Standardized reporting for systematic global evaluation of axial spondyloarthritis: An evidence-based and consensus-driven initiative

INTRODUCTION

National and international scientific societies advocate for a regular, systematic, and standardized global evaluation of axial spondyloarthritis (axSpA) patients. However, there are no recommendations specifying the content of this global evaluation. This initiative aimed to propose a standardized reporting framework, using evidence-based and consensus approaches, to collect data on all domains of axSpA.

METHODS

A literature review and consensus process involved a steering committee and an expert panel of 37 rheumatologists and health professionals. The first steering committee took place in March 2022 and identified the main domains for inclusion in the standardized report. A hierarchical literature review was conducted to identify items within these domains and tools for assessment. The items and tools for assessment were discussed and consensus was reached through a vote session during an expert meeting that took place in March 2023.

RESULTS

The steering committee identified four main domains to include in the standardized reporting framework: disease assessment, comorbidities, lifestyle, and quality of life. Items and tools for assessment were adopted after the expert meeting. Additionally, recommendations regarding digital tools (websites, apps, social media) were provided.

CONCLUSION

This initiative led to a consensus, based on evidence and expertise, on a reporting framework for use during periodic systematic global evaluations of axSpa in daily practice.

Recommendations of the French Society of Rheumatology for the management in current practice of patients with polymyalgia rheumatica

OBJECTIVE

To develop recommendations for the routine management of patients with polymyalgia rheumatica (PMR).

METHODS

Following standard procedures, a systematic review of the literature by five supervised junior rheumatologists, based on the questions selected by the steering committee (5 senior rheumatologists), was used as the basis for working meetings, followed by a one-day plenary meeting with the working group (15 members), leading to the development of the wording and determination of the strength of the recommendations and the level of agreement of the experts.

RESULTS

Five general principles and 19 recommendations were drawn up. Three recommendations relate to diagnosis and the use of imaging, and five to the assessment of the disease, its activity and comorbidities. Non-pharmacological therapies are the subject of one recommendation. Three recommendations concern initial treatment based on general corticosteroid therapy, five concern the reduction of corticosteroid therapy and follow-up, and two concern corticosteroid dependence and steroid-sparing treatments (anti-IL-6).

CONCLUSION

These recommendations take account of current data on PMR, with the aim of reducing exposure to corticosteroid therapy and its side effects in a fragile population. They are intended to be practical, to help practitioners in the day-to-day management of patients with PMR.

Towards the Lowest Efficacious Dose: Results From a Multicenter Noninferiority Randomized Open-Label Controlled Trial Assessing Tocilizumab or Abatacept Injection Spacing in Rheumatoid Arthritis in Remission

OBJECTIVE

We assess the clinical and structural impact at two years of progressively spacing tocilizumab (TCZ) or abatacept (ABA) injections versus maintenance at full dose in patients with rheumatoid arthritis in sustained remission.

METHODS

This multicenter open-label noninferiority (NI) randomized clinical trial included patients with established rheumatoid arthritis in sustained remission receiving ABA or TCZ at a stable dose. Patients were randomized to treatment maintenance (M) at full dose (M-arm) or progressive injection spacing (S) driven by the Disease Activity Score in 28 joints every 3 months up to biologics discontinuation (S-arm). The primary end point was the evolution of disease activity according to the Disease Activity Score in 44 joints during the 2-year follow-up analyzed per protocol with a linear mixed-effects model, evaluated by an NI test based on the one-sided 95% confidence interval (95% CI) of the slope difference (NI margin 0.25). Other end points were flare incidence and structural damage progression.

RESULTS

Overall, 202 of the 233 patients included were considered for per protocol analysis (90 in S-arm and 112 in M-arm). At the end of follow-up, 16.2% of the patients in the S-arm could discontinue their biologic disease-modifying antirheumatic drug, 46.9% tapered the dose and 36.9% returned to a full dose. NI was not demonstrated for the primary outcome, with a slope difference of 0.10 (95% CI 0.10-0.31) between the two arms. NI was not demonstrated for flare incidence (difference 42.6%, 95% CI 30.0-55.1) or rate of structural damage progression at two years (difference 13.9%, 95% CI -6.7 to 34.4).

CONCLUSION

The Towards the Lowest Efficacious Dose trial failed to demonstrate NI for the proposed ABA or TCZ tapering strategy.

Identification of distinct subgroups of Sjögren's disease by cluster analysis based on clinical and biological manifestations: data from the cross-sectional Paris-Saclay and the prospective ASSESS cohorts

BACKGROUND

Sjögren's disease is a heterogenous autoimmune disease with a wide range of symptoms-including dryness, fatigue, and pain-in addition to systemic manifestations and an increased risk of lymphoma. We aimed to identify distinct subgroups of the disease, using cluster analysis based on subjective symptoms and clinical and biological manifestations, and to compare the prognoses of patients in these subgroups.

METHODS

This study included patients with Sjögren's disease from two independent cohorts in France: the cross-sectional Paris-Saclay cohort and the prospective Assessment of Systemic Signs and Evolution of Sjögren's Syndrome (ASSESS) cohort. We first used an unsupervised multiple correspondence analysis to identify clusters within the Paris-Saclay cohort using 26 variables comprising patient-reported symptoms and clinical and biological manifestations. Next, we validated these clusters using patients from the ASSESS cohort. Changes in disease activity (measured by the European Alliance of Associations for Rheumatology [EULAR] Sjögren's Syndrome Disease Activity Index [ESSDAI]), patient-acceptable symptom state (measured by the EULAR Sjögren's Syndrome Patient Reported Index [ESSPRI]), and lymphoma incidence during follow-up were compared between clusters. Finally, we compared our clusters with the symptom-based subgroups previously described by Tarn and colleagues.

FINDINGS

534 patients from the Paris-Saclay cohort (502 [94%] women, 32 [6%] men, median age 54 years [IQR 43-64]), recruited between 1999 and 2022, and 395 patients from the ASSESS cohort (370 [94%] women, 25 [6%] men, median age 53 years [43-63]), recruited between 2006 and 2009, were included in this study. In both cohorts, hierarchical cluster analysis revealed three distinct subgroups of patients: those with B-cell active disease and low symptom burden (BALS), those with high systemic disease activity (HSA), and those with low systemic disease activity and high symptom burden (LSAHS). During follow-up in the ASSESS cohort, disease activity and symptom states worsened for patients in the BALS cluster (67 [36%] of 186 patients with ESSPRI score <5 at month 60 vs 92 [49%] of 186 at inclusion; p<0·0001). Lymphomas occurred in patients in the BALS cluster (five [3%] of 186 patients; diagnosed a median of 70 months [IQR 42-104] after inclusion) and the HSA cluster (six [4%] of 158 patients; diagnosed 23 months [13-83] after inclusion). All patients from the Paris-Saclay cohort with a history of lymphoma were in the BALS and HSA clusters. This unsupervised clustering classification based on symptoms and clinical and biological manifestations did not correlate with a previous classification based on symptoms only.

INTERPRETATION

On the basis of symptoms and clinical and biological manifestations, we identified three distinct subgroups of patients with Sjögren's disease with different prognoses. Our results suggest that these subgroups represent different heterogeneous pathophysiological disease mechanisms, stages of disease, or both. These findings could be of interest when stratifying patients in future therapeutic trials.

FUNDING

Fondation pour la Recherche Médicale, French Ministry of Health, French Society of Rheumatology, Innovative Medicines Initiative 2 Joint Undertaking, Medical Research Council UK, and Foundation for Research in Rheumatology.

How do patient reported outcome measures affect treatment intensification and patient satisfaction in the management of psoriatic arthritis? A cross sectional study of 503 patients

OBJECTIVES

The ASSIST study investigated prescribing in routine psoriatic arthritis (PsA) care and whether the patient reported outcome: PsA Impact of Disease questionnaire (PsAID-12), impacted treatment. This study also assessed a range of patient and clinician factors and their relationship to PsAID-12 scoring and treatment modification.

METHODS

Patients with PsA were selected across the UK and Europe between July 2021-March 2022. Patients completed the PsAID questionnaire, with the results shared with their physician. Patient characteristics, disease activity, current treatment methods, treatment strategies, medication changes and patient satisfaction scores were recorded.

RESULTS

503 patients recruited. 36.2% had changes made to treatment, 88.8% of this had treatment escalation. Overall, the mean PsAID-12 score was higher for patients with treatment escalation; the PsAID-12 score was associated with odds of treatment escalation (OR: 1.58; p< 0.0001). However, most clinicians reported PsAID-12 did not impact their decision to escalate treatment, instead supporting treatment reduction decisions. Physician's assessment of disease activity had the most statistically significant effect on likelihood of treatment escalation, (OR = 2.68, per 1-point score increase). Escalation was more likely in patients not treated with biologic therapies. Additional factors associated with treatment escalation included: patient characteristics, physician characteristics, disease activity and disease impact.

CONCLUSION

This study highlights multiple factors impacting treatment decision making for individuals with PsA. PsAID-12 scoring correlates with multiple measures of disease severity and odds of treatment escalation. However, most clinicians reported the PsAID-12 did not influence treatment escalation decisions. PsAID scoring could be used to increase confidence in treatment de-escalation.

Abatacept in early polymyalgia rheumatica (ALORS): a proof-of-concept, randomised, placebo-controlled, parallel-group trial

BACKGROUND

Medium-dose glucocorticoids can improve symptoms in nearly all patients with polymyalgia rheumatica. According to its good safety profile, abatacept could be used instead of glucocorticoids in early polymyalgia rheumatica. We aimed to determine whether the efficacy of abatacept is sufficient to justify larger studies in early polymyalgia rheumatica.

METHODS

To evaluate whether abatacept allows low disease activity without glucocorticoids in early polymyalgia rheumatica, we conducted a proof-of-concept, randomised, double-blind, placebo-controlled, parallel-group trial. Participants were recruited from five centres in France (in Brest, Le Mans, Morlaix, Dinan and Saint Malo, and Strasbourg) and were included if they had recent-onset (<6 months) polymyalgia rheumatica with a C-reactive protein (CRP) polymyalgia rheumatica activity score (PMR-AS) of more than 17 without any signs or symptoms of giant cell arteritis (clinical and [18F]fluorodeoxyglucose PET-CT evaluation). Participants were randomly assigned (1:1) to receive weekly subcutaneous abatacept (125 mg) or matching placebo, with glucocorticoid rescue therapy allowed in cases of high disease activity, for 12 weeks, and then glucocorticoid treatment based on disease activity, until week 36. Investigators, patients, outcome assessors, and sponsor personnel were masked to group assignments. The primary endpoint was low disease activity (CRP PMR-AS ≤10) at week 12 without glucocorticoids and without rescue treatment. The study was powered to demonstrate a 60% difference in response rates between groups. Open-ended adverse events were collected at each visit by clinicians and were categorised following system organ class classification after study completion. The ALORS trial is registered with ClinicalTrials.gov, NCT03632187.

FINDINGS

34 patients (22 women and 12 men) were randomly assigned between Dec 13, 2018, and Oct 21, 2021. All patients who had been randomly assigned were included in the analysis. The primary endpoint was reached by eight (50%) of 16 patients in the abatacept group and four (22%) of 18 patients in the placebo group (relative risk 2·2 [0·9-5·5]); crude p=0·15; adjusted p=0·070). Eight (50%) patients in the abatacept and 15 (83%) in the placebo group had adverse events. Four patients (one [6%] in the abatacept group and three [17%] in the placebo group) had serious adverse events. There were no deaths or new safety concerns.

INTERPRETATION

This study suggests that the effect of abatacept alone is not strong enough to justify larger studies in early polymyalgia rheumatica. This is only a first step in deciding whether a larger study should be conducted in early polymyalgia rheumatica and does not exclude a potential effect of abatacept in glucocorticoid-dependent polymyalgia rheumatica.

FUNDING

BMS Pharma France.

An international multi-centre analysis of current prescribing practices and shared decision-making in psoriatic arthritis

OBJECTIVES

Shared decision-making (SDM) is advocated to improve patient outcomes in Psoriatic arthritis (PsA). We analysed current prescribing practices and the extent of SDM in PsA across Europe.

METHODS

The ASSIST study was a cross-sectional observational study of PsA patients aged ≥18 years attending face-to-face appointments between July 2021-March 2022. Patient demographics, current treatment and treatment decisions were recorded. SDM was measured by the clinician's effort to collaborate (CollaboRATE questionnaire) and patient communication confidence (PEPPI-5 tool).

RESULTS

503 patients were included from 24 centres across the UK, France, Germany, Italy and Spain. Physician- and patient-reported measures of disease activity were highest in the UK. Conventional synthetic DMARDs constituted a higher percentage of current PsA treatment in UK than continental Europe (66.4% vs 44.9%), which differed from biologic DMARDs (36.4% vs 64.4%). Implementing treatment escalation was most common in the UK. CollaboRATE and PEPPI-5 scores were high across centres. Of 31 patients with low CollaboRATE scores (<4.5), no patients with low PsAID-12 scores (<5) had treatment escalation. However, of 465 patients with CollaboRATE scores ≥4.5, 59 patients with low PsAID-12 scores received treatment escalation.

CONCLUSIONS

Higher rates of treatment escalation seen in the UK may be explained by higher disease activity and a younger cohort. High levels of collaboration in face-to-face PsA consultations suggests effective implementation of the SDM approach. Our data indicate that, in patients with mild disease activity, only those with higher perceived collaboration underwent treatment escalation. Prospective studies should examine the impact of SDM on PsA patient outcomes.

TRIAL REGISTRATION

clinicaltrials.gov, NCT05171270.

Development and Validation of a Self-Administered Questionnaire Measuring Essential Knowledge in Patients With Axial Spondyloarthritis

OBJECTIVE

To develop and validate a patient knowledge questionnaire regarding axial spondyloarthritis (axSpA).

METHODS

Knowledge considered essential for patients with axSpA was identified through Delphi rounds among rheumatologists, healthcare professionals (HCPs), and patients, then reformulated to develop the knowledge questionnaire. Cross-sectional validation was performed in 14 rheumatology departments to assess internal validity (Kuder-Richardson coefficient), external validity, acceptability, reproducibility (Lin concordance correlation coefficient), and sensitivity to change (knowledge score before vs after patient education sessions and effect size).

RESULTS

The Spondyloarthritis Knowledge Questionnaire (SPAKE) is a self-administered 42-item questionnaire with a 32-item short form, both scored 0 to 100, assessing knowledge of disease, comorbidities, pharmacological treatments, nonpharmacological treatments, self-care, and adaptive skills. In the validation study (130 patients; 67 [51.5%] male, mean age 43.5 [SD 12.9] yrs), the mean (SD) score of the long-form questionnaire was 71.6 (15.4), with higher scores (better knowledge) in nonpharmacological treatments and adaptive skills and lower scores in cardiovascular comorbidity and pharmacological treatments. Acceptability was good, with no missing data; the internal validity coefficient was 0.85. Reproducibility was good (0.81, 95% CI 0.72-0.89). SPAKE showed good sensitivity to change; scores were 69.2 (15.3) then 82.7 (14.0) after patient education sessions (Hedges effect size = 0.92, 95% CI 0.52-1.31).

CONCLUSION

SPAKE is a knowledge questionnaire for patients with axSpA, developed with the involvement of HCPs and patients and reflecting current recommendations for the management of axSpA. SPAKE will be useful in assessing knowledge acquisition and self-management strategies in routine care and research.

Patient-defined flares and disease activity worsening in 222 patients with psoriatic arthritis from 14 countries

OBJECTIVES

To explore patient-defined flares in psoriatic arthritis (PsA), compared to an increase in disease activity in psoriatic arthritis (DAPSA) and to analyze the validity of a patient-reported flare question.

METHODS

ReFlap (NCT03119805) was a longitudinal study in 14 countries of consecutive patients with definite PsA. Patients were seen twice in the context of usual care, 4.5±2.2 months apart. Flares were reported by patients and physicians at the second visit using a single question. DAPSA worsening was defined as a change to a higher DAPSA category. Agreement between the definitions of worsening was calculated by prevalence adjusted bias adjusted kappa (PABAK). Validity of patient-reported flare was assessed by comparing patients with versus without flare and transition to flares.

RESULTS

In 222 patients, mean disease duration 10.8±8.3 years, 127 (58.8%) males: disease activity was low (mean DAPSA 11.5±14.0); 63.3% received a bDMARD. Patient-reported flares between the 2 visits were seen in 27% patients (for these patients, mean 2.2±3.7 flares per patient, mean duration 12.6±21.0 days per flare). Physician- reported flares were seen in 17.6% and worsening in DAPSA in 40.1% of patients. Agreement between definitions was moderate (PABAK=0.32-0.59). Patients in flare had significantly more active disease than patients not in flare for all outcomes (all P<0.001). At the patient-level, transition to flare state was associated to a worsening in disease activity and impact outcomes.

CONCLUSIONS

Patient flares were frequent and were associated with active and symptomatic disease. These findings provide preliminary validation for patient-reported flares in PsA.

Effect of Tocilizumab on Disease Activity in Patients With Active Polymyalgia Rheumatica Receiving Glucocorticoid Therapy: A Randomized Clinical Trial

IMPORTANCE

Few treatments are available for patients with glucocorticoid-dependent polymyalgia rheumatica. IL-6 antagonists may reduce disease activity in patients with active glucocorticoid-dependent polymyalgia rheumatica.

OBJECTIVE

To compare the efficacy of tocilizumab vs placebo in patients with glucocorticoid-dependent polymyalgia rheumatica.

DESIGN, SETTING, AND PARTICIPANTS

This double-blind, parallel-group, placebo-controlled randomized clinical trial enrolled 101 patients with polymyalgia rheumatica at 17 hospitals in France from February 2017 to October 2019. Final follow-up occurred in November 2020. Inclusion criteria were persistent disease activity (polymyalgia rheumatica activity score computed using the C-reactive protein level [CRP PMR-AS] >10) and prednisone dose greater than or equal to 10 mg per day.

INTERVENTIONS

Patients were randomly assigned to receive intravenous tocilizumab (8 mg/kg; n = 51) or placebo (n = 50) every 4 weeks for 24 weeks, combined with predefined standardized tapering of oral prednisone.

MAIN OUTCOMES AND MEASURES

The primary efficacy end point was CRP PMR-AS less than 10 (range, 0-100; higher values indicate greater activity; no minimal clinically important difference defined) combined with either prednisone dose less than or equal to 5 mg per day or a decrease in prednisone dose greater than or equal to 10 mg from baseline at week 24. There were 11 secondary outcomes assessed at week 24 included in this report, including disease activity (measured by CRP PMR-AS) and the proportion of patients no longer taking prednisone.

RESULTS

Of the 101 randomized patients (mean age, 67.2 years; 68 [67.3%] women), 100 (99%) received at least 1 infusion and 100 completed the trial. The primary end point was achieved in 67.3% of patients in the tocilizumab group and 31.4% of patients in the placebo group (adjusted difference, 36.0% [95% CI, 19.4%-52.6%]; adjusted relative risk, 2.3 [95% CI, 1.5-3.6]; P < .001). Of 11 reported secondary end points at 24 weeks, 7 showed significant differences favoring tocilizumab, including mean CRP PMR-AS score (7.5 [95% CI, 5.4-9.6] vs 14.9 [95% CI, 11.4-18.4]; adjusted difference, -7.5 [95% CI, -11.2 to -3.8]; P < .001) and the percentage of patients no longer receiving prednisone (49.0% vs 19.6%; adjusted difference, 29.3% [95% CI, 18.9%-39.7%]; adjusted relative risk, 2.5 [95% CI, 1.8-3.5]; P < .001). The most frequent adverse events were infections, experienced by 23 patients (46.9%) in the tocilizumab group and 20 (39.2%) in the placebo group.

CONCLUSIONS AND RELEVANCE

Among patients with active polymyalgia rheumatica despite prednisone therapy, tocilizumab, compared with placebo, resulted in a significantly greater percentage of patients with a CRP PMR-AS less than 10 with reduced prednisone requirements at week 24. Further research is needed to confirm efficacy and to determine the balance of potential benefits and harms.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02908217.

AB1449 ADHERENCE TO MTX AT INITIATION OF FIRST TARGETED THERAPY (PREVALENCE AND ASSOCIATED FACTORS): RESULTS OF THE STRATEGE2 STUDY

Background

Treatment adherence is a major challenge in chronic inflammatory rheumatic disease (CIRD). Mainly studied in rheumatoid arthritis (RA), this ranges from 30 to 80% [1]. Given the impact of non-adherence to disease-modifying therapy among RA patients, guidelines aiming to facilitate management of adherence were published in 2019 [2]. These guidelines highlight the multifactorial characteristics and importance of clarifying the factors determining non-adherence. In addition, treatment adherence was also listed as a point to consider for the management of difficult-to-treat RA by an EULAR task force [3].

Objectives

Based on inclusion results of STRATEGE 2 we explore the adherence to methotrexate (MTX) and its associated factors prior to initiation of a first targeted therapy.

Methods

The objective of STRATEGE2 is to describe the therapeutic strategy in RA patients treated with MTX for at least 3 months, naive of targeted biological (bDMARD) or synthetic (tsDMARD) therapy and who are candidates for initiation of first b/tsDMARD therapy due to RA activity. Patients were included prospectively in 2019-2020 and completed the Compliance Questionnaire for Rheumatology (CQR) [4], a self-administered questionnaire specific to rheumatology, measuring treatment adherence. They were then divided into 2 groups: adherence (Ad) (CQR19>80) vs. non-adherence (NAd) to investigate factors liable to be associated with adherence. Then, univariate and multivariate analysis was applied to identify potential predictors for adherence.

Results

Between Feb. 2019 and Dec. 2020, 230 patients were included, with 124 RA patients having an analysable CQR19: 73.4% females, mean age 56.6 years (±13.2), diagnosed 5.6 years (±7.4) previously, treatment with MTX for 4.4 years (±5.3) and a mean DAS of 4.3 (±1.2). The mean CQR score was 75.8. Patient distribution: 45.2% in the Ad group and 54.8% in the NAd group.

Table 1.At baseline (before b/tsDMARD initiation)Ad - N=56NAd - N=68pSex: female73.2%73.5%-Age (mean)59.3 (±13.6)54.4 (±12.4)p < 0.05BMI (mean)27.2 (±7.0)25.0 (±4.7)p < 0.15Still in work39.3%55.9%p < 0.15At least 1 comorbidity60.7%47.1%p < 0.15Positive anti-CCP67.9%80.6%p < 0.15Positive rheumatoid factor69.8%84.8%p < 0.05Radiological signs57.1%41.8%p < 0.15RA duration (years)4.9 ±6.76.3 ±8.0-Average MTX initiation (years)4.0 ±4.74.8 ±5.7-Per os MTX28.6%29.4%-→ mean dosage (mg/week)16.4 ±4.515.6 ±4.6Subcutaneous MTX69.6%70.6%-→ mean dosage (mg/week)20.1 ±4.619.4 ±3.3-Intramuscular MTX1.8%0%-Patients self-administration30.0%12.5%P < 0.05Corticosteroid therapy53%50.6%-→ mean dosage (mg/day)8.1 ±4.19.5 ±5.8Mean DAS284.5 ± 1.34.2 ±1.2-Mean HAQ1.1 ± 0.70.9 ±0.7p < 0.15

In the multivariate analysis, no formal predictive factors to MTX adherence was identified except BMI>30kg/m2 (odds ratio, OR (95% confidence interval, CI)=4.00, 1.08-14.86, p=0,038) and adherents who estimate having completely participate to the decision-making for the targeted therapy (OR (95% CI)=6.41, 2.32-17.65, p<0.001).

Conclusion

In this cohort, beyond the recently published guidelines, nearly half of patients do not show adherence to MTX (CQR19-based evaluation) before initiation of b/tsDMARD. As physicians tend to overestimate adherence to medication, clarification of the factors associated with non-adherence would help improve patient assessment and, therefore, management. Supplementary data on patients’ adherence evolution and adherence predictors, might be observed on the follow-up data at 12 and 24 months of this cohort.

References

[1]Beauvais C, et al. Joint Bone Spine 2020;87(6):668-669.

[2]Gossec C, et al. Joint Bone Spine 2019;86(1):13-19.

[3]Nagy G, et al. Ann Rheum Dis 2021;0:1–14.

[4]De Klerk E, et al. J Rheumatol 2003;30(11):2469-2475

Acknowledgements

The authors wish to acknowledge RCTs for their contribution to the statistical analysis, the investigators, centres and patients.

Disclosure of Interests

Cécile Gaujoux-Viala Speakers bureau: AbbVie; Amgen; Boehringer Ingelheim, Bristol-Myers Squibb; Celgene; Eli Lilly; Galapagos; Gilead Sciences, Inc.; Janssen; Medac; Merck-Serono; Mylan; Nordic Pharma; Novartis; Pfizer; Roche; Sandoz; Sanofi; and UCB, Consultant of: AbbVie; Amgen; Boehringer Ingelheim, Bristol-Myers Squibb; Celgene; Eli Lilly; Galapagos; Gilead Sciences, Inc.; Janssen; Medac; Merck-Serono; Mylan; Nordic Pharma; Novartis; Pfizer; Roche; Sandoz; Sanofi; and UCB, Emmanuelle Dernis Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Galapagos, Gilead, Janssen, MSD, Nordic Pharma, Roche-Chugaï Novartis, Pfizer, Roche, Sandoz, Sanofi and UCB Pharma., Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Galapagos, Gilead, Janssen, MSD, Nordic Pharma, Roche-Chugaï Novartis, Pfizer, Roche, Sandoz, Sanofi and UCB Pharma., Eric Senbel Speakers bureau: AbbVie, Amgen, Biogen, Janssen, Lilly, MSD, Nordic Pharma, Pfizer Roche-Chugai and Sandoz, Sanofi., Consultant of: AbbVie, Amgen, Biogen, Janssen, Lilly, MSD, Nordic Pharma, Pfizer Roche-Chugai and Sandoz, Sanofi., Hélène Herman-Demars Employee of: Nordic Pharma France, Jennifer Becker Employee of: Nordic Pharma France, René-Marc Flipo Speakers bureau: Abbvie, Bristol-Myers Squibb, Eli-Lilly, Janssen, Medac, MSD, Nordic-Pharma, Novartis, Pfizer, Roche-Chugaï, and Sanofi., Consultant of: Abbvie, Bristol-Myers Squibb, Eli-Lilly, Janssen, Medac, MSD, Nordic-Pharma, Novartis, Pfizer, Roche-Chugaï, and Sanofi.

POS0700 IMPACT OF DELAYING INITIATION OF METHOTREXATE BY 1 MONTH ON THE OUTCOME OF RHEUMATOID ARTHRITIS AT 1 YEAR

Background

It is recommended that vaccinations should be performed prior to start methotrexate (MTX) knowing that delaying initiation of background therapy may have an impact on the progression of RA.

Objectives

To access the impact of delaying initiation of MTX by 1 month on the outcome of RA at 1 year.

Methods

The VACIMRA study is a prospective, randomized, parallel-group, multicenter trial comparing the vaccine protection obtained in patients with rheumatoid arthritis according to the 1-month delay between anti-pneumococcal vaccine PCV13 and methotrexate initiation in one arm, versus immediate introduction of MTX following vaccination in the other arm. We analyzed disease activity based on DAS28-ESR at baseline (M0), 1, 2, 3, 6 and 12 months between the 2 groups. For structural progression, we performed a radiographic analysis of 79 RA patients included in the Montpellier center at baseline, 6 and 12 months. This analysis was performed by the same physician two times, blinded to the patient’s group. Structural damage progression at 6 months and 1 year was assessed according to van-der-Heijde-modified Sharp score (vSHS) on radiographs performed at inclusion, at 6 and 12 months of follow-up. Comparisons of the means of activity scores and radiographic scores were made with the non-parametric Wilcoxon-Mann-Whitney test.

Results

Of the 276 patients randomized, 261 could be analyzed (131 in the IMMEDIATE group and 130 in the DELAY group). At inclusion, there were no significant differences in demographic, disease activity (DAS28-ESR), biological and radiographic characteristics between the 2 groups (Table 1).

Table 1.

Baseline characteristics

VariableModalityTotal populationGROUP IMMEDIATEGROUPE DELAYpGender, n(%)N=261n=131n=1300.97Man74 (28.35)37 (28.24)37 (28.46)Woman187 (71.65)94 (71.76)93 (71.54)Age (years)Mean (± SD)55.74 (± 14.68)55.31 (± 15.27)56.16 (± 14.11)0.76MTX true naive (n(% col))No13 (4.98)8 (6.11)5 (3.85)0.40yes248 (95.02)123 (93.89)125 (96.15)Age at diagnosis (years)Mean (± SD)N=205 55.86 (± 15.16)n=98 55.31 (± 16.07)n=107 56.37 (± 14.34)0.80Positive rheumatoid factorn(% col)166 (64.59)84 (65.12)82 (64.06)0.86Positive ACPAn(% col)174 (68.24)89 (68.99)85 (67.46)0.79CRP (mg/L)Mean (± SD)N=260 17.62 (± 24.87)n=131 15.36 (± 17.95)n=129 19.91 (± 30.23)0.65DAS28-ESRMean (± SD)N=249 5.01 (± 1.11)n=125 5.03 (± 1.13)n=12 4.98 (± 1.10)0.54Sharp modified VdH total radiographic scoreMean (± SD)N=93 1.53 (± 3.62)n=47 1.57 (± 3.68)n=46 1.48 (± 3.60)0.88

DAS 28-ESR evolution during 1 year of follow-up

There was a significant difference in the means of DAS28-ESR at 1 month between the DELAY and IMMEDIAT groups (3.96 ± 1.46 vs 3.41 ± 1.33; p<0.001, respectively). There was no significant difference in the means of DAS28-ESR between the 2 groups at 3 months (3.19± 1.46 in the 2 groups p<0.91), at 6 months (3.11 ± 1.42 vs 3.24 ± 1.43; p=0.46, respectively) and at 12 months (2.96 ± 1.34 vs 2.98 ± 1.26p=0.89) (Graphic). Similarly, there was no significant difference in mean radiographic scores at 6 months (2.00 ± 4.41 vs. 1.80 ± 4.03 p=0.81) or at 12 months (2.23 ± 4.86 vs. 2.00 ± 4.07 p=0.93).

There was no significant variation between radiographic scores at 6 months compared to baseline in either group (mean difference 0.21 ± 0.52 vs. 0.36 ± 1.01, p=0.90) nor at 12 months compared to baseline (mean difference 0.40 ± 1.06 vs. 0.62 ± 1.58, p=0.85).

Conclusion

In patients with rheumatoid arthritis, initiation of methotrexate 1 month after PCV13 vaccination has no significant impact on RA activity and structural outcome at 1 year. Performing vaccinations 1 month before starting MTX can be proposed without significant impact on RA outcome at 1 year.

Figure 1.

Disclosure of Interests

None declared

POS1076 OBESITY IS ASSOCIATED WITH LESS LIKELIHOOD OF REMISSION/ LOW DISEASE IN PSORIATIC ARTHRITIS, A CROSS-SECTIONAL STUDY OF 414 PATIENTS

Background

Obesity is a risk factor for psoriatic arthritis (PsA) and is associated with higher disease activity [1].

Objectives

We aimed to evaluate whether obese patients with PsA were less likely to achieve remission/low disease in a real-life multi-centre cohort.

Methods

We used data from the ReFlap study (NCT03119805)[2], which recruited consecutive adult patient with definite PsA for more than 2 years of disease duration from 14 countries. We collected demographic characteristics, self-reported weight and height, clinical data and patient reported outcomes. Remission/low disease was defined as Disease Activity in PSoriatic Arthritis (DAPSA) ≤ 4, or Minimal disease activity (MDA). Obesity was defined as body mass index (BMI) ≥ 30kg/m2. We compared patient characteristics, disease activity parameters and impact scores between patients with obesity versus non-obese. A multivariable regression model was performed for demographic variables associated with reaching each definition of remission/low disease, adjusted on age, sex, level of education, disease duration, current use of conventional (c-) and biological (b-) disease modifying anti-rheumatic drugs (DMARDs).

Results

Among 414 patients (49.3% women, mean disease duration 11.0 ±8.2 years), 119 (28.7%) had BMI ≥ 30kg/m2 (obese). Obese patients were more likely to be female, had higher swollen joint and enthesitis counts, higher self-reported pain, poorer physical function, more fatigue and poorer mental health (Table 1). Obese patients were half as likely to achieve MDA or DAPSA remission in multivariable analysis with odd ratios of 0.6 (95% confidence interval, CI: 0.3, 0.8, p=0.049) and 0.4 (95% CI: 0.2, 0.8, p=0.012), respectively for obese compared to non-obese patients (Figure 1).

Table 1.

Patient characteristics and remission achievement between obese and non-obese patients with psoriatic arthritis

Non-obese (n=295)BMI ≥30 (n=119)pFemale, %44.361.50.002Number of comorbidities1.61 (0.93)2.83 (2.01)<0.001Tender joints, 0-683.56 (7.81)5.75 (10.0)0.018Swollen joints, 0-662.19 (7.29)1.46 (2.39)0.285Leeds enthesitis index, 0-60.48 (1.23)0.86 (1.70)0.012PGA disease activity, 0-103.90 (2.73)4.76 (2.67)0.004DAPSA14.9 (15.5)18.3 (16.1)0.045HAQ-DI, 0-30.56 (0.65)0.89 (0.70)<0.001PsAID-12, 0-103.11 (2.36)3.96 (2.50)0.001pain, 0-103.80 (2.81)4.54 (2.83)0.017fatigue, 0-103.93 (3.01)4.68 (3.17)0.025work or leisure activities, 0-103.39 (3.01)4.75 (3.11)<0.001functional capacity, 0-103.36 (2.97)4.40 (3.16)0.002depression, 0-101.88 (2.70)2.75 (3.26)0.006

Mean (SD) shown unless specified otherwise. HAQ-DI: Health Assessment Questionnaire – Disability Index; PsA: psoriatic arthritis; PGA: patient global assessment of disease activity; DAPSA: Disease Activity in PSoriatic Arthritis; PsAID: Psoriatic Arthritis Impact of Disease.

Conclusion

In this real-life data from 14 countries, obesity was frequent and PsA patients with BMI ≥ 30kg/m2 were more likely to be female, and had higher subjectively reported disease activity and illness impact compared to those with lower BMI. Obese patients had a two-fold lower likelihood of achieving remission/low disease defined by both MDA and DAPSA compared to non-obese patients. PsA patients with comorbid obesity may have different disease profiles from non-obese patients, and require specific management.

References

[1]Eder, L., et al., Obesity is associated with a lower probability of achieving sustained minimal disease activity state among patients with psoriatic arthritis. Ann Rheum Dis, 2015. 74(5): p. 813-7.

[2]Gorlier, C., et al., Comparing patient-perceived and physician-perceived remission and low disease activity in psoriatic arthritis: an analysis of 410 patients from 14 countries. Ann Rheum Dis, 2019. 78(2): p. 201-208.

Acknowledgements

This study was funded by Pfizer.

Disclosure of Interests

None declared

POS1000 MORE THAN 30 % OF WOMEN WITH SPONDYLOARTHRITIS HAVE AN UNFAVORABLE PREGNANCY OUTCOME MOST FREQUENTLY DUE TO SMALL FOR GESTATIONAL AGE: ANALYSIS OF THE PROSPECTIVE GR2 COHORT

Background

Spondyloarthritis (SpA) is one of the most common chronic inflammatory diseases and regularly affects women of childbearing age1. However, there is limited knowledge about the impact of the disease and its treatment on pregnancy.

Objectives

The aim of the study was to determine the factors associated with adverse pregnancy outcome in women with SpA.

Methods

All SpA patients (diagnosis according to the Rheumatologist) included in the national multicenter GR2 cohort from 2015 to June 2021 were included in the analysis. Patients could be included either with a pregnancy wish (i.e., preconceptional period) or because of a clinical pregnancy (<12 weeks of gestation). The main endpoint was favorable pregnancy outcome, a composite outcome defined as a live birth at term ≥ 37 gestation weeks of a healthy newborn with a weight greater than the 10th percentile. We performed a multilevel logistic regression model, in which we considered patient and center random effects (patient random effect for some women included in the cohort two times). Disease activity was defined by a BASDAI score ≥ 4 at least once during pregnancy. We used a multiple imputation to address missing data among the explanatory variables. Results are presented as an odds ratio (OR) with confidence interval (CI).

Results

Among the 207 pregnancies in women with SpA included in the GR2 cohort, 126 were retained for analysis of obstetrical outcome. Of these, 29 (23.0%), 14 (11.1%), 69 (54.8%) were exposed to corticosteroid, NSAID and biologics at least once during pregnancy, respectively. An active disease at least once during pregnancy was found in 47 (37.3%) pregnancies. A live birth was found in 116 (92.1%) women, including 110 (87.3%) full-term births. Early miscarriages and stillbirths were observed in 7 (0.06%) and 3 (0.02%) women, respectively. A caesarean section was performed in 20 (17.2%) cases.

A favorable pregnancy outcome was found in 80 (63.5%) of the women. Unfavorable pregnancy outcome was most frequently due to small for gestational age, observed in 22 (19%) pregnancies. The multivariate model adjusted for age, BMI, nulliparity, active disease during pregnancy, smoking, and exposure to NSAIDs and corticosteroids during pregnancy found an association between unfavorable pregnancy outcome with nulliparity (OR 2.63 95% CI [1.01-6.81] p = 0.05).

Conclusion

This study provides original results on pregnancy in women with SpA. It found a favorable pregnancy outcome in 63.5% of women. Unfavorable pregnancy outcome was most frequently due to small for gestational age, which should lead to a coordinated management with obstetricians for the follow-up of pregnancy in women with SpA.

References

[1]Van den Brandt S. Arthritis Res Ther. 2017;19(1):64.

Table 1.

Multilevel logistic regression model: factors associated with unfavorable pregnancy outcome in women with SpA.

Univariate analysesMultivariate analysesCrude OR 95% CIpAdjusted OR 95% CIpAge1.01 [0.92-1.10]0.8591.05 [0.95-1.17]0.297BMI0.99 [0.91-1.07]0.7960.99 [0.90-1.08]0.747Nulliparity2.16 [0.94-4.94]0.0712.63 [1.01-6.81]0.049Smoking0.84 [0.23-3.03]0.8050.84 [0.22-3.21]0.805Disease activity*0.98 [0.40-2.43]0.9641.15 [0.43-3.07]0.778Corticosteroids**1.09 [0.45-2.65]0.8761.15 [0.51-2.71]0.902NSAIDs**0.65 [0.18-2.33]0.1960.67 [0.18-2.56]0.565

* BASDAI score ≥ 4 at least once during pregnancy.

** Use at least once during pregnancy

Acknowledgements

The GR2 Cohort is supported by the French Society of Rheumatology, the French Internal Medicine Society, and unrestricted grants from UCB.

Disclosure of Interests

SABRINA HAMROUN: None declared, Marion Couderc: None declared, Rene-Marc Flipo: None declared, Jérémie SELLAM: None declared, Christophe Richez Speakers bureau: CR has received consulting/speaker’s fees from Abbvie, Amgen, Astra Zeneca, Biogen, BMS, Celltrion, Eli Lilly, Galapagos, GSK, MSD, Novartis, and Pfizer, all unrelated to this manuscript., Rakiba Belkhir: None declared, Laure Gossec: None declared, Hubert MAROTTE: None declared, Emmanuelle Dernis: None declared, Aline Frazier-Mironer: None declared, Elisabeth Gervais: None declared, Cédric Lukas: None declared, Valerie Devauchelle-Pensec: None declared, Laëtitia Dunogeant: None declared, Alban Deroux: None declared, Nathalie Costedoat-Chalumeau: None declared, Anna Moltó: None declared

AB0123 IMPACT OF TOBACCO ON PRIMARY SJÖGREN SYNDROME: ANALYSIS OF THE FRENCH COHORT ASSESS

Background

It has been shown that smoking could be negatively associated with the risk of developing primary Sjögren’s Syndrome (pSS), and that amongst smoking pSS patients, seropositivity for anti SSA antibodies and frequency of focal sialadenitis were lower. However, data are scarce concerning the impact of smoking on disease activity, glandular features, patient reported outcomes (PROs) and disease progression.

Objectives

To describe the impact on smoking on pSS disease characteristics and outcome.

Methods

ASSESS (Assessment of Systemic Signs and Evolution in Sjögren’s Syndrome) is a French prospective multicenter, longitudinal cohort involving 395 patients with pSS enrolled in 15 French centers between 2006 and 2009 and followed since then. In these patients, we compared baseline characteristics and outcome (change in activity and PROs) during the first 5 years of follow-up, according to their smoking status (ever/never). For change during follow-up, any change of ≥ 3 points of ESSDAI or ≥ 1 point of ESSPRI or individual VAS, ≥ 25% of unstimulated salivary flow (UWSF) were considered.

Results

Data on smoking at inclusion were available for 394 patients, 106 (26.9%) of them were ever-smokers. Compared to never smokers, ever-smokers were significantly younger (54.0 ± 11.3 vs 59.2 ± 12.2, p < 0.001), and more frequently men (14 (13.2%) vs 12 (4.2%), p = 0.0013). The mean ESSDAI did not differ according to smoking status, (5.0 ± 4.9 vs 5.5 ± 5.8, p = 0.436).

There were no significant differences regarding the use of corticosteroids (49 (46.2%) vs 159 (55.2%), p = 0.113), immunosuppressive drugs (21 (19.8%) vs 77 (26.7%), p = 0.158), or hydroxychloroquine (49 (46.2%) vs 165 (57.3%), p = 0.05), even though numerically less smokers were taking these treatments. Smokers tended to have a lower dryness VAS and were less likely to use treatment for dry mouth (64 (60.4%) vs 210 (73%), p = 0.016).

No difference was observed in PROs (ESSPRI 5.2 ± 2.2 vs 5.5 ± 2.1, p = 0.259), and in UWSF (0.5 ± 0.75 vs 0.4 ± 1.0, p = 0.672) between smokers and non-smokers.

After five years, no difference in change of disease activity (ESSDAI change ≥ 3 points: 12/77 (15.6%) vs 30/207 (14.5%), p = 0.818), or in PROs (ESSPRI change ≥ 1: 30/70 (42.9%) vs 91/198 (46%) p = 0.654) was observed according smoking status, as well as no change in dryness (p = 0.968), pain (p = 0.280), fatigue (p = 0.605) or in UWSF (p = 0.132).

Table 1.

Baseline characteristics and change in patient-reported outcomes at 5 years

BaselineSmokers n = 106Non smokers n = 288p-valueAge (years)54.0 ± 11.359.2 ± 12.20.00008Sex, females92 (86.0)276 (95,8)0.0013Disease duration (years) median [IQR]3.9 [1.1; 8.7]5.5 [2.6; 9.7]0.257ESSPRI5.2 ± 2.2 (n = 97)5.5 ± 2.1 (n = 267)0.259 Dryness4.9 ± 2.5 (n = 98)5.5 ± 2.2 (n = 270)0.053 Fatigue5.9 ± 2.8 (n =101)6.0 ± 2.6 (n = 275)0.924 Pain4.6 ± 2.8 (n = 101)4.9 ± 2.9 (n = 274)0.359Unstimuled salivary flow (mL/min)0.5 ± 0.75 (n = 89)0.4 ± 1.0 (n = 241)0.672Treatment for dry mouth64 (60.4)210 (73.0)0.016ESSDAI5.0 ± 4.9 (n = 104)5.5 ± 5.8 (n = 281)0.436Corticosteroids49 (46.2)159 (55.2)0.113Hydroxychloroguine49 (46.2)165 (57.3)0.050Immunosuppresive drugs21 (19.8)77 (26.7)0.158Lymphocytes count (/mm3)1661.1 ± 919.31492.1 ± 1072.0 (n = 280)0.128After five yearsChange in ESSDAI ≥ 312 (15.6) (n = 77)30 (14.5) (n = 207)0.818Change in ESSPRI ≥ 130 (42.9) (n = 70)91 (46.0) (n = 198)0.654Change in salivary flow ≥ 25%29 (44.6) (n = 65)55 (34.0) (n = 162)0.132

Data are given as mean ± SD or n (%) unless otherwise specified. SD, standard deviation; IQR, interquartile range; ESSPRI, EULAR Sjögren’s Syndrome Patient Reported Index; ESSDAI, EULAR Sjögren’s Syndrome Disease Activity Index.

Continuous variables were compared using student t test and qualitative variable using chi-square

Conclusion

Smokers pSS patients are more likely to be men and younger than non-smokers. Ever smokers tended to have less dryness, and take less frequently treatment for dryness, corticosteroids, hydroxychloroquine or immunosuppressants. After five years, no difference was observed, according to smoking status, in terms of change in disease activity or PROs.

Disclosure of Interests

None declared

POS0004 WHAT DOES WORSENING IN DAPSA DISEASE ACTIVITY CATEGORIES MEAN FOR PATIENTS WITH PSORIATIC ARTHRITIS? AN ANALYSIS OF 222 PATIENTS

Background

In psoriatic arthritis (PsA), disease activity states have been defined using the DAPSA (Disease Activity index for Psoriatic Arthritis) score (1). The disease activity states have been validated using structural progression as the gold standard (2). However, the worsening in DAPSA states has not been compared to the patient’s perspective.

Objectives

To assess the association between a worsening in disease activity (i.e., change in DAPSA disease activity category) versus the patient’s judgement of disease worsening.

Methods

ReFlap (NCT03119805) was a longitudinal study in 14 countries of consecutive adult patients with definite PsA and more than 2 years of disease duration. Patients were seen twice in the context of usual care, around 4 months apart (3). Worsening in disease activity between the 2 visits was defined as a transition to a more active disease category, based on the DAPSA categories [(remission, low disease activity (LDA), moderate disease activity (MDA) and high disease activity (HDA)] (1).This change was compared to (a) patient perceived-flares collected according to a patient-reported question: “At this time, are you having a flare of your psoriatic arthritis, if this means the symptoms are worse than usual?”; and (b) a worsening according to the MCID (Minimal Clinical Important Difference) question. The agreement between the definitions of worsening were calculated by frequency, Cohen’s kappa and prevalence adjusted bias adjusted kappa (PABAK). There was no imputation of missing data.

Results

Overall, 222 patients were analyzed: 127 (58.8%) were male, aged 53.5±12.3 years and with 10.8±8.3 years of disease duration. Disease activity was moderate: 35.9% had no current psoriasis skin lesions, mean tender joint count (TJC, 0-68) was 3.0±7.5, mean swollen joint count (SJC, 0-66) was 1.6±6.6, and mean DAPSA was 11.5±14.0.

At 4.5±2.2 months follow-up, the proportion of DAPSA worsening was 40.1% [95% confidence interval, 33.9-46.7] (n=89). Most of the changes corresponded to patients going from remission to LDA (N=24, 27.0% of worsened patients) or from LDA to MDA (N=24, 27.0%).

Patient-reported flares were reported in 27.0% [21.6-33.2] (n=60), and MCID worsening was reported in 14.0% [33.9-46.5] (n=31).

Figure 1 shows the distribution of patients with worsening in DAPSA category, versus patient-defined worsening. Of the 89 patients who worsened according to DAPSA categories, 41 (46.1%) had self-perceived flares and 20 (22.5%) had worsening according to MCID. Among patients who worsened in DAPSA category, the mean change in DAPSA was higher in patients with self-perceived flares (increase of 22.2±15.0) than in patients without self-perceived flares (increase of 14.3±12.3). Of 133 patients with no worsening according to DAPSA, 114 (85.7%) had no self-perceived flares and 122 (91.7%) had no MCID worsening. The kappa [95% confidence interval] (PABAK) coefficients between DAPSA and either patient flare or MCID worsening were 0.34 [0.21-0.46] (0.40) and 0.16 [0.05-0.27] (0.28), respectively.

Figure 1.

Venn diagram for disease worsening between 2 visits

Conclusion

After 4 months of follow-up, 40.1% patients with long-standing PsA had a change in DAPSA category corresponding to more active disease. Most of these changes reflected transitions from remission to LDA, or from LDA to MDA. Among patients changing DAPSA category, only 46.1% reported themselves in flare at the second visit and only 22.5% reported themselves as worsened by MCID, leading to only fair (for flares) to low (for MCID worsening) agreement between the assessments of worsening. It is important to assess both disease activity, and the patient’s perspective of flare.

References

[1]Schoels M, et al. Ann Rheum Dis. 2016;75(5):811-8.

[2]Aletaha D, et al. Ann Rheum Dis. 2017;76(2):418-421.

[3]Gorlier C, et al. Ann Rheum Dis 2019;78:201-208.

Disclosure of Interests

None declared

POS0698 CHANGES IN RA PATIENT PROFILE AT INITIATION OF FIRST TARGETED THERAPY OVER A FIVE-YEAR PERIOD: ANALYSIS OF THE STRATEGE 1 AND STRATEGE 2 STUDIES

Background

The objective of the STRATEGE2 study (inclusion period: Feb. 2019-Dec. 2020) is to describe the therapeutic strategy in rheumatoid arthritis (RA) patients treated with methotrexate (MTX) for at least 3 months, not having received targeted biological (bDMARD) or synthetic (tsDMARD) therapy and who are candidates for initiation of first b/tsDMARD therapy due to RA activity.

The STRATEGE1 study [1] (conducted between 2014 and 2015) described the therapeutic strategies introduced for RA patients with an inadequate response to MTX monotherapy.

Objectives

We aim to compare the profiles of patients included in these two studies at first prescription of b/tsDMARD therapy, in order to evaluate changes in rheumatologist practices over this five-year period.

Methods

STRATEGE1 and 2 are two French multicentre, prospective, longitudinal, observational studies including patients with confirmed RA (ACR 1987 or ACR/EULAR 2010). Our aim is to compare baseline data. Only data from the sub-group of patients initiating b/tsDMARD therapy are presented for STRATEGE1. Qualitative variables are compared by Fisher’s exact test and quantitative variables by t-test.

Results

In STRATEGE1 (2014-2015), 117 out of 854 patients initiated a b/tsDMARD therapy. In STRATEGE2 (2019-2020), 230 patients were included, with 180 in the analysis population.

Table 1.At baseline (before b/tsDMARD initiation)STRATEGE1 (N=117)STRATEGE2 (N=180)pMean age (years)52.6 ±12.556.4 ±13.60.0158RA duration (years)6.5 ±7.15.6 ±7.2NSRadiological signs50.0%48.0%NSAverage MTX initiation (years)4.6 ±4.34.3 ±5.3NSMTX per os44.0%28.9%0.0088→ mean dosage (mg/week)16.2 ±3.616.0 ±4.1NSMTX subcutaneous52.6%70.6%0.003→ mean dosage (mg/week)18.5 ±3.219.9 ±3.9NS→ Patients self-administration53.8%75.8%0.0001Corticosteroid therapy53%50.6%NS→ mean dosage (mg/day)8.1 ±4.19.5 ±5.8NSMean DAS284.6 ± .14.3 ±1.20.0074Mean HAQ1.4 ±0.91.0 ±0.7<0.0001

The baseline visits involved initiation of b/tsDMARD therapy with 100% vs. 88.9% bDMARD (anti-TNF: 78.8% vs. 58.3%; anti-IL6: 6.7% vs. 12.8%; CTLA4 Ig: 11.5% vs. 16.7%; anti-CD20: 2.9% vs. 1.1%) and 0% vs. 11.1% tsDMARD. Therapeutic decisions concerning MTX were (STRATEGE 1 vs STRATEGE 2): identical regimen maintained (pharmaceutical form + dosage): 69.2% vs. 76.1%; discontinuation: 4.3% vs. 2.2%; adjustment: 26.7% vs. 21.7% [with dose reduction: 18.2% vs. 93.5% and/or change in pharmaceutical form (p.o. to SC): 54.5% vs. 0%].

Main reasons for adjusting treatment were (STRATEGE 1 vs STRATEGE 2): active RA: 86.1% vs. 77.8%; RA not in remission: 3.5% vs. 21.1%; exacerbation based on clinical/laboratory parameters: 42.6% vs. 10%.

Conclusion

Over the five-year period, these results suggest a change in practices for RA patients with an inadequate response to MTX and initiating their first targeted therapy: now with earlier recourse to first targeted therapy, for less active RA, and more pronounced investigation of remission.

References

[1]C. Gaujoux-Viala et al. MTX optimization or adding bDMARD equally improve disease activity in rheumatoid arthritis: results from the prospective study STRATEGE. Rheumatology 2021;0:1-11. doi:10.1093/rheumatologykeab274.

Acknowledgements

The authors wish to acknowledge RCTs for their contribution to the statistical analysis, the investigators, centres and patients.

Disclosure of Interests

Cécile Gaujoux-Viala Speakers bureau: AbbVie; Amgen; Boehringer Ingelheim, Bristol-Myers Squibb; Celgene; Eli Lilly; Galapagos; Gilead Sciences, Inc.; Janssen; Medac; Merck-Serono; Mylan; Nordic Pharma; Novartis; Pfizer; Roche; Sandoz; Sanofi; and UCB., Consultant of: AbbVie; Amgen; Boehringer Ingelheim, Bristol-Myers Squibb; Celgene; Eli Lilly; Galapagos; Gilead Sciences, Inc.; Janssen; Medac; Merck-Serono; Mylan; Nordic Pharma; Novartis; Pfizer; Roche; Sandoz; Sanofi; and UCB., Emmanuelle Dernis Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Galapagos, Gilead, Janssen, MSD, Nordic Pharma, Roche-Chugaï Novartis, Pfizer, Roche, Sandoz, Sanofi and UCB Pharma., Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Galapagos, Gilead, Janssen, MSD, Nordic Pharma, Roche-Chugaï Novartis, Pfizer, Roche, Sandoz, Sanofi and UCB Pharma., Eric Senbel Speakers bureau: Abbvie, Amgen, Biogen, Janssen, Lilly, MSD, Nordic Pharma, Pfizer Roche-Chugai and Sandoz, Sanofi., Consultant of: Abbvie, Amgen, Biogen, Janssen, Lilly, MSD, Nordic Pharma, Pfizer Roche-Chugai and Sandoz, Sanofi., Hélène Herman-Demars Employee of: Nordic Pharma France, Agnès Courbeyrette Employee of: Nordic Pharma France, René-Marc Flipo Speakers bureau: Abbvie, Bristol-Myers Squibb, Eli-Lilly, Janssen, Medac, MSD, Nordic-Pharma, Novartis, Pfizer, Roche-Chugaï, and Sanofi., Consultant of: Abbvie, Bristol-Myers Squibb, Eli-Lilly, Janssen, Medac, MSD, Nordic-Pharma, Novartis, Pfizer, Roche-Chugaï, and Sanofi.

OP0127 UNFAVORABLE PREGNANCY OUTCOME IS SIGNIFICANTLY ASSOCIATED WITH CORTICOSTEROID EXPOSURE DURING PREGNANCY IN WOMEN WITH RHEUMATOID ARTHRITIS: ANALYSIS OF THE PROSPECTIVE GR2 COHORT

Background

Rheumatoid arthritis (RA) is one of the most common chronic inflammatory diseases and regularly affects women of childbearing age1. However, there is limited knowledge about the impact of the disease and its treatment on pregnancy.

Objectives

The aim of the study was to determine the factors associated with adverse pregnancy outcome in women with RA.

Methods

All RA patients (diagnosis according to the Rheumatologist) included in the national multicenter GR2 cohort from 2015 to June 2021 were included in the analysis. Patients could be included either with a pregnancy wish (i.e., preconceptional period) or because of a clinical pregnancy (<12 weeks of gestation). The main endpoint was favorable pregnancy outcome, a composite outcome defined as a live birth at term ≥ 37 gestation weeks of a healthy newborn with a weight greater than the 10th percentile. Disease activity was defined by a DAS28-CRP score > 3.2 at least once during pregnancy. We performed a multilevel logistic regression model, in which we considered patient and center random effects (patient random effect for some women included in the cohort two times). We used a multiple imputation procedure to address missing data among the explanatory variables. Results are presented as an odds ratio (OR) with confidence interval (CI).

Results

Among the 167 pregnancies in women with RA included in the GR2 cohort, 92 were retained for analysis of obstetrical outcome. Of these, 43 (46.2%), 8 (7.9%), 40 (43.5%) were exposed to corticosteroid, NSAID and biologics at least once during pregnancy, respectively. A moderate or severe disease activity at least once during pregnancy was found in 20 (21.8%) pregnancies. A live birth was found in 83 (90.2%) women, including 69 (83.1%) full-term births. Early miscarriages were observed in 9 (0.1%) women. A caesarean section was performed in 22 (23.9%) cases.

A favorable pregnancy outcome was found in 52 (56.5%) of the women. Unfavorable pregnancy outcome was mainly due to prematurity and small for gestational age, observed in 14 (16.9%) and 17 (20.5%), respectively. The multivariate model adjusted for age, BMI, nulliparity, active disease during pregnancy, smoking, and exposure to biologics and corticosteroids during pregnancy found an association between an unfavorable pregnancy outcome and nulliparity (OR 6.2 95% CI [2.1-17.8] p = 0.002), age (OR (per year) 1.1 95% CI [1.0-1.3] p = 0.02) and exposition to corticosteroids during pregnancy (OR 3.2 95% CI [1.1-9.6] p = 0.04).

Conclusion

This study provides original results on pregnancy in women with RA. It found a favorable pregnancy outcome in 56.5% of women. Unfavorable pregnancy outcome was associated with age, nulliparity and corticosteroids use during pregnancy, which argues for their careful use during pregnancy.

References

[1]Van den Brandt S. Arthritis Res Ther. 2017;19(1):64.

Table 1.

Multilevel logistic regression model: factors associated with unfavorable pregnancy outcome in women with RA.

Univariate analysesMultivariate analysesCrude OR 95% CIpAdjusted OR 95% CIpAge1.09 [1.01-1.19]0.0361.14 [1.02-1.28]0.019BMI0.93 [0.83-1.04]0.1960.91 [0.77-1.08]0.204Nulliparity4.18 [1.66-10.53]0.0036.16 [2.13-17.76]0.002Smoking1.08 [0.29-3.36]0.9961.65 [0.37-7.22]0.141Disease activity*1.06 [0.40-2.81]0.9110.98 [0.21-2.28]0.753Corticosteroids**2.45 [1.05-5.68]0.0393.22 [1.09-9.57]0.038Biologics**1.05 [0.11-3.54]0.5892.02 [0.70-4.12]0.194

* Moderate or severe disease activity at least once during pregnancy.

** Use at least once during pregnancy

Acknowledgements

The GR2 Cohort is supported by the French Society of Rheumatology, the French Internal Medicine Society, and unrestricted grants from UCB.

Disclosure of Interests

SABRINA HAMROUN: None declared, Marion Couderc: None declared, Rene-Marc Flipo: None declared, Laure Gossec: None declared, Christophe Richez Speakers bureau: CR has received consulting/speaker’s fees from Abbvie, Amgen, Astra Zeneca, Biogen, BMS, Celltrion, Eli Lilly, Galapagos, GSK, MSD, Novartis, and Pfizer, all unrelated to this manuscript., Rakiba Belkhir: None declared, Aline Frazier-Mironer: None declared, Valerie Devauchelle-Pensec: None declared, Hubert MAROTTE: None declared, Jérémie SELLAM: None declared, Elisabeth Gervais: None declared, Alban Deroux: None declared, Cédric Lukas: None declared, Emmanuelle Dernis: None declared, Emmanuel Chatelus: None declared, Nathalie Costedoat-Chalumeau: None declared, Anna Moltó: None declared

What influences patients' opinion of remission and low disease activity in psoriatic arthritis? Principal component analysis of an international study

OBJECTIVE

In PsA, the treatment objective is remission or low disease activity (LDA), but patients' perception of remission is poorly studied. This analysis aimed to identify factors associated with patient-defined remission.

METHODS

This analysis uses ReFlaP data, an international PsA study, with remission defined as 'At this time, is your psoriatic arthritis in remission, if this means: you feel your disease is as good as gone?'. Variables associated with, first, patient-defined remission and, second, LDA were identified using multivariable logistic regression and principal component analysis (PCA) to explore correlated variables.

RESULTS

Of 424 patients (50.2% male, mean age 52 years) with established disease, 94 (22.2%) reported themselves as being in remission and 191 (45.0%) as LDA alone. In multivariable analysis pain, psoriasis, impact of disease, physician opinion of symptoms from joint damage and Groll comorbidity index were independent predictors of remission. For LDA, results were similar. Using PCA, variance explained was 74% by five components for men and 80% by six components for women. The key component from PCA for remission was, for both sex, disease impact (Psoriatic Arthritis Impact of Disease, pain and HAQ) explaining 22.2-27.5% of variance. Other factors included musculoskeletal disease activity, chronicity/joint damage, psoriasis, enthesitis and CRP. For LDA, similar factors were identified but the variance explained was lower (64-68%).

CONCLUSION

Many factors impact on patients' opinion of remission, dominated by disease impact. Disease activity in multiple domains, chronicity/age, comorbidities and symptoms due to other conditions contribute to a robust model highlighting that patient-defined remission is multifaceted.

TRIALS REGISTRATION

Clinicaltrials.gov, http://clinicaltrials.gov, NCT03119805.

New-Onset Inflammatory Bowel Diseases Among IL-17 inhibitors-Treated Patients: Results From The Case-Control MISSIL Study

OBJECTIVES

To describe new-onset inflammatory bowel diseases (new IBD) in patients treated with interleukin 17 inhibitors (IL-17i), to assess their incidence and to identify their risk factors in real life.

METHODS

A French national registry (MISSIL) aimed to report all cases of new IBD in patients treated with IL-17i from January 2016 to December 2019. Using the estimated number of patients treated by IL-17 in France during the study period, the annual incidence rates of new IBD was reported in IL-17i-treated patients. A case-control study was performed with two controls per new IBD case matched by gender, age and underlying inflammatory disease.

RESULTS

31 cases of new IBD under IL-17i were collected: 27 patients treated for spondyloarthritis and 4 patients for psoriasis. All were observed with secukinumab (SEK). The median time to onset of new IBD symptoms was 4.0 (1.5-7.5) months. SEK was discontinued in all patients. The evolution was favourable with complete resolution (17/31), improvement (7/31) or stabilization (5/31). 2 patients died: one due to a massive myocardial infarction and one due to post-colectomy complications. The incidence of new IBD decreased from 0.69/100 PY (7/1010) in 2016, to 0.08/100PY (6/7951) in 2019. No previous treatment with etanercept (OR = 0.33, IC95% 0.14-0.80, p= 0.014) and low number of previous biological therapies (OR = 0.67, 95%CI 0.47-0.94, p= 0.021) were significantly associated with new IBD.

CONCLUSION

The incidence of new IBD was low and decreased from 2016 to 2019. The outcome was favourable in 24 out of 31 patients, but two patients died.

Clinical characteristics and management of olecranon and prepatellar septic bursitis in a multicentre study

BACKGROUND

No current guidelines are available for managing septic bursitis (SB).

OBJECTIVES

To describe the clinical characteristics and management of olecranon and prepatellar SB in five French tertiary care centres.

METHODS

This is a retrospective observational multicentre study. SB was diagnosed on the basis of positive cultures of bursal aspirate. In the absence of positive bursal fluid, the diagnosis came from typical clinical presentation, exclusion of other causes of bursitis and favourable response to antibiotic therapy.

RESULTS

We included 272 patients (median age of 53 years, 85.3% male and 22.8% with at least one comorbidity). A microorganism was identified in 184 patients (67.6%), from bursal fluids in all but 4. We identified staphylococci in 135 samples (73.4%), streptococci in 35 (19%) and 10 (5.5%) were polymicrobial, while 43/223 bursal samples remained sterile (19.3%). Forty-nine patients (18%) were managed without bursal fluid analysis. Antibiotic treatment was initially administered IV in 41% and this route was preferred in case of fever (P = 0.003) or extensive cellulitis (P = 0.002). Seventy-one (26%) patients were treated surgically. A low failure rate was observed (n = 16/272, 5.9%) and failures were more frequent when the antibiotic therapy lasted <14 days (P = 0.02) in both surgically and medically treated patients.

CONCLUSIONS

Despite variable treatments, SB resolved in the majority of cases even when the treatment was exclusively medical. The success rate was equivalent in the non-surgical and the surgical management groups. However, a treatment duration of <14 days may require special attention in both groups.

Features and Outcomes of Microcrystalline Arthritis Treated by Biologics: A Retrospective Study

OBJECTIVES

The usual treatments for crystal-associated arthritis are sometimes contraindicated; thus, new therapies against interleukin-1beta (IL-1) have been developed. We evaluated the characteristics of patients who received biological treatment for crystal-associated arthritis.

PATIENTS AND METHODS

We conducted a multicentric retrospective observational study in six rheumatology units in western France. Patients receiving a biological treatment for crystal-associated arthritis between 1 January 2010 and 31 December 2018 were included. Improvement was defined as at least a 50% decrease in the count of synovitis and C-reactive protein level.

RESULTS

Forty-six patients were included: 31 (67.4%) were treated for gouty arthritis, and 15 (32.6%) for calcium pyrophosphate crystal deposition disease (CCPD). The first biotherapy used was anakinra for 14 patients (93.3%) with CCPD and 31 patients (100.0%) with gout. The first biotherapy course was more efficient in treating gout than in treating CCPD, with success in 28 patients (90.3%) and 5 patients (35.7%), respectively (p = 0.001). Six patients (42.9%) with CCPD stopped their first biotherapy course because of side effects. Among the patients with gout, urate-lowering therapy was more frequently used after (100%) than before the first biotherapy course (67.7%) (p = 0.002).

CONCLUSION

Anakinra was prescribed for cases of refractory crystal-associated arthritis or cases with contraindications for usual treatments. The efficacy of anakinra in treating CCPD was not obvious. Patients with CCPD had more side effects. The biotherapy was introduced with a long-term objective, while anti-IL-1 therapies are approved for acute crises only.

OP0298 ARE PATIENTS WITH PSORIATIC ARTHRITIS BEING TREATED OPTIMALLY ACROSS THE WORLD? DISPARITIES IN HEALTH CARE FOR PATIENTS WITH PSORIATIC ARTHRITIS ACROSS COUNTRIES WITH DIFFERENT GDP’S, AN ANALYSIS OF 429 PATIENTS FROM 13 COUNTRIES

Background:

In psoriatic arthritis (PsA), EULAR recommendations are to aim for remission or low disease activity(1). Many treatments are now available, though some are costly and not widely available in all countries. Country of patient care, and in particular Gross Domestic Product (GDP) may be linked to PsA outcomes(2). Although patients with high disease activity are eligible for targeted therapies such as biologic disease-modifying anti-rheumatic drugs (bDMARDs), they may not be able to get the benefits from these efficacious treatments in all countries equally.

Objectives:

The objective was to explore the rate of PsA patients with high to moderate disease activity, not receiving bDMARDs across countries, and to assess the consequences on functional incapacity.

Methods:

This was a cross-sectional analysis of an observational study (ReFlap, NCT03119805)(3), which included adult patients with PsA with ≥ 2 years disease duration from 14 countries. One country was excluded from this analysis since only 7 patients were included. We explored the rate of patients with significant disease activity (i.e based on DAPSA > 14) and no ongoing bDMARD prescription. Countries of inclusion were analysed separately, and classified into tertiles by GDP/capita (lowest tertile: Brazil, Turkey, Russia, Romania, Estonia; middle tertile: Spain, Italy, UK, France; highest tertile: Canada, Germany, USA and Singapore). The rate of no bDMARDs - DAPSA > 14 patients was analysed by country and compared between the 3 tertiles of GDP/capita by parametric tests. Functional capacity (HAQ) was compared between no bDMARDs - DAPSA > 14 patients and the other patients (pooling patients with moderate or high disease activity with bDMARD, low disease activity and remission with or without bDMARD). There was no imputation of missing data.

Results:

Of the 459 patients, 429 had complete data available and were analysed: mean age 52.3 (SD 12.6) years, mean disease duration 10.2 (SD 8.2) years, 215 (50.1%) males. The rate of no bDMARDs - DAPSA > 14 patients was 18.4% (76/414). The rate ranged from 7.4% (UK and Spain) to 40% (Russia): Figure 1. A link was seen with the country and the tertiles of countries according to GDP/capita, with higher rate of no bDMARDs - DAPSA > 14 patients in the lowest GDP/capita countries (28.8%, 15.3% and 14.3% in the 3 GDP/capita tertiles, respectively, p=0.005; Figure 1). Of note, 40/76 no bDMARDs - DAPSA > 14 patients received a treatment intensification during the visit. Among no bDMARDs - DAPSA > 14 patients, functional incapacity was higher than in the other patients, as expected (mean HAQ 0.96 (SD 0.64) vs 0.57 (SD 0.63), p<0.001).

Figure 1.

The size of the bubbles represent the number of patients per country (range, 13 to 89). The horizontal lines represent the mean proportion of patients with no bDMARDs – DAPSA > 14 for each tertiles of countries by GDP/capita.

Conclusion:

In this exploratory comparison of disease patterns and treatments choices in 13 countries, we observed that more PsA patients with high or moderate disease activity and living in low GDP/capita countries were less likely to be treated with bDMARDs. As a consequence, no bDMARDs – DAPSA > 14 patients had worse functional incapacity. Equitable access to bDMARDs should be aimed for all patients regardless of their country of origin.

References:

[1]Gossec L et al. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update. Ann Rheum Dis. 2020 Jun;79(6):700-712.

[2]Gossec L et al. Are There Country Differences in Disease Activity and Life Impact of Psoriatic Arthritis? An Analysis of 436 Patients from 14 Countries [abstract]. Arthritis Rheumatol. 2019; 71 (suppl 10).

[3]Gorlier C et al. Comparing patient-perceived and physician-perceived remission and low disease activity in psoriatic arthritis: an analysis of 410 patients from 14 countries. Ann Rheum Dis. 2019 Feb;78(2):201-208.

Disclosure of Interests:

None declared.

OP0138 FEASIBILITY OF PROGRESSIVE ANTI-TNF TAPERING IN AXIAL SPONDYLOARTHRITIS PATIENTS IN LOW DISEASE ACTIVITY: RESULTS FROM THE MULTICENTER NON-INFERIORITY PROSPECTIVE RANDOMIZED CONTROLLED TRIAL SPACING

Background:

Anti-TNF treatments (TNFi) have shown high efficacy in axial spondyloarthritis (ax-SpA) with inadequate response to non-steroidal anti-inflammatory drugs (NSAIDs). However their effect remains predominantly symptomatic, and their long-term tolerance as well as significant societal cost justify investigation about a potential reduction in drug dosage, or –most feasible and comfortable for the patient– increase in intervals between doses.

Objectives:

To assess if a progressive and monitored reduction of administered TNFi by increase of intervals between injections results in a comparable proportion of patients remaining after 12 months (m) in low disease activity state despite a decreased cumulative treatment dose received.

Methods:

Non-inferiority randomized controlled trial, having included adult patients with ax-SpA fulfilling ASAS criteria, already treated by anti-TNF, and in stable low disease activity for at least 6 m (current and at least 6 m old BASDAI<4/10), who were randomized into 2 groups: either keeping on their usual treatment with stable doses (“unchanged” group), or progressive spacing of injections of their treatment (“spacing” group). Follow-up was done every 3 m during 12 m, with regular monitoring of disease activity and, in patients from the group “spacing”, modification of the rhythm of injections according to disease activity and predefined standardized protocol (either increase or decrease (step-back) of intervals between injections). The primary endpoint was the difference of proportions of patients having a low disease activity state (BASDAI<4/10) after 12 m of follow-up between the 2 groups. It was estimated on the ITT population after multiple imputation. The 90% confidence interval associated was calculated using the Farrington-Manning method and the lower bound was compared to the non-inferiority margin of -20%. With an expected proportion of 85% patients remaining in low disease activity in the unchanged group, and α and β risks at respectively 5% and 90%, the required number of patients was calculated at 358, and thus 398 had to be included with a 10% expected proportion of patients with unavailable data.

Results:

398 patients were randomized in 23 French rheumatology units (197 and 201 in the spacing and unchanged groups respectively), and 389 included in analyses (9 did not receive the allocated treatment). Mean (SD) age was 44.3 (12.4) years, 71.2% were males. Mean (SD) BASDAI at inclusion was 1.45 (1.02). TNFi used were etanercept (35.7%), adalimumab (33.9%), infliximab (20.6%), golimumab (9.3%) and certolizumab (0.5%). For the 373 patients with complete follow-up (93.7%), 162/184 (88.0%) had a low disease activity in the “spacing” group vs. 173/189 (91.5%) in the “unchanged” group at 12 m. After multiple imputation for the 16 patients with missing data, the difference of proportion between the two groups was estimated to -4.18% [CI90% -10.0; 1.7], thus confirming the non-inferiority of the “spacing” procedure. In the “spacing” group at 12 m, 134/162 (82.7%) patients in low disease activity were still receiving a lowered TNFi dose.

Conclusion:

In ax-SpA patients with BASDAI<4 for at least 6 months under TNFi, it is possible to increase intervals between injections while maintaining a low disease activity by adjusting treatment with quarterly monitoring of SpA activity.

Disclosure of Interests:

Cédric Lukas Speakers bureau: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, UCB, Consultant of: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, UCB, Grant/research support from: Pfizer, Novartis and Roche-Chugai, Anne Tournadre Speakers bureau: Abbvie, Fresenius, Janssen, MSD, Pfizer, Roche Chugai, Sanofi, Paid instructor for: Fresenius, Consultant of: Abbvie, Fresenius, Lilly, Novartis, Sanofi, Grant/research support from: Fresenius, Novartis, Pfizer, UCB, Marie Christine Picot: None declared, Erika Nogué: None declared, Emmanuelle Dernis Speakers bureau: Roche chugai, UCB, BMS, Novartis, Lilly, Mylan, Pfizer, Celgène, Consultant of: UCB, MSD, BMS, Lilly, Novartis, Philippe Goupille Speakers bureau: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Janssen, Lilly, Medac, MSD, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Consultant of: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Janssen, Lilly, Medac, MSD, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Grant/research support from: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Janssen, Lilly, Medac, MSD, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Bernard Combe Speakers bureau: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Consultant of: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Jacques Morel Speakers bureau: Abbvie, Biogen, BMS, Fresenius Kabi, Lilly, Mylan, Novartis, Pfizer, Sanofi, Consultant of: Abbvie, BMS, Boerhinger Ingelheim, Galpaagos, GSK, Lilly, Novartis, Sanofi

Evaluation of the impact of a nurse-led program of patient self-assessment and self-management in axial spondyloarthritis: results of a prospective, multicentre, randomized, controlled trial (COMEDSPA)

OBJECTIVE

To evaluate the impact of a nurse-led program of self-management and self-assessment of disease activity in axial spondyloarthritis.

METHODS

Prospective, randomized, controlled, open, 12-month trial (NCT02374749). Participants were consecutive axial spondyloarthritis patients (according to the rheumatologist) and nurses having participated in a 1-day training meeting. The program included self-management: educational video and specific video of graduated, home-based exercises for patients; and self-assessment: video presenting the rationale of tight monitoring of disease activity with composite scores (Ankylosing Spondylitis Disease activity Score, ASDAS/Bath Ankyslosing Spondylitis Disease Activity Index, BASDAI). The nurse trained patients to collect, calculate and report (monthly) ASDAS/BASDAI. Treatment allocation was by random allocation to this program or a comorbidities assessment (not presented here and considered here as the control group).

RESULTS

A total of 502 patients (250 and 252 in the active and control groups, respectively) were enrolled (age: 46.7 (12.2) years, male gender: 62.7%, disease duration: 13.7 (11.0) years). After the one-year follow-up period, the adherence to the self-assessment program was considered good (i.e. 79% reported scores >6 times). Despite a lack of statistical significance in the primary outcome (e.g. coping) there was a statistically significant difference in favor of this program for the following variables: change in BASDAI, number and duration of the home exercises in the active group, and physical activity (international physical activity score, IPAQ).

CONCLUSION

This study suggests a short-term benefit of a nurse-led program on self-management and self-assessment for disease activity in a young axial spondyloarthritis population in terms of disease activity, exercises and physical activity.

Comparing the Patient-Reported Physical Function Outcome Measures in a Real-Life International Cohort of Patients With Psoriatic Arthritis

OBJECTIVE

We evaluated the psychometric properties of 3 patient-reported outcome measures to assess the physical function in psoriatic arthritis (PsA).

METHODS

Data were available for the Health Assessment Questionnaire disability index (HAQ DI), the 12-item Short Form instrument physical component summary (SF-12 PCS), and the Psoriatic Arthritis Impact of Disease instrument functional capacity score (PsAID-FC). Data came from a longitudinal study in 14 countries of consecutive adults with definite PsA with ≥2 years of duration. The score distribution, construct validity, responsiveness, and thresholds of meaning of the patient-reported outcome measures were evaluated.

RESULTS

At baseline, 414 subjects (52% male) were analyzed. The mean ± SD age was 52.4 ± 12.5 years and duration of illness was 10.9 ± 8.1 years. Ceiling effects were noted in 31% and 21% of patients for HAQ DI and PsAID-FC, respectively; floor effects were minimal. All 3 patient-reported outcome measures met a priori hypotheses for construct validity. After a median follow-up of 4.1 (interquartile range 2.7) months in 350 patients, 27%, 54%, and 18% of patients reported themselves improved, not changed, and worsened, respectively. Change scores were statistically different for groups for worsening versus no-change for all patient-reported outcome measures. PsAID-FC was more sensitive to change than the other 2 patient-reported outcome measures. Comparing groups with worsening condition to no-change, the standardized response mean square ratios were HAQ DI 29.9, SF-12 PCS 16.7, and PsAID-FC 40.1.

CONCLUSION

HAQ DI, SF-12 PCS, and PsAID-FC are valid measures of physical function for PsA. PsAID-FC, a single question, performed similarly to the other patient-reported outcome measures and may be an additional option to measure PsA-specific physical function.

Psychometric validation of a patient-reported outcome questionnaire (Qualipsosex) assessing the impact of psoriasis and psoriatic arthritis on patient perception of sexuality

ABSTRACT

Psoriasis (Pso) and psoriatic arthritis (PsA) frequently have a negative impact on patients' sexual health. We have developed a specific questionnaire assessing the impact of Pso and PsA on patient perception of sexuality: the QualipsoSex Questionnaire (QSQ). The aim of the present study was to further validate this questionnaire by checking its psychometric properties including validity, reliability, and responsiveness.A cross sectional observational study with a longitudinal component for responsiveness and test-retest reliability was performed in 12 centers in France including 7 dermatologists and 5 rheumatologists. Psychometric properties were examined according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) check-list.At baseline, 114 patients had Pso and 35 patients had PsA including 17 peripheral arthritis, 4 axial disease, 13 patients with both axial disease and peripheral arthritis and one patient with an undifferentiated phenotype. The mean Pso Area and Severity Index score was 12.5. Genital organs were involved in 44.7% of Pso cases. Internal consistency, construct validity, and reliability were good with Cronbach's α coefficient, measure of sampling adequacy and intraclass correlation coefficient respectively at 0.87, 0.84, and 0.93. The QSQ also demonstrated acceptable sensitivity to change.The QSQ has demonstrated good psychometric properties fulfilling the validation process relative to the recommendations of the COSMIN check list. The QSQ is simple to score and may hopefully be valuable in clinical practice and in clinical trials.

Determinants of Patient-Reported Psoriatic Arthritis Impact of Disease: An Analysis of the Association With Sex in 458 Patients From Fourteen Countries

OBJECTIVE

Sex differences may modify symptoms, disease expression, and treatment effects. The objective of this study was to evaluate the link between life impact and sex in psoriatic arthritis (PsA).

METHODS

Remission and Flare in Psoriatic Arthritis (ReFlaP; ClinicalTrials.gov identifier: NCT03119805) was a study in 14 countries of consecutive adult patients with definite PsA. Participants underwent comprehensive PsA assessment using the following measures: Disease Activity in Psoriatic Arthritis (DAPSA), Minimal Disease Activity (MDA), and Psoriatic Arthritis Impact of Disease (PsAID). Disease activity was compared by sex using t-tests or Wilcoxon tests. The association of PsAID with sex was analyzed using hierarchical generalized linear models.

RESULTS

Of 458 participants, 50.2% were male and the mean ± SD age was 53.1 ± 12.6 years. The mean ± SD PsA duration was 11 ± 8.2 years, and 51.5% of participants were being treated with biologic disease-modifying antirheumatic drugs. Women, compared to men, had worse mean ± SD Leeds Enthesitis Index scores (0.8 ± 1.7 versus 0.3 ± 0.9), pain on a numerical rating scale (NRS; range 0-10) (4.7 ± 2.7 versus 3.5 ± 2.7), HAQ DI scores (0.9 ± 0.7 versus 0.5 ± 0.6), fatigue on an NRS (5.2 ± 3 versus 3.3 ± 2.8), and PsAID scores (4.1 ± 2.4 versus 2.8 ± 2.3) (P < 0.001 for all). Women were also less frequently at treatment target compared to men according to DAPSA (cutoffs of ≤4 for remission and >4 and ≤14 for low disease activity; mean ± SD score 16.9 ± 14.9 in women versus 12.6 ± 16.6 in men) and MDA (25.7% versus 50.0%; P < 0.001 for all) scores. High life impact (PsAID score ≥4) was associated with female sex (odds ratio [OR] 2.3), enthesitis (OR 1.34), tender joints (OR 1.10)(P < 0.001 for all), and comorbidities (OR 1.22, P = 0.002).

CONCLUSION

High life impact was independently associated with female sex, enthesitis, comorbidities, and tender joints. At treatment target, women had higher life impact compared to men. It is necessary for life impact to become a part of PsA treat-to-target strategies.

Increased high molecular weight adiponectin and lean mass during tocilizumab treatment in patients with rheumatoid arthritis: a 12-month multicentre study

Background

Patients with rheumatoid arthritis (RA) have an increased risk of cardiovascular (CV) disease. Adiponectin is involved in the metabolism of glucose and lipids with favourable effects on CV disease, especially its high molecular weight (HMW) isoform. Body composition changes are described in RA with various phenotypes including obesity. The effects of tocilizumab on serum adiponectin and body composition, especially fat mass, in patients with RA are not well determined.

Methods

Patients with active RA despite previous csDMARDs and/or bDMARDs and who were tocilizumab naïve were enrolled in a multicentre open-label study. They were evaluated at baseline, 1, 3, 6 and 12 months. Clinical assessment included body mass index (BMI) and anthropometric measurements. Lipid and metabolic parameters, serum adiponectin (total and HMW), leptin, resistin and ghrelin were measured at each time point. Body composition (lean mass, fat mass, % fat, fat in the android and gynoid regions) was evaluated at baseline, 6 and 12 months.

Results

One hundred seven patients were included. Both total and HMW adiponectin significantly increased from baseline to month 3, peaking respectively at month 3 (p = 0.0105) and month 1 (p < 0.0001), then declining progressively until month 6 to 12 and returning to baseline values. Significant elevation in HMW adiponectin persisted at month 6 (p = 0.001). BMI and waist circumference significantly increased at month 6 and 12, as well as lean mass at month 6 (p = 0.0097). Fat mass, percentage fat and android fat did not change over the study period. Lipid parameters (total cholesterol and LDL cholesterol) increased while glycaemia, insulin and HOMA-IR remained stable. Serum leptin, resistin and ghrelin did not change during follow-up.

Conclusions

Tocilizumab treatment in RA patients was associated with a significant increase in total and HMW adiponectin, especially at the onset of the treatment. Tocilizumab also induced a significant gain in lean mass, while fat mass did not change. These variations in adiponectin levels during tocilizumab treatment could have positive effects on the CV risk of RA patients. In addition, tocilizumab may have an anabolic impact on lean mass/skeletal muscle.

Trial registration

The ADIPRAT study was a phase IV open-label multicentre study retrospectively registered on ClinicalTrials.gov under the number NCT02843789 (date of registration: July 26, 2016).

THU0370 CLUSTER-RANDOMIZED PRAGMATIC CLINICAL TRIAL EVALUATING THE POTENTIAL BENEFIT OF A TIGHT-CONTROL AND TREAT-TO-TARGET STRATEGY IN AXIAL SPONDYLOARTHRITIS: THE RESULTS OF THE TICOSPA TRIAL

Background:

Current recommendations for axial spondyloarthritis (axSpA) management include tight control and treat-to-target (TC) strategies, but no study has evaluated its potential benefit

Objectives:

To evaluate the benefit of TC strategies in comparison to usual care (UC) in patients with axSpA.

Methods:

Study design:Pragmatic, prospective, cluster-randomized controlled (2 arms), one-year trial (NCT03043846).Centers: 18 axSpA expert centers randomly allocated (1:1) to the treatment arm: TC vs. UC.Patients: axSpA diagnosis and ASAS criteria, non-optimally treated with NSAIDs, bDMARD-naïve, and ASDAS > 2.1 at inclusion.Study treatment:a) TC arm: the strategy was pre-specified by the scientific committee based on current axSpA recommendations and aiming at a target (ASDAS <2.1); visits every 4w;b) UC arm:treatment decisions were at the rheumatologist’s discretion with visits every 12w.Outcomes:the % of patients with a significant (>30%) improvement in the ASAS-HI score over one-year follow-up was the main outcome. Other outcomes (disease activity, quality of life, treatment, …) over follow-up were evaluated (Table 1). The number/type of adverse events were collected.Statistical analysis: this was an intention-to-treat analysis. To take into account the cluster-randomization design, for all outcomes, two models were performed: first a two-level mixed model with 2 random effects was used to estimate the % of responders/the change of the outcome over follow-up (i.e. mod1); in a second step, the imbalanced variables observed at baseline were included in the model (i.e.mod2). Cost-effectiveness was assessed by estimating the (baseline- and cluster-adjusted) incremental cost per quality-adjusted life-year (QALY) gained for TC vs. UC.

Estimated outcomes at week 48Cluster-adjusted (mod1)Cluster and imbalance-adjusted (mod2)TCUCASDAS LDA*76.5%59.5%<0.010.03ASDAS ID25.9%18.7%--ASDAS CII61.2%46.0%<0.010.02ASDAS MI16.5%14.9%--ASAS4052.3%34.7%<0.010.01ASAS2094.9%85.9%<0.010.03BASDAI 5079.0%43.8%0.010.03Physician Global (0-10)2.0 (0.2)1.8 (0.2)--CRP (mg/L)3.9(1.4)3.5 (1.5)--BASG (0-10)2.6 (0.5)3.4 (0.5)0.09-BASFI (0-10)1.7(0.5)2.4 (0.5)--ASAS HI SMD47.3%36.1%--EQ5D0.7(0.1)0.8(0.1)0.02-ASAS-NSAID score1.5(2.2)- 4.9 (2.9)--

Results:

160 patients were included (80 in TC and 80 in UC). Mean age was 37.9(11.0) years with a disease duration of 3.7(6.2) years, 51.2% were males. A radiographic damage of the SI-joints, a (ever) positive MRI sacroiliitis and HLA-B27+ were seen in 46.9%, 81.9% and 75.0% patients respectively. Mean ASDAS at inclusion was 3.0 (0.7) and mean ASASHI was 8.6 (3.7). 72 patients per group attended the one-year visit. Although 47.3% vs. 36.1% patients in the TC and UC arms achieved a significant improvement in ASASHI at the one-year visit, the difference was not statistically significant, with either model. Across all other outcomes a trend was observed in favor of the TC arm (Table 1). The number of bDMARDs was significantly higher in TC arm (56.2% vs. 27.2%). The number of infections was comparable in both groups (15 vs. 16 in the TC and UC, respectively), with only 2 severe infections occurring in the UC arm. From a societal perspective, TC resulted in an additional 0.04 QALY and saved €265 when compared to UC and a 67% probability of being cost-effective at a cost-effectiveness threshold of €20,000 per QALY.

Conclusion:

In this setting of SpA expert centers, UC resulted in a good outcome in a substantial number of patients but the TC was not superior for the primary outcome despite a greater number of bDMARDs prescription. Nevertheless, a general trend in favor of the tight control was observed, with a comparable safety profile and was found to be favorable from a societal health economic perspective.

Acknowledgments:

this trial has been conducted thanks to an unrestricted grant from UCB

Disclosure of Interests:

Anna Moltó Grant/research support from: Pfizer, UCB, Consultant of: Abbvie, BMS, MSD, Novartis, Pfizer, UCB, Clementina López-Medina: None declared, Filip van den Bosch Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Speakers bureau: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Annelies Boonen Grant/research support from: AbbVie, Consultant of: Galapagos, Lilly (all paid to the department), Casper Webers: None declared, Emmanuelle Dernis Speakers bureau: Lilly, Novartis, Floris A. van Gaalen: None declared, Martin SOUBRIER: None declared, Pascal Claudepierre Speakers bureau: Janssen, Novartis, Lilly, Athan Baillet Consultant of: Athan BAILLET has received honorarium fees from Abbvie for his participation as the coordinator of the systematic literature review, Mirian Starmans-Kool: None declared, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Maxime Dougados Grant/research support from: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Consultant of: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Speakers bureau: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma

FRI0449 MANAGEMENT AND OUTCOME OF SEPTIC ARTHRITIS OF NATIVE JOINT: A NATIONWIDE SURVEY

Background:

Objectives:

To describe current management and outcome of septic arthritis on native joint in French rheumatology departments.

Methods:

Retrospective, nation-wide multicentric study. 127 French rheumatology departments were contacted to report 10 successive cases of septic arthritis on native joint that occurred between the 01/01/16 to 31/12/17 (excluding mycobacteria). Characteristics, diagnosis procedure, therapeutic management and outcome were recorded.

Results:

52 centers included 363 patients (mean age 64± 18.7 years, mean Charlson comorbidity index 4±3). 28.3% patients had a preexisting arthropathy on affected joint. Monoarthritis was observed in 89.6% patients, knee was the most frequent site (38.9%). The most frequent pathogens wereStaphylococcus sp(50.7%) andStreptococcus sp.(23.3%). Bacteremia was found in 156 (45.1%) patients and endocarditis in only 12 (3.0%). Management was heterogeneous. All patients received antibiotics for a mean duration of 46.7±22 days (including intravenous route: 17.3±15.4 d). An initial monotherapy was administered in 42.3% of patients. Surgical procedure (mostly lavage 70.6%) was performed in 171 (48.3%), joint immobilization in 128 (35.3%) (median duration of 21.7±14.1 days). 94 (29.2%) patients have had serious complications including 29 (9.5%) death. Factors associated with death are reported in the table.

Conclusion:

This study shows that management of septic arthritis is very heterogenous with a still high rate of morbidity and mortality. We identified age, comorbidities, bacteremia and recent antibiotherapy were associated with mortality. Of note, duration of antibiotics was not. Thus, new guidelines are needed in order to facilitate septic arthritis management.

Table:FactorsSurvivor(N=276)Dead(N=29)Univariate analysispAdjusted Odds ratio (95%IC)Multivariate analysispAge65 (16-97)82 (32-98)<0,0011,07 (1,03-1,12)< 0.001Charlson’s index1 (0-12)2 (0-9)0,00011,3 (1,05-1,63)0,018Delay before antibiotic initiation8,5 (0-310)5 (0-75)0,04840,99 (0,96-1,02)0,562Corticosteroid in the previous 3 months13,9%33,3%0,01842,56 (0,75-8,74)0,133Bacteriemia42,4%71,4%0,00615,07 (1,4-18,370,013Antibiotics in the previous 3 months26,6%56,6%0,00566,7 (2,04-22,01)0,002

Disclosure of Interests:

Pauline Richebé: None declared, Sophie Godot: None declared, Guillaume Coiffier: None declared, Pascal GUGGENBUHL: None declared, Denis Mulleman: None declared, Marion Couderc: None declared, Emmanuelle Dernis Speakers bureau: Lilly, Novartis, Valentine Deprez: None declared, Carine Salliot: None declared, Saik Urien: None declared, Rachel Brault: None declared, Adeline Ruyssen-Witrand Grant/research support from: Abbvie, Pfizer, Consultant of: Abbvie, BMS, Lilly, Mylan, Novartis, Pfizer, Sandoz, Sanofi-Genzyme, Emmanuel Hoppe: None declared, Jacques-Eric Gottenberg Grant/research support from: BMS, Pfizer, Consultant of: BMS, Sanofi-Genzyme, UCB, Speakers bureau: Abbvie, Eli Lilly and Co., Roche, Sanofi-Genzyme, UCB, Christian Roux: None declared, Sebastien Ottaviani: None declared, Maxime Breban: None declared, Marie Beaufrere: None declared, Alexia Michaut: None declared, Loic Pauvele: None declared, Christelle Darrieutort: None declared, Daniel Wendling: None declared, Pascal COQUERELLE: None declared, Géraldine Bart: None declared, Elisabeth Gervais: None declared, Vincent Goeb: None declared, Marc Ardizzone: None declared, Edouard Pertuiset: None declared, Sophie Derolez: None declared, Jean Marc Ziza: None declared, René-Marc Flipo Consultant of: Johnson and Johnson, MSD France, Novartis, Sanofi, Speakers bureau: Johnson and Johnson, MSD France, Novartis, Sanofi, Raphaèle Seror Consultant of: BMS UCB Pfizer Roche

FRI0095 SARILUMAB IMPROVED PATIENT-PERCEIVED IMPACT OF RHEUMATOID ARTHRITIS WHATEVER THE BASELINE DISEASE ACTIVITY: FIRST RESULTS FROM AN INTERVENTIONAL NON CONTROLLED STUDY: SARIPRO, IN MODERATE AND SEVERE RHEUMATOID ARTHRITIS PATIENTS

Background:

Sarilumab, an anti-IL-6R antibody, is approved for the treatment of moderate to severe RA and shown efficacy on disease activity and patient-reported outcomes (PROs). Detailed analyses of drug efficacy from the patient point of view is important. SariPRO is a pragmatic interventional study close to the daily practice.

Objectives:

To assess the effectiveness of sarilumab on several PROs using the RAID (Rheumatoid Arthritis Impact of Disease) score.

Methods:

The SariPRO study (NCT 03449758) was a French multicenter interventional study assessing the effects of sarilumab 200 mg on PROs in patients with moderately to severely active RA with an inadequate response or intolerance to conventional synthetic or biologic DMARDs. The primary endpoint was change in total RAID score from baseline to week 24 (RAID ranges 0-10 where 10 is maximal impact). Changes from baseline for RAID, DAS28-ESR and CDAI according to baseline disease activity were analyzed as secondary outcomes. Safety was assessed by monitoring adverse events (AE). All statistical analyses were descriptive, 95% CI was given when appropriate.

Results:

84 patients were included in 31 centers and 62 were evaluable and analyzed for effectiveness. They had similar characteristics to the 84 patients at baseline and were as expected for an RA population initiating a biologic: mean (SD) age: 59.9 (12.4) years, 71.0% female, disease duration 9.7 (10.3) years, rheumatoid factor positivity 82.5%, ACPA positivity 86.4%, and DAS28=4.9 (11). Total RAID score decreased significantly from 5.7 (2.0) at baseline to 3.3 (2.5) at W24; mean change was -2.4 [95% CI: -3.0; -1.8]. Furthermore, this improvement was noted both for highly and less active patients at baseline: for patients with DAS28-ESR < 5.1 (n=31), mean change was -1.56 [-2.28; -0.83] and for patients with DAS28-ESR≥5.1 (n=27), mean change was -1.98 [-2.91; -1.05]. Changes in DAS28-ESR and CDAI were significant (-2.8 [-3.2; -2.4] and -15.2 [-18.5; -11.8], respectively). AEs were consistent with the safety profile of anti-IL-6R antibodies and with results from RCTs (data not shown).

Conclusion:

In this real world study, treatment with sarilumab during 24 weeks in RA patients led to an improvement in the total RAID score irrespective of baseline levels of disease activity. This is the first time RAID score is used as the primary endpoint in a study.

References:

[1]Study was sponsored by Sanofi Genzyme

Disclosure of Interests:

Laure Gossec Grant/research support from: Lilly, Mylan, Pfizer, Sandoz, Consultant of: AbbVie, Amgen, Biogen, Celgene, Janssen, Lilly, Novartis, Pfizer, Sandoz, Sanofi-Aventis, UCB, René-Marc Flipo Consultant of: Johnson and Johnson, MSD France, Novartis, Sanofi, Speakers bureau: Johnson and Johnson, MSD France, Novartis, Sanofi, Thierry Schaeverbeke: None declared, Christine Albert: None declared, Athan Baillet Consultant of: Athan BAILLET has received honorarium fees from Abbvie for his participation as the coordinator of the systematic literature review, marie-Christophe Boissier: None declared, Cyrille Confavreux: None declared, Gregoire CORMIER: None declared, Emmanuelle Dernis Speakers bureau: Lilly, Novartis, Elisabeth Gervais Solau: None declared, Sophie Godot: None declared, Jacques-Eric Gottenberg Grant/research support from: BMS, Pfizer, Consultant of: BMS, Sanofi-Genzyme, UCB, Speakers bureau: Abbvie, Eli Lilly and Co., Roche, Sanofi-Genzyme, UCB, Philippe Goupille Grant/research support from: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Consultant of: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Speakers bureau: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Slim Lassoued: None declared, Thierry Lequerre: None declared, Frederic Lioté Consultant of: CME: Nordic Pharma, Christian Marcelli: None declared, Yves Maugars: None declared, Minh Nguyen: None declared, Aleth Perdriger: None declared, Yves-Marie Pers: None declared, Edouard Pertuiset: None declared, Lucile Poiroux: None declared, Carole Rosenberg: None declared, Christian Roux: None declared, Adeline Ruyssen-Witrand Grant/research support from: Abbvie, Pfizer, Consultant of: Abbvie, BMS, Lilly, Mylan, Novartis, Pfizer, Sandoz, Sanofi-Genzyme, Martin SOUBRIER: None declared, Pascale Vergne-Salle: None declared, Charles Zarnitsky: None declared, Eric Fakra Consultant of: Janssen, Lundbeck, Otsuka, Sanofi, Hubert MAROTTE Grant/research support from: Bristol Myers Sqibb, Lilly France, MSD, Novartis, Nordic Pharma, Pfizer, SanofiAventis, Consultant of: AbbVie, Amgen, Bristol Myers Sqibb, Lilly France, MSD, Novartis, Nordic Pharma, Pfizer, SanofiAventis, Paid instructor for: Sanofi-Aventis, Speakers bureau: Sanofi-Aventis, Florence E Lévy-Weil Employee of: Sanofi Genzyme employee

THU0393 INFLAMMATORY BOWEL DISEASES AMONG SECUKINUMAB-TREATED PATIENTS: 24 CASES FROM THE MISSIL REGISTRY

Background:

An alert regarding about the tolerance of Interleukin 17 (IL-17) inhibitors has been issued from data of randomized controlled trials showing cases of de novo inflammatory bowel diseases (IBD). In a recent analysis of pooled data from 21 clinical trials, cases of IBD events (including Crohn’s disease (CD), ulcerative colitis (UC) and inflammatory bowel disease unclassified (IBDU)) were uncommon (1). Yet, real-world data are lacking.

Objectives:

To describe real-world data about patients treated by IL-17 inhibitors developing new onset IBD (CD or UC).

Methods:

A French national registry called MISSIL was started in February 2018 to collect the cases of patients treated by IL-17 inhibitors developing new onset IBD. This registry is conducted by rheumatologist, dermatologist and gastroenterologist learned societies specialized on immune-mediated inflammatory diseases. In France, secukinumab (SEK) has been granted market authorization since June 2016 and ixekizumab since April 2018.

Results:

24 cases under SEK were reported between February 2018 and January 2020: 3 patients with psoriasis and 21 patients with spondylwoarthritis. There were 20 patients with new onset CD and 4 with UC. Mean age was 51.7 ± 15.7 years old and 12/24 were female; 10 presented an axial spondyloarthritis, 5 a peripheral spondyloarthritis and 6 both,13/17 were HLA-B27 positive,7/19 had a radiographic sacroiliitis and 11/17 a MRI sacroiliitis. Only 2 were biological Disease-modifying antirheumatic drug (bDMARD)-naïve. Crohn’s disease was mainly located at the ileum, colon and rectum. The median time to onset of symptoms was 2 (1-6) months. The main symptoms were diarrhea, nausea and vomiting and loss of weight. Median CRP at the onset of symptoms was 68 mg/L (41-140.5); 21 patients underwent biopsies, 12 were in favor of CD. IL-17 inhibitors were consistently stopped. Patients were treated by corticosteroids (16/24), mesalazine (7/24), methotrexate (3/24), thiopurines (2/24), infliximab (9/243), adalimumab (3/24), golimumab (2/24), ustekinumab (5/24). The evolution was favorable under treatment with complete resolution (4/24), improvement (11/24) or stabilization (5/24). 3 patients worsened under treatment and 1 died (massive myocardial infarction).

Conclusion:

IBD flare in patients treated with IL-17 inhibitors are rare and lead to discuss the potential iatrogenic role of IL-17 inhibitor drugs. Further cases are needed to better characterize this complication. A case-control study will be conducted to identify patients at risk to develop IBD under IL-17 inhibitor.

References:

[1]Reich et al. Incidence rates of inflammatory bowel disease in patients with psoriasis, psoriatic arthritis and ankylosing spondylitis treated with secukinumab: a retrospective analysis of pooled data from 21 clinical trials. Ann Rheum Dis. 2019;78:473-479

Disclosure of Interests:

Jean-Guillaume Letarouilly Grant/research support from: Research grant from Pfizer, Benjamin Pariente: None declared, Delphine Staumont-Sallé Speakers bureau: Lilly, Novartis, Philippe Goupille Grant/research support from: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Consultant of: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Speakers bureau: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Pascal Claudepierre Speakers bureau: Janssen, Novartis, Lilly, Stephane Varin: None declared, Sylvain Lanot: None declared, Emmanuelle Dernis Speakers bureau: Lilly, Novartis, Tristan Pascart Speakers bureau: Novartis, Lilly, Beatrice Banneville Speakers bureau: Lilly, Novartis, Pauline Baudart: None declared, Bruno Gombert: None declared, Elodie BAUER: None declared, Laurianne Plastaras: None declared, Sébastien Barbarot: None declared, Renaud FELTEN: None declared, Loïc Le Dantec: None declared, Nathalie Sultan-Bichat: None declared, Céline Girard: None declared, Arnaud Constantin Grant/research support from: Study was sponsored by Sanofi Genzyme, Consultant of: Consulting fees from Abbvie, BMS, Celgene, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, Daniel Wendling: None declared, Philippe Gaudin Speakers bureau: Lilly, Denis Jullien Speakers bureau: Lilly, Novartis, Thao Pham Speakers bureau: Novartis, Janssen, Lilly, Rene-Marc Flipo Speakers bureau: Novartis, Janssen, Lilly

Evaluation of the impact of a nurse-led program of systematic screening of comorbidities in patients with axial spondyloarthritis: The results of the COMEDSPA prospective, controlled, one year randomized trial

OBJECTIVE

To evaluate the impact of a nurse-led program of systematic screening for the management (detection/prevention) of comorbidities.

METHODS

Prospective, randomized, controlled, open, 12-month trial (NCT02374749).

PARTICIPANTS

consecutive patients with axial Spondyloarthritis (axSpA) (according to the rheumatologist) THE PROGRAM: A nurse collected data on comorbidities during a specific outpatient visit. In the event of non-agreement with recommendations, the patient was informed and a specific recommendation was given to the patient (orally and in a with a detailed written report). Patients were seen after one year in a nurse-led visit. TREATMENT ALLOCATION: random allocation (i.e. either this program or an educational program not presented here and considered here as the control group).

MAIN OUTCOME

change after one year of a weighted comorbidity management score (0 to 100 where 0= optimal management).

RESULTS

502 patients were included (252 and 250 in the active and control groups, respectively): age: 47±12 years, male gender: 63%, disease duration: 14±11y. After one year, no differences were observed in a weighted comorbidity management score. However, the number of patients in agreement with recommendations was significantly higher in the active group for vaccinations (flu vaccination: 28.6% vs. 9.9%, p<0.01; pneumococcal vaccination:40.0% vs. 21.1%,p=0.04), for cancer screening (skin cancer screening: 36.3% vs. 17.2%, p=0.04) and for osteoporosis (bone densitometry performed: 22.6% vs. 8.7%, p<0.01; Vitamin D supplementation initiation: 51.9% vs. 9.4%, p<0.01).

CONCLUSIONS AND RELEVANCE

This study suggests the short-term benefit of a single-visit nurse-led program for systematic screening of comorbidities for its management in agreement with recommendations, even in this young population of patients with axSpA.

Methotrexate effect on immunogenicity and long-term maintenance of adalimumab in axial spondyloarthritis: a multicentric randomised trial

Objectives

Anti-drug antibodies (ADA) are responsible for decreased adalimumab efficacy in axial spondyloarthritis (SpA). We aimed to evaluate the ability of methotrexate (MTX) to decrease adalimumab immunisation.

Methods

A total of 110 patients eligible to receive adalimumab 40 mg subcutaneously (s.c.) every other week were randomised (1:1 ratio) to receive, 2 weeks before adalimumab (W-2) and weekly, MTX 10 mg s.c. (MTX+) or not (MTX−). ADA detection and adalimumab serum concentration were assessed at weeks 4 (W4), 8 (W8), 12 (W12) and 26 (W26) after starting adalimumab (W0). The primary outcome was the proportion of patients with ADA at W26. Four years after the study completion, we retrospectively analysed adalimumab maintenance in relation with MTX co-treatment duration.

Results

We analysed data for 107 patients (MTX+; n=52; MTX-; n=55). ADA were detected at W26 in 39/107 (36.4%) patients: 13/52 (25%) in the MTX+ group and 26/55 (47.3%) in the MTX− group (p=0.03). Adalimumab concentration was significantly higher in the MTX+ than MTX− group at W4, W8, W12 and W26. The two groups did not differ in adverse events or efficacy. In the follow-up study, MTX co-treatment >W26 versus no MTX or ≤W26 was significantly associated with adalimumab long-term maintenance (p=0.04).

Conclusion

MTX reduces the immunogenicity and ameliorate the pharmacokinetics of adalimumab in axial SpA. A prolonged co-treatment of MTX>W26 seems to increase adalimumab long-term maintenance.

Comparing patient-perceived and physician-perceived remission and low disease activity in psoriatic arthritis: an analysis of 410 patients from 14 countries

Background

The objective was to compare different definitions of remission and low disease activity (LDA) in patients with psoriatic arthritis (PsA), based on both patients’ and physicians’ perspectives.

Methods

In ReFlap (Remission/Flare in PsA; NCT03119805), adults with physician-confirmed PsA and >2 years of disease duration in 14 countries were included. Remission was defined as very low disease activity (VLDA), Disease Activity index for PSoriatic Arthritis (DAPSA) ≤4, and physician-perceived and patient-perceived remission (specific question yes/no), and LDA as minimal disease activity (MDA), DAPSA <14, and physician-perceived and patient-perceived LDA. Frequencies of these definitions, their agreement (prevalence-adjusted kappa), and sensitivity and specificity versus patient-defined status were assessed cross-sectionally.

Results

Of 410 patients, the mean age (SD) was 53.9 (12.5) years, 50.7% were male, disease duration was 11.2 (8.2) years, 56.8% were on biologics, and remission/LDA was frequently attained: respectively, for remission from 12.4% (VLDA) to 36.1% (physician-perceived remission), and for LDA from 25.4% (MDA) to 43.9% (patient-perceived LDA). Thus, patient-perceived remission/LDA was frequent (65.4%). Agreement between patient-perceived remission/LDA and composite scores was moderate to good (kappa range, 0.12–0.65). When patient-perceived remission or LDA status is used as reference, DAPSA-defined remission/LDA and VLDA/MDA had a sensitivity of 73.1% and 51.5%, respectively, and a specificity of 76.8% and 88.0%, respectively. Physician-perceived remission/LDA using a single question was frequent (67.6%) but performed poorly against other definitions.

Conclusion

In this unselected population, remission/LDA was frequently attained. VLDA/MDA was a more stringent definition than DAPSA-based remission/LDA. DAPSA-based remission/LDA performed better than VLDA/MDA to detect patient-defined remission or remission/LDA. Further studies of long-term outcomes are needed.

HIBISCUS: Hydroxychloroquine for the secondary prevention of thrombotic and obstetrical events in primary antiphospholipid syndrome

The relapse rate in antiphospholipid syndrome (APS) remains high, i.e. around 20%-21% at 5 years in thrombotic APS and 20-28% in obstetrical APS [2, 3]. Hydroxychloroquine (HCQ) appears as an additional therapy, as it possesses immunomodulatory and anti-thrombotic various effects [4-16]. Our group recently obtained the orphan designation of HCQ in antiphospholipid syndrome by the European Medicine Agency. Furthermore, the leaders of the project made the proposal of an international project, HIBISCUS, about the use of Hydroxychloroquine in secondary prevention of obstetrical and thrombotic events in primary APS. This study has been launched in several countries and at now, 53 centers from 16 countries participate to this international trial. This trial consists in two parts: a retrospective and a prospective study. The French part of the trial in thrombosis has been granted by the French Minister of Health in December 2015 (the academic trial independent of the pharmaceutical industry PHRC N PAPIRUS) and is coordinated by one of the members of the leading consortium of HIBISCUS.

Extra-haematological manifestations related to human parvovirus B19 infection: retrospective study in 25 adults

Background

To describe extra-haematological manifestations associated with human parvovirus B19 (HPV-B19) infection.

Methods

We conducted a nationwide multicentre study to retrospectively describe the characteristics and outcome of extra-haematological manifestations in French adults.

Results

Data from 25 patients followed from 2001 to 2016 were analysed. Median age was 37.9 years (range: 22.7–83.4), with a female predominance (sex ratio: 4/1). Only 3 patients had an underlying predisposing condition (hemoglobinopathy or pregnancy). The most common manifestations were joint (80%) and skin (60%) involvement. Four patients (16%) had renal involvement (endocapillary proliferative or membranoproliferative glomerulonephritis, focal segmental glomerulosclerosis). Three patients (12%) had peripheral nervous system involvement (mononeuritis, mononeuritis multiplex, Guillain-Barré syndrome) and 2 (8%) presented muscle involvement. Other manifestations included hemophagocytic lymphohistiocytosis (n = 1), myopericarditis and pleural effusion (n = 1), and lymphadenopathy and splenomegaly mimicking lymphoma with spleen infarcts (n = 1). Immunological abnormalities were frequent (56.5%). At 6 months, all patients were alive, and 54.2% were in complete remission. In 2 patients, joint involvement evolved into rheumatoid arthritis. Six patients (24%) received intravenous immunoglobulin (IVIg), with a good response in the 3 patients with peripheral nervous system involvement.

Conclusions

HPV-B19 infection should be considered in a wide range of clinical manifestations. Although the prognosis is good, IVIg therapy should be discussed in patients with peripheral nerve involvement. However, its efficacy should be further investigated in prospective studies.

Psoriatic arthritis screening by the dermatologist: development and first validation of the 'PURE-4 scale'

BACKGROUND

Dermatologists are recommended to ask psoriasis patients about musculoskeletal complaints to allow early detection and treatment of psoriatic arthritis (PsA). Screening tools have been developed to help identify patients warranting further rheumatologic assessment, but evidence suggests room for improvement in their diagnostic value and ease of use for outpatient practice.

OBJECTIVE

To develop and internally validate a brief tool for dermatologists to screen patients to refer to a rheumatologist for PsA diagnosis.

METHODS

After the literature review, 23 items were selected, covering pain at various locations and inflammatory signs of PsA. The validation study was conducted in medically diagnosed psoriasis patients consecutively recruited between 2012 and 2014 (Saint Joseph Hospital, Paris, France). Patients were enrolled by a dermatologist who helped to complete the questionnaire. Diagnosis of PsA was established by a rheumatologist based on CASPAR criteria. Multivariate logistic regression models were performed to build the scale, assessing discrimination through sensitivity, specificity and area under the ROC curve (AUC). Final model was internally validated using bootstrapping techniques.

RESULTS

One hundred and sixty-eight patients were recruited, of whom nine were excluded for known PsA and 21 did not attend the rheumatologist consultation. Of 137 included patients (median age 43 years, 59.6% men), 21 (15.3%) had a PsA diagnosis. Final regression model retained four independent items, including evocative signs of dactylitis, inflammatory heel pain, bilateral buttock pain and peripheral joint pain with swelling in patients aged <50. A total score (the PURE-4) was computed (0-4 points) that demonstrated excellent discriminative power (AUC = 87.6%; Sensitivity = 85.7% and Specificity = 83.6% at the threshold of ≥1/4 points), with no evidence for over-optimism in bootstrapped internal validation.

CONCLUSION

These findings demonstrate the good diagnostic properties of a new screening scale using only four easy-to-collect items. If confirmed in other populations, it may prove useful in outpatient dermatology clinics for triage of psoriasis patients requiring further assessment by the rheumatologist.

Ultrasonography and detection of subclinical joints and tendons involvements in Systemic Lupus erythematosus (SLE) patients: A cross-sectional multicenter study

OBJECTIVES

The aims of this study in SLE population were (1) to describe ultrasonography (US) joint abnormalities, (2) to estimate the reliability of clinical swollen joint count (C-SJC) and SLEDAI (C-SLEDAI) versus US-SJC and US-SLEDAI scores, (3) to highlight specific patterns of lupus patients with Power Doppler (PD) abnormalities.

METHOD

For this cross-sectional multicenter study, 151 consecutive adult SLE patients were recruited. Evaluation included a clinical standardized joint assessment, B-mode and PD US of 40 joints and 26 tendons blinded for clinical examination. Reliability and agreement between clinical and B-mode US were calculated using the intraclass correlation coefficients (ICC [95% Confidence Interval]).

RESULTS

We found a very high frequency of subclinical US abnormalities in asymptomatic patients: 85% of patients without joint symptoms had at least 1 US abnormality. Among them 46 patients (87%) had a history of joint involvement. The most frequent abnormalities were joint effusmaions (108 patients), synovial hypertrophy (SH, 109 patients) and synovitis (61 patients). Joint or tendon PD signal (grade>1) was found in 44% of patients (67/151). Synovitis were mainly located especially on MCPs and wrists. Even if reliability between clinical and grey-scale US SJC assessments was poor, reliability between clinical and US SLEDAI was good. Comparison between SLE patients with and without PD signal did not show any specific SLE pattern.

CONCLUSION

US may be useful to assess joint involvement in SLE patients but did not significantly change SLEDAI score.