Wunderlich syndrome as a rare complication of polyarteritis nodosa: a case report

Spontaneous subcapsular and perirenal hemorrhage, known as Wunderlich syndrome (WS), is a rare clinical manifestation of polyarteritis nodosa (PAN). We report a case of a 48-year-old male with a history of recurrent episodes of leg muscle tenderness and dysesthesia, bilateral flank pain, painful nodular skin lesions in the lower limbs, weight loss, and difficult-to-control arterial hypertension. The abdominopelvic computed tomography angiography showed a large left perirenal hematoma, leading to the patient's admission to the intensive care unit. After the exclusion of infectious or neoplastic foci, the patient was diagnosed with PAN and started intravenous methylprednisolone pulses with a good response. Since WS is a rare initial clinical manifestation of PAN, an early diagnosis and aggressive treatment will significantly improve clinical outcomes.

Mechanical osteoarthritis of the hip in a one medicine concept: a narrative review

Human and veterinary medicine have historically presented many medical areas of potential synergy and convergence. Mechanical osteoarthritis (MOA) is characterized by a gradual complex imbalance between cartilage production, loss, and derangement. Any joint instability that results in an abnormal overload of the joint surface can trigger MOA. As MOA has a prevailing mechanical aetiology, treatment effectiveness can only be accomplished if altered joint mechanics and mechanosensitive pathways are normalized and restored. Otherwise, the inflammatory cascade of osteoarthritis will be initiated, and the changes may become irreversible. The management of the disease using non-steroidal anti-inflammatory drugs, analgesics, physical therapy, diet changes, or nutraceuticals is conservative and less effective. MOA is a determinant factor for the development of hip dysplasia in both humans and dogs. Hip dysplasia is a hereditary disease with a high incidence and, therefore, of great clinical importance due to the associated discomfort and significant functional limitations. Furthermore, on account of analogous human and canine hip dysplasia disease and under the One Medicine concept, unifying veterinary and human research could improve the well-being and health of both species, increasing the acknowledgement of shared diseases. Great success has been accomplished in humans regarding preventive conservative management of hip dysplasia and following One Medicine concept, similar measures would benefit dogs. Moreover, animal models have long been used to better understand the different diseases' mechanisms. Current research in animal models was addressed and the role of rabbit models in pathophysiologic studies and of the dog as a spontaneous animal model were highlighted, denoting the inexistence of rabbit functional models to investigate therapeutic approaches in hip MOA.

The REWRITE Study - REal-WoRld effectIveness of TrifluridinE/tipiracil in Patients with Previously Treated Metastatic Colorectal Cancer

AIMS

In the pivotal RECOURSE trial, trifluridine/tipiracil improved survival outcomes in refractory metastatic colorectal cancer (mCRC), while demonstrating an acceptable toxicity profile. Routine clinical practice evidence is important to support the ongoing value of recently approved medicines. Our objective was to assess the utilisation patterns and real-world effectiveness of trifluridine/tipiracil in previously treated mCRC patients.

MATERIALS AND METHODS

This was a retrospective observational study including consecutive patients who started trifluridine/tipiracil between 1 April 2018 and 30 September 2019 in the medical oncology departments of three major public hospitals in Portugal. The primary outcome measure was overall survival. Associations between overall survival and patient and tumour characteristics were assessed using multivariate Cox regression analyses.

RESULTS

In total, 111 patients were included in the study, with a mean age of 64 years. From these, 45.9% received two prior lines of treatment, 47.8% had three or more previous lines of treatment and 83.6% had Eastern Cooperative Oncology Group (ECOG) performance status 0-1 at baseline. The median duration of trifluridine/tipiracil treatment was 3.7 cycles (95% confidence interval 3.4-4.1). Most patients (80.4%) remained on their planned dose throughout the trifluridine/tipiracil treatment period, fulfilling 100% relative dose intensity. The median overall survival in the total study cohort was 7.9 months (95% confidence interval 6.4-9.8) and the median progression-free survival was 3.4 months (95% confidence interval 3.2-3.9). The median overall survival was significantly higher in patients with a normal serum lactate dehydrogenase (LDH) level (median overall survival 11.2 months for [135, 205] IU/l LDH [95% confidence interval 8.2-NR] and 13.6 months for [205, 251] IU/l LDH [95% confidence interval 8.2-NR]) and in better fitted (ECOG = 0-1) patients (median overall survival 8.0 months; 95% confidence interval 6.7-10.0). The median time to worsening performance status was 6.2 months (95% confidence interval 5.0-8.0). Treatment discontinuation due to adverse events was low (3.1%).

CONCLUSION

Our study confirms the effectiveness of trifluridine/tipiracil in real-life mCRC patients. Overall survival and progression-free survival outcomes are consistent with the efficacy profile reported in the earlier randomised RECOURSE clinical trial. Like other real-world studies, we found no additional safety concerns in the use of trifluridine/tipiracil.

Pathergy-like reaction induced by laser hair removal in a patient with Behçet disease

Behçet disease (BD) is a rare systemic vasculitis of unknown etiology, primarily characterized by recurrent oral aphthous ulcers, genital ulcers, uveitis, and skin lesions. Pathergy test positivity is a nonspecific inflammatory response of the skin to trauma and supports the diagnosis. Recently, new inducers of pathergy reactions have been identified, for example, the placement of dental braces and laser hair removal. Our clinical case highlights the importance of thinking about this potential pathergy inducer in BD patients, to improve their quality of life and avoid complications.

The data project: a shared approach between stakeholders of the healthcare system in definition of a therapeutic algorithm for inflammatory arthritis

Rheumatic musculoskeletal diseases or RMD [rheumatoid arthritis (RA) and spondyloarthritis (SpA)] are systemic inflammatory diseases for which there are no biomarkers capable of predicting treatments with a higher likelihood of response in naive patients. In addition, the expiration of the anti-TNF blocking drugs' patents has resulted in the availability of anti-TNF biosimilar drugs with the same efficacy and safety than originators but at significantly reduced prices. To guarantee a personalized therapeutic approach to RMD treatment, a board of rheumatologists and stakeholders from the Campania region, Italy, developed a clinically applicable arthritis therapeutic algorithm to guide rheumatologists (DATA project). The general methodology relied on a Delphi technique forecast to produce a set of statements that summarized the experts' consensus. Selected clinical scenarios were discussed in light of the available evidence, and there were two rounds of voting on the therapeutic approaches. Separate discussions were held regarding rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. The decision-making factors for each disease were clinical presentation, demographics, and comorbidities. In this paper, we describe a virtuous process between rheumatologists and healthcare system stakeholders that resulted in the development of a shared therapeutic algorithm for RMD patients naive to bDMARDs.

Effectiveness and safety profile of tofacitinib and baricitinib in rheumatoid arthritis patients: results from a 24-month real-life prospective study in Southern-Italy

The primary objectives of the study were to evaluate the efficacy and safety of tofacitinib and baricitinib up to 24 months of follow-up in patients with rheumatoid arthritis (RA) treated in Southern Italy. Patients' data, activity index, and clinimetric scores were collected at baseline (T0), six (T6), twelve (T12), and twenty-four (T24) months following treatment initiation. At six, twelve, and twenty-four months, adverse events and treatment cessation were also recorded. Sixty-eight patients (mean age: 62.2±10.9 years; mean RA duration: 15±9.6 years) were enrolled over a period of 12 weeks. At baseline, twenty-four patients (35.3%) were treated with tofacitinib, and forty-four patients (64.7%) were treated with baricitinib. The baseline mean disease activity was moderate as measured by DAS28- ESR (5.0±1.0), DAS 28 CRP (4.69±0.94), and SDAI (26.87±10.73) score. Before beginning JAKinhibs therapy, thirty-two patients (61.8%) were taking bDMARDs, while the remaining thirty-six (38.2%) were bDMARDs-naïve. The 24-month retention rate for JAKinhibs was 91.1%. Six months after beginning treatment with JAKinhibs, a statistically significant improvement was observed in all evaluated activity indices and clinimetric scores. Improvement was confirmed during the 12- and 24-month follow-up evaluations. The positive correlation between baseline-T6 SDAI delta and discontinuation of JAKinhibs (p=0.02) suggests that RA worsening in the first six months may be a predictor of therapy withdrawal. Patients with RA responded favorably to tofacitinib and baricitinib in this prospective, real-world study from a single center in Southern Italy. Efficacy was observed despite an underlying persistent and treatment-resistant disease.

Impact de l’infection par le SARS-CoV-2 sur l’activité de la maladie des patients atteints de rhumatisme psoriasique sous bDMARD : données réelles

Introduction

L’infection par le SARS-CoV-2 peut entraîner une inflammation sévère et il a été suggéré d’induire des poussées de rhumatisme psoriasique (RP). Cependant, l’impact sur l’activité de la maladie et la réponse aux DMARD biologiques modificateurs de la maladie (bDMARD) reste inconnu.

Patients et méthodes

Nous avons réalisé une analyse rétrospective incluant tous les patients atteints de RP, répondant aux critères CASPAR et sous biothérapie, suivis dans le service de rhumatologie d’un CHU universitaire tertiaire. Les données démographiques et cliniques, y compris la survenue d’une infection par le SARS-CoV-2, ont été collectées à partir de notre base de données nationale (reuma.pt). L’activité de la maladie (CDAI, SDAI, DAS28 4v, BASDAI, ASDAS) et les réponses aux bDMARD (réponses EULAR, ASDAS, ASAS, ACR et PsARC) ont été évaluées avant et après l’infection par le SARS-Cov-2.

Résultats

Au total, 102 patients atteints de RP ont été inclus. Cinquante-deux étaient des femmes (51 %). L’âge moyen était de 53 ± 11,09 ans et la durée médiane de la maladie était de 15 ans [min 2, max 47]. Au total, 54 (53 %) patients avaient une atteinte axiale prédominante, 26 (26 %) périphérique et 36 (37 %) enthésopathique. Le bDMARD le plus utilisé était l’étanercept (n = 28, 27,5 %) suivi de l’adalimumab (n = 22, 21,6 %) et du sécukinumab (n = 18, 17,6 %). La prévalence de l’infection par le SARS-CoV-2 était de 15,7 % (n = 16). Soixante-trois pour cent ont reçu le vaccin BNT162b2 (Pfizer/BioNtech), 31 % ont reçu l’ARNm-1273 (Moderna), 13 % ont reçu l’AZD1222 (AstraZeneca) et 13 % ont reçu l’AD26.COV2.S (Janssen/Johnson & Johnson). Soixante-trois pour cent étaient infectés avant toute vaccination, 13 % après la première dose et 25 % après la seconde. Les symptômes les plus fréquents étaient l’anosmie (65 %), la dysgueusie (56 %) et la toux (56 %). Tous les patients se sont complètement remis de l’infection, sans nécessiter d’hospitalisation. Quel que soit le score utilisé, la différence entre l’activité moyenne de la maladie après l’infection par le SARS-CoV-2 et celle au départ n’a pas atteint la signification statistique. Au départ et après l’infection, les paramètres moyens de l’activité de la maladie étaient respectivement : CDAI 8,6 ± 5,7 vs 8,6 ± 5,7, p = 0,997 ; SDAI 9,3 ± 6,6 contre 9,2 ± 6,1, p = 0,928 ; DAS 28 4v 2,9 ± 1,2 contre 2,9 ± 1,2, p = 0,818 ; BASDAI 3,6 ± 2,6 contre 3,2 ± 2,7, p = 0,506 ; ASDAS 2,2 ± 1,2 contre 2,2 ± 1, p = 0,721. Le nombre de patients ne répondant pas aux bDMARD (selon EULAR, ASDAS, ASAS, ACR et PsARC) avant l’infection n’était pas différent de celui post-infection.

Conclusion

Notre étude suggère que l’infection par le SARS-CoV-2 n’a aucun impact négatif sur l’activité de la maladie PSA et les réponses bDMARD. Cependant, d’autres études sont encore nécessaires pour mieux comprendre les effets à long terme de l’infection par le SARS-CoV-2.

Implementation gaps of the Portuguese National Health Plan: a stakeholders’ perception analysis

Background

The Portuguese National Health Plan (PNS) 2012-2016, extended to 2020, was the strategic health document shaping the direction of intervention within the Health System. The National Institute of Health Doutor Ricardo Jorge (INSA) is the institution responsible for carrying out its final evaluation. To underpin PNS final evaluation a multistep process was designed.

Methods

A mixed methods study using a convenience sample was implemented to assess stakeholders’ perception about five PNS dimensions: dissemination, communication, implementation, impact, and evaluation. For this purpose, two different tools were used. Semi-structured interviews with former health policy managers were conducted. In addition, an online survey was designed and widely distributed to additional stakeholders. From October 2019 to February 2020, data was collected using two separate instruments. Integral transcriptions of the interviews were made. Qualitative content analysis and quantitative descriptive analysis were used.

Results

A total of 12 interviews and 179 valid surveys were obtained. Regarding stakeholders’ perception about PNS implementation process, there was an overall positive recognition about the strategic and operational relevance of the PNS, as a common dialogue platform and a tool for health improvements both for health status and health system function in Portugal. Among pointed implementation barriers, management was mentioned as the major constraint, mainly due to shortage of human and financial resources to carry out the recommended interventions within the PNS timeline.

Conclusions

As part of the evaluation process the research team found relevant gain knowledge of the wider context in which PNS was developed and implemented, based on stakeholders’ perception. Their considerations are important not only to support the definition of the questions and criteria for PNS final evaluation, but also to highlight key issues for the future policy cycle.

Key messages

Promoting implementation of “Good and Best Practices” through Health Promotion and Prevention Registries

Health promotion and disease prevention programme registries can play an important role in increasing transparency of “good/ best Practices” and promoting their implementation. In the EU, there are different approaches to how registries seek to support the implementation of practices. However, there is limited knowledge of the extent to which there are informative differences or overlaps in the mechanisms chosen for accreditation, capacity building and implementation. This presentation focuses on six national registries in the EU (Finland, Germany, Italy, Netherlands, Poland, Slovenia) and the European Public Health Best Practice Portal. Information was obtained through a working group on Good/ Best Practice Portals, established in 2019. Information on the process of adding good/best practices to the registry and on measures that promote implementation was gathered and evaluated through a descriptive case comparison. The comparison suggests that implementation can be promoted through different approaches for capacity building measures and incentives for implementation. The latter included funding resources, titling/awarding of practice and professional feedback in only a few registries. Registries may be useful not only for transparency of good and best Practices but also for implementation through capacity building and several incentives. The information provided in this presentation may be informative in guiding development of similar resources elsewhere and a starting point for discussion on how to support best the implementation of good/ best practices.

Outcome measurement instruments in Rett syndrome: A systematic review

OBJECTIVE

The aim of the study was to identify and characterize outcome measures for objective and subjective assessment in persons with Rett syndrome (RS).

METHODS

A systematic review was conducted consulting the EBSCO, Cochrane, Web of Science, Scielo, MEDLINE and PsycINFO databases for published studies describing the use of patient-reported outcome measures (PROMs) and other outcome measures in persons with RS. Validation studies and observational studies were included. The PROMs were first described, and then the measurement properties were evaluated using predefined criteria according to the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN). The outcome measures were then grouped according to the International Classification of Functioning, Disability and Health (ICF) to establish a relationship between outcome measures and ICF domains.

RESULTS

Twenty out of 2327 articles were appraised, and seventeen different outcome measures were identified and described. Ten outcome measures corresponded to evaluation questionnaires, while the remaining seven assessed functional outcomes: walking distance, physical activity level and ability to interact visually. A relation between these outcome measures that assess RS and the ICF allows understanding that most of the instruments (fifteen) include the assessment of activity limitations.

CONCLUSIONS

The findings of this study seem to be promising for their use by clinicians and researchers, although they have methodological limitations. The accuracy and quality of these individual outcome measures should continue to be assessed in an attempt to gather a consensus on the best tools used in RS.

POS0560 ASSESSMENT OF THE SWOLLEN TO TENDER JOINT COUNT RATIO AS A PREDICTOR OF RESPONSE IN RHEUMATOID ARTHRITIS PATIENTS: A COHORT STUDY

Background

Several response predictors have already been studied in rheumatoid arthritis, especially since the introduction of biological therapies. The swollen to tender joint count ratio (STR) has been proposed as a predictor of response in patients receiving anti-TNF therapy, but its usefulness in other therapies is not yet well established.

Objectives

To assess whether STR can be a predictor of response in patients with rheumatoid arthritis under b/tsDMARD.

Methods

Longitudinal and retrospective study that included patients diagnosed with rheumatoid arthritis followed in the Rheumatology Department of a tertiary hospital, under therapy with b/tsDMARD.

Demographic, laboratory, and clinical data were collected, including tender and swollen joint counts (as included in DAS 28), Visual Analog Scale (VAS), DAS28 4V, SDAI, CDAI, ACR and EULAR responses, and HAQ. All patients were evaluated at 0, 6 and 12 months after starting the first b/tsDMARD therapy performed after 2015. The variation in each parameter compared to baseline was calculated at 6 and 12 months and represented as a delta. A cutoff of 1 was defined for comparison between STR groups.

The correlations between the continuous variables were assessed by Pearson’s test and comparison between groups of ratios using t test (continuous variables) and chi-square test (categorical variables). Multiple linear regression and multivariate logistic regression were performed to determine response predictors.

Results

A total of 287 patients were included, 238 (82.9%) females, aged 55.7±10.8 years and diagnosed with rheumatoid arthritis for 11.2±8.1 years. Two hundred and sixty-nine (93.7%) were on csDMARD; with regard to b/tsDMARD therapy, 66 started etanercept (23.0%), 62 tocilizumab (21.6%), 58 rituximab (20.2%), 44 adalimumab (15.3%), 17 golimumab (5.9%), 14 abatacept (4.9%), 7 certolizumab (2.4%), 5 upadacitinib and baricitinib (1.7%), 4 infliximab (1.4%), 3 tofacitinib (1.0%), and 2 anakinra (0.7%).

At the start of therapy with b/tsDMARD, the mean DAS28 4V was 4.7±1.5, CDAI 20.4±12.2, SDAI 22.8±16.4, erythrocyte sedimentation rate 31.8±24.4, C-reactive protein (CRP) 1.5±1.7, patient VAS 62.6±1.5, physician VAS 41.4±29.7, pain VAS 62.5±24.8, and HAQ 1.5±0.6; median tender joint count was 4 (interquartile range - IQR - 6), swollen joint count was 3 (IQR 6), and STR joint count was 0.9 (IQR 0.5). When the STR < 1 and STR ≥1 groups were compared, it was found that there were no differences in these variables when starting b/tsDMARD, nor in the therapies they performed.

At 6 months, the STR ≥1 group showed a higher proportion of patients in CDAI remission (CDAI ≤2.8 – 15.3% vs 6.9%, p=0.033) and in DAS28 4V remission or low disease activity according to DAS28 4V (DAS28 4V ≤3.2 – 36.5% vs 22.4%, p=0.008).

At 12 months, the STR ≥1 group exhibited less disease activity (mean DAS28 4V 3.2±1.2 vs 3.6±1.3, p=0.028) and a higher proportion of patients in DAS28 4V remission (25.2% vs 19.7%, p=0.047).

No significant differences were found between the groups in the other variables studied.

In the correlation studies, a weak correlation was identified between STR and CRP at 12 months (r=0,28, p<0,001).

In multiple linear regression studies, when adjusted for sex, age, prednisolone, csDMARD, inflammatory parameters, b/tsDMARD, STR was not shown to be a predictor of DAS28 4V disease activity at 1 year; in multivariate logistic regression studies, when adjusted for the same variables previously described, STR was not shown to be a predictor of remission or remission or low disease activity according to DAS28 4V at 1 year.

Conclusion

The STR is a practical, easy-to-use index that can be used as an adjunct in clinical practice in the evaluation of patients with rheumatoid arthritis, as it is associated with a better response to b/tsDMARD therapy, regardless of patient status and therapy, although it should not be used alone, as it does not appear to be a predictor of response, according to the indices that are currently used.

References

[1]Kristensen LE et al. Arthritis Care Res (Hoboken). 2014 Feb;66(2):173-9.

Disclosure of Interests

None declared.

AB0850 Enthesitis, female gender and vitality perception as fatigue determinants in spondyloarthritis patients under bDMARD

Background

Fatigue is an important domain in quality of life of spondyloarthritis patients, not always directly associated with disease course. The explanatory factors of fatigue in these patients are still not clearly understood.

Objectives

To assess the determinants of fatigue in patients with SpA under biologic disease modifying anti-rheumatic drugs (bDMARDs).

Methods

A retrospective observational study was performed using registry data of patients with SpA under bDMARD therapy followed at a tertiary level hospital. Data regarding disease activity, response criteria measures, analytic markers, function, metrology, pain, general health and fatigue (using FACIT score) was gathered at baseline, 6 months (t6) and 12 months (t12) after introduction of bDMARD. Statistical analysis (significance at p < 0.05) was performed using paired T-test, Wilcoxon test and McNemar tests for paired samples, Mann Whitney-U, Kruskall-Walis and One Way ANOVA for independent samples. Linear and logistic regression models were performed to assess direction and strength of association.

Results

A total of 46 SpA patients were analysed; most were male (24, 52.2%) with a predominantly axial involvement (31, 68.9%) and 74.4% of them were positive for HLA-B27. Most patients had high school or lower education (29, 69.1%), never smoked (26, 61.9%), never drank (34, 79.1%) and had a full-time job (38, 88.4%). All patients were under TNF inhibitors, mostly adalimumab (23, 50%). There was a significant decrease in inflammatory markers (p<0.001), disease activity scores (ASDAS-CRP and BASDAI) (p<0.001), function index BASFI (p< 0.001), metrology indexes (p<0.05) and MASES enthesitis score (p< 0.01). Patient, physician and night pain VAS were significantly lower (p< 0.001) at t6 and t12, but spine VAS only varied significantly between t0 - t6 (p = 0.021) and not t0 - t12 (p= 0.405). FACIT didn’t vary significantly after bDMARD initiation, and among the domains of SF36 questionnaire, only SF36 vitality score varied significantly (p<0.05). No significant changes in EQ5D, HADs anxiety or depression scores were observed.

At baseline, there was a strong negative correlation between fatigue, expressed by FACIT score, and pain VAS (R = 0.9, p=0.037), without other significant associations. Several positive correlations with fatigue at t6 were observed, the strongest with anxiety and depression HADs (p < 0.001), BASFI (p < 0.001) and ASDAS-CRP (p< 0.001). Other positive associations were seen with 66 TJC (p <0.01), patient VAS (p<0.001, pain VAS (p = 0.001), nocturnal pain VAS (p <0.001), BASDAI (p <0.001) and MASES (p <0.001). Fatigue at t6 had a negative correlation with increased ASAS response measures mean value (p = 0.014), all domains of SF36 (p < 0.001), the strongest correlation of which was with the general health domain (R=-0.811), and EQ5D (p<0.001). When comparing subgroups at t6, there was more fatigue in the female group (p=0.01) and in patient with higher ASDAS disease activity score (p < 0.05), with no differences according to work status, alcohol consumption or tobacco use, educational level, TNF inhibitor exposure or ASAS response.

Prediction analysis showed univariable association between several baseline variables and fatigue (lower FACIT scoring) at t6: age at bDMARD introduction (B = - 0,405, p = 0.02), age at diagnosis (B = -0.43, p = 0.02), physician VAS (B = 0.149, p < 0.05), MASES (B = -1.732, p <0.001), SPARCC (p < 0.05) and female gender (B = -7.95, p = 0.01). Multivariate linear regression analysis allowed for creation of a predictive model for FACIT scoring at t6 (R2 = 0.900, p = 0.019): (-3.426) x MASES t0 + (-24.074) x female gender + 0.949 x SF36 vitality score.

Conclusion

Enthesitis, female gender and subjective assessment of vitality seem to be determinants of fatigue in SpA patients under bDMARD. Fatigue in this population is associated with diverse factors that should be optimized in a holistic approach to the patient.

Disclosure of Interests

None declared

AB0190 THE LONG-TERM PREDICTORS OF FATIGUE IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED BIOLOGICAL DISEASE-MODIFYING ANTIRHEUMATIC DRUGS

Background

Fatigue is one of the major complaints of patients with rheumatoid arthritis (RA). However, the literature relating fatigue to other disease-related parameters has presented discrepant results and longitudinal studies with multivariate analyses are scarce.

Objectives

To explore potential associations between fatigue and demographic variables and other patient-reported outcomes (PROMs) in patients with RA treated with biological disease-modifying antirheumatic drugs (bDMARDs) over the time.

Methods

A 24-month (24M) monocentric observational retrospective cohort study was conducted. Patients diagnosed with RA, according to the 2010 American College of Rheumatology (ACR)/ European League Against Rheumatism (EULAR) criteria, and registered on the Rheumatic Diseases Portuguese Register (Reuma.pt) who started their first bDMARD between 2015 and 2021 were included. Age, gender, disease duration, body mass index (BMI) and PROMs were obtained by consulting Reuma.pt. Fatigue was monitored at baseline, 12 and 24M using Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), a 13-item questionnaire with a total score ranging from 0 to 52. A score ≤ 39 indicates the presence of clinically significant fatigue. Health Assessment Questionnaire (HAQ), EuroQol-5D (EQ-5D), 36-Item Short Form Survey (SF-36), patient global assessment visual analogue scale (VAS) and pain VAS were assessed at baseline, 12 and 24M. Multivariate linear regression models were conducted with FACIT-F as the dependent variable.

Results

A total of 40 patients (47.4±11.4 years; 90.2% female) with a BMI of 29.87±8.54 kg/m2 and a mean disease duration of 10.4±5.6 years were included. A total of 47.5% of patients were treated with an anti-TNF. About 85% of patients had clinically significant fatigue at baseline (FACIT-F 26.9±11.8). At baseline, patient global assessment VAS (β=-0.4, 95%CI [- 0.68; -0.095]) and pain VAS (β=- 0.34, 95%CI [-0.6; -0.068]) predicted fatigue. SF-36 predicted fatigue at baseline (β=0.35, 95%CI [0.14;0.56]), 12M (β=0.23, 95%CI [0.084;0.37]) and 24M (β=0.26, 95%CI [0.13;0.39]). HAQ predicted fatigue at baseline (β=- 12.2, 95%CI [- 19.8; - 4.5]) and 24M (β=- 11.4, 95%CI [- 17.47; - 5.38]). EQ-5D (β=39.5, 95%CI [15.84; 63.22]) predicted fatigue at 24M.

Conclusion

Our results showed that pain levels and patient global assessment of disease activity predicted a higher level of fatigue at baseline. The decrease in physical function and a worse overall health status perceived by patient predicted higher fatigue over the time. Previous research has suggested that disease-related factors, such as inflammation, pain or decreased physical function are associated with greater fatigue in RA (1). These findings encourage the pre-treatment screening of fatigue in patients with RA in order to design individualized non-pharmacological approaches in addition to bDMARDs therapy.

References

[1]Katz P. Curr Rheumatol Rep. 2017;19(5):25.

Disclosure of Interests

None declared

AB1113 THE IMPACT OF SARS-COV-2 INFECTION ON DISEASE ACTIVITY AND CLINICAL RESPONSE TO BIOLOGICAL DMARDS IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Infections are a known trigger for Rheumatoid Arthritis (RA) flares.1 It is still unclear whether SARS-Cov-2 infection affects RA disease activity and the clinical response to biological disease-modifying antirheumatic drugs (bDMARDs).

Objectives

To evaluate the effect of SARS-Cov-2 infection on disease activity and bDMARD responses in patients with RA.

Methods

A retrospective study was carried out in a cohort of RA patients treated with bDMARDs from a tertiary hospital centre. Demographic and clinical data, including occurrence of SARS-Cov-2 infection, were obtained through medical records. Disease activity (DAS28, DAS28-CRP, CDAI and SDAI) and ACR and EULAR bDMARD responses were evaluated at four time points: baseline (t1 - last evaluation before Covid-19 pandemic), before (t2) and after (t3) SARS-Cov-2 infection and at the end of follow-up (t4 - last appointment of 2021). In patients with no record of SARS-Cov-2 infection the middle evaluations were obtained from two random consecutive appointments during Covid-19 pandemic. Statistical analysis (significance at p<0.05) was performed using paired t-test, Wilcoxon and McNemar tests for paired samples and unpaired t-test, Mann-Whitney, Fisher and χ2 tests for independent samples according to the type of variable and the presence of normal distribution.

Results

Of the 237 patients included, most of them was women [n = 195 (82.3%)], with a mean age of 59.6 ± 10.1 years old and a median [min, max] disease duration of 18 [2, 50] years. The majority presented rheumatoid factor (RF) and/or anti-citrullinated protein antibodies (ACPA) positivity [n = 204 (87.9%)] and radiographic erosions [n = 119 (72.6%)]. The prevalence of SARS-Cov-2 infection was 11.4% (n=27). Mean disease activity was lower after SARS-Cov-2 infection compared to the previous evaluation on all scores used; however, this difference was not statistically significant. Nevertheless, when compared to the mean disease activity at the end of follow-up, there were statistically significant differences in DAS28-CRP (t2 3.2±1.0 vs. t4 2.8±1.1, p=0.017) and CDAI (t2 11.1±8.1 vs. t4 8.7±6.2, p=0.05) scores. The relative number of patients with no ACR or EULAR bDMARD responses before SARS-Cov-2 infection wasn’t different from post infection and at the end of follow-up. At baseline, the infected and uninfected groups were similar regarding gender, age, RF and/or ACPA positivity, erosive disease, disease and biologic treatment durations, baseline disease activity and ACR and EULAR response. The variation in disease activity and the relative number of patients with worsening or improving EULAR and ACR bDMARD responses between t2 and t3 were not significantly different in the two groups, as well as between t2 and t4. The prevalence of patients who switched to another bDMARD was significantly higher in the group of patients who had Covid-19 [n=4 (14.8%) vs. 9 (4.3%), p=0.047]. The main reason for switching was the ineffectiveness of the therapy (n=11).

Conclusion

No worsening of disease activity or ACR and EULAR bDMARD responses was found after SARS-Cov-2 infection in RA patients under bDMARD. However, the later can be explained by the small sample size. Indeed, these patients exhibited a higher rate of switch due to ineffectiveness of therapy, suggesting a negative impact of SARS-Cov2 infection on the disease course.

References

[1]Rashmi Roongta, Alakendu Ghosh. Managing rheumatoid arthritis during COVID-19. Clinical Rheumatology (2020)

Disclosure of Interests

None declared

AB0107 IMPACT OF SARS-CoV-2 INFECTION ON THE DISEASE ACTIVITY OF PATIENTS WITH PSORIATIC ARTHRITIS UNDER bDMARDs: REAL LIFE DATA

Background

SARS-CoV-2 infection can lead to severe inflammation and has been suggested to induce Psoriatic Arthritis (PsA) flares.1 However, the impact on disease activity and response to biological disease modifying anti-rheumatic drugs DMARDs (bDMARDs) remains unknown.

Objectives

To evaluate the effect of SARS-CoV-2 infection on disease activity and bDMARDs responses in patients with PsA.

Methods

We performed a retrospective analysis including all the patients with PsA, meeting the CASPAR criteria and under biologic therapy, followed in the Rheumatology department of a tertiary university hospital. Demographic and clinical data, including occurrence of SARS-CoV-2 infection, were collected from our national database (reuma.pt). Disease activity (CDAI, SDAI, DAS28 4v, BASDAI, ASDAS) and bDMARDs responses (EULAR, ASDAS, ASAS, ACR and PsARC responses) were evaluated before and after SARS-Cov-2 infection. Statistical analysis was performed with SPSS. Continuous variables were compared through paired samples t-test.

Results

A total of 102 patients with PsA were included. Fifty-two were females (51%).The mean age was 53 ± 11.09 years and the median disease duration was 15 years [min 2, max 47]. Overall, 54 (53%) patients had predominant axial involvement, 26 (26%) peripheric and 36 (37%) enthesopathic. The most used bDMARD was etanercept (n=28, 27.5%) followed by adalimumab (n=22, 21.6%) and secukinumab (n=18, 17.6%).

The prevalence of SARS-CoV-2 infection was 15.7% (n=16). Sixty-three per cent received the BNT162b2 (Pfizer/BioNtech) vaccine, 31% received mRNA-1273 (Moderna), 13% received AZD1222 (AstraZeneca) and 13% received AD26.COV2.S (Janssen/Johnson & Johnson). Sixty-three percent were infected before any vaccination, 13% after the first dose and 25% after the second. The most common symptoms were anosmia (65%), dysgeusia (56%) and cough (56%). All patients fully recovered from the infection, with no need for hospitalization.

Regardless of the score used, the difference between the mean disease activity after SARS-CoV-2 infection and that at baseline did not reach statistical significance. At baseline and after infection, mean (SD) disease activity parameters were, respectively: CDAI 8.6±5.7 vs 8.6±5.7, p=0.997; SDAI 9.3±6.6 vs 9.2±6.1, p=0,928; DAS 28 4v 2.9±1.2 vs 2.9 ±1.2, p= 0.818; BASDAI 3.6 ±2.6 vs 3.2±2.7, p=0.506; ASDAS 2.2±1.2 vs 2.2±1, p=0.721.

The number of patients unresponsive to bDMARDs (according EULAR, ASDAS, ASAS, ACR and PsARC) before the infection wasn’t different from post-infection.

Conclusion

Our study suggests that SARS-CoV2 infection has no negative impact on PsA disease activity and bDMARD responses. However, more studies are still needed to better understand the long-term effects of SARS-CoV2 infection.

References

[1]Zhou Q et al. SARS-CoV-2 Infection Induces Psoriatic Arthritis Flares and Enthesis Resident Plasmacytoid Dendritic Cell Type-1 Interferon Inhibition by JAK Antagonism Offer Novel Spondyloarthritis Pathogenesis Insights. Front Immunol. 2021 Apr 15; 12:635018

Disclosure of Interests

None declared

AB1478 RELIABILITY AND CONTENT VALIDITY OF THE PORTUGUESE VERSION OF THE COMMISSIONING FOR QUALITY IN RHEUMATOID ARTHRITIS PATIENT-REPORTED EXPERIENCE MEASURE (CQRA-PREM): PRELIMINARY RESULTS

Background

The CQRA-PREM has been developed in the United Kingdom to evaluate the perspective of patients with rheumatoid arthritis (RA) about the care provided in rheumatology units of the National Health Service (1). This PREM might also be feasible to be used in Portugal, yet an adaptation and validation process is needed.

Objectives

We aimed to translate and cross-cultural adapt CQRA-PREM to Portuguese and evaluate the reliability and content validity of this version.

Methods

A study combining qualitative and quantitative approaches was conducted with patients with RA from a single rheumatology center. The translation and cultural adaptation of Portuguese CQRA-PREM included initial translation and cultural adaptation by 2 native Portuguese researchers, evaluation of this initial translation by a panel of 5 experts during an online meeting and back translation by 1 bilingual researcher. Authors of the original version approved this initial translation. CQRA-PREM includes 7 domains for patient-centered care: Needs and preferences (5 items); Coordination of care and communication (4 items); Information, education, and self-care (4 items); Daily living and physical comfort (2 items); Emotional support (2 items); Family and friends (1 item); Access to care (5 items) and 1 question for the overall experience with the care provided. Answers are given on a 5-point Likert scale (strongly disagree-1 to strongly agree-5). A total of 21 patients were invited to participate in online focus groups and 14 accepted. Patients were then asked to fill in a consent form and the preliminary version of the CQRA-PREM. The focus groups were transcribed and analyzed using thematic analysis. Questionnaire responses were analyzed with descriptive statistics and reliability (internal consistency) with the Cronbach´s alpha (α).

Results

A total of 12 patients (53±9y; 92% female) with a mean disease duration of 14±9 years participated in 2 focus groups (duration 95±7min). The focus groups revealed that patients considered CQRA-PREM “simple” and “objective” and that all questions were easy to understand. Nevertheless, patients suggested the addition of synonyms for certain terms and of daily living examples to clarify some items. The “Needs and preferences” and “Access to care” were the domains with better experience (Table 1). The Cronbach’s alpha was 0.94 for the total questionnaire and between 0.71 and 0.91 for the domains.

Table 1.

Median’s responses and quartile (Q) for each domain (1-Strongly disagree; 2-Disagree; 3-Neither agree nor disagree; 4-Agree; 5- Strongly agree).

CQRA-PREM domainsMedian (Q1-Q3)1.Needs and preferences4.5(4.25-4.5)2.Coordination of care and communication4(3.25-4.5)3.Information, Education and Self-care3(2-4)4.Daily living and physical comfort3.255.Emotional support3.256.Family and friends4(3-4)7.Access to care4.5(2.5-5)

Conclusion

Our findings suggest that both content validity and internal consistency of the Portuguese version of CQRA-PREM are acceptable. In future, a field-testing study to assess other psychometric properties (e.g., test-reliability and validity) should be conducted. We believe this PREM will contribute to optimize patient-centered care in Portugal.

References

[1]Bosworth A, et al. Curr. Rheumatol. Rev. 2015;11.

Disclosure of Interests

None declared

POS0297 EFFECTIVENESS AND SAFETY OF SECUKINUMAB IN AXIAL SPONDYLOARTHRITIS: A 24-MONTH PROSPECTIVE, MULTICENTER REAL-LIFE STUDY

Background

Axial Spondyloarthritis (axSpA) can be distinguished in radiographic axSpA (r-axSpA) and non-radiographic (nr-axSpA). Secukinumab (SEC) is a novel treatment for axSpA, but data from real-life are still missing.

Objectives

To evaluate, in a multicentric-Italian-cohort of axSpA patients on SEC followed for 24-months: a)the long-term effectiveness and safety of SEC; b)the drug-retention-rate and low-disease-activity (LDA) measured as BASDAI<4/ASDAS<2.1 and very-low-disease-activity (VLDA) measured as BASDAI<2/ASDAS<1.3; c)any differences in outcomes according to: line of biological treatment (naïve/non-naïve), gender (male/female), subtype of axSpA (r-axSpA/nr-axSpA).

Methods

Consecutive patients with active axSpA (diagnosis according Assessment of SpondyloArthritis International Society ASAS criteria), who started SEC treatment, were evaluated prospectively. Data on disease characteristics, previous/ongoing treatments and imaging were collected. Disease-activity/functional/clinical scores and biochemical values were recorded at baseline (T0), at 6 (T6), 12 (T12), and 24 (T24) months. Effectiveness was evaluated over-time with descriptive statistics; multivariate Cox and logistic regression models were used to evaluate predictors of drug-discontinuation and LDA at T6. Infections, adverse events were recorded.

Results

249 patients (47.8% male; median age 51 years) were enrolled; 40.9% had HLA-B27; 53.8% had r-axSpA and 46.2% nr-axSpA. SEC was prescribed in 28.9% naïve and in 71.1% non-naïve patients. SEC effectiveness was shown as an improvement in several outcomes, such as ASDAS [T0=3.5(2.9-4.4) vs. T24=1.9(1.2-2.4);p=0.02] and BASDAI [T0=6.5(5.0-7.5) vs. T24=2.8(1.8-4.0);p=0.03]. After 24-months of treatment, 90.7% of naïve and 75.3% of non-naïve patients achieved LDA (BASDAI<4). At T24 naïve-patients showed better physical-functioning and lower disease-activity than non-naïve (Table 1). Similarly, at T24 we observed better physical functioning and lower inflammatory activity in males vs. females and in nr-axSpA vs. r-axSpA subjects. Retention-rate at T24 was 75% in the whole population, with some difference depending on gender (log-rank 9.319; p=0.002) (Figure 1). Treatment was discontinued in 61 patients (24.5%), mainly due to primary/secondary loss of effectiveness events (20 and 24 subjects, respectively), and only 17 patients (6.8%) due to adverse events (7 for reactions at the injection site or skin manifestations, 1 for gastro-intestinal complications, 1 for relapsing uveitis, 1 for hypertransaminasemia, 4 for severe recurrent infections, 3 due to the onset of new cancer).

Table 1.

Clinical, functional, disease activity and serological parameters of naïve (n=72) and non-naïve (n=177) axSpA patients during the 24-month follow-up

T0T6T12T24BASMI [0-10], median (IQR)naïve2.0 (1.0-4.0)2.0 (0.0-3.3)1.0 (0.0-2.8)1.0 (0.0-2.0)non-naïve4.0 (1.0-7.0)4.0 (1.0-7.0)2.0 (1.0-4.0)2.0 (1.0-3.0)pp=0.03p=0.04nsnsHAQ-S [0-8], median (IQR)naïve0.8 (0.5-1.3)0.5 (0.0-1.0)0.3 (0.0-1.0)0.1 (0.0-0.5)non-naïve1.1 (0.8-1.5)1.0 (0.4-1.3)0.6 (0.4-0.9)0.7 (0.1-0.9)pp=0.04p=0.04p=0.04p=0.04ASDAS [0-6], median (IQR)naïve3.3 (2.7-3.9)2.1 (1.6-2.7)2.0 (1.2-2.8)1.3 (1.0-2.2)non-naïve3.7 (2.9-4.7)2.9 (2.0-3.7)2.1 (1.9-3.1)2.3 (1.6-2.3)pnsnsnsp=0.04ESR [0-25](mm/h), median (IQR)naïve14.0 (6.0-27.0)10.0 (4.0-19.5)8.0 (3.1-12.8)5.0 (2.0-15.0)non-naïve18.5 (10.0-31.3)15.0 (8.0-25.0)12.0 (6.0-20.0)12.0 (6.0-19.0)pp=0.04p=0.04p=0.04p=0.04

Legend: BASMI: Bath Ankylosing Spondylitis Metrology Index; HAQ: Health Assessment Questionnaire modified for spondyloarthritis; ASDAS: Ankylosing Spondylitis Disease Activity Score; ESR: erythrocyte sedimentation rate

Conclusion

In a real-life clinical-setting, SEC proved to be safe and effective in axSpA, mainly in naïve-patients, with a notable drug-retention-rate. No differences were observed between r-axSpA and nr-axSpA.

Acknowledgements

Contributing authors of the Spondyloartritis and Psoriatic Arthritis SIR Study Group “Antonio Spadaro”: Alberto Cauli, MD, PhD, Rheumatology Unit, Department of Medical Sciences, AOU and University of Cagliari, Cagliari, Sardegna, Italy; Angelo Semeraro, MD, Rheumatology Unit, Martina Franca-ASL Taranto, Puglia, Italy; Leonardo Santo, MD, Rheumatology Unit, ASL BT Andria – DSS4 Barletta, Italy, Barletta-Andria-Trani, Puglia, Italy; Emanuela Praino, MD, Rheumatology Unit, ASL BT Andria – DSS4 Barletta, Italy, Barletta-Andria-Trani, Puglia, Italy; Giorgio Amato, MD, Rheumatology Unit, A.O.U. Policlinico S. Marco, Catania, Sicilia, Italy; Nicolò Girolimetto, MD, Rheumatology Unit, Department of Internal Medicine, Azienda USL-IRCCS, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Emilia Romagna, Italy.

Disclosure of Interests

Giacomo Cozzi: None declared, Mariagrazia Lorenzin: None declared, Maria Sole Chimenti: None declared, Salvatore D’Angelo: None declared, Antonio Marchesoni: None declared, Carlo Salvarani: None declared, Ennio Lubrano: None declared, Luisa Costa: None declared, Ylenia Dal Bosco: None declared, Elena Fracassi: None declared, Augusta Ortolan: None declared, Mario Ferraioli: None declared, Antonio Carriero: None declared, elisa visalli: None declared, RICCARDO BIXIO: None declared, Francesca Desiati: None declared, ALBERTO BERGAMINI: None declared, elisa pedrollo: None declared, Andrea Doria Grant/research support from: Novartis, Abbvie, Pfizer, MSD, Janssen, Rosario Foti: None declared, Antonio Carletto: None declared, Roberta Ramonda Grant/research support from: Novartis, Abbvie, Pfizer, MSD, Janssen

AB1110 COVID19 IN SPONDYLOARTHRITIS PATIENTS UNDER bDMARD – A COMPREHENSIVE ASSESSMENT

Background

SARS-Cov-2 infection had a major impact on patients with inflammatory rheumatic diseases. Spondyloarthritis (SpA) patients were one of the most affected groups of these patients.

Objectives

To assess the impact of Covid19 in spondyloarthritis patients under biological disease modifying anti-rheumatic drugs (bDMARDs).

Methods

A retrospective observational study was conducted using registry data of patients with SpA under bDMARD therapy, followed at a tertiary level hospital, that have been diagnosed with COVID19 from March 2019 to December 2021. At least one evaluation previous (t0) and two evaluations after SARS-CoV-2 infection (t1, t2) were included in our analysis. Sociodemographic, clinical, disease activity, therapeutic response, function and general health status data were collected. Statistical analysis (significance at p < 0.05) was performed using paired T-test, Wilcoxon test and McNemar tests for paired samples. Linear and logistic regression models were performed to assess direction and strength of association

Results

Thirty-two patients with SpA under bDMARD had COVID19, mostly women (20, 62.5%), with a disease course time averaged 18.65 (± 9.69) years, mainly with axial involvement (19, 59.4%) and positive for HLA-B27 antigen (11, 64.7%). The majority were under TNF inhibitors (30, 93.75%), with golimumab being the most common (9, 28.1%), and with a median bDMARD persistence of 2.63 (5.09) years. Seven (21.9%) were under a cDMARD, 3 (9.4%) under NSAID and 18 (56.3%) under corticosteroids. Three (9.4%) were already vaccinated against SARS-CoV-2, 2 (66.6%) with the mRNA-1273 vaccine, presenting a medium time since inoculation of 240 (± 234.01) days. Arterial hypertension was the most common comorbidity (5, 15.6%) and one patient (3.1%) had a previous diagnosis of type 2 diabetes. Most were never-smokers (17, 53.1%) and never-drinkers (29, 90.6%).

The average age at infection was 40.97 (± 6.15) years and the most common symptom was cough (22, 68.8%), followed by headache (20, 62.5%) and myalgia (19, 59.4%). Event tree analysis didn’t show association with SpA subtype, education level, work status, tobacco or alcohol consumption. Only one patient needed hospital admission but without needing of oxygen, therapy, ventilator or ECMO. Only one patient had an overlaid bacterial infection and no thromboembolic complications were observed. Two patients needed specific SARS CoV-2 infection treatment, one with hydroxychloroquine and another with azithromycin. Twelve (37.5%) patients suspended bDMARD at the time of infection, with only 2 (6.3%) maintaining suspension at the time of the first post-infection visit.

When comparing clinical variables, higher disease activity was seen at t1 only for BASDAI mean values, without statistical significance. Higher all domains VAS scores were also observed at t1, but not at t2, also without statistical significance; moreover, physical function didn’t change significantly. No differences were observed according to gender or SpA subtype, nor with the use of cDMARDs, NSAIDs or corticosteroids. The only statistically significant difference concerned MASES score between t0 and t1 (1 ± 4 vs. 2 ± 6, p=0.04), but not between t0 and t2. Higher baseline tender joint score (p < 0.01) and higher baseline LEI (p=0.03) negatively correlated with MASES score variation. Several baseline variables correlated positively with MASES at t1, including female gender (p < 0.01), corticosteroid use (p = 0.04), BASDAI (p < 0.01), ASDAS-ESR (p < 0.01), ASDAS-CRP (p < 0.01), DAS28 (p < 0.01), SPARCC (p = 0.04), physician VAS (p = 0.03) and total spine VAS (p = 0.01). Working status varied significantly after SARS-Cov-2 infection (at least part-time - 29, 90.6% vs. 22, 68.8%, p= 0.016).

Conclusion

SpA patients on bDMARD had a mild course of SARS-CoV-2 infection, with slight changes in enthesitis score in the short term, the latter particularly in those with higher disease activity in the pre-infection period. Long-term effects on work status could represent confounding factors related to the economic constraints of the pandemic.

Disclosure of Interests

None declared

AB0914 Is tender to swollen joint count ratio a useful clinical marker of response to biological treatment in psoriatic arthritis patients?

Background

Chronic inflammation in psoriatic arthritis (PsA) may trigger both peripheral and central sensitization via central modifications of pain pathways that can lead to disconnection between tender and swollen joint count. This can result in increased difficulties for the clinician in the assessment of the disease and response to treatment.

Objectives

To study the impact of tender to swollen joint count ratio (TSR) on treatment response to a first course of biologic disease-modifying antirheumatic drug (bDMARD) therapy in PsA patients.

Methods

Observational study including PsA patients under bDMARD, followed with clinical and laboratory examination at baseline, 6 and 12 months of treatment. All patients meet the CASPAR classification criteria. TSR was defined as the tender joint count divided by the swollen joint count, using the 68/66 joint assessment. Patients with no tender nor swollen joints at baseline were excluded. TSR was categorized into 3 groups, based on the empirical distribution, with cuts corresponding to the 20th and 70th percentiles. Disease activity was assessed using the Clinical Disease Activity Index (CDAI), the Simplified Disease Activity Index (SDAI) and Disease Activity Score based on 28 joints (DAS28-CRP(4)). Individual time profiles were plotted within each TSR group. CDAI, SDAI and DAS28-CRP(4) individual time profiles within each TSR group were modelled by mixed-effects linear regression using the TSR group and time as fixed factors and a random factor at the intercept level (accounting for the intra-individual correlation structure). The identification of the statistically significant pairwise differences was obtained from the Tukey’s method for multiple comparisons.

Results

We included 113 patients, 62 (54.0% females) with a mean age of 48.1±10.8 years-old at the start of the first bDMARD. Sixty-four patients (56.6%) had symmetric polyarthritis, 19 (16.8%) spondyloarthritis, 25 (22.1%) asymmetric oligoarthritis, 2 (1.8%) distal arthritis and 1 (0.9%) arthritis mutilans. Forty-three percent were under corticosteroid therapy and 57.5% under conventional synthetic DMARD (csDMARD) therapy at baseline (mostly methotrexate, in 45.1% of patients under csDMARD). Etanercept (n=35, 31.0%), adalimumab (n=34, 30.1%), golimumab (n=25, 22.1%), infliximab (n=6, 5.3%), certolizumab (5, 4.4%), secukinumab (n=8, 7.1%) were the bDMARD started in these patients. TSR was categorized into 3 groups, namely low [TSR < 1], moderate [1 ≤ TSR ≤ 2.2] and high [TSR > 2.2], with frequencies 15 (13.3%), 66 (58.4%) and 32 (28.3%), respectively. Whenever the number of tender joints was different from 0 and that of swollen joints equal to 0, patients were included in the group high TSR. All TSR groups, with initiation of bDMARD, showed significantly decreases at 6 months in CDAI (low: p=0.006, moderate: p<0.001, high: p<0.001), SDAI (low: p<0.001, moderate: p<0,001, high: p<0.001) and DAS28-CRP(4) (low: p<0.001, moderate: p<0.001, high: p<0.001). From 6 to 12 months of treatment, the differences were not significant in any of the groups (p>0.05). At baseline, CDAI, SDAI and DAS28-CRP(4) means did not differ between groups (p>0.05). There were also no differences in the means of outcome measures at 6 months as well as at 12 months of treatment (p>0.05). Despite this, patients with low baseline TSR had lower mean values of CDAI, SDAI and DAS28-CRP(4) at 6 and 12 months of treatment, consistent with a low disease activity.

Conclusion

To our knowledge this is the first study exploring the TSR on treatment response in samples of patients exclusively with PsA. All patients benefited from bDMARD therapy, regardless of the group, suggesting that TSR might not be a good predictor of treatment response in patients with PsA.

Disclosure of Interests

None declared

AB0360 THE LONG-TERM IMPACT OF FATIGUE ON DISEASE ACTIVITY IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH BIOLOGICAL DISEASE-MODIFYING ANTIRHEUMATIC DRUGS

Background

Fatigue is common among patients with rheumatoid arthritis (RA) with a substantial impact on quality of life (1). Biological disease-modifying antirheumatic drugs (bDMARDs) have been shown to significantly improve fatigue in these patients. However, fatigue is under-assessed by the physicians and evidence is still scarce regarding a possible impact of fatigue on disease activity over time.

Objectives

To explore the long-term impact of fatigue on the disease activity in patients with RA treated with bDMARDs.

Methods

A monocentric observational retrospective cohort study was conducted with 24 months (M) of follow-up. Patients diagnosed with RA, according to the 2010 American College of Rheumatology (ACR)/ European League Against Rheumatism (EULAR) criteria, and registered on the Rheumatic Diseases Portuguese Register (Reuma.pt) who started their first bDMARD between 2015 and 2021 were included. Demographic, clinical and laboratory data were obtained by consulting Reuma.pt. Fatigue was monitored at baseline, 12 and 24M using Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F). This scale is a 13-item self-reported questionnaire with a total score ranging from 0 to 52. A score ≤ 39 indicates the presence of clinically significant fatigue. Disease Activity Score for 28 joints with erythrocyte sedimentation rate (DAS28), DAS28 with C-reactive Protein (CRP) [DAS28-CRP], DAS28 delta, Clinical Disease Activity Index (CDAI) and Simplified Disease Activity Index (SDAI) were calculated to measure disease activity. Clinical response was evaluated by EULAR criteria in three response categories- good, mild and no response- and by ACR criteria (0 to 100%) at 12 and 24M. To correlate fatigue score with EULAR clinical response Chi-square test was used. Multivariate linear regression models adjusted for age, gender and disease duration were used to assess the effect of fatigue on disease activity and ACR clinical response over time.

Results

A total of 40 patients with RA were included, with a mean age of 47.4±11.4 years old and disease duration of 10.4±5.6 years. Most patients were female (90.2%). Rheumatoid Factor was positive in 70% of patients. The majority of patients (85%) had clinically significant fatigue at baseline moment (FACIT-F 26.9±11.8). Treatment characteristics and baseline disease activity scores are described in Table 1. Fatigue at baseline moment predicted DAS28(CRP) (β=-0.061, 95%CI [-0.12; -0.003]) and CDAI (β=- 0.30, 95%CI [-0.57; -0.029]) at 12M. Additionally, fatigue predicted SDAI (β=-0.38, 95%CI [-0.72; -0.047]) and CDAI (β=- 0.39, 95%CI [-0.73; -0.051]) at 24M. In general, for these models, fatigue as a symptom was shown to have negative effects on the different outcomes analysed. Fatigue did not associate with EULAR and ACR responses over time.

Table 1.

Baseline characteristics of sample. LEGEND: SD: Standard deviation; DAS28: Disease Activity Score for 28 joints; CRP: C-reactive Protein; CDAI: Clinical Disease Activity Index; SDAI: Simplified Disease Activity Index.

VariableDescriptive statisticTreatment optionsn(%)Glucocorticoids37(92.5)Conventional DMARDs37(92.5)Anti-TNF19(47.5)Etanercept13(32.5)Rituximab4(10)Tocilizumab4(10)Disease activity scoreMean±SDDAS285.4±0.87DAS28-CRP4.9±0.69CDAI27.6±8.5SDAI28.9±8.7

Conclusion

These findings showed that, in our sample, the most RA patients had severe fatigue and its presence may be a predictor of increased disease activity. Indeed, previous research observed a positive association between fatigue and disease activity over the time in patients with RA (2). Therefore, fatigue should be regularly monitored in patients with RA and its impact on treatment must be considered. Moreover, further research with larger samples is needed to explore the impact of fatigue on clinical response and the potential of fatigue relief as an outcome measure of RA treatment.

References

[1]Katz P. Curr Rheumatol Rep. 2017;19(5):25.

[2]Holten K, et al. Ann. Rheum. Dis. 2021; 0:1–7.

Disclosure of Interests

None declared

POS1337 ADULT-ONSET STILL’S DISEASE WITH ELDERLY ONSET, RESULTS FROM A MULTICENTRE STUDY AND ASSESSMENT OF AGE INFLUENCE ON CLINICAL FEATURES AND DISEASE OUTCOMES

Background

Aging is a physiological, multidimensional, and irreversible process, occurring in humans over time. Interestingly, multiple lines of evidence have recently suggested that some diseases, generally affecting young adults, are nowadays described in the elderly, although possibly associated with different symptoms or complications. In this context, a possible occurrence of adult onset Still’s disease (AOSD) in elderly has been suggested. This is a rare inflammatory disorder of unknown origin usually observed in young adults [1-3].

Objectives

In this study, we aimed at describing the clinical characteristics, life-threatening complications occurrence, and mortality of AOSD patients with an elderly onset. The manifestations of these patients were also compared with those with a younger onset. Furthermore, the predictive role of age was evaluated on clinical features and disease outcomes. Finally, in these patients, an assessment of associated comorbidities was also performed.

Methods

A retrospective assessment of prospectively followed patients, from January 2001 to April 2021, was provided to analyse clinical features, life-threatening complications occurrence, and mortality in AOSD patients with onset in elderly. AOSD patients, who were included in multicentre Gruppo Italiano di Ricerca in Reumatologia Clinica e Sperimentale (GIRRCS) cohort, were evaluated.

Results

Out of 221 assessed patients, 37 (16.7%) had an onset of the disease aged over than 60 years. When compared with younger patients, these were characterised by a higher prevalence of pericarditis (p=0.008), comorbidities (p<0.0001), and mortality (p=0.023).

Additionally, our analysis showed that pleuritis and pericarditis positively correlated with age (coefficient=0.227, p=0.001; coefficient=0.213, p=0.001, respectively). Furthermore, the occurrence of parenchymal lung disease was significantly related with age (coefficient=0.168, p=0.012). The presence of comorbidities positively correlated with age (coefficient=0.443, p<0.0001). Moreover, age was negatively related to the polycyclic pattern (coefficient=-0.209, p=0.002). A correlation between mortality and age was also retrieved (coefficient=0.158, p=0.019).

Age predicted the presence of serositis in both univariate (HR: 1.02, 95%CI: 1.01-1.03, p=0.007) and multivariate analyses (HR: 1.02, 95%CI: 1.01-1.04, p=0.007). Age was also a significant predictor of parenchymal lung disease in both univariate (HR: 1.03, 95%CI: 1.01-1.05, p=0.017) and multivariate analyses (HR: 1.03, 95%CI: 1.00-1.05, p=0.048). No significant results were observed assessing the predictive role of age on occurrence of macrophage activation syndrome. Furthermore, age resulted to be a negative predictor of polycyclic pattern only in univariate analysis (HR: 0.99, 95%CI: 0.97-1.00, p=0.048). Finally, age significantly predicted the mortality in both univariate (HR: 1.03, 95%CI: 1.00-1.06, p=0.034) and multivariate analyses (HR: 1.05, 95%CI: 1.01-1.08, p=0.012).

Conclusion

Clinical features of AOSD patients with elderly onset were described in our multicentre cohort. Although the main clinical characteristics were similar comparing older and younger patients, patients aged over 60 years at disease onset were characterised by an increased prevalence of serositis, comorbidities, mostly cardiometabolic, and a higher mortality rate. Age predicted the presence of parenchymal lung disease and mortality, and it could be considered a further negative prognostic factor in AOSD.

References

[1]Mollaeian A, Chen J, et al. BMC Rheumatol. 2021;5(1):12.

[2]Maruyama A, et al. Mod Rheumatol. 2021;31(4):862-868.

[3]Suzuki E, et al. Tohoku J Exp Med. 2021;255(3):195-202.

Disclosure of Interests

None declared

AB0939 Psoriatic arthritis related fatigue: what is the magnitude of this problem and what are the correlated factors? A cross-sectional study

Background

Fatigue is a common constitutional feature and has a significant impact on quality of life in patients with chronic inflammatory rheumatic diseases, such as psoriatic arthritis (PsA). It is a complex phenomenon and its pathogenesis remains unclear. Despite being a common symptom, it is largely ignored and rarely assessed in clinical practice.

Objectives

This study aims to evaluate the incidence and severity of fatigue in PsA patients under biological agents and to assess the influence of several clinical and demographic features on PsA related fatigue.

Methods

We conducted a cross-sectional study including patients with PsA, according to CASPAR criteria, treated with biological agents, from our University Hospital and registered in the national database (reuma.pt). Fatigue was assessed by a 13-item self-administered questionnaire (Functional Assessment of Chronic Illness Therapy-Fatigue [FACIT-F]). Data collected and analyzed included: demographic data, disease activity data, functional status, comorbidities and therapies. Student’s t-test, ANOVA and Pearson’s correlation were performed to compare data, as appropriate. A p-value <0.05 was considered statistically significant.

Results

60 PsA patients were included, 61.7% were males, with a mean age at diagnosis of 38.1±10.5 years and a median disease duration of 13.0 (8.75-19.25) years. Most of the included patients had a predominant polyarticular pattern (n=33, 55.0%). The mean FACIT-F score was 34.48±11.61. No differences were found in the FACIT-F score according to gender, pattern of joint involvement, presence or absence of cutaneous involvement, nail dystrophy and/ or dactylitis. Patients with depression and enthesitis exhibited a lower FACIT-F score (p=0.017 and p=0.007, respectively). Patients treated with tofacitinib had a lower FACIT-F score than patients treated with adalimumab (p=0.025). No differences were found among the other biological agents. Patients in remission (according to EULAR response criteria) had a higher FACIT-T score than patients with moderate disease activity (p=0.032). In patients with a predominant axial involvement, inactive disease (according to ASDAS) was associated with a higher FACIT-T score, when compared to very high disease activity (p=0.02). Also, patients with moderate disease activity had a higher FACIT-T score than patients with very high (p=0.003) and high (p=0.008) disease activity.

FACIT-F showed a significant correlation with disease activity scores as BASDAI (r=-0.546, p<0.001), DAS 28 CRP (r=-0.506, p<0.001), CDAI (r=-0.672, p<0.001), SDAI (r=-0.641, p<0.001) and ASDAS CRP (r=-0.500, p<0.001). FACIT-F was also correlated with BASFI (r=-0.598, p<0.001), HAQ (r=-0.701, p<0.001), BASMI (r=-0.431, p<0.001) and MASES (r=-0.401, p<0.001). The authors found strong correlations between FACIT-F and HADS domains (Depression and Anxiety domains; r=-0.850, p<0.001 and r=-0.748, p<0.001, respectively). A strong correlation was also found between the FACIT-F and the 8 domains of health of the SF36 (p<0.001).

Conclusion

Fatigue was a common symptom in our sample of PsA patients and, its magnitude was closely related with disease activity, physical function, depression and anxiety status, indicating its multifactorial nature. We can speculate that achieving disease remission could significantly alleviate the fatigue intensity and vice versa. As recommended by EULAR/ACR task force in 2008, fatigue should be measured in clinical practice and should be part of the multidisciplinary approach, in addition to controlling disease activity.

Disclosure of Interests

None declared

Micronutrients deficiencies in patients with spondylarthritis: the potential immunometabolic crosstalk in disease phenotype

OBJECTIVE

Micronutrient deficiencies (MNDs) are common among patients with certain chronic inflammatory diseases. They are associated with a pro-inflammatory status and co-morbidities. However, no studies have specifically investigated MNDs in Spondyloarthritis (SpA). This paper aimed at analyzing the occurrence of anemia and deficiencies of ferritin (Fe), vitamin D [25(OH)D], vitamin B12 (B12), and folic acid (FA) in SpA patients. The interplay of MNDs with age, gender, and metabolic abnormalities was also explored.

PATIENTS AND METHODS

MNDs were evaluated in 220 SpA outpatients (137 females and 83 age-matched males) with psoriatic arthritis (PsA, n=110) and non-psoriatic SpA (n=110). Metabolic parameters were analyzed. Disease activity was assessed by either Disease Activity in PSoriatic Arthritis (DAPSA) or Ankylosing Spondylitis Disease Activity Score with C-Reactive Protein (ASDAS-CRP) as appropriate, while the functional status was evaluated using Health Assessment Questionnaire modified for SpA (HAQ-S).

RESULTS

Anemia occurred in 13.6% of subjects of the study cohort and almost wholly in females (p=0.004). Females showed higher Fe deficiency (p=0.04) and lower Fe levels (p=0.0003) than males. Hemoglobin (Hb) resulted inversely related to age and CRP (p=0.01 and p=0.008) in male group. The 25(OH)D deficiency (≤20 ng/ml) was present in 23.2% of the cohort with a higher prevalence in males than females (p=0.02): moreover, 25(OH)D inversely correlated with disease duration (p=0.02) in males. The B12 deficiency (≤200 pmol/l) was rare (13.2%), while FA ≤4 ng/ml was frequent (22%) and associated with B12 deficiency in 31% of cases. SpA patients in moderate/high disease activity had higher Body Mass Index (BMI) (p=0.04) and HAQ-S (p<0.0001), as well as lower Hb (p=0.02), and Fe (p=0.03) than patients in remission/low disease activity (LDA). In patients with extra-articular manifestations, female sex was prevalent (F:M=2) and B12 levels were lower than in patients without (p=0.005). Interestingly, 25(OH)D was lower (p=0.04) and both BMI and HAQ-S (p=0.036 and p=0.01) were higher in patients without extra-articular involvement than patients with.

CONCLUSIONS

Our findings documented a relevant prevalence of MNDs in SpA patients, and its strict interplay with gender and metabolic abnormalities by highlighting the role of MNDs in inflammatory-dependent dysmetabolism in SpA.

Building a roadmap for the evaluation of a National Health Plan: the experience of Portugal

Issue

The National Health Plan (PNS) 2012-2016 (extended until 2020) is the Portuguese strategic health document that presents the direction of intervention within the Health System. A final evaluation of PNS was foreseen, with National Institute of Health Dr Ricardo Jorge (INSA) being responsible for carrying out this task. The experience gained by INSA in defining a roadmap to be used in this process can be important in steering other actors to policy evaluation.

Description of the problem

In order to analyze the impact of policies, it is necessary to collect evidence that can evaluate the results achieved, and more importantly, identify gaps in implementation and evaluation issues. Herein, we aim to present the methodological approach developed to pave the way to the final assessment of PNS.

Results

As part of the Biennial Collaborative Agreement 2016-2017, WHO sponsored a high-level technical consultative process with relevant experts to address the condition for defining the work plan. It was devised to undertake: i) A scoping review based upon data collected from PNS implementation evidence mapping; ii) A qualitative analysis of the perception from main stakeholders on PNS impact and their expectations. Thus, a matrix of evidence was built to analyze the alignment of PNS at national and local levels, and with the main health framework targets and indicators. Also, online surveys and face-to-face interviews were done with key stakeholders in order to identify evidence gaps and critical factors for the successful PNS implementation, among others.

Lessons

To characterize its implementation and impact on citizens' health, a sound PNS evaluation should be guided by clear assessment questions, supported by validated tools and complemented by international guidance. In addition, a long-term consultative process with key stakeholder support is required to properly identify opportunities, priorities, and outcomes.

Key messages

Institutionalization of an evaluation process as part of public policies life cycle is a powerfull tool to foster learning and crucial to achievement of proposed goals. A clear structure to support the policy evaluation approach is mandatory to guarantee impartiality, independence and transparency on the overall process.

Health impact assessment of a voluntary protocol to decrease salt in bread: what can we learn?

Issue

Hypertension (HT) is a major and modifiable risk factor for cardiovascular diseases (CVD), which can be caused by excessive salt intake. Portugal has one of the highest mortality rate due to CVD in Europe, mainly due to HT. Thus, reduction of salt intake from food products is one of major strategies advocated to modify blood pressure (BP) and its impact on HT.

Description of the problem

The Portuguese population has excessive daily salt intake mainly due to bread consumption. Thus, in 2017 a voluntary ‘Protocol' was signed between stakeholders with the goal to reduce salt content in bread by 2021. Herein, using a Health Impact Assessment (HIA) approach we aimed to estimate the potential effect in BP from the implementation of this ‘Protocol'. Thus, two national surveys were used to find average values of salt intake and BP on population, while estimates of BP reduction were calculated based upon meta-analysis data.

Results

It was expected that the implementation of the ‘Protocol' could reduce salt ingestion and have a higher BP effect, mostly in more vulnerable populations. In fact, results showed that individuals with low educational level, men, aged and residents in the South region of Portugal were the ones that could more benefit from the ‘Protocol' implementation. However, this study found that the effects were be very low for all groups analysed, suggesting that only slight health gains can occur.

Lessons

The ‘Protocol' as a voluntary agreement is not sufficient to attain the public health targets devised. Following the HIA framework, further complementary and intersectoral integrated measures, through the use of compulsory food and fiscal policies preferably extended to other highly consumed food products, were thus recommended. HIA could be used as a comprehensive tool to assess health impacts, supporting at each national context the design and implementation of effective strategies to promote salt intake reduction and effectively prevent hypertension.

Key messages

The systematic use of HIA to design the appropriate policy framework and to inform adequately political decision-making is crucial to promote health and prevent Non-Communicable Diseases. Voluntary agreements should be complemented by other integrated measures to improve the efficacy of policies aiming to reduce salt intake and prevent hypertension.

Evaluation of corn hybrids for silage grown in different locations

ABSTRACT The aim of this study was to evaluate the yield, morphometric and chemical characteristics, and the digestibility of various corn hybrids cultivated in different locations for silage production. Four corn hybrids were grown: P2866H, P3456H, P30R50VYH and P4285YHR, in four locations, defined as farm A; B; C and D. The hybrid P4285YHR presented the highest plant and ear insertion heights (2.72m, 1.52m respectively), with a minimum registered height of 2.63 m and 1.42 m, for plant and ear insertion height, and for that reason it presented the highest yield of fresh biomass (78,089kg ha-1). The TND values showed trend very close to that observed in the DISMS of the whole-plant, with hybrid P3456H presenting the highest estimated value (68.74%), and the hybrid P4285YHR the lowest among them (65.25%). In general, lower fibrous carbohydrates and lignin content, higher fibrous carbohydrates content, together with satisfactory grains participation in the plant structure led to a greater dry matter digestibility. Hybrids with lower plant heights do not necessarily have lower dry biomass yields, but hybrids of greater height and with high stem and leaf participation tend to have a higher aFDN content and less dry matter digestibility.

The major endocannabinoid anandamide (AEA) induces apoptosis of human granulosa cells

The endocannabinoid system (ECS) plays a crucial role in human reproduction. Changes in anandamide (AEA) levels affect reproductive events and has already been suggested as biomarker of reproductive potential of male and female gametes. Although cannabinoid-receptor 1 (CB1) was already identified in human granulosa cells (hGCs) the ECS was not characterized on granulosa cells line COV434 nor the effects of AEA on GCs viability and function depicted. Therefore, the aim of this study was to characterize the ECS elements and explore the effects of AEA on both COV434 and hGCs. Our results revealed that hGCs express the full enzymatic machinery responsible for AEA metabolism as well as cannabinoid receptors. In addition, AEA induced a reduction in both COV434 and hGCs viability in a concentration and time-dependent manner. Nevertheless, the effects of AEA in cell viability was independent of either CB1 or CB2 receptors. There was no ROS release in both cell models; however, AEA induced morphological changes, presenting chromatin condensation at 72 h, and variation on mitochondrial membrane potential. Moreover, AEA induced an increase in caspase -3/-7 activities in both cell models, but in hGCs there was also an increase in caspase 8 activity. This study supports the idea that ECS balance is crucial for folliculogenesis and oocyte quality as dysregulated AEA levels may compromise female fertility.

AB0515 MICRONUTRIENT DEFICIENCIES IN PATIENTS WITH SPONDYLOARTHRITIS: AGE AND GENDER IMPLICATIONS

Background:

Micronutrient deficiencies (MNDs) are common among patients with chronic inflammatory diseases. These are associated with a pro-inflammatory status and co-morbidities, and influenced by several factors, such as age and gender.

Objectives:

No any study has investigated MNDs and their correlation with gender in Spondyloarthritis (SpA). With this purpose, this study analyzed the occurrence of anemia and the status of ferritin (Fe), vitamin D [25(OH)D], vitamin B12 (B12), and folic acid (FA) in a cohort of patients with SpA.

Methods:

Levels of Hb, Fe, 25(OH)D, B12, FA, were evaluated in 220 SpA outpatients (137 females and 83 age-matched males) with Psoriatic arthritis (PsA, n=110) and SpA (n=110). Disease activity was assessed by DAPSA or ASDAS-CRP as appropriate and functional status was evaluated with HAQ score. Body Mass Index (BMI) was selected as a metabolic clinic parameter.

Results:

Male and female patients were similar for disease duration and severity as well as the distribution of diagnosis and treatments (Table 1). In males, BMI was higher than in females (P=0.03) and positively correlated with the age (P=0.01). In female patients, BMI directly correlated with HAQ (P=0.03). The prevalence of anemia (Hb<12) was 13.6% of the study cohort; half of anemic patients had PsA, the others had enteropathic SpA (ESpA). Anemia resulted almost wholly in female patients (99%). In the male group, Hb resulted inversely related to age (P=0.01) and CRP levels (P=0.008). Ferritin was lower in females than in males (P=0.0003). 25(OH)D deficiency (≤20 ng/ml) was present in 23.2% of the cohort: males had lower 25(OH)D than females (P=0.02). Among male patients, disease duration correlated positively with ferritin (P<0.001) and inversely with 25(OH)D (P=0.02). Low levels of serum B12 (≤200 pmol/l) were rare (13.2%), while deficiency in FA (≤4 ng/ml) was frequent (22%) and associated with B12 defect in 31% of cases, with almost similar occurrence in males and females. A diagnosis of ESpA occurred in 55% of cases with B12 deficiency and 62.5% of FA defect, without gender difference. Mean levels of ferritin, 25(OH)D, B12, and FA did not differ significantly between PsA and SpA patients.

Table 1.

Data from the study population.

Females (n=137)Males (n=83)PAge (yrs; §)51.65 ± 1352.9 ± 12.8NSBMI (*)24 [17.2 - 50.2]25.8 [19.6 - 43.6]< 0.05CRP (mg/l; *)2.9 [0 - 53]2 [0 - 61]NSHb (g/dl; §)13 ± 1.214.4 ± 1.4NSFe (mg/l; *)37 [2 - 148]64 [4 - 452]< 0.0525(OH)D (ng/ml; *)28.2 [5 - 67]25 [5 - 50]< 0.05Vitamin B12 (pmol/l; *)350 [60 - 990]313 [47 - 797]NSFolic Acid (ng/ml; *)7 [1.7 - 40]6.9 [1.8 - 39]NSPsA (N/%)73/68.2334/31.77NSSpA (N/%)64/4149/59NSConcomitant IBD (n/%)56/65.929/34.1NSDisease duration (months; *)69 [6 - 540]76.5 [3 - 768]NSLow D.A. (N/%)62/45.2547/56.6NSModerate-high D.A. (N/%)75/54.7536/43.4NSCOXIB-inhibitors (N/%)21/15.48/9.6NScDMARDs monotherapy (N/%)35/25.510/12NSbDMARDs (N/%)81/59.1265/78.4NS

BMI, body mass index; CRP, C-reactive protein; Hb, haemoglobin; Fe, ferritin; 25(OH)D, vitamin D; PsA, psoriatic arthritis; SpA, spondyloarthritis; IBD, inflammatory bowel disease; D.A., disease activity; cDMARDs, conventional Disease Modifying Antirheumatic Drugs; bDMARDs, biological DMARDs; § mean ± SD; * median [min-max].

Conclusion:

Our study describes for the first time the possibility of a relevant prevalence of MNDs in SpA patients. Furthermore, we show that MNDs could be also influenced by gender difference and age. Of note, our findings highlight the importance of a screening focused on MNDs in SpA patients. This could be key in optimizing management of SpA patients, in which inflammatory-dependent dysmetabolism is frequent.

References:

[1]Yamamoto EA, Jørgensen TN. Relationships Between Vitamin D, Gut Microbiome, and Systemic Autoimmunity. Front Immunol. 2020;10:3141.

[2]Charoenngam N, Holick MF. Immunologic Effects of Vitamin D on Human Health and Disease. Nutrients. 2020;12:2097.

[3]Bañuls-Mirete M, Ogdie A, Guma M. Micronutrients: Essential Treatment for Inflammatory Arthritis? Curr Rheumatol Rep. 2020;22:87.

Disclosure of Interests:

None declared.

POS0502 WHAT IS THE ROLE OF VITAMIN D STATUS IN DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH bDMARDs? – DATA FROM A RHEUMATOLOGY CENTER

Background:

Vitamin D is a fat-soluble vitamin, mainly involved in the regulation of calcium metabolism, and it has gained increasing interest in recent years because of its potential role in immunomodulatory activity. Recent data suggest that it is negatively associated with disease activity in rheumatoid arthritis (RA), however this is not yet fully understood.

Objectives:

This study’s aim was to investigate if there is any correlation between vitamin D serum levels at baseline, before taking the first biological disease-modifying antirheumatic drug (bDMARD), and at 6 months after, with disease activity in a cohort of RA patients.

Methods:

This is a cross-sectional study, including all the rheumatoid arthritis patients taking the first bDMARD with evaluation of the vitamin D status at baseline and 6 months after biologic therapy at our Rheumatology Department and registered in the national database (Reuma.pt).

Demographic, clinical and laboratorial characteristics and disease activity measures were collected from the baseline visit and the visit after 6 months of treatment with the first biologic. For the statistical analysis, two groups were defined, based on the serum levels of 25(OH) vitamin D, considering the most common cut-off of 30 ng/mL. For comparison analyses between groups, chi-square test was used for categorical variables and Mann-Whitney U and T-tests were applied for continuous variables.

Results:

Seventy-seven patients were included, 58 (75.3%) were females; the mean age was 54.24 ±11.0 years and seropositivity was founded in 65 (84.4%) for anti-citrullinated protein antibodies and in 58 (75.3%) for rheumatoid factor. The first bDMARD most commonly prescribed were etanercept (28.6%) and rituximab (26%). Regarding the vitamin D status at baseline, the mean serum level for 25(OH)vitamin D was 28.35 ± 18.21 ng/mL, with the majority of patients having vitamin D insufficiency (25(OH)vitamin D < 30 ng/mL) (63.6%). After 6 months of treatment with the first bDMARD, disease activity measures showed that remission or low activity were achieved in 29.9% of the patients, using DAS28 criteria; in 42.9% and 46.8%, according CDAI and SDAI criteria, respectively. Vitamin D serum levels at 6 months were 26.81 ±11.72, with the majority of patients still with vitamin D insufficiency (62.3%).

At baseline, patients with vitamin D insufficiency had greater patient VAS (79.00 ± 19,14 vs 71.71 ± 21.95), greater erythrocyte sedimentation rate (ESR) (40.67 ± 23.17 vs 32.46 ± 26.09) and greater Health Assessment Questionnaire (HAQ) score (1.75 ± 0.609 VS 1.61 ± 0.659) with neither of them having statistical significance. However, when comparing CRP levels at 6 months, it achieved statistical significance with the Mann-Whitney U-test (1.05 ± 1.79 VS 1.41 ± 5.22; p=0.026).

The same tendency was confirmed when analyzing vitamin D levels at 6 months. Patients with vitamin D insufficiency presented greater patient VAS (55.33 ± 28.82 vs 42.86 ± 28.28), greater ESR (26.19 ± 21.57 vs 21.00 ± 20.38) and greater HAQ score (1.35 ± 0.662 VS 1.34 ± 0.705), although without statistical significance. However, it did achieve statistical significance when comparing baseline DAS28 and HAQ (5.60 ± 0.91 VS 5.38 ± 1.31; p=0.013 and 1.76 ± 0.53 VS 1.59 ± 0.75; p=0.007, respectively).

Conclusion:

Our data failed to demonstrate a statistically significant association between vitamin D serum levels at baseline and at 6 months with disease activity in our RA sample. However, it revealed a positive trend of vitamin D insufficiency related to higher activity disease. Interestingly, it showed that vitamin D insufficiency after 6 months of bDMARD treatment is related to higher DAS28 and HAQ at baseline. Nonetheless, we insist it is of paramount importance to conduct larger studies to confirm these findings.

References:

[1]Bellan M, Sainaghi PP, Pirisi M. Role of Vitamin D in Rheumatoid Arthritis. Adv Exp Med Biol. 2017;996:155-168.

Disclosure of Interests:

None declared

AB0476 VITAMIN D SERUM CONCENTRATION VARIES ACCORDING TO DISEASE ACTIVITY IN SPONDYLOARTHRITIS

Background:

Several studies have shown dissimilar results for the relationship between serum 25-hydroxyvitamin D concentration (25-OH-D) and disease activity in spondyloarthritis (SpA).

Objectives:

This study aims to assess whether vitamin D levels vary according to disease activity in patients with SpA before and after starting treatment with biologic disease-modifying anti-rheumatic drugs (bDMARDs).

Methods:

An observational retrospective study was performed in SpA patients followed in the Rheumatology department of a tertiary university hospital. Demographic and clinical data were collected from the Rheumatic Diseases Portuguese Register (Reuma.pt). Patients were assessed for 25-OH-D levels before and after 6 months of treatment with the first bDMARD. Correlation between 25-OH-D levels and disease activity measured by Ankylosing Spondylitis Disease Activity Score (ASDAS) at baseline and after 6 months were assessed using student’s t-test for two samples and one-way ANOVA and with post hoc tests for multiple comparisons.

Results:

A total of 189 patients were included. Ninety-seven patients were females (51.3%). The mean age at diagnosis was 34.8±11.2 years and the median disease duration at the start of the first bDMARD was 4.9 years (min: 0.1; max: 46.0). All patients fulfilled the ASAS criteria for SpA. Nonsteroidal anti-inflammatory drugs were used by 102 patients (54.0%) and conventional synthetic DMARDs by 69 patients (36.5%). At 6 months, 188 patients were treated with tumor necrosis factor inhibitors and one with interleukin-17 inhibitor. According to ASDAS criteria, at baseline 36.8% of patients had high disease activity and 59.5% had very high disease activity. After 6 months of treatment with bDMARD 14.7% of patients have inactive disease, 21.6% low disease activity, 36.3% high activity and 12.6% very high disease activity. The mean value of 25-OH-D at baseline was significantly lower in the group of patients with very high disease activity compared to the patients with high disease activity (21.9±11.1 ng/ml vs 26.1±11.6 ng/ml, p= 0.02). At 6 months of treatment the mean value of 25-OH-D in inactive, low, high and very high disease activity was 31.0±17.1ng/ml, 28.5±11.2ng/ml, 25.8±10.8ng/ml and 19.3 ±9.5ng/ml, respectively. There was a statistically significant difference between the groups, as determined by one-way ANOVA (p = 0.001). A post hoc Dunnett T3 test revealed that patients with very high disease activity have significantly lower mean 25-OH-D levels (19.29 ± 9.5) than patients with inactive disease (31.0 ± 17.1, p = 0.025) and low activity (28.5 ± 11.2, p = 0.009). Among the groups with high and very high disease activity, the significance is only marginal (p = 0.068).

Conclusion:

Vitamin D serum concentration varies according to disease activity in SpA. In fact, SpA patients with lower levels of 25-OH-D are associated with higher rates of disease activity, even in patients treated with biologics agents. It is important to be aware of vitamin D level as it can play a role in the management and treatment of the disease, mainly in the most severe patients.

References:

[1]Zhao SZ, Thong D, Duffield S, Goodson N. Vitamin D Deficiency in Axial Spondyloarthritis is Associated With Higher Disease Activity. Arch Rheumatol. 2017 Mar 24;32(3):209-215. doi: 10.5606/ArchRheumatol.2017.6212. PMID: 30375524; PMCID: PMC6190948.

Disclosure of Interests:

None declared.

POS1067 BASELINE VITAMIN D LEVELS AND DISEASE ACTIVITY AND RESPONSE IN PORTUGUESE PATIENTS WITH PSORIATIC ARTHRITIS UNDER bMDARD: DOES IT MAKE A DIFFERENCE?

Background:

There is growing evidence that vitamin D [25(OH)D]) plays an important role in maintaining skeletal health and modulating the immune system. Epidemiological data indicate that vitamin D deficiency is common in immune-mediated rheumatic diseases, especially in rheumatoid arthritis, but there is little data regarding its association with disease activity and response to therapy in patients with psoriatic arthritis (PsA) under bDMARD therapy.

Objectives:

We aimed to assess whether 25(OH)D basal levels correlate with disease activity and clinical response to the first bDMARD, at 6 and 12 months of therapy, in a monocentric cohort of patients with PsA.

Methods:

This retrospective study was carried out on PsA patients from a Rheumatology department of a tertiary hospital, fulfilling CASPAR criteria and registered in our national database (Reuma.pt), who started the first bDMARD since 2008. Demographic, clinical and laboratory criteria were evaluated at 0, 6 and 12 months of biologic therapy. Disease activity was assessed using CDAI, SDAI, DAS28(4V), BASDAI, ASDAS, DAPSA and the response was measured using the EULAR, BASDAI50, ASDAS, ASAS, ACR and PsARC responses. Correlations were made between absolute serum levels of 25(OH)D and continuous variables, as well as associations between different vitamin D cutoffs and disease activity measures and response criteria. Multiple linear and logistic regression analyses were performed to determine whether vitamin D is a predictor of disease activity and therapeutic response.

Results:

We included 81 patients, 41 (50.6%) females; with a mean age of 48.0±11.7 years, a mean disease duration of 9.5±7.4 years and a mean body mass index of 28.4±5.2 kg/m2. Thirteen (16.0%) were smokers. The mean 25(OH)D basal level was 25.5±13.2 ng/ml, 21 (25.9%) had 25(OH)D basal levels ≥30 ng/mL and 31 (38.3%) ≤20 ng/mL. Sixty-two patients (76.5%) were under csDMARD therapy. Golimumab (29, 35,8%), etanercept (28, 34.6%) and adalimumab (10, 12.3%) were the most frequently prescribed bDMARDs. There were only very weak, albeit positive, correlations between 25(OH)D levels and measures of disease activity. The BASDAI50 response at 6 months was associated with higher basal 25(OH)D levels (29.5±14.5 vs 21.5±10.2 ng/mL, p = 0.013); the ASAS20 (33.9±15.9 vs 24.2±12.8 ng/mL; p = 0.023), ASAS40 (31.9±14.6 vs 25.0±13.8 ng/mL; p = 0.023) and ASAS70 (47.0±4.2 vs 26.6±14.2; p = 0.027) responses at 12 months were associated with higher basal levels of 25(OH)D; basal 25(OH)D levels were ≥ 30ng/mL in a significantly higher proportion of patients who achieved CDAI (38.9% vs 10.5%; p = 0.027) and SDAI (38.9% vs 7.7%; p = 0.008) remission and ASDAS disease inactive (29.4% vs 7.3%; p = 0.040) at 1 year. In the regression models, basal levels of 25(OH)D were found to be predictors of good EULAR responders (OR 1.315, 1.017-1.213 95% CI; p = 0.037) at 6 months. Basal levels of 25(OH)D were not significantly different in patients who discontinued bDMARD and no significant correlations or associations were identified regarding more specific PsA activity measures, such as DAPSA and PsARC, nor were they predictive of these responses.

Conclusion:

We can conclude that there is a global trend for an association between higher levels of vitamin D and lower measures of disease activity and better therapeutic responses to the first biologic. It was possible to find statistically significant associations with some disease activity measures and response criteria that, although primarily designed for other rheumatic diseases, are often used in PsA.

Disclosure of Interests:

None declared.

AB0608 BONE MINERAL DENSITY, VITAMIN D STATUS AND BONE METABOLISM IN A COHORT OF ADULT PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Background:

Patients with inflammatory bowel disease (IBD) have an increased risk of low bone mineral density (BMD) and bone fractures due to several mechanisms. However, the best management of osteoporosis in this population is yet to determine.

Objectives:

To evaluate bone mineral density and other clinical, analytical and demographic features related with the risk of bone fractures in an IBD cohort.

Methods:

Retrospective monocentric study including all the patients with IBD consecutively reffered from Gastroenterology to the Rheumatology Department in a tertiary university hospital between January of 2013 and October 2020. Demographic, clinical and analytical data and BMD by dual-energy X-ray absorptiometry (DXA) (total hip, femoral neck and lumbar spine) were collected at the time of the first visit in the Rheumatology outpatient center. Correlations between variables were evaluated by Spearman rank test and Mann-Whitney U test was used in the comparison analysis between groups (significance level at p<0.05), using SPSS 25.0 software.

Results:

A total of 222 patients were included: 128 (57.7%) females, mean age of 43.4 (±13.6) years, mean IBD duration of 11.6 (±9.7) years. Regarding IBD: 163 (73.4%) had Crohn’s disease (CD) and 59 (26.6%) had ulcerative colitis (UC); azathioprine (41.9%) and infliximab (29.8%) were the most frequently used drugs; 10 patients (4.5%) were taking glucocorticoids, 104 (46.8%) had been previously treated with glucocorticoids and 65 (29.3%) had already been exposed to high doses of glucocorticoids (prednisolone equivalent dose ≥ 7.5 mg/day).

Ten patients (4.5%) had previous fragility fractures and 32 (14.4%) fulfilled diagnostic criteria of osteoporosis by DXA (T score ≤ -2.5). One hundred eighty-one (81.5%) patients exhibited low levels of 25-hydroxy vitamin D (<30ng/mL), 24 (10.8%) had high levels of parathormone and 150 (67.6%) showed elevated serum concentrations of beta-carboxy-terminal type-1 collagen crosslinks (beta-CTX). Three patients (1.4%) were under treatment with bisphosphonates and 18 (8.1%) were taking calcium and/or vitamin D supplements.

Of interest, serum levels of albumin correlated negatively with beta-CTX (r=-0.401; p<0.001) and positively with osteocalcin (r=0.259; p<0.001). Correlations between clinical/analytical variables and BMD are presented in Table 1.

Patients under glucocorticoids had lower mean total hip BMD (0.874±0.159 vs 1.008±0.176; p=0.022) and femoral neck BMD values (0.797±0.174 vs 0.933±0.179; p=0.014) in comparison with the group of patients that were not taking glucocorticoids.

No statistically significant differences in BMD values were found between the following subgroups: DC vs UC; normal vs low levels of 25-hydroxy vitamin D; patients exposed vs not exposed to high doses of glucocorticoids.

Table 1.

Correlations between clinical/analytical variables and the BMD in an IBD population (BMD: Bone Mineral Density; IBD: Inflammatory Bowel Disease; n.s. not significant).

Total hip BMDFemoral neck BMDLumbar Spine BMDAger=-0.356;p<0.001r=-0.469;p<0.001r=-0.259;p<0.001Age at IBD diagnosisr=-0.254;p<0.001r=-0.327;p<0.001r=-0.226;p=0.001IBD durationr=-0.147;p=0.031r=-0.218;p=0.001n.s.Hemoglobinr=0.249;p<0.001r=0.209;p=0.002n.s.Albuminr=0.189;p=0.005r=0.208;p=0.002n.s.Erythrocyte sedimentation rater=-0.231;p=0.001r=-0.206;p=0.003n.s.

Conclusion:

Our results show an important prevalence of undiagnosed and untreated osteoporosis in patients with IBD. Stronger correlations were found between clinical/analytical variables and femoral neck BMD. Of note are the weak correlations of BMD with acute-phase markers (negative correlation with erythrocyte sedimentation rate and positive correlations with hemoglobin and albumin) and of nutritional status (evaluated by albumin) with bone markers (negative correlation with the bone reabsorption marker beta-CTX and positive correlation with the bone formation marker osteocalcin).

Disclosure of Interests:

None declared.

AB0137 THE ASSOCIATION BETWEEN AUTOANTIBODY LEVELS AND THE OUTCOMES OF ANTI-TUMOUR NECROSIS FACTOR ALPHA TREATMENT IN RHEUMATOID ARTHRITIS - A RETROSPECTIVE COHORT STUDY WITH TWO YEARS FOLLOW-UP

Background:

In rheumatoid arthritis (RA), autoantibodies namely anticitrullinated protein antibodies (Anti-CCP) have prognostic value, independently predicting radiologic progression. However, the evidence is still controversial about how the autoantibody levels change over time and their role in treatments outcomes and in monitoring disease activity in RA.

Objectives:

This study aimed to characterize the changes of autoantibodies levels (rheumatoid factor (RF) and Anti-CCP) over time and to explore the association between these autoantibodies and the outcomes of the first anti-tumour necrosis factor alfa (anti-TNF-α) therapy as first biologic agent in RA.

Methods:

An observational retrospective cohort study was conducted with two years of follow-up. Patients with diagnosis of RA according to American College of Rheumatology (ACR) criteria and registered on Rheumatic Diseases Portuguese Register (Reuma.pt) who started their first anti-TNFα agent (as first biologic) between 2003 and 2018 were included. Patients with positive RA (>30 UI/mL) and/or positive Anti-CCP (>10 U/mL) at their first visit were included. Demographic, clinical and laboratory data were obtained by consulting Reuma.pt. Disease Activity Score for 28 joints [DAS28(3v); DAS28(4v); DAS28(3v; C-Reactive Protein (CRP)), DAS28(4v; CRP), delta DAS28(4v)], Health Assessment Questionnaire (HAQ), delta HAQ, Anti-CCP and RF levels were assessed at baseline, 12 and 24 months. Continuous variables are presented with mean, standard deviation, median, quartile 1 and quartile 3. Categorical variables are presented with absolute and relative frequencies. To examine the differences between Anti-CCP and RF levels at baseline, 12 months and 24 months the Wilcoxon test for paired samples was performed. In order to correlate the Anti-CCP and RF levels with DAS28 variables, delta DAS28(4v), HAQ and delta HAQ at baseline, 12 months and 24 months, a correlation coefficient, Spearman’s coefficient, was used.

Results:

A total of 116 patients (mean age of 50.2±10.4 years old; 85.3% female) with RA were included with a median disease duration of 10.5 [5-18.5] years and a follow-up time of 8 [5-14] years. About 49% of patients were FR and Anti-CCP positivity, 38% only FR positivity and 13% only Anti-CCP positivity. At baseline, 64 (55.2%) patients had an erosive disease and 50 (43.1%) had extra-articular manifestations. Compared to the baseline (160[74.8-496]), FR levels decreased significantly at 12 months (121[49.1-321.8]) and 24 months (107.5[43.3-332]) with a p=0.017 and p=0.029, respectively. There were no differences in Anti-CCP levels over time. No correlation was found between FR/Anti-CCP levels and different DAS28 variables, DAS28(4v) delta, HAQ, and HAQ delta at 12 months and 24 months.

Conclusion:

We found that in patients with RA treated with a first anti-TNF-α agent as first biologic, FR levels decreased at 12 months and 24 months follow-up. However, our study failed to demonstrate a correlation between autoantibodies levels and disease activity (DAS28 variables and delta DAS28(4v)), HAQ and delta HAQ. In fact, previous research demonstrated that there is an association between autoantibodies levels and disease activity in RA, nonetheless not being static and increasing with signs of inflammation at baseline. So, further research with large samples is needed to explore this correlation considering the adjustment for confounding inflammatory variables, such as number of swollen or tender joints and morning stiffness.

Disclosure of Interests:

None declared

AB0835 IS BASELINE VITAMIN D STATUS RELATED WITH THE RESPONSE TO BDMARDS IN SPONDYLOARTHRITIS PATIENTS?

Background:

Vitamin D is thought to have an important role in immune regulation and is being subject of research in several autoimmune diseases. Some data suggest that vitamin D deficiency is common in Spondyloarthritis (SpA) and may be associated with disease activity and structural damage.

Objectives:

To evaluate if there is a relation between baseline vitamin D status and the response to biologic disease-modifying antirheumatic drugs (bDMARDs) in a SpA monocentric cohort.

Methods:

Retrospective study including all the SpA patients (ASAS classification criteria) followed at our Rheumatology Department, registered in the national database and treated with bDMARD between June 2008 and July 2020. Demographic, clinical and laboratorial data (including 25-hydroxyvitamin D [25-OHvitD]) at baseline and disease activity measures at 6 and 12 months of treatment with the first bDMARD were collected. Correlations between variables were evaluated by Spearman rank test, Mann-Whitney U test was used to the comparison analysis between groups and univariate logistic regression was used in the prediction analysis.

Results:

A total of 195 SpA patients were included: 103 (52.8%) females, 47 (24.1%) smokers and 91 (46.7%) HLA-B27 positive; 139 (71.3%) had Ankylosing Spondylitis, 18 (9.2%) had Inflammatory Bowel Disease Associated SpA and 38 (19.5%) had Undifferentiated SpA. At the time of the first bDMARD, the mean age was 43.5 years (±9.6) and the median disease duration was 12.4 years (0.7-52.7). The mean ASDAS-CPR (Ankylosing Spondylitis Disease Activity Score with C-reactive protein) was 3.9 (±0.8) and, in addition, 61 (31.3%) patients had 25-OHvitD levels below 30 ng/mL and 12 (6.2%) had 25-OHvitD levels below 20 ng/mL. Fifty-three patients (27.2%) were taking NSAIDs (nonsteroidal anti-inflammatory drugs), 77 (39.5%) were under csDMARDs (conventional synthetic disease-modifying antirheumatic drugs). Adalimumab (56%) and golimumab (33.3%) were the most frequently initiated bDMARDs in the first line.

There were no statistically significant correlations between baseline 25-OHvitD levels and ASDAS-CRP at 6 (r=0.031; p=0.714) and 12 months (r=0.035; p=0.672) of bDMARD.

In the subgroup analysis: there were no statistically significant differences in the response to bDMARD at 6 and 12 months evaluated by ASDAS response and ASAS 20, 40 and 70 responses according to the baseline 25-OHvitD levels (25-OHvitD <20ng/mL vs ≥20ng/mL; 25-OHvitD <30ng/mL vs ≥30ng/mL); and there were no statistically significant differences in the baseline 25-OHvitD levels at baseline according to the response to bDMARD at 6 and 12 months of bDMARD (ASDAS: no response vs clinically important improvement or major improvement; ASAS 20: no response vs response).

In the line of these previous results, baseline 25-OHvitD levels did not predict the ASDAS response at 6 (OR 0.97 [0.95-1.00], 95% CI) or 12 (OR 0.98 [0.95-1.01], 95% CI) months of bDMARD.

Conclusion:

Despite some data that suggest that lower levels of 25-OHvitD may be associated with higher disease activity in SpA, our results failed to demonstrate that the baseline 25-OHvitD levels can be related or predict treatment response after 6 and/or 12 months of therapy with the first bDMARD in real-life SpA patients.

Disclosure of Interests:

None declared

POS1106 FRAX AND THE EFFECT OF TERIPARATIDE ON BONE MINERAL DENSITY IN SECONDARY OSTEOPOROSIS

Background:

Teriparatide has been shown to increase spine and hip bone mineral density (BMD) and to reduce vertebral and non-vertebral fractures. (1) It is currently not clear whether the effect of teriparatide is dependent on the baseline risk of fracture or osteoporosis (OP) type, a finding that could have an impact on our therapeutic decision.

Objectives:

Investigate if there is a relationship between teriparatide effect in BMD and baseline 10-year fracture probability, assessed using FRAX®, in primary and secondary OP patients.

Methods:

This is a longitudinal, retrospective study including consecutive patients with the diagnosis of OP treated with teriparatide for 24 months, with a ten-year follow-up period, at our rheumatology department. Demographic, clinical, laboratorial, BMD and occurrence of fracture data were collected. The 10-year risk of osteoporotic fracture was estimated using the fracture risk assessment tool (FRAX) v 4.1 with the Portuguese population reference. Statistical analysis was performed using the software SPSS 23.0. Correlations between continuous variables were evaluated with spearman coefficient. p<0.05 was considered statistically significant.

Results:

Eighty patients (88.8% female, median age 65.00 (59; 75)) were included. Forty-nine patients (61.3%) has secondary OP, mainly of cortisonic etiology (61.2%, n=30). Before treatment, median lumbar spine BMD was 0.870 [0.767, 0.964] g/cm2, median T-score of -2.60 (-3.30, -1.90); median total femur BMD was 0.742 [0.667, 0.863] g/cm2, median T-score of -2.10 (-2.80, -1.30); median femoral neck BMD was 0.671 [0.611, 0.787] g/cm2, median T-score of -2.50 [-3.20, -1.85]. Regarding fracture risk, median FRAX-based 10-year major fracture risk (with BMD) at baseline was 16% [10.0; 23], and median hip fracture risk was 7.2% [3.4; 13.8].

The median variation of BMD, after finishing teriparatide treatment, in the spine was 0.107 [0.029; 0.228]; median BMD variation in total femur was 0.013 [-0.013; 0.068] and median BMD femoral neck was 0.046 [-0.002; 0.109]. We observed a numerically superior effect, albeit without any statistical significance, of teriparatide on bone mineral density gain in secondary OP (versus primary OP) at lumbar spine, total femur and femoral neck.

Most patients continued anti-osteoporotic treatment with a bisphosphonate (81.2%, n=65) and, during follow-up, 17 patients had an incident fracture (8 hip fractures and 6 vertebral fractures), median of 5 [1.75, 8.25] years after ending teriparatide.

We found a discrete correlation between FRAX-based hip fracture probability and the variation of bone mineral density in total femur (Spearman’s coefficient 0.248, p = 0.04). There was no correlation between FRAX-based major fracture probability and and the variation of bone mineral density in the spine or femur. When we separately analyze the relationship between the variation in total hip BMD and the FRAX-based fracture risk, depending on whether it is a secondary or primary OP, we find that the correlation is stronger and only remains in secondary OP (Spearman’s coefficient 0.348, p = 0.03).

Conclusion:

Our data suggest that teriparatide could be an important weapon in the treatment of secondary cause OP, particularly cortisonic, and in patients at high fracture risk, although further larger studies are needed to confirm these findings.

References:

[1]Kendler DL, Marin F, Zerbini CAF, Russo LA, Greenspan SL, Zikan V, Bagur A, Malouf-Sierra J, Lakatos P, Fahrleitner-Pammer A, Lespessailles E, Minisola S, Body JJ, Geusens P, Möricke R, López-Romero P. Effects of teriparatide and risedronate on new fractures in post-menopausal women with severe osteoporosis (VERO): a multicentre, double-blind, double-dummy, randomised controlled trial. Lancet. 2018 Jan 20;391(10117):230-240. doi: 10.1016/S0140-6736(17)32137-2.

Disclosure of Interests:

None declared.