OP0073 NEW PERSPECTIVES IN AXIAL SPONDYLOARTHRITIS - FIRST RESULTS OF GENDER-SPECIFIC ASSESSMENT OF MRI IMAGING CRITERIA

Background

Gender-specific differences in patients with axial spondyloarthritis (axSpA) are often seen in the clinical presentation and may differ in MRI findings1. Male axSpA patients tend to show structural changes earlier, whereas in female axSpA patients the peripheral joints are more often affected2. This can lead to a delay in axSpA diagnosis in women. For this reason, gender-specific data collection and establishment of gender-specific imaging criteria are of particular importance.

Objectives

To evaluate the diagnostic performance of different combinations of imaging markers to derive data-driven imaging criteria for MRI in axSpA, separately for men and women.

Methods

A total of 1194 patients were included in the study. Considering the exclusion criteria (available MRI image data sets, confirmed diagnoses), 684 patients (379 axSpA and 305 control group) were included for further statistical analysis. Two trained readers scored the MRI images separately for the presence of ankylosis, as well as erosion, sclerosis, fat metaplasia, and bone marrow edema differentiated for 3 regions (ventral/mid/dorsal) for sacral-sided and iliac-sided sacroiliac joint. Chi^2 test was applied to compare lesion frequencies per group. Contingency table analysis was performed to assess diagnostic performances. The diagnostic performances were compared using the diagnostic odd ratio (DOR).

Results

Overall, 136 female and 243 male axSpA patients were included. Higher prevalence for ankylosis (24.3 vs. 7.4%) and fat metaplasia (58.8 vs. 42.6%) was shown in male axSpA patients; in contrast, sclerosis was more common in female axSpA patients (75.0 vs. 57.6%). No sex differences in frequency were shown for bone marrow edema and erosion. In male axSpA patients, the most significant difference in individual parameters was shown for ankylosis (DOR 40.1) compared with females (DOR 4.7). The detection of erosion and fat metaplasia as markers was also better in male axSpA patients (DOR 17.6 vs. 11.1 and 18.6 vs. 6.3). Sclerosis and bone marrow edema were better suited in female axSpA patients (DOR 3.0 vs. 2.5 and 5.0 vs. 3.7). Overall, diagnostic accuracy was improved when only lesions in the middle and dorsal articular compartments were considered.

Conclusion

The diagnostic performance of established image markers on MRI is significantly lower in female axSpA patients. This is especially true for ankylosis, which provides the risk for false-positive findings in women. Based on these findings, future revisions of imaging criteria may include gender-specific recommendations to improve diagnostic accuracy for male and female axSpA patients.

References

[1]Braun J, Baraliakos X, Bülow R, et al. Striking sex differences in magnetic resonance imaging findings in the sacroiliac joints in the population. Arthritis Res Ther. 2022 Jan 20;24(1):29. doi: 10.1186/s13075-021-02712-7.

[2]Mease PJ, McLean RR, Dube B, et al. Comparison of Men and Women With Axial Spondyloarthritis in the US-based Corrona Psoriatic Arthritis/Spondyloarthritis Registry. J Rheumatol 2021;48(10):1528-36. doi: 10.3899/jrheum.201549 [published Online First: 2021/04/17]

Disclosure of Interests

Sevtap Tugce Ulas: None declared, Fabian Proft Speakers bureau: Novartis, Lilly and UCB, as well as personal fees from AbbVie, AMGEN, BMS, Hexal, Janssen, MSD, Pfizer and Roche, Grant/research support from: Novartis, Eli Lilly and UCB., Torsten Diekhoff Speakers bureau: MSD, Novartis and Eli Lilly., Valeria Rios Rodriguez Speakers bureau: AbbVie and Falk e.V., Judith Rademacher Grant/research support from: Berlin Institute of Health (BIH) during the conduct of this study (Clinician Scientist Programme)., Mikhail Protopopov Grant/research support from: UCB, Sarah Ohrndorf: None declared, Denis Poddubnyy Speakers bureau: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, Bristol-Myers Squibb, Roche, UCB, Biocad, GlaxoSmithKline and Gilead, Grant/research support from: AbbVie, Eli Lilly, MSD, Novartis and Pfizer., Katharina Ziegeler Grant/research support from: Assessment of Spondyloarthritis international Society (ASAS) during the conduct of this study.

POS1007 MRI CHANGE SCORE BUT NOT THE STATUS SCORE IS RELATED TO DISEASE ACTIVITY AND CLINICAL RESPONSE OVER TIME IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS: RESULTS FROM ESTHER STUDY

Background

Magnetic resonance imaging (MRI) of the spine and sacroiliac joints (SIJ) are important tools for the diagnosis of axial SpA. However, there is very little data investigating how clinical symptoms and response to treatment relate to the degree of MRI inflammation and to its change over time.

Objectives

To evaluate the relationship between clinical response in axial SpA patients and inflammation in MRI of spine and SIJ after 6 months of treatment.

Methods

In the ESTHER study1, a total of 76 patients with early axial SpA with a symptom duration less than 5 years, and with active inflammation on MRI in the spine and/or SIJ at baseline were randomized to be treated with etanercept (n=40) or sulfasalazine (n=36) for one year.

Clinical and laboratory outcome assessments included C-reactive protein (CRP), Bath ankylosing spondylitis disease activity index (BASDAI), Bath ankylosing spondylitis functional index (BASFI) and ankylosing spondylitis disease activity score (ASDAS). The following efficacy parameters were calculated: change in CRP, BASDAI, BASFI and ASDAS between baseline and Week 24; response of the ASAS response criteria for 20 and 40% improvement in disease activity (ASAS20 and ASAS40); and ASAS criteria for partial remission at Week 24.

MRI of spine and SIJ were performed at weeks 0, 24, and 48; and were scored by two radiologists, who were blinded for all clinical data, treatment arm and time point, according to the Berlin scoring system. The final osteitis score for the SIJ and for the spine was calculated as the mean score of both readers. Residual inflammation in MRI at Week 24 was defined as an osteitis score of ≥5 for SIJ and >0 for the spine (median values at Week 24).

To understand the relationship between MRI and clinical outcomes, two types of models were performed: 1) a model with status scores at baseline and Week 24 for MRI and clinical outcome parameters; and 2) a model with change scores between baseline and Week 24 for MRI and clinical outcome parameters.

Results

A total of 67 patients with axial SpA were included in this analysis due to availability of MRIs at baseline and Week 24. The characteristics of patients included for this analysis were similar to the whole group of the ESTHER study. SIJ and spine osteitis score on MRI at baseline (mean±SD) was 6.9±6.1 and 1.5±2.5, respectively.

The status scores showed no association at baseline, neither at Week 24, with the only exception of ASAS20 at Week 24 (Figure 1). However, changes in osteitis score of SIJ and spine were associated to clinical response outcomes between baseline and Week 24 (Figure 1). Further, we compared patients with and without residual inflammation on MRI of the spine and SIJ as defined above. There were no differences between the groups regarding clinical response and disease activity at week 24.

Figure 1.

Association between disease activity parameters and MRI osteitis score in spine and SIJ in patients with axial spondyloarthritis over 6 months of treatment. Each line in the figure refers to an outcome (dependent variable) in the multivariable regression analysis, which were adjusted for age, sex, symptom duration and HLA-B27 positivity. MRI, magnetic resonance imaging; SIJ, sacroiliac joints.

Conclusion

Change of score for osteitis in MRI of spine and SIJ was associated to disease activity in patients with axial SpA during 6 months of treatment. Presence of residual inflammation on MRI after 6 months of treatment seems to be irrelevant regarding clinical response and clinical disease activity.

References

[1]Song IH, et al. Ann Rheum Dis. 2011;70(4):590-596.

Acknowledgements

The ESTHER study was supported by an unrestricted research grant from Pfizer. We would like to thank to Anja Weiß and Christian Althoff who participated in the analysis of the study.

Disclosure of Interests

Valeria Rios Rodriguez Speakers bureau: Falk e.V., Consultant of: AbbVie, Murat Torgutalp: None declared, Hildrun Haibel Speakers bureau: MSD, Janssen, Roche, Pfizer, Novartis, AbbVie, and Sobi, Consultant of: Boehringer, Janssen, MSD, Novartis, Sobi, Kay-Geert A Hermann: None declared, Fabian Proft Speakers bureau: AbbVie, AMGEN, BMS, Hexal, MSD, Pfizer, Roche and Janssen, Grant/research support from: Novartis, Lilly and UCB, Mikhail Protopopov: None declared, Judith Rademacher: None declared, Joachim Sieper Speakers bureau: Abbvie, Janssen, Lilly, Merck,Novartis, UCB, Consultant of: AbbVie, Lilly, Merck, Novartis, UCB, Denis Poddubnyy Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, and UCB., Consultant of:: AbbVie, Biocad, Eli Lilly, Gilead, GlaxoSmithKline, Janssen, MSD, Novartis, Pfizer, Samsung Bioepis, and UCB, Grant/research support from: AbbVie, Eli Lilly, MSD, Novartis, Pfizer

OP0026 CLINICAL AND IMAGING-BASED CHARACTERIZATION OF A PROSPECTIVE COHORT OF PATIENTS WITH AXIAL PSORIATIC ARTHRITIS (AXIAL PsA). GESPIC-AXIAL PsA: RESULTS OF AN INTERIM ANALYSIS

Background

Psoriatic arthritis (PsA) is a chronic inflammatory disease, which is subsumed together with axial spondyloarthritis (axial SpA) under the umbrella term spondyloarthritis, whose clinical presentations are very heterogeneous. Axial involvement (axial PsA) has been described to be present in 34% of PsA patients [1] and has been systematically investigated only retrospectively or in cross-sectional studies [2]. Although axial PsA seems to have similar characteristics to axial SpA, it is not clear whether axial PsA and axial SpA, are a spectrum of the same disease with different expression patterns or different diseases with great similarities.

Objectives

To prospectively investigate the clinical and imaging morphology patterns in a well-defined cohort of patients with axial PsA from the German SPondyloarthritis Inception Cohort (GESPIC).

Methods

Prospective, longitudinal, observational study of patients with an imaging confirmed diagnosis of axial PsA. In addition to clinical and laboratory characterization, conventional radiographs and magnetic resonance imaging (MRI) - scans of the entire spine and sacroiliac joints (SIJs) are performed at the baseline visit and patients are followed up every 6 months according to a predefined protocol. After 2 years, additional imaging (X-ray and MRI) is performed for follow-up. In this interim analysis baseline data are presented.

Results

Between August 2019 and December 2021, 85 axial PsA patients were included. The mean age was 45.2 ± 12.9 years with a proportion of 55.3% female patients. Peripheral involvement was present in 43 (50.6%) patients, HLA-B27 was positive in 39 (45.9%), and C-reactive protein was elevated (>5mg/l) in 27 (31.8%) patients. Inflammatory back pain (IBP) in the discretion of the treating rheumatologist was present in 64 (75.3%) patients (Table 1). The modified New York criteria were fulfilled in 44.9% (n=35). MRI of the SIJ showed active inflammatory changes in 44 (55%) and structural changes in 59 (73.8%) patients. MRI of the spine showed active inflammation in 60% (n=48). Exclusively active and/or structural changes of the spine without changes in the SIJ were seen in 18.8% (n=15) (Figure 1).

Table 1.

Characteristics of patients with axial PsA

ParametersAxial PsA (n=85)Age in years (mean ± SD)45.2 ± 12.9Female sex, n (%)47 (55.3%)Inflammatory back pain (IBP) present, n (%)64 (75.3%)Peripheral Involvement, n (%)43 (50.6%)Nail Involvement, n (%)39 (45.9%)PASI-Score (mean ± SD)3.3 ± 5.1BASDAI (mean ± SD), 0-104.9 ± 2.0BASFI (mean ± SD), 0-103.8 ± 2.5ASDAS-CRP (mean ± SD)2.8 ± 1.0DAPSA (mean ± SD)14.5 ± 9.2HLA-B 27 positive, n (%)39 (45.9%)CRP >5mg/l, n (%)27 (31.8%)

ASDAS-CRP =Ankylosing Spondylitis Disease Activity Score - CRP, BASDAI = Bath Ankylosing Spondylitis Disease Activity Index, BASFI =Bath Ankylosing Spondylitis Functional Index, CRP = C-reactive protein, DAPSA = Disease Activity in PSoriatic Arthritis-Score, PASI = Psoriasis Area Severity Index, PsA = Psoriatic arthritis, SD = standard deviation.

Figure 1.

MRI-imaging patterns of axial PsA patients (n=80*). MRI= magnetic resonance imaging, SIJs= sacroiliac joints. *Full imaging data available for 80 patients only due to variable reasons.

Conclusion

In the here presented interims analysis of the baseline data of our prospective cohort study of patients with an imaging-based diagnosis of axial PsA, it is shown that these patients are less frequently HLA-B27 positive and more frequently female when compared to previously described cohorts of “classical” axial SpA patients. Noteworthy, nearly 20% of the patients showed an isolated spinal involvement without active or structural changes in the SIJs.

References

[1]Gladman, D.D., et al., Psoriatic arthritis (PSA)--an analysis of 220 patients. Q J Med, 1987. 62(238): p. 127-41.

[2]Feld, J., et al., Axial disease in psoriatic arthritis and ankylosing spondylitis: a critical comparison. Nat Rev Rheumatol, 2018. 14(6): p. 363-371.

Acknowledgements

The GESPIC-axial PsA cohort is partially supported by an independent research grant from Novartis.

We would especially like to thank C. Höppner, C. Lorenz, and all referring rheumatologists for their tireless support.

Disclosure of Interests

Henriette Käding: None declared, Susanne Lüders: None declared, Mikhail Protopopov: None declared, Judith Rademacher: None declared, Valeria Rios Rodriguez: None declared, Laura Spiller: None declared, Murat Torgutalp: None declared, Denis Poddubnyy: None declared, Fabian Proft Speakers bureau: AMGEN, AbbVie, BMS, Celgene, Janssen, MSD, Novartis, Pfizer, Roche, UCB.

Consultant of: AbbVie, Celgene, Janssen, Novartis, UCB.

Grant/research support from: Novartis, Lilly, UCB.

AB0826 Keep an Eye on the Back: Spondyloarthritis in Patients with Acute Anterior Uveitis

Background

Patients with acute anterior uveitis (AAU) have an increased risk for concomitant spondyloarthritis (SpA). Different referral strategies have been proposed to identify AAU patients with high probability of SpA, among them an Assessment of SpondyloArthritis international Society(ASAS)-based referral strategy focusing on patients with chronic back pain starting before the age of 45 years and the Dublin Uveitis Evaluation Tool (DUET) also including psoriasis, HLA-B27 and arthralgia (Poddubnyy et al., Haroon et al., both ARD 2015).

Objectives

To analyse the prevalence of SpA in patients with AAU, to identify parameters associated with SpA presence, and to evaluate referral algorithms.

Methods

Patients with non-infectious AAU underwent structured rheumatologic assessment including magnetic resonance imaging of sacroiliac joints allowing a definitive diagnosis/exclusion of concomitant SpA. Fisher’s exact test and Mann–Whitney U test were used to compare AAU patients with and without SpA. Furthermore, logistic regression analyses were performed. Sensitivity, specificity, positive predictive value, positive and negative likelihood ratios were analysed for referral strategies.

Results

The 189 AAU patients with complete rheumatologic assessment and SIJ imaging were 40.8 years old, and 55% were males. SpA was diagnosed in 106 AAU patients (56%). The majority (93%) had predominantly axial SpA, 7 patients peripheral SpA. In 74 patients (70%), the SpA diagnosis was established for the first time. Pelvic X-rays were available for 88 (89%) of the axSpA patients, 66% of whom were classified as having radiographic axSpA.

SpA was equally frequent in patients experiencing the first episode of AAU and in patients with recurrent disease. In our cohort, AAU patients with and without underlying SpA showed no differences in their ophthalmologic examination. In multivariable logistic regression analysis, psoriasis (OR 12.5 [95%CI 1.3-120.2]), HLA-B27 positivity (OR 6.3 [95%CI 2.4-16.4]), elevated CRP (OR 4.8 [95%CI 1.9-12.4]) and male sex (OR 2.1 [95%CI 1.1-4.2]) were associated with SpA presence.

Table 1.

Parameters associated with the presence of spondyloarthritis in patients with acute anterior uveitis.

univariablemultivariableOR95%CIOR95%CIPsoriasis (ever)14.6(1.9; 112.4)12.5(1.3; 120.2)HLA-B27 positivity6.2(2.7; 14.6)6.3(2.4; 16.4)Elevated CRP (≥ 5 mg/l)4.1(1.8; 9.0)4.8(1.9; 12.4)Male sex2.2(1.2; 4.0)2.1(1.1; 4.2)Inflammatory back pain (ASAS definition)2.1(1.2; 3.9)1.9(0.9; 4.0)Any peripheral manifestation (ever)1.9(1.1; 3.5)1.9(0.9; 3.8)Age in years1.0(1.0; 1.0)1.0(1.0; 1.0)

Univariable and multivariable logistic regression analyses. ASAS Assessment of SpondyloArthritis international Society; CRP C-reactive protein; OR odds ratio; CI confidence interval.

The Dublin Uveitis Evaluation Tool showed higher specificity for SpA recognition than the ASAS referral tool (42% vs. 28%), which had slightly higher sensitivity (78% vs. 80%). However, both referral strategies would have missed more than 20% of SpA patients.

Conclusion

We revealed a high prevalence of overall and previously undiagnosed SpA in AAU patients. Therefore, we propose rheumatologic evaluation for all AAU patients with musculoskeletal symptoms. Rheumatologists should consider that SpA in AAU patients might present “atypically” with back pain starting after 45 years and lasting shorter than 3 months.

Figure 1.

Performance of Referral Strategies in Patients with Acute Anterior Uveitis. Dublin Uveitis Evaluation Tool (DUET) and an ASAS-based referral tool (ASAS). + respective tool fulfilled, - not fulfilled. ASAS Assessment of SpondyloArthritis international Society; AxSpA axial spondyloarthritis, pSpA peripheral spondyloarthritis.

Acknowledgements

The authors would like to thank the rheumatologists S. Lüders, B. Muche and A.-K. Weber for participating in the clinical data acquisition; and A. Langdon and L. Meinke for their support monitoring and coordinating this study. Furthermore, we are grateful to all participating ophthalmologists who included their patients in this study and to all patients. The study was supported by an unrestricted research grant from AbbVie. AbbVie had no role in the study design or in the collection, analysis, or interpretation of the data, the writing of the manuscript, or the decision to submit the manuscript for publication. Dr. Judith Rademacher and Dr. Dominika Pohlmann are participants in the BIH-Charité Clinician Scientist Program funded by the Charité –Universitätsmedizin Berlin and the Berlin Institute of Health.

Disclosure of Interests

Judith Rademacher: None declared, Hanna Müllner: None declared, Torsten Diekhoff Speakers bureau: AbbVie, MSD, Novartis, Canon MS, Consultant of: Lilly, Hildrun Haibel Speakers bureau: AbbVie, MSD, Janssen, Roche, Pfizer, Sobi, Consultant of: Janssen, Sobi, Novartis, Sabrina Igel: None declared, Dominika Pohlmann Speakers bureau: Bayer, Consultant of: AbbVie, Celgene, Janssen, Novartis, UCB, Grant/research support from: Bayer, Allergan, Fabian Proft Speakers bureau: AMGEN, AbbVie, BMS, Celgene, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Consultant of: AbbVie, Celgene, Janssen, Novartis, UCB, Grant/research support from: UCB, Novartis, Lilly, Mikhail Protopopov Consultant of: Novartis, Valeria Rios Rodriguez Consultant of: AbbVie, Falk e.V., Murat Torgutalp: None declared, Uwe Pleyer Shareholder of: stock or stock options from Novartis, BionTec, Speakers bureau: AbbVie, Alimera, Novartis, Grant/research support from: AbbVie, Denis Poddubnyy Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer and UCB, Consultant of: AbbVie, Biorad, Eli Lilly, Gilead, GlaxoSmithKline, Janssen, MSD, Novartis, Pfizer, Samsung Bioepis and UCB, Grant/research support from: AbbVie, Eli Lilly, MSD, Novartis, Pfizer

AB0875 Assessment of Clinical Signs of Spondyloarthritis in Patients with Inflammatory Bowel Disease

Background

Patients with inflammatory bowel disease (IBD), Crohn’s disease (CD) and ulcerative colitis (UC), commonly face the presence of extraintestinal manifestations (EIMs). Spondyloarthritis (SpA) is present in about 10-39% of patients with IBD, being the most frequent EIM [1]. Diagnosis of axial SpA (axSpA) in IBD represents a clinical challenge. The diagnostic value of Ankylosing Spondylitis Assessment Society (ASAS) criteria that are used for defining inflammatory back pain (IBP) in axSpA, in patients with the association of axSpA and IBD is not clear.

Objectives

To determine the diagnostic value of ASAS criteria for IBP (2009) and to evaluate factors that are associated with a higher risk of axial SpA in patients with IBD.

Methods

The study included 91 patients with IBD (UC - 52 patients (57.1%), CD - 39 (42.9%), males – 47 (51.6%), mean age 40.2±11.7 years, duration of IBD – 7.7±7.6 years). IPB was defined by ASAS criteria (2009). AxSpA in patients with IBD is recommended to be diagnosed by the combination of Inflammatory Back Pain (IBP), and imaging (MRI and X-ray) [2]. Imaging of lumbar spine and sacroiliac joints was performed to patients, who fulfilled the ASAS criteria for IBP: X-ray - 55 patients; MRI (T1, STIR) - 41 patients. Imaging was considered positive when patients had at least unilateral sacroiliitis stage 2 or higher according to the accepted grading system on X-Ray, or MRI-verified sacroiliitis.

Results

Low back pain was observed in 84 (92.3%) patients with IBD, 39 (42.9%) patients fulfilled the criteria ASAS for IBP. MRI-verified sacroiliitis was present in 26 patients. Changes on X-ray were present in 40 patients. After imaging, 26 patients were diagnosed with axSpA, 14 of them fulfilled the modified New York criteria for the ankylosing spondylitis. Diagnostic value of the ASAS criteria was the following: sensitivity 76.9%, specificity 67.2%, PPV 0.51, NPV 0.87, LR+ 2.3, and LR- 0.3 (ECCO consensus definition used as the “gold standard”). Presence of arthritis - OR 10.77 [95% CI 2.26-44.2], p=0.005, arthralgia - OR 4.12 [95% CI 1.55-10.95], p=0.005, CD - OR 2.92 [95% CI 1.14-7.48], p=0.025 and IBP – OR 8.07 [95% CI 2.8-23.23], p=0.001 was associated with a higher risk of axSpA diagnosis in the univariate logistic regression model. The associations remained statistically significant when multivariate logistic regression model was constructed – arthritis 20.03 [95% CI 3.05 -131.69], CD – 3.51 [95% CI 1.04-11.82], IBP – 8.72 [95% CI 2.64-28.79], R2=0.486.

Conclusion

The ASAS criteria for IBP had a good diagnostic value in patients with IBD. The diagnostic value of the ASAS criteria for IBP (2009) in patients with IBD was comparable to the following in the patients with chronic back pain. Clinicians should pay attention to the presence of arthritis, arthralgia, IBP and CD, as these factors were associated with a higher risk of being diagnosed with axSpA in patients with IBD.

References

[1]Fragoulis, G. (2019). Inflammatory bowel diseases and spondyloarthropathies: From pathogenesis to treatment. World Journal Of Gastroenterology, 25(18), 2162-2176.

[2]Harbord, M. (2015). The First European Evidence-based Consensus on Extra-intestinal Manifestations in Inflammatory Bowel Disease. Journal Of Crohn’s And Colitis, 10(3), 239-254.

Disclosure of Interests

None declared

POS1445 EARLY DETECTION OF AXIAL PSORIATIC ARTHRITIS IN PATIENTS WITH PSORIASIS: A PROSPECTIVE, MULTICENTER STUDY

Background

In the absence of reliable serological and/or imaging biomarkers that can support an early diagnosis of psoriatic arthritis (PsA) in patients with psoriasis (PsO), and considering the known diagnostic delay there is a need for screening tools for detection of early PsA. While different validated screening/referral tools focusing on peripheral manifestations of PsA exist, validated referral algorithms for PsA with axial involvement (also referred to as axial PsA - axPsA) are still missing.

Objectives

In this prospective, multicenter study we applied a dermatologist-centered screening tool and a structured rheumatologic examination including magnetic resonance imaging (MRI) of sacroiliac joints (SIJs) and spine to detect axPsA in patients with psoriasis (PsO).

Methods

Patients with PsO were systematically screened by their dermatologist for eligibility for referral to a rheumatology clinic. Eligible patients were ≥ 18 years with a confirmed diagnosis of PsO who reported having chronic back pain (≥ 3 months) with onset prior to 45 years of age and who had not been treated with any biologic or targeted synthetic DMARD 12 weeks prior to screening. For those patients who qualified for referral a rheumatologic investigation including clinical, laboratory and genetic assessments as well as imaging with conventional radiography and MRI of sacroiliac joints and spine was performed. The primary outcome of the study was the proportion of patients diagnosed with axPsA among all referred PsO patients.

Results

In total 355 patients were screened at 14 dermatology sites, of whom 151 (42.5%) qualified for referral to rheumatology clinic and 100 (28.2%) were seen by a rheumatologist. The diagnosis of axPsA was confirmed in 14 patients (3/14 with both, axial and peripheral involvement) and the diagnosis of peripheral PsA (pPsA) without axial involvement was made in five patients. The ASAS classification criteria for axSpA were fulfilled in nine (64.3%) of the patients diagnosed with axPsA. All but one patient diagnosed with PsA (13/14 with axPsA and 5/5 with pPsA) fulfilled the CASPAR criteria for PsA.

Patient characteristics are presented in Table 1. All patients diagnosed with axPsA had active inflammatory and/or structural (post)inflammatory changes in the sacroiliac joints and/or spine on imaging. In five patients (35.7%), MRI changes indicative of axial involvement were found only in the spine as illustrated in Figure 1.

Table 1.

Clinical characteristics of all referred patients with PsO and suspicion of axSpA.

Patient characteristicpPsA (N=5)axPsA (N=14)No PsA (N=81)p-value1Age (years) – Mean (SD)42.8 (9.0)46.2 (13.6)45.7 (13.3)0.883Female – n (%)2 (40.0)9 (64.3)45 (55.6)0.543PASI – Mean (SD)3.3 (2.1)4.3 (4.9)4.0 (4.5)0.971Inflammatory back pain – n (%)5 (100.0)8 (57.1)36 (44.4)0.379HLA-B27 positive – n (%)04 (28.6)12 (14.8)0.204Elevated CRP (>5 mg/L) – n (%)1 (20.0)5 (35.7)11 (13.6)0.041Peripheral arthritis, current (last 7 days) – n (%)5 (100.0)3 (21.4)3 (3.7)0.012Radiographic sacroiliitis as per mNY criteria – n (%)04 (28.6)1 (1.2)<0.001Active inflammation, sacroiliac joint (MRI) – n (%)08 (57.1)0<0.001Structural (post)inflammatory changes, sacroiliac joint (MRI) – n (%)08 (57.1)0<0.001Active inflammation, spine (MRI) – n (%)013 (92.9)0<0.001Structural (post)inflammatory changes, spine (MRI) – n (%)08 (57.1)0<0.001

1Statistically significant differences between the axPsA and No PsA groups of patients were determined by using Mann–Whitney U test for continuous data and Chi-square test for categorical data

Figure 1.

Imaging features of axial involvement in PsO patients diagnosed with axPsA

Conclusion

Our study revealed that applying a dermatologist-centered screening tool may be useful for the early detection of patients with a high probability of PsA (and specifically axPsA) in PsO patients. Given the high prevalence of isolated spinal involvement (without SIJs), imaging of the entire axial skeleton may be required as a part of diagnostic procedure in patients with suspected axPsA.

Acknowledgements

Caroline Höppner, Rebecca Bolce, David Sandoval, Hagen Russ, Burkhard Muche, Judith Rademacher, Hildrun Haibel, Laura Spiller and all cooperating dermatologists.

Disclosure of Interests

Fabian Proft: None declared, Susanne Lüders: None declared, Theresa Hunter Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Gustavo Luna: None declared, Valeria Rios Rodriguez: None declared, Mikhail Protopopov: None declared, Katharina Meier: None declared, Georgios Kokolakis: None declared, Kamran Ghoreschi: None declared, Denis Poddubnyy: None declared

AB0796 Quantitative bone marrow lesion characterization at the sacroiliac joint with T1-mapping

Background

Conventional magnetic resonance imaging (MRI) uses T1-weighted and short-tau inversion recovery (STIR) sequences to characterize bone marrow lesions in axial spondyloarthritis. However, quantification is restricted to the extent of marrow lesions because signal intensities are highly variable within and across patients and scanners. Furthermore, some marrow lesions are less visible in MRI and need further characterization with computed tomography (CT), e.g. sclerosis. Quantitative MRI in form of mapping sequences might help to better characterize bone marrow lesions.

Objectives

To evaluate the performance of T1-mapping for differentiating different bone marrow lesions at the sacroiliac joints in patients with suspected axial spondyloarthritis.

Methods

Sixty-two patients (mean age 41±12.5; thirty-two were finally diagnosed with axial spondyloarthritis and 30 with another condition) underwent CT and MRI of the sacroiliac joints. Besides standard oblique coronal T1 and STIR sequences a T1-mapping sequence (Modified Look-Locker Inversion Recovery) was added to the protocol. Bone marrow lesions (maximum 4 lesions per patient, 1 lesion of the same type per joint) were characterized by an expert radiologist into four groups, namely sclerosis (lesion type (LT) 1), osteitis (LT2), fat lesion (LT3) and mixed marrow lesions (LTm). Relaxation times on T1-maps were compared using Kruskal-Wallis test correcting for multiple comparisons and correlated to quantitative measures from conventional MRI sequences and CT.

Results

119 lesions were selected (LT1: 38, LT2: 27, LT3: 40; LTm: 14). T1-map showed highly significant differences between LT1-3 with the lowest values for sclerosis (1522±227 ms), followed by osteitis (1906±82 ms) and fat lesions (2391±200 ms); p<0.0005. However, mixed lesions showed a broad distribution of values (1869±670), irrespective of their characteristics. T1-map correlated to a high degree with conventional T1-values (r = 0.74) and Hounsfield units in CT (r = -0.69) with p < 0.0001, respectively, but not with STIR (p = 0.8).

Conclusion

T1-Mapping allows for accurately characterizing lesions at the sacroiliac joint in patients with suspected axial spondyloarthritis and, thus, may combine information from two conventional sequences and CT into one in the future while providing superior capacity for quantification. However, in our study mixed lesions and inhomogeneous bone marrow remained problematic. Thus, further sequence development is needed before its implementation in clinical routine.

Figure 1.

T1-mapping values of the different lesions, LT1: Sclerosis, LT2: Osteitis, LT3: Fat lesion, LTm: Mixed lesion. Differences are highly significant, which allows T1-mapping to characterize those different lesions in one sequence.

Disclosure of Interests

Torsten Diekhoff Speakers bureau: Novartis, Eli Lilly, MSD, Canon MS, Consultant of: Novartis, Dominik Deppe: None declared, Denis Poddubnyy: None declared, Katharina Ziegeler: None declared, Fabian Proft: None declared, Kay-Geert Hermann: None declared, Mikhail Protopopov: None declared, Felix Radny: None declared, Marcus Makowski: None declared

POS0970 SAME OR DIFFERENT? ANALYSIS OF SIMILARITIES AND DIFFERENCES OF CROHN’S DISEASE AND ULCERATIVE COLITIS IN SPONDYLOARTHRITIS: AN ANCILLARY ANALYSIS FROM THE WORLDWIDE ASAS-perSpA STUDY

Background

Crohn’s disease (CD) and ulcerative colitis (UC) are grouped as inflammatory bowel disease (IBD), and both are frequently found as extra-musculoskeletal manifestations in spondyloarthritis (SpA). Several studies have described the connection between SpA and IBD in both directions. Still until today, no studies have investigated possible differences in the musculoskeletal manifestations between the two main entities of inflammatory bowel disease: CD and UC.

Objectives

To evaluate the clinical characteristics associated with the presence of CD or UC in patients with spondyloarthritis from the international cross-sectional ASAS-perSpA study.

Methods

We analyzed 3152 patients from the ASAS per-SpA cohort who had a diagnosis of axial SpA or peripheral SpA according to the treating rheumatologist. Patients with IBD - confirmed by endoscopy - were identified and stratified by CD or UC. Patients in which their IBD disease was not specified, were excluded. Demographics, clinical characteristics, treatments and patient-reported outcomes were compared between both subgroups.

Results

Among the 146 patients diagnosed with IBD from the 3152 patients included in the analysis, 87 (59.6%) presented with CD (75 patients with axial SpA and 12 with peripheral SpA) and 39 (26.7%) with UC (34 patients with axial SpA and 5 with peripheral SpA) - Figure 1. A total of 20 (13.7%) patients with IBD were excluded, due to an inconclusive diagnosis of IBD. Patients with CD and UC had similar age (44.9 vs 44.0 years old) and sex distribution, although a slightly higher frequency of males was observed in CD than UC (63.2% vs 51.3%). The diagnostic delay for SpA was 7.0 years for CD and 8.1 years for UC. We did not find differences between both groups related to any musculoskeletal manifestations such as chronic back pain, uveitis, arthritis, enthesitis or dactylitis (Table 1). The only parameter showing a significant difference between CD and UC was the Bath Ankylosing Spondylitis Functional Index (BASFI) with a mean score of 3.3 vs 2.2 respectively (p=0.02) (Table 1). CD patients showed a higher tendency to be HLA-B27 positive (51.9% in CD vs. 39.4% in UC), but this did not reach statistical significance. No differences were observed regarding treatment patterns between both groups.

Table 1.

Demographics and clinical characteristics related to spondyloarthritis of patients with concomitant Crohn’s disease or ulcerative colitis (n=146).

Crohn’s Disease N=87Ulcerative Colitis N=39PAge, mean (SD)44.9 (13.5)44.0 (13.0)0.68Sex, n/N (%) male55/87 (63.2)20/39 (51.3)0.21Smoker ever, n/N (%)36/87 (41.4)19/39 (48.7)0.44Diagnostic delay of SpA (years), mean (SD)7.0 (6.9)8.8 (8.1)0.38Psoriasis ever, n/N (%)9/87 (10.3)6/39 (15.4)0.47Uveitis ever, n/N (%)17/87 (19.5)11/39 (28.2)0.28Synovitis ever, n/N (%)42/87 (48.3)18/39 (46.2)0.83Enthesitis ever, n/N (%)26/87 (29.9)14/39 (35.9)0.50Dactylitis ever, n/N (%)3/87 (3.4)1/39 (2.6)0.79Axial involvement ever (according to the rheumatologist), n/N (%)79/87 (90.8)37/39 (94.9)0.44Sacroiliitis on X-ray, n/N (%)64/87 (73.6)26/39 (66.7)0.19HLA-B27 positive, n/N (%)28/54 (51.9)13/33 (39.4)0.26CRP mg/L, mean (SD)11.1 (33.8)15.3 (30.1)0.13ASDAS-CRP, mean (SD)2.4 (1.0)2.4 (1.1)0.84BASFI, mean (SD) 0-103.3 (2.6)2.2 (2.1)0.02csDMARDs ever, n/N (%)71/87 (81.6)35/39 (89.7)0.25bDMARDs ever, n/N (%)72/87 (82.8)33/39 (84.6)0.80

ASDAS, Ankylosing Spondylitis Disease Activity Score; BASFI, Bath Ankylosing Spondylitis Functional Index; bDMARD, biological disease-modifying antirheumatic drugs; CRP, c-reactive protein; csDMARD, conventional synthetic disease-modifying antirheumatic drugs; SD, standard deviation; SpA, spondyloarthritis.

Conclusion

In our ancillary analysis of the ASAS-perSpA study in patients with SpA and concomitant CD or UC, no differences in the clinical presentation or demographic characteristics between the two subgroups were observed, except for the BASFI.

Disclosure of Interests

None declared

AB0878 Higher vitamin D serum level is associated with a better clinical response to bDMARDs in patients with axial spondyloarthritis

Background

Vitamin D deficiency has been shown to be associated with higher disease activity and severity of several inflammatory diseases such as rheumatoid arthritis, inflammatory bowel disease and spondyloarthritis (SpA). It is, however, unknown if vitamin D level might affect the response to treatment with biologic disease-modifying anti-rheumatic drugs (bDMARDs) in patients with SpA.

Objectives

To investigate the association between vitamin D serum levels and the response to a bDMARD therapy in patients with axial SpA.

Methods

Patients with a radiographic axial SpA (r-axSpA), fulfilling the modified New York criteria and starting a bDMARD therapy were recruited between 2015 and 2019 in an extension of the prospective German Spondyloarthritis Inception Cohort (GESPIC-AS). All patients were required to have at inclusion high disease activity (BASDAI >=4 and/or ASDAS >=2.1) despite previous treatment with nonsteroidal anti-inflammatory drugs. Demographics, patient clinical characteristics and vitamin D serum levels were collected at baseline. Disease activity measures (BASDAI, CRP, ASDAS) were assessed at baseline and after 6 months of bDMARD treatment. Vitamin D deficiency was defined as serum level of 25-hydroxyvitamin D < 20 ng/mL. A multivariable regression analysis was performed to determine the association between vitamin D serum level at baseline and the treatment response as defined by BASDAI and ASDAS change scores at month 6 as compared to baseline.

Results

A total of 129 patients with r-axSpA were included in the study. No patient took supplements of vitamin D at baseline. Patients had an average age (mean±SD) of 36.5±10.5 years, 64.3% were males and 86.6% were HLA-B27 positive. The prevalence of vitamin D deficiency in our cohort was 54.3%. Patient characteristics and disease activity were comparable with regard to the presence of vitamin D at baseline (Table 1); with the exception of body mass index (BMI), which was higher in patients with vitamin D deficiency. In the multivariable linear regression analysis, baseline serum level of vitamin D was independently and significantly associated with higher change in BASDAI and ASDAS (Figure 1).

Table 1.

Baseline characteristics of patients with radiographic axial SpA (n=129) according to vitamin D levels at baseline.

Patients with vitamin D deficiency (<20 ng/mL)n=70Patients with normal levels of vitamin Dn=59Age, years36.6±11.036.3±10.0Male sex46 (65.7)37 (62.7)BMI, kg/m226.0±4.5*24.0±3.8Smoking, ever41 (58.6)29 (49.2)Winter and Spring, n (%)33 (47.1)23 (39.0)Symptom duration, years11.5±11.310.3±7.1HLA-B27 positive62 (88.6)50 (84.7)Uveitis ever17 (24.3)12 (20.3)Psoriasis ever11 (15.7)7 (11.9)IBD ever, n (%)2 (2.9)7 (11.9)CRP, mg/L12.9±19.313.9±15.3BASDAI5.7±1.45.4±1.4ASDAS3.4±0.83.5±0.8BASFI4.6±2.24.4±1.9BASMI3.1±1.52.7±1.3NSAID intake, current50 (71.4)45 (76.3)DMARDs intake, ever9 (12.9)6 (10.2)TNFi naive55 (78.6)47 (79.7)Corticoids intake, current5 (7.1)2 (3.4)

*p value <0.05.

All numerical variables were presented as mean±SD, all categorical variables were presented as n (%).

BMI, body mass index; CRP, C-reactive protein; DMARD, disease-modifying antirheumatic drug; IBD, inflammatory bowel disease; NSAID, nonsteroidal anti-inflammatory drug; TNFi, tumor necrosis factor inhibitor.

Figure 1.

Association between the response to bDMARDs (change in BASDAI and ASDAS after 6 months) and level of vitamin D at baseline in patients with radiographic axial SpA in the multivariable regression analysis.

Conclusion

Higher vitamin D levels at baseline may predict a better treatment response to bDMARDs in patients with r-axSpA. It has to be shown, however, if vitamin D supplementation might result in a better treatment response in axial SpA.

Disclosure of Interests

None declared

POS1460 CONTRIBUTING TO THE TRAINING OF IMAGING IN RHEUMATOLOGY BY EXPERTS WORLDWIDE VIA INTERACTIVE MOBILE E-TEACHING: BERLINCASEVIEWER

Background

Rheumatology education today can be very diverse, and you can find everything from structured textbooks to YouTube channels to social media accounts. Peer-reviewed content is still recognized as a very high-quality source of information. App-based content has the advantage of bundling information in one place, always available on the go. However, the majority of offerings are only available in English.

Objectives

An app was to be created to learn about imaging in rheumatology in a very easy to understand way in different languages, with experts being able to create translated content very easily.

Methods

Using mySQL, Java, Objective C and JavaScript, a case database with specific structure and numerous interactive elements was created for academic teaching. Special functions for the annotation of images were provided. The development was initially for devices with the iOS operating system, and later for Android. Rheumatologists and radiologists worldwide were invited to participate via the social media channels LinkedIn, Instagram, Facebook, Twitter, and TikTok.

Results

The app, called BerlinCaseViewer, was developed for smartphones, tablets and Mac computers. All information is entered and processed in a web-based database. Using XML files and ZIP archives, the relevant data is then transferred to the mobile apps. Case of the month and learning modules on rheumatoid arthritis, psoriatic arthritis, and axial spondyloarthritis are available, many in English, Spanish, French, Italian, Portuguese, German, and other languages (Figure 1). In addition to the medical image data, the patient’s medical history is also presented in an exciting way with the help of multiple-choice questions. Only when all questions are answered, the diagnosis becomes visible. Timeline functions can be used to visualize medical courses as well. Colored overlays are used to annotate images and can be placed with pixel precision. The user can decide whether these should be displayed as aids. Content is peer-reviewed before publication.

Figure 1.

Multi-lingual presentation of medical training cases.

Conclusion

BerlinCaseViewer is a new approach not only to train medical professionals, but also to connect colleagues and overcome language barriers. As a platform, BerlinCaseViewer is open to all medical professionals to collaborate, whether to contribute their own cases or translate existing cases for use in the local language.

References

[1]BerlinCaseViewer home page: https://www.berlincaseviewer.de/

Disclosure of Interests:

Kay-Geert Hermann Shareholder of: Co-founder of BerlinFlame GmbH, Mikhail Protopopov: None declared, Aline Serfaty: None declared, Ihsane Hmamouchi: None declared, Fernando Sommerfleck: None declared, Fabio Macori: None declared, Katharina Ziegeler: None declared, Torsten Diekhoff: None declared, Denis Poddubnyy Shareholder of: Co-founder of BerlinFlame GmbH, Joachim Sieper Shareholder of: Co-founder of BerlinFlame GmbH

OP0152 A DEEP LEARNING FRAMEWORK FOR MRI DETECTION OF ACTIVE INFLAMMATORY AND STRUCTURAL CHANGES IN THE SACROILIAC JOINT CONSISTENT WITH AXIAL SPONDYLOARTHRITIS: AN INTERNATIONAL COLLABORATIVE STUDY

Background

Magnetic resonance tomography (MRI) plays a key role in the early diagnosis of axial spondyloarthritis (axSpA). However, the detection of changes indicative of axSpA requires specific expertise, which poses a challenge to non-specialized centers. Deep learning (an advanced machine learning method) based on training an artificial neural network may facilitate and support diagnostics in clinical practice.

Objectives

To create a reliable deep learning tool for the detection of active inflammatory and structural changes indicative of axSpA on MRI of sacroiliac joints.

Methods

In this study, MRIs of sacroiliac joints from 477 patients from four cohorts (GESPIC-AS, GESPIC-Crohn, GESPIC-Uveitis and OptiRef comprising 266 patients with and 211 without axSpA) were used to develop a deep learning framework (randomly divided into training, n=404, and validation, n=73, datasets). MRIs from the ASAS cohort (n=116) were used for independent testing (test dataset). Each examination in the training/validation dataset was evaluated for the presence of active inflammatory and structural changes indicative of SpA by six experienced, trained and calibrated readers and by seven expert readers in the test dataset. The presence of the changes was defined as the majority vote amongst readers. Discordant cases in the training/validation dataset underwent consensus reading. In addition, the test dataset was evaluated by three radiologists not specifically trained in SpA. Diagnostic performance was evaluated using the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity and specificity.

Results

The prevalence of positive imaging findings for active inflammatory/structural changes indicative of axSpA was 41%/51% in the training/validation dataset and 22%/22% in the test dataset. The model for the detection of active inflammatory changes showed an AUC of 0.91 (0.83 – 0.97) – Figure 1 – and an accuracy of 84% on the validation dataset; the corresponding sensitivity and specificity were 96% and 76%, respectively. Despite a substantially lower prevalence of active inflammatory changes in the test dataset, the model showed good generalization with an AUC of 0.91 (0.84−0.97) and an accuracy of 75%; the sensitivity and specificity were 88% and 71%, respectively. The model demonstrated a similar performance on the validation and test datasets for the detection of active inflammatory changes fulfilling the ASAS definition. The model for the detection of structural changes indicative of axSpA showed good performance on the validation dataset with an AUC of 0.90 (0.82-0.96) for the detection of structural changes and an overall accuracy of 85%. The associated sensitivity and specificity were 95% and 75%, respectively. The model showed reasonable generalization to new data with an AUC of 0.89 (0.81−0.96) and an accuracy of 79%; the sensitivity and specificity were 85% and 78%, respectively. Overall, the model performed close to the individual human experts - Figure 1.

Conclusion

The developed framework allowed the detection of active inflammatory and structural changes indicative of axSpA on MRI. This approach may be used as an assistant tool in the diagnostic workflow.

Acknowledgements

GESPIC-AS has been financially supported by the German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung - BMBF). GESPIC-Crohn has been supported by the Clinical Research Unit grant from the Berlin Institute of Health (BIH). GESPIC-Uveitis has been supported by a research grant from AbbVie. OptiRef has been supported by a research grant from Novartis. The Assessment of Spondyloarthritis International Society (ASAS) has supported the project with a research grant and provided access to the MRI images of the ASAS calssifiaction cohort.

We want to thank colleagues who performed annotation of the images from the ASAS classification cohort: Pedro Machado, Mikkel Ostergaard, Suzanne Juhl Pedersen, Ulrich Weber. Further, we thank Torsten Karge for the development of the MRI reading interface for GESPIC and OptiRef images, Joel Paschke for development of the scoring interface for ASAS images.

LCA is grateful for her participation in the BIH Charité–Junior Clinician and Clinician Scientist Program and KKB is grateful for his participation in the BIH Charité Digital Clinician Scientist Program all funded by the Charité–Universitätsmedizin Berlin and the Berlin Institute of Health. JR is grateful for her participation in the BIH Charité–Junior Clinician and Clinician Scientist Program.

Disclosure of Interests

None declared

OP0149 RADIOGRAPHIC PROGRESSION FROM NON-RADIOGRAPHIC TO RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS: RESULTS FROM A 5-YEAR MULTICOUNTRY PROSPECTIVE OBSERVATIONAL STUDY

Background

Patients (pts) with axial spondyloarthritis (axSpA) are classified into radiographic axSpA (r-axSpA) and non-radiographic axSpA (nr-axSpA) based on the presence or absence of radiographic sacroiliitis. Approximately 20% to 80% of newly diagnosed axSpA pts have nr-axSpA and 8% to 40% progress to r-axSpA over the next 2 to 10 years.

Objectives

To evaluate progression from nr-axSpA to r-axSpA over 5 years in a prospective multicentre cohort.

Methods

PROOF was a global, real-world, prospective, observational study conducted in rheumatology clinical practices in 29 countries across 6 different geographic regions.1 The study enrolled adults with chronic back pain for ≥3 months and onset before 45 years of age. This analysis included pts diagnosed with axSpA who also fulfilled the Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axSpA. Study visits occurred at baseline (BL) and yearly thereafter. Baseline and follow-up radiographs of sacroiliac joints (SIJ) were evaluated for pts with initial nr-axSpA diagnosis independently by 2 central readers according to the modified New York criteria. In the case of disagreement on the classification (nr- or r-axSpA), images were adjudicated by a third reader. Radiographic progression from nr-axSpA to r-axSpA over 5 years was evaluated by Kaplan-Meier analysis. Cox proportional hazards regression analyses for time to radiographic progression from nr-axSpA to r-axSpA were conducted. For model 1, ‘imaging arm vs clinical arm’ was used as an independent variable, and for model 2, ‘active inflammation on magnetic resonance imaging highly suggestive of sacroiliitis associated with SpA’ was used. Further, potential predictive factors included in the models were age, gender, back pain duration, number of SpA parameters, smoking status, CRP, good response to NSAIDs, HLA-B27 status, and current use of NSAIDs and TNF inhibitors.

Results

Among 2633 enrolled pts, 2165 (82%) were diagnosed with axSpA and fulfilled the ASAS classification criteria. Among these, 1612 (74%) were classified as having r-axSpA (1050 [65%]) or nr-axSpA (562 [35%]) by central reading. The majority of nr-axSpA pts (77%) fulfilled the ASAS classification criteria due to positive findings on imaging (plus ≥1 SpA feature) and 23% were classified according to the clinical arm. A total of 246 nr-axSpA pts who had ≥1 follow-up SIJ radiograph were included in this analysis. Among these 246 pts, progression from initial nr-axSpA to r-axSpA at any of the follow-up visits was observed in 40 pts (16%) over 5 years. Mean time to radiographic progression was 2.4 years (ranging from 0.9 to 5.1 years) in descriptive analysis (Kaplan-Meier curve shown in Figure 1). In model 1 of the Cox regression analysis, male gender (hazard ratio [HR]: 3.16 [95% CI: 1.22–8.17]; P=0.0174), fulfilment of the imaging arm (HR: 6.64 [1.37–32.25]; P=0.0188), and good response to NSAIDs, (HR: 4.66 [1.23–17.71]; P=0.0237), were significantly associated with progression to r-axSpA (Figure 1). In model 2, HLA-B27 positivity showed a significant association with progression (HR: 3.99 [1.10–14.49]; P=0.0353; Figure 1).

Conclusion

In this study, 16% of nr-axSpA pts progressed to r-axSpA within 5 years. The mean time to disease progression was 2.4 years. Predictors of radiographic progression were male gender, good response to NSAIDs, and fulfilment of the imaging arm as well as HLA-B27 positivity.

References

[1]Poddubnyy D. et al, Rheumatology (Oxford). 2021; doi: 10.1093/rheumatology/keab901

Disclosure of Interests

Denis Poddubnyy Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Biocad, Eli Lilly, Gilead, GlaxoSmithKline, MSD, Novartis, Pfizer, Samsung Bioepis, and UCB, Grant/research support from: AbbVie, Eli Lilly, MSD, Novartis, and Pfizer, Joachim Sieper Speakers bureau: AbbVie, Janssen, Merck, Novartis, Pfizer, Roche, and UCB, Consultant of: AbbVie, Janssen, Lilly, Merck, Novartis, Pfizer, and UCB, Servet Akar Speakers bureau: AbbVie, Lilly, MSD, Novartis, Pfizer, Roche, Janssen, and UCB, Consultant of: AbbVie, Lilly, MSD, Novartis, Pfizer, Roche, Janssen, and UCB, Grant/research support from: AbbVie, Lilly, MSD, Novartis, Pfizer, Roche, Janssen, and UCB, Santiago Muñoz-Fernández Speakers bureau: AbbVie, BMS, Galapagos, Janssen, MSD, Novartis, Pfizer, Roche, and UCB., Consultant of: AbbVie, BMS, Galapagos, Janssen, MSD, Novartis, Pfizer, Roche, and UCB., Grant/research support from: AbbVie, BMS, Galapagos, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Hildrun Haibel Speakers bureau: AbbVie, Janssen, MSD, Pfizer, Sobi, Novartis, and Roche, Consultant of: Boehringer, Janssen, MSD, Novartis, and Roche, Torsten Diekhoff Paid instructor for: Novartis, MSD, Canon MS, Consultant of: Eli Lilly, Mikhail Protopopov: None declared, Elisabeth Altmaier Consultant of: AbbVie, Fabiana Ganz Shareholder of: Owns AbbVie stock or stock options., Employee of: AbbVie, Robert Inman Consultant of: AbbVie, Amgen, Janssen, Lilly, Novartis, Pfizer, and Sandoz, Grant/research support from: AbbVie, Amgen, and Janssen

OP0021 TREATMENT WITH NON-STEROIDAL ANTI-INFLAMMATORY DRUGS IS ASSOCIATED WITH RETARDATION OF RADIOGRAPHIC SPINAL PROGRESSION IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS: 10-YEAR RESULTS FROM THE GERMAN SPONDYLOARTHRITIS INCEPTION COHORT

Background

There are conflicting data regarding effect of nonsteroidal anti-inflammatory drugs (NSAID) on radiographic spinal progression in axial spondyloarthritis (axSpA). The analysis of the first 2-year of the GErman SPondyloarthritis Inception Cohort (GESPIC) showed that higher NSAID intake may retard new bone formation in r-axSpA. It remained, however, unclear, whether cyclooxygenase-2 selective inhibitors (COX2i) might have a stronger effect than non-selective (NS) ones and if the effect could be observed also in nr-axSpA.

Objectives

To investigate the effect of NSAIDs (COX2i and NS) intake on radiographic spinal progression in patients with r-axSpA and nr-axSpA.

Methods

Based on availability of at least two sets of spinal radiographs during 10-year follow-up, 243 patients with early axSpA (130 and 113 nr- and r-axSpA, respectively) from GESPIC were included in this analysis. The patients contributed a total of 540 2-year radiographic intervals. Radiographs were scored by 3 trained and calibrated readers according to modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). Final mSASSS was calculated as a mean of 3 readers, and progression was defined as absolute mSASSS change score over 2 years. NSAID type, daily dose, and frequency of intake were recorded at visits. The ASAS index of NSAID intake (0-100) counting both dose and duration of intake was calculated for intervals. The association between NSAID intake (NSAID type and NSAID score) and radiographic spinal progression over 2 years was analysed using longitudinal generalized estimated equations (GEE).

Results

At baseline, 161 (66.3%) patients were treated with NSAIDs. While 289 (53.5%) and 128 (23.7%) 2-year radiographic intervals were covered by NS and COX-2i respectively, 123 (22.8%) intervals were not covered by NSAID. The significant association between higher NSAID intake and retardation of radiographic spinal progression was found in adjusted multivariable longitudinal GEE analysis. This effect was mostly attributable to patients with r-axSpA (Table 1). mSASSS progression was numerically lower in patients taking COX2i (irrespectively of dose) as compared to patients treated with NS-NSAIDs; in stratified analysis, however, there was no clear dose-dependency (as reflected by NSAID index) in both groups (Figure 1, Table 1).

Table 1.

The association between radiographic spinal progression (mSASSS change score) and NSAID intake in patients with axSpA in multivariable longitudinal GEE

All axSpA β (95% CI)* (n=461)nr-axSpA β (95% CI)*(n=244)r-axSpA β (95% CI)* (n=217)NSAID intake score, per 10 points-0.04 (-0.09, 0.00)-0.02 (-0.06, 0.02)-0.07 (-0.13, 0.00)NSAID type§ NS inhibitors vs No NSAID0.30(-0.07, 0.66)0.25(-0.07, 0.57)0.26(-0.40, 0.92) COX2i vs No NSAID0.17(-0.19, 0.54)0.15(-0.15, 0.46)0.18(-0.49, 0.85) COX2i vs NS inhibitors-0.12(-0.37, 0.12)-0.10(-0.28, 0.09)-0.08(-0.57, 0.40)Analysis stratified according to NSAID typeNon-selective NSAID intake score, per 10 points-0.06(-0.12, 0.00)-0.04(-0.09, 0.01)-0.07(-0.17, 0.03)COX2 selective NSAID intake score, per 10 points-0.06(-0.13, 0.02)-0.03(-0.07, 0.02)-0.09(-0.18, 0.01)

axSpA: axial spondyloarthritis; COX2i, cyclooxygenase-2 selective inhibitors; n, number of current 2-year radiographic intervals in multivariable analyses; NS, non-selective COXi; NSAID, non-steroidal anti-inflammatory drugs.

*All multivariable models were adjusted for sex, symptom duration at the beginning of the interval, time-averaged ASDAS the interval, classification as radiographic axSpA, smoking in the interval, mSASSS at the beginning of theinterval, and TNFi use in the interval.

§NSAID intake score was added in this model.

Conclusion

Higher NSAID intake is associated with lower radiographic spinal progression, particularly in r-axSpA patients. COX2i might possess a stronger inhibitory effect on radiographic progression as compared to NS-NSAIDs.

Disclosure of Interests

Murat Torgutalp: None declared, Valeria Rios Rodriguez Consultant of: AbbVie, Grant/research support from: Falk e.V, Ani Dilbaryan: None declared, Fabian Proft Speakers bureau: Novartis, Lilly, UCB AbbVie, AMGEN, BMS, Hexal, MSD, Pfizer, Roche and Janssen, Grant/research support from: Novartis, Lilly and UCB, Mikhail Protopopov Consultant of: Novartis and UCB, Maryna Verba: None declared, Judith Rademacher Consultant of: Novartis and UCB, Hildrun Haibel Consultant of: Boehringer, Janssen, MSD, Novartis, Sobi, Roche, Pfizer, AbbVie, and Sobi, Joachim Sieper Speakers bureau: Abbvie, Janssen, Lilly, Merck, Novartis, UCB, Consultant of: AbbVie, Lilly, Merck, Novartis, UCB, Martin Rudwaleit Speakers bureau: AbbVie, Boehringer Ingelheim, Celgen, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, UCB., Consultant of: AbbVie, Boehringer Ingelheim, Celgen, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, UCB., Denis Poddubnyy Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, and UCB., Consultant of: AbbVie, Biocad, Eli Lilly, Gilead, GlaxoSmithKline, Janssen, MSD, Novartis, Pfizer, Samsung Bioepis, and UCB, Grant/research support from: AbbVie, Eli Lilly, MSD, Novartis, Pfizer.

OP0018 COMPARISON OF THE EFFECT OF TREATMENT WITH NSAIDs ADDED TO ANTI-TNF THERAPY VERSUS ANTI-TNF THERAPY ALONE ON PROGRESSION OF STRUCTURAL DAMAGE IN THE SPINE OVER TWO YEARS IN PATIENTS WITH ANKYLOSING SPONDYLITIS (CONSUL) – AN OPEN-LABEL, RANDOMIZED CONTROLLED, MULTICENTER TRIAL

Background

There is some evidence that NSAIDs, in particular celecoxib (CEL), might possess not only symptomatic efficacy but also disease-modifying properties in radiographic axial spondyloarthritis (r-axSpA) formerly known as ankylosing spondylitis, retarding progression of structural damage in the spine if taken continuously. For biological disease-modifying antirheumatic drugs (bDMARDs), retardation of structural damage progression has also been demonstrated, but at least 4 years of treatment seem to be necessary (at least for tumour necrosis factor inhibitors – TNFi) to see such an effect. Therefore, a combination of an NSAID with a TNFi might bring additional benefits in terms of retardation of structural damage progression especially in high-risk patients.

Objectives

The aim of this RCT was to evaluate the impact of treatment with the COX-II-selective NSAID (CEL) when added to a TNFi (golimumab - GOL) compared with TNFi (GOL) alone on progression of structural damage in the spine over 2 years in patients with r-axSpA.

Methods

Eligible patients had r-axSpA and high disease activity (BASDAI ≥4), NSAID failure and risk factors for radiographic spinal progression: C-reactive protein >5 mg/l and/or ≥1 syndesmophyte(s). The trial consisted of two phases: a 12-week run-in phase, in which all included patients received treatment with GOL 50 mg every 4 weeks sc, followed by a 96-week controlled treatment period, in which patients who achieved a BASDAI improvement of ≥2 points were randomly assigned to GOL + CEL 200 mg bid or GOL alone arms. The primary endpoint was radiographic spinal progression as assessed by the change in the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) after 108 weeks in the intent-to-treat population, read by 3 independent readers blinded for the treatment arm and the time-point.

Results

Of the 157 screened patients, 81.5% (n=128) were enrolled into the run-in phase. 109 patients fulfilled the BASDAI response criterion at w12 and were randomized 1:1 (54 vs. 55) to GOL+CEL or GOL alone; 97 (45 vs. 52) patients completed the study at w108. Clinical characteristics of the randomized patients are shown in Tab. 1. The mSASSS change after w108 was 1.1 (95%CI 0.2; 2.0) vs. 1.7 (95%CI 0.8; 2.6) in the GOL+CEL vs. GOL alone groups, respectively, p=0.79. Figure 1 shows the cumulative probability of the mSASSS change in both treatment arms. New syndesmophytes in the opinion of three readers occurred in 11% vs. 25% of the patients in the GOL+CEL vs. GOL alone groups, respectively, p=0.12. During the study, a total of 14 serious adverse events (SAE) were reported (7 in the GOL+CEL group, 5 in the GOL alone group and 2 during the run-in phase).

Figure 1.

Cumulative probability plot of mSASSS progression over 108 weeks of treatment.

Conclusion

In this study, a combined therapy with GOL+CEL did not show significant superiority over GOL monotherapy in retarding radiographic spinal progression over two years in r-axSpA patients.

However, the observed numerical reduction in radiographic spinal progression associated with the combined treatment might be, however, clinically relevant for patients at high risk for progression.

Table 1.

Baseline characteristics of randomized patients

ParametersGOL+CEL N=54GOL alone N=55All patients N=109validnvaluevalidnvaluevalidnvalueSex, malen (%)5440 (74.1)5541 (74.5)10981 (74.3)Age, yearsMean (SD)5439.9 (9.9)5537.5 (10.8)10938.7 (10.4)Smokern (%)5319 (35.8)5522 (40)10841 (38)HLA-B27 positivityn (%)5445 (83.3)5147 (92.2)10592 (87.6)BASDAIMean (SD)546.2 (1)556.1 (1.1)1096.1 (1.1)BASMIMean (SD)542.6 (1.9)542.9 (1.4)1082.8 (1.6)CRP > 5 mg/Ln (%)5438 (70.4)5538 (69.1)10976 (69.7)ASDAS-CRPMean (SD)543.6 (0.6)553.7 (0.9)1093.7 (0.8)Prior bDMARDsn (%)5417 (31.5)559 (16.4)10926 (23.9)Presence of ≥ 1 syndesmophyte(s)n (%)5427 (50)5528 (50.9)10955 (50.5)mSASSSMean (SD)5413.5 (16.9)5510.3 (13.2)10911.9 (15.2)

Acknowledgements

The CONSUL study has been supported by a grant from the German Ministry of Education and Research (BMBF), grant number FKZ 01KG1603 and study medication (golimumab) was provided free of charge by MSD Sharp & Dohme GmbH, Munich, Germany.

Furthermore we would like to thank Anne Weber, Bianca Mandt, Claudia Lorenz, Hildrun Haibel, Judith Rademacher, Laura Spiller, Petra Tietz as well as all participating rheumatologist and included patients.

Disclosure of Interests

Fabian Proft Speakers bureau: AMGEN, AbbVie, BMS, Celgene, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Consultant of: Novartis, Grant/research support from: Novartis, UCB, Lilly, Burkhard Muche Speakers bureau: UCB Pharma, AMGEN, Consultant of: UCB Pharma, AMGEN, Valeria Rios Rodriguez Speakers bureau: AbbVie, Falk e.V., Murat Torgutalp: None declared, Mikhail Protopopov Consultant of: Novartis, Joachim Listing: None declared, Maryna Verba: None declared, Uta Kiltz: None declared, Jan Brandt-Juergens: None declared, Maren Sieburg: None declared, Swen Holger Jacki: None declared, Joachim Sieper Speakers bureau: AbbVie, Janssen, Merck, Novartis, Consultant of: Abbvie, Janssen, Lilly, Merck, Novartis, UCB, Denis Poddubnyy Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Biocad, Eli Lilly, Gilead, GlaxoSmithKline, Janssen, MSD, Novartis, Pfizer, Samsung Bioepis, and UCB, Grant/research support from: AbbVie, Eli Lilly, MSD, Novartis, and Pfizer.

The ASAS-OMERACT core domain set for axial spondyloarthritis

BACKGROUND

The current core outcome set for ankylosing spondylitis (AS) has had only minor adaptations since its development 20 years ago. Considering the significant advances in this field during the preceding decades, an update of this core set is necessary.

OBJECTIVE

To update the ASAS-OMERACT core outcome set for AS into the ASAS-OMERACT core outcome set for axial spondyloarthritis (axSpA).

METHODS

Following OMERACT and COMET guidelines, an international working group representing key stakeholders (patients, rheumatologists, health professionals, pharmaceutical industry and drug regulatory agency representatives) defined the core domain set for axSpA. The development process consisted of: i) Identifying candidate domains using a systematic literature review and qualitative studies; ii) Selection of the most relevant domains for different stakeholders through a 3-round Delphi survey involving axSpA patients and axSpA experts; iii) Consensus and voting by ASAS; iv) Endorsement by OMERACT. Two scenarios are considered based on the type of therapy investigated in the trial: symptom modifying therapies and disease modifying therapies.

RESULTS

The updated core outcome set for axSpA includes 7 mandatory domains for all trials (disease activity, pain, morning stiffness, fatigue, physical function, overall functioning and health, and adverse events including death). There are 3 additional domains (extra-musculoskeletal manifestations, peripheral manifestations and structural damage) that are mandatory for disease modifying therapies and important but optional for symptom modifying therapies. Finally, 3 other domains (spinal mobility, sleep, and work and employment) are defined as important but optional domains for all trials.

CONCLUSION

The ASAS-OMERACT core domain set for AS has been updated into the ASAS-OMERACT core domain set for axSpA. The next step is the selection of instruments for each domain.

POS0410 BIOMARKERS REFLECTING DISTURBED GUT BARRIER DIFFER IN PATIENTS WITH SPONDYLOARTHRITIS, CROHN’S DISEASE AND ACUTE ANTERIOR UVEITIS

Background:

Spondyloarthritides (SpA) are characterized by frequent extra-musculoskeletal manifestations (EMM) among them acute anterior uveitis (AAU) and Crohn’s disease (CD). Vice versa, about 50% of AAU and 20% of CD patients have concomitant SpA. SpA patients show gut dysbiosis together with frequent subclinical gut inflammation. Biomarkers reflecting disturbed gut barrier (intestinal-fatty acid binding protein (iFABP), lipopolysaccharide binding protein (LBP) and zonulin) were previously found to be elevated in patients with radiographic axial SpA (r-axSpA) (1).

Objectives:

To evaluate whether biomarkers reflecting leaky gut are altered in patients with AAU, CD and SpA compared to healthy controls and whether they differ between patients with EMM with and without concomitant SpA.

Methods:

A total of 100 patients from the German Spondyloarthritis Inception Cohort (GESPIC) were included – among them 20 patients with r-axSpA without EMM, 40 patients with CD and 40 patients with non-infectious AAU – out of which 19 and 20 patients, respectively, had concomitant SpA (11/8 and 20/0 axial/peripheral SpA, respectively). The GESPIC patients were compared to 20 age- and sex-matched healthy donors (HD). The following five serum biomarkers were analyzed with ELISA: calprotectin, iFABP, LBP, soluble CD14 (sCD14) and zonulin.

Results:

Patient characteristics are shown in Table 1. Serum levels of calprotectin, LBP, sCD14 and zonulin differed significantly between patients with r-axSpA, AAU and CD with and without concomitant SpA and HD (Figure 1). When comparing patients with EMM with and without underlying SpA, calprotectin serum levels were significantly elevated in CD patients with SpA (8.6µg/ml (SD 5.5µg/ml)) compared to CD patients without SpA (5.7µg/ml (SD 4.1µg/ml); Mann-Whitney U Test, p=0.031). Serum levels of the analyzed biomarkers did not differ between AAU patients with and without axSpA. Spearman rank correlation revealed a significant association between CRP and calprotectin (correlation coefficient r=0.230; p=0.012), LBP (r=0.596; p<0.0001), sCD14 (r=0.428; p<0.0001) and zonulin (r=0.221; p=0.016), respectively. Furthermore, LBP and zonulin serum levels correlated positively (r=0.208; p=0.023); as well as LBP and sCD14 levels (r=0.418; p<0.0001).

Table 1.

Patient characteristics. Mean values (standard deviation) or absolute numbers are shown.

CD + SpACDr-axSpAAAU + axSpAAAUHDN192120202020Age39.1 (11.3)38.7 (14.4)38.4 (10.3)39.6 (12.0)39.2 (12.5)38.6 (12.9)Male (%)9 (47%)9 (43%)9 (45%)9 (45%)9 (45%)9 (45%)HLA-B27 positive (%)5 (26%)3 (14%)17 (85%)17 (85%)13 (65%)2 (10%)CRP in mg/l14.3 (25.6)18.0 (41.8)9.1 (11.3)6.7 (9.9)2.3 (3.4)0.6 (0.7)ASDAS2.8 (1.1)3.2 (0.6)2.2 (1.0)BASDAI4.1 (2.2)5.4 (1.2)3.2 (2.4)Figure 1.

Biomarkers reflecting disturbed gut barrier show distinct signatures in patients with acute anterior uveitis, Crohn’s disease and axial Spondyloarthritis. Kruskal Wallis Test; p values shown. Dunn-Bonferroni Post-Hoc analyses, significant pairwise differences are marked; * p<0.05; **p<0.01; ***p<0.0001Conclusion:

We found substantial differences in biomarkers reflecting disturbed gut barrier between with SpA, CD, AAU and healthy controls. The presence of SpA was associated with higher calprotectin serum levels in CD as compared to CD without SpA.

References:

[1]Ciccia F, et al. Dysbiosis and zonulin upregulation alter gut epithelial and vascular barriers in patients with ankylosing spondylitis. 2017.

Acknowledgements:

Dr. Judith Rademacher is participant in the BIH-Charité Clinician Scientist Program funded by the Charité –Universitätsmedizin Berlin and the Berlin Institute of Health.

Disclosure of Interests:

None declared

OP0139 A TIME-SHIFTED EFFECT OF TUMOR NECROSIS FACTOR INHIBITORS ON RADIOGRAPHIC SPINAL PROGRESSION IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS: LONG-TERM RESULTS FROM THE GERMAN SPONDYLOARTHRITIS INCEPTION COHORT

Background:

There are inconclusive data on the effect of tumor necrosis factor inhibitors (TNFi) on radiographic spinal progression in axial spondyloarthritis (axSpA). Although inflammation and new bone formation are linked in axSpA, TNFi failed to show inhibition of radiographic spinal progression over two years compared to historical cohorts in pivotal studies in radiographic axSpA. Subsequent observational studies suggested that a longer treatment duration, earlier treatment initiation and effective inflammation suppression might be required to achieve inhibition of radiographic progression.

Objectives:

The aim of the current study was to evaluate the effect of TNFi on radiographic spinal progression in patients with early axSpA in a long-term inception cohort.

Methods:

A total of 266 patients with early axSpA (with r-axSpA with symptom duration ≤10 years and nr-axSpA with symptom duration ≤5 years) from the German Spondyloarthritis Inception Cohort (GESPIC) with at least two sets of spinal radiographs obtained at least 2 years apart during a 10-year follow-up were included. These patients contributed with a total of 542 2-year radiographic intervals. Spinal radiographs were evaluated by three trained and calibrated readers according to the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). The final mSASSS was calculated as a mean of three reader scores. The association between the current TNFi, previous TNFi and radiographic spinal progression defined as the absolute mSASSS change score over 2 years was analyzed using longitudinal generalized estimating equations (GEE) analysis.

Results:

Only 9 patients were treated with a tumor necrosis factor inhibitor (TNFi) at baseline, and a total of 77 patients received TNFi during the entire follow-up period that gave 103 2-year intervals covered by TNFi of any duration, and 78 intervals covered by TNFi with treatment duration of at least 12 months. Radiographic spinal progression in axSpA patients receiving TNFi in the current 2-year interval was not different from progression in patients not treated with TNFi, while TNFi in the previous 2-year interval was associated with lower progression compared to patients without TNFi in this interval (Figure 1). The latter was also evident for patients who received TNFi in both previous and current 2-year intervals, i.e. patients treated with TNFi over 4 years. The longitudinal GEE analysis confirmed no significant association between current TNFi treatment and radiographic spinal progression but a significant association between TNFi in the previous 2-year interval (especially if this was continued also in the current interval giving 4 years in total) and the progression in the current one (Table 1).

Table 1.

The association between the change of the mSASSS over two years and current and/or previous treatment with TNFi in the longitudinal generalized estimation equation analysis.

TNFi treatment definitionReferenceβ*(95% CI)TNFi for ≥12 months in the previous 2-year intervalTNFi for ≥12 months in the current 2-year intervalYesNo TNFi for ≥12 months in the current 2-year interval-0.19(-0.56 to 0.18)YesNo TNFi for ≥12 months in the previous 2-year interval-0.56(-0.95 to -0.17)YesYesNo TNFi for ≥12 months in the current and previous 2-year intervals-0.59(-1.03 to -0.15)

*Parameter estimates from the multivariable models adjusted for sex, symptom duration at the beginning of the current 2-year interval, time-averaged ASDAS in the current 2-year interval, smoking in the current 2-year interval, classification as non-radiographic or radiographic axSpA, and mSASSS at the beginning of the current 2-year interval.

Conclusion:

TNFi treatment exhibits a time-shifted inhibitory effect on radiographic spinal progression in axSpA that becomes evident only in the second 2-year interval after treatment initiation.

Acknowledgements:

GESPIC was initially supported by the BMBF. As consequence of the funding reduction by BMBF according to schedule in 2005 and stopped in 2007, complementary financial support has been obtained also from Abbott, Amgen, Centocor, Schering–Plough, and Wyeth. Starting from 2010, the core GESPIC cohort was supported by AbbVie.

Disclosure of Interests:

Denis Poddubnyy Speakers bureau: AbbVie, Bristol-Myers Squibb, Lilly, MSD, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Biocad, Gilead, GlaxoSmithKline, Eli Lilly, MSD, Novartis, Pfizer, Samsung Bioepis, and UCB, Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Valeria Rios Rodriguez: None declared, Murat Torgutalp: None declared, Ani Dilbaryan: None declared, Maryna Verba: None declared, Fabian Proft: None declared, Mikhail Protopopov: None declared, Judith Rademacher: None declared, Hildrun Haibel: None declared, Joachim Sieper: None declared, Martin Rudwaleit Consultant of: AbbVie, BMS, Celgene, Janssen, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB Pharma

POS0241 VALIDATION OF THE ANKYLOSING SPONDYLITIS DISEASE ACTIVITY SCORE WITH A QUICK QUANTITATIVE C-REACTIVE PROTEIN ASSAY (ASDAS-QCRP) IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS (AXSPA): A PROSPECTIVE, NATIONAL, MULTICENTER STUDY

Background:

According to international recommendations, the Ankylosing Spondylitis Disease Activity Score (ASDAS) is the preferred score for assessing disease activity in axial spondyloarthritis (axSpA) [1]. However, routine determination of C-reactive protein (CRP) to calculate ASDAS values takes hours to days. This limits the use of ASDAS in clinical routine and clinical trials and hinders the implementation of treat-to-target approaches in axSpA. Whereas quick quantitative CRP (qCRP) tests allow CRP assessment within a few minutes. In a pilot project the performance of qCRP-based ASDAS assessment (ASDAS-qCRP) was already investigated in a single center study of 50 newly diagnosed, bDMARD-naïve axSpA patients with promising results [2].

Objectives:

To validate the ASDAS-qCRP in a prospective, multicenter study of axSpA patients in a typical axSpA cohort with an appropriate sample size.

Methods:

The study was conducted in five centers in Germany. Consecutive adult (≥ 18 years) axSpA patients were included. In addition to a rheumatological assessment, including patient reported outcomes (PROs), routine CRP and erythrocyte sedimentation rate (ESR) were measured in the local labs. Additionally, a qCRP testing with the „QuikRead go instrument“ (Aidian Oy, Finland) was performed at the study center (measurement range 0.5 - 200 mg/l for hematocrit concentrations of 40 – 45%). Statistical analysis included descriptive statistics, cross tabulation and weighted Cohen´s kappa comparing disease activity categories, Bland-Altman plots and intraclass correlation coefficient (ICC) for ASDAS-CRP and ASDAS-qCRP.

Results:

In this study 251 axSpA patients were included between January and September 2020 (mean age: 38.4 years; mean disease duration: 6.2 years, 159 patients (63.3%) were male, 211 (84.1%) HLA-B27 positive and 195 (77.7%) were classified as radiographic axSpA). 143 patients (57.0%) were treated with bDMARDs. CRP and qCRP showed mean values of 2.12 and 2.17 mg/l, respectively. With the ASDAS-qCRP, 242 patients (96.4%) were assigned to the same disease activity category as compared to the ASDAS based on the conventional lab CRP measurement (Table 1). Weighted Cohen´s kappa was 0.966 (95%CI: 0.943; 0.988). ICC for ASDAS-CRP- and ASDAS-qCRP-values was 0.997 (95%CI: 0.994; 0.999). The agreement of ASDAS-qCRP and ASDAS-CRP is shown in a Bland-Altman plot (Figure 1).

Table 1.

Disease activity categories by ASDAS-qCRP vs. ASDAS-CRP

ASDAS-qCRP (n = 251)Inactive Disease(< 1.3)Low Disease Activity (1.3 - < 2.1)High Disease Activity (2.1 - 3.5)Very high Disease Activity (> 3.5)ASDAS-CRPInactive Disease(< 1.3)56 (22.3%)2 (0.8%)Low Disease Activity (1.3 - < 2.1)62 (24.7%)7 (2.8%)High Disease Activity (2.1 - 3.5)97 (38.6%)Very high Disease Activity (> 3.5)27 (10.8%)

The fields highlighted in red indicate that disease activity categories do not match.

ASDAS = Ankylosing Spondylitis Disease Activity Score, CRP = C-reactive protein, qCRP = quick quantitative CRP

Conclusion:

The ASDAS-qCRP and ASDAS-CRP showed an almost perfect agreement on the assignment to disease activity categories (96%) with the important advantage of time. With ASDAS-qCRP, rheumatologists could base their clinical decision-making on a disease activity measurement by using a composite score immediately. ASDAS-qCRP, therefore, can be integrated in clinical routine and clinical trials in the future and may facilitate implementation of the treat-to-target concept in axial SpA.

References:

[1]Smolen JS, et al. Ann Rheum Dis. 2018 Jan; 77(1):3-17.

[2]Proft F, et al. Joint Bone Spine. 2019 Jul 29.

Figure 1.

Bland-Altman plot for ASDAS-qCRP and ASDAS-CRP

Acknowledgements:

The authors would like to deeply thank Braun T, Doerwald C, Deter N, Höppner C, Lackinger J, Lorenz C, Lunkwitz K, Mandt B, Sron S and Zernicke J for their practical support and coordinating the study.

Funding statement: The AQUA study was supported by an unrestricted research grant from Novartis. Testing kits were provided free of charge from Aidian Oy, Finland.

Disclosure of Interests:

None declared

OP0137 TUMOR NECROSIS FACTOR INHIBITORS SHOW A DELAYED EFFECT ON RADIOGRAPHIC SACROILIITIS PROGRESSION IN PATIENTS WITH EARLY AXIAL SPONDYLOARTHRITIS: 10-YEAR RESULTS FROM THE GERMAN SPONDYLOARTHRITIS INCEPTION COHORT

Background:

Observational cohort studies have shown that there is low, but still detectable progression level in radiographic sacroiliitis, which might also have an impact on the function in patients with axial spondyloarthritis (axSpA). Recent data showed that tumor necrosis factor inhibitors (TNFi) might retard spinal progression when initiated earlier and taken longer in patients with axSpA. However, the question of whether they also have such an effect on radiographic progression in sacroiliac joints (SIJs) is still unclear.

Objectives:

To investigate the longitudinal association between radiographic sacroiliitis progression and treatment with TNFi in patients with early axial SpA in a long-term inception cohort.

Methods:

Based on the availability of at least two sets of SIJ radiographs, 301 patients (166 with nr-axSpA, symptom duration ≤5 years and 135 with r-axSpA, symptom duration ≤10 years) from the German Spondyloarthritis Inception Cohort (GESPIC) were included in this analysis. These patients contributed with a total of 737 2-year radiographic intervals. Two trained and calibrated central readers scored the radiographs according to the modified New York criteria. If both scored an image as definite radiographic sacroiliitis, the patient was classified as having r-axSpA. The sacroiliac sum score was calculated as a mean of both readers. The association between previous as well as current TNFi use and radiographic sacroiliitis progression, which was defined as the change in the sacroiliitis sum score over 2 years, was analysed using longitudinal generalized estimating equations (GEE) analysis.

Results:

At baseline, 9 (3.0%) patients were treated with a TNFi, and 87 (28.9%) patients received at least one TNFi during the entire follow-up period. A total of 141 of the radiographic intervals were covered with TNFi of any duration, while 109 of them were covered with a TNFi of at least 12 months. While receiving ≥12 months TNFi in the previous interval was associated with a lower progression of the sacroiliitis sum score compared to not receiving TNFi in the previous interval, this was not the case in patients who received TNFi ≥12 months in the current 2-year interval (Figure 1). The significant association between TNF ≥12 months in the previous interval and progression in the sacroiliitis sum score were confirmed in the adjusted multivariable longitudinal GEE analysis. In addition, a similar trend for the beneficial effects was observed in different models, which included other treatment definitions with TNFi in the previous 2-year interval (Table).

Table 1.

The longitudinal GEE analysis of the association between progression in the sacroiliitis sum score and TNFi use.

TNFi treatment definitionReferenceβ* (95% CI)TNFi for ≥ 12 months in the previous 2-year intervalNo TNFi for ≥ 12 months in the previous 2-year interval-0.09 (-0.18, -0.003)Any TNFi use in the previous 2-year intervalNo TNFi use in the previous 2-year interval-0.09 (-0.17, 0.002)TNFi for ≥ 12 months in the current 2-year intervalNo TNFi for ≥ 12 months in the current 2-year interval-0.03 (-0.11, 0.06)Any TNFi use in the current 2-year intervalNo TNFi use in the current 2-year interval0.05 (-0.05, 0.14)TNFi for ≥ 12 months in the previous and ≥ 12 months in the current 2-year intervalNo TNFi for ≥ 12 months in the previous and ≥ 12 months in the current 2-year interval-0.08 (-0.17, 0.004)

* Parameter estimates from the multivariable models adjusted for sex, age at the beginning of the current 2-year interval, HLA-B27 positivity, symptom duration at the beginning of the current 2-year interval, time-averaged elevated CRP, time-averaged BASDAI, and time-averaged NSAID intake score in the current 2-year interval.

Conclusion:

Treatment with TNFi was associated with retardation of radiographic sacroiliitis progression in patients with axSpA. This effect becomes evident between 2 and 4 years after treatment initiation.

References:

Acknowledgements:

GESPIC was initially supported by the BMBF. As a consequence of the funding reduction by BMBF according to schedule in 2005 and stopped in 2007, complementary financial support has been obtained also from Abbott, Amgen, Centocor, Schering–Plough, and Wyeth. Starting from 2010, the core GESPIC cohort was supported by AbbVie.

Disclosure of Interests:

Murat Torgutalp: None declared, Valeria Rios Rodriguez: None declared, Maryna Verba: None declared, Mikhail Protopopov: None declared, Fabian Proft: None declared, Judith Rademacher: None declared, Hildrun Haibel: None declared, Martin Rudwaleit Consultant of: AbbVie, BMS, Celgene, Janssen, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB Pharma, Joachim Sieper: None declared, Denis Poddubnyy Speakers bureau: AbbVie, Bristol-Myers Squibb, Lilly, MSD, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Biocad, Gilead, GlaxoSmithKline, Eli Lilly, MSD, Novartis, Pfizer, Samsung Bioepis, and UCB, Grant/research support from: AbbVie, MSD, Novartis, and Pfizer

OP0048 DIAGNOSING AXIAL SPONDYLOARTHRITIS: ESTIMATION OF THE DISEASE PROBABILITY IN PATIENTS WITH A PRIORI DIFFERENT LIKELIHOODS OF THE DIAGNOSIS

Background:

The diagnostic approach in axial spondyloarthritis (SpA) relies on a estimation of the post-test disease probability that is based on evaluation of positive and negative results of diagnostic tests in the context of the pre-test disease probability.

Objectives:

To evaluate the diagnostic value of SpA parameters and their combination for the diagnosis of axial SpA in patients with an a priori different probability of the diagnosis.

Methods:

A total of 361 patients with chronic back pain and suspicion of axial SpA (181 referred by primary care physicians or orthopaedists, 180 recruited via an online screening tool) received a structured rheumatologic examination as a part of the OptiRef study [1], which resulted into a diagnosis or exclusion of axial SpA. The prevalence of axial SpA indicating the pre-test probability was 40% in the physician-referred subgroup and 20% in the online screening subgroup. Sensitivities, specificities, and likelihood ratios (LRs) for SpA features were determined in both subgroups and the respective post-test probabilities of axial SpA were calculated.

Results:

The relative diagnostic value of single SpA features varied substantially between the groups with different referral pathways – see the online disease probability calculator http://www.axspa.de/calculator.html. It can be seen that the diagnostic values of the SpA parameters vary substantially between the groups. For instance, HLA-B27 positivity increased the probability of the presence of axial SpA by 35% to 55% in online-screened patients and by 22% to 62% in physician-referred patients. Furthermore, the absence of HLA-B27 resulted in a sharp decrease in the probability of the presence of axial SpA in physician-referred patients (from 40% to 6%). This decrease was less sharp in the online screening group (from 20% to 10%). Furthermore, combinations of parameters performed differently in the studied subgroups. Figure 1 illustrates that the observed differences in the diagnostic values of the SpA parameters in different subgroups were only clinically relevant in the presence of a low number of positive test results. For instance, combining IBP with anterior uveitis increased the post-test probability for axial SpA to 78% in the online screening group and to 87% in the physician-referred group, whereas using HLA-B27 positivity and active sacroiliitis on MRI in combination with IBP resulted in a surge in the post-test probability of the presence of axial SpA to around 95% in both groups.

Conclusion:

The diagnostic value of a single diagnostic test in the clinical practice is not fixed and a number of factors including the referral pathway can affect it. Fluctuation of the diagnostic values is especially relevant when the number of positive parameters is low (1-2).

References:

[1]Proft F, et al. Semin Arthritis Rheum. 2020;50:1015-1021.

Acknowledgements:

The OptiRef study was supported by a research grant from Novartis.

Disclosure of Interests:

None declared

POS0453 VALIDATION OF THE SIMPLIFIED DISEASE ACTIVITY INDEX (SDAI) WITH A QUICK QUANTITATIVE C-REACTIVE PROTEIN ASSAY (SDAI-Q) IN PATIENTS WITH RHEUMATOID ARTHRITIS: A NATIONAL, MULTICENTER STUDY

Background:

Therapeutic decisions in RA patients should be based on regular disease activity assessment using scores like the Simplified Disease Activity Index (SDAI) or the Clinical Disease Activity Index (CDAI) [1]. The CDAI has the benefit of being immediately available, while the SDAI encompasses with the C-reactive protein (CRP) an acute phase reactant and therefore is the recommended score for the use in clinical trials. However, CRP determination takes hours to days, thus hindering the treat-to-target concept using the SDAI. Quick quantitative CRP (qCRP) tests allow CRP measurement within a few minutes. Therefore, qCRP based SDAI (SDAI-Q) could combine the advantages of both scores.

Objectives:

To validate the SDAI-Q in a prospective, multicenter study of RA patients.

Methods:

The study was conducted in five centers in Berlin, Germany. Consecutive adult (≥ 18 years) RA patients were included. In addition to a rheumatological assessment, including patient reported outcomes, routine CRP was measured in the local labs. Additionally, a qCRP testing with the „QuikRead go instrument“ (Aidian Oy, Finland) was performed locally (measurement range 0.5 - 200 mg/l). Statistical analysis included descriptive statistics, cross tabulation and weighted Cohen´s kappa comparing disease activity categories, Bland-Altman plots and intraclass correlation coefficient (ICC) for CRP, qCRP, SDAI, SDAI-Q and CDAI.

Results:

In this study 100 RA patients were included (mean age: 60.9 years, mean disease duration: 11.4 years, 73.0% were female, 63.0% RF positive, 57.0% ACPA positive, 49.0% positive and 29% negative for both parameters). 75.0% were treated with csDMARD, 15% with tsDMARDs, 39.0% with bDMARDs and 40% with glucocorticoids (mean prednisolone equivalent: 5.4 mg prednisolone/d). Mean CRP and qCRP-levels were 6.97 and 7.89 mg/l, respectively (ICC 0.992; 95%CI: 0.987; 0.995). Comparing SDAI-Q and SDAI, all patients (100%) achieved the same disease activity status (Table 1A); weighted Cohen´s kappa was 1.000 (95%CI: 1.000; 1.000). ICC for SDAI-Q- and SDAI-values was 1.000 (95%CI: 1.000; 1.000). The agreement of SDAI-Q and SDAI is shown in a Bland-Altman plot (Figure 1). When comparing the CDAI with the SDAI-Q 93 patients (93%) were assigned to the same disease activity category (Table 1B); weighted Cohen´s kappa was 0.929 (95%CI: 0.878; 0.981). ICC for numerical values of SDAI-Q and CDAI was 0.989 (95%CI: 0.978; 0.994).

Conclusion:

SDAI-Q showed an absolute agreement with SDAI on the assignment to disease activity categories with the important advantage of time. With SDAI-Q, rheumatologists could base their clinical decision-making immediately on an index-based disease activity measurement by using a composite score considering acute phase reactants. Consequently, SDAI-Q can be integrated in clinical routine and clinical trials and could be implemented into the treat-to-target concept in RA patients.

References:

[1]Smolen JS, et al. Ann Rheum Dis. 2016 Jan; 75(1):3-15.

Table 1.

A) Disease activity categories by SDAI-Q vs. SDAI; B) Disease activity categories by SDAI-Q vs. CDAI

ASDAI-Q (n = 100)Remission (≤ 3.3)Low Disease Activity (> 3.3 and ≤ 11)Moderate Disease Activity (> 11 and ≤ 26)High Disease Activity (> 26)SDAIRemission (≤ 3.3)28 (28.0%)Low Disease Activity (> 3.3 and ≤ 11)31 (31.0%)Moderate Disease Activity (> 11 and ≤ 26)35 (35.0%)High Disease Activity (> 26)6 (6.0%)BSDAI-Q (n = 100)Remission (≤ 3.3)Low Disease Activity (> 3.3 and ≤ 11)Moderate Disease Activity (> 11 and ≤ 26)High Disease Activity (> 26)CDAIRemission (≤ 2.8)26 (26.0%)Low Disease Activity (> 2.8 and ≤ 10)2 (2.0%)28 (28.0%)2 (2.0%)Moderate Disease Activity (> 10 and ≤ 22)3 (3.0%)33 (33.0%)High Disease Activity (> 22)6 (6.0%)

Fields highlighted in red indicate that disease activity categories do not match.

SDAI = Simplified Disease Activity Index;

SDAI-Q = SDAI calculated with a quick quantitative CRP assay;

CDAI = Clinical Disease Activity Index.

Figure 1.

Bland-Altman plot for SDAI and SDAI-Q Acknowledgements

The authors would like to deeply thank Braun T, Doerwald C, Deter N, Höppner C, Lackinger J, Lorenz C, Lunkwitz K, Mandt B, Sron S and Zernicke J for their practical support and coordinating the study.

Funding statement:

The AQUA study was supported by an unrestricted research grant from Novartis. Testing kits were provided free of charge from Aidian Oy, Finland.

Disclosure of Interests:

None declared

POS1069 VALIDATION OF THE DISEASE ACTIVITY INDEX FOR PSORIATIC ARTHRITIS (DAPSA) WITH A QUICK QUANTITATIVE C-REACTIVE PROTEIN ASSAY (Q-DAPSA) IN PATIENTS WITH PSORIATIC ARTHRITIS (PSA): A PROSPECTIVE, NATIONAL, MULTICENTER STUDY

Background:

Psoriatic arthritis (PsA) is a heterogeneous disease with multiple musculoskeletal and dermatological manifestations. Due to this multifaceted clinical appearance, international guidelines do not provide a clear recommendation for one specific score to assess disease activity in PsA [1]. The Disease Activity Index for Psoriatic Arthritis (DAPSA), a validated, unidimensional score focusing on joint involvement, is one of the recommended options [1]. However, routine determination of C-reactive protein (CRP) to calculate DAPSA values takes hours to days. In contrast, quick quantitative CRP (qCRP) tests require only a few minutes and might facilitate regular assessment of the DAPSA (as Q-DAPSA) in clinical routine.

Objectives:

To validate the Q-DAPSA in a prospective, multicenter study of PsA patients. Since the Disease Activity Score 28 (DAS28) is not only used in rheumatoid arthritis, but also in PsA patients, the study also investigated the performance of a qCRP based DAS28 (DAS28-qCRP) in a PsA cohort.

Methods:

The study was conducted in five centers in Berlin, Germany. Consecutive adult (≥ 18 years) PsA patients were included. In addition to a rheumatological assessment, including patient reported outcomes (PROs), routine CRP and erythrocyte sedimentation rate (ESR) were measured in the local labs. Additionally, a qCRP testing with the „QuikRead go instrument“ (Aidian Oy, Finland) was performed locally at the study center (measurement range 0.5 - 200 mg/l for hematocrit concentrations of 40 – 45%). Statistical analysis included descriptive statistics, cross tabulation and weighted Cohen´s kappa comparing disease activity categories, Bland-Altman plots and intraclass correlation coefficient (ICC) for DAPSA, Q-DAPSA, DAS28-CRP and DAS28-qCRP.

Results:

In this study 104 patients were included between January and October 2020 (mean age: 51.2 years, mean disease duration: 7.1 years, 49 patients (47.1%) were male). 53 patients (51.0%) were treated with a bDMARD and 37 patients (35.6%) with csDMARDs. CRP and qCRP showed mean values of 5.20 and 6.17 mg/l, respectively. With the Q-DAPSA, 103 patients (99.0%) were assigned to the same disease activity category when compared to DAPSA (Table 1). Weighted Cohen´s kappa was 0.990 (95%CI 0.970; 1.000). ICC for numerical values of DAPSA and Q-DAPSA was 1.000 (95%CI 0.999; 1.000). The agreement of Q-DAPSA and DAPSA is shown in a Bland-Altman plot (Figure 1). DAS28-CRP and -qCRP were available for 103 patients; 101 patients (98.1%) showed the same disease activity category in the DAS28-qCRP and weighted Cohen´s kappa was 0.951 (95%CI 0.886; 1.000).

Conclusion:

The Q-DAPSA and DAPSA showed an almost perfect agreement on the assignment to disease activity categories (99%) with the important advantage of time. With Q-DAPSA, rheumatologists could base their clinical decision-making on a disease activity measurement by using a composite score immediately. Consequently, Q-DAPSA can be integrated in clinical routine and clinical trials and could be implemented into the treat-to-target concept in PsA patients. For rheumatologists who prefer DAS28-CRP for assessing disease activity in PsA patients, DAS28-qCRP may serve as a suitable alternative.

References:

[1]Smolen JS, et al. Ann Rheum Dis. 2018 Jan; 77(1):3-17.

Table 1.

Disease activity categories by Q-DAPSA vs. DAPAS

Q-DAPSA (n = 104)Remission (≤ 4)Low Disease Activity (> 4 and ≤ 14)High Disease Activity (> 14 and≤ 28)Very high Disease Activity (> 28)DAPSARemission (≤ 4)36 (34.6%)1 (1.0%)Low Disease Activity (> 4 and ≤ 14)39 (37.5%)High Disease Activity (> 14 and ≤ 28)22 (21.2%)Very high Disease Activity (> 28)6 (5.8%)

The fields highlighted in red indicate that disease activity categories do not match. DAPSA = Disease activity index for Psoriatic Arthritis, Q-DAPSA = DAPSA calculated based on a quick quantitative CRP

Figure 1.

Bland-Altman plot for Q-DAPSA and DAPSA

Acknowledgements:

The authors would like to deeply thank Braun T, Doerwald C, Deter N, Höppner C, Lackinger J, Lorenz C, Lunkwitz K, Mandt B, Sron S and Zernicke J for their practical support and coordinating the study.

Funding statement:

The AQUA study was supported by an unrestricted research grant from Novartis. Testing kits were provided free of charge from Aidian Oy, Finland.

Disclosure of Interests:

None declared.

POS1007 OPTIMIZING A REFERRAL STRATEGY FOR PATIENTS WITH A HIGH PROBABILITY OF AXIAL SPONDYLOARTHRITIS: THE ROLE OF AGE AND SYMPTOM DURATION

Background:

One of the most important prerequisites for a timely diagnosis of axial spondyloarthritis (axSpA) is the early referral of a patient with back pain to a rheumatologist. In the past years a number of referral strategies has been proposed, most of them in line with the ASAS referral recommendations [1] and with a similar performance – about 30-40% of the referred patients can be diagnosed with axSpA after examination by a rheumatologist. In addition to physician-based strategies, an online self-referral (OSR) strategy has been recently proposed and evaluated about 20% of the patients being diagnosed with axSpA after rheumatologic evaluation [2].

Objectives:

The objective of the current analysis was to investigate the role of age and symptom duration for the optimization of a physician-based and an OSR strategy for axSpA.

Methods:

In the OptiRef study, patients with chronic back pain and suspicion of axSpA either referred by primary care physicians /orthopedists using the Berlin referral tool (=physician based) or based on a referral recommendation of an OSR were evaluated by rheumatologists in a specialized center [2]. All patients underwent a structured examination including imaging that resulted into the final diagnosis of axSpA or no axSpA. The relationship between age, symptom duration and the likelihood of axSpA diagnosis was evaluated in this analysis.

Results:

A total of 360 patients (180 presented via the OSR and 180 referred by the physician based referral strategy) were included in this analysis. Patient’s characteristics are shown in Table 1. A total of 71 patients (39.4%) in the physician-based group and 35 patients (19.4%) in the OSR group were finally diagnosed with axSpA. The heatmaps depicting the relationship between the proportions of patients diagnosed with axSpA and age plus symptom duration (Figure 1) showed a clear decline of the axSpA probability with increasing age. In the physician-referred group, however, axSpA was diagnosed even in patients who were above 50 years at the time-point of the examination, while there were only few patients with axSpA in the self-referred group aged 40-49 years, and none in the age group ≥50 years. Interestingly, there was no clear relationship between symptom duration and probability of the diagnosis: axSpA was diagnosed in a substantial proportion of patients even with a long history of back pain (>12 years) in both subgroups.

Conclusion:

The probability of axSpA is high in patients suffering from back pain and aged <40 years with a substantial decline thereafter. Therefore, a referral strategy based on self-evaluation of symptoms should be more focused on a younger patient population, while physician-based strategies do not require such a restriction.

References:

[1]Poddubnyy D, et al. Ann Rheum Dis 2015 Aug; 74(8):1483-1487.

[2]Proft F, et al. Semin Arthritis Rheum. 2020; 50(5):1015-1021.

Table 1.

Patient characteristics

TotalN=360Berlin toolN=180Self-referralN=180p-valueDiagnosis of axial SpA, n (%)106 (29.4%)71 (39.4%)35 (19.4%)<0.0001Age, years, mean (SD)36.9 (10.4)37.2 (11.5)36.6 (9.2)>0.99Male sex, n (%)177 (49.2%)100 (55.6%)77 (42.8%)0.02Back pain duration, years, mean (SD)7.9 (7.6)6.5 (6.9)9.2 (8.1)<0.0001HLA-B27 positive, n (%)141 (40.9%)104 (59.8%)37 (21.6%)<0.0001CRP elevation, n (%)52 (14.8%)34 (19.4%)18 (10.2%)0.02Inflammatory back pain, n (%)204 (56.7%)103 (57.2%)101 (56.1%)0.92Figure 1.

Heatmaps depicting the proportions of patients diagnosed with axSpA in relation to age and symptom duration in the physician-based (A) and OSR (B) groups.

Acknowledgements:

We would like to thank all orthopaedists and primary care physicians who referred their patients. Further, we thank Dr. Anne-Katrin Weber and Dr. Susanne Lüders for the data collection support, Annegret Langdon for the data management support and Torsten Karge for set-up and support of the online screening tool.

Funding statement

The OptiRef study was supported by an unrestricted research grant from Novartis.

Disclosure of Interests:

None declared.

POS0979 ASSOCIATION BETWEEN HIGHER INTAKE OF CARBOHYDRATES AND FREE SUGAR WITH HIGHER DISEASE ACTIVITY IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background:

Diet has been previously described as an impact factor on the course of rheumatic diseases, such as rheumatoid arthritis and systemic lupus erythematosus (SLE). It has been previously reported that dietary sugar intake may contribute to subclinical inflammation and disease activity in SLE. However, there is very little investigation on the possible association between nutritional parameters and their influence on spondyloarthritis (SpA).

Objectives:

To investigate the possible impact of nutritional parameters on the disease activity in patients with SpA.

Methods:

Patients with radiographic axial SpA and starting a biological therapy were recruited between 2015 and 2019 in an extension of the prospective German Spondyloarthritis Inception Cohort (GESPIC). Dietary habits were collected at baseline using the country-specific validated food frequency questionnaire (FFQ) developed for the use in the German Health examination Survey for Adults 2008-2011. The FFQ includes questions about the frequency and amount of 53 food items, consumed during the past 4 weeks, and enabled to compute individual mean consumptions of foods in grams per day. Total energy intake (in Kcal per day) and nutritional parameters: carbohydrates, free sugars, total fats, saturated fats, mono and poly-unsaturated fats, proteins and dietary fiber, were calculated for each patient using a nutrition organization software and the database of Federal Food Code (Bundeslebensmittelschlüssel), version 3.02. Disease activity measures (BASDAI, CRP and ASDAS), as well as height, weight and body mass index (BMI) were assessed at baseline before starting the biological treatment.

Results:

A total of 104 patients from 129 patients with axial SpA enrolled in the cohort were included in this nutritional analysis. The mean age (mean±SD) was 37.0±11.0 years old with symptoms duration of 11.3±9.9 years, 68.3% were males, and 86.5% were HLA-B27 positive. Patients presented BMI of 25.1±4.3 kg/m2, BASDAI 5.6±1.4, CRP 14.0±18.2 mg/l, and ASDAS 3.5±1.0.

In the univariable and multivariable regression analysis, a higher energy intake and carbohydrates were associated with higher disease activity, measured by ASDAS, BASDAI and CRP. This association was attributable to the full intake of carbohydrates and specifically to the total of free sugars (monosaccharides and disaccharides) and the decrease of dietary fiber as shown in the multivariable analyses (Figure 1). This effect was independent of age, sex, smoker status and BMI.

Conclusion:

A higher intake of carbohydrates and a higher consumption of free sugars are associated with higher disease activity in patients with AS.

Figure 1.

Multivariable linear regression analysis of the association between CRP and nutritional parameters in patients with radiographic axial SpA (n=104), adjusted for age, sex, body mass index and smoker status. Model 1 included variable of total energy intake, model 2 included variable of total intake of carbohydrates (CH) and model 3 included variable of free-sugar (monosaccharides and disaccharides).

B, linear regression coefficient; CH, carbohydrates; CI, confidence interval; MS-FA, monosaturated fatty acids; PuS-FA, polyunsaturated fatty acids, S-FA, saturated fatty acids.

Disclosure of Interests:

None declared.

AB0660 LONG-TERM CLINICAL OUTCOME OF ANTI-TNF TREATMENT IN PATIENTS WITH EARLY AXIAL SPONDYLOARTHRITIS: 10-YEAR DATA OF THE ETANERCEPT VS. SULFASALAZIN IN EARLY AXIAL SPONDYLOARTHRITIS TRIAL

Background:

Long-term data on anti-TNF treatment in patients with early axial spondyloarthritis (SpA) is scarce.

Objectives:

The objective of this analysis was to assess the long-term clinical efficacy (up to 10 years of treatment) of a tumor necrosis factor (TNF) inhibitor etanercept (ETN) in patients with early axial spondyloarthritis, who participated in the long-term (until year 10) extension of the ESTHER (Etanercept vs. Sulfasalazine in Early Axial Spondyloarthritis Trial) trial.

Methods:

In the previously reported ESTHER trial, patients with early active axial SpA [including both non-radiographic axial SpA (nr-axSpA) and radiographic axial SpA (r-axSpA)/ankylosing spondylitis (AS)] with a symptom duration of <5 years and a positive MRI of the sacroiliac joints (SIJs) and/or the spine at baseline) were treated with ETN (n= 40) or sulfasalazine (SSZ) (n= 36) during the first year (1). At year 1, all patients who were not in remission continued with - or switched (in case of SSZ therapy) to – ETN for up to 10 years in total (1). Patients in remission discontinued their therapy and were followed-up until end of year 2; in case of remission loss, ETN was (re)-introduced and continued till the end of year 10.

Results:

Out of 76 initial patients, 25% (n=19, 12 with r-axSpA and 7 with nr-axSpA) completed year 10 of the study. At baseline, completers were significantly more often male and showed lower values of patient (PGA) and physician global assessments of disease activity (PhGA), ASDAS (Ankylosing Spondylitis Disease Activity Score), BASMI (Bath Ankylosing Spondylitis Metrology Index), and AS-QoL (Ankylosing Spondylitis Quality of Life Questionnaire) as compared to non-completers (Table 1). When analyzing clinical data of the completers, mean BASDAI, BASFI and ASDAS values were constantly <2 during the follow up with no statistically significant differences between the r-axSpA and nr-axSpA sub-groups (Table 2, Figure 1B). In the entire group, a sustained clinical response was observed over 10 years of follow up (Figure 1A). A total of 39 serious adverse events were documented over the 10 years of the study, while six of them were seen as possibly associated with ETN treatment, which lead in five patients (one lymphoma, one sarcoidosis, one demyelinating neurological disease, one elevated liver enzymes and one recurrent minor infections) to an ETN discontinuation.

Conclusion:

A sustained clinical response was shown over the 10 years of the study for the completers with comparable rates between r-axSpA and nr-axSpA. ETN was well tolerated across the entire treatment period and showed a good safety profile with no new safety signals.

Table 1.

Baseline characteristics of patients with axial spondyloarthritis who completed the study as compared to patients who dropped out.

Completer(n=19)Non-Completer(n=57)p valueAge, years32.5 (7.4)32.8 (8.9)0.91Male patients, n (%)15 (78.9)29 (50.9)0.034Symptomduration, years1.1 (1.2)1 (1.7)0.81HLA-B27 positivity, n (%)18 (94.7)44 (77.2)0.091Elevated CRP (CRP>5mg/l), n (%)7 (38.9)33 (62.3)0.088Fulfilled New York criteria, n (%)12 (63.2)27 (47.4)0.24Patient global (0-10)6.1 (1.9)7.2 (1.7)0.025Physician global (0-10)5.5 (1.5)6.5 (1.2)0.007ASDAS3 (0.7)3.5 (0.8)0.042BASDAI (0-10)5.4 (1.1)5.8 (1.3)0.27BASFI (0-10)4 (2.1)4.4 (2)0.41BASMI (0-10)1.2 (1.3)2 (1.6)0.039AS-QoL (0-18)7.6 (3.9)10.1 (3.9)0.019

Acknowledgments:

The ESTHER study was supported by an unrestricted research grant from Pfizer.

Murat Torgutalp’s work at Charité was supported by an award from the Scientific and Technological Research Council of Turkey.

Disclosure of Interests:

Fabian Proft Grant/research support from: Novartis Pharma GmbH, Consultant of: Consultancy / speaker fees from: Abbvie, BMS, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: Consultancy / speaker fees from: Abbvie, BMS, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Murat Torgutalp: None declared, Anja Weiß: None declared, Mikhail Protopopov Consultant of: Novartis, Valeria Rios Rodriguez Consultant of: Abbvie, Novartis, Hildrun Haibel Consultant of: Abbvie, Jansen, MSD, and Novartis, Speakers bureau: Abbvie, Jansen, MSD, and Novartis, Olaf Behmer Employee of: Pfizer Pharma GmbH, Joachim Sieper Consultant of: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Speakers bureau: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB

FRI0303 PERIPHERAL SYMPTOMS ARE ASSOCIATED WITH LESS SPINAL RADIOGRAPHIC PROGRESSION IN PATIENTS WITH EARLY AXIAL SPONDYLOARTHRITIS: RESULTS FROM THE GERMAN SPONDYLOARTHRITIS INCEPTION COHORT

Background:

Peripheral symptoms (PS), such as arthritis, enthesitis, and dactylitis, are common in axial spondyloarthritis (axSpA); data showing the association of PS and spinal radiographic progression in axSpA are controversial.

Objectives:

To analyze the association of PS and spinal radiographic progression in patients with axSpA.

Methods:

A total of 210 patients with axSpA (115 with radiographic and 95 with non-radiographic axSpA) were selected for analysis. Spinal radiographs were scored by two readers in a random order according to the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS). Pelvic radiographs were scored according to the grading system of the modified New York criteria; a sacroiliitis sum score was calculated as a sum of the grades for both sacroiliac joints. Mann-Whitney and Fisher exact tests were performed for group comparisons. A multivariable regression analysis was performed to analyze the influence of PS on radiographic progression.

Results:

Of the 101 (48.1%) patients with PS, 78 had peripheral arthritis, 48 - enthesitis, 12 - dactylitis. 32 patients had ≤1 PS. Patients with PS were older, less frequently HLA-B27 positive, compared with patients with no PS (73 (73.0%) vs. 93 (85.3%), p=0.028), had higher disease activity (time-averaged ASDAS over 2 years 2.6 ± 0.9 vs. 2.3 ± 0.9; p=0.032), worse physical function (BASFI 3.5 ± 2.3 vs. 2.3 ± 2.2, p<0.001), higher exposure to disease modifying anti-rheumatic drugs (39 (38.6%) vs. 22 (20.2%), p=0.003) and lower baseline radiographic sacroiliitis sum score (3.8 ± 1.9 vs. 4.4 ± 2.1, p=0.026); other baseline characteristics were similar. Patients with PS had lower absolute progression in mSASSS after 2 years of follow-up than those without (0.28 ± 1.39 vs 1.15 ± 2.9, p=0.045); 7.9% of patients with PS had a progression of mSASSS by ≥2 points compared to 20.2% in patients without PS (p=0.011). Radiographic progression of sacroiliitis was similar in both groups. In a multivariable regression analysis, presence of PS was associated with a lower mSASSS progression and lower odds for the mSASSS progression by ≥2 points after 2 years of follow-up: β=-0.98 (95% -1.68 to -0.28) OR=0.33 (95% CI 0.12 to 0.91), respectively – Table 1.

Table 1.

Association of peripheral symptoms with radiographic progression in axial spondyloarthritis after 2 years of follow-up.

Multivariable linear regression analysisOutcomeβ (95 %CI)mSASSS change score−0.98 (-1.68 to -0.28)*Change of the sacroiliitis sum score−0.06 (-0.32 to 0.20)**Multivariable logistic regression analysisOutcomeOdds ratio (95 %CI)Progression of mSASSS by ≥2 points0.33 (0.12 to 0.91)*Progression of sacroiliitis by at least 1 grade in opinion of both readers0.84 (0.33 to 2.09)**

mSASSS - modified Stoke Ankylosing Spondylitis Spine Score.

*Adjusted for the smoking status, HLA-B27 status, NSAIDs intake, baseline syndesmophytes, and time-averaged ASDAS.

**Adjusted for the smoking status, HLA-B27 status, NSAIDs intake, sacroiliitis sum score at baseline, and time-averaged ASDAS.

Conclusion:

Presence of PS is associated with distinct characteristics of SpA including slower radiographic spinal progression which might be explained partly by the numerically lower mSASSS score at baseline.

Acknowledgments:

GESPIC has been financially supported by the German Federal Ministry of Education and Research (BMBF). As funding by BMBF was reduced in 2005 and stopped in 2007, financial support has been obtained from Abbott / Abbvie, Amgen, Centocor, Schering-Plough, and Wyeth. Since 2010 GESPIC is supported by Abbvie.

Dr. Murat Torgutalp was supported by the Scientific and Technological Research Council of Turkey (TUBITAK).

Disclosure of Interests:

Murat Torgutalp: None declared, Mikhail Protopopov Consultant of: Novartis, Fabian Proft Grant/research support from: Novartis Pharma GmbH, Consultant of: Consultancy / speaker fees from: Abbvie, BMS, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: Consultancy / speaker fees from: Abbvie, BMS, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Joachim Sieper Consultant of: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Speakers bureau: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Valeria Rios Rodriguez Consultant of: Abbvie, Novartis, Hildrun Haibel Consultant of: Abbvie, Jansen, MSD, and Novartis, Speakers bureau: Abbvie, Jansen, MSD, and Novartis, Martin Rudwaleit Consultant of: AbbVie, BMS, Celgene, Janssen, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB Pharma, Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB

FRI0323 THE PRESENCE OF SPONDYLOARTHRITIS IS ASSOCIATED WITH HIGHER CLINICAL DISEASE ACTIVITY IN PATIENTS WITH EARLY CROHN’S DISEASE: RESULTS OF A PROSPECTIVE COHORT STUDY

Background:

Inflammatory bowel disease (IBD) and specifically Crohn’s disease (CD) is known to be associated with spondyloarthritis (SpA). However, only little is known about factors associated with the development of spondyloarthritis in CD.

Objectives:

To identify factors associated with the presence of SpA in a cohort of patients with CD.

Methods:

Patients with a definite diagnosis of CD naïve to or not being treated with biological agents for at least 3 months were included in a CD-arm of the German Spondyloarthritis Inception Cohort (GESPIC-Crohn). Gastroenterologists were encouraged to include consecutively recently diagnosed CD patients. Patients were classified according to the Montreal classification including location and behavior of CD. Patients received a structured assessment of SpA manifestations (including magnetic resonance imaging of sacroiliac joints and spine) by a rheumatologist who was responsible for the final diagnosis of SpA / no SpA. Clinical activity of CD was assessed by the Harvey-Bradshaw Index (HBI). In addition, colonoscopy was performed, Simple endoscopic Score for Crohn’s Disease (SES-CD) was determined and fecal calprotectin was measured.

Results:

A total of 108 patients with CD were enrolled. The mean (mean ± SD) age was 36.6 ± 12.7 years, and CD symptom duration was 5.3 ± 7.4 years. At baseline, 44 (40.7%) patients were treated with non-biologic immunomodulating drugs: 16 (14.8%) patients received mesalazine, 27 (25.0%) azathioprine, and 1 (0.9%) methotrexate. Oral steroids were given to 38 (35.2%) patients. A total of 103 (96.3%) patients were biologics naïve. SpA was diagnosed in 23 (21.3%) patients: 12 had axial SpA and 11 peripheral SpA. Patients with SpA had higher prevalence of HLA-B27, of clinical SpA features (back pain, inflammatory back pain, peripheral arthritis, enthesitis), higher level of CRP and higher activity of CD as measured by the HBI. There were not substantial differences between SpA vs. non-SpA patients in terms of CD duration, endoscopic activity, disease location or behavior, or treatment, except for mesalazine, which was more frequently administered in patients with SpA than non-SpA (39.1% vs. 8.2%, p=0.001, respectively).

Conclusion:

SpA was present in 21% of patients with CD in this early cohort with almost equal proportions of axial and peripheral forms. Presence of HLA-B27 and higher clinical activity of CD were associated with the presence of SpA.

TABLE.

Baseline demographic and clinical characteristics of the included patients with Crohn’s disease with or without spondyloarthritis.

VARIABLETOTALn=108SpAn=23No SpAn=85PAge, years, mean ± SD36.6 ± 12.737.5 ± 11.336.3 ± 13.10.44Male sex, n (%)50 (46.3)10 (43.5)40 (47.1)0.82CD symptom duration, years, mean ± SD5.3 ± 7.45.4 ± 7.25.1 ± 7.50.63HLA-B27 positive, n (%)13 (12.0)6 (26.1)7 (8.2)0.03Montreal classification Location: L1 - ileal68 (63.0)13 (56.5)55 (64.7)0.48 L2 - colonic000 L3 - ileocolonic39 (36.1)7 (30.4)32 (37.6)0.63 L4 – isolated upper disease10 (9.3)3 (13.0)7 (8.2)0.44Behavior:B1 – non-stricturing, non-penetrating69 (63.9)15 (65.2)54 (63.5)1.00 B2 - stricturing19 (17.6)4 (17.4)15 (17.6)1.00 B3 - penetrating6 (5.6)06 (7.1)0.34 Peri-anal disease7 (6.5)2 (8.7)5 (5.9)0.64 C-reactive protein, mg/l, mean ± SD10.7 ± 24.813.6 ± 23.210.0 ± 25.30.02 Harvey-Bradshaw Index, mean ± SD3.6 ± 4.05.5 ± 4.73.1 ± 3.60.01 Fecal calprotectin, mcg/d, mean ± SD185.9 ± 213.7211.7 ± 243.8179.5 ± 207.90.43Treatment of CD Mesalazine, n (%)16 (14.8)9 (39.1)7 (8.2)0.001 Methotrexate, n (%)27 (25.0)3 (13.0)24 (28.2)0.18 Azathioprine, n (%)1 (0.9)01 (1.2)1.00 Biologics naive, n (%)103 (96.3)22 (95.7)81 (96.4)1.00

Disclosure of Interests:

Valeria Rios Rodriguez Consultant of: Abbvie, Novartis, Mikhail Protopopov Consultant of: Novartis, Fabian Proft Grant/research support from: Novartis Pharma GmbH, Consultant of: Consultancy / speaker fees from: Abbvie, BMS, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: Consultancy / speaker fees from: Abbvie, BMS, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Susanne Lüders: None declared, Judith Rademacher: None declared, Hildrun Haibel Consultant of: Abbvie, Jansen, MSD, and Novartis, Speakers bureau: Abbvie, Jansen, MSD, and Novartis, Maryna Verba: None declared, Joachim Sieper Consultant of: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Speakers bureau: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Elena Sonnenberg: None declared, Michael Schumann: None declared, Lea Isabell Kredel: None declared, Britta Siegmund Consultant of: Abbvie, Boehringer, Celgene, Falk, Janssen, Lilly, Pfizer, Prometheus, Takeda, Speakers bureau: Abbvie, CED Service GmbH, Falk, Ferring, Janssen, Novartis, Takeda (BS served as representative of the Charité), Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB

THU0400 CLINICAL COURSE OF EARLY AXIAL SPONDYLOARTHRITIS OVER TEN YEARS: LONG-TERM RESULTS FROM THE GERMAN SPONDYLOARTHRITIS INCEPTION COHORT

Background:

Previous studies showed that patients with non-radiographic and radiographic axial spondyloarthritis (nr- and r-axSpA) have similar disease burden and similar response to anti-inflammatory therapy given similar level of inflammatory activity. Only little is known, however, about long-term disease course in patients with early axSpA.

Objectives:

To investigate the long-term (up to 10 years) clinical course of patients with early axSpA.

Methods:

In total, 525 patients with early axSpA (r-axSpA with symptom duration ≤10 years and nr-axSpA with symptom duration ≤5 years) from the German Spondyloarthritis Inception Cohort (GESPIC) were included. The final patient classification was based on central reading results in 458 patients with available pelvic X-rays, and on local rheumatologist judgement in 67 patients. A total of 251 patients were finally classified as r-axSpA and 274 as nr-axSpA. Clinical evaluation, which included disease activity (BASDAI, C-reactive protein – CRP, ASDAS) as well as therapy recording, was performed at baseline and every 6 months thereafter until year 2 and annually thereafter till year 10. Treatment was conducted at the discretion of the local rheumatologist.

Results:

Since the cohort has started prior to introduction of TNF inhibitors (TNFi), only 2% patients received TNFi at baseline that increased to 23% at year 10 (15% in nr-axSpA and 31% in r-axSpA) – Figure 1. The use of NSAIDs and csDMARDs decreased in both groups (Figure 1), while use of systemic steroids did not change substantially (9% at baseline, 8% at year 10). The proportion of patients with low disease activity according to BASDAI (<4) was higher in r-axSpA as compared to nr-axSpA at almost all time points, while the proportion of patients with low disease activity according to ASDAS (<2.1), as well as with ASDAS inactive disease (<1.3) was similar between nr-axSpA and r-axSpA (Figure 2). In the group of patients who completed year 10 (n=134 in total, 68 with nr-axSpA, 67 with r-axSpA) the same trends in therapy and disease activity were observed.

Conclusion:

Patients with nr-axSpA and r-axSpA showed a similar disease course in terms of disease activity on the group level. The drop-out rate in this observational cohort was overall high, but comparable between groups. The lower proportion of patients with nr-axSpA being treated with TNFi might reflect a later introduction of TNFi for this indication.

Acknowledgments:

GESPIC has been financially supported by the German Federal Ministry of Education and Research as well as by Abbott, Amgen, Centocor, Schering–Plough, and Wyeth. From 2010 till 2019 GESPIC has been supported by Abbvie.

Disclosure of Interests:

Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Valeria Rios Rodriguez Consultant of: Abbvie, Novartis, Murat Torgutalp: None declared, Maryna Verba: None declared, Johanna Callhoff: None declared, Mikhail Protopopov Consultant of: Novartis, Fabian Proft Grant/research support from: Novartis Pharma GmbH, Consultant of: Consultancy / speaker fees from: Abbvie, BMS, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: Consultancy / speaker fees from: Abbvie, BMS, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Judith Rademacher: None declared, Hildrun Haibel Consultant of: Abbvie, Jansen, MSD, and Novartis, Speakers bureau: Abbvie, Jansen, MSD, and Novartis, Joachim Sieper Consultant of: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Speakers bureau: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Martin Rudwaleit Consultant of: AbbVie, BMS, Celgene, Janssen, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB Pharma

AB0716 SEX DIFFERENCES IN CLINICAL PHENOTYPE AND RADIOGRAPHIC DISEASE PROGRESSION IN AXIAL SPONDYLOARTHRITIS: RESULTS FROM THE GERMAN SPONDYLOARTHRITIS INCEPTION COHORT

Background:

It is presumed that the phenotype of the axial spondyloarthritis (axSpA) may differ in females and males; the published data are controversial.

Objectives:

To explore the sex differences in disease features and radiographic progression in axSpA.

Methods:

A total of 210 patients with axSpA (115 with radiographic and 95 with non-radiographic axSpA) were selected for analysis. Spinal radiographs were scored by two readers in a random order according to the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS). Pelvic radiographs were scored according to the grading system of the modified New York criteria; a sacroiliitis sum score was calculated as a sum of the grades for both sacroiliac joints. Mann-Whitney and Fisher exact tests were performed for group comparisons. A multivariable regression analysis was performed to analyze the influence of gender on radiographic progression.

Results:

Males (n=107; 51%) were significantly younger at disease onset (34.8 ± 10.3 vs. 31.5 ± 11.2 years, p=0.008) and at diagnosis (37.5 ± 10.2 vs. 34.1 ± 11.2 years, p=0.006); symptom duration at baseline was similar (4.1 ± 2.6 vs. 4.3 ± 2.8 years, p=0.66). Females were less often HLA-B27 positive (74 (72.5%) vs. 92 (86.0%), p=0.02), had higher baseline disease activity (BASDAI 4.3±2.2 vs 3.7±2.0; p=0.05), but lower baseline C-reactive protein level (7.1 ± 10.9 vs. 12.3 ±18.2 mg/l, p=0.08), and similar time-averaged ASDAS (2.5±0.8 vs 2.4±1.0; p=0.385). Males more frequently had definite radiographic sacroiliitis (70.1% vs. 38.8%; p<0.001), higher sacroiliitis sum score (4.9 ±1.9 vs 3.2±1.8, p<0.001), and higher mean mSASSS (6.1 ± 10.7 vs 2.4 ± 4.0; p=0.100) at baseline. Other variables were comparable between the groups. There was a trend for a higher radiographic progression in males in all explored outcomes, statistically significant only for the formation/progression of syndesmophytes (23 (21.5%) vs. 10 (9.7%), p=0.023), with no differences in the radiographic progression of sacroiliitis. In a multivariate logistic regression analysis, similar odds for spinal radiographic progression, new syndesmophyte formation and radiographic progression of sacroiliitis by ≥1 grade were seen –Table 1.

Conclusion:

There was a trend for male patients to have more radiographic damage at the baseline and more progression after two years, as reflected by the percentage of patients with new syndesmophytes.

:

Table 1.

Association of sex with radiographic progression in spine and sacroiliac joints after 2 years of follow-up.

Parameter, n (%) or mean±SDFemale(n=103)Male(n=107)PSpinal radiographic progressionmSASSS change0.46 ± 1.631.00 ± 2.850.25Progression of mSASSS by ≥2 points10 (9.7)20 (18.7)0.08New syndesmophytes or progression of syndesmophytes10 (9.7)23 (21.5)0.02Progression of radiografic sacroiliitisChange of the sacroiliitis sum score0.14 ± 0.940.13 ± 0.730.58Progression of sacroiliitis by at least 1 grade in opinion of both readers17 (16.5)9 (8.4)0.09

mSASSS – modified Stoke Ankylosing Spondylitis Spine Score;

Acknowledgments:

GESPIC has been financially supported by the German Federal Ministry of Education and Research (BMBF). As funding by BMBF was reduced in 2005 and stopped in 2007, financial support has been obtained from Abbott / Abbvie, Amgen, Centocor, Schering-Plough, and Wyeth. Since 2010 GESPIC is supported by Abbvie.

Dr. Murat Torgutalp was supported by the Scientific and Technological Research Council of Turkey (TUBITAK).

Disclosure of Interests:

Mikhail Protopopov Consultant of: Novartis, Murat Torgutalp: None declared, Joachim Sieper Consultant of: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Speakers bureau: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Hildrun Haibel Consultant of: Abbvie, Jansen, MSD, and Novartis, Speakers bureau: Abbvie, Jansen, MSD, and Novartis, Fabian Proft Grant/research support from: Novartis Pharma GmbH, Consultant of: Consultancy / speaker fees from: Abbvie, BMS, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: Consultancy / speaker fees from: Abbvie, BMS, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Valeria Rios Rodriguez Consultant of: Abbvie, Novartis, Martin Rudwaleit Consultant of: AbbVie, BMS, Celgene, Janssen, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB Pharma, Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB

THU0401 IMPACT OF BODY COMPOSITION MEASURES ON THE RESPONSE TO BIOLOGICAL DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS IN PATIENTS WITH ANKYLOSING SPONDYLITIS

Background:

Data on the impact of body weight and body mass index (BMI) on the response to biological disease-modifying anti-rheumatic drugs (bDMARDs) in axial spondyloarthritis (axSpA) including ankylosing spondylitis (AS) are still contradictory. Data on the impact of different components of the body composition on the treatment response are lacking.

Objectives:

To investigate the impact of body composition on the response to biological disease-modifying anti-rheumatic drugs (bDMARD) in patients with AS after 6 months of treatment.

Methods:

Patients with AS (radiographic axSpA), fulfilling the modified New York criteria and starting a bDMARD therapy were recruited between 2015 and 2019 in an extension of the prospective German Spondyloarthritis Inception Cohort (GESPIC-AS). All patients were required to be candidates for bDMARD therapy at baseline with high disease activity (BASDAI >=4 and/or ASDAS >=2.1) despite previous treatment with nonsteroidal anti-inflammatory drugs. Disease activity measures (BASDAI, CRP, ASDAS), as well as body composition parameters were assessed at baseline and after 6 months of bDMARD treatment. Body composition was assessed by the bioelectrical impedance analysis (BIA). Weight, body mass index (BMI), fat mass index (FMI), fat free mass index (FFMI), skeletal muscle mass value (SMM), visceral adipose tissue (VAT), total body water (TBW), and extracellular water (ECW) values were collected. The primary measure of the treatment response was ASDAS change at month 6 as compared to baseline.

Results:

A total of 129 patients with AS were included in this cohort. BIA was performed in 77 patients. There were 71.4% males, and 85.7% were HLA-B27 positive. At baseline, BASDAI was 5.4±1.4, CRP was 12.8±16.5 mg/l, and ASDAS - 3.0±1.0. The baseline BMI was 25.0±4.3 kg/m2. A total of 75 patients were treated with TNFi, 2 patients received an IL-17 inhibitor.

A higher BMI at baseline was associated with a worse response to bDMARD therapy that was attributable to both, the fat mass as reflected by FMI and to the fat-free mass reflected by FFMI, but not to SMM or VAT or water components – Table. This effect was independent of age, sex, symptom duration, HLA-B27 status and ASDAS at baseline.

Table.

Univariable and multivariable linear regression analysis of the association between response to bDMARD treatment (change in the ASDAS score after 6 months) and body composition parameters in patients with AS (n=77)

VariablesUnivariableMultivariable analysis*Analysisß (95%CI)Model 1ß (95%CI)Model 2ß (95%CI)Model 3ß (95%CI)Model 4ß (95%CI)Model 5ß (95%CI)Model 6ß (95%CI)Model 7ß (95%CI)BMI, kg/m2-0.016(-0.063; 0.031)-0.043(-0.079;-0.006)------FMI, kg/m2-0.024(-0.103; 0.054)--0.065(-0.128;-0.003)-----FMMI,kg/m2-0.010(-0.133; 0.112)---0.138(-0.253;-0.022)----SMM, kg0.026(-0.020; - 0.071)---0.012(-0.044; 0.069)---VAT, liters0.069(-0.099; 0.238)-----0.095(-0.248; 0.057)--TBW, liters0.020(-0.016; 0.056)-----0.007(-0.036; 0.051)-ECW, liters0.054(-0.43; 0.150)------0.005(-0.98; 0.107)

*Adjusted for age, sex, HLA-B27 status, symptom duration, and ASDAS at baseline.

BMI: Body Mass Index; FMI: Fat Mass Index; SMM: Skeletal Muscle mass; VAT: Visceral Adipose Tissue; AS: ankylosing spondylitis; bDMARD: biological disease-modifying anti-rheumatic drug; CI: 95% confidence interval.

Conclusion:

Both fat mass and fat free mass have an impact on the response to bDMARDs after 6 months of treatment in patients with AS. Interestingly, skeletal muscle mass, visceral fat as well as water components showed no association with treatment response.

Acknowledgments:

GESPIC has been financially supported by ArthroMark and METARTHROS projects.

Disclosure of Interests: :

Valeria Rios Rodriguez Consultant of: Abbvie, Novartis, Mikhail Protopopov Consultant of: Novartis, Fabian Proft Grant/research support from: Novartis Pharma GmbH, Consultant of: Consultancy / speaker fees from: Abbvie, BMS, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: Consultancy / speaker fees from: Abbvie, BMS, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Judith Rademacher: None declared, Burkhard Muche: None declared, Anne Katrin Weber: None declared, Susanne Lüders: None declared, Hildrun Haibel Consultant of: Abbvie, Jansen, MSD, and Novartis, Speakers bureau: Abbvie, Jansen, MSD, and Novartis, Maryna Verba: None declared, Joachim Sieper Consultant of: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Speakers bureau: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB

SAT0389 FREQUENCY OF DISEASE FLARES UNDER LONG-TERM ANTI-TNF THERAPY IN PATIENTS WITH EARLY AXIAL SPONDYLOARTHRITIS: RESULTS FROM THE ETANERCEPT VERSUS SULFASALAZINE IN EARLY AXIAL SPONDYLOARTHRITIS TRIAL

Background:

Disease flares in axial spondyloarthritis (axSpA) might occur even in patients with otherwise stable disease receiving highly effective anti-inflammatory therapy such as TNF inhibitors. The frequency of disease flares, especially in patients with axSpA receiving long-term stable therapy, and factors associated with flares are not sufficiently investigated.

Objectives:

The objective was to assess the frequency of disease flares and to identify factors associated with flares in patients with early axSpA receiving continuous long-tem (up to 10 years) treatment with a TNF inhibitor etanercept.

Methods:

In the ESTHER (etanercept versus sulfasalazine in early axial spondyloarthritis trial), patients with early axSpA (symptom duration ≤5 years) were treated with ETN (n=40) versus sulfasalazine (n=36) for 48 weeks [2]. After one year all patients were treated continuously with etanercept (n=17 patients temporarily interrupted treatment in the 2nd year to assess time to flare and were then (re-)treated with etanercept, except 4 patients who completed the study in sustained remission) for up to 10 years in total. Only patients who were continuously treated with etanercept for at least 6 months were included in the current analysis. The disease flare was defined as a worsening of the ASDAS by ≥0.9 as compared to the value obtained at the previous visit. Univariate and multivariable cox-regression analyses were performed to analyze the predictors of flares.

Results:

Out of 76 patients who entered the study at baseline, 62 patients (n=32 with radiographic (r-) axSpA and n=30 with non-radiographic (nr-) axSpA) fulfilled the criterion of the continuous etanercept treatment. A total of 22 patients (35%) experienced at least one flare over the entire treatment period 10 patients (31.3%) in the r-axSpA and 12 patients (40%) in the nr-axSpA subgroup) - figure. A total of 81 flares occurred (33 and 48 in the r- and nr-axSpA subgroups, respectively) in the 10 years of follow-up. None of the documented disease flares resulted in a direct study withdrawal. The majority of flares occurred within first 4 years of treatment (figure). There were also no statistically significant differences between nr- and r-axSpA in the time until the first flare (p=0.4, Log-rank test). In the multivariable Cox regression analysis normal CRP values (≤5mg/l), HLA-B27 negativity, higher physician global assessment, a longer symptom duration at study entry, higher spinal ankylosis and higher fatty degeneration in the sacroiliac joints but lower spinal osteitis scores and lower ankylosis scores in the sacroiliac joints at baseline MRI were associated with a higher risk for flares.

Conclusion:

Disease flares according to the ASAS definition of clinically important worsening in axSpA based on ASDAS occurred ~1/3 of patients with early axSpA who received a treatment with etanercept for up to 10 years without major differences between r- and nr- forms of axSpA. HLA-B27 negativity, normal CRP, higher spinal ankylosis scores, higher fatty degeneration scores but lower ankylosis scores in the SIJ´s at baseline MRI were associated with a higher risk for flares.

Figure 1.

Baseline characteristics of all patients with with continous ETC treatment.

all≥1 flareno flarepatientsn (%)62 (100)22 (35.5)40 (64.5)malen (%)38 (61.3)16 (72.7)22 (55)agemean (SD)34.1 (8.3)32.6 (7.8)35 (8.6)BASDAImean (SD)2.7 (2)1.8 (1.8)3.2 (1.9)ASDASmean (SD)1.6 (0.8)1.3 (0.7)1.7 (0.8)Figure 2.

Kaplan-Meier curves indicating time to first flare and flare free survival propability.

Acknowledgments:

The ESTHER study was supported by an unrestricted research grant from Pfizer. Murat Torgutalp’s (MT) work at Charité - Universitätsmedizin was supported by an award from the Scientific and Technological Research Council of Turkey (TUBITAK).

Disclosure of Interests:

Fabian Proft Grant/research support from: Novartis Pharma GmbH, Consultant of: Consultancy / speaker fees from: Abbvie, BMS, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: Consultancy / speaker fees from: Abbvie, BMS, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Murat Torgutalp: None declared, Anja Weiß: None declared, Mikhail Protopopov Consultant of: Novartis, Valeria Rios Rodriguez Consultant of: Abbvie, Novartis, Hildrun Haibel Consultant of: Abbvie, Jansen, MSD, and Novartis, Speakers bureau: Abbvie, Jansen, MSD, and Novartis, Kay Hermann: None declared, Christian Althoff: None declared, Olaf Behmer Employee of: Pfizer Pharma GmbH, Joachim Sieper Consultant of: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Speakers bureau: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB

FRI0292 TREATMENT RESPONSE TO BIOLOGICAL DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS IS ASSOCIATED WITH FAVORABLE CHANGES OF THE BODY COMPOSITION IN PATIENTS WITH ANKYLOSING SPONDYLITIS

Background:

There is few data available regarding differences in body composition and its possible changes in patients with ankylosing spondylitis (AS) treated with biological disease-modifying anti-rheumatic drugs (bDMARDs). An increase of body weight and lean mass in patients receiving TNF inhibitors, as well as a possible muscle wasting by high disease activity have been previously described. Bioelectrical impedance analysis (BIA) is a valid method to assess body composition and allows to distinguish between fat, fat-free mass and skeletal muscle mass.

Objectives:

To evaluate changes in body composition in patients with AS after 6 months of treatment with bDMARDs.

Methods:

Patients with a diagnosis of AS, fulfilling the modified New York criteria and starting a bDMARD therapy were included in the extension of the prospective German Spondyloarthritis Inception Cohort (GESPIC). All patients had high disease activity (BASDAI >=4 and/or ASDAS >=2.1) despite previous treatment with nonsteroidal anti-inflammatory drugs. Disease activity and body composition were assessed at baseline and after 6 months of bDMARD treatment. Body composition was assessed by the BIA with the seca© mBCA 515 device (SECA Deutschland GmbH, Hamburg/Germany) and included the following parameters: weight, body mass index (BMI), fat mass index (FMI), fat free mass index (FFMI), skeletal muscle mass value (SMM), and visceral adipose tissue value (VAT). Response to a bDMARD therapy was defined as achievement of clinically important improvement of ASDAS (>=1.1).

Results:

A total of 129 patients (66.7% male) with AS were recruited in this cohort extension between 2015 and 2019. The mean (mean ± SD) age was 36.2 ± 10.3 years, and symptom duration was 10.7 ± 9.1 years. HLA-B27 test was positive in 89.1% patients. BIA was assessed in 77 patients; the baseline characteristics of these patients were similar to those of the whole cohort. Of these, 75 patients were treated with TNF inhibitors and 2 patients were treated with an IL-17A inhibitor.

After 6 months of a bDMARD treatment, body composition changed significantly with an increase of weight and BMI due to the gain of FMI but also of FFMI and SMM, while there was no increase of the visceral fat – table. In responders (improvement of ASDAS>=1.1 after 6 months) the results were similar to the whole group with a significantly gain (mean±SD) on BMI, FMI, FFMI and SMM (0.3 ± 1.4 kg/m2, 0.3 ± 1.0 kg/m2, 0.2 ±0.5 kg/m2, 0.5 ± 1.2 kg, p<0.05, respectively). In non-responders, there were no significant changes on the body composition after 6 months of treatment.

Conclusion:

Treatment with bDMARDs is associated with favorable changes of the body composition with increase of the muscle mass but not of the visceral fat. These changes were evident in treatment responders only.

TABLE 1.

Body composition parameter at baseline and after 6 months of treatment with a bDMARDs in patients with AS (n=77)

Mean±SDDifference, mean±SD95% CIP*LowerUpperWeight at baseline, kg77.19±15.710.75±3.800.041.470.04Weight at 6 months, kg77.94±16.25BMI at baseline, kg/m225.03±4.320.30±1.290.060.550.02BMI at 6 months, kg/m225.33±4.43FMI at baseline, kg/m26.74±3.390.31±0.970.070.540.01FMI at 6 months, kg/m27.05±3.42FFMI at baseline, kg/m218.27±2.180.15±0.480.040.270.01FFMI at 6 months, kg/m218.42±2.27SMM at baseline, kg27.40±5.850.32±1.110.050.590.02SMM at 6 months, kg27.73±5.90VAT at baseline, liters1.94±1.62-0.12±0.63-0.270.040.14VAT at 6 months, liters1.82±1.56

BMI: Body Mass Index; FMI: Fat Mass Index; FFMI: Free Fat Mass Index; SMM: Skeletal Muscle mass; VAT: Visceral Adipose Tissue.

*Wilcoxon test

Acknowledgments:

GESPIC has been financially suported by ArthroMark and METARTHROS projects

Disclosure of Interests:

Valeria Rios Rodriguez Consultant of: Abbvie, Novartis, Mikhail Protopopov Consultant of: Novartis, Fabian Proft Grant/research support from: Novartis Pharma GmbH, Consultant of: Consultancy / speaker fees from: Abbvie, BMS, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: Consultancy / speaker fees from: Abbvie, BMS, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Judith Rademacher: None declared, Burkhard Muche: None declared, Anne Katrin Weber: None declared, Susanne Lüders: None declared, Hildrun Haibel Consultant of: Abbvie, Jansen, MSD, and Novartis, Speakers bureau: Abbvie, Jansen, MSD, and Novartis, Maryna Verba: None declared, Joachim Sieper Consultant of: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Speakers bureau: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB