New-Onset Rheumatic Immune-Mediated Inflammatory Diseases Following SARS-CoV-2 Vaccinations until May 2023: A Systematic Review

A comprehensive, up-to-date systematic review (SR) of the new-onset rheumatic immune-mediated inflammatory diseases (R-IMIDs) following COVID-19 vaccinations is lacking. Therefore, we investigated the demographics, management, and prognosis of new R-IMIDs in adults following SARS-CoV-2 vaccinations. A systematic literature search of Medline, Embase, Google Scholar, LitCovid, and Cochrane was conducted. We included any English-language study that reported new-onset R-IMID in adults following the post-COVID-19 vaccination. A total of 271 cases were reported from 39 countries between January 2021 and May 2023. The mean age of patients was 56 (range 18-90), and most were females (170, 62.5%). Most (153, 56.5%) received the Pfizer BioNTech COVID-19 vaccine. Nearly 50% of patients developed R-IMID after the second dose of the vaccine. Vasculitis was the most prevalent clinical presentation (86, 31.7%), followed by connective tissue disease (66, 24.3%). The mean duration between the vaccine's 'trigger' dose and R-IMID was 11 days. Most (220, 81.2%) received corticosteroids; however, 42% (115) received DMARDs such as methotrexate, cyclophosphamide, tocilizumab, anakinra, IV immunoglobulins, plasma exchange, or rituximab. Complete remission was achieved in 75 patients (27.7%), and 137 (50.6%) improved following the treatment. Two patients died due to myositis. This SR highlights that SARS-CoV-2 vaccines may trigger R-IMID; however, further epidemiology studies are required.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

AB0393 SURVIVAL ON JANUS KINASE INHIBITORS VERSUS OTHER ADVANCED THERAPIES IN RHEUMATOID ARTHRITIS

Background

Four Janus Kinase inhibitors (JAKi) are licensed in the UK for treating rheumatoid arthritis (Upadacitinib, Tofacitinib, Filgotinib and Baricitinib). Several analyses have examined the survival in these groups of drugs and found them more likely to be tolerated more or equivalently than other modes of action. Recent data suggested an age influence on survival on these drugs.

Objectives

To study the overall survival rates of JAKi compared to the other biologic treatments in a single centre cohort.

Methods

We analysed patients commencing advanced treatments (anti-Tumour necrosis factor, Interleukin 6 blocker, Rituximab and Abatacept) between February 2011 and October 2021. Variables examined included gender and age. The time on drug was compared between JAKi and other treatments using student’s T test. Chi squared test was used to compare categorical variables. A Cox regression model was fitted to compare length of stay on each agent JAKi length of stay was compared to length of stay on other agents combined.

Results

592 patients were included in the analysis. 168 (28%) were started on JAKi. 435 (73.48%) were females. Mean age at drug start was 60.6 years (SD 13.5). The numbers on drug were Filgotinib n=10, Tofacitinib n=35, Upadacitinib n=37, Baricitinib n=86, Adalimumab n=211, Abatacept n=36, Certolizumab n=18, Etanercept n=112, Golimumab n=21 and Tocilizumab n=26. 93 (15.7%) discontinued their drug, mostly due to lack of efficacy. Mean number of days on any biologic treatment was 918.9 (SD 711.5). Patients on JAKi had a significantly shorter survival on drug 652.7 days vs 1024.4 days (P<0.001).

There were no significant differences in age and gender between the groups. Univariate regression showed a hazard ratio of 1.19 (95%CI 0.75,1.98). This remained non-significant after adjusting for age and gender (1.18 95%CI 0.71,1.95). The only predictor of stoppage was age (HR 1.03 95%CI 1.01,1.04).

Conclusion

In this relatively large observational study, there was no difference in predictors of stoppage between JAKi and other advanced therapies. Increasing age was found to be a predictor for stoppage. This is in line with other reports in the literature. Further work looking at the impact of serology and disease activity will be performed.

Disclosure of Interests

Nauman Bakhtiar: None declared, Leanne Gray: None declared, Syed Mujtaba Bilgrami Grant/research support from: Grants for BSR & EULAR Conferences in the past., Lesley Ottewell: None declared, Fiona Wood: None declared, Marwan Bukhari Speakers bureau: Bristol-Myers Squib, UCB celltech, Roche/Chugai, Pfizer, Abbvie, Merck, Mennarini, Sanofi-aventis, Eli-Lilly, Janssen, Amgen, Novartis and Gilead

OA41 Audit of the rheumatology PIFU pathway at the UHMB Trust

Background/Aims

Patient initiated follow up (PIFU) is an initiative that allows patients to access follow-up when required by initiating their own appointments. The disruptive impact of the COVID-19 pandemic has created significant capacity constraints on many services that were already experiencing pressures prior to the pandemic, piquing interest in PIFU as a sustainable model of care. The BSR has produced draft PIFU guidance to support rheumatology units to develop and deliver safe, robust and sustainable PIFU care models. We audited our PIFU pathway in line with the BSR’s recommended standards to establish its safety and efficacy since its implementation in 2018.

Methods

This was a retrospective analysis of patients transferred to an active PIFU access plan within UHMBT between February 2018 and November 2019. Patients were identified by the informatics team from the active PIFU access plans. We captured data to include treatments used. The electronic case notes were reviewed to establish reasons for appointment triggers in those who contacted the service, analyse waiting times for clinical review further to making contact and assess subsequent outcomes. Data were entered and analysed in Microsoft Excel 2016.

Results

We had a total of 420 patients on PIFU. We audited 100 of these. 56 were female. Mean age was 63.4 years (24-96). The most common diagnosis was inflammatory arthritis (n = 78). The majority of patients (n = 53) were on a single disease-modifying anti-rheumatic drug (DMARD). 17 patients were on &gt; 1 DMARD and 5 patients were on prednisolone monotherapy, mean steroid dose 4.9 mg daily. 25 patients were not on any treatment. Of those on DMARDS, 63% (44) were on methotrexate, either as monotherapy or in combination with other DMARDs. 68% (30) of those on methotrexate were on a dose of ≤ 15mg weekly. Of the 100 patients, 9 triggered a review within the follow up period. This was usually via the nurse helpline (n = 7). Occasionally the GP triggered a review on behalf of the patient via the advice and guidance line (n = 2). The most common reason for a trigger was a flare of inflammatory arthritis (n = 7) and the remaining two appointments were due to side effects of DMARDs. Patients were contacted via nurse telephone call back within 48 hours of contacting the helpline (n = 8). One patient required an urgent face-to-face consultant review and was seen within 7 days. After contacting the service, all nine patients were reverted to regular follow-up.

Conclusion

Our results confirmed a robust PIFU pathway with appropriate safety nets ensuring prompt access to clinician input when needed. The use of PIFU pathway did not compromise care or result in any worsening clinical outcomes. After validation at 2 years, the majority of our patients on this pathway were onwardly managed through the PIFU model.

Disclosure

S. Achieng: None. L. Gray: None. L. Ottewell: None.

P013 Driving improvement through audit: impact of 2017 regional audit and survey upon giant cell arteritis services in 2020

Background/Aims 

In 2017 an audit and survey of giant-cell arteritis (GCA) services were conducted across northwest England (reported previously). This re-survey in 2020, following publication of revised BSR guidance, sought to identify what changes were made in the intervening period, and provided the opportunity to assess the impact of COVID-19.

Methods 

Rheumatologists from 16 hospitals in northwest England were invited to complete a survey in July 2020. Questions focused on service provision for GCA, including pathways, diagnostics and steroid prescription.

Results 

Responses were received from 14/16 sites in 2017, and 15/16 in 2020. 9/15 (60%) sites reported that the 2017 audit and survey prompted changes to GCA services, with two (13%) stating that it clarified the need for implementation of existing plans. Two sites had a GCA pathway in 2017. Four of the seven sites who committed to introducing one have now done so, bringing the total in 2020 to six. Eight of the nine remaining sites plan to implement one, six with a specific date within six months. Six (40%) have completed additional local audit/QI since 2017. Temporal artery (TA) ultrasound (US) is now available in an additional four sites, bringing the total to 6/15 (40%) in 2020. Two sites reported improvement in both time between first rheumatology consultation and TA biopsy, and time to receive results (now <7 days for each task in 6/15 (40%)). Six additional sites reported providing leaflets on steroids routinely, bringing the total in 2020 to 12/15 (80%), versus 6/14 (43%) previously. Four sites (27%) now have a database of GCA patients (one in 2017). There was no major change in sites having a standard protocol for steroid taper (n = 8 2017; n = 7 2020, 89% and 100% of whom respectively use BSR guidance), nor in the number of patients routinely provided steroid cards (six in 2017; five in 2020). The three sites who do not report giving leaflets on steroids routinely, all had a pathway. 8/15 (53%) reported COVID-19 having an adverse effect upon services, including: reduced access to diagnostics (n = 7: TA US, biopsy, and PET-CT); delayed appointments (n = 4); delayed referrals (n = 3). The tertiary referral centre reported an improvement because access to tocilizumab was facilitated by a relaxation of rules by NHS England.

Conclusion 

The original audit and survey of current GCA practice in 2017 highlighted areas for improvement for each site, and regionally. Sites contributing to this re-survey report that the exercise stimulated them to improve their current care. The 2017 exercise showed a strong correlation between reported practice (survey) and actual practice (audit), leading us to have confidence that responses provided a true picture of care. This work demonstrates the power of audit to drive improvement, at a regional level.

Disclosure 

C.A. Sharp: None. J. Little: None. A. Shahbaz: None. E.F. Wood: None. S. Wig: None. P. Watson: None. S. Varughese: None. L. Teh: None. P. Shah: None. C. Saleh: None. L. Ottewell: None. L. Newton: None. S.R. Moore: None. E. McCarthy: Consultancies; E.M. has received consultancy fees from Chugai. E. MacPhie: None. K. Lazarewicz: None. J. Brockbank: None. J. Bluett: None. L. Mercer: None.

THU0205 RESPONSE TO SMALL MOLECULES IS MOSTLY DRIVEN BY PATIENT GLOBAL ASSESSMENT OF DISEASE: A REAL WORLD OBSERVATION

Background:

Two Small molecules (Tofacitinib and Baricitinib) have been licensed in the UK for the use in rheumatoid arthritis. Their licensing came from several studies that showed good efficacy with baricitinib (1) study showing superior efficacy to adalimumab and tofacitinib showing non inferiority to TNF drugs (2). The response has also been shown in patient reported outcomes (find reference). Response when measure using the DAS score has two relatively subjective components (tender joints and patient global assessment) and two relatively objective components (Swollen joints and inflammatory markers)

Objectives:

To determine in a real world setting if the response to small molecules is mostly due to a drop in subjective or objective components of the DAS score

Methods:

A retrospective chart review was done on all new starters on small molecules in a district hospital in the North of England. Data were collected at baseline, three months and six months from October 2018 to date. Drop in the components of the DAS28 score was calculated and overall drop in DAS28 was modelled as the explanatory variable using linear regression modelling. This was the done Adjusting for age gender and duration of disease. Sensitivity of the model was examined using a logistic model of EULAR moderate/good response and using adjusted R squared estimates for linear model of improvement of the DAS28 score.

Results:

76 patients were included in the analysis from 85 starters on small molecules.61 (71.8 %) were on baricitinib and the baseline median DAS28 score was .5.97 (IQR 5.35,6.55)The median drop at three months in the DAS28 score was 2.42 (IQR 1.33,3.31). and at six months was 2.77 (IQR 2.01,3.83). There was numerical relative increased efficacy of baricitinib but this was not statistically significant (DAS drop at three months 2.54 IQR 1.73,3.09 vs 2.12 IQR 1.51,3.5). The relative contribution of the individual components of the DAS score to the drop ae in DAS are shown in table 1 below. Sensitivity analysis looking at predictors of a DAS drop of >0.6 confirmed this finding.

Table 1.

Results of the adjusted linear regression models.

Component of DAS dropping at three monthsAdjusted R squared at 3 monthsAdjusted R squared at six monthsSwollen Joints0.120.05Tender Joints0.280.18Patient global assessment0.310.48Erythrocyte sedimentation rate0.040.17

Conclusion:

In this real world observational study, there was a good response to both small molecules with numerical better response to baricitinib. Tender joint count and patient global response accounted for more of the drop in DAS28 than swollen joints and inflammatory markers. At six months the biggest contributor to response was patient global assessment. This shows that JAK inhibitors might mediate their response initially mostly through pain modulation then by inflammation as exposure to drug continues.

References:

[1]N Engl J Med. 2017 Feb 16;376(7):652-662

[2]N Engl J Med. 2014 Jun 19;370(25):2377-86

Disclosure of Interests: :

Clerin Joseph: None declared, Syed Mujtaba Bilgrami Speakers bureau: Pfizer, Lesley Ottewell: None declared, Leanne Gray: None declared, William Mitchell: None declared, Fiona Wood: None declared, Marco Massarotti: None declared, Marwan Bukhari Speakers bureau: Bristol-Myers Squib, UCB celltech, Roche/Chugai, Pfizer, Abbvie, Merck, Mennarini, Sanofi-aventis, Eli-Lilly, Janssen, Amgen and Novartis.

P45 Interstitial pneumonitis induced by secukinumab therapy in a patient with psoriatic arthritis

Background

Inhibition of pro-inflammatory interleukin-17A (IL-17A) with secukinumab (an anti-IL-17A antibody) has been utilised in patients with chronic autoimmune disease such as psoriasis seronegative spondyloarthopathies. In mouse models, IL-17A was involved in the development of pulmonary inflammation and progression of fibrosis, with blockade of IL-17A implicated as a potential therapeutic target in such conditions. Here we report a case of, seemingly paradoxical, interstitial lung disease (ILD) secondary to secukinumab therapy in a 61-year-old patient with psoriatic arthritis.

Methods

Please refer to the results section.

Results

Initial therapy was with adalimumab achieving good disease control for 9 years, at which point his arthritis began to progress. Secukinumab was commenced with good clinical response from his arthritis, however he developed a persistent cough with blood-stained secretions, and shortness of breath on exertion. A CT thorax was arranged at 21 weeks after initiation of secukinumab, and showed florid bibasal, lingula and middle lobe ground glass density air space opacification. He went on to have bronchoscopy with bronchoalveolar lavage (BAL) and differential cell count. BAL was negative for atypical infection including P. jirovecii, growing upper respiratory tract flora only. Microscopy of BAL showed lymphocytosis in keeping with the diagnosis of drug induced ILD, with no atypical cells. The patient made a significant improvement on withdrawal of secukinumab therapy within 7-8 weeks of cessation - both clinically and radiologically.

Conclusion

A review of the current literature at this time indicates this is now a third case of secukinumab induced ILD. Given this potentially idiosyncratic reaction we suggest further work may be necessary to understand the underlying immunogenic potential of secukinumab, and an increased awareness as well as vigilance in reporting, to determine those at-risk populations of this phenomenon.

Disclosures

C. Saleh None. S. Bilgrami None. T. Gatheral None. L. Ottewell None.

Novel optical assessments of tissue composition and viability using fluorescence spectroscopy and tissue oxygenation spectrophotometry in patients with systemic sclerosis: a pilot study

OBJECTIVE

Patients with systemic sclerosis (SSc) experience significant morbidity and mortality, therefore, the development of tests to aid its early diagnosis are very important. The aim of this pilot study was to assess the diagnostic value of novel optical non-invasive skin fluorescence spectroscopy (FS) and tissue oxygen saturation (TOS) viability measurements in patients with established SSc.

APPROACH

Two groups were studied, comprising 14 SSc patients and nine healthy controls (93% and 73% females, respectively). FS and TOS measurements were collected from three body sites: the forearm, chest, and calf. Fluorescence intensities at wavelengths attributed to collagen, elastin, and L-tryptophan were computed, with adjustment for melanin, and a normalised combined fluorescence score (NCFS) was determined.

MAIN RESULTS

The NCFS was significantly higher (p  <  0.001) and the combined TOS significantly lower (p  <  0.001) in the SSc group. TOS measurements alone showed good classification accuracy (95.7%) at separating SSc from healthy control participants, with some clustering of values close to the 50% oxygenation level in both groups. When the composition and viability measures were combined and modelled using binary logistic regression, excellent results for the sample were obtained following leave one out cross validation (100%).

SIGNIFICANCE

The results of this pilot study demonstrate the potential diagnostic utility of FS and TOS assessments in SSc patients and further work is now needed to validate these techniques prospectively in a larger group of SSc patients across the spectrum of the disease, and also patients with other types of vasculopathy and conditions that can cause skin fibrosis.

The prevalence and significance of positive antinuclear antibodies in patients with fibromyalgia syndrome: 2-4 years' follow-up

The aim of this study was to ascertain whether fibromyalgia patients with positive ANA develop other features of connective tissue disease over 2-4 years' follow-up. Patients attending our clinic with a diagnosis of fibromyalgia were identified. All ANA-positive patients (n = 12) were recruited and matched for age and sex with 12 ANA-negative FMS patients. As further control groups, patients with a diagnosis of osteoarthritis (OA) were included. A screening questionnaire for possible features of connective tissue disease was sent to all participants. Patients who had three or more positive criteria were invited for further assessment. The ANA-positive rate was 12/137 (8.8%) in FMS and 20/225 (8.9%) in OA patients. All ANA positivity was at a low titre. Fourteen out of 20 (70%) FMS patients and 17/30 (56.7%) OA patients had three or more criteria (P = 0.34). No significant differences in the number of the positive criteria were found between those who were ANA positive or negative in both groups. On full assessment we found one patient who fulfilled the criteria for SLE from the ANA-positive FMS group and one in the ANA-negative group who fulfilled the criteria for primary Sjögren's syndrome. Of the patients with OA, one who was ANA positive was diagnosed as having rheumatoid arthritis. The results from our study show that ANA (at least in low titre) is not a good predictor of the future development of connective tissue.