Lofgren Syndrome: Achieving an Accurate Diagnosis for Improved Patient Care

Lofgren syndrome is a clinically distinct phenotype of sarcoidosis. It is characterized by the triad of bilateral hilar lymphadenopathy, arthritis (usually the ankles), and fever. We present the case of a 31-year-old male patient who presented with fever and edema in both lower limbs, with palpation of subcutaneous nodules. A chest contrast-enhanced computerized axial tomography (CECT) scan revealed perihilar and mediastinal lymphadenopathy. In making the diagnosis, tuberculosis and lymphoma were both ruled out. A mediastinoscopy confirmed Lofgren syndrome. In medicine, a good differential diagnosis is important, as it will help inform the best treatment for the patient.

Hepatitis B vaccination associated with low response in patients with rheumatic diseases treated with biologics

BACKGROUND

Hepatitis B virus (HBV) vaccination is recommended for non-immunised patients with rheumatic diseases starting biological disease-modifying antirheumatic drugs (bDMARDs). There is some evidence that HBV vaccination is effective in patients under conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), but it is currently unclear whether this also applies to bDMARDs.

OBJECTIVES

To assess the efficacy and safety of HBV vaccination in patients with inflammatory arthritides treated with bDMARDs.

METHODS

A prospective cohort with inflammatory arthritides treated with bDMARDs, negative for anti-HBs and anti-HBc and never vaccinated for HBV was recruited. Engerix B was administered at 0, 1 and 6 months and anti-HBs was reassessed ≥1 month after last dose. Response was defined as anti-HBs≥10 IU/L and compared against vaccinated healthy controls. Disease flare, serious adverse events and immune-related disorders not previously present were recorded.

RESULTS

62 patients, most treated with TNF inhibitors (TNFi), and 38 controls were recruited. Most patients were taking csDMARDs (67.7%) and were in remission/low disease activity (59.4%). Only 20/62 patients (32.3%) had a positive response to vaccination, in comparison to 36/38 age-matched controls (94.7%, p<0.001). Response was seen in 19/51 patients treated with TNFi (37.3%) and in 1/11 (9.1%) patients treated with non-TNFi (p=0.07), including 1/6 treated with tocilizumab (16.7%). Among TNFi, response rates ranged from 4/22 (18.2%) for infliximab to 8/14 (57.1%) for etanercept. No relevant safety issues were identified.

CONCLUSIONS

HBV vaccination response in patients with rheumatic diseases treated with bDMARDs was poorer than expected. Our data reinforce the recommendation for vaccination prior to starting bDMARDs.

The idiopathic inflammatory myopathies module of the Rheumatic Diseases Portuguese Register

AIMS

To characterise the idiopathic inflammatory myopathies (IIM) module of the Rheumatic Diseases Portuguese Register (Reuma.pt/myositis) and the patients in its cohort.

METHODS

Reuma.pt is a web-based system with standardised patient files gathered in a registry. This was a multicentre open cohort study, including patients registered in Reuma.pt/myositis up to January 2022.

RESULTS

Reuma.pt/myositis was designed to record all relevant data in clinical practice and includes disease-specific diagnosis and classification criteria, clinical manifestations, immunological data, and disease activity scores. Two hundred eighty patients were included, 71.4% female, 89.4% Caucasian, with a median age at diagnosis and disease duration of 48.9 (33.6-59.3) and 5.3 (3.0-9.8) years. Patients were classified as having definite (N=57/118, 48.3%), likely (N=23/118, 19.5%), or possible (N=2/118, 1.7%) IIM by 2017 EULAR/ACR criteria. The most common disease subtypes were dermatomyositis (DM, N=122/280, 43.6%), polymyositis (N=59/280, 21.1%), and myositis in overlap syndromes (N=41/280, 14.6%). The most common symptoms were proximal muscle weakness (N=180/215, 83.7%) and arthralgia (N=127/249, 52.9%), and the most common clinical signs were Gottron's sign (N=75/184, 40.8%) and heliotrope rash (N=101/252, 40.1%). Organ involvement included lung (N=78/230, 33.9%) and heart (N=11/229, 4.8%) involvements. Most patients expressed myositis-specific (MSA, N=158/242, 65.3%) or myositis-associated (MAA, 112/242, 46.3%) antibodies. The most frequent were anti-SSA/SSB (N=70/231, 30.3%), anti-Jo1 (N=56/236, 23.7%), and anti-Mi2 (N=31/212, 14.6%). Most patients had a myopathic pattern on electromyogram (N=101/138, 73.2%), muscle oedema in magnetic resonance (N=33/62, 53.2%), and high CK (N=154/200, 55.0%) and aldolase levels (N=74/135, 54.8%). Cancer was found in 11/127 patients (8.7%), most commonly breast cancer (N=3/11, 27.3%). Most patients with cancer-associated myositis had DM (N=8/11, 72.7%) and expressed MSA (N=6/11) and/or MAA (N=3/11). The most used drugs were glucocorticoids (N=201/280, 71.8%), methotrexate (N=117/280, 41.8%), hydroxychloroquine (N=87/280, 31.1%), azathioprine (N=85/280, 30.4%), and mycophenolate mofetil (N=56/280, 20.0%). At the last follow-up, there was a median MMT8 of 150 (142-150), modified DAS skin of 0 (0-1), global VAS of 10 (0-50) mm, and HAQ of 0.125 (0.000-1.125).

CONCLUSIONS

Reuma.pt/myositis adequately captures the main features of inflammatory myopathies' patients, depicting, in this first report, a heterogeneous population with frequent muscle, joint, skin, and lung involvements.

Predictors of cardiac involvement in idiopathic inflammatory myopathies

Objectives

Idiopathic inflammatory myopathies (IIM) are a group of rare disorders that can affect the heart. This work aimed to find predictors of cardiac involvement in IIM.

Methods

Multicenter, open cohort study, including patients registered in the IIM module of the Rheumatic Diseases Portuguese Register (Reuma.pt/Myositis) until January 2022. Patients without cardiac involvement information were excluded. Myo(peri)carditis, dilated cardiomyopathy, conduction abnormalities, and/or premature coronary artery disease were considered.

Results

230 patients were included, 163 (70.9%) of whom were females. Thirteen patients (5.7%) had cardiac involvement. Compared with IIM patients without cardiac involvement, these patients had a lower bilateral manual muscle testing score (MMT) at the peak of muscle weakness [108.0 ± 55.0 vs 147.5 ± 22.0, p=0.008] and more frequently had oesophageal [6/12 (50.0%) vs 33/207 (15.9%), p=0.009] and lung [10/13 (76.9%) vs 68/216 (31.5%), p=0.001] involvements. Anti-SRP antibodies were more commonly identified in patients with cardiac involvement [3/11 (27.3%) vs 9/174 (5.2%), p=0.026]. In the multivariate analysis, positivity for anti-SRP antibodies (OR 104.3, 95% CI: 2.5-4277.8, p=0.014) was a predictor of cardiac involvement, regardless of sex, ethnicity, age at diagnosis, and lung involvement. Sensitivity analysis confirmed these results.

Conclusion

Anti-SRP antibodies were predictors of cardiac involvement in our cohort of IIM patients, irrespective of demographical characteristics and lung involvement. We suggest considering frequent screening for heart involvement in anti-SRP-positive IIM patients.

POS0891 REUMA.pt/MYOSITIS – THE PORTUGUESE REGISTRY OF INFLAMMATORY MYOPATHIES

Background

The idiopathic inflammatory myopathies (IMM) module of the Rheumatic Diseases Portuguese Register (Reuma.pt/Myositis) is a tool used to systematically evaluate IIM patients.

Objectives

To clinically characterise the Reuma.pt/Myositis cohort.

Methods

Multicentre open cohort study, including IIM patients registered in Reuma.pt up to January 2022. Data collected included demographic, clinical, and treatment data and patient-reported outcomes. Data were presented as frequencies and median (interquartile range) for categorical and continuous variables, respectively.

Results

280 patients were included, 71.4% female, 89.4% Caucasian, with a median age at diagnosis and disease duration of 48.9 (33.6-59.3) and 5.3 (3.0-9.8) years, respectively. Patients were classified as having definite (N=57/118, 48.3%; N=35/224, 15.6%), likely (N=23/118, 19.5%; N=50/224, 22.3%), or possible (N=2/118, 1.7%; N=46/224, 20.5%) IIM by 2017 EULAR/ACR and Bohan-Peter criteria, respectively. Disease subtypes included dermatomyositis (DM, N=122/280, 43.6%), polymyositis (N=59/280, 21.1%), myositis in overlap syndromes (N=41/280, 14.6%), clinically amyopathic DM (N=17/280, 6.1%), nonspecific myositis (N=13/280, 4.6%), mixed connective tissue disease (N=12/280, 4.3%), immune-mediated necrotizing myositis (N=9/280, 3.2%), and inclusion bodies myopathy (N=7/280, 2.5%). Over the course of the disease, the most common symptoms were proximal muscle weakness (N=180/215, 83.7%), arthralgia (N=127/249, 52.9%), erythema (N=63/166, 38.0%), fatigue (N=47/127, 37.0%), Raynaud’s phenomenon (N=76/234, 32.5%), and dysphagia (N=33/121, 27.3%), and the most common clinical signs were Gottron’s sign (N=75/184, 40.8%), heliotrope rash (N=101/252, 40.1%), Gottron’s papules (N=93/237, 39.2%), and arthritis (N=38/98, 38.8%). Organ involvement included lung (N=78/230, 33.9%), oesophageal (N=40/221, 18.1%), and heart (N=11/229, 4.8%) involvements. Most patients expressed myositis-specific (MSA, N=158/242, 65.3%) and/or myositis-associated (MAA, 112/242, 46.3%) antibodies. The most frequent antibodies were anti-SSA/SSB (N=70/231, 30.3%), anti-Jo1 (N=56/236, 23.7%), and anti-Mi2 (N=31/212, 14.6%). Most patients had a myopathic pattern on electromyogram (N=101/138, 73.2%), muscle oedema in magnetic resonance (N=33/62, 53.2%), and high CK (N=154/200, 55.0%) and aldolase levels (N=74/135, 54.8%) at diagnosis, with median highest CK levels of 1308 (518-3172) and aldolase of 42 (12-121) mg/dL. Neoplasia was found in 11/127 patients (8.7%), most commonly breast (N=3/11, 27.3%), non-melanoma skin (N=2/11, 18.2%), and colorectal (N=2/11, 18.2%) cancer (Table 1). Most patients with cancer-associated myositis had DM (N=8/11, 72.7%) and expressed MSA (N=6/11) and/or MAA (N=3/11). The most used drugs over the course of disease were glucocorticoids (N=201/280, 71.8%), methotrexate (N=117/280, 41.8%), hydroxychloroquine (N=87/280, 31.1%), azathioprine (N=85/280, 30.4%), mycophenolate mofetil (N=56/280, 20.0%), intravenous immunoglobulin (N=55/280, 19.6%), and rituximab (N=45/280, 16.1%). At the last follow-up, there was a median MMT8 of 150 (142-150), modified DAS skin of 0 (0-1), global VAS of 10 (0-50) mm, and HAQ of 0.125 (0.000-1.125).

Table 1.

Autoantibodies in cancer-associated myositis

CancerIIMAutoantibodiesBreastDM (3)Mi2, SRP (+ SSA/SSB), Pm/SclSkin (non-melanoma)Clinically amyopathic DM, PMJo1, SAE1 (+SSA/SSB)ColorectalDM (2)Mi2 (2)KidneyDM-LungDM-LymphomaInclusion bodies myopathy-UnknownDM-

Conclusion

Reuma.pt/Myositis adequately captures the main features of inflammatory myopathies’ patients, depicting in this first report a heterogeneous population, with frequent muscle, joint, skin and lung involvements. Of interest, most patients reached low disease activity at the last follow-up appointment.

Disclosure of Interests

None declared

Tuberculosis under anti-TNF therapy: case series of a center (reporting the experience from the period 2006-2019)

Patients with inflammatory rheumatic diseases refractory to conventional disease modifying antirheumatic drugs (DMARDs)have been treated with biologics for the last two decades. It is also known that patients under biotechnological therapy present a higher risk of developing Tuberculosis (TB).Portugal has now a TB incidence classified as low. National recommendations advise on latent TB screening before the beginning of the biological therapy. This screening consists in the detection of risk factors and/or signs and symptoms of latent TB through clinical history, physical examination, chest X-ray, tuberculin skin test and Interferon Gamma Release Assay (IGRA) test. We describe five clinical cases of patients who underwent biotechnological therapy at our Hospital after 2006 and developed TB.

AB0044 ESTABLISHED RHEUMATOID ARTHRITIS PATIENTS HAVE INCREASED FREQUENCIES OF FOLLICULAR REGULATORY T CELLS IN PERIPHERAL BLOOD

Background:

Several studies have demonstrated that an immune dysregulation affecting both B and T cells occurs in rheumatoid arthritis (RA). Follicular helper T (Tfh) cells are crucial for B cell maturation, activation and class-switching as well as for germinal center (GC) formation, whereas follicular regulatory T (Tfr) cells can modulate the GC reaction by suppressing Tfh and B cells.

Objectives:

The main goal of this study was to analyze the phenotype and frequency of circulating follicular T cell subsets in established RA patients.

Methods:

Blood samples were collected from established RA patients with active disease, treated with methotrexate (n=32) and from a group of age and sex-matched healthy donors (n=11). Peripheral blood mononuclear cells (PBMC) were isolated and Tfh (CD4+CXCR5+CD45RO+) and Tfr (CD4+ CXCR5+CD25+FoxP3+) cells, as well as their three major subsets [CXCR3+CCR6- (Th1-like), CXCR3-CCR6- (Th2-like) and CXCR3-CCR6+ (Th17-like)] were evaluated by flow cytometry.

Results:

The frequency of circulating Tfh cells was similar between established RA patients and controls. Nonetheless, RA patients had a decreased frequency of Th1-like Tfh cells, and an increased frequency of Th2-like Tfh cells when compared to controls. No significant differences were observed in the frequencies of Th17-like Tfh cells between both groups. The frequency of circulating Tfr cells was significantly increased in RA patients in comparison to controls. Furthermore, Tfr cells from RA patients had significantly increased CD69 median fluorescence intensity (MFI) values when compared to controls. No significant differences were found in the percentages and MFI values of PD-1, ICOS, CD28, CTLA-4, CD40-L and HLA-DR expressed by Tfh and Tfr cells in RA patients when compared to controls.

Conclusion:

Established RA patients have increased circulating frequencies of Tfr cells, with higher CD69 expression levels, when compared to healthy controls. These results suggest a pre-activation state of Tfr cells in RA and a potential role in the disease physiopathology.

*RA Moura, JE Fonseca and L Graca are joint senior authors.

Disclosure of Interests:

None declared

AB1149 POOR RESPONSE TO HEPATITIS B VACCINATION IN RHEUMATIC PATIENTS TREATED WITH BIOLOGIC THERAPY – IMPLICATIONS FOR CLINICAL PRACTICE

Background:

Hepatitis B virus (HBV) vaccination is recommended for rheumatic patients starting biologic therapy. There is some evidence that HBV vaccination is effective in patients under conventional disease modifying anti-rheumatic drugs (DMARDs), but it is currently unclear whether this also applies to biologics.

Objectives:

To assess the efficacy and safety of HBV vaccination in patients with rheumatic diseases treated with biologics.

Methods:

We included patients with any inflammatory rheumatic diseases treated with any biologic, who were negative for anti-HBs and anti-HBc and had never been vaccinated for HBV. Engerix B® was administered at 0, 1 and 6 months and anti-HBs was re-assessed ≥1 month after last dose. Response was defined as anti-HBs>10IU/L and compared against healthy controls (HC) undergoing Occupational Health immunization. Disease flare was evaluated before and until at least 1 month post-vaccination. We recorded serious adverse events (SAE) and immune-related disorders not previously present.

Results:

We included 67 patients, most treated with TNF inhibitors (TNFi), and 70 HC (Table 1). Most patients were taking concomitant DMARDs (69%) and were in remission/low disease activity (59%). Only 20 patients (30%) had a positive response to vaccination, in comparison to 68 HC (97%, p<0.001). Mean post-vaccination anti-HBs titre was significantly lower in responding patients than HC (569 ± 772 vs 1316 ± 811U/L, p<0.001). Responders diagnoses were RA (n=8 [25%]), PsA (n=7 [39%]), AS (n=4 [33%]) and IBD-associated SpA (n=1[100%]). Response was seen in 19/53 patients treated with TNFi (36%), but only 1/14 (7%) of patients treated with non-TNFi (p=0.037). Importantly, some responders had to temporarily interrupt biologic therapy due to other intercurrences for at least one administration. No clinical or demographic variables were associated with response, including age and disease activity. Fourteen patients (21%) experienced disease flares, of which 7 were mild and did not require therapy adjustment; 3 patients required minor treatment/dose adjustments; 4 patients had secondary failures that led to switches. There were 3 SAE (acute diverticulitis; abdominal infection; atrial fibrillation and urinary infection) 1-4 months after 1st/2nddose, deemed not to be related to vaccination. One RA patient on infliximab had bilateral uveitis 2 months after the 1stvaccine dose, which resolved with topical therapy.

Table 1.

Baseline characteristics of study participants.

Patients (n=67)Controls (n=70)pAge (years)56 ± 946 ± 9<0.001Female (%)40 (60)62 (89)<0.001Diagnosis (%)RA32 (48)PsA / AS18 (27) / 13 (19)Other4 (6)Disease duration (years)17 ± 10Biologic (%)TNF-inhibitor53 (79)Tocilizumab / Abatacept6 (9) / 1 (1)Rituximab / Belimumab2 (3) / 4 (6)Anakinra1 (1)Conventional DMARDs (%)MTX / LEF39 (58) / 1 (1)SSZ / Other6 (9) / 3 (4)None21 (31)Prednisolone (%) / Dose (mg)29 (43) / 5.6 ± 2.1DAS283.1 ± 1.4ASDAS2.2 ± 1.4

Conclusion:

In this study, HBV vaccination response was poor and lower in rheumatic patients treated with biologic therapy than in healthy adults. Vaccination was overall safe but there were 4 severe flares and 3 SAE that lead to treatment switch/interruption, although causal association is difficult to establish. Our data reinforce the recommendation for HBV vaccination prior to starting biologic therapy, possibly even as soon as the diagnosis is established. Alternative HBV vaccination strategies should be investigated in patients already treated with biologics.

Disclosure of Interests:

Vasco C Romão: None declared, Pedro Ávila-Ribeiro Grant/research support from: Novartis, Maria João Gonçalves: None declared, Ana Rita Cruz-Machado: None declared, André Guerreiro: None declared, Vítor Teixeira: None declared, Ana Valido: None declared, Joana Silva-Dinis: None declared, Elsa Vieira-Sousa: None declared, Maria João Saavedra: None declared, Ema Leite: None declared, Rui Tato Marinho: None declared, Joao Eurico Fonseca: None declared

Muscle Evaluation in Axial Spondyloarthritis-The Evidence for Sarcopenia

Sarcopenia is a syndrome defined as a progressive and generalized skeletal muscle disorder associated with an increased likelihood of adverse outcomes such as falls, fractures, physical disability, and death. The actual definition of sarcopenia is based on a reduction in the values of three parameters: strength, muscle mass quantity or quality, and physical performance (the determinant of severity). Muscle wasting is a common feature in several chronic diseases, such as spondyloarthritis (SpA), and significantly increases patient morbidity and mortality. Although there has been huge progress in this field over recent years, the absence of a clear definition and clear diagnostic criteria of sarcopenia has resulted in inconsistent information regarding muscle-involvement in SpA. Thus, the aim of this review is to collect relevant evidence on muscular changes occurring during the disease process from the published literature, according to the recommended tools for sarcopenia evaluation proposed by the European Working Group on Sarcopenia in Older People 2 (EWGSOP2). In addition, data from histological, electromyography, and biochemical muscle analyses of SpA patients are also reviewed. Overall, a reduction in muscle strength with a systemic decrease in lean mass seems to be associated with a gait speed compromise. This information is usually fragmented, with no studies considering the three parameters together. This paper represents a call-to-action for the design of new studies in the future.

Efficacy, immunogenicity and cost analysis of a systematic switch from originator infliximab to biosimilar CT-P13 of all patients with inflammatory arthritis from a single center

Biosimilar drugs are intended to be as effective as the originator product but with a lower cost to healthcare systems. In our center we promoted a switch from originator infliximab (IFXor) to biosimilar infliximab (CT-P13). We analyzed efficacy, safety, immunogenicity and cost savings of switching. Eligible patients were adults with the diagnosis of rheumatoid arthritis (RA), spondyloarthritis (SpA) and psoriatic arthritis (PsA) on therapy with IFXor for at least 6 months and with stable disease activity. Efficacy was measured considering change from baseline in Disease Activity Score in 28 joints (DAS28) for RA and PsA and in Ankylosing Spondylitis Disease Activity Score (ASDAS) for SpA. Disease worsening was considered when an increase of 1.2 from baseline in DAS28 or an increase of 1.1 in ASDAS occurred. Serum IFX levels (sIFX) were dichotomized as therapeutic (between 3-6 µg/mL), low (< 3 µg/mL), and high (> 6 µg/mL). Anti-drug antibody (ADA) levels were dichotomized into detectable (> 10 ng/ml) or non-detectable (< 10 ng/ml). A cost analysis was done based on the purchasing prices of the 2 drugs at our center. During a period of 1 year switch to CT-P13 was performed in 60 patients for non-medical reasons. We had a total of 36 patients with SpA, 16 with RA and 8 with PsA. Disease activity was stable over the observation period and similar to the values observed with IFXor. Median follow-up time was 15 months during which 5 patients stopped CT-P13. Forty two switchers had blood samples collected before and after switch. A total of 27 patients had unaltered sIFX levels and ADA status during follow up. Three patients had detectable ADA at baseline, with low sIFX levels. After switch, ADAs became negative in 2 of those patients, and the other patient kept detectable ADA levels. ADAs became positive in 5 patients after switch. The switch to CT-P13 represented a 26.4 % reduction of costs in the use of IFX therapy in these patients. The switch in routine care of a group of RA, SpA and PsA patients from IFXor to CT-P13 did not affect efficacy, safety, immunogenicity and reduced costs in 26.4%. The observed changes in blood samples were not associated with higher disease activity and did not lead to stopping IFX therapy.

Loss to follow-up in registries of rheumatic patients treated with biologics: a potential information bias in assessing pharmacovigilance and efficacy outcomes

BACKGROUND

The information associated with loss to follow-up (LFU) patients may affect real-world data evaluation of the use of biologics that is not being adequately captured in registries.

METHODS

We identified all patients (Pts) treated with biologics in our center who had no visits registered for more than 6 months, in the Rheumatic Diseases Portuguese Register, Reuma.pt. We retrieved baseline information from Reuma.pt and from the hospital electronic clinical record. We then performed a telephonic interview to characterize the reasons for LFU at our day care unit. For Pts unable to be contacted by telephone a letter of invitation to an appointment at the hospital was sent.

RESULTS

From a total of 794 Pts registered in Reuma.pt at our center with active biologic therapy 227 did not have any information registered in the last 6 months. Of this, 36 Pts were on biologic therapy prescribed by other departments and maintained follow-up in these departments. 102 Pts had suspended biologic administration by medical indication and this information was registered in the hospital electronic clinical records but not updated in Reuma.pt. For 89 Pts no information could be retrieved from either the hospital electronic clinical record or Reuma.pt and we classified these Pts as true LFU. 26 of these LFU Pts were being followed up in another Rheumatology center. 26 of the LFU Pts died. 11 Pts had an adverse effect. 4 Pts of the LFU were considering to be in remission. We were not able to contact 15 of the LFU pts.

CONCLUSION

Identifying LFU Pts and clarifying the reason for the loss of data in a register contributes to a better knowledge on strategies to discontinue biologics in stable pts, to a better pharmacovigilance of adverse effects and to more efficiency in data capture by registries. Due to data protection reasons it was impossible to have access to the Pts's death certificates.

Outcomes of rheumatic patients referred from Portuguese speaking African countries for medical evaluation in Portugal

Bureaucratic, social and economic barriers may influence several clinical aspects of rheumatic diseases in patients from Portuguese speaking African countries (PALOP) displaced for medical care in Portugal. Despite the apparent advantages of dislocating patients to a more resourceful country, these patients present with long-lasting and severe rheumatic diseases with chronic damage, due to lack of precise diagnosis, ineffective referrals, lack of appropriate treatment and concomitant infectious comorbidities that may jeopardize the outcomes of these strategies.

Tocilizumab and rituximab have similar effectiveness and are both superior to a second tumour necrosis factor inhibitor in rheumatoid arthritis patients who discontinued a first TNF inhibitor

OBJECTIVES

To compare the effectiveness of a 2nd TNF inhibitor (TNFi), Tocilizumab (TCZ) and Rituximab (RTX), measured by drug retention and by response rates, in RA patients after discontinuing a first-line TNFi and to clarify the reasons and predictors for discontinuation of a second-line biologic.

MATERIAL AND METHODS

Non-interventional prospective study of RA patients exposed to a 2nd TNFi, TCZ or RTX after previous TNFi discontinuation using real-world data from Reuma.pt database. Drug retention was estimated using Kaplan-Meier analysis and Cox models. Crude and LUNDEX adjusted response rates were evaluated at 6 months, 1 and 2 years and reasons for discontinuation were compared according to biologic class.

RESULTS

In total, 643 patients were included, 88.8% females, with a mean age of 59.4±12.8 years. Of those, 390 (60.7%) initiated a 2nd TNFi, 147 (22.9%) TCZ and 106 (16.5%) RTX. Drug retention was significantly greater among patients who initiated TCZ (76.4±4.3 months) or RTX (80.8±4.8 months), compared with those who initiated a 2nd TNFi (52.7±2.6 months) (log rank test, p < 0.001). In the adjusted Cox model, hazards of discontinuation were significantly lower for TCZ (HR 0.39, 95% CI 0.23-0.64, p < 0.001) and RTX (HR 0.42, 95% CI 0.25-0.72, p=0.001). Smokers had a significantly higher risk for discontinuation (HR 2.43, 95%CI 1.50-3.95, p < 0.001) as well as patients with higher HAQ at baseline (HR 1.51, 95%CI 1.14-2.00, p=0.004). The proportion of patients in remission or low disease activity according to Clinical Disease Activity Index (CDAI) at 6 months, 1 and 2 years was, respectively, 46.5%/50.0%/61.2% for TNFi, 52.9%/53.6%/ 69.2% for TCZ and 37.7%/48.0%/50.0% for RTX. After LUNDEX adjustment, response rates were, respectively, 33.0%/31.0%/31.8% for 2nd TNFi, 42.8%/41.8%/53.3% for TCZ and 32.0%/39.4%/39.0% for RTX. The main reasons for discontinuation were inefficacy for 2nd TNFi and RTX and adverse events for TCZ (p < 0.001).

CONCLUSIONS

Our findings showed a significantly higher drug retention for TCZ and RTX, compared with 2nd TNFi, and similar persistence among TCZ and RTX, in patients who discontinued a first-line TNFi. These data corroborate the notion that switching to a biologic with a different mode of action is more effective than to a second TNFi.

Intravitreal Bevacizumab in Aggressive Posterior Retinopathy of Prematurity

The anatomic response to intravitreal bevacizumab injection in three patients with aggressive, posterior retinopathy of prematurity is described. In all cases, the worse eye was treated with a single intravitreal injection of 0.75 mg of bevacizumab as monotherapy or complementary to laser therapy. In 24 hours, all injected eyes showed regression of the tunica vasculosa lentis and iris vessel engorgement and disappearance of iris rigidity. In addition, plus disease and retinal proliferation began to regress. None of the eyes required additional treatment. Follow-up of up to 10 months