation, may reflect disease progression with clinical relevance for the risk of joint failure. Objectives To evaluate baseline (BL) BM sCTX-I and uCTX-II as predictors of TJR. Methods Data from two clinical trials investigating oral salmon calcitonin (SMC) in OA, NCT00486434 and NCT00704847, was analyzed post-hoc. Data was dichotomized by the bottom and top quartile of the respective BM concentration at BL to compare the number TJRs of the knee or hip in groups with high vs. low sCTX-I or uCTX-II, respectively. For means of visualization, plotted in Kaplan-Meier curves. Cox Proportional Hazard Regression was performed to determine the association of BL sCTX-I and uCTX-II to the incidence of TJR while adjusting for co-variates; age, BMI, and gender. Data from both treatment groups were analyzed. Only the first reported incident was included in the analysis for each subject. Results A total of 68 TJRs of knee or hip were reported, of which 49 were knees and 18 were hips. One patient underwent two TJRs, resulting in 67 subjects with events. Results from the Cox Proportional Hazard Regression adjusted for covariates of age, BMI, and sex (table 1), indicate that high BL sCTX-I compared to low was associated with a 3.4 times higher risk of undergoing an arthroplasty of the knee or hip within a two-year period (p=0.04). High BL uCTX-II compared to low was associated with a 3.1 times higher risk of undergoing a TJR of the knee or hip during the study period (p=0.04), and an 8.9-fold increased risk of undergoing a knee replacement during the study period (p=0.02). TJR events over time in groups of high or low uCTX-II through the study are illustrated in figure 1. Conclusion High levels of sCTX-I and uCTX-II at BL were associated with increased risk of undergoing TJR of the knee or hip during the two year study. Our findings support the role of sCTX-I and uCTX-II as important biomarkers in clinical OA trials evaluating incidence of TJRs. Disclosure of Interests Jonathan Bjerre-Bastos Employee of: I am a full-time employee in Nordic Bioscience, Anne-Christine Bay-Jensen Shareholder of: I own shares of Nordic Bioscience, Employee of: I am a full-time employee in Nordic Bioscience, Morten Karsdal Shareholder of: I own shares of Nordic Bioscience, Employee of: I am a full-time employee in Nordic Bioscience, Inger Byrjalsen Employee of: I am a full-time employee in Nordic Bioscience, Jeppe Ragnar Andersen Shareholder of: Nordic Bioscience, Employee of: Nordic Bioscience, Bente Juel Riis Shareholder of: Yes, I own shares in Nordic Bioscience, Employee of: I am a full-time employee in Nordic Bioscience, Claus Christiansen Shareholder of: Yes, I own shares in Nordic Bioscience, Employee of: I am a full-time employee in Nordic Bioscience, Asger Reinstrup Bihlet Shareholder of: Yes, I own shares in Nordic Bioscience., Employee of: I am a full-time employee in Nordic Bioscience

Background Osteoarthritis (OA) leads to joint failure and total joint replacement (TJR, either hip (H) or knee (K)). Worsening of pain and joint space narrowing are believed to be surrogates for joint failure; however, we hypothesize that TJR, as a reflection of joint failure, can be used as an endpoint in event-driven clinical trials within a reasonable duration. We explored the incidence of TJR in the Prospective Epidemiologic Risk Factor (PERF I) study. Methods A total of 5855 Danish postmenopausal women aged 49–88 enrolled in the PERF I study during 1999–2001 (baseline). Three-, six- and twelve-year follow-up data from the Danish National Patient Registry was collected, including occurrence of TJR and OA diagnosis. At baseline the women were asked whether they had OA. Results The women with a TJR diagnosis before or after baseline were on average 1 year older (p

Background: Development of new disease-modifying drugs in OA (DMOADs) is complicated by heterogeneous study populations and insensitive endpoints of structural change and symptoms, and discordance between structural disease severity and reported symptoms. In such trials, counterintuitively, mild structural disease may be associated with severe symptoms and vice versa. Research to uncover factors distorting the perceived severity of symptoms is needed to better characterize the clinical relevance of structural improvement, if any, in DMOAD trials. Anxiety and depressive (AD) disorders are known to affect pain sensitivity and perception, and as common co-morbidities of OA, these conditions may partly explain the observed discordance between structure and symptoms. If established, exclusion of patients with AD in DMOAD trials could potentially improve the understanding of structural benefit in a clinical context. Objectives: The main objective of this analysis was to investigate the impact of AD on the association between structural features of OA and patient-reported pain. Methods: Baseline data from two phase 3 trials investigating oral salmon calcitonin in OA, NCT00486434 and NCT00704847 (total N=2206), was analyzed in a post-hoc cross-sectional analysis. Patients with self-reported current or previous depression, anxiety or post-traumatic stress syndrome (PTSD) were selected and compared to a control group, matched by sex, age, BMI and JSW. Spearman’s correlation coefficient between JSW and WOMAC pain was calculated for both groups. Multiple regression analyses of both groups with WOMAC pain as the outcome variable, and age, sex, body mass index (BMI) and baseline JSW or KL-grade as explanatory variables were performed. Results: In the AD group, 149 patients had AD in medical history of which 123 reported the condition as ongoing at baseline. The study groups of AD and matched controls (MC) were comparable in terms of age, sex, BMI, JSW, KL-grade and WOMAC pain. Associations between pain and JSW In the AD group, no significant correlation between JSW and WOMAC Pain score was found, while BMI was found to be weakly associated with WOMAC pain (R= 0.19, p=0.02) in the multiple regression analysis. In the MC group, a statistically significant (p=0.004), correlation (R= -0.24) was found between JSW and pain indicating that lower JSW was associated with higher pain, with JSW accounting for approximately 6% of the total natural variation behind reported pain. In addition, a positive significant association between male sex and WOMAC pain (R=0.18, p=0.04) was found. The univariate linear relationship between JSW and pain is illustrated in Figure 1, and multivariate analyses are shown in Table 1. Associations between pain and KL-Grade In the model evaluating associations between KL-grade and symptoms, there was no correlation between KL-grade and symptoms in the AD group. Similar to the findings relating to JSW, in the MC group, a weak (R=0.16), borderline statistically significant association (p=0.07) was found between KL-grade and WOMAC pain. Conclusion: A marked structure-symptoms discordance was found in OA patients with AD, while a statistically significant correlation was seen in matched controls without AD. The results suggest that exclusion of trial patients with anxiety and depression in medical history may improve the accuracy of pain reporting in clinical OA trials. Disclosure of Interests: Jonathan Jetsmark Bjerre-Bastos Employee of: Nordic Bioscience, Inger Byrjalsen Employee of: Nordic Bioscience, Morten Asser Karsdal Shareholder of: Nordic Bioscience, Employee of: Nordic Bioscience, Jeppe Ragnar Andersen Shareholder of: Nordic Bioscience, Employee of: Nordic Bioscience, Asger Bihlet Shareholder of: Nordic Bioscience, Employee of: Nordic Bioscience

Osteoarthritis (OA) is the biggest unmet medical need among the many musculoskeletal conditions and the most common form of arthritis. It is a major cause of disability and impaired quality of life in the elderly. We review several ambitious but failed attempts to develop joint structure-modifying treatments for OA. Insights gleaned from these attempts suggest that these failures arose from unrealistic hypotheses, sub-optimal selection of patient populations or drug dose, and/or inadequate sensitivity of the trial endpoints. The long list of failures has prompted a paradigm shift in OA drug development with redirection of attention to: (1) consideration of the benefits of localized vs systemic pharmacological agents, as indicated by the increasing number of intra-articularly administered compounds entering clinical development; (2) recognition of OA as a complex disease with multiple phenotypes, that may each require somewhat different approaches for optimizing treatment; and (3) trial enhancements based on guidance regarding biomarkers provided by regulatory agencies, such as the Food and Drug Administration (FDA), that could be harnessed to help turn failures into successes.

Background:Development of improved topical treatments of painful joints is warranted. A novel diclofenac sodium gel formulation, AMZ001, has been developed with the purpose of improving 1) The onset and duration of pain relief, and 2) The ease of use by reducing the required daily frequency of gel application. Previous trials in human subjects have confirmed improved permeability of a reduced volume of AMZ001 gel as compared to approved diclofenac topical products with a comparable safety and tolerability profile, supporting trials to evaluate the efficacy and safety of AMZ001 in painful joint conditions.Objectives:The current abstract reports the main results of a randomized trial of AMZ001 once or twice daily application versus placebo in symptomatic knee osteoarthritis.Methods:The trial was a placebo-controlled, parallel group, double-blind, randomized trial to evaluate the efficacy and safety of AMZ001 or placebo in subjects with knee osteoarthritis. The main inclusion criteria were Kellgren-Lawrence radiographic severity of 1-3, and pain ≥40 and ≤90 out of 100 using the WOMAC pain subscale (5 questions) at the time of screening. The subjects were randomized to apply AMZ001 gel once (QD) or twice (BID) daily or placebo twice daily per OA knee for a period of 28 days, or to apply Voltaren® Gel 1 % four times daily (QID) in a single-blind fashion for exploratory comparison. The primary endpoint was change from baseline at week 4 in WOMAC pain (5 questions). The main secondary endpoints included WOMAC subscales, Patient Global Assessment (PGA) and quality of life using the EQ-5D. In addition to the main analysis, a post-hoc subgroup analysis of subjects meeting the pain criterion at both screening and baseline was performed.Results:A total of 444 subjects were randomized. The main baseline characteristics were well balanced between treatment groups.AMZ001 QD and BID led to statistically significant reductions in pain compared to baseline with an estimated difference (95% CI) normalized to 0-100 at week 4 of -27.33 (-30.50, -24.17), and -26.49 (-29.60, -23.38), respectively. Reduction in pain at week 4 was statistically significantly superior to placebo for AMZ001 QD (p=0.04), and borderline significant for AMZ001 BID (pBoth AMZ001 QD and BID led to statistically significant improvements in PGA at week 4 compared to placebo (pWhile the study design and differences in sample sizes does not allow formal comparisons between the double- and single blinded groups, the exploratory comparator, Voltaren QID, did not reach statistically significant differences to placebo or AMZ001 in any of the endpoints, in neither the ITT nor the subgroup analyses.The safety and tolerability of AMZ001 was favorable, as the frequency of AEs leading to discontinuation of treatment was similarly low (ranging between 2.8 % to 6.6 %) between AMZ001 once or twice daily and placebo or Voltaren Gel 1%. The most common treatment-emergent AEs were application site dryness, and application site erythema. No serious adverse events were reported during the trial.Conclusion:AMZ001, a novel topical diclofenac formulation, either once or twice daily was efficacious in the treatment of knee OA pain with a good tolerability and safety profile, suggesting AMZ001 may be a promising alternative to existing pain-relieving treatments in knee OA.References:NADisclosure of Interests:Asger Bihlet Shareholder of: Nordic Bioscience, Consultant of: Amzell BV, Medivir AB, Xintela AB, Merck KGaA, Employee of: Nordic Bioscience, Inger Byrjalsen Employee of: Nordic Bioscience, Henning Bay Nielsen: None declared, Jeppe Andersen Shareholder of: Minor shareholder of Nordic Bioscience, Consultant of: Medivir AB, Xintela AB, Employee of: Nordic Bioscience, Laetitia Delpy Employee of: Amzell BV, Caroline Derne Employee of: Amzell BV, Dario Carrara Employee of: Amzell BV

Background:Exercise is recommended in osteoarthritis (OA) to limit pain and preserve joint function. Cycling is considered healthy, while the safety of running in OA has been controversial. The acute impact on cartilage in response to exercise (weight bearing vs non-weight bearing) remains to be explored.Biomarkers originating from type I-III and VI collagen can be measured in serum and urine and may reflect cartilage turnover.We report the first ever data on acute effects of exercise on a panel of collagen biomarkers in OA.Objectives:To investigate the effect of running vs cycling on biomarkers of collagen type I-III and VI reflecting cartilage turnover.Methods:We conducted a randomized, crossover clinical study (approval number: H-18038807) of subjects with primary knee OA. Screening included a maximal heart rate test to standardize exercise intensity. Participants underwent 30 minutes of running and cycling on separate days with blood samples taken at baseline and 0.5, 1, 2 and 3 hours after exercise initiation and again 24 hours after the exercise in order to evaluate the dynamic levels of biomarkers. Urine samples were collected before exercise and approximately 1 hour and 24 hours after. Potential diurnal variation was taken into account by measurements at comparable times from participants on a separate day with no exercise (resting). Levels of serum CTX-I, C2M, C3M, C6M and urine CTX-II were measured by enzyme-linked immunosorbent assays.Biomarker dynamics were plotted. Error bars represent 95% CI. CTX-I and C6M are displayed.Results:20 subjects were included of which 20 completed cycling and resting and 15 completed running. Subject characteristics displayed in table.CTX-I decreased significantly from baseline at three hours after both running (pC2M was decreased at 1 hour after running (Change: -9.4%, 95%CI: -18.4--1.0, pC3M was decreased at 2 hours after cycling (Change: -6.3%, 95%CI: -12.1--0.5, pC6M was increased at 1 hour after initiating rest and decreased 1 and 2 hours after running (pThe variation in CTX-II was higher, compared with the serum-based markers. A trend of decreasing CTX-II in response to rest was observed, but no significant changes were seen in response to exercise.GroupCycling/Resting(N = 20)Running(N = 15)Mean age, years (SD)61.8 (9.1)61.9 (7.5)Male sex, n (%)5 (25)4 (26.6)Mean BMI (kg/m2) (SD)26.3 (3.4)26.5 (3.6)Baseline KL-grade, n (%)1: 3 (15.0)2: 8 (40.0)3: 9 (45.0)1: 2 (13.3)2: 8 (53.3)3: 5 (33.3)Conclusion:Cycling and running acutely influenced markers of type I-III and VI collagen. The results suggest no harmful effects on bone and cartilage in OA. The sensitivity of biomarkers to physical activity and inactivity is important to take into account, when using them in clinical research.Disclosure of Interests:Jonathan Bjerre-Bastos: None declared, Henning Bay Nielsen: None declared, Abigail Mackey: None declared, Morten Karsdal Shareholder of: Nordic Bioscience A/S., Employee of: Full time employee at Nordic Bioscience A/S., Anne-Christine Bay-Jensen Shareholder of: Nordic Bioscience A/S, Employee of: Full time employee at Nordic Bioscience A/S., Jeppe Ragnar Andersen Shareholder of: Nordic Bioscience A/S., Employee of: Full time employee of Nordic Bioscience., Mikael Boesen Consultant of: AbbVie, AstraZeneca, Eli Lilly, Esaote, Glenmark, Novartis, Pfizer, UCB, Paid instructor for: IAG, Image Analysis Group, AbbVie, Eli Lilly, AstraZeneca, esaote, Glenmark, Novartis, Pfizer, UCB (scientific advisor)., Speakers bureau: Eli Lilly, Esaote, Novartis, Pfizer, UCB, Yi He Employee of: YH is a full time employee of Nordic Bioscience A/S, Asger Reinstrup Bihlet Shareholder of: Nordic Bioscience A/S.

Background:MTX is the first line treatment in early RA. There is robust evidence from cohort studies, but less from RCTs, that a “window of opportunity” exists over 12-16 weeks symptom duration. CR6086 is a selective prostaglandin EP4 receptor antagonist, with an immunomodulatory profile.Objectives:To test efficacy and safety of CR6086 added to MTX in early RA, DMARD-naïve patients.Methods:Patients with RA (ACR/EULAR 2010 criteria), < 1 year from symptom onset and naïve to DMARDs were randomized to oral CR6086 30, 90, 180mg, or placebo bid and oral MTX (20mg weekly) for 13 weeks (NCT03163966). Primary endpoint was the ACR20 response rate: 240 patients were needed to detect a difference among groups, with 50% responders on placebo and 70% on the 90mg CR6086 target dose. Pairwise comparisons of proportions were performed, with nonresponder imputation for withdrawals. A subgroup of patients underwent dynamic contrast-enhanced (DCE) MRI for quantification of synovitis at MCP and wrist joints, evaluated as DEMRIQ-ME and DEMRIQ-vol.Results:The ITT population included all 244 randomized patients receiving at least one dose of study drugs (59 CR6086 30mg/MTX, 60 CR6086 90mg/MTX, 63 CR6086 180mg/MTX, 62 placebo/MTX). Safety was good with no increased rate of infections or other disorders; however, there were more minor upper GI adverse events (AEs) with CR6086, and increased dropouts due to AEs with the 180mg dose (9/63, 14.3% vs 1.7-3.4% in other groups). There were more ACR20 responders with MTX monotherapy than predicted (59.7%) and thus the 10.3% difference with the 90mg target dose (70.0%) was not significant. The low 30mg dose was no better than placebo (55.9%), while the high 180mg dose did not provide additional benefit compared with 90mg (74.0% net of dropouts). CR6086 90mg and 180mg induced a significant improvement in MRI, compared with placebo (Fig. 1). In a post-hoc analysis in patients < 6 months from symptom onset (ACR definition of early RA: 98/244, 40.2%), MTX monotherapy exerted a large 76% ACR20 response rate that precluded potentiation. Conversely, in patients of 6-12 months disease duration (146/244, 59.8%) ACR20 responders were 48.6% with MTX monotherapy vs 68.4% with 90mg, i.e. a 19.8% difference as postulated, with proportional differences in secondary endpoints (Tab. 1).Conclusion:There was no benefit demonstrated for CR6086 added to MTX in the study cohort as a whole. However, in a post-hoc analysis, enhanced responses were observed with CR6086 90mg bid added to MTX in patients >6 months disease duration. This generated the hypothesis that addition of CR6086 90mg bid may benefit in RA patients initiating MTX after the window of opportunity, to be tested in further studies.Table 1.Patient characteristics & pregnancy outcomesSymptom onset (principal analysis)Symptom onset 6-12 months(post-hoc analysis)*Placebo+MTX(N=62)CR6086 90mg+MTX(N=60)Placebo+MTX(N=37)CR6086 90mg+MTX(N=38)ACR20, %59.7%70.0%48.6%68.4%ACR50, %33.9%38.3%29.7%39.5%ACR70, %17.7%23.3%10.8%28.9%DAS28 (CRP) 12.9%20.0%8.1%18.4%CDAI ≤2.8, %8.1%11.7%5.4%15.8%SDAI ≤3.3, %6.5%10.0%2.7%15.8%Boolean-based remission, %6.5%6.7%2.7%10.5%*In patients with symptom onset Figure 1.Change in MRI (DEMRIQ-ME#) after 13 weeksDisclosure of Interests:Karel Pavelka Consultant of: Abbvie, MSD, BMS, Egis, Roche, UCB, Medac, Pfizer, Biogen, Speakers bureau: Abbvie, MSD, BMS, Egis, Roche, UCB, Medac, Pfizer, Biogen, Ivanova Delina2 Delina: None declared, Minodora Mazur: None declared, Massimo D’Amato Employee of: Rottapharm Biotech, GIAMPAOLO GIACOVELLI Employee of: Rottapharm Biotech, Federica Girolami Employee of: Rottapharm Biotech, Marek Krogulec: None declared, René Østgård: None declared, Asger Reinstrup Bihlet Shareholder of: Nordic Bioscience A/S., Olga Kubassova Shareholder of: IAG, Image Analysis Group, Consultant of: Novartis, Takeda, Lilly, Employee of: IAG, Image Analysis Group, Lucio Rovati Shareholder of: Rottapharm Biotech, Employee of: Rottapharm Biotech, Peter C. Taylor Grant/research support from: Celgene, Eli Lilly and Company, Galapagos, and Gilead, Consultant of: AbbVie, Biogen, Eli Lilly and Company, Fresenius, Galapagos, Gilead, GlaxoSmithKline, Janssen, Nordic Pharma, Pfizer Roche, and UCB

Background:It is challenging to monitor treatment effects after intra-articular (IA) injection with tissue modifying drugs. Assessment of biomarker levels in synovial fluid may be one solution to the challenge. Sprifermin is a truncated form of fibroblast growth factor (FGF) 18 known to induce chondrocyte proliferation and type II collagen formation [1,2]. Data from preclinical investigations show that cartilage formation happens in different phases after therapy with sprifermin, starting with a phase of cartilage degradation during the induction of proliferation of chondrocytes followed by a phase of cartilage formation/production of extracellular matrix.Objectives:The aim was to investigate the effect of IA administrated sprifermin on cartilage turnover activity as compared to placebo in the injected joint by measurement of markers using longitudinal synovial fluid samples of patients participating in the FORWARD study.Methods:Each included patient had baseline and at least one FU sample available. Synovial fluid (SF) from participants receiving injections at three consecutive weeks in six month intervals through to week (wk) 80 (fig.A) available from the phase II clinical trial evaluating the efficacy and safety of intraarticularly delivered sprifermin [3] were selected for the investigations. Biochemical markers were measured in available SF samples of the placebo (containing saline IA, n=38) and the highest sprifermin dose group (100 mcg/IAx4, n=59). Samples were pretreated with ultrasound and centrifugation to decrease viscosity. Markers measured were PRO-C2 (type II collagen formation), huARGS (aggrecan degradation), and FBN-C (fibronectin). Markers are technically validated for synovial fluid measurement. Data were individually normalized to baseline to investigate the median proportional change over time.Results:Baseline mean (SD) levels of the markers in SF at BL were: PRO-C2, 21.4 (13.6) ng/mL, huARGS, 1117 (516) pM and FBN-C, 2556 (1959) ng/mL. PRO-C2 was initially decreased (from BL to wk 2) after injection with sprifermin; however, the level was increased at the beginning of each new injection cycle followed by a decrease after injection of sprifermin (Fig.B). Overall synovial PRO-C2 levels increased over time in therapy with sprifermin, while no change was observed for the placebo arm. huARGS showed a similar pattern as PRO-C2 – there was an overall increase in ARGS over time in the sprifermin group (fig.C). Interestingly ARGS continuously decreased over time in the placebo group. FBN-C is continuously increased after injection’s cycles, whereas no effect was seen in the placebo group (fig.D).Conclusion:Confirmatory of the preclinical investigations a biphasic response on cartilage turnover after injection with sprifermin was observed. Biochemical indications of cartilage formation and chondrocyte proliferation was only modulated in the sprifermin group, and cartilage degradation (ARGS) was temporal induced and reduced by sprifermin and placebo injections, respectively.References:[1]Gigout A, et al. “Sprifermin (rhFGF18) enables proliferation of chondrocytes producing a hyaline cartilage matrix”. Osteoarthr Cartil. 2017;25.[2]Reker D, et al. “Sprifermin (rhFGF18) modulates extracellular matrix turnover in cartilage explants ex vivo”. J Transl Med. 2017;15.[3]Hochberg MC, et al. “Effect of Intra-Articular Sprifermin vs Placebo on Femorotibial Joint Cartilage Thickness in Patients With Osteoarthritis”. JAMA. 2019; Oct 8;322(14).Disclosure of Interests:Anne-Christine Bay-Jensen Shareholder of: Nordic Bioscience A/S, Employee of: Full time employee at Nordic Bioscience A/S., Angela Manginelli Employee of: Merck KGaA, Flavie Moreau Employee of: Merck KGaA, Yi He Employee of: YH is a full time employee of Nordic Bioscience A/S, Yunyun Luo Employee of: Nordic Bioscience A/S, Jeppe Ragnar Andersen Shareholder of: Nordic Bioscience A/S., Employee of: Full time employee of Nordic Bioscience., Asger Reinstrup Bihlet Shareholder of: Nordic Bioscience A/S., Morten Karsdal Shareholder of: Nordic Bioscience A/S., Employee of: Full time employee at Nordic Bioscience A/S., Hans Gühring Employee of: Merck KGaA, Christoph Ladel Employee of: Merck KGaA

Background Excessive cartilage degradation is a known characteristic of osteoarthritis (OA). Biochemical markers, such as uCTX-II, have been shown to be associated with disease severity, yet the tissue origin of CTX-II has been disputed. This analysis investigates the association between OA knee joints at different radiographic stages and pain categories with levels of uCTX-II and biomarkers of bone resorption and formation. Methods Baseline data of two randomised clinical trials (NCT00486434 and NCT00704847) in patients with radiographic OA and presence of pain were analysed post hoc. A subgroup with available urine samples and evaluable radiographs for both knees (N = 1241) was analysed. Urine CTX-I, urine CTX-II and serum osteocalcin were analysed for associations with combined Kellgren-Lawrence (KL) scores, gender and pain for both knees to assess the contribution of joints at different stages. Results Pain, BMI, age, gender and KL grade were all significantly associated with uCTX-II. The association between pain and CTX-II appeared to be driven by weight-bearing pain. The level of uCTX-II incrementally increased with higher radiographic severity of each knee. Levels of bone markers CTX-I and osteocalcin were both significantly associated with BMI and gender, but neither were associated with radiographic severity. Biomarker levels between male or female groups of identical KL scores were found to be higher in females compared to males in some but not all KL score groups. Conclusions These results indicate that levels of uCTX-II are independently associated with radiographic severity of OA and pain intensity. CTX-II was associated with weight-bearing pain, but not non-weight-bearing pain, independent of co-variates. Bilateral OA knee joints appear to contribute to uCTX-II levels in an incremental manner according to radiographic severity of single joints. The data suggest that biomarker differences between genders should be taken into account when evaluating these markers in the context of structural features of OA.

Background Sprifermin, a novel recombinant human fibroblast growth factor 18, is currently being investigated as a potential disease-modifying osteoarthritis (OA) drug. Two-year results of the 5 year phase II FORWARD study showed a statistically significant dose-dependent cartilage thickness increase in the total femorotibial joint (TFJ), and in the medial, lateral and central medial sub-region TFJ compartments by quantitative magnetic resonance imaging (qMRI). Objectives Here we report the pre-specified 3 year results. Methods Patients (pts) aged 40–85 years with symptomatic radiographic knee OA, Kellgren-Lawrence grade (KLG) 2 or 3, and medial mJSW ≥2.5 mm in the target knee were randomised (1:1:1:1:1) to receive 3 weekly i.a. injections with double-blinded placebo (PBO) or sprifermin, administered q6mo (0, 6, 12, and 18 months) or q12mo (0 and 12 months). The primary endpoint was the change in TFJ cartilage thickness from baseline (BL) to Year 2 with pre-specified analyses at Year 3. The intent-to-treat (ITT) population (all randomised pts) was used for non-qMRI endpoints; and the modified ITT population (all ITT pts with BL and ≥1 post-treatment MRI up to Year 2) for qMRI endpoints. Results 549 pts were randomised (median age 65 years, 69% women, 80% white, 69% KLG2, and ~70% predominantly medial disease); of which 18.4% (sprifermin) and 24.1% (PBO) discontinued the study within 3 years. TFJ cartilage thickness decreased from Year 2 to 3 in all treatment groups; however, the 0.05 mm difference between sprifermin 100 µg q6mo and PBO was maintained (0.00 vs −0.05 mm; p Conclusions The 3 year results of the FORWARD study are consistent with the 2 year results: although cartilage thickness declined in all treatment groups between Year 2 and 3, the difference at Year 2 with sprifermin 100 µg vs PBO was maintained up to Year 3. Based on qMRI sprifermin is effective at increasing cartilage thickness in a dose-dependent manner in knee OA patients, and has an acceptable safety profile. Disclosure of Interest M. Hochberg Consultant for: Bioiberica SA, Bristol Myers Squibb, EMD Serono, Inc., Galapagos, IBSA Biotechniq SA, Novartis Pharma AG, Pfizer Inc., Plexxikon, Samumed LLC, Theralogix LLC and TissueGene Inc, A. Guermazi Consultant for: OrthoTrophix, GE Healthcare, Merck Serono, AstraZeneca, Sanofi, TissueGene and Pfizer, Employee of: Boston Imaging Core Lab, LLC, H. Guehring Employee of: Merck KGaA, A. Aydemir Employee of: EMD Serono, Inc., S. Wax Employee of: EMD Serono, Inc., P. Fleuranceau-Morel Employee of: EMD Serono, Inc., A. Reinstrup Bihlet Shareholder of: Nordic Bioscience, Employee of: Nordic Bioscience, I. Byrjalsen Employee of: Nordic Bioscience, J. Ragnar Andersen Shareholder of: Nordic Bioscience, Employee of: Nordic Bioscience, F. Eckstein Shareholder of: Chondrometrics GmbH, Consultant for: Merck KGaA, Samumed LLC, Abbvie, Bioclinica, TissueGene, Servier and Roche, Employee of: Chondrometrics GmbH

Background Osteoarthritis (OA) is a heterogeneous disease described by a combination of joint pain, physical disability and radiographic alterations leading to joint failure and total joint replacement (TJR). Commonly used endpoints in OA trials are worsening of pain and joint space narrowing. TJR is normally not considered an endpoint. Age and female gender are considered as major risk factors for developing OA. Objectives We hypothesise that TJR can be used as an endpoint in OA outcome studies within reasonable time frame. To investigate the basis for this hypothesis, we explored the prevalence and incidence of TJR as a reflection of joint failure in the Prospective Epidemiologic Risk Factor (PERF I) study. Methods A total of 5,855 Danish postmenopausal women aged 49–88 enrolled in the Prospective Epidemiologic Risk Factor (PERF I) study during 1999–2001 (baseline). Three, six and twelve year follow-up data from the Danish National registry was collected in end of 2014, including occurrence of TJR, OA and other relevant diagnosis. Also, women where at baseline and in 2014 asked whether they had a TJR or OA. The biomarker C1M was measured in baseline serum samples. The PERF I study was carried out in accordance with ICH-GCP and the study protocol was approved by the local ethics committees. Results There were 798 women that had their first TJR between baseline and 12 year follow-up; giving an incidence proportion of 13.6%. The TJR women were on average 1 year older (p=0.010) and heavier (1.7 kg/cm2, p 40 ng/mL, median) that after baseline underwent there first ever TJR (841). Group 1 is as described above. The 3, 6 and 12 incidence rates were 9.0, 17.3% and 29.7% for the prior TJR group, 6.2, 12.1% and 23.3% for the OA group, and 7.6, 13.6% and 25.1% for the OA +C1M group. The age-dependent prevalence and incidence for the first TJR. The prevalence was insignificant for the age group younger than 60 years old ( Conclusions Within a timeframe of 3, 6 or 12 years TJR incidence for women with an OA diagnosis reached 6, 12% and 23%, which was a doubling compared to the All population. The incidence increased by adding a single diagnostic measure. This reflects that TJRs are frequent amongst elderly women and that if designed minutiously, such as including specific diagnostic criteria (e.g. biomarker, OA diagnose), it may be feasible to conduct clinical studies with TJR as an endpoint. However, special attention much be directed to the objectiveness of the criteria for TJR. This may build a case for design of outcome studies (joint failure) for developing drugs in OA. Disclosure of Interest A. Bay-Jensen Shareholder of: Nordic Bioscience, Grant/research support from: ApproacH (IMI support), Employee of: Nordic Bioscience, C. Bager Employee of: Proscion, A. Bihlet Shareholder of: Nordic Bioscience, Employee of: Nordic Bioscience, C. Thudium Employee of: Nordic Bioscience, I. Byrjalsen Employee of: Nordic Bioscience, H. Nielsen Employee of: Nordic Bioscience, J. Andersen Shareholder of: Nordic Bioscience, Employee of: Nordic Bioscience, B. Riis Shareholder of: Nordic Bioscience, C. Christiansen Shareholder of: Nordic Bioscience, M. Karsdal Shareholder of: Nordic Bioscience, Grant/research support from: ApproacH (IMI support), Employee of: Nordic Bioscience

Summary Background/Purpose The aim of this study was to identify key characteristics of disease progression through investigation of the association of radiographic progression over two years with baseline Joint Space Width (JSW), Kellgren–Lawrence (KL) grade, Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain, Joint Space Narrowing (JSN), and BMI. Methods Data from 2206 subjects (4390 knees) were combined for this post-hoc analysis of two randomized, double-blind, multi-center, placebo-controlled phase III trials (NCT00486434 and NCT00704847) that evaluated the efficacy and safety of 2-years treatment with oral salmon calcitonin of subjects with painful knee osteoarthritis (OA). Results There was a clear positive and significant correlation between KL grade and WOMAC pain and total WOMAC, albeit the variance in pain measures was from min-to-max for all KL categories, emphasizing the heterogeneity of this patient population and pain perception. 32% of target knees did not progress, and only 51% had changes over minimum significant change (MSC). BMI, KL-Score and WOMAC pain was diagnostic, but only KL-score and pain had prognostic value, albeit pain in a non-linear manner. Conclusion These data clearly describe significant associations between KL grade, JSW, pain and BMI in patients with symptomatic knee OA. KL grade, BMI and WOMAC pain were diagnostically associated with OA based on JSW but only KL-score and pain in a non-linier fashion was prognostic. 50% of patients did not progress more than MSC, highlighting the importance for identification of structural progressors and the phenotypes associated with these. These results suggest that disease phenotypes, rather than disease status, are responsible for disease progression.

Pain is the principal clinical symptom of osteoarthritis (OA), and development of safe and effective analgesics for OA pain is needed. Drug development of new analgesics for OA pain is impaired by substantial change in pain in patients receiving placebo, and more data describing clinical characteristics and pain categories particularly associated with this phenomenon is needed. The purpose of this post-hoc analysis was to investigate clinical characteristics and pain categories and their association with radiographic progression and placebo pain reduction (PPR) in OA patients as measured the Western Ontario and McMasters Arthritis (WOMAC). Pooled data from the placebo groups of two phase III randomized clinical trials in patients with knee OA followed for 2 years were analyzed. Differences between individual sub-scores and pain categories of weight-bearing and non-weight bearing pain over time were assessed. Selected patient baseline characteristics were assessed for association with PPR. Association between pain categories and radiographic progression was analyzed. The reduction of pain in placebo-treated patients was significantly higher in the composite of questions related to weight-bearing pain compared to non-weight-bearing pain of the target knee. Baseline BMI, age and JSW were not associated with pain change. Pain reduction was higher in the Target knee, compared to the Non-Target knee at all corresponding time-points. A very weak correlation was found between weight-bearing pain and progression in the non-target knee. These results indicate that the reduction in pain in patients treated with placebo is significantly different between pain categories, as weight-bearing pain was significantly more reduced compared to non-weight-bearing pain. Further research in pain categories in OA is warranted. NCT00486434 (trial 1) and NCT00704847 (trial 2)

Background: Osteoarthritis (OA) leads to joint failure and total joint replacement (TJR, either hip (H) or knee (K)). Worsening of pain and joint space narrowing are believed to be surrogates for joint failure; however, we hypothesize that TJR, as a reflection of joint failure, can be used as an endpoint in event-driven clinical trials within a reasonable duration. We explored the incidence of TJR in the Prospective Epidemiologic Risk Factor (PERF I) study. Methods: A total of 5,855 Danish postmenopausal women aged 49-88 enrolled in the PERF I study during 1999-2001 (baseline). Three-, six- and twelve-year follow-up data from the Danish National Patient Registry was collected, including occurrence of TJR and OA diagnosis. At baseline the women were asked whether they had OA. Findings: The TJR women were on average 1 year older (p

Background Change in forced expiratory volume in one second (FEV1) is important for defining severity of chronic obstructive pulmonary disease (COPD). Serological neoepitope markers of collagen turnover may predict rate of change in FEV1. Methods One thousand COPD subjects from the observational, multicentre, three-year ECLIPSE (Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints) study (NCT00292552, trial registration in February 2006) were included. Matrix metalloproteinase (MMP)-generated fragments of collagen type I, and type VI (C1M and C6M) were assessed in month six serum samples. A random-coefficient model with both a random intercept and a random slope was used to test the ability of the markers to predict post-dose bronchodilator FEV1 (PD-FEV1) change over two years adjusting for sex, age, BMI, smoking, bronchodilator reversibility, prior exacerbations, emphysema and chronic bronchitis status at baseline. Results Annual change of PD-FEV1 was estimated from a linear model for the two-year study period. Serum C1M and C6M were independent predictors of lung function change (p = 0.007/0.005). Smoking, bronchodilator reversibility, plasma hsCRP and emphysema were also significant predictors. The effect estimate between annual change in PD-FEV1 per one standard deviation (1SD) increase of C1M and C6M was +10.4 mL/yr. and +8.6 mL/yr. C1M, and C6M, had a significant association with baseline FEV1. Conclusion We demonstrated that markers of tissue turnover were significantly associated with lung function change. These markers may function as prognostic biomarkers and possibly as efficacy biomarkers in clinical trials focusing on lung function change in COPD. Trial registration NCT00292552, Retrospectively registered, trial registration in February 2006. Electronic supplementary material The online version of this article (10.1186/s12890-017-0505-4) contains supplementary material, which is available to authorized users.

Background There are two major needs in clinical development of DMOADs: 1) Identifying a suitable population with an active and progressive disease in order to demonstrate significant improvements by an efficacious intervention; and 2) Phenotyping patients and linking them to a corresponding treatment mode-of-action (e.g. anti-inflammatory). The biochemical marker CRPM is a neoepitope of C-reactive protein (CRP) and is released from the local inflamed tissue when CRP is degraded by proteases such as matrix metalloproteinases Objectives The purpose of this study was to translate the CRPM, from rheumatoid arthritis (RA), where it has been extensively tested, to OA, and to test whether it is predictive of radiographic OA. Methods The placebo arms of two phase III OA trial (clinicaltrial.gov: NCT00486434 and NCT00704847), a phase III RA study (the LITHE study, N=490), which included patients with active, moderate-severe RA (NCT00106535), as well as in an early RA cohort (N=92) were used. Subjects with symptomatic and radiographic knee OA: WOMAC pain ≥150mm and/or WOMAC function ≥510mm, and Kellgren-Lawrence grade (KLG) 2 or 3. KLG were scored for both knees at baseline and year 2 (Y2). Serum CRPM and hsCRP were measured at baseline. The association between serum CRPM levels and disease activity score (DAS28) and hsCRP was investigated by Spearman9s correlations. Quartile ranges of CRPM in the early RA cohort were used to define the cut-off between inflammatory OA and non-inflammatory OA. OA knees were divided into cases and controls based on a terminology proposed by the FNIH-OAI consortium (1); knees with KLG≥2 at BL were excluded, and incidence OA at Y2 was defined KLG≥2. Logistic regression was used to compare cases and controls. Results There was a significant correlation between disease activity measures and CRPM in both RA studies. Seventy-five percent of the LITHE patients had high or very high levels of CRPM at BL, which was changed to a pattern similar to early RA after treatment. The mean CRPM levels were significantly lower in OA (8.5 [95% CI 8.3–8.8] ng/mL) compared to the RA patients (15.6 [9.5–21.6] ng/mL); however, a significant subset of OA patients (41% and 31% in SMC2301 and SMC2302) had CRPM levels ≥9ng/mL, as 75% of patients with early RA. Patients with BL or Y2 CRPM levels ≥9ng/mL were more likely to develop knee OA than patients with low level of CRPM. Overall, moderate to very high levels of CRPM at BL and Y2 were predictive of incidence OA with odds ratio of 4.6 [1.2–17] and 2.5 [1.2–4.8]. Conclusions A subset of OA patients, up to 41%, appear to have tissue inflammation comparable to that of RA, reflected by the level of CRPM. Furthermore, high CRPM levels was prognostic of incident knee OA. These data suggest that CRPM is blood-based biochemical marker for finding OA patients with an inflammatory phenotype. References Longitudinal validation of periarticular bone area and 3D shape as biomarkers for knee OA progression? Data from the FNIH OA Biomarkers Consortium.Hunter D et al.Ann Rheum Dis. 2016 Sep;75(9):1607–14. Disclosure of Interest A. Bay-Jensen Shareholder of: Nordic Bioscience, Grant/research support from: DBOARD, Employee of: Nordic Bioscience, A. Bihlet Shareholder of: Nordic Bioscience, Employee of: Nordic Bioscience, I. Byrjalsen Employee of: Nordic Bioscience, J. Andersen Shareholder of: Nordic Bioscience, Employee of: Nordic Bioscience, Y. He Employee of: Nordic Bioscience, A. S. Siebuhr Employee of: Nordic Bioscience, C. Thudium Employee of: Nordic Bioscience, B. Riis Shareholder of: Nordic Bioscience, C. Christiansen Shareholder of: Nordic Bioscience, M. Karsdal Shareholder of: Nordic Bioscience, Employee of: Nordic Bioscience

Importance Sprifermin is under investigation as a disease-modifying osteoarthritis drug. Objective To evaluate the effects of sprifermin on changes in total femorotibial joint cartilage thickness in the more symptomatic knee of patients with osteoarthritis. Design, Setting, and Participants FORWARD (FGF-18 Osteoarthritis Randomized Trial with Administration of Repeated Doses) was a 5-year, dose-finding, multicenter randomized clinical trial conducted at 10 sites. Eligible participants were aged 40 to 85 years with symptomatic, radiographic knee osteoarthritis and Kellgren-Lawrence grade 2 or 3. Enrollment began in July 2013 and ended in May 2014; the last participant visit occurred on May 8, 2017. The primary outcome at 2 years and a follow-up analysis at 3 years are reported. Interventions Participants were randomized to 1 of 5 groups: intra-articular injections of 100 μg of sprifermin administered every 6 months (n = 110) or every 12 months (n = 110), 30 μg of sprifermin every 6 months (n = 111) or every 12 months (n = 110), or placebo every 6 months (n = 108). Each treatment consisted of weekly injections over 3 weeks. Main Outcomes and Measures The primary end point was change in total femorotibial joint cartilage thickness measured by quantitative magnetic resonance imaging at 2 years. The secondary end points (of 15 total) included 2-year change from baseline in total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. The minimal clinically important difference (MCID) is unknown for the primary outcome; for total WOMAC score in patients with hip and knee osteoarthritis, the absolute MCID is 7 U (95% CI, 4 to 10 U) and the percentage MCID is 14% (95% CI, 9% to 18%). Results Among 549 participants (median age, 65.0 years; 379 female [69.0%]), 474 (86.3%) completed 2-year follow-up. Compared with placebo, the changes from baseline to 2 years in total femorotibial joint cartilage thickness were 0.05 mm (95% CI, 0.03 to 0.07 mm) for 100 μg of sprifermin administered every 6 months; 0.04 mm (95% CI, 0.02 to 0.06 mm) for 100 μg of sprifermin every 12 months; 0.02 mm (95% CI, −0.01 to 0.04 mm) for 30 μg of sprifermin every 6 months; and 0.01 mm (95% CI, −0.01 to 0.03 mm) for 30 μg of sprifermin every 12 months. Compared with placebo, there were no statistically significant differences in mean absolute change from baseline in total WOMAC scores for 100 μg of sprifermin administered every 6 months or every 12 months, or for 30 μg of sprifermin every 6 months or every 12 months. The most frequently reported treatment-emergent adverse event was arthralgia (placebo: n = 46 [43.0%]; 100 μg of sprifermin administered every 6 months: n = 45 [41.3%]; 100 μg of sprifermin every 12 months: n = 50 [45.0%]; 30 μg of sprifermin every 6 months: n = 40 [36.0%]; and 30 μg of sprifermin every 12 months: n = 48 [44.0%]). Conclusions and Relevance Among participants with symptomatic radiographic knee osteoarthritis, the intra-articular administration of 100 μg of sprifermin every 6 or 12 months vs placebo resulted in an improvement in total femorotibial joint cartilage thickness after 2 years that was statistically significant, but of uncertain clinical importance; there was no significant difference for 30 μg of sprifermin every 6 or 12 months vs placebo. Durability of response also was uncertain. Trial Registration ClinicalTrials.gov Identifier:NCT01919164

Background Chronic obstructive pulmonary disease (COPD) is characterized by airflow obstruction and loss of lung tissue mainly consisting of extracellular matrix (ECM). Three of the main ECM components are type I collagen, the main constituent in the interstitial matrix, type VI collagen, and elastin, the signature protein of the lungs. During pathological remodeling driven by inflammatory cells and proteases, fragments of these proteins are released into the bloodstream, where they may serve as biomarkers for disease phenotypes. The aim of this study was to investigate the lung ECM remodeling in healthy controls and COPD patients in the COPDGene study. Methods The COPDGene study recruited 10,300 COPD patients in 21 centers. A subset of 89 patients from one site (National Jewish Health), including 52 COPD patients, 12 never-smoker controls and 25 smokers without COPD controls, were studied for serum ECM biomarkers reflecting inflammation-driven type I and VI collagen breakdown (C1M and C6M, respectively), type VI collagen formation (Pro-C6), as well as elastin breakdown mediated by neutrophil elastase (EL-NE). Correlation of biomarkers with lung function, the SF-36 quality of life questionnaire, and other clinical characteristics was also performed. Results The circulating concentrations of biomarkers C6M, Pro-C6, and EL-NE were significantly elevated in COPD patients compared to never-smoking control patients (all p

Background There is a need to identify individuals with COPD at risk for disease progression and mortality. Lung tissue remodeling is associated with the release of extracellular matrix (ECM) fragments into the peripheral circulation. We hypothesized that ECM remodeling was associated with mortality in COPD and measured neo-epitopes originating from ECM proteins associated with lung tissue remodeling. Methods Biomarkers of ECM remodeling were assessed in a subpopulation (n = 1000) of the Evaluation of COPD Longitudinally to Identify Predictive Surrogate End-points (ECLIPSE) cohort. Validated immunoassays measuring serological neo-epitopes produced by proteolytic cleavage associated with degradation of collagen type I, III, IV, and VI, elastin, and biglycan, and formation of collagen type VI as well as fibrinogen and C-reactive protein were used. Multivariate models were used to assess the prognostic value of these biomarkers. Results Thirty subjects (3.0 %) died during follow-up. Non-survivors were older, had reduced exercise capacity, increased dyspnea score, and included fewer current smokers. All collagen biomarkers were significantly elevated in non-survivors compared to survivors. Mortality risk was significantly increased for subjects with collagen remodeling biomarkers in the upper quartile, especially for the degradation fragment of collagen type IV C6M (hazard ratio 6.6 [95 % confidence interval 2.9-15.2], P

Background: There is a need to identify the patients with COPD at risk for rapid disease progression and mortality. Lung tissue remodeling is associated with release of extracellular matrix (ECM) fragments into the circulation which may serve as candidate biomarkers. We hypothesized that ECM turnover is related to mortality in COPD, and measured a panel of degradation markers of proteins associated with the fibrotic response. Methods: Week 26 serum and year 1 plasma samples were used to assess biomarkers of ECM turnover in a subpopulation (n=1000) of the Evaluation of COPD Longitudinally to Identify Predictive Surrogate End-points (ECLIPSE) cohort. Competitive ELISAs measured biomarkers produced by proteolytic cleavage associated with degradation of ECM proteins, including collagens and elastin. Cox proportional hazards analysis was used to assess the predictive value of biomarkers for year 3 mortality. Results: A total of 30 subjects (3.0%) died over the 3 years of observation. Several blood biomarkers were significantly elevated in subjects deceased at year 3 compared to survivors, including degradation fragments of collagen type VI (C6M, P Conclusion: We have demonstrated for the first time that blood biomarkers of lung tissue destruction were strongly associated with mortality in patients with COPD. These results indicate that assessment of tissue remodeling may be useful in prognosis of COPD and identification of patients with fastest progression and worst outcome.

Background: Markers of extracellular matrix turnover were evaluated in the ECLIPSE study, an observational, multicentre, three-year study ([NCT00292552][1]). Methods: 1000 COPD subjects from ECLIPSE (GOLD stage II-IV) selected based on the most or the least rapid lung function decline were included. Tissue turnover was assessed in serum samples from the year 1 visit by ELISAs measuring MMP-generated fragments of collagen type I, and VI. A random-coefficient model with both a random intercept and a random slope was used to test the ability of the markers to predict post-dose bronchodilator FEV1 (FEV1-PD) and FEV1% predicted (FEV1%-PD) loss over two years including the co-variates gender, age, BMI, smoking, bronchodilator reversibility, #prior AECOPDs, emphysema and chronic bronchitis status at baseline. Results: Annual loss of lung function by FEV1-PD and FEV1%-PD was estimated from a linear model for the year 1 to 3 study period. Serum C1M and C6M were independent predictors of lung function decline ( p=0.007/0.005 (FEV1-PD) and p=0.02/0.03 (FEV1%-PD), respectively). Smoking status, bronchodilator reversibility, and emphysema were also confirmed as predictors. The effect on annual change in FEV1-PD (mL/yr) per 1 standard deviation (1SD) of C1M and C6M was 10.4mL and 8.6mL, respectively; for FEV1%-PD (%/yr) the effect of 1SD change in C1M and C6M was 0.37% and 0.29%, respectively. Conclusion: We demonstrated that markers of tissue turnover were prognostic for progression of lung function decline and may used as prognostic biomarkers and possibly as efficacy biomarkers in clinical trials. Funding statement: ECLIPSE (SCO104960, [NCT00292552][1]) was sponsored by GSK. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00292552&atom=%2Ferj%2F46%2Fsuppl_59%2FPA3988.atom

Despite massive investments in the development of novel treatments for heterogeneous diseases such as COPD, the resources spent have only benefited a fraction of the population treated. Personalized health care to guide selection of a suitable patient population already in the clinical development of new compounds could offer a solution. This review discusses past successes and failures in drug development and biomarker research in COPD, describes research in COPD phenotypes and the required characteristics of a suitable biomarker for identifying patients at higher risk of progression, and examines the role of extracellular matrix proteins found to be upregulated in COPD. Novel biomarkers of connective tissue remodeling that may provide added value for a personalized approach by detecting subgroups of patients with active disease suitable for pharmacologic intervention are discussed.

Background Pain is the principal clinical symptom of osteoarthritis (OA), and development of safe and effective analgesics for OA pain is needed. Trials of new analgesics for OA pain is impaired by substantial placebo-response (PR), and data describing characteristics and pain sub-types particularly associated with placebo-response is needed. Objectives The purpose of this post-hoc analysis was to investigate clinical characteristics and pain subtypes associated with PR as measured by the five pain questions of the Western Ontario and McMasters Arthritis (WOMAC) Index of the target (T)- and the non-target (NT) knees in the pooled data of two phase III randomized clinical trials of an oral treatment in OA. Methods Pooled data from the placebo-groups of two phase III randomized clinical trials (NCT00486434 and NCT00704847) in patients with knee OA followed for two years were analyzed. Main inclusion criteria for T knees were a Kellgren-Lawrence grade of 2 or 3, Joint-Space Width (JSW) of minimum of 2.0 mm at the medial tibio-femoral joint, and WOMAC pain ≥150 out of 500 mm. All analyses were performed on data from the T knees (N=771) and a sub-group of NT knees matching the pain inclusion criteria of the T knees (N=256). All subjects in the analysis belonged to the Per-Protocol population. Pain of the T and NT knees was measured using the WOMAC pain sub-index, five questions: Q1; during walking on a flat surface, Q2; using stairs, Q3 at night while in bed, Q4; sitting or lying and Q5; while standing. Changes in percent from baseline pain were calculated at months 1, 6, 12 and 24, and differences between individual questions were assessed using a repeated measures ANOVA. Pain by category (“under load”; WOMAC questions 1, 2 and 5 and “idle”; WOMAC questions 3 and 4) were similarly analyzed for change over time, and compared in a repeated measures ANOVA. Selected patient baseline characteristics; pain by WOMAC question, Joint-space width (JSW), age, and BMI were assessed for association with PR defined as change in percent from baseline to year two using Spearman9s correlation. Results Baseline pain was significantly higher in WOMAC Q2, compared to other pain questions (p The level of PR was significantly higher in questions related to pain while under load (Q1, Q2, Q5) compared to pain while idle (Q3, Q4), and this was statistically significant in the T knee (p Baseline BMI, age and JSW was not associated with PR. This indicates while no common clinical characteristics were associated with PR, other, perhaps psychological, factors may affect the susceptibility to PR. Conclusions These results indicate that the level of PR is significantly different between pain subtypes, as pain under load is significantly more susceptible to lead to PR than pain while idle. Disclosure of Interest A. Bihlet Shareholder of: Nordic Bioscience, Employee of: Nordic Bioscience, M. Karsdal Shareholder of: Nordic Bioscience, Employee of: Nordic Bioscience, I. Byrjalsen Employee of: Nordic Bioscience, A.-C. Bay-Jensen Shareholder of: Nordic Bioscience, Employee of: Nordic Bioscience, C. Christiansen Shareholder of: Nordic Bioscience, Employee of: Nordic Bioscience, J. Andersen Shareholder of: Nordic Bioscience, Employee of: Nordic Bioscience, H. Guhring: None declared, C. Ladel: None declared, M. Michaelis: None declared, B. Riis Shareholder of: Nordic Bioscience, Employee of: Nordic Bioscience, I. Valter: None declared