Hormone Replacement Therapy Is Associated with Disease Activity Improvement among Post-Menopausal Women with Inflammatory Bowel Disease

(1) Background: There are limited data available to guide clinical decision-making regarding the effects of hormone replacement therapy (HRT) in post-menopausal women with inflammatory bowel disease (IBD). In this study, we sought to characterize a population of post-menopausal women with IBD and to determine the effects of HRT on their disease activity. (2) Methods: A multicenter, retrospective, case-control cohort study of post-menopausal women with IBD was conducted. The physician global assessment (PGA) score was used to quantify disease activity. To control for the effects of menopause, IBD patients who had not undergone HRT were used as controls. (3) Results: There was a significant reduction in the frequency of PGA scores ≥2 post HRT treatment (p < 0.01). HRT treatment was associated with a 5.6× increase in the odds of post-HRT PGA score improvement compared to controls (OR 5.6; 95% CL 1.6, 19.7) in our univariate logistic regression analysis. (4) Conclusion: Post-menopausal IBD women who underwent HRT therapy showed an improvement in their disease symptoms following HRT compared to post-menopausal women without HRT therapy, who showed no change.

Sarcopenia Is More Prevalent Among Inflammatory Bowel Disease Patients Undergoing Surgery and Predicts Progression to Surgery Among Medically Treated Patients

BACKGROUND

Sarcopenia is common in inflammatory bowel disease (IBD); however, estimates of its prevalence and impact on clinical outcomes are variable. This study sought to compare the prevalence of sarcopenia in IBD patients starting new biologics vs patients undergoing IBD surgeries, and its association with common clinical predictors of nutritional status, adverse events, and clinical outcomes.

METHODS

This was a multicenter retrospective cohort study of IBD patients who had a computed tomography (CT) scan within 6 months prior to new biologic initiation (medical cohort) or IBD surgery (surgery cohort). The lowest sex-specific quartile of the total psoas area index at the L3 level defined sarcopenia. Prevalence and predictors of sarcopenia, performance of common clinical nutritional markers, and association with adverse events and clinical outcomes at 1 year were determined.

RESULTS

A total of 156 patients were included (48% medical cohort, 52% surgery cohort). Sarcopenia was more common in the surgery cohort (32% vs 16%; P < .02). In the medical cohort, sarcopenia predicted need for surgery at 1 year (odds ratio, 4.75; 95% confidence interval, 1.10-20.57; P = .04). Low albumin and body mass index (BMI) were associated with the presence of sarcopenia; however, 24% of sarcopenic patients had both normal BMI and albumin.

CONCLUSIONS

Sarcopenia is more prevalent among IBD patients undergoing surgery and predicts the need for surgery in patients starting new biologic therapy. Low albumin and BMI were similar between cohorts, suggesting a unique role for sarcopenia as a relevant clinical marker of lean muscle mass depletion for surgically and medically treated IBD patients.

Continuing Medical Education Questions: October 2022

Article Title: The ACG Monograph on GI Diseases and Endoscopy in Pregnancy and Postpartum Period.

Boosting corrects a memory B cell defect in SARS-CoV-2 mRNA-vaccinated patients with inflammatory bowel disease

Immunosuppressed patients with inflammatory bowel disease (IBD) generate lower amounts of SARS-CoV-2 spike antibodies after mRNA vaccination than healthy controls. We assessed SARS-CoV-2 spike S1 receptor binding domain–specific (S1-RBD–specific) B lymphocytes to identify the underlying cellular defects. Patients with IBD produced fewer anti–S1-RBD antibody–secreting B cells than controls after the first mRNA vaccination and lower amounts of total and neutralizing antibodies after the second. S1-RBD–specific memory B cells were generated to the same degree in IBD and control groups and were numerically stable for 5 months. However, the memory B cells in patients with IBD had a lower S1-RBD–binding capacity than those in controls, which is indicative of a defect in antibody affinity maturation. Administration of a third shot to patients with IBD elevated serum antibodies and generated memory B cells with a normal antigen-binding capacity. These results show that patients with IBD have defects in the formation of antibody-secreting B cells and affinity-matured memory B cells that are corrected by a third vaccination.

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

Background

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

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

Objectives

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

Methods

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

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

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

Results

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

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

Table 1.

Registered infectious events

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

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

Figure 1.

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

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

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

Conclusion

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

Disclosure of Interests

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

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

Background

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

Objectives

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

Methods

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

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

Results

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

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

Table 1.

Independent predictors of anti-TNF treatment discontinuation

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

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

Conclusion

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

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

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

Figure 1.

Adjusted analysis of treatment survival on TNF inhibitors

Disclosure of Interests

None declared

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

References

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

Disclosure of Interests

None declared

Comparative Safety and Effectiveness of Vedolizumab to Tumor Necrosis Factor Antagonist Therapy for Ulcerative Colitis

BACKGROUND & AIMS

We aimed to compare safety and effectiveness of vedolizumab to tumor necrosis factor (TNF)-antagonist therapy in ulcerative colitis in routine practice.

METHODS

A multicenter, retrospective, observational cohort study (May 2014 to December 2017) of ulcerative colitis patients treated with vedolizumab or TNF-antagonist therapy. Propensity score weighted comparisons for development of serious adverse events and achievement of clinical remission, steroid-free clinical remission, and steroid-free deep remission. A priori determined subgroup comparisons in TNF-antagonist-naïve and -exposed patients, and for vedolizumab against infliximab and subcutaneous TNF-antagonists separately.

RESULTS

A total of 722 (454 vedolizumab, 268 TNF antagonist) patients were included. Vedolizumab-treated patients were more likely to achieve clinical remission (hazard ratio [HR], 1.651; 95% confidence interval [CI], 1.229-2.217), steroid-free clinical remission (HR, 1.828; 95% CI, 1.135-2.944), and steroid-free deep remission (HR, 2.819; 95% CI, 1.496-5.310) than those treated with TNF antagonists. Results were consistent across subgroup analyses in TNF-antagonist-naïve and -exposed patients, and for vedolizumab vs infliximab and vs subcutaneous TNF-antagonist agents separately. Overall, there were no statistically significant differences in the risk of serious adverse events (HR, 0.899; 95% CI, 0.502-1.612) or serious infections (HR, 1.235; 95% CI, 0.608-2.511) between vedolizumab-treated and TNF-antagonist-treated patients. However, in TNF-antagonist-naïve patients, vedolizumab was less likely to be associated with serious adverse events than TNF antagonists (HR, 0.192; 95% CI, 0.049-0.754).

CONCLUSIONS

Treatment of ulcerative colitis with vedolizumab is associated with higher rates of remission than treatment with TNF-antagonist therapy in routine practice, and lower rates of serious adverse events in TNF-antagonist-naïve patients.

A Vanishing Cecal Mass: A Rare Gastrointestinal Manifestation of Systemic Mastocytosis

Systemic mastocytosis (SM) is a heterogeneous disease that often involves the gastrointestinal (GI) tract. Activation and accumulation of mast cells in GI organs can result in symptoms of abdominal pain, nausea and diarrhea along with organ damage with more aggressive disease. Mast cell degranulation can also result in anaphylactic reactions, which can be life-threatening. Recognition of GI manifestations is important for gastroenterologists to aid in diagnosis and management when GI involvement is suspected. Edema, small nodules, urticarial lesions and occasionally ulceration in the small bowel and colon are the most commonly described endoscopic findings. Here we describe a case of SM presenting as a large colonic mass and provide a brief review of the literature on GI involvement of SM.

Modifying Crohn's Colitis Recurrence Through Surgery? The Jury Is Still Out

ABSTRACT

Data suggesting that the mesentery plays an important pathophysiologic role in Crohn's disease and recurrence make the mesentery an attractive therapeutic target during surgical management of Crohn's disease. A new study by Zhu et al. demonstrates that patients with Crohn's colitis who undergo a more extensive mesenteric resection may have a lower rate of needing subsequent operations. We discuss some of the reasons why these data, although much needed by the inflammatory bowel disease community, do not yet sway standard surgical practice for Crohn's colitis.

High-affinity memory B cells induced by SARS-CoV-2 infection produce more plasmablasts and atypical memory B cells than those primed by mRNA vaccines

Although both infections and vaccines induce memory B cell (MBC) populations that participate in secondary immune responses, the MBCs generated in each case can differ. Here, we compare SARS-CoV-2 spike receptor binding domain (S1-RBD)-specific primary MBCs that form in response to infection or a single mRNA vaccination. Both primary MBC populations have similar frequencies in the blood and respond to a second S1-RBD exposure by rapidly producing plasmablasts with an abundant immunoglobulin (Ig)A⁺ subset and secondary MBCs that are mostly IgG⁺ and cross-react with the B.1.351 variant. However, infection-induced primary MBCs have better antigen-binding capacity and generate more plasmablasts and secondary MBCs of the classical and atypical subsets than do vaccine-induced primary MBCs. Our results suggest that infection-induced primary MBCs have undergone more affinity maturation than vaccine-induced primary MBCs and produce more robust secondary responses.

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

Table 1.

Cohort characteristics

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Table 1.

Description of treatment episodes included in the analysis

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

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

Conclusion:

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

Picture 1.

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Table 1.

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

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

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

Results:

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

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

Conclusion:

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

References:

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

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

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

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

Acknowledgements:

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

Table 1.

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

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

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

Disclosure of Interests:

None declared.

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

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

Conclusion:

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

References:

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

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

Acknowledgements:

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

Disclosure of Interests:

None declared.

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

The following predictors of withdrawal risk were identified –

1.The total duration of the disease

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

3.Gender

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

5.The line of biologic treatment

6.The level of education

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

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

Conclusion:

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

Table 1.

Hazard ratio for treatment withdrawal

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

*- withdrawal risk relative to ETA

Figure 1.

Picture 1. Treatment withdrawal risk

Disclosure of Interests:

None declared

Effect of Concomitant Therapy With Steroids and Tumor Necrosis Factor Antagonists for Induction of Remission in Patients With Crohn's Disease: A Systematic Review and Pooled Meta-analysis

BACKGROUND & AIMS

It is not clear whether concomitant therapy with corticosteroids and anti-tumor necrosis factor (TNF) agents is more effective at inducing remission in patients with Crohn's disease (CD) than anti-TNF monotherapy. We aimed to determine whether patients with active CD receiving corticosteroids during induction therapy with anti-TNF agents had higher rates of clinical improvement than patients not receiving corticosteroids during induction therapy.

METHODS

We systematically searched the MEDLINE, Embase, and CENTRAL databases, through January 20, 2016, for randomized trials of anti-TNF agents approved for treatment of CD and identified 14 trials (5 of adalimumab, 5 of certolizumab, and 4 of infliximab). We conducted a pooled meta-analysis of individual patient and aggregated data from these trials. We compared data from participants who continued oral corticosteroids during induction with anti-TNF therapy to those treated with anti-TNF agents alone. The endpoints were clinical remission (CD activity index [CDAI] scores <150) and clinical response (a decrease in CDAI of 100 points) at the end of induction (weeks 4-14 of treatment).

RESULTS

We included 4354 patients who received induction therapy with anti-TNF agents, including 1653 [38.0%] who were receiving corticosteroids. The combination of corticosteroids and an anti-TNF agent induced clinical remission in 32.0% of patients, whereas anti-TNF monotherapy induced clinical remission in 35.5% of patients (odds ratio [OR], 0.93; 95% CI, 0.74-1.17). The combination of corticosteroids and an anti-TNF agent induced a clinical response in 42.7% of patients, whereas anti-TNF monotherapy induced a clinical response in 46.8% (OR 0.84; 95% CI, 0.73-0.96). These findings did not change with adjustment for baseline CDAI scores and concurrent use of immunomodulators.

CONCLUSIONS

Based on a meta-analysis of data from randomized trials of anti-TNF therapies in patients with active CD, patients receiving corticosteroids during induction therapy with anti-TNF agents did not have higher rates of clinical improvement compared with patients not receiving corticosteroids during induction therapy. Given these findings and the risks of corticosteroid use, clinicians should consider early weaning of corticosteroids during induction therapy with anti-TNF agents for patients with corticosteroid-refractory CD.

Development and Validation of Clinical Scoring Tool to Predict Outcomes of Treatment With Vedolizumab in Patients With Ulcerative Colitis

BACKGROUND & AIMS

We created and validated a clinical decision support tool (CDST) to predict outcomes of vedolizumab therapy for ulcerative colitis (UC).

METHODS

We performed logistic regression analyses of data from the GEMINI 1 trial, from 620 patients with UC who received vedolizumab induction and maintenance therapy (derivation cohort), to identify factors associated with corticosteroid-free remission (full Mayo score of 2 or less, no subscore above 1). We used these factors to develop a model to predict outcomes of treatment, which we called the vedolizumab CDST. We evaluated the correlation between exposure and efficacy. We validated the CDST in using data from 199 patients treated with vedolizumab in routine practice in the United States from May 2014 through December 2017.

RESULTS

Absence of exposure to a tumor necrosis factor (TNF) antagonist (+3 points), disease duration of 2 y or more (+3 points), baseline endoscopic activity (moderate vs severe) (+2 points), and baseline albumin concentration (+0.65 points per 1 g/L) were independently associated with corticosteroid-free remission during vedolizumab therapy. Patients in the derivation and validation cohorts were assigned to groups of low (CDST score, 26 points or less), intermediate (CDST score, 27-32 points), or high (CDST score, 33 points or more) probability of vedolizumab response. We observed a statistically significant linear relationship between probability group and efficacy (area under the receiver operating characteristic curve, 0.65), as well as drug exposure (P < .001) in the derivation cohort. In the validation cohort, a cutoff value of 26 points identified patients who did not respond to vedolizumab with high sensitivity (93%); only the low and intermediate probability groups benefited from reducing intervals of vedolizumab administration due to lack of response (P = .02). The vedolizumab CDST did not identify patients with corticosteroid-free remission during TNF antagonist therapy.

CONCLUSIONS

We used data from a trial of patients with UC to develop a scoring system, called the CDST, which identified patients most likely to enter corticosteroid-free remission during vedolizumab therapy, but not anti-TNF therapy. We validated the vedolizumab CDST in a separate cohort of patients in clinical practice. The CDST identified patients most likely to benefited from reducing intervals of vedolizumab administration due to lack of initial response. ClinicalTrials.gov no: NCT00783718.

Comparative safety and effectiveness of vedolizumab to tumour necrosis factor antagonist therapy for Crohn's disease

BACKGROUND

Direct comparisons are lacking between vedolizumab and tumour necrosis factor (TNF)-antagonist therapy in Crohn's disease (CD).

AIM

To compare safety and effectiveness of vedolizumab and TNF-antagonist therapy in adult CD patients.

METHODS

Retrospective observational cohort (May 2014-December 2017) propensity score-weighted comparison of vedolizumab vs TNF-antagonist therapy (infliximab, adalimumab, certolizumab) in CD. Propensity scores were weighted for age, prior treatments, disease complications, extent and severity, steroid dependence, and concomitant immunosuppressive drug use. The primary outcome was comparative risk for infections or non-infectious serious adverse events (requiring antibiotics, antivirals, antifungals, hospitalisation, or treatment discontinuation, or resulting in death). Secondary comparative effectiveness outcomes were clinical remission (resolution of CD-related symptoms), steroid-free clinical remission and endoscopic remission (absence of ulcers/erosions).

RESULTS

We included 1266 patients (n = 659 vedolizumab). Rates of non-infectious serious adverse events (odds ratio [OR] 0.072, 95% confidence interval [CI] 0.012-0.242), but not serious infections (OR 1.183, 95% CI 0.786-1.795), were significantly lower with vedolizumab vs TNF-antagonist therapy. Safety comparisons for non-infectious serious adverse events remained significant after adjusting for differences in duration of exposure. No significant difference was observed between vedolizumab and TNF-antagonist therapy for clinical remission (hazard ratio [HR] 0.932, 95% CI 0.707-1.228), steroid-free clinical remission (HR 1.250, 95% CI 0.677-2.310) or endoscopic remission (HR 0.827, 95% CI 0.595-1.151). TNF-antagonist therapy was associated with higher treatment persistence compared with vedolizumab.

CONCLUSIONS

There was a lower risk of non-infectious serious adverse events, but not serious infections, with vedolizumab vs TNF-antagonist therapy, with no significant difference for achieving disease remission.

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Table 1.

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

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

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

Figure 1.

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

Figure 2.

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

Table 2.

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

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

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

Conclusion:

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

Acknowledgments :

Pfizer

Disclosure of Interests: :

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

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Table 1.

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

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

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

Conclusion:

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

References:

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

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

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

Disclosure of Interests:

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

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

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

Conclusion:

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

Disclosure of Interests:

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

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

Background:

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

Objectives:

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

Methods:

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

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

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

Results:

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

Table.

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

Conclusion:

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

Disclosure of Interests:

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

Use of Exclusive Enteral Formula Diet as Adjunctive Therapy for Treatment of a Crohn's Disease Flare

Introduction

We report the case of an adult patient who achieved remission of a Crohn's disease flare after treatment with exclusive enteral nutrition as adjunctive therapy to medication.

Case Report

A 46-year-old man with severe, stricturing Crohn's presented for severe abdominal pain and weight loss; estimated Crohn's Disease Activity Index score greater than 300. Antibiotics, vedolizumab, budesonide, and exclusive enteral nutrition diet were instituted. Approximately 30 days later, his Crohn's Disease Activity Index score improved to 170.

Discussion

This case illustrates the possible utility of an exclusive enteral formula diet as an adjunct to medication to induce remission of a Crohn's disease flare.

Shorter Disease Duration Is Associated With Higher Rates of Response to Vedolizumab in Patients With Crohn's Disease But Not Ulcerative Colitis

BACKGROUND & AIMS

Patients with Crohn's disease (CD), but not ulcerative colitis (UC), of shorter duration have higher rates of response to tumor necrosis factor (TNF) antagonists than patients with longer disease duration. Little is known about the association between disease duration and response to other biologic agents. We aimed to evaluate response of patients with CD or UC to vedolizumab, stratified by disease duration.

METHODS

We analyzed data from a retrospective, multicenter, consortium of patients with CD (n = 650) or UC (n = 437) treated with vedolizumab from May 2014 through December 2016. Using time to event analyses, we compared rates of clinical remission, corticosteroid-free remission (CSFR), and endoscopic remission between patients with early-stage (≤2 years duration) and later-stage (>2 years) CD or UC. We used Cox proportional hazards models to identify factors associated with outcomes.

RESULTS

Within 6 months initiation of treatment with vedolizumab, significantly higher proportions of patients with early-stage CD, vs later-stage CD, achieved clinical remission (38% vs 23%), CSFR (43% vs 14%), and endoscopic remission (29% vs 13%) (P < .05 for all comparisons). After adjusting for disease-related factors including previous exposure to TNF antagonists, patients with early-stage CD were significantly more likely than patients with later-stage CD to achieve clinical remission (adjusted hazard ratio [aHR], 1.59; 95% CI, 1.02-2.49), CSFR (aHR, 3.39; 95% CI, 1.66-6.92), and endoscopic remission (aHR, 1.90; 95% CI, 1.06-3.39). In contrast, disease duration was not a significant predictor of response among patients with UC.

CONCLUSIONS

Patients with CD for 2 years or less are significantly more likely to achieve a complete response, CSFR, or endoscopic response to vedolizumab than patients with longer disease duration. Disease duration does not associate with response vedolizumab in patients with UC.

Changes in Vedolizumab Utilization Across US Academic Centers and Community Practice Are Associated With Improved Effectiveness and Disease Outcomes

BACKGROUND

Vedolizumab effectiveness estimates immediately after Food and Drug Administration (FDA) approval for ulcerative colitis (UC) and Crohn's disease (CD) are limited by use in refractory populations. We aimed to compare treatment patterns and outcomes of vedolizumab in 2 time frames after FDA approval.

METHODS

We used 2 data sets for time trend analysis, an academic multicenter vedolizumab consortium (VICTORY) and the Truven MarketScan database, and 2 time periods, May 2014-June 2015 (Era 1) and July 2015-June 2017 (Era 2). VICTORY cumulative 12-month clinical remission, corticosteroid-free remission, and mucosal healing rates, and Truven 12-month hospitalization and surgery rates, were compared between Eras 1 and 2 using time-to-event analyses.

RESULTS

A total of 3661 vedolizumab-treated patients were included (n = 1087 VICTORY, n = 2574 Truven). In both cohorts, CD and UC patients treated during Era 2 were more likely to be biologic naïve. Compared with Era 1, Era 2 CD patients in the VICTORY consortium had higher rates of clinical remission (31% vs 40%, P = 0.03) and mucosal healing (42% vs 58%, P < 0.01). These trends were not observed for UC. In the Truven database, UC patients treated during Era 2 had lower rates of inflammatory bowel disease-related hospitalization (22.4% vs 9.6%, P < 0.001) and surgery (17.2% vs 9.4%, P = 0.008), which was not observed for CD.

CONCLUSION

Since FDA approval, remission and mucosal healing rates have increased for vedolizumab-treated CD patients, and vedolizumab-treated UC patients have had fewer hospitalizations and surgeries. This is likely due to differences between patient populations treated immediately after drug approval and those treated later.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Retrospective Analysis of Safety of Vedolizumab in Patients With Inflammatory Bowel Diseases

BACKGROUND & AIMS

There are few real-world data on the safety of vedolizumab for treatment of Crohn's disease (CD) or ulcerative colitis (UC). We quantified rates and identified factors significantly associated with infectious and non-infectious adverse events in clinical practice.

METHODS

We performed a retrospective review of data from a multicenter consortium database (from May 2014 through June 2017). Infectious and non-infectious adverse events were defined as those requiring antibiotics, hospitalization, vedolizumab discontinuation, or resulting in death. Rates were quantified as proportions and events per 100 patient years of exposure (PYE) or follow up (PYF). We performed multivariable logistic regression analyses to identify factors significantly associated with events and reported as odds ratios (OR) with 95% CIs.

RESULTS

Our analysis comprised 1087 patients (650 with CD and 437 with UC; 55% female; median age, 37 years) with 861 PYE and 955 PYF. Infections were observed in 68 patients (6.3%; 7.9 per 100 PYE, 7.1 per 100 PYF); gastrointestinal infections (n = 31, 2.4 per 100 PYE, 2.2 per 100 PYF) and respiratory infections (n = 14, 1.6 per 100 PYE, 1.5 per 100 PYF) were the most common. Arthralgias were the most common non-infectious adverse events (n = 31, 2.9%; 3.6 per 100 PYE). Two patients developed malignancies (squamous cell skin cancer and colorectal cancer; 0.23 per 100 PYE, 0.21 per 100 PYF). Active smoker status (OR, 3.39) and number of concomitant immunosuppressive agents (corticosteroids or immunomodulators; OR, 1.72 per agent) used were independently associated with infections.

CONCLUSION

In a retrospective cohort study of patients with IBD, we found vedolizumab to be well tolerated with an overall favorable safety profile. Active smoking and concomitant use of immunosuppressive agents were independently associated with infections.

A Longitudinal Study of Sexual Function in Women With Newly Diagnosed Inflammatory Bowel Disease

BACKGROUND

The literature provides conflicting data on sexual function in women with inflammatory bowel disease (IBD). We aim to describe sexual function at baseline and over time in a prospective inception cohort of adult women with IBD.

METHODS

Women age 18 years or older enrolled in the Ocean State Crohn's & Colitis Area Registry (OSCCAR) with 2 years of prospective follow-up were included in the study. All subjects were enrolled within 1 year of IBD diagnosis. Female sexual function was assessed using the Female Sexual Function Index (FSFI). Linear mixed effects models were used to assess changes in FSFI by various demographic and clinical factors.

RESULTS

One hundred sixteen of 130 eligible women (89%) were included in the study. Ninety-seven percent of women had sexual dysfunction, defined as an FSFI score of <26.55, with a baseline mean FSFI score (SD) of 16.4 (8.4) overall (15.5 [8.6] in Crohn's disease, 17.4 [8.1] in UC, P = 0.22). Despite improvement in overall disease activity, there was no significant change in the FSFI score or individual domain scores over the entire 2-year study period. Among all women with IBD, older age, nonsingle marital status, lower Short Form Health Survey (SF-36) Physical Component Summary score, and the use of biologics were independent risk factors for sexual dysfunction.

CONCLUSIONS

Almost all women experienced sexual dysfunction that did not improve over time despite improvement in overall disease activity. Future studies are warranted to identify underlying mechanisms that explain the associations between demographic and clinical factors and sexual dysfunction among newly diagnosed women.

Predictors and Management of Loss of Response to Vedolizumab in Inflammatory Bowel Disease

BACKGROUND

We quantified loss of response (LOR) to vedolizumab (VDZ) in clinical practice and assessed the effectiveness of VDZ dose intensification for managing LOR.

METHODS

Retrospective review (May 2014-December 2016) of a prospectively maintained inflammatory bowel disease (IBD) registry. Kaplan-Meier estimates were used to determine rates of LOR to VDZ . Independent predictors of LOR were identified using univariate and multivariable Cox proportional hazard regression. Success of recapturing response (>50% reduction in symptoms from baseline) and remission (complete resolution of symptoms) after dose intensification was quantified.

RESULTS

Cumulative rates for VDZ LOR were 20% at 6 months and 35% at 12 months, with slightly lower rates in Crohn's disease than in ulcerative colitis (6 months 15% vs 18% and 12 months 30% vs 39%, P = 0.03). On multivariable analysis, LOR to a tumor necrosis factor (TNF) antagonist before VDZ use was associated with an increased risk for LOR to VDZ [hazard ratio (HR) 1.93; 95% confidence interval (CI) 1.25-2.97] in all patients. For Crohn's disease patients specifically, higher baseline C-reactive protein concentration was associated with increased risk for LOR to VDZ (HR 1.01 per mg/dL increase, 95% CI 1.01-1.02). Shortening of VDZ infusion interval from 8 to every 4 or 6 weeks recaptured response in 49% and remission in 18% of patients.

CONCLUSIONS

LOR to a TNF antagonist before VDZ use and higher baseline C-reactive protein are important predictors of VDZ LOR. Treatment response can be recaptured in almost half of these patients with VDZ infusion interval shortening.

Vedolizumab for Ulcerative Colitis: Treatment Outcomes from the VICTORY Consortium

OBJECTIVES

We aimed to quantify the safety and effectiveness of vedolizumab (VDZ) when used for UC, and to identify predictors of response to treatment.

METHODS

Retrospective review (May 2014-December 2016) of VICTORY Consortium data. Adults with follow-up after starting VDZ for clinically active UC were included. Primary effectiveness outcomes were cumulative rates of clinical remission (resolution of all UC-related symptoms) and endoscopic remission (Mayo endoscopic sub-score 0). Key secondary effectiveness outcomes included cumulative rates of corticosteroid-free remission and deep remission (clinical remission and endoscopic remission). Cox proportional hazard analyses were used to identify independent predictors of treatment effectiveness. Non-response imputation (NRI) sensitivity analyses were performed for effectiveness outcomes. Key safety outcomes were rates of serious infection, serious adverse events, and colectomy.

RESULTS

We included 321 UC patients (71% prior TNFα antagonist exposure, median follow-up 10 months). The 12-month cumulative rates of clinical remission and endoscopic remission were 51% and 41%, respectively. Corresponding rates for corticosteroid-free remission and deep remission were 37% and 30%, respectively. Using NRI, 12-month rates were 20% (n = 64/321) for clinical remission, 17% (n = 35/203) for endoscopic remission, 15% (n = 30/195) for corticosteroid-free remission, and 14% (n = 28/203) for deep remission. A majority of the patients without adequate follow-up at 12 months who were deemed non-responders using NRI had already achieved clinical remission (n = 70) or a significant clinical response (n = 36) prior to 12 months. VDZ discontinuation prior to 12 months was observed in 91 patients, for lack of response (n = 56), need for surgery (n = 29), or adverse event (n = 6). On multivariable analyses, prior exposure to a TNFα antagonist was associated with a reduced probability of achieving clinical remission (HR 0.53, 95% CI 0.38-0.75) and endoscopic remission (HR 0.51, 95% CI 0.29-0.88). Serious adverse events and serious infections were reported in 6% and 4% of patients, respectively. Overall cumulative rates of colectomy over 12 months were 13%, with lower rates observed in patients naive to TNFα antagonist therapy (2%) than those who had been exposed to TNFα antagonists (19%).

CONCLUSION

In this large real-world cohort we observed that VDZ was well tolerated and effective in achieving key clinical outcomes.

Development and Validation of a Scoring System to Predict Outcomes of Vedolizumab Treatment in Patients With Crohn's Disease

BACKGROUND & AIMS

As more treatment options for inflammatory bowel diseases become available, it is important to identify patients most likely to respond to different therapies. We created and validated a scoring system to identify patients with Crohn's disease (CD) who respond to vedolizumab.

METHODS

We collected data from the GEMINI 2 phase 3 trial of patients with active CD treated with vedolizumab for 26 weeks (n = 814) and performed logistic regression analysis to identify factors associated with clinical, steroid-free, and durable remission (derivation set). We used these data to develop a clinical decision support tool, which we validated using data from 366 participants in a separate clinical practice observational cohort of patients with active CD treated with vedolizumab for 26 weeks (the VICTORY cohort). We evaluated the ability of this tool to identify patients in clinical remission or corticosteroid-free remission, or those with mucosal healing (MH), clinical remission with MH, or corticosteroid-free remission with MH after vedolizumab therapy using receiver operating characteristic area under the curve (AUC) analyses. The primary outcome was to develop and validate a list of factors associated with achieving remission by vedolizumab in patients with active CD.

RESULTS

In the derivation analysis, we identified absence of previous treatment with a tumor necrosis factor antagonist (+3 points), absence of prior bowel surgery (+2 points), absence of prior fistulizing disease (+2 points), baseline level of albumin (+0.4 points per g/L), and baseline concentration of C-reactive protein (reduction of 0.5 points for values between 3.0 and 10.0 mg/L and 3.0 points for values >10.0 mg/L) as factors associated with remission. In the validation set, our model identified patients in clinical remission with an AUC of 0.67, patients in corticosteroid-free remission with an AUC of 0.66, patients with MH with an AUC of 0.72, patients in clinical remission with MH with an AUC of 0.73, and patients in corticosteroid-free clinical remission with MH with an AUC of 0.75. A cutoff value of 13 points identified patients in clinical remission after vedolizumab therapy with 92% sensitivity, patients in corticosteroid-free remission with 94% sensitivity, patients with MH with 98% sensitivity, patients with clinical remission and MH with 100% sensitivity, and patients with corticosteroid-free clinical remission with MH with 100% sensitivity.

CONCLUSIONS

We developed and validated a scoring system to identify patients with CD most likely to respond to 26 weeks of vedolizumab therapy. Further studies are needed to optimize its accuracy in select populations and determine its cost-effectiveness.

Clinical significance of incidental [18 F]FDG uptake in the gastrointestinal tract on PET/CT imaging: a retrospective cohort study

Background

The frequency and clinically important characteristics of incidental (18)F-fluorodeoxyglucose ([18 F]FDG) positron emission tomography (PET) uptake in the gastrointestinal tract (GIT) on PET/CT imaging in adults remain elusive.

Methods

All PET/CT reports from 1/1/2000 to 12/31/2009 at a single tertiary referral center were reviewed; clinical information was obtained from cases with incidental (18)F-FDG uptake in the GIT, with follow-up through October, 2012.

Results

Of the 41,538 PET/CT scans performed during the study period, 303 (0.7 %) had incidental GIT uptake. The most common indication for the PET/CT order was cancer staging (226 cases, 75 %), with 74 % for solid and 26 % for hematologic malignancies. Of those with solid malignancy, only 51 (17 %) had known metastatic disease. The most common site of GIT uptake was the colon, and of the 240 cases with colonic uptake, the most common areas of uptake were cecum (n = 65), sigmoid (n = 60), and ascending colon (n = 50). Investigations were pursued for the GIT uptake in 147 cases (49 %), whereas 51 % did not undergo additional studies, largely due to advanced disease. There were 73 premalignant colonic lesions diagnosed in 56 cases (tubular adenoma, n = 36; tubulovillous adenoma with low grade dysplasia, n = 27; sessile serrated adenoma, n = 4; tubulovillous adenoma with high grade dysplasia, n = 3; villous adenoma, n = 3), and 20 cases with newly diagnosed primary colon cancer. All 20 (100 %) patients with malignant colonic lesions had a focal pattern of [18 F]FDG uptake. Among cases with a known pattern of [18 F]FDG uptake, 98 % of those with premalignant lesions had focal [18 F]FDG uptake. Eighteen (90 %) of the cases with newly diagnosed colon cancer were not known to have metastatic disease of their primary tumor. Areas of incidental uptake in the ascending colon had the greatest chance (42 %) of being malignant and premalignant lesions than in any other area.

Conclusion

Focality of uptake is highly sensitive for malignant and premalignant lesions of the GIT. In patients without metastatic disease, incidental focal [18]FDG uptake in the GIT on PET/CT imaging warrants further evaluation.

The Real-World Effectiveness and Safety of Vedolizumab for Moderate-Severe Crohn's Disease: Results From the US VICTORY Consortium

OBJECTIVES

We assessed the real-world effectiveness and safety of vedolizumab (VDZ) in moderate-severe Crohn's disease (CD).

METHODS

Retrospective cohort study of seven medical centers, from May 2014 to December 2015. Adults with moderate-severe CD treated with VDZ, with follow-up after initiation of therapy, were included. Using the multivariable Cox proportional hazard analyses, we identified independent predictors of clinical remission or mucosal healing with VDZ. Rates of serious infection (requiring antibiotics, resulting in discontinuation of VDZ, hospitalization or death) and serious adverse events (discontinuation of VDZ, hospitalization or death) were described quantitatively.

RESULTS

We included 212 patients with moderate-severe CD (median age 34 years; 40% male; 90% tumor necrosis factor (TNF)-antagonist exposed) with a median follow-up (IQR) of 39 weeks (25-53). Twelve-month cumulative rates of clinical remission, mucosal healing, and deep remission (clinical remission+mucosal healing) were 35%, 63%, and 26%, respectively. Individuals with prior TNF-antagonist exposure (hazard ratio (HR) 0.40; 95% confidence interval (CI): 0.20-0.81), smoking history (HR 0.47; 95% CI: 0.25-0.89), active perianal disease (HR 0.49; 95% CI: 0.27-0.88), and severe disease activity (HR 0.54; 95% CI: 0.31-0.95) were less likely to achieve clinical remission. Those with prior TNF-antagonist exposure (HR 0.29; 95% CI: 0.12-0.73), and severe disease activity (HR 0.54; 95% CI: 0.31-0.95) were less likely to achieve mucosal healing. During 160 patient years of follow-up (PYF) and 1,433 VDZ infusions, 5 patients developed infusion reactions (3.5 per 1,000 infusions), 21 developed serious infections (13 per 100 PYF), and 17 developed serious adverse events (10 per 100 PYF). A minority of adverse events required discontinuation of therapy (6 per 100 PYF).

CONCLUSIONS

VDZ is a safe and effective treatment option for moderate-severe CD in routine practice. Clinical remission and deep remission (clinical remission and mucosal healing) can be achieved in 1/3 of individuals, and a minority of individuals require discontinuation of therapy due to adverse events.

Normal villous architecture with increased intraepithelial lymphocytes: a duodenal manifestation of Crohn disease

OBJECTIVES

To assess a possible association between inflammatory bowel disease (IBD) and the histologic finding in duodenal biopsy specimens of increased intraepithelial lymphocytes (IELs) with normal villous architecture.

METHODS

We identified all patients with duodenal biopsy specimens obtained between 2000 and 2010 showing increased IELs and normal architecture. Among the 74 such patients who also had IBD, we characterized the clinical features of IBD and reviewed all available upper gastrointestinal biopsy specimens.

RESULTS

Fifty-eight patients had Crohn disease, 13 had ulcerative colitis, and three had IBD, type unclassified. No duodenal sample with increased IELs had other histologic features of IBD. Among gastric biopsy specimens from 34 patients with Crohn disease, nearly half (16) had focal gastritis.

CONCLUSIONS

We propose that Crohn disease be included in the differential diagnosis for increased IELs with normal villous architecture in duodenal biopsy specimens, particularly when gastric biopsy specimens show focal gastritis.

Increasing duodenal intraepithelial lymphocytosis found at upper endoscopy: time trends and associations

BACKGROUND

Increased intraepithelial lymphocytosis (IEL) with preserved villous architecture is a common yet nonspecific finding on duodenal biopsies.

OBJECTIVE

To study the change in frequency of isolated IEL on duodenal biopsy over time and determine whether previously reported disease associations have changed during that period.

DESIGN

Retrospective study.

SETTING

Single tertiary-care referral center.

PATIENTS

Adults with a duodenal biopsy that showed normal villi and increased number of intraepithelial lymphocytes.

INTERVENTION

Duodenal biopsy. Comprehensive electronic medical record search from January 1, 2000 through December 31, 2010.

MAIN OUTCOME MEASUREMENTS

Demographic and clinical information.

RESULTS

Of the 15,839 duodenal biopsies performed during the study period, 1105 (7.0%) had the histologic finding of interest. The odds of finding newly diagnosed celiac disease (CD) decreased by 0.9 on average during each year, whereas the odds of finding a non-celiac association increased by 1.12 times each year. Isolated increased IEL attributed to nonsteroidal anti-inflammatory drug (NSAID) use and small-intestine bacterial overgrowth (SIBO) increased by 1.06 and 1.3 times, respectively, for each year on average.

LIMITATIONS

Retrospective design, single center.

CONCLUSION

During the years 2000 through 2010, there has been an increased frequency with which duodenal biopsies were noted to have isolated increased IEL. The odds of a diagnosis of CD accounting for this finding have been decreasing, whereas the odds of NSAID use and SIBO have been increasing. Although the finding of isolated increased IEL on duodenal biopsy warrants work-up for CD in all patients, further investigation for other possible causes, including NSAID use and SIBO, should be considered as well.

Net-like pattern of calcification on plain soft-tissue radiographs in patients with calciphylaxis

BACKGROUND

Calciphylaxis is a rare, life-threatening syndrome marked by vascular calcification and cutaneous necrosis. The role of radiographic imaging in assisting in diagnosis has not been established.

OBJECTIVE

To investigate the potential role of plain radiographic imaging in the diagnosis of calciphylaxis.

METHODS

We searched for cases of patients at our tertiary referral center with a diagnosis of calciphylaxis between Jan 1, 1996, and Dec 31, 2010. Two control patients receiving dialysis but without calciphylaxis were age- and sex-matched to each study patient. Plain radiographs were obtained from the date closest to diagnosis in patients with calciphylaxis and from matched controls at approximately the same dates. Two radiologists, masked as to cases and controls, read each image together. Size of calcified vessels, pattern and extent of calcifications, presence of net-like or other calcifications, and bone density/mineralization were recorded and analyzed.

RESULTS

Twenty-nine patients with calciphylaxis (mean age, 57 years; 21 [72%] women) were identified. Mean age at diagnosis was 57 years (range, 36-75 years). Compared with those of controls, plain radiographs of patients with calciphylaxis had more vascular calcifications, more small-vessel calcifications, and a netlike pattern of calcifications. A netlike pattern of calcifications had considerable strength of association with calciphylaxis (odds ratio, 9.4) and a specificity of nearly 90%. These findings were preserved even if only one image was used per patient.

LIMITATIONS

This was a retrospective study.

CONCLUSION

A netlike pattern of calcifications on plain radiographs was more common in patients with calciphylaxis and may aid in diagnosis.

Psoriasis and palmoplantar pustulosis associated with tumor necrosis factor-α inhibitors: the Mayo Clinic experience, 1998 to 2010

BACKGROUND

Tumor necrosis factor (TNF)-α antagonists have been associated with the induction of de novo or worsening psoriasis.

OBJECTIVE

We sought to retrospectively examine the clinical characteristics and outcomes of patients with psoriasis associated with anti-TNF-α therapy.

METHODS

We performed a retrospective review of patients with new-onset or worsening psoriasis during TNF-α inhibitor therapy between 1998 and 2010.

RESULTS

Of the 56 patients (mean age at psoriasis onset, 48.1 years), 41 (73%) were female. In all, 22 patients (39%) had Crohn's disease and 14 (25%) had rheumatoid arthritis. Thirty patients (54%) were treated with infliximab, 19 (34%) with adalimumab, and 7 (12%) with etanercept. New-onset or worsening psoriasis occurred after a mean treatment duration of 17.1 months. Plaque psoriasis (n = 27), palmoplantar pustulosis (n = 25), scalp psoriasis (n = 12), generalized pustular psoriasis (n = 7), erythrodermic psoriasis (n = 2), and inverse psoriasis (n = 2) were the cutaneous presentations. Among the 39 patients for whom full treatment response data were available, 33 (85%) had a complete or partial response; combined response rates (complete and partial) were slightly higher among those who discontinued anti-TNF-α therapy (16 of 17 patients [94%]) than among those who continued anti-TNF-α therapy (17 of 22 patients [77%]).

LIMITATIONS

Retrospective nature, possible referral bias, and lack of complete follow-up for some patients are limitations.

CONCLUSION

Although some patients sufficiently controlled their psoriasis while continuing anti-TNF-α therapy, those who discontinued therapy achieved higher rates of complete response. Further studies should explore the efficacy and safety of switching to an alternative anti-TNF-α agent.

The liver in celiac disease: clinical manifestations, histologic features, and response to gluten-free diet in 30 patients

Descriptive reports of liver histologic features in celiac disease (CD) are sparse, and the effect of a gluten-free diet (GFD) on the course of liver injury is poorly understood. We reviewed liver biopsy specimens in 30 patients with CD and performed immunostains for IgG, IgG4, IgM, and IgA. Subsequent liver biochemical tests and compliance with the GFD were recorded. Of the patients, 19 had autoimmune-mediated liver disease (AILD; autoimmune hepatitis, 9; primary sclerosing cholangitis, 7; and primary biliary cirrhosis, 3). The remaining 11 patients had cryptogenic hepatitis (5), hepatitis C (2), steatohepatitis (2), sarcoidosis (1), and T-cell lymphoma (1). The liver disease diagnosis preceded the CD diagnosis in all groups except steatohepatitis. Although 82% of patients without AILD had symptomatic CD, only 26% of patients with AILD had such symptoms. The pathology of the specific liver disease was not atypical in histologic features or IgG/IgM ratios. While GFD improved cryptogenic hepatitis, it did not seem to affect AILD. We propose that AILD and cryptogenic hepatitis in patients with CD represent distinct clinical, histologic, and immunohistochemical entities rather than 2 ends of a spectrum of liver injury.