AB1135 RESPONSE TO SARS-COV-2 VACCINATION IN SYSTEMIC AUTOIMMUNE RHEUMATIC DISEASE DEPENDS ON IMMUNOSUPPRESSIVE REGIMEN: A MATCHED, PROSPECTIVE COHORT STUDY

Background

Vaccination efficiency has been demonstrated to be reduced in patients with systemic autoimmune rheumatic disease (SARD) compared with the general population.

Objectives

To assess the humoral response to mRNA vaccine in patients with (SARD) and the effect of immunosuppressive medication in a matched cohort study.

Methods

Patients with SARD were enrolled and matched 1:1 for gender and age with healthy control subjects (HC). Differences in the humoral response to two doses of mRNA vaccine BNT162b2 in terms of seroconversion rate and SARS-COV-2 antibody titer between the two groups and impact of treatment within SARD patients was assessed using Fisher’s exact test, Student’s t-test, Mann-Whitney test and Kruskal-Wallis test, adjusting for multiple testing.

Results

We enrolled 82 patients with SARD and 82 matched HC (Table 1). Among patients the seroconversion rate was significantly lower after the 1st dose (65% compared to 100% in HC, p<0.0001) but levelled up after the 2nd dose (94% vs. 100%). While the difference in seroconversion rate was independent of treatment regime (no disease modifying anti-rheumatic drug (DMARD), DMARD monotherapy, DMARD combination therapy), the seroconversion rate of SARD patients on mono- or combination DMARD therapy was also significantly lower as compared to those receiving no DMARD therapy (56% for monotherapy and 57% for combination therapy compared to 77% for no DMARD therapy, p=0.002 and p=0.004 respectively; Figure 1A). Seroconversion rate after the 2nd dose was significantly lower for patients on combination DMARD therapy compared to all other groups (81% compared to 95% for monotherapy, and 100% for both no DMARD therapy and HC respectively, all p<0.0001); also antibody titers after the 2nd dose were lower when comparing patients on combination DMARD therapy to all other groups (49 binding antibody units (BAU)/ml versus 1673 BAU/ml in HC, p<0.0001; 2500 BAU/ml in those on no DMARD therapy, p<0.0001; and 687 BAU/ml in those on DMARD monotherapy, p=0.0072; Figure 1B). Considering effects of individual compounds, mycophenolate mofetil in mono- or combination therapy led to lower antibody titers after the 2nd dose as compared to HC or patients receiving no DMARDs (2 BAU/ml versus 1673 BAU/ml and 2500 BAU/ml respectively, both p<0.0001).

Figure 1.

Seroconversion rate (A) and anti-SARS-Cov 2 S antibody levels (B) after the 1stand 2ndvaccination between the healthy control (HC) group and patients according to therapy

Table 1.

Study subject characteristics

SARD (n=82)HC (n=82)Age, mean (±SD)52.05 (±14.06)52.15 (±13.42)Female, n (%)65 (79%)65 (79%)Different disease entity, n (%):33 (40%) Systemic lupus erythematosus Systemic sclerosis13 (16%) Other connective tissue diseases*15 (18%) Vasculitides#17 (21%) Miscellaneous$4 (5%)Treatment groups, n (%):43 (52%) csDMARD or b/tsDMARD monotherapy csDMARD and/or b/tsDMARD combination therapy16 (20%) No therapy23 (28%)Treatment agents, n (%):13 (16%) Methotrexate Mycophenolate14 (17%) Hydroxychloroquine28 (34%) Azathioprine13 (10%) Belimumab3 (4%) Tocilizumab3 (4%) Tacrolimus2 (2%) Olumiant1 (1%)

*dermato-/polymyositis (n=4), mixed connective tissue disease (n=2), primary Sjögren’s syndrome (n=6), undifferentiated connective tissue disease (n=3)

#antineutrophil cytoplasmic antibody (ANCA) associated vasculitis (n=3), Behcet’s disease (n=1), large-vessel vasculitis (n=3), polymyalgia rheumatica (n=10)

$ adult-onset Still’s disease (n=1), immune deficiency (n=2), sarcoidosis (n=1)

b/tsDMARD: biological/targeted synthetic disease modifying antirheumatic drug; csDMARD: conventional synthetic disease modifying antirheumatic drug; HC: healthy control; n: number; SARD: systemic autoimmune rheumatic disease; SD: standard deviation;

Conclusion

Patients with SARD showed a good response after the 2nd vaccination with the mRNA vaccine. However, the choice of immunosuppressive regimen has a marked effect on both seroconversion rate and overall antibody titer.

Acknowledgements

We thank Sylvia Taxer and Zoltan Vass for their support.

Disclosure of Interests

Peter Mandl Speakers bureau: AbbVie, Janssen, Novartis, Consultant of: AbbVie, Janssen, Novartis, Grant/research support from: AbbVie, BMS, Lilly, Novartis, MSD, UCB, Selma Tobudic: None declared, Helmut Haslacher: None declared, Daniel Mrak: None declared, Thomas Nothnagl: None declared, Thomas Perkmann: None declared, Helga Radner Speakers bureau: Gilead, Merck Sharp, Pfizer, Abbvie, Consultant of: Gilead, Merck Sharp, Pfizer, Abbvie, Judith Sautner Speakers bureau: Otsuka, Novartis, Consultant of: Lilly, Astro Pharma, UCB, Abbvie, Elisabeth Simader Grant/research support from: Pfizer, Bristol-Myers Squibb, Florian Winkler: None declared, Heinz Burgmann: None declared, Daniel Aletaha Speakers bureau: Abbvie, Amgen, Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Consultant of: Abbvie, Amgen, Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sandoz

, Grant/research support from: Abbvie, Amgen, Lilly, Novartis, Roche, SoBi, Sanofi, Stefan Winkler: None declared, Stephan Blüml Speakers bureau: Novartis, Abbvie, Consultant of: Gilead, Merck, Novartis, Abbvie

POS1390 ULTRASOUND BASED WITHDRAWAL OF BIOLOGICS IN RHEUMATOID ARTHRITIS (RA-BioStop)

Background

Discontinuation of biological (b)DMARDs may be considered in rheumatoid arthritis (RA) patients in persistent clinical remission [1]. Some earlier studies reported that baseline ultrasound may predict successful tapering or withdrawal of bDMARDs, while others found that ultrasound had little additional value over clinical parameters alone [2-4]. The majority of these studies, however, were limited by small sample size, inadequate remission criteria and variable tapering regimens.

Objectives

To test the hypothesis whether ultrasound-verified subclinical inflammation might predict a relapse in RA patients in stringent clinical remission who discontinue bDMARDs.

Methods

Prospective, phase IV clinical trial including RA patients in persistent clinical remission according to the ACR/EULAR criteria treated with a combination of conventional synthetic (cs)DMARD plus bDMARDs. Upon stopping the bDMARD, 9 study visits were conducted within 52 weeks. At each visit, patients underwent clinical examination and ultrasound of 14 joints. The primary hypothesis was that a Power Doppler (PD) score >0 predicted a relapse until week 16 after bDMARD cessation. Relapse was defined as change from remission to moderate/high disease activity according to the simplified disease activity index.

Results

Although 110 patients were required by the protocol, inclusion had to be stopped after reaching 38 (34.5%) due to insufficient recruitment. There were 9, 10 and 13 relapses between baseline and weeks 16, 24 and 52, respectively. Relapses till week 16 tended to be more common in patients with PD score >0 at baseline than in those without [9/30 (30.0%) vs. 0/7 (0%), p=0.160)]. Similar observations were made for weeks 24 [9/30 (30.0%) vs. 1/7 (14.3%), p=0.647)] and 52 [12/30 (40.0%) vs. 1/7 (14.3%), p=0.383)]. Kaplan-Meier plot indicates the relapse-free survival in patients with and without PD+ synovitis at baseline (Figure 1).

Figure 1.

Kaplan-Meier analysis of relapses according to presence or absence of Power Doppler (PD) synovitis at baseline.

PD scores were higher at the time of relapse as compared to the preceding visits [mean difference in the PD score 3.2 (±4.5) points, p=0.034]. PD scores were also higher at visits preceding a relapse [mean 5.6 (±3.9), n=13] as compared to the mean PD score across all visits of patients without a relapse [mean 2.0 (±1.5), n=24, p=0.003, respectively]. There were trends towards a higher mean baseline PD score in patients who had a relapse between baseline and week 16 as compared to those who remained in remission (5.2 ± 5.8 vs. 2.3 ± 3.0, p=0.079). Similar observations were made for relapses until weeks 24 and 52. No difference was observed comparing mean residual swollen or tender joint counts at baseline between patients with and without a relapse. There were 9 adverse events. All of them were mild to moderate.

Conclusion

In RA patients in strict clinical remission, PD assessment at baseline but not clinical joint count could help identify patients who will relapse after the cessation of a bDMARD. Due to insufficient recruitment and limited power of the present trial, however, no definitive conclusion can be made.

References

[1]Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis 2020;79:685-99.

[2]Naredo E, Valor L, De la Torre I, et al. Predictive value of Doppler ultrasound-detected synovitis in relation to failed tapering of biologic therapy in patients with rheumatoid arthritis. Rheumatology (Oxford) 2015;54:1408–14.

[3]Lamers-Karnebeek FB, Luime JJ, Cate DFT, et al. Limited value for ultrasonography in predicting flare in rheumatoid arthritis patients with low disease activity stopping TNF inhibitors. Rheumatology (Oxford) 2017;56:1560–5.

[4]Terslev L, Brahe CH, Hetland ML, et al. Doppler ultrasound predicts successful discontinuation of biological DMARDs in rheumatoid arthritis patients in clinical remission. Rheumatology (Oxford) 2021;60:5549–59.

Acknowledgements

This study was funded by a grant of the Austrian Research Fund (KLI514-B30)

Disclosure of Interests

Christian Dejaco Speakers bureau: Pfizer, AbbVie, MSD, Roche, BMS, UCB, Consultant of: Pfizer, AbbVie, MSD, Roche, BMS, UCB, Grant/research support from: Pfizer, Irina Gessl: None declared, Rusmir Husic Speakers bureau: MSD, Lilly und Abbvie, Thomas Deimel: None declared, Angelika Lackner: None declared, Gabriela Supp: None declared, Josef Hermann Speakers bureau: Novartis, Lilly, AbbVie, Janssen, Consultant of: GlaxoSmithKline, Otsuka Pharmaceutical Europe Ltd, Josef S. Smolen Speakers bureau: AbbVie, Amgen, AstraZeneca, Astro, Bristol-Myers Squibb, Celgene, Celltrion, Chugai, Gilead, ILTOO, Janssen, Lilly, Merck Sharp & Dohme, Novartis- Sandoz, Pfizer, Roche, Samsung, Sanofi, and UCB, Consultant of: AbbVie, Amgen, AstraZeneca, Astro, Bristol-Myers Squibb, Celgene, Celltrion, Chugai, Gilead, ILTOO, Janssen, Lilly, Merck Sharp & Dohme, Novartis- Sandoz, Pfizer, Roche, Samsung, Sanofi, and UCB, Grant/research support from: Abbvie, AstraZeneca, Lilly and Roche, Martin Stradner Speakers bureau: Eli Lilly, Pfizer, MSD, BMS, AbbVie, Janssen, Consultant of: Eli Lilly, AbbVie, Janssen, Daniel Aletaha Speakers bureau: Abbvie, Amgen, Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Consultant of: Abbvie, Amgen, Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Grant/research support from: Abbvie, Amgen, Lilly, Novartis, Roche, SoBi, Sanofi, Gerold Schwantzer: None declared, Peter Mandl Speakers bureau: AbbVie, Janssen and Novartis, Grant/research support from: AbbVie, BMS, Novartis, Janssen, MSD and UCB

AB0180 CLINICAL AND ULTRASOUND-BASED COMPOSITE DISEASE ACTIVITY INDICES AND RADIOGRAPHIC PROGRESSION IN RHEUMATOID ARTHRITIS

Background

Musculoskeletal ultrasound (US) has been reported to predict radiographic progression in rheumatoid arthritis (RA).

Objectives

To test the predictive value of composite disease activity indices (DAI) based on solely clinical as well as clinical and US (USDAI) information to predict radiographic progression in RA.

Methods

Data from the Swiss Clinical Quality Management (SCQM) database were extracted from patients with RA; USDAIs were created based on previous publications (1) (Table 1). In summary, the disease activity score in 28 joints (DAS28) and the simplified disease activity index (SDAI) were modified by supplementing or replacing the clinical swollen JC with joints showing signs of power Doppler (PD) and/or grey scale (GS) synovitis. Series with two standard x-rays of the hands (difference ≥ 183 days) and ≥1 visit with clinical and US data in between were analyzed. Progression was defined as an increase of ≥6.27 points of the Ratingen-Rau x-ray score. Receiver operating curve (ROC) analyses were used to assess predictive ability of every DAI for radiographic progression. As a subanalysis, ROCs using the median DAIs of series with ≥2 DAIs between two x-rays were run. Clinical DAS28/SDAIs were compared to their respective USDAI counterpart with the highest area under the curves (AUC).

Table 1.

Area under the curves (AUC) of receiver operating characteristic curves for the predictive value of the composite disease activity indices for radiographic progression. DAI disease activity index; DAS28, disease activity score for 28 joints; GS, grey scale; PD, power Doppler; SDAI, simplified disease activity index; SJC: swollen joint count; + positive

Disease activity indexesAll seriesSeries with ≥ 2 DAIs95% CI95% CIAUCLowerUpperAUCLowerUpperDAS28.58.52.58.62.45.78DAS28_GSSJC replaced by GS+ joints.56.49.56.62.44.80DAS28_PDSJC replaced by PD+ joints.60.53.60.63.46.81DAS28_GSPDSJC replaced by GS AND PD+ joints.57.50.57.62.44.80DAS28_plus_GSSJC supplemented by GS+ joints.57.50.57.62.44.8ßDAS28_plus_PDSJC supplemented by PD+ joints.59.52.59.61.43.79DAS28_plus_GSPDSJC supplemented by GS AND PD+ joints.57.50.57.62.44.79SDAI.57.50.57.48.26.70SDAI_GSSJC replaced by GS+ joints.53.46.53.47.23.71SDAI_PDSJC replaced by PD+ joints.58.52.58.51.27.75SDAI_GSPDSJC replaced by GS AND PD+ joints.53.46.53.47.23.71SDAI_plus_GSSJC supplemented by GS+ joints.54.47.54.47.23.70SDAI_plus_PDSJC supplemented by PD+ joints.58.51.58.48.25.72SDAI_plus_GSPDSJC supplemented by GS AND PD+ joints.54.47.54.46.23.70

Results

We included 649 series in 475 patients. Progression was observed in 84/649 (12.9%) series. Mean difference between the x-rays was 27.6±18.0 months. Mean age was 56.3±12.7 years, 474/649 (73%) series were from female patients. There was no significant difference between the AUC of the ROC of SDAI vs. SDAI_PD (p=0.19) nor between DAS28 vs. DAS28_PD: (p=0.17) (Figure 1A, Table 1). Similarly, when analyzing only series with ≥2 DAIs (143 series) we observed no difference between the AUC of the ROC of SDAI vs. SDAI-PD (p=0.28) nor between that of DAS28 vs. DAS28_PD (p=0.23) (Figure 1B, Table 1).

Figure 1.

Receiver operating characteristic (ROC) curve of clinical and ultrasound-based composite disease activity indices (A) overall and (B) for the subgroup with series with ≥ disease activity indices. DAS, disease activity score; GS, grey scale; PD, power Doppler; SDAI, simplified disease activity index;

Conclusion

The predictability of radiographic progression by disease activity measures was generally limited. The composite USDAIs containing sonographic JC were not superior for predicting radiographic progression compared to their clinical counterparts although there was a trend for higher predictive value for indices containing PD.

References

[1]Mandl P, Balint P, Brault Y et al. Arthritis Care Res 2013;65:879-87.

Disclosure of Interests

Irina Gessl: None declared, Thomas Deimel: None declared, Paul Studenic: None declared, Giorgio Tamborrini: None declared, Pascal Zufferey: None declared, Daniel Aletaha Speakers bureau: Abbvie, Amgen, Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Grant/research support from: Abbvie, Amgen, Lilly, Novartis, Roche, SoBi, Sanofi, Burkhard Moeller: None declared, Peter Mandl Speakers bureau: from AbbVie, Janssen and Novartis, Grant/research support from: from AbbVie, BMS, Novartis, Janssen, MSD and UCB

AB1177 SEXUALITY, FAMILY PLANNING AND MENTAL HEALTH AMONG REPRODUCTIVE-AGE WOMEN WITH RHEUMATIC DISEASE DURING THE COVID-19 PANDEMIC

Background

Women with rheumatic disease are more likely to suffer from sexual dysfunction, infertility, depression, and anxiety. The pandemic may have affected these constraints.

Objectives

To investigate the effect of the Covid-19 pandemic on sexuality, family planning and mental health in a sample of women with rheumatic disease.

Methods

Women aged 18-50 with a rheumatic disease and women in an age-matched healthy control group received questionnaires featuring: 1) demographic information, sexual frequency, family planning; 2) the Female Sexual Function Index (FSFI); 3) the Depression, Anxiety and Stress Scale (DASS-21); and 4) the Coronavirus Anxiety Scale (CAS). Recruitment took place 3/21-12/21. Patients with rheumatic conditions were recruited at the Vienna University Clinic (AKH) and the control group through social media. Parameters were compared between the patients and the healthy control group, and with data on sexuality from women with rheumatic disease from 2019.

Results

A preliminary analysis was conducted with 83 patients with rheumatic disease and 124 healthy controls. The rheumatic disease group exhibited lower levels of stress (6.46 vs. 8.36 p<0.01) and Coronavirus Anxiety (6.27 vs 7.50 p<0.01) than the control group and was less likely to report that the pandemic led to a reduction of their sexual frequency (p<0.01). The control group cited “stress” frequently the decrease of sexual frequency. The FSFI analysis revealed that patients with rheumatic disease experienced higher levels of pain (p<0.001) during sex than the control group but were more satisfied with their relationships (p<0.05). In comparison to 58 patients with rheumatic conditions, whose data was collected in 2019, the 2021 cohort reported reduced FSFI values in the domains of desire (p<0.01), arousal (p<0.05), lubrication (p<0.05), and orgasms (p<0.01).

Conclusion

Consistent with research on female sexuality during the pandemic among healthy women, we found that patients with rheumatic conditions reported lower FSFI values in 2021, in comparison to 2019. Our finding that the pandemic had less impact on the patient group than a healthy control group, is consistent with research on MS and IBD patients, who showed surprising resilience in the face of the Covid-19 pandemic.

Disclosure of Interests

None declared

POS1243 ACCELERATED WANING OF PROTECTIVE IMMUNITY AFTER SARS-CoV-2 mRNA VACCINATION IN PATIENTS TREATED WITH BIOLOGICAL AND TARGETED SYNTHETIC DISEASE MODIFYING ANTIRHEUMATIC DRUGS

Background

Little is known about the duration of humoral antibody levels after two SARS-CoV-2 mRNA vaccinations in patients with immunosuppression. During this ongoing global epidemic, it is of essential interest to gather information about the time of protection after initial immunization in the vulnerable patients receiving either conventional synthetic disease modifying antirheumatic drugs (csDMARD) or biological/ targeted drugs (b/tsDMARDs).

Objectives

In this study we compared the antibody level development after vaccination and after six months in patients with inflammatory arthritis, inflammatory bowel disease (IBD) and healthy controls. Furthermore, we assessed factors affecting the quality and quantity of the humoral response.

Methods

We enrolled 85 healthy controls (HC), 75 patients with rheumatoid arthritis and spondyloarthritis and 41 patients suffering from IBD. Patients treated with B-cell depleting therapies were excluded from this study. Binding antibody units were measured after vaccination and 6 or more months. Neutralizing antibodies were measured after 6 months. Multivariate regression analyses analyzing factors associated with low titers after 6 months was performed.

Results

We found that patients with inflammatory arthritis or IBD showed reduced anti-SARS-CoV-2 S titers compared to HC. When we stratified for therapies, we found that patients receiving conventional synthetic disease modifying antirheumatic dugs (csDMARDs) had comparable anti-SARS-CoV-2 S titers to HC. In contrast, patients receiving biological or targeted synthetic (b/tsDMARDs) showed reduced anti-SARS-CoV-2 Igs as well as neutralizing antibody titers compared with healthy controls (HC) or patients receiving conventional synthetic (cs)DMARDs. We further show that anti-SARS-CoV-2 titers declined more rapidly in patients receiving b/tsDMARDs compared to HC, leading to a 50 percent reduction in vaccination-associated protection time in patients receiving b/tsDMARDs when compared to those receiving csDMARDs or even HC. In multivariate regression analyses, we found that in addition to the type of treatment, also age as well as corticosteroid use were associated with reduced anti-SARS-CoV-2 S titers.

Conclusion

Patients under ongoing b/tsDMARDs therapy exposed an accelerated waning of anti-SARS-CoV-2 S titers and therefore decreased immunity and protection against severe Covid-19 infections over time. These results may lead to more personalized approaches for further vaccination strategies in this group of immunosuppressed patients.

Figure 1.

A, Analysis of anti-SARS-CoV-2 S titers 6 months after the second vaccination in patients with inflammatory arthritis, inflammatory bowel disease and HC (** p ≤ 0.01; *** p ≤ 0.005, **** p ≤ 0.001). B, Determination of neutralizing antibody activity in sera of HC and patients with inflammatory arthritis receiving the indicated therapies.

Disclosure of Interests

Selma Tobudic: None declared, Elisabeth Simader Grant/research support from: Pfizer, Bristol-Myers Squibb, Thomas Deimel: None declared, Peter Mandl Speakers bureau: AbbVie, Janssen, Bristol-Myers Squibb, Merck Sharp & Dohme, Celgene, Novartis, Pfizer, Roche, Sanofi, UCB, Consultant of: Novartis, Celgene, Grant/research support from: Novartis, Celgene, Abbvie, Roche, Bristol-Myers Squibb

, Helmuth Haslacher Grant/research support from: Glock Health, BlueSky Immunotherapies and Neutrolis;, Thomas Perkmann: None declared, Lisa Schneider: None declared, Thomas Nothnagl: None declared, Helga Lechner-Radner: None declared, Florian Winkler: None declared, Heinz Burgmann Speakers bureau: Shionogi, Pfizer, MSD, Paid instructor for: Valneva, MSD, Gilead, Consultant of: from MSD, Pfizer, Takeda, Gilead, Karin Stiasny Grant/research support from: Pfizer, Gottfried Novacek: None declared, Walter Reinisch: None declared, Daniel Aletaha Speakers bureau: Abbvie, Amgen, Lilly, Novartis, Roche, SoBi, Sanofi

Merck, Pfizer, Roche, Sandoz, Stefan Winkler: None declared, Stephan Blüml Speakers bureau: Abbvie, personal fees from Novartis

OP0168 DEVELOPMENT OF AN ULTRASOUND SCORING SYSTEM FOR CPPD EXTENT: RESULTS FROM A DELPHI PROCESS AND WEB-RELIABILITY EXERCISE BY THE OMERACT US WORKING GROUP

Background

Ultrasound (US) has proven to be an excellent imaging technique for detecting calcium pyrophosphate (CPP) deposition disease (CPPD); it is also widely available and inexpensive and can be performed during the clinic visit making it the preferred imaging modality for many rheumatologists. However, no validated grading systems have yet been developed allowing for a quantification of the extent of crystal deposition in CPPD.

Objectives

The aim of this study was to develop a scoring system for the quantification of CPP deposition at a patient level according to the OMERACT framework.

Methods

As part of the OMERACT methodology, we performed a systematic literature review (SLR) and meta-analysis aimed to estimate the prevalence of CPP deposition in peripheral joints by imaging, in order to identify relevant joints for CPPD monitoring. A preliminary survey was also circulated among the members of the OMERACT US – CPPD working group to collect their own suggestions according to their personal experience. Subsequently, a Delphi survey was prepared and circulated between members of the group, including statements that reflected both the results of the SLR and of the preliminary survey. In total, 32 statements were generated regarding the type of scoring for single structures, the sites to be included, the final scoring at patient level, and the scanning technique. Participants were asked to reply on a 5-point Likert scale (1, strongly disagree to 5, strongly agree) and agreement was achieved when 4 and 5 grades reached 75% or more of concordance. In case of disagreement, new statements were proposed according to the members’ suggestions and circulated for voting in a subsequent round. After agreement of a scoring system, the validation process began. Two rounds of a web-based exercise on static images were conducted on 120 images representing equally all sites under investigation and all degrees of crystal deposition, to assess the intra- and inter-reader reliability of the new scoring system. Representative images of the scoring system were visible throughout the entire exercise in order to facilitate the scoring of the lesions.

Results

Three Delphi rounds were needed to reach agreement on all items. 32/41 members of the OMERACT US-CPPD working group replied in the first round, 26/32 in the second, and 25/26 in the third round. Twenty statements were approved in the first round, 3 in the second, and 3 in the third round. Only the knees (menisci and hyaline cartilage) and the triangular fibrocartilage of the wrist were included in the final score, using a four-grade system (0-3). It was decided that each anatomical structure should be scored separately and then also summed in order to define the joint score. The sum of the assessed joints was the total score at patient level. The final scoring system with the definitions and the relative technical notes is represented in Figure 1. 33/41 members participated to the reliability exercise. The inter-reader reliability of the scoring was substantial (kappa of 0.72), and the intra-reader reliability was almost perfect (kappa of 0.82).

Conclusion

This is the first study for developing a scoring system for the extent of CPP crystal deposition in patients with CPPD. The scoring system demonstrated to be reliable in static images. The next step of the validation process is to assess the reliability of the scoring system in a patient-based exercise. This study represents a fundamental step in the OMERACT process of validating US as an outcome measure instrument, and above proposed scoring system will hopefully provide a useful tool for clinical practice and research.

Disclosure of Interests

None declared

AB0205 TENDERNESS AND RADIOGRAPHIC PROGRESSION IN RHEUMATOID ARTHRITIS AND PSORIATIC ARTHRITIS

Background

In inflammatory arthritis swelling is regarded as a sign of synovitis and is associated with radiographic progression. However, the association of tenderness with radiographic progression is not clear.

Objectives

To assess the predictive value of tenderness alone and with consideration of sonographic signs for synovitis, disease duration and baseline radiographic damage for subsequent radiographic progression in rheumatoid arthritis (RA) and psoriatic arthritis (PsA).

Methods

Clinical and sonographic (grey scale (GS) and power Doppler (PD)) examination of 22 joints of the hand were performed cross-sectionally in consecutive patients with RA and PsA with at least one tender joint. Radiographs were scored for erosions and joint space narrowing (JSN) at inclusion and radiographic progression of each joint was assessed after 2 years. The impact of tenderness on progression was analyzed in non-swollen joints for RA and PsA separately with logistic regression analyses. As a second step, the association of PD, GS, disease duration, C-reactive protein, baseline erosions and JSN and global joint counts with subsequent structural damage was assessed using univariate logistic regression in tender non-swollen joints again on the joint level.

Results

We included 1207 joints in 54 RA patients and 396 joints in 18 PsA patients. Tenderness was associated with subsequent radiographic progression in non-swollen joints in PsA (OR 3.44, 95%CI 1.78-6.62, p<0.01) but not in RA (OR 1.60, 95% CI 0.99-2.48, p=0.55) (Figure 1). In tender non-swollen joints in RA patients, PD (OR 3.74, 95% CI 1.10-13.30, p=0.04) and baseline erosions (OR 4.42, 95% CI 1.22-15.95, p=0.02) had a significant impact on radiographic progression. In PsA patients, PD (OR 8.46, 95% CI 1.72-41.72, p<0.01), baseline erosions (OR 6.71, 95% CI 1.43-31.39, p=0.02), baseline JSN (OR 7.27, 95% CI 1.47-35.89, p=0.02) and SJC (OR 1.26, 95%CI 1.07-1.48, p<0.01) were associated with radiographic progression.

Figure 1.

The proportion of joints with progression in tender non-swollen and non-tender non-swollen joints in patients with rheumatoid and psoriatic arthritis; NTNS: non-tender non-swollen; TNS: tender non-swollen

Conclusion

Our findings indicate that tenderness in non-swollen joints is associated with subsequent radiographic progression in PsA, while in RA it is a risk factor for radiographic progression only in the presence of additional factors, such as sonographic signs for synovitis.

Disclosure of Interests

Irina Gessl: None declared, Mihaela Popescu: None declared, Gabriela Supp: None declared, Thomas Deimel: None declared, Paul Studenic: None declared, Martina Durechova: None declared, Michael Zauner: None declared, Josef S. Smolen Speakers bureau: AbbVie, Amgen, AstraZeneca, Astro, Bristol-Myers Squibb, Celgene, Celltrion, Chugai, Gilead, ILTOO, Janssen, Lilly, Merck Sharp & Dohme, Novartis- Sandoz, Pfizer, Roche, Samsung, Sanofi, and UCB, Grant/research support from: Abbvie, AstraZeneca, Lilly and Roche, Daniel Aletaha Speakers bureau: Abbvie, Amgen, Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Grant/research support from: Abbvie, Amgen, Lilly, Novartis, Roche, SoBi, Sanofi

, Peter Mandl Speakers bureau: from AbbVie, Janssen and Novartis, Grant/research support from: from AbbVie, BMS, Novartis, Janssen, MSD and UCB;

OP0260 RESPONSIVENESS OF A COMBINED POWER DOPPLER AND GREYSCALE ULTRASOUND SCORE FOR ASSESSING SYNOVITIS AT JOINT LEVEL IN PSORIATIC ARTHRITIS PATIENTS WITH INADEQUATE RESPONSE TO csDMARDs: DATA FROM THE ULTIMATE TRIAL

Background

Power Doppler ultrasound (PDUS) is a sensitive non-invasive imaging tool that allows the visualisation of articular and periarticular inflammation in patients with psoriatic arthritis (PsA).1 ULTIMATE (NCT02662985) was the first large randomised clinical trial that showed the responsiveness of the Global OMERACT-EULAR ultrasound synovitis score (GLOESS) in PsA and confirmed the rapid and continued benefits of secukinumab through 52 weeks.2,3

Objectives

To report the distribution of ultrasound-detected synovitis at joint level, by degree of severity at baseline and over time, and the contribution of each core component of GLOESS, synovial hypertrophy (SH) by greyscale (GS; B-mode) and power Doppler (PD) signal, to responsiveness.3

Methods

This was a 52-week study with a 12-week double-blind, placebo-controlled treatment period followed by a 12-week open-label period and a 6-month open-label extension secukinumab treatment period.3 The number of joints with synovitis measured by GLOESS2 was assessed up to Week 52. The assessments included distribution of synovitis based on composite PDUS score across 24 pairs of joints (with worse score of the pair of the joints used) by grade of severity (0-3) and change from baseline to Week 52 in each core component of GLOESS.3-5 Data are presented as observed.

Results

A total of 166 patients (mean age, 46.7 years; males, 45.2%) were enrolled, of which 90% (75/83) of secukinumab and 83% (69/83) of placebo-secukinumab participants completed 52 weeks. The mean (SD) number of PDUS detected synovitis at baseline was 9.2 (4.9) and 10.2 (5.2) in the secukinumab and placebo group, respectively. The most frequent locations with synovitis at baseline were: wrist, metatarsophalangeal (MTP), knees and metacarpophalangeal (MCP) joints (Table 1). An early and continued improvement in GLOESS was observed in both secukinumab and placebo-secukinumab groups after switching to active therapy, as previously reported at Week 12 and through Week 52.2,3 Among the two core components of GLOESS, SH was mainly responsible for the change in GLOESS from baseline to Week 52, in contrast with PD signal in this dataset. The distribution of synovitis by grade of severity showed that MTP joints, wrist, knee, MCP1/2 and tibiotalar joints mostly contributed to the composite PDUS at Week 12 (Figure 1). Similar patterns were observed through 52 weeks.

Table 1.

Proportion of patients with PDUS detected synovitis at baseline*

Synovitis joint, data presented as n (%)Secukinumab (N=83)Placebo (N=83)Wrist66 (80)66 (80)MTP256 (68)65 (78)MTP158 (70)60 (72)MTP352 (63)60 (72)MTP446 (55)59 (71)Knee50 (60)47 (57.)MCP136 (43)52 (63)MCP235 (42)41 (49)MTP530 (36)41 (49)

*Data for top nine pairs of joints with most frequently detected power Doppler ultrasound (PDUS) synovitis are presented here. Synovitis was scored by a OMERACT-EULAR synovitis composite score >0 for each paired joint (irrespective of right or left side). The OMERACT-EULAR composite PDUS score (for individual joints) ranged from 0 to 3 and was composed of the two core components synovial hypertrophy and power Doppler.

N, total number of randomised patients; n, number of evaluable patients

Conclusion

The distribution of synovitis at baseline reflected a predominance of small joints (feet and hands) and large joints (wrist and knee) and were mostly responsive to secukinumab over time in the ULTIMATE trial. Synovial hypertrophy was the most responsive core component of GLOESS driving an early and continued reduction of synovitis with secukinumab through Week 52. This finding could be useful to select a restricted number of joints in future ultrasound trials in PsA.

References

[1]D’Agostino MA and Coates LC. J Rheumatol. 2019;46:337–9.

[2]D’Agostino MA et al. Arthritis Rheumatol. 2021;73(10).

[3]D’Agostino MA, et al. Rheumatology (Oxford) 2021;keab628.

[4]D’Agostino MA and Coates LC. RMD Open 2017;3:e000428.

[5]Uson J, et al. Rheumatol Clin. 2018;14:27–35.

Disclosure of Interests

Maria-Antonietta D’Agostino Speakers bureau: Sanofi, Novartis, BMS, Janssen, Celgene, Roche, AbbVie, UCB, and Eli Lilly, Consultant of: Sanofi, Novartis, BMS, Janssen, Celgene, Roche, AbbVie, UCB, and Eli Lilly, Maarten Boers Consultant of: Novartis, Corine Gaillez Shareholder of: Novartis and BMS, Employee of: Novartis, Carlos Gamez: None declared, LUCIO VENTURA: None declared, Javier Rosa Speakers bureau: Abbvie, Pfizer, Lilly, Janssen, Novartis and BMS, Ilaria Padovano: None declared, Peter Mandl Speakers bureau: AbbVie, BMS, Celgene, Janssen, Lilly, MSD, Novartis, Roche and UCB, Grant/research support from: AbbVie, BMS, Celgene, Janssen, Lilly, MSD, Novartis, Roche and UCB, Arnd Kleyer Speakers bureau: Abbvie, Lilly, Novartis, MEDAC; Janssen, Consultant of: Abbvie, Lilly, UCB, Novartis, BMS, Sanofi, Galapagos, Catherine Bakewell Speakers bureau: AbbVie, Novartis, Pfizer, Janssen, UCB, and Sanofi Genzyme/Regeneron, Consultant of: AbbVie, Novartis, Pfizer, Janssen, UCB, and Sanofi Genzyme/Regeneron, Weibin Bao Shareholder of: Novartis, Employee of: Novartis, Punit Goyanka Employee of: Novartis, Philip G Conaghan Speakers bureau: AbbVie, Amgen, AstraZeneca, Eli Lilly, Galapagos, Gilead, Novartis, Pfizer and UCB, Consultant of: AbbVie, Amgen, AstraZeneca, Eli Lilly, Galapagos, Gilead, Novartis, Pfizer and UCB, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Lilly, Novartis, Roche and UCB

OP0291 SCORING STRUCTURAL DAMAGE IN RHEUMATOID ARTHRITIS BY ULTRASOUND: RESULTS FROM A DELPHI PROCESS AND WEB-RELIABILITY EXERCISE BY THE OMERACT US WORKING GROUP

Background

Structural damage in rheumatoid arthritis (RA) includes bone erosion, cartilage change, and joint malalignment; historically evaluated with conventional radiography. Ultrasound (US) has been shown to be a valid tool for evaluating both cartilage change and bone erosion.

Objectives

To obtain agreement on definitions and develop semiquantitative scoring systems for assessing structural damage by US and to validate these in a web-based reliability exercise.

Methods

A Delphi survey of statements was prepared by an OMERACT US Working Group task force (USWG) based on a previously published systematic literature review (1) and circulated between group members, including definitions on normal US appearance of joint components, definitions of elementary lesions and scoring systems for bone erosions and joint malalignment. Definitions and a US scoring system for scoring cartilage change were recently developed and validated by the USWG (2) After agreement was achieved (≥75% of grades 4-5 on 1-5 Likert scale) on the statements, still images of metacarpophalangeal and proximal interphalangeal joints 2-5 in healthy controls and in RA patients with varying degrees of pathology were acquired by the USWG members. A dataset of 100 anonymized images, representing various grades of the 3 components of structural damage was created and utilized in 2 rounds of a web-based exercise. Intra- and inter-reader reliability of the scoring systems was assessed by kappa statistics.

Results

19 USWG members needed 4 Delphi rounds to reach agreement on a total of 9 statements. 4/12 statements were approved in the first, 2/6 in the second, 1/5 in the third and 2/2 in the fourth round. Final scoring systems and representative images are shown in Table 1 & Figure 1. 22 members participated in the web-based reliability exercise. The intra-reader reliability was almost perfect for bone erosion (kappa: 0.87) and cartilage change (kappa: 0.83) and substantial for malalignment (kappa of 0.72). The inter-reader reliability was almost perfect for bone erosion (kappa: 0.85), and substantial for cartilage change (kappa: 0.79) and malalignment (0.62).

Table 1.

Final definitions of scoring systems of elementary lesions of structural damage in rheumatoid arthritis

AgreementBone erosionA 4-grade semiquantitative scoring system can be used to score erosions as follows: grade 0. intact cortical bone; grade 1. single small erosion (diameter: ≤2mm); grade 2. single large erosion (diameter: >2mm) or 2 small erosions; grade 3. 2 large erosions or ≥3 erosions, regardless of size. Both longitudinal and transverse scans should be considered, and the largest measure chosen for each erosion.100%Cartilage changeA 3-grade semiquantitative scoring system can be used to grade hyaline cartilage change as follows: grade 0. normal cartilage; grade 1. minimal change: focal thinning or incomplete loss of cartilage; grade 2. severe change: diffuse thinning or complete loss of cartilage.80% (2)MalalignmentA 3-grade semiquantitative scoring system can be used to grade malalignment as follows: 0. normal alignment; 1. subluxation or partial dislocation, where the two bone endings are malaligned so that one bone ending is dislocated from its normal position, but still within the articulation; 2. luxation or total dislocation, where the luxated bone ending moves beyond the articulation and the opposing bone ending. Bone position may be compared with a contralateral or similar intact joint if available.94%Figure 1.

Representative images of the scoring systems for bone erosion (A), cartilage change (B) and malalignment (C)

Conclusion

This first attempt to create a composite US instrument based on scoring systems encompassing all aspects of structural damage, demonstrates that US is a reliable tool for evaluating and scoring bone erosion, cartilage change and malalignment in the finger joints of RA patients.

References

[1]Gessl I, et al. Semin Arthritis Rheum. 2021 Jun;51(3):627-39.

[2]Mandl P, et al. Rheumatology (Oxford). 2019 Oct 1;58(10):1802-11.

Disclosure of Interests

Peter Mandl Speakers bureau: AbbVie, Janssen, Lilly, Novartis, Consultant of: AbbVie, Janssen, Lilly, Novartis, Grant/research support from: AbbVie, BMS, Novartis, Janssen, Lilly, MSD, UCB, Irina Gessl: None declared, Georgios Filippou: None declared, Silvia Sirotti: None declared, Lene Terslev Speakers bureau: Novartis, Pfizer, UCB, Janssen, GE, Carlos Pineda: None declared, Helen Keen Speakers bureau: Roche, AbbVie, Janssen, Consultant of: Sanofi, Marina Backhaus: None declared, David Andrew Bong: None declared, Edoardo Cipolletta: None declared, PAZ COLLADO: None declared, Christian Dejaco Speakers bureau: Roche, AbbVie, Sanofi, Lilly, Pfizer, Novartis, Janssen, Galapagos, Consultant of: Roche, AbbVie, Sanofi, Lilly, Pfizer, Novartis, Janssen, Galapagos, Andrea Delle Sedie Speakers bureau: Abbvie, Amgen, Lilly, MSD, Novartis, UCB, Paid instructor for: Abbvie, Amgen, Lilly, MSD, Novartis, UCB, Consultant of: Abbvie, Amgen, Lilly, MSD, Novartis, UCB, Christina Duftner: None declared, Hilde Berner Hammer: None declared, Annamaria Iagnocco: None declared, Zunaid Karim: None declared, Ingrid Möller Speakers bureau: Bristol-Myers Squibb, Ibsa, Pfizer, Galapagos, Esperanza Naredo Speakers bureau: Abbvie, Pfizer, Lilly, Novartis, Janssen, Celgene GmbH, Paid instructor for: Novartis, Consultant of: Novartis, Lilly, Grant/research support from: Lilly, Pfizer, Wolfgang A. Schmidt: None declared, Marcin Szkudlarek: None declared, Giorgio Tamborrini: None declared, Priscilla C Wong: None declared, Emilio Filippucci Speakers bureau: AbbVie, Amgen, Bristol -Myers Squibb, Janssen-Cilag, Lilly, Novartis, Pfizer, Roche, Union Chimique Belge Pharma, Peter Balint Speakers bureau: Abbvie, Janssen, Lilly, Novartis, Maria-Antonietta D’Agostino: None declared

OP0294 REDUCED JOINT SYNOVITIS ASSESSMENT VERSUS THE GLOBAL EULAR OMERACT SYNOVITIS SCORE (GLOESS) TO PREDICT THE RESPONSE TO SECUKINUMAB IN PATIENTS WITH ACTIVE PSORIATIC ARTHRITIS AND INADEQUATE RESPONSE TO CONVENTIONAL DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS: EXPLORATORY RESULTS FROM THE ULTIMATE TRIAL

Background

The combined use of B-mode ultrasound (US) and Power Doppler (PD; combination termed as PDUS) allows visualisation of morphological and pathophysiological changes of the synovium. ULTIMATE (NCT02662985) was the first large, randomised, double-blind, placebo-controlled PDUS phase IIIb study in psoriatic arthritis (PsA), to demonstrate that Global OMERACT EULAR Synovitis Score (GLOESS), a US score at patient level, was sensitive to detect the early and continuous decrease in synovitis in a multicenter setting using different US devices and examiners.1 However, the US assessment for GLOESS was time-consuming owing to the number of joints assessed.

Objectives

To investigate the value of various reduced joint sets to predict the validated GLOESS score.

Methods

ULTIMATE was a 52-week study with a 12-week double-blind, placebo-controlled period followed by 12-week open-label (OL) treatment and 6-month OL extension period.1 In the ULTIMATE trial, GLOESS for the 24 paired joints was calculated, with a potential score ranging between 0 to 144.1 A Spearman’s rank correlation matrix and a Cluster Image Map were constructed to identify highly correlated joint clusters based on the composite PDUS scores. Based on the different approaches (best correlation, model optimization, etc.), representative joints were then selected from each group, which yielded several corresponding combinations of joints. Linear models were developed with these reduced joint sets as predictors of GLOESS, using data from 60% of patients randomly selected from the ULTIMATE study. The remaining 40% data were used for model validation and diagnostics.

Results

Five models were established with reduced pairs of joint sets (9–13 pairs). The joints included in each linear model are summarized in Table 1. All five models of reduced joint sets showed high correlation with GLOESS score of R2 ~ 0.95. Figure 1 depicts all the 5 models of reduced joint sets for PDUS-detected synovitis versus the actual GLOESS in secukinumab and placebo-secukinumab groups, with modified GLOESS scores using reduced PDUS joint sets demonstrating changes very close to that of validated GLOESS.

Table 1.

Joints included across five linear models, indicated by green shading

Joint pairsModel 1 (N=9)Model 2 (N=9)Model 3 (N=9)Model 4 (N=13)Model 5 (N=12)ElbowKneeMTP2WristMCP1DIP4MTP4MCP2MCP4MCP5PIP3PIP4PIP1, PIP5DIP2DIP3, DIP5MTP1MTP5ShoulderTibiotalar

N, number of joint pairs used in model. DIP, distal interphalangeal; MCP, metacarpophalangeal; MTP, metatarsophalangeal;

PIP, proximal interphalangeal

Figure 1.

Reduced set of joints synovitis score vs GLOESS score

Conclusion

All models of reduced joint sets for PDUS-detected synovitis predicted GLOESS well. The next steps will be to document responsiveness and ability to discriminate between active and placebo treatment.

References

[1]D’Agostino MA, et al. Rheumatology (Oxford) 2021;keab628.

Disclosure of Interests

Maria-Antonietta D’Agostino Speakers bureau: AbbVie, BMS, Celgene, Eli Lilly, Janssen, Novartis, Roche, Sanofi, and UCB, Consultant of: AbbVie, BMS, Celgene, Eli Lilly, Janssen, Novartis, Roche, Sanofi, and UCB, Maarten Boers Consultant of: BMS, GSK, Novartis, Pfizer, Consultant of: BMS, GSK, Novartis and Pfizer, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Lilly, Novartis, Roche and UCB, Philip G Conaghan Speakers bureau: AbbVie, AstraZeneca, BMS, Eli Lilly, Galapagos, Gilead, Novartis and Pfizer, Consultant of: AbbVie, AstraZeneca, BMS, Eli Lilly, Galapagos, Gilead, Novartis and Pfizer, Esperanza Naredo Speakers bureau: AbbVie, BMS, Celgene GmbH, Janssen, Lilly, Novartis, Pfizer, Roche, UCB, Grant/research support from: Honoraria for clinical trials from Abbvie, BMS and Novartis; Research Grants from Lilly, Peter Mandl Speakers bureau: AbbVie, BMS, Celgene, Janssen, Lilly, MSD, Novartis, Roche and UCB., Grant/research support from: AbbVie, BMS, Celgene, Janssen, Lilly, MSD, Novartis, Roche and UCB., Philippe Carron Speakers bureau: AbbVie, Bristol Myers Squibb, Celgene Corporation, Eli Lilly, Gilead, Merck Sharp Dohme, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Bristol Myers Squibb, Celgene Corporation, Eli Lilly, Gilead, Merck Sharp Dohme, Novartis, Pfizer, and UCB, Grant/research support from: Merck Sharp Dohme, Pfizer and UCB, Marina Backhaus Speakers bureau: BMS, Gilead, Jonsson, MSD, Novartis, Pfizer, Roche and UCB, Consultant of: BMS, Gilead, Jonsson, MSD, Novartis, Pfizer, Roche, UCB, Grant/research support from: BMS, Gilead, Jonsson, MSD, Novartis, Pfizer, Roche, UCB, Alejandra López-Rodríguez Speakers bureau: Eli Lilly, GSK, Janssen, Novartis, Roche and UCB, Consultant of: Eli Lilly, GSK, Janssen, Novartis, Roche and UCB, Petra Hanova: None declared, Punit Goyanka Employee of: Novartis, Braja Gopal Sahoo Employee of: Novartis, Corine Gaillez Shareholder of: Shareholder of Novartis and BMS, Employee of: Novartis, Weibin Bao Employee of: Novartis

POS1141 ASSESSING RELEVANT JOINTS FOR MONITORING CPPD DISEASE: A SYSTEMATIC LITERATURE REVIEW OF IMAGING TECHNIQUES BY THE OMERACT ULTRASOUND – CPPD SUBGROUP

Background:

Imaging has been extensively used for the Calcium Pyrophosphate Deposition Disease (CPPD) diagnosis but the prevalence of joint calcifications at imaging in CPPD patients has not been thoroughly assessed.

Objectives:

This systematic literature review (SLR) is aimed to estimate the prevalence of calcium crystal deposition in peripheral joints by imaging in suspected or definite CPPD patients to establish relevant joints for CPPD monitoring

Methods:

After defining PICOs, Pubmed and Embase were searched from inception to October 2020 for identifying studies that evaluated the use of Conventional Radiography (CR), Ultrasound (US), Computed Tomography (CT) and Dual Energy Computed Tomography (DECT) in detecting calcifications at peripheral joints in patients with defined or probable CPPD. Search strategies based on MeSH terms and free text were applied. Six reviewers independently screened titles and abstracts, eligible article full texts were evaluated for inclusion and data extraction.

Results:

The SLR identified 1149 manuscripts. 524 papers entered in the full text evaluation and 181 articles were finally included. Considering excluded abstracts and full texts, 23 and 17 were excluded as duplicate, 156 and 9 for language, 171 and 48 for population, 171 and 20 for intervention, 57 and 117 for outcome, 47 and 70 for study type and 76 for full text unavailability. Among included, 41 papers considered patients with definite CPPD with a total population of 1239 patients, 908 cases and 331 controls and 140 papers referred to patients with suspected CPPD with a total population of 26785 patients, 2896 affected by CPPD and 23889 controls. The results about all joints are summarized in the Table 1. In patients with definite diagnosis, knee and wrist are the joints with the highest prevalence of calcifications at all imaging types, followed by hip and acromion-clavicular joint while in patients with suspected CPPD, the knee is the most prevalent followed by the wrist, hip and ankle (only sites with more than 50 patients assessed considered). The hand joints are characterized by CPPD lowest prevalence at imaging. Bilateral imaging findings varies depending on the technique used, the site and the patient’s type.

Table 1.

Definite CPPD Diagnosis

KNEEWRISTHANDELBOWSHOULDERACHIPANKLEFOOTTMXRImaging positive cases/all cases330/584 57%214/409 52%43/158 27%54/212 25%65/249 26%37/84 44%140/293 48%30/255 12%15/59 25%0Cases positivebilaterally99/146 68%30/79 38%0/104/12 33%2/2 100%9/17 53%7/10 70%7/10 70%00USImaging positive cases/all cases155/252 62%86/118 75%4/42 9%2/2 100%0/304/30 13%47/80 59%30/255 12%15/59 25%0Cases positivebilaterally83/96 86%33/47 70%1/ 4 25%003/ 4 75%29/47 62%7/10 70%00CTImaging positive cases/all cases41/50 82%22/28 78%00000000Cases positivebilaterally27/30 90%000000000DECTImaging positive cases/all cases8/10 80%9/10 90%1/1 100%0000000Cases positivebilaterally001/1 100%0000000Suspected CPPD diagnosisKNEEWRISTHANDELBOWSHOULDERACHIPANKLEFOOTTMXRImaging positive cases/all cases1989/2442 81%549/1024 54%98/602 16%29/72 40%75/185 41%27/31 87%322/887 36%56/116 48%24/42 57%0Cases positive bilaterally611/1068 57%209/334 63%64/85 75%22/23 96%41/46 89%0/294/196 48%44/53 83%18/19 95%0USImaging positive cases/all cases241/261 93%125/185 68%2/39 5%1/1 100%4/12 33%02/2 100%27/78 35%8/37 22%0Cases positivebilaterally4/9 44%74/93 80%00000000CTImaging positive cases/all cases019/23 83%002/2 100%02/2 100%001/1 100%Cases positivebilaterally0000000001/1 100%DECTImaging positive cases/all cases1/1 100%2/2 100%00000000Cases positivebilaterally1/1 100%000000000

Table 1 For each joint, are summarized the ratio between positive joints and overall evaluated joints and the ratio between the joints positive bilaterally and overall joints evaluated bilaterally.

AC Acromion Clavicular, TM temporo mandibular

Conclusion:

According to the results of this SLR, knees and wrists could be the sentinel joints for CPPD detection by imaging.

Disclosure of Interests:

None declared.

POS0547 METEOROLOGICAL VARIABLES HAVE DIFFERENT INFLUENCE ON CORE MEASURES OF DISEASE ACTIVITY IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

The notion that weather conditions may influence the symptoms and course of rheumatic and musculoskeletal diseases goes back to ancient times. However, despite the seemingly obvious relationship, previous studies assessing how meteorological variables affect pain and disease activity have yielded contradictory results.

Objectives:

To evaluate whether meteorological variables influence disease activity in patients with rheumatoid arthritis (RA).

Methods:

We assessed correlations between clinical measures of disease activity (pain, patient global assessment [PGA], tender- and swollen 28 joint counts [TJC and SJC]) and individual meteorological variables: temperature (temp.), effective (eff.) temperature, saturation vapor pressure (SVP), absolute humidity (AH), relative humidity (RH), dew point, vapor pressure (VP) and precipitation. Assessments documented in the Care for Rheumatoid Arthritis database of our institution were matched with these meteorological variables on a daily basis for a period of 12 years between 2005 and 2017 and analyzed utilizing generalized estimating equations. Patients with <5 visits in the study period, those with <1 visit/quarter or with no pain (VAS=0) in ≥3 consecutive visits and those living outside of the catchment area were excluded. Patients were grouped into remission or low (≤11) vs. moderate or high (>11) disease activity based on the simplified disease activity index (SDAI).

Results:

A total of 461 patients with an average disease duration at first visit of 5.7±7.4 years, average age of 55.3±14.5 years and a mean SDAI of 22.1±12.7 were analyzed. Among patients with moderate or high disease activity, higher temp./eff. temp. and SVP were associated with lower pain, TJC and SJC (Figure 1); on the contrary, higher RH was associated with higher pain and higher SJC. In those in remission or low disease activity, higher RH, AH, VP or dew point were associated with lower PGA. Higher precipitation was associated with lower SJC.

Figure 1.

Association of meteorological parameters and clinical measures of disease activity. PGA: patient’s global assessment, SDAI: simplified disease activity index, SJC: swollen joint count, TJC: tender joint count. * p≤ 0.05, ** p≤ 0.01, *** p≤ 0.001

Conclusion:

In this large association study of meteorological parameters with RA, both temperature and humidity parameters were modestly inversely associated with pain, TJC and SJC.

Disclosure of Interests:

None declared

POS0197 RESPONSIVENESS OF ULTRASOUND SYNOVITIS AND CLINICAL OUTCOMES IN PSORIATIC ARTHRITIS TREATED WITH SECUKINUMAB: DATA FROM THE ULTIMATE TRIAL

Background:

Power Doppler ultrasonography is a sensitive imaging tool to assess synovitis in psoriatic arthritis (PsA).1,2 ULTIMATE (NCT02662985) is the first large, randomised, double-blind placebo-controlled phase IIIb study in PsA, using ultrasound to evaluate early response to secukinumab on synovitis. The use of the standardised and reliable global EULAR-OMERACT composite ultrasound synovitis score at patient level (GLOESS) as the primary endpoint showed the early and significant benefit of secukinumab vs. placebo on synovitis at week 12.3

Objectives:

To investigate the responsiveness and discriminative validity of GLOESS compared to clinical outcomes on joints at week 12 and report ultrasound and clinical efficacy data up to week 24.

Methods:

This is a 52-week study with a 12-week double-blind, placebo-controlled period followed by 12-week open-label (OL) and 6-month OL extension. All placebo patients were switched to secukinumab (300 or 150 mg) at week 12.3 Discriminative validity of GLOESS was analysed post-hoc: within-group responsiveness was assessed by comparing its standardised response mean (SRM) to that of core set of ACR response in the initial secukinumab group over 12 and 24 weeks. Mean change from baseline up to week 12 of GLOESS was determined with mixed-effect model repeated measures analysis (MMRM) and from week 12-24 as observed. 24 week efficacy outcomes included ACR responses, HAQ-DI, PASI response and resolution of dactylitis. These outcomes were exploratory and reported either according to non-responder imputation (ACR response), or as observed (HAQ-DI, PASI response and resolution of dactylitis).

Results:

Of 166 patients enrolled, a total of 155 patients (93%) completed 24 weeks of treatment (secukinumab, 79 patients 95%; placebo, 76 patients 92%). Mean change from baseline to week 24 in GLOESS was similar in the initial secukinumab and placebo-secukinumab groups. A continued improvement in GLOESS was observed in the secukinumab group, with catch-up improvement in the placebo group after switch to active therapy (Figure 1). Both SRM of GLOESS and ACR core components over 12 and 24 weeks were high (Table 1). Similar clinical response rates were reported for clinical joint count, skin, dactylitis and function at week 24 in secukinumab and placebo switchers groups (Table 1).

Conclusion:

These analyses highlight the responsiveness and high discriminative validity of GLOESS in PsA, resembling that of key clinical PsA manifestations and physical function.

References:

[1]D’Agostino MA and Coates LC. J Rheumatol. 2019;46:337–9.

[2]Uson J, et al. Rheumatol Clin. 2018;14:27–35.

[3]D’Agostino MA, et al. Arthritis Rheumatol. 2020;72 (suppl 10).

Figure 1.

Mean change from baseline in GLOESS by treatment through Week 24

Table 1.

Responsiveness of GLOESS - analysed by standardised response mean and efficacy outcomes at week 24

Standardised response mean(Initial secukinumab)Efficacy of secukinumabWeek0–12(N = 83)Week0–24(N = 83)Responders(%)Secukinumabweek 0–24(N = 83)Placebo switchersweek 12–24(N = 83)GLOESS1.051.06ACR208774Tender joint count1.031.35ACR506449Swollen joint count0.911.18ACR703423Patient global assessment of disease activity1.371.55HAQ-DI*8063Physician global assessment of disease activity1.592.39PASI 75†7259Pain1.321.53PASI 90†6245HAQ-DI score1.321.32Resolutionof dactylitis (LDI=0)6759

*HAQ-DI response is defined as an improvement of at least 0.35 score points compared to baseline (change ≤ −0.35)

†N value for PASI response in secukinumab and placebo groups are 36 and 33; respectively. PASI response was calculated for patients with BSA ≥ 3 %.

BSA, Body Surface Area; LDI, Leeds Dactylitis Index

Disclosure of Interests:

Maarten Boers Consultant of: BMS, Novartis, Pfizer, GSK, Philip G Conaghan Speakers bureau: AbbVie, AstraZeneca, BMS, Eli Lilly, Galapagos, Gilead, Novartis and Pfizer, Consultant of: AbbVie, AstraZeneca, BMS, Eli Lilly, Galapagos, Gilead, Novartis and Pfizer, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, Peter Mandl Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, MSD, Novartis, Roche and UCB, Grant/research support from: AbbVie, BMS, Celgene, Janssen, Eli Lilly, MSD, Novartis, Roche and UCB, Esperanza Naredo Speakers bureau: AbbVie, Roche, BMS, Pfizer, UCB, Eli Lilly, Novartis, Janssen, and Celgene, Consultant of: AbbVie, Novartis and BMS, Grant/research support from: Eli Lilly, Filip van den Bosch Speakers bureau: AbbVie, Celgene, Janssen, Eli Lilly, Galapagos, Merck, Novartis, Pfizer, and UCB Pharma, Consultant of: AbbVie, Celgene, Janssen, Eli Lilly, Galapagos, Merck, Novartis, Pfizer, and UCB Pharma, Ruben Burgos-Vargas: None declared, Anne-Marie Duggan Employee of: Novartis, Punit Goyanka Employee of: Novartis, Corine Gaillez Shareholder of: Novartis and BMS, Employee of: Novartis, Maria-Antonietta D’Agostino Speakers bureau: Sanofi, Novartis, BMS, Janssen, Celgene, Roche, AbbVie, UCB, and Eli Lilly, Consultant of: Sanofi, Novartis, BMS, Janssen, Celgene, Roche, AbbVie, UCB, and Eli Lilly

Structural damage in rheumatoid arthritis assessed by musculoskeletal ultrasound: A systematic literature review by the Structural Joint Damage Task Force of the OMERACT Ultrasound Working Group

OBJECTIVES

To identify and synthesize the evidence for the use and measurement properties of musculoskeletal ultrasound in assessing structural joint damage in patients with rheumatoid arthritis (RA).

METHODS

A systematic literature search (SLR) of the PubMed, Embase and Cochrane Library was performed. Original articles were included published in English reporting on ultrasound of bone erosion, cartilage damage and the measurement properties of ultrasound according to the OMERACT filter 2.1.

RESULTS

Of the 1.495 identified articles 149 were included in the final review, most of which reported on cross-sectional studies and used the OMERACT definitions for ultrasonographic pathology. Among these, bone erosions were assessed in 139 (93.3%), cartilage damage in 24 (16.1%), enthesophytes in 8 (5.4%), osteophytes in 15 (10.1%) and malalignment and ankylosis in a single (0.9%) study, respectively. Most studies (126/149, 84.6%) assessed the joints of the hands. The overwhelming majority of studies (127/149, 85.2%) assessed structural joint damage bilaterally. Validity, reliability and responsiveness were assessed in 21 (14.1%), 34 (22.8%) and 17 (11.4%) studies, respectively.

CONCLUSION

While the results of this SLR suggest that ultrasound is a sensitive, reliable and feasible tool to detect damage in RA, they also highlight the need for further research and validation. Findings of this SLR will inform the next steps of the OMERACT Ultrasound Working Group in developing an ultrasound score for assessing structural joint damage in patients with RA.

SAT0036 ULTRASOUND IN THE ASSESSMENT OF JOINT DAMAGE IN RHEUMATOID ARTHRITIS: A SYSTEMATIC LITERATURE REVIEW BY THE OMERACT ULTRASOUND WORKING GROUP

Background:

The detection of damage in patients with rheumatoid arthritis (RA) is crucial for monitoring of therapy targets as well as for early diagnosis. Conventional radiography (CR) is commonly used to detect structural damage, in the form of bone erosions or loss of hyaline cartilage. Over the last years, musculoskeletal ultrasound (MSUS) was shown to be a sensitive and reliable method to detect erosion and cartilage loss as well as damage to soft tissue structures.

Objectives:

To identify and synthesize the evidence for the use and measurement properties of MSUS in assessing structural damage in patients with RA.

Methods:

A systematic literature search (SLR) of the PubMed, Embase and Cochrane Library was performed. Original articles were included that were published in English until 01/01/2019, reporting MSUS of bone erosion, cartilage loss or damage and tendon damage, and the measurement properties of MSUS according to the OMERACT Filter 2.1.

Results:

Of the 1.266 identified articles 79 were finally included, most of which reported on cross-sectional studies. The majority of the studies used the OMERACT definitions for ultrasonographic pathology. Among these, erosions were assessed in 72 (91.1%), cartilage damage in 12 (15.2%), tendons in 4 (5.1%) studies and enthesophytes in a single (1.3%) study. Erosions were rated by binary grading in 56 (77.8%) studies and by semiquantitative scoring in 27 (37.5%) studies. Global or sum scores were calculated in only 9 (12.5%) studies. Among 23 studies assessing erosions both by US and CR, only 1/23 (4.3%) study found a higher sensitivity of CR as compared to MSUS. Among studies assessing tendons, 3 (75%) used a semiquantitative score and one scored tendon rupture as being present or absent. Cartilage damage was graded in binary fashion, quantitatively by measuring cartilage thickness or semi-quantitatively. Hand joints were the most frequently evaluated joints (58, 73.4%). The overwhelming majority of studies assessed structural damage bilaterally (68, 86.1%), with 5 (6.3%) studies assessing only the dominant hand, 5 (6.3%) studies evaluating the clinically more affected side and 1 (1.3%) study assessing only the right hand. Validity, reliability and responsiveness were assessed in only 8 (10.1%), 10 (12.7%) and 4 (5.1%) studies respectively. Feasibility was not considered in any of the studies.

Conclusion:

While the results of this SLR suggest that US is a sensitive and feasible tool to detect damage in RA, they also highlight the need for further research and validation. Findings of this SLR will inform the next steps of the Working Group in developing an ultrasound score for assessing structural damage in patients with RA.

Disclosure of Interests:

None declared

Comorbidity clusters in generalized osteoarthritis among female patients: A cross-sectional study

OBJECTIVES

To investigate the prevalence of comorbidities among female patients with generalized osteoarthritis (GOA) in comparison to an age- and sex matched control group. To identify clusters of comorbidities in both groups.

METHODS

An observational, cross-sectional study was conducted. Consecutive female patients with hand and knee osteoarthritis according to the American College of Rheumatology (ACR) classification criteria were invited to participate in the study. A control group of participants without musculoskeletal symptoms, history or evidence of osteoarthritis or inflammatory rheumatic disease were also included. Cardiovascular, obstructive pulmonary, gastrointestinal, endocrine, neurological, malignant diseases and depression were recorded in both groups. In both study groups comorbidity cluster and factor analysis was performed.

RESULTS

The study population included 200 GOA and 200 control participants. The following comorbidities were observed adjusted to Bonferroni correction with a significantly higher prevalence among individuals with GOA: hypertension, uterine leiomyoma, gastroesophageal reflux disease, diverticulosis, upper gastrointestinal tract ulcers, depression, diseases with vertigo (benign paroxysmal positional vertigo and vertebrobasilar insufficiency) and surgery due to otoclerosis. In the GOA group 5 clusters were identified with different comorbidity patterns.

CONCLUSION

We report a high comorbidity rate in GOA. Cluster analysis allowed us to identify different comorbidity subsets for vascular, gastrointestinal and malignant gynaecological disorders. Further research is required to understand the links between GOA and non-musculoskeletal comorbidities.

Estimation and control in Markov chains

We consider a finite controlled Markov chain, the description of which depends on an unknown parameter a, and investigate the following control policy. To each a an optimal stationary control is associated. a is estimated recurrently from the trajectory by the minimum contrast method, and the optimal stationary control corresponding to the estimate is used. We present asymptotic properties of the estimate and of the criterion function. They follow from the law of large numbers and from the central limit theorem for controlled Markov chains derived with the aid of martingales.

Educational recommendations for the conduct, content and format of EULAR musculoskeletal ultrasound Teaching the Teachers Courses

OBJECTIVE

To produce educational guidelines for the conduct, content and format of theoretical and practical teaching at EULAR musculoskeletal ultrasound (MSUS) Teaching the Teachers (TTT) Courses.

METHODS

A Delphi-based procedure with 24 recommendations covering five main areas (Duration and place of the course; Faculty members; Content of the course; Evaluation of the teaching skills; TTT competency assessment) was distributed among a group of experts involved in MSUS teaching, in addition to an advisory educational expert being present. Consensus for each recommendation was considered achieved when the percentage of agreement was >75%.

RESULTS

21 of 24 invited participants responded to the first Delphi questionnaire (88% response rate). All 21 participants also responded to the second round. Agreement on 19 statements was obtained after two rounds.

CONCLUSIONS

This project has led to the development of guidelines for the conduct, content and format of teaching at the EULAR MSUS TTT Courses that are organised annually, with the aim of training future teachers of EULAR MSUS Courses, EULAR Endorsed MSUS Courses, as well as national and local MSUS Courses. The presented work gives indications on how to homogenise the teaching at the MSUS TTT Courses, thus resolving current discrepancies in the field.

Persistence of subclinical sonographic joint activity in rheumatoid arthritis in sustained clinical remission

BACKGROUND

Sonographic assessment, measuring grey scale (GS) and power Doppler (PD) signals, is a sensitive tool for the evaluation of inflammatory joint activity in patients with rheumatoid arthritis (RA). We evaluated the persistence of PD and GS signals in previously clinically active RA joints that have reached a state of continuous clinical inactivity.

METHODS

We performed sonographic imaging of 22 joints of the hands of patients with RA, selected all joints without clinical activity but showing ongoing sonographic signs of inflammation, and evaluated the time from last clinical joint activity.

RESULTS

A total of 90 patients with RA with 1980 assessed joints were included in this study. When comparing the mean time from clinical swelling, we found a significantly longer period of clinical inactivity in joints showing low sonographic activity (mean±SD time from swelling of 4.1±3.2 vs 3.1±2.9 years for PD1 vs PD≥2, p=0.031 and 4.5±3.4 vs 3.3±3.2 years for GS1 vs GS≥2, p≤0.0001).

CONCLUSIONS

We conclude that subclinical joint activity is long-lasting in RA joints in clinical remission, but attenuates over time. The latter conclusion is based on the observed shorter time duration from last clinical activity for strong compared with weaker sonographic signals.

EULAR recommendations for the use of imaging in the diagnosis and management of spondyloarthritis in clinical practice

A taskforce comprised of an expert group of 21 rheumatologists, radiologists and methodologists from 11 countries developed evidence-based recommendations on the use of imaging in the clinical management of both axial and peripheral spondyloarthritis (SpA). Twelve key questions on the role of imaging in SpA were generated using a process of discussion and consensus. Imaging modalities included conventional radiography, ultrasound, magnetic resonance imaging, computed tomography (CT), positron emission tomography, single photon emission CT, dual-emission x-ray absorptiometry and scintigraphy. Experts applied research evidence obtained from systematic literature reviews using MEDLINE and EMBASE to develop a set of 10 recommendations. The strength of recommendations (SOR) was assessed by taskforce members using a visual analogue scale. A total of 7550 references were identified in the search process, from which 158 studies were included in the systematic review. Ten recommendations were produced using research-based evidence and expert opinion encompassing the role of imaging in making a diagnosis of axial SpA or peripheral SpA, monitoring inflammation and damage, predicting outcome, response to treatment, and detecting spinal fractures and osteoporosis. The SOR for each recommendation was generally very high (range 8.9–9.5). These are the first recommendations which encompass the entire spectrum of SpA and evaluate the full role of all commonly used imaging modalities. We aimed to produce recommendations that are practical and valuable in daily practice for rheumatologists, radiologists and general practitioners.

Defining enthesitis in spondyloarthritis by ultrasound: results of a Delphi process and of a reliability reading exercise

OBJECTIVE

To standardize ultrasound (US) in enthesitis.

METHODS

An initial Delphi exercise was undertaken to define US-detected enthesitis and its core components. These definitions were subsequently tested on static images taken from spondyloarthritis patients in order to evaluate their reliability.

RESULTS

Excellent agreement (>80%) was obtained for including hypoechogenicity, increased thickness of the tendon insertion, calcifications, enthesophytes, erosions, and Doppler activity as core elementary lesions of US-detected enthesitis. US definitions were subsequently obtained for each elementary component. On static images, the intraobserver reliability showed a high degree of variability for the detection of elementary lesions, with kappa coefficients ranging from 0.13-1. The interobserver kappa values were variable, with the lowest kappa coefficient for enthesophytes (0.24) and the highest coefficient for Doppler activity at the enthesis (0.63).

CONCLUSION

This is the first consensus-based US definition of enthesitis and its elementary components and the first step performed to ensure a higher degree of homogeneity and comparability of results between studies and in daily clinical work.