Assessing the effects of distinct biologic therapies on rheumatoid arthritis pain by nociceptive, neuropathic and nociplastic pain components: a randomised feasibility study

BACKGROUND

Pain management is a major unmet need in people with rheumatoid arthritis (RA). Although many patients are treated with disease modifying anti-rheumatic drugs (DMARDS), including biologic therapies, many people with RA continue to experience significant pain. We aimed to determine whether performing a comprehensive pain evaluation is feasible in people with active RA receiving conventional DMARDs and biologic therapies.

METHODS

The BIORA-PAIN feasibility study was an open-label, randomised trial, which recruited participants suitable for treatment with biologic therapy. The primary feasibility outcomes were recruitment, randomisation and retention of eligible participants. All participants underwent pain assessment for nociceptive, neuropathic and nociplastic pain during the 12-month study period, with quarterly assessments for VAS (Visual Analogue Scale) pain, painDETECT and QST (quantitative sensory testing). This trial was registered in clinicaltrials.gov NCT04255134.

RESULTS

During the study period, 93 participants were screened of whom 25 were eligible: 13 were randomised to adalimumab and 12 to abatacept. Participant recruitment was lower than expected due to the COVID-19 pandemic. Pain assessments were practical in the clinical trial setting. An improvement was observed for VAS pain from baseline over 12 months, with a mean (SEM) of 3.7 (0.82) in the abatacept group and 2.3 (1.1) in the adalimumab group. There was a reduction in painDETECT and improvement in QST measures in both treatment groups during the study. Participant feedback included that some of the questionnaire-based pain assessments were lengthy and overlapped in their content. Adverse events were similar in both groups. There was one death due to COVID-19.

CONCLUSIONS

This first-ever feasibility study of a randomised controlled trial assessing distinct modalities of pain in RA met its progression criteria. This study demonstrates that it is feasible to recruit and assess participants with active RA for specific modalities of pain, including nociceptive, neuropathic and nociplastic elements. Our data suggests that it is possible to stratify people for RA based on pain features. The differences in pain outcomes between abatacept and adalimumab treated groups warrant further investigation.

TRIAL REGISTRATION

NCT04255134, Registered on Feb 5, 2020.

Treatment of gangrenous digit-threatening paraneoplastic acrocyanosis with vasodilator therapy

A man in his 70s, with a recent diagnosis of transitional cell carcinoma of the bladder, reported a 2-month history of discolouration, pain and paraesthesia affecting his fingers. Clinical assessment noted peripheral acrocyanosis with areas of digital ulceration and gangrene. Following further work-up to evaluate potential causes, he was diagnosed with paraneoplastic acrocyanosis. He proceeded to undergo robotic cystoprostatectomy and received adjuvant chemotherapy for the management of his cancer. In parallel to the chemotherapy, vasodilatory therapy was administered as two courses of intravenous synthetic prostacyclin analogue iloprost along with sildenafil. This resulted in a significant improvement in digital pain and gangrene with healing of ulceration.

Lingual Raynaud's phenomenon: a rare presentation

A woman in her mid-60s presented to transient ischaemic attack (TIA) clinic with a 3-year history of intermittent sensory changes and white discolouration affecting the left side of her tongue. Following extensive investigation, a provisional diagnosis of posterior circulation TIA was made, and the patient was commenced on clopidogrel therapy. Despite anti-platelet treatment, she continued to have identical episodic symptoms. She was referred to the rheumatology team for assessment of possible underlying autoimmune pathology. On rheumatology assessment, the patient reported colour changes on the tongue, associated with numbness, followed by paraesthesia of the affected area. A comprehensive assessment excluded secondary causes and a diagnosis of primary Raynaud's phenomenon of the tongue was made. The diagnosis of TIA was revoked. This case illustrates a rare presentation of a common condition and highlights the sensory symptoms which are associated with Raynaud's phenomenon.

P31 Chicken or egg: Inflammatory bowel disease in ankylosing spondylitis

Introduction/Background

Inflammatory bowel disease (IBD) is an important extra-articular manifestation of spondyloarthritis (SpA) and has significant implications on patient quality of life and rheumatological management. We report a case of severe Crohn’s disease in a patient with axial spondyloarthritis (AxSpA) and secondary non-response to Tumour Necrosis Factor inhibition (TNFi). We will focus on the rationale for treatment decisions and the important factors to consider in patients with co-existent IBD and SpA.

Description/Method

A 34-year-old Caucasian gentleman presented to the emergency department (ED) with a 3-week history of diarrhoea and abdominal pain. He had a background of AxSpA which was diagnosed three years previously following referral to rheumatology clinic. At diagnosis, he reported cervical and lumbar back pain and previous Achilles tendonitis. MRI showed bilateral sacroiliitis and thoracolumbar Romanus lesions. HLA-B27 was negative. Naproxen and adalimumab resulted in a significant initial improvement in symptoms however following 18 months of therapy (with which the patient was compliant), he noted worsening pain and stiffness affecting his right hip, cervical spine and sacroiliac joints.

On ED assessment, the patient reported upper abdominal pain and four-to-five episodes of loose, watery stools per day. His CRP was 45mg/L and a CT abdomen-pelvis showed oedema and mucosal enhancement of the distal ileum, an inflammatory phlegmon in the right iliac fossa and low-grade obstruction of the small bowel. Features were suggestive of active Crohn’s disease (CD). The patient was admitted under the gastroenterology team and commenced on intravenous antibiotics and exclusive enteral nutrition (EEN). After two days of inpatient treatment, he was discharged.

The patient was discussed in the gastroenterology biologics meeting. Bloods showed subtherapeutic adalimumab levels with positive anti-drug antibodies (ADA). He was therefore switched to infliximab in combination with methotrexate. Shortly after receiving his first dose of infliximab, he represented to hospital with ongoing right iliac fossa pain and low-grade fevers. His CRP was 77mg/L and a CT abdomen-pelvis showed persistence of the inflammatory phlegmon and distal ileitis. During a second five-day inpatient admission, he received two further doses of infliximab and a 10-day course of antibiotics. Following discharge, he received a fourth dose of infliximab and is clinically improving with resolving abdominal symptoms, inflammatory markers and joint pain.

Discussion/Results

SpA and IBD are auto-inflammatory conditions with epidemiological, genetic and pathological links. Patients with SpA have a 4-14% lifetime risk of IBD and a 60% prevalence of subclinical gut inflammation. IBD can precede, develop in synchrony or follow the onset of joint symptoms with increased risk in patients with higher disease activity. Dysregulated type 3 immunity is implicated in both conditions however the pathological link between gut and joint inflammation is poorly understood. Furthermore, important differences in immunopathogenesis exist with notable implications for biological treatments, for example IL-17 inhibition is an effective treatment for AxSpA but worsens IBD.

This case highlights some of the differences in the immunomodulatory and biological treatment of AxSpA and IBD. In CD, methotrexate is commonly used to maintain remission. This contrasts to the guidance for AxSpA where the use of conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) is not recommended. As illustrated in this case, TNFi are used in the treatment of both AxSpA and IBD however infliximab dosing in IBD is conventionally higher with doses of 5mg/kg given at weeks 0, 2, 6 and then 8-weekly.

In this case, the patient developed secondary non-response to TNFi due to the presence of functional ADA. ADA are associated with lower serum drug levels, loss of therapeutic response, infusion reactions and discontinuation of TNFi. In some case series, ADA are present in 15-30% of patients on adalimumab. Co-prescription of immunomodulatory therapies are associated with improved pharmacokinetics of TNFi, lower risk of ADA and reduced risk for treatment failure. This is particularly important when switching between TNFis when there is increased risk of ADA with second-line TNFi agents. As illustrated in this case, gastroenterology guidelines recommend the measurement of adalimumab levels and ADA to guide treatment decisions. This is an area in rheumatological practice where consensus is required.

Key learning points/Conclusion

1. IBD is an important extra-articular manifestation of SpA that rheumatologists should be alert for. The link between joint and gut inflammation in SpA is an area of ongoing research and has important treatment implications for patients with co-existent disease. When IBD is present, the choice of disease modifying therapy can differ.

2. TNFi are used in the management of both CD and AxSpA however there are differences in dose selection and dose titration between the two conditions. Higher doses are typically used in IBD.

3. In patients with secondary non-response to TNFi, the British Society for Gastroenterology (BSG) guidelines suggest measurement of drug levels and ADAs to guide further management. In patients with adequate drug concentration or positive ADAs, the BSG guidelines suggest switching to an alternative TNFi or alternative class. In inflammatory rheumatic disease, clear clinical guidance does not yet exist despite a growing body of evidence supporting the use of therapeutic drug monitoring in some scenarios.

4. In patients with CD who formed ADA against one TNFi, gastroenterology guidelines recommend the co-prescription of an immunomodulatory medication to reduce the risk of non-response to a second TNFi. Current rheumatology guidelines do not advocate this approach and this is an area of uncertainty in the management of AxSpA patients.

5. In all cases of co-existent IBD and SpA, close collaboration between rheumatology and gastroenterology colleagues is of upmost importance.

What is the full potential of baricitinib in treating patients with COVID-19?

This has been removed as per the suggestions from the editorsEditorial.

Associated outcomes of various iterations of the dedicated orthopaedic trauma room: a literature review

<abstract> <p>Scheduling urgent, orthopaedic trauma cases has long been a challenge for health care institutions. Traditionally, these cases are scheduled for an operating room (OR) slot in the middle of the night, by “bumping” elective cases to later in the day, by adding a case on after-hours, or by delaying the case for several days until an OR becomes available. As a solution to the challenges facing traditional scheduling modules, trauma centers around the country have instituted the use of a dedicated orthopaedic trauma room (DOTR). While there are multiple studies analyzing the effects of DOTRs on various outcomes, there is not a centralized review of these studies. This paper will serve as a review of the various models of the DOTR as well as the effect of the DOTR on after-hours procedures, time to surgery (TTS), duration of surgery (DOS), length of stay (LOS), cost, and surgical complications. An extensive review of the literature was performed through PubMed and Embase. 17 studies were found to meet eligibility criteria. This review suggests that DOTRs have favorable effects on after-hours procedures, cost, and surgical complications. There is variability in the data regarding the effect on TTS, DOS, and LOS.</p> </abstract>

Lack of Effect of Propranolol on the Reconsolidation of Conditioned Fear Memory due to a Failure to Engage Memory Destabilisation

The prospect of exploiting memory reconsolidation to treat mental health disorders has received great research interest, particularly following demonstrations that the β-adrenergic receptor antagonist propranolol, which is safe for use in humans, can disrupt the reconsolidation of pavlovian conditioned fear memories. However, recent studies have failed to replicate the effects of propranolol on fear memory reconsolidation, and have questioned whether treatments based upon reconsolidation blockade would be robust enough for clinical translation. It remains possible, though, that studies reporting no effect of propranolol on memory reconsolidation could be due to a failure to engage the memory destabilisation process, which is necessary for the memory to become susceptible to disruption with amnestic agents. Demonstrating that memory destabilisation has not been engaged is challenging when only using behavioural measures, but there are molecular correlates of memory destabilisation that can be used to determine whether memory lability has been induced. Here, we attempted to replicate the classic finding that systemic administration of propranolol disrupts the reconsolidation of a pavlovian auditory fear memory. Following a failure to replicate, we manipulated the parameters of the memory reactivation session to enhance prediction error in an attempt to overcome the boundary conditions of reconsolidation. On finding no disruption of memory despite these manipulations, we examined the expression of the post-synaptic density protein Shank in the basolateral amygdala. Degradation of Shank has been shown to correlate with the induction of memory lability, but we found no effect on Shank expression, consistent with the lack of observed behavioural effects.

POS1195 ASSESSING ANTIBODY STATUS FOR SARS-CoV-2 IN PEOPLE WITH CORONAVIRUS INFECTION: A TIME COURSE STUDY IN PEOPLE WITH AUTOIMMUNE CONDITIONS

Background:

With the emergence of the global coronavirus pandemic, increasing concerns have been raised about the course of SARS-CoV-2 infection in people with immune-mediated disorders.

Objectives:

In this study we aimed to assess the time course of proven SARS-CoV-2 infection, development of humoral immunity with detectable antibodies to the virus and evaluate any changes in antibody titres over time.

Methods:

We recruited 114 participants in total who had potential symptoms of Covid-19 infection. Participants were recruited from rheumatology or inflammatory bowel disease (IBD) clinics from their records who attended a London Teaching hospital for care. Ethical Approval was in place for the study. Age- and gender- matched control participants without any underlying rheumatological condition/IBD were recruited as a comparator group. Clinical symptoms for Covid-19 infection were assessed using the Covid-19 Rheumatology Global Alliance assessment criteria (https://rheum-covid.org/). Information about Disease Modifying Anti-Rheumatic Drug (DMARD) drug use was also recorded. Participants’ serum samples were collected for quantitative serological assessment of antibodies to SARS-CoV-2 using the Mologic Enzyme-Linked ImmunoSorbent Assay (ELISA) IgG kit. The optical density values were plotted aganist time using a normalisation as previously described (1). A cut-off above 0 indicated positive serology.

Results:

A total of 114 subjects were recruited into the study. Subjects were recruited if they had suspected Covid symptoms. Of the population recruited, the total number subsequently testing positive for SARS-CoV-2 was n=59 (either on serology or PCR). The number of subjects with autoimmune conditions diagnosed with Covid-19 was 32, with 30 subjects being symptomatic (the asymptomatic 2 subjects were excluded from further analyses). Of the 30 symptomatic subjects, the average age was 56, with a female to male ratio of 19:11. The most prevalent diagnoses were RA (30%), Psoriatic Arthritis (16.7%), SLE (10%), sarcoidosis 10%), Ulcerative Colitis (10%), Crohn’s disease (10%), seronegative inflammatory arthritis (6.7%), Sjogren’s (3.3%) and Juvenile Idiopathic Arthritis (3.3%). The majority were on csDMARDs (60%), biologic DMARDs (20%), tacrolimus (3.3%) and the remaining 16.7% were not on DMARDs. Most subjects required treatment in hospital (56.7%), a smaller number required high dependency care (6.7%) and the rest were treated at home (36.6%). The majority required no oxygen (63.3%), with a further 30% requiring oxygen and 6.7% needed more supportive care i.e. CPAP/ventilation. We also had a matched control group (n=29) of subjects who developed SARS-CoV-2 but had no underlying autoimmune conditions. These subjects had a mean age of 55, female: male ratio 18: 11. Of these 31% had home management, 55.2% had ward level treatments and 13.8% had intensive care treatment. Of the controls, 48.3% did not require oxygen, 37.9% needed simple oxygen and 13.8% were on CPAP. A total of 35 subjects from the original study have attended for follow-up visits. Antibody titres for IgG using the Mologic ELISA detection assay were compared at two visits for the control and autoimmune group. Results showed that subjects with autoimmune conditions and those without who developed SARS-CoV-2 showed very similar antibody titres by optical density (OD) (Figure 1) and maintained antibody responses beyond 6 months in most cases.

Conclusion:

Serological assays can assist in the understanding of disease severity of SAR-CoV-2 infection. They can be a useful tool for patient surveillance, especially in people who are on immunomodulatory drugs and are being seen in Rheumatology services. Future work is needed to assess the duration and potential protective nature of humoral antibody responses to SARS-CoV-2.

References:

[1]Staines HM, Kirwan D, Clark DJ et al. Dynamics of IgG seroconversion and pathophysiology of COVID:19 infections. medRxiv preprint doi: https://doi.org/10.1101/2020.06.07.20124636.

Disclosure of Interests:

Kathryn Biddle: None declared, Soraya Koushesh: None declared, Anna Blundell: None declared, David Clark: None declared, Sanjeev Krishna: None declared, Nidhi Sofat Consultant of: Advisory work for Pfizer and Eli Lilly, Grant/research support from: Received grants from Bristol Myers Squibb and Pfizer for Investigator Initiated Studies.

P057 What is the course of SARS-CoV-2 infection in people with autoimmune conditions on immunomodulators in comparison to people without autoimmune disease?

Background/Aims 

The pathogenesis and outcomes of COVID-19 in patients with autoimmune disease remains poorly understood. We aimed to evaluate clinical features and antibody mediated immunity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in subjects with autoimmune disease, compared to those without.

Methods 

Patients who developed COVID-19 were identified through the audit department/clinician identification. In total, there were 48 subjects with autoimmune disease and confirmed COVID-19. Of these patients, 6 had sadly died. In recruited patients, clinical data regarding COVID-19 symptoms, treatment and outcomes were collected. Blood was taken for quantitative serology testing against SARS-CoV-2 using the Mologic test kit. A binary logistic regression was used to compare serology results in subjects with and without autoimmune diagnoses.

Results 

Our sample included 103 participants. 26 subjects with autoimmune disease and confirmed COVID-19 were recruited, the most common diagnoses being rheumatoid arthritis (27%), psoriatic arthritis (19%) and inflammatory bowel disease (15%). 21 of 28 participants were on immunomodulatory medications including 16 on conventional synthetic disease modifying anti-rheumatic drugs (DMARDs), four on biologic DMARDs and one on tacrolimus. We age- and gender-matched these subjects to 26 without autoimmune disease with confirmed SARS-CoV-2 infection. 17 further subjects reported viral-symptoms during the COVID-19 pandemic but had negative serology. 30 subjects had rheumatic conditions but denied symptoms suggestive of COVID-19. 4 of the asymptomatic patients tested positive for COVID-19 on serology. 23 stored serum samples, obtained before 2019, were all negative for antibodies against SARS-CoV-2. In patients with confirmed COVID-19, clinical features and serology were compared in those with and without autoimmune disease. Logistic regression showed a significant impact of COVID-19 severity on antibody titres in people with and without autoimmune disease (p = 0.003 and <0.001 respectively). In both mild and severe disease, autoimmunity had no effect on antibody titres (p = 0.253 and 0.119 respectively).

Conclusion 

People with and without autoimmune disease presented with similar symptoms of COVID-19. In our sample, subjects with autoimmune disease were less likely to be hospitalised or require respiratory support. Serology revealed no difference in antibody titres against SARS-CoV-2 in participants with and without autoimmune disease. P057 Table 1:

O03 A case of hyperinflammatory COVID-19 that responded to tocilizumab therapy

Case report - Introduction

Coronavirus disease 19 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2), has reached pandemic level and led to over 46,000 deaths in the UK. COVID-19 is primarily a respiratory illness and 10-20% of infected individuals develop severe disease with interstitial pneumonia or acute respiratory distress syndrome (ARDS). In this subgroup of patients, severe clinical manifestations are postulated to result from a hyperactive immune response. This has led to the proposal that immunomodulatory medications could be used for the treatment of COVID-19. Here, we report a case of COVID-19 that was treated with the IL-6 inhibitor, tocilizumab.

Case report - Case description

A 54-year-old Middle Eastern woman presented to A&E with a one-week history of fever, cough, headache and ageusia. Her past medical history was significant for asthma, chronic headaches, gastro-oesophageal reflux syndrome and subarachnoid haemorrhage. On presentation, she had a low-grade temperature (37.8 °C) but her observations were otherwise normal, and her oxygen saturations were 99% on room air. Examination revealed right basal chest crackles. Bloods showed a mild lymphopenia (0.9x109/l) and a raised CRP (82mg/l) and a chest radiograph demonstrated bibasal shadowing. The patient was diagnosed with probable COVID-19 and discharged with a course of oral doxycycline and a plan for review in the ambulatory unit the following day. When reviewed the next day, her oxygen saturations had fallen to 90% on room air. At this point, her SARS-CoV-2 assay had been resulted as positive and a decision was made to admit her for oxygen therapy.

The patient continued to deteriorate despite optimal supportive therapy and the addition of intravenous benzylpenicillin for possible superadded bacterial infection. On day 7 of admission, her respiratory rate was 32-38 breaths per minute, and she required 13l/min of oxygen. Her bloods revealed CRP 474mg/L, D dimer &gt;6000 ng/ml, ferritin 224 μg/L, neutrophils 9.5x109/l and lymphocytes 0.6 x109/l. There were no signs of superadded bacterial infection despite a thorough infection screen. Given her clinical deterioration, she was reviewed by the critical care team for consideration of transfer to higher-level care. The ward team decided to administer a single dose of the anti-IL-6 agent tocilizumab for the treatment of a cytokine storm secondary to COVID-19 infection. 

Within 24 hours of tocilizumab treatment, her oxygen requirements fell to 5l/min and her work of breathing significantly improved. On day 15 of admission, she was discharged with saturations of 92% on room air. 

Case report - Discussion

The patient described in this case showed significant clinical deterioration with features suggestive of cytokine storm secondary to COVID-19. IL-6 is thought to be a key cytokine responsible for initiating the acute phase response and we postulate that IL-6 levels were raised in this patient. Unfortunately, we did not have the assay available to measure this. The treating clinical team decided to prescribe a single dose of tocilizumab on a compassionate use basis. This resulted in a rapid clinical improvement and the patient was subsequently discharged without the need for intensive care. In this case, we propose that tocilizumab inhibited further cytokine activation and prevented the positive feedback loop of inflammation that can otherwise result in rapid clinical deterioration.

There are several interesting points to be noted from this case. In this patient, tocilizumab resulted in a rapid reduction in CRP levels. This is thought to correspond to the inhibition of IL-6 mediated release of acute phase proteins by the liver. Therefore, it should be noted that post-tocilizumab treatment, patients should be closely monitored for superadded bacterial infection as they may not mount a full immune response.

Larger trials of tocilizumab for the treatment of COVID-19 are currently underway and are required to confirm the efficacy of IL-6 inhibition for COVID-19. The phase III COVACTA trial of tocilizumab in COVID-19 patients did not meet its primary endpoint of improved clinical status however a trend towards shorter hospital admissions was seen. Further studies are ongoing to investigate the role of tocilizumab in other treatment settings, including in combination with an antiviral medication. Further information is required to determine which patients should receive immunomodulatory medications and at which point in their illness. Data is also needed to understand the most efficacious dosing regimen for tocilizumab and its side-effect profile in COVID-19 patients.

Case report - Key learning points

The COVID-19 pandemic has affected millions of people worldwide and has led to an unprecedented effort from the scientific community to understand the pathophysiology of the disease and to find effective treatments. Emerging evidence suggests that SARS-CoV-2 can induce a hyperactive immune response in a subgroup of patients who develop highly elevated levels of acute phase proteins. It has been proposed that the overactive immune response is responsible for some of the severe clinical manifestations seen and this has led to the suggestion that immunomodulatory medications could be used for the treatment of COVID-19.

Indeed, dexamethasone has been shown to be an effective treatment and other immunomodulatory medications including hydroxychloroquine, the IL-1 inhibitor anakinra and JAK-kinase inhibitors are currently being trialled for the treatment of COVID-19. This case highlights the clinical and biochemical features of a patient who developed features suggestive of a cytokine storm secondary to COVID-19 and who responded to treatment with the IL-6 inhibitor tocilizumab. Further work is required to understand the role of immunomodulatory medications for the management of COVID-19 infection.

Post-Transplantation Diabetes Mellitus

Solid organ transplantation (SOT) is an established therapeutic option for chronic disease resulting from end-stage organ dysfunction. Long-term use of immunosuppression is associated with post-transplantation diabetes mellitus (PTDM), placing patients at increased risk of infections, cardiovascular disease and mortality. The incidence rates for PTDM have varied from 10 to 40% between different studies. Diagnostic criteria have evolved over the years, as a greater understating of PTDM has been reached. There are differences in pathophysiology and clinical course of type 2 diabetes and PTDM. Hence, managing this condition can be a challenge for a diabetes physician, as there are several factors to consider when tailoring therapy for post-transplant patients to achieve better glycaemic as well as long-term transplant outcomes. This article is a detailed review of PTDM, examining the pathogenesis, diagnostic criteria and management in light of the current evidence. The therapeutic options are discussed in the context of their safety and potential drug-drug interactions with immunosuppressive agents.

Naming-speed processes, timing, and reading: a conceptual review

This article integrates the findings in the special issue with a comprehensive review of the evidence for seven central questions about the role of naming-speed deficits in developmental reading disabilities. Cross-sectional, longitudinal, and cross-linguistic research on naming-speed processes, timing processes, and reading is presented. An evolving model of visual naming illustrates areas of difference and areas of overlap between naming speed and phonology in their underlying requirements. Work in the cognitive neurosciences is used to explore two nonexclusive hypotheses about the putative links between naming speed and reading processes and about the sources of disruption that may cause subtypes of reading disabilities predicted by the double-deficit hypothesis. Finally, the implications of the work in this special issue for diagnosis and intervention are elaborated.