Flemish network on rare connective tissue diseases (CTD): patient pathways in systemic sclerosis. First steps taken

Despite the low prevalence of each rare disease, the total burden is high. Patients with rare diseases encounter numerous barriers, including delayed diagnosis and limited access to high-quality treatments. In order to tackle these challenges, the European Commission launched the European Reference Networks (ERNs), cross-border networks of healthcare providers and patients representatives. In parallel, the aims and structure of these ERNs were translated at the federal and regional levels, resulting in the creation of the Flemish Network of Rare Diseases. In line with the mission of the ERNs and to ensure equal access to care, we describe as first patient pathways for systemic sclerosis (SSc), as a pilot model for other rare connective and musculoskeletal diseases. Consensus was reached on following key messages: 1. Patients with SSc should have multidisciplinary clinical and investigational evaluations in a tertiary reference expert centre at baseline, and subsequently every three to 5 years. Intermediately, a yearly clinical evaluation should be provided in the reference centre, whilst SSc technical evaluations are permissionably executed in a centre that follows SSc-specific clinical practice guidelines. In between, monitoring can take place in secondary care units, under the condition that qualitative examinations and care including interactive multidisciplinary consultations can be provided. 2. Patients with early diffuse cutaneous SSc, (progressive) interstitial lung disease and/or pulmonary arterial hypertension should undergo regular evaluations in specialised tertiary care reference institutions. 3. Monitoring of patients with progressive interstitial lung disease and/or pulmonary (arterial) hypertension will be done in agreement with experts of ERN LUNG.

A case of anti-HMGCR myopathy in a patient with breast cancer and anti-Th/To antibodies

Statins competitively inhibit the activity of HMGCR (3-hydroxy-3-methylglutaryl coenzyme A reductase), which is a key enzyme in cholesterol synthesis. These are effective drugs for the management of cardiovascular disease and are generally well tolerated but several side effects have been reported. Muscular adverse symptoms are various and, rarely, statin exposure may lead to authentic immune-mediated necrotizing myopathy (IMNM), namely anti-HMGCR myopathy. However, cases of IMNM associated with cancer have been described. We discuss herein a case of IMNM in a patient with breast cancer previously exposed to statins and with the presence of anti-Th/To antibodies without clinical correlation.

Hematogenous septic arthritis of a non-prosthetic shoulder caused by Capnocytophaga canimorsus: A case report and review of the literature

Capnocytophaga canimorsus, oral inhabitants of dogs and cats is a cause of zoonotic infections. It is transmitted to humans by bites, scratches, licks, or close exposure to these animals. Infections due to Capnocytophaga canimorsus have a wide range of severity and can sometimes be fatal. We report the case of an 89-years-old man who suffered from a sudden swollen native right shoulder. The blood test revealed an inflammatory syndrome and cytologic evaluation of joint aspiration showed an elevated nucleated cells count suspicious of infection. A Gram-negative bacillus grew after 48 h in the arthrocentesis and was identified as Capnocytophaga canimorsus. After 4 days, blood culture also grew Capnocytophaga canimorsus leading to the diagnosis of hematogenous septic arthritis of a non-prosthetic right shoulder. Antimicrobial therapy was empirically started with cefuroxime then switched to doxycycline for seven weeks with good clinical outcomes. It is important to inquire about patients' environment including their proximity to animals as it can lead to zoonotic infections that can be of high severity. Moreover, hygiene rules must be applied when dog scratches or lick wounds occurred to avoid the spread of zoonotic germs. Prophylactic antibiotic therapy should be given for animal bites.

A case of left foot drop as initial symptom of granulomatosis with polyangiitis: Triggered by COVID-19 disease?

In Granulomatosis with polyangiitis (GPA), involvement of the peripheral nervous system is frequent but its occurrence as an initial presentation is unusual. This case highlights the importance of this occurrence to permit an early diagnosis. Moreover, GPA started after a coronavirus disease 2019 infection and could have been induced by this.

The physicians should recognize peripheral neuropathy as one of the first presentations of GPA, even if it’s rare, in order to permit an early diagnosis. Moreover, this case complements previously reported cases of COVID‐19‐induced auto‐immune disease.

Standardised nailfold capillaroscopy in children with rheumatic diseases: a worldwide study

OBJECTIVES

To standardly assess and describe nailfold videocapillaroscopy (NVC) assessment in children and adolescents with juvenile rheumatic and musculoskeletal diseases (jRMD) versus healthy controls (HC).

METHODS

In consecutive jRMD children and matched HC from 13 centres worldwide, 16 NVC images per patient were acquired locally and read centrally per international consensus standard evaluation of the EULAR Study Group on Microcirculation in Rheumatic Diseases. 95 patients with juvenile idiopathic arthritis (JIA), 22 with dermatomyositis (JDM), 20 with systemic lupus erythematosus (cSLE), 13 with systemic sclerosis (jSSc), 21 with localized scleroderma (lSc), 18 with mixed connective tissue disease (MCTD) and 20 with primary Raynaud's phenomenon (PRP) were included. NVC differences between juvenile subgroups and HC were calculated through multivariable regression analysis.

RESULTS

A total number of 6474 images were assessed from 413 subjects (mean age 12.1-years, 70.9% female). The quantitative NVC-characteristics were significantly lower (↓) or higher (↑) in the following subgroups compared to HC: For density: ↓ in jSSc, JDM, MCTD, cSLE and lSc; For dilations: ↑ in jSSc, MCTD and JDM; For abnormal shapes: ↑ JDM and MCTD; For haemorrhages: ↑ in jSSc, MCTD, JDM and cSLE. The qualitative NVC-assessment of JIA, lSc and PRP did not differ from HC, whereas the cSLE and jSSc, MCTD, JDM, cSLE subgroups showed more non-specific and scleroderma patterns respectively.

CONCLUSION

This analysis resulted from a pioneering registry of NVC in jRMD. The NVC-assessment in jRMD differed significantly from HC. Future prospective follow up will further elucidate the role of NVC in jRMD.

POS0240 WHICH FACTORS DRIVE THE CHOICE BETWEEN A 1ST AND 2ND GENERATION tsDMARD THERAPY IN RA THERAPY?

Background

Tofacitinib and Baricitinib are Janus Kinase Inhibitors (JAKi) considered first generation targeted synthetic DMARD (tsDMARDs) for the treatment of Rheumatoid Arthritis (RA). The second generation of JAKi (Upadacitinib and Filgotinib) seem to target JAK1 more selectively. Choice of JAKi is left to the treating rheumatologist as no head-to head-study or guidelines exist on this choice in RA.

Objectives

To investigate differences in demographics and clinical variables of patients with RA receiving either a 1st or a 2nd generation JAKi in daily practice.

Methods

Patients were included from the electronic platform “Tool for Administrative Reimbursement Drug Information Sharing” (TARDIS). Data from all Belgian RA patients on biologic (b) and tsDMARDs are here collected for drug reimbursement. Patients were selected for this analysis if starting a JAKi in 2021. Differences in demographic and clinical data were compared by χ2-tests and t-tests. Stepwise logistic regression models with tsDMARD choice as dependent variable was constructed with variables with p<0.05 in univariate analyses. Sensitivity analyses for bionaïve and bioexperienced patients were performed.

Results

In total, 1643 patients with RA starting JAKi therapy in 2021 were included. Of these, 433 (26.4%) were 1s generation and 1210 (73.6%) were 2nd generation. Patients starting a 1st generation JAKi were older, had higher Health Assessment Questionnaire (HAQ) scores, had a higher erythrocyte sedimentation rate (ESR), and less patients starting a 1st generation JAKi were bioexperienced (Table 1).

Table 1.

Comparison of baseline demographic and clinical characteristics between 1st and 2nd generation tsDMARDs

All populationBionaïve patientsBioexperienced patients1st generation tsDMARDs2nd generation tsDMARDs1st generation tsDMARDs2nd generation tsDMARDs1st generation tsDMARDs2nd generation tsDMARDsnumber4331210207482226728Age (years)60.8 ± 12.6*57.5 ± 13.1*60.5 ± 12.5*57.9 ± 13.5*60.8 ± 12.8*57.2 ± 12.7*Gender (women)304 (72.6%)833 (74.6%)137 (66.2%)344 (71.4%)175 (77.4%)550 (75.6%)Weight (kg)73.3 ± 15.374.2 ± 15.374.7 ± 16.474.2 ± 14.472.4 ± 13.874.6 ± 16.1Disease duration (years)9.0 ± 8.910.0 ± 9.75.6 ± 6.65.7 ± 7.111.9 ± 9.712.5 ± 10.1HAQ (0-3)1.9 ± 0.6*1.3 ± 0.8*1.8 ± 0.71.4 ± 0.71.9 ± 0.5*1.2 ± 0.8*PGA (0-100)63.5 ± 19.263.0 ± 21.565.0 ± 17.666.0 ± 20.162.0 ± 21.061.0 ± 21.8CRP (mg/l)12.8 ± 11.011.7 ± 10.716.3 ± 19.513.3 ± 15.410.5 ± 16.010.1 ± 13.5ESR (mm/h)25.3 ± 20.1*22.5 ± 18.3*28.1 ± 20.2*23.7 ± 17.5*21.9 ± 19.321.4 ± 19.3TJC288.8 ± 5.58.4 ± 5.78.7 ± 5.29.4 ± 5.48.9 ± 5.9*7.7 ± 5.8*SJC286.1 ± 4.65.9 ± 4.66.1 ± 4.16.6 ± 4.16.1 ± 4.95.5 ± 4.8DAS284.8 ± 1.04.7 ± 1.15.0 ± 0.95.0 ± 4.94.7 ± 1.1*4.5 ± 1.2*Bio-Experienced (yes)226 (51.1%) *728 (60.2%) *----N previous b/tsDMARDs2.0 ± 1.9*2.3 ± 2.2*--2.8 ± 1.0*3.1 ± 1.4*

Number given are mean ± SD or number, proportion. b=biologic; ts= targeted synthetic, HAQ= health assessment questionnaire, PGA= Patient Global assessment; CRP= C-reactive protein; ESR= erythrocyte sedimentation rate; TJC= tender joint count; SJC= Swollen joint Count; DAS28 = disease activity score based on the 28joints; N= number. * Signifies p<0.05.

The final logistic regression model included older age (OR(95%) =1.0(1.0-1.0)) and number of previous b/ts DMARDs ((OR(95%) =0.9(0.8-0.9))) as predictors of choice of 1st generation tsDMARDs (Table 2). In bionaive patients, only ESR (OR(95%) =1.0(1.0-1.0)) was predictive. In bioexperienced patients, older age (OR(95%) =1.0(1.0-1.0)), number of previous b/ts DMARDs ((OR(95%) =0.8(0.7-0.9)) and TJC (OR(95%) =1.0(1.0-1.1)) were predictors for choice of 1st generation tsDMARDs. HAQ was not included as it was missing in 90% of patients.

Conclusion

The high uptake of 2nd generation JAKi, just launched in 2021, is remarkable. Some variables effecting the choice of JAKi were found, yet these effects seemed to be small-sized. These drug choices could also be driven by other factors such as socio-economic status, illness perceptions or other patient reported outcomes, and also by marketing and sales.

Disclosure of Interests

None declared

AB0169 EARLY REMISSION AT 6 MONTHS AS A PREDICTOR OF LONGTERM REMISSION IN NEW ONSET RHEUMATOID ARTHRITIS

Background

Early therapeutic intervention is crucial for patients with early rheumatoid arthritis (ERA). The goal of remission is achievable in a large proportion of ERA patients.

Objectives

To evaluate the rate of patients in remission at 6 months and to correlate the 36 and 60 months remission rate in the Belgian CAP48 cohort and the UCLouvain Brussels cohort. To identify baseline characteristics differences between patients achieving remission or not.

Methods

We included patients with ERA from the CAP48 cohort and from the UCLouvain Brussels cohort who met the ACR/EULAR 2010 RA classification criteria. All patients were naïve to csDMARDs therapy. We collected patient characteristics at baseline and clinical response was analysed at 6, 36 and 60 months.

Results

287 RA patients from our UCLouvain Brussels Cohort and the CAP48 cohort were analysed (211 Females, 76 Males, mean age 46.2 years, 43.4% with baseline erosion, 70.1% with ACPA, 70.3% with Rheumatoid Factor, mean HAQ 1.16, mean DAS28-CRP 4.67, mean SDAI 24.9 and mean CDAI 24.1).

Table 1.

The clinical results are summarized in the Table.

DAS28-CRPMean(±SD)SDAIMean(±SD)CDAIMean(±SD)Remission(DAS28-CRP), %HAQMean(±SD)Baseline n=2874.67 (±1.38)26.5 (±15.5)24.1 (±14.4)/1.16 (±0.70)Months 6 n=2872.97 (±1.34)11.3(±12.3)10.5 (±11.8)44,9%0.60 (±0.62)Months 36 n=2872.24 (±1.04)7.5(±8.6)6.2 (±7.8)71,1%0.52 (±0.59)Months 60 n=1962.41 (±1.00)6.4(±6.5)5.7 (±6.2)66,3%0.56 (±0.63)

We divided the patients according to whether they achieved remission DAS28-CRP < 2.6 (group 1), or not (group 2) at 6 months.

Patient baseline characteristics were similar in the two groups respectively: age (46.7 vs 45.4 yrs); female (68.5 vs 77.3%); smoker (25.6 vs 27.0%); ACPA positive (70.1 vs 75.4%); baseline X-ray erosion (45.0 vs 54.7%).

DAS28-CRP, SDAI and CDAI at 6 months could predict long-term remission at 36 and 60 months, Figure:

Figure 1.

In group 1 global remission (DAS28-CRP<2.6, HAQ<0.5 and no X-ray progression) was observed in 75.6% at 60 months. The majority of these patients (69.4%) are still treated with Methotrexate, the others were treated with combination therapy.

Conclusion

Early and long term remission is an achievable goal in our two cohorts. Early diagnosis is critical in standard of care. At 6 months, all remission index criteria are good predictor for long term remission and could be used in daily care.

Disclosure of Interests

None declared

POS0694 WHAT TREATMENT GIVES THE BEST CLINICAL RESPONSE AFTER CESSATION OF JAKi THERAPY IN PATIENTS WITH RA? DATA OF THE TARDIS-RA REGISTRY, A NATIONWIDE BELGIAN BIOLOGIC REGISTRY

Background

JAKi represent a new important class in Rheumatoid Arthritis (RA) treatment options. It is unknown which specific bDMARD or mode of action should be selected after stopping a JAKi.

Objectives

To study if clinical response differs between advanced therapies that are initiated after stopping a JAKi.

Methods

Patients were included from the electronic platform “Tool for Administrative Reimbursement Drug Information Sharing” (TARDIS). Data from all Belgian RA patients on biologic and targeted therapy are collected here for drug reimbursement. Patients were selected for this analysis if they had stopped JAKi therapy and initiated a subsequent therapy. Patients were grouped by TNFi, T/B cell therapy, IL6i or JAKi therapy. The DAS28 response and proportion of patients in remission at the first follow-up (between 3 and 6 months) were compared between groups. Remission was defined as DAS28<2.6. Analyses were repeated in patients who were prescribed the stopped JAKi as first-line or as subsequent line therapy. Data were compared via χ2, Anova and t-tests.

Results

In total, 1238 patients who had stopped JAKi therapy were included. TNFi, T/B cell therapy, IL6i or JAKi therapy was initiated in 36% (441/1238), 19% (233/1238), 18% (227/1238) and 27% (337/1238) respectively. Most baseline demographic and clinical characteristics differed between groups (Table 1).

Table 1.TNFiB/T cellIL6iJAKip-valueNumber441 (36%)233 (19%)227 (18%)337 (27%)Age (years)55 ± 1457 ± 1355 ± 1459 ± 12<0.001Gender (women)323 (73%)177 (76%)186 (82%)257 (76%)0.100Weight (kg)74 ± 1579 ± 1775 ± 1575 ± 150.111Disease duration (years)9 ± 810 ± 911 ± 911 ± 90.002HAQ (0-3)1.6 ± 0.71.8 ± 0.61.5 ± 0.71.5 ± 0.80.353PGA (0-100)65 ± 2068 ± 2167 ± 2157 ± 24<0.001CRP (mg/l)10 ± 1614 ± 2016 ± 2811 ± 170.003ESR (mm/h)22 ± 2124 ± 1927 ± 2125 ± 220.117TJC288 ± 68 ± 69 ± 67 ± 60.001SJC285 ± 46 ± 56 ± 45 ± 50.006DAS284.7 ± 1.14.8 ± 1.14.9 ± 1.24.4 ± 1.3<0.0012nd line of therapy after initial JAKi therapy211 (48%)56 (24%)52 (23%)112 (33%)<0.001

Numbers given are mean ± SD or number, proportion. TNFi = tumour necrosis factor inhibitor, ts= targeted synthetic, HAQ= health assessment questionnaire, PGA= Patient Global assessment; CRP= C-reactive protein; ESR= erythrocyte sedimentation rate; TJC= tender joint count; SJC= Swollen joint Count; DAS28 = disease activity score based on the 28joints

The clinical response could be studied in 577 patients. Patients on rituximab were excluded as these were retreated on flare, following Belgian reimbursement criteria. TNFi, Tcell therapy, IL6i or JAKi therapy was initiated in 37% (211/577), 13% (76/577), 18% (102/577) and 33% (188/577) of these patients respectively. DAS28 decreased on average with 1.7 ± 1.5, 1.6 ± 1.4, 2.4 ± 1.6* and 1.3 ± 1.6 for patients on TNFi, T cell therapy, IL6i or JAKi therapy respectively (*p<0.001). Remission was reached in 42%, 41%, 56%* and 39% for patients on TNFi, T cell therapy, IL6i or JAKi therapy respectively (*p=0.045).

Before switching, JAKi therapy was the first advanced therapy in 35% (204/577). In this “naïve” subgroup, DAS28 decreased on average with 1.9 ± 1.5, 1.9 ± 1.3, 2.4 ± 1.8 and 1.0 ± 1.7* for patients on TNFi, Tcell therapy, IL6i or JAKi therapy respectively (*p=0.001). Remission was reached in 44%, 48%, 58% and 35% for patients on TNFi, Tcell therapy, IL6i or JAKi therapy respectively (p=0.279).

In the “experienced” subgroup, who started JAKi therapy as subsequent line therapy in 65% (373/577), DAS28 decreased on average with 1.5 ± 1.6, 1.5 ± 1.4, 2.3 ± 1.6* and 1.4 ± 1.6 for patients on TNFi, Tcell therapy, IL6i or JAKi therapy respectively (*p<0.001). Remission was reached in 40%, 38%, 55% and 41% for patients on TNFi, Tcell therapy, IL6i or JAKi therapy respectively (p=0.118).

Conclusion

Our results show clearly that IL6 inhibitors have a better clinical response after JAKi cessation compared to other mode of actions, including other JAKi. However, considerable baseline differences existed, that could influence our results.

Disclosure of Interests

None declared

Tapering of Etanercept is feasible in patients with Rheumatoid Arthritis in sustained remission: a pragmatic randomized controlled trial

Objective: In patients with rheumatoid arthritis (RA) in sustained remission, tapering of biological disease-modifying anti-rheumatic drugs can be considered. Tapering has already been investigated, but its feasibility remains to be determined. Therefore, we explored the feasibility of tapering etanercept in RA in a setting close to practice.Method: Patients with RA in 28-joint Disease Activity Score (DAS28) remission (≥ 6 months) and treated with etanercept 50 mg weekly (≥ 1 year) were included in the pragmatic 1 year open-label multicentre randomized controlled TapERA (Tapering Etanercept in Rheumatoid Arthritis) trial. Patients were assigned to continue etanercept weekly or to taper to every other week (EOW). Patients who lost remission [DAS28-C-reactive protein (CRP) ≥ 2.6] were re-escalated to etanercept weekly. The primary outcome was the proportion of patients maintaining DAS28-CRP remission for 6 months.Results: Sixty-six patients were randomized to etanercept weekly (n = 34) or EOW (n = 32). After 6 months, 26/34 patients (76%) in the weekly and 19/32 (59%) in the EOW group maintained disease control (p = 0.136). In the EOW group, 20/32 patients (63%) remained on their tapered treatment during the trial. Two patients reintroduced weekly etanercept themselves. Ten patients were re-escalated to etanercept weekly by the rheumatologist, after a median (interquartile range) interval of 3.0 (2.0-6.0) months. Among these patients, 7/10 regained remission after re-escalation, four of them at the next study visit.Conclusions: Although non-inferiority could not be demonstrated, tapering of etanercept to EOW appeared feasible in patients in sustained remission.

A Cross-Sectional and Longitudinal Study to Define Alarmins and A-SAA Variants as Companion Markers in Early Rheumatoid Arthritis

Nowadays, in the study of rheumatoid arthritis (RA), more and more interest is directed towards an earlier effective therapeutic intervention and the determination of companion markers for predicting response to therapy with the goal to prevent progressive joint damage, deformities, and functional disability. With the present work, we aimed at quantifying in a cohort of early RA (ERA) patients naïve to DMARD therapy, proteins whose increase was previously found associated with RA: serum amyloid A (A-SAA) and alarmins. Five A-SAA variants (SAA1α, SAA1β, SAA1γ, SAA2α, and SAA2β) but also S100A8 and S100A9 proteins were simultaneously quantified in plasma applying a method based on single targeted bottom-up proteomics LC-MS/MS. First, we compared their expression between ERA (n = 100) and healthy subjects (n = 100), then we focused on their trend by monitoring ERA patients naïve to DMARD treatment, 1 year after starting therapy. Only SAA1α and SAA2α levels were increased in ERA patients, and SAA2α appears to mostly mediate the pathological role of A-SAA. Levels of these variants, together with SAA1β, only decreased under biologic DMARD treatment but not under methotrexate monotherapy. This study highlights the importance to better understand the modulation of expression of these variants in ERA in order to subsequently better characterize their biological function. On the other hand, alarmin expression increased in ERA compared to controls but remained elevated after 12 months of methotrexate or biologic treatment. The work overcomes the concept of considering these proteins as biomarkers for diagnosis, demonstrating that SAA1α, SAA1β, and SAA2α variants but also S100A8 and S100A9 do not respond to all early treatment in ERA and should be rather considered as companion markers useful to improve the follow-up of treatment response and remission state. Moreover, it suggests that earlier use of biologics in addition to methotrexate may be worth considering.

Serum calprotectin (S100A8/A9): a promising biomarker in diagnosis and follow-up in different subgroups of juvenile idiopathic arthritis

Introduction

In the management of juvenile idiopathic arthritis (JIA), there is a lack of diagnostic and prognostic biomarkers. This study assesses the use of serum calprotectin (sCal) as a marker to monitor disease activity, and as a classification and prognosis tool of response to treatment or risk of flares in patients with JIA.

Methods

Eighty-one patients with JIA from the CAP48 multicentric cohort were included in this study, as well as 11 non-paediatric healthy controls. An ELISA method was used to quantify sCal with a commercial kit.

Results

Patients with an active disease compared with healthy controls and with patients with inactive disease showed an eightfold and a twofold increased level of sCal, respectively. sCal was found to be correlated with the C-reactive protein (CRP) and even more strongly with the erythrocyte sedimentation rate. Evolution of DAS28 scores correlated well with evolution of sCal, as opposed to evolution of CRP. With regard to CRP, sCal could differentiate forms with active oligoarthritis from polyarthritis and systemic forms. However, sCal brought an added value compared with the CRP as a prognosis marker. Indeed, patients with active disease and reaching minimal disease activity (according to Juvenile Arthritis Disease Activity Score) at 6 months following the test had higher sCal levels, while patients with inactive disease had higher sCal levels if a flare was observed up to 3–9 months following the test.

Conclusions

This study confirms the potential uses of sCal as a biomarker in the diagnosis and follow-up of JIA.

POS1203 EFFECT OF THE COVID19 PANDEMIC ON RHEUMATOLOGIST PRESCRIPTION BEHAVIOUR OF NEW ADVANCED THERAPY: DATA OF THE TARDIS-RA REGISTRY, A NATIONWIDE BELGIAN BIOLOGIC REGISTRY

Background:

Belgium suffered considerably from the COVID19 pandemic with high hospitalisation rates during 2 periods: a first wave in March and April 2020, and a second starting from October until the end of 2020. Measures of lowering social interaction were taken throughout 2020 and intensified during the first and second wave when needed. This pandemic could have influenced the access to care and advanced therapies for patients with Rheumatoid Arthritis (RA). In the electronic platform “Tool for Administrative Reimbursement Drug Information Sharing” (TARDIS), data from all Belgian RA patients on biologic and targeted therapy are collected during the submission of a request for initiation and prolongation of reimbursement for these drugs.

Objectives:

to investigate the effect of the COVID19 pandemic on the monthly prescription behaviour of a new advanced therapy in 2020 by comparing it to 2019.

Methods:

Patients were selected for this analysis if they started a new TNFi, B/T cell therapy, IL6 inhibitors or tsDMARD therapy in the TARDIS registry in 2019 or in 2020. Rheumatologists request reimbursement via the online TARDIS tool, which is considered here as a new drug prescription. Prescription behaviour was compared between 2019 and 2020, between bionaive and bioexperienced patients, and between the different drug classes

Results:

In 2019, 2949 patients were prescribed any new advanced therapy, including 1153 TNFi, 469 B/T cell therapy, 436 IL6 inhibitors and 891 tsDMARDs. In 2020, 2998 patients were prescribed any new advanced therapy including 1233 TNFi, 382 B/T cell therapy, 496 IL6 inhibitors and 887 tsDMARDs.

On a monthly basis, on average 246 and 250 new advanced therapies were prescribed in 2019 and 2020 respectively. Monthly deviations from this average in 2019 ranged from -19% to +16%. Monthly deviations from this average in 2020 ranged from -50% to +30%. Figure 1A shows the monthly prescription of new advanced therapies in 2019 and 2020.

For bionaive and bioexperienced patients, the same trend can be noted. Monthly deviations in bionaive patients in 2020 ranged from -60% to +38%, compared to -18% to +21% in 2019. Monthly deviations in bioexperienced patients ranged from -40% to +25%, compared to -19% to +17% in 2019.

Comparison per drug class in 2020 show similar trends. IL6 inhibitors show a slightly different timeline than other drugs classes with other periods of less or more prescriptions changes compared to the other drugs classes. See Figure 1B.

Conclusion:

The COVID19 pandemic did affect reimbursement requests for patients starting new advanced therapies in March and April 2020, especially for bionaive patients. The latter half of 2020 was apparently used to catch up with reimbursement requests for patients in need for advanced therapies resulting in similar total numbers of patients treated with advanced therapy in 2019 and 2020. The choice for a particular drug type was not clearly influenced by the pandemic. IL6 inhibitor use did seem to be affected differently by the pandemic, yet caution is warranted as these relatively large differences in proportional changes parallel small differences in actual drug numbers.

In sum, the observed effect of the pandemic on initiating advanced therapy during the first wave corresponds with Belgian governmental measures that restricted non-essential care which was less observed in the latter half of 2020.

Disclosure of Interests:

None declared.

Antibodies against carbamylated proteins: prevalence and associated disease characteristics in Belgian patients with rheumatoid arthritis or other rheumatic diseases

Objectives: Anti-carbamylated protein antibodies (anti-CarP) are reported to be associated with increased disease activity and with more severe joint damage in rheumatoid arthritis (RA) patients. The present study investigated the presence of anti-CarP in various rheumatic diseases, and their specific clinical significance in RA, in Belgian rheumatology patients.Method: We tested sera from 254 RA patients, 56 healthy controls, and 153 patients with different rheumatic conditions: juvenile idiopathic arthritis (JIA), axial spondyloarthritis, systemic sclerosis, and Sjögren's syndrome (SS). An in-house enzyme-linked immunosorbent assay was used to detect immunoglobulin G antibodies against carbamylated foetal calf serum.Results: Anti-CarP were detected in 88 RA patients (34.6%), of whom 82% were also positive for anti-citrullinated protein antibodies (ACPAs) and 81% were also rheumatoid factor (RF) positive. Of note, 11 anti-CarP single-positive patients were detected (4.3%). The previously reported association with joint erosions was not detected. However, in ACPA- and RF-negative RA patients, the presence of anti-CarP was associated with higher disease activity and disability. Fifteen per cent of JIA patients and 30% of SS patients also tested positive for anti-CarP and their antibody levels did not differ significantly from those of anti-CarP-positive RA patients. Anti-CarP levels were, however, significantly higher in ACPA- or RF-positive patients.Conclusion: Anti-CarP antibodies were detected in the sera of a cohort of Belgian RA patients. Moreover, they were also detected in primary SS patients and in JIA patients. In the seronegative subset of RA patients, anti-CarP antibodies showed prognostic value.

The importance of skin manifestations, serology and nailfold (video)capillaroscopy in morphea and systemic sclerosis: current understanding and new insights

Since the field around morphea and systemic sclerosis (SSc) is evolving rapidly, this review approaches conventional as well as more recent clinical developments from a dermatological point of view. Skin manifestations are critical in sub-classifying these diseases ensuring a correct prognosis for these patients. They can be discretely present, and therefore, diagnosis can be challenging sometimes, implicating a thorough dermatological examination is mandatory. Furthermore, a growing amount of dermatologists perform nailfold videocapillaroscopy (NVC), a more recent reliable non-invasive imaging technique used for in vivo assessment of the microcirculation at the nailfold. After all, specific NVC-changes are present in a majority of patients with SSc. This way, dermatologists not only take part in the diagnosis process through clinical investigation but also through the use of a modern state of the art imaging technique that is becoming the golden standard in SSc multidisciplinary workup. In this review, current understandings for NVC in morphea and SSc are revised. So far, the role of NVC in the diagnosis/prognosis/classification of morphea patients has not been thoroughly investigated to make proper conclusions. As for SSc, it is well known that NVC contributes to the diagnosis and can make a fundamental difference especially when obvious clinical SSc signs are absent. This review emphasizes the (somewhat underestimated) role of dermatologists in the process of diagnosis and follow-up, and thus, the difference we can make for our patients and fellow colleagues in the multidisciplinary workup of SSc and morphea.

Association Between Nursing Support Levels and Effectiveness of Golimumab in the Management of Patients with Rheumatologic Diseases

INTRODUCTION

The main objective of this study was to assess the level of nursing support received by biologic-naïve rheumatological patients treated with golimumab during their first cycle.

METHODS

Adult patients (N = 119; aged 46.9 ± 13.4 years (mean ± standard deviation); 49.6% males), with rheumatoid arthritis (N = 40), ankylosing spondylitis (N = 58) or psoriatic arthritis (N = 21), and treated with golimumab (first tumor necrosis factor-α inhibitor) during a first reimbursement cycle were included by 17 Belgian centers. Patients were categorized in three levels of nursing support (intense, medium, or low). They filled in a non-validated and exploratory questionnaire about satisfaction, quality, and helpfulness of information.

RESULTS

The nursing support was considered intense, medium, or low for 98 (82.4%), 10 (8.4%), and 11 (9.2%) patients, respectively. All disease activity scores improved versus baseline, and 90% of the patients qualified for treatment prolongation without major differences between nursing level groups. The proportion of patients able to self-inject golimumab was 88, 90, and 73% in the intense, medium, and low support groups, respectively. Satisfaction was high in all three nursing support groups.

CONCLUSIONS

This prospective open-label study has confirmed the short-term effectiveness of golimumab in three rheumatological diseases, with most of the patients qualifying for reimbursement renewal. The limited sample size and the fact that the vast majority of patients benefited from an intense nursing support did not allow drawing definite conclusions concerning the impact of the nursing level on the treatment effectiveness and changes in the disease activity. Nurses seem however to play a crucial role in this short-term study but this remains to be confirmed in a longer-term study.

Glycosylation deficiency of lipopolysaccharide-binding protein and corticosteroid-binding globulin associated with activity and response to treatment for rheumatoid arthritis

BACKGROUND

Serum protein glycosylation is an area of investigation in inflammatory arthritic disorders such as rheumatoid arthritis (RA). Indeed, some studies highlighted abnormalities of protein glycosylation in RA. Considering the numerous types of enzymes, monosaccharides and glycosidic linkages, glycosylation is one of the most complex post translational modifications. By this work, we started with a preliminary screening of glycoproteins in serum from RA patients and controls.

METHODS

In order to isolate glycoproteins from serum, lectin wheat germ agglutinin was used and quantitative differences between patients and controls were investigated by LC-MS/MS. Consequently, we focused our attention on two glycoproteins found in this explorative phase: corticosteroid-binding globulin (CBG) and lipopolysaccharide-binding protein (LBP). The subsequent validation with immunoassays was widened to a larger number of early RA (ERA) patients (n = 90) and well-matched healthy controls (n = 90).

RESULTS

We observed a significant reduction of CBG and LBP glycosylation in ERA patients compared with healthy controls. Further, after 12 months of treatment, glycosylated CBG and LBP levels increased both to values comparable to those of controls. In addition, these changes were correlated with clinical parameters.

CONCLUSIONS

This study enables to observe that glycosylation changes of CBG and LBP are related to RA disease activity and its response to treatment.

Two years follow-up of an open-label pilot study of treatment with rituximab in patients with early diffuse cutaneous systemic sclerosis

OBJECTIVES

Following results in open-label studies of rituximab in patients with systemic sclerosis, a Belgian three-centre initiative was launched to explore safety and efficacy of rituximab in early, diffuse cutaneous systemic sclerosis (dcSSc).

METHODS

Open-label study of 17 patients with early dcSSc, treated with two courses of rituximab, at month 0 and 6. Clinical examination, lung function testing, echocardiography, disease activity score (DAS) and functional status were performed at baseline and over 24 months of follow-up.

RESULTS

Modified Rodnan skin score (MRSS) changed significantly over time, with a mean of 25.5 (standard deviation [SD] 6.0) at baseline to 12.6 (SD 5.1) at month 24 (Mixed Model Analysis [MMA] p < 0.0001), which is a decrease of 51% at month 24 vs. baseline. DAS showed significant decrease over the total study period, with a score of 4.1 (SD 1.7) at baseline to 1.5 (SD 1.8) at month 24 (MMA p < 0.0001). Additionally, this was significant at all time points vs. baseline, both for MRSS and DAS. Internal organ status remained clinically stable throughout the study period. No statistically significant differences compared to baseline were found at the follow-up time points. Seven serious adverse events took place, all except for one, considered unrelated to study medication.

CONCLUSIONS

This is the first multicentre Belgian collaboration investigating potential efficacy of rituximab in early dcSSc. Rituximab appears to be safe and tolerable and it may have beneficial effects on skin involvement, on overall disease activity and on stabilization of internal organ status in early dcSSc.

Hidradenitis suppurativa (HS): An unrecognized paradoxical effect of biologic agents (BA) used in chronic inflammatory diseases

BACKGROUND

Paradoxical hidradenitis suppurativa (HS) induced by biologic agents (BA) is scarcely reported.

OBJECTIVE

We sought to describe the clinical characteristics and outcome of patients developing paradoxical HS under BA.

METHODS

This was a multicenter nationwide retrospective study asking physicians to report all cases of HS, confirmed by a dermatologist, occurring during treatment of an inflammatory disease by a BA.

RESULTS

We included 25 patients (15 inflammatory rheumatism, 9 Crohn's disease, 1 psoriasis) treated by 5 BA (adalimumab = 12, infliximab = 6, etanercept = 4, rituximab = 2, tocilizumab = 1). Median duration of BA exposure before HS onset was 12 (range 1-120) months. Patients were mostly Hurley stage I (n = 13) or II (n = 11). Simultaneously to HS or within 1 year, 11 patients developed additional inflammatory diseases, including paradoxical reactions (psoriasis = 9, Crohn's disease = 3, alopecia areata = 1, erythema elevatum diutinum = 1). Complete improvement of HS was more frequently obtained after BA discontinuation or switch (n = 6/10, 60%) rather than maintenance (n = 1/14, 7%). Reintroducing the same BA resulted in HS relapse in 3 of 3 patients.

LIMITATIONS

Retrospective nature and lack of complete follow-up for some patients are limitations.

CONCLUSION

HS is a rare paradoxical adverse effect of BA, but fortuitous association cannot be excluded in some cases. We observed a trend toward better outcome when the BA was discontinued or switched.

Higher expression of TNFα-induced genes in the synovium of patients with early rheumatoid arthritis correlates with disease activity, and predicts absence of response to first line therapy

BACKGROUND

IL6-related T cell activation and TNFα-dependent cell proliferation are major targets of therapy in the RA synovium. We investigated whether expression of these pathways in RA synovial biopsies is associated with disease activity and response to therapy.

METHOD

Correlation and gene set enrichment studies were performed using gene expression profiles from RA synovial biopsies. Immunostaining experiments of GADD45B and PDE4D were performed on independent additional sets of early untreated RA samples, obtained in two different centers by needle-arthroscopy or US-guided biopsies.

RESULTS

In 65 RA synovial biopsies, transcripts correlating with disease activity were strongly enriched in TNFα-induced genes. Out of the individual variables used in disease-activity scores, tender joint count, swollen joint count and physician's global assessment, but not CRP or patient's global assessment displayed a similar correlation with the expression of TNFα-dependent genes. In addition, TNFα-induced genes were also significantly enriched in transcripts over-expressed in synovial biopsy samples obtained from poor-responders to methotrexate or tocilizumab, prior to initiation of therapy. GADD45B (induced by TNFα in monocytes) and PDE4D (induced by TNFα in FLS) immunostaining was significantly higher in overall poor-responders to therapy in 46 independent baseline samples obtained from early untreated RA patients prior to initiation of therapy. GADD45B (but not PDE4D) immunostaining was significantly higher in the sub-group of patients with poor-response to methotrexate therapy, and this was confirmed in another population of methotrexate-treated patients.

CONCLUSION

Higher expression of TNFα-induced transcripts in early RA synovitis is associated with higher disease activity, and predicts poor response to first-line therapy. That over-expression of TNFα-induced genes predicts poor-response to therapy regardless of the drug administered, indicates that this molecular signature is associated with disease severity, rather than with specific pathways of escape to therapy.

[The new classification criteria for spondylarthritis: implications in clinical practice]

" Spondyloarthritis" consists of a group of several diseases sharing clinical, radiological and genetic similarities. Ankylosing spondylitis is the main representative of this group and is characterized by a predominant axial involvement. The presence of radiographic sacroiliitis is essential for the diagnosis of ankylosing spondylitis according to the modified New York criteria. Because the occurence of radiographic sacroiliitis takes 8 to 11 years, the diagnosis of spondyloarthritis is often delayed. Magnetic resonance imaging can depict sacroiliac joint inflammation before the appearance of radiographic damage thereby defining the concept of " non-radiographic axial spondylo-arthritis". This entity was defined by the axial spondyloarthritis classification criteria published by the Assessment of SpondyloArthritis international Society (ASAS). Some factors, such as elevated levels of C-reactive protein at baseline, have been identified as predictors of radiographic sacroiliitis progression, leading to a definite diagnosis of ankylosing spondylitis. These two entities show similar clinical expression (clinical features and activity levels), suggesting continuity between the two diseases. Non-radiographic forms most often affect women and patients with recent symptoms, and are therefore considered as a pre-radiographic status. If the use of magnetic resonance imaging is necessary for the identification of non-radiographic axial spondyloarthritis according to the ASAS criteria, the presumptive diagnosis is mainly based on complaints of inflammatory back pain. The presence of other typical clinical features, such as HLA B27 positivity and/or radiographic sacroiliitis increases the diagnostic probability and indicates the need for referral to a specialist.

[Early diagnosis of rheumatoid arthritis]

Rheumatoid arthritis is the most common chronic inflammatory rheumatic disorder, and is characterized by inflammation of the joint, which can lead to irreversible bone damage, joint deformity and disability, if not diagnosed timely or treated adequately. New classification criteria were developed in 2010 in order to identify patients at risk of developing persistent or erosive arthritis, and requiring early therapy. In order to detect early arthritis or bone erosions before their appearance on X-rays, ultrasound and magnetic resonance imaging are now routinely used by clinicians, and also seem to deliver prognostic information about the disease. Synovial biopsies are potentially interesting in case of early arthritis to identify markers of diagnosis, prognosis or therapeutic response. Genetic or environmental risk factors were described to play a role in the development or maintenance of the disease; they could also help to screen early RA. A rapid diagnosis is eventually based on the right information and a tight collaboration between the primary care physician and the rheumatology care specialist.

sIL7R concentrations in the serum reflect disease activity in the lupus kidney

OBJECTIVES

Evaluation of disease activity in systemic lupus erythematosus (SLE) nephritis is a challenge, and repeated renal biopsies are usually needed in order to confirm a suspicion of flare. In a previous cross-sectional study, we reported that serum soluble form of the interleukin-7 receptor (sIL7R) levels is strongly associated with nephritis in SLE patients. In the present study, we wanted to confirm the association between changes in serum sIL7R concentrations and renal disease activity in a large longitudinal cohort of SLE nephritis patients.

METHODS

Sera were harvested longitudinally in 105 SLE nephritis patients. Serum sIL7R cut-off value for the detection of SLE nephritis activity was determined as the mean sIL7R concentration in non-nephritis SLE patients + 2 SDs using data collected in our previous study. Patients with glomerular filtration rate (GFR) <60 mL/min/1.73 m(2) (n=17) were excluded from the study due to persistently elevated serum sIL7R values.

RESULTS

Serum sIL7R concentrations above the renal cut-off value were observed in 25 (out of 88) patients with a normal GFR. These patients had significantly higher serum double-stranded DNA (dsDNA) Ab and urinary protein to creatinine (UPC) ratio. Strikingly, 12 of them developed a renal British Isles Lupus Assessment Group index (BILAG) A within the next 3 months, while this was only the case in four out of the 63 other patients (p<0.0001). The test had 75.0% sensitivity and 81.9% specificity for the detection of a renal BILAG A. Combination of serum sIL7R with any of the classical tests (anti-dsDNA Ab titres, UPC ratio, serum C3) resulted in an increased specificity for the detection of a renal flare. Administration of immunosuppressive therapy resulted in a significant decrease in serum sIL7R concentrations.

CONCLUSIONS

Serum sIL7R is a sensitive and specific marker of renal disease activity in SLE. Elevated serum sIL7R values in SLE patients are associated with or predict the occurrence of an SLE nephritis flare.

Serum soluble interleukin 7 receptor is strongly associated with lupus nephritis in patients with systemic lupus erythematosus

BACKGROUND

The soluble form of the interleukin 7 receptor (sIL-7R) is produced by fibroblasts after stimulation with proinflammatory cytokines. Increased sIL-7R serum and synovial fluid levels were recently demonstrated in patients with rheumatoid arthritis.

OBJECTIVES

To investigate whether sIL-7R production is dysregulated in systemic lupus erythematosus (SLE), and whether this correlates with disease activity.

METHODS

Serum and urine sIL-7R concentrations were measured by ELISA, and sIL-7R quantitative PCR (qPCR) studies were performed in peripheral blood mononuclear cells (PBMCs). IL-7R, tumour necrosis factor α (TNFα), IL-1β and IL-17 immunostainings were performed on kidney sections.

RESULTS

sIL-7R concentrations were significantly higher in SLE sera than in controls, and correlated with SLE Disease Activity Index (SLEDAI) scores. Accordingly, serum sIL-7R levels were strongly raised in patients with nephritis. Moreover in patients with lupus nephritis, serum sIL-7R decreased upon treatment. sIL-7R gene expression in PBMCs was similar in patients with lupus nephritis and controls. By contrast, abundant perivascular IL-7R expression was seen in SLE kidney biopsy specimens, which was associated with expression of TNFα in the surrounding tissue.

CONCLUSIONS

Our data indicate that sIL-7R is a marker of SLE disease activity, especially nephritis. In contrast to conventional disease activity markers, sIL-7R is not produced by immune cells, but might instead reflect activation of tissue cells in the target organ.

Anti-cyclic citrullinated peptide antibodies: a comparison of different assays for the diagnosis of rheumatoid arthritis

OBJECTIVES

Anti-cyclic citrullinated peptide (anti-CCP) antibodies are highly specific markers of rheumatoid arthritis (RA). Considering the heterogeneity of the target antigens involved, and the test platforms and conjugates proposed in commercial anti-CCP assays, we assessed the diagnostic performances of four fully automated anti-CCP assays in a cohort of patients with RA compared to patients with other autoimmune and inflammatory disorders. We also evaluated the agreement between the qualitative results of these immunoassays.

METHOD

We evaluated three anti-CCP2 assays [Eurodiagnostica enzyme-linked immunosorbent assay (ELISA), Elecsys electrochemiluminescence immunoassay (ECLIA) on the Modular E170 Analyzer, and Zenit chemiluminescence immunoassay (CLIA) on the Zenit RA Analyzer] and one anti-CCP3 assay (Inova ELISA). ELISAs were performed on an automated workstation. Samples from 112 patients with RA and a disease control group of 136 patients (53 with autoimmune diseases, 65 non-autoimmune disorders, and 18 infectious diseases) were studied (included 161 samples submitted consecutively to the laboratory).

RESULTS

At a fixed specificity of 92%, the anti-CCP3 assay presented the highest sensitivity (75%) compared to the anti-CCP2 assays evaluated (63-72%). The Zenit anti-CCP2 assay gave the most false-positive results (especially in patients with viral infections and connective tissue diseases). The agreement between assays ranged from 86.3% to 95.2% and Kappa coefficients ranged from 0.724 to 0.899.

CONCLUSIONS

Recently released automated workstations provide a valuable alternative to ELISA to diagnose RA. However, differences in diagnostic performances are highlighted in our experience, especially for the Zenit assay. In our cohort, the anti-CCP3 assay gave slightly better performances than the anti-CCP2 assays (with the exception of the Zenit assay).

Rheumatoid arthritis synovial fibroblasts produce a soluble form of the interleukin-7 receptor in response to pro-inflammatory cytokines

We previously demonstrated that baseline synovial overexpression of the interleukin-7 receptor α-chain (IL-7R) is associated with poor response to tumour necrosis factor (TNF) blockade in rheumatoid arthritis (RA). We found that IL-7R gene expression is induced in fibroblast-like synovial cells (FLS) by the addition of TNF-α, IL-1β and combinations of TNF-α+ IL-1β or TNF-α+ IL-17, thereby suggesting that these cytokines play a role in the resistance to TNF blockade in RA. Because FLS and CD4 T cells also produce a soluble form of IL-7R (sIL-7R), resulting from an alternative splicing of the full-length transcript, we wondered whether expression of sIL-7R is similarly regulated by pro-inflammatory cytokines. We also investigated whether sIL-7R is detectable in the serum of RA patients and associated with response to TNF blockade. RA FLS were cultured in the presence of pro-inflammatory cytokines and sIL-7R concentrations were measured in culture supernatants. Similarly, sIL-7R titres were measured in sera obtained from healthy individuals, early untreated RA patients with active disease and disease-modifying anti-rheumatic drug (DMARD)-resistant RA patients prior to initiation of TNF-blockade. Baseline serum sIL-7R titres were correlated with validated clinical measurements of disease activity. We found that exposure of RA FLS to pro-inflammatory cytokines (TNF-α, IL-1β and combinations of TNF-α and IL-1β or TNF-α and IL-17) induces sIL-7R secretion. Activated CD4 T cells also produce sIL-7R. sIL-7R serum levels are higher in RA patients as compared to controls. In DMARD-resistant patients, high sIL-7R serum concentrations are strongly associated with poor response to TNF-blockade. In conclusion, sIL-7R is induced by pro-inflammatory cytokines in RA FLS. sIL-7R could qualify as a new biomarker of response to therapy in RA.

Gene expression profiling in the synovium identifies a predictive signature of absence of response to adalimumab therapy in rheumatoid arthritis

Introduction

To identify markers and mechanisms of resistance to adalimumab therapy, we studied global gene expression profiles in synovial tissue specimens obtained from severe rheumatoid arthritis (RA) patients before and after initiation of treatment.

Methods

Paired synovial biopsies were obtained from the affected knee of 25 DMARD (disease-modifying antirheumatic drug)-resistant RA patients at baseline (T0) and 12 weeks (T12) after initiation of adalimumab therapy. DAS28-CRP (disease activity score using 28 joint counts-C-reactive protein) scores were computed at the same time points, and patients were categorized as good, moderate, or poor responders according to European League Against Rheumatism criteria. Global gene expression profiles were performed in a subset of patients by means of GeneChip Human Genome U133 Plus 2.0 Arrays, and confirmatory immunohistochemistry experiments were performed on the entire cohort.

Results

Gene expression studies performed at baseline identified 439 genes associated with poor response to therapy. The majority (n = 411) of these genes were upregulated in poor responders and clustered into two specific pathways: cell division and regulation of immune responses (in particular, cytokines, chemokines, and their receptors). Immunohistochemistry experiments confirmed that high baseline synovial expression of interleukin-7 receptor α chain (IL-7R), chemokine (C-X-C motif) ligand 11 (CXCL11), IL-18, IL-18 receptor accessory (IL-18rap), and MKI67 is associated with poor response to adalimumab therapy. In vitro experiments indicated that genes overexpressed in poor responders could be induced in fibroblast-like synoviocytes (FLS) cultures by the addition of tumor necrosis factor-alpha (TNF-α) alone, IL-1β alone, the combination of TNF-α and IL-17, and the combination of TNF-α and IL-1β.

Conclusions

Gene expression studies of the RA synovium may be useful in the identification of early markers of response to TNF blockade. Genes significantly overexpressed at baseline in poor responders are induced by several cytokines in FLSs, thereby suggesting a role for these cytokines in the resistance to TNF blockade in RA.

Spontaneous coronary artery dissection: favorable outcome illustrated by angiographic data

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction. It typically occurs in young women receiving oral contraceptive therapy or during the peripartum period. In the case presented here, spontaneous complete healing at angiography and the favorable outcome may support the role of conservative treatment in such patients.