Real-world efficacy of belimumab in achieving remission or low-disease activity in systemic lupus erythematosus: A retrospective study

OBJECTIVES

We investigated the effect of belimumab (BEL) on achieving low disease activity (LDA) and remission as an additive molecular-targeting agent to standard of care (SoC) in patients with SLE.

METHODS

Clinical information was retrospectively collected from patients with SLE who received BEL additive to SoC (BEL+SoC), and from patients treated with SoC alone as a control arm. Disease activity was measured by SLE-disease activity score (SLE-DAS). The proportion of patients in LDA and remission at 12 months was compared after propensity score matching. The factors contributing to LDA and remission achievement was identified by Cox proportional hazard model.

RESULTS

BEL+SoC significantly reduced SLE-DAS at 6 months, with a significantly higher proportion of patients achieving LDA and remission at 12 months compared to SoC alone. The presence of arthritis at baseline was significantly associated with achieving LDA and remission. Additionally, both treatment groups experienced a significant reduction in daily glucocorticoid dose.

CONCLUSIONS

Adding BEL to SoC was beneficial for patients with arthritis, leading to higher proportion of achieving LDA and remission, while also reducing their glucocorticoid dose. Our results indicate the utility of BEL in a treat-to-target approach for SLE patients in a real-world setting.

The pathogenic role of lupus-specific autoantibodies and Interleukin-6 on demyelination of the brainstem and spinal cord in systemic lupus erythematosus

OBJECTIVES

Demyelinating syndromes that result in brainstem and/or spinal cord lesions similar to those observed in neuromyelitis optica spectrum disorder (NMOSD) as neuropsychiatric syndromes in systemic lupus erythematosus (NPSLE) occasionally develop in patients with SLE. Cerebrospinal fluid (CSF) interleukin (IL)-6 is a known biomarker for NMOSD; however, its application in patients with SLE with brainstem and/or spinal cord lesions is unknown. Additionally, the breakdown of blood-brain barrier (BBB) integrity by autoantibodies is another mechanism of NMOSD; however, it is not elucidated in SLE. Therefore, this study was designed to clarify the use of CSF IL-6 and investigate whether autoantibodies contribute to BBB breaches and the development of brainstem and/or spinal cord lesions.

METHODS

Data from patients with NPSLE who had NMOSD-like demyelinating lesions in the central nervous system (CNS), including brainstem and/or spinal cord lesions, were retrospectively analyzed. We retrospectively investigated the interval changes in CSF IL-6 and clinical and serological factors related to BBB permeability using CSF/serum albumin ratio (QAlb).

RESULTS

Twelve patients with NPSLE who had demyelinating lesions in the brainstem and/or spinal cord were recruited. Before treatment, CSF IL-6 levels were 29.1 pg/mL and significantly decreased to 3.8 pg/mL by treatment (p = 0.008). Before treatment, CSF IL-6 was significantly correlated with the anti-dsDNA antibody titer (p = 0.027). Furthermore, before treatment, QAlb was significantly correlated with the serum anti-Smith antibody titer. In patients with atypical NMOSD who had specific lesions defined in the NMOSD diagnostic criteria but were negative for antiaquaporin four antibody, a significant correlation was observed between the serum anti-Smith antibody titer and CSF IL-6 (p = 0.025) and QAlb (p = 0.033) values before treatment.

CONCLUSION

CSF IL-6 could be a surrogating marker for disease activity, and serum anti-Smith antibody permeabilizes the BBB in patients with NPSLE, supporting the development of NMOSD-like CNS lesions.

A case of rheumatoid arthritis with bilateral shoulder bursitis accompanied by gas image

We experienced a case of bilateral shoulder bursitis with gas images in a rheumatoid arthritis (RA) patient. A 60-year-old man with RA had been treated with weekly methotrexate 10 mg and daily prednisolone (PSL) 10 mg for 7 months. Generalized pain, especially in the bilateral shoulder joints, developed and exacerbated daily with increased C-reactive protein (CRP) level. Despite the initiation of biweekly sarilumab 200 mg, joint symptoms and CRP level continued to worsen. Computed tomography (CT) scan to determine the cause of severe shoulder inflammation revealed low absorption areas with contrast effects at the margins around the bilateral shoulder joints, accompanied by internal gas images. In addition, magnetic resonance imaging demonstrated subacromial bursae and coracoid bursae and bursitis, leading to the suspicion of abscess formation depending on the presence of gas image. In spite of antimicrobial therapy, arthralgia did not improve, and a CT-guided arthrocentesis of the left shoulder joint resulted in negative findings of infection in culture and pathological examinations. Switching treatment to intensive anti-inflammatory therapy with high-dose steroids and etanercept finally improved symptoms and CRP levels associated with the reduction of low absorption areas and disappearance of gas images at bilateral shoulder joints. Our case indicated that bursitis with gas image in RA patients involves unusual pathophysiology and requires intensive anti-rheumatic treatment.

AB0363 COMPARING THE ULTRASONOGRAPHIC EVALUATION IN PATIENTS WITH JAPANESE RHEUMATOID ARTHRITIS BETWEEN JAK AND TNF INHIBITOR THERAPY

Background

JAK inhibitor (JAK) and TNF inhibitor (TNF) are the important therapeutic agent for the treatment of rheumatoid arthritis.However there is still few studies of improvement of ultrasonographic findings in RA treated comparison with JAK and TNF.

Objectives

To evaluate the clinical efficacy of JAK and TNF therapy patients with rheumatoid arthritis (RA) using ultrasonography (US).

Methods

Participants comprised 32 and 39 Japanese RA patients who had recently received JAK (BAR23, PEF9) and TNF. All patients with a diagnosis of RA according to the 2010 ACR/EULAR criteria. Patients underwent clinical and laboratory assessments every 4 weeks from baseline to 24 weeks, and US assessments at baseline, 4, 12 and 24 weeks. Gray scale (GS) and power doppler (PD) signals were scored using a semi-quantitative scale from 0 to 3 at 26 (0-78) synovial sites (22 joints) in the following joints: bilateral first to fifth metacarpopharangeal (MCP) joints (dorsal recess); first interphalangeal (IP) and second to fifth proximal interphalangeal (PIP) (dorsal recess) joints; and the wrists (dorsal radial, median and ulnar). We evaluated the improvement of GS and PD score from baseline to week 24.

Results

In the patients receiving JAK (n=32) and TNF (n=39), the mean age was 54.7 vs 55.1 years old (p=0.871), disease duration was 7.4 vs 6.1 years (p=0.290), the rate of MTX use was 75% vs 87% (p=0.187), the mean MTX dose was 9.9 vs 10.2 mg/w (p=0.813), the rate of ACPA positive was 94% vs 79% (p=0.086), DAS28-ESR was 4.79 vs 4.65 (p=0.435), CDAI was 22.4 vs 19.1 (p=0.239), GS score was 20.8 vs 18.3 (p=0.995) and PD score was 14.0 vs 11.0 (p=0.940). The degree of improvement respective changes in GS and PD score after 4, 12 and 24 weeks were as follows: GS: -5.1 vs -4.3 (p=0.817) and PD: -5.3 vs -2.7 (p=0.855) after 4 weeks, GS: -9.1 vs -6.6 (p=0.880) and PD: -7.9 vs -4.5 (p=0.476) after 12 weeks, GS: -10.4 vs -9.5 (p=0.463) and PD: -8.1 vs -6.7 (p=0.968) after 24 weeks between JAK and TNF (Figures 1 and 2). Next, The improvement rate of respective changes in GS and PD score after 4, 12 and 24 weeks were as follows: GS: -13.7% vs -18.3% (p=0.489) and PD: -20.4% vs -16.5% (p=0.777) after 4 weeks, GS: -29.7% vs -26.0% (p=0.922) and PD: -30.9% vs -30.8% (p=0.890) after 12 weeks, GS: -38.1% vs -36.4% (p=0.567) and PD: -33.4% vs -50.1% (p=0.977) after 24 weeks between JAK and TNF.

Conclusion

The present study provides evidence supporting the JAK and TNF therapy improved similarly the inflammatory synovitis of US findings.

Disclosure of Interests

None declared

AB1027 CLINICLAL EFFICACY OF SEQUENTIAL TREATMENT AFTER ROMOSOZUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS FOR 18 MONTHS

Background

Romosozumab (ROMO), a monoclonal antibody that binds sclerostin, increases bone formation and decreases bone resorption. And although it is a novel therapeutic agent for osteoporosis, which has shown high effects of increasing bone density and inhibiting fragile fracture in overseas clinical trials. However the clinical efficacy for rheumatoid arthritis complicated with osteoporosis (RA-OP) is unknown.

Objectives

To evaluate the clinical efficacy of ROMO for 12months and denosumab (DMB) 6months in patients with RA-OP for 18 months.

Methods

RA patients diagnosed according to the 2010 ACR/EULAR criteria. All patients met at least one of the following criteria were eligible; a bone mineral density T score of -2.5 or less at the lumber spine or total hip and either one or more moderate or severe vertebral fractures or two or more mild vertebral fractures. All patients were initiated ROMO from between April, 2019 and March, 2020. The total number of patients was 12 cases. The ROMO dose was 210mg at once every 1 months. After 12 months of ROMO, all cases were changed to DMB. In all cases native or activated vitamin D has been used. We reviewed the results for 12 months about the increase and decrease of bone mineral density (BMD) of lumbar spine(LS) and total hip(TH) by DEXA and bone turnover markers, intact n-terminal propeptide type I procollagen(PINP) and tartrate-resistant acid phopshatate form 5b(TRACP-5b).

Results

he gender was all female. The mean age was 72.8 ± 7.0; disease duration was 17.7 ± 16.5 years; the body mass index was 19.4 ± 3.1 and the FRAX was 36.0 ± 14.9. Clinical findings related to RA-OP at baseline were as follows; CRP 1.25 ± 1.75; DAS28-CRP 3.45 ± 0.99; HAQ 1.56 ± 0.99 and, bone turnover markers and bone mineral density at baseline were as follows; P1NP 62.4 ± 36.2; TRACP-5b 485 ± 252; LS-BMD and T-score 0.79 ± 0.14 g/cm2 and -2.82 ± 0.99 and TH-BMD 0.55 ± 0.07 g/cm2 and -3.14 ± 0.53 g/cm2. The rate of increased P1NP from baseline to 1, 3, 6, 12 and 18 months were each 116.3 ± 68.7% at 1 month, 135.0 ± 131.3% at 3 month, 126.1 ± 177.0% at 6 month, 83.7 ± 179.1% at 12 month and -45.1 ± 35.7% at 18 month and decreased TRAC-5b were -13.0 ± 91.4% at 1 month, 6.9 ± 38.8% at 3 month, 20.0 ± 63.4% at 6 month, 14.8 ± 64.5% at 12 month and -11.4 ± 95.9% at 18 month. The rate of increased LS-BMD from baseline to 6, 12 and 18 months were 10.8 ± 8.0%, 15.2 ± 9.5% and 18.9 ± 10.4% and TH-BMD were 4.1 ± 4.5%, 5.7 ± 6.3% and 8.4 ± 8.1% (Figure 1, 2).

Conclusion

Clinical efficacy of treatment with ROMO for 12months and DMB for 6months for RA-OP was extremely effective and has the high potential to be an important option in the treatment of RA-OP.

Disclosure of Interests

None declared

A Patient with Castleman's Disease Initially Manifesting Symmetrical Synovitis with Pitting Edema

Castleman's disease (CD), especially multicentric CD (MCD) has been known to manifest a variety of clinical features such as fatigue, anemia, fever and hypergammaglobulinemia. Here, we report a 72-year-old female patient who had complicated severe synovitis, as an initial manifestation of the disease, lastly diagnosed as MCD. Initially, she had been diagnosed as remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome because of bilateral leg pitting edema with significant c-reactive protein and matrix metalloproteinase-3 elevation but no disease-specific autoantibodies. Promptly, corticosteroid (CS) and additionally weekly methotrexate (MTX) was introduced, but her leg edema and inflammatory findings did not adequately come to be a remission. A lymph node biopsy from the groin region was performed because multiple lymph node swelling in ultrasound examination appeared even after introducing treatments, which revealed mixed-type CD. Multiple lymphadenopathies were observed in the axilla and inguinal region, finally, we diagnosed her as idiopathic MCD and introduced tocilizumab (TCZ) which significantly improved leg edema as well as inflammatory findings. As is shown in this case, manifestations included in RS3PE syndrome could be one of the clinical phenotypes in MCD, which should be considered as a differential diagnosis of MCD.

Anti-ribosomal P protein antibodies in patients with systemic lupus erythematosus is associated with hyperferritinemia

AIM

Anti-ribosomal P protein antibodies (anti-ribo P) have been reported as one of the specific autoantibodies in patients with systemic lupus erythematosus (SLE) and has been demonstrated to bind and activate macrophages in vitro. Clinically, hyperferritinemia has been known to be a biomarker for macrophage activation. The aim of this study is to clarify the relationship of anti-ribo P and clinical characteristics and biomarkers including serum ferritin in patients with SLE.

METHODS

Clinical parameters and laboratory data were measured in patients with active SLE (N = 127) in our university hospital. The risk factors affected by anti-ribo P were retrospectively calculated by logistic regression analysis, and the correlation of anti-ribo P and clinical factors was demonstrated.

RESULTS

Anti-ribo P was significantly elevated in active SLE compared to non-SLE diseases (P < .0001). Sensitivity and the specificity of anti-ribo P in patients with SLE were 32.0% and 99.3%, respectively. Patients positive for anti-ribo P had the highest risk for elevated serum ferritin (odds ratio: 8.432). Accordingly, anti-ribo P positive patients had significantly elevated serum ferritin compared to negative patients (P = .024). A significant positive correlation was observed between the anti-ribo P titer and the serum ferritin level (r²  = .07, t = 5.22, P = .0081), but not serum interleukin (IL)-6 in SLE patients.

CONCLUSION

The presence of anti-ribo P is a risk factor for higher ferritin levels that is independent of systemic inflammation regulated by IL-6. We speculate that anti-ribo P could be directly associated with macrophage activation leading to hyperferritinemia in patients with SLE.

AB0233 REASONS AND RISK FACTOR FOR DISCONTINUATION OF BIOLOGIC AGENTS FOR RHEUMATOID ARTHRITIS PATIENTS IN LONG-TERM OBSERVATION

Background:

Rheumatoid arthritis (RA) patients who failed a first biologic agent due to any reasons have the option of switching to a second one along with the strategy of biologic agent treatment. Patients go over switching to the next one at failing their biologic agent. On the other hand, there are some patients who discontinue any biologic agent treatment due to various reasons such as tolerability concern, complications, economic issue, remission and so on1 2. The impact of this concern has been less studied.

Objectives:

The objective of this study was to investigate the reasons and the risk factors for discontinuation any biologic agent in RA patients.

Methods:

To Include patients who are observed long-term, patients who underwent biologic agent treatment between 2003 and 2007 at Nagoya University Hospital and 12 other institutes (Tsurumai Biologics Communication Study Group) were enrolled. 570 patients who were confirmed continuation or discontinuation of biologic agent treatment were enrolled. The last observation was September 2017. We analyzed the retention rate of biologic agent treatment and the reasons for discontinuation. To identify the risks for discontinuation, baseline demographics were compared between the continuing group and the disc continuing group using cox hazard regression analysis.

Results:

In total 570 patients, the average duration of treatment with biologics was 6.6±3.3 (years) and total patient-year was 3739 in this study. 458 patients were administered biologics continuously, 112 patients were withdrawn. Table 1 showed the demographic data in total patients. The retention rate was 96.0% (discontinuation n=23) at least 1 year from starting biologics treatment, 92.6% (n=42) at 3 years, 88.2% (n=67) at 5 years, 84.4% (n=89) at 7 years, 81.1% (n=108) at 10 years. In 112 patients who discontinued, the reasons were adverse events in 74 patients, lack of effectiveness in 11 patients, others in 27 patients. Comparison of incidence for discontinuation using cumulative hazard function, the reason of adverse events was significantly higher than others reasons (Figure 1). To identify the risks of discontinuation, we analyzed by multivariable Cox proportional hazard modeling in patients who discontinued treatment due to adverse events, the risk factors (hazard ratio: HR, confidence interval: CI) were over 3 of Steinblocker class (HR 1.85 [1.02-2.04]), age (HR:1.07 [1.04-1.10]) and Non-concomitant with methotrexate (HR 1.90 [1.08-3.33]) (Figure 2).

Table 1.Age (years)56.1 ± 13.4Gender n (% male)110 (19%) n (% female)460 (81%)Disease duration (years)11.1 ± 9.8stage 1,2104 (19%) 3,4455 (81%)class 1,2336 (60%) 3,4225 (40%)Methotrexate use, no (%)400 (70%)Glucocorticoid use, no (%)262 (47%)Rheumatoid Factor, no (%)287 (65%)anti CCP antibody, no (%)137 (87%)

Conclusion:

The most common reason for discontinuation was adverse events in long term observation. The risk factors for discontinuation were class, age, and non-concomitant MTX. These results suggested that comorbidity has a significant impact on continuation rates because there are some reasons of non-concomitant MTX in addition to relate with age and the activities of daily living.

References:

[1]Marussa B, et al. j.clin thera. 2011; 33(7): 901-913

[2]Alejandro S, et al. Rheumatol. 2016; 55(3): 523-34

Disclosure of Interests:

KENYA TERABE: None declared, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Yuji Hirano Speakers bureau: Tanabe-Mitsubishi, Pfizer, Eisai, Abbie, Chugai, Bristol-Meyers, Jansen, Astellas, UCB, Eli-Lilly, Asahikasei, Daiichi-Sankyo, Amgen, Yasuhide Kanayama: None declared, Toshihisa Kojima Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Consultant of: AbbVie, Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis

OP0107 CLINICAL EFFICACY OF ROMOSOZUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS FOR 12 MONTHS

Background:

Romosozumab (ROMO), a monoclonal antibody that binds sclerostin, increases bone formation and decreases bone resorption. And although it is a novel therapeutic agent for osteoporosis, which has shown high effects of increasing bone density and inhibiting fragile fracture in overseas clinical trials. However the clinical efficacy for rheumatoid arthritis complicated with osteoporosis (RA-OP) is unknown.

Objectives:

To evaluate the clinical efficacy of ROMO in patients with RA-OP for 12 months.

Methods:

RA patients diagnosed according to the 2010 ACR/EULAR criteria. All patients met at least one of the following criteria were eligible; a bone mineral density T score of -2.5 or less at the lumber spine or total hip and either one or more moderate or severe vertebral fractures or two or more mild vertebral fractures. All patients were initiated ROMO from between March and December, 2019. The total number of patients was 13 cases. The ROMO dose was 210mg at once every 1 months. In all cases native or activated vitamin D has been used. We reviewed the results for 12 months about the increase and decrease of bone mineral density (BMD) of lumbar spine(LS) and total hip(TH) by DEXA and bone turnover markers, intact n-terminal propeptide type I procollagen(PINP) and tartrate-resistant acid phopshatate form 5b(TRACP-5b).

Results:

The gender was all female. The mean age was 73.2 ± 7.6; disease duration was 20.5 ± 16.9 years; the body mass index was 19.7 ± 3.0 and the FRAX was 40.5 ± 16.2. Clinical findings related to RA-OP at baseline were as follows; CRP 1.29 ± 1.66; DAS-CRP 3.43 ± 0.96; HAQ 1.59 ± 0.97 and, bone turnover markers and bone mineral density at baseline were as follows; P1NP 58.1 ± 33.5; TRACP-5b 438 ± 216; LS-BMD and T-score 0.81 ± 0.15 g/cm2 and -2.63 ± 1.05 and TH-BMD 0.54 ± 0.08 g/cm2 and -3.22 ± 0.64 g/cm2. The rate of increased P1NP from baseline to 1, 3, 6 and 12 months were each 114.3 ± 90.6% at 1 month, 131.6 ± 134.3% at 3 month, 122.6 ± 174.3% at 6 month and 80.4 ± 181.6% at 12 month and decreased TRAC-5b were -10.7 ± 20.8% at 1 month, 7.9 ± 36.9% at 3 month, 25.5 ± 64.6% at 6 month and 32.5 ± 77.0% at 12 month. The rate of increased LS-BMD from baseline to 6 and 12 months were 8.6 ± 8.0%, 12.5 ± 11.1% and TH-BMD were 4.3 ± 5.0%, 6.8 ± 6.9% (Fig. 1, 2).

Conclusion:

Clinical efficacy of ROMO for RA-OP was extremely effective and has the high potential to be an important option in the treatment of RA-OP.

References:

Disclosure of Interests:

None declared

POS0635 COMPARING THE ULTRASONOGRAPHIC EVALUATION IN PATIENTS WITH JAPANESE RHEUMATOID ARTHRITIS BETWEEN BARICITINIB AND TNF ANTAGONIST THERAPY

Background:

Baricitinib (BAR) and TNF antagonist are the important therapeutic agent for the treatment of rheumatoid arthritis.However there is still few studies of improvement of ultrasonographic findings in RA treated comparison with BAR and TNF.

Objectives:

To evaluate the clinical efficacy of BAR and TNF therapy patients with rheumatoid arthritis (RA) using ultrasonography (US).

Methods:

Participants comprised 16 and 45 Japanese RA patients who had recently received BAR and TNF. All patients with a diagnosis of RA according to the 2010 ACR/EULAR criteria. Patients underwent clinical and laboratory assessments every 4 weeks from baseline to 24 weeks, and US assessments at baseline, 4, 12 and 24 weeks. Gray scale (GS) and power doppler (PD) signals were scored using a semi-quantitative scale from 0 to 3 at 26 (0-78) synovial sites (22 joints) in the following joints: bilateral first to fifth metacarpopharangeal (MCP) joints (dorsal recess); first interphalangeal (IP) and second to fifth proximal interphalangeal (PIP) (dorsal recess) joints; and the wrists (dorsal radial, median and ulnar). We evaluated the improvement of GS and PD score from baseline to week 24.

Results:

In the patients receiving BAR (n=16) and TNF (n=45), the mean age was 55.9 vs 54.6 years old (p=0.682), disease duration was 10.2 vs 6.1 years (p=0.094), the rate of MTX use was 75% vs 89% (p=346), the mean MTX dose was 9.3 vs 10.2 mg/w (p=0.443), the rate of ACPA positive was 94% vs 82% (p=0.476), DAS28-ESR was 4.25 vs 4.61 (p=0.289), CDAI was 15.8 vs 18.5 (p=0.210), GS score was 21.6 vs 16.3 (p=0.436) and PD score was 15.0 vs 9.5 (p=0.260). The degree of improvement respective changes in GS and PD score after 4, 12 and 24 weeks were as follows: GS: -7.2 vs -3.7 (p=0.268) and PD: -7.6 vs -2.3 (p=0.158) after 4 weeks, GS: -10.9 vs -5.0 (p=0.161) and PD: -9.2 vs -3.8 (p=0.049) after 12 weeks, GS: -12.9 vs -6.1 (p=0.485) and PD: -11.3 vs -5.7 (p=0.062) after 24 weeks between BAR and TNF (Fig.1, 2). Next, The improvement rate of respective changes in GS and PD score after 4, 12 and 24 weeks were as follows: GS: -23.8% vs -11.6% (p=0.580) and PD: -30.3% vs -16.5% (p=0.343) after 4 weeks, GS: -39.6% vs -15.6% (p=0.129) and PD: -47.1% vs -30.8% (p=0.210) after 12 weeks, GS: -52.2% vs -22.2% (p=0.248) and PD: -77.1% vs -50.1% (p=0.048) after 24 weeks between BAR and TNF.

Conclusion:

The present study provides evidence supporting both the BAR and TNF therapy showed improvement effect over time, but in a comparison between BAR and TNF, the PD score of BAR showed a siginificant improvement effect compared to TNF at 12 and 24 weeks. It was suggeted that BAR may improve inflammatory synovitis earlier compared to TNF.

Disclosure of Interests:

None declared

A case of anti-MDA5 antibody-positive dermatomyositis developing reversible cerebral vasospasm syndrome successfully treated by multi-immunosuppressant combination including mycophenolate mofetil

A 39-year-old woman admitted with multiple joint pain, hand rashes, and shortness of breath was diagnosed with anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive dermatomyositis (DM) with interstitial pneumonia (IP). Because of progressive dyspnoea and hypoxaemia, her IP was considered rapidly progressive interstitial lung disease. Initially, prednisolone 60 mg/day, cyclosporine A (CyA), and intravenous cyclophosphamide (IVCY) were initiated. A few days following the initiation of treatment, she experienced massive thunderclap headache, which was diagnosed as reversible cerebral vasospasm syndrome based on the findings of contraction in cerebral arteries with brain magnetic resonance imaging. Treatment with CyA and IVCY was discontinued, and diltiazem and mycophenolate mofetil (MMF) were initiated as an alternative immunosuppressant. Considering IVCY as the cause of Reversible cerebral vasospasm syndrome based on her clinical course, tacrolimus was commenced, which improved both DM and IP. DM patients who are anti-MDA5 antibody-positive are considered to have poor prognosis and require aggressive immunosuppressive treatments. In patients experiencing adverse events with standard IVCY, MMF with high-dose steroids and alternative calcineurin inhibitor should be considered.

AB0362 HERPES ZOSTER IN BARICITINIB-TREATED JAPANESE PATIENTS WITH RHEUMATOID ARTHRITIS USING REAL-WORLD CLINICAL DATA

Background:

Similar to biologic disease-modifying anti-rheumatic drugs, the association between Janus kinase (JAK) inhibitors and infection is particularly interesting. The incidence of herpes zoster (HZ) among patients treated with JAK inhibitors is twofold to threefold higher in several regions of Asia (e.g., Japan and Korea) as compared with that observed in North America and Western Europe [1].

Objectives:

To evaluate the characteristics of patients who developed HZ during baricitinib treatment using real-world, multicenter, clinical data for Japanese population.

Methods:

The study enrolled 97 patients with rheumatoid arthritis (RA) who were treated with baricitinib therapy (68 biologic-naïve patients and 29 biologic-experienced patients) were enrolled in the study (observation period: 2–27 months). The severity of HZ infection was determined based on the extent of the rash and the presence or absence of organ damage. We evaluated the characteristics and clinical courses of patients who developed HZ.

Results:

Eight patients with HZ. The incidence ratio (IR) was 8.2 per patient-year. Patient data are described in Table 1 and Table 2. The IR was a little higher than that reported in clinical trials [2], which could be attributed to the high average age (i.e., 67.3 years) of the patients in this study. It was reported that adverse events occurred more frequently in elderly patients aged ≥65 years compared with younger patients [3]. The period from baricitinib administration to the onset of HZ varied between 2 months and 16 months. It is suggested that HZ may develop at any time during baricitinib therapy. There were no distinctive patient characteristics, except for age, at the time of initial baricitinib administration between patients who developed HZ and those who did not.

Table 2.

Response rates of non-medical Switch from Cellcept to Myfortic

Case- No.Age (years)Time (years) from RA onsetGenderFemale:FMale: M)BMIBari dose (mg/d)PSL(mg/d)MTX (mg/w)HZ historyNumber of prior biologics1741.5F25.64012No226133F19.2206No136111.1F23.64010Yes04730.5M23.3408Yes057421.9F20.9200No06781.2F19.8406No074823.2F24.1448No08795.0F22.422.54No0Table 1.

Fatigue in NPSLE and non-NPSLE patients (N = 222)

Case No.HZ incidence period after baricitinib administration (months)Priod of baricitinib withdrawal (weeks)Severity(Mild; MilModerate: Mod)1164Mod224Mod3131Mil431Mil586Mod634Mil ~ Mod733Mod820Discontinuation due to pateient’s choiceMod

None of the patients had severe symptoms, and none of them experienced organ damage. All patients were cured with anti-viral agents. It should be noted that patients who had a history of HZ had milder symptoms than those who had no history of HZ. We noted an interesting finding in one patient (case 2). The half-life of baricitinib in the blood was very short (about 6 hours), and it is reported that the drug is almost fully excreted from the body 24 hours after its administration [4]. However, this patient developed an incidence of HZ at 17 days after the withdrawal of baricitinib for surgery management. Cells may take longer time to regain their original immune status even after excretion of the drug, especially, during intense stress such as in cases of surgical invasion.

Conclusion:

The HZ risk in Japanese patients with RA treated with baricitinib in real-world practice was high, especially in elderly patients. It is notable that HZ events were nonserious and that patients could restart baricitinib treatment after healing with antiviral therapy, for the most part.

References:

[1]Taylor PC et al. N Engl J Med. 2017;376:652-62

[2]Harigai M et al. Mod Reumatol. 2019;20:1-8.

[3]Fleischmann R et al. RMD open. 2017;3:e000546.

[4]Shi JG et al. J Clin Pharmacol. 2014;54:1354-61

Disclosure of Interests:

Eiji Torikai: None declared, Yuji Hirano Speakers bureau: Tanabe-Mitsubishi, Pfizer, Eisai, Abbie, Chugai, Bristol-Meyers, Jansen, Astellas, UCB, Eli-Lilly, Asahikasei, Daiichi-Sankyo, Amgen, Daisuke Suzuki: None declared, Yasuhide Kanayama: None declared

SAT0472 GOAL-DIRECTED TREATMENT OF OSTEOPOROSIS IN PATIENTS WITH RHEUMATOID ARTHRITIS USING DENOSUMAB FOR FIVE YEARS

Background:

Osteoporosis (OP) is frequent complication identified in patients with rheumatoid arthritis (RA). Effective treatment must be provided to treat OP in RA (RAOP). Denosumab (DMB) is one of the promising drugs that are currently being used for the treatment of RAOP. We reported the results of 12-month DMB treatment for RAOP as part of Japanese multicenter registry study (TBCR-BONE) in EULAR2016 [1]. Recently, a treatment goal of OP was reported by the American Society for Bone and Mineral Research and the National Osteoporosis Foundation (ASBMR-NOF) working group [2]. This report advocated that the goal of treatment is a T-score of >-2.5 at the femoral neck, total hip (TH) or lumbar spine (LS) on DXA if the primary reason for starting treatment was a T-score of ≤-2.5 at the abovementioned skeletal sites. The working group noted that it was reasonable to expect that initial treatment should offer at least a 50% chance of achieving the treatment goal within 3 to 5 years of initiating therapy. We have reported the achievement rates of treatment goal in RAOP with 3-year DMB treatment on RAOP in EULAR2019 [3].

Objectives:

The aim of this retrospective study was to evaluate whether 5-year DMB treatment can achieve treatment goal of OP using data from TBCR-BONE.

Methods:

The study included 46 female patients who had completed 5-year DMB treatment. The LS-BMD analysis included 22 patients with a baseline (BL) LS-BMD T-score of ≤ -2.5. The TH-BMD analysis included 29 patients with a BL TH-BMD T-score of ≤ -2.5. Similar to clinical setting in Japan, 60mg of DMB was administered once every 6 months with a vitamin D3 supplement. BL characteristics, change in T-score over time, and achievement of the treatment goal (T-score>-2.5) were evaluated.

Results:

BL characteristics of the 46 female patients included: mean age of 69.1 years and RA duration of 16 years. Prednisolone was administered to 37% of the patients. In the LS-BMD analysis, T-scores improved significantly; the mean value at BL was −3.4, which increased to −3.0 at 1 year, −2.6 at 3 years, and ultimately to −2.5 at 5 years. The fraction of patients who achieved the treatment goal was as follows: 36.4% at 1 year, 40.9% at 2 years, 45.5% at 3 years, 50.0% at 4 years, and 54.5% at 5 years (Fig. 1A). The patients who achieved this treatment goal were those who had a significantly lower risk of fracture at BL as determined by FRAX (17.9% vs. 32.2%, p = 0.044), who had significantly higher BL serum TRACP-5b level (572.8 vs. 401.0: p = 0.03), and who had significantly better BL LS-BMD T-scores (−3.0 vs. −3.9, p < 0.01) than the nonachievers. In the TH-BMD analysis, T-scores improved significantly; the mean value at BL was −3.0, and it increased to −3.0 at 1 year, −2.7 at 3 years, and reached −2.7 at 5 years. The fraction of patients who achieved the treatment goal was as follows: 20.7% at 1 year, 31.0% at 2 years, 34.5% at 3 years, 31.0% at 4 years, and 37.9% at 5 years (Fig. 1B). The patients who achieved this treatment goal were those who had significantly better BL TH-BMD T-scores (−2.7 vs. −3.2: p < 0.01) than the nonachievers. Cut-off values at BL for achievement of the treatment goal determined using ROC analysis were −3.1 for the LS-BMD (sensitivity 83.3%, specificity 90.0%) and −2.85 for the TH-BMD (sensitivity 100.0%, specificity 81.0%).

Conclusion:

The results of this study suggested that achievement of the treatment goal was comparatively easy for those with LS-BMD loss; however, it was comparatively difficult for those with TH-BMD loss. Early initiation or longer duration of DMB therapy may be necessary to improve achievement rates. Likewise, other agents, such as romosozumab, may be considered for those with significant TH-BMD loss.

References:

[1]Hiranoet al.Ann Rheum Dis 2016; 75 (Suppl 2): 94

[2]Cummingset al.J Bone Miner Res 2017; 32: 3-10

[3]Hiranoet al.Ann Rheum Dis 2019; 78 (Suppl 2): A940

Disclosure of Interests:

Yuji Hirano Speakers bureau: Tanabe-Mitsubishi, Pfizer, Eisai, Abbie, Chugai, Bristol-Meyers, Jansen, Astellas, UCB, Eli-Lilly, Asahikasei, Daiichi-Sankyo, Amgen, Yasuhide Kanayama: None declared, Hironobu Kosugiyama: None declared, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda

THU0182 THE EFFECTIVENESS OF BIOLOGICAL AGENTS CONCOMITANT WITH TACROLIMUS IN RHEUMATOID ARTHRITIS

Background:

In Japan, oral tacrolimus (TAC) was approved for the treatment of RA in 2005 and the improvement of symptoms thorough the use concomitant with disease modifying antirheumatic drugs (DMARDs), including MTX has been reported1 2. On the other hand, the efficacy and tolerance of biological agents therapy concomitant with TAC are unknown.

Objectives:

The objective of this study was to investigate the efficacy and tolerance of biological agents concomitant with TAC in Japanese patients with RA using retention rate analysis.

Methods:

Total patients (n=2860) who underwent 5 biological agents (etanercept: ETN, adalimumab: ADA, golimumab:GLM, tocilizumab: TCZ, abatacept: ABT) treatment between 2003 and 2017 at Nagoya University Hospital and 12 other institutes (Tsurumai Biologics Communication Study Group) were enrolled3. In each biologics analysis, patients were divided into three groups: (1) concomitant only MTX (MTX group) (2) concomitant only TAC (TAC group) (3) others (others group). In TAC or MTX group, these drugs were only ones which concomitant with biologics. Kaplan-Meier analysis was used to estimate retention rate in each biologics group. To estimate the tolerance of concomitant biologics with TAC, cumulative hazard function in adverse events rate was performed in each biologics group. In both analyses, hazard ratios (HR) were assessed by Cox proportional hazards modeling adjusted for age, sex, disease duration and previously used biologics.

Results:

In total 2860 patients, 142 patients (5.0%) administered each biologics concomitant with TAC (ETN: n=47, ADA: n=10 GLM: n=14, TCZ: n=27, ABT: n=49). Baseline characteristics of 142 patients were shown in table 1. Average dosages of TAC at starting were ETN: 2.2±0.7mg ADA: 2.4±1.0mg GLM: 1.9±1.0mg TCZ: 1.7±0.9mg ABT: 1.9±0.9mg. With comparison of retention rate between 3 groups in each biologics under analysis of cox proportional hazard modeling, in ETN and ABT analysis, the retention rate of TAC group was higher than others group (table 2, figure 1). Comparison of incidence of adverse event between 3 group using cumulative hazard function and cox proportional hazard modeling in ETN and ABT analysis. In ETN analysis, incident rate of other group was higher than TAC group. In ABT analysis, there was no significant difference between 3 gruops (figure 2).

Table 1.Baseline characteristic (n=142)age (years)63 ± 3gendermale33 (23%)female109 (77%)disease duration (years)12.0 ± 7.8stage1,234 (24%)3,4108 (76%)class1,299 (70%)3,443 (30%)naïve vs switchnaïve71 (50%)switch71 (50%)corticosteroid use, no (%)+98 (75%)-32 (25%)corticosteroid dose (mg)5.6 ± 3.2DAS28-ESR4.71 ± 1.55Table 2.HR (95%CI)/p-valuen (MTX/TAC/others)ETNADAGLMTCZABT(774/ 47/ 486)(339/ 10/ 135)(156/ 14/ 61)(272/ 27/ 207)(213/ 49/ 178)TAC vs others0.27 (0.16-0.45)<0.0010.9 (0.37-2.20)ns0.46 (0.13-1.63)ns0.55 (0.24-1.31)ns0.51 (0.26-0.97)<0.05TAC vs MTX0.65 (0.38-1.08)ns1.42 (0.61-3.31)ns0.83 (0.24-2.87)ns0.5 (0.21-1.17)ns0.74 (0.39-1.42)nsMTX vs others0.42 (0.35-0.50)<0.0010.9 (0.50-0.88)<0.0010.56 (0.33-0.96)<0.051.01 (0.78-1.57)ns0.68 (0.46-0.99)<0.05

Bold italic: p<0.05CI: confidence interval ns: not significant

Conclusion:

We suspected that, in ETN and ABT treatment, combination therapy with TAC are subsequent options for treatment to RA patients, especially in whom MTX cannot be administration.

References:

[1]Kino T, et al. Antibiot. 1987 Sep 40(9): 1256-65

[2]Kondo H, et al. J Rheumatol. 2004 Feb;31(2):243-51

[3]Kojima T, et al. Mod Rheumatol. 2011 Sep 3.

Disclosure of Interests:

KENYA TERABE: None declared, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Atsushi Kaneko Speakers bureau: Abbvie, Asahi-Kasei, Astellas, Bristol-Myers Squibb, Chugai, Eisai, Eli Lily, Mitsubishi-Tanabe, Pfizer, and UCB Japan, Yuji Hirano Speakers bureau: Tanabe-Mitsubishi, Pfizer, Eisai, Abbie, Chugai, Bristol-Meyers, Jansen, Astellas, UCB, Eli-Lilly, Asahikasei, Daiichi-Sankyo, Amgen, Yasuhide Kanayama: None declared, Yuichiro Yabe Speakers bureau: Asahi Kasei, Janssen, and Mitsubishi Tanabe, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

SAT0156 EFFECTIVE OF BARICITINIB ON RADIOGRAPHIC PROGRESSION OF STRUCTURAL JOINT DAMAGE AT 48 WEEKS IN PATIENTS WITH RHEUMATOID ARTHRITIS IN REAL-WORLD MULTICENTER CLINICAL DATA

Background:

Baricitinib (bari) is an oral Janus kinase 1 (JAK1)/JAK2 selective inhibitor that has demonstrated good efficacy in patients with rheumatoid arthritis (RA) and adequate response to conventional synthetic (cs) DMARDs in some clinical trials [1,2]. We report the efficacy and safety of bari within 24 weeks in real-world clinical data at EULAR2019.

Objectives:

To evaluate the radiographic progression of structural joint damage at 48 weeks in Japanese patients with RA in real-world multicenter clinical data.

Methods:

We included 53 Japanese patients with RA who showed an inadequate response to csDMARDs or biologic (b) DMARDs. Patients were scheduled to receive a once-daily dose of 4 or 2 mg/day bari as monotherapy or in combination with other csDMARDs. We divided the patients into two groups: those treated with 2 mg/day of bari (2mg-group; n = 27) and those treated with 4 mg/day of bari (4-mg group; n = 26) throughout the observation period. Patients were allowed to decrease their predonisolone and csDMARDs combined with bari treatment if their disease activity improved. First, we evaluated changes in CDAI and HAQ-DI after 48 weeks. Second, we evaluated the change in the van der Heijdge modified total sharp score (ΔmTSS), erosion score (ΔERN), and joint space narrowing score (ΔJSN). In addition, we assessed predictors for suppression of joint destruction at 48 weeks after bari treatment.

Results:

The baseline characteristics of the patients were as summarized in Table 1. There were no significant differences in any items. CDAI scores significantly improved 4 weeks after the treatment. This tendency continued until the final evaluation (Table 2). At 48 weeks, remission and low disease activity rates were 37.0% and 74.1% in the 2-mg group and 38.4% and 76.9% in the 4-mg group, respectively. Structural remission (mTSS ≤ 0.5) was noted in 21 patients (80.8%) and 21 patients (77.8%) in 4-mg group and 2-mg group, respectively (Figure). Mean scores (ΔmTSS, ΔERN, and ΔJSN) of all patients in the 2-mg group and 4-mg groups were (0.26, 0.15, and 0.11), (0.30, 0.17, and 0.13) and (0.23, 0.13, and 0.10), respectively (Figure). There were no significant differences in ΔmTSS scores between the two groups. A matrix metalloproteinase-3 score within the standard value at 12 weeks after the treatment was associated with a predictor for suppression of joint destruction at 48 weeks (logistic regression analysis; odds ratio = 11.6, 95% confidence interval: 1.5–112.4,P= 0.020).

Table 1.

Characteristics of patients at baricitinib initiation

2mg-group (n=27)4mg-group (n=26)p-valueAge (years)69.1 (12.0)65.6 (10.3)0.20Gender, female, n (%)19 (73.1)23 (85.2)0.28Disease duration (years),9.7 (10.4)5.7 (7.4)0.23Prior use of biologics, (0/1/2/3)(18/6/2/1)(18/2/5/1)------MTX (mg/week),4.5 (3.7)6.5 (4.29)0.08PSL (mg/day)1.0 (1.9)1.2 (1.8)0.49RF, U/ml254 (372)134 (222)0.21ACPA, U/m152 (176)133 (301)0.45MMP-3196 (220)215 (221)0.43Table 2.

Serial change of clinical assessment

2mg-groupBaseline4 week12 week24 week48 weekCDAI22.5 (9.2)7.4 (7.7)6.7 (6.9)6.9 (6.8)6.9 (6.8)HAQ-DI0.88 (0.51)0.45 (0.47)0.53 (0.58)0.56 (0.56)0.56 (0.56)MMP-3196 (221)98.9 (62.2)115 (164)106 (78)106 (78)4mg-groupBaseline4 week12 week24 week48 weekCDAI24.4 (9.7)9.4 (5.7)8.6 (6.3)6.7 (8.6)6.8 (8.6)HAQ-DI1.01 (0.51)0.58 (0.48)0.54 (0.60)0.45 (0.49)0.44 (0.45)MMP-3216 (222)99 (62)101 (123)89 (72)95 (81)

Conclusion:

The data showed that bari has a favorable effect on the radiographic progression of structural joint damage regardless of its dose in a real-world clinical setting. In consideration of the risk/benefit balance, we suggest that the dose of bari could be reduced in patients with favorable disease activity.

References:

[1]Tanaka Y et al. Mod Rheumatol. 2018;28:583-91

[2]Tanaka Y et al. Mod Rheumatol. 2018;28:20-9

Disclosure of Interests:

Eiji Torikai: None declared, Yuji Hirano Speakers bureau: Tanabe-Mitsubishi, Pfizer, Eisai, Abbie, Chugai, Bristol-Meyers, Jansen, Astellas, UCB, Eli-Lilly, Asahikasei, Daiichi-Sankyo, Amgen, Daisuke Suzuki: None declared, Yasuhide Kanayama: None declared

THU0171 EFFICACY OF ABATACEPT FOR SUPPRESSING RADIOGRAPHIC PROGRESSION OF CERVICAL LESIONS IN PATIENTS WITH RHEUMATOID ARTHRITIS COMPARISON WITH METHOTREXATE TREATMENT; TWO YEARS OF FOLLOW-UP ~A MULTICENTER REGISTRY STUDY ~

Background:

Cervical lesions are known to occur at high frequency as a complication of rheumatoid arthritis (RA). Treatment with biological agents are more clinically effective than the DMARDs that were in use previously, in particular, with their efficacy in suppressing joint destruction having been emphasized. We reported the efficacy of infliximab, anti-tumor necrosis factor antibodies for suppressing the radiographic progression of RA cervical lesions at ACR2009, EULAR2010, 11, 12, 13, 14,16 and 18. However there is still few studies of efficacy of against RA cervical lesions of Abatacept (ABT) that inhibits T cell activation by binding to CD80/86.

Objectives:

To evaluate the efficacy of ABT for suppressing the radiographic progression of RA cervical lesions comparison with MTX for 2 years.

Methods:

We used ABT or MTX for treating Japanese patients with active RA who fulfilled the ACR criteria in 1987. The final study cohort of each 60 and 75 patients received continuous ABT and MTX treatment for at least 2 years. For evaluation of cervical lesions, the atlanto-dental interval (ADI), the space available for the spinal cord (SAC), and the Ranawat value were measured by plain lateral radiographs in the flexion position, at initiation and Year 1,2.

Results:

In the patients receiving ABT (n=60) and MTX (n =75), the number of female were each 48(80%) and 52(69%) cases(p=0.160). The mean age was 67.7 ± 12.9 and 63.6 ± 11.0 years old (p=0.004); disease duration was 16.7 ± 14.2 and 8.0 ± 9.5 years (p<0.001) and the mean dose of MTX was 8.4 ± 3.6 and 8.2 ± 2.9 mg/w (p=0.804). Clinical findings related to RA were as follows; CRP 2.2± 2.1 and 1.7± 2.3 mg/dl(p=0.008); ESR 47.2 ± 23.4 and 31.9 ± 21.8mm/h(p<0.001); MMP3 253 ± 280 and 223 ± 350ng/ml(p=0.003); the number of RF-positive 57(95%) and 60(80%) cases(p=0.011); DAS28-ESR 5.13 ± 0.99 and 4.30 ± 1.38 (p<0.001); ADI 3.6 ± 2.1 and 2.6 ± 1.6mm(p=0.003); SAC 18.5 ± 2.8 and 20.8 ± 2.5mm(p<0.001) and Ranawat value 14.4 ± 1.9 and 16.0 ± 1.5mm (p<0.001). The respective changes in cervical lesion parameters after 1 year were as follows: ADI: 0.20 ± 0.40 and 0.27 ± 0.45 mm (p = 0.367); SAC: −0.12 ± 0.32 and −0.17 ± 0.38 mm (p = 0.359); and Ranawat value: −0.15 ± 0.36 and −0.13 ± 0.34 mm (p = 0.783). The respective changes in cervical lesion parameters after 2 years were as follows: ADI: 0.35 ± 0.58 and 0.55 ± 0.70 mm (p = 0.099); SAC: −0.25 ± 0.47 and −0.45 ± 0.62 mm (p = 0.047); and Ranawat value: −0.23 ± 0.47 and −0.33 ± 0.55 mm (p = 0.293) in the patients receiving ABT and MTX (Fig. 1). The numbers of patients who did not showed progression in ADI, SAC and Ranawat value were each 42(70%) and 43(57%) cases(p=0.130); 46(77%) and 46(61%) cases(p=0.057) and 47(78%) and 53(71%) cases(p=0.313) after 2 years. Also the number who was able to suppress progression in all three parameters were each 42 cases (70%) receiving ABT and 43 cases (57%) receiving MTX (p=0.130) after 2 years (Fig. 2).

Conclusion:

This study suggested that ABT treatment can be used to suppress the progression of RA cervical lesions more than MTX treatment.

Disclosure of Interests:

Yasuhide Kanayama: None declared, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Yuji Hirano Speakers bureau: Tanabe-Mitsubishi, Pfizer, Eisai, Abbie, Chugai, Bristol-Meyers, Jansen, Astellas, UCB, Eli-Lilly, Asahikasei, Daiichi-Sankyo, Amgen, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Yukiyoshi Oishi: None declared, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

FRI0137 Discontinuation of baricitinib after achieving low disease activity in patients with rheumatoid arthritis in clinical practice; a multicenter observational study

Background:

Baricitinib (bari) is an oral Janus kinase (JAK) 1/JAK2 selective inhibitor that has shown good efficacy in patients with RA and adequate response to conventional synthetic DMARDs in some clinical trials [1,2]. However, concerning the high cost and long-term safety related to the inhibition of particular molecules, we would like to discontinue bari after achieving long low disease activity (LDA).

Objectives:

To evaluate the clinical outcomes in patients with RA who discontinued bari after achieving LDA for 24 weeks in real-world multicenter clinical data.

Methods:

Japanese 67 patients with RA who show an inadequate response to csDMARDs or bDMARDs were scheduled to receive bari 4 or 2 mg/day once daily dose as a monotherapy or in combination with other csDMARDs. We included 51 patients who achieved and maintained LDA at least for 24 weeks after baricitinib therapy. They were allowed to decrease baricitinib after discontinuation of prednisolone. Bari was either discontinued or continued after study enrolment. The decision of discontinuation and continuation of baricitinib was determined based on patient-physician decision making with informed consent. We divided patients into two groups: a discontinuation group (D group; n = 23) and a continuation group (C group; n = 28). We evaluated the proportion of patients who remained LDA for 24 weeks in both groups. Clinical outcomes including Clinical Disease Activity Index (CDAI), and HAQ-DI were compared between both groups. The last observational carried forward method was used for patients who could not discontinue baricitinib due to flare before 24 weeks. In D group, patients were treated with re-initiation of bari or initiation of the other DMARDs in the event of flare. We investigated the serial changes of patients treated with re-initiation of bari in CDAI after flare.

Results:

The baseline characteristics of the patients are summarized in Table. The titer of RF was lower in D group than that in C group. There were no significant differences in any other items. Ten of 23 (43.4%) in D group remained bari-free without disease activity flare. Serial changes of CDAI were summarized in Figure. CDAI in D group significantly increased from 3.6 at baseline to 9.8 at last observation. LDA rates in C group were 92.9% at last observation. CDAI in C group did not change throughout the follow-up period. CDAI at last observation was higher in D group than that in C group. HAQ-DI in D group changed from 0.28 at baseline to 0.45 at last observation. There was no significant change in HAQ-DI between both groups (P = 0.28). In D group, rescue by re-administration of bari or other DMARDs induced improvement, reducing CDAI from 15.5 at disease flare to 6.8. Especially, all patients treated with re-initiation of bari resulted in re-introduction of LDA in this study.

Table.

Characteristics of patients at baricitinib initiation

D group (n=23)C group (n=28)p-valueAge (years)66.9 (8.6)67.9 (12.7)0.31Gender, female, n (%)6 (73.9)24 (85.7)0.49Disease duration (years)7.6 (10.3)8.3 (9.9)0.37Prior use of biologics, n (0/1/2/≥3)(21/2/0/0)(17/6/4/1)------MTX (mg/w)5.5 (3.8)4.9 (4.3)0.62PSL (mg/d)1.4 (1.9)0.9 (0.9)0.51RF, U/ml99 (141)187 (214)0.04ACPA, U/ml135 (173)194 (214)0.11CDAI24.4 (9.2)22.5 (9.7)0.36HAQ-DI0.83 (0.49)0.83 (0.52)0.98

Conclusion:

It was possible to discontinue bari without flare in about 43% of patients with RA. Overall the patients treated with re-initiation of bari could result in re-introduction of LDA without deterioration of HAQ-DI.

References:

[1]Tanaka Y et al. Mod Rheumatol. 2018;28:583-91

[2]Tanaka Y et al. Mod Rheumatol. 2018;28:20-9

Disclosure of Interests:

Eiji Torikai: None declared, Yuji Hirano Speakers bureau: Tanabe-Mitsubishi, Pfizer, Eisai, Abbie, Chugai, Bristol-Meyers, Jansen, Astellas, UCB, Eli-Lilly, Asahikasei, Daiichi-Sankyo, Amgen, Daisuke Suzuki: None declared, Yasuhide Kanayama: None declared

Long-term effects of calcium antagonists and angiotensin-converting enzyme inhibitors in patients with chronic renal failure of IgA nephropathy

Long-term effects of Ca antagonist and ACE inhibitor on renal function in hypertensive patients with chronic renal failure of IgA nephropathy were studied. Both Ca antagonists and ACE inhibitors were equally effective in reducing blood pressure.

Overexpression of the Arabidopsis thaliana EDS5 gene enhances resistance to viruses

The Arabidopsis thaliana ENHANCED DISEASE SUSCEPTIBILITY 5 gene (EDS5) is required for salicylic acid (SA) synthesis in pathogen-challenged plants. SA and EDS5 have an important role in the Arabidopsis RCY1 gene-conferred resistance against the yellow strain of Cucumber mosaic virus [CMV(Y)], a Bromoviridae, and HRT-conferred resistance against the Tombusviridae, Turnip crinkle virus (TCV). EDS5 expression and SA accumulation are induced in response to CMV(Y) inoculation in the RCY1-bearing ecotype C24. To further discern the involvement of EDS5 in Arabidopsis defence against viruses, we overexpressed the EDS5 transcript from the constitutively expressed Cauliflower mosaic virus 35S gene promoter in ecotype C24. In comparison to the non-transgenic control, the basal level of salicylic acid (SA) was twofold higher in the 35S:EDS5 plant. Furthermore, viral spread and the size of the hypersensitive response associated necrotic local lesions (NLL) were more highly restricted in CMV(Y)-inoculated 35S:EDS5 than in the non-transgenic plant. The heightened restriction of CMV(Y) spread was paralleled by more rapid induction of the pathogenesis-related gene, PR-1, in the CMV(Y)-inoculated 35S:EDS5 plant. The 35S:EDS5 plant also had heightened resistance to the virulent CMV strain, CMV(B2), and TCV. These results suggest that, in addition to R gene-mediated gene-for-gene resistance, EDS5 is also important for basal resistance to viruses. However, while expression of the Pseudomonas putida nahG gene, which encodes the SA-degrading salicylate hydroxylase, completely suppressed 35S:EDS5-conferred resistance against CMV(Y) and TCV, it only partially compromised resistance against CMV(B2), indicating that SA-dependent and -independent mechanisms are associated with 35S:EDS5-conferred resistance against viruses.