AB1411 JOINT RHEUMA-DERMA CLINIC: FOUR YEARS OF EXPERIENCE AT THE SAN MARCO HOSPITAL IN CATANIA

Background

Psoriatic arthritis (PsA) affects up to one-third of patients with psoriasis. Many recent works in literature have underline that the percentage of undiagnosed PsA is still high.

A direct collaboration between dermatologists and rheumatologists appears fundamental for a better management of these patients, to reduce the risk of joint damage, disability, and comorbidities.

Objectives

The aim of this study is to highlight the benefits of a Rheuma-Derma clinic and a shared approach, focused to an early diagnosis and prompt therapeutic strategy of PsA.

Methods

Patients with psoriasis complaining joint symptoms or rheumatologic patients with cutaneous involvement, were simultaneously assessed by a dermatologist and a rheumatologist.

The collected data included demographics, clinical characteristics as joint patterns (axial/peripheral), clinimetric index evaluated (DAS28, HAQ, BASDAI, DAPSA, PASI, PGA) family history of psoriasis or PsA, BMI (Mass Body Index), psoriasis, comorbidities and Charlson Index, gastrointestinal and ophthalmic involvement, and previous and current treatments with conventional (csDMARDS) and/or biological therapy (bDMARDs).

Results

During the period from 2012 to 2016 the Rheumatology Department registered 255 of patients under biological treatment, against 374 of patients during the Rheuma-Derma Clinic (2017-2021), with an increase of 47% in number. CsDMARDs therapy counted 367 patients before the Rheuma-Derma Clinic and 539 after the shared outpatient activity, with a raise of the 46%. Globally the number of patients with the diagnosis of PsA moved from 622 to 913, reaching an increase of 47% of patients.

The joint pattern have shown a peripheral involvement in 69.3% of cases in comparison to 11% of cases with axial involvement and a mixed for the rest of population, 19.8%. In the group analyzed 539 patients were treated with csDMARDs, 76.5% methotrexate, 30.7% salazopyrine and only 6.7% with cyclosporine. 374 patients under treatment with bDMARD: the majority of patients (86.1%) were treated with TNFα inhibitors, 25.4% Secukinumab, 20.1% Ustekinumab, 16% Apremilast, 4.8% Ixekizumab, 1.1% Tofacitinib. The Charlson Comorbidity Index (CCI) assesses comorbidity level by taking into account the number, the severity of pre-defined comorbid conditions and the age of patients. It provides a weighted score in a range from 0 to 8, which can be used to predict short term and long-term outcomes such as function, hospital length of stay and mortality rates. In our study the majority of patients (27%) had a score of 2 while fortunately only 0.5% of population had a score of 8. The most frequent comorbidities registred in our cohort were hypertension (24.6%) and dyslipidemia (28.3%). Psoriasis was diagnosed in 41% of patients: in 80% of them the skin disease preceded the articular symptoms while 20% of patients developed psoriasis after the arthritis onset. History of family psoriasis was positive in 26% of patients. The nails involvement was observed only in 8% of patients, followed by gastrointestinal disorders (3%) and uveitis (7%). The value of BMI (Body Mass Index), the majority of patients (56%) have shown a normal weight, followed by over-weight patients (31.7%); only 10% of patients presented an obesity grade I and 1.1% an obesity grade II-III.

For all the clinimetric index evaluated (DAS28, HAQ, BASDAI, DAPSA, PASI, PGA), there was an improvement over the twelve months under the Reuma-Derma clinic

Conclusion

In conclusion, the diagnosis of an Early PsA is essential, as an early treatment and management can alter the natural course of PsA and prevent irreversible joint damage. Our experience proved the increased number of patients since the Rheuma-Derma Clinic have started, such as an increased number of patients under treatment, leading to a significant improvement in the quality of life of PsA and Pso patients.

References

[1]Mease PJ J Am Acad Dermatol. 2013;69:729–735.

[2]Scher JU Nat Rev Rheumatol. 2019 Mar;15(3):153-166.

[3]Radtke MA J Eur Acad Dermatol Venereol. 2009 Jun;23(6):683-91. doi: 10.1111/j.1468-3083.2009.03159.x

Disclosure of Interests

None declared

Immune checkpoint inhibitor associated vitiligo and its impact on survival in patients with metastatic melanoma: an Italian Melanoma Intergroup study

Background

Checkpoint inhibitors in melanoma can lead to self-immune side-effects such as vitiligo-like depigmentation (VLD). Beyond the reported association with favorable prognosis, there are limited data regarding VLD patient features and their echo on the therapeutic outcomes.

Methods

To assess the association between VLD and a series of clinical and biological features as well as therapeutic outcomes, we built an observational cohort study by recruiting patients who developed VLD during checkpoint inhibitors.

Results

A total of 148 patients from 15 centers (101 men, median age 66 years, BRAF mutated 23%, M1c 42%, Eastern Cooperative Oncology Group (ECOG) status 0/1 99%, normal lactate dehydrogenase 74%) were enrolled. VLD was induced by ipilimumab, programmed cell death-1 (PD-1) inhibitors, and their combination in 32%, 56%, and 12%, respectively. The median onset was 26 weeks and it was associated with other skin and nonskin toxicities in 27% and 28%, respectively. After 3 years of VLD onset, 52% (95% confidence interval 39% to 63%) were progression free and 82% (95% confidence interval 70% to 89%) were still alive. The overall response rate was 73% with 26% complete response. Univariable analysis indicated that BRAF V600 mutation was associated with a better overall survival (P = 0.028), while in multivariable analysis a longer progression-free survival was associated with BRAF V600 (P = 0.093), female sex (P = 0.008), and M stage other than 1a (P = 0.024). When VLD occurred, there was a significant decrease of white blood cell (WBC) count (P = 0.05) and derived WBC-to-lymphocytes ratio (dWLR; P = 0.003). A lower monocyte count (P = 0.02) and dWLR (P = 0.01) were also reported in responder patients.

Conclusions

Among VLD population, some features might help to identify patients with an effective response to immunotherapy, allowing clinicians to make more appropriate choices in terms of therapeutic options and duration.

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This multicentric retrospective study outlined the melanoma profile of 148 patients with vitiligo-like depigmentation (VLD) induced by checkpoint inhibitors.

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Median VLD onset was 26 weeks and it was associated with other immune toxicities in one-third of cases.

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After 3 years of VLD onset, 52% and 82% of patients, respectively, were progression free and still alive with a response rate of 73%.

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Some features such as BRAF V600, female sex, and M stage were associated with better outcomes as well as a specific blood profile.