Treatment of pulmonary arterial hypertension in patients with connective tissue diseases: a systematic review and meta-analysis

The evidence for the treatment of connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH) mostly depends on subgroup or post hoc analysis of randomized controlled trials (RCTs). Thus, we performed a meta-analysis of RCTs that reported outcomes for CTD-PAH. PubMed and EMBASE were searched for CTD-PAH treatment. The selected outcomes were functional class (FC) change, survival rates, 6-min walk distance (6-MWD), clinical worsening (CW), N-terminal prohormone BNP (NT-proBNP), pulmonary vascular resistance (PVR), mean pulmonary arterial pressure (mPAP), right atrial pressure (RAP), and cardiac index (CI). The meta-analysis was conducted according to the PRISMA guidelines and registered in PROSPERO (CRD42020153560). Twelve RCTs conducted with 1837 patients were included. The diagnoses were systemic sclerosis in 59%, SLE in 20%, and other CTDs in 21%. The pharmacological interventions were epoprostenol, treprostinil, sildenafil, tadalafil, bosentan, macitentan, ambrisentan, riociguat, and selexipag. There was a significant difference between interventions and placebo in FC, 6MWD, CW, PVR, RAP, and CI that favored intervention. Our analysis showed a 39% reduction in the CW risk with PAH treatment. The short-term survival rates and mean serum NT-proBNP changes were similar between the study and control groups. Treatment for CTD-PAH had favorable effects on clinical and hemodynamic outcomes but not on survival and NT-proBNP levels. Different from the previous meta-analyses that focused on 6-MWD, time to clinical worsening, and CW as outcomes, this meta-analysis additionally reports the pooled analysis of change in FC, hemodynamic measurements (RAP, PVR, CI), and NT-proBNP, some of which have prognostic value for PAH.

Screening for pulmonary arterial hypertension in patients with systemic sclerosis in the era of new pulmonary arterial hypertension definitions

OBJECTIVES

This study compares the performance of three composite pulmonary arterial hypertension (PAH) screening tools in a real-life SSc cohort, according to both the previous 2015 ESC/ERS guideline and the recent 2022 ESC/ERS guideline haemodynamic criteria.

METHODS

Consecutive SSc patients without a previous diagnosis of pulmonary hypertension (PH) were screened for PAH using the European Society of Cardiology/European Respiratory Society (ESC/ERS), DETECT, and Australian Scleroderma Interest Group (ASIG) algorithms. Right heart catheterisation (RHC) referral performances for PAH were compared according to the 2022 ESC/ERS PAH criteria.

RESULTS

Thirty-five of the 81 patients required RHC; 15 (18.5%) according to ESC/ERS, 27 (33.3%) according to DETECT, and 25 (31%) according to ASIG. The final diagnoses were no-PH in 17 patients, WHO group 1 PH (PAH) in 8 patients, WHO group 2 PH in 8 patients, and WHO group 3 PH in 2 patients. When the hemodynamic criteria of the previous ESC/ERS guideline were applied, only one patient was diagnosed with PAH. The sensitivities of the algorithms for the diagnosis of PAH were 62.5% for ESC/ERS, 75% for DETECT, 87.5% for ASIG according to the 2022 ESC/ERS guideline definition, and 100% for all according to the previous ESC/ERS guideline.

CONCLUSIONS

With the recent criteria, PAH diagnosis in patients with SSc increased by 1.8-fold. Current algorithms for screening PAH are less sensitive with these revised criteria. Although the ASIG algorithm seems more sensitive, it can still miss the diagnosis. The multimodal/algorithmic approach seems to be the best option for predicting PAH.

Disease and Treatment-Specific Complications of Behçet Syndrome

PURPOSE OF REVIEW

We aimed to highlight disease-related and treatment-related complications of Behçet syndrome (BS) based on previous and recent studies and our own experience.

RECENT FINDINGS

The Behçet's Disease Overall Damage Index is a newly developed instrument to assess damage in BS. Validation studies showed that damage is already present in some patients at diagnosis and continues to progress during the follow-up, mainly related to treatment complications. Nervous system and eye involvement are important causes of long-term disability. Cyclophosphamide seems to be associated with infertility and an increased risk of malignancies among BS patients, prompting the consideration of shortening the treatment duration. Flares in mucocutaneous manifestations have been reported with tocilizumab, and de novo BS manifestations with secukinumab therapy. Earlier diagnosis and treatment are essential to prevent disease-related damage in BS. Treatment-related complications seem to be the leading cause of damage during the disease course.

Epidemiology of systemic vasculitis

PURPOSE OF REVIEW

Epidemiology of vasculitides exhibit geographic variation and data from some parts of the world are still scarce. Increased recognition of these rare diseases and improvement in diagnosis and patient care may lead to changes in their epidemiology. In this review, we aimed to highlight the most recent work on the epidemiology of systemic vasculitis.

RECENT FINDINGS

New data from countries where information on the epidemiology of giant cell arteritis, Takayasu arteritis and Behçet syndrome were limited have revealed that these conditions are not as rare as previously believed. The incidence rates during the coronavirus disease 2019 pandemic highlight the link between Kawasaki disease and respiratory pathogens. The use of different classification criteria hampers the comparison of true incidence and prevalence rates in antineutophil cytoplasmic antibody (ANCA)-associated vasculitis and its subtypes between geographies and over time.

SUMMARY

Recent studies have highlighted the epidemiology of vasculitides in different parts of the world and changing trends. Standardization of study design and disease definitions is needed to improve the reliability and comparability of the results.

Mycophenolate mofetil may be an alternative for maintenance therapy of Behçet syndrome uveitis: a single-center retrospective analysis

Experience with mycophenolate in uveitis due to Behçet syndrome (BS) is limited. Twelve patients with panuveitis or posterior uveitis who were started mycophenolate were included. Data on demographic characteristics, therapies, ocular attacks, and adverse events were extracted from patient charts. Seven patients with BS uveitis were prescribed mycophenolate for remission induction, of which 6 were refractory/intolerant to conventional immunosuppressives. Mycophenolate was combined with anti-TNFs in 3 patients, resulting in no further ocular attacks. Mycophenolate had to be stopped in the fourth patient due to adverse events. The remaining 3 patients continued to have ocular attacks and were switched to other agents without any drop in visual acuity. Among the 5 patients who were prescribed mycophenolate for maintenance, 2 were relapse free, but 3 experienced ocular attacks. One patient had an exacerbation of mucocutaneous lesions, and 2 experienced adverse events. Mycophenolate monotherapy may not be adequate for remission induction of refractory BS uveitis, but it can be a safe and effective alternative when combined with a biologic agent. It may also be an option for maintenance therapy.

Therapeutic approach to central nervous system involvement of Behçet's disease

BACKGROUND

Neurologic involvement in Behçet's disease (BD) represents a major cause of disease morbidity and mortality. Early recognition and timely treatment represent crucial aspects that aim at preventing long-term disability. The absence of robust and evidence-based studies further complicates the management of neuro-BD (NBD). In this review we aim at collecting the best available evidence and suggest a treatment algorithm for an optimal and personalized management of NBD.

EVIDENCE ACQUISITION

PubMed (NLM) database for papers written in English language was used to retrieve relevant articles for this review.

RESULTS AND CONCLUSIONS

Neurologic involvement in BD is one of the most serious and challenging aspects to manage, particularly in its chronic progressive form. It is important to distinguish between acute and chronic progressive NBD, as treatment may vary considerably. Currently, no standardized treatment guidelines support physicians in the decision-making process that therefore relies on low-level evidence. High dose corticosteroids remain the cornerstone for managing acute phase both in the parenchymal and non-parenchymal involvement. Prevention of relapses and control of disease progression represent crucial goals for acute and chronic progressive NBD respectively. In this regard, mycophenolate mofetil and azathioprine are valuable options in the acute NBD. On the other hand, low weekly dose methotrexate has been suggested for chronic progressive NBD. Refractory cases or intolerant patients to conventional therapies may benefit from biologic agents, particularly infliximab. First-line infliximab may be preferred in severe patients with high risk of damage. Other agents including tocilizumab, interleukin-1 inhibitors, B-cell depletion therapy and to a lesser extent, interferon-α and intravenous immunoglobulins are potential options in severe and multidrug resistant cases. Due to multiple organ involvement in BD, long-term treatment should be determined by a multidisciplinary approach. Therefore, multicenter collaborations in the context of international registry-based projects could promote data sharing, standardization of more clinical outcomes and knowledge diffusion that hopefully may optimize therapy and personalize the management of patients with such a complex syndrome.

Treatment of systemic sclerosis-associated digital ulcers: recommendations of the Turkish Society for Rheumatology

OBJECTIVES

Digital ulcers (DUs) are associated with a significant burden in systemic sclerosis (SSc) by leading to severe pain, physical disability, and reduced quality of life. This effort aimed to develop recommendations of the Turkish Society for Rheumatology (TRD) on the management of DUs associated with SSc.

METHODS

In the first meeting held in December 2020 with the participation of a task force consisting of 23 rheumatologists the scope of the recommendations and research questions were determined. A systematic literature review was conducted by 5 fellows and results were presented to the task force during the second meeting. The Oxford system was used to determine the level of evidence. The preliminary recommendations were discussed, modified, and voted by the task force and then by members of TRD via e-mail invitation allowing personalised access to a web-based questionnaire [SurveyMonkey®].

RESULTS

A total of 23 recommendations under 7 main headings were formulated covering non-pharmacological measures for the prevention of DUs and pharmacological treatments including vasodilators, anti-aggregants, antibiotics, wound care, pain control, and interventions including sympathectomy, botulinum toxin, and surgery. Risk factors, poor prognostic factors, prevention of DU and adverse effects of medical treatments were reported as 4 overarching principles.

CONCLUSIONS

These evidence-based recommendations for the management of SSc-associated DUs were developed to provide a useful guide to all physicians who are involved in the care of patients with SSc, as well as to point out unmet needs in this field.

Infliximab for vascular involvement in Behçet's syndrome

OBJECTIVE

Vascular involvement is an important cause of morbidity and mortality in patients with Behçet's syndrome (BS). We aimed to survey the efficacy and safety of infliximab (IFX) in BS patients with vascular involvement followed in a dedicated tertiary center.

METHODS

Charts of all BS patients who used IFX for vascular involvement between 2004 and 2022 were reviewed. Primary endpoint was remission at Month 6, defined as lack of new clinical symptoms and findings associated with vascular lesion, lack of worsening of the primary vascular lesion and a new vascular lesion on imaging, and CRP < 10 mg/L. Relapse was defined as development of a new vascular lesion or recurrence of the preexisting vascular lesion.

RESULTS

Among the 127 patients (102 men, mean age at IFX initiation: 35.8 ± 9.0 years) treated with IFX, 110 (87%) had received IFX for remission induction and 87 of these (79%) were already on immunosuppressives when the vascular lesion requiring IFX developed. The remission rate was 73% (93/127) at Month 6 and 63% (80/127) at Month 12. Seventeen patients experienced relapses. Remission rates were better among patients with pulmonary artery involvement and venous thrombosis compared to patients with non-pulmonary artery involvement and venous ulcers. Fourteen patients had adverse events leading to IFX discontinuation and 4 had died due to lung adenocarcinoma, sepsis, and pulmonary hypertension-related right heart failure due to pulmonary artery thrombosis (n = 2).

CONCLUSION

Infliximab seems to be effective in majority of BS patients with vascular involvement, even in those who are refractory to immunosuppressives and glucocorticoids.

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.

Difficult-to-treat Behçet syndrome: A therapeutic approach

Behcet syndrome is a systemic vasculitis which can involve many different organ systems. As such, treatment decisions need to be based on organ system involved. In addition, specific patient characteristics potentially predict milder or more severe course, and all these factors need to be taken into consideration when making treatment decisions. In this paper, we review the current approaches to treating Behcet syndrome patients.

Vascular Behçet syndrome: from pathogenesis to treatment

Behçet syndrome is a rare, chronic inflammatory disease of unknown aetiopathogenesis, most commonly presenting with mucocutaneous and ocular manifestations. Vascular involvement, most frequently superficial vein and deep vein thrombosis, can occur in up to 50% of patients with Behçet syndrome. Venous thrombosis at atypical sites (inferior and superior vena cava, suprahepatic veins with Budd-Chiari syndrome, portal vein, cerebral sinuses and right atrium and/or ventricle) and arterial involvement (mostly in situ thrombosis and aneurysms of the pulmonary arteries, as well as aneurysms of the abdominal aorta, and peripheral and visceral arteries) are also unique features of Behçet syndrome. Behçet syndrome is considered a natural model of inflammation-induced thrombosis in humans, with an impaired immune-inflammatory response rather than traditional cardiovascular risk factors contributing to thrombogenesis. Specifically, neutrophil hyperactivation and neutrophil-mediated mechanisms of damage directly promote endothelial dysfunction, platelet activation and thrombogenesis in Behçet syndrome. This unusual pathogenesis directly determines the treatment approach, which relies mostly on immunosuppressants rather than anticoagulants for treatment of thrombosis and for secondary prevention. This Review discusses the main histopathological, pathogenetic and clinical aspects of vascular Behçet syndrome, addressing their implications for therapeutic management. Future perspectives in terms of pathogenetic studies, disease monitoring and treatment strategies are also discussed.

Current pharmacological solutions for Behçet's syndrome

INTRODUCTION

Behçet's syndrome (BS) has a heterogeneous clinical phenotype, and its clinical manifestations may respond differently to drugs commonly used to treat BS. The type, dose, and duration of immunomodulatory, immunosuppressive, and biologic agents should be tailored individually.

AREAS COVERED

We reviewed the literature for articles on BS management that were published until June 2022 and summarized the management options in BS for each type of organ involvement. We aimed to cover all currently available pharmacological agents used in BS, as well as surgical and interventional options, focusing on recent evidence.

EXPERT OPINION

The management aims in BS are to preserve function and quality of life and to avoid damage. The choice of treatment modalities depends on the organs that are actively involved, the severity of that involvement, and prognostic factors. A treat-to-attack strategy would help improve long-term outcomes in BS.

Treat to target in Behcet's disease: Should we follow the paradigm of other systemic rheumatic diseases?

During the last decades the efficacy of biologic agents, mainly of anti-TNFs, in controlling the activity of serious manifestations of Behcet's Disease (BD) has been established. On the other hand, the clinical heterogeneity of BD has precluded the validation of a widely-accepted composite index for disease assessment and for target disease-state definitions, such as low disease activity and remission, and the testing of their implementation in clinical practice. Therefore, in contrast to other systemic rheumatic diseases, a treat-to-target strategy has not yet been developed in BD. There are several challenges towards this approach, including standardization of outcome measures for assessing the disease activity in each-affected organ and construction of a composite disease activity index. The challenges for the development of a treat-to-target strategy and possible solutions are discussed in this position paper, which stemmed from a round table discussion that took place in the 19th International Conference on BD.

Frequency of AA amyloidosis has decreased in Behçet's syndrome: a retrospective study with long-term follow-up and a systematic review

OBJECTIVE

A decline in the frequency of AA amyloidosis secondary to RA and infectious diseases has been reported. We aimed to determine the change in the frequency of AA amyloidosis in our Behçet's syndrome (BS) patients and to summarize the clinical characteristics of and outcomes for our patients, and also those identified by a systematic review.

METHODS

We identified patients with amyloidosis in our BS cohort (as well as their clinical and laboratory features, treatment, and outcome) through a chart review. The primary end points were end-stage renal disease and death. The prevalence of AA amyloidosis was estimated separately for patients registered during 1976-2000 and those registered during 2001-2017, in order to determine whether there was any change in the frequency. We searched PubMed and EMBASE for reports on BS patients with AA amyloidosis. Risk of bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool.

RESULTS

The prevalence of AA amyloidosis was 0.62% (24/3820) in the earlier cohort and declined to 0.054% (3/5590) in the recent cohort. The systematic review revealed 82 cases in 42 publications. The main features of patients were male predominance and a high frequency of vascular involvement. One-third of patients died within 6 months after diagnosis of amyloidosis.

CONCLUSION

The frequency of AA amyloidosis has decreased in patients with BS, which is similar to the decrease observed for AA amyloidosis due to other inflammatory and infectious causes. However, AA amyloidosis is a rare, but potentially fatal complication of BS.

2022 American College of Rheumatology/EULAR Classification Criteria for Takayasu Arteritis

OBJECTIVE

To develop and validate new classification criteria for Takayasu arteritis (TAK).

METHODS

Patients with vasculitis or comparator diseases were recruited into an international cohort. The study proceeded in 6 phases: 1) identification of candidate criteria items, 2) collection of candidate items present at diagnosis, 3) expert panel review of cases, 4) data-driven reduction of candidate items, 5) derivation of a points-based classification score in a development data set, and 6) validation in an independent data set.

RESULTS

The development data set consisted of 316 cases of TAK and 323 comparators. The validation data set consisted of an additional 146 cases of TAK and 127 comparators. Age ≤60 years at diagnosis and imaging evidence of large-vessel vasculitis were absolute requirements to classify a patient as having TAK. The final criteria items and weights were as follows: female sex (+1), angina (+2), limb claudication (+2), arterial bruit (+2), reduced upper extremity pulse (+2), reduced pulse or tenderness of a carotid artery (+2), blood pressure difference between arms of ≥20 mm Hg (+1), number of affected arterial territories (+1 to +3), paired artery involvement (+1), and abdominal aorta plus renal or mesenteric involvement (+3). A patient could be classified as having TAK with a cumulative score of ≥5 points. When these criteria were tested in the validation data set, the model area under the curve was 0.97 (95% confidence interval [95% CI] 0.94-0.99) with a sensitivity of 93.8% (95% CI 88.6-97.1%) and specificity of 99.2% (95% CI 96.7-100.0%).

CONCLUSION

The 2022 American College of Rheumatology/EULAR classification criteria for TAK are now validated for use in research.

Development and implementation of the AIDA International Registry for patients with Behçet's disease

Purpose of the present paper is to point out the design, development and deployment of the AutoInflammatory Disease Alliance (AIDA) International Registry dedicated to pediatric and adult patients with Behçet's disease (BD). The Registry is a clinical physician-driven non-population- and electronic-based instrument implemented for the retrospective and prospective collection of real-life data about demographics, clinical, therapeutic, laboratory, instrumental and socioeconomic information from BD patients; the Registry is based on the Research Electronic Data Capture (REDCap) tool, which is thought to collect standardised information for clinical real-life research, and has been realised to change over time according to future scientific acquisitions and potentially communicate with other existing and future Registries dedicated to BD. Starting from January 31st, 2021, to February 7th, 2022, 110 centres from 23 countries in 4 continents have been involved. Fifty-four of these have already obtained the approval from their local Ethics Committees. Currently, the platform counts 290 users (111 Principal Investigators, 175 Site Investigators, 2 Lead Investigators, and 2 data managers). The Registry collects baseline and follow-up data using 5993 fields organised into 16 instruments, including patient's demographics, history, clinical manifestations and symptoms, trigger/risk factors, therapies and healthcare access. The development of the AIDA International Registry for BD patients will facilitate the collection of standardised data leading to real-world evidence, enabling international multicentre collaborative research through data sharing, international consultation, dissemination of knowledge, inclusion of patients and families, and ultimately optimisation of scientific efforts and implementation of standardised care.Trial registration NCT05200715 in 21/01/2022.

Behçet's disease risk-variant HLA-B51/ERAP1-Hap10 alters human CD8 T cell immunity

OBJECTIVES

The endoplasmic reticulum aminopeptidase (ERAP1) haplotype Hap10 encodes for a variant allotype of the endoplasmic reticulum (ER)-resident peptide-trimming aminopeptidase ERAP1 with low enzymatic activity. This haplotype recessively confers the highest risk for Behçet's diseases (BD) currently known, but only in carriers of HLA-B*51, the classical risk factor for the disease. The mechanistic implications and biological consequences of this epistatic relationship are unknown. Here, we aimed to determine its biological relevance and functional impact.

METHODS

We genotyped and immune phenotyped a cohort of 26 untreated Turkish BD subjects and 22 healthy donors, generated CRISPR-Cas9 ERAP1 KOs from HLA-B*51 ⁺ LCL, analysed the HLA class I-bound peptidome for peptide length differences and assessed immunogenicity of genome-edited cells in CD8 T cell co-culture systems.

RESULTS

Allele frequencies of ERAP1-Hap10 were similar to previous studies. There were frequency shifts between antigen-experienced and naïve CD8 T cell populations of carriers and non-carriers of ERAP1-Hap10 in an HLA-B*51 background. ERAP1 KO cells showed peptidomes with longer peptides above 9mer and significant differences in their ability to stimulate alloreactive CD8 T cells compared with wild-type control cells.

CONCLUSIONS

We demonstrate that hypoactive ERAP1 changes immunogenicity to CD8 T cells, mediated by an HLA class I peptidome with undertrimmed peptides. Naïve/effector CD8 T cell shifts in affected carriers provide evidence of the biological relevance of ERAP1-Hap10/HLA-B*51 at the cellular level and point to an HLA-B51-restricted process. Our findings suggest that variant ERAP1-Hap10 partakes in BD pathogenesis by generating HLA-B51-restricted peptides, causing a change in immunodominance of the ensuing CD8 T cell response.

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

Frequency and severity of COVID-19 in patients with various rheumatic diseases treated regularly with colchicine or hydroxychloroquine

This study aimed to investigate whether patients regularly using colchicine or hydroxychloroquine (HCQ) have an advantage of protection from coronavirus disease 2019 (COVID-19) or developing less severe disease. 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 in the study. The clinical data regarding COVID-19 were collected using a standard form, and serum samples were analyzed for anti-severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) nucleocapsid immunoglobulin G (IgG). 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-COV-2 IgG was positive in 43 (6.8%) regular colchicine users and 35 (5.4%) household contacts (odds ratio [OR] = 1.3; 95% confidence interval [CI]:0.8-2; p = 0.3). 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. Seropositive subjects were observed in 22 (6.9%) regular HCQ users and 24 (7.2%) household contacts (OR = 1.1; 95% CI: 0.6-1.9; p =  0.8). 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). Being on a regular treatment of colchicine or HCQ did not result in the prevention of COVID-19 or amelioration of its manifestations.

Takayasu arteritis

PURPOSE OF REVIEW

The purpose of this review is to summarize the recent advances in Takayasu arteritis (TAK), mainly focusing on pathogenesis, imaging modalities, and management.

RECENT FINDINGS

Three novel clusters based on angiographic findings were identified in the Indian cohort and replicated in the North American cohorts. Different new imaging modalities have been tried in the assessment of arterial inflammation with promising results. There is more evidence on the long-term use of tocilizumab, but relapses are common. In light of the recent findings on the pathogenesis of TAK, Janus kinase inhibitors seem to be promising.

SUMMARY

Improvement in imaging modalities and in our understanding of the disease pathogenesis will allow us to better assess the disease activity and identify effective therapeutic agents.

Emergence of New Manifestations During Infliximab Treatment in Behçet Syndrome

OBJECTIVES

Infliximab (IFX) is being increasingly used for the treatment of severe manifestations of Behçet syndrome (BS). However, emergence of new manifestations has also been occasionally reported during IFX treatment. We aimed to assess the frequency of new manifestations in our BS patients treated with IFX.

METHODS

A chart review was conducted to identify all BS patients treated with IFX in our clinic between 2004 and 2020. Demographic data, indications for IFX initiation, concomitant treatments, and outcomes were recorded. A new manifestation was defined as the emergence of a new organ involvement or mucocutaneous manifestation developing for the first time during IFX treatment or within 12 weeks after the last infusion of IFX.

RESULTS

Among our 282 patients who used IFX, 19 (7%) patients had developed a total of 23 new manifestations during a mean follow up of 20.0 ± 15.3 months. Patients with vascular involvement were more likely to develop a new manifestation (12/19, 63%). Initial manifestations that required IFX were in remission at the time of new manifestation in 14/19 patients. IFX treatment was intensified (n = 6) and/or glucocorticoids, immunosuppressives, or colchicine were added to IFX (n = 21). IFX was switched to another agent for the remaining manifestations (n = 8). These treatment modifications led to remission in 17/19 patients.

CONCLUSION

New manifestations developed during IFX treatment in 7% of our patients with BS. They could be managed by intensifying IFX treatment or adding other agents in majority of these manifestations.

The incidence, clinical characteristics, and outcome of COVID-19 in a prospectively followed cohort of patients with Behçet's syndrome

Initial case series of small number of patients at the beginning of the pandemic reported a rather guarded prognosis for Behçet’s syndrome (BS) patients infected with SARS-CoV-2. In this prospective study, we describe the incidence, clinical characteristics, disease course, management, and outcome in a large cohort of BS patients with laboratory-confirmed infection of SARS-CoV-2. We defined a cohort of 1047 registered BS patients who were aged between 16 and 60 years and seen routinely before the pandemic at the multidisciplinary outpatient clinic. We followed prospectively this cohort from beginning of April 2020 until the end of April 2021. During 13 months of follow-up, of the 1047 (599 M/448 F) patients, 592 (56.5%) were tested for SARS-CoV-2 PCR at least once and 215 (20.5%; 95% CI 0.18–0.23) were tested positive. We observed 2 peaks which took place in December 2020 and April 2021. Of the 215 PCR positive patients, complete information was available in 214. Of these 214, 14 (6.5%) were asymptomatic for COVID-19. In the remaining, the most common symptoms were anosmia, fatigue, fever, arthralgia, and headache. A total of 40 (18.7%) had lung involvement, 25 (11.7%) were hospitalized, 1 was admitted to the intensive care unit while none died. Favipiravir was the most prescribed drug (74.3%), followed by colchicine (40.2%), and hydroxychloroquine (20.1%) in the treatment of COVID-19. After COVID-19, 5 patients (2.3%) were given supplemental O₂ and 31 (14.5%) antiaggregant or anticoagulants. During COVID-19, of the 214 PCR positive patients, 116 (54.2%) decreased the dose of their immunosuppressives or stopped taking completely; 36 (16.8%) experienced a BS flare which was mostly oral ulcers (10.3%). None of the patients reported a thrombotic event. A total of 93 (43.5%) patients reported BS flares after a median 45 days of COVID-19 infection and this was found to be significantly associated with immunosuppressive drug discontinuation. Multiple regression analysis adjusted for age and gender indicated that smoking and using interferon-alpha decreased the likelihood of getting COVID-19. The incidence and severity of COVID-19 did not differ between those who were using colchicine or not. The cumulative incidence of COVID-19 in this prospectively followed cohort of BS patients was almost two folds of that estimated for the general population living in Istanbul, Turkey, however, the clinical outcome of COVID-19 was not severe and there was no mortality. The protective effect of smoking and interferon deserves further investigation. On the other hand, colchicine did not have any positive or negative effect against COVID-19. Significant number of patients flared after COVID-19, however, this was significantly associated with immunosuppressive discontinuation during the infection. Contrary to our previous observations, COVID-19 did not seem to exacerbate thrombotic events during or after the infection.

Behçet syndrome

Behçet syndrome is a systemic vasculitis with an unknown aetiology affecting the small and large vessels of the venous and arterial systems. The presence of symptom clusters, regional differences in disease expression and similarities with, for example, Crohn's disease suggest that multiple pathological pathways are involved in Behçet syndrome. These disease features also make formulating disease criteria difficult. Genetic studies have identified HLA-B*51 as a genetic risk factor. However, the low prevalence of HLA-B*51 in many patients with bona fide disease, especially in non-endemic regions, suggests that other factors must also be operative in Behçet syndrome. Despite lacking a clear aetiological mechanism and definition, management of manifestations that include major vascular disease, eye disease and central nervous system involvement has improved with the help of new technology. Furthermore, even with our incomplete understanding of disease mechanisms, the prognoses of patients with Behçet syndrome, including those with eye disease, continue to improve. New treatment options and a better understanding of the underlying pathogenesis for various manifestations of this condition are required to further improve the management of the disease, which will improve patient quality of life.

Recent Insights into the Management of Behçet Syndrome

Behçet syndrome (BS) is a multisystem vasculitis with variable vessel involvement that shows significant heterogeneity among patients in terms of clinical manifestations and disease course. Treatment choice and response are both influenced by this heterogeneity. BS treatments’ main goals are to quickly suppress inflammatory exacerbations and prevent relapses in order to protect organ functions and provide good quality of life. Besides the long-term experience with steroids and traditional immunosuppressives, biologic drugs, especially TNF inhibitors, have gained increasing importance in the treatment of BS over the years. In this review, we aimed to give an overview of the studies with conventional and biological drugs with proven efficacy in the treatment of BS, as well as promising drugs and current management strategies according to clinical phenotypes.

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

COVID-19 Among Patients With Inflammatory Rheumatic Diseases

Background

The course of novel coronavirus disease 2019 (COVID-19) has been of special concern in patients with inflammatory rheumatic diseases (IRDs) due to the immune dysregulation that may be associated with these diseases and the medications used for IRDs, that may affect innate immune responses.

Objective

In this cohort study, we aimed to report the disease characteristics and variables associated with COVID-19 outcome among Turkish patients with IRDs.

Methods

Between April and June, 2020, 167 adult IRD patients with COVID-19 were registered from 31 centers in 14 cities in Turkey. Disease outcome was classified in 4 categories; (i) outpatient management, (ii) hospitalization without oxygen requirement, (iii) hospitalization with oxygen requirement, and (iv) intensive care unit (ICU) admission or death. Multivariable ordinal logistic regression analysis was conducted to determine variables associated with a worse outcome.

Results

165 patients (mean age: 50 ± 15.6 years, 58.2% female) were included. Twenty-four patients (14.5%) recovered under outpatient management, 141 (85.5%) were hospitalized, 49 (30%) required inpatient oxygen support, 22 (13%) were treated in the ICU (17 received invasive mechanic ventilation) and 16 (10%) died. Glucocorticoid use (OR: 4.53, 95%CI 1.65-12.76), chronic kidney disease (OR: 12.8, 95%CI 2.25-103.5), pulmonary disease (OR: 2.66, 95%CI 1.08-6.61) and obesity (OR: 3.7, 95%CI 1.01-13.87) were associated with a worse outcome. Biologic disease-modifying antirheumatic drugs (DMARDs) do not seem to affect COVID-19 outcome while conventional synthetic DMARDs may have a protective effect (OR: 0.36, 95%CI 0.17-0.75). Estimates for the associations between IRD diagnoses and outcome were inconclusive.

Conclusions

Among IRD patients with COVID-19, comorbidities and glucocorticoid use were associated with a worse outcome, while biologic DMARDs do not seem to be associated with a worse outcome.

Long term follow-up of Behçet's syndrome patients treated with cyclophosphamide

OBJECTIVES

CYC remains an important treatment option for Behçet's syndrome (BS) patients with life-threatening manifestations. However, adverse events may occur with CYC and this has led to increased use of biologic agents in other vasculitides. We investigated short and long term adverse events associated with CYC use in BS patients.

METHODS

We conducted a retrospective chart review of all BS patients treated with CYC between 1972 and 2006. Patients were called in and a standard form was used for collecting demographic characteristics, indication for CYC, its cumulative dose and short term adverse events, defined as those causing discontinuation of CYC, hospitalization and/or death, long term adverse events, including infertility and malignancy, and outcome.

RESULTS

Of 5790 BS patients, 198 (3.4%) had used at least one dose of CYC. Main indications were vascular or neurological involvement. After a median follow-up of 17 years, 52 (26%) patients had died, 113 (57%) could be contacted, and 33 (17%) were lost to follow-up. Vascular involvement was the leading cause of death (n = 27). Seventeen (9%) patients experienced short term adverse events with haemorrhagic cystitis being the most common. After a median follow-up of 25 years (interquartile range: 15-26 years), 17 malignancies occurred in 15 (8%) patients. Infertility was experienced by 26 (30%) patients.

CONCLUSION

Long term adverse events such as malignancy and infertility were major problems in our BS patients treated with CYC. These results underline the need for safer treatment modalities that are at least as effective as CYC.

Immunogenicity of Infliximab Among Patients With Behçet Syndrome: A Controlled Study

Background

Immunogenicity of tumor necrosis factor alpha inhibitors (TNFis) has been recognized as an important problem that may cause loss of efficacy and adverse events such as infusion reactions. TNFis are being increasingly used among patients with Behçet syndrome (BS) and scarce data exist on this topic.

Objective

We aimed to investigate the prevalence of anti-infliximab (IFX) antibodies in patients with Behçet syndrome together with suitable controls.

Methods

We collected serum samples from 66 consecutive Behçet syndrome patients (51 M, 15 F, mean age 37 ± 9 years) who were treated with IFX. Additionally, similarly treated 27 rheumatoid arthritis, 53 ankylosing spondylitis, 25 Crohn's disease patients, and 31 healthy subjects were included as controls. Samples were collected just before an infusion, stored at -80°C until analysis, and serum IFX trough levels and anti-IFX antibodies were measured by ELISA. We used a cut-off value of 1 μg/ml for serum IFX trough level, extrapolating from rheumatoid arthritis studies.

Results

Anti-IFX antibodies were detected in four (6%) Behçet syndrome, five (18.5%) rheumatoid arthritis, three (12%) Crohn's disease, and one (2%) ankylosing spondylitis patient. The median serum IFX trough level was significantly lower in patients with anti-IFX antibodies compared to those without antibodies [2.32 (IQR: 0.6-3.6) vs. 3.35 (IQR: 1.63-5.6); p = 0.019]. The serum IFX trough level was lower than the cut-off value in 6/13 (46%) patients with anti-IFX antibodies and in 25/158 (16%) patients without anti-IFX antibodies (p = 0.015). Among the four Behçet syndrome patients with anti-IFX antibodies, two experienced relapses and two had infusion reactions.

Conclusions

Immunogenicity does not seem to be a frequent problem in Behçet syndrome patients treated with IFX, but may be associated with relapses and infusion reactions, when present.

Clinical course of acute deep vein thrombosis of the legs in Behçet's syndrome

OBJECTIVES

Lower extremity deep vein thrombosis (LEDVT) is a serious complication of Behçet's syndrome. Management constitutes mainly of administration of immunosuppressives, but the predictors of relapse and the optimal choice of immunosuppressives remain unclear. In this prospective study, we aimed to detect the risk and predictors of relapse and treatment response to different modalities.

METHODS

All Behçet's syndrome patients who presented with a first episode of acute LEDVT between 2010 and 2014 were prospectively followed with a standard protocol. Acute LEDVT was confirmed by Doppler ultrasonography. Serial planned Doppler ultrasonography assessments were performed during follow-up and additionally repeated in case of clinical suspicion. Recanalization rate was assessed at each visit. Our first-line treatment strategy consisted of AZA and CSs. IFN-alpha was used in patients who were refractory to or could not tolerate AZA or had concomitant eye involvement requiring further treatment.

RESULTS

Thirty-three patients with LEDVT (26 M/7 F) were prospectively followed for 40.7 ± 13.4 months. Among the 33 patients, 23 relapses were observed in 15 patients. Relapse rates were 29%, 37% and 45% at 6, 12 and 24 months, respectively. Among the possible predictors of relapse, poor recanalization was the only significant factor [hazard ratio 4.34 (95% CI 1.96, 10.0)]. Overall 29 patients were treated with AZA and 17 with IFN-alpha. The relapse rate was lower and recanalization rate was higher with IFN-alpha compared with AZA (12% vs 45% and 86% vs 45%).

CONCLUSION

The relapse rate for LEDVT in Behçet's syndrome is high despite AZA treatment. IFN-alpha seems to be a promising agent for preventing LEDVT relapses and achieving good recanalization.

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