Reciprocal modulation of responses to nitrate starvation and hypoxia in roots and leaves of Arabidopsis thaliana

The flooding of agricultural land leads to hypoxia and nitrate leaching. While understanding the plant's response to these conditions is essential for crop improvement, the effect of extended nitrate limitation on subsequent hypoxia has not been studied in an organ-specific manner. We cultivated Arabidopsis thaliana without nitrate for 1 week before inducing hypoxia by bubbling the hydroponic solution with nitrogen gas for 16 h. In the roots, the transcripts of two transcription factor genes (HRA1, HRE2) and three genes involved in fermentation (SUS4, PDC1, ADH1) were ~10- to 100-fold upregulated by simultaneous hypoxia and nitrate starvation compared to the control condition (replete nitrate and oxygen). In contrast, this hypoxic upregulation was ~5 to 10 times stronger when nitrate was available. The phytoglobin genes PGB1 and PGB2, involved in nitric oxide (NO) scavenging, were massively downregulated by nitrate starvation (~1000-fold and 105-fold, respectively), but only under ambient oxygen levels; this was reflected in a 2.5-fold increase in NO concentration. In the leaves, HRA1, SUS4, and RAP2.3 were upregulated ~20-fold by hypoxia under nitrate starvation, whereas this upregulation was virtually absent in the presence of nitrate. Our results highlight that the plant's responses to nitrate starvation and hypoxia can influence each other.

Beliefs about medicines in gout patients: results from the NOR-Gout 2-year study

OBJECTIVE

Adherence to urate-lowering therapy (ULT) in gout is challenging. This longitudinal study aimed to determine 2 year changes in beliefs about medicines during intervention with ULT.

METHOD

Patients with a recent gout flare and increased serum urate received a nurse-led ULT intervention with tight control visits and a treatment target. Frequent visits at baseline and 1, 2, 3, 6, 9, 12, and 24 months included the Beliefs about Medicines Questionnaire (BMQ), and demographic and clinical variables. The BMQ subscales on necessity, concerns, overuse, harm, and the necessity-concerns differential were calculated as a measure of whether the patient perceived that necessity outweighed concerns.

RESULTS

The mean serum urate reduced from 500 mmol/L at baseline to 324 mmol/L at year 2. At years 1 and 2, 85.5% and 78.6% of patients, respectively, were at treatment target. The 2 year mean ± sd BMQ scores increased for the necessity subscale from 17.0 ± 4.4 to 18.9 ± 3.6 (p < 0.001) and decreased for the concerns subscale from 13.4 ± 4.9 to 12.5 ± 2.7 (p = 0.001). The necessity-concerns differential increased from 3.52 to 6.58 (p < 0.001), with a positive change independent of patients achieving treatment targets at 1 or 2 years. BMQ scores were not significantly related to treatment outcomes 1 or 2 years later, and achieving treatment targets did not lead to higher BMQ scores.

CONCLUSION

Patient beliefs about medicines improved gradually over 2 years, with increased beliefs in the necessity of medication and reduced concerns, but this improvement was unrelated to better outcomes.

TRIAL REGISTRATION

ACTRN12618001372279.

Fluctuation and change of serum urate levels and flares in gout: results from the NOR-Gout study

A gout attack may evolve after a purine-rich diet or alcohol and after starting urate-lowering therapy (ULT). The relationships between fluctuation and change in serum urate (SU) with the occurrence of flares were investigated in this study. In the prospective NOR-Gout study, gout patients with increased SU and a recent flare were treated to target with ULT over 1 year, with follow-up at year 2 with SU and flare as outcomes. SU and flares were assessed at both monthly and 3-monthly intervals until target SU was reached. Fluctuation over periods and changes in SU between two time points were assessed and compared in patients with and without flares. At year 1, 186 patients completed follow-up (88.2%) and 173 (82.0%) at year 2. Mean age (SD) at baseline was 56.4 (13.7) years, disease duration was 7.8 (7.6) years, and 95.3% were men. The first-year SU fluctuation and change were related to flare occurrence during year 1 (both p < 0.05). High fluctuation with an absolute sum of all SU changes during the first 9 months was related to flares over 3-month periods (all p < 0.05), and high fluctuation during the first 3 months was related to flares in months 3-6 (p = 0.04). Monthly and high SU changes or again reaching higher SU levels > 360 µmol/l were not related to flares. Fluctuation and change in SU were related to flare occurrence during the first year of ULT, while changes between visits and reaching SU levels > 360 µmol/L were not related to flares. Key Points • Urate-lowering therapy seeks to achieve a treatment target and prevent gout flares, and changes in serum urate are related to gout flares. • Fluctuation and changes in serum urate were associated with gout flares, suggesting that fluctuation in serum urate is unfavourable during gout treatment. • During urate-lowering therapy in gout in clinical practice, fluctuation of serum urate, for example, due to lack of adherence, should be observed and avoided.

POS0516 PLASMA CALPROTECTIN WAS ASSESSED IN MULTIPLE BIOLOGICAL TREATMENT STRATEGIES FOR EARLY RHEUMATOID ARTHRITIS

Background

Plasma calprotectin is a sensitive inflammatory marker in patients with rheumatoid arthritis (RA) and reflects activation of granulocytes and macrophages. Plasma calprotectin has not previously been studied in a head-to-head trial of multiple biological mechanisms of action versus active conventional therapy (ACT) with methotrexate and prednisolone.

Objectives

To assess the effect of treatment on plasma calprotectin levels in patients with early RA by determining the 24-week change in the four arms of the NORD-STAR Study, a large multicenter randomized head-to-head clinical trial of ACT versus tumor necrosis factor inhibition, T-cell co-stimulation inhibition, and interleukin-6 inhibition (1).

Methods

Calprotectin was analyzed in plasma samples at baseline, week 4 and week 24 from 400 treatment naïve patients with early RA in the NORD-STAR Study. Samples were analyzed using a calprotectin ELISA alkaline phosphatase (ALP) kit from CalproLab (Oslo, Norway) in a Dynex DS2 processing system (normal levels <910 µg/L). Patients were assessed by clinical (CRP, 28 SJC/TJC, physician global) and patients’ reported assessments. Crude and adjusted linear regression analyses were performed in R 4.0.3 with calprotectin levels at week 24 as the outcome. The four arms were represented by three dummy variables. The adjustment variables were age, sex, anti-CCP status and country. Both analyses were adjusted for baseline calprotectin levels.

Results

At baseline, the mean time since diagnosis was 15.7 days (SD) (22.9), mean age 53.7 (15.0) years, ACPA positive 81%, and female 66%. Mean calprotectin levels were 1931 (1495) µg/L at baseline, 866 (951) µg/L at week 4, and 629 (661) µg/L at week 24. At baseline, normal calprotectin levels (<910 µg/L) were observed in 27% of all patients (ACT 22%, certolizumab-pegol and methotrexate 30%, abatacept and methotrexate 25%, tocilizumab and methotrexate 31%). At week 24, normal calprotectin levels were observed in 82% of all patients (ACT 68%, certolizumab-pegol and methotrexate 91%, abatacept and methotrexate 80%, tocilizumab and methotrexate 90%).

Observed calprotectin levels at week 24 were significantly lower in patients treated with certolizumab-pegol and methotrexate -336µg/L (97) (p< 0.006) or tocilizumab and methotrexate -284 (99) (p < 0.004), versus ACT when adjusted for age, sex, anti-CCP status, baseline calprotectin level, and country; however, a significant difference was not observed in patients treated with abatacept and methotrexate -110 (96) (p = 0.25). The Figure 1 shows the average percentage change in calprotectin levels from baseline to week 24 for all treatment groups.

Figure 1.

Average percentage change in calprotectin levels from baseline to week 24. ACT: active conventional therapy, CZP+MTX: certolizumab-pegol and methotrexate, ABA+MTX: abatacept and methotrexate, TCZ+MTX: tocilizumab and methotrexate.

Conclusion

Calprotectin, a sensitive biomarker of inflammation, normalized in the majority of patients. The decline differed between treatment groups and was largest in patients treated with a TNF inhibitor and methotrexate, suggesting that calprotectin reflects the activity of specific inflammatory pathways rather than overall inflammation. The findings of this study should be further explored.

References

[1]Hetland ML, et. al., Active conventional treatment and three different biological treatments in early rheumatoid arthritis: phase IV investigator initiated, randomised, observer blinded clinical trial. BMJ. 2020 Dec 2;371:m4328. doi: 10.1136/bmj.m4328. PMID: 33268527; PMCID: PMC7708829.

Acknowledgements

I would like to acknowledge the NORD-STAR Study group.

Disclosure of Interests

David Stevens: None declared, Marte Heiberg: None declared, Amirhossein Kazemi: None declared, Ronald van Vollenhoven: None declared, Jon Lampa: None declared, Anna Rudin: None declared, Kristina Lend: None declared, Merete Lund Hetland: None declared, Mikkel Østergaard: None declared, Michael Nurmohamed: None declared, Kim Hørslev-Petersen: None declared, Dan Nordström Consultant of: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Björn Gudbjornsson: None declared, Till Uhlig: None declared, Espen A Haavardsholm: None declared, Hilde Berner Hammer Speakers bureau: AbbVie, Novartis, and Lilly.

POS0281 FLUCTUATIONS IN SERUM URATE ARE RELATED TO GOUT FLARES IN THE NOR-Gout STUDY

Background

Urate lowering therapy (ULT) is expected to prevent new gout flares, but flares still do occur during the first year, and could be related to fluctuations in serum urate (SUA), being a result of proinflammatory signals. Knowledge on the relationship between fluctuation in SUA and gout flares is limited.

Objectives

To study how fluctuation in SUA is related to gout flares in the first year of ULT.

Methods

In a prospective observational 2-year study 211 included patients with crystal-proven gout were evaluated for flare frequency. Patients were frequently followed during ULT (allopurinol or febuxostat) with monthly dose escalation until SUA was at target (<360 µmol/L or <300 µmol/L if tophi), and met also for visits at 3, 6, 9, 12 during year 1 and at year 2. Self-reported flares were continuously registered at all study visits.

Fluctuations in SUA were defined with various measures of SUA: a.) sum of changes between all consecutive visits over the whole 2-year period as a global measure, b. SUA change during 3-month visits at year 1 and during year 2. Further, the frequency of patients exceeding SUA changes with threshold >30, >60 and >90 µmol in these periods was calculated.

Fluctuations in SUA were then related to self-reported flares during the same 3-month periods year 1, and the whole years 1 and 2.

Results

Age was 56.4 (SD 13.7) years, 95.3% were males, disease duration 7.8 (SD 7.6) years.

SUA decreased from mean 500 µmol/L at baseline to 311 µmol at 1 year and 324 µmol/L at year 2. Flares were seen in year 1 in 81.2% (155/186) and year 2 26.0% (45/173) of patients.

The total sum of SUA changes over 2 years as a global measure for individual SUA fluctuation was related to flares in all 3-month periods during year 1 (Table 1) and for year 1 overall (Figure 1), but not for year 2.

Table 1.

Flares and fluctuation of serum urate (SUA) measures during defined observation periods.

Flare period (Mths)NSum of all SUA changes (mean)SUA change (mean)>30 µmol/L SUA change (% patients)>60 µmol/L SUA change (% patients)>90 µmol/L SUA change (% patients)0-3Flare +63467*141*88.183.167.8Flare -14838816595.591.580.83-6Flare +91459**1938.828.210.6Flare -1203751739.424.514.96-9Flare +56482*1049.0**25.525.5Flare -1553862626.515.515.59-12Flare +70470*432.216.911.9Flare -116406922.69.46.60-12Flare +155445*19398.094.090.7*Flare -3634516091.786.075.012-24Flare +454111324.411.16.7Flare -1284491425.811.74.7

*P<0.05, **P<0.01 for comparisons +/-Flare

Other measures of SUA fluctuation (SUA change during periods, and exceeding thresholds of change) were generally not related to incidence of flares, neither were sensitivity analyses for incidence of flares in periods succeeding observed SUA fluctuations.

Conclusion

Fluctuation in SUA, defined as the total sum of mean SUA changes between all study visits, was related to gout flares during year1. Our findings support that a pattern of SUA fluctuation is related to gout flares.

Disclosure of Interests

Till Uhlig Speakers bureau: SOBI, Consultant of: Grünenthal, Lars Karoliussen: None declared, Joe Sexton: None declared, Tore K. Kvien Speakers bureau: AbbVie, MSD, UCB, Hospira/Pfizer, Eli-Lilly, Roche, Hikma, Orion, Sanofi, Celltrion, Sandoz, Biogen, Amgen, Egis, Ewopharma, Mylan, Grant/research support from: BMS, Espen Andre Haavardsholm Speakers bureau: Pfizer, UCB, Eli Lilly, Celgene, Janssen-Cilag, AbbVie, Gilead, Fernando Perez-Ruiz Speakers bureau: Algorithm, Alnylam, Astellas, Arthriti, Menarini, NMD, Parexel, Hilde Berner Hammer Speakers bureau: AbbVie, Lilly, Novartis

OP0059 PROFOUND ANTICOAGULANT EFFECTS OF INITIAL ANTIRHEUMATIC TREATMENTS IN EARLY RHEUMATOID ARTHRITIS PATIENTS: A NORD-STAR SPIN-OFF STUDY

Background

Patients with rheumatoid arthritis (RA) are at an increased risk of venous thromboembolism. Thus far, there have not been any comparative studies investigating the effects of initial antirheumatic treatments in (very) early RA patients.

Objectives

To assess the effects of different initial treatments on hemostatic parameters in patients with early RA.

Methods

NORD-STAR is an international, multicentre, open-label, assessor-blinded, phase 4 study where patients with newly diagnosed RA started methotrexate (MTX) and were randomised 1:1:1:1 to a) conventional treatment (either prednisolone tapered to 5mg/day, or sulfasalazine combined with hydroxychloroquine and intra-articular corticosteroids), b) certolizumab pegol, c) abatacept, d) tocilizumab1. This study is a spin-off from the main NORD-STAR study extensively investigating hemostatic system in 24 per protocol consecutive Dutch participants at baseline, 12 weeks and 24 weeks after the start of the treatment. Statistical analysis was done using paired samples t-test in SPSS version 28.

Results

The mean age of investigated patients was 51.8 (± 12.7) years and 58.3% were female. At baseline patients had an average DAS28 score of 4.6 (± 0.9) and had elevated levels of investigated coagulation biomarkers: Factor 1 + 2, fibrinogen, D-dimer and parameters of the two global hemostatic assays, i.e. endogenous thrombin potential (ETP) and overall hemostasis potential (OHP). These biomarkers decreased significantly at 12 and 24 weeks in patients in all groups (Table 1). Overall fibrinolytic potential (OFP) was decreased and clot lysis time (CLT) was prolonged at baseline, demonstrating impaired fibrinolytic activity in early RA. The reduction of coagulation parameters was significantly higher in biological treatment arms in comparison to the standard MTX treatment arm. In addition, tocilizumab was more effective compared to certolizumab and abatacept, (Figure 1), which was expected considering the direct inhibitory effect of this drug on the IL-6 synthesis and consequently the coagulation activation as well. After 24 weeks of treatment with methotrexate and tocilizumab, the average fibrinogen of patients was reduced by 63% vs 31% and 36% in the certolizumab and abatacept groups, respectively. The changes in DAS-28 and the changes in fibrinogen had a correlation of 0.385 which did not reach statistical significance.

Table 1.

Measurements are marked with * if p<0.05, ** if p<0.01 and *** if p<0.001

BaselineW12W24Factor 1 + 2 (pmol/L)270.25 (149.4)190.36 (108.6)**179.52 (85.3)***Fibrinogen (g/L)4.64 (1.5)3.61 (1.6)**2.63 (1.2)***D-dimer (mg/L)2.17 (3.0)0.33 (0.23)**0.29 (0.2)**OHP (Abs-sum)157.38 (64.9)120.62 (68.7)*100.49 (53.8)***OCP (Abs-sum)369.52 (58.8)305.04 (101.7)*275.91 (83.1)***OFP (%)57.97 (13.1)63.20 (12.7)*65.25 (11.4)***Lag time (s)304.5 (71.1)306.8 (71.8)312.7 (65.4)Slope0.07 (0.02)0.066 (0.03)0.094 (0.12)Max Abs1.17 (0.3)1.00 (0.4)*0.91 (0.3)**CLT (s)1405 (356)1317 (377)1231 (320)**ETP (nM*min)1480 (471)1395 (395)*1337 (429)*Peak (nM)231 (78)223 (68)223 (74)Lagtime (min)4.06 (2.1)3.28 (1.2)**2.87 (1.0)***ttPeak (min)7.40 (2.2)6.61 (1.5)*6.13 (1.4)**Figure 1.

Conclusion

Our results indicate an enhanced coagulation and fibrinolytic impairment in newly diagnosed RA patients. Effective antirheumatic treatments reduce this hemostatic imbalance, with significantly more pronounced effects of biologic drugs compared to conventional (MTX+glucocorticoids) treatment.

References

[1]Hetland M et al. BMJ. 2020

Disclosure of Interests

Bas Dijkshoorn: None declared, Aleksandra Antovic: None declared, Daisy Vedder: None declared, Anna Rudin: None declared, Dan Nordström Speakers bureau: Novartis, UCB, Consultant of: Abbvie, BMS, Lilly, Novartis, Pfizer, Roche, UCB, Björn Gudbjornsson Speakers bureau: Amgen and Novartis - not related to this work, Consultant of: Novartis - not related to this work, Kristina Lend: None declared, Till Uhlig Speakers bureau: Grünenthal, Novartis, Consultant of: Grünenthal, Novartis, Grant/research support from: NORDFORSK, Espen A Haavardsholm Consultant of: Pfizer, AbbVie, Celgene, Novartis, Janssen, Gilead, Eli-Lilly, UCB, Grant/research support from: NORDFORSK, Norwegian Regional Health Authorities, South-Eastern Norway Regional Health Authority, Gerdur Gröndal: None declared, Merete Lund Hetland Consultant of: Abbvie, Biogen, BMS, Celltrion, Eli Lilly, Janssen Biologics B.V, Lundbeck Fonden, MSD, Pfizer, Roche, Samsung Biopies, Sandoz, Novartis, Grant/research support from: Abbvie, Biogen, BMS, Celltrion, Eli Lilly, Janssen Biologics B.V, Lundbeck Fonden, MSD, Pfizer, Roche, Samsung Biopies, Sandoz, Novartis, Marte Heiberg: None declared, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Celgene, Eli-Lilly, Galapagos, Gilead, Janssen, Merck, Novartis, Orion, Pfizer, Roche and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, Amgen, BMS, Merck, Celgene and Novartis, Kim Hørslev-Petersen: None declared, Jon Lampa Speakers bureau: Pfizer, Janssen, Novartis, Ronald van Vollenhoven Speakers bureau: Abbvie, Galapagos, GSK, Janssen, Pfizer, R-Pharma, UCB, Consultant of: Abbvie, AstraZeneca, Biogen, BMS, Galapagos, Janssen, Miltenyi, Pifzer, UCB, Grant/research support from: BMS, GSK, UCB, Michael Nurmohamed Speakers bureau: Abbvie, Janssen, Celgene, Consultant of: Abbvie, Grant/research support from: Abbvie, Amgen, Pfizer, Galapagos, BMS.

POS0139 TWO-YEAR REDUCTION OF URATE LOAD IN DUAL-ENERGY CT DURING A TREAT-TO-TARGET APPROACH IN GOUT PATIENTS: RESULTS FROM A LONGITUDINAL STUDY (NOR-GOUT)

Background:

Dual-energy computed tomography (DECT) detects urate depositions, and is included in the ACR/EULAR classification criteria for gout. There is lack of longitudinal studies in large patient populations for changes in urate deposition measured by DECT during urate lowering therapy (ULT).

Objectives:

To explore by DECT the longitudinal changes urate depositions during a treat-to-target approach in gout with ULT.

Methods:

In a prospective observational study, patients with crystal-proven gout were included if they presented after a recent gout flare and with increased serum urate levels (>360 μmol/L/>6 mg/dl). In a treat-to-target approach they received ULT with escalating drug doses with monthly follow-up during the first year until the treatment target was met with serum urate <360 μmol/L or 360 µmol/L if tophi.

A DECT scanner (General Electric Discovery CT750 HD) acquired data from bilateral forefeet and ankles at 80 KW and 140 KV, processed with a software with a 2-material decomposition algorithm which colour codes urate. Follow-up DECT was performed after one and two years.

Images were scored with a semiquantitative method (Bayat et al. 2015) by one experienced radiologist in known order and blinded to serum urate and clinical data. Each scan assessed four regions: the first metatarsophalangeal (MTP1) joint, the other joints of the toes, the ankles and midfeet, and all visible tendons in the feet and ankles. Each region was then scored according to the maximum amount of urate deposition observed on visual inspection (0=no deposits, 1=dots, 2=single deposit, 3=more than one deposit). A total DECT sum score was derived by adding all values from the four regions, with a maximum score of 12.

Results:

DECT was at baseline measured in 187 of 211 patients. 95.2% were males, mean (SD) age was 56.7 (13.7) years, disease duration 8.1 (7.9) years), and 17% had clinical tophi.

The total DECT scores and all subscores decreased from baseline to 2 years (p<0.001 for all comparisons versus baseline), table 1.

The mean (SD) serum urate level (μmol/L) decreased from 501 (80) at baseline to 311 (48) at 12 months and 322 (67) at 24 months. Reaching the treatment target <360 µmol/L after year 1 or 2 was only numerically but not statistically related to reductions in DECT scores. Patients with clinical tophi at baseline had larger reductions in total DECT scores after 1 (3.4 vs. 1.5, p<0.01) and 2 years (6.5 vs. 2.3, p<0.001) than patients without tophi.

Conclusion:

During a treat-to-target approach urate deposition visualised by DECT were clearly reduced in ankles and feet after 1 year with further reduction after 2 years.

Table 1.Baseline (n=187) Mean (SD)1 year (n=157) Mean (SD)2 years (n=166) Mean (SD)MTP1 (0-3)1.4 (2.0)1.0 (1.7)0.6 (1.3)Toes (0-3)1.0 (1.8)0.6 (1.4)0.3 (1.0)Ankle/Midfoot (0-3)1.2 (2.1)0.7 (1.60.3 (1.0)Tendons (0-3)1.0 (1.7)0.5 (1.2)0.3 (0.8)Sum score (0-12)4.6 (6.4)2.8 (4.7)1.5 (3.2)

Disclosure of Interests:

Till Uhlig Speakers bureau: Grünenthal, Novartis, Consultant of: Grünenthal, Novartis, Tron Eskild: None declared, Lars Fridtjof Karoliussen: None declared, Tore K. Kvien Consultant of: AbbVie, MSD, UCB, Hospira/Pfizer, Eli-Lilly, Roche, Hikma, Orion, Sanofi, Celltrion, Sandoz, Biogen, Amgen, Egis, Ewopharma, Mylan, Grant/research support from: BMS, AbbVie, MSD, UCB, Hospira/Pfizer, Eli-Lilly, Espen A Haavardsholm Consultant of: Pfizer, UCB, Eli Lilly, Celgene, Janssen-Cilag, AbbVie and Gilead, Nicola Dalbeth Speakers bureau: Menarini, AstraZeneca, Takeda, S. Nicolaou, Consultant of: AstraZeneca, Fonterra, Takeda, Pfizer, Cymabay, Crealta, Grant/research support from: AstraZeneca, Siemens Healthcare, Hilde Berner Hammer Consultant of: AbbVie, Lilly and Novartis

Reversible and Stable Hemiaminal Hydrogels from Polyvinylamine and Highly Reactive and Selective Bis(N-acylpiperidone)s

Water-soluble bis(N-acylpiperidone)s with aldehyde-like reactivity are reported to react rapidly with polyvinylamine at room temperature, providing unprecedented clean reaction products. Unlike most amine/ketone reactions that result in arbitrary mixtures of imines, aminals, hemiaminals, or hydrates, in the present study hemiaminals, aminals, or hemiaminal/aminal mixtures are exclusively found. Detailed NMR spectroscopy of solutions, gels, and solids, aided by model reactions, reveals that the hemiaminal/aminal ratio depends on pH, water content, and cross-linking density. Network formation is fully reversible upon changes in pH, with the resulting moduli from rheology spanning almost 3 orders of magnitude. The self-healing ability of the system is probed by rheology as well, demonstrating maintained material properties of fractured and healed samples. The unusually clean, fast, and reversible chemistry highlights bispiperidones as a class of efficient building blocks with unprecedented possibilities in dynamic covalent chemistry.

OP0018 A MULTICENTER RANDOMIZED STUDY IN EARLY RHEUMATOID ARTHRITIS TO COMPARE ACTIVE CONVENTIONAL THERAPY VERSUS THREE BIOLOGICAL TREATMENTS: 24 WEEK EFFICACY RESULTS OF THE NORD-STAR TRIAL

Background:

The optimal first-line treatment of patients (pts) with early rheumatoid arthritis (RA) is yet to be established.

Objectives:

The primary aim was to assess and compare the proportion of pts who achieved remission with active conventional therapy (ACT) and with three different biologic therapies after 24 wks. Secondary aims were to assess and compare other efficacy measures.

Methods:

The investigator-initiated NORD-STAR trial (NCT01491815) was conducted in the Nordic countries and Netherlands. In this multicenter, randomized, open-label, blinded-assessor study pts with treatment-naïve, early RA with DAS28>3.2, and positive RF or ACPA, or CRP >10mg/L were randomized 1:1:1:1. Methotrexate (25 mg/week after one month) was combined with: 1) (ACT): oral prednisolone (tapered quickly);or: sulphasalazine, hydroxychloroquine and mandatory intra-articular (IA) glucocorticoid (GC) injections in swollen joints <wk 20; 2) certolizumab 200 mg EOW SC (CZP); 3) abatacept 125 mg/wk SC (ABA); tocilizumab 162 mg/wk SC (TCZ). IA GC was allowed in all arms <wk 20. Primary outcome was clinical disease activity index remission (CDAI≤2.8) at wk 24. Secondary outcomes included CDAI remission over time and other remission criteria. Dichotomous outcomes were analyzed by adjusted logistic regression with non-responder imputation (NRI). Non-inferiority analyses had a pre-specified margin of 15%.

Results:

812 pts were randomized. Age was 54.3±14.7 yrs (mean±SD), 31.2% were male, DAS28 5.0±1.1, 74.9% were RF and 81.9% ACPA positive. Fig 1 shows the adjusted CDAI remission rates over time with 95% CI. Table shows crude remission and response rates and absolute differences in adjusted remission and response rates (superiority analysis). Differences in remission and response rates with CZP and TCZ, but not with ABA, remained within the pre-defined non-inferiority margin versus ACT, Fig 2.

Figure 1.

CDAI remission over time (adj. estimates with 95% CI)

Figure 2.

Non-inferiority analysis of protocol population. Estimated differences in CDAI remission rates between Arm 1 (active conventional therapy) and Arms 2, 3, and 4 (biologic arms) as reference with 95% confidence intervals, adjusted for gender, ACPA status, country, age, body-mass index and baseline DAS28-CRP. ABA, abatacept; CZP, certolizumab-pegol; MTX, methotrexate; TCZ, tocilizumab.

Conclusion:

High remission rates were found across all four treatment arms at 24 wks. Higher CDAI remission rate was observed for ABA versus ACT (+9%) and for CZP (+4%), but not for TCZ (-1%). With the predefined 15% margin, ACT was non-inferior to CZP and TCZ, but not to ABA. This underscores the efficacy of active conventional therapy based on MTX combined with glucocorticoids and may guide future treatment strategies for early RA.

Table.

Primary and key secondary outcomes at 24 weeks (ITT)

Active conventional therapy (ACT)Certolizumab+MTXAbatacept+MTXTocilizumab+MTXNo of pts (ITT)200203204188§Crude remission and response ratesCDAI remission42.0%47.8%52.5%41.0%ACR/EULAR Boolean remission34.0%38.4%37.3%31.4%DAS28 remission63.5%68.5%69.6%63.3%SDAI remission41.5%49.8%51.5%42.6%EULAR good response71.5%76.9%79.9%71.3%Difference (95% CI) in rates with Arm 1 as reference (adjusted)CDAI remissionRef4% (-5 to 13%)9% (0.1 to 19%)-1% (-10 to 9%)ACR/EULAR Boolean remissionRef4% (-6 to 13%)5% (-5 to 14%)-4% (-13 to 6%)DAS28 remissionRef3% (-6 to 11%)5% (-4 to 13%)-1% (-10 to 8%)SDAI remissionRef6% (-3 to 18%)9% (-0.3 to 18%)1% (-8 to 11%)EULAR good responseRef4% (-4 to 14%)8% (-2 to 18%)0.4% (-10 to 11%)

§17 patients allocated to Tocilizumab did not receive it due to its unavailability and were excluded from ITT.

Acknowledgments:

Manufacturers provided CZP and ABA.

Disclosure of Interests:

Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis, Espen A Haavardsholm Grant/research support from: AbbVie, UCB Pharma, Pfizer Inc, MSD Norway, Roche Norway, Consultant of: Pfizer, AbbVie, Janssen-Cilag, Gilead, UCB Pharma, Celgene, Lilly, Paid instructor for: UCB Pharma, Speakers bureau: Pfizer, AbbVie, UCB Pharma, Celgene, Lilly, Roche, MSD, Anna Rudin Consultant of: Astra/Zeneca, Dan Nordström Consultant of: Abbvie, Celgene, Lilly, Novartis, Pfizer, Roche and UCB., Speakers bureau: Abbvie, Celgene, Lilly, Novartis, Pfizer, Roche and UCB., Michael Nurmohamed Grant/research support from: Not related to this research, Consultant of: Not related to this research, Speakers bureau: Not related to this research, Björn Gudbjornsson Speakers bureau: Novartis and Amgen, Jon Lampa Speakers bureau: Pfizer, Janssen, Novartis, Kim Hørslev-Petersen: None declared, Till Uhlig Consultant of: Lilly, Pfizer, Speakers bureau: Grünenthal, Novartis, Gerdur Gröndal: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Marte Heiberg: None declared, Jos Twisk: None declared, Simon Krabbe: None declared, Kristina Lend: None declared, Inge Olsen: None declared, Joakim Lindqvist: None declared, Anna-Karin H Ekwall Consultant of: AbbVie, Pfizer, Kathrine L. Grøn Grant/research support from: BMS, Meliha C Kapetanovic: None declared, Francesca Faustini: None declared, Riitta Tuompo: None declared, Tove Lorenzen: None declared, Giovanni Cagnotto: None declared, Eva Baecklund: None declared, Oliver Hendricks Grant/research support from: Pfizer, MSD, Daisy Vedder: None declared, Tuulikki Sokka-Isler: None declared, Tomas Husmark: None declared, Maud-Kristine A Ljosa: None declared, Eli Brodin: None declared, Torkell Ellingsen: None declared, Annika Soderbergh: None declared, Milad Rizk Speakers bureau: AbbVie, Åsa Reckner: None declared, Per Larsson: None declared, Line Uhrenholt Speakers bureau: Abbvie, Eli Lilly and Novartis (not related to the submitted work), Søren Andreas Just: None declared, David Stevens: None declared, Trine Bay Laurberg Consultant of: UCB Pharma (Advisory Board), Gunnstein Bakland Consultant of: Novartis, UCB, Ronald van Vollenhoven Grant/research support from: BMS, GSK, Lilly, UCB, Pfizer, Roche, Consultant of: AbbVie, AstraZeneca, Biogen, Biotest, Celgene, Gilead, Janssen, Pfizer, Servier, UCB, Speakers bureau: AbbVie, Pfizer, UCB

THU0446 SUCCESSFUL TREATMENT OF GOUT IS FREQUENT IN CLINICAL PRACTICE WHEN APPLYING A TREAT-TO-TARGET STRATEGY: RESULTS FROM THE NOR-GOUT STUDY

Background:

International EULAR and ACR recommendations support lifestyle changes, diet and urate lowering therapy (ULT) in gout. Treat-to-target ULT is often not performed, resulting in insufficient treatment of gout. We studied how many patients achieved the recommended treatment target of <360 µmol/l for serum urate (SUA) when a treat-to-target approach was applied in clinical practice, and which factors predicted reaching this target.

Objectives:

We studied how many patients achieved the recommended treatment target of <360 µmol/l for serum urate (SUA) when a treat-to-target approach was applied in clinical practice, and which factors predicted reaching this target.

Methods:

211 patients with crystal proven gout were included into the prospective, observational NOR-Gout study if they recently had a gout flare as well as insufficiently treated serum urate SUA >360 µmol/l).

The intervention consisted of individual verbal information on lifestyle, including factors related to physical activity, diet and the importance of drug adherence. ULT (mainly allopurinol) was initiated and escalated monthly according to EULAR recommendations. Patients were during the first year seen by physician and nurse every three months with additional visits after month 1 and month 2, with further visits monthly as necessary until the treatment target of SUA <360 µmol/l (or <300 if tophi) was met.

Baseline age was 53.6 (SD 12.2) years, disease duration 7.8 years (SD 7.6), BMI 28.8 (SD 4.5) kg/m2, 95.3% were males. Baseline SUA was 500 (77) µmol/l and 16.6% had subcutaneous tophi. Assessments included questions on frequency of alcohol use, and application of the self-efficacy scales for symptoms (SES, range 10-100) as well as the beliefs in medicines questionnaire (BMQ), which included a scale for general overuse of medicines (range 4-16).

186/211 (88.2%) patients completed the visit for the primary SUA endpoint at 12 months.

Results:

SUA continuously declined over 12 months and the frequency of responders increased (table 1):

Table 1

Responders and SUA levels during the treat-to-target intervention

MonthMonth 01236912%n RespondersSUA<36000/21121.3 43/20248.794/19369.3131/18986.7151/18781.9136/16685.5159/186SUA µmol/l (mean, SD)500 (78)413 (77)371 (64)341 (61)327 (59)316 (56)311 (49)

At 12 months 87.6% (163/186) of patients used allopurinol and 13.4% (23/186) febuxostat with mean daily doses of 289 mg (range 100-900) and 59 (20-120) mg, respectively.

Reaching the treatment target of SUA after 12 months was bivariately related to work status, alcohol use, and beliefs in general overuse of medicines. In multivariable analyses in the final model also adjusted for baseline SUA, several variables predicted reaching the SUA target of <360 µmol/l: age (per 10 years) (OR 1.5; 95% CI 1.06 – 1.96, p=0.026), alcohol use no more than monthly vs. at least weekly (OR 6.9, 95% CI 1.90 – 25.2, p=0.003), self-efficacy for symptoms (per 10 units) (OR1.31; 95% CI 1.00 – 1.63; p=0.05), and low belief that medicines are generally overused (per decreasing unit) (OR 1.30; 1.04 – 1.62, p=0.019).

Conclusion:

Most patients (85.5%) with recent gout flare und increased SUA reached the target SUA after 12 months. A good treatment result was predicted by increasing age,

less frequent alcohol use, when patients believed they could cope with symptoms and when they did not believe that drugs are generally overused.

Disclosure of Interests: :

Till Uhlig Consultant of: Lilly, Pfizer, Speakers bureau: Grünenthal, Novartis, Lars Fridtjof Karoliussen: None declared, Tore K. Kvien Grant/research support from: Received grants from Abbvie, Hospira/Pfizer, MSD and Roche (not relevant for this abstract)., Consultant of: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Paid instructor for: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Speakers bureau: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Espen A Haavardsholm Grant/research support from: AbbVie, UCB Pharma, Pfizer Inc, MSD Norway, Roche Norway, Consultant of: Pfizer, AbbVie, Janssen-Cilag, Gilead, UCB Pharma, Celgene, Lilly, Paid instructor for: UCB Pharma, Speakers bureau: Pfizer, AbbVie, UCB Pharma, Celgene, Lilly, Roche, MSD, Hilde Berner Hammer: None declared

THU0425 ULTRASOUND DETECTED URATE CRYSTALS DEPOSITIONS ARE ASSOCIATED WITH ELEVATED CALPROTECTIN AND CRP INDICATING SUBCLINICAL INFLAMMATION; BASELINE RESULTS FROM THE NOR-GOUT STUDY

Background:

Ultrasound detects depositions of monosodium urate (MSU) crystals in gout patients. The OMERACT ultrasound group has developed definitions for elementary lesions in gout including the double contour (DC) sign (depositions of crystals on the surface of cartilage) and tophus (larger hypo-echoic aggregation of crystals, usually well delineated). Calprotectin is a major granulocyte protein found to be sensitive to reflect the level of inflammation in several immunological diseases. There may be an association between low grade inflammation and co-morbidity (including cardio-vascular pathology) in gout patients.

Objectives:

To explore whether the extent of depositions (e.g. DC and tophi) was associated with inflammation in gout patients.

Methods:

The baseline data from NOR-GOUT, a prospective observational study of patients with crystal-proven gout with increased serum urate levels (>360 μmol/L), were presently used. All patients had an extensive ultrasound examination(GE E9 machine, grey scale 15MHz) to assess MSU depositions (DC and tophi) with bilateral assessment of radiocarpal joint, MCP 2, insertion of triceps and quadriceps, proximal and distal patellar and the Achilles tendon, cartilage of distal femur (maximal flexed knee), the talar cartilage of tibiotalar joint and MTP 1 joint. The degree of elementary lesions was semi-quantitatively scored 0-3 (0=none, 1=possible, 2=certain, 3=major deposits). Total sum scores of DC and tophi were calculated and the associations with calprotectin (plasma assessed by ELISA (Calpro), normal levels <910 µg/L) as well as C-reactive protein (CRP, assessed as a routine at our laboratory, normal levels <4mg/L) were explored. Correlations were performed by use of Spearman and differences between groups were investigated by Mann-Whitney tests.

Results:

A total of 111 patients who had calprotectin assessed were included in the study (92% men, mean (SD) age 54.5 (14.5) years, disease duration 7.1 (6.6) years) when initiating MSU lowering treatment. The mean (SD) sum sore DC and tophi was 9.1 (7.8), calprotectin 780 (500) µg/L, CRP 7 (15) mg/L, serum urate (SUA) 505 (87) μmol/L, creatinine 96 (18) μmol/l and eGFR 79 (20) ml/min/1.73m2. Table 1 shows significant correlations between sum sore DC/tophi and calprotectin, CRP, SUA, creatinine and eGFR. Increased calprotectin levels (≥910 µg/L) were found in 28% and increased CRP (≥ 4 mg/L) in 39%. Patients with increased vs normal levels of calprotectin had significantly higher levels of DC/tophi depositions (mean (SD) 13.0 (10.4) vs 7.4 (5.8), p=0.01), and similar was found for CRP (11.4 (9.5) vs 7.6 (6.2), p=0.033) (illustrated in table 2).

Conclusion:

In gout patients, higher load of MSU depositions was associated with increased inflammatory markers. This indicates that the amount of depositions is associated with higher inflammatory activity, which could have systemic implications.

Sum score DC and tophiCalprotectinCRPSUACreatinineCalprotectin0.31*CRP0.29*0.65**SUA0.31**0.22*0.19Creatinine0.34**0.25*0.150.36**eGFR-0.38**-0.27*-0.21*-0.18-0.86**

*p≤0.05, **p≤0.001

Disclosure of Interests: :

Hilde Berner Hammer Consultant of: Has received fees as consultant from Roche, AbbVie and Novartis., Speakers bureau: Has received fees for speaking from AbbVie, BMS, Pfizer, UCB, Roche, MSD and Novartis, Gro Jensen: None declared, Lars Karoliussen: None declared, Lene Terslev Speakers bureau: LT declares speakers fees from Roche, MSD, BMS, Pfizer, AbbVie, Novartis, and Janssen., Espen Andre Haavardsholm Grant/research support from: Research funding from Pfizer, UCB, Roche, MSD and AbbVie, Consultant of: Pfizer, Speakers bureau: Pfizer, UCB, Roche, and AbbVie,, Tore K. Kvien Grant/research support from: Received grants from Abbvie, Hospira/Pfizer, MSD and Roche (not relevant for this abstract)., Consultant of: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Paid instructor for: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Speakers bureau: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Till Uhlig Consultant of: Lilly, Pfizer, Speakers bureau: Grünenthal, Novartis

FRI0425 EVALUATION OF THE DOYLE INDEX AS A MEASURE OF PAIN SENSITIZATION IN PERSONS WITH HAND OSTEOARTHRITIS: EXPLORATORY ANALYSES FROM THE NOR-HAND STUDY

Background:

Pressure pain threshold (PPT) is a measure of pain sensitization; altered pain mechanisms in the peripheral and/or central nervous system causing increased pain sensitivity. PPT testing may be a useful tool to classify pain phenotypes but requires special equipment not available in the clinic. The Doyle index (DI) is a clinical measure of joint tenderness upon palpation. It is considered as an outcome measure of pain and disease activity in hand OA and is a potential alternative to PPT. It is unclear if joint tenderness is related to pain sensitization, as joint tenderness could reflect pure nociceptive pain without sensitization.

Objectives:

Using data from the Nor-Hand study we will explore how DI performs as a measure of pain sensitization in hand OA by examining associations and agreements between DI and PPT at joint level, and correlations between PPT values and DI sum score at person level.

Methods:

PPT was tested with a hand-held algometer (FPIX25, 1cm2flat rubber tip) at the dorsal side of the most painful DIP/PIP and a non-painful DIP/PIP joint (local PPTs) and left radioulnar joint and mid-portions of the trapezius and tibialis anterior muscle (remote PPTs). Low local PPTs indicate peripheral and/or central sensitization, while low remote PPTs indicate central sensitization. According to DI, tenderness in the bilateral thumb base and finger joints were graded by a rheumatologist by pressing on the lateral joint margins: 0=no pain, 1=patient complains of pain, 2=patient complains of pain and winces, 3=patient complains of pain, winces and withdraws joint. We examined whether increasing DI was associated with local PPT using mixed models. To assess agreement between DI and PPT, we categorized PPT of the painful finger joints into a semi-quantitative scale with the same number of categories (n=4) as DI. We identified the cut-offs for the PPT categories that maximized the agreement (weighted kappa) with DI. Finally, we examined Spearman’s correlations between DI sum score [range 0-90] and PPTs of local and remote sites.

Results:

The majority of the 285 eligible participants were women (88%) and mean (SD) age was 61 (6) years. Joints with high DI had lower PPT values (Figure 1). We found a linear association of lower PPT with increasing DI for all joints combined (beta -0.7, 95% CI -0.8, -0.6). Similar results were found for the painful joints (beta -0.8, 95% CI -1.0, -0.6), but weaker for non-painful joints (beta -0.5, 95% CI -1.0, 0.0) where few joints had DI grade 2-3 (Figure 1). The analyses on maximized agreement between DI and the PPT categories gave a weighted kappa equal to 0.32 (Table).

Median (IQR) DI sum score was 9 (5, 15). We found weak inverse correlations between DI sum score and PPT at local (painful finger: ρ -0.24 (95% CI -0.32, -0.16), non-painful finger: ρ -0.22 (95% CI -0.29, -0.11) and remote sites (radioulnar joint: ρ -0.17 (95% CI -0.29, -0.06), trapezius: ρ -0.25 (95% CI -0.36, -0.14), tibialis anterior: ρ -0.20 (95% CI-0.31, -0.09)).

Conclusion:

The DI was associated with lower PPT at painful finger joints. Large variance of PPT within each DI grade resulted in fair agreement. DI of non-painful finger joints was weakly associated with PPT, demonstrating that the DI does not differentiate pain sensitization in joints without ongoing nociceptive pain. Correlations between DI sum score and PPT of remote sites were also weak. The two measures seem to assess different constructs and are therefore not interchangeable.

Table.

Cross tabulation of DI with the best PPT categorization of painful finger joints. Cells = joint count

PPT categories (range, kg/cm2)0(4.7-12)1(3.4-4.6)2(2.1-3.3)3(0-2.0)DI03221113121293172152231163271522

PPT categories 0-3 (i.e. decreasing PPT) represent the categorization that gave maximized agreement with DI (weighted kappa = 0.32)

Disclosure of Interests:

Pernille Steen Pettersen: None declared, Tuhina Neogi Grant/research support from: Pfizer/Lilly, Consultant of: Pfizer/Lilly, EMD-Merck Serono, Novartis, Karin Magnusson: None declared, Barbara Slatkowsky-Christensen: None declared, Hilde Berner Hammer Consultant of: Has received fees as consultant from Roche, AbbVie and Novartis., Speakers bureau: Has received fees for speaking from AbbVie, BMS, Pfizer, UCB, Roche, MSD and Novartis, Till Uhlig Consultant of: Lilly, Pfizer, Speakers bureau: Grünenthal, Novartis, Tore K. Kvien Grant/research support from: Received grants from Abbvie, Hospira/Pfizer, MSD and Roche (not relevant for this abstract)., Consultant of: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Paid instructor for: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Speakers bureau: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Ida K. Haugen: None declared

AB0760 SERIOUS INFECTIONS IN PATIENTS WITH RHEUMATOID ARTHRITIS AND PSORIATIC ARTHRITIS TREATED WITH TNFi: DATA FROM THE NOR-DMARD STUDY

Background:

Infection is an important complication in patients with rheumatoid arthritis (RA), especially when exposed to therapy with tumor-necrosis-factor-inhibitors (TNFi) compared to conventional syntethic DMARDs. The majority of studies have been in RA populations and less is known about the risk of serious infections (SIs) in patients with psoriatic arthritis (PsA).

Objectives:

To compare the incidence and risk of SI between RA and PsA patients treated with TNFi.

Methods:

The NOR-DMARD is a prospective observational multi-centre study. Patients diagnosed with clinical RA or PsA, starting treatment with a TNFi between Jan 2009 to Dec 2018 were included. SI was identified through linkage to the Norwegian Cause of Death Registry and the Norwegian Patient Register and defined as an infection requiring hospital admission with at least one-night hospital stay and/or as an infection causing death. A predefined list of ICD10 diagnosis for infections was used. Time at risk was defined as time from baseline to the first SI, 30 days after discontinuation of TNFi therapy, emigration or end of study period. Crude incidence rates (IRs) of SIs for RA and PsA were presented as events per 100 patient years at risk (PYR) and hazard ratios (HRs) were adjusted for age and gender. The risk of SI in PsA vs RA patients was estimated in cox-regression models adjusted for age and gender, and corrected for multiple observations. The models were stratified by age < 50 vs ≥ 50 years, gender, DAS28-CRP remission (<2.6) vs non-remission at 3 months, and use of methotrexate as co-medication.

Results:

A total of 3180 treatment courses on TNFi were identified (1780 RA and 1400 PsA) in 2368 patients (1356 RA and 1012 PsA) with 5697 person years at risk. The mean age in RA patients was 53.2 (SD 13.9), in PsA 48.2 (SD 11.9), p <0.001. 1542 (65 %) were women. Mean disease duration in years in RA patients was 10.0 (SD 9,7) and 8.5 (SD 9.0) in PsA patients, with no significant difference in disease duration, p = < 0.001. There were 124 cases of SI in RA patients and 55 cases in PsA patients during treatment with a TNFi. The crude SI IRs were 4.00 (3.35, 4.76) in RA patients and 2.12 (1.63, 2.76) in PsA patients. Compared with RA patients, patients with PsA had a lower risk of SI (HR 0.64, 95 % CI 0.46-0.91) when adjusted for age and gender. The HR for females was (HR, p-value) (1.00, 0.97), age ≥ 50 was (1.80, 0.001), MTX co-medication (1.00, 0.99), DAS28-CRP >2.6 at 3 months was (1.20, <0.001) and for seropositives (0.95, 0.77).

Conclusion:

In patients starting treatment with a TNFi, the risk of SI was significantly lower in patients with PsA, compared to patients with RA, when adjusted for age and gender. The incidence rate of SI was lower in patients aged < 50, and in patients in DAS28-CRP remission for both PsA and RA patients.

Table 1.

Disclosure of Interests:

Ingrid Egeland Christensen: None declared, Siri Lillegraven: None declared, Joe Sexton: None declared, Tore K. Kvien Grant/research support from: Received grants from Abbvie, Hospira/Pfizer, MSD and Roche (not relevant for this abstract)., Consultant of: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Paid instructor for: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Speakers bureau: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Till Uhlig Consultant of: Lilly, Pfizer, Speakers bureau: Grünenthal, Novartis, Sella Aarrestad Provan Consultant of: Novartis

THU0537 VALIDITY AND DIAGNOSTIC PERFORMANCE OF FLUORESCENCE OPTICAL IMAGING MEASURING SYNOVITIS IN HAND OSTEOARTHRITIS. RESULTS FROM THE NOR-HAND STUDY

Background:

Fluorescence Optical Imaging (FOI) demonstrates enhanced microcirculation in finger joints as a sign of inflammation.

Objectives:

We wanted to assess the validity and diagnostic performance of FOI measuring synovitis, comparing it with Magnetic Resonance Imaging (MRI)- and ultrasound-detected synovitis in persons with hand osteoarthritis (OA).

Methods:

Two hundred and twenty-one participants (88% female, age (SD) 60.6 (6.2) years) with hand OA from the Nor-Hand study underwent FOI and grey scale (GS) and power Doppler (PD) ultrasound of the bilateral hands and contrast-enhanced MRI of the dominant hand. The FOI scan was performed after the administration of an intravenous fluorescence dye (indocyanine green, ICG) and 360 images (1/second) were produced in 6 minutes. One reader scored the bilateral distal interphalangeal (DIP), proximal interphalangeal (PIP), metacarpophalangeal (MCP) and first carpometacarpal (CMC-1) joints for FOI enhancement, blinded for clinical information and other imaging data. Images were scored according to the ‘FOI activity score’ (FOIAS) where four out of 360 images are assessed, defined as phase 1, 2, and 3, based on the inflow and washing out of the fluorescence dye, and a composite image (Prima Vista Mode; PVM) of the 240 first images. Two readers evaluated separately the severity of MRI-defined synovitis (grade 0-3) in the DIP, PIP, MCP and CMC-1 joints of the dominant hand and the severity of GS synovitis (grade 0-3) and PD activity (grade 0-3) in the same joints of the hands bilaterally. Spearman’s rho was calculated for correlations between sum scores of all joints for FOI, MRI and ultrasound and sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and area under the curve (AUC) for FOI using MRI and ultrasound as reference.

Results:

Despite frequent MRI and ultrasound findings in the CMC-1 joint, no FOI enhancement was detected in the thumb base, and CMC-1 was excluded from the analyses. FOI had poor to fair correlations with MRI and GS synovitis and PD activity. The strongest correlation with MRI was found for PVM in the PIP joints with Spearman’s rho of 0.32, while the DIP joints had consistently the weakest correlations ranging from 0 to 0.14 (Figure 1). None of the FOI phases or PVM demonstrated both good sensitivity and specificity, and AUC remained low with both MRI and GS synovitis as a reference (table 1). The NPVs of FOI were consistently higher when GS synovitis was used as reference rather than MRI, due to higher frequency of low degree MRI-defined synovitis. However, when changing cut-off for MRI synovitis as reference from grade 1 to grade 2 the diagnostic performance of FOI increased to the level of GS synovitis. The diagnostic performance for FOI was similar with both GS synovitis and PD activity as reference.

Table 1.

Diagnostic performance of FOI measuring synovitis in hand OA using MRI and GS synovitis as reference

FOIReferenceSensitivitySpecifisityPPVNPVAUCPVMMRI0.480.720.610.610.61Phase 10.020.990.610.530.50Phase 20.580.620.580.620.60Phase 30.240.900.670.570.57PVMGS0.590.640.170.930.62Phase 10.020.990.280.890.51Phase 20.690.560.170.940.63Phase 30.230.860.170.900.56

FOI; Fluorescence optical imaging, PVM; Prima Vista Mode, GS; Grey scale, PVM; Prima Vista Mode, PPV; Positive Predictive Value, NPV; Negative Predictive Value, AUC; Area under the curve

Conclusion:

FOI sum scores showed poor to fair correlations with MRI- and ultrasound-detected synovitis in persons with hand OA. These findings might be explained by the low-grade inflammation with minor vascularization in the majority of inflamed joints. None of the FOI phases or PVM demonstrated both good sensitivity and specificity and the method was not able to detect CMC-1 synovitis.

Disclosure of Interests:

Øystein Maugesten: None declared, Alexander Mathiessen: None declared, Hilde Berner Hammer Consultant of: Has received fees as consultant from Roche, AbbVie and Novartis., Speakers bureau: Has received fees for speaking from AbbVie, BMS, Pfizer, UCB, Roche, MSD and Novartis, Tore K. Kvien Grant/research support from: Received grants from Abbvie, Hospira/Pfizer, MSD and Roche (not relevant for this abstract)., Consultant of: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Paid instructor for: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Speakers bureau: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Sigrid Valen Hestetun: None declared, Till Uhlig: None declared, Sarah Ohrndorf: None declared, Ida K. Haugen: None declared

THU0129 SLEEP DISTURBANCE AND LOW INFLAMMATION PREDICT A PATTERN OF CHRONIC FATIGUE IN ACTIVELY TREATED PATIENTS WITH ESTABLISHED RA

Background:

Fatigue is common among patients with rheumatoid arthritis (RA) and has major impact on the burden of disease. There is little knowledge regarding the factors predicting the longitudinal development of chronic fatigue.

Objectives:

To identify baseline predictors for the development of chronic fatigue in patients with RA who initiate biological DMARD (bDMARD) treatment, and to compare disease courses across categories of fatigue for 12 months follow-up.

Methods:

Different trajectories of fatigue were calculated from a cohort of 209 established RA patients initiating bDMARDs. Fatigue was assessed by use of the fatigue Numeric Rating Scale (0-10) from the Rheumatoid Arthritis Impact of Disease (RAID) questionnaire. The patients were assessed at 0, 1, 2, 3, 6 and 12 months. We defined three groups: no fatigue (≤3 at all visits), improved fatigue (>3 at baseline but ≤3 at follow-up) and chronic fatigue (≥ 4 at all visits). All patients had clinical/subjective assessments (28 tender/swollen joint count, assessor’s/patient’s global VAS, RAID score, widespread pain, pain catastrophizing, the Hospital Anxiety and Depression Scale and inflammatory markers (ESR, CRP and calprotectin (a major granulocyte protein sensitive for inflammation in RA patients)). All patients were assessed by ultrasound (grey scale (GS) and power Doppler (PD)) of 36 joints and 4 tendons with semi-quantitative scoring (0-3). Differences between groups at baseline was assessed by bivariate analyses, and logistic regression models adjusted for age and gender were used to explore baseline predictors of chronic vs improved fatigue. Trajectories of different groups were plotted as estimated marginal means in figures, and differences between groups assessed by mixed models with maximum likelihood random effects, adjusted for age and sex.

Results:

Table 1 describes demographics and clinical factors of the three groups with significant differences shown in bold. Logistic regression with multivariate assessments found anti-CCP and low inflammation (calprotectin) to be predictors of chronic versus improved fatigue. Sleep disturbance was highly predictive of chronic fatigue. Figure 1 illustrates the trajectories for the three groups at all visits, showing the chronic fatigue group to have significantly higher DAS28, level of widespread pain, depression and sleep disturbance in contrast to no higher level of inflammation assessed by CRP and ultrasound PD.

Table 1.No fatigueImproved fatigueChronicfatigueNo fatigue vs Improved fatigueImproved fatigue vs chronic fatigueNo fatigue vs. chronic fatigue482943pppAge, mean (SD) years51 (2)48 (2)54 (2)0.280.090.28Female gender (%)35 (73)24 (83)38 (88)0.400.500.09Higher Education (%)31 (65)23 (79)20 (47)0.170.010.17Anti-CCP positive (%)29 (60)20 (69)36 (84)0.720.010.002RF positive (%)27 (56)17 (59)30 (70)0.760.110.15Disease duration, mean (SD) years7 (1)8 (1)11 (1)0.810.110.03RA disease activityDAS28CRP3.2 (0.1)3.9 (0.2)4.7 (0.2)0.0030.004<0.001Swollen joints (28)5.7 (0.7)5.6 (1.0)6.2 (0.7)0.900.600.63CRP mg/L mean (SD)9.4 (2.4)15.6 (4.1)11.0 (2.6)0.020.020.58Calprotectin mg/L mean (SD)1.6 (0.3)2.0 (0.4)1.5 (0.2)0.440.200.92Sum score PD mean (SD)14.3 (1.8)13.8 (2.5)12.3 (1.9)0.850.620.43Sum score GS mean (SD)31.6 (2.8)29.3 (3.4)28.2 (2.7)0.610.810.39Psychosocial factorsRAID sleep (VAS 0-10)1.2 (0.3)4.3 (0.6)6.7(0.4)<0.001<0.001<0.001RAID fatigue (VAS 0-10)1.4 (0.2)5.6 (0.3)7.1 (0.3)<0.0010.003<0.001Widespread pain (0-25)4.3 (0.4)7.0 (0.8)8.6 (0.7)0.0010.16<0.001HADS anxiety1.5 (0.3)1.4 (0.6)3.4 (0.7)0.260.580.10HADS depression0.8 (0.2)0.9 (0.4)3.0 (0.8)0.980.360.05Pain Catastrophizing (0-6)1.0 (0.2)2.5 (0.3)2.9 (0.3)<0.0010.31<0.001

Conclusion:

Sleep disturbance is a modifiable factor presently found to predict chronic versus improved fatigue. Thus, attention should be given to RA patients with sleep problems to seek to avoid development of chronic fatigue. This issue should be explored in further studies.

Disclosure of Interests:

Hilde Berner Hammer Consultant of: Has received fees as consultant from Roche, AbbVie and Novartis., Speakers bureau: Has received fees for speaking from AbbVie, BMS, Pfizer, UCB, Roche, MSD and Novartis, Brigitte Michelsen Grant/research support from: Research support from Novartis, Consultant of: Consulting fees Novartis, Joe Sexton: None declared, Till Uhlig Consultant of: Lilly, Pfizer, Speakers bureau: Grünenthal, Novartis, Sella Aarrestad Provan Consultant of: Novartis

OP0019 STABLE VERSUS TAPERED AND WITHDRAWN TREATMENT WITH TUMOR NECROSIS FACTOR INHIBITOR IN RHEUMATOID ARTHRITIS REMISSION (ARCTIC REWIND): A RANDOMISED, OPEN-LABEL, PHASE 4, NON-INFERIORITY TRIAL

Background:

Remission is the preferred treatment target in rheumatoid arthritis (RA), and many patients require biologic DMARDs to reach this state. It is debated whether tapering of tumor necrosis factor inhibitor (TNFi) treatment to discontinuation should be considered in RA patients who sustain remission on treatment (1).

Objectives:

The primary study objective was to assess the effect of tapering and withdrawal of TNFi on the risk of flares in RA patients in clinical remission.

Methods:

In the non-inferiority ARCTIC REWIND trial, RA patients in remission for at least 12 months on stable TNFi therapy were randomly assigned to continued stable TNFi or tapering (half-dose TNFi for 4 months, thereafter withdrawal of TNFi), with visits every four months. csDMARD co-medication was kept stable in both arms. Patients had to be in DAS remission at inclusion with 0/44 swollen joints. The primary endpoint was the proportion of patients with disease flare during the 12-month study period (defined as DAS>1.6, change in DAS>0.6 and 2 or more swollen joints, or the physician and patient agreed that a clinically significant flare had occurred). Full-dose TNFi was reinstated in case of flares in the tapering arm. The non-inferiority margin was 20%, with a predefined superiority test if non-inferiority was not shown. The inferiority null-hypothesis was tested in the per-protocol population by mixed effect logistic regression. Radiographs were scored by van der Heijde modified Sharp score (0 and 12 months, average of two readers, progression: ≥1 unit change). ClinicaltrialsNCT01881308.

Results:

We randomised 99 patients, 92 received the allocated treatment strategy, 84 were included in the per-protocol population. Baseline characteristics, clinical and ultrasound disease activity were balanced (Table). csDMARD co-medication was used by 93% in the stable and 88% in the tapering arm. In the primary analysis, 5% of patients in the stable TNFi arm experienced a flare during 12 months, compared to 63% in the tapering TNFi arm. The risk difference (95% CI) was 58% (42% to 74%, Fig 1), with stable treatment being deemed superior to tapering. 90% in the stable and 81% in the tapering arm did not show progression of radiographic joint damage, difference (95% CI) -9% (-24%, 6%). At 12 months, DAS scores, DAS remission and function were similar between groups (Fig 2). The numbers of adverse events (AE)/serious AE in the stable and tapering arm were 57/2 and 50/3, respectively, with 26 and 15 infections.

Conclusion:

In a randomised clinical trial assessing patients in prolonged and deep RA remission, we observed a large increase in the flare rate in patients who tapered and discontinued TNFi. Patients responded well to reinstated treatment and remission rates in the two study arms were comparable at 12 months.

References:

[1]Smolen et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. ARD 2020

Table 1.

Baseline values – n (%), mean (SD), or median (IQR)

Stable, n=45Tapering, n=47Age, yrs57 (11)58 (13)Female30 (67%)25 (53%)ACPA+35 (78%)36 (77%)Symptom duration, yrs10 (7)12 (7)DAS0.9 (0.4)0.8 (0.3)CRP mg/L1 (1 – 2)1 (1 – 3)No ulttrasound power Doppler signal in any of 32 joints42 (96%)44 (94%)

Disclosure of Interests:

Siri Lillegraven: None declared, Nina Paulshus Sundlisæter: None declared, Anna-Birgitte Aga: None declared, Joe Sexton: None declared, Inge Olsen: None declared, Åse Lexberg: None declared, Tor Magne Madland: None declared, Hallvard Fremstad: None declared, Christian A. Høili Consultant of: Novartis, Gunnstein Bakland Consultant of: Novartis, UCB, Cristina Spada: None declared, Hilde Haukeland Consultant of: Novartis, Inger M. Hansen: None declared, Ellen Moholt: None declared, Till Uhlig Consultant of: Lilly, Pfizer, Speakers bureau: Grünenthal, Novartis, Daniel Solomon Grant/research support from: Funding from Abbvie and Amgen unrelated to this work, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Tore K. Kvien Grant/research support from: Received grants from Abbvie, Hospira/Pfizer, MSD and Roche (not relevant for this abstract)., Consultant of: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Paid instructor for: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Speakers bureau: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Espen A Haavardsholm Grant/research support from: AbbVie, UCB Pharma, Pfizer Inc, MSD Norway, Roche Norway, Consultant of: Pfizer, AbbVie, Janssen-Cilag, Gilead, UCB Pharma, Celgene, Lilly, Paid instructor for: UCB Pharma, Speakers bureau: Pfizer, AbbVie, UCB Pharma, Celgene, Lilly, Roche, MSD

SAT0148 TAPERING OF CONVENTIONAL SYNTHETIC DISEASE MODIFYING ANTI-RHEUMATIC DRUGS IN SUSTAINED RHEUMATOID ARTHRITIS REMISSION: RESULTS FROM A RANDOMIZED CONTROLLED TRIAL

Background:

Sustained remission is the goal of rheumatoid arthritis (RA) care, and more patients reach and maintain this state on conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) with treat-to-target strategies. The knowledge about whether csDMARDs can be tapered in RA remission is limited.

Objectives:

The primary objective of the study was to assess the effect of tapering of csDMARDs on the risk of flares in RA patients in sustained clinical remission.

Methods:

In the open, phase 4, non-inferiority ARCTIC REWIND trial, RA patients in clinical remission for ≥ 12 months on stable csDMARD therapy were randomised to continued stable csDMARD or half dose csDMARD. Patients had to be in DAS remission at inclusion with no swollen joints (of 44). The primary endpoint was the proportion of patients with a disease flare during 12 months (defined as a combination of DAS >1.6, change in DAS >0.6 and ≥2 swollen joints, or the physician and patient agreed that a clinically significant flare had occurred). Patients attended visits every 4 months, with extra visits in case of flares. The non-inferiority margin was 20%, with a predefined superiority test if non-inferiority was not shown. Mixed effect logistic regression was used to test the inferiority null-hypothesis in the per-protocol population. Radiographs at 0 and 12 months were scored by van der Heijde Sharp score (average score of two readers, progression: ≥1 unit change/year). Clinicaltrials.govNCT01881308.

Results:

We enrolled 160 patients, 155 received the allocated treatment strategy. Baseline characteristics were overall well balanced (Table). 78% of patients in the stable csDMARD arm and 84% in the half-dose csDMARD arm used methotrexate monotherapy. In the primary analysis, we observed flares in 6% of patients on stable csDMARD, compared to 25% in the half-dose csDMARD arm, giving a risk difference (95% CI) of 18.3% (7.2% to 29.3%, Fig 1). Non-inferiority could not be claimed, with the results showing superiority of the stable arm over the half-dose arm (Fig 1). Similar results were found in methotrexate monotherapy users. In the stable arm, 2/5 (40%) escalated DMARD medication following the flares, compared to 18/19 (95%) in the tapering arm. No progression of radiographic joint damage was observed in 79.5% of patients on stable DMARDs and 62.7% of those tapering, difference (95% CI) -17.7% (-33.0%, -2.3%, Fig 2E). At 12 months, 92% of patients in the stable and 85% of patients in the tapered arm were in DAS remission (Fig 2C). The frequency of adverse events was 75 in the stable arm and 53 in the tapered arm, with serious adverse events in 2 (2.6%) of patients in the stable and 4 (5.1%, including two serious infections) patients in the tapered arm.

Conclusion:

In RA patients in sustained remission on csDMARDs, continued csDMARD therapy with stable dosage led to significantly fewer disease activity flares and less frequent radiographic joint damage progression than tapered csDMARD treatment.

Table.

Baseline values; mean (SD), n (%) or median (IQR)

Stable, n=78Tapering, n=78Age, yrs55 (12)56 (12)Female50 (64%)54 (69%)ACPA+57 (73%)63 (81%)Symptom dur., yrs3.7 (1.8)3.4 (1.4)DAS0.8 (0.4)0.8 (0.3)CRP mg/L2 (1, 3)2.0 (1,3)MTX monotherapy61 (78%)65 (84%)

Disclosure of Interests:

Siri Lillegraven: None declared, Nina Paulshus Sundlisæter: None declared, Anna-Birgitte Aga: None declared, Joe Sexton: None declared, Inge Olsen: None declared, Hallvard Fremstad: None declared, Cristina Spada: None declared, Tor Magne Madland: None declared, Christian A. Høili Consultant of: Novartis, Gunnstein Bakland Consultant of: Novartis, UCB, Åse Lexberg: None declared, Inger Johanne Widding Hansen: None declared, Inger M. Hansen: None declared, Hilde Haukeland Consultant of: Novartis, Maud-Kristine A Ljosa: None declared, Ellen Moholt: None declared, Till Uhlig Consultant of: Lilly, Pfizer, Speakers bureau: Grünenthal, Novartis, Daniel Solomon Grant/research support from: Funding from Abbvie and Amgen unrelated to this work, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Tore K. Kvien Grant/research support from: Received grants from Abbvie, Hospira/Pfizer, MSD and Roche (not relevant for this abstract)., Consultant of: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Paid instructor for: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Speakers bureau: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Espen A Haavardsholm Grant/research support from: AbbVie, UCB Pharma, Pfizer Inc, MSD Norway, Roche Norway, Consultant of: Pfizer, AbbVie, Janssen-Cilag, Gilead, UCB Pharma, Celgene, Lilly, Paid instructor for: UCB Pharma, Speakers bureau: Pfizer, AbbVie, UCB Pharma, Celgene, Lilly, Roche, MSD

Burden of gout in the Nordic region, 1990-2015: findings from the Global Burden of Disease Study 2015

OBJECTIVE

To explore the burden of gout in the Nordic region, with a population around 27 million in 2015 distributed across six countries.

METHOD

We used the findings of the 2015 Global Burden of Diseases study to report prevalence and disability associated with gout in the Nordic region.

RESULTS

From 1990 to 2015, the number of prevalent gout cases rose by 30% to 252 967 [95% uncertainty interval (UI) 223 478‒287 288] in the Nordic region. In 2015, gout contributed to 7982 (95% UI 5431‒10 800) years lived with disability (YLDs) in the region, an increase of 29% (95% UI 24‒35%) from 1990. While the crude YLD rate of gout increased by 12.9% (95% UI 7.8‒18.1%) between 1990 and 2015, the age-standardized YLD rate remained stable. Gout was ranked as the 63rd leading cause of total YLDs in the region in 2015, with the highest rank in men aged 55-59 years (38th leading cause of YLDs). The corresponding rank at the global level was 94. Of 195 countries studied, four Nordic countries [Greenland (2nd), Iceland (12th), Finland (14th), and Sweden (15th)] were among the top 15 countries with the highest age-standardized YLD rate of gout.

CONCLUSION

The burden of gout is rising in the Nordic region. Gout's contribution to the total burden of diseases in the region is more significant than the global average. Expected increases in gout burden owing to population growth and ageing call for stronger preventive and therapeutic strategies for gout management in Nordic countries.

Developing and testing a consensus-based core set of outcome measures for rehabilitation in musculoskeletal diseases

OBJECTIVES

Rehabilitation is important for people with musculoskeletal diseases (MSDs), and evaluating the effect of rehabilitation on both an individual and group level is advocated. A consensus concerning use of outcome measures will improve collaboration between healthcare providers, and increase the possibility of conducting meta-analyses in future research. The aim of this study was to develop a consensus-based core set of outcome measures for rehabilitation in MSDs, and to test the feasibility and responsiveness of the set.

METHOD

The core set was developed through a stepwise process comprising a Delphi consensus procedure, systematic literature searches, and a pilot study, including 386 patients, to test the feasibility and responsiveness of the set.

RESULTS

The following aspects and outcome measures were selected: pain [numeric rating scale (NRS)], fatigue (NRS), physical fitness (the 30-second Sit to Stand test), mental health (Hopkins Symptom Checklist 5), daily activities (Hannover Functional Questionnaire), goal attainment (Patient-Specific Functional Scale including motivation score for baseline assessment), quality of life (5-level EuroQol 5 Dimensions), social participation (the social participation item from COOP/WONCA) and coping (Effective Musculoskeletal Consumer Scale-17). All tested outcome measures were found to be feasible, with high completion rates and acceptable score distribution. Standard response means varied from 0.3 to 0.9.

CONCLUSIONS

A consensus-based core set of patient reported outcome measures is presented for evaluating rehabilitation in MSDs. The core set is feasible and responsive for use in Norway, but needs further testing in other countries.

2016 updated EULAR evidence-based recommendations for the management of gout

Background

New drugs and new evidence concerning the use of established treatments have become available since the publication of the first European League Against Rheumatism (EULAR) recommendations for the management of gout, in 2006. This situation has prompted a systematic review and update of the 2006 recommendations.

Methods

The EULAR task force consisted of 15 rheumatologists, 1 radiologist, 2 general practitioners, 1 research fellow, 2 patients and 3 experts in epidemiology/methodology from 12 European countries. A systematic review of the literature concerning all aspects of gout treatments was performed. Subsequently, recommendations were formulated by use of a Delphi consensus approach.

Results

Three overarching principles and 11 key recommendations were generated. For the treatment of flare, colchicine, non-steroidal anti-inflammatory drugs (NSAIDs), oral or intra-articular steroids or a combination are recommended. In patients with frequent flare and contraindications to colchicine, NSAIDs and corticosteroids, an interleukin-1 blocker should be considered. In addition to education and a non-pharmacological management approach, urate-lowering therapy (ULT) should be considered from the first presentation of the disease, and serum uric acid (SUA) levels should be maintained at<6 mg/dL (360 µmol/L) and <5 mg/dL (300 µmol/L) in those with severe gout. Allopurinol is recommended as first-line ULT and its dosage should be adjusted according to renal function. If the SUA target cannot be achieved with allopurinol, then febuxostat, a uricosuric or combining a xanthine oxidase inhibitor with a uricosuric should be considered. For patients with refractory gout, pegloticase is recommended.

Conclusions

These recommendations aim to inform physicians and patients about the non-pharmacological and pharmacological treatments for gout and to provide the best strategies to achieve the predefined urate target to cure the disease.

Economic considerations and patients' preferences affect treatment selection for patients with rheumatoid arthritis: a discrete choice experiment among European rheumatologists

OBJECTIVE

To compare the value that rheumatologists across Europe attach to patients' preferences and economic aspects when choosing treatments for patients with rheumatoid arthritis.

METHODS

In a discrete choice experiment, European rheumatologists chose between two hypothetical drug treatments for a patient with moderate disease activity. Treatments differed in five attributes: efficacy (improvement and achieved state on disease activity), safety (probability of serious adverse events), patient's preference (level of agreement), medication costs and cost-effectiveness (incremental cost-effectiveness ratio (ICER)). A Bayesian efficient design defined 14 choice sets, and a random parameter logit model was used to estimate relative preferences for rheumatologists across countries. Cluster analyses and latent class models were applied to understand preference patterns across countries and among individual rheumatologists.

RESULTS

Responses of 559 rheumatologists from 12 European countries were included in the analysis (49% females, mean age 48 years). In all countries, efficacy dominated treatment decisions followed by economic considerations and patients' preferences. Across countries, rheumatologists avoided selecting a treatment that patients disliked. Latent class models revealed four respondent profiles: one traded off all attributes except safety, and the remaining three classes disregarded ICER. Among individual rheumatologists, 57% disregarded ICER and these were more likely from Italy, Romania, Portugal or France, whereas 43% disregarded uncommon/rare side effects and were more likely from Belgium, Germany, Hungary, the Netherlands, Norway, Spain, Sweden or UK.

CONCLUSIONS

Overall, European rheumatologists are willing to trade between treatment efficacy, patients' treatment preferences and economic considerations. However, the degree of trade-off differs between countries and among individuals.

The EULAR Outcome Measures Library: development and an example from a systematic review for systemic lupus erythematous instruments

OBJECTIVES

Patient reported outcomes (PROs) are relevant in rheumatology. Variable accessibility and validity of commonly used PROs are obstacles to homogeneity in evidence synthesis. The objective of this project was to provide a comprehensive library of "validated PROs".

METHODS

A launch meeting with rheumatologists, PROs methodological experts, and patients, was held to define the library's aims and scope, and basic requirements. To feed the library we performed systematic reviews on selected diseases and domains. Relevant information on PROs was collected using standardised data collection forms based on the COSMIN checklist.

RESULTS

The EULAR Outcomes Measures Library (OML), whose aims are to provide and to advise on PROs on a user-friendly manner albeit based on scientific grounds, has been launched and made accessible to all. PROs currently included cover any domain and, are generic or specifically target to the following diseases: rheumatoid arthritis, osteoarthritis, spondyloarthritis, low back pain, systemic lupus erythematosus, gout, osteoporosis, juvenile idiopathic arthritis, and fibromyalgia. Up to 236 instruments (106 generic and 130 specific) have been identified, evaluated, and included. The systematic review for SLE, which yielded 10 specific instruments, is presented here as an example. The OML website includes, for each PRO, information on the construct being measured and the extent of validation, recommendations for use, and available versions; it also contains a glossary on common validation terms.

CONCLUSIONS

The OML is an in progress library led by rheumatologists, related professionals and patients, that will help to better understand and apply PROs in rheumatic and musculoskeletal diseases.