Disease evolution and organ damage accrual in patients with stable UCTD: a long-term monocentric inception cohort

OBJECTIVES

Undifferentiated connective tissue diseases (UCTDs) are systemic autoimmune conditions that cannot be diagnosed nor classified as defined CTD; the majority maintains an undifferentiated profile (stable UCTD, sUCTD) over time. Data on long-term outcomes of sUCTD are lacking.

METHODS

Retrospective longitudinal analysis of an inception cohort of 141 patients with sUCTD.Disease evolution and damage accrual were evaluated at 1, 5 and 10 years. Partial least square (PLS) regression was used to identify the basal variables contributing to damage accrual at 1, 5 and 10 years of follow-up. Trend of damage over time was compared with a cohort of age-matched and sex-matched patients with systemic lupus erythematosus (SLE) by means of Nelson-Aalen analysis.

RESULTS

11.3% of patients evolved to a definite CTD after a median 11 years (IQR 6-25) from the first symptom. At last visit, 10% were on glucocorticoids and 6% on immunosuppressive therapy. In 27.3%, at least one item of organ damage was recorded according to the SLICC/DI score (mean score 1.19±0.46). At PLS analysis, age at diagnosis and age at first symptoms were related to damage at 1 year, not taking antimalarials and taking immunosuppressants were associated with damage at 5 years.The mean survival without damage was 9.3 years in sUCTD and 8.4 years in SLE. The 10-year probability without damage was 62% and 23% in SLE and sUCTD, respectively (p=0.015).

CONCLUSIONS

Although less significantly impacted than in patients with SLE, in the long-term UCTDs can accumulate organ damage and evolve into defined connective tissue diseases.

Management of pregnancy in autoimmune rheumatic diseases: maternal disease course, gestational and neonatal outcomes and use of medications in the prospectiveItalian P-RHEUM.it study

OBJECTIVES

To investigate pregnancy outcomes in women with autoimmune rheumatic diseases (ARD) in the Italian prospective cohort study P-RHEUM.it.

METHODS

Pregnant women with different ARD were enrolled for up to 20 gestational weeks in 29 Rheumatology Centres for 5 years (2018-2023). Maternal and infant information were collected in a web-based database.

RESULTS

We analysed 866 pregnancies in 851 patients (systemic lupus erythematosus was the most represented disease, 19.6%). Maternal disease flares were observed in 135 (15.6%) pregnancies. 53 (6.1%) pregnancies were induced by assisted reproduction techniques, 61 (7%) ended in miscarriage and 11 (1.3%) underwent elective termination. Obstetrical complications occurred in 261 (30.1%) pregnancies, including 2.3% pre-eclampsia. Two cases of congenital heart block were observed out of 157 pregnancies (1.3%) with anti-Ro/SSA. Regarding treatments, 244 (28.2%) pregnancies were treated with glucocorticoids, 388 (44.8%) with hydroxychloroquine, 85 (9.8%) with conventional synthetic disease-modifying anti-rheumatic drugs and 122 (14.1%) with biological disease-modifying anti-rheumatic drugs. Live births were 794 (91.7%), mostly at term (84.9%); four perinatal deaths (0.5%) occurred. Among 790 newborns, 31 (3.9%) were small-for-gestational-age and 169 (21.4%) had perinatal complications. Exclusive maternal breast feeding was received by 404 (46.7%) neonates. The Edinburgh Postnatal Depression Scale was compiled by 414 women (52.4%); 89 (21.5%) scored positive for emotional distress.

CONCLUSIONS

Multiple factors including preconception counselling and treat-to-target with pregnancy-compatible medications may have contributed to mitigate disease-related risk factors, yielding limited disease flares, good pregnancy outcomes and frequency of complications which were similar to the Italian general obstetric population. Disease-specific issues need to be further addressed to plan preventative measures.

Analysis of belimumab prescription and outcomes in a 10-year monocentric cohort: is there an advantage with early use?

OBJECTIVE

The objective is to evaluate perscriptions of belimumab (BEL), how these have changed over the years and their impact on clinical outcomes in patients with systemic lupus erythematosus (SLE).

METHODS

This is a retrospective analysis of prospectively collected data. We retrieved demographic and clinical data and concomitant therapies at BEL starting (baseline). Disease activity was assessed at baseline and after 6 and 12 months and organ damage at baseline and at the last visit.

RESULTS

From 422 patients followed in the Pisa SLE cohort, 102 patients received BEL and were included and 22 (21.6%) were immunosuppressant (IS)-naïve. Lupus Low Disease Activity State (LLDAS) with a glucocorticoid (GC) dosage ≤5 mg/day (LLDAS5) and remission were achieved by 47% and 38% of patients at 6 months, and by 75% and 66% at 12 months. Comparing IS-naïve patients with those who received BEL after at least one conventional IS, we did not find significant differences in baseline characteristics and in the achievement of LLDAS5 and remission. Despite at baseline we did not observe significant differences in mean GC daily dosage, IS-naïve patients were taking a significantly lower GC daily dose at 6 and 12 months. Interestingly, IS-naïve patients were more common in the most recent years.

CONCLUSIONS

Our data confirm that BEL is effective in controlling disease activity, and in recent years BEL has been considered as an earlier treatment option before other IS. Early introduction of BEL can be at least as effective as a step-up approach and can help to reduce the GC dosage.

Which extra-renal flare is 'difficult to treat' in systemic lupus erythematosus? A one-year longitudinal study comparing traditional and machine learning approaches

OBJECTIVES

To describe phenotypes and outcomes of extra-renal flares in SLE, to identify clusters of extra-renal flares based on baseline features, and to develop a machine learning (ML) tool capable of predicting 'difficult to treat' (D2T) flares.

METHODS

Extra-renal flares that occurred in our cohort over the last five years with at least one year of follow-up were included. Baseline clinical variables were described and flares assigned to clusters. Attainment of remission and low disease activity state (LLDAS) at 12 months were compared. Flares were then considered 'D2T' in case of non-attainment of LLDAS at 6 and 12 months. Baseline features were used to train a ML model able to predict future D2T-flares, at admission. Traditional approaches were then compared with informatic techniques.

RESULTS

Among 420 SLE patients of the cohort, 114 flares occurred between 2015 and 2021; 79 extra-renal flares, predominantly mucocutaneous (24.1%) and musculoskeletal (45.6%), were considered. After 12 months, 79.4% and 49.4% were in LLDAS and in remission, respectively, while 17 flares were classified as D2T (21.5%); D2T flares received a higher cumulative and daily dose of glucocorticoids. Among the clusters, cluster 'D' (mild-moderate flares with mucocutaneous manifestations in patients with history of skin involvement) was associated with the lowest rate of remission. Among clinical data, not being on LLDAS at 3 months was the unique independent predictor of D2T flares.

CONCLUSIONS

Our clusterization well separates extra-renal flares according to their baseline features and may propose a new identification standard. D2T flares, especially refractory skin manifestations, are frequent in SLE and represent an unmet need in the management of the disease as they are associated with higher glucocorticoid (GC) dosage and risk of damage accrual. Our ML model could help in the early identification of D2T flares, flagging them to elevate the attention threshold at admission.

Adherence to medication during pregnancy in systemic autoimmune diseases: results from a prospective study

OBJECTIVES

To evaluate adherence to medication in patients with systemic autoimmune diseases (SAD), comparing pregnant and non-pregnant women.

METHODS

200 patients with SAD were consecutively enrolled, 100 pregnant and 100 non-pregnant women. Each patient completed the 8-item Morisky Medication Adherence Scale (MMAS-8), one copy for hydroxychloroquine (HCQ) and one for other treatments for rheumatic disease, and Hospital Anxiety and Depression Scale (HADS).

RESULTS

No significant differences were found in ongoing therapies between pregnant and non-pregnant women. 148 patients (74.0%) were taking HCQ and 160 (80.0%) other therapies for rheumatic disease. The mean MMAS-8 score was >6 in all groups indicating a good adherence, on average. The rate of patients with good medication adherence was higher in pregnant patients (73.9% vs. 63.3% and 76.5% vs. 64.5%, for HCQ and other therapies, respectively) although this difference was not statistically significant. Eight patients had very poor medical adherence, and all were non-pregnant women. Anxiety (15% of patients) was associated to low medication adherence for drugs other than HCQ (p=0.02), while depression (4% of patients) did not seem to have an impact on adherence.

CONCLUSIONS

In our cohort we recorded a good adherence to prescribed medication, although adequate adherence was not achieved in about 30% of patients, confirming that non-adherence is an important issue in SAD. It is difficult to define a profile of patients at risk of poor adherence, but it appears important to implement communication and adherence monitoring strategies since strict monitoring also during pregnancy could improve medical adherence.

Variations of C3 and C4 Before and During Pregnancy in Systemic Lupus Erythematosus: Association With Disease Flares and Obstetric Outcomes

OBJECTIVE

To analyze complement level variations in systemic lupus erythematosus (SLE) pregnancies, focusing on disease flares and obstetric complications.

METHODS

SLE pregnancies prospectively followed by multidisciplinary teams from 1987 to 2018 in 2 Italian rheumatology centers were retrospectively analyzed. As reference, pregnancy-modified ranges of normal levels of C3 and C4 were derived from 175 pregnancies from the general obstetric population (GOP), as previously described by our group.

RESULTS

Two hundred forty-six pregnancies in 172 patients with SLE were analyzed. Eighty-nine percent were live births. Thirty-five flares were recorded in 30 pregnancies (12.2%) and obstetric complications occurred in 47 pregnancies (19.1%) including 27 pregnancy losses, 11 severely preterm births (2 resulting in perinatal death), and 15 hypertensive disorders. C3 and C4 levels were higher in the GOP than in patients with SLE, at any time point. C3 and C4 levels progressively increased during pregnancy in both GOP and SLE pregnancies without flare and obstetric complications, whereas this physiological increase was not observed in pregnancies with flares or obstetric complications. A significantly higher frequency of low C4 was found in pregnancies with flares (at preconception and in each trimester) and preterm births (at preconception). In multivariate analysis, low C4 at preconception was associated with flares (odds ratio 13.81, 95% CI 3.10-61.43, P < 0.001).

CONCLUSION

Low C4 at preconception was found to be an independent risk factor for SLE flare during pregnancy. Not only C3 and C4 levels but also their variations should be observed, as their failure to increase can be useful to predict risk of complications and suggest closer monitoring.

Pregnancy in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease which frequently affects women of childbearing age. Nowadays, pregnancy is not contraindicated in cases of well-controlled disease activity, but pregnancies are still at higher risk of maternal and fetal complications compared to the general population. During pregnancy and puerperium patients are at risk of disease flare, and obstetric complications are more frequent in cases of active disease at conception/beginning of pregnancy, a history of lupus nephritis, and concomitant presence of antiphospholipid syndrome. To improve pregnancy outcomes in SLE patients, appropriate preconception counseling with changes in medication, if necessary, and close rheumatological and obstetrical monitoring are fundamental. This review aims to summarize the risk factors for adverse pregnancy outcomes and provide an update on developments in medical care for pregnancy in SLE patients.

Treat-to-Target in Systemic Lupus Erythematosus: Reality or Pipe Dream

Treat-to-target is a therapeutic approach based on adjustments to treatment at set intervals in order to achieve well-defined, clinically relevant targets. This approach has been successfully applied to many chronic conditions, and in rheumatology promising results have emerged for rheumatoid arthritis. For systemic lupus erythematosus (SLE), defining the most meaningful treatment targets has been challenging, due to disease complexity and heterogeneity. Control of disease activity, the reduction of damage accrual and the patient's quality of life should be considered as the main targets in SLE, and several new drugs are emerging to achieve these targets. This review is focused on describing the target to achieve in SLE and the methods to do so, and it is also aimed at discussing if treat-to-target could be a promising approach also for this complex disease.

Systemic lupus erythematosus: one year in review 2023

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a wide range of clinical manifestations and a relapsing-remitting course. New data regarding pathogenic pathways, biomarkers and clinical manifestations of SLE are emerging, and new drugs and therapeutic protocols have been proposed to improve the control of disease activity. Furthermore, new insights into comorbidities and reproductive health in SLE patients are constantly emerging.This annual review aims to summarise the most relevant data on SLE that was published in 2022.

Gender differences in SLE: report from a cohort of 417 Caucasian patients

BACKGROUND

SLE is an autoimmune disease that predominantly affects women. As most epidemiological and interventional studies are on populations with a clear female prevalence, the influence of gender in disease course, drug response and damage accrual is yet to be fully explored and comprehended.

OBJECTIVES

To describe gender differences in disease course, comorbidities, use of medications and long-term outcomes of a large cohort of patients with SLE.

METHODS

Retrospective gender-based analysis of prospectively collected data from a monocentric cohort of Caucasian patients with SLE with at least 1 year of follow-up.

RESULTS

417 patients were included, 51 men and 366 women. Men displayed a significantly higher median age at disease onset and diagnosis and a higher prevalence of late-onset SLE, serositis at disease onset, antiphospholipid syndrome (APS) and use of mycophenolate within the first year of disease. Women had a higher prevalence of haematological abnormalities, a higher cumulative exposure to azathioprine and higher cumulative dose of glucocorticoids at 5 years. Male patients had a shorter time to first damage item and a higher prevalence of damage at 1 and 5 years, but this association was no longer significant when late-onset patients were excluded. No differences were found in prevalence of childhood onset, delay between onset and diagnosis, time to renal involvement and histology, cumulative autoantibody positivity, number of flares and hospitalisations, median SLE Damage Index score, type of damage, age and time to first cardiovascular event, chronic kidney disease and death.

CONCLUSIONS

In our cohort, clinical manifestations and disease course were similar in male and female patients; however, male patients displayed higher prevalence of APS and early damage accrual probably due to the later disease onset. These data highlight the importance of an intensive follow-up, prevention and treatment of complications in this category of patients, especially in the first years of disease.

Treatment With Anifrolumab for Discoid Lupus Erythematosus

This case report describes 2 women with severe and refractory discoid lupus erythematosus that was treated with anifrolumab.

Patient Care Pathways for Pregnancy in Rare and Complex Rheumatic Diseases: Results From an International Survey

OBJECTIVE

To map existing organizational care pathways in clinical centers of expertise that care for pregnant women affected by rare and complex connective tissue diseases (rcCTDs).

METHODS

An international working group composed of experts in the field of pregnancy in rcCTDs co-designed a survey focused on organizational aspects related to the patient's pathway before, during, and after pregnancy. The survey was distributed to subject experts through referral sampling.

RESULTS

Answers were collected from 69 centers in 21 countries. Patients with systemic lupus erythematosus and/or antiphospholipid syndrome were followed by more than 90% of centers, whereas those with disorders such as IgG4-related diseases were rarely covered. In the majority of centers, a multidisciplinary team was involved, including an obstetrician/gynecologist in 91.3% of cases and other healthcare professionals less frequently. Respondents indicated that 96% of the centers provided routine pre-pregnancy care, whereas the number of patient visits during pregnancy varied across centers. A formalized care pathway was described in 49.2% of centers, and 20.3% of centers had a predefined protocol for the monitoring of pregnant patients. Access to therapies during pregnancy also was heterogeneous among different centers.

CONCLUSION

In international referral centers, a high level of care is provided to patients with rcCTDs before, during, and after pregnancy. No significant discrepancies were found between European and non-European countries. However, this work highlights a potential benefit to streamlining the care approaches across countries to optimize pregnancy and perinatal outcomes among patients with rcCTDs.

Exploring patient's experience and unmet needs on pregnancy and family planning in rare and complex connective tissue diseases: a narrative medicine approach

OBJECTIVE

The aim of this work is to explore patient' unmet needs of rare and complex rheumatic tissue diseases (rCTDs) patients during pregnancy and its planning by means of the narrative-based medicine (NBM) approach.

METHODS

A panel of nine rCTDs patients' representatives was identified to codesign a survey aimed at collecting the stories of rCTD patients who had one or more pregnancies/miscarriages. The results of the survey and the stories collected were analysed and discussed with a panel of patients' representatives to identify unmet needs, challenges and possible strategies to improve the care of rCTD patients.

RESULTS

129 replies were collected, and 112 stories were analysed. Several unmet needs in the management of pregnancy in rCTDs were identified, such as fragmentation of care among different centres, lack of education and awareness on rCTD pregnancies among midwifes, obstetricians and gynaecologists. The lack of receiving appropriate information and education on rCTDs pregnancy was also highlighted by patients and their families. The need for a holistic approach and the availability specialised pregnancy clinics with a multidisciplinary organisation as well as the provision of psychological support during all the phases around pregnancy was considered also a priority.

CONCLUSION

The adoption of the NBM approach enabled a direct identification of unmet needs, and a list of possible actions was elaborated to improve the care of rCTD patients and their families in future initiatives.

POS0753 PROSPECTIVE EVALUATION OF HEALTH-RELATED QUALITY OF LIFE (HRQoL) IN A MONOCENTRIC COHORT OF PATIENTS WITH LONGSTANDING SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Background

The optimization of HRQoL in SLE patients is defined as one of the treatment goals in the 2019 EULAR recommendations1 for the management of SLE. Most studies have examined HRQoL at one point in time, while the few longitudinal studies do not report a clear variation in Patient Reported Outcomes (PROs) with respect to changes in disease activity. It would be important to understand if, even in a real-life setting, the improvement of patients’ HRQoL may represent an achievable target.

Objectives

the aim of this study was to analyze HRQoL over time in a monocentric cohort of patients with SLE and investigate which disease-related factors determine short-term variation of HRQoL in a real-life setting.

Methods

this is a longitudinal, prospective monocentric study which included consecutive adult outpatients with SLE (1997 ACR classification criteria), regularly followed at the Rheumatology Unit of Pisa. Patients were enrolled over a period of 2 years, before the pandemic outbreak, and had at least 2 assessments per year. For each patient, demographics, comorbidities, treatment, clinical and laboratory data were collected. Disease activity was evaluated with the SELENA-SLEDAI and organ damage with the SLICC/DI. We defined as a significant variation of disease activity, a difference of clinical SELENA-SLEDAI ≥ 4 points between 2 subsequent evaluations. At each visit, patients completed the following PROs: SF-36, FACIT-Fatigue and LIT.

Results

we enrolled 210 consecutive SLE patients, mainly female (93.8%) and of Caucasian ethnicity (97.1%), with a mean age at enrollment of 45.1±12.7 years and a median disease duration of 13 years (IQR 5-21). At baseline, the median SLEDAI of the cohort was 2 (IQR 0-4). The most frequent active disease manifestations were: articular (17.1%) and hematological (15.2%); 6.7% of patients had active renal disease. 47.14% had a SLICC-DI > 0 with a median SLICC-DI among them of 2 (IQR 1-3). 11.43% of patients had a concomitant fibromyalgia. Most patients were on Hydroxychloroquine (78.1%) and low dose glucocorticoid (55.2%), with a median daily dose of 2 mg (IQR 0-4) of prednisone equivalent; 41.4% were on conventional immunosuppressants and 11.9% on biologics, mainly belimumab. The median scores of PROs at enrollment are reported in Table 1. At baseline, fibromyalgia confirmed to have a significant negative impact on all PROs after adjustment for confounding factors (p<0.05). Each patient underwent two consecutive evaluations, with a median interval between them of 11.4 months. We observed a significant variation of disease activity in 36/210 patients (17.14%). Then, we compared the subgroup of patients with unchanged disease activity with that of patients who showed a significant variation of disease activity. We found that FACIT and LIT scores didn’t change over time in both subgroups, whereas PCS (p<0.001) and MCS (p<0.01) scores of the SF-36 showed a significant variation in both groups, between the first and the second clinical assessment. However, in the subgroup of patients with a significant change of disease activity, the variation of PCS and MCS was not correlated with the variation of disease activity or ongoing treatment. In particular, patients with a significant improvement of HRQoL over time didn’t have a corresponding significant reduction of the SLEDAI score or of the daily glucocorticoid dose.

Table 1.

PROs scores at baseline.

PROsMedian scores at baselineSF-36 PCS58 (IQR 49.09- 68)SF-36 MCS57 (IQR 46.42-67)FACIT42 (IQR 32-46)LIT20 (IQR 7.5-40)

Conclusion

our findings seem to suggest that HRQoL over time in outpatients with longstanding SLE tends to be stable (maybe because patients are able to adapt to their illness) or varies unpredictably, maybe influenced by not disease-related factors. Further studies are needed to better understand which factors influence HRQoL over time and which questionnaires are more sensitive to catch its variation.

References

[1]PMID: 30926722

Disclosure of Interests

None declared

AB0555 SYMPTOMATIC NON-SEROSITIC LUNG INVOLVEMENT IN A MONOCENTRIC COHORT OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE): A REAL-LIFE EXPERIENCE

Background

A growing interest has been addressed to the study of lung involvement in systemic autoimmune diseases. Non-serositic pulmonary manifestations have also been described in SLE. However, little is known about their exact prevalence, clinical features and outcomes.

Objectives

To describe the prevalence, clinical and immunological characteristics of symptomatic non-serositic lung involvement in a monocentric cohort of SLE patients.

Methods

This observational, retrospective study included patients with SLE, regularly followed at the Rheumatology Unit of Pisa, that presented a clinically relevant non-serositic pulmonary involvement during their disease history. Patients with lung manifestations related to other causes (e.g. infections, emphysema, Chronic Obstructive Lung Disease, bronchial asthma etc.) were excluded. The following data were collected from clinical charts: demographics, smoke exposure, comorbidities, respiratory symptoms, disease duration and disease activity (SELENA-SLEDAI) at the onset of lung involvement, immunological profile, treatment, CT and spirometry parameters.

Results

Over 450 SLE patients in regular follow-up, we found 11 female patients with a history of clinically relevant non-serositic lung involvement: 7 interstitial lung disease (ILD), 2 acute lupic pneumonitis (ALP), 1 diffuse alveolar hemorrhage (DAH) and 1 shrinking lung syndrome. 45.4% of patients had a history of smoke exposure and had stopped smoking on average 9 years before the onset of lung manifestations. For the 2 patients with ALP, this was the first manifestation of SLE. Among the other 9 patients, lung involvement was diagnosed after a mean disease duration of 14 ± 15 years. At the diagnosis of pulmonary involvement, 10/11 patients presented respiratory symptoms and an overall active disease, with a median SLEDAI of 9 (IQR 6-13). Clinical characteristics are summarized in Table 1. All patients were hospitalized and 2 of them (1 ALP and 1 DAH) were admitted in intensive care unit.

Table 1.

Clinical characteristics at the diagnosis of lung involvement

SystemicActive skin manifestations36%Arthritis36%Fever36%Leukopenia36%Hypocomplementemia91%Anti-dsDNA positivity36%RespiratoryDyspnea54%Exertional dyspnea18%Cough45%Acute respiratory failure27%

As for the immunologic profile, SSA/Ro60 were positive in 72% of patients and SSA/Ro52, SSB, U1-RNP in 36%; 36% had Sjogren Syndrome (SS) in overlap.

Spirometry was available for 6/11 patients: a restrictive pattern and a moderate/severe reduction of diffusing capacity of the lung for carbon monoxide was found in 5 patients.

In the ILD subgroup, the most prevalent CT pattern was the Non-specific interstitial pneumonia (NSIP) (5/7). 2 patients presented a Bronchiolitis obliterans/organizing pneumonia (BOOP) pattern.

Lung involvement was the driving manifestation in the treatment choice for 6/11 patients: 1 DAH, 2 ALP, 1 Shrinking lung and 2 ILD. All received pulse steroids and in 3 cases (2 ILD and 1 DAH) cyclophosphamide was added for the induction treatment; the patient with Shrinking lung had an overlap SS and was treated with Rituximab.

At last visit (mean follow-up of 8 ± 8.7 years since lung disease onset), 7/11 patients presented no respiratory symptoms and a complete resolution of CT alterations. 3/11 presented a residual exertional dyspnea and mild spirometry alterations. No patients developed respiratory insufficiency; only 1 patient died for cardiovascular complications.

Conclusion

In our large cohort of SLE patients, non-serositic lung involvement seems to be overall rare; the most frequent type of lung manifestation is ILD which appears to be associated with anti-SSA/SSB and anti-U1RNP positivity. The low prevalence of lung involvement (2.4%) in our cohort could be due to the presence of patients with a subclinical involvement. Further studies are needed to assess the real prevalence of subclinical lung manifestations in SLE and to identify the clinical phenotype of patients more prone to develop pulmonary disease.

Disclosure of Interests

Davide Schilirò: None declared, Elena Elefante: None declared, Chiara Stagnaro: None declared, Viola Signorini: None declared, Dina Zucchi: None declared, Francesca Trentin: None declared, Gaetano La Rocca: None declared, Linda Carli: None declared, Francesco Ferro: None declared, Chiara Tani: None declared, Marta Mosca Speakers bureau: advisor LILLY, ASTRA ZENECA, GSK, Consultant of: advisor LILLY, ASTRA ZENECA, GSK

POS0364 UNMET NEEDS IN THE TREATMENT OF EXTRA-RENAL FLARES IN SLE PATIENTS: REAL LIFE EXPERIENCE VS ARTIFICIAL APPROACH

Background

Systemic lupus erythematosus (SLE) is a heterogeneous disease which can affect various organs and is characterized by different clinical phenotypes. While the treatment of renal involvement is quite standardized, the therapeutic approach to extra-renal manifestations is subjected to a degree of variability.

Objectives

1. To describe extra-renal disease flares in terms of clinical phenotype and outcomes in SLE patients 2. To compare data from a real-life setting with a machine learning (ML) approach.

Methods

This study is a retrospective analysis of data from a monocentric cohort of SLE patients who experienced a disease flare between 2015 and 2020. Each flare was followed for one year and was classified according to the organ involvement and categorized according to the BILAG definition of flare. At baseline and at 3,6,12 months the following variables were collected: disease activity (SELENA-SLEDAI score), ongoing therapy and disease state (DORIA definition of remission). Demographic data and previous organ involvement were retrieved from clinical charts. Flares’ features at baseline and during follow up were analyzed in terms of explained variance across the dataset’s Principal Components and clustered with a hierarchical unsupervised learning approach. A ML model based on neural networks was built to early detect flares’ therapeutic difficulty: it was validated after data augmentation to satisfy statistical requirements during the training phase.

Results

66 extra-renal flares were investigated (Table 1); 5 flares (7.5%) were treated with glucocorticoid (GC) pulses and 61 (92.5%) with oral GC therapy, while an immunosuppressive (IS) treatment was prescribed in 44 flares (66.7%). The remission rate at 12 months for the whole group was 50%, with musculo-skeletal (MS) flares, mucocutaneous (MC) flares and others (neuropsychiatric, cardiopulmonary, constitutional, haematologic) that was respectively 63.6%, 31.3% and 41.2%, showing lower rate of remission for MC flares. In 12 months, 17 flares (25.8%) did not respond to treatment (non-responders), requiring an increase in the dose of GC or the introduction of a new IS therapy. Using a machine learning approach, we were able to identify 4 flare clusters, grouping flares in relation to phenotypic characteristics (Figure 1), and recognized statistically relevant features for patients’ stratification (cluster 1“flare in systemic disease with high activity”, cluster 2 “outcast flares”, cluster 3 “flare in polymorphic disease with mild activity” and cluster 4 “recurrent skin flares”). Interestingly, cluster 4 (recurrent skin flares) was associated with the lowest rate of remission at 12 months with respect to clusters 1, 2, and 3 (33% vs 40%, 76.5% and 56% respectively). Moreover the neural network model correctly predicts difficult to treat flares in up to 80% of the cases

Table 1.WHOLE GROUPMUSKELMUCOCUTCONSTITUTIONALCARDIOPULMHAEMATOLNEUROpNUMBER (%)6633 (50)16 (24.2)7 (10.6)4 (6.1)5 (7.6)1 (1.5)SLEDAI at baseline median (IQR)7 (4-29)8 (6-10)5.5 (4-10)5 (4-9)9 (4.5-12)5 (5-6)29 (29-29)SLEDAI 12 mos median (IQR)2 (0-20)0.5 (0-4)3 (0-4)3 (2 – 4)0 (0-0)2 (0-3)14 (14 – 14)REMISSION 12 mos number (%)33 (50)21 (63.6)5 (31.3)4 (57.1)2 (40)2 (40%)1 (100)0.217NON RESPONSE 12 mos number (%)17 (25.8)8 (25)5 (31.3)2 (28.6)1 (20)1 (20%)1 (100)0.467Figure 1.

Flare clusters.

Conclusion

These data suggest that, in a real-life setting, the clinical response rate to therapy of patients with an extra-renal flare is not satisfactory, thus identifying an unmet need in the treatment of SLE and highlighting the absence of a standard treatment. Both the real-life data and the machine learning approach identify flares with MC manifestations as the most difficult to treat with the lower rate of remission after one year. Further prospective studies are necessary to improve the neural network model; ML techniques could help in the early identification of difficult to treat flares to be candidates for new and more aggressive therapeutic strategies for extra-renal manifestations.

Disclosure of Interests

None declared

POS0721 ASSOCIATION BETWEEN PRECONCEPTION COMPLEMENT LEVELS AND USE OF HYDROXYCHLOROQUINE WITH PREGNANCY OUTCOME IN PATIENTS WITH PRIMARY ANTIPHOSPHOLIPID SYNDROME AND CARRIERS OF ANTIPHOSPHOLIPID ANTIBODIES: AN INTERNATIONAL MULTICENTER STUDY

Background

Antiphospholipid Syndrome (APS) is a rare autoimmune disease characterized by thrombotic events and/or pregnancy morbidities in the presence of confirmed positivity for antiphospholipid antibodies (aPL). Complement was demonstrated to be involved in aPL-related pregnancy loss in animal models and several groups investigated the significance of complement levels in human disease. C3 and C4 serum levels were assessed in several cohorts of pregnant patients with APS and/or aPL positivity in order to relate complement consumption with adverse pregnancy outcome (APO).

According to some authors, hydroxychloroquine (HCQ) can control the activation of the complement system, improve pregnancy outcome and reduce aPL title.

Objectives

This study was designed to verify the effect of HCQ in addition to low dose aspirin (LDA) + low molecular weight heparin (LMWH) treatment in a multicenter cohort of primary APS (PAPS) and aPL carriers pregnant women and the possible correlation with preconception serum C3/C4 levels.

Methods

Medical records of pregnant women with confirmed positivity for aPL antibodies attending twelve referral centers from January 2010 to December 2020 were retrospectively evaluated. We considered as aPL-related APO: spontaneous abortions (<10 weeks of gestation), fetal loss (≥10 weeks of gestation), neonatal death (death of a formed fetus alive at birth in the first 28 days of life), preterm delivery before 37 weeks of gestation, preeclampsia, eclampsia or HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet).

Results

We have analyzed 164 singleton PAPS/aPL carrier pregnancies (22 aPL carriers - 13%) in 128 patients: all were treated with combination therapy (LDA+LMWH), and in 30 HCQ was added. 58 pregnancies (43%) had low levels of preconception C3/C4. A triple aPL positivity was observed in 54 pregnancies, 14 of them were treated with combination therapy + HCQ. When considering the whole cohort, the addition of HCQ had not significantly improved the gestational outcome. Further stratification was performed on the basis of complement consumption. In the group of patients with preconception low C3/C4 levels the addition of HCQ had not significantly improved pregnancy outcome. We have lastly evaluated 40 pregnancies with a high-risk profile (triple aPL positivity and complement consumption), in which we have found that HCQ significantly improved gestational outcome (p=0.018, Table 1).

Table 1.

Relationship between APO, therapy during pregnancy and risk profile.

All pregnancies (n=164)Reduced C3/C4 (n=58)Triple aPL+ and reduced C3/C4 (n=40)LDA+LMWH (n, %)LDA+LMWH+HCQ (n, %)pLDA+LMWH (n, %)LDA+LMWH+HCQpLDA+LMWHLDA+LMWH+HCQp(n, %)(n, %)(n, %)APO62 (46%)16 (53%)ns32 (68%)4 (36%)ns23 (77%)3 (30%)0.018No APO72 (54%)14 (47%)15 (32%)7 (64%)7 (23%)7 (70%)Total1343047113010

This observation could not be confirmed in patients with single or double aPL positivity.

Conclusion

The study shows that administering HCQ in addition to combination therapy can improve gestational outcome in aPL/PAPS high-risk patients. This observation confirms that HCQ exerts a beneficial effect on aPL pregnancies by complement inhibition as it was shown in animal models. In addition, our results provide the clinicians a useful tool to implement conventional treatment in patients at high risk of pregnancy complication or loss.

References

[1]De Carolis S, et al. Is there any role for the hydroxychloroquine (HCQ) in refractory obstetrical antiphospholipid syndrome (APS) treatment? Autoimmun Rev 2015;14:760-2.

[2]Mekinian A, et al. The efficacy of hydroxychloroquine for obstetrical outcome in antiphospholipid syndrome: data from a European multicenter retrospective study. Autoimmun Rev 2015;40:498-502.

[3]Mekinian A et al. Obstetrical APS: is there a place for hydroxychloroquine to improve the pregnancy outcome? Autoimmun Rev 2015;14:23-9.

Disclosure of Interests

None declared

AB0423 STRATEGIES FOR GLUCOCORTICOID TREATMENT IN SYSTEMIC LUPUS ERYTHEMATOSUS FLARES: A REAL-LIFE EXPERIENCE

Background

Glucocorticoids (GC) are a cornerstone for the treatment of Systemic Lupus Erythematosus (SLE) manifestations but there is still open debate concerning their optimal therapeutic employment.

Objectives

To describe and compare the GC therapeutic strategies used in a real-life setting for the initial treatment of SLE flares.

Methods

This study is a retrospective analysis of data from a monocentric cohort of SLE patients who registered a disease flare between 2015 and 2020. Flares were first categorized in “pulse-treated” (PT) and “non pulse-treated” (NPT). PT flares were then divided into “low-dose regimen” (250 mg iv 6MP for 3 consecutive days or less) and “high-dose regimen” (more than 250 mg iv 6MP for 3 days). GC daily and cumulative 6MP doses, rate of remission and relapse were evaluated at 3, 6 and 12 months.

Results

101 flares were analyzed (30 PT and 71 NPT). PT flares were more severe in terms of median SLEDAI (PT 16(12-22) vs NPT 8(5-10) p=0,00) and BILAG score index (BILAG A PT 71% vs NPT 30% p=0,001). PT patients received significantly higher GC doses at 1 month (PT median cumulative dose 1372 IQR 1028 – 3076 mg of 6MP vs NPT median 160 IQR 120-288 mg of 6MP, p=0,000), 6 months (PT median cumulative dose 2964 IQR 2294 – 4305 mg of 6MP vs NPT 880 IQR 720 – 1284 mg of 6MP, p=0,000) and 12 months (PT median cumulative dose 3510 IQR 3014-5025 vs NPT median cumulative dose 1571 IQR 1098 – 2122 mg of 6MP, p=0,000). Characteristics of flares that were treated with low-dose (N=19) or high-dose (N=11) pulse regimen are summarized in Table 1. As expected, the “low-dose regimen” subgroup received lower cumulative GC dosage over time. However, no statistically significant differences were found neither in term of disease severity at baseline nor in term of disease activity, remission rates or new flares over time.

Table 1.

Comparison between low-dose pulse regimen and high-dose pulse regimen in terms of cumulative GC dose and outcome in the first year after a SLE flare

Median GC doses (6MP)Low-dose regimenN=19 (63,33%)High-dose regimenN=11 (36,67%)P value Median SLEDAI16 (12 -20)18 (8-24)0,6186BILAG score (A, B, C)A=14, B=4, C=1A=10, B=1, C=00,488Cum. dose 1 mo1350 (1028 – 1534)1752 (960 – 2356)0,126Cum. dose 3 mos1858 (1604 – 2463)2784 (2184 – 3240)0,040Cum. dose 6 mos2450 (2218 – 3586)3456 (2906 – 4380)0,029Cumulative doses 12 mos3150 (2851 - 4448)4246 (3591 – 5772)0,011Remission 3 mos no – (%)2 (10%)0 (0%)0,265Remission 6 mos no – (%)8 (42%)1 (9%)0,057Remission 12 mos no – (%)12 (63%)5 (45%)0,346Median SLEDAI 3 mos4 (2 – 9)9 (4 – 12)0,138Median SLEDAI 6 mos3 (0 - 4)4 (0 – 9)0,154Median SLEDAI 12 mos2 (0 – 5)2 (0 – 12)0,363New flares 6 mos no – (%)2 (10%)1 (9%)0,900New flares 12 mos no – (%)2 (10%)2 (18%)0,552

GC=glucocorticoids, 6MP=6-methylprednisolone, no=number, Cum.=cumulative, mos=months

Conclusion

These data suggest that in a real-life setting, pulse GC therapy is preferred over oral administration for severe SLE flares and entails administration of high cumulative doses of GC. However, the experience outlined suggests that the low-dose pulse regimen is as effective in remission induction of severe flares as the high-dose regimen, allowing significant GC sparing. Since the cumulative GC dose is a known strong predictor of organ damage, strategies aimed to minimize the GC dosage should be encouraged.

Disclosure of Interests

None declared

POS1502-HPR A PHYSICAL EXERCISE PROGRAM FOR THE MANAGEMENT OF FATIGUE IN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) AT THE TIME OF PANDEMIC: A PILOT STUDY

Background

Fatigue in SLE has a multifactorial origin and disease activity seems to contribute only minimally to its genesis. Therefore, non-pharmacological therapeutic strategies should also be considered in the management of fatigue. There is some evidence on the effectiveness of aerobic exercise programs in improving fatigue, without a negative impact on disease manifestations.

Objectives

the aim of this study was to analyze fatigue and Health Related Quality of Life (HRQoL) in a monocentric cohort of patients with SLE, in a condition of stable remission or low disease activity, before and after a program of physical exercise, through the administration of validated Patient Reported Outcomes (PROs).

Methods

this is a cross-sectional interventional study which included patients with SLE, aged between 18 and 55 years, in a condition of stable (≥12 months) remission (DORIS)1 or low disease activity (LLDAS)2. Patients enrolled had a FACIT score ≤40 in the previous 6 months. Patients with other possible causes of fatigue (e.g.: anemia, hypothyroidism, severe vitamin D deficiency), active arthritis or physical disabilities were excluded. For each patient, demographics, comorbidities, treatment, clinical and laboratory data were collected. Disease activity was evaluated with the SELENA-SLEDAI and organ damage with the SLICC/DI. Each patient completed the following PROs before and after the interventional program: SF-36, FACIT-Fatigue, LIT, HADS. Due to the limitations related to the COVID-19 pandemic, the physical exercise sessions were carried out using the Google Meet digital platform. Patients were asked to participate to at least 70% of the lessons. The physical exercise program included moderate intensity aerobic exercises (muscle strengthening, joint mobility, breathing, static and dynamic stretching, balance and neuro-dynamics); workouts were performed 3 times a week, consisting of 60 minutes each. The program lasted for 12 weeks.

Results

we enrolled 12 female patients, regularly followed at the Rheumatology Unit of Pisa; only 9 of them completed the study (mean age 38.56 ± 9.1 years; median disease duration 7 years (IQR 5,25-9,75)). 8/9 were in stable remission, while 1/9 was in LLDAS for the presence of leukopenia.

2/9 patients presented organ damage, one for cataract and one for renal insufficiency, while none presented damage in the musculoskeletal system. 33.3% of patients had fibromyalgia. 88.8% was on treatment with Hydroxychloroquine, 55.5% was on low dose steroids (2±1.9 mg/daily), 33.3% was on Mycophenolate Mofetil; only 1 patient was on Belimumab. All PROs showed a trend to improvement at the end of the 12-week program of physical activity (Table 1). We demonstrated a statistically significant improvement of: FACIT, LIT, depression score of the HADS and MCS of the SF-36. The items of role physical (RP), vitality (VT) and mental health (MH) of the SF-36 also showed a significant improvement.

Table 1.

Scores of PROs before and after the physical exercise program.

PROsMean scores at baselineMean scores after the 12-week exercise programpFACIT30.2 ± 4.939.3 ± 7.20.01PF73.18 ± 10.978.9 ± 10.50.18RP50 ± 13.267.4 ± 18.60.03BP52 ± 12.154.1 ± 11.10.73GH41.7 ± 11.148.4 ± 11.10.07VT34.7 ± 12.559.0 ± 14.20.002SF58.3 ± 15.666.7 ± 16.70.3RE55.5 ± 21.569.4 ± 18.00.13MH58.3 ± 15.867.2 ± 16.20.03PCS43.8 ± 4.046.1 ± 4.80.19MCS38.6 ± 8.845.6 ± 8.70.03LIT36.9 ± 14.227.5 ± 14.10.05HADS (A)9 ± 4.47.7 ± 3.20.4HADS (D)7.9 ± 4.45.1 ± 2.960.05

Conclusion

In a small cohort of SLE patients in remission but with severe fatigue, in the difficult context of COVID-19 pandemic, we demonstrated that an online program of physical exercise may determine a significant improvement of fatigue, perception of disease burden and mental health. In the context of a multidisciplinary management, finding effective intervention programs to improve fatigue and HRQoL in SLE patients appears of utmost importance, with the final aim of improving patients’ health status.

References

[1]PMID 27884822; 2PMID 26458737

Disclosure of Interests

None declared

OP0128 ADHERENCE TO MEDICATIONS DURING PREGNANCY IN SYSTEMIC AUTOIMMUNE DISEASE

Background

Low medication adherence is a well known issue in the management of patients with systemic autoimmune diseases (SAD), little however is known on adherence to medication during pregnancy, especially in these patients with high risk pregnancies.

Objectives

This study is aimed at evaluating the level of adherence to medication in pregnant patients with SAD in comparison with non-pregnant patients with SAD, and at identifying determinants of low adherence.

Methods

Pregnant and non-pregnant patients with an established diagnosis of SAD were consecutively enrolled. Pregnant patients were included in a tight monitoring protocol for high risk pregnancies, and treatments were checked every month. The following data were collected at enrolment: epidemiological and demographic characteristics, disease duration and type of medications. Each patient completed the following anonymous questionnaires: the 8-item Morisky Medication Adherence Scale (MMAS-8) and Hospital Anxiety and Depression Scale (HADS) to assess the presence of anxiety and depression. With regard to MMAS-8, we assessed adherence to hydroxychloroquine (HCQ) and to other disease modifying antirheumatic drugs (DMARDs) separately. We considered a score ≥ 6 as indicator of good adherence. Vitamins and dietary supplements were not considered.

Results

A total of 80 pregnant women and 72 non-pregnant women were enrolled. Clinical data and results of the questionnaires are summarized in Table 1.

Table 1.

Characteristics of the cohort

Pregnant patients N=80Non-pregnant patients N=72P valueAge at study entry (years, mean ±SD)35.8±4.340.1±12.20.001Disease duration (years, mean ±SD)8.5±6.68.6±9.1n.sNumber of tablets/day (mean ±SD)4.3±1.64.1±1.8n.sNumber of assumption/day (mean ±SD)1.4±0.61.6±0.8n.sScore MMAS for HCQ (mean ±SD)6.99±0.26.38±0.20.039Score MMAS for other DMARDs (mean ±SD)6.99±0.36.39±0.20.018Patients with good adherence to HCQ (%)38/50 (76.0%)34/59 (57.6%)0.044Patients with good adherence to medications (%)53/71 (74.6%)37/60 (61.7%)n.sPatients with low adherence to HCQ (%)12/50 (24%)25/59 (42.4%)0.044Patients with low adherence to medications (%)18/71 (25.4%)23/60 (38.3%)n.sAnxiety (%)20 (25%)30 (41.7%)0.029Depression (%)11 (13.7%)19 (26.4%)0.051

MMAS-8 score was significantly higher in pregnant women both for HCQ (p=0.039) and other DMARDs (p=0.018), as well as the rate of patients with good medication adherence for HCQ (76.0% vs 57.6%, p=0.044). The rate of patients with good medication adherence for other DMARDs was higher in pregnant patients (74.6% vs 61.7%) but this different was not statistically different.

Demographic and clinical characteristics and the number of therapies received didn’t seem to influence treatment adherence. Fifty patients (32.8%) suffered from anxiety, and this disorder was a significant determinant of low medication adherence in all groups. Conversely, depression didn’t seem to have an impact on adherence on neither group.

Conclusion

Overall, pregnant patients with SAD had a good adherence to prescribed medication; nevertheless, 25% of patients didn’t take therapies adequately despite being closely monitored in a dedicated clinic for high risk pregnancies and an adequate pregnancy counselling; anxiety seems to be one determinant of low medications adherence both in pregnant and non-pregnant women.

Disclosure of Interests

None declared

Impact of low-dose acetylsalicylic acid on pregnancy outcome in systemic lupus erythematosus: results from a multicentre study

Objective

It is still a matter of debate whether low-dose acetylsalicylic acid (LDASA) should be prescribed to all patients with SLE during pregnancy. This study aimed at investigating the impact of LDASA on pregnancy outcomes in patients with SLE without history of renal involvement and without antiphospholipid antibodies (aPL).

Methods

This is a retrospective analysis of prospectively monitored pregnancies at seven rheumatology centres. Previous/current renal involvement and aPL positivity were the exclusion criteria. Adverse pregnancy outcome (APO) is the composite outcome of the study and included proteinuric pre-eclampsia, preterm delivery <37 weeks, small-for-gestational age infant, low birth weight <2500 g, intrauterine growth restriction and intrauterine fetal death after 12 weeks of gestation of a morphologically normal fetus.

Results

216 pregnancies in 187 patients were included; 82 pregnancies (38.0%) were exposed to LDASA treatment. No differences in terms of age at conception, disease duration, clinical manifestations, comorbidities and disease flare during pregnancy were observed between patients taking LDASA and those who did not take LDASA during pregnancy. APO was observed in 65 cases (30.1%), including 13 cases (6.1%) of pre-eclampsia. The incidence of all complications was similar in the two groups. However, it is interesting to note that pre-eclampsia had lower frequency in patients taking LDASA versus those not taking LDASA (2.4% vs 8.3%, p=0.14).

Conclusions

In pregnant patients with SLE without renal involvement and were aPL-negative, there is a low risk of severe obstetric complications, such as early pre-eclampsia. LDASA treatment does not provide a statistically significant advantage over these complications. However, a careful individual risk–benefit balance is warranted.

OP0125 THE MANAGEMENT OF PREGNANCY IN AUTOIMMUNE RHEUMATIC DISEASES: ANALYSIS OF 758 PREGNANCIES FROM THE PROSPECTIVE NATIONWIDE P-RHEUM.IT STUDY (THE ITALIAN REGISTRY OF PREGNANCY IN THE RHEUMATIC DISEASES)

Background

Pregnancy is a topic of fundamental importance for women living with autoimmune rheumatic diseases (ARD). Efforts at national and international levels have been put in the collection and harmonization of data in order to implement an evidence-based management of pregnant patients.

Objectives

The P-RHEUM.it study was designed as a nationwide, web-based longitudinal observational cohort study to collect data about pregnancy in ARD in 26 centers in Italy. The study started in May 2018 and has been supported by the Italian Society for Rheumatology.

Methods

Pregnant patients with a definite rheumatic disease according international criteria were enrolled up to gestational week (GW) 20. The course of maternal disease activity, the use of medications, fetal and maternal complications, and the quality of life (EuroQoL questionnaire) were collected for each trimester, as well as pregnancy outcome, mode of delivery, neonatal complications, and maternal and children’s follow-up to 6 months after delivery, including the screening for post-partum depression by means of EPDS (Edinburgh Postnatal Depression Scale).

Results

As of December 2021, 758 pregnancies had been enrolled, 205 (27%) ongoing and 553 (73%) with outcome. Pregnancy loss occurred in 54 (9.8%) cases (40 spontaneous miscarriages; 6 voluntary terminations). Live births were 495 (89.5%), perinatal death occurred in 4 (0.7%) cases. Table 1 reports on the group of 495 live births, along with subgroups of Rheumatoid Arthritis (RA) and Systemic Lupus Erythematosus (SLE), the two most represented diseases. Regarding treatments, 166 (30%) pregnancies were exposed to corticosteroids, 239 (43%) to hydroxychloroquine, 59 (10.7%) to csDMARDs, 84 (15.2%) to TNF inhibitors, 1 (0.2%) to non-TNFi bDMARDs, 299 (54%) to low dose acetylsalicylic acid, and 126 (22.8%) to heparin.

Table 1.PREGNANCIES WITH LIVE BIRTHS, EXCLUDING PERINATAL DEATHSTotal pregnancies (n=495)RA pregnancies (n=69)SLE pregnancies (n=93)Age at conception (years)34 (31 - 37)34.5 (32 - 38)34 (31 - 36)Disease duration (years)6.1 (2.2 - 11.1)7.1 (4.3 - 11.6)9.3 (5.9 - 15.9)Caucasian431 (87.8%)53 (79.1%)75 (80.6%)Never smokers358 (73.8%)53 (80.3%)66 (71.7%)Body Mass Index >3045 (9.5%)7 (10.3%)5 (5.6%)Arterial Hypertension6 (1.2%)0 (0%)2 (2.2%)Time to pregnancy (months)3 (1 - 6)3 (1 - 6)3 (0 - 10)Physician-reported flares in the 12 months prior to conception107 (23%)22 (34.4%)13 (14.8%)Physician global assessment at enrolment (VAS 0-100)5 (0 - 17)5 (0 - 20)4 (0 - 10)Patient global health at enrolment (VAS 0-100)18 (7 - 30)10 (5 - 29)10 (5 - 25)EuroQoL at enrolment (-1.6 – 1)1 (0.8 - 1)1 (0.8 - 1)1 (0.8 - 1)Flares during pregnancy35 (7.1%)6 (8.7%)7 (7.5%)Hypertensive disturbances*8 (1.7%)1 (1.6%)6 (6.6%)Delivery at term (≥37 GW)410 (85.1%)53 (77.9%)74 (80.4%)Spontaneous vaginal delivery173 (35.9%)23 (33.8%)23 (25.3%)Congenital malformations11 (2.4%)2 (3.1%)1 (1.1%)Small for gestational age (SGA) neonate24 (4.9%)1 (1.4%)9 (9.9%)Breastfeeding in the first 4 weeks after delivery341 (79.7%)45 (77.6%)59 (76.6%)EPDS score at risk for post-partum depression22 (14.1%)0 (0%)3 (10.3%)

Continuous variables are expressed as median (interquartile range); *gestational hypertension/preeclampsia/HELLP syndrome/eclampsia.

Conclusion

Multiple factors may have contributed to the high rate of live births, including good disease control before and during pregnancy thanks to the use of anti-rheumatic drugs and low frequency of general risk factors. SLE pregnancy was affected by a higher frequency of complications (hypertensive disturbances, SGA babies) as compared to RA pregnancy. Nearly 80% of patients breastfed in the first month after delivery. For the first time, data about the screening questionnaire for post-partum depression were collected, showing at least 1 out 10 patients can be at risk.

References

[1]Meissner Y et al. Arthritis Res Ther;21(1):241; Ann Rheum Dis. 2021;80(1):49-56.

Acknowledgements

P-RHEUM.it study is supported by the Italian Society for Rheumatology (SIR). All the Investigators are acknowledged for their contribution.

Disclosure of Interests

None declared

Self-Reported Anxiety and Depression in a Monocentric Cohort of Patients With Systemic Lupus Erythematosus: Analysis of Prevalence, Main Determinants, and Impact on Quality of Life

Aims of the study

To analyze the prevalence of self-reported anxiety and depression in a monocentric cohort of patients with Systemic Lupus Erythematosus (SLE); to study the main determinants and the impact on quality of life (QoL).

Methods

A cross-sectional observational study including adult outpatients with SLE. Demographic and clinical data were analyzed: indices of disease activity (SELENA-SLEDAI); damage (SLICC-DI); comorbidities and concomitant therapies. The definitions for remission (DORIS) and “Lupus Low Disease Activity State” (LLDAS) were applied. At enrollment, each patient completed the following questionnaires: SF-36, FACIT-Fatigue, Lupus Impact Tracker (LIT), Systemic Lupus Activity Questionnaire (SLAQ), and the Hospital Anxiety and Depression Scale (HADS) in order to self-assess anxiety and depression symptoms. The Student t-test and Chi² tests were conducted for univariate analysis. The Spearman test was used for linear correlation between continuous data. Multivariate analysis was performed by multiple linear and logistic regression.

Results

One hundred fifty-four consecutive patients with SLE were enrolled, the majority female and Caucasian with a mean age = 43.3 ± 13.7 years. 79.9% were in LLDAS or remission. 36.4% had a SDI > 1. 13.7% of patients had concomitant fibromyalgia. 37.4% had symptoms indicating anxiety and 25% of depression according to the HADS questionnaire. In the multivariate analysis, patients with active disease were significantly more anxious and depressed (p < 0.01) compared to patients in LLDAS or remission. Fibromyalgia and older age were independently associated with anxiety and depression, respectively (p < 0.05). Active skin involvement was significantly linked to depression (p < 0.05). Higher scores on the HADS questionnaire (higher levels of anxiety and depression) were found to be significantly linked to patients’ perception of higher disease activity and worse quality of life, irrespective of disease activity, age and fibromyalgia.

Conclusion

Symptoms of anxiety and depression are frequent in SLE patients, including outpatients with mild/moderate disease. Such symptoms have a significant negative impact on QoL and perception of disease activity, regardless of other factors. Moreover, disease activity, advanced age and fibromyalgia appear to be significantly linked to mood disorders. Assessing symptoms of the anxious-depressive spectrum in patients with SLE could lead to improvement in patients’ perception of health status and quality of life.

One year in review 2022: systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic multisystem auto-immune disease with extremely varied clinical manifestations and a complex pathogenesis. New insights in SLE about pathogenetic pathways, biomarkers, and data on clinical manifestations are progressively emerging, and new drugs and new therapeutic strategies have been proposed to improve the control of disease activity. Thus, this review is aimed to summarise the most relevant data about SLE emerged during 2021, following the previous annual review of this series.

POS0756 HOW HAS OUR MANAGEMENT OF SLE CHANGED OVER THE LAST THREE DECADES? REAL LIFE DATA FROM A MONOCENTRIC COHORT

Background:

Over the last decades new therapies have been approved and new treatment strategies have been proposed in the treatment of SLE. In particular, recently, EULAR recommendations1 and the Treat to Target2 approach established a new paradigm for the treatment of SLE based on the early introduction of immunosuppressive treatment and glucocorticoids (GC) minimization.

Objectives:

to evaluate changes in therapeutic approach and outcomes over the last three decades in a monocentric cohort of SLE patients.

Methods:

This is a retrospective analysis of prospectively collected data from a monocentric cohort of patients with SLE with disease diagnosis between 1990 and 2020. Based on the year of diagnosis, patients were divided in three groups, each of them corresponding to a decade: group 1: decade 1990-1999; group 2: decade 2000-2009; group 3: decade 2010-2020. For each patient, epidemiological and demographic characteristics, cumulative organ involvement and serology, previous and ongoing therapies, comorbidities were collected and compared among the 3 groups. Organ damage was evaluated by the SLICC-DI (SDI)3 at 1 and 5 years from diagnosis, as comorbidities we considered hypertension, diabetes, osteoporosis and cardiovascular (CV) events occurred during the follow-up.

Results:

A total of 262 SLE patients were enrolled in the study (97% Caucasian, 90.5% females): 69 patients in group 1, 100 in group 2 and 93 in group 3. Demographic and clinical characteristics of whole cohort and of the three groups are summarized in table 1. Differences in therapies during the first year from diagnosis among the groups are summarized in table 1. In group 3 the use of Micophenolate Mofetil was significantly more common with respect to the group 1 (25% vs 1.4%, p= 0.001) and similar to group 2 (25% vs 25.5%, p=ns); on the contrary, in group 3, Azathioprine (AZA) and Cyclosporine (Cya) were less used (13.2% vs 27.5%, p=0.003 and 3.3% vs 14.3%, p= 0.019 respectively). As Cyclophosphamide (CYC) is concerned, it was used with the same frequency in the three decades, but in group 1, the total dose of CYC was significantly higher than second and third group (4.8 g vs 2.3 and 0.9, p=0.02 and p=0.001 respectively). In group 2 and 3, during the first year of disease, biological drugs (Rituximab or Belimumab) have been used more frequently (2% and 2.2% vs 0%, p=0.04). Any differences have not been showed for GC among the groups. However, in group 3 a significantly higher proportion of patients stopped GC therapy within 5 years from diagnosis (34.5% vs 8.8% and 12.5%, p=0.001) and in the same group the duration of GC therapy was significantly shorter with respect to previous two decades (3.1 years vs 16.8 and 10.5 respectively, p=0.001). As regard damage accrual, at 1 and 5 years from diagnosis, no significant differences among groups were observed; however, hypertension resulted significantly less common in group 3 (10% vs 26% and 37.3%, p=0.001), even adjusting for age (OR=0.2); less CV events were recorded in group 3, but significance is lost adjusting for age.

Table 1.Whole cohortGroup 1Group 2Group 3pPatients (n)2626910093Caucasian (%)97%99%98%94.6%.n.s.Females (%)90.5%94.2%95%92.5%n.s.Median age at diagnosis IQR)29 (20-36)27 (20-32)28.5 (20-36)34 (23-44)0.001Cumulative organ involvementRenal48.1%52.2%57%35.5%0.007Articular74.4%75.3%66%82.8%n.s.Serositic19.5%20.3%22%16.1%n.s.Neuropsychiatric8%11.6%6%7.5%n.s.Cutaneous63%70%60%61.3%n.s.Hematological58.4%51.5%61%61.3%n.s.Therapies 1styearAZA17.2%8.7%27.5%13.2%0.003MMF18.7%1.4%25.5%25.3%0.001CYC22.5%21.7%27%17%n.s.Cya9.9%13%14.3%3.30.019Biologicals1.5%0%2%2.2%n.s

Conclusion:

These data show that new therapies and new treatment strategies have actually been implemented in clinical practice over the past 30 years; further studies with a longer follow-up are necessary to appreciate the impact of these advancement on clinical outcomes.

References:

[1]Bertsias G, et al. Ann Rheum Dis 2008.

[2]van Vollenhoven RF, et al.Ann Rheum Dis 2014.

[3]Gladman DD, et al. J Rheumatol 2000.

Disclosure of Interests:

None declared

POS0737 LOW PRECONCEPTIONAL COMPLEMENT LEVEL IS RELATED WITH ADVERSE OBSTETRIC OUTCOME IN A MULTICENTRIC COHORT OF PREGNANCY IN PATIENTS WITH APS AND APL POSITIVITY

Background:

The role of complement in the antiphospholipid (aPL) related pathology has been widely studied in animal models. Antiphospholipid antibodies can induce fetal loss in experimental animals but mice deficient in specific complement components (C4, C3, C5) appear somehow protected. In addition, in pregnant mice injected with aPL, antibody deposition has been found at decidual level causing focal necrosis, apoptosis and neutrophil infiltrates and supporting aPL pathogenetic potential. On the other hand, human studies did find hypocomplementemia associated to pregnancy complications in patients with obstetric antiphospholipid syndrome (APS). These results, however, are not unanimously confirmed and, in addition, some studies only show increased levels of complement activation products (i.e. Bb) and not decreased levels of C3 and/or C4. A recently study focusing on complement level in early pregnancy and before pregnancy showed a significant correlation with pregnancy complications and loss in a large cohort of primary APS.

Objectives:

To investigate if the simple detection of low C3 and/or C4 could be considered a risk factor for adverse pregnancy outcome in APS and aPL carriers pregnancies.

Methods:

We performed a multicentric study including patients from 10 Italian and 1 Russian Centers. Data on pregnancies in women with primary APS (n=434) and asymptomatic carriers with persistently positive aPL but not fulfilling clinical criteria for APS (n=218) were retrospectively collected. Serum C3 and C4 levels were evaluated by nephelometry; hypocomplementemia was defined by local laboratory reference values. Statistical analysis was performed using GraphPad.

Results:

Preconceptional complement levels and gestational outcome were available for 107 (25%) pregnancies in APS out of 434 and for 196 (90%) pregnancies in aPL carriers women out of 218. In pregnancies with low preconceptional C3 and/or C4, a significantly higher prevalence of pregnancy losses was observed (p=0.019). A subgroup analysis focusing on triple aPL positive patients was also performed. Preconceptional low C3 and/or C4 levels were found to be associated with an increased rate of pregnancy loss (p = 0.027) in this subgroup also. Otherwise, adverse pregnancy outcomes in single or double aPL positive women were not related to preconception complement levels (p = 0.44) (Table 1). Of note, all the pregnancy losses in the triple positive group occurred in patients treated with low dose aspirin and low molecular weight heparin from the time of positive pregnancy test.

Conclusion:

Our findings confirm that decreased complement levels before pregnancy are associated with increased risk of adverse outcome. This has been seen only in in women with triple aPL positivity, indeed single or double positivity does not show this trend. Complement levels are cheap and easy to be measured therefore they could represent a useful aid to identify patients at increased risk of pregnancy loss. test positivity.

References:

[1]De Carolis S, et al. Complementemia and obstetric outcome in pregnancy with antiphospholipid syndrome. Lupus (2012) 21:776–8.

[2]Kim MY, et al. Complement activation predicts adverse pregnancy outcome in patients with systemic lupus erythematosus and/or antiphospholipid antibodies. Ann Rheum Dis (2018) 77:549–55.

[3]Fredi M, et al. Risk Factors for Adverse Maternal and Fetal Outcomes in Women With Confirmed aPL Positivity: Results From a Multicenter Study of 283 Pregnancies. Front Immunol. 2018 May 7;9:864.

Triple aPL positivitySingle or double aPL positivityGestational outcomeLow C3/C4 (n=49)Normal C3/C4(n=17)pLow C3/C4 (n=57)Normal C3/C4(n=165)pTerm live birth (>37w)15 (31%)6 (35%)ns34 (60%)110 (67%)nsPreterm live birth (≤37w)22 (45%)11 (65%)ns15 (26%)38 (23%)nsPregnancy losses (abortion and miscarriages)12 (24%)0 (0%)0.0278 (14%) 17 (10%)ns

Disclosure of Interests:

None declared

POS0760 MONITORING C3 AND C4 VARIATIONS IN SYSTEMIC LUPUS ERYTHEMATOSUS PREGNANCIES IS USEFUL TO RECOGNIZE COMPLICATIONS. DATA FROM 2 ITALIAN CENTERS

Background:

In SLE pregnancies adverse pregnancy outcomes (APO) are more frequent than in general obstetric population (GOP). In clinical practice, low C3 and C4 levels are associated with active disease and, during pregnancy, complement activation products are shown to be associated with APO.

Objectives:

To analyse complement variations during SLE pregnancies, focusing on disease flares and APO.

Methods:

Data on SLE pregnancies prospectively-followed by multidisciplinary team in 2 Italian Centers from 1987 to 2018 were retrospectively analysed. C3 and C4 normal levels were calculated in general obstetric population (GOP) as previously described1, and related to maternal and fetal outcome. Non categorical variables were compared using Mann-Whitney test or Wilcoxon test when appropriate.

Results:

Two hundred forty-six pregnancies in 172 SLE patients were analysed (mean age at conception 31.3 ±4.9 years; mean disease duration 8.3 ±7.1). Anti-Ro antibodies were positive in 64 patients (37%) and anti-phospholipid antibodies (aPL) were positive in 84 (48%), with single positivity in 54%, double in 24% and triple in 21%; 9 patients (5%) had also a diagnosis of obstetric-antiphospholipid syndrome (APS) and 8 (4%) had thrombotic-APS. Seventy-one patients (41%) had history of Lupus Nephritis.

Thirty-five flares were recorded in 30 pregnancies (12%). APO occurred in 47 pregnancies (19%) and were: 27 fetal loss (20 early miscarriage <10th week and 7 intrauterine fetal death), 11 severe preterm birth (<34th week) and 15 hypertensive disorder (11 pre-eclampsia and 5 pre-eclampsia+HELLP syndrome).

In GOP, C3 progressively increased throughout pregnancy and C4 increase from the 1st trimester to the 2nd trimester, as well as in SLE pregnancies without flares and without APO, from preconception (Fig 1). In the other SLE groups, C3 and C4 showed a different trend: in pregnancies with flares, they did not increase from preconception to the 1st trimester; in fetal losses and severe pre-term births, they remained stable throughout pregnancy; in hypertensive disorders they increased only between preconception and the 1st trimester.

C3 and C4 levels were higher in GOP than in all SLE pregnancies groups (including those without flares and without APO) in each trimester. SLE pregnancies without flares showed higher C3 and C4 levels than pregnancies with flares, at preconception and in each trimester. SLE pregnancies without APO had higher C3 and C4 levels than pregnancies with fetal death at 2nd trimester, higher C3 levels than severe pre-term births in each trimester and higher C4 at 3rd trimester (Fig.1).

At preconception, pregnancies with flares showed a higher frequency of low C3 and of low C4 than in pregnancies without flares (76% vs 42%, p=0.01; 76% vs 26%, p<0.001, respectively). Using the normality range previously calculated in GOP, SLE pregnancies with flares had higher frequency of low C4 in every trimester as compared with pregnancies without flares (1st: 82% vs 48%, p=0.003; 2nd: 82% vs 64%, p=0.01; 3rd: 64% vs 30%, p=0.002). At multivariate analysis, low C4 at preconception was associated with flare (OR [95% CI]: 10.34 [2.52-42.39]; p=0.001).

Figure 1.

Variations of C3 and C4 median levels (mg/dL) throughout pregnancy in GOP1 and in SLE pregnancies without and with flare (a) and without and with APO (b).

* p <0.05

^as compared with SLE groups: p<0.05; § as compared with SLE pregnancies without flare: p<0.05; + as compared with SLE pregnancies without APO: p<0.05

Conclusion:

In SLE pregnancies, monitoring of C3 and C4 is important: its failure to increase can be useful to recognize potential risk situations which deserve particular monitoring.

References:

[1]Reggia R. et al. Rheumatology 2012;51:2186-2190.

Disclosure of Interests:

None declared

POS0789 APPLICATION OF THE NEW ACR/EULAR 2019 CLASSIFICATION CRITERIA OF SYSTEMIC LUPUS ERYTHEMATOSUS TO A INCEPTION, MONOCENTRIC COHORT OF UNDIFFERENTIATED CONNECTIVE TISSUE DISEASES POPULATION AT ONSET OF THE DISEASE

Background:

undifferentiated connective tissue diseases (UCTDs) are a group of systemic autoimmune diseases that share clinical and serological manifestations with definite connective tissue diseases (CTDs), but do not satisfy existing classification criteria1. Within this group, it is possible to identify very heterogeneous conditions: transitory and self-limiting forms, stable conditions over time and forms that will evolve towards definite CTDs, in particular Systemic Lupus Erythematosus (SLE). The availability of new classification criteria for CTDs could be useful in identifying major CTDs from their onset and help in the differentiation from stable UCTDs, which will maintain their undifferentiated profile over time.

Objectives:

the aim of this study was to apply the new ACR/EULAR 2019 classification criteria of SLE2 to patients included, at the onset of UCTD, to evaluate how many patients could be re-classified as SLE.

Methods:

this is a retrospective observational study that enrolls patients who received the diagnosis of UCTD at the Rheumatology Unit of Pisa, according to the classification criteria proposed by Mosca et al1, and were then regularly followed in the same clinic (inception cohort). For each patient, demographics, comorbidities, treatment, clinical and serological data were collected, at baseline and during follow-up. The new ACR/EULAR 2019 classification criteria of SLE were applied to the inception cohort at the onset of the disease. The characteristics of patients re-classified as SLE according to the new classification criteria and those of patients who “remained” classified as UCTD were compared.

Results:

we enrolled 202 patients with a diagnosis of UCTD, mainly female (F:M 193:9) and of Caucasian ethnicity (97.5%), mean age at the diagnosis 38,5 ± 13,2 years and a median follow-up of 5 years (IQR 2-10).

During the follow-up, 10 patients (4.9%) in our cohort developed clinical and serological characteristics that led to a diagnosis of a definite CTD, in particular: 7 SLE, 2 Mixed Connective Tissue Disease (MCTD) and 1 Sjogren’s syndrome.

Applying the ACR/EULAR 2019 classification criteria of SLE to patients enrolled at the onset of the disease, 38/202 (18.8%) would have been classified as SLE (with a median score of 12 (IQR 11-15)) on the basis of the presenting clinical and serological manifestations. Interestingly, 6/7 patients who received a diagnosis of SLE during the follow-up were among these 38 patients.

Among the items of the new classification criteria of SLE, the most frequently satisfied by patients “re-classified” were arthritis (63.2%), hematological (44.7%) and skin (23.7%) manifestations; as for the “immunological” items, hypocomplementemia (71%), SLE-specific (52.6%) and antiphospholipid (35.1%) autoantibodies.

Comparing the subgroup of patients “re-classified” as SLE with that of patients who “remained” UCTD, we found that the first group presented more frequently hematological manifestations, hypocomplementemia and anti-dsDNA, anti-Sm, anti-RNP, anti-beta2GPI positivity at the onset of the disease (p<0.01). Moreover, during the follow-up, the subgroup of patients “re-classified” as SLE developed more frequently malar (p<0.05) and discoid rash and arthritis (p<0.01) compared to patients who “remained” UCTD.

Conclusion:

The development of increasingly sensible and specific classification criteria for definite CTDs may guide in the identification of stable UCTDs since their early stages and consequently in better definition of these conditions that can be considered as a distinct clinical entity.

The early identification of stable UCTD is of great importance not only for clinical management (follow-up schedules as well as therapeutic protocols) but also for scientific implications.

References:

[1]Mosca M. et al., Clin Exp Rheumatol. Sep-Oct 1999;17(5):615-20; 2. Fanouriakis A. et al., Ann Rheum Dis. 2020 Jun;79(6):713-723.

Disclosure of Interests:

None declared

Impact of fatigue on health-related quality of life and illness perception in a monocentric cohort of patients with systemic lupus erythematosus

Background

Fatigue is a very common and debilitating symptom in patients with systemic lupus erythematosus (SLE), even among those with a mild or inactive disease. The objective of this study is to define fatigue determinants and describe the impact of fatigue on health-related quality of life (HRQoL) and illness perception in a monocentric cohort of patients with SLE.

Methods

This is a cross-sectional study. Adult patients with SLE were included. For each patient, demographics, medications, comorbidities, organ damage (Systemic Lupus International Collaborating Clinics Damage Index), active disease manifestations and Systemic Lupus Disease Activity Index scores were collected. It was evaluated if each patient met the definitions of remission and low disease activity. At enrolment, each patient completed the Short Form-36 (SF-36), Functional Assessment Chronic Illness Therapy-Fatigue (FACIT-F), Lupus Impact Tracker (LIT), Systemic Lupus Activity Questionnaire (SLAQ) and Brief Index of Lupus Damage (BILD). The FACIT-F questionnaire was also administered to a group of healthy controls.

Results

223 patients were included (mean age 44.9±13.2 years, median disease duration 13 years). 18.2% had an active disease, 43.5% met the definition of remission on treatment, and 11.8% had a concomitant fibromyalgia. The median FACIT-F score of our cohort was significantly lower compared with that of healthy controls (40 vs 47; p<0.001). FACIT-F scores were irrespective of age, disease duration, disease activity and damage. FACIT-F score was significantly lower in patients with fibromyalgia (p<0.01). FACIT-F scores demonstrated a significant correlation with all other patient-reported outcomes: SF-36 (r=0.53–0.77), LIT (r=−0.78), SLAQ (r=−0.72) and BILD (r=−0.28).

Conclusions

Fatigue in patients with SLE has a strong negative impact on HRQoL and patient perception of the disease burden. Fatigue seems irrespective of disease activity but significantly influenced by the presence of fibromyalgia.

Are remission and low disease activity state ideal targets for pregnancy planning in Systemic Lupus Erythematosus? A multicentre study

OBJECTIVES

To determine whether disease remission or low disease activity state at the beginning of pregnancy in SLE patients is associated with better pregnancy outcome.

METHODS

pregnancies in SLE patients prospectively monitored by pregnancy clinics at four rheumatology centres were enrolled. Patient demographics and clinical information were collected at baseline (pregnancy visit before 8 weeks of gestation) including whether patients were in remission according to DORIS criteria and and/or Lupus Low Disease Activity State (LLDAS). Univariate and multivariate analysis were performed to determine predictors of disease flare and adverse pregnancy outcomes (APOs) including preeclampsia, preterm delivery, small for gestational age infant, intrauterine growth restriction and intrauterine fetal death.

RESULTS

347 pregnancies were observed in 281 SLE patients. Excluding early pregnancy losses, 212 pregnancies (69.7%) occurred in patients who were in remission at baseline, 33 (10.9%) in patients in LLDAS, and the remainder in active patients. 73 flares (24%) were observed during pregnancy or puerperium, and 105 (34.5%) APOs occurred. Multivariate analysis revealed that patients in disease remission or taking hydroxychloroquine were less likely to have disease flare, while a history of lupus nephritis increased the risk. The risk of APOs was increased in patients with shorter disease duration, while being on hydroxychloroquine resulted a protective variable. An almost significant association between complete remission and a decreased risk of APOs was observed.

CONCLUSIONS

Prenatal planning with a firm treat-to-target goal of disease remission is an important strategy to reduce the risk of disease flares and severe obstetrical complications in SLE pregnancies.

Impact of first wave of SARS-CoV-2 infection in patients with Systemic Lupus Erythematosus: Weighting the risk of infection and flare

Introduction

The aim of this study was to investigate the incidence and clinical presentation of SARS-CoV-2 infections in a Systemic Lupus Erythematosus (SLE) cohort; to assess correlations with disease characteristics and rheumatic therapy; and to evaluate the occurrence of treatment discontinuation and its impact on disease activity.

Materials and methods

SLE patients monitored by a single Italian centre were interviewed between February and July 2020. Patients were considered to be positive for SARS-CoV-2 infections in case of 1) positive nasopharyngeal swab; 2) positive serology associated with COVID19 suggesting symptoms. The following data were also recorded: clinical symptoms, adoption of social distancing measures, disease activity and treatment discontinuation.

Results

332 patients were enrolled in the study. Six patients (1.8%) tested positive for SARS-CoV-2 infection, with the incidence being significantly higher in the subgroup of patients treated with biological Disease-Modifying Anti-Rheumatic Drugs (p = 0.005), while no difference was observed for other therapies, age at enrollment, disease duration, type of cumulative organ involvement or adoption of social isolation. The course of the disease was mild. Thirty-six patients (11.1%) discontinued at least part of their therapy during this time period, and 27 (8.1%) cases of disease flare were recorded. Correlation between flare and discontinuation of therapy was statistically significant (p<0.001). No significant increase of rate of flare in a subgroup of the same patients during 2020 was observed.

Conclusion

Treatment discontinuation seems to be an important cause of disease flare. Our findings suggest that abrupt drug withdrawal should be avoided or evaluated with caution on the basis of individual infection risk and comorbidities.

How do systemic lupus erythematosus patients with very-long disease duration present? Analysis of a monocentric cohort

OBJECTIVE

to describe the disease path and the very long-term outcome in a monocentric cohort of patients with Systemic Lupus Erythematosus (SLE).

METHODS

SLE patients with a disease duration of at least 15 years from diagnosis were enrolled. The number of hospitalizations, the disease flares occurred over the disease course and the organ damage accumulation were evaluated at 1, 2, 3, 4, 5, 10 years from diagnosis and at last observation in 2019 as well. Disease state, ongoing therapies and quality of life measures were also assessed at last visit.

RESULTS

126 Caucasian SLE patients were included in the analysis (95% female, median age 47.5 IQR 41-53, median disease duration 21 IQR19-26). At last visit, the majority of the patients (78.6%) was on LLDAS (remission included), 53.4% were on GC treatment and 35.7% on immunosuppressant. Furthermore, 53.2% had at least one organ damage. The majority of patients (66.7%) presented a relapsing-remitting course, for a total of 158 flares during the disease course (incidence rate: 0.79/patient-year); moreover, 84.9% of the cohort experienced at least one hospital admission, amounting to a total of 328 hospitalizations (incidence rate: 0.85/patient-year). The main reason for admission was disease activity, while the percentage of hospitalizations due to other causes has been growing over the 10 years of follow-up.

CONCLUSION

after a very long period of disease, most of the patients with SLE are in remission and are not taking GC therapy; however, the risk of incurring in disease flare remains a real problem.

Articular involvement, steroid treatment and fibromyalgia are the main determinants of patient-physician discordance in systemic lupus erythematosus

Background

Remission or the lowest possible disease activity is the main target in the management of systemic lupus erythematosus (SLE). Anyway, conflicting data are present in the literature regarding the correlation between physician-driven definitions and patient perception of the disease. The objective of this study is to evaluate the relationship between the definition of lupus low disease activity state (LLDAS) and patient’s health-related quality of life (HRQoL).

Methods

This is a cross-sectional, monocentric study. Adult SLE patients were included. For each patient, demographics, disease duration, medications, comorbidities, organ damage, active disease manifestations and SELENA-SLEDAI were assessed. Patients have been categorised as follows: LLDAS, remission and active disease. Each patient completed the following patient-reported outcomes (PROs): SF-36, LIT, FACIT-Fatigue and SLAQ. A SLAQ score < 6 (25° percentile of our cohort) was used as the cut-off value to define a low disease activity state according to patient self-evaluation.

Results

We enrolled 259 consecutive SLE patients (mainly female and Caucasian, mean age 45.33 ± 13.14 years, median disease duration 14 years). 80.3% were in LLDAS, of whom 82.2% were in remission; 19.7% were active. No differences emerged for any of the PROs used between the LLDAS and the active group.

Considering the LLDAS subgroup, we identified 56 patients with a subjective low disease activity (SLAQ < 6) and we defined them as “concordant”; the remaining 152 patients in LLDAS presented a subjective active disease (SLAQ ≥ 6) and were defined “discordant”. Discordant patients presented more frequently ongoing and past joint involvement (p < 0.05) and a diagnosis of fibromyalgia (p < 0.01); furthermore, they were more likely to be on glucocorticoid therapy (p < 0.01). Discordant patients showed a significantly poorer HRQoL, assessed by all PROs (p < 0.0001).

Conclusions

Joint involvement, glucocorticoid therapy and comorbid fibromyalgia resulted to be the most important variables determining the poor concordance between patient and physician perspective on the disease.

Translation, cultural adaptation and validation of the Italian version of the Brief Index of Lupus Damage: the BILDit

Objectives

The Brief Index of Lupus Damage (BILD) is an instrument of self-evaluation of organ damage for systemic lupus erythematosus (SLE) patients. The objectives of this study were the translation, cultural adaptation and validation of the Italian version of the BILD (BILDit).

Methods

The process of translation and cultural adaptation followed published guidelines. The BILDit was pretested in a pilot study with 30 SLE patients in order to evaluate acceptability, reliability, comprehension and feasibility, and then validated in consecutive SLE patients attending our clinic.

Results

A total of 167 SLE patients were enrolled. In the pilot study, the BILDit demonstrated good acceptability, feasibility and comprehensibility and a very high degree of reliability (Cronbach’s α = 1). In the validation cohort, the BILDit showed a significant positive correlation with the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI; ρ = 0.69; p < 0.001). Analysing the item-by-item correlation between the BILDit and the SDI, a good correlation ( p < 0.001) was found for 73.1% of the items. In the multivariate analysis, the BILDit showed a significant positive correlation with age and disease duration ( p < 0.01).

Conclusions

The BILDit seems to be an acceptable and reliable instrument for patient self-evaluation of disease damage, with a good correlation with the SDI. It can be considered as a screening tool for the evaluation of organ damage starting from the patient’s perceptive.

Pregnancy and undifferentiated connective tissue disease: outcome and risk of flare in 100 pregnancies

OBJECTIVE

UCTD is a systemic autoimmune condition that fails to fulfil the criteria for a definite CTD. Given that there are a lack of studies on links between pregnancy and UCTD, the purpose of this study was to evaluate the risk of disease flares or development of CTD in addition to the risk of adverse pregnancy outcomes in patients with UCTD.

METHODS

This is a retrospective study using prospectively collected data for 100 pregnancies in 81 incidences of UCTD treated in a single referral centre.

RESULTS

A total of 11 pregnancies (11%) ended in miscarriage in the first trimester and the remaining 89 (89%) ended with a live birth. Thirteen patients (13%) flared during pregnancy or puerperium and three (3%) suffered major flares that led to the development of SLE with renal involvement. Obstetric complications occurred in 26 of the 89 successful pregnancies (29%), including 1 case (1%) of pre-eclampsia; in some cases, a single pregnancy was affected by more than one complication. There was a significant link between disease flare and both anti-dsDNA-positive antibodies at baseline (P < 0.01) and disease activity at the beginning of pregnancy (P < 0.01).

CONCLUSION

The impact on pregnancy in the study's cohort appears to be less serious in UCTD than in other CTDs. Nevertheless, disease flares and obstetric complications can represent a clinical challenge and clinical and serological disease activity would appear to represent important determinants of pregnancy outcomes. Pre-pregnancy counselling and planning as well as close monitoring during pregnancy is therefore essential.

One year in review 2020: systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a relapsing-remitting course that can affect various organs or systems, leading to a broad spectrum of clinical manifestations. In the past year, many studies have been published on SLE, providing a significant advancement in disease knowledge and patient management. The aim of this review is to summarise the most relevant scientific contributions on SLE pathogenesis, clinical manifestations and comorbidities, biomarkers and treatment strategies published in 2019.

THU0254 ARTICULAR INVOLVEMENT, STEROID TREATMENT AND FIBROMYALGIA ARE THE MAIN DETERMINANTS OF PATIENT-PHYSICIAN DISCORDANCE IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Remission or the lowest possible disease activity are the main targets in the management of Systemic Lupus Erythematosus (SLE). Anyway, conflicting data are present in the literature regarding the correlation between physician-driven definitions and patient perception of the disease. The discordance between patient and physician perspectives may have a negative impact on disease outcomes.

Objectives:

The aim of this study was to identify the main determinants of patient-physician discordance in the evaluation of SLE and health status.

Methods:

This is a cross-sectional study that enrolls patients with a diagnosis of SLE (ACR 1997 criteria). For each patient, demographics, comorbidities, treatment, clinical and laboratory data were collected. Disease activity was evaluated with the SELENA-SLEDAI score and organ damage with the SLICC/DI. Patients included have been categorized according to the following categories: remission, on or off treatment1, low disease activity (LLDAS)2and active disease status. At enrollment, each patient completed the following PROs: SF-36, FACIT-Fatigue, LIT and SLAQ. We defined a SLAQ score<6, corresponding to the 25° percentile of our cohort, as the cut-off value to define a low disease activity state according to the patient self-evaluation.

Results:

We enrolled 259 consecutive adult SLE patients (93.05% female, 97.2% Caucasian, mean age 45.33±13.14 years, median disease duration 14 years (IQR 6-21)). 208/259 patients satisfied the definition of LLDAS and among them 171 were in remission; 51/259 patients were active. No significant differences emerged as for the results of PROs between groups. Considering the subgroup of 208 patients in LLDAS, we identified 56 patients with a subjective condition of low disease activity (SLAQ<6) and we defined them as “concordant”; the remaining 152 patients in LLDAS presented a subjective active disease (SLAQ≥6) and we defined them as “discordant”. Comparing these two groups, we found that “discordant” patients had more frequently ongoing and past joint involvement (p<0.05) and a concomitant diagnosis of fibromyalgia (p<0.01); finally, they were more frequently on glucocorticoid therapy (p<0.01). “Discordant” patients showed a significantly worse quality of life, evaluated by all PROs (p<0.0001) (Tab 1).

Table 1.

Determinants of patient-physician discordance

Discordant patients(152/208)Concordant patients(56/208)p-valueAge at enrollment(years)47.7±13.144.3±10.8nsDisease duration(years)15.5±10.213.8±9.2nsSLICC-DI1.3±1.70.9±1.7nsOngoing joint involvement(% of patients)10.5%0p<0.05Past joint involvement(% of patients)70.9%55.3%p<0.05GC therapy(% of patients)50%28.6%p<0.01GC daily dose(mg of prednisone)1.6±1.91.1±1.9p=0.06Fibromyalgia(% of patients)15.8%1.8%p<0.01PCS54.7±14.165.8±20.4p<0.0001MCS54±14.564.3±17.7p<0.0001LIT28.4±20.414±16.8p<0.0001FACIT35.3±10.147.3±3.6p<0.0001

Conclusion:

Articular involvement, fibromyalgia and ongoing glucocorticoid treatment, even at low dose, are the major determinants of patient-physician discordance in SLE, determining a negative patient perception of health status.

References:

[1]van Vollenhoven R, et al. Ann Rheum Dis 2017 - Review. PMID 27884822;

[2]Franklyn K, et al. Ann Rheum Dis 2016. PMID 26458737

Disclosure of Interests:

None declared

One year in review 2019: systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune connective-tissue disorder with a wide range of clinical manifestations that predominantly affect women. Many aspects of its pathogenesis are still unclear, and new therapeutic strategies are progressively emerging. Thus, in this review we aim to summarise the most relevant data on SLE that emerged during 2018, following the previous annual review of this series. In particular, the review will focus on new insights in SLE regarding new pathogenetic pathways, new biomarkers, new data on clinical manifestations, clinical outcomes and comorbidities and what has emerged on new drugs and new therapeutic strategies.

One year in review 2019: novelties in the treatment of rheumatoid arthritis

The current treatment approach in rheumatoid arthritis (RA) follows a stepwise management, starting from early introduction of conventional synthetic (cs) disease-modifying anti-rheumatic drugs (DMARDs), moving to biological (b) DMARDs and targeted synthetic (ts) DMARDs. In the last few years, new drugs with different mechanisms of action have demonstrated their efficacy in treating such a disabling condition, and their approval, along with other more "experienced" treatments, has established their effectiveness on disease activity, damage accrual prevention, patients' quality of life improvement, confirming their safety profile. Moreover, new molecular pathways are under investigation as potential targets of new advanced therapies. Clinicians' capability of stratifying treatment strategies and decisions has improved, with several new tools for the optimisation of long-term management of RA; however, a high proportion of patients are refractory to the available drugs. Finally, as RA is a systemic disease, the knowledge in multi-systemic complications of the disease has grown, as well as the possibility in improving extra-articular manifestations of the disease, although certain drugs have potentially relevant non-articular effects, which need to be monitored. This narrative review summarises the most relevant studies published over the last year in the field of treatment of RA, with the major aim to let clinicians and researchers reflect on "what is new", "what is effective" and "what is safe".

Glucocorticoid withdrawal in systemic lupus erythematosus: are remission and low disease activity reliable starting points for stopping treatment? A real-life experience

Objectives

To evaluate the proportion of patients who have successfully withdrawn glucocorticoids (GCs) in a longitudinal cohort of patients with systemic lupus erythematosus (SLE) over a period of 6 years; to evaluate patient characteristics during GC withdrawal in relation to existing definitions of remission and Lupus Low Disease Activity State (LLDAS); and to evaluate the occurrence of flares after GC withdrawal.

Methods

Patients who attempted GC withdrawal were identified for the cohort, and the following information was assessed during withdrawal attempts: date of last disease flare, disease activity and damage and ongoing treatment. Information regarding the occurrence of disease flares after GC withdrawal was also recorded for patients who successfully stopped treatment.Definitions of remission were applied to GC withdrawal in line with European consensus criteria (Definitions of remission in SLE [DORIS]) and LLDAS in line with the Asian Pacific Lupus Consortium definition.

Results

148 patients were involved in the study; GC withdrawal was attempted in 91 patients (61.5%) with 77 patients (84.6%) successfully stopping GCs. At the beginning of the GC reduction, the majority of patients were in complete or clinical remission (48.9% and 39.6%, respectively). Disease activity was significantly lower in patients who successfully stopped GCs, and the proportion of patients in complete remission was higher (54.2%) with respect to patients who failed in their attempt. Among patients who stopped GCs, 18 flares were recorded after a median of 1 year. The time period since the last flare was shorter in patients who experienced flares with respect to patients who did not flare (mean 0.93 years vs 6.0, p<0.001).

Conclusions

GC withdrawal is an achievable goal in SLE and may be attempted after a long-term remission or LLDAS to protect the patient from disease flares.

One year in review 2018: systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a systemic autoimmune condition characterised by a wide spectrum of clinical manifestations, partly related to the disease itself, but also linked to its comorbidities and drugs adverse reactions. Following the previous annual reviews, we focused on new insights in SLE clinical features, pathogenic pathways, biomarkers of specific organ involvement and therapeutic strategies. We finally concentrated on SLE aspects that could significantly influence patients' quality of life and that need to be investigated in detail through the development and validation of disease-specific patient-reported outcomes.