[Castleman's disease in the rheumatological practice]

The term Castleman's disease encompasses a group of rare lymphoproliferative diseases that show histopathological similarities in lymph node biopsy. Diagnostic criteria and a specific ICD-10 code have been available for a few years. Case studies listed at the beginning illustrate that close cooperation between clinicians and pathologists is required to enable a reliable diagnosis. For an optimal histopathological assessment, the pathologist is also dependent on the removal of a complete lymph node. Before distinguishing a potentially fatal multicentric idiopathic Castleman's disease from the resectable unicentric form, which is important in terms of prognosis and treatment, early diagnosis presupposes that Castleman's disease is considered in the differential diagnosis. Various immune phenomena and overlaps with autoimmune diseases can increase the probability of misdiagnosis or undetected cases in the clinical routine of rheumatologists. The intention of the present overview is therefore to point out the similarities with autoimmune diseases that are relevant for differential diagnoses and to point out situations that justify a review of the previous diagnosis.

POS0429 ACTIVATED RHEUMATOID ARTHRITIS SYNOVIAL FIBROBLASTS ALTER OSTEOCLAST DIFFERENTIATION AND ACTIVITY

Background

In rheumatoid arthritis (RA), osteoclasts are one of the most important mediators of bone erosion. In addition, RA synovial fibroblasts (RASF) have a major influence on joint erosion in RA. They affect osteoclast differentiation e.g. by increased RANKL production or secretion of other pro-osteoclastogenic factors such as IL-6. In addition to the pro-osteoclastogenic effect of soluble factors such as RANKL and IL-1, visfatin inhibits osteoclast differentiation. Furthermore, visfatin increases the secretion of pro-inflammatory factors by RASF, such as IL-6 or matrix degrading enzymes.

Objectives

In this study, the effect of RASF with/without activation by visfatin and IL-1 on osteoclastogenesis was evaluated.

Methods

Blood from healthy donors and RA patients was used for PBMC isolation. RANKL, TGF-β and hM-CSF were added to induce osteoclast differentiation. RASF-conditioned media (CM) were prepared from confluent RASF cultured for 48h. Differentiating PBMCs in monoculture were compared to PBMC cultured with CM from RASF (CM: 10%, 20%, 30%) as well as in direct co-culture with RASF with/without stimulation with IL-1 (0.05ng/ml), visfatin (25ng/ml). After two weeks in culture, cells were stained using TRAP staining. 3-5 images per well were used for quantification dependent on the variability of the wells. IL-6 was measured by ELISA in supernatants collected at day 14.

Results

IL-6 production increased by IL-1 (e.g. co-culture: 2,8-fold) and visfatin (CM-visfatin: 10%=4,3-fold, 20%=5,4-fold, 30%=4,2-fold; co-culture: 9,5-fold) compared to unstimulated control in all settings. In addition, IL-6 was increased with the addition of CM compared to unstimulated controls (healthy donors CM 30%: unstimulated p=0.0342, IL-1 p=0.0133, visfatin p=0,0133; RA: unstimulated p=0.0133, IL-1 p=0.0342, visfatin p=0.0133, n=3 each). Of note, baseline IL-6 concentrations were higher in PBMC from RA patients compared to healthy donors. Co-culture showed an additional increase in IL-6 levels in all settings (e.g. monoculture: IL-1 4.71±5.75pg/ml, visfatin 141.09±182.79pg/ml; co-culture: IL-1 7241±10398pg/ml, visfatin 24535±16994pg/ml;). During osteoclast differentiation, addition of CM showed similar osteoclastogenesis with similar proportion of osteoclasts with 2 and 3-5 vs. higher numbers of nuclei per cell compared to control. In coculture with RASF osteoclasts showed a stronger TRAP signal compared to monoculture especially for unstimulated and IL-1 stimulated co-cultures.

Conclusion

Both, in monoculture with CM and in coculture, IL-6 levels were increased compared to control, whereas in RA patients the IL-6 levels were higher compared to healthy donors. The CM containing secreted factors of RASF did not have a prominent influence on osteoclastogenesis. However, the presence of RASF increased the TRAP signal showing an increased activity of differentiated osteoclasts especially in unstimulated and IL-1 stimulated co-cultures but not with addition of visfatin.

References

None.

Disclosure of Interests

None declared.

POS0873 PERSISTENT INFLAMMATION IN SYSTEMIC SCLEROSIS IS STRONGLY ASSOCIATED WITH SEVERE DISEASE AND MORTALITY: AN ANALYSIS FROM THE EUSTAR DATABASE

Background

Systemic sclerosis (SSc) is a heterogeneous autoimmune disease, with a high disease-related mortality and morbidity. A subset of patients show elevated CRP levels (20-35%), which has been reported as inflammatory SSc. Preliminary data suggest that this subset is characterized by a severe phenotype.

Objectives

To analyse the phenotype and the survival of inflammatory compared with non-inflammatory SSc patient subsets.

Methods

Data from 8571 SSc patients with available CRP measurement from the EUSTAR cohort were analysed. Exclusion criteria included acute infection, missing follow-up and tocilizumab treatment. Patients with a CRP ≥5mg/l at ≥80% of visits were stratified as persistent inflammatory and as non-inflammatory if CRP was ≥5 mg/l at <20% of visits (as described previously (1)). As a sensitivity analysis, patients were defined as inflammatory and non-inflammatory based on a single CRP measurement at baseline only (CRP ≥5 or <5mg/l, respectively). We compared baseline characteristics using Chi-square and non-parametric Kruskal–Wallis tests as appropriate. Kaplan Meier curves with log-rank tests were used to estimate time from baseline to death or censoring, and Cox regression to compare mortality risks adjusted for time from diagnosis to baseline.

Results

Out of 2883 patients with more than two visits, 404 (14%) showed persistent inflammation and 1032 (36%) a non-inflammatory phenotype. Out of 5619 patients with more than one visit, 1830 (33%) were stratified as inflammatory as defined by as single CRP measurement at baseline and 3789 (67%) as non-inflammatory. With both definitions, the inflammatory subset revealed a more severe phenotype than non-inflammatory patients, including more frequent diffuse-cutaneous disease, anti-Scl-70 autoantibodies, pulmonary fibrosis, pulmonary hypertension, higher modified Rodnan skin score, and lower forced vital capacity and diffusing capacity for carbon monoxide. Patients with persistent inflammation had a strongly increased risk of all-cause mortality (HR 7.1 [95%CI 3.7 to 13.5], p<0.001) compared to non-inflammatory patients, whereas this association was weaker when based on a single CRP measurement (HR 2.6 [95%CI 2.1 to 3.2], p<0.001).

Conclusion

The severe phenotype and decreased survival of the inflammatory SSc subset, which was most prominent in patients with persistently elevated CRP levels, suggest a distinct disease subset. Therefore both, the need for more regular monitoring of inflammatory parameters and implications for immune-modulating treatment, needs to be carefully analysed.

References

[1]Mitev, A., et al., Inflammatory stays inflammatory: a subgroup of systemic sclerosis characterized by high morbidity and inflammatory resistance to cyclophosphamide. Arthritis Res Ther, 2019. 21(1): p. 262. PMID: 31791379

Figure 1.

Overall mortality from baseline onward a. by persistent inflammatory phenotype, b. by inflammatory phenotype at baseline

Disclosure of Interests

Adela-Cristina Sarbu: None declared, Sabina Guler: None declared, Odile Stadler: None declared, Yannick Allanore: None declared, Vera Bernardino: None declared, Jörg H.W. Distler: None declared, Armando Gabrielli: None declared, Anna-Maria Hoffmann-Vold: None declared, Marco Matucci-Cerinic: None declared, Ulf Müller-Ladner: None declared, Vera Ortiz-Santamaria: None declared, Simona Rednic: None declared, Valeria Riccieri: None declared, Vanessa Smith: None declared, Susanne Ullman: None declared, Ulrich Walker: None declared, Thomas Geiser: None declared, Oliver Distler: None declared, Britta Maurer Speakers bureau: Boehringer-Ingelheim, Consultant of: Novartis, Boehringer Ingelheim, Janssen-Cilag, Grant/research support from: AbbVie, Protagen, Novartis Biomedical Research, Florian Kollert Shareholder of: Roche, Consultant of: BMS, Actelion, Boehringer-Ingelheim, Pfizer, Grant/research support from: Roche, Gilead, Pfizer, Employee of: Roche

POS1232 LONG-TERM OUTCOMES OF COVID-19 VACCINATION IN PATIENTS WITH RARE AND COMPLEX CONNECTIVE TISSUE DISEASES: AN AD-INTERIM ANALYSIS OF ERN-ReCONNET VACCINATE STUDY

Background

Since the COVID-19 vaccination campaign was launched all over Europe, there has been general agreement on how benefits of SARS-CoV2 vaccines outweigh the risks in patients with rare connective tissue diseases (rCTDs). Yet, there is still limited evidence regarding safety and efficacy of such vaccines in these patients, especially in the long-term. For this reason, in the framework of ERN-ReCONNET, an observational long-term study (VACCINATE) was designed in order to explore the long-term outcome of COVID-19 vaccination in rCTDs patients. The consent form was developed thanks to the involvement of the ERN ReCONNET ePAG Advocates (European Patients Advocacy Group).

Objectives

To evaluate the safety profile of COVID-19 vaccination in rCTDs patients and the potential impact on disease activity. Primary endpoints were the prevalence of adverse events (AEs) and of disease exacerbations post-vaccination. Secondary endpoints were the proportion of serious adverse events (SAEs) and adverse events of special interest for COVID-19 (adapted from https://brightoncollaboration.us/wp-content/uploads/2021/01/SO2_D2.1.2_V1.2_COVID-19_AESI-update-23Dec2020-review_final.pdf)

Methods

The first ad-interim analysis of the VACCINATE study involved 9 ERN-ReCONNET Network centres. Patients over 18 years of age with a known rCTD and who received vaccine against COVID-19 were eligible for recruitment. Demographic data and diagnoses were collected at the time of enrolment, while the appearance of AEs and potential disease exacerbations were monitored after one week from each vaccination dose, and then after 4, 12 and 24 weeks from the second dose. A disease exacerbation was defined as at least one of the following: new manifestations attributable to disease activity, hospitalization, increase in PGA from previous evaluation, addition of corticosteroids or immunosuppressants.

Results

A cohort of 300 patients (261 females, mean age 52, range 18-85) was recruited. Systemic lupus erythematosus (44%) and systemic sclerosis (16%) were the most frequent diagnoses, followed by Sjogren’s syndrome (SS,12%), idiopathic inflammatory myositis (IMM,10%), undifferentiated connective tissue disease (UCTD,8%), mixed connective tissue disease (MCTD,4%), Ehlers-Danlos’s syndrome (EDS,4%), antiphospholipid syndrome (APS,2%). AEs appearing 7 days after the first and second doses were reported in 93 (31%) and 96 (32%) patients respectively, mainly represented by fatigue, injection site reaction, headache, fever and myalgia. Otitis, urticaria, Herpes Simplex-related rash, stomatitis, migraine with aura, vertigo, tinnitus and sleepiness were reported with very low frequency. Less than 2% of patients experienced AEs within 24 weeks from the second dose. No SAEs or AEs of special interest were observed in the study period. There were 25 disease exacerbations (8%), 7 of which severe. The highest number of exacerbations was observed after 4 weeks from the second dose (12 within week 4, 6 within week 12 and 7 within week 24). Disease exacerbation was most frequent in patients with EDS (33%) and MCTD (25%).

Conclusion

This preliminary analysis shows that COVID-19 vaccination is safe in rCTDs patients. AEs appear most often early after vaccination and are usually mild. Disease exacerbations are not frequent, but can be potentially severe and tend to occur most frequently within the first month after vaccination. Exacerbations can also occur 3-6 months after vaccination, although a causal relationship with the vaccination remains to be established. Our present data underline the importance of long-term observational studies.

Table 1.

AEs and disease exacerbations per disease

DiagnosisPatients enrolled (%) (n=300)EAs after 1st and 2nd dose (%)Exacerbations (%)APS25714EDS45033IIM10527MCTD44225SS12598SLE44698SSC16492UCTD850-

Acknowledgements

VACCINATE is a study promoted by the European Reference Network on rare and complex connective tissue diseases, ERN ReCONNET. This publication was funded by the European Union’s Health Programme (2014-2020)

Disclosure of Interests

None declared

AB0348 THE PROPER STUDY: A 48-WEEK ANALYSIS OF A PAN-EU REAL-WORLD STUDY OF SB5 BIOSIMILAR FOLLOWING TRANSITION FROM REFERENCE ADALIMUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS, AXIAL SPONDYLOARTHRITIS OR PSORIATIC ARTHRITIS

Background

SB5, a biosimilar to reference adalimumab (ADL), received EU marketing authorisation in 2017, based on pre-clinical and clinical phase I and III studies that demonstrated bioequivalence and comparable efficacy, safety and immunogenicity to ADL.

Objectives

The real-world study ‘PROPER’ is designed to provide insights into outcomes of the transition from ADL to SB5 outside the randomised, controlled, clinical trial setting.

Methods

Under an umbrella design, 1000 patients with immune-mediated inflammatory disease were enrolled at centres in Belgium, Germany, Ireland, Italy, Spain and the UK, and followed for 48 weeks post-transition. Eligible patients with a diagnosis of rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), ulcerative colitis or Crohn’s disease had been transitioned to SB5 as part of routine treatment following a minimum of 16 weeks’ treatment with ADL. Data were captured from patient charts retrospectively for 24 weeks prior to and prospectively and/or retrospectively up to 48 weeks after SB5 initiation. This analysis of the rheumatology cohort reports clinical characteristics, disease scores, persistence on SB5, clinical management and safety up to the closing date of November 30th, 2021.

Results

Of the 496 patients included in this analysis, the majority were enrolled in UK (n=174), Germany (n=145) and Spain (n=73); Italy, Ireland and Belgium enrolled 45, 44 and 15 patients respectively. At study close, 487 patients had completed 48 weeks of follow-up; 397 of those remained on SB5 throughout.

Methotrexate was received as concomitant therapy by 37% of patients and 20% had received a biologic therapy prior to reference ADL. Most patients (89.3% of RA, 92.1% of axSpA, 97.3% of PsA) transitioned to SB5 at the same dose regimen received for ADL.

Clinical characteristics, SB5 dose and flare are detailed in Table 1, disease scores in Figure 1.

Table 1.

Patient clinical characteristics, SB5 dose, flare

RA (N=207)axSpA (N=127)PsA (N=162)Age at SB5 initiation (years), mean (SD); IQR60.1 (11.8)53.0, 68.050.3 (13.4)38.0, 61.053.3 (12.0)45.0, 62.0Duration of disease (years), mean (SD); IQR13.3 (11.4)5.0, 19.518.8 (13.5)9.0, 25.012.2 (9.9)4.0, 19.0n%n%n%Women15072.54031.57345.1Patients receiving SB5 40mg Q2WBaseline15273.411590.614992.0Week 4813272.59387.712491.9Episodes of Flare018790.310784.313985.81209.71814.22012.3200.021.631.9How was Flare diagnosedDisease score1155.0731.81038.5Patient-reported symptoms1995.022100.026100.0Secondary Loss of Response315.000.0726.9Action taken for FlareBiologic therapy dose adjusted420.029.1519.2Non-biologic therapy dose adjusted840.0313.6934.6Clinical investigation00.014.5311.5Other*945.01359.11661.5

*Includes cessation of therapy, prescription of corticosteroids, physical exercise, no action.

IQR, interquartile range; SD, standard deviation; Q2W once two-weekly.

Figure 1.

Disease scores (paired patients), mean (95% CI)

Fifteen patients each experienced one unrelated Serious Adverse Event (SAE): 2 in the axSpA cohort [tachycardia, intracranial haemorrhage]; 6 in the PsA cohort [myocardial infarct (2), breast carcinoma, COVID-19, gallbladder calculus, dyspnoea]; 7 in the RA cohort [facial numbness, depression, COVID-19, pneumonia, diverticulitis, parvovirus, coronary occlusion]. Two patients reported SAEs considered causally related to SB5: Herpes zoster and pneumonia (RA cohort), and ALS with worsening (PsA cohort).

Conclusion

This analysis of a large, contemporary cohort of EU patients with established RA, axSpA or PsA shows treatment effectiveness maintained at 48 weeks after switching from ADL to SB5, with most patients continuing on SB5 Q2W throughout. Episodes of flare were uncommon, and the importance of patient-reported symptoms in recognition of flare is evident. No new safety signals were observed.

Acknowledgements

Statistical services were provided by FGK Clinical Research GmbH, Munich, Germany. Data management services were provided by Worldwide Clinical trial, Research Triangle Park, NC, USA. Funding was provided by Biogen International GmbH.

Disclosure of Interests

Ulf Müller-Ladner Consultant of: Biogen, Grant/research support from: Biogen, Karl Gaffney Speakers bureau: Novartis, UCB, AbbVie, Lilly, Consultant of: Novartis, UCB, AbbVie, Lilly, Pfizer, Grant/research support from: NAAS, AbbVie, Pfizer, UCB, Novartis, Lilly, Cellgene, Celltrion, Janssen, Gilead, Biogen, Deepak Jadon Consultant of: AbbVie, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Oxford University Press, Pfizer, Roche, Sandoz, UCB, Grant/research support from: AbbVie, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Oxford University Press, Pfizer, Roche, Sandoz, UCB, Marco Matucci-Cerinic Consultant of: Chemomab, Biogen, Pfizer, Lilly, Behring, Janssen, MSD, Eugenio Chamizo Carmona Speakers bureau: Abbvie, Amgen, Biogen, BMS, Celgene, Eli Lilly, Fresenius-Kabi, Galapagos, Janssen, MSD, Novartis, Pfizer, and UCB, Consultant of: Abbvie, Amgen, Biogen, BMS, Celgene, Eli Lilly, Fresenius-Kabi, Galapagos, Janssen, MSD, Novartis, Pfizer, and UCB, Ulrich Freudensprung Shareholder of: May hold stock in Biogen, Employee of: Biogen, Janet Addison Shareholder of: May hold stock in Biogen, Employee of: Biogen

POS1246 COVID-19 IN RITUXIMAB TREATED PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES

Background

At the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease 2019 (COVID-19) pandemic, the influence of anti-inflammatory therapy on the course of SARS-CoV-2 infection in patients with inflammatory rheumatic diseases (IRD) was unknown. In the meantime, several data indicate an association of severe courses of COVID-19 with the use of rituximab (RTX).

Objectives

To gather further knowledge about SARS-CoV-2 infections in RTX-treated IRD patients, data from the German COVID-19-IRD-registry were analysed.

Methods

Hospitalisation was used as a surrogate of COVID-19 severity. Baseline characteristics, disease features, medication and outcome of COVID-19 were compared in RTX-treated inpatients and outpatients.

Results

In total, 3592 cases were reported in the registry, which included 130 RTX patients (3.6%) for our analysis. RTX-treated inpatients were older than RTX-treated outpatients (median age 63 y vs 56 y, p=0.007). Patients with granulomatosis with polyangiitis treated with RTX (n=32) showed a significant higher COVID-19 related hospitalisation rate (33% vs 11%, p=0.005), which was not the case for patients with rheumatoid arthritis (49% vs 50%). Cardiovascular comorbidities were reported more frequently in hospitalised RTX-treated patients (20% vs. 6%, p=0.032). More than 50% of the RTX-treated inpatients developed COVID-19 related complications, e.g. acute respiratory distress syndrome. The median time period between the last RTX treatment and SARS-CoV-2 infection was shorter in inpatients than in non-hospitalised patients (3 (range 0-17) vs. 4 months (range -29), p=0.039). The COVID-19 related mortality rate was 14% (n=19) in RTX-treated IRD patients. In RTX-treated inpatients and outpatients, there were no relevant differences with respect to the use of concomitant glucocorticoids or other disease modifying anti-rheumatic drugs, disease activity, median last RTX dose or median number of immunomodulatory drugs prior to RTX treatment.

Conclusion

In addition to general risk factors, such as age and comorbidities, it is already known that IRD patients treated with RTX show a higher rate of severe COVID-19. In our registry, RTX-treated patients with granulomatosis with polyangiitis appear to be at even higher risk to develop severe COVID-19 compared to other IRD. Moreover, the shorter the time since the last RTX treatment, the higher seems to be the risk of developing severe COVID-19. This might be explained by a more profound B-cell depletion in the first weeks after RTX treatment warranting further studies.

Disclosure of Interests

None declared

POS0893 FACTORS TO CONSIDER FOR MEASURING THE EFFECT OF LUNG FUNCTION ON PATIENT REPORTED OUTCOMES IN SYSTEMIC SCLEROSIS PATIENTS: ANALYSIS OF THE EUSTAR DATABASE

Background

Patient Reported Outcomes (PROs) are central to measure how patients feel and function especially when determining the effect of disease modifying agents. In patients with Systemic Sclerosis associated Interstitial Lung Disease (SSc-ILD), dyspnea is the main driver of HAQ decline but the effect of reduced lung function on both generic and specific measures of functional impairment is not well defined, and there are many potential confounding biases that could distort the apparent extent and direction of this relationship. Moreover, collider biases potentially induced by selection into the cohort and in clinical trials can also play a role.

Objectives

To define within the EUSTAR database, the correlation of Forced Vital Capacity (FVC) and functional impairment PROs and identify potential confounders to be considered in casual inference studies.

Methods

A cross-sectional analysis included for each patient with SSc-ILD (by X-ray and/or HRCT) in the EUSTAR registry the last visit with at least one PRO (Health Assessment Questionnaire Disability Index [HAQ-DI], Cochin hand function scale [CHFS] and/or dyspnoea visual analogue scale [VAS]) and % predicted FVC (%pFVC), if available. Patients with LVEF≤50% or pulmonary arterial hypertension at RHC were excluded. SSc-ILD with restricted lung volume was defined as %pFVC≤70 [1]. Spearman’s correlation analysis was performed. Results of this analysis and literature review were integrated to design a directed acyclic graph (DAG) and identify the appropriate confounder adjustment set for the total causal effect of FVC on functional impairment PROs.

Results

Among 17.338 SSc patients in the EUSTAR registry (extracted in November 2019), 727 SSc-ILD patients fulfilled the inclusion criteria (median %pFVC 90 (IQR 74-104), median %pDLCO 60 (IQR 47-52)). Patients with %pFVC<70 (n=149), as compared to those with %pFVC≥70 (n=578) had worse HAQ-DI, CHFS and VAS-dyspnoea scores (Table 1). In unadjusted analysis, %pFVC showed a weak correlation with HAQ-DI (r=-0.21) and CHFS (r=-0.17), but a stronger correlation with VAS dyspnoea (r=-0.33).

Table 1.

Results are reported as number/number available (%) for dichotomic variables, or as median (IQR) (n available) for continuous variables.

%pFVC≥70 (n=578)%pFVC<70 (n=149)Age at disease onset (years)60.6 (52.3-69.3) (546)52.5 (45.6-63-7) (137)Disease duration (months)134.4 (77.5-212.2) (546)110.3 (66.3-199.7) (137)Male sex84/578 (14.5)32/149 (21.5)Anti-Scl70+231/468 (40.7)81/122 (66.4)Smoker ever52/389 (13.4)17/107 (15.9)Caucasian ethnicity545/569 (95.8)131/145 (90.3)dcSSc167/559 (29.9)74/147 (50.3)Oesophageal symptoms319/571 (55.9)93/147 (63.3)Muscle weakness78/565 (13.8)37/149 (24.8)CRP elevation141/540 (26.1)53/134 (39.6)Elevated sPAP (ECHO)45/456 (9.9)21/121 (17.2)Pericardial effusion2/448 (0.4)4/110 (3.6)Diastolic function abnormality151/431 (35.0)31/102 (30.4)Conduction blocks78/480 (16.3)35/120 (29.2)%pDLCO62 (52-74) (527)42 (35-53) (118)CHFS7 (1-23) (493)16 (2-34.8) (114)HAQ-DI0.63 (0.13-1.13) (578)1.25 (0.38-2) (139)VAS dyspnoea (0-100)15 (10-45) (391)40 (20-70) (109)NYHA stage 3/447/561 (8.4)37/143 (25.9)

Subsequently, we created a DAG showing the proposed causal pathway considered relevant to the relationship between FVC and HAQ (Figure 1).

Conclusion

Lung function as measured by FVC appears to correlate with worse patient-reported function in our unadjusted analysis of the large multicentre EUSTAR dataset. However, to estimate the total causal effect we must consider a multitude of potentially confounding factors, which need to be integrated and analysed in a causal inference framework. The proposed DAG will inform the development of simulations of the potential impact of bias (confounding, collider and omitted variable) on effect estimates we could obtain from EUSTAR cohort.

References

[1]Goh NS, et al. Am J Respir Crit Care Med, 2008.

Disclosure of Interests

Maria Grazia Lazzaroni Grant/research support from: Research grant from Boehringer-Ingelheim, Michelle Wilson Grant/research support from: Research grant from Boehringer-Ingelheim, Elizabeth Hensor: None declared, Jörg H.W. Distler: None declared, Giovanna Cuomo: None declared, Elise Siegert: None declared, Ulf Müller-Ladner: None declared, Yannick Allanore: None declared, Maria Joao Salvador: None declared, Branimir Anic: None declared, Ulrich Walker: None declared, László Czirják: None declared, Camillo Ribi: None declared, Cristina-Mihaela Tanaseanu: None declared, Armando Gabrielli: None declared, Anna-Maria Hoffmann-Vold: None declared, Oliver Distler: None declared, Francesco Del Galdo: None declared

POS0387 RISK STRATIFICATION APPROACHES PERFORM DIFFERENTLY IN SSc-ASSOCIATED PAH IN EUSTAR

Background

Pulmonary arterial hypertension (PAH) is a major clinical challenge in systemic sclerosis (SSc), and is associated with high mortality. Risk stratification provides an estimate for individual patient risk of 1-year mortality. The aim is to detect patients with the worst prognosis to optimize management strategies. Nine risk stratification approaches have been proposed in PAH, but have not been validated in SSc-PAH.

Objectives

To assess four risk stratification models and their performance to predict 1- and 3- year mortality and to identify the best risk assessment approach for SSc-PAH.

Methods

We included all patients with SSc diagnosed with PAH by right heart catheterization (RHC) from the European scleroderma trial and research (EUSTAR) database from 2001 to February 2021. PAH was defined as mean pulmonary arterial pressure (mPAP) ≥25 mmHg, pulmonary artery wedge pressure (PAWP) ≤15mmHg, and pulmonary vascular resistance (PVR) >3 Wood units (WU) in the absence of significant interstitial lung disease. We applied four different approaches for risk stratification at time of PAH diagnosis. Risk parameters included New York Heart Association (NYHA) class, 6-minute walk distance (6MWD), NT-proBNP or BNP, and echocardiographic and hemodynamic parameters with cut-off values based on the 2015 ESC/ERS Guidelines. Model 1 and 2 stratified patients into low, intermediate and high-risk categories; while Model 3 and 4 stratified the patients into four categories (low, intermediate-low, intermediate-high and high).

Model 1: Patients with ≥ 1 high-risk parameter were considered at high risk; with ≥ 1 intermediate-risk parameter at intermediate risk, otherwise at low risk1

Model 2: Each variable was graded from 1 to 3 representing low to high risk. The mean of available risk parameters was rounded to the nearest integer to define the risk category2

Model 3: Equals Model 2, but the intermediate risk group was divided into intermediate-low and intermediate-high based on the mean score3

Model 4: Stratifies patients into four risk categories based on the proportion of low-risk parameters3

We performed analysis of 1- and 3- year mortality in patients with a minimum follow-up of 1 and 3 years, respectively.

Results

Of 911 patients who conducted RHC, 273 (30%) were diagnosed with SSc-PAH according to the inclusion criteria (Table 1). Median follow-up time was 2.8 years (IQR 1.3-5.3). The models varied in their ability to predict mortality (Figure 1). Model 1 and 4 either over- or underestimated mortality. Model 2 stratified patients according to the expected 1-year mortality of <5%, 5-10% and >10% suggested by the ESC/ERS Guidelines. Model 3, which divided the intermediate risk group in two different risk groups, segregated the risk of mortality further within this group.

Table 1.

Demographic and clinical characteristics of patients segregated by risk stratification (Model 3)

NAll patients (n=273)Low-risk (n=78)Intermediate-low (n=118)Intermediate-high (n=56)High-risk (n=21)Age, years (SD)27365 (10.7)65 (10.3)65 (10.7)65 (10.8)67 (12.8)Female sex, n (%)273230 (84)64 (82)98 (83)48 (86)20 (95)lcSSc, n (%)263221 (84)60 (80)99 (86)47 (90)15 (71)NYHA 3 or 4, n (%)261155 (59)12 (16)75 (68)49 (89)19 (95)NT-proBNP, pg/ml (IQR)1111941 (230-1485)215 (103-377)763 (325-1418)1926 (1051-5681)3314 (1129-6553)6MWD, m (SD)196321 (124.1)404 (119.7)314 (99.9)262 (128.6)215 (96.0)RHC:- mPAP, mmHg (SD)27340 (11.0)35 (8.8)41 (11.5)41 (10.8)45 (11.6)- PAWP, mmHg (SD)2739 (3.2)9 (3.0)9 (3.4)9 (3.2)8 (3.1)- Cardiac index, l/min/m2(SD)2602.8 (0.8)3.2 (0.7)2.7 (0.8)2.6 (1.0)2.0 (0.5)- PVR, WU (SD)2737.4 (4.1)5.3 (2.8)7.9 (4.0)7.9 (4.2)11.3 (4.7)Figure 1.

1- and 3-year mortality according to risk category in the four different models

Conclusion

Model 3 provides signals for a better risk stratification of patients with newly diagnosed SSc-PAH, with progressively increasing mortality across the categories. This may provide guidance for optimized management in clinical practice.

References

[1]Hoffmann-Vold, Rheum 2018

[2]Kylhammar, Eur Heart J 2018

[3]Kylhammar, ERJ open 2021

Acknowledgements

The authors thank all EUSTAR collaborators.

Disclosure of Interests

Hilde Jenssen Bjørkekjær: None declared, Cosimo Bruni Speakers bureau: Actelion, Consultant of: Boehringer-Ingelheim, Patricia Carreira: None declared, Paolo Airò Speakers bureau: Boehringer Ingelheim, Bristol-Myers-Squibb, Consultant of: Bristol-Myers-Squibb, Grant/research support from: Bristol-Myers-Squibb, Roche, Janssen, CSL Behring, Carmen Pilar Simeón-Aznar Speakers bureau: Janssen, Boehringer Ingelheim and MSD, Consultant of: Janssen, Boehringer Ingelheim, Marie-Elise Truchetet: None declared, Alessandro Giollo: None declared, Alexandra Balbir-Gurman: None declared, Mickael Martin: None declared, Christopher P Denton Speakers bureau: Boehringer Ingelheim; Janssen, Consultant of: Boehringer Ingelheim; GSK; Corbus; Sanofi; Roche; Horizon; CSL Behring; Acceleron, Grant/research support from: CSL Behring; Horizon; GSK; Servier, Armando Gabrielli: None declared, Håvard Fretheim Consultant of: Bayer, GSK, Actelion, Imon Barua: None declared, Helle Bitter Speakers bureau: Boehringer Ingelheim, Øyvind Midtvedt: None declared, Kaspar Broch: None declared, Arne Andreassen: None declared, Yoshiya Tanaka Speakers bureau: Gilead, Abbvie, Behringer-Ingelheim, Eli Lilly, Mitsubishi-Tanabe, Chugai, Amgen, YL Biologics, Eisai, Astellas, Bristol-Myers, Astra-Zeneca, Consultant of: Eli Lilly, Daiichi-Sankyo, Taisho, Ayumi, Sanofi, GSK, Abbvie, Grant/research support from: Asahi-Kasei, Abbvie, Chugai, Mitsubishi-Tanabe, Eisai, Takeda, Corrona, Daiichi-Sankyo, Kowa, Behringer-Ingelheim, Gabriela Riemekasten: None declared, Ulf Müller-Ladner: None declared, Marco Matucci-Cerinic: None declared, Ivan Castellví: None declared, Elise Siegert: None declared, Eric Hachulla Speakers bureau: Johnson & Johnson, GlaxoSmithKline, Roche-Chugai, Consultant of: Bayer, Boehringer Ingelheim, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Sanofi-Genzyme, Grant/research support from: CSL Behring, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Sanofi-Genzyme, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim

AB0675 Health related quality of life in patients with mixed connective tissue disease: A comparison with matched systemic sclerosis patients

Background

Mixed connective tissue disease (MCTD) is a systemic auto-immune disorder, being probably the least common among the connective tissue diseases. Symptoms can be severe and could affect health-related quality of life (HRQoL). Identification of the burden of MCTD patients is of key importance to provide appropriate pharmacological and non-pharmacological care. No reports on HRQoL have been published in adult patients with MCTD.

Objectives

To perform an explorative study to evaluate HRQoL and its main determinants in MCTD patients, and compare HRQoL between MCTD and matched systemic sclerosis (SSc) patients.

Methods

MCTD patients fulfilling the Kahn criteria and participating in the MCTD prospective follow-up cohort of the Leiden University Medical Center were included. In addition, SSc patients matched for age, gender and disease duration were included for comparison. Data on disease characteristics, functional disability and HRQoL were collected annually for both disease groups. HRQoL was evaluated using the 36-Item Short Form Health Survey (SF36) and EuroQol (EQ5D). At baseline, HRQoL, as reflected by SF36 mental component score (MCS), SF 36 physical component score (PCS) and EQ5D were compared between MCTD and SSc patients. For MCTD patients, factors associated with HRQoL at baseline were identified using linear regression and change in HRQoL over 3 years was evaluated using linear mixed models. In addition, characteristics of MCTD patients who showed worsening of MCS and/or had PCS superior to the minimal clinical important difference of three points were identified.

Results

Thirty-four MCTD patients (121 visits; 82% female, mean age 42 years, median disease duration 45 months) and 102 SSc patients (424 visits; 82% female, mean age 45 years, median disease duration 49 months) were included. At baseline, MCTD-patients more often had ILD (47% vs. 34%, p=0.027), cardiac involvement (30% vs. 2%, p<0.001), synovitis (26% vs. 11%, p=0.004) and myositis (15% vs. 1%, p=0.001) compared to SSc patients, whereas SSc patients more often used immunosuppressive treatments except for hydroxychloroquine (MCTD:18% vs. SSc:7%, p=0.007).

Baseline HRQoL in MCTD was comparable to HRQoL in SSc, with mean SF36-PCS of 40.2 (SD:9.1) and mean SF36-MCS of 44.9 (SD:9.9), which is (nearly) one standard deviation lower than the general Dutch population. The SF36 subscore “general health perception” was the most impacted in both groups (MCTD: 38.5 [SD:7.0], SSc: 39.9 [SD:8.9]). The median EQ5DNL was 0.38 (IQR:0.14 – 0.54) and comparable between SSc and MCTD.

At baseline, in MCTD, ILD was significantly associated with SF36-PCS (β:6.98, 95% CI: 1.10 to 12.86) and SF36-MCS (β:-8.10, 95% CI:-14.93 to -1.26). Sclerodactyly was significantly associated with EQ5DNL (β:0.006; 95% CI:0.002 to 0.010) and SF36-PCS (β:0.12, 95% CI:0.03 to 0.21). No other significant associations were identified.

Over time, in MCTD, both the SF36-MCS and SF36-PCS improved significantly (MCS: β:2.35/year [95% CI:0.58 to 4.13], PCS: β:1.34/year [95% CI:0.03 to 2.65), whereas EQ5DNL was stable. Explorative analyses did not reveal a specific clinical characteristic with significant impact on the change of HRQoL over time. With an MCID of 3 points on the MCS and PCS, 7 MCTD-patients worsened on the MCS and 3 on the PCS. Patients who showed worsening of MCS over time tended to be older, more often had ILD, sclerodactyly and GI complaints, and had worse exercise tolerance. All these differences did not reach statistical significance. The patients who decreased PCS more often had ILD (100% vs. 41%, p=0.015), and used glucocorticoids more often (33% vs. 0%, p=0.046), were slightly older and had a worse exercise tolerance as compared to those who showed a stable/improving PCS over time.

Conclusion

Like in SSc, HRQoL is significantly impaired in MCTD, especially the general health perception of patients. Cardiac involvement, ILD, age and worse functional disability might specifically impact HRQoL in MCTD. However, these associations need further evaluations in larger cohorts.

Disclosure of Interests

None declared

AB0622 The Joint Vasculitis Registry in German-speaking countries (GeVas) – subgroup analysis of 113 GPA-patients

Background

Granulomatosis with polyangiitis (GPA) is the second most frequent vasculitis in Germany with an annual incidence of 34 per million and a prevalence of 210 per million [1]. GPA is characterized by its chronic course, frequent relapses, significant overall morbidity and mortality, and substantial socio-economic impact. Multiorgan involvement affecting the respiratory tract, kidney, and other organs is common. Limited variants also occur [2]. So far, prospective long-term observational data on the disease course of GPA are missing in Germany. Therefore, the Joint Vasculitis Registry in German-speaking countries (GeVas) has been established to follow the course of patients recently diagnosed with vasculitis or a change of their treatment due to a relapse (inception cohort). The GeVas registry allows long-term follow-up of a substantial cohort of vasculitis patients in a multicenter setting.

Objectives

To present the first data on the follow-up of newly diagnosed and relapsing GPA enrolled in the GeVas registry.

Methods

GeVas is a prospective, web-based, multicenter, clinician-driven registry for the documentation of organ manifestations, damage, long-term outcomes, and therapy regimens in various types of vasculitis. Recruitment started in June 2019. By January 2022, 17 centers in Germany were initiated and started enrolling patients. Meanwhile, more than 350 patients have been documented in the registry. Sites in Austria and the German-speaking cantons of Switzerland will be integrated soon [3].

Results

By mid-October 2021, the participating centers included 113 patients with GPA. The majority of patients were PR3-ANCA positive and affected by general symptoms, ENT, lung, renal, and neurological involvement. Patients commonly received cyclophosphamide or rituximab in combination with glucocorticoids for the induction of remission. Fewer patients received methotrexate or other immunosuppressants. Patient characteristics and therapy are summarized in Table 1.

Table 1.

Patient characteristics (n = 113). *Unless otherwise specified.

CategoryFeaturen (%)*AgeAge (years); median [range]60 [51 - 70]GenderMale61 (54.0)Female52 (46.0)Reason for inclusion in the registryNewly diagnosed vasculitis57 (51.4)Relapse56 (49.6)ANCA statusPR3-ANCA99 (87.6)MPO-ANCA4 (3.6)ANCA negative9 (7.9)Organ manifestationGeneral symptoms86 (76.1)ENT69 (61.1)Lung/chest66 (58.4)Renal35 (31.0)Cardiovascular7 (6.2)GI3 (2.7)Neurological27 (23.9)TherapyGlucocorticoid102 (90.3)Rituximab56 (49.6)Cyclophosphamide37 (32.7)Methotrexate and other immunosuppressants, respectively26 (23.0) and 19 (16.8), respectively

Conclusion

Here, we present the first interim analysis of the GeVas registry. Clinical manifestations of GPA reported herein show less frequent renal involvement in comparison with a recent report from another European registry (POLVAS) and an UK study [4, 5]. This is potentially related to the predominance of recruiting rheumatology centers thus far. By contrast, respiratory tract involvement is more frequent and PR3-ANCA less common in Japan [5]. Further data are prospectively documented and a follow up analysis is in progress.

References

[1]Hellmich B, et al. New insights into the epidemiology of ANCA-associated vasculitides in Germany: results from a claims data study. Rheumatology 2021;60:4868-73.

[2]Kitching AR, et al. ANCA-associated vasculitis. Nat Rev Dis Primers 2020;6:71.

[3]Iking-Konert C, et al. The Joint Vasculitis Registry in German-speaking countries (GeVas) – a prospective, multicenter registry for the follow-up of long-term outcomes in vasculitis. BMC Rheumatol 2021;5:40.

[4]Wójcik K, et al. Clinical characteristics of Polish patients with ANCA-asscoiated vasculitides – retrospective analysis of POLVAS registry. Clin Rheumatol 2019;38:2553-63.

[5]Furuta S, et al. Comparison of the phenotype and outcome of granulomatosis with polyangiitis between UK and Japanese cohorts. J Rheumatol 2017;44:216-22.

Acknowledgements

GeVas was supported by unrestricted grants by: DGRh, John Grube Foundation, Vifor and Roche Pharma

Disclosure of Interests

Sabrina Arnold: None declared, Pia Wallmeier: None declared, Fabian Schubach: None declared, Gabriele Ihorst: None declared, Peer Aries: None declared, Raoul Bergner Consultant of: VIFOR, Jan Philip Bremer: None declared, Norman Görl: None declared, Bernhard Hellmich: None declared, Jörg Henes: None declared, Bimba Hoyer: None declared, Antje Kangowski: None declared, Ina Kötter: None declared, Claudia Metzler: None declared, Ulf Müller-Ladner: None declared, Matthias Schaier: None declared, Ulf Schönermark: None declared, Jens Thiel: None declared, Leonore Unger: None declared, Nils Venhoff Speakers bureau: Roche and Vifor: speaker honoraries, Consultant of: Roche and Vifor: advisory boards, Grant/research support from: John-Grube Research Award 2021, Julia Weinmann-Menke: None declared, Jana Petersen: None declared, Christof Iking-Konert Speakers bureau: Lecture fees from: Chugai, GSK, Roche, and Vifor, Consultant of: Consulting fees from: Chugai, GSK, Roche, and Vifor, Grant/research support from: Research grants for GeVas: Roche, Vifor, DGRh, John Grube Foundation, Peter Lamprecht Speakers bureau: Chugai, GSK, Roche, and Vifor, Consultant of: Chugai, GSK, Roche, and Vifor, Grant/research support from: DGRh, John Grube Foundation, Roche, and Vifor

POS0800 THE JOINT VASCULITIS REGISTRY IN GERMAN-SPEAKING COUNTRIES (GeVas) – SUBGROUP ANALYSIS OF 131 GCA-PATIENTS REFERENCES:

Background

The most frequent form of vasculitis in elderly people is giant cell arteritis (GCA) with an annual incidence rate less than 10 per 100,000 persons over the age of 50. Like most vasculitides, GCA is characterized by chronicity and relapses, leading to significant overall morbidity and higher mortality in a subset of patients with aortic involvement and dissection. Most studies carried out so far have been retrospective, used monocentric study designs and small patient cohorts. Therefore, the Joint Vasculitis Registry in German-speaking countries (GeVas) has been established to record patients, who have been recently diagnosed with vasculitis or who have changed their treatment due to a relapse (inception cohort). The GeVas-Registry allows a long-term follow-up of a substantial cohort of vasculitis patients in a prospective and multicenter manner.

Objectives

To describe the subgroup of GCA and its characteristics within the GeVas registry.

Methods

GeVas is a prospective, web-based, multicenter, clinician-driven registry for the documentation of organ manifestations, damage, long-term outcomes, and therapy regimens in various types of vasculitis. Recruitment started in June 2019. By January 2022, 17 centers in Germany were initiated and have begun enrolling patients. Meanwhile, more than 350 patients have been documented in the registry. Sites in Austria and the German-speaking cantons of Switzerland will be integrated soon (1).

Results

By mid-October 2021, the participating centers recruited 131 GCA patients into the registry. 21.7% of patients (n=28) were enrolled in the registry due to relapse, and 78.3% (n=101) due to a first-time diagnosis. In accordance with long-standing epidemiology data, the majority of patients (67,2%), were female (n=88), and 32.8% (n=43) were male. Mean age was 74 years (max. 92y, min. 52y). The most frequently recorded organ manifestations in GCA patients addressed cranial and ophthalmic symptoms, and the cardiovascular system. However, vascular lung/chest involvement was also observed in 3% of cases (n=4). Out of the 131 patients, 97.7% (n=128) received immunosuppressive therapy, three refused to take any medication. An equal number of patients were treated with glucocorticoid (GC) therapy. While about two equal parts were treated by stable long term oral GC therapy (47,7%, n=62) or by i.v. pulse therapy followed by tapering (49,2%, n=64), only about 2.3% (n=3) were treated by oral GC therapy with intermittent i.v. pulses. 48.5% (n=63) of patients received tocilizumab as additional immunosuppressive therapy, 19.2% (n=25) methotrexate, and 18.5% (n=24) cyclophosphamide i.v. pulses.

Conclusion

In June 2019, we successfully established the prospective multicenter vasculitis registry GeVAS. It describes the first systematically recorded prospective GCA cohort in German-speaking countries. Its characteristics correspond to those that can be expected from the literature, with some unexpected finding e.g. the high proportion of patients treated with cyclosphosphamid, probably reflecting a sicker patient population with e.g. aortic or central nervous involvement. After 2.5 years of follow-up documentation, the first long-term results will be systematically evaluated and interpreted. The newly acquired data on disease manifestation, diagnostics and therapy regimens will provide important insights into the treatment of GCA patients in Germany and may generate further research goals.

References

Trial registration: German Clinical Trials Register (Deutsches Register Klinischer Studien): DRKS00011866. Registered 10 May 2019. 3

[1]C Iking-Konert; P Wallmeier; S Arnold; S Adler; K de Groot; B Hellmich; B Hoyer; K Holl-Ulrich; Ihorst; M Kaufmann; I Kötter; U Müller-Ladner; T Magnus; J. Rech; H. Schulze-Koops; N. Venhoff; T. Wiech; P. Villiger; F. Schubach; P. Lamprecht. The Joint Vasculitis Registry in German-speaking countries (GeVas) – a prospective, multicenter registry for the follow-up of long-term outcomes in vasculitis. BMC Rheumatol. 2021 Jul 31;5(1):40. doi: 10.1186/s41927-021-00206-2.

Acknowledgements

GeVas was supported by unrestricted grants by: DGRh, John Grube Foundation, Vifor and Roche Pharma

Disclosure of Interests

Pia Wallmeier: None declared, Sabrina Arnold: None declared, Fabian Schubach: None declared, Gabriele Ihorst: None declared, Peer Aries: None declared, Raoul Bergner Consultant of: Advisory Board VIFOR, Grant/research support from: John-Grube Research Award 2021, Jan Philip Bremer: None declared, Norman Görl: None declared, Bernhard Hellmich: None declared, Jörg Henes: None declared, Bimba Hoyer: None declared, Antje Kangowski: None declared, Ina Kötter: None declared, Tim Magnus: None declared, Claudia Metzler: None declared, Ulf Müller-Ladner: None declared, Matthias Schaier: None declared, Ulf Schönermark: None declared, Jens Thiel: None declared, Leonore Unger: None declared, Nils Venhoff Speakers bureau: Roche and Vifor, Consultant of: Roche and Vifor, Grant/research support from: John-Grube Research Award 2021, Julia Weinmann-Menke: None declared, Jana Petersen: None declared, Peter Lamprecht Speakers bureau: Lecture fees from: Chugai, GSK, Roche, Consultant of: Consulting & lecture fees from: Chugai, GSK, Roche, and Vifor., Grant/research support from: Research grants for GeVas: DGRh, John Grube Foundation, Roche, and Vifor, Christof Iking-Konert Speakers bureau: lecture fees from: Chugai, GSK, Roche, and Vifor., Consultant of: Consulting fees from: Chugai, GSK, Roche, and Vifor., Grant/research support from: Research grants for GeVas: DGRh, John Grube Foundation, Roche, and Vifor;

OP0179 CHARACTERISTICS AND OUTCOMES OF SARS-CoV-2 BREAKTHROUGH INFECTIONS AMONG DOUBLE AND TRIPLE VACCINATED PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES

Background

SARS-CoV-2 vaccines offer the most effective way to reduce the risk of severe COVID-19. Recent data indicate sufficient immune response after vaccination in most patients with inflammatory rheumatic diseases (IRD) on immunomodulatory treatments.

Objectives

To investigate the clinical profile of SARS-CoV-2 breakthrough infections among double and triple vaccinated patients with IRD.

Methods

Data from the German COVID-19-IRD registry, collected by treating rheumatologists between February 2021 and January 2022 were analysed. Patients double or triple vaccinated against COVID-19 ≥14 days prior to proven SARS-CoV-2 infection were identified, and type of IRD, vaccine, immunomodulation, comorbidities and outcome of the infection were compared with 737 unvaccinated IRD-patients with COVID-19.

Results

In total, 271 cases of breakthrough infections were reported, 250 patients (91%) had received two doses of vaccines, 21 (9%) patients three. More than 70% of the patients received Pfizer/Biontech vaccine for the first, second and third vaccination. The median time from second/third vaccine dose to infection was 148 days (range 14-302) days. Most of the patients were diagnosed with inflammatory joint diseases (Table 1). Most of the patients were treated with methotrexate (Table 1). The use of Januskinase inhibitors(i) was more frequently reported in double vaccinated patients (10.4% vs 4.8%), whereas tumor necrosis (TNF)i were reported more often in triple vaccinated patients (33.3% vs. 22.8). Hospitalisation rate was higher in unvaccinated IRD-patients than in vaccinated ones, while fatality rate was similar in unvaccinated and double vaccinated patients. Although the rate of comorbidities and median age were higher in triple-vaccinated patients, infected patients showed a lower rate of hospitalisation, neither COVID-19 related complications, nor the need of oxygen treatment or death.

Table 1.

Profile of vaccinated IRD patients

unvaccinated2ndvaccination3rdvaccinationNumber (737)%Number (250)%Number (21)%Age56 (18-93)57 (22-90)63 (35-88)Female47864.915863.21361.9BMI26.8 (17-53)26.7 (17-55)25.4 (18-41)Inflammatory rheumatic disease (multiple selections possible)Inflammatory joint diseases56175.918674.41676.2Connective tissue diseases10112.8301229.6Vasculitis719.6228.8314.3Other IRD638.52911.614.8Immunomodulation (multiple selections possible)Glucocorticoid21228.86726.8523.8Methotrexate27036.69036838.1Azathioprine192.672.8//Cyclosporine30.410.4//Leflunomide506.872.8//Hydroxychloroquine7910.7239.214.8Sulfasalazine202.793.6//JAKi547.32610.414.8TNFi15821.45722.8733.3Abatacept91.231.2//Rituximab212.8114.414.8Other biologics597.93212.829.6Mycophenolate15241.6//Immunoglobulines20.310.4//Apremilast40.5////Cyclophosphamide10.110.4//No immunomodulation7410228.814.8No/low disease activity62584.822389.21885.7Moderate/high disease activity10213.82710.8314.3ComorbiditiesCardiovascular diseases32944.6130521361.9Diabetes mellitus7610.32510//Osteoporosis435.8218.429.5Chronic renal failure405.4166.4419Cancer/history of cancer152.0104314.3COPD253.4104//ILD162.272.8//Bronchial asthma344.6166.4//Pregnancy70.910.414.8No comorbidity25434.59738.8523.8Complications due to COVID-19Hospitalisation13518.32911.629.5Oxygen treatment11415.5249.6//Invasive ventilation253.493.6//Death162.272.8//

Conclusion

In this cohort of triple-vaccinated IRD patients no fatal courses and no COVID-19 related complications were reported, although median age and rate of comorbidities were higher compared to double-vaccinated and unvaccinated patients. These results support the general recommendations to reduce the risk of severe COVID-19 disease by administering three doses of vaccine, especially in patients with older age, presence of comorbidities, and on immunomodulatory treatment.

Disclosure of Interests

None declared

The influence of the SARS-CoV-2 lockdown on patients with inflammatory rheumatic diseases on their adherence to immunomodulatory medication: a cross sectional study over 3 months in Germany

Objectives

To evaluate the influence of the SARS-CoV-2 pandemic on the adherence of patients with inflammatory rheumatic diseases (IRD) to their immunomodulatory medication during the three-months lockdown in Germany.

Methods

From March 16^th until June 15^th 2020, IRD patients from private practices and rheumatology departments were asked to answer a questionnaire addressing their behaviour with respect to their immunomodulating therapy. Eight private practices and nine rheumatology departments which included rheumatology primary care centres and university hospitals participated. 4252 questionnaires were collected and evaluated.

Results

The majority of patients (54%) were diagnosed with rheumatoid arthritis, followed by psoriatic arthritis (14%), ankylosing spondylitis (10%), connective tissue diseases (12%) and vasculitides (6%). The majority of patients (84%) reported to continue their immunomodulatory therapy. Termination of therapy was reported by only 3% of the patients. The results were independent from the type of IRD, the respective immunomodulatory therapy and by whom the patients were treated (private practices vs rheumatology departments). Younger patients (<60 years) reported just as often as older patients to discontinue their therapy.

Conclusion

The data show that most of the patients continued their therapy in spite of the pandemic. A significant change in behavior with regard to their immunomodulatory therapy was not observed during the three months of observation. The results support the idea that the immediate release of recommendation of the German Society of Rheumatology were well received, supporting the well-established physician-patient-relationship in times of a crisis.

POS0314 PROSPECTIVE EVALUATION OF A DEDICATED, SERIAL OCCUPATIONAL THERAPY EXERCISE PROGRAM ON HAND FUNCTION IN RHEUMATOID ARTHRITIS (RA)

Background:

Rheumatoid arthritis (RA) frequently affects the joints of the hands causing severe pain and significant functional impairment affecting all activities of daily living. At early stages, functional impairment is primarily caused by reversible joint and tendon sheath effusions while at later stages synovial thickening, muscular atrophy and irreversible damage to cartilge, bone, tendons and ligaments cause a reduced range of motion and deformities. Occupational therapy aims to maintain and improve joint mobility and function. However, there is limited data on the effectiveness of serial exercise programs specifically aiming at maintaining and improving hand function in RA.

Objectives:

To prospectively evaluate the effects of a dedicated exercise program on hand function, grip strength, joint mobility and pain compared with conventional outpatient physiotherapy not specifically targeting hand function.

Methods:

A total of 51 RA patients receiving outpatient physiotherapy once a week were enrolled and randomized to either continue their usual therapy (control group) or to participate in a dedicated hand function training (HFT) twice a week in addition to their usual therapy (HFT group). The HFT program was supervised by an occupational therapist who conducted once weekly HFT sessions and instructed the participants to perform an additional self-administered HFT session at home once a week. Study duration was six months with an option to continue HFT for additional 6 months. Study participants were evaluated at baseline and every 3 months.

The primary outcomes hand function and grip strength were assessed using standardized questionnaires (Cochin hand function scale (CHFS), Australian/Canadian Osteoarthritis Hand Index (AUSCAN), Michigan Hand Outcomes Questionnaire (MHOQ)) and dynamometer/pinch gauge readings for different types of grip (cylindrical grasp, spherical grasp, hook grasp, tip to tip pinch and key pinch), respectively. The secondary outcomes joint mobility and pain were assessed using a digital goniometer and visual analogue scales (VAS), respectively. Statistical analysis used the Wilcoxon test for evaluating changes of parameters over time within the groups and the Kruskal Wallis test for group comparisons and Bonferroni-Holm correction.

Results:

41 of the 51 patients (HFT group: n = 20, mean age 60.3 ± 8.4 years; control group: n = 21, mean age 60.5 ± 11.5 years) completed the 6-month study period, 14 patients extended their HFT to 12 months. Within the 6-month study period there were no significant improvements of the primary outcome parameters and of pain within the groups vs. baseline and no significant differences between the groups. Only the CHFS improved significantly in the HFT group as of month 9. A significant improvement of the range of motion vs. baseline was achieved by HFT as early as 3 months after baseline which persisted up to month 12. As some improvement was also seen in the control group, there was no significant difference between the groups. Hand mobility improved particularly in the subgroup of patients >60 years of age. There was no influence by pain intensity at baseline (VAS ≤50 mm vs. VAS >50 mm).

Conclusion:

Serial dedicated HFT for 6 months resulted in improved joint mobility but did not improve global hand function, grip strength and pain in RA patients. A longer treatment duration (≥12 months), a higher treatment frequency (>2 times/week) and a larger cohort of patients may be required.

Disclosure of Interests:

None declared

AB0043 EFFECT OF ANTI-INFLAMMATORY MEDICATION ON INTERACTION OF SYNOVIAL FIBROBLASTS WITH MACROPHAGES IN RHEUMATOID ARTHRITIS

Background:

One of the key mechanisms in the pathogenesis of rheumatoid arthritis (RA) is the interaction of macrophages and synovial fibroblasts during joint inflammation. Increased synergistic proinflammatory activity of both cell types leads to the release of high levels of proinflammatory cytokines, especially of interleukin-6 (IL-6), and of matrix degrading enzymes. If this mechanism is uncontrolled, progressive destruction of articular cartilage and bone will take place.

In active disease, immediate anti-inflammatory treatment with glucocorticoids is usually replaced by disease-modifying anti-rheumatic drugs (DMARDS), especially by methotrexate (MTX) and biologics such as TNF-α- or IL-6-inhibitors. This led to great improvements in prognosis and outcome for RA patients. However, about 40% of patients experience no remission or suffer from side effects of medication. To optimize established substances and to develop new treatment strategies, it is necessary to understand the mechanisms underlying the limited therapeutic effects.

Objectives:

Evaluation of the effect of prednisolone, MTX, adalimumab, tocilizumab on IL-6 secretion by RA synovial fibroblasts (RASF) and macrophages.

Methods:

RA synovium was used for RASF isolation. Peripheral blood mononuclear cells (PBMCs) were isolated from blood of healthy donors and RA patients by using Ficoll© medium followed by density gradient centrifugation. Mononuclear cells were seeded on six well plates (6x10^6/well) and incubated for one week. Then they were stimulated with Interferon-у (20 ng/ml) and LPS (50 ng/ml) for 48h to initiate differentiation into proinflammatory M1 macrophages. The M1 macrophages were co-cultured with RASF (100.000/well) and different treatments added (prednisolone: 10, 25, 50, 75, 100 nM, 1 µM; adalimumab: 100, 500 µg/ml; tocilizumab: 1, 5 µg/ml; MTX: 0,5, 1, 5, 10, 100 nM, 1µM). After 24h culture supernatants were collected and IL-6- and TNFα-ELISAs were performed.

Results:

IL-6 concentrations of untreated controls were comparable, regardless whether M1 macrophages from healthy donors or RA-patients were used for co-culture. Prednisolone reduced co-culture-induced IL-6 up to 56% (p<0.001) in co-culture of RASF and M1 macrophages of healthy donors and up to 60% (p<0.001) in co-culture of RASF and RA M1 macrophages. Adalimumab reduced IL-6 up to 28% (p<0.05) in M1 of healthy donors and up to 45% (p<0.01) in RA M1 macrophage co-cultures. A minor reduction by 10-20% of IL-6 was observed with tocilizumab and no significant effect could be achieved after treatment with MTX.

Conclusion:

Prednisolone and adalimumab clearly decrease but do not eliminate proinflammatory synergistic activity of RASF and M1 macrophages. These results confirm the clinical observation, that there is a large number of RA-patients that independent of anti-inflammatory treatment still suffer from low-level joint inflammation.

The synergistic proinflammatory activity of M1 macrophages and RASF seems to be a complex and multifactorial mechanism that is difficult to eliminate by a single treatment substance. Since it is one of the key mechanisms in RA pathogenesis, there is a critical need to investigate how therapy effects could be optimized. This study confirmed RASFs as one of the leading effector cells of increased synergistic proinflammatory activity, thus underlining their promising role as a treatment target in rheumatoid arthritis.

Disclosure of Interests:

None declared

POS0844 EFFECTS OF SERIAL LOCALLY APPLIED WATER-FILTERED INFRARED A RADIATION IN PATIENTS WITH SYSTEMIC SCLEROSIS WITH SEVERE RAYNAUD’S SYNDROME RECEIVING PROSTAGLANDINE TREATMENT – A RANDOMIZED CONTROLLED TRIAL

Background:

More than 95% of patients with systemic sclerosis (SSc) suffer from Raynaud’s syndrome (RS) leading to digital ulcerations (DU). In severe RS, intravenous application of prostaglandins is required. Moreover, these patients profit from an additional non-pharmacological treatment using hyperthermia to increase vasodilatation and perfusion, and to reduce pain.

Serial locally applied water-filtered infrared A radiation (sl-wIRAR) is a hyperthermia treatment modality using infrared heat radiation in the range of 780-1400nm with high tissue penetration and low thermal load on the skin surface [1]. wIRAR has both, temperature-dependent and non-dependent effects, which do not inherit thermal energy transfer and/or relevant temperature changes [1]. It is therefore not only used in acute and chronic wound healing as it promotes perfusion, alleviates pain and has anti-infectious effects [2], but is also used in oncology [3] and rheumatology [4].

Objectives:

We conducted a randomized controlled trial with a follow-up visit after 2 weeks to evaluate the value of a high-frequent hyperthermia treatment using sl-wIRAR in comparison to a low-frequent hyperthermia treatment (our standard) in SSc patients with severe RS receiving Iloprost treatment.

Methods:

Eligible patients had SSc according to the 2013 ACR/EULAR classification criteria, were 18 to 80 years old and had RS requiring treatment with Iloprost in an in-patient setting. Key exclusion criteria were contraindications to any hyperthermia treatment such as infection or heat insensitivity. The trial was conducted at Campus Kerckhoff of Justus-Liebig University Giessen. Eligible patients were equally randomized to the intervention group (IG) receiving additional sl-wIRAR treatment (2 treatments for 30 min per day for 8 days) plus the standard of care (Iloprost treatment over 8 days plus daily carbon dioxide hand baths of 20 min) and the control group (CG) receiving only the standard of care. Primary outcome was the between-group difference in pain measured on a numeric rating scale (NRS) after intervention. Key secondary outcomes included a change in RS frequency, RS duration, and a change in Interleukin (IL) -6 and VEGF levels.

Results:

From 01.03.2020 to 31.12.2020 49 SSc patients met the inclusion criteria. 42 patients were enrolled (IG: 21, CG: 21). 38 patients (IG:19, CG: 19) completed the full trial period and were analyzed. There was no statistically significant between-group difference in pain levels (NRS) (p=0.284, Z -1.082 (Mann-Whitney U Test)) and thus the primary outcome was not met. Therefore, all p values for secondary outcomes are nominal. Intensity (Visual analogue scale 0-100mm) and duration (min) of RS were reduced in the IG (mean ± standard error) -14.579 ± 7.214 mm (p=0.058) and -2.917 ± 1.510 min (p=0.08), respectively. Intra- and inter-group comparison of IL-6 and VEGF levels showed no relevant change.

Conclusion:

The additive and frequent use of sl-wIRAR in the treatment of SSc patients with RS requiring Iloprost treatment does not improve outcomes regarding pain levels, RS intensity or frequency nor IL-6 and VEGF levels when compared to Iloprost treatment and low-frequent hyperthermia application.

References:

[1]Hoffmann G. Clinical applications of water-filtered infrared-A (wIRA) – a review. Phys Med Rehab Kuror. 2017;27(05):265–274.

[2]Hoffmann G, Harte M, Mercer JB. Heat for wounds – water-fil- tered infrared-a (wIRA) for wound healing – a review. GMS Ger Med Sci. 2016;14:Doc08.

[3]Notter M, Thomsen AR, Nitsche M, et al. Combined wIRA-hyperthermia and hypofractionated re-irradiation in the treatment of locally recurrent breast cancer: evaluation of therapeutic outcome based on a novel size classification. Cancers (Basel). 2020;12(3): 606.

[4]Klemm P, Eichelmann M, Aykara I et al. Serial locally applied water-filtered infrared a radiation in axial spondyloarthritis – a randomized controlled trial, International Journal of Hyperthermia, 37:1, 965-970.

Acknowledgements:

We acknowledge the help of Carina Schreiyäck.

This study was in part supported by the Dr. med. h.c. Erwin Braun Foundation, Basel, a charitable, nonprofit Swiss scientific foundation approved by the Swiss Federal Administration. The foundation supports clinical investigation of waterfiltered infrared-A. The foundation was not involved in any content- or decision-related aspect of the study.

This study was prospectively registered at www.drks.de (German Registry of Clinical Studies): DRKS00021098

Disclosure of Interests:

None declared

OP0283 DOES TNF-INHIBITION DECREASE THE RISK OF SEVERE COVID-19 IN RMD-PATIENTS?

Background:

Patients with rheumatic and musculoskeletal diseases (RMD) might have an increased risk for infection due to their immunomodulatory treatment, secondary to their disease and comorbidities. Recent studies suggest a decreased risk of severe COVID-19 in RMD-patients treated with biologics.

Objectives:

The aim of this study was to assess courses of RMD patients treated with TNF-inhibitors (TNF-I) included in the German COVID-19 registry.

Methods:

In the German physician-reported COVID-19-RMD registry, patients with an RMD and confirmed SARS-CoV-2-infection were documented (data entered between March 30, 2020 and January 30, 2021). We analysed TNF-I treated patients, their course and outcome of the infection. Data were compared to RMD-patients treated with other immunomodulatory drugs (OID) than TNF-I.

Results:

A total of 269 patients were treated with a TNF-I (57% female) compared to 874 patients who were treated with OID (68% female). Median age was 52 years (range: 19-87) in the TNF-I-group versus 58 years (range: 18-91) in the OID-group. Rheumatoid arthritis was the most common diagnosis (38% in TNF-I-group vs. 52% in the OID-group), followed by ankylosing spondylitis (32% vs. 6%), psoriatic arthritis (22% vs. 11%) and other RMD (9% vs. 31%). Adalimumab (35%) and etanercept (35%) were the most frequently used TNF-I (tab. 1). Glucocorticoids (GC) were used in 22% of TNF-I-treated patients and in 42% of the OID-group.

Under TNF-I, stable disease was reported prior to the SARS-CoV-2-infection in 53% of the patients (OID-group: 47%), followed by low disease activity in 35% (OID: 34%), moderate disease activity in 6% (OID: 12%) and high disease activity in 4% (OID: 3%). Most frequent comorbidities were arterial hypertension (29% under TNF-I vs. 35% under OID), diabetes (8% vs. 11%) and cardiovascular diseases (7% vs. 12%).

The most common reported COVID-19 symptoms were dry cough (57% vs. 55%), fever (53% vs. 61%) and fatigue (50% vs. 49%). Hospitalization due to SARS-CoV infection was required in only 12% of the TNF-I-treated cases vs. in 29% in the OID-group. Oxygen treatment was necessary in 5% of the patients under TNF-I compared to 22% under OID and invasive ventilation in 2% in the TNF-I-group compared to 6% under OID. Most notably, no fatal courses of COVID-19 were reported among the 269 RMD-patients treated with TNF-I versus 49 deaths in the 874 cases (5.6%) treated with OID. Focussing on the hospitalizated TNF-I patients, the rate of concomitant GC use (p<0.001) and higher disease activity (p=0.005) was significant higher (tab.1).

Conclusion:

High or moderate RMD-disease activity is an important factor associated with severity of COVID-19 including mortality. In this large cohort RMD patients treated with TNF-I show a low hospitalisation rate and no fatal course. This is reassuring for patients and treating rheumatologists to use TNF-I to control RMD disease activity. The use of glucocorticoids and high disease activity seem to counteract possible protective effects of TNF-I.

Table 1.TNF inhibition (269)Other immunomodulation (874)Total patientsRate (%)Total patientsRate (%)Disease activitystable1415340847low933529934Moderate15610812High104293Comorbiditiescardiovascular diseases18710412arterial hypertension772930335bronchial asthma124657COPD/interstitial lung disease1148610chronic renal failure93779Osteoporosis135678Diabetes2289211COVID-19 related symptomsFever1425347855dry cough1525753061Expectoration3112839muscular pain973628032Fatigue1355042449Headache1013823727shortness of breath491824528no symptoms239566COVID-19 outcomeOutpatients2378861971Inpatients321225529need of oxygen treatment18718922invasive ventilation52496fatal course00496TNF inhibitorsAdalimumab9535Infliximab239Certolizumab3312Golimumab249Etanercept9435GC and disease activity in TNF-I treated patientsTNF-I inpatients treated with GC18/3256p< 0.001TNF-I outpatients treated with GC42/23718TNF-I inpatients with high disease activity4/3213TNF-I outpatients with high disease activity6/2376p= 0.005

Acknowledgements:

The authors would like to thank all physicians and personnel involved in the documentation of the cases in our registry.

Disclosure of Interests:

None declared

POS0015 PREVALENCE OF NEUROPATHIES IN RHEUMATIC AND MUSCULOSKELETAL DISEASES

Background:

In rheumatic and musculoskeletal diseases (RMDs), peripheral neurons can be affected, which can result in sensory symptoms like pain, burning, tingling, numbness and motor symptoms like muscle-atrophy or even paresis. More detailed knowledge about the prevalence and the cause of neuropathy (NP) in RMD are urgently needed, especially as RMD patients may develop different subtypes of NP.

Objectives:

The aim of this project was to assess the prevalence and the individual types of NP in rheumatoid arthritis (RA), spondyloarthritis (SpA) and systemic sclerosis (SSc) patients, and to elucidate the clinical, neurophysiological and neuropathologic features of associated NP.

Methods:

Baseline questionnaires and neurological and physical examination were used to elucidate the presence of neuropathic pain and autonomic dysfunction. Laboratory tests were performed to exclude other causes for NP. Electrophysiological tests were performed to differentiate demyelinating from axonal large fiber (LF)NPs. Additionally, skin biopsies were used to detect an involvement of small fibres (SF).

Results:

A total of 31 patients (median age 64 years (range 43-75)) were included. The majority of patients were female (90%). The mean disease duration was 10 years (1-41 years). More than 50% of the patients were diagnosed with RA, 7 with SpA and 6 with SSc. Of 31 patients, 48% (15/31) had clinical signs of NP and of those, neurophysiological examination showed 14 axonal 2, demyelinating and 4 mixed types. A combined LFNP and SFNP was present in 35% (11/31) of the patients. In 4 patients, only a SFNP was detectable, and in only two patients, no NP was detectable.

Conclusion:

NP was detectable in 94% (29/31) of the RMD patients, with LFNP predominating. This high proportion of NP in RMD suggests a surprisingly high coincidence of both diseases.

Table 1.

Subtypes of NP in RMD

Number of patientsAxonal NP14/31 (45%)Demyelinating NP2/31 (6%)Mixed axonal and demyelinating NP4/31 (12%)Sensory NP9/31 (26%)Sensorimotor NP5/31 (10%)Motor NP1/31 (3%)

Disclosure of Interests:

None declared.

AB0204 THE PROPER STUDY: INTERIM ANALYSIS OF A PAN-EU REAL-WORLD STUDY OF SB5 BIOSIMILAR FOLLOWING TRANSITION FROM REFERENCE ADALIMUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS, AXIAL SPONDYLOARTHRITIS, OR PSORIATIC ARTHRITIS

Background:

SB5, a biosimilar to reference adalimumab (ADL), received EU marketing authorisation in August 2017, based on the totality of evidence from pre-clinical and clinical Phase I and III studies that demonstrated bioequivalence, similar efficacy, and comparable safety and immunogenicity to the reference. This real-world study provides data on outcomes of the transition from reference to biosimilar ADL outside the controlled, randomised, clinical trial setting.

Objectives:

To evaluate candidate predictors of persistence on SB5 in EU patients (pts) across multiple indications.

Methods:

This ongoing observational study enrolled 1000 pts with rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), ulcerative colitis, or Crohn’s disease who initiated SB5 as part of routine clinical practice following a minimum of 16 weeks’ treatment with reference ADL, at clinics in Belgium, Germany, Ireland, Italy, Spain, and the UK. Data are captured from clinic records retrospectively for the 24 weeks prior to transition, and prospectively and/or retrospectively for 48 weeks following transition. Primary outcome measures include baseline clinical characteristics, disease activity scores and clinical management over time; data on COVID-19 infection has recently been captured. This interim analysis (IA) provides an overview of baseline characteristics, disease scores and dose regimen up to 48 weeks post-initiation of SB5, and COVID-19 infection reported to date, in subjects with RA, axSpA, or PsA enrolled at 35 specialist sites and followed up to the data extract date of 18th December 2020.

Results:

Of the 504 pts included in this IA, 201 have RA, 169 have PsA, and 134 axSpA. At time of data extract, 216 pts had completed 48 weeks on SB5, 73 pts had discontinued SB5, and 8 had discontinued the study.

RA (N=201)axSpA (N=134)PsA (N=169)Mean (SD)Q1, Q3Mean (SD)Q1, Q3Mean (SD)Q1, Q3Age at SB5 initiation (years)60.2 (11.7)53, 6850.5 (13.6)38, 6153.0 (12.2)43, 62Duration of disease (years)13.5 (11.7)4.5, 2018.7 (13.2)9, 2512.7 (9.9)4, 20n%n%n%Women14471.64130.67745.6SB5 Dosing regimen:Baseline 40 mg Q2W14974.112089.615692.3Week 48 40mg Q2W6977.56785.99892.5Baseline Other*5225.91410.4137.7Week 48 Other*2022.41114.187.5Disease Score(paired patients)DAS28FFbHBASDAITender Joint CountSwollen Joint CountBaseline, n, mean (95% CI)692.5 (2.3–2.7)2273.9 (65.6–82.1)422.8 (2.3–3.4)491.8 (0.1–3.0)490.6 (0.2–0.9)Week 48, n, mean (95% CI)692.6 (2.3–2.8)2272.1 (64.0–80.2)423.0 (2.4–3.7)491.9 (0.5–3.3)490.6 (0.1–1.1)Patient diagnosed with COVID-19 at any time on-study, n (%)No14295.39688.114098.6Yes32.010.910.7Unknown42.71211.010.7Imraldi regimen stopped or changed due to COVID-19, regardless of diagnosis, n (%)No13098.510697.2134100Yes21.532.800

SD standard deviation; Q1 1st quartile, Q3 3rd quartile; CI Confidence Interval

*Other includes all other reported doses and/or dosing intervals: 40mg QW, 80mg Q2W, and unspecified frequency

DAS28 Disease Activity Score 28; FFbH Hanover Functional Ability Questionnaire; BASDAI Bath Ankylosing Spondylitis Disease Activity Index

Conclusion:

This IA provides a first insight into clinical management of pts over 48 weeks, in a contemporary cohort of EU pts with established RA, axSpA and PsA, switched from reference to biosimilar ADL SB5 in clinical practice. The majority of pts showed no meaningful difference in disease score or dose regimen of SB5 by Week 48 post-transition. As of data extract date, the proportion of pts with a known positive COVID-19 test was low (1.3%) and a small minority (1.3%) had SB5 treatment changed or interrupted as a result of the COVID-19 pandemic. With follow-up of pts ongoing to Q4 2021, the study will continue to provide pertinent information about clinical outcomes of transition from reference to biosimilar ADL in real-world practice and in indications not investigated in controlled studies.

Acknowledgements:

Statistical services gave been provided by FGK Clinical Research GmbH, Munich, Germany. Data management services were provided by Worldwide Clinical trial, Research Triangle Park, NC, USA; funding was provided by Biogen International GmbH.

Disclosure of Interests:

Ulf Müller-Ladner Consultant of: Biogen, Grant/research support from: Biogen, Karl Gaffney Consultant of: AbbVie, Celgene, Gilead, Lilly, MSD, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Celgene, Gilead, Lilly, MSD, Novartis, Pfizer, and UCB, Deepak Jadon Consultant of: AbbVie, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Oxford University Press, Pfizer, Roche, Sandoz, UCB, Grant/research support from: AbbVie, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Oxford University Press, Pfizer, Roche, Sandoz, UCB, Ulrich Freudensprung Shareholder of: Biogen, Employee of: Biogen, Janet Addison Shareholder of: Biogen, Employee of: Biogen

POS0834 LONG-TERM OUTCOME OF SSC ASSOCIATED ILD: IMPROVED SURVIVAL IN PPI TREATED PATIENTS

Background:

Gastroesophageal reflux disease (GERD) occurs frequently in patients with systemic sclerosis (SSc) and SSc-associated interstitial lung disease (SSc-ILD). PPI use has to been shown to improve survival in patients with idiopathic pulmonary fibrosis, whereas to date there are no data on the use of PPI in SSc-ILD.

Objectives:

This study was aimed to assess whether use of PPI is associated with progression of SSc-ILD and survival.

Methods:

We retrospectively analysed 1931 patients with SSc and SSc-ILD from the German Network for Systemic Sclerosis (DNSS) database (2003 onwards). Kaplan–Meier analysis compared overall survival (OS) and progression-free survival (PFS) in patients with vs. without GERD (SSc and SSc-ILD), and PPI vs. no PPI use (SSc-ILD only). Progression was defined as a decrease in either % predicted forced vital capacity ≥10% or single-breath diffusing capacity for carbon monoxide ≥15%, or death.

Results:

GERD was not associated with decreased OS or PFS in patients with either SSc or SSc-ILD. In patients with SSc-ILD, PPI use was associated with improved OS vs. no PPI use after 1 year (98.4% [95% confidence interval: 97.6–99.3]; n=760 vs. 90.8% [87.9–93.8]; n=290) and after 5 years (91.4% [89.2–93.8]; n=357 vs. 70.9% [65.2–77.1]; n=106; p<0.0001). PPI use was also associated with improved PFS vs. no PPI use after 1 year (95.9% [94.6–97.3]; n=745 vs. 86.4% [82.9–90.1]; n=278) and after 5 years (66.8% [63.0–70.8]; n=286 vs. 45.9% [39.6–53.2]; n=69; p<0.0001).

Conclusion:

GERD had no effect on survival in SSc or SSc-ILD. PPIs improved survival in patients with SSc-ILD; however, controlled, prospective trials are needed to confirm this finding.

Disclosure of Interests:

Michael Kreuter Speakers bureau: Boehringer, Consultant of: Boehringer, Grant/research support from: Boehringer, Francesco Bonella Speakers bureau: Boehringer, Roche, GSK, Consultant of: Boehringer, Roche, GSK, Grant/research support from: Boehringer, Kuhr Kathrin: None declared, Jörg Henes Speakers bureau: Abbvie, Boehringer, Chugai, Roche, Janssen, Novartis, SOBI, Pfizer and UCB, Consultant of: Boehringer, Celgene, Chugai, Roche, Janssen, Novartis, SOBI, Grant/research support from: Chugai, Roche, Janssen, Novartis, SOBI, Pfizer, Elise Siegert: None declared, Gabriela Riemekasten Speakers bureau: Novartis, Janssen, Roche, GSK, Boehringer, Consultant of: Janssen, Actelion, Boehringer, Norbert Blank Consultant of: Sobi, Novartis, Roche, UCB, MSD, Pfizer, Actelion, Abbvie, Boehringer, Grant/research support from: Novartis, Sobi, Christiane Pfeiffer: None declared, Ulf Müller-Ladner: None declared, Alexander Kreuter Speakers bureau: MSD, Boehringer, InfectoPharm, Paid instructor for: MSD, PETER KORSTEN Consultant of: Glaxo, Abbvie, Pfizer, BMS, Chugai, Sanofi, Lilly, Boehringer, Novartis, Grant/research support from: Glaxo, Aaron Juche: None declared, Marc Schmalzing Speakers bureau: Chugai Roche, Boehringer, Celgene, Medac, UCB, Paid instructor for: Novartis, Abbvie, Astra Zeneca, Chugai Roche, Janssen, Consultant of: Chugai Roche, Hexal Sandoz, Gilead, Abbvie, Janssen, Boehringer, Margitta Worm Speakers bureau: Boehringer, Ilona Jandova Speakers bureau: Boehringer, Novartis, Abbvie, Laura Susok Speakers bureau: MSD, Novartis, BMS, Sunpharma, Consultant of: MSD, Tim Schmeiser Consultant of: Abbvie, Boehringer, Novartis, UCB, Claudia Guenther Paid instructor for: Advisory Board Boehringer January 2020, Employee of: Novartis 2002-2005, Gernot Keyszer Consultant of: Boehringer, Jan Ehrchen Speakers bureau: Boehringer, Janssen, Chugai, Sobi, Employee of: Pfizer, Actelion (now Janssen), Andreas Ramming Speakers bureau: Boehringer, Gilead, Janssen, Pfizer, Roche, Consultant of: Boehringer, Pfizer, Grant/research support from: Novartis, Pfizer, Ina Kötter Speakers bureau: several companies, Consultant of: several companies, Grant/research support from: several companies, Hanns-Martin Lorenz Speakers bureau: Abbvie, Astra Zeneca, Actelion, Alexion Amgen, Bayer Vital, Baxter, Biogen, Boehringer, BMS, Celgene, Fresenius, Genzyme, GSK, Gilead, Hexal, Janssen, Lilly, Medac, MSD, Mundipharm, Mylan, Novartis, Octapharm, Pfizer, Roche Chugai, Sandoz, Sanofi, Shire SOBI, Thermo Fischer, UCB, Grant/research support from: basic research studies: Pfizer, Novartis, Abbvie, Gilead, Lilly, MSD, Roche Chugai, Pia Moinzadeh Speakers bureau: Boehringer, Actelion, Grant/research support from: Actelion, Nicolas Hunzelmann Speakers bureau: Boehringer Janssen, Roche, Sanofi, Consultant of: Boehringer

POS1492-HPR EVALUATION OF A VIRTUAL REALITY-BASED APPLICATION TO EDUCATE HEALTHCARE PROFESSIONALS AND MEDICAL STUDENTS ABOUT INFLAMMATORY ARTHRITIS

Background:

Inflammatory arthritides (IA), such as rheumatoid arthritis or psoriatic arthritis, are disorders that can be difficult to comprehend for health professionals and students in terms of the heterogeneity of clinical symptoms and pathologies. New didactic approaches using innovative technologies such as Virtual Reality (VR) applications could be helpful to demonstrate disease manifestations as well as joint pathologies in a more comprehensive way. However, the potential of using a VR education concept in IA has not yet been evaluated.

Objectives:

We evaluated the feasibility of a VR application to educate healthcare professionals and medical students about IA.

Methods:

We developed a VR application using IA patients data as well as two- and three-dimensional visualized pathological joints from X-ray and computed tomography generated images (1). This VR application (called Rheumality) allows the user to interact with representative arthritic joint and bone pathologies of IA patients (Figure 1 A, B). In a consensus meeting an online questionnaire was designed to collect basic demographic data (age, sex), profession of the participants, and their feedback on the general impression, knowledge gain and potential areas of application of the VR application. The VR application was subsequently tested and evaluated by healthcare professionals (physicians, researchers, and other healthcare professionals) and medical students at predefined events (two annual rheumatology conferences and academic teaching seminars at two sites in Germany).

Results:

125 individuals participated in this study (56% female, 43% male, 1% non-binary). 59% of the participants were between 18-30 years of age, 18% between 31-40, 10% between 41-50, 8% between 51-60 and 5% were between 61-70. Of the participants, 50 were physicians, five researchers and four other health care professionals, the remaining were medical students (66). The participants rated the application as excellent (Figure 1 C, D), the mean rating of the VR application was 9.0/10 (SD 1.2) and many participants would recommend the use of the application, with a mean recommendation score of 3.2/4 (SD 1.1). A large majority stated that the presentation of pathological bone formation improves the understanding of the disease (120 out of 125 (96%)).

Conclusion:

The data show that IA-targeting innovative teaching approaches based on VR technology are feasible. The use of VR applications enables a disease-specific knowledge visualization and may add a new educational pillar to conventional educational approaches.

References:

[1]Kleyer A et al. Z Rheumatol 78, 112–115 (2019)

Figure 1.

Illustration of the VR application and evaluation results

Two- and three-dimensional visualized pathological joints from X-ray and computed tomography generated images in a patient with long-standing (inadequately treated) RA (A) and a patient with early RA (B). Overall rating (range 0-10) on the VR application divided into four different professional subgroups (C); recommendations of VR application in the four different professional subgroups (D). HC, health care professionals; Boxplot explanation: Crossbars represent medians, whiskers represent 5-95 percentiles (points below the whiskers are drawn as individual points), box always extends from the 25th to 75th percentiles (hinges of the plot).

Disclosure of Interests:

Philipp Klemm Consultant of: Lilly Deutschland GmbH, Arnd Kleyer Speakers bureau: Lilly Deutschland GmbH, Consultant of: Lilly Deutschland GmbH, Grant/research support from: Lilly Deutschland GmbH, Koray Tascilar: None declared, Louis Schuster: None declared, Timo Meinderink: None declared, Florian Steiger: None declared, Uwe Lange: None declared, Ulf Müller-Ladner: None declared, Johannes Knitza Speakers bureau: Lilly Deutschland GmbH, Philipp Sewerin Speakers bureau: Lilly Deutschland GmbH, Paid instructor for: Lilly Deutschland GmbH, Johanna Mucke Consultant of: Lilly Deutschland GmbH, Alexander Pfeil Speakers bureau: Lilly Deutschland GmbH, Paid instructor for: Lilly Deutschland GmbH, Consultant of: Lilly Deutschland GmbH, Georg Schett: None declared, Fabian Hartmann Consultant of: Lilly Deutschland GmbH, Axel Hueber Consultant of: Lilly Deutschland GmbH, Grant/research support from: Lilly Deutschland GmbH, David Simon Speakers bureau: Lilly Deutschland GmbH, Paid instructor for: Lilly Deutschland GmbH, Consultant of: Lilly Deutschland GmbH, Grant/research support from: Lilly Deutschland GmbH

AB0044 ENDOTHELIAL CELL AND RHEUMATOID ARTHRITIS SYNOVIAL FIBROBLAST MIGRATION AND ADHESION ARE ALTERED BY ACTIVIN/FOLLISTATIN

Background:

Activin A and follistatin belong to an anti-inflammatory auto-regulatory cycle. Patients with rheumatoid arthritis (RA) have increased activin A levels in the synovial fluid and tissue. During inflammation, activin A is released systemically, then inducing its antagonist follistatin. This negative feedback is active in different cell types but not RA synovial fibroblasts (SF). Fibroblasts interact with endothelial cells in inflamed tissues inducing angiogenesis.

Objectives:

Evaluation of the role of activin A and follistatin on RASF and endothelial cell interactions.

Methods:

RA synovium was used for RASF isolation, HUVEC were commercially obtained. RASF and HUVEC were stimulated in mono- and coculture. Direct: RASF together with HUVEC; indirect: inserts with HUVEC separated by a membrane from RASF. Stimuli: activin A 15ng/ml, follistatin 500ng/ml, IL-1β 1ng/ml. Proliferation was analyzed by BrdU assay. RASF were Calcein-AM stained. Cells were transferred to 24-well plates after 18h stimulation. After adhesion for 1h, non-adherent cells were removed by shaking 3x for 5 min. Afterwards, fluorescent cells were quantified. For the flow-adhesion assay, HUVEC were cultured on rattail collagen coated capillary slides. HUVEC and RASF were stimulated for 4h with TNFα, TNFα+activin A or TNFα+follistatin. After stimulation, 2x10^6 RASF were resuspended in 20ml medium and sent through the capillaries. Two 1min videos were recorded (18.4ml/h, 30.5ml/h). Settings: TNFα-stimulated RASF on HUVEC stimulated wit TNFα or activin A+TNFα or follistatin+ TNFα. For migration assays, 2% FCS medium with 1x10^5 cells were placed in inserts (8µm membrane) into wells with 10% FCS (control: 2%FCS vs. 2%FCS) and stimulated with, IL-1, IL-1+activinA and IL-1+follistatin. After 16h, migrated cells were quantified. For scratch-assay 4x10^5 cells were cultured overnight, then cells were scratched and stimulated, afterwards 3 pictures per scratch were taken at start, after 10h and every 1.5h. Cells migrating into the scratch area were quantified.

Results:

IL-1 induced activin A in RASF and HUVEC in all settings. IL-1-induced activin A release was reduced by follistatin in HUVEC monoculture and both cocultures compared to IL-1 alone but not in RASF monoculture. IL-1-induced IL-6 release was reduced by activin A in HUVEC and indirect coculture but not in RASF monoculture and direct coculture. Follistatin did not alter IL-6 responses. IL-1 induced VEGF in RASF but not in HUVEC and was not altered by activin A. Short-term adhesion showed no significant influence of activin A or follistatin (n=4). Flow adhesion assay showed reduced adherence/rolling of RASF on HUVEC stimulated with TNFα and activin A (n=4). Migration assays showed that IL-1 decreased migration but without significant difference between the induced effects mediated by IL-1+activinA and IL-1+follistatin (n=4). Scratch assay showed increased migration in dicrect coculture with greater difference between stimulated and unstimulated cells in RASF monoculture and indirect coculture (n=4). Proliferation was not altered by activin A or follistatin.

Conclusion:

In direct and indirect coculture of HUVEC with RASF the effect on HUVEC was dominant leading to reduced IL-1-induced activin A release. However, the IL-1-induced IL-6 release in RASF or HUVECs was decreased by activin A in HUVEC monoculture and indirect coculture but not during cell-contact between both cell types. The direct interaction of RASF with HUVEC seems to prevent the reducing activin A effect on IL-6 release in HUVECs. Activin A seems to not to have an impact on short-term cell adhesion but first observations show, that activin A alters selectin-mediated adhesion under flow conditions. The migration assay shows that IL-1-induced effects on cell migration were enhanced by activin A and follistatin. Migration assay shows that IL-1-induced decrease on migration more prominent in indirect coculture and RASF monoculture than in direct coculture although in gap migration in the scratch assay was highest in direct coculture.

Disclosure of Interests:

None declared

POS1261 DISEASE ACTIVITY AND PAIN LEVELS ARE NOT INFLUENCED BY THE CURRENT COVID19 PANDEMIC IN PATIENTS WITH RHEUMATIC DISEASES IN GERMANY – DATA FROM THE GERMAN COVID-19 PATIENT SURVEY

Background:

The current pandemic constitutes an entirely new situation for patients as well as physicians. The insecurity of the early phase, shutdowns, increasing infection rate and appearing SARS-CoV2 mutations have created a situation that makes live difficult especially for chronic diseases i.e. patients with rheumatic and musculoskeletal diseases (RMD) and their treating physicians. The psychosocial burden that is created by this special situation is completely unknown and is estimated to be higher in patients than in the general population.

Objectives:

In order to measure the impact on our patients, the German COVID19-Rheuma patient survey was set up in April 2020, during Germany’s first shut down.

Methods:

The German COVID19-Rheuma patient survey is a patient reported longitudinal online survey where patients with RMD who registered between April and July 2020 are asked on a monthly base using an online survey on social, personal, medical factors, whether a COVID19 infection occurred, isolation measures were changed and scores regarding stress and anxiety are recorded. Between April and July 2020, 637 patients registered and completed a first survey. Up to January 2021, about 400 patients are still enrolled.

Here we present an interim analysis of the first 6 months regarding patients that were enrolled in April and May during the first shut-down. This first analysis compares the situation in the first lockdown to July, a phase with very low infection numbers in Germany, and to November, the beginning of the second lockdown.

Results:

150 patients (87% female) were enrolled in April/early May 2020. Mean age was 48 years (range 11-89). The majority of patients suffered from rheumatoid arthritis (51%), followed by psoriatic arthritis (17%), other spondyloarthropathies (10%) and connective tissue diseases (10%).

The majority of patients received antirheumatic therapies: 32% glucocorticoids (GC), 31% cDMARDs, 21% TNF inhibitors, 7% Jak inhibitors, and 9% other biologicals. Of the patients treated with GC, 25% were on GC monotherapy.

In the first lockdown, 26% of patients were working remotely and 24% were self-isolating (doubles included). Additionally, 48% were using masks that were not mandatory at that time and 41% were using disinfection in a regular manner. The rates for remote work and self-isolation did not change significantly over time while the mask use increased to 98% with the official obligation to do so. The use of disinfectants increased to 88% in November.

Regarding disease activity, no change in patient global assessment could be observed over time (4.3 ± 2.5 vs. 4.0 ±2.6 and 4.0 ± 2.5). Self-reported pain was also stable over time as were sleep disturbances. While 48.2% of patients who were receiving physiotherapy paused in April, only 10 and 14% did so in July and November, respectively. 11% of the patients paused their medication in the first lockdown, whereas only 2.75% did so in July and 3.4% in November. Contact with the treating rheumatologist was maintained over time in the majority of cases.

Conclusion:

While in the beginning of the pandemic the insecurity was considerable and the concern that the fear for infection would lead to inadequately treated patients with RMDs, we here show for the first time that on the one hand our patients were timely in taking adequate measures to keep themselves safe (e.g. self-isolating, mask use) and adapted to the clinical situation in not pausing their medication. Altogether, in this alert cohort, the pandemic did not lead to an increase of patient-reported disease activity in the first six months.

Acknowledgements:

Thanks goes to all patients who participated in the study.

Disclosure of Interests:

None declared

OP0075 EVALUATION OF A VIRTUAL REALITY TEACHING CONCEPT FOR MEDICAL STUDENTS DURING THE SARS-COV-2 PANDEMIC

Background:

The ongoing COVID-19 pandemic has disrupted face-to-face teaching of medical students and forced efforts in finding alternative approaches. In order to help maintain high-quality education, a new virtual reality (VR)-based concept for training medical students in rheumatic and musculoskeletal diseases (RMD) has been developed. This VR training concept is based on the integration of real patient data with two- and three-dimensional visualized pathological joints from X-ray and computed tomography generated images.

Objectives:

To evaluate the practicability and acceptance of the VR training application in the digital curricular education of medical students during the COVID-19 pandemic.

Methods:

A short refresher lecture on rheumatic diseases (duration 60 minutes) was followed by presenting the VR training concept to the students. The VR training concept included the demonstration of three virtual patients with early rheumatoid arthritis, rheumatoid arthritis psoriatic arthritis regarding the symptoms, current medical problems, disease patterns at the imaging (conventional radiographs and high-resolution computed tomography) and therapy options. The practicability and acceptance of the VR was evaluated by medical students using a survey.

Results:

The study encompassed 237 medical students (163 female, 73 male, one diverse, age range 20 to 40 years). 72 % of the participants rated the virtual teaching as good or very good. 87 % presented an expanded knowledge for rheumatoid arthritis and psoriatic arthritis through the VR. Moreover, 91 % reported that the lecture provided a deeper understanding of RMD. Furthermore, 60 % of the students asked for additional courses by VR.

Conclusion:

The study highlighted the usefulness of innovative VR tools for teaching medical students digitally about RMD. VR applications can be a complementary educational modality for medical students, especially during the COVID-19 pandemic, to provide students with the best possible clinical experience while ensuring that patient, student, and staff safety is not compromised.

Figure 1.

A Screen view of virtual reality included three virtual patients with early rheumatoid arthritis (RA), RA, and psoriatic arthritis (PsA) and B demonstration of structural damage in RA and PsA using hand X-ray and high-resolution quantitative computed tomography images.

Disclosure of Interests:

Alexander Pfeil Speakers bureau: Lilly Pharma Deutschland GmbH, Franz Marcus: None declared, Tobias Hoffmann: None declared, Philipp Klemm Consultant of: Lilly Pharma Deutschland GmbH, Peter Oelzner: None declared, Ulf Müller-Ladner Consultant of: Lilly Pharma Deutschland GmbH, Axel Hueber Consultant of: Lilly Pharma Deutschland GmbH, Uwe Lange: None declared, Gunter Wolf: None declared, Georg Schett: None declared, David Simon Consultant of: Lilly Pharma Deutschland GmbH, Arnd Kleyer Consultant of: Lilly Pharma Deutschland GmbH

POS0316 MODELLING SHORT-TERM FVC CHANGES FROM SENSCIS TO LONG-TERM FVC COURSE IN SSc-ILD DEMONSTRATES CLINICALLY MEANINGFUL REDUCTION OF FVC DECLINE AND SURVIVAL BENEFITS

Background:

Nintedanib has shown to slow FVC decline by 41ml over 52 weeks in systemic sclerosis-associated interstitial lung disease (SSc-ILD). However, the long-term effect of nintedanib treatment on ILD progression and mortality in SSc patients is so far unknown.

Objectives:

Here, the 52-week treatment efficacy of nintedanib was modeled and extrapolated on the long-term FVC course and survival in SSc-ILD patients from the European Scleroderma Trial and Research (EUSTAR) database.

Methods:

SSc patients from the EUSTAR database fulfilling the inclusion criteria of the SENSCIS trial (SSc classification criteria, ILD confirmed by imaging, disease duration of <7 years, FVC≥40%pred, diffusion capacity of the lung for carbon monoxide (DLCO) 30-89%pred); and matched for baseline characteristics as well as matched for the 52-week FVC change of SENSCIS patients were included (n=236). Linear mixed models including time, risk factors at baseline (sex, age, dyspnea class, DLCO%, CRP, modified Rodnan skin score, SSc subtype, SSc auto-antibodies, disease duration, synovitis and muscle weakness) were used to estimate the natural FVC course over time. On this natural course of FVC, the observed effect from the SENSCIS trial representing the absolute 52-week difference of FVC decline between the nintedanib and the placebo group was applied as continuous annual effect (SENSCIS effect model). Survival was estimated for both the natural course as well as the SENSCIS effect model using Cox regression.

Results:

Of the 236 included patients, 75% were females, 65% had diffuse cutaneous SSc. Mean age was 50.6 years, mean FVC 78.2%pred and DLCO 56.3%pred at time of inclusion. Mean FVC change after 12±3 months was -2.3 ±6.9%pred. These parameters were largely similar to the characteristics of the SENSCIS population.

In the longitudinal follow up of this population, the natural course of FVC showed a total FVC decline of -16.3%pred over 5 years. With assumed SENSCIS effects (effects of nintedanib treatment reported in SENSCIS), the 5-year FVC decline was reduced to -10.3%pred (Figure 1).

The reduced FVC progression translated into an improved survival. The natural 5-year survival of this SSc-ILD population was 88.2%. When extrapolating also a severe FVC decline early in the course, frequently terminated by early mortality of SSc patients excluding them from long-term outcome assessment, the estimated 5-year survival was reduced to 81.6%. When the SENSCIS effects on FVC were considered, the 5-year extrapolated survival was increased to 86.3% (Figure 2).

Conclusion:

Long-term experience of nintedanib treatment in SSc-ILD patients is lacking so far, therefore we modeled and extrapolated the 52-week treatment efficacy of nintedanib on the long-term FVC course and survival in SSc-ILD patients from the EUSTAR database. We could demonstrate a significant reduction of FVC decline by extrapolating the annual treatment effects of nintedanib from the SENSCIS trial from 1 to 5 years in EUSTAR. Translating these reductions of FVC decline into survival, the 5-year mortality rate was reduced from 18% to 13%.

Disclosure of Interests:

Anna-Maria Hoffmann-Vold Speakers bureau: Boehringer Ingelheim, Actelion, Roche, Merck Sharp & Dohme, Lilly, Consultant of: Actelion, Boehringer Ingelheim, Roche, Bayer, Merck Sharp & Dohme, ARXX, Lilly and Medscape, Grant/research support from: Boehringer Ingelheim, Dörte Huscher: None declared, Paolo Airò Speakers bureau: Boehringer Ingelheim, Consultant of: Bristol-Myers-Squibb, Novartis, Elisabetta Zanatta Speakers bureau: Boehringer Ingelheim, Actelion, GSK, Paid instructor for: GSK, Consultant of: Boehringer Ingelheim, GSK, Patricia Carreira Speakers bureau: Actelion, Boehringer Ingellheim, Janssen, GSK, Paid instructor for: Boehringer Ingelheim, Consultant of: AbbVie, Boehringer Ingelheim, VivaCell, Emerald Health Pharmaceuticals, Gesynta Pharma, Sanofi Genzyme, Grant/research support from: Roche, GSK, Yannick Allanore Consultant of: Honorarium received from Boehringer, Medsenic

Sanofi, Menarini, Grant/research support from: Grants received from Alpine, Ose Immunogenetics, Ulf Müller-Ladner Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Alessandro Giollo: None declared, Maria Rosa Pozzi: None declared, CAROLINA SOUZA MULLER Speakers bureau: Boehinger Ingelheim, Janssen, Roche, LIBBS, Bristol-Myers-Squib, Radim Bečvář Consultant of: Actelion, Boehringer Ingelheim, Michele Iudici: None declared, Dominik Majewski Speakers bureau: Boehringer Ingelheim - 2 x paid as a speaker, Armando Gabrielli Grant/research support from: Pfizer, CSL Behring, Margarida Alves Employee of: Boehringer Ingelheim, Nils Schoof Employee of: Boehringer Ingelheim International GmbH, Oliver Distler Speakers bureau: Boehringer Ingelheim, Medscape, IQone, Roche, Consultant of: Abbvie, Acceleron Pharma, Amgen, AnaMar, Arxx Therapeutics, Baecon Discovery, Blade Therapeutics, Bayer, Boehringer Ingelheim, ChemomAb, Corbus Pharmaceuticals, CSL Behring, Galapagos NV, Glenmark Pharmaceuticals, GSK, Horizon (Curzion) Pharmaceuticals, Inventiva, iQvia, Italfarmaco, Kymera Therapeutics, Lilly, Medac, Mitsubishi Tanabe Pharma, MSD, Novartis, Pfizer, Roche, Sanofi, Serodapharm, Topadur, Target Bioscience and UCB, Grant/research support from: Kymera Therapeutics, Mitsubishi Tanabe

[Most important vaccinations in patients with rheumatological diseases and why]

Lange Zeit schienen die meisten Infektionen beherrschbar geworden zu sein. Hierzu haben besonders auch Impfungen beigetragen. In den letzten Jahren gefährden neu aufgetretene bakterielle Infektionen durch multiresistente Erreger und Virusinfektionen wie das Chikungunya-Virus, Influenzaepidemien oder aktuell auch COVID-19 die Weltbevölkerung. Dies gilt in besonderer Weise für von rheumatologischen Erkrankungen Betroffene, die oft zusätzlich einer immunsuppressiven Therapie bedürfen und damit besonders durch Infektionen gefährdet sind. Impfungen können die Betroffenen sowohl individuell wie auch durch die Erzeugung einer Herdenimmunität schützen und stellen somit ein wichtiges Instrument dar, um die Morbidität und Mortalität durch Infektionen zu vermindern. Die Kenntnis über Indikation und Anwendung der einzelnen Impfungen ist für eine konsequente Umsetzung der aktuellen Empfehlungen besonders wichtig.

[Is complete immunity against measles a realistic target for patients with rheumatic diseases and how can it possibly be achieved?]

Measles outbreaks occur rather frequently in Germany. Patients with chronic inflammatory diseases are often treated with immunosuppressants. A recent study showed that about 7% of such patients are not protected against measles according to the lack of documentation in the vaccination card or the absence of protective antibodies. The Standing Committee on Immunization (STIKO) recommends a first vaccination against measles as a measles-mumps-rubella combined vaccination (MMR) in children aged 11-14 months and a second vaccination at 14-23 months. For adults born after 1970, vaccination against measles is recommended if they have not yet been vaccinated against measles or have only been vaccinated once against measles or if their vaccination status is unclear. In April 2019, STIKO published instructions for vaccinations recommended for immunodeficiency. Since March 1, 2020, measles vaccination have been compulsory in Germany.

[Biological therapy after COVID-19 infection : No reactivation of a COVID-19 infection with positive SARS-CoV-2 antibody status under biological therapy]

Berichtet wird über einen Fall mit rheumatoider Arthritis und unzureichender Kompensation unter einer Kombinationslangzeittherapie mit Methotrexat und Leflunomid. Nach durchgemachter COVID-19-Infektion erfolgte eine Neueinstellung auf einen Tumornekrosefaktor(TNF)-Blocker. Hierunter zeigte sich bisher keine Reaktivierung der COVID-19-Infektion bei positivem Antikörperstatus SARS-CoV‑2.

THU0535 ARE THERE DISCRIMINATING FEATURES BETWEEN “SCLERODERMA” AND “SCLERODERMA-LIKE” CAPILLAROSCOPIC PATTERN?

Background:

The “scleroderma” type capillaroscopic pattern is a diagnostic criterion of the EULAR/ACR scoring system for systemic sclerosis (SSc). In addition, the validated staging system of Cutolo et al. is used that categorizes the capillaroscopic changes into an “early”, ”active” and ”late” phase. A “scleroderma-like” capillaroscopic pattern can also be observed in a number of rheumatic diseases, i.e., dermatomyositis (DM), systemic lupus erythematosus (SLE), undifferentiated connective tissue diseases, overlap syndromes, and rheumatoid arthritis (RA).

Objectives:

To evaluate the categories “early”, “active” and “late” in “scleroderma-like” pattern in rheumatic diseases different from SSc and to assess the presence of discriminating features between “scleroderma” and “scleroderma-like” capillaroscopic pattern.

Methods:

544 capillaroscopic images that showed a “scleroderma” and “scleroderma-like” pattern have been analysed from the following groups: 405 images from 42 SSc patients, 66 images from 4 patients with DM, 37 images from 9 RA patients and 36 images from 5 SLE patients.

Results:

30 of the images obtained from SSc patients demonstrated an “early” phase capillaroscopic pattern, 284 an “active” phase, and 29 a “late” phase. In 62 images, neoangiogenesis could be observed in images from an “active” phase capillaroscopic pattern that could be classified as “active-to late stage of transition”. Among the 66 images from DM patients, 43 capillaroscopic pictures revealed an “active” phase and 23 - neoangiogenic capillaries with giant capillary loops, capillary loss and derangement (“active neoangiogenic” pattern). An “early” and ”late” phase capillaroscopic pattern was not present in this group. The images from SLE patients (n=36) could be classified into the following groups: 3 images “early” phase, 29 images “active” phase, and 4 images with neoangiogenesis during the active phase. A “late” phase capillaroscopic pattern was not observed. In the group of capillaroscopic pictures from RA patients (n=37), an “early” phase changes could be observed in 11 images (8 out of 9 patients) and an “active” phase in 3 images (2 patients). 23 of the images from RA patients demonstrated evidence of neoangiogenesis associated with mild capillary derangement, moderate capillary loss, and single giant capillaries (“advanced neoangiogenic” pattern).

Conclusion:

In conclusion, an “early” phase “scleroderma” pattern is present in RA and SLE patients, but obviously not in DM patients. An “active” phase “scleroderma” pattern was found in all three patients groups other that SSc i.e., DM, SLE and RA. In DM, profound neoangiogenesis is also a characteristic finding. In RA, advanced neoangiogenesis with moderate devascularization and single giant capillaries could also be documented. A classic “late” phase “scleroderma” pattern was found only in SSc patients and was not observed in other rheumatic diseases i.e., SLE, RA, DM. The results of the current study suggest presence of differences between “scleroderma” and ”scleroderma-like” capillaroscopic pattern that may reflect different pathogenic mechanisms of microvascular damage.

Disclosure of Interests:

Sevdalina Lambova: None declared, Ulf Müller-Ladner Speakers bureau: Biogen

AB0584 DOES ANTI-ACID TREATMENT INFLUENCE DISEASE PROGRESSION IN SYSTEMIC SCLEROSIS INTERSTITIAL LUNG DISEASE (SSC-ILD)? DATA FROM THE GERMAN SSC-NETWORK

Background:

Gastroesophageal reflux (GER) is common in SSc and thus treatment with anti-acid therapy (AAT) is frequent. An association between GER and the development / progression of SSc-ILD has been hypothesized. However, outcomes of AAT on disease progression in SSc-ILD has only sparsely been studied.

Objectives:

Methods:

The German Network for Systemic Scleroderma (DNSS), which includes SSc pts. prospectively, was analyzed for SSc-ILD. Those without progression at ILD 1stdiagnosis were categorized in AAT vs. no-AAT users and disease outcome was assessed.

Results:

SSc-ILD was reported in 1165 (28.2%) out of 4131 pts. 712 of SSc-ILD pts had no disease progression at ILD 1stdiagnosis. 567 used AAT while 145 did not. Baseline characteristics were similar between groups with regards to age (mean 54.7 years), BMI, time since SSc diagnosis and immunosuppressant use. Significant differences in no-AAT vs. AAT were found for gender (male 18% vs. 25%, p=0.05), SSc subtype (p=0.002, diffuse more common in AAT), lung function (DLCO 66% vs. 58%, p=0.001; FVC 86% vs. 77%, p=0.001), mRSS (8 vs. 11.5, p<0.01), esophageal involvement (32% vs. 56%, p<0.01) and steroid use (30% vs. 43%, p=0.005). While mortality did not differ between groups (3.9%, p= 0.59), disease progression was more common in the AAT group than in no-AAT users (24.5% vs. 13%, p=0.03). Furthermore, there was a significant difference in decline of FVC≥10% with 30% in the AAT compared to 14% in no-AAT (p=0.018); a decline in DLCO≥15% was more common in the AAT group by trend (23% vs. 14%, p=0.087).

Conclusion:

While results may have partially been biased by differences in baseline characteristics, this current analysis disfavors the approach of AAT use for SSc-ILD.

Disclosure of Interests:

Michael Kreuter Grant/research support from: Roche, Boehringer, Consultant of: Roche, Boehringer, Speakers bureau: Boehringer, Roche, Francesco Bonella Grant/research support from: Boehringer, Consultant of: Boehringer, Roche, Bristol MS, Galapagos, Speakers bureau: Boehringer, Roche, Gabriela Riemekasten Consultant of: Cell Trend GmbH, Janssen, Actelion, Boehringer Ingelheim, Speakers bureau: Actelion, Novartis, Janssen, Roche, GlaxoSmithKline, Boehringer Ingelheim, Pfizer, Ulf Müller-Ladner Speakers bureau: Biogen, Jörg Henes Grant/research support from: Novartis, Roche-Chugai, Consultant of: Novartis, Roche, Celgene, Pfizer, Abbvie, Sanofi, Boehringer-Ingelheim,, Elise Siegert Grant/research support from: Actelion, Consultant of: AEC, Speakers bureau: NA, Claudia Guenther: None declared, Ina Koetter Grant/research support from: Novartis, Roche, Speakers bureau: Abbvie, Actelion, Celgene, MSD, UCB, Sanofi, Lilly, Pfizer, Novartis, Chugai, Roche, Boehringer, Norbert Blank Speakers bureau: Actelion, Roche, Boehringer, Pfizer, Chugai, Christiane Pfeiffer: None declared, Marc Schmalzing: None declared, Gabriele Zeidler: None declared, PETER KORSTEN Grant/research support from: Novartis, Juarms GmbH, Consultant of: Abbvie, Pfizer, Lilly, BMS, Speakers bureau: Abbvie, Pfizer, chugai, BMS, Lilly, Sanofi aventis, Laura Susok: None declared, Aaron Juche: None declared, Margitta Worm Consultant of: Mylan Gemany, Bencard Allergie, BBV Technologies S.A., Novartis, Biotest, Sanofi, Aimmune Therapies, Regeneron, Speakers bureau: ALK-Abello, Novartis, Sanofi, Biotest, Mylan, Actelion, HAL Allergie, Aimmune Bencard Allergie, Ilona Jandova: None declared, Jan Ehrchen: None declared, Cord Sunderkoetter: None declared, Gernot Keyszer: None declared, Andreas Ramming Grant/research support from: Pfizer, Novartis, Consultant of: Boehringer Ingelheim, Novartis, Gilead, Pfizer, Speakers bureau: Boehringer Ingelheim, Roche, Janssen, Tim Schmeiser Speakers bureau: Actelion, UCB, Pfizer, Alexander Kreuter Speakers bureau: Sanofi, Abbvie, Merck Sharp&Dohme, Boehringer, Kathrin Kuhr: None declared, Hanns-Martin Lorenz Grant/research support from: Consultancy and/or speaker fees and/or travel reimbursements: Abbvie, MSD, BMS, Pfizer, Celgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, Astra-Zeneca, Lilly. Scientific support and/or educational seminars and/or clinical studies: Abbvie, MSD, BMS, Pfizer, Celgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, Astra-Zeneca, Lilly, Baxter, SOBI, Biogen, Actelion, Bayer Vital, Shire, Octapharm, Sanofi, Hexal, Mundipharm, Thermo Fisher., Consultant of: see above, Pia Moinzadeh: None declared, Nicolas Hunzelmann Speakers bureau: Actelion, Boehringer

AB0100 PHENOTYPIC AND FUNCTIONAL CHARACTERIZATION OF SYNOVIAL FLUID-DERIVED FIBROBLAST-LIKE SYNOVIOCYTES IN RHEUMATOID ARTHRITIS

Background:

Fibroblast-like synoviocytes (FLS) are central cellular components in persistent inflammatory joint diseases such as rheumatoid arthritis (RA). Pathological subsets of FLS have been identified from synovial tissue. However, the synovial tissue obtained from arthroplasty procedures is acquired at late disease stages and the cellular yield obtained from synovial tissue biopsies is fairly low. Collectively, challenging the robustness of human RAin vivoandin vitromodels. FLS obtained from the synovial fluid (SF-FLS) are proposed as an alternative source of FLS, but a detailed phenotypical and functional characterization of FLS subsets from the synovial fluid has not been performed.

Objectives:

The aim of this study was to determine the phenotypical and functional characteristics of synovial fluid-derived fibroblast-like synoviocytes in rheumatoid arthritis.

Methods:

In the present study, paired peripheral blood mononuclear cells (PBMC) and SF-FLS from patients with RA were obtained (n=7). FLS were isolated from the synovial fluid by a strict trypsinization protocol1and their cellular characteristics and functionality were evaluated at passage 4. Monocultures (SF-FLS) and autologous co-cultures (SF-FLS and PBMC) were established from five patients with RA and subsequently evaluated by flow cytometry, Western blotting and multiplex immunoassays. Human cartilage-sponges (n=3) with SF-FLS and without SF-FLS (n=3) were co-implanted subcutaneously in SCID mice (n=15), mice with only cell-free human cartilage-sponges were used as controls (n=12). After 45 days, the implants were evaluated using stained sections to determine the SF-FLS invasion score based on perichondrocytic cartilage degradation. Data are expressed as median (25-75 percentile). P-values <0.05 were considered statistically significant.

Results:

The homogeneous subpopulations of FLS, isolated from the synovial fluid, were negative for CD34 and CD45 [98.9%, (97.5-99.7]) and positive for Thy-1 and PDPN [94.6%, (79.9-97.4]). Without stimulation, RA SF-FLS showed high and comparable levels of NFκB related pathway proteins and secreted multiple pro-inflammatory cytokines and chemokines dominated by IL-6 [2648 pg/mL, (1327-6116)] and MCP-1 [2458 pg/mL, (692-8719)]. SF-FLS increased their ICAM-1 and HLA-DR expression after encountering autologous PBMCs (p<0.01), (p<0.05). Further, SF-FLS and PBMC interacted synergistically in a co-culture model of RA and significantly increasing the secretion of several cytokines (IL-1β, IL-2, IL-6, (p<0.01)) and a chemokine (MCP-1, (p<0.01)). The invasion score of the human SF-FLSin vivowas at primary site, [1.6, (1.3-1.7)] and contralateral implantation site [1.5, (1.1-2.2)]. The invasion score of the human SF-FLS-containing implants both at primary and contralateral site were significantly higher compared with cartilage-sponges evaluated from SF-FLS-free control mice (p<0001).

Conclusion:

This phenotypical and functional characterization of SF-FLS, acquired and activated at the site of pathology, lays a foundation for establishingin vivoandin vitroFLS models. These FLS models will be beneficial in our understanding of the role of this cellular subset in arthritis and for characterization of drugs specifically targeting this pathological RA FLS subset.

References:

[1]Nielsen M. A. et al. Responses to Cytokine Inhibitors Associated with Cellular Composition in Models of Immune-Mediated Inflammatory Arthritis. ACR Open Rheumatology, 2(1):3-10.http://doi.org/10.1002/acr2.11094

Disclosure of Interests:

Ditte Køster: None declared, Johanne Hovgaard Egedal: None declared, Malene Hvid: None declared, Martin Roelsgaard Jakobsen: None declared, Ulf Müller-Ladner Speakers bureau: Biogen, Bent Deleuran: None declared, Tue Wenzel Kragstrup Shareholder of: iBio Tech ApS, Consultant of: Bristol-Myers Squibb, Speakers bureau: TWK has engaged in educational activities talking about immunology in rheumatic diseases receiving speaking fees from Pfizer, Bristol-Myers Squibb, Eli Lilly, Novartis, and UCB., Elena Neumann: None declared, Morten Aagaard Nielsen: None declared

FRI0375 VISFATIN EFFECTS ON MSCS DURING OD VIA DIFFERENTIAL REGULATION OF LNCRNA H19 AND MICRO RNA 675-3P

Background:

Long non-coding (lnc-)RNA are regulatory molecules transcribed from DNA similar to mRNA and interact directly with DNA, RNA and proteins. Some lncRNAs have been shown to contain micro (mi-)RNAs in their sequence that can be released by splicing and lead to active miRNA molecules, e.g. lncRNA H19 includes two miRNAs 675-3p and -5p in its sequence.

Adipose tissue derived factors (adipokines) are involved in inflammation processes and osteoarthritis (OA) development. The proinflammatory adipokine visfatin has been shown to alter osteogenic differentiation (OD) of pluripotent mesenchymal stem cells (MSCs) and reduces elastic fiber expression, increases matrix mineralization and proinflammatory cytokine and chemokine production(1).

Objectives:

We evaluated a novel effect of visfatin on lncRNA H19 in MSCs during OD. The goal was to explore the kinetics of the visfatin effect during OD with regard to H19 regulation and to investigate H19 downstream mechanisms leading to the observed altered MSC differentiation and osteoblast activity.

Methods:

MSCs isolated from OA hip or knee bone (phMSC) and commercially obtained healthy human (h-)MSCs were differentiated towards osteoblasts with/without visfatin, resistin, leptin, TNF and Wnt/TGFβ1 pathway inhibitors. Supernatants were collected at days 2, 7, 9, 14 and 21 of OD, cell lysates at day 2, 7, 9, 14 and matrix mineralization assays conducted at day 21. H19 and miRNA expression was evaluated by real-time PCR after mi-/RNA isolation. IL-6 was analyzed by ELISA.

Results:

H19 was continuously upregulated in unstimulated controls as expected during OD but also when stimulated with other adipokines. In contrast, stimulation with visfatin significantly decreased H19 (day 2 to 14 of OD, hip-phMSCs: p = 0.0097, knee-phMSCs: p=0.0075, h-MSC: p = 0.044). Visfatin increased matrix mineralization and IL-6 production as expected (hMSC: p = 0.03, phMSC: p = 0.013)(1). TNF stimulation during OD did not lead to a downregulation of H19 nor increased matrix mineralization, thus showing that the effects were visfatin-dependent. H19s endogenous miRNA 675-5p was changed in parallel with H19, increased during control OD and significantly down-regulated by visfatin (e.g. day 14 p = 0.015). However, H19s endogenous miRNA 675-3p was inversely regulated, downregulated during control OD while visfatin stimulation attenuated this effect (e.g. day 14 p = 0.025). Altered Wnt-signaling and involvement of the TGFβ1 pathway could not be observed.

Conclusion:

H19 is upregulated during OD and may therefore play a regulatory role in the process of osteogenesis. Visfatin stimulation of MSCs during OD showed pro-inflammatory effects, increased matrix mineralization while reducing elastic fiber production(1). These effects were associated with a downregulation of H19, a specific visfatin effect not triggered by other adipokines or TNF. The H19 sequence includes two endogenous micro-RNAs 675-3p and 5p. We demonstrated miRNA 675-5p to be regulated in parallel to H19, whereas miRNA 675-3p was inversely regulated and increased continuously upon visfatin stimulation. Based on these results, we hypothesize that visfatin provides a specific stimulus for the splicing of miRNA 675-3p from H19, in turn leading to H19 reduction. miRNA 675-3p thus represents an effector mechanism of visfatin that contributes to the observed functional effects in differentiating MSCs.

References:

[1]Tsiklauri, L.et al.Visfatin alters the cytokine and matrix-degrading enzyme profile during osteogenic and adipogenic MSC differentiation.Osteoarthr. Cartil.26, 1225–1235 (2018).

Disclosure of Interests:

Dennis Küppers: None declared, Lali Tsiklauri: None declared, Marie Hülser: None declared, Klaus Frommer: None declared, Stefan Rehart: None declared, Caroline Ospelt Consultant of: Consultancy fees from Gilead Sciences., Ulf Müller-Ladner Speakers bureau: Biogen, Elena Neumann: None declared

THU0068 COMPARISON OF INFLAMMATION DURING METABOLIC CHANGES IN RHEUMATOID AND OSTEOARTHRITIS MOUSE MODELS

Background:

Arthritis is influenced by metabolic changes. Adipokines are bioactive factors produced by adipose tissue with important effects on energy homeostasis and immune responses but are also involved in the pathogenesis of rheumatoid arthritis (RA) and osteoarthritis (OA).

Objectives:

To evaluate inflammation during metabolic and adipokine induced changes in experimental models of RA and OA at different time points, an obesity model (high-fat-died, HFD) was therefore combined with an OA (DMM, destabilization of the medial meniscus) and RA (collagen induced arthritis, CIA) mouse model.

Methods:

Mice were fed with HFD or ND (normal diet) for 12 (OA) or 6 (RA) weeks prior to arthritis induction. DMM was performed in C57Bl/6 mice and CIA was induced in DBA/1Rj mice. After 4, 6 and 8 (DMM) or after 4, 5 and 7 weeks (CIA) of arthritis induction animals were sacrificed to collect histological and serological data. Clinical scoring for CIA and histological scorings for both models were performed to evaluate disease development and progression. Diet-induced effects were monitored by weight, fatty liver score and crown-like structures (CLS) counts in adipose tissue. To evaluate HFD-induced adipokine levels adiponectin, leptin and visfatin serum concentrations were measured in parallel to the CRP. Local tissue adipokine expression was evaluated by immunohistochemistry.

Results:

Induction of OA and RA was successful in an HFD setting, shown by histological joint destruction and the increased fatty liver score and bodyweight. Compared to healthy animals, CRP levels were significantly increased after CIA induction, confirming systemic inflammation. In DMM, the number of CLS were significantly higher in HFD (0.2 ± 0.16, n=7) compared to ND (5.2 ± 0.98, n=8). No difference was found in CIA-severity between HFD and ND. However, CIA induction increased the number of CLS in HFD (2.77 ± 1.07, n=6) and interestingly in ND animals (8.14 ± 0.23, n=5) compared to healthy ND (0.45 ± 0.03, n=4) and healthy HFD mice (2.57 ± 0.53, n=4) without CIA. As expected, HFD led to a significant increase in systemic leptin in healthy animals in both models. Interestingly, CIA and DMM induction decreased systemic leptin levels significantly in ND and HFD, which was more prominent in CIA. The systemic effect was not reflected by local leptin distribution in the joints (CIA) which were not altered by diet. 5. and 7 weeks after CIA induction HFD led to a reduction in local adiponectin and visfatin expression, which were not reflected in systemic levels.

Conclusion:

The data show that HFD deteriorates OA, which is similar to observations in humans. In contrast, HFD induction showed no significant difference in CIA severity compared to ND. Furthermore, CIA reduced local adipokine expression under HFD at later time points but not under ND. According to high numbers of CLS in ND/CIA animals and the strong reduction of leptin in CIA with HFD, CIA onset and severity seems to be obesity independent and more dependent on inflammation while OA appears to be directly influenced by obesity. However, HFD-induced obesity seems to alter local and systemic adipokine expression also in CIA. Interestingly, local adipokine distribution in affected joints was independent from systemic adipokine levels.

Disclosure of Interests:

Hani Manfred Sauermilch: None declared, Marie-Lisa Hülser: None declared, Carina Schreiyäck: None declared, Yubin Luo: None declared, Aline Bozec: None declared, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, Ulf Müller-Ladner Speakers bureau: Biogen, Elena Neumann: None declared

AB0157 IGG FROM PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS AND SYSTEMIC SCLEROSIS HAVE AN INFLUENCE ON COAGULATION FACTORS IN HUMAN CEREBRAL MICROVASCULAR ENDOTHELIAL CELLS IN-VITRO

Background:

Endothelial cells from the microvasculature (hBMEC) of the brain show significant morphological and functional differences compared to EC from other anatomical areas. They are characterized by tight junctions, are not fenestrated and show less active transport mechanisms. On the other hand, the mitochondrial density is relatively high in hBMEC due to the high cerebral glucose metabolism.

It could be already observed that interferon-α from SLE-sera induces the expression of MHC class I molecules on human dermal microendothelial cell line, but it is not known whether this also occurs on hBMEC. hBMECs can synthesize pro-inflammatory cytokines and chemokines such as IL-1β, but in lower concentrations than human umbilical vein endothelial cells.

Patients suffering from systemic lupus erythematosus (SLE) or systemic sclerosis (SSc) show a wide spectrum of central nervous symptoms. Both, SLE and SSc, are characterised by different autoantibodies and endothelial vascular damage, especially in microvessels. 10-40% of patients with SLE suffer from lupus vasculopathy. Vascular dysfunction is one of the earliest pathological changes in SSc. Anti-endothelial autoantibodies (AECA) appear in SLE as well as in SSc and other connective tissue diseases. Research within the last years revealed that AECA play a critical role within the vascular pathogenesis of SLE and SSc. So far there is no evidence that AECA bind to hBMEC and it is not clear whether they have an effect on this special endothelial class.

Objectives:

In this project, we investigated if autoantibodies against hBMEC are detectable in SLE and SSc patients and if they have an influence on the activation of the endothelium by inducing adhesion molecules and on haemostasis by inducing factors of the clotting cascade.

Methods:

HiTrap Protein G HP antibody purification columns were used to purify IgG antibodies. Flow cytometry was used for analysis of autoantibodies against human cerebral microvascular endothelial cell line (hCMEC/D3). 26 sera of patients with SLE and 29 sera of patients with SSc were tested for presence of autoantibodies against hCMEC/D3. To analyse in vitro effects on hCMEC/D3, we measured changes in the expression of the following surface proteins: ICAM-1, VCAM-1, MHC class I and II, tissue factor, von-Willebrand-Factor, E-Selectin, P-Selectin, Thrombomodulin, CD73 and t-PA, each before and after three- and 24-hours incubation with IgG-fractions. IgG fractions of 12 SLE patients, 13 SSc patients and 13 healthy control persons (HC) were tested.

Results:

Autoantibodies against hCMEC/D3 were found in 21 of 26 patients with SLE (81%) and in 19 of 29 patients with SSc (66%) (p > 0.05) but not in healthy donors. After three hours incubation of hCMEC/D3 IgG-fractions, an upregulation of tissue factor by SSc-IgG (6.7% ± 5.2%) compared to HC-IgG (1.1% ± 2.8%, p < 0.01) and to SLE-IgG (1.6% ± 3.9%, p < 0.05), was detectable.

There was no significant correlation between changes in surface protein expression and detection of ANA or of anti-hCMEC/D3 antibodies (p > 0.05).

No change in expression of ICAM-1, VCAM-1, MHC class I and II, von-Willebrand-Factor, E-Selectin, P-Selectin, Thrombomodulin, CD73 and t-PA could be detected after incubation with IgG-fractions.

Conclusion:

Both, patients with SLE and patients with SSc showed autoantibodies against hBMEC. IgG fractions of patients with SSc, but not with SLE, induced an upregulation of tissue factor on the cell surface of hCMEC/D3. This could be an indicator for a direct pathogenic effect of AECA on hBMEC and might have an influence on haemostasis by activating the clotting cascade. Inhibition of these antibodies could reduce cerebral involvement of SSc.

References:

[1]Weksler BB, Subileau EA, Perriere N, et al. Blood-brain barrier-specific properties of a human adult brain endothelial cell line. Faseb J 2005;19:1872-1874.

Disclosure of Interests:

Rebecca Hasseli: None declared, Magdalena Maria Fürst: None declared, Pratibha Singh: None declared, Ulf Müller-Ladner Speakers bureau: Biogen, Manfred Kaps: None declared, Franz Blaes: None declared, Tibo Gerriets: None declared, Marlene Tschernatsch: None declared

AB0311 THE PROPER STUDY: RESULTS OF THE FIRST INTERIM ANALYSIS OF A PAN-EU REAL-WORLD STUDY OF SB5 BIOSIMILAR FOLLOWING TRANSITION FROM REFERENCE ADALIMUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS, AXIAL SPONDYLOARTHRITIS OR PSORIATIC ARTHRITIS

Background:

SB5, a biosimilar to reference adalimumab (ADA), received EU marketing authorisation in August 2017, based on the totality of evidence from pre-clinical and clinical Phase I and III studies that demonstrated bioequivalence, similar efficacy, and comparable safety and immunogenicity to the reference. There are few published data on the transition from reference to biosimilar ADA outside the controlled, randomised, clinical trial setting.

Objectives:

To evaluate candidate predictors of persistence on SB5 in EU patients across multiple indications.

Methods:

This ongoing observational study will enrol approximately 1200 subjects with rheumatoid arthritis (RA), axial spondyloarthritis (axSpA) or psoriatic arthritis (PsA), who initiated SB5 as part of routine clinical practice following a minimum of 16 weeks’ treatment with reference ADA, at clinics in Belgium, Germany, Ireland, Italy, Spain and the UK. Data are captured from clinic records retrospectively for the 24 weeks prior to transition, and prospectively and/or retrospectively for 48 weeks following transition. The primary objective is to evaluate candidate predictors of persistence, and primary outcome measures include baseline clinical characteristics, disease activity scores, clinical management and patient satisfaction over time. This interim analysis provides an overview of baseline characteristics for subjects enrolled and followed up by the data extract date of 20thDecember 2019.

Results:

Of the 123 patients included in this interim analysis, 43 suffer from RA, 42 from axSpA and 38 from PsA.

Table 1.

Patient baseline characteristics

RA (N=43)axSpA (N=42)PsA (N=38)Mean (SD)Q1, Q3Mean (SD)Q1, Q3Mean (SD)Q1, Q3Age (years)58.7 (11.3)53, 6452.3 (13.3)41, 6353.7 (14.1)48, 63Duration of disease (years)6.8 (9.5)1, 622.0 (14.4)12.5, 32.513.8 (9.4)5.5, 22n%n%n%Women3172.11638.11642.1Dosing regimen ADA to SB5: 40mg Q2W: 40mg Q2W3485.03685.73489.5 Other*615.0614.3410.5Stable disease (physician opinion)3491.92765.93085.7Disease Activity Score:Mean (SD)95% CIMean (SD)95% CIMean (SD)95% CI DAS28 (n = 26)2.71 (0.88)2.36, 3.06---- BASDAI (n = 31)--3.71 (2.89)2.65, 4.77-- PsA scores (n = 23)0.3 (0.9)  Swollen joint2.9 (5.7)-0.1, 0.8  Tender joint0.4, 5.4Patient Awareness:n%n%n%Instructed in self-administration43100.03790.23594.6Know to remove SB5 from fridge 30 minutes pre-injection43100.03895.03697.3Know SB5 can be stored out of fridge <25oc for 28 days4297.73382.52875.7

DAS-28 Disease Activity Score 28; BASDAI Bath Ankylosing Spondylitis Disease Activity Index; SD standard deviation; Q1 1stquartile, Q3 3rdquartile; CI Confidence Interval

‘Other’ includes all other reported doses and/or dosing intervals: 40mg QW, 80mg Q2W, and unspecified frequency

Conclusion:

This interim analysis provides a first insight into a contemporary cohort of EU patients with established RA, axSpA and PsA, switched from reference to biosimilar ADA in clinical practice. The majority of patients have stable disease at transition, 85% or more of each cohort transitioned to the same dose regimen of biosimilar as received for the reference prior to transition, and most are aware of correct storage and self-administration of their biosimilar medication. With ongoing enrolment and longer follow-up, the study will provide pertinent information about clinical outcomes of transition from reference to biosimilar adalimumab in real-world practice and in indications not investigated in controlled studies.

Disclosure of Interests:

Ulf Müller-Ladner Speakers bureau: Biogen, Karl Gaffney Grant/research support from: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Consultant of: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Speakers bureau: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Deepak Jadon: None declared, Ulrich Freudensprung Shareholder of: Biogen International GmbH, Employee of: Biogen International GmbH, Janet Addison Shareholder of: Biogen Idec, Employee of: Biogen Idec

THU0350 LOGOPEDIC TESTING IN SSC PATIENTS REVEALS HIGH FREQUENCY OF OROPHARYNGEAL DYSFUNCTION: A MONOCENTRIC EXPERIENCE

Background:

Up to 98% of patients with systemic sclerosis (SSc) show involvement of the gastrointestinal system (GI) [1]. While meteorism, heartburn and GI dysmotility are very common and accessible to pharmacologic treatment on an evidence based level [1–3], checking for oropharyngeal dysfunction is usually not part of the standard diagnostic algorithm. However, in a survey of the German Network for Systemic Sclerosis (DNSS) patients reported coughing and/or a sore voice in up to 78% [1]. As impairment in speaking or swallowing for example does not only substantially reduce quality of life, it can also be very stigmatizing. In addition, the usual prokinetic therapy of GI-involvement, e.g. metoclopramide, does not appear to improve these symptoms. As the first step to approach this problem is the qualitative and quantitative description, we evaluated the oropharyngeal function in our cohort of SSc patients by detailed logopedic assessment.

Objectives:

To evaluate the frequency and type of oropharyngeal dysfunction, e.g. swallowing or speaking, in patients with SSc and to elucidate the correlating and associated factors, e.g. disease duration or modified Rodnan Skin Score.

Methods:

After obtaining written consent, oropharyngeal function using a standardized assessment protocol was evaluated in patients with SSc fulfilling the ACR/EULAR criteria by a speech therapist. Furthermore, we investigated whether oropharyngeal dysfunction is associated with patients’ characteristics. In addition, all patients received instruction for a training program to treat their individual oropharyngeal dysfunction.

Results:

37 patients with d/lSSc were assessed for eligibility. 34 patients met the inclusion criteria (3 patients did not speak German) and written consent was obtained.

Oropharyngeal dysfunction (impairment of speaking, swallowing, breathing or oropharyngeal muscle function) was found in 29 of 34 (85%) of both l/dSSc patients. Neither the subtype of SSc, disease duration nor mRSS were significantly correlated with oropharyngeal dysfunction in general. Only GI involvement in general was associated with oropharyngeal dysfunction.

After logopedic therapy, 28 of the 34 (82%) patients with oropharyngeal dysfunction reported a benefit after 3 days of training and were motivated to continue logopedic training at home.

Oropharyngeal dysfunctionPresent(n=29)absent(n=5)p-values (x2-test)dcSSc800,027lcSSc2240,027disease duration (mean)12,7 y12 y0,462mRSS<4920,322mRSS>42030,322Raynauds syndrom2950,673digital ulcers1920,812lung fibrosis1120,596eosophageal dilatation1520,566eosophageal dysmotility1900,015GI-involvement2310,007

Conclusion:

Logopedic assessment revealed a high incidence of oropharyngeal dysfunction in our cohort of SSc patients. Oropharyngeal dysfunction was not associated with disease duration, skin- or lung-involvement or dcSSc/lcSSc differentiation. A logopedic training program seems to be of benefit for this currently not pharmacologically treatable problem.

References:

[1]Schmeiser T, Saar P, Jin D, Noethe M, Müller A, Soydan N, et al. Profile of gastrointestinal involvement in patients with systemic sclerosis. Rheumatol Int 2012;32:2471–8.doi:10.1007/s00296-011-1988-6.

[2]Boeckxstaens GE, Bartelsman JFWM, Lauwers L, Tytgat GNJ. Treatment of GI dysmotility in scleroderma with the new enterokinetic agent prucalopride. Am J Gastroenterol 2002;97:194–7.doi:10.1016/S0002-9270(01)03958-2.

[3]Mercado U, Arroyo de Anda R, Avendaño L, Araiza-Casillas R, Avendaño-Reyes M. Metoclopramide response in patients with early diffuse systemic sclerosis. Effects on esophageal motility abnormalities. Clin Exp Rheumatol 2005;23:685–8.

Disclosure of Interests:

Miriam Wirths: None declared, Ole Hudowenz: None declared, Ulrike Hoffmann: None declared, Ulf Müller-Ladner Speakers bureau: Biogen, Uwe Lange: None declared, Philipp Klemm Consultant of: Lilly, Medac

OP0251 THE EULAR SYSTEMIC SCLEROSIS IMPACT OF DISEASE (SCLEROID) SCORE – A NEW PATIENT-REPORTED OUTCOME MEASURE FOR PATIENTS WITH SYSTEMIC SCLEROSIS

Background:

Patient reported outcome measures (PROM) are important for clinical practice and research. Given the unmet need for a comprehensive PROM for systemic sclerosis (SSc), the ScleroID questionnaire was developed by a joint team of patients with SSc and medical experts. This is intended as a brief, specific, patient-derived, disease impact score for research and clinical use in SSc.

Objectives:

Here, we present the validation and final version of the ScleroID.

Methods:

This EULAR-endorsed project involves 9 European expert SSc centers. Patients fulfilling the ACR/EULAR 2013 criteria were prospectively included since 05/16 in a large observational cohort study. Patients completed the ScleroID and comparators SHAQ, EQ5D, SF36. They also weighted the 10 dimensions of the ScleroID by distributing 100 points according to the perceived impact on their health. The final score calculation is based on the ranking of the weights. The validation study included a reliability arm and a longitudinal arm, looking at sensitivity to change at follow-up.

Results:

Of the 472 patients included at baseline, 109 patients also had a reliability visit and 113 patients a follow-up visit. 84.5% of patients were female, 29.8% had diffuse SSc, mean age was 54.6 years, and mean disease duration 9.5 years. The highest weights were assigned by the patients to Raynaud`s phenomenon, fatigue, hand function and pain, confirming our previous results. The total ScleroID score showed good Spearman correlation coefficients with the comparators (SHAQ, 0.73; EQ5D -0.48; Patient’s global assessment, VAS 0.77; HAQ-DI 0.62; SF36 physical score -0.62; each p<0.001). The internal consistency was good: Crohnbach’s alpha 0.866, similar to SS-HAQ (0.88) and higher than EQ5D (0.77). The ScleroID had a very good reliability: intra-class correlation coefficient 0.839 (ranging 0.608 to 0.788 for the individual items), superior to all comparators. Twenty of 113 patients reported a change in their disease status at follow up. Sensitivity to change: the standardized response mean was 0.34 for the total ScleroID score and highest for lower GI (0.633) and life choices domains (0.521), superior to all other PROM. Figure 1 shows the final ScleroID.

Figure 1.

Conclusion:

The EULAR ScleroID is a novel PROM designed for use in clinical practice and clinical trials to reflect the disease impact of SSc, showing good performance in the validation study. Importantly, Raynaud syndrome, impaired hand function, pain and fatigue were the main patient reported drivers of disease impact.

Disclosure of Interests:

Mike O. Becker: None declared, Rucsandra Dobrota: None declared, Kim Fligelstone: None declared, Annelise Roennow: None declared, Yannick Allanore Grant/research support from: BMS, Inventiva, Roche, Sanofi, Consultant of: Actelion, Bayer AG, BMS, BI, Patricia Carreira Grant/research support from: Actelion, Roche, MSD, Consultant of: GlaxoSmithKline, VivaCell Biotechnology, Emerald Health Pharmaceuticals, Boehringer Ingelheim, Roche, Speakers bureau: Actelion, GlaxoSmithKline, Roche, László Czirják Consultant of: Actelion, BI, Roche-Genentech, Lilly, Medac, Novartis, Pfizer, Bayer AG, Christopher Denton Grant/research support from: GlaxoSmithKline, CSL Behring, and Inventiva, Consultant of: Medscape, Roche-Genentech, Actelion, GlaxoSmithKline, Sanofi Aventis, Inventiva, CSL Behring, Boehringer Ingelheim, Corbus Pharmaceuticals, Acceleron, Curzion and Bayer, Roger Hesselstrand: None declared, Gunnel Sandqvist: None declared, Otylia Kowal-Bielecka Consultant of: Bayer, Boehringer Ingelheim, Inventiva, MSD, Medac, Novartis, Roche and Sandoz, Speakers bureau: Bayer, Boehringer Ingelheim, Inventiva, MSD, Medac, Novartis, Roche and Sandoz, Cosimo Bruni Speakers bureau: Actelion, Eli Lilly, Marco Matucci Cerinic: None declared, Carina Mihai: None declared, Ana Maria Gheorghiu: None declared, Ulf Müller-Ladner Speakers bureau: Biogen, Joe Sexton: None declared, Turid Heiberg: None declared, Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche

SAT0145 EFFICACY AND SAFETY OF UPADACITINIB MONOTHERAPY IN MTX-NAÏVE PATIENTS WITH EARLY ACTIVE RA RECEIVING TREATMENT WITHIN 3 MONTHS OF DIAGNOSIS: A POST-HOC ANALYSIS OF THE SELECT-EARLY

Background:

Early treatment of RA within the therapeutic window(0-3 months from symptom onset), has been associated with improved clinical outcomes and physical function. However, ≤42% of RA patients(pts) visit a rheumatologist within 90 days of symptom onset1,2.

Objectives:

To assess safety and efficacy of Upadacitinib(UPA), an oral, reversible, potent JAK-1 selective inhibitor3, in pts with moderate to severely active RA who were MTX-naïve or had an inadequate response to csDMARDs/bDMARDs4-6.

Methods:

In SELECT–EARLY, MTX-naïve pts with active RA and poor prognosis were randomized 1:1:1 to once-daily UPA monotherapy at 15 or 30 mg or weekly MTX (titrated up to 20 mg/week through Week 8). Efficacy (including ACR, DAS28(CRP), CDAI responses and change in mTSS) and safety outcomes from a post-hoc analysis of patients who received treatment within 90 days from diagnosis are reported here. The statistical significance defined asp<0.05was exploratory in nature.

Results:

A total of 270 pts commenced treatment within 90 days from RA diagnosis (median: 44 days [11, 89]). Pts in each arm were mostly female (70%), had moderately to severely active RA with mean DAS28(CRP) =5.9±1.02, had structural joint damage (mean mTSS =7.7±21.5) and were seropositive for both ACPA and RF at baseline (72%)4. At Week 24, compared to MTX, significantly greater proportions of pts receiving UPA 15 or 30 mg monotherapy achieved efficacy outcomes including ACR20, 50 and 70 responses, DAS28CRP<2.6, CDAI≤2.8 or Boolean remission. Improvements in physical function (HAQ-DI) and decrease in pain were also significantly greater in pts receiving UPA 15 and 30 mg vs MTX at Week 24. Treatment with UPA was also associated with a greater inhibition of structural joint damage compared with MTX (Figure 1). Safety outcomes were consistent with the full study and the integrated safety analysis (all phase 3 studies of UPA). Compared to MTX, higher frequencies of serious infections and herpes zoster were reported in both UPA groups. There were 2 deaths in total (UPA 30 mg: 1 due to cardiovascular death and 1 due to pneumonia and sepsis) (Figure 2).

Conclusion:

In RA pts, early initiation of treatment with UPA 15 mg and 30 mg monotherapy within 3 months from diagnosis was associated with clinically meaningful improvements in efficacy, including remission and inhibition of progression of structural joint damage compared to MTX. The safety profile was consistent with the overall study and the integrated phase 3 safety analysis7. UPA seems to be a promising treatment option for more patients to reach their treatment targets of remission or low disease activity when treated within 3 months of diagnosis.

References:

[1]Raza K et al. Ann Rheum Dis. 2011;70(10):1822-5.

[2]Stack RJ et al. BMJ Open. 2019;9:e024361.

[3]Parmentier et al. BMC Rheumatol. 2018;2:23.

[4]van Vollenhoven R et al, Arth Rheumatol. 2018; 70 (s10) [Abs ACR2018].

[5]Burmester GR et al. Lancet 2018;391:2503-12.

[6]Genovese MC et al, Lancet 2018;391:2513-24.

[7]Cohen S et al, Ann Rheum Dis [Abs EULAR2019].

Disclosure of Interests:

Meliha C Kapetanovic: None declared, Maria Andersson Shareholder of: AbbVie, Employee of: AbbVie, Alan Friedman Shareholder of: AbbVie Inc, Employee of: AbbVie Inc, Tim Shaw Shareholder of: AbbVie, Employee of: AbbVie, Yanna Song Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Daniel Aletaha Grant/research support from: AbbVie, Novartis, Roche, Consultant of: AbbVie, Amgen, Celgene, Lilly, Medac, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi Genzyme, Speakers bureau: AbbVie, Celgene, Lilly, Merck, Novartis, Pfizer, Sanofi Genzyme, UCB, Maya H Buch Grant/research support from: Pfizer, Roche, and UCB, Consultant of: Pfizer; AbbVie; Eli Lilly; Gilead Sciences, Inc.; Merck-Serono; Sandoz; and Sanofi, Ulf Müller-Ladner Speakers bureau: Biogen, Janet Pope Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly & Company, Merck, Roche, Seattle Genetics, UCB, Consultant of: AbbVie, Actelion, Amgen, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Eicos Sciences, Eli Lilly & Company, Emerald, Gilead Sciences, Inc., Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Speakers bureau: UCB

CO0004 OLDER AGE, CARDIOVASCULAR COMORBIDITY AND GLUCOCORTICOSTEROIDS ARE RISK FACTORS FOR COVID-19 HOSPITALISATION IN PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES: FIRST RESULTS OF THE GERMAN COVID-19-IRD REGISTRY

Background:

Patients with inflammatory rheumatic diseases (IRD) and infection with SARS-CoV-2 may be at risk to develop a severe course of COVID-19. To gather knowledge about SARS-CoV-2 infections in IRD patients, a national registry was established to elucidate IRD specific profiles of COVID-19.

Objectives:

To identify risk factors for hospitalisation.

Methods:

Patients from the German registry on SARS-CoV-2 infection in IRD were analysed. Patients are enrolled with a pre-existing IRD and a positive lab-result for a SARS-CoV-2 infection. The main outcome parameter was hospitalisation versus non-hospitalisation. Multivariable logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI). Covariates included in the model were age group, gender, key comorbidities (cardiovascular, lung diseases, chronic renal insufficiency), prior and/or current use of glucocorticosteroids (GC) or NSAIDs and remission.

Results:

Until May 17th, 2020, data from 192 IRD patients with SARS-CoV-2 infection were reported (67 males; 124 females; 1 diverse). 64 patients were hospitalised, 21 patients were ventilated non-invasively/invasively and 15 patients died.

Baseline characteristics are shown in table 1, stratified into the patient groups non-hospitalisation, hospitalisation without ventilation, and hospitalisation with ventilation. Non-hospitalised patients were younger, had less comorbidities and were less often treated with GC. In the group of hospitalised patients compared to non-hospitalised patients more patients were male (42% vs 32% male) with an even higher proportion in the ventilated patient group (57% male).

In the multivariable logistic regression model, age>65 years (OR 5.1; 95%CI 2.3-11.4), cardiovascular comorbidity (OR 2.3; 95%CI 1.0-5.0), and prior and/or current treatment with GC (OR 2.6; 95%CI 1.2-5.4) were independently associated with hospitalisation.

Parameter, N (%)Non-hospitalisation128 (66.7)Hosp. without ventilation42 (22.4)Hosp. with ventilation21 (10.9)Age [years], mean (SD)53.8 (13.4)65.2 (15.5)69.7 (9.9)Female87 (68.5)28 (65.1)9 (42.9)RA60 (46.9)24 (55.8)12 (57.1)Psoriasis23 (18)3 (7)3 (14.3)Axial spondyloarthritis14 (10.9)2 (4.7)0Lupus7 (5.5)1 (2.3)0Remission of IRD67 (52.3)23 (53.5)4 (19)Number of comorbidities, mean (SD)1 (1.2)1.8 (1.4)2.4 (1.5)Cardiovascular disease42 (32.8)25 (58.1)16 (76.2)Pulmonary disease16 (12.5)8 (18.6)8 (38.1)Chronic renal insufficiency5 (3.9)7 (16.3)4 (19)Cancer2 (1.6)4 (9.3)2 (9.5)Obesity (BMI>30)23 (18)5 (11.6)3 (14.3)Diabetes3 (2.3)7 (16.3)4 (19)Other comorbidities20 (15.6)9 (20.9)6 (28.6)csDMARD (without HCQ)59 (46.1)25 (58.1)8 (38.1)HCQ13 (10.2)1 (2.3)2 (9.5)bDMARD48 (37.5)15 (34.9)8 (38.1)tsDMARD5 (3.9)1 (2.3)1 (4.8)Glucocorticosteroids47 (37)29 (67.4)13 (61.9)NSAIDs21 (16.4)5 (11.6)1 (4.8)

Conclusion:

As has been described for COVID-19 in general, also in IRD male gender may be associated with a more severe course of the infection as the descriptive analysis of data shows. Risk factors for SARS-CoV-2 infection-dependent hospitalisation in IRD patients include age (>65 years), cardiovascular comorbidities, and prior and/or current treatment with GC.

Disclosure of Interests:

Anne Regierer Speakers bureau: Novartis, Celgene, Janssen-Cilag, Rebecca Hasseli Grant/research support from: Pfizer, Consultant of: Pfizer, Gilead, Novartis, Celgene, Abbvie, Medac, Bimba Hoyer: None declared, Andreas Krause: None declared, Hanns-Martin Lorenz Grant/research support from: Consultancy and/or speaker fees and/or travel reimbursements: Abbvie, MSD, BMS, Pfizer, Celgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, Astra-Zeneca, Lilly. Scientific support and/or educational seminars and/or clinical studies: Abbvie, MSD, BMS, Pfizer, Celgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, Astra-Zeneca, Lilly, Baxter, SOBI, Biogen, Actelion, Bayer Vital, Shire, Octapharm, Sanofi, Hexal, Mundipharm, Thermo Fisher., Consultant of: see above, Alexander Pfeil Grant/research support from: This study Investigator Initiated Study “Automatic assessment of joint space narrowing in rheumatoid arthritis based on the Post-hoc analysis” (number: IIS-2016-110818) is a part of the of the Investigator Initiated Study “The quantification of inflammatory related periarticular bone loss in certolizumab pegol treated patients with rheumatoid arthritis” (number: IIS-2014-101458) which is supported by UCB Pharma GmbH, Monheim, Germany., Jutta Richter Grant/research support from: Grant/research support from: GlaxoSmithKline and UCB Pharma for performing the LuLa-study., Tim Schmeiser Speakers bureau: Actelion, UCB, Pfizer, Christof Specker Consultant of: Abbvie, Boehringer Ingelheim, Chugai, Lilly, Novartis, Sobi, UCB, Celgene, Janssen-Cilag, MSD, Pfizer, Roche, UCB, Toshiba, Anja Strangfeld Speakers bureau: AbbVie, BMS, Pfizer, Roche, Sanofi-Aventis, Reinhard Voll: None declared, Hendrik Schulze-Koops: None declared, Ulf Müller-Ladner Speakers bureau: Biogen

[A cross sectional study on patients with inflammatory rheumatic diseases in terms of their compliance to their immunsuppressive medication during COVID-19 pandemic]

The current COVID-19 pandemic inherits an unprecedented challenge for the treating rheumatologists. On the one hand, antirheumatic drugs can increase the risk of infection and potentially deteriorate the course of an infection. On the other hand, an active inflammatory rheumatic disease can also increase the risk for an infection. In the recommendations of the German Society for Rheumatology (www.dgrh.de), it is recommended that our patients continue the antirheumatic therapy to maintain remission or low state of activity despite the pandemic. In this study, patients with inflammatory rheumatic disease were asked in the first weeks of the pandemic on their opinion of their immunomodulating therapy. The result shows that over 90% of the patients followed the recommendation of the rheumatologist to continue the antirheumatic therapy, and only a small percentage of the patients terminated the therapy on their own. This result was independent of the individual anti-rheumatic therapy. Taken together, the results of this study illustrate not only the trustful patient-physician partnership in a threatening situation but also the high impact of state-of-the art recommendations by the respective scientific society.

Modellprojekt zur interdisziplinären universitären Lehre – Studierende der Medizin und der Psychologie lernen erstmals gemeinsam

Eine interdisziplinäre Zusammenarbeit ist in der medizinischen Versorgung chronisch erkrankter Patienten mit komplexen Erkrankungen erforderlich. Vor allem im Bereich der internistischen Rheumatologie ist eine interdisziplinäre Arbeit unerlässlich, um die komplexen somatischen und psychosozialen Aspekte einer chronischen Erkrankung zu berücksichtigen. Dennoch werden die Aspekte der interprofessionellen Arbeit im Studium der Medizin und Psychologie unzureichend thematisiert. Aus diesem Grund wurde ein Modellprojekt zur interdisziplinären universitären Lehre konzipiert, welches beide Fächer miteinander vereint. Die Veranstaltung wurde im Wintersemester 2019/20 erstmalig durchgeführt und stieß bei den Teilnehmer*innen auf positive Resonanz. Das Hauptziel der Veranstaltung ist die Implementierung interprofessioneller Arbeit in die Ausbildung des medizinischen Personals. Zusätzlich konnte das Fach der internistischen Rheumatologie den Studierenden nähergebracht werden.

Rituximab in routine care of severe active rheumatoid arthritis : A prospective, non-interventional study in Germany

OBJECTIVE

To assess safety, effectiveness and onset of effect of rituximab (RTX) in routine clinical treatment of severe, active rheumatoid arthritis (RA).

METHODS

Prospective, multi-centre, non-interventional study in rheumatological outpatient clinics or private practices in Germany. RTX-naïve adult patients were to receive RTX according to marketing authorisation and at their physician's discretion. Also according to their physician's discretion, patients could receive a second cycle of RTX (re-treatment = treatment continuation). Major outcome was the change in Disease Activity Score based on 28-joints count and erythrocyte sedimentation rate (DAS28-ESR) over 24 weeks and during 6 months of re-treatment.

RESULTS

Overall, 1653 patients received at least one cycle RTX; 99.2% of these had received disease-modifying antirheumatic drugs (DMARD) pre-treatment and 75.5% anti-tumor necrosis factor(TNF)‑α pre-treatment. After a mean interval of 8.0 months, 820 patients received RTX re-treatment. Mean DAS28-ESR decreased from 5.3 at baseline to 3.8 after 24 weeks (-1.5 [95% confidence interval, CI: -1.6; -1.4]), and from 4.1 at start of cycle 2 to 3.5 at study end (change from baseline: -1.8 [95% CI: -2.0; -1.7]). Improvements in DAS28-ESR and Health Assessment Questionnaire (HAQ) score occurred mainly during the first 12 weeks of RTX treatment, with further DAS28-ESR improvement until week 24 or month 6 of re-treatment. Improvements in DAS28-ESR and EULAR responses were more pronounced in seropositive patients. RF was a predictor of DAS28-ESR change to study end. Safety analysis showed the established profile of RTX.

CONCLUSION

RTX was safe and effective in a real-life setting with rapid and sustained improvement in RA signs and symptoms.

[Treatment of systemic sclerosis-associated interstitial lung disease]

BACKGROUND

Systemic sclerosis (SSc) is a fibrosing autoimmune disease of the connective tissue. In addition to skin fibrosis, pulmonary involvement and interstitial lung disease (ILD) in particular are the most common and severe manifestations of SSc. The disease is associated with a substantial risk of morbidity and mortality, especially in progressive ILD. In the last 5 years new treatment concepts for SSc-ILD have been investigated in numerous clinical studies.

MATERIAL AND METHODS

This review is based on a literature search in PubMed, focusing on the most relevant papers published up to the end of 2018 with the keywords "SSc" and "treatment".

RESULTS

The treatment of SSc-ILD has changed over the last few years due to the results of many clinical studies. The updated guidelines of the European League Against Rheumatism (EULAR) recommend the use of cyclophosphamide or hematopoietic stem cell transplantation. Data for a positive influence on SSc-ILD are also available for mycophenolate, tocilizumab and anabasum. Because of the pathophysiological similarities to idiopathic pulmonary fibrosis, the use of the antifibrotic agents nintedanib and pirfenidone is currently being investigated in randomized, multicenter clinical trials and could be a novel and promising therapeutic strategy.

CONCLUSION

Current drug studies may provide innovative therapeutic perspectives for SSc-ILD and could significantly improve the prognosis of affected patients in the future.

[Rheumatoid arthritis]

Rheumatoid arthritis (RA) is a chronic and progressive systemic disease of the connective tissue, which is particularly manifested with destructive alterations to the joints. Inflammatory reactions in the synovium lead to the influx of peripheral inflammatory cells as well as the activation of local cells. Released growth factors, chemokines and especially cytokines play a key role in chronic inflammatory responses. In addition to the central lymphocytes, the T and B cells and their subpopulations, locally resident cells, such as neutrophils, macrophages and fibroblasts as well as cells of bone metabolism are activated by the inflammatory milieu and contribute to and drive inflammation and tissue damage. The destruction of cartilage and bone substance by local tissue cells, synovial fibroblasts and osteoclasts is characteristic for this disease. Untreated, the local inflammatory and destructive processes as well as systemic inflammatory factors lead to progressive and irreversible joint destruction. Cellular and immunological processes in RA are closely interwoven; therefore, besides the general inhibition of immunological processes, specific inhibition of central key molecules can reduce or completely stop the inflammatory destructive processes; however, a high heterogeneity can be observed among RA patients and disease progression. Therefore, an expansion of the therapeutic options is desirable as not all patients are able to equally benefit from the therapeutic treatment. It is important to characterize new molecular mechanisms, which could lead to the development of new therapeutic options. Some of the more recent insights are summarized in this overview.

Classification, categorization and essential items for digital ulcer evaluation in systemic sclerosis: a DeSScipher/European Scleroderma Trials and Research group (EUSTAR) survey

BACKGROUND

A consensus on digital ulcer (DU) definition in systemic sclerosis (SSc) has been recently reached (Suliman et al., J Scleroderma Relat Disord 2:115-20, 2017), while for their evaluation, classification and categorisation, it is still missing. The aims of this study were to identify a set of essential items for digital ulcer (DU) evaluation, to assess if the existing DU classification was useful and feasible in clinical practice and to investigate if the new categorisation was preferred to the simple distinction of DU in recurrent and not recurrent, in patients with systemic sclerosis (SSc).

METHODS

DeSScipher is the largest European multicentre study on SSc. It consists of five observational trials (OTs), and one of them, OT1, is focused on DU management. The DeSScipher OT1 items on DU that reached ≥ 60% of completion rate were administered to EUSTAR (European Scleroderma Trials and Research group) centres via online survey. Questions about feasibility and usefulness of the existing DU classification (DU due to digital pitting scars, to loss of tissue, derived from calcinosis and gangrene) and newly proposed categorisation (episodic, recurrent and chronic) were also asked.

RESULTS

A total of 84/148 (56.8%) EUSTAR centres completed the questionnaire. DeSScipher items scored by ≥ 70% of the participants as essential and feasible for DU evaluation were the number of DU defined as a loss of tissue (level of agreement 92%), recurrent DU (84%) and number of new DU (74%). For 65% of the centres, the proposed classification of DU was considered useful and feasible in clinical practice. Moreover, 80% of the centres preferred the categorisation of DU in episodic, recurrent and chronic to simple distinction in recurrent/not recurrent DU.

CONCLUSIONS

For clinical practice, EUSTAR centres identified only three essential items for DU evaluation and considered the proposed classification and categorisation as useful and feasible. The set of items needs to be validated while further implementation of DU classification and categorisation is warranted.

TRIAL REGISTRATION

Observational trial on DU (OT1) is one of the five trials of the DeSScipher project (ClinicalTrials.gov; OT1 Identifier: NCT01836263 , posted on April 19, 2013).

[Treatment of rheumatic diseases and pulmonary toxicity]

Rheumatic diseases are treated with manifold different drugs that can potentially be pneumotoxic. Adverse effects of drug therapy may induce a wide variety of bronchopulmonary and pleural disorders, which can have a life-threatening course. These side effects rarely have pathognomonic features; therefore, drug-induced diseases are relevant differential diagnoses of pulmonary manifestations of rheumatic diseases, infections, and other independent genuine pulmonary diseases. Diagnosis is based mainly on verification of a compatible disease pattern and exclusion of differential diagnoses, as well as on assessment of the temporal relationship and the consequences of drug abstention.