Introduction

Chronic visceral pain is a clinical challenge in >50% of Inflammatory Bowel Disease (IBD) cases (Morrison et al., 2013). A randomized controlled trial (RCT) demonstrated that transcranial direct current stimulation (tDCS) can modulate brain activity and effectively alleviate chronic abdominal pain associated with IBD (Neeb et al., 2019). To elucidate the underlying mechanism of tDCS, we implemented this technique in a mouse model of inflammatory, chronic DSS colitis.

Aims & Methods

The tDCS protocol, including a total of 10 stimulations, was designed based on established human tDCS studies. An anodal direct current (0.5 mA, 20 min) was administered to both primary motor cortices over two separate periods with each period consisting of five consecutive days of stimulation, separated by a two-day break. The study was controlled by including a sham-treatment-group (0.5-minute sham stimulation).
For histology, H&E stained FFPE-sections of colon were assessed by scoring (Koelink et al., 2018). Barrier integrity was analysed by Ussing chamber experiments. To confirm that tDCS was affecting murine activity, mice were tracked in home cages using subcutaneously injected RFID-chips. Myenteric plexus (MP) cells of the murine small intestine, primarily the terminal ileum, were isolated and cultivated for 10 days. Staining with beta3-tubulin and S100B was performed confirming neuronal cell identity. Bulk-RNA sequencing was conducted using the NovaSeq Xplus system (read length 150 bp, read depth 30 million copies/run).

Results

The distal colon of DSS-treated mice revealed significantly stronger inflammation in the H&E scores compared to control mice (mean±SEM: Ctrl: 0.14±0.08; DSS: 1.52±0.19; MWU: p=0.0005). Only a tendency towards less inflammation was observed in tDCS-treated mice compared to sham-tDCS.
The DSS caused an inflammation-driven thickening of the colon wall, resulting in an increased transmural resistance. This effect was ameliorated by the tDCS-treatment (mean±SEM: DSS+sham-tDCS: 72.2±8.2 Ω·cm²; DSS+tDCS: 48.1±2.1 Ω·cm²; MWU: p=0.007).
DSS colitis was associated with a reduced activity, which was partially recovered by tDCS (mean±SEM: DSS+sham-tDCS: 70.7±15.2 relative distance units/day; DSS+tDCS: 205.9±40.4 relative distance units/day; MWU: p=0.029).
Neuronal cell identity was confirmed in isolated murine MP cells by immunostaining (beta3-tubulin, S100B). Bulk-RNAseq revealed a clear separation of tDCS and sham-tDCS treated colitis mice by PCA. Subsequently, 739 differentially expressed genes (DEGs) were identified in tDCS-treated DSS colitis mice compared to a sham-tDCS-treatment (622 upregulated, 117 downregulated genes; log2(fold-change)≥1.5; padj<0.05), Table 1. Analysis of KEGG and GO pathways revealed involvement in several biological processes, comprising neuroactive ligand-receptor interaction (p=7.94·10^-3), gated channel activity (p=2.4·10^-7), substrate-specific channel activity (p=1.99·10^-7), and leukocyte migration (p=3.99·10^-7).

Table 1 Selection of neurologically relevant DEGs

Conclusion

In colitis, transcranial direct current stimulation (tDCS) has the capacity to modulate activity of DSS-treated mice and alters gene expression in MP cells. This reveals another layer of evidence for the impact of central pathways on the gut / brain-gut-axis.

References

Morrison, G. et al., Inflamm. Bowel Dis., 2013. 19(6): 1210-7: Inflammatory Bowel Diseases publishes original basic science, translational, and clinical research regarding pathogenesis, epidemiology, evaluation, and treatment of IBD.
Neeb, L. et al., Brain Stimulation, 2019: BMJ 2019; 364 doi: Comparative efficacy and acceptability of non-surgical brain stimulation for the acute treatment of major depressive episodes in adults: systematic review and network meta-analysis.
Koelink, P. J. et al., JCC 2018: Journal of Crohn’s and Colitis, Volume 12, Issue 7, July 2018, Pages 794–803, Development of Reliable, Valid and Responsive Scoring Systems for Endoscopy and Histology in Animal Models for Inflammatory Bowel Disease.

Introduction

Upadacitinib, a selective JAK inhibitor, is approved for moderate-to-severe Crohn’s disease (CD). However, real-world data on its effectiveness and safety, particularly in highly refractory populations, remain scarce. The UPITA-Crohn registry was established to evaluate the outcomes of upadacitinib in clinical practice across multiple centers in Andalusia, Spain.

Aims & Methods

This ambispective, multicenter registry included 142 patients with refractory CD treated with upadacitinib in 12 Andalusian hospitals. Clinical and biochemical data were collected at baseline, weeks 12 and 16, and at 6 months. Clinical remission (CR) was defined as a Harvey-Bradshaw Index (HBI) <5; clinical-biochemical remission (CBR) as HBI <5, CRP <5 mg/L, and fecal calprotectin <250 μg/g; and steroid-free remission (SFR) as HBI <5 without corticosteroids from week 12. Outcomes were also analyzed overall and according to prior exposure to advanced therapies.

Results

The UPITA-Crohn registry cohort included 142 patients with refractory Crohn’s disease. The mean age was 40.8 years (range 18–76), with 40% male. The mean disease duration at the time of upadacitinib initiation was 13.3 years (range 1–42), with a mean of 2.7 failed advanced therapies, highlighting a population with longstanding and complex disease. Most patients had ileocolonic involvement (50%), 22% had perianal disease, and 32% had previously undergone resective surgery.
The majority (74.4%) received induction with upadacitinib 45 mg for 12 weeks. At week 12, clinical remission was achieved by 54% of patients, with 15% reaching clinical-biochemical remission. At 6 months, among those still on treatment, 48.3% maintained clinical remission, 16.1% achieved clinical-biochemical remission, and 18.4% achieved steroid-free remission (Table 1).
When stratified by prior therapy, 6-month clinical remission was similar between patients with ≥2 prior advanced therapies (48.5%) and those with only 1 prior therapy (47.4%), with no significant difference. Steroid-free and clinical-biochemical remission rates were also slightly higher among less refractory patients, but differences were modest.
A total of 31 patients (21.8%) discontinued upadacitinib before 6 months, mainly due to primary non-response (70.9%). Adverse events were reported in 21.1% of patients, most commonly infections (9 cases), acne (7), transient transaminase elevation (5), and herpes zoster (2). Seven discontinuations were due to serious adverse events, including thrombosis, stroke, myocardial infarction, fever, and severe infections.

Table 1: Effectiveness Outcomes

Conclusion

Upadacitinib demonstrated meaningful effectiveness and a manageable safety profile in a real-world cohort of refractory Crohn’s disease patients. Notably, clinical remission rates remained stable even in those with multiple prior advanced therapies, suggesting upadacitinib may be a valuable option for patients with limited alternatives.

Introduction

^​​​​​​T cells, are a major regulator and source of pro-inflammatory cytokines, which may promote colitis, but be protective in some cancers^1,2. Nevertheless, limited efforts have been made to explore factors which determine the phenotype of T cells and their impact on the above-mentioned phenomena. The adhesion G protein-coupled receptor F5 (ADGRF5) belongs to seven-transmembrane receptor subfamily and may be related to development of some cancer types³.

Aims & Methods

The aim of the study was to assess the significance of ADGRF5 for T cell function and its impact on colitis and colon cancer progression. WT and ADGRF5 knockout CD4⁺ T cells were examined for cytokine genes and proteins using real-time PCR, Western blot and multiplex analysis. Tumor killing assay and flow cytometry analysis were performed to evaluate tumor killing properties of T cells co-cultured with MC38 colon cancer cells. ADGRF5 WT and KO mice were utilized to examine the impact of ADGRF5 on colitis, colitis-associated cancer development and colon cancer growth. Adoptive transfer of WT and ADGRF5 knockout CD4⁺ and CD8⁺ T cells were examined in tumor models to assess their role in disease progression.

Results

In murine model of colon cancer, animals with ADGRF5 knockout developed significantly smaller tumors which was accompanied by enhanced CD3 expression and hyperproduction of cytokines related to T cell action compared to wild type mice. Ex vivo analysis of two main population of T cells obtained from spleen of wild type and ADGRF5 knockout mice revealed that activated CD4⁺ but not CD8⁺ T cells with ADGRF5 were manifested by increased production of major anti-cancer molecules such as interferon γ (IFN- γ), perforin and granzyme B, and were characterized by secretion profile of cytokines related to mixed phenotype of T helper (T_h) 1 and T_h2 cells. Moreover, we documented higher proportion of apoptotic cells in co-culture of MC38 colon cancer cells with ADGRF5 knockout but not wild type CD4⁺ T cells. Finally, in the murine model of colon cancer adoptive transfer of CD4⁺ T cells with ADGRF5 knockout led to a significant reduction of tumor volume which was reversed by administration of antibody against IFN-γ. Nevertheless, ADGRF5 knockout in mice with colitis-associated colorectal cancer and colitis was related to significantly higher number of colon tumors and worse disease activity index compared to wild type animals, respectively. These results together with the analysis of gene expression signature in inflamed colons suggest opposite role for ADGRF5 in colitis than in the allograft colon cancer.

Conclusion

ADGRF5 is a critical regulator of T cell function and specific knockout of ADGRF5 reprograms CD4⁺ T cells into the pro-inflammatory phenotype. Our in vitro and in vivo studies indicated that ADGRF5 knockout in T cells promote pro-inflammatory cytokines, which prevent gastrointestinal cancer progression while boost both colitis and colitis-associated colorectal cancer development.

References

1. Jacenik D., Karagiannidis I., Beswick E.J. 2022. T_h2 cells inhibit growth of colon and pancreas cancers by promoting anti-tumorigenic responses from macrophages and eosinophils. Br J Cancer. 128: 387-397. doi: 10.1038/s41416-022-02056-2.
2. Shale M., Schiering C., Powrie F. 2013. CD4⁺ T cell subsets in intestinal inflammation. Immunol Rev. 252: 164-82. doi: 10.1111/imr.12039.
3. Jacenik D., Hikisz P., Beswick E.J., Fichna J. 2023. The clinical relevance of the adhesion G protein-coupled receptor F5 for human diseases and cancers. Biochim Biophys Acta Mol Basis Dis. 1869: 166683 doi: 10.1016/j.bbadis.2023.166683.

Disclosure

The work was supported by the National Science Centre, Poland under research project no 2019/32/C/NZ5/00064 (DJ).

Introduction

The efficacy of IL-23 blockade has been established in the treatment of patients with ulcerative colitis (UC). While studies in psoriasis have indicated that selectively targeting the IL-23 subunit p19 is more effective than general IL-23 blockade, it remains unclear whether a similar response can be expected in UC.

Aims & Methods

This study aimed to assess the efficacy and safety of monoclonal antibodies against the interleukin-23 subunit p19 (IL-23 p19 monoclonal antibodies) vs. placebo for induction therapy of patients with moderate to severely active UC who had failure to conventional treatment. We searched PubMed, Embase, and Cochrane databases. The primary outcomes were clinical remission and clinical response. The secondary outcomes were endoscopy remission, symptomatic remission, and adverse events (AEs). We pooled the risk ratios (RR) with 95% confidence intervals (CI) for dichotomous outcomes and used the DerSimonian-Laird random-effects model. P-values inferior to 0.05 were deemed indicative of statistical significance. Heterogeneity was assessed with I² statistics.

Results

We included 3 RCTs (1,716 patients) conducted on several continents. A total of 1,227 patients (70.9%) received IL23 p19 monoclonal antibodies (Mirikizumab, 1019 patients [59.4%]; Guselkumab, 208 patients [12.1%]) and 489 patients (28.5%) received placebo. The mean disease duration was ≥ 6 years. and the follow-up period was 12 weeks. Patients in both the intervention and placebo groups concomitantly received aminosalicylates, glucocorticoids, or immunomodulators. The results of the pooled analyses are shown in Table 1. The IL-23 p19 monoclonal antibodies group had a significantly higher probability of clinical remission (RR 1.91; 95% CI 1.46-2.49), clinical response (RR 1.88; 95% CI 1.36-2.61), endoscopic remission (RR 1.76; 95% CI 1.40-2.21) and symptomatic remission (RR 1.94; 95% CI 1.46-2.56) compared to the placebo group. Additionally, the IL-23 p19 monoclonal antibodies group presented a lower risk of serious AEs (RR 0.54; 95% CI 0.32-0.90) and discontinuation of treatment due to AEs (RR 0.24; 95% CI 0.14-0.43) than the placebo group. However, there was no significant difference between the groups in terms of overall AEs (RR 0.94; 95% CI 0.84–1.05).

Table 1. Results from the pooled analyses

Conclusion

This analysis supports the use of IL-23 p19 monoclonal antibodies as a safe and effective option for induction therapy in patients with moderate to severely active UC who had failure to conventional treatment. However, new large RCTs are required to confirm these findings.

References

1. D'Haens G, Dubinsky M, Kobayashi T, et al. Mirikizumab as Induction and Maintenance Therapy for Ulcerative Colitis. N Engl J Med. 2023;388(26):2444-2455.
2. Peyrin-Biroulet L, Allegretti JR, Rubin DT, et al. Guselkumab in Patients With Moderately to Severely Active Ulcerative Colitis: QUASAR Phase 2b Induction Study. Gastroenterology. 2023 Dec;165(6):1443-1457.
3. Sandborn WJ, Ferrante M, Bhandari BR, et al. Efficacy and Safety of Mirikizumab in a Randomized Phase 2 Study of Patients With Ulcerative Colitis. Gastroenterology. 2020;158(3):537-549.e10.

Introduction

A deeper understanding of the pathogenesis of UC has led to the emergence of new therapeutic strategies. One of them consists of targeted exposure with biological drugs to certain molecules that regulate the interaction between leukocytes and endothelial cells in the inflammatory zone (mainly leukocyte integrins and endothelial cell adhesion molecules of the immunoglobulin superfamily).

Aims & Methods

Purpose of the study: To study the content of adhesion molecules ICAM-1, ICAM-2 and L-selectin in the peripheral blood of patients with ulcerative colitis (UC) and the effect of vedolizumab (Intivio) on their levels.
Materials and methods: We examined 12 patients with moderate and severe forms of UC and the ineffectiveness of previous standard therapy. The severity of the UC attack was calculated according to the Mayo index. Antivio® 300 mg was administered to patients intravenously according to the attached instructions. The content of adhesion molecules in the peripheral blood was studied before and 6 weeks after the first injection of vedilizumab. The control group consisted of 15 healthy volunteers. The content of ICAM-1, ICAM-2 and L-selectin in blood serum was determined by multilayer ELISA analysis (Bender med.Systems, Austria). Statistical processing of the obtained results was carried out using SPSS 13.0 software.

Results

It was found that the initial levels of ICAM-1 (461.9±28.4 ng/ml), ICAM-2 (323.3±18.4 ng/ml) and sL-selectin (1650±12.25 U/ml) ) in the peripheral blood of patients with UC were increased (P<0.05 with control), the Mayo index was 9 points. After four infusions of Vedolizumab (week 14), the levels of soluble molecules decreased in 4 patients, with a predominant decrease in sL-selectin (201±9.32 ng/ml, 197±8.54 pg/ml and 1008±15.3 U/ml respectively). The Mayo index was 5 points. In 8 patients, by the 6th week of treatment, the levels of the studied adhesive molecules did not change, although the Mayo index decreased by 3 points.

Conclusion

The initial level of ICAM-1, ICAM-2 and sL-selectin in the peripheral blood of patients with severe forms of UC is increased. The dynamics of the synthesis of adhesive molecules by immunocompetent cells under the influence of the fourth administration of Vedolizumab may predict the possibility of continuing the administration of the drug.

Introduction

The efficacy and safety of risankizumab (RZB), an anti-interleukin 23p19 monoclonal antibody, as induction and maintenance therapy for adults with moderately to severely active ulcerative colitis (UC) was recently reported.^1,2 Influences of baseline disease characteristics on clinical outcomes are important to consider when optimizing UC treatment. Herein we analyze the efficacy of RZB stratified by baseline UC disease characteristics.

Aims & Methods

In the 12-week phase 3 INSPIRE induction study (NCT03398148) patients with moderately to severely active UC were randomized 2:1 to receive intravenous (IV) RZB 1200 mg or placebo (PBO) at weeks 0, 4, and 8. Patients with clinical response to RZB IV induction at week 12 or 24 in the phase 2b/3 induction studies were randomized 1:1:1 to receive subcutaneous (SC) RZB 180 mg, RZB 360 mg, or PBO (RZB withdrawal) every 8 weeks in the 52-week phase 3 COMMAND maintenance study (NCT03398135). This post hoc analysis evaluates clinical response, clinical remission, endoscopic remission, endoscopic improvement, and histological-endoscopic mucosal improvement (HEMI) at week 12 and 52 in subgroups stratified by baseline disease characteristics (Adapted Mayo score, pancolitis, high‑sensitivity C‑reactive protein [hs‑CRP], Mayo endoscopic subscore [ES], and disease duration).

Results

The induction analysis included 650 and 325 patients who received RZB 1200 mg IV and PBO IV, respectively. The maintenance analysis included 179, 186, and 183 patients who received RZB 180 mg SC, RZB 360 mg SC, and PBO (RZB withdrawal) SC, respectively. At induction week 12, the proportions of patients receiving RZB 1200 mg IV who achieved clinical response were numerically higher for the following baseline characteristic subgroups: pancolitis absence (70.5%) vs pancolitis presence (58.4%), Mayo ES of 2 (75.5%) vs Mayo ES of 3 (59.0%), and hs-CRP ≤ 5 mg/mL (68.9%) vs hs-CRP > 5 mg/mL (57.3%); the proportions of patients receiving RZB 1200 mg IV who achieved clinical remission at induction week 12 were also numerically higher for subgroups with pancolitis absence (25.3%) vs pancolitis presence (15.6%), Mayo ES of 2 (31.7%) vs Mayo ES of 3 (14.9%), and hs-CRP ≤ 5 mg/mL (23.7%) vs hs-CRP > 5 mg/mL (14.5%; Table). Differences in outcomes were not observed between subgroups stratified by Adapted Mayo score or disease duration. At week 52 of the maintenance study, there was no impact of baseline disease characteristics on achievement of clinical response and clinical remission with RZB (Table).

Conclusion

RZB induction and maintenance therapy improved clinical outcomes, regardless of baseline disease characteristics. Numerically higher RZB induction efficacy was observed for patients with no baseline pancolitis, Mayo ES of 2, and hs‑CRP ≤ 5 mg/L. These trends are consistent with prior observations that patients with milder UC disease phenotypes tend to be more responsive to therapy.

References

1. Louis E, et al. United Eur Gastroenterol J . 2023;11(S8):26–28. Abstract OP021.
2. Louis E, et al. J Crohns Colitis. 2024;18(S1):i10–12. Abstract OP06.

Disclosure

CH has served as a consultant, advisor, and/or has received education funds from AbbVie, Bausch Health, BMS, the Helmsley Charitable Trust, Janssen, Pfizer, Roivant, and Takeda.
MDL has received consulting fees and/or research grants from AbbVie, BMS, Intercept, Janssen, Lilly, Pfizer, Prometheus, Takeda, and Target RWE.
SRF has served as a consultant or advisor for AbbVie, Janssen, MSD, Takeda, Tillots, and Vitoria.
TF has received research grants and/or speaking honoraria from AbbVie, Ajinomoto, Alfresa, BI, BMS, Celgene, Celltrion, Daiichi Sankyo, EA Pharma, Eisai, Gilead, Janssen, Kissei, Kyorin, Kyowa Hakko Kirin, Lilly, Mebix, Mitsubishi Tanabe, Mochida, Nichiiko, Nippon Kayaku, Pfizer, Sanofi, Taiho, Takeda, and Zeria.
ZR has no disclosures to report.
JK, PL, SC, LC, RV, and PMH are employees of AbbVie and may hold AbbVie stock and/or stock options.
FA-A has served as a consultant and/or has received grants and speaker fees from AbbVie, Celltrion, Kern, MSD, and Takeda.
RA has served as a consultant or advisor for AbbVie, AstraZeneca, BI, Biogen, BMS, CED-Service GmbH, Celltrion, Falk Foundation, Galapagos, Gilead, InDex, Janssen-Cilag, Lilly, MSD, Roche, and Takeda.
Funding
AbbVie funded this study and participated in the study design, research, data collection, analysis, interpretation of data, reviewing, and approval of the abstract. All authors had access to relevant data and participated in the drafting, review, and approval of this abstract. No honoraria or payments were made for authorship. AbbVie and the authors thank all trial investigators and the patients who participated in this clinical trial. Medical writing support was provided by Morgan A Gingerich, PhD, of JB Ashtin, and funded by AbbVie, and Karen Chien, PhD, of AbbVie.

Introduction

Obefazimod is an oral small molecule that has demonstrated long-term efficacy and safety in patients with moderate-to-severe ulcerative colitis (UC) (1,2). Obefazimod is known to modulate inflammation by upregulating a specific anti-inflammatory micro-RNA (miR-124) (3). We examined the long-term effects of obefazimod on miR-124 in blood and rectal biopsies of patients enrolled in a 96-week maintenance study.

Aims & Methods

Patients received placebo or obefazimod 25mg, 50mg or 100mg once daily (od) during a 16-week induction phase and, irrespective of their clinical response, could enter an open-label 96-week maintenance phase with obefazimod 50mg od. Absolute quantification (QuantaSoft Pro) of the miR-124 copy number was performed at baseline, weeks 48 and 96 by using droplet digital PCR technology on 115 whole blood samples and 508 rectal biopsy samples. An ANOVA was performed including treatment, time, the interaction between treatment and time, the baseline value as fixed factor and time as repeated effect.

Results

A daily treatment with obefazimod 50 mg significantly upregulated miR-124 over time in blood and rectal tissue at weeks 48 and 96 (p<0.001 vs. baseline). The miR-124 upregulation was observed in all patients, including those previously receiving placebo during the induction phase.

Table: Upregulated miR-124 in rectal tissue and blood of patients receiving obefazimod 50 mg during the maintenance phase

Conclusion

The 96-week efficacy of obefazimod 50mg od in patients with moderate-to-severe UC is associated with a maintained increase in miR-124 expression in blood and rectal tissue.

References

1. Vermeire S, Sands B, Tilg H et al. ABX464 (obefazimod) for moderate-to-severe, active ulcerative Colitis: a phase 2b, double-blind, randomised, placebo-controlled induction trial and 48 week, open-label extension. Lancet Gastroenterol Hepatol 2022, 7 (11): 1024-1035
2. Vermeire S, Sands B, Biguenet S et al. ABX464 (obefazimod) in patients with moderate-to-severe ulcerative colitis: an Interim 48-week the safety and efficacy analysis from an ongoing 96-week open-label maintenance phase 2b study. UEG journal 2022, 10 (S8): p.340
3. Apolit C, Campos N, Vautrin A et al. ABX464 (obefazimod) up-regulates miR-124 to reduce pro-inflammatory markers in inflammatory bowel diseases. Clin Trans Gastroenterol; 14(4):p e00560, April 2023; DOI: 10.14309/ctg.0000000000000560

Disclosure

Bruce E Sands reports consulting fees from Abbvie, Alimentiv , Amgen, Arena Pharmaceuticals, Artugen Therapeutics, Astra Zeneca, Boehringer Ingelheim, Boston Pharmaceuticals, Calibr, Celgene, Celltrion, ClostraBio, Equillium, Enthera, Evommune, Fresenius Kabi, Galapagos, Genentech (Roche), Gilead Sciences, GlaxoSmithKline, Gossamer Bio, Index Pharmaceuticals, Innovation Pharmaceuticals, Inotrem, Kaleido, Kallyope, Merck, Morphic Therapeutics, MRM Health, Progenity, Prometheus Biosciences, Prometheus Laboratories, Protagonist Therapeutics, Q32 Bio, Sun Pharma, Surrozen, Target RWE,Teva, TLL Pharmaceutical, Ventyx Biosciences; consulting and speaking fees from Abivax; consulting and speaking fees and other support from Lilly; research grants, consulting and speaking fees and other support from Bristol Myers Squibb, Janssen, Pfizer, Takeda; research grants and consulting fees from Theravance Biopharma; and stock options from Ventyx Biopharma.
Séverine Vermeire has received grants from AbbVie, J&J, Pfizer, Takeda and Galapagos; Séverine Vermeire has received consulting and/or speaking fees from: AbbVie, Abivax, AbolerIS Pharma, AgomAb, Alimentiv, Arena Pharmaceuticals, AstraZeneca, Avaxia, BMS, Boehringer Ingelheim, Celgene, CVasThera, Cytoki Pharma, Dr Falk Pharma, Ferring, Galapagos, Genentech-Roche, Gilead, GSK, Hospira, Imidomics, Janssen, J&J, Lilly, Materia Prima, MiroBio, Morphic, MrMHealth, Mundipharma, MSD, Pfizer, Prodigest, Progenity,