Impact of osteoporosis and osteoporosis medications on fracture healing: a narrative review

Antiresorptive medications do not negatively affect fracture healing in humans. Teriparatide may decrease time to fracture healing. Romosozumab has not shown a beneficial effect on human fracture healing.

BACKGROUND

Fracture healing is a complex process. Uncertainty exists over the influence of osteoporosis and the medications used to treat it on fracture healing.

METHODS

Narrative review authored by the members of the Fracture Working Group of the Committee of Scientific Advisors of the International Osteoporosis Foundation (IOF), on behalf of the IOF and the Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT).

RESULTS

Fracture healing is a multistep process. Most fractures heal through a combination of intramembranous and endochondral ossification. Radiographic imaging is important for evaluating fracture healing and for detecting delayed or non-union. The presence of callus formation, bridging trabeculae, and a decrease in the size of the fracture line over time are indicative of healing. Imaging must be combined with clinical parameters and patient-reported outcomes. Animal data support a negative effect of osteoporosis on fracture healing; however, clinical data do not appear to corroborate with this. Evidence does not support a delay in the initiation of antiresorptive therapy following acute fragility fractures. There is no reason for suspension of osteoporosis medication at the time of fracture if the person is already on treatment. Teriparatide treatment may shorten fracture healing time at certain sites such as distal radius; however, it does not prevent non-union or influence union rate. The positive effect on fracture healing that romosozumab has demonstrated in animals has not been observed in humans.

CONCLUSION

Overall, there appears to be no deleterious effect of osteoporosis medications on fracture healing. The benefit of treating osteoporosis and the urgent necessity to mitigate imminent refracture risk after a fracture should be given prime consideration. It is imperative that new radiological and biological markers of fracture healing be identified. It is also important to synthesize clinical and basic science methodologies to assess fracture healing, so that a convergence of the two frameworks can be achieved.

OP0188 CLINICAL EFFECTIVENESS OF STRATIFIED EXERCISE THERAPY COMPARED TO USUAL EXERCISE THERAPY IN PATIENTS WITH KNEE OSTEOARTHRITIS: A CLUSTER RANDOMIZED CONTROLLED TRIAL (OCTOPuS-STUDY)

Background

There is strong, high-quality evidence for the effectiveness of exercise therapy in people with knee osteoarthritis (OA).1 However, although effective, the average effect size is only moderate (approximately 0.5).1 This may be attributed to the current ‘one-size-fits-all’ exercise approach, while a stratified approach may yield superior clinical and economic outcomes. We are the first to test a model of stratified exercise therapy in patients in knee OA. This model was based on 3 previously identified subgroups2 that are aligned with well-accepted OA phenotypes3, namely a ‘low muscle strength subgroup’ (‘age-induced phenotype’), ‘high muscle strength subgroup’ (‘post-traumatic phenotype’) and ‘obesity subgroup’ (‘metabolic phenotype’). For each subgroup, a subgroup-specific exercise therapy intervention was developed and pilot-tested4, which was supplemented by a dietary intervention for the ‘obesity subgroup’.

Objectives

The OCTOPuS-trial aimed to determine the effectiveness of stratified exercise therapy in reducing knee pain and improving physical function, compared to usual, ‘non-stratified’ exercise therapy, in patients with knee OA.

Methods

We conducted a pragmatic cluster randomized controlled trial in a primary care setting in 335 people with knee osteoarthritis: 153 in the experimental arm and 182 in the control arm. Physiotherapy practices were randomized into the experimental arm providing the model of stratified exercise therapy supplemented by a dietary intervention from a dietician for the ‘obesity subgroup’ or the control arm proving usual, ‘non-stratified’ exercise therapy. Primary outcomes were knee pain severity (NRS pain, 0-10) and physical function (KOOS subscale daily living, 0-100). Measurements were performed at baseline, and 3- (primary endpoint), 6-, and 12-months follow-up. Intention-to-treat, multilevel, regression analysis was performed.

Results

We found statistically non-significant differences in knee pain (mean difference (95% confidence interval): 0.19 (-0.31, 0.69)) and physical function (-0.40 (-3.91, 3.12)) at 3-months follow-up, with within-group effect sizes ranging between 0.5 and 0.7. Non-significant differences were also found for all other time points and for nearly all secondary outcome measures. Moreover, effects of experimental and control intervention were similar in each of the 3 subgroup separately.

Conclusion

This trial demonstrated no added value with respect to clinical outcomes of our model of stratified exercise therapy compared to usual exercise therapy. This could be attributed to the experimental arm therapists facing difficulty in effectively applying the model (especially in the ‘obesity subgroup’) and to elements of the model possibly being applied in the control arm.

References

[1]Fransen M et al. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015 Jan 9;1:CD004376.

[2]Knoop J et al. Identification of phenotypes with different clinical outcomes in knee osteoarthritis: data from the Osteoarthritis Initiative. Arthritis Care Res (Hoboken). 2011;63(11):1535-1542.

[3]Bijlsma JW et al. Osteoarthritis: an update with relevance for clinical practice. Lancet. 2011; Jun 18;377(9783):2115-26.

[4]Knoop J et al. Is a model of stratified exercise therapy by physical therapists in primary care feasible in patients with knee osteoarthritis? A mixed methods study. Physiotherapy. 2019.

Disclosure of Interests

None declared

POS0411 COMPARISON OF MTX-POLYGLUTAMATE ACCUMULATION PROFILES IN PERIPHERAL BLOOD MONONUCLEAR CELLS AND ERYTHROCYTES DURING 6 MONTHS MTX-THERAPY IN THE METHOTREXATE MONITORING (MeMo) TRIAL

Background

Optimal dosing of methotrexate (MTX) in rheumatoid arthritis (RA) remains challenging. To this end, monitoring of intracellular MTX polyglutamates (MTX-PGs) in red blood cells (RBCs) has been investigated as a potential marker of MTX (non-)response, with contradictory results. As enucleated, non-proliferative cells, mature RBCs lack regulated folate metabolism and are devoid of folylpolyglutamate synthetase (FPGS) activity catalyzing the conversion of MTX to MTX-PGs. Therefore, it has been argued that analysis of MTX-PG in immune-effector cells, represented by peripheral blood mononuclear cells (PBMCs), would be more relevant. However, no prospective study has been performed measuring MTX-PG levels in PBMCs nor in comparison with RBCs.

Objectives

To investigate the pharmacokinetics of MTX-PG accumulation in RBCs and PBMCs in newly diagnosed RA patients in the early phase of MTX treatment.

Methods

In a clinical prospective cohort study (Methotrexate Monitoring (NTR7149)), RA patients were administered MTX op to 25 mg/week, as described before. (1) At 1, 2, 3 and 6 months after start of therapy, blood was collected and RBCs were isolated by centrifugation and PBMCs after Ficoll density gradient centrifugation. MTX-PG1-6 concentrations in these cells were analyzed using a UPLC-MS/MS method with including custom-made stable isotopes of MTX-PG1-6 as internal standards. (2) UPLC-MS/MS measurements for MTX-PG1-6 were performed with a Waters Acquity BEH C18 column coupled to an AB Sciex 6500+ with the ESI operating on the positive mode. MTX dosing and concomitant treatments were in conformity with clinical practice. (3)

Results

46 consecutive patients were included in this study; 76% female, mean age: 57.8 years, mean baseline DAS28-ESR: 3.5, as described before. (1) Mean dosage was 10.5 mg (SD: 1.5) at baseline, 16.3 mg (2.5) at month 1, 22.7 mg (4.5) at month 2, 19.5 mg (6.3) at month 3 and 19.1 mg (6.2) at month 6.

MTX-PG accumulation in PBMCs and RBCs revealed a disparate profile in both MTX-PG distribution and absolute accumulation levels (Figure 1A/B). Remarkably, MTX-PG distribution in PBMCs was mainly composed of MTX-PG1 (58%), and to a lesser extent MTX-PG2 (27%) and MTX-PG3 (15%). Longer chain MTX-PG4-6 were also detectable in PBMCs, but at lower levels (mean: 4.0 – 6.7 fmol/10^6 cells) than MTX-PG1-3. Moreover, this MTX-PG distribution profile in PBMCs remained constant over a MTX therapy period of 6 months (Figure 1A). The RBC MTX-PG accumulation profile shows mainly MTX-PG1 and lower levels of MTX-PG2-6 at 1 month after the start of therapy. After 3 months of therapy, MTX-PG3 is the main PG-moiety with also MTX-PG4,5,6 being detected. This profile is largely similar after 6 months of therapy. With respect to total intracellular MTX-PG1-6 accumulation, PBMCs had significantly (p<0.001) 10-20-fold higher levels than RBCs at all analyzed time points (Figure 1A/B). Total MTX-PG1-6 levels in RBCs and PBMCs at all time points were weakly correlated (r=0.41, p<0.01) (Figure 1C).

Figure 1.

Individual MTX-PG concentrations in PBMCs (A) and RBCs (B) during the first 6 months of MTX administration (note the different scaling of the y-axes). At 6 months, 36 patients were still on MTX treatment. Panel (C): Spearman’s correlation plot of total MTX-PGs in RBCs versus PBMCs of all time points.

The disparate MTX-PG accumulation and distribution profiles in PBMCs versus RBCs of RA patients may be associated with the shorter life span of PBMCs and the low FPGS activity in RBCs. (4)

No significant relation between MTX-PGs and DAS28 was found (data not shown).

Conclusion

This study shows that in newly diagnosed RA patients starting MTX therapy, MTX-PG concentrations in PBMCs are significantly 10-20-fold higher than in RBCs over a period of 6 months, with a disparate MTX-PG distribution profile in PBMCs (highest: MTX-PG1) than RBCs (highest: MTX-PG3).

References

[1]RCF Hebing, Arthr Rheum (2021)

[2]E den Boer, Anal Bioanal Chem (2013)

[3]J Smolen, Ann Rheum Dis (2020)

[4]IB Muller, Ther Drug Monit (2019)

Acknowledgements

Acknowledgements: We would like to thank all participating patients and Pfizer (grant 53233663 / WI230458), AmsterdamUMC (AI&II extension grant) and NVKC (Noyons grant 2018)

Disclosure of Interests

Renske Hebing Grant/research support from: Pfizer (grant 53233663 / WI230458), NVKC (Netherlands Society for Clinical Chemistry, Noyons grant 2018) and AmsterdamUMC (extension grant), Marry Lin: None declared, Eduard Struys: None declared, Sohaila Mahmoud: None declared, Ittai Muller: None declared, Sandra Heil: None declared, Pieter Griffioen: None declared, WIllem Lems: None declared, Bart van den Bemt Speakers bureau: Pfizer, UCB, Sanofi-Aventis, Galapagos, Amgen and Eli Lilly, Michael Nurmohamed Grant/research support from: Pfizer grant 53233663 / WI230458, Gerrit Jansen: None declared, Robert De Jonge Grant/research support from: NVKC (Netherlands Society for Clinical Chemistry, Noyons grant)

OP0263 FAVORABLE BALANCE OF BENEFIT AND HARM OF LONG-TERM, LOW-DOSE PREDNISOLONE ADDED TO STANDARD TREATMENT IN RHEUMATOID ARTHRITIS PATIENTS AGED 65+: THE PRAGMATIC, MULTICENTER, PLACEBO- CONTROLLED GLORIA TRIAL

Background

Low-dose glucocorticoid (GC) therapy is widely used in RA but the true balance of benefit and harm is still unknown.

Objectives

We studied the effects of prednisolone (5 mg/day, 2 years) in RA patients aged 65+, requiring adjustment of antirheumatic therapy (DAS28≥2.60).

Methods

Pragmatic double-blind placebo-controlled randomized trial; all co-treatments and changes therein were allowed during the trial except long-term open label GC; Ca/D supplementation was advised in all patients. Minimal exclusion criteria were tailored to seniors.

Harm outcome: the number of patients with ≥1 serious adverse event (SAE), or ≥1 ‘other adverse event of special interest’ (other AESI). Other AESI comprised any AE (except worsening of RA) causing study discontinuation, and GC-specific events (Table 1).

Table 1.

Adverse events of special interest (AESI).*

prednisolone (n=224)placebo (n=225)Events by protocol-defined categorySAEother AESISAEother AESI Infection261241691  Urinary tract449429  Pneumonia217213  Other20581049 Cardiovascular8260 Symptomatic fracture21146 New onset  Hypertension1407  Diabetes mellitus0201  Cataract0726  Glaucoma0103 Other†43433526Total8019463140

*AESI: Comprises serious adverse events (SAE) and other AESI, defined by protocol.

†‘Other’ other AESI: non-serious AE outside of the above predefined categories, but associated with premature discontinuation.

Benefit outcomes: improvement in disease activity (DAS28) and joint damage progression (Sharp/van der Heijde).

Longitudinal mixed models analyzed the data. Given prior knowledge we report one-sided 95% confidence limit (95%CL) and statistical tests, performed only for the main outcomes.

Results

We randomized 451 RA patients in 7 EU countries, 449 received the intervention; of these 63% prednisolone vs 61% placebo patients completed 2 years of follow up. Discontinuations were similar in both groups: for AE (14%) and active disease (4%); the remainder mostly for ‘trial fatigue’ and covid-related access issues (20%). Mean time on study drug was 19 (SD 8) months.

70% of patients were female, mean age was 72 (max 88) years, RA duration 11 years; 67% were RF+, 56% ACPA+, 96% had joint damage on radiographs: mean score 20, median 8. Mean DAS28 was 4.5. Most patients (79%) were on current DMARD treatment, including 14% on biologics; 47% had previously used GC, 14% changed DMARD therapy at baseline. Patients had mean 2.1 active comorbidities, and used median 7 drugs.

Benefit: Disease activity rapidly declined to stabilize after 1 year (Figure 1), and was lower on prednisolone (adjusted mean difference in DAS28 over 2 years: 0.37, 95%CL 0.23, p<0.0001). The contrast in early (3-month) response was larger in 331 patients adherent to protocol on stable treatment: mean difference in DAS28 0.62 (95%CL 0.44), more responders on prednisolone (Figure 1). Significant time-treatment interaction in secondary analyses suggested a decrease in contrast after the first year, most likely caused by significantly more changes in DMARD treatment on placebo. Joint damage progression over 2 years was significantly lower on prednisolone: mean 0.6 (SD 1.9) v 1.8 (6.4) score points on placebo, difference 1.2 (95%CL 0.2, p=0.02).

Harm: 60% prednisolone vs 49% placebo patients experienced the harm outcome: adjusted RR 1.24, 95%CL 1.04, p=0.02; number needed to harm 9.5 (Table 1). During the study 1 vs 2 patients died, and 3 vs 0 died within 5 months of discontinuation. Per 100 patient-years, AE totaled 278 in prednisolone vs 206 in placebo patients, and the difference was most marked for infections (Table 1); these were mostly mild or moderately severe. Other GC-specific AESI were rare without relevant differences.

Conclusion

Add-on low dose prednisolone has beneficial long-term effects on disease activity and damage progression in senior RA patients on standard treatment. The tradeoff is a 24% increase in patients with mostly mild to moderate AE, suggesting a favorable balance of benefit and harm.

Acknowledgements

Trial registration: NCT02585258 (clinicaltrials.gov).

The trial is part of a larger project funded by the European Union’s Horizon 2020 research and innovation program under grant agreement No. 634886.

Apart from the listed authors and centers, the GLORIA Trial Consortium comprises:

L.M. Middelink, Middelinc BV The Netherlands, Operational Lead;

V. Dekker, Amsterdam UMC, Vrije Universiteit, Financial Lead;

Partners:

Trial operations: N. van den Bulk, CR2O BV, The Netherlands;

Study Medication (Development, Manufacturing & Supply): R.M.A. Pinto,

Bluepharma – Indústria Farmacêutica, S.A., Portugal;

Data management: L. Doerwald, Linical Netherlands BV, The Netherlands; S. Manger, Department of Epidemiology & Data Science, Amsterdam UMC, Vrije Universiteit, The Netherlands.

Adherence monitoring: J. Redol, BeyonDevices LDA, Portugal;

Safety monitoring: K. Prinsen, Clinfidence BV, The Netherlands;

Patient partner: M. Scholte-Voshaar, Stichting Tools (Tools2Use), The Netherlands.

Investigators (other recruiting centers):

T.L.T.A. Jansen, VieCuri – location Venlo, The Netherlands;

C. Codreanu, Clinical Center for Rheumatic Diseases, Bucarest, Rumania;

R.M.Zandhuis-Mooij, MSc, Gelre Ziekenhuis, Apeldoorn, The Netherlands;

E. Molenaar, Groene Hart Ziekenhuis, Gouda, The Netherlands;

J.M. van Laar, UMC Utrecht, The Netherlands;

Y.P.M. Ruiterman, Haga Ziekenhuis, Den Haag, The Netherlands;

A.E.R.C.H. Boonen, MUMC, Maastricht, The Netherlands;

M. Micaelo, Instituto Português de Reumatologia, Lisboa, Portugal;

J. Costa, Hospital de Ponte Lima, Portugal;

M. Sieburg, Rheumatologische Facharztpraxis Magdeburg, Germany;

J.P.L. Spoorenberg, UMC Groningen, The Netherlands;

U. Prothmann, Knappschaftsklinikum Saar GbmH, Puettlingen, Germany;

M.J. Saavedra, Hospital de Santa Maria, Lisboa, Portugal;

I. Silva, Hospital de Egas Moniz, Lisboa, Portugal;

M.T. Nurmohamed, Reade, Amsterdam, The Netherlands;

J.W.G. Jacobs, UMC Utrecht, The Netherlands; and

S.W. Tas, Amsterdam UMC, University of Amsterdam, The Netherlands.

Scientific Advisory Committee:

J.W.J. Bijlsma, UMC Utrecht, The Netherlands;

R. Christensen, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark;

Y.M. Smulders, Amsterdam UMC, VU University, The Netherlands; and

S.H. Ralston, University of Edinburgh, Edinburgh, UK.

Radiographic assessment:

D.M.F.M. van der Heijde (Imaging Rheumatology BV, the Netherlands)

coordinated the reading of the hand and foot x-rays.

A.F. Marsman and W.F. Lems scored the spine X-rays.

Patient panel:

C. Rusthoven and M. Bakkers, The Netherlands

E. Frazão Mateus, and G. Mendes, Portugal

C. Elling-Audersch and D. Borucki, Germany

A. Cardone, Italy

P. Corduta and O. Constantinescu, Romania

P. Richards, United Kingdom

G. Aanerud, Norway

Disclosure of Interests

Maarten Boers Consultant of: Novartis, Linda Hartman: None declared, Daniela Opris-Belinski Consultant of: Abbvie, Pfizer, MSD, Novartis, Eli Lilly, Ewo Pharma, UCB, Reinhard Bos: None declared, Marc R Kok: None declared, José Antonio P. da Silva: None declared, Eduard N. Griep: None declared, Ruth Klaasen: None declared, Cornelia Allaart: None declared, Paul Baudoin: None declared, Hennie Raterman Consultant of: Abbvie, Pfizer, MSD, Novartis, Eli Lilly, Ewo Pharma, UCB, Zoltán Szekanecz: None declared, Frank Buttgereit Consultant of: Abbvie, AstraZeneca, Gruenenthal, Horizon Therapeutics, Mundipharma, Pfizer, Roche, Pavol MASARYK: None declared, Thomas Klausch: None declared, Sabrina Paolino: None declared, Annemarie M. Schilder Consultant of: Eli Lilly, Novartis, Genzyme, WIllem Lems Consultant of: Pfizer, Galapagos, Lilly, Amgen, UCB., Maurizio Cutolo: None declared

POS0529 LONG-TERM LOCAL JOINT DAMAGE PROGRESSION IN RHEUMATOID ARTHRITIS IS RELATED TO CUMULATIVE LOCAL CLINICAL JOINT INFLAMMATION

Background

Previously we showed that joint inflammation in rheumatoid arthritis (RA) tends to recur in the same joint, suggesting local factors contributing to joint inflammation. In the same study population, we now investigated whether cumulative local joint inflammation is associated with local radiographic damage progression.

Objectives

To investigate whether there is an association between long-term cumulative joint swelling and progression of radiographic damage in treated-to-target patients with RA.

Methods

Data from the BeSt study were used, in which newly diagnosed patients with RA (ACR 1987 criteria) were treated-to-target (DAS ≤2.4) during 10 years. Local joint swelling (yes/no) was determined by clinical evaluation by trained nurses of all hand and foot joints at 3-monthly study visits. Yearly radiographs of hand and feet were scored for radiographic joint damage (Sharp-van der Heijde method) in random order by two independent readers who were blind for clinical results. Per joint, damage was expressed as the percentage of the maximum possible damage score, to account for differences in maximal scores per joint. Missing values were imputed using the last observation carried forward method. A generalized linear mixed model was used to assess the association between local joint swelling over time (i.e., percentage of study visits with observed local joint swelling) and degree of joint damage at the end of follow-up. Joints were clustered within patients. The model was adjusted for baseline damage and follow-up duration. To test the association between cumulative local joint swelling and joint damage as a local or a general inflammation effect, we did two analyses. First, we additionally adjusted the primary analysis for the mean disease activity score (DAS) over time. Second, we did a permutation test to study whether joint damage progression was better predicted by joint swelling in the joint itself than by joint swelling in randomly selected other joints, which is indicated by a p-value of <0.05.

Results

Of the 16,150 joints of 475 patients with at least one year follow-up with both radiographic and joint swelling assessment available, 16% (2,564) had radiographic joint damage (damage score ≥ 0.5) at the end of follow-up. Median (IQR) follow-up time was 10 (6-10) years. Of the joints with damage at the end of follow-up, 46% (1,163) was swollen at baseline, versus 36% (4,818) of the joints without damage. The median (IQR) percentage of visits at which joint swelling was observed was 6 (0-17) and 3 (0-8) for joints with and without joint damage respectively.

We found a β of 0.13 (95% CI 0.12 to 0.14) for the association between cumulative local joint swelling and local progression, that is, with each 1% increase in the number of visits with local joint swelling, local radiographic joint damage progression on average increased with 0.13 percent. In an analysis with 10-years completers only (both baseline and year 10 damage score available, n = 9,520) we also found an association between cumulative local joint swelling and local radiographic damage (β 0.24, 95% CI 0.22 to 0.26). The association was also found in a subset of joints that were swollen at least once (β 0.20, 95% CI 0.18 to 0.22), indicating that joint damage is not only associated with ever-occurrence but also with the frequency of joint swelling.

This association was found for both erosions (β 0.07, 95% CI 0.07 to 0.08) and joint space narrowing (β 0.21, 95% CI 0.19 to 0.22). The results of the primary analysis did not change after adjustment for DAS over time. The permutation test showed that local joint damage progression was better predicted by the frequency of joint swelling of that joint, than by joint swelling frequency of other joints (p<0.001). These results indicate a local, rather than a general, inflammation effect.

Conclusion

Cumulative local joint swelling over time is associated with joint damage progression in the same joint in treated-to-target (DAS ≤2.4) patients with RA. Our results indicate that this is a local effect rather than an effect of general disease activity.

Disclosure of Interests

Sascha Heckert: None declared, Sytske Anne Bergstra: None declared, Yvonne Goekoop-Ruiterman: None declared, Melek Güler-Yüksel: None declared, WIllem Lems: None declared, M. van Oosterhout: None declared, Thomas Huizinga: None declared, Cornelia Allaart Grant/research support from: The original BeSt study was funded by a research grant from the Dutch College of Health Insurances with additional funding from Schering-Plough BV and Centocor Inc.

OP0178 COVID-19 BREAKTHROUGH INFECTIONS IN VACCINATED PATIENTS WITH IMMUNE-MEDIATED INFLAMMATORY DISEASES AND CONTROLS – DATA FROM TWO PROSPECTIVE COHORT STUDIES

Background

Concerns have been raised regarding risks of COVID-19 breakthrough infections in vaccinated patients with immune-mediated inflammatory diseases (IMIDs) treated with immunosuppressants, but data on COVID-19 breakthrough infections in these patients are still scarce.

Objectives

The primary objective was to compare the incidence and severity of COVID-19 breakthrough infections with the SARS-CoV-2 delta variant between fully vaccinated IMID patients with immunosuppressants, and controls (IMID patients without immunosuppressants and healthy controls). The secondary objective was to explore determinants of breakthrough infections.

Methods

In this study we pooled data collected from two large ongoing prospective multi-center cohort studies (Target to-B! [T2B!] study and ARC study). Clinical data were collected between February and December 2021, using digital questionnaires, standardized electronic case record forms and medical files. Post-vaccination serum samples were analyzed for anti-RBD antibodies (T2B! study only) and anti-nucleocapsid antibodies to identify asymptomatic breakthrough infections (ARC study only). Logistic regression analyses were used to assess associations with the incidence of breakthrough infections. Multivariable models were adjusted for age, sex, cardiovascular disease, chronic pulmonary disease, obesity and vaccine type.

Results

We included 3207 IMID patients with immunosuppressants and 1810 controls (985 IMID patients without immunosuppressants and 825 healthy controls). The incidence of COVID-19 breakthrough infections was comparable between patients with immunosuppressants (5%) and controls (5%). The absence of SARS-CoV-2 IgG antibodies after COVID-19 vaccination was independently associated with an increased incidence of breakthrough infections (P 0.044). The proportion of asymptomatic COVID-19 breakthrough cases that were additionally identified serologically in the ARC cohort was comparable between IMID patients with immunosuppressants and controls; 66 (10%) of 695 patients vs. 64 (10%) of 647 controls. Hospitalization was required in 8 (5%) of 149 IMID patients with immunosuppressants and 5 (6%) of 86 controls with a COVID-19 breakthrough infection. Hospitalized cases were generally older, and had more comorbidities compared with non-hospitalized cases (Table 1). Hospitalization rates were significantly higher among IMID patients treated with anti-CD20 therapy compared to IMID patients using any other immunosuppressant (3 [23%] of 13 patients vs. 5 [4%] of 128 patients, P 0.041; Table 1).

Table 1.

Determinants of the severity of COVID-19 breakthrough infections.

Ambulatory care (n = 222)Hospitalized (n = 13)Group - no. (%)IMID patients with immunosuppressants141(64)8(62)IMID patients without immunosuppressants49(22)3(23)Healthy controls32(14)2(15)Patient characteristicsAge, years – mean (SD)51(14)60(11)Female sex – no. (%)143(64)4(31)Comorbidities – no. (%)Cardiovascular disease17(8)5(39)Chronic pulmonary disease17(8)4(31)Diabetes15(7)3(23)Obesity34(15)5(39)Immunosuppressants– no. (%)Methotrexate36(16)2(15)TNF inhibitor48(22)2(15)Anti-CD20 therapy13(6)3(23)Mycophenolate mofetil3(1)0(0)S1P modulator5(2)0(0)Other immunosuppressants70(32)3(23)

Conclusion

The incidence of COVID-19 breakthrough infections in IMID patients with immunosuppressants was comparable to controls, and infections were mostly mild. Anti-CD20 therapy might increase patients’ susceptibility to severe COVID-19 breakthrough infections, but traditional risk factors also continue to have a critical contribution to the disease course of COVID-19. Therefore, we argue that most patients with IMIDs should not necessarily be seen as a risk group for severe COVID-19, and that integrating other risk factors should become standard practice when discussing treatment options, COVID-19 vaccination, and adherence to infection prevention measures with patients.

Disclosure of Interests

None declared

AB0061 PHARMACOKINETICS OF METHOTREXATE POLYGLUTAMATES IN PERIPHERAL BLOOD MONONUCLEAR CELLS OF RA PATIENTS IS SIMILAR AFTER SUBCUTANEOUS OR ORAL ADMINISTRATION IN THE METHOTREXATE MONITORING (MeMo) TRIAL

Background

Pharmacokinetics of methotrexate (MTX) after oral and subcutaneous administration to RA patients differs: MTX levels in plasma and MTX-polyglutamate (MTX-PG) accumulation in erythrocytes are higher during equidosed subcutaneous compared to oral MTX treatment. (1,2) No data are available whether administration route of MTX differentially impacts the intracellular concentrations of MTX-PGs in peripheral blood mononuclear cells (PBMCs) during MTX therapy.

Objectives

To investigate the pharmacokinetics of MTX-PGs in PBMCs of newly diagnosed RA patients receiving oral or subcutaneous MTX in the early phase (1, 2, 3 and 6 months) of MTX treatment.

Methods

In a clinical prospective cohort study (MeMo study (NTR7149)), RA patients were

administered oral (n=24) or subcutaneous (n=22) MTX up to 25 mg MTX/week, as described before. (1) At 1, 2, 3 and 6 months after the start of therapy, PBMCs were isolated via Ficoll density gradient centrifugation. Individual MTX-PG forms (MTX-PG1-6) in PBMCs were analyzed by a UPLC-MS/MS method including custom-made stable isotopes of MTX-PG1-6 as internal standards (3). UPLC-MS/MS measurements of the PBMCs were performed with a Waters Acquity BEH C18 column coupled to an AB Sciex 6500+ with the ESI operating on the positive mode. Dosing, concomitant treatments and DAS28-ESR assessments were in conformity with clinical practice. (4)

Results

46 consecutive patients were included in this study; 76% female, mean age: 57.8 years, BMI: 25.8, smokers: 20%, mean baseline DAS28-ESR: 3.5, as described before. (1) MTX dose at baseline was 10.5 mg (SD: 1.5) for both groups, 15.4 mg (4.4) and 16.8 mg (1.8) at 1 month, 22.8 mg (3.9) and 22.4 mg (5.2) at 2 months, 20.1 mg (6.3) and 20.8 mg (5.6) at 3 months, and 19.7 mg (6.1) and 18.5 mg (6.7) at 6 months for oral and subcutaneous use, respectively. MTX-PG analyses in PBMCs for individual and total MTX-PGs revealed no significant differences between oral and subcutaneous administration groups at 1, 2, 3, and 6 months (Figure 1). Linear regression of LN transformed MTX-PG levels in PBMCs and administration route, corrected for age, baseline DAS28, smoking, BMI, eGFR and MTX dose, showed a trend towards higher MTX-PG levels in PBMCs after subcutaneous MTX administration compared to oral administration (data not shown). MTX-PG distribution in PBMCs was mainly composed of MTX-PG1 (58%), and to a lesser extent MTX-PG2 (27%) and MTX-PG3 (15%). Longer chain MTX-PGs beyond MTX-PG4 were detectable in PBMCs, but at levels lower than MTX-PG1-3 (mean: 4.0 – 6.7 fmol/106 cells). Total MTX-PG accumulation in PBMCs was approximately 10-20 fold higher than in erythrocytes. PBMC accumulation was rather stable, whereas RBC MTX-PG accumulation increased between 1 to 3 months to reach a plateau (Figure 1).

Figure 1.

Loess regression of MTX-PG concentrations in PBMCs (MTX-PG1-3) and RBCs (MTX-PG1-6) of RA patients during the first 6 months of oral or subcutaneous MTX administration. At 6 months, 18 patients using oral and 18 patients using subcutaneous MTX were still continuing MTX treatment. Means (lines) and SE (grey areas) are depicted.

Conclusion

This study demonstrated that MTX-PG accumulation in PBMCs early on in the MTX treatment of RA patients was not significantly different between oral or subcutaneous MTX administration routes.

References

[1]RCF Hebing et al, Arthritis Rheum (2021); 60:339-348

[2]M Hoekstra et al, J Rheumatol (2004); 31:645-8

[3]E Den Boer et al, Anal Bioanal Chem (2013); 405: 1673-1681

[4]J Smolen et al, Ann Rheum Dis (2020); 79:685-699

Acknowledgements

We would like to thank all participating patients and Pfizer (grant 53233663 / WI230458), NVKC (Noyons grant) and AmsterdamUMC (AI&II extension grant).

Disclosure of Interests

Renske Hebing Grant/research support from: Pfizer, grant number 53233663 / WI230458, Amsterdam UMC (AI&II extension grant), NVKC (Netherlands Society for Clinical Chemistry, Noyons grant), Marry Lin: None declared, Eduard Struys: None declared, Sohaila Mahmoud: None declared, Ittai Muller: None declared, WIllem Lems: None declared, Bart van den Bemt Speakers bureau: Pfizer, UCB, Sanofi-Aventis, Galapagos, Amgen and Eli Lilly, Gerrit Jansen: None declared, Robert De Jonge Grant/research support from: NVKC (Netherlands Society for Clinical Chemistry, Noyons grant), Michael Nurmohamed Grant/research support from: Pfizer grant

POS0589 CARDIOVASCULAR DISEASE RISK IN INFLAMMATORY ARTHRITIS STILL ELEVATED IN 2021!

Background

Patients with inflammatory rheumatic diseases as rheumatoid arthritis (RA), psoriatic arthritis (PsA) and spondyloarthritis (SpA) are at higher risk for developing cardiovascular diseases (CVD) than the general population. This is due to a higher prevalence of ‘traditional’ CV risk factors as hypertension and dyslipidemia, and the underlying systemic inflammation. During the past two decades, the burden of inflammation has been reduced by more efficacious anti-rheumatic treatment, leading to a reduced CVD risk, albeit still elevated in comparison to the general population. Therefore, it remains important to monitor the presence of CVD in rheumatic patients in systematically controlled cohorts.

Objectives

To evaluate whether, nowadays, the CVD risk of patients with inflammatory rheumatic diseases still differs from the general population.

Methods

In March 2020, all adult patients with an inflammatory rheumatic disease from the Amsterdam Rheumatology and Immunology Center, location “Reade” were systematically asked to participate in a prospective cohort study, which focused on the impact of the COVID-19 pandemic. The patients were compared with age and sex matched controls. In the third questionnaire, sent out in January 2021, questions regarding CV risk factors and comorbidities were added. Baseline characteristics and prevalence of CV risk factors and CVD were compared between RA, PsA or SpA patients, and healthy controls.

Results

2050 consecutive patients with an inflammatory rheumatic disease (1312 RA patients, 353 PsA patients, 385 SpA patients), and 939 healthy controls completed the questionnaires (Table 1). The prevalence of at least one CV comorbidity was more frequently reported in RA, PsA and SpA patients compared to healthy controls: 69 (5%), 24 (7%), 17 (4%) compared to 31 (3%), respectively. Events were primarily cardiac (i.e. myocardial infarction and coronary angioplasty). Inflammatory arthritis patients more often had hypertension or hypercholesterolemia than healthy controls, which were untreated in nearly half the cases. RA patients most often used anticoagulant medication.

Table 1.

Baseline characteristics. Values are displayed as mean ± standard deviation (SD) or frequencies with percentages (%). RA = rheumatoid arthritis, PsA = psoriatic arthritis, SpA = spondyloarthritis, CV = cardiovascular, DMARD = disease modifying anti-rheumatic drug

Patient characteristicsAll patients (n = 2050)RA(n = 1312)PsA(n = 353)SpA(n = 385)Control(n = 939)Mean age – yr57 ± 1360 ± 1257 ± 1251 ± 1355 ± 13Female sex - no (%)1266 (63)923 (70)164 (47)179 (47)636 (69)CV risk factors - no (%)Hypertension746 (37)482 (38)134 (39)130 (34)213 (23) Antihypertensive med411 (20)271 (21)78 (22)62 (16)131 (14)Hypercholesterolemia594 (30)391 (31)102 (30)101 (27)197 (21) Statins335 (16)223 (17)59 (17)53 (14)98 (10)Anticoagulants246 (12)180 (14)34 (10)32 (8)74 (8)CV diseases - no (%)Overall110 (5)69 (5)24 (7)17 (4)31 (3)Cardiac91 (4)60 (5)17 (5)14 (4)26 (3)Cerebral27 (1)12 (1)9 (3)6 (2)4 (0)Peripheral14 (1)10 (1)3 (1)1 (0)3 (0)Anti-rheumatic drugs - no (%)Prednisone202 (10)175 (13)17 (5)10 (3)n/aConventional synthetic DMARD1118 (55)902 (69)184 (52)32 (8)n/aBiological DMARD895 (44)512 (39)166 (47)217 (56)n/aTargeted synthetic DMARD20 (1)11 (1)5 (1)4 (1)n/a

Conclusion

The prevalence of CVD was approximately 1.5 times higher in patients with inflammatory rheumatic diseases compared to healthy controls (5% vs 3%), similar to older investigations. The prevalence of CV risk factors also remained elevated, and often undertreated. This indicates that the CVD risk in arthritis patients is still elevated in 2021 compared to the general population, despite improved anti-rheumatic treatment. Therefore, adequate and timely treatment of CV risk factors and optimization of anti-rheumatic drug treatment remains important in all inflammatory arthritis patients.

References

[1]Hooijberg F et al. (2020) Patients with rheumatic diseases adhere to COVID-19 isolation measures more strictly than the general population. The Lancet Rheumatology 2, 582-585.

Disclosure of Interests

None declared.

OP0270 TAPERING OF LONG-TERM, LOW-DOSE GLUCOCORTICOIDS IN SENIOR RHEUMATOID ARTHRITIS PATIENTS: FOLLOW-UP OF THE PRAGMATIC, MULTICENTRE, PLACEBO-CONTROLLED GLORIA TRIAL

Background

Guidelines suggest glucocorticoids (GC) should be used as bridge therapy in rheumatoid arthritis (RA), but many patients are treated chronically with low doses. The effects of withdrawal in such patients has not been studied extensively.

Objectives

To study disease activity score (DAS28), disease flares and signs of adrenal insufficiency after withdrawal of blinded trial medication (prednisolone 5 mg/day or placebo for 2 years).

Methods

The 2-year, double-blind GLORIA trial evaluated the long-term benefits and harms of low dose GC added to standard care (see main GLORIA trial abstract). Senior RA patients (≥ 65 years) were randomly assigned to prednisolone 5 mg/day or placebo.

After the final trial visit study medication was linearly tapered to zero in 3 months by adding a stop day every two weeks, and patients were reassessed. Those who successfully completed the trial and did not receive open-label GC during the 4 weeks after the final trial visit were included in this follow-up study.

The primary outcome was change in DAS28 at follow-up compared to the final trial visit. Secondary outcomes included the occurrence of disease flares (DAS28 increase > 0.6 or open-label GC between week 4 and 12 of the taper phase) and signs of adrenal insufficiency, assessed by 9 items selected from the 57-symptom list from the MDHAQ questionnaire (1) and hypotension (systolic RR < 90 or diastolic RR < 60). In a subset of patients from 3 Dutch centres, cortisol and ACTH were measured in spot serum samples during the follow-up visit.

Analysis of covariance assessed the change in DAS28. Linear regression and chi-square test were used for the remaining outcomes.

Results

278 participants completed the GLORIA study, 21 received GC within 4 weeks after the end of the trial, 58 had missing data, leaving 199 patients eligible for this study.

34 patients received open label GC after 4 weeks and were excluded for the primary analysis. In the remaining 165 patients (80 prednisolone, 85 placebo), mean (SD) DAS28 was higher on placebo: 3.14 (1.04) vs 2.92 (1.13) prednisolone at the final trial visit. After tapering, disease activity increased significantly (p=0.02) in the prednisolone group to 3.18 (1.20) but was stable in placebo (3.14). The difference in the increase of DAS28 between the groups was 0.21 (95%CI –0.05;0.47; p=0.11).

For signs of adrenal insufficiency, 33 out of 165 had missing data, leaving 60 in the prednisolone group and 72 in placebo (Table 1). Mean (SD) number of signs for prednisolone was 1.1 (1.1) versus 0.9 (1.3) for placebo at final trial visit and 0.8 (1.2) versus 0.8 (1.0) at follow-up. Difference in the change of the number of signs was –0.1 (95%CI –0.4;0.3; p=0.66).

Table 1.

Adrenal insufficiency signs and symptoms.

prednisolone (n=60)placebo(n=72)end of trialchange after 3 monthsend of trialchange after 3 monthsFatigue (unusual)15113–1Appetite loss5–144Muscle weakness7–26–2Dizziness32101Stomach pain3431Muscle pain19–619–1Nausea5–322Vomiting1001Diarrhoea5–23–2Hypotension*2–14–2Sum**1.1 (1.1)–0.2 (1.3)0.9 (1.3)0.0 (1.3)

* Systolic RR < 90 or diastolic RR < 60.

**Mean (SD)

No differences were seen in ACTH or cortisol levels: mean (SD) ACTH was 5.8 (4.1) in 23 prednisolone patients, and 5.1 (3.7) in 24 placebo patients; cortisol 296 (113) v 310 (166), cortisol/ACTH 67 (40) v 77 (54). Two prednisolone and one placebo patient had cortisol levels below 80. None developed clinical hypoadrenalism during further follow-up.

199 patients qualified for the disease flares sample, 99 prednisolone and 100 placebo; 44 patients flared on prednisolone tapering vs 31 on placebo, relative risk 1.43 (95%CI 0.99; 2.07; p=0.07).

Conclusion

Tapering prednisolone moderately increases disease activity to placebo levels (mean still at low disease activity levels) and numerically increases the risk of flare without any evidence of adrenal insufficiency. This suggests that withdrawal of low dose prednisolone is feasible after 2 years of administration.

References

[1]DeWalt DA et al. Clin Exp Rheumatol. 2004;22:453-61.

Acknowledgements

The GLORIA trial is registered at clinicaltrials.gov under NCT02585258.

The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‘’Personalizing Health and Care’’, grant agreement No 634886.

Disclosure of Interests

Abdullah Almayali: None declared, Maarten Boers Consultant of: Novartis, Linda Hartman: None declared, Daniela Opris-Belinski Consultant of: Abbvie, Pfizer, MSD, Novartis, Eli Lilly, Ewo Pharma, UCB, Reinhard Bos: None declared, Marc R Kok: None declared, José Antonio P. da Silva: None declared, Eduard N. Griep: None declared, Ruth Klaasen: None declared, Cornelia Allaart: None declared, Paul Baudoin: None declared, Hennie Raterman Consultant of: AbbVie, Amgen, Celgene, Roche, Sandoz, Sanofi Genzyme and UCB, Zoltán Szekanecz: None declared, Frank Buttgereit Consultant of: Abbvie, AstraZeneca, Gruenenthal, Horizon Therapeutics, Mundipharma, Pfizer, Roche, Pavol MASARYK: None declared, WIllem Lems Consultant of: Pfizer, Galapagos, Lilly, Amgen, UCB., Maurizio Cutolo: None declared, Marieke ter Wee: None declared

POS1402 COST-EFFECTIVENESS AND COST-UTILITY OF ADD-ON, LOW-DOSE PREDNISOLONE IN RA PATIENTS AGED 65+: THE PRAGMATIC, MULTICENTER, PLACEBO-CONTROLLED GLORIA TRIAL

Background

Rheumatoid arthritis (RA) is a disease with substantial impact on quality of life, healthcare and societal costs [1]. Current treatment strategies, especially biologic drugs, result in high costs [2]. Previous studies have already found that a combination treatment strategy of disease-modifying antirheumatic drug(s) with initially medium-to-high doses of prednisolone resulted in better effects and lower costs compared to the treatment strategies without prednisolone [3, 4]. However, to our knowledge the cost-effectiveness of low-dose glucocorticoids (GCs), and that of GC overall in established RA has not been examined separately.

Objectives

To evaluate the cost-effectiveness and cost-utility of low-dose prednisolone in RA patients aged 65+.

Methods

The economic evaluation was performed as part of the placebo-controlled GLORIA trial of RA patients aged 65+ with a disease activity score in 28 joints (DAS28) ≥2.60. Eligible patients were randomized to 2 years 5 mg/day prednisolone or placebo. Patients were recruited from 28 clinical centers in seven European countries. All co-treatment, except for chronic oral GC, was allowed.

The economic evaluation had a societal perspective with a time horizon of two years. Cost data were collected with questionnaires and from recorded events, and valued with unit prices of 2017. The primary effectiveness outcome was the DAS28. For cost-utility, quality-adjusted life years (QALYs) were estimated from the EuroQol-5 Dimension (EQ-5D) questionnaire.

Standard regression models were used to estimate incremental costs and effects between the treatment groups. Bootstrapping assessed the uncertainty around the average differences in costs and health outcomes.

Results

In total, 444 of 451 randomized patients were included in the modified-intention-to-treat analysis (see main GLORIA study abstract). Patients were on average 72 years and had median 4 active comorbidities at baseline. Mean total costs over 2 years were k€10.8 in the prednisolone group, k€0.4 (95% CI –3.7; 1.9) lower than in the placebo group. Total direct medical costs were k€0.5 (95% CI –4.0; 1.5) lower in the prednisolone group. The mean number of QALYs was similar in both groups (difference 0.02 [–0.03; 0.06] in favor of prednisolone). The DAS28 was 0.38 lower in the prednisolone group than in the placebo group (0.19;0.56).

The cost-effectiveness plane shows that the majority of the bootstrapped cost-effect pairs was situated in the southwest quadrant of the plane confirming the larger effects (i.e. decrease in DAS28) and non-significant lower costs in the prednisolone group (Figure 1). The cost-utility plane shows that the number of QALYs was similar for both groups and that the bootstrapped cost-utility pairs were slightly more located in the southeast quadrant confirming a very small increase in QALYs and slightly lower costs in the prednisolone group (Figure 1).

Conclusion

With greater effectiveness at non-significantly lower costs, low-dose, add-on prednisolone is cost-effective for RA compared to placebo over two years. QALYs were equal in both groups, most likely due to the impact of multiple comorbidities.

References

[1]Kobelt G. Elsevier. 2009;83-9.

[2]Souliotis K et al. PLoS One. 2019;14:e0226287.

[3]Ter Wee MM et al. RMD Open. 2017;3:e000502.

[4]Verhoeven AC et al. Br J Rheumatol. 1998;37:1102-9.

Acknowledgements

The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‘’Personalizing Health and Care’’, grant agreement No 634886.

Disclosure of Interests

Linda Hartman: None declared, Mohamed El Alili: None declared, Maurizio Cutolo: None declared, Daniela Opris-Belinski Speakers bureau: Abbvie, Pfizer, MSD, Novartis, Eli Lilly, Ewo Pharma, UCB, José Antonio P. da Silva: None declared, Zoltán Szekanecz: None declared, Frank Buttgereit Speakers bureau: Abbvie, AstraZeneca, Gruenenthal, Horizon Therapeutics, Mundipharma, Pfizer, Roche, Pavol MASARYK: None declared, Reinhard Bos: None declared, Marc R Kok: None declared, Sabrina Paolino: None declared, Veerle M. H. Coupé: None declared, WIllem Lems Speakers bureau: Pfizer, Galapagos, Lilly, Amgen, UCB, Maarten Boers Speakers bureau: BMS, Novartis, Pfizer

AB0166 PROTOCOL VIOLATIONS IN AN OPEN, RANDOMIZED, TRIAL IN EARLY RA PATIENTS: POTENTIAL IMPACT OF SHARED DECISION MAKING

Background

Modern trials in RA often have a strict protocolized treat-to-target design, whereas in daily practice shared decision making is the preferred way to manage treatment.

Objectives

To document the protocol violations in an early RA trial that illustrate potential conflicts between these strategies.

Methods

In the COBRA treat-to-target trial, treatment-naive early RA patients were classified into a low- and high-risk group, and treated according to two different protocols. Treatment target was minimal disease activity (DAS44 <1.6) or EULAR good response. Non-responders at 13 weeks were randomized to treatment intensification or continuation, with as primary endpoint the proportion of patients achieving the treatment target at 26 weeks.

Results

In total 190 patients were included. High-risk patients (n=150) were initially treated with COBRA-light (30 mg/day oral prednisolone, tapered in 8 weeks to 7.5 mg/day, and MTX increasing to 25 mg/week): 110 (73%) patients reached the treatment target at 13 weeks. The 31 non-responders were randomized to treatment intensification (n=15) or treatment continuation (n=16) for weeks 14 to 26. Intensification comprised 60 mg/day prednisolone, tapered in 6 weeks to 7.5 mg/day, and addition of sulfasalazine 2000 mg/day and hydroxychloroquine 400 mg/day (COBRA-plus).

The low-risk group (n=40) was treated with MTX monotherapy increasing to 25 mg/week: only 20 (50%) reached the target at week 13. The 15 non-responders were randomized to treatment intensification with a COBRA-light oral pulse of prednisolone (n=8) or continuation (n=7).

Over the whole study period 79 of 190 patients (42%) had a protocol violation. In the first 13 weeks, 27 (18%) high-risk and 8 (20%) low-risk patients had a protocol violation. In the responders at week 13, 15 (14%) high-risk and 3 (18%) low-risk patients had a protocol violation in week 14-26. In the high-risk non-responders, 18 of 31 had a protocol violation (58%) after randomization at 13 weeks, 11 in the intensification group and 7 in the continuation group (Table). Remarkably, increased intensification of therapy was only found in the continuation group (3 patients); decreased intensification was mainly found in the intensification group (11 patients, vs 3 patients in the continuation group). In the low-risk non-responders, violations occurred in 8 out of 15 (53%) patients after randomization, 4 in both groups.

Table

Protocol treatment violations after randomization of non-responders at week 13 by risk group.

High-riskLow-riskContinuation (16)Intensification (15)Continuation(7)Intensification (8)Week 14-26Number of violations71144Increased intensity Rheumatologist3 Other physician1Decreased intensity AEs MTX11 No MTX due to AEs1 Rheumatologist131 Rheumatologist, patient17 Patient12Mixed (increase + decrease) AEs MTX, rheumatologist1 Rheumatologist, patient11

Violations are categorized by direction of intensification and by reason/initiator.

AE=adverse event; MTX=methotrexate.

Conclusion

In this study almost half of the patients had a protocol violation. The high frequency is most likely related to the open design of the trial, the risk of adverse effects through intensification with high dose prednisolone and other DMARDs, the randomization phase, and, last but not least, by the shared decision making. Shared decision making by physician and patient may jeopardizes protocol adherence in trials with an open treat-to-target design.

Acknowledgements

We have received an unrestricted grant from Pfizer.

Disclosure of Interests

Linda Hartman: None declared, Linda A. Rasch: None declared, S.A. Turk: None declared, Marieke ter Wee: None declared, Pit J. S. M. Kerstens: None declared, Conny J. van der Laken: None declared, Michael T Nurmohamed: None declared, Dirkjan van Schaardenburg: None declared, Lilian H. D. van Tuyl: None declared, Alexandre Voskuyl: None declared, Maarten Boers Consultant of: Novartis, WIllem Lems Speakers bureau: Pfizer, Galapagos, Lilly, Amgen, UCB, Consultant of: Pfizer, Galapagos, Lilly, Amgen, UCB

POS1410 DEVELOPMENT OF PREDICTION MODELS FOR SENIOR PATIENTS WITH RHEUMATOID ARTHRITIS AND COMORBIDITIES TREATED WITH CHRONIC LOW-DOSE GLUCOCORTICOIDS IN THE GLORIA TRIAL

Background

Rheumatoid arthritis (RA) is a systemic, inflammatory disease primarily located in the joints resulting in pain, joint damage, functional disability and reduced quality of life. Treatment of RA is essential to prevent these outcomes, but the treatment itself may also result in adverse events and comorbidity [1]. Although many investigators are working on personalized medicine [2], better models to predict harm and benefit from a certain drug need to be developed before they can be used in daily clinical practice [3].

Objectives

To develop prediction models for individual patient harm and benefit outcomes in senior patients with RA and comorbidities treated with chronic low-dose glucocorticoid therapy or placebo.

Methods

In the GLORIA trial 451 RA patients aged 65+ were randomized to 2 years 5 mg/day prednisolone or placebo. Eight prediction models were developed from the dataset in a stepwise procedure. In preparation, to limit excessive statistical testing and false positive results, possible predictors were grouped into five predictor sets based on prior knowledge (Table 1). The first set of four models disregarded study treatment and examined general predictive factors. The second set of four models was similar but examined the additional role of study treatment, as main factor and as interaction factor with other predictive variables. In each set two models focused on harm (1: occurrence of ≥1 adverse event of special interest (AESI); 2: number of AESIs per year) and two on benefit (3: early clinical response–disease activity; 4: lack of joint damage progression). AESI comprised all serious adverse events, events leading to discontinuation of study treatment, and events related to glucocorticoid exposure (see main GLORIA study abstract). Linear and logistic multivariable regression methods with backward selection were used to develop the models. The final models were assessed and internally validated with bootstrapping techniques, and their performance was evaluated with model fit and discrimination measures.

Table 1.

Predictor sets.

Personal factorsDisease factorsComorbiditiesAgeDAS28Active comorbidity: cont, dich,SexRA durationGC-relatedEducationRFPrior comorbidity: cont, dich,SmokingAnti-CCPGC-relatedAlcoholDamage (cont, dich)# comorbidity medicationsBMICoping RAJoint surgeryBlood pressureImpact RA# patient symptomsMedicationHealth and daily functioning# concomitant medicationsHAQPrevious use DMARD, bDMARD, GCQoLCurrent use bDMARDVAS healthAdherenceSF36 physical, mentalSwitch antirheumatic drugs

cont=continuous; dich=dichotomous; GC=glucocorticoid.

Results

Study treatment (i.e. prednisolone) was highly predictive as a main factor in models 5-8, increasing the risk of both benefit and harm. In addition, a few additional variables were slightly (but not relevantly) predictive for the outcome in one of the models (Figure 1). Their association was much weaker than that of study treatment. In three instances, prednisolone interacted with another predictive factor (see Figure 1). The quality of the prediction models was sufficient, the performance low to moderate: explained variance: 12-15%, AUC 0.67-0.69.

Conclusion

Baseline factors are not helpful to select senior RA patients for treatment with low-dose prednisolone given their low power to predict the chance of benefit or harm.

References

[1]Smolen JS et al. Lancet. 2016;388(10055):2023-38.

[2]Huizinga TWJ. J Intern Med. 2015;277(2):178-87.

[3]De Punder YMRVR et al. Journal of Rheumatology. 2015;42(3):391-7.

Acknowledgements

The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‘’Personalizing Health and Care’’, grant agreement No 634886.

Disclosure of Interests

Linda Hartman: None declared, José Antonio P. da Silva: None declared, Frank Buttgereit Speakers bureau: Abbvie, AstraZeneca, Gruenenthal, Horizon Therapeutics, Mundipharma, Pfizer, Roche, Maurizio Cutolo: None declared, Daniela Opris-Belinski Speakers bureau: Abbvie, Pfizer, MSD, Novartis, Eli Lilly, Ewo Pharma, UCB, Zoltán Szekanecz: None declared, Pavol MASARYK: None declared, Marieke Voshaar: None declared, Martijn W. Heijmans: None declared, WIllem Lems Speakers bureau: Pfizer, Galapagos, Lilly, Amgen, UCB, Désirée van der Heijde: None declared, Maarten Boers Speakers bureau: BMS, Novartis, Pfizer

NT-proBNP and sRAGE levels in early rheumatoid arthritis

OBJECTIVE

Several biomarkers of cardiovascular function are found to be increased in rheumatoid arthritis (RA), with some suggesting a relationship with disease activity and improvement with adequate anti-rheumatic treatment. Promising biomarkers include N-terminal pro-brain natriuretic peptide (NT-proBNP) and the soluble receptor form of advanced glycation end-products (sRAGE). The objective of this study was to investigate associations between NT-proBNP and sRAGE levels and markers of inflammation and disease activity in early RA patients and their changes during (effective) anti-rheumatic treatment.

METHOD

Data from 342 consecutive early RA patients participating in the 'Parelsnoer' cohort were used. At baseline and after 6 months' disease activity, NT-proBNP and sRAGE levels were assessed.

RESULTS

After 6 months, NT-proBNP decreased from 83 pmol/L (mean) at baseline to 69 pmol/L at follow-up (p < 0.001), while sRAGE increased from 997 pg/mL to 1125 pg/mL (p < 0.001). A larger decrease in erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) was associated with larger changes in NT-proBNP and sRAGE. For every point decrease in ESR, there was a 1.7-point decrease in NT-proBNP and a 2.2-point increase in sRAGE. For CRP, these values were 1.7 and 2.7, respectively (p < 0.001).

CONCLUSION

Suppressing inflammation, independently of achieving remission, increases sRAGE levels and decreases NT-proBNP levels significantly. Whether this translates into a decrease in incident cardiovascular disease remains to be elucidated.

Patient perspective on remission in rheumatoid arthritis: Validation of patient reported outcome instruments to measure absence of disease activity

OBJECTIVE

Patients have identified pain, fatigue and independence as the most important domains that need to be improved to define remission in rheumatoid arthritis (RA). This study identified and validated instruments for these domains and evaluated their added value to the ACR/EULAR Boolean remission definition.

METHODS

Patients with a 28-joint Disease Activity Score (DAS28) ≤3.2 or in self-perceived remission (declaring their disease activity 'as good as gone') from the Netherlands, Portugal, Australia, and Canada, were assessed at 0, 3 and 6 months for patient-reported outcomes and the WHO-ILAR RA core set. Instrument validity was evaluated cross-sectionally, longitudinally and for the ability to predict future good outcome in terms of physical functioning. Logistic regression quantified the added value to Boolean remission.

RESULTS

Of 246 patients, 152 were also assessed at 3, and 142 at 6 months. Most instruments demonstrated construct validity and discriminative capacity. Pain and fatigue were best captured by a simple numerical rating scale (NRS). Measurement of independence proved more complex, but a newly developed independence NRS was preferred. NRS for pain, fatigue and independence, in addition to or instead of patient global assessment did not add enough information to justify modification of the current Boolean definition of remission in RA.

CONCLUSION

Key elements of the patient perspective on remission in RA can be captured by NRS pain, fatigue, and independence. Although this study did not find conclusive evidence to improve the current definition of remission in RA, the information from these instruments adds value to the physician's assessment of remission and further bridges the gap between physician and patient.

POS0524 CARDIOVASCULAR DISEASE RISK IN INFLAMMATORY ARTHRITIS PATIENTS STILL SUBSTANTIALLY ELEVATED IN 2020

Background:

Patients with inflammatory rheumatic diseases such as rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS) are at a higher risk for developing cardiovascular diseases (CVD) than the general population. This increased risk is partly due to a higher incidence of traditional cardiovascular (CV) risk factors, such as hypertension and dyslipidemia, and partly due to the underlying systemic inflammation. During the past two decades, the burden of the systemic inflammation has been reduced by more efficacious anti-inflammatory treatment, which somewhat attenuated the increased CV risk of rheumatic patients. However, it remains important to monitor the effects of these new treatment strategies on the prevalence of CVD in patients with a rheumatic disease in systematically controlled cohorts.

Objectives:

The aim of the current report was to evaluate whether the CV risk of patients with inflammatory rheumatic diseases still differs from the general population, despite advances In anti-rheumatic treatment strategies.

Methods:

In March 2020, all adult patients with an inflammatory rheumatic disease from the Amsterdam Rheumatology and Immunology Center, location “Reade” were systematically asked to participate in a prospective cohort study. The primary aim of this study was to monitor the impact of the COVID-19 pandemic on patients with inflammatory rheumatic diseases compared to age and sex matched healthy controls. Between April 26, 2020 and May 27, 2020, participants completed the first online questionnaire of the study. Amongst others, information on demographic data, including CV comorbidities and risk factors, and medication use was collected. The baseline characteristics and prevalence of CVD were compared between RA, PsA or AS and healthy controls.

Results:

In total, 1455 consecutive patients with an inflammatory rheumatic disease (979 RA patients, 261 PsA patients and 215 AS patients), and 414 healthy controls completed the first questionnaire, as shown in table 1. CV comorbidities were more frequently reported in RA, PsA and AS patients compared to healthy controls; 107 (11%), 28 (11%) and 22 (10%) compared to 30 (7%), respectively.

Table 1.

Biological DMARD usage in RA, PsA and AS patients

Patient characteristicsAll patients (n=1455)RA (n=979)PsA (N=261)AS (n=215)Controls (n=414)Mean age - yr55 ± 1358 ± 1255 ± 1348 ± 1353 ± 13Female sex - no (%)934 (64)728 (74)119 (46)87 (41)298 (72)BMI (IQR)25 (23-28)25 (22-28)26 (24-30)25 (22-28)24 (22-27)Smoking - no (%)178 (12)126 (13)17 (7)35 (16)34 (8)Cardiovascular disease – no (%)157 (11)107 (11)28 (11)22 (10)30 (7)Rheumatic medication - no (%)csDMARDs877 (60)712 (73)148 (57)17 (8)N.A.Oral glucocorticoids161 (11)139 (14)17 (7)5 (2)2 (0.4)TNF inhibitor563 (39)336 (34)121 (46)106 (49)N.A.IL-6 inhibitor19 (1)19 (2)00N.A.IL-17 inhibitor17 (1)2 (0.2)7 (3)8 (4)N.A.

Table 1. Baseline characteristics. Values are displayed as mean ± standard deviation (SD), median with interquartile range (IQR) or frequencies with percentages (%). RA = rheumatoid arthritis, PsA = psoriatic arthritis, AS = ankylosing spondylitis, BMI = body mass index, TNF = anti-tumor necrosis factor, IL = interleukin.

Conclusion:

We demonstrated that the prevalence of CVD is approximately 1.5 times higher in patients with rheumatic diseases compared to healthy controls (11% vs. 7%, respectively). This corresponds with previous research, although the reported prevalence of CVD in PsA and AS patients is even higher compared to prior studies. This suggests that the CVD risk of patients with rheumatic diseases is still elevated in 2020 compared to the general population, despite the improved management of rheumatic disease activity. Therefore, adequate and timely treatment of CV risk factors remains relevant, not only in patients with RA, but in patients other rheumatic diseases as well.

References:

[1]Hooijberg F et al. (2020) Patients with rheumatic diseases adhere to COVID-19 isolation measures more strictly than the general population. The Lancet rheumatology 2(10), 583-585.

Disclosure of Interests:

None declared

AB0251 INCREASED ACCUMULATION OF ERYTHROCYTE METHOTREXATE POLYGLUTAMATES DURING EARLY PHASE SUBCUTANEOUS VERSUS ORAL METHOTREXATE TREATMENT OF RHEUMATOID ARTHRITIS PATIENTS

Background:

Optimal dosing of methotrexate (MTX) for individual rheumatoid arthritis (RA) patients to achieve adequate disease control is an ongoing challenge. Assessment of erythrocyte MTX-polyglutamates (PGs) levels has been employed as a tool to monitor clinical response of RA patients in the first 3-12 months of treatment and MTX-PG2-4 and total MTX-PGs were associated with a lower DAS28 over 9 months.1 However, data from earlier time points, MTX-PG6 and per route of administration are unavailable.

Objectives:

To investigate the pharmacokinetics and -dynamics of erythrocyte MTX-PG accumulation in RA patients receiving oral or subcutaneous MTX in the early phase (1, 2, and 3 months) of MTX treatment initiation.

Methods:

In a clinical prospective cohort study (MeMo study (NTR7149)), newly diagnosed RA patients were administered oral (n=24) or subcutaneous (n=22) MTX, mostly according to the COBRA-light schedule (start 10 mg MTX, increased to 25 mg MTX in 8 weeks). At 1, 2, and 3 months after start of therapy, blood was collected and individual MTX-PGs (MTX-PG1 – MTX-PG6) were analyzed in erythrocytes at a minimal detection limit of 1 nmol/L, using a validated UHPLC-MS/MS method with labeled internal standards.1 Dosing, concomitant treatments and DAS28-ESR assessments were in conformity with clinical practice. Adverse events were recorded.

Results:

46 consecutive patients were included in this study; 76% female, mean age: 57.8 years, BMI: 25.8, 20% smokers, mean baseline DAS28-ESR: 3.5. Notwithstanding marked interpatient variability, patients starting subcutaneous MTX had accumulated significantly higher (approximately 2-fold) long chain MTX-PGs (MTX-PG4-6) when compared to patients in the oral MTX group at 1 and 2 months (Figure 1A, Table 1). Similarly, MTX-PG1-6 and MTX-PG3 accumulation were higher in subcutaneous MTX-users at month 1 (p=0.022 and p=0.011) compared to the oral group (median 68.6 nmol/L (IQR:40.5) vs 51.9 (55.6) and 17.4 (11.1) vs 11.2 (15.6), respectively (Figure 1B, Table 1).

Table 1.

Linear regression of MTX-PG levels and administration route, corrected for age, baseline DAS28, smoking, BMI, eGFR and MTX dose.

monthß (P-value)1ß (P-value)2ß (P-value)3MTX-PG1-61.65 (0.022)1.51 (0.073)1.30 (0.233)MTX-PG1,21.13 (0.599)1.19 (0.470)1.12 (0.623)MTX-PG31.75 (0.011)1.51 (0.071)1.19 (0.439)MTX-PG4-61.97 (0.036)2.04 (0.033)1.55 (0.136)

Mean MTX dose at baseline was 10.5mg (SD 1.5) for both groups, 15.4 (4.4) and 16.8 (1.8) at 1 month and 22.8 (3.9) and 22.4 (5.2) at 2 months for oral and subcutaneous use respectively.

DAS28 decreased with 1.6 in the oral group and 1.1 in the subcutaneous group (p=0.382). With and without corrections for age, baseline DAS28, eGFR, MTX dose (1 month before sampling), smoking and BMI, no significant relation between MTX-PG concentrations and DAS28 was observed during the first 3 months of treatment.

43 patients reported any side effect, mostly headache and dizziness, which was similar in both groups and uncorrelated with MTX-PG levels.

No association was found between MTX-PG1 levels and number of days between timing of blood withdrawal and last administration.

Figure 1.

Erythrocyte long chain MTX-PG(A) and total MTX-PG(B) accumulation in RA patients of the first 3 months of oral(C) or subcutaneous(D) MTX administration. At 3 months, 18 patients using oral and 18 patients using subcutaneous MTX were still continuing MTX treatment. Medians and IQR are depicted.

Conclusion:

This study shows the feasibility of measuring erythrocyte MTX-PGs early on in the treatment of RA patients with MTX and demonstrated significantly higher accumulation of MTX-PGs following subcutaneous versus oral MTX administration. Early phase erythrocyte MTX-PG analyses may hold potential for positioning in optimizing individual patient MTX dose scheduling.

References:

[1]de Rotte MC, et al. Methotrexate polyglutamates in erythrocytes are associated with lower disease activity in patients with rheumatoid arthritis. Ann Rheum Dis 2015(74):408-14.

Acknowledgements:

We would like to thank all participating patients and Pfizer (grant 53233663 / WI230458).

Disclosure of Interests:

Renske Hebing Grant/research support from: Pfizer, Ittai Muller: None declared, Marry Lin: None declared, Sohaila Mahmoud: None declared, Sandra Heil: None declared, WIllem Lems: None declared, Michael Nurmohamed: None declared, Robert De Jonge: None declared, Gerrit Jansen: None declared

AB0160 HIGH NUMBER OF CONCOMITANT MEDICATIONS AND COMORBIDITIES AT BASELINE IN THE GLUCOCORTICOID LOW-DOSE OUTCOME IN RHEUMATOID ARTHRITIS (GLORIA) STUDY: AN OLDER POPULATION WITH RHEUMATOID ARTHRITIS

Background:

Treatment with low-dose glucocorticoids (GCs) (≤7.5 mg prednisolone) in combination with standard care is highly effective in rheumatoid arthritis (RA), but despite 70 years of clinical experience, evidence-based information on its balance of benefit and harm is incomplete. This leads to an ongoing debate, with under- and over-use of GCs as result. The GLORIA pragmatic trial was developed to assess harm, benefit and costs of low-dose GCs added to the standard treatment of older RA patients.

Objectives:

The objective of this abstract is to document the baseline status and frequency of comorbid conditions in the GLORIA study population. The results of the unblinded data will be submitted as late-breaking abstract.

Methods:

This double-blind, randomized, placebo-controlled, multicenter trial (1) was open for patients with RA according to the 1987 or 2010 (2) criteria, age ≥65 years, and disease activity score of 28 joints (DAS28) of ≥2.6. Patients were recruited from rheumatology clinics in Germany, Hungary, Italy, The Netherlands, Portugal, Romania and Slovakia. Eligible patients were randomized to two years of treatment with daily 5 mg prednisolone or matching placebo. All other medication was allowed, except for GCs. The presented data are blinded because the database is not closed yet.

Results:

The population consists of 451 patients with mean disease duration 10.6 (Q1-Q3: 3-15) years. The majority (70%) is female, mean age is 72.5 (Q1-Q3: 68-76, range: 65-88) years, 66% were positive for rheumatoid factor and 56% for ACPA. Patients had a mean of 4.3 (SD 2.8) comorbidities besides RA (3.4 active) and therefore used multiple concomitant medications (3.9 (SD 3.4)) (Table 1). The most common comorbidities (provisional data of 161 patients with complete coding) in this older population are: vascular disorders (58%), musculoskeletal and connective tissue disorders (57%) and a history of surgical and medical procedures (45%). Patients were most frequently on beta blocking agents (22%, mainly metoprolol) and HMG CoA reductase inhibitors (20%, mainly simvastatin). Most patients also have an extensive history of anti-rheumatic treatment. At the start of the trial most patients (82%) were on cDMARD treatment; 15% were on bDMARDs/tsDMARDs. Almost half of the patients previously had been treated with GCs, with a mean duration of 3.4 years and a mean last dose of 4.6 mg/day.

Conclusion:

The baseline data shows that we have an older study population who have relatively many other comorbidities next to RA and who are almost all treated with multiple concomitant medications in addition to the study medication. Therefore, we expect to report a high adverse event rate. Research among older patients is urgently needed, but the frailty of this population as represented by the multiple comorbidities and concomitant medications have to be taken into account in the analyses and interpretation of the results.

References:

[1]Hartman L, Rasch LA, Klausch T, Bijlsma HWJ, Christensen R, Smulders YM, et al. Harm, benefit and costs associated with low-dose glucocorticoids added to the treatment strategies for rheumatoid arthritis in elderly patients (GLORIA trial): study protocol for a randomised controlled trial. Trials. 2018;19:67.

[2]Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO, et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010;62:2569-81.

Table 1.

Comorbidities and concomitant medications at baseline in the GLORIA trial.

MeanSDRangeComorbidities 4.32.8 0-15 Active 3.4 Past 1.9Concomitant medications (count) 3.93.4 0-15 Beta blocking agents (%)22 HMG CoA reductase inhibitors (%)20 Platelet aggregation inhibitors (%)16 ACE inhibitors (%)12 Angiotensin II antagonists (%)11DAS28 4.521.05DAS28CRP 4.060.97HAQ (0-3) 1.20.7RA treatmentCurrent (%)Previous (%) cDMARD8492 bDMARD/tsDMARD1522 NSAID5129 Glucocorticoids 049

Acknowledgements:

The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‘’Personalizing Health and Care’’, grant agreement No 634886.

Disclosure of Interests:

None declared

OP0189 MACROPHAGE PET/CT IMAGING OF THE FEET CAN CONTRIBUTE TO EARLY PREDICTION OF THERAPY OUTCOME IN RHEUMATOID ARTHRITIS

Background:

Treat-to-target strategies for rheumatoid arthritis (RA) have shown significant improvements in therapy outcomes. Nevertheless, it usually takes a minimum of 12 weeks before clinical assessment of treatment response can be made. Quantitative positron emission tomography (PET) has shown potential to predict clinical response at a very early stage in the treatment in RA patients.(1) In particular, macrophage imaging by [11C]-(R)-PK11195 PET allows for highly sensitive and specific imaging of RA disease activity.(2,3)

Objectives:

To determine whether quantitative assessment using [11C]-(R)-PK11195 PET/CT imaging at 0-2 weeks is associated with subsequent clinical response to therapy with methotrexate and step-down prednisolone (COBRA-light) therapy in therapy-naive RA patients.

Methods:

Whole body [11C]-(R)-PK11195 PET/CT scans were performed at baseline and after two weeks of treatment in thirty-five clinically active and therapy-naive RA patients and at least two clinically inflamed joints. All patients were DMARD-naïve and received medication according to the COBRA-light schedule. (4) Clinical follow up with DAS44 assessment was performed at 0, 2 and 13 weeks of treatment. PET/CT scans were visually assessed by two experienced readers blinded to clinical data and quantitatively analyzed using in-house software. Regions of interest (ROIs) with a fixed size per joint (on both visual PET positive and negative joints) were placed on shoulders, elbows, hips, knees and hand and feet joints, with the CT-scan as anatomical reference. Standardized uptake values (SUVs) normalized for body weight were calculated in these ROIs to determine the amount of tracer uptake per joint. SPSS version 22.0 was used to perform regression analyses. The sum of visually positive joints and the average SUV in hand joints, feet joints and all joints in the body were compared with DAS44 scores.

Results:

Included patients were mostly male (51%) and aged 54 ± 12. Baseline DAS44 was 3.2 ± 1.0; all but one of the thirty-five patients demonstrated visually enhanced tracer uptake in one or more joints on PET/CT. A total of 171 (out of 1470) joints (12%) were visually PET positive at baseline. Over 90% of PET positive sites were located either in the wrists (15%), small hand joints (37%), or small feet joints (40%; Figure 1A). After 2 weeks, the number of PET positive joints had decreased to 100, with the highest decrease in quantitative uptake in feet joints (Figure 1B). Notably, both visual and quantitative PET data at baseline and differences between baseline and 2 weeks did not correlate with DAS44 at 13 weeks (DAS44-13wks). However, at 2 weeks, the average SUV in the feet (SUVfeet-2wks) – but not average SUVhands-2wks or average SUVtotalbody-2wks – was significantly correlated with DAS44-13wks (R2 = 0.14, p = 0.04). DAS44-2wks and SUVfeet-2wks both contributed independent information to the prediction DAS44-13wks (combined R2 = 0.297, p < 0.01).

Figure 1.

Changes in [11C]-(R)-PK11195 uptake in MTP joints of a RA patient, before (A) and 2 weeks after initiation of COBRA light treatment (B).

Conclusion:

Quantitative macrophage PET assessment in feet joints after 2 weeks of COBRA light treatment in early RA patients correlates with clinical response after 3 months of treatment. This correlation further increases when combined with the DAS44 score at 2 weeks. Therefore, quantitative, non-invasive macrophage PET/CT, especially when combined with early clinical assessment, may be useful for early assessment of response to treatment. Further studies will help optimize timing and focus of the PET examination in prediction of treatment response.

References:

[1]Elzinga EH, et al. J Nucl Med. 2011; 52(1):77-80.

[2]Van der Laken CJ et al. Arthritis Rheum. 2008 Nov;58(11):3350-5.

[3]Gent YY, et al. J Rheumatol. 2014; 41: 2145-52

[4]Den Uyl D, et al. Ann Rheum Dis. 2014;73(6):1071-8.

Disclosure of Interests:

Nicki J.F. Verweij: None declared, Marieke ter Wee: None declared, Jerney de Jongh: None declared, Gerben C.J. Zwezerijnen: None declared, Maqsood Yaqub: None declared, Dirkjan van Schaardenburg: None declared, Alexandre Voskuyl: None declared, WIllem Lems Speakers bureau: Pfizer, Galapagos, Eli Lilly, Amgen, UCB, Curaphar, Consultant of: Pfizer, Galapagos, Eli Lilly, Amgen, UCB, Curaphar, Grant/research support from: Pfizer, Adriaan A. Lammertsma Consultant of: Roche, Maarten Boers Consultant of: Novartis, BMS, Pfizer, Conny J. van der Laken Consultant of: Novartis, Pfizer, Abbvie, UCB, BMS, GSK, Galapagos, Grant/research support from: Novartis, Pfizer, Abbvie, UCB, BMS, GSK, Galapagos

POS0213 20 Year Follow-Up Of Cardiovascular Event Risk In Rheumatoid Arthritis Compared To Diabetes

Background:

Patients with rheumatoid arthritis have an increased risk for developing cardiovascular diseases (CVD) compared to the general population, similar to the CVD risk in patients with diabetes mellitus. However, there are no controlled studies investigating the incidence of cardiovascular (CV) events in RA patients with follow up of more than 20 years.

Objectives:

The objectives of the current study were to investigate the incidence rates of CV events in a long-term follow up cohort of RA patients, and to compare these to a similar cohort representing the general population, ie. The Hoorn study.

Methods:

The CARRÉ study is an ongoing prospective cohort study, which started in 2001, investigating CV mortality and morbidity in 353 randomly selected patients with RA. Primary endpoints, i.e. verified medical history of coronary, cerebral or peripheral arterial disease, were determined at baseline, and after three, ten, fifteen and twenty years of follow up. Patients were censored at the date of an experienced CV event or their death. Incidence density rates per 100 patient years were calculated. Data were compared to results from the Hoorn study, a Dutch cohort study of glucose metabolism and other CV risk factors that began in 1989. All 2,484 participants were subject to an extensive and repeated CV screening program similar to that used in the CARRÉ study.

Results:

After 20 years of follow up 118 patients (33%) developed at least one CV event in the Carré group. Mean (SD) follow up time was 11 (6) years with a total of 3,500 years at risk and an incidence rate of 3.4 per 100 patient-years; this is slightly up from the figure reported at 15 years, i.e. 3.2 per 100 patient-years. A CV event-free survival curve is shown in figure 1. After 30 years of follow up, 295 participants of the Hoorn study had developed a CV event, during a mean follow up time 20 (8) years. Total time at risk was 50,000 years, with an incidence rate of 0.6 CV events per 100 patient years.

Conclusion:

In our cohort the incidence rate of CV events in RA patients has remained consistently high when compared with the general population, despite better control of RA inflammation in recent years. This again confirms the need for timely CVD-risk screening and management.

References:

[1]Agca R, Hopman L, Laan KJC, van Halm VP, Peters MJL, Smulders YM, et al. Cardiovascular Event Risk in Rheumatoid Arthritis Compared with Type 2 Diabetes: A 15-year Longitudinal Study. J Rheumatol. 2020;47(3):316-24.

Figure 1.

Survival curve of participants with rheumatoid arthritis. RA = rheumatoid arthritis

Disclosure of Interests:

None declared

POS0043 PERIPHERAL QUANTITATIVE COMPUTED TOMOGRAPHY IN THE ASSESSMENT OF BONE MINERAL DENSITY IN ANTI-TNF-TREATED RHEUMATOID ARTHRITIS AND ANKYLOSING SPONDYLITIS PATIENTS

Background:

Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) have been associated with osteoporosis. There have been very few data on the use of peripheral quantitative computed tomography (QCT) in anti-TNF-treated patients.

Objectives:

We wished to assess volumetric bone mineral density (BMD) by forearm QCT in conjunction with dual-energy X-ray absorptiometry (DXA) and bone biomarkers in RA and AS.

Methods:

Forty RA and AS patients treated with etanercept (ETN) or certolizumab pegol (CZP) were included in a 12-month follow-up study. Peripheral QCT and DXA BMD were determined. Bone biomarkers, such as PTH, osteocalcin, RANKL, 25-hydroxyvitamin D (VITD), P1NP, CTX, sclerostin, DKK-1 and cathepsin K (CATHK) were assessed by ELISA.

Results:

There was no further bone loss during anti-TNF treatment. Volumetric and areal BMD showed significant correlations with each other (p<0.05). Total QCT BMD after 12 months was inversely determined by disease activity at baseline in the full cohort (p=0.030). Cortical BMD was negatively determined by baseline disease activity (p=0.005) and CATHK (p=0.025). In RA, VITD-0 determined QTRABBMD-12 (p=0.005). In the full cohort, the one-year change in QTRABBMD was related to TNF inhibition together with higher VITD-0 (p=0.031). Therapy and lower CATHK determined QCORTBMD changes (p=0.006). In RA, treatment together with VITD-0 (p<0.01) or CATHK-0 (p=0.002), while in AS, treatment together with RANKL-0 (p<0.05) determined QCT BMD changes.

Conclusion:

QCT confirmed that biologics may attenuate bone loss. Disease activity, CATHK, RANKL and VITD may predict the effects of anti-TNF treatment on volumetric BMD changes. There may be differences between RA and AS in this respect.

Acknowledgements:

This research was supported by Hungarian National Scientific Research Fund (OTKA) grant No. K 105073 (H.P.B. and Z.S.); by the European Union and the State of Hungary and co-financed by the European Social Fund in the framework of TAMOP-4.2.4.A/2-11/1-2012-0001 ‘National Excellence Program ’(Z.S.); by the European Union grant GINOP-2.3.2-15-2016-00050 (Z.S.); and by the Pfizer Investigator Initiated Research Grants no. WS1695414 and WS1695450 (Z.S.).

Disclosure of Interests:

Balázs Juhász: None declared, Katalin Gulyás: None declared, Ágnes Horváth: None declared, Edit Végh: None declared, Anita Pusztai: None declared, Agnes Szentpetery: None declared, Zsófia Pethö: None declared, Nóra Bodnár: None declared, Attila Hamar: None declared, Levente Bodoki: None declared, Harjit Pal Bhattoa: None declared, Éva Szekanecz: None declared, Katalin Hodosi: None declared, Andrea Domjan: None declared, Szilvia Szamosi Speakers bureau: Roche, Csaba Horváth: None declared, Sándor Szántó Speakers bureau: Abbvie, MSD, Novartis, Consultant of: Abbvie, Novartis, Gabriella Szücs Speakers bureau: Roche, Boehringer, Actelion, Sager, Consultant of: Actelion, Boehringer, Hennie Raterman: None declared, WIllem Lems Speakers bureau: Pfizer, Amgen, Lilly, UCB, Galapagos, Consultant of: Pfizer, Amgen, Lilly, UCB, Galapagos, Oliver FitzGerald Speakers bureau: AbbVie, Janssen, Pfizer, Consultant of: BMS, Celgene, Eli Lilly, Janssen, Pfizer, Grant/research support from: AbbVie, BMS, Eli Lilly, Novartis, Pfizer, Zoltán Szekanecz Speakers bureau: Pfizer, Roche, Abbvie, Novartis, Lilly, Sanofi, Consultant of: Pfizer, Abbvie, Novartis, Grant/research support from: Pfizer, UCB.

A patient-level key performance indicator set to measure the effectiveness of fracture liaison services and guide quality improvement: a position paper of the IOF Capture the Fracture Working Group, National Osteoporosis Foundation and Fragility Fracture Network

The International Osteoporosis Foundation (IOF) Capture the Fracture® Campaign with the Fragility Fracture Network (FFN) and National Osteoporosis Foundation (NOF) has developed eleven patient-level key performance indicators (KPIs) for fracture liaison services (FLSs) to guide quality improvement.

INTRODUCTION

Fracture Liaison Services (FLSs) are recommended worldwide to reduce fracture risk after a sentinel fracture. Given not every FLS is automatically effective, the IOF Capture the Fracture working group has developed and implemented the Best Practice Framework to assess the organisational components of an FLS. We have now developed a complimentary KPI set that extends this assessment of performance to the patient level.

METHODS

The Capture the Fracture working group in collaboration with the Fragility Fracture Network Secondary Fragility Fracture Special Interest Group and National Osteoporosis Foundation adapted existing metrics from the UK-based Fracture Liaison Service Database Audit to develop a patient-level KPI set for FLSs.

RESULTS

Eleven KPIs were selected. The proportion of patients: with non-spinal fractures; with spine fractures (detected clinically and radiologically); assessed for fracture risk within 12 weeks of sentinel fracture; having DXA assessment within 12 weeks of sentinel fracture; having falls risk assessment; recommended anti-osteoporosis medication; commenced of strength and balance exercise intervention within 16 weeks of sentinel fracture; monitored within 16 weeks of sentinel fracture; started anti-osteoporosis medication within 16 weeks of sentinel fracture; prescribed anti-osteoporosis medication 52 weeks after sentinel fracture. The final KPI measures data completeness for each of the other KPIs. For these indicators, levels of achievement were set at the < 50%, 50-80% and > 80% levels except for treatment recommendation where a level of 50% was used.

CONCLUSION

This KPI set compliments the existing Best Practice Framework to support FLSs to examine their own performance using patient-level data. By using this KPI set for local quality improvement cycles, FLSs will be able to efficiently realise the full potential of secondary fracture prevention and improved clinical outcomes for their local populations.

AB1165 MEDICATION ADHERENCE DATA IN A RANDOMIZED TRIAL: LARGE CHALLENGES TO COME FROM RAW DATA TO A WORKABLE AND RELIABLE DATASET

Background:

Medication adherence in the GLORIA trial, among elderly patients with rheumatoid arthritis, is measured with caps that register openings of the medication bottle. At each study visit, one or two medication bottles with cap (kits) are dispensed, each containing 90 capsules. Multiple steps are needed to come to a workable dataset to describe adherence.

Objectives:

To describe the steps that are needed to come from raw data to a workable dataset to analyze adherence data that are recorded by electronic caps.

Methods:

The medication bottle contains a cap with the ability to register cap openings. The raw dataset from the caps consist of an excel file with one opening event per row, recorded as date and time. One cap yields approximately 90 rows. First, the kit numbers were matched to the corresponding patient numbers, that are recorded in another excel file. Instances where two kits were dispensed were recorded with two kit numbers in one cell and need to be copied to two cells with one kit number. Second, the VLOOKUP function was used to combine dates and kit numbers. One row now contains all openings from one kit. Then, the number of days between first opening and each next opening date was calculated. A range of 90 days was made to calculate how many times the bottle was opened on each day of the 90-days period. The results were color-coded to visualize instances of zero, one or ≥two openings on a day.

Results:

The colored calendar matrix (Figure 1) can now be used to categorize adherence patterns.

Conclusion:

A monitoring cap seems a simple instrument to measure adherence. However, multiple steps and a lot of time are needed to come to a workable dataset for the study of adherence patterns.

Acknowledgments:

The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‟Personalizing Health and Care’’, grant agreement No 634886.

Disclosure of Interests:

Linda Hartman: None declared, Elisa Alessandri: None declared, Reinhard Bos: None declared, Daniela Opris-Belinski Speakers bureau: as declared, Marc R Kok Grant/research support from: BMS and Novartis, Consultant of: Novartis and Galapagos, Hanneke Griep-Wentink: None declared, Ruth Klaasen: None declared, Cornelia Allaart: None declared, George Bruyn: None declared, Hennie Raterman Grant/research support from: UCB, Consultant of: Abbvie, Amgen, Bristol-Myers Sqibb, Cellgene and Sanofi Genzyme, Marieke Voshaar Grant/research support from: part of phd research, Speakers bureau: conducting a workshop (Pfizer), Nuno Gomes: None declared, Rui Pinto: None declared, Thomas Klausch: None declared, WIllem Lems Grant/research support from: Pfizer, Consultant of: Lilly, Pfizer, Maarten Boers: None declared

FRI0373 ASSOCIATIONS OF VASCULAR PATHOPHYSIOLOGY AND BONE METABOLISM IN ANTI-TNF- TREATED RHEUMATOID ARTHRITIS AND ANKYLOSING SPONDYLITIS PATIENTS

Background:

Cardiovascular (CV) disease and osteoporosis (OP) have become increasing challenges in the ageing population, even more in patients with inflammatory rheumatic diseases, such as rheumatoid arthritis (RA) and spondyloarthropathies. Both RA and ankylosing spondylitis (AS) have been associated with generalized and localized bone loss, accelerated atherosclerosis, increased CV morbidity and mortality.

Objectives:

Bone and vascular biomarkers and parameters along with the effect of one-year anti-TNF therapy on these markers were assessed in order to determine correlations between vascular pathophysiology and bone metabolism in RA and AS.

Methods:

Fifty-three patients including 36 RA patients treated with etanercept (ETN) or certolizumab pegol (CZP) and 17 AS patients treated with ETN were included in a 12-month follow-up study. Bone and vascular markers were assessed by ELISA. Bone density was assessed by DXA and quantitative CT (QCT). Flow-mediated vasodilation (FMD), common carotid intima-media thickness (ccIMT) and pulse-wave velocity (PWV) were assessed by ultrasound. The effects of vascular markers on bone and bone effects on vasculature undergone statistical analysis.

Results:

Serum levels of vascular endothelial growth factor (VEGF), PDGF-BB, angiopoietin 2 (Ang2) and cathepsin K (CathK) decreased, procollagen type 1 N-propeptide (P1NP) and sclerostin (SOST) levels increased, soluble receptor activator nuclear kappa B ligand (sRANKL) and osteoprotegerin (OPG) levels showed no differences. When bone and vascular markers were correlated with each other, at baseline, OPG correlated with Ang2 and adiponectin. SOST correlated positively with ccIMT. DXA L2-4 BMD, DXA L1 BMD and DXA femoral neck (FN) BMD correlated with FMD and CRP. QCT trabecular BMD correlated with ccIMT and PON1. According to the univariate analysis, FMD correlated with OPG, ccIMT correlated with SOST and QCT trabecular BMD. Ang1, Ang2 and PDGF-BB showed correlation with Dickkopf-1 (DKK1). Ang2 also correlated with OPG. As suggested by the multivariate analysis, OPG determined FMD; DKK1 was an independent predictor of Ang1, Ang2 and PDGF-BB. OPG was a predictor of Ang2.

Conclusion:

In our study of anti-TNF treated RA and AS patients, vascular and bone parameters showed numerous correlations. The therapy was clinically effective, it halted further bone loss over 1 year and reduced the production of angiogenic markers.

Acknowledgments:

This research was supported by an investigator-initiated research grant from Pfizer.

Disclosure of Interests:

Monika Czókolyová: None declared, Katalin Gulyás: None declared, Ágnes Horváth: None declared, Edit Végh: None declared, Zsófia Pethö: None declared, Szilvia Szamosi: None declared, Attila Hamar: None declared, Anita Pusztai: None declared, Emese Balogh: None declared, Nóra Bodnár: None declared, Levente Bodoki: None declared, Agnes Szentpetery: None declared, Harjit Pal Bhattoa: None declared, György Kerekes: None declared, Katalin Hodosi: None declared, Andrea Domjan: None declared, Sándor Szántó: None declared, Gabriella Szücs: None declared, Hennie Raterman Grant/research support from: UCB, Consultant of: Abbvie, Amgen, Bristol-Myers Sqibb, Cellgene and Sanofi Genzyme, WIllem Lems Grant/research support from: Pfizer, Consultant of: Lilly, Pfizer, Zoltán Szekanecz Grant/research support from: Pfizer, UCB, Consultant of: Sanofi, MSD, Abbvie, Pfizer, Roche, Novertis, Lilly, Gedeon Richter, Amgen

THU0634-HPR KNEE EXTENSOR MUSCLE STEADINESS IN RELATION TO MAXIMAL TORQUE AND PHYSICAL FUNCTIONING IN PATIENTS WITH KNEE OSTEOARTHRITIS

Background:

Osteoarthritis (OA) of the knee is characterized by knee pain and limitations in daily activities. Muscle weakness is associated with these characteristics, quantified as maximal voluntary muscle torque (MVT). The quality of muscle contraction is presented by fluctuations observed on a torque-time curve and the extent of these fluctuations is referred to as muscle steadiness. Whether muscle steadiness is associated with maximal muscle torque and consequently with pain and activity limitations is unknown.

Objectives:

To determine the association of knee extensor muscle steadiness with MVT and to explore the association of muscle steadiness with physical functioning in subjects with knee OA.

Methods:

Baseline data of 172 patients out of 177 patients with knee OA, who participated in the VIDEX trial (trial registration number, NL47786.048.14), were used for this study. Maximal voluntary knee extension torque (MVT) was assessed using an isokinetic dynamometer. Torque-time curve data were processed into (i) coefficient of magnitude of torque variance (CV) in percentage (%), (ii) frequency of torque variance as peak power frequency (PPF) in Hertz (Hz) and (iii) MVT in Newton meters (Nm). Physical functioning was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire, the Get-Up & Go (GUG) test, the 6-minute walk test (6MWT) and the Stair climb up & down test. Correlation and Regression analyses were performed to determine associations. Sex, age, BMI, KL-grade, knee alignment and pain were considered as potential confounders.

Results:

Lower CV and PPF, reflecting better muscle steadiness, were significantly associated (p< 0.01 and p<0.05, respectively) with higher MVT, but associations were weak. Regression analyses showed a significant association of lower CV with better physical functioning on the WOMAC (p<0.05), also after correction for relevant confounders. The association with WOMAC was confounded by pain, but not by sex, age and BMI. No associations of CV with the GUG test, the 6MWT and the Stair climb up & down test were found. PPF was not significantly associated with physical functioning.

Conclusion:

This is the first explorative study of muscle steadiness in relation to physical functioning in knee OA patients. Muscle steadiness is, to some extent, related to better physical functioning, but this is not consistent across all measures of physical functioning in this study. There seems to be some relationship, but it is weak and needs further exploration. No previous studies comparing clinical scores to muscle steadiness in knee OA were found to compare our results. Studies on muscle steadiness are needed to improve our understanding on this aspect of muscle torque.

References:

N/A

Disclosure of Interests:

Anuja Satam: None declared, Marike van der Leeden: None declared, Arjan de Zwart: None declared, Simon Verberne: None declared, Jim Schrijvers: None declared, Joost Dekker: None declared, WIllem Lems Grant/research support from: Pfizer, Consultant of: Lilly, Pfizer, Jaap Haarlaar: None declared, Martin van der Esch: None declared

SAT0551 WHOLE BODY MACROPHAGE PET IMAGING THAT INCLUDES THE FEET CAN PROVIDE ADDITIONAL INFORMATION TO CLINICAL ASSESSMENT IN PATIENTS WITH EARLY RHEUMATOID ARTHRITIS

Background:

Clinical assessment of arthritis is the cornerstone in the diagnosis and treatment of rheumatoid arthritis (RA). Nevertheless, reliable determination of (sub)clinical arthritis can be difficult, especially in the feet. Advanced imaging techniques may contribute to early diagnosis and therapy monitoring through sensitive detection and (quantitative) monitoring of synovitis. Previously, it has been demonstrated that macrophage imaging using (R)-[11C]PK11195 positron emission tomography (PET) allows for highly sensitive and specific imaging of RA disease activity in the hands.(1,2)Whole body macrophage PET imaging that includes the feet has not yet been evaluated in RA.

Objectives:

To compare whole body macrophage PET imaging to clinical assessment of arthritis activity in clinically active, early RA patients.

Methods:

Thirty-five previously untreated RA patients (age 54 ± 12, 51% male) with at least two clinically inflamed joints were included. They underwent a whole body (R)-[11C]PK11195 PET/computed tomography (CT) scan in addition to standard clinical assessment of number of tender and swollen joints (TJC and SJC, respectively). Two readers blinded to clinical assessment (GZ and CvdL) visually scored intensity of uptake in joints on a 0 to 3 scale. A PET positive joint score was defined at ≥ 1. Additionally, (R)-[11C]PK11195 uptake in joints was assessed quantitatively as standardized uptake values (SUV). Visual parameters were compared to clinical parameters using Cohen’s kappa, and quantitative parameters were analyzed using an independent T-test.

Results:

All patients showed enhanced tracer uptake in one or more joints (Figure 1). A total of 168 joints were visually PET positive, with the following distribution: 16% in the wrists, 14% in the metacarpophalangeal joints, 25% in the proximal interphalangeal joints, 4% in the ankles, 37% in the metatarsophalangeal joints. Positivity in other large joints was rare (4%). The number of discrepant findings between PET and clinical outcome (TJC and/or SJC) varied based on anatomic localization; more joints were clinically active in the hands, and more joints were active on the PET scan in the feet. Consequently, agreement between visual PET positivity and clinical activity was low, with only moderate agreement found in the ankles (κ = 0.46 and 0.41 for SJC and TJC respectively). Quantitative PET data showed a trend towards higher SUV values in joints that were clinically tender and/or swollen, reaching a significant difference in the feet (ankles + MTPs) versus SJC (Figure 2; 0.7 vs 1.0,p< 0.001). However, parts of the clinically non-affected joints also depicted moderately increased SUV values, and vice versa.

Figure 1.

Visual PET uptake in the left MTP5-joint.

Figure 2.

(R)-[11C]PK11195 (SUV) in both clinically affected and non-affected feet joints (defined as swollen yes or no).

Conclusion:

Whole body macrophage PET imaging showed clear uptake of (R)-[11C]PK11195 in several joints of clinically active, early RA patients, especially in MTP-joints. The best correlation between quantitative PET data and clinical assessment of swelling was observed in the feet. In general, however, PET also provided distinct information from clinical assessment, which may provide a means for detecting subclinical synovitis. We are performing longitudinal studies to further assess the value of macrophage PET in RA.

References:

[1]Elzinga EH, et al. J Nucl Med. 2011; 52(1): 77-80.

[2]Gent YY, et al. J Rheumatology. 2014; 41: 2145-52

Acknowledgments:

We thank ReumaNederland and Pfizer for financial support of this investigator initiated study.

Disclosure of Interests:

Nicki J.F. Verweij: None declared, Marieke ter Wee: None declared, Jerney de Jongh: None declared, Gerben C.J. Zwezerijnen: None declared, Maqsood Yaqub: None declared, Maarten Boers: None declared, Alexandre Voskuyl: None declared, Adriaan A. Lammertsma: None declared, WIllem Lems Grant/research support from: Pfizer, Consultant of: Lilly, Pfizer, Conny J. van der Laken: None declared

OP0219 MORTALITY OF RHEUMATOID ARTHRITIS PATIENTS, TREATED TO TARGET AT LOW DISEASE ACTIVITY: 17-YEARS FOLLOW-UP OF THE BEST COHORT

Background:

Rheumatoid arthritis is known to be associated with increased mortality over the years when compared to the general population. In the BeSt study, 508 patients were treated to target (Disease Activity Score ≤2.4) for 10 years between April 2000 and August 2012. At the end of the initial study follow-up, the observed mortality in the BeSt cohort was similar to mortality in the general population. In the current study we evaluated the mortality in the BeSt cohort after 17 years follow-up and compared it to the general Dutch population.

Objectives:

Evaluate long-term mortality in the BeSt study cohort.

Methods:

In the BeSt study 508 patients diagnosed with early RA were randomized to four initial treatment strategies: 1. Sequential monotherapy; 2. Step-up combination therapy; 3. Initial combination therapy with prednisone; or 4. Initial combination therapy with infliximab. During the 10-year follow-up period treatment was steered at low disease activity (DAS ≤2.4) and adjusted every three months when necessary. After 10-years patients were treated and followed-up according to regular care. We explored mortality through the Dutch state registry for mortality (Centrum voor Familiegeschiedenis) and treating rheumatologist. Mortality in the BeSt cohort was compared to the general Dutch population (Statistics Netherlands) matched by gender, age and calendar year using the standardized mortality ratio (SMR). Kaplan-Meier curves and the log-rank test were used to compare survival among the initial treatment strategies.

Results:

The mean duration of follow-up in non-deceased patients was 17 years (range 16-18). In total, 143 patients died (28%) compared to a total of 105 (21%) expected deaths in the reference population. The overall SMR after 17 years was 1.37 (95% CI: 1.16-1.61). Within the study population, no statistically significant difference in survival-curves was observed between the four initial treatment strategies (log-rank p=0.76) (table 1, and figure 1).

Table 1.

BeSt study cohort mortality - stratified for initial treatment strategy

Sequential monotherapyn=126Step-up combination therapyn=121Initial combination therapy with prednisonen=133Initial combination therapy with infliximabn=128N (%) †38 (30)31 (26)41 (31)33 (26)SMR (95% CI)1.41 (1.03–1.94)1.20 (0.84-1.70)1.53 (1.13-2.09)1.31 (0.93-1.85)

SMR: standardized mortality ratio (number observed deaths/number expected deaths); CI: confidence interval.Conclusion:

Figure 1.

Survival curves – stratified for initial treatment strategy

After a mean of 17 years follow-up the mortality was increased in the BeSt study cohort when compared to the general Dutch population. We observed no difference in survival curves among the four treatment strategies.

Disclosure of Interests:

Johanna M. Maassen: None declared, Yvonne Goekoop-Ruiterman: None declared, Hans van Groenendael: None declared, WIllem Lems Grant/research support from: Pfizer, Consultant of: Lilly, Pfizer, Pit Kerstens: None declared, Thomas Huizinga Grant/research support from: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Consultant of: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Cornelia Allaart: None declared

AB1320-HPR THE ASSOCIATION BETWEEN PHYSICAL ACTIVITY AND CARDIORESPIRATORY FITNESS IN PATIENTS WITH RHEUMATOID ARTHRITIS AND HIGH CARDIOVASCULAR RISK

Background:

Rheumatoid arthritis (RA) is associated with increased risk of cardiovascular disease (CVD) disease and CV mortality1. High values of cardiorespiratory fitness (CRF) are protective against CVD and CV mortality2. Physical activity levels in patients with RA are low. Knowledge on whether physical activity is associated with CRF in patients with RA and high CV risk is scarce. This knowledge is important because improving the level of physical activity could improve CRF and lower CV risk in this group of patients with RA and high CV risk. However, it is unclear whether physical activity is associated with CRF in this group of patients. This study presents the preliminary results at baseline of the association of physical activity with CRF from an ongoing pilot study aimed at improving CRF through exercise therapy in patients with RA and high CV risk.

Objectives:

To determine (i) the level of physical activity in patients with RA and high CV risk and (ii) whether physical activity is associated with CRF in patients with RA and high CV risk.

Methods:

Patients with RA and high CV risk participated in this pilot study. Increased 10-year risk of CV mortality was determined by using the Dutch SCORE-table. Anthropometrics and disease characteristics were collected. Physical activity was assessed with an Actigraph accelerometer to determine the number of steps and intensity of physical activity expressed in terms of sedentary, light, and moderate-to-vigorous time per day. Participants wore the accelerometer for seven days. A minimum of four measurement days with a wear time of at least 10 hours was required. The VO2max measured with a graded maximal exercise test was used to determine the CRF. Pearson correlation coefficients were calculated for the associations between the different measures of physical activity and VO2max. For the variables that were associated, linear regression analysis was carried out, with pain and disease activity as possible confounders.

Results:

Thirteen females and five males were included in the study. The mean age was 66.5 (± 15.0) years. Only 22% of the patients met public health physical activity guidelines for the minimal amount of 150 minutes a week. The mean step count was 6237 (± 2297) steps per day and mean moderate-to-vigorous physical activity time was 16.50 (± 23.56) minutes per day. The median VO2max was 16.23 [4.63] ml·kg-1·min-1, which is under the standard. Pearson correlations showed a significant positive association for step count with VO2max. No associations were found for sedentary, light, and moderate-to-vigorous physical activity with VO2max. The significant association between step count and VO2max(p = 0.01) was not confounded by disease severity and pain.

Discussion:

Since better CRF protects against CVD, increasing daily step count may be a simple way to reduce the risk of CVD in patients with RA and high CV risk. However, these results need to be confirmed in a larger study group. Future research should investigate if improving daily step count will lead to better CRF levels and ultimately will lead to a reduction in CV risk in patients with RA and high CV risk.

Conclusion:

Physical activity levels of patients with RA and high CV risk do not meet public health requirements for physical activity criteria and the VO2max was under the standard. Step count is positively associated with CRF.

References:

[1]Agca et al. Atherosclerotic cardiovascular disease in patients with chronic inflammatory joint disorders. Heart. 2016;102(10):790-795.

[2]Lemes et al. Cardiorespiratory fitness and risk of all-cause, cardiovascular disease, and cancer mortality in men with musculoskeletal conditions. J Phys Act Health. 2019;16;134-140.

Disclosure of Interests:

Joëlle van den Hoek: None declared, Marike van der Leeden: None declared, George Metsios: None declared, Georeg Kitas: None declared, Harald Jorstad: None declared, WIllem Lems Grant/research support from: Pfizer, Consultant of: Lilly, Pfizer, Michael Nurmohamed Grant/research support from: Not related to this research, Consultant of: Not related to this research, Speakers bureau: Not related to this research, Martin van der Esch: None declared

FRI0581 IN ELDERLY PATIENTS, CAPS THAT RECORD MEDICATION BOTTLE OPENINGS ARE UNRELIABLE AND THUS NOT THE GOLD STANDARD FOR ADHERENCE

Background:

Adherence is a serious problem in treatment of inflammatory diseases. To measure adherence, caps that record medication bottle openings may be superior to capsule counts (1). In the ongoing two-year GLORIA trial on the addition of low-dose (5 mg) prednisolone or placebo to standard of care in elderly patients (65+ years) with rheumatoid arthritis, adherence was measured in both ways during the whole trial.

Objectives:

To describe adherence patterns, and to compare adherence as assessed with adherence caps and with capsule counts in the GLORIA trial.

Methods:

The recorded adherence patterns of patients (blinded for treatment group) were classified according to descriptive categories. Overall adherence according to number of bottle openings was compared with adherence according to the capsule count. Good adherence was defined as 80%: i.e. for caps 80% of days one opening recorded, and for counts less than 20% of prescribed tablets returned at the subsequent visit. Each patient has a maximum of 8 periods of 90 days.

Results:

Trial inclusion has closed in 2018 at 452 patients; the current dataset contains adherence data of 385 patients. Mean number of recorded 90-day periods per patient was 4 (range 1-8). Based on capsule counts over all periods, 90% of the patients met the 80% threshold of adherence; based on cap data only 31% met this criterion.

The four adherence patterns are shown in a calendar matrix, with yellow for zero, green for one and blue for ≥two openings on a day (Figure 1). Bottles were supposed to be opened once a day.

Patients were categorized according to the opening pattern seen in at least 50% of assessed periods:

32% non-use(<20% of the days an opening);26% stable use(≥80% of the days 1 opening);40% irregular use(different adherence patterns, in or between periods);2% weekly use(1 opening per week).

Conclusion:

In our trial of elderly rheumatoid arthritis patients, patients appeared to be mostly adherent according to conventional capsule counts. Results from adherence caps were highly discrepant with the capsule counts, with patterns suggesting patients did not use the bottle for daily dispensing, despite specific advice to do so.

References:

[1] El Alili M, Vrijens B, Demonceau J, Evers SM, Hiligsmann M. A scoping review of studies comparing the medication event monitoring system (MEMS) with alternative methods for measuring medication adherence. Br J Clin Pharmacol 2016;82:268-79.

Acknowledgments:

The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‘’Personalizing Health and Care’’, grant agreement No 634886.

Disclosure of Interests:

Linda Hartman: None declared, Sabrina Paolino: None declared, Reinhard Bos: None declared, Daniela Opris-Belinski Speakers bureau: as declared, Marc R Kok Grant/research support from: BMS and Novartis, Consultant of: Novartis and Galapagos, Hanneke Griep-Wentink: None declared, Ruth Klaasen: None declared, Cornelia Allaart: None declared, George Bruyn: None declared, Hennie Raterman Grant/research support from: UCB, Consultant of: Abbvie, Amgen, Bristol-Myers Sqibb, Cellgene and Sanofi Genzyme, Marieke Voshaar Grant/research support from: part of phd research, Speakers bureau: conducting a workshop (Pfizer), Nuno Gomes: None declared, Rui Pinto: None declared, Thomas Klausch: None declared, WIllem Lems Grant/research support from: Pfizer, Consultant of: Lilly, Pfizer, Maarten Boers: None declared

Efficacy and safety of denosumab vs. bisphosphonates in postmenopausal women previously treated with oral bisphosphonates

Transitioning postmenopausal women with osteoporosis from a bisphosphonate to denosumab appears to be safe and more effective at improving BMD than continuing treatment with a bisphosphonate.

INTRODUCTION

We conducted a patient-level pooled analysis of four studies to estimate the efficacy and safety of transitioning to denosumab vs. continuing bisphosphonate treatment in postmenopausal women who previously received oral bisphosphonates.

METHODS

Patients received 60 mg denosumab once every 6 months or a bisphosphonate (oral alendronate, risedronate, ibandronate, or intravenous zoledronic acid). Endpoints were change from baseline in lumbar spine, total hip, femoral neck, and 1/3 radius BMD at month 12, change from baseline in serum CTX-1 and P1NP, and incidence of adverse events.

RESULTS

A total of 2850 randomized patients (1424 bisphosphonate:1426 denosumab) were included in the analysis. Percentage change in BMD was significantly greater (p < 0.001) for denosumab vs. bisphosphonate at each skeletal site; differences in BMD changes ranged from 0.6 to 2.0%. Percentage decrease in serum CTX-1 and P1NP was significantly greater (p < 0.0001) for denosumab vs. bisphosphonate at months 1, 6, and 12; in the denosumab group only, percentage change in serum CTX-1 at month 1 was significantly correlated with percentage change in lumbar spine and total hip BMD at month 12. The incidences of adverse events were similar between treatment groups. Three patients (one bisphosphonate and two denosumab) had atypical femoral fractures, all from the denosumab vs. zoledronic acid study.

CONCLUSION

Postmenopausal women can safely transition from a bisphosphonate to denosumab, which is more effective at improving BMD than continuing with a bisphosphonate.

CLINICAL TRIALS REGISTRATION

NCT00377819, NCT00919711, NCT00936897, NCT01732770.