Juvenile and adult-onset scleroderma: different clinical phenotypes

OBJECTIVES

Systemic sclerosis (SSc) represents extremely rare disease with majority of data coming from adults. Studies comparing juvenile- (jSSc) and adult-onset (aSSc) patients are limited. We aimed to compare clinical features, treatment modalities and survival rates of jSSc and aSSc patients.

METHODS

A retrospective study among pediatric and adult Scl patients has been performed. Demographic characteristics, clinical features, autoantibody profiles, and treatment data were retrieved from the databases. Survival analysis was done using Kaplan-Meier plot and factors associated with mortality were identified with multiple regression analysis.

RESULTS

A total of 158 adults and 58 juvenile Scl patients were identified. The mean age at the disease onset was 37±14.7 vs. 8.8 ± 4.1 years, mean age at diagnosis 42±15.2 vs. 10.4 ± 3.8 years and mean follow-up duration was 6.3 ± 4.9 years vs. 6.6 ± 4.9 years for aSSc and jSSc patients, respectively. The frequency of interstitial lung disease (ILD) (50.9% vs 30%, p<0.001) and systemic hypertension (17.9% vs 0, p = 0.009) was significantly higher among aSSc. While aSSc patients had presented mostly with limited cutaneous subset (74.1%), diffuse cutaneous subset was the dominant subset among jSSc (76.7%), (p<0.001). The mortality rate was significantly higher among adults (p = 0.005). The ILD (p = 0.03) and cardiac insufficiency (p = 0.05) were independent risk factors of mortality in both aSSc and jSSc patients.

CONCLUSION

Juvenile and adult-onset Scl represent rarely seen conditions with different clinical phenotypes. Pediatric patients with LS are more commonly seen by pediatric rheumatologists, in contrary to adults. Diffuse disease subset is the dominant form among juvenile patients, whereas limited form is the main disease subset among adults. On the other hand, juvenile-onset patients have a better survival than those with adult-onset.

AB1082 FREQUENCY AND SEVERITY OF COVID-19 IN PATIENTS WITH VARIOUS RHEUMATIC DISEASES TREATED REGULARLY WITH COLCHICINE OR HYDROXYCHLOROQUINE

Background

Several anti-inflammatory drugs which were targeted different mechanisms and investigated for both prevention and treatment for COVID-19.

Objectives

The current study aimed to investigate whether patients regularly using colchicine or hydroxychloroquine (HCQ) have an advantage of protection from COVID-19 or developing less severe disease.

Methods

Patients who were taking colchicine or HCQ regularly for a rheumatic disease including Familial Mediterranean Fever, Behçet’s syndrome, Systemic Lupus Erythematosus, Rheumatoid Arthritis and Sjogren’s syndrome as well as their healthy household contacts as the control group were included into the study. The clinical data regarding COVID-19 were collected using a standard form, and serum samples were analyzed for anti-SARS-COV-2 nucleocapsid IgG. Patients treated with any biologic or immunosuppressive treatments were not included into the study.

Results

A total of 635 regular colchicine users with their 643 household contacts and 317 regular HCQ users with their 333 household contacts were analyzed. Anti-SARS-Cov2 IgG was positive in 43 (6.8%) regular colchicine users and 35 (5.4%) household contacts (OR=1.3; 95% CI:0.8-2; p=0.3) (Table 1). COVID-19 related symptoms were described by 29 (67.4%) of the patients and 17 (48.6%) household contacts (OR=2.2; 95% CI:0.9-5.5; p=0.09), and hospital admission was observed in five (11.6%) and one (2.9%) of these subjects (OR=4.5; 95% CI:0.5-40.2; p=0.1), respectively (Figure 1). Seropositive subjects were observed in 22 (6.9%) regular HCQ users and 24 (7.2%) household contacts (OR=1.1; CI:0.6-1.9; p=0.8) (Table 1). COVID-19-related symptoms occurred in 16 (72.7%) of the 22 patients and 12 (50%) of 24 household contacts (OR=2.7; 95% CI:0.8-9.1; p=0.1). Three patients (13.6%) were admitted to hospital, while one household contact (4.2%) was hospitalized (OR=3.6; 95% CI:0.3- 37.8; p=0.2) (Figure 1). Disease-specific analyses disclosed that there was no significant difference in terms of COVID-19 frequency and severity between a particular disease subset and household contacts (Table 1). Univariate logistic regression analysis showed no effect of age and gender on the SARS-CoV-2 seroprevalence rate among regular colchicine or HCQ users and household contacts (p=0.2 and p=0.7, respectively for colchicine users versus contacts, p=0.7 and p=0.3, respectively for HCQ users versus contacts).

Figure 1.

Severity of COVID-19 in regular colchicine or HCQ users and these patients’ household contacts

Table 1.

Disease specific outcomes of the entire cohort

VariableFMF (n=373)FMF HHC* (n=386)PBehcet Patients (n=262)Behcet HHC (N=257)PSLE Patients (N=197)SLE HH (n=221)pRA Patients (n=79)RA HH (n=73)PSjögren patients (N=41)Sjögren HH (N=39)pAge, mean ± SD years36.4 ± 13.236.3 ± 16.10.942.9 ± 11.438.1 ± 15.20.00144.2 ± 12.639.4 ± 170.00253.9 ± 10.340.3 ± 16.60.00157.1 ± 11.246.2 ± 16.10.001Gender, n (%) Female249 (66.8)173 (44.8)0.001160 (61.1)118 (45.9)0.001184 (93.4)75 (33.9)0.00173 (61.1)20 (27.4)0.00141 (100)10 (25.1)0.001Positive antibody to SARS-COV-2, n (%)25 (6.7)23 (5.9)0.618 (6.9)12 (4.7)0.314 (7.1)19 (8.6)0.64 (5.1)2 (2.7)0.54 (9.8)3 (7.7)0.9Symptomatic COVID-19 in seropositive cases, n (%)18 (72)10 (43.4)0.0411 (61.1)7 (58.3)0.611 (78.6)9 (47.3)0.073 (75)0 (0)0.42 (50)3 (100)0.4Hospital admission in seropositive cases, n (%)1 (3.8)0 (0)-4 (22.2)1 (8.3)0.32 (14.3)0 (0)0.21 (25)0 (0)-1 (25)1 (33.3)0.3Mean colchicine dose, mg/day ± SD1.5 ± 0.4--1.4 ±0.4-----------Mean duration of colchicine usage, years ± SD11.3 ± 8.3--10.4 ± 7.7-----------Mean HCQ dose, mg/day ± SD------263.6 ± 95.1--255 ± 90.8--273.7 ± 132.5--Mean duration of HCQ usage, years ± SD------10.1 ± 6.6--7.3 ± 5.2--9 ± 6.3--

HCQ hydroxychloroquine, FMF familial mediterranean fever, HHC household contacts, RA rheumatoid arthritis, SLE systemic lupus erythematosus

Conclusion

Being on a regular treatment of colchicine or HCQ was not resulted in the prevention of COVID-19 or amelioration of its manifestations.

Disclosure of Interests

None declared

POS1363 THE VALIDITY AND RELIABILITY OF THE TURKISH VERSION OF BEHÇET’S SYNDROME OVERALL DAMAGE INDEX IN A RETROSPECTIVE COHORT

Background

Behçet’s syndrome Overall Damage Index (BODI) is a newly developed damage index specific to Behçet syndrome (BS).

Objectives

We aimed to evaluate validity, reliability and feasibility of the Turkish version of BODI and evaluate its performance for use in retrospective cohort studies for different phenotypes of BS.

Methods

The study included 295 patients with at least 3 visits at 6 months intervals out of 590 consecutive BS patients who were admitted between January 2015 and August 2017. Turkish version of the BODI form was developed by translating into Turkish and backwards by 2 people. BODI scores were calculated for each year during the follow-up period. The test-retest reliability of BODI was assessed by scoring the same 50 patients at 6-month intervals by the same observer (YYO). Two different observers (YYO- YO) assessed the same 50 patients for inter-observer agreement. The intra-class correlation coefficient (ICC) was used to assess the inter and intra-observer agreement. We also evaluated the median time to fill out the form in patients with different types of involvements.

Results

Among the 295 (158 F/137 M) patients, mean age was 39 (9.9) and the mean disease duration was 8.8 (5.9) years. Clinical features of BS patients were summarized in the Table 1. BODI median score was 1 (IQR=0-1). We observed an increase in BODI score in 111 (38%) patients during follow-up. The main reasons for increasing BODI scores were eye, vascular and neurological involvement (Table 1). The mean ICC for inter-observer agreement was 0.94 (95% CI, 0.89-0.96) and for intra-observer agreement was 1. The median (range) time to complete the form was 2 (1-8) minutes.

Table 1.

Clinical features and BODI scores of Behçet syndrome patients.

Oral ulceration99.7Genital ulceration81.3Erythema nodosum57.1Papulopustular lesions89.5Joint involvement25.2Ocular involvement47.3Vascular involvement21.4Neurologic involvement3.1Gastrointestinal involvement2.7N of patients with more than 3 BODI scores*(%)194 (66)Causes for increase in BODI score**(n=111) (%)Ocular involvement77 (69)Vascular involvement17 (15)Neurological involvement8 (7)Gastrointestinal involvement3 (3)Mucocutaneous inv.6 (5)Cardiovascular inv.1 (0.9)Diabetes mellitus4 (4)Avascular necrosis2 (2)Osteoporosis related fracture1 (0.9)

*All patients had at least 3 BODI scores,

**Some patients had more than 1 type of involvement

Conclusion

This study showed that the Turkish version of BODI was a reliable and feasible instrument that could capture the change over time in damage, and could be used in retrospective cohort studies. Ocular involvement was the most common cause of progressive damage in this cohort.

Disclosure of Interests

Yeliz Yagiz Ozogul: None declared, Yesim Ozguler Speakers bureau: Yesim Ozguler has received honorariums for presentations from UCB Pharma, Novartis, and Pfizer., Didar Ucar: None declared, Ugur Uygunoglu: None declared, Zekayi Kutlubay: None declared, Vedat Hamuryudan Speakers bureau: Vedat Hamuryudan has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma., Grant/research support from: Vedat Hamuryudan has received grant/research support from Celgene, Gulen Hatemi Speakers bureau: Gulen Hatemi has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma., Grant/research support from: Gulen Hatemi has received grant/research support from Celgene.

AB1308 MYCOPHENOLATE FOR THE TREATMENT OF EYE INVOLVEMENT IN PATIENTS WITH BEHÇET’S SYNDROME

Background

Experience with mycophenolate in uveitis associated with Behçet’s syndrome (BS) is limited.

Objectives

We aimed to report the efficacy and safety of mycophenolate mofetil (MMF) and mycophenolate sodium (MPA) in the treatment of BS uveitis.

Methods

All patients with panuveitis or posterior uveitis who used mycophenolate for eye involvement between 2016 and 2018 were included. Patient charts were reviewed and data on demographic features, previous immunosuppressives, concomitant therapies, ocular attacks and outcome, and adverse events were extracted. Follow up was ended on October 2021.

Results

We included 12 BS patients (M/W: 8/4, mean age: 35±7 years) treated with mycophenolate during a mean follow-up of 42±19 months (Table 1). All but 3 patients had bilateral eye involvement. IFX and INF-α had been discontinued due to adverse events in all patients, AZA in 10/12, and Cy-A in 7/10.

Table 1.

Demographic, treatment and outcome of the 12 patients

Age /genderPrevious therapiesRemission induction or Maintenance therapyConcomitant biologicTime to ocular attack (months)Treatment after ocular attackAt the end of the follow-upMMF duration (months)25/MAZA,Cy-ARemission inductionNone2ADA was addedADA and MPAa were switched to INF due to further ocular attacks3842/WAZA,Cy-A, INF, IFXRemission inductionIFXN/AN/AStill on IFX and MMF7237/MAZA,Cy-A, INF, IFX, ADARemission inductionADAN/AN/AStill on ADA and MMF2732/MAZARemission inductionNone12IFX was addedStill on IFX and MMF5233/WAZA, Cy-A, INF, ADA, IFXRemission inductionNoneN/AN/AMPAb was switched to certolizumab and MTX524/MAZARemission inductionIFXN/AN/AStill on MMF and IFX was stopped due to remission6337/MAZA, Cy-ARemission inductionNone6IFX was addedIFX and MMF were switched to INF due to further ocular attacks4136/WAZA,Cy-A, INFMaintenanceNone2ADA was addedStill on ADA and MMF5036/MAZA,Cy-A, INF, IFXMaintenanceIFXN/AN/AStill on IFX and MMF was stopped due to remission1749/WAZA,Cy-A, INFMaintenanceNoneN/AN/AStill on MMF3937/MAZA, INFMaintenanceNone31Cy-A was addedStill on MMF and Cy-A38 d31/MAZA, Cy-A, INFMaintenanceNone5IFX was addedOff treatment for 2 years38

a MMF was switched to MPA due to numbness in hands and feet, and MPA was stopped due to arthralgia.

b MMF was switched to MPA due to diarrhea

Seven patients were prescribed mycophenolate for remission induction. One of these patients had had his first uveitis attack while on AZA treatment due to gastrointestinal involvement. The remaining 6 patients were using other immunosuppressives and experienced relapses that led to mycophenolate use. MMF was added to a biologic agent in 2 patients (IFX and ADA) and was initiated in combination with IFX in 1 patient. These 3 patients did not experience further ocular attacks and IFX was stopped due to remission in 1 patient. In the fourth patient, MMF was switched to MPA due to numbness in hands and feet and MPA was stopped due to arthralgia. This patient did not experience ocular attacks during 5 months of MPA therapy. The remaining 3 patients had further uveitis attacks without decrease in visual acuity 2, 6, and 12 months after MMF initiation, and IFX was added in 2 patients, and ADA in 1 patient. Two of these patients were switched to INF-α due to uveitis relapses. MMF was switched to MPA for diarrhea in 1 patient.

Five patients had received MMF for maintenance. One of these was using IFX when MMF was started and these 2 agents were used together. This patient discontinued MMF due to remission 17 months after MMF initiation and is still on IFX monotherapy. The second patient is still on MMF for 39 months without further ocular attacks. ADA, IFX and Cy-A were added in the remaining 3 patients due to ocular attacks 2, 5 and 31 months after MMF initiation. One of these 3 patients stopped IFX and MMF due to remission and is off treatment for 2 years.

Conclusion

Mycophenolate may be an alternative treatment modality in addition to biologics for patients with eye involvement who are intolerant to conventional therapies. Further data is needed to show whether it would be effective when used alone.

Disclosure of Interests

Didar Ucar: None declared, Yilmaz Ozyazgan: None declared, Sinem Nihal Esatoglu Speakers bureau: Sinem Nihal Esatoglu has received honorariums for presentations from UCB Pharma, Roche, Pfizer, and Merck Sharp Dohme, Emir Cerme: None declared, Vedat Hamuryudan Speakers bureau: Vedat Hamuryudan has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma, Grant/research support from: Vedat Hamuryudan has received grant/research support from Celgene., Melike Melikoglu: None declared, Izzet Fresko: None declared, Sebahattin Yurdakul: None declared, Hasan Yazici: None declared, Gulen Hatemi Speakers bureau: Gulen Hatemi has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma., Grant/research support from: Gulen Hatemi has received grant/research support from Celgene.

AB0938 A new screening tool for Psoriatic Arthritis in Psoriasis Patients: TurPAS

Background

Psoriatic arthritis (PsA) is a heterogenous disease with different disease manifestations. Several tools have been developed for screening of PsA in patients with psoriasis with variable performances. An optimal screening tool for PsA is still an unmet need.

Objectives

We aimed to develop a new screening tool in Turkish which could detect different domains involved.

Methods

A core group was determined including 11 rheumatologists/10 dermatologist and a systematic literature review on PubMed until 15 August 2020 using the keyword ‘psoriatic arthritis` was performed. The review revealed tools named PEST, PASE, EARP, STRIPP, SIPAS, SIPAT, TOPAS-II, GEPARD, PASQ, CONTEST, A novel, short, and simple screening questionnaire. Each item of those tools were included in the Delphi set. After the 3 rounds of Delphi, a new set of screening questionss was developed.

Results

Overall 85 items were inquired, including questions on joint, dactylitis, enthesitis, back, skin-nail domains as well as morning stiffness, function, treatment and others for the first round of Delphi. Seventeen experts (9 dermatologists/ 8 rheumatologists from the core group) and fifteen patients (Female/Male= 9/6) answered the Delphi (mean (SD) age of 39.3 (10.9) participated to the first round. The involvemet types were peripheral (73.4%), axial (40%), entheseal (33.4) and dactylitis was present in 14% of the patients. As a result of this first evaluation, 44 out of 85 questions were selected and carried to second round The distribution of these questions was as follows; joint question n=13, skin and nail involvement n=6, dactylitis n=5, morning stiffness n=5, axial n=3, enthesitis n=2, general questions n=5. These questions were sent to the members through rheumatology and dermatology societies. In total, 85 rheumatology specialists and 48 dermatology specialists answered the questions in the second round. At the second tour, the number of questions was reduced from 44 to 22. The distribution of the questions was as follows; Skin and nail involvement n=5, dactylitis n=3, joint question n=2, axial involvement n=2, morning stiffness n=2, axial involvement and morning stiffness n=2, enthesitis n=1, general questions n=5. A consensus meeting was held to discuss 22 questions determined at the end of the second round within the initial core group. Each question was handled one by one, some of the questions were combined, if necessary, adapted to Turkish. The tool was given its final form. The final version of the questionnaire consists of 6 questions. (Table 1).

Table 1.

The new screening tool

DomainTurkish versionEnglish versionJointEl/ayak parmaklarinizda ya da herhangi bir ekleminizde hiç şişlik veya ağri oldu mu?Have you ever had swelling or pain in your fingers/toes or any of your joints?DactylitisResimde gösterildiği gibi el veya ayak parmağinizda sosis şeklinde şişlik oldu mu?Have you had a sausage-shaped swelling on your fingers or toes as shown in the picture?EnthesitisTopuk ağriniz olur mu?Do you have heel pain?Axial involvement and morning stiffnessBelinizde, sirtinizda veya boynunuzda istirahatle artan, özellikle sabaha karşi kötüleşen veya sabahlari hareketinizi kisitlayan ağriniz olur mu?Do you have pain in your lower back, back, or neck that increases with rest, worsens especially in the morning, or restricts your movement in the morning?Drug useEklem şikayetleriniz için zaman zaman ilaç kullanir misiniz?Do you take medication for your joint complaints from time to time?History of rheumatic diseaseSize daha önce iltihapli romatizma tanisi konuldu mu?Have you ever been diagnosed with a rheumatic disease before?

Conclusion

A new screening tool targeting different domains in Psoriatic disease was developed in Turkish. While cultural differences play an important role in screening, we believe that the first tool developed in Turkish will be helpful in clinical practice and research settings. Further assessments will be done to understand its validity and reliability within a large cohort of psoriatic patients.

Disclosure of Interests

None declared

AB1305 A SYSTEMATIC REVIEW OF AA AMYLOIDOSIS AMONG PATIENTS WITH BEHÇET’S SYNDROME

Background

Data on patients with Behçet’s syndrome (BS) complicated with AA amyloidosis is limited to case reports or case series with a small number of patients.

Objectives

In this study, we aimed to perform a systematic review (SR) of published reports on BS patients with AA amyloidosis.

Methods

PubMed and EMBASE were searched with the keywords “Behcet* AND amyloidosis”, without date and language restriction, until May 2020. Two independent reviewers (SNE, GK) performed title/abstract and full text screening and data extraction. A third reviewer (GH) made the final decision in case of disagreement between the two reviewers. Studies that reported patients who were reported by authors as having BS and AA amyloidosis were included. The risk of bias assessment was done using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool.

Results

The systematic literature search yielded 760 articles of which 703 were excluded after title and abstract review. After full-text review, we further excluded 15 duplicate articles and 1 article was added after handsearching the reference lists of the full texts. Finally, we included 43 articles reporting 96 cases. Among these articles, 38 were case reports and 5 were case series reporting between 6 and 14 patients. All patients but 8 were reported from Mediterranean countries. The quality of all articles according to GRADE was very low due to the lack of a control group.

The main features of the patients were male predominance (81/96, 84%), a high frequency of major organ involvement (62/80, 77.5%) especially vascular involvement (60%), a low frequency of comorbidities predisposing to AA amyloidosis (11/96, 11.5%), and a very low frequency of gastrointestinal involvement (3/72, 4%). All but 8 patients were diagnosed with BS and AA amyloidosis simultaneously. The most common presentation was nephrotic syndrome (60/81, 74%). Presenting symptoms other than proteinuria were diarrhea (n=2), acute renal failure (n=2), upper gastrointestinal bleeding (n=1), end stage renal disease (ESRD) (n=1), cardiac symptoms due to cor pulmonale (n=1), and hypertension (n=1). Renal biopsy (72%) and rectal biopsy (17%) were the most commonly used procedures to diagnose AA amyloidosis.

After diagnosing AA amyloidosis, colchicine was initiated in 58 patients, cyclophosphamide in 16, and biologics in 3 (1 anakinra and 2 tocilizumab). In the 67 patients with available data on follow-up, 43% of the patients were followed-up for ≤1 year and median follow-up duration was 20 months (IQR: 4-48). Among the 64 patients with available data, 30 (47%) had developed ESRD. Among the 72 patients with available data on survival status, 30 patients (42%) had died. Ten patients (33%) had died within 6 months, 15 had died after a median follow-up of 48 months (IQR: 24-150), and follow-up duration was not available in the remaining 5 patients including 3 patients whose diagnoses were made by autopsy. Reasons for death were infection (n=7), ESRD (n=6), intractable diarrhea (n=3), pulmonary embolism (n=1), cor pulmonale (n=1), hemorrhage due to pulmonary artery aneurysm (n=1), liver cirrhosis (n=1), gastric cancer (n=1), subarachnoid hemorrhage (n=1), and not reported (n=8).

Conclusion

Male gender and major organ involvement, especially vascular involvement, appear to be risk factors for the development of AA amyloidosis in BS patients. While BS patients complicated with AA amyloidosis have been reported rarely, it is a fatal complication of BS. One third of the patients had died within 6 months after AA amyloidosis diagnosis.

Disclosure of Interests

Güzin Karatemiz: None declared, Sinem Nihal Esatoglu Speakers bureau: Sinem Nihal Esatoglu has received honorariums for presentations from UCB Pharma, Roche, Pfizer, and Merck Sharp Dohme., Mert Gurcan: None declared, Yesim Ozguler Speakers bureau: Yesim Ozguler has received honorariums for presentations from UCB Pharma, Novartis, and Pfizer., Sebahattin Yurdakul: None declared, Vedat Hamuryudan Speakers bureau: Vedat Hamuryudan has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma., Grant/research support from: Vedat Hamuryudan has received grant/research support from Celgene., Izzet Fresko: None declared, Melike Melikoglu: None declared, Emire Seyahi Speakers bureau: Emire Seyahi has received honorariums for presentations from Novartis, Pfizer, AbbVie, and Gliead., Serdal Ugurlu: None declared, Huri Ozdogan: None declared, Hasan Yazici: None declared, Gulen Hatemi Speakers bureau: Gulen Hatemi has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma, Grant/research support from: Gulen Hatemi has received grant/research support from Celgene.

AB0635 Central Nervous System Involvement and Mimickers in ANCA Associated Vasculitis

Background

Central nervous system (CNS) involvement is rare in ANCA associated vasculitis (AAV). Besides, complications of immunosuppressive (IS) therapy or other conditions that mimic CNS involvement may occur in some AAV patients.

Objectives

We aimed to assess the clinical, laboratory and imaging features of our AAV patients with CNS involvement and conditions other than CNS involvement that caused neurologic signs and symptoms.

Methods

We reviewed the charts of our AAV patients with neurologic sign or symptoms and extracted data on their demographics, types of AAV, neurologic symptoms/signs, final diagnoses after neurologic work-up, and their outcome.

Results

Nineteen AAV patients (13 men, mean age: 46.6±16.6 SD years) with neurologic signs or symptoms were identified. Fifteen patients had GPA, 3 had MPA, and 1 had EGPA. Neurologic symptoms were present at disease onset in 9 patients while they developed within a mean follow up of 36.7 ± 40.1 SD months after AAV diagnosis in the remaining 10. At the time of the occurrence of neurologic symptoms, all patients had active disease (median (IQR) BVAS: 13.8 (9.5-18.5)). Eight patients (42%) also had accompanying peripheral nervous system involvement.

Final diagnosis was CNS involvement of AAV in 5 (26%) patients. These were ischemic cerebrovascular accident (CVA) in 2 patients, hemorrhagic CVA in 1 patient, and cranial neuropathy (peripheral facial nerve palsy) in 2 patients. Cranial MRI revealed T2 FLAIR hyperintensities in 2 patients with ischemic CVA. One also had border zone ischemic changes and the other had areas compatible with terminal branch ischemia. Corticosubcortical hematoma in the left parietal lobe and microhemorrhages in the right frontal lobe were observed in a patient with hemorrhagic CVA. Among the 2 patients with facial nerve palsy, cranial MRI was normal in one while the other had nonspecific increased T2 signals in the cerebral cortex. Cranial neuropathy resolved with high dose glucocorticoid (GC) treatment without sequel in 1 patient and regressed with high dose GC and cyclophosphamide (CYC) in the other. One patient with ischemic CVA was lost to follow-up, and the other recovered with high dose GC and CYC treatment without sequela. The patient with hemorrhagic CVA had died.

Neurologic symptoms were diagnosed to be due to other AAV manifestations in 6 (32%) patients. These were sinonasal involvement in 3 patients with sensorineural hearing loss (n=2), and blurred vision (n=1); orbital involvement in 2 patients with headache (n=2) and ocular involvement (scleritis) in 1 patient with blurred vision. Neurologic symptoms of these 6 patients recovered with immunosuppressive therapy including high dose GC (n=6), mycophenolate mofetil (n=2), methotrexate (n=2), rituximab (RTX) (n=1), and both CYC and plasmapheresis (n=1).

Three patients (16%) had secondary complications affecting the CNS. One patient with seizures had posterior reversible encephalopathy syndrome (PRES) and recovered with CYC and anti-epileptic drugs. The second patient with blurred vision and headache had cerebral venous sinus thrombosis (CVST) and recovered with anticoagulant therapy. The third patient with muscle weakness died due to spondylodiscitis complicated with aortic pseudoaneurysm.

In 5 patients (26%), neurologic work-up did not lead to an underlying condition. The presenting symptoms of these patients were transient acute vision loss in 2, numbness of extremities in 1, syncope in 1 and vertigo in 1 patient. Neurologic symptoms resolved after high dose GC and RTX in the patient with vertigo. At the onset of neurologic symptoms, 3 patients were using IS therapy including azathioprine, MMF and CYC in 1 patient each. The fourth patient was off treatment. Neurologic symptoms were transient in these patients, and did not recur during our follow-up of 36, 52, 57, and 120 months.

Conclusion

CNS involvement appears to be rare in AAV and non-CNS entities including ocular, orbital and sinonasal involvement and complications such as PRES, CVST and infections may mimic CNS involvement in patients with AAV.

Disclosure of Interests

Yeliz Yagiz Ozogul: None declared, Sinem Nihal Esatoglu Speakers bureau: Sinem Nihal Esatoglu has received honorariums for presentations from UCB Pharma, Roche, Pfizer, and Merck Sharp Dohme, Murat Ozogul: None declared, Osman Kizilkilic: None declared, Yesim Ozguler Speakers bureau: Yesim Ozguler has received honorariums for presentations from UCB Pharma, Novartis, and Pfizer., Vedat Hamuryudan Speakers bureau: Vedat Hamuryudan has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma., Grant/research support from: Vedat Hamuryudan has received grant/research support from Celgene., Gulen Hatemi Speakers bureau: Gulen Hatemi has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma, Grant/research support from: Gulen Hatemi has received grant/research support from Celgene.

POS0816 DRUG SURVIVAL OF INFLIXIMAB IN BEHÇET’S SYNDROME PATIENTS WITH DIFFERENT TYPES OF INVOLVEMENT

Background

Infliximab (IFX) is an effective therapeutic option in the management of severe and refractory manifestations of Behçet’s syndrome (BS).

Objectives

We aimed to evaluate long term drug survival of IFX in a large cohort of BS patients.

Methods

We reviewed the charts of BS patients who received IFX between 2004 and June 2021 and noted demographic features, reasons for IFX use, IFX duration, and reasons for discontinuation.

Results

371 patients (290 men, mean age at IFX initiation: 35.5 ± 10 years) received IFX for uveitis (n=164), vascular involvement (n=114), central nervous system (CNS) involvement (n=55), arthritis (n=19), gastrointestinal (GI) involvement (n=15), mucocutaneous involvement (n=10), venous ulcers (n=13), and secondary amyloidosis (n=1). Twenty patients had more than one type of involvement requiring IFX.

During a median follow-up of 30 months (IQR: 13-52), 175 (47%) patients were still receiving IFX for a median period of 40 months (IQR: 22-66) while 196 (53%) patients had discontinued IFX after a median follow-up of 19 months (IQR: 8-34).

IFX retention rate was 50% for mucocutaneous involvement, 43% for uveitis, 49% for vascular involvement, 58% for CNS involvement, 37% for arthritis, 53% for GI involvement, and 31% for venous ulcer (Table 1).

Table 1.

Drug survival of infliximab and reasons for infliximab discontinuation

Mucocutaneous involvement (n=10)Uveitis (n=164)Vascular (n=114)CNS (n=55)Arthritis (n=19)GIS (n=15)Venous ulcer (n=13)Male (n, %)3 (30)127 (77)89 (78)49 (89)14 (74)9 (60)12 (92)Age at infliximab initiation (mean ± SD years)35.8 ± 9.334 ± 9.936 ± 9.136.2 ± 10.439.6 ± 10.743 ± 14.137.4 ± 8.2Number of patients who used concomitant immunosuppressives (n, %)5 (50)108 (66)86 (75)38 (69)5 (26)11 (73)7 (54)Duration of infliximab use (mean ± SD months)33 ± 3845 ± 3828 ± 2337 ± 2837 ± 3526 ± 2625 ± 25Number of patients who discontinued infliximab (n, %)5 (50)93 (57)58 (51)23 (42)12 (63)7 (47)9 (69)Due to remission-30212121Due to primary inefficacy157---5Due to secondary inefficacy212545--Due to adverse event1231211541Due to noncompliance11113--2Due to other reasons-1212311-

Reasons for discontinuation were adverse events in 56 (15%), remission in 54 (15%) patients, inefficacy in 45 (12%) (secondary inefficacy in 26 (7%), primary inefficacy in 19 (5%)), and lack of patient compliance in 18 (5%). Other reasons were preparation for surgical operation (n=4), pregnancy (n=4), lack of health insurance (n=4), preferring subcutaneous administration during the pandemic (n=3), due to prison sentence (n=3), willing to get pregnant (n=1), rejecting the treatment (n=1), and death (n=3).

Adverse events (n=56) leading to the cessation of IFX were infusion reactions (n=22), infections (n=7), tuberculosis (n=6), malignancy (n=6), palmoplantar psoriasis (n=5), hepatotoxicity (n=4), lichen planus (n=1), drug induced lupus (n=1), auricular chondritis (n=1), macrophage activation syndrome (n=1), splenic infarction (n=1) and a decrease in left ventricular ejection fraction (n=1).

At the end of the follow-up, 2 patients had died due to lung adenocarcinoma, 1 patient had died due to pneumosepsis, 1 due to severe parenchymal neurologic involvement and 1 with pulmonary artery involvement due to massive hemorrhage during IFX treatment. Additionally, 7 patients had died 9, 10 months, 3, 3, 4, 7 and 9 years after IFX discontinuation. The causes of death were severe nervous system involvement in 2 patients, right heart failure due to pulmonary hypertension, laryngeal adenocarcinoma, lung adenocarcinoma, sepsis and gastrointestinal bleeding in 1 patient each.

Conclusion

IFX seems to be effective for the treatment of organ and life-threatening manifestations in the majority of the patients. However, drug retention rate was not optimal, mainly due to adverse events, inefficacy and patient non-compliance.

Disclosure of Interests

Sinem Nihal Esatoglu Speakers bureau: Sinem Nihal Esatoglu has received honorariums for presentations from UCB Pharma, Roche, Pfizer, and Merck Sharp Dohme, Beyza Tukek: None declared, Sitki Safa Taflan: None declared, Yilmaz Ozyazgan: None declared, Didar Ucar: None declared, Vedat Hamuryudan Speakers bureau: Vedat Hamuryudan has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma, Grant/research support from: Vedat Hamuryudan has received grant/research support from Celgene., Yesim Ozguler Speakers bureau: Yesim Ozguler has received honorariums for presentations from UCB Pharma, Novartis, and Pfizer., Emire Seyahi Speakers bureau: Emire Seyahi has received honorariums for presentations from Novartis, Pfizer, AbbVie, and Gliead, Melike Melikoglu: None declared, Ugur Uygunoglu Speakers bureau: Ugur Uygunoglu has received speaker fees from F Hoffmann La-Roche, F Hoffmann La-Roche, Bayer, Merck-Serono, Novartis, Teva, and Biogen Idec/Gen Pharma of Turkey, Consultant of: Ugur Uygunoglu has received advisory board honorariums from F Hoffmann La-Roche, F Hoffmann La-Roche, Bayer, Merck-Serono, Novartis, Teva, and Biogen Idec/Gen Pharma of Turkey, Aksel Siva Speakers bureau: Aksel Siva received honorariums from Teva for speaking engagements., Consultant of: Aksel Siva received honorariums from Bayer-Schering AG, Biogen/Gen Ilac of Turkey, Genzyme, Merck-Serono, and Roche for consulting, fees from Novartis as a consultant and advisory committee member,., Grant/research support from: Aksel Siva received travel and registration reimbursements from Genzyme., Zekayi Kutlubay: None declared, Izzet Fresko: None declared, Sebahattin Yurdakul: None declared, Hasan Yazici: None declared, Gulen Hatemi Speakers bureau: Gulen Hatemi has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma., Grant/research support from: Gulen Hatemi has received grant/research support from Celgene.

AB0634 Variability in Phenotype Clusters in Behçet’s Syndrome: A Systematic Review

Background

The presence of distinct clinical phenotypes with clustering of certain organ manifestations is well-recognized Behçet’s syndrome (BS). Differences in demographic features, treatment response, and possibly inflammatory pathways involved in the pathogenesis of different phenotypes have been proposed. However, studies from different BS cohorts have shown variability in the phenotypes that were defined.

Objectives

We aimed to explore the causes of variability in clinical phenotype clustering across different countries and cohorts.

Methods

An electronic search was carried out in PubMed to find articles published in or before November 2021, using the keywords of Behcet, cluster and factor analysis. Two reviewers independently performed a screening of titles, abstracts, and full-texts .

Results

Amongst 496 articles searched, 30 full-texts were assessed, and 10 studies were relevant for data extraction. Ten articles studied 12 different cohorts, 3 from China, 3 from Turkey, 2 from Japan, 1 from South Korea, 1 from Israel, 1 from Greece, and 1 from Italy. 9 out of 10 studies demonstrated clustering of organ manifestations (11 cohorts). There were important differences between the clusters that were identified in these studies (Table 1). Clusters including skin and mucosa manifestations were present in all cohorts, but the skin and mucosa manifestations that clustered together differed from cohort to cohort. Uveitis stood by itself in some studies, whereas it clustered with vascular and central nervous system (CNS) involvement in some cohorts, and certain skin and mucosa lesions in another. Papulopustular lesions (PPL) and arthritis showed a positive correlation in 4 cohorts whereas these manifestations were negatively correlated in 1 cohort. Moreover, no clusters were identified in 1 study. Potential causes of differences in clusters that we have identified in these studies were: study design (database vs multicenter vs single-centre cohort), statistical analysis method (hierarchical cluster vs factor analysis) patient population (pediatric vs adult vs late onset), setting (dermatology vs rheumatology), diagnostic criteria (ISG vs ICBD), disease duration, definition of organ involvement (such as PPL vs folliculitis, or CNS involvement vs dural sinus thrombosis, ascertainment of manifestations (confirmed gastrointestinal involvement vs any diarrhea, lack of ascertainment in diagnosis of nodular lesions as erythema nodosum vs superficial thrombophlebitis), time interval (manifestations throughout the disease course vs manifestations that were active during the last 3 months), and change in the natural history of BS over decades.

Table 1.

Clinical phenotype clustering across cohorts

Author, yearnCluster 1Cluster 2Cluster 3Cluster 4Cluster 5Cluster 6Zou,202169MC (G, EN, PPL)U, V, NBSGIZou ,2021860MC (G, EN, PPL)UGIJCVS, NBSZou ,2021152MC (G, EN, PPL)U, V, NBSGIJSoejima, 2021657MC(O, G and Skin) w/o JUNegative correlation of GI &UMC (O, G and Skin inv.), JNBSSoejima, 20216754MC (O, G and Skin) w/ o JU, O, G and Skin inv.Negative correlation of GI &UMC (O, G and Skin), JNBSU, O, SkinKrause 199968MC(G, PPL)Negative correlation of STM and ENGI, PPLJDVT, NBSChung 2021338EN dominantMixt EN and PPLPPL dominantKaraca 2012186MC(G, EN)USTM, DVTJ, PPL, OKaraca 2012221MC(O, G, EN)USTM, DVTJ, PPLTunc, 2002272MC (O, G, EN)USTM DVTJ, PPLSota, 2020396MC (O, G, EN, PF)UNegative correlation of J and PPLArida, 2009142No cluster was found

CVS: Cardiovascular, DVT: deep vein thrombosis; EN: erythema nodosum; G: genital ulcers; GI: gastrointestinal J: joint; MC: mucocutaneous; NBS: Neuro-Behçet syndrome, O: oral ulcers; PF: pseudofolliculitis; PPL: papulopustular lesions; STM: superficial thrombophlebitis; U: uveitis; V: vascular

Conclusion

Differences in phenotype clusters may result from differences in study characteristics rather than real geographic or ethnic differences. A large multi-national study with uniform inclusion criteria is needed to better understand phenotype clusters and their implication towards management strategies in BS.

Disclosure of Interests

Betul Macit: None declared, Kevser Akyuz: None declared, Sinem Nihal Esatoglu Speakers bureau: Dr Esatoglu received honorariums for presentations from UCB Pharma, Roche, Pfizer, and Merck Sharp Dohme., Gulen Hatemi Speakers bureau: Dr Hatemi served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma., Grant/research support from: Dr Hatemi has received grant/research support from Celgene.

POS0814 OUTCOME OF VASCULAR INVOLVEMENT OF BEHÇET’S SYNDROME TREATED WITH INFLIXIMAB: A RETROSPECTIVE COHORT STUDY

Background

Vascular involvement is the most common cause of mortality and an important cause of disability in patients with Behçet’s syndrome (BS). Cyclophosphamide has been the treatment choice for severe vascular involvement, but high frequency of adverse events such as infertility and infections cause concern. TNF inhibitors can be an alternative for BS patients with vascular involvement.

Objectives

To survey the efficacy and safety of infliximab (IFX) in BS patients with arterial and venous vascular involvement.

Methods

We reviewed the charts of BS patients who used IFX for vascular involvement. We extracted data on demographic and clinical features, type of vascular involvement, laboratory tests, imaging modalities, concomitant immunosuppressives, duration of IFX use, and outcome. The primary endpoint was remission, defined as the presence of all of the following 3 parameters: 1) lack of new clinical symptoms/findings associated with the vascular lesion 2) normalization of CRP level defined as <10 mg/dl) 3) lack of worsening of the primary vascular lesion or a new lesion vascular at another site on imaging. Remission was assessed at month 6 and month 12. Secondary endpoints were relapse, overall disease activity assessed with BDCAF at baseline and at the final visit, development of new organ involvement other than vascular involvement during IFX treatment, severe adverse events leading to discontinuation of IFX therapy, hospitalization or death, and death.

Results

Among the 371 patients who used IFX between 2004 and June 2021, 127 patients (102 men, 25 women, mean age 40 ± 8.7 years) had used it for vascular involvement. The types of vascular involvement that required IFX were venous thrombosis in 61 patients (48%), pulmonary artery involvement in 37 (29%), non-pulmonary artery involvement in 16 (13%), and venous ulcer in 13 (10%). Remission rate was 72% (92/127) at month 6 and 61% (71/117) at month 12. 17/99 (17%) patients experienced 22 relapses during a mean follow-up of 28.4±21 months of IFX therapy. Among the 22 relapses, 12 were the progression of the pre-existing vascular lesion and 10 were new vascular lesions. Overall disease activity improved with a decrease in mean BDCAF score from 1.76 ± 1.27 to 0.6 ± 0.8 at the final visit (p<0.001). Remission and relapse rates according to type of vascular involvement and causes of IFX discontinuation are presented in the Table 1. Adverse events leading to IFX discontinuation were infusion reactions in 5, tuberculosis, disseminated zona, lung adenocarcinoma, fibromyxoid sarcoma, heart failure, SLE, palmoplantar pustulosis, auricular chondritis, and aortic stent graft infection in 1 patient each.

Table 1.

The frequency of concomitant immunosuppressive use, duration of infliximab use and outcomes of BS patients with vascular involvement treated with IFX

Venous thrombosis (n=61)Pulmonary artery involvement (n=37)Non-pulmonary arterial involvement (n=16)Venous ulcers (n=13)Overall (n=127)Number of patients who used concomitant immunosuppressives48 (79)24 (65)14 (87)7 (54)93 (73)Duration of IFX use (mean ± SD months)24 ± 19.725 ± 19.335 ± 29.626 ± 2425 ± 21Remission rate at month 650 (82)31 (84)10 (63)1 (8)92 (72)Remission rate at month 12a40 (70)21 (64)8 (53)2 (17)71 (60)Relapse rate4 (7)4 (11)9 (60)017 (13)Number of patients who discontinued IFX31 (51)23 (62)5 (31)9 (69)68 (54)Due to remission1560122Due to inefficacy313411Due to relapse10102Due to adverse event741113Due to noncompliance340310Due to new organ development10001Due to other reasonsb18009Death22004

a Since 10 patients did not reach the 12th month yet, the percentages were calculated on 117 patients.

b Other reasons were preparation for surgical operation (n=2), not wanting to come to the infusion frequently during the pandemic (n=2), pregnancy (n=1), willing to get pregnant (n=1), lack of health insurance (n=1), due to prison sentence (n=1), and death (n=1).

Conclusion

Infliximab may be beneficial in BS patients with vascular involvement, even in those who are refractory to immunosuppressives and corticosteroids.

Disclosure of Interests

Gulen Hatemi Speakers bureau: Gulen Hatemi has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma, Grant/research support from: Gulen Hatemi has received grant/research support from Celgene, Beyza Tukek: None declared, Sinem Nihal Esatoglu Speakers bureau: Sinem Nihal Esatoglu has received honorariums for presentations from UCB Pharma, Roche, Pfizer, and Merck Sharp Dohme., Yesim Ozguler Speakers bureau: Yesim Ozguler has received honorariums for presentations from UCB Pharma, Novartis, and Pfizer., Sitki Safa Taflan: None declared, Melike Melikoglu: None declared, Serdal Ugurlu: None declared, Izzet Fresko: None declared, Zekayi Kutlubay: None declared, Sebahattin Yurdakul: None declared, Hasan Yazici: None declared, Vedat Hamuryudan Speakers bureau: Vedat Hamuryudan has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma, Grant/research support from: Vedat Hamuryudan has received grant/research support from Celgene.

AB0601 FACTORS ASSOCIATED WITH THROMBOSIS IN BEHÇET SYNDROME: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Behçet syndrome (BS) is a unique vasculitis that can affect arteries and veins of all sizes. Thrombosis is an important component of vascular involvement in BS. Although several studies were conducted to highlight the mechanism of thromboinflammation in BS, it is still not fully understood.

Objectives

We performed a systematic review and meta-analysis of studies investigating thrombotic, fibrinolytic, and endothelial factors in BS.

Methods

We searched PubMed and EMBASE with the keyword “Behcet*” in four languages (English, German, French and Turkish) from their inception up to April 2020. Titles and/or abstracts of all studies were screened independently by two reviewers (GGO and BY) and conflicts were solved by a third reviewer (GH). Studies comparing BS patients with and without thrombosis and studies comparing BS patients with thrombosis and patients with thrombosis due to other causes were analyzed separately. The pooled odds ratios (OR) with 95%CI were calculated for binary outcomes and standardized mean differences (MD) were calculated for continuous outcomes using RevMan 5.3. We categorized the factors into 4 groups based on acting mechanism 1- those that decrease anticoagulant activity 2- those that increase procoagulant activity 3- those that decrease the activity of fibrinolytic system 4- pathogenetic/endothelial factors.

Results

Of 15548 articles, 15157 were excluded due to duplication and inappropriate study design after reviewing titles and abstracts. Full text review of the remaining 391 articles yielded 103 papers meeting our predetermined inclusion criteria.

Factors significantly associated with BS thrombosis compared to BS without thrombosis were high frequency of factor V Leiden mutation (15 studies, OR 2.55, 95%CI 1.66-3.93), high homocysteine level (14 studies, MD: 4.27, 95%CI 2.31-6.22), high protein C level (5 studies, SMD: 0.80, 95%CI 0.15-1.45) and high alpha1-antitrypsin level (1 study, MD: 3.00, 95%CI 0.15-5.85) in Group 1; high factor 8 level (4 studies, MD: 17.17, 95%CI 7.79-6.55), high thrombin level (1 study, MD: 35.90, 95%CI 12.40-59.40), high neutrophil/lymphocyte ratio (2 studies, MD: 1.37, 95%CI 0.24-2.50) and high platelet/neutrophil complex level (1 study, MD: 10.50, 95%CI 0.76-20.24) in Group 2; high TAFI activity (1 study, MD: 28, 95%CI 4.12-51.88) in Group 3; high VEGF level (2 studies, SMD: 1.63, 95%CI 0.21-3.05), high CEC concentration (2 studies, SMD: 1.00, 95%CI 0.22-1.77), high MCP-1 level (1 study, MD: 74.16, 95%CI 61.29-87.03), high anti-C1q level (1 study, MD: 9.11, 95%CI 0.51-17.71), high platelet microaggregate formation (1 study, MD: 75.00, 95%CI 7.62-142.38), high frequency of P-selectin glycoprotein ligand 1 gen polymorphism (heterozygous (AB+AC+BC)) (1 study, OR: 1.88, 95%CI 1.07-3.31), high ADMA level (1 study, MD: 0.16, 95%CI 0.08-0.24), high sICAM-1 level (1 study, MD: 59.30, 95%CI 3.35-115.25) and low brachial artery flow-mediated (endotelium-dependant) dilatation (1 study, MD: -3.22, 95%CI -5.18--1.26) in Group 4.

Factors that were associated with BS thrombosis compared to thrombosis due to other causes including JAK-2 mutation, circulating endothelial cells, activated protein C resistance, tPA, and PAI were assessed in 1 study each. Among these, tPA levels (MD: -6.00, 95%CI -10.99--1.01), APCR (OR: 0.09, 95%CI 0.01-0.73) and JAK-2 mutations (OR: 0.01, 95%CI 0.00-0.06) were significantly less in patients with BS thrombosis compared to patients with thrombosis due to other causes.

Conclusion

Several factors were identified that may potentially be associated with thrombosis in BS. However, the cut-offs used for defining the normal level for these factors, time of blood collection (during acute or chronic stage of thrombosis, use of anticoagulants) and the type of thrombosis (arterial, venous, or cerebral sinus) were not uniform across the studies. Studies investigating these factors together, in a large number of patients, and together with appropriate controls are needed to confirm these results.

Disclosure of Interests

None declared

POS0828 CONSISTENT EFFICACY WITH APREMILAST IN MEN AND WOMEN TO TREAT ORAL ULCERS ASSOCIATED WITH BEHÇET’S SYNDROME: PHASE 3 RELIEF STUDY RESULTS

Background:

Painful, recurring oral ulcers (OU) associated with Behçet’s syndrome negatively affect quality of life (QoL). Differences across sexes were reported in the frequency of disease manifestations, disease course, and response to colchicine. The phase 3, randomized, double-blind, placebo (PBO)-controlled RELIEF study showed overall efficacy of apremilast (APR) for OU associated with Behçet’s syndrome, including improvements in OU pain, disease activity, and QoL.

Objectives:

To evaluate the consistency of efficacy with APR in men and women with Behçet’s syndrome.

Methods:

Adults with active Behçet’s syndrome and ≥3 OU at randomization or ≥2 OU at screening and randomization, without active major organ involvement, were randomized to APR 30 mg BID or PBO during the 12-wk PBO-controlled phase. Randomization was stratified by sex. The primary endpoint was area under the curve for the number of OU through Wk 12 (AUCWk0-12) to assess continued efficacy over the time period in a symptom that waxed and waned. Key secondary endpoints included OU pain, complete response (OU-free), maintenance of complete response, and QoL at Wk 12. Disease activity was also assessed using Behçet’s Syndrome Activity Score (BSAS) and Behçet’s Disease Current Activity Index Form (BDCAF). QoL was assessed using Behçet’s Disease QoL (BDQoL). Prespecified subgroup analyses in men and women were performed to assess treatment effect in primary and secondary endpoints.

Results:

Eighty men and 127 women were randomized and received ≥1 dose of study medication. Mean age was 38.7 yrs (men) and 40.8 yrs (women). Mean (SD) OU count at baseline was 3.4 (1.4) (PBO) and 3.7 (1.5) (APR) for men and 4.3 (3.2) (PBO) and 4.5 (4.5) (APR) for women. Greater improvements in favor of APR vs PBO were observed in AUCWk0-12 in men and women (Figure 1). Consistency in efficacy with APR was observed between men and women, with greater reduction in pain and achievement of OU complete response (OU-free) and maintenance of response at Wk 12 vs PBO (Table 1). In men and women, consistent treatment effects in favor of APR vs PBO were observed for disease activity and QoL measures, although moderate treatment differences were observed in BDCAI (men/women) and BDQoL (men) (Table 1).

Conclusion:

Consistent treatment effects in favor of APR vs PBO in clinically relevant outcomes, including OU number and pain, OU complete response, and disease activity measures, were observed in men and women with OU associated with Behçet’s syndrome.

Key Secondary Efficacy Outcomes at Wk 12MenWomenPBO(n = 40)APR(n = 40)Tx Difference[95% CI]PBO(n = 63)APR(n = 64)Tx Difference[95% CI]OU CR, n/N (%)8/40 (20.0)21/40 (52.5)32.6 [12.8, 52.4]15/63 (23.8)34/64 (53.1)29.3 [13.2, 45.4]OU CR 6 + 6*, n/N (%)1/40 (2.5)10/40 (25.0)22.8 [8.8, 36.8]4/63 (6.3)21/64 (32.8)26.5 [13.6, 39.3]Pain (VAS)†-12.0 (4.8)-37.6 (4.9)-25.6 [-37.2, -14.1]-17.4 (4.4)-41.5 (4.3)-24.1 [-34.9, -13.3]BSAS†-1.3 (2.4)-14.4 (2.4)-13.1 [-18.8, -7.3]-7.7 (2.4)-19.7 (2.4)-12.0 [-18.0, -6.0]BDCAF†BDCAI-0.1 (0.3)-0.5 (0.3)-0.4 [-1.1, 0.4]-0.7 (0.3)-1.3 (0.3)-0.6 [-1.2, 0.0]Patient’s Perception of Disease Activity-0.2 (0.3)-1.4 (0.3)-1.2 [-1.9, -0.5]-1.0 (0.2)-1.8 (0.2)-0.9 [-1.4, -0.3]Clinician’s Overall Perception of Disease Activity-0.2 (0.3)-1.5 (0.3)-1.3 [-1.9, -0.7]-1.0 (0.2)-1.7 (0.2)-0.7 [-1.3, -0.2]BDQoL†-0.7 (1.0)-2.2 (1.0)-1.5 [-3.8, 0.8]-0.3 (0.9)-4.4 (0.9)-4.1 [-6.3, -2.0]

LOCF analyses. *Proportion of patients achieving an OU CR by Wk 6, and remaining OU-free for ≥6 additional wks during the 12-wk PBO-controlled treatment phase. †LS mean (SE) change from baseline. BSAS = Behçet’s Syndrome Activity Scores; BDCAF = Behçet’s Disease Activity Form; CR = complete response; n = number of patients randomized to treatment; Tx = treatment.

Acknowledgements:

This study was funded by Celgene. Additional analyses were funded by Amgen Inc. Writing support was funded by Amgen Inc. and provided by Kristin Carlin, RPh, MBA, of Peloton Advantage, LLC, an OPEN Health company.

Disclosure of Interests:

Gulen Hatemi Speakers bureau: AbbVie, Novartis, and UCB, Grant/research support from: Celgene, Alfred Mahr Speakers bureau: Chugai and Roche, Consultant of: Celgene and Chugai, Mitsuhiro Takeno Speakers bureau: AbbVie, Esai, and Mitsubishi-Tanabe, Consultant of: Celgene, Grant/research support from: Novartis, Doyoung Kim: None declared, Melike Melikoglu: None declared, Sue Cheng Employee of: Amgen Inc., Sven Richter Employee of: Amgen Inc., Shauna Jardon Employee of: Amgen Inc., Maria Paris Employee of: Amgen Inc., Mindy Chen Employee of: Amgen Inc., Yusuf Yazici Consultant of: Bristol-Myers Squibb, Celgene, Genentech, and Sanofi

POS0929 FACTORS ASSOCIATED WITH THE DEVELOPMENT OF ANTI-DRUG ANTIBODIES TO TUMOUR NECROSIS FACTOR INHIBITORS IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS; A TWO YEAR FOLLOW-UP STUDY

Background:

Axial spondyloarthritis (axSpA) is a chronic inflammatory rheumatic disease affecting sacroiliac joints and spine as well as peripheral joints and entheses. Tumour necrosis factor inhibitors (TNFi) are widely used in patients with persistently high disease activity despite non-steroidal anti-inflammatory drugs. Some patients fail to respond or loose responsiveness during therapy with TNFi. The development of anti-drug antibodies (ADA) might play a role in non-response or some adverse events. However it has never been evaluated for 2-years period.

Objectives:

Therefore, the aim of the present study was to evaluate the development of ADA against TNFi longitudinally during 2-years period in axSpA patients and factors associated with it.

Methods:

In total 180 axSpA patients according to ASAS classification criteria with a new TNFi prescription in the last two weeks period were included in this observational study. Clinical data and serum samples were collected at baseline and at every 12 weeks. Serum drug levels and ADAs were measured on 12, 24, 52 and 104 weeks of treatment by ELISA in one center to avoid inter-assay variability. The development of ADA over time was investigated by using generalized estimating equations (GEE) which is a technique for longitudinal data analysis allowing the use of all available data even deviated from normality.

Results:

180 biologic naive axSpA patients (116 male, median [IQR] 44,5 [14,5] years) who started anti-TNF agents (infliximab [20%], adalimumab [27,2%], etanercept [32,2%] and golimumab [20,6%]) were included in the analysis. In comparison to baseline values BASDAI, ASDAS-CRP and CRP values were significantly decreased in third months of follow-up (Figure 1). In total 172 patients had at 12 weeks, 154 at 24, 121 at 52, and 73 at 104 week serum samples available for ADA determination. In longitudinal analysis; baseline age and TNFi type, as well as longitudinal BASDAI, ASDAS, serum CRP levels and the development of adverse events and discontinuation of the drug were found to be associated with the development of ADA. In order to determine independent association/s with the development of ADA two longitudinal multivariable models were run; (a) with ASDAS as an activity measure, (b) with BASDAI and CRP levels and produced that all the variables were independently associated with longitudinally development of anti-drug antibodies (Table 1). Antibodies to adalimumab were related with lower serum drug levels.

Conclusion:

The results of the present study with up to 2 years of follow-up, revealed that the development of ADA against TNFi therapy is associated with high disease activity, the development of adverse events and treatment discontinuation in patients with axSpA. And etanercept might be negatively associated with the development of ADA.

Table 1.

Factors associated with the development of anti-drug antibodies

Model 1Model 2B95% CIPB95% CIPAge years-0.061-0.109;-0.0120.015-0.058-0.107;-0.0100.018TNFi Treatment ETN-1.981-4.369; -0.1340.104-2.475-4.791; -0.0760.036 ADA1.438-0.002; 0.4070.0731.275-0.119; -0.1600.064 INF1.5503.010; 3.1020.0501.2552.666; 2.6290.073 GOL0a0aPresence of advers event, no-0.824-1.451; -.01980.010-0.835-1.461; -0.2080.009TNF treatment discontinuation1.2890.043;2.5340.0431.248-0.075; 2.5710.065BASDAI0.0350.015; 0.0550.001CRP0.020-0.035; 0.0050.008ASDAS-CRP0.8520.466; 1.2380.000

0a:set to zero because this parameter is redundant.

Figure 1.

Mean change in disease activity and CRP levels during follow-up duration. (P values for 3rd months BASDAI<0.0001, CRP<0.001, ASDAS-CRP<0.001 respevtively)

Disclosure of Interests:

None declared

POS0819 EMERGENCE OF DE NOVO MANIFESTATIONS DURING INFLIXIMAB TREATMENT IN BEHÇET SYNDROME

Background:

Infliximab (IFX) is increasingly used in the management of severe, relapsing or refractory manifestations of Behçet Syndrome (BS). Emergence of de novo manifestations have been reported during IFX treatment, despite efficacy for the initial manifestation that required IFX use1.

Objectives:

We aimed to survey a sizeable cohort of BS patients treated with IFX for the development of de novo manifestations during treatment.

Methods:

A chart review was conducted to identify all BS patients who were given IFX in our Behçet Disease Research Center between 2004 and 2020. Demographic data, indications for IFX initiation, concomitant drugs, prior treatments, and outcomes were recorded. De novo manifestations were defined as new BS manifestations that had not occurred before IFX treatment.

Results:

A total of 252 patients used IFX with the main indications being uveitis in 122, vascular involvement in 82, parenchymal central nervous system involvement in 32, gastrointestinal involvement in 11, arthritis in 10, mucocutaneous involvement in 4, and secondary amyloidosis in 1. Of these patients, 17 (6%) had developed a total of 21 de-novo manifestations during a mean follow-up of 38.4 ± 92 (SD) months (Table 1). Vascular involvement was the main indication for IFX in the majority (n=12; 71%) of these 17 patients followed by eye involvement (n=3; 18%), central nervous system involvement (n=1), and joint involvement (n=1). Concomitant medications were prednisolone in 14 patients, azathioprine in 6 patients, mycophenolate mofetil, cyclosporine-A and methotrexate in 1 patient each. Thirteen patients (76%) were in remission for the main indication when de-novo manifestations emerged. In 10 patients IFX treatment was intensified either by increasing the dose to 10 mg/kg (2 patients) or by shortening the infusion intervals to 4 weeks (2 patients) along with the addition of corticosteroids or immunosuppressives. In the remaining 7 patients IFX was switched to another agent (cyclophosphamide in 5, adalimumab in 1 and anakinra in 1). At the time of this survey 8/17 patients were still on IFX for a mean follow-up of 32.5 ± 24.6 (SD) months, with concomitant low dose prednisolone in 5, azathioprine in 3 and mycophenolate mofetil in 3. In addition to the 7 patients who discontinued IFX at the time of de-novo manifestations, 2 more patients had discontinued IFX due to allergic reactions.

Conclusion:

De novo manifestations developed during IFX treatment in 6% of BS patients, despite efficacy for the initial manifestation. Appearance of de novo manifestations mostly in patients with vascular involvement is noteworthy. Intensification of IFX treatment was efficacious in managing de novo manifestations in more than half of these patients.

References:

[1]Hamuryudan V et al. Semin Arthritis Rheum. 2015;45(3):369-73.

Table 1.

Distribution of de novo manifestations that have emerged in 17 patients

De-novo manifestations21Pulmonary artery aneurysm1Pulmonary artery thrombosis2Coronary artery involvement3Superficial thrombophlebitis5Arthritis5Erythema nodosum3Gastrointestinal involvement1Central nervous system involvement1

Disclosure of Interests:

None declared

POS0814 DRUG RETENTION RATE, REASONS FOR DISCONTINUATION AND OUTCOME OF INFLIXIMAB USE IN BEHÇET SYNDROME

Background:

Infliximab (IFX) plays a key role in the management of severe and refractory manifestations of Behçet syndrome (BS). However we had previously shown that its sustained use may be limited due to adverse events and lack of patient compliance (1).

Objectives:

To assess the retention rate of IFX, adverse events, causes of discontinuation and outcome after cessation of IFX in a larger group of BS patients who were followed in a tertiary center.

Methods:

The charts of BS patients who were prescribed IFX between 2004 and 2020 were reviewed to determine demographic features, reasons for IFX use, previous and concomitant drugs, IFX duration, reasons for cessation of IFX and time to flare following cessation of IFX. Follow-up was censored on March 2020.

Results:

A total of 252 patients (195 men, mean age 40±10 years) received IFX for uveitis (n=122), vascular involvement (n=82), parenchymal neurologic involvement (n=32), gastrointestinal involvement (n=11), arthritis (n=10), mucocutaneous involvement (n=4), and secondary amyloidosis (n=1). Ten patients had more than 1 involvement requiring IFX.

During a median follow-up of 52 (IQR: 30-88) months, 122 (48%) patients were still receiving IFX for a median period of 33 (IQR: 15-56) months while 130 (52%) patients had discontinued IFX after a median follow-up of 17 (IQR: 7-31) months. Reasons for discontinuation were remission in 25 (19%) patients, adverse events in 39 (30%), lack of efficacy in 23 (18%) (4 primary and 19 secondary), lack of patient compliance in 36 (28%), pregnancy in 4, and preparation for surgery in 3 patients.

Adverse events (n=39) that required the cessation of IFX were infusion reaction (n=17), infection (n=7), hepatotoxicity (n=4), malignancy (n=4), palmoplantar psoriasis (n=3), lichen planus (n=1), drug induced lupus (n=1), splenic infarction (n=1), and a decrease in left ventricular ejection fraction (n=1).

Among the 25 patients who discontinued IFX due to remission, 5 (20%) had a relapse after 4, 21, 26, 29, 38 and 46 months. The remaining patients did not experience a relapse during a median follow-up of 35 (IQR: 24-68) months.

At the end of the follow-up, 2 patients had died due to lung adenocarcinoma during IFX treatment and 3 patients had died 1 year, 3 and 8 years after IFX discontinuation. The causes of death were with right heart failure due to pulmonary hypertension in 1, and severe nervous system involvement in 2 of the patients.

Conclusion:

Despite its successful use for the management of potentially organ and life-threatening manifestations in more than half of our patients with BS, long term maintenance was not possible in 42%, mainly due to adverse events, lack of patient compliance and inefficacy.

Reference:

[1]Esatoglu SN, Tukek B, Taflan SS, et al. SAT0258 Drug Retention Rate and Prognosis After Discontinuation of Infliximab in Patients with Behçet Syndrome. Annals of the Rheumatic Diseases 2020;79: 1071-1072.

Reasons for infliximab treatmentNo of patientsNo (%) of patients who were still receiving infliximabNumber (%) of patients who discontinued infliximabReasons for discontinuationDuration of infliximab use(median (IQR) months)Eye involvement12259 (48)63 (52)Remission (n=17)Inefficacy (n=10)Lack of patient compliance (n=19)Adverse event (n=12)Others (n)=5)28 (12.5-52)Vascular involvement8240 (49)42 (51)Remission (n=10)Inefficacy (n=7)Lack of patient compliance (n=12)Adverse event (n=12)Others (n=4)18.5 (9-33.5)Parenchymal neurologic involvement3221 (66)11 (34)Adverse event (n=8)Inefficacy (n=2)Lack of patient compliance (n=1)25 (14.5-50)Gastrointestinal involvement114 (36)7 (64)Remission (n=1)Inefficacy (n=1)Adverse event (n=2)Lack of patient compliance (n=4)7 (2-17)Joint involvement102 (20)8 (80)Inefficacy (n=1)Adverse event (n=5)Lack of patient compliance (n=2)20 (4-35)Mucocutaneous involvement431Inefficacy (n=1)6, 10, 12, 104 monthsAA amyloidosis101Inefficacy (n=1)6 years

Disclosure of Interests:

None declared

POS0820 INFLIXIMAB FOR VASCULAR INVOLVEMENT IN BEHÇET SYNDROME

Background:

Vascular involvement is an important cause of morbidity and mortality in patients with Behçet syndrome (BS). TNF inhibitors have been reported to be effective for almost all serious manifestations of BS but data on vascular involvement is still limited.

Objectives:

To survey the efficacy and safety of infliximab (IFX) in BS patients with vascular involvement followed in a dedicated tertiary center.

Methods:

We reviewed the charts of all BS patients who used IFX and identified those who used this drug for vascular involvement. A standard form was used for extracting data on demographic and clinical features, type of vascular involvement, concomitant immunosuppressives, duration of IFX use, relapses, adverse events and outcome.

Results:

83 patients (67 men, 16 women, mean age 39.5 ± 8.4 SD years) had used IFX for vascular involvement. The number of patients with each type of vascular involvement as the main indication for IFX, and previous treatment modalities right before IFX are presented in the Table 1. 33 patients had more than 1 type of vascular lesion. Additional organ manifestations were eye involvement in 32, central nervous system involvement in 4 and gastrointestinal involvement in 3 patients. All but one patient used IFX at a dose of 5 mg/kg every 6-8 weeks. All patients used concomitant prednisolone and 51 received pulse methylprednisolone during induction. Other concomitant medications were azathioprine in 21 and mycophenolate mofetil in 4 patients. Outcome of IFX treatment at the end of a mean follow-up of 25.9 months (range 1-103) is tabulated according to arterial and venous involvement (Table 1). Overall, 57/83 (68%) patients obtained remission with no further relapses and IFX could be stopped in 12 (14%) of them. IFX was discontinued due to adverse events in 15 patients. These were allergic reactions in 8, tuberculosis, disseminated zona, lung adenocarcinoma, fibromyxoid sarcoma, heart failure, systemic lupus erythematosus, and palmoplantar pustulosis in 1 patient each. Three patients had died. Causes of death were lung adenocarcinoma in one patient and pulmonary hypertension related right heart failure due to pulmonary artery thrombosis in 2 patients.

Conclusion:

Infliximab seems to be beneficial in Behçet syndrome patients with vascular involvement, even in those who are refractory to immunosuppressives and corticosteroids. No further relapses occurred in 68% of the patients, and adverse events leading to discontinuation were observed in 18%.

Arterial Involvement (n=36)Venous Involvement (n=47)Main reason for infliximab usePulmonary artery aneurysm and/or thrombosis, n=29Peripheral artery aneurysm, n=4Aortic aneurysm, n=3Vena cava superior and/or inferior thrombosis, n=5Lower extremity DVT, n=24Budd-Chiari syndrome, n=4Intracardiac thrombosis, n=2Dural sinus thrombosis, n=7Leg ulcer, n=5Previous treatmentFirst line infliximab413Corticosteroids3438Cyclophosphamide (CYC)25 (15/25 refractory to CYC; 10/25 for maintenance after CYC)11 (8/11 refractory to CYC; 3/11 for maintenance after CYC)Interferon-alpha-13Azathioprine2117Mycophenolate Mofetil12Cyclosporine A-2None due to non-compliance21OutcomeRemission, still on infliximab1623Discontinued due to remission48Discontinued due to adverse events59Discontinued due to relapse53Discontinued due to non-compliance53Died2 (1 had previously discontinued due to relapse)1

Disclosure of Interests:

None declared

AB0579 INSTRUMENTS FOR SCREENING PSORIATIC ARTHRITIS AMONG PATIENTS WITH PSORIASIS: A SYSTEMATIC LITERATURE REVIEW

Background:

Timely diagnosis is essential for the optimal management of psoriatic arthritis (PsA). Several instruments have been developed for screening PsA among patients with psoriasis. However, a delay in diagnosis is still frequently reported, possibly due to the lack of a wide use of these instruments.

Objectives:

We aimed to identify and compare the reported performance of these instruments with special emphasis on the PsA phenotypes.

Methods:

We conducted a systematic literature search on PubMed until 15 August 2020 using the keyword ‘psoriatic arthritis’. Two independent reviewers identified all studies published in English, that report on the validation, psychometric evaluation or use of an instrument for screening PsA. Any disagreements were resolved by the third investigator. Data on sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were extracted or calculated for each instrument. Additionally, instruments were assessed for their performance in patients with different disease phenotypes.

Results:

A total of 10754 references were screened, and 42 were identified that reported on 15 different screening instruments. Psoriatic Arthritis Screening and Evaluation (PASE), Psoriasis Epidemiology Screening Tool (PEST), Early Arthritis for Psoriatic Patients questionnaire (EARP) were the most commonly used instruments. There was important variability across studies regarding the sensitivity, specificity, PPV and NPV of these instruments based on the cut-offs for positivity, setting, patient population and disease phenotypes (Table 1). Specificity was higher when patients with a previous diagnosis of other rheumatic diseases were excluded. Lower sensitivity was reported among patients with shorter disease duration and when patients with a prior diagnosis of PsA were excluded from the study, whereas higher sensitivity was reported among patients with prior NSAID use. Screening tools showed differences in sensitivity in different domains (Figure 1).

Figure 1.

Performance Among Patients with Each Domain

Conclusion:

This systematic literature review revealed wide variability in the diagnostic estimates of currently available questionnaire-based screening instruments for identifying PsA among psoriasis patients, depending on study populations and disease phenotypes. There is an unmet need for a screening instrument with a better performance in all disease domains.

Table 1.

Diagnostic estimates of screening tools in different studies

InstrumentNumber of studiesSensitivity%Specificity%PPV%NPV%PASE1824-9138-9518-8813-96PEST1140 – 8537.2-98.623-9647.1-99.3EARP941-97.234-97.214-93.357.5-100TOPAS641-89.129.7-9025.7-91.868-81.6TOPAS-II444-95.880.5-9863.4-95.891-98PsA-Disk questionnaire187.246.458.678.5CONTEST270-76.556.5-9116-8968-95STRIPP191.593.379.697.5SiPAS179877390PASQ267-92.764-81.84383GEPARD277706680Swedish- Psoriasis Assessment Questionnaire163724585PAQ160622687.5SiPAT169699169A novel, short, and simple screening questionnaire186.971.35393.6

PASE: Psoriatic Arthritis Screening and Evaluation, PEST: Psoriasis Epidemiology Screening Tool, EARP: Early Arthritis for Psoriatic Patients questionnaire, TOPAS: Toronto Psoriatic Arthritis Screening Questionnaire, STRIPP: Screening Tool for Rheumatologic Investigation,

SIPAS: Simple Psoriatic Arthritis Screening questionnaire, PASQ: Psoriasis and Arthritis Screening Questionnaire, GEPARD: German Psoriatic Arthritis Diagnostic Questionnaire, PAQ: Psoriatic and Arthritic Questionnaire, SiPAT: Siriraj Psoriatic Arthritis Screening Tool

Disclosure of Interests:

None declared.

POS1351 CAUSES OF HOSPITALIZATION IN BEHÇET SYNDROME

Background:

The causes of hospitalization may provide important information on the course of diseases and treatment-related adverse effects.

Objectives:

We aimed to determine the causes and outcome of hospitalizations among patients with Behçet Syndrome (BS) in a dedicated center.

Methods:

We surveyed hospitalization records in our clinic between January 2002 and December 2019 and identified those with a diagnosis of BS. The records of these patients were reviewed for demographic and clinical features, causes of hospitalization and outcome. We divided hospitalization causes into 2 as being BS related (organ involvement or deterioration) and non-BS related (treatment complication or others).

Results:

Three-hundred and thirty BS patients (75% men, mean age 37.7 ±11.4 SD years) were hospitalized for a total of 456 times during 18 years. The mean disease duration was 10.8± 8.8 SD years. Two-hundred and ninety-one (64%) patients were using immunosuppressives (IS) with or without corticosteroids (CSs) and 72 (16%) of them were under biologic treatment at the time of hospitalization. The mean duration of hospitalization was 12.7±10.7 SD days. The reasons for hospitalization were directly related to BS in 259 patients (57%) and non-related to BS in 191 (42%). Six patients were hospitalized for both BS and non-BS related reasons at the same time. The most common reasons were vascular involvement (n=169, 64%) for BS related reasons and infections (n=64, 32%) for non-BS related reasons (Table 1). Patients hospitalized for BS related causes were younger (35.2±10.6 vs 41.1±11.7, p<0.001), had short mean disease duration (8.5±7.5 vs. 13.6±9.4 years, p<0.001), stayed shorter in the hospital (11.6±8.6 vs 14.0±12.9 days p=0.03) and had less frequent IS±CSs use (59% vs 70%, p=0.02) compared to those with non-BS related hospitalizations. There were no differences between the groups regarding gender distribution (203 M/62 F vs. 143 M/54 F) and use of biologic agents (15% vs 17%). Three patients died during hospitalization. The reasons were malignancy, infection and right heart failure due to pulmonary artery thrombosis and pulmonary hypertension, respectively.

Conclusion:

Vascular involvement is the leading cause of hospitalization among BS patients, followed by infections. The predominance of men among hospitalized patients underlines the relatively severe course of BS in men. The retrospective design and inclusion of patients who were hospitalized only in the rheumatology unit are limitations of this study.

Table 1.

Distributions of BS related and non-BS related reasons of hospitalizations

BS patients hospitalized with BS related reasons(n of pts=195, n of hospitalizations=265)*BS patients hospitalized with non-BS related reasons(n of pts=170, n of hospitalizations=197)*Causes of hospitalizations (per hospitalization)Vascular inv. (n=169, 64 %)Pulmonary artery inv. (n=64, 24 %)Deep vein thrombosis (n=39, 15 %)Budd-Chiari synd. (n=24, 9%)Vena cava inf. thrombosis (n=19, 7 %)Peripheral artery inv. (n=15, 6 %)Vena cava sup. thrombosis (n=14, 5 %)Aorta inv. (n=14, 5%)Coronary artery inv. (n=4, 2 %)Infection (n=64, 32%)Pneumonia (n=17, 8%)Tuberculosis (n=8, 4%)Urinary tract inf (n=7, 4%)Gastroenteritis (n=4, 2%)Osteomyelitis (n=3, 2%)Septic arthritis (n=3, 2%)Aspergillosis (n=2, 1%)Nocardia (n=1, 1%)Salmonella (n=1, 1%)Others (n=18, 9%)Neurologic inv. (n=50, 19 %)Parenchymal inv. (n=37, 14%)Dural sinus thrombosis (n=13, 5%)Drug side effects other than infections (n=29, 15 %)Interferon (n=10, 5%)Azathioprine (n=7, 4%)Cyclosporine (n=5, 3%)Steroid (n=3, 2%)TNF antagonists (n=3, 2%)IVIG (n=1, 1%)GI inv. (n=18, 7%)Additional rheumatologic diseases (n=17, 9%)Joint inv. (n=12, 5%)Renal disease (n=16, 8 %)Mucocutaneous inv. (n=10, 4%)Cardiovascular dis. (n=12, 6%)Eye inv. (n=8, 3%)Avascular necrosis (n=4, 2%)Others (n=8, 3%)Malignancy (n=11, 6%)Others (n=40, 20%)

*Some patients were hospitalized more than one times and for both BS related and non-BS related reasons at different time and had more than one type of BS related and/or non-BS related reasons.

Disclosure of Interests:

None declared

POS0254 EFFICACY OF APREMILAST IN THE TREATMENT OF ORAL ULCERS OF BEHÇET’S SYNDROME: RESULTS FROM THE EUROPEAN SUBGROUP OF RELIEF

Background:

Behçet’s syndrome, a chronic, multi-system variable vessel vasculitis, is often characterized by painful oral ulcers (OU) affecting quality of life (QoL). Apremilast (APR), an oral PDE4 inhibitor, demonstrated efficacy in OU treatment in the phase 3 multinational RELIEF study.

Objectives:

To evaluate APR efficacy in OU treatment in patients with active Behçet’s syndrome in a prespecified subgroup of patients enrolled in 13 European RELIEF sites (France, Germany, Greece, and Italy).

Methods:

patients were adults with active Behçet’s syndrome and ≥3 OU at randomization or ≥2 OU at screening and randomization, without active major organ involvement. Patients were randomized (1:1) to APR 30 mg BID or PBO during a 12-week double-blind phase. The primary endpoint was area under the curve for the number of OU through Week 12 (AUCWk0-12). Other outcomes were OU pain visual analog scale (VAS); achievement of OU complete response (ie, OU-free) and maintenance of OU complete response (ie, complete response at Week 6 and remaining OU-free for ≥6 additional weeks); OU partial response (ie, OU reduction ≥50%); disease activity (Behçet’s Syndrome Activity Score [BSAS]; Behçet’s Disease Current Activity Form [BDCAF], including Behçet’s Disease Current Activity Index [BDCAI], and Patient’s and Clinician’s Perception of Disease Activity); and QoL (BDQoL; Short Form Health Survey version 2 [SF-36v2], including Physical Functioning [PF] scale and Physical and Mental Component Summary [PCS, MCS]).

Results:

Of 207 patients randomized and treated in RELIEF, 52 were in the European subgroup. Mean (±SD) age in the subgroup was 39 (±12) years; 54% were women. Baseline disease characteristics were similar between treatment groups (Table 1). Patients receiving APR achieved lower AUCWk0-12 for OU vs PBO (Figure 1) and greater reduction in pain. A greater proportion of patients receiving APR achieved complete, maintained, or partial OU responses at Week 12 vs those receiving PBO (Table 1). Consistent treatment effects favoring APR vs PBO were observed in disease activity, as shown by BSAS and BDCAF component scores at Week 12 (Table 1). Greater improvement in SF-36v2 MCS was observed favoring APR vs PBO at Week 12, and moderate treatment differences were seen for other QoL measures (BDQoL, SF-36v2 PF, and SF-36v2 PCS).

Conclusion:

In the European subgroup of patients with Behçet’s syndrome and OU in RELIEF, APR resulted in greater reduction in OU count, OU pain, and disease activity as well as favorable treatment effect on QoL measures than PBO. These results are consistent with the efficacy of APR treatment in the overall RELIEF population.

Baseline Disease Characteristics, Mean*PBO (n = 27)APR (n = 25)Duration of BD, years9.08.2OU count3.84.0OU pain (VAS 0-100)60.664.2BSAS (0-100)38.741.4BDCAI (0-12)3.53.6BDQoL (0-30)10.59.0Efficacy Outcomes at 12 Weeks*PBO (n = 27)APR (n = 25)Treatment Difference [95% CI]OU pain (VAS 0-100), mean†–17.7–48.7–31.0 [–44.7, –17.3]OU complete response, n (%)‡4 (14.8)16 (64.0)51.5 [29.8, 73.3]OU maintained response, n (%)‡1 (3.7)8 (32.0)26.7 [7.4, 46.0]OU partial response, n (%)‡11 (40.7)21 (84.0)46.0 [23.9, 68.0]BSAS (0-100)†,§–5.23–20.68–15.5 [–22.6, –8.3]BDCAI (0-12)†,§–0.0–1.4–1.4 [–2.2, –0.6]Patient’s Perception of Disease Activity†,§–0.4–1.6–1.2 [–2.1, –0.4]Clinician’s Overall Perception of Disease Activity†,§−0.6−1.7–1.0 [–1.7, –0.4]BDQoL (0-30)†,§–1.25–2.37–1.12 [–3.8, 1.5]SF-36v2 MCS (0-100)†,§–2.14.26.3 [2.2, 10.4]

*ITT population.†LS mean of the change from baseline at Week 12.‡Non-responder imputation for missing data.§LOCF approach. All efficacy endpoints (except BDQoL) were significant at the level of P<0.05.

Acknowledgements :

This study was funded by Celgene. Additional analyses were funded by Amgen Inc. Writing support was funded by Amgen Inc. and provided by Kristin Carlin, RPh, MBA, of Peloton Advantage, LLC, an OPEN Health company.

Disclosure of Interests:

Alfred Mahr Speakers bureau: Chugai; Roche, Consultant of: Celgene; Chugai, Gulen Hatemi Speakers bureau: AbbVie, Novartis, and UCB, Grant/research support from: Celgene, Mitsuhiro Takeno Speakers bureau: AbbVie, Esai, and Mitsubishi-Tanabe, Consultant of: Celgene, Grant/research support from: Novartis, Doyoung Kim: None declared, Melike Melikoglu: None declared, david Saadoun Consultant of: AbbVie, Celgene, Janssen, and Roche, Grant/research support from: AbbVie and Roche, Christos C. Zouboulis Speakers bureau: Amgen, Galderma, Pierre Fabre, PPM and Sobi, Consultant of: AbbVie, AccureAcne, Almirall, Bayer Healthcare, GSK/Stiefel, Incyte, Inflarx, Janssen, Novartis, PPM, Regeneron, and UCB, Grant/research support from: Celgene, NAOS-BIODERMA, and Relaxera, Sue Cheng Employee of: Amgen Inc, Sven Richter Employee of: Amgen Inc, Shauna Jardon Employee of: Amgen Inc, Maria Paris Employee of: Amgen Inc, Mindy Chen Employee of: Amgen Inc, Yusuf Yazici Consultant of: Bristol-Myers Squibb, Celgene, Genentech, and Sanofi

AB0364 DO PATIENTS PARTICIPATING IN MEETINGS REPRESENT THE ACTUAL PATIENT POPULATION IN BEHÇET SYNDROME?

Background:

The importance of patient involvement in healthcare research is increasingly emphasized. Patients participate as research partners in designing studies and development of management recommendations, measurement tools and outcome measures. However, ensuring representation of the general patient population by specific patient groups may be challenging for multisystem diseases with heterogenous phenotype.

Objectives:

We aimed to evaluate whether patients with Behcet syndrome (BS) participating in a patient convention represent the actual patient population attending the clinic.

Methods:

A questionnaire was applied to 104 BS patients (Meeting group) attending the patient convention which was held during the Cerrahpasa Behcet Disease Symposium in Istanbul in February 2020. Patients had been invited to the convention through posters, advertisement on our website and social media. The questionnaire was conducted with a keypad given to the patients and it consisted of 21 items including age, gender, education level, working status, disease duration, BS manifestations, and treatment. The same questionnaire was filled by 97 consecutive patients (Clinic group) who attended our rheumatology outpatient clinic for their routine controls. Chi-square test was used to compare the groups.

Results:

Table 1 shows demographic and disease characteristics of the patient groups. The groups were similar in terms of sex and education level. There were more men in both groups, probably reflecting the more severe disease course among men in BS. There were significantly more patients who were >40 years of age and had a disease duration more than 20 years in the Meeting group. Although there were more patients who had a job in Clinic group, the difference was not significant. Central nervous system involvement, vascular involvement, genital ulcers, erythema nodosum, and arthritis were significantly more common in patients in the Meeting group compared with those in the Clinic group. The frequency of eye involvement, gastrointestinal involvement and papulopustular lesions were similar in the two groups. Cyclophosphamide use was significantly more common in Meeting group compared to the Clinic group.

Table 1.

Demographics, clinical characteristics, and treatments

Meeting Group(n=104)(n/N, %) Clinic Group(n=97)(n, %)POral aphthous ulcers 88/97(91)94(97)0.13Genital ulcers86/104(83)68(70)0.045 Erythema nodosum77/103(75)47(48)0.0003 Papulopustular skin lesions 69/103(67)75(77)0.09Arthritis78/102(77)46(47)<0.0001Eye involvement51/103(50)53(55)0.48Vascular involvement42/98(43)25(26)0.036CNS involvement14/103(14)2(2)0.016GI involvement14/97(14)6(6)0.10Prednisolone - still using30/104(29)34(35)0.37Prednisolone - ever used88/104 (85)72(74)0.08Colchicine - still using43/100 (43)46(47)0.57Colchicine - ever used86/100(86)74(76)0.10AZA - still using45/100 (45)41(42)0.77AZA - ever used81/100 (81)74(76)0.49 CYC - still using1/96(1)0(0)NSCYC - ever used16/96(17)7(7)0.048bDMARDs - still using20/101(20) 26(27) 0.31bDMARDs - ever used28/101(28)32(33) 0.44

* Adjusted P-values by Bonferroni correction were <0.001.

BS: Behcet Syndrome, CNS: Central nervous system, GI: Gastrointestinal, AZA: Azathioprine, CYC: Cyclophosphamide; bDMARDs: Biologic disease-modifying anti-rheumatic drugs; NS: non-significant

Conclusion:

Patients in the Meeting group had more severe disease compared to the Clinic group. Patients with all types of involvement were adequately represented in the Meeting group.

Disclosure of Interests:

None declared

FRI0237 COMPARISON OF DIFFERENT PULMONARY HYPERTENSION SCREENING ALGORITHMS IN PATIENTS WITH SYSTEMIC SCLEROSIS

Background:

Pulmonary hypertension (PH) is an important cause of morbidity and mortality in patients with systemic sclerosis (SSc). Different screening algorithms have been proposed for identifying patients who have a high probability of PH and require right heart catheterization (RHC), which is the gold standard for diagnosing PH.

Objectives:

To compare the performance of PH screening algorithms in our patients with SSc.

Methods:

Sixty-nine consecutive pts fulfilling ACR/EULAR 2013 SSc criteria have been screened for PH until now, using the 2015 ESC/ERS, DETECT and ASIG algorithms. Pulmonary function tests (PFT), diffusing capacity of the lung for carbon monoxide (DLCO), trans-thoracic echocardiography, serum NT-proBNP and uric acid assay and high-resolution computed tomography (HRCT) were performed as needed. Patients with known PH, severe interstitial lung disease and severe left ventricular dysfunction (LVD) were not included. RHC was performed in all patients with positive screening according to any one of the screening algorithms. Pts with PH were classified according to the updated PH classification criteria. Sensitivity and specificity of the 3 screening algorithms were evaluated according to the established cut-off value of 25 mmHg for mean systolic pulmonary artery pressure and for the recently proposed cut-off value of 20 mmHg.

Results:

Among the 69 SSc pts, 27 were excluded due to ILD(n=6), LVD(n=6), already diagnosed PH(n=4) no measurable TRV(n=5), lung cancer (n=2), pulmonary embolism (n=1) and nephrotic syndrome (n=1). Among the remaining 42 patients, 17 required RHC according to at least one of the screening algorithms (Table 1). Number of patients who had suspected pulmonary hypertension and required RHC according to ESC/ERS 2015, DETECT and ASIG were 7 (%17), 13 (%31), and 12 (%29) respectively (Figure 1). Among the 17 pts. who had RHC, PH was present in 3 pts according to the 25-mmHg cut-off (Group 2 in 2, Group 3 in 1) and in 9 pts according to the 20-mmHg cut-off (Group 1 in 5, Group 2 in 3, Group 3 in 1). The sensitivity and specificities were presented in Table 2. ASIG and DETECT had better sensitivity for 25-mmHg cut-off and was better with ASIG for 20 mmHg cut-off. The specificity was better with ESC/ERS for both cut-off values.

Conclusion:

The ASIG algorithm has a better sensitivity and ESC/ERS algorithm has a better specificity for detecting PH in patients with SSc. A limitation of this study was that RHC was not performed in patients who did not fulfill criteria according to any of the screening algorithms. The sensitivities may be lower than what we propose if there are patients with PH who are asymptomatic and not captured with any of the algorithms.

Disclosure of Interests:

Mustafa Erdogan: None declared, Burcak Kilickiran Avci: None declared, Cansu Ebren: None declared, Yagmur Ersoy: None declared, Zeki Ongen: None declared, Gul Ongen: None declared, Vedat Hamuryudan Speakers bureau: Pfizer, AbbVie, Amgen, MSD, Novartis, UCB, Gulen Hatemi Grant/research support from: BMS, Celgene Corporation, Silk Road Therapeutics – grant/research support, Consultant of: Bayer, Eli Lilly – consultant, Speakers bureau: AbbVie, Mustafa Nevzat, Novartis, UCB – speaker

AB0481 EFFICACY OF APREMILAST FOR THE TREATMENT OF GENITAL ULCERS ASSOCIATED WITH ACTIVE BEHÇET’S SYNDROME: A COMBINED ANALYSIS OF TWO RANDOMIZED CONTROLLED TRIALS

Background:

Behçet’s syndrome is a chronic, multi-system inflammatory disorder characterized by painful, recurrent oral ulcers (OU) and genital ulcers (GU).1The GU associated with Behçet’s syndrome can contribute to difficulties with sexual activity, walking, and sitting2; may cause scarring1; and may impair quality of life.1,2Apremilast (APR), an oral phosphodiesterase 4 inhibitor, has demonstrated efficacy in the treatment of the OU associated with Behçet’s syndrome in the phase III, randomized RELIEF study (BCT-002).3

Objectives:

To describe the efficacy of APR for the treatment of GU associated with active Behçet’s syndrome in the RELIEF study and in a pooled data analysis of RELIEF and the phase II study.

Methods:

Adult patients (≥18 years of age) with active Behçet’s syndrome and ≥3 OU at randomization or ≥2 OU at screening and randomization, without active major organ involvement, were randomized (1:1) to APR 30 mg twice daily or placebo (PBO). In RELIEF, clinical improvement in GU was assessed by evaluating the time to the first GU recurrence after loss of complete response, the mean number of GU in patients without GU at baseline, and the proportion of patients who were GU-free (complete response) at Week 12 (regardless of baseline GU status). A pooled analysis of patients in RELIEF and a randomized, phase II study4were conducted to assess achievement of GU complete response in patients with GU at baseline. In patients with GU complete response before Week 12, the median time to the first GU recurrence after loss of complete response was based on Kaplan-Meier estimates. The mean number of GU was summarized descriptively using data as observed. Between-group differences in the proportion of patients who were GU-free at Week 12 were analyzed by Cochran-Mantel-Haenszel test using non-responder imputation to handle missing data. Statistical tests were 2 sided (α=0.05).

Results:

A total of 207 patients were randomized and received ≥1 dose of study medication (APR: n=104; PBO: n=103). In all, 17 patients in the APR group and 17 in the PBO group had GU at baseline, with mean GU counts of 2.9 (APR) and 2.6 (PBO). Among patients with GU at baseline in RELIEF, 12/17 (70.6% [APR]) and 7/17 (41.2% [PBO]) achieved GU complete response at Week 12 (P=0.110). The median time to first GU recurrence in these patients occurred earlier with PBO (6.1 weeks) vs. APR (not calculable). In the pooled analysis of RELIEF and the phase II study, a significantly greater proportion of patients with GU at baseline achieved GU complete response at Week 12 with APR vs. PBO (21/27 [77.8%] vs. 9/23 [39.1%];P=0.011) (Figure 1). The proportion of patients who were GU-free was significantly greater with APR (92/104 [88.5%]) vs. PBO (72/101 [71.3%]), regardless of baseline number of GU (P=0.002) (Figure 2).

Conclusion:

The number of patients with GU was low, but the totality of the data shows a favorable trend in the treatment effect of APR on GU. Greater proportions of APR-treated patients were GU-free at Week 12 vs. patients receiving PBO, and the time to the first GU recurrence occurred earlier with PBO vs. APR.

References:

[1]Kokturk A. Patholog Res Int. 2012;2012:690390. 2. Senusi A, et al. Orphanet J Rare Dis. 2015;10:117. 3. Hatemi G, et al. N Engl J Med. 2019;381:1918-1928. 4. Hatemi G, et al. N Engl J Med. 2015;372:1510-1518.

Disclosure of Interests:

Gulen Hatemi Grant/research support from: BMS, Celgene Corporation, Silk Road Therapeutics – grant/research support, Consultant of: Bayer, Eli Lilly – consultant, Speakers bureau: AbbVie, Mustafa Nevzat, Novartis, UCB – speaker, Alfred Mahr Consultant of: Celgene, Speakers bureau: Roche, Chugai, Mitsuhiro Takeno Speakers bureau: Esai, Tanabe-Mitsubishi – speaker; Celgene Corporation – advisory board, Doyoung Kim: None declared, Melike Melikoglu: None declared, Sue Cheng Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Shannon McCue Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Sven Richter Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Michele Brunori Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Maria Paris Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Mindy Chen Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of the conduct, Yusuf Yazici Consultant of: BMS, Celgene Corporation, Genentech, Sanofi – consultant, Consultant of: BMS, Celgene Corporation, Genentech, Sanofi – consultant

FRI0202 WHAT IS NOT NERVOUS SYSTEM INVOLVEMENT IN BEHÇET SYNDROME: A SURVEY OF PATIENTS WITH BEHÇET SYNDROME REFERRED TO NEUROLOGY

Background:

Nervous system involvement of Behçet syndrome (neuroBS) is a serious, but infrequent manifestation of Behçet syndrome (BS). Although many BS patients present with signs and symptoms related to the nervous system, several of these are diagnosed with conditions other than neuroBS. The differential diagnosis may be difficult in such patients.

Objectives:

To identify conditions mimicking neuroBS among patients with BS and to determine clinical, laboratory and imaging findings that may help the differential diagnosis.

Methods:

We retrospectively screened the charts of 500 BS patients who were registered to our clinic between February 2012 and April 2015, to identify those who were referred to neurology at any time during their follow-up. We follow our BS patients in a multidisciplinary clinic and all patients with a sign or symptom related to the nervous system are seen by one of the neurologist members of the clinic. The final diagnoses, as well as presenting signs and symptoms, laboratory and imaging results and results of any other diagnostic modalities were retrieved from patient charts. Patients who did not have a follow-up visit during the last 3 months were invited to the clinic for their final condition. Those who were not able to come, or one of their family members if they were not able to talk, were interviewed on the phone.

Results:

Among the 500 BS patients who were screened, 116 (23%) were referred to neurology (53 men, 63 women, mean age 32.8 (±9.8), 98 (84%) fulfilled ISG criteria). Among these, 29 (5.8%) were diagnosed with neuroBS, 30 (6%) had other conditions related to the nervous system, 46 (9.2%) were not diagnosed with a nervous system disorder and their symptoms disappeared and 11 (2.2%) were inconclusive and lost to follow-up. Of the 29 patients with neuroBS, 20 had parenchymal involvement, 7 had cerebral venous sinus thrombosis, 1 had concurrent parenchymal involvement and cerebral venous sinus thrombosis and 1 had atypical neuroBS. Of the 30 BS patients who were diagnosed with another nervous system condition, 14 (2.8%) had primary headache syndromes including tension type headache (n=5) and migraine (n=9), 6 (1.2%) had psychiatric disorders including psychotic disorder (n=1), depression (n=4) and somatization disorder (n=1), the remaining patients had other diagnoses which were entrapment neuropathy (n=2), epilepsy, glial tumor, multiple sclerosis, Meniere’s disease, optic neuritis, neuroretinitis, steroid myopathy and polyneuropathy in one patient each. Presentation features such as cerebellar symptoms, motor symptoms, visual problems, altered consciousness, seizure, fever and facial palsy were more common among patients with neuroBS, whereas sensory symptoms and isolated headache were more common among BS patients with other nervous system conditions (Table).

Table.

Clinical characteristics of patients with neuroBS versus other diagnoses

Clinical findings at presentationBS patients with nervous system involvement (neuroBS) (n=29)BS patients with other nervous system conditions (n=30)Only headache2 (7%)17 (56%)Cerebellar symptoms*8 (27%)4 (13%)Motor symptoms*4 (14%)2 (7%)Sensory symptoms*3 (10%)5 (17%)Visual problems*(diplopia, blurred vision)9 (31%)1 (3%)Cognitive symptoms*2 (7%)2 (7%)Other* (Alteration of consciousness, seizure, fever, facial palsy)9 (31%)1 (3%)

* Accompanying more than 1 symptom/sign

Conclusion:

Nervous system conditions other than neuroBS are common in patients with BS who present with nervous system findings. Caution is required to avoid misdiagnosis of these patients as neuroBS.

Disclosure of Interests:

Elif Dincses: None declared, E. Buse Caliskan: None declared, Z. Ece Kaya: None declared, Ugur Uygunoglu: None declared, Melih Tutuncu: None declared, Sabahattin Saip: None declared, Aksel Siva: None declared, Melike Melikoglu: None declared, Vedat Hamuryudan Speakers bureau: Pfizer, AbbVie, Amgen, MSD, Novartis, UCB, Gulen Hatemi Grant/research support from: BMS, Celgene Corporation, Silk Road Therapeutics – grant/research support, Consultant of: Bayer, Eli Lilly – consultant, Speakers bureau: AbbVie, Mustafa Nevzat, Novartis, UCB – speaker

OP0032 ERAP1-MEDIATED IMMUNOGENICITY AND IMMUNE-PHENOTYPES IN HLA-B51+ BEHÇET’S DISEASE POINT TO PATHOGENIC CD8 T CELL EFFECTOR RESPONSES

Background:

HLA-B51 is a definite risk factor for Behçet’s disease (BD). A coding variant of ERAP1, Hap10 – with low peptide-trimming activity – vastly potentiates this risk, but is mechanistically unclear1,2).

Objectives:

To test the hypothesis that low or absent ERAP1 activity alters CD8 T cell immunogenicity through changes in the HLA-B51 peptidome and shapes the CD8 T cell immune response in affected subjects.

Methods:

We generated HLA-B51+ERAP1 KO LCL clones using CRISPR-Cas9, performed mass spectrometry of the immunoprecipitated MHC-class I peptidome with subsequent computational deconvolution for HLA-B51-binding peptides. We then assessed single cell (ICS), bulk (ELISA) and proliferative (CFSE) CD8 effector (IFNg, granzyme B, perforin) T cell responses through stimulation of allogeneic donor cells with WT vs KO LCL and determined ERAP1 haplotypes in 49 untreated Turkish BD subjects with ocular and/ or major vascular involvement as well as healthy donors (HD) whose PBMC were profiled using 6 multicolour flow cytometry panels.

Results:

WT and KO peptidomes differed significantly (p<0.0005 Fisher’s exact test) with a distinctive shift of peptide length frequencies exceeding 9-mer (binding optimum) in the KO vs WT. This held true for computationally deconvoluted HLA-B51 binders. IFNg secretion from CD8 T cells stimulated with KO LCL was significantly different from WT (ICS, p=0.0006; ELISA, p=0.0059) as were CD8 T cell proliferation and ICS of perforin/granzyme B+CD8 T cells. Analysis of 133 T, B, NK and monocyte cell populations revealed predominance of CD8 T and NKT cell subset in HLA-B51+/Hap10+ BD vs HLA-B51+/Hap10- BD and HD, accounting for 80% of all populations reaching significance (p<0.05, Mann-Whitney). Naive and effector memory CD8 T cell subsets were inversely correlated. Cohen’s effect sizes were large (>0.8) or very large (>1.2).

Conclusion:

We show that absence of functional ERAP1 alters human CD8 T cell immunogenicity. This is mediated by an HLA-class I peptidome with propensity for longer peptides above 9mer and suggests loss or de-novo presentation of peptide-HLA-B51 complexes to cognate CD8 TCR. The reciprocal changes in antigen- experienced vs naive CD8 T cell subsets in affected subjects point to biologic significance of HLA-B51/Hap10 in BD. Collectively, our findings suggest that an altered HLA-B51 peptidome modulates immunogenicity of CD8 effector T cells in ERAP1-Hap10 carriers with BD and identify targets for future drug development.

References:

[1]Kirino, Y., G. Bertsias, Y. Ishigatsubo, N. Mizuki, I. Tugal-Tutkun, E. Seyahi, Y. Ozyazgan, F. S. Sacli, B. Erer, H. Inoko, Z. Emrence, A. Cakar, N. Abaci, D. Ustek, C. Satorius, A. Ueda, M. Takeno, Y. Kim, G. M. Wood, M. J. Ombrello, A. Meguro, A. Gul, E. F. Remmers, and D. L. Kastner. 2013. ‘Genome-wide association analysis identifies new susceptibility loci for Behcet’s disease and epistasis between HLA-B*51 and ERAP1’,Nat Genet, 45: 202-7.

[2]Takeuchi, M., M. J. Ombrello, Y. Kirino, B. Erer, I. Tugal-Tutkun, E. Seyahi, Y. Ozyazgan, N. R. Watts, A. Gul, D. L. Kastner, and E. F. Remmers. 2016. ‘A single endoplasmic reticulum aminopeptidase-1 protein allotype is a strong risk factor for Behcet’s disease in HLA-B*51 carriers’,Ann Rheum Dis, 75: 2208-11.

Disclosure of Interests:

Arshed F. Al-Obeidi: None declared, Ann Cavers: None declared, Yesim Ozguler: None declared, Olivier Manches: None declared, Hua Zhong: None declared, Berna Yurttas: None declared, Beatrix Ueberheide: None declared, Gulen Hatemi Grant/research support from: BMS, Celgene Corporation, Silk Road Therapeutics – grant/research support, Consultant of: Bayer, Eli Lilly – consultant, Speakers bureau: AbbVie, Mustafa Nevzat, Novartis, UCB – speaker, Matthias Kugler: None declared, Johannes Nowatzky: None declared

SAT0260 PENTOXYFILLINE GEL FOR ORAL ULCERS IN PATIENTS WITH BEHÇET’S SYNDROME

Background:

Oral ulcers, the hallmark lesion of Behçet’s syndrome (BS) can be disabling and impair eating, drinking and speaking. Despite recent advances in systemic medications for the treatment of oral ulcers, some patients do not achieve complete remission. Topical agents may help such patients by decreasing the pain and duration of oral ulcers. Pentoxyfilline (PTX) is a methylxanthine derivative that inhibits phosphodiesterase and is thought to have immunomodulatory effects in addition to improving blood flow which is its main reason for use in peripheral vascular disorders.

Objectives:

The aim of this study is to assess the efficacy and safety of PTX gel for oral ulcers in patients with BS. We also aimed to explore the best tools for the assessment of treatment response to topical agents in randomized controlled trials (Clinicaltrial.gov ID: NCT 03888846).

Methods:

This was an open-label, randomized, parallel group study comparing PTX gel in addition to colchicine (PTX-COL) with colchicine alone (COL). Patients with BS who were treated with colchicine and not using any other systemic medications for BS, having at least one oral ulcer that appeared during the last 48 hours were included. PTX 5% gel with a dose of 1000 mg/day was applied in 4 divided doses per day for 14 days. Patients were contacted daily for 14 consecutive days. Photographs were taken every 24 - 48 hours and graphical processing software was used to calculate the area of the index ulcer. Duration of the index ulcer, time to start of index ulcer shrinkage, time to 50% reduction in oral ulcer pain on a 10 mm visual analog scale (VAS), change from baseline in the area of the index ulcer over time, total number of oral ulcers and adverse events were evaluated.

Results:

A total of 41 patients were randomized, 39 patients (18 in the PTX-COL group and 21 in the COL group) completed the study and 2 patients in PTX-COL group withdrew from the study due to unacceptable dysgeusia and nausea. Mean duration of index ulcer, time to start of index ulcer shrinkage, time to 50% reduction in oral ulcer pain, and number of patients with no detectable ulcers on day 4 in each group were lower in the PTX-COL group as presented in the Table. Change from baseline in the area of index ulcer and pain score over time is shown in the Figure. There were no serious adverse events. Fifteen (75%) patients reported nausea, 11 (55%) reported dysgeusia and 2 reported vomitting in the PTX-COL group, while 2 patients (10%) reported nausea in the COL group.

Conclusion:

This pilot phase 2 open label, randomized controlled study supports the hypothesis that topical PTX in addition to colchicine accelerates the healing of BS oral ulcers compared to colchicine alone. A phase 3 controlled study with a higher number of patients is planned with improving the taste for tolerability of the product.

Disclosure of Interests:

Gulen Hatemi Grant/research support from: BMS, Celgene Corporation, Silk Road Therapeutics – grant/research support, Consultant of: Bayer, Eli Lilly – consultant, Speakers bureau: AbbVie, Mustafa Nevzat, Novartis, UCB – speaker, Berna Yurttas: None declared, Zekayi Kutlubay: None declared, Tim Cote Employee of: Silk Road Therapeutics is in Washington, DC, USA, Şemsi Burak Derkunt Employee of: Silk Road Therapeutics is in Washington, DC, USA, Yusuf Yazici: None declared, Hasan Yazici: None declared

AB0542 REACTIONS TO PNEUMOCOCCAL 13-VALENT VACCINE IN PATIENTS WITH BEHCET SYNDROME

Background:

The European League Against Rheumatism (EULAR) recommends pneumococcal 13-valent (PCV13) and 23-valent vaccines in patients with rheumatic diseases (1). Adverse reactions to 23-valent pneumococcal vaccine were previously reported in patients with Behçet Syndrome (BS) (2). These were proposed to be associated with the pathergy phenomenon which may be observed in patients with BS.

Objectives:

To determine the frequency of adverse reactions to PCV13 in patients with BS who were candidates for TNF inhibitor treatment, together with ankylosing spondylitis (AS) and rheumatoid arthritis (RA) patients as controls.

Methods:

All of our patients who are candidates for TNF inhibitor therapy have been offered vaccination with PCV13 since 2016. We surveyed all patients with BS, AS and RA who were vaccinated with PCV13 in our infectious diseases outpatient clinic since 2016. Patients’ charts were reviewed and additionally patients were telephoned to identify any adverse local or systemic reactions. Local reactions were defined as redness, swelling, pain, and limitation of arm movement. Systemic reactions were defined as fever, headache, chills, rash, vomiting, joint pain, and muscle pain.

Results:

A total of 88 patients with BS, 143 patients with AS and 133 patients with RA had been vaccinated in our infectious diseases outpatient clinic. Among these, 55/88 (62%) patients with BS, 86/143 (60%) patients with AS and all 98/143 (68%) patients with RA could be contacted. Twenty-one of 55 (38%) patients with BS, 18/86 (20%) patients with AS and 27/98 (27%) patients with RA reported at least one local and/or systemic reaction after vaccination. Patients with BS reported more systemic reactions than the other two groups (48%, 12%, 23% respectively). On the other hand local reactions were less common among patients with BS (52%, 88%, 77% respectively). The local reactions were confined to erythema at injection site, pain and difficulty in moving among patients with AS and RA while 2 patients with BS had severe papulopustular skin lesions at injection site, in addition to erythema, pain and difficulty in moving. Both of these patients were pathergy positive at the time of the diagnosis.

Conclusion:

Severe papulopustular skin lesions at PCV13 injection site were observed only, but rarely, in patients with BS. Possibility of recall bias due to the retrospective nature of our study and the lack of other vaccines as controls are limitations of our study. Whether the skin lesions are caused by the skin pathergy reaction needs to be studied prospectively, as the pathergy status at diagnosis may be changed by the time these patients become candidates for TNF inhibitor treatment.

References:

[1]Furer V, Rondaan C, Heijstek MW, Agmon-Levin N, van Assen S, Bijl M, Breedveld FC, D’Amelio R, Dougados M, Kapetanovic MC, van Laar JM, de Thurah A, Landewé RB, Molto A, Müller-Ladner U, Schreiber K, Smolar L, Walker J, Warnatz K, Wulffraat NM, Elkayam O. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis. 2020 Jan;79(1):39-52. doi: 10.1136/annrheumdis 2019-215882. Epub 2019 Aug 14. PubMed PMID: 31413005.

[2]Saeidinejad M, Kardash S, Connell L. Behcet’s disease and severe inflammatory reaction to 23-valent pneumococcal polysaccharide vaccine: a case report and review of literature. Scott Med J. 2018 Sep 25:36933018801215. doi: 10.1177/0036933018801215. [Epub ahead of print] PubMed PMID: 30253703.

Disclosure of Interests:

Berna Yurttas: None declared, Sitki Safa Taflan: None declared, Nese Saltoglu: None declared, Gulen Hatemi Grant/research support from: BMS, Celgene Corporation, Silk Road Therapeutics – grant/research support, Consultant of: Bayer, Eli Lilly – consultant, Speakers bureau: AbbVie, Mustafa Nevzat, Novartis, UCB – speaker

OP0028 EFFICACY OF APREMILAST FOR THE PAIN OF ORAL ULCERS ASSOCIATED WITH ACTIVE BEHÇET’S SYNDROME: 12-WEEK RESULTS FROM THE RANDOMIZED, PHASE III RELIEF STUDY

Background:

Oral ulcers (OU) associated with Behçet’s syndrome are often painful, may interfere with the ability to eat and can negatively affect quality of life.1,2Apremilast (APR), an oral phosphodiesterase 4 inhibitor, demonstrated efficacy in the treatment of OU associated with Behçet’s syndrome in a phase III, multicenter, randomized, double-blind, placebo (PBO)-controlled study (RELIEF; BCT-002).3

Objectives:

To describe the efficacy of APR treatment in improving OU pain associated with Behçet’s syndrome in RELIEF.

Methods:

Patients were randomized (1:1) to APR 30 mg twice daily (APR 30 BID) or PBO twice daily for a 12-week PBO-controlled phase, followed by a 52-week active treatment extension. Eligible patients were ≥18 years of age and had active Behçet’s syndrome with ≥3 OU at randomization or ≥2 OU at screening and randomization and without active major organ involvement. Clinical improvement in OU was evaluated by the area under the curve for the number of OU through Week 12 (AUCWk0-12; primary efficacy endpoint) and by assessments of OU number. Patient-reported OU pain was evaluated by the 100-mm visual analogue scale (VAS). The statistical tests were 2-sided (α=0.05). The proportions of patients achieving the minimal clinically important difference (MCID) and higher rates of improvement, defined as ≥10-mm,4≥30-mm (3-fold MCID), ≥50-mm (5-fold MCID) improvements in OU pain VAS scores, respectively, were analyzed through Week 12. An ANCOVA model was used to analyze the primary endpoint and assessments of OU number and OU pain (VAS). The proportion of patients achieving improvement in OU pain VAS scores at Week 12 were summarized descriptively.

Results:

A total of 207 patients were randomized and received ≥1 dose of study medication (APR: n=104; PBO: n=103). At baseline, the mean (SD) number of OU was 4.2 (3.7) in the APR 30 BID group and 3.9 (2.7) in the PBO group, and the mean (SD) OU pain VAS scores were 61.2 (27.6) and 60.8 (26.9), respectively. At Week 12, significantly greater improvements were observed with APR 30 BID vs. PBO in AUCWk0-12(least-squares [LS] mean [SE]: 129.5 [15.9] vs. 222.1 [15.9];P<0.0001), number of OU (LS mean [SE]: 1.1 [0.2] vs. 2.0 [0.3];P=0.0003) and OU pain VAS scores (LS mean [SE] change from baseline: −40.7 [3.3] vs. −15.9 [3.3];P<0.0001). The proportion of patients who achieved the MCID of ≥10-mm improvement in OU pain VAS scores at Week 12 was greater with APR 30 BID vs. PBO; this pattern was also observed for the higher 3- and 5-fold improvements in MCID (Figure 1). Greater proportions of APR 30 BID vs. PBO patients achieved ≥10-mm and ≥30-mm improvements in OU pain VAS scores over 12 weeks. Notably, greater achievement of ≥50-mm improvement in OU pain VAS scores was observed with APR 30 BID vs. PBO as early as Week 1 and maintained up to Week 12 (Figure 2).

Conclusion:

For patients with active Behçet’s syndrome, APR 30 BID provided significantly greater improvements vs. PBO in OU number and OU pain at Week 12, including the greater proportion of patients achieving MCID and 3- and 5-fold MCID of OU pain in the APR 30 BID group vs. the PBO group. These results indicate a clinically meaningful treatment effect of APR 30 BID on the OU associated with Behçet’s syndrome.

References:

[1]Kokturk A.Patholog Res Int. 2012;2012:690390.

[2]Hatemi G, et al.Ann Rheum Dis. 2008;67:1656-1662.

[3]Hatemi G, et al.N Engl J Med. 2019;381:1918-1928. 4. Dworkin RH, et al.J Pain. 2008;9:105-121.

Disclosure of Interests:

Gulen Hatemi Grant/research support from: BMS, Celgene Corporation, Silk Road Therapeutics – grant/research support, Consultant of: Bayer, Eli Lilly – consultant, Speakers bureau: AbbVie, Mustafa Nevzat, Novartis, UCB – speaker, Alfred Mahr Consultant of: Celgene, Speakers bureau: Roche, Chugai, Mitsuhiro Takeno Speakers bureau: Esai, Tanabe-Mitsubishi – speaker; Celgene Corporation – advisory board, Doyoung Kim: None declared, Melike Melikoglu: None declared, Sue Cheng Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Shannon McCue Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Sven Richter Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Michele Brunori Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Maria Paris Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Mindy Chen Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of the conduct, Yusuf Yazici Consultant of: BMS, Celgene Corporation, Genentech, Sanofi – consultant, Consultant of: BMS, Celgene Corporation, Genentech, Sanofi – consultant

SAT0258 DRUG RETENTION RATE AND PROGNOSIS AFTER DISCONTINUATION OF INFLIXIMAB IN PATIENTS WITH BEHÇET SYNDROME

Background:

Infliximab (IFX) has become an important treatment option for all manifestations of Behçet syndrome (BS). Adverse events, loss of efficacy, lack of patient compliance and cost may limit its sustained use in patients with BS.

Objectives:

We aimed to evaluate the drug retention rates, causes of discontinuation and outcome after cessation of IFX.

Methods:

We reviewed the charts of 850 patients with BS who were registered in our clinic between 2009 and 2013 and identified those who had used IFX. The charts of these patients were surveyed for demographic features, the reasons for IFX use, previous and concomitant drugs, IFX duration, reasons for discontinuation and time to flare after discontinuation of IFX. We defined flare as disease activity in the organ involvement that necessitated IFX use. New major organ involvement that developed during or after discontinuation of IFX were also be noted.

Results:

A total of 50/850 patients were treated with IFX (40 men, mean age 40±9.5 years), for uveitis (n=29), vascular involvement (n=11), parenchymal neurologic involvement (n=8), arthritis (n=1) and venous ulcer (n=1). Of these 50 patients, 22 (43%) are still receiving IFX for a median duration of 40 (IQR: 25-83) months. The remaining 28 (47%) patients had discontinued IFX after a median follow-up of 12 (IQR: 7-30) months. Reasons for discontinuation were remission in 7 patients, adverse events in 10, primary lack of efficacy in 2, and lack of patient compliance in 9 patients. Among the 7 patients who discontinued IFX due to remission, only 1 patient with uveitis had a flare, 11 months after discontinuation, while on azathioprine. The remaining 6 did not experience any flares during a median follow-up of 29.5 (IQR: 4-24) months. Five of these patients used azathioprine and 1 used mycophenolate mofetil for maintenance. Among the 10 patients who discontinued due to adverse events, IFX was switched to adalimumab in 3 patients and none experienced flares under adalimumab. The remaining 7 patients continued to receive azathioprine or mycophenolate mofetil without a biologic. Among these, 1 patient with uveitis 1 with arthritis experienced flares 6 months after discontinuing IFX. Among the 9 patients who discontinued IFX due to lack of patient compliance, 3 patients (2 with uveitis and 1 with arthritis) had flares after 5 months, 1 year and 1.5 years. IFX was re-initiated in all. The remaining 6 patients did not experience any flares after a mean follow up of 5±1.5 years. Two with uveitis and 2 with venous thrombosis used azathioprine for maintenance, while 2 patients did not receive further treatment. New major organ involvement was not observed. New BS manifestations developed in 2 patients under IFX, arthritis in one patient and both epididymitis and erythema nodosum in the other.

Conclusion:

Almost half of our patients with BS remained on IFX during a median follow-up of 5.4 years (IQR:2.4-7). Main reasons for discontinuation were adverse events, remission and lack of patient compliance. Our observations further support the efficiency of IFX in managing patients with BS.

Disclosure of Interests:

Sinem Nihal Esatoglu: None declared, Beyza Tukek: None declared, Sitki Safa Taflan: None declared, Yilmaz Ozyazgan: None declared, Didar Ucar: None declared, Emire Seyahi: None declared, Melike Melikoglu: None declared, Vedat Hamuryudan Speakers bureau: Pfizer, AbbVie, Amgen, MSD, Novartis, UCB, Ugur Uygunoglu: None declared, Aksel Siva: None declared, Izzet Fresko: None declared, Sebahattin Yurdakul: None declared, Hasan Yazici: None declared, Gulen Hatemi Grant/research support from: BMS, Celgene Corporation, Silk Road Therapeutics – grant/research support, Consultant of: Bayer, Eli Lilly – consultant, Speakers bureau: AbbVie, Mustafa Nevzat, Novartis, UCB – speaker

Patients' experiences with Behçet's syndrome: structured interviews among patients with different types of organ involvement

OBJECTIVES

Behçet's syndrome (BS) is a multisystem variable-vessel vasculitis with significant life impact. The aim of this study was to explore the perspectives of patients with BS with different types of organ involvement.

METHODS

Semi-structured qualitative interviews were conducted with 20 patients with BS with different types of organ involvement. Interviews were audio-recorded, transcribed, and translated into English. A Grounded Theory approach was employed in thematic analysis of translated interviews.

RESULTS

Interviews with participants yielded four themes, including symptoms (skin problems, pain, vision problems, fatigue/sleep disturbances, and gastrointestinal/weight loss), impact on function (impact on speech and vision, mobility, energy for tasks, adaptations, and self-care), psychological impact (emotions and emotional management techniques), and social impact (ability to socialize generally and impact on familial relationships).

CONCLUSIONS

Patients with BS identified several domains, including physical functioning, psychological state, and social identity that are significantly modulated by the symptoms of BS. Those are inter-related with physical symptoms, reflecting the multi-system character of BS, and impair patients' function impacting on psychological and social identities. This work advances an understanding of BS, and will be useful in developing patient-oriented outcome measures for use in studying BS.

Development of eosinophilic granulomatosis with poliangiitis (Churg-Strauss syndrome) and brain tumor in a patient after more than 7 years of omalizumab use: A case report

Omalizumab is a monoclonal anti-immunoglobulin E antibody used for the treatment of severe perennial allergic asthma. Previous reports have suggested that omalizumab treatment can be associated with the development of eosinophilic granulomatosis with poliangiitis (EGPA) (formerly known as Churg-Strauss syndrome) and an increased risk of malignancy. Long-term risks of omalizumab treatment are not very well defined. Here, we report the case of a 75-year-old woman with concurrent occurrence of EGPA and brain tumor after more than 7 years of omalizumab treatment. The possibility of EGPA should be borne in mind during long-term treatment with omalizumab. Despite the absence of definitive data, an association may also exist between the development of malignancy and omalizumab use.

Sexual dysfunction and depression in premenopausal women with mucocutaneous Behçet's disease

AIM

The aim of this study was to investigate depression and sexual dysfunction in female patients with mucocutaneous Behçet's disease (BD).

METHODS

Twenty-five consecutive, sexually active premenopausal female patients with mucocutaneous BD (mean age: 34.76 ± 4.61 SD years) followed at a rheumatology outpatient clinic were enrolled into the study. The control group consisted of 27 age-matched (mean age: 37.0 ± 4.6 SD years), sexually active, healthy volunteers. The Female Sexual Function Index (FSFI) and Beck Depression Inventory (BDI) were used for sexual and psychiatric assessment.

RESULTS

Depression was found in four of 27 (14.8%) in the control group and eight of 25 (32%) in the BD group (P = 0.01). The median total FSFI score for patients with BD was 21.85 (interquartile range [IQR]: 18.25-27.9) and for healthy controls, 27 (IQR 21.5-29.3; P = 0.03). Female sexual dysfunction was diagnosed in 14 of 25 (56%) in the BD group and in 11 of 27 (41%) in the control group (P = 0.27). The pain domain was significantly higher in the BD group at 5.6 (4.4-6.0) than in the control group at 4.4 (3.2-5.5; P = 0.03). None of the other domains (desire, arousal, lubrication, orgasm and satisfaction) of the BD and control groups were different. There were no statistically significant differences between the FSFI, BDI scores and presence of genital ulceration in the BD patients.

CONCLUSION

Depression and FSD were more common in the patients with BD than in the healthy subjects. This might have been a result of the depressive effect of chronic disease as well as BD and low androgen levels.