[Frequency and severity of sarcopenia in patients with inflammatory and noninflammatory musculoskeletal diseases : Results of a monocentric study in a tertiary care center]

INTRODUCTION

Sarcopenia (SP) is defined as the pathological loss of muscle mass and function. This is a clinically relevant problem, especially in geriatric patients, because SP is associated with falls, frailty, loss of function, and increased mortality. People with inflammatory and degenerative rheumatic musculoskeletal disorders (RMD) are also at risk for developing SP; however, there is little research on the prevalence of this health disorder in this patient group using currently available SP criteria.

OBJECTIVE

To investigate the prevalence and severity of SP in patients with RMD.

METHODS

A total of 141 consecutive patients over 65 years of age with rheumatoid arthritis (RA), spondylarthritis (SpA), vasculitis, and noninflammatory musculoskeletal diseases were recruited in a cross-sectional study at a tertiary care center. The European Working Group on Sarcopenia in Older People (EWGSOP 1 and 2) definitions of presarcopenia, SP, and severe SP were used to determine the prevalence. Lean mass as a parameter of muscle mass and bone density were measured by dual X‑ray absorptiometry (DXA). Handgrip strength and the short physical performance battery (SPPB) were performed in a standardized manner. Furthermore, the frequency of falls and the presence of frailty were determined. Student's T-test and the χ2-test were used for statistics.

RESULTS

Of the patients included 73% were female, the mean age was 73 years and 80% had an inflammatory RMD. According to EWGSOP 2, 58.9% of participants probable had SP due to low muscle function. When muscle mass was added for confirmation, the prevalence of SP was 10.6%, 5.6% of whom had severe SP. The prevalence was numerically but not statistically different between inflammatory (11.5%) and noninflammatory RMD (7.1%). The prevalence of SP was highest in patients with RA (9.5%) and vasculitis (24%), and lowest in SpA (4%). Both osteoporosis (40% vs. 18.5%) and falls (15% vs. 8.6%) occurred more frequently in patients with SP than those without SP.

DISCUSSION

This study showed a relatively high prevalence of SP, especially in patients with RA and vasculitis. In patients at risk, measures to detect SP should routinely be performed in a standardized manner in the clinical practice. The high frequency of muscle function deficits in this study population supports the importance of measuring muscle mass in addition to bone density with DXA to confirm SP.

POS0994 DEVELOPMENT OF AN AUTOMATED ALGORITHM BASED ON METHODS OF ARTIFICIAL INTELLIGENCE TO ASSIST IN THE PREDICTION OF CORRECT REFERRALS OF PSORIATIC ARTHRITIS AND AXIAL SPONDYLOARTHRITIS BY USING PATIENT HISTORY TEXTS

Background

Diagnosis and treatment of PsA and axSpA is often delayed due to missing clear diagnostic criteria and limitations in resources for referral to rheumatologist including high numbers of incorrect referrals. Primary care is usually provided by either general practitioner, dermatologists, or orthopedics. Clinical discriminators with a high specificity for rheumatic conditions include morning stiffness (MST; peripheral or axial, >30min). Artificial intelligence (AI) and natural language processing (NLP) methods offer algorithms for learning systems to recognize disease associated terms and classify clinical phenotypes using large data sets that may support early identification of patients with suspected diagnosis of PsA or axSpA.

Objectives

AI and NLP methods are used to identify patients with typical attributes for inflammation by using morning stiffness as one potential discriminating pattern, which can be detected automatically and might help to prioritize referral for rheumatologist appointments.

Methods

Within a multicentre observational study, patients with visits at the rheumatologist with a suspected diagnosis of PsA or axSpA from the referral primary care provider were recruited. All data on clinical examinations and findings were collected and evaluated by rheumatologists in focus on criteria for diagnosis of PsA/axSpA (gold standard for evaluation). Unstructured text from the patient history was used to extract diagnosis-relevant characteristics. The information extraction algorithms used NLP models to detect expert curated “morning stiffness” (MST) keywords and puts them into a contextualized framework that allows to capture possible negations.

Results

A total of 116 patients were recruited (73 female, 63%) with a median age of 42 (IQR: 34-54). 51 patients were referred as axSpA (44%) and 60 as PsA (52%) by primary care providers. After preselection for PsA and axSpA patients, we observed a 23% rate of referrals without rheumatic diagnosis. Only 7.1% of patients were admitted without signs of MST, 29% with axial MST, 35% with peripheral MST and 28% with both MST types. Average morning stiffness duration was recorded as 35 minutes; patients with a finally confirmed rheumatic diagnosis had a higher average MST duration reported (36 minutes) compared to patients without a confirmed diagnosis. Our AI assisted extraction of MST identified MST in 82.7% of patient history texts. In 75% NLP methods correctly identified the negation of MST symptoms (6 of 8), and 94% of MST was detected when both axial and peripheral joints were affected (30 of 32). Manual inspection of 20 patient history reports where MST was not detected by our automated algorithm revealed that 17 reports did not contain information about MST and three mention unspecific early morning discomfort, without mention of MST.

Conclusion

The high rate of correct detection of MST from patient history text using NLP methods allowed us to assess the potential for NLP models to support automated analysis of patient reports to facilitate intelligent patient referral.

Acknowledgements

We thank the Fraunhofer Excellence Cluster for Immune-Mediated Diseases CIMD for the financial support.

Disclosure of Interests

None declared

POS0954 WHAT DOES IT MEAN – A GOOD RESPONSE TO NSAIDs? A SYSTEMATIC COMPARISON OF PATIENTS WITH AXIAL SPONDYLOARTHRITIS AND CONTROLS WITH CHRONIC BACK PAIN

Background

A fast response to non-steroidal anti-inflammatory drugs (NSAIDs) is an important finding in the evaluation of clinical findings within the items comprising the ASAS classification criteria but also for the treatment decision for escalation to a bDMARD in patients with axial spondyloarthritis (axSpA). However, the differentiation of NSAID responses between patients with axSpA and degenerative or unspecific back pain is still unclear.

Objectives

To study the differences in the velocity and magnitude of NSAID response velocity in patients with established bDMARD naïve axSpA vs. patients with other, non-inflammatory reasons of back pain.

Methods

Patients with axSpA without degenerative reasons for back pain or patients with degenerative or unspecific back pain presenting due to high levels of back pain (NRS≥4/10) were consecutively recruited. Assessments included clinical examination, laboratory tests and MRI of the lumbar spine.

Previous NSAID intake was allowed only if it was taken in low doses without showing a clinical response, otherwise patients were NSAID naïve. Upon study inclusion, patients were treated with the maximum possible dose of an NSAID that they have reported to tolerate in lower doses in the past, independent of whether this was a Cox-2 inhibitor or a non-coxib. Assessment of response was performed using a standardized questionnaire after 2, 6, 12, 24, 36, 48 hours and after 1, 2 and 4 weeks. Any NSAID response was defined as improvement of pain >2/10 points and a good response to NSAIDs as an improvement >50% from the initial status.

Results

A total of 68 patients with axSpA, 107 patients with degenerative back pain and 58 patients with unspecific back pain were included.

The mean age was 42.7±10.7, 51.2±11.3, and 45.8±10.0 years, the main symptom duration 15.1±11.1, 16.1±12.6, and 11.9 ±10.1 years and the proportion of males was 57.4%, 19.6%, and 19.0% respectively. Inflammatory back pain was reported by 42 (75%), 48 (57.8%), and 29 (60.4%) patients, respectively and the mean pain score was 6.2±2.3,6.7±1.8, and 6.2±1.8, respectively.

In axSpA, the mean BASDAI and BASFI scores were 5.5±1.8 and 4.5±2.5, respectively.

There was no difference in the cumulative response to NSAIDs between all three diagnoses, with an overall proportion of 27%-30% of patients showing improvement. However, better but not faster responses were found for the subgroups of patients with nr-axSpA (Figure 1) and for the male patients in the entire axSpA group, while axSpA patients with systemic inflammatory activity defined by increased CRP showed lower rates of response as compared to non-inflammatory reasons of back pain diagnoses. All other subanalyses did not reveal any differences between axSpA patients and other non-inflammatory reasons of back pain.

Figure 1.

Conclusion

In this prospective evaluation, the generally proposed better response of axSpA patients to treatment with high doses of NSAIDs as compared with non-inflammatory back pain was not confirmed, although the overall rate of responders was similar to previously reported rates. On the other hand, better responses were found in patients treated in the early (nr-axSpA) stage and in male patients. axSpA patients with increased CRP values showed lower rates of response.

Disclosure of Interests

None declared

AB0587 THE RISK OF PATIENTS WITH POLYMYALGIA RHEUMATICA AND GIANT CELL ARTERITIS TO DEVELOP DIABETES AND OSTEOPOROSIS ON FOLLOW UP

Background

Patients with polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are commonly treated with glucocorticoids (GC) in different dosages. Therefore, the most common comorbidities that may develop are osteoporosis (OPO) and diabetes mellitus (DM).

Objectives

To study the development of these comorbidities in the management of PMR and GCA in a real-life setting.

Methods

In a retrospective study design, longitudinal data of patients with a clinical diagnosis of PMR and GCA treated in a tertiary center were studied. Patients and disease characteristics were documented according to clinical routine in patients in whom ≥ 2 documented visits ≥ 3 months apart had been documented.

Results

A total of 550 patients (382 PMR, 168 GCA) was analysed (Table 1). The time period of follow up (FU) ranged between 3 months and 13.6 years (mean 1.4 (0.3) years). The majority of patients received a diagnosis of PMR or GCA in our center while 29.5% of patients came for a second opinion. Their mean age was around 70 years, and most patients were female (Table 1). Eight GCA patients were already blind (4.8%) at first presentation, and 77 and 80 patients had a diagnosis of DM (15.5%) and OPO (16.0), respectively, already at baseline. During FU 56 PMR (16.0%) and 7 GCA patients (4.2%) were diagnosed with another autoimmune disease, mainly with rheumatoid arthritis (n=50 (69.4%)). The mean dose of GC differed substantially between groups (Table 1). On FU, 9 (2.4%) and 5 (3.0%) of PMR and GCA patients developed DM and 17 (4.5%) and 14 (8.4%) OPO, respectively. Thus, about 20% and 25% of patients with PMR or GCA finally had DM and OPO, respectively. Almost all patients received vitamin D and antiresorptive agents.

Table 1.

Patients and disease characteristics

PMR patients (n=382)GCA patients (n=168)SignificanceAge (years)68,2 (9.3)71.1 (8,6)0.9BMI (kg/m2)27.0 (4.9)26.0 (5,3)0.44Female sex, n (%)216 (56.6)121 (72,0)<0.001Time to rheumatologist (months)2.1 (9,7)1.4 (5,4)0,33CRP at baseline (mg/dl)3,8 (4,6)4,5 (5,5)0,07Prednisolone at baseline (mg/d)25.1 (20,2)52.0 (69,7)<0.001Comorbidities at baseline-Number of comorbidities (mean)1.45 (1.12)1.51 (1.12)0.26-Diabetes, n (%)61 (16.0)24 (14.3)0.36-Osteoporosis, n (%)64 (16.8)30 (17.9)0.7-Ischemic heart disease, n (%)38 (9.9)19 (11.4)0.46Organ manifestation and comorbidities at FU-Blindness n (%)6 (1.6)8 (4.8)0.048-Aneurysm n (%)1 (0.3)9 (5.4)<0.001-Diabetes, n (%)70 (18.4)29 (17.3)0.89-Osteoporosis, n (%)81 (21.4)44 (26.3)0.003-Vascular stenosis4,610,10,048

values given as mean (SD)

Conclusion

In this large real-life cohort, patients with PMR and GCA aged around 70 years were seen by rheumatologists about 1-2 months after their first symptom but 8 GCA patients were already blind at first visit. DM and OPO were frequent comorbidities in both, PMR and GCA patients, already at baseline and during follow-up more patients developed these comorbidities despite prophylactic and therapeutic medication. OPO and DM should be a routine concern in the care of PMR and GCA patients - already when glucocorticoids are started.

Disclosure of Interests

None declared

AB1356 QUANTITATIVE ANALYSIS BY SODIUM AND PROTON BASED 3-TESLA MR IMAGING OF THE ACHILLES TENDON

Background

Decrease of proteoglycan is the initiating stage of post-inflammatory tissue degradation. Sodium MRI is promising great potential for identification and monitoring of proteoglycan changes in tendons and cartilage associated with inflammatory and degenerative musculoskeletal diseases, where the Achilles tendon is frequently affected.

Objectives

Proof-of-concept study to examine the usage of sodium MRI in quantifying sodium concentrations in the Achilles tendon in healthy volunteers.

Methods

Sodium (23Na) MR imaging of the Achilles tendon together with established proton (1H) MRI sequences were performed in 10 healthy volunteers (6 males, 4 females, age 29 ± 9 years) using a dual-tuned 23Na/1H surface coil (RAPID Biomedical GmbH, Würzburg-Rimpar, Germany). Imaging was performed using a 3D density adapted radial sequence [1] providing sufficient signal-to-noise ratio for sodium imaging. Reference tubes on the backside of the coil were used to enable assessment of sodium concentration from sodium signal-to-noise ratio maps. Sodium concentrations were determined for tendon insertion into calcaneus bone (INS), middle portion of the tendon (MID) and muscle-tendon junction (MTJ) and for the whole Achilles tendon. Statistical differences were analysed by Wilcoxon test.

Results

Sodium concentrations c [mM] of the Achilles tendon could be quantified in all 10 (exemplary selected volunteer is shown in Figure 1). Significantly higher sodium concentrations were obtained in INS compared to MID (p=0.002) and MTJ (p=0.002) and in MID compared to MTJ (p=0.037). The average sodium concentration of the whole Achilles tendon was 57.23±17.69 mM with only minor outliers in this healthy population.

Figure 1.

Sodium concentrations of the Achilles tendon. Highest sodium concentrations c(mM) were observed at the tendon insertion into calcaneus bone (INS), whereas lower concentrations were measured in the middle portion of the tendon (MID) and muscle-tendon junction (MTJ).

Conclusion

Performance of quantitative sodium imaging of the Achilles tendon in a high-field MRI machine is feasible for assessing sodium concentrations, a surrogate biomarker for proteoglycan content. Molecular MR studies investigating changes in the proteoglycan content of the Achilles tendon in patients with inflammatory and degenerative musculoskeletal diseases could support early diagnosis or therapy monitoring in the future.

References

[1]Nagel et al. Magn Reson Med (2009) 62(6):1565-73. DOI: 10.1002/mrm.22157

Disclosure of Interests

None declared

AB1400 ARE COMORBIDITIES IN PATIENTS WITH CHRONIC INFLAMMATORY RHEUMATIC DISEASES ASSOCIATED WITH TREATMENT NON-ADHERENCE TO BIOSIMILARS IN A NON-MEDICAL SWITCH SCENARIO?

Background

The availability of biosimilars has created a financial incentive to encourage non-medical switching if cheaper products are on the market. In patients with chronic inflammatory rheumatic diseases (CIRD), we have previously reported a relatively high retention rate after switching from originator etanercept to its biosimilar. However, this has been different in other studies and the reasons for non-adherence are poorly understood. Comorbidity has recently gained much attention in patients with CIRD and might be a reason for non-adherence.

Objectives

The aim of this study was to analyse the effectiveness and safety of systematic non-medical switching from originator adalimumab (ADA) to ADA ABP501 biosimilar (ABP) over 6 months in patients with CIRD and to investigate the influence of comorbidities on retention rates.

Methods

Patients with CIRD on originator ADA who switched to ABP subsequently from October 2018 onwards were identified from a large routine database and then followed for 6 months. The presence of comorbidities and disease characteristics as well as measures of disease activity, physical function and changes in treatment were documented at baseline (the time of switching from originator ADA to ABP), and at months 3 and 6. Longitudinal data including information on the clinical efficacy and safety of ABP, and the reasons for discontinuation were documented.

Results

A total of 111 CIRD patients on treatment with originator ADA were switched to the biosimilar ABP (Table 1). More than half of the patients (62%) had a Charlson comorbidity score of 0, though there were differences between disease subtypes. RA patients were comparatively older (mean age 65 years) and had the highest mean Charlson score (1.8). Treatment retention varied only slightly between patients with a Charlson score of 0 and those with ≥0 (Figure 1). In both groups, the majority of patients (90% vs 95%) continued therapy with ABP, while only a small proportion either switched back to originator ADA (6% vs 5%), switched to a different biologic (3% vs 0%), or dropped out (1% vs 0%). The main reason for back switch was the occurrence of adverse events, mostly subjective complaints, most frequently pain. Patients with a Charlson comorbidity score > 0 tended to have poorer scores in trajectories of scores for disease activity and physical function stratified by disease subtype.

Figure 1.

Treatment retention after 6 months stratified by the Charlson comorbidity score

Table 1.

Patients and disease characteristics

RAaxSpAPsAOtherN=23N=68N=15N=5Age (years), mean (SD)65.1 (12.0)47.3 (13.1)51.1 (11.2)41.8 (14.2)Women60.9% (14)32.4% (22)53.3% (8)40.0% (2)Disease duration (years), median (IQR)4.0 (3.0-8.0)5.0 (2.0-8.0)4.0 (2.0-13.0)7.0 (4.0-7.0)Duration originator ADA therapy (month), mean (SD)43.8 (28.6)39.4 (26.9)34.7 (29.0)60.9 (27.7)Charlson score, mean (SD)1.8 (2.1)0.6 (1.1)0.7 (1.2)0.2 (0.4)Gastroenterological comorbidities26.1% (6)22.1% (15)6.7% (1)0Hepatic comorbidities17.4% (4)2.9% (2)13.3% (2)0Hematological conditions8.7% (2)2.9% (2)13.3% (2)0Cardiovascular comorbidities60.9% (14)32.4% (22)33.3% (5)60.0% (3)Neurological and psychological comorbidities8.7% (2)17.6% (12)33.3% (5)0Metabolic comorbidities21.7% (5)7.4% (5)26.7% (4)40.0% (2)Osteoporosis43.5% (10)11.9% (8)6.7% (1)20.0% (1)Lung diseases21.7% (5)8.8% (6)040.0% (2)Skin diseases26.1% (6)26.5% (18)80.0% (12)20.0% (1)Eye diseases8.7% (2)23.5% (16)6.7% (1)60.0% (3)Kidney diseases13.0% (3)10.3% (7)040.0% (2)

Conclusion

Comorbidity had no influence on the biosimilar retention rate after 6 months in this study but the majority of patients did not have Charlson scores > 0. However, disease activity and physical function tended to be worse among CIRD patients with comorbidity. Cardiovascular disease and osteoporosis were more often present in RA patients than in axSpA or PsA patients, while neurological and psychological comorbidities were more often observed in the latter.

Disclosure of Interests

Imke Redeker: None declared, Stefan Moustakis: None declared, Styliani Tsiami: None declared, Xenofon Baraliakos Speakers bureau: Abbvie, Pfizer, MSD, UCB, Novartis, Lilly, Galapagos, Hexal, Paid instructor for: Abbvie, Pfizer, MSD, UCB, Novartis, Lilly, Galapagos, Hexal, Consultant of: Abbvie, Pfizer, MSD, UCB, Novartis, Lilly, Galapagos, Hexal, Grant/research support from: Abbvie, Pfizer, MSD, UCB, Novartis, Lilly, Galapagos, Hexal, Ioana Andreica Speakers bureau: UCB, MSD, Novartis, Abbvie, Lilly, Janssen, SOBI, Consultant of: Lilly, Novartis, Galapagos, Amgen, Takkeda, SOBI, Grant/research support from: Lilly, Bjoern Buehring Speakers bureau: UCB, Amgen, Gilad/Galapagos, Biogen, Sanofi/Genzyme, Consultant of: UCB, Theramex, Gilead/Galapagos, Amgen, Abbvie, Juergen Braun Speakers bureau: Abbvie, Amgen, Biogen, BMS, Boehringer, Celltrion, Chugai, Fresenius, Hexal, Janssen, Lilly, Medac, MSD, Mylan, Mundipharma, Novartis, Pfizer und UCB, Consultant of: Abbvie, Amgen, Biogen, BMS, Boehringer, Celltrion, Chugai, Fresenius, Hexal, Janssen, Lilly, Medac, MSD, Mylan, Mundipharma, Novartis, Pfizer und UCB, Grant/research support from: Abbvie, Amgen, Biogen, BMS, Boehringer, Celltrion, Chugai, Fresenius, Hexal, Janssen, Lilly, Medac, MSD, Mylan, Mundipharma, Novartis, Pfizer und UCB, Uta Kiltz Speakers bureau: AbbVie, Biocad, Biogen, Chugai, Eli Lilly, Hexal, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Consultant of: AbbVie, Biocad, Biogen, Chugai, Eli Lilly, Fresenius, Hexal, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Grant/research support from: AbbVie, Amgen, Biogen, Fresenius, GSK, Hexal, Novartis, Pfizer.

POS1004 THE IMPACT OF MRI SLICE THICKNESS ON THE DETECTION OF SPINAL SYNDESMOPHYTES IN AXIAL SPONDYLOARTHRITIS

Background

Conventional radiographs (CR) are the gold standard for detecting syndesmophytes in axial Spondyloarthritis (axSpA), mainly because magnetic resonance imaging (MRI) is not able to detect thin bony structures due to its slicing technique.

Objectives

To assess the ability and performance of detection of syndesmophytes using different slice thicknesses on MRI and compare them with findings on CR.

Methods

MRI with T1W and STIR images with slice thicknesses of 1-6mm and CR of the lower thoracic and lumbar spine performed on the same day were prospectively performed in 43 axSpA patients. Clinical and laboratory characteristics of the patients from the same timepoint were available. Each vertebral corner (VC) (anterior superior and posterior, inferior anterior and posterior) from the thoracic (Th11) to the lumbar (L5) vertebral body were assessed for the presence/absence of syndesmophytes but also fat lesion (FL) on MRI by two experienced readers (one radiologist and one rheumatologist) independently. Disagreements were solved in consensus.

Results

A total of 1.204 VCs was assessed from all patients. The mean time needed for scoring the MRIs varied between 2:27 and 4:12min for the MRI thicknesses of 1-6mm, respectively.

Syndesmophytes were detected in 19.3% VCs on CR and in 38.3%, 37.5%, 34.8%, 33.7%, 31.4%, 28.7% VCs on MRI slice thicknesses of 1-6mm, respectively (p≤0.001 for all MRI vs. CR evaluations and within MRI slice thicknesses). The anterior superior VC of L1 was the most affected site among all vertebral corners in all MRI slice thicknesses and CRs. In thoracic spine, the anterior superior corner of T12 was the most frequently affected site in both MRI (all slice thicknesses) and CR. Although MRI could detect more syndesmophytes in both lumbar and thoracic vertebrae than CR, MRI at any slice thickness could not detect 15.4%-23.2% of syndesmophytes detected in CR (Table 1).

Table 1.

Agreement and disagreement of CR and MRI for syndesmophyte detection per MRI slice thickness

CRAgreement CR/MRIFalse positive MR based on CR as gold standardMRIyesno1mmyes18227972,6%23,2%no516922mmyes18426773,8%22,2%no497043mmyes18123875,9%19,8%no527334mmyes17523176,0%19,2%no587405mmyes16920977,3%17,4%no647626mmyes16018678,5%15,4%no73785

Fat lesions were detected in 38.3%, 37.5%, 34.8%, 33.7%, 31.4%, 28.7% of VC with MRI slice thicknesses of 1-6mm, respectively. MRI slice thickness had no role in detecting fat lesions (p>0.05 within MRI slice thicknesses).

Conclusion

MRI of the lower thoracic and the lumbar spine at any slice thickness detected more syndesmophytes than CR, but the best agreement and least false-positive findings on MRI based on CR as gold standard was found in the thicker slice thicknesses. The presence of fat lesions did not influence syndesmophyte detection on MRI. These results may influence the performance of spinal MRI in identification of SpA-specific spinal lesions in daily practice.

Disclosure of Interests

None declared

AB1068 HIGH FREQUENCY OF STRUCTURAL DAMAGE IN THE LOWER SPINE OF PATIENTS WITH CHONDROCALCINOSIS

Background

Calcium pyrophosphate dihydrate crystal deposition disease (CPPD, chondrocalcinosis) is known to affect fibrocartilaginous tissue in the large and smaller peripheral joints. The affection of similar structures in the axial skeleton is unclear.

Objectives

To assess the frequency and severity of structural changes in the lower spine in patients with established CPPD in comparison to degenerative disc disease (DDD).

Methods

In a retrospective study, patients with CPPD or DDD as a main diagnosis with available spinal conventional radiographs (CR) performed during 2014 – 2020 were included. Definite other inflammatory conditions affecting the spine were excluded. The CR segments T7/8-L5/S1 were evaluated for the occurrence of disc calcification, intradiscal vacuum phenomenon, disc height (normal, narrowing, complete loss), endplate erosion, osteophytes and spondylolisthesis. When lumbar spine MRIs of the same time point were available, discovertebral units were evaluated for the occurrence of vacuum phenomena, endplate erosion, Modic changes and disc dehydration (Pfirrmann). Follow up CR were assessed if available. All available images were evaluated by 2 independent readers and discrepancies were solved by consensus.

Results

CR of 140 patients (1.171 discovertebral units) with CPPD and 99 DDD (803 discovertebral units) were evaluated (mean age 74.4±9.9 and 71±6.2, 20% vs. 20.2% males, respectively). MRIs of the spine were available from 48 CPPD and 44 DDD patients. Vacuum phenomena, disc calcification, osteophytes and erosion were significantly more frequently seen in patients with CPPD compared to DDD (Table 1) with no differences between the thoracic and the lumbar spine. Follow-up CR were available for 29 patients with CPPD and 46 DDD. Both groups presented statistically significant progression of endplate erosions and osteophytes (p 0.001 - 0.02 for both groups). Notably, even though CR follow-up times in the CPPD group were, compared to DDD (median (IQR) 1.9 (2.4) vs 3.0 (3.1) years, p=0.033, respectively), shorter, radiographic progression was noted more frequently in CPPD vs. DDD for erosive changes (6.8% vs. 0.6%, p=0.018) and disc calcification (5.8% vs. 0.6%, p=0.007), respectively. When comparing MRIs, a higher number of discovertebral units was affected by vacuum phenomena (34 vs 13, p=0.04) and endplate erosions (L4/5 (45.5% vs 24.4%, p=0.04), L5/S1(40.4% vs 19.5%, p=0.03) in patients with CPPD vs. DDD, respectively.

Table 1.

Frequency of affected discovertebral units on conventional radiographs

CPPDDDDpVacuum phenomenon156 (13.3%)44 (5.5%)<0.001Disc calcification193 (16.5%)42 (5.2%)<0.001Endplate erosion159 (13.6%)26 (3.2%)<0.001Osteophytes861 (73.5%)480 (59.8%)<0.001Spondylolisthesis126 (10.8%)69 (8.6%)0.264

CPPD: calcium pyrophosphate dihydrate crystal deposition disease DDD: degenerative disc disease

Conclusion

Patients with chondrocalcinosis showed more severe and progressive degenerative findings in the lower spine as assessed by both, CR and MRI, even more in comparison to established DDD. This data shows that disease manifestations of CPPD in the axial skeleton are clinically relevant.

Disclosure of Interests

None declared

AB1419 PERFORMANCE OF AN EARLY TRIAGE SYSTEM FOR IDENTIFICATION OF PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES

Background

The preselection of patients with suspicion of an inflammatory rheumatic disease is not easy for general practitioners and orthopedists. In countries with a limited number of practicing rheumatologists waiting lists are often long, since a full rheumatologic examination often needs a long consultation time.

Objectives

To test the performance of an early triage strategy for early identification of patients with inflammatory rheumatic diseases.

Methods

Prior to the SARS-CoV 2 pandemic, physicians caring for patients contacting a tertiary rheumatologic cente were first contacted by a health-care professional (HPR) who offered an appointment the timing of which was based on the symptoms reported (Step 1). Patients were then seen by a rheumatologist who, within a 10-minute consultation (Step 2), shortly examined the patient to determine the urgency of a planned full work up. The main outcome of the study was the comparison between the initial assessment and the final expert diagnosis (Step 3).

Results

Within 9 months, physicians caring for 1.180 patients contacted the hospital, 972 of whom kept their appointment (82.4%). Most patients were transferred by GPs (73.1%) and orthopedists (22.1%). The mean time between Step 1 and Step 2 was 10.4 days, while 6.2% of patients were seen within 4 days, 24.4% within 7 days and 69.3% within 12 weeks. Only 36 patients (3.7%) of patients had an already established rheumatic disease. Complaints lasting between 0-4 weeks were reported by 69 (7.1%), of > 4-12 weeks by 100 (10.3%), and of > 12 weeks by 973 (82.6%) patients. Almost 90% of patients reported a pain intensity >4/10 (NRS) for < 2 weeks. An elevated CRP was found in 207 patients (24.5%). Prior treatment with glucocorticoids was reported in 163 (16.8%) and with NSAIDs in 730 (75.1% of) patients. The confirmed diagnosis at Step 3 was rheumatoid arthritis in 127 (13.1%), spondyloarthritis including psoriatic arthritis in 72 (7.4%), systemic diseases including connective tissue diseases in 112 (11.5%), vasculitides in 41 (4.2%), and crystal arthropathy in 38 (3.9%) patients, while 38 (3.9%) had an infection, a malignancy or a differential diagnosis such as Raynaud’s phenomenon or sicca syndrome. Degenerative joint diseases (n=254; 26.1%) and non-inflammatory soft tissue syndromes such as fibromyalgia (n=369; 38%) accounted for more than half of the patients.

Conclusion

This study describes the performance of a standardized triage system hereby confirming the need for an early identification and preselection of patients with rheumatic musculoskeletal symptoms, including involvement of HPRs in the initial phase of contact. Based on the results, three patients with musculoskeletal complaints had to be examined in order to identify one patient with an inflammatory rheumatic disease.

Disclosure of Interests

None declared

OP0107 SERUM GRANULOCYTE-MONOCYTE COLONY STIMULATING FACTOR (GM-CSF) IS INCREASED IN PATIENTS WITH ACTIVE ANKYLOSING SPONDYLITIS (AS) AND PERSISTS DESPITE ANTI-TNF TREATMENT

Background

There is increasing evidence of the pathogenetic role of monocytes and neutrophils in AS, while the neutrophil-to-lymphocyte ratio correlates with disease activity (1). Granulocyte-Monocyte Colony Stimulating Factor (GM-CSF) is a growth factor for both myeloid lineages and a potent pro-inflammatory cytokine activating myeloid cells, including pro-inflammatory M1 macrophage polarization, production of TNF and other cytokines, and promoting osteoclastogenesis (2). It signals through the JAK-STAT pathway.

Objectives

To measure serum GM-CSF together with markers of bone metabolism in patients with AS before and after anti-TNF treatment.

Methods

The study included patients with the clinical diagnosis of AS (also fulfilling the 1984 modified NY criteria) with increased disease activity despite treatment with NSAIDs, all being eligible for treatment with a biologic DMARD. Decision for treatment with a TNF-inhibitor was made by the treating rheumatologist. Healthy donors were sampled as controls. Serum was collected before (baseline, BL) and after 4-6 months (follow-up, FU) of anti-TNF treatment and the following molecules were measured using ELISA: GM-CSF, Sclerostin (SOST) and Dickkopf-1 (Dkk-1).

Results

Twelve patients with AS (7 males, 5 females, median age 37 years, range 22-52) with a median disease duration of 1 year (range 0.5-25) and 16 age- and sex-matched controls were included. At BL, patients had mean BASDAI 6.3±2 and ASDAS 3.2±0.7. At FU the mean BASDAI decreased to 4.1±1.7 and ASDAS decreased to 2.2±0.6. At BL, AS patients had significantly higher mean serum levels of GM-CSF (150 vs 62pg/ml, p=0.049), significantly lower Dkk-1 (1228 vs 3052pg/ml, p=0.001), but similar levels of SOST (369 vs 544pg/ml, p=0.144) compared to controls. Anti-TNF treatment did not significantly affect GM-CSF, Dkk-1 or SOST levels (p>0.05 for all comparisons at FU vs baseline). Spearman correlation analysis showed that GM-CSF correlated positively with ASDAS at baseline (r=0.61, p=0.039), negatively with age (r=-0.68, p=0.018), but not with disease duration (r=-0.27, p=0.400). No correlations were identified between bone markers (Dkk-1, SOST) and GM-CSF or disease activity indices.

Conclusion

GM-CSF is increased in patients with active AS, particularly in younger ages, and strongly correlates with disease activity, but not with disease duration. In contrast, TNF inhibition does not affect GM-SCF levels, despite improving disease activity. GM-CSF may represent an important pathway in AS that could be responsible for residual inflammation during TNF blockade, but also explain the efficacy pathway of treatment with JAK inhibitors.

References

[1]Sen R, Kim E, Cheng E et al. A Tough Cell: The Argument for a Biomarker of Clinical and Imaging Outcomes in Spondyloarthritis: The Neutrophil Lymphocyte Ratio and the Platelet Lymphocyte Ratio [abstract]. Arthritis Rheumatol. 2021; 73 (suppl 10).

[2]Crotti C, Agape E, Becciolini A et al. Targeting Granulocyte-Monocyte Colony-Stimulating Factor Signaling in Rheumatoid Arthritis: Future Prospects. Drugs. 2019 Nov;79(16):1741-1755

Acknowledgements

There are no acknowledgements to declare.

Disclosure of Interests

None declared

POS0584 ULTRASONOGRAPHY OF THE MEDIAN NERVE IN PATIENTS WITH RHEUMATOID ARTHRITIS UNDER SUSPICION OF CARPAL TUNNEL SYNDROME

Background:

Carpal tunnel syndrome (CTS) is the most common nerve compression syndrome and a common extra-articular manifestation of rheumatoid arthritis (RA). Different causes of CTS are known, among them inflammatory and non-inflammatory pathologies. Electroneurography (ENG) of the median nerve, the method of choice to diagnose CTS, measures impairment of nerve conduction velocity without explaining its underlying cause. However, because the electrical stimulation is often not well tolerated, ENG results may come out inconclusive. Using greyscale ultrasonography (GS-US) provides anatomic information including a structural representation of the carpal tunnel.

Objectives:

To investigate the performance of nerve GS-US in the diagnosis of CTS in patients with RA.

Methods:

Consecutive patients with active RA under suspicion of CTS presenting to a large rheumatologic center were included. Both hands were examined by an experienced neurologist including ENG and a GS-US (ML linear probe with 6-15 Hz) of the median nerve. An established grading system for ENG (1), and an established system for GS-US based on cut-offs for the nerve cross sectional area (CSA) [mild: 0,11-0,13cm2, moderate: 0,14-0,15 cm2, severe: > 0,15 cm2 CTS (2)] were used. In addition, the Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ) was used to assess CTS symptoms (3).

Results:

Both hands of 58 patients with active RA (n=116) and clinical suspicion of CTS (in 38 cases bilaterally) were included. After clinical examination, CTS was suspicious in 96 hands (82.8%), and 59 of all hands had a final diagnosis of CTS (50.9%). Of the latter, 43 hands (72.9%) had a positive ENG and 16 (27.1%) a positive GS-US finding only, while 30 hands (50.8%) were positive in both examinations.

There was a good correlation of the cross-sectional area (CSA) as well as the CSA-ratio to the ENG findings: the larger the CSA, the more severe was the CTS as assessed by ENG (Spearman’s rho=0.554; p<0.001). The more severe the GS-US findings of CTS were, the more definite were the distal motor latency (Spearman’s rho=0.554; p<0.001) and sensible nerve conduction velocity of the median nerve (Spearman’s rho=-0.5411; p<0.001).

In the 46 hands positive in GS-US, tenosynovial hypertrophy of the flexor tendons was detected in 19 hands (41.3%), 7 of which (36.8%) also showed an additional cystic mass. In these 19 patients, clinical complains were more severely present than in patients with non-inflammatory CTS, as assessed by the BCTSQ with a total score of 68.8±13.4 vs. 59.3±13.7, respectively (p=0.007).

Conclusion:

In patients with active RA and clinical complains of CTS, ultrasound examinations provide additional information about inflammation which is helpful for a diagnosis of CTS. Thus, ENG and nerve GS-US should be used complementary for a diagnostic workup of CTS in RA patients with a suspicion of CTS. Power-Doppler may further improve the diagnostic performance of GS-US.

References:

[1]Padua L et al. Acta Neurol Scand 1997; 96:211–217

[2]El Miedany et al., Rheumatology (Oxford). 2004 Jul; 43(7):887-895

[3]Levine DW et al. J Bone Joint Surg Am 1993; 75: 1585-1592

Figure 1.

BCTSQ scores in patients with diagnosis of CTS and absence or presence of RA-related tenosynovial hypertrophy

Disclosure of Interests:

None declared

AB0823 TREATMENT WITH ADALIMUMAB IN PATIENTS WITH CHRONIC INFLAMMATORY RHEUMATIC DISEASES: A STUDY OF TREATMENT TRAJECTORIES ON A PATIENT LEVEL IN CLINICAL PRACTICE

Background:

There is evidence that drug retention rates to adalimumab (ADA) in patients (pts.) with chronic inflammatory rheumatic diseases (CIRD) are impaired by loss of efficacy and adverse events, and that about 50% of users had discontinued ADA within 5 years (1). With the introduction of ADA biosimilars in October 2018, non-medical switching from originator to ADA biosimilars is now increasingly part of daily practice in rheumatologic care.

Objectives:

The aim was to study treatment trajectories over two years in pts. with CIRD receiving originator ADA.

Methods:

Pts. with CIRD on originator ADA who switched to ADA biosimilar from October 2018 onwards were identified and followed until 2020. Disease activity (ASDAS), physical function (HAQ, BASFI), and changes in treatment were documented every 3 months. The four predefined treatment trajectories “continued ADA biosimilar therapy”, “back-switch to originator ADA therapy”, “switch to other biological (b) disease modifying anti-rheumatic drug (DMARD) therapy”, and “stopped bDMARD therapy /death /drop out” were used to compare characteristics of pts. with different trajectories.

Results:

A total of 111 CIRD pts. on treatment with originator ADA were switched to ADA biosimilar (Table 1). The majority of pts. 75 continued therapy with ADA biosimilar (Figure 1 next page) while 16% switched back to originator ADA, 7% switched to a different bDMARD, and 9% either stopped treatment (n=9) or died (n=1). Pts. who continued ADA biosimilar were more frequently male, older or with a longer disease duration than those who switched therapy back to originator ADA and those who switched to a different bDMARD (Table 1). The previous duration on originator ADA treatment was increased in patients who continued ADA biosimilar compared to those who switched therapy back to originator ADA and those who switched to a different bDMARD. There was more functional impairment (HAQ, BASFI) and higher disease activity (ASDAS) in pts. who switched compared to those who continued ADA biosimilar therapy (Table 1). Treatment with csDMARDs and glucocorticoids was increased in pts. who continued ADA biosimilar therapy, while pts. who switched therapy had more previous bDMARD therapies (Table 1).

Table 1.

Characteristics of patients at baseline for the entire group and stratified by treatment trajectory

Total groupN=111 (100%)Treatment trajectorycontinued ADA biosimilar therapyN=75 (67.6%)back-switch to originator ADA therapyN=18 (16.2%)switch to different bDMARD therapyN=8 (7.2%)no bDMARD therapy /death /drop outN=10 (9.0%)Age, y51.2 (14.5)51.5 (13.6)50.6 (16.8)43.5 (9.5)56.4 (19.0)Women, No. (%)46 (41.4)27 (36.0)9 (50.0)6 (75.0)4 (40.0)RA23 (20.7)17 (22.7)2 (11.1)1 (12.5)3 (30.0)axSpA68 (61.3)47 (62.7)11 (61.1)6 (75.0)4 (40.0)PsA15 (13.5)7 (9.3)4 (22.2)1 (12.5)3 (30.0)Other diagnoses5 (4.5)4 (5.3)1 (5.6)0 (0.0)0 (0.0)Disease duration, median (IQR), y5.0 (2.0-8.0)5.0 (2.0-9.0)3.5 (2.0-6.0)2.0 (1.0-5.5)4.5 (2.0-8.0)Duration previous originator ADA therapy40.7 (27.7)45.3 (27.8)35.0 (25.2)20.3 (24.7)32.3 (25.1)DAS283.0 (1.0)2.9 (1.0)3.4 (1.0)-3.3 (1.2)CRP, median (IQR), mg/L0.2 (0.1-0.3)0.1 (0.1-0.2)0.2 (0.0-0.5)0.2 (0.2-1.3)0.3 (0.2-0.4)HAQ score1.3 (0.8)1.1 (0.7)1.7 (0.8)-1.8 (1.0)ASDAS2.2 (1.1)2.0 (1.0)3.0 (1.2)2.7 (0.9)2.3 (0.2)BASFI3.5 (2.6)3.0 (2.5)5.4 (2.4)3.4 (1.6)5.4 (1.6)

+values are given as mean (SD)

Conclusion:

Two thirds of pts. who switched to ADA biosimilar remained on this therapy for 2 years. As many as 16% of pts. switched back to ADA originator. Whether or to what degree this was influenced by nocebo effects needs further study. The same is true for the effect of functional impairment – it would be interesting to know whether this was due to inflammation or structural damage.

References:

[1]Neovius M et al. Ann Rheum Dis 2015; 74:354-360

[2]The study was funded by Hexal Germany.

Figure 1.

Treatment trajectories of ADA therapy in patients with CIRD during two years ADA: adalimumab; bDMARD: biological disease modifying anti-rheumatic drug.

Disclosure of Interests:

None declared

POS0245 PERFORMANCE OF STANDARDIZED SCORES FOR DISEASE ASSESSMENT AND PAIN IN PATIENTS WITH SPONDYLOARTHRITIS AND FIBROMYALGIA

Background:

The pathogenesis of spondyloarthritis (SpA) including axial SpA (axSpA) and psoriatic arthritis (PsA) differs from fibromyalgia (FM). However, symptoms partially overlap and both patient groups suffer from pain and stiffness. In addition, SpA patients may also develop a secondary form of FM. Classification criteria for SpA and diagnostic criteria for FM are used to differentiate between these subsets. Patient reported outcomes (PRO) often generated by questionnaires are used to assess severity and other disease features.

Objectives:

To study whether PROs developed for axSpA, PsA, and related physician-based information behave in a similar way in patients diagnosed with FM without an additional chronic inflammatory rheumatic disease (CIRD) as in patients with a primary diagnosis of SpA without or with secondary FM.

Methods:

Patients were consecutively recruited. The main inclusion criterion was a clinical diagnosis of FM (without CIRD), axSpA or PsA (without or with secondary FM) and the indication for a treatment adaptation (escalation or change within the same class) for any reason, based on the judgement of experienced rheumatologists. Standardized assessment tools and lab parameters (BASDAI, ASDAS-CRP, DAPSA, patient´s and global assessment (NRS), CRP, BASFI, Fibromyalgia Impact questionnaire (FIQ), Leeds Enthesitis Index (LEI), Maastricht Ankylosing Spondylitis (MASES) and SpA Research Consortium of Canada (SPARCC) Enthesitis Score were assessed and compared between subgroups.

Results:

The baseline demographics of 300 recruited patients (100 FM. 100 axSpA and 100 PsA) are shown in Table 1. All patients with FM (primary or secondary to SpA) showed the highest scores in almost all assessments, and this was independent of the main diagnosis (Table 2). In comparison, patients with axSpA or PsA without secondary FM showed significantly lower scores in all PROs as compared to those with primary and secondary FM, with exception of (i) scores of ASDAS-CRP and (ii) duration of morning stiffness (Question 6 of BASDAI), which were not affected by the presence of secondary FM (Table 2).

Conclusion:

Secondary FM is leading to significantly higher levels of SpA-specific scores. ASDAS-CRP was the only score that was not influenced by the presence of secondary FM in patients with axSpA even though it was also increased in patients with primary FM, while similar results were found for the duration but not the level of morning stiffness. On the other hand, FM-specific questionnaires also showed high scores in patients with axSpA and PsA with concomitant FM but not in those without.

Table 1.

Baseline characteristics of all diagnosis subtypes and comparison (p-values) to primary FM diagnosis. ‘+’: diagnosis with concomitant FM, ‘-‘: diagnosis without concomitant FM

Table 2.

Mean values (±standard deviation) of the assessed diseasespecific indices and comparison (p-values) to primary FM diagnosis.

Disclosure of Interests:

None declared

POS0038 THE INFLUENCE OF AGE ON THE PREVALENCE OF INFLAMMATORY AND POST-INFLAMMATORY MRI LESIONS IN THE SACROILIAC JOINTS OF PATIENTS WITH AND WITHOUT AXIAL SPONDYLOARTHRITIS

Background:

Axial spondyloarthritis (axSpA) is clinically characterized by chronic inflammatory back pain and by inflammatory and structural changes in the sacroiliac joint (SIJ) as assessed by magnetic resonance imaging (MRI). Several studies have reported high rates of bone marrow edema (BME) suggestive of inflammatory SIJ changes in up to 20% of individuals in the general population <45 years. An update of the definition of a positive MRI of the SIJ in axSpA for classification purposes, based on the number of slices or quadrants showing BME or structural changes such as erosions or fat lesions (FL), was recently published by ASAS.

Objectives:

To compare the influence of age on the prevalence of inflammatory and structural MRI changes in the SIJ of patients with chronic low back pain diagnosed with axSpA or non-SpA.

Methods:

MRIs of the SIJ of patients referred for differential diagnosis of back pain who were finally diagnosed with axSpA or not by experienced rheumatologists, were evaluated using semi-coronal STIR and T1-weighted MRI sequences. All images were scored blinded to, age, sex and diagnosis for the occurrence of BME, FL, erosions and ankylosis on the level of SIJ-quadrants (SIJ-Q). Patient groups were built based on decade of age (until 29, 30-39, 40-49 and ≥50 years).

Results:

A total of 309 patients (175 axSpA and 134 non-SpA) with complete MRI sets were included in the analysis. The mean age was 38.5±11.4 and 43.4±13.8, 66.9% and 35.8% were male, the mean CRP was 1.6±2.4 and 1.1±2.1mg/dl and the median back pain symptom duration was 48 and 60 months, respectively. The number of SIJ-Q with BME and erosions was significantly higher in axSpA vs. non-SpA independent of the age group (Table 1). In comparison, with exception of the patients in the oldest population (≥50 years), the number of SIJ-Q with FL and the number of patients with at least one FL was not different between subgroups, while the number of erosions and FL but not BME was higher in both groups with increasing age. In the univariate analysis, only female sex was significantly associated with higher occurrence of FL.

Conclusion:

Despite a relatively high prevalence in non-SpA patients, BME and erosions were significantly more frequent in axSpA independent of age, while the presence of FL was not different between groups. FL and erosions are increasingly found in older age groups independent of diagnosis. These data are relevant for the interpretation of MRI findings in the SIJ of patients suspicious of axSpA.

Table 1.

Comparison of MRI findings between axSpA and non-SpA patients at different age groups

Disclosure of Interests:

None declared.

POS1145 PREVALENCE OF CHONDROCALCINOSIS IN PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES – FREQUENTLY FOUND IN PATIENTS WITH RHEUMATOID ARTHRITIS AND VICE VERSA

Background:

Calcium pyrophosphate deposition disease (CPPD), also known as pseudogout, is a prominent member of the crystal deposition diseases much like gout where urate crystals are the pathogens. CPPD is differentiated from chondrocalcinosis, a radiographic finding showing joint calcification, which may or may not be relevant for the clinical picture of patients (1).

Objectives:

To determine the prevalence of chondrocalcinosis in different inflammatory rheumatic diseases.

Methods:

In a retrospective cross-sectional study design we reviewed the records of not established new patients presenting to our center between 1.1.2016 and 31.12.2018. Based on the availability of radiographs of hands and feet, 514 patients were identified including 181 patients with CPPD, 273 with rheumatoid arthritis (RA), 143 seropositive (52.4%) and 130 seronegative, 30 with gout and 30 with polymyalgia rheumatica (PMR). Radiographs of hands and feet were available from all patients, of the knee in 376 cases. All images were read by two experienced readers with no access to clinical data.

Results:

Almost all patients had a short disease duration of < 1 year. In patients diagnosed with CPPD all radiographs showed chondrocalcinosis (93%) at some location, mostly in the hands. This was different in seronegative (36.5%) and seropositive (30.3%) RA. Chondrocalcinosis was found less frequently also in gout (18.8%) and PMR (12.5%). More data are shown in the Table 1. Radiographic chondrocalcinosis was present in more than one joint in 36.6% patients with CPPD, in 11.9% in seropositive and in 17.3% in seronegative RA. Patients with CPPD were older and had acute attacks more often than RA patients. While RA patients were more frequently on methotrexate (MTX), patients with CPPD were more often on colchicine.

Table 1.

Radiographic and clinical features of the examined patients

Conclusion:

There were a lot of similarities but also some important differences between patients with CPPD and RA with no major differences between seropositive and seronegative RA. Of interest, radiographic chondrocalcinosis was seen in more than a third of RA patients. Importantly, clinical symmetry of arthritis and involvement of hands did not differentiate between CPPD and RA, mainly the acuteness of attacks did. Co-occurrence of both diseases was frequently observed. There was no major difference between seropositive and seronegative RA.

References:

[1]Rosenthal AM, Ryan LM. N Engl J Med. 2016

Disclosure of Interests:

None declared.

[How well are patients with inflammatory rheumatic diseases protected against measles?]

Hintergrund

Patienten mit entzündlich rheumatischen Erkrankungen haben aufgrund ihrer Autoimmunerkrankung, aber auch bedingt durch die immunsuppressive Medikation ein erhöhtes Infektrisiko. Obwohl Impfungen in der Primärprophylaxe von Infektionen bekanntermaßen effektiv sind, ist die Impfrate in Deutschland generell zu niedrig. Wegen des zuletzt zunehmenden, teils epidemieartigen Auftretens von Masern ist die Lebendimpfung gegen Masern in Deutschland seit Kurzem gesetzlich vorgeschrieben.

Fragestellung

Wie viele Patienten mit entzündlich rheumatischen Erkrankungen sind aktuell ausreichend gegen Masern geschützt?

Methode

Patienten mit entzündlich rheumatischen Erkrankungen des Rheumazentrums Ruhrgebiet wurden zwischen Dezember 2017 und Oktober 2018 prospektiv und konsekutiv eingeschlossen. Dabei wurden Daten zu Erkrankung und Therapie auf Ebene von Substanzklassen sowie die Impf- und Infektanamnese erhoben. Alle Angaben zu Impfungen wurden im Impfpass kontrolliert. Antikörpertiter gegen Masern wurden mit ELISA bestimmt. Als Schwellenwert für einen ausreichenden Schutz gegen Masern wurden 150 mIU/ml festgelegt.

Ergebnis

Von 975 Patienten konnten 540 (55,4 %) einen Impfausweis vorlegen. Bei 201 Patienten mit Ausweis (37,2 %) lagen dokumentierte Impfungen seit Geburt vor. Insgesamt hatten 45 von 267 nach 1970 geborene Patienten (16,9 %) einen suffizienten Impfschutz gegen Masern. Die anamnestischen Angaben zu einer Masernerkrankung in der Kindheit differenzierten nicht zwischen Patienten mit und ohne protektiven Masern-IgG-Antikörpern. Protektive Masern-IgG-Antikörper wurden bei 901 Patienten von 928 Patienten mit Messung der Masern-IgG-Antikörperspiegel (97,1 %) nachgewiesen. Die unterschiedlichen Wirkprinzipien der aktuellen immunsuppressiven Therapie hatten darauf keinen Einfluss.

Diskussion

Diese Daten zeigen, dass mindestens 2,9 % der Patienten keinen ausreichenden Schutz gegen Masern haben. Interessanterweise hatte die Mehrheit der nach 1970 geborenen Patienten protektive Antikörper trotz fehlenden Impfschutzes gegen Masern. Die Anstrengungen sowohl im primär- als auch im fachärztlichen Bereich sollten dringend verstärkt werden, um eine adäquate Infektionsprophylaxe bei besonders gefährdeten Patienten gewährleisten zu können.

SAT0365 EFFECTS OF ANTI-TNF-THERAPY ON OSTEOBLASTIC ACTIVITY IN ANKYLOSING SPONDYLITIS – RESULTS FROM A PROSPECTIVE STUDY USING PET-MRI OF SIJ AND SPINE

Background:

The clinical efficacy of tumor necrosis factor inhibitors (TNFi) in patients with axial spondyloarthritis (axSpA) is well established but its effect on new bone formation is still unclear (1). Positron emission tomography (PET) using bone-seeking18F-Fluoride [18F]F in combination with magnetic resonance imaging ([18F]F /MRI) has been shown to depict not only bone marrow edema (BME) but also shows the quantity of tracer uptake in the late phase of perfusion suggestive of remodeling and osteoblastic activity, not only in radiographic axSpA (r-axSpA) (2).

Objectives:

Assess the effect of TNFi on bone remodeling processes in the axial skeleton of r-axSpA patients using [18F]F/MRI prior (baseline, BL) and 4 months after (follow-up, FU) treatment.

Methods:

Patients (11 male, 5 female, mean age 38.6±12.0 years) with clinically active r-axSpA (BASDAI>4, failure of NSAIDs, no previous biologics) prospectively underwent 3-Tesla and [18F]F PET/MRI (40 minutes after injection of a mean activity of 157 MBq [18F]F). Images of the SIJ (n=16 patients) and the whole spine (n=10 patients) were performed at BL and FU. Three readers (1 for [18F]F/MRI and 2 for conventional MRI) evaluated all images independently and blinded to timepoint allocation. Only lesions on which all readers agreed on were used for further analyses. Inflammation (bone marrow edema, BME), structural lesions (fat deposition (FD), sclerosis, erosions and ankylosis) and focal [18F]F uptake were recorded on the level of SIJ (SIJ-Q) and vertebral quadrants (V-Q), with each SIJ or vertebral body consisting of 4 VQs (superior and inferior sacral and iliac for the SIJ, and superior and inferior, anterior and posterior for the vertebral bodies).

Results:

A total of 128 SIJ-Q and 920 VQs were analyzed at both BL and FU. In the SIJs, 75 (58.6%), 120 (93.8%), 69 (53.9%), 99 (77.3%) and 16 (12.5%) SIJ-Q showed BME, FD, sclerosis, erosions and ankylosis, while 111 (86.7%) SIJ-Q showed focal [18F]F-uptake at BL. Association with increased [18F]F-uptake was found most frequently in SIJ-Q with BME (70/75 SIJ-Q, 93.3%), sclerosis (65/69 SIJ-Q, 94.2%) and FD (105/120 SIJ-Q, 87.5%). At FU, 37 SIJ-Q still showed BME (improvement by 50.7%), while almost no changes were observed in chronic lesions. In comparison, improvement of focal [18F]F-uptake was found in all lesion combinations, with improvement of focal [18F]F-lesions associated with BME by 62.9%, with sclerosis by 33.8% and with FD by 22.9% of SIJ-Q.

In the spine, only 41 (4.5%), 61 (6.6%), 14 (1.5%) V-Q showed BME, FD and sclerosis, respectively, while 77 V-Q (8.4%) showed focal [18F]F-uptake. An association to increased [18F]F-uptake was found most frequently with sclerosis (7/14 V-Q, 50%) and FD (25/61 V-Q, 41%). At FU, 12 V-Q still showed BME (improvement by 70.7%), while, similar to SIJ, almost no changes were observed in the chronic lesions. The largest improvement was found in focal [18F]F-lesions associated with BME 81.8% and with FD by 22.9% of V-Q.

Conclusion:

In this first prospective study on whole spine and SIJ [18F]F/MRI in patients with r-axSpA, a significant decrease of osteoblastic activity was observed over 4 months of continuous anti-TNF treatment. The effect of treatment was observed not only at sites with inflammatory lesions (BME) but also at sites with pre-existing chronic structural lesions, while some osteoblastic activity remained visible at 4 months. These data support a short-term effect of anti-TNF treatment on osteoblastic activity, while the long-term effects need to be further studied.

References:

[1]Van der Heijde D et al, Ann Rheum Dis 2017

[2]Buchbender C et al, J Rheumatol 2015

This work was supported by an unrestricted Grant by MSD GmbH, Germany

Disclosure of Interests:

Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Styliani Tsiami: None declared, Christoph Rischpler: None declared, Nils-Martin Bruckmann: None declared, Wolfgang Fendler: None declared, Julian Kirchner: None declared, Ken Hermann: None declared, Lino Sawicki: None declared, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma

AB1144 DAILY CLINICAL CARE OF PATIENTS WITH MUSCULOSKELETAL COMPLAINTS – HOW HELPFUL IS A TRIAGE SYSTEM FOR EARLY RECOGNITION OF INFLAMMATORY RHEUMATIC DISEASES?

Background:

Early diagnosis and treatment are important for the management of inflammatory rheumatic diseases (RMD). However, the availability of rheumatologists is limited in most European countries and selection strategies lack sensitivity and/or specificity.

Objectives:

To evaluate a triage strategy that offers the possibility to see patients within 4 weeks for short term appointments in order to check the probability of an inflammatory RMD and the necessity to further evaluate the patients in due time.

Methods:

Physician’s and patient’s information who called our tertiary rheumatology department´s outpatient clinic for a date in the triage system were included in this analysis. The time to first appointment as assessed by a nurse (Step 1), the short evaluation by a rheumatologist in the triage (Step 2) and the patient´s complaints and the diagnoses after an extensive diagnostic evaluation (Step 3) were documented.

Results:

In a period of 9 months in 2018, a total of 982 patients presented. A total of 62 patients (6.3%) were considered urgent (appointment within 3 days), while 240 (24.4%) were appointed within 4 weeks at Step 2. Of the former 46 (19.2%), and of the latter 151 patients (62.9%) were diagnosed with inflammatory RMD at Step 3.

In total, 334 patients (34.0%) were diagnosed with inflammatory RMD at Step 3, including 126 with RA (37.7%), 71 with axSpA/PsA (21.3%), 95 with connective tissue disease/vasculitis (28.4%) and 20 with gout (6.0%). The diagnosis suspected in Step 2 was confirmed in Step 3 in 77.9% of cases. In 217 patients, the diagnosis suspected in Step 2 was not confirmed in Step 3. Of them, 34 (15.7%) had unclear findings at Step 2 but an inflammatory RMD was found at Step 3, while 148 (68.2%) had a suspected inflammatory RMD at Step 2 but this was not confirmed at Step 3.

The most frequent musculoskeletal complaint at the time point of referral was pain in small peripheral joints (hands and/or feet) in 858 patients (87.4%), in large peripheral joints (knees, shoulders and/or hips) in 780 patients (79.4%) and back pain in 682 patients (69.5%). Fever, night sweats and unclear weight loss was reported by 50 patients (5.1%), while 210 patients (24.5%) presented with findings suspicious of inflammatory RMD such as elevated CRP of unclear origin, and 43 patients (4.8%) because of a threat of organ damage such as unclear elevation of creatinine, as reported by the referring physician. In addition, 167 patients (17.0%) had received glucocorticoids prior to referral, 87 (52.1%) of which finally did not receive the diagnosis of inflammatory RMD at Step 3, while 737 patients (75.1%) were receiving NSAIDs prior to referral.

Conclusion:

In this prospective evaluation of a triage system where all patients were pre-screened by a nurse and were seen within 4 weeks by a rheumatologist, clinical differentiation could be performed timely due to a successfully structured triage system. The initially suspected diagnosis was finally confirmed in ≥75% of cases, while ≥1/3 of patients had a definite inflammatory RMD.

This work was supported by an unrestricted Grant from Abbvie

Disclosure of Interests:

Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Imke Redeker: None declared, Maria Zacharopoulou: None declared, Styliani Tsiami: None declared, Konstantia Tsiaousi: None declared, Doris Morzeck: None declared, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma

SAT0579 SYSTEMATIC GERIATRIC ASSESSMENT IN OLDER PATIENTS WITH RHEUMATIC DISEASES - THE RheuMAGIC PILOT STUDY

Background:

Current demographic data predict that the number of older adults with rheumatic diseases will considerably increase in the coming years. Geriatric patients differ from younger adults in many ways including their clinical presentation, co-morbidities and response to medication. The management of such patients is often challenging due to the presence of multi-morbidity, polypharmacy and geriatric syndromes (i.e. conditions in which symptoms result from impairments in multiple systems rather than a discrete disease). To systematically assess geriatric patients, specific tools have been developed; however, they are not routinely utilized by rheumatologists. Using these tools could improve patient management and satisfaction in rheumatologic care.

Objectives:

To examine the prevalence of 17 common geriatric health problems using validated geriatric assessment tools in older patients with rheumatic and musculoskeletal diseases.

Methods:

Adults 65 years and older who presented to a tertiary rheumatologic hospital were included after informed consent. All patients recruited were assessed using theMAngableGeriatrICAssessment (MAGIC) which addresses 14 common geriatric health problems. In addition, polypharmacy (≥ 5 medication), muscle function using the Short Physical Performance Battery and frailty applying the Fried definition were assessed. Disability was quantified with the “Funktionsfragebogen Hannover” (FFbH), a validated tool for patients with rheumatologic diseases that can be easily converted to Health Assessment Questionnaire (HAQ) scores. Primary outcome was the frequency of the selected 17 geriatric health problems; the correlation of the total number of problems with HAQ scores was a secondary outcome.

Results:

Of the 300 individuals included 67% were female with a mean age of 73±6.6 years; 85% (> 50% with rheumatoid arthritis) had a rheumatologic diagnosis. The remaining participants had either a chronic pain syndrome or degenerative joint/spine disease. On average participants had 7 out of 17 assessed geriatric problems. Females had more such problems than males (8 vs. 6, p<0.0001). Chronic pain and polypharmacy were most common but several others were also seen in more than 50% of patients (see Table). The mean HAQ Score was 1.67±0.79. There was a positive correlation (see Graph) between the number of problems and the HAQ Score (R2= 0.44, p<0.0001).

Conclusion:

A systematic geriatric assessment can be successfully used to discover and quantify geriatric health problems in older patients with rheumatic and musculoskeletal diseases. These problems appear to be very common and importantly, patients with more problems had poorer functional status. Frailty, depression, incomplete vaccination status, cognitive impairment or polypharmacy are all known to negatively impact patient care. Recognizing and addressing geriatric problems has the potential to lead to health care improvements including adherence and medication side effects and might increase patient satisfaction and functional status independent of disease activity.

References:

[1]Buehring, B. and S. Barczi, Assessing the Aging Patient, in Spine Surgery in an Aging Population, N. Brooks and A. Strayer, Editors. 2019, Thieme: New York. p. 208.

[2]Cleutjens F, Boonen A, van Onna MGB. Geriatric syndromes in patients with rheumatoid arthritis: a literature overview. Clin Exp Rheumatol 2019;37(3):496-501

Geriatric Problem% presentProblems with Daily Activities67Problems with Vision28Problems with Hearing38Problems with Falls11Problems with Urinary Incontinence38Problems with Depression57Lack of Social Support10Incomplete Vaccinations53Problems with Cognition31Problems with Chronic Pain90Problems with Dizziness44Problems with Mobility41Problems with Unintentional Weight Loss30Inappropriate Medications present17Polypharmacy present81Frailty present46Short Physical Performance Battery low57

Acknowledgments:

None

Disclosure of Interests:

Anna Berrisch: None declared, Ioana Andreica: None declared, Styliani Tsiami: None declared, David Kiefer Grant/research support from: Novartis, Uta Kiltz Grant/research support from: AbbVie, Amgen, Biogen, Novartis, Pfizer, Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer, Roche, UCB, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Bjoern Buehring Grant/research support from: GE/Lunar, Kinemed, Consultant of: Gilead, Abbvie, Lilly, GE/Lunar, Janssen, Amgen, Speakers bureau: UCB

FRI0521 EARLY RECOGNITION OF PATIENTS WITH AXIAL SPONDYLOARTHRITIS BY USING A PRACTICAL REFERRAL SYSTEM – EVALUATION OF THE RECENTLY PROPOSED 2-STEP STRATEGY

Background:

Chronic back pain (CBP) of the inflammatory type (IBP) is frequently reported in axSpA but also in the general population.

Objectives:

We evaluated a recently proposed two-step referral system for early recognition of axSpA (concentrating on patients ≤45 years with chronic back pain who present with buttock pain, improvement by movement, psoriasis, positive testing for HLA-B27) in primary care and compare it to other combinations of symptoms and SpA-related items.

Methods:

Consecutive patients ≤45 years who presented in PC to general practitioners or orthopedic surgeons working in PC with back pain lasting ≥2 months who had not been diagnosed before received questionnaires (Q1) relevant for the referral process. Thereafter, the PC physician asked the same questions in a separate questionnaire (Q2), including the decision on HLA-B27 testing. All patients were then referred to two experienced rheumatologists in a tertiary center who performed a complete workup including clinical, laboratory and imaging with radiographs and magnetic resonance imaging (MRI) examinations before their final diagnosis of axSpA or non-SpA (Q3).

Results:

A total of 320 patients (mean age 35.9±10.3 years) was recruited. The proposed referral strategy (prS) was fulfilled by 127 patients in Q1 (39.7%), 160 in Q2 (50%), 102 by both, Q1 and Q2 (31.9%), and 83 with either Q1 or Q2 (25.9%). Overall, 47 patients were diagnosed with axSpA by the rheumatologist at Q3 (14.7%), 66% of which were male, mean age 34.7±10.1 years, 70.2% HLA-B27 positive, mean CRP 0.8±1.4mg/dl, mean ASDAS 3.2±0.8, mean BASDAI 5.1±2.0. Of these, 37 patients had fulfilled the prS in Q1 or Q2 (78.7%), and 31 in both Q1 and Q2 (66%), respectively. In the latter, the HLA-B27 prevalence was significantly higher (27/31, 87.1%) as compared to patients diagnosed with axSpA at Q3 but who did not fulfill the prS in Q1 and Q2 (5/16, 31.3%) (p<0.001).

The sensitivity and specificity of the prS was 78.7% and 69.2% in Q1, 78.7% and 62.2% in Q2, and in both, Q1 and Q2, 66% and 74%, respectively.

AxSpA patients correctly identified by the prS in Q1 and Q2, were significantly more frequently positive for HLA-B27 and CRP and fulfilled more frequently the ASAS definition of inflammatory back pain in Q3.

Conclusion:

A simple two-step referral strategy using a combination of clinical features for identifying axSpA patients in PC without laboratory and imaging examinations was confirmed in a large population from daily practice. This strategy performed well as selection for referral at the patient and PC physician level.

This work was supported by an unrestricted Grant by Novartis Pharma GmbH, Germany

Table 1.OR (95% CI)Overall P valueInpatient stay duration0.87 (0.82, 0.93)<0.001Opioids prescribed at discharge0.23 (0.09, 0.55)0.001Patient’s location before admission:0.02Home1.0 (réf.)A&E Department0.25 (0.10, 0.65)Other Department0.35 (0.05, 2.53)Charlson comorbidity index0.76 (0.82, 0.93)Main diagnosis (only significant conditions displayed):0.03Low back pain, sciatica1.0 (réf.)Abarticular conditions0.03 (0.002, 0.47)Osteoporotic fracture0.17 (0.05, 0.52)

Predictors of home discharge. Multivariate logistic regression analysis. N=223.

Disclosure of Interests:

Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Styliani Tsiami: None declared, Doris Morzeck: None declared, Kirill Fedorov: None declared, Uta Kiltz Grant/research support from: AbbVie, Amgen, Biogen, Novartis, Pfizer, Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer, Roche, UCB, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma

AB1245 DAILY MANAGEMENT OF PATIENTS WITH AXIAL SPONDYLOARTHRITIS: SELF-MONITORING OF DISEASE ACTIVITY WITH A SMARTPHONE APP IS FEASIBLE – A PROOF OF CONCEPT STUDY

Background:

Assessment and monitoring of disease activity and functioning is of major importance for the course of axial spondyloarthritis (axSpA). This is equally important for patient monitoring in daily routine as also for tight control strategies. Even though there is evidence that a closer monitoring of patients is better than routine care, more intensive treatment schedules are often not realized in daily practice for several reasons including shortage of time and personal resources. Using application software devices (apps) in clinical routine for the recording of disease-specific patient reported outcomes (PRO) may facilitate monitoring and improve clinical decision processes but there is a lack of data on the use of apps.

Objectives:

To investigate the use of such App technology in respect to usability, feasibility and equivalence of data in daily care of patients with axSpA. In more detail, it will be first determined how many patients are capable and ready to use the technology in a routine setting. Furthermore, the usage and behavior of patients using the app will be studied, the usability of the app and the equivalence of the collected parameters as well as the adherence to the documentation of disease activity over time.

Methods:

Patients diagnosed with axSpA were consecutively included in this ongoing monocentric prospective cohort study. In addition to patient and disease characteristics, information on previous experience with digital health apps was collected. Patients were asked to submit BASDAI and BASFI scores regularly every 2 weeks. The free to use AxSpA Live App is available for Android and iOS as a Class I certified medical device.

Results:

Out of 103 axSpA patients asked, 69 patients with axSpA (mean age 41.5 ± 11.3, 58% male, 76.8% use of bDMARDs, BASDAI 4.3 ± 2.0, BASFI 3.8 ± 2.5) out of 103 patients (67%) agreed to use participate, while 5 did not have a smartphone, 1 was unable to download the app for technical reasons, 28 reported other personal reasons). Of the 69, 62 patients (89.9%) reported using electronic media frequently and had used digital health apps (mean apps used 1.0 ± 1.3) in everyday life before. There were no systematic differences between pain levels documented on paper or by app at baseline (ICC 0.9 (95%CI 0.82 – 0.93). Out of 55 patients who completed week 2, only 33 patients (60%) used the App regularly to transmit their BASDAI/BASFI responses within the first two weeks (60%). Patients who started a new drug treatment because of high disease activity, reported BASDAI values more often than patients without a treatment change within a follow-up period of 5.5± 2.4 weeks (Table).

Conclusion:

The majority of patients with axSpA were able to use the AxSpA Live App. Most patients report scores regularly. The current disease activity seems to influence the adherence to reporting.

Patients without change in their medication (n=53)Patients with change in their medication (n=16)Age, years42.0 (11.9)39.8 (9.3)Sex, male (%)62.343.8BASDAI, baseline4.1 (2.1)4.9 (1.7)BASFI, baseline3.8 (2.6)3.8 (2.3)Time of follow-up, in weeks5.4 (2.4)5.6 (2.5)Number of transmitted BASDAI values at week 222 (41%)11 (69%)Median number of transmitted BASDAI values during follow up1.0(3.6)1.5 (1.4)

This work was supported by an unrestricted Grant by Novartis Pharma GmbH, Germany

Acknowledgments:

n/a

Disclosure of Interests:

Uta Kiltz Grant/research support from: AbbVie, Amgen, Biogen, Novartis, Pfizer, Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer, Roche, UCB, Robin Kempin: None declared, Anna Schlegel: None declared, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Styliani Tsiami: None declared, Bjoern Buehring Grant/research support from: GE/Lunar, Kinemed, Consultant of: Gilead, Abbvie, Lilly, GE/Lunar, Janssen, Amgen, Speakers bureau: UCB, David Kiefer Grant/research support from: Novartis, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma

AB1171 Effects of successive switches of two different biosimilars of etanercept on outcomes in inflammatory rheumatic diseases in daily practice

Background:

A single switch from an originator to a biosimilar product has been shown to be safe and effective in the treatment of rheumatic musculoskeletal diseases (RMDs). The availability of biosimilars has created a financial incentive to encourage switching to cheaper products (“non-medical switch”). This is naturally associated with multiple switches. However, the effect of multiple switching between biosimilars of the same reference product has not been thoroughly investigated to date.

Objectives:

To assess the effectiveness and safety of systematic non-medical switching from innovator etanercept (ETN) to biosimilar ETN (SB4) and successive to another biosimilar ETN (GP2015) in adult patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) or axial spondyloarthritis (axSpA) in a real-life setting.

Methods:

This retrospective study was performed in a tertiary center in adult patients with RA, PsA or axSpA who had been treated with the innovator ETN and who had been switched to two ETN biosimilars for economic reasons thereafter. The first switch from innovator ETN to the first biosimilar ETN occurred between February-May 2017 and the second switch from the first to the second biosimilar ETN occurred between September-December 2017. The end of the observation period was October 2019. Disease activity, function and adverse events (AE) were regularly assessed, and any changes in outcome were recorded during the follow-up period. The scores documented at week 12 week after the second switch were taken as primary outcome.

A total of 100 patients (54 RA, 27 axSpA, 19 PsA, mean age 54.3±15.1, 46% male) who switched twice to those ETN biosimilars over a follow-up period of 21.1±7.4 months were included. The retention rate after the second ETN biosimilar switch was 89% about 6 months after the second switch. While 2 patients were lost to follow-up and 1 patient died (cardiac arrest), 7 patients discontinued due to inefficacy or AE, including one pancreatic cancer. One patient was withdrawn due to pregnancy. Overall, 14 AEs were reported in 8 patients. Among them, 4 patients switched back to originator etanercept in month 6, 1 patient re-administered GP2015 successfully in month 3 after suffering from mucosal erosions and in 3 patients another mode of action was prescribed. The scores at week 12 of both, disease activity and function, remained unchanged (Table 1).

Table 1.

Patient characteristics

AssessmentBaseline(n=100)SB4 Follow-up 12 weeks(n=100)SB 4 Follow-up 24 weeks(n=100)Second switch to GP2015(n=100)GP2015 Follow-up 12 weeks(n=97)GP2015 Follow-up 24 weeks(n=89)RADAS283,0 (1,2)2,9 (1,4)3,1 (1,2)2,8 (1,4)3,4 (2,5)3,0 (1,4)HAQ1,4 (0,8)1,6 (0,9)1,0 (0,9)1,5 (0,8)1,5 (0,8)1,6 (0,9)PsADAS283,8 (1,4)1,9 (1,4)2,8 (1,5)3,1 (1,1)4,5 (2,6)3,6 (2,6)HAQ1,2 (0,9)1,0 (0,9)0,9 (0,9)1,0 (0,8)1,0 (0,9)1,2 (0,8)axSpABASDAI5,1 (2,7)4,5 (2,6)5,1 (3,8)4,1 (2,2)4,6 (2,5)4,3 (2,4)ASDAS3,4 (0,8)2,5 (0,8)2,7 (0,8)3,2 (1,8)2,7 (1,2)2,5 (0,9)BASFI4,4 (2,7)4,3 (2,7)4,3 (3,2)4,6 (2,6)4,5 (2,7)4,8 (3,0)

*Values are mean ± standard deviation

Disclosure: Hexal funded this research

Conclusion:

The retention rate after multiple switches from innovator ETN to two ETN biosimilars was close to 90%. No major changes in disease activity and function were observed in all three indications.