POS1229 THE IMPACT OF COVID-19 ON MEDICATION NON-ADHERENCE IN A RHEUMATOID AND PSORIATIC ARTHRITIS UK COHORT

Background

In March 2020, as part of the UK’s COVID-19 prevention strategy, those identified as ‘clinically extremely vulnerable’, were advised to shield. This included a number of patients prescribed anti-rheumatic drugs, who were asked to continue their current treatment unless they developed symptoms of infection. Suboptimal treatment adherence (16.0%-81.0%) has been reported in patients with arthritic diseases, and is associated with psychological factors, including anxiety (1). Previous literature in non-UK cohorts has highlighted suboptimal adherence levels in immunosuppressed patients during the pandemic, although many were single centre studies (2,3).

Objectives

The aim of this multi-centre study is to investigate the impact of the COVID-19 pandemic on adherence to anti-rheumatic medications in patients with established rheumatoid (RA) and psoriatic (PsA) arthritis in the UK who had recently commenced a biologic or targeted synthetic DMARD.

Methods

Between September 2020 and May 2021, RA and PsA patients prescribed biologic or targeted synthetic anti-rheumatic drugs from two multi-centre observational studies (BRAGGSS and OUTPASS) were sent a questionnaire on medication usage, adherence, and perceptions to establish the impact of COVID-19 on these parameters. Patients were asked about compliance during the COVID-19 pandemic using a 5-point Likert scale (always, often, sometimes, rarely, and never) and the reason for non-adherence. Adherence was defined as never missing or delaying a dose, unless medically advised. Descriptive summary statistics were calculated, and logistic regression and Pearson’s chi-squared tests were employed to investigate variables associated with self-reported non-adherence.

Results

In total 159 questionnaires were returned (81.1% RA and 18.9% PsA). Methotrexate (53.5%) was the most frequently prescribed agent, followed by etanercept (25.2%), sulfasalazine (22.6%), hydroxychloroquine (21.4%) and adalimumab (19.5%). Furthermore, 68.6% of patients were prescribed ≥2 drugs. During the pandemic, 42.1% of patients reported missing or delaying a treatment dose for any reason. Adherence information was available for 97.5% of patients with 25.8% reporting non-adherence which was not medically advised. Methotrexate non-adherence was 27.1%, with similar levels reported for etanercept (20.0%), sulfasalazine (27.8%), hydroxychloroquine (35.3%) and adalimumab (29.0%). No drugs had significantly different adherence compared to methotrexate. Furthermore, there was no association between disease type or perception of disease control and adherence. Of non-adherent patients, 17.5% reported increased anxiety, fear, and increased risk due to the COVID-19 pandemic as an influencing factor. Meanwhile, 37.5% of non-adherent patients listed non-COVID-19 intentional reasons and 45.0% reported non-intentional reasons, with forgetting and running out of treatment listed most frequently.

Conclusion

In a UK cohort self-reported non-adherence was reported in 25.8% of patients during the COVID-19 pandemic, despite medical advice, with reasons including increased anxiety due to COVID-19.

References

[1]Medication adherence and persistence in patients with rheumatoid arthritis, psoriasis, and psoriatic arthritis: a systematic literature review. Patient Prefer Adherence. 2018;12:1483–503.

[2]Vakirlis E, Bakirtzi K, Papadimitriou I, Vrani F, Sideris N, Lallas A, et al. Treatment adherence in psoriatic patients during COVID-19 pandemic: Real-world data from a tertiary hospital in Greece. J Eur Acad Dermatology Venereol. 2020;34(11):e673–5.

[3]Polat Ekinci A, Pehlivan G, Gökalp MO. Surveillance of psoriatic patients on biologic treatment during the COVID-19 pandemic: A single-center experience. Dermatol Ther. 2020;(December 2020):19–22.

Acknowledgements

on behalf of the BRAGGSS consortium

Disclosure of Interests

Philippa Curry: None declared, Hector Chinoy Speakers bureau: UCB, Biogen, Consultant of: Novartis, Eli Lilly, Orphazyme, Astra Zeneca, Grant/research support from: Eli Lilly, UCB, Meghna Jani: None declared, Darren Plant: None declared, Kimme Hyrich Consultant of: consultancy/honoraria from AbbVie, Grant/research support from: Pfizer, BMS, Ann Morgan Speakers bureau: Roche, Chugai, Consultant of: GSK, Roche, Chugai, AstraZeneka, Regeneron, Sanofi, Vifor, Grant/research support from: Roche, Kiniksa Pharmaceuticals, Anthony G Wilson: None declared, John Isaacs Speakers bureau: Abbvie, Gilead, Roche, UCB, Grant/research support from: GSK, Janssen, Pfizer, Andrew Morris: None declared, Anne Barton Grant/research support from: I have received grant funding from Pfizer, Galapagos, Scipher Medicine and Bristol Myers Squibb., James Bluett Grant/research support from: Pfizer Limited. JB has received travel/conference fees from UCB, Pfizer and Eli Lilly

POS0035 GENE REGULATION IN T-CELLS FROM PsA PATIENTS DIFFERS BETWEEN PERIPHERAL BLOOD AND THE INFLAMED JOINTS: IMPLICATIONS FOR THE INTERPRETATION OF GWAS SIGNALS

Background

Genome-wide association studies (GWAS) have identified variants that are associated with complex diseases such as Psoriatic Arthritis (PsA). The majority of these variants do not affect the coding sequence of proteins but rather regulatory elements which are highly cell type and state specific, and can affect distally located genes via chromatin interaction mechanisms.

We and others have previously analysed GWAS loci for multiple conditions (including PsA and Rheumatoid Arthrtitis) in cell lines using functional genomics techniques, providing putative mechanisms to many loci with previously unknown function [1].

However, multiple studies have identified large differences in gene regulatory mechanisms between cell lines and primary cells, which could significantly alter the proposed mechanisms. Differences between between samples from healthy volunteers and patients, in particular from the affected tissue, have although not been exhaustively investigated.

Objectives

To assess the impact of using primary cells derived from PsA patients compared to healthy volunteers in functional genomics studies.

Methods

CD4+ and CD8+ T cells were isolated from peripherial blood from 10 healthy controls and 48 PsA patients and from 6 PsA synovial fluid samples.

We performed RNA-seq and ATAC-seq on these two cell types to analyse the global patterns of gene expression and chromatin activity.

Results

We find subtle differences between PsA patients and healthy controls in cells isolated from blood. RNA-seq analysis identified only a handful of differentially expressed genes whilst ATAC-seq analysis identified only 28 differential loci.

On the other hand, T cells isolated from synovial fluid showed significant differences compared to T cells isolated from patient’s blood. Interestingly, we find that CD4+ T cells show substantially more differentially expressed genes compared to CD8+ T cells (1168 vs 346 Log2FoldChange > 1, FDR < 0.01). Genes overexpressed in synovial CD4+ T cells are more strongly enriched for immune pathways such as cytokine signaling and T cell proliferation compared to synovial CD8+ T cells

We also find that synovial CD4+ T cells highly overexpress MHC class II genes (Figure 1).

Figure 1.

Normalized counts of the alpha chains of MHC class 2 genes in CD4+ and CD8+ T cells purified from blood from healthy subjects and patients and synovial fluid.

Conclusion

This preliminary analysis suggests that T cells isolated from peripherial blood do not seem to differ significantly between PsA patients and healthy controls. In contrast, cells isolated from synovial fluid are highly specialized and activated. Moreover, these cells do not resemble canonically activated T cells which means that this state can not be easily emulated in vitro.

This study indicates the importance of not only studying GWAS loci in relevant primary cells from patients, but also that attention needs to be given to cells isolated from the affected site.

References

[1]Shi C, Ray-Jones H, Ding J, et al (2021) Chromatin Looping Links Target Genes with Genetic Risk Loci for Dermatological Traits. J Invest Dermatol 141:1975–1984. https://doi.org/10.1016/J.JID.2021.01.015

Acknowledgements

This work was funded by the Wellcome Trust (award references 207491/Z/17/Z and 215207/Z/19/Z), the Versus Arthritis (award reference 21754), the NIHR Manchester Biomedical Research Centre, and the Medical Research Council (award reference MR/N00017X/1).

Disclosure of Interests

None declared

POS0665 DEVELOPMENT OF A BIOCHEMICAL TOFACITINIB ADHERENCE ASSAY IN RHEUMATOID ARTHRITIS: THE ORAL ADHERE STUDY

Background

Tofacitinib is a potent inhibitor of the JAK1/JAK3 tyrosine kinases effective in the treatment of rheumatoid arthritis (RA). Unlike biologic DMARDs, tofacitinib is administered orally. Oral administration offers a major benefit to patients, removing the risk of injection site reactions and previous research has shown that patients prefer an oral DMARD which may affect patient’s adherence (1).

Non-adherence is a health behaviour that results in reduced response and increased healthcare costs but can be challenging to accurately measure. Direct tofacitinib measurement may be an accurate measure of adherence that could, in the future, be used in a clinical setting as part of a behaviour change intervention.

Tofacitinib can be measured using High Performance Liquid Chromatography Selected Reaction Monitoring Mass Spectrometry (HPLC-SRM-MS). Previous tofacitinib studies have demonstrated an assay sensitivity of 0.1ng/ml may be sufficient for the detection of adherence following 5mg twice daily administration (2).

Objectives

The aim of this study is to develop a HPLC-SRM-MS assay to measure biochemical tofacitinib adherence in patients with RA.

Methods

Human serum for method development was obtained from volunteers recruited to the collection of blood and urine samples from volunteers for the development of analytical methods study (UREC 12346) and the National Repository Study (REC 99/8/84) following informed consent.

Samples were spiked with Tofacitinib/Tofacitinib-d3 and subjected to protein precipitation. LC-MS/MS analysis was performed on a TSQ Vantage triple quadrupole mass spectrometer coupled with an Accela UHPLC system (Thermo Fisher Scientific, USA). Validation of the assay was tested as adapted from European Medicines Agency guidelines on Bioanalytical Validation. Specifically, the lower limit of quantification (LLOQ), carryover, accuracy, linearity, precision, recovery and stability of the assay was determined.

To investigate the ability of the assay to detect adherence, serum samples (n=10) of patients prescribed tofacitinib from the Biologics in Rheumatoid Arthritis Genetics and Genomics Study Syndicate (BRAGGSS) were analysed (REC reference: 04/Q1403/37). Participants self-reported date and time of tofacitinib ingestion prior to venepuncture. Samples were analysed in triplicate.

Results

The assay demonstrated a tofacitinib LLOQ of 0.1ng/ml, carryover of sample following injection of a 1000 ng/ml tofacitinib was <1%, linearity of r2=0.998, within run accuracy was between 81-85% at LLOQ and between 91-107% at all other levels. Between run accuracy was within 14.9% at LLOQ and within 0.2-5.1% of the nominal concentration at all other levels. Samples of tofacitinib spiked in whole blood and left at room temperature for seven days were within 0.98-10.25% of serum samples spiked on the day of analysis for all concentrations. To demonstrate the potential of the assay to determine adherence, all 10 BRAGGSS samples revealed tofacitinib levels above 0.1ng/ml with CV<15% (Table 1).

Table 1.Sample IDTime difference between self-reported tofacitinib ingestion and blood sample (hours)Mean Tofacitanib (ng/ml, n=3)CV (%)497.026.432.82402.8100.555.51703.673.232.27681.5150.378.09201.5137.469.09301.8117.8514.97331.490.891.18795.4217.4711.40172.8108.437.43372.5335.043.48

Conclusion

A novel tofacitinib LC-MS/MS assay has been developed. The ability of the assay to measure biochemical adherence has been explored. Further research to establish the sensitivity of the assay and the ability of the assay to detect non-adherence are required.

References

[1]Alten R, Krüger K, Rellecke J, Schiffner-Rohe J, Behmer O, Schiffhorst G, et al. Examining patient preferences in the treatment of rheumatoid arthritis using a discrete-choice approach. Patient Prefer Adherence. 2016;10:2217-28.

[2]Suzuki M, Tse S, Hirai M, Kurebayashi Y. Application of Physiologically-Based Pharmacokinetic Modeling for the Prediction of Tofacitinib Exposure in Japanese. Kobe J Med Sci. 2017;62(6):E150-E61.

Acknowledgements

Financial support was provided as an Investigator Sponsored Research Grant from Pfizer Limited

Disclosure of Interests

Stephanie Church Grant/research support from: Financial support was provided as an Investigator Sponsored Research Grant from Pfizer Limited, Kimme Hyrich Speakers bureau: Honoraria as a speaker received from Abbvie, Grant/research support from: Financial support was provided as an Investigator Sponsored Research Grant from Pfizer Limited.

Research grant award from BMS, Kayode Ogungbenro Consultant of: Afferent, Biogen, Buzzard, Grant/research support from: Financial support was provided as an Investigator Sponsored Research Grant from Pfizer Limited., Richard Unwin Grant/research support from: Financial support was provided as an Investigator Sponsored Research Grant from Pfizer Limited, Anne Barton Grant/research support from: Financial support was provided as an Investigator Sponsored Research Grant from Pfizer Limited. AB has received grant funding from Scipher Medicine Ltd, Bristol Myers Squibb and Galapagos in the past 12 months., James Bluett Grant/research support from: Financial support was provided as an Investigator Sponsored Research Grant from Pfizer Limited. JB has received travel/conference fees from UCB, Pfizer and Eli Lilly

POS0033 GENETIC INVESTIGATION OF TUMOUR NECROSIS FACTOR INHIBITOR IMMUNOGENICITY IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Rheumatoid arthritis (RA) is a chronic inflammatory disease that primarily affects the synovial joints. Tumour Necrosis Factor inhibitor (TNFi) therapy has transformed the clinical management of RA. However, monoclonal antibody derived TNFi is associated with development of immunogenicity and subsequent loss of therapeutic effects. Previous studies have observed associations between certain HLA alleles and TNFi immunogenicity. For example HLA-DQA1 and HLA-DRB1 have been associated with immunogenicity in inflammatory bowel disease 1,2 and RA 3,4, respectively.

Objectives

The aims of this study were to identify associations between HLA alleles and immunogenicity to TNFi in an observational cohort of RA patients and to replicate findings from previous studies.

Methods

Anti-drug antibody titres were measured using radioimmunoassay in serum samples from RA patients participating in Biologics in Rheumatoid Arthritis Genetics and Genomics Study Syndicate (BRAGGSS). An anti-drug antibody titre of ≥12 AU/mL following six months on treatment was used to define positive immunogenicity. Genotype data were generated using Illumina HumanCoreExome Arrays. Standard quality control (QC) was applied prior to HLA imputation using SNP2HLA software before low minor allele frequency markers were removed. Logistic regression was used to study the association between HLA alleles and immunogenicity, whilst the omnibus test was applied to amino acid positions; sex and concurrent conventional synthetic DMARD use were included as a covariate in all the models.

Results

In total, 445 RA patients were analysed, 377 patients (70 immunogenicity events) were underdoing adalimumab therapy and 68 certolizumab (30 immunogenicity events) therapy. Following QC, 162 HLA alleles and 361 amino acids positions were available for analysis. The strongest HLA allele association was observed for HLA-DQA1*03 when all patients were analysed (OR = 0.61; 95% CI = 0.43 – 0.86; p-value = 5e-3). The amino acids positions 187 (p-value = 5e-3) and 26 (p-value = 5e-3) within the HLA-DQA1 gene were significantly associated with immunogenicity events. When both drugs were analysed separately, they produced similar effect size for HLA-DQA1*03 association; patients treated with adalimumab (OR = 0.59; 95% CI = 0.38 – 0.88; p-value = 1e-2) and certolizumab (OR = 0.52; 95% CI = 0.24 – 1.1; p-value = 1e-1). Another strong association was found in HLA-DRB1*04 (OR = 0.62; 95% CI = 0.44 – 0.88; p-value = =7e-3) and the amino acid position of 180 (p-value = 7e-3) and 33 (p-value = 7e-3) of HLA-DRB1 gene. Additionally, the similar protective effect between the two presented alleles suggested possibility of linkage disequilibrium, upon investigation the r2 between the 2 alleles is 0.69.

Conclusion

The current study increases the evidence for association between immunogenicity development with HLA-DQA1 and HLA-DRB1 alleles in patients receiving monoclonal antibody derived TNFi therapy. Further well powered studies are now required to determine the utility of HLA markers as a potential tool to aid the clinical management of RA.

References

[1]Sazonovs, A. et al. HLA-DQA1*05 Carriage Associated With Development of Anti-Drug Antibodies to Infliximab and Adalimumab in Patients With Crohn’s Disease. Gastroenterology158, 189–199 (2020).

[2]Billiet, T. et al. Immunogenicity to infliximab is associated with HLA-DRB1. Gut64, 1344–1345 (2015).

[3]Liu, M. et al. Identification of HLA-DRB1 association to adalimumab immunogenicity. PLoS One13, e0195325 (2018).

[4]Rigby, W. et al. HLA-DRB1 risk alleles for RA are associated with differential clinical responsiveness to abatacept and adalimumab: data from a head-to-head, randomized, single-blind study in autoantibody-positive early RA. Arthritis Res. Ther.23, 245 (2021).

Disclosure of Interests

Chuan Fu Yap: None declared, Nisha Nair: None declared, Kimme Hyrich Speakers bureau: Abbvie, Grant/research support from: Pfizer and BMS, Anthony G Wilson: None declared, John Isaacs Speakers bureau: Abbvie, Gilead, Roche, UCB, Grant/research support from: GSK, Janssen, Pfizer, Ann Morgan Speakers bureau: Roche, Chugai, Consultant of: GSK, Roche, Chugai, AstraZeneca, Regeneron, Sanofi, Vifor, Grant/research support from: Roche, Kiniksa Pharmaceuticals, Anne Barton Grant/research support from: I have received grant funding from Pfizer, Galapagos, Scipher Medicine and Bristol Myers Squibb., Darren Plant: None declared

AB0011 DNA METHYLATION AS A BIOMARKER OF TOCILIZUMAB RESPONSE IN RHEUMATOID ARTHRITIS PATIENTS

Background

Tocilizumab (TCZ) is a disease-modifying antirheumatic biologic drug, which targets the IL-6 signalling pathway and is effective in ameliorating disease activity in rheumatoid arthritis (RA). However, approximately 50% of patients do not respond adequately to TCZ and some patients report adverse events. Considering there is growing evidence that DNA methylation is implicated in RA susceptibility and response to some biologics (1, 2), we investigated DNA methylation as a candidate biomarker for response to TCZ in RA.

Objectives

To identify differential DNA methylation signatures in whole blood associated with TCZ response in patients with RA.

Methods

Epigenome-wide DNA methylation patterns were measured using the Infinium EPIC 850k BeadChip (Illumina) in whole blood-derived DNA samples from patients with RA. DNA was extracted from blood samples taken pre-treatment and following 3 months on therapy, and response was determined at 6 months using the Clinical Disease Activity Index (CDAI). Patients who had good response (n=10) or poor response (n=10) to TCZ by 6 months were selected. Samples from secondary poor responders (n=10) (patients who had an improvement of CDAI and were in remission at 3 months, followed by a worsening of CDAI at 6 months) were also analysed. Differentially methylated positions (DMPs) were identified using linear regression, adjusting for gender, age, cell composition, smoking status, and glucocorticoid use.

Results

In the pre-treatment samples, 20 DMPs were significantly associated with response status at 6 months (unadjusted p-value <10-6), whilst in the 3 month samples, 21 DMPs were associated with response. One DMP, cg03121467, was significantly less methylated in good responders compared to poor responders in the pre-treatment samples. This DMP is close to EPB41L4A and may play a role in β–catenin signalling. Interestingly, cg10136146 was significantly less methylated in secondary poor responders compared to both good and poor responders in the 3 month samples. This DMP maps close to CD81, which plays a role in mediating the development and activation of B and T lymphocytes.

Conclusion

These preliminary results provide evidence that DNA methylation patterns may predict response to TCZ. Further regional and pathway analyses is in progress and validation of these findings in other larger data sets is required.

References

[1]Liu,Y., Aryee,M.J., Padyukov,L., Fallin,M.D., Hesselberg,E., Runarsson,A., Reinius,L., Acevedo,N., Taub,M., Ronninger,M., et al. (2013) Epigenome-wide association data implicate DNA methylation as an intermediary of genetic risk in rheumatoid arthritis. Nat. Biotechnol., 31, 142–147.

[2]Plant,D., Webster,A., Nair,N., Oliver,J., Smith,S.L., Eyre,S., Hyrich,K.L., Wilson,A.G., Morgan,A.W., Isaacs,J.D., et al. (2016) Differential Methylation as a Biomarker of Response to Etanercept in Patients With Rheumatoid Arthritis. Arthritis Rheumatol. (Hoboken, N.J.), 68, 1353–60.

Disclosure of Interests

Nisha Nair: None declared, Darren Plant: None declared, John Isaacs Speakers bureau: Abbvie, Gilead, Roche, UCB, Grant/research support from: GSK, Janssen, Pfizer, Ann Morgan Speakers bureau: Roche/Chugai, Consultant of: GSK, Roche, Chugai, AstraZeneca, Regeneron, Sanofi, Vifor, Grant/research support from: Roche, Kiniksa Pharmaceuticals, Kimme Hyrich Consultant of: AbbVie, Grant/research support from: Pfizer, BMS, Anne Barton Grant/research support from: I have received grant funding from Pfizer, Galapagos, Scipher Medicine and Bristol Myers Squibb., Anthony G Wilson: None declared

AB0345 THERAPEUTIC DRUG LEVELS TO ACHIEVE GOOD EULAR RESPONSE IN PATIENTS WITH RHEUMATOID ARTHRITIS RECEIVING ADALIMUMAB: RESULTS FROM THE BIOLOGICS IN RHEUMATOID ARTHRITIS GENETICS AND GENOMICS STUDY SYNDICATE (BRAGGSS) COHORT

Background

Rheumatoid arthritis (RA) is a systemic inflammatory disease often treated with biologic disease-modifying anti-rheumatic drugs (bDMARDs) such as Adalimumab (ADL), a tumour-necrosis factor inhibitor (TNFi). However, it is known that about a third of patients do not respond to ADL treatment. Previous studies have reported associations between poor response, decreased serum drug levels (SDLs) and poor adherence, but a therapeutic SDL has not been defined nor applied in clinical practice.

Objectives

To assess median ADL SDLs in RA European Alliance of Associations for Rheumatology (EULAR) good vs non/moderate responders, and to determine cut-off SDLs associated with a “Good” response in fully adherent RA patients.

Methods

In a prospective observational cohort study, patients with RA were treated with ADL. At baseline, 3-, 6-, and 12-months patients had 4-component DAS28 scores, self-reported treatment adherence data and SDLs measured. Median drug levels and receiver-operator characteristics (ROC) curves were used to compare SDLs between responders and non-responders, and to establish cut-off SDLs in self-reported fully adherent patients. Serum drug levels were measured using a sandwich ELISA produced by Progenika Biopharma. Patients were considered fully adherent if they self-reported never having altered, forgotten or omitted any dose of their biologic drug at follow-up. Between group comparisons were assessed using Fisher’s exact test, with a threshold for significance set at p<0.05. Statistical analyses were performed in R Version 4.1.0 and RStudio Version 1.4.1106.

Results

A total of 283 RA patients taking ADL were included in the analysis. Baseline characteristics are shown in Table 1. Of these patients 93 (32.9%) self-reported being fully adherent to treatment at 3 months follow-up and had SDLs measured.

Table 1.

Baseline characteristics of patient cohort with RA taking ADL (n=283)

CharacteristicnMissing (%)Age at baseline, median years (IQR)58 (51, 64)0Disease duration, median years (IQR)7 (3, 16)0Female Sex, n (%)206 (73)0BMI, median (IQR)27.4 (23.7, 31.9)0Smoking Status132 (46)Current, n (%)57 (38)-Ex, n (%)32 (21)-Non, n (%)62 (41)-On concurrent DMARD(s)1 (0.4)No, n (%)34 (12)-Yes, n (%)248 (88)-Baseline DAS Score, median (IQR)5.61 (5.18, 6.14)On MTX at baseline38 (13)No, n (%)44 (18)Yes, n (%)201 (82)

In 93 fully adherent RA patients taking ADL at 3 months, good EULAR responders had significantly higher SDLs compared to non/moderate EULAR responders (p=0.0234). In 47/93 (50.5%) fully adherent good responders median SDL at 3 months was 10.94mg/L (IQR 7.75 to 12.0), whereas in 46/93 (49.5%) non/moderate responders, median SDL at 3 months was 9.014 (IQR 6.96 to 11.1).

ROC analysis (see Figure 1) reported a 3-month non-trough ADL SDL cut-off of 7.5mg/L in fully adherent RA patients which discriminated Good EULAR responders compared to non/moderate responders with an AUC of 0.63 (95% CI 0.52 – 0.75), 39.1% specificity, and 80.9% sensitivity.

Figure 1.

ROC curve analysis: EULAR non/moderate vs good responders with 3 month ADL SDLs.

Conclusion

In keeping with previous work, SDLs were higher in adherent compared with non-adherent patients, but this is the first study to demonstrate that SDLs are higher in fully adherent good EULAR responders compared with non/moderate responders. Based on our methods, cut-offs of 7.5mg/L for ADL may be useful targets in clinical practice to achieve good EULAR response.

References

[1]Jani M, Chinoy H, Warren RB, Griffiths CEM, Plant D, Fu B, et al. Clinical Utility of Random Anti–Tumor Necrosis Factor Drug–Level Testing and Measurement of Antidrug Antibodies on the Long-Term Treatment Response in Rheumatoid Arthritis. Arthritis & Rheumatology. 2015;67(8):2011-9.

[2]Pouw MF, Krieckaert CL, Nurmohamed MT, van der Kleij D, Aarden L, Rispens T, et al. Key findings towards optimising adalimumab treatment: the concentration-effect curve. Ann Rheum Dis. 2015;74(3):513-8.

Disclosure of Interests

None declared

POS1418 SEPARATING THE EFFECTS OF CHILDHOOD AND ADULT BODY SIZE ON INFLAMMATORY ARTHRITIS: A MENDELIAN RANDOMISATION STUDY

Background

Obesity is strongly associated with inflammation and inflammatory arthritis, but most studies to date have only examined adulthood body mass index (BMI). Whether childhood obesity has a direct and long-term influence on risk of inflammatory arthritis is unclear. This question is important as childhood obesity becomes a growing and global public health crisis [1], but traditional epidemiologic approaches may be limited by reverse causation (obesity can be cause and consequence of disease) and confounding. Mendelian randomisation (MR) uses genetic variants as instrumental variables to estimate the effect of an exposure on an outcome. Since variants are randomly allocated at conception, MR is less susceptible to reverse causation and confounding.

Objectives

To examine whether childhood body size affects risk of inflammatory arthritides – rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), gout and systemic lupus erythematosus (SLE) – after accounting for the effect of adult body size using two-sample univariable and multivariable MR.

Methods

Genetic instruments for childhood (age 10 years) and adult body size were derived using data from 453,169 individuals from the UK biobank study (313 and 580 variants respectively; r2<0.001, p<5x10-8), which have been previously validated using BMI data from three independent populations [2]. Participants recalled their body size at age 10 as “thinner”, “about average” or “plumper”. Adult body size was determined using BMI at a mean age of 57 years and, to facilitate comparison, split into three groups to match the proportions for childhood body size. Genome-wide association data comprised of 22,350 RA, 9,069 AS, 3,609 PsA, 13,179 gout and 5,201 SLE cases. We conducted univariable MR to estimate the total effects of childhood and adult body size on outcomes and multivariable MR to examine the independent effect of childhood body size after accounting for adult body size. F statistics were calculated for each exposure with a value >10 considered suggestive of adequate instrument strength.

Results

The F statistic for childhood and adult body size instruments were 30 and 23 respectively. Genetically predicted childhood body size had a total effect on risk of PsA (OR 2.18 per change in body size category; 95%CI 1.43, 3.31), gout (OR 2.18; 1.43, 3.31) and SLE (OR 2.44; 1.14, 5.22), but not RA (OR 0.95; 0.70, 1.29) or AS (OR 0.96; 0.61, 1.52). After accounting for adult body size, the direct effect of childhood body size was little changed for PsA (OR 1.92; 1.14, 3.25) and SLE (OR 2.69; 1.24, 5.87), but was attenuated for gout (OR 1.40; 0.94, 2.09).

Figure 1.

Mendelian randomisation estimates of the effect of childhood and adult body size on inflammatory arthritis.

Conclusion

Results of this study suggest that the risk conferred from having a larger body size during childhood may not be fully reversable even when a healthy size is achieved in adulthood. How the immune system is altered by early life adiposity to increase risk of PsA and SLE is unclear. Differential effect estimates of body size on each inflammatory arthritis (PsA vs AS, RA vs SLE) may help shed light on their unique pathophysiology in future studies.

References

[1]Han et al. Childhood obesity. Lancet 2010;375:1737–48.

[2]Richardson et al. Use of genetic variation to separate the effects of early and later life adiposity on disease risk: mendelian randomisation study. BMJ 2020;369:m1203.

Acknowledgements

We thank the participants of the UK Biobank study and the genome-wide association study consortia who made their summary statistics publicly available for this study.

Disclosure of Interests

None declared

POS0395 EXPLORING THE POTENTIAL OF GENOMIC RISK PREDICTION FOR CORONARY ARTERY DISEASE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Patients with rheumatoid arthritis (RA) have a higher prevalence of coronary artery disease (CAD) than the general population which contributes to early mortality. However, CAD screeing tools developed in the general population are less effective for estimating CAD risk in RA patients. This is mainly due to the differing contribution from traditional risk factors and the contribution from disease-specific factors. Understanding of the genetic basis of CAD has improved over recent years and shows promise for improving risk prediction in the form of genetic risk scores (GRs), in particular with the development of the metaGRS approach, which combines multiple polygenic risk scores.

Objectives

This study hypothesise that the metaGRS approach can help us improve CAD risk prediction in patients with RA.

Methods

Patients were recruited from the Norfolk Arthritis Register (NOAR), a longitudinal observational study focused on the cause and outcome of inflammatory polyarthritis. Analysis was restricted to patients who satisfied the 2010 ACR criteria cumulatively over five years and had detailed clinical history at baseline and follow-up for ten years. We developed a prediction model based on traditional risk factors[1], and explored the inclusion of a metaGRS. We used a meta-analytic approach to calculate a new metaGRS for CAD, using the effect-sizes from three large-scale, genome-wide, and targeted GRs derived from 1,745,179 [2], 6,630,150 [3], and 40,079 SNPs [4]. We tested the metaGRS in combination with available data on traditional risk factors in a subset of patients with available genetic data. Cox proportional hazards models were used to derive risk equations for evaluation of 10-year risk of CAD. We applied multiple imputations with chained equations to replace missing values. Calibration and discrimination were determined in a separate cohort of 423 individuals.

Results

A total of 2123 patients were included in the analysis with 136 incident cases of self-reported CAD (defined as a composite outcome of myocardial infarction, angina, heart attack, arrhythmia, angioplasty, and coronary artery bypass grafting).The model using only traditional risk factors achieved an AUC of 0.81 (95% CI 0.80, 0.82), with a calibration slope of 1.10, and explained approximately 71% (95% CI 69, 72%) of the variance of the outcome. The hazard ratio for age was found to be 1.00 (95% CI 0.99, 1.01) indicating risk remains the same across all age groups. Inclusion of a CAD metaGRS improves the AUC to 0.82 (95% CI 0.80, 0.83), explains more of the variance at 81% (95% CI 79, 82%) but worsens calibration slope to 0.93. A likelihood ratio test indicates that the integrated model is a better fit (p = 0.04).

Conclusion

An integrated risk score, that combines traditional risk factors with a metaGRS, improves CAD prediction in patients with RA. Further research is required to better understand the role of heritable components contributing to CAD risk in RA patients. By refining the underlying GRS, we hope to further improve risk prediction, through this integrated approach.

References

[1]Hippisley-Cox, Julia, Carol Coupland, and Peter Brindle. “Development and validation of QRISK3 risk prediction algorithms to estimate future risk of cardiovascular disease: prospective cohort study.” bmj 357 (2017).

[2]Inouye M, Abraham G, Nelson CP, Wood AM, Sweeting MJ, Dudbridge F, et al. Genomic Risk Prediction of Coronary Artery Disease in 480,000 Adults: Implications for Primary Prevention. J Am Coll Cardiol. 2018;72(16):1883–93.

[3]Khera A V., Chaffin M, Aragam KG, Haas ME, Roselli C, Choi SH, et al. Genome-wide polygenic scores for common diseases identify individuals with risk equivalent to monogenic mutations. Nat Genet [Internet]. 2018;50(9):1219–24. Available from: http://dx.doi.org/10.1038/s41588-018-0183-z

[4]Elliott J, Bodinier B, Bond TA, Chadeau-Hyam M, Evangelou E, Moons KGM, et al. Predictive Accuracy of a Polygenic Risk Score-Enhanced Prediction Model vs a Clinical Risk Score for Coronary Artery Disease. JAMA - J Am Med Assoc. 2020;323(7):636–45.

Disclosure of Interests

None declared.

OP0088 STRATIFIED MEDICINE: GENETIC PREDICTORS OF RADIOGRAPHIC OUTCOME IN RHEUMATOID ARTHRITIS

Background

Rheumatoid arthritis (RA) displays great heterogeneity between patients for susceptibility to developing erosions. Genetic variations within the HLA-DRB1 gene (the shared epitope (SE) and polymorphisms coding for Valine at position 11) have been consistently associated with both susceptibility and radiographic outcome in RA.(1) However, associations of non-HLA markers are much less conclusive. Most studies looking outside the HLA have been candidate gene studies and very few have been replicated in independent cohorts.

Objectives:

1. Identify all single nucleotide polymorphisms (SNPs) outside the HLA that have ever been associated with radiographic outcome in RA

2. To perform a replication study to determine which of these are associated with radiographic outcome in the Norfolk Arthritis Register (NOAR), the worldwide largest prospective cohort with genetic and radiographic outcome data.

Methods

A systematic literature search was conducted as shown in the Figure 1.

Figure 1.

Flow chart for systematic review.

The Norfolk Arthritis register (NOAR) is a large primary care-based inception cohort of patients diagnosed with inflammatory polyarthritis. Patients were recruited at baseline from 1989 and followed up prospectively for up to 20 years with serial X-rays. Genome-wide genotyping was performed on the Illumina Human/Infinium Core Exome array and imputed with Minimac4 to the Haplotype Reference Consortium panel. Quality control resulted in 7.5 million SNPs available in each patient. SNPs identified from the literature were extracted and tested for an association with the presence of erosions (as a longitudinal binary variable) using a generalized estimating equation (GEE) model in STATA/IC 14.0.in NOAR.

Results

A total of 2119 participants (2440 radiographs) were identified with both genetic and radiographic data available. 66.2% of these patients were female and 33.3% were anti-CCP positive. Median age of onset was 54.5 and 74.9% satisfied the American College of Rheumatology (ACR) 1987 criteria for rheumatoid arthritis.

A total of 113 different non-HLA SNPs associated with radiographic outcome in RA were identified from the literature. Of these, 102 were successfully identified within NOAR and 91 were deemed to be independent SNPs based on R2 of 0.6. 14 SNPs were found to be significantly associated with the presence of erosions within NOAR (Table 1).

Table 1.

SNPs found to be associated with radiographic severity within NOAR. *Significant results only; Dominant models used (Odds ratios displayed in relation to minor alleles)

GeneChromosomeSNP (single nucleotide polymorphismOdds ratio (95% CI)P valueIL2RB2rs7437771.23 (1.01, 1.05)0.0398IL154rs68211710.82 (0.67, 1.00)0.0451IL45rs22432501.36 (1.08, 1.70)0.0094FOX036rs122120670.75 (0.58, 0.97)0.0278OPG8rs20736180.79 (0.64, 0.98)0.0295TRAF19rs107601301.33 (1.06, 1.65)0.0118TRAF19rs108184881.32 (1.06, 1.64)0.0141TRAF19rs29001801.32 (1.07, 1.61)0.0079IL4r16rs18050101.25 (1.01, 1.56)0.0393IL4r16rs18050111.31 (1.03, 1.66)0.0260LGALS917rs37639591.28 (1.03, 1.59)0.0260SOST17rs47929091.34 (1.09, 1.65)0.0052LILRA319rs1032940.80 (0.65, 0.98)0.0334MMP920rs119083520.70 (0.57, 0.85)0.0005

Conclusion

113 non-HLA SNPs have been previously reported to be associated with radiographic outcome in RA. Of these, only ~15% also showed an association in NOAR, the largest cohort with genetic and radiographic outcome data worldwide. Interestingly, rs2243250, a SNP located on chromosome 5 (IL4), previously found to be associated in a small Egyptian cohort, has been replicated in NOAR.(2) Current work consists of assessing the added clinical value of a genetic risk score based on HLA and non-HLA markers in predicting radiographic outcome when combined with clinical/serological/demographic markers.

References

[1]S. Viatte et al., JAMA313, 1645-1656 (2015).

[2]Y. M. Hussein, A. S. El-Shal, N. A. Rezk, S. M. Abdel Galil, S. S. Alzahrani, Cytokine61, 849-855 (2013).

Disclosure of Interests

None declared.

POS0307 IMPAIRED GLYCAEMIC CONTROL IS ASSOCIATED WITH INCREASED RISK OF PSORIATIC ARTHRITIS: MENDELIAN RANDOMISATION STUDY

Background

Psoriatic arthritis (PsA) and psoriasis are both strongly associated with impaired glycaemic control and type 2 diabetes. The risk of developing type 2 diabetes is estimated to be ~40% higher in PsA compared to controls [1]. However, these observational findings are susceptible to bias from reverse causation: Insulin resistance and impaired glycaemic control are evident well over a decade before clinical onset of type 2 diabetes [2]. Therefore, whether impaired glycaemic control is a cause or consequence of PsA is unclear. Testing this hypothesis using traditional observational designs is challenging since longitudinal assessments of glycaemic control before PsA onset are often not available. Mendelian randomisation (MR) is an epidemiologic method that provides evidence about putative causal relationships between modifiable exposures and disease outcomes using genetic variants as instrumental variables. MR is less likely to be affected by confounding or reverse causation than conventional observational designs because genetic variants are randomly allocated at conception.

Objectives

To estimate the effect of genetically predicted glycaemic traits - glycated haemoglobin (HbA1c), 2-hour glucose after oral glucose challenge (2hG), fasting glucose (FG), and fasting insulin (FI) - on risk of PsA and psoriasis compared to controls using two-sample MR.

Methods

We selected 320 independent (r2<0.001) genome-wide significant (p<5x10-8) variants as instruments for HbA1c from a UK biobank genome-wide association study (GWAS) of 344,182 individuals, and 14 variants for 2hG, 67 for FG and 38 for FI from up to 200,622 individuals from a MAGIC consortium meta-analysis that adjusted for body mass index. Genetic associations for PsA were obtained from a GWAS comprising 3,609 cases (majority fulfilling CASPAR criteria) and 9,192 controls. Psoriasis data were obtained from 5,278 cases (96% European, defined using ICD and phecodes) and 650,391 controls from the UK biobank, FinnGen and BioBank Japan [3]. We used the inverse-variance weighted method to combine effect estimates from each variant using fixed-effect meta-analysis.

Results

Genetically predicted HbA1c increased risk of PsA (OR 1.18 per standard deviation (6.7 mmol/mol) increase in HbA1c; 95%CI 1.02, 1.36). 2hG (OR 1.55 per SD (0.6 mmol/L) increase; 95%CI 1.26, 1.89) and FG (OR 1.73 per SD (1.6 mmol/L) increase; 95%CI 1.35, 2.21) similarly increased PsA risk (Figure 1). FI was not associated with PsA risk. 2hG was the only glycaemic trait significantly associated with psoriasis (OR 1.21; 95%CI 1.04, 1.40).

Figure 1.

Mendelian randomisation estimates of the effect of glycaemic traits on risk of psoriatic arthritis and psoriasis.

Conclusion

This study provides supportive genetic evidence that impaired glycaemic control increases risk of PsA. By contrast, estimates were smaller when comparing psoriasis against controls with confidence intervals including the null. Improving glycaemic control may reduce PsA risk, although further studies are required to confirm these findings and to compare PsA directly against cutaneous only psoriasis.

References

[1]Solomon et al. The Risk of Diabetes Among Patients with Rheumatoid Arthritis, Psoriatic Arthritis, and Psoriasis. Ann Rheum Dis 2010;69:21147-7.

[2]Tabák et al. Prediabetes: A high-risk state for developing diabetes. Lancet 2012;379:2279-90.

[3]Sakaue et al. A cross-population atlas of genetic associations for 220 human phenotypes. Nature Genetics 2021;53:1415-24.

Acknowledgements

This work was supported by Versus Arthritis (grant number 21173, grant number 21754 and grant number 21755).

Disclosure of Interests

None declared

POS0509 DEVELOPMENT OF A MULITNOMIAL PREDICTION MODEL OF TREATMENT RESPONSE TO ETANERCEPT IN A MULTI-CENTRE COHORT OF PATIENTS WITH ESTABLISHED RA

Background

Treatment response in rheumatoid arthritis (RA) is assessed through EULAR response groups of good, moderate, and poor response. Clinical prediction models from the literature typically frame this as a binary model, to differentiate poor from good and moderate responders. Here, we develop a multinomial model, to predict each group separately, after 3 months on the anti-TNF drug Etanercept (ETN).

Objectives

Develop and validate a multinomial prediction model of treatment response to ETN in RA, based on baseline clinical covariates.

Methods

We identified patients treated with ETN or biosimilars (N = 778) from the Biologics in RA Genetics and Genomics Study Syndicate (BRAGGSS). Response groups were derived from the CRP based 4C-DAS28 at baseline and 3 month follow up, yielding 310 good, 320 moderate, and 148 poor responders. A multinomial logistic regression model was fitted, using good responders as reference category. Multiple imputation by chained equations was used to impute missing data, and models were internally validated via bootstrapping. We report model accuracy, as well as calibration, and compare effect sizes across response groups. Table 1shows the baseline statistics, and odds ratios for the included covariates.

Table 1.

Baseline covariate statistics and odds ratios (in bold: significant at p < 0.05); HADS: Hospital Anxiety and Depression Scale

VariableMean (± SD)ORModerate [95% CI]pORPoor [95% CI]por % YesSwollen Joint8.84450.980.350.948e-3Count (SJC)(± 5.20)[0.95 1.02][0.89 0.98]Tender Joint14.68771.076e-61.050.01Count (TJC)(± 6.74)[1.04 1.10][1.01 1.08]General Health74.74291.000.60.981e-3Visual Analog Scale (GHVAS)(±17.79)[0.99 1.01][0.97 0.99]CRP19.07391.000.220.990.26(±25.07)[1.00 1.01][0.98 1.00]BMI30.30351.000.481.000.41(±23.28)[0.99 1.01][0.99 1.01]Age of47.33301.010.121.020.06onset(±13.86)[1.00 1.03][1.00 1.04]Disease9.94011.000.840.990.45duration(±10.35)[0.98 1.02][0.96 1.02]HAQ1.60851.480.022.951e-6(± 0.65)[1.06 2.08][1.91 4.54]HADS-Anxiety8.08681.040.191.060.12(± 4.54)[0.98 1.10][0.99 1.13]HADS-Depression7.38411.060.120.970.55(± 4.02)[0.99 1.13][0.89 1.06]Concurrent81.49%0.412e-40.520.03DMARD[0.26 0.66][0.28 0.94]Female78.66%1.390.121.110.71[0.92 2.10][0.65 1.87]Seropositive77.89%0.540.020.470.01[0.33 0.89][0.26 0.86]1st Biologic90.62%1.060.860.480.03[0.55 2.06][0.24 0.94]

Results

Adjusted for optimism, the multinomial model achieves an accuracy of 50.7% (IQR: 50 – 51.3%), with calibration slopes of 0.574 (IQR: 0.569 - 0.579) and 0.534 (IQR: 0.525 - 0.544) for moderate and poor response, respectively. Figure 1 shows a comparison of odds ratios (OR) for the different outcome groups. The Health Assessment Questionnaire (HAQ) score is the biggest driver of both moderate and poor response. Previous biologic treatment also predicts poor but not moderate response. Compared to the multinomial model, a binary model, that discriminates poor from moderate and good responders, underestimates the effect size of HAQ.

Figure 1.

Odds ratios of FIRSTBIO and HAQ for moderate and poor response. Size of crosses indicate 95% confidence intervals.

Conclusion

The model predicts EULAR response groups moderately well but is poorly calibrated, which can partly be explained by the generally higher sample size requirement of multinomial modelling. In the multinomial model, moderate and poor response is largely driven by the same covariates, which leads to blurred boundaries between good and poor responders, when response groups are merged to create a binary problem. Future research should consider the most appropriate model choice to describe data, including the use of multinomial instead of binomial models. More research and bigger sample sizes are required to improve on this multinomial model.

Disclosure of Interests

Michael Stadler: None declared, Stephanie Ling: None declared, Nisha Nair: None declared, John Isaacs Speakers bureau: Abbvie, Gilead, Roche, UCB, Grant/research support from: GSK, Janssen, Pfizer, Kimme Hyrich Speakers bureau: Abbvie, Grant/research support from: Pfizer and BMS, Ann Morgan Speakers bureau: Roche/ Chuga, Consultant of: GSK, Roche, Chugai, AstraZeneka, Regeneron, Sanofi, Vifor, Grant/research support from: Roche, Kiniksa Pharmaceuticals, Anthony G Wilson: None declared, Darren Plant: None declared, John Bowes: None declared, Anne Barton Grant/research support from: Pfizer, Galapagos, Scipher Medicine, and Bristol Myers Squibb.

AB0337 BASELINE C-REACTIVE PROTEIN PREDICTS ADHERENCE TO ADALIMUMAB THERAPY AT 3 MONTHS IN AN OBSERVATIONAL COHORT OF PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Adherence to biologic treatment in rheumatoid arthritis (RA) is often self-reported and little is known about the predictors of adherence to biologic medications. Many studies have reported the predictors of adherence to be linked to psychological factors. A systematic review [1] identified several predictors of adherence to methotrexate in RA patients with the strongest predictors related to psychological factors including beliefs in medication necessity and absence of low mood. Mild disease activity was also found to be a significant predictor of adherence from this study. It is unknown whether similar factors will predict adherence in an established cohort of patients with RA starting biologic therapy.

Objectives

To investigate levels of self-reported adherence to adalimumab treatment and identify the contribution of demographic, physical and psychological factors to medication adherence in an RA cohort.

Methods

Patients with RA who were commencing on adalimumab were recruited through the Biologics in Rheumatoid Arthritis Genetics and Genomics Study Syndicate (BRAGGSS), a large UK multicentre prospective observational cohort study. Demographics, baseline clinical and psychological measures including illness and medication beliefs were collected. Self-reported adherence, defined as the patient has never stopped, altered, missed, forgot to take, or took a lower dose than prescribed of adalimumab, were recorded at 3 months. Potential baseline predictors of adherence to adalimumab therapy were determined using logistic regression analyses.

Results

202 patients were included; 76% female, median (IQR): age 59 (52-67) years, pre-treatment DAS28-CRP score 5.6 (5.1-6.1) and disease duration 5 (2-15) years. During the first 3 months following commencement of adalimumab, 176 (87%) patients reported full adherence. Univariable analyses found that high baseline C-reactive protein (CRP) [odds ratio (OR) 1.04 per mg/L, 95% CI 1.01, 1.09] was associated with adherence to adalimumab at 3 months. However, there were no associations identified from the psychological variables and this includes perceived necessity towards medication [OR 0.92, 95% CI 0.79, 1.05], hospital depression score [OR 0.94, 95% CI 0.84, 1.06] and hospital anxiety score [OR 0.97, 95% CI 0.88, 1.08].

Conclusion

These findings suggest that the psychological measures were less able to predict adherence to adalimumab therapy. The high percentage of adherence during the first three months of therapy may limit power to detect small effects in this cohort. Further research to investigate whether psychological variables correlate with drug levels as an alternative surrogate for adherence and to consider including other biological agents with a longer follow-up timeline are needed.

High baseline CRP levels were associated with adherence. This finding suggests active disease with higher levels of inflammation in RA may be a factor for adherence in patients who are commencing biologic therapy.

References

[1]Hope, H. F., Bluett, J., Barton, A., Hyrich, K. L., Cordingley, L., & Verstappen, S. M. M. (2016). Psychological factors predict adherence to methotrexate in rheumatoid arthritis; findings from a systematic review of rates, predictors and associations with patient-reported and clinical outcomes. RMD Open, 2(1), e000171. https://doi.org/10.1136/rmdopen-2015-000171

Disclosure of Interests

Adlan Wafi Ramli: None declared, Nisha Nair: None declared, Kimme Hyrich Consultant of: AbbVie, Grant/research support from: Pfizer, BMS, John Isaacs Speakers bureau: Abbvie, Gilead, Roche, UCB, Grant/research support from: GSK, Janssen, Pfizer, Ann Morgan Speakers bureau: Roche/Chugai, Consultant of: GSK, Roche, Chugai, AstraZeneca, Regeneron, Sanofi, Vifor, Grant/research support from: Roche, Kiniksa Pharmaceuticals, Darren Plant: None declared, Anthony G Wilson: None declared, Anne Barton Grant/research support from: I have received grant funding from Pfizer, Galapagos, Scipher Medicine and Bristol Myers Squibb.

OP0109 EXPRESSION QUANTITATIVE TRAIT LOCI IN EARLY TREATMENT-NAÏVE RHEUMATOID ARTHRITIS

Background

To date more than 100 genetic loci have been associated with rheumatoid arthritis (RA), particularly in the human leukocyte antigen (HLA) region. Our understanding of the functional consequences of genetic variation in RA causality, however, is limited and it has been shown that a substantial portion of complex disease risk alleles modify gene expression in a cell-specific manner [1]. The Pathobiology of Early Arthritis Cohort (PEAC) is a longitudinal study looking at treatment-naiv̈e RA patients with genotyped data as well as both synovial and blood RNA-sequenced biopsies prior to treatment with disease modifying anti-rheumatic drugs (DMARDs).

Objectives

To explore expression quantitative trait loci (eQTL) in synovium and blood within PEAC and characterise the effects of genetic variation on gene expression measured by RNA-sequencing. A further goal was to investigate the role of these variants in RA disease severity and response variables.

Methods

Genotypes were generated by Illumina Human CoreExome-24 version 1-0 array in 118 RA patients. Single nucleotide polymorphisms (SNPs) in the HLA region were imputed using HLA-TAPAS. A candidate gene study was performed on variants within the HLA region using Plink v2.0. Synovial (n=85) and blood (n=51) RNA-sequenced samples then underwent cis-eQTL analysis (loci within ±5x105Mb of the variant) based on linear regression models with the matrixeQTL R package using PEER [2] and PCA eigenvectors as covariates. Differences in eQTL between tissues were determined using a linear interaction term.

Results

The candidate gene study determined several amino acids around HLA-DRB1 acting as markers for seropositivity, which replicated findings by Raychaudhuri et. al. [3]. Using eQTL analysis, around 33,000 synovial SNPs were found with genome-wide significance (p ≤ 5x10-8) and around 29,000 in blood. This corresponded to 279 unique significant genes in synovium and 417 in blood (Figure 1). There were 100 genes common to both synovium and blood, including PSORS1C3, HLA-DRB9 and ERAP2, which have known associations with autoimmune diseases and inflammatory arthritis. Notably, 92 genes showed significantly different patterns of QTL expression between synovial tissue and blood (p ≤ 5x10-8). eQTL data also confirmed the triad of genetic variants significantly driving tissue gene expression of HLA-DPB2, while both HLA-DPB2 SNPs and HLA-DPB2 RNA-sequencing synovial expression correlated highly with erythrocyte sedimentation rate (ESR).

Figure 1.

Manhattan plots for cis-expression quantitative trait loci (eQTL) analysis performed on 85 synovial samples (top) and 51 blood samples (middle). Tissue interaction eQTL (bottom) show significant differences between tissues (p ≤ 5x10-8).

Conclusion

The high significance of genes in the HLA region in both tissues is in-keeping with the strong association between HLA and susceptibility to RA, as well as other autoimmune diseases. Most notably variants linked to HLA-DPB2 synovial expression were found to be a marker for disease severity through ESR association. Additionally, the significant differences between eQTL in blood and synovium highlight the need to explore functional consequences of genetic associations in the diseased tissue directly.

References

[1]Thalayasingam et. al. (2018). CD4+ and B lymphocyte expression quantitative traits at rheumatoid arthritis risk loci in patients with untreated early arthritis: implications for causal gene identification. Arthritis & Rheumatology, 70(3), 361-370.

[2]Stegle et al. (2012). Using probabilistic estimation of expression residuals (PEER) to obtain increased power and interpretability of gene expression analyses. Nature protocols, 7(3), 500-507.

[3]Raychaudhuri et al. (2012). Five amino acids in three HLA proteins explain most of the association between MHC and seropositive rheumatoid arthritis. Nature genetics, 44(3), 291-296.

Disclosure of Interests

None declared

OP0190 COMPREHENSIVE GENETIC AND FUNCTIONAL ANALYSES OF Fc GAMMA RECEPTORS EXPLAIN RESPONSE TO RITUXIMAB THERAPY FOR AUTOIMMUNE RHEUMATIC DISEASES

Background

Rituximab is widely used to treat rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) but clinical response varies. Efficacy is determined by the efficiency of depletion, which may depend on a variety of Fc gamma receptor (FcγR)-dependent mechanisms. Previous research was limited by complexity of the FCGR locus, not integrating copy number variation with functional SNP, and small sample size.

Objectives

The study objectives were to assess the effect of the full range of FcγRs variants on depletion, clinical response and functional effect on NK-cell-mediated killing in two rheumatic diseases with a view to personalised B-cell depleting therapies.

Methods

A prospective longitudinal cohort study was conducted in 873 patients [RA=611; SLE=262] from four cohorts (BSRBR-RA and BILAG-BR registries, Leeds RA and Leeds SLE Biologics). For RA, the outcome measures were 3C-DAS28CRP and 2C-DAS28CRP at 6 (+/-3) months post-rituximab (adjusted for baseline DAS28). For SLE, major clinical response (MCR) was defined as improvement of active BILAG-2004 domains to grade C/better at 6 months. B-cell depletion was evaluated by highly-sensitive flow cytometry. Qualitative and quantitative polymorphisms for five major FcγRs were measured using a commercial multiplex ligation-dependent probe amplification. Median NK cell FcγRIIIa expression (CD3-CD56+CD16+) and NK-cell degranulation (CD107a) in the presence of rituximab-coated Daudi/Raji B-cell lines were assessed using flow cytometry.

Results

In RA, for FCGR3A, carriage of V allele (coefficient -0.25 (SE 0.11); p=0.02) and increased copies of V allele (-0.20 (0.09); p=0.02) were associated with greater 2C-DAS28 response. Irrespective of FCGR3A genotype, increased gene copies were associated with a better response. In SLE, 177/262 (67.6%) achieved BILAG response [MCR=34.4%; Partial=33.2%]. MCR was associated with increased copies of FCGR3A-158V allele, OR 1.64 (95% CI 1.12-2.41) and FCGR2C-ORF allele 1.93 (1.09-3.40). Of patients with B-cells data in the combined cohort, 236/413 (57%) achieved complete depletion post-rituximab. Only homozygosity for FCGR3A-158V and increased FCGR3A-158V copy number were associated with increased odds of complete depletion. Patients with complete depletion had higher NK cell FcγRIIIa expression at rituximab initiation than those with incomplete depletion (p=0.04) and this higher expression was associated with improved EULAR response in RA. Moreover, for FCGR3A, degranulation activity was increased in V allele carriers vs FF genotype in the combined cohort; p=0.02.

Conclusion

FcγRIIIa is the major low affinity FcγR and increased copies of the FCGR3A-158V allele, encoding the allotype with a higher affinity for IgG1, was associated with clinical and biological responses to rituximab in two autoimmune diseases. This was supported by functional data on NK cell-mediated cytotoxicity. In SLE, increased copies of the FCGR2C-ORF allele was also associated with improved response. Our findings indicate that enhancing FcγR-effector functions could improve the next generation of CD20-depleting therapies and genotyping could stratify patients for optimal treatment protocols.

References

None

Acknowledgements

This research was funded/supported by the joint funding from the Medical Research Council (MRC) and Versus Arthritis of MATURA (grant codes 36661 and MR/K015346/1). MASTERPLANS was funded by the MRC (grant code MR/M01665X/1). The Leeds Biologics Cohort was part funded by programme grants from Versus Arthritis (grant codes 18475 and 18387), the National Institute for Health Research (NIHR) Leeds Biomedical Research Centre (BRC) and Diagnostic Evaluation Co-operative and the Ann Wilks Charitable Foundation. The BILAG-BR has received funding support from Lupus UK, and unrestricted grants from Roche and GSK.

The functional studies were in part supported through a NIHR/HEFCE Clinical Senior Lectureship and a Versus Arthritis Foundation Fellowship (grant code 19764) to AWM, the Wellcome Trust Institutional Strategic Support Fund to JIR and MYMY (204825/Z/16/Z), NIHR Doctoral Research Fellowship to MYMY (DRF-2014-07-155) and NIHR Clinician Scientist to EMV (CS-2013-13-032). . AWM, INB, JDI and PE were supported by NIHR Senior Investigator awards. Work in JDI’s laboratory is supported by the NIHR Newcastle BRC, the Research Into Inflammatory Arthritis Centre Versus Arthritis, and Rheuma Tolerance for Cure (European Union Innovative Medicines Initiative 2, grant number 777357). INB is funded by the NIHR Manchester BRC.

This article/paper/report presents independent research funded/supported by the NIHR Leeds BRC and the NIHR Guy’s and St Thomas’ BRC. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Disclosure of Interests

Md Yuzaiful Md Yusof: None declared, James Robinson: None declared, Vinny Davies: None declared, Dawn Wild: None declared, Michael Morgan: None declared, John Taylor: None declared, Yasser El-Sherbiny: None declared, David Morris: None declared, Lu Liu: None declared, Andrew Rawstron: None declared, Maya H Buch: None declared, Darren Plant: None declared, Heather Cordell: None declared, John Isaacs: None declared, Ian N. Bruce: None declared, Paul Emery Speakers bureau: Roche, Consultant of: Roche, Grant/research support from: Roche, Anne Barton: None declared, Timothy Vyse: None declared, Jennifer Barrett: None declared, Edward Vital Consultant of: Roche, Grant/research support from: Roche, Ann Morgan Speakers bureau: Roche/Chugai, Consultant of: GSK, Roche, Chugai, AstraZeneka, Regeneron, Sanofi, Vifor, Grant/research support from: Roche, Kiniksa Pharmaceuticals

Evaluation of the effect of tongue ties on stress parameters, behaviour and heart-rate variability in racehorses

Fixation of the tongue to the mandible using so-called tongue ties (TTs) is common practice in Standardbred (SB) and Thoroughbred (TB) racing, but little is known about their impact on animal welfare. In this study, the influence of TTs on heart-rate variability (HRV), stress parameters in plasma (cortisol, glucose, lactate) and behaviour was evaluated in 30 SBs and 29 TBs (n = 59) presenting with exercise insufficiency. Overall, 36/59 horses (24 SBs, 12 TBs) were familiar with TTs. Blood was taken at rest, after TT application and after racing in all horses, additionally samples were taken without TT in SBs another day. HRV was calculated over 3 min before, during and after racing. Additionally, SBs' behaviour during TT application and racing was documented in real time. TT application did not increase cortisol levels significantly, while highly significant increases in cortisol levels were found after racing. Lactate levels were not influenced by TT application, but also significantly increased after racing. No significant differences were found for glucose. Seventeen out of 30 SBs showed mild (n = 8), moderate (n = 8) and severe (n = 1) reactions during TT application, none during or after race training. At rest, 23/30 SBs had a low/high frequency (LF/HF) ratio < 1.5 (1.05 [± 0.61], n = 30, dominating parasympathetic activity). After TT application, the LF/HF ratio increased to 1.4 (± 0.45) (increased sympathetic activity). In TBs, sympathetic activity dominated at rest. No differences in LF, HF and LF/HF were found after TT application or comparing HRV after racing with/without TT. The stress response (blood parameters and HRV) was not influenced by horses' naivety to TTs, however an increased stress response was observed in SB mares. Overall, obvious adverse behaviour, but only slight evidence of an increased systemic stress response, was found in this study. These results might provide objective evidence for future decisions from equine sports organisations concerning further regulations on TTs.

POS0348 GENETIC SUSCEPTIBILITY VARIANTS FOR RHEUMATOID ARTHRITIS ARE NOT ASSOCIATED WITH EARLY REMISSION; A MULTI-COHORT STUDY

Background:

Patients who achieve remission promptly could have a specific genetic risk profile that supports regaining immune tolerance. The identification of these genes could provide novel drug targets.

Objectives:

To test the association between RA genetic risk variants with achieving remission at 6 months.

Methods:

We computed genetic risk scores (GRS) comprising of the RA susceptibility variants1 and HLA-SE status separately in 4425 patients across eight datasets from inception cohorts. Remission was defined as DAS28CRP<2.6 at 6 months. Missing DAS28CRP values in patients were imputed using predictive mean matching by MICE. We first tested whether baseline DAS28CRP changed with increasing GRS using linear regression. Next, we calculated odds ratios for GRS and HLA-SE on remission using logistic regression. Heterogeneity of the outcome between datasets was mitigated by running inverse variance meta-analysis.

Results:

Evaluation of the complete dataset, baseline clinical variables did not differ between patients achieving remission and those who did not (Table 1). Distribution of GRS was consistent between datasets. Neither GRS nor HLA-SE was associated with baseline DAS2DAS (OR1.01; 95% CI 0.99-1.04). A fixed effect meta-analysis (Figure 1.) showed no significant effect of the GRS (OR 0.99; 95% CI 0.94-1.03) or HLA-SE (OR 0.8CRP87; 95% CI 0.75-1.01) on remission at 6 months.

Table 1.

Summary of the data separated by disease activity after 6 months.

allRemission at 6 monthsNo remission at 6 monthsN4425*15582430Age, mean (sd)55.38 (13.87)5517 (14.09)55.62 (13.59)Female %68.98%65.43%70.73%ACPA+ %61.94%63.53%61.67%Baseline DAS28, mean (sd)4.76 (1.22)4.47 (1.23)5.1 (1.15)

*not all patients had 6 months data

Conclusion:

In these combined cohorts, RA genetics risk variants are not associated with early disease remission. At baseline there was no difference in genetic risk between patients achieving remission or not. Studies encompassing other genetic variants are needed to elucidate the genetics of RA remission.

References:

[1]Knevel R et al. Sci Transl Med. 2020;12(545):eaay1548.

Acknowledgements:

This project has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 777357, RTCure.

This project has received funding from Pfizer Inc.

Disclosure of Interests:

Samantha Jurado Zapata: None declared, Marc Maurits: None declared, Yann Abraham Employee of: Pfizer, Erik van den Akker: None declared, Anne Barton: None declared, Philip Brown: None declared, Andrew Cope: None declared, Isidoro González-Álvaro: None declared, Carl Goodyear: None declared, Annette van der Helm - van Mil: None declared, Xinli Hu Employee of: Pfizer, Thomas Huizinga: None declared, Martina Johannesson: None declared, Lars Klareskog: None declared, Dennis Lendrem: None declared, Iain McInnes: None declared, Fraser Morton: None declared, Caron Paterson: None declared, Duncan Porter: None declared, Arthur Pratt: None declared, Luis Rodriguez Rodriguez: None declared, Daniela Sieghart: None declared, Paul Studenic: None declared, Suzanne Verstappen: None declared, Leonid Padyukov: None declared, Aaron Winkler Employee of: Pfizer, John D Isaacs: None declared, Rachel Knevel Grant/research support from: Pfizer

POS0357 MiRNAs CORRELATE WITH IMPROVEMENT IN DISEASE ACTIVITY IN PATIENTS WITH RHEUMATOID ARTHRITIS ON TUMOUR NECROSIS FACTOR INHIBITORS

Background:

Tumour necrosis factor inhibitors (TNFi) although effective in the treatment of rheumatoid arthritis (RA), show a variable response rate. Therefore, there is a need to identify treatment response predictors to inform therapy selection in order to practise precision medicine. MicroRNAs (miRNAs) are endogenous, single-stranded, non-coding RNAs that can alter gene expression by regulating messenger RNA translation. There is evidence for miRNA involvement in RA pathogenesis and they may serve as a useful biomarker of treatment response.

Objectives:

To identify miRNAs associated with response to TNFi in RA.

Methods:

Biologic naïve patients were selected from the Biologics in Rheumatoid Arthritis Genetics and Genomics Study Syndicate (BRAGGSS), a prospective multi-center UK study investigating treatment response biomarkers to TNFi with a primary outcome measure of change in DAS28 scores. Patients were stratified into European League Against Rheumatism (EULAR) good or non-responders based on their 3 or 6-month DAS28-CRP score.

Pre-treatment and 3-month post-treatment serum samples were substrates for miRNA profiling, which was conducted by FIRALIS using the HTG EdgeSeq miRNA whole transcriptome V2 targeted sequencing assay. Linear modelling using R package limma compared miRNA expression at (i) pre-treatment and at three-months, in EULAR good-responders and non-responders (ii) longitudinal change in expression from pre-treatment to three-months in EULAR good and non-responders.

A literature search was conducted to identify miRNAs associated with RA as a diagnostic and/or treatment response predictor. Data on these miRNAs were extracted from the miRNAs identified in the serum samples. A correction for multiple testing was applied to statistical tests.

Results:

A total of 54 patients were analysed; of these, 35 (65%) were female, median disease duration [inter-quartile range] was 6 years [2 – 14] (n=51), and 44/51 (86%) patients were on a concomitant disease modifying anti-rheumatic drug. Of the 54 patients, 39 (72%) were classified as EULAR good-responders and 15 (28%) as non-responders. 1880 miRNAs were detected in the serum samples. 64 miRNAs were identified to be associated with RA from the literature, of which, 26 were identified in the serum samples tested.

No difference in pre-treatment or three-month miRNA levels was seen comparing EULAR good-responders and non-responders (FDR p<0.05). There was a significant differential expression of four miRNAs at 3-months in good-responders compared with pre-treatment levels; miR-125a-3p (downregulated, p-value 0.002), miR-149-3p (upregulated, p-value 0.004), miR-766-3p (downregulated, p-value 0.008), miR-146b-5p (upregulated, p-value 0.006). No significant differences were observed between 3-months and baseline in non-responders.

Conclusion:

Although no pre-treatment miRNAs were associated with TNFi response, changes in the levels of four miRNAs were detected at 3-months compared to baseline in EULAR good-responders. Future work involves validation of these samples in a larger patient cohort and analysing miRNA levels at 6 and 12 months. Replication and validation of these results in larger studies are required to analyse the role of miRNAs in stratifying EULAR good-responders from non-responders at three-months, and as treatment response predictors to TNFi in RA.

Acknowledgements:

Joint last-author: Dr. Darren Plant

Disclosure of Interests:

Trixy David: None declared, Nisha Nair: None declared, James Oliver: None declared, Eric Schordan: None declared, Hüseyin Firat: None declared, Kimme Hyrich Consultant of: consultancy/honoraria from AbbVie, Grant/research support from: Pfizer, UCB, BMS, Ann Morgan: None declared, Anthony G Wilson: None declared, John D Isaacs Speakers bureau: consultancy/speaker fees from AbbVie, Gilead, Roche, UCB, Consultant of: consultancy/speaker fees from AbbVie, Gilead, Roche, UCB, Grant/research support from: Pfizer, Darren Plant: None declared, Anne Barton: None declared

POS0471 ASSOCIATION OF HLA-DRB1 HAPLOTYPES WITH CARDIOVASCULAR MORTALITY IN INFLAMMATORY POLYARTHRITIS: RESULTS FROM THE NORFOLK ARTHRITIS REGISTER

Background:

Haplotypes defined by amino acids at HLA-DRB1 positions 11, 71 and 74 associated with susceptibility to rheumatoid arthritis (RA), are associated with radiological outcome, anti-TNF response and all cause-mortality in RA.(1, 2) RA is associated with cardiovascular (CV) morbidity and mortality, but the increased prevalence of risk factors of CV disease in RA only partially explains this association.

Objectives:

The aim was to investigate whether haplotypes associated with RA disease susceptibility and disease severity are also associated with CV mortality.

Methods:

The Norfolk Arthritis register (NOAR) is a primary care-based inception cohort of patients with inflammatory polyarthritis (IP).(1, 2) NOAR patients with at least 2 years of follow-up and available mortality and genetic data were included in this study. Mortality data was provided by the Office for National Statistics.

Univariate Cox proportional hazard models were applied using STATA/IC 14.0. Models for CV mortality were adjusted for CV risk factors selected using stepwise regression: namely obesity, gender and hypertension. Hazard models were applied to the entire cohort of patients with inflammatory polyarthritis (IP). When calculating differences between highest and lowest risk genetic factors, bivariate analysis was used.

Results:

HLA-DRB1 amino acids, haplotypes or haplotype groups associated with RA susceptibility are also associated with CV mortality as shown in the table 1. HLA-DRB1 polymorphisms encoding amino-acid haplotypes associated with an increased or decreased susceptibility to RA consistently show the same magnitude and direction of association for overall and CV mortality in IP. For example, the SEA-haplotype, associated with the lowest susceptibility to RA, and the best radiographic outcome, was found to be associated with decreased CV mortality (HR 0.67, 95% CI 0.47, 0.91, p=0.023). The relative difference in CV mortality between carriers of the high susceptibility VKA haplotype and carriers of the SEA haplotype was significant (HR 1.67, 95% CI 1.13, 2.48, p=0.01).

Table 1.

Hazard ratios for CV mortality by genetic factors among patients with IP. Total number (n) of deaths are also displayed alongside the total number (n) of patients included in each analysis.

Amino acid / Haplotype /GroupHazard Ratio (95% CI)Nvaline 111.10 (0.93, 1.30)343 (2514)serine 110.82 (0.70, 0.96)*343 (2514)Difference1.23 (1.01, 1.49)*VKA haplotype1.16 (0.94, 1.43)310 (2328)SEA haplotype0.67 (0.47, 0.94) *310 (2328)Difference1.67 (1.13, 2.48)*Group 1 †1.10 (0.93, 1.31)319 (2328)Group 4 †0.73 (0.60, 0.89)*319 (2328)Difference1.37 (1.09, 1.72)*

* p<0.05

†Haplotype groups as defined previously (2)

HLA-DRB1 haplotypes can be ranked according to the magnitude of their association with RA susceptibility and this hierarchy is conserved for various measures of disease outcome and overall mortality.(2, 3) The figure 1 shows that this risk hierarchy is also conserved for CV mortality: HLA-DRB1 haplotypes that predispose to RA also predispose to increased CV mortality, independent of known CV risk factors.

Figure 1.

Haplotypes with frequency >12% in NOAR are shown. X axis: susceptibility to ACPA-positive RA as ORs.(2) Y axis: CV mortality risk in IP as HRs, derived from multi-variate cox-proportional hazard models adjusted for CV risk factors. Values are on a logarithmic scale. A one-tailed p value was calculated using linear regression to determine the association between β coefficients of susceptibility and CV mortality.

Conclusion:

The originally reported genetic associations between HLA-DRB1 polymorphisms and overall mortality were likely driven by associations with CV mortality.

References:

[1]S. Viatte et al., JAMA313, 1645-1656 (2015).

[2]S. Raychaudhuri et al., Nat Genet44, 291-296 (2012).

[3]D. P. Symmons, A. J. Silman, Clin Exp Rheumatol21, S94-99 (2003).

Disclosure of Interests:

None declared

Balance Right in Multiple Sclerosis (BRiMS): a feasibility randomised controlled trial of a falls prevention programme

Background

Balance, mobility impairments and falls are problematic for people with multiple sclerosis (MS). The “Balance Right in MS (BRiMS)” intervention, a 13-week home and group-based exercise and education programme, aims to improve balance and minimise falls. This study aimed to evaluate the feasibility of undertaking a multi-centre randomised controlled trial and to collect the necessary data to design a definitive trial.

Methods

This randomised controlled feasibility study recruited from four United Kingdom NHS clinical neurology services. Patients ≥ 18 years with secondary progressive MS (Expanded Disability Status Scale 4 to 7) reporting more than two falls in the preceding 6 months were recruited. Participants were block-randomised to either a manualised 13-week education and exercise programme (BRiMS) plus usual care, or usual care alone.

Feasibility assessment evaluated recruitment and retention rates, adherence to group assignment and data completeness. Proposed outcomes for the definitive trial (including impact of MS, mobility, quality of life and falls) and economic data were collected at baseline, 13 and 27 weeks, and participants completed daily paper falls diaries.

Results

Fifty-six participants (mean age 59.7 years, 66% female, median EDSS 6.0) were recruited in 5 months; 30 randomised to the intervention group. Ten (18%) participants withdrew, 7 from the intervention group. Two additional participants were lost to follow up at the final assessment point. Completion rates were > 98% for all outcomes apart from the falls diary (return rate 62%).

After adjusting for baseline score, mean intervention—usual care between-group differences for the potential primary outcomes at week 27 were MS Walking Scale-12v2: − 7.7 (95% confidence interval [CI] − 17.2 to 1.8) and MS Impact Scale-29v2: physical 0.6 (CI − 7.8 to 9), psychological − 0.4 (CI − 9.9 to 9). In total, 715 falls were reported, rate ratio (intervention:usual care) for falls 0.81 (0.41 to 2.26) and injurious falls 0.44 (0.41 to 2.23).

Conclusions

Procedures were practical, and retention, programme engagement and outcome completion rates satisfied a priori progression criteria. Challenges were experienced in completion and return of daily falls diaries. Refinement of methods for reporting falls is therefore required, but we consider a full trial to be feasible.

Trial registration

ISRCTN13587999

Date of registration: 29 September 2016

SAT0038 CHANGES IN ILLNESS PERCEPTIONS IN PEOPLE WITH RHEUMATOID ARTHRITIS OVER THE FIRST YEAR OF TREATMENT WITH METHOTREXATE

Background:

Illness perceptions at treatment onset are known to be important predictors of treatment response in rheumatoid arthritis (RA). Yet it is unknown how these perceptions change over time after the initiation of treatment, or which factors are associated with changing perceptions.

Objectives:

To identify groups of patients with early RA who have similar changes in illness perceptions over the first year following treatment, and assess predictors of these changes.

Methods:

Patients starting methotrexate (MTX) for the first time were recruited to the Rheumatoid Arthritis Medication Study (RAMS), a one-year prospective cohort. The DAS28 was calculated and patients completed a questionnaire at baseline and 12 months, reporting demographics and completing the HAQ, the Hospital Anxiety and Depression Scale (HADS), pain and fatigue visual analogue scales (VAS) and the Brief Illness Perception Questionnaire (B-IPQ). The B-IPQ consists of eight Likert scales: five represent cognitive illness perceptions (B-IPQ1-5), two represent emotional representations (B-IPQ6 & 8) and one represents illness comprehensibility (B-IPQ7). Change in illness perceptions and EULAR response were calculated over 12 months in those with data at both timepoints. Latent profile analysis was used to identify profiles of patients with similar changes in illness perceptions. Candidate predictors of profile membership were assessed using logistic regression. The association between profile and EULAR response was assessed using ordered logistic regression.

Results:

In total 1188 patients were included (mean [SD] age: 59.8 [12.7], 781 [65.7%] women). On average, illness perceptions for the whole cohort improved over 12 months, other than patients’ perception of longevity of arthritis (B-IPQ2) and of treatment helpfulness (B-IPQ4). Three profiles were identified: Small Improvers (N=900), Small Deteriorators (N=78) and Large Improvers (N=210) (Figure). Small Improvers improved on all B-IPQ items other than their perception of longevity of arthritis (B-IPQ2) and of treatment helpfulness (B-IPQ4). All B-IPQ items improved in the Large Improvers group to a greater extent than the Small Improvers, other than arthritis longevity (B-IPQ2). The perceptions of Small Deteriorators all worsened, other than arthritis comprehensibility (B-IPQ7). Higher baseline pain was associated with greater odds of being in both the Small Deteriorators and Large Improvers compared to Small Improvers (Small Deteriorators: OR 1.56 per standard deviation (SD) increase in pain [95% CI 1.11, 2.18]; Large Improvers: OR 1.46 per SD increase in pain [95% CI 1.15, 1.85]). Odds of better EULAR response were greater in the Large Improvers (OR 4.37 [95% CI 3.01, 6.33]) and worse in the Small Deteriorators (OR 0.50 [95% CI 0.29, 0.87]) compared to Small Improvers.

Conclusion:

In general, illness perceptions improved over the first year of MTX treatment and improvements were associated with better treatment response. Worsening illness perceptions may be driven by poor treatment response. These poor illness perceptions at follow-up may compound poor treatment response in the future. Greater understanding of patients’ initial and subsequent illness perceptions is crucial, given the association with treatment response.

Figure:

Disclosure of Interests:

James Gwinnutt Grant/research support from: BMS, Sam Norton: None declared, Kimme Hyrich Grant/research support from: Pfizer, UCB, BMS, Speakers bureau: Abbvie, Mark Lunt: None declared, Anne Barton Consultant of: AbbVie, Lis Cordingley Grant/research support from: Unrestricted award from Pfizer unrelated to current abstract, Speakers bureau: Janssen, AbbVie, Celgene, Sanofi, Eli Lilly, Novartis all unrelated to current abstract, Suzanne Verstappen Grant/research support from: BMS, Consultant of: Celltrion, Speakers bureau: Pfizer

OP0127 TRANSCRIPTIONAL ACTIVITY OF SURVIVIN CONTRIBUTES TO MATURATION AND FUNCTION OF THE INTERFERON-GAMMA PRODUCING T CELLS IN RHEUMATOID ARTHRITIS

Background:

Interferon gamma (IFNg) signalling and downstream effects make important contribution in pathogenesis of rheumatoid arthritis (RA). Here, we propose a mechanism by which oncoprotein survivin participates in development of IFN-dependent repertoire of T cells in RA patients.

Objectives:

We study the role of survivin in the phenotype of CD4 T cells of RA patients.

Methods:

CD4 cells of RA patients and healthy controls were purified from blood, activated and subjected to RNAseq, ChIPseq with antibodies to survivin (BIRC5) was performed on CD4+ cells. Histone H3 ChIPseq was performed using antibodies to H3K27ac, H3K27me3 and H3K4me3. Statistical analysis was performed In R-studio using the Bioconductor package DESeq2, clustering using Spearman and Ward.D2.

Results:

Unsupervised clustering of CD4 samples by expression of 48 core Th cell markers identified subsets of CD28hiCD27hiIFNnegcentral memory cells (Tcm), CD28loCD27loIFNloeffector memory cells (Tem) and CD28nullCD27nullIFNhiterminal effector cells (Tte). Tte cells showed classical features of Th1 cells including high levels of TBX21, TNFa and IL32 and signs of activation in IFN signalling machinery. Interestingly, they combined the features of peripheral Tregs CD25hiFoxp3hiIKZF2negand IL10 producing cells together with type 1 regulatory cells, which rely on transcription factors BATF and IRF1 for the differentiation and produced high amounts of perforin and granzyme B. Importantly, Tte CD4 cells had also high transcription of BIRC5 (p=1.15e-18).

To study if BIRC5 is a part of IFN signalling, CD4 cells were cultured with survivin inhibitor YM155 and activated with IFNg. RNAseq analysis revealed 2033 (FC<2.0, n=336) differentially expressed genes in the IFN stimulated cultures. Interestingly, a substantial number of these IFN-dependent genes was significantly reduced in the survivin-deficient cultures and included among others CD28, FoxP3, IKZF2, ICOS, BATF, PRDM1, CXCR3, IRF4 and IRF8. Analysis of the peak sequences identified enrichment for composite motifs for IRFs (ETS:IRF, p1.0e-124; bZIP:IRF, p=1.0e-640), indicating that survivin is important for IFNg signalling. Numerically, the peaks containing ETS:IRF motifs were most prevalent and identified in total within 49.7% of all survivin-ChIP peaks. Frequent was co-localisation of the IRF:bZIP and IRF:ETS motifs within the survivin peaks. Among the IRF motifs dominated those suitable for IRF1 (p=1,0e-127) and IRF8 (p=1,0e-84). However, the DNA binding motifs of these two are alike.

Encouraged by the survivin ChIPseq results, we wanted to know its relation to histone marks. We observed that 50% of survivin peaks containing both IRF:bZIP and IRF:ETS motifs are co-localized with the H3K27ac marks. In total, 16 of 48 core Th cell markers used for patients clustering were identified by survivin ChIPseq, co-localized with IRF composite motifs and histone marks. They were also dependent of survivin for expression.

Conclusion:

his study showed that survivin binds to DNA and regulates the core gene expression contributing to maturation and function of the IFNg producing Th1 cells.

References:

-

Disclosure of Interests:

Malin Erlandsson: None declared, Karin ME Andersson: None declared, Nisha Nair: None declared, Anastasius Damdimopoulos: None declared, Sofia Töyrä Silfverswärd: None declared, Rille Pullerits: None declared, Anne Barton Consultant of: AbbVie, Maria I Bokarewa: None declared

THU0005 VARIABILITY OF DNA METHYLATION IS A DRIVER OF LYMPHOCYTE DYSREGULATION IN EARLY RHEUMATOID ARTHRITIS

Background:

DNA methylation patterns differ between leukocyte subsets and mediate the impact of environmental exposures on the molecular and functional phenotype of immune cells. Besides differences in mean methylation of CpG positions amongst patients with immune mediated diseases, recent evidence indicates variability of site-specific DNA methylation also contributes to pathogenesis1,2.

Objectives:

To seek evidence of altered DNA methylation patterns in RA, controlling for systemic inflammation and immunotherapy use.

Methods:

Patients with confirmed clinical diagnoses were enrolled from the Northeast Early Arthritis Cohort (NEAC). CD4+and CD19+lymphocytes were isolated from fresh blood by positive selection prior to therapeutic immune modulation. Methylation was quantified in cell subset-specific DNA (Infinium MethylationEPIC BeadChip, Illumina)3. Differentially methylated positions and regions (DMPs, DMRs) between RA and non-RA patients were identified (linear modelling, filtering on 5% pairwise difference in mean DNA methylation, and DMRcate package). Next, to identify instances where methylation variance differed between comparator groups, Bartlett’s test was performed using the iEVORA package, which accounts for outlier values4. Findings were controlled for technical confounders and subject to multiple test correction (FDR). A validated hypergeometric test was used to annotate enriched pathways.

Results:

After sample- and probe-level quality control, CD4+ and B lymphocyte specific data were respectively available for 45 and 49 RA patients, and 64 and 81 disease controls matched for systemic inflammation (CRP, ESR). No DMPs were identified in either cell type at FDR < 0.05 and Δβ ≥0.05. Only following relaxation of multiple test correction was it possible to identify DMRs in either cell type, most notably encapsulating 10 CpGs relatively hypomethylated at the promoter of the endosome protein-encodingRUFY1gene in CD4+ lymphocytes of RA patients (Δβ = 0.076). By contrast, striking evidence for differential variation in DNA methylation was observed at 291 and 601 CpGs of CD4+ and B lymphocytes, respectively (exemplars depicted in Figure 1). Only 15 of these differentially variable positions (DVPs) were common to both cell types. Pathway analysis highlighted potential functional consequences of DVP associations; for example, RA-specific hypervariability implicates prostaglandinsignalling in CD4+ lymphocytes.

Conclusion:

We highlight a role for altered variability in DNA methylation during the molecular pathogenesis of RA, and emphasise the importance of its study in relevant cell subsets.

References:

[1]Paul DSet al. Nature Communications 7, 13555 doi: 10.1038/ncomms13555 (2016).

[2]Webster AP et al. Genome Medicine 10, 64 (2018)doi:10.1186/s13073-018-0575-9.

[3]Clark AD et al. Journal of Allergy and Clinical Immunology 2019; doi: 10.1016/j.jaci.2019.12.910

[4]Teschendorff AE et al. Nature Communications 2016; 7:12.

Disclosure of Interests:

Alexander Clark: None declared, Najib Naamane: None declared, Nisha Nair: None declared, Amy Anderson: None declared, Nishanthi Thalayasingam: None declared, Julie Diboll: None declared, Anne Barton Consultant of: AbbVie, Stephen Eyre: None declared, John D Isaacs Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Gilead, Janssen, Merck, Pfizer, Roche, Louise Reynard: None declared, Arthur Pratt Grant/research support from: Pfizer, GlaxoSmithKlein

THU0022 DIFFERENTIAL DNA METHYLATION AS A PREDICTOR OF TOCILIZUMAB RESPONSE IN RHEUMATOID ARTHRITIS PATIENTS

Background:

Tocilizumab (TCZ) is a biological disease-modifying antirheumatic drug that blocks IL-6 signalling and is effective in ameliorating disease activity in rheumatoid arthritis (RA). However, approximately 50% of patients do not respond adequately to TCZ and some patients report adverse events. Considering there is growing evidence that DNA methylation is implicated in RA susceptibility and response to some biologics (1, 2), we investigated DNA methylation as a candidate biomarker for response to TCZ in RA.

Objectives:

To identify differential DNA methylation signatures in whole blood associated with TCZ response in patients with RA.

Methods:

Epigenome-wide DNA methylation patterns were measured using the Infinium EPIC BeadChip (Illumina) in whole blood-derived DNA samples from patients with RA. DNA was extracted from blood samples taken pre-treatment and following 3 months on therapy, and response was determined at 6 months using the Clinical Disease Activity Index (CDAI). Patients who had good response (n=10) or poor response (n=10) to TCZ by 6 months were selected. Samples from secondary poor responders (n=10) (patients who had an improvement of CDAI and were in remission at 3 months, followed by a worsening of CDAI at 6 months) were also analysed. Differentially methylated positions and regions (DMPs/DMRs) were identified using linear regression, adjusting for gender, age, cell composition, smoking status, and glucocorticoid use. Gene Set Enrichment Analysis (GSEA) was used to identify significant pathways associated with response and Functional Epigenetic Module analysis of interactome hotspots in regions of differential methylation.

Results:

20 DMPs were significantly associated with response status at 6 months in the pre-treatment samples. Another 21 DMPs were associated with response in the 3 month samples. Within good responders, 10 DMPs showed significant change in methylation level between pre-treatment and the 3 month samples (unadjusted P-value <10-6). One DMP, cg03121467, was significantly less methylated in good responders compared to poor responders in the pre-treatment samples. This DMP is close toEPB41L4Aand thought to have a role in β–catenin signalling. GSEA of DMRs in non- and secondary non- responders identified histone acetyltransferase pathways and included theKAT2Agene, which is a repressor of NF-κB. Additional analysis of interaction hotspots of differential methylation identified significant interactions withSTAMBPandPTPN12associated with response status.

Conclusion:

These preliminary results provide evidence that DNA methylation patterns may predict response to TCZ. Validation of these findings in other larger data sets is required.

References:

[1]Liu,Y., Aryee,M.J., Padyukov,L., Fallin,M.D., Hesselberg,E., Runarsson,A., Reinius,L., Acevedo,N., Taub,M., Ronninger,M.,et al.(2013) Epigenome-wide association data implicate DNA methylation as an intermediary of genetic risk in rheumatoid arthritis.Nat. Biotechnol.,31, 142–147.

[2]Plant,D., Webster,A., Nair,N., Oliver,J., Smith,S.L., Eyre,S., Hyrich,K.L., Wilson,A.G., Morgan,A.W., Isaacs,J.D.,et al.(2016) Differential Methylation as a Biomarker of Response to Etanercept in Patients With Rheumatoid Arthritis.Arthritis Rheumatol. (Hoboken, N.J.),68, 1353–60.

Disclosure of Interests:

Nisha Nair: None declared, Darren Plant: None declared, John Isaacs Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Gilead, Janssen, Merck, Pfizer, Roche, Ann Morgan Grant/research support from: I have received a grant from Roche Products Ltd to establish a registry for GCA patients treated with tocilizumab., Consultant of: I have undertaken consultancy work for Roche, Chugai, Regeneron, Sanofi and GSK in the area of GCA therapeutics., Speakers bureau: I have presented on tocilizumab therapy for GCA and glucocorticoid toxicity on behalf of Roche products ltd., Kimme Hyrich Grant/research support from: Pfizer, UCB, BMS, Speakers bureau: Abbvie, Anne Barton Consultant of: AbbVie, Anthony G Wilson: None declared

P1652Limited correlation of calculated plasma volume status with invasive right heart pressures in patients with heart failure

Background

Estimated plasma volume (ePV) can be calculated from haematocrit and body weight, and has been shown to correlate with PV measured using 125Iodine labelled human serum albumin. Comparing a patient's ePV to ideal PV (iPV), an estimate of a patient's relative congestion, called PV status (PVS), is possible. Higher PVS is associated with increased mortality in patients with heart failure (HF), and has been proposed as a simple, cheap, and non-invasive way of assessing congestion.

Purpose

Whether PVS is associated with invasively measured markers of congestion is unknown. We calculated PVS in patients with HF who had right heart catheterisation (RHC), and assessed any correlation between PVS and invasive measures of congestion.

Methods

We calculated PVS in consecutive patients who had RHC performed as part of transplant assessment. iPV was calculated as: iPV = c × weight (kg) where c=39 in males and c=40 in females. ePV was calculated using subjects' haematocrit and weight as follows: ePV = (1 − haematocrit) × [a + (b × weight in kg)], where haematocrit is a fraction, a=1530 in males and a=864 in females, and b=41 in males and b=47.9 in females. PVS was calculated as: PVS = PVS = (ePV − iPV) /iPV × 100%. Correlation between PVS and invasive wedge pressure, mean right atrial (RA) pressure, and NTproBNP were made using Pearson correlation.

Results

PV indices and RHC data were available for 61 patients, 43 (71%) were male. Median age was 55 [IQR 48, 58] years. 20 (33%), 24 (39%), and 15 (25%) were NYHA association class II, III, and IV respectively. The median NTproBNP was 1390 [IQR 512, 3612] pg/ml and median ejection fraction was 29 [IQR 20, 35] %. The median PVS was −5.9% (IQR −12.5, −1.6]. Median wedge and mean-RA pressures were 14 [7, 21] and 4 [1, 8] mmHg, respectively. Correlation between mean RA pressure and PVS is shown in the figure. There was no correlation between PVS and mean RA pressure (r=0.12, p=0.34) or wedge pressure (r=0.01, p=0.92). There was a weak correlation between NTproBNP and PVS (r=0.31, p=0.01)

Correlation mean RA pressure and PVS

Conclusion

PVS did not correlate with the invasive measures of congestion, mean RA and wedge pressure, but was weakly correlated with NTproBNP. Although there were limited number of patients in this study, we question the conclusion that PVS is a marker of congestion, and whether it can be used clinically for this purpose.

Alopecia areata is characterized by dysregulation in systemic type 17 and type 2 cytokines, which may contribute to disease-associated psychological morbidity

BACKGROUND

Alopecia areata (AA) is a common autoimmune disease, causing patchy hair loss that can progress to involve the entire scalp (totalis) or body (universalis). CD8⁺ NKG2D⁺ T cells dominate hair follicle pathogenesis, but the specific mechanisms driving hair loss are not fully understood.

OBJECTIVES

To provide a detailed insight into the systemic cytokine signature associated with AA, and to assess the association between cytokines and depression.

METHODS

We conducted multiplex analysis of plasma cytokines from patients with AA, patients with psoriatic arthritis (PsA) and healthy controls. We used the Hospital Anxiety and Depression Scale (HADS) to assess the occurrence of depression and anxiety in our cohort.

RESULTS

Our analysis identified a systemic inflammatory signature associated with AA, characterized by elevated levels of interleukin (IL)-17A, IL-17F, IL-21 and IL-23 indicative of a type 17 immune response. Circulating levels of the type 2 cytokines IL-33, IL-31 and IL-17E (IL-25) were also significantly increased in AA. In comparison with PsA, AA was associated with higher levels of IL-17F, IL-17E and IL-23. We hypothesized that circulating inflammatory cytokines may contribute to wider comorbidities associated with AA. Our assessment of psychiatric comorbidity in AA using HADS scores showed that 18% and 51% of people with AA experienced symptoms of depression and anxiety, respectively. Using linear regression modelling, we identified that levels of IL-22 and IL-17E are positively and significantly associated with depression.

CONCLUSIONS

Our data highlight changes in both type 17 and type 2 cytokines among people with AA, suggesting that complex systemic cytokine profiles may contribute both to the pathogenesis of AA and to the associated depression. What's already known about this topic? NKG2D⁺ CD8⁺ T cells cause hair loss in alopecia areata (AA) but the immunological mechanisms underlying the disease are not fully understood. AA is associated with changes in levels of interleukin (IL)-6, tumour necrosis factor-α, IL-1β and type 17 cytokines. Psychiatric comorbidity is common among people with AA. What does this study add? People with AA have increased plasma levels of the type 2 cytokines IL-33, IL-31 and IL-17E (IL-25), in addition to the type 17 cytokines IL-17A, IL-21, IL-23 and IL-17F. Levels of IL-17E and IL-22 positively predict depression score. What is the translational message? AA is associated with increased levels of multiple inflammatory cytokines, implicating both type 17- and type 2 immune pathways. Our data indicate that therapeutic strategies for treating AA may need to address the underlying type 17- and type 2 immune dysregulation, rather than focusing narrowly on the CD8⁺ T-cell response. An immunological mechanism might contribute directly to the depression observed in people with AA.

The impact of emergency department patient-controlled analgesia (PCA) on the incidence of chronic pain following trauma and non-traumatic abdominal pain

The effect of patient-controlled analgesia during the emergency phase of care on the prevalence of persistent pain is unkown. We studied individuals with traumatic injuries or abdominal pain 6 months after hospital admission via the emergency department using an opportunistic observational study design. This was conducted using postal questionnaires that were sent to participants recruited to the multi-centre pain solutions in the emergency setting study. Patients with prior chronic pain states or opioid use were not studied. Questionnaires included the EQ5D, the Brief Pain Inventory and the Hospital Anxiety and Depression scale. Overall, 141 out of 286 (49% 95%CI 44-56%) patients were included in this follow-up study. Participants presenting with trauma were more likely to develop persistent pain than those presenting with abdominal pain, 45 out of 64 (70%) vs. 24 out of 77 (31%); 95%CI 24-54%, p < 0.001. There were no statistically significant associations between persistent pain and analgesic modality during hospital admission, age or sex. Across both abdominal pain and traumatic injury groups, participants with persistent pain had lower EQ5D mobility scores, worse overall health and higher anxiety and depression scores (p < 0.05). In the abdominal pain group, 13 out of 50 (26%) patients using patient-controlled analgesia developed persistent pain vs. 11 out of 27 (41%) of those with usual treatment; 95%CI for difference (control - patient-controlled analgesia) -8 to 39%, p = 0.183. Acute pain scores at the time of hospital admission were higher in participants who developed persistent pain; 95%CI 0.7-23.6, p = 0.039. For traumatic pain, 25 out of 35 (71%) patients given patient-controlled analgesia developed persistent pain vs. 20 out of 29 (69%) patients with usual treatment; 95%CI -30 to 24%, p = 0.830. Persistent pain is common 6 months after hospital admission, particularly following trauma. The study findings suggest that it may be possible to reduce persistent pain (at least in patients with abdominal pain) by delivering better acute pain management. Further research is needed to confirm this hypothesis.

Genetics of immune-mediated inflammatory diseases

Immune-mediated inflammatory diseases (IMIDs) are characterized by dysregulation of the normal immune response, which leads to inflammation. Together, they account for a high disease burden in the population, given that they are usually chronic conditions with associated co-morbidities. Examples include systemic lupus erythematosus, rheumatoid arthritis, Crohn's disease and type 1 diabetes. Since the advent of genome-wide association studies, evidence of considerable genetic overlap in the loci predisposing to a wide range of IMIDs has emerged. Understanding the genetic risk and extent of genetic overlap between IMIDs may help to determine which genes control which aspects of the different diseases; it may identify potential novel therapeutic targets for a number of these conditions, and/or it may facilitate repurposing existing therapies developed originally for different conditions. The findings show that autoantibody-mediated autoimmune diseases cluster more closely with each other than autoantibody-negative diseases such as psoriasis, psoriatic arthritis, Crohn's disease and ankylosing spondylitis which, instead, form a seronegative genetic cluster. The genetic clustering largely mirrors the known response to existing biological therapies, but apparent anomalies in treatment response are discussed.

A pilot randomised controlled trial investigating a mindfulness-based stress reduction (MBSR) intervention in individuals with pulmonary arterial hypertension (PAH): the PATHWAYS study

BACKGROUND

Pulmonary arterial hypertension (PAH) is an uncommon condition with progressive heart failure and premature death. Treatment costs up to £120,000 per patient per year, and the psychological burden of PAH is substantial. Mindfulness-based stress reduction (MBSR) is an intervention with the potential to reduce this burden, but to date, it has not been applied to people with pulmonary hypertension. We wished to determine whether a trial of MBSR for people with PAH would be feasible.

METHODS

A customised gentle MBSR programme of eight sessions was developed for people with physical disability due to PAH, and they were randomised to group-based MBSR or treatment as usual. The completeness of outcome measures including Beck Anxiety Index, Beck Depression Inventory and standard physical assessment at 3 months after randomisation were recorded. Health care utilisation was measured. Attendance at the sessions and the costs involved in delivering the intervention were assessed. Semi-structured interviews were conducted to explore the acceptability of the MBSR intervention and when appropriate the reasons for trial non-participation.

RESULTS

Fifty-two patients were recruited, but only 34 were randomised due to patients finding it difficult to travel to sessions. Twenty-two completed all questionnaires and attended all clinics, both routine and additional in order to collect outcomes measures. The MSBR sessions were delivered in Bristol, Cardiff and London, costing, on average, between £2234 (Cardiff) and £4128 (London) per patient to deliver. Attendance at each session averaged between two patients in Bristol and Cardiff and three in London. For those receiving treatment as usual, clinician blinding was achievable. Interviews revealed that people who attended MBSR found it interesting and helpful in managing their symptoms and minimising the psychological component of their disease.

CONCLUSIONS

We found that attendance at group MBSR was poor in people with chronic PAH within the context of a trial. Achieving better MBSR intervention attendance or use of an Internet-based programme might maximise the benefit of MBSR.

Balance Right in Multiple Sclerosis (BRiMS): a guided self-management programme to reduce falls and improve quality of life, balance and mobility in people with secondary progressive multiple sclerosis: a protocol for a feasibility randomised controlled trial

BACKGROUND

Impaired mobility is a cardinal feature of multiple sclerosis (MS) and is rated by people with MS as their highest priority. By the secondary progressive phase, balance, mobility and physical activity levels are significantly compromised; an estimated 70% of people with secondary progressive MS fall regularly. Our ongoing research has systematically developed 'Balance Right in MS' (BRiMS), an innovative, manualised 13-week guided self-management programme tailored to the needs of people with MS, designed to improve safe mobility and minimise falls. Our eventual aim is to assess the clinical and cost effectiveness of BRiMS in people with secondary progressive MS by undertaking an appropriately statistically powered, multi-centre, assessor-blinded definitive, randomised controlled trial. This feasibility study will assess the acceptability of the intervention and test the achievability of running such a definitive trial.

METHODS/DESIGN

This is a pragmatic multi-centre feasibility randomised controlled trial with blinded outcome assessment. Sixty ambulant people with secondary progressive MS who self-report two or more falls in the previous 6 months will be randomly allocated (1:1) to either the BRiMS programme plus usual care or to usual care alone. All participants will be assessed at baseline and followed up at 15 weeks and 27 weeks post-randomisation. The outcomes of this feasibility trial include:Feasibility outcomes, including trial recruitment, retention and completionAssessment of the proposed outcome measures for the anticipated definitive trial (including measures of walking, quality of life, falls, balance and activity level)Measures of adherence to the BRiMS programmeData to inform the economic evaluation in a future trialProcess evaluation (assessment of treatment fidelity and qualitative evaluation of participant and treating therapist experience).

DISCUSSION

The BRiMS intervention aims to address a key concern for MS service users and providers. However, there are several uncertainties which need to be addressed prior to progressing to a full-scale trial, including acceptability of the BRiMS intervention and practicality of the trial procedures. This feasibility trial will provide important insights to resolve these uncertainties and will enable a protocol to be finalised for use in the definitive trial.

TRIAL REGISTRATION

ISRCTN13587999.

The cost-effectiveness of patient-controlled analgesia vs. standard care in patients presenting to the Emergency Department in pain, who are subsequently admitted to hospital

The clinical effectiveness of patient-controlled analgesia has been demonstrated in a variety of settings. However, patient-controlled analgesia is rarely utilised in the Emergency Department. The aim of this study was to compare the cost-effectiveness of patient-controlled analgesia vs. standard care in participants admitted to hospital from the Emergency Department with pain due to traumatic injury or non-traumatic abdominal pain. Pain scores were measured hourly for 12 h using a visual analogue scale. Cost-effectiveness was measured as the additional cost per hour in moderate to severe pain avoided by using patient-controlled analgesia rather than standard care (the incremental cost-effectiveness ratio). Sampling variation was estimated using bootstrap methods and the effects of parameter uncertainty explored in a sensitivity analysis. The cost per hour in moderate or severe pain averted was estimated as £24.77 (€29.05, US$30.80) (bootstrap estimated 95%CI £8.72 to £89.17) for participants suffering pain from traumatic injuries and £15.17 (€17.79, US$18.86) (bootstrap estimate 95%CI £9.03 to £46.00) for participants with non-traumatic abdominal pain. Overall costs were higher with patient-controlled analgesia than standard care in both groups: pain from traumatic injuries incurred an additional £18.58 (€21.79 US$23.10) (95%CI £15.81 to £21.35) per 12 h; and non-traumatic abdominal pain an additional £20.18 (€23.67 US$25.09) (95%CI £19.45 to £20.84) per 12 h.

Immunosuppression in pediatric liver transplant recipients: Unique aspects

Pediatric liver transplantation has experienced improved outcomes over the last 50 years. This can be attributed in part to establishing optimal use of immunosuppressive agents to achieve a balance between minimizing the risks of allograft rejection and infection. The management of immunosuppression in children is generally more complex and can be challenging when compared with the use of these agents in adult liver transplant patients. Physiologic differences in children alter the pharmacokinetics of immunosuppressive agents, which affects absorption, distribution, metabolism, and drug excretion. Children also have a longer expected period of exposure to immunosuppression, which can impact growth, risk of infection (bacterial, viral, and fungal), carcinogenesis, and likelihood of nonadherence. This review discusses immunosuppressive options for pediatric liver transplant recipients and the unique issues that must be addressed when managing this population. Further advances in the field of tolerance and accommodation are needed to relieve the acute and cumulative burden of chronic immunosuppression in children. Liver Transplantation 23 244-256 2017 AASLD.

Endothelin-1 Attenuates Apoptosis in Cultured Trophoblasts From Term Human Placentas

The authors test the hypothesis that endothelin-1 (ET-1) modulates apoptosis in human term trophoblasts. Primary cultures of cytotrophoblasts from term human placentas (n = 5) were cultured for 16 hours total or 24 hours prior to harvest at 72 hours in atmospheres of <1%, 8%, and 20% oxygen, in the presence of 10% serum, ET-1 (1-100 pmol/mL), both, or neither. The apoptotic cleavage products of poly-ADP-ribose polymerase and cytokeratin 18 filaments were quantified by Western analysis and immunocytochemistry. The expression of BAD, pBAD-serine 112, p53, and 2 isoforms of MDM2 were quantified by immunoblotting, and endothelin A and B receptors were analyzed by immunocytochemistry. Compared to vehicle control, increasing concentrations of ET-1 reduce by 3- to 6-fold the level of apoptosis in cytotrophoblasts exposed to serum-free conditions at 20% oxygen. Similarly, syncytiotrophoblast cultures grown for 24 hours without serum in 100 pmol/mL ET-1 show a 3-fold lower level of apoptosis compared with vehicle control. ET-1 significantly reduces apoptosis in cultures exposed to 20% oxygen but not in cultures exposed to 8% or 1% oxygen. The effect of ET-1 on apoptosis in 20% oxygen is accompanied by reduced p53 expression and is correlated with enhanced expression of endothelin B receptor, compared to cultures in 8% or 1% oxygen. ET-1 reduces apoptosis in cultured human trophoblasts, and this finding suggests a role for ET-1 in protecting trophoblasts against injury.

Investigation of the genetic overlap between rheumatoid arthritis and psoriatic arthritis in a Greek population

OBJECTIVES

Several rheumatoid arthritis (RA) susceptibility loci have also been found to be associated with psoriatic arthritis (PsA), demonstrating that there is a degree of genetic overlap between various autoimmune diseases. We sought to investigate whether single nucleotide polymorphisms (SNPs) mapping to previously reported RA and/or PsA susceptibility loci, including PLCL2, CCL21, REL, STAT4, CD226, PTPN22, and TYK2, are associated with risk for the two diseases in a genetically homogeneous Greek population.

METHOD

This study included 392 RA patients, 126 PsA patients, and 521 healthy age- and sex-matched controls from Greece. Genotyping of the SNPs was performed with Taqman primer/probe sets. Bioinformatic analysis was performed using BlastP, PyMOL, and Maestro and Desmond.

RESULTS

A significant association was detected between the GC genotype of rs34536443 (TYK2) in both the PsA and RA cohorts. The C allele of this SNP was associated with PsA only. Evidence for association with PsA was also found for the GG genotype and G allele of the rs10181656 SNP of STAT4. The TC genotype of the rs763361 SNP of CD226 was associated with PsA only.

CONCLUSIONS

Genetic overlap between PsA and RA was detected for the rs34536443 SNP of the TYK2 gene within a Greek population. An association of STAT4 (rs10181656) with PsA was confirmed whereas CD226 (rs763361) was associated with PsA but not with RA, in contrast to previous reports. The different findings of this study compared to previous ones highlights the importance of comparative studies that include various ethnic or racial populations.