Emollients in dermatological creams: Early evaluation for tailoring formulation and therapeutic performance

The targeted choice of the emollient of a cream determines its physicochemical properties and clinical effectiveness. This work researched the effects of emollient properties on the final characteristics and potential performance of oil-in-water dermatological creams. Seven emollients with different chemical characteristics and structures (alkane, triglyceride, ether, silicone, vegetable oils, and mineral oil) were tested in a model formulation. Early stability, pH, droplet size distribution, rheology, tackiness, adhesivity, spreadability, tribology, and release profile of a lipophilic substance model (in Franz cells, through a synthetic membrane, for six hours) were assessed. The creams had acid epicutaneous pH and a "shear-thinning" "solid-like" viscoelastic behavior. Among the seven emollients' properties, polarity, density, and viscosity were the most influential. Droplet parameters were the most impacted, pH and release were moderately affected, and the textural properties were lowly to moderately impacted. The emollient substitution in the model formulation affected the experimental parameters differently, allowing formulation optimization and tailoring its potential therapeutic performance regarding drug release, coadjutant effects, and dwell time on the skin. By looking at the creams' characteristics, it was possible to select the best-suited emollients for releasing a lipophilic drug, applying on painful skin, and formulation in wash-off products or leave-on protective barrier creams.

Wunderlich syndrome as a rare complication of polyarteritis nodosa: a case report

Spontaneous subcapsular and perirenal hemorrhage, known as Wunderlich syndrome (WS), is a rare clinical manifestation of polyarteritis nodosa (PAN). We report a case of a 48-year-old male with a history of recurrent episodes of leg muscle tenderness and dysesthesia, bilateral flank pain, painful nodular skin lesions in the lower limbs, weight loss, and difficult-to-control arterial hypertension. The abdominopelvic computed tomography angiography showed a large left perirenal hematoma, leading to the patient's admission to the intensive care unit. After the exclusion of infectious or neoplastic foci, the patient was diagnosed with PAN and started intravenous methylprednisolone pulses with a good response. Since WS is a rare initial clinical manifestation of PAN, an early diagnosis and aggressive treatment will significantly improve clinical outcomes.

Adjusted estimate of the prevalence of hepatitis delta virus in 25 countries and territories

BACKGROUND & AIMS

Hepatitis delta virus (HDV) is a satellite RNA virus that requires the hepatitis B virus (HBV) for assembly and propagation. Individuals infected with HDV progress to advanced liver disease faster than HBV-monoinfected individuals. Recent studies have estimated the global prevalence of anti-HDV antibodies among the HBV-infected population to be 5-15%. This study aimed to better understand HDV prevalence at the population level in 25 countries/territories.

METHODS

We conducted a literature review to determine the prevalence of anti-HDV and HDV RNA in hepatitis B surface antigen (HBsAg)-positive individuals in 25 countries/territories. Virtual meetings were held with experts from each setting to discuss the findings and collect unpublished data. Data were weighted for patient segments and regional heterogeneity to estimate the prevalence in the HBV-infected population. The findings were then combined with The Polaris Observatory HBV data to estimate the anti-HDV and HDV RNA prevalence in each country/territory at the population level.

RESULTS

After adjusting for geographical distribution, disease stage and special populations, the anti-HDV prevalence among the HBsAg+ population changed from the literature estimate in 19 countries. The highest anti-HDV prevalence was 60.1% in Mongolia. Once adjusted for the size of the HBsAg+ population and HDV RNA positivity rate, China had the highest absolute number of HDV RNA+ cases.

CONCLUSIONS

We found substantially lower HDV prevalence than previously reported, as prior meta-analyses primarily focused on studies conducted in groups/regions that have a higher probability of HBV infection: tertiary care centers, specific risk groups or geographical regions. There is large uncertainty in HDV prevalence estimates. The implementation of reflex testing would improve estimates, while also allowing earlier linkage to care for HDV RNA+ individuals. The logistical and economic burden of reflex testing on the health system would be limited, as only HBsAg+ cases would be screened.

IMPACT AND IMPLICATIONS

There is a great deal of uncertainty surrounding the prevalence of hepatitis delta virus among people living with hepatitis B virus at the population level. In this study, we aimed to better understand the burden in 25 countries and territories, to refine techniques that can be used in future analyses. We found a lower prevalence in the majority of places studied than had been previously reported. These data can help inform policy makers on the need to screen people living with hepatitis B virus to find those coinfected with hepatitis delta virus and at high risk of progression, while also highlighting the pitfalls that other researchers have often fallen into.

Validation of a hematology analyzer in donkey medicine

Asinina de Miranda is a protected donkey sub-species from the Mirandês plateau in northeastern of Portugal. Donkeys are animals that have substantially lost their place as working animals in modern society, this had led to a decrease in their population numbers. A need to preserve native species has led to the foundation of organizations like Associação para o Estudo e Proteção do Gado Asinino (AEPGA) and the development of studies regarding breed welfare, such as hematology. The IDEXX ProCyte Dx is a veterinary hematology analyzer validated for several species, but not for donkeys. The aim of this study was to validate the ProCyte Dx for Asinina de Miranda donkeys. The validation requires a controlled study of precision, carryover, linearity and comparison between the equipment and the manually obtained values for the leukocyte differential count and hematocrit. Results indicated coefficient of variation was good (below 5 %) for both the intra-assay and the inter-assay precision, except for basophils. Carryover was 0 % for all the parameters except platelets (5.88 %). Linearity showed a very high Pearson correlation coefficient, above 0.99, for erythrocytes, hematocrit, hemoglobin, leucocytes, neutrophils, lymphocytes, monocytes, eosinophils, platelets and plateletcrit. Comparison demonstrated excellent agreement for hematocrit (rs=0.96) and good Spearman rank correlation for neutrophils (rs=0.84) and lymphocytes (rs=0.90). Accuracy for total leukocyte count and platelets could not be determined. In conclusion, the ProCyte Dx seems appropriate to be used in Asinina de Miranda hematology.

Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis recurrence temporally associated with allergen-specific immunotherapy in a female adolescent: a case report

Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is the most common periodic fever syndrome in pediatric patients. It is clinically characterized by fever flares lasting 3-7 days, reappearing every 2-8 weeks with a distinctive clockwork regularity. PFAPA generally begins before 5 years of age and usually ceases 3-5 years after onset. Recurrences may be observed in adolescence and adulthood in up to 20% of cases. The authors aim to describe a case of PFAPA recurrence in adolescence temporally associated with allergen-specific immunotherapy (ASIT). A 16-year-old female patient was referred to the rheumatology unit due to recurrent episodes of fever one month after initiating ASIT for allergic rhinitis. These episodes occurred every 4 weeks and lasted 3 days. During these episodes, she also presented with a sore throat, tonsillar exudates, and cervical lymphadenopathy. Abortive treatment with oral prednisolone was attempted in these episodes, with complete resolution of fever after a single dose. After reviewing her medical background, she had previously experienced febrile episodes accompanied by aphthous ulcers and tonsillar exudates occurring every 7-8 weeks from age 2-7. The etiopathogenesis of PFAPA remains uncertain. Environmental triggers, particularly those with immunomodulator effects, may interfere with the immune responses responsible for PFAPA occurrence, but the mechanisms are still unclear. The authors describe the first report of the reappearance of PFAPA flares, possibly due to ASIT. Further studies are needed to fully clarify if ASIT constitutes a true environmental trigger of PFAPA.

Uveitis in patients with oligoarticular juvenile idiopathic arthritis and juvenile spondyloarthritis/enthesitis related arthritis: is there any difference?

Juvenile idiopathic arthritis (JIA) is the most common systemic disease causing uveitis in childhood and adolescence.

Impact de l’infection par le SARS-CoV-2 sur l’activité de la maladie des patients atteints de rhumatisme psoriasique sous bDMARD : données réelles

Introduction

L’infection par le SARS-CoV-2 peut entraîner une inflammation sévère et il a été suggéré d’induire des poussées de rhumatisme psoriasique (RP). Cependant, l’impact sur l’activité de la maladie et la réponse aux DMARD biologiques modificateurs de la maladie (bDMARD) reste inconnu.

Patients et méthodes

Nous avons réalisé une analyse rétrospective incluant tous les patients atteints de RP, répondant aux critères CASPAR et sous biothérapie, suivis dans le service de rhumatologie d’un CHU universitaire tertiaire. Les données démographiques et cliniques, y compris la survenue d’une infection par le SARS-CoV-2, ont été collectées à partir de notre base de données nationale (reuma.pt). L’activité de la maladie (CDAI, SDAI, DAS28 4v, BASDAI, ASDAS) et les réponses aux bDMARD (réponses EULAR, ASDAS, ASAS, ACR et PsARC) ont été évaluées avant et après l’infection par le SARS-Cov-2.

Résultats

Au total, 102 patients atteints de RP ont été inclus. Cinquante-deux étaient des femmes (51 %). L’âge moyen était de 53 ± 11,09 ans et la durée médiane de la maladie était de 15 ans [min 2, max 47]. Au total, 54 (53 %) patients avaient une atteinte axiale prédominante, 26 (26 %) périphérique et 36 (37 %) enthésopathique. Le bDMARD le plus utilisé était l’étanercept (n = 28, 27,5 %) suivi de l’adalimumab (n = 22, 21,6 %) et du sécukinumab (n = 18, 17,6 %). La prévalence de l’infection par le SARS-CoV-2 était de 15,7 % (n = 16). Soixante-trois pour cent ont reçu le vaccin BNT162b2 (Pfizer/BioNtech), 31 % ont reçu l’ARNm-1273 (Moderna), 13 % ont reçu l’AZD1222 (AstraZeneca) et 13 % ont reçu l’AD26.COV2.S (Janssen/Johnson & Johnson). Soixante-trois pour cent étaient infectés avant toute vaccination, 13 % après la première dose et 25 % après la seconde. Les symptômes les plus fréquents étaient l’anosmie (65 %), la dysgueusie (56 %) et la toux (56 %). Tous les patients se sont complètement remis de l’infection, sans nécessiter d’hospitalisation. Quel que soit le score utilisé, la différence entre l’activité moyenne de la maladie après l’infection par le SARS-CoV-2 et celle au départ n’a pas atteint la signification statistique. Au départ et après l’infection, les paramètres moyens de l’activité de la maladie étaient respectivement : CDAI 8,6 ± 5,7 vs 8,6 ± 5,7, p = 0,997 ; SDAI 9,3 ± 6,6 contre 9,2 ± 6,1, p = 0,928 ; DAS 28 4v 2,9 ± 1,2 contre 2,9 ± 1,2, p = 0,818 ; BASDAI 3,6 ± 2,6 contre 3,2 ± 2,7, p = 0,506 ; ASDAS 2,2 ± 1,2 contre 2,2 ± 1, p = 0,721. Le nombre de patients ne répondant pas aux bDMARD (selon EULAR, ASDAS, ASAS, ACR et PsARC) avant l’infection n’était pas différent de celui post-infection.

Conclusion

Notre étude suggère que l’infection par le SARS-CoV-2 n’a aucun impact négatif sur l’activité de la maladie PSA et les réponses bDMARD. Cependant, d’autres études sont encore nécessaires pour mieux comprendre les effets à long terme de l’infection par le SARS-CoV-2.

Prevalence of RV dysfunction in patients under cardiotoxic chemoterapy: a preliminary analysis

Background

Chemotherapy-induced cardiotoxicity is a serious complication often leading to heart failure. While the left ventricle (LV) has been thoroughly implicated in this process, data is scarce on right ventricular (RV) function following cardiotoxic chemotherapies. Our goal was to determine the prevalence and clinical significance of RV dysfunction in a cohort of patients who had received these drugs.

Methodology

Single-center retrospective study of cancer patients performing 2D transthoracic echocardiogram between January 2020 and December 2021. Those previously exposed to anthracyclines and/or anti-HER2 agents (≥6 months prior to echocardiogram) were included. Patients with known coronary artery disease or cardiomyopathy were excluded. LV function was assessed through LV ejection fraction (LVEF) and global longitudinal strain (GLS). LV cardiotoxicity was defined as per 2020 ESMO guidelines. RV function was considered abnormal if the following criteria were met: tricuspid annular plane systolic excursion (TAPSE) <17 mm, peak systolic velocity of the tricuspid annulus by pulsed wave TDI (S'VD) <12 cm/s, fraction area change (FAC) <35% and mean free wall longitudinal strain (FWLS) >−20%.

Results

Forty patients were included (58±13 years; 95% female; 93% with breast cancer; 30%, 20% and 50% previously treated with anthracyclines, anti-HER2 or both, respectively). Mean LVEF and GLS were 56±7% and −17±3%. Overall, 13 patients had current LV cardiotoxicity. RV dysfunction was documented in 15 (38%) patients (7 [18%] with isolated RV dysfunction), most often detected through FWLS (14 [35%], 7 [18%], 6 [15%] and 5 [13%] patients with abnormal FWLS, TAPSE, FAC and S'VD, respectively) – Figure 1. Seven patients (18%) and one patient (3%) had ≥2 and ≥3 abnormal RV parameters. Those with RV dysfunction were more often symptomatic (NYHA class ≥2: 53% vs. 16%; p=0.013), had higher NT-proBNP levels (516 [204–2400] vs. 66 [46–191] pg/mL; p=0.003) and most often had LV cardiotoxicity (62% vs. 26%, p=0.029); pulmonary artery systolic pressures were similar between both groups.

Conclusion

In our cohort of patients treated with cardiotoxic anti-neoplastic drugs, RV dysfunction was observed in two out of every five patients, most often detected by RV 2D strain and associated with worse symptoms and higher NT-proBNP levels. This data suggests that RV cardiotoxicity may be common and clinically impactful in those under cardiotoxic chemotherapies.

Funding Acknowledgement

Type of funding sources: None.

POS0560 ASSESSMENT OF THE SWOLLEN TO TENDER JOINT COUNT RATIO AS A PREDICTOR OF RESPONSE IN RHEUMATOID ARTHRITIS PATIENTS: A COHORT STUDY

Background

Several response predictors have already been studied in rheumatoid arthritis, especially since the introduction of biological therapies. The swollen to tender joint count ratio (STR) has been proposed as a predictor of response in patients receiving anti-TNF therapy, but its usefulness in other therapies is not yet well established.

Objectives

To assess whether STR can be a predictor of response in patients with rheumatoid arthritis under b/tsDMARD.

Methods

Longitudinal and retrospective study that included patients diagnosed with rheumatoid arthritis followed in the Rheumatology Department of a tertiary hospital, under therapy with b/tsDMARD.

Demographic, laboratory, and clinical data were collected, including tender and swollen joint counts (as included in DAS 28), Visual Analog Scale (VAS), DAS28 4V, SDAI, CDAI, ACR and EULAR responses, and HAQ. All patients were evaluated at 0, 6 and 12 months after starting the first b/tsDMARD therapy performed after 2015. The variation in each parameter compared to baseline was calculated at 6 and 12 months and represented as a delta. A cutoff of 1 was defined for comparison between STR groups.

The correlations between the continuous variables were assessed by Pearson’s test and comparison between groups of ratios using t test (continuous variables) and chi-square test (categorical variables). Multiple linear regression and multivariate logistic regression were performed to determine response predictors.

Results

A total of 287 patients were included, 238 (82.9%) females, aged 55.7±10.8 years and diagnosed with rheumatoid arthritis for 11.2±8.1 years. Two hundred and sixty-nine (93.7%) were on csDMARD; with regard to b/tsDMARD therapy, 66 started etanercept (23.0%), 62 tocilizumab (21.6%), 58 rituximab (20.2%), 44 adalimumab (15.3%), 17 golimumab (5.9%), 14 abatacept (4.9%), 7 certolizumab (2.4%), 5 upadacitinib and baricitinib (1.7%), 4 infliximab (1.4%), 3 tofacitinib (1.0%), and 2 anakinra (0.7%).

At the start of therapy with b/tsDMARD, the mean DAS28 4V was 4.7±1.5, CDAI 20.4±12.2, SDAI 22.8±16.4, erythrocyte sedimentation rate 31.8±24.4, C-reactive protein (CRP) 1.5±1.7, patient VAS 62.6±1.5, physician VAS 41.4±29.7, pain VAS 62.5±24.8, and HAQ 1.5±0.6; median tender joint count was 4 (interquartile range - IQR - 6), swollen joint count was 3 (IQR 6), and STR joint count was 0.9 (IQR 0.5). When the STR < 1 and STR ≥1 groups were compared, it was found that there were no differences in these variables when starting b/tsDMARD, nor in the therapies they performed.

At 6 months, the STR ≥1 group showed a higher proportion of patients in CDAI remission (CDAI ≤2.8 – 15.3% vs 6.9%, p=0.033) and in DAS28 4V remission or low disease activity according to DAS28 4V (DAS28 4V ≤3.2 – 36.5% vs 22.4%, p=0.008).

At 12 months, the STR ≥1 group exhibited less disease activity (mean DAS28 4V 3.2±1.2 vs 3.6±1.3, p=0.028) and a higher proportion of patients in DAS28 4V remission (25.2% vs 19.7%, p=0.047).

No significant differences were found between the groups in the other variables studied.

In the correlation studies, a weak correlation was identified between STR and CRP at 12 months (r=0,28, p<0,001).

In multiple linear regression studies, when adjusted for sex, age, prednisolone, csDMARD, inflammatory parameters, b/tsDMARD, STR was not shown to be a predictor of DAS28 4V disease activity at 1 year; in multivariate logistic regression studies, when adjusted for the same variables previously described, STR was not shown to be a predictor of remission or remission or low disease activity according to DAS28 4V at 1 year.

Conclusion

The STR is a practical, easy-to-use index that can be used as an adjunct in clinical practice in the evaluation of patients with rheumatoid arthritis, as it is associated with a better response to b/tsDMARD therapy, regardless of patient status and therapy, although it should not be used alone, as it does not appear to be a predictor of response, according to the indices that are currently used.

References

[1]Kristensen LE et al. Arthritis Care Res (Hoboken). 2014 Feb;66(2):173-9.

Disclosure of Interests

None declared.

AB0850 Enthesitis, female gender and vitality perception as fatigue determinants in spondyloarthritis patients under bDMARD

Background

Fatigue is an important domain in quality of life of spondyloarthritis patients, not always directly associated with disease course. The explanatory factors of fatigue in these patients are still not clearly understood.

Objectives

To assess the determinants of fatigue in patients with SpA under biologic disease modifying anti-rheumatic drugs (bDMARDs).

Methods

A retrospective observational study was performed using registry data of patients with SpA under bDMARD therapy followed at a tertiary level hospital. Data regarding disease activity, response criteria measures, analytic markers, function, metrology, pain, general health and fatigue (using FACIT score) was gathered at baseline, 6 months (t6) and 12 months (t12) after introduction of bDMARD. Statistical analysis (significance at p < 0.05) was performed using paired T-test, Wilcoxon test and McNemar tests for paired samples, Mann Whitney-U, Kruskall-Walis and One Way ANOVA for independent samples. Linear and logistic regression models were performed to assess direction and strength of association.

Results

A total of 46 SpA patients were analysed; most were male (24, 52.2%) with a predominantly axial involvement (31, 68.9%) and 74.4% of them were positive for HLA-B27. Most patients had high school or lower education (29, 69.1%), never smoked (26, 61.9%), never drank (34, 79.1%) and had a full-time job (38, 88.4%). All patients were under TNF inhibitors, mostly adalimumab (23, 50%). There was a significant decrease in inflammatory markers (p<0.001), disease activity scores (ASDAS-CRP and BASDAI) (p<0.001), function index BASFI (p< 0.001), metrology indexes (p<0.05) and MASES enthesitis score (p< 0.01). Patient, physician and night pain VAS were significantly lower (p< 0.001) at t6 and t12, but spine VAS only varied significantly between t0 - t6 (p = 0.021) and not t0 - t12 (p= 0.405). FACIT didn’t vary significantly after bDMARD initiation, and among the domains of SF36 questionnaire, only SF36 vitality score varied significantly (p<0.05). No significant changes in EQ5D, HADs anxiety or depression scores were observed.

At baseline, there was a strong negative correlation between fatigue, expressed by FACIT score, and pain VAS (R = 0.9, p=0.037), without other significant associations. Several positive correlations with fatigue at t6 were observed, the strongest with anxiety and depression HADs (p < 0.001), BASFI (p < 0.001) and ASDAS-CRP (p< 0.001). Other positive associations were seen with 66 TJC (p <0.01), patient VAS (p<0.001, pain VAS (p = 0.001), nocturnal pain VAS (p <0.001), BASDAI (p <0.001) and MASES (p <0.001). Fatigue at t6 had a negative correlation with increased ASAS response measures mean value (p = 0.014), all domains of SF36 (p < 0.001), the strongest correlation of which was with the general health domain (R=-0.811), and EQ5D (p<0.001). When comparing subgroups at t6, there was more fatigue in the female group (p=0.01) and in patient with higher ASDAS disease activity score (p < 0.05), with no differences according to work status, alcohol consumption or tobacco use, educational level, TNF inhibitor exposure or ASAS response.

Prediction analysis showed univariable association between several baseline variables and fatigue (lower FACIT scoring) at t6: age at bDMARD introduction (B = - 0,405, p = 0.02), age at diagnosis (B = -0.43, p = 0.02), physician VAS (B = 0.149, p < 0.05), MASES (B = -1.732, p <0.001), SPARCC (p < 0.05) and female gender (B = -7.95, p = 0.01). Multivariate linear regression analysis allowed for creation of a predictive model for FACIT scoring at t6 (R2 = 0.900, p = 0.019): (-3.426) x MASES t0 + (-24.074) x female gender + 0.949 x SF36 vitality score.

Conclusion

Enthesitis, female gender and subjective assessment of vitality seem to be determinants of fatigue in SpA patients under bDMARD. Fatigue in this population is associated with diverse factors that should be optimized in a holistic approach to the patient.

Disclosure of Interests

None declared

AB0190 THE LONG-TERM PREDICTORS OF FATIGUE IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED BIOLOGICAL DISEASE-MODIFYING ANTIRHEUMATIC DRUGS

Background

Fatigue is one of the major complaints of patients with rheumatoid arthritis (RA). However, the literature relating fatigue to other disease-related parameters has presented discrepant results and longitudinal studies with multivariate analyses are scarce.

Objectives

To explore potential associations between fatigue and demographic variables and other patient-reported outcomes (PROMs) in patients with RA treated with biological disease-modifying antirheumatic drugs (bDMARDs) over the time.

Methods

A 24-month (24M) monocentric observational retrospective cohort study was conducted. Patients diagnosed with RA, according to the 2010 American College of Rheumatology (ACR)/ European League Against Rheumatism (EULAR) criteria, and registered on the Rheumatic Diseases Portuguese Register (Reuma.pt) who started their first bDMARD between 2015 and 2021 were included. Age, gender, disease duration, body mass index (BMI) and PROMs were obtained by consulting Reuma.pt. Fatigue was monitored at baseline, 12 and 24M using Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), a 13-item questionnaire with a total score ranging from 0 to 52. A score ≤ 39 indicates the presence of clinically significant fatigue. Health Assessment Questionnaire (HAQ), EuroQol-5D (EQ-5D), 36-Item Short Form Survey (SF-36), patient global assessment visual analogue scale (VAS) and pain VAS were assessed at baseline, 12 and 24M. Multivariate linear regression models were conducted with FACIT-F as the dependent variable.

Results

A total of 40 patients (47.4±11.4 years; 90.2% female) with a BMI of 29.87±8.54 kg/m2 and a mean disease duration of 10.4±5.6 years were included. A total of 47.5% of patients were treated with an anti-TNF. About 85% of patients had clinically significant fatigue at baseline (FACIT-F 26.9±11.8). At baseline, patient global assessment VAS (β=-0.4, 95%CI [- 0.68; -0.095]) and pain VAS (β=- 0.34, 95%CI [-0.6; -0.068]) predicted fatigue. SF-36 predicted fatigue at baseline (β=0.35, 95%CI [0.14;0.56]), 12M (β=0.23, 95%CI [0.084;0.37]) and 24M (β=0.26, 95%CI [0.13;0.39]). HAQ predicted fatigue at baseline (β=- 12.2, 95%CI [- 19.8; - 4.5]) and 24M (β=- 11.4, 95%CI [- 17.47; - 5.38]). EQ-5D (β=39.5, 95%CI [15.84; 63.22]) predicted fatigue at 24M.

Conclusion

Our results showed that pain levels and patient global assessment of disease activity predicted a higher level of fatigue at baseline. The decrease in physical function and a worse overall health status perceived by patient predicted higher fatigue over the time. Previous research has suggested that disease-related factors, such as inflammation, pain or decreased physical function are associated with greater fatigue in RA (1). These findings encourage the pre-treatment screening of fatigue in patients with RA in order to design individualized non-pharmacological approaches in addition to bDMARDs therapy.

References

[1]Katz P. Curr Rheumatol Rep. 2017;19(5):25.

Disclosure of Interests

None declared

AB1113 THE IMPACT OF SARS-COV-2 INFECTION ON DISEASE ACTIVITY AND CLINICAL RESPONSE TO BIOLOGICAL DMARDS IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Infections are a known trigger for Rheumatoid Arthritis (RA) flares.1 It is still unclear whether SARS-Cov-2 infection affects RA disease activity and the clinical response to biological disease-modifying antirheumatic drugs (bDMARDs).

Objectives

To evaluate the effect of SARS-Cov-2 infection on disease activity and bDMARD responses in patients with RA.

Methods

A retrospective study was carried out in a cohort of RA patients treated with bDMARDs from a tertiary hospital centre. Demographic and clinical data, including occurrence of SARS-Cov-2 infection, were obtained through medical records. Disease activity (DAS28, DAS28-CRP, CDAI and SDAI) and ACR and EULAR bDMARD responses were evaluated at four time points: baseline (t1 - last evaluation before Covid-19 pandemic), before (t2) and after (t3) SARS-Cov-2 infection and at the end of follow-up (t4 - last appointment of 2021). In patients with no record of SARS-Cov-2 infection the middle evaluations were obtained from two random consecutive appointments during Covid-19 pandemic. Statistical analysis (significance at p<0.05) was performed using paired t-test, Wilcoxon and McNemar tests for paired samples and unpaired t-test, Mann-Whitney, Fisher and χ2 tests for independent samples according to the type of variable and the presence of normal distribution.

Results

Of the 237 patients included, most of them was women [n = 195 (82.3%)], with a mean age of 59.6 ± 10.1 years old and a median [min, max] disease duration of 18 [2, 50] years. The majority presented rheumatoid factor (RF) and/or anti-citrullinated protein antibodies (ACPA) positivity [n = 204 (87.9%)] and radiographic erosions [n = 119 (72.6%)]. The prevalence of SARS-Cov-2 infection was 11.4% (n=27). Mean disease activity was lower after SARS-Cov-2 infection compared to the previous evaluation on all scores used; however, this difference was not statistically significant. Nevertheless, when compared to the mean disease activity at the end of follow-up, there were statistically significant differences in DAS28-CRP (t2 3.2±1.0 vs. t4 2.8±1.1, p=0.017) and CDAI (t2 11.1±8.1 vs. t4 8.7±6.2, p=0.05) scores. The relative number of patients with no ACR or EULAR bDMARD responses before SARS-Cov-2 infection wasn’t different from post infection and at the end of follow-up. At baseline, the infected and uninfected groups were similar regarding gender, age, RF and/or ACPA positivity, erosive disease, disease and biologic treatment durations, baseline disease activity and ACR and EULAR response. The variation in disease activity and the relative number of patients with worsening or improving EULAR and ACR bDMARD responses between t2 and t3 were not significantly different in the two groups, as well as between t2 and t4. The prevalence of patients who switched to another bDMARD was significantly higher in the group of patients who had Covid-19 [n=4 (14.8%) vs. 9 (4.3%), p=0.047]. The main reason for switching was the ineffectiveness of the therapy (n=11).

Conclusion

No worsening of disease activity or ACR and EULAR bDMARD responses was found after SARS-Cov-2 infection in RA patients under bDMARD. However, the later can be explained by the small sample size. Indeed, these patients exhibited a higher rate of switch due to ineffectiveness of therapy, suggesting a negative impact of SARS-Cov2 infection on the disease course.

References

[1]Rashmi Roongta, Alakendu Ghosh. Managing rheumatoid arthritis during COVID-19. Clinical Rheumatology (2020)

Disclosure of Interests

None declared

AB0107 IMPACT OF SARS-CoV-2 INFECTION ON THE DISEASE ACTIVITY OF PATIENTS WITH PSORIATIC ARTHRITIS UNDER bDMARDs: REAL LIFE DATA

Background

SARS-CoV-2 infection can lead to severe inflammation and has been suggested to induce Psoriatic Arthritis (PsA) flares.1 However, the impact on disease activity and response to biological disease modifying anti-rheumatic drugs DMARDs (bDMARDs) remains unknown.

Objectives

To evaluate the effect of SARS-CoV-2 infection on disease activity and bDMARDs responses in patients with PsA.

Methods

We performed a retrospective analysis including all the patients with PsA, meeting the CASPAR criteria and under biologic therapy, followed in the Rheumatology department of a tertiary university hospital. Demographic and clinical data, including occurrence of SARS-CoV-2 infection, were collected from our national database (reuma.pt). Disease activity (CDAI, SDAI, DAS28 4v, BASDAI, ASDAS) and bDMARDs responses (EULAR, ASDAS, ASAS, ACR and PsARC responses) were evaluated before and after SARS-Cov-2 infection. Statistical analysis was performed with SPSS. Continuous variables were compared through paired samples t-test.

Results

A total of 102 patients with PsA were included. Fifty-two were females (51%).The mean age was 53 ± 11.09 years and the median disease duration was 15 years [min 2, max 47]. Overall, 54 (53%) patients had predominant axial involvement, 26 (26%) peripheric and 36 (37%) enthesopathic. The most used bDMARD was etanercept (n=28, 27.5%) followed by adalimumab (n=22, 21.6%) and secukinumab (n=18, 17.6%).

The prevalence of SARS-CoV-2 infection was 15.7% (n=16). Sixty-three per cent received the BNT162b2 (Pfizer/BioNtech) vaccine, 31% received mRNA-1273 (Moderna), 13% received AZD1222 (AstraZeneca) and 13% received AD26.COV2.S (Janssen/Johnson & Johnson). Sixty-three percent were infected before any vaccination, 13% after the first dose and 25% after the second. The most common symptoms were anosmia (65%), dysgeusia (56%) and cough (56%). All patients fully recovered from the infection, with no need for hospitalization.

Regardless of the score used, the difference between the mean disease activity after SARS-CoV-2 infection and that at baseline did not reach statistical significance. At baseline and after infection, mean (SD) disease activity parameters were, respectively: CDAI 8.6±5.7 vs 8.6±5.7, p=0.997; SDAI 9.3±6.6 vs 9.2±6.1, p=0,928; DAS 28 4v 2.9±1.2 vs 2.9 ±1.2, p= 0.818; BASDAI 3.6 ±2.6 vs 3.2±2.7, p=0.506; ASDAS 2.2±1.2 vs 2.2±1, p=0.721.

The number of patients unresponsive to bDMARDs (according EULAR, ASDAS, ASAS, ACR and PsARC) before the infection wasn’t different from post-infection.

Conclusion

Our study suggests that SARS-CoV2 infection has no negative impact on PsA disease activity and bDMARD responses. However, more studies are still needed to better understand the long-term effects of SARS-CoV2 infection.

References

[1]Zhou Q et al. SARS-CoV-2 Infection Induces Psoriatic Arthritis Flares and Enthesis Resident Plasmacytoid Dendritic Cell Type-1 Interferon Inhibition by JAK Antagonism Offer Novel Spondyloarthritis Pathogenesis Insights. Front Immunol. 2021 Apr 15; 12:635018

Disclosure of Interests

None declared

AB1110 COVID19 IN SPONDYLOARTHRITIS PATIENTS UNDER bDMARD – A COMPREHENSIVE ASSESSMENT

Background

SARS-Cov-2 infection had a major impact on patients with inflammatory rheumatic diseases. Spondyloarthritis (SpA) patients were one of the most affected groups of these patients.

Objectives

To assess the impact of Covid19 in spondyloarthritis patients under biological disease modifying anti-rheumatic drugs (bDMARDs).

Methods

A retrospective observational study was conducted using registry data of patients with SpA under bDMARD therapy, followed at a tertiary level hospital, that have been diagnosed with COVID19 from March 2019 to December 2021. At least one evaluation previous (t0) and two evaluations after SARS-CoV-2 infection (t1, t2) were included in our analysis. Sociodemographic, clinical, disease activity, therapeutic response, function and general health status data were collected. Statistical analysis (significance at p < 0.05) was performed using paired T-test, Wilcoxon test and McNemar tests for paired samples. Linear and logistic regression models were performed to assess direction and strength of association

Results

Thirty-two patients with SpA under bDMARD had COVID19, mostly women (20, 62.5%), with a disease course time averaged 18.65 (± 9.69) years, mainly with axial involvement (19, 59.4%) and positive for HLA-B27 antigen (11, 64.7%). The majority were under TNF inhibitors (30, 93.75%), with golimumab being the most common (9, 28.1%), and with a median bDMARD persistence of 2.63 (5.09) years. Seven (21.9%) were under a cDMARD, 3 (9.4%) under NSAID and 18 (56.3%) under corticosteroids. Three (9.4%) were already vaccinated against SARS-CoV-2, 2 (66.6%) with the mRNA-1273 vaccine, presenting a medium time since inoculation of 240 (± 234.01) days. Arterial hypertension was the most common comorbidity (5, 15.6%) and one patient (3.1%) had a previous diagnosis of type 2 diabetes. Most were never-smokers (17, 53.1%) and never-drinkers (29, 90.6%).

The average age at infection was 40.97 (± 6.15) years and the most common symptom was cough (22, 68.8%), followed by headache (20, 62.5%) and myalgia (19, 59.4%). Event tree analysis didn’t show association with SpA subtype, education level, work status, tobacco or alcohol consumption. Only one patient needed hospital admission but without needing of oxygen, therapy, ventilator or ECMO. Only one patient had an overlaid bacterial infection and no thromboembolic complications were observed. Two patients needed specific SARS CoV-2 infection treatment, one with hydroxychloroquine and another with azithromycin. Twelve (37.5%) patients suspended bDMARD at the time of infection, with only 2 (6.3%) maintaining suspension at the time of the first post-infection visit.

When comparing clinical variables, higher disease activity was seen at t1 only for BASDAI mean values, without statistical significance. Higher all domains VAS scores were also observed at t1, but not at t2, also without statistical significance; moreover, physical function didn’t change significantly. No differences were observed according to gender or SpA subtype, nor with the use of cDMARDs, NSAIDs or corticosteroids. The only statistically significant difference concerned MASES score between t0 and t1 (1 ± 4 vs. 2 ± 6, p=0.04), but not between t0 and t2. Higher baseline tender joint score (p < 0.01) and higher baseline LEI (p=0.03) negatively correlated with MASES score variation. Several baseline variables correlated positively with MASES at t1, including female gender (p < 0.01), corticosteroid use (p = 0.04), BASDAI (p < 0.01), ASDAS-ESR (p < 0.01), ASDAS-CRP (p < 0.01), DAS28 (p < 0.01), SPARCC (p = 0.04), physician VAS (p = 0.03) and total spine VAS (p = 0.01). Working status varied significantly after SARS-Cov-2 infection (at least part-time - 29, 90.6% vs. 22, 68.8%, p= 0.016).

Conclusion

SpA patients on bDMARD had a mild course of SARS-CoV-2 infection, with slight changes in enthesitis score in the short term, the latter particularly in those with higher disease activity in the pre-infection period. Long-term effects on work status could represent confounding factors related to the economic constraints of the pandemic.

Disclosure of Interests

None declared

AB0914 Is tender to swollen joint count ratio a useful clinical marker of response to biological treatment in psoriatic arthritis patients?

Background

Chronic inflammation in psoriatic arthritis (PsA) may trigger both peripheral and central sensitization via central modifications of pain pathways that can lead to disconnection between tender and swollen joint count. This can result in increased difficulties for the clinician in the assessment of the disease and response to treatment.

Objectives

To study the impact of tender to swollen joint count ratio (TSR) on treatment response to a first course of biologic disease-modifying antirheumatic drug (bDMARD) therapy in PsA patients.

Methods

Observational study including PsA patients under bDMARD, followed with clinical and laboratory examination at baseline, 6 and 12 months of treatment. All patients meet the CASPAR classification criteria. TSR was defined as the tender joint count divided by the swollen joint count, using the 68/66 joint assessment. Patients with no tender nor swollen joints at baseline were excluded. TSR was categorized into 3 groups, based on the empirical distribution, with cuts corresponding to the 20th and 70th percentiles. Disease activity was assessed using the Clinical Disease Activity Index (CDAI), the Simplified Disease Activity Index (SDAI) and Disease Activity Score based on 28 joints (DAS28-CRP(4)). Individual time profiles were plotted within each TSR group. CDAI, SDAI and DAS28-CRP(4) individual time profiles within each TSR group were modelled by mixed-effects linear regression using the TSR group and time as fixed factors and a random factor at the intercept level (accounting for the intra-individual correlation structure). The identification of the statistically significant pairwise differences was obtained from the Tukey’s method for multiple comparisons.

Results

We included 113 patients, 62 (54.0% females) with a mean age of 48.1±10.8 years-old at the start of the first bDMARD. Sixty-four patients (56.6%) had symmetric polyarthritis, 19 (16.8%) spondyloarthritis, 25 (22.1%) asymmetric oligoarthritis, 2 (1.8%) distal arthritis and 1 (0.9%) arthritis mutilans. Forty-three percent were under corticosteroid therapy and 57.5% under conventional synthetic DMARD (csDMARD) therapy at baseline (mostly methotrexate, in 45.1% of patients under csDMARD). Etanercept (n=35, 31.0%), adalimumab (n=34, 30.1%), golimumab (n=25, 22.1%), infliximab (n=6, 5.3%), certolizumab (5, 4.4%), secukinumab (n=8, 7.1%) were the bDMARD started in these patients. TSR was categorized into 3 groups, namely low [TSR < 1], moderate [1 ≤ TSR ≤ 2.2] and high [TSR > 2.2], with frequencies 15 (13.3%), 66 (58.4%) and 32 (28.3%), respectively. Whenever the number of tender joints was different from 0 and that of swollen joints equal to 0, patients were included in the group high TSR. All TSR groups, with initiation of bDMARD, showed significantly decreases at 6 months in CDAI (low: p=0.006, moderate: p<0.001, high: p<0.001), SDAI (low: p<0.001, moderate: p<0,001, high: p<0.001) and DAS28-CRP(4) (low: p<0.001, moderate: p<0.001, high: p<0.001). From 6 to 12 months of treatment, the differences were not significant in any of the groups (p>0.05). At baseline, CDAI, SDAI and DAS28-CRP(4) means did not differ between groups (p>0.05). There were also no differences in the means of outcome measures at 6 months as well as at 12 months of treatment (p>0.05). Despite this, patients with low baseline TSR had lower mean values of CDAI, SDAI and DAS28-CRP(4) at 6 and 12 months of treatment, consistent with a low disease activity.

Conclusion

To our knowledge this is the first study exploring the TSR on treatment response in samples of patients exclusively with PsA. All patients benefited from bDMARD therapy, regardless of the group, suggesting that TSR might not be a good predictor of treatment response in patients with PsA.

Disclosure of Interests

None declared

AB0360 THE LONG-TERM IMPACT OF FATIGUE ON DISEASE ACTIVITY IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH BIOLOGICAL DISEASE-MODIFYING ANTIRHEUMATIC DRUGS

Background

Fatigue is common among patients with rheumatoid arthritis (RA) with a substantial impact on quality of life (1). Biological disease-modifying antirheumatic drugs (bDMARDs) have been shown to significantly improve fatigue in these patients. However, fatigue is under-assessed by the physicians and evidence is still scarce regarding a possible impact of fatigue on disease activity over time.

Objectives

To explore the long-term impact of fatigue on the disease activity in patients with RA treated with bDMARDs.

Methods

A monocentric observational retrospective cohort study was conducted with 24 months (M) of follow-up. Patients diagnosed with RA, according to the 2010 American College of Rheumatology (ACR)/ European League Against Rheumatism (EULAR) criteria, and registered on the Rheumatic Diseases Portuguese Register (Reuma.pt) who started their first bDMARD between 2015 and 2021 were included. Demographic, clinical and laboratory data were obtained by consulting Reuma.pt. Fatigue was monitored at baseline, 12 and 24M using Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F). This scale is a 13-item self-reported questionnaire with a total score ranging from 0 to 52. A score ≤ 39 indicates the presence of clinically significant fatigue. Disease Activity Score for 28 joints with erythrocyte sedimentation rate (DAS28), DAS28 with C-reactive Protein (CRP) [DAS28-CRP], DAS28 delta, Clinical Disease Activity Index (CDAI) and Simplified Disease Activity Index (SDAI) were calculated to measure disease activity. Clinical response was evaluated by EULAR criteria in three response categories- good, mild and no response- and by ACR criteria (0 to 100%) at 12 and 24M. To correlate fatigue score with EULAR clinical response Chi-square test was used. Multivariate linear regression models adjusted for age, gender and disease duration were used to assess the effect of fatigue on disease activity and ACR clinical response over time.

Results

A total of 40 patients with RA were included, with a mean age of 47.4±11.4 years old and disease duration of 10.4±5.6 years. Most patients were female (90.2%). Rheumatoid Factor was positive in 70% of patients. The majority of patients (85%) had clinically significant fatigue at baseline moment (FACIT-F 26.9±11.8). Treatment characteristics and baseline disease activity scores are described in Table 1. Fatigue at baseline moment predicted DAS28(CRP) (β=-0.061, 95%CI [-0.12; -0.003]) and CDAI (β=- 0.30, 95%CI [-0.57; -0.029]) at 12M. Additionally, fatigue predicted SDAI (β=-0.38, 95%CI [-0.72; -0.047]) and CDAI (β=- 0.39, 95%CI [-0.73; -0.051]) at 24M. In general, for these models, fatigue as a symptom was shown to have negative effects on the different outcomes analysed. Fatigue did not associate with EULAR and ACR responses over time.

Table 1.

Baseline characteristics of sample. LEGEND: SD: Standard deviation; DAS28: Disease Activity Score for 28 joints; CRP: C-reactive Protein; CDAI: Clinical Disease Activity Index; SDAI: Simplified Disease Activity Index.

VariableDescriptive statisticTreatment optionsn(%)Glucocorticoids37(92.5)Conventional DMARDs37(92.5)Anti-TNF19(47.5)Etanercept13(32.5)Rituximab4(10)Tocilizumab4(10)Disease activity scoreMean±SDDAS285.4±0.87DAS28-CRP4.9±0.69CDAI27.6±8.5SDAI28.9±8.7

Conclusion

These findings showed that, in our sample, the most RA patients had severe fatigue and its presence may be a predictor of increased disease activity. Indeed, previous research observed a positive association between fatigue and disease activity over the time in patients with RA (2). Therefore, fatigue should be regularly monitored in patients with RA and its impact on treatment must be considered. Moreover, further research with larger samples is needed to explore the impact of fatigue on clinical response and the potential of fatigue relief as an outcome measure of RA treatment.

References

[1]Katz P. Curr Rheumatol Rep. 2017;19(5):25.

[2]Holten K, et al. Ann. Rheum. Dis. 2021; 0:1–7.

Disclosure of Interests

None declared

AB0939 Psoriatic arthritis related fatigue: what is the magnitude of this problem and what are the correlated factors? A cross-sectional study

Background

Fatigue is a common constitutional feature and has a significant impact on quality of life in patients with chronic inflammatory rheumatic diseases, such as psoriatic arthritis (PsA). It is a complex phenomenon and its pathogenesis remains unclear. Despite being a common symptom, it is largely ignored and rarely assessed in clinical practice.

Objectives

This study aims to evaluate the incidence and severity of fatigue in PsA patients under biological agents and to assess the influence of several clinical and demographic features on PsA related fatigue.

Methods

We conducted a cross-sectional study including patients with PsA, according to CASPAR criteria, treated with biological agents, from our University Hospital and registered in the national database (reuma.pt). Fatigue was assessed by a 13-item self-administered questionnaire (Functional Assessment of Chronic Illness Therapy-Fatigue [FACIT-F]). Data collected and analyzed included: demographic data, disease activity data, functional status, comorbidities and therapies. Student’s t-test, ANOVA and Pearson’s correlation were performed to compare data, as appropriate. A p-value <0.05 was considered statistically significant.

Results

60 PsA patients were included, 61.7% were males, with a mean age at diagnosis of 38.1±10.5 years and a median disease duration of 13.0 (8.75-19.25) years. Most of the included patients had a predominant polyarticular pattern (n=33, 55.0%). The mean FACIT-F score was 34.48±11.61. No differences were found in the FACIT-F score according to gender, pattern of joint involvement, presence or absence of cutaneous involvement, nail dystrophy and/ or dactylitis. Patients with depression and enthesitis exhibited a lower FACIT-F score (p=0.017 and p=0.007, respectively). Patients treated with tofacitinib had a lower FACIT-F score than patients treated with adalimumab (p=0.025). No differences were found among the other biological agents. Patients in remission (according to EULAR response criteria) had a higher FACIT-T score than patients with moderate disease activity (p=0.032). In patients with a predominant axial involvement, inactive disease (according to ASDAS) was associated with a higher FACIT-T score, when compared to very high disease activity (p=0.02). Also, patients with moderate disease activity had a higher FACIT-T score than patients with very high (p=0.003) and high (p=0.008) disease activity.

FACIT-F showed a significant correlation with disease activity scores as BASDAI (r=-0.546, p<0.001), DAS 28 CRP (r=-0.506, p<0.001), CDAI (r=-0.672, p<0.001), SDAI (r=-0.641, p<0.001) and ASDAS CRP (r=-0.500, p<0.001). FACIT-F was also correlated with BASFI (r=-0.598, p<0.001), HAQ (r=-0.701, p<0.001), BASMI (r=-0.431, p<0.001) and MASES (r=-0.401, p<0.001). The authors found strong correlations between FACIT-F and HADS domains (Depression and Anxiety domains; r=-0.850, p<0.001 and r=-0.748, p<0.001, respectively). A strong correlation was also found between the FACIT-F and the 8 domains of health of the SF36 (p<0.001).

Conclusion

Fatigue was a common symptom in our sample of PsA patients and, its magnitude was closely related with disease activity, physical function, depression and anxiety status, indicating its multifactorial nature. We can speculate that achieving disease remission could significantly alleviate the fatigue intensity and vice versa. As recommended by EULAR/ACR task force in 2008, fatigue should be measured in clinical practice and should be part of the multidisciplinary approach, in addition to controlling disease activity.

Disclosure of Interests

None declared

Epicardial mapping as first intention approach for structural ventricular tachycardia ablation

Funding Acknowledgements

Type of funding sources: None.

Introduction

In several structural arrhythmogenic diseases that comprise intricate endocardial, intramural and epicardial substrates, endocardial ablation of ventricular tachycardia (VT) is not sufficient and epicardial ablation has lately become a complementary and necessary tool.

Purpose

To evaluate the clinical characteristics of patients (pts) most suitable for first intention epicardial VT ablation.

Methods

Single-center prospective study of consecutive pts with structural heart disease undergoing first intention epicardial VT mapping between August 2015 and June 2021. Decision for epicardial approach was based on the etiology, VT electrocardiogram (ECG) and cardiac magnetic resonance (CMR) results. Under general anesthesia, subxiphoid access using a Tuhoy needle was done using fluoroscopic guidance and with high-density epicardial mapping was performed. Epicardial ablation was performed if relevant arrhythmogenic findings were locally confirmed.

Results

First intention epicardial VT ablation was attempted in 18 pts (mean age 59.8±12 years,94% male) of whom 16 had non-ischemic dilated cardiomyopathy (NICM,idiopathic:11; post-myocardis:4; hereditary:1) and 2 had right ventricular arrhythmogenic cardiomyopathy. Mean LVEF was 33% and 79% had a previous ICD (53% in primary prevenon). 69% were referred for ablation due to arrhythmic storm (1pt in cardiogenic shock). Epicardial access was achieved in 17 pts (94%), without acute complications. In 35% pts with NICM the decision for epicardial approach was based on the detection of subepicardial CMR delayed-hyperenhancement and relevant epicardial arrhythmic substrate was confirmed by mapping in all cases. In 3 pts radiofrequency (RF) applicaons were not performed at epicardium, as no abnormal electrograms were locally detected, and an addional endocardial approach was prosecuted. The mean overall procedure and fluoroscopic time were 123 and 28min, respectively, with a mean RF application me of 51min. After the procedure 1pt required pericardial drainage due to inflammatory pericardial effusion. No other acute complications occurred. During a mean follow-up of 2.8±1.8 years, only 3pts (17%) had VT recurrence; 5pts (28%) died due to end-stage heart failure and 2pts (11%) underwent heart transplantation.

Conclusion

In NICM a first intention epicardial VT ablation performed by experienced operators/centers is efficient, particularly if guided by CMR findings,and presents a safety profile.

Transformative effect of a Humanitarian Program for individuals affected by rare diseases: building support systems and creating local expertise

Rare diseases affect > 400 million people globally with a disproportionate burden falling on children, resulting in high morbidity and mortality rates. Affected individuals in some under-resourced countries have limited access to expert care or treatments; moreover, they suffer long diagnostic journeys during which debilitating and life-threatening complications occur. Lysosomal storage disorders (LSD) are prototype rare diseases due, in the main, to inherited deficiencies of lysosomal enzymes/transporters that affect up to 1 in 5000 newborns. Recognizing the need to provide treatment access to people with LSDs everywhere, a collaborative partnership was pioneered and set up 30 years ago. Partnering with local authorities, non-government organizations across six continents, local as well as international experts, a robust, sustainable Humanitarian Program emerged that now represents the most enduring charitable access program for LSD treatment. Here we present the history, process, lasting beneficial effect of the program to develop healthcare systems and infrastructures, and the lessons learned from addressing major unmet needs for LSDs.

Spread of Gamma (P.1) Sub-Lineages Carrying Spike Mutations Close to the Furin Cleavage Site and Deletions in the N-Terminal Domain Drives Ongoing Transmission of SARS-CoV-2 in Amazonas, Brazil

The Amazonas was one of the most heavily affected Brazilian states by the COVID-19 epidemic. Despite a large number of infected people, particularly during the second wave associated with the spread of the Variant of Concern (VOC) Gamma (lineage P.1), SARS-CoV-2 continues to circulate in the Amazonas. To understand how SARS-CoV-2 persisted in a human population with a high immunity barrier, we generated 1,188 SARS-CoV-2 whole-genome sequences from individuals diagnosed in the Amazonas state from 1st January to 6th July 2021, of which 38 were vaccine breakthrough infections. Our study reveals a sharp increase in the relative prevalence of Gamma plus (P.1+) variants, designated Pango Lineages P.1.3 to P.1.6, harboring two types of additional Spike changes: deletions in the N-terminal (NTD) domain (particularly Δ144 or Δ141-144) associated with resistance to anti-NTD neutralizing antibodies or mutations at the S1/S2 junction (N679K or P681H) that probably enhance the binding affinity to the furin cleavage site, as suggested by our molecular dynamics simulations. As lineages P.1.4 (S:N679K) and P.1.6 (S:P681H) expanded (Re > 1) from March to July 2021, the lineage P.1 declined (Re < 1) and the median Ct value of SARS-CoV-2 positive cases in Amazonas significantly decreases. Still, we did not find an increased incidence of P.1+ variants among breakthrough cases of fully vaccinated patients (71%) in comparison to unvaccinated individuals (93%). This evidence supports that the ongoing endemic transmission of SARS-CoV-2 in the Amazonas is driven by the spread of new local Gamma/P.1 sublineages that are more transmissible, although not more efficient to evade vaccine-elicited immunity than the parental VOC. Finally, as SARS-CoV-2 continues to spread in human populations with a declining density of susceptible hosts, the risk of selecting more infectious variants or antibody evasion mutations is expected to increase. IMPORTANCE The continuous evolution of SARS-CoV-2 is an expected phenomenon that will continue to happen due to the high number of cases worldwide. The present study analyzed how a Variant of Concern (VOC) could still circulate in a population hardly affected by two COVID-19 waves and with vaccination in progress. Our results showed that the answer behind that was a new generation of Gamma-like viruses, which emerged locally carrying mutations that made it more transmissible and more capable of spreading, partially evading prior immunity triggered by natural infections or vaccines. With thousands of new cases daily, the current pandemics scenario suggests that SARS-CoV-2 will continue to evolve and efforts to reduce the number of infected subjects, including global equitable access to COVID-19 vaccines, are mandatory. Thus, until the end of pandemics, the SARS-CoV-2 genomic surveillance will be an essential tool to better understand the drivers of the viral evolutionary process.

COVID-19 pandemic impact on Primary Health Care Accessibility in Portugal

 

The COVID-19 pandemic disrupted health systems worldwide, mobilizing most of its resources to COVID-19 care. In Portugal, since mid-March 2020, the scheduled assistance activity of the primary health care services has been altered or interrupted, to respond to the needs of users with suspected or diagnosed SARS-CoV-2 infection. This study intends aims to assess the impact of the COVID-19 pandemic in terms of access to primary health care during 2020 in Portugal. Primary Health Care accessibility data were extracted from the national data transparency portal. Data were aggregated by the 5 health regions and compared to homologous periods for years 2019 and 2020. In Portugal, in 2020 the number of primary health care consultations decreased in the regions of Alentejo (-5%), Algarve (-1%) and Centre (-1%) but increased in both North (+6%) and Lisbon and the Tagus Valley regions (+7%). The number of scheduled appointments decreased in the 5 regions (-16%), increasing the unscheduled appointments (+24%). Those differences were higher during the first lockdown (-42% schedule appointments vs + 13% unscheduled appointments). Presential consultations decreased by 38%, non-presential increased by 101%, and domiciliary consultations were reduced by 37%. Changes to regular activity of primary health care units compromised the access to presential health care by the non-COVID-19 population. After the first pandemic wave, the resumption of scheduled activity changed from face-to-face to non-presential consultation. The adoption of new technologies and telemedicine increased the total of registered consultations, compared to previous year. However, not all non-presential consultation is in fact patient-facing teleconsultation, with some of them being just for prescription renewal or to prescribe complementary exams. Predominantly urban regions were less affected by the suspension of presential activity, maintaining their assistance by non-presential provision of care and telework.

Key messages

Amidst the COVID-19 pandemic, the Portuguese primary health care services ensured the assistance to their population by non-presential provision of care. Predominantly rural regions were most affected by the suspension of presential consultation.

POS0502 WHAT IS THE ROLE OF VITAMIN D STATUS IN DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH bDMARDs? – DATA FROM A RHEUMATOLOGY CENTER

Background:

Vitamin D is a fat-soluble vitamin, mainly involved in the regulation of calcium metabolism, and it has gained increasing interest in recent years because of its potential role in immunomodulatory activity. Recent data suggest that it is negatively associated with disease activity in rheumatoid arthritis (RA), however this is not yet fully understood.

Objectives:

This study’s aim was to investigate if there is any correlation between vitamin D serum levels at baseline, before taking the first biological disease-modifying antirheumatic drug (bDMARD), and at 6 months after, with disease activity in a cohort of RA patients.

Methods:

This is a cross-sectional study, including all the rheumatoid arthritis patients taking the first bDMARD with evaluation of the vitamin D status at baseline and 6 months after biologic therapy at our Rheumatology Department and registered in the national database (Reuma.pt).

Demographic, clinical and laboratorial characteristics and disease activity measures were collected from the baseline visit and the visit after 6 months of treatment with the first biologic. For the statistical analysis, two groups were defined, based on the serum levels of 25(OH) vitamin D, considering the most common cut-off of 30 ng/mL. For comparison analyses between groups, chi-square test was used for categorical variables and Mann-Whitney U and T-tests were applied for continuous variables.

Results:

Seventy-seven patients were included, 58 (75.3%) were females; the mean age was 54.24 ±11.0 years and seropositivity was founded in 65 (84.4%) for anti-citrullinated protein antibodies and in 58 (75.3%) for rheumatoid factor. The first bDMARD most commonly prescribed were etanercept (28.6%) and rituximab (26%). Regarding the vitamin D status at baseline, the mean serum level for 25(OH)vitamin D was 28.35 ± 18.21 ng/mL, with the majority of patients having vitamin D insufficiency (25(OH)vitamin D < 30 ng/mL) (63.6%). After 6 months of treatment with the first bDMARD, disease activity measures showed that remission or low activity were achieved in 29.9% of the patients, using DAS28 criteria; in 42.9% and 46.8%, according CDAI and SDAI criteria, respectively. Vitamin D serum levels at 6 months were 26.81 ±11.72, with the majority of patients still with vitamin D insufficiency (62.3%).

At baseline, patients with vitamin D insufficiency had greater patient VAS (79.00 ± 19,14 vs 71.71 ± 21.95), greater erythrocyte sedimentation rate (ESR) (40.67 ± 23.17 vs 32.46 ± 26.09) and greater Health Assessment Questionnaire (HAQ) score (1.75 ± 0.609 VS 1.61 ± 0.659) with neither of them having statistical significance. However, when comparing CRP levels at 6 months, it achieved statistical significance with the Mann-Whitney U-test (1.05 ± 1.79 VS 1.41 ± 5.22; p=0.026).

The same tendency was confirmed when analyzing vitamin D levels at 6 months. Patients with vitamin D insufficiency presented greater patient VAS (55.33 ± 28.82 vs 42.86 ± 28.28), greater ESR (26.19 ± 21.57 vs 21.00 ± 20.38) and greater HAQ score (1.35 ± 0.662 VS 1.34 ± 0.705), although without statistical significance. However, it did achieve statistical significance when comparing baseline DAS28 and HAQ (5.60 ± 0.91 VS 5.38 ± 1.31; p=0.013 and 1.76 ± 0.53 VS 1.59 ± 0.75; p=0.007, respectively).

Conclusion:

Our data failed to demonstrate a statistically significant association between vitamin D serum levels at baseline and at 6 months with disease activity in our RA sample. However, it revealed a positive trend of vitamin D insufficiency related to higher activity disease. Interestingly, it showed that vitamin D insufficiency after 6 months of bDMARD treatment is related to higher DAS28 and HAQ at baseline. Nonetheless, we insist it is of paramount importance to conduct larger studies to confirm these findings.

References:

[1]Bellan M, Sainaghi PP, Pirisi M. Role of Vitamin D in Rheumatoid Arthritis. Adv Exp Med Biol. 2017;996:155-168.

Disclosure of Interests:

None declared

AB0476 VITAMIN D SERUM CONCENTRATION VARIES ACCORDING TO DISEASE ACTIVITY IN SPONDYLOARTHRITIS

Background:

Several studies have shown dissimilar results for the relationship between serum 25-hydroxyvitamin D concentration (25-OH-D) and disease activity in spondyloarthritis (SpA).

Objectives:

This study aims to assess whether vitamin D levels vary according to disease activity in patients with SpA before and after starting treatment with biologic disease-modifying anti-rheumatic drugs (bDMARDs).

Methods:

An observational retrospective study was performed in SpA patients followed in the Rheumatology department of a tertiary university hospital. Demographic and clinical data were collected from the Rheumatic Diseases Portuguese Register (Reuma.pt). Patients were assessed for 25-OH-D levels before and after 6 months of treatment with the first bDMARD. Correlation between 25-OH-D levels and disease activity measured by Ankylosing Spondylitis Disease Activity Score (ASDAS) at baseline and after 6 months were assessed using student’s t-test for two samples and one-way ANOVA and with post hoc tests for multiple comparisons.

Results:

A total of 189 patients were included. Ninety-seven patients were females (51.3%). The mean age at diagnosis was 34.8±11.2 years and the median disease duration at the start of the first bDMARD was 4.9 years (min: 0.1; max: 46.0). All patients fulfilled the ASAS criteria for SpA. Nonsteroidal anti-inflammatory drugs were used by 102 patients (54.0%) and conventional synthetic DMARDs by 69 patients (36.5%). At 6 months, 188 patients were treated with tumor necrosis factor inhibitors and one with interleukin-17 inhibitor. According to ASDAS criteria, at baseline 36.8% of patients had high disease activity and 59.5% had very high disease activity. After 6 months of treatment with bDMARD 14.7% of patients have inactive disease, 21.6% low disease activity, 36.3% high activity and 12.6% very high disease activity. The mean value of 25-OH-D at baseline was significantly lower in the group of patients with very high disease activity compared to the patients with high disease activity (21.9±11.1 ng/ml vs 26.1±11.6 ng/ml, p= 0.02). At 6 months of treatment the mean value of 25-OH-D in inactive, low, high and very high disease activity was 31.0±17.1ng/ml, 28.5±11.2ng/ml, 25.8±10.8ng/ml and 19.3 ±9.5ng/ml, respectively. There was a statistically significant difference between the groups, as determined by one-way ANOVA (p = 0.001). A post hoc Dunnett T3 test revealed that patients with very high disease activity have significantly lower mean 25-OH-D levels (19.29 ± 9.5) than patients with inactive disease (31.0 ± 17.1, p = 0.025) and low activity (28.5 ± 11.2, p = 0.009). Among the groups with high and very high disease activity, the significance is only marginal (p = 0.068).

Conclusion:

Vitamin D serum concentration varies according to disease activity in SpA. In fact, SpA patients with lower levels of 25-OH-D are associated with higher rates of disease activity, even in patients treated with biologics agents. It is important to be aware of vitamin D level as it can play a role in the management and treatment of the disease, mainly in the most severe patients.

References:

[1]Zhao SZ, Thong D, Duffield S, Goodson N. Vitamin D Deficiency in Axial Spondyloarthritis is Associated With Higher Disease Activity. Arch Rheumatol. 2017 Mar 24;32(3):209-215. doi: 10.5606/ArchRheumatol.2017.6212. PMID: 30375524; PMCID: PMC6190948.

Disclosure of Interests:

None declared.

POS1067 BASELINE VITAMIN D LEVELS AND DISEASE ACTIVITY AND RESPONSE IN PORTUGUESE PATIENTS WITH PSORIATIC ARTHRITIS UNDER bMDARD: DOES IT MAKE A DIFFERENCE?

Background:

There is growing evidence that vitamin D [25(OH)D]) plays an important role in maintaining skeletal health and modulating the immune system. Epidemiological data indicate that vitamin D deficiency is common in immune-mediated rheumatic diseases, especially in rheumatoid arthritis, but there is little data regarding its association with disease activity and response to therapy in patients with psoriatic arthritis (PsA) under bDMARD therapy.

Objectives:

We aimed to assess whether 25(OH)D basal levels correlate with disease activity and clinical response to the first bDMARD, at 6 and 12 months of therapy, in a monocentric cohort of patients with PsA.

Methods:

This retrospective study was carried out on PsA patients from a Rheumatology department of a tertiary hospital, fulfilling CASPAR criteria and registered in our national database (Reuma.pt), who started the first bDMARD since 2008. Demographic, clinical and laboratory criteria were evaluated at 0, 6 and 12 months of biologic therapy. Disease activity was assessed using CDAI, SDAI, DAS28(4V), BASDAI, ASDAS, DAPSA and the response was measured using the EULAR, BASDAI50, ASDAS, ASAS, ACR and PsARC responses. Correlations were made between absolute serum levels of 25(OH)D and continuous variables, as well as associations between different vitamin D cutoffs and disease activity measures and response criteria. Multiple linear and logistic regression analyses were performed to determine whether vitamin D is a predictor of disease activity and therapeutic response.

Results:

We included 81 patients, 41 (50.6%) females; with a mean age of 48.0±11.7 years, a mean disease duration of 9.5±7.4 years and a mean body mass index of 28.4±5.2 kg/m2. Thirteen (16.0%) were smokers. The mean 25(OH)D basal level was 25.5±13.2 ng/ml, 21 (25.9%) had 25(OH)D basal levels ≥30 ng/mL and 31 (38.3%) ≤20 ng/mL. Sixty-two patients (76.5%) were under csDMARD therapy. Golimumab (29, 35,8%), etanercept (28, 34.6%) and adalimumab (10, 12.3%) were the most frequently prescribed bDMARDs. There were only very weak, albeit positive, correlations between 25(OH)D levels and measures of disease activity. The BASDAI50 response at 6 months was associated with higher basal 25(OH)D levels (29.5±14.5 vs 21.5±10.2 ng/mL, p = 0.013); the ASAS20 (33.9±15.9 vs 24.2±12.8 ng/mL; p = 0.023), ASAS40 (31.9±14.6 vs 25.0±13.8 ng/mL; p = 0.023) and ASAS70 (47.0±4.2 vs 26.6±14.2; p = 0.027) responses at 12 months were associated with higher basal levels of 25(OH)D; basal 25(OH)D levels were ≥ 30ng/mL in a significantly higher proportion of patients who achieved CDAI (38.9% vs 10.5%; p = 0.027) and SDAI (38.9% vs 7.7%; p = 0.008) remission and ASDAS disease inactive (29.4% vs 7.3%; p = 0.040) at 1 year. In the regression models, basal levels of 25(OH)D were found to be predictors of good EULAR responders (OR 1.315, 1.017-1.213 95% CI; p = 0.037) at 6 months. Basal levels of 25(OH)D were not significantly different in patients who discontinued bDMARD and no significant correlations or associations were identified regarding more specific PsA activity measures, such as DAPSA and PsARC, nor were they predictive of these responses.

Conclusion:

We can conclude that there is a global trend for an association between higher levels of vitamin D and lower measures of disease activity and better therapeutic responses to the first biologic. It was possible to find statistically significant associations with some disease activity measures and response criteria that, although primarily designed for other rheumatic diseases, are often used in PsA.

Disclosure of Interests:

None declared.

AB0137 THE ASSOCIATION BETWEEN AUTOANTIBODY LEVELS AND THE OUTCOMES OF ANTI-TUMOUR NECROSIS FACTOR ALPHA TREATMENT IN RHEUMATOID ARTHRITIS - A RETROSPECTIVE COHORT STUDY WITH TWO YEARS FOLLOW-UP

Background:

In rheumatoid arthritis (RA), autoantibodies namely anticitrullinated protein antibodies (Anti-CCP) have prognostic value, independently predicting radiologic progression. However, the evidence is still controversial about how the autoantibody levels change over time and their role in treatments outcomes and in monitoring disease activity in RA.

Objectives:

This study aimed to characterize the changes of autoantibodies levels (rheumatoid factor (RF) and Anti-CCP) over time and to explore the association between these autoantibodies and the outcomes of the first anti-tumour necrosis factor alfa (anti-TNF-α) therapy as first biologic agent in RA.

Methods:

An observational retrospective cohort study was conducted with two years of follow-up. Patients with diagnosis of RA according to American College of Rheumatology (ACR) criteria and registered on Rheumatic Diseases Portuguese Register (Reuma.pt) who started their first anti-TNFα agent (as first biologic) between 2003 and 2018 were included. Patients with positive RA (>30 UI/mL) and/or positive Anti-CCP (>10 U/mL) at their first visit were included. Demographic, clinical and laboratory data were obtained by consulting Reuma.pt. Disease Activity Score for 28 joints [DAS28(3v); DAS28(4v); DAS28(3v; C-Reactive Protein (CRP)), DAS28(4v; CRP), delta DAS28(4v)], Health Assessment Questionnaire (HAQ), delta HAQ, Anti-CCP and RF levels were assessed at baseline, 12 and 24 months. Continuous variables are presented with mean, standard deviation, median, quartile 1 and quartile 3. Categorical variables are presented with absolute and relative frequencies. To examine the differences between Anti-CCP and RF levels at baseline, 12 months and 24 months the Wilcoxon test for paired samples was performed. In order to correlate the Anti-CCP and RF levels with DAS28 variables, delta DAS28(4v), HAQ and delta HAQ at baseline, 12 months and 24 months, a correlation coefficient, Spearman’s coefficient, was used.

Results:

A total of 116 patients (mean age of 50.2±10.4 years old; 85.3% female) with RA were included with a median disease duration of 10.5 [5-18.5] years and a follow-up time of 8 [5-14] years. About 49% of patients were FR and Anti-CCP positivity, 38% only FR positivity and 13% only Anti-CCP positivity. At baseline, 64 (55.2%) patients had an erosive disease and 50 (43.1%) had extra-articular manifestations. Compared to the baseline (160[74.8-496]), FR levels decreased significantly at 12 months (121[49.1-321.8]) and 24 months (107.5[43.3-332]) with a p=0.017 and p=0.029, respectively. There were no differences in Anti-CCP levels over time. No correlation was found between FR/Anti-CCP levels and different DAS28 variables, DAS28(4v) delta, HAQ, and HAQ delta at 12 months and 24 months.

Conclusion:

We found that in patients with RA treated with a first anti-TNF-α agent as first biologic, FR levels decreased at 12 months and 24 months follow-up. However, our study failed to demonstrate a correlation between autoantibodies levels and disease activity (DAS28 variables and delta DAS28(4v)), HAQ and delta HAQ. In fact, previous research demonstrated that there is an association between autoantibodies levels and disease activity in RA, nonetheless not being static and increasing with signs of inflammation at baseline. So, further research with large samples is needed to explore this correlation considering the adjustment for confounding inflammatory variables, such as number of swollen or tender joints and morning stiffness.

Disclosure of Interests:

None declared

AB0835 IS BASELINE VITAMIN D STATUS RELATED WITH THE RESPONSE TO BDMARDS IN SPONDYLOARTHRITIS PATIENTS?

Background:

Vitamin D is thought to have an important role in immune regulation and is being subject of research in several autoimmune diseases. Some data suggest that vitamin D deficiency is common in Spondyloarthritis (SpA) and may be associated with disease activity and structural damage.

Objectives:

To evaluate if there is a relation between baseline vitamin D status and the response to biologic disease-modifying antirheumatic drugs (bDMARDs) in a SpA monocentric cohort.

Methods:

Retrospective study including all the SpA patients (ASAS classification criteria) followed at our Rheumatology Department, registered in the national database and treated with bDMARD between June 2008 and July 2020. Demographic, clinical and laboratorial data (including 25-hydroxyvitamin D [25-OHvitD]) at baseline and disease activity measures at 6 and 12 months of treatment with the first bDMARD were collected. Correlations between variables were evaluated by Spearman rank test, Mann-Whitney U test was used to the comparison analysis between groups and univariate logistic regression was used in the prediction analysis.

Results:

A total of 195 SpA patients were included: 103 (52.8%) females, 47 (24.1%) smokers and 91 (46.7%) HLA-B27 positive; 139 (71.3%) had Ankylosing Spondylitis, 18 (9.2%) had Inflammatory Bowel Disease Associated SpA and 38 (19.5%) had Undifferentiated SpA. At the time of the first bDMARD, the mean age was 43.5 years (±9.6) and the median disease duration was 12.4 years (0.7-52.7). The mean ASDAS-CPR (Ankylosing Spondylitis Disease Activity Score with C-reactive protein) was 3.9 (±0.8) and, in addition, 61 (31.3%) patients had 25-OHvitD levels below 30 ng/mL and 12 (6.2%) had 25-OHvitD levels below 20 ng/mL. Fifty-three patients (27.2%) were taking NSAIDs (nonsteroidal anti-inflammatory drugs), 77 (39.5%) were under csDMARDs (conventional synthetic disease-modifying antirheumatic drugs). Adalimumab (56%) and golimumab (33.3%) were the most frequently initiated bDMARDs in the first line.

There were no statistically significant correlations between baseline 25-OHvitD levels and ASDAS-CRP at 6 (r=0.031; p=0.714) and 12 months (r=0.035; p=0.672) of bDMARD.

In the subgroup analysis: there were no statistically significant differences in the response to bDMARD at 6 and 12 months evaluated by ASDAS response and ASAS 20, 40 and 70 responses according to the baseline 25-OHvitD levels (25-OHvitD <20ng/mL vs ≥20ng/mL; 25-OHvitD <30ng/mL vs ≥30ng/mL); and there were no statistically significant differences in the baseline 25-OHvitD levels at baseline according to the response to bDMARD at 6 and 12 months of bDMARD (ASDAS: no response vs clinically important improvement or major improvement; ASAS 20: no response vs response).

In the line of these previous results, baseline 25-OHvitD levels did not predict the ASDAS response at 6 (OR 0.97 [0.95-1.00], 95% CI) or 12 (OR 0.98 [0.95-1.01], 95% CI) months of bDMARD.

Conclusion:

Despite some data that suggest that lower levels of 25-OHvitD may be associated with higher disease activity in SpA, our results failed to demonstrate that the baseline 25-OHvitD levels can be related or predict treatment response after 6 and/or 12 months of therapy with the first bDMARD in real-life SpA patients.

Disclosure of Interests:

None declared

POS1106 FRAX AND THE EFFECT OF TERIPARATIDE ON BONE MINERAL DENSITY IN SECONDARY OSTEOPOROSIS

Background:

Teriparatide has been shown to increase spine and hip bone mineral density (BMD) and to reduce vertebral and non-vertebral fractures. (1) It is currently not clear whether the effect of teriparatide is dependent on the baseline risk of fracture or osteoporosis (OP) type, a finding that could have an impact on our therapeutic decision.

Objectives:

Investigate if there is a relationship between teriparatide effect in BMD and baseline 10-year fracture probability, assessed using FRAX®, in primary and secondary OP patients.

Methods:

This is a longitudinal, retrospective study including consecutive patients with the diagnosis of OP treated with teriparatide for 24 months, with a ten-year follow-up period, at our rheumatology department. Demographic, clinical, laboratorial, BMD and occurrence of fracture data were collected. The 10-year risk of osteoporotic fracture was estimated using the fracture risk assessment tool (FRAX) v 4.1 with the Portuguese population reference. Statistical analysis was performed using the software SPSS 23.0. Correlations between continuous variables were evaluated with spearman coefficient. p<0.05 was considered statistically significant.

Results:

Eighty patients (88.8% female, median age 65.00 (59; 75)) were included. Forty-nine patients (61.3%) has secondary OP, mainly of cortisonic etiology (61.2%, n=30). Before treatment, median lumbar spine BMD was 0.870 [0.767, 0.964] g/cm2, median T-score of -2.60 (-3.30, -1.90); median total femur BMD was 0.742 [0.667, 0.863] g/cm2, median T-score of -2.10 (-2.80, -1.30); median femoral neck BMD was 0.671 [0.611, 0.787] g/cm2, median T-score of -2.50 [-3.20, -1.85]. Regarding fracture risk, median FRAX-based 10-year major fracture risk (with BMD) at baseline was 16% [10.0; 23], and median hip fracture risk was 7.2% [3.4; 13.8].

The median variation of BMD, after finishing teriparatide treatment, in the spine was 0.107 [0.029; 0.228]; median BMD variation in total femur was 0.013 [-0.013; 0.068] and median BMD femoral neck was 0.046 [-0.002; 0.109]. We observed a numerically superior effect, albeit without any statistical significance, of teriparatide on bone mineral density gain in secondary OP (versus primary OP) at lumbar spine, total femur and femoral neck.

Most patients continued anti-osteoporotic treatment with a bisphosphonate (81.2%, n=65) and, during follow-up, 17 patients had an incident fracture (8 hip fractures and 6 vertebral fractures), median of 5 [1.75, 8.25] years after ending teriparatide.

We found a discrete correlation between FRAX-based hip fracture probability and the variation of bone mineral density in total femur (Spearman’s coefficient 0.248, p = 0.04). There was no correlation between FRAX-based major fracture probability and and the variation of bone mineral density in the spine or femur. When we separately analyze the relationship between the variation in total hip BMD and the FRAX-based fracture risk, depending on whether it is a secondary or primary OP, we find that the correlation is stronger and only remains in secondary OP (Spearman’s coefficient 0.348, p = 0.03).

Conclusion:

Our data suggest that teriparatide could be an important weapon in the treatment of secondary cause OP, particularly cortisonic, and in patients at high fracture risk, although further larger studies are needed to confirm these findings.

References:

[1]Kendler DL, Marin F, Zerbini CAF, Russo LA, Greenspan SL, Zikan V, Bagur A, Malouf-Sierra J, Lakatos P, Fahrleitner-Pammer A, Lespessailles E, Minisola S, Body JJ, Geusens P, Möricke R, López-Romero P. Effects of teriparatide and risedronate on new fractures in post-menopausal women with severe osteoporosis (VERO): a multicentre, double-blind, double-dummy, randomised controlled trial. Lancet. 2018 Jan 20;391(10117):230-240. doi: 10.1016/S0140-6736(17)32137-2.

Disclosure of Interests:

None declared.

AB0231 OUTCOMES IN RHEUMATOID ARTHRITIS PATIENTS UNDER TOCILIZUMAB AS FIRST bDMARD: A REAL-LIFE MONOCENTRIC COHORT STUDY

Background:

Rheumatoid arthritis (RA) is one of the most frequent systemic inflammatory rheumatic diseases, being constantly assessed regarding new disease activity monitoring tools and new therapeutic targets and therapies. Tocilizumab (TCZ) is one of the latest biological disease-modifying antirheumatic drugs (bDMARDs) approved for RA’s treatment, usually as a second line agent in daily clinical practice.

Objectives:

Evaluate the different disease and patient reported outcomes in patients undergoing treatment with tocilizumab as the first biologic therapy.

Methods:

All patients with a definite RA diagnosis who had undergone treatment with TCZ as the first biologic therapy at a tertiary hospital’s rheumatology department were included in this analysis. Diverse socio-demographic data, as well as disease and patient related outcomes were assessed at baseline, 6 and 12 months of treatment with TCZ, and posteriorly extracted from the Portuguese register of rheumatic diseases (Reuma.PT). Statistical analysis included non-parametric tests such as Wilcoxon test and univariate analysis using linear and logistic regression models.

Results:

Fifty-one patients were included, 88.2% females, with a median age at introduction of TCZ of 53.5 +/- 10.4 years; mainly seropositive for either rheumatoid factor (66%) or anti citrullinated peptide antibody (ACPA; 68%), with an erosive disease (75.6%) and concomitantly treated with a conventional synthetic disease modifying anti-rheumatic drug (csDMARD) (70.5%). During follow-up there was a statistically significant reduction at 6 and 12 months of TCZ treatment regarding DAS28 (4 variables) (4v) and DAS28(4V)-CRP scores (p < 0.001), SDAI (p < 0.001), CDAI (p < 0.001), 68/66 tender and swollen joint counts (TJC/SJC) (p < 0.001), ESR and CRP (p < 0.001), patient and physician VAS (p < 0.001) and HAQ score (p = 0.01 at 6 months and p < 0.001 at 12 months). Rheumatoid factor and ACPA serum levels weren’t statistically different at 6 and 12 months of treatment with TCZ compared to the initial assessment, as well as the ACR responders at the same 6 months versus those at 12 months. A majority of patients showed good EULAR response at 6 (52.6%) and 12 (56.3%) months, as well as moderate to high mean improvement in ACR core set measures at 6 (53.3±22.7) and 12 (54.3±25.2) months. Assessment of subsequent therapeutic maintenance showed that 75% of patients remained under tocilizumab with an average treatment duration of 48.8±37.7 months. Reasons for switch ranged from adverse effects (63.6%) to primary failure (18.2%) and secondary failure (18.2%). There was a significant reduction in DAS28(4V), DAS28(4V)-CRP, CDAI, SDAI, TJC and SJC, ESR, CRP, patient and physician VAS and HAQ scores between 6 and 12 months of therapy (p < 0,001). ACR and EULAR responses didn’t differ significantly between assessments at 6 and 12 months. In the absence of a representative number of RA patients on TCZ monotherapy, it wasn’t possible to draw conclusions about the need to use combined therapy with a csDMARD for better clinically significant response.

A higher degree of ACR response at 6 months was associated with higher serum rheumatoid factor levels (OR 1.13, p < 0.05) at baseline, while a lower degree of response was seen with higher TJC (p = 0.05) and HAQ score (p < 0.01). ACR response at 12 months was lower in patients with erosive disease at baseline (p < 0.05). Regarding EULAR response criteria at 6 months, there was a negative association with higher TJC (p < 0.05), while at 12 months the negative trend was associated with ESR levels (p < 0.05) and HAQ scores (p < 0.05) at baseline.

Conclusion:

There seems to be evidence of good therapeutic response to TCZ in bDMARD naïve RA patients assessed at 6 months from baseline, without evidence of significant improvement of response measures further down the line. Basal serum rheumatoid factor levels, TJC, HAQ scores and the presence of erosive disease may have some predictive value on the therapeutic response. Further studies comparing TCZ as the first bDMARD in naïve RA patients against TNF inhibitors are needed.

Disclosure of Interests:

None declared

AB0536 EFFICACY OF TNF INHIBITORS IN MONOTHERAPY VERSUS COMBINATION THERAPY WITH csDMARDs IN PORTUGUESE PATIENTS WITH PSORIATIC ARTHRITIS: A REAL-WORLD STUDY

Background:

Tumor necrosis factor inhibitors (TNFi) are a key therapeutic weapon in psoriatic arthritis (PsA), and can be used as monotherapy or in combination with other csDMARDs, which are usually used as first line therapy in these patients, although its efficacy is not as well documented as in other rheumatic diseases. The optimal use of iTNF in PsA, as monotherapy or in combination therapy with csDMARDs, is still under debate.

Objectives:

We aimed to compare the response to treatment with TNFi in monotherapy and combined with csDMARDs, as first biologic, in patients with PsA.

Methods:

Retrospective study that included PsA patients followed at our Rheumatology department under TNFi as first biologic, fulfilling CASPAR classification criteria and registered in Reuma.pt. Clinical and laboratory data were collected at the start of the first iTNF and in the last visit of 2019. Disease activity was assessed using CDAI, SDAI, DAS28(4V), BASDAI, ASDAS, and the response measured using the BASDAI50, ASDAS, ASAS, ACR and PsARC responses. Comparison between groups was performed using the chi-square test, Mann-Whitney U/t-test (categorical and continuous variables, respectively). Logistic regression analyses were performed to determine predictors of bDMARD failure, and survival analysis to measure persistence under the first bDMARD regarding csDMARD status at baseline.

Results:

We included 99 patients, 47 (47.5% females) with a mean age of 47.9 ± 11.7 years at the start of the first iTNF. Fifty-one patients (51.5%) had symmetric polyarthritis, 26 (26.3%) spondyloarthritis, 16 (16.2%) asymmetric oligoarthritis, 3 (3.0%) distal arthritis and 1 (1.0%) arthritis mutilans. Sixty-three percent were under corticosteroid therapy and 77.8% under csDMARD therapy at the start of the first iTNF (mostly methotrexate, in 55.6% of patients under csDMARD). Etanercept (41, 41.4%), golimumab (25, 25.3%), adalimumab (22, 22.2%), infliximab (9, 9.1%) and certolizumab (2, 2.0%) were the iTNF started in these patients.

Patients who started iTNF as monotherapy had more frequent involvement of axial skeleton compared with combined therapy (54.5% vs 19.5%, p=0.001), were less exposed to corticosteroids (26.3% vs 72.6%, p<0.001) and had higher mean BASMI (3.7±1.8 vs 3.0±0.8, p=0.021) and BASFI (6.7±1.3 vs 4.7±2.5, p=0.036). Patients who were on iTNF monotherapy at the last consultation (43.4%) had lower mean tender (1.0±1.5 vs 3.6±4.3, p=0.002) and swollen (0.2±0.7 vs 0.8±1.0, p=0.012) joint counts, median patient VAS (30±46 vs 50±44, p=0.023), mean CDAI (5.6±4.4 vs 8.7±4.9, p=0.019), SDAI (6.2±4.6 vs 9.1±5.1, p=0.032), and DAS28(4V) (2.2±0.8 vs 2.7±0.9, p=0.047). iTNF failure was not significantly different in both groups. In the regression models, we found that basal DAS28(4V) (OR 1.874, 1.147-3.062 95%CI; p=0,012) was a predictor of first iTNF failure; there were no differences regarding csDMARD status.

When evaluating only patients without spondyloarthritis, we found that, at the last visit, iTNF monotherapy patients still had less exposure to corticosteroids (26.9% vs 54.3%, p=0.002), fewer mean tender (0.7±1.0 vs 2.6±4.4, p=0.006) and swollen (0.2±0.7 vs 1.1±2.5, p=0.025) joint counts, with no other differences observed. In the regression models, we found no differences regarding csDMARD status in these patients, while adalimumab (OR 0.009, 0.001-0.139 95% CI; p=0.009) was a negative predictor of bDMARD failure. Survival analysis revealed no differences between mono- and combined therapy.

Conclusion:

We can conclude that the differences observed regarding csDMARD status in patients with PsA are mainly due to different patterns of arthritis, namely, predominance of axial involvement. In patients without spondyloarthritis, iTNF monotherapy did not differ significantly in terms of response to treatment and disease activity measures, nor does monotherapy predict bDMARD failure and treatment response. These results suggest that iTNF monotherapy is possible in PsA without compromising treatment response.

Disclosure of Interests:

None declared.

AB0327 DRUG-INDUCED LUPUS ERYTHEMATOSUS SECONDARY TO ANTI-TNF-Α AGENTS IN PATIENTS WITH SPONDYLOARTHRITIS AND PSORIATIC ARTHRITIS

Background:

Induction of autoantibodies is frequently observed in patients treated with TNF-α antagonist and the possible development of drug-induced lupus erythematosus (DILE) remains a matter of concern. The prevalence of DILE secondary to anti-TNF-α therapy is estimated around 0.5-1% and clinical features include arthritis/arthralgia, rash, serositis, fever, myalgias, cytopenias, among others. According to the literature, DILE secondary to anti-TNF-α agents differs in several ways from the clinical and laboratory findings typically associated with classic DILE.

Objectives:

To estimate the incidence of induction of antinuclear antibodies (ANA) and DILE in a monocentric cohort of patients with spondyloarthritis and psoriatic arthritis treated with anti-TNF-α agents. To describe the clinical and laboratorial features and outcomes of patients with DILE.

Methods:

We performed a retrospective analysis of patients with spondyloarthritis and psoriatic arthritis treated with anti-TNF-α agents, from our University Hospital, who have been registered on the Portuguese Rheumatic Diseases Register (Reuma.pt) between July 2001 and December 2020. Patients with positive ANA (titer > 1/100) before the anti-TNF-α therapy were excluded. Because specific criteria for the diagnosis of DILE have not been established, we considered the diagnosis in case of a temporal relationship between clinical manifestations and anti-TNF-α treatment and fulfillment of ACR/EULAR 2019 classification criteria for SLE. In patients with DILE, clinical features, laboratory findings, systemic therapies and outcome after discontinuation of medication were collected from reuma.pt and medical records. For the clinical and demographic predictors, continuous variables were analyzed using a two-sided t-test and categorical variables using a Fisher’s exact test. P-value <0.05 was considered statistically significant.

Results:

In the spondyloarthritis group, 290 patients were included (44.8% females, mean age at diagnosis of 33.3 ± 11.5 years and mean disease duration of 15.1 ± 10.4 years) and in the psoriatic arthritis group, 116 patients were included (50.0% females, mean age at diagnosis of 40.1 ± 11.0 years and mean disease duration of 13.1 ± 6.8 years). In our study, we observed high serology conversion rates (positive ANA in 67.9% and 58.6% of patients with Spondyloarthritis and Psoriatic Arthritis, respectively), with similar conversion rates between different anti-TNF drugs. Three patients with spondyloarthritis (1.0%) and 1 patient with psoriatic arthritis (0.9%) developed DILE. Etanercept was the causative agent in 2 cases, infliximab and adalimumab in 1 case, each. Peripheral arthritis (new onset or abrupt worsening) occurred in 2 patients, serositis in 1 patient, constitutional symptoms in 2 patients, subnephrotic proteinuria in 1 patient, lymphopenia in 2 patients and hypocomplementemia in 1 patient. Specific treatment was prescribed to the 4 patients (oral corticosteroids) and they achieved complete recovery. After anti–TNF-α treatment interruption, no patient had recurrent disease. We observed that patients with DILE had a significantly longer disease duration (> 8.4 years; p=0.04) and a significantly longer duration of therapy with anti-TNF (> 4.0 years; p=0.04) when compared to patients without DILE.

Conclusion:

Despite the frequent induction of autoantibodies, the development of DILE secondary to anti–TNF-α agents is rare. Our study demonstrates an incidence rate similar to other studies reported before. The clinical and laboratorial characteristics of our patients with DILE attributable to anti–TNF-α agents differ significantly from DILE due to more traditional agents, as is described in literature. Overall, patients in this study had mild disease that improved after therapy discontinuation, without recurrence of the disease. It seems that a longer disease duration and a longer period under anti-TNF-α therapy may increase the risk of DILE development.

Disclosure of Interests:

None declared

POS1113 ANTIRESORPTIVE THERAPY AFTER TERIPARATIDE DISCONTINUATION – WHEN IS THE BEST TIME TO STARTING IT?

Background:

Treatment with teriparatide (TPTD) is associated with reduction of fracture risk in patients with severe osteoporosis. This drug can only be used for up to 2 years. After that a treatment course with antiresorptives should be considered, in order to prevent the rebound of bone turnover observed after TPTD discontinuation. In this regard, interest in sequential osteoporosis therapy has grown in recent years but the ideal timing for starting another treatment after TPTD is not well established.

Objectives:

The aim of this study is to assess if the timing of onset of antiresorptive therapy after TPTD discontinuation has implications in total hip bone mineral density (BMD) and in fracture risk.

Methods:

We performed a retrospective cohort study that included patients with severe osteoporosis treated with TPTD 20mcg/day for 24 months and followed for at least 2 more years in the rheumatology department of a tertiary university hospital. For analysis, demographic and clinical data and results of dual-energy X-ray absorptiometry (DXA) after cessation of teriparatide were used. For comparison between groups Mann-Whitney U test was used.

Results:

Fifty-five patients with osteoporosis, with a median age of 68 (32-85) years, were included. Forty-nine patients were female (89.1%). Nineteen patients (34.5%) had primary osteoporosis and 36 (65.5%) glucocorticoid-induced osteoporosis. The median time for initiating antiresorptive treatment was 7 (0-35) months after cessation of TPTD. Forty-three patients (78.2%) started a bisphosphonate, 6 denosumab (10.9%) and 6 patients did not receive any other treatment. The most prescribed bisphosphonate was zoledronate (69.8%). All patients received calcium and vitamin D supplementation. After completion of TPTD regimen 8 patients experienced at least one fragility fracture (14.5%). At follow-up, 37 (67.3%) of patients underwent DXA on average 30.0±15.4 months after starting antiresorptive agents. The median total hip BMD in patients who started antiresorptive therapy in the first 12 months (inclusive) after cessation of TPTD regime was 0,738 (0.587-0.993) g/cm2 and the median total hip BMD of patients who started therapy after one year of discontinuation of TPTD was 0.683 (0.390-0.813) g/cm2. This difference is marginally significant (p=0.067). The median time in starting antiresorptive treatment is higher in patients with new fragility fractures after TPTD than in patients without new fractures however this difference was not statistically significant (10.0 [2-35] vs 6.0 [0-35] months; p=0.393, respectively).

Conclusion:

Although this study is unable to show that anti-resorptive treatment should be started in the first year after discontinuation of TPTD, it is promising since the difference between the medians in the total hip BMD values obtained until one year and after one year are marginally significant. These results can be linked to the small sample size and highlight the need for further studies in this area.

References:

[1]Napoli N, Langdahl BL, Ljunggren Ö, Lespessailles E, Kapetanos G, Kocjan T, Nikolic T, Eiken P, Petto H, Moll T, Lindh E, Marin F. Effects of Teriparatide in Patients with Osteoporosis in Clinical Practice: 42-Month Results During and After Discontinuation of Treatment from the European Extended Forsteo® Observational Study (ExFOS). Calcif Tissue Int. 2018 Oct;103(4):359-371. doi: 10.1007/s00223-018-0437-x. Epub 2018 Jun 16. PMID: 29909449; PMCID: PMC6153867.

Disclosure of Interests:

None declared.

POS0488 THE IMPACT OF ANTINUCLEAR ANTIBODIES INDUCED BY ANTI-TUMOUR NECROSIS FACTOR ALPHA AGENTS ON THE LONG-TERM TREATMENT OUTCOMES IN RHEUMATOID ARTHRITIS PATIENTS

Background:

The seroconversion of antinuclear antibodies (ANA) induced by anti-tumour necrosis factor alpha (anti-TNF-α) therapy remains a matter of concern in various inflammatory conditions namely rheumatoid arthritis. However, evidence is still scarce regarding the impact of these autoantibodies on the clinical response to treatment in these patients.

Objectives:

This study aimed to explore the impact of ANA induced by anti-TNF-α therapy on the outcomes of treatment in patients with rheumatoid arthritis over two years of follow-up.

Methods:

An observational retrospective cohort study was conducted with two years of follow-up. Patients diagnosed with rheumatoid arthritis, according to the American College of Rheumatology (ACR) criteria, and registered on the Rheumatic Diseases Portuguese Register (Reuma.pt) who started their first anti-TNFα agent as first biologic between 2003 and 2018 were included. Patients with positive ANA (titer ≥100) and/or positive anti-double stranded DNA (anti-dsDNA) antibodies and/or with a diagnosis of SLE at their first visit were excluded. Demographic, clinical and laboratory data were obtained by consulting Reuma.pt. Disease Activity Score for 28 joints (DAS28), DAS28 delta, Health Assessment Questionnaire (HAQ), HAQ delta were assessed at baseline, 6, 12, 18 and 24 months. Clinical response was evaluated by EULAR criteria and three response categories were defined: good, mild and no response. The rate of switch of biological treatment was assessed over 24 months. To examine the differences between groups with and without ANA seroconversion independent samples t test for normally distributed continuous data, Mann-Whitney U-tests for non-normally distributed continuous data and Chi-square tests for categorical data were used. Logistic regression models were used to assess the effects of ANA seroconversion on clinical response to treatment over 6, 12, 18 and 24 months.

Results:

A total of 185 patients (mean age of 49.3±10.9 years old; 85.4% female) with a median follow-up of 7 [4-14] years were included. We found an ANA seroconversion rate (titer ≥100) of 77.3% (n=143) with median time of 36 [15-72.3] months. There were no differences among groups regarding age, gender, disease duration, be seropositivity or not (for rheumatoid factor and/or anti-citrullinated protein antibodies) and have an erosive disease or not. DAS28 delta was significantly different (p=0.035) between group with positive ANA (2.01±1.29) and negative ANA (1.15±1.51) at 6 months. DAS28 was significantly different (p=0.014) between group with positive ANA (5.06±3.39) and negative ANA (3.99±1.43) at 12 months. No statistically significant differences were found in the DAS28, DAS28 delta, HAQ, HAQ delta at 18 and 24 months and in the EULAR response at any time. Switch rate was significantly different between patients with ANA seroconversion (median 1[0-1]) versus absence of seroconversion (median 0[0-1]), p=0.025. In the regression model ANA seroconversion did not predict switch rate and EULAR response over time.

Conclusion:

This study showed that the majority of patients with rheumatoid arthritis treated with an anti-TNF-α agent developed ANA and that their presence may be associated with worse clinical results (DAS28) at 6 and 12 months. In fact, previous research suggested that a decrease in anti-TNF-α drug concentration due to the production of autoantibodies may lead to worse outcomes of treatment. Moreover, our data demonstrated that patients with ANA seroconversion had a higher switch rate. Despite these results, there are no differences in the EULAR response between the two groups and ANA seroconversion did not predict this response over time. Therefore, ANA induced by anti-TNF-α agents should be monitored in patients with rheumatoid arthritis and its impact on treatment must be considered. Further research is needed to explore these results through large-scale prospective studies.

Disclosure of Interests:

None declared

POS0914 IS THERE AN ASSOCIATION BETWEEN AUTOANTIBODIES INDUCTION AND LOSS OF THERAPEUTIC EFFICACY IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS AND PSORIATIC ARTHRITIS TREATED WITH ANTI-TNF-α AGENTS?

Background:

Induction of autoantibodies is frequently observed in patients treated with a TNF-α blocker. According to other authors, the incidence of induction of antinuclear antibodies (ANA) and anti-double stranded DNA antibodies (anti-dsDNA) varies between 23-57% and 9-33%, respectively. However, it is unknown whether the induction of these autoantibodies affects the pharmacokinetics and bioavailability of biotherapy and, consequently, reduces the efficacy and safety of the drug.

Objectives:

To analyze if there is an association between autoantibodies induction and therapeutic efficacy in a monocentric cohort of patients with axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) treated with anti-TNF-α agents.

Methods:

The authors performed a retrospective analysis of patients with axSpA and PsA treated in our University Hospital with a TNF-α blocker as first biologic agent, and analysed the autoantibodies induction rate after 12 (T12) and 24 (T24) months of therapy. Then, they investigated the influence of autoantibodies in therapeutic efficacy at T12 and T24. Clinical evaluation, laboratory findings including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) and disease activity and functional scores (Bath Ankylosing Spondylitis Disease Activity Index – BASDAI, AS Disease Activity Score with CPR - ASDAS-CRP, Bath AS Functional Index - BASFI) were collected from reuma.pt and medical records. For PsA patients, Disease Activity Score-28-CRP (DAS28-CRP), Simple Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI) and Health Assessment Questionnaire (HAQ) scores were also collected. Patients with positive ANA (titer > 1/100) prior to anti-TNF-α therapy were excluded. Continuous variables were analyzed using a t-test and categorical variables using a Chi-square test. P-value <0.05 was considered statistically significant.

Results:

In the axSpA group, 235 patients were included, 44.5% were females, mean age at diagnosis of 42.3 ± 12.4 years and median disease duration of 11.5 (IQR 6.0-21.0) years. Positive ANA were observed in 16.9% at T12 and 26.3% at T24 and positive anti-dsDNA in 3.4% at T12 and 3.8% at T24, with similar conversion rates between different anti-TNF drugs and no significant gender difference. A significant difference in ASDAS-CPR was found in axSpA patients with and without ANA at T12 (p=0.047). ASDAS-CPR was 1.16 times higher in patients with ANA comparing to patients without them. However, no difference was found in the others disease activity and functional scores at T12. Furthermore, no significant difference, including ASDAS-CPR, was found at T24. Also, there was no significant difference found when comparing patients with and without anti-dsDNA.

In the PsA group, 94 patients were included, 46.8% were females, mean age at diagnosis of 46.7 ± 11.7 years and median disease duration of 11.5 (IQR 6.5-16.5) years. Positive ANA were found in 14.9% at T12 and 21.3% at T24 and positive anti-dsDNA in 2.1% at T12 and 3.2% at T24. When comparing the groups with and without ANA and with and without anti-dsDNA at T12 and T24, no significant difference in disease activity and functional scores was found.

Conclusion:

This study revealed high rates of serology conversion, similar to the rates described before. The authors found that ASDAS-CPR was higher in axSpA patients with ANA after 12 months of therapy. However, this difference was no longer evident after 24 months. No other significant difference was found between patients with and without ANA or with and without anti-dsDNA. The authors consider that the induction of autoantibodies may interfere with the response to anti-TNF-α therapy in a short and initial period of time. Long-term follow-up data are lacking to say whether that influence will disappear consistently over the long run, as they observed after 12 months of therapy. However, they can state that, a priori, seroconversion should not lead to treatment suspension because of concerns about loss of efficacy.

Disclosure of Interests:

None declared

AB0478 IN PREVIOUSLY BIOLOGIC-NAÏVE RHEUMATIC PATIENTS WITH DRUG INDUCED LUPUS SECONDARY TO A FIRST ANTI-TNF THERAPY, IS IT SAFE TO SWITCH TO A SECOND ANTI-TNF-α AGENT?

Background:

Drug-induced lupus erythematosus (DILE) secondary to anti-TNF-α agents results from an immunogenicity phenomena not yet fully understood and is a rare condition. Withdrawal of anti-TNF- α therapy usually leads to total resolution of symptoms, however sometimes immunosuppression is needed. It is not clear if this condition is drug specific or class related. Therefore, there are doubts about the safety of switching to a second TNF inhibitor: will a further anti-TNF-α agent increase the risk of DILE recurrence?

Objectives:

To analyze the outcomes in patients with DILE secondary to an anti-TNF-α agent that switch to a second anti-TNF-α agent.

Methods:

We performed a retrospective analysis of patients with spondyloarthritis, psoriatic arthritis and rheumatoid arthritis from our University Hospital, who developed DILE secondary to an anti-TNF-α agent as a first biologic and switch to a second anti-TNF-α agent. Because specific criteria for the diagnosis of DILE have not been established, DILE diagnosis was considered when a temporal relationship between clinical manifestations and anti-TNF alpha treatment was found and ACR/EULAR 2019 classification criteria for SLE were fulfilled. Clinical and laboratorial features and outcomes were collected from the Portuguese Rheumatic Diseases Register (Reuma.pt) and medical records.

Results:

Six of 617 patients developed DILE secondary to anti-TNF-α agents (2 secondary to etanercept, 2 to adalimumab and 2 to infliximab). These patients had total resolution of symptoms and autoantibodies (ANA and anti-DNAds), induced by the therapy, disappeared after withdrawal of the anti-TNF-α agent implied.

Afterwards, 4 of these 6 patients switched to a second anti-TNF-α agent: 1 to etanercept, 1 to certolizumab, 1 to adalimumab and another to golimumab. The time interval between the two therapies was 2,0 ± 0,8 months. Regarding the outcomes, in all four patients, no DILE recurrence or autoantibodies induction recurrence was observed. These patients have a good response to the new biotherapy, without side effects reported, and a significant clinical improvement was observed.

Conclusion:

Our study results are in agreement with the literature described before. It seems that exist a low rate of DILE recurrence with an alternative anti-TNF-α agent. Thus, this condition seems to be drug specific rather than class related. Therefore, it seems secure to use a second anti-TNF-α agent, even in a short period of time after DILE development. There is no evidence about the best or securest second TNF inhibitor, so any anti-TNF-α agent can be prescribed. A carefully monitoring of symptoms of relapse should be ensured. In conclusion, DILE secondary to a TNF inhibitor should not be an absolute contraindication to the use of a subsequent anti-TNF-α agent.

Disclosure of Interests:

None declared.

AB0112 TNF INHIBITOR MONOTHERAPY IN RHEUMATOID ARTHRITIS: IS THERE REALLY A DIFFERENCE IN COMPARISON WITH COMBINATION THERAPY WITH CSDMARDS IN REAL-LIFE?

Background:

In Rheumatoid Arthritis (RA), tumor necrosis factor inhibitors (TNFi) in combination with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) has shown advantages concerning efficacy and immunogenicity in comparison with monotherapy. However, in clinical practice, up to 40% of patients under biological DMARDs (bDMARDs) are on monotherapy.

Objectives:

To compare the efficacy outcomes of TNFi in monotherapy and in combination therapy in a RA monocentric cohort.

Methods:

Retrospective, cross-sectional study including all the RA patients under TNFi followed at our Rheumatology Department and registered in the national database. Demographic, clinical and laboratorial data and disease activity measures were collected at the last visit of 2019 from each patient. Mann-Whitney U and chi-square tests were used to the comparison analysis between the two groups (continuous and categorical variables, respectively).

Results:

A total of 144 patients were included: 84% were females; at the last visit of 2019, the mean age was 56.3±10.9 years and the mean disease duration was 18.3±10.2 years; 73.6% were positive for rheumatoid factor (RF), 81.9% for anti-citrullinated protein autoantibodies (ACPA) and 45.1% had erosive disease. There were no statistically significant differences in these variables between the monotherapy and the combination therapy groups (table 1).

Table 1.

Demographic and disease-related variables in the monotherapy and the combination therapy group.

Monotherapy(n=31)Combination therapy (n=113)Age - mean±SD59.1±14.0 years55.5±9.8 yearsDisease duration - mean±SD20.5±11.2 years17.7±9.7 yearsRF positive - n (%)20 (60.4%)86 (76.8%)ACPA positive - n (%)25 (80.6%)93 (85.3%)Erosive disease - n (%)15 (48.4%)50 (44.6%)

Thirty-one patients (21.5%) were under monotherapy with TNFi and etanercept was the most frequent TNFi in both groups (54.8% vs 50.0%; monotherapy and combination therapy groups, respectively). At the start of the first bDMARD, the monotherapy group had a higher disease activity score 28 - 4 variables (DAS 28 4V; 6.083±0.930 vs 5.605±1.043, p=0.039) and a higher simple disease activity score (SDAI; 36.12±11.77 vs 28.76±9.98, p=0.035); also, in the monotherapy group more patients had already started the bDMARD in monotherapy (22.6% vs 2.7%, p<0.001), less patients were under (38.7% vs 73.2%, p=0.001) or had already been treated with (77.4% vs 93.8%, p=0.007) methotrexate, in comparison with the combination group therapy.

At the last visit of 2019, the monotherapy group had a higher mean years of duration of iTNF treatment (5.5±5.8 vs 3.4±4.5, p=0.048), a higher mean patient global assessment - visual analogue scale (PGA-VAS; 49±18 vs 39±25, p=0.023), a higher mean prednisolone equivalent dose in mg/day (7.6±6.3 vs 5.6±3.2, p=0.045) and a lower proportion of American College of Rheumatology 50 and 70 responses (ACR 50: 12.9% vs 17.0%, p=0.023; ACR 70: 3.2% vs 10.7%, p=0.045) in comparison with the combination therapy group.

Conclusion:

In line with the literature, our real-life results demonstrate some direct (higher PGA-VAS and lower ACR 50 and 70 responses) and indirect (higher current prednisolone equivalent dose) data that suggest that patients with TNFi monotherapy may have a worst disease activity control in comparison with combination therapy.

Disclosure of Interests:

None declared

POS0100 VITAMIN D LEVEL IN RHEUMATOID ARTHRITIS PATIENTS STARTING A BIOLOGIC DISEASE-MODIFYING DRUG AND ITS CORRELATION WITH DISEASE ACTIVITY AND RESPONSE TO TREATMENT

Background:

Vitamin D, a fat soluble vitamin that is mainly involved in the regulation of calcium/phosphate metabolism, has a increasingly understood role in immunomodulatory activity, both in innate and adaptive immune system. In rheumatoid arthritis (RA), vitamin D showed to suppress the proliferation of synoviocytes and to reduce the production of proinfammatory cytokines, in vitro. (1) Recently the hypothesis has been raised that vitamin D has a negative association with RA activity. (2)

Objectives:

This study aimed to evaluate the relationship between the 25-hydroxyvitamin D (25(OH) vitD) level, RA activity and response to a first biologic disease-modifying drug (bDMARD).

Methods:

This is a longitudinal, retrospective study including consecutive patients with the diagnosis of RA followed at our rheumatology department. Demographic, clinical, and laboratorial data were collected from our national database at baseline, 6 and 12 months after initiation of a first bDMARD. Statistical analysis was performed using SPSS 23.0. Correlations between variables were studied using Spearman correlation analysis and comparison between groups was performed using Wilcoxon and Kruskal-Wallis tests; p<0.05 was considered statistically significant.

Results:

Mean age of patients (n=236) was 51.5 ± 11.2 years old, 192 (81.4%) were females with a median disease duration of 10.1 [4.7, 16.7] years. Seropositivity for anti-citrullinated protein antibodies was present in 192 (81.4%) patients and for rheumatoid factor in 175 (74.2%). The majority exhibited a very high or high disease activity at baseline (median DAS28 5.75 [4.99 – 6.63]) and 90% (n=212) of them were concomitantly using corticosteroids and/or other disease-modifying anti-rheumatic drugs (117 with methotrexate (MTX), 62 with leflunomide and 32 with sulfasalazine). Regarding bDMARD, 56.8% (n=134) initiated an TNF alpha inhibitor.

After 6 and 12 months from a bDMARD initiation there was a significant reduction of ESR, CRP levels, TJCs, SJCs and DAS28 (all p-values < 0.001), as expected. Median baseline serum 25(OH) vitD concentrations was 25.5 [16.5, 30.0] ng/ml; notably, 34.2% of our sample was affected by hypovitaminosis D at baseline (25(OH) vitD< 20 ng/mL).

Among our study population 42.5% patients were responders to first bDMARD (23.8% good and 18.7% moderate responders) according to the EULAR response criteria. Disease remission (DAS28 < 2.6) was achieved by 17.6% of patients.

The percentage of good responders was significantly lower in the subgroup of patients with hypovitaminosis D compared to subjects with normal 25(OH) vitamin D levels at baseline (p=0.002), as it was for the percentage of disease remission (p=0.015).

The bivariate correlation analyses showed that 25(OH) vit D levels at baseline correlated with CRP levels and good response to RA treatment after 12 months (Spearman’s coefficient -0.201, p = 0.028; Spearman’s coefficient 0.255, p < 0.019, respectively). 25(OH) vit D levels at baseline, 6 and 12 months after bDMARD initiation did not correlate with age, BMI, ESV, number of tender or swollen joints, DAS28, HAQ or with SDAI or CDAI at 6 or 12 months of treatment.

Conclusion:

In patients with RA, basal 25(OH) vit D levels correlated with response to a bDMARD. These results suggest a role of basal vitamin D status in the prediction of disease evolution and support the hypothesis that vitamin D has an immunomodulatory potential.

References:

[1]Huhtakangas JA, Veijola J, Turunen S et al. 1,25(OH)2D3 and calcipotriol, its hypocalcemic analog, exert a long-lasting anti-infammatory and anti-proliferative effect in synoviocytes cultured from patients with rheumatoid arthritis and osteoarthritis. J Steroid Biochem Mol Biol 2017; 173: 13- 22.

[2]Lee YH, Bae SC. Vitamin D level in rheumatoid arthritis and its correlation with the disease activity: a meta-analysis. Clin Exp Rheumatol. 2016 Sep-Oct;34(5):827-833. Epub 2016 Apr 6. PMID: 27049238.

Disclosure of Interests:

None declared

POS0204 AUTOANTIBODIES AND SYSTEMIC LUPUS ERYTHEMATOSUS INDUCED BY ANTI-TUMOUR NECROSIS FACTOR ALPHA THERAPY IN RHEUMATOID ARTHRITIS

Background:

Anti-tumour necrosis factor alpha (anti-TNF-α) therapy is commonly used to treat inflammatory conditions such as rheumatoid arthritis (RA). Autoantibodies namely antinuclear antibodies (ANA) induced by these treatments are well established. However, anti-TNF-α-induced systemic lupus erythematosus (SLE) is rarely described and its incidence is yet unknown.

Objectives:

This study aimed to determine the prevalence of ANA seroconversion and to characterize the development of SLE induced by anti-TNF-α therapy in patients with RA over time.

Methods:

An observational retrospective cohort study was conducted with at least one year of follow-up. Patients with diagnosis of RA, according to American College of Rheumatology criteria (ACR), and registered on Rheumatic Diseases Portuguese Register (Reuma.pt) who started their first anti-TNFα between 2003 and 2019 were included. Patients with positive ANA (titer ≥100) and/or positive double-strand DNA (dsDNA) antibodies and/or with a diagnosis of SLE at their first visit were excluded. Demographic, clinical and laboratory data were obtained by consulting Reuma.pt. As there are no recognized criteria for drug-induced SLE, the diagnosis of SLE induced by anti-TNF-α was considered if there is a temporal relationship between clinical manifestations and anti-TNF-α-therapy, the presence of at least 1 serologic ACR criteria (ANA or anti-dsDNA) and at least 1 nonserologic ACR criteria (arthritis, serositis, hematologic disorder or malar rash) [1]. Continuous variables are presented with mean, standard deviation, median, quartile 1 and quartile 3. Categorical variables are presented with absolute and relative frequencies.

Results:

A total of 211 patients (mean age of 49.9±10.9 years old; 84.4% female) were included with a median follow-up time of 6 [3-14] years. We found a seroconversion rate for ANA of 75.4% (n=159) with median treatment duration of 31 [8.5-70.5] months. The most common titre was 1/100 with diffuse and speckled patterns. ANA seroconversion was higher for etanercept (47.8%, n=76) than with adalimumab (23.9%, n=38), infliximab (13.8%, n=22), golimumab (12.6%, n=20) or certolizumab (1.9%, n=3). SLE induced by anti-TNF-α occurred in two patients (0.9%) with erosive and seropositive (rheumatoid factor and anti-citrullinated protein antibodies) RA previously treated with two conventional synthetic disease-modifying antirheumatic drugs, including methotrexate. The first patient, a female with 66 years old and 17 years of disease duration, developed SLE after 16 months of infliximab, with constitutional symptoms, abrupt worsening of polyarthritis, ANA titer of 1/320 diffuse pattern and positive dsDNA (248 UI/mL) antibodies. The second patient, a woman with 43 years old and 11 years of disease duration, developed SLE after 41 months of adalimumab with malar rash and ANA titer of 1/320 diffuse pattern, positive dsDNA (285 UI/mL), positive anti-histone antibodies and hypocomplementemia. In these two cases, anti-TNF-α therapy was stopped and recovery was spontaneous without treatment. The first patient switched to adalimumab and the second switched to golimumab without recurrence of SLE for more than ten years.

Conclusion:

We found a high rate of ANA seroconversion induced by anti-TNFα therapy in patients with RA. However, similar to previous literature, only 0.9% of patients developed SLE with mild manifestations without major organ involvement. Although the drug with the highest ANA seroconversion rate was etanercept, those responsible for induced SLE were infliximab and adalimumab. Patients improved after discontinuation of therapy and tolerated an alternative anti-TNF-α drug without recurrence of induced SLE over time. Therefore, ANA and SLE induced by anti-TNF-α should be considered and reported in the follow-up of RA patients. Further research is needed to explore the impact of this adverse event on the outcomes of treatment over time.

References:

[1]Hochberg MC. Arthritis Rheum. 1997;40(9):1725.

Disclosure of Interests:

None declared

AB0483 CAN WE PREDICT WHICH PATIENTS WITH SPONDYLOARTHRITIS WILL NEED DOSE ESCALATION OF SECUKINUMAB TO 300 mg MONTHLY?

Background:

Secukinumab is a fully human monoclonal antibody against interleukin-17A, approved in several countries for the treatment of ankylosing spondylitis (AS) and psoriatic arthritis. It is known that some patients benefit from increasing the monthly dose of secukinumab from 150mg, the most commonly used dose, to 300mg. However, the baseline clinical characteristics that differentiate these patients are not yet fully understood.

Objectives:

This study aimed to investigate whether there are any variables at the beginning of biologic therapy that might predict a greater probability of having to increase the dose of secukinumab to 300mg in order to obtain a response to treatment.

Methods:

This is a retrospective cohort study, including all the spondyloarthritis and psoriatic arthritis patients under secukinumab at our Rheumatology Department and registered in the national database (Reuma.pt).

Demographic, clinical and laboratorial characteristics and disease activity measures were collected from the first visit before the patient began secukinumab. For comparison between the 2 groups, continuous variables were analyzed using Mann-Whitney U and T-tests and categorical variables were analyzed using a Chi-square test. Multivariate regression analyses assessed the impact of selected variables on the need to increase the dose of secukinumab to 300mg.

Results:

Thirty-two patients with a mean age of 53±11.96 years were included, 19 (58%) were females and 16 (48.5%) had psoriasis. Twenty-seven (81.8%) patients were under a nonsteroidal anti-inflammatory drug (NSAID), 11(33.3%) were under corticosteroid and 11(33.3%) were under conventional synthetic disease-modifying antirheumatic drug (csDMARD); 25 (75,8%) had previously been treated with a biological disease-modifying antirheumatic drug (bDMARD). The mean patient baseline VAS and physician baseline VAS were 74,39±19,77 and 47,55±23,38, respectively; the mean erythrocyte sedimentation rate (ESR) and C-Reactive Protein (CRP) were 26,33±22,62 mm/hr and 10,81±16,88 mg/dL, respectively; the mean swollen joint count (SJC) and tender joint count (TJC) were 1,30±1,63 and 3,67±3,14, respectively; the mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Ankylosing Spondylitis Disease Activity Score (ASDAS) were 6,18±2,06 and 3,41±0,84, respectively; the mean Bath Ankylosing Spondylitis Metrological Index (BASMI) and Bath Ankylosing Spondylitis Functional Index (BASFI) were 4,22±1,58 and 6,28±2,53, respectively; the mean Maastrich Ankylosing Spondylitis Enthesitis Score (MASES) was 2,85±3,23.

Nineteen patients (57.6%) had the dose of secukinumab increased to 300mg. At the baseline visit, the group of patients which had their secukinumab monthly dose increased to 300mg were more frequently men (12 vs 2, p=0.005) and had psoriasis (12 vs 4, p=0.049). On the other hand, these patients also exhibited lower MASES values (2±1.089 VS 4±0.501, p=0.022).

A regression analysis was conducted, estimating the relationships between the outcome binary variable of the monthly dose of secukinumab and the following predictors: gender, psoriasis, MASES value and use of corticosteroid. Female gender (OR 0.070, CI95% 0.005-0.890; p=0.040) and absence of psoriasis (OR 0.104, CI95% 0.011-0.952; p=0.045) were predictors for maintaining secukinumab at a dose of 150mg monthly.

Conclusion:

Our data suggest that the most common characteristics of patients in need of increasing the monthly dose of secukinumab from 150 to 300 mg to achieve a better treatment response are: male gender, coexistence of psoriasis and lower MASES value at baseline. The first two variables remained statistically significant in a multivariate model of regression analysis. Nonetheless, we insist it is of paramount importance to conduct larger studies to confirm these findings.

References:

[1]Deodhar A, et all. Long-term safety of secukinumab in patients with moderate-to-severe plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis. Arthritis Res Ther. 2019 May 2;21(1):111.

Disclosure of Interests:

None declared.

AB0816 PREDICTORS OF RESPONSE TO THE FIRST BDMARD IN BIOLOGIC-NAÏVE PATIENTS WITH SPONDYLOARTHRITIS: A COHORT STUDY

Background:

Several markers of response to biologic disease-modifying antirheumatic drugs (bDMARDs) have been identified in Rheumatoid Arthritis. However, data on predictors of response in Spondyloarthritis (SpA) are more limited.

Objectives:

To identify predictors of response to bDMARDs in a SpA population.

Methods:

Monocentric retrospective study including all the SpA patients (ASAS classification criteria) followed at our Rheumatology Department, registered in the national database and treated with bDMARD between July 2001 and August 2020. Demographic, clinical and laboratorial data at baseline and disease activity measures at 6 and 12 months of bDMARD were collected. Mann-Whitney U test and chi-square tests were used to the comparison analysis between groups (continuous and categorical variables, respectively) and univariate logistic regression was used in the prediction analysis.

Results:

A total of 325 patients were included, 178 (54.8%) males, 76 (23.4%) smokers and 164 (50.5%) HLA-B27 positive. Concerning SpA subtypes: 236 (72.6%) had Ankylosing Spondylitis, 31 (9.5%) had Inflammatory Bowel Disease Associated SpA and 58 (17.9%) had Undifferentiated SpA. The mean age at the start of the first bDMARD was 41.7 years (±12.2) and the median disease duration was 12.1 years (0.5-52.7). The mean ASDAS-CPR (Ankylosing Spondylitis Disease Activity Score with C-reactive protein) was 4.0 (±0.8) and most patients (57.2%) exhibited very high disease activity at baseline as evaluated by ASDAS-CRP. Ninety-five (29.2%) patients were taking NSAIDs (nonsteroidal anti-inflammatory drugs) and 131 (40.3%) were under csDMARDs (conventional synthetic disease-modifying antirheumatic drugs), being sulfasalazine the most frequent (28.3%). All patients started iTNF (tumor necrosis factor inhibitors): adalimumab (30.2%) and golimumab (24.6%) were the most frequently started bDMARDs.

At 6 and 12 months of bDMARD, 63.5% and 65.7% of the patients had ASDAS response (clinically important improvement or major improvement). Variables that showed statistically significant differences at baseline between those different groups are presented at Table 1.

Table 1.

Baseline characteristics that showed statistically significant differences at baseline between groups of patients with vs without ASDAS responses at 6 and 12 months of bDMARD. (bDMARD: biologic disease-modifying antirheumatic drug; BMI: body mass index; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate).

ASDAS response at 6 monthsASDAS response at 12 monthsyesnop-valueyesnop-valueAge at start of bDMARD (mean±SD)39.6±12.2 years44.2±10.7 yearsp=0.01240.7±12.8 years44.2±10.9 yearsp=0.035Age at SpA diagnosis (mean±SD)32.2±11.1 years35.8±11.9 yearsp=0.02331.3±10.7 years35.4±11.2 yearsp=0.010BMI (mean±SD)25.7±4.3kg/m228.7±6.0 kg/m2p=0.04525.6±4.3 kg/m228.5±5.7 kg/m2p=0.005CRP (mean±SD)3.2±3.5 mg/dL1.1±1.2 mg/dLp<0.0013.4±3.5 mg/dL1.4±1.6 mg/dLp<0.001ESR (mean±SD)36±2225±20p<0.00138±2427±17p=0.001ASDAS-CRP(mean±SD)4.1±0.83.5±0.4p<0.0014.2±0.83.6±0.8p<0.001HLA-B27+61.5%26%p=0.00660.1%44.4%p=0.033Males62.3%35.7%p=0.00462.3%37.5%p=0.001

Body mass index (BMI) (OR 0.89 [0.80-0.99], 95% CI) and ASDAS-CRP at baseline (OR 2.8 [1.2-6.6], 95% CI) predicted ASDAS response at 6 months; moreover, only BMI (OR 0.91 [0.83-0.99], 95% CI) predicted ASDAS response at 12 months of bDMARD.

Conclusion:

Our results demonstrate that a higher baseline disease activity predicts the response to bDMARDs in SpA. Interestingly, BMI at baseline also predicts ASAS response at 6 and 12 monthes of treatment with bDMARD, in line with some data that suggest an association between BMI and disease activity in SpA.

Disclosure of Interests:

None declared

Vascular depression – regarding a case report

Introduction

Age-related vascular changes have long been documented as an etiopathogenic factor of some geriatric depressive syndromes. More recently, it has emerged the concept of “Vascular Depression” recognizing that cardiovascular disease may predispose, precipitate or perpetuate late life depression. This condition was defined by an episode of major depressive disorder within the preceding 12 months in elderly with cardiovascular/cerebrovascular disease, or major cardiovascular risk factors. Vascular Depression isn`t described in DSM-V, and that difficults clinical recognition and affects clinically informed systematic studies.

Objectives

Regarding a clinical case, we enphasize the clinical impact of Vascular Depression`s hypothesis.

Methods

We present a qualitative review of this topic using the Pubmed Central database.

Results

74 years old male patient, with major depressive disorder about ten years. Depressive and cognitive symptoms didn`t respond to antidepressive treatment and his functional state has gradually declined.

Conclusions

Vascular depression develops after the 60 – 65 years in the absence of personal and family history of affective disorder. The key symptoms are low energy, anhedonia, deficits in selfinitiation, psychomotor retardation, reduced processing speed and lack of insight into mood symptoms. Clinical assessment includes a review of history of vascular risk factors or/and disease, but also an imagiological evidence demonstrating subcortical white matter abnormalities. Insidious and chronic course tends to delay its recognition and management. This becomes critical because Vascular Depression is associated with poor response to antidepressant treatment and persistent depressive symptoms. It`s also associated with poor selfmanagement of comorbidities and impairment in daily function. Increased mortality from all causes is widely documented.

Marine litter footprint in the Azores Islands: A climatological perspective

Marine litter (ML) consists of any item of anthropogenic origin that has been lost, discarded or intentionally disposed of into the environment, being acknowledged as a worldwide environmental and ecological threat. In the last decade, there has been an attempt across different sectors to tackle, reduce and mitigate sources of litter. In this study, meso and macrodebris between 2 and 30 cm was recorded and classified in two established study areas (Porto Pim and Conceição beaches), throughout five monitoring years (2012-2018). The litter abundance, density and weighted average by abundance were evaluated in eight main categories: plastics, cloths/fabrics, glass, metals, rubber, processed lumber, other and large. Field surveys provided evidence that plastic represented 95% of all litter. ML abundance was treated as an "environmental variable" and used to determine its anomalies, temporal trends and forecasts. Results from this time-series addressed possible periodic oscillations and density peaks of litter. Reference values of ML presence were obtained and could potentially be used for developing a diagnostic tool for anthropogenic pollution in the Azores.

Preparedness and response in Portuguese emergency plans - Interaction with public health

Background

Articulation between Civil Protection and Public Health authorities is of paramount importance to control, reduce and prevent threats to the health of the population in situations of crisis or catastrophes. National Civil Protection Authority produces Emergency Plans which describe the role of every stakeholder in emergency situations. Role and importance of Public Health and Public Health Authorities is not always present or well described and known amongst stakeholders.

Methods

Data was collected from all Districtal Emergency Plans (n = 18). Each document was analysed considering time frame, refences to Public Health and Health Authorities, definition of roles, communication channels, coordination and inclusion of intersectoral communication flow. Quantitative analysis included absolute and relative frequencies and qualitative analysis to all parts related to the terms “Public Health” and “Health Authority”. Each document was reviewed by 2 independent researchers.

Results

From 18 Districtal Emergency Plans (DEP) analysed, 94,4% (n = 17) had references to Public Health, but none referred the role of Public Health Officers. Only 16,7% referred to Health Authorities, although 94,4% mentioned the law 135/2013, defining the role and attributes of Health Authority. In 72,2%, coordination of Public Health Measures was attributed to the National Medical Emergency Institute. Epidemiological surveillance and Public Health Emergencies were referred in 55,6%, and attributed to the Regional Administration of Health.

Conclusions

Public Health Authorities and Public Health Medical Officers role in articulation with National Civil Protection Authority in emergency situations lacks severely, with this role being replaced by other entities. This is of great concern regarding management and control of diseases, particularly communicable diseases.

Key messages

Public Health Authorities lack the necessary involvement in Emergency Plans and emergency situations. Public health measures are coordinated by other entities rather than Public Health Authorities.