Circulating immune profile in granulomatosis with polyangiitis reveals distinct patterns related to disease activity

Granulomatosis with polyangiitis (GPA) is an autoimmune disorder characterized by recurrent relapses that can cause severe tissue damage and life-threatening organ dysfunction. Multiple immune cells and cytokines/chemokines are involved in the different stages of the disease. Immune profiling of patients may be useful for tracking disease activity, however, reliable immune signatures for GPA activity are lacking. In this study, we examined circulating immune profiles in GPA patients during active and remission disease states to identify potential immune patterns associated with disease activity. The distribution and phenotypic characteristics of major circulating immune cells, and the profiles of circulating cytokines/chemokines, were studied on cryopreserved peripheral blood mononuclear cells from GPA patients (active, n = 20; remission, n = 20) and healthy controls (n = 20) leveraging a 40-color optimized multicolor immunofluorescence panel (OMIP-69) and in serum using a 46-plex Luminex multiplex assay, respectively. Deep phenotyping uncovered a distinct composition of major circulating immune cells in active GPA and GPA in remission, with the most significant findings emerging within the monocyte compartment. Our detailed analysis revealed circulating monocyte diversity beyond the conventional monocyte subsets. We identified eight classical monocyte populations, two intermediate monocyte populations, and one non-classical monocyte population. Notably, active GPA had a higher frequency of CD45RA+CCR5+CCR6-CCR7+/lowCD127-HLA-DR+CD2- classical monocytes and a lower frequency of CD45RA-CCR5-/lowCCR6-CCR7-CD127-HLA-DR+CD2+/- classical monocytes, which both strongly correlated with disease activity. Furthermore, serum levels of CXCL1, CXCL2, and CCL20, all linked to monocyte biology, were elevated in active GPA and correlated strongly with disease activity. These findings shed light on the circulating immune profile of GPA and may lead to immune signature profiles for assessing disease activity. Monocytes in particular may be studied further as potential markers for monitoring GPA.

Nitrous-oxide-induced polyneuropathy and subacute combined degeneration of the spine: clinical and diagnostic characteristics in 70 patients, with focus on electrodiagnostic studies

BACKGROUND AND PURPOSE

Nitrous oxide (N2 O) induced neurological symptoms are increasingly encountered. Our aim is to provide clinical and diagnostic characteristics with a focus on electrodiagnostic studies.

METHODS

Patients with neurological sequelae due to N2 O presenting in our hospital between November 2018 and December 2021 reporting clinical and diagnostic data were retrospectively reviewed.

RESULTS

Seventy patients (median 22 years) were included. Median N2 O usage was 4 kg/week during 12 months. Patients' history revealed a higher rate of sensory symptoms compared to motor (97% vs. 57%) and 77% walking difficulties. Clinical diagnosis was polyneuropathy (PNP) in 44%, subacute combined degeneration (SCD) of the spine in 19%, both in 37%. Median vitamin B12 level was low (159 pmol/L), normal in 16%. The median methylmalonic acid was increased (2.66 μmol/L). Electrodiagnostic abnormalities were observed in 91%, with 72% fulfilling axonal PNP criteria, 20% showing mild to intermediate slowing. One patient fulfilled demyelinating PNP criteria not related to N2 O abuse (Charcot-Marie-Tooth type 1a). More prominent motor nerve conduction abnormalities were found; lower limbs were more affected. In 64% with normal conduction, myography showed signs of axonal loss. Magnetic resonance imaging showed cervical myelopathy in 58% involving generally five to six segments.

CONCLUSIONS

Nitrous oxide (N2 O) leads to neurological symptoms by causing PNP and/or SCD primarily involving the legs. Distinguishing PNP and SCD clinically was shown to be insufficient. Electrodiagnostic studies showed axonal PNP. Demyelinating PNP due to N2 O abuse was not present in our cohort. Therefore, further diagnostic work-up is warranted if demyelinating features are present.

CSF Findings in Relation to Clinical Characteristics, Subtype, and Disease Course in Patients With Guillain-Barré Syndrome

BACKGROUND AND OBJECTIVES

To investigate CSF findings in relation to clinical and electrodiagnostic subtypes, severity, and outcome of Guillain-Barré syndrome (GBS) based on 1,500 patients in the International GBS Outcome Study.

METHODS

Albuminocytologic dissociation (ACD) was defined as an increased protein level (>0.45 g/L) in the absence of elevated white cell count (<50 cells/μL). We excluded 124 (8%) patients because of other diagnoses, protocol violation, or insufficient data. The CSF was examined in 1,231 patients (89%).

RESULTS

In 846 (70%) patients, CSF examination showed ACD, which increased with time from weakness onset: ≤4 days 57%, >4 days 84%. High CSF protein levels were associated with a demyelinating subtype, proximal or global muscle weakness, and a reduced likelihood of being able to run at week 2 (odds ratio [OR] 0.42, 95% CI 0.25-0.70; p = 0.001) and week 4 (OR 0.44, 95% CI 0.27-0.72; p = 0.001). Patients with the Miller Fisher syndrome, distal predominant weakness, and normal or equivocal nerve conduction studies were more likely to have lower CSF protein levels. CSF cell count was <5 cells/μL in 1,005 patients (83%), 5-49 cells/μL in 200 patients (16%), and ≥50 cells/μL in 13 patients (1%).

DISCUSSION

ACD is a common finding in GBS, but normal protein levels do not exclude this diagnosis. High CSF protein level is associated with an early severe disease course and a demyelinating subtype. Elevated CSF cell count, rarely ≥50 cells/μL, is compatible with GBS after a thorough exclusion of alternative diagnoses.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that CSF ACD (defined by the Brighton Collaboration) is common in patients with GBS.

Modified Erasmus GBS Respiratory Insufficiency Score: a simplified clinical tool to predict the risk of mechanical ventilation in Guillain-Barré syndrome

BACKGROUND

This study aimed to determine the clinical and diagnostic factors associated with mechanical ventilation (MV) in Guillain-Barré syndrome (GBS) and to simplify the existing Erasmus GBS Respiratory Insufficiency Score (EGRIS) for predicting the risk of MV.

METHODS

Data from the first 1500 patients included in the prospective International GBS Outcome Study (IGOS) were used. Patients were included across five continents. Patients <6 years and patients from Bangladesh were excluded. Univariable logistic and multivariable Cox regression were used to determine which prespecified clinical and diagnostic characteristics were associated with MV and to predict the risk of MV at multiple time points during disease course.

RESULTS

1133 (76%) patients met the study criteria. Independent predictors of MV were a shorter time from onset of weakness until admission, the presence of bulbar palsy and weakness of neck flexion and hip flexion. The modified EGRIS (mEGRIS) was based on these factors and accurately predicts the risk of MV with an area under the curve (AUC) of 0.84 (0.80-0.88). We internally validated the model within the full IGOS cohort and within separate regional subgroups, which showed AUC values of 0.83 (0.81-0.88) and 0.85 (0.72-0.98), respectively.

CONCLUSIONS

The mEGRIS is a simple and accurate tool for predicting the risk of MV in GBS. Compared with the original model, the mEGRIS requires less information for predictions with equal accuracy, can be used to predict MV at multiple time points and is also applicable in less severely affected patients and GBS variants. Model performance was consistent across different regions.

An International Perspective on Preceding Infections in Guillain-Barré Syndrome: The IGOS-1000 Cohort

BACKGROUND AND OBJECTIVES

Infections play a key role in the development of Guillain-Barré syndrome (GBS) and have been associated with specific clinical features and disease severity. The clinical variation of GBS across geographical regions has been suggested to be related to differences in the distribution of preceding infections, but this has not been studied on a large scale.

METHODS

We analyzed the first 1,000 patients included in the International GBS Outcome Study with available biosamples (n = 768) for the presence of a recent infection with Campylobacter jejuni, hepatitis E virus, Mycoplasma pneumoniae, cytomegalovirus, and Epstein-Barr virus.

RESULTS

Serologic evidence of a recent infection with C. jejuni was found in 228 (30%), M. pneumoniae in 77 (10%), hepatitis E virus in 23 (3%), cytomegalovirus in 30 (4%), and Epstein-Barr virus in 7 (1%) patients. Evidence of more than 1 recent infection was found in 49 (6%) of these patients. Symptoms of antecedent infections were reported in 556 patients (72%), and this proportion did not significantly differ between those testing positive or negative for a recent infection. The proportions of infections were similar across continents. The sensorimotor variant and the demyelinating electrophysiologic subtype were most frequent across all infection groups, although proportions were significantly higher in patients with a cytomegalovirus and significantly lower in those with a C. jejuni infection. C. jejuni-positive patients were more severely affected, indicated by a lower Medical Research Council sum score at nadir (p = 0.004) and a longer time to regain the ability to walk independently (p = 0.005). The pure motor variant and axonal electrophysiologic subtype were more frequent in Asian compared with American or European C. jejuni-positive patients (p < 0.001, resp. p = 0.001). Time to nadir was longer in the cytomegalovirus-positive patients (p = 0.004).

DISCUSSION

Across geographical regions, the distribution of infections was similar, but the association between infection and clinical phenotype differed. A mismatch between symptom reporting and serologic results and the high frequency of coinfections demonstrate the importance of broad serologic testing in identifying the most likely infectious trigger. The association between infections and outcome indicates their value for future prognostic models.

Electrodiagnostic subtyping in Guillain-Barré syndrome: Use of criteria in practice based on a survey study in IGOS

Electrodiagnostic (EDx) studies are helpful in diagnosing and subtyping of Guillain‐Barré syndrome (GBS). Published criteria for differentiation into GBS subtypes focus on cutoff values, but other items receive less attention, although they may influence EDx subtyping: (a) extensiveness of EDx testing, (b) nerve‐specific considerations, (c) distal compound muscle action potential (CMAP)‐amplitude requirements, (d) criteria for conduction block and temporal dispersion. The aims of this study were to investigate how these aspects were approached by neuromuscular EDx experts in practice and how this was done in previously published EDx criteria for GBS. A completed questionnaire was returned by 24 (of 49) members of the electrophysiology expertise group from the International GBS Outcome Study. Six published EDx criteria for GBS subtyping were compared regarding these aspects. The indicated minimal number of motor nerves to study varied among respondents and tended to be more extensive in equivocal than normal studies. Respondents varied considerably regarding usage of compression sites for subtyping (median/wrist, ulnar/elbow, peroneal/fibular head): 29% used all variables from all sites, 13% excluded all sites, and 58% used only some sites and/or variables. Thirty‐eight percent of respondents required a minimal distal CMAP amplitude to classify distal motor latency as demyelinating, and 58% did for motor conduction velocity. For proximal/distal CMAP‐amplitude ratio and F‐wave latency, a requisite minimal CMAP amplitude was more often required (79%). Also, the various published criteria sets showed differences on all items. Practical use of EDx criteria for subtyping GBS vary extensively across respondents, potentially lowering the reproducibility of GBS subtyping.

AB1469 SPANISH TRANSLATION AND CROSS-CULTURAL ADAPTATION OF THE mSQUASH

Background

Regular physical activity is recommended for all patients in the ASAS/EULAR recommendations for the management of axial spondyloarthritis (axSpA). However, there is a lack of outcome measures that assess the amount and type of physical activity in patients with axSpA. For this matter, the modified Short QUestionnaire to Assess Health enhancing physical activity (mSQUASH) was developed and validated, originally in Dutch1.

Objectives

To translate and cross-culturally adapt the mSQUASH into Spanish and to test the equivalence of the translated version in patients with axSpA.

Methods

The mSQUASH was translated into Spanish and then back-translated into Dutch, following forward-backward procedure as described by Beaton2 (Figure 1). Two bi-lingual translators (native speakers for European Spanish) produced independent forward translations of the item content, response options, and instructions of the mSQUASH into Spanish. Both versions were harmonized in a meeting among the Spanish translators, a methodologist and a rheumatologist into a consensual version. Another translator (native speaker for Dutch), blinded for the original version, back translated the synthesized version into Dutch. An expert committee, including all translators, one methodologist and a rheumatologist, reached consensus on discrepancies, ensuring equivalence between the Dutch and Spanish versions, and developed a pre-final version of the Spanish mSQUASH. The field test with cognitive debriefing involved a sample of 10 patients with axSpA covering the full spectrum of the disease -radiographic axSpA (r-axSpA) and non-radiographic axSpA (nr-axSpA)- with different gender, age, disease duration, and educational background. Each patient was interviewed to check understandability, interpretation and cultural relevance of the translation.

Figure 1.

Cross-cultural adaptation of the mSQUASH

Results

The translation process of the mSQUASH was completed without major complications following the forward-backward procedure. The first translation needed several iterations due to small discrepancies in the wording. Back-translation was performed without difficulties, and the expert committee agreed upon a final version of the questionnaire. A total of 10 patients with axSpA participated in the field test (Table 1). Seven were male, mean age (SD) was 38.9 (14.4) years; 6 patients had r-axSpA, 9 were HLA-B27+. Cognitive debriefing showed the Spanish questionnaire to be, relevant, understandable and comprehensive. The preliminary version was accepted with minor modifications. As a result of the interviews, minor spelling errors were corrected, and the wording of the response categories was homogenized (“despacio/ligero”). Besides, the term “colegio”- translated literally from the Dutch “school”- was found not comprehensive enough to reflect possibilities on education (i.e. it does not include university), so it was adapted to “el lugar de estudio”.

Table 1.

Patients’ characteristics

#GenderAgeWorking statusEducationaxSpA subtypeDisease durationHLA-B27DrugBASDAI1Male63WorkingUniversityr-axSpA35 y+NSAIDs2.32Male24StudentSecondaryr-axSpA6 y+NSAIDs03Male37WorkingUniversityr-axSpA5 y+ADA2.54Male66RetiredUniversityr-axSpA23 y+IFN3.15Male29WorkingUniversityr-axSpA11 y+ADA06Female26WorkingUniversitynr-axSpA2 y+NSAIDs-7Male24StudentUniversitynr-axSpA1 y+ETA4.58Male35WorkingUniversityr-axSpA12 y+GOL09Female40WorkingSecondarynr-axSpA4 y+NSAIDs-10Female45UnemployedPrimarynr-axSpA9 y-GOL8.2

Conclusion

The resulting Spanish version of the mSQUASH showed good linguistic and face validity according to the field test, revealing potential for use in both clinical practice and research settings. In order to conclude the cross-cultural adaptation of the mSQUASH into Spanish, the next step is the assessment of psychometric properties of the Spanish version.

References

[1]Beaton DE, et al. Spine. 2000; 25:3186-91

[2]Carbo et al. Semin Arthritis Rheum. 2021; 51:719-27

Disclosure of Interests

Diego Benavent Speakers bureau: Jannsen, Roche, Grant/research support from: Novartis, Andrea Jochems: None declared, DORA PASCUAL-SALCEDO Speakers bureau: Pfizer, Menarini, Takeda, Abvvie., Grant/research support from: Pfizer, Menarini, Takeda, Abvvie., Gijs Jochems: None declared, Chamaida Plasencia Speakers bureau: Pfizer, Abbvie, Lilly, Sandoz, Sanofi, Biogen, Roche and Novartis, Grant/research support from: Pfizer and Abbvie, Sofia Ramiro Speakers bureau: Eli Lilly, MSD, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, UCB, Sanofi, Grant/research support from: AbbVie, Galapagos, Novartis, Pfizer, UCB, Suzanne Arends: None declared, Anneke Spoorenberg Consultant of: AbbVie, Novartis, Pfizer; UCB, Lilly, Grant/research support from: AbbVie, Pfizer, Alejandro Balsa Speakers bureau: Pfizer, Abbvie, Lilly, Galapagos, BMS, Sandoz, Nordic Pharma, Gebro, Roche, Sanofi, UCB, Consultant of: Pfizer, Abbvie, Lilly, Galapagos, BMS, Nordic Pharma, Sanofi, UCB, Grant/research support from: Pfizer, Abbvie, BMS, Nordic Pharma, Gebro, Roche, UCB, Victoria Navarro-Compán Speakers bureau: AbbVie, Eli Lilly, Janssen, MSD, Novartis, Pfizer, UCB Pharma, Consultant of: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, UCB Pharma, Grant/research support from: AbbVie and Novartis

POS1012 PATIENT CHARACTERISTICS AND CLINICAL ASSESSMENTS ASSOCIATED WITH PROGRESSION FROM NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS TO ANKYLOSING SPONDYLITIS

Background

Part of the patients with non-radiographic spondyloarthritis (nr-axSpA) will progress to ankylosing spondylitis (AS). Varying factors are reported to be predictive of this progression of which the presence of elevated CRP and active sacroliitis on MRI are most often found1.

Objectives

To explore patient characteristics and clinical assessments associated with progression from nr-axSpA to AS up to 6 years follow-up in daily clinical practice.

Methods

Patients from the ongoing Groningen Leeuwarden axial SpA (GLAS) cohort classified as nr-axSpA enrolled into the cohort (baseline) between 2009 and 2018 were included in the analyses. Nr-axSpA was defined as sacroiliitis of ≥ 2 grade bilaterally or ≥ 3 unilaterally on the AP view of pelvic radiographs, according to the modified New-York (mNY) criteria. Baseline and available radiographs at 2 (n=85), 4 (n=53) and 6 years (n=30) of follow-up were randomized with radiographs of patients with AS and scored with known time sequence according to the mNY criteria by 2 trained readers (SK and RW). In case of disagreement in classification, the score of a third independent reader (AS) was used. Progression to AS was defined as progression in mNY sacroiliitis score to a score of ≥2 bilaterally or ≥3 unilaterally at any time during the 6-year follow-up period. Patient characteristics and clinical assessments at baseline were compared between patients who did and did not progress from nr-axSpA to AS, using chi-squared tests, Mann-whitney U tests or independent t-tests when appropriate.

Results

85 patients were classified as nr-axSpA at baseline. Mean age was 39±11 years, 52% was male, median symptom duration was 6 (IQR 3-17) years, 75% was HLA-B27+, and mean ASDAS was 2.7±1.1.

After 2, 4 and 6 years, 9/85 (10.6%), 4/47 (8.5%) and 2/24 (8.3%) of nr-axSpA patients progressed to AS. In total, 15 patients progressed to AS and 31 and 19 patients did not yet reach follow-up at 4 and 6 years, respectively.

Patients with nr-axSpA progressing to AS were significantly more often current smokers (62% vs. 21%, p=0.003) and had more often a history of uveitis (47 vs. 11%, p=0.001). Furthermore, patients with nr-axSpA progressing to AS tended to have higher CRP (and therefore ASDAS), more entheseal involvement, and worse lumbar spinal mobility then non-progressors; however, due to the relatively low number of progressors during the analyzed follow-up period, significance could not be reached (Table 1).

Table 1.

Comparison of baseline characteristics between patients with nr-axSpA who did and did not progress to AS. Values presented as mean ± SD, median (IQR) and n (%) for normally distributed, non-normally distributed and categorical variables, respectively. *p<0.05.

Baseline characteristicsAll patients (n=85)No progression (n=70)Progression (n=15)pMale sex44 (52%)39 (56%)5 (33%)0.115Age38.6 ± 10.838.4 ± 10.239.5 ± 13.80.774Symptom duration6 (3 – 17)7 (3 – 16)4 (2 – 20)0.663HLA-B27+62 (75%)52 (74%)10 (67%)0.758Currently smoking22 (28%)14 (21%)8 (53%)0.003*BMI26.1 ± 4.426.2 ± 4.525.8 ± 4.20.750History of uveitis15 (18%)8 (11%)7 (47%)0.001*History of IBD7 (8%)6 (9%)1 (8%)0.808History of psoriasis12 (14%)10 (15%)2 (13%)0.923ASDAS2.7 ± 1.12.6 ± 1.13.2 ± 1.00.107- ASDAS >2.151 (72%)41 (68%)10 (91%)0.126BASDAI5.3 (3.4 – 6.7)5.4 (3.2 – 6.8)4.7 (3.6 – 6.7)0.538CRP ≥5.021 (27%)16 (25%)5 (39%)0.320Start TNFi (during first 2 years of follow-up)27 (32%)23 (33%)4 (27%)0.640Chest expansion (cm)5.2 ± 2.15.3 ± 2.14.7 ± 2.10.367Lateral spinal flexion (cm)14.4 (10.5 – 17.5)14.5 (10.7 – 17.7)11.3 (9.0 – 17.5)0.163mSchober (cm)14.1 ± 1.314.1 ± 1.313.7 ± 1.30.308

Conclusion

In our cohort, active smoking and a history of uveitis were independently associated with the progression of nr-axSpA to AS. Combining data of different cohorts will help to assess a more robust picture of axSpA features and patient characteristics associated with progression to AS.

References

[1]Protopopov M, Poddubnyy D. Expert Rev Clin Immunol. 2018;14(6):525-533

Acknowledgements

The GLAS cohort has received unrestricted grants from Novartis.

Disclosure of Interests

Stan Kieskamp: None declared, Rick Wilbrink: None declared, Mark Siderius: None declared, Freke Wink: None declared, Reinhard Bos: None declared, Hendrika Bootsma Speakers bureau: Bristol-Myers Squibb, Novartis, Consultant of: Bristol-Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Grant/research support from: Unrestricted grants from Bristol-Myers Squibb and Roche, Suzanne Arends: None declared, Anneke Spoorenberg Paid instructor for: Abbvie, Consultant of: AbbVie, Novartis Pharma, Pfizer, UCB Pharma, Lilly, Grant/research support from: Novartis Pharma, Pfizer

POS0754 PATIENT ACCEPTABLE SYMPTOM STATE (PASS) IN PATIENTS WITH PRIMARY SJÖGREN’S SYNDROME IN DAILY CLINICAL PRACTICE

Background

Primary Sjögren’s syndrome (pSS) has great impact on all aspects of patients’ lives, not only physically, but also mentally, socially and financially.1 Sicca symptoms are mainly treated with local treatment, but no systemic immunosuppressive treatment is registered yet for pSS, which may have significant consequences on whether patients find their symptom state acceptable (PASS). In a previous study, a cut-off for acceptable symptom state based on the EULAR Sjögren’s Syndrome Patient Reported Index (ESSPRI, score <5) was developed for inclusion of patients with an unacceptable symptom state in clinical trials.2

Objectives

To explore the presence of PASS in a standard of care cohort of pSS patients and to compare patient characteristics and disease activity including ESSPRI between patients with and without PASS.

Methods

Consecutive outpatients with pSS from the REgistry of Sjögren Syndrome LongiTudinal (RESULT) cohort, who fulfilled the ACR/EULAR classification criteria and had available PASS data at baseline were included. Patient-reported outcomes were reported through questionnaires, which included the PASS (“Considering all the different ways your disease is affecting you, if you were to stay in this state for the next few months, do you consider your current state satisfactory?”; yes/no) and ESSPRI (“How severe has your dryness, fatigue and pain been during the last two weeks?”; scale 0-10). An acceptable ESSPRI symptom state has been defined as <5.2 Systemic disease activity was assessed with EULAR Sjögren’s Syndrome Disease Activity Index (ESSDAI). Independent samples t-test, Mann-Whitney U test or Chi Square test were used to analyse differences between patients with or without PASS.

Results

Of 277 included pSS patients, 248 (90%) were female, median age was 54 years (IQR 43-64) and disease duration 5 years (2-11). 198 (71%) patients scored their symptom state as acceptable according to PASS. Patients with PASS were significantly older and had a longer disease duration compared to patients without PASS. Furthermore, patients with PASS had more often a low disease activity according to ESSDAI, and less often moderate disease activity (Table 1). The difference in ESSDAI activity was mainly observed in the articular and constitutional domains. ESSPRI was significantly lower in patients with PASS (median 5 vs. 7). No differences were seen in functional or laboratory parameters (Table 1). Of all included patients, only 86 (31%) patients had an acceptable symptom state according to the pre-defined cut-off point for ESSPRI (score <5). Sensitivity and specificity of this ESSPRI cut-off point for reaching PASS was 40% and 92%, respectively.

Table 1.

Baseline characteristics of pSS patients with and without PASS

PASS (n=198)Without PASS (n=79)Gender (female)177 (89)71 (90)Age (years)57 (44-65)*49 (41-60)*Disease duration (years)6 (2-12)*5 (2-8)*ESSDAI (total)4 (2-6) (n=191)4 (2-9) (n=75)<5127 (66)*38 (51)*5-1452 (27)*32 (43)*≥1412 (6)5 (7)ESSPRI (total)5 (4-7)**7 (6-8)**<580 (40)**6 (8)**Schirmer’s test (mm)4 (1-10) (n=179)4 (1-10) (n=72)Ocular staining score2 (1-4) (n=190)2 (0-4) (n=77)Unstimulated whole salivary flow (ml/min)0.05 (0.01-0.14) (n=187)0.08 (0.01-0.19) (n=76)Stimulated whole salivary flow (ml/min)0.54 (0.15-0.99) (n=189)0.58 (0.21-0.97) (n=76)SSA positive172/197 (87)66/79 (84)IgG (g/L)14 (11-19) (n=196)14 (10-19) (n=79)Rheumatoid factor (IU/ml)12 (3-39) (n=196)16 (2-47) (n=78)

Data presented as median (IQR) or n (%)

*Significant difference p<0.05

***Significant difference p<0.001

Conclusion

The majority (71%) of pSS patients reported being in an acceptable symptom state according to the PASS question in our standard of care cohort in daily clinical practice, despite high ESSPRI scores (60% with score ≥5). Further analyses of influences of treatment in these patients will be conducted.

References

[1]Vieira et al. Clin Exp Rheum 2021;39(Suppl. 133):S14-S16.

[2]Seror et al. Ann Rheum Dis 2016;75:382-389.

Acknowledgements

Unrestricted grants from the Dutch Arthritis Patients Association (ReumaNL), Bristol-Myers Squibb and Novartis

Disclosure of Interests

Liseth de Wolff: None declared, Suzanne Arends: None declared, Esther Mossel: None declared, Greetje S. van Zuiden: None declared, Jolien F. van Nimwegen Speakers bureau: Bristol-Myers Squibb, Consultant of: Bristol-Myers Squibb, Lisette Olie: None declared, Alja J. Stel: None declared, Konstantina Delli: None declared, Gwenny M. Verstappen: None declared, Frans G.M. Kroese: None declared, Arjan Vissink: None declared, Hendrika Bootsma Speakers bureau: Bristol Myers Squibb and Novartis, Consultant of: Bristol Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Grant/research support from: Unrestricted grants from Bristol Myers Squibb and Roche

POS0145 CLINICAL RESPONSE TO RITUXIMAB IS ASSOCIATED WITH PREVENTION OF B-CELL DRIVEN SALIVARY GLAND INFLAMMATION AND EPITHELIAL RESTORATION AS REVEALED BY MOLECULAR PATHOLOGY: RESULTS FROM THE TRACTISS TRIAL IN PRIMARY SJOGREN’S SYNDROME

Background

The TRial for Anti-B-Cell Therapy In patients with pSS (TRACTISS) is the largest multi-centre, placebo-controlled, phase-III trial with the administration of 2 cycles of Rituximab (RTX) or placebo at week 0 and 24, with trial clinical endpoints at week 48. Despite the primary endpoints (30% reduction in fatigue or oral dryness) were not met, RTX treated patients showed an improvement in secondary endpoints, such as unstimulated whole salivary flow (UWSF), and salivary gland (SG) total ultrasound score1,2. Additionally, recent post-hoc analysis of TRACTISS using novel CRESS composite endpoints3, highlighted a significantly increased response rate in the RTX vs placebo arm.

Objectives

To perform the first longitudinal analysis of matched transcriptomic and histological data of SG biopsies of pSS patients treated with RTX vs placebo at 3 time points, over 48 weeks, from the TRACTISS cohort, in order to identify mechanisms of response/resistance to B cell depletion.

Methods

29 pSS patients randomised to RTX or placebo arm consented for labial SG biopsies at week 0, 16 and 48. Patients received two 1000mg cycles of RTX or placebo at week 0 and 24. SG focus score, inflammatory aggregate area fraction, B-cells (CD20+), T-cells (CD3+), follicular dendritic cells (FDCs) (CD21+) and plasma cells (CD138+) density were assessed using quantitative digital image analysis. RNA sequencing with deconvolution and pathway analysis was performed to identify genes signatures and consensus gene modules as biomarkers of disease evolution and response/resistance to therapy.

Results

Placebo-treated SGs showed worsening of SG inflammation highlighted by the increment of aggregate size, B-cell density, development of new FDC networks, and a higher ectopic GC prevalence over 48 weeks, compared to RTX-treated patients. No difference in focus score, total T-cell and plasma cell infiltration was observed. RTX downregulated genes involved in immune cell recruitment and inflammatory aggregate organisation (e.g. CXCL13, CCR7 and PDCD1). Gene signature-based analysis of 35 immune cell types using XCell highlighted how RTX blocked class-switched and memory-B-cells accumulation in SGs over 48 weeks. Pathway analyses confirmed the downregulation of leukocyte migration, MHC-II antigen presentation, and T-cell co-stimulation immunological pathways, such as the CD40 receptor complex pathway. Among RTX-treated patients, only CRESS-responders demonstrated prevention of worsening B cell-driven molecular pathology signatures over time and a significant improvement in UWSF, in parallel with the upregulation of molecular pathways associated to SG restoration of the glandular epithelium. None of the above effects were observed at week 16 after the first RTX cycle.

Conclusion

Two RTX infusions repeated at week 24 exerted beneficial effects on labial SG inflammatory infiltration in pSS by downregulating genes involved in immune cell recruitment, activation and organisation in ectopic GCs. Conversely, all the above parameters showed significant evolution in placebo treated patients over 48 weeks demonstrating progression of SG immunopathology. Clinical responders to RTX based on CRESS response criteria were characterised by preservation of exocrine function which appear driven by SG epithelial restoration.

References

[1]Fisher, B. A. et al. Effect of rituximab on a salivary gland ultrasound score in primary Sjögren’s syndrome: results of the TRACTISS randomised double-blind multicentre substudy. Ann. Rheum. Dis.77, 412–416 (2018).

[2]Bowman, S. J. et al. Randomized Controlled Trial of Rituximab and Cost-Effectiveness Analysis in Treating Fatigue and Oral Dryness in Primary Sjögren’s Syndrome. Arthritis Rheumatol.69, 1440–1450 (2017).

[3]Arends, S. et al. Composite of Relevant Endpoints for Sjögren’s Syndrome (CRESS): development and validation of a novel outcome measure. Lancet Rheumatol.3, e553–e562 (2021).

Disclosure of Interests

None declared

POS0581 HIGHER SKIN AUTOFLUORESCENCE IN INDIVIDUALS AT RISK FOR RHEUMATOID ARTHRITIS: RESULTS FROM A LARGE POPULATION BASED COHORT

Background

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease which is associated with increased mortality, mostly because of a higher incidence of cardiovascular disease (CVD), which cannot be explained by traditional risk factors alone. (1,2) Also studies showed that the cardiovascular events can already occur at a higher than expected rate shortly after the first symptoms of RA. (3)This raises the question if individuals with clinical suspect arthralgia (CSA) but not yet diagnosed with RA, already have an increased risk for developing cardiovascular disease compared to healthy controls and if this is also true for ACPA positive individuals without symptoms of clinical suspect arthralgia.

In our study we used skin autofluorescence (SAF), measured with the AGE reader, as an early non-invasive tool to identify subjects who are at increased risk for developing cardiovascular disease. (4) SAF measures the accumulation of AGEs in the skin and thereby offers a simple alternative to invasive measurement of AGE accumulation. (5)

Objectives

To investigate skin autofluorescence (SAF) levels, as an early indicator for cardiovascular disease, in relation to the presence of anticitrullinated protein antibodies (ACPA), clinical suspect arthralgia (CSA) and rheumatoid arthritis (RA) in a large population-based cohort.

Methods

Cross-sectional data were used from 17346 participants of the Dutch Lifelines Cohort Study, of whom baseline SAF and ACPA levels were available. The presence of CSA was determined using EULAR questions from the connective tissue disease screening questionnaire (CSQ). Individuals were divided into four groups: ACPA negative controls (n=17211), ACPA positive without CSA (n=49), ACPA positive with CSA (n=31) and defined RA (n=52). Multinomial regression was used to compare SAF levels and correct for potential confounders.

Results

SAF levels were higher in the ACPA positive with CSA group (OR 2.04, p=0.034) and the defined RA group (OR 3.10, p<0.001) compared to controls, but not in the ACPA positive without CSA group (OR 1.07, p=0.875). The difference in SAF levels remained statistically significant in the defined RA group after adjusting for age (OR 2.09, p=0.011), smoking status, renal function or HbA1c. In the ACPA positive with CSA group, the effect was found to be comparable (corrected for age: OR 2.09).

Conclusion

Our results indicate that ACPA positive individuals with CSA have elevated SAF levels, which is regarded as an early marker for oxidative stress and a possible indicator for development of cardiovascular disease. Therefore it is important to conduct further studies to explore if, in individuals with clinical suspect arthralgia, cardiovascular risk management should be considered in future clinical practice.

References

[1]Wolfe F, Mitchell DM, Sibley JT, Fries JF, Bloch DA, Williams CA, et al. The mortality of rheumatoid arthritis. Arthritis Rheum 1994 Apr;37(4):481-494.

[2]Symmons DP, Jones MA, Scott DL, Prior P. Longterm mortality outcome in patients with rheumatoid arthritis: early presenters continue to do well. J Rheumatol 1998 June 01;25(6):1072-1077.

[3]Kerola AM, Kauppi MJ, Kerola T, Nieminen TV. How early in the course of rheumatoid arthritis does the excess cardiovascular risk appear? Ann Rheum Dis 2012 October 01;71(10):1606-1615.

[4]Stirban A, Heinemann L. Skin Autofluorescence - A Non-invasive Measurement for Assessing Cardiovascular Risk and Risk of Diabetes. Eur Endocrinol 2014 August 01;10(2):106-110.

[5]Meerwaldt R, Graaff R, Oomen PHN, Links TP, Jager JJ, Alderson NL, et al. Simple non-invasive assessment of advanced glycation endproduct accumulation. Diabetologia 2004 July 01;47(7):1324-1330.

Figure 1.

The top chart shows SAF levels measured with the AGE reader in the 4 groups: ACPA negative controls, ACPA positive without CSA group, APCA positive with CSA group and defined RA group.

The lower picture shows the AGE reader we used from DiagnOptics Technologies BV, Groningen, the Netherlands: https://www.diagnoptics.com/

Acknowledgements

The Lifelines initiative has been made possible by subsidy from the Dutch Ministry of Health, Welfare and Sport, the Dutch Ministry of Economic Affairs, the University Medical Center Groningen (UMCG), Groningen University and the Provinces in the North of the Netherlands (Drenthe, Friesland, Groningen).

Disclosure of Interests

None declared.

POS0193 EVALUATION OF CRESS IN THE PHASE 2 RANDOMISED PLACEBO-CONTROLLED STUDY OF SEQUENTIAL BELIMUMAB/RITUXIMAB ADMINISTRATION IN PATIENTS WITH PRIMARY SJÖGREN’S SYNDROME

Background

EULAR Sjögren’s syndrome disease activity index (ESSDAI) assesses systemic disease activity in patients (pts) with primary Sjögren’s syndrome (pSS); however, weaknesses include exclusion of patient-reported symptoms, tear and salivary gland function, and a marked placebo (PBO) response. Composite of Relevant Endpoints for Sjögren’s Syndrome (CRESS) is a recently developed composite outcome measure validated using data from three Phase 3 randomised controlled trials of pts with pSS.1 Concise CRESS (cCRESS) is used when ocular staining score and salivary gland ultrasonography are unavailable. ESSDAI was an endpoint in a Phase 2, PBO-controlled study, evaluating the safety and efficacy of belimumab (BEL) and rituximab (RTX) sequential administration (BEL/RTX), and BEL and RTX monotherapies in pts with pSS. Although the results numerically favoured BEL/RTX over PBO, this was not statistically significant.

Objectives

To evaluate the efficacy of BEL/RTX and monotherapies using cCRESS overall responses at Weeks (Wks) 24, 52, and 68, and individual item responses at Wk 24 in pts with pSS who completed the Phase 2 study.

Methods

In the Phase 2, double-blind, 68-Wk study (NCT02631538) adults were randomised (2:2:2:1) into 4 treatment arms: BEL/RTX (n=24; weekly BEL 200 mg subcutaneous [SC] to Wk 24 followed by weekly PBO SC to Wk 52 + RTX 1000 mg intravenous [IV], Wk 8 + 10), BEL monotherapy (n=24; weekly BEL 200 mg SC to Wk 52), RTX monotherapy (n=25; RTX 1000 mg IV, Wk 8 + 10), or PBO (n=13). Pts were classified post hoc as cCRESS responders when ≥3 of the following 5 items were met: 1) Clinical (Clin)ESSDAI score <5 (low disease state); 2) decrease of ≥1 point or ≥15% from baseline (BL) in EULAR Sjögren’s Syndrome Patient Reported Index (ESSPRI); 3) increase of ≥5 mm from BL in abnormal Schirmer’s test, or no change to abnormal if normal at BL; 4) unstimulated whole saliva (UWS) increase of ≥25% from BL, or any increase from BL if score was 0 at BL; 5) decrease of ≥25% in the rheumatoid factor (RF) titre from BL, or decrease of ≥10% in IgG from BL.1

Results

Of 86 randomised pts, 60 completed follow-up to Wk 68 (completer population) and were included in the analysis. Most pts were female (95%, n=57); mean (SD) age was 49.6 (13.0) years. BL disease characteristics are presented in the Table 1.

Table 1.

Clinical, functional, and laboratory parameters at BL and cCRESS responders at Wks 24, 52, and 68 (completer population)

PBO (n=8)BEL/RTX (n=17)BEL (n=19)RTX (n=16)Pt parameters at BL, mean (SD)ClinESSDAI11.1 (3.76)11.7 (5.47)9.2 (3.77)11.7 (4.76)ESSPRI6.4 (2.05)6.0 (1.97)6.5 (1.68)5.9 (2.20)Schirmer, mm/5 min2.7 (3.25)5.3 (6.44)3.3 (3.16)2.8 (3.15)UWS, ml/min0.1 (0.11)0.1 (0.12)0.1 (0.09)0.1 (0.14)RF, KU/l60.8 (42.24)30.9 (38.20)37.0 (34.98)105.0 (200.97)IgG, g/l20.4 (6.65)16.7 (5.00)18.1 (7.19)16.5 (6.09)cCRESS responders, n (%)Wk 244 (50.0)9 (52.9)7 (36.8)5 (31.3)Wk 524 (50.0)10 (58.8)8 (42.1)4 (25.0)Wk 681 (12.5)6 (35.3)7 (36.8)3 (18.8)

At Wks 24 and 52, the proportion of cCRESS responders was numerically higher with BEL/RTX than with either BEL, RTX, or PBO, but the difference was not significant (Table 1). At Wk 68, the proportion of cCRESS responders was numerically higher with BEL/RTX than with RTX or PBO (Table 1). The 5 cCRESS items contributed relatively equally to total cCRESS response, with the highest response observed in the RF/IgG item and the lowest in the tear gland item (Schirmer’s test; Figure 1).

Figure 1.

cCRESS and individual item responders at Wk 24 (completer population)

Conclusion

At Wks 24, 52, and 68, BEL/RTX was generally associated with a numerically higher cCRESS response rate compared with the monotherapies or PBO. The PBO response for cCRESS was notable and similar to the PBO response for ClinESSDAI. The PBO response in the tear and salivary gland items was greater than in the other treatment arms, perhaps due to the use of cCRESS instead of CRESS. Due to the small sample size, the results should be interpreted with caution.

References

[1]Arends S, et al. Lancet Rheumatol 2021;3:553–62

Acknowledgements

This post hoc analysis of the GSK Study 201842 was funded by GlaxoSmithKline (GSK). Medical writing support was provided by Casmira Brazaitis, PhD, Fishawack Indicia Ltd, UK, part of Fishawack Health, and was funded by GSK.

Disclosure of Interests

Hendrika Bootsma Consultant of: BSM, Roche, Novartis, Medimmune and Union Chimique Belge, Grant/research support from: BSM and Roche, Suzanne Arends: None declared, Liseth de Wolff: None declared, Kenneth L Clark Shareholder of: GSK, Employee of: GSK, Andre van Maurik Shareholder of: GSK, Employee of: GSK, Prafull Mistry Shareholder of: GSK, Employee of: GSK, Pragya Shukla Shareholder of: GSK, Employee of: GSK, Svetlana Nihtyanova Shareholder of: GSK, Consultant of: Roche, Employee of: GSK, Norma Lynn Fox Shareholder of: GSK, Employee of: GSK, David Roth Shareholder of: GSK, Employee of: GSK

POS0986 SELF-REPORTED PHYSICAL ACTIVITY IN PATIENTS WITH axSpA: ADHERENCE TO PUBLIC HEALTH RECOMMENDATIONS AND ASSOCIATION WITH HEALTH STATUS IN TWO DUTCH COHORTS

Background

In general, regular physical activity (PA) is associated with a reduced risk of cardiovascular disease and all-cause mortality. In people with axial spondyloarthritis (axSpA) specifically, regular PA has shown beneficial effects on function, spinal mobility and pain. The World Health Organization (WHO) developed public health recommendations for the frequency, intensity and duration of PA in adults required to offer significant health benefits and mitigate health risks.

Objectives

To assess the proportion of axSpA patients fulfilling the WHO PA recommendations and to investigate the association of the amount of PA with health status and quality of life (QoL).

Methods

Patients from two Dutch cohorts were included; one in the Northern (GLAS cohort, n=148) and one in the Western (LUMC cohort, n=193) part of the Netherlands. The (m)SQUASH was used to assess the type, intensity and time spent on PA during a normal week in the past month. Fulfillment of the WHO PA recommendations was defined as aerobic PA of least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity (or an equivalent combination), and muscle-strengthening activities twice a week. Univariate linear regression analysis was used to explore the association of (m)SQUASH total score with health status (ASAS-HI) and quality of life (ASQoL). Multivariate regression analysis was used to correct these associations for age, gender, BMI and ASDAS as potential confounders.

Results

In the GLAS cohort, 59% were male, mean age (± SD) was 48.5 ± 13.2 years, median (IQR) ASAS-HI was 4.4 (1.9-8.1) and median ASQoL was 4 (1-9). In the LUMC cohort, 69% were male, mean age was 55.7 ± 14.1 years, and median ASAS-HI was 5.3 (2.1-8.0). Of these GLAS and LUMC patients, 57 (40%) and 62 (35%) fulfilled the WHO PA recommendations, respectively. Total (m)SQUASH score was significantly associated with ASAS-HI (GLAS cohort: R2 0.16, B (95%CI) -0.4 (-4.3;-1.6); LUMC cohort: R2 0.13, B (95%CI) -0.3 (-4.3;-2.0)) and ASQoL (GLAS cohort: R2 0.18, B (95%CI) -4.4 (-3.5;-1.4). These associations remained significant after correcting for age, gender, BMI and ASDAS (Table 1).

Table 1.

Association between total (m)SQUASH score and health status or quality of life in axSpA patients.

ASAS-HIASQoLR2B (95% CI)P-valueR2B (95% CI)P-valueGLAS cohortmSQUASH total score0.16-0.4 (-4.3;-1.6)<0.0010.18-4.4 (-3.5;-1.4)<0.001mSQUASH corrected for age, gender0.19-0.4 (-0.1;-1.5)<0.0010.21-4.2 (-0.9;-1.3)<0.001mSQUASH corrected for age, gender, BMI, ASDAS0.30-4.4 (-6.3;.2.6)<0.0010.31-3.4 (-5.1;-1.9)<0.001LUMC cohortSQUASH total score0.13-0.3 (-4.3;-2.0)<0.001SQUASH corrected for age, gender0.23-2.7 (-3.9;-1.6)<0.001

Conclusion

In both Dutch cohorts, only 35-40% of axSpA patients fulfilled the WHO PA recommendations, which seems less compared to the average 48% in the Dutch adult population1. AxSpA patient reporting a higher level of PA had better health status and QoL. Therefore, in daily clinical practice, greater awareness and focus on moderate-to-high intensity and muscle strengthening activity is desirable for axSpA patients.

References

[1]Duijvestijn et al. Int J Environ Res Public Health 2020.

Acknowledgements

The authors would like to thank ASAS and the Dutch Arthritis Society for supporting the original studies within the GLAS and LUMC cohorts.

Disclosure of Interests

Marlies Carbo: None declared, Bas Hilberdink: None declared, Davy Paap: None declared, Freke Wink: None declared, T.P.M. Vliet Vlieland: None declared, Salima van Weely: None declared, Anneke Spoorenberg Paid instructor for: AbbVie, Consultant of: AbbVie, Novartis Pharma, Pfizer, UCB Pharma, Lilly, Grant/research support from: Novartis Pharma, Pfizer, Suzanne Arends: None declared

POS0454 DIGITAL IMAGE ANALYSIS OF INTRAEPITHELIAL B-LYMPHOCYTES AS AN OBJECTIVE ALTERNATIVE TO ASSESS LYMPHOEPITHELIAL LESIONS IN SALIVARY GLANDS OF SJÖGREN’S SYNDROME PATIENTS

Background

Salivary glands of primary Sjögren’s syndrome (pSS) patients characteristically contain periductal lymphocytic infiltrates. Associated with these infiltrates, lymphoepithelial lesions (LELs) can be formed. LELs are composed of hyperplastic ductal epithelium with infiltrating lymphocytes and may assist in the diagnostic process of pSS1. However, manual identification of LELs on H&E staining is a subjective process and can be challenging. A more objective histological parameter that could assist in identification of LELs is the presence of intraepithelial lymphocytes within striated ducts, since we previously showed an association between intraepithelial B-lymphocytes and hyperplasia of the ductal epithelium2. These results, however, warrant validation in a larger cohort. Furthermore, associations between clinical parameters of pSS patients and presence of intraepithelial lymphocytes are not yet known.

Objectives

To investigate if detection of intraepithelial lymphocytes using digital image analysis can be used as an objective alternative to assess LELs, and to correlate presence of intraepithelial lymphocytes to clinical parameters of pSS patients.

Methods

Paired labial and parotid salivary gland biopsies of 109 patients clinically suspected for pSS were serially sectioned and stained for CD3 (T-lymphocytes), high molecular weight cytokeratin (striated ducts) and CD20 (B-lymphocytes). We developed a virtual triple staining digital image analysis (DIA) algorithm using the Visiopharm Integrator System (Visiopharm, Hørsholm, Denmark) to detect intraepithelial T- and B-lymphocytes within regions of interest comprising striated ducts. A maximum of 10 regions of interests was selected per biopsy. Presence of ductal hyperplasia was assessed on consecutive H&E stained slides. Patients were classified as pSS or non-SS according to the ACR-EULAR criteria.

Results

The DIA algorithm presented in this study was an accurate and objective method to detect intraepithelial lymphocytes within striated ducts in salivary gland tissue. Presence of intraepithelial B-lymphocytes, in contrast to intraepithelial T-lymphocytes, was a specific finding in salivary gland biopsies of pSS patients. In total, 59% of labial and 68% of parotid gland biopsies of pSS patients contained intraepithelial B-lymphocytes, against only 2% of patients classified as non-SS. Intraepithelial B-lymphocytes were not only detected within striated ducts with hyperplasia (LELs), but also in around 25% of analyzed striated ducts without hyperplasia of pSS patients (precursor stage of LEL). PSS patients with presence of intraepithelial B-lymphocytes in the labial gland showed lower stimulated whole salivary flow (p=0.011) and higher ocular staining scores (p=0.048), compared to patients without intraepithelial B-lymphocytes. Serological parameters, such as, rheumatoid factor-, IgG- and ESR levels were significantly higher in pSS patients with presence of B-lymphocyte containing ducts, irrespective whether the labial or parotid gland was taken into account.

Conclusion

Presence of B-lymphocyte containing ducts is a specific finding in salivary gland biopsies of pSS patients and is associated with clinical parameters of pSS. Together, identification of B-lymphocyte containing ducts by using DIA could be used as an objective marker in the diagnostic histopathological work-up of patients suspected of pSS.

References

[1]Ihrler S et al. Lymphoepithelial duct lesions in Sjogren-type sialadenitis. Virchows Archiv. 1999 Apr;434(4):315–23.

[2]Van Ginkel MS et al. Presence of intraepithelial B-lymphocytes is associated with the formation of lymphoepithelial lesions in salivary glands of primary Sjögren’s syndrome patients. Clinical and Experimental Rheumatology. 2019;37:S42–8.

Disclosure of Interests

Martha S. van Ginkel: None declared, Tineke van der Sluis: None declared, Marian L.C. Bulthuis: None declared, Henk J. Buikema: None declared, Erlin A. Haacke: None declared, Suzanne Arends: None declared, Stine Harder Employee of: SH is an employee of Visiopharm, Fred K.L. Spijkervet: None declared, Hendrika Bootsma: None declared, Arjan Vissink: None declared, Frans G.M. Kroese: None declared, Bert van der Vegt Consultant of: BvdV is on the scientific advisory board of Visiopharm, for which UMCG is compensated.

POS0738 IMMUNOGENICITY AND SAFETY OF COVID-19 VACCINATION IN PATIENTS WITH PRIMARY SJÖGREN’S SYNDROME

Background

Patients with primary Sjögren’s syndrome (pSS) worry about the effectiveness and safety of COVID-19 vaccination. pSS is characterized by B-cell hyperactivity, and previous influenza vaccination studies showed that pSS patients generate higher influenza-specific antibodies than healthy controls (HC).1,2 Furthermore, influenza vaccination resulted in elevated auto-antibody levels.1,2 Therefore, it is hypothesized that COVID-19 vaccination may also lead to a higher spike-specific antibody response.

Objectives

To evaluate humoral and cellular immune response and adverse events (AEs) after COVID-19 vaccination in pSS patients compared to HC, and disease activity following vaccination in pSS patients. Furthermore, to evaluate change in spike-specific antibody levels in saliva and anti-SSA levels in serum following vaccination.

Methods

In this prospective, longitudinal cohort study, pSS patients and HC were included in a 2:1 ratio. Participants received COVID-19 vaccinations following the Dutch vaccination programme. pSS patients did not use immunomodulatory drugs, except hydroxychloroquine (HCQ). Anti-spike 1 (S1) receptor binding domain (RBD) IgG serum antibody levels were measured 28 days after complete vaccination. AEs were collected 7 days after vaccination. Change in disease activity following vaccination was measured with EULAR Sjögren’s Syndrome Patient Reported Index (ESSPRI) and EULAR Sjögren’s Syndrome Disease Activity Index (ESSDAI). In a subgroup of participants, spike-specific T-cell response was measured 7 days after complete vaccination with IFN-γ ELIspot. Definition of a T-cell responder was ≥2-fold increase in spot-forming cell (SFC) counts from pre- to post-vaccination and SFC counts of ≥50/106 cells in the post-vaccination sample. Salivary anti-S1 and anti-RBD antibodies and serological anti-SSA antibodies were also measured in this subgroup in pre- and post-vaccination samples (28 days after complete vaccination).

Results

In total, 67 pSS patients and 33 HC were included. Of these, 47 (70%) and 14 (42%) received BNT162b2 (Pfizer-BioNtech), 13 (19%) and 5 (15%) received ChAdOx1 nCoV-19 (AstraZeneca), 6 (9%) and 8 (24%) received mRNA-1273 (Moderna), and 1 (1%) and 6 (18%) received Ad.26.COV2.S (Janssen), respectively. Overall, pSS patients were significantly older than HC, which was mainly due to the younger age in the Moderna and Janssen groups.

All participants had positive anti-SARS-CoV-2 antibody levels (>2500 AU/ml) post-vaccination. No differences in anti-SARS-CoV-2 antibody levels were observed between pSS patients and HC, for any of the vaccine types (Figure 1). Percentage of spike-specific T-cell responders was comparable between pSS patients (20/24, 83%) and HC (4/5, 80%). Salivary anti-SARS-CoV-2 IgG antibodies, but not IgA, increased post-vaccination in pSS patients (n=26) and HC (n=9). Salivary anti-RBD IgG antibodies were significantly correlated with serum anti-RBD antibodies (r= 0.597, p<0.001).

Figure 1.

Anti-S1 RBD IgG antibody levels of participants who received A) Pfizer-BioNtech B) AstraZeneca C) Moderna or D) Janssen. Dashed line indicates positive level.

No serious AEs occurred. Frequencies of systemic AEs were comparable between pSS patients and HC (first vaccination: 34/67 (51%) vs. 16/33 (48%), p=0.83; second: 41/66 (62%) vs. 14/25 (56%), p=0.59). No significant worsening was observed in median ESSPRI (baseline: 6 (IQR 5-7), post-vaccination: 6 (4-7), p=0.16, n=64) and ESSDAI (baseline: 3 (IQR 1-4), post-vaccination: 2 (0-5), p=0.88, n=36). Furthermore, no increase in anti-Ro52 and anti-Ro60 antibody levels was seen (p=0.65 and p=0.58, respectively).

Conclusion

pSS patients had similar humoral and cellular immune responses as HC, providing evidence that COVID-19 vaccination is effective in pSS patients. AEs were also comparable, and no increase in disease activity was seen in pSS patients, indicating COVID-19 vaccination is safe in pSS patients.

References

[1]Brauner et al. Ann Rheum Dis 2017;76:1755-63.

[2]Bjork et al. Rheumatology 2020;59:1651-61.

Acknowledgements

This work was funded by unrestricted grants of AstraZeneca and the Dutch Sjögren’s Patient Association (NVSP)

Disclosure of Interests

Gwenny M. Verstappen: None declared, Liseth de Wolff: None declared, Suzanne Arends: None declared, Hella-Marie Heiermann: None declared, Yannick van Sleen: None declared, Annie Visser: None declared, Janneke H. Terpstra: None declared, Dimitri Diavatopoulos: None declared, Marieke van der Heiden: None declared, Arjan Vissink: None declared, Debbie van Baarle: None declared, Frans G.M. Kroese: None declared, Hendrika Bootsma Speakers bureau: Bristol-Myers Squibb, Novartis, Consultant of: Bristol-Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Grant/research support from: Unrestricted grants from Bristol-Myers Squibb and Roche

POS0946 THE COURSE OF BONE MINERAL DENSITY DURING 8 YEARS OF TREATMENT WITH TNF-α INHIBITORS IN PATIENTS WITH ANKYLOSING SPONDYLITIS

Background

Bone loss reflected by lower bone mineral density (BMD) compared to age and gender matched healthy controls is a common feature of ankylosing spondylitis (AS) and can already be observed at early stages of the disease1. AS patients starting TNF-α inhibitors (TNFi) show overall a rapid increase in BMD2. However, the course of BMD during long-term TNFi in these patients is not known.

Objectives

To assess the course of BMD of the lumbar spine (LS) and hip in AS patients treated with TNFi during 8 years.

Methods

Patients from the GLAS cohort who received TNFi for at least 8 years were included. Patients were excluded when they used bisphosphonates. BMD of the LS (AP projection L1-L4) and hip (total proximal femur) was measured at baseline, 1 year, 2 years and then bi-annually using DEXA. Low BMD was defined as LS and/or hip BMD Z-score ≤1. Generalized estimating equations were used to analyze BMD Z-scores over time within subjects.

Results

131 AS patients were included; 73% were male, mean ± SD age was 41.3 ± 10.8 years, median (IQR) symptom duration was 14 (7-24) years, 83% were HLA-B27+, mean ASDAScrp was 3.8 ± 0.8, median CRP level was 13 (6-22) mg/L, and median vitamin 25(OH)D3 was 61 (46-80) nmol/L at baseline. Disease activity showed rapid and sustained during TNFi treatment, with mean ASDAScrp of 2.1 ± 0.9 and median CRP of 2 (2-5) at 8 years. Serum levels of vitamin D remained stable, with median vitamin 25(OH)D3 of 60 (47-81) at 8 years. At baseline, mean LS and hip BMD Z-scores were -0.37 ± 1.08 and -0.05 ± 1.04, respectively. Low BMD at the LS and hip (Z-score ≤1) was present in 34% and 19% of patients, respectively. Overall, both LS and hip BMD Z-scores improved significantly during TNFi at all follow-up visits compared to baseline. Significant improvement of BMD Z-scores compared to the previous time point was found up to and including 4 years for LS and up to and including 2 years for hip. Thereafter, deflection of improvement was observed. Median percentage of improvement in absolute BMD after 8 years of TNFi compared to baseline was 7.1% (IQR 0.8-13.5) for LS and 1.6% (IQR -3.5-5.5) for hip (Figure 1). At 8 years, low BMD at the LS and hip (Z-score ≤1) was present in 23% and 19% of patients, respectively.

Conclusion

In AS patients treated long-term with TNFi, both hip and LS BMD significantly increased especially during the first 2-4 year of treatment and stabilized thereafter. This effect was most pronounced in the LS and small in the hip.

References

[1]Van der Weijden et al. Clin Rheumatol. 2012 Nov;31(11):1529-35

[2]Arends et al. Arthritis Res Ther. 2012;14(2):R98

Disclosure of Interests

Mark Siderius: None declared, Anneke Spoorenberg Consultant of: AbbVie, Novartis Pharma, Pfizer, UCB Pharma, Lilly, Grant/research support from: Novartis Pharma, Pfizer, Employee of: AbbVie, Novartis Pharma, Pfizer, UCB Pharma, Lilly, Freke Wink: None declared, Suzanne Arends: None declared

Electrodiagnosis of Guillain-Barre syndrome in the International GBS Outcome Study: Differences in methods and reference values

OBJECTIVE

To describe the heterogeneity of electrodiagnostic (EDx) studies in Guillain-Barré syndrome (GBS) patients collected as part of the International GBS Outcome Study (IGOS).

METHODS

Prospectively collected clinical and EDx data were available in 957 IGOS patients from 115 centers. Only the first EDx study was included in the current analysis.

RESULTS

Median timing of the EDx study was 7 days (interquartile range 4-11) from symptom onset. Methodology varied between centers, countries and regions. Reference values from the responding 103 centers were derived locally in 49%, from publications in 37% and from a combination of these in the remaining 15%. Amplitude measurement in the EDx studies (baseline-to-peak or peak-to-peak) differed from the way this was done in the reference values, in 22% of motor and 39% of sensory conduction. There was marked variability in both motor and sensory reference values, although only a few outliers accounted for this.

CONCLUSIONS

Our study showed extensive variation in the clinical practice of EDx in GBS patients among IGOS centers across the regions.

SIGNIFICANCE

Besides EDx variation in GBS patients participating in IGOS, this diversity is likely to be present in other neuromuscular disorders and centers. This underlines the need for standardization of EDx in future multinational GBS studies.

POS0949 NO CHANGE IN SERUM LEVELS OF BONE TURNOVER MARKERS CORRECTED FOR AGE AND GENDER DURING THE FIRST YEAR OF SECUKINUMAB TREATMENT IN PATIENTS WITH ANKYLOSING SPONDYLITIS

Background

In patients with ankylosing spondylitis (AS), TNF-α inhibitors influence the course of serum bone turnover markers (BTM), favoring an increase in mineralization during the first years1. Little is known about the effect of IL-17 inhibitors on these serum BTM levels.

Objectives

To evaluate serum markers of bone resorption, formation, and mineralization during 1 year of secukinumab treatment in AS patients in daily clinical practice.

Methods

Included were consecutive outpatients from the GLAS cohort with a clinical diagnosis of AS who started treatment with secukinumab between April 2016 and June 2020, and had available serum samples at ≥1 visit. Standardized follow-up visits were performed at baseline (before start of secukinumab) and after 3 or 6 months and 1 year of treatment. BTM were measured in serum: osteocalcin (OC; regulation marker), serum type 1 collagen C-telopeptide (sCTX; collagen resorption marker), procollagen type 1 N-terminal peptide (PINP; collagen formation marker) and bone-specific alkaline phosphatase (BALP; bone mineralization marker). BTM Z-scores were calculated using a healthy reference population to correct for the normal influence of age and gender. Patients using bisphosphonates were excluded from analyses. Data was coded missing if patients experienced a fracture or received systemic corticosteroids within 1 year of a study visit. Generalized estimating equations were used to analyze BTM Z-scores over time within patients.

Results

In total, data of 26 AS patients were eligible for analyses; 50% were male, mean age was 46.0±14.6 years, 81% were HLA-B27 positive, mean ASDAS at baseline was 3.7±1.0, and 50% was TNFi naïve. Before secukinumab treatment, median PINP and BALP Z-scores were +0.6 and +0.7 SD, respectively, compared to age and gender matched healthy controls, however, the large majority remained within the normal range of ±2 SD. Overall, BTM Z-scores of OC, sCTX, PINP and BALP did not change significantly compared to baseline during the 1st year of secukinumab treatment (Figure 1).

Conclusion

In daily clinical practice, serum BTM levels including mineralization corrected for the normal influence of age and gender did not change during the 1st year of secukinumab treatment in patients with AS. Our data confirm recent findings of stable BTM levels at group level during 2 years of secukinumab treatment in posthoc analysis of MEASURE 12.

References

[1]Arends et al. Arthritis Res Ther. 2012;14(2):R98

[2]Braun et al. BMC Musculoskelet Disord 22, 1037 (2021

Acknowledgements

This study was supported by an investigator initiated research grant from Novartis.

Disclosure of Interests

Mark Siderius: None declared, Suzanne Arends: None declared, Freke Wink: None declared, Anneke Spoorenberg Consultant of: AbbVie, Novartis Pharma, Pfizer, UCB Pharma, Lilly, Grant/research support from: Novartis Pharma, Pfizer

POS0042-HPR HOW DOES WEEKLY SUPERVISED GROUP EXERCISE CONTRIBUTE TO FULFILLING EXERCISE RECOMMENDATIONS IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS?

Background

Supervised group exercise (SGE) has been recommended for people with axial spondyloarthritis (axSpA) since decades, but the proportion and type of axSpA patients that engage in SGE is unknown. In addition, the 2018 EULAR recommendations for physical activity advocate that people with axSpA should engage in aerobic, strength and mobility exercises according to public health physical activity guidelines. However, it is unclear if SGE contributes to fulfilment of these exercise recommendations.

Objectives

To compare characteristics, health status and fulfilment of exercise recommendations between axSpA patients with and without SGE.

Methods

Cross-sectional data from three Dutch axSpA study cohorts were analysed: two cohorts with patients recruited at rheumatology outpatient clinics (n=196 and n=153) in which participation in SGE was recorded (yes/no) and one cohort with only SGE participants (n=128). Assessments included sociodemographic and disease characteristics, health status (ASAS Health Index), spinal mobility and the ‘short questionnaire to assess health enhancing physical activity’ (SQUASH). The SQUASH was used to determine fulfilment of the public health recommendations for leisure-time aerobic exercise (≥150 min/week of moderate-intensity or ≥75 min/week of vigorous-intensity exercise) and for strength and mobility exercises (≥2 sessions/week). Differences between patients with and without SGE were analysed using the Mann-Whitney U test and the Chi-Square test. Multivariate regression models were performed to correct the association between SGE and fulfilment of the exercise recommendations for age, sex, employment and health status.

Results

In the two outpatient axSpA cohorts, 17 of the 349 patients (5%) participated in SGE. The total group of SGE participants (n=145) was significantly older, had longer disease duration, was less frequently employed, used less disease related medication and had worse spinal mobility than the patients without SGE (n=332). There were no significant differences in health status. AxSpA patients with SGE performed more minutes per week of aerobic exercise (median 420; IQR 285-660) than patients without SGE (median 283; IQR 120-540), p < 0.001. As shown in Figure 1, SGE participants fulfilled the recommendations for moderate-intensity aerobic exercise (89% vs. 69%, p < 0.001) and for strength and mobility exercise (44% vs. 29%, p < 0.01) more often than patients without SGE. However, the recommendation for vigorous-intensity aerobic exercise was fulfilled less often by the SGE participants (5% vs. 12%, p < 0.05). After correcting for age, sex, employment and health status, the differences in fulfilment of the moderate-intensity aerobic and strength and mobility exercise recommendations remained significant.

Conclusion

SGE is used by just few and especially older axSpA patients and contributes to fulfilling recommendations for moderate-intensity aerobic as well as mobility and strength exercise. However, both in patients with and without SGE, only a minority fulfilled the recommendations for vigorous-intensity aerobic and strength and mobility exercises. Therefore, future promotion of physical activity should focus on implementing these types of exercise.

Acknowledgements

The authors would like to thank ASAS and the Dutch Arthritis Society for supporting the three cohorts.

Disclosure of Interests

Bas Hilberdink: None declared, Marlies Carbo: None declared, Davy Paap: None declared, Suzanne Arends: None declared, T.P.M. Vliet Vlieland: None declared, Florus van der Giesen: None declared, Anneke Spoorenberg Paid instructor for: AbbVie, Consultant of: AbbVie, Novartis Pharma, Pfizer, UCB Pharma, Lilly, Grant/research support from: Novartis Pharma, Pfizer, Salima van Weely: None declared

POS0985 MILD PSORIASIS SEEMS OFTEN UNDERDIAGNOSED IN PATIENT WITH AXIAL SPONDYLOARTHRITIS

Background

Axial spondyloarthritis (axSpA) is known to be associated with several extra-skeletal manifestations, including the inflammatory skin disease psoriasis. It is important to recognize and diagnose psoriasis timely in axSpA to provide the most optimal treatment and outcome for both axSpA and psoriasis. Furthermore, in patients suspected of axSpA, it may add to making the axSpA diagnosis.

Objectives

To explore the self-reported prevalence of psoriasis in axSpA patients using a questionnaire with prototypical color pictures, and to compare this with the prevalence of a verified diagnosis. Secondly, to explore if there are differences in disease and patient characteristics between axSpA patients with and without self-reported psoriasis.

Methods

All patients from the Dutch Groningen Leeuwarden Axial Spondyloarthritis (GLAS) cohort included before June 2016, were sent a questionnaire with self-screening psoriasis questions. The applied self-diagnostic psoriasis question “Do you have psoriasis?” was supported with the following brief elucidation: “Psoriasis is a skin disease in which red and scaly patches develop on the body, especially on the elbows, knees and hairy head. The nails can also be affected, and sometimes there are joint complaints.” In addition, to enable patients to self-assess the presence of psoriasis more accurately, prototypical color pictures of psoriasis lesions were added. Patients could reply with “no”, “yes, in the past” or “yes, currently”. In patients who indicated having psoriasis symptoms, a medical record check was done to verify previously diagnosed psoriasis. The diagnosis of psoriasis was considered valid if it was described in the medical record by a dermatologist or rheumatologist.

Results

Of the 592 questionnaires sent, 471 (79.6%) were returned, of which 448 (75.7%) were eligible for analysis. Of these 448 included patients, 79% were diagnosed with AS and 21% with nr-axSpA, mean (±SD) age was 50.1±12.7 years, 64% were male, median (IQR) SpA symptom duration was 21.0 (12.0-32.0) years, 79% were HLA-B27 positive and mean ASDASCRP was 2.2±1.0. History of peripheral arthritis, enthesitis and dactylitis was present in 39%, 20% and 7% of patients, respectively. The male-female ratio between the 448 included and 144 excluded patients was similar. Excluded patients were significantly younger (43.3 ± 13.6, p<0.001).

Of the 448 respondents, 58 (13%) had a positive self-screening for psoriasis symptoms, currently or in the past. In 28 (48%) of these 58 patients, psoriasis diagnosis could be verified by medical records, resulting in a confirmed psoriasis prevalence rate of 6.3%.

AxSpA patients reporting psoriasis symptoms without a verified diagnosis mentioned more often mild than moderate or severe psoriasis symptoms (25% vs. 3%, p=0.02) and their psoriasis lesions were less often located on the torso area (3% vs. 18%, p=0.04), intergluteal cleft (0% vs. 25%, p=0.02) and legs (7% vs. 43%, p<0.01) compared to axSpA patients with a confirmed diagnosis. Of the 31 axSpA patients who reported currently active psoriasis (irrespective of confirmed diagnosis), 23 (74%) had only mild psoriasis symptoms.

Conclusion

Especially mild psoriasis seems often underdiagnosed in patient with axSpA according to a patient questionnaire with prototypical pictures of psoriasis lesions. This questionnaire could be beneficial in tracing patients with undiagnosed psoriasis in daily clinical practice, however further validation of this questionnaire is needed in daily clinical practice.

Disclosure of Interests

Laura van Marle: None declared, Angelique Rondags: None declared, Barbara Horvath Paid instructor for: Janssen-Cilag, AbbVie, Consultant of: Janssen-Cilag, AbbVie, Novartis Pharma, UCB Pharma, Leo Pharma, Celgene, Akari therapeutics, Philips, Roche, Regeneron, Sanofi, Grant/research support from: Janssen-Cilag, AbbVie, Novartis Pharma, Solenne B.V., Celgene, Akari therapeutics, Freke Wink: None declared, Suzanne Arends Paid instructor for: AbbVie, Consultant of: AbbVie, Novartis Pharma, Pfizer, UCB Pharma, Lilly, Grant/research support from: Novartis Pharma, Pfizer, Anneke Spoorenberg: None declared

POS0758 REDUCED CENTRAL NERVOUS SYSTEM DRIVE IN PRIMARY SJÖGREN’S SYNDROME IS ASSOCIATED WITH OBJECTIVE DECLINE IN MOTOR PERFORMANCE AND SELF-REPORTED FATIGUE

Background

Fatigue is a major complaint in primary Sjögren’s syndrome (pSS). The importance of fatigue in pSS is demonstrated by its inclusion as one of the three domains of the EULAR Sjögren’s Syndrome Patient Reported Index (ESSPRI) as well as being the primary outcome measure of a large clinical trial.1 To date, there is no effective treatment for fatigue and more fundamental studies are needed to identify potential targets for therapy. In a conceptual framework, fatigue is defined as a self-reported symptom derived from two attributes: performance fatigability and perceived fatigability (Figure 1).

Figure 1.

Conceptual framework (adapted from Enoka)2

Objectives

To acquire a better understanding of fatigue in pSS, we investigated objective measures of performance decline and evaluated the relation of self-reported fatigue with performance fatigability and factors modulating perceptions of fatigability.

Methods

39 pSS patients and 27 healthy controls were included. To assess performance fatigability, force decline was measured during a sustained (124s) maximal voluntary contraction (MVC) with the index finger abductor muscle, and voluntary muscle activation was indexed using peripheral nerve stimulation superimposed on maximal voluntary contractions. Self-reported fatigue was quantified using the Fatigue Severity Scale (FSS) and Modified Fatigue Impact Scale (MFIS). Pain, depression, and anxiety were assessed using questionnaires and serological inflammatory markers were measured in serum as factors relating to perceived fatigability.

Results

Self-reported fatigue was significantly higher in pSS than controls (FSS: 4.8 vs. 2.3, p<0.001); 67% of patients and no controls reported significant fatigue (FSS>4). Mean voluntary muscle activation was reduced in pSS compared to controls (81.5% vs. 87.8%, p=0.030). Force decline during the sustained MVC did not differ between groups (60.6% vs. 63.1%, p=0.246). MFIS physical was positively associated with symptoms (ESSPRI pain: ρ=0.51, HADS depression: ρ=0.45 and HADS anxiety: ρ=0.29) and negatively associated with serological inflammatory markers (MxA: ρ=-0.49 and CXCL10: ρ=-0.37).

Multivariable linear regression showed that force decline, pain and depression were associated with the MFIS physical domain in pSS (total explained variance of 47%). The inclusion of serological inflammatory markers did not help to explain more variance in this model.

Conclusion

This study demonstrates that performance fatigability in pSS was compromised by a reduced capacity of the central nervous system to drive the muscle. Furthermore, self-reported fatigue is a multifactorial symptom associated with both performance fatigability and perceived fatigability in patients with pSS.

References

[1]Bowman et al. Arthritis Rheumatol. 2017;69, 1440–50.

[2]Enoka and Duchateau. Med. Sci. Sports Exerc. 2016;48,2228–38.

Disclosure of Interests

Roeland Prak: None declared, Suzanne Arends: None declared, Gwenny M. Verstappen: None declared, Greetje S. van Zuiden: None declared, Frans G.M. Kroese: None declared, Hendrika Bootsma Speakers bureau: Bristol Myers Squibb, Novartis, Consultant of: Bristol Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Grant/research support from: Bristol Myers Squibb, Roche, Inge Zijdewind: None declared

POS1010 SPINAL RADIOGRAPHIC PROGRESSION AND ITS ASSOCIATION WITH PROGRESSION TO ANKYLOSING SPONDYLITIS IN PATIENTS WITH NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS

Background

Prevention of structural damage of the axial skeleton is an important goal of treatment in axial spondyloarthritis (axSpA)1. Most studies concerning spinal radiographic progression focused on ankylosing spondylitis (AS). Data on spinal radiographic progression in patients with non-radiographic (nr)-axSpA is limited and data on the relation between spinal and sacroiliac radiographic progression in this population is lacking.

Objectives

To assess long-term spinal radiographic progression in patients with nr-axSpA. Secondly, to explore the association between radiographic progression to AS and spinal radiographic progression in these patients.

Methods

Patients enrolled in the ongoing Groningen Leeuwarden Axial SpA (GLAS) cohort, classified as nr-axSpA at baseline, with pelvic and spinal (lumbar and cervical) radiographs available at baseline and at least one follow-up visit at 2, 4 or 6 years were selected for analyses. Progression from nr-axSpA to AS was defined as progression to modified New York (mNY) sacroiliitis score ≥2 bilaterally or ≥3 unilaterally. Radiographs of nr-axSpA patients were randomized with radiographs of AS patients and scored in known time sequence by two trained readers blinded for patient characteristics. SK and RW scored the SI joints and in case of disagreement in axSpA classification, the score of a third independent reader (AS) was used. SK and MS scored the spinal radiographs according to the modified stoke ankylosing spondylitis spinal score (mSASSS; 0-72), and the mean of both total scores was calculated. In case of >5 points discrepancy between both readers, the mSASSS of a third independent reader (FM) together with the closest of the scores of the primary readers was used. The mSASSS change of nr-axSpA patients who did en did not progress to AS was compared with Mann-Whitney U tests.

Results

Included were 60 patients with a clinical diagnosis of nr-axSpA, confirmed by their sacroiliac radiographic score at baseline. Mean age was 37±10 years, 53% were male, median symptom duration was 9 (IQR 2-17) years, 75% were HLA-B27+, and mean ASDAS was 2.6±1.1.

In total 15 patients progressed to AS. Median mSASSS at baseline was 1.5 (IQR 0.5 – 4.4). Median change in mSASSS from baseline was 0.0 (IQR 0.0 – 1.0) vs. 1.0 (IQR 0.0 – 1.5) at 2 years; 1.2 (IQR 0.3 – 3.5) vs. 2.0 (0.5 – 2.7) at 4 years; and 1.8 (1.0 – 3.8) vs. 2.5 (0.5 – 3.5) at 6 years for non-AS progressors and AS progressors, respectively (Figure 1). These mSASSS changes weres were not significantly different at any timepoint (p = 0.456, p=0.814, p=0.929 for 2-, 4-, and 6-year follow-up, respectively).

Figure 1.

Comparison of mSASSS progression between patients with and without progression to AS during the first 6 years of follow-up.

Conclusion

In our observational cohort of patients with nr-axSpA with up to 6 years of follow-up, mSASSS progression was low (< 1 mSASSS unit/year) and was not different between patients who did and did not progress to AS.

References

[1]Van der Heijde D. et al. Ann Rheum Dis. 2017;76(6):978-991.

Acknowledgements

The GLAS cohort was supported by an unrestricted grant from Novartis.

Disclosure of Interests

Stan Kieskamp: None declared, Mark Siderius: None declared, Rick Wilbrink: None declared, Fiona Maas: None declared, Freke Wink: None declared, Reinhard Bos: None declared, Hendrika Bootsma Speakers bureau: Bristol-Myers Squibb, Novartis, Consultant of: Bristol-Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Grant/research support from: Unrestricted grants from Bristol-Myers Squibb and Roche, Suzanne Arends: None declared, Anneke Spoorenberg Paid instructor for: Abbvie, Consultant of: Abbvie, Novartis Pharma, Pfizer, UCB Pharma, Lilly, Grant/research support from: Novartis Pharma, Pfizer

POS1006 DIAGNOSIS OF AXIAL SpA AND ADDITIONAL FEATURES IN HLA-B27 POSITIVE INDIVIDUALS REPORTING CHRONIC INFLAMMATORY BACK PAIN: DATA FROM A LARGE DUTCH POPULATION-BASED COHORT

Background

Chronic low back pain (CLBP; back pain >3 months with age of onset <45) and inflammatory back pain (IBP) are regarded as early and key features of axSpA. HLA-B27 is the most important genetic risk factor. Despite improved diagnostics, especially the use of MRI in demonstrating active sacroiliitis, the substantial delay in axSpA diagnosis has not improved1.

Objectives

To explore the presence of CLBP and IBP in combination with HLA-B27 and the presence of other axSpA associated features in the general population.

Methods

Participants of the Lifelines cohort, a large population-based cohort which is representative of the mostly Caucasian Northern region of the Netherlands2, responded to a survey with questions concerning the presence of CLBP and the European Spondyloarthropathy Study Group (ESSG) criteria for IBP. HLA-B haplotypes were imputed from genome-wide SNPs genotyped with the Illumina GSA beadchip-24 v1.0, using the R-package HIBAG with published parameter estimates. Analyses were performed on participants with available HLA-B haplotype and CLBP/IBP data. Prevalence rates were calculated and logistic regression was performed to identify whether participant characteristics and other available SpA features were independently associated with the presence of the key axSpA features HLA-B27, CLBP and IBP.

Results

20,619 participants had data available on CLBP, IBP and HLA-B haplotype. Of these participants, 1,610 (7.8%) were HLA-B27+, 3,717 (18.0%) reported CLBP, 2,670 (13.0%) fulfilled the IBP criteria, and 47 (0.23%) reported a previous SpA diagnosis, of which 37 (0.18%) reported axSpA. In total, 226 (1.1%) participants had the combination of CLBP/IBP/HLA-B27. Only 11 (4.9%) of these 226 participants reported a previous SpA diagnosis, all of which were axSpA. Participant characteristics and the presence of other available SpA related features are presented in Table 1.

Table 1.

Characteristics and features associated with SpA in the different subgroups of Lifelines participants. Data presented as mean ± SD or n (%). 1Participants already reporting a previous SpA diagnosis excluded from this group.

Available data in Lifelines of CLBP/IBP & HLA-B (n=20,619)Self-reported SpA diagnosis (n=47)CLBP+(n=3,6981)CLBP+/IBP+(n=2,6531)HLA-B27+(n=1,5851)CLBP+/IBP+/ HLA-B27+(n=2261)General characteristicsMale8173 (39.6%)24 (51.1%)1443 (39.0%)1058 (39.9%)630 (39.7%)89 (41.4%)Age44.2 ± 14.248.1 ± 12.642.5 ± 13.244.0 ± 12.844.1 ± 14.141.7 ± 12.5BMI25.7 ± 4.126.7 ± 4.326.2 ± 4.526.3 ± 4.325.7 ± 4.425.9 ± 4.6Features associated with SpAReported diagnosis of:- Uveitis11 (0.1%)1 (2.1%)1 (0.0%)0 (0%)2 (0.1%)0 (0%)- IBD179 (0.9%)3 (6.4%)31 (0.8%)22 (0.8%)14 (0.9%)2 (0.9%)- Psoriasis588 (2.9%)8 (17%)491 (2.8%)79 (3.0%)52 (3.3%)7 (3.3%)Current NSAID use766 (3.7%)20 (42.6%)252 (6.8%)189 (7.1%)82 (5.2%)22 (10.2%)History of peripheral arthritis609 (3.0%)7 (14.9%)229 (6.2%)196 (7.4%)43 (2.7%)17 (7.9%)Reported rheumatism in FDR3572 (17.3%)12 (25.5%)724 (19.6%)535 (20.2%)315 (19.9%)47 (21.9%)At least 1 of above features4803 (23.3%)30 (63.8%)1013 (27.4%)744 (28.0%)418 (26.4%)69 (32.1%)At least 2 of above features302 (1.5%)7 (14.9%)85 (2.2%)66 (2.5%)34 (2.1%)7 (3.3%)

In multivariable logistic regression analysis, current NSAID use and a reported history of peripheral arthritis were independently associated with the axSpA key features CLBP, IBP, and IBP+HLA-B27.

Conclusion

In this large Dutch population-based cohort only 4,9% of participants presenting the combined axSpA key features IBP and HLA-B27 reported a previous axSpA diagnosis, indicating possible axSpA underdiagnosis. Although not all SpA features were available in Lifelines, current NSAID use and a history of peripheral arthritis in combination with the axSpA key features may have additional value in identifying patients with axSpA in primary care.

References

[1]Zhao SS et al. Rheumatology (Oxford). 2021;6:60(4):1620-8.

[2]Scholtens S et al. Int J Epidemiol. 2015;44:1172-80.

Acknowledgements

This study was supported by a grant from ReumaNederland.

Disclosure of Interests

Stan Kieskamp: None declared, Suzanne Arends: None declared, Elisabeth Brouwer Speakers bureau: Roche, Consultant of: Roche, Hendrika Bootsma Speakers bureau: Bristol-Myers Squibb, Novartis, Consultant of: Bristol-Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Grant/research support from: Unrestricted grants from Briostol-Myers Squibb and Roche, Ilja M. Nolte: None declared, Anneke Spoorenberg Paid instructor for: AbbVie, Consultant of: AbbVie, Novartis Pharma, Pfizer, UCB Pharma, Lilly, Grant/research support from: Novartis Pharma, Pfizer

AB0830 Turkish translation and cross-cultural adaptation of the modified Short QUestionnaire to Assess Health-enhancing physical activity (mSQUASH)

Background

The Short Questionnaire to Assess Health-enhancing physical activity (SQUASH) is a validated tool measuring the duration, frequency, and intensity of physical activity. The modified version of the SQUASH (mSQUASH) has been developed, in collaboration between spondyloarthritis (SpA) experts and axial (ax)SpA patients, to better address the needs of these patients in the assessment physical activity (1).

Objectives

To translate and cross-cultural adapt the mSQUASH into Turkish as well as its cognitive debriefing to test the conceptual equivalence of the translated version among patients with axSpA.

Methods

The mSQUASH was translated into Turkish by 2 bilingual translators, native speakers of Turkish one from medical (informed) and the other is without medical background (uninformed). The consensus on forward-translation was reached by the team included two rheumatologist (GA and LK) and the translators. Backward-translation into Dutch was performed by 2 bilingual translators, native speakers of Dutch and who were blinded to the original mSQUASH version. After the review of the Turkish version by an expert committee that included translators, two patients and the research team a pre-final version was prepared. This version was used in a field-test with cognitive debriefing and involved a sample of 10 axSpA patients (7 radiographic- and 3 non-radiographic axSpA patients) with variation in gender, age, disease duration, and educational background. The final Turkish mSQUASH version was reached after the patients were interviewed to check understandability, interpretation and cultural relevance of the translation. The whole process was performed according to the Beaton method (Figure 1) (2).

Figure 1.

Flow-chart of the translation and cross-cultural adaptation process

Results

After the forward-backward translation process, small incompatibilities were resolved during the expert committee meeting. For example: `Ander transport (heen en terug)` was translated as `Diğer hedeflere (gidip gelmek)`. The meaning in English is `Other transport (round trip)’. This item questions the way of going to other places and the discrepancy raised whether to use `transportation` or the `target` as the title. To make it culturally adaptable consensus reached to use a word equivalent to `the target` which is semantically equal to the Dutch version. A total of 10 patients with axSpA [7 females, mean (SD) age of 38 (10)] participated in the field test. Mean (SD) time to complete the mSQUASH was 6.1 (2.4) minutes. Cognitive debriefing showed that items of the mSQUASH are clear, relevant, understandable, and easy to complete. None of the patients indicate any important aspect of physical activity that is missing from the questionnaire items. During the cognitive debriefing, 2 patients suggested a change in the wording of one item to make it more suitable to the Turkish culture. This item inquires after sport activities and patients raised the concern that the example activities, ice-skating, tennis, handball are not culturally suitable. According to their comments these items were replaced by other examples such as football.

Conclusion

The final Turkish version of the mSQUASH showed acceptable linguistic validity and can be used in both clinical practice and for research purposes. However, to implement the Turkish version of the mSQUASH, further assessment of its psychometric properties (validity and reliability) is needed.

References

[1]Carbo MJ, et al. Semin Arthritis Rheum. 2021 Aug;51(4):719-727.

[2]Beaton DE, et al.. Spine (Phila Pa 1976). 2000 Dec 15;25(24):3186-91

Disclosure of Interests

Gizem Ayan: None declared, Sofia Ramiro Speakers bureau: Eli Lilly, MSD, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, UCB, Sanofi, Grant/research support from: AbbVie, Galapagos, Novartis, Pfizer, UCB, Fernando M Pimentel-Santos Speakers bureau: Abbvie, Novartis, UCB, Tecnimed, Consultant of: AbbVie, Eli Lilly, Novartis, Pfizer, Tecnimed, UCB, Grant/research support from: Abbvie, Janssen, Novartis, Anneke Spoorenberg Speakers bureau: AbbVie, Novartis Pharma, Pfizer, UCB Pharma, Lilly, Consultant of: AbbVie, Novartis Pharma, Pfizer, UCB Pharma, Lilly, Grant/research support from: AbbVie, Novartis Pharma, Pfizer, Suzanne Arends: None declared, Levent Kiliç: None declared

POS0948 SIX YEARS TREATMENT WITH TNF-α INHIBITORS DOES NOT LEAD TO LONG-TERM CONTINUOUS HYPERMINERALIZATION IN PATIENTS WITH ANKYLOSING SPONDYLITIS

Background

In a previous study, we showed that the bone turnover balance favored bone formation, especially mineralization, during the first years of treatment with TNF-α inhibitors (TNFi)1 in patients with ankylosing spondylitis (AS).

Objectives

To explore if this effect continues during more long-term TNFi treatment. Therefore our goal was to investigate the prolonged course of serum levels of bone turnover markers (BTM) during 6 years of TNFi treatment in patients with AS.

Methods

Included were consecutive AS outpatients from the UMCG GLAS cohort who were treated with TNFi for at least 6 years. Patients were excluded when they used bisphosphonates. Data for a specific visit was coded as missing when patients either had experienced a fracture or received systemic corticosteroids within 1 year from that particular visit regarding the possible effect on BTM. Standardized follow-up visits were performed at baseline (before start of TNFi), 3 and 6 months, 1, 2, 4 and 6 years. Serum markers of collagen resorption sCTX, bone regulation OC, collagen formation PINP, and bone mineralization BALP were measured. Z-scores were calculated to correct for the normal influence of age and gender using a healthy reference population. Generalized estimating equations were performed to analyze BTM Z-scores over time within patients.

Results

53 AS patients were eligible for analyses: 66% were male, mean (SD) age was 38.5 ± 11.3 years, median (IQR) symptom duration was 16 (9-25) years, 87% were HLA-B27+, mean ASDAS was 3.8 ± 1.0, and median CRP 14 (7-27) mg/L. Etanercept, infliximab or adalimumab was prescribed as first TNFi in 60%, 2% and 38% of patients, respectively. 26% (n=14) of patients switched to a second TNF-α inhibitor during follow-up. Disease activity showed rapid and sustained improvement after start of TNFi (Figure 1). At group level, collagen resorption marker sCTX Z-score did not significantly change during treatment. Bone regulation marker OC Z-score was only significantly increased at 3 months compared to baseline. Collagen formation marker PINP Z-score showed significantly increased levels at 3 and 6 months and 2 years. Bone mineralization marker BALP Z-score was significantly increased at all time points up to and including 2 years and decreased thereafter. Only a few patients still had higher BTM values above the normal range (+2 SD) (Figure 2). The net effect of collagen metabolism corrected for the normal influence of age and gender (PINP Z-score – sCTX Z-score) confirmed that the initial balance was in favor of collagen formation; this increase was only significant at 6 months compared to baseline.

Conclusion

In AS patients receiving long-term TNFi, the bone turnover balance favored bone formation during the first 2 years of treatment. Thereafter, at group level, serum levels of BTM returned to levels not significantly different from baseline. Therefore, 6 years of treatment with TNF-α inhibitors did not seem to lead to long-term continuous hypermineralization in patients with AS.

References

[1]Arends et al. Arthritis Res Ther. 2012;14(2):R98

Disclosure of Interests

Mark Siderius: None declared, Anneke Spoorenberg Consultant of: AbbVie, Novartis Pharma, Pfizer, UCB Pharma, Lilly, Grant/research support from: Novartis Pharma, Pfizer, Eveline Van der Veer: None declared, Frans G.M. Kroese: None declared, Suzanne Arends: None declared

Guillain-Barré syndrome after SARS-CoV-2 infection in an international prospective cohort study

In the wake of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, an increasing number of patients with neurological disorders, including Guillain-Barré syndrome (GBS), have been reported following this infection. It remains unclear, however, if these cases are coincidental or not, as most publications were case reports or small regional retrospective cohort studies. The International GBS Outcome Study is an ongoing prospective observational cohort study enrolling patients with GBS within 2 weeks from onset of weakness. Data from patients included in this study, between 30 January 2020 and 30 May 2020, were used to investigate clinical and laboratory signs of a preceding or concurrent SARS-CoV-2 infection and to describe the associated clinical phenotype and disease course. Patients were classified according to the SARS-CoV-2 case definitions of the European Centre for Disease Prevention and Control and laboratory recommendations of the World Health Organization. Forty-nine patients with GBS were included, of whom eight (16%) had a confirmed and three (6%) a probable SARS-CoV-2 infection. Nine of these 11 patients had no serological evidence of other recent preceding infections associated with GBS, whereas two had serological evidence of a recent Campylobacter jejuni infection. Patients with a confirmed or probable SARS-CoV-2 infection frequently had a sensorimotor variant 8/11 (73%) and facial palsy 7/11 (64%). The eight patients who underwent electrophysiological examination all had a demyelinating subtype, which was more prevalent than the other patients included in the same time window [14/30 (47%), P = 0.012] as well as historical region and age-matched control subjects included in the International GBS Outcome Study before the pandemic [23/44 (52%), P = 0.016]. The median time from the onset of infection to neurological symptoms was 16 days (interquartile range 12-22). Patients with SARS-CoV-2 infection shared uniform neurological features, similar to those previously described in other post-viral GBS patients. The frequency (22%) of a preceding SARS-CoV-2 infection in our study population was higher than estimates of the contemporaneous background prevalence of SARS-CoV-2, which may be a result of recruitment bias during the pandemic, but could also indicate that GBS may rarely follow a recent SARS-CoV-2 infection. Consistent with previous studies, we found no increase in patient recruitment during the pandemic for our ongoing International GBS Outcome Study compared to previous years, making a strong relationship of GBS with SARS-CoV-2 unlikely. A case-control study is required to determine if there is a causative link or not.

Antecedent infections in Guillain-Barré syndrome in endemic areas of arbovirus transmission: A multinational case-control study

Half of the world's population is at risk of arthropod‐borne virus (arbovirus) infections. Several arbovirus infections have been associated with Guillain‐Barré syndrome (GBS). We investigated whether arboviruses are driving GBS beyond epidemic phases of transmission and studied the antibody response to glycolipids. The protocol of the International Guillain‐Barré syndrome Outcome Study (IGOS), an observational prospective cohort study, was adapted to a case‐control design. Serum samples were tested for a recent infection with Zika virus (ZIKV), dengue virus (DENV), chikungunya (CHIKV) virus, hepatitis E virus, Epstein‐Barr virus (EBV), cytomegalovirus (CMV), Campylobacter jejuni, and Mycoplasma pneumoniae, and for antibodies to glycolipids. Forty‐nine patients were included from Brazil (63%), Argentina (14%), and Malaysia (22%). Evidence of a recent infection was found in 27/49 (55%) patients: C jejuni (n = 15, 31%), M pneumoniae (n = 5, 10%), CHIKV (n = 2, 4%), EBV (n = 1, 2%), C jejuni and M pneumoniae (n = 2, 4%), CMV and DENV (n = 1, 2%), and C jejuni and DENV (n = 1, 2%). In 22 patients, 35 paired controls were collected. Odds ratio for recent infections did not significantly differ between cases and controls. No typical anti‐ganglioside antibody binding was associated with recent arbovirus infection. We conclude that arbovirus infections occur in GBS patients outside of epidemic viral transmission, although not significantly more than in controls. Broad infection and anti‐ganglioside antibody serology are important to establish the most likely pathogenic trigger in GBS patients. Larger studies are necessary to determine the association between arboviruses and GBS.

AB0462 BMI IS ASSOCIATED WITH BOTH DISEASE ACTIVITY AND TNF-α INHIBITOR SERUM TROUGH LEVELS IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS ON LONG-TERM TREATMENT WITH TNF-α INHIBITORS

Background:

TNF-α inhibitors (TNFi) are widely used in axial spondyloarthritis (axSpA) patients with active disease. Approximately half of patients stop TNFi treatment, often due to loss of treatment efficacy.1 TNFi serum trough levels have been associated with initial therapeutic response in axSpA patients.2 Additionally, a relation was found between serum trough TNFi levels and BMI.3

Objectives:

To explore in axSpA patients on long-term TNFi therapy associations between randomly measured TNFi serum trough levels, disease activity and BMI.

Methods:

Patients from the UMCG on adalimumab or etanercept and a regular visit in the Groningen Leeuwarden Axial Spondyloarthritis (GLAS) cohort were approached for a random TNFi serum trough level measurement. Based on reference values of Sanquin3, serum trough levels were stratified in therapeutic and below therapeutic levels. The Ankylosing Spondylitis Disease Activity Score (ASDAS) from a regular outpatient GLAS visit was used for analyses, if assessed <2 months of the serum trough level measurement. Active disease according to ASDAS was defined as ≥2.1. Correlations and univariable logistic regression were performed. Multivariable logistic regression was performed to correct the relation between therapeutic drug levels and ASDAS for potential confounders.

Results:

94 axSpA patients on adalimumab or etanercept were approached for a random TNFi serum trough level measurement, of which 55 (59%) had a measurement taken. See Table 1 for patient characteristics. No significant correlations were found for adalimumab or etanercept serum trough levels (as continuous variable) with ASDAS (adalimumab: r=-0.16, p=0.39; etanercept: r=-0.29, p=0.20). According to Sanquin definitions of therapeutic TNFi levels, 26 patients (47%) had therapeutic serum trough levels: 19/34 (56%) for adalimumab and 7/21 (33%) for etanercept. Univariable logistic regression showed no significant associations between therapeutic levels (yes/no) and ASDAS. In multivariable analyses, BMI was identified as the only confounder for the relationship between therapeutic drug levels and ASDAS. Median BMI was higher, although not statistically significant, in patients with below-therapeutic serum trough levels compared to therapeutic levels (27.1, IQR 24.6-31.7 vs. 24.3, IQR 22.7-31.4, p=0.08). Furthermore, BMI had a significant, negative correlation with adalimumab and etanercept serum levels (adalimumab: r=-0.48, p=0.01, etanercept: r=-0.46, p=0.04) (Figure 1). Patients with active disease according to ASDAS had higher BMI than patients with inactive disease (median 29.7 vs. 24.5, p=0.01).

Conclusion:

In this cross-sectional, observational study of axSpA patients on long-term TNFi treatment, BMI was significantly correlated with adalimumab and etanercept serum trough levels. Furthermore, BMI was significantly higher in patients with active disease. Therefore, overweight /obese patients on TNFi treatment and active disease, might benefit from an increase in TNFi dose.

References:

[1]Arends et al, Clin Exp Rheumatol 2017;35:61-68

[2]Kneepkens et al, Ann Rheum Dis 2015;74:396-401

[3]Rosas et al, Clin Exp Rheum 2017;35:145-148

[4]Sanquin Amsterdam. Diagnostic tests. Available via: www.sanquin.org/nl/producten-en-diensten/diagnostiek/diagnostische-testen/index

Table 1.

Characteristics of 55 axSpA patients with random adalimumab or etanercept serum trough level measurements

Adalimumab (n=34)Etanercept (n=21)Age (years)45 ± 1346 ± 12Gender (male)14 (41)12 (57)BMI (kg/m2)26.6 (24.5-32.7)24.3 (21.9-29.5)*Symptom duration (years)21 ± 1420 ± 8HLA-B27 positive26 (79)16 (84)ASDAS2.3 (1.7-3.1)1.6 (1.3-2.0)**Treatment duration current TNFi (months)27 (7-57)58 (12-76)Serum trough level (μg/ml)5.2 (3.7-8.0)1.6 (1.1-2.4)

Values are mean ± SD, median (IQR) or n (%)

*Significant difference (p<0.05) and **(p<0.01) compared to patients on adalimumab

Figure 1.

Scatterplot of BMI and serum trough level of adalimumab (A) and of etanercept (B)

Disclosure of Interests:

Liseth de Wolff: None declared., Suzanne Arends Grant/research support from: Pfizer, Elisabeth Brouwer Grant/research support from: Pfizer, Hendrika Bootsma: None declared., Anneke Spoorenberg Consultant of: Abbvie, Pfizer, MSD, Novartis and UCB, Grant/research support from: Abbvie, Pfizer and Novartis.

OP0046 CAN PATIENTS WITH AXIAL SPONDYLOARTHRITIS INDICATE WHETHER PAIN IS MAINLY RELATED TO INFLAMMATION OR STRUCTURAL DAMAGE?

Background:

Patients with axial spondylarthritis (axSpA) mainly rate disease activity on experienced symptoms such as pain (1). Pain is also included in the assessments (ASDAS and BASDAI) used to monitor disease activity in axSpA. However, besides disease activity, also other factors including the presence of structural damage may be related to experienced pain and discomfort.

Objectives:

To explore to what extent axSpA patients relate their experienced pain in neck, back and hips to inflammation and/or structural damage.

Methods:

Patients from the Groningen Leeuwarden Axial Spondyloarthritis (GLAS) cohort visiting the out-patient clinic between May 2016 and October 2019 were included in this cross-sectional analysis. Patients filled out two additional questions related to question 2 of the BASDAI: To what extent do you think pain in your neck, back and hips is related to: 1. inflammation caused by axSpA?, 2. damage of spine and joints caused by axSpA? These questions were answered on a NRS from 0 (none) to 10 (very much). A difference of ≥2 points was considered as clinically relevant. Patients who differentiated the cause of their pain were allocated to an inflammation or damage group, in favour of their highest score. Furthermore, patient characteristics and clinical assessments were compared between the inflammation and damage groups.

Results:

In total, 688 axSpA patients were included, 62.4% were male, mean age was 47.9 years, median symptom duration was 19 years, 77.9% were HLA-B27+, mean BASDAI was 3.9 and mean ASDASCRP was 2.3. Respectively 13% and 14% of the patients reported a score of 0 on the additional questions about inflammation or damage.

In total, 517 (75%) patients could not differentiate between inflammation or damage. 102 (15%) patients interpreted experienced pain as mainly related to inflammation and 69 (10%) patients interpreted their pain as mainly related to structural damage.

Patients who interpreted pain as mainly related to inflammation were significantly younger, had shorter symptom duration, were more frequently diagnosed as non-radiographic axSpA and had higher ASDASCRP, which was driven by the patient-reported questions as the objective marker CRP was not significantly different between both groups (Table 1).

Table 1.

Patients characteristics and clinical assessments of axSpA patients who related pain mainly to inflammation versus to structural damage.

Inflammation group(n = 102)Structural damage group(n = 69)P-valueAge (years)39.5 ± 12.448.9 ± 12.4<0.001Symptom duration (years)12 (6 – 20)28 (17 – 35)<0.001Diagnosis non-radiographic axSpA39 (40%)8 (13%)<0.001Male gender60 (59%)44 (64%)0.627BASDAI4.2 ± 1.83.9 ± 2.00.371BASDAI – Q26 (3 – 7)4 (2 – 6)0.005Patient global disease activity4 (3 – 7)3 (2 – 5)<0.001ASDASCRP2.6 ± 0.92.2 ± 0.80.003CRP3.0 (2.0 – 8.0)2.5 (2.0 – 4.4)0.094Occiput wall distance (cm)0.0 (0.0 – 4.0)4.0 (0.0 – 10.0)<0.001Chest expansion (cm)5.8 (4.0 – 7.0)4.0 (3.0 – 6.0)0.006Modified Schober test (cm)14.0 ± 1.613.5 ± 1.60.052Lateral flexion mean (cm)15.3 ± 6.512 ± 5.90.001Cervical rotation mean (degrees)80 (70 – 90)70 (45 - 81)<0.001mSASSS *3.0 (0.0 – 9.0)8.0 (1.8 – 26.0)0.061

* only available in a subgroup of patients. Inflammation group (n=31), structural damage group (n=39).

Patients who reported their pain as mainly related to structural damage showed significantly worse spinal mobility on almost all spinal mobility tests. In the subgroup of patients with available mSASSS data, there was also a trend towards more spinal radiographic damage (Table 1).

Conclusion:

In our large observational cohort of axSpA patients, the vast majority (75%) could not rate whether experienced pain in neck, back and hips was more related to inflammation or structural damage. However, if patients were able to relate pain to inflammation or damage, it seems in accordance with the outcome of their clinical assessments.

References:

[1]Spoorenberg A et al. Rheumatology (Oxford), 2005;44(6):789-95.

Disclosure of Interests:

None declared

POS0031 THE PREVALENCE OF INFLAMMATORY BACK PAIN AND HLA-B27 IN A LARGE POPULATION-BASED COHORT IN THE NETHERLANDS

Background:

Although chronic low back pain (≥3 months) before the age of 45 and inflammatory back pain (IBP) are regarded as early presenting and key features of axial spondyloarthritis (axSpA), and Magnetic Resonance Imaging (MRI) can be used to demonstrate sacroiliitis, the substantial delay in the diagnosis of axSpA has not improved.(1) Additionally, knowledge on the prevalence of chronic low back pain before the age of 45 and IBP in combination with the axSpA-related genetic risk factor Human Leukocyte Antigen-B27 (HLA-B27) in the general population is scarce.

Objectives:

To estimate the prevalence of chronic low back pain before the age of 45 and IBP in combination with the presence of HLA-B27 in a large Dutch population based cohort.

Methods:

Participants of the Lifelines cohort, a large population-based cohort of the northern region of the Netherlands, filled out a questionnaire on chronic low back pain and IBP. Chronic low back pain was defined as an affirmative answer to the question ‘Did you suffer from low back pain for ≥3 months?’. IBP was questioned based on the validated European Spondyloarthropathy Study Group (ESSG) IBP criteria and was confirmed if at least 4 out of the following 5 criteria were present: (a) onset before age 45, (b) insidious onset, (c) improvement with exercise, (d) associated with morning stiffness, (e) at least 3 months duration. Participants reporting to have been diagnosed with axSpA were identified using variations of the search terms “Bechterew”, ”spondyloarthritis” and “ankylosing spondylitis”. The Illumina global screening array (GSA) beadchip-24 v1.0 was used to genotype genome-wide SNPs in a subset of Lifelines participants. HLA-B haplotypes were imputed using neighboring SNPs with HIBAG, which is an R-package, using published parameter estimates.(2) The predicted HLA-B haplotype was considered valid if the posterior probability was >80%.

Results:

In total 94,277 Lifelines participants answered the chronic low back pain question, of which 93,665 (99.4%) completed the ESSG IBP questions. Of these participants, 56,008 (59.8%) were female, mean age was 45.6 ± 12.8 years and 22,192 (23.7%) reported to have been suffering from chronic low back pain. In this chronic low back pain group, the pain began before the age of 45 in 17,122 (77.2%; 18,3% of entire Lifelines population) participants, and 13,514 (60.9%; 14.4% of entire Lifelines population) participants reported to have IBP according to the ESSG criteria.

Of 32,785 participants genetic data were available and in 29,399 (89.7%) the HLA-B haplotype could be determined with high prediction accuracy, of which 2,279 (7.8%) participants were HLA-B27 positive. Of these HLA-B27 positive participants, 1,610 (70.6%) also had available chronic low back pain data, of which 373 (23.2%) reported chronic low back pain. Of these 373 patients with chronic back pain and HLA-B27 positivity, the pain began before the age of 45 in 296 (79.4%), and 237 (64.2%) fulfilled the ESSG IBP criteria of which only 11 (4.6%) participants reported to be diagnosed with axSpA.

Conclusion:

In this large population-based cohort, 18.3% of participants reported chronic low back pain that began before the age of 45. 14.4% of the participants reported IBP, which is relatively high in comparison to previous studies. HLA-B27 prevalence (7.8%) was similar to previously published data from the North-Western European population. The vast majority of participants with both IBP and the presence of HLA-B27 did not report an axSpA diagnosis. A next step in the analyses will be to explore associations with other demographic and clinical factors present including additional SpA features.

References:

[1]Zhao SS, et al. Rheumatology (Oxford). 2021; keaa807

[2]Internet: https://zhengxwen.github.io/HIBAG/hibag_index.html (Accessed: 25 November 2020)

Disclosure of Interests:

Stan Kieskamp: None declared, Suzanne Arends Grant/research support from: Research support from Pfizer, Elisabeth Brouwer Speakers bureau: Roche, Consultant of: Roche, Hendrika Bootsma Grant/research support from: Roche, Ilja M. Nolte: None declared, Anneke Spoorenberg Consultant of: Abbvie, Pfizer, MSD, UCB, Novartis, Grant/research support from: Abbvie, Pfizer, UCB, Novartis.

POS0412 CD21-/LOW B-CELLS ARE INCREASED IN PATIENTS WITH ANKYLOSING SPONDYLITIS

Background:

Ankylosing spondylitis (AS) is a chronic immune mediated inflammatory rheumatic disease, in which primarily the sacroiliac joints and the spine are affected. Extra-skeletal manifestations (ESM) include uveitis, psoriasis, inflammatory bowel disease and peripheral arthritis. In studies into the pathogenesis of AS, B-cells have received little attention most likely due to the lack of auto-antibodies1. A B-cell subset that has been particularly associated with autoreactivity is characterized by low expression of CD21. These CD21-/low B-cells are increased in systemic autoimmune diseases, including rheumatoid arthritis, systemic lupus erythematosus and primary Sjögren syndrome (pSS)2. At least part of the CD21-/low B-cells are considered to represent anergic, autoreactive B-cells, that fail to become activated through conventional B-cell receptor and CD40 signaling2.

Objectives:

To phenotypically study the peripheral B-cell compartment in in the blood of AS patients compared to pSS patients, a typical B-cell-associated autoimmune disease, and healthy controls (HC). Special emphasis was given to the CD21-/low compartment.

Methods:

The proportions and phenotype of peripheral B-cells were assessed in cryopreserved peripheral blood mononuclear cells of 45 AS patients (62% male, mean age 49.2±13.2 years, mean ASDAS 2.5±1.0), 20 age-matched patients with pSS (20% male, mean age 50.6±12.0, median (IQR) ESSDAI 3±6.25) and 30 age- and sex-matched HCs, using 15-color flow-cytometry analysis. Differences between groups were tested using the Independent Samples t-test or Mann-Whitney U test depending on the distribution of variables. Associations between CD21-/low B-cells and clinical parameters were explored using the Pearson or Spearman correlation coefficient.

Results:

The percentage of total B-cells in AS patients did not differ from pSS patients and HCs. In AS patients, percentages of CD27+ memory B-cells and CD27-IgD+ naïve B-cells were also similar to HCs, whereas CD27+IgD- memory B-cells were significantly reduced in pSS patients, as expected. The proportions of CD27-CD38lowCD21-/low B-cells among total B-cells were significantly increased in both AS (median 6.4%, p<0.0001) and pSS patients (median 7.8%, p<0.0001) compared to HCs (median 4.9%). Interestingly, only in AS patients, expression of chemokine receptors CXCR3 and CXCR5 was significantly elevated on CD27-CD38lowCD21-/low B-cells compared to HCs (p<0.001 and p<0.01, respectively). In comparison to HCs the expression of the immune markers T-bet and CD11c by CD27-CD38lowCD21-/low B-cells was significantly lower in AS patients (p<0.01 and p<0.01, respectively). The distribution of IgM and IgD expression within the CD27-CD38lowCD21-/low B-cell population was similar between all three study groups. Regarding the association between CD27-CD38lowCD21-/low B-cells and clinical parameters in AS patients, we observed a positive correlation with age (r=0.347, p=0.02) and erythrocyte sedimentation rate (ρ=0.386, p=0.01). Furthermore, AS patients with ESM showed increased proportions of CD27-CD38lowCD21-/low B-cells compared to patients without ESM (p<0.05).

Conclusion:

In this cross-sectional study, we observed an increased proportion of circulating CD27-CD38lowCD21-/low B-cells in AS patients, similar as in patients with pSS, a typical B-cell-mediated autoimmune disease. The elevated expression of CXCR3 on CD27-CD38lowCD21-/low B-cells in AS patients is suggestive for active involvement in the inflammatory response. These findings are indicative of B-cell involvement in the pathogenesis of AS, against current dogma.

References:

[1]Ranganathan V et al. Nat Rev Rheumatol. 2017;13(6):359-367.

[2]Thorarinsdottir K et al. Scand J Immunol. 2015;82(3):254-261.

Disclosure of Interests:

Rick Wilbrink: None declared, Anneke Spoorenberg: None declared, Suzanne Arends: None declared, Frans G.M. Kroese Speakers bureau: BMS, Roche, Janssen-Cilag, Consultant of: BMS, Grant/research support from: BMS, Gwenny M. Verstappen: None declared

AB0082 PERSISTENT LOW COMPLEMENT LEVELS AND INTERFERON GENE UPREGULATION ARE PREDICTIVE FOR DISEASE PROGRESSION IN PATIENTS WITH INCOMPLETE SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

A subgroup of lupus patients present with mild symptoms and immunologic features, while they do not meet classification criteria for SLE. This disease state can be referred to as “incomplete systemic lupus erythematosus” (iSLE). Up to 55% of iSLE patients progress to SLE. Furthermore, previous research has shown that iSLE might overlap with early primary Sjögren’s disease (pSS).(1) Unfortunately, there are no predictive markers available for progression to classifiable disease. Type-I interferon (IFN) plays an important role in disease initiation of both SLE and pSS.(2,3) Myxovirus-resistance protein A (MxA) is a GTP-ase that has previously be demonstrated to correlate strongly with IFN-type I expression. Furthermore, interferon-inducible chemokines IFN-γ induced protein 10 (IP-10), and B-cell activating factor (BAFF), that are both inducible by IFN, are of interest, because it is demonstrated that these proteins are increased prior to the diagnosis of SLE.(4)

Objectives:

To find predictive markers that identify patients with incomplete systemic lupus erythematosus (iSLE) who are at the highest risk to progress to classifiable systemic lupus erythematosus (SLE) or primary Sjögren’s syndrome (pSS).

Methods:

Patients with iSLE (ANA ≥ 1:80, ≥ 1 clinical SLICC criterion, but not fulfilling the criteria, and disease manifestation <5 years) were included in a longitudinal observational study. Every half year, clinical status was evaluated and regular immunological serologic assessment was performed. Annually, interferon (IFN)-gene expression was determined by RT-PCR in whole blood using 14 genes. These genes represented 3 IFN-related modules. Some genes were mainly inducible by IFN-type I, others by IFN-type II. Furthermore, IFN-related mediators Myxovirus resistance protein A (MxA), interferon-gamma-induced protein 10 (IP-10) and B-cell activating factor (BAFF) were measured.

Results:

Of 38 included iSLE patients, 6 had developed SLE and 1 develop pSS (18%) after median follow up of 36 months. The 7 patients who developed SLE/pSS were all women, and were younger at baseline than those who remained having iSLE (median 26 years, IQR 20-29 vs. median 42 years, IQR 30-56, p=0.0009). Over time, these patients had significantly lower complement 3 (p<0.0001) and complement 4 levels (p=0.005), higher IFN-gene expression (p=0.007), and lower neutrophil counts (p=0.033) (see Figure 1.). No difference was found between IFN-type I and IFN-type II inducible genes. Levels of MxA, IP-10 and BAFF did not differ between patients who remained iSLE and who progressed to SLE/pSS.

Figure 1.

Conclusion:

Gender, age at diagnosis, persistent low complement levels, and high IFN-gene expression can help to identify iSLE patients at the highest risk of progressing to classifiable disease.

References:

[1]Md Yusof MY, et al. Prediction of autoimmune connective tissue disease in an at-risk cohort: Prognostic value of a novel two-score system for interferon status. Ann Rheum Dis. 2018;1–8.

[2]Yao Y, et al. Type I interferons in Sjögren’s syndrome. Autoimmun Rev. 2013;12(5):558–66.

[3]Crow MK. Type I Interferon in the Pathogenesis of Lupus. J Immunol [Internet]. 2014;192(12):5459–68.

[4]Lu R, et al. Dysregulation of innate and adaptive serum mediators precedes systemic lupus erythematosus classification and improves prognostic accuracy of autoantibodies. J Autoimmun. 2016;74:182–93.

Disclosure of Interests:

None declared

POS1014 CENTRAL SENSITIZATION HAS MAJOR IMPACT ON QUALITY OF LIFE IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background:

Maintaining optimal health-related quality of life (QoL) is the ultimate goal of treatment in axial spondyloarthritis (axSpA). Chronic pain has a large potential impact on QoL. Central sensitization (CS) may explain part of the chronic pain in axSpA. However, the role of central sensitization (CS) herein has only been studied to a limited degree and current axSpA guidelines pay little attention to identification and treatment of CS.

Objectives:

To explore the relationship between CS and QoL in axSpA.

Methods:

Consecutive outpatients with axSpA from the Groningen Leeuwarden Axial Spondyloarthritis (GLAS) cohort were included. CS was assessed with the Central Sensitization Inventory (CSI; 0-100), QoL with the AS Quality of Life questionnaire (ASQoL; 0-18) and disease activity with the AS Disease Activity Score (ASDASCRP). A high probability of CS was defined as CSI score ≥40 and active disease as ASDASCRP score ≥2.1. Patient characteristics and clinical assessments were compared between groups with CSI score <40 and ≥40.(1) Multivariable regression analysis was conducted to investigate the relationship between CSI and ASQoL scores, correcting for potential confounders.

Results:

Of the 178 axSpA patients with available CSI score, 149 completed the ASQoL. Mean age of the 178 included patients was 47.4 ± 14.1 years, 78 (44%) were female, mean symptom duration was 21.4 ± 13.6 years and 88 (52%) were using bDMARDS. Mean CSI score was 38.0 ± 14.1, mean ASQoL 6.0 ± 5.3 and mean ASDASCRP 2.1 ± 1.0. CSI score ≥40 was significantly associated with higher mean ASQoL (9.7 vs. 3.3), higher mean ASDASCRP (2.6 vs. 1.7), female gender (60% vs. 29%) and more often entheseal involvement (61% vs. 26%) (Table 1).

Table 1.

Selection of patient characteristics, disease activity and clinical outcome variables for patients with axSpA, divided in subgroups for CSI score with a cutoff point of 40.

CharacteristicsAll patientsn = 178CSI<40n = 98 (55%)CSI≥40n = 80 (45%)Age (years)47.4 ± 14.148.7 ± 15.045.8 ± 12.7Female78 (44)27 (29)44 (60)*Symptom duration (years)21.4 ± 13.621.5 ± 13.521.2 ± 13.8HLA-B27+133 (79)70 (79)54 (79)Smoker45 (27)28 (32)15 (23)BMI (kg/m2)26.7 ± 5.026.2 ± 4.427.5 ± 5.8Completed higher education181 (71)48 (70)34 (76)Biological use88 (52)49 (52)39 (51)RDCI (0-9)0.0 (0.0 – 1.0)0.0 (0.0 – 1.0)0.0 (0.0 – 1.8)Peripheral arthritis210 (6)5 (6)5 (8)Entheseal involvement364 (40)23 (26)38 (61)*ASDASCRP2.1 ± 1.01.7 ± 0.92.6 ± 1.0*CRP (mg/ml)2.9 (1.1 – 6.8)2.6 (1.1-6.0)3.6 (1.4 – 7.0)ASQoL (0-18)6.0 ± 5.33.3 ± 3.69.7 ± 4.9*CSI (0-100)38.0 ± 14.128.0 (23 – 34)50.0 (43.0 –56.0)N/A

Values are n (%), mean ± SD or median (IQR).

1International Standard Classification of Education (ISCED) level >4; 2Swollen Joint Count >0; 3Maastricht Ankylosing Spondylitis Enthesitis Score >0. *p<0.001. ASDASCRP: Ankylosing Spondylitis Disease Activity Score; ASQoL: Ankylosing Spondylitis Quality of Life questionnaire; CRP: C-reactive protein; CSI: Central Sensitization Inventory; RDCI: Rheumatic Disease Comorbidity Index.

Patients with low ASDASCRP (<2.1) and also low CSI score (<40) showed good QoL (median ASQoL 1.1). Patients with low ASDASCRP combined with high CSI score (≥40) and patients with high ASDASCRP (≥2.1) combined with low CSI score reported worse QoL (median ASQoL 5.6 and 4.1, respectively). Patients with high ASDASCRP and also high CSI score reported the worst QoL (median ASQoL 12.0). (Figure 1).

Figure 1.

ASQoL score in patients with axSpA with CSI score ≥40 and <40, divided for ASDASCRP (cutoff 2.1)

Additionally, in univariable analysis, the CSI score explained a large proportion of the variation of the ASQoL (R2=0.46). This association remained significant after correction for ASDASCRP, gender, symptom duration, entheseal involvement, smoking status, BMI category, educational level and comorbidities in multivariable analysis (CSI p<0.001).

Conclusion:

In daily clinical practice, CS seems strongly related to patient-reported QoL in patients with long-term axSpA.

References:

[1]Neblett R et al. J Pain. 2013;14:438–45.

Acknowledgements:

The authors would like to thank all patients who participated in the GLAS cohort. Furthermore, the authors wish to acknowledge Mrs. B. Burmania, Mrs. B. Hollander, Mrs. S. Katerbarg, Mrs. S. Lange, Mrs. E. Markenstein, Mrs. R. Rumph and Mrs. M. de Vries-Veldman for their contribution to clinical data collection.

Disclosure of Interests:

Stan Kieskamp: None declared, Davy Paap: None declared, Marlies Carbo: None declared, Freke Wink Consultant of: Abbvie, Reinhard Bos: None declared, Hendrika Bootsma Grant/research support from: Roche, Suzanne Arends Grant/research support from: Pfizer, Anneke Spoorenberg Consultant of: Abbvie, Pfizer, MSD, UCB, Lilly, Novartis, Grant/research support from: Abbvie, Pfizer, UCB, Novartis.

POS1002 BASELINE CALPROTECTIN AND VISFATIN LEVELS PREDICT RADIOGRAPHIC SPINAL PROGRESSION AFTER 2 YEARS IN ANKYLOSING SPONDYLITIS PATIENTS ON TNF INHIBITOR THERAPY

Background:

Radiographic spinal progression determinates functional status and mobility in ankylosing spondylitis (AS)1.

Objectives:

To analyse whether biomarker of inflammation, bone turnover and adipokines at baseline or their change after 3 months or 2 years can predict spinal radiographic progression after 2 years in AS patients treated with TNF-α inhibitors (TNFi).

Methods:

Consecutive AS patients from the Groningen Leeuwarden Axial Spondyloarthritis (GLAS) cohort2 starting TNFi between 2004 and 2012 were included. The following serum biomarkers were measured at baseline, 3 months and 2 years of follow-up with ELISA:

 - Markers of inflammation: calprotectin, matrix metalloproteinase-3 (MMP-3), vascular endothelial growth factor (VEGF)

 - Markers of bone turnover: bone-specific alkaline phosphatase (BALP), serum C-terminal telopeptide (sCTX), osteocalcin (OC), osteoprotegerin (OPG), procollagen typ I and II N-terminal propeptide (PINP; PIINP), sclerostin.

 - Adipokines: high molecular weight (HMW) adiponectin, leptin, visfatin

Two independent readers assessed spinal radiographs at baseline and 2 years of follow-up according to the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). Radiographic spinal progression was defined as mSASSS change ≥2 units or the formation of ≥1 new syndesmophyte over 2 years. Logistic regression was performed to examine the association between biomarker values at baseline, their change after 3 months and 2 years and radiographic spinal progression. Multivariable models for each biomarker were adjusted for mSASSS or syndesmophytes at baseline, elevated CRP (≥5mg/l), smoking status, male gender, symptom duration, BMI, and baseline biomarker level (the latter only in models with biomarker change).

Results:

Of the 137 included AS patients, 72% were male, 79% HLAB27+; mean age at baseline was 42 years (SD 10.8), ASDAScrp 3.8 (0.8) and mSASSS 10.6 (16.1). After 2 years of follow-up, 33% showed mSASSS change ≥2 units and 24% had developed ≥1 new syndesmophyte. Serum levels of biomarkers of inflammation and bone formation showed significant changes under TNFi therapy, whereas adipokine levels were not altered from baseline (Figure 1).

Univariable logistic regression revealed a significant association of baseline visfatin (odds ratio OR [95% confidence interval] 1.106 [1.007-1.215]) and sclerostin serum levels (OR 1.006 [1.001-1.011]) with mSASSS progression after 2 years. Baseline sclerostin levels were also associated with syndesmophyte progression (OR 1.007 [1.001-1.013]). In multivariable logistic analysis, only baseline visfatin level remained significantly associated (OR 1.465 [1.137-1.889]) with mSASSS progression. Furthermore, baseline calprotectin showed a positive association with both, mSASSS (OR 1.195 [1.055-1.355]) and syndesmophyte progression (OR 1.107 [1.001-1.225]) when adjusting for known risk factors for radiographic progression.

Univariable logistic regression showed that change of sclerostin after 3 months was associated with syndesmophytes progression (OR 1.007 [1.000-1.015), change of PINP level after 2 years was associated with mSASSS progression (OR 1.027 [1.003-1.052]) and change of visfatin after 2 years was associated with both measures of radiographic progression – mSASSS (OR 1.108 [1.004-1.224]) and syndesmophyte formation (OR 1.115; [1.002-1.24]). However, those associations were lost in multivariable analysis.

Conclusion:

Independent of known risk factors, baseline calprotectin and visfatin levels were associated with radiographic spinal progression after 2 years of TNFi. Although biomarkers of inflammation and bone formation showed significant changes under TNFi therapy, these changes were not significantly related to radiographic spinal progression in our cohort of AS patients.

References:

[1]Poddubnyy et al 2018

[2]Maas et al 2019

Acknowledgements:

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

Disclosure of Interests:

Judith Rademacher: None declared, Mark Siderius: None declared, Laura Gellert: None declared, Freke Wink Consultant of: AbbVie, Maryna Verba: None declared, Fiona Maas: None declared, Lorraine M Tietz: None declared, Denis Poddubnyy: None declared, Anneke Spoorenberg Consultant of: Abbvie, Pfizer, MSD, UCB, Lilly and Novartis, Grant/research support from: Abbvie, Pfizer, UCB, Novartis, Suzanne Arends Grant/research support from: Pfizer.

POS0034 RADIOGRAPHIC ENTHESEAL LESIONS AT HIP AND PELVIC REGION ARE ASSOCIATED WITH LONGER DISEASE DURATION, HIGHER BMI AND MORE SEVERE SPINAL AND HIP RADIOGRAPHIC DAMAGE IN PATIENTS WITH ANKYLOSING SPONDYLITIS

Background:

Enthesitis is an important feature of ankylosing spondylitis (AS) and structural and inflammatory entheseal lesions (EL) are frequently present on ultrasound. Plain radiographs also provide good imaging of structural entheseal involvement1. Until now, little is known about the presence of structural EL at the hip and pelvic region and the association with patient characteristics in AS.

Objectives:

Our aim was to investigate the prevalence of radiographic EL at the hip and pelvic region in AS patients compared to age and sex matched control subjects and to explore the relation with AS patient characteristics.

Methods:

AS patients from the Groningen Leeuwarden Axial SpA (GLAS) cohort, included between November 2004 and December 2010, with available anteroposterior (AP) pelvis radiographs at baseline were included. All patients fulfilled the modified New York criteria for AS. Additionally, 100 randomly selected AP pelvis radiographs from age and sex matched control subjects were obtained from the radiology department of the University Medical Center Groningen. The sacroiliac joints of all radiographs were blinded and radiographs were scored independently by two trained observers unaware of patient characteristics and treatment. The entheseal sites scored were: trochanter major, trochanter minor, os ischium, crista iliaca, both left and right side. The following 3 EL were scored: erosion/cortical irregularity, calcification and enthesophyte. Only lesions with absolute agreement between both observers were used for analyses. Radiographic spinal involvement was scored according to the modified Stoke AS Spine Score (mSASSS; range 0-72) and radiographic hip involvement according to the Bath AS Radiology Index (BASRI)-hip (range 0-4). Independent samples t test, Mann-Whitney U test, Chi-Square test, and Fisher Exact test were used to compare patient characteristics between patients with and without radiographic EL.

Results:

Of the 167 included AS patients, 117 (70%) were male, mean age was 43 ± 11 years, 133 (80%) were HLA-B27 positive and median symptom duration was 16 years (range 1-53). 127 (76%) AS patients and 58 (58%) controls showed EL, with 501 lesions in total of which 377 (75%) in AS patients. AS patients showed significantly more lesions than controls at all 5 locations. Os ischii showed the most lesions in both AS patients and controls (66% vs 53%, p<0.05). The most prevalent type of lesion in both groups was erosion/cortical irregularity (72% vs 51%, p<0.005). Enthesophytes were also more often observed in AS patients than in controls (31% vs 21%, p=0.07). Prevalence of calcifications was low in both groups and not significantly different (5% vs 2%, p=0.22). AS patients with EL were significantly older (mean 45.2 vs 35.1 yrs, p<0.005) and had longer symptom duration (median 18 vs 7.5 yrs, p<0.005) than patients without EL. Furthermore, patients with BMI >25 had significantly more often enthesophytes (42% vs 16%, p<0.05) than patients with a normal BMI. Additionally, AS patients with EL had significantly more often radiographic spinal damage than patients without EL with median mSASSS total score 8.7 vs 1.0 (p<0.005) and a trend toward significance for radiographic hip involvement (BASRI-hip score ≥2; p=0.06).

Conclusion:

Radiographic EL at hip and pelvic region are significantly more prevalent in AS patients than in age and sex matched controls. AS patients with EL were significantly older, had longer symptom duration and more spinal radiographic damage than patient without EL. Furthermore, BMI >25 was associated with a higher prevalence of enthesophytes. These new findings contribute to the knowledge of entheseal involvement in AS.

References:

[1]Voudouris et al. J Musculoskelet Neuronal Interact. 2003;3(1):89-100.

Disclosure of Interests:

Freke Wink Consultant of: Abbvie, Thomas Diemel: None declared, Suzanne Arends: None declared, Anneke Spoorenberg Consultant of: Abbvie, Pfizer, MSD, UCB, and Novartis, Grant/research support from: Abbvie, Pfizer, UCB and Novartis.

OP0130 COMPOSITE OF RELEVANT ENDPOINTS IN SJÖGREN’S SYNDROME (CRESS): A COMPREHENSIVE TOOL FOR CLINICAL TRIALS

Background:

Several large randomised controlled trials (RCTs) in primary Sjögren’s syndrome (pSS) failed to demonstrate drug efficacy.1-4 Many of these trials used ESSDAI as primary endpoint, showing large but similar response rates in active treatment and placebo groups.1,3,4 Given the heterogeneous nature of pSS, there is need for a composite endpoint including multiple clinically relevant parameters.

Objectives:

To develop and validate the Composite of Relevant Endpoints in Sjögren’s Syndrome (CRESS).

Methods:

A multidisciplinary team of pSS experts selected clinically relevant items and measurements to include in the CRESS. Definition of response of CRESS items was based on clinical relevance, previously defined minimal clinically important improvement (MCII) and data of the single-centre ASAP-III (abatacept) trial.1 CRESS was validated in three independent RCTs: TRACTISS (rituximab) trial2, multi-centre abatacept trial3 and ETAP (tocilizumab) trial4. CRESS response rates were assessed at the primary endpoint visit of all four trials.

Results:

Five complementary items were selected to form CRESS: systemic disease activity, patient-reported symptoms, tear gland, salivary gland and serological item. Definition of response per item is presented in Table 1. Total CRESS response was defined as response on ≥3 of 5 items. Since not all trials have ocular staining score or salivary gland ultrasonography (SGUS) available, the concise CRESS (cCRESS) was developed simultaneously, leaving Schirmer’s test and unstimulated whole saliva flow for the tear and salivary gland items, respectively. In the ASAP-III trial, CRESS response rates were 24/40 (60%) for abatacept vs. 7/39 (18%) for placebo at week 24 (p<0.001).

Table 1.

CRESS items and definition of response

ItemsMeasurementsDefinition of responseSystemic disease activityClinESSDAIScore<5 (low disease activity)Patient-reported symptomsESSPRIDecrease of ≥1 point or ≥15%Tear gland*Schirmer/OSS**-If abnormal Schirmer (≤5 mm) at baseline: increase of ≥5 mm in Schirmer-Or if abnormal OSS (≥3 points) at baseline: decrease ≥2 points in OSS-Or if both Schirmer/OSS normal scores at baseline: no change to abnormal in bothSalivary gland*UWS/SGUSIncrease of ≥25% in UWS (or if score is 0 at baseline, any increase)Or decrease of ≥25% in total Hocevar score (SGUS)SerologicalRF/IgGDecrease of ≥25% in RFOr decrease of ≥10% in IgGCRESS responderResponder on ≥3 of 5 items

Ocular Staining Score (OSS), Unstimulated whole salivary flow (UWS), Salivary gland ultrasonography (SGUS), Rheumatoid factor (RF), Immunoglobuline G (IgG)

*Concise CRESS (cCRESS): CRESS without OSS and SGUS, leaving Schirmer and UWS for tear and salivary gland items, respectively

**Mean of both eyes

In the external validation trials, cCRESS response rates for TRACTISS were: 33/67 (49%) rituximab vs. 20/66 (30%) placebo at week 48 (p=0.026). CRESS response rates (without SGUS) for the multi-centre abatacept trial were: 41/92 (45%) abatacept vs. 30/95 (32%) placebo at week 24 (p=0.067). cCRESS response rates (without rheumatoid factor) for ETAP were: 10/55 (18%) tocilizumab vs. 13/55 (24%) placebo at week 24 (p=0.482) (Figure 1A-D). Compared to ESSDAI MCII of ≥3 points decrease, CRESS was able to approximately halve placebo response rates in RCTs with high baseline ESSDAI scores (>5) (Figures 1E-H).

Conclusion:

CRESS shows lower placebo response rates compared to ESSDAI MCII, which is crucial for demonstrating treatment efficacy. With the CRESS, higher response rates in abatacept and rituximab treated patients compared to placebo were found in RCTs which previously showed negative primary endpoint results. CRESS confirmed that no differences were found for almost all outcome measures between tocilizumab and placebo,4 with low response rates. The CRESS is a well-balanced, feasible, composite endpoint for use in clinical trials in pSS patients.

References:

[1]Van Nimwegen 2020;9913(19):1–11

[2]Bowman 2017;69(7):1440–50

[3]Baer (doi:218599)

[4]Felten (doi:21846)

Acknowledgements:

The authors would like to acknowledge all contributors of the included trials.

Disclosure of Interests:

Suzanne Arends: None declared, Liseth de Wolff: None declared, Jolien F. van Nimwegen Speakers bureau: Bristol Myers Squibb, Consultant of: Bristol Myers Squibb, Gwenny M. Verstappen: None declared, Jelle Vehof: None declared, Michele Bombardieri Consultant of: MedImmune, GlaxoSmithKline, Grant/research support from: MedImmune, Simon J. Bowman Consultant of: AstraZenecea/MedImmune, Bristol Myers Squibb, Celgene, Eli Lilly, Glenmark, GlaxoSmithKline, MTPharma, Novartis, Ono, Pfizer, Takeda, UCB, XTLBio, Elena Pontarini: None declared, Alan Baer Consultant of: Bristol Myers Squibb, Sanofi, VielaBio, Novartis, Marleen Nys Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Jacques-Eric Gottenberg Grant/research support from: Bristol Myers Squibb, Pfizer, Renaud FELTEN: None declared, Neelanjana Ray Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Arjan Vissink: None declared, Frans G.M. Kroese Speakers bureau: Bristol Myers Squibb, Roche and Janssen-Cilag, Consultant of: Bristol Myers Squibb, Grant/research support from: Unrestricted grants from Bristol Myers Squibb, Hendrika Bootsma Speakers bureau: Bristol Myers Squibb and Novartis, Consultant of: Bristol Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Grant/research support from: Unrestricted grants from Bristol Myers Squibb and Roche

Adalimumab and infliximab survival in patients with hidradenitis suppurativa: a daily practice cohort study

BACKGROUND

Biologics are often required for the treatment of hidradenitis suppurativa (HS). However, data on the drug survival of biologics in daily practice are currently lacking.

OBJECTIVES

To assess the drug survival of antitumour necrosis factor biologics in a daily practice cohort of patients with HS and to identify predictors for drug survival.

METHODS

A retrospective multicentre study was performed in two academic dermatology centres in the Netherlands. Adult patients with HS using biologics between 2008 and 2020 were included. Drug survival was analysed with Kaplan-Meier survival curves and predictors of survival with univariate Cox regression analysis.

RESULTS

The overall drug survival of adalimumab (n = 104) at 12 and 24 months was 56·3% and 30·5%, respectively, which was predominantly determined by infectiveness. Older age (P = 0·02) and longer disease duration (P < 0·01) were associated with longer survival time. For infliximab (n = 44), overall drug survival was 58·3% and 48·6% at 12 and 24 months, respectively, and was predominantly determined by infectiveness and side-effects. Surgery during treatment was associated with a longer survival time (P = 0·01).

CONCLUSIONS

Survival rates were comparable for adalimumab and infliximab at 12 months, and were mainly determined by ineffectiveness. Age, disease duration (adalimumab) and surgery (infliximab) are predictors for longer survival.

Second intravenous immunoglobulin dose in patients with Guillain-Barré syndrome with poor prognosis (SID-GBS): a double-blind, randomised, placebo-controlled trial

BACKGROUND

Treatment with one standard dose (2 g/kg) of intravenous immunoglobulin is insufficient in a proportion of patients with severe Guillain-Barré syndrome. Worldwide, around 25% of patients severely affected with the syndrome are given a second intravenous immunoglobulin dose (SID), although it has not been proven effective. We aimed to investigate whether a SID is effective in patients with Guillain-Barré syndrome with a predicted poor outcome.

METHODS

In this randomised, double-blind, placebo-controlled trial (SID-GBS), we included patients (≥12 years) with Guillain-Barré syndrome admitted to one of 59 participating hospitals in the Netherlands. Patients were included on the first day of standard intravenous immunoglobulin treatment (2 g/kg over 5 days). Only patients with a poor prognosis (score of ≥6) according to the modified Erasmus Guillain-Barré syndrome Outcome Score were randomly assigned, via block randomisation stratified by centre, to SID (2 g/kg over 5 days) or to placebo, 7-9 days after inclusion. Patients, outcome adjudicators, monitors, and the steering committee were masked to treatment allocation. The primary outcome measure was the Guillain-Barré syndrome disability score 4 weeks after inclusion. All patients in whom allocated trial medication was started were included in the modified intention-to-treat analysis. This study is registered with the Netherlands Trial Register, NTR 2224/NL2107.

FINDINGS

Between Feb 16, 2010, and June 5, 2018, 327 of 339 patients assessed for eligibility were included. 112 had a poor prognosis. Of those, 93 patients with a poor prognosis were included in the modified intention-to-treat analysis: 49 (53%) received SID and 44 (47%) received placebo. The adjusted common odds ratio for improvement on the Guillain-Barré syndrome disability score at 4 weeks was 1·4 (95% CI 0·6-3·3; p=0·45). Patients given SID had more serious adverse events (35% vs 16% in the first 30 days), including thromboembolic events, than those in the placebo group. Four patients died in the intervention group (13-24 weeks after randomisation).

INTERPRETATION

Our study does not provide evidence that patients with Guillain-Barré syndrome with a poor prognosis benefit from a second intravenous immunoglobulin course; moreover, it entails a risk of serious adverse events. Therefore, a second intravenous immunoglobulin course should not be considered for treatment of Guillain-Barre syndrome because of a poor prognosis. The results indicate the need for treatment trials with other immune modulators in patients severely affected by Guillain-Barré syndrome.

FUNDING

Prinses Beatrix Spierfonds and Sanquin Plasma Products.

Low body weight and involuntary weight loss are associated with Raynaud's phenomenon in both men and women

Objectives: Low body weight is an easily assessable cause of Raynaud's phenomenon (RP), and is frequently overlooked by clinicians. We aim to investigate the association of low body weight (body mass index < 18.5 kg/m²), involuntary weight loss, and nutritional restrictions with the presence of RP.Method: Participants from the Lifelines Cohort completed a validated self-administered connective tissue disease questionnaire. Subjects who reported cold-sensitive fingers and biphasic or triphasic colour changes were considered to suffer from RP. Patient characteristics, anthropometric measurements, and nutritional habits were collected. Statistical analyses was stratified for gender.Results: Altogether, 93 935 participants completed the questionnaire. The prevalence of RP was 4.2% [95% confidence interval (CI) 4.1-4.4%], and was three-fold higher in women than in men (5.7% vs 2.1%, p < 0.001). Subjects with RP had a significantly lower daily caloric intake than those without RP. Multivariate analysis, correcting for creatinine level, daily caloric intake, and other known aetiological factors associated with RP, revealed that low body weight [men: odds ratio (OR) 5.55 (95% CI 2.82-10.93); women: 3.14 (2.40-4.10)] and involuntary weight loss [men: OR 1.32 (1.17-1.48); women: 1.31 (1.20-1.44)] were significantly associated with the presence of RP. Low-fat diet was also associated with RP in women [OR 1.27 (1.15-1.44)].Conclusion: Low body weight and prior involuntary weight loss are associated with an increased risk of RP in both men and women. This study emphasizes that low body weight and weight loss are easily overlooked risk factors for RP, and should be assessed and monitored in subjects with RP.

SAT0170 COMPOSITE OF RELEVANT ENDPOINTS FOR SJÖGREN’S SYNDROME (CRESS)

Background:

Defining a primary study endpoint that is able to discriminate between active treatment and placebo is crucial for clinical trials in primary Sjögren syndrome (pSS). Recent trials used the validated ESSDAI as primary endpoint, but found large ‘response rates’ in the placebo group too. Since pSS is a very heterogenous disease, a composite endpoint including multiple aspects (i.e., systemic, patient-reported, functional and biological) may be more appropriate to demonstrate clinical efficacy.

Objectives:

To develop a composite endpoint for pSS based on expert opinion and analysis of trial data.

Methods:

Based on expert opinion, 5 items were found to be most relevant to assess the effect of treatment in pSS patients: ESSDAI, ESSPRI, OSS, SWS and RF/IgG (Figure 1). These items were tested using data at week 24 of the randomized, double blind, placebo-controlled ASAP-III trial.1ROC analysis was used to assess the discrimination of effect between the abatacept (n=40) and placebo (n=39) treatment groups. The optimal cut-off point per item was defined by the highest sum of sensitivity and specificity. The percentage of patients responding to the individual items (Figure 1) and the composite endpoint (named CRESS) was calculated.

Results:

For ESSDAI, ROC analysis showed that both absolute and relative change in ESSDAI were not able to discriminate between treatment groups (AUC 0.536 and 0.559) and no optimal cut-off point could be identified. According to an in SLE developed endpoint and based on expert opinion, it was decided to aim for the validated definition of low disease activity (ESSDAI<5)2.

For ESSPRI, ROC analysis (AUC 0.629) showed an optimal cut-off point of -13.8%. Therefore, the validated definition of ESSPRI response (≥-15% or 1 point)2was used. For OSS and SWS, ROC analysis (AUC 0.555 for OSS>3 at baseline and AUC 0.556 for SWS>0 at baseline) could not identify an optimal cut-off point, so the definitions based on expert opinion were kept (Figure 1).

For serological items, ROC analysis (AUC 0.861 for RF>0 at baseline and 0.615 for IgG) showed optimal cut-off points of -23% and -2.2%, respectively. It was decided to round these numbers to ≥25% decrease in RF or ≥5% decrease in IgG. Responding to ≥3 of the 5 items discriminated best between the abatacept and placebo groups. The final response rate to our composite endpoint (CRESS responders) was 55% vs. 13% in the abatacept and placebo groups, respectively (P<0.001). Further analysis of how many patients who met the composite endpoint also met the single endpoints and vice versa demonstrated that all individual items contributed to the overall response rate.

Conclusion:

This concept of the new ‘Composite of Relevant Endpoints for Sjögren’s Syndrome’ (CRESS) is developed. With this composite endpoint, it is possible to discriminate between abatacept and placebo response in pSS patients. Additional validation analyses in independent, global, multi-center, placebo-controlled trials of biological DMARDs in pSS and NECESSITY will be performed.

References:

[1]van Nimwegen et al. Lancet Rheumatol.Published online 31-01-2020.

[2]Seror et al. Ann Rheum Dis. 2016;75(2):382-9.

Acknowledgments:

The authors would like to thank Raphaele Seror for initial discussions on potential components and criteria to be explored in the creation of a composite pSS endpoint. The authors would also like to acknowledge valuable discussions with Marleen Nys, Miroslawa Nowak, Dennis Grasela, Antoine Sreih and Subhashis Banerjee.

Disclosure of Interests:

Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Jolien F. van Nimwegen Consultant of: Bristol-Myers Squibb, Speakers bureau: Bristol-Myers Squibb, Gwenny M. Verstappen: None declared, Arjan Vissink: None declared, Neelanjana Ray Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Frans G.M. Kroese Grant/research support from: Unrestricted grant from Bristol-Myers Squibb, Consultant of: Consultant for Bristol-Myers Squibb, Speakers bureau: Speaker for Bristol-Myers Squibb, Roche and Janssen-Cilag, Hendrika Bootsma Grant/research support from: Unrestricted grants from Bristol-Myers Squibb and Roche, Consultant of: Consultant for Bristol-Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Speakers bureau: Speaker for Bristol-Myers Squibb and Novartis.

THU0376 THE EFFECT OF 8 YEARS OF TNF-Α BLOCKING THERAPY ON BONE MINERAL DENSITY IN PATIENTS WITH ANKYLOSING SPONDYLITIS

Background:

Ankylosing spondylitis (AS) is a chronic inflammatory disease that mainly affects the axial skeleton. Bone loss reflected by low bone mineral density (BMD) is a common feature of AS and can already be observed at early stages of the disease. A recent cohort study of 135 AS patients reported 7.2% improvement in lumbar spine BMD and 2.2% improvement in hip BMD after 4 years of tumor necrosis factor-alpha (TNF-α) blocking therapy.1

Objectives:

To assess the effect of 8 years of TNF-α blocking therapy on BMD of the lumbar spine and hip in AS patients.

Methods:

Included in this study were consecutive AS outpatients from the Groningen-Leeuwarden Axial SpA (GLAS) cohort who received TNF-α blocking therapy for at least 8 years. A maximum of one switch to another TNF-α inhibitor was allowed. Patients were excluded when they used bisphosphonates at baseline or during follow-up. BMD of the lumbar spine (anterior-posterior projection L1-L4) (LS-BMD) and hip (total proximal femur) (hip-BMD) was measured at baseline, 1 year, 2 years and then bi-annually using dual-energy X-ray absorptiometry (Hologic QDR Discovery (UMCG) or Hologic QDR Delphi (MCL), Waltman, MA, USA). Z-scores, the number of SD from the normal mean corrected for age and gender, were calculated using the NHANES reference database. Low BMD was defined as lumbar spine and/or hip BMD Z-score ≤1. Generalized estimating equations were used to analyze BMD over time within subjects. Pairwise contrast were used to compare baseline and follow-up visits. P values <0.05 were considered statistically significant.

Results:

In total, 131 AS patients were included; 73% were male, 83% HLA-B27+, mean age was 41.3 ± 10.8 years, median symptom duration 14 years (IQR 7-24), median CRP levels 13 mg/L (IQR 6-22), and 28% had poor vitamin 25(OH)D3 status (<50) at baseline. 27% of patients switched to a second TNF-α inhibitor during follow-up and disease activity improved significantly during treatment: mean ASDASCRP3.8 ± 0.8 at baseline and 2.1 ± 0.9 after 8 years (P<0.001). At baseline, low BMD at the lumbar spine and hip was present in 34% and 19% patients, respectively. Both LS-BMD and hip BMD Z-scores were significantly improved during TNF-α blocking therapy at all follow-up visits compared to baseline. Significant improvement compared to the previous time point was found up to and including 4 years for the lumbar spine and up to and including 2 years for the hip. Thereafter, flattening of improvement was observed. Median percentage of improvement in absolute BMD after 8 years of TNF-α blocking therapy compared to baseline was 7.1% (IQR 0.8-13.5) for the lumbar spine and 1.6% (IQR -3.5-5.5) for the hip (Figure 1).

Conclusion:

In AS patients with established disease, both lumbar spine and hip BMD improved significantly at group level during 8 years of TNF-α blocking therapy. This effect was most pronounced in the lumbar spine, which corresponds to the disease process in AS. Main improvements in lumbar spine BMD were observed during the first 4 years of treatment.

References:

[1]Beek et al. J Bone Miner Res. 2019; jun;34(6):1041-8

Disclosure of Interests:

Mark Siderius: None declared, Freke Wink Consultant of: Abbvie, Janssen, Anneke Spoorenberg: None declared, Suzanne Arends Grant/research support from: Grant/research support from Pfizer

FRI0300 ARE COPING STRATEGIES, ANXIETY AND DEPRESSION ASSOCIATED WITH DAILY PHYSICAL ACTIVITY IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS?

Background:

Patients with axial spondyloarthritis (axSpA) who are more physically active experience less pain and better physical functioning.1Psychological factors such as anxiety and depression are associated with physical functioning and reduction of Quality of Life (QoL).2Furthermore, evasive coping strategies are commonly used in health-related coping.3However, as far as we know, no data is available regarding the influence of coping strategies, anxiety and depression on daily physical activity in axSpA.

Objectives:

To determine if coping strategies, anxiety and depression are associated with daily physical activity in patients with axSpA.

Methods:

Consecutive outpatients from the Groningen Leeuwarden AxSpA cohort (GLAS) participated in this study. Additionally to the standardized follow-up assessments, patients filled out the axSpA-Short Questionnaire to assess health-enhancing physical activity (axSpA-SQUASH), the Coping with Rheumatic Stressors (CORS) and the Hospital Anxiety and Depression Scale (HADS). Univariable and multivariable linear regression analyses were performed to explore associations of copings strategies, anxiety and depression, and patient- and disease related factors with daily physical activity. Additionally, patients were stratified into three tertiles of physical activity: low, intermediate and high. To identify group differences, Kruskal-Wallis test or Chi-Square test were used with post-hoc testing.

Results:

In total 85 patients were included; 59% were male, mean age was 49±14, median symptom duration 19.5 years (IQR 12.0-31.0), 71% were HLA-B27 positive and mean ASDAS was 2.1±1.0. Median axSpA-SQUASH total physical activity score was 9406.3 (IQR 5538.8–12081.3). Median scores of HADS-Anxiety (scale 7-28) and HADS-Depression (scale 7-28) were scores of 12 (IQR 10.0-14.0) and 10(IQR 9.0-12.5). The mostly frequently used coping strategie was comforting cognitions (for pain, range 9-36); median of 25.5 (IQR 22.0-28.0).

Univariable analysis showed that lower daily physical activity was significantly associated with gender (female), higher disease activity (BASDAI), worse physical function (BASFI), worse quality of life (ASQoL), coping strategies ‘decreasing activities’ and ‘pacing’, higher depression score (HADS) and higher perceived influence of axSpA on general well-being. In multivariable analysis, only the coping strategy “decreasing activity” was independently associated with physical activity (β: -419.3, R2: 0.155, P<0.001). Additionally, patients in the highest physical activity tertile were significantly more often male, had higher working status, lower BASDAI and ASDAS, better BASFI and ASQoL and scored lower on the coping strategy “decreasing activities”.

Conclusion:

In this cross-sectional study in axSpA patients with established disease, multiple patient and disease related factors were associated with daily physical activity. The evasive coping strategy ‘decreasing activities’ was the only independently associated factor. These findings suggest that to improve daily physical activity in axSpA patients attention should be paid not only on targeting disease activity, but also to other patient and disease related aspects, especially coping strategies used.

References:

[1]Regel A et al.RMD Open. 2017;3(1):e000397.

[2]Kilic G et al.Med (United States). 2014;93(29):e337.

[3]Peláez-Ballestas I et al.Med (United States). 2015;94(10):e600.

Acknowledgments:

The authors would like to thank all patients who participated in the GLAS cohort.

Disclosure of Interests:

Marlies Carbo: None declared, Laura Overbeeke: None declared, Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Yvo Kamsma: None declared, Freke Wink Consultant of: Abbvie, Janssen, Davy Paap: None declared, Anneke Spoorenberg: None declared

THU0402 SERUM MARKERS OF BONE RESORPTION, FORMATION, AND MINERALIZATION DURING 8 YEARS OF TNF-Α BLOCKING THERAPY IN PATIENTS WITH ANKYLOSING SPONDYLITIS

Background:

Ankylosing spondylitis (AS) is a chronic inflammatory disease, characterized by both excessive bone formation and bone loss. The bone turnover marker (BTM) bone-specific alkaline phosphatase (BALP) plays a central role in bone mineralization. Our previous study demonstrated that 3 years of TNF-α blocking therapy results in a significant increase in BALP.1However, longer follow-up is needed to investigate whether BALP stays elevated during TNF-α blocking therapy and also to explore the course of other BTM, osteocalcin (OC), procollagen type 1 N-terminal peptide (PINP) and serum type 1 collagen C-telopeptide (sCTX) in AS.

Objectives:

To evaluate serum markers of bone resorption, formation, and mineralization during 8 years of TNF-α blocking therapy in AS patients.

Methods:

Included were consecutive AS outpatients from the University Medical Center Groningen (UMCG) attending the Groningen-Leeuwarden Axial SpA (GLAS) cohort and who were treated with a maximum of 2 TNF-α blockers for at least 8 years. Patients were excluded when they used bisphosphonates at baseline or during follow-up. Data for a specific visit was coded as missing when patients either had experienced a fracture or received systemic corticosteroids within 1 year of that particular visit. Clinical and laboratory measurements were performed at baseline (before start of TNF-α blocking therapy), 3 and 6 months as well as 1, 2, 4, 6 and 8 years. Markers of bone formation OC, PINP and BALP, and marker of bone resorption sCTX were measured in serum. Z-scores of BTM were calculated using matched 10-years-cohorts of a Dutch reference group to correct for the normal influence that age and gender have on bone turnover. Serum levels of 25-hydroxyvitamin D (25(OH)D3) were assessed yearly. Generalized estimating equations were used to analyze BTM Z-scores over time within patients. Simple contrast was used to compare follow-up visits to baseline. P-values <0.05 were considered statistically significant.

Results:

In total, 37 AS patients were analyzed; 62% were male, 86% HLA-B27+, mean age was 38.6 ± 10.4 years, median symptom duration 14 years (IQR 10-25), median CRP 13 mg/L (IQR 6-25), and 30% had low vitamin 25(OH)D3 status (<50) at baseline. 35% of patients switched to a second TNF-α inhibitor during follow-up. ASDASCRPimproved significantly during treatment, from mean 3.8 ± 0.9 at baseline to 1.9 ± 0.9 after 8 years of follow-up (P<0.001). 25(OH)D3 levels were stable at group level, median 58 nmol/L (IQR 45-70) at baseline and 60 nmol/L (IQR 50-70) after 8 years. Bone regulation marker OC Z-score was found to be significantly increased only after 3 months of TNF-α blocking therapy compared to baseline. No significant changes during follow-up were found for collagen resorption marker sCTX Z-score. Collagen formation marker PINP Z-score was significantly increased after 3 and 6 months as well as 2 years of TNF-α blocking therapy. Bone mineralization marker BALP Z-score was significantly increased at all time points up to and including 2 years and returned to baseline levels during 4 to 8 years of TNF-α blocking therapy (Figure 1).

Conclusion:

In this subgroup of AS patients with established and active disease responding to TNF-α blocking therapy, we observed that the bone turnover balance favored bone formation during the first years of TNF-α blocking therapy, which corresponds to previously reported improvement in bone mineral density, especially at the lumbar spine.1New finding of our study is that after 8 years of treatment, markers of bone resorption, formation, and mineralization were all comparable to baseline values.

References:

[1]Arends et al. Arthritis Res Ther. 2012;14(2):R98

Disclosure of Interests: :

Mark Siderius: None declared, Anneke Spoorenberg: None declared, Suzanne Arends Grant/research support from: Grant/research support from Pfizer

OP0162 ABATACEPT TREATMENT FOR PATIENTS WITH EARLY ACTIVE PRIMARY SJÖGREN’S SYNDROME: OPEN-LABEL EXTENSION PHASE OF A RANDOMIZED CONTROLLED PHASE III TRIAL

Background:

Abatacept (CTLA-4-Ig) targets the CD80/CD86:CD28 co-stimulatory pathway required for full T-cell activation and T-cell dependent activation of B-cells. The Abatacept Sjögren Active Patients phase III (ASAPIII) trial is a mono-center, investigator-initiated, placebo controlled study with an open-label extension phase (NCT02067910), which assessed the efficacy and safety of weekly subcutaneous abatacept (125mg) in patients with early active primary Sjögren’s syndrome (pSS). Previous analyses of the double blind phase showed no significant effect of abatacept treatment compared to placebo on the primary endpoint, difference in EULAR Sjögren’s syndrome disease activity index (ESSDAI) at week 24.1

Objectives:

To evaluate the efficacy and safety of extended (48 weeks) open label abatacept treatment in pSS patients.

Methods:

Included patients had biopsy-proven pSS, fulfilled the AECG and ACR-EULAR criteria, had disease duration ≤7 years (median 2 years), ESSDAI ≥5, and 89% were anti–SSA positive. All 40 patients who received abatacept (ABA) in week 0-24 were subsequently treated with abatacept from week 24-48. Of the 40 patients who received placebo (PLB) in week 0-24, 2 were lost to follow up, and 38 were treated with abatacept from week 24-48. Systemic disease activity (ESSDAI), patient reported symptoms (ESSPRI), serological outcomes (RF and IgG), ocular staining score (OSS) and unstimulated whole salivary flow (UWS) were assessed. We evaluated whether outcomes improved within treatment groups, from week 0 to subsequent visits and from week 24 to subsequent visits:

GEE modeling was used to test significance of changes over time. Missing data were not imputed.

Results:

ESSDAI and ESSPRI were improved within ABA/ABA patients between week 0-48 with additional efficacy after week 24, and within PLB/ABA patients after switching to ABA. Significant decreases in ESSDAI and ESSPRI were also seen within PLB treated patients between week 0-24 (Figure 1). IgG and RF were improved within ABA/ABA patients between week 0-48 with additional efficacy after week 24, and within PLB/ABA patients after switching to ABA. OSS was improved within ABA/ABA treated patients between week 0-48. UWS only showed significant improvement in week 36 within ABA/ABA treated patients. No changes in IgG, RF, OSS or UWS were seen within PLB treated patients. No deaths occurred. One serious adverse event possibly related to intervention occurred during ABA treatment.

Conclusion:

ESSDAI and ESSPRI improved significantly during 48-week treatment with abatacept. Placebo treated patients also showed significant improvement in both indices and further improvement occurred after switching to abatacept. Biological activity was decreased by abatacept treatment. 48-week abatacept treatment improved OSS, and might improve UWS. Abatacept was well tolerated by pSS patients.

References:

[1]van Nimwegen et al. Lancet Rheumatol.Published online 31-01-2020

Acknowledgments:

This study was funded by Bristol-Myers Squibb. We thank all patients for participation in the ASAP-III trial.

Disclosure of Interests:

Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Jolien F. van Nimwegen Consultant of: Bristol-Myers Squibb, Speakers bureau: Bristol-Myers Squibb, Esther Mossel: None declared, Greetje S. van Zuiden Speakers bureau: Roche, Konstantina Delli: None declared, Alja J. Stel: None declared, Bert van der Vegt Consultant of: Advisory board member for Philips and Visiopharm., Erlin A. Haacke: None declared, Lisette Olie: None declared, Leoni Los: None declared, Gwenny M. Verstappen: None declared, Sarah A. Pringle: None declared, Fred K.L. Spijkervet: None declared, Frans G.M. Kroese Grant/research support from: Unrestricted grant from Bristol-Myers Squibb, Consultant of: Consultant for Bristol-Myers Squibb, Speakers bureau: Speaker for Bristol-Myers Squibb, Roche and Janssen-Cilag, Arjan Vissink: None declared, Hendrika Bootsma Grant/research support from: Unrestricted grants from Bristol-Myers Squibb and Roche, Consultant of: Consultant for Bristol-Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Speakers bureau: Speaker for Bristol-Myers Squibb and Novartis.

AB0662 TREATMENT AND FOLLOW-UP OF AXIAL SPONDYLOARTHRITIS IN DAILY CLINICAL PRACTICE - A SURVEY AMONG DUTCH RHEUMATOLOGISTS

Background:

ASAS-EULAR have developed management recommendations for axial spondyloarthritis (axSpA) to provide guidance to the management of patients with axSpA1. However, there is limited insight into how rheumatologists treat axSpA patients in daily clinical practice and if these recommendations are used.

Objectives:

To get insight into the management of axSpA patients in daily practice in the Netherlands.

Methods:

We performed a survey among rheumatologists in the Netherlands with 21 multiple choice questions; 5 general questions on characteristics of their practice and 16 questions addressing treatment and follow-up of axSpA patients in daily practice. The questionnaire was taken during structured face-to-face interviews by employees of the medical department of Novartis NL Rheumatologists in the Netherlands were invited to participate, aiming to get a sample of rheumatologists varying in geographical location and hospital type, as well as a mix of SpA-experts and non-SpA-experts. Rheumatologists gave approval for anonymous use of the data, which were entered in a database and analyzed using descriptive statistics.

Results:

Between October 15 2019 and January 16 2020, 36 rheumatologists participated; 6 from university hospitals, 27 from general hospitals and 3 from private care centers.

81% of the rheumatologists referred most of their axSpA patients (76-100%) after diagnosis for information and education concerning axSpA, exercise and lifestyle to a specialized nurse practitioner. Furthermore, 53% of rheumatologists referred most of their axSpA patients (76-100%) to a physiotherapist for exercise therapy. At diagnosis, approximately 55% of axSpA patients used the daily maximum dose of NSAIDs, compared to 25% for patients on biological treatment.

The reported level of importance of different axSpA related aspects for starting a biological was largely similar for AS and nr-axSpA, although some differences could be observed (Figure 1): Most rheumatologists graded insufficient response to 2 NSAIDs during 4 weeks (94% for AS and 92% for nr-AxSpA) and bone marrow edema on MRI (75% and 89%) as important for starting a biological. About 60% of rheumatologists considered active disease using ASDAS/BASDAI important for the decision to start a biological, which was similar to the importance of the level of pain. For nr-axSpA, more rheumatologists graded elevated CRP and bone marrow edema on MRI as important for starting a biological, than for AS.

Most rheumatologists (67%) do not base a decision that a biological is ineffective on ASDAS or BASDAI. To assess disease activity in axSpA, 86% of the rheumatologists always measured C-reactive protein (CRP), compared to 42% and 31% for BASDAI and ASDAS, respectively. 77% of rheumatologists reported to follow the 2016 ASAS-EULAR treatment recommendations for axSpA for treatment and follow-up of axSpA patients.

Conclusion:

This survey among Dutch rheumatologists suggests that ASDAS and BASDAI are as important for starting a biological in axSpA as is the level of pain. Moreover, in contrast to ASAS-EULAR treatment recommendations, most rheumatologists do not use validated disease activity instruments to assess biological ineffectiveness, which may be a topic for increasing awareness and education.

References:

[1]Van der Heijde D et al, Ann Rheum Dis 2017;76:978-91.

Acknowledgments:

We would like to thank all participating rheumatologists.

Disclosure of Interests:

Anneke Spoorenberg: None declared, Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Reindert Bruin Employee of: Current employee of Novartis Pharma B.V., Marjolein de Hair Employee of: Current employee of Novartis Pharma B.V.

FRI0568 MEASURING DAILY PHYSICAL ACTIVITY IN AXSPA PATIENTS: CONTENT VALIDITY AND MEASUREMENT PROPERTIES OF THE NEW AXSPA-SQUASH

Background:

The ASAS-EULAR recommendations for management of axial Spondyloarthritis (axSpA) includes that patients should be encouraged to exercise.1So far, there is no validated instrument for measuring daily physical activity in axSpA. Our previous study recommends to adapt the Short QUestionnaire to Assess Health-enhancing physical activity (SQUASH) to improve the validity in axSpA patients.2

Objectives:

AxSpA-disease specific adaptation of the physical activity questionnaire SQUASH to improve content validity and measurement properties.

Methods:

This study was conducted according to the OMERACT-filter within the Groningen Leeuwarden AxSpA (GLAS) cohort and was performed in two parts. Part 1: adaptation and evaluation of content validity using a qualitative stepwise approach with in-depth interviews with different healthcare professionals (n=9) and patients (n=8), field testing in patients (n=10), and consensus meeting for final adaptations. Thereafter, content validity (n=45) was tested by filling out axSpA-SQUASH and SQUASH in random order two weeks apart. Part 2: measurement properties were tested using the International Physical Activity Questionnaire (IPAQ) as comparator. Criterion validity (n=40): Spearman’s correlation with accelerometer as golden standard and classification accuracy of intensity. Construct validity (n=106): Spearman’s correlation with disease activity, physical functioning and quality of life as clinical outcome with expected fair to moderated associations. Test-retest reliability (n=45): intraclass correlation coefficients (ICC) after 2 weeks. Responsiveness (n=47): standardized response mean (SRM) after 3 months stratified by Ancor method.

Results:

In total 156 patients were included: mean age 48±13 years, 56% males, 72% HLA-B27 positive, symptom duration 21±13.3 years and ASDAS 2.0±1.0. Part 1: main adaptations were better explanation of intensities, adding answer option “not applicable”, examples were modernized, physiotherapy and activity “shopping” were added. Compared to the original SQUASH, the adapted axSpA-SQUASH measured a systematically higher activity count and had less missing values (8% vs. 32%). Part 2: criterion validity: axSpA-SQUASH correlated better with accelerometer compared to IPAQ (ρ=0.51 vs. ρ=0.35). Classification accuracy: accelerometer defined most activity as light (97%), whereas axSpA-SQUASH and IPAQ defined most activity as moderate intensity (55% and 62% resp.). Construct validity: correlations were low to moderate and strongest for axSpA-SQUASH compared to IPAQ. Construct validity: correlations were low to moderate and stronger for axSpA-SQUASH compared to IPAQ (BASDAI -0.27 vs -0.15, BASDAI –0.27 vs. -0.15, ASDAS -0.24 vs -0.09, BASFI -0.39vs. -0.21, ASQoL -0.39 vs. -0.35). Test-retest reliability: ICC axSpA-SQUASH: 0.80. Responsiveness: axSpA-SQUASH changed over time in the corresponding direction (Table 1). Feasibility: considered comprehensible and average completion time was 7 minutes.

Table 1.

Responsiveness of the axSpA-SQUASH versus change in BASDAI

SRM95% CIBASDAI T1BASDAI T2Improved (n=12)-0.36-0.99 to 0.285.01 (2.10)3.93 (1.60)Stable (n=21)0.28-0.18 to 0.733.76 (2.05)3.76 (2.05)Decreased (n=14)0.750.18 to 1.334.71 (1.96)5.79 (2.42)

Conclusion:

The new axSpA-SQUASH resulted in improved content validity and measurement properties. It seems the most appropriate questionnaire and can be used to assess daily physical activity in patients with axSpA.

References:

[1] Van Der Heijde D et al.Ann Rheum Dis. 2017;76:978-91.

[2] Arends S et al.Arthritis Res Ther. 2013;15:R99.

Acknowledgments:

We thank the ASAS for the reserch grant that supported this work.

Disclosure of Interests:

Marlies Carbo: None declared, Davy Paap: None declared, Fiona Maas: None declared, Anna Jetske Baron: None declared, Laura van Overbeeke: None declared, Mark Siderius: None declared, Freke Wink Consultant of: Abbvie, Janssen, Hendrika Bootsma Grant/research support from: Unrestricted grants from Bristol-Myers Squibb and Roche, Consultant of: Consultant for Bristol-Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Speakers bureau: Speaker for Bristol-Myers Squibb and Novartis., Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Anneke Spoorenberg: None declared

OP0080 CENTRAL SENSITIZATION AND ILLNESS PERCEPTIONS SHOULD BE TAKEN INTO ACCOUNT WHEN INTERPRETING DISEASE ACTIVITY IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background:

Up to 40% of ankylosing spondylitis patients report persistently high pain scores of >4 (scale of 0-10) even after responding to long-term TNF-alpha blocking therapy.[1] In other rheumatic diseases, nociplastic pain (due to altered functioning of the nervous system leading to peripheral and central sensitization) is common.[2] In axial spondyloarthritis (axSpA), patient illness and pain perceptions were shown to influence disease outcome.[3] Therefore, we hypothesized that central sensitization and patients’ illness perceptions are associated with persistently high disease activity in axSpA.

Objectives:

To investigate to what extent central sensitization, pain catastrophizing and patients’ perceptions play a role in axSpA and to explore associations with disease activity.

Methods:

Between April and September 2019, consecutive outpatients from the Groningen Leeuwarden axSpA (GLAS) cohort,[4] an ongoing large prospective cohort, were included in this study. Besides the standardized assessments, patients filled out three additional questionnaires: Central Sensitization Inventory (CSI), Pain Catastrophizing Scale (PCS) and Revised Illness Perception Questionnaire (IPQ-R). Univariable and multivariable linear regression analyses were used to investigate the association of CSI, PCS and each of the eight subscales of the IPQ-R, and disease activity assessments ASDAS-CRP, BASDAI, and CRP. We corrected for the following potential confounders: gender, symptom duration, BMI, educational level, smoking status and HLA-B27 status.

Results:

Of 171 included patients, 58% were male, 79% were HLA-B27 positive, median symptom duration was 21 (IQR 10-32), mean ASDAS-CRP 2.1 ± 1.0, mean BASDAI 3.9 ± 2.2 and median CRP 2.9 (IQR 1.2-6.3). Mean CSI score was 37.8 ± 14.1 (scale of 0-100), and 44% of patients scored ≥40 on the CSI.[5] Median PCS score was 15 (IQR 7-22) (scale of 0-52), median IPQ-R illness identity subscore 3 (IQR 2-4) (scale of 0-14) and mean IPQ-R treatment control subscore 18.1 ± 3.4 (scale of 5-25). In univariable regression analysis, CSI and PCS scores and IPQ-R subscores all showed significant associations with ASDAS-CRP, and all except the IPQ-R subscale personal control showed significant associations with BASDAI. Only IPQ-R treatment control was significantly associated with CRP. Central sensitization, two IPQ-R subscales (perceived treatment control and the number of symptoms patients attributed to their axSpA: illness identity) and BMI were independently associated with disease activity assessments BASDAI (R2=0.46) and ASDAS-CRP (R2=0.36) (Figure 1).

Conclusion:

In this axSpA population with long-term disease, 44% scored above the CSI cutoff point of 40, indicating a high probability of central sensitization. CSI score, illness identity and treatment control were independently associated with disease activity assessments.

References:

[1]Arends Set al.Clin Exp Rheumatol 2017;35(1):61-8.

[2]Meeus Met al.Semin Arthritis Rheum 2012;41(4):556-67.

[3]Van Lunteren Met al. Arthritis Care Res (Hoboken) 2018;70(12):1829-39.

[4]Arends Set al.Arthritis Res Ther 2011;13(3):R94.

[5]Neblett Ret al.J Pain 2013;14(5):438-45.

Disclosure of Interests:

Stan Kieskamp: None declared, Davy Paap: None declared, Marlies Carbo: None declared, Freke Wink Consultant of: Abbvie, Janssen, Reinhard Bos: None declared, Hendrika Bootsma Grant/research support from: Unrestricted grants from Bristol-Myers Squibb and Roche, Consultant of: Consultant for Bristol-Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Speakers bureau: Speaker for Bristol-Myers Squibb and Novartis., Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Anneke Spoorenberg: None declared

SAT0392 DIAGNOSIS OF AXIAL SPONDYLOARTHRITIS IN DAILY CLINICAL PRACTICE – A SURVEY AMONG DUTCH RHEUMATOLOGISTS

Background:

Since publication of the ASAS classification criteria for axial spondyloarthritis (axSpA) in 20091and the development of ASAS-endorsed recommendation for early referral of patients with a suspicion of axSpA,2awareness for non-radiographic (nr-) axSpA besides Ankylosing Spondylitis (AS) has increased. Still there is limited information of how nr-AxSpA is addressed in daily clinical practice.

Objectives:

To get insight into the diagnostic phase of axSpA in daily rheumatologic practice in the Netherlands, and to explore if nr-axSpA is addressed differently from AS.

Methods:

We set up a 21 multiple choice question survey for rheumatologists in the Netherlands with 5 general questions about their practice and 16 questions addressing the diagnostic phase of axSpA. The questionnaire was taken by representatives of the medical department of Novartis NL during structured face-to-face interviews. Rheumatologists in the Netherlands were invited to participate, aiming to get a sample of rheumatologists varying in geographical location and hospital type, as well as a mix of SpA-experts and non-SpA-experts. Rheumatologists gave approval for anonymous use of the data, which were entered in a database and subsequently analyzed using descriptive statistics.

Results:

From October 15th2019 until January 16th2020, 36 Dutch rheumatologists participated in the face-to-face survey; 6 from university hospitals, 27 from general hospitals and 3 from private care centers. Most of axSpA patients (61%) were referred by the general practitioner and mean time between referral and first visit was 2-6 weeks. More than 50% of rheumatologists reported a mean symptom duration of >1 year and in 30% even >2 years before first visit. For diagnosing axSpA rheumatologists performed in almost all cases X-pelvis (mean 100% (SD 0%) for both AS and nr-axSpA), CRP/ESR (91% (26%) for AS; 94% (22%) for nr-axSpA) and HLA-B27 (74% (40%) for AS; 86% (26%) for nr-axSpA. MRI of the SI joints was performed in 31% and 82% of patients, respectively, and about 60% of the rheumatologists used of classification criteria for diagnosing axSpA. In addition, rheumatologists marked the level of importance of several (SpA) clinical features for making the diagnosis AS or nr-axSpA (Figure 1). Most rheumatologists graded inflammatory back pain, arthritis/enthesitis/dactylits and uveitis as very important for contributing to the diagnosis. Functional impairment of the spine and male sex were mostly graded neutral or not important for making a diagnosis of axSpA. All features were graded of similar importance for the diagnosis AS and nr-axSpA, except for backpain starting before the age of 45, which was considered more important for diagnosing AS.

Conclusion:

This survey among Dutch rheumatologists showed that in 30% of patients referred with possible suspicion of axSpA, symptom duration still was >2 years. Almost 60% of rheumatologists make use of the ASAS classification criteria for diagnosing nr-axSpA. Therefore, for early referral awareness of axSpA in first line should enhance. Furthermore, rheumatologists should become aware that classification criteria are not similar to diagnostic criteria and cannot be used as a tick box for diagnosis.

References:

[1]Rudwaleit M et al, Ann Rheum Dis 2009;68:777-83, 2. Poddubnyy D et al, Ann Rheum Dis 2015;74:1483–7

Acknowledgments:

We would like to thank all participating rheumatologists.

Disclosure of Interests:

Anneke Spoorenberg: None declared, Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Mark Sinnige Employee of: Current employee of Novartis Pharma B.V., Marjolein de Hair Employee of: Current employee of Novartis Pharma B.V.

Meralgia paresthetica: Nerve stimulator-guided injection with methylprednisolone/lidocaine, a double-blind randomized placebo-controlled study

BACKGROUND

Meralgia paresthetica is a mononeuropathy of the lateral femoral cutaneous nerve. A common therapy is injection with corticosteroids. The goal of this study was to analyze the effect of injection with methylprednisolone/lidocaine vs placebo.

METHODS

After randomization, 10 patients received a nerve stimulator-guided injection with methylprednisolone/lidocaine, and 10 patients received saline. The primary outcome measure was pain (visual analogue scale, VAS).

RESULTS

In the placebo group, there was a significant pain reduction (baseline VAS, 6.8; VAS week 12, 4.3; P = .014). The VAS score in the methylprednisolone group did not show a significant reduction (baseline VAS, 7.4; VAS week 12, 4.8; P = .053). There was no significant difference in pain reduction between the groups.

CONCLUSIONS

We found no objective evidence for benefit from nerve stimulator-guided injection with corticosteroids in meralgia paresthetica, although this study is limited by a small sample size. Future placebo-controlled studies using ultrasound-guided injection are warranted.