AB0142 EVIDENCE OF TYPE I INTERFERON ACTIVATION DURING VASCULAR MANIFESTATIONS OF SYSTEMIC SCLEROSIS

Background

Vascular involvement in Systemic Sclerosis (SSc) is known to start even before clinical diagnosis, to drive Digital Ulcer disease and later in the disease natural history to cause Pulmonary Artery Hypertension, among other manifestations. Despite the proven immune origin of Scleroderma, vascular involvement is not currently targeted by immune driven interventions. Similarly, little data is available on immune or inflammatory biomarkers and outcome measures of vascular disease in SSc. Digital Artery Volume Index (DAVIX) has been recently proposed as imaging surrogate outcome measure of vascular disease activity in SSc [1].

Objectives

Here we aimed to determine the value of DAVIX as overall biomarker of vascular involvement and its correlation with Type I IFN activation in patients with SSc.

Methods

Eighty-six patients attending our Scleroderma Program were consecutively enrolled for the evaluation of serum IFN score as previously described [2]. Clinical features including presence or history of Digital Ulcers, Presence of Pulmonary Artery Hypertension (PAH) and DLCO, were recorded. Digital Artery Vascular Index (DAVIX) of the dominant hand’s fingers was calculated using time of flight magnetic resonance images analysed through IAG proprietary algorithm, as previously described [1]. Medians were compared by Mann-Whitney-Wilcoxon test, correlation with clinical parameters was performed using Spearman’s or Pearson test, as appropriate (R).

Results

Sixty-two patients fulfilled the 2013 ACR/EULAR classification criteria for SSc (diffuse cutaneous 24.6%, limited cutaneous 75.4%) whereas 23 were classified as Very Early Diagnosis of Scleroderma (Criteria score between 6 and 8). Twenty-three patients had DU disease (History of DUs in the previous 24 weeks, presence of DUs at baseline assessment, or onset of new DUs during the following 24 weeks). Eighteen patients had reduced DLCO (<70) with FVC/DLCO>1.8 (suspected PAH). DAVIX showed a negative correlation with disease duration (r=-0.33 and p=.003) and with FVC/DLCO ratio (r=-0.34 and p=.009). Patients with DU disease presented lower DAVIX than patients without (p=.018).

DAVIX showed a significant correlation with Serum IFN score (r=-0.24, p<0.032). Accordingly, patients classified as IFN-HI had lower DAVIX than those within the IFN-LO group (p=0.016).

Conclusion

DAVIX correlated both with presence of Digital Ulcer disease, DLCO and disease duration. The correlation of DAVIX and Serum IFN score does support the notion of innate immune involvement in vascular disease manifestations of SSc. Prospective testing in the context of Randomised controlled trial will determine the value of DAVIX as surrogate outcome measure of vascular disease severity in SSc.

References

[1]Gjeloshi K, et al. Arthritis Rheumatol. 2020.

[2]Hinchcliff M et al. Arthritis Rheumatol. 2021.

Disclosure of Interests

Stefano Di Donato: None declared, Mike Hughes: None declared, Giuseppina Abignano: None declared, Giovanni Lettieri: None declared, Rebecca Ross: None declared, Enrico De Lorenzis: None declared, Philip O’Connor: None declared, Olga Kubassova Shareholder of: IAG Image Analysis Group, CEO, Francesco Del Galdo: None declared

POS0890 NINTEDANIB REAL-LIFE EFFICACY AND SAFETY IN SYSTEMIC SCLEROSIS (SSc)-INTERTISTIAL LUNG DISEASE (ILD): AN ITALIAN MULTICENTRE PRELIMINARY STUDY

Background

Nintedanib (NTD) has been approved for Systemic Sclerosis (SSc)-Interstitial Lung Disease (ILD) following the positive results of the SENSCIS trial.

Objectives

to describe the efficacy and safety of NTD in SSc-ILD in a real-life setting.

Methods

The clinical data of SSc-ILD patients treated with NTD from 10 Italian SSc centres were retrospectively evaluated at baseline, 6 and 12 months: SSc clinical features, NTD tolerability, pulmonary function tests (PFTs) and modified Rodnan skin score (mRSS) were recorded.

Results

69 SSc-ILD patients (22 males [32%], mean age 60±12 years, disease onset 50±13 years, 4 [6%] anti-centromere, 53 [77%] anti-topoisomerase I, 3 [4%] anti-RNA-polimerase III) were identified. The vast majority (84%) was previously treated with immunosuppressants: 27 (39%) cyclophosphamide, 45 (65%) mycophenolate mofetil, 6 (9%) methotrexate, 9 (13%) azathioprine, 6 (9%) tocilizumab and 22 (32%) rituximab. In 11 (16%) patients, NTD was the first treatment for SSc-ILD. At baseline, 57 patients (83%) were on corticosteroids (mean daily prednisone dose 6±5 mg), 58 (84%) on immunosuppressants, 47 (68%) on mycophenolate mofetil, 14 (20%) on rituximab, 3 (4%) on tocilizumab, 2 on methotrexate (3%) and 1 (1%) on azathioprine. At baseline HRCT showed UIP pattern in 27 (39%) and NSIP pattern in 42 (61%) patients. The modifications of PFTs and mRSS over time are shown in Table 1. Since NTD introduction, gastro-intestinal (GI) side effects were recorded in 34 (49%) patients, with diarrhoea being the most common complaint (35%), followed by nausea/vomiting (23%) and weight loss (16%). In 21 (30%) patients, after a mean time of 2.6±3.4 months, NTD was maintained after dose adjustment. In 5 (7%) patients NTD was stopped after a median time of 5 (1-6) months due to subocclusion and persistent diarrhoea in 3 patients, untreatable nausea and vomiting in one patient and liver toxicity in 1 patient. During the follow-up after a median time of 10 (6 – 33) months, 4 patients died.

Table 1.

Pulmonary function tests and mRSS at baseline, 6 and 12 months in SSc-ILD on NTD.

Baseline6 monthsP valueBaseline12 monthsP valueFVC (% predicted)64 ± 1865 ± 18 (33 pts)0.63870 ± 1969 ± 18 (20 pts)0.586TLC (% predicted)64 ± 1561 ± 14 (27 pts)0.15464 ± 1465 ± 18 (16 pts)0.944DLCO (% predicted)40 ± 1741 ± 18 (29 pts)0.66040 ± 1838 ± 18 (20 pts)0.304mRSS9 ± 68 ± 6 (26 pts)0.0027 ± 48 ± 6 (15 pts)0.334

pts= patients

Conclusion

Our preliminary data confirm that in a real-life clinical scenario NTD, in combination with immunosuppressants, may stabilize PFT. However, despite the fact that GI side effects are frequent, they may be controlled with NTD dose adjustment thus retaining the drug in SSc-ILD patients. The NTD efficacy on skin involvement needs to be thoroughly evaluated on a larger SSc population.

Disclosure of Interests

Corrado Campochiaro Speakers bureau: Boeboehringer ingelheim, Giacomo De Luca Speakers bureau: boehringer ingelheim, Maria Grazia Lazzaroni Grant/research support from: boehringer ingelheim, Giuseppe Armentaro: None declared, Amelia Spinella: None declared, Barbara Vigone: None declared, Barbara Ruaro: None declared, Anna Stanziola: None declared, Devis Benfaremo: None declared, Enrico De Lorenzis: None declared, Francesco Benvenuti: None declared, Silvia Laura Bosello Speakers bureau: boehringer ingelheim, Gianluca Moroncini: None declared, Giovanna Cuomo: None declared, Marco Confalonieri: None declared, Lorenzo Beretta: None declared, Elisabetta Zanatta: None declared, Dilia Giuggioli: None declared, Nicoletta Del Papa: None declared, Paolo Airò: None declared, Lorenzo Dagna: None declared, Marco Matucci-Cerinic Speakers bureau: boehringer ingelheim

AB0704 LOW BODY MASS INDEX IN PATIENTS WITH RAYNAUD PHENOMENON IS ASSOCIATED WITH ENLARGED CAPILLARIES AND REDUCTION IN CAPILLARY DENSITY AT NAILFOLD VIDEOCAPILLAROSCOPY

Background

Increased prevalence of peripheral vascular symptoms like Raynaud’s phenomenon (RP) and acrocianosis is reported in anorexia nervosa (AN) and correlates with a more severe malnutrition.

Objectives

We aimed to characterize nailfold video capillaroscopy (NVC) abnormalities in patients with RP and BMI<18.5 kg/m2, according to adipokine levels, compared to subjects with RP and normal BMI.

Methods

We performed NVC in 21 female patients with primary RP with BMI<18.5 kg/m2, in 18 patients with primary RP and normal BMI, and in 18 patients classifiable as VEDOSS (Very Early Diagnosis of Systemic Sclerosis) and normal BMI, using a video-capillaroscope. Fingers two to four were evaluated bilaterally. Mean and minimum capillary density were registered for each patient, as well as maximum diameter and number of enlarged and giant capillaries, number of micro-haemorrhages and micro-thrombosis. We scored the frequency of enlarged capillaries considering the percentage of dilated capillaries out of the total. Demographic and clinical features of all patients were recorded.

Results

Patients with RP and low BMI presented a great number of elementary alterations on NVC; some of these modifications were typical of the scleroderma pattern. The percentage of enlarged capillaries was more than 33% of the total in 17(81%) patients with RP and low BMI with respect to 9(50%) of patients with RP and normal BMI (p=0.041). Furthermore, the number of megacapillaries was higher in patients with RP and low BMI compared to patients with normal BMI, while the maximum diameter of capillaries was comparable. Eight patients with low BMI presented a picture resembling an early scleroderma pattern (44%). The frequency of micro-thrombosis, micro-hemorrhages and microaneurysms were comparable in the twogroups. Patients with RP and low BMI presented a lower mean capillary and minimum capillary density compared to patients with RP and normal BMI (mean density: 7.4±1.4vs8.2±1.4,p=0.031; minimum density:4.8±1.0vs5.4±1.0,p=0.05). Patients with RP and low BMI presented a comparable frequency of enlarged capillaries, number of megacapillaries when compared with patients with VEDOSS. Leptin and chemerin levels were lower in patients with low BMI with respect to patients with normal BMI (57.5±35.6vs124.2±92.0pg/mL, p<0.001; 46.9±11.9vs58.3±17.2 ng/mL, p=0.017, respectively); adiponectin levels were comparable.

Conclusion

Patients with low BMI and primary RP presented a great frequency of enlarged capillaries and a reduction of capillary density when compared with patients with normal BMI. The increased number of microvascular abnormalities on NVC in patients with low BMI reminds the NVC findings typical of early scleroderma, supporting the hypothesis of an endothelial dysfunction in such patients

Disclosure of Interests

None declared

POS1251 INCIDENCE AND OUTCOMES OF SARS-CoV-2 INFECTION IN PATIENTS WITH SYSTEMIC AUTOIMMUNE RHEUMATIC DISEASES: A POPULATION-BASED STUDY OF MORE THAN FOUR MILLION INHABITANTS IN THE LAZIO ITALIAN REGION

Background

The impact of the severe acute respiratory syndrome Coronavirus 2 disease (COVID-19) pandemic on people with systemic autoimmune rheumatic diseases (SARDs) remains to be fully established. It is unclear whether SARDs are an independent risk factor for COVID-19 infection and poor outcome.

Objectives

The aim of our study is to assess the incidence and prognosis of test-proven SARS-CoV-2 infection during the first COVID-19 wave in a large population of SARD patients of the Lazio Italian region.

Methods

We retrospectively evaluated in a cohort of 4.716.119 subjects aged over 18 years and affiliated to the health system of the Lazio Italian Region, the incidence and 30-day outcomes of COVID-19 infection in 40.490 SARD pts and compared to the affiliated population as incidence rate ratio adjusted for demographics and comorbidities (adjIRR). SARD diagnosis and comorbidities were derived from medical administrative records using the Chronic Related Group classification system. Data on COVID-19 infection were derived from a dedicated regional digital network.

Results

The risk of COVID-19 infection was increased in patients with Psoriatic Arthritis (adjIRR=1.21, 95% CI 1.10-1.33) and Undifferentiated Connective Tissue Disease (adjIRR=1.26, 95% CI 1.03-1.54). The risk of hospitalisation was higher in patients with Axial Spondylarthritis (adjIRR=2.16, 95% CI 1.45-3.22), and Systemic Vasculitis (adjIRR=1.81, 95% CI 1.07-3.06) while the risk of Intensive care unit admission was higher in Systemic Erythematous Lupus (adjIRR=3.67, 95% CI 1.52-8.83) and primary Sjögren Syndrome (adjIRR=4.13, 95% CI 1.71-9.96) patients. An increased COVID-19 mortality was reported in patients with Rheumatoid Arthritis (adjIRR=1.50, 95% CI 1.04-2.17), Systemic Erythematous Lupus (adjIRR=2.67, 95% CI 1.10-6.44), primary Sjögren Syndrome (adjIRR=2.51, 95% CI 1.12-5.62), and Scleroderma (adjIRR=4.60, 95% CI 2.06-10.29).

Conclusion

The incidence of severe COVID-19 is not increased in the same percentage in SARDs. Each SARD presents a peculiar pattern in terms of increased risk of COVID-19 incidence, hospitalisation, intensive care unit admission and death, that is not linked to the immunosuppressive behaviour of the disease.

Disclosure of Interests

None declared

POS0887 CHORIORETINAL MICROVASCULAR INVOLVEMENT IN SYSTEMIC SCLEROSIS

Background

The optical coherence tomography angiography (OCTA) is a new non-invasive imaging technique that can detect flow and provide information about the vessel density (VD) at different layers in the eye. The ocular microvascular network has been only occasionally addressed as disease target in scleroderma (SSc) considering the relatively low prevalence of ocular symptoms in these patients.

Objectives

The study aims to evaluate retinal and choriocapillaris microvasculature in a group of SSc patients compared to matched controls (HC)and according to disease characteristics, capillaroscopy findings and pulmonary function tests.

Methods

VD was assessed through OCTA at the retinal superficial (SCP) and deep (DCP) capillary plexus, at the foveal avascular zone perimeter (FAZP) and at the choriocapillaris (CC) of 30 SSc patients compared to 30 sex- and age-matched subjects without any retinal disease.

Results

The SSc patients (age 57.3±10.0, female 86.7%) had diffuse cutaneous skin disease in 30.0% of the cases, an average disease duration of 10.4±7.2 yy, and anti-centromere and anti-Scl70 antibody positivity in 40.0%and in 30.0% of the cases, respectively. Compared to the HC, SSc showed an impaired VD at SCP (47.7±3.6 vs59.1±3.5%, p=0.009), DCP (50.0±6.7 vs 54.3±6.4%, p=0.015), FAZP (48.7±4.55 vs 51.0±3.55%, p=0.034) and CC(67.1±2.2 vs 68.6±1.7, p=.005). Moreover, in the SSc group, the presence of digital ulcers (46.7%),telangiectasias (43.3%) and interstitial lung disease (46.7%) was related to reduced VD at FAZP (46.8±4.1 vs50.3±4.3%, p=0.033), CC (66.1±1.4 vs 67.9±2.4%, p=0.004), and DCP (47.2±8.8 vs 51.9±4.3, p=0.004),respectively. Lastly, the average capillary density on capillaroscopy showed a positive correlation with VD at FAZP (r=0.474, p=0.008), DCP (r=0.414, p=0.023), and foveal CC (r=0.482, p=0.007) and there was also a correlation between CC and both DLco (r=0.467, p=0.009) and FVC/DLco (r=-0.436, p=0.004).

Conclusion

The SSc patients in our cohort showed lower ocular vessel density at different levels compared to HC. Furthermore, impaired VD at different levels of the eye correlates with the organ involvement and the degree of digital and pulmonary microvascular impairment. According to those data, the OCTA could be proposed as a biomarker tool to investigate the microvascular abnormalities in SSc.

Disclosure of Interests

None declared

POS0876 SERUM INTERFERON SCORE PREDICTS SEVERITY OF PATIENT REPORTED HAND DISABILITY IN SYSTEMIC SCLEROSIS

Background

Hand involvement is a major cause of disability in systemic sclerosis (SSc) patients. Loss of hand function is the result of a complex and overlapping series of manifestations including Raynaud’s, cutaneous ulcerations as well as skin fibrosis, joint inflammation, and contractures. The natural history of hand involvement in SSc and potential biomarkers to predict its outcome are still poorly defined. Type 1 Interferon (IFN) activation has been extensively correlated with skin fibrosis, joint disease activity, vascular manifestations, and poor prognosis in SSc patients.

Objectives

To characterize hand disability burden in SSc and explore its relationship with IFN activation in a national, multicenter, longitudinal, observational cohort of patients with SSc.

Methods

The Cochin Hand Function Scale (CHFS) was assessed in consecutively enrolled SSc patients at baseline and after 12 months. CHFS values above the patient acceptable symptom state (PASS)(CHFS>25)1 were considered as clinically meaningful hand impairment (CMHI). Minimal clinically important difference (MCID) in CHFS for improvement (reduction of 13.1%) and worsening (increase >24.6%) were assessed in longitudinal analysis. Serum IFN score was evaluated as previously described2.

Results

A total of 397 SSc patients from 10 centers (female 85.3%, aged 54.9±11.5 years, white Caucasian 88.2%) were available for longitudinal (12m) analysis. The median disease duration was 9 (IQR 3-16) years, 37.1% of patients had a diffuse cutaneous variant, while anticentromere (ACA) and anti-Scl70 antibody positivity was reported in 41.2% and 33.5% of cases, respectively. Hand digital ulcers, forearm-hand-finger skin score ≥6, and tenosynovitis/arthritis were clinically reported in 24.0%, 15.3%, and 17.9% of patients, respectively. 37.3% of patients reported a CHFS > PASS at baseline. CMHI was associated with male gender (p<.001), diffuse cutaneous variant (p<.001), anti Scl70 positivity (p<.001), ACA negativity (p=.002), and digital ulcers (p=.001). Patients with CMHI had greater serum IFN score than patients with CHFS < PASS (p=.002). In multivariate logistic regression analysis, high serum IFN score remained associated with CHFS>PASS when adjusted for male gender, ACA positivity, anti-Scl70 positive, diffuse subset, and current digital ulcers (OR 2.67, p=.005). Over the 12-month follow-up, vasoactive and immunosuppressive treatment were escalated or introduced in 7.2 and 7.8% of patients, respectively. Median CHFS worsened over time (from 18 (IQR 5-37) to 21 (IQR 6-37), p=.002)) with 32.5% of patients having a clinically meaningful worsening and 32.0% improving their hand function. Functional hand worsening was associated with lower baseline CHFS (p=.001) and ACA negativity (p=.002), while improving with female gender (p=.047), limited cutaneous subset (p=.029), higher baseline CHFS (p=.001), and active baseline tenosynovitis (p=.014).

Conclusion

One third of the patients within our cohort complain of a significant hand impairment. This is associated with higher IFN activation and worsens at group level in patients despite standard of care treatment.

References

[1]Daste C et al. Semin Arthritis Rheum. 2019;48(4):694-700. [2] Hinchcliff M et al. Arthritis Rheumatol. 2021; 73 (suppl 10).

Disclosure of Interests

Enrico De Lorenzis: None declared, Vishal Kakkar: None declared, rebecca ross: None declared, Stefano Di Donato: None declared, Theresa Barnes: None declared, Benazir Saleem: None declared, Ariane Herrick: None declared, Muhammad Nisar: None declared, Catherine Morley: None declared, Karen Douglas: None declared, Christopher P Denton: None declared, Emma Derrett-Smith: None declared, Philip Helliwell Consultant of: PH received consulting fees (Eli Lilly) and fees for educational services (Abbvie, Amgen, Novartis, Janssen), Grant/research support from: PH received consulting fees (Eli Lilly) and fees for educational services (Abbvie, Amgen, Novartis, Janssen), Francesco Del Galdo Consultant of: FDG has received research support and personal fees, not directly related to the content of this study, from

Abbvie, AstraZeneca, Boehringer-Ingelheim, Capella Biosciences, Chemomab LTD, Janssen, Kymab LTD, Mitsubishi-Tanabe, Grant/research support from: FDG has received research support and personal fees, not directly related to the content of this study, from

Abbvie, AstraZeneca, Boehringer-Ingelheim, Capella Biosciences, Chemomab LTD, Janssen, Kymab LTD, Mitsubishi-Tanabe

AB0700 HIGH BRONCHOALVEOLAR FLUID NEUTROPHILS INDEPENDENTLY PREDICT 15-YEAR MORTALITY IN SCLERODERMA PATIENTS WITH INTERSTITIAL LUNG DISEASE NAIVE TO IMMUNOSUPPRESSANTS

Background

Scleroderma interstitial lung disease (SSc-ILD) has a variable and poorly predictable course. Data about the role of bronchoalveolar lavage fluid (BALF) analysis in prognostic stratification of SSc-ILD patients (pts) are conflicting.

Objectives

To assess BALF analysis role in prognostic stratification of SSc-ILD pts.

Methods

Forty SSc-ILD pts naive to immunosuppressants underwent comprehensive clinical evaluation, BALF analysis with total and differential leukocyte count, pulmonary

function tests (PFTs), high-resolution computed tomography (HRCT) of the chest. All pts had fibrosing lung disease affecting more than 10% of lung volume on HRCT. Baseline alveolar and interstitial scores were computed. The 15-year crude mortality rate was retrospectively assessed.

Results

The enrolled pts (male 20%, aged 53.9±13 years) had a disease duration of4.3±3.4 years. Diffuse cutaneous involvement LeRoy variant was present in 47.5% of pts, while anti-Scl70 and anti-centromere antibodies were detected in 57.5% and 12.5% of pts, respectively. The average alveolar and interstitial scores were 6.5±4.8 and 6.2±2.7, respectively; 25% of the pts had FVC less than or equal to 80% and 35% had DLco less than or equal to 80%. During the follow-up, 18 pts (45%) received immunosuppressants. BALF neutrophilia (> 3%), eosinophilia (>1%) and lymphocytosis (>15%) were reported in 40%, 16% and 5% of pts, respectively. Twenty-five pts (62.5%) died within 15 years after bronchoscopy. Fifteen-year mortality was predicted by neutrophilia (HR 5.5, 95% IC 1.9-15.7), log-transformed total cell count (HR 2.5, 95% IC 1.1-5.7), absolute neutrophil (HR 1.8, 95% IC 1.3-2.5) and eosinophil (HR 1.3, 95% IC 1.1-1-6) cell counts, and macrophage (HR 0.1, 95% IC 0-0.6), neutrophil (HR 1.9, 95% IC 1.3-2.7), and eosinophil (HR1.3, 95% IC 1-1.7) percentages. Only absolute and relative neutrophil counts were independently associated with mortality also in regression models adjusted for demographics (age, gender), main disease traits (diffuse cutaneous variant, anti-Scl70 positivity), pulmonary function tests (FVC, DLco), HRCT involvement (alveolar and interstitial scores) and vascular complications (presence of pulmonary hypertension, digital ulcers).

Conclusion

High BALF neutrophils were associated with high 15-year mortality independently from established clinical risk factors. BALF analysis could improve prognosis prediction in SSc-ILD pts.

Disclosure of Interests

None declared

POS0289 CANCER RISK IN IMMUNOSUPPRESSED SCLERODERMA PATIENTS: A PROPENSITY SCORE MATCHING ANALYSIS

Background:

An increased incidence of cancer in patients with systemic sclerosis (SSc) is well-established1. Current knowledge about the onco-transforming power of immunosuppressive treatments in both non-rheumatological and rheumatological pathologies, suggests an increased incidence of hematological and solid neoplasms2. Evidences on the possible role of the immunosuppressants in the onset of cancer during SSc are lacking.

Objectives:

To evaluate the incidence of malignancies in SSc patients exposed to immunosuppressive therapy.

Methods:

The incidence of neoplasia in a cohort of 600 patients with SSc was evaluated retrospectively. Patients diagnosed with malignancy within 36 months from SSc onset were excluded from the analysis since suspected for paraneoplastic form. Patients exposed to methotrexate, cyclophosphamide, azathioprine and mycophenolate were confronted with a group comparable for age at onset, sex, disease variant, autoantibodies and exposure to other disease-specific therapies, using propensity score matching analysis. The considered follow-up was between the clinical onset and the diagnosis of cancer or the last available visit or the twenty-fifth year of illness.

Results:

The analysis was carried out on 526 patients observed for an average period of 12.1 ± 6.0 years (males 9.5%, age at onset 49.0 ± 15.3 years); 24.9% had diffuse cutaneous variant of the disease and 39.0% and 34.8% were respectively positive for anti-centromere and anti-Scl70 antibodies. During the follow-up, 19.0% of patients were exposed to cyclophosphamide, 15.3% to azathioprine, 14.4% to methotrexate and 11.6% to mycophenolate mofetil. Sixty-five cancer diagnoses were made after the 36th month from onset (incidence 1.02: 100 patients/year), comprising 16 mammary cancers, 12 cancers of the gastro-intestinal tract, 11 cancers of the head-neck area, 10 cancers of the lungs, 9 cases of skin-cancer, 5 haematological malignancies and 1 brain tumour. The incidence of cancers did not differ in relation to treatment with cyclophosphamide (X2 = 0.001, p = 0.961), azathioprine (X2 = 2.141, p = 0.143), mycophenolate mofetil (X2 = 0.001, p = 0.993) or methotrexate (X2 = 0.920, p = 0.337) (Figure 1).

Conclusion:

Our data are consistent with an increased incidence of neoplasms in the course of SSc, with a rate that appears almost doubled compared to the general Italian population with similar sex and age distribution (0.55: 100 patients/year; Italian Association of Tumor Registries data3). In our SSc cohort this risk is independent of exposure to immunosuppressive drugs commonly used for the treatment of scleroderma disease.

References:

[1]Akira O et al. Cancer Incidence in Systemic Sclerosis: Meta-Analysis of Population-Based Cohort Studies. Arthritis & Rheumatism. 2013

[2]Zitvogel L et al. Cancer despite immunosurveillance: immunoselection and immunosubversion. Nat Rev Immunol. 2006

[3]Registri Tumori di popolazione in Italia: la Banca Dati AIRTUM (Associazione Italiana Registri Tumori). 2020

Disclosure of Interests:

None declared

POS0891 IMPROVED SURVIVAL IN SYSTEMIC SCLEROSIS PATIENTS DURING LAST DECADE: CURRENT FINDINGS AND COMPARISON WITH DIFFERENT PREVIOUS ITALIAN COHORTS

Background:

Systemic Sclerosis (SSc) is a chronic rheumatic disease characterized by an autoimmune disorder with vasculopathy that leads to an excess in collagen and other extracellular matrix proteins deposition. This process results in progressive fibrotic and vascular damage of skin and visceral organs. According to observational studies conducted in last decades, mean survival of SSc patients had improved with significant changes in causes of death.

Objectives:

To assess the 10-years survival in a large Italian multicentre cohort of SSc patients in the last decade compared to previous periods published since the 1980s, and to identify features that can justify any change.

Methods:

We retrospectively analysed all medical records of our longitudinal SSc cohorts, fulfilling 1980 ARA and/or 2013 EULAR/ACR Classification Criteria, with a median (IQR) follow-up of 91.5 (51-120) months from 4 Scleroderma Units since January 2009. All clinical, laboratory and instrumental findings have been recorded and analysed. Survival rate was calculated with Kaplan-Meier curves and log-rank tests, and Cox proportional hazards models were used to identify any predictor. Then, observed SSc survival was compared to those previously published and to that expected in the general population, calculated using official data published on the website United Nation World Population Prospects (www.macrotrends.net/countries/ITA/italy/death-rate).

Results:

Of 912 SSc patients (91.6% female; mean (SD) age at first non-Raynaud symptom (RS) 51 (15.4) years; median (IQR) disease duration from non-RS 24 (0-84.7) months) diffuse cutaneous involvement was defined in 182 (20%) patients. Anti-centromere and anti-topoisomerase-I were detected in 390 (42.8%) and 302 (33.1%) patients, respectively, while 220 (24.1%) presented antibodies for other extractible nuclear antigens. Prevalent non-Raynaud manifestations were interstitial lung disease detected in 459 (50.3%), digital ulcers in 395 (43.3%) and oesophagopathy in 371 (40.7%) patients, respectively, while other gastrointestinal manifestations were reported in 234 (25.7%) patients. Chronic renal failure was observed in 61 (6.7%) patients and pulmonary arterial hypertension (PAH) was confirmed at right heart catheterization in 38 (4.2%) patients. Three hundred twenty-two (35.3%) patients received immunosuppressant, 215 (23.5%) assumed an endothelin receptor antagonist and/or a 5-phosphodiesterase inhibitor, and 72 (7.9%) were treated with a biologic agent. The global 10-years survival was 89.4%; female gender (HR 0.33, CI95% 0.17-0.67), diffuse cutaneous involvement (HR 2.14, CI95% 1.17-3.91), presence of pulmonary hypertension (HR 2.61, CI95%1.31-5.16) and older age at non-RS (HR 1.1, CI95% 1.06-1.12) affected survival. Furthermore, as compared to previous Italian studies, our cohort showed a significant improvement in rate (see Figure 1).

Conclusion:

Survival in SSc patients has improved in last 5 decades but still reduced compared to that expected in general population above all 5 years after diagnosis. Early diagnosis, with reduced renal involvement, along with better screening and innovative therapeutic strategies may explain these achievements.

Figure 1.

Ten-years survival in SSc patients since 2009 (left); comparison of survival across different Italian SSc cohorts (box: current analysis) (right).

References:

[1]Giordano M, et al. The Journal of Rheumatology. 1986; 13:911-916.

[2]Ferri C, et al. Medicine. 2002; 81:139-53.

[3]Vettori S, et al. Reumatismo. 2010; 62(3):202-209.

[4]Ferri C, et al. Autoimmun Rev. 2014; 13(10):1026-34.

Disclosure of Interests:

None declared

POS0864 ELIGIBILITY FOR ANTI-FIBROTIC TREATMENT WITH NINTEDANIB OF PATIENTS WITH SYSTEMIC SCLEROSIS RELATED INTERSTITIAL LUNG DISEASE

Background:

Pulmonary involvement is the main determinant of disease-related mortality in systemic sclerosis (SSc). The SENSCIS and INBUILD trials have documented the efficacy of the antifibrotic drug Nintedanib (NTN) in the treatment of SSc-related interstitial lung disease (SSc-ILD) and progressive forms of ILD other than Idiopathic Pulmonary Fibrosis1,2. The criteria for the use of this drug in patients with SSc-ILD in clinical practice are currently being defined.

Objectives:

To evaluate the proportion of patients eligible for NTN treatment based on the enrollment criteria fof the SENSCIS and INBUILD studies in a real-life cohort of SSc-ILD patients.

Methods:

We considered consecutive patients with ILD extension on CT ≥10% and disease duration ≤7 years with at least one visit in the period between September 2016 and December 2019. Data of the clinical visits were retrospectively evaluated. For each patient, we examined the visits during which a well-tolerated immunosuppressive therapy was modified because of progression of SSc-ILD and the most recent follow-up visit. Eligibility of patients for NTN was defined according to the inclusion criteria of the SENSCIS and INBUILD trials. Patients with more than 2 acral ulcers at the time of evaluation, history of digital amputation, pulmonary hypertension (functional class III-IV) and increased hemorrhagic or thrombotic risk were judged not eligible to NTN in trials.

Results:

A total of 177 visits regarding 78 patients were examined (females 80.8%, diffuse skin disease 51.3%, anti-Scl70 antibodies positivity 55.7%, age 54.8±16.0 years, disease duration 4.0±2.4 years). Considering the visits in which indication for a therapeutic change was given, 54 patients (54.5%) were eligible for NTN according to SENSCIS criteria and of these 31 (31.3%) also according to INBUILD criteria (Figure 1). In this group, 25 patients were treated with mycophenolate mofetil, 11 with azathioprine, 10 with cyclophosphamide, 7 with methotrexate and 8 with rituximab (2 in combination). At the latest available evaluation, 42 patients (62.8%) were eligible for NTN according to SENSCIS criteria and of these 12 (15.4%) also according to INBUILD criteria (Figure 1). In this group, 30 patients were in mycophenolate mofetil (6 in combination with biologic treatment), 5 in azathioprine, 1 in cyclophosphamide, 1 in methotrexate, 6 in rituximab, 2 in tocilizumab and 1 in pirfenidone. Overall, the factors limiting NTN start according to the trial enrollment criteria would have been: uncompromised (19.2%) or too low (6.4%) DLco values, too low FVC (3.4%), severe acral disease with ulcers (16.9%), severe pulmonary arterial hypertension (6.2%), increased thrombotic or haemorrhagic risk (6.2%). In the scenario of eligibility, skin progression was detectable in 43.4% of all visits.

Conclusion:

Treatment that can modify the progression of SSc-ILD are currently limited. Based on our retrospective analysis, the use of NTN in accordance with current clinical evidence could be considered in a significant percentage of patients with SSc-ILD.

References:

[1]Flaherty KR, et al. Nintedanib in Progressive Fibrosing Interstitial Lung Diseases. N Engl J Med. 2019.

[2]Distler O, et al. Nintedanib for Systemic Sclerosis-Associated Interstitial Lung Disease. N Engl J Med. 2019.

Disclosure of Interests:

None declared

AB0757 ASSOCIATION BETWEEN DEPRESSIVE SYMPTOMS AND ENDOTHELIAL DYSFUNCTION IN PATIENTS WITH PSORIATIC ARTHRITIS

Background:

Cardiovascular complications are the leading cause of death in patients with psoriatic arthritis (PsA), but current strategies for reducing cardiovascular risk are still inadequate. Depression is a common comorbidity in PsA patients and it is recognized as an independent cardiovascular risk factor in the general population. Endothelial dysfunction, assessed as a reduction in brachial artery Flow Mediated Dilation (FMD), is a predictor of major cardiovascular events in high and low risk populations.

Objectives:

To investigate the relationship between endothelial function and depressive symptoms in a cohort of patients with PsA.

Methods:

Sixty consecutive patients with PsA, aged between 30 and 79 years, with no history of major cardiovascular events, were characterized for traditional cardiovascular risk factors and features of psoriatic disease. The risk of cardiovascular events according to traditional risk factors was calculated using the Framingham Risk Score (FRS) and the presence of depressive symptoms was defined through the Hospital Anxiety and Depression Scale (HDS) using the validated cut-off of 8. Endothelial function was assessed by FMD. Serum IL-6 was quantified by ELISA, IL-17 and TNF-α levels by Luminex method.

Results:

Patients had an average age of 52.1±11.0 years, 43.3% of them were male, 23.3% obese and 25.0% active smokers; 38.3%, 25.0% and 11.7% were treated for high blood pressure, dyslipidemia and diabetes mellitus, respectively. The 10-year risk of major cardiovascular events estimated by FRS was 10.4%. The mean duration of PsA was 9.4 years, 30.0% of patients were in minimal disease activity (MDA) and 61.7% and 46.7% were treated with conventional and biotechnological DMARDs, respectively. The mean HDS value was 6.9±3.2 and 43.4% of patients had significant depressive symptoms. The severity of depressive symptoms according to HDS correlated with disease activity according to DAPSA (r=0.449, p=0.001). The mean FMD was 7.8±3.8%, this value correlated inversely with age (r=-0.408,p<0.001), risk of major cardiovascular events according to FRS (r=-0.327, p=0.011) and severity of depressive symptoms according to HDS (r=-0.285, p=0.027). The correlation between FMD and serum IL-6, IL-17 and TNF-alpha levels was not statistically significant. In multivariate linear regression models, the relationship between FMD and HDS was significant also when corrected for age (β=-0.26, p=0.03, R2=0.23) and FRS normalized through logarithmic transformation (β=-0.32, p=0.009, R2=0.22).

Conclusion:

The degree of endothelial dysfunction quantified by FRS correlates with the severity of the depressive symptoms in patients with PsA, independently of the cardiovascular risk attributable to classical risk factors. The weak relationship between FRS and serum levels of IL-6, IL-17 and TNF-alpha suggests a role of factors independent of inflammation in the regulation of endothelial function in patients with PsA. Systematic research and treatment of depressive symptoms could contribute to a more complete stratification and a better management of cardiovascular risk in patients with PsA.

Disclosure of Interests:

Enrico De Lorenzis: None declared, Angela Di Giorgio: None declared, Gerlando Natalello: None declared, Antonio Nesci: None declared, Dario Bruno: None declared, Donatella Lucchetti: None declared, Giacomo Tanti: None declared, Clara Di Mario: None declared, Pietro Rubortone: None declared, Maria Rosaria Magurano: None declared, Barbara Tolusso: None declared, Angelo Santoliquido: None declared, Giusy Peluso: None declared, Elisa Gremese Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Novartis, Sanofi, UCB, Roche, Pfizer, Speakers bureau: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Novartis, Sanofi, UCB, Roche, Pfizer

FRI0230 THE 2009-2019 SURVIVAL AND MORTALITY PREDICTORS IN A LARGE MULTICENTRE SYSTEMIC SCLEROSIS COHORT

Background:

Systemic sclerosis (SSc) is one of the connective tissue diseases with the poorer prognosis and disease-related causes, particularly pulmonary fibrosis, PAH and cardiac involvement, accounting the most deaths.

Objectives:

This multicentre study aimed to evaluate the global survival and any predictor of mortality in a large multicentric cohort of SSc patients.

Methods:

We performed a retrospective analysis examining the medical records of our longitudinal SSc cohorts with a median (IQR) follow-up of 11 (6-18) years from 3 Scleroderma Units since January 2009. All clinical, laboratory and instrumental findings have been recorded and analyzed using Chi-squared tests, Kaplan-Meier curves, log-rank tests, and Cox proportional hazards models.

Results:

Data from 750 SSc patients (91.9% female; mean (SD) age at first Non-Raynaud symptom 48.4 (15.3) years, median (IQR) disease duration 3 (0-8) years; diffuse cutaneous involvement 162 (21.6%) patients) fulfilling the 1980 ARA and/or 2013 ACR/EULAR classification criteria, were collected. All patients were positive for ANA, anti-Topo-I Abs were found in 235 (31.3%) and Cenp-B Abs in 300 (40%) patients. 98 (13.1%) patients were positive to other Abs (Anti-RNA polymerase III, anti-Pm/Scl) and anti-ENA were negative/unknown for 117 (15.6%) patients. Interstitial lung disease (ILD) was present in 202 (26.9%), pulmonary arterial hypertension (PAH) was found in 29 (3.9%), and 50/750 (6.7%) patients presented pulmonary hypertension combined with ILD (PH-ILD). The overall 10-years survival was 93.1% and, it was significantly impaired by the presence of ILD, PAH or PH-ILD [Figure]. The univariate analysis showed that female gender, higher age at first Non-Raynaud symptom, earlier referral to a tertiary Scleroderma center, absence of any ENA antibodies, and PH-ILD presence were survival predictors. After multivariate analysis the significance of PH-ILD was lost [Table]. Disease duration, basal Rodnan skin score, smoking, renal or gastrointestinal comorbidities, NYHA functional class, steroid or immune-suppressive treatments did not reach the statistically significance.

Conclusion:

Our study demonstrated a global 10-years survival rate over 93%. Male patients and rapid evolution of Non-Raynaud symptoms represent the main death predictors in our SSc cohort. A rapid referral to a tertiary rheumatological centre and early treatment with effective agents are associated to a better prognosis.

Figure.

Kaplan-Meier curves for 5-years survival in SSc patients (Log-rank 8.96, p=0.03).

Table.

Prognostic factors for 10-years survival at univariate and multivariate analysis.

UNIVARIATE ANALYSISMULTIVARIATE ANALYSISHR95%ICPHR95%ICPFemale gender0.350.15-0.810.010.310.15-0.660.002Age at first Non-Raynaud symptom1.071.04-1.10.0011.081.05-1.110.001Time referral to a tertiary SSc centre0.830.76-0.920.0010.840.77-0.930.001Absence of any ENA antibodies0.080.01-0.620.010.090.01-0.710.02PH-ILD presence2.61.01-6.820.042.40.93-6.10.069

Disclosure of Interests:

Fabio Cacciapaglia Speakers bureau: BMS; Roche; Pfizer; Abbvie, Enrico De Lorenzis: None declared, Addolorata Corrado: None declared, Silvia Laura Bosello Speakers bureau: Abbvie, Pfizer, Boehringer, Marco Fornaro: None declared, Fabio Montini: None declared, Livio Urso: None declared, Lucrezia Verardi: None declared, Alberto Altomare: None declared, Francesco Paolo Cantatore: None declared, Elisa Gremese Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Novartis, Sanofi, UCB, Roche, Pfizer, Speakers bureau: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Novartis, Sanofi, UCB, Roche, Pfizer, Florenzo Iannone Consultant of: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Speakers bureau: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD

AB0621 TOLERABILITY AND SAFETY OF ACETYLSALICYLIC ACID IN PATIENTS WITH SYSTEMIC SCLEROSIS

Background:

Systemic Sclerosis (SSc) is characterized by an increased incidence of macro- and microvascular complications. Current evidences on efficacy, safety and tolerability of acetylsalicylic acid (ASA) in SSc patients are limited, and the indication to this treatment is based on the experience of each single centre or physician. Esophagus and stomach are the portions of the digestive tract that are more frequently affected by adverse events due to ASA exposure.

Objectives:

We evaluated the incidence of adverse events associated with low-dose ASA treatment in a cohort of patients affected by SSc.

Methods:

Demographic data and disease features of 302 patients affected by SSc treated with low-dose ASA were collected and patients were followed-up for a median period of 6.9 years (range: 0-20 years). The proportion of patients taking ASA for secondary prevention for cardiovascular disease was also noted. The incidence of discontinuation of the drug, gastrointestinal intolerance, bleeding and death in the observation period was recorded.

Results:

Patients had a median age of 54.0 years (19.6-89.4); 91.9% were female, 13.2% were smokers and 44.0% had a BMI≥30Kg/m2. The prevalence of ischemic heart disease, peripheral vascular disease and stroke was of 8.6%, 5.3% and 3.3%, respectively; 48.7% of the patient took ASA in primary cardiovascular prevention. Therapy started after a median disease duration of 4.8 years (range: 0.0- 30.1 years) since the first non-Raynaud symptom and 56.6% of patients had an early disease (less than three years of disease duration). During the observation period, 30 patients (14.3 per 1000 person-years) discontinued ASA after an average period of assumption of 4.6 years (range: 0.3-18.0 years). The main adverse events were heartburn, dyspepsia and hematochezia, recorded in 18 patients (8.6 per 1000 person-years). Eight of them (3.8 per 1000 person-years) had evidence of digestive tract bleeding. Five patients (2.4 per 1000 person-years) discontinued ASA due to recurrent epistaxis. Twenty-eight patients (13.4 per 1000 person-years) died in the follow-up period, 16 of these (7.6 per 1000 person-years) because of SSc-related causes. None of them had evidence of major bleeding. We used Kaplan-Meier analysis to evaluate the incidence of ASA discontinuation. The history of digital ulcers (Log rank test X24.7, p=0.037) and male sex (Log rank test X24.3, p=0.03) were associated with a higher cumulative ASA discontinuation rate due to gastrointestinal intolerance.

Conclusion:

In our cohort of SSc patients, ASA resulted safe and well tolerated in most cases, despite the risk of gastroesophageal abnormalities due to disease. Although this comforting results, taking in account the lack of controlled-randomized trials about efficacy and safety, the choice to start antiplatelet therapy with ASA should be mandatorily preceded by a careful evaluation of risks and benefits. Furthermore, an attentive monitoring for possible adverse effects is needed during ASA treatment. Patients with digital ulcers and male sex could present less drug tolerability.

References:

[1]Valentini G et al. Ann Rheum Dis 2019. Beckett VL et al. Arthritis Rheum 1984. Kavian N et al. Vascul Pharmacol 2015. Lavie CJ et al. Curr Probl Cardiol 2017.

Disclosure of Interests:

Lucrezia Verardi: None declared, Enrico De Lorenzis: None declared, Gerlando Natalello: None declared, Laura Gigante: None declared, Umberto La Porta: None declared, Elisa Gremese Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Novartis, Sanofi, UCB, Roche, Pfizer, Speakers bureau: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Novartis, Sanofi, UCB, Roche, Pfizer, Silvia Laura Bosello Speakers bureau: Abbvie, Pfizer, Boehringer

OP0009 DERIVATION AND VALIDATION OF THE SCLERODERMA LUNG 3-STAGE INDEX (SL3SI), A NEW FUNCTIONAL INDEX FOR INTERSTITIAL LUNG DISEASE WITH PROGNOSTIC IMPLICATIONS

Background:

The staging of interstitial lung disease (ILD) is important to monitor disease progression and for prognostication. A disease severity scale of Systemic Sclerosis (SSc)-related lung disease has long been proposed (i.e. Medsger’s severity scale). This scale was mostly developed by discussion and consensus and stage thresholds were not computed by a data-driven approach. Hidden Markov models (HMM) are methods to estimate population quantities for chronic diseases with a staged interpretation which are diagnosed by markers measured at irregular intervals.

Objectives:

To build a SSc-ILD specific disease severity scale with prognostic relevance via HMM modeling.

Methods:

A total of 358 SSc patients at risk for or with ILD were enrolled in a discovery (207 cases, Milan1) and in a validation (151 cases, Milan2, Pavia and Rome) cohort. Patients were included if satisfied the following criteria: 1) Diagnosis of SSc according to the EULAR/ACR 2013 criteria, 2) absence of anticentromere antibodies, 3) dcSSc subset or 4) other subsets with either 4a) ILD-related antibodies (Scl70, PmScl, Ku) or 4b) evidence of ILD on HRCT, 5) disease duration < 5 years at the time of the first pulmonary function test (PFT). Serial PFTs were retrieved and the time up to the last available visit -if the patient alive-, or to death due to pulmonary complications, was recorded. HMM were used to estimate the threshold of a 3-stage model (SL3SI, Scleroderma Lung 3-Stage Index) based on PFT functional values (normal/mild, moderate, severe involvement) in the discovery cohort. Survival estimates of the SL3SI model were compared to Medsger’s severity classes estimates and their predictive capability evaluated via the explained residual variation (R2) of prediction errors (the higher the better). One-hundred random replicates were generated to simulate the prediction effort in patients with different disease duration and lung severity.

Results:

Patients characteristics are summarized in the Table. Fifteen-years survival estimates for Mesdger’s classes in the discovery set were: normal=0.88, mild=0.86, moderate=0.84 and severe=0.71. The SL3SI was defined by the following thresholds: normal/mild, FVC and DLco >=75%; moderate FVC or DLco 74-55%; severe, FVC or DLco <55%. SL3SI 15-yrs survival estimates were: normal/mild=0.89, moderate=0.82 and severe=0.63. Prediction analysis showed a higher R2values at 15 yrs for the SL3SI compared to Medsger’s classes, providing evidence for a better predictive capability of the former (discovery: 0.31 vs 0.25; validation: 0.28 vs 0.19).

Conclusion:

The SL3SI, a simplified 3-stage functional model of SSc-ILD, yields better survival estimates and long-term prognostic information than Medsger’s classes. Its reproducibility and ease of use make it a useful tool for the functional and prognostic evaluation of SSc patients at risk for or with ILD.

Table:VariablesDiscovery (n=207)Replication (n=151)DcSSc62 (30%)98 (64%)Age at first PFR48.6±1249.1±14.4Disease duration at first PFR1.7±1.61.3±2.4FVC90.5±18.191.1±20.2DLco70.7±19.861.3±20.1ILD on HRCT179 (86%)125 (80%)Scl70157 (76%)153 (78%)SSA63 (30%)32 (21%)n of visits38571473Follow-up time, yrs11±5.610.6±5.7Deaths27 (13%)23 (15%)

Disclosure of Interests:

Alessandro Santaniello: None declared, Chiara Bellocchi: None declared, Luca Bettolini: None declared, Marcello Cassavia: None declared, Gaia Montanelli: None declared, Adriana Severino: None declared, Monica Caronni: None declared, Corrado Campochiaro Speakers bureau: Novartis, Pfizer, Roche, GSK, SOBI, Enrico De Lorenzis: None declared, Gerlando Natalello: None declared, Paolo Delvino: None declared, Claudio Tirelli: None declared, Lorenzo Cavagna: None declared, Giacomo De Luca Speakers bureau: SOBI, Novartis, Celgene, Pfizer, MSD, Silvia Laura Bosello: None declared, Lorenzo Beretta Grant/research support from: Pfizer

SAT0405 CLINICAL AND PSYCHOLOGICAL PREDICTORS OF GASTROINTESTINAL INTOLERANCE TO METHOTREXATE IN PATIENTS WITH PSORIATIC ARTHRITIS

Background:

Methotrexate (MTX) is a first-line treatment for psoriatic arthritis (PsA). Gastrointestinal intolerance (GI) to the drug is a common adverse event that limits its use and can be mediated by autonomic dysfunction or classical conditioning phenomena to repeated drug exposure. Anxiety and depression could promote these processes.

Objectives:

To assess the prevalence of GI to MTX and its association with anxiety and depression in PsA patients.

Methods:

One hundred unselected PsA patients in stable MTX treatment were characterized by disease characteristics, adherence to treatment by Morisky Medication Adherence Scale (MMAS-8) and comorbidity by Rheumatic Disease Comorbidity Index (RDCI). Depressive and anxious symptoms were assessed by Hospital Anxiety and Depression Scale (HADS). The presence and the severity of nausea, vomiting, abdominal pain and diarrhoea after administration (associative symptoms) and just before or even at the thought of taking MTX (anticipatory symptoms) were recorded.

Results:

Patients had a mean age of 56.9±12.0 years and a disease duration of 9.5 years (0.1-58.0 years). They were male, smokers and overweight in 40.0%, 20.0% and 65.0% of cases, respectively. The prevalence of both significant anxious and depressive symptoms was 42.0%. DAPSA showed remission, low disease activity (LDA), moderate disease activity (MDA) and high disease activity (HDA) in 24.0%, 41.0%, 32.0% and 3.0% of patients, respectively. MTX was taken orally by 15.0% of patients and associated with another conventional or biological DMARD in 14.0% and 35.0% of cases, respectively. Symptoms of GI to MTX were complained by 69.3% of patients. Specifically, the prevalence of nausea, diarrhea, vomiting and abdominal pain was 59.0%, 23.0%, 21.0% and 30.0% with associative pattern and 43.0%, 12.0%, 10.0% and 16.0% with anticipatory pattern, respectively. Patients with anxious symptoms experienced more frequently moderate to severe associative nausea (71.4% vs 50.0%, p=0.032) and abdominal pain (42.9% vs 20.7%, p=0.017), and anticipatory nausea (42.9% vs 19.0%, p=0.009), vomiting (14.3% vs 6.9%,p=0.046), and abdominal pain (26.2% vs 8.6%, p=0.018) than non-anxious patients. Patients with depressive symptoms more commonly had associative diarrhea (33.0% vs 15.5%, p=0.037), with no difference in the prevalence of anticipatory symptoms. The presence of associative and anticipatory nausea was associated with higher anxiety scores (p=0.006 and p=0.02 respectively) without differences in the depression score. Associative nausea characterized younger patients (p=0.001), female (p=0.02), with lower BMI (p=0.02) and treated with higher MTX doses (p=0.05). Anticipatory nausea was associated with a lower age (p=0.02), a lower BMI (p=0.005), a longer disease duration (p=0.028), a lower DAPSA (p=0.02), an higher MTX doses (p=0.02) and a lower comorbidity burden (p=0.03). The anticipatory and associative nausea determined lower compliance according to MMAS-8 (p=0.007 and p=0.001, respectively). An anxious profile characterized patients with moderate to severe associative nausea also in the logistic regression model corrected for age (≥65 years), gender, BMI (≥25 kg/m2) and MTX dose (≥0.2mg/kg/week) (OR 3.0, IC 1.1-8.4, p=0.036), and patients with anticipatory nausea also in the model corrected for age (≥65 years), gender, BMI (≥25 kg/m2) and MTX dose (≥0.2mg/kg/week) and disease duration (≥6 years) (OR 3.0, IC 1.1-8.0,p=0.027).

Conclusion:

Up to two-thirds of patients with PsA who have been treated with MTX experienced symptoms of GI, leading to reduced therapeutic adherence. Associative and anticipatory symptoms characterize patients with a specific clinical and psychological profile.

Disclosure of Interests:

Gerlando Natalello: None declared, Enrico De Lorenzis: None declared, Giacomo Tanti: None declared, Pietro Rubortone: None declared, Maria Rosaria Magurano: None declared, Giusy Peluso: None declared, Elisa Gremese Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Novartis, Sanofi, UCB, Roche, Pfizer, Speakers bureau: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Novartis, Sanofi, UCB, Roche, Pfizer

Robot-assisted radical prostatectomy: recent advances

Robot assisted radical prostatectomy (RARP) represents the leading application of robotic surgery in the urologic field and it has become the main treatment option for localized prostate cancer (PCa) in the USA In the present review we summarized and critically analyzed the literature of the past five years about this widely used robotic procedure. RARP has continuously evolved in terms of technical modifications and procedural steps. Long-term data are now available, suggesting comparable oncological outcomes to those of open and laparoscopic radical prostatectomy. Good functional outcomes have also been demonstrated. Technological innovations and the introduction of more advanced robotic platforms featuring novel arm-integrated equipment, together with a mature clinical experience with the robotic approach, are likely to lead towards optimal outcomes. Despite the expanding clinical implementation of RARP in the management of prostate cancer, some issues related to this procedure remain matter of debate, such as costs, comparative outcomes versus other approaches, and its role in high risk disease.

Middle and long-term outcomes of dual kidney transplant: a multicenter experience

INTRODUCTION

Dual kidney transplantation (DKTx) to reduce the disparity between demand and supply of organs was evaluated in two Italian centers (Bari and Novara).

MATERIALS AND METHODS

Between October 2000 and October 2011, we performed 97 DKT (26 ipsilateral/71 bilateral) following routine biopsy of all kidneys obtained from expanded criteria donors by Remuzzi-Karpinsky scores. The reference group was 379 single grafts from donors older than 60 years single kidney transplantation ([SKT] × > 60).

RESULTS

Good postoperative renal function was observed in 56 DKTx (57.7%); whereas acute tubular necrosis requiring dialysis was observed in 41 (42.3%) patients. After a mean follow-up of 60 months, DKTx graft survivals were 96%, 93%, and 90% and patient survivals, 96%, 91%, and 91% at 1, 3, and 5 years, respectively. Complications in expanded criteria donor kidney transplantations included a high rate of cytomegalovirus (CMV) disease especially dual kidney cases. DKTx represented the only independent risk factor for CMV disease upon multivariate analysis (odds ratio [OR] 2.33, 95% confidence interval [CI] 1.28-4.2; P = .006). We did not observe any significant difference in graft or patient survival between DKTx and SKTx > 60 years.

CONCLUSIONS

We observed good outcomes up to 5 years after transplantation in terms of graft and patient survival despite the use of inferior grafts. Comparing DKTx and SKT > 60, we noted that the mean Karpinski score for SKTx was significantly better than DKTx, although patient and graft survivals were similar. This trend confirms that the use of a biopsy to allocate expanded criteria donor kidneys may be too protective; therefore, the criteria to select DKTx require further refinement.