AB0400 A SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS INTO THE SUCCESS RATE OF GLUCOCORTICOID DISCONTINUATION AFTER THEIR USE AS INITIAL BRIDGING THERAPY IN RHEUMATOID ARTHRITIS PATIENTS IN OBSERVATIONAL COHORTS AND CLINICAL TRIALS

Background

Glucocorticoids (GC) are widely used for the initial treatment of rheumatoid arthritis (RA), to induce rapid suppression of inflammation and clinical symptoms and thereby limit radiographic damage progression. There are concerns that GC use in the long term is associated with a dose and duration dependent risk of serious side effects. Therefore, international guidelines have recommended to start GC when initiating a csDMARD, but to discontinue GC as rapidly as clinically feasible, preferably within 3 months (bridging therapy). In contrast, due to the concerns of GC side effects, the ACR guidelines published in 2021 conditionally recommend to start csDMARD monotherapy without GC bridging therapy.

Objectives

We aim to evaluate the success rate of GC discontinuation after using temporary GC as part of initial therapy (‘bridging’) both in observational cohorts and clinical trials in newly diagnosed RA patients.

Methods

Systematic literature searches were conducted to identify observational cohorts (scoping search) and clinical trials (in-depth search) that included RA patients who were treated with initial GC bridging therapy. GC bridging was defined as oral or intramuscular GC treatment that was discontinued within one year, alongside conventional DMARD therapy. Patient percentages still or again using GC were considered to represent the reverse of successful discontinuation. Random-effects meta-analyses were performed stratified by time point.

Results

The literature search on observational cohort studies could not identify any study answering the research question, since it remained unclear which patients had received GC as part of the initial treatment. The literature search for clinical trials identified 7160 abstracts, resulting in 10 included studies, with varying type and dose of GC and varying tapering schedules (Table 1). Of these included studies, 4 reported sufficient data on GC discontinuation or GC use after the bridging phase. The pooled proportion of patients who were still using GC was 22% (95% Confidence Interval (CI) 8; 37, based on 4 trials) at 12 months and 10% at 24 months (95% CI -1; 22, based on 2 trials) (Figure 1). Thus, the vast majority had stopped GC. Heterogeneity was substantial (I2 ≥ 65%).

Table 1.

Overview of included clinical trials.

Study (publication year)Tapering schedule (mg/day)COBRA (1997)In 7 weeks to 7.5. Stop after 28 weeks.*BeSt (2005)In 7 weeks to 7.5. Stop in 8 weeks after week 28 if DAS persistently ≤2.4IDEA (2014)N.A.COBRA-light (2015)arm 1: in 7 weeks to 7.5 arm 2: in 9 weeks to 7.5 Stop after 32 weeks if DAS<1.6.IMPROVED (2014)In 7 weeks to 7.5. Stop after 20 weeks if DAS <1.6 at 4 months.ARCTIC (2016)In 7 weeks to 0 if DAS <1.6 and no swollen joints present.tREACH (2013)In 10 weeks to 0.*CareRA (2017)- in 7 weeks to 7.5, further tapered from week 28, stop after 34 weeks.- Classic- in 6 weeks to 5, further tapered from week 28, stop after 34 weeks.- Slim- in 6 weeks to 5, further tapered from week 28, stop after 34 weeks.- Avant gardeAll if DAS28(CRP) ≤3.2.Hua et al. (2020)Tapering after 4 months to 5, stop after 6 months.*NORD-STAR (2020) - arm 1A (oral prednisolone)In 9 weeks to 5. Stop after 9 months.*

DAS=disease activity score; mg=milligram; N.A.=not applicable.

*GC tapered and stopped according to protocol, not depending on disease activity score.

Conclusion

The success rate of GC discontinuation after bridging as part of initial treatment of RA has been described in a limited number of studies. Reports on observational cohorts did not answer the research question and in clinical trials reports, GC (dis)continuation data were also scarce. However, the available data show that GC can be discontinued successfully in a large majority of patients. The paucity of data also reveals that more efforts are needed to provide data towards identifying the optimal GC bridging and discontinuation strategy, combining Treatment to Target with Starting to Stop.

Acknowledgements

We would like to thank J.W. Schoones for his help and expertise in the systematic literature search.

Disclosure of Interests

Lotte van Ouwerkerk: None declared, Andriko Palmowski: None declared, Isabell Nevins: None declared, Frank Buttgereit Consultant of: Consultant of AstraZeneca, AbbVie, Grünenthal, Horizon Pharma, Pfizer, and Roche., Grant/research support from: Grant/research support from AbbVie, Horizon Pharma, Pfizer, and Roche., Patrick Verschueren Consultant of: Was consultant for ABBVIE, BMS, Celltrion, Eli Lilly, Galapagos, Gilead, Nordic Pharma, Pfizer and UCB., Employee of: Holds the Pfizer Chair Early Rheumatoid Arthritis Management at KU Leuven., Josef Smolen: None declared, Robert B.M. Landewé Shareholder of: Shareholder of: Director of Rheumatology Consultancy BV., Consultant of: Consultant of: Honoraria from AbbVie, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Eli-Lilly, Novartis, Pfizer, UCB Pharma., Hans Bijlsma Consultant of: Consultant for Galapagos, Lilly and Sun., Grant/research support from: Received study grants from AbbVie and Roche., Andreas Kerschbaumer: None declared, Rene Westhovens Consultant of: Was consultant for Celltrion, Galapagos and Gilead., Thomas Huizinga: None declared, Cornelia Allaart Grant/research support from: Received study grants for BeSt and IMPROVED from Centocor Inc. (now Janssen) and AbbVie, respectively., Sytske Anne Bergstra Grant/research support from: Received an ASPIRE grant from Pfizer.

Enzyme functionalized microgels enable precise regulation of dissolved oxygen and anaerobe culture

Anaerobes are a major constituent of the gut microbiome and profoundly influence the overall health of humans. However, the lack of a simple, cost-effective, and scalable system that mimics the anaerobic conditions of the human gut is hindering research on the gut microbiome and the development of therapeutics. Here, we address this gap by using glucose oxidase and catalase containing gelatin microparticles (GOx-CAT-GMPs) to precisely regulate dissolved oxygen concentration [O2] via GOx-mediated consumption of oxygen. Fluorescence images generated using conjugated polymer afterglow nanoparticles showed that [O2] can be tuned from 257.9 ​± ​6.2 to 0.0 ​± ​4.0 ​μM using GOx-CAT-GMPs. Moreover, when the obligate anaerobe Bacteroides thetaiotaomicron was inoculated in media containing GOx-CAT-GMPs, bacterial growth under ambient oxygen was comparable to control conditions in an anaerobic chamber (5.4 ​× ​105 and 8.8 ​× ​105 colony forming units mL-1, respectively). Finally, incorporating GOx-CAT-GMPs into a bioreactor that permitted continuous radial diffusion of oxygen and glucose generated a gut-mimetic [O2] gradient of 132.4 ​± ​2.6 ​μM in the outer ring of the reactor to 7.9 ​± ​1.7 ​μM at the core. Collectively, these results indicate that GOx-CAT-GMPs are highly effective oxygen-regulating materials. These materials can potentially be leveraged to advance gut microbiome research and fecal microbiota transplantation, particularly in low-resource settings.

Shape memory polymers with enhanced visibility for magnetic resonance- and X-ray imaging modalities

Currently, monitoring of minimally invasive medical devices is performed using fluoroscopy. The risks associated with fluoroscopy, including increased risk of cancer, make this method especially unsuitable for pediatric device delivery and follow-up procedures. A more suitable method is magnetic resonance (MR) imaging, which makes use of harmless magnetic fields rather than ionizing radiation when imaging the patient; this method is safer for both the patient and the performing technicians. Unfortunately, there is a lack of research available on bulk polymeric materials to enhance MR-visibility for use in medical devices. Here we show the incorporation of both physical and chemical modifying agents for the enhancement of both MR and X-ray visibility. Through the incorporation of these additives, we are able to control shape recovery of the polymer without sacrificing the thermal transition temperatures or the mechanical properties. For long-term implantation, these MR-visible materials do not have altered degradation profiles, and the release of additives is well below significant thresholds for daily dosages of MR-visible compounds. We anticipate our materials to be a starting point for safer, MR-visible medical devices incorporating polymeric components.

STATEMENT OF SIGNIFICANCE

Shape memory polymers (SMPs) are polymeric materials with unique shape recovery abilities that are being considered for use in biomedical and medical device applications. This paper presents a methodology for the development of MR and X-ray visible SMPs using either a chemically loaded or physical loaded method during polymer synthesis. Such knowledge is imperative for the development and clinical application of SMPs for biomedical devices, specifically for minimally-invasive vascular occlusion treatments, and while there are studies pertaining to the visibility of polymeric particles, little work has been performed on the utility of biomaterials intended for medical devices and the impact of how adding multiple functionalities, such as imaging, may impact material safety and degradation.

Treat-to-target (T2T) recommendations for gout

OBJECTIVES

The treat-to-target (T2T) concept has been applied successfully in several inflammatory rheumatic diseases. Gout is a chronic disease with a high burden of pain and inflammation. Because the pathogenesis of gout is strongly related to serum urate levels, gout may be an ideal disease in which to apply a T2T approach. Our aim was to develop international T2T recommendations for patients with gout.

METHODS

A committee of experts with experience in gout agreed upon potential targets and outcomes, which was the basis for the systematic literature search. Eleven rheumatologists, one cardiologist, one nephrologist, one general practitioner and one patient met in October 2015 to develop T2T recommendations based on the available scientific evidence. Levels of evidence, strength of recommendations and levels of agreement were derived.

RESULTS

Although no randomised trial was identified in which a comparison with standard treatment or an evaluation of a T2T approach had been performed in patients with gout, indirect evidence was provided to focus on targets such as normalisation of serum urate levels. The expert group developed four overarching principles and nine T2T recommendations. They considered dissolution of crystals and prevention of flares to be fundamental; patient education, ensuring adherence to medications and monitoring of serum urate levels were also considered to be of major importance.

CONCLUSIONS

This is the first application of the T2T approach developed for gout. Since no publication reports a trial comparing treatment strategies for gout, highly credible overarching principles and level D expert recommendations were created and agreed upon.

Opportunistic infections and biologic therapies in immune-mediated inflammatory diseases: consensus recommendations for infection reporting during clinical trials and postmarketing surveillance

No consensus has previously been formed regarding the types and presentations of infectious pathogens to be considered as ‘opportunistic infections’ (OIs) within the setting of biologic therapy. We systematically reviewed published literature reporting OIs in the setting of biologic therapy for inflammatory diseases. The review sought to describe the OI definitions used within these studies and the types of OIs reported. These findings informed a consensus committee (infectious diseases and rheumatology specialists) in deliberations regarding the development of a candidate list of infections that should be considered as OIs in the setting of biologic therapy. We reviewed 368 clinical trials (randomised controlled/long-term extension), 195 observational studies and numerous case reports/series. Only 11 observational studies defined OIs within their methods; no consistent OI definition was identified across studies. Across all study formats, the most numerous OIs reported were granulomatous infections. The consensus group developed a working definition for OIs as ‘indicator’ infections, defined as specific pathogens or presentations of pathogens that ‘indicate’ the likelihood of an alteration in host immunity in the setting of biologic therapy. Using this framework, consensus was reached upon a list of OIs and case-definitions for their reporting during clinical trials and other studies. Prior studies of OIs in the setting of biologic therapy have used inconsistent definitions. The consensus committee reached agreement upon an OI definition, developed case definitions for reporting of each pathogen, and recommended these be used in future studies to facilitate comparison of infection risk between biologic therapies.