Early detection of interstitial lung disease in rheumatic diseases: A joint statement from the Portuguese Pulmonology Society, the Portuguese Rheumatology Society, and the Portuguese Radiology and Nuclear Medicine Society

INTRODUCTION

Interstitial lung disease (ILD) contributes significantly to morbidity and mortality in connective tissue disease (CTD). Early detection and accurate diagnosis are essential for informing treatment decisions and prognosis in this setting. Clear guidance on CTD-ILD screening, however, is lacking.

OBJECTIVE

To establish recommendations for CTD-ILD screening based on the current evidence.

METHOD

Following an extensive literature research and evaluation of articles selected for their recency and relevance to the characterization, screening, and management of CTD-ILD, an expert panel formed by six pulmonologists from the Portuguese Society of Pulmonology, six rheumatologists from the Portuguese Society of Rheumatology, and six radiologists from the Portuguese Society of Radiology and Nuclear Medicine participated in a multidisciplinary discussion to produce a joint statement on screening recommendations for ILD in CTD.

RESULTS

The expert panel achieved consensus on when and how to screen for ILD in patients with systemic sclerosis, rheumatoid arthritis, mixed connective tissue disease, Sjögren syndrome, idiopathic inflammatory myopathies and systemic lupus erythematous.

CONCLUSIONS

Despite the lack of data on screening for CTD-ILD, an expert panel of pulmonologists, rheumatologists and radiologists agreed on a series of screening recommendations to support decision-making and enable early diagnosis of ILD to ultimately improve outcomes and prognosis in patients with CTD.

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.

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

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

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

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.

POS0359 MOLECULAR PROFILING OF RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS PATIENTS REVEALS AN ASSOCIATION BETWEEN INNATE AND ADAPTIVE CELL POPULATIONS AND THERAPEUTIC RESPONSE TO ADALIMUMAB

Background:

The response to treatment in spondylarthropaties is heterogeneous, due to factors yet to be better described. For that reason, it is important to find tools that might help clinicians to decide what is the best available therapeutic option for each patient.

Objectives:

The goal of this study is to use comprehensive molecular profiling to characterize clinical response to therapy in a real-world setting. Specifically, to identify molecular biomarkers differentiating good responders and non-responders to TNF inhibitors (TNFi) treatment, using adalimumab, in radiographic axial spondyloarthritis | ankylosing spondylitis (r-axSpA|AS) patients context.

Methods:

Whole-blood mRNA and plasma proteins were measured in a cohort of biologic naïve r-axSpA|AS patients (n = 35) from the Bioefficacy study (Biomarkers identification of anti-TNF alpha agent efficacy in AS patients using RNA sequencing and mass spectrometry), pre and post (14 weeks) TNFi treatment using adalimumab. Response to treatment was categorized according to ASAS20. Results of differential expression analysis were used to identify the most enriched pathways and in predictive models to distinguish responses to TNFi.

Results:

A treatment-related signature, independent of the type of response, suggests a reduction in inflammatory disease activity. We found genes and proteins robustly differentially expressed between baseline and week 14 in responders, including the GWAS AS-associated genes TNFRSF1A, FCGR2A, TYK2, TBKBP1, IL1R1, IL6R, ICOSLG, IL7R, HHAT and LTBR. Moreover, CRP and HP proteins showed strong and early decrease in the plasma of AS patients, while a cluster of apolipoproteins (APO1, APO2, APO3) showed an increased expression at week 14. Good responders to TNFi treatment tend to have higher expression of innate immunity genes at baseline, and lower expression of markers associated with adaptive immunity, particularly B-cells. A logistic regression model incorporating ASDAS-CRP, gender and Gene x, the top differentially expressed gene at baseline between responders and non-responders, enabled an accurate prediction of response to adalimumab in our cohort (AUC=0.97).

Conclusion:

Differences in disease activity and/or innate/adaptive immune cell type composition at baseline may be a major contributor to response to adalimumab in r-axSpA|AS. Alternatively, a model including clinical and gene expression variables could be considered, particularly in patients with mild disease activity.

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

POS0640 EFFECTIVENESS AND SAFETY OF ORIGINAL AND BIOSIMILAR ETANERCEPT IN bDMARD-NAÏVE PATIENTS IN A REAL-WORLD COHORT OF PORTUGAL

Background:

The patent expiration of the original etanercept in Europe has facilitated the development of biosimilar products. Non-significant differences in efficacy and safety were noted in clinical trials which are not expected to influence clinical performance. Nonetheless, daily practice data should be gathered to support the claim for biosimilarity.

Objectives:

To compare the effectiveness and safety of original and biosimilar etanercept, in biological-Disease Modifying Antirheumatic Drug (bDMARD)-naïve patients.

Methods:

A retrospective multicenter non-interventional study, using data collected prospectively from Reuma.pt (The Rheumatic Diseases Portuguese Register) was done, including patients with: age ≥ 18 years old; diagnosis of Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) or Spondyloarthritis (SpA) (axial or peripheral); active disease who initiated treatment with etanercept as first line of biological treatment after 2010. Kaplan-Meyer was used to calculate the persistence rate in treatment. Disease activity at baseline and follow-up data at 6, 12, 18 and 24 months of treatment was compared using the chi-square for categorical variables and t-student or Mann-Whitney tests for continuous variables. Reasons for discontinuing therapy were summarized using descriptive statistics. Statistical significance was assumed for 2-sided p-values >0.05.

Results:

We included 1694 patients (413 on biosimilar and 1280 on original etanercept) 864 with RA, 335 with PsA and 494 with SpA. The population’s baseline characteristics were not significantly different among both groups, except concomitant treatment in RA (higher use of conventional DMARDs in biosimilar group and higher use of NSAIDs in original group) and in SpA patients (higher use of corticosteroids in original group).

At baseline, a higher joint count was found in patients treated with original etanercept with a statistical difference for swollen (p=0.03) and tender (p=0.01) joints count (SJC and TJC, respectively) in RA and in TJC in SpA patients (p=0.02). In RA patients, CDAI and SDAI were higher in patients who started original (p=0.03; p=0.04, respectively). Pain measured by visual analogic scale was higher in SpA patients treated with biosimilar (p=0.03).

The 3-year PR was not significantly different between both treatment groups in RA, PsA and SpA (Figure1). In RA, PR in biosimilar was 72.6%, with a median time-on-drug (TOD) of 28.3 months; for original etanercept PR was 63.6%, with a median TOD of 27.4 months (p=0.566). In PsA patients, the PR for biosimilar was 70.6%, with a median TOD of 27.6 months, and in original drug 67.0%, with a median TOD of 28.1 months (p=0.743). In SpA patients, the PR were 78.4% for biosimilar (median TOD of 27.4 months) and 71.5% for original treatment (median TOD of 28.0 months (p=0.816)).

Figure 1.

Drug survival in biosimilar and original etanercept in Rheumatoid Arthritis, Psoriatic Arthritis and Spondyloarthritis

In RA patients, we did not find differences between the two treatment groups for the proportion of patients in remission or low disease activity by CDAI ≤10, SDAI≤11 or DAS28 <3.2 at 6, 12, 18 and 24 months of treatment. For PsA, no differences were found in the same timelines for DAPSA≤14, DAS28<3.2, BASDAI<4, ASDAS<2.1 or PsARC response. Also, in SpA patients, no differences were found in BASDAI<4, BASFI<4, ASDAS<2.1, ASDAS response and BASDAI response in all the timelines with the exception of BASDAI response at 18 months, which was achieved in fewer patients in biosimilar therapy (p=0.02).

Overall, 535 (31.6%) patients stopped etanercept (428 patients on original and 107 patients on biosimilar). Discontinuations due to inefficacy were the most frequent, but there were no significant differences between both groups as for adverse events. Discontinuations due to “other reasons” were higher for the original group, both in RA (p=0.01) and in SpA (p=0.04).

Conclusion:

Biosimilar and original used as first-line biological treatment showed similar effectiveness and safety in our long-term cohort of patients with RA, PsA, and SpA

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.

AB0231 OUTCOMES IN RHEUMATOID ARTHRITIS PATIENTS UNDER TOCILIZUMAB AS FIRST bDMARD: A REAL-LIFE MONOCENTRIC COHORT STUDY

Background:

Rheumatoid arthritis (RA) is one of the most frequent systemic inflammatory rheumatic diseases, being constantly assessed regarding new disease activity monitoring tools and new therapeutic targets and therapies. Tocilizumab (TCZ) is one of the latest biological disease-modifying antirheumatic drugs (bDMARDs) approved for RA’s treatment, usually as a second line agent in daily clinical practice.

Objectives:

Evaluate the different disease and patient reported outcomes in patients undergoing treatment with tocilizumab as the first biologic therapy.

Methods:

All patients with a definite RA diagnosis who had undergone treatment with TCZ as the first biologic therapy at a tertiary hospital’s rheumatology department were included in this analysis. Diverse socio-demographic data, as well as disease and patient related outcomes were assessed at baseline, 6 and 12 months of treatment with TCZ, and posteriorly extracted from the Portuguese register of rheumatic diseases (Reuma.PT). Statistical analysis included non-parametric tests such as Wilcoxon test and univariate analysis using linear and logistic regression models.

Results:

Fifty-one patients were included, 88.2% females, with a median age at introduction of TCZ of 53.5 +/- 10.4 years; mainly seropositive for either rheumatoid factor (66%) or anti citrullinated peptide antibody (ACPA; 68%), with an erosive disease (75.6%) and concomitantly treated with a conventional synthetic disease modifying anti-rheumatic drug (csDMARD) (70.5%). During follow-up there was a statistically significant reduction at 6 and 12 months of TCZ treatment regarding DAS28 (4 variables) (4v) and DAS28(4V)-CRP scores (p < 0.001), SDAI (p < 0.001), CDAI (p < 0.001), 68/66 tender and swollen joint counts (TJC/SJC) (p < 0.001), ESR and CRP (p < 0.001), patient and physician VAS (p < 0.001) and HAQ score (p = 0.01 at 6 months and p < 0.001 at 12 months). Rheumatoid factor and ACPA serum levels weren’t statistically different at 6 and 12 months of treatment with TCZ compared to the initial assessment, as well as the ACR responders at the same 6 months versus those at 12 months. A majority of patients showed good EULAR response at 6 (52.6%) and 12 (56.3%) months, as well as moderate to high mean improvement in ACR core set measures at 6 (53.3±22.7) and 12 (54.3±25.2) months. Assessment of subsequent therapeutic maintenance showed that 75% of patients remained under tocilizumab with an average treatment duration of 48.8±37.7 months. Reasons for switch ranged from adverse effects (63.6%) to primary failure (18.2%) and secondary failure (18.2%). There was a significant reduction in DAS28(4V), DAS28(4V)-CRP, CDAI, SDAI, TJC and SJC, ESR, CRP, patient and physician VAS and HAQ scores between 6 and 12 months of therapy (p < 0,001). ACR and EULAR responses didn’t differ significantly between assessments at 6 and 12 months. In the absence of a representative number of RA patients on TCZ monotherapy, it wasn’t possible to draw conclusions about the need to use combined therapy with a csDMARD for better clinically significant response.

A higher degree of ACR response at 6 months was associated with higher serum rheumatoid factor levels (OR 1.13, p < 0.05) at baseline, while a lower degree of response was seen with higher TJC (p = 0.05) and HAQ score (p < 0.01). ACR response at 12 months was lower in patients with erosive disease at baseline (p < 0.05). Regarding EULAR response criteria at 6 months, there was a negative association with higher TJC (p < 0.05), while at 12 months the negative trend was associated with ESR levels (p < 0.05) and HAQ scores (p < 0.05) at baseline.

Conclusion:

There seems to be evidence of good therapeutic response to TCZ in bDMARD naïve RA patients assessed at 6 months from baseline, without evidence of significant improvement of response measures further down the line. Basal serum rheumatoid factor levels, TJC, HAQ scores and the presence of erosive disease may have some predictive value on the therapeutic response. Further studies comparing TCZ as the first bDMARD in naïve RA patients against TNF inhibitors are needed.

Disclosure of Interests:

None declared

AB0536 EFFICACY OF TNF INHIBITORS IN MONOTHERAPY VERSUS COMBINATION THERAPY WITH csDMARDs IN PORTUGUESE PATIENTS WITH PSORIATIC ARTHRITIS: A REAL-WORLD STUDY

Background:

Tumor necrosis factor inhibitors (TNFi) are a key therapeutic weapon in psoriatic arthritis (PsA), and can be used as monotherapy or in combination with other csDMARDs, which are usually used as first line therapy in these patients, although its efficacy is not as well documented as in other rheumatic diseases. The optimal use of iTNF in PsA, as monotherapy or in combination therapy with csDMARDs, is still under debate.

Objectives:

We aimed to compare the response to treatment with TNFi in monotherapy and combined with csDMARDs, as first biologic, in patients with PsA.

Methods:

Retrospective study that included PsA patients followed at our Rheumatology department under TNFi as first biologic, fulfilling CASPAR classification criteria and registered in Reuma.pt. Clinical and laboratory data were collected at the start of the first iTNF and in the last visit of 2019. Disease activity was assessed using CDAI, SDAI, DAS28(4V), BASDAI, ASDAS, and the response measured using the BASDAI50, ASDAS, ASAS, ACR and PsARC responses. Comparison between groups was performed using the chi-square test, Mann-Whitney U/t-test (categorical and continuous variables, respectively). Logistic regression analyses were performed to determine predictors of bDMARD failure, and survival analysis to measure persistence under the first bDMARD regarding csDMARD status at baseline.

Results:

We included 99 patients, 47 (47.5% females) with a mean age of 47.9 ± 11.7 years at the start of the first iTNF. Fifty-one patients (51.5%) had symmetric polyarthritis, 26 (26.3%) spondyloarthritis, 16 (16.2%) asymmetric oligoarthritis, 3 (3.0%) distal arthritis and 1 (1.0%) arthritis mutilans. Sixty-three percent were under corticosteroid therapy and 77.8% under csDMARD therapy at the start of the first iTNF (mostly methotrexate, in 55.6% of patients under csDMARD). Etanercept (41, 41.4%), golimumab (25, 25.3%), adalimumab (22, 22.2%), infliximab (9, 9.1%) and certolizumab (2, 2.0%) were the iTNF started in these patients.

Patients who started iTNF as monotherapy had more frequent involvement of axial skeleton compared with combined therapy (54.5% vs 19.5%, p=0.001), were less exposed to corticosteroids (26.3% vs 72.6%, p<0.001) and had higher mean BASMI (3.7±1.8 vs 3.0±0.8, p=0.021) and BASFI (6.7±1.3 vs 4.7±2.5, p=0.036). Patients who were on iTNF monotherapy at the last consultation (43.4%) had lower mean tender (1.0±1.5 vs 3.6±4.3, p=0.002) and swollen (0.2±0.7 vs 0.8±1.0, p=0.012) joint counts, median patient VAS (30±46 vs 50±44, p=0.023), mean CDAI (5.6±4.4 vs 8.7±4.9, p=0.019), SDAI (6.2±4.6 vs 9.1±5.1, p=0.032), and DAS28(4V) (2.2±0.8 vs 2.7±0.9, p=0.047). iTNF failure was not significantly different in both groups. In the regression models, we found that basal DAS28(4V) (OR 1.874, 1.147-3.062 95%CI; p=0,012) was a predictor of first iTNF failure; there were no differences regarding csDMARD status.

When evaluating only patients without spondyloarthritis, we found that, at the last visit, iTNF monotherapy patients still had less exposure to corticosteroids (26.9% vs 54.3%, p=0.002), fewer mean tender (0.7±1.0 vs 2.6±4.4, p=0.006) and swollen (0.2±0.7 vs 1.1±2.5, p=0.025) joint counts, with no other differences observed. In the regression models, we found no differences regarding csDMARD status in these patients, while adalimumab (OR 0.009, 0.001-0.139 95% CI; p=0.009) was a negative predictor of bDMARD failure. Survival analysis revealed no differences between mono- and combined therapy.

Conclusion:

We can conclude that the differences observed regarding csDMARD status in patients with PsA are mainly due to different patterns of arthritis, namely, predominance of axial involvement. In patients without spondyloarthritis, iTNF monotherapy did not differ significantly in terms of response to treatment and disease activity measures, nor does monotherapy predict bDMARD failure and treatment response. These results suggest that iTNF monotherapy is possible in PsA without compromising treatment response.

Disclosure of Interests:

None declared.

AB0327 DRUG-INDUCED LUPUS ERYTHEMATOSUS SECONDARY TO ANTI-TNF-Α AGENTS IN PATIENTS WITH SPONDYLOARTHRITIS AND PSORIATIC ARTHRITIS

Background:

Induction of autoantibodies is frequently observed in patients treated with TNF-α antagonist and the possible development of drug-induced lupus erythematosus (DILE) remains a matter of concern. The prevalence of DILE secondary to anti-TNF-α therapy is estimated around 0.5-1% and clinical features include arthritis/arthralgia, rash, serositis, fever, myalgias, cytopenias, among others. According to the literature, DILE secondary to anti-TNF-α agents differs in several ways from the clinical and laboratory findings typically associated with classic DILE.

Objectives:

To estimate the incidence of induction of antinuclear antibodies (ANA) and DILE in a monocentric cohort of patients with spondyloarthritis and psoriatic arthritis treated with anti-TNF-α agents. To describe the clinical and laboratorial features and outcomes of patients with DILE.

Methods:

We performed a retrospective analysis of patients with spondyloarthritis and psoriatic arthritis treated with anti-TNF-α agents, from our University Hospital, who have been registered on the Portuguese Rheumatic Diseases Register (Reuma.pt) between July 2001 and December 2020. Patients with positive ANA (titer > 1/100) before the anti-TNF-α therapy were excluded. Because specific criteria for the diagnosis of DILE have not been established, we considered the diagnosis in case of a temporal relationship between clinical manifestations and anti-TNF-α treatment and fulfillment of ACR/EULAR 2019 classification criteria for SLE. In patients with DILE, clinical features, laboratory findings, systemic therapies and outcome after discontinuation of medication were collected from reuma.pt and medical records. For the clinical and demographic predictors, continuous variables were analyzed using a two-sided t-test and categorical variables using a Fisher’s exact test. P-value <0.05 was considered statistically significant.

Results:

In the spondyloarthritis group, 290 patients were included (44.8% females, mean age at diagnosis of 33.3 ± 11.5 years and mean disease duration of 15.1 ± 10.4 years) and in the psoriatic arthritis group, 116 patients were included (50.0% females, mean age at diagnosis of 40.1 ± 11.0 years and mean disease duration of 13.1 ± 6.8 years). In our study, we observed high serology conversion rates (positive ANA in 67.9% and 58.6% of patients with Spondyloarthritis and Psoriatic Arthritis, respectively), with similar conversion rates between different anti-TNF drugs. Three patients with spondyloarthritis (1.0%) and 1 patient with psoriatic arthritis (0.9%) developed DILE. Etanercept was the causative agent in 2 cases, infliximab and adalimumab in 1 case, each. Peripheral arthritis (new onset or abrupt worsening) occurred in 2 patients, serositis in 1 patient, constitutional symptoms in 2 patients, subnephrotic proteinuria in 1 patient, lymphopenia in 2 patients and hypocomplementemia in 1 patient. Specific treatment was prescribed to the 4 patients (oral corticosteroids) and they achieved complete recovery. After anti–TNF-α treatment interruption, no patient had recurrent disease. We observed that patients with DILE had a significantly longer disease duration (> 8.4 years; p=0.04) and a significantly longer duration of therapy with anti-TNF (> 4.0 years; p=0.04) when compared to patients without DILE.

Conclusion:

Despite the frequent induction of autoantibodies, the development of DILE secondary to anti–TNF-α agents is rare. Our study demonstrates an incidence rate similar to other studies reported before. The clinical and laboratorial characteristics of our patients with DILE attributable to anti–TNF-α agents differ significantly from DILE due to more traditional agents, as is described in literature. Overall, patients in this study had mild disease that improved after therapy discontinuation, without recurrence of the disease. It seems that a longer disease duration and a longer period under anti-TNF-α therapy may increase the risk of DILE development.

Disclosure of Interests:

None declared

POS1113 ANTIRESORPTIVE THERAPY AFTER TERIPARATIDE DISCONTINUATION – WHEN IS THE BEST TIME TO STARTING IT?

Background:

Treatment with teriparatide (TPTD) is associated with reduction of fracture risk in patients with severe osteoporosis. This drug can only be used for up to 2 years. After that a treatment course with antiresorptives should be considered, in order to prevent the rebound of bone turnover observed after TPTD discontinuation. In this regard, interest in sequential osteoporosis therapy has grown in recent years but the ideal timing for starting another treatment after TPTD is not well established.

Objectives:

The aim of this study is to assess if the timing of onset of antiresorptive therapy after TPTD discontinuation has implications in total hip bone mineral density (BMD) and in fracture risk.

Methods:

We performed a retrospective cohort study that included patients with severe osteoporosis treated with TPTD 20mcg/day for 24 months and followed for at least 2 more years in the rheumatology department of a tertiary university hospital. For analysis, demographic and clinical data and results of dual-energy X-ray absorptiometry (DXA) after cessation of teriparatide were used. For comparison between groups Mann-Whitney U test was used.

Results:

Fifty-five patients with osteoporosis, with a median age of 68 (32-85) years, were included. Forty-nine patients were female (89.1%). Nineteen patients (34.5%) had primary osteoporosis and 36 (65.5%) glucocorticoid-induced osteoporosis. The median time for initiating antiresorptive treatment was 7 (0-35) months after cessation of TPTD. Forty-three patients (78.2%) started a bisphosphonate, 6 denosumab (10.9%) and 6 patients did not receive any other treatment. The most prescribed bisphosphonate was zoledronate (69.8%). All patients received calcium and vitamin D supplementation. After completion of TPTD regimen 8 patients experienced at least one fragility fracture (14.5%). At follow-up, 37 (67.3%) of patients underwent DXA on average 30.0±15.4 months after starting antiresorptive agents. The median total hip BMD in patients who started antiresorptive therapy in the first 12 months (inclusive) after cessation of TPTD regime was 0,738 (0.587-0.993) g/cm2 and the median total hip BMD of patients who started therapy after one year of discontinuation of TPTD was 0.683 (0.390-0.813) g/cm2. This difference is marginally significant (p=0.067). The median time in starting antiresorptive treatment is higher in patients with new fragility fractures after TPTD than in patients without new fractures however this difference was not statistically significant (10.0 [2-35] vs 6.0 [0-35] months; p=0.393, respectively).

Conclusion:

Although this study is unable to show that anti-resorptive treatment should be started in the first year after discontinuation of TPTD, it is promising since the difference between the medians in the total hip BMD values obtained until one year and after one year are marginally significant. These results can be linked to the small sample size and highlight the need for further studies in this area.

References:

[1]Napoli N, Langdahl BL, Ljunggren Ö, Lespessailles E, Kapetanos G, Kocjan T, Nikolic T, Eiken P, Petto H, Moll T, Lindh E, Marin F. Effects of Teriparatide in Patients with Osteoporosis in Clinical Practice: 42-Month Results During and After Discontinuation of Treatment from the European Extended Forsteo® Observational Study (ExFOS). Calcif Tissue Int. 2018 Oct;103(4):359-371. doi: 10.1007/s00223-018-0437-x. Epub 2018 Jun 16. PMID: 29909449; PMCID: PMC6153867.

Disclosure of Interests:

None declared.

POS0488 THE IMPACT OF ANTINUCLEAR ANTIBODIES INDUCED BY ANTI-TUMOUR NECROSIS FACTOR ALPHA AGENTS ON THE LONG-TERM TREATMENT OUTCOMES IN RHEUMATOID ARTHRITIS PATIENTS

Background:

The seroconversion of antinuclear antibodies (ANA) induced by anti-tumour necrosis factor alpha (anti-TNF-α) therapy remains a matter of concern in various inflammatory conditions namely rheumatoid arthritis. However, evidence is still scarce regarding the impact of these autoantibodies on the clinical response to treatment in these patients.

Objectives:

This study aimed to explore the impact of ANA induced by anti-TNF-α therapy on the outcomes of treatment in patients with rheumatoid arthritis over two years of follow-up.

Methods:

An observational retrospective cohort study was conducted with two years of follow-up. Patients diagnosed with rheumatoid arthritis, according to the American College of Rheumatology (ACR) criteria, and registered on the 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 ANA (titer ≥100) and/or positive anti-double stranded DNA (anti-dsDNA) antibodies and/or with a diagnosis of SLE at their first visit were excluded. Demographic, clinical and laboratory data were obtained by consulting Reuma.pt. Disease Activity Score for 28 joints (DAS28), DAS28 delta, Health Assessment Questionnaire (HAQ), HAQ delta were assessed at baseline, 6, 12, 18 and 24 months. Clinical response was evaluated by EULAR criteria and three response categories were defined: good, mild and no response. The rate of switch of biological treatment was assessed over 24 months. To examine the differences between groups with and without ANA seroconversion independent samples t test for normally distributed continuous data, Mann-Whitney U-tests for non-normally distributed continuous data and Chi-square tests for categorical data were used. Logistic regression models were used to assess the effects of ANA seroconversion on clinical response to treatment over 6, 12, 18 and 24 months.

Results:

A total of 185 patients (mean age of 49.3±10.9 years old; 85.4% female) with a median follow-up of 7 [4-14] years were included. We found an ANA seroconversion rate (titer ≥100) of 77.3% (n=143) with median time of 36 [15-72.3] months. There were no differences among groups regarding age, gender, disease duration, be seropositivity or not (for rheumatoid factor and/or anti-citrullinated protein antibodies) and have an erosive disease or not. DAS28 delta was significantly different (p=0.035) between group with positive ANA (2.01±1.29) and negative ANA (1.15±1.51) at 6 months. DAS28 was significantly different (p=0.014) between group with positive ANA (5.06±3.39) and negative ANA (3.99±1.43) at 12 months. No statistically significant differences were found in the DAS28, DAS28 delta, HAQ, HAQ delta at 18 and 24 months and in the EULAR response at any time. Switch rate was significantly different between patients with ANA seroconversion (median 1[0-1]) versus absence of seroconversion (median 0[0-1]), p=0.025. In the regression model ANA seroconversion did not predict switch rate and EULAR response over time.

Conclusion:

This study showed that the majority of patients with rheumatoid arthritis treated with an anti-TNF-α agent developed ANA and that their presence may be associated with worse clinical results (DAS28) at 6 and 12 months. In fact, previous research suggested that a decrease in anti-TNF-α drug concentration due to the production of autoantibodies may lead to worse outcomes of treatment. Moreover, our data demonstrated that patients with ANA seroconversion had a higher switch rate. Despite these results, there are no differences in the EULAR response between the two groups and ANA seroconversion did not predict this response over time. Therefore, ANA induced by anti-TNF-α agents should be monitored in patients with rheumatoid arthritis and its impact on treatment must be considered. Further research is needed to explore these results through large-scale prospective studies.

Disclosure of Interests:

None declared

POS0914 IS THERE AN ASSOCIATION BETWEEN AUTOANTIBODIES INDUCTION AND LOSS OF THERAPEUTIC EFFICACY IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS AND PSORIATIC ARTHRITIS TREATED WITH ANTI-TNF-α AGENTS?

Background:

Induction of autoantibodies is frequently observed in patients treated with a TNF-α blocker. According to other authors, the incidence of induction of antinuclear antibodies (ANA) and anti-double stranded DNA antibodies (anti-dsDNA) varies between 23-57% and 9-33%, respectively. However, it is unknown whether the induction of these autoantibodies affects the pharmacokinetics and bioavailability of biotherapy and, consequently, reduces the efficacy and safety of the drug.

Objectives:

To analyze if there is an association between autoantibodies induction and therapeutic efficacy in a monocentric cohort of patients with axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) treated with anti-TNF-α agents.

Methods:

The authors performed a retrospective analysis of patients with axSpA and PsA treated in our University Hospital with a TNF-α blocker as first biologic agent, and analysed the autoantibodies induction rate after 12 (T12) and 24 (T24) months of therapy. Then, they investigated the influence of autoantibodies in therapeutic efficacy at T12 and T24. Clinical evaluation, laboratory findings including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) and disease activity and functional scores (Bath Ankylosing Spondylitis Disease Activity Index – BASDAI, AS Disease Activity Score with CPR - ASDAS-CRP, Bath AS Functional Index - BASFI) were collected from reuma.pt and medical records. For PsA patients, Disease Activity Score-28-CRP (DAS28-CRP), Simple Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI) and Health Assessment Questionnaire (HAQ) scores were also collected. Patients with positive ANA (titer > 1/100) prior to anti-TNF-α therapy were excluded. Continuous variables were analyzed using a t-test and categorical variables using a Chi-square test. P-value <0.05 was considered statistically significant.

Results:

In the axSpA group, 235 patients were included, 44.5% were females, mean age at diagnosis of 42.3 ± 12.4 years and median disease duration of 11.5 (IQR 6.0-21.0) years. Positive ANA were observed in 16.9% at T12 and 26.3% at T24 and positive anti-dsDNA in 3.4% at T12 and 3.8% at T24, with similar conversion rates between different anti-TNF drugs and no significant gender difference. A significant difference in ASDAS-CPR was found in axSpA patients with and without ANA at T12 (p=0.047). ASDAS-CPR was 1.16 times higher in patients with ANA comparing to patients without them. However, no difference was found in the others disease activity and functional scores at T12. Furthermore, no significant difference, including ASDAS-CPR, was found at T24. Also, there was no significant difference found when comparing patients with and without anti-dsDNA.

In the PsA group, 94 patients were included, 46.8% were females, mean age at diagnosis of 46.7 ± 11.7 years and median disease duration of 11.5 (IQR 6.5-16.5) years. Positive ANA were found in 14.9% at T12 and 21.3% at T24 and positive anti-dsDNA in 2.1% at T12 and 3.2% at T24. When comparing the groups with and without ANA and with and without anti-dsDNA at T12 and T24, no significant difference in disease activity and functional scores was found.

Conclusion:

This study revealed high rates of serology conversion, similar to the rates described before. The authors found that ASDAS-CPR was higher in axSpA patients with ANA after 12 months of therapy. However, this difference was no longer evident after 24 months. No other significant difference was found between patients with and without ANA or with and without anti-dsDNA. The authors consider that the induction of autoantibodies may interfere with the response to anti-TNF-α therapy in a short and initial period of time. Long-term follow-up data are lacking to say whether that influence will disappear consistently over the long run, as they observed after 12 months of therapy. However, they can state that, a priori, seroconversion should not lead to treatment suspension because of concerns about loss of efficacy.

Disclosure of Interests:

None declared

POS1270 MUSCULOSKELETAL MANIFESTATIONS IN A COHORT OF 234 INFLAMMATORY BOWEL DISEASE PATIENTS

Background:

Musculoskeletal symptoms represent the most common extraintestinal manifestations of inflammatory bowel disease (IBD) and a major cause of impaired quality of life in these patients. Spondyloarthritis (SpA) is classically associated with IBD, but other rheumatic manifestations may occur.

Objectives:

To characterize musculoskeletal symptoms and rheumatic diseases in an IBD cohort.

Methods:

Retrospective monocentric descriptive study including all the patients with IBD consecutively reffered from Gastroenterology to the Rheumatology Department between January of 2013 and December 2020 in a tertiary university hospital. Demographic and clinical data and musculoskeletal symptoms were collected at the time of the first visit in the Rheumatology outpatient center and the rheumatic diseases diagnosed during the entire follow-up were registered.

Results:

A total of 234 patients were included, 136 (58.1%) females, 20 (8.5%) smokers. At the first Rheumatology consultation the mean age was 43.6 (±13.7) years and the mean IBD duration was 11.7 (±9.7) years. Concerning IBD: 172 (73.5%) had Crohn’s disease and 62 (26.5%) had ulcerative colitis; azathioprine (39.7%), infliximab (28.2%) and mesalazine (26.5%) were the most frequently used drugs; eleven patients (4.7%) were taking glucocorticoids and 106 (45.3%) had already been treated with glucocorticoids.

Regarding musculoskeletal symptoms: 76 (32.5%) patients had peripheral symptoms and 98 (41.9%) had axial symptoms (Table 1).

Table 1.

Characterization of peripheral and axial musculoskeletal symptoms in patients with Inflammatory Bowel Disease.

N (%)Peripheral symptomsNo158 (67.5%)Arthritis / “inflammatory” joint pain24 (10.3%)“Mixed” rhythm joint pain15 (6.4%)“Mechanical” joint pain29 (12.4%)Enthesopathy8 (3.4%)Axial symptomsNo136 (58.1%)“Inflammatory” back pain46 (19.7%)“Mixed” rhythm back pain35 (14.9%)“Mechanical” back pain17 (7.3%)Total234 (100%)

Twenty-six (11.1%) patients had radiographic sacroiliitis, 14 (6.0%) had sacroiliitis in computed tomography and 9 (3.8%) in magnetic resonance. Forty-four (18.8%) patients fulfilled Assessment of SpondyloArthritis international Society (ASAS) criteria for axial SpA and 5 (2.1%) for peripheral SpA. Also of note, 16 (6.8%) patients had a previous diagnosis of psoriasis and 5 (2.1%) had uveitis in the past.

Concerning other rheumatic diagnosis, we observed: osteoarthritis in 64 (27.3%), osteoporosis in 16 (6.9%), diffuse idiopathic skeletal hyperostosis in 6 (2.6%), systemic lupus erythematosus in 4 (1.7%), rotator cuff tendinopathy in 2 (0.9%), rheumatoid arthritis, gout, calcium pyrophosphate deposition disease, fibromyalgia, drug-induced lupus, osteitis condensans ilii, Dupuytren’s contracture and avascular necrosis of the femoral head in 1 (0.4%), each.

Conclusion:

Our results demonstrate a high prevalence of musculoskeletal symptoms and rheumatic diseases in patients with IBD. These diagnoses are not limited to the group of SpA and osteoporosis, emphasizing the importance of rheumatologists being alert to other rheumatic diagnoses in patients with IBD.

Disclosure of Interests:

None declared

AB0478 IN PREVIOUSLY BIOLOGIC-NAÏVE RHEUMATIC PATIENTS WITH DRUG INDUCED LUPUS SECONDARY TO A FIRST ANTI-TNF THERAPY, IS IT SAFE TO SWITCH TO A SECOND ANTI-TNF-α AGENT?

Background:

Drug-induced lupus erythematosus (DILE) secondary to anti-TNF-α agents results from an immunogenicity phenomena not yet fully understood and is a rare condition. Withdrawal of anti-TNF- α therapy usually leads to total resolution of symptoms, however sometimes immunosuppression is needed. It is not clear if this condition is drug specific or class related. Therefore, there are doubts about the safety of switching to a second TNF inhibitor: will a further anti-TNF-α agent increase the risk of DILE recurrence?

Objectives:

To analyze the outcomes in patients with DILE secondary to an anti-TNF-α agent that switch to a second anti-TNF-α agent.

Methods:

We performed a retrospective analysis of patients with spondyloarthritis, psoriatic arthritis and rheumatoid arthritis from our University Hospital, who developed DILE secondary to an anti-TNF-α agent as a first biologic and switch to a second anti-TNF-α agent. Because specific criteria for the diagnosis of DILE have not been established, DILE diagnosis was considered when a temporal relationship between clinical manifestations and anti-TNF alpha treatment was found and ACR/EULAR 2019 classification criteria for SLE were fulfilled. Clinical and laboratorial features and outcomes were collected from the Portuguese Rheumatic Diseases Register (Reuma.pt) and medical records.

Results:

Six of 617 patients developed DILE secondary to anti-TNF-α agents (2 secondary to etanercept, 2 to adalimumab and 2 to infliximab). These patients had total resolution of symptoms and autoantibodies (ANA and anti-DNAds), induced by the therapy, disappeared after withdrawal of the anti-TNF-α agent implied.

Afterwards, 4 of these 6 patients switched to a second anti-TNF-α agent: 1 to etanercept, 1 to certolizumab, 1 to adalimumab and another to golimumab. The time interval between the two therapies was 2,0 ± 0,8 months. Regarding the outcomes, in all four patients, no DILE recurrence or autoantibodies induction recurrence was observed. These patients have a good response to the new biotherapy, without side effects reported, and a significant clinical improvement was observed.

Conclusion:

Our study results are in agreement with the literature described before. It seems that exist a low rate of DILE recurrence with an alternative anti-TNF-α agent. Thus, this condition seems to be drug specific rather than class related. Therefore, it seems secure to use a second anti-TNF-α agent, even in a short period of time after DILE development. There is no evidence about the best or securest second TNF inhibitor, so any anti-TNF-α agent can be prescribed. A carefully monitoring of symptoms of relapse should be ensured. In conclusion, DILE secondary to a TNF inhibitor should not be an absolute contraindication to the use of a subsequent anti-TNF-α agent.

Disclosure of Interests:

None declared.

AB0112 TNF INHIBITOR MONOTHERAPY IN RHEUMATOID ARTHRITIS: IS THERE REALLY A DIFFERENCE IN COMPARISON WITH COMBINATION THERAPY WITH CSDMARDS IN REAL-LIFE?

Background:

In Rheumatoid Arthritis (RA), tumor necrosis factor inhibitors (TNFi) in combination with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) has shown advantages concerning efficacy and immunogenicity in comparison with monotherapy. However, in clinical practice, up to 40% of patients under biological DMARDs (bDMARDs) are on monotherapy.

Objectives:

To compare the efficacy outcomes of TNFi in monotherapy and in combination therapy in a RA monocentric cohort.

Methods:

Retrospective, cross-sectional study including all the RA patients under TNFi followed at our Rheumatology Department and registered in the national database. Demographic, clinical and laboratorial data and disease activity measures were collected at the last visit of 2019 from each patient. Mann-Whitney U and chi-square tests were used to the comparison analysis between the two groups (continuous and categorical variables, respectively).

Results:

A total of 144 patients were included: 84% were females; at the last visit of 2019, the mean age was 56.3±10.9 years and the mean disease duration was 18.3±10.2 years; 73.6% were positive for rheumatoid factor (RF), 81.9% for anti-citrullinated protein autoantibodies (ACPA) and 45.1% had erosive disease. There were no statistically significant differences in these variables between the monotherapy and the combination therapy groups (table 1).

Table 1.

Demographic and disease-related variables in the monotherapy and the combination therapy group.

Monotherapy(n=31)Combination therapy (n=113)Age - mean±SD59.1±14.0 years55.5±9.8 yearsDisease duration - mean±SD20.5±11.2 years17.7±9.7 yearsRF positive - n (%)20 (60.4%)86 (76.8%)ACPA positive - n (%)25 (80.6%)93 (85.3%)Erosive disease - n (%)15 (48.4%)50 (44.6%)

Thirty-one patients (21.5%) were under monotherapy with TNFi and etanercept was the most frequent TNFi in both groups (54.8% vs 50.0%; monotherapy and combination therapy groups, respectively). At the start of the first bDMARD, the monotherapy group had a higher disease activity score 28 - 4 variables (DAS 28 4V; 6.083±0.930 vs 5.605±1.043, p=0.039) and a higher simple disease activity score (SDAI; 36.12±11.77 vs 28.76±9.98, p=0.035); also, in the monotherapy group more patients had already started the bDMARD in monotherapy (22.6% vs 2.7%, p<0.001), less patients were under (38.7% vs 73.2%, p=0.001) or had already been treated with (77.4% vs 93.8%, p=0.007) methotrexate, in comparison with the combination group therapy.

At the last visit of 2019, the monotherapy group had a higher mean years of duration of iTNF treatment (5.5±5.8 vs 3.4±4.5, p=0.048), a higher mean patient global assessment - visual analogue scale (PGA-VAS; 49±18 vs 39±25, p=0.023), a higher mean prednisolone equivalent dose in mg/day (7.6±6.3 vs 5.6±3.2, p=0.045) and a lower proportion of American College of Rheumatology 50 and 70 responses (ACR 50: 12.9% vs 17.0%, p=0.023; ACR 70: 3.2% vs 10.7%, p=0.045) in comparison with the combination therapy group.

Conclusion:

In line with the literature, our real-life results demonstrate some direct (higher PGA-VAS and lower ACR 50 and 70 responses) and indirect (higher current prednisolone equivalent dose) data that suggest that patients with TNFi monotherapy may have a worst disease activity control in comparison with combination therapy.

Disclosure of Interests:

None declared

POS0100 VITAMIN D LEVEL IN RHEUMATOID ARTHRITIS PATIENTS STARTING A BIOLOGIC DISEASE-MODIFYING DRUG AND ITS CORRELATION WITH DISEASE ACTIVITY AND RESPONSE TO TREATMENT

Background:

Vitamin D, a fat soluble vitamin that is mainly involved in the regulation of calcium/phosphate metabolism, has a increasingly understood role in immunomodulatory activity, both in innate and adaptive immune system. In rheumatoid arthritis (RA), vitamin D showed to suppress the proliferation of synoviocytes and to reduce the production of proinfammatory cytokines, in vitro. (1) Recently the hypothesis has been raised that vitamin D has a negative association with RA activity. (2)

Objectives:

This study aimed to evaluate the relationship between the 25-hydroxyvitamin D (25(OH) vitD) level, RA activity and response to a first biologic disease-modifying drug (bDMARD).

Methods:

This is a longitudinal, retrospective study including consecutive patients with the diagnosis of RA followed at our rheumatology department. Demographic, clinical, and laboratorial data were collected from our national database at baseline, 6 and 12 months after initiation of a first bDMARD. Statistical analysis was performed using SPSS 23.0. Correlations between variables were studied using Spearman correlation analysis and comparison between groups was performed using Wilcoxon and Kruskal-Wallis tests; p<0.05 was considered statistically significant.

Results:

Mean age of patients (n=236) was 51.5 ± 11.2 years old, 192 (81.4%) were females with a median disease duration of 10.1 [4.7, 16.7] years. Seropositivity for anti-citrullinated protein antibodies was present in 192 (81.4%) patients and for rheumatoid factor in 175 (74.2%). The majority exhibited a very high or high disease activity at baseline (median DAS28 5.75 [4.99 – 6.63]) and 90% (n=212) of them were concomitantly using corticosteroids and/or other disease-modifying anti-rheumatic drugs (117 with methotrexate (MTX), 62 with leflunomide and 32 with sulfasalazine). Regarding bDMARD, 56.8% (n=134) initiated an TNF alpha inhibitor.

After 6 and 12 months from a bDMARD initiation there was a significant reduction of ESR, CRP levels, TJCs, SJCs and DAS28 (all p-values < 0.001), as expected. Median baseline serum 25(OH) vitD concentrations was 25.5 [16.5, 30.0] ng/ml; notably, 34.2% of our sample was affected by hypovitaminosis D at baseline (25(OH) vitD< 20 ng/mL).

Among our study population 42.5% patients were responders to first bDMARD (23.8% good and 18.7% moderate responders) according to the EULAR response criteria. Disease remission (DAS28 < 2.6) was achieved by 17.6% of patients.

The percentage of good responders was significantly lower in the subgroup of patients with hypovitaminosis D compared to subjects with normal 25(OH) vitamin D levels at baseline (p=0.002), as it was for the percentage of disease remission (p=0.015).

The bivariate correlation analyses showed that 25(OH) vit D levels at baseline correlated with CRP levels and good response to RA treatment after 12 months (Spearman’s coefficient -0.201, p = 0.028; Spearman’s coefficient 0.255, p < 0.019, respectively). 25(OH) vit D levels at baseline, 6 and 12 months after bDMARD initiation did not correlate with age, BMI, ESV, number of tender or swollen joints, DAS28, HAQ or with SDAI or CDAI at 6 or 12 months of treatment.

Conclusion:

In patients with RA, basal 25(OH) vit D levels correlated with response to a bDMARD. These results suggest a role of basal vitamin D status in the prediction of disease evolution and support the hypothesis that vitamin D has an immunomodulatory potential.

References:

[1]Huhtakangas JA, Veijola J, Turunen S et al. 1,25(OH)2D3 and calcipotriol, its hypocalcemic analog, exert a long-lasting anti-infammatory and anti-proliferative effect in synoviocytes cultured from patients with rheumatoid arthritis and osteoarthritis. J Steroid Biochem Mol Biol 2017; 173: 13- 22.

[2]Lee YH, Bae SC. Vitamin D level in rheumatoid arthritis and its correlation with the disease activity: a meta-analysis. Clin Exp Rheumatol. 2016 Sep-Oct;34(5):827-833. Epub 2016 Apr 6. PMID: 27049238.

Disclosure of Interests:

None declared

POS0204 AUTOANTIBODIES AND SYSTEMIC LUPUS ERYTHEMATOSUS INDUCED BY ANTI-TUMOUR NECROSIS FACTOR ALPHA THERAPY IN RHEUMATOID ARTHRITIS

Background:

Anti-tumour necrosis factor alpha (anti-TNF-α) therapy is commonly used to treat inflammatory conditions such as rheumatoid arthritis (RA). Autoantibodies namely antinuclear antibodies (ANA) induced by these treatments are well established. However, anti-TNF-α-induced systemic lupus erythematosus (SLE) is rarely described and its incidence is yet unknown.

Objectives:

This study aimed to determine the prevalence of ANA seroconversion and to characterize the development of SLE induced by anti-TNF-α therapy in patients with RA over time.

Methods:

An observational retrospective cohort study was conducted with at least one year of follow-up. Patients with diagnosis of RA, according to American College of Rheumatology criteria (ACR), and registered on Rheumatic Diseases Portuguese Register (Reuma.pt) who started their first anti-TNFα between 2003 and 2019 were included. Patients with positive ANA (titer ≥100) and/or positive double-strand DNA (dsDNA) antibodies and/or with a diagnosis of SLE at their first visit were excluded. Demographic, clinical and laboratory data were obtained by consulting Reuma.pt. As there are no recognized criteria for drug-induced SLE, the diagnosis of SLE induced by anti-TNF-α was considered if there is a temporal relationship between clinical manifestations and anti-TNF-α-therapy, the presence of at least 1 serologic ACR criteria (ANA or anti-dsDNA) and at least 1 nonserologic ACR criteria (arthritis, serositis, hematologic disorder or malar rash) [1]. Continuous variables are presented with mean, standard deviation, median, quartile 1 and quartile 3. Categorical variables are presented with absolute and relative frequencies.

Results:

A total of 211 patients (mean age of 49.9±10.9 years old; 84.4% female) were included with a median follow-up time of 6 [3-14] years. We found a seroconversion rate for ANA of 75.4% (n=159) with median treatment duration of 31 [8.5-70.5] months. The most common titre was 1/100 with diffuse and speckled patterns. ANA seroconversion was higher for etanercept (47.8%, n=76) than with adalimumab (23.9%, n=38), infliximab (13.8%, n=22), golimumab (12.6%, n=20) or certolizumab (1.9%, n=3). SLE induced by anti-TNF-α occurred in two patients (0.9%) with erosive and seropositive (rheumatoid factor and anti-citrullinated protein antibodies) RA previously treated with two conventional synthetic disease-modifying antirheumatic drugs, including methotrexate. The first patient, a female with 66 years old and 17 years of disease duration, developed SLE after 16 months of infliximab, with constitutional symptoms, abrupt worsening of polyarthritis, ANA titer of 1/320 diffuse pattern and positive dsDNA (248 UI/mL) antibodies. The second patient, a woman with 43 years old and 11 years of disease duration, developed SLE after 41 months of adalimumab with malar rash and ANA titer of 1/320 diffuse pattern, positive dsDNA (285 UI/mL), positive anti-histone antibodies and hypocomplementemia. In these two cases, anti-TNF-α therapy was stopped and recovery was spontaneous without treatment. The first patient switched to adalimumab and the second switched to golimumab without recurrence of SLE for more than ten years.

Conclusion:

We found a high rate of ANA seroconversion induced by anti-TNFα therapy in patients with RA. However, similar to previous literature, only 0.9% of patients developed SLE with mild manifestations without major organ involvement. Although the drug with the highest ANA seroconversion rate was etanercept, those responsible for induced SLE were infliximab and adalimumab. Patients improved after discontinuation of therapy and tolerated an alternative anti-TNF-α drug without recurrence of induced SLE over time. Therefore, ANA and SLE induced by anti-TNF-α should be considered and reported in the follow-up of RA patients. Further research is needed to explore the impact of this adverse event on the outcomes of treatment over time.

References:

[1]Hochberg MC. Arthritis Rheum. 1997;40(9):1725.

Disclosure of Interests:

None declared

AB0483 CAN WE PREDICT WHICH PATIENTS WITH SPONDYLOARTHRITIS WILL NEED DOSE ESCALATION OF SECUKINUMAB TO 300 mg MONTHLY?

Background:

Secukinumab is a fully human monoclonal antibody against interleukin-17A, approved in several countries for the treatment of ankylosing spondylitis (AS) and psoriatic arthritis. It is known that some patients benefit from increasing the monthly dose of secukinumab from 150mg, the most commonly used dose, to 300mg. However, the baseline clinical characteristics that differentiate these patients are not yet fully understood.

Objectives:

This study aimed to investigate whether there are any variables at the beginning of biologic therapy that might predict a greater probability of having to increase the dose of secukinumab to 300mg in order to obtain a response to treatment.

Methods:

This is a retrospective cohort study, including all the spondyloarthritis and psoriatic arthritis patients under secukinumab 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 first visit before the patient began secukinumab. For comparison between the 2 groups, continuous variables were analyzed using Mann-Whitney U and T-tests and categorical variables were analyzed using a Chi-square test. Multivariate regression analyses assessed the impact of selected variables on the need to increase the dose of secukinumab to 300mg.

Results:

Thirty-two patients with a mean age of 53±11.96 years were included, 19 (58%) were females and 16 (48.5%) had psoriasis. Twenty-seven (81.8%) patients were under a nonsteroidal anti-inflammatory drug (NSAID), 11(33.3%) were under corticosteroid and 11(33.3%) were under conventional synthetic disease-modifying antirheumatic drug (csDMARD); 25 (75,8%) had previously been treated with a biological disease-modifying antirheumatic drug (bDMARD). The mean patient baseline VAS and physician baseline VAS were 74,39±19,77 and 47,55±23,38, respectively; the mean erythrocyte sedimentation rate (ESR) and C-Reactive Protein (CRP) were 26,33±22,62 mm/hr and 10,81±16,88 mg/dL, respectively; the mean swollen joint count (SJC) and tender joint count (TJC) were 1,30±1,63 and 3,67±3,14, respectively; the mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Ankylosing Spondylitis Disease Activity Score (ASDAS) were 6,18±2,06 and 3,41±0,84, respectively; the mean Bath Ankylosing Spondylitis Metrological Index (BASMI) and Bath Ankylosing Spondylitis Functional Index (BASFI) were 4,22±1,58 and 6,28±2,53, respectively; the mean Maastrich Ankylosing Spondylitis Enthesitis Score (MASES) was 2,85±3,23.

Nineteen patients (57.6%) had the dose of secukinumab increased to 300mg. At the baseline visit, the group of patients which had their secukinumab monthly dose increased to 300mg were more frequently men (12 vs 2, p=0.005) and had psoriasis (12 vs 4, p=0.049). On the other hand, these patients also exhibited lower MASES values (2±1.089 VS 4±0.501, p=0.022).

A regression analysis was conducted, estimating the relationships between the outcome binary variable of the monthly dose of secukinumab and the following predictors: gender, psoriasis, MASES value and use of corticosteroid. Female gender (OR 0.070, CI95% 0.005-0.890; p=0.040) and absence of psoriasis (OR 0.104, CI95% 0.011-0.952; p=0.045) were predictors for maintaining secukinumab at a dose of 150mg monthly.

Conclusion:

Our data suggest that the most common characteristics of patients in need of increasing the monthly dose of secukinumab from 150 to 300 mg to achieve a better treatment response are: male gender, coexistence of psoriasis and lower MASES value at baseline. The first two variables remained statistically significant in a multivariate model of regression analysis. Nonetheless, we insist it is of paramount importance to conduct larger studies to confirm these findings.

References:

[1]Deodhar A, et all. Long-term safety of secukinumab in patients with moderate-to-severe plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis. Arthritis Res Ther. 2019 May 2;21(1):111.

Disclosure of Interests:

None declared.

AB0816 PREDICTORS OF RESPONSE TO THE FIRST BDMARD IN BIOLOGIC-NAÏVE PATIENTS WITH SPONDYLOARTHRITIS: A COHORT STUDY

Background:

Several markers of response to biologic disease-modifying antirheumatic drugs (bDMARDs) have been identified in Rheumatoid Arthritis. However, data on predictors of response in Spondyloarthritis (SpA) are more limited.

Objectives:

To identify predictors of response to bDMARDs in a SpA population.

Methods:

Monocentric 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 July 2001 and August 2020. Demographic, clinical and laboratorial data at baseline and disease activity measures at 6 and 12 months of bDMARD were collected. Mann-Whitney U test and chi-square tests were used to the comparison analysis between groups (continuous and categorical variables, respectively) and univariate logistic regression was used in the prediction analysis.

Results:

A total of 325 patients were included, 178 (54.8%) males, 76 (23.4%) smokers and 164 (50.5%) HLA-B27 positive. Concerning SpA subtypes: 236 (72.6%) had Ankylosing Spondylitis, 31 (9.5%) had Inflammatory Bowel Disease Associated SpA and 58 (17.9%) had Undifferentiated SpA. The mean age at the start of the first bDMARD was 41.7 years (±12.2) and the median disease duration was 12.1 years (0.5-52.7). The mean ASDAS-CPR (Ankylosing Spondylitis Disease Activity Score with C-reactive protein) was 4.0 (±0.8) and most patients (57.2%) exhibited very high disease activity at baseline as evaluated by ASDAS-CRP. Ninety-five (29.2%) patients were taking NSAIDs (nonsteroidal anti-inflammatory drugs) and 131 (40.3%) were under csDMARDs (conventional synthetic disease-modifying antirheumatic drugs), being sulfasalazine the most frequent (28.3%). All patients started iTNF (tumor necrosis factor inhibitors): adalimumab (30.2%) and golimumab (24.6%) were the most frequently started bDMARDs.

At 6 and 12 months of bDMARD, 63.5% and 65.7% of the patients had ASDAS response (clinically important improvement or major improvement). Variables that showed statistically significant differences at baseline between those different groups are presented at Table 1.

Table 1.

Baseline characteristics that showed statistically significant differences at baseline between groups of patients with vs without ASDAS responses at 6 and 12 months of bDMARD. (bDMARD: biologic disease-modifying antirheumatic drug; BMI: body mass index; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate).

ASDAS response at 6 monthsASDAS response at 12 monthsyesnop-valueyesnop-valueAge at start of bDMARD (mean±SD)39.6±12.2 years44.2±10.7 yearsp=0.01240.7±12.8 years44.2±10.9 yearsp=0.035Age at SpA diagnosis (mean±SD)32.2±11.1 years35.8±11.9 yearsp=0.02331.3±10.7 years35.4±11.2 yearsp=0.010BMI (mean±SD)25.7±4.3kg/m228.7±6.0 kg/m2p=0.04525.6±4.3 kg/m228.5±5.7 kg/m2p=0.005CRP (mean±SD)3.2±3.5 mg/dL1.1±1.2 mg/dLp<0.0013.4±3.5 mg/dL1.4±1.6 mg/dLp<0.001ESR (mean±SD)36±2225±20p<0.00138±2427±17p=0.001ASDAS-CRP(mean±SD)4.1±0.83.5±0.4p<0.0014.2±0.83.6±0.8p<0.001HLA-B27+61.5%26%p=0.00660.1%44.4%p=0.033Males62.3%35.7%p=0.00462.3%37.5%p=0.001

Body mass index (BMI) (OR 0.89 [0.80-0.99], 95% CI) and ASDAS-CRP at baseline (OR 2.8 [1.2-6.6], 95% CI) predicted ASDAS response at 6 months; moreover, only BMI (OR 0.91 [0.83-0.99], 95% CI) predicted ASDAS response at 12 months of bDMARD.

Conclusion:

Our results demonstrate that a higher baseline disease activity predicts the response to bDMARDs in SpA. Interestingly, BMI at baseline also predicts ASAS response at 6 and 12 monthes of treatment with bDMARD, in line with some data that suggest an association between BMI and disease activity in SpA.

Disclosure of Interests:

None declared

SAT0320 BONE MINERAL DENSITY AND FRACTURE RISK IN A COHORT OF PORTUGUESE SYSTEMIC SCLEROSIS PATIENTS

Background:

Although poorly understood, patients with Systemic Sclerosis (SSc) seem to have higher prevalence of low bone mineral density (BMD) and an increased spine fracture risk.

Objectives:

We aim to determine, by conventional densitometry (DXA) and using the fracture risk assessment tool (FRAX), the prevalence of low BMD and the fracture risk, respectively, in our SSc cohort and its potential determinants.

Methods:

Observational transversal study was performed including consecutive patients with the diagnosis of SSc. We collected data regarding demographics, BMD (lumbar spine and femoral neck) and occurrence of fracture. Ten-year risk of osteoporotic fracture was estimated using FRAXv4.1with the Portuguese population reference. Statistical analysis was performed using SPSS 23.0; p<0.01 was considered statistically significant.

Results:

Median age of patients (n=97) was 62 years old [56, 70], 88.7% females (n=86). Seventy-eight patients (80.4%) had limited cutaneous form, 5 (5.2%) presented a diffuse cutaneous form and 13 (13.4%) an overlap syndrome. Regarding clinical features: digital ulcers in 30 patients (30.9%), interstitial lung disease (ILD) in 16 (6.5%), gastrointestinal involvement in 16 (16.5%), miositis in 4 (4.1%) and pulmonary arterial hypertension in 3 (3.1%). Anti-topoisomerase I antibody (anti-Scl70) positivity was present in 15 patients (15.5%) and anti-centromere antibody (ACA) positivity in 63 (64.9%). Nine patients (9.3%) were smokers and 6 (6.2%) reported an alcohol consumption of 3 or more units/day. Median body mass index (BMI) was 25.4 Kg/m2[21.4, 29.1], with 5 patients (5.2%) being underweight. Vitamin D insufficiency was reported in 19 patients (19.6%). Twenty-one patients (21.6%) have been exposed to oral glucocorticoids (GCT) for more than 3 months at a dose of 5mg daily or more. Eleven patients (11.3%) had previous low impact fractures: 10 of which were vertebral and 1 wrist fracture. Regarding the prescribed anti-osteoporotic treatment (AOP), we found: alendronate (n=7, 7.2%), zoledronic acid (n=7, 7.2%), denosumab (n=2, 2.1%) and teriparatide (n=1, 1%).

Low BMD was present in 45 patients (46.4%); median femoral neck BMD (FN-BMD) was 0.827 [0.709, 0.893].Ten year probability of fracture (%) was: median risk for major fracture was 5.1 [3.5, 9.7] and 3.8 [2.5, 8], with and without FN-BMD, respectively; for hip fracture the estimated risk was 1.2 [0.6, 3.1] and 1.0 [0.4, 2.5], with and without FN-BMD, respectively. According to FRAX thresholds for the Portuguese population, 25 patients (25.8%) met criteria to start AOP treatment. Among them, only 10 patients (40%) started it, as the agreement between the indication to treat by FRAX and the onset of treatment was weak (k= 0.338). A strong agreement was found between FRAX risk threshold with DXA and World Health Organization (WHO) threshold for starting AOP (k= 0.814) and no agreement was found between FRAX risk without DXA and WHO threshold.

FN-BMD presented a weak correlation with BMI (r = 0.393), a moderate inverse correlation with major fracture risk with and without FN-BMD (r = -0.704, r=-0.412, respectively) and with hip fracture risk with and without FN-BMD (r = -0.799, r=-0.412, respectively). Major fracture risk with and without FN-BMD presented a moderate correlation with spine fractures (r = 0.350; r=0.397, respectively).

No correlation was found between WHO threshold and spine fractures. No correlations were found between FN-BMD or fracture risk estimated by FRAX and disease manifestations, anti-Scl70 or ACA positivity, vitamin D insufficiency, smoking or GCT use.

Conclusion:

In our cohort, low BMD was prevalent and had correlation with BMI. FRAX appears to be an useful instrument as it correlated with spine fractures, contrary to what was verified when we used the WHO threshold. Early monitoring of BMD and estimating fracture risk using FRAX appear to be useful tools for the prevention of fractures in this population.

Disclosure of Interests:

Salomé Garcia: None declared, Bruno Miguel Fernandes: None declared, Sara Ganhão: None declared, Maria Rato: None declared, Filipe Pinheiro: None declared, Georgina Terroso: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared

FRI0062 THE USE OF A COMORBIDITY INDEX FOR PREDICTING CLINICAL RESPONSE IN RHEUMATOID ARTHRITIS PATIENTS RECEIVING THEIR FIRST BIOLOGICAL AGENT

Background:

Several studies in Rheumatoid arthritis (RA) have suggested that a greater number of comorbidities is associated with worse functional status and disease activity measures. However, it is useful to use a composite comorbidity index, such as Rheumatic Disease Comorbidity Index (RDCI) that is validated for the use in patients with rheumatic diseases, to better understand the overall role of comorbidities in treatment outcomes.

Objectives:

To evaluate the impact of comorbidities on 12-month clinical response in a cohort of patients with RA treated with a first-line biologic disease-modifying antirheumatic drug (bDMARD), by using the RDCI.

Methods:

Observational retrospective study was performed including consecutive patients with the diagnosis of RA followed at our Rheumatology Department. The prevalence of comorbidities was computed, and patients were stratified according to RDCI for evaluating its role in clinical response disease activity at baseline and follow up (6 and 12 months). Correlations between variables were studied using Spearman correlation analysis, comparison between groups was performed using Kruskal-Wallis and Chi-square. A multivariate logistic regression model was developed to examine the role of RDCI along with other baseline factors as potential predictor of achieving remission, low disease activity (LDA), and EULAR good/moderate response. Statistical analyses were performed using SPSS statistical software, version 23.0.

Results:

A total of 251 patients were included: 83.7% (n=210) females, mean age of 58 (± 11.10) years old, with a median disease duration of 16.11 years [10.79 - 23.04]. The majority exhibited a very high or high disease activity at baseline (median DAS28 3V 5.48 [4.70 – 6.19]) and 90% (n=226) of them were concomitantly using corticosteroids and/or other disease-modifying anti-rheumatic drugs (129 with methotrexate (MTX), 96 with leflunomide and 35 with sulfasalazine). The most frequently reported comorbidities were cardiovascular disorders (37.5%), osteoporosis (7.6%) and depression (6.8%). The median RDCI score was 1.0 [0.0 – 2.0] and the majority of patients (63.6%) carried at least one comorbidity. When comparing baseline demographic and clinical characteristics of the 4 subgroups, stratified according to RDCI score (RDCI=0, 1, 2, or ≥3), we found statistically significant differences in age, age at diagnosis, sex and the prescribed anti-TNF agent (p<0.05). There was a progressive increase in the mean age as the RDCI score increased between the subgroups.

RDCI strongly correlates with the number of comorbidities (NC) (r=0.764, p<0.01). NC was weakly correlated with patient and physician global assessment of disease activity (pVAS and phVAS) (r=0.183, p<0.01 and r=0.196, p=0.019, respectively), DAS28 3V (r=0.192, p=0.046) and HAQ-DI (r=0.301, p<0.01) at 6 months. Moreover, RDCI poorly correlated with CRP (r=0.192, p=0.01), pVAS (r=0.183, p=0.02) and HAQ-DI (r=0.202, p<0.01). Weaker correlations were also found at 12 months: NC with pVAS (r= 0.196, p=0.02), DAS28 3V (r=0.216, p=0.01) and HAQ-DI (r=0.187, p=0.04); RDCI with phVAS (r= 0.196, p=0.04).

The 12-month DAS28 remission rate was 37.8% (n=95); 6.7% (n=17) achieved EULAR good response and 54.4% (n=137) a moderate EULAR response. RDCI was not an independent predictor of DAS remission (OR 0.794, 95% CI 0.561- 1.125,p =0.194) nor it was of EULAR good/moderate response (OR 0,720, 95% CI 0.430- 1.206, p= 0.212).

Conclusion:

Although our data point to a weak association between morbidities, assessed by the RDCI, and response to a first bDMARD, it is important to consider this simple and useful tool in future prospective and broader studies, since information bias regarding comorbidities may have been responsible for our results.

Disclosure of Interests:

Salomé Garcia: None declared, Bruno Miguel Fernandes: None declared, Georgina Terroso: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared

AB0825 TIME-COURSE CHANGE IN AXIAL MOBILITY IN PSORIATIC ARTHRITIS PATIENTS UNDER bDMARD

Background:

Spinal mobility is assessed frequently in patients with psoriatic arthritis (PsA) usingBath Ankylosing Spondylitis Metrology Index(BASMI) to provide baseline measurement, monitor changes over time and to assess the impact of clinical interventions. BASMI comprises 4 measures of spinal mobility (cervical rotation, tragus-to-wall distance, modified Schober’s test and lumbar lateral flexion) and one hip mobility measurement (intermalleolar distance).

Objectives:

The aim of this study is to investigate the time-course change of BASMI in PsA patients after 6 months ofBiologic Disease-modifying Antirheumatic Drug(bDMARD) therapy. The authors also pretend to evaluated, at baseline and after 6 months of treatment, the association between BASMI, disease activity scores and physical function.

Methods:

An observational retrospective study was performed in patients with PsA under bDMARD followed in the Rheumatology department of a tertiary university hospital. Were included patients treated with only one bDMARD. Demographic and clinical data were collected from the Rheumatic Diseases Portuguese Register. For spinal mobility calculation BASMI was used. Disease activity was evaluated withAnkylosing Spondylitis Disease Activity Score(ASDAS) andBath Ankylosing Spondylitis Activity Index(BASDAI). Physical function was assessed withBath Functional Index(BASFI). The variation of BASMI, ASDAS, BASDAI and BASFI was calculated as the difference between values registered at 6 months and at baseline and presented as Δ. Correlations between ΔBASMI, ΔASDAS and ΔBASFI was calculated using Pearson test.

Results:

A total of 55 patients were included. Thirty patients were males (54.5%). The mean age at diagnosis was 44.6 ± 12.6 years and the median disease duration at start of bDMARD was 5.4 years (min: 0.30; max: 25.5). In total, 19 (34.5%) patients had predominant axial involvement, 36 (65.5%) peripheric and 36 (65.5%) enthesopathic. Almost all patients fulfilled the CASPAR criteria for PsA (n=50, 90.9%). According to ASDAS criteria, at the baseline 20 patients (36.4%) had high disease activity and 34 (61,8%) very high. The most used bDMARD was etanercept (n=21, 38,3%) followed by golimumab (n=19, 34.5%) and adalimumab (n=8, 14.5%). Three patients were treated with infliximab, two with certolizumab and other two with secukinumab. Forty-one patients (75.9%) were concomitantly treated with conventional synthetic DMARDs. Axial PsA patients had more limitations in spinal mobility (BASMI mean 4.5 ± 1.5) and more functional limitation (BASFI mean 6.8±1.9) than patients with predominant peripheric involvement (BASMI mean 3.3± 1.2, p=0.004; BASFI mean 5.4±3, p=0,0048). Statistically significant differences in ASDAS and BASDAI in these two groups were not observed (p=0.332 and p=0.605, respectively). For all patients, BASMI did not vary significantly (p=0.691) at baseline (mean 3.7± 1.4) and after 6 months (mean 3.8±1.3) of treatment. Although the ΔBASMI for etanercept was negative (mean -0.12±0.9) and for golimumab positive (0.14±0.8), it was not statistically significant. At baseline there is a significant positive association between BASMI and ASDAS (r=0.435, p=0.001), BASMI and BASDAI (r=0.567, p<0.001) and BASMI and BASFI (r=0.510, p<0.001). However, there was not a statistically significant association between ΔBASMI and: ΔASDAS, ΔBASDAI and ΔBASFI (r=0.158; p=0.269, r=0.019; p=0.096 and r=0.121; p=0.397, respectively).

Conclusion:

In PsA patients treated with bDMARDs, at least in short-term follow-up, BASMI does not improve with time. Changes in BASMI did not correlate with changes in activity disease and in functional outcome. Studies with longer follow-up and with more patients are needed to better evaluate these associations.

Disclosure of Interests:

Maria Rato: None declared, Filipe Pinheiro: None declared, Salomé Garcia: None declared, Bruno Miguel Fernandes: None declared, Sara Ganhão: None declared, Rita Gaio: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Alexandra Bernardo: None declared, Lúcia Costa: None declared

AB0769 THE IMPACT OF BODY MASS INDEX ON DISEASE ACTIVITY AND ENTHESITIS IN PSORIATIC ARTHRITIS

Background:

Overweight/obesity has increased exponentially in the last decades, becoming a huge Public Health problem. Moreover, an increase in adipose tissue is associated with an increased production of several proinflammatory cytokines and acute phase reactants. Higher BMI has been related with new bone formation including syndesmophytes and enthesophytes. In fact, besides rheumatologic conditions including Psoriatic Arthritis (PsA), enthesopathy can be a consequence of several clinical conditions including metabolic syndrome, mechanical injuries and degeneration.

Objectives:

To evaluate the effect of body mass index (BMI) on disease activity scores and enthesitis scores in Psoriatic Arthritis.

Methods:

Retrospective study including all the patients with PsA meeting the CASPAR criteria, beginning first-line biologic therapy at our centre. Demographic and clinical data were collected from the Portuguese database Reumapt. Statistical analysis was performed with SPSS. Continuous variables were compared through Spearman/Pearson correlations.

Results:

The mean BMI was 26.8 (SD 0.5). In our sample of 119 PsA patients, 21.5% were overweight and 8.3% were obese. The mean age of patients was 46.3 ± 1.03 years; 60 female and 59 male. The median disease duration was 6.8 (0.3-33.8) years. At baseline mean (SD) disease activity variables were: DAS 28 4vESR 4.9 (0.2), ESR 33.2 (2.3) mm/h; CRP 2.35 (0.3) mg/dL, BASDAI 6.6 (0.2), ASDAS 3.9 (0.1), BASMI 3.7 (0.2), BASFI 5.8 (0.3), MASES 1.9 (0.3), SPARCC 2.3 (0.3). There were statistically significant positive correlations between BMI and MASES at baseline (p=0.024, r=0.411) but there weren’t with SPARCC, DAS 28 4vESR, ESR, CRP, BASDAI, ASDAS, BASMI and BASFI.

Conclusion:

The data showed that patients with higher BMI values had higher enthesitis scores suggesting that overweight/obesity may have a negative impact on enthesopathy. Further studies are still needed to further understand that possible relationship.

References:

[1]Bakirci S, Dabague J, Eder L, McGonagle D, Aydin SZ. The role of obesity on inflammation and damage in spondyloarthritis: a systematic literature review on body mass index and imaging. Clin Exp Rheumatol. 2019 Apr 29.

Disclosure of Interests:

Sara Ganhão: None declared, Bruno Miguel Fernandes: None declared, Salomé Garcia: None declared, Filipe Pinheiro: None declared, Maria Rato: None declared, Eva Mariz: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared

SAT0478 OSTEOPOROSIS TREATMENT IN PORTUGUESE PATIENTS WITH PSORIATIC ARTHRITIS – WHAT IS THE VALUE OF THE FRACTURE RISK ASSESSMENT TOOL (FRAX)?

Background:

Few studies have evaluated the prevalence and treatment of osteoporosis (OP) in patients with psoriatic arthritis (PsA), and many of these patients are not screened using dual-energy X-ray absorptiometry (DXA). FRAX makes it possible to stratify the risk and define which patients may benefit from anti-osteoporotic treatment, but its usefulness in this population is not well established.

Objectives:

The aim of this study was to determine whether the application of FRAX changes the indication for anti-osteoporotic treatment in PsA patients, according to the Portuguese guidelines.

Methods:

In this cross-sectional study, we evaluated PsA patients from a tertiary hospital, registered in a national database (Reuma.pt), aged between 40 and 90 years and with a last consultation in 2019. FRAX was applied in all of them, regardless of being under anti-osteoporotic treatment and, when DXA was available, the femoral neck bone mineral density was used. Patients were stratified according to the risk of fracture, and those at high risk were considered candidates for anti-osteoporotic treatment, according to national guidelines [FRAX ≥11% for major osteoporotic fracture (MOF) or ≥ 3% for hip fracture (HF) without DXA; FRAX ≥9% for MOF or ≥ 2.5% for HF, with DXA].

Results:

We included 100 patients, 52 females, with a mean age of 54,4 ±8,9 years and a median disease duration of 10 (6-17) years. Only 43 had already performed DXA and 6 had OP according to World Health Organization criteria. Seven patients were identified as having a high risk of fracture; applying femoral neck bone mineral density, 2 more patients with indication for treatment were recognized, totalizing 9 patients. There was a low agreement between the indication for treatment based only on DXA and FRAX (Cohen’s k 0.066). There was a moderate and significant correlation between percentage of risk of MOF by FRAX with and without DXA (Spearman’s ρ 0.804, p <0.001); for the risk of HF by FRAX with and without DEXA the correlation was weaker but still significant (Spearman’s ρ 0.439, p = 0.004). There was no association between the indication for treatment by FRAX and the performance of DXA (chi-square test, p = 0.597), nor the fact of performing DXA significantly affected the risk of MOF (Wilcoxon test, p = 0.185) or of HF (Wilcoxon test, p = 0.785) by FRAX.

Conclusion:

In line with Portuguese guidelines, FRAX seems to be, in itself, a very useful tool in patients with PsA, and the performance of DXA does not significantly alter the indication for anti-osteoporotic treatment.

References:

[1]Rodrigues AM, Canhao H, Marques A, Ambrosio C, Borges J, Coelho P, et al. Portuguese recommendations for the prevention, diagnosis and management of primary osteoporosis - 2018 update. Acta Reumatol Port. 2018;43(1):10-31.

[2]Del Puente A, Esposito A, Parisi A, Atteno M, Montalbano S, Vitiello M, et al. Osteoporosis and psoriatic arthritis. J Rheumatol Suppl. 2012;89:36-8.

[3]Gulati AM, Michelsen B, Diamantopoulos A, Grandaunet B, Salvesen O, Kavanaugh A, et al. Osteoporosis in psoriatic arthritis: a cross-sectional study of an outpatient clinic population. RMD Open. 2018;4(1):e000631.

[4]Adami G, Fassio A, Rossini M, Caimmi C, Giollo A, Orsolini G, et al. Osteoporosis in Rheumatic Diseases. Int J Mol Sci. 2019;20(23).

[5]Kanis JA, Harvey NC, Johansson H, Oden A, Leslie WD, McCloskey EV. FRAX Update. J Clin Densitom. 2017;20(3):360-7.

Disclosure of Interests:

Filipe Pinheiro: None declared, Maria Rato: None declared, Bruno Miguel Fernandes: None declared, Salomé Garcia: None declared, Sara Ganhão: None declared, Pedro Madureira: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared

THU0387 THE IMPACT OF TREATMENT WITH A BIOLOGICAL DISEASE-MODIFYING ANTIRHEUMATIC DRUG ON SPINAL MOBILITY AND ITS CORRELATION WITH DISEASE ACTIVITY IN PATIENTS WITH SPONDYLOARTHRITIS

Background:

Bath Ankylosing Spondylitis Metrology Index (BASMI) is an instrument developed to assess spinal and hip mobility. The relationship between BASMI and disease activity is not always linear and, above all, the data that correlate the variation in BASMI values (ΔBASMI) with the variation in disease activity scores and response to treatment are not unanimous.

Objectives:

Explore the effect of biological disease-modifying antirheumatic drugs (bDMARD) in spine mobility (as assessed by BASMI) and the associations between ΔBASMI and disease activity.

Methods:

Observational retrospective study was performed including consecutive patients with the diagnosis of Spondyloarthritis (SpA) followed at our Rheumatology Department. Demographic, clinical, including Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), BASMI, Ankylosing Spondylitis Disease Activity Score with erythrocyte sedimentation rate and C-reactive protein (ASDAS ESR and ASDAS CRP, respectively), and laboratorial data were collected from our national database at baseline, 6 and 12 months after initiation of a bDMARD. The variation of each parameter was calculated as the difference between the levels recorded at 6 and 12 months and the reference level and presented in the form of Δ. Statistical analysis was performed using SPSS 23.0. Correlations between variables were studied using Spearman correlation analysis and comparison between groups was performed using Wilcoxon and Kruskal-Wallis tests.

Results:

Median age of patients (n=178) was 42 years old [34, 50], 92 (51.7%) were males with a median disease duration of 4.9 [1.0, 10.3] years. One hundred and twenty-six patients (70.8%) had Ankylosing Spondylitis, 15 (8.4%) Inflammatory Bowel Disease related SPA and 30 (16.9%) Undifferentiated SpA. Fifty four (30.3%) patients were taking glucocorticoids and regarding conventional synthetic disease-modifying anti-rheumatic drugs use before starting the bDMARD: Sulfasalazine (52, 29.2%), Methotrexate (31, 17.4%) and Leflunomide (3, 1.7%). Regarding the bDMARD, only one patient started Secukinumab and the others a Tumor necrosis factor inhibitor (TNFi) [Golimumab (n= 64, 36.0%), Adalimumab (n=36, 20.2%), Infliximab (n= 35, 19.7%), Etanercept (n= 32, 18.0%) and Certolizumab (n= 10, 5.6%)].

The majority of the patients had very high disease activity at baseline (86.0%, n=153); median ESR was 29 mm/h [15, 47], median CRP was 13.7 mg/L, [6.60, 27.3], median ASDAS CRP was 7.6 [6.0, 9.0] and median BASMI was 8.0 [7-0, 9.0]. After 6 and 12 months of treatment, mean ESR, CRP, ASDAS-CRP and BASMI were significantly lower than mean baseline values (p<0.01), with median ASDAS-CRP at 12 months of 2.20 [1.50, 2.90] and median ΔBASMI of -4.10 [-5.50, -2.40].

BASMI at baseline showed a moderate correlation with ASDAS CRP (r=0.468, p<0.01), BASDAI (r=0.496, p<0.01) and patient visual analogic scale (VAS) (r=0.563, p<0.01). No correlations were found between BASMI and CRP, ESR, physician VAS or the consumption of nonsteroidal anti inflammatory drugs at baseline.

A significant positive correlation was found between ΔBASMI and ΔASDAS at 6 months and 12 months (r=0.243, p=0.02; r=0.286; p<0.01) and also between ΔBASMI and ΔBASDAI at 6 and 12 months (r=0.183, p=0.04; r=0.291, p=0.02). No correlations were found between ΔBASMI and ΔCRP or ΔESR. No differences were observed in ΔBASMI, regarding the bDMARD of choice.

Conclusion:

In our cohort, starting a bDMARD improved BASMI scores through a 12 month period and there was a correlation between the variation of BASMI and disease activity improvement. As such, a TNFi may retard the progression of spinal mobility dysfunction in SpA patients. We cannot draw conclusions regarding differences between TNFi and interleukin 17 inhibitors and further work is needed to clarify possible differences in their impact in improving spine mobility.

Disclosure of Interests:

Salomé Garcia: None declared, Bruno Miguel Fernandes: None declared, Sara Ganhão: None declared, Maria Rato: None declared, Filipe Pinheiro: None declared, Georgina Terroso: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared

FRI0293 EFFECTIVENESS OF SWITCHING BETWEEN TNF INHIBITORS IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS: IS THE REASON TO SWITCH RELEVANT?

Background:

It has been common practice to start a second TNF inhibitor (TNFi) in patients with axial spondyloarthritis (axSpA) who discontinue their first TNFi. It remains unclear if the reason for discontinuation of the first TNFi influences the response to the second.

Objectives:

To assess if the reason of discontinuation of the first TNFi influences the response to the second TNFi.

Methods:

Patients with axSpA from the ReumaPt registry, who discontinued their first TNFi and started a second TNFi and who had complete data on Ankylosing Spondylitis Disease Activity Score (ASDAS) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) at baseline, 3 and 6 months for their first TNFi were included. Then, they were followed every 6 months up to 12 years. The main outcome was the ASDAS clinically important improvement (ASDAS CII). Secondary outcomes were ASDAS major important improvement (ASDAS MI); ASDAS low disease activity (ASDAS LDA); ASDAS inactive disease (ASDAS ID) and BASDAI 50. The reason for discontinuation of the first TNFi was defined as: i) Primary failure, ASDAS CII was not achieved at 3 or 6 months; ii) Secondary failure, ASDAS CII achieved at 3 or 6 months but lost in ≥1 follow-up visit; iii) Adverse events; iv) Other (e.g. pregnancy, surgery). The response to the first TNFi at 3 and 6 months was compared to the response to the second TNFi at the same visits, adjusting for age, gender and C-reactive protein (CRP). The association between the reason of discontinuation of the first TNFi and response the second TNFi over time was tested in generalized estimating equations (GEE) models, adjusted for age, gender and CRP.

Results:

In total, 193 patients (53% male, mean age 45 (SD:11) years) were included, with a median follow-up time on the second TNFi of 1.5 years. Patients had a lower response to the second TNFi compared to the first TNFi according to the main outcome (ASDAS CII) at 3 months (41% vs 51%) and 6 months (35% vs 56%). There was an association between the reason to discontinue the first TNFi and response to the second TNFi as defined by the most stringent outcomes (ASDAS MI and ASDAS ID), but not for ASDAS CII (Table). Compared to patients who discontinued their first TNFi due to primary failure, patients were more likely to achieve ASDAS ID with the second TNFi when they discontinued their first TNFi due to secondary failure (OR: 7.3 [(95%CI: 1.9; 27.7]), adverse events (OR: 9.1 [2.5; 33.3]), or other reasons (OR: 7.7 [1.6; 37.9]).

Conclusion:

In axSpA, response to the second TNFi is worse compared to the first TNFi. Patients with a secondary failure to the first TNFi have a better response to the second TNFi compared to those discontinuing the first TNFi due to primary failure, particularly for most stringent outcomes.

Table.

Association between the reason for discontinuation of the first TNFi and response to the second TNFi

Reason to discontinue first TNFi*Outcome for the second TNFiOR (95% CI)ASDAS-CII (N=135)ASDAS-MII (N=135)ASDAS-LDA (N=166)ASDAS-ID (N=166)BASDAI50 (N=147)(ref Primary failure) -Secondary failure1.9 (0.7;4.8)4.8 (1.3;18.2)1.2 (0.6;2.4)7.3 (1.9;27.7)1.4 (0.6;3.0) -Adverse events1.5 (0.6;3.5)2.4 (0.6;9.6)0.9 (0.5;1.7)9.1 (2.5;33.3)1.1 (0.5;2.3) -Other1.0 (0.3;3.8)1.7 (0.1;19.4)1.0 (0.4;2.4)7.7 (1.6;37.9)0.5 (0.1;1.7)

*GEE models with the reason of discontinuation of the first TNFi as predictor (reference category: primary failure); all models adjusted for age, gender and C-reactive protein. OR in bold are statistically significant (p<0.05).

Disclosure of Interests:

Santiago Rodrigues-Manica Speakers bureau: Jansse, MSD, Novartis, Alexandre Sepriano: None declared, Fernando Pimentel dos Santos Speakers bureau: Novartis, Pfizer, Biogen, Vitoria,, Nélia Gouveia: None declared, Anabela Barcelos Speakers bureau: Bene, Eli-Lilly, Pfizer, MSD, Novartis, Jaime Branco Speakers bureau: Vitoria, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Raquel Ferreira: None declared, Elsa Vieira-Sousa: None declared, Sofia C Barreira: None declared, Filipe Vinagre: None declared, Raquel Roque: None declared, Helena Santos Speakers bureau: AbbVie, Eli-Lilly, Janssen, Pfizer, Novartis, Nathalie Madeira: None declared, João Rovisco: None declared, Alexandra Daniel: None declared, Sofia Ramiro Grant/research support from: MSD, Consultant of: Abbvie, Lilly, Novartis, Sanofi Genzyme, Speakers bureau: Lilly, MSD, Novartis

SAT0465 FRACTURE RISK ASSESSMENT BY FRAX IN A SYSTEMIC LUPUS ERYTHEMATOSUS PORTUGUESE COHORT

Background:

Osteoporosis is commonly seen in patients with Systemic Lupus Erythematosus (SLE), even in pre-menopausal patients. The etiology is multifactorial and chronic glucocorticoid therapy seems to play a central role.

Objectives:

To investigate the ten-year risk of fracture assessed by Fracture Risk Assessment Tool (FRAX), with and without dual-energy X-ray absorptiometry (DXA) and to determine possible demographic or clinical factors associated with an increased risk of fracture in a SLE population.

Methods:

Retrospective study including all the over 40 years-old patients with the diagnosis of SLE (2012 SLICC classification criteria) followed at our Rheumatology Department registered in our national database. Demographic, clinical and laboratorial data were collected at the last follow-up visit. Data from the last DXA (until 3 years prior to the last visit) were collected. Indication for pharmacological treatment by FRAX was assessed according to the national recommendations: estimated fracture risk, without DXA, ≥11% for major osteoporotic fracture or ≥3% for hip fracture and/or estimated fracture risk, with DXA, ≥9% for major osteoporotic fracture or ≥2.5% for hip fracture.

Results:

We included 104 patients, 101 (97.1%) females, aged 54.5±9.9 years, with a median disease duration of 19.3 years [4.3-51.6]. Twelve patients (11.5%) were current smokers, 31 (29.8%) had elevated anti-dsDNA antibodies (≥100 IU/mL) and 27 (26.0%) had complement consumption (C3c<83mg/dL or C4<12mg/dL). 73 patients (70.2%) were taking glucocorticoids with a mean daily prednisolone equivalent dosage of 4.4±5.2 mg/day. Regarding SLE treatment, 69 patients (66.3%) were under hydroxychloroquine, 22 (21.2%) under azathioprine, 16 (15.4%) under mycophenolate mofetil, 5 (4.8%) under belimumab, 4 (3.8%) under methotrexate, 1 (1.0%) under leflunomide and 1 (1.0%) under rituximab.

Ten patients (9.6%) had previous fragility fractures, 54 patients (51.9%) had DXA in the last 3 years and 81 (77.9%) were taking calcium and/or vitamin D supplements.

Sixteen (15.4%) had indication for treatment by FRAX without DXA and 8 of these (50%) were under treatment. Moreover, thirteen (12.5%) had indication for treatment by FRAX with DXA and 8 of these (61.5%) were under treatment.

Five patients (4.8%) were reclassified in FRAX with DXA: 3 patients (2.9%) had no indication for treatment by FRAX without DXA but conquered it by FRAX with DXA and 2 patients (1.9%) had indication for treatment by FRAX without DXA but lost it by FRAX with DXA. We found a good level of agreement in the indication for treatment between FRAX with and without DXA (kappa=0.741; p<0.001).

There was no significant difference in the risk of fracture estimated by FRAX with or without DXA, both for major osteoporotic fracture and for hip fracture. Correlations between fracture risk and some clinical variables can be seen in table 1.

Table 1.

Correlations between the risk of fracture estimated by FRAX and disease related features.

Age at SLE diagnosisDisease DurationESRSLEDAIEstimated fracture risk by FRAX:without DXAmajor osteoporotic fracturer=0.483p<0.001n.s.r=0.249p=0.012r=-0.586p=0.028hip fracturer=0.481p<0.001n.s.r=-0.552p=0.041n.s.with DXAmajor osteoporotic fracturer=0.386p=0.005r=0.299p=0.033n.s.n.s.hip fracturer=0.338p=0.015n.s.n.s.n.s.

Conclusion:

A higher number of patients had indication for pharmacological treatment by FRAX with DXA in comparison with FRAX without DXA. However, we found no statistically significant difference in the estimated fracture risk with and without DXA. This, together with the good level of agreement between FRAX with and without DXA, suggests that the fracture risk estimation, even without DXA, may be an appropriate approach. The low number of patients with indication for pharmacological treatment by FRAX, with and without DXA, may be explained by their low mean age and the high number of them under vitamin D/calcium supplementation.

Disclosure of Interests:

Bruno Miguel Fernandes: None declared, Salomé Garcia: None declared, Sara Ganhão: None declared, Maria Rato: None declared, Filipe Pinheiro: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared

SAT0416 ENTHESITIS AND CLINICAL RESPONSE IN PSORIATIC ARTHRITIS: REAL-LIFE DATA

Background:

Psoriatic arthritis (PsA) is an inflammatory arthritis that is characterized by a broad spectrum of clinical conditions, including axial skeletal involvement, enthesitis, dactylitis, uveitis and arthritis. Among those, enthesitis, the inflammation of the junction where the tendon, ligament or joint capsule inserts into the bone, is assigned to be the hallmark, affecting 35–50% of patients. Several clinical methods have been developed to measure it, including The Maastricht AS Enthesitis Score (MASES) index, which tests 13 entheses and the Spondyloarthritis Research Consortium of Canada (SPARCC) index that assesses 16.

Objectives:

To assess the relationship between enthesitis and clinical response in psoriatic arthritis.

Methods:

Retrospective study including all the patients with PsA meeting the CASPAR criteria, beginning first-line biologic therapy at our centre. Demographic and clinical data including age, gender, body mass index (BMI), smoking status, physical examination findings such as presence of enthesitis, dactylitis, chronic back pain, tender and swollen joint counts (TJC/ SJC), ESR, CRP, DAS 28 4vESR, BASDAI, BASFI, BASMI, ASDAS, HAQ, patient VAS score, MASES and SPARCC were collected from the Portuguese database Reumapt. Statistical analysis was performed with SPSS. Continuous variables were analysed through Spearman correlations.

Results:

We included 119 patients with PsA (60 female), of which 14.9% were active smokers. The mean age of patients was 46.3 ± 1.03 years. The median disease duration was 6.8 (0.3-33.8) years and the mean BMI was 26.8 ± 0.5 Kg/m2.

Enthesitis, dactylitis, inflammatory back pain, peripheral arthritis, ungueal distrophy, and psoriasis were present in 53 (45.7%), 45 (38.8%), 76 (65.5%), 109 (94%), 45 (38.8%), 104 (89.7%) patients, respectively.

At baseline, mean (SD) disease activity parameters were: DAS 28 4vESR 4.9 (0.2), ESR 33.2 (2.3) mm/h; CRP 2.35 (0.3) mg/dL, HAQ 1.3 (0.1), BASDAI 6.6 (0.2), ASDAS 3.9 (0.1), BASMI 3.7 (0.2), BASFI 5.8 (0.3), MASES 1.9 (0.3), SPARCC 2.3 (0.3). Median (min-max) values of TJC, SJC and patient VAS score at baseline were 4 (0-28), 3 (0-19), 76 (0-100), respectively.

There were statistically significant positive correlations (0-12 months) between ΔMASES and ΔDAS 28 4vESR (p=0.02, rho=0.432), Δpatient VAS score (p=0.027, rho=0.307), ΔHAQ (p=0.02, rho=0.411), ΔBASDAI (p=0.025, rho=0.326), ΔBASFI (p=0.037, rho=0.315), ΔASDAS (p=0.023, rho= 0.331). Correlations between ΔSPARCC and ΔDAS 28 4vESR (p=0.023, rho=0.332), Δpatient VAS score (p=0.003, rho=0.402), ΔHAQ (p=0.012, rho=0.440), ΔBASDAI (p=0.011, rho=0.368), ΔBASFI (p=0.001, rho=0.445), ΔASDAS (p=0.002, rho= 0.437), ΔCDAI (p=0.039, rho=0.320) and ΔSDAI (p=0.039, rho=0.319), were also significant. However, there weren’t strong correlations between ΔMASES neither ΔSPARCC and PsARC response at 12 months.

Conclusion:

Our results suggest that enthesitis is correlated with clinical response in PsA, supporting the idea that it is a major determinant of disease activity. It should be given more importance, namely by incorporating it in daily clinical practice, due to its major role, both in establishing an early diagnosis and in assessing treatment response.

References:

[1]Sunar I, Ataman S, Nas K, Kilic E, Sargin B, Kasman SA, et al. Enthesitis and its relationship with disease activity, functional status, and quality of life in psoriatic arthritis: a multi‑center study. Rheumatol Int. 2019 Nov 26. doi: 10.1007/s00296-019-04480-9.

Disclosure of Interests:

Sara Ganhão: None declared, Salomé Garcia: None declared, Bruno Miguel Fernandes: None declared, Maria Rato: None declared, Filipe Pinheiro: None declared, Eva Mariz: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared

SAT0449 SPONDYLOARTHRITIS AND FRACTURE RISK: DOES DXA REALLY HAVE AN IMPACT IN THE RISK OF FRACTURE ESTIMATED BY FRAX?

Background:

Low bone mineral density (BMD) is common in ankylosing spondylitis (AS). The fracture risk (FR) is increased and its reduction with pharmacologic therapy is not clearly defined in this population. However, early screening and bisphosphonates as first-line treatment are recommended.

Objectives:

To investigate the influence of dual-energy X-ray absorptiometry (DXA) in the ten-year risk of fracture assessed by FR Assessment Tool (FRAX) and to determine possible demographic or clinical factors associated with an increased FR in a spondyloarthritis (SpA) population.

Methods:

Retrospective study including all the over 40 years-old SpA patients (ASAS classification criteria) followed at our Rheumatology Department and registered in the national database. Demographic, clinical and laboratorial data were collected at the time of the last follow-up visit. Data from the last DXA (until 3 years prior to the last visit) were collected. Indication for pharmacological treatment by FRAX was assessed according to the national recommendations.

Results:

A total of 231 SpA patients were included: 126 males (54.5%), 53 (22.9%) smokers; 171 (74%) had AS, 23 (10%) had Inflammatory Bowel Disease Associated SpA and 37 (16%) had Undifferentiated SpA. At the last follow-up visit, the mean age was 52.9 years (±9.6) and the median disease duration was 21.9 years [1.0-55.5]. The mean ASDAS-CRP was 2.5 (±0.9) and the majority of patients had moderate (25.5%) or high (48.5%) disease activity (according to ASDAS). One hundred and thirty patients (56.3%) were taking NSAIDs, 45 (19.5%) were taking glucocorticoids, 85 (36.8%) were under csDMARDs and 170 (73.6%) under bDMARDs [157 (68%) under TNFi, 11 (4.8%) under secukinumab and 2 (0.9%) under ustekinumab].

Eleven patients (4.8%) had previous fragility fractures, 118 (51.1%) had DXA in the last 3 years and 167 (72.3%) were taking calcium and/or vitamin D supplements.

Sixteen patients (6.9%) had indication for treatment by FRAX without DXA and 9 of these (56.3%) were already under treatment. Similarly, 16 (6.9%) had indication for treatment by FRAX with DXA and 13 of these (81.3%) were already under treatment. Ten patients (4.3%) were reclassified in FRAX with DXA: 7 (3%) had no indication for treatment by FRAX without DXA but obtained it by FRAX with DXA and 3 (1.3%) had indication for treatment by FRAX without DXA but they lost it by FRAX with DXA. We found a moderate level of agreement in the indication for treatment between FRAX with and without DXA (kappa=0.595; p<0.001). The use of DXA in FRAX estimated a significant higher median FR, both for major osteoporotic fracture (2.4% [0.8-31.0] vs 1.8% [0.6-20.0]; p<0.001) and for hip fracture (0.5% [0.0-23.0] vs 0.2% [0.0-14.0]; p<0.001).

We found significant correlations between FR and some disease-related variables (table 1).

Table 1.

Correlations between the risk of fracture estimated by FRAX and disease-related variables.

Disease durationBASDAIASDAS-CRPBASMIBASFIEstimated fracture risk by FRAX:without DXAmajor osteoporotic fracturer=0.352p<0.001r=0.204p=0.002r=0.214p=0.001r=0.301p<0.001r=0.317p<0.001hip fracturer=0.389p<0.001r=0.142p=0.034r=0.170p=0.011r=0.305p<0.001r=0.275p<0.001with DXAmajor osteoporotic fracturer=0.227p=0.014r=0.314p=0.001r=0.356p<0.001r=0.293p=0.002r=0.379p<0.001hip fracturen.s.r=0.197p=0.036r=0.269p=0.004r=0.271p=0.004r=0.258p=0.006

Conclusion:

Our results showed that a similar number of patients had indication for pharmacological treatment by FRAX both with and without DXA. Although the inclusion of DXA resulted in a higher estimated FR by FRAX, the observed moderate level of agreement between FRAX with and without DXA suggests that the FR estimation by FRAX, even without DXA, may be a reasonable approach in SpA patients. In line with literature, we found significant associations between the estimated risk fracture by FRAX and some disease activity and function measures.

Disclosure of Interests:

Bruno Miguel Fernandes: None declared, Salomé Garcia: None declared, Sara Ganhão: None declared, Maria Rato: None declared, Filipe Pinheiro: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared

SAT0482 FRAX 10-YR FRACTURE RISK IN RHEUMATOID ARTHRITIS ASSESSED WITH AND WITHOUT BONE MINERAL DENSITY – ARE WE TREATING OUR PATIENTS UNDER bDMARDs?

Background:

Patients with rheumatoid arthritis (RA) have a higher risk of osteoporosis not only due to chronic inflammation status, but also due to the treatment with glucocorticoids. FRAX is a computer-based algorithm developed by the World Health Organization for estimation of the 10-year risk of a hip or major osteoporotic fracture. Inclusion of femoral neck bone mineral density (BMD) in the estimation is optional.

Objectives:

The study aimed to identify the RA patients under treatment with biological disease-modifying antirheumatic drug (bDMARD), who have FRAX scores, calculated with and without BMD, classified as high fracture risk and evaluate if they are receiving treatment for osteoporosis. The authors also investigated the intra-individual agreement between FRAX fracture risk calculated with and without BMD.

Methods:

Demographic and clinical data and BMD results from RA patients followed in a tertiary university hospital and registered in the Rheumatic Diseases Portuguese Register were used for analysis. Patients under 40 years of age at the last visit were excluded. McNemar test was applied for the identification of discordance of risk categories. The Wilcoxon test was used to characterize the intraindividual differences between paired FRAX risks with and without BMD. Correlations between pairs of variables were evaluated by the Spearman test. For independent variables Mann-Whitney test was used.

Results:

A total of 303 patients were included, 244 were females (80.5%) and 49 current smokers (16.2%). Mean age was 59.5 ± 9.54 years and mean disease duration 18.5 ± 10.4 years. Two hundred and twenty patients (72.4%) and 243 (80.2%) were RF and ACPA positive, respectively, and 51.5% had erosive disease. Mean disease activity score (DAS28-4V-CRP) was 3.08 ± 1.18 and mean femoral neck BMD 0.84 ± 0.12 g/cm2. One hundred and seventy nine patients (58.9%) were concomitantly treated with conventional synthetic DMARDs and 215 (70.7%) with glucocorticoids. Among all the patients, 35 (11.6%) had previous fractures and 19 (6.3%) have family history of fracture. The median 10-year risk of a major fracture and a hip fracture, calculated without BMD, was 6.0 (1.2-50) and 1.5 (0.1-39), respectively; with BMD it was 6.9 (1.3-61) and 1.7 (0-49). When FRAX score is calculated without BMD (n=303), 76 (25.1%) patients were categorized as high fracture risk. Among them, only 41 (54%) were receiving osteoporosis treatment. FRAX assessment with BMD (n=231) identified 99 (32.7%) patients with high fracture risk, 51 (51,5%) in treatment for osteoporosis. Thirty patients (21%) previously classified as low fracture risk using FRAX without BMD were recategorized as high risk (p<0.001). Despite that, there was a strong correlation between fracture risks assessed with and without BMD for both major and hip fracture (r = 0.867, p < 0.0001 and r = 0.728, p < 0.0001, respectively). ACPA and RF positive patients did not have higher FRAX scores (including or not BMA). Patients with erosive disease had a higher 10-year probability of major fracture evaluated by FRAX when it includes BMD (p=0.041).

Conclusion:

It is very important to accurately assess the risk of osteoporotic fractures in RA patients to treat them properly. The authors highlight the high number of patients who are not receiving treatment according to FRAX categorization. In spite of the correlation between estimated fracture risk by FRAX with and without BMD, there is a discordance in fracture risk categorization, as one fifth of patients of low risk were reclassified as high risk. For the RA population treated with bDMARDS, our findings raise the need to request a DXA not only for patients classified as having an intermediate risk of fracture, but also for low-risk patients.

Disclosure of Interests:

Maria Rato: None declared, Filipe Pinheiro: None declared, Salomé Garcia: None declared, Bruno Miguel Fernandes: None declared, Sara Ganhão: None declared, Rita Gaio: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Alexandra Bernardo: None declared, Lúcia Costa: None declared

FRI0299 EVALUATION OF ENTHESITIS INDICES AND RESPONSE TO BDMARD THERAPY IN PORTUGUESE PATIENTS WITH SPONDYLOARTHRITIS

Background:

Enthesitis is a hallmark clinical feature of spondyloarthritis (SpA), but to date, few studies have investigated how the overall response to biological treatment relates to the evolution of enthesitis counts.

Objectives:

Assess whether the variation in enthesitis indices reflects the overall response to bDMARD therapy in SpA.

Methods:

This longitudinal, retrospective study included patients who met Assessment of Spondyloarthritis international Society (ASAS) criteria for SpA followed at the Rheumatology Department of a tertiary hospital, under bDMARD therapy. Demographic, laboratorial and clinical data were collected, including Bath Ankylosing Spondylitis Metrology Index (BASMI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score-C-reactive protein (ASDAS-CRP), Maastrich Ankylosing Spondylitis Enthesitis Score (MASES), Leeds Enthesitis Index (LEI) and Spondyloarthritis Research Consortium of Canada (SPARCC) scores. All were evaluated at baseline and at 6, 12, 18 and 24 months after starting the first biological therapy. The variation in each parameter compared with the baseline values was calculated at 6, 12, 18 and 24 months and represented in the form of delta. Correlations between variables were assessed using Spearman test and comparison between groups using Wilcoxon, Mann-Whitney U and Kruskal-Wallis tests.

Results:

We included 273 patients, 123 (45,1%) females, aged 42,0±12,3 years and with diagnosis of SpA for 15,4±11,2 years at the start of bDMARD therapy. Eighteen (6,6%) had depression. At baseline, mean BASDAI was 6,43 ±1,62, ASDAS-CRP was 4,01 ± 0,86, median MASES was 1 (0-4), LEI 0 (0-1,75) and SPARCC 1 (0-4). Seventy-two patients (26,4%) started golimumab, 71 (26,0%) adalimumab, 66 (24,2%) infliximab, 54 (19,8%) etanercept, 9 (3,3%) certolizumab and 1 (0,4%) secukinumab. Enthesitis indices were significantly higher at baseline in females [median MASES-females 2 (0-5) vs 0 (0-2), p<0,001; LEI-females 0 (0-2) vs 0 (0-1), p=0,03; and SPARCC-females 2 (0-5) vs 0 (0-2), p<0,001], and remained so at 24 months [median MASES-females 1 (0-3,5) vs 0 (0-0), p<0,001; LEI-females 0 (0-0,5) vs 0 (0-0), p<0,001; and SPARCC-females 1 (0-3) vs 0 (0-0), p<0,001]. MASES and SPARCC, but not LEI, at baseline were significantly higher in patients with depression [median MASES-depression 3,5 (2-6) vs 1 (0-4), p=0,01; SPARCC-depression 4 (0-8) vs 1 (0-3), p=0,03], but at 24 months no differences were observed. There was a significant difference between each of the 3 scores of enthesitis when assessed at 6, 12, 18 and 24 months, compared to baseline (p <0.004). No differences were observed regarding the choice of bDMARD. At baseline, MASES had a significant correlation with patient visual analogic scale (VAS) (r=0,18; p=0,01), BASDAI (r=0,36; p<0,001) and BASFI (r=0,21; p=0,003); LEI had a significant correlation with BASDAI (r=0,31; p<0,001) and BASFI (r=0,21; p=0,003); SPARCC had a significant correlation with patient VAS (r=0,19; p=0,01), BASDAI (r=0,37; p<0,001) and BASFI (r=0,26; p<0,001). ΔLEI at 6 months had a significant correlation with ΔBASDAI (r=0,25; p=0,005), ΔASDAS (r=0,190; p=0,03), Δpatient VAS (r=0,23; p=0,01) and Δphysician VAS (r=0,25; p=0,01), but not with ΔESR, ΔCRP and ΔBASMI; no correlation was found at 6 months for ΔMASES or ΔSPARCC. At 12 months, ΔMASES had a significant correlation with ΔBASDAI (r=0,18; p=0,03); ΔLEI with ΔBASDAI (r=0,23; p=0,01) and Δpatient VAS (r=0,19; p=0,03); for ΔSPARCC no significant correlations were found. At 18 months and 24 months, no correlations were found.

Conclusion:

The initiation of bDMARD led to improved enthesitis indices over a 24-month period. ΔLEI correlates better with SpA activity scores and measurements than the other indices, especially at the first 12 months of initiation of bDMARD therapy.

Disclosure of Interests:

Filipe Pinheiro: None declared, Maria Rato: None declared, Bruno Miguel Fernandes: None declared, Salomé Garcia: None declared, Sara Ganhão: None declared, Pedro Madureira: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared