AB0306 PNEUMOCOCCAL VACCINATION REDUCES THE RISK OF RESPIRATORY INFECTIONS IN PATIENTS WITH RHEUMATOID ARTHRITIS RECEIVING TARGETED THERAPY. DATA FROM MOSCOW UNIFIED ARTHRITIS REGISTRY (MUAR)

Background

The incidence of infections, mainly pneumonias, is significantly increased in patients with rheumatoid arthritis (RA). The risk increases more in persons treated with targeted anti-inflammatory drugs (tDMARDs), biological or targeted synthetic.

Pneumococcal vaccination is recommended for most patients with rheumatic diseases. However, only the immunological effectiveness of such vaccination has been sufficiently confirmed. There is sparse evidence of its clinical efficacy in patients with rheumatic diseases.

Objectives

to evaluate the effect of 23-valent pneumococcal polysaccharide vaccine (PPV23) and 13-valent pneumococcal conjugate vaccine (PCV13) on the risk of infections in RA patients receiving tDMARDs.

Methods

The data from the Moscow Unified Arthritis Registry (MUAR) for the period 2018-2020 were analyzed. We included patients with RA, over 18 years old, received tDMARDs (all available biologics or tofacitinib).

The analysis included episodes of observation from the moment of vaccination with pneumococcal vaccine until the development of the analyzed event (any infection, respiratory infection or serious infection) or until the end of follow up. For unvaccinated patients, episodes began since October 20, 2018 (the average date of vaccination of persons who received immunization).

The risks were compared using Cox regression. An adjustment was made for confounders identified in an earlier study: age and smoking.

Results

The analysis included 832 patients: 40 were vaccinated with PCV13, 35 – with PPV23. There were 144 men (17.3%). The mean age was 55.4 ± 12.1 years. The duration of observation was 319 ± 198 days.

A total of 237 infectious events were registered, of which 201 were respiratory and 21 serious (Table 1). There was a significantly lower risk of any infection (relative risk (RR) – 0.39 CI: 0.18 - 0.84, p = 0.015) and the risk of respiratory infection (RR - 0.32; CI: 0.13 -0.79; p = 0.014) in the group of patients vaccinated with PCV13 compared with unvaccinated. The differences remained statistically significant after adjusting for the age and smoking, Figure 1.

Table 1.

Registered infectious events

Event groupsLocalisationNumberOf them seriousRespiratory infectionsEar, paranasal sinuses, tonsils162Upper respiratory tract1660Pneumonia1814Lung abscess11Other infectionsEye and appendages30Skin and subcutaneous tissue71Bones and joint22Urogenital tract60Digestive system, including the oral cavity21Herpes infections*160

* - events are included in the group, regardless of localization, these events were not included in other sections

Figure 1.

Survival without infectious events (A) and without respiratory infections (B) adjusted for age and smoking

The interaction of the effects of vaccination with the factor of the used tDMARD, as well as with the factor of the use of methotrexate in their effect on the risk of any and respiratory infections was evaluated. There was no significant interaction between these variables.

There were no significant differences in the risk of serious infections due to a small number of events of this kind. No serious infections were registered among patients vaccinated with PCV13.

Conclusion

Vaccination with 13-valent conjugated pneumococcal vaccine in patients with rheumatoid arthritis receiving tDMARDs can significantly reduce the risk of infectious complications, mainly due to acute respiratory infections. We found no significant effect of targeted drug and treatment with methotrexate on the effectiveness of vaccination.

Disclosure of Interests

Evgeniy Zhilyaev Speakers bureau: UCB Pharma, Biocad, Galina Lukina Speakers bureau: Pfizer, MSD, Biocad, Ekaterina Koltsova: None declared, Dzhamilya Murtazalieva: None declared, Evgeniya Shmidt: None declared, Karine Lytkina Speakers bureau: UCB Pharma, Anna Shmitko: None declared, Dmitry Blagovidov: None declared, Mikhail Kostinov: None declared

POS1056 PREDICTORS OF RISK OF ANTI-TNF TREATMENT WITHDRAWAL IN PATIENTS WITH PSORIATIC ARTHRITIS – DATA FROM MOSCOW UNIFIED ARTHRITIS REGISTRY (MUAR)

Background

Retention on therapy is the most important integrative indicator of the success of the drug, reflecting both the effectiveness and tolerability and general acceptability of treatment. This indicator can be evaluated with high accuracy in observational trials.

Objectives

to identify predictors of TNF inhibitors withdrawal risk in patients with PSA.

Methods

Patients with (PSA) from Moscow Unified Arthritis Registry (MUAR) treated with TNF inhibitors were analyzed. All treatment episodes interrupted due to non-medical reasons were excluded from the study. Breaks in biologic therapy up to 4 months were allowed (for infliximab a break in therapy up to 6 month was considered possible)

The search for predictors of treatment withdrawal risk was carried out in two steps. At the first step possible predictors of the risk of TNF inhibitors therapy discontinuation were selected in univariate сorrelations. At the second step significant predictors of retention on TNF inhibitors therapy were selected by forward stepwise variable selection within multivariate Cox regression. The relationship between the line of anti-TNF treatment and the risk of therapy discontinuation was analyzed separately.

Results

We analyzed 371 treatment episodes in 239 patients with PSA enrolled in MUAR, 97 male (40.6%), 50.2±12.1 years old. The age of disease onset was 36.8 ± 12.7 years. The patients received adalimumab (ADA) (101 treatment episodes), golimumab (GOL) (n=32), infliximab (INF) (n=55), certolizumab pegol (CER) (n=31), etanercept (ETA) (n=152). There were 187 (50.4%) completed treatment episodes.

The relationship between risk of TNF inhibitors discontinuation and the drug line was analyzed. We found that the withdrawal risk on the second TNF inhibitor didn’t significantly differ from the withdrawal risk on the first line anti-TNF drug (p=0,201). The third and subsequent lines of TNF inhibitors where associated with the significantly higher risk of withdrawal. Direct step-by-step selection of variables made possible to identify the following significant predictors of retention on therapy – social status, the presence of HLA B-27, fever during the disease, pain in sacral zone at the onset of the disease, coccidinia during the disease, patient reports on the association of the onset of the disease with a genital infection (uretritis, adnexitis, prostatitis, endometritis) (Table 1)

Table 1.

Independent predictors of anti-TNF treatment discontinuation

PredictorsDirection of association with the dicontinuitation riskpSocial statusWorking patients had a lower risk0.038The presence of HLA-B27HLA-B27 positive patients had lower risk0.005Temperature elevation during the diseasePatients WHO reported an increase in body temperature during the disease had an increased risk< 0.001Sacral pain at the onset of the diseasePatients who reported sacral pain at the onset of the disease had an increased risk0.037Coccygeal pain during the diseasePatients who reported pain in the coccyx during the disease had an increased risk0.026Presence of genital infectionsPatients who reported a link between the onset of the disease and a history of urethritis or endometritis had a high risk0.011

After adjusting for the line of therapy and the identified predictors of the risk of drug withdrawal it was found that retention on all analyzed TNF inhibitors in patients with PSA didn’t differ significantly (Figure 1)

Conclusion

The identified significant mutually independent predictors of the risk of discontinuation of treatment may be useful when choosing biological therapy in patients with PSA.

Discontinuation therapy risk of various TNF inhibitors does not differ significant.

The risk of withdrawal therapy with the second TNF inhibitor is not significantly differ from the first one. Thus, in case of failure of the first attempt of treatment with an TNF inhibitor, a second attempt can be made The probability of success of subsequent attempts seems to be very low

Figure 1.

Adjusted analysis of treatment survival on TNF inhibitors

Disclosure of Interests

None declared

AB0162 PREDICTION OF TREATMENT DISCONTINUATION DUE TO ADVERSE EVENTS IN PATIENTS WITH RHEUMATOID ARTHRITIS USED BIOLOGICAL DMARDs AND TARGETED SYNTHETIC DMARDs

Background

The main goal of rheumatoid arthritis (RA) patients therapy is to achieve low activity or remission of the disease (T2T strategy). However, it is sometimes necessary to interrupt effective treatment due to the development of adverse events.

Objectives

To reveal predictors of target drug withdrawal due to adverse RA.

Methods

The study includes patients with RA used bDMARDs, total 1217 treatment events. Search for predictors was carried out in two steps. At the first step were selected variables which demonstrated significant correlation with time to treatment discontinuation in Kaplan-Meier analysis. At the second step selected factors were included in the Cox regression model. The final set of independent significant predictors was obtained by backward stepwise variable selection.

Results

Of 661 patients 85,8% were women, the mean age of onset disease 58,7 ± 12,9 years, the mean disease duration 14,6 years. The longest mean time till withdrawal due to adverse events had Abatacept, Toficitinib, Tocilizumab, the shortest time had Infliximab. There were 146 cases of therapy discontinuation due to adverse events. The side effects that caused the cancellation of treatment were: infections of respiratory system, skin, urinary system, allergic and infusion reactions, drug-induced hepatitis, changes in the hematopoietic system, death and other. Рresence of rheumatoid nodules (p < 0.001), higher doses of glucocorticoids (p<0.001), lower doses of methotrexate (p = 0.009) were independent significant predictors of increased risk of bDMARDs withdrawal due to adverse events. Used target drug also showed independent significant correlation with this risk. Relative risk (compared to Etanercept) was for Infliximab - 6.57 (CI: 3.69-11.73), Certolizumab pegol - 2.61 (CI: 1.23-5.56), Abatacept - 1.23 (CI: 0.65-2.30), Adalimumab - 1.37 (CI: 0.75-2.50), Rituximab - 0.56 (CI: 0.26-1.20), Tofacitinib - 0.46 (CI: 0.15-1.40), Tocilizumab - 0.77 (CI: 0.37-1.60).

Conclusion

Growth glucocorticoid doses for every 1 mg increases the risk of discontinuation of therapy by 8.7%. Reducing the methotrexate doses for every 1 mg increases the risk of discontinuation of bDMARDs and tsDMARDS by 3%. There are significant differences between target drugs for the risk of cancellation due to adverse events. High risk of infliximab discontinuation was associated more with infusion reactions and infection, discontinuation of certolizumab pegol was associated with infection.

References

[1]The identified predictors for the treatment withdrawal due to side effects may be discussed to identify measures necessary to prevent adverse events in patients with RA who are using bDMARDs and tsDMARDs. These measures are: the use of full doses of methotrexate, avoid long-term use of glucocorticoids, or prescription of the targeted drug with lower risk of adverse events.

Disclosure of Interests

None declared

AB0703 THE COURSE OF COVID-19 INFECTION IN PATIENTS WITH ARTHRITIS RECEIVING TARGETED DMARDS

Background:

WHO declared the COVID-19 outbreak as a pandemic on March 12th, 2020. Assessing the risk of severe course in patients with rheumatic diseases, especially those who receive targeted immunosuppressive treatment, is an urgent problem for rheumatologists.

Objectives:

determine the relationship between used targeted biologic and synthetic DMARDs (tDMARDs) and the severity of course of COVID-19 infection.

Methods:

The analysis included the data of patients with chronic arthritis and COVID-19, used tDMARDs. COVID-19 infection was confirm by serology tests or immune system molecules (immunoglobulins/antibodies). The presence of symptoms, the need for hospitalization, and the need for oxygen therapy were considered as indicators of the severity of the infection. We also analyzed the spread of the lung involvement according to CT data, symptoms during the disease (fever, cough, anosmia, diarrhea).

Results:

Analyses included 78 patients, among them 32 patients has ankylosing spondylitis, 31 patients - rheumatoid arthritis, 12 patients has psoriatic arthritis, 3 patients - juvenile arthritis. The average age of the included patients was 51,8 ± 11,69. Most of patients used TNF inhibitors - 43 (Adalimumab -10, Golimumab -4, Infliximab – 4, Certolizumab pegol -3, Etanercept – 22), JAK inhibitor tofacitinib used 13 patients, 5 patients each was treated with Abatacept and Tocilizumab, 3 patients used Rituximab and 2 patients each used Netakimab and Ustekinumab (Table 1). None of the patients included in the analysis required treatment in the ICU and/or mechanical ventilation. The course of the disease in patients treated with tDMARDs did not seem to be more severe than in 5 patients with arthritis who stopped treatment with tDMARDs before the onset of the pandemic. There was a direct correlation between the severity of the infection and the age of the patients (p=0.007). There were no significant differences in the severity of the infection depending on the drug, including when adjusting for age.

Conclusion:

COVID-19 does not look extremely dangerous in patients with rheumatic diseases, used target DMARDs. Used of tsDMARDs doesn’t reliably increase the risk of COVID-19 severity. There is reliable correlation between age and COVID-19 severity.

Table 1.

Cohort characteristics

DrugsMean ageNumber ofpatientsPatientswithsymptomsHospitalized patientsAsymptomaticcourseAdalimumab41,0±11,410921Golimumab51,0±11,034400Infliximab42,7±11,84004Certolizumab41,6±11,73300Etanercept50,7±11,4222062Tofacitinib56,8±10,4131221Abatacept57,4±10,95411Tocilizumab48,8±10.95312Rituximab55,6±10,73310Netakimab44,0±15,82210Ustekinumab48,0±10,52101

Disclosure of Interests:

None declared

AB0241 FACTORS THAT DIFFERENTLY ASSOCIATE WITH THE RETENTION ON TARGETED THERAPY OF PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

A personalized approach to prescribing targeted drugs implies the availability of data that can be used to suggest that a particular drug is better suited for a given patient than others. Retention on the treatment can be considered as an integral indicator of the acceptability of the drug in real practice. For the purposes of treatment personalization, the indicators that are associated with better retention on some drugs and with worse retention, or that do not have a clear association with retention on others, are of particular interest.

Objectives:

to identify predictors those are differently associated with retention on different targeted drugs for the treatment of rheumatoid arthritis.

Methods:

Data of the patients with rheumatoid arthritis (RA) from the Moscow Unified Register of Arthritis (MUAR) were used. The analysis includes episodes of treatment with biological or synthetic targeted drugs (tDMARDs) that continue or end during the patient’s follow-up in the registry. Within the framework of the Cox proportional risk regression model, significant independent predictors of tDMARDs cancellation were identified. These indicators were later considered as confounders. Further, in the generated linear regression risk model, all available indicators were tested for the presence of a statistically significant interaction with the factor of used tDMARD.

Results:

The study included 944 episodes of tDMARDs treatment (Table 1.) in 832 patients. The average age is 55.3 + 12.4 years. There were 131 males (16.1%). The average duration of the disease is 13.1 + 9.4 years. Smoking, family history of RA, and the nature of RA onset (acute or gradual) were identified as reliable mutually independent predictors of retention on tDMARDs treatment. As a result of the search for indicators that reliably interact with used tDMARD, patient’s reports of the association of the onset of arthritis 1) with symptoms of intestinal dyspepsia (p < 0.001), 2) with genital inflammatory disease (p = 0.002) were revealed. Most strongly associated with factor 1) was retention on abatacept (ABA), rituximab (RIT), and tofacitinib (TOFA). The second indicator was most strongly associated with retention on ABA, adalimumab (ADA) and TOFA (Picture 1).

Table 1.

Description of treatment episodes included in the analysis

ABAADACERETAтGOLINFRITTOCTOFATotalNumber of episodes1751503418685513011393944Completed (%)39 (22,3%)51 (34,0%)13 (38,2%)55 (29,6%)2 (25,0%)39 (70,9%)31 (23,8%)14 (12,4%)9 (9,7%)253 (26,8%)Line of treatment 183 (47,4%)24 (70,6%)113 (60,8%)120 (80,0%)3 (37,5%)50 (90,9%)70 (61,9%)66 (50,8%)35 (37,6%)564 (59,7%) 262 (35,4%)6 (17,6%)52 (28,0%)24 (16,0%)2 (25,0%)4 (7,3%)22 (19,5%)39 (30,0%)30 (32,3%)241 (25,5%) 322 (12,6%)1 (2,9%)13 (7,0%)6 (4,0%)1 (12,5%)1 (1,8%)15 (13,3%)21 (16,2%)14 (15,1%)94 (10,0%)>  38 (4,6%)3 (8,8%)8 (4,3%)0 (0,0%)2 (25,0%)0 (0,0%)6 (5,3%)4 (3,1%)14 (15,1%)45 (4,8%)

ABA – abatacept, ADA – adalimumab, CER – certolizumab paegol, ETA- etanercept, GOL – golimumab, INF – infliximab, TOC- tocilizumab, TOFA – tofacitinib.

Conclusion:

Anamnestic indications of the association of the onset of rheumatoid arthritis with symptoms of intestinal dyspepsia and with preceding genital inflammation are differently associated with retention on different targeted drugs in patients with RA. These indicators can be used to personalize the treatment.

Picture 1.

Retention on the abatacept depending on the features of the onset of rheumatoid arthritis

Disclosure of Interests:

None declared

OP0027 AS-RELATED TCR BETA CLONOTYPES ARE PRESENT IN DIFFERENT INFLAMED TISSUES OF PATIENTS WITH SPONDYLOARTHROPATHIES

Background:

Recently a group of T-cell clones with characteristic T-cell receptor (TCR) motif was identified in peripheral blood and synovial fluid of HLA-B*27+ patients with ankylosing spondylitis (AS) [1-2] - a prototypic disease from a wider group of spondyloarthropathies (SpAs). Extraarticular manifestations of AS could involve skin, intestine or eye. Emerging data indicate linkage between intestinal and joint inflammation, including expression of gut-associated integrins on synovial T-cells [3-4]. However, clonal T-cell composition and presence of identical clones in different inflamed sites in SpAs remains poorly studied.

Objectives:

To investigate clonal T-cell repertoire and presence of AS-related TCR motif in different sites of inflammation of patients with SpA.

Methods:

Samples of synovial fluid (SF) were obtained from HLA-B*27+ and HLA-B*27- patients with ankylosing spondylitis (AS) and psoriatic arthritis (PsA), as well as gut biopsy samples from patients with AS and Crohn’s disease (AS/CD) or ulcerative colitis (AS/UC), and conjunctival swabs from patients with uveitis (Uv) and with or without articular manifestations (Table 1). Also SF and gut biopsy samples were obtained from HLA-B*27+ patients with juvenile idiopathic arthritis (JIA). For one patient PsA patient paired samples of SF and gut biopsy were obtained.

Table 1.

Detection of the AS-related motif TRBV9_CASS[V/A/L/P][G/A] [L/T/V][F/Y]STDTQYF_TRBJ2-3 in bTCR repertoires of samples from different inflamed sites of patients with SpA

TissueDiagnosisB27+B27-AS-related TCR motif+ among all samples from B27+ donorsSynovial fluidAS2012PsAJIAIntestinal biopsyAS/CD433 / 4AS/UCJLAConjunctival swabUv804 / 8

SF and gut samples were processed to isolate mononuclear cells, while conjunctival swabs were directly lysed in the lysis buffer. CD3+ β7-intergin+ cells were isolated from SF by fluorescence-activated cell sorting. Deep TCR repertoire profiling was carried out using UMI-based cDNA library preparation technology [1].

Results:

Identical T-cell clonotypes were detected between paired SF and gut samples of the same patient with psoriatic arthritis and intestinal inflammation. The subpopulation of β7-intergin+ SF T-cells shared significantly more identical clonotypes with gut biopsy repertoire compared to the bulk SF T-cell repertoire.

Clonotypes belonging to the AS-related TCR beta motif TRBV9_CASS[V/A/L/P][G/A][L/T/V][F/Y]STDTQYF_TRBJ2-3 were detected in all inflamed tissues tested: synovial fluid, intestinal biopsies and conjunctival swabs of SpA patients (Table 1). Importantly, we observed these clonotypes exclusively in samples from HLA-B*27+ donors (n=26), but not in HLA-B27- context (n=15) with comparable analysis depth, thus confirming strong HLA-B*27-restriction of the clonotypes. The AS-related clonotypes were detected in the subpopulation of β7-intergin+ SF T-cells from HLA-B*27+ patients with PsA.

Conclusion:

For the first time we directly report the T-cell clonal sharing between synovial fluid and inflamed gut tissue of SpA patients. In sum our data suggests involvement of identical T-cell clones in inflammation in different anatomical sites in SpA.

References:

[1]Komech et al. Rheumatology (Oxford). 2018;57(6):1097-1104.

[2]Faham et al. Arthritis Rheumatol. 2016;11(10):300-308.

[3]Guggino et al.Ann Rheum Dis. Published Online First: 18 October 2019.doi:10.1136/annrheumdis-2019-216456.

[4]Qaiyum et al Ann Rheum Dis. 2019;78(11):1566-1575.

Acknowledgements:

We thanks all the patients and medical personnel involved in the study

Disclosure of Interests:

None declared

AB0475 COMPARATIVE EFFECTIVENESS OF BIOLOGICAL DISEASE-MODIFYING ANTIRHEUMATIC DRUGS IN REAL CLINICAL PRACTICE ACCORDING TO THE MOSCOW UNIFIED ARTHRITIS REGISTER (MUAR)

Background:

This study is the first analysis of biological disease-modifying antirheumatic drugs (bDMARDs) for ankylosing spondylitis (AS) within the Moscow Unified Arthritis Register (MUAR).

Objectives:

to compare the effectiveness of bDMARDs in patients with AS using data from the MUAR.

Methods:

The analysis included the data of patients with AS who were included in the MUAR and received biological therapy for at least 6 months. The effectiveness of the drugs was assessed by the achieved values of the indices of diseases activity and its manifestations: ASDAS(C-RP), BASDAI, LEI, MASES, indicators of the functional ability of patients (BASFI, HAQ) at the last completed visit. Comparison of indicators between drugs was in a general linear model, adjusted for the identified confounders. The search for confounders was in 2 stages: first, by univariate analysis, were identified indicators significantly related to the achieved ASDAS. Then, within the multivariate general linear model, by backward stepwise selection were determinate variables significantly and independently associated with ASDAS.

Results:

The current study included 363 episodes of treatment with bDMARDs in 361 patients. There were 240 men (66.5%). The average age of the included patients was 46.3 ± 11.2, the age at the onset of the disease was 27.3 ± 11.4. The average duration of a treatment episode until the patient was assessed 1135 ± 900 days. Significant differences of the values of ASDAS(p = 0.033) and ESR (p = 0.007) between bDMARDs were revealed. In pairwise comparisons of the achieved ASDAS using the Shidak adjustment, demonstrated that the values on infliximab and adalimumab were significantly lower than on certolizumab pegol (p = 0.009 and p = 0.041, respectively). Also significantly higher ESR values on certolizumab compared to all other drugs (p < 0.001 for all) were found. There were no statistically significant differences between the drugs for other studied parameters.

Conclusion:

The studied bDMARDs (infliximab, adalimumab, etanercept, certolizumab pegol, golimumab, secukinumab) demonstrate generally similar clinical efficacy in real clinical practice. The effect of golimumab and sekukinumab which have been recently introduced into clinical practice doesn’t differ significantly from the effect of TNF inhibitors which has been used for a long time.

Table 1.

Achieved values of the indices of activity and functional ability against the background of treatment with bDMARDs.

ASDAS(С-RP)BASDAIHAQBASFIunadjustedadjustedunadjustedadjustedunadjustedadjustedunadjustedadjustedADA1,89 ±0,891,54 ± 0,293,07 ± 1,612,89 ± 0,250,63 ± 0,420,60 ± 0,073,25 ± 2,023,09 ± 0,32GOL2,08 ± 0,992,22 ± 0,313,09 ± 1,963,44 ± 0,490,66 ± 0,610,78 ± 0,143,74 ± 2,934,00 ± 0,63INF1,57 ± 0,821,29 ± 0,322,64 ± 1,552,19 ± 0,380,56 ± 0,520,57 ± 0,112,81 ± 2,292,93 ± 0,49ETA1,96 ± 0,851,94 ± 0,243,19 ± 1,693,44 ± 0,190,65 ± 0,530,72 ± 0,063,39 ± 2, 263,88 ± 0,24CER2,69 ± 1,032,95 ± 0,464,07 ± 2,283,65 ± 0,521,12 ± 0,820,84 ± 0,155,07 ± 2,954,19 ± 0,67SEK2,69 ± 1,311,66 ± 0,513,72 ± 2,223,71 ± 0,490,85 ± 0,470,85 ± 0,143,46 ± 2,133,46 ± 0,63

ADA – Adalimumab, GOL – Golimumab, INF – Infliximab, ETA – Etanercept, CER – Certolizumab pegol, SEK – Sekukinumab, ASDAS - Ankylosing Spondylitis Disease Activity Score, BASDAI Bath Ankylosing Spondylitis Disease Activity Index, BASFI - Bath Ankylosing Spondylitis Functional Index, HAQ - Health Assessment Questioner, C-RP – C-reactive protein.

Disclosure of Interests:

None declared.

POS0004 T-CELL REPERTOIRE OF SYNOVIAL FLUID IN SPONDYLOARTHROPATHIES EXHIBITS HALLMARKS OF HLA-DEPENDENT CLONAL EXPANSIONS AND REMAINS STABLE OVER 1.5 YEARS

Background:

Different studies show involvement of T-cells in pathogenesis of spondyloarthropathies (SpAs) - a group of rheumatic diseases strongly associated with presence of several MHC-I alleles (HLA-B*27, -B*38, -B*39, etc). Recently we and others identified a specific T-cell receptor motif in blood and synovial fluid of HLA-B*27+ AS patients that reinforces the “arthritogenic peptide” hypothesis of AS pathogenesis [1-2]. However, common characteristics of clonal T-cell repertoire of synovial fluid in SpAs remain poorly investigated.

Objectives:

We aimed to investigate synovial fluid T-cell repertoires of SpA patients with different HLA-genotypes and stability of the clonal composition in recurring flares of the disease.

Methods:

Mononuclear cells were isolated from paired peripheral blood (PB) and synovial fluid (SF) samples of SpA patients (ankylosing spondylitis and psoriatic arthritis, n=27). For 3 patients additional SF samples were collected during relapse of the synovitis (after 9-15 months). CD4 and CD8 T-cells were isolated by immunomagnetic separation. Deep sequencing of UMI-tagged TCR beta cDNA libraries was used to accurately reconstruct clonal T-cell repertoires. HLA class I and II were typed for each donor using an in-house NGS-based system.

Results:

We observed restricted T-cell clonal composition in synovial fluid: on average only 6% of PB T-cell clonotypes were detected in SF of the same donor. T-cell repertoires of both CD4 and CD8 SF subsets compared to PB were highly oligoclonal (index Gini PB vs SF: CD4 0.36±0.10 vs 0.68±0.08, CD8 0.57±0.17 vs 0.81±0.12) in all patients. Number of identical amino acid CDR3 sequences between two repertoires correlated with the number of identical HLA-alleles for the donors. This trend was exhibited more strikingly in SF compared to PB, suggesting that common antigens may play a role in accumulation of identical T-cell clonotypes in the inflamed joint. Using several bioinformatic approaches we identified groups of highly similar SF clonotypes linked to HLA-B*27 and/or HLA-B*38 genotype.

Total SF repertoires of relapsing synovitis of the same donor showed huge clonal overlap, and the most frequent clonotypes remained almost unchanged (Morisita’s overlap index for total SF repertoires 0.69±0.26; for top 1000 clonotypes 0.79±0.19, n=3).

Conclusion:

We report HLA-dependent sharing of identical and similar T-cell clonotypes in SF of patients with ankylosing spondylitis and psoriatic arthritis and high stability of SF repertoire during several flares that support antigen-driven accumulation of T-cells in the site of inflammation.

References:

[1]Komech EA et al. Rheumatology (Oxford). 2018;57(6):1097-1104.

[2]Faham M et al. Arthritis Rheumatol. 2016;11(10):300-308.

Acknowledgements:

The work is supported by Russian Science Foundation grant №20-75-00041.

Disclosure of Interests:

None declared.

POS0937 TREATMENT SURVIVAL ON BIOLOGICS IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS – DATA FROM MOSCOW UNIFIED ARTHRITIS REGISTRY (MUAR)

Background:

The number of new biologics in treatment of axial spondyloarthritis (axSpA) is rapidly increasing. It is important to assess timely their place in the treatment of axSpA, especially with regard to retention on therapy.

Objectives:

To compare retention on therapy with different biologics in patients with axSpA.

Methods:

We retrospectively analyzed the data of axSpA patients receiving biologics from the MUAR register. Predictors of retention on therapy were selected by forward stepwise variable selection within Cox regression proportional hazard model. These predictors were considered as confounders when comparing the risks of biologics withdrawal.

Results:

990 treatment episodes in 640 patients with axSpA were analyzed (non-radiographic axSpA – 4.1%, ankylosing spondylitis - 95.9%). The duration of episodes was 824±920 days. Men were 66,6%, mean age 46,4±11,4.The patients were treated with Adalimumab (ADA) (n= 252 treatment episodes), Golimumab (GOL) (n=82), Infliximab (INF) (n=167), Netakimab (NET) (n=9), Secukinumab (SEC) (n=75), Certolizumab pegol (CER) (n=66), Etanercept (ETA) (n=339).

The following predictors of withdrawal risk were identified –

1.The total duration of the disease

2.The duration of the disease before the onset of biologic treatment

3.Gender

4.Family history of non-inflammatory spondylopathy (degenerative spinal disease)

5.The line of biologic treatment

6.The level of education

The severity of radiographic sacroiliitis and HLA B-27 positivity were not associated with the risk of discontinuation of biologics.

The identified predictors were further considered as confounders. Adjusted for confounders, ETA had the lowest treatment withdrawal risk (Figure 1). ADA, GOL, INF, SEC, CER had significantly higher risk of withdrawal compared with ETA (Table 1).

Conclusion:

Our analysis detected predictors associated with risk of biologics withdrawal in axSpA patients in real clinical practice. There are significant differences between biologics regarding retention on treatment.

Table 1.

Hazard ratio for treatment withdrawal

DrugHazard ratio (Exp B)pADA1.52*0.004GOL2.95*0.000INF2.574*0.000NET3.680*0.073SEC2.133*0.005CER2.922*0.000

*- withdrawal risk relative to ETA

Figure 1.

Picture 1. Treatment withdrawal risk

Disclosure of Interests:

None declared

SAT0141 LONG-TERM EFFECTIVENESS OF TOFACITINIB IN CONVENTIONAL DMARDS NON-RESPONDERS WITH RHEUMATOID ARTHRITIS: RESULTS OF RUSSIAN NATIONAL REGISTER

Background:

Tofacitinib is an oral Janus Kinase inhibitor for the treatment of rheumatoid arthritis (RA).

Objectives:

To evaluate the three-year effectiveness of tofacitinib in RA conventional synthetic (cs) DMARDs non-responders.

Methods:

Data from 374 patients from Russian national register OREL of patients with RA treated with tofacitinib not less than 3 years after failure of conventional DMARDs were included in the statistical analysis. Clinical and laboratory data from 4 consecutive visits with an interval of 12 months between the visits (± 28 days) were analyzed. Treatment with any biologics ever was an exclusion criteria. Demographical (age, sex) and disease-related characteristics of RA (symptoms duration, RF- and ACCP positivity, presence of joint erosions, DAS28, CDAI, number of tender and swollen joints (NTJ, NSJ), erythrocytes sedimentation rate (ESR), C-reactive protein (CRP)) collected. Statistical analysis performed with statistical programs SPSS2017 and GraphPadPrizm. p-value < 0.05 considered as significant.

Results:

Baseline characteristics of RA patients, involved in the analysis are presented in table 1.

Table 1.

Baseline characteristics of the patients with RA (n=374).

ParameterCharacteristicsMale, n (%)92 (24.5)Age, years (mean±SD)53.4±13.38Symptoms duration, month (mean±SD)140±137Positive rheumatoid factor (RF), n (%)123(32.8)Positive antibodies to cyclic citrullinated peptide (ACCP), n (%)329(87.9)Erosions of hand joints (X-rays), n (%)372 (99.4)BMI, kg/m2(mean ±SD)26.8 ± 6.14Smokers (current and in the past), n (%)54 (14.4)

Changes in the diseases activity parameters in patients with RA, treated with tofacitinib not less than 3 years after cs DMARD failure are presented in table 2, figure 1, and figure 2.

Figure 1.

DAS28 of patients with RA, treated with tofacitinib (n=374) – 3-years follow-up (time-points are presented in years ± 28 days).

Figure 2.

DAS28 of patients with RA, treated with tofacitinib (n=374) – 3-years follow-up (time-points are presented in years ± 28 days).

Table 2.

Changes in RA parameters in patients treated with tofacitinib, n=374 (M±SE).

Disease characteristicsBaselineYear 1#Year 2#Year 3#C-RP, mg/L30.1±35.08.3±12.87.6±10.79.4±13.5ESR, mm/h35.2±21.222.7±17.221.9±17.722.3±17.3NTJ from 2811.2±6.54.6±4.94.8±5.03.9±3.8NTJ from 287.6±5.12.4±3.21.7±3.11.4±2.8

*difference with baseline is significant with p<0.000.#- ±28 days

Conclusion:

According to the real world data treatment with tofacitinib may provide good response rates in RA patients, refractory to the previous csDMARDs treatment in long-term perspective.

Acknowledgments :

Pfizer

Disclosure of Interests: :

Inna Gaydukova Grant/research support from: JSC BIOCAD, Speakers bureau: Pfizer, Novartis, AbbVie, JSC BIOCAD, Сelgene, MSD, Sanofi, V Mazurov: None declared, Alexander Lila: None declared, Andrey Baranov Grant/research support from: Bayer, Galina Lukina Speakers bureau: Novartis, Pfizer, UCB, Abbvie, Biocad, MSD, Roche, Evgeniy Zhilyaev Speakers bureau: Novartis, UCB, Pfizer, Biocad, Abbvie, MSD, Roche, Ekaterina Koltsova: None declared, Evgeniya Shmidt Speakers bureau: MSD, Novartis, Pfizer, Oxana Fomina: None declared, Irina Bondareva: None declared, Olga Anoshenkova: None declared, Aleksey Vasilenko: None declared, Elizaveta Vasilenko: None declared, Natalya Yudina: None declared, Larisa Knyazeva: None declared, Vyacheslav Poncratov: None declared, Ekaterina Gaydukova: None declared, Evgeny Nasonov Speakers bureau: Lilly, AbbVie, Pfizer, Biocad, R-Pharm

AB0306 EXPERIENCE WITH RITUXIMAB BIOSIMILAR BCD-020 IN PATIENTS WITH RHEUMATOID ARTHRITIS IN REAL-WORLD CLINICAL PRACTICE ACCORDING TO DATA FROM MOSCOW UNIFIED ARTHRITIS REGISTRY (MUAR)

Background:

The introduction of perspective anti-rheumatic biologic agents into clinical practice has not only increased therapy efficacy and improved medical prognosis in patients with rheumatoid arthritis (RA), but also resulted in a dramatic increase in treatment cost and, therefore, in a reduced accessibility of the innovative treatment for patients. For this reason, over the last years, there has been a huge interest towards developing biosimilars [1,2].

Objectives:

To assess the effectiveness and safety of switching from reference rituximab (RTXref) to rituximab biosimilar (RTXbs) BCD-020 in patients with RA in real clinical practice according to the data from MUAR.

Methods:

Patients with RA who treated by RTXrefat the onset and then switched to RTXbs(BCD-020) were enrolled in the study. For all patients were performed: swollen and tender joints count, ESR, CRP, biochemistry and immunologic blood analyses. Assessment of dynamic of DAS28, RAPID3, HAQ-DI was performed. The great attention was given to the therapy safety assessment. RTXrefeffectiveness and safety profile was assessed at the moment of switching; data for RTXbs(BCD-020) were collected not earlier than 6 months after switching.

Results:

46 patients with RA were enrolled, 80.5% were women; the mean age was 59.5±12.2 years; 91.3% were RF-positive, 63% - ACCPA-positive, the disease activity at the moment of switching was moderate, the mean DAS28 was 3.5. The duration of RTXreftherapy until switching was 36.8 ± 26.8 months; the duration of the follow-up period for BCD-020 biosimilar was 12.1 ± 6.18 months. In 43.5% of patients, previously inefficiency or intolerance of other biologics was discovered. The proportion of patients who received concomitant therapy with glucocorticoids or methotrexate (MTX) was 45.7% and 43.5%, respectively. The mean MTX dose was 13.6 mg/wk. The mean dose of RTXref/BCD-020 was 1000 mg. The stability dynamic of clinical parameters was retained after switching to biosimilar (Tab.1) without significant difference between the rituximab products (р>0.05).

Table 1.

Comparison of Efficiency Parameters for the Reference Rituximab and Biosimilar BCD-020

ParameterReference rituximabBiosimilar BCD-020DAS28 (ESR)3.393.34HAQ-DI1.481.44RAPID312.912.6

The safety profile of RTXrefand RTXbs(BCD-020) was also similar. None of the patients discontinued BCD-020 therapy for reasons related to safety or inefficiency.

Conclusion:

Within the framework of routine clinical practice, switching from reference rituximab to BCD-020 biosimilar is not accompanied by a change in efficiency and safety profile of the therapy and does not pose a risk of discontinuation, which is coherent with the results of the registration clinical trial for BCD-020. [3]

References:

[1]Edwards CJ, et al. Switching to biosimilars: current perspectives in immune-mediated inflammatory diseases. Expert Opin Biol Ther. 2019 Oct;19(10):1001-1014. doi: 10.1080/14712598.2019.1610381. Epub 2019 May 6.

[2]Dörner T, et al. The changing landscape of biosimilars in rheumatology. Ann Rheum Dis 2016;75:974–982. doi:10.1136/annrheumdis-2016-209166

[3]Nasonov EL, et al. The results of a phase III comparative clinical trial of rituximab (Acellbia and MabThera) in rheumatoid arthritis (the BIORA study). Nauchno-Prakticheskaya Revmatologiya = Rheumatology Science and Practice. 2016;54(5):510-519 (In Russ.). doi:http://dx.doi.org/10.14412/1995-4484-2016-510-519

Disclosure of Interests:

Galina Lukina Speakers bureau: Novartis, Pfizer, UCB, Abbvie, Biocad, MSD, Roche, Ekaterina Koltsova: None declared, Evgeniya Shmidt Speakers bureau: MSD, Novartis, Pfizer, Karine Lytkina Speakers bureau: Novartis, Eli Lilly, Pfizer, UCB, Abbvie, Biocad, MSD, Jonson&Jonson, Evgeniy Zhilyaev Speakers bureau: Novartis, UCB, Pfizer, Biocad, Abbvie, MSD, Roche

AB0303 PREDICTORS OF SERIOUS INFECTIONS IN PATIENTS WITH RHEUMATOID ARTHRITIS RECEIVING TARGET THERAPY

Background:

The problem of infectious complications in patients receiving bDMARDs deserves special attention. Serious infectious adverse events (SIAE) are a most important issue. To develop measures for their prevention it is necessary to know the predisposing factors.

Objectives:

to detect predictors of serious infections among patients with rheumatoid arthritis receiving targeted therapy

Methods:

The study includes patients with rheumatoid arthritis from the Moscow Unified Arthritis Registry (MUAR), receiving treatment with biologics or tofacitinib. Search for predictors was carried out in two steps. At first step we selected patient related predictors (confounders) that significantly correlate with risk of SIAE. At the second step in the Cox risk regression model by forward stepwise selection were identified independent significant predictors of risk. which demonstrated significant correlation with development of serious infections. Then data about the treatment was added to the generated model: used targeted DMARDs, doses of glucocorticoids (GC), doses of methotrexate (MTX).

Results:

Analysis includes 1052 treatment events in 772 patients. There were 44 serious infections. The mean age was 57,1 ± 12,8 years. The mean observation time – 5.3 years. Independent patient related predictors of SIAE risk were the age RR - 1.12 per year (CI: 1.06-1.19), the age of onset disease RR - 0.94 per year (CI: 0.90-0.98), the year of inclusion in the registry RR - 0.64 per year (CI: 0.49-0.85). The dose of MTX and the doses of GC positively correlate with SIAE risk. RR for MTX is 1.05 per mg (CI: 1.005-1.109), RR for GC - 1.11 per mg (CI: 1.004-1.236).

Used targeted DMARD didn’t show any significant correlation with SIAE risk.

Conclusion:

Higher doses of methotrexate and glucocorticoids are independent significant predictors of serious infections in RA patients receiving targeted DMARDs.

Disclosure of Interests:

Ekaterina Koltsova: None declared, Galina Lukina Speakers bureau: Novartis, Pfizer, UCB, Abbvie, Biocad, MSD, Roche, Evgeniya Shmidt Speakers bureau: MSD, Novartis, Pfizer, Karine Lytkina Speakers bureau: Novartis, Eli Lilly, Pfizer, UCB, Abbvie, Biocad, MSD, Jonson&Jonson, Evgeniy Zhilyaev Speakers bureau: Novartis, UCB, Pfizer, Biocad, Abbvie, MSD, Roche

SAT0161 THE ANALGESIC EFFECT OF TOFACITINIB MAY HAVE CLINICAL SIGNIFICANCE IN PATIENTS WITH RHEUMATOID ARTHRITIS. DATA FROM THE MOSCOW UNIFIED REGISTER OF ARTHRITIS (MUAR)

Background:

Some theoretical data suggest that the JAK-kinase blocker tofacitinib (TOFA) may have a direct analgesic effect.

Objectives:

to evaluate the clinical significance of the analgesic effect in patients with rheumatoid arthritis (RA) in real clinical practice.

Methods:

Hypothesis being tested: the analgesic effect of TOFA may be manifested by a decrease in the ratio of subjective to objective indicators of arthritis activity.

Data from RA patients receiving biologics (bDMARD) and/or TOFA and included in the MUAR register were analyzed. The tender joints count (TJC), the HAQ-DI functional ability index, and the RAPID3 disease activity index were considered as subjective estimates. The swollen joints count (SJC) and the level of CRP were treated as objective indicators. The estimation of quotients from the division of subjective indicators into objective ones in all combinations is made.

Taking into account the observational nature of the study, we searched for confounders for each of these ratios. Comparison of the calculated indices during the treatment with various targeted DMARDs (tDMARDs) was made with an adjustment for the detected confounders.

Results:

the analysis included 944 treatment episodes in 832 patients, including 93 episodes of TOFA treatment. The average age was 55.3 ± 12.4 years, women - 698 (83.9%), seropositive for RF -672 (80.8%). The analysis of the adjusted values showed that the ratios of the TJC, HAQ-DI and RAPID3 to the SJC during the treatment with TOFA was significantly lower than with tDMARDs on average. There were no significant differences in the ratios of objective indicators to the CRP level (Table).

Table.

Ratios of objective and subjective indicators during the treatment with tofacitinib and with tDMARDs therapy in general

Conclusion:

the severity of subjective feelings and functional disorders in RA patients receiving TOFA may be less with the same level of objective signs of arthritis compared with bDMARDs.

Disclosure of Interests:

Evgeniy Zhilyaev Speakers bureau: Novartis, UCB, Pfizer, Biocad, Abbvie, MSD, Roche, Galina Lukina Speakers bureau: Novartis, Pfizer, UCB, Abbvie, Biocad, MSD, Roche, Ekaterina Koltsova: None declared, Evgeniya Shmidt Speakers bureau: MSD, Novartis, Pfizer, Karine Lytkina Speakers bureau: Novartis, Eli Lilly, Pfizer, UCB, Abbvie, Biocad, MSD, Jonson&Jonson

Erectile Dysfunction Is Highly Prevalent in Men With Newly Diagnosed Inflammatory Bowel Disease

BACKGROUND AND AIMS

Cross-sectional studies on sexual function in men with inflammatory bowel disease (IBD) yield mixed results. Using a prospective incidence cohort, we aimed to describe sexual function at baseline and over time and to identify factors associated with impaired sexual function in men with IBD.

METHODS

Men 18 years and older enrolled between April 2008 and January 2013 in the Ocean State Crohn's and Colitis Area Registry (OSCCAR) with a minimum of 2 years of follow-up were eligible for study. Male sexual function was assessed using the International Index of Erectile Function (IIEF), a self-administered questionnaire that assesses 5 dimensions of sexual function over the most recent 4 weeks. To assess changes in the IIEF per various demographic and clinical factors, linear mixed effects models were used.

RESULTS

Sixty-nine of 82 eligible men (84%) completed the questionnaire (41 Crohn's disease, 28 ulcerative colitis). The mean age (SD) of the cohort at diagnosis was 43.4 (19.2) years. At baseline, 39% of men had global sexual dysfunction, and 94% had erectile dysfunction. Independent factors associated with erectile dysfunction are older age and lower physical and mental component summary scores on the Short Form Health Survey (SF-36).

CONCLUSION

In an incident cohort of IBD patients, most men had erectile dysfunction. Physicians should be aware of the high prevalence of erectile dysfunction and its associated risk factors among men with newly diagnosed IBD to direct multidisciplinary treatment planning.