Practice pattern for the use of intravenous iloprost for the treatment of peripheral vasculopathy in systemic sclerosis: A case-control study from the Italian national multicenter "SPRING" (Systemic Sclerosis Progression InvestiGation) Registry

Background

Intravenous iloprost has been widely used for the treatment of systemic sclerosis peripheral vasculopathy. No agreement has been found on the regimen and the dosage of intravenous iloprost in different scleroderma subset conditions. This study aimed to evaluate the modalities of intravenous iloprost administration within a large cohort of systemic sclerosis patients from the SPRING Registry and to identify any associated clinical-demographic, instrumental or therapeutic data.

Patients and Methods

Data of systemic sclerosis patients treated with intravenous iloprost for at least 1 year (case group) were retrospectively analyzed, including different timing and duration of intravenous iloprost session, and compared with those of untreated patients (control group).

Results

Out of 1895 analyzed patients, 937 (49%) received intravenous iloprost treatment, while 958 (51%) were assigned to the control group. Among cases, about 70% were treated every 4 weeks, 24% with an interval of more than 4 weeks, and only 6% of less than 4 weeks. Most patients receiving the treatment every 4 weeks, or less, underwent infusion cycle for 1 day only, while if it was scheduled with an interval of more than 4 weeks, a total number of 5 consecutive days of infusions was the preferred regimen. The comparison between the two groups revealed that patients treated with intravenous iloprost had a higher frequency of DUs (p < 0.001), pitting scars (p < 0.001), diffuse cutaneous involvement (p < 0.001), interstitial lung disease (p < 0.002), as well as higher rates of anti-topoisomerase I, "late" scleroderma pattern at nailfold videocapillaroscopy. These findings were confirmed by multivariate analysis.

Conclusion

Our data provide a picture on the Italian use of intravenous iloprost among systemic sclerosis patients and showed that it was usually employed in patients with a more aggressive spectrum of the disease. The disparity of intravenous iloprost treatment strategies in the different centers suggests the need of a rational therapeutical approach based on the clinical characteristics of different patients' subsets.

Does the Impact of COVID-19 on Patients With Systemic Sclerosis Change Over Time?

OBJECTIVE

The outcome of patients with COVID-19 improved over the pandemic, including patients with systemic rheumatic diseases. However, data on patients with systemic sclerosis (SSc) are lacking. This study aimed to assess the outcome of patients with both SSc and COVID-19 over several waves.

METHODS

Patients with both SSc and COVID-19 who were registered in the European Scleroderma Trials and Research group (EUSTAR) were collected between April 2020 and April 2021. Patients were assigned to waves 1, 2, or 3 depending on the date of their COVID-19 diagnosis. Primary endpoints were death, intensive care unit stay, or ventilatory support (severe outcome). Subgroup analyses of patients who were hospitalized or died were conducted. General and SSc-specific characteristics and treatment were compared over the waves. Descriptive statistics and multivariate logistic regression were applied.

RESULTS

A total of 333 patients were included; 57 patients (17%) had a severe outcome, and 30 patients (9%) died. Compared to wave 1, significantly fewer patients with SSc suffered from severe COVID-19 in waves 2 and 3 (28.2% vs 9.8% and 12.7%; P < 0.001), fewer patients required hospitalization (46.7% vs 19.6% and 25.5%; P < 0.001) or ventilatory support (24.0% vs 8.7% and 10.9%; P = 0.001), and fewer patients died (15.7% vs 5.0% and 7.5%; P = 0.011). Patients were significantly younger, more often men, had less frequent arterial hypertension, and less SSc cardiac involvement over waves 1 to 3. Patients received significantly less medium to high doses of corticosteroids as they did SSc treatment.

CONCLUSION

The outcome of patients with both SSc and COVID-19 improved significantly over time because of intrinsic and extrinsic factors.

Janus kinase inhibitors: between prescription authorization and reimbursability

Following the restrictions on the reimbursability of Janus kinase inhibitors introduced by the Italian Medicines Agency, the Italian Society of Rheumatology has drafted this document to shed light on the clinical conditions and reimbursability criteria set out in the prescription forms.

Plasma pentraxin 3 in idiopathic inflammatory myopathies: a possible new biomarker of disease activity

Pentraxin-3 (PTX3) is a component of humoral innate immunity with essential functions both in promotion and resolution of inflammation. We aimed to study the PTX3 in the plasma and in the muscle of patients with idiopathic inflammatory myopathies (IIM) and whether PTX3 may correlate with disease activity. Plasma PTX3 levels were assessed in 20 patients with IIMs, 10 dermatomyositis (DM), and 10 polymyositis (PM), compared to 10 patients with rheumatoid arthritis (RA) and 10 healthy donors (HDs) aged, sex, and body mass index matched. Disease activity in IIMs was assessed by Myositis Disease Activity Assessment Visual Analog Scale (MYOACT), while disease activity score on 28 joints (DAS28) was used for RA patients. Muscle histopathology and immunohistochemical (IHC) analyses were also performed. Mean plasma PTX3 levels were significantly higher in IIM patients than HDs (518 ± 260 pg/ml vs. 275 ± 114 pg/ml, P = 0.009). Linear regression analysis adjusted for age, sex, and disease duration showed a direct correlation between PTX3 and CPK levels (β: 0.590), MYOACT (β: 0.759), and physician global assessment of disease activity (β: 0.832) in IIMs. No association between PTX3 levels and DAS28 was found in RA. Global PTX3 pixel fraction was higher in IIM than HDs muscle, but a lower PTX3 expression was found in perifascicular areas of DM and in myofibers with sarcolemmal staining for membrane attack complement. PTX3 plasma levels were increased in IIMs and correlated with disease activity suggesting a possible role as biomarker of disease activity. PTX3 showed a different distribution in DM or PM muscle.

Impact of COVID-19 and vaccination campaign on 1,755 systemic sclerosis patients during first three years of pandemic. Possible risks for individuals with impaired immunoreactivity to vaccine, ongoing immunomodulating treatments, and disease-related lung involvement during the next pandemic phase

Introduction

The impact of COVID-19 pandemic represents a serious challenge for 'frail' patients' populations with inflammatory autoimmune systemic diseases such as systemic sclerosis (SSc). We investigated the prevalence and severity of COVID-19, as well the effects of COVID-19 vaccination campaign in a large series of SSc patients followed for the entire period (first 38 months) of pandemic.

Patients and method

This prospective survey study included 1755 unselected SSc patients (186 M, 1,569F; mean age 58.7 ± 13.4SD years, mean disease duration 8.8 ± 7.3SD years) recruited in part by telephone survey at 37 referral centers from February 2020 to April 2023. The following parameters were carefully evaluated: i. demographic, clinical, serological, and therapeutical features; ii. prevalence and severity of COVID-19; and iii. safety, immunogenicity, and efficacy of COVID-19 vaccines.

Results

The prevalence of COVID-19 recorded during the whole pandemic was significantly higher compared to Italian general population (47.3 % vs 43.3 %, p < 0.000), as well the COVID-19-related mortality (1.91 % vs 0.72 %, p < 0.001). As regards the putative prognostic factors of worse outcome, COVID-19 positive patients with SSc-related interstitial lung involvement showed significantly higher percentage of COVID-19-related hospitalization compared to those without (5.85 % vs 1.73 %; p < 0.0001), as well as of mortality rate (2.01 % vs 0.4 %; p = 0.002). Over half of patients (56.3 %) received the first two plus one booster dose of vaccine; while a fourth dose was administered to 35.6 %, and only few of them (1.99 %) had five or more doses of vaccine. Of note, an impaired seroconversion was recorded in 25.6 % of individuals after the first 2 doses of vaccine, and in 8.4 % of patients also after the booster dose. Furthermore, the absence of T-cell immunoreactivity was observed in 3/7 patients tested by QuantiFERON® SARSCoV-2 Starter Set (Qiagen). The efficacy of vaccines, evaluated by comparing the COVID-19-related death rate recorded during pre- and post-vaccination pandemic periods, revealed a quite stable outcome in SSc patients (death rate from 2.54 % to 1.76 %; p = ns), despite the significant drop of mortality observed in the Italian general population (from 2.95 % to 0.29 %; p < 0.0001).

Conclusions

An increased COVID-19 prevalence and mortality rate was recorded in SSc patients; moreover, the efficacy of vaccines in term of improved outcomes was less evident in SSc compared to Italian general population. This discrepancy might be explained by concomitant adverse prognostic factors: increased rate of non-responders to vaccine in SSc series, low percentage of individuals with four or more doses of vaccine, ongoing immunomodulating treatments, disease-related interstitial lung disease, and/or reduced preventive measures in the second half of pandemic. A careful monitoring of response to COVID-19 vaccines together with adequate preventive/therapeutical strategies are highly recommendable in the near course of pandemic in this frail patients' population.

Effectiveness of biological targeted therapies may discriminate seronegative from seropositive rheumatoid arthritis

OBJECTIVE

To assess the real-world effectiveness of targeting biologic drugs (bDMARD) in rheumatoid arthritis (RA) patients negative for rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA).

METHODS

We retrospectively selected 81 seronegative and 404 seropositive RA patients receiving treatment with abatacept, anti-tumor necrosis factor (TNF) alpha, or tocilizumab. Effectiveness was evaluated by analyzing drug survival using Kaplan-Meyer analysis over 10-year follow-up. Survival rates were compared by log rank test, and hazard ratios (HRs) of therapy discontinuation were estimated through multivariate Cox-regression.

RESULTS

Clinical characteristics were similar between the two groups, except for a significantly higher percentage of inadequate responders to prior bDMARDs in the seronegative RA patients (p= 0.02). Among seronegative RA, tocilizumab demonstrated a survival rate of 73.9% with a mean survival time (MST) of 76.8 months (95% CI 61-92), which was significantly higher than abatacept (37.5%, MST 37.1 months (95% CI 22-51; p= 0.01). Anti-TNF alpha therapy fell in the middle (50.0%, MST 63.5 months (95% CI 47-79) but the difference was not significant. Nevertheless, seropositive RA patients did not show significantly different drug survival rates. Negative predictors of drug discontinuation were RF/ACPA positivity (HR 0.56) and sex male (HR 0.58), but treatment with abatacept (HR 1.88) or anti-TNF alpha (HR 1.79), no co-therapy with cDMARD (HR 1.74), absence of bone erosions (HR 1.41), and higher HAQ (HR 1.58) were positive predictors.

CONCLUSIONS

To confirm these preliminary findings and to explore the hypothesis of a distinctive therapeutic algorithm in seronegative RA, prospective studies on larger cohorts are needed.

Effects of cytotoxic T-lymphocyte-associated protein 4 compared to TNF inhibitors on lipid profile: Results from an observational multicentre rheumatoid arthritis cohort

AIM

To evaluate the impact of selective cytotoxic T-lymphocyte-associated protein 4 (CTLA-4Ig) compared to tumor necrosis factor inhibitors (TNFi) on cardiovascular (CV) clinical and laboratory outcomes in patients with rheumatoid arthritis (RA).

METHODS

We performed a prospective observational multicenter study of RA patients included in the "Cardiovascular Obesity and Rheumatic DISease (CORDIS)" Study Group database, collecting demographic, clinical, and laboratory data of those starting a CTLA-4Ig or TNFi at baseline, 6-month, and 12-month follow-up.

RESULTS

Of the 206 RA patients without previous CV events enrolled in the study, 64 received a CTLA-4Ig and 142 a TNFi. The two groups did not differ in age, gender, or smoking habits, and the prevalence of hypertension, diabetes, and metabolic syndrome was similar. Over a follow-up period of 12 months, although no significant differences were found in the disease activity course, we observed that LDL cholesterol levels slightly decreased only in the CTLA-4Ig-treated patients.

CONCLUSIONS

Patients treated with both CTLA-4Ig and TNFi did not differ in disease activity response and changes in traditional CV risk factors after 12 months of treatment. However, CTL-A-4Ig treatment is associated with a favorable change in lipid profile at 12-month follow-up.

Italian recommendations for the assessment of cardiovascular risk in rheumatoid arthritis: a position paper of the Cardiovascular Obesity and Rheumatic DISease (CORDIS) Study Group of the Italian Society for Rheumatology

OBJECTIVES

Rheumatoid arthritis (RA) patients are at high risk of cardiovascular (CV) events. The aim of this position paper is to provide Italian rheumatologists with an easy, feasible and time-saving CV risk assessment in their daily clinical practice.

METHODS

A narrative review of the literature and an assessment of the methodological strength underlying the current evidence on CV risk assessment in patients with RA were performed. The evidence-based results were shared among the members of the steering committee of the CORDIS study group of the Italian Society of Rheumatology. Subsequently, a unanimously agreed-upon algorithm was discussed and finally approved by the experts.

RESULTS

RA patients should have their CV profile monitored using the Italian 'Progetto Cuore' chart, according to the current EULAR recommendations for CV risk management, at least every 5 years. In the presence of high disease activity, or a multi-drug failure condition, when prolonged treatment with glucocorticoids and/or NSAIDs is required, or if hypertension, dyslipidaemia, or diabetes mellitus are concomitant, a more stringent CV risk assessment should be considered. When moderate CV risk is documented, patients should undergo intima-media thickening measurement. The condition of high CV risk requires a cardiological evaluation.

CONCLUSIONS

This position paper provides five Italian recommendations for CV risk assessment in RA patients. A general and uniform approach to CV risk profiling may be useful to identify those patients who should undertake intensive preventive strategies to improve their CV outcomes.

Clinical Features of Diabetes Mellitus on Rheumatoid Arthritis: Data from the Cardiovascular Obesity and Rheumatic DISease (CORDIS) Study Group

Rheumatoid arthritis (RA) and diabetes mellitus (DM) are linked by underlying inflammation influencing their development and progression. Nevertheless, the profile of diabetic RA patients and the impact of DM on RA need to be elucidated. This cross-sectional study includes 1523 patients with RA and no episodes of cardiovascular events, followed up in 10 Italian University Rheumatologic Centers between 1 January and 31 December 2019 belonging to the “Cardiovascular Obesity and Rheumatic DISease (CORDIS)” Study Group of the Italian Society of Rheumatology. The demographic and clinical features of DM RA patients were compared to non-diabetic ones evaluating factors associated with increased risk of DM. Overall, 9.3% of the RA patients had DM, and DM type 2 was more common (90.2%). DM patients were significantly older (p < 0.001), more frequently male (p = 0.017), with a significantly higher BMI and mean weight (p < 0.001) compared to non-diabetic patients. DM patients were less likely to be on glucocorticoids (p < 0.001), with a trend towards a more frequent use of b/ts DMARDs (p = 0.08), and demonstrated higher HAQ (p = 0.001). In around 42% of patients (n = 114), DM diagnosis preceded that of RA. Treatment lines were identical in diabetic and non-diabetic RA patients. DM is a comorbidity that may influence RA management and outcome. The association between DM and RA supports the theory of systemic inflammation as a condition underlying the development of both diseases. DM may not have a substantial impact on bDMARDs resistance, although further investigation is required to clarify the implications of biological therapy resistance in RA patients.

Systemic sclerosis sine scleroderma: clinical and serological features and relationship with other cutaneous subsets in a large series of patients from the national registry 'SPRING' of the Italian Society for Rheumatology

OBJECTIVE

To describe demographic, clinical and laboratory features of systemic sclerosis sine scleroderma (ssSSc) in a large multicentre systemic sclerosis (SSc) cohort.

METHODS

Data involving 1808 SSc patients from Italian Systemic sclerosis PRogression INvestiGation registry were collected. The ssSSc was defined by the absence of any cutaneous sclerosis and/or puffy fingers. Clinical and serological features of ssSSc were compared with limited cutaneous (lcSSc) and diffuse cutaneous (dcSSc) subsets.

RESULTS

Among patients with SSc, only 61 (3.4%) were classified as having ssSSc (F/M=19/1). Time from Raynaud's phenomenon (RP) onset to diagnosis was longer in ssSSc (3 years, IQR 1-16.5) than lcSSc (2 years, IQR 0-7), and dcSSc (1 year, IQR 0-3) (p<0.001). Clinical ssSSc phenotype was comparable to lcSSc, except for digital pitting scars (DPS) (19.7% vs 42%, p=0.01), but significantly milder than dcSSc, particularly for digital ulcers (DU) (6.6% vs 35.7%, p<0.001), oesophagus (46.2% vs 63.5%, p=0.009), lung (mean diffusion capacity for carbon monoxide 72.2±19.6 vs 62.4±22.8, p=0.009; mean forced vital capacity 105.6±21.7 vs 89.2±20.9, p<0.001) and major videocapillaroscopic alterations (late pattern 8.6% vs 47.6%, p<0.001). Moreover, in ssSSc the percentages of anticentromere and antitopoisomerase were comparable to lcSSc (40% and 18.3% vs 36.7% and 26.6%), but divergent respect to dcSSc (8.6% and 67.4%, p<0.001).

CONCLUSION

The ssSSc is a quite rare disease variant characterised by clinico-serological features comparable to lcSSc, but significantly different from dcSSc. Overall, longer RP duration, low percentages of DPS and peripheral microvascular abnormalities, and increased anti-centromere seropositivity distinguish ssSSc. Further investigations based on national registries might provide useful insights on the actual relevance of the ssSSc within the scleroderma spectrum.

COVID-19 and Mixed Cryoglobulinemia Syndrome: Long-Term Survey Study on the Prevalence and Outcome, Vaccine Safety, and Immunogenicity

PURPOSE

Mixed cryoglobulinemia syndrome (MCs) is a rare immunoproliferative systemic disorder with cutaneous and multiple organ involvement. Our multicenter survey study aimed to investigate the prevalence and outcome of COVID-19 and the safety and immunogenicity of COVID-19 vaccines in a large MCs series.

METHODS

The survey included 430 unselected MCs patients (130 M, 300 F; mean age 70 ± 10.96 years) consecutively collected at 11 Italian referral centers. Disease classification, clinico-serological assessment, COVID-19 tests, and vaccination immunogenicity were carried out according to current methodologies.

RESULTS

A significantly higher prevalence of COVID-19 was found in MCs patients compared to Italian general population (11.9% vs 8.0%, p < 0.005), and the use of immunomodulators was associated to a higher risk to get infected (p = 0.0166). Moreover, higher mortality rate was recorded in MCs with COVID-19 compared to those without (p < 0.01). Patients' older age (≥ 60 years) correlated with worse COVID-19 outcomes. The 87% of patients underwent vaccination and 50% a booster dose. Of note, vaccine-related disease flares/worsening were significantly less frequent than those associated to COVID-19 (p = 0.0012). Impaired vaccination immunogenicity was observed in MCs patients compared to controls either after the first vaccination (p = 0.0039) and also after the booster dose (p = 0.05). Finally, some immunomodulators, namely, rituximab and glucocorticoids, hampered the vaccine-induced immunogenicity (p = 0.029).

CONCLUSIONS

The present survey revealed an increased prevalence and morbidity of COVID-19 in MCs patients, as well an impaired immunogenicity even after booster vaccination with high rate of no response. Therefore, MCs can be included among frail populations at high risk of infection and severe COVID-19 manifestations, suggesting the need of a close monitoring and specific preventive/therapeutical measures during the ongoing pandemic.

Effectiveness and safety of tocilizumab in patients with systemic sclerosis: a propensity score matched controlled observational study of the EUSTAR cohort

Objectives

Tocilizumab showed trends for improving skin fibrosis and prevented progression of lung fibrosis in systemic sclerosis (SSc) in randomised controlled clinical trials. We aimed to assess safety and effectiveness of tocilizumab in a real-life setting using the European Scleroderma Trial and Research (EUSTAR) database.

Methods

Patients with SSc fulfilling the American College of Rheumatology (ACR)/EULAR 2013 classification criteria, with baseline and follow-up visits at 12±3 months, receiving tocilizumab or standard of care as the control group, were selected. Propensity score matching was applied. Primary endpoints were the modified Rodnan skin score (mRSS) and FVC at 12±3 months compared between the groups. Secondary endpoints were the percentage of progressive/regressive patients for skin and lung at 12±3 months.

Results

Ninety-three patients with SSc treated with tocilizumab and 3180 patients with SSc with standard of care fulfilled the inclusion criteria. Comparison between groups did not show significant differences, but favoured tocilizumab across all predefined primary and secondary endpoints: mRSS was lower in the tocilizumab group (difference −1.0, 95% CI −3.7 to 1.8, p=0.48). Similarly, FVC % predicted was higher in the tocilizumab group (difference 1.5 (−6.1 to 9.1), p=0.70). The percentage of progressive/regressive patients favoured tocilizumab over controls. These results were robust regarding the sensitivity analyses. Safety analysis confirmed previously reported adverse event profiles.

Conclusion

Although this large, observational, controlled, real-life EUSTAR study did not show significant effectiveness of tocilizumab on skin and lung fibrosis, the consistency of direction of all predefined endpoints generates hypothesis for potential effectiveness in a broader SSc population.

C-reactive protein and 10-year cardiovascular risk in rheumatoid arthritis

OBJECTIVES

To evaluate the association between C-reactive protein (CRP) and 10-year risk of cardiovascular (CV) events using the Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis (ERS-RA), based on conventional and RA-specific risk factors but not CRP, in RA patients without previous cardiovascular events.

METHODS

ERS-RA was calculated in 1,251 "Cardiovascular Obesity and Rheumatic Disease Study (CORDIS)" database patients [(age 60.4(9.3) years; 78% female; disease duration, 11.6(8) years; CDAI, 9(9); CRP, 6.8(12) mg/L].

RESULTS

The mean (SD) 10-year risk of CV events was 12.9% (10). After adjusting for the use of DMARDs and biologics, CRP concentrations were significantly associated with 10-year risk of CV events (coefficient=0.005 for each 10 mg/L CRP increment; 95%CI 0.000-0.111; p = 0.047). In mediation analysis, the association between CRP and ERS-RA was not explained by disease activity.

CONCLUSION

In a large cohort of RA patients without previous cardiovascular events, a 20 mg/L increase in CRP concentrations was associated with a 1% increase in 10-year risk of CV events. This suggests that actively targeting residual inflammatory risk beyond conventional and RA-specific risk factors might further reduce CV event rates in RA patients.

Subcutaneous immunoglobulin therapy for refractory skin thickening in rapidly progressive systemic sclerosis: A case report and literature review

The use of immunoglobulin is a therapeutic option with increasing evidence of efficacy for different rheumatologic autoimmune systemic diseases. Some studies concerning immunoglobulin use in systemic sclerosis have been published with encouraging results. We present the case of a young woman diagnosed with rapidly progressive diffuse cutaneous systemic sclerosis, refractory to therapy with methotrexate and rituximab, which presented a relevant skin improvement after one year of subcutaneous immunoglobulin (2 g/kg cumulative monthly dose, refracted in weekly administrations). Furthermore, a narrative literature review of the evidence for alternative treatments with a focus on immunoglobulin use for systemic sclerosis skin involvement was carried out.

Survival and Prognostic factors from a multicentre large cohort of unselected Italian Systemic Sclerosis patients

OBJECTIVES

Survival and death prognostic factors of systemic sclerosis (SSc) patients varied during the last decades. We aimed to update the 5- and 10-year survival rates and identify prognostic factors in a multicentre cohort of Italian SSc patients diagnosed after 2009.

METHODS

Patients who received a diagnosis of SSc after January 1st, 2009, and were longitudinally followed up in 4 Italian Rheumatologic Centres were retrospectively assessed up to December 31st, 2020. Overall survival of SSc patients was described using the Kaplan-Meier method. Predictors of mortality at 10-year follow-up were assessed by the Cox-regression model. A comparison of our cohort with the Italian general population was performed by determining the standardized mortality ratio (SMR).

RESULTS

A total of 912 patients (91.6% females, 20% dcSSc) were included. Overall survival rates at 5 and 10 years were 94.4%, and 89.4% respectively. The SMR was 0.96 (95% CI 0.81-1.13), like that expected in the Italian general population. Pulmonary arterial hypertension (PAH) and interstitial lung disease (ILD) associated with pulmonary hypertension (PH) significantly reduced survival (p< 0.0001). Main death predictors were male gender (HR = 2.76), diffuse cutaneous involvement (HR = 3.14), older age at diagnosis (HR = 1.08), PAH (HR = 3.21), ILD-associated PH (HR = 4.11), comorbidities (HR = 3.53), and glucocorticoid treatment (HR = 2.02).

CONCLUSIONS

In the last decade, SSc patients have reached similar mortality of that expected in the Italian general population. Male gender, diffuse cutaneous involvement, comorbidities, and PAH with or without ILD represent the main poor prognostic factors.

Absent or suboptimal response to booster dose of COVID-19 vaccine in patients with autoimmune systemic diseases

Autoimmune systemic diseases (ASD) show impaired immunogenicity to COVID-19 vaccines. Our prospective observational multicenter study aimed at evaluating the seroconversion elicited by COVID-19 vaccine over the entire vaccination cycle including the booster dose.

Among 478 unselected ASD patients originally evaluated at the end of the first vaccination cycle (time 1), 344 individuals were re-evaluated after a 6-month period (time 2), and 244 after the booster vaccine dose (time 3). The immunogenicity of mRNA COVID-19 vaccines (BNT162b2 and mRNA-1273) was assessed by measuring serum IgG-neutralizing antibody (NAb) on samples obtained at the three time points in both patients and 502 age-matched controls.

In the 244 ASD group that received booster vaccine and monitored over the entire follow-up, the mean serum NAb levels (time 1, 2, and 3: 696.8 ± 52.68, 370.8 ± 41.92, and 1527 ± 74.16SD BAU/mL, respectively; p < 0.0001) were constantly lower compared to controls (p < 0.0001), but they significantly increased after the booster dose compared to the first two measurements (p < 0.0001). The percentage of patients with absent/suboptimal response to vaccine significantly decreased after the booster dose compared to the first and second evaluations (time 1, 2, and 3: from 28.2% to 46.3%, and to 7.8%, respectively; p < 0.0001). Of note, the percentage of patients with absent/suboptimal response after the booster dose was significantly higher compared to controls (19/244, 7.8% vs 1/502, 0.2%; p < 0.0001). Similarly, treatment with immune-modifiers increased the percentage of patients exhibiting absent/suboptimal response (16/122, 13.1% vs 3/122, 2.46%; p = 0.0031). Overall, the above findings indicate the usefulness of booster vaccine administration in ASD patients. Moreover, the persistence of a significantly higher percentage of individuals without effective seroconversion (7.8%), even after the booster dose, warrants for careful monitoring of NAb levels in all ASD patients to identify those with increased risk of infection. In this particularly frail patients’ setting, tailored vaccination and/or therapeutic strategy are highly advisable.

Prevalence and death rate of COVID-19 in systemic autoimmune diseases in the first three pandemic waves. Relationship to disease subgroups and ongoing therapies

OBJECTIVE

Autoimmune systemic diseases (ASD) represent a predisposing condition to COVID-19. Our prospective, observational multicenter telephone survey study aimed to investigate the prevalence, prognostic factors, and outcomes of COVID-19 in Italian ASD patients.

METHOD

The study included 3,918 ASD pts (815 M, 3103 F; mean age 59±12SD years) consecutively recruited between March 2020 and May 2021 at the 36 referral centers of COVID-19 & ASD Italian Study Group. The possible development of COVID-19 was recorded by means of a telephone survey using a standardized symptom assessment questionnaire.

RESULTS

ASD patients showed a significantly higher prevalence of COVID-19 (8.37% vs 6.49%; p<0.0001) but a death rate statistically comparable to the Italian general population (3.65% vs 2.95%). Among the 328 ASD patients developing COVID-19, 17% needed hospitalization, while mild-moderate manifestations were observed in 83% of cases. Moreover, 12/57 hospitalized patients died due to severe interstitial pneumonia and/or cardiovascular events; systemic sclerosis (SSc) patients showed a significantly higher COVID-19-related death rate compared to the general population (6.29% vs 2.95%; p=0.018). Major adverse prognostic factors to develop COVID-19 were: older age, male gender, SSc, pre-existing ASD-related interstitial lung involvement, and long-term steroid treatment. Of note, patients treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) showed a significantly lower prevalence of COVID-19 compared to those without (3.58% vs 46.99%; p=0.000), as well as the SSc patients treated with low dose aspirin (with 5.57% vs without 27.84%; p=0.000).

CONCLUSION

During the first three pandemic waves, ASD patients showed a death rate comparable to the general population despite the significantly higher prevalence of COVID-19. A significantly increased COVID-19-related mortality was recorded in only SSc patients' subgroup, possibly favored by preexisting lung fibrosis. Moreover, ongoing long-term treatment with csDMARDs in ASD might usefully contribute to the generally positive outcomes of this frail patients' population.

POS0295 OCCURRENCE OF SERIOUS INFECTIONS IN RHEUMATOID ARTHRITIS PATIENTS CONCURRENTLY TREATED WITH A BIOLOGIC AGENT AND DENOSUMAB: A RETROSPECTIVE STUDY WITH PROPENSITY SCORE

Background

Denosumab is a monoclonal antibody used in patients with osteoporosis. It inhibits the receptor activator NF-kB ligand (RANKL), an essential cytokine mediator of osteoclastogenesis. Some concerns have been raised about Denosumab safety profile, especially when it is administered concurrently with biologic drugs for rheumatoid arthritis (RA) (1,2). Indeed, RANK and RANKL have a known immunomodulatory effect (2). In a retrospective study, Lau et al. (1) showed that patients concurrently treated with Denosumab and biologic disease modifying anti-rheumatic drugs (bDMARDs) had a higher rate of serious infections compared to patients taking bDMARDs only, but no adjustment was made for any observed imbalances in potential confounders, such as age and disease activity, between the groups.

Objectives

This study aims to evaluate, in a monocentric cohort of RA patients concurrently treated with bDMARDs and Denosumab, the safety of such combination.

Methods

We retrospectively observed RA patients on bDMARDs ± methotrexate and denosumab (DEN group) for comorbid osteoporosis and RA patients treated with bDMARDs±methotrexate (noDEN group) who started treatment in a tertiary care centre from 2015 to 2020. Clinical characteristics were gathered at baseline and at 12-month follow up. We also recorded the occurrence of serious infections between groups (defined as infections requiring hospitalization and/or parenteral antibiotics). We deployed the nearest-neighbour matching algorithm (1:4), based on Propensity Score (PS), in order to adjust for non-randomization. The McNemar’s test was used to compare the frequency of serious infection in the two groups.

Results

DEN group consisted of 36 patients were recruited, while the cohort of patients in noDEN group consisted of 547 individuals (Table 1). After PS matching only 58 patients were noDEN group, matched for disease duration, presence/absence of ACPA antibodies, baseline BMI, baseline DAS28 and daily prednisone dosage. In the matched cohort, we found an increase in terms of frequency of serious infections in DEN group, even if not statistically significant (Figure 1). All the infections were completely resolved after hospitalization and/or parenteral antibiotic treatment, without fatal events or irreversible complications. Both groups were not stratified for bDMARDs mechanism of action (MoA). Of note, in the DEN group Rituximab therapy was admnistered in 22% of patients, while in noDEN group in 12% of them.

Table 1.

Patients’ characteristics at baseline.

Av. Obs.bDMARDs OnlyAv. Obs.bDMARDs + DenosumabFemale, n (%)547466 (85.2%)3834 (89.4%)Age, y (mean±sd)54753.3±13.23863.4±11.1Disease duration, m (mean±sd)472120.2±105.338207.9±126.5DAS28, n(mean±sd)5324.55±1.39382.90±1.44PCR, mg/dL (mean±sd)5391.77±4.51380.81±1.22HAQ, n (mean±sd)5161.28±0.86381.54±0.87ACPA, n. (%)541416 (76.8%)3817 (44.7%)Figure 1.

Occurrence of serious infections at 12-months follow-up.

Conclusion

The occurrence of serious infections among RA patients receiving denosumab in combination with bDMARDs ± MTX for RA was not significantly increased compared to those receiving bDMARDs ± MTX alone at 12 months from treatment baseline. Further studies powered for detecting difference between bDMARDs MoA are necessary in order to assess the infection risk of denosumab co-administration.

References

[1]Occurrence of Serious Infection in Patients with Rheumatoid Arthritis Treated with Biologics and Denosumab Observed in a Clinical Setting. J Rheumatol. 2018 Feb;45(2):170-176. doi: 10.3899/jrheum.161270. Epub 2017 Nov 15.

[2]Is denosumab associated with an increased risk for infection in patients with low bone mineral density? A systematic review and meta-analysis of randomized controlled trials. Int J Rheum Dis. 2021 Jul;24(7):869-879. doi: 10.1111/1756-185X.14101. Epub 2021 Apr 1.

Disclosure of Interests

None declared

AB0134 IN-VITRO STUDY ON THE EFFECT OF SELECTIVE Jak-INHIBITORS ON PBMCs STAT3 PHOSPHORYLATION FROM SYSTEMIC SCLEROSIS PATIENTS

Background

Systemic sclerosis (SSc) is a rare autoimmune connective tissue disease characterized by autoimmunity-driven damage and vasculopathy leading to fibrosis of the skin and internal organs (1). The Janus kinase (Jak) - signal transducer and activator of transcription (STAT) pathway has been evidenced markedly activated in SSc patients (2, 3), and its inhibition has been proved in preclinical and clinical trials (4), but no data on Jak selective inhibition are available.

Objectives

To explore the effect of selective inhibition of Jak/STAT pathway in peripheral blood mononuclear cells (PBMC) from SSc patients.

Methods

In vitro Jak inhibition of the subunit 3 of phosphorylated (p) than activated STAT was measured by flow cytometry in peripheral blood mononuclear cells (PBMC) from SSc patients naïve to any immunosuppressive and/or corticosteroids (n.5). pSTAT3 activity was also assessed after stimulation with recombinant human 0.1 ng/ml IL-6 (Peprotech – NJ, USA). The PBMC were overnight incubated with IC50 concentrations of selective Jak1-, Jak2-, Jak3- and Tyk2-inhibitors (Biovision Inc. – CA, USA). Percentages of pSTAT3 positive cells were compared in presence of different compounds stimulation.

Results

After overnight incubation, percentage of pSTAT3 positive cells was significantly higher in CD14pos compared to CD4pos (16.3%; 95CI 10-22 vs 10.7%; 95CI 4--18, – p=0.02). pSTAT3posCD14pos cells were halved only by selective Jak3-inhibitor, while pSTAT3posCD4pos cells were reduced by 36% by selective Jak1-inhibitor. Selective Jak2- or Tyk2-inhibitors did not interfere with STAT3 phosphorylation in PBMC from SSc patients. After IL-6 stimulation, we observed a 2- and a 1.5-fold increase in percentage of pSTAT3posCD4pos and pSTAT3posCD14pos cells, respectively. pSTAT3posCD14pos cells were reduced in the PBMC co-culture with IL-6 and Jak-selective inhibitors, in contrast no effects were found in CD4pos cells. Specifically, selective Jak1- and Jak3-inhibitors reduced pSTAT3posCD14pos cells by an average of 37% and 25%, respectively. No effects were observed after co-culture with IL-6 and selective Jak2- or Tyk2-inhibitors.

Conclusion

Jak/STAT3 pathway of PBMC from SSc patients with active disease may be differently modulated by specific inhibitors. Selectivity of Jak1- and Jak3-inhibitors seems more relevant, especially in CD14pos monocytes after IL-6 stimulation. These preliminary findings highlight some evidence for effectiveness of selective Jak-inhibitors in SSc treatment.

References

[1]Benfaremo D, et al. Systemic Sclerosis: From Pathophysiology to Novel Therapeutic Approaches. Biomedicines. 2022;10(1):163.

[2]Talotta R. The rationale for targeting the JAK/STAT pathway in scleroderma-associated interstitial lung disease. Immunotherapy. 2021;13(3):241-256.

[3]Cacciapaglia F, et al. Phosphorylated signal transducer and activator of transcription 3 (pSTAT3) is highly expressed in CD14+ circulating cells of scleroderma patients. Rheumatology (Oxford). 2020;59(6):1442-1444.

[4]Karalilova RV, et al. Tofacitinib in the treatment of skin and musculoskeletal involvement in patients with systemic sclerosis, evaluated by ultrasound. Rheumatol Int. 2021;41(10):1743-1753.

Disclosure of Interests

None declared

POS0928 THE IDENTIFICATION OF PENTRAXIN 3 AS BIOMARKER OF DISEASE ACTIVITY IN IDIOPATHIC INFLAMMATORY MYOPATHIES

Background

Muscle involvement is only one feature of idiopathic inflammatory myopathies (IIM). Muscle enzymes do not always represent the best marker of disease activity and other inflammation markers such as ESR and CRP may be normal even with an active disease. Pentraxin-3 (PTX3) is an inflammatory marker produced in many inflammatory and non-inflammatory cells and serum level has been related to higher risk of major cardiovascular events and atherosclerosis1. PTX3 levels have been examined in various rheumatic and autoimmune diseases2, but data of PTX3 levels in patients affected with IIM have not been reported.

Objectives

The aim of the current study was to identify whether serum PTX3 level could be a marker of disease activity in patients affected with IIM.

Methods

Twenty patients affected with IIM (13 Dermatomyositis and 7 Polymyositis), 10 rheumatoid arthritis patients and 10 healthy controls (HC) aged, sex and BMI matched were evaluated. PTX3 levels was assessed using a commercially available enzyme-linked immunosorbent assay (Human Pentraxin3 ELISA Kit, Abcam) kit. Three different cardiovascular risk scores were used to estimate the 10-years CV risk. Carotid intima media thickness (cIMT) was measured with a My Lab XPro80 (Esaote SpA, Genova, Italy) using a linear array ultrasound probe small parts broadband transducer (5–15 MHz) both in right and left carotid. Myositis disease activity was evaluated by using myositis disease activity assessment visual analog scales (MYOACT) [19] established by the International Myositis Assessment and Clinical Studies (IMACS) group. Manual muscle test (MMT8) was used to assess muscle impairment. Exclusion criteria were a diagnosis of diabetes or a history of previous major CV events.

Results

Demographic and disease characteristics of our cohort are showed in Table 1. IIM patients showed higher levels of PTX3 compared to HCs (518±260 pg/ml vs 275±114 pg/ml, p<0.05), while no difference was observed compared to RA patients (383±260 pg/ml). PTX3 levels do not correlate with lipid levels, QIMT and cardiovascular risk scores both in IIM, RA and HC. No correlation was found between DAS28-ESR and PTX3 levels in RA patients. Of note, a direct correlation was found between PTX3 levels and MYOACT-GLOBAL DISEASE ACTIVITY (r=0.675, p=0.002), PTX3 levels and MYOACT- GLOBAL-EXTRA-SKELETAL MUSCLE DISEASE ACTIVITY (r=0.542, p=0.013), while an inverse correlation was found between PTX3 levels and MMT8 (r=-0.510, p=0.02).

Table 1.IIM 20pz (13 DM, 7 PM)RA 10pzHealthy Control 10pzFemale, n. (%)18 (90%)9 (90%)9 (90%)Age55,3 (7,8)58,3 (5,9)54,6 (6,5)BMI25,5 (4,1)23,9 (3,1)24,6 (3,5)Duration of disease, median (IQR)7,3 (4 – 12,8)13,5 (10,5 – 18,5)*Physician Global Assessment2,1 (2,1)2 (2,2)Patient Global Assessment4 (3,6)2,7 (2,3)Health Assessment Questionnaire0,7 (0,8)0,9 (0,9)Manual Muscle Testing 876,2 (6,6)DAS282,6 (1,1)Skin involvement, n. (%)13 (65)Lung involvement, n. (%)7 (35)Dysphagia, n. (%)11 (55)Arthritis, n. (%)4 (20)Malignancies, n. (%)0 (0)0 (0)0 (0)Arterial hypertension, n. (%)6 (30)2 (20)1 (10)Current steroid therapy2,5 (0 – 5)0 (0 – 3,8)Smoking, n. (%)6 (30)2 (20)3 (30)Total cholesterol, mg/dl203,3 (28,6)215,0 (29,5)216,2 (27,3)HDL cholesterol, mg/dl62,7 (14,7)62,6 (14,2)65,1 (18,2)ESR, mm/h16,7 (12,2)19 (11,7)PCR, mg/l2,9 (2,1)4,1 (5)SCORE median (IQR)0,5 (0 – 2)1 (0 – 3)1 (0,8 – 1,3)CUORE median (IQR)1,9 (0,6 – 3,5)1,6 (1 – 4)1,7 (1,2 – 2,8)QRISK3 median (IQR)4,7 (2,1 – 11,3)7,5 (3,2 – 13,6)4,2 (3,1 – 5,5)QIMT Max, median (IQR)742,5 (636,8 – 804)833 (685,3 – 961) *756 (711 – 820)Mean QIMT, median (IQR)679 (613,1 – 736,3)764,3 (664,5 – 854,1) *703,3 (697,3 – 742,8)Pentraxin 3, pg/ml518 (260)383 (146)275 (114)*

Data are expressed as “mean (SD)” where not otherwise specified.

*p<0.05, **p<0.01, ***p<0.001 vs IIM

Conclusion

In IIM patients, PTX3 levels are higher than HC and correlate with disease activity, both for muscular and extra-muscular manifestations, being a possible biomarkers of disease activity.

References

[1]Front Immunol. 2019; 10: 823

[2]Arch Med Sci. 2020; 16(1): 81–86

Disclosure of Interests

None declared

AB0920 Safety of Apremilast in PsA patients with history of malignancies or active cancer: a retrospective study

Background

One of the most intriguing aspects in the management of patients with inflammatory arthritis is the safety of novel therapies in those with a recent history of malignancy or active neoplasm. In this regard, apremilast (APR), an oral PDE4 inhibitor, is emerging as one of the safest therapeutic options in patients with PsA with comorbid cancer.

Objectives

This retrospective study aims to assess the effectiveness and safety of APR in PsA patients with a recent history of malignancy or active cancer.

Methods

We retrospectively observed patients with a history of neoplasm diagnosed from 1997 to 2021, who underwent apremilast treatment from 2017 to 2021 in a tertiary care centre. We recorded demographic and clinical characteristics at APR baseline and last visit. Furthermore, we recorded the eventual recurrence of primary cancer or the onset of new neoplasms. Paired t-test was used to assess the difference of continuous variables at different follow-ups.

Results

Thirteen patients (sex: female 6/13, 46,15%; mean age (mean ± 63,7 years sd ± 9,9 years)) started Apremilast between 2017 to 2021 in a tertiary care center. We assessed their clinical condition using DAPSA, LEI and PASI score in the baseline and in the last visit. Mean follow-up time was 32,02 ± 18,92 months.

Mean DAPSA at baseline 20,55 ± 9,15 decreased to 16,21 ± 1,73 at last visit. Similarly mean LEI at baseline was 1,23 ± 1,58 and decreased to 0,61 ± 0,35 at last visit, even in absence of statistical significance (p=0,15). Conversely mean PASI at baseline (1,76 ± 2,57) did not show a decrease (1,61 ± 0,93);

Ten patients were still treated with apremilast at last available follow-up. Patient 6 (Table 1) experienced the relapse of Ductal Breast Papilloma. For patient 8, a relapse of primary cancer occurred. Patient 9 had the onset of a new neoplasm. The APR was not discontinued as such malignancies were not considered as treatment associated.

Three patients (4, 6, 10) discontinued APR due to intolerance or lack of efficacy.

Conclusion

APR seems a safe option in PsA patients with a recent history of malignancy or active cancer, improving articular involvement.

Disclosure of Interests

None declared

POS1062 HARNESSING THE POWER OF MACHINE LEARNING TO PREDICT REMISSION IN PATIENTS WITH PSORIATIC ARTHRITIS ON SECUKINUMAB: IMPLEMENTATION AND VALIDATION OF A CANDIDATE ALGORITHM ON 121 PATIENTS

Background

Although novel therapies with biotechnological agents and small molecules may lead to the complete clearing of psoriasis in the vast majority of patients, the latter drugs only allow Psoriatic Arthritis (PsA) disease control in up to 50% of patients (1). In an increasing number of clinical scenarios, machine learning (ML) is emerging as a tool for the implementation of multi-parametric decision algorithms. ML allows to handle complex non-linear relationships between patient attributes that are hard to model with traditional statistical methods, merging them to output a forecast or a probability for a given outcome, enabling personalized medicine (2).

Objectives

We aimed to develop a ML algorithm capable of predicting the probability of remission in PsA patients on Secukinumab to support clinicians in choosing the optimal treatment strategy.

Methods

Patients with classified PsA according to CASPAR criteria undergoing Secukinumab treatment between September 2017 and September 2020 at our tertiary Centre were retrospectively observed.Either at treatment baseline and at 12-month follow up, we retrieved demographic and clinical characteristics, including Body Mass Index (BMI), disease phenotypes, Disease Activity in PsA (DAPSA), Leeds Enthesitis Index (LEI) and Ankylosing Spondylitis Disease Activity Score (ASDAS, on C-Reactive Protein). After a ML variable selection method, based on an eXtreme Gradient Boosting (XGBoost) wrapper, an attribute core set with the least number of predictors was used for implementing n.3 ML algorithms, namely Logistic Regression (LR), Decision Trees (DT) and XGBoost. Each algorithm was trained and validated with 10-fold cross-validation. The performance of each algorithm in both phases was assessed in terms of of accuracy and area under receiver operating characteristic curve (AUROC).

Results

The dataset consisted of n.121 PsA patients (62/121 female, 51.2%), with mean age (±SD) 52.9±10.1 years and mean disease duration of 5.9 ±10.4 years. Twenty-five of them (20.7%) had axial involvement whereas 88/121 (72.7%) had polyarticular involvement. Psoriasis was present in 84/121 patients (69.4%). At baseline, mean DAPSA was 14.9 ± 9.2, mean HAQ-DI 1.1 ± 0.7, mean LEI 0.6 ± 1, mean ASDAS 2.5 ± 0.8, mean PASI 2 ± 2.9, mean BMI 28.4 ± 4.9 . Secukinumab at 300 mg dose was administered to 79/121 patients (65.3%). At 12 months DAPSA remission was achieved by 24/121 patients (19.8%). Accuracy of LR, DT and XGBoost was of 0.70 ± 0.11, 0.81 ± 0.07 and 0.89 ± 0.05, respectively. Consistently AUROC (Figure 1 Panels ABC) were 0.63 ± 0.2, 0.79 ± 0.2 and 0.93 ± 0.1, respectively. A sample decision tree explaining XGBoost algorithm function has been provided (Figure 1 Panel D). LEI and DAPSA at baseline were shown as the most important attributes for such algorithm (Figure 1 Panel E).

Figure 1.

Conclusion

ML can support Rheumatologists in profiling those patients more likely to respond to Secukinumab.

References

[1]Scher JU, Ogdie A, Merola JF, Ritchlin C. Preventing psoriatic arthritis: focusing on patients with psoriasis at increased risk of transition. Nat Rev Rheumatol. 2019 Mar;15(3):153-166. doi: 10.1038/s41584-019-0175-0.

[2]Venerito V, Angelini O, Cazzato G, Lopalco G, Maiorano E, Cimmino A, Iannone F. A convolutional neural network with transfer learning for automatic discrimination between low and high-grade synovitis: a pilot study. Intern Emerg Med. 2021 Sep;16(6):1457-1465. doi: 10.1007/s11739-020-02583-x. Epub 2021 Jan 2.

Disclosure of Interests

Vincenzo Venerito Speakers bureau: Abbvie, Paid instructor for: Pfizer, Lilly, Marco Fornaro: None declared, Fabio Cacciapaglia Speakers bureau: Lilly, Abbvie, BMS. Pfizer, Paid instructor for: Lilly, Sabina Tangaro: None declared, Giuseppe Lopalco Speakers bureau: SOBI NOVARTIS BMS ABBVIE, Paid instructor for: PFIZER, Florenzo Iannone Speakers bureau: Abbvie Pfizer UCB BMS Galapagos Novartis Lilly SOBI ROCHE, Paid instructor for: pfizer

POS1267 LONG-TERM SURVEY STUDY OF THE IMPACT OF COVID-19 ON SYSTEMIC AUTOIMMUNE DISEASES. LOW DEATH RATE DESPITE THE INCREASED PREVALENCE OF SYMPTOMATIC INFECTION. ROLE OF PRE-EXISTING INTERSTITIAL LUNG DISEASE AND ONGOING TREATMENTS

Background

Patients with autoimmune systemic diseases (ASDs) can be counted among frail populations as regards the predisposition to COVID-19 due to the frequent visceral organ involvement and comorbidities, as well as the ongoing immunomodulating treatments.

Objectives

Our long-term multicenter telephone survey prospectively investigated the prevalence, prognostic factors, and outcomes of COVID-19 in Italian ASD patients during the first 3 pandemic waves.

Methods

A large series of 3,918 ASD patients (815 M, 3103 F; mean age 59±12SD years) was consecutively recruited at the 36 referral centers of COVID-19 & ASD Italian Study Group. In particular, ASD series encompassed the following conditions: rheumatoid arthritis (n: 981), psoriatic arthritis (n: 471), ankylosing spondylitis (n: 159), systemic sclerosis (n: 1,738), systemic lupus (172), systemic vasculitis (n: 219), and a miscellany of other ASDs (n: 178). The development of COVID-19 was recorded by means of telephone survey using standardized symptom-assessment questionnaire (1).

Results

A significantly increased prevalence of COVID-19 (8.37% vs 6.49%; p<0.0001) was observed in our ASD patients, while the cumulative death rate revealed statistically comparable to the Italian general population (3.65% vs 2.95%; p: ns). In particular, among the 328 ASD patients complicated by COVID-19, 57 (17%) needed hospitalization, while mild-moderate manifestations were observed in the large majority of individuals (83%). In addition, 12/57 hospitalized patients died due to severe interstitial pneumonia and/or cardiovascular manifestations.

Interestingly, a significantly higher COVID-19-related death rate was observed in systemic sclerosis patients compared to the Italian general population (6.29% vs 2.95%; p=0.018). Other adverse prognostic factors to develop COVID-19 were the patients’ older age, male gender, pre-existing ASD-related interstitial lung involvement, and chronic steroid treatment. Conversely, patients treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) showed a significantly lower prevalence of COVID-19 compared to those without (3.58% vs 46.99%; p=0.000), as well as the chronic administration of low dose aspirin in a subgroup of SSc patients (with 5.57% vs without 27.84%; p=0.000).

Conclusion

The cumulative impact of COVID-19 on ASD patients after the first 3 pandemic waves revealed less severe than that observed during the first phase of pandemic (1), especially with regards to the death rate that was comparable to the Italian general population in spite of the increased prevalence of complicating COVID-19 in the same ASD series.

Ongoing long-term treatments, mainly csDMARDs, might usefully contribute to generally positive outcomes of in this frail patients’ population.

Of note, a significantly increased COVID-19-related mortality was recorded in only SSc patients’ subgroup, possibly favored by pre-existing lung fibrosis. Among different ASD, SSc deserves special attention, since it shares the main pathological alterations with COVID-19, namely the interstitial lung involvement and the endothelial injury responsible for diffuse microangiopathy.

Besides SSc, the patients’ subgroups characterized by older age, chronic steroid treatment, pre-existing interstitial lung disease, and/or impaired COVID-19 vaccine response (1-3), may deserve well-designed prevention and management strategies.

References

[1]Ferri C, et al. Ann Rheum Dis. 2020 Oct 14 doi: 10.1136/annrheumdis-2020-219113.

[2]Ferri C et al. J Autoimmun. 2021 Dec;125:102744. doi: 10.1016/j.jaut.2021.102744.

[3]Visentini M et al. Ann Rheum Dis. 2021 Nov 24. doi: 10.1136/annrheumdis-2021-221248

Disclosure of Interests

None declared

AB0070 INHIBITION OF STAT3 IN PBMCs FROM RHEUMATOID ARTHRITIS PATIENTS: CLUES TO UNDERSTAND SELECTIVITY OF JANUS KINASE INHIBITORS

Background

The Janus kinase (Jak) - signal transducer and activator of transcription (STAT) pathway has 4 Jak proteins and 7 STAT factors that mediate intracellular downstream of cytokine receptors. Targeted small-molecule therapies with different bond affinity to Jak proteins have been demonstrated effective in rheumatoid arthritis (RA) treatment, but the clinical significance of selective inhibition remains unclear.

Objectives

To explore the effect of selective inhibition of Jak-STAT pathway in peripheral blood mononuclear cells (PBMC) from RA patients compared to healthy donors (HD).

Methods

In vitro Jak inhibition of the subunit 3 of phosphorylated (p) than activated STAT was measured by flow cytometry in peripheral blood mononuclear cells (PBMC) from RA patients with active disease (DAS28>5.1) naïve to any DMARDs (n.5) and HD (n.5), following recombinant human 0.1 ng/ml IL-6 (Peprotech – NJ, USA) stimulation. After blood separation, PBMC were overnight incubated with IC50 concentrations of selective Jak1-, Jak2-, Jak3- and Tyk2-inhibitors (Biovision Inc. – CA, USA) with or without IL-6 stimulation. Mean fold-increase of pSTAT3 was then compared in presence of different compounds stimulation.

Results

Mean pSTAT3 activity after overnight incubation was significantly higher in RA patients compared to HD (37%; 95CI 8.2-56.7 vs 17.9%; 95CI 4.6-21 – p=0.01). After IL-6 stimulation, a 2-fold and a 1.4-fold increase in pSTAT3 levels was observed in PBMC from RA patients and HD, respectively. In unstimulated PBMC from HD Jak-inhibitors didn’t significantly reduced pSTAT3 activity. In CD14+ cells from RA patients, pSTAT3 activity was reduced with no differences between all four selective Jak-inhibitors, while in CD4+ cells only Jak1-inhibition was able to reduce by 40% pSTAT3 activity. After IL-6 stimulation, the co-culture with Jak1- or JaK3- selective inhibitors was able to significantly reduce pSTAT3 levels in CD4+ lymphocytes, by an average of 20%. While in CD14+ monocytes Jak1-, Jak2- and Jak3- selective inhibitors were able to reduce pSTAT3 activity by a mean of 30%. Tyk-2 selective inhibitor did not interfere with STAT3 activation by IL-6 stimulation of PBMC from RA patients and HD.

Conclusion

Jak/STAT3 activity of PBMC from RA patients with active disease may be differently modulated by specific inhibitors. Selectivity of Jak-inhibitors seems more relevant in lymphocytes after IL-6 stimulation. These preliminary findings may explain discrepancies in effectiveness of selective Jak-inhibitors and pave the way for different choices in clinical practice.

References

[1]Tanaka Y, et al. Nat Rev Rheumatol. 2022 Jan 5:1–13.

[2]Traves PG, et al. Ann Rheum Dis. 2021 Jul;80(7):865-875.

[3]Choy EH. Rheumatology (Oxford). 2019 Jun 1;58(6):953-962.

Disclosure of Interests

None declared

A Machine Learning Approach for Predicting Sustained Remission in Rheumatoid Arthritis Patients on Biologic Agents

METHODS

In this longitudinal study, patients with RA who started a biological disease-modifying antirheumatic drug (bDMARD) in a tertiary care center were analyzed. Demographic and clinical characteristics were collected at treatment baseline, 12-month, and 24-month follow-up. A wrapper feature selection algorithm was used to determine an attribute core set. Four different ML algorithms, namely, LR, random forest, K-nearest neighbors, and extreme gradient boosting, were then trained and validated with 10-fold cross-validation to predict 24-month sustained DAS28 (Disease Activity Score on 28 joints) remission. The performances of the algorithms were then compared assessing accuracy, precision, and recall.

RESULTS

Our analysis included 367 patients (female 323/367, 88%) with mean age ± SD of 53.7 ± 12.5 years at bDMARD baseline. Sustained DAS28 remission was achieved by 175 (47.2%) of 367 patients. The attribute core set used to train algorithms included acute phase reactant levels, Clinical Disease Activity Index, Health Assessment Questionnaire-Disability Index, as well as several clinical characteristics. Extreme gradient boosting showed the best performance (accuracy, 72.7%; precision, 73.2%; recall, 68.1%), outperforming random forest (accuracy, 65.9%; precision, 65.6%; recall, 59.3%), LR (accuracy, 64.9%; precision, 62.6%; recall, 61.9%), and K-nearest neighbors (accuracy, 63%; precision, 61.5%; recall, 54.8%).

CONCLUSIONS

We showed that ML models can be used to predict sustained remission in RA patients on bDMARDs. Furthermore, our method only relies on a few easy-to-collect patient attributes. Our results are promising but need to be tested on longitudinal cohort studies.

Long-term safety of rituximab in rheumatic patients with previously resolved hepatitis B virus infection

Conflicting results can be found in the literature on the frequency of hepatitis B virus (HBV) reactivation (HBVr) on rituximab (RTX) in rheumatic patients with previously resolved HBV (prHBV) infection. Here, we report the frequency of HBVr in a large historical cohort of caucasian rheumatic patients with prHBV receiving RTX. Registry data of rheumatic patients treated with RTX were retrospectively analysed. Demographic and clinical characteristics including evaluation of anti-HCV and HBV markers, annual HBV-DNA determination and aminotransferase levels assessed every three months, were recorded. Kaplan-Meier estimate was used to compare the risk of being still under therapy at different time points in patients with or without prHBV infection. Cox regression analysis was used to determine the association between recorded variables and treatment discontinuation. A total of 311 patients treated with RTX, 44 (14.1%) with and 267 (85.9%) without prHBV were analysed. No significant difference between the two groups regarding demographic and clinical characteristics was observed. During RTX treatment, detectable HBV-DNA and reappearance of HBsAg in patients with prHBV (seroreversion) were never observed. Kaplan-Meier functions were similar in patients with or without prHBV infection which was not associated with RTX discontinuation neither at univariate nor at multivariate analysis. These data are in favor of the concept that patients with rheumatologic diseases have a very low risk of reactivation of the HBV infection under RTX treatment. However, future prospective studies, including a larger number of patients, are still necessary to draw definitive conclusions.

Comparison of Adalimumab to Other Targeted Therapies in Rheumatoid Arthritis: Results from Systematic Literature Review and Meta-Analysis

Few studies compared adalimumab to other targeted therapies in head-to-head randomized clinical trials (RCTs) for rheumatoid arthritis (RA), but multiple comparisons are not available. This Bayesian Network Meta-Analysis evaluated which targeted therapy is more likely to achieve ACR50 response with good safety at 24 weeks of treatment in RA. A systematic literature review was conducted for head-to-head phase 3 RCTs that compared adalimumab to other targeted therapies in combination with methotrexate (MTX) or as monotherapy to treat RA patients, and searched through MEDLINE, EMBASE, Cochrane Library and Clinicaltrial.gov. The outcomes of interest were ACR50 response and withdrawals due to adverse events at 24 weeks. WinBUGS 1.4 software (MRC Biostatistics Unit, Cambridge, UK) was used to perform the analyses, using a random effect model. Sixteen studies were included in the analysis. The most favorable SUCRA for the ACR50 response rate at 24 weeks of treatment in combination with MTX was ranked by upadacitinib, followed by baricitinib, tofacitinib and filgotinib. As monotherapy, the highest probability was ranked by tocilizumab followed by sarilumab. No significant differences in safety profile among treatment options were found. Jak-inhibitors in combination with MTX and interleukin-6 antagonism as monotherapy showed the highest probability to achieve ACR50 response after 24 weeks of treatment. None of assessed targeted therapies were associated to risk of withdrawal due to adverse events. Key messages: Direct and indirect comparison between adalimumab and other targeted therapies demonstrated some differences in terms of efficacy that may help to drive RA treatment. Jak-inhibitors and interleukine-6 antagonists ranked as first in the probability to achieve ACR50 response after 24 weeks of treatment in combination with methotrexate or monotherapy, respectively.

Estimated 10-year cardiovascular risk in a large Italian cohort of rheumatoid arthritis patients: Data from the Cardiovascular Obesity and Rheumatic DISease (CORDIS) Study Group

BACKGROUND

Several cardiovascular (CV) risk algorithms are available to predict CV events in the general population. However, their performance in patients with rheumatoid arthritis (RA) might differ from the general population. This cross-sectional multicentre study aimed to estimate the 10-year CV risk using two different algorithms in a large RA cohort and in patients with osteoarthritis (OA).

METHODS

In a consecutive series of RA patients and matched OA controls without prior CV events, clinical and serologic data and traditional CV risk factors were recorded. The 10-year CV risk was assessed with the Systematic COronary Risk Evaluation (SCORE) and the "Progetto Cuore" algorithms.

RESULTS

1,467 RA patients and 342 OA subjects were included. RA patients were more frequently diabetic (9.9% vs 6.4%; p=0.04) and smokers (20.4% vs 12.5%; p=0.002) but had lower prevalence of obesity (15% vs 21%; p=0.003). Dyslipidaemia was more prevalent in OA (32.5% vs 21.7%; p<0.0001). The 10-year estimated CV risk was 1.6% (95%CI 1.3-1.9) in RA and 1.4% (95%CI 1.3-1.6) in OA (p=0.002) according to SCORE and 6.5% (95%CI 6.1-6.9) in RA and 4.4% (95%CI 3.9-5.1) in OA (p<0.001) according to "Progetto Cuore". Regardless of the score used, RA patients had a 3- to-4-fold increased 10-year risk of CV events compared to OA subjects.

CONCLUSION

RA patients have a significantly higher 10-year risk of CV events than OA subjects. In addition to effective disease control and joint damage prevention, specific protective measures targeting modifiable traditional CV risk factors should be implemented in RA.

Safety profile and low risk of disease relapse after BNT162b2 mRNA SARS-COV-2 vaccination in patients with rare rheumatic diseases

Vaccination today represents the first defence against the effects of the Coronavirus disease 2019, mainly in rheumatic patients, where an increased risk for hospitalization and death has been reported (1,2). The previous studies on the safety and tolerability of BNT162b2 mRNA-SARS-CoV-2 (3) vaccine in patients affected with rheumatic diseases(RDs) included predominantly patients with inflammatory arthritis (4-6). This study was focused on patients affected with rare RDs and systemic lupus erythematosus (SLE) to assess the safety of the BNT162b2 mRNA SARS-CoV-2 vaccine and possible disease flares after vaccination.

Immunogenicity of BNT162b2 mRNA SARS-CoV-2 vaccine in patients with psoriatic arthritis on TNF inhibitors

BACKGROUND

Scanty data on the immunogenicity of the BNT162b2 vaccine in patients with psoriatic arthritis (PsA) on Tumor Necrosis Factor inhibitors (TNFi) have been published.

OBJECTIVE

To investigate the humoral response to BNT162b2 vaccination patients with PsA on TNFi, comparing immunogenicity with healthy controls.

METHODS

Forty patients with classified PsA on TNFi undergoing vaccination with the BNT162b2 mRNA SARS-CoV-2 vaccine (BioNTech/Pfizer) were enrolled. Fifteen days after the second shot, serum IgG levels against SARS-CoV-2 (Abbott ARCHITECT i2000SR, positivity cut-off 50 AU/mL) were assayed in all patients. Clinimetrics and treatment data were gathered. TNFi treatment was not discontinued throughout the whole period, whereas methotrexate (MTX) was discontinued for 1 week after each shot in those on combination therapy. Sera from healthcare professionals were considered as healthy controls for 1:1 propensity score matching; any of them was taking medication.Student's t-test and logistic regression were used for investigating differences in immunogenicity between groups and predictors of antibody response.

RESULTS

Clinical Disease Activity Index did not change before and after vaccination (7.06±5.23 to 7.10±5.27, p=0.92).Patients with PsA achieved a positive anti-SARS-CoV-2 IgG level with a mean (±SD) of 13794.44±15 815.42 AU/mL. Although lower, the antibody level was not significantly different from matched controls (19227.4±11.8460.45 AU/mL, p=0.08). In the overall sample, those on MTX (12/80, 15%) had a trend toward lower immune response (p=0.07); glucocorticoid therapy (11/80, 13.8%) predicted lower antibody levels (p=0.04).

CONCLUSIONS

Continuing TNFi in patients with PsA throughout the vaccination did not hamper immunogenicity.

The Impact of Biologic Drugs on High-Density Lipoprotein Cholesterol Efflux Capacity in Rheumatoid Arthritis Patients

BACKGROUND

One of the most intriguing conundrums in patients with rheumatoid arthritis (RA) is the lack of correlation between cholesterol levels and cardiovascular (CV) events, diminishing the reliability of plasmatic lipid levels in estimating the CV risk. High-density lipoprotein cholesterol efflux capacity (HDLc-EC) directly indicates the functional ability of HDL to scavenge cholesterol from vascular wall and may provide better information on the atherogenic risk. The aim of this study was to examine the effects of different disease-modifying antirheumatic drugs on HDLc-EC in RA.

METHODS

Consecutive RA patients treated with different biologic disease-modifying antirheumatic drugs or methotrexate monotherapy were longitudinally observed. Demographic and clinical features as well as lipid profile were recorded at baseline, 24-week, and 52-week follow-up. At the same time points, HDLc-EC was evaluated using J771 macrophages and a fluorometric assay.

RESULTS

We analyzed 100 RA patients on methotrexate, infliximab, tocilizumab, abatacept, or rituximab. No significant changes in the lipoprotein levels were detected, whereas the mean HDLc-EC statistically increased from baseline (22.5% ± 4.8%) to 24 weeks (24.5% ± 5.7%; p < 0.001) and 52 weeks (25.1% ± 5.9%; p < 0.001). Patients on tocilizumab showed the highest increase in HDLc-EC, already at 24 weeks. Patients on treatment with infliximab or rituximab showed a significant increase in HDLc-EC at 52 weeks. No significant changes were detected in abatacept and methotrexate groups.

CONCLUSIONS

Some treatments may impact cholesterol reverse transport in RA. The improved HDLc-EC, independently from lipid levels, may be one of the missing links between inflammation, lipids, and CV risk in RA.

Sex-related Differences in Systemic Sclerosis: A Multicenter Cross-sectional Study From the National Registry of the Italian Society for Rheumatology

OBJECTIVE

There is still a great deal to learn about the influence of sex in systemic sclerosis (SSc). In this respect, national registries provide large and homogeneous patient cohorts for analytical studies. We therefore investigated a wide-ranging and well-characterized SSc series with the aim of identifying sex differences in disease expression, with a special focus on demographic, clinical, and serological characteristics.

METHODS

A multicenter SSc cohort of 2281 patients, including 247 men, was recruited in the Italian Systemic sclerosis PRogression INvestiGation (SPRING) registry. Demographic data, disease manifestations, serological profile, and internal organ involvement were compared.

RESULTS

The overall female/male ratio was 8.2:1. Female/male ratios for limited cutaneous SSc, diffuse cutaneous SSc, and SSc sine scleroderma subsets were 8.7:1, 4.9:1, and 10.7:1, respectively. A shorter time from onset of Raynaud phenomenon to SSc diagnosis, an increased prevalence of the diffuse cutaneous subset, renal crisis, and digital ulcers were found in males, whereas a significantly higher percentage of sicca syndrome, serum antinuclear antibodies, antiextractable nuclear antigens, anti-La/SSB, and anticentromere protein B was detected in the female group. Males exhibited lower left ventricular ejection fraction, as well as higher prevalence of conduction blocks, arrhythmias, ground glass, and honeycombing. Moreover, forced vital capacity and total lung capacity were medially lower in men than in women. Finally, males were more frequently treated with immunosuppressive drugs.

CONCLUSION

Our study further supports the presence of several sex-related differences in patients with SSc. These differences were pronounced in the severity of cutaneous, peripheral vascular, and cardiopulmonary involvement for male patients, whereas an increased prevalence of sicca syndrome and a specific autoantibody profile characterized the female sex.

Impaired immunogenicity to COVID-19 vaccines in autoimmune systemic diseases. High prevalence of non-response in different patients' subgroups

Autoimmune systemic diseases (ASD) may show impaired immunogenicity to COVID-19 vaccines. Our prospective observational multicenter study aimed to evaluate the seroconversion after the vaccination cycle and at 6-12-month follow-up, as well the safety and efficacy of vaccines in preventing COVID-19.

The study included 478 unselected ASD patients (mean age 59 ± 15 years), namely 101 rheumatoid arthritis (RA), 38 systemic lupus erythematosus (SLE), 265 systemic sclerosis (SSc), 61 cryoglobulinemic vasculitis (CV), and a miscellanea of 13 systemic vasculitis. The control group included 502 individuals from the general population (mean age 59 ± 14SD years). The immunogenicity of mRNA COVID-19 vaccines (BNT162b2 and mRNA-1273) was evaluated by measuring serum IgG-neutralizing antibody (NAb) (SARS-CoV-2 IgG II Quant antibody test kit; Abbott Laboratories, Chicago, IL) on samples obtained within 3 weeks after vaccination cycle.

The short-term results of our prospective study revealed significantly lower NAb levels in ASD series compared to controls [286 (53–1203) vs 825 (451–1542) BAU/mL, p < 0.0001], as well as between single ASD subgroups and controls. More interestingly, higher percentage of non-responders to vaccine was recorded in ASD patients compared to controls [13.2% (63/478), vs 2.8% (14/502); p < 0.0001]. Increased prevalence of non-response to vaccine was also observed in different ASD subgroups, in patients with ASD-related interstitial lung disease (p = 0.009), and in those treated with glucocorticoids (p = 0.002), mycophenolate-mofetil (p < 0.0001), or rituximab (p < 0.0001). Comparable percentages of vaccine-related adverse effects were recorded among responder and non-responder ASD patients.

Patients with weak/absent seroconversion, believed to be immune to SARS-CoV-2 infection, are at high risk to develop COVID-19. Early determination of serum NAb after vaccination cycle may allow to identify three main groups of ASD patients: responders, subjects with suboptimal response, non-responders. Patients with suboptimal response should be prioritized for a booster-dose of vaccine, while a different type of vaccine could be administered to non-responder individuals.

Covid-19 And Rheumatic Autoimmune Systemic Diseases: Role of Pre-Existing Lung Involvement and Ongoing Treatments

BACKGROUND

The Covid-19 pandemic may have a deleterious impact on patients with autoimmune systemic diseases (ASD) due to their deep immune-system alterations.

OBJECTIVE

To investigate the prevalence of symptomatic Covid-19 and its correlations with both organ involvement and ongoing treatments in a large series of Italian ASD patients during the first wave of pandemic.

METHOD

Our multicenter telephone 6-week survey included 3,029 unselected ASD patients enrolled at 36 tertiary referral centers of northern, central, and southern Italian macro-areas with different diffusion of pandemic. Symptomatic SARS-CoV-2 infection was classified as definite Covid-19 (presence of symptoms plus positive oral/nasopharyngeal swabs) or highly suspected Covid-19 (highly suggestive symptoms, in absence of a swab testing).

RESULTS

A significantly higher prevalence of definite plus highly suspected Covid-19 compared to Italian general population was detected in the whole ASD series (p=.000), as well as in patients from the three macro-areas (p=.000 in all). Statistically higher prevalence of Covid-19 was also found in connective tissue diseases compared to chronic arthritis subgroup (p=.000) and in ASD patients with pre-existing interstitial lung involvement (p=.000). Patients treated with either conventional disease modifying anti-rheumatic drugs (DMARDs) and/or biological DMARDs showed a significantly lower prevalence of Covid-19 (p=.000 in both). Finally, scleroderma patients undergoing low-dose aspirin showed significantly lower rate of Covid-19 compared to those without (p=0.003).

CONCLUSION

The higher prevalence of Covid-19 in ASD patients along with the significant correlations with important clinical features and therapeutic regimens suggests the need to develop targeted prevention/management strategies during the current pandemic wave.

Body mass index and adipokines/cytokines dysregulation in systemic sclerosis

Body fat has regulatory functions through producing cytokines and adipokines whose role in the pathogenesis of systemic sclerosis (SSc) is currently emerging. Changes in body mass, either over‐ or underweight, entail a dysregulation of the cytokine/adipokine network that may impact upon SSc disease activity. We evaluated serum levels of adipokines and cytokines in SSc patients and correlated them to clinical features and body mass index (BMI) categories. The study included 89 SSc patients and 26 healthy donors (HD). Serum levels of adiponectin, leptin, resistin, visfatin, tumor necrosis factor (TNF)‐α, interferon (IFN)‐γ, interleukin (IL)‐2, IL‐10 and IL‐17A were measured by multiplex immunoassay and correlated to BMI and disease‐specific features. Student’s t‐test or analysis of variance (ANOVA) were used for comparisons between groups. Spearman’s or Pearson’s tests were used for correlation analysis. Serum levels of TNF‐α, IL‐2, leptin and resistin were significantly higher in SSc than in HD. Leptin levels were significantly higher in interstitial lung disease (ILD)‐ and pulmonary arterial hypertension (PAH)‐SSc subgroups. The highest levels of IL‐17A, IL‐2, IL‐10, leptin and visfatin were detected in SSc patients with obesity (p < 0.01). Conversely, underweight SSc patients showed the highest TNF‐α levels (p < 0.05). Adipokines, IL‐2, IL‐10 and IL‐17A were found to be increased in SSc patients with obesity, but whether or not they play a role in the pathogenesis of the disease remains to be investigated. Intriguingly, underweight patients had the highest TNF‐α levels, suggesting a potential role of TNF‐α in inducing the cachexia observed in long‐lasting disease.

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

Figure 1.

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

References:

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

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

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

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

Disclosure of Interests:

None declared

AB0380 MACHINE LEARNING CAN PREDICT GIANT CELL ARTERITIS RELAPSE AFTER GLUCOCORTICOID TAPERING

Background:

To date reliable biomarkers and risk factors for relapsing giant cell arteris (GCA) after glucocorticoid (GC) tapering are still lacking.

In an increasing number of social and clinical scenarios, machine learning (ML) is emerging as a promising tool for the implementation of complex multi-parametric decision algorithms. A ML approach allows to handle complex non-linear relationships between patient attributes that are hard to model with traditional statistical methods, merging them to output a forecast or a probability for a given outcome.

Objectives:

To assess whether ML algorithms can predict GCA relapse after glucocorticoid tapering.

Methods:

GC-naïve GCA patients who presented to 4 tertiary care centers between January 2015 and January 2019, who underwent GC therapy and regular follow up visits for at least 12 months were retrospectively analyzed and used for training and validation (through 10-fold cross-validation) of n.2 ML algorithms, namely Decision Trees (DT) and Random Forest (RF).

Test of the algorithms was carried out GCA patients referred to the same centers from March 2019 to September 2020 whose data was longitudinally recorded during the 12 months after presentation.

Demographic, clinical an laboratory characteristics (Erythrocyte Sedimentation Rate (ESR) and C Reactive Protein (CRP) levels) were gathered.

The outcome of interest was the GCA relapse within 12 months after induction of remission, during GC tapering.

The accuracy of the algorithms in both validation and test phases was assessed.

Results:

The training and validation dataset consisted of n.85 GCA patients (59 female, 69.4%) with mean age 73.8 (±8.7) years at presentation. They were treated with 27.1 (±17.4) mg prednisone (PDN) equivalent at first visit. During GC tapering 34 of them (40%) experienced a disease relapse within 12 months. The test dataset consisted of n.22 patients (14 female, 63.4%) with mean age 75.5 (±8.7) years at presentation, who underwent GC induction therapy with a mean dose of 30.3 (±17.3) mg PDN equivalent. Nine of them (40.9%) had a GCA flare during GC tapering, within 12 months. Accuracy of DT and RF in predicting the outcome of interest on the training dataset was 68.3% and 73.4% respectively. On testing datasets DT and RF accuracy was 57.1 and 72.4%, respectively.

As shown in Figure 1, the most important patient attributes for RF forecast were found to be CRP and ESR baseline levels as well as age and symptom duration (months) at first visit.

Conclusion:

RF algorithm can predict GCA relapse after glucocorticoid tapering with fairly good accuracy. To date this is one of the most accurate predictive modeling for such outcome. This ML method represents a reproducible tool executable on computers as well as mobile devices and capable of supporting clinicians in GCA patient management.

References:

[1]Hellmich B., Agueda A., Monti S., et al. 2018 Update of the EULAR recommendations for the management of large vessel vasculitis Annals of the Rheumatic Diseases 2020;79:19-30.

[2]Venerito, V., Angelini, O., Cazzato, G. et al. A convolutional neural network with transfer learning for automatic discrimination between low and high-grade synovitis: a pilot study. Internal and Emergency Medicine 2021.

Disclosure of Interests:

None declared

POS1437 LATENT TUBERCULOSIS INFECTION IN RHEUMATIC DISEASES: A REAL-LIFE STUDY OF THREE APULIAN CENTRES. DATA FROM BIOPURE REGISTRY

Background:

Latent tuberculous infection (LTBI) is very common in the world and screening for it is essential before starting treatment with biotechnological drugs

Objectives:

The aims of our study were to assess the prevalence in Apulia of LTBI among patients affected with rheumatic disease and to record the cases of tuberculosis (TB) infection among patients treated with biologic agents.

Methods:

We analysed data of patients included in BIOPURE registry from 2008 to 2018, who underwent Quantiferon (QTF) test as routinely screening for biologic treatment. Demographic and clinical data were recorded at the time of the first QTF assessment and this time point was considered the “baseline” of the study. Data regarding further QTF tests performed during follow-up was also acquired by electronic charts. Prophylaxis administration and bDMARD treatments were recorded for patients with positive QTF test. All tuberculosis infections were recorded during the entire time of follow-up.

Results:

Three thousand thirty-five patients (female 67.2%, mean age 52 ± 18.3 years) were included in these study, 2692 patients (88.7%) had inflammatory arthritis (28.2% rheumatoid arthritis, 33% psoriatic arthritis and 27.4% spondyloarthritis), 129 (4.2%) patients had connective tissue disease, whereas 214 (7.1%) patients were affected by others rheumatic diseases. The prevalence of LTBI was 10.7% (326 patients) at baseline. Comparisons between positive and negative patients for QTF are reported in Table 1. We acquired data of LTBI prophylaxis of 284 patients; 235 out 265 patients treated with isoniazid completed the treatment, whereas 19 out 19 patients treated with rifampicin completed the prophylaxis regimen. The main cause of isoniazid withdrawal was hypertransaminasemia, but 8 patients then completed prophylaxis with rifampicin. During the entire follow-up (42.6±30.5 months), we recorded 5 (0.02%) cases of primary TB infection in patients on anti-TNFα agents treatment, which had baseline screening negative for LTBI. Data and outcome of these patients are reported in Table 2. The mean time of follow-up of patients on bDMARDs treatment with positive QTF at baseline was 52.7±35.2 months. bDMARD treatment regimens are reported in Table 3. No case of TB reactivation was found among patients with positive baseline QTF. Moreover, of 1563 (51.5%) patients who repeated QTF during follow-up, 62 (4%) of them showed a change in the test result. We observed a change to a positive state in 36 patients with previous negative QTF test, whereas 26 patients with previous positive QTF showed a shift to a negative test during follow-up.

Conclusion:

Our study shows a prevalence of LTBI of 10.7% in Apulian patients affected with rheumatic disease. bDMARDs therapy appears to be safe in patients with positive QTF test treated according to current recommendations1. However, cases of primary TB infections, especially in patients receiving anti-TNFα drugs, have been observed.

References:

[1]Cantini F, et al, Guidance for the management of patients with latent tuberculosis infection requiring biologic therapy in rheumatology and dermatology clinical practice, Autoimmun Rev (2015).

Disclosure of Interests:

None declared

POS0214 ASSOCIATION BETWEEN C-REACTIVE PROTEIN AND 10-YEAR RISK OF CARDIOVASCULAR DISEASE IN RHEUMATOID ARTHRITIS USING THE ERS-RA SCORE: A CROSS-SECTIONAL ANALYSIS OF THE CORDIS COHORT

Background:

Rheumatoid arthritis (RA) is associated with an increased risk of atherosclerotic cardiovascular disease (CVD). The Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis (ERS-RA) estimates the 10-year risk of myocardial infarction, stroke or CVD-related death based on conventional and RA-specific (clinical disease activity index, CDAI, disease duration, glucocorticoid use) risk factors (1).

Objectives:

We evaluated the associations between ERS-RA 10-year risk of CVD, high-sensitivity C-reactive protein (hs-CRP) concentrations, and pharmacological treatment in 1,251 RA patients collected by the “Cardiovascular Obesity and Rheumatic Disease Study (CORDIS)” group of the Italian Society of Rheumatology (SIR).

Methods:

We assessed independent associations between ERS-RA risk score and each relevant variable using multivariate regression (ENTER approach; listwise deletion analysis). Given the relatively high number of missing hs-CRP data (n=385), regression analysis was also performed using multiple imputation (10 sets, Stata 16.1). Regression models were not adjusted for independent variables included in the ERS-RA score.

Results:

Among 1,251 RA patients [mean (SD) age 60.4(9.3), range (40-80) years; 78% female; mean (SD) disease duration, 11.6(8) years; mean (SD) CDAI, 9(9); mean (SD) HAQ, 0.77(0.7); mean (SD) hs-CRP, 6.8(12) mg/L] the estimated 10-year CVD risk was 11.6(0.9) % [mean (SD)]. Regarding treatment, 539(43%) received glucocorticoids, 676(54%) a biological or targeted synthetic disease-modifying anti-rheumatic drug (b/tsDMARD) (n missing=1), and 885(81%) at least one conventional synthetic DMARD (csDMARD). Ninety-three (7.4%) patients did not receive any treatment. After adjusting for the use of b/tsDMARD and csDMARD, hs-CRP concentrations were significantly associated with 10-year risk of CVD both in standard multiple regression (n=865; coefficient=0.005 for each 10 mg/L hs-CRP increment, 95% confidence interval (0.000-0.100), p=0.043) and after multiple imputation (n=1,251; coefficient=0.005 for each 10 mg/L hs-CRP increment, 95% confidence interval (0.000-0.114), p=0.035) (Table 1). This corresponds to an increase of 10-year CV risk of 1% for every 20 mg/L increase in hs-CRP concentrations.

Conclusion:

In a large cohort of RA patients, we observed a significant, positive, and independent association between hs-CRP concentrations and 10-year CV risk estimated by ERS-RA. The cross-sectional design of the study did not allow to establish a cause-effect relationship between hs-CRP and CV risk. Given that conventional CV risk factors and inflammation-related variables are accounted for in the ERS-RA risk score, other, unexplored, mechanisms may underlie the observed association between hs-CRP and CV risk.

References:

[1]Solomon, D. H., et al. “Derivation and internal validation of an expanded cardiovascular risk prediction score for rheumatoid arthritis: a Consortium of Rheumatology Researchers of North America Registry Study.” Arthritis & rheumatology 67.8 (2015): 1995-2003.

Table 1.

Multiple regression models

Model 1n= 865Model 2n= 1, 251ERS-RA scoreCoefficient95% CI, pCoefficient95% CI, phs-CRP, every 10 mg/L increment0.0050.000 to 0.100, 0.0430.0050.000 to 0.011, 0.035b/tsDMARD use-0.002-0.005 to 0.001, 0.199-0.000-0.002 to 0.002, 0.963csDMARD use0.002-0.003 to 0.007, 0.3940.002-0.002 to 0.006, 0.371Prob >F, model with only CRP0.030.03Prob >F, full model0.070.08

A multiple linear regression (ENTER method) was performed for the dependent variable ERS-RA score using a listwise deletion analysis (Model 1) and a multiple imputation analysis (Model 2).

Disclosure of Interests:

None declared

POS0631 COMPARATIVE EFFICACY OF COMBINATION THERAPY WITH BIOLOGIC OR TARGET SYNTHETIC DRUGS FOR RHEUMATOID ARTHRITIS: A BAYESIAN NETWORK META-ANALYSIS

Background:

Biologic agents and small molecules have shown long term benefit when added in patients with active RA non-responders to conventional DMARDs treatment (1). In head-to-head trials only adalimumab was compared to other drugs in combination with methotrexate, with some evidence of superiority but no data on multiple comparisons have been reported (2). The availability of biosimilar agents led in clinical practice to prefer mainly the cheaper one, so the choice of the most effective treatment remains a clinical unmet need (3).

Objectives:

To assess the relative efficacy of different therapeutic strategies for achieving ACR50 response at 24 weeks of treatment in patients with active RA, based on direct and indirect evidence.

Methods:

We performed systematic reviews of MEDLINE, EMBASE, and Cochrane Library databases, searching for all published phase 3 Randomised Controlled Trials (RCTs) comparing adalimumab originator to its biosimilars, abatacept, baricitinib, certolizumab pegol, tofacitinib or upadacitinib, combined to MTX, in patients with active RA inadequate responders to previous conventional DMARDs. American College of Rheumatology (ACR) 50% response at 24 weeks of treatment had to be evaluated both in adalimumab branch and in examined drug branch. Bayesian fixed-effect network meta-analysis was performed to combine the direct and indirect evidence using the WinBUGS 1.4 software (MRC Biostatistics Unit, Cambridge, UK).

Results:

Eleven RCTs evaluating 6’004 patients were included in the analysis, namely originator (1) and biosimilars (2) adalimumab, abatacept (3), baricitinib (4), certolizumab pegol (5), tofacitinib (6) and upadacitinib (7). Convergence was reached at n.100’000 iterations. Upadacitinib seems to be more effective than both originator and biosimilar adalimumab in achieving ACR 50 (OR 1.65 95% CI 1.25-2.14 and OR 1.22 95%CI 1.10-2.18; see Figure 1). Similarly, tofacitinib was more effective of originator adalimumab (OR 1.25 95%CI 1.01-155). Upadacitinib was ranked first among treatments with a probability of being the agent more likely to induce ACR 50 response of 86.3%. In this regard tofacitinib had a probability of 4.8%, hence it was ranked second among treatments.

Figure 1.

Caterpillar plot OR for ACR50 at 24 weeks (originator [1] and biosimilars [2] adalimumab; abatacept [3]; baricitinib [4]; certolizumab pegol [5]; tofacitinib [6]; upadacitinib [7]).

Conclusion:

Although patients with active RA and inadequate response to MTX have different therapeutic combination of biologics or small molecules options, the best relative efficacy in terms of ACR50 response after 24 weeks of treatment is for upadacitinib 15 mg/day.

References:

[1]Smolen JS, et al. Annals of the Rheumatic Diseases 2020;79:685-699.

[2]Combe B, Lukas C. Joint Bone Spine, 2020,105004.

[3]Caporali R, et al. Biomed Res Int. 2018 Sep 9;2018:3878953.

Disclosure of Interests:

Fabio Cacciapaglia Speakers bureau: Roche, Pfizer, Eli Lilly, MSD, UCB, BMS, Abbvie, Vincenzo Venerito: None declared, Stefano Stano: None declared, Marco Fornaro: None declared, Giuseppe Lopalco Speakers bureau: Celgene, BMS, Abbvie, Novartis, Florenzo Iannone Speakers bureau: Roche, Pfizer, Eli Lilly, MSD, UCB, BMS, Abbvie, Novartis, Celgene

High disease relapse after bDMARD spacing in psoriatic arthritis compared to rheumatoid arthritis and axial spondyloarthritis patients: real-life data from BIOPURE registry

The objective is to evaluate the effectiveness of a spacing strategy of bDMARDs in a cohort of selected patients in disease remission or low-disease activity (LDA) without glucocorticoids affected with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA). This was a single-centre study carried out on patients prospectively enrolled in the biologic Apulian registry. Patients whose disease was in remission or LDA without taking glucocorticoids during the previous 6 months and who had agreed to increase the time interval between bDMARD doses were included in this study. Demographic and clinical characteristics were recorded at baseline and at 3, 6 and 12 months of follow-up. Endpoint of the study was the survival of spacing doses in the time lag of the study. Failure of spacing was defined as the first flare of disease. Thirty-seven RA, 28 PsA and 20 axSpA patients underwent bDMARD spacing according to a local strategy. During the follow-up, 5 RA, 6 PsA and 4 axSpA patients had a joint flare, but further 5 PsA patients manifested a skin relapse. Global persistence was 86.5% for RA (MST = 41 (95% CI: 37-45) months) and 80% for axSpA patients (MST = 36 (95% CI: 31-42) months). PsA patients showed a lower persistence, being of 60.7% (MST = 30 (95% CI: 23-36) months) (log-rank test, p = 0.03). Dose reduction by spacing bDMARD doses may be a feasible approach in patients with persistent remission/LDA activity. However, PsA patients might have greater odds of spacing failure because of skin psoriasis relapse. Key Points • Spacing of bDMARDs may be a feasible strategy for some patients with rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis who achieve the target and withdrawn glucocorticoids. • Psoriatic arthritis patients showed lower persistence because of both articular and skin relapses.

Predictors of long-term clinical remission in rheumatoid arthritis

AIM

Little is known about possible predictors of long-term survival on biologic disease-modifying antirheumatic drugs (bDMARD) after achievement of deep clinical remission in rheumatoid arthritis (RA) patients. We aimed at assessing factors associated with drug persistence of the first bDMARD in RA patients who achieved Simplified Disease Activity Index (SDAI) remission.

METHODS

The clinical charts of RA patients beginning a first bDMARD were retrospectively reviewed, and those who achieved SDAI-based remission were selected for this analysis. Drug retention rate and mean survival time (MST) were estimated using Kaplan-Meier curves, and hazard ratios (HRs) of discontinuing bDMARD were estimated by multivariate Cox-regression models.

RESULTS

Eight-six patients were on SDAI remission, and the survival rate of bDMARDs since 'baseline-time' was 82.6% (MST = 77.8 (95% CI: 69-86) months). Once on remission, patients not taking concomitant glucocorticoids had significantly higher survival rate (90.7%, MST = 86.3 (95% CI: 78-95) months) than patients who continued to intake low dose of glucocorticoids (68.8%, MST = 56.9 (95% CI: 45-69) months; P = .008). On the contrary, those patients assuming methotrexate (MTX) had significantly higher survival (87.7% (MST = 81.8 (95% CI: 73-91) months) than patients who were not taking MTX (66.7% (MST = 55.3 (95% CI: 40-71) months) (log-rank 4.72, P = .03). After the achievement of disease remission, stopping glucocorticoids (HR 0.31, 95% CI: 0.10-0.93) and methotrexate co-therapy (HR 0.34, 95% CI: 0.12-0.98) were independently associated with a lower risk of bDMARD discontinuation.

CONCLUSIONS

Among RA patients on clinical remission with a first bDMARD, those stopping glucocorticoids and continuing MTX had much longer survival on bDMARD.

Pulmonary arterial hypertension: guidelines and unmet clinical needs

The term pulmonary arterial hypertension (PAH) identifies a heterogeneous group of diseases characterized by a progressive increase in pulmonary arterial resistance (PVR), which causes a significant burden in terms of quality of life, right heart failure and premature death. The pathogenesis of PAH is not completely clear: the remodeling of the small pulmonary vessels is crucial, causing an increase in the resistance of the pulmonary circle. Its diagnosis is based on cardiac catheterization of the right heart. According to the present hemodynamic definition of pulmonary hypertension (PH) proposed by the Guidelines of the European Society of Cardiology/European Respiratory Society (ESC-ERS), the mean pulmonary arterial pressure (mPAP) values are ≥25 mmHg. In case of PAH, apart from an mPAP value ≥25 mmHg, patients must have a >3 Wood units increase in PVR and normal pressure values of the left heart. PH is a pathophysiological condition observed in more than 40 different diseases, while PAH is a primary disease of the pulmonary bloodstream potentially treatable with specific drugs. PAH is a severe complication of systemic sclerosis (SSc) affecting about 10% of the patients. Due to the devastating nature of SSc-PAH, there is a clear need to systematically adopt appropriate screening programs. In fact, despite awareness of the negative impact of SSc-PAH on quality of life and survival, as well as on the severity of lung function, at the moment standardized and shared guidelines and/or screening programs for the diagnosis and the subsequent early treatment of PAH in SSc are not available. The aim of the present paper is to highlight the lights and shadows of SSc-PAH, unraveling the unmet clinical needs on this topic with a proposal of clinical-diagnostic and therapeutic guidelines.