POS1094 CORRELATION OF FLUORESCENCE-OPTICAL IMAGING AND PHYSICIAN TJC/SJC ASSESSMENT AND ULTRASOUND IN PSORIASIS PATIENTS WITHOUT ARTHRITIS BUT MUSCULOSKELETAL COMPLAINTS WITHIN THE LAST 6 MONTHS

Background

Psoriasis (PsO) is one of the most common chronic inflammatory skin diseases in Europe. Psoriatic arthritis (PsA) is closely associated to PsO; up to 40% of PsO patients develop PsA. The transition from PsO to PsA includes different stages with unspecific clinical symptoms such as fatigue or musculoskeletal (MSK) symptoms as well as changes in synovial vascularization combined with increased expression of proangiogenic factors [1]. Fluorescence-optical imaging (FOI, [Xiralite]) is an easy-to-use method to detect changes in microvascularisation of the hands.

Objectives

To compare findings from FOI assessment to clinical examination (SJC/TJC) and musculoskeletal ultrasound in patients (MSUS) with non-specific MSK-symptoms and changes in microvascularisation without evidence of clinical active PsA.

Methods

The German multicentre observational XCITING study recruited patients with dermatological confirmed PsO at risk for development of PsA (either nail psoriasis or MSK symptoms such as joint pain or swelling within the last 6 months). Clinical examination (CE; swollen (66) and tender (68) joint count, enthesitis, dactylitis assessment), standardized MSUS and FOI assessment were performed by a qualified rheumatologist at one time point with focus on the question of presence of PsA. Data were analyzed in focus on increased vascularization of MSK structures of both hands as marker of inflammation. The patients at-risk for PsA development but without clinically active PsA (CE negative, FOI positive) were analyzed. Results from CE of joints, MSUS and FOI were compared.

Results

391 PsO patients were recruited for the XCITING study in total. 108 patients (27.6%) were identified as at-risk population (CE negative, FOI positive). Baseline characteristics included a mean age of 51.4 years (SD 11.3), 61.1% female, mean BMI 27.8 kg/m2 (SD 5.2), mean age of onset PsO 30.4 years (SD 17), mean duration of PsO of 16.9 years (SD 14.4), mean PASI 4.3 (SD 5.8) and mean patient’s global disease activity for PsO of 24.4mm (SD 21.1). In 24.1% psoriasis plaques on the hand were documented. Pattern for frequency of scores in FOI, CE and MSUS in the dominant hand were compared (Figure 1). Frequency of swollen joints and synovitis with power Doppler activity (PD Mode) was very low in these patients whereas TJC, detection of synovitis in MSUS and FOI signals were detected in overlapping regions at the hands, showing high correlation. The highest correlation is found between TJC and FOI (Figure 1).

Figure 1.

Overview of frequency of involvement in joints for the different assessments (MSUS, SJC/TJC and FOI)

Conclusion

FOI signals in the hands correlate to the findings of TJC (and B-Mode US) in the clinical examination indicating early stages of MSK inflammation that may result in active PsA development. FOI as standardized and easy-to-use technique might be a suitable tool for early detection of PsA in Psoriasis population. A follow up in these patients will reveal prediction values of the method.

References

[1]Scher, J.U., et al., Preventing psoriatic arthritis: focusing on patients with psoriasis at increased risk of transition. Nat Rev Rheumatol, 2019. 15(3): p. 153-166.

Disclosure of Interests

Michaela Köhm Grant/research support from: Pfizer, Sarah Ohrndorf: None declared, Xenofon Baraliakos: None declared, Konstantin Hallmann Grant/research support from: Pfizer, Susanne Kempinski: None declared, Ann Christina Foldenauer Grant/research support from: Pfizer, Tanja Rossmanith Grant/research support from: Pfizer, Ulf Henkemeier Grant/research support from: Pfizer, Frank Behrens Grant/research support from: Pfizer

AB1099 EVALUATION OF DIFFERENT FLUORESCENCE-OPTICAL IMAGING (FOI) ASSESSMENT METHODS TO DIFFERENTIATE CLINICAL PSORIATIC ARTHRITIS FROM PSORIASIS

Background:

Psoriasis (Pso) is one of the most common chronic inflammatory skin diseases in Europe. Psoriatic arthritis (PsA) is closely associated to Pso whereas the skin manifestation appears usually years before PsA-related symptoms emerge. Up to 30% of Pso patients develop PsA, but there is no clear correlation between disease duration of Pso and PsA development. In early PsA, changes in synovial vascularisation combined with increased expression of proangiogenic factors appear first. Therefore, imaging biomarkers for detection of changes in vascularisation might be useful for early detection of musculoskeletal disease. Fluorescence-optical imaging (FOI) is an indocyanine green (ICG) tailored method to detect microvascular changes in the hands using ICG kinetics over 360 sec. Different methods for assessment of FOI are available. It has not yet been demonstrated to what extent these methods can be used to differentiate psoriasis from psoriasis arthritis.

Objectives:

To evaluate different reader dependent assessment methods to evaluate FOI in psoriasis and psoriatic arthritis.

Methods:

FOI data (clinical PsA n=137, PsO without PsA n=202) from an observational prospective multicentre trial in Germany was used for manual assessment of the films using two different published assessment methods:(1) FOI activity score (FOIAS) and (2) individual characteristics of ICG kinetics. For (1) FOIAS, the levels of signal enhancement were scored using a scoring system from 0 to 3 (0=no enhancement, 3=strong enhancement) per joint as well as an assessment of the summation picture. (2) Kinetics were determined by joint-related signal enhancements as well as by ICG related flow-on and flow-off behaviour. Time to the first appearance of the signal, the time to the maximum enhancement and the time to the end of the signal were determined.

Results:

By use of (1) FOIAS, the maximum score (overall signals of all joints assessed by FOIAS) showed a significant difference (p=0.0075) between PsA (mean 4.76) and PsO (mean 3.84). (2) Time to global maximum showed no significant difference (PsA mean 91.1 sec vs PsO 92.6 sec). Moreover, the mean time to maximum and clearance of ICG did not differ between the two diseases. The duration of the 3 phases of kinetic (phase 1: flow-in, phase 2: stable, phase 3: clearance) was 52.4 sec, 180.2 sec and 119.8 sec for PsA and 57.6 sec, 186.0 sec and 130.5 sec for PsO with an earlier phase 2 and 3 for PsA by trend. The most frequently affected joints in PsA (affected > 10%): PIP 3 right and PIP 5 right.

Conclusion:

FOI is a sensitive method to detect changes in microvascularisation in the hands. The use of the manual FOIAS is able to differentiate significantly between PsA and PsO patients by comparison of the sum of scores over all joints (maximum score). The assessment of ICG kinetics is limited to discriminate between musculoskeletal and joint disease, differentiation of diseases is only seen by trend. Both methods characterize disease states differently. A combination of both methods might be useful to increase the potential of manual assessment of FOI signals.

Figure 1.

Maximum sum score of FOIAS in PsO and PsA patients (p=0.0075 in two-sided t-test).

Disclosure of Interests:

Luis Haan: None declared, Ulf Henkemeier: None declared, Ann Christina Foldenauer: None declared, Harald Burkhardt Grant/research support from: Pfizer, Roche, Abbvie, Consultant of: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Speakers bureau: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Frank Behrens Grant/research support from: Pfizer, Janssen, Chugai, Celgene, Lilly and Roche, Consultant of: Pfizer, AbbVie, Sanofi, Lilly, Novartis, Genzyme, Boehringer, Janssen, MSD, Celgene, Roche and Chugai, Michaela Köhm Grant/research support from: Pfizer, Janssen, BMS, LEO, Consultant of: BMS, Pfizer, Speakers bureau: Pfizer, BMS, Janssen, Novartis

SAT0325 STELLATE BLOCKADE COMBINED TO ILOPROST AS SUPPORTIVE TREATMENT OPTION IMPROVES PAIN AND ISCHAEMIC SYMPTOMS IN PATIENTS WITH SYSTEMIC SCLEROSIS

Background:

Peripheral ischaemia is a common symptom in systemic sclerosis (SSc) patients with risk of development of digital ulcers (DU). For its treatment, intravenous iloprost is the most effective option. Accompanying pain symptoms worsen the ischaemic symptoms, so a combination with anaesthetic procedures may improve ischaemic status and the subjective sensation of raynaud and pain. The aim of this study was to observe the impact of a combined treatment of iloprost with stellate blockade (ILOST) in improvement of ischaemic symptoms compared to iloprost treatment only (ILO).

Objectives:

To evaluate efficacy of the ILOST treatment on changes in vascularisation and sensation of patients with SSc and indication for vasodilatative treatment with Iloprost.

Methods:

Twenty SSc-patients with indication for ILO-treatment (prophylactic or due to digital ulcerations (DU)) will be included in a prospective observational study. Patients will be offered to combine ILO with stellate blockade (ILOST). Beside documentation of disease activity characteristics (mRSS, number of DU, capillary microscopy at baseline, after ILO-treatment and at week 12), patients are assessed using fluorescence-optical imaging (FOI) as innovative method for illustration of changes in microvascularisation and patient reported outcomes (DASH, VAS) at week 12.

Results:

This interims analysis includes the result of the first 11 patients treated. Mean baseline characteristics (age and gender) are well balanced. Iloprost treatment was initiated due to prophylactic treatment to avoid DU in all patients. 100% of the patients in the ILOST-group were diagnosed as limited SSc compared to 60% in the ILO-group (diffuse type with 40%). All patients showed abnormalities in capillary microscopy (ILOST group: 83,3% late pattern 16.7% active pattern; ILO group: 80% late pattern, 20% early pattern). MRSS was low in both groups with 1.8, the disease duration in mean 15.3 years in the ILOST-group compared to 13.2 in the ILO-group, respectively. In both groups, no new DU occurred in the 12-week follow-up. Improvement in VAS pain was reported in 83% of the patients in the ILOST group compared to 60% in the ILO group. DASH improved with a mean of 5.5 points in the ILOST group compared to 3 points in the ILO group. FOI was compared individual at both arms in the ILOST group only. The arm with stellatum blockade showed a pronounced increase of FOI signals of 5% in mean whereas the opposite site showed a decrease of the signal shortly after ILO treatment indicating a pronounced increase of vascularisation in the ILOST treated body site.

Conclusion:

A new treatment approach to improve acute ischaemic symptoms was tested by combining stellate blockade to iloprost treatment. No new DU occurred up to 12 weeks after treatment in all patients of both groups indicating the relevance of iloprost as effective vascular dilatative therapy in SSc. The additional intervention was well tolerated and asked to repeat. Subjective sensation on pain of the hands as well as DASH was improved in the combined group. FOI showed a relevant increase in vascularisation in the blockade arm compared to the opposite site in which signals decreased indicating a stronger effect of the combined treatment for improvement of vascularisation.

Disclosure of Interests:

Franziska Höcketstaller Grant/research support from: Rheumazentrum Rhein-Main, Ulf Henkemeier: None declared, Michael Zimmermann: None declared, Harald Burkhardt Grant/research support from: Pfizer, Roche, Abbvie, Consultant of: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Speakers bureau: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Frank Behrens Grant/research support from: Pfizer, Janssen, Chugai, Celgene, Lilly and Roche, Consultant of: Pfizer, AbbVie, Sanofi, Lilly, Novartis, Genzyme, Boehringer, Janssen, MSD, Celgene, Roche and Chugai, Ulrich Drott: None declared, Michaela Köhm Grant/research support from: Pfizer, Janssen, BMS, LEO, Consultant of: BMS, Pfizer, Speakers bureau: Pfizer, BMS, Janssen, Novartis

AB1138 ASSESSMENT OF FLUORESCENCE-OPTICAL IMAGING TECHNIQUE OF THE HANDS IN PSORIASIS AND PSORIATIC PATIENTS USING AN INNOVATIVE OBJECTIVE METHOD

Background:

Psoriasis (Pso) is one of the most common chronic inflammatory skin diseases in Europe. Psoriatic arthritis (PsA) is closely associated to Pso whereas the skin manifestation appears usually years before PsA-related symptoms emerge. Up to 30% of Pso patients develop PsA, biomarkers for its early detection are of major importance. In early PsA, changes in synovial vascularisation appear first. Imaging biomarkers for detection of changes in vascularisation might be useful for early detection of musculoskeletal disease. Fluorescence-optical imaging (FOI) is a new method to detect changes in microvascularisation of the hands. Each collected data set of the FOI system contains 360 images representing a time progression of the indocyanine green (ICG) distribution.

Objectives:

To evaluate a reader-independent assessment method for evaluation of FOI in patients with PsO and PsA.

Methods:

A prospective study including patients with dermatological confirmed skin PsO was performed. 411 patients were included from German dermatology units without PsA diagnosis but potential risk for its development. Clinical examination (CE) was performed by a qualified rheumatologist. For a reader independent evaluation of the FOI images an objective joint-based scoring method was developed. For this method, the joint areas are defined by image segmentation and scored based on generated heatmaps. To calculate a heatmap indicating conspicuous joints from a data set containing 360 images, each pixel is converted to a time series containing 360 values. From this time series, three independent values (features) are extracted: amplitude, average value and maximal slope. Thus, each pixel is reduced to three different feature values. After the three features are determined for each pixel, k-means clustering is performed on each feature. The numbers of centroids (k) are set to 3, 5, 7 and 9. 12 heatmaps (3 features à 4 ks) are calculated, which results in 12 scores for each joint as well. The clusters are then sorted dependent on their centroid value and coloured accordingly to a predefined heatmap colour palette. To finally score each joint, the pixels in the segmented joint area and their assigned cluster are summed and normalized by the area’s amount of pixels and k.

Results:

271 of the patients were investigated by the newly developed method and compared with the CE scoring. 6426 joints were labeled as healthy whereas 1162 joints were either labeled as swollen, tender or both. The result over all investigated patients for k = 9 is summed in table 1. It is observable that every average and median healthy value is lower than the corresponding affected value.

Table 1.

Resulting scores for k = 9 for all 271 patients.

Feature Statistic valueAmplitudeMeanSlopeHealthyAffectedHealthyAffectedHealthyAffectedAverage0.5030.5280.4860.5090.3950.414Median0.4960.5320.4820.5050.3890.415

Conclusion:

FOI is an innovative method that detects early changes in vascularization of the hands. So, this method can be useful in early detection of arthritis especially in risk populations such as PsO patients. The results of the objective scoring method show that a clear distinction between healthy and affected joints is possible with the average scores as well as the median values. However, if the range of the scores is considered, the overlap between healthy and affected is not neglectable. Thus, the current scoring system can be used as an indicator but not as a single classification marker. Nevertheless, the research at hand has shown the expected outcome and motivates further development on the heatmap approach.

Disclosure of Interests:

Lukas Zerweck: None declared, Ulf Henkemeier: None declared, Phuong-Ha Nguyen: None declared, Tanja Rossmanith Grant/research support from: Janssen, BMS, LEO, Pfizer, Andreas Pippow: None declared, Harald Burkhardt Grant/research support from: Pfizer, Roche, Abbvie, Consultant of: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Speakers bureau: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Frank Behrens Grant/research support from: Pfizer, Janssen, Chugai, Celgene, Lilly and Roche, Consultant of: Pfizer, AbbVie, Sanofi, Lilly, Novartis, Genzyme, Boehringer, Janssen, MSD, Celgene, Roche and Chugai, Michaela Köhm Grant/research support from: Pfizer, Janssen, BMS, LEO, Consultant of: BMS, Pfizer, Speakers bureau: Pfizer, BMS, Janssen, Novartis

SAT0032 INCIDENCE OF RHEUMATOID ARTHRITIS IN PATIENTS WITH NEW ONSET OF MUSCULOSKELETAL SYMPTOMS AND ANTI-CPP POSITIVITY COMPARED TO ANTI-CPP NEGATIVE PATIENTS

Background:

Rheumatoid Arthritis (RA) is a chronic inflammatory joint disease. Strategies for its early detection and diagnosis are of high importance as prompt treatment improves clinical and structural outcome. Autoantibodies against cyclic citrullinated proteins (anti-CCP) have been associated with RA-development. Non-specific musculoskeletal (nsMSK) symptoms are often described prior to RA development. Majority of patients with nsMSK symptoms present to their general practice (GP) first. Studies of early arthritis cohorts have shown that many early arthritis patients cannot be accurately diagnosed at their first visit and are often referred as undifferentiated arthritis patients.

Objectives:

To evaluate the incidence of anti-CCP positivity in patients with new onset of nsMSK symptoms and the incidence of RA in these patients over a 3-year follow-up period compared to anti-CPP negative patients.

Methods:

In this prospective study (PANORA), 978 patients with new onset of nsMSK symptoms were included in 77 GP sites in Germany. Patients with a positive anti-CCP rapid-test (CCPoint®) were referred to Rheumatology Department (RD) for rheumatological assessment, RA-evaluation and an anti-CCP validation test (ELISA). ELISA anti-CCP positive patients without RA were monitored every 6 months for a total follow-up of 36 months or until RA-diagnosis. Patients with a negative anti-CPP result (CCPoint® or ELISA) are followed up with a questionnaire after 1 and 3 y.

Results:

From 978 included patients, 105 (10.7%) were CCPoint® positive. 96 were tested with ELISA and 27 (28.1%) were confirmed anti-CCP positive. 9 (33.3%) were diagnosed with RA at the first RD visit (study visit 2); 4 further patients were diagnosed with RA during the follow-up (FU) period so far. Overall, 48.1% of ELISA-positive (ELISA+) patients were diagnosed with RA up to now; 11 ELISA+ patients are still in the FU period of the study. Of the 868 CCPoint® negative patients, currently, 282 have filled out a 1-year FU questionnaire; 3.5% of those reported a RA diagnosis (Table 1). As expected, clinical parameters at V2 (e.g. CRP, swollen and tender joint count) were worse in the ELISA+/RA+ group compared to the ELISA-/RA- group, but no obvious differences were detected between ELISA+ patients who were diagnosed with RA during the FU period (after V2) and ELISA-/RA- patients

Table 1.

Number and percentage of patients with a RA diagnosis

Anti-CCP statusVisit 2Follow-up*TotalPoint-of-Care Test --3.5% (10 of 282)#3.5% (10 of 282)#Point-of-Care Test + / ELISA -2.9% (2 of 69)0% (0 of 34)#2.9% (2 of 69)Point-of-Care Test + / ELISA +33.3% (9 of 27)14.8% (4 of 27)48.1% (13 of 27)$

* 1 year-questionnaire for Point-of-Care Test and ELISA negative patients or every 6 months follow-up for ELISA positive patients;#Patient-reported;$11 patients are still in the follow-up phase of the study

Conclusion:

Currently, 48.1% of anti-CCP+ (ELISA) patients have received a RA diagnosis, whereas 3.5% of the anti-CCP- (CCPoint®) received a RA diagnosis (patient reported), which underlines, that anti-CCP can be used as a marker to identify high-risk patients in GP setting. While clinical parameters are correlated with the diagnosis of RA, they are not suited for predicting future RA development alone. Anti-CCP, possibly in combination with additional parameters imaging, might increase the likelihood to early diagnose or predict RA development.

Figure 1.

Study overview: Patient distribution depending on anti-CCP results and RA diagnosis.

Disclosure of Interests:

Stephanie Dauth Grant/research support from: BMS, Michaela Köhm Grant/research support from: Pfizer, Janssen, BMS, LEO, Consultant of: BMS, Pfizer, Speakers bureau: Pfizer, BMS, Janssen, Novartis, Timm Oberwahrenbrock Grant/research support from: BMS, Ulf Henkemeier: None declared, Tanja Rossmanith Grant/research support from: Janssen, BMS, LEO, Pfizer, Karola Mergenthal Grant/research support from: BMS, Juliana J. Petersen Grant/research support from: BMS, Harald Burkhardt Grant/research support from: Pfizer, Roche, Abbvie, Consultant of: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Speakers bureau: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Frank Behrens Grant/research support from: Pfizer, Janssen, Chugai, Celgene, Lilly and Roche, Consultant of: Pfizer, AbbVie, Sanofi, Lilly, Novartis, Genzyme, Boehringer, Janssen, MSD, Celgene, Roche and Chugai

[Do we still need clinical studies in rheumatology?]

Despite a large number of approved therapies demonstrating efficacy in the treatment of rheumatic diseases, only 60-85 % of patients with the indications for rheumatoid arthritis are adequately treated in Germany. Additionally, approved therapies for other immune-mediated diseases are often entirely lacking, indicating the great medical need for the development of new innovative therapies in this specialized field. The development of new drugs is expensive due to the high costs of conducting clinical trials in all phases of development up to obtaining approval; therefore, pharmaceutical companies are looking for ways to save costs in the particular developmental stages. Although the classical regions for drug development (i.e. western Europe, the USA and Japan) offer both a high level of data quality and a good infrastructure to conduct clinical trials due to high standards of education and quality, clinical trials are expensive in these regions. Beside high costs, the comparatively low recruitment rates in these regions are one of the main reasons for the shifting of drug developmental stages from classical regions to eastern European, Latin American and Asian countries, which provide services for drug development and high recruitment rates for comparatively less money. However, there are many strong arguments for the participation of regions in western Europe, especially German sites in clinical trials. In this article these arguments are discussed and possible solutions and strategies for conducting and compensation of study centers in Germany for clinical trials in the field of rheumatology are provided.