POS0366 MODERATE RATES OF TREATMENT INTENSIFICATION IN SLE PATIENTS WITH RESIDUAL DISEASE ACTIVITY

Background

The treat-to-target (T2T) strategy has gained significant attention in SLE,1 while EULAR has set remission or low disease activity as the goal of treatment.2 Nevertheless, the degree to which T2T is followed in real-life clinical settings has not been extensively studied.

Objectives

To assess the proportion of lupus patients with residual disease activity that had their therapy intensified during their most recent visit, identify associated factors, and assess the validity of the SLEDAI-2k as a predictor of this intensification.

Methods

Cross-sectional study of SLE patients who were evaluated in three tertiary centers in Greece during their last visit. Patients were categorized in four disease activity states (remission on and off treatment, low disease activity and non-optimally controlled), according to definitions used in previous studies.3 Intensification of treatment was defined as addition/increase of glucocorticoids (GC) or addition/increase of immunosuppressive (IS) agent (conventional or biologic). Logistic regression analysis was used to identify factors associated with treatment intensification and ROC analysis tο calculate sensitivity, specificity of different SLEDAI-2k cut-off values to predict this escalation.

Results

332 patients were included [93.1% female, mean (SD) age 48.5 (14.7) years, median (IQR) disease duration 6.5 (12.4) years]. Regarding disease activity states, 23.2% (n=77) of patients were in remission (off or on therapy), 36.7% (n=122) were in LDA, while 40.1% (n=133) were categorized as non-optimally controlled disease.

Within patients with residual disease activity, therapy intensification was offered to 25.8% and 48.9% of those with low disease activity and non-optimally controlled disease, respectively. In multivariable analysis, proteinuria (OR 6.78, 95% CI 2.06 – 22.25), arthritis (OR 5.48, 95% CI 3.20 - 9.40) and rash (OR 3.23, 95% CI 1.81 - 5.75), were associated with intensification of therapy. The AUC of the ROC analysis for total SLEDAI-2k to predict therapy escalation was 0.761, indicating only fair accuracy; the cut-off value with the best combination of sensitivity and specificity was 3 (sensitivity 87%, with a specificity of 55%). For clinical SLEDAI-2k, the respective AUC was marginally better (0.779), with a cut-off of 3 being associated with the best sensitivity (80%), with compromised specificity (64%). (Figure 1).

Figure 1.

ROC analysis of total and clinical SLEDAI to predict any increase in therapy

Conclusion

In real-life clinical settings, no therapy intensification was offered in more than half of patients categorized as non-optimally controlled disease. Total and clinical SLEDAI-2k showed only fair accuracy to predict therapy escalation, reflecting the role of additional parameters in the decision to escalate therapy in an individual patient.

References

[1]van Vollenhoven RF, Mosca M, Bertsias G, et al. Treat-to-target in systemic lupus erythematosus: recommendations from an international task force. Ann Rheum Dis 2014; 73: 958–967.

[2]Fanouriakis A, Kostopoulou M, Alunno A, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis 2019; 78: 736–745.

[3]Ugarte-Gil MF, Wojdyla D, Pons-Estel GJ, et al. Remission and Low Disease Activity Status (LDAS) protect lupus patients from damage occurrence: data from a multiethnic, multinational Latin American Lupus Cohort (GLADEL). Ann Rheum Dis 2017; 76: 2071–2074.

Disclosure of Interests

None declared

POS0183 THE EFFECT OF BELIMUMAB ON SRI-4 RESPONSE IN MULTIPLE SUBGROUPS OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: RESULTS OF A LARGE INTEGRATED ANALYSIS

Background

Belimumab (BEL) is approved for the treatment of active autoantibody-positive systemic lupus erythematosus (SLE).1 Four Phase 3 studies have consistently demonstrated greater SLE Responder Index (SRI) response rates with BEL vs placebo (PBO).2-5 This robust dataset allows for additional exploration of the onset of efficacy of BEL and response rates by patient (pt) characteristics.

Objectives

To perform a post hoc analysis evaluating the effect of BEL on SRI-4 response across a large, pooled population and pt subgroups.

Methods

The Belimumab Summary of Lupus Efficacy (Be-SLE) integrated analysis evaluated data from adults with SLE from 5 double-blind, PBO-controlled BEL trials: BLISS-76, BLISS-52, BLISS-NEA, BLISS-SC, and EMBRACE.2-6 Pts were randomised to BEL (monthly intravenous 10 mg/kg or weekly subcutaneous 200 mg) or PBO, plus standard therapy. Data were collected every 4 weeks (wks) from baseline (BL) to Wk 52. The SRI-4 response rate (a composite measure that includes ≥4-point reduction in Safety of Estrogens in Lupus Erythematosus National Assessment - SLE Disease Activity Index [SELENA-SLEDAI] score, stable Physician Global Assessment [PGA] increase of <0.3, and no new British Isles Lupus Assessment Group [BILAG] 1A/2B organ domain scores) by visit and time to first SRI-4 response maintained through Wk 52 were determined for both treatment groups. SRI-4 response rates at Wk 52 were evaluated by BL characteristic subgroups: SELENA-SLEDAI score; SLE International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) score; disease duration; biomarker levels (anti-dsDNA, complement [C]3/C4); glucocorticoid (GC), immunosuppressant (IS), and antimalarial (AM) use.

Results

Overall, 3086 pts were included (BEL, n=1869; PBO, n=1217). Most were female (94.4%); mean (standard deviation [SD]) age was 37.0 (11.6) years. Mean (SD) SLE duration was 6.4 (6.4) years.

At Wk 52, in the overall population, significantly more BEL vs PBO pts were SRI-4 responders (Figure 1). A significantly greater proportion of SRI-4 responders was observed with BEL vs PBO as early as Wk 8 (38.4% vs 33.3%; odds ratio, OR [95% confidence interval, CI] 1.25 [1.07, 1.46]; p=0.0060), which continued to increase to Wk 52 (54.8% vs 41.6%; OR [95% CI] 1.70 [1.46, 1.98]; p<0.0001). At Wk 52, more BEL vs PBO pts had a 4-point reduction in SELENA-SLEDAI (56.3% vs 43.1%; OR [95% CI] 1.71 [1.47, 2.00]; p<0.0001), no worsening in PGA (76.6% vs 67.9%; OR [95% CI] 1.52 [1.28, 1.79]; p<0.0001), and no new BILAG 1A/2B organ domain scores (77.1% vs 69.4%; OR [95% CI] 1.47 [1.25, 1.74]; p<0.0001). Pts on BEL were 52% more likely to experience an SRI-4 response that was maintained through Wk 52 (hazard ratio, HR [95% CI] 1.52 [1.36, 1.69]; p<0.0001).

Figure 1.

SRI-4 response at Wk 52 in the overall population and by BL characteristic subgroups.

*OR (95% CI) and p-value are from a logistic regression model for BEL vs PBO comparison with covariates of treatment group, study and BL SELENA-SLEDAI score (≤9 vs ≥10)

SRI-4 response rates were significantly higher with BEL vs PBO in most subgroups, with the highest response rates observed in pts with SELENA-SLEDAI score of ≥10, low C3 and/or C4 + anti-dsDNA ≥30 IU/ml, and low C3 and/or C4 at BL (Figure 1).

Conclusion

Significantly more pts receiving BEL had SRI-4 response rates that occurred from Wk 8 and were maintained through Wk 52 compared with pts receiving PBO. The efficacy of BEL was consistent across multiple pt subgroups, with higher response rates in pts with SELENA-SLEDAI scores of ≥10, low C3 and/or C4 + anti-dsDNA ≥30 IU/ml and low C3 and/or C4 at BL. These results further substantiate the benefits of BEL in the treatment of adults with SLE.

References

[1]GlaxoSmithKline. Benlysta US prescribing information. 2021

[2]Furie R, et al. Arthritis Rheumatol 2011;63(12):3918–30

[3]Navarra SV, et al. Lancet 2011;377(9767):721–31

[4]Stohl W, et al. Arthritis Rheum 2017;69(5):1016–27

[5]Zhang F, et al. Ann Rheum Dis 2018;77(3):355–63

[6] Ginzler E, et al. Arthritis Rheum 2021; doi: 10.1002/art.41900

Acknowledgements

This analysis was funded by GlaxoSmithKline (GSK). Medical writing support was provided by Lulu Hill, MPharmacol, Fishawack Indicia Ltd. UK, part of Fishawack Health, and was funded by GSK.

Disclosure of Interests

Michelle A Petri Consultant of: GSK, Grant/research support from: GSK, George Bertsias Speakers bureau: Pfizer, Aenorasis, UCB, Novartis, Lilly, SOBI, Consultant of: Novartis, GSK, AstraZeneca, Grant/research support from: GSK, Pfizer, Mark Daniels Shareholder of: GSK, Employee of: GSK, Norma Lynn Fox Shareholder of: GSK, Employee of: GSK, Bevra H. Hahn Consultant of: UCB, GSK, Anne Hammer Shareholder of: GSK, Employee of: GSK, Julia Harris Shareholder of: GSK, Employee of: GSK, Holly Quasny Shareholder of: GSK, Employee of: GSK, Chiara Tani Speakers bureau: GSK, AstraZeneca, Anca Askanase Consultant of: AstraZeneca, Aurinia Pharmaceuticals Inc., Amgen, AbbVie Inc., BMS, GSK, Grant/research support from: AstraZeneca, Eli Lilly and Company, GSK, Idorsia Pharmaceuticals Ltd, Janssen Pharmaceuticals, Pfizer

POS0781 RESIDUAL DISEASE ACTIVITY IN SLE: A REAL-LIFE CROSS-SECTIONAL STUDY IN THREE TERTIARY CENTRES TO EXPLORE THE ROOM FOR NOVEL THERAPIES

Background

According to updated EULAR recommendations, the goal of treatment in systemic lupus erythematosus (SLE) should be remission or low disease activity in all organ systems, achieved with the least possible dose of glucocorticoids.1 The proportion of patients achieving these two activity states under conventional therapies may vary between different patient cohorts and clinical settings.

Objectives

To assess the current disease activity state of SLE patients during their most recent visit in three tertiary centres experienced in the management of SLE.

Methods

In a cross-sectional study, patients were categorized as: 1) Remission off-therapy: SLE Disease Activity Index (SLEDAI)=0 without glucocorticoids (GC) or immunosuppressive drugs (IS), 2) Remission on-therapy: SLEDAI=0, GC ≤5mg/day prednisone (Pz) and/or IS (conventional and biologic, maintenance phase), 3) Low disease activity (LDA): SLEDAI ≤4, Pz ≤7.5mg/day and/or IS (maintenance phase), 4) Active/Non-optimally controlled: SLEDAI >4 and/or Pz >7.5mg/day and/or IS (induction phase).2 Hydroxychloroquine (HCQ) was allowed in all groups.

Results

A total of 332 patients were included [93.1% female, mean (SD) age 48.5 (14.7) years, median (IQR) disease duration 6.5 (12.4) years]. 81% (n=269) of patients were on HCQ and 69.6% (n=231) were receiving an additional IS at last visit. Regarding glucocorticoids (GC), almost half of our patients (48.2%, n=160) were not receiving any GC and of those receiving, only 7.8% (n=26) were receiving a Pz dose > 7.5 mg/day.

Mean (SD) total and clinical SLEDAI were 3.7 (3.0) and 3.0 (2.9), respectively. At their most recent visit, 33.7% (n=112) of patients had no clinical activity (clinical SLEDAI=0) and 24.4% (n=81) had neither clinical nor serological activity (total SLEDAI=0). 31.6% and 49.1% of patients had a total SLEDAI-2K ≥6 and a clinical SLEDAI-2K ≥4, respectively (Table 1). Regarding disease activity states, 23.2% (n=77) of patients were in remission (off or on therapy), 36.7% (n=122) were in LDA, while 40.1% (n=133) were categorized as non-optimally controlled. In the latter group, a total SLEDAI > 4 was present in most of patients (79.2% vs. 21.9% for prednisone > 7.5 mg/day and 19.8% for IS at induction regimen). In patients with LDA or non-optimally controlled disease, activity was mainly driven by the mucocutaneous and musculoskeletal components of SLEDAI, along with serologic activity (Figure 1). The latter was more common in LN patients. Overall, 83 patients (25.0%) in our cohort had evidence of serologic activity, of whom 31 (9.3% of total) had a clinical SLEDAI of 0.

Table 1.

Distribution of patients based on total and clinical SLEDAI-2K score at most recent visit

Total SLEDAIClinical SLEDAIScorePatients, n(%)ScorePatients, n(%)081(24.4)0112(33.7)1-5146(44)1-357(17.2)6-10101(30.4)4-8154(46.5)>104(1.2)>89(2.7)Figure 1.

Components of SLEDAI-2K at most recent visit (total cohort of patients and patients with LN)

Conclusion

Although a significant proportion of our patients were on HCQ and additional IS, about 40% of them were not in optimal control. Yet, residual disease activity, based on SLEDAI-2K, was moderate, compared to relatively high mean baseline SLEDAI-2K of lupus trials. These data provide a pragmatic view of lupus patients, who could be potential candidates for novel treatments or inclusion in clinical trials.

References:

[1]Fanouriakis A, Kostopoulou M, Alunno A, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis 2019; 78: 736–745.

[2]Ugarte-Gil MF, Wojdyla D, Pons-Estel GJ, et al. Remission and Low Disease Activity Status (LDAS) protect lupus patients from damage occurrence: data from a multiethnic, multinational Latin American Lupus Cohort (GLADEL). Ann Rheum Dis 2017; 76: 2071–2074.

Disclosure of Interests

None declared

Real-Life Outcome of Lupus Nephritis with Current Therapies: Study Protocol of a Multicentre Observational Study

Lupus nephritis (LN) affects a significant proportion of patients with systemic lupus erythematosus (SLE) and is characterised by increased morbidity and mortality. The updated joint EULAR/European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) recommendations for the management of LN have set as target of therapy the optimisation (preservation or improvement) of kidney function, accompanied by a reduction in proteinuria of at least 25% by 3 months, 50% by 6 months, and below 500-700 mg/g by 12 months (complete clinical response). It is currently unknown what proportion of Greek patients with LN reach these proposed targets with the current available treatments. At the same time, recent successful phase 3 trials have led to the approval of both belimumab and voclosporin for the treatment of patients with LN and have steered discussions as to whether the "induction-maintenance" paradigm should be substituted by an early combination treatment for all patients. To inform future therapeutic decisions and facilitate the positioning of these new drugs in the therapeutic algorithm of LN, the current study protocol aims to map the unmet needs in the treatment of LN in Greece, by quantifying the proportion of patients who attain the recommended treatment targets in everyday clinical practice.

AB0375 IN PATIENTS STARTING ETANERCEPT, MALE SEX, ABSENCE OF COMORBIDITIES AND NO csDMARDs CO-ADMINISTRATION ARE INDEPENDENT PREDICTORS OF LONG-TERM (MORE THAN 3 YEARS) PERSISTENCE TO THERAPY, IRRESPECTIVELY OF THE CLINICAL DIAGNOSIS

Background

Comparative data among rheumatoid arthritis (RA), spondylarthritis (SpA) and psoriatic arthritis (PsA) patients regarding long-term survival of etanercept (ETN) in clinical practice are limited.

Objectives

The first aim of this study was to analyze the long-term (>3 years) ETN survival comparatively between its three main indications. We also aimed to analyze for predictors of long term ETN survival.

Methods

We analyzed data from the University of Crete Rheumatology Clinic Registry (UCRCR), a single center prospective cohort study. All patients with a diagnosis of RA, SpA or PsA starting treatment with a biologic DMARD are recorded prospectively based on a common follow-up protocol. For the first aim, ETN survival >3 years was compared among the 3 diseases. For the 2nd aim patients on ETN >3 years were compared to those stopping ETN during the first 2 years. We analyzed baseline and early on treatment (first 6 months) characteristics, comedications, comorbidities as predictors for long term survival applying univariate and multivariate models.

Results

A total of 711 patients who were started on ETN were analyzed (RA: 450, SpA: 177, PsA: 84). As expected, patients’ and disease characteristics at baseline differed significantly between the 3 diagnoses (Table 1). Patients’ function was compromised irrespective of the diagnosis, while inflammatory activity was significant across diseases.

Table 1.

Baseline parameters [Medians (IQR) unless otherwise specified]

RA (n=450)SpA (n=177)PsA (n=84)pWomen N (%)370 (82)66 (37)46 (55)<0.001Age61.5 (53-70)44.5 (35-54)51 (41-62)<0.001Disease duration2.6 (0.9-6.5)0.8 (0.1-5.1)1.7 (0.6-4.9)<0.001Follow-up years1.0 (0.5-2.1)1.0 (0.4-3.1)1.1 (0.4-3.6)0.649Total comorbidities nr.3 (1-4)1 (0-3)2 (1-4)<0.001RDCI1 (1-2)0 (0-1)1 (0-1)<0.001Ever smokers N(%)124 (39)82 (67)30 (61)<0.001BMI31 (26-35)27 (25-32)29 (23-32)0.015Treatment line N (%): 1st264 (59)87 (49)43 (51)0.012  2nd119 (26)70 (39.5)24 (29)  ≥ 3rd67 (15)20 (11)17 (20)Nr of previous csDMARDs2 (1-3)1 (0-2)1 (1-2)<0.001Co-administered MTX N(%)284 (63)65 (37)50 (60)<0.001Monotherapy, N (%)60 (13)100 (56.5)25 (30)<0.001Ongoing corticosteroids N(%)153 (34)25 (14)17 (20)<0.001DAS28 - ESR5.8 (5.0-6.5)3.7 (2.9-4.7)5.3 (4.5-6.4)<0.001ASDAS-ESR-3.4 (2.8-4.1)3.6 (3.2-4.7)0.067CRP (mg/dl)0.4 (0.3-1.1)1.1 (0.3-2.4)0.8 (0.4-2.0)<0.001

During a follow-up of 1371 patient-years, 466 (65.5%) patients stopped therapy. The estimated percentage of patients persisting on ETN therapy for > 3 years was 28.4%, 42.8% and 44% of RA, SpA and PsA respectively. The main reason for therapy discontinuation was inefficacy (75% of stop reasons in RA vs. 58% in SpA vs. 69% in PsA).

In multivariable Cox regression analyses the most important predictor for ETN survival was the achievement of LDA/remission at 6 months based on DAS28 for RA or ASDAS for SpA [Odds Ratio (OR) 1.98, p=0.008 and 3.02, p=0.001 respectively]. Prognostic factors for ETN discontinuation specifically due to inefficacy were comorbidities number and csDMARDs coadministration (p<0.05 for both), while older age and no co-therapy with MTX predicted ETN stop due to adverse events (p<0.05 for both).

Logistic regression analysis indicated that male sex [OR: 2.08, p=0.004], calendar year of treatment start [OR per 3 years: 0.74, p=0.001], comorbidities’ number [OR: 0.82, p=0.045] and monotherapy [OR: 1.81, p=0.027] predict persistence on ETN therapy beyond 3 years, while the clinical diagnosis or other baseline parameters are not significant predictors.

Conclusion

In this prospective cohort study, we found that ETN survival was higher for patients with SpA/PsA as compared to RA. Male sex, absence of comorbidities and no csDMARDs co-administration are independent predictors of long-term persistence to therapy, irrespectively of the clinical diagnosis. Notably, both in RA and SpA, 6-month response predicted ETN survival in the long term.

Acknowledgements

This study was funded by the Pancretan Health Association and Pfizer Global Medical Grants.

Disclosure of Interests

None declared

POS0368 EARLY (3 MONTHS) IMPROVEMENT IN PHYSICIAN GLOBAL ASSESSMENT OF DISEASE ACTIVITY PREDICTS LONG-TERM RETENTION OF BELIMUMAB TREATMENT IN SLE: A MULTICENTRE OBSERVATIONAL STUDY OF 184 PATIENTS

Background

Belimumab has been introduced in the management of SLE for more than 10 years, however long-term efficacy and safety data are still limited and mostly derive from the extended phase of randomized clinical trials.

Objectives

To evaluate the long-term survival of belimumab treatment, reasons for treatment cessation and associated predictors in routine care setting.

Methods

Multicentre observational study of adult SLE patients who were treated with belimumab according to physician discretion and in line with the EULAR recommendations. Disease activity (Physician Global Assessment [PGA]: scale 0-3; SLE disease activity index-2000 [S2K]), flares (SELENA-SLEDAI Flare Index), organ damage (SLICC damage index [SDI]), co-administered treatments and dosage, adverse events and causes of belimumab discontinuation were monitored prospectively at 3–6-month intervals. Cox-regression analysis was performed to identify factors associated with reduced drug survival.

Results

A total 184 patients treated with belimumab for at least 3 months were included (women 95.6%; mean ± SD age 48.8 ± 13.4 years; disease duration 9.2 ± 11.3 years). Baseline S2K and PGA were 7.5 ± 3.0 and 1.64 ± 0.42, respectively, both demonstrating significant improvement at 6 months (4.5 ± 3.5 and 1.02 ± 0.69, respectively; p<0.001) and 12 months (3.5 ± 3.1 and 0.68 ± 0.55, respectively; p<0.001). Of patients receiving glucocorticoids at onset, 49.0% tapered the dose and 17.6% completely withdrew them. After a median (interquartile range) follow-up of 15.1 (16.9) months, 44.0% of patients discontinued belimumab due to suboptimal efficacy as judged by the treating physician (28.3%), adverse events (including infections) (9.8%) or other causes (e.g., pregnancy, patient decision). Accordingly, efficacy-related drug survival rates at 1 and 2 years were 70% and 61%, respectively, with corresponding safety-related survival rates of 94% and 87%, respectively. Baseline factors associated with belimumab discontinuation due to suboptimal efficacy included PGA >1.50 (hazard ratio [HR] 3.66; 95% confidence interval [95% CI] 1.14–11.73; p=0.029) and severe (RA-like) arthritis (HR 2.56; 95% CI 1.16–5.68; p=0.020) but not disease duration, use of glucocorticoids, active serology or organ damage. Notably, patients with early (3 months) improvement (i.e., any decrease in PGA) showed significantly lower risk for treatment cessation (HR 0.38; 95% CI 0.22–0.67; p=0.001) (Figure 1) and this effect was independent of the initial PGA level. Baseline use of hydroxychloroquine was associated with prolonged safety-related belimumab survival (HR 0.32; 95% CI 0.12–0.88; p=0.028).

Figure 1.

Efficacy-related survival of belimumab according to improvement or not of PGA at 3 months since treatment initiation.

Conclusion

In real-life setting, about 28% of SLE patients discontinue belimumab due to suboptimal treatment response per physician judgement, especially those with moderate-to-high activity and severe arthritis. Improvement in PGA at 3 months predicts long-term drug maintenance, therefore suggesting its value for patient monitoring. Our data confirm the very good tolerability of belimumab and identify hydroxychloroquine co-administration as a predictor for prolonged safety-related drug survival.

Acknowledgements

The study was partly funded by the Greek Rheumatology Society and the Greek Association of Professional Rheumatologists (ERE-EPERE) and by Pfizer Global Medical Grants

Disclosure of Interests

Myrto Nikoloudaki: None declared, Dionysis Nikolopoulos: None declared, SOFIA KOUTSOVITI: None declared, Irini Flouri: None declared, Noemin Kapsala: None declared, ARGYRO REPA: None declared, PELAGIA KATSIMPRI: None declared, EVANGELOS THEOTIKOS: None declared, Sofia Pitsigavdaki: None declared, Katerina Pateromichelaki: None declared, Anastasios Eskitzis: None declared, ANTONIA ELEZOGLOU: None declared, Prodromos Sidiropoulos: None declared, Antonis Fanouriakis: None declared, Dimitrios Boumpas: None declared, George Bertsias Speakers bureau: GSK, AstraZeneca, Pfizer, SOBI, UCB, Novartis, AENORASIS, Abbvie, Grant/research support from: GSK, Pfizer

AB0630 Assessment of organ damage accrual in Behçet's Syndrome over 2-year follow-up: results from the BODI Project longitudinal extension

Background

Preventing accrual of organ damage is a major goal in the treatment of Behçet’s Syndrome (BS). The BS Overall Damage Index (BODI) is the first damage assessment tool developed and preliminarily validated for BS.

Objectives

To assess the prevalence, extent, and determinants of organ damage accrual in the BODI validation cohort over 24 months of follow-up.

Methods

Overall, 189 patients from the multicenter BODI cohort underwent a 24 ±3 months follow-up (FU) visit. Demographics, ongoing medication, Behçet’s Disease Current Activity Form (BDCAF) score, Physician (PGA) and Patient Global Assessment (PtGA) of disease activity, disease relapsing (defined by any treatment change due to increased disease activity), and the BODI score were recorded. Damage accrual was defined as any increase ≥1 in the BODI score between baseline and follow-up visit (Δ-BODI). Logistic regression models were built to identify factors associated with BODI damage accrual.

Results

The mean age (standard deviation) at enrolment and the disease duration was 46.2 (12.1) and 10.8 (8.3) years, respectively, and 92/189 (48.7%) patients were males. During 24 months, 36 (19.0%) patients had an increase in the BODI score of at least 1 point (mean increase of 1.7 points). The BODI score increased from 1.6 (2.1) to 1.9 (2.1), with a mean Δ-BODI of 0.3 (0.8). Overall, 61 new BODI items of damage were recorded (Figure 1); 22 (34%) were steroid-related (diabetes, osteoporotic fractures, cataract). Factors independently associated with increased BODI score were longer glucocorticoids exposure (OR 1.01 per month, 95%CI 1.01-1.02, p<0.001), and occurrence of flares (OR 3.1, 95%CI 1.1-8.9, p = 0.035), whereas stable treatment with conventional and/or biologic immunosuppressants was negatively associated with an increase in the BODI score (OR 0.19, 95% 0.07-0.97, p <0.001) (Table 1).

Table 1.

Determinants of organ damage accrual over 2 years of follow-up.

Univariate analysisMultivariate analysisCandidate determinantsΔ-BODI ≥1 (n 36)Δ-BODI = 0 (n 153)pOR (95%CI)pMales16 (44.4%)76 (49.7%)0.572Age at enrolment56.2 (42.9-62.0)46.6 (35.4-53.1)0.001----Disease duration12.9 (7.1-22.0)11.1 (5.4-21.2)0.483Major organ involv.22 (61.1%)72 (47.1%)0,129BDCAF at BL3 (0-5)2. (0-5)0.365BDCAF at FU visit3.0 (3-5)3 (0-7)0.188GC duration112 (26.0-147.0)24.0 (8.0-72.0)<0.0011.012 (1.006-1.018<0.001cIS or TNFì ever24 (66.7%)133 (86.9%)0.0040.194 (0.073-0.972)<0.001Relapse9 (25.0%)20 (13.1%)0.0703.093 (1.066-8.972)0.038BODI score at BL1.0 (0-2.0)1 (0-2)0.579

Continuous variables are presented as median (IQR). Dichotomic variable are presented as n (%). BODI, Behçet’s Syndrome Overall Damage Index. FU, follow-up. cIS, conventional immunosuppressant. Δ-BODI increase of BODI score from baseline to the FU visit.

Conclusion

Despite the relatively high disease duration in the studied cohort, organ damage accrual was recorded in a relevant proportion of patients. BODI proved to capture the damage associated with major determinants such as inadequate control of disease activity and prolonged exposure to glucocorticoids.

Disclosure of Interests

None declared

Molecular Taxonomy of Systemic Lupus Erythematosus Through Data-Driven Patient Stratification: Molecular Endotypes and Cluster-Tailored Drugs

Objectives

Treatment of Systemic Lupus Erythematosus (SLE) is characterized by a largely empirical approach and relative paucity of novel compound development. We sought to stratify SLE patients based on their molecular phenotype and identify putative therapeutic compounds for each molecular fingerprint.

Methods

By the use of whole blood RNA-seq data from 120 SLE patients, and in a data-driven, clinically unbiased manner, we established modules of commonly regulated genes (molecular endotypes) and re-stratified patients through hierarchical clustering. Disease activity and severity were assessed using SLEDAI-2K and Lupus Severity Index, respectively. Through an in silico drug prediction pipeline, we investigated drugs currently in use, tested in lupus clinical trials, and listed in the iLINCS prediction databases, for their ability to reverse the gene expression signatures in each molecular endotype. Drug repurposing analysis was also performed to identify perturbagens that counteract group-specific SLE signatures.

Results

Molecular taxonomy identified five lupus endotypes, each characterized by a unique gene module enrichment pattern. Neutrophilic signature group consisted primarily of patients with active lupus nephritis, while the B-cell expression group included patients with constitutional features. Patients with moderate severity and serologic activity exhibited a signature enriched for metabolic processes. Mild disease was distributed in two groups, exhibiting enhanced basic cellular functions, myelopoiesis, and autophagy. Bortezomib was predicted to reverse disturbances in the "neutrophilic" cluster, azathioprine and ixazomib in the "B-cell" cluster, and fostamatinib in the "metabolic" patient subgroup.

Conclusion

The clinical spectrum of SLE encompasses distinct molecular endotypes, each defined by unique pathophysiologic aberrancies potentially reversible by distinct compounds.

OP0014 CTLA4-Ig INDUCES TOLEROGENIC PROPERTIES OF DENDRITIC CELLS BY ALTERING CELLULAR METABOLISM

Background

Dendritic cells (DCs) are well-recognized for their dual role either for T cell activation (1) or for inducing T cells tolerance (2). Their ability to modulate T-cell responses has made them an interesting tool for the immunotherapy of autoimmune diseases (3). Cytotoxic T lymphocyte antigen 4 (CTLA4) is a negative co-stimulatory molecule, which binds to CD80/CD86 on DCs. CTLA4 induces its immunoregulatory function through trans-endocytosis resulting in impaired co-stimulation (4), or through the induction of indoleamine-pyrrole 2,3-dioxygenase (IDO) enzyme (5). Moreover, it has been demonstrated that CTLA4 impairs the autophagic machinery of DCs and therefore suppresses DC inflammatory function (6). Nevertheless, the molecular mechanisms underlying the CTLA4-mediated immunomodulatory phenotype, require a more comprehensive understanding.

Objectives

In this study we focused on tolerogenic DCs (tolDCs) and we applied CTLA4-Ig as a tool to induce them. We aim to assess the immunoregulatory potential of CTLA4-mediated tolDCs and to investigate thoroughly the intracellular pathways that are involved in the induction of tolerance.

Methods

Healthy human monocytes were isolated from peripheral blood and differentiated into monocyte-derived dendritic cells (DCs). After 6 days, immature DCs activated with LPS were treated with CTLA4-Ig or IgG control for 18 hours. The anti-inflammatory function of DCs was validated using RT-PCR and flow cytometry and DCs proceeded to RNA sequencing. The metabolic pathways were studied using a Seahorse bioanalyzer.

Results

CTLA4-Ig-treated DCs showed significantly decreased HLA-DR, CD80/CD86 expression as compared to IgG-treated cells (n=4, p=0,0294, n=5 p=0,0079). Moreover, IL6 and TNFα mRNA expression, hallmarks of inflammatory cytokines secreted by DCs, was reduced upon CTLA4-Ig (n=5, p=0,0079). To elucidate the pathways involved in DC reprogramming upon CTLA4-Ig treatment, we performed RNA sequencing and we concluded with 1270 differentially expressed genes (p-value <0.05 counts>10). Interestingly, transcriptomic analysis revealed that the majority of genes (n=900) participated in metabolic processes, specifically in OXPHOS pathway and mitochondrial function. To further support the above metabolic changes, we performed Seahorse assays and confirmed that tolDCs had lower basal OXPHOS and decreased ATP production compared with mature DCs. Furthermore, expression of phosphorylated mammalian target of rapamycin (mTOR) and AKT1, central regulators of metabolism, was increased in CTLA4-mediated tolDCs (n=3, p= 0,0308 and p=0,0347).

Conclusion

Herein we confirmed that CTLA4 restricts the pro-inflammatory properties of activated DCs. RNA-seq analysis revealed that this anti-inflammatory deviation of DCs is characterized by the modification of the expression of genes implicated in cellular metabolism. Metabolic experiments confirmed that CTLA4-mediated tolDCs have reduced OXPHOS and ATP production, whereas, mTOR signaling is upregulated. In future experiments, we will investigate the mechanism that CTLA4 may promote metabolic changes thus contributes to the immunoregulatory phenotype of DCs and could represent a therapeutic target.

References

[1]Van Brussel et al., Mediators Inflamm2012, 690-643 (2012).

[2]B. Pulendran et al., Nature immunology11, 647-655 (2010).

[3]B. E. Phillips et al., Front Immunol8, 1279 (2017).

[4]O. S. Qureshi et al., Science332, 600-603 (2011).

[5]D. H. Munn et al., J Immunol172, 4100-4110 (2004).

[6]T. Alissafi et al., J Clin Invest127, 2789-2804 (2017).

Acknowledgements

This research is co-financed by Greece and the European Union (European Social Fund- ESF) through the Operational Programme «Human Resources Development, Education and Lifelong Learning» in the context of the project “Strengthening Human Resources Research Potential via Doctorate Research” (MIS-5000432), implemented by the State Scholarships Foundation (ΙΚΥ).

Disclosure of Interests

None declared.

OP0108 NEW INSIGHTS IN THE GENOMIC “GRAMMAR” OF RHEUMATOID ARTHRITIS

Background

Rheumatoid arthritis (RA) is a complex disease, caused by a combination of genetic, epigenetic and environmental factors common to other related autoimmune diseases including Multiple Sclerosis (MS) and Systemic Lupus Erythematosus (SLE) [1]. Using state of the art Bioinformatics tools we are able to formulate an ensemble of associated components (genomic grammar) for each disease and distinguish important differences and common aspects in a specific group of disease such as ensembles of autoimmune diseases [2].

Objectives

To create, collect and evaluate the most credible and unique gene variants, epigenetic variants and single nucleotide polymorphisms (SNPs) causing the basis of an immune disease (the genomic grammar of the disease), which could potentially assist in the process of the RA disease prevention, diagnosis and treatment [3].

Methods

RA related publications from the PubMed have been analyzed using data mining and semantic techniques towards extracting the candidate causative SNPs. The extracted knowledge has been filtered, evaluated, annotated, and classified in a structured database which also includes GWAS information regarding SNPs. Additional clinical, genomic, structural, functional and biological information was also extracted from biological databases including dbSNP, LitVar, ClinVar and OMIM and cross-correlated with other available autoimmune disease related SNP databases, including the Demetra application, Epione application and Panacea application databases [3, 4].

Results

A holistic genetic map of the studied autoimmune diseases with more than 2000 related SNPs has been estimated and specific sub-clusters with crucial nodes have been identified across the RA, SLE and MS diseases. Based on these results, the three studied autoimmune diseases share a 10% common SNPs genetic background (Figure 1 and Table 1) [5]. The optimal genomic grammar of the RA contains 1682 SNPs, with 73% responding to non-coding regions and 27% responding to coding regions of more than 1.300 genes, pseudogenes, primers and promoters. RA also shares 464 common SNPs with SLE and 113 with MS.

Table 1.

Common Related Genes based on the analyzed SNP targets in the studied disease.

A/AGene / RegionA/AGene / Region1.ADAM332.LOC2856263.ADIPOQ4.MIR3142HG5.CD406.MIR499A7.CIITA8.MTHFR9.CTLA410.MT-ND511.FCRL312.NCF113.HLA-DPB114.NLRP115.HLA-DRA16.NOS317.HLA-G18.NR3C119.IL17A20.PADI421.IL1RN22.PDCD123.IL224.PON125.IL23R26.STAT427.IL628.TGFB129.IL7R30.TLR931.IRAK132.TNF33.VDR34.TNFRSF1A35.IRF536.TYK237.KIF5A38.UCP239.LEPFigure 1.

Three class Venn diagram of the genomic grammar between RA, MS and SLE.

Conclusion

The identification of the optimal genomic grammar in RA will help towards understanding the nature of the disease. Specific genetic targets via determined SNPs could act as biomarkers that aid in forming the right diagnosis [6].

References

[1]Acosta-Herrera et al, J Clin Med 2019;8:826

[2]Chatzikyriakidou et al, Semin Arthritis Rheum 2013;43:29

[3]Papageorgiou et al, Int J Mol Med 2021;47:115

[4]Papageorgiou et al, Int J Mol Med 2022;49:8

[5]Wang, Y et al, Ann Rheum Dis 2021Epub ahead of print:doi:10.1136/annrheumdis-2021-220066

[6]Kurko et al, Clin Rev Allergy Immunol 2013;45:170

Disclosure of Interests

None declared

First Diagnosis of Systemic Lupus Erythematosus in Hospitalized Patients: Clinical Phenotypes and Pitfalls for the Non-Specialist

BACKGROUND

Prompt recognition of systemic lupus erythematosus (SLE) in hospitalized patients presenting with severe disease is essential to initiate treatment. We sought to characterize the phenotype of hospitalized patients with new-onset SLE and estimate potential diagnostic delays.

METHODS

An observational study of 855 patients ("Attikon" SLE cohort). Clinical phenotype was categorized according to the leading manifestation that led to hospitalization. Disease features, time to diagnosis, classification criteria, and the SLE Risk Probability Index (SLERPI) were recorded for each patient.

RESULTS

There were 191 patients (22.3% of the total cohort) hospitalized due to manifestations eventually attributed to SLE. Main causes of admission were neuropsychiatric syndromes (21.4%), cytopenias (17.8%), nephritis (17.2%), and thrombotic events (16.2%). Although 79.5% of patients were diagnosed within 3 months from hospitalization, in 39 patients diagnosis was delayed, particularly in those with hematological manifestations. At hospitalization, a SLERPI >7 (indicating high probability for SLE) was found in 87.4% of patients. Patients missed by the SLERPI had fever, thrombotic or neuropsychiatric manifestations not included in the algorithm. Lowering the SLERPI threshold to 5 in patients with fever or thrombotic events increased the diagnostic rate from 88.8% to 97.9% in this subgroup, while inclusion of all neuropsychiatric events yielded no additional diagnostic value.

CONCLUSION

One in five patients with new-onset SLE manifest disease presentations required hospitalization. Although early diagnosis was achieved in the majority of cases, in approximately 20%, diagnosis was delayed. A lower SLERPI cut-off (≥5) in patients with fever or thrombosis could enhance early diagnosis.

The association between lupus serology and disease outcomes: A systematic literature review to inform the treat-to-target approach in systemic lupus erythematosus

INTRODUCTION

Serological markers such as anti-double stranded (ds)DNA antibodies and complement fractions C3/C4, are integral components of disease activity assessment in patients with systemic lupus erythematosus (SLE). However, it remains uncertain whether treatment should aim at restoration of serological abnormalities.

OBJECTIVES

To analyze and critically appraise the literature on the prognostic impact of active lupus serology despite clinical disease quiescence.

METHODS

A systematic literature review was performed in PubMed and EMBASE using the PICOT(S) (population, index, comparator, outcome(s), timing, setting) system to identify studies evaluating the association of serum anti-dsDNA, C3 and C4 levels assessed at the time of clinical remission or during the disease course, against the risk for impending flares and organ damage. Risk of bias was determined by the Quality in Prognosis Studies and ROB2 tools for observational and randomized controlled studies, respectively.

RESULTS

Fifty-three studies were eligible, the majority having moderate (70.6%) or high (11.8%) risk of bias and not adequately controlling for possible confounders. C3 hypocomplementemia during stable/inactive disease was associated with increased risk (2.0 to 3.8-fold) for subsequent flare in three out of seven relevant studies. Three out of four studies reported a significant effect of C4 hypocomplementemia on flare risk, including one study in lupus nephritis (likelihood ratio-positive 12.0). An increased incidence of flares (2.0 to 2.8-fold) was reported in 11 out of 16 studies assessing the prognostic effect of high anti-dsDNA, and similarly, the majority of studies yielded significant relationships with renal flares. Six studies examined the effect of combined (rather than individual) serological activity, confirming the increased risk (2.0 to 2.7-fold) for relapses. No consistent association was found with organ damage.

CONCLUSION

Notwithstanding the heterogeneity and risk of bias, existing evidence indicates a modest association between abnormal serology and risk for flare in patients with stable/inactive SLE. These findings provide limited support for inclusion of serology in the treat-to-target approach but rationalize to further investigate their prognostic implications especially in lupus nephritis.

Deciphering the Molecular Mechanism of Flares in Patients with Systemic Lupus Erythematosus through Single-Cell Transcriptome Analysis of the Peripheral Blood

A remarkable, yet poorly explained feature of Systemic Lupus Erythematosus (SLE) is the propensity to flare following a preceding period of disease inactivity. The clinical burden of lupus flares is substantial since they often tend to involve multiple or major organs, and carry a near two-fold increased risk for accrual of irreversible organ damage. The cellular and molecular mechanisms underlying the progression of SLE from inactive to active state remain ill-defined. Application of novel sequencing technologies together with cellular immunology assays, have illustrated the important role of multiple types of both innate and adaptive cells and associated pathways. We have previously described significant differences in the blood transcriptome of SLE patients at active versus inactive disease, and we have also defined genome regions (domains) with co-ordinated expression of genes implicated in the disease. In the present study, we aim to decipher the cellular and molecular basis of SLE exacerbations by utilising novel single-cell sequencing approaches, which allow us to characterise the transcriptional and epigenetic landscapes of thousands of cells in the peripheral blood of patients. The significance of the study lies in the detailed characterisation of the molecular and regulatory program of immune cell subpopulations that underlie progression from inactive to active SLE. Accordingly, our results may be exploited to identify biomarkers for disease monitoring and novel therapeutic targets.

Bilateral Recurrent Uveitis in a Young Patient with Family History of Spondyloarthritis: Spondyloarthritis or Not?

We present the case of a young man with a strong family history of SpA, who was referred to the Rheumatology Clinic due to bilateral uveitis refractory to treatment with corticosteroids. The patient’s renal function gradually deteriorated and a subsequent biopsy was positive for interstitial nephritis. After excluding all other systemic diseases, the diagnosis of TINU syndrome was confirmed. Although rare, TINU syndrome should be considered in the differential diagnosis of non-infective uveitis especially in the presence of urinalysis abnormalities.

Screening for cognitive impairment in systemic lupus erythematosus: Application of the Montreal Cognitive Assessment (MoCA) in a Greek patient sample

BACKGROUND

Cognitive impairment (CI) is one of the most frequent neuropsychiatric manifestations of systemic lupus erythematosus (SLE). Given that extensive neuropsychological testing is not always feasible in routine clinical practice, brief cognitive screening tools are desirable. The aim of this study was to evaluate the Montreal Cognitive Assessment (MoCA) as a screening tool for CI in SLE.

METHODS

Consecutive SLE patients followed at a single centre were evaluated using MoCA and an extensive neuropsychological test battery (NPT), including the Digits Forward and Digits Backwards, Rey Auditory Verbal Learning Memory Test, Trail Making Test, Stroop Colour-Word Test, Semantic and Phonetic Verbal Fluency tests and a 25-problem version of the General Adult Mental Ability test. The criterion validity of MoCA was assessed through receiver operating characteristic (ROC) analyses using three different case definitions: i) against normative population data, ii) and iii) against average performance of a comparison group of rheumatoid arthritis (RA) patients, to adjust for possible confounding effects of chronic illness and inflammatory processes on cognitive performance. The effect of patient-related (age, years of education, anxiety, depression, fatigue and pain) and disease-related (activity, damage, age at diagnosis, disease duration, use of glucocorticoid, psychotropic and pain medication) parameters on the MoCA was examined.

RESULTS

A total of 71 SLE patients were evaluated. MoCA significantly correlated with all NPT scores and was affected by education level (p < 0.001), but not by other demographic or clinical variables. The optimal cutoff for detecting CI, as defined on the basis of normative population data, was 23/30 points, demonstrating 73% sensitivity and 75% specificity. A cutoff of 22/30 points, using neuropsychological profiles of the RA group as inflammatory disease controls, exhibited higher sensitivity (100%, based on both definitions) and specificity (87% and 90%, depending on the definition). The standard cutoff of 26/30 points displayed excellent sensitivity (91-100%) with significant expenses in specificity (43-45%).

CONCLUSION

The MoCA is an easily applied tool, which appears to be reliable for identifying CI in SLE patients. The standard cutoff score (26/30) ensures excellent sensitivity while lower cutoff scores (22-23/30) may, also, provide higher specificity.

2021 DORIS definition of remission in SLE: final recommendations from an international task force

Objective

To achieve consensus on a definition of remission in SLE (DORIS).

Background

Remission is the stated goal for both patient and caregiver, but consensus on a definition of remission has been lacking. Previously, an international task force consisting of patient representatives and medical specialists published a framework for such a definition, without reaching a final recommendation.

Methods

Several systematic literature reviews were performed and specific research questions examined in suitably chosen data sets. The findings were discussed, reformulated as recommendations and voted on.

Results

Based on data from the literature and several SLE-specific data sets, a set of recommendations was endorsed. Ultimately, the DORIS Task Force recommended a single definition of remission in SLE, based on clinical systemic lupus erythematosus disease activitiy index (SLEDAI)=0, Evaluator’s Global Assessment <0.5 (0–3), prednisolone 5 mg/day or less, and stable antimalarials, immunosuppressives, and biologics.

Conclusion

The 2021 DORIS definition of remission in SLE is recommended for use in clinical care, education, and research including clinical trials and observational studies.

Epione application: An integrated web‑toolkit of clinical genomics and personalized medicine in systemic lupus erythematosus

Genome wide association studies (GWAS) have identified autoimmune disease-associated loci, a number of which are involved in numerous disease-associated pathways. However, much of the underlying genetic and pathophysiological mechanisms remain to be elucidated. Systemic lupus erythematosus (SLE) is a chronic, highly heterogeneous auto-immune disease, characterized by differences in autoantibody profile, serum cytokines and a multi-system involvement. This study presents the Epione application, an integrated bioinformatics web-toolkit, designed to assist medical experts and researchers in more accurately diagnosing SLE. The application aims to identify the most credible gene variants and single nucleotide polymorphisms (SNPs) associated with SLE susceptibility, by using patient's genomic data to aid the medical expert in SLE diagnosis. The application contains useful knowledge of >70,000 SLE-related publications that have been analyzed, using data mining and semantic techniques, towards extracting the SLE-related genes and the corresponding SNPs. Probable genes associated with the patient's genomic profile are visualized with several graphs, including chromosome ideograms, statistic bars and regulatory networks through data mining studies with relative publications, to obtain a representative number of the most credible candidate genes and biological pathways associated with the SLE. Furthermore, an evaluation study was performed on a patient diagnosed with SLE and is presented herein. Epione has also been expanded in family-related candidate patients to evaluate its predictive power. All the recognized gene variants that were previously considered to be associated with SLE were accurately identified in the output profile of the patient, and by comparing the results, novel findings have emerged. The Epione application may assist and facilitate in early stage diagnosis by using the patients' genomic profile to compare against the list of the most predictable candidate gene variants related to SLE. Its diagnosis-oriented output presents the user with a structured set of results on variant association, position in genome and links to specific bibliography and gene network associations. The overall aim of the present study was to provide a reliable tool for the most effective study of SLE. This novel and accessible webserver tool of SLE is available at http://geneticslab.aua.gr/epione/.

NETs decorated with bioactive IL-33 infiltrate inflamed tissues and induce IFN-α production in patients with SLE

IL-33, a nuclear alarmin released during cell death, exerts context-specific effects on adaptive and innate immune cells, eliciting potent inflammatory responses. We screened blood, skin, and kidney tissues from patients with systemic lupus erythematosus (SLE), a systemic autoimmune disease driven by unabated type I IFN production, and found increased amounts of extracellular IL-33 complexed with neutrophil extracellular traps (NETs), correlating with severe, active disease. Using a combination of molecular, imaging, and proteomic approaches, we show that SLE neutrophils, activated by disease immunocomplexes, release IL-33–decorated NETs that stimulate robust IFN-α synthesis by plasmacytoid DCs in a manner dependent on the IL-33 receptor ST2L. IL33-silenced neutrophil-like cells cultured under lupus-inducing conditions generated NETs with diminished interferogenic effect. Importantly, NETs derived from patients with SLE are enriched in mature bioactive isoforms of IL-33 processed by the neutrophil proteases elastase and cathepsin G. Pharmacological inhibition of these proteases neutralized IL-33–dependent IFN-α production elicited by NETs. We believe these data demonstrate a novel role for cleaved IL-33 alarmin decorating NETs in human SLE, linking neutrophil activation, type I IFN production, and end-organ inflammation, with skin pathology mirroring that observed in the kidneys.

Demyelination with autoimmune features: a distinct clinical entity? Results from a longitudinal cohort

OBJECTIVE

CNS demyelinating syndromes occurring in the context of SLE may represent a manifestation of neuropsychiatric lupus, or an overlap of SLE and multiple sclerosis (MS). We evaluated prospectively patients presenting with demyelinating syndrome for clinical and serological evidence of SLE and characterized the evolution of their clinical syndrome to a defined disease.

METHODS

Patients with CNS demyelinating syndromes not fulfilling the criteria for MS were evaluated in a rheumatology unit for features of SLE and followed longitudinally (enrolment period 2016-20). Clinical, laboratory and neuroimaging data were recorded at every visit, following multidisciplinary evaluation. At end of follow-up, patients were assessed for their final neurological and rheumatological diagnosis, and classified accordingly.

RESULTS

A total of 79 patients were included in the study [91.1% female, mean (s.d.) age at first demyelinating episode 38.4 (10.3) years, median (interquartile range) observation period 39 (57) months]. At last follow-up, 38 patients (48.1%) had evolved into MS. Of the remaining patients, 7 (17.1%) had SLE, while 34 (82.9%) had features of systemic autoimmunity without fulfilling classification criteria for SLE. The most common rheumatological features of these patients were inflammatory arthritis (73.5%), acute cutaneous lupus (47.1%) and positive ANA (72.1%). Importantly, these patients were less likely to have elevated IgG index (odds ratio 0.11, 95% CI 0.04, 0.32) and positive oligoclonal bands (odds ratio 0.21, 95% CI 0.08, 0.55).

CONCLUSION

A significant number of patients with demyelination do not fulfill criteria for either MS or SLE at follow-up. These patients exhibit lupus-like autoimmune features and may represent a distinct entity, 'demyelination with autoimmune features'.

Achieving remission or low disease activity is associated with better outcomes in patients with systemic lupus erythematosus: a systematic literature review

BACKGROUND

Remission and low disease activity (LDA) have been proposed as the treatment goals for patients with systemic lupus erythematosus (SLE). Several definitions for each have been proposed in the literature.

OBJECTIVE

To assess the impact of remission/LDA according to various definitions on relevant outcomes in patients with SLE.

METHODS

This systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses using PubMed (1946-week 2, April 2021), Cochrane library (1985-week 2, week 2, April 2021) and EMBASE (1974-week 2, April 2021). We included longitudinal and cross-sectional studies in patients with SLE reporting the impact of remission and LDA (regardless their definition) on mortality, damage accrual, flares, health-related quality of life and other outcomes (cardiovascular risk, hospitalisation and direct costs). The quality of evidence was evaluated using the Newcastle-Ottawa Scale.

RESULTS

We identified 7497 articles; of them, 31 studies met the inclusion criteria and were evaluated. Some articles reported a positive association with survival, although this was not confirmed in all of them. Organ damage accrual was the most frequently reported outcome, and remission and LDA were reported as protective of this outcome (risk measures varying from 0.04 to 0.95 depending on the definition). Similarly, both states were associated with a lower probability of SLE flares, hospitalisations and a better health-related quality of life, in particular the physical domain.

CONCLUSION

Remission and LDA are associated with improvement in multiple outcomes in patients with SLE, thus reinforcing their relevance in clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42020162724.

Quality indicators for systemic lupus erythematosus based on the 2019 EULAR recommendations: development and initial validation in a cohort of 220 patients

BACKGROUND

Quality of care is receiving increased attention in systemic lupus erythematosus (SLE). We developed quality indicators (QIs) for SLE based on the 2019 update of European League Against Rheumatism recommendations.

METHODS

A total of 44 candidate QIs corresponding to diagnosis, monitoring and treatment, were independently rated for validity and feasibility by 12 experts and analysed by a modified Research and Development Corporation/University of California Los Angeles model. Adherence to the final set of QIs and correlation with disease outcomes (flares, hospitalisations and organ damage) was tested in a cohort of 220 SLE patients with a median monitoring of 2 years (IQR 2-4).

RESULTS

The panel selected a total of 18 QIs as valid and feasible. On average, SLE patients received 54% (95% CI 52.3% to 56.2%) of recommended care, with adherence ranging from 44.7% (95% CI 40.8% to 48.6%) for diagnosis-related QIs to 84.3% (95% CI 80.6% to 87.5%) for treatment-related QIs. Sustained remission or low disease activity were achieved in 26.8% (95% CI 21.1% to 33.2%). Tapering of prednisone dose to less than 7.5 mg/day was achieved in 93.6% (95% CI 88.2% to 97.0%) while 73.5% (95% CI 66.6% to 79.6%) received the recommended hydroxychloroquine dose. Higher adherence to monitoring-related QIs was associated with reduced risk for a composite adverse outcome (flare, hospitalisation or damage accrual) during the last year of observation (OR 0.97 per 1% adherence rate, 95% CI 0.96 to 0.99).

CONCLUSION

We developed QIs for assessing and improving the care of SLE patients. Initial real-life data suggest face validity, but a variable degree of adherence and a need for further improvement.

Development and preliminary validation of the Behçet's syndrome Overall Damage Index (BODI)

Objective

To develop and validate the evidence-based and consensus-based Behçet’s Syndrome Overall Damage Index (BODI).

Methods

Starting from 120 literature-retrieved preliminary items, the BODI underwent multiple Delphi rounds with an international multidisciplinary panel consisting of rheumatologists, internists, ophthalmologists, neurologists, and patient delegates until consensus was reached on the final content. The BODI was validated in a cross-sectional multicentre cohort of 228 patients with Behçet’s syndrome (BS) through the study of (a) correlation between BODI and Vasculitis Damage Index (VDI) and (b) correlation between BODI and disease activity measures (ie, Behçet’s Disease Current Activity Form (BDCAF), Physician Global Assessment (PGA), Patient Global Assessment (PtGA)), c) content and face validity and (d) feasibility.

Results

The final BODI consists of 4 overarching principles and 46 unweighted-items grouped into 9 organ domains. It showed good to excellent reliability, with a mean Cohen’s k of 0.84 (95% CI 0.78 to 0.90) and a mean intra-class correlation coefficient of 0.88 (95% CI 0.80 to 0.95). Overall, 128 (56.1%) patients had a BODI score ≥1, with a median score of 1.0 (range 0–14). The BODI significantly correlated with the VDI (r=0.693, p<0.001), demonstrating to effectively measure damage (construct validity), but had greater sensitivity in identifying major organ damage and did not correlate with disease activity measures (ie, BDCAF: p=0.807, PGA: p=0.820, PtGA: p=0.794) discriminating damage from the major confounding factor. The instrument was deemed credible (face validity), complete (content validity) and feasible by an independent group of clinicians.

Conclusions

Pending further validation, the BODI may be used to assess organ damage in patients with BS in the context of observational and controlled trials.

Management of lupus nephritis: a systematic literature review informing the 2019 update of the joint EULAR and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations

Objectives

To analyse the current evidence for the management of lupus nephritis (LN) informing the 2019 update of the EULAR/European Renal Association-European Dialysis and Transplant Association recommendations.

Methods

According to the EULAR standardised operating procedures, a PubMed systematic literature review was performed, from January 1, 2012 to December 31, 2018. Since this was an update of the 2012 recommendations, the final level of evidence (LoE) and grading of recommendations considered the total body of evidence, including literature prior to 2012.

Results

We identified 387 relevant articles. High-quality randomised evidence supports the use of immunosuppressive treatment for class III and class IV LN (LoE 1a), and moderate-level evidence supports the use of immunosuppressive treatment for pure class V LN with nephrotic-range proteinuria (LoE 2b). Treatment should aim for at least 25% reduction in proteinuria at 3 months, 50% at 6 months and complete renal response (<500–700 mg/day) at 12 months (LoE 2a-2b). High-quality evidence supports the use of mycophenolate mofetil/mycophenolic acid (MMF/MPA) or low-dose intravenous cyclophosphamide (CY) as initial treatment of active class III/IV LN (LoE 1a). Combination of tacrolimus with MMF/MPA and high-dose CY are alternatives in specific circumstances (LoE 1a). There is low-quality level evidence to guide optimal duration of immunosuppression in LN (LoE 3). In end-stage kidney disease, all methods of kidney replacement treatment can be used, with transplantation having the most favourable outcomes (LoE 2b).

Conclusions

There is high-quality evidence to guide the initial and subsequent phases of class III/IV LN treatment, but low-to-moderate quality evidence to guide treatment of class V LN, monitoring and optimal duration of immunosuppression.

POS0764 EULAR RECOMMENDATION-BASED QUALITY INDICATORS (QIS) FOR SYSTEMIC LUPUS ERYTHEMATOSUS (SLE): ELABORATION, FINAL SET, PERFORMANCE AND INITIAL VALIDATION

Background:

Targets of therapy and quality of care are receiving increased attention in systemic lupus erythematosus (SLE).

Objectives:

To develop Quality Indicators (QIs) for the care of SLE patients based on the EULAR recommendations, and assess their performance.

Methods:

Using the published EULAR recommendations for SLE, we developed 44 candidate QIs. These were independently rated for validity and feasibility by 12 experts, analysed by a modified RAND/UCLA model and further scrutinized based on the scorings and expert opinion. (Fig.1) Adherence to the final set of QIs was tested in a cohort of 220 SLE patients combined with an assessment on its impact on disease outcomes such as flares, hospitalizations and organ damage.

Results:

The panel rated 18 QIs as valid and feasible. These involve diagnosis; disease and damage assessment; monitoring for lupus nephritis and drug toxicity; therapy and targets of therapy; fertility and pregnancy; and adjunct therapy (preventive measures for osteoporosis, vaccination, cardiovascular disease). On average, SLE patients received 54% (95%CI 52–56%) of the indicated care with adherence ranging from 41% for QIs related to monitoring to 88% for treatment-related QIs. Regarding targets of therapy, sustained remission or low disease activity were achieved in 27%, while 94% of patients received low-dose glucocorticoids, and 92% the recommended hydroxychloroquine dose. Dependent upon individual QI tested, adherence for lupus nephritis-related QIs was 88% for receiving appropriate adjunct therapy (ACE inhibitors) to 100% for being treated with the indicated immunosuppressive treatment. In contrast, adherence to QIs related to preventive measures and other adjunct therapies was moderate to low. Notably, patients who were eligible for cardiovascular risk modification, vaccination, and osteoporosis management received lower quality of care (40.5%, 47.7% and 45.5% respectively) while 91.4% had sunscreen protection. In reference to laboratory work-up and monitoring, complete laboratory work-up at diagnosis was performed in 48%, while disease activity and damage, were fully assessed only in 14.1% (in three consecutive visits) and 28.6% (annually) respectively, Similarly, reproductive health and pregnancy counselling adherence rates were modest estimated at 50% and 62% respectively. Higher adherence to the indicated care during follow-up (monitoring QIs) was associated with reduced risk for adverse outcomes during the last year of observation (OR 0.97, 95%CI 0.96-0.99). Patients who achieved sustained remission or LLDAS, exhibited fewer flares (OR=0.15, p-value<0.001) and damage accrual (OR=0.35, p-value<0.001). Of interest, patients who received low-dose of GCs or were appropriately vaccinated, had a lower risk of experiencing a flare (OR=0.23 and 0.46 respectively).

Conclusion:

A set of 18 QIs based on the EULAR recommendations for SLE was developed to be used towards improving care in SLE. Initial real-life data suggest variable degree of adherence with higher adherence resulting in reduced adverse outcomes.

References:

[1]Fanouriakis, et al., 2019 Update of the EULAR recommendations for the management of systemic lupus erythematosus. In Annals of the Rheumatic Diseases (Vol. 78, Issue 6, pp. 736–745). BMJ Publishing Group. https://doi.org/10.1136/annrheumdis-2019-215089.

[2]Nikolopoulos, D., et al., Evolving phenotype of systemic lupus erythematosus in Caucasians: low incidence of lupus nephritis, high burden of neuropsychiatric disease and increased rates of late-onset lupus in the ‘Attikon’ cohort. Lupus, 29(5), 514–522. https://doi.org/10.1177/0961203320908932.

Acknowledgements:

This project has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (grant agreement No 742390)

Disclosure of Interests:

None declared

OP0019 DEFINING SYSTEMIC LUPUS ERYTHEMATOSUS MOLECULAR TAXONOMY THROUGH DATA-DRIVEN RESTRATIFICATION AND IDENTIFICATION OF CLUSTER-TAILORED DRUGS FOR A PERSONALIZED MEDICINE APPROACH

Background:

Systemic Lupus Erythematosus (SLE) is characterized by lack of treatment diversity, largely empirical treatment decisions, and paucity of novel compound development.

Objectives:

We sought to stratify SLE patients based on their molecular phenotype and predict personalized therapeutic compounds, tailored to the molecular fingerprint of each subgroup.

Methods:

We performed a co-expression analysis using our publicly available whole blood RNA-seq data of 120 SLE patients. Modules of commonly regulated genes were established and used to re-stratify patients through hierarchical clustering, in a data-driven, clinically independent, manner. Next, we established an in silico, subgroup signature-based, drug prediction pipeline. Investigated drugs included both those currently in practice and those who have been tested in SLE clinical trials and are listed in the iLINCS prediction databases. Finally, drug repurposing analysis was performed, to identify novel perturbagens that counteract group-specific SLE signatures.

Results:

Molecular taxonomy identified five distinct lupus molecular endotypes, each characterized by a unique gene module enrichment pattern. A group defined by strong neutrophilic signature encompassed almost exclusively patients with active nephritis, while a B-cell expression group included patients with severe lupus phenotype. Metabolic processes enrichment defined a group of patients with disease of moderate severity and serologic activity. Finally, patients with mild lupus features were distributed in two groups, which demonstrated enhanced basic cellular functions, myelopoiesis, and autophagy. The ability of different compounds to reverse the transcriptomic aberrancies observed in each patient group was examined. Bortezomib efficiently reversed disturbances in the “neutrophilic” cluster. Azathioprine and ixazomib might be a reasonable option for patients of the “B-cell” cluster, whereas fostamatinib appeared efficacious for the “Metabolism” patient subgroup.

Conclusion:

The clinical spectrum of SLE encompasses distinct molecular endotypes, each defined by unique pathophysiologic aberrancies, which can be utilized to guide personalized care and direct novel compound development.

Acknowledgements:

This project has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (grant agreement No 742390).

Disclosure of Interests:

None declared

POS0580 COMORBIDITY BURDEN IS HIGH IN RHEUMATOID ARTHRITIS AND SPONDYLOARTHRITIS PATIENTS STARTING BIOLOGICS AND PREDICTS THE INCIDENCE OF SERIOUS ADVERSE EVENTS DURING THERAPY

Background:

There is limited information on the burden of comorbidities in patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA) in real-world clinical practice and its impact on the incidence of serious adverse events (SAE) during biologic disease-modifying anti-rheumatic drug (bDMARD) therapy.

Objectives:

To evaluate the number of comorbidities in patients with RA and SpA initiating a bDMARD in everyday clinical practice and to explore its association with the occurrence of a SAE during therapy.

Methods:

Prospective study of all patients who start any bDMARD treatment in a tertiary centre University Hospital. All comorbidities and SAEs (AEs necessitating hospitalization or resulting in significant incapacity/death) are registered by treating physicians. Comorbidities’ number was evaluated using two different indices: total comorbidities count (CC) and Rheumatic Disease Comorbidity Index (RDCI). Statistical analysis was performed using multinomial logistic and Cox regression models.

Results:

A total of 799 patients were analysed, of which 428 (54%) had ≥3 comorbidities (Table 1). Comorbidity burden was higher in RA, however in multivariable analyses, comorbidities were not significantly associated with diagnosis, but mainly with increasing patient age. Patients received 1701 bDMARD treatments. During a follow-up of 4019 patient-years, 198 patients (RA:134, SpA:64) had a total of 295 SAE (RA: 217, SpA:78).

Each one additional comorbidity in CC index was resulting in 16% increased adjusted risk for the first SAE [HR (95%CI) = 1.16 (1.12-1.20), p<0.001], and each additional comorbidity of the RDCI index was resulting in 28% increased risk [HR (95%CI) = 1.28 (1.20-1.37), p<0.001]. Other baseline independent predictors of the first SAE were greater age [HR=1.04, p<0.001] and use of corticosteroids [HR=1.42, p=0.006].

Table 1.

Biologic treatments and clinical characteristics at baseline

Patients, ΝTotalRASpAp799501298Females, Ν (%)535 (67)404 (81)131 (44)<0.001Age, median (IQR) έτη55 (45-65)60 (51-68)46 (36-54)<0.001Disease duration, median (IQR) έτη6.0 (2.5-13)5.4 (3-11)7.4 (2.0-15)<0.001Comorbidities count, median (IQR)3 (1-5)3 (2-6)2 (1-4)<0.001Patients with no comorbidities, Ν (%)103 (13)43 (9)60 (20)<0.001Patients with 1 comorbidity, Ν (%)134 (17)77 (15)57 (19)0.172Patients with 2 comorbidities, Ν (%)134 (17)76 (15)58 (19,5)0.118Patients with ≥3 comorbidities, Ν (%)428 (54)305 (61)123 (41)<0.001RDCI, median (IQR)1 (0-2)2 (0-3)1 (0-2)<0.001Patients with RDCI = 0, Ν (%)267 (33)128 (25.5)139 (47)<0.001Patients with RDCI = 1, Ν (%)185 (23)119 (24)66 (22)0.665Patients with RDCI = 2, Ν (%)163 (20)113 (23)50 (17)0.057Patients with RDCI ≥ 3, Ν (%)184 (23)141 (28)43 (14)<0.001Total bDMARDs initiated by patients, Ν17011098603Co-administered methotrexate, Ν(%)946 (56)674 (61)272 (45)<0.001Co-administered corticosteroids, Ν (%)493 (29)397 (36)96 (16)<0.001DAS28, median (IQR) (in RA and perSpA)5.8 (4.9-6.6)5.8 (5.0-6.6)5.4 (4.2-6.3)<0.001BASDAI, median (IQR) (in axSpA)--5.6 (4.5-7.0)

Conclusion:

Patients with RA and SpA initiating a bDMARD treatment in real-world clinical practice have a significant comorbidity burden which increases with age and is an independent predictor for an SAE during therapy.

Acknowledgements:

This research is co-financed by Greece and the European Union (European Social Fund- ESF) through the Operational Programme «Human Resources Development, Education and Lifelong Learning» in the context of the project “Reinforcement of Postdoctoral Researchers - 2nd Cycle” (MIS-5033021), implemented by the State Scholarships Foundation (ΙΚΥ).

Disclosure of Interests:

None declared

OP0074 A FRAMEWORK OF POTENTIAL INTERVENTIONS TO ACCELERATE GENDER-EQUITABLE CAREER ADVANCEMENT IN ACADEMIC RHEUMATOLOGY

Background:

A growing number of professional societies in clinical and medically related disciplines investigate evidence, make recommendations, and take action to advance gender equity. Evidence on women’s advancement and leadership in the context of the European Alliance of Associations for Rheumatology, EULAR, is limited [1].

Objectives:

The objective of the EULAR Task Force on Gender Equity in Academic Rheumatology was to establish the extent of the unmet need for support of female rheumatologists, health professionals and non-clinical scientists in academic rheumatology and develop a framework to address this through EULAR and Emerging EULAR Network (EMEUNET).

Methods:

Potential interventions to accelerate gender-equitable career advancement in academic rheumatology were gathered from a narrative review of the relevant literature, expert opinion of a multi-disciplinary Task Force (comprised of 23 members from 11 countries), data from the surveys of EULAR scientific member society leaders, EULAR and EMEUNET members, and EULAR Executive Committee members. These interventions were rated by Task Force members, who ranked each according to perceived priority on a five-point numeric scale from 1 = very low to 5 = very high.

Results:

A framework of 29 potential interventions was formulated, which covers six thematic areas, namely, EULAR policies, advocacy and communication, EULAR Congress and associated symposia, training courses, mentoring/peer support, and EULAR funding (Figure 1).

Figure 1.

A framework of potential interventions with the levels of priority, mean and standard deviation (SD)

Conclusion:

The framework provides structured interventions for accelerating gender-equitable career advancement in academic rheumatology.

References:

[1]Andreoli L, Ovseiko PV, Hassan N, et al. Gender equity in clinical practice, research and training: Where do we stand in rheumatology? Joint Bone Spine 2019;86(6):669-72.

Acknowledgements:

The task force is grateful to EULAR for funding this activity under project number EPI 024.

Disclosure of Interests:

None declared

POS0370 TYPE I INTERFERON PATHWAY ASSAYS IN PATIENTS WITH RHEUMATIC AND MUSCULOSKELETAL DISEASES - SYSTEMATIC LITERATURE REVIEW (SLR) AND DEVELOPMENT OF CONSENSUS TERMINOLOGY FROM A EULAR TASKFORCE

Background:

The interferon (IFN) pathway is a complex system with multiple proteins and diverse downstream effects on gene and protein expression. IFNs have been implicated in multiple RMDs. Despite significant potential, IFN assays have not progressed into clinical practice.

Objectives:

To perform a SLR on IFN assays in RMDs and propose a consensus terminology.

Methods:

OvidMedline, Embase and Web of Science were searched for reports of IFN and RMDs up to October 2019. Information about the properties of assays measuring type I IFN and measures of truth were extracted and summarised. Terminology was agreed through an interactive consensus process with reference to the existing evidence.

Results:

10037 abstracts were identified. 275 fulfilled eligibility criteria, and were used for data extraction. Some used more than one technique to measure IFN-I pathway activation. Hence, 275 papers generated data on 393 methods. There was great heterogeneity in the methods used and presentation of results. IFN-I pathway activation was measured using: qPCR (n=121), immunoassays (n=101), microarray (n=69), reporter cell assay (n=38), DNA methylation (n=14), flow cytometry (n=14), cytopathic effect assay (n=11), RNA sequencing (n=9), Plaque reduction assay (n=8), Nanostring (n=5), bisulphite sequencing (n=3). All papers fulfilled Face Validity. Due to lack of gold standard for IFN-I pathway activation, evidence of criterion validity was variable. Concurrent validity was presented for n=150 assays. The terminology used to describe aspects of type I IFN pathway activation was not consistent, so a consensus terminology for IFN research (Table 1) was proposed by the taskforce.

Table 1.

Consensus terminology

TermAbbreviationDefinitionInterferonIFNProteins with anti-viral activity; IFNs are mediators of an anti-viral response. They belong to the Type I, Type II and Type III IFN families.Type I interferonIFN-IThe IFNs alpha, beta, omega, kappa, epsilon, secreted by any nucleated cell, and binding to the IFNAR, which is expressed on any nucleated cell.Type II interferonIFN-IIIFN gamma, mostly secreted by T cells, binding to the IFNGR, which is expressed on most leucocytes.Type III interferonIFN-IIIIFN lambda, which are structurally more similar to IL-10 but share downstream signalling and gene expression with IFN-I.Interferon-stimulated genesISGsGenes whose expression is known to be upregulated by any kind of IFN. Individual ISGs may not exclusively represent Type I IFN pathway activation.Type I Interferon pathway activationAny evidence for function of the components of the Type I IFN pathway. This includes: secretion of a Type I IFN protein, binding to the IFNAR, initiation of JAK/STAT signalling pathways, expression of IFN-stimulated genes, expression of IFN-stimulated proteins.Type I interferon pathway assayAn assay measuring one or more components of the Type I IFN pathway at a molecular or functional level.Interferon stimulated gene expression signatureA qualitative description of coordinated expression of a set of ISGs that is indicative of Type I IFN pathway activation.Interferon stimulated gene expression scoreA quantitative variable derived from expression of a defined set of ISGs that is indicative of Type I IFN pathway activation.Interferon stimulated protein scoreA variable derived from expression of a defined set of soluble biomarkers known to be upregulated by IFN, although not specific for Type I IFN.InterferonopathyMonogenic diseases in which there is constitutive Type I IFN pathway activation with a causal role in pathology. The clinical picture may resemble rheumatic musculoskeletal diseases. However, most diseases with IFN pathway activation are not Interferonopathies.

Conclusion:

Diverse methods have been reported as IFN assays and these differ in what elements of type IFN-I pathway activation they measure. The taskforce consensus terminology on type I IFN reporting should be considered for research and clinical applications.

Disclosure of Interests:

Agata Burska: None declared, Javier Rodriguez Carrio: None declared, Philip G Conaghan: None declared, Willem A Dik: None declared, Robert Biesen: None declared, Maija-leena Eloranta: None declared, Giulio Cavalli: None declared, Marianne Visser: None declared, Dimitrios Boumpas: None declared, George Bertsias: None declared, Marie Wahren-Herlenius: None declared, Jan Rehwinkel: None declared, Marie-Louise Frémond: None declared, Mary K. Crow Consultant of: AstraZeneca, Bristol Meyers Squibb, Lilly, Shannon Pharmaceuticals, Grant/research support from: Gilead, Lars Ronnblom Consultant of: AstraZeneca, Edward Vital Speakers bureau: GSK, Consultant of: AURINIA, SANDOZ, GSK, AstraZeneca, Roche, Modus, Grant/research support from: AstraZeneca, Marjan Versnel: None declared

OP0296 THE 2021 DORIS DEFINITION OF REMISSION IN SLE – FINAL RECOMMENDATIONS FROM AN INTERNATIONAL TASK FORCE

Background:

Remission is the stated goal for both patient and care-giver (1), but consensus on a definition of remission has been lacking. Previously, an international task force consisting of patient representatives and medical specialists published a frame-work for such a definition (2), but without making a final recommendation.

Objectives:

To achieve consensus around a definition of remission in SLE (DORIS).

Methods:

The DORIS task force met annually from 2015 to 2020 and consisted of patient representatives and specialists in rheumatology, nephrology, dermatology, and clinical immunology. Systemic literature reviews of several key topics were done and specific research questions were examined in suitably chosen datasets. The findings were discussed, reformulated as recommendations, and voted upon. Level of evidence (LoE), strength of recommendation (SoR), and agreement were determined in standard fashion. The final recommendation for the DORIS definition of remission was established by electronic vote after finalization of the minutes of the most recent task force meeting.

Results:

Based on data from the literature and from several SLE-specific data sets, five key recommendations were endorsed (Table 1) that should be seen as additions to those published previously (2). Literature reviews identified strong support for the face-, content-, construct- and criterion validity of the definition based on the clinical SLEDAI (not including anti-DNA and complement) equal to zero plus low physician global assessment and allowing stable medical treatment. Thus, the DORIS Task Force recommended a single definition of remission in SLE, based on clinical SLEDAI = 0, evaluator’s global assessment <0.5 (0-3), prednisone 5 mg/day or less, and stable antimalarials, immunosuppressives and biologics.

Table 1.Vote in favorLoESoRAgreement1.Inclusion of serology [anti-DNA, complement] in the DORIS definition of remission-on-treatment does not meaningfully alter the construct validity and therefore it is not recommended to include it90%2aB8.382.While the goal of treatment is sustained remission, a definition of remission should be able to be met at any point in time; therefore, duration should not be included in the definition100%5C9.023.To date, the SLEDAI-based definitions of remission have formally been investigated more extensively than BILAG-or ECLAM-based definitions. The SLEDAI-based definitions can therefore more confidently be recommended91%2aB9.254.Remission off treatment, while the ultimate goal for many patients and providers, is achieved very rarely. In clinical research and as an outcome in clinical trials, the definition for remission-on-treatment is recommended92%2aB9.525.In clinical trials, the LLDAS definition for low disease activity and the DORIS definition of remission are both recommended as outcomes100%5C9.25

The 2021 DORIS definition of remission in SLE:

Conclusion:

The 2021 DORIS definition of remission in SLE was established. It is recommended for use as an aspirational treatment target in clinical care, a clear concept in education, and a key outcome in research including clinical trials and observational studies.

References:

[1]van Vollenhoven RF, Mosca M, Bertsias G, et al. Treat-to-target in systemic lupus erythematosus: recommendations from an international task force. Ann Rheum Dis 2014;73:958-67.

[2]van Vollenhoven R, Voskuyl A, Bertsias G, et al. A framework for remission in SLE: consensus findings from a large international task force on definitions of remission in SLE (DORIS). Ann Rheum Dis 2016.

Disclosure of Interests:

Ronald van Vollenhoven Speakers bureau: AbbVie, Galapagos, GSK, Janssen, Pfizer, UCB, Consultant of: AbbVie, AstraZeneca, Biogen, Biotest, Celgene, Galapagos, Gilead, Janssen, Pfizer, Sanofi, Servier, UCB, Vielabo, Grant/research support from: BMS, GSK, Lilly, UCB, George Bertsias: None declared, Andrea Doria: None declared, David Isenberg: None declared, Eric F. Morand: None declared, Michelle A Petri: None declared, Bernardo Pons-Estel Consultant of: GSK, Janssen, Anisur Rahman: None declared, Manuel Ugarte-Gil Grant/research support from: Janssen, Pfizer, Alexandre Voskuyl: None declared, Laurent Arnaud Consultant of: Alexion, Amgen, Astra-Zeneca, BMS, GSK, Janssen-Cilag, LFB, Lilly, Menarini France, Medac, Novartis, Pfizer, Roche-Chugaï, UCB., Ian N. Bruce: None declared, Ricard Cervera Consultant of: GSK, Alexion, Eli Lilly, Astra Zeneca, Termo-Fisher, Rubió, Nathalie Costedoat-Chalumeau: None declared, Caroline Gordon Speakers bureau: UCB, Consultant of: Center for Disease Control, Astra-Zeneca, MGP, Sanofi, UCB, Frederic Houssiau: None declared, Marta Mosca: None declared, Matthias Schneider: None declared, Michael Ward: None declared, Cynthia Aranow: None declared.

POS0759 THE JOURNEY OF PATIENTS FROM FIRST SYMPTOMS TO DIAGNOSIS OF SYSTEMIC LUPUS ERYTHEMATOSUS (SLE): AN OBSERVATIONAL STUDY

Background:

The lack of pathognomonic features poses a considerable challenge in SLE diagnosis. The time from symptom onset to diagnosis has been reported to range from two to six years1.

Objectives:

To document the initial symptoms of the disease and the time lapse until its diagnosis.

Methods:

We examined 438 patients from the “Attikon” SLE cohort2. For diagnosis, we used the classification criteria (ACR, SLICC, EULAR-ACR) or in few cases clinical diagnosis (n=32, 7.3%). Data were collected using patient interviews, in-person clinical visits and medical charts review. Initial symptoms were recorded and determined chronologically using prespecified forms with a list of typical manifestations (skin, joints, renal, nervous system, pleuropulmonary, cardiovascular, anti-phospholipid syndrome) as well as characteristic disease features (Raynaud’s phenomenon, fatigue, fever, sicca symptoms). Questions also included the time between symptom onset and initial physician visit, the time from first medical consultation until first rheumatologist assessment, the time from rheumatologist assessment to SLE definite diagnosis, the number of physicians seen before SLE diagnosis, the specialty of first physician and of diagnosing physician. Information on demographic and clinical characteristics, disease activity and disease damage, was collected both at enrolment and at last follow-up visit.

Results:

88.5% of patients were females, mean (±SD) age at diagnosis was 41.9 years ± 15.4 and disease duration was 6.7 ± 7 years. Most common systems involved were joints (94.5%), skin (73.7%), blood (39.2%) and renal (17.5%). At diagnosis, 9.8% of patients were ANA negative. The most common initial symptoms at disease onset were arthritis/arthralgia (74.4%), followed by fatigue (53.1%) and photosensitive rash (50.9%) (Table 1). Among non-criteria features, Raynaud’s phenomenon was reported by 146 patients (33.3%) prior the diagnosis. The median interval between symptoms onset and the SLE diagnosis was 16 months (IQR 5-60). SLE was diagnosed earlier in ANA-positive than -negative patients [median time 14 months (IQR 5-60) vs 36 months (IQR 10.5-84); P=0.1, t-test]. Approximately half of the patients (52.5%) were diagnosed after 12 months from disease onset with only 15.9% diagnosed within 3 months of symptoms presentation. The median lag time between onset of symptoms and the first medical consultation was 2 months (IQR 1-12). Internists were the most common first consultants (27.8%) followed by orthopedists (15.9%), dermatologists (13.6%) and rheumatologists (13.4%). The median interval between the first medical assessment and first rheumatologist evaluation was 3 months (IQR 0-11.5) while the median time from rheumatologist assessment to definite diagnosis was 0 months (IQR 0-4). SLE patients consulted an average of 3 different physicians before the definite diagnosis, which in 95.8% was established by rheumatologists.

Conclusion:

Approximately 50% of patients were diagnosed with SLE after 12 months from symptom onset with a mean time from symptoms to definite diagnosis almost 4 years. Increasing awareness of internists to SLE and avoidance of strict adherence to ANA as a requirement for diagnosis may improve early diagnosis.

Table 1.

Initial symptoms prior to diagnosis

SymptomsN=438 (%)Duration*(mean months ±SD)Arthralgias326 (74.4)37.5 ±69.4Photosensitive rash223 (50.9)30.6 ±70.2Malar rash168 (38.3)22.6 ±62Alopecia167 (38.1)19.6 ±54.6Ulcers106 (24.2)16.8 ±54.4Fever103 (23.5)9.3 ±43.8Raynaud’s phenomenon146 (33.3)22.3 ±68.5Fatigue233 (53.1)19.7 ±45.7

*Mean time from symptom onset to established diagnosis

References:

[1]Nightingale AL, Davidson JE, Molta CT et al. Lupus Science & Medicine 2017; doi:10.1136/lupus-2016-000172.

[2]D Nikolopoulos et al. Lupus 2020; doi: 10.1177/0961203320908932.

Acknowledgements:

This project has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (grant agreement No 742390)

Disclosure of Interests:

None declared

OP0299 IN RHEUMATOID ARTHRITIS PATIENTS HIGHER NUMBER OF COMORBIDITIES PREDICTS 6-MONTH INSUFFICIENT RESPONSE TO FIRST BIOLOGIC THERAPY AND EVENTUAL CATEGORIZATION OF THE DISEASE AS DIFFICULT-TO-TREAT

Background:

Difficult-to-treat rheumatoid arthritis (D2T RA) was recently defined by a EULAR study group (1) and, as a disease category it is largely complicated and under-researched. Patient comorbidities may play a significant role in the response to therapy with biologic disease-modifying antirheumatic drugs (bDMARDs) and in the disease classification as D2T RA.

Objectives:

To evaluate the impact of comorbidities [studied as total Comorbidities Count (CC) and rheumatic disease comorbidity index (RDCI)] on 6-month response to therapy with the first bDMARD in real-world clinical practice and on eventual disease designation as D2T RA.

Methods:

Prospective study of all RA patients who start any bDMARD in a tertiary centre University Hospital after their consent. All patient comorbidities [among a list of approximately 100 pre-specified major comorbidities] are registered by treating physicians. Response to therapy was defined as achievement of low disease activity or remission (LDA/Rem) according to simplified disease activity index (SDAI) and health assessment questionnaire (HAQ) improvement of ≥ 0.25.

D2T RA patient group was defined according to the EULAR definition of D2T RA and was compared to: a/ all other patients and b/ to a sub-group of patients designated as “well-controlled RA” (follow-up ≥2 years and ≥2 visits in the last year in LDA/Rem).

Logistic regression models were used to adjust for the potential confounding of age, sex, disease duration, seropositivity, number of previous synthetic DMARDs, type of 1st bDMARD initiated (TNF inhibitor vs. non-TNF inhibitor), co-administered methotrexate and corticosteroids (yes/no), baseline SDAI and HAQ and year of therapy start.

Results:

Analysis included 501 RA patients who received a total of 1098 bDMARD treatments. At 1st bDMARD treatment start, patients (women: 81%) had a median (IQR) age: 60 (51-68) years, disease duration: 5.4 (3-11) years, SDAI: 36 (28-46), HAQ: 1.0 (0.5-1.5), CC: 3 (2-6) και RDCI: 2 (0-3).

In adjusted analyses, total comorbidity count (CC) ≤1 (vs ≥ 2) was predicting LDA/Rem at 6 months of therapy [OR (95%CI) = 4.1 (1.5-11), p=0.005], while RDCI=0 (vs. ≥ 1) was predicting HAQ improvement ≥ 0.25 [OR (95% CI) = 2.6 (1.2-6.7), p=0.046].

During 2614 patient-years of follow-up, the disease in 98 patients could be classified as “D2T RA”, while 127 patients had “well-controlled RA”. Baseline independent predictors for D2T RA compared to all other patients were RDCI ≥ 1 (vs. 0) [OR = 3.3 (1.7-9.4), p = 0.024], female sex [OR =3.1 (1.01-9.5)] and age [OR = 0.97 (0.94-0.99)]. Multivariable analyses for predictors of “D2T” compared to “well-controlled” RA yielded similar results.

Conclusion:

In RA patients starting the first bDMARD treatment, a higher number of comorbidities at baseline is an independent predictor of lower 6-month response to therapy and final disease classification as “difficult-to-treat” RA.

References:

[1]Nagy G, Roodenrijs NM, Welsing PM, Kedves M, Hamar A, van der Goes MC, et al. EULAR definition of difficult-to-treat rheumatoid arthritis. Ann Rheum Dis. 2021 Jan;80(1):31–5.

Acknowledgements:

Pancretan Health Association and Special Account for Research Grants (ELKE) – University of Crete.

Disclosure of Interests:

None declared.

POS0757 SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) DIAGNOSED DURING HOSPITALIZATION: CLINICAL PHENOTYPE AND PERFORMANCE OF THE SLE RISK PROBABILITY INDEX (SLERPI)

Background:

Systemic Lupus Erythematosus (SLE) can first present with severe or critical disease leading to hospitalization. Prompt recognition of the disease in hospitalized patients may lead to early institution of treatment and improve outcomes. We have recently developed a clinician-friendly algorithm for SLE diagnosis based on classical clinical and serological SLE features [SLE Risk Probability Index (SLERPI)]1.

Objectives:

To determine the clinical phenotype of SLE patients first diagnosed during hospitalization, the interval between hospitalization and SLE diagnosis and the potential impact of SLERPI on early diagnosis.

Methods:

Mixed prospective (from June 2020 to January 2021) and retrospective study of SLE patients from “Attikon” cohort (n=820)2. Clinical phenotype was divided into 10 core domains (neuropsychiatric, thrombosis, nephritis, serosal, haematologic, pulmonary, cardiovascular, gastrointestinal, skin-joints, other). Chart review and patient interview was performed to assess the lag time between 1) the onset of symptoms and 2) the hospitalization and the final diagnosis. Demographic and clinical characteristics, SLERPI and SLICC damage index were recorded for each patient at the time of diagnosis. SLE diagnosis was based on at least one of the three existing classification criteria.

Results:

Out of 820 SLE patients, 202 (24.6%) diagnosed during hospitalization were included. Among them, 185 patients (91.5%) were hospitalized because of a lupus related feature, while in the remaining 17 SLE patients, hospitalization was due to non-lupus related manifestations. The most common lupus-related clinical phenotype leading to hospital admission was neuropsychiatric lupus (n=51, 25.2%) with cerebrovascular events constituting the dominant clinical syndrome (n=8/51). Thrombotic events (n=32, 15.8%), mainly pulmonary embolism (n=20/32), cytopenias (n=32, 15.8%), lupus nephritis (n=30, 14.8%), skin-joint disease (n=26, 12.8%) and serositis (n=24, 11.8%) were also common as dominant manifestations. Pulmonary disease (n=16, 7.9%), heart disease (n= 4, 1.9%) and gastrointestinal disease (n=2, 0.9%) were less common. On admission, 11.3% of patients (n=23) had symptoms from at least 2 clinical domains as defined. Most patients (93.5%) had multisystem disease while only 6.5% had organ-dominant disease. Early diagnosis (within 3 months from hospitalization) was established in 86.6% while 27 patients had their SLE diagnosis more than 3 months from hospitalization. The mean lag time between the hospitalization and the diagnosis was approximately 14 months (SD 19.9). Overall, the mean interval between the onset of symptoms and the diagnosis was 48.2 months (SD 73.2). Importantly, a SLERPI >7 (suggesting probable SLE) at hospitalization was present in 92.5% of SLE patients with delayed diagnosis.

Conclusion:

One out of four SLE patients first present with moderate to severe disease necessitating hospitalization, while in approximately 15% of such patients, diagnosis is initially missed. Application of the SLERPI may facilitate early SLE diagnosis.

References:

[1]Adamichou C et al. Ann Rheum Dis. 2021; DOI: 10.1136/annrheumdis-2020-219069.

[2]D Nikolopoulos et al. Lupus 2020; doi: 10.1177/0961203320908932.

Acknowledgements:

This project has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (grant agreement No 742390)

Disclosure of Interests:

None declared

POS0941 IN SPONDYLOARTHRITIS PATIENTS THE PRESENCE OF COMORBIDITIES IS AN INDEPENDENT PREDICTOR OF INSUFFICIENT RESPONSE TO THERAPY WITH BIOLOGIC AGENTS AND TREATMENT DISCONTINUATION

Background:

Long-term observational studies of patients under biologic disease-modifying anti-rheumatic drug (bDMARD) therapies in routine clinical practice can provide us with important data regarding patients with comorbidities, who are usually excluded from randomized controlled studies.

Objectives:

To study the impact of comorbidities in the outcome (response and persistence to therapy) of patients with spondyloarthritis (SpA) receiving bDMARDs in real-world clinical practice.

Methods:

Prospective study of all patients who start a bDMARD in a tertiary centre University Hospital after their consent. All patient comorbidities [among a list of approximately 100 pre-specified major comorbidities] are registered by treating physicians at baseline and during follow-up.

Comorbidities were studied as total Comorbidities Count (CC) and rheumatic disease comorbidity index (RDCI). Statistical analyses were performed using logistic and Cox regression models, adjusting for the potential confounding of age, sex, disease duration, diagnosis (axial vs. peripheral SpA), number of previous conventional synthetic and biologic DMARDs, year of therapy start, and co-administered methotrexate and corticosteroids (yes/no). Analyses of response to therapy also included baseline BASDAI or ASDAS indices as confounding variables.

Results:

A total of 603 biologic treatments (1st: 298, 2nd: 157, ≥3rd: 148) were analyzed. Half (51%) of the patients were female, 413 patients had axial SpA (AxSpA) and 190 peripheral SpA (perSpA). At baseline, median (IQR) age: 48 (38-57) years, disease duration: 11 (4-19) years, CC: 2 (1-4) and RDCI: 1 (0-2). Both comorbidity indices were significantly higher in perSpA compared to AxSpA (p<0.001).

At 6 months of therapy, 31% of patients with AxSpA achieved BASDAI50 and 39% had ASDAS-ESR < 2.1. Higher CC was an independent predictor of insufficient response according to BASDAI50 [OR (95%) = 0.70 (0.52-0.94), p=0.019] and higher RDCI was predicting failure to achieve ASDAS-ESR < 2.1 [OR (95%) = 0.59 (0.37-0.94), p=0.027]. Other independent predictors of non-response were age, longer disease duration and (for ASDAS-ESR<2.1) higher baseline disease activity.

During 1405 patient-years of follow-up, 349 (58%) treatments were discontinued. The adjusted hazard ratio for bDMARD discontinuation within the first 2 years of treatment due to insufficient response was doubled in patients with CC ≥2 versus those with CC ≤1 [HR = 2.27 (1.14-4.53), p=0.020] or with RDCI ≥1 (vs. RDCI = 0) [HR = 2.23 (1.22-4.07), p=0.009]. Comorbidities’ indices were not significant predictors of treatment discontinuations due to adverse events.

Conclusion:

The presence of comorbidities in patients with SpA is an independent predictor for insufficient 6-month response to bDMARDs and resultant treatment discontinuation due to failure.

Acknowledgements:

This research is co-financed by Greece and the European Union (European Social Fund- ESF) through the Operational Programme «Human Resources Development, Education and Lifelong Learning» in the context of the project “Reinforcement of Postdoctoral Researchers - 2nd Cycle” (MIS-5033021), implemented by the State Scholarships Foundation (ΙΚΥ).

Disclosure of Interests:

None declared

Rituximab for refractory eosinophilic fasciitis: a case series with long-term follow-up and literature review

KEY MESSAGE

RTX could be an effective and safe alternative treatment for refractory EF. Rituximab (RTX) is a successful therapeutic option for various autoimmune diseases. Our aim is to report our experience with RTX in eosinophilic fasciitis (EF) and review published data on its efficacy for the treatment of EF. We reviewed the medical charts of all patients with a diagnosis of EF treated with RTX from 2008 to 2020 in the Department of Rheumatology and Clinical Immunology in the University Hospital of Heraklion, Crete, Greece. We also reviewed the English literature for cases of EF treated with RTX. Demographics, clinical manifestations, laboratory findings, prior treatments, response to RTX, cumulative RTX dose, duration of treatment and follow-up are reported. We report three cases of EF refractory to conventional DMARDs (cDMARDs) that responded to RTX. Furthermore, literature review revealed five cases. In our case series in all patients, RTX was the first biologic. RTX could be effective in cases of (EF) refractory to standard immunosuppressive treatment.

Anxiety and depression severity in neuropsychiatric SLE are associated with perfusion and functional connectivity changes of the frontolimbic neural circuit: a resting-state f(unctional) MRI study

OBJECTIVE

To examine the hypothesis that perfusion and functional connectivity disturbances in brain areas implicated in emotional processing are linked to emotion-related symptoms in neuropsychiatric SLE (NPSLE).

METHODS

Resting-state fMRI (rs-fMRI) was performed and anxiety and/or depression symptoms were assessed in 32 patients with NPSLE and 18 healthy controls (HC). Whole-brain time-shift analysis (TSA) maps, voxel-wise global connectivity (assessed through intrinsic connectivity contrast (ICC)) and within-network connectivity were estimated and submitted to one-sample t-tests. Subgroup differences (high vs low anxiety and high vs low depression symptoms) were assessed using independent-samples t-tests. In the total group, associations between anxiety (controlling for depression) or depression symptoms (controlling for anxiety) and regional TSA or ICC metrics were also assessed.

RESULTS

Elevated anxiety symptoms in patients with NPSLE were distinctly associated with relatively faster haemodynamic response (haemodynamic lead) in the right amygdala, relatively lower intrinsic connectivity of orbital dlPFC, and relatively lower bidirectional connectivity between dlPFC and vmPFC combined with relatively higher bidirectional connectivity between ACC and amygdala. Elevated depression symptoms in patients with NPSLE were distinctly associated with haemodynamic lead in vmPFC regions in both hemispheres (lateral and medial orbitofrontal cortex) combined with relatively lower intrinsic connectivity in the right medial orbitofrontal cortex. These measures failed to account for self-rated, milder depression symptoms in the HC group.

CONCLUSION

By using rs-fMRI, altered perfusion dynamics and functional connectivity was found in limbic and prefrontal brain regions in patients with NPSLE with severe anxiety and depression symptoms. Although these changes could not be directly attributed to NPSLE pathology, results offer new insights on the pathophysiological substrate of psychoemotional symptomatology in patients with lupus, which may assist its clinical diagnosis and treatment.

Relevant domains and outcome measurement instruments in Neuropsychiatric Systemic Lupus Erythematosus: a systematic literature review

OBJECTIVES

Although neuropsychiatric involvement in Systemic Lupus Erythematosus (NPSLE) is one of the most complex and troubling manifestations of the disease, validated outcome instruments to be used as sensitive endpoints in controlled clinical trials are lacking. We set out a systematic literature review (SLR) to identify outcome measurement instruments and domains used to assess NPSLE.

METHODS

The Preferred Reporting Items for systematic reviews and Meta-analysis (PRISMA) guidelines were used. Articles available in English (1967-2020), listed in PubMed, EMBASE, PsycINFO, Cochrane Library and EULAR outcome measures library were screened. All domains and outcome measurement instruments were characterized according to the OMERACT Filter 2.1, considering core areas (manifestations/abnormalities, life impact, death/lifespan, societal/resource use) and contextual factors.

RESULTS

Of 3,392 abstracts evaluated, 83 studies were included in the SLR (15,974 patients, females 89.9%). Eligible studies included domains and instruments pertinent to all core areas defined by OMERACT, except for "societal/resource use". The most common core areas were "manifestations/abnormalities", covering 10 domains pertinent to laboratory and instrumental markers, indexes and neuropsychiatric dimension (cognitive, neurologic and psychiatric field), and "life impact", covering 7 domains related to physical function (from both the perspective of the patient and the physician), pain and quality of life.

CONCLUSION

Our study revealed great heterogeneity in the instruments derived from populations with NPSLE and none of these had high-quality evidence. This supports the need to develop and further validate a core domain set and outcome measurement instruments to promote clinical research in this field, enhancing comparability across studies.

Treatment of neuropsychiatric systemic lupus erythematosus: clinical challenges and future perspectives

Introduction: Neuropsychiatric (NP) involvement represents an emerging frontier in systemic lupus erythematosus (SLE), posing significant challenges due to its clinical diversity and obscure pathophysiology. The authors herein discuss selected aspects in the management of NPSLE based on existing literature and our experience, aiming to facilitate routine medical care.Areas covered: Research related to diagnosis, neuroimaging, treatment and outcome is discussed, focusing on data published in PubMed during the last 5 years. Selected translational studies of clinical relevance are included.Expert opinion: Identification of NPSLE patients who may benefit from appropriate treatment can be facilitated by attribution algorithms. Immunosuppressants are typically indicated in recurrent seizures, optic neuritis, myelopathy, psychosis and peripheral nerve disease, although a low threshold is recommended for cerebrovascular disease and other NP manifestations, especially when SLE is active. With the exception of stroke with positive antiphospholipid antibodies, anti-coagulation is rarely indicated in other syndromes. Refractory NPSLE can be treated with rituximab, whereas the role of other biologics remains unknown. Advances in the fields of biomarkers, neuroimaging for brain structural, perfusion or functional abnormalities, and design of novel compounds targeting not only systemic autoimmunity but also inflammatory and regenerative pathways within the nervous system, hold promise for optimizing NPSLE management.

High Comorbidity Burden in Patients with SLE: Data from the Community-Based Lupus Registry of Crete

Comorbidities and multimorbidity, often complicating the disease course of patients with chronic inflammatory rheumatic diseases, may be influenced by disease-intrinsic and extrinsic determinants including regional and social factors. We analyzed the frequency and co-segregation of self-reported comorbid diseases in a community-based Mediterranean registry of patients (n = 399) with systemic lupus erythematosus (SLE). Predictors for multimorbidity were identified by multivariable logistic regression, strongly-associated pairs of comorbidities by the Cramer's V-statistic, and comorbidities clusters by hierarchical agglomerative clustering. Among the most prevalent comorbidities were thyroid (45.6%) and metabolic disorders (hypertension: 24.6%, dyslipidemia: 33.3%, obesity: 35.3%), followed by osteoporosis (22.3%), cardiovascular (20.8%), and allergic (20.6%) disorders. Mental comorbidities were also common, particularly depression (26.7%) and generalized anxiety disorder (10.7%). Notably, 51.0% of patients had ≥3 physical and 33.1% had ≥2 mental comorbidities, with a large fraction (n = 86) displaying multimorbidity from both domains. Sociodemographic (education level, marital status) and clinical (disease severity, neurological involvement) were independently associated with physical or mental comorbidity. Patients were grouped into five distinct clusters of variably prevalent comorbid diseases from different organs and domains, which correlated with SLE severity patterns. Conclusively, our results suggest a high multimorbidity burden in patients with SLE at the community, advocating for integrated care to optimize outcomes.

European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) SLE classification criteria item performance

BACKGROUND/OBJECTIVES

The European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) 2019 classification criteria for systemic lupus erythematosus system showed high specificity, while attaining also high sensitivity. We hereby analysed the performance of the individual criteria items and their contribution to the overall performance of the criteria.

METHODS

We combined the EULAR/ACR derivation and validation cohorts for a total of 1197 systemic lupus erythematosus (SLE) and n=1074 non-SLE patients with a variety of conditions mimicking SLE, such as other autoimmune diseases, and calculated the sensitivity and specificity for antinuclear antibodies (ANA) and the 23 specific criteria items. We also tested performance omitting the EULAR/ACR criteria attribution rule, which defines that items are only counted if not more likely explained by a cause other than SLE.

RESULTS

Positive ANA, the new entry criterion, was 99.5% sensitive, but only 19.4% specific, against a non-SLE population that included other inflammatory rheumatic, infectious, malignant and metabolic diseases. The specific criteria items were highly variable in sensitivity (from 0.42% for delirium and 1.84% for psychosis to 75.6% for antibodies to double-stranded DNA), but their specificity was uniformly high, with low C3 or C4 (83.0%) and leucopenia <4.000/mm³ (83.8%) at the lowest end. Unexplained fever was 95.3% specific in this cohort. Applying the attribution rule improved specificity, particularly for joint involvement.

CONCLUSIONS

Changing the position of the highly sensitive, non-specific ANA to an entry criterion and the attribution rule resulted in a specificity of >80% for all items, explaining the higher overall specificity of the criteria set.

Treating systemic lupus erythematosus in the 21st century: new drugs and new perspectives on old drugs

Besides treating acute flares, the management of SLE should aim at preventing organ damage accrual and drug-associated harms, improving health-related quality of life and prolonging survival. At present, therapy is based on combinations of antimalarials (mainly HCQ), considered the backbone of SLE treatment, glucocorticoids and immunosuppressive drugs. However, these regimens are not universally effective and a substantial degree of damage can be caused by exposure to glucocorticoids. In this review we provide a critical appraisal of the efficacy and safety of available treatments as well as a brief discussion of potentially novel compounds in patients with SLE. We emphasize the use of methylprednisolone pulses for moderate–severe flares, followed by low–moderate doses of oral prednisone with quick tapering to maintenance doses of ≤5 mg/day, as well as the prompt institution of immunosuppressive drugs in the setting of severe disease but also as steroid-sparing agents. Indications for the use of biologic agents, namely belimumab and rituximab, in refractory or organ-threatening disease are also presented. We conclude by proposing evidence- and experience-based treatment strategies tailored to the clinical scenario and prevailing organ involvement that can aid clinicians in managing this complex disease.

Comparable or higher prevalence of comorbidities in antiphospholipid syndrome vs rheumatoid arthritis: a multicenter, case-control study

OBJECTIVES

Evidence on comorbidity prevalence in antiphospholipid syndrome (APS) and its difference from high comorbidity burden rheumatic diseases is limited. Herein, we compare multiple comorbidities between APS and RA.

METHODS

A total of 326 patients from the Greek APS registry [237 women, mean age 48.7 (13.4) years, 161 primary APS (PAPS), 165 SLE-APS] were age/sex matched (1:2 ratio) with 652 patients from a Greek multicentre RA cohort of 3115 patients. Prevalence of cardiovascular (CV) risk factors, stroke, coronary artery disease (CAD), osteoporosis, diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), depression and neoplasms were compared between APS and RA patients using multivariate regression analysis.

RESULTS

Ηyperlipidemia and obesity (ΒΜΙ ≥ 30 kg/m2) were comparable while hypertension, smoking, stroke and CAD were more prevalent in APS compared with RA patients. Osteoporosis and depression were more frequent in APS, while DM, COPD and neoplasms did not differ between the two groups. Comparison of APS subgroups to 1:2 matched RA patients revealed that smoking and stroke were more prevalent in both PAPS and SLE-APS vs RA. Hypertension, CAD and osteoporosis were more frequent only in SLE-APS vs RA, whereas DM was less prevalent in PAPS vs RA. Hyperlipidaemia was independently associated with CV events (combined stroke and CAD) in PAPS and SLE-APS, while CS duration was associated with osteoporosis in SLE-APS.

CONCLUSION

Comorbidity burden in APS (PAPS and SLE-APS) is comparable or higher than that in RA, entailing a high level of diligence for CV risk prevention, awareness for depression and CS exposure minimization.