BACKGROUND. Monogenic IFN–mediated autoinflammatory diseases present in infancy with systemic inflammation, an IFN response gene signature, inflammatory organ damage, and high mortality. We used the JAK inhibitor baricitinib, with IFN-blocking activity in vitro, to ameliorate disease.METHODS. Between October 2011 and February 2017, 10 patients with CANDLE (chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperatures), 4 patients with SAVI (stimulator of IFN genes–associated [STING-associated] vasculopathy with onset in infancy), and 4 patients with other interferonopathies were enrolled in an expanded access program. The patients underwent dose escalation, and the benefit was assessed by reductions in daily disease symptoms and corticosteroid requirement. Quality of life, organ inflammation, changes in IFN-induced biomarkers, and safety were longitudinally assessed.RESULTS. Eighteen patients were treated for a mean duration of 3.0 years (1.5–4.9 years). The median daily symptom score decreased from 1.3 (interquartile range [IQR], 0.93–1.78) to 0.25 (IQR, 0.1–0.63) (P < 0.0001). In 14 patients receiving corticosteroids at baseline, daily prednisone doses decreased from 0.44 mg/kg/day (IQR, 0.31–1.09) to 0.11 mg/kg/day (IQR, 0.02–0.24) (P < 0.01), and 5 of 10 patients with CANDLE achieved lasting clinical remission. The patients’ quality of life and height and bone mineral density Z-scores significantly improved, and their IFN biomarkers decreased. Three patients, two of whom had genetically undefined conditions, discontinued treatment because of lack of efficacy, and one CANDLE patient discontinued treatment because of BK viremia and azotemia. The most common adverse events were upper respiratory infections, gastroenteritis, and BK viruria and viremia.CONCLUSION. Upon baricitinib treatment, clinical manifestations and inflammatory and IFN biomarkers improved in patients with the monogenic interferonopathies CANDLE, SAVI, and other interferonopathies. Monitoring safety and efficacy is important in benefit-risk assessment.TRIAL REGISTRATION. ClinicalTrials.gov NCT01724580 and NCT02974595.FUNDING. This research was supported by the Intramural Research Program of the NIH, NIAID, and NIAMS. Baricitinib was provided by Eli Lilly and Company, which is the sponsor of the expanded access program for this drug.

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BackgroundElevated serum IP-10 (CXCL10) levels and gene expression studies showing a prominent “interferon (IFN) signature” suggested modulation of IFN signaling might be a therapeutic option in CANDLE patients.ObjectivesThe objective of this compassionate use program is to provide baricitinib (JAK1/JAK2 inhibitor) to CANDLE patients who have no other comparable or satisfactory treatment options. Potential efficacy of treatment was assessed by a reduction in mean Autoinflammatory Diary Scores (ADS) to <0.5 and reduction of steroid doses by at least 50% in patients receiving steroids at baseline.MethodsPaired t-test was used to compare mean ADS and prednisone doses at the last NIH clinic visit to baseline data.ResultsBetween October 2011 and January 1st, 2016, 11 CANDLE patients have been treated (mean duration 2.5 years (SD±1)). 9 of 11 patients achieved an ADS of <0.5 at the time of their last visit (mean ADS decreased from 1.3 ± 0.8 at baseline to 0.2 ± 0.3) (p<0.005), 8 of 10 patients achieved a reduction in steroids doses > than 50% from baseline (mean total prednisone dose decreased from 0.8 mg/kg/day (0.2–1.8) to 0.2 mg/kg/day (0–1.1)) (p<0.005), 4 patients discontinued prednisone completely. The mean dose of baricitinib at the last patient visit was 6.9 ± 2.8 mg/day. 7 patients reported at least 1 serious adverse event (SAE), infection being the most common. 2 patients have been discontinued due to SAEs (avascular necrosis; BK viremia and azotemia). 1 patient required temporary interruption of baricitinib due to neutropenia, and 3 other patients had their dose electively reduced after testing positive for BK viremia: patients were asymptomatic. The most common adverse events were upper respiratory infections, cough, and BK viruria (baseline BK virus screening was not performed).1 patient died due to worsening interstitial lung disease with development of respiratory failure 4 months after discontinuation of baricitinib and initiation of another JAK inhibitor.ConclusionsPreliminary efficacy data in 11 CANDLE patients treated with baricitinib are encouraging and suggest that targeting IFN signaling with a JAK1/JAK2 inhibitor may be a successful therapeutic strategy. Monitoring BK viral titers in blood and urine, in addition to other measures of safety and efficacy, may be important in dose selection and the benefit-risk assessment of baricitinib for CANDLE patients.Disclosure of InterestG. Montealegre: None declared, A. Reinhardt: None declared, P. Brogan: None declared, Y. Berkun: None declared, A. Zlotogorski: None declared, D. Brown: None declared, L. Gao: None declared, J. Dare: None declared, S. Schalm: None declared, T. Klausmeier: None declared, S. Murias: None declared, D. Chapelle: None declared, H. Kim: None declared, S. Judd: None declared, M. O'Brien: None declared, A. de Jesus: None declared, B. Kost: None declared, S. Paul: None declared, R. Colbert Grant/research support from: CRADA (NIH -Eli Lilly), A. Brofferio: None declared, C. Lee: None declared, C. Hadigan: None declared, T. Heller: None ...