Beliefs about medicines in gout patients: results from the NOR-Gout 2-year study

OBJECTIVE

Adherence to urate-lowering therapy (ULT) in gout is challenging. This longitudinal study aimed to determine 2 year changes in beliefs about medicines during intervention with ULT.

METHOD

Patients with a recent gout flare and increased serum urate received a nurse-led ULT intervention with tight control visits and a treatment target. Frequent visits at baseline and 1, 2, 3, 6, 9, 12, and 24 months included the Beliefs about Medicines Questionnaire (BMQ), and demographic and clinical variables. The BMQ subscales on necessity, concerns, overuse, harm, and the necessity-concerns differential were calculated as a measure of whether the patient perceived that necessity outweighed concerns.

RESULTS

The mean serum urate reduced from 500 mmol/L at baseline to 324 mmol/L at year 2. At years 1 and 2, 85.5% and 78.6% of patients, respectively, were at treatment target. The 2 year mean ± sd BMQ scores increased for the necessity subscale from 17.0 ± 4.4 to 18.9 ± 3.6 (p < 0.001) and decreased for the concerns subscale from 13.4 ± 4.9 to 12.5 ± 2.7 (p = 0.001). The necessity-concerns differential increased from 3.52 to 6.58 (p < 0.001), with a positive change independent of patients achieving treatment targets at 1 or 2 years. BMQ scores were not significantly related to treatment outcomes 1 or 2 years later, and achieving treatment targets did not lead to higher BMQ scores.

CONCLUSION

Patient beliefs about medicines improved gradually over 2 years, with increased beliefs in the necessity of medication and reduced concerns, but this improvement was unrelated to better outcomes.

TRIAL REGISTRATION

ACTRN12618001372279.

Fluctuation and change of serum urate levels and flares in gout: results from the NOR-Gout study

A gout attack may evolve after a purine-rich diet or alcohol and after starting urate-lowering therapy (ULT). The relationships between fluctuation and change in serum urate (SU) with the occurrence of flares were investigated in this study. In the prospective NOR-Gout study, gout patients with increased SU and a recent flare were treated to target with ULT over 1 year, with follow-up at year 2 with SU and flare as outcomes. SU and flares were assessed at both monthly and 3-monthly intervals until target SU was reached. Fluctuation over periods and changes in SU between two time points were assessed and compared in patients with and without flares. At year 1, 186 patients completed follow-up (88.2%) and 173 (82.0%) at year 2. Mean age (SD) at baseline was 56.4 (13.7) years, disease duration was 7.8 (7.6) years, and 95.3% were men. The first-year SU fluctuation and change were related to flare occurrence during year 1 (both p < 0.05). High fluctuation with an absolute sum of all SU changes during the first 9 months was related to flares over 3-month periods (all p < 0.05), and high fluctuation during the first 3 months was related to flares in months 3-6 (p = 0.04). Monthly and high SU changes or again reaching higher SU levels > 360 µmol/l were not related to flares. Fluctuation and change in SU were related to flare occurrence during the first year of ULT, while changes between visits and reaching SU levels > 360 µmol/L were not related to flares. Key Points • Urate-lowering therapy seeks to achieve a treatment target and prevent gout flares, and changes in serum urate are related to gout flares. • Fluctuation and changes in serum urate were associated with gout flares, suggesting that fluctuation in serum urate is unfavourable during gout treatment. • During urate-lowering therapy in gout in clinical practice, fluctuation of serum urate, for example, due to lack of adherence, should be observed and avoided.

The MCP2 and the wrist plus two extensor compartments are the most affected and responsive joints/tendons out of the US7 score in patients with rheumatoid arthritis-an observational study

Background

There is no international consensus on an optimal ultrasound score for monitoring of rheumatoid arthritis (RA) on patient-level yet. Our aim was to reassess the US7 score for the identification of the most frequently pathologic and responsive joint/tendon regions, to optimize it and contribute to an international consensus. Furthermore, we aimed to evaluate the impact of disease duration on the performance of the score.

Methods

RA patients were assessed at baseline and after 3 and 6 months of starting/changing DMARD therapy by the US7 score in greyscale (GS) and power Doppler (PD). The frequency of pathologic joint/tendon regions and their responsiveness to therapy were analyzed by Friedman test and Cochrane-Q test respectively, including the comparison of palmar vs. dorsal regions (chi-square test). The responsiveness of different reduced scores and the amount of information retained from the original US7 score were assessed by standardized response means (SRM)/linear regression. Analyses were also performed separately for early and established RA.

Results

A total of 435 patients (N = 138 early RA) were included (56.5 (SD 13.1) years old, 8.2 (9.1) years disease duration, 80% female). The dorsal wrist, palmar MCP2, extensor digitorum communis (EDC) and carpi ulnaris (ECU) tendons were most frequently affected by GS/PD synovitis/tenosynovitis (wrist: 45%/43%; MCP2: 35%/28%; EDC: 30%/11% and ECU: 25%/11%) and significantly changed within 6 months of therapy (all p ≤0.003 by GS/PD). The dorsal vs. palmar side of the wrist by GS/PD (p < 0.001) and the palmar side of the finger joints by PD (p < 0.001) were more frequently pathologic. The reduced US7 score (GS/PD: palmar MCP2, dorsal wrist, EDC and ECU, only PD: dorsal MCP2) showed therapy response (SRM 0.433) after 6 months and retained 76% of the full US7 score’s information.

No major differences between the groups of early and established RA could be detected.

Conclusions

The wrist, MCP2, EDC, and ECU tendons were most frequently pathologic and responsive to therapy in both early and established RA and should therefore be included in a comprehensive score for monitoring RA patients on patient-level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02874-y.

POS0176 A COMPARISON OF ULTRASOUND-DETECTED PATHOLOGIES IN PERSONS WITH AND WITHOUT KNEE OSTEOARTHRITIS AND THE ASSOCIATIONS WITH PAIN

Background

Ultrasound can evaluate osteophytes and synovitis in persons with knee OA. However, albeit the literature demonstrates a positive association between knee pain and synovitis, the instruments used to report pain, the number of patients included, the strengths of associations and the overall quality of the studies varies greatly (1).

Objectives

1) To compare the degree of OA changes by ultrasound among people with and without clinical knee OA according to established classification criteria.

2) Study the associations between ultrasound findings and pain.

Methods

We included 286 of 300 participants from the NOR-HAND study, a hospital-based observational cohort after excluding participants with knee prostheses or arthrodesis.

The participants reported the levels of knee/hip pain using the Western/Ontario McMaster University index (WOMAC) and marked their painful joints (including the bilateral knees) during the last 24 hours and last 6 weeks on two separate homunculi.

An experienced rheumatologist (BSC) examined whether the participants fulfilled the clinical ACR criteria for knee OA or not (n=7 missing).

A trained medical student performed the ultrasound examination of the knees using a General Electric (GE) Logic E9 ultrasound machine with a 6-15Mz probe. Both knees were scored for 1) osteophytes in the medial and lateral tibia and femur on 0-3 semi-quantitative scales (0=no, 1=small, 2=medium, and 3=large), and 2) grey-scale synovitis on 0-3 semi-quantitative scales (0=no, 1=mild, 2=moderate, and 3=severe pathology). The highest score of osteophytes and grey-scale synovitis (range: 0-3) and the sum scores of both knees together (range: 0-24 for osteophytes and 0-6 for synovitis) were calculated.

We compared the degree of ultrasound pathologies in persons with vs. without clinical knee OA using Chi square tests and Mann-Whitney U test or T test as appropriate. The associations between ultrasound pathologies and pain scores were explored by logistic regression analyses, adjusted for age, sex and BMI. Generalized Estimating Equations were applied to account for two knees belonging to the same person.

Results

Knee osteophytes, but not grey-scale synovitis, were more common in persons with vs. without clinical knee OA (median sum score of osteophytes: 2 vs. 0, p<0.001) and were associated with higher levels of WOMAC pain (beta=0.18, 95% confidence interval (CI) 0.03-0.32). The same association to WOMAC pain was not found for synovitis (beta=0.03, 95% CI -0.33-0.40). However, in analyses on joint level, both osteophytes and synovitis were associated with pain in the same joint in both a short (24 hours) and longer term (6 weeks), with stronger associations for more severe ultrasound scores (Table 1).

Table 1.

Associations between ultrasound pathologies and a) WOMAC pain and b) joint pain in the same joint previous 24 hours and c) previous 6 weeks, adjusted for age, sex and BMI.

a) WOMAC pain both kneesBeta (95%CI)b) OR (95% CI) of pain in the same knee joint previous 24 hoursc) OR (95% CI) of pain in the same knee joint previous 6 weeksOsteophyte sum score (both knees; range 0-24)0.18 (0.03-0.32)Highest osteophyte score -Grade 00.0 (ref)1.00 (ref.)1.00 (ref.) -Grade 11.13 (-1.3, 2.4)1.85 (1.20, 2.84)1.79 (1.19, 2.68) -Grade 20.67 (-0.74, 2.07)2.77 (1.64, 4.70)2.98 (1.76, 5.06) -Grade 31.87 (0.04, 3.7)9.02 (4.04, 20.10)6.50 (2.95, 14.30)Grey-scale synovitis sum score (both knees; range 0-6)0.03 (-0.33, 0.40)Highest GS synovitis score -Grade 00.0 (ref)1.00 (ref.)1.00 (ref.) -Grade 10.24 (-0.99, 1.47)1.00 (0.66, 1.53)0.95 (0.61, 1.47) -Grade 20.27 (-1.33, 1.87)1.67 (0.96, 2.91)1.32 (0.78, 2.25) -Grade 30.46 (-1.73, 2.65)6.63 (2.26, 19.43)4.32 (1.59, 11.71)

Conclusion

Both osteophytes and grey-scale synovitis were associated with pain in the same joint, supporting the validity of ultrasound in knee OA. Grey-scale synovitis was commonly present in people not fulfilling the ACR criteria for clinical knee OA and seems to be less specific for clinical knee OA than osteophytes.

References

[1]doi 10.1016/j.joca.2016.03.004

Disclosure of Interests

Caroline Dekkerhus: None declared, Alexander Mathiessen: None declared, Caroline Fjellstad: None declared, Barbara Slatwkosky-Christensen: None declared, Hilde Berner Hammer: None declared, Ida K. Haugen Consultant of: Novartis, Grant/research support from: Pfizer

POS0106 THE MCP2 AND WRIST PLUS 2 TENDONS ARE THE MOST AFFECTED AND RESPONSIVE JOINTS/TENDONS OUT OF THE ‘US7 SCORE’ IN PATIENTS WITH RHEUMATOID ARTHRITIS – AN OBSERVATIONAL STUDY

Background

There is no international consensus on an optimal ultrasound scoring system in patients with rheumatoid arthritis (RA) yet.

Objectives

To assess the musculoskeletal ultrasound score on seven joints (‘US7 score’) (1) for the identification of the most frequently pathologic and responsive joint regions during 3 and 6 months of therapy in order to optimize the score. Furthermore, to evaluate the impact of disease duration on the performance of the score.

Methods

RA patients were recruited from 54 German rheumatology centers when starting or changing DMARD therapy. Patients were assessed by the US7 score in greyscale (GS) and power Doppler (PD) at baseline, after 3 and 6 months. The frequency of pathologic joint/tendon regions and their responsiveness to therapy were assessed including the comparison of palmar vs. dorsal regions.

Differences between the palmar and the dorsal sides were analyzed using Chi-square test, the gradings of the US-joint inflammation were compared between baseline, 3 months, and 6 months by Friedman test with Dunn test as post-hoc test.

We used standard response mean to determine the responsiveness of possible reduced scores and linear regression to assess the amount of information retained from the original score. Analyses were also performed separately for early and established RA.

Results

A total of 435 patients (n=138 early RA) were included (56.5 (SD 13.1) years old, 8.2 (9.1) years disease duration, 80% female). The dorsal wrist, palmar MCP2, extensor digitorum communis (EDC) and carpi ulnaris (ECU) tendons out of 7 joints were most frequently affected by GS/PD synovitis/tenosynovitis (wrist: 45%/43%; MCP2: 35%/28%; EDC: 30%/11% and ECU: 25%/11%) and significantly changed within 6 months of therapy (all p≤0.003 in GS/PD).

The dorsal vs. palmar side of the wrist by GS/PD (p<0.001) and the palmar vs. dorsal side of the finger joints by PD (p<0.001) were more frequently pathologic. The reduced US7 score (GS and PD: dorsal MCP2, dorsal wrist, EDC and ECU, only GS: palmar MCP2) showed therapy response (SRM 0.433) after 6 months and retained 76% of the information of the full US7 score. No major differences between the groups of early and established RA could be detected.

Conclusion

The wrist, MCP2, EDC and ECU tendons were most frequently pathologic and responsive to therapy, representing an optimized score for monitoring of RA patients for both early and established RA and should therefore be included in comprehensive scores for monitoring RA patients.

References

[1]Backhaus M, Ohrndorf S, Kellner H, Strunk J, Backhaus TM, Hartung W, et al. Evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: a pilot project. Arthritis Rheum. 2009;61(9):1194-201.

Acknowledgements

We thank Gabriela Schmittat for logistical support in the study.

Disclosure of Interests

Annika Franziska Podewski: None declared, Anne-Marie Glimm: None declared, Imma Fischer: None declared, George Bruyn: None declared, Petra Hanova: None declared, Hilde Berner Hammer Speakers bureau: Paid speaker for Lilly, Novartis and AbbVie, Employee of: Advisory board for AbbVie, Anna-Birgitte Aga Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer and UCB, Consultant of: AbbVie, Eli Lilly, Novartis, Pfizer and UCB, Espen A Haavardsholm: None declared, Sofia Ramiro Speakers bureau: Eli Lilly, MSD, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, UCB, Sanofi, Grant/research support from: AbbVie, Galapagos, Novartis, Pfizer, UCB, Gerd Rüdiger Burmester: None declared, Marina Backhaus Speakers bureau: Speaker fee from AbbVie, BMS, Galapagos, UCB, Novartis, Sarah Ohrndorf: None declared

POS0174 PAIN SEVERITY ACROSS HAND OA PHENOTYPES BASED ON A BIOPSYCHOSOCIAL APPROACH

Background

Hand osteoarthritis (OA) pain is heterogeneous and multifactorial, involving biological, psychological and social aspects extending beyond the OA disease process. Different phenotypes may differ in prognosis and treatments requirements, and thus be of clinical importance. The presence of hand OA phenotypes has not previously been examined.

Objectives

To explore classes based on a biopsychosocial framework as possible phenotypes in a hand OA population, and examine whether pain severity differ between the classes.

Methods

Biological, psychological, and social domains were assessed including self-reported questionnaires, clinical assessment and imaging in 300 persons with hand OA. Central pain sensitization was tested by pressure pain thresholds (PPT; kg/cm2) and temporal summation (TS). Variables used for comparison across the classes included age, sex, hand and overall bodily pain severity (Numeric Rating Scales (NRS) last 24h (0-10)). We used Latent Class Analysis followed by posterior fit statistics. Differences in age, sex and pain between classes were assessed by one-way ANOVAs and chi-squared tests.

Results

We identified 4 classes (Table 1): Class 1 had the lowest hand OA severity, high levels of pain sensitization, comorbidities, sleep problems, psychological distress and the lowest frequencies of working participants. Class 2 had the lowest pain sensitization levels and the highest proportion of participants with university education and living with a partner. Class 3 had the highest level of hand OA severity, and the lowest levels of comorbidity burden and psychological distress. Class 4 was similar to class 1 with high levels of pain sensitization, comorbidities and sleep problems and fewer with university education. Compared with class 1 they had less psychological distress and more severe hand OA.

Table 1.Class 1: n=25 (8%)Class 2: n=53 (18%)Class 3: n=103 (34%)Class 4: n=119 (40%)P-valueBiological domainOA severity (Kellgren-Lawrence; 0-128)22.2 (15.8)28.4 (15.6)33.6 (20.1)29.7 (20.0)0.05PPT tibialis anterior3.9 (1.8)9.4 (1.9)5.6 (1.9)4.2 (1.6)< 0.001PPT trapezius2.8 (0.9)7.2 (1.8)4.5 (1.4)3.4 (1.5)< 0.001TS change2.6 (1.7)0.8 (1.0)1.4 (1.5)1.9 (1.6)< 0.001BMI28.4 (5.2)25.7 (4.5)24.9 (3.6)27.9 (5.6)< 0.001Comorbidity burden (0-45)10.7 (4.7)7.2 (3.5)4.9 (2.9)9.8 (3.9)< 0.001Poor sleep, n (%)24 (96%)30 (57%)57 (55%)112 (94%)< 0.001Psychological domainHADS (0-42)20.9 (5.9)5.1 (4.4)4.6 (4.2)8.0 (4.5)< 0.001ASES (10-100)47.7 (13.6)73.8 (9.5)76.6 (12.7)63.6 (10.1)< 0.001PCS (0-52)23.5 (8.3)9.6 (7.0)6.3 (5.3)12.9 (7.1)< 0.001Social domainUniversity education, n (%)13 (52%)40 (77%)72 (70%)48 (41%)0.01Working, n (%)8 (32%)38 (72%)68 (66%)45 (38%)< 0.001Living with partner, n (%)16 (64%)34 (71%)70 (61%)76 (64%)0.03

SD=standard deviation; BMI= Body Mass Index; HADS=Hospital Anxiety and Depression Scale; PCS=Pain Catastrophizing Scale; ASES=Arthritis Self Efficacy Scale.

Hand and overall pain severity differed significantly between the classes. Class 3 reported the lowest mean (SD) NRS hand and overall pain (2.7 (1.8) and 2.8 (1.7), p=0.01). The highest mean (SD) for NRS hand and overall pain (5.8 (2.7) and 5.8 (2.4), p=0.05) where reported by Class 1, which also had the lowest mean age of 56.9 (SD 6.5), p< 0.001. Class 2 held the highest proportion of men (n=15; 29%), although not significantly different from the other classes.

Conclusion

Four potential hand OA phenotypes that differed in hand and overall pain severity were identified. The phenotypes with higher levels of pain sensitization, comorbidities, psychological and social burden tended to have more severe hand pain than persons with lower levels. The phenotypes with lowest hand OA severity reported the highest pain severity which may reflect the discordance between OA severity and pain experience. Biopsychosocial factors are likely important in defining hand OA phenotypes and may present a possibility for improved clinical outcomes.

Biopsychosocial characteristics across the proposed hand OA phenotypes.

Data presented as mean (SD) unless otherwise indicated.

Disclosure of Interests

Elisabeth Mulrooney: None declared, Tuhina Neogi Consultant of: Regeneron

Pfizer/Lilly, Hanne Solveig Dagfinrud: None declared, Hilde Berner Hammer Speakers bureau: Novartis, Lilly, Roche and AbbVie, Pernille Steen Pettersen: None declared, Tore K. Kvien: None declared, Karin Magnusson: None declared, Ida K. Haugen Consultant of: Novartis: Payment to myself, Grant/research support from: Pfizer: Payment to institution

OP0168 DEVELOPMENT OF AN ULTRASOUND SCORING SYSTEM FOR CPPD EXTENT: RESULTS FROM A DELPHI PROCESS AND WEB-RELIABILITY EXERCISE BY THE OMERACT US WORKING GROUP

Background

Ultrasound (US) has proven to be an excellent imaging technique for detecting calcium pyrophosphate (CPP) deposition disease (CPPD); it is also widely available and inexpensive and can be performed during the clinic visit making it the preferred imaging modality for many rheumatologists. However, no validated grading systems have yet been developed allowing for a quantification of the extent of crystal deposition in CPPD.

Objectives

The aim of this study was to develop a scoring system for the quantification of CPP deposition at a patient level according to the OMERACT framework.

Methods

As part of the OMERACT methodology, we performed a systematic literature review (SLR) and meta-analysis aimed to estimate the prevalence of CPP deposition in peripheral joints by imaging, in order to identify relevant joints for CPPD monitoring. A preliminary survey was also circulated among the members of the OMERACT US – CPPD working group to collect their own suggestions according to their personal experience. Subsequently, a Delphi survey was prepared and circulated between members of the group, including statements that reflected both the results of the SLR and of the preliminary survey. In total, 32 statements were generated regarding the type of scoring for single structures, the sites to be included, the final scoring at patient level, and the scanning technique. Participants were asked to reply on a 5-point Likert scale (1, strongly disagree to 5, strongly agree) and agreement was achieved when 4 and 5 grades reached 75% or more of concordance. In case of disagreement, new statements were proposed according to the members’ suggestions and circulated for voting in a subsequent round. After agreement of a scoring system, the validation process began. Two rounds of a web-based exercise on static images were conducted on 120 images representing equally all sites under investigation and all degrees of crystal deposition, to assess the intra- and inter-reader reliability of the new scoring system. Representative images of the scoring system were visible throughout the entire exercise in order to facilitate the scoring of the lesions.

Results

Three Delphi rounds were needed to reach agreement on all items. 32/41 members of the OMERACT US-CPPD working group replied in the first round, 26/32 in the second, and 25/26 in the third round. Twenty statements were approved in the first round, 3 in the second, and 3 in the third round. Only the knees (menisci and hyaline cartilage) and the triangular fibrocartilage of the wrist were included in the final score, using a four-grade system (0-3). It was decided that each anatomical structure should be scored separately and then also summed in order to define the joint score. The sum of the assessed joints was the total score at patient level. The final scoring system with the definitions and the relative technical notes is represented in Figure 1. 33/41 members participated to the reliability exercise. The inter-reader reliability of the scoring was substantial (kappa of 0.72), and the intra-reader reliability was almost perfect (kappa of 0.82).

Conclusion

This is the first study for developing a scoring system for the extent of CPP crystal deposition in patients with CPPD. The scoring system demonstrated to be reliable in static images. The next step of the validation process is to assess the reliability of the scoring system in a patient-based exercise. This study represents a fundamental step in the OMERACT process of validating US as an outcome measure instrument, and above proposed scoring system will hopefully provide a useful tool for clinical practice and research.

Disclosure of Interests

None declared

POS0516 PLASMA CALPROTECTIN WAS ASSESSED IN MULTIPLE BIOLOGICAL TREATMENT STRATEGIES FOR EARLY RHEUMATOID ARTHRITIS

Background

Plasma calprotectin is a sensitive inflammatory marker in patients with rheumatoid arthritis (RA) and reflects activation of granulocytes and macrophages. Plasma calprotectin has not previously been studied in a head-to-head trial of multiple biological mechanisms of action versus active conventional therapy (ACT) with methotrexate and prednisolone.

Objectives

To assess the effect of treatment on plasma calprotectin levels in patients with early RA by determining the 24-week change in the four arms of the NORD-STAR Study, a large multicenter randomized head-to-head clinical trial of ACT versus tumor necrosis factor inhibition, T-cell co-stimulation inhibition, and interleukin-6 inhibition (1).

Methods

Calprotectin was analyzed in plasma samples at baseline, week 4 and week 24 from 400 treatment naïve patients with early RA in the NORD-STAR Study. Samples were analyzed using a calprotectin ELISA alkaline phosphatase (ALP) kit from CalproLab (Oslo, Norway) in a Dynex DS2 processing system (normal levels <910 µg/L). Patients were assessed by clinical (CRP, 28 SJC/TJC, physician global) and patients’ reported assessments. Crude and adjusted linear regression analyses were performed in R 4.0.3 with calprotectin levels at week 24 as the outcome. The four arms were represented by three dummy variables. The adjustment variables were age, sex, anti-CCP status and country. Both analyses were adjusted for baseline calprotectin levels.

Results

At baseline, the mean time since diagnosis was 15.7 days (SD) (22.9), mean age 53.7 (15.0) years, ACPA positive 81%, and female 66%. Mean calprotectin levels were 1931 (1495) µg/L at baseline, 866 (951) µg/L at week 4, and 629 (661) µg/L at week 24. At baseline, normal calprotectin levels (<910 µg/L) were observed in 27% of all patients (ACT 22%, certolizumab-pegol and methotrexate 30%, abatacept and methotrexate 25%, tocilizumab and methotrexate 31%). At week 24, normal calprotectin levels were observed in 82% of all patients (ACT 68%, certolizumab-pegol and methotrexate 91%, abatacept and methotrexate 80%, tocilizumab and methotrexate 90%).

Observed calprotectin levels at week 24 were significantly lower in patients treated with certolizumab-pegol and methotrexate -336µg/L (97) (p< 0.006) or tocilizumab and methotrexate -284 (99) (p < 0.004), versus ACT when adjusted for age, sex, anti-CCP status, baseline calprotectin level, and country; however, a significant difference was not observed in patients treated with abatacept and methotrexate -110 (96) (p = 0.25). The Figure 1 shows the average percentage change in calprotectin levels from baseline to week 24 for all treatment groups.

Figure 1.

Average percentage change in calprotectin levels from baseline to week 24. ACT: active conventional therapy, CZP+MTX: certolizumab-pegol and methotrexate, ABA+MTX: abatacept and methotrexate, TCZ+MTX: tocilizumab and methotrexate.

Conclusion

Calprotectin, a sensitive biomarker of inflammation, normalized in the majority of patients. The decline differed between treatment groups and was largest in patients treated with a TNF inhibitor and methotrexate, suggesting that calprotectin reflects the activity of specific inflammatory pathways rather than overall inflammation. The findings of this study should be further explored.

References

[1]Hetland ML, et. al., Active conventional treatment and three different biological treatments in early rheumatoid arthritis: phase IV investigator initiated, randomised, observer blinded clinical trial. BMJ. 2020 Dec 2;371:m4328. doi: 10.1136/bmj.m4328. PMID: 33268527; PMCID: PMC7708829.

Acknowledgements

I would like to acknowledge the NORD-STAR Study group.

Disclosure of Interests

David Stevens: None declared, Marte Heiberg: None declared, Amirhossein Kazemi: None declared, Ronald van Vollenhoven: None declared, Jon Lampa: None declared, Anna Rudin: None declared, Kristina Lend: None declared, Merete Lund Hetland: None declared, Mikkel Østergaard: None declared, Michael Nurmohamed: None declared, Kim Hørslev-Petersen: None declared, Dan Nordström Consultant of: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Björn Gudbjornsson: None declared, Till Uhlig: None declared, Espen A Haavardsholm: None declared, Hilde Berner Hammer Speakers bureau: AbbVie, Novartis, and Lilly.

OP0291 SCORING STRUCTURAL DAMAGE IN RHEUMATOID ARTHRITIS BY ULTRASOUND: RESULTS FROM A DELPHI PROCESS AND WEB-RELIABILITY EXERCISE BY THE OMERACT US WORKING GROUP

Background

Structural damage in rheumatoid arthritis (RA) includes bone erosion, cartilage change, and joint malalignment; historically evaluated with conventional radiography. Ultrasound (US) has been shown to be a valid tool for evaluating both cartilage change and bone erosion.

Objectives

To obtain agreement on definitions and develop semiquantitative scoring systems for assessing structural damage by US and to validate these in a web-based reliability exercise.

Methods

A Delphi survey of statements was prepared by an OMERACT US Working Group task force (USWG) based on a previously published systematic literature review (1) and circulated between group members, including definitions on normal US appearance of joint components, definitions of elementary lesions and scoring systems for bone erosions and joint malalignment. Definitions and a US scoring system for scoring cartilage change were recently developed and validated by the USWG (2) After agreement was achieved (≥75% of grades 4-5 on 1-5 Likert scale) on the statements, still images of metacarpophalangeal and proximal interphalangeal joints 2-5 in healthy controls and in RA patients with varying degrees of pathology were acquired by the USWG members. A dataset of 100 anonymized images, representing various grades of the 3 components of structural damage was created and utilized in 2 rounds of a web-based exercise. Intra- and inter-reader reliability of the scoring systems was assessed by kappa statistics.

Results

19 USWG members needed 4 Delphi rounds to reach agreement on a total of 9 statements. 4/12 statements were approved in the first, 2/6 in the second, 1/5 in the third and 2/2 in the fourth round. Final scoring systems and representative images are shown in Table 1 & Figure 1. 22 members participated in the web-based reliability exercise. The intra-reader reliability was almost perfect for bone erosion (kappa: 0.87) and cartilage change (kappa: 0.83) and substantial for malalignment (kappa of 0.72). The inter-reader reliability was almost perfect for bone erosion (kappa: 0.85), and substantial for cartilage change (kappa: 0.79) and malalignment (0.62).

Table 1.

Final definitions of scoring systems of elementary lesions of structural damage in rheumatoid arthritis

AgreementBone erosionA 4-grade semiquantitative scoring system can be used to score erosions as follows: grade 0. intact cortical bone; grade 1. single small erosion (diameter: ≤2mm); grade 2. single large erosion (diameter: >2mm) or 2 small erosions; grade 3. 2 large erosions or ≥3 erosions, regardless of size. Both longitudinal and transverse scans should be considered, and the largest measure chosen for each erosion.100%Cartilage changeA 3-grade semiquantitative scoring system can be used to grade hyaline cartilage change as follows: grade 0. normal cartilage; grade 1. minimal change: focal thinning or incomplete loss of cartilage; grade 2. severe change: diffuse thinning or complete loss of cartilage.80% (2)MalalignmentA 3-grade semiquantitative scoring system can be used to grade malalignment as follows: 0. normal alignment; 1. subluxation or partial dislocation, where the two bone endings are malaligned so that one bone ending is dislocated from its normal position, but still within the articulation; 2. luxation or total dislocation, where the luxated bone ending moves beyond the articulation and the opposing bone ending. Bone position may be compared with a contralateral or similar intact joint if available.94%Figure 1.

Representative images of the scoring systems for bone erosion (A), cartilage change (B) and malalignment (C)

Conclusion

This first attempt to create a composite US instrument based on scoring systems encompassing all aspects of structural damage, demonstrates that US is a reliable tool for evaluating and scoring bone erosion, cartilage change and malalignment in the finger joints of RA patients.

References

[1]Gessl I, et al. Semin Arthritis Rheum. 2021 Jun;51(3):627-39.

[2]Mandl P, et al. Rheumatology (Oxford). 2019 Oct 1;58(10):1802-11.

Disclosure of Interests

Peter Mandl Speakers bureau: AbbVie, Janssen, Lilly, Novartis, Consultant of: AbbVie, Janssen, Lilly, Novartis, Grant/research support from: AbbVie, BMS, Novartis, Janssen, Lilly, MSD, UCB, Irina Gessl: None declared, Georgios Filippou: None declared, Silvia Sirotti: None declared, Lene Terslev Speakers bureau: Novartis, Pfizer, UCB, Janssen, GE, Carlos Pineda: None declared, Helen Keen Speakers bureau: Roche, AbbVie, Janssen, Consultant of: Sanofi, Marina Backhaus: None declared, David Andrew Bong: None declared, Edoardo Cipolletta: None declared, PAZ COLLADO: None declared, Christian Dejaco Speakers bureau: Roche, AbbVie, Sanofi, Lilly, Pfizer, Novartis, Janssen, Galapagos, Consultant of: Roche, AbbVie, Sanofi, Lilly, Pfizer, Novartis, Janssen, Galapagos, Andrea Delle Sedie Speakers bureau: Abbvie, Amgen, Lilly, MSD, Novartis, UCB, Paid instructor for: Abbvie, Amgen, Lilly, MSD, Novartis, UCB, Consultant of: Abbvie, Amgen, Lilly, MSD, Novartis, UCB, Christina Duftner: None declared, Hilde Berner Hammer: None declared, Annamaria Iagnocco: None declared, Zunaid Karim: None declared, Ingrid Möller Speakers bureau: Bristol-Myers Squibb, Ibsa, Pfizer, Galapagos, Esperanza Naredo Speakers bureau: Abbvie, Pfizer, Lilly, Novartis, Janssen, Celgene GmbH, Paid instructor for: Novartis, Consultant of: Novartis, Lilly, Grant/research support from: Lilly, Pfizer, Wolfgang A. Schmidt: None declared, Marcin Szkudlarek: None declared, Giorgio Tamborrini: None declared, Priscilla C Wong: None declared, Emilio Filippucci Speakers bureau: AbbVie, Amgen, Bristol -Myers Squibb, Janssen-Cilag, Lilly, Novartis, Pfizer, Roche, Union Chimique Belge Pharma, Peter Balint Speakers bureau: Abbvie, Janssen, Lilly, Novartis, Maria-Antonietta D’Agostino: None declared

AB1338 CALPROTECTIN, A SENSITIVE MARKER OF INFLAMMATION, IS ROBUSTLY ASSESSED IN PLASMA FROM PATIENTS WITH ESTABLISHED RA BY USE OF DIFFERENT LABORATORY METHODS

Background

Calprotectin (S100A8/S100A9, MRP8/MRP14) in plasma has been shown to be more sensitive than C-Reactive Protein (CRP) or Erythrocyte Sedimentation Rate (ESR) in reflecting inflammatory activity in patients with rheumatoid arthritis (RA).1,2

Objectives

The present objective was to explore the robustness of laboratory examination of calprotectin by comparing the results from assessments by use of two different methods.

Methods

Frozen plasma samples from a study of 177 patients with established RA initiating biologic disease modifying drugs were analysed for calprotectin levels at baseline and after 1, 2, 3, 6 and 12 months by use of either enzyme-linked immunosorbent assay (ELISA) or fluoroenzyme immunoassay (FEIA).

The ELISA technique used kits from Calpro AS (Oslo, Norway) and the samples were assessed in a semi-automatic analysis machine Dynex DS2 (Dynex Technologies, Virginia, USA) at Diakonhjemmet hospital. The Calpro AS kits included all necessary buffers, cleansing solutions, enzyme substrate, standards, and controls (high and low calprotectin levels) and their protocol was used for the calprotectin assessments. The standards and controls were used as the mean of two measures, while all the patient samples were analysed as single measures.

As a sub-study in NORA (a study exploring personalized medicine in RA by including several study cohorts from the Nordic countries), the same plasma samples were additionally assessed by FEIA. The FEIA technology used the EliATM calprotectin 2 wells in a Research Use Only setting on the PhadiaTM 2500 instrument (Phadia AB, Uppsala, Sweden) with a 1:50 dilution.

Spearman was used for correlation assessments. To explore differences across concentration levels the baseline calprotectin levels were divided into 3 groups based on results from the Calpro AS assay (normal levels; ≤ 910 µg/L; moderately elevated; 911-2000 µg/L, highly elevated; > 2000 µg/L).

Results

A total of 917 samples from the 177 patients (mean (SD) age 52.9 (13) years, disease duration 10 years (ranging from a few months to 46 years), 81% women, 78% anti-CCP IgG positive and 81% RF IgM positive) were included. The median of the correlation coefficients between the two methods at the six visits was 0.96 (range 0.91-0.97). Correlations were very high for normal levels (0.91) but somewhat lower for moderate and highly elevated levels (0.85 and 0.79, respectively). There were no significant differences between the associations depending on age, sex, or disease duration, nor on the anti-CCP IgG and RF IgM status of the patient.

Conclusion

The present study supports the robustness of calprotectin analyses, showing similar results across two different analytical methods, and that the concentrations were not influenced by demographic or immunological variables. Being a robust and more sensitive marker of inflammation than the commonly used CRP and ESR, calprotectin analyses should be available for assessments of RA patients in routine clinical care.

References

[1]Hammer, H.B., et al., Calprotectin (a major leucocyte protein) is strongly and independently correlated with joint inflammation and damage in rheumatoid arthritis. Ann Rheum Dis, 2007. 66(8): p. 1093-7.

[2]Hilde Haugedal Nordal HH et al. Calprotectin (S100A8/A9) has the strongest association with ultrasound-detected synovitis and predicts response to biologic treatment: results from a longitudinal study of patients with established rheumatoid arthritis Arthritis Research & Therapy (2017) 19:3

Disclosure of Interests

Hilde Berner Hammer Speakers bureau: AbbVie, Lilly and Novartis, Sigve Lans Pedersen: None declared, Isabel Gehring: None declared, Linda Mathsson-Alm: None declared, Joe Sexton: None declared, Johan Askling Grant/research support from: AbbVie, AstraZeneca, Bristol Myers Squibb, Eli Lilly, Janssen, Merck, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB

POS0111 MORE METICULOUSLY FOLLOWING TREAT-TO-TARGET IN RA DOES NOT LEAD TO LESS RADIOGRAPHIC PROGRESSION: A LONGITUDINAL ANALYSIS IN BIODAM

Background

A Treat-to-Target approach (T2T) is broadly considered to lead to better clinical outcomes and recommended in patients with RA. However, very few studies have analyzed the effect of T2T on radiographic progression, and any such studies have provided inconsistent results.

Objectives

To investigate whether meticulously following a treat-to-target (T2T)-strategy in daily clinical practice leads to lower radiographic progression in RA.

Methods

Patients from the multicenter RA-BIODAM cohort with ≥2 consecutive visits with radiographs available were included. In RA-BIODAM patients were enrolled as they were initiating a new csDMARD/bDMARD treatment were followed-up with the intention to benchmark and intensify treatment. The primary outcome of this analysis was the change in Sharp-van der Heijde score (SvdH, 0-448), assessed every 6 months, using average scores from 2 readers (scores with known chronological order). Following a DAS44-T2T remission strategy, which was defined at each 3-month visit, was the main variable of interest. Patients were categorized based on the proportion of visits in which T2T was followed according to our definition: very low (≤40% of the visits, low (>40%, <62.5%), high (≥62.5%, ≤75%) and very high (>75%). Radiographic progression at 2 years was visualized across groups by cumulative probability plots. Per 3-month interval T2T could be followed zero, one or two times (in a total of 2 visits). Associations between the number of visits with T2T in an interval and radiographic progression, both in the same and in the subsequent 6-month interval, were analysed by generalised estimating equations, adjusted for age, gender, disease duration and country.

Results

In total, 511 patients were included (mean (SD) age: 56 (13) years; 76% female). After 2 years, patients showed on average 2.2 (4.1) units progression (median:1 unit). Mean (SD) 2-year progression was not significantly different across categories of T2T: very low: 2.1 (2.7)-units; low: 2.8 (6.0); high: 2.4 (4.5), very high: 1.6 (2.2) (Figure 1). Meticulously following-up T2T in a 3-month interval neither reduced progression in the same 6-month interval (parameter estimates (for yes vs no): +0.15 units (95%CI: -0.04 to 0.33) for 2 vs 0 visits; and +0.08 units (-0.06;0.22) for 1 vs 0 visits) nor did it reduce progression in the subsequent 6-month interval (Table 1).

Table 1.

Effect of following DAS44-remission-T2T strategy on 6-month radiographic progression over 2 years

Change in radiographic damage(regression coefficient (95% CI))N=506T2T during 3 months on radiographic progression in the same 6-month period 2 visits vs 0 followed0.15 (-0.04; 0.33) 1 visit vs 0 followed0.08 (-0.06; 0.22)T2T during 3 months on radiographic progression in the subsequent 6-month period 2 visits vs 0 followed-0.09 (-0.28; 0.10) 1 visit vs 0 followed-0.10 (-0.24; 0.05)Figure 1.

Cumulative probability plot with 2-year radiographic progression according to the proportion of 3-monthly visits with T2T followed

Conclusion

In this daily practice cohort, more meticulously following T2T principles did not result in more reduction of radiographic progression than a somewhat more liberal attitude toward T2T. One possible interpretation of these results is that the intention to apply T2T already suffices and that a more stringent approach does not further improve outcome.

Acknowledgements

BIODAM was financially supported by an unrestricted grant from AbbVie

Disclosure of Interests

Sofia Ramiro Speakers bureau: Eli Lilly, MSD, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, UCB, Sanofi, Grant/research support from: AbbVie, Galapagos, Novartis, Pfizer, UCB, Robert B.M. Landewé Speakers bureau: AbbVie, BMS, Gilead, Galapagos, GSK,Janssen, Lilly, Novartis, Pfizer, UCB, Consultant of: AbbVie, BMS, Gilead, Galapagos, GSK,Janssen, Lilly, Novartis, Pfizer, UCB

Dr Landewé owns Rheumatology Consultancy BV, Désirée van der Heijde Consultant of: AbbVie, Bayer, BMS, Cyxone, Eisai, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Lilly, Novartis, Pfizer, UCB Pharma. Director of Imaging Rheumatology bv., Alexandre Sepriano Speakers bureau: Novartis, Consultant of: UCB, Oliver FitzGerald Speakers bureau: Biogen, Novartis, AbbVie, BMS, Pfizer, Grant/research support from: BMS, Novartis, UCB, Pfizer, Lilly, Janssen, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Celgene, Eli-Lilly, Galapagos, Gilead, Janssen, Merck, Novartis, Orion, Pfizer, Roche and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, Amgen, BMS, Merck, Celgene and Novartis, Joanne Homik: None declared, Ori Elkayam Speakers bureau: Pfizer, Lilly, Novartis, Abbvie, BI, Janssen, Consultant of: Pfizer, Lilly, Novartis, Abbvie, BI, Janssen, Grant/research support from: Pfizer, Abbvie, Janssen, Carter Thorne Consultant of: Abbvie, Organon, Pfizer, Sandoz, Maggie Larché Speakers bureau: AbbVie, Actelion, Amgen, BMS, Boehringer-Ingelheim, Fresenius-Kabi, Gilead, Janssen, Mallinckrodt, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, Sobi, UCB, Grant/research support from: Abbvie, BMS, Gianfranco Ferraccioli Speakers bureau: SOBI, Consultant of: Abbivie, Marina Backhaus: None declared, Gilles Boire Speakers bureau: Abbvie Canada, BMS Canada, Lilly Canada, Janssen Canada, Merck Canada, Pfizer Canada, Viatris, Consultant of: Abbvie Canada, Amgen Canada, BMS Canada, Celgene, GileadSciences, Janssen Canada, Lilly Canada, Merck Canada, Mylan Canada, Novartis Canada, Pfizer Canada, Roche Canada, Samsung Bioepis, Sanofi Canada, Teva, Grant/research support from: Lilly Canada, BMS Canada, Pfizer, Sandoz Canada, UCB Canada, Merck Canada, Novartis Canada, Roche Canada, Bernard Combe Speakers bureau: Abbvie, BMS,Celltrion,Galapgos-Gilead, Janssen, Lilly, MERCK, Pfizer,Roche-Chugai, Consultant of: Abbvie, Celltrion,Galapgos-Gilead, Janssen, Lilly, MERCK, Roche-Chugai, Grant/research support from: Pfizer, Roche-chugai, Thierry Schaeverbeke: None declared, Alain Saraux Speakers bureau: Abbvie, Lilly, Nordic, Novartis, Pfizer, Roche-Chugai, Sanofi, UCB, Consultant of: Abbvie, Lilly, Nordic, Novartis, Pfizer, Roche-Chugai, UCB, Grant/research support from: Novartis, Fresenius, Lilly, Maxime Dougados Consultant of: Pfizer, AbbVie, UCB, Merck, Lilly, Novartis, BMS, Galapagos, Biogen, Roche, Grant/research support from: Pfizer, AbbVie, UCB, Merck, Lilly, Novartis, BMS, Galapagos, Biogen, Roche, Maurizio Rossini Speakers bureau: Amgen, Abbvie, BMS, Eli-Lilly, Galapagos,MSD, Novartis, Pfizer, Sandoz, Theramex, UCB, Marcello Govoni Speakers bureau: Abbvie, Pfizer, Galapagos, BMS, Eli-Lilly, Paid instructor for: Pfizer, Consultant of: Abbvie, BMS, Novartis, Astrazeneca, Pfizer, Luigi Sinigaglia: None declared, Alain Cantagrel Speakers bureau: Abbvie, Amgen, Biogen, BMS, Janssen, Lilly France, Médac, MSD France, Nordic-Pharma, Novartis, Pfizer, Sanofi Aventis, UCB, Consultant of: BMS, Janssen, Lilly France, MSD France, Sandoz, Grant/research support from: MSD France, Novartis, Pfizer, Cornelia Allaart: None declared, Cheryl Barnabe Speakers bureau: Sanofi Genzyme, Pfizer, Fresenius Kabi, Janssen, Consultant of: Gilead, Celltrion Healthcare, Clifton Bingham Consultant of: AbbVie, BMS, Eli Lilly, Janssen, Moderna, Pfizer, Sanofi, Grant/research support from: BMS, Dirkjan van Schaardenburg: None declared, Hilde Berner Hammer Speakers bureau: AbbVie, Novartis, Lilly, Rana Dadashova: None declared, Edna Hutchings: None declared, Joel Paschke: None declared, Walter P Maksymowych Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, UCB, Consultant of: Abbvie, Boehringer Ingelheim, Celgene, Eli-Lilly, Galapagos, Novartis, Pfizer, UCB, Grant/research support from: Abbvie, Novartis, Pfizer

POS0281 FLUCTUATIONS IN SERUM URATE ARE RELATED TO GOUT FLARES IN THE NOR-Gout STUDY

Background

Urate lowering therapy (ULT) is expected to prevent new gout flares, but flares still do occur during the first year, and could be related to fluctuations in serum urate (SUA), being a result of proinflammatory signals. Knowledge on the relationship between fluctuation in SUA and gout flares is limited.

Objectives

To study how fluctuation in SUA is related to gout flares in the first year of ULT.

Methods

In a prospective observational 2-year study 211 included patients with crystal-proven gout were evaluated for flare frequency. Patients were frequently followed during ULT (allopurinol or febuxostat) with monthly dose escalation until SUA was at target (<360 µmol/L or <300 µmol/L if tophi), and met also for visits at 3, 6, 9, 12 during year 1 and at year 2. Self-reported flares were continuously registered at all study visits.

Fluctuations in SUA were defined with various measures of SUA: a.) sum of changes between all consecutive visits over the whole 2-year period as a global measure, b. SUA change during 3-month visits at year 1 and during year 2. Further, the frequency of patients exceeding SUA changes with threshold >30, >60 and >90 µmol in these periods was calculated.

Fluctuations in SUA were then related to self-reported flares during the same 3-month periods year 1, and the whole years 1 and 2.

Results

Age was 56.4 (SD 13.7) years, 95.3% were males, disease duration 7.8 (SD 7.6) years.

SUA decreased from mean 500 µmol/L at baseline to 311 µmol at 1 year and 324 µmol/L at year 2. Flares were seen in year 1 in 81.2% (155/186) and year 2 26.0% (45/173) of patients.

The total sum of SUA changes over 2 years as a global measure for individual SUA fluctuation was related to flares in all 3-month periods during year 1 (Table 1) and for year 1 overall (Figure 1), but not for year 2.

Table 1.

Flares and fluctuation of serum urate (SUA) measures during defined observation periods.

Flare period (Mths)NSum of all SUA changes (mean)SUA change (mean)>30 µmol/L SUA change (% patients)>60 µmol/L SUA change (% patients)>90 µmol/L SUA change (% patients)0-3Flare +63467*141*88.183.167.8Flare -14838816595.591.580.83-6Flare +91459**1938.828.210.6Flare -1203751739.424.514.96-9Flare +56482*1049.0**25.525.5Flare -1553862626.515.515.59-12Flare +70470*432.216.911.9Flare -116406922.69.46.60-12Flare +155445*19398.094.090.7*Flare -3634516091.786.075.012-24Flare +454111324.411.16.7Flare -1284491425.811.74.7

*P<0.05, **P<0.01 for comparisons +/-Flare

Other measures of SUA fluctuation (SUA change during periods, and exceeding thresholds of change) were generally not related to incidence of flares, neither were sensitivity analyses for incidence of flares in periods succeeding observed SUA fluctuations.

Conclusion

Fluctuation in SUA, defined as the total sum of mean SUA changes between all study visits, was related to gout flares during year1. Our findings support that a pattern of SUA fluctuation is related to gout flares.

Disclosure of Interests

Till Uhlig Speakers bureau: SOBI, Consultant of: Grünenthal, Lars Karoliussen: None declared, Joe Sexton: None declared, Tore K. Kvien Speakers bureau: AbbVie, MSD, UCB, Hospira/Pfizer, Eli-Lilly, Roche, Hikma, Orion, Sanofi, Celltrion, Sandoz, Biogen, Amgen, Egis, Ewopharma, Mylan, Grant/research support from: BMS, Espen Andre Haavardsholm Speakers bureau: Pfizer, UCB, Eli Lilly, Celgene, Janssen-Cilag, AbbVie, Gilead, Fernando Perez-Ruiz Speakers bureau: Algorithm, Alnylam, Astellas, Arthriti, Menarini, NMD, Parexel, Hilde Berner Hammer Speakers bureau: AbbVie, Lilly, Novartis

POS0307 FATIGUE IN RHEUMATOID ARTHRITIS PATIENTS IS ASSOCIATED TO SUBJECTIVE BUT NOT OBJECTIVE ASSESSMENTS OF DISEASE ACTIVITY DURING TREATMENT WITH TOCILIZUMAB

Background:

Fatigue is common in patients with rheumatoid arthritis (RA), and its association with inflammatory activity is not fully understood.

Objectives:

To explore the associations between fatigue and inflammation by clinical, laboratory and ultrasound examinations during follow-up of RA patients on biological treatment.

Methods:

A Nordic (Denmark, Finland, Norway, Sweden) open-label, single-arm study (part of the umbrella program – TOZURA (1)), enrolled patients with inadequate response to conventional synthetic (cs) DMARDs. Patients received tocilizumab 162 mg sc weekly for 24 weeks as monotherapy or in combination with a csDMARD. Stable oral NSAIDs and corticosteroids (≤10 mg/day prednisone or equivalent), were allowed. Patients were assessed at baseline, 4, 12 and 24 weeks for fatigue (FACIT-F questionnaire (total sum scores)), patient reported outcome measures ((PROMs) including joint pain and patient’s global visual analogue scale (VAS) as well as HAQ-DI), clinical assessments (tender and swollen joints, assessor’s global VAS), laboratory examinations (ESR, CRP) and ultrasound assessments (36 joints and 4 tendons, scored according to the Norwegian US atlas (2)). Spearman correlations, performed both at baseline and for changes from baseline of variables during follow-up, explored associations between fatigue and PROMs, clinical, laboratory as well as ultrasound variables. Predictive value of fatigue was investigated by linear regression.

Results:

110 patients were included (83% female, mean (SD) age 55.6 (12.1) years and RA duration 8.7 (9.5) years, 81% anti-CCP positive). All PROMs, clinical, laboratory and ultrasound variables decreased significantly, already after 4 weeks (p<0.001). Both for baseline assessments as well as for changes during follow-up, fatigue was associated with PROMs (Table 1 (baseline) and Table 2 (follow-up)). However, there were no or low associations between fatigue and clinical, laboratory and ultrasound assessments at baseline or during follow-up. In addition, baseline fatigue was predictive of joint pain, patient’s global VAS and HAQ-DI during follow-up (p<0.05-0.001), but not for the clinical, laboratory or ultrasound assessments.

Conclusion:

Fatigue assessed by an established questionnaire did not show any associations with several assessments of inflammatory activity in RA patients, neither at baseline nor during effective treatment. Thus, the present study adds to the increasing number of papers finding fatigue to reflect other aspects of RA disease activity than inflammation.

References:

[1]Choy E et al. Rheumatology 2018; 2. Hammer HB et al, ARD 2011

Table 1.

Spearman correlations between FACIT-F total score and patient reported outcomes, clinical, laboratory and ultrasound assessments. *p<0.05. **p<0.001

Table 2.

Spearman correlations between changes in FACIT-F total score from baseline to 4, 12 and 24 weeks and changes in patient reported outcomes, clinical, laboratory and ultrasound assessments. *p<0.05. **p<0.001

Disclosure of Interests:

Hilde Berner Hammer Speakers bureau: AbbVie, Pfizer, Roche, Lilly and Novartis, Consultant of: Novartis, Birte Agular Employee of: Roche, Lene Terslev Speakers bureau: Roche, MSD, BMS, Pfizer, AbbVie, Novartis and Janssen

POS0139 TWO-YEAR REDUCTION OF URATE LOAD IN DUAL-ENERGY CT DURING A TREAT-TO-TARGET APPROACH IN GOUT PATIENTS: RESULTS FROM A LONGITUDINAL STUDY (NOR-GOUT)

Background:

Dual-energy computed tomography (DECT) detects urate depositions, and is included in the ACR/EULAR classification criteria for gout. There is lack of longitudinal studies in large patient populations for changes in urate deposition measured by DECT during urate lowering therapy (ULT).

Objectives:

To explore by DECT the longitudinal changes urate depositions during a treat-to-target approach in gout with ULT.

Methods:

In a prospective observational study, patients with crystal-proven gout were included if they presented after a recent gout flare and with increased serum urate levels (>360 μmol/L/>6 mg/dl). In a treat-to-target approach they received ULT with escalating drug doses with monthly follow-up during the first year until the treatment target was met with serum urate <360 μmol/L or 360 µmol/L if tophi.

A DECT scanner (General Electric Discovery CT750 HD) acquired data from bilateral forefeet and ankles at 80 KW and 140 KV, processed with a software with a 2-material decomposition algorithm which colour codes urate. Follow-up DECT was performed after one and two years.

Images were scored with a semiquantitative method (Bayat et al. 2015) by one experienced radiologist in known order and blinded to serum urate and clinical data. Each scan assessed four regions: the first metatarsophalangeal (MTP1) joint, the other joints of the toes, the ankles and midfeet, and all visible tendons in the feet and ankles. Each region was then scored according to the maximum amount of urate deposition observed on visual inspection (0=no deposits, 1=dots, 2=single deposit, 3=more than one deposit). A total DECT sum score was derived by adding all values from the four regions, with a maximum score of 12.

Results:

DECT was at baseline measured in 187 of 211 patients. 95.2% were males, mean (SD) age was 56.7 (13.7) years, disease duration 8.1 (7.9) years), and 17% had clinical tophi.

The total DECT scores and all subscores decreased from baseline to 2 years (p<0.001 for all comparisons versus baseline), table 1.

The mean (SD) serum urate level (μmol/L) decreased from 501 (80) at baseline to 311 (48) at 12 months and 322 (67) at 24 months. Reaching the treatment target <360 µmol/L after year 1 or 2 was only numerically but not statistically related to reductions in DECT scores. Patients with clinical tophi at baseline had larger reductions in total DECT scores after 1 (3.4 vs. 1.5, p<0.01) and 2 years (6.5 vs. 2.3, p<0.001) than patients without tophi.

Conclusion:

During a treat-to-target approach urate deposition visualised by DECT were clearly reduced in ankles and feet after 1 year with further reduction after 2 years.

Table 1.Baseline (n=187) Mean (SD)1 year (n=157) Mean (SD)2 years (n=166) Mean (SD)MTP1 (0-3)1.4 (2.0)1.0 (1.7)0.6 (1.3)Toes (0-3)1.0 (1.8)0.6 (1.4)0.3 (1.0)Ankle/Midfoot (0-3)1.2 (2.1)0.7 (1.60.3 (1.0)Tendons (0-3)1.0 (1.7)0.5 (1.2)0.3 (0.8)Sum score (0-12)4.6 (6.4)2.8 (4.7)1.5 (3.2)

Disclosure of Interests:

Till Uhlig Speakers bureau: Grünenthal, Novartis, Consultant of: Grünenthal, Novartis, Tron Eskild: None declared, Lars Fridtjof Karoliussen: None declared, Tore K. Kvien Consultant of: AbbVie, MSD, UCB, Hospira/Pfizer, Eli-Lilly, Roche, Hikma, Orion, Sanofi, Celltrion, Sandoz, Biogen, Amgen, Egis, Ewopharma, Mylan, Grant/research support from: BMS, AbbVie, MSD, UCB, Hospira/Pfizer, Eli-Lilly, Espen A Haavardsholm Consultant of: Pfizer, UCB, Eli Lilly, Celgene, Janssen-Cilag, AbbVie and Gilead, Nicola Dalbeth Speakers bureau: Menarini, AstraZeneca, Takeda, S. Nicolaou, Consultant of: AstraZeneca, Fonterra, Takeda, Pfizer, Cymabay, Crealta, Grant/research support from: AstraZeneca, Siemens Healthcare, Hilde Berner Hammer Consultant of: AbbVie, Lilly and Novartis

Major reduction of ultrasound-detected synovitis during subcutaneous tocilizumab treatment: results from a multicentre 24 week study of patients with rheumatoid arthritis

Objective: Few studies have investigated the efficacy of subcutaneous tocilizumab (TCZ-SC) on ultrasound-detected inflammation. This study aimed to explore the clinical efficacy of TCZ-SC treatment in rheumatoid arthritis (RA) patients and to evaluate the response by ultrasound compared to Composite Disease Activity Scores (CDAS).Method: This open-label, single-arm study enrolled RA patients with inadequate response to conventional synthetic disease-modifying anti-rheumatic drugs initiating TCZ-SC 162 mg once weekly for 24 weeks, with clinical assessments at baseline, 2, 4, 8, 12, 16, 20, and 24 weeks. Ultrasound examinations [semi-quantitative score (0-3) of 36 joints and four tendons] were performed at baseline, 4, 12, and 24 weeks. CDAS and American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) response, and sum scores of ultrasound grey scale/Doppler were calculated. Changes during follow-up were explored by the Mann-Whitney test and correlations by Spearman's rho.Results: In total, 133 patients (mean ± sd age 55.9 ± 12.0 years) were assessed clinically and 110 patients were also examined with ultrasound. All clinical and ultrasound scores decreased significantly after 4 weeks (p < 0.001). At 24 weeks there was EULAR good response in 87.7% and ACR 70% response in 47.4%. Ultrasound scores had no or low correlations with patient-reported outcomes. At 24 weeks, CDAS remission was achieved in 27.4-83.5% and a sum score Doppler of 0 was found in 53.3%.Conclusions: Clinical and ultrasound scores decreased rapidly. Ultrasound scores were not associated with patient-reported variables. Half of the patients reached ultrasound remission, while there were large discrepancies in the percentage of patients reaching remission based on different CDAS.Trial registration: Study ML28691, registered 28 January 2014, ClinicalTrials.gov identifier: NCT02046616.

FRI0534 PATIENT-REPORTED MEASURES OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS VARY ACROSS THE NORDIC COUNTRIES, RESULTS FROM A NORDIC COLLABORATION

Background:

Disease activity in rheumatoid arthritis (RA) patients is measured through composite scores which are considered treatment targets and thus facilitate clinical decision making. Scores often combine a mix of objective and subjective measures, and, although the latter (e.g. pain, patient’s global, 28 tender joint count (TJC)) may be impacted by contextual and cultural factors, these clinical metrics are often assumed to be comparable across different settings and reflecting the RA disease.

Objectives:

To explore whether there are systematic differences in patient-reported measures of RA disease activity (i.e. TJC and a measure of pain on a Visual Analog Scale (VAS)) across countries, at similar time-points in the course of the RA disease, taking objective measures of concomitant disease activity and other factors into account.

Methods:

RA patients starting a first ever tumor necrosis factor inhibitor (TNFi) 2008 through 2017 were identified in rheumatologic registers in five Nordic countries. Data were pooled for analysis. Clinical metrics were retrieved at three time-points: at TNFi start, and after three and twelve months, irrespective of treatment.

Baseline clinical variables distributions were compared between countries. The correlation between pain and patient’s global VAS was calculated with the Pearson correlation coefficient (r). At each time-point the subjective measures (TJC and pain) were compared between countries and analyzed with linear models: (i) crude; (ii) adjusted for age, sex, birth decade, disease duration (DD), year of TNFi treatment start (year), C-reactive protein (CRP) and 28 swollen joint count (SJC)) from the time-point in question.

Results:

A total of 23 796 RA patients were included (Table 1). At baseline, the significant differences between Nordic countries for TJC and pain (crude model) were slightly modified after adjustment but remained statistically significant (Table 2). Compared to baseline, the inter-countries differences were reduced at 3 and 12 months, but also were statistically significant (Figure 1).

Table 1.

RA patients starting a first TNFi baseline characteristics, median [Interquartile range].

SwedenDenmarkFinlandNorwayIcelandN (% female)†13621 (75)6701 (75)1946 (73)1113 (71)415 (73)CRP (mg/L)‡6 [3-17]9 [3-20]8 [3-20]6 [3-14]8 [3-19]Physician’s global VAS‡30 [14-50]31 [19-47]35 [20-50]32 [23-45]60 [43-70]Patient’s global VAS#‡50 [28-70]67 [46-82]50 [28-70]48 [26-69]71 [53-86]Pain VAS‡50 [26-70]60 [37-76]52 [30-71]42 [23-65]67 [49-79]SJC‡4 [1-8]4 [1-7]4 [1-9]4 [1-7]6 [3-11]TJC‡4 [1-9]6 [3-11]4 [1-10]4 [1-9]7 [4-12]DAS28‡5 [3-5]5 [4-5]4 [3-5]4 [3-5]5 [4-6]

#Patient’s global and pain correlation: r=0.85

†χ2test; p-value=0.04

‡One-way ANOVA; all p-values < 0.001

Table 2.

Mean crude and adjusted differences in baseline TJC and pain between countries, using the largest (Sweden) as reference.

SEDKFINOISCrude modelTJCref1.80.80.5*3.7Painref7.21.4†-4.011.1Adjusted model#TJCref2.30.70.6**2.4Painref7.90.7NS-3.37.2**

All p-values <0.001 except:NS> 0.10;†< 0.10; * < 0.05; ** < 0.01

#adjusted for age, sex, birth decade, year, DD, CRP, SJC

Conclusion:

In this observational study of 23 796 RA patients from 5 Nordic countries starting 1stTNFi, patient-reported variables related to RA disease activity (pain VAS, TJC) varied across countries. These differences were not explained by differences in demographic (age, sex, birth decade, year) or objective RA measures (DD, CRP, SJC). This implies a limit to the direct comparability of results obtained from subjective measures from different countries.

Acknowledgments:

Partly funded by grants from Nordforsk and Foreum

Disclosure of Interests:

Bénédicte Delcoigne: None declared, Sella Aarrestad Provan: None declared, Hilde Berner Hammer Consultant of: Has received fees as consultant from Roche, AbbVie and Novartis., Speakers bureau: Has received fees for speaking from AbbVie, BMS, Pfizer, UCB, Roche, MSD and Novartis, Daniela Di Giuseppe: None declared, Thomas Frisell: None declared, Bente Glintborg Grant/research support from: Grants from Pfizer, Biogen and Abbvie, Gerdur Gröndal: None declared, Björn Gudbjornsson Speakers bureau: Novartis and Amgen, Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis, Brigitte Michelsen: None declared, Dan Nordström Consultant of: Abbvie, Celgene, Lilly, Novartis, Pfizer, Roche and UCB., Speakers bureau: Abbvie, Celgene, Lilly, Novartis, Pfizer, Roche and UCB., Heikki Relas Grant/research support from: Abbvie., Consultant of: Abbvie, Celgene, and Pfizer., Speakers bureau: Abbvie, Celgene, and Pfizer., Niels Steen Krogh: None declared, Johan Askling Grant/research support from: JA acts or has acted as PI for agreements between Karolinska Institutet and the following entities, mainly in the context of the ARTIS national safety monitoring programme of immunomodulators in rheumatology: Abbvie, BMS, Eli Lilly, Merck, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB Pharma

FRI0381 ASSOCIATIONS BETWEEN MEASURES OF OVERWEIGHT/OBESITY AND JOINT PAIN IN PERSONS WITH HAND OSTEOARTHRITIS: RESULTS FROM THE NOR-HAND STUDY

Background:

Overweight and obesity are well-known risk factors for osteoarthritis (OA) in weight-bearing joints. However, the role of increased body mass index (BMI) and waist circumference in OA of the non-weight-bearing joints is more controversial. Few hand OA studies have explored the associations between increased BMI/waist circumference and pain.

Objectives:

The aim of this study was to explore whether BMI and waist circumference were associated with self-reported pain in the hands, feet, knees and hips as well as pain sensitization in persons with hand OA. Further, we examined whether synovitis could partly explain the association between BMI/waist circumference and pain, due to a low-grade inflammatory state in overweight persons.

Methods:

The Nor-Hand study is an observational study of 300 participants with hand OA. We measured their height and weight in addition to their waist circumference. Participants completed Numeric Rating Scales (NRS) (0-10) about pain during the last 24 hours in their hands and feet, in addition to the Western Ontario and McMaster Universities OA Index (WOMAC) knee/hip pain subscale (0-20). Pressure pain thresholds (PPTs) (kg/cm2) were measured at both a painful and a non-painful interphalangeal joint of the hand, the left distal radioulnar joint and at the tibialis anterior and trapezius muscles. Temporal summation (TS) was measured with a weighted probe that was tapped 10 times at the left distal radioulnar joint. We considered TS to be present if the pain rating increased by ≥2 (i.e., >smallest detectable change) points on the NRS during the test. Ultrasound was used to score grey-scale synovitis on 0-3 scales in a total of 30 joints in the hands, 26 joints in the feet and the bilateral knees. We evaluated the relation of BMI and waist circumference to the pain scales and synovitis sum scores using linear regression, and to presence of pain sensitization assessed by PPT values and TS using linear and logistic regression, respectively. All analyses were adjusted for age, sex and education.

Results:

The majority of participants were female (n=266, 89%), and the median (IQR) age was 61 (57-66) years. Persons with higher BMI and waist circumference reported higher pain intensity in their hands, feet, knees and hips (Table). Higher BMI and waist circumference were associated with lower PPTs at the tibialis anterior muscle (Table). No associations were found between BMI/waist circumference and PPTs at the other test sites (data not shown). Persons with higher BMI and waist circumference were more likely to have TS (Table). Increased BMI and waist circumference were not associated with more synovitis in the hands, feet or knees (data not shown).

Table.

Data presented as B (95% CI) for the pain measures/PPT value and OR (95% CI) for presence of TS. All analyses were adjusted for age, sex and education.

NRS hand pain (0-10)NRS feet pain(0-10)WOMAC knee/hip pain(0-20)PPT tibialis anterior(kg/cm2)Presenceof TSBMI per SD increase*0.5 (0.2, 0.7)0.7 (0.4, 1.0)1.3 (0.8, 1.8)-0.4 (-0.7,-0.1)1.4 (1.1, 1.8)Waist circumference per SD increase**0.5 (0.3, 0.8)0.6 (0.3, 0.9)1.3 (0.8, 1.8)-0.4 (-0.7,-0.1)1.4 (1.1, 1.8)

*Standard deviation (SD)=5.0 kg/m2, **SD=12.9 cm

Conclusion:

In the Nor-Hand cohort, persons with higher BMI and waist circumference reported higher pain intensity in their hands, feet, knees and hips. This relation was not explained by higher levels of synovitis in the joints. However, the association may at least partly be driven by a higher prevalence of central pain sensitization in persons with higher BMI. Due to the cross-sectional study design we cannot conclude about causality.

Disclosure of Interests:

Marthe Gløersen: None declared, Pernille Steen Pettersen: None declared, Tuhina Neogi Grant/research support from: Pfizer/Lilly, Consultant of: Pfizer/Lilly, EMD-Merck Serono, Novartis, Tore K. Kvien Grant/research support from: Received grants from Abbvie, Hospira/Pfizer, MSD and Roche (not relevant for this abstract)., Consultant of: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Paid instructor for: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Speakers bureau: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Karin Magnusson: None declared, Hilde Berner Hammer Consultant of: Has received fees as consultant from Roche, AbbVie and Novartis., Speakers bureau: Has received fees for speaking from AbbVie, BMS, Pfizer, UCB, Roche, MSD and Novartis, Ida K. Haugen: None declared

THU0425 ULTRASOUND DETECTED URATE CRYSTALS DEPOSITIONS ARE ASSOCIATED WITH ELEVATED CALPROTECTIN AND CRP INDICATING SUBCLINICAL INFLAMMATION; BASELINE RESULTS FROM THE NOR-GOUT STUDY

Background:

Ultrasound detects depositions of monosodium urate (MSU) crystals in gout patients. The OMERACT ultrasound group has developed definitions for elementary lesions in gout including the double contour (DC) sign (depositions of crystals on the surface of cartilage) and tophus (larger hypo-echoic aggregation of crystals, usually well delineated). Calprotectin is a major granulocyte protein found to be sensitive to reflect the level of inflammation in several immunological diseases. There may be an association between low grade inflammation and co-morbidity (including cardio-vascular pathology) in gout patients.

Objectives:

To explore whether the extent of depositions (e.g. DC and tophi) was associated with inflammation in gout patients.

Methods:

The baseline data from NOR-GOUT, a prospective observational study of patients with crystal-proven gout with increased serum urate levels (>360 μmol/L), were presently used. All patients had an extensive ultrasound examination(GE E9 machine, grey scale 15MHz) to assess MSU depositions (DC and tophi) with bilateral assessment of radiocarpal joint, MCP 2, insertion of triceps and quadriceps, proximal and distal patellar and the Achilles tendon, cartilage of distal femur (maximal flexed knee), the talar cartilage of tibiotalar joint and MTP 1 joint. The degree of elementary lesions was semi-quantitatively scored 0-3 (0=none, 1=possible, 2=certain, 3=major deposits). Total sum scores of DC and tophi were calculated and the associations with calprotectin (plasma assessed by ELISA (Calpro), normal levels <910 µg/L) as well as C-reactive protein (CRP, assessed as a routine at our laboratory, normal levels <4mg/L) were explored. Correlations were performed by use of Spearman and differences between groups were investigated by Mann-Whitney tests.

Results:

A total of 111 patients who had calprotectin assessed were included in the study (92% men, mean (SD) age 54.5 (14.5) years, disease duration 7.1 (6.6) years) when initiating MSU lowering treatment. The mean (SD) sum sore DC and tophi was 9.1 (7.8), calprotectin 780 (500) µg/L, CRP 7 (15) mg/L, serum urate (SUA) 505 (87) μmol/L, creatinine 96 (18) μmol/l and eGFR 79 (20) ml/min/1.73m2. Table 1 shows significant correlations between sum sore DC/tophi and calprotectin, CRP, SUA, creatinine and eGFR. Increased calprotectin levels (≥910 µg/L) were found in 28% and increased CRP (≥ 4 mg/L) in 39%. Patients with increased vs normal levels of calprotectin had significantly higher levels of DC/tophi depositions (mean (SD) 13.0 (10.4) vs 7.4 (5.8), p=0.01), and similar was found for CRP (11.4 (9.5) vs 7.6 (6.2), p=0.033) (illustrated in table 2).

Conclusion:

In gout patients, higher load of MSU depositions was associated with increased inflammatory markers. This indicates that the amount of depositions is associated with higher inflammatory activity, which could have systemic implications.

Sum score DC and tophiCalprotectinCRPSUACreatinineCalprotectin0.31*CRP0.29*0.65**SUA0.31**0.22*0.19Creatinine0.34**0.25*0.150.36**eGFR-0.38**-0.27*-0.21*-0.18-0.86**

*p≤0.05, **p≤0.001

Disclosure of Interests: :

Hilde Berner Hammer Consultant of: Has received fees as consultant from Roche, AbbVie and Novartis., Speakers bureau: Has received fees for speaking from AbbVie, BMS, Pfizer, UCB, Roche, MSD and Novartis, Gro Jensen: None declared, Lars Karoliussen: None declared, Lene Terslev Speakers bureau: LT declares speakers fees from Roche, MSD, BMS, Pfizer, AbbVie, Novartis, and Janssen., Espen Andre Haavardsholm Grant/research support from: Research funding from Pfizer, UCB, Roche, MSD and AbbVie, Consultant of: Pfizer, Speakers bureau: Pfizer, UCB, Roche, and AbbVie,, Tore K. Kvien Grant/research support from: Received grants from Abbvie, Hospira/Pfizer, MSD and Roche (not relevant for this abstract)., Consultant of: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Paid instructor for: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Speakers bureau: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Till Uhlig Consultant of: Lilly, Pfizer, Speakers bureau: Grünenthal, Novartis

AB1106 DO TENDER JOINTS IN PSORIATIC ARTHRITIS REFLECT INFLAMMATION ON ULTRASOUND?

Background:

Ultrasound (US) is a sensitive method for evaluating inflammation in arthritis, but several studies have shown discrepancies in inflammatory findings on US examination and clinically assessed disease activity, both in rheumatoid arthritis (RA) and psoriatic arthritis (PsA) (1, 2). In RA, a recent study found that swollen but not tender joints reflect synovitis detected by US (3). In PsA tenderness without joint swelling is a frequent finding.

Objectives:

To investigate the agreement of clinical joint evaluation (swollen joints (SJ) and tender joints (TJ)) and US findings of inflammation in PsA assessing joints and periarticular tissue involvement (e.g. joint capsule, adjacent ligaments etc.).

Methods:

We included 42 patients with active PsA (min. 3 swollen and tender joints) and hand involvement (min. 1 finger joint and/or 1 finger with dactylitis). All patients had US examination performed by one examiner (blinded to clinical data) using a high-end US scanner with a high-frequency 14 MHz linear transducer. 2-5th metacarpophalangeal- (MCP), proximal and distal interphalangeal (PIP and DIP) and 1-5th metatarsophalangeal (MTP) -joints were assessed by greyscale (GS) and power Doppler (PD) mode, bilaterally. Synovitis was scored for GS and PD change (0-3) according to OMERACT guidelines (4), PIP and DIP joints were additionally scored for volar synovitis (0-3) and presence of periarticular PD activity (PD activity in the joint capsule and/or adjacent structures). SJ (76) and TJ (78) counts were performed by an experienced rheumatologist blinded to US findings. As prevalence of lesions was low, agreement between TJ, SJ and US was calculated using the prevalence and bias adjusted Kappa (PABAK) on dichotomized values (0-1 vs 2-3 for GS scores (based on the highest score for each joint), 0 vs. 1-3 for PD scores). US synovitis was defined as GS>1 and PD>0.

Results:

Population characteristics and US findings are presented in table 1.

Agreement between clinical and US joint evaluation is seen in table 2. There was poor agreement between TJ and US synovial hypertrophy and hyperaemia (PABAK 0.12 and 0.20, respectively) and fair agreement with periarticular PD (PABAK 0.25). Moderate agreement was found for SJ and intraarticular PD activity (PABAK 0.55). Our definition of US synovitis showed similar agreements with TJ and SJ as US hyperaemia.

Table 1.

Population characteristics

Sex (female)18 (43)Age (y)49 (40-61)Disease duration (y)8.5 (5-15)Swollen joints (76)9 (5-16)Tender joints (78)22 (11-41)Dactylitis (no. of patients with)18 (43%)Physicians global disease activity VAS51 (38-64)Patients global disease activity VAS66 (66-78)Patient Pain VAS63 (49-74)DAS28-CRP4.8 (4.2-5.5)CRP4.6 (1.8-8.9)US synovitis sum scores (0-102)GS29 (21-38)PD2 (1-5)US periarticular PD sum score (0-16) (PIP + DIP)1 (0-3)

Median(IQR), no(%) VAS: Visual analogue scale (0-100). DAS28:

Disease Activity Score 28 joint count CRP: C-reactive protein

US: Ultrasound GS: Greyscale PD: PowerDoppler

Table 2.

PABAK agreement of clinical examination and US findings.

Swollen jointUS synovial hypertrophy(GS)US synovial hyperaemia(PD)US synovitis(GS>1, PD>0)USperiarticularPDUS synovial/ periarticular PDNo. of joints3108142814281428672672Tender joint0.530.120.200.200.250.20Swollen joint0.350.550.560.450.55

Prevalence and bias adjusted Kappa (PABAK) US: Ultrasound GS: Greyscale. PD: Power Doppler

Conclusion:

In this study TJ did not reflect intra- or periarticular US inflammation in PsA patients. SJ had a better agreement with US findings of inflammation, especially PD, which is in line with previous RA studies.

References:

[1]Michelsen B et al, Ann Rheum Dis. 2016

[2]Lackner A et al, Sem Artrihtis Rheum 2016

[3]Hammer HB et al, Ann Rheum Dis. 2019

[4]D’Agostino MA et al, RMD open. 2017

Disclosure of Interests:

Sara Kamp Felbo Grant/research support from: Celgene, Charlotte Wiell: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Hilde Berner Hammer Consultant of: Has received fees as consultant from Roche, AbbVie and Novartis., Speakers bureau: Has received fees for speaking from AbbVie, BMS, Pfizer, UCB, Roche, MSD and Novartis, Marcin Szkudlarek: None declared, Lene Terslev Speakers bureau: LT declares speakers fees from Roche, MSD, BMS, Pfizer, AbbVie, Novartis, and Janssen.

FRI0425 EVALUATION OF THE DOYLE INDEX AS A MEASURE OF PAIN SENSITIZATION IN PERSONS WITH HAND OSTEOARTHRITIS: EXPLORATORY ANALYSES FROM THE NOR-HAND STUDY

Background:

Pressure pain threshold (PPT) is a measure of pain sensitization; altered pain mechanisms in the peripheral and/or central nervous system causing increased pain sensitivity. PPT testing may be a useful tool to classify pain phenotypes but requires special equipment not available in the clinic. The Doyle index (DI) is a clinical measure of joint tenderness upon palpation. It is considered as an outcome measure of pain and disease activity in hand OA and is a potential alternative to PPT. It is unclear if joint tenderness is related to pain sensitization, as joint tenderness could reflect pure nociceptive pain without sensitization.

Objectives:

Using data from the Nor-Hand study we will explore how DI performs as a measure of pain sensitization in hand OA by examining associations and agreements between DI and PPT at joint level, and correlations between PPT values and DI sum score at person level.

Methods:

PPT was tested with a hand-held algometer (FPIX25, 1cm2flat rubber tip) at the dorsal side of the most painful DIP/PIP and a non-painful DIP/PIP joint (local PPTs) and left radioulnar joint and mid-portions of the trapezius and tibialis anterior muscle (remote PPTs). Low local PPTs indicate peripheral and/or central sensitization, while low remote PPTs indicate central sensitization. According to DI, tenderness in the bilateral thumb base and finger joints were graded by a rheumatologist by pressing on the lateral joint margins: 0=no pain, 1=patient complains of pain, 2=patient complains of pain and winces, 3=patient complains of pain, winces and withdraws joint. We examined whether increasing DI was associated with local PPT using mixed models. To assess agreement between DI and PPT, we categorized PPT of the painful finger joints into a semi-quantitative scale with the same number of categories (n=4) as DI. We identified the cut-offs for the PPT categories that maximized the agreement (weighted kappa) with DI. Finally, we examined Spearman’s correlations between DI sum score [range 0-90] and PPTs of local and remote sites.

Results:

The majority of the 285 eligible participants were women (88%) and mean (SD) age was 61 (6) years. Joints with high DI had lower PPT values (Figure 1). We found a linear association of lower PPT with increasing DI for all joints combined (beta -0.7, 95% CI -0.8, -0.6). Similar results were found for the painful joints (beta -0.8, 95% CI -1.0, -0.6), but weaker for non-painful joints (beta -0.5, 95% CI -1.0, 0.0) where few joints had DI grade 2-3 (Figure 1). The analyses on maximized agreement between DI and the PPT categories gave a weighted kappa equal to 0.32 (Table).

Median (IQR) DI sum score was 9 (5, 15). We found weak inverse correlations between DI sum score and PPT at local (painful finger: ρ -0.24 (95% CI -0.32, -0.16), non-painful finger: ρ -0.22 (95% CI -0.29, -0.11) and remote sites (radioulnar joint: ρ -0.17 (95% CI -0.29, -0.06), trapezius: ρ -0.25 (95% CI -0.36, -0.14), tibialis anterior: ρ -0.20 (95% CI-0.31, -0.09)).

Conclusion:

The DI was associated with lower PPT at painful finger joints. Large variance of PPT within each DI grade resulted in fair agreement. DI of non-painful finger joints was weakly associated with PPT, demonstrating that the DI does not differentiate pain sensitization in joints without ongoing nociceptive pain. Correlations between DI sum score and PPT of remote sites were also weak. The two measures seem to assess different constructs and are therefore not interchangeable.

Table.

Cross tabulation of DI with the best PPT categorization of painful finger joints. Cells = joint count

PPT categories (range, kg/cm2)0(4.7-12)1(3.4-4.6)2(2.1-3.3)3(0-2.0)DI03221113121293172152231163271522

PPT categories 0-3 (i.e. decreasing PPT) represent the categorization that gave maximized agreement with DI (weighted kappa = 0.32)

Disclosure of Interests:

Pernille Steen Pettersen: None declared, Tuhina Neogi Grant/research support from: Pfizer/Lilly, Consultant of: Pfizer/Lilly, EMD-Merck Serono, Novartis, Karin Magnusson: None declared, Barbara Slatkowsky-Christensen: None declared, Hilde Berner Hammer Consultant of: Has received fees as consultant from Roche, AbbVie and Novartis., Speakers bureau: Has received fees for speaking from AbbVie, BMS, Pfizer, UCB, Roche, MSD and Novartis, Till Uhlig Consultant of: Lilly, Pfizer, Speakers bureau: Grünenthal, Novartis, Tore K. Kvien Grant/research support from: Received grants from Abbvie, Hospira/Pfizer, MSD and Roche (not relevant for this abstract)., Consultant of: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Paid instructor for: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Speakers bureau: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Ida K. Haugen: None declared

THU0537 VALIDITY AND DIAGNOSTIC PERFORMANCE OF FLUORESCENCE OPTICAL IMAGING MEASURING SYNOVITIS IN HAND OSTEOARTHRITIS. RESULTS FROM THE NOR-HAND STUDY

Background:

Fluorescence Optical Imaging (FOI) demonstrates enhanced microcirculation in finger joints as a sign of inflammation.

Objectives:

We wanted to assess the validity and diagnostic performance of FOI measuring synovitis, comparing it with Magnetic Resonance Imaging (MRI)- and ultrasound-detected synovitis in persons with hand osteoarthritis (OA).

Methods:

Two hundred and twenty-one participants (88% female, age (SD) 60.6 (6.2) years) with hand OA from the Nor-Hand study underwent FOI and grey scale (GS) and power Doppler (PD) ultrasound of the bilateral hands and contrast-enhanced MRI of the dominant hand. The FOI scan was performed after the administration of an intravenous fluorescence dye (indocyanine green, ICG) and 360 images (1/second) were produced in 6 minutes. One reader scored the bilateral distal interphalangeal (DIP), proximal interphalangeal (PIP), metacarpophalangeal (MCP) and first carpometacarpal (CMC-1) joints for FOI enhancement, blinded for clinical information and other imaging data. Images were scored according to the ‘FOI activity score’ (FOIAS) where four out of 360 images are assessed, defined as phase 1, 2, and 3, based on the inflow and washing out of the fluorescence dye, and a composite image (Prima Vista Mode; PVM) of the 240 first images. Two readers evaluated separately the severity of MRI-defined synovitis (grade 0-3) in the DIP, PIP, MCP and CMC-1 joints of the dominant hand and the severity of GS synovitis (grade 0-3) and PD activity (grade 0-3) in the same joints of the hands bilaterally. Spearman’s rho was calculated for correlations between sum scores of all joints for FOI, MRI and ultrasound and sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and area under the curve (AUC) for FOI using MRI and ultrasound as reference.

Results:

Despite frequent MRI and ultrasound findings in the CMC-1 joint, no FOI enhancement was detected in the thumb base, and CMC-1 was excluded from the analyses. FOI had poor to fair correlations with MRI and GS synovitis and PD activity. The strongest correlation with MRI was found for PVM in the PIP joints with Spearman’s rho of 0.32, while the DIP joints had consistently the weakest correlations ranging from 0 to 0.14 (Figure 1). None of the FOI phases or PVM demonstrated both good sensitivity and specificity, and AUC remained low with both MRI and GS synovitis as a reference (table 1). The NPVs of FOI were consistently higher when GS synovitis was used as reference rather than MRI, due to higher frequency of low degree MRI-defined synovitis. However, when changing cut-off for MRI synovitis as reference from grade 1 to grade 2 the diagnostic performance of FOI increased to the level of GS synovitis. The diagnostic performance for FOI was similar with both GS synovitis and PD activity as reference.

Table 1.

Diagnostic performance of FOI measuring synovitis in hand OA using MRI and GS synovitis as reference

FOIReferenceSensitivitySpecifisityPPVNPVAUCPVMMRI0.480.720.610.610.61Phase 10.020.990.610.530.50Phase 20.580.620.580.620.60Phase 30.240.900.670.570.57PVMGS0.590.640.170.930.62Phase 10.020.990.280.890.51Phase 20.690.560.170.940.63Phase 30.230.860.170.900.56

FOI; Fluorescence optical imaging, PVM; Prima Vista Mode, GS; Grey scale, PVM; Prima Vista Mode, PPV; Positive Predictive Value, NPV; Negative Predictive Value, AUC; Area under the curve

Conclusion:

FOI sum scores showed poor to fair correlations with MRI- and ultrasound-detected synovitis in persons with hand OA. These findings might be explained by the low-grade inflammation with minor vascularization in the majority of inflamed joints. None of the FOI phases or PVM demonstrated both good sensitivity and specificity and the method was not able to detect CMC-1 synovitis.

Disclosure of Interests:

Øystein Maugesten: None declared, Alexander Mathiessen: None declared, Hilde Berner Hammer Consultant of: Has received fees as consultant from Roche, AbbVie and Novartis., Speakers bureau: Has received fees for speaking from AbbVie, BMS, Pfizer, UCB, Roche, MSD and Novartis, Tore K. Kvien Grant/research support from: Received grants from Abbvie, Hospira/Pfizer, MSD and Roche (not relevant for this abstract)., Consultant of: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Paid instructor for: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Speakers bureau: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Sigrid Valen Hestetun: None declared, Till Uhlig: None declared, Sarah Ohrndorf: None declared, Ida K. Haugen: None declared

THU0129 SLEEP DISTURBANCE AND LOW INFLAMMATION PREDICT A PATTERN OF CHRONIC FATIGUE IN ACTIVELY TREATED PATIENTS WITH ESTABLISHED RA

Background:

Fatigue is common among patients with rheumatoid arthritis (RA) and has major impact on the burden of disease. There is little knowledge regarding the factors predicting the longitudinal development of chronic fatigue.

Objectives:

To identify baseline predictors for the development of chronic fatigue in patients with RA who initiate biological DMARD (bDMARD) treatment, and to compare disease courses across categories of fatigue for 12 months follow-up.

Methods:

Different trajectories of fatigue were calculated from a cohort of 209 established RA patients initiating bDMARDs. Fatigue was assessed by use of the fatigue Numeric Rating Scale (0-10) from the Rheumatoid Arthritis Impact of Disease (RAID) questionnaire. The patients were assessed at 0, 1, 2, 3, 6 and 12 months. We defined three groups: no fatigue (≤3 at all visits), improved fatigue (>3 at baseline but ≤3 at follow-up) and chronic fatigue (≥ 4 at all visits). All patients had clinical/subjective assessments (28 tender/swollen joint count, assessor’s/patient’s global VAS, RAID score, widespread pain, pain catastrophizing, the Hospital Anxiety and Depression Scale and inflammatory markers (ESR, CRP and calprotectin (a major granulocyte protein sensitive for inflammation in RA patients)). All patients were assessed by ultrasound (grey scale (GS) and power Doppler (PD)) of 36 joints and 4 tendons with semi-quantitative scoring (0-3). Differences between groups at baseline was assessed by bivariate analyses, and logistic regression models adjusted for age and gender were used to explore baseline predictors of chronic vs improved fatigue. Trajectories of different groups were plotted as estimated marginal means in figures, and differences between groups assessed by mixed models with maximum likelihood random effects, adjusted for age and sex.

Results:

Table 1 describes demographics and clinical factors of the three groups with significant differences shown in bold. Logistic regression with multivariate assessments found anti-CCP and low inflammation (calprotectin) to be predictors of chronic versus improved fatigue. Sleep disturbance was highly predictive of chronic fatigue. Figure 1 illustrates the trajectories for the three groups at all visits, showing the chronic fatigue group to have significantly higher DAS28, level of widespread pain, depression and sleep disturbance in contrast to no higher level of inflammation assessed by CRP and ultrasound PD.

Table 1.No fatigueImproved fatigueChronicfatigueNo fatigue vs Improved fatigueImproved fatigue vs chronic fatigueNo fatigue vs. chronic fatigue482943pppAge, mean (SD) years51 (2)48 (2)54 (2)0.280.090.28Female gender (%)35 (73)24 (83)38 (88)0.400.500.09Higher Education (%)31 (65)23 (79)20 (47)0.170.010.17Anti-CCP positive (%)29 (60)20 (69)36 (84)0.720.010.002RF positive (%)27 (56)17 (59)30 (70)0.760.110.15Disease duration, mean (SD) years7 (1)8 (1)11 (1)0.810.110.03RA disease activityDAS28CRP3.2 (0.1)3.9 (0.2)4.7 (0.2)0.0030.004<0.001Swollen joints (28)5.7 (0.7)5.6 (1.0)6.2 (0.7)0.900.600.63CRP mg/L mean (SD)9.4 (2.4)15.6 (4.1)11.0 (2.6)0.020.020.58Calprotectin mg/L mean (SD)1.6 (0.3)2.0 (0.4)1.5 (0.2)0.440.200.92Sum score PD mean (SD)14.3 (1.8)13.8 (2.5)12.3 (1.9)0.850.620.43Sum score GS mean (SD)31.6 (2.8)29.3 (3.4)28.2 (2.7)0.610.810.39Psychosocial factorsRAID sleep (VAS 0-10)1.2 (0.3)4.3 (0.6)6.7(0.4)<0.001<0.001<0.001RAID fatigue (VAS 0-10)1.4 (0.2)5.6 (0.3)7.1 (0.3)<0.0010.003<0.001Widespread pain (0-25)4.3 (0.4)7.0 (0.8)8.6 (0.7)0.0010.16<0.001HADS anxiety1.5 (0.3)1.4 (0.6)3.4 (0.7)0.260.580.10HADS depression0.8 (0.2)0.9 (0.4)3.0 (0.8)0.980.360.05Pain Catastrophizing (0-6)1.0 (0.2)2.5 (0.3)2.9 (0.3)<0.0010.31<0.001

Conclusion:

Sleep disturbance is a modifiable factor presently found to predict chronic versus improved fatigue. Thus, attention should be given to RA patients with sleep problems to seek to avoid development of chronic fatigue. This issue should be explored in further studies.

Disclosure of Interests:

Hilde Berner Hammer Consultant of: Has received fees as consultant from Roche, AbbVie and Novartis., Speakers bureau: Has received fees for speaking from AbbVie, BMS, Pfizer, UCB, Roche, MSD and Novartis, Brigitte Michelsen Grant/research support from: Research support from Novartis, Consultant of: Consulting fees Novartis, Joe Sexton: None declared, Till Uhlig Consultant of: Lilly, Pfizer, Speakers bureau: Grünenthal, Novartis, Sella Aarrestad Provan Consultant of: Novartis

Biomarkers of cardiovascular risk across phenotypes of osteoarthritis

Background

The objective of this study was to explore the associations between ultrasonographic and radiographic joint scores and levels of arterial CVD risk markers in patients with osteoarthritis (OA). Secondly, to compare the levels of arterial CVD risk markers between OA phenotypes and controls.

Method

The "Musculoskeletal pain in Ullensaker" Study (MUST) invited residents of Ullensaker municipality with self-reported OA to a medical examination. OA was defined according to the American College of Rheumatology (ACR) criteria and phenotyped based on joint distribution. Joints of the hands, hips and knees were examined by ultrasonography and conventional radiography, and scored for osteosteophytes. Hands were also scored for inflammation by grey scale (GS) synovitis and power Doppler (PD) signal. Control populations were a cohort of inhabitants of Oslo (OCP), and for external validation, a UK community-based register (UKPC).Pulse pressure augmentation index (AIx) and pulse wave velocity (PWV) were measured using the Sphygmocor apparatus (Atcor®). Ankel-brachial index (ABI) was estimated in a subset of patients. In separate adjusted regression models we explored the associations between ultrasonography and radiograph joint scores and AIx, PWV and ABI. CVD risk markers were also compared between phenotypes of OA and controls in adjusted analyses.

Results

Three hundred and sixty six persons with OA were included (mean age (range); 63.0 (42.0-75.0)), (females (%); 264 (72)). Of these, 155 (42.3%) had isolated hand OA, 111 (30.3%) had isolated lower limb OA and 100 (27.3%) had generalized OA. 108 persons were included in the OCP and 963 persons in the UKPC; (mean age (range); OCP: 57.2 (40.4-70.4), UKPC: 63.9 (40.0-75.0), females (%); OCP: 47 (43.5), UKPC: 543 (56.4%). Hand osteophytes were associated with AIx while GS and PD scores were not related to CVD risk markers. All OA phenotypes had higher levels of AIx compared to OCP in adjusted analyses. External validation against UKPC confirmed these findings.

Conclusions

Hand osteophytes might be related to higher risk of CVD. People with OA had higher augmented central pressure compared to controls.Words 330.

Smoking and alcohol use are associated with structural and inflammatory hand osteoarthritis features

OBJECTIVES

To explore whether smoking and alcohol use are associated with hand osteoarthritis (OA) features in two different OA cohorts.

METHOD

We studied 530 people with radiographic hand OA from the Musculoskeletal pain in Ullensaker STudy (MUST) and 187 people from the Oslo hand OA cohort [mean (sd) age 65 (8.0) and 62 (5.7) years, 71% and 91% women, respectively]. Smoking, alcohol use and hand pain were self-reported. Participants underwent conventional hand radiographs and ultrasound examination of 30 hand joints. The Kellgren-Lawrence sum score for radiographic OA severity (0-120 scale) and the proportion of participants having at least one joint with grey-scale synovitis (grade ≥1) were calculated. We studied whether smoking and alcohol use were cross-sectionally associated with radiographic OA, synovitis, and pain using adjusted linear and logistic regression analyses.

RESULTS

Smoking was associated with less radiographic OA in both cohorts [β = -4.71, 95% confidence interval (CI) -8.36 to -1.06 for current smoking in MUST and β = -0.15, 95% CI -0.29 to -0.02 for smoking pack-years in the Oslo hand OA cohort]. Stratified analyses indicated that the association was present in men only. Being a monthly drinker (examined in MUST only) was significantly associated with present synovitis compared to never drinkers (odds ratio = 2.35, 95% CI 1.27 to 4.34) (no gender differences). Neither smoking nor alcohol was associated with hand pain.

CONCLUSIONS

Smoking was associated with less radiographic hand OA whereas alcohol consumption was associated with present joint inflammation in hand OA. Future longitudinal studies are needed to explore the causal associations and explanatory mechanisms behind gender differences.

Synovitis and radiographic progression in non-erosive and erosive hand osteoarthritis: is erosive hand osteoarthritis a separate inflammatory phenotype?

OBJECTIVE

To compare the prevalence of synovitis, pain and radiographic progression in non-erosive and erosive hand osteoarthritis (HOA), and to explore whether the different rate of disease progression is explained by different levels of synovitis and structural damage.

DESIGN

We included 31 and 34 participants with non-erosive and erosive HOA at baseline, respectively. Using Generalized Estimating Equations, we explored whether participants with erosive HOA had more synovitis (by MRI, ultrasound and clinical examination) independent of the degree of structural damage. Similarly, we explored whether pain at baseline and radiographic progression after 5 years were higher in erosive HOA, independent of the levels of synovitis and structural damage. All analyses were adjusted for age and sex.

RESULTS

Power Doppler activity was found mainly in erosive HOA. Participants with erosive HOA demonstrated more moderate-to-severe synovitis, assessed by MRI (OR = 1.73, 95% CI 1.11-2.70), grey-scale ultrasound (OR = 2.02, 95% CI 1.25-3.26) and clinical examination (OR = 1.80, 95% CI 1.44-2.25). The associations became non-significant when adjusting for more structural damage. The higher frequency of joint tenderness in erosive HOA was at least partly explained more structural damage and inflammation. Radiographic progression (OR = 2.53, 95% CI 1.73-3.69) was more common in erosive HOA independent of radiographic HOA severity and synovitis (here: adjusted for grey-scale synovitis by ultrasound).

CONCLUSION

Erosive HOA is characterized by higher frequency and more severe synovitis, pain and radiographic progression compared to non-erosive HOA. The higher rate of disease progression was independent of baseline synovitis and structural damage.

Educational recommendations for the conduct, content and format of EULAR musculoskeletal ultrasound Teaching the Teachers Courses

OBJECTIVE

To produce educational guidelines for the conduct, content and format of theoretical and practical teaching at EULAR musculoskeletal ultrasound (MSUS) Teaching the Teachers (TTT) Courses.

METHODS

A Delphi-based procedure with 24 recommendations covering five main areas (Duration and place of the course; Faculty members; Content of the course; Evaluation of the teaching skills; TTT competency assessment) was distributed among a group of experts involved in MSUS teaching, in addition to an advisory educational expert being present. Consensus for each recommendation was considered achieved when the percentage of agreement was >75%.

RESULTS

21 of 24 invited participants responded to the first Delphi questionnaire (88% response rate). All 21 participants also responded to the second round. Agreement on 19 statements was obtained after two rounds.

CONCLUSIONS

This project has led to the development of guidelines for the conduct, content and format of teaching at the EULAR MSUS TTT Courses that are organised annually, with the aim of training future teachers of EULAR MSUS Courses, EULAR Endorsed MSUS Courses, as well as national and local MSUS Courses. The presented work gives indications on how to homogenise the teaching at the MSUS TTT Courses, thus resolving current discrepancies in the field.

Rosuvastatin-Induced Carotid Plaque Regression in Patients With Inflammatory Joint Diseases: The Rosuvastatin in Rheumatoid Arthritis, Ankylosing Spondylitis and Other Inflammatory Joint Diseases Study

OBJECTIVE

Patients with rheumatoid arthritis (RA) and carotid artery plaques have an increased risk of acute coronary syndromes. Statin treatment with the goal of achieving a low-density lipoprotein (LDL) cholesterol level of ≤1.8 mmoles/liter (≤70 mg/dl) is recommended for individuals in the general population who have carotid plaques. The aim of the ROsuvastatin in Rheumatoid Arthritis, Ankylosing Spondylitis and other inflammatory joint diseases (RORA-AS) study was to evaluate the effect of 18 months of intensive lipid-lowering treatment with rosuvastatin with regard to change in carotid plaque height.

METHODS

Eighty-six patients (60.5% of whom were female) with carotid plaques and inflammatory joint disease (55 with RA, 21 with AS, and 10 with psoriatic arthritis) were treated with rosuvastatin to obtain the LDL cholesterol goal. Carotid plaque height was evaluated by B-mode ultrasonography.

RESULTS

The mean ± SD age of the patients was 60.8 ± 8.5 years, and the median compliance with rosuvastatin treatment was 97.9% (interquartile range [IQR] 96.0-99.4). At baseline, the median number and height of the carotid plaques were 1.0 (range 1-8) and 1.80 mm (IQR 1.60-2.10), respectively. The mean ± SD change in carotid plaque height after 18 months of treatment with rosuvastatin was -0.19 ± 0.35 mm (P < 0.0001). The mean ± SD baseline LDL cholesterol level was 4.0 ± 0.9 mmoles/liter (154.7 ± 34.8 mg/dl), and the mean reduction in the LDL cholesterol level was -2.3 mmoles/liter (95% confidence interval [95% CI] -2.48, -2.15) (-88.9 mg/dl [95% CI -95.9, -83.1]). The mean ± SD LDL cholesterol level during the 18 months of rosuvastatin treatment was 1.7 ± 0.4 mmoles/liter (area under the curve). After adjustment for age/sex/blood pressure, no linear relationship between a reduction in carotid plaque height and the level of LDL cholesterol exposure during the study period was observed. Attainment of the LDL cholesterol goal of ≤1.8 mmoles/liter (≤70 mg/dl) or the amount of change in the LDL cholesterol level during the study period did not influence the degree of carotid plaque height reduction.

CONCLUSION

Intensive lipid-lowering treatment with rosuvastatin induced atherosclerotic regression and reduced the LDL cholesterol level significantly in patients with inflammatory joint disease.

Global ultrasound assessment of structural lesions in osteoarthritis: a reliability study by the OMERACT ultrasonography group on scoring cartilage and osteophytes in finger joints

OBJECTIVE

Ultrasonography is sensitive for the evaluation of cartilage pathology and degree of osteophytes in patients with hand osteoarthritis (OA). High consistency of assessments is essential, and the OMERACT (Outcome Measures in Rheumatology) ultrasonography group took the initiative to explore the reliability of a global ultrasonography score in patients with hand OA using semiquantitative ultrasonography score of cartilage and osteophytes in finger joints.

METHODS

Ten patients with hand OA were examined by 10 experienced sonographers over the course of two days. Semiquantitative scoring (0-3) was performed on osteophytes (carpo-metacarpal 1, metacarpo-phalangeal (MCP) 1-5, proximal interphalangeal 1-5 and distal interphalangeal 2-5 joints bilaterally with an ultrasonography atlas as reference) and cartilage pathology (MCP 2-5 bilaterally). A web-based exercise on static cartilage images was performed a month later. Reliability was assessed by use of weighted κ analyses.

RESULTS

Osteophyte scores were evenly distributed, and the intraobserver and interobserver reliabilities were substantial to excellent (κ range 0.68-0.89 and mean κ 0.65 (day 1) and 0.67 (day 2), respectively). Cartilage scores were unevenly distributed, and the intraobserver and interobserver reliability was fair to moderate (κ range 0.46-0.66 and mean κ 0.39 (day 1) and 0.33 (day 2), respectively). The web-based exercise showed acceptable agreement for cartilage being normal (κ 0.47) or with complete loss (κ 0.68), but poor for the intermediate scores (κ 0.22-0.30).

CONCLUSIONS

Use of the present semiquantitative ultrasonography scoring system for cartilage pathology in hand OA is not recommended (while normal or total loss of cartilage may be assessed). However, the OMERACT ultrasonography group will endorse the use of semiquantitative scoring of osteophytes with the ultrasonography atlas as reference.

Defining enthesitis in spondyloarthritis by ultrasound: results of a Delphi process and of a reliability reading exercise

OBJECTIVE

To standardize ultrasound (US) in enthesitis.

METHODS

An initial Delphi exercise was undertaken to define US-detected enthesitis and its core components. These definitions were subsequently tested on static images taken from spondyloarthritis patients in order to evaluate their reliability.

RESULTS

Excellent agreement (>80%) was obtained for including hypoechogenicity, increased thickness of the tendon insertion, calcifications, enthesophytes, erosions, and Doppler activity as core elementary lesions of US-detected enthesitis. US definitions were subsequently obtained for each elementary component. On static images, the intraobserver reliability showed a high degree of variability for the detection of elementary lesions, with kappa coefficients ranging from 0.13-1. The interobserver kappa values were variable, with the lowest kappa coefficient for enthesophytes (0.24) and the highest coefficient for Doppler activity at the enthesis (0.63).

CONCLUSION

This is the first consensus-based US definition of enthesitis and its elementary components and the first step performed to ensure a higher degree of homogeneity and comparability of results between studies and in daily clinical work.

EFSUMB minimum training requirements for rheumatologists performing musculoskeletal ultrasound

In order to optimize and standardize musculoskeletal ultrasonography education for rheumatologists, there is a need for competency assessments addressing the required training and practical and theoretical skills. This paper describes how these competency assessments for rheumatologists were developed and what they contain.

Interleukin-15 induces interleukin-17 production by synovial T cell lines from patients with rheumatoid arthritis

IL-17-producing T cells (Th17 cells) are believed to contribute to local inflammation and joint damage in rheumatoid arthritis (RA). Limited data exist on Th17 cells located within the inflamed synovial tissue (ST) of patients with RA. Here, we aimed to generate polyclonal T cell lines (TCLs) from the RA ST and assess their cytokine production, including the effects of exogenous IL-15 on IL-17 production in vitro. For five patients with RA, polyclonal TCLs were established from ST obtained by joint surgery. Synovial TCLs were expanded and stimulated by anti-CD3/CD28 microbeads and exogenous cytokines. Cytokine production was assessed by culture supernatant analyses and intracellular flow cytometry, and TCLs were sorted based on their surface expression of CCR6. In addition to IL-17, we detected IL-6, IL-10, IFN-γ and TNF-α in the synovial TCL culture supernatants. Exogenous IL-15 increased the production of IL-17 as well as the other cytokines except IFN-γ. For IL-17, this effect was more pronounced after prolonged culture times. Intracellular flow cytometry confirmed the presence of IL-17+ and IL-17+ IFN-γ+ CD4+ T cells in the TCLs. IL-17+ and IL-17+ IFN-γ+ T cells were enriched in the CD4+ CCR6+ population. In conclusion, Th17 cells can be detected after polyclonal expansion and stimulation of RA synovial TCLs generated by joint surgery. The Th17 cells from the RA ST were enriched in the CD4+ CCR6+ population, and they were sensitive to exogenous IL-15. Th17 cells present within the synovial compartment may contribute to the RA pathogenesis and local joint damage.

Ultrasonography shows significant improvement in wrist and ankle tenosynovitis in rheumatoid arthritis patients treated with adalimumab

OBJECTIVE

Tenosynovitis is common in rheumatoid arthritis (RA) but knowledge is limited regarding its response to anti-inflammatory treatment. This study used ultrasonography (US) to examine the distribution and responsiveness of tenosynovitis to anti-tumour necrosis factor (anti-TNF) treatment in RA patients.

METHODS

Twenty patients with RA were examined at baseline and 1, 3, 6, and 12 months after starting adalimumab treatment, and grey-scale (GS) and power Doppler (PD) US scoring (semi-quantitative range 0-3) of wrist and ankle tendons was performed in addition to assessment of the 28-joint Disease Activity Score (DAS28), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR).

RESULTS

The extensor carpi ulnaris (ECU) tendon in the wrists and the closely related tendons tibialis posterior (TB) and flexor digitorum longus (FDL) in the ankles were most often inflamed. Median sum scores for this reduced number of tendons at baseline/12-month follow-up were 5/0.5 for GS (p < 0.001) and 4/0 for PD (p < 0.05), with reductions in the US scores during follow-up as large as those found for sum scores of all tendons. The standardized response means (SRMs) for sum GS or PD scores of the reduced number of tendons were higher (range -0.53 to -0.93) than for the sum scores of all tendons (-0.23 to -0.74), and showed larger responsiveness than CRP (-0.10 to -0.43) and ESR (-0.03 to -0.71).

CONCLUSION

Bilateral assessments of ECU, TB, and FDL tendons were as sensitive to change as the sum scores of all tendons, and scoring of this reduced number of tendons is suggested to be included in US scorings for follow-up of RA patients.

Ultrasonography shows increased cross-sectional area of the median nerve in patients with arthritis and carpal tunnel syndrome

OBJECTIVES

To examine whether patients with arthritic diseases and carpal tunnel syndrome (CTS) have increased cross-sectional areas of the median nerves measured by ultrasonography (US). Enlarged cross-sectional areas have previously been found in non-arthritic patients with idiopathic CTS.

METHODS

During 1 yr, all 12 patients with rheumatoid arthritis (RA) or other arthritic diseases hospitalized in our department for surgery for CTS were included. Nine of the patients had bilateral CTS, giving a total of 21 pathological nerves. The median duration of CTS symptoms was 9.5 months. The controls were 30 randomly selected RA patients without symptoms of CTS and 30 healthy persons. Both CTS patients and controls were examined bilaterally by use of US at the entrance of the carpal tunnel, and the cross-sectional areas of the median nerves were calculated.

RESULTS

Cross-sectional areas of the median nerves were significantly higher in the CTS patients compared with the RA controls and healthy persons; median (range) areas were 15.7 mm(2) (11.1-21.8), 8.5 mm(2) (5.8-11.0) and 8.0 mm(2) (4.9-12.0), respectively (P<0.0001). No significant differences in cross-sectional areas were observed between the two control groups, or between the right and left hand in the control groups.

CONCLUSIONS

Higher cross-sectional areas were found in the arthritic patients with CTS than in RA patients and healthy persons without CTS. This supports previous studies of idiopathic CTS in which increased cross-sectional areas have been found. Thus, as in idiopathic CTS, arthritic patients may be examined by US of the median nerve when CTS is suspected.

Changes in laboratory variables in rheumatoid arthritis patients during a trial of fasting and one-year vegetarian diet

We have previously reported that significant improvement may be obtained in rheumatoid arthritis patients by fasting followed by a vegetarian diet for one year. The present study was carried out to examine to what extent biochemical and immunological variables changed during the clinical trial of fasting and vegetarian diet. For the patients who were randomised to the vegetarian diet there was a significant decrease in platelet count, leukocyte count, calprotectin, total IgG, IgM rheumatoid factor (RF), C3-activation products, and the complement components C3 and C4 after one month of treatment. None of the measured parameters changed significantly during this period in the group of omnivores. The course of 14 of 15 measured variables favored the vegetarians compared with the omnivores, but the difference was only significant for leukocyte count, IgM RF, and the complement components C3 and C4. Most of the laboratory variables declined considerably in the vegetarians who improved according to clinical variables, indicating a substantial reduction in inflammatory activity. The leukocyte count, however, decreased in the vegetarians irrespective of the clinical results. Thus, the decline in leukocyte count may be attributed to vegetarian diet per se and not to the reduction in disease activity. The results of the present study are in accordance with the findings from the clinical trial, namely that dietary treatment can reduce the disease activity in some patients with rheumatoid arthritis.

A longitudinal study of calprotectin as an inflammatory marker in patients with reactive arthritis

OBJECTIVE

To examine the value of calprotectin, a major granulocyte protein with bactericide properties, as an inflammatory marker in patients with reactive arthritis.

METHODS

Twenty-five patients with Chlamydia-induced and 27 patients with enterobacteria-induced reactive arthritis were analysed. At the first visit and after 3, 12, 24, 52 and 104 weeks, calprotectin concentrations were measured in plasma and when possible, in synovial fluid. C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) were analysed and clinical assessments of disease activity were performed.

RESULTS

Of the inflammatory markers, the plasma calprotectin concentrations were the first to normalize during recovery. Calprotectin concentrations in the plasma were highly correlated with CRP and ESR, and calprotectin was found to have high correlation coefficients with the clinical assessments of disease activity. High calprotectin concentrations were found in the synovial fluid.

CONCLUSION

The high correlations between calprotectin in plasma and clinical and laboratory markers of inflammation, as well as the rapid normalization following clinical improvement, demonstrate that calprotectin may be used as an inflammatory marker in patients with reactive arthritis.

Terminal complement pathway activation and low lysis inhibitors in rheumatoid arthritis synovial fluid

OBJECTIVE

To investigate terminal complement activation and lysis inhibitors in rheumatoid arthritis (RA).

METHODS

C5a, vitronectin and clusterin were quantitated by enzyme immunoassays in plasma and synovial fluid (SF) in RA (n = 30) and osteoarthritis (OA) (n = 11).

RESULTS

In RA the concentration of C5a was 3-fold increased in plasma (21.9 vs 7.2 micrograms/l) and 5-fold increased in SF (7.8 vs 1.7 micrograms/l) compared to OA. The SF/plasma ratios for C5a, vitronectin and clusterin were 0.35, 0.36 and 0.23, respectively, not significantly different in the 2 diseases.

CONCLUSION

SF terminal pathway activation in RA combined with low local levels of lysis inhibitors might allow lytic or sublytic attacks on local cells, resulting in inflammation and cell damage.