Distinct long-term disease activity trajectories differentiate early on treatment with etanercept in both rheumatoid arthritis and spondylarthritis patients: a prospective cohort study

To characterize disease activity trajectories and compare long-term drug retention between rheumatoid (RA) and spondylarthritis (SpA) patients initiating tumor necrosis factor inhibitor (TNFi) treatment (etanercept). Prospective observational study of RA, axial (AxSpA) and peripheral SpA (PerSpA) patients initiating etanercept during 2004-2020. Kaplan-Meier plots were used for drug retention comparisons and multivariable Cox regression models for predictors of discontinuation. Long-term disease activity trajectories were identified by latent class growth models using DAS28-ESR or ASDAS-CRP as outcome for RA and AxSpA respectively. We assessed 711 patients (450 RA, 178 AxSpA and 83 PerSpA) with a median (IQR) follow-up of 12 (5-32) months. At 5 years, 22%, 30% and 21% of RA, AxSpA and PerSpA patients, respectively, remained on therapy. Etanercept discontinuation was independent of the diagnosis and was predicted by gender and obesity in both RA and SpA groups. Four disease activity (DA) trajectories were identified from 6th month of treatment in both RA and AxSpA. RA patients in remission-low DA groups (33.7%) were younger, had shorter disease duration, fewer comorbidities and lower baseline disease activity compared to moderate (40.6%) & high DA (25.7%) groups. In AxSpA 74% were in inactive-low DA and they were more often males, non-obese and had lower number of comorbidities compared to higher ASDAS-CRP trajectories. In RA and AxSpA patients, disease activity trajectories revealed heterogeneity of TNFi treatment responses and prognosis. Male gender, lower baseline disease activity and fewer comorbidities, characterize a favourable outcome in terms of disease burden accrual and TNFi survival.

Patterns of comorbidities differentially affect long-term functional evolution and disease activity in patients with 'difficult to treat' rheumatoid arthritis

BACKGROUND

Characterisation of the long-term outcome of patients with 'difficult to treat' (D2T) rheumatoid arthritis and factors contributing to its evolution are unknown. Herein, we explored the heterogeneity and contributing factors of D2T long-term outcome.

METHODS

Patients included from a prospective single centre cohort study. The EULAR definition of D2T was applied. Longitudinal clustering of functional status (modified Health Assessment Questionnaire (mHAQ)) and disease activity (Disease Activity Score-28 (DAS28)) were assessed using latent-class trajectory analysis. Multiple linear mixed models were used to examine the impact of comorbidities and their clusters on the long-term outcome.

RESULTS

251 out of 1264 patients (19.9%) were identified as D2T. Younger age, fibromyalgia, osteoarthritis, DAS28-erythrocyte sedimentation rate (ESR) at first biological or targeted synthetic disease-modifying antirheumatic drug (b/ts-DMARD) initiation and failure to reduce DAS28-ESR scores within the first 6 months of b/ts-DMARD therapy were significant predictors of patients becoming D2T. Long-term follow-up (total of 5872 person-years) revealed four groups of functional status evolution: 18.2% had stable, mildly compromised mHAQ (mean 0.41), 39.9% had gradual improvement (1.21-0.87) and two groups had either slow deterioration or stable significant functional impairment (HAQ>1). Similarly, four distinct groups of disease activity evolution were identified. Among the different clusters of comorbidities assessed, presence of 'mental-health and pain-related illnesses' or 'metabolic diseases' had significant contribution to mHAQ worsening (p<0.0001 for both) and DAS28 evolution (p<0.0001 and p=0.018, respectively).

CONCLUSION

D2T patients represent a heterogeneous group in terms of long-term disease course. Mental-health/pain-related illnesses as well as metabolic diseases contribute to long-term adverse outcomes and should be targeted in order to optimise the prognosis of this subset of rheumatoid arthritis.

A Peripheral Blood Signature of Increased Th1 and Myeloid Cells Combined with Serum Inflammatory Mediators Is Associated with Response to Abatacept in Rheumatoid Arthritis Patients

Abatacept (CTLA4-Ig)-a monoclonal antibody which restricts T cell activation-is an effective treatment for rheumatoid arthritis (RA). Nevertheless, only 50% of RA patients attain clinical responses, while predictors of response are rather limited. Herein, we aimed to investigate for early biomarkers of response to abatacept, based on a detailed immunological profiling of peripheral blood (PB) cells and serum proteins. We applied flow cytometry and proteomics analysis on PB immune cells and serum respectively, of RA patients starting abatacept as the first biologic agent. After 6 months of treatment, 34.5% of patients attained response. At baseline, Th1 and FoxP3+ T cell populations were positively correlated with tender joint counts (p-value = 0.047 and p-value = 0.022, respectively). Upon treatment, CTLA4-Ig effectively reduced the percentages of Th1 and Th17 only in responders (p-value = 0.0277 and p-value = 0.0042, respectively). Notably, baseline levels of Th1 and myeloid cell populations were significantly increased in PB of responders compared to non-responders (p-value = 0.009 and p-value = 0.03, respectively). Proteomics analysis revealed that several inflammatory mediators were present in serum of responders before therapy initiation and strikingly 10 amongst 303 serum proteins were associated with clinical responses. Finally, a composite index based on selected baseline cellular and proteomics' analysis could predict response to abatacept with a high sensitivity (90%) and specificity (88.24%).

Comorbidities Burden and Implementation of the Treat-to-Target Strategy in Predicting Real-World Patient Outcomes in Spondyloarthritides

New biologic and small molecule targeted agents have expanded the armamentarium of Spondyloarthritides (SpA), allowing more therapeutic options for patients who do not respond to therapy. The implementation of the treat-to-target (T2T) strategy with close monitoring and frequent treatment adaptations targeting disease remission has been proposed as the means to prevent radiographic progression and long-term adverse outcomes. In this project we will employ the "University of Crete Rheumatology Clinic Registry" to prospectively study in real-world practice musculoskeletal and extraarticular disease activity, patient function, comorbidities, sociodemographics, imaging, compliance to therapy and other lifestyle factors in axial and peripheral SpA patients. The predictive value of these variables in long-term (2years) outcomes will be evaluated. We will also assess the implementation of the T2T approach as well as its impact on long-term patients' outcomes (quality of life, productivity, adverse events). The successful completion of this study could pave the way for improved and personalized therapy in patients with SpA.

Rheumatoid arthritis patients initiating rituximab with low number of previous bDMARDs failures may effectively reduce rituximab dose and experience fewer serious adverse events than patients on full dose: a 5-year cohort study

Background

Rituximab is used for the treatment of active rheumatoid arthritis. In the present study, we examined the long-term flare risk and safety of reduced doses of rituximab.

Patients-methods

This was a prospective, observational, single-center study of patients starting rituximab on standard dose (SD). Patients were switched to low dose (LD) (1 g every 6 months), based on the treating rheumatologist’s decision after having achieved sustained clinical responses, while the rest of the patients continued on standard dose (SD). During a 60-month period, we assessed (Kaplan–Meier survival analysis) the relapse rate (increase ≥ 1.2 in DAS28-ESR for ≥ 6 months) and discontinuations due to treatment failure in the low dose group, and we compared the incidence of serious adverse events (SAEs) between LD and SD groups.

Results

Out of 361 patients [females 83.4%, mean age 61.9 (10.6) years, seropositive 50.3%, median total comorbidities count 4], 81 patients (22.4%) entered LD in a median time of 24 months (95% CI 18–30 months). Seropositivity (OR 1.823), more than 2 previous bDMARDs failures (OR 0.428), and DAS28 < 4.88 at 6 months (OR 2.329) predicted the odds of entering LD (p < 0.05 for all). During 60 months of follow-up, only 7.5% of patients on LD relapsed. Patients on LD had significantly less SAEs and all-cause hospitalizations as compared to the SD group (p < 0.05 for all). Linear regression analysis showed that previous hospitalization while on bDMARDs (p < 0.0001), use of prednisolone > 5 mg/day while on rituximab (p < 0.0001), and a history of ≥ 2 previous csDMARDs (p = 0.041) predicted the risk of SAEs.

Conclusion

In a cohort of patients with established RA and significant comorbidities who taper rituximab after substantial initial disease activity improvement, a low rate of relapses and lower risk of SAEs compared to SD were recorded. Seropositivity, a lower number of previous bDMARDs use, and lower DAS28 at 6 months predicted the probability of entering the LD regimen.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02826-6.

POS0768 PRESENCE OF ANTI-Ro/SSA AUTOANTIBODIES, HYPOCOMPLEMENTEMIA AND PHOTOSENSITIVITY INDICATE INDIVIDUALS WITH CONNECTIVE TISSUE DISEASE FEATURES WHO ARE AT INCREASED RISK FOR TRANSITION TO SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Early or pre-clinical forms of lupus encompass a broad range of presentations, spanning from asymptomatic individuals with immunological abnormalities to individuals with autoantibodies and some features suggestive of SLE who do not yet meet the classification criteria. Research on this topic could reveal predictive and diagnostic biomarkers for individuals at-risk for progression to SLE.

Objectives

To examine the rate of transition from at-risk to classified (ACR 1997 criteria) SLE, and identify demographic and clinical predictors. To prospectively evaluate the sensitivity and accuracy of the newer classification criteria (SLICC 2012, EULAR/ACR 2019) and the SLE Risk Predictive Index (SLERPI)[1] in patients at-risk who progress or not to classified SLE.

Methods

This is a single-centre analysis of individuals at-risk for SLE as part of an ongoing multicentric inception cohort study aiming to identify clinical, environmental and molecular prognostic factors for SLE onset. Enrolled individuals: a) were 18–55 years old; b) had clinical and/or serological features suggestive of SLE; c) had no clinical diagnosis of SLE or other autoimmune rheumatic disease; and d) did not fulfill the ACR 1997 classification criteria. Prospective monitoring at 6-month intervals was performed to determine accrual of classification and non-classification features, and ascertain the disease status (at-risk/undifferentiated connective tissue disease, SLE, other connective tissue disease).

Results

A total 124 subjects were included, all Whites, 94.4% women, with an average (standard deviation) age 36 (11) years. At first assessment, individuals fulfilled 2.25 (0.72) ACR 1997 criteria with ANA being the most prevalent feature (75.8%) followed by low complement (43.5%), arthritis (37.9%), photosensitivity (28.2%), malar rash (23.4%), and non-scarring alopecia (18.5%). After a median follow-up of 16 months, 27 participants (21.8%) fulfilled the ACR 1997 criteria, of whom 8 (6.5%) developed moderate or severe SLE. Multivariable-adjusted logistic regression identified anti-Ro/SSA (odds ratio [OR] 6.93; 95% confidence interval [95% CI] 1.75–27.5, p=0.006), combined low C3 and low C4 (OR 4.82; 95% CI 1.42–16.3, p=0.012) and photosensitivity (OR 3.25; 95% CI 1.17–8.99, p=0.023) as independent predictors for transition to classified SLE. The sensitivity of SLICC 2012, EULAR/ACR 2019 and SLERPI (>7) at baseline for detecting individuals who progressed to SLE (ACR 1997) was 40.7%, 25.9% and 40.7%, respectively, with corresponding specificities of 83.5%, 88.7% and 79.4%.

Conclusion

Among individuals at-risk for SLE, about 20% may evolve into classified disease after a medium follow up of 16 months which is predominantly of mild severity. Presence of anti-Ro/SSA, hypocomplementemia, and photosensitivity indicate subjects who at increased risk for transition to SLE. Newer classification systems may capture as many as 40% of progressors with acceptable specificity.

References

[1]doi: 10.1136/annrheumdis-2020-219069

Acknowledgements

This work was funded by the Foundation for Research in Rheumatology (FOREUM).

Disclosure of Interests

None declared

AB0265 RHEUMATOID ARTHRITIS PATIENTS HOSPITALIZED FOR A SERIOUS INFECTION HAVE HIGH INCIDENCE OF SEPSIS WHILE THOSE ON bDMARDs HAVE LOWER MORTALITY COMPARED TO THOSE ON csDMARDs

Background

The treatment of rheumatoid arthritis (RA) includes conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and biologic DMARDs (bDMARDs). RA is associated with an increased risk of serious infections (SI) and the use of bDMARDs almost doubles this risk. SI can lead to sepsis, a life-threatening condition manifested by organ failure caused by a dysregulated host response to a pathogen. bDMARDs target pro-inflammatory cytokines which mediate the inflammation cascade activated both in RA and sepsis. However, very few data exist regarding the incidence of sepsis in patients with a SI while on treatment with bDMARDs.

Objectives

To assess the outcomes of sepsis and death in RA patients with a SI and compare them between patients on bDMARD and csDMARDs. Secondary aims were the comparison of subgroups of patients treated with different bDMARD classes [Tumor necrosis factor inhibitor (TNFi) vs. non-TNFi] and subgroups based on age (geriatric vs. younger patients).

Methods

Single-center retrospective analysis of adult RA patients registered in the University of Crete Rheumatology Clinic Registry (UCRCR), who were hospitalized for ≥1 SI between 2004-2020. Patients were assigned to “bDMARD group” if they were receiving bDMARDs at the time of the SI or “Control group” if there was no bDMARD exposure at least 3 months before the SI. Demographics, RA characteristics, and comorbidities were retrieved from UCRCR database, while details regarding hospitalization were sought in the patients’ electronic and paper files. Together with the “Sequential Organ Failure Assessment” (SOFA) criteria at admission and during 76-92 hours of hospitalization used to define the diagnosis of sepsis, we also analyzed the criteria of septic shock and in-hospital mortality.

Results

A total of 117 hospitalizations for SI in RA patients were included: 66 in patients receiving bDMARDs and 51 in the control group (65% bDMARD-naive and 35% bDMARD-experienced). The majority of the patients (76%) were women in both groups, however, patients on bDMARDs were younger than control patients [70 (IQR 62-77) and 78 (IQR 68-82) years old respectively, p=0.002]. Other demographics, disease characteristics, disease activity at baseline, and comorbidities did not differ between the two groups, except for a higher prevalence of one or more previous hospitalizations for infection in patients on bDMARDs.

During hospitalization, 14 patients (12%) died. Mortality was significantly higher in the control group (19.6% of patients) compared to the bDMARD group (6%) (p=0.025). Sepsis criteria were fulfilled in 56 patients (47.9%) at admission and/or at 76-92 hours of hospitalization. Sepsis was marginally more frequent in the control group versus the bDMARD group (56.9% vs. 40.9% respectively, p=0.087). In the subgroup analysis based on the type of bDMARD, no statistical difference was found for the outcomes of sepsis or death between patients on TNFi versus those on non-TNFi. However, in the subgroup of patients ≥65 years old, there was a tendency for a lower incidence of sepsis or death in patients on TNFi compared to those on non-TNFi or the control group [14% vs 53%, vs 85% respectively (p=0.120) for the outcome of sepsis and 7% vs. 21%, vs. 71% (p=0.138) for the outcome of death].

Receiver operating characteristic (ROC) analysis indicated older age (p<0.001), higher SOFA score at admission (p<0.001), septic shock at 76-92 hours (p<0.001), and non-exposure to TNFi (p=0.040) as predictors of in-hospital death. However, in multivariable logistic regression analysis, older age was the only significant predictor of sepsis and death during hospitalization.

Conclusion

In the present study, we found a high incidence of sepsis (47.9%) and mortality (12%) in RA patients hospitalized for a serious infection. Older age is the most significant predictor of adverse outcomes, however, patients on bDMARDs showed lower mortality and a tendency for a lower incidence of sepsis compared to the control group.

Disclosure of Interests

None declared

AB0375 IN PATIENTS STARTING ETANERCEPT, MALE SEX, ABSENCE OF COMORBIDITIES AND NO csDMARDs CO-ADMINISTRATION ARE INDEPENDENT PREDICTORS OF LONG-TERM (MORE THAN 3 YEARS) PERSISTENCE TO THERAPY, IRRESPECTIVELY OF THE CLINICAL DIAGNOSIS

Background

Comparative data among rheumatoid arthritis (RA), spondylarthritis (SpA) and psoriatic arthritis (PsA) patients regarding long-term survival of etanercept (ETN) in clinical practice are limited.

Objectives

The first aim of this study was to analyze the long-term (>3 years) ETN survival comparatively between its three main indications. We also aimed to analyze for predictors of long term ETN survival.

Methods

We analyzed data from the University of Crete Rheumatology Clinic Registry (UCRCR), a single center prospective cohort study. All patients with a diagnosis of RA, SpA or PsA starting treatment with a biologic DMARD are recorded prospectively based on a common follow-up protocol. For the first aim, ETN survival >3 years was compared among the 3 diseases. For the 2nd aim patients on ETN >3 years were compared to those stopping ETN during the first 2 years. We analyzed baseline and early on treatment (first 6 months) characteristics, comedications, comorbidities as predictors for long term survival applying univariate and multivariate models.

Results

A total of 711 patients who were started on ETN were analyzed (RA: 450, SpA: 177, PsA: 84). As expected, patients’ and disease characteristics at baseline differed significantly between the 3 diagnoses (Table 1). Patients’ function was compromised irrespective of the diagnosis, while inflammatory activity was significant across diseases.

Table 1.

Baseline parameters [Medians (IQR) unless otherwise specified]

RA (n=450)SpA (n=177)PsA (n=84)pWomen N (%)370 (82)66 (37)46 (55)<0.001Age61.5 (53-70)44.5 (35-54)51 (41-62)<0.001Disease duration2.6 (0.9-6.5)0.8 (0.1-5.1)1.7 (0.6-4.9)<0.001Follow-up years1.0 (0.5-2.1)1.0 (0.4-3.1)1.1 (0.4-3.6)0.649Total comorbidities nr.3 (1-4)1 (0-3)2 (1-4)<0.001RDCI1 (1-2)0 (0-1)1 (0-1)<0.001Ever smokers N(%)124 (39)82 (67)30 (61)<0.001BMI31 (26-35)27 (25-32)29 (23-32)0.015Treatment line N (%): 1st264 (59)87 (49)43 (51)0.012  2nd119 (26)70 (39.5)24 (29)  ≥ 3rd67 (15)20 (11)17 (20)Nr of previous csDMARDs2 (1-3)1 (0-2)1 (1-2)<0.001Co-administered MTX N(%)284 (63)65 (37)50 (60)<0.001Monotherapy, N (%)60 (13)100 (56.5)25 (30)<0.001Ongoing corticosteroids N(%)153 (34)25 (14)17 (20)<0.001DAS28 - ESR5.8 (5.0-6.5)3.7 (2.9-4.7)5.3 (4.5-6.4)<0.001ASDAS-ESR-3.4 (2.8-4.1)3.6 (3.2-4.7)0.067CRP (mg/dl)0.4 (0.3-1.1)1.1 (0.3-2.4)0.8 (0.4-2.0)<0.001

During a follow-up of 1371 patient-years, 466 (65.5%) patients stopped therapy. The estimated percentage of patients persisting on ETN therapy for > 3 years was 28.4%, 42.8% and 44% of RA, SpA and PsA respectively. The main reason for therapy discontinuation was inefficacy (75% of stop reasons in RA vs. 58% in SpA vs. 69% in PsA).

In multivariable Cox regression analyses the most important predictor for ETN survival was the achievement of LDA/remission at 6 months based on DAS28 for RA or ASDAS for SpA [Odds Ratio (OR) 1.98, p=0.008 and 3.02, p=0.001 respectively]. Prognostic factors for ETN discontinuation specifically due to inefficacy were comorbidities number and csDMARDs coadministration (p<0.05 for both), while older age and no co-therapy with MTX predicted ETN stop due to adverse events (p<0.05 for both).

Logistic regression analysis indicated that male sex [OR: 2.08, p=0.004], calendar year of treatment start [OR per 3 years: 0.74, p=0.001], comorbidities’ number [OR: 0.82, p=0.045] and monotherapy [OR: 1.81, p=0.027] predict persistence on ETN therapy beyond 3 years, while the clinical diagnosis or other baseline parameters are not significant predictors.

Conclusion

In this prospective cohort study, we found that ETN survival was higher for patients with SpA/PsA as compared to RA. Male sex, absence of comorbidities and no csDMARDs co-administration are independent predictors of long-term persistence to therapy, irrespectively of the clinical diagnosis. Notably, both in RA and SpA, 6-month response predicted ETN survival in the long term.

Acknowledgements

This study was funded by the Pancretan Health Association and Pfizer Global Medical Grants.

Disclosure of Interests

None declared

POS0580 COMORBIDITY BURDEN IS HIGH IN RHEUMATOID ARTHRITIS AND SPONDYLOARTHRITIS PATIENTS STARTING BIOLOGICS AND PREDICTS THE INCIDENCE OF SERIOUS ADVERSE EVENTS DURING THERAPY

Background:

There is limited information on the burden of comorbidities in patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA) in real-world clinical practice and its impact on the incidence of serious adverse events (SAE) during biologic disease-modifying anti-rheumatic drug (bDMARD) therapy.

Objectives:

To evaluate the number of comorbidities in patients with RA and SpA initiating a bDMARD in everyday clinical practice and to explore its association with the occurrence of a SAE during therapy.

Methods:

Prospective study of all patients who start any bDMARD treatment in a tertiary centre University Hospital. All comorbidities and SAEs (AEs necessitating hospitalization or resulting in significant incapacity/death) are registered by treating physicians. Comorbidities’ number was evaluated using two different indices: total comorbidities count (CC) and Rheumatic Disease Comorbidity Index (RDCI). Statistical analysis was performed using multinomial logistic and Cox regression models.

Results:

A total of 799 patients were analysed, of which 428 (54%) had ≥3 comorbidities (Table 1). Comorbidity burden was higher in RA, however in multivariable analyses, comorbidities were not significantly associated with diagnosis, but mainly with increasing patient age. Patients received 1701 bDMARD treatments. During a follow-up of 4019 patient-years, 198 patients (RA:134, SpA:64) had a total of 295 SAE (RA: 217, SpA:78).

Each one additional comorbidity in CC index was resulting in 16% increased adjusted risk for the first SAE [HR (95%CI) = 1.16 (1.12-1.20), p<0.001], and each additional comorbidity of the RDCI index was resulting in 28% increased risk [HR (95%CI) = 1.28 (1.20-1.37), p<0.001]. Other baseline independent predictors of the first SAE were greater age [HR=1.04, p<0.001] and use of corticosteroids [HR=1.42, p=0.006].

Table 1.

Biologic treatments and clinical characteristics at baseline

Patients, ΝTotalRASpAp799501298Females, Ν (%)535 (67)404 (81)131 (44)<0.001Age, median (IQR) έτη55 (45-65)60 (51-68)46 (36-54)<0.001Disease duration, median (IQR) έτη6.0 (2.5-13)5.4 (3-11)7.4 (2.0-15)<0.001Comorbidities count, median (IQR)3 (1-5)3 (2-6)2 (1-4)<0.001Patients with no comorbidities, Ν (%)103 (13)43 (9)60 (20)<0.001Patients with 1 comorbidity, Ν (%)134 (17)77 (15)57 (19)0.172Patients with 2 comorbidities, Ν (%)134 (17)76 (15)58 (19,5)0.118Patients with ≥3 comorbidities, Ν (%)428 (54)305 (61)123 (41)<0.001RDCI, median (IQR)1 (0-2)2 (0-3)1 (0-2)<0.001Patients with RDCI = 0, Ν (%)267 (33)128 (25.5)139 (47)<0.001Patients with RDCI = 1, Ν (%)185 (23)119 (24)66 (22)0.665Patients with RDCI = 2, Ν (%)163 (20)113 (23)50 (17)0.057Patients with RDCI ≥ 3, Ν (%)184 (23)141 (28)43 (14)<0.001Total bDMARDs initiated by patients, Ν17011098603Co-administered methotrexate, Ν(%)946 (56)674 (61)272 (45)<0.001Co-administered corticosteroids, Ν (%)493 (29)397 (36)96 (16)<0.001DAS28, median (IQR) (in RA and perSpA)5.8 (4.9-6.6)5.8 (5.0-6.6)5.4 (4.2-6.3)<0.001BASDAI, median (IQR) (in axSpA)--5.6 (4.5-7.0)

Conclusion:

Patients with RA and SpA initiating a bDMARD treatment in real-world clinical practice have a significant comorbidity burden which increases with age and is an independent predictor for an SAE during therapy.

Acknowledgements:

This research is co-financed by Greece and the European Union (European Social Fund- ESF) through the Operational Programme «Human Resources Development, Education and Lifelong Learning» in the context of the project “Reinforcement of Postdoctoral Researchers - 2nd Cycle” (MIS-5033021), implemented by the State Scholarships Foundation (ΙΚΥ).

Disclosure of Interests:

None declared

OP0299 IN RHEUMATOID ARTHRITIS PATIENTS HIGHER NUMBER OF COMORBIDITIES PREDICTS 6-MONTH INSUFFICIENT RESPONSE TO FIRST BIOLOGIC THERAPY AND EVENTUAL CATEGORIZATION OF THE DISEASE AS DIFFICULT-TO-TREAT

Background:

Difficult-to-treat rheumatoid arthritis (D2T RA) was recently defined by a EULAR study group (1) and, as a disease category it is largely complicated and under-researched. Patient comorbidities may play a significant role in the response to therapy with biologic disease-modifying antirheumatic drugs (bDMARDs) and in the disease classification as D2T RA.

Objectives:

To evaluate the impact of comorbidities [studied as total Comorbidities Count (CC) and rheumatic disease comorbidity index (RDCI)] on 6-month response to therapy with the first bDMARD in real-world clinical practice and on eventual disease designation as D2T RA.

Methods:

Prospective study of all RA patients who start any bDMARD in a tertiary centre University Hospital after their consent. All patient comorbidities [among a list of approximately 100 pre-specified major comorbidities] are registered by treating physicians. Response to therapy was defined as achievement of low disease activity or remission (LDA/Rem) according to simplified disease activity index (SDAI) and health assessment questionnaire (HAQ) improvement of ≥ 0.25.

D2T RA patient group was defined according to the EULAR definition of D2T RA and was compared to: a/ all other patients and b/ to a sub-group of patients designated as “well-controlled RA” (follow-up ≥2 years and ≥2 visits in the last year in LDA/Rem).

Logistic regression models were used to adjust for the potential confounding of age, sex, disease duration, seropositivity, number of previous synthetic DMARDs, type of 1st bDMARD initiated (TNF inhibitor vs. non-TNF inhibitor), co-administered methotrexate and corticosteroids (yes/no), baseline SDAI and HAQ and year of therapy start.

Results:

Analysis included 501 RA patients who received a total of 1098 bDMARD treatments. At 1st bDMARD treatment start, patients (women: 81%) had a median (IQR) age: 60 (51-68) years, disease duration: 5.4 (3-11) years, SDAI: 36 (28-46), HAQ: 1.0 (0.5-1.5), CC: 3 (2-6) και RDCI: 2 (0-3).

In adjusted analyses, total comorbidity count (CC) ≤1 (vs ≥ 2) was predicting LDA/Rem at 6 months of therapy [OR (95%CI) = 4.1 (1.5-11), p=0.005], while RDCI=0 (vs. ≥ 1) was predicting HAQ improvement ≥ 0.25 [OR (95% CI) = 2.6 (1.2-6.7), p=0.046].

During 2614 patient-years of follow-up, the disease in 98 patients could be classified as “D2T RA”, while 127 patients had “well-controlled RA”. Baseline independent predictors for D2T RA compared to all other patients were RDCI ≥ 1 (vs. 0) [OR = 3.3 (1.7-9.4), p = 0.024], female sex [OR =3.1 (1.01-9.5)] and age [OR = 0.97 (0.94-0.99)]. Multivariable analyses for predictors of “D2T” compared to “well-controlled” RA yielded similar results.

Conclusion:

In RA patients starting the first bDMARD treatment, a higher number of comorbidities at baseline is an independent predictor of lower 6-month response to therapy and final disease classification as “difficult-to-treat” RA.

References:

[1]Nagy G, Roodenrijs NM, Welsing PM, Kedves M, Hamar A, van der Goes MC, et al. EULAR definition of difficult-to-treat rheumatoid arthritis. Ann Rheum Dis. 2021 Jan;80(1):31–5.

Acknowledgements:

Pancretan Health Association and Special Account for Research Grants (ELKE) – University of Crete.

Disclosure of Interests:

None declared.

POS0941 IN SPONDYLOARTHRITIS PATIENTS THE PRESENCE OF COMORBIDITIES IS AN INDEPENDENT PREDICTOR OF INSUFFICIENT RESPONSE TO THERAPY WITH BIOLOGIC AGENTS AND TREATMENT DISCONTINUATION

Background:

Long-term observational studies of patients under biologic disease-modifying anti-rheumatic drug (bDMARD) therapies in routine clinical practice can provide us with important data regarding patients with comorbidities, who are usually excluded from randomized controlled studies.

Objectives:

To study the impact of comorbidities in the outcome (response and persistence to therapy) of patients with spondyloarthritis (SpA) receiving bDMARDs in real-world clinical practice.

Methods:

Prospective study of all patients who start a bDMARD in a tertiary centre University Hospital after their consent. All patient comorbidities [among a list of approximately 100 pre-specified major comorbidities] are registered by treating physicians at baseline and during follow-up.

Comorbidities were studied as total Comorbidities Count (CC) and rheumatic disease comorbidity index (RDCI). Statistical analyses were performed using logistic and Cox regression models, adjusting for the potential confounding of age, sex, disease duration, diagnosis (axial vs. peripheral SpA), number of previous conventional synthetic and biologic DMARDs, year of therapy start, and co-administered methotrexate and corticosteroids (yes/no). Analyses of response to therapy also included baseline BASDAI or ASDAS indices as confounding variables.

Results:

A total of 603 biologic treatments (1st: 298, 2nd: 157, ≥3rd: 148) were analyzed. Half (51%) of the patients were female, 413 patients had axial SpA (AxSpA) and 190 peripheral SpA (perSpA). At baseline, median (IQR) age: 48 (38-57) years, disease duration: 11 (4-19) years, CC: 2 (1-4) and RDCI: 1 (0-2). Both comorbidity indices were significantly higher in perSpA compared to AxSpA (p<0.001).

At 6 months of therapy, 31% of patients with AxSpA achieved BASDAI50 and 39% had ASDAS-ESR < 2.1. Higher CC was an independent predictor of insufficient response according to BASDAI50 [OR (95%) = 0.70 (0.52-0.94), p=0.019] and higher RDCI was predicting failure to achieve ASDAS-ESR < 2.1 [OR (95%) = 0.59 (0.37-0.94), p=0.027]. Other independent predictors of non-response were age, longer disease duration and (for ASDAS-ESR<2.1) higher baseline disease activity.

During 1405 patient-years of follow-up, 349 (58%) treatments were discontinued. The adjusted hazard ratio for bDMARD discontinuation within the first 2 years of treatment due to insufficient response was doubled in patients with CC ≥2 versus those with CC ≤1 [HR = 2.27 (1.14-4.53), p=0.020] or with RDCI ≥1 (vs. RDCI = 0) [HR = 2.23 (1.22-4.07), p=0.009]. Comorbidities’ indices were not significant predictors of treatment discontinuations due to adverse events.

Conclusion:

The presence of comorbidities in patients with SpA is an independent predictor for insufficient 6-month response to bDMARDs and resultant treatment discontinuation due to failure.

Acknowledgements:

This research is co-financed by Greece and the European Union (European Social Fund- ESF) through the Operational Programme «Human Resources Development, Education and Lifelong Learning» in the context of the project “Reinforcement of Postdoctoral Researchers - 2nd Cycle” (MIS-5033021), implemented by the State Scholarships Foundation (ΙΚΥ).

Disclosure of Interests:

None declared

THU0245 PENALIZED REGRESSION ANALYSIS IDENTIFIES CRITERIA AND NON-CRITERIA FEATURES THAT MAY INCREASE THE ACCURACY OF EXISTING SETS OF CRITERIA FOR CLASSIFYING SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Background:

The ACR-1997, SLICC-2012 and EULAR/ACR-2019 classification criteria have high sensitivity and specificity for SLE, yet they classify non-overlapping groups of patients suggesting that they can be supplemented with additional features to improve their diagnostic performance.

Objectives:

To identify criteria and non-criteria manifestations that are significantly associated with SLE in clinical practice and can be used to complement the existing sets of classification criteria.

Methods:

Individual items from all three classification criteria (ACR-1997, SLICC-2012, EULAR/ACR-2019) and non-criteria features were analyzed in a randomly selected sample of 800 adults diagnosed with SLE or control rheumatologic diseases (1:1 ratio). The classification performance of each set of criteria was analyzed in combination with complementary features; multivariable least absolute shrinkage and selection operator (LASSO) logistic regression was performed for feature selection. We calculated the diagnostic odds ratio (DOR) of the criteria and the additional features retained in each model.

Results:

Τhe EULAR/ACR-2019 and SLICC-2012 criteria have increased accuracy for SLE classification as compared to the ACR-1997 criteria (univariate DOR: 243.2 and 157.3versus78.8, respectively). In multivariable regression based on the ACR-1997 criteria, inclusion of additional features such as maculopapular rash, alopecia and hypocomplementemia significantly enhanced the model predictive capacity (area under the curve [AUC]: 0.95versus0.87 of the ACR-1997 criteria alone). Similar analysis based on the SLICC-2012 and EULAR/ACR-2019 criteria identified photosensitivity as an additional criterion significantly associated with SLE (multivariable DOR: 5.4 and 9.4, respectively). Accordingly, models including photosensitivity had superior predictive capacity over the criteria-only models (AUC: 0.94versus0.91 for SLICC-2012, 0.96versus0.91 for EULAR/ACR-2019). Furthermore, non-criteria features including Raynaud’s/livedo reticularis, anti-RNP antibodies, splenomegaly and myocarditis were independently associated with SLE thus enhancing further the predictive capacity of criteria-based models.

Conclusion:

We identified a number of criteria and non-criteria features which can be used in combination with the existing sets of criteria to increase classification of SLE patients in clinical practice. Photosensitivity could be considered as an additional feature to improve sensitivity of the recent classification criteria.

Disclosure of Interests:

Christina Adamichou: None declared, Irini Genitsaridi: None declared, Dionysis Nikolopoulos: None declared, Alessandra Bortoluzzi: None declared, Antonis Fanouriakis Paid instructor for: Paid instructor for Enorasis, Amgen, Speakers bureau: Paid speaker for Roche, Genesis Pharma, Mylan, Eleni Kalogiannaki: None declared, Emmanouil Papastefanakis: None declared, Irini Gergianaki: None declared, Prodromos Sidiropoulos: None declared, Dimitrios Boumpas: None declared, George Bertsias Grant/research support from: GSK, Consultant of: Novartis

FRI0155 Α MULTICENTER “AT-RISK” COHORT FOR THE DISCOVERY OF ENVIRONMENTAL, CLINICAL AND MOLECULAR PREDICTORS FOR THE TRANSITION INTO SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Background:

SLE onset is preceded by a preclinical phase evidenced by the presence of anti-nuclear and other autoantibodies (autoAbs), which however, have low predictive value for development of clinical SLE.

Objectives:

To define the subgroup of autoAbs-positive individuals who are at high risk for progression into SLE by integrating environmental, clinical/serological, genetic and transcriptome data.

Methods:

A multicenter, across five European countries, inception cohort of autoAbs-positive individuals or first-degree relatives (FDRs) of SLE patients who are monitored prospectively over five years for possible transition to SLE according to the classification criteria. Structured data collection on demographics, family and medical history, clinical (criteria and selected non-criteria manifestations) and serological parameters, use of medications, hydroxyvitamin D levels and lifestyle (tobacco, alcohol use, physical activity, adherence to Mediterranean diet). Blood samples are stored for RNA-sequencing and genotyping.

Results:

A total 254 at-risk individuals (93% women, 99% Caucasians, aged [mean ± standard deviation] 36 ± 12 years) have been included and enrolment/monitoring is still ongoing. Forty individuals (16%) have FDR with SLE and 88 individuals (35%) have FDR with another autoimmune disorder. The frequency of active and past use of tobacco was 28% and 20%, respectively. Sedentary lifestyle (moving only for necessary chores or outdoor activity 1-2 times/week) was reported by 54% and adherence to the Mediterranean diet was low (3.4 ± 2.3, maximum score: 9). At enrolment, individuals had 1.9 ± 1.1 ACR-1997 classification criteria, with anti-nuclear antibodies (ANA) being the most frequent (88%), followed by synovitis (39%), photosensitivity (33%) and immunologic disorder (30%) (Table 1). During follow-up of 15.2 ± 7.2 months, a total 15 individuals (5.9%) have progressed into classified SLE, including cases with severe hematological and neurological disease.

Table 1.

Baseline characteristics of the at-risk for SLE cohort

N (%) or mean ± SDACR 1997 classification criteria1.9 ± 1.1 Malar rash68 (27%) Discoid rash29 (11%) Photosensitivity83 (33%) Mucosal ulcers49 (19%) Synovitis100 (39%) Serositis30 (12%) Renal disorder28 (11%) Neurologic disorder31 (12%) Hematologic disorder58 (23%) Immunologic disorder77 (30%) ANA222 (88%)SLICC 2012 classification criteria Clinical criteria1.0 ± 0.9 Immunological criteria1.3 ± 0.9

Conclusion:

Among individuals with positive autoAbs or FDRs with SLE, the short-term risk for transition into clinical SLE is low. Following the study completion, clinical and lifestyle data will be combined with blood transcriptome to define a high-risk subgroup of individuals for progression into SLE.

Acknowledgments:

The study is supported by the Foundation for Research in Rheumatology (FOREUM; preclin016)

Disclosure of Interests:

Christina Adamichou: None declared, Dionysis Nikolopoulos: None declared, Myrto Nikoloudaki: None declared, Zahra Rahme: None declared, Micaela Fredi: None declared, Antigoni Pieta: None declared, ARGYRO REPA: None declared, Alice Parma: None declared, Eleni Kalogiannaki: None declared, Nestor Avgustidis: None declared, Nikolaos Kougkas: None declared, Aggelos Banos: None declared, Anastasios Eskitzis: None declared, Alessandra Bortoluzzi: None declared, Søren Jacobsen: None declared, Prodromos Sidiropoulos: None declared, Emmanouil Dermitzakis: None declared, Marta Mosca: None declared, Luís Inês: None declared, Laura Andreoli: None declared, Angela Tincani: None declared, Antonis Fanouriakis Paid instructor for: Paid instructor for Enorasis, Amgen, Speakers bureau: Paid speaker for Roche, Genesis Pharma, Mylan, George Bertsias Grant/research support from: GSK, Consultant of: Novartis

In an early SLE cohort the ACR-1997, SLICC-2012 and EULAR/ACR-2019 criteria classify non-overlapping groups of patients: use of all three criteria ensures optimal capture for clinical studies while their modification earlier classification and treatment

OBJECTIVES

Classification criteria are biased towards classifying long-standing disease. We compared the European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR)-2019, Systemic Lupus International Collaborating Clinics (SLICC)-2012 and ACR-1997 criteria in an early (median 48 months) systemic lupus erythematosus (SLE) cohort.

METHODS

Patients diagnosed with SLE (n=690) or control diseases (n=401). Sensitivity, specificity of the criteria and time-to-classification were calculated. Modified classification algorithms were derived from a random 80% and validated in the remaining 20% of the dataset running multiple iterations.

RESULTS

At last assessment, sensitivities of ACR-1997, SLICC-2012 and EULAR/ACR-2019 criteria were 85.7%, 91.3% and 88.6%, with specificities 93.0%, 93.8% and 97.3%, respectively. Both SLICC and EULAR/ACR enabled earlier classification. Only 76.7% of patients with SLE met all three criteria suggesting non-overlapping groups. Notably, unclassified patients had high prevalence of British Isles Lupus Assessment Group moderate/severe manifestations (43.3%-60%) and SLICC/ACR organ damage (30%-50%). At diagnosis, criteria missed 25.6%-30.5% of patients. Modification of EULAR/ACR and SLICC algorithms to include hypocomplementaemia and/or positive anti-phospholipid antibodies as alternative entry criterion, and/or allow classification with fewer clinical criteria from multiple organs, increased their sensitivity at diagnosis (median 82.0% and 86.2%) and overall (93.7% and 97.1%) with modest decreases in specificity. Importantly, patients who were still missed by the modified criteria had lower incidence of major organ involvement, use of immunosuppressive/biological therapies and organ damage.

CONCLUSIONS

The SLICC and EULAR/ACR are more sensitive than the ACR and the EULAR/ACR criteria have superior specificity in early SLE, although patients with significant disease can be missed. Combination and/or modification of the classification algorithms may enhance their sensitivity, allowing earlier classification and treatment of more patients with high disease burden.

Comparative analysis of the sensitivity and specificity of the classification criteria and correlation with prognosis of disease in patients with Systemic Lupus Erythematosus

Background:

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by significant clinical heterogeneity with early diagnosis being a major challenge, complicated by the absence of formal diagnostic criteria. Instead, classification criteria have been developed to enable the homogenous inclusion of patients in clinical trials, with the most commonly used those of the American College of Rheumatology (ACR 1997) and the Systemic Lupus International Collaborating Clinics Classification Criteria (SLICC 2012). These criteria are widely used in clinical practice as diagnostic tools, although they fail to diagnose up to 20% of patients with SLE or may delay diagnosis. These restrictions have led to the recent (2018) introduction of new classification criteria jointly by the European League Against Rheumatism (EULAR) and ACR.

Aims of the Study:

We will compare the sensitivity and specificity of the earlier and new classification criteria after a systematic analysis (retrospective study) of a group of SLE patients. In addition, we will examine which set of criteria permits the earliest classification of the disease in a prospective cohort of patients with undifferentiated connective tissue disease (UCTD). The prognostic impact (permanent organ damage) of the classification of SLE patients with the three sets of criteria will also be examined.

Methods:

Data from the existing Cretan lupus registry will be used to retrospectively include consecutively registered patients aged ≥15 years diagnosed with SLE during 01/2005–12/2016 by an expert physician and followed-up for at least 6 months. All sets of criteria (ACR 1997, SLICC 2012, EULAR/ACR 2018) will be tested at the time of physician-based diagnosis and also at last follow-up. A prospective study arm will include cases with a diagnosis of UCTD and will be followed-up in the outpatient clinic for 3–5 years.

Anticipated Benefits:

This is the first study to include the application of the new criteria (EULAR/ACR 2018) to a group of SLE patients. Determining their diagnostic value in comparison to existing criteria or diagnosis by a specialist will provide important information both for the value of their application at the level of clinical studies and for their use in clinical practice as diagnostic criteria.