The Sjögren's Working Group: The 2023 OMERACT meeting and provisional domain generation

Sjögren's disease (SjD) is a systemic autoimmune exocrinopathy with key features of dryness, pain, and fatigue. SjD can affect any organ system with a variety of presentations across individuals. This heterogeneity is one of the major barriers for developing effective disease modifying treatments. Defining core disease domains comprising both specific clinical features and incorporating the patient experience is a critical first step to define this complex disease. The OMERACT SjD Working Group held its first international collaborative hybrid meeting in 2023, applying the OMERACT 2.2 filter toward identification of core domains. We accomplished our first goal, a scoping literature review that was presented at the Special Interest Group held in May 2023. Building on the domains identified in the scoping review, we uniquely deployed multidisciplinary experts as part of our collaborative team to generate a provisional domain list that captures SjD heterogeneity.

Evolution of monoclonal gammopathy of undetermined significance in patients treated with JAK inhibitors for rheumatic diseases: data from the MAJIK-SFR registry

OBJECTIVE

Monoclonal gammopathy of undetermined significance (MGUS) is common, but there are scarce data regarding the effect of DMARDs on this premalignant condition. We aimed to evaluate the impact of JAK inhibitors (JAKis) on MGUS when initiated for an active rheumatic disease.

METHODS

Patients with monoclonal abnormality prior to JAKi initiation for an active rheumatic disease were identified through the MAJIK-SFR Registry, a French multicentre prospective study. Clinical and biological data were collected using a standardized case report form.

RESULTS

Twenty patients were identified with a mean age of 65 years and a diagnosis of RA (n = 15), PsA (n = 3), and axial SpA (n = 2). The JAKi prescribed was baricitinib (n = 9), tofacitinib (n = 6) or upadacitinib (n = 5), with a mean duration of 15.5 months. Seventeen patients had individualized serum monoclonal protein (IgG kappa n = 9; IgG lambda n = 4; IgM kappa n = 3; IgA lambda n = 1) ranging from 0.16 to 2.3 g/dl, and three patients did not have an initial measurable spike but they had a positive serum immunofixation. With a follow-up of 4-28 months, the serum monoclonal protein level decreased in 8 of 17 patients (47%), remained stable in 8 patients (47%) and increased in 1 patient (6%). The maximal decrease observed was an initial IgG kappa of 2.3 g/dl, decreasing to 0.2 g/dl at month 14.

CONCLUSION

This study provides reassuring and promising data on MGUS evolution in patients treated with JAKis for rheumatic diseases, which may guide the choice of treatment in patients with both conditions.

Characterisation of airway disease associated with Sjögren disease

OBJECTIVE

Although airway disease associated with Sjögren's disease (Sjo-AD) is common, it is poorly studied compared with interstitial lung disease (ILD). In this study, we aimed to assess factors associated with Sjo-AD, the characteristics and prognosis of this manifestation.

METHODS

We performed a retrospective multicentric study involving nine centres. We included Sjo-AD patients confirmed by at least one clinician and one CT scan report. Clinical and biological data, pulmonary function test (PFT), and CT scans were collected. A single radiologist specialist in thoracic diseases reviewed CT scans. Sjo-AD patients were compared with Sjo controls without pulmonary involvement, randomly selected after matching for age and disease duration.

RESULTS

We included 31 Sjo-AD and 62 Sjo controls without pulmonary history. Sjo-AD had a higher disease activity (ESSDAI) compared with controls, even when excluding the pulmonary domain of the score (7 vs 3.8, p<0.05), mainly due to the biological activity. Sjo-AD was multilobar (72%) and associated with signs of both bronchiectasis and bronchiolitis (60%). Obstructive lung disease occurred in 32% at the time of Sjo-AD diagnosis. Overall, PFT was stable after 8.7±7 years follow-up but repeated CT scans showed extended lesions in 41% of cases within 6±3.2 years. No patient developed Sjo-ILD. Sjo-AD progression was independent of the global disease activity.

CONCLUSIONS

Sjo-AD preferentially affects Sjo patients with higher biological activity. It is often characterised as a diffuse disease, affecting both proximal and distal airways, with a slow evolution over time and no progression to Sjo-ILD.

Estimated prevalence, incidence and healthcare costs of Sjögren's syndrome in France: a national claims-based study

OBJECTIVES

To estimate prevalence, incidence and mortality rates, and annual healthcare costs of primary Sjögren's syndrome (pSS) and SS associated with other autoimmune disorders (SS+AID) in France.

METHODS

French national healthcare claims-based study within the prospective Système National des Données de Santé database that includes the majority of the French population. An algorithm was developed to identify patients with SS and SS-related healthcare claims were analysed between 2011 and 2018.

RESULTS

Overall, 23 848 patients with pSS and 14 809 with SS+AID were identified. From 2011 to 2018, the prevalence rate increased slightly for pSS (23-32 per 100000) and SS+AID (16-20 per 100 000), with females comprising 90%-91% and 92%-93% of cases, respectively. The incidence rate of SS per 100 000 persons decreased from 2012 (pSS: 4.3; SS+AID: 2.0) to 2017 (pSS: 0.7; SS+AID: 0.3). Mortality rates per 100 000 persons increased from 2012 to 2018 in patients with pSS (0.2-0.8) or SS+AID (0.1-0.5); mean age of death also increased. Artificial tears and hydroxychloroquine were the most common drug reimbursements. Less than half of patients received annual specialist care from a dentist or ophthalmologist. Healthcare costs associated with SS increased from 2011 to 2018 and exceeded the national estimate of expected costs for chronic diseases.

CONCLUSION

In this large French population database study, the low prevalence of pSS confirms that it is an orphan disease. SS is clinically and economically burdensome; these findings may help clinicians better understand routine healthcare received by patients.

Examining the biological pathways underlying clinical heterogeneity in Sjogren's syndrome: proteomic and network analysis

OBJECTIVES

Stratification approaches are vital to address clinical heterogeneity in Sjogren's syndrome (SS). We previously described that the Newcastle Sjogren's Stratification Tool (NSST) identified four distinct clinical subtypes of SS. We performed proteomic and network analysis to analyse the underlying pathobiology and highlight potential therapeutic targets for different SS subtypes.

METHOD

We profiled serum proteins using O-link technology of 180 SS subjects. We used 5 O-link proteomics panels which included a total of 454 unique proteins. Network reconstruction was performed using the ARACNE algorithm, with differential expression estimates overlaid on these networks to reveal the key subnetworks of differential expression. Furthermore, data from a phase III trial of tocilizumab in SS were reanalysed by stratifying patients at baseline using NSST.

RESULTS

Our analysis highlights differential expression of chemokines, cytokines and the major autoantigen TRIM21 between the SS subtypes. Furthermore, we observe differential expression of several transcription factors associated with energy metabolism and redox balance namely APE1/Ref-1, FOXO1, TIGAR and BACH1. The differentially expressed proteins were inter-related in our network analysis, supporting the concept that distinct molecular networks underlie the clinical subtypes of SS. Stratification of patients at baseline using NSST revealed improvement of fatigue score only in the subtype expressing the highest levels of serum IL-6.

CONCLUSIONS

Our data provide clues to the pathways contributing to the glandular and non-glandular manifestations of SS and to potential therapeutic targets for different SS subtypes. In addition, our analysis highlights the need for further exploration of altered metabolism and mitochondrial dysfunction in the context of SS subtypes.

Factors associated with COVID-19 severity in patients with spondyloarthritis: Results of the French RMD COVID-19 cohort

OBJECTIVES

The objective of the current study was to evaluate the severity of COVID-19 and identify factors associated with severe disease outcomes in patients with spondyloarthritis (SpA), a chronic inflammatory rheumatic and musculoskeletal disease (RMD).

METHODS

We utilized patient data from the French national multicenter RMD COVID-19 cohort (NCT04353609). The primary outcome was to describe COVID-19 characteristics in patients with SpA based on disease severity of COVID-19 (mild, moderate or severe) with serious infection including moderate and severe cases. The secondary outcome was to identify the factors associated with serious COVID-19 classification.

RESULTS

Among the 626 patients with SpA (56% female, mean age 49±14 years) from the French RMD cohort, COVID-19 severity was mild in 508 (81%), moderate in 93 (15%), and severe in 25 (4%) patients. Clinical signs and symptoms of COVID-19 were reported in 587 (94%) patients, with the most frequent presented symptom of fever (63%) and cough (62%), followed by flu-like symptoms (53%), agueusia (39%), anosmia (37%), dyspnea (32%) and diarrhea (19.9%). COVID-19 severity was associated with corticosteroid therapy (OR=3.08 [95% CI: 1.44-6.58], P=0.004) and age (OR=1.06 [95% CI: 1.04-1.08], P<0.001) while use of tumor necrosis factor inhibitor (TNFi, OR=0.27 [95% CI: 0.09-0.78], P=0.01) was associated with less severe disease. We did not identify an association between NSAID use and COVID-19 severity.

CONCLUSIONS

In this study, the majority of patients with SpA had a favorable COVID-19 outcome. We confirmed age and corticosteroids therapy had a negative impact on disease outcomes while TNFi use was protective.

Association between infection and the onset of giant cell arteritis and polymyalgia rheumatica: a systematic review and meta-analysis

OBJECTIVE

We aimed to analyse the association between infections and the subsequent risk of giant cell arteritis (GCA) and/or polymyalgia rheumatica (PMR) by a systematic review and a meta-analysis of observational studies.

METHODS

Two databases (Medline and Embase) were systematically reviewed. Epidemiological studies studying the association between any prior infection and the onset of GCA/PMR were eligible. Risk of bias was assessed using the Newcastle-Ottawa quality assessment scale. Outcomes and pooled statistics were reported as OR and their 95% CI.

RESULTS

Eleven studies (10 case-control studies and one cohort study) were analysed, seven of them were included in the meta-analysis. Eight were at low risk of bias. A positive and significant association was found between prior overall infections and prior Herpes Zoster (HZ) infections with pooled OR (95% CI) of 1.27 (1.18 to 1.37) and 1.20 (1.08 to 1.21), respectively. When analysed separately, hospital-treated and community-treated infections, were still significantly associated with the risk of GCA, but only when infections occurring within the year prior to diagnosis were considered (pooled OR (95% CI) 1.92 (1.67 to 2.21); 1.67 (1.54 to 1.82), respectively). This association was no longer found when infections occurring within the year prior to diagnosis were excluded.

CONCLUSION

Our study showed a positive association between the risk of GCA and prior overall infections (occurring in the year before), and prior HZ infections. Infections might be the reflect of an altered immunity of GCA patients or trigger the disease. However, reverse causation cannot be excluded.CRD42023404089.

Comparison between primary Sjögren's disease patients with high or low level of dryness

OBJECTIVES

To describe primary Sjögren's disease (SjD) patients presenting no or low level of dryness and to compare them with SjD patients with oral or ocular dryness features.

METHODS

All patients diagnosed with SjD according to AECG or ACR/EULAR criteria in our tertiary reference centre were included. Patients with high or low subjective symptoms or objective signs of dryness were compared.

RESULTS

Overall, 509 patients were included for the comparison of patients with high (n=456) or low (n=53) level of subjective dryness and 472 for the comparison of patients with (n=359) or without (n=113) high objective dryness. Compared with patients with subjective dryness, patients without high subjective dryness were significantly younger (median 49 (39-62) years vs 58 (47-67) years, p<0.01), diagnosed earlier (median time from first symptoms to diagnosis 2 (0.5-4.5) years vs 4 (1-9.25), p=0.0056), more frequently anti-SSA positive ((83% vs 64%, p=0.008) and had less focal sialadenitis in minor salivary gland biopsy (69% vs 83%, p=0.02).The patients without high level of objective dryness (n=113) were also younger (51 (41-60) vs 58 (47-67) years, p<0.001) and were more frequently anti-SSA positive (79% vs 63%, p=0.002).In both groups, no difference was observed regarding disease activity.

CONCLUSIONS

Among the patients with SjD, those without high subjective or objective dryness features had a younger profile, a faster diagnosis which may result from a more acute onset, were more frequently anti-SSA positive than patients with high dryness features.

Association Between Bruton's Tyrosine Kinase Gene Overexpression and Risk of Lymphoma in Primary Sjögren's Syndrome

OBJECTIVE

We undertook this study to analyze whole blood gene expression and to investigate the role of B cell genes in primary Sjögren's syndrome-related non-Hodgkin lymphoma (primary SS-NHL).

METHODS

Peripheral whole blood samples were collected from 345 well-phenotyped patients with primary SS enrolled in the prospective Assessment of Systemic Signs and Evolution in Sjögren's Syndrome (ASSESS) cohort. Transcriptomic analysis was performed using human Clariom S Arrays (Affymetrix). In our primary analysis, we considered patients with incident lymphoma (i-primary SS-NHL) as the case group and all patients without lymphoma as the comparison group. In our sensitivity analyses, we considered all patients with primary SS-NHL, including those with a history of lymphoma (h-primary SS-NHL), as the case group and primary SS patients without lymphoma, stratified on their risk factors of lymphoma, as the comparison group.

RESULTS

Twenty-one patients with primary SS-NHL (including 8 with i-primary SS-NHL and 13 h-primary SS-NHL) were eligible for transcriptomic analysis; we compared these patients to 324 primary SS controls without lymphoma, including 110 with moderate to severe disease activity and 61 with no risk factor of lymphoma. Functional clustering analyses revealed an enrichment of genes related to innate and adaptive immunity, including B cell-related genes. Bruton's tyrosine kinase (BTK) and a proliferation-inducing ligand (APRIL) genes were overexpressed before the occurrence of lymphoma in patients with incident lymphoma compared with patients without lymphoma. In sensitivity analyses, BTK was consistently up-regulated across all comparisons performed. BTK expression was associated with risk of lymphoma on multivariate analyses, which considered 9 validated predictors of lymphoma in primary SS.

CONCLUSION

BTK and APRIL were overexpressed in the peripheral blood of primary SS patients prior to lymphoma. The association between BTK, APRIL, and primary SS-NHL requires confirmation in other prospective cohorts.

Prophylaxis with tixagevimab/cilgavimab is associated with lower COVID-19 incidence and severity in patients with autoimmune diseases

OBJECTIVE

To describe the clinical efficacy of tixagevimab/cilgavimab in pre-exposure prophylaxis in patients at risk of severe COVID-19 and unresponsive to vaccination (anti-SARS-CoV-2 antibodies <260 BAU/mL) in rheumatology.

METHODS

In this multicenter observational study we included patients with autoimmune or inflammatory diseases who received a pre-exposure prophylaxis by tixagevimab/cilgavimab between December 2021 and August 2022. The endpoint was incidence and severity of COVID-19.

RESULTS

Tixagevimab/cilgavimab was administered to 115 patients, median age 62 years (52-71), with chronic arthritis (n = 53), connective tissue disease (n = 38) or vasculitis (n = 11). Main background immunosuppressants were rituximab (n = 98), corticosteroids (n = 62, median dose 5mg, CI95% 5-8 mg) and methotrexate (n = 48). During a median follow-up of 128 days (93-173), COVID-19 occurred in 23/115patients (20%), Omicron identified for the 8 genotyped patients. During study period, the average weekly incidence was 1071/100.000 inhabitants in Ile-de-France vs. 588/100.000 in our patients. Patients who received a 2-injections regimen had a lower risk of infection than with a single injection (16/49, 33% vs. 5/64, 8%, p = 0.0012). The COVID-19+ patients did not differ from uninfected patients concerning age, comorbidities, underlying rheumatic disease, immunosuppressant. All COVID-19 were non-severe. The tolerance of injections was excellent.

CONCLUSION

In a population with autoimmune or inflammatory diseases at risk of severe COVID-19 unresponsive to vaccination, pre-exposure prophylaxis by tixagevimab/cilgavimab was associated with lower incidence of COVID-19 and no severe infection to report.

Management of dental care of patients on immunosuppressive drugs for chronic immune-related inflammatory diseases: a survey of French dentists' practices

OBJECTIVES

The aim of the study was to provide an overview of the practices of French general dentists (GDs) and specialists (SDs) concerning the management of patients with inflammatory bowel diseases (IBDs), rheumatic inflammatory diseases (IRDs), and vasculitis on biologic disease-modifying antirheumatic drugs (bDMARDs), conventional DMARDs, or immunosuppressants (ISs).

MATERIALS AND METHODS

An online national cross-sectional survey with 53 questions was developed by a multidisciplinary team including rheumatologists, gastroenterologists and dentists based on their clinical experience. It was refined following a test with nine dentists in private practice and in hospital before being disseminated to the members of French scientific societies and colleges of dentistry teachers over 3 months. Responses of general dentists versus specialists were compared with respect to their experience in managing patients with IRDs or IBDs, knowledge/training, type of invasive procedure performed, management of medical treatment, perioperative oral-care protocols, and frequency of postoperative complications after invasive dental care procedures.

RESULT

In total, 105 practitioners fully completed the survey (participation rate 11.1%). SDs more frequently performed invasive surgical procedures and were more aware of the recommendations of learned societies than GDs. They encountered more post-operative complications for patients on bDMARDs. For both SDs and GDs, most patients were managed without stopping treatment and pre- and postoperative antibiotics were prescribed to more than 75% of patients. When medical treatment was stopped, the decision was made by the prescribing physician.

CONCLUSION

Complications were reported more frequently by SDs when highly invasive procedures were performed on patients under active drug therapy. Certain common procedures, such as scaling and root planing, appear to be safe, regardless of treatment management. However, adapted guidelines for the practice of dentistry are needed to standardize the management of patients on bDMARDS, conventional DMARDs, or ISs.

CLINICAL RELEVANCE

French dentists perform a wide range of oral procedures on patients on bDMARDS, conventional DMARDs, or ISs under antibiotic coverage and antiseptic mouthwashes. SDs reported more postoperative complications after extensive invasive procedures for patients under active drug therapy, despite their greater knowledge of recommendations on how to manage such patients.

Impact of patient ancestry on heterogeneity of Sjögren's disease

OBJECTIVES

We aimed to compare disease characteristics between primary Sjögren's syndrome (pSS) patients of African ancestry (AA) and Caucasian ancestry.

METHODS

We conducted a retrospective, case-control study in a French national and European referral centre for pSS. All patients with pSS of AA were matched with two Caucasians patients having similar follow-up duration. We explored clinical and biological parameters associated with a cumulative EULAR Sjögren's Syndrome Disease Activity Index (cumESSDAI ≥5) (consisting of individual clinESSDAI domain maximum throughout follow-up).

RESULTS

We identified 74 patients of AA matched with 148 Caucasian. Median age at pSS diagnosis was younger in AA patients (43 years (IQR 33-51) vs 56 years (44.8-59.2), p<0.001). AA patients presented higher median titre of gammaglobulins (18.5 g/L (IQR 15-22.8) vs 13.4 g/L (9.9-16.9), p<0.001), more frequently positive for anti-SSA (88% vs 72%, p=0.007) and anti-RNP (11% vs 2.7%, p=0.023) antibodies. During the follow-up (median: 6 years (IQR 2-11)), AA patients presented more systemic complications: arthritis, myositis, interstitial lung disease, lymphadenopathy, central nervous system involvement. Median cumESSDAI score was higher in AA patients (7.5 (IQR 3.2-16.0) vs 4.0 (IQR 2.0-9.0), p=0.002). Interestingly, in multivariate analyses, factors associated with disease activity were sub-Saharan AA (OR 2.65 (95% CI 1.06 to 6.94)), rheumatoid factor (OR 2.50 (95% CI 1.28 to 4.96)) and anti-RNP positivity (OR 11.1 (95% CI 1.88 to 212)).

CONCLUSION

Patients of AA display higher disease activity with a hallmark of higher B-cell activation. Studies to investigate biological drivers behind such differences are needed.

Chemosensory dysfunction in primary Sjögren's syndrome: a topical review

Primary Sjögren's syndrome is an autoimmune exocrinopathy related to lymphocytic infiltration of the exocrine glandular epithelia (such as salivary, lacrimal, nasal, and sebaceous glands or vaginal mucosa) with systemic manifestations of an immuno-inflammatory nature, and not associated with any other systemic disease. It is characterized by severe dryness (Sicca syndrome), particularly in mouth and eyes, with potential strong impact on quality of life and could increase the risk of depression in Sjögren's patient. To date, the impairment of taste and olfactory functions related to Sjögren syndrome remains poorly assessed; so is the trigeminal functions which remain sparsely studied in patients with Sjögren disease. However, other factors can also modify chemosensory functions (olfactory or gustatory sensations and trigeminal nerves), in particular the reduction of the masticatory coefficient or halitosis, due to oral saliva flow decrease, and poor dental condition, which are often present in Sjögren patients. Of the 12 articles evaluated after a 22-year literature search of this review, chemosensory disorders (including taste, smell, and trigeminal impairments) are described and evaluated in pSS patients, with mainly poorer performance compared to healthy controls. Diagnostic and therapeutic (including rehabilitation) approaches of chemosensory disorders in pSS are discussed in this review. Clinician should be more attentive to taste as well as olfacto-trigeminal disorders in primary Sjögren's disease, if possible at the earlier stage, in order to take the best care of Sjögren's patients. This review also highlights some lack in knowledge on pSS chemosensory disorders that should provide new research perspectives. Key Points •Chemosensory functions (including taste, smell, and trigeminal functions) are altered in patients with primary Sjögren's syndrome (pSS) due to dryness of the mouth and the nose. •The trigeminal nerve which interacts with olfactory and gustatory nerves contributes to olfactory and taste perception but remains little studied to date. •Chemosensory function should be considered in the daily clinical assessment of patients with pSS. •Chemosensory function treatment is not standardized yet, however symptomatic treatment of Sjögren syndrome-associated dryness transiently would improve taste and smell, and olfactory or gustatory rehabilitation in pSS patients would be useful.

Characterization and outcomes of 414 patients with primary SS who developed haematological malignancies

OBJECTIVE

To characterize 414 patients with primary SS who developed haematological malignancies and to analyse how the main SS- and lymphoma-related features can modify the presentation patterns and outcomes.

METHODS

By January 2021, the Big Data Sjögren Project Consortium database included 11 966 patients fulfilling the 2002/2016 classification criteria. Haematological malignancies diagnosed according to the World Health Organization (WHO) classification were retrospectively identified.

RESULTS

There were 414 patients (355 women, mean age 57 years) with haematological malignancies (in 43, malignancy preceded at least one year the SS diagnosis). A total of 376 (91%) patients had mature B-cell malignancy, nearly half had extranodal marginal zone lymphoma (MZL) of mucosa-associated lymphoid tissue (MALT lymphoma) (n = 197), followed by diffuse large B-cell lymphoma (DLBCL) (n = 67), nodal MZL lymphoma (n = 29), chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) (n = 19) and follicular lymphoma (FL) (n = 17). Rates of complete response, relapses and death were 80%, 34% and 13%, respectively, with a 5-year survival rate of 86.5% after a mean follow-up of 8 years. There were significant differences in age at diagnosis (younger in MALT, older in CLL/SLL), predominant clinical presentation (glandular enlargement in MALT lymphoma, peripheral lymphadenopathy in nodal MZL and FL, constitutional symptoms in DLBCL, incidental diagnosis in CLL/SLL), therapeutic response (higher in MALT lymphoma, lower in DLBCL) and survival (better in MALT, nodal MZL and FL, worse in DLBCL).

CONCLUSION

In the largest reported study of haematological malignancies complicating primary SS, we confirm the overwhelming predominance of B-cell lymphomas, especially MALT, with the salivary glands being the primary site of involvement. This highly-specific histopathological scenario is linked with the overall good prognosis with a 5-year survival rate of nearly 90%.

A randomized, phase II study of sequential belimumab and rituximab in primary Sjögren's syndrome

BACKGROUNDPrimary Sjögren's syndrome (pSS) is characterized by B cell hyperactivity and elevated B-lymphocyte stimulator (BLyS). Anti-BLyS treatment (e.g., belimumab) increases peripheral memory B cells; decreases naive, activated, and plasma B cell subsets; and increases stringency on B cell selection during reconstitution. Anti-CD20 therapeutics (e.g., rituximab) bind and deplete CD20-expressing B cells in circulation but are less effective in depleting tissue-resident CD20+ B cells. Combined, these 2 mechanisms may achieve synergistic effects.METHODSThis 68-week, phase II, double-blind study (GSK study 201842) randomized 86 adult patients with active pSS to 1 of 4 arms: placebo, s.c. belimumab, i.v. rituximab, or sequential belimumab + rituximab.RESULTSOverall, 60 patients completed treatment and follow-up until week 68. The incidence of adverse events (AEs) and drug-related AEs was similar across groups. Infections/infestations were the most common AEs, and no serious infections of special interest occurred. Near-complete depletion of minor salivary gland CD20+ B cells and a greater and more sustained depletion of peripheral CD19+ B cells were observed with belimumab + rituximab versus monotherapies. With belimumab + rituximab, reconstitution of peripheral B cells occurred, but it was delayed compared with rituximab. At week 68, mean (± standard error) total EULAR Sjögren's syndrome disease activity index scores decreased from 11.0 (1.17) at baseline to 5.0 (1.27) for belimumab + rituximab and 10.4 (1.36) to 8.6 (1.57) for placebo.CONCLUSIONThe safety profile of belimumab + rituximab in pSS was consistent with the monotherapies. Belimumab + rituximab induced enhanced salivary gland B cell depletion relative to the monotherapies, potentially leading to improved clinical outcomes.TRIAL REGISTRATIONClinicalTrials.gov NCT02631538.FUNDINGFunding was provided by GSK.

Tolerance and efficacy of targeted therapies prescribed for off-label indications in refractory systemic autoimmune diseases: data of the first 100 patients enrolled in the TATA registry (TArgeted Therapy in Autoimmune Diseases)

Objectives

To assess the tolerance and efficacy of targeted therapies prescribed off-label in refractory low-prevalence autoimmune and inflammatory systemic diseases.

Methods

The TATA registry (TArgeted Therapy in Autoimmune Diseases) is a prospective, observational, national and independent cohort follow-up. The inclusion criteria in the registry are as follows: age >18 years; low-prevalence autoimmune and inflammatory systemic disease treated with off-label drugs started after 1 January 2019.

Results

Hundred (100) patients (79 women) were enrolled. The median age was 52.5 years (95% CI 49 to 56) and the median disease duration before enrolment was 5 years (3 to 7). The targeted therapies at enrolment were as follows: Janus kinase/signal transducers and activators of transcription inhibitors (44%), anti-interleukin (IL)-6R (22%), anti-IL-12/23, anti-IL-23 and anti-IL-17 (9%), anti-B cell activating factor of the tumour necrosis factor family (5%), abatacept (5%), other targeted treatments (9%) and combination of targeted treatments (6%). 73% of patients were receiving corticosteroid therapy at enrolment (median dose 10 mg/day). The current median follow-up time is 9 months (8 to 10).

Safety: 11 serious infections (incidence rate of 14.8/100 patient-years) and 1 cancer (1.3 cancers/100 patient-years) were observed. Two patients died from severe COVID-19 (2.7 deaths/100 patient-years).

Efficacy: the targeted treatment was considered effective by the clinician in 56% of patients and allowed, in responders, a median reduction of oral corticosteroids of 15 (9 to 21) mg/day, below 7.5 mg/day in 76% of patients, while 28% discontinued.

Conclusion

These initial results of the TATA registry confirm the diversity of targeted treatments prescribed off-label in refractory autoimmune diseases and their corticosteroid-sparing effect when effective. Tolerance was acceptable in these refractory patients with a long history of treatment with immunosuppressive drugs.

Management and outcome of native joint septic arthritis: a nationwide survey in French rheumatology departments, 2016-2017

OBJECTIVES

To describe current management and outcome of native joint septic arthritis (NJSA) in French rheumatology departments.

METHODS

For this retrospective, nationwide multicentric study, 127 French rheumatology departments were contacted to report up to 12 cases of NJSA that occurred between 1 January 2016 and 31 December 2017. Characteristics, diagnosis procedures, therapeutic management and outcome were recorded.

RESULTS

Overall, 362 patients were included (mean age 64.0±18.6 years, median Charlson comorbidity index 3.5 (0-14)). Knee was the most frequent site (n=160 (38.9%)), and Staphylococcus sp (n=185 (51.4%)), the most frequent pathogen. All patients received antibiotics for a mean duration of 46.8 (±22.0) days, including intravenous route for a mean of 17.2 (±15.4) days. Management was heterogeneous. Surgical procedure was performed in 171 (48.3%), joint immobilisation in 128 (43.8%). During follow-up, 91 (28.3%) patients have had serious complications and 28 (9.2%) of them died. Factors associated with 1-year mortality were age (OR 1.08, 95% CI 1.04 to 1.13; p<0.001), Charlson's index (OR 1.30, 95% CI 1.06 to 1.58; p=0.012), presence of bacteraemia (OR 4.02, 95% CI 1.35 to 11.99; p=0.008), antibiotic use in the previous 3 months (OR 3.32, 95% CI 1.11 to 9.87; p=0.029) and Staphylococcus aureus NJSA compared with Streptococcus sp. NJSA (OR 7.24, 95% CI 1.26 to 41.68, p=0.027). The complete recovery with no adverse joint outcome at 1 year was observed in n=125/278 patients (55.0%).

CONCLUSION

Prognosis of NJSA remained severe with a high rate of morbimortality. Its management was very heterogeneous. This study highlights the importance of the new French recommendations, published after the completion of the study, in order to facilitate NJSA management.

Development and preliminary validation of the Sjögren's Tool for Assessing Response (STAR): a consensual composite score for assessing treatment effect in primary Sjögren's syndrome

OBJECTIVE

To develop a composite responder index in primary Sjögren's syndrome (pSS): the Sjögren's Tool for Assessing Response (STAR).

METHODS

To develop STAR, the NECESSITY (New clinical endpoints in primary Sjögren's syndrome: an interventional trial based on stratifying patients) consortium used data-driven methods based on nine randomised controlled trials (RCTs) and consensus techniques involving 78 experts and 20 patients. Based on reanalysis of rituximab trials and the literature, the Delphi panel identified a core set of domains with their respective outcome measures. STAR options combining these domains were proposed to the panel for selection and improvement. For each STAR option, sensitivity to change was estimated by the C-index in nine RCTs. Delphi rounds were run for selecting STAR. For the options remaining before the final vote, a meta-analysis of the RCTs was performed.

RESULTS

The Delphi panel identified five core domains (systemic activity, patient symptoms, lachrymal gland function, salivary gland function and biological parameters), and 227 STAR options combining these domains were selected to be tested for sensitivity to change. After two Delphi rounds, a meta-analysis of the 20 remaining options was performed. The candidate STAR was then selected by a final vote based on metrological properties and clinical relevance.

CONCLUSION

The candidate STAR is a composite responder index that includes all main disease features in a single tool and is designed for use as a primary endpoint in pSS RCTs. The rigorous and consensual development process ensures its face and content validity. The candidate STAR showed good sensitivity to change and will be prospectively validated by the NECESSITY consortium in a dedicated RCT.

Associations between ocular and extra-ocular assessment in primary Sjögren's syndrome

OBJECTIVES

To assess associations between ophthalmological features and the main systemic biomarkers of primary Sjögren's Syndrome (pSS), and to identify systemic biomarkers associated with severe keratoconjunctivitis sicca (KCS) in pSS patients.

METHODS

In this cross-sectional study, data was retrospectively extracted from the monocentric cohort of the French reference centre for pSS. We analysed data from the initial visit of patients admitted for suspicion of pSS and included patients validating pSS ACR/EULAR classification criteria. Ophthalmological assessment included Schirmer's test, tear break-up time, ocular staining score (OSS), and visual analogue scale (DED-VAS) for dry eye disease (DED) symptoms. Results of minor salivary gland biopsy, unstimulated whole salivary flow rate, anti-SSA/Ro antibodies, anti-SSB/La antibodies, and rheumatoid factor (RF) were collected.

RESULTS

A total of 253 patients (245 females) with confirmed pSS, aged 56.6 ± 13.0 years, were included, among which 37% had severe KCS. Multivariate analysis showed that the presence of anti-SSA/Ro antibodies, anti-SSB/La antibodies and RF were associated with conjunctival OSS (odds ratio -OR- = 1.25 per OSS unit increase; confidence interval -CI- 95% = 1.05 - 1.49; p = 0.01; OR = 1.31 per OSS unit increase; CI95% = 1.09 - 1.58, p = 0.002, and OR = 1.34 per OSS unit increase; CI95% = 1.12-1.59; p = 0.001, respectively). Both anti-SSB/La antibodies and DED-VAS ≥ 5 were significantly associated with severe KCS (OR = 2.03; CI95% = 1.03 - 4.00; p < 0.05 and OR = 2.52, CI95% = 1.31 - 4.90; p < 0.01, respectively).

CONCLUSIONS

Association between conjunctival OSS and systemic biomarkers of pSS indicate the crucial importance of conjunctival staining when pSS is suspected as a cause of DED. Conversely, patients with anti-SSB and DED-VAS ≥ 5 features should be prioritized for extensive evaluation by an ophthalmologist due to their association with severe KCS.

POS1429 IMPROVING ACCURACY OF SELF-REPORTED DIAGNOSES OF POLYMYALGIA RHEUMATICA AND GIANT CELL ARTERITIS IN THE FRENCH PROSPECTIVE E3N COHORT: A VALIDATION STUDY

Background

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are two associated inflammatory diseases that probably share common pathophysiological mechanisms. Data on environmental risk factors are lacking. Population based cohort studies are the most adequate and less biased sources for identifying such factors. But case validation of disease diagnoses is the first necessary step for running such studies, even though it is not easy to perform.

Objectives

To assess the accuracy of self-reported GCA/PMR diagnoses and to develop algorithms to ascertain GCA/PMR in a large French population-based cohort, using combined data of a dedicated questionnaire and medication reimbursement database.

Methods

The E3N cohort study (Etude Epidémiologique auprès des femmes de la Mutuelle générale de l’Education Nationale) includes 98,995 healthy French women born between 1925 and 1950, recruited in 1990 and was designed to investigate lifestyle and environmental factors associated with chronic conditions. Participants completed biennially mailed questionnaires to update their health-related information, lifestyle characteristics, and newly diagnosed diseases. Women who self-reported a diagnosis of GCA and/or PMR were sent a specific validation questionnaire designed to ascertain the diagnosis including clinical, biological, and therapeutic data, along with ACR 1990 classification criteria for GCA and ACR/EULAR 2012 classification criteria for PMR. We then devised algorithms based on self-reported answers and a medication reimbursement database, and evaluated their accuracy, comparing them with diagnoses obtained from medical chart review.

Results

Among the 98,995 participants, 1,392 women self-reported GCA/PMR. The specific questionnaire was sent to 1,143 (82.1%) of the eligible women (249 women could not be contacted because of death or withdrawn consent) and response was obtained for 830 women (59.6%). Among them, 202 women provided sufficient medical data to ascertain a diagnosis and study accuracy of developed algorithms. 56 women were classified as ACG and 121 as PMR. Self-reported diagnoses alone had an accuracy of 87.6% with medical chart review. If women additionally self-reported a diagnosis confirmation by a physician and the use of glucocorticoids for ≥ 3 months, the accuracy was improved to 89.9%. For patients who did not respond to validation questionnaire, adding the use of glucocorticoids for ≥ 3 months in the reimbursement database also improved the diagnosis accuracy to 92.8%. These two designed algorithms also had the benefit of reducing the number of false positive cases by 10 and 16 respectively. Finally, 589 GCA and/or PMR cases were confirmed by our two devised algorithms: 401 cases with algorithm using the specific GCA/PMR questionnaire and 188 with medication reimbursement database. The mean age at diagnosis was 70.3 (± 8.0) years [73.4 (± 6.2) years for cases detected using the specific GCA/PMR questionnaire and 68.9 (± 8.3) years for cases detected with medication reimbursement database]. Demographic and clinical data were similar between our population of validated cases by medical chart review and the cases detected by our algorithms in the cohort.

Conclusion

The accuracy of self-reported diagnosis of GCA/PMR was high in the E3N-cohort. Using additional data such as medication reimbursement and/or other self-reported data from a specific questionnaire, particularly the prolonged use of glucocorticoids led to a better accuracy with a very small number of false positive cases and seemed to be sufficient to correctly ascertained GCA and/or PMR diagnoses. With the validation of nearly 600 GCA and/or PMR cases in our cohort, we will be able to conduct epidemiological studies to identify risk factors of these diseases.

Acknowledgements

The authors are indebted to all participants for their continued participation. The authors would like to thank Pascale Gerbouin-Rerolle, Mariam Alyaniakian, Sofiane Harizi and Roselyn Rima Gomes for their help on data management. The present work was performed using data from the Inserm E3N cohort and support from the MGEN, Gustave Roussy, and the Ligue contre le Cancer for setting up and maintaining the cohort. The cohort was supported by a state grant ANR-10-COHO-0006 from the Agence Nationale de la Recherche within the Investissement d’Avenir program. The present work was conducted thanks to a research grant from the Agence Régionale de Santé – Île de France.

Disclosure of Interests

None declared

POS0748 COMPARISON BETWEEN PRIMARY SJÖGREN’S SYNDROME PATIENTS WITH AND WITHOUT DRYNESS

Background

To date, no study has clinically focused on primary Sjögren’s Syndrome (pSS) patients presenting without or with low level of dryness features.

Objectives

To describe pSS patients presenting no dryness or with low level of dryness and to compare them with pSS patients with dryness features to determine whether a specific clinical presentation can be identified in these patients.

Methods

All patients diagnosed with pSS according to AECG or ACR/EULAR criteria in our tertiary reference center were included. All patients were recruited between 1999 and 2020. Patient were considered without subjective dryness if the VAS for dry eyes or dry mouth was ≤ 30/100 and/or without objective dryness if having both normal Schirmer and salivary flow rate.

Results

Overall, 509 patients were included in the subjective dryness comparison group and 434 in the objective one (Table 1). Compared to patients with subjective dryness (n=456), patients without subjective dryness (n=53) were significantly younger (p=0,0025), were diagnosed earlier (p=0,0056), were more frequently anti-SSA positive (p=0,008), had lower levels of fatigue (p=0,0005). But no difference was observed regarding the level of disease activity or frequency of organ involvement. By contrast, patients reporting subjective dryness had more frequently chronic cough (p=0,022), with no more frequent objective lung involvement. Thus, the higher prevalence of chronic cough might be explained by dryness of the upper airways. Table 1.

The patients without objective dryness (n=108) were also younger (p=0,0026), and had more frequently anti-SSA positive (p=0,0042). They also had a higher disease activity (mean ESSDAI: 3,46 versus 2,96, p=0,056). In this group of patients, the higher frequency of anti-SSA might be explained by the need of other criteria to fulfil diagnostic criteria, in the absence of abnormal Schirmer and salivary flow. Patients with objective dryness had more frequently arthralgia (p=0,04), a higher level of pain VAS (p=0,03) and subjective dryness VAS (p=0,019 for ocular and p=0,01 for oral) than patients without objective dryness.

Among the 108 patients with no objective dryness, only 17 had also had no subjective dryness (VAS <30mm).

P value corresponds to the comparison of the two strata with Student’s t or Mann Whitney-U test

Conclusion

Among the patients with pSS, those without subjective or objective dryness features had a younger profile, shorter diagnosis delay which may result from a more acute onset, were more frequently anti-SSA positive. Those having no objective dryness also had more systemic disease, arthralgias and pain than patients with dryness features. Subjective dryness was associated with higher level of fatigue.

References

[1]Characters from table content including title and footnotes:

Disclosure of Interests

None declared

AB1531-HPR ECOLOGICAL MOMENTARY ASSESSMENT OF THE SYMPTOMS IN SJÖGREN’S SYNDROME: DEVELOPMENT AND VALIDATION OF A DEDICATED WebApp

Background

Primary Sjögren’s syndrome (pSS) is a rare systemic autoimmune disease with no specific treatment at present. To better assess patient symptoms, we have developed a web application (WebApp) to collect patient symptom intensity on a regular basis.

Objectives

To measure the daily variability of symptoms using the WebApp. We also evaluated its ease of use.

Methods

45 consecutive patients with pSS were included in 3 referral centers. Symptoms were assessed during the baseline and 3 month visits. We collected the VAS relating to fatigue, dryness and pain as well as the ESSPRI score. Patients used the WebApp daily for 3 months. The variability of symptoms over time was assessed by the predicted median error. This value was determined using a linear regression model, in order to predict the value at the 3rd month, then this value was compared to the actual value collected at the 3rd month during the clinical visit. The ease of use of the WebApp was assessed using a satisfaction score (SUS score).

Results

Of the 45 patients included, 91.1% were women with an average age of 57 years, and low systemic disease activity (84.4% had an ESSDAI score below 5). The intensity of the symptoms collected during the clinical visits was similar at baseline and at 3 months. The values ​​of the median error for each measurement are between 0.5 and 0.8. The 3-month predicted median error values ​​ranged from 2 to -3. The patients all used the web application for 3 months with good attendance (80% of data completion) and were satisfied with this tool (median SUS score = 90).

Conclusion

Symptoms of pSS fluctuate from day to day in the majority of patients, making a point measurement imprecise. The developed WebApp is easy to use, and could allow more sensitive detection of the effect of a therapeutic intervention. This tool will soon be evaluated during prospective interventional clinical trials.

Acknowledgements

I would like to thanks all people who have helped and were directly or indirectly involved in this study.

Disclosure of Interests

None declared

AB1120 PSYCHOLOGICAL ASSESSMENT IN PATIENTS WITH CHRONIC RHEUMATIC, SYSTEMIC AUTOIMMUNE, OR AUTOINFLAMMATORY DISEASES PRESENTED WITH COVID-19: THE MentCOVRMD STUDY

Background

The COVID-19 pandemic has raised concerns about its psychological effects. Sleep disturbances, anxiety and/or depressive symptoms, post-traumatic stress symptoms have been reported in general population. Patients with chronic rheumatism, systemic autoimmune disease or auto-inflammatory disease, due to immunosuppression, are at risk of severe forms of infection. Currently, there is little information on psychological impact of the pandemic on the mental health of these more vulnerable patients.

Objectives

To compare psychological assessment between patients with chronic rheumatic, autoimmune and/or autoinflammatory diseases who presented with COVID-19 infection between March and September 2020, first wave of French pandemic, and patients with same diseases who did not presented with infection to date.

Methods

The MentCOVRMD study was a multicenter descriptive study. Cases were patients with chronic rheumatic, autoimmune and/or autoinflammatory diseases from the French RMD cohort who presented COVID-19 infection between March and September 2020. Controls were patients with same diseases who did not develop infection. The study is registered in Clinical Trials under number 2020-A02058-31.

For participants, following criteria were collected: demographics (age, gender, smoking status); psychological assessment questionnaires: Insomnia Severity Index (ISI); Post-traumatic stress disorder (PTSD) checklist; Patient Health Questionnaire (PHQ9) Depression; Generalized Anxiety Disorder (GAD7) Anxiety; Patient Health Questionnaire-15 (PHQ-15) and Somatic Symptom Disorder (SSD)-12.

Results

Between February and December 2021, 60 cases (46 (76.7%) women), median age 52.0 (39.0; 63.0) were included, of which 15 (25%) had been hospitalized during infection, and 169 controls (148 (87.6%) women), median age of 52.0 (38.0; 63.0). There were more smokers in the group of cases 12 (20%) than controls 14 (9.1%) (p=0.028) as well as more cases on ARA2 treatment (8 (13.3%)) than controls (7 (4.5%)) (p=0.035) with no statistically significant difference in others comorbidities or treatments.

There was no statistically difference concerning the ISI scores between cases (11.83 ± 7.31) of which 60% had sleep disorders and controls (11.64 ± 6.82) of which 70.4% had sleep disorders. There was no statistically significant difference in PTSD scores of 15.5 (5.0 to 28.0) for cases and 18.0 (8.0 to 35.0) for controls, of which respectively 12 (20%) had values indicating possible PTSD for cases and 50 (29.6%) for controls. There was no statistically significant difference in PHQ-9 scores (5.5 (1.5 to 11.0)) of which 50% had depressive symptoms and controls (6.0 (2.0 to 11.0)) of which 54.5% had symptoms. There was no statistically significant difference in GAD-7 scores (3.5 (0.0 to 8.0)) of which 40% had anxiety symptoms and controls (4.0 (0.0 to 8.0)) of which 43.2% had symptoms. There was no statistically significant difference in PHQ-15 scores (11.4 ± 6.7), 85% of whom reported presence of symptoms, and controls (10.9 ± 6.2), 82.3% of whom reported symptoms. There was no statistically significant difference in SSD scores between cases (17.7 ± 10.9) and controls (18.4 ± 10.9).

There was a statistically significant difference in reported VAS scores of pain related to inflammatory rheumatism in cases with a median of 4.5 (3.0 to 6. 0) compared to controls with a median of 4.0 (1.0 to 6.0) (p=0.011).

There was no statistically significant difference in any of the psychological assessment scores between the inpatient and outpatient COVID cases.

Conclusion

There was no statistically significant difference between COVID cases and controls in the evaluation of these psychological parameters. Prevalence of all these variables were high in the whole study population, testifying to the need to manage these psychological aspects for patients with chronic rheumatisms, autoimmune and/or autoinflammatory diseases.

Disclosure of Interests

None declared

AB1450 CHARACTERISTICS, OUTCOME AND FACTORS ASSOCIATED WITH EVOLUTION TO MULTIPLE MYELOMA AND SURVIVAL IN PATIENTS WITH SOLITARY BONE PLASMACYTOMA

Background

Solitary bone plasmacytoma (SPB) is a rare malignancy whose main risk is progression to multiple myeloma (MM).

Objectives

To describe the characteristics and outcome of patients treated for SBP and to identify factors associated with progression to MM and death.

Methods

This retrospective study was conducted between 1992 and 2020. Patients were included if they met the International Myeloma Working Group (IMWG) criteria for the diagnosis of SBP (1). Treatment response was assessed according to the IMWG criteria (2) for patients with detectable monoclonal protein and according to radiological response only for non-secretory SBP. Hazard ratios (HR) and their 95% confidence intervals (CI) were estimated by Cox proportional hazards models, adjusted for potential confounders. When available, 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) were reviewed by two experienced nuclear physicians.

Results

A total of 77 patients diagnosed with SBP were included. The median age was 59 years [range: 27-89]. Median follow-up duration was 87.1 months [range: 1.6-306.8]. At the end of the follow-up, 45 (58.4%) patients had developed a MM and 13 (16.9%) deaths occurred, including 10 patients with progression to MM. Five-year myeloma-free survival and overall survival were 47.9% and 86.8% respectively. All patients received radiotherapy with a median dose of 45 Grays [range: 30-55]. Chemotherapy was prescribed in 32 (41.6%) patients, concomitant to radiotherapy in 8, because of high risk of local extension, or adjuvant in 24 because of persistent disease after radiotherapy. Chemotherapy included mainly immunomodulatory drugs (28/32 (87.5%)) and/or proteasome inhibitors (11/32 (34.4%)) based combinations. Adjuvant chemotherapy after radiotherapy was associated with a reduced risk of MM compared to patients treated by radiotherapy alone, in a multivariate model adjusted for potential confounding factors, including response after radiotherapy alone (adjuvant chemotherapy versus no chemotherapy, HR 0.30, 95%CI [0.14-0.64]). Response to the first line of treatment (radiotherapy +/- chemotherapy) was the main factor associated with progression to MM (complete response versus partial response or progressive disease, HR 0.25, 95%CI [0.11-0.59]) and death (HR 0.22, 95%CI [0.05-0.99]). A non-significant trend between bone marrow plasmacytosis ≥ 5% at diagnosis and higher risk of MM was observed (≥ 5% versus <5%, HR 2.40, 95%CI [1.00-5.74]). 18F-FDG PET/CT images were available for review in only 36/77 patients. A significant decrease of 18F-FDG uptake after treatment was observed whereas the lesion size was unchanged. No association was observed with the risk of MM but the limited available images may have resulted in underpowered analyses.

Conclusion

In this large study of patients with SBP, we observed that even though mostly prescribed for insufficient response to radiotherapy alone, treatment with adjuvant chemotherapy was associated with a decreased risk of evolution to MM, suggesting that this treatment might be systematically prescribed in addition to radiotherapy alone. These observations need to be confirmed and justify conduction of a prospective trial evaluating adjuvant chemotherapy in patients with SBP.

References

[1]Rajkumar SV, Dimopoulos MA, Palumbo A, Blade J, Merlini G, Mateos M-V, et al. International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. Lancet Oncol. nov 2014;15(12):e538-548.

[2]Kumar S, Paiva B, Anderson KC, Durie B, Landgren O, Moreau P, et al. International Myeloma Working Group consensus criteria for response and minimal residual disease assessment in multiple myeloma. Lancet Oncol. août 2016;17(8):e328‑46.

Acknowledgements

The authors are indebted to all participants for their continued participation.

Disclosure of Interests

None declared

POS0322 CARDIOVASCULAR RISK FACTORS AND RISK OF GIANT CELL ARTERITIS AND/OR POLYMYALGIA RHEUMATICA: RESULTS FROM THE FRENCH E3N COHORT STUDY

Background

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are two associated inflammatory diseases with incompletely known common pathophysiological mechanism. Cardiovascular (CV) risk factors have been thought to play a role in the underlying chronic vascular inflammation involved in GCA and PMR pathophysiology. However, available data on CV risk factors are conflicting.

Objectives

To investigate the association between CV risk factors and the risk of GCA and/or PMR in a large prospective cohort of French women.

Methods

The E3N cohort study (Etude Epidémiologique auprès des femmes de la Mutuelle générale de l’Education Nationale) is a French prospective cohort including 98,995 French women born between 1925 and 1950, recruited in 1990. They completed biennially mailed questionnaires to update their health-related information. A validation study based on the use of a specific GCA/PMR questionnaire and medication reimbursement database was conducted prior to this study. The history of CV risk factors (hypertension, type 2 diabetes, dyslipidemia, active smoking status and family history of cardiovascular disease) was self-reported at each questionnaire. Hazard ratios (HRs) and their 95% confidence intervals (95%CIs) for incident GCA and/or PMR were estimated by Cox proportional hazards regression models with age as the time scale. Multi-adjusted models included all CV risk factors and educational level. Further analyses were conducted to separately analyse the risk of incident GCA and of PMR.

Results

The overall population included 79,804 women, during a total follow-up of 1,899,742 person-years. Among them, 399 incident GCA and/or PMR cases were identified (incidence 31/100,000 person-years): 282 PMR alone, 112 GCA cases, and 5 patients who could not be classified. Incident GCA/PMR cases were diagnosed after a mean of 17.9 (± 5.2) years after recruitment. Mean age at diagnosis was 69 (± 7.2) years. Type 2 diabetes was inversely associated with risk of incident GCA/PMR in age-adjusted and multivariable models (HR 0.41; 95%CI 0.2–0.9 in multivariate model). Other CV risk factors such as hypertension, smoking status, dyslipidaemia, familial history of cardiovascular events were not associated with incident GCA/PMR (Table 1). The inverse association remained statistically significant when studying separately the risk of incident PMR (HR 0.3; 95%CI 0.09–0.91) but no longer with incident GCA (HR 0.5; 95%CI 0.1–2.0), probably due to a reduced statistical power.

Table 1.

Hazard ratios for the risk incident GCA and/or PMR according to cardiovascular risk factors

NON-CASESN=79,405GCA/PMRCASESN=399M1M2Number (%)Number (%)HR [95%CI]HR [95%CI]Smoking status Never-smoker42,2745 (53.2)233 (58.4)ReferenceReference Past smoker30,824 (38.8)134 (33.6)0.91 [0.74;1.13]0.90 [0.73; 1.12] Current smoker6,307(7.9)32 (8.0)1.05 [0.72; 1.52]1.04 [0.72; 1.51]High-blood pressure No hypertension38,813 (48.9)210 (52.6)ReferenceReference Hypertension40,592 (51.1)189 (47.4)0.84 [0.89; 1.03]0.85 [0.69; 1.04]Type 2 diabetes No diabetes75,704 (95.3)386 (96.7)ReferenceReference Diabetes3,701 (4.7)13 (3.3)0.41 [0.18; 0.91]0.41 [0.18; 0.92]BMI <25 kg/m252,054 (65.6)269 (67.4)ReferenceReference ≥ 25 kg/m227,351 (34.4)130 (32.6)1.01 [0.82; 1.25]1.06 [0.85; 1.31]Dyslipidemia No43,944 (55.3)237 (59.4)ReferenceReference Yes33,169 (41.8)147 (36.8)1.17 [0.94; 1.44]1.18 [0.95; 1.45]Familial history of cardiovascular disease No64,878 (81.7)336 (84.2)ReferenceNA Yes3,121 (3.9)20 (5.0)1.30 [0.85; 2.09]NA

M1: Adjusted for age and educational level educational level (<high school, up to 2 years of university, > 3 years of university),

M2: M1+ smoking status, body mass index(kg/m2), hypertension, diabetes, dyslipidemia

Conclusion

Type 2 diabetes was associated with a decreased risk of subsequent GCA/PMR development. Further work should be carried out to determine potential mechanisms, and especially to analyze the respective role of diabetes itself and its treatments.

Acknowledgements

The authors are indebted to all participants for their continued participation. The authors would like to thank Pascale Gerbouin-Rerolle, Mariam Alyaniakian, Sofiane Harizi and Roselyn Rima Gomes for their help on data management. The present work was performed using data from the Inserm E3N cohort and support from the MGEN, Gustave Roussy, and the Ligue contre le Cancer for setting up and maintaining the cohort. The cohort was supported by a state grant ANR-10-COHO-0006 from the Agence Nationale de la Recherche within the Investissement d’Avenir program. The present work was conducted thanks to a research grant from the Agence Régionale de Santé – Île de France.ledgements to declare.

Disclosure of Interests

None declared

POS1227 TIME BETWEEN SECOND AND THIRD DOSES INFLUENCES RESPONSE TO COVID-19 VACCINE IN AUTO-IMMUNE DISEASE PATIENTS TREATED WITH RITUXIMAB WITHOUT RESPONSE TO TWO DOSES

Background

It is now well established that patients treated with rituximab (RTX) for auto-immune disease (AID) have a diminished antibody response to COVID-19 vaccines after two doses. Optimizing antibody response is a key objective in this population. To achieve this goal, a 3rd booster dose may be considered.

Objectives

Focusing on the population of AID patients treated with RTX without any antibody response after two doses we sought to explore how these patients could respond to a 3rd dose and identify factors of response.

Methods

We performed a French retrospective bicentric observational trial which is a follow up of previously published work (1). We included consecutive patients treated with RTX that were non-responders regarding their anti-Spike antibody (anti-S) status at least one month after the second dose of COVID-19 vaccination. Patients were included between March and October 2021. All patients then received a third dose according to local guidelines and had an anti-S measurement at least one month after the third dose. Some patients without response to a third dose had a fourth dose. Anti-S were measured in serum with various kits, but all results were in BAU/mL with upper quantification limit at 243. Patients with anti-S above 49 BAU/mL, which has been demonstrated to be the threshold associated with detectable neutralizing response were considered as responders (1).

Results

60 patients treated with RTX without response to 2 doses (Anti-S Ab < 49 BAU/mL) were included in the study. 9/60 (15%) patients responded to the 3rd vaccine dose with anti-S > 49BAU/ml.

Responders and non-responders had similar demographic characteristics (Table 1). There was a positive correlation between anti-S Ab levels after dose 3 and time between 2nd and 3rd doses (r=0,41 p=0,001) (Figure 1). Nevertheless, the median time between 2nd and 3rd doses was numerically but not significantly higher in responders than in non-responders (129 vs 80 days, p=0.30). There was no correlation between anti-S levels after the third dose and the time between the last RTX infusion and the third vaccine dose. There was a trend towards more patients with methotrexate co-medication in the non-responder group 31/51 (61%) vs 3/9 (33%) in the responder group (p=0,15). Seven non-responder patients after the 3rd dose received a 4th dose and 4 (57%) responded.

Table 1.

Characteristics of patients without response after the second dose of vaccine treated with Rituximab for auto-immune diseases according to their seroconversion status after the third dose.

Non responders (n=51)Responders (n=9)pAge, median (min-max)61 (17-85)58 (36-78)0,33Female sex n (%)42 (82)6 (67)0,36Underlying disease n (%) Rheumatoid Arthritis36 (69)5 (56)0,46 Other auto-immune disease16 (31)4 (44)Rituximab treatmentReceived a RTX infusion between dose 2 and 3 n (%)14(27)3(33)0,70Time between the last RTX infusion and the 3rd dose of vaccine in days median (min-max)162 (1-687)187 (79-959)0,16Previous number of RTX injections, median (min-max)7 (0-34)6 (1-22)0,58Vaccination schemeInterval between 2nd and 3rd vaccine dose in days, median (min-max)80 (23-287)129 (24-220)0,30Less than 3 months between 2nd and 3rd vaccine dose n (%)27(53)2(22)0,14Co-medicationsPatients on steroids n (%)20(40)5 (37,5)0,99Prednisone equivalent dose per day in mg median (min-max)5(2-25)5(5-10)0,48Figure 1.

Correlation between anti- spike Ab levels after the third dose and time in days between doses 2 and 3.

Conclusion

A third vaccine dose of COVID-19 vaccine leads to only 15% of response in previously non-responding RTX treated AID patients. A longer time between 2nd and 3rd doses might positively influences response to a 3rd COVID-19 vaccine. Finally exploratory findings show that a fourth dose could be useful to obtain response non-responders.

References

[1]Bitoun S, Henry J, Desjardins D, et al. Rituximab impairs B-cell response but not T-cell response to COVID-19 vaccine in auto-immune diseases. Arthritis Rheumatol Hoboken NJ Published Online First: 28 December 2021.

Disclosure of Interests

None declared

POS1431 FISH CONSUMPTION AND RISK OF RHEUMATOID ARTHRITIS: FINDINGS FROM THE E3N COHORT STUDY

Background

Rheumatoid arthritis (RA) is an inflammatory rheumatic disease of multifactorial aetiology, which preferentially affects women. To date, active personal smoking has been the most reproducibly reported risk factor for anti-citrullinated protein antibodies (ACPA) positive RA. Fish consumption has been thought to reduce the risk of rheumatoid arthritis (RA), but reported data were conflicting.

Objectives

To assess the association between fish consumption (overall, lean fish, and oily fish) and the risk of RA.

Methods

The E3N study (Etude Epidémiologique auprès des femmes de la Mutuelle générale de l’Education Nationale) is a French prospective cohort investigating environmental factors associated with chronic diseases. It follows 98,995 healthy French women since 1990 covered by a national health insurance primarily involving teachers. RA cases have been previously identified with specific questionnaires and medication reimbursement database. Dietary data were collected via a validated food-frequency questionnaire in 1993. Cox proportional hazards models were used to calculate HRs and 95% CIs for incident RA depending on the tertiles of consumption of overall, lean and oily fish. Models were adjusted for age and for the main potential confounders. Stratified analyses were conducted depending on the active smoking status (never or ever-smoker).

Results

Among 62,629 women, 480 incident cases of RA were identified. In the overall population, we did not find a linear association between overall fish consumption and RA risk (p for trend 0.65), but a moderate consumption of fish (16.7−31.1 g/day, roughly corresponding to 1 to 2 servings a week) was associated with a decreased risk of RA (HR 0.74; 95% CI 0.59—0.94 for tertile 2 compared with tertile 1), especially among ever smoking women (HR 0.61; 95% CI 0.44—0.85). Although not statistically significant, a trend towards an inverse association was only found with oily fish consumption (HR 0.81; 95% CI 0.65—1.02 for tertile 2), but not with lean fish.

Conclusion

In our large population-based cohort study of French women, there was a U-shaped relationship between overall fish consumption and the risk of RA, with a reduced RA risk only in moderate consumers. The inverse association was restricted to ever-smokers. When separately considering oily and lean fish, the second tertile of oily fish consumption was inversely associated with the risk of RA only in never-smokers, while there was no association with lean fish.

Table 1.

Hazard ratios (95% confidence intervals) for the risk of rheumatoid arthritis (RA) by tertiles of fish consumption (N = 62,629)

Fish consumptionNon-cases N (%)RA N (%)Model 1 HR (95% CI)Model 2 HR (95% CI)All populationN=62,149N=480 Tertile 1 (0−16.7 g/day)20,509 (33.00)172 (35.83)ReferenceReference Tertile 2 (16.7−31.1 g/day)19,628 (31.58)121 (25.21)0.74 [0.58; 0.93]0.74 [0.59; 0.94] Tertile 3 (31.1−261 g/day)22,012 (35.42)187 (38.96)0.99 [0.80; 1.22]0.99 [0.80; 1.22]  Ptrend0.630.65Never smokersN=33,314N=244 Tertile 1 (0−16.7 g/day)11,322 (33.99)79 (32.38)ReferenceReference Tertile 2 (16.7−31.1 g/day)10,556 (31.69)66 (27.05)0.89 [0.64; 1.24]0.90 [0.65; 1.25] Tertile 3 (31.1−261 g/day)11,436 (34.33)99 (40.57)1.19 [0.88; 1.60]1.21 [0.90; 1.64]  Ptrend0.150.12Ever smokersN=28,835N=236 Tertile 1 (0−16.7 g/day)9,187 (31.86)93 (39.41)ReferenceReference Tertile 2 (16.7−31.1 g/day)9,072 (31.46)55 (23.31)0.60 [0.43; 0.84]0.61 [0.44;0.85] Tertile 3 (31.1−261 g/day)10,576 (36.68)88 (37.29)0.81 [0.60; 1.09]0.81 [0.60; 1.08]  Ptrend0.390.36

M1: Adjusted for total daily intake and age

M2: M1+ body mass index (kg/m2), smoking status (current smoker, non-smoker, former smoker, except for stratified analyses), passive smoking in childhood (no, yes), gastrointestinal transit (normal, diarrhoea, constipation, alternating diarrhoea/constipation), educational level (< High School, up to 2-level university, 3-4 level university), and physical activity (in quartiles)

Disclosure of Interests

None declared

AB1131 IDENTIFICATION OF FACTORS ASSOCIATED WITH THE OCCURRENCE OF SEVERE FORMS OF COVID-19 INFECTION IN PATIENTS WITH AUTOIMMUNE/INFLAMMATORY RHEUMATIC DISEASES

Background

Patients with autoimmune/inflammatory rheumatic diseases (AIRD) were suspected to be an at-risk population of severe COVID-19. However, whether this higher risk is linked to the disease or to its treatment is difficult to determine.

Objectives

To identify, among AIRD patients, factors associated with occurrence of moderate-to-severe COVID19 infection and to evaluate if having an AIRD was associated with an increased risk of severe form of COVID19 infection (defined by hospitalization in ICU or death), compared to general population.

Methods

Data source: The “Entrepôt des Données de Santé (EDS)” collect data from electronic health records of all patients hospitalized or followed in the AP-HP (39 hospitals in Paris area, France). The French RMD COVID19 cohort is a national multi-center cohort that included patients with confirmed AIRD and diagnosed with COVID-19. All AIRD patients diagnosed with COVID-19 before September 2020 from both cohorts were included.

-We Identified factors associated with severe COVID-19 was made in a combined analysis of the 2 cohorts.

-Then, we compared COVID-19 infection severity in the EDS-COVID database in AIRD patients and controls, by a propensity score (PS)-matched case-control (1:4) study

Results

Among 1213 patients (334 in EDS and 879 in RMD cohort), 195 (16.1%) experienced a severe COVID19. In multivariate analysis, greater age, history of interstitial lung disease, arterial hypertension, obesity, sarcoidosis, vasculitis, auto-inflammatory disease and treatment with corticosteroids or rituximab were associated with severe COVID-19 (Table 1).

Table 1.

AIRD patient’s characteristics associated with severity of COVID-19

Patients with mild or moderate infectionPatients with severe infectionOR ajustés 95%CIp-value(N = 1018)(N = 195)Patients characteristics Age55.9 (16.7%)70.3 (14.3%)1.05 [1.03;1.07]<0.001 Gender: Female695 (68.3%)105 (54.1%)0.59 [0.38;0.94]0.025 Interstitial pneumonia38 (3.7%)20 (10.3%)2.94 [1.34;6.34]0.008 Obesity143 (17.8%)38 (27.7%)2.09 [1.26;3.43]0.004 Hypertension268 (26.3%)114 (58.5%)1.81 [1.13;2.89]0.013Underlying Disease: Chronic inflammatory arthritis618 (60.8%)72 (36.9%)Ref. Auto-inflammatory disease29 (2.9%)5 (2.6%)3.91 [1.2;11.32]0.025 Other29 (2.9%)4 (2.1%)0.35 [0.06;1.41]0.15 Connectivitis190 (18.7%)34 (17.4%)1.13 [0.62;2.01]0.69 Sarcoidosis40 (3.9%)24 (12.3%)5.19 [2.15;12.3]<0.001 Vasculitis111 (10.9%)56 (28.7%)1.8 [1.02;3.16]0.044Treatments Corticosteroid318 (31.2%)117 (60.0%)2.47 [1.58;3.87]<0.001 Leflunomide44 (4.3%)2 (1.0%)0.13 [0;0.97]0.045 Rituximab37 (3.7%)22 (11.5%)4.05 [1.96;8.27]<0.001Not significant in multivariate analysisCOPD, Asthma, Coronary heart diseases, stroke, diabetes, smoking, cancer, non-steroidal anti-inflammatory drugs, colchicine, hydroxychloroquine, methotrexate, salazopyrine, mycophenolate mofetil, azathioprine, intravenous immunoglobulins, anti-TNFα, anti-IL1, -IL6, -IL17, Abatacept, JAK inhibitor

Among 35741 COVID-19 patients in EDS, 316 with AIRD were compared to 1264 PS-matched controls. Severe form occurred in 118 (37,3%) AIRD cases and 384 (30.4%) controls (Adjusted OR (aOR) for severe form= 1.43 [1.1;1.9], p=0,01). In analysis restricted to rheumatoid arthritis (RA) and spondylarthritis (SpA), no increased risk of severe form (aOR=1.11 [0.68;1.81]) form or death (aOR=1.00 [0.55;1.81]) was observed.

Conclusion

In this multicenter study we confirmed that AIRD patients treated with rituximab or corticosteroids were at increased risk of severe COVID-19, as were those with vasculitis, auto-inflammatory disease, and sarcoidosis. Also, when compared to controls from the same cohort of hospitalized patients, AIRD patients had, overall, an increased risk of severe COVID-19, increased risk not observed in an analysis restricted to patients with RA or SpA.

Acknowledgements

FAI2R /SFR/SNFMI/SOFREMIP/CRI/IMIDIATE consortium and contributors

Patricia Martel

All clinicians/physicians implicated in COVID-19 patient care in APHP hospital and generated EDS patient data

Disclosure of Interests

None declared

OP0254 FACTORS ASSOCIATED WITH THE SEVERITY OF COVID-19 INFECTION IN PATIENTS WITH SPONDYLOARTHRITIS: RESULTS OF THE FRENCH RMD COVID-19 COHORT

Background

To our knowledge, no published work has described precisely the severity and evolution of SARS-CoV-2 infection in patients with spondyloarthritis (SpA). Data on COVID-19 from cohorts of patients with immune-mediated inflammatory diseases concern small samples of SpA.

Objectives

Our objective was to describe the severity and course of COVID-19 in a large cohort of patients with SpA, including axial SpA (axSpA) and psoriatic arthritis (PsA), and to identify factors associated with severe forms.

Methods

Patients: individuals with Spondyloarthritis (SpA) from the French RMD COVID-19 cohort (observational, national, multicenter cohort) with a diagnosis of COVID-19 (clinical, PCR, CT or serology) were included.

Data collected: demographics, type of SpA, comorbidities, treatments, severity of COVID-19. Severity of COVID-19 was graded according to care needed: mild = outpatient care; moderate = non-intensive hospital treatment; severe = intensive care unit admission or death; severe = moderate or severe.

Statistical analyses: Logistic regression models were used to identify factors associated with these severe forms. All variables with p <0.20 in the univariate analysis were proposed in the multivariate model. Treatment variables (non-steroidal anti-inflammatory drugs (NSAIDs), methotrexate (MTX), sulfasalazine (SLZ), TNF inhibitors (TNFi), IL-17 inhibitors (IL-17i) and IL-23p19/p40 inhibitors (IL-23p19/p40i)) were included in the models, even if p≥0.20.

Results

Between March 2020 and April 2021, 626 SpAs reported COVID-19 with a mild course in 508 cases (81.1%), moderate in 93 cases (14.8%), and severe in 25 cases (3.9%), including 6 deaths.

The cohort analyzed included 349 women (55.8%), mean age 49.3 ± 14.1 years, mean BMI 27.1 ± 5.4 with 403 axSpA (64.4%), 187 PsA (29.9%) and 36 other SpA, duration of disease 11.3 ± 9.8 years; 352 (56.2%) had at least one comorbidity, of which obesity (23.6%), hypertension (15.5%), and smoking (10.4%) were the most frequent. Among them, 104 were treated with NSAIDs (16.6%), 186 with conventional synthetic disease-modifying antirheumatic drugs (DMARDs) including 156 MTX, and 460 (73.5%) with biological DMARDs (379 TNFi, 57 IL-17i, 15 IL-23p19/p40i, 9 others).

The following variables were associated with severe COVID-19 outcomes: age, body mass index, chronic obstructive lung disease, cardiovascular disease, diabetes, hypertension, interstitial lung disease, renal failure, and corticosteroids intake.

The factors independently associated with severe COVID-19 outcomes were corticosteroid intake (3.15 [CI95%: 1.46-6.76], p 0.004), and age (OR=1.06 [CI95%: 1.04-1.08], p <0.001] while anti-TNF (OR=0.26 [CI95%: 0.09-0.78], p=0.01]) was protective. NSAIDs intake (OR=0.97 [CI95%: 0.48-1.98]), SLZ (OR=7.9 [CI95%: 0.60-103]), or anti-IL17 (OR=0.37 [CI95%: 0.10-1.31]) was not associated with infection severity.

Conclusion

The course of COVID-19 was mild for the majority of SpA patients (81.1%). Corticosteroid intake was associated with more severe COVID-19 outcomes, whereas TNFi were found to be protective.

Disclosure of Interests

None declared

AB0123 IMPACT OF TOBACCO ON PRIMARY SJÖGREN SYNDROME: ANALYSIS OF THE FRENCH COHORT ASSESS

Background

It has been shown that smoking could be negatively associated with the risk of developing primary Sjögren’s Syndrome (pSS), and that amongst smoking pSS patients, seropositivity for anti SSA antibodies and frequency of focal sialadenitis were lower. However, data are scarce concerning the impact of smoking on disease activity, glandular features, patient reported outcomes (PROs) and disease progression.

Objectives

To describe the impact on smoking on pSS disease characteristics and outcome.

Methods

ASSESS (Assessment of Systemic Signs and Evolution in Sjögren’s Syndrome) is a French prospective multicenter, longitudinal cohort involving 395 patients with pSS enrolled in 15 French centers between 2006 and 2009 and followed since then. In these patients, we compared baseline characteristics and outcome (change in activity and PROs) during the first 5 years of follow-up, according to their smoking status (ever/never). For change during follow-up, any change of ≥ 3 points of ESSDAI or ≥ 1 point of ESSPRI or individual VAS, ≥ 25% of unstimulated salivary flow (UWSF) were considered.

Results

Data on smoking at inclusion were available for 394 patients, 106 (26.9%) of them were ever-smokers. Compared to never smokers, ever-smokers were significantly younger (54.0 ± 11.3 vs 59.2 ± 12.2, p < 0.001), and more frequently men (14 (13.2%) vs 12 (4.2%), p = 0.0013). The mean ESSDAI did not differ according to smoking status, (5.0 ± 4.9 vs 5.5 ± 5.8, p = 0.436).

There were no significant differences regarding the use of corticosteroids (49 (46.2%) vs 159 (55.2%), p = 0.113), immunosuppressive drugs (21 (19.8%) vs 77 (26.7%), p = 0.158), or hydroxychloroquine (49 (46.2%) vs 165 (57.3%), p = 0.05), even though numerically less smokers were taking these treatments. Smokers tended to have a lower dryness VAS and were less likely to use treatment for dry mouth (64 (60.4%) vs 210 (73%), p = 0.016).

No difference was observed in PROs (ESSPRI 5.2 ± 2.2 vs 5.5 ± 2.1, p = 0.259), and in UWSF (0.5 ± 0.75 vs 0.4 ± 1.0, p = 0.672) between smokers and non-smokers.

After five years, no difference in change of disease activity (ESSDAI change ≥ 3 points: 12/77 (15.6%) vs 30/207 (14.5%), p = 0.818), or in PROs (ESSPRI change ≥ 1: 30/70 (42.9%) vs 91/198 (46%) p = 0.654) was observed according smoking status, as well as no change in dryness (p = 0.968), pain (p = 0.280), fatigue (p = 0.605) or in UWSF (p = 0.132).

Table 1.

Baseline characteristics and change in patient-reported outcomes at 5 years

BaselineSmokers n = 106Non smokers n = 288p-valueAge (years)54.0 ± 11.359.2 ± 12.20.00008Sex, females92 (86.0)276 (95,8)0.0013Disease duration (years) median [IQR]3.9 [1.1; 8.7]5.5 [2.6; 9.7]0.257ESSPRI5.2 ± 2.2 (n = 97)5.5 ± 2.1 (n = 267)0.259 Dryness4.9 ± 2.5 (n = 98)5.5 ± 2.2 (n = 270)0.053 Fatigue5.9 ± 2.8 (n =101)6.0 ± 2.6 (n = 275)0.924 Pain4.6 ± 2.8 (n = 101)4.9 ± 2.9 (n = 274)0.359Unstimuled salivary flow (mL/min)0.5 ± 0.75 (n = 89)0.4 ± 1.0 (n = 241)0.672Treatment for dry mouth64 (60.4)210 (73.0)0.016ESSDAI5.0 ± 4.9 (n = 104)5.5 ± 5.8 (n = 281)0.436Corticosteroids49 (46.2)159 (55.2)0.113Hydroxychloroguine49 (46.2)165 (57.3)0.050Immunosuppresive drugs21 (19.8)77 (26.7)0.158Lymphocytes count (/mm3)1661.1 ± 919.31492.1 ± 1072.0 (n = 280)0.128After five yearsChange in ESSDAI ≥ 312 (15.6) (n = 77)30 (14.5) (n = 207)0.818Change in ESSPRI ≥ 130 (42.9) (n = 70)91 (46.0) (n = 198)0.654Change in salivary flow ≥ 25%29 (44.6) (n = 65)55 (34.0) (n = 162)0.132

Data are given as mean ± SD or n (%) unless otherwise specified. SD, standard deviation; IQR, interquartile range; ESSPRI, EULAR Sjögren’s Syndrome Patient Reported Index; ESSDAI, EULAR Sjögren’s Syndrome Disease Activity Index.

Continuous variables were compared using student t test and qualitative variable using chi-square

Conclusion

Smokers pSS patients are more likely to be men and younger than non-smokers. Ever smokers tended to have less dryness, and take less frequently treatment for dryness, corticosteroids, hydroxychloroquine or immunosuppressants. After five years, no difference was observed, according to smoking status, in terms of change in disease activity or PROs.

Disclosure of Interests

None declared

Risk of malignancy in rheumatoid arthritis patients initiating biologics: an historical propensity score matched cohort study within the French nationwide healthcare database

Objective

To compare the risk of malignancy between patients with rheumatoid arthritis (RA) initiating their first biological disease-modifying antirheumatic drug (bDMARD) and those continuing conventional synthetic DMARDs (csDMARDs).

Methods

Nine-year historical Propensity Score (PS) matched cohort study within the French national healthcare database (87% of the French population; ~57 million people), including adults RA without malignancy. Exposures started with the first use of any systemic treatment (csDMARDs and/or bDMARDs). Incident users of bDMARDs were matched on a dynamic PS to patients continuing csDMARDs. Their risk of malignancy was compared by Cox model.

Results

From 1 January 2007 to 31 December 2014, 83 706 patients with RA started their first systemic treatment (63 837 remained on csDMARDs and 19 869 initiated a bDMARD during follow-up). After dynamic PS matching, 19 727 bDMARD initiators were compared with 19 727 RA remaining on csDMARDs. They did not statistically differ in risk of overall malignancies (HR 0.99 (95% CI 0.86 to 1.14)), solid cancer (HR 0.95 (95% CI 0.82 to 1.11)), nor lymphoma (HR 1.35 (95% CI 0.72 to 2.53)). Results were similar when bDMARDs were given as monotherapy or in association with csDMARDs. Analyses restricted to patients starting TNF inhibitor as first bDMARD compared with matched RA remaining on csDMARDs, provided similar results (HR for overall malignancy 1.03 (95% CI 0.88 to 1.21)). Sensitivity analyses, varying carry-over periods (up to 5 years) to define risk periods, provided similar results.

Conclusions

In this historical cohort study within the French nationwide healthcare database, the risk of overall, solid or haematological malignancies did not significantly differ between patients with RA initiating bDMARD and those continuing csDMARDs.

POS0711 TOLERANCE AND EFFICACY OF TARGETED THERAPIES PRESCRIBED FOR OFF-LABEL INDICATIONS IN REFRACTORY SYSTEMIC AUTOIMMUNE DISEASES: DATA OF THE FIRST 100 PATIENTS ENROLLED IN THE TATA REGISTRY (TARGETED THERAPY IN AUTOIMMUNE DISEASES)

Background

The low prevalence of systemic autoimmune diseases and the diversity of their clinical manifestations make complex to conduct randomised clinical trials to assess the potential efficacy of targeted treatments.

Objectives

To assess the tolerance and efficacy of targeted therapies prescribed off-label in refractory autoimmune diseases.

Methods

The TATA registry (TArgeted Therapy in Autoimmune Diseases) is a prospective, observational, national and independent cohort follow-up. The inclusion criteria in the registry are as follows: age > 18 years; rare systemic autoimmune disease (systemic lupus erythematosus, Sjögren’s syndrome, systemic scleroderma, inflammatory myopathy, vasculitis) or other refractory rheumatism treated with off-label drugs started after 1st January 2019.

Results

Hundred (100) patients (79 females) were enrolled. The median age was 52.5 years [49;56], the median disease duration before enrolment was 5 years [3;7]. The targeted therapies at enrolment were as follows: JAK/STAT inhibitors (44%), anti-IL6R (22%), anti-IL12/23, anti-IL23 and anti-IL17 (9%), anti-BAFF (5%), abatacept (5%), other targeted treatments (9%), and combination of targeted treatments (6%). 73% of patients were receiving corticosteroid therapy at enrolment (median dose 10 mg/day). The current median follow-up time is 9 months [8;10].

Safety: 11 serious infections (incidence rate of 14.8 /100 patient-years) and 1 cancer (1.3 cancers/100 patient-years) were observed. Two patients died from severe COVID-19 (2.7 deaths/100 patient-years).

Efficacy: The targeted treatment was considered effective by the clinician in 56% of patients and allowed in responders a median reduction of oral corticosteroids of 15 [9-21] mg/day.

Conclusion

These initial results of the TATA registry confirm the diversity of targeted treatments prescribed off-label in refractory autoimmune diseases and their corticosteroid-sparing effect when effective. Tolerance was acceptable in these refractory patients with a long history of treatment with immunosuppressive drugs.

References

[1]B. Terrier et al., Safety and efficacy of rituximab in systemic lupus erythematosus: results from 136 patients from the French AutoImmunity and Rituximab registry. Arthritis Rheum 62, 2458-2466 (2010).

[2]J. E. Gottenberg et al., Efficacy of rituximab in systemic manifestations of primary Sjogren’s syndrome: results in 78 patients of the AutoImmune and Rituximab registry. Ann Rheum Dis 72, 1026-1031 (2013).

[3]J. E. Gottenberg et al., Risk factors for severe infections in patients with rheumatoid arthritis treated with rituximab in the autoimmunity and rituximab registry. Arthritis Rheum 62, 2625-2632 (2010).

[4]F. R. S. S. S. C. I. consortium, contributors, Severity of COVID-19 and survival in patients with rheumatic and inflammatory diseases: data from the French RMD COVID-19 cohort of 694 patients. Ann Rheum Dis, (2020).

[5]R. Felten et al., B-cell targeted therapy is associated with severe COVID-19 among patients with inflammatory arthritides: a 1-year multicentre study in 1116 successive patients receiving intravenous biologics. Ann Rheum Dis 81, 143-145 (2022).

[6]D. J. Wallace et al., Baricitinib for systemic lupus erythematosus: a double-blind, randomised, placebo-controlled, phase 2 trial. Lancet 392, 222-231 (2018).

[7]J. J. Paik et al., Study of Tofacitinib in Refractory Dermatomyositis: An Open-Label Pilot Study of Ten Patients. Arthritis Rheumatol 73, 858-865 (2021).

[8]S. Cole et al., Integrative analysis reveals CD38 as a therapeutic target for plasma cell-rich pre-disease and established rheumatoid arthritis and systemic lupus erythematosus. Arthritis Res Ther 20, 85 (2018).

[9]S. J. Bowman et al., Safety and efficacy of subcutaneous ianalumab (VAY736) in patients with primary Sjogren’s syndrome: a randomised, double-blind, placebo-controlled, phase 2b dose-finding trial. Lancet 399, 161-171 (2022).

Acknowledgements

French networks (FAI2R, CRI, IMIDIATE, SFR, SNFMI) focused on rare systemic autoimmune diseases contributed this work by the contribution of network-affiliated physicians.

Disclosure of Interests

Jacques-Eric Gottenberg Consultant of: Abbvie, BMS, Gilead, Galapagos, Novartis, Lilly Roche Chugai, Sanofi, Janssen, Pfizer, Grant/research support from: BMS.

Lilly and Pfizer for this register (with no access to data)., Aurore Chaudier: None declared, Yves Allenbach: None declared, Arsene Mekinian: None declared, Zahir Amoura: None declared, Patrice cacoub: None declared, Divi Cornec: None declared, Eric Hachulla: None declared, Pierre Quartier: None declared, isabelle melki: None declared, Christophe Richez: None declared, Raphaèle Seror: None declared, Benjamin Terrier: None declared, Valerie Devauchelle-Pensec: None declared, Julien Henry: None declared, MARC GATFOSSE: None declared, LAURENCE BOUILLET: None declared, Emeline GAIGNEUX: None declared, Vincent ANDRE: None declared, Gildas BAULIER: None declared, Aurélie SAUNIER: None declared, Marie Desmurs: None declared, Antoine POULET: None declared, Mathieu ETE: None declared, Marie-Elise Truchetet: None declared, Martin Michaud: None declared, Claire Larroche: None declared, AZEDDINE DELLAL: None declared, Amelie LEURS: None declared, Sebastien Ottaviani: None declared, Hubert NIELLY: None declared, Guillaume VIAL: None declared, Roland JAUSSAUD: None declared, Benedicte ROUVIERE: None declared, Pierre-Yves JEANDEL: None declared, Aurelien GUFFROY: None declared, Anne-Sophie Korganow: None declared, Mathieu JOUVRAY: None declared, alain meyer: None declared, Emmanuel Chatelus: None declared, Christelle Sordet: None declared, Renaud FELTEN: None declared, Jean Sibilia: None declared, Samira AHMED YAHIA: None declared, Jean François Kleinmann: None declared, Xavier Mariette Consultant of: BMS, Galapagos, GSK, Janssen, Novartis, Pfizer, Sanofi, UCB

OP0286 DEVELOPMENT AND PRELIMINARY VALIDATION OF THE SJÖGREN’S TOOL FOR ASSESSING RESPONSE (STAR): A CONSENSUAL COMPOSITE SCORE FOR ASSESSING TREATMENT EFFECT IN PRIMARY SJÖGREN’S SYNDROME

Background

Today, there are still no DMARDs licensed for primary Sjögren Syndrome (pSS) patients. Among the explanations, are the limitations of current outcome measures used as primary endpoints: e.g; high placebo response rate, evaluation of either symptoms or systemic activity, and important features not being assessed. The NECESSITY consortium (https://www.necessity-h2020.eu/), including pSS experts from academia, pharmaceutical industry and patient groups formed to develop a new composite responder index, the Sjögren’s Tool for Assessing Response (STAR) that solve the issues of current outcome measures in pSS and is intended for use in clinical trials as an efficacy endpoint.

Objectives

To develop a composite responder index in primary Sjögren’s syndrome (pSS): the STAR.

Methods

To develop the STAR, the NECESSITY consortium used data-driven methods, based on 9 randomized controlled trials (RCTs), and consensus techniques, involving 78 experts and 20 patients. Based on reanalysis of rituximab trials (TRACTISS and TEARS) and literature review, the Delphi panel identified a core set of domains to include in the STAR, with their respective outcome measures. STAR options combining these domains were designed and proposed to the panel to select and improve them. For each STAR option, sensitivity to change was estimated by the C-index (derived from Effect size) in all 9 RCTs. Delphi rounds were run for selecting STAR among these options. The Delphi panel also voted to classify trials as positive, negative or “in between” in regards to primary but also key secondary endpoints. For the options remaining before the final vote, meta-analyses of the RCTs were performed separately for positive and “in between” trials together, and for negative trials.

Results

The Delphi panel identified 5 core domains (systemic activity, patient symptoms, lachrymal gland function, salivary gland function and biological parameters), and 227 STAR options, combining these domains, were selected to be tested for sensitivity to change. After two Delphi rounds, meta-analyses of the 20 remaining options were performed. The candidate STAR was selected by a final vote based on metrological properties and clinical relevance. In positive/in between trials, candidate STAR detected a difference between arms (OR 3.29, 95%-CI [2.07;5.22], whereas it did not in negative trials (OR 1.53, 95%-CI [0.81;2.91]).

Conclusion

The candidate STAR is a composite responder index, including in a single tool all main disease features, and is designed for use as a primary endpoint in pSS RCTs. Its rigorous and consensual development process ensures its face and content validity. The candidate STAR showed good sensitivity and specificity to change. The candidate STAR will be prospectively validated in a dedicated three arms RCT of the NECESSITY consortium that will evaluate combination of synthetic DMARDs (hydroxychloroquine + lefunomide or hydroxychloroquine + mycophenolate vs placebo). We encourage the use of STAR in any ongoing and future trials.

Table 1.

Candidate STAR

DomainPointDefinition of responseSystemic activity3Decrease of clinESSDAI ≥ 3Patient reported outcome3Decrease of ESSPRI ≥ 1 point or ≥ 15%Lachrymal gland function1Schirmer:If abnormal score at baseline: increase ≥ 5 mm from baselineIf normal score at baseline: no change to abnormalOrOcular Staining Score:If abnormal score at baseline: decrease ≥ 2 points from baselineIf normal score at baseline: no change to abnormalSalivary gland function1Unstimulated Whole Salivary Flow:If score > 0 at baseline: increase ≥ 25% from baselineIf score is 0 at baseline: any increase from baselineorUltrasound:Decrease ≥ 25% in total Hocevar score from baselineBiological1Serum IgG levels: decrease ≥ 10%orRheumatoid Factor levels: decrease ≥ 25%Candidate STAR responder≥ 5 points

ESSDAI: EULAR Sjögren syndrome disease activity index; ESSPRI: EULAR Sjögren syndrome patient reported index; IgG: Immunoglobulin G;

Acknowledgements

NECESSITY WP5 STAR development participants: Suzanne Arends (University Medical Center Groningen, Department of Rheumatology and Clinical Immunology, Groningen 9700 RB, Netherlands), Francesca Barone (Centre for Translational Inflammation Research, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK), Albin Björk (Division of Rheumatology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden), Coralie Bouillot (Association Française du Gougerot Sjögren et des Syndromes Secs, France), Guillermo Carvajal Alegria (University of Brest, Inserm, CHU de Brest, LBAI, UMR1227, Brest, France; Service de Rhumatologie, Centre de Référence Maladies Autoimmunes Rares CERAINO, CHU Cavale Blanche, Brest, France), Wen-Hung Chen (GlaxoSmithKline, Research Triangle Park, North Carolina, USA), Kenneth Clark (GlaxoSmithKline Medicines Research Centre, Gunnels Wood Road, Stevenage, Hertfordshire SG1 2NY, United Kingdom), Konstantina Delli (Department of Oral and Maxillofacial Surgery, University Medical Center Groningen (UMCG), University of Groningen, The Netherlands), Salvatore de Vita (Rheumatology Clinic, University Hospital of Udine, Italy), Liseth de Wolff (University Medical Center Groningen, Department of Rheumatology and Clinical Immunology, Groningen 9700 RB, Netherlands), Jennifer Evans (Novartis Pharmaceuticals corporation USA), Stéphanie Galtier (Institut de Recherches Internationales Servier (IRIS), Suresnes Cedex, France), Saviana Gandolfo (Rheumatology Clinic, Department of Medical area, University of Udine, ASUFC, 33100 Udine, Italy), Mickael Guedj (Institut de Recherches Internationales Servier (IRIS), Suresnes Cedex, France), Dewi Guellec (CHU de Brest, Service de Rhumatologie, Inserm, CIC 1412, Brest, France), Safae Hamkour (Center of Translational Immunology, Department of Immunology, University Medical Center Utrecht, Utrecht 3584 GA, Netherlands), Dominik Hartl (Novartis Institutes for BioMedical Research, Basel, Switzerland), Malin Jonsson (Section for Oral and Maxillofacial Radiology, Department of Clinical Dentistry, Faculty of Medicine and Dentistry, University of Bergen, Norway), Roland Jonsson (Broegelmann Research Laboratory, Department of Clinical Science, University of Bergen, Department of Rheumatology, Haukeland University Hospital, Bergen, Norway), Frans Kroese (University Medical Center Groningen, Department of Rheumatology and Clinical Immunology, Groningen 9700 RB, Netherlands), Aike Albert Kruize (University Medical Center Utrecht, Department Rheumatology and Clinical Immunology, Utrecht, Netherlands), Laurence Laigle (Institut de Recherches Internationales Servier (IRIS), Suresnes Cedex, France), Véronique Le Guern (AP-HP, Hôpital Cochin, Centre de référence maladies auto-immunes et systémiques rares, service de médecine interne, Paris, France), Wen-Lin Luo (Department of Biometrics and Statistical Science, Novartis Pharmaceuticals, East Hanover, New Jersey), Esther Mossel (University Medical Center Groningen, Department of Rheumatology and Clinical Immunology, Groningen 9700 RB, Netherlands), Wan-Fai Ng (Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne NE2 4HH, UK), Gaëtane Nocturne (Department of Rheumatology, Université Paris-Saclay, INSERM U1184: Centre for Immunology of Viral Infections and Autoimmune Diseases, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin Bicêtre, Paris, France), Marleen Nys (Global Biometric Sciences, Bristol Myers Squibb, Braine L’Alleud, Belgium), Roald Omdal (Clinical Immunology Unit, Department of Internal Medicine, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway), Jacques-Olivier Pers (LBAI, UMR1227, University of Brest, Inserm, Brest, France and CHU de Brest, Brest, France), Maggy Pincemin (Association Française du Gougerot Sjögren et des Syndromes Secs, France), Manel Ramos-Casals (Department of Autoimmune Diseases, Hospital Clinic de Barcelona Institut Clinic de Medicinai Dermatologia, Barcelona, Catalunya, Spain), Philippe Ravaud (Centre d’Epidémiologie Clinique, Hôpital Hôtel-Dieu, Assistance Publique-Hôpitaux de Paris, Paris, France), Neelanjana Ray (Global Drug Development - Immunology, Bristol Myers Squibb Company, Princeton, New Jersey, USA), Alain Saraux (HU de Brest, Service de Rhumatologie, Univ Brest, Inserm, UMR1227, Lymphocytes B et Autoimmunité, Univ Brest, Inserm, LabEx IGO, Brest, France), Athanasios Tzioufas (Rheumatology Clinic, Department of Medical area, University of Udine, ASUFC, 33100 Udine, Italy), Gwenny Verstappen (University Medical Center Groningen, Department of Rheumatology and Clinical Immunology, Groningen 9700 RB, Netherlands), Arjan Vissink, Marie Wahren-Herlenius (Division of Rheumatology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden). We thank the following experts: Esen Karamursel Akpek, Alan Baer, Chiara Baldini, Elena Bartoloni, Marí-Alfonso Begona, Johan Brun, Vatinee Bunya, Laurent Chiche, Troy Daniels, Paul Emery, Robert Fox, Roberto Giacomelli, John Gonzales, John Greenspan, Robert Moots, Susumu Nishiyama, Elizabeth Price, Christophe Richez, Caroline Shiboski, Roser Solans Laque, Muthiah Srinivasan, Peter Olsson, Tsutomu Takeuchi, Frederick Vivino, Paraskevi Voulgari, Daniel Wallace, Ava Wu, Wen Zhang. We thank the anonymous patients from the NECESSITY Patient Advisory Group and the Sjögren Foundation for their valuable contribution to the Delphi process. We thank EW StClair and AN Baer who generated the baminercept data and made them publicly available.

Disclosure of Interests

Raphaèle Seror Consultant of: GlaxoSmithKline, Boehringer, Janssen and Novartis, Grant/research support from: GlaxoSmithKline and Amgen, Gabriel Baron: None declared, Marine Camus: None declared, Divi Cornec Consultant of: GlaxoSmithKline, Bristol Myers Squibb, Janssen, Amgen, Pfizer and Roche, Elodie Perrodeau: None declared, Simon J. Bowman Consultant of: Abbvie, Astra Zeneca, Galapagos and Novartis Pharmaceuticals, Michele Bombardieri Consultant of: UCB, Amgen/Medimmune, Janssen, and GlaxoSmithKline, Grant/research support from: Amgen/Medimmune, Janssen, and GlaxoSmithKline, Hendrika Bootsma: None declared, Jacques-Eric Gottenberg Consultant of: AbbVie, Bristol Myers Squibb, Eli Lilly, Galapagos, Gilead, Pfizer, Roche, Sanofi, Novartis, MSD, CSL-Behring and Genzyme, Grant/research support from: Bristol Myers Squibb, Benjamin Fisher Speakers bureau: Bristol Myers Squibb and Novartis, Consultant of: Novartis, Bristol Myers Squibb, Janssen and Servier, Grant/research support from: Servier, Galapagos and Janssen, Wolfgang Hueber Shareholder of: Novartis Pharma, Employee of: Novartis Pharma, Joel van Roon: None declared, Valerie Devauchelle-Pensec: None declared, Peter Gergely Shareholder of: Novartis Pharma, Employee of: Novartis Pharma, Xavier Mariette Consultant of: Bristol Myers Squibb, Galapagos, GlaxoSmithKline, Janssen, Novartis, Pfizer and UCB, Grant/research support from: Ose Pharmaceuticals, Raphaël Porcher: None declared

AB0410 EVOLUTION OF MONOCLONAL GAMMOPATHY OF UNDETERMINED SIGNIFICANCE IN PATIENTS TREATED WITH JAK INHIBITORS FOR RHEUMATIC DISEASES (JAKPIC STUDY)

Background

Monoclonal Gammopathy of Undetermined Significance (MGUS) is common in patients with inflammatory rheumatic diseases but there are scarce data regarding the effect of disease-modifying antirheumatic drugs (DMARDs) on this pre-malignant condition. Recently, preclinical data and phase I trial have shown efficacy of JAK inhibitors (JAKi) in multiple myeloma.

Objectives

We aimed to evaluate the impact of JAKi on MGUS when initiated for an active rheumatic disease.

Methods

Patients with monoclonal abnormality prior to JAKi initiation for an active rheumatic disease were identified through the MAJIK-SFR Registry, a french multicentre prospective study, and a call for observation via the “Club Rhumatismes et Inflammations”. Clinical and biological data were collected using a standardised case report form.

Results

Nineteen patients were identified, 10 women and 9 men, with a mean age of 65 years and a diagnosis of rheumatoid arthritis (n=14), psoriatic arthritis (n=3) or spondyloarthritis (n=2). The JAKi prescribed was baricitinib (n=8), tofacitinib (n=6) or upadacitinib (n=5), with a mean duration of 13 months.

Sixteen patients had individualized serum monoclonal protein (IgG Kappa n=9; IgG Lambda n=6; IgM Kappa n=3; IgA Lambda n=1) ranging from 0,16g/dL to 2,3g/dL. With a follow-up of 2 to 47 months, 8 of 16 patients experienced a decrease in serum monoclonal protein level and 8 had a stable serum monoclonal protein level. The maximal decrease observed was an initial IgG Kappa of 2.3g/dL decreasing to 0.2g/dL at month 14. During follow-up, two patients did not have any detectable serum monoclonal protein on serum electrophoresis (initial value of 5.2g/l and 1.6g/l), but still a positive immunofixation. One patient had bone marrow aspirate with 8% of plasma cells before JAKi introduction and 3% after 4 months of treatment.

Three patients did not have initial measurable spike but a positive immunofixation that became negative at month 8 and 11 (IgG Lambda, n=2) or stable (IgG Kappa, n=1).

Conclusion

This study brings reassuring and promising data on the MGUS evolution in patients treated with JAKi for rheumatic diseases, which may guide the choice of treatment in patients with both conditions.

References

[1]Berenson JR, To J, Spektor TM, et al. A Phase I Study of Ruxolitinib, Lenalidomide, and Steroids for Patients with Relapsed/Refractory Multiple MyelomaClin Cancer Res. 2020 May 15;26(10):2346-2353.

Acknowledgements

MAJIK-SFR Registry and Club Rhumatismes et Inflammations

Disclosure of Interests

None declared

Passive smoking in childhood and adulthood and risk of rheumatoid arthritis in women: results from the French E3N cohort study

Objective

The association between passive smoking exposure in childhood or in adulthood, and the risk of rheumatoid arthritis (RA) has been incompletely investigated. We aimed to assess the relationship between exposure to passive smoking and the risk of incident RA in a French prospective cohort of healthy women.

Methods

The E3N Study (Etude Epidémiologique auprès des femmes de la Mutuelle générale de l’Education Nationale) is a French prospective cohort of women included in 1990. Exposures to passive smoking were assessed using self-reported questionnaires. RA cases were self-reported and subsequently validated. Cox proportional hazards regression models adjusted for age and for potential confounders were used to estimate HRs and 95% CIs for incident RA.

Results

Among 79 806 women, 698 incident cases of RA were identified; 10 810 (13.5%) women were exposed to passive smoking in childhood, and 42 807 (53.6%) in adulthood. Median age at inclusion was 47.8 years. Passive smoking in childhood and in adulthood was associated with RA risk in all models (HRs (95% CIs) 1.24 (1.01 to 1.51) and 1.19 (1.02 to 1.40), respectively). The absolute risk of RA among never smokers with exposure to passive smoking in childhood and/or adulthood (47.6/100 000 person-years) was close to the risk of ever smokers with no passive smoking exposure (47.2/100 000 person-years), while it was highest in ever smokers also exposed to passive smoking (53.7/100 000 person-years).

Conclusion

Exposure to passive smoking in childhood and/or adulthood increases the risk of RA by the same order than active smoking. Such exposure should be suppressed, especially in individuals at risk of RA.

Articular manifestations in patients with inflammatory bowel diseases treated with anti-TNF

Objective

To describe and identify factors associated with articular manifestations occurring in patients treated with anti-tumour necrosis factor (TNF) for inflammatory bowel diseases (IBDs).

Methods

Retrospective monocentric study, including all patients who received an anti-TNF for an IBD in our hospital. All incident articular manifestations occurring during treatment were analysed. Characteristics of patients with paradoxical articular manifestations were compared with that of patients without inflammatory articular manifestations.

Results

Between February 2013 and May 2017, we identified 442 patients (36.2±15 years, 50.5% men) who had ever received an anti-TNF for an IBD: Crohn’s disease (n=277), ulcerative colitis (n=154) and undetermined colitis (n=11). 115 (26%) patients developed new articular manifestations after a mean of 20 (±22) months of treatment. Among them, 59 (13.3%) had inflammatory manifestations: paradoxical in 39%, concomitant of an IBD flare in 27%, linked to an immunisation against anti-TNF in 27% and 7% to another diagnosis. Among paradoxical articular manifestations, 19 (83%) were new articular symptoms, including 8 (35%) de novo spondyloarthritis. There were no predictive factors of paradoxical articular manifestation. Paradoxical manifestations spontaneously resolved in 16 (70%) patients despite continuation of anti-TNF.

Conclusion

Inflammatory articular manifestations occurred in about 13% of patients treated with anti-TNF for IBD. More than a quarter were linked to an immunisation against anti-TNF, which has to be searched in this situation. About 40% were paradoxical. In most of cases, they were transitory and did not require anti-TNFs discontinuation.

Features of non-Hodgkin’s lymphoma diagnosed in minor salivary gland biopsies from primary Sjögren’s syndrome patients

Objective

To evaluate the contribution of minor salivary gland biopsy (mSGB) histology to diagnosing primary Sjögren’s syndrome (pSS)-associated non-Hodgkin B cell lymphoma (NHL).

Methods

pSS patients with mSGB at NHL diagnosis were included.

Results

Among the 24 patients (92.3% female; mean age: 61.3 years) with an mSGB at NHL diagnosis, 13 (54.2%) had mSGB-histology–revealed NHL (mSGB+); it was the only site enabling NHL diagnosis in 10/13 (76.9%) patients. Mucosa-associated lymphoid tissue (MALT) lymphoma was found in 23/24 (95.8%) patients; 100% of mSGB+ identified MALT lymphomas. pSS and lymphoma characteristics were comparable for mSGB+ and mSGB– patients. Eight (61.5%) of the 13 mSGB+ patients and all 11 mSGB– patients were treated for lymphoma. Between diagnosis and 1 year of follow-up, ESSDAI without the NHL item remained stable (7.4 vs 5.0; p = 0.33) for the five untreated patients, while it decreased significantly for the 19 treated patients (15.8 vs 5.1; p = 0.004).

Conclusion

For pSS patients with suspected NHL, mSGB histology enabled NHL diagnosis in half of them, MALT was found in 95.8% and all mSGBs+ were MALT lymphomas, thereby avoiding more invasive biopsy. Our results suggest that mSGB should be obtained at pSS diagnosis and repeated during follow-up, when NHL is suspected.

Use of 18F FDG PET-CT to discriminate polymyalgia rheumatica and atypical spondylarthritis in clinical practice

OBJECTIVE

To evaluate the relevance of ¹⁸F-labeled fluorodeoxyglucose-positron emission tomography/computed tomography (¹⁸F-FDG PET-CT) for discriminating polymyalgia rheumatica (PMR) and spondylarthritis (SpA) in atypical presentations.

METHODS

In 2 rheumatology departments, we identified PMR and atypical SpA patients who underwent ¹⁸F-FDG PET-CT and compared the 2 groups. The relevant ¹⁸F-FDG PET-CT findings identified on univariate analyses as discriminant for both groups were entered into a multivariable logistic regression model to derive a composite musculoskeletal score.

RESULTS

Between September 2012 and August 2018, we enrolled 35 PMR and 27 SpA patients (median [interquartile range] age 71 years [63.5-74.5] and 54 years [41.5-63], p < 0.001). ¹⁸F-FDG uptake in enthesis/bursae was more frequent in PMR than SpA (ischial tuberosities: 88.6% vs 48.1%, p < 0.001; interspinous processes: 91.4% vs 51.9%, p < 0.001). ¹⁸F-FDG uptake in sacroiliac joints was specific to SpA but rare (14.8% vs 0 in PMR, p < 0.05). The intensity of ¹⁸F-FDG uptake was similar in both conditions. The musculoskeletal score, including ¹⁸F-FDG uptake of the shoulders, ischial tuberosities and interspinous process, was higher for PMR than SpA patients (2.74 vs 1.11, p < 0.001). A score ≥ 2 provided sensitivity and specificity of 74.1% and 77.1% for the diagnosis of PMR.

CONCLUSION

¹⁸F-FDG PET-CT patterns of atypical SpA and PMR widely overlap, so differentiating the conditions is challenging. The use of the proposed PET-CT composite score could improve the diagnostic performance of ¹⁸F-FDG PET-CT to discriminate these 2 entities in clinical practice.

Facteurs associés à la sévérité de l’infection COVID-19 chez les patients atteints de spondyloarthrite : résultats de la French RMD COVID-19 cohorte

Introduction

Il n’y a pas, à notre connaissance, de publication décrivant précisément la sévérité et l’évolution de l’infection à SARS-CoV-2 dans la spondyloarthrite (SpA). Les données sur la COVID-19 issues des cohortes de patients avec maladies inflammatoires à médiation immunitaire concernent de faibles effectifs de SpA.

Notre objectif était de décrire la sévérité et l’évolution de la COVID-19 dans une large cohorte de patients atteints de SpA (SpA axiale et rhumatisme psoriasique) et d’identifier les facteurs associés aux formes sévères.

Patients et méthodes

Patients : spondyloarthrites (SpA) de la French RMD COVID-19 cohort (cohorte observationnelle, nationale, multicentrique) avec un diagnostic de COVID-19 (clinique, PCR, scanner ou sérologie). Données collectées : démographiques, type de SpA, comorbidités, traitements, gravité de la COVID-19. La gravité de la COVID-19 a été classée en fonction des soins nécessaires : bénin = soins ambulatoires ; modéré = traitement hospitalier non intensif ; sévère = admission en unité de soins intensifs ou décès ; grave = modéré ou sévère.

Analyses statistiques : des modèles de régression logistique ont été utilisés pour identifier les facteurs associés à ces formes graves. Toutes les variables avec p < 0,20 en analyse univariée ont été proposées dans le modèle multivarié. Les variables de traitement (AINS, méthotrexate [MTX], sulfasalazine [SLZ], anti-TNF et anti-IL17) étaient incluses dans les modèles, même si p ≥ 0,20.

Résultats

Entre mars 2020 et avril 2021, 626 SpA ont déclaré une COVID-19 dont l’évolution avait été bénigne dans 508 cas (81,1 %), modérée dans 93 cas (14,8 %) et sévère dans 25 cas (3,9 %), dont 6 décès.

La cohorte analysée comprenait 349 femmes (55,8 %), âge moyen 49,3 ± 14,1 ans, IMC moyen 27,1 ± 5,4 avec 403 SpA axiale (64,4 %), 187 RPso (29,9 %) et 36 autres SpA, durée de la maladie 11,3 ± 9,8 ans ; 352 (56,2 %) avaient au moins une comorbidité dont l’obésité (23,6 %), l’hypertension artérielle (15,5 %) et le tabagisme (10,4 %) étaient les plus fréquentes. Parmi eux, 104 étaient traités par AINS (16,6 %), 186 par csDMARD dont 156 méthotrexate, et 460 (73,5) % par biomédicaments (379 anti-TNF, 57 anti-IL17 : 57, 15 anti-IL12/23, 9 autres).

Les facteurs indépendamment associés à une COVID-19 grave étaient la corticothérapie (OR = 2,83 [IC95 % : 1,41–5,66]) et l’âge (OR = 1,07 [1,05–1,09]) alors le genre féminin (OR = 0,64 [0,41–0,99]) et les anti-IL17 (OR = 0,51 [0,32–0,81]) avaient un caractère protecteur. Un traitement par AINS (OR = 0,91 [IC95 % : 0,47–1,77]), par sulfasalazine (OR = 6,81 [0,59–77,41]) ou par anti-TNF (OR = 0,67 [0,33–1,35]) n’était pas associé à la gravité de l’infection.

Conclusion

L’évolution de la COVID-19 a été bénigne pour la majorité des patients atteints de SpA (81,1 %). La corticothérapie était associée à des infections plus graves alors que les anti-IL17 avaient un caractère protecteur.

Lymphoma complicating rheumatoid arthritis: results from a French case-control study

Objectives

To study the characteristics of B-cell non-Hodgkin’s lymphoma (NHL) or Hodgkin lymphoma complicating rheumatoid arthritis (RA) and to identify RA-related factors associated with their occurrence.

Methods

A multicentre case–control study was performed in France. Cases were patients with RA fulfilling ACR-EULAR 2010 criteria in whom B-cell NHL or Hodgkin lymphoma developed after the diagnosis of RA. For each case, 2 controls were assigned at random from the ESPOIR cohort and were matched on age at lymphoma diagnosis (cases)/age at the 10-year follow-up visit in the cohort (controls). Case and control characteristics were compared to identify parameters associated with the occurrence of lymphoma.

Results

54 cases were included and matched to 108 controls. Lymphomas were mostly diffuse large B-cell lymphoma (DLBCL, n=27, 50.0%). On immunochemistry, 4 of 27 (14.8%) lymphoma cases were positive for Epstein-Barr virus. On univariate analysis, factors associated with the occurrence of lymphoma were male sex (OR 3.3, 95% CI 1.7 to 6.7), positivity for ACPA (OR 5.1, 95% CI 2.0 to 15.7) and rheumatoid factor (OR 3.9, 95% CI 1.6 to 12.2), and erosions on radiographs (OR 3.8, 95% CI 1.7 to 8.3) and DAS28 (OR 2.0, 95% CI 1.5 to 2.7), both at the time of matching. Methotrexate, TNF blockers and a number of previous biologics were not associated with the occurrence of lymphoma. On multivariable analysis, erosions and DAS28 remained significantly associated with increased risk of lymphoma.

Conclusion

Lymphomas complicating RA are mostly DLBCL. Risk of lymphoma in patients with RA was increased with markers of disease activity and severity, which supports the paradigm of a continuum between autoimmunity and lymphomagenesis in RA.

Efficacy and safety of rituximab in peripheral ulcerative keratitis associated with rheumatoid arthritis

Objective

Peripheral ulcerative keratitis (PUK) is a rare but severe ocular complication of rheumatoid arthritis (RA). It can be considered as an ocular manifestation of rheumatoid vasculitis (RV). Our case series aimed to evaluate the efficacy of rituximab (RTX) for PUK occurring in patients with RA.

Methods

Study population were patients with RA-associated PUK treated with RTX 1000 mg on days 1 and 15 at least once after the diagnosis. We identified patients referred to the rheumatology and ophthalmology departments of our hospital between February 2014 and June 2020. We also included patients referred by their specialist after being contacted through the Club Rhumatismes et Inflammation. Demographic data and clinical and biological features were retrospectively collected.

Results

We included seven patients (three men and four women, median age 58 years). All but one had a long-standing RA with a median disease duration of 13.9 years (IQR 0–30.2). RA was erosive in six out of seven patients. All patients had rheumatoid factors and anticitrullinated peptides antibodies were positive in six of them. PUK was complicated by corneal perforation in three patients and required surgery. After a median follow-up of 29.8 months (IQR 5–75), corneal inflammation was controlled in all patients. PUK recurred in one patient, 8 months after a single infusion of RTX. 71% of the patients presented a good articular response. No patient developed other manifestations of RV. No serious adverse event related to RTX was observed.

Conclusion

RTX appears to be an efficient and safe therapeutic option in the treatment of RA-associated PUK.