POS1416 LONG-TERM OUTCOME OF SYSTEMIC LUPUS ERYTHEMATOSUS (SLE); DATA FROM THE LARGE POPULATION-BASED SOUTHEAST SLE COHORT (Nor-SLE)

Background

Population-based studies on Systemic Lupus Erythematosus (SLE) patients with a verified diagnosis is considered the gold standard to find true outcomes in SLE, but few population-based SLE cohorts have follow-up over 15 years [1]. Norway is among the few countries worldwide where social and structural factors facilitate the gathering of complete population-based cohorts in rare disease like SLE due to its healthcare organization.

Objectives

To examine long-term outcome of SLE in a population-based setting and determine if immediate cause of death differs between SLE patients and the general population.

Methods

The study included all SLE patients who were resident in the Southeast region of Norway during 1999 - 2017 and met the 1997 American College of Rheumatology classification criteria for SLE. All SLE diagnosis was confirmed by chart review. SLE patients and 15 controls for each case (matched by age, gender and ethnicity) were linked to the Norwegian Cause of Death Registry. We examined survival by means of Kaplan-Meyer estimates and used log rank test to test for differences. To estimate risk of death, we performed calculations of standard mortality rate (SMR) by dividing the number of deaths on the number of years observed. The excepted number of deaths referred to the number of deaths for the matched control group. All SLE cases were included in SMR. The 95 % confidence interval (CI) of SMR was calculated with Mid-P exact test. We defined immediate cause of death as the final event directly leading to death. An International Classification of Diseases 10th revision code of I00-99 or R96 classified as death from cardiovascular disease (CVD) (except pulmonary embolism and cerebral bleeding) and of infections A00-B99, J10-18, N39, M86 or U07.

Results

We identified 1298 SLE patients in the region, of whom 673 was incident cases; all captures within one year from diagnosis. Of the incident cases, 76 (11%) died during 8434 years of follow-up (Table 1). The five-, ten-, 15- and 20-year survival for incident SLE patients (controls) was respectively 98 (98), 94 (96), 87 (94) and 82 (88) % and differed significantly first after ten years of disease duration compared to controls. Figure 1 shows 20-year survival for incident SLE patients and matched controls; stratified by gender. SMR for all SLE cases was 2.3 (95 % CI 1.5. - 4.0); female SLE 2.5 (95 % CI 1.6 – 3.9) and male SLE 1.9 (95 % CI 1.3 – 2.2). The most common immediate cause of death in SLE patients was CVD; whereof myocardial infarction (21 %) was most frequent. SLE patients died more often of CVD than controls (29 % vs. 21 %, p = 0.01) and had a tendency to more infections (23 % vs. 18 %, p = 0.07), whereof pneumonia (58 %) was most frequent.

Table 1.

Patient demographics, follow-up time and number of deaths in the total Systemic Lupus Erythematosus (SLE) cohort and in incident SLE patients.

Total SLE cohortIncident SLEFemaleMalen = 1298n = 577n = 96Of European descent, n (%)1140 (88)472 (82)86 (90)Juvenile onseta, n (%)93 (7)31 (5)6 (6)LNb, n (%)470 (36)177 (30)49 (51)Cumulative ACR criteriac, µ (SD)5.4 (1.2)5.3 (1.2)5.1(1.1)Follow-up years, total1925261601217Deaths, n (%)282 (23)54 (9)22 (23)Age at diagnosis, years µ (SD)35.5 (15.7)37.4 (15.6)44 (17.9)Disease duration at death, years µ (SD)20.4 (12.5)9.6 (5.8)10.6 (10.5)

µ: mean, n: number, SD: standard deviation

a Diagnosed before age of 16 b Lupus Nephritis defined by 1999 American College of Rheumatology classification criteria for Systemic Lupus Erythematosus c1997 American Collee of Rheumatology classification criteria for Systemic Lupus Erythematosus

Conclusion

Mortality in SLE is substantially increased. Differences in survival compared to the general population only appear after ten years of disease duration. CVD was the most common immediate cause of death and more frequent in SLE patients.

References

[1]Reppe Moe, S., Haukeland, H., Molberg, Ø., & Lerang, K. (2021). Long-Term Outcome in Systemic Lupus Erythematosus; Knowledge from Population-Based Cohorts. J Clin Med, 10(19). doi:10.3390/jcm10194306

Disclosure of Interests

None declared

AB0597 FDG-PET/CT IN THE DIAGNOSE AND FOLLOW UP OF TAKAYASU VASCULITIS

Background

Takayasu vasculitis (TAK) is a chronic disease, where clinic and serological markers as CRP/ESR may fail to predict development of new vascular lesions in the disease course (1). Similarly, 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) studies show conflicting results on the association between vessel uptake of FDG and clinical and laboratory finding. A study on new FDG-PET activity scoring system, PETVAS was newly published but has not been validated in other cohorts (2). To date there are limited data on FDG-PET/CT finding at time of diagnoses before treatment induction and 18-FDG uptake and development of new stenosis during follow up.

Objectives

The goal of this study was to see; 1) FDG-PET/CT uptake in newly diagnosed patients before any treatment start 2) FDG-PET/CT uptake and development of new vascular lesions during follow up magnetic resonance angiography (MRA) 3) assess PETVAS score before and after treatment induction.

Methods

All patients in a population-based TAK cohort with FDG-PET/CT at the time of diagnoses before treatment induction were identified. Disease activity was assessed with the NIH activity score (1). Patients had to have clinical, laboratory and MR-angiography prior to/or right after FDG-PET/CT and a minimum of one follow up MRA. The clinical report from the FDG-PET/CT and MRA were reviewed and arteries/aorta regions with reported pathological uptake and stenosis/aneurysm were registrated. Images were reviewed and uptakes in 16 arteries/aorta regions of interest (supraaortic arteries, aorta, iliaca and femoral arteries) scored from 0-3, where 0 represent no uptake, 1 less then liver, 2 same as liver and 3 higher than liver and finally summarized these to PETVAS score.

Results

Twenty-three patients fulfilled the study’s inclusion criteria. Twenty-one of the patients were females (91%) and twenty-two were European Caucasian. The mean age was 39.3 (SD 14) at the time of diagnose (Table 1). Five patients were in clinical and laboratory remission at diagnose (NIH=0). Correspondently, none of them had sign of active FDG vessel uptake at PET-CT. They had a median 7 in PETVAS (range 0-13). The remaining 17 patients had clinical active disease (NIH>1) at diagnoses. All 17 patients had uptake on PET/CT in at least one artery/aorta region. The mean PETVAS score at diagnosis was 21.5 (SD 8). At last imaging the patients had developed median 2 new lesions. All the arteries that developed new lesion had active uptake on the original PET/CT. Fourteen patients had FDG PET/CT after treatment start. The PETVAS score decreased from 22.4 (SD 8.7) to 10.7 (SD 6.8) after treatment start (p<0.001).

Table 1.PatientAge at pet 1NIH 0-4CrpPETVAS1PETVAS 2Treatment at PET211512016264233169predn 10 mg, mtx 15 mg3263207180predn 15 mg, INF434313187predn 2.5 mg, mtx 20 mg, INF54033173213predn 10 mg, mtx 156483122216predn 5 mg, mtx 207553593720predn 10 mg, mtx 1585431823525predn 5 mg, mtx 15921419133predn 5 mg, mtx 2010364145184predn 7.5 mg, mtx 17.5 mg1127433147predn 5 mg, mtx 22.5123947157predn 10 mg, mtx 22.5 mg13314752111predn 10 mg, mtx 25, INF14394802416predn 7.5 mg, mtx 20 mg156341063516predn 10 mg, mtx 2016224120201727426321

Conclusion

All patients with clinical active disease at diagnoses had pathological FDG uptake. Only arteries with increased FDG uptake in the vascular wall subsequently developed new lesion. The study also showed that the PETVAS score fell significantly after treatment induction.

References

[1]Kerr GS, Hallahan CW, Giordano J, Leavitt RY, Fauci AS, Rottem M, et al. Takayasu arteritis. Annals of internal medicine. 1994;120(11):919-29. Epub 1994/06/01.

[2]Grayson PC, Alehashemi S, Bagheri AA, Civelek AC, Cupps TR, Kaplan MJ, et al. (18) F-Fluorodeoxyglucose-Positron Emission Tomography As an Imaging Biomarker in a Prospective, Longitudinal Cohort of Patients With Large Vessel Vasculitis. Arthritis & rheumatology (Hoboken, NJ). 2018;70(3):439-49. Epub 2017/11/18.

Disclosure of Interests

None declared

POS0925 HIGH LEVELS OF BOTH CCL2 AND CCL17 WERE ASSOCIATED WITH MORE SEVERE SSc-ILD

Background

Systemic sclerosis (SSc) carries a high risk for progressive interstitial lung disease (ILD). Several anti-inflammatory therapies have been used to treat SSc-ILD and recently the first antifibrotic therapy has been approved. Personalized treatment strategies are largely missing to date. The two chemokines, CCL2 (MCP-1) and CCL17 (TARC), have been shown to be markers of inflammation and fibrosis, respectively.

Objectives

To examine associations between ILD severity and serum levels of CCL2 and CCL17 in two different but complementary sources of biomaterial.

Methods

Sera from the prospective Oslo University Hospital SSc cohort (n=371) and healthy blood donor controls (HC; n=100) and lung tissue at the time of lung transplantation from UCLA SSc-ILD patients (n = 12) and healthy donors (n = 12) were analyzed for CCL2 and CCL17 by multiplex assays. CCL2 and CCL17 levels were defined in serum as high or low using 95% CI in HC sera as cut-off values. Paired pulmonary function tests and HRCT images were obtained at baseline and follow-up. ILD was diagnosed on HRCT and categorized by the extent of lung fibrosis as limited (<10%) or extensive (>10%) ILD. Cellular sources of CCL-2 and CCL-17 in lung tissues were determined by immunohistochemistry. Descriptive statistics were applied.

Results

CCL2 and CCL17 were increased in SSc in sera and in lung tissue compared to HC (Figure 1). High levels of CCL17 (>700 pg/ml) and CCL2 (>1000pg/ml) in sera were identified in 43/254 (17%) and 84/471(18%) of the SSc patients (Table 1 and Figure 1). High levels of both CCL17 and CCL2 were associated with lower FVC at baseline and higher extent of lung fibrosis on HRCT (Table 1). Of those with high CCL2 and CCL17, 67% had extensive lung fibrosis. Categorization of ILD into no ILD, limited or extensive ILD showed an association between high CCL17 levels and the extent of fibrosis (Table 1). Reactive epithelium and macrophages and plasma cells expressed TARC, while more AM and infiltrating mononuclear cells expressed CCL-2.

Conclusion

High levels of both CCL17 and CCL2 were associated with more severe ILD and expressed in end-stage kung tissue and may reflect an ongoing inflammatory and fibrotic processes in SSc-ILD. This may have an implication on treatment choices for SSc-ILD.

Disclosure of Interests

Imon Barua: None declared, Vyacheslav Palchevskiy: None declared, Håvard Fretheim Shareholder of: non-financial support from GSK and

Actelion, outside the submitted work.,, Consultant of: Consultant of: Personal fees from Bayer and non-financial support from GSK and Actelion, outside the submitted work.,, Henriette Didriksen: None declared, Torhild Garen: None declared, Trond Mogens Aaløkken: None declared, Stephen Samuel Weigt: None declared, Øyvind Molberg: None declared, John Belperio: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche,, Consultant of: Actelion, ARXX therapeutics, Bayer, Janssen,, MSD, Lilly, Roche, Boehringer-Ingelheim, Medscape.,,, Grant/research support from: Boehringer Ingelheim

POS0065 INTERSTITIAL LUNG DISEASE ASSOCIATED WITH PRIMARY SJÖGREN’S SYNDROME IS FREQUENTLY PROGRESSIVE

Background

Interstitial lung disease (ILD) in primary Sjögren’s syndrome (pSS) has been reported to be present in 10-15% of patients, but pSS-ILD behavior over time is not well characterized.

Objectives

Assess the pattern of ILD in pSS, its disease behavior and factors associated with disease progression in a well-characterized pSS-ILD cohort.

Methods

All pSS patients from the Oslo University Hospital (OUH) were included if ILD was diagnosed on HRCT. Clinical characteristics, lung function tests including forced vital capacity (FVC) and diffusing capacity for carbon monoxide (DLCO) and ILD pattern on HRCT assessed by a radiologist were evaluated. We determined ILD progression, defined as absolute FVC decline >5% or absolute DLCO decline >10% over 12 +/-6 months and increasing extent of ILD on HRCT over the observation period. Factors associated with disease progression were chosen based on expert opinion. Descriptive analyses were conducted

Results

Of 702 pSS patients followed at OUH, we identified 60 pSS patients with ILD with 33 (55%) having follow-up at 12 months (Table 1). Patients with pSS-ILD were characterized by high number of males (18%) and by frequent other extra-pulmonary organ involvement (48%) (Table 1). Mean time from pSS diagnosis to ILD diagnosis was 7.4 years. In 67% ILD was diagnosed after pSS, in 13% simultaneously, in 11% before pSS diagnosis and in 9% unknown. In total, 28 (47%) were diagnosed with lymphocytic interstitial pneumonia (LIP) and 32 (53%) with reticular pattern on HRCT. Over mean follow-up of 10.9 months (SD 4.2), 7/33 (21%) showed a FVC >5% decline, 9/32 (28%) a DLCO >10% decline and 12 (36%) had at least one of these defined lung function declines on standard of care treatment. Treatment was registered as ever used and by any indication. Over an observation period of 15.4 (SD 10.6) years, 27/47 (45%) showed any ILD progression on HRCT. HRCT pattern was not associated with risk of >10% DLCO decline or ILD progression on HCRT. >5% FVC decline occurred more frequently in patients with reticular pattern compared to LIP (6/17 (35%) vs 1/16 (6%), p=0.041). Factors significantly associated with ILD progression on lung function included higher baseline FVC (99% (SD16.4) vs 87% (SD14.9), p=0.032), higher DLCO (81% (SD13.1) vs 67% (SD17.4), p=0.020), increased CRP (2/10 (20%) vs 0/16 (0%), p=0.045) and presence of polyneuropathy (2/9 (22%) vs 1/17 (6%), p=0.045).

Table 1.

Clinical characteristics, demographics and outcome of pSS with ILD

pSS-ILD(n=60)Age at pSS diagnosis, y (SD)50 (21.9)Time from pSS to ILD diagnosis, y (SD)7.4 (8.9)Male sex, n (%)11 (18)Anti-SSA AB, n/50 (%)46 (92)Increased CRP, n/47 (%)7 (15)Low complements, n/49 (%)5 (10)Extra-pulmonary involvement, n/46 (%)22 (48)Deceased, n (%)10 (17)Pulmonary involvementFVC% predicted (SD)91 (18.7)FVC decline>5%, n/33 (%)7 (21)DLCO% predicted (SD)70 (20.7)DLCO decline >10%, n/32 (%)9 (32)ILD progression on HRCT, n/47 (%)27 (45)Treatment during follow upRituximab, n (%)11 (18)Any other immunosuppressive, n (%)20 (33)Hydroxychloroquine, n (%)16 (27)Nintedanib, n (%)1 (2)Lung transplant, n (%)1 (2)

Conclusion

A substantial number of patients with pSS-ILD progressed during the time of observation. This highlights the importance of close monitoring and active consideration of treatment options in pSS-ILD. Recommendations for disease management including screening, diagnosis, disease monitoring and treatment for pulmonary involvement in pSS are lacking to date, but are highly needed.

Disclosure of Interests

Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Håvard Fretheim Consultant of: Bayer, Grant/research support from: Jansen, Phuong Phuong Diep Speakers bureau: Boehringer Ingelheim, Karoline Lerang: None declared, Helena Andersson: None declared, Øyvind Midtvedt: None declared, Torhild Garen: None declared, Mike Durheim Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim and Roche, Grant/research support from: Boehringer Ingelheim and Roche, Trond M Aaløkken Speakers bureau: Boehringer Ingelheim, Øyvind Palm: None declared, Øyvind Molberg: None declared

POS0215 PHENOTYPES AND DISEASE CHARACTERISTICS OF IgG4-RELATED DISEASE IN NORWAY

Background

Milestones in the field of IgG4-related disease (IgG4-RD) include the 2011 Comprehensive Diagnostic Criteria (CDC) (1), the 2019 ACR/EULAR classification criteria (2), and the recent identification of four distinct clinical phenotypes (3). Performance of the criteria and phenotypic disease expression in Scandinavian populations are largely unknown.

Objectives

Describe disease characteristics, phenotypes, and performance of the 2011 CDC and 2019 ACR/EULAR classification criteria in patients with IgG4-RD in Norway.

Methods

Consenting, adult patients with a clinical diagnosis of IgG4-RD, seen at the Department of Rheumatology, Oslo University Hospital were included. Two experts (JV, ØMi) assigned patients to phenotypes (”Pancreato-Hepato-Biliary”, “Retroperitoneum and Aorta”, “Head and Neck-Limited” or “Mikulicz and Systemic”) based on pattern of organ involvement. Fulfillment of the CDC and classification criteria were assessed. Disease activity and damage were scored with the IgG4-RD responder index (IgG4-RD RI). We used descriptive statistics.

Results

We identified 60 patients with IgG4-RD (Table 1). Clinical characteristics were as expected, with approximately equal number of patients in each phenotype group. Of all patients diagnosed by expert opinion, 42 (70%) fulfilled the ACR/EULAR classification criteria. Reasons for not fulfilling the criteria were (i) failure to meet the inclusion criterium (n = 3) due to “atypical” organ involvement: tonsils (n = 1), nasal cavity (n = 1); coronary artery (n = 1); (ii) presence of ≥ 1 exclusion criterium (n = 5): fever (n = 1), leukopenia (n = 1), thrombocytopenia (n = 1), positive anti-MPO-ANCA (n = 3), anti-SSA (n = 1) and/or anti-RNP (n = 1) antibody; and (iii) score < 20 points (n = 10). In the latter group, 8 (80%) were not biopsied, and 1 (10%) had only performed fine needle biopsy. Among the patients not meeting the inclusion criterium or having ≥ 1 exclusion criteria, 1 (33%) and 4 (80%) scored ≥ 20 points, respectively. Of all patients, 56 (93%) fulfilled CDC, with 32 (53%), 10 (17%) and 14 (23%) patients characterized as “definite”, “probable” and “possible” IgG4-RD, respectively. Of the 18 patients not fulfilling the ACR/EULAR classification criteria, 15 (83%) fulfilled CDC (4 “definite”, 3 “probable”, 8 “possible”). Of the 4 patients not fulfilling CDC, 1 fulfilled the ACR/EULAR classification criteria.

Table 1.All (60)Pancreato-Hepato-Biliary (14)Retroperitoneum and aorta (12)Head and Neck-Limited (17)Mikulicz and Systemic (17)Male, n (%)44 (73)11 (79)9 (75)10 (59)14 (82)Caucasian, n (%)52 (87)14 (100)11 (92)13 (77)14 (82)Age at diagnosis, years (SD)60 (14)66 (9)64 (10)50* (17)61 (11)Time from onset to diagnosis, years (SD)2 (3)2 (3)2 (4)1 (1)4 (5)Serum IgG4, g/L (SD) (n=51)8 (9)5 (5)3 (2)7 (5)16* (13)Elevated baseline serum IgG4, n (%) (n=51)44 (86)9 (69)10 (91)11 (92)14 (93)CRP, mg/dL (SD)11 (26)4 (7)36* (52)9 (17)5 (4)ESR, mm/h (SD)35 (32)16 (11)63* (36)29 (29)39 (30)Eosinophilia, n (%) (n=46)17 (37)2 (22)06 (38)9 (64)CDC definite, n (%)32 (53)10 (71)3 (25)8 (47)11 (65)CDC probable, n (%)10 (17)3 (21)1 (8)5 (29)1 (6)CDC possible, n (%)14 (23)06 (50)4 (24)4 (24)ACR/EULAR classification criteria, n (%)42 (70)13 (93)5 (42)8 (47)16 (94)Number of involved organs (SD)Active, all4 (2)3 (2)2 (2)3 (1)6* (2)Active, symptoms2 (1)2 (1)1 (0)2 (1)3* (1)Active, urgent1 (1)1 (1)1 (1)0* (0)1 (1)Damage2 (1)2* (1)1 (1)1 (1)2* (2)IgG4-RD RI (SD)10 (5)9 (4)7 (4)7 (3)15* (4)

*p < 0,05 by one-way ANOVA

Conclusion

Despite expected clinical characteristics, phenotype distribution and fulfilment of CDC in our cohort, the performance of the ACR/EULAR classification criteria was lower than expected, especially in the “Retroperitoneum and Aorta” and “Head and Neck-Limited” phenotypes. This may have important implications for the comparability across studies and inclusion in future clinical trials.

References

[1]Umehara et al. Mod Rheumatol. 2012;22(1):21-30.

[2]Wallace et al. Ann Rheum Dis. 2020;79(1):77-87.

[3]Wallace et al. Ann Rheum Dis. 2019;78(3):406-412

Disclosure of Interests

Jens Vikse Speakers bureau: Novartis, Consultant of: Novartis, Jupiter Life Science Consulting, Øyvind Midtvedt: None declared, Øyvind Molberg: None declared, Bjørg Tilde Svanes Fevang: None declared, Øyvind Palm: None declared, Torhild Garen: None declared, Katrine Brække Norheim: None declared, Gunnstein Bakland: None declared, Marianne Wallenius: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim

POS1366 RITUXIMAB IN IgG4-RD: AN OPEN-LABEL NON-RANDOMIZED OBSERVATIONAL STUDY

Background

IgG4-related disease (IgG4-RD) is a rare, heterogenous and potentially severe disease. An open-label trial demonstrated efficacy of rituximab (RTX) in IgG4-RD [1]. Recently, four distinct phenotypes of IgG4-RD were identified [2]. There is a paucity of studies investigating RTX efficacy across these phenotypes.

Objectives

Investigate efficacy and safety of RTX in IgG4-RD and segregated by phenotypes.

Methods

This is an open-label non-randomized single center observational study. All patients with IgG4-RD (diagnosed by expert opinion) at the Oslo University Hospital treated with ≥ 1 dose of RTX with 12 months follow-up were included. Two experts (JV, ØMi) assigned patients to phenotypes. Glucocorticoid (GC) treatment was allowed. We measured disease activity by the IgG4-RD Responder Index (IgG4-RD RI) at baseline, 6 months, and 12 months. We defined a composite primary outcome consisting of two measures; (i) reduced disease activity (i.e., ≥2 points improvement in IgG4-RD RI from baseline and/or IgG4-RD RI score 0 at follow-up), and (ii) no disease flares (i.e., no ≥2 points worsening of IgG4-RD RI and no need to increase GC dose) at 6 months. Secondary outcomes were (a) reduced disease activity at months 6 or 12, (b) remission (IgG4-RD RI score 0 and GC dose ≤ 7.5 mg) at 6 or 12 months and (c) safety. Descriptive statistics were applied.

Results

We included 40 patients, of which 30 (75%) were male and 35 (88%) Caucasian. Mean age and disease duration at time of first RTX infusion was 58 and 3 years, respectively. Seventeen of the 40 patients (43%) received RTX as add-on therapy (following GC for > 3 months), while 13 (33%) received RTX as upfront combination therapy with GC, and 10 (25%) received RTX as upfront monotherapy. All 40 patients received an infusion of 1000 mg RTX at study baseline (dose 1A at week 0) and 39 of these 40 patients (98%) received a second RTX infusion (dose 1B) at week 2. Additional infusions of 500-1000 mg RTX were administered at weeks 26 (dose 2A) and 28 (dose 2B) in 24 (60%) and 7 (18%) patients, respectively. The composite primary endpoint was met by 31/40 patients (78%). Reduced disease activity at 6 and 12 months were seen in 34 (87%) and 35 (90%) patients, respectively. Fifteen patients (38%) were in remission at 6 months, and 22 (56%) were in remission at 12 months. “Retroperitoneum and Aorta” showed lowest response rates, while “Head and Neck-Limited” had the highest rate of flares (Table 1). Mild infusion reaction occurred in 8 (20%) patients. Hypogammaglobulinemia was observed in 4 (10%). Infection requiring hospitalization occurred in 6 (15%), including one fatal infection which was the only death in the study period.

Table 1.All40 (100)Pancreato-Hepato-Biliary9 (23)Retroperitoneum and Aorta 6* (15)Head and Neck-Limited 14 (35)Mikulicz and Systemic 11 (28)Baseline (n=40)Male, n (%)30 (75)8 (89)5 (83)8 (57)9 (82)Caucasian (%)35 (88)9 (100)6 (100)12 (86)8 (73)Age, years (SD)58 (14)63 (9)66 (3)49 (18)60 (11)Disease duration, years (SD)3 (4)4 (3)3 (4)2 (2)5 (6)2019 ACR/EULAR classification criteria (%)28 (70)8 (89)3 (50)6 (43)11 (100)IgG4-RD RI at diagnosis (SD)10 (6)10 (5)7 (4)7 (3)17 (4)IgG4-RD RI at RTX 1A, (SD)8 (6)9 (4)5 (4)6 (4)12 (7)6 months (n=39)*IgG4-RD RI (SD)2 (2)3 (3)2 (2)1 (1)1 (2)Primary outcome, n (%) (n=40)31 (78)9 (100)3 (50)9 (64)10 (91)Reduced disease activity, n (%)34 (87)9 (100)3 (60)12 (86)10 (91)Remission, n (%)15 (38)4 (44)06 (43)5 (46)Flare, n (%)3 (8)003 (21)012 months (n=39)*IgG4-RD RI (SD)1 (1)1 (1)0 (1)1 (1)1 (2)Reduced disease activity, n (%)35 (90)9 (100)4 (80)12 (86)10 (91)Remission, n (%)22 (56)7 (78)3 (60)7 (50)5 (45)Flare, n (%)4 (10)1 (11)1 (20)2 (14)0

*One patient died shortly after 1A, and is not included in secondary efficacy outcomes

Conclusion

In our observational study, RTX appears safe and effective in IgG4-RD, with the highest response in patients with Pancreato-Hepato-Biliary phenotype. Relatively low remission rates across all phenotypes indicate an unmet need for improved treatment.

References

[1]Carruthers MN et al. Ann Rheum Dis. 2015;74(6):1171-1177.

[2]Wallace ZS et al. Ann Rheum Dis. 2019;78(3):406-412.

Disclosure of Interests

Jens Vikse Speakers bureau: Novartis, Consultant of: Novartis, Jupiter Life Science Consulting, Øyvind Midtvedt: None declared, Øyvind Molberg: None declared, Bjørg Tilde Svanes Fevang: None declared, Øyvind Palm: None declared, Torhild Garen: None declared, Katrine Brække Norheim: None declared, Gunnstein Bakland: None declared, Marianne Wallenius: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim

POS0867 ALTERATION OF DUODENAL HISTOLOGY IN SYSTEMIC SCLEROSIS PATIENTS AFTER FECAL MICROBIOTA TRANSPLANTATION

Background:

Systemic sclerosis (SSc) is a complex autoimmune, multi-organ disease with gastro-intestinal tract (GIT) involvement significantly contributing to comorbidity. While understanding of mechanisms behind SSc-related GIT disease is incomplete, recent work shows that altered gut microbiota (dysbiosis) is present in many patients and associates with specific GIT symptoms. Intending to improve dysbiosis, we set up the controlled ReSScue pilot trial, where fecal microbiota transplantation (FMT) was conducted by duodenal infusions of Anaerobic Cultivated Human Intestinal Microbiome (ACHIM) or placebo. The results indicated that FMT by ACHIM induced short-term improvement on patient reported GIT symptoms, as evaluated by the validated UCLA GIT score (1). Duodenal biopsies were taken before and after FMT to assess potential effects of ACHIM on small intestinal mucosa.

Objectives:

Assessment of duodenal histology and GIT symptoms before and after FMT by ACHIM compared to placebo.

Methods:

In this explorative study, we assessed duodenal biopsies collected prior to first FMT (week 0), prior to second FMT (week 2) and at study end (week 16) from ReSScue trial patients who either received ACHIM (n=5) or placebo (n=4). To examine potential effects of FMT on the duodenal mucosa, we performed immunohistochemistry (IHC) staining on paraffin-embedded tissue samples using the following markers: Sirius red (SIR) for collagen fibers and monoclonal antibodies against gp38 (podoplanin, as marker for lymphatic vessels and fibroblasts), CD38 (as preliminary marker for adaptive immune cells) and CD64 (as preliminary marker for innate immune cells). We determined staining per area in the individual tissue slides for each marker using ImageJ Fiji. The mean total UCLA GIT score for the patients were calculated at week 0, 2 and 16, as well as the mean staining per area of the duodenum biopsies at week 0, 2 and 6 for all the markers. Finally, correlations between mean staining per area and mean total UCLA GIT score were assessed for ACHIM and placebo patient groups by Pearson correlation (r).

Results:

All nine patients included in the pilot trial were female and had limited cutaneous SSc. Groups receiving ACHIM and placebo had comparable disease duration (1). We found that relative change in staining per area for SIR from week 0 to week 2 differed between the ACHIM group and the placebo group (Figure 1A, left panel). Similar changes were observed for anti-gp38, anti-CD38 and anti-CD64 (left panel in Figures 1B-D). Strong correlations were found between mean total UCLA GIT score and the mean staining per area of the markers SIR (r=0.98), anti-gp38 (r=0.94), anti-CD34 (r=0.85) and CD64 (r=0.93) in the ACHIM group (Figure 1, A-D). In the placebo group, there was no correlation between the UCLA GIT score and anti-gp38 (r=0.22) and anti-CD64 (r=0.21), however, a strong correlation were observed to SIR (r=0.86) and anti-CD38 (r=0.92) staining (Figure 1A-D, right panel).

Conclusion:

This explorative data set indicates different effects of FMT by ACHIM and placebo on the duodenal mucosa of SSc patients with GIT affection. Interestingly, we observed correlations between mucosal markers and improved patient reported GIT symptoms in the ACHIM group.

References:

[1]Fretheim H, Chung BK, Didriksen H, Bækkevold ES, Midtvedt Ø, Brunborg C, et al. Fecal microbiota transplantation in systemic sclerosis: A double-blind, placebo-controlled randomized pilot trial. PLoS One. 2020;15(5):e0232739.

Figure 1.

Relative staining per area in ACHIM and placebo group (left panel) and correlation between total UCLA GIT score and staining ratios at time point 0, 2 and 16 weeks in patients receiving ACHIM and placebo (right panel).

Acknowledgements:

We will like to thank Maria Comazzi for all the work she have done with the IHC stainings

Disclosure of Interests:

Henriette Didriksen Speakers bureau: Travel bursary - GSK

Travel bursary and speaker - Actelion, Noemi Strahm: None declared, Øyvind Molberg: None declared, Håvard Fretheim Speakers bureau: Received travel bursaries from Actelion, and remuneration from Bayer., Torhild Garen: None declared, Øyvind Midtvedt: None declared, Oliver Distler Speakers bureau: Actelion, Kymera Therapeutics, Mitsubishi Tanabe Pharma, Abbvie, Acceleron, Alexion, Amgen, AnaMar, Arxx Therapeutics, Baecon Discovery, Blade Therapeutics, Corbus Pharmaceuticals, Drug Development International Ltd, CSL Behring, Galapagos NV, Glenmark Pharmaceuticals, GSK, Horizon (Curzion) Pharmaceuticals, Inventiva, iQvia, Kymera Therapeutics, Lilly, Novartis, Pfizer, Topadur and UCB, Grant/research support from: Boehringer Ingelheim, Beyer, Gabriela Kania: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Roche, Bayer, Merck Sharp & Dohme, Lilly, ARXX and Medscape, Grant/research support from: Boehringer Ingelheim

AB0433 STUDY DESIGN FOR THE RANDOMISED CONTROLLED PHASE II ReSScue TRIAL: SAFETY AND EFFICACY OF FAECAL MICROBIOTA TRANSPLANTATION BY ANAEROBIC CULTIVATED HUMAN INTESTINAL MICROBIOME (ACHIM) IN PATIENTS WITH SYSTEMIC SCLEROSIS

Background:

Gastro-intestinal tract (GIT) symptoms is highly prevalent in patients with systemic sclerosis (SSc). The GIT-symptoms impact on the quality of life is significant, and available treatment alternatives are limited. Recently published articles show associations between gut microbiota changes and GIT-symptoms in SSc. We, therefore, performed a successful feasibility trial on faecal microbiota transplantation (FMT) in SSc patients using the single-donor bacterial culture “Anaerobic Cultivated Human Intestinal Microbiome (ACHIM)”. Based on the promising results from the feasibility trial, we aim to evaluate the safety and efficacy of FMT by ACHIM in SSc patients. (NCT04300426)

Objectives:

To design a clinical trial that explores the safety and efficacy of FMT in SSc patients.

Methods:

The ReSScue trial is a phase II, placebo-controlled, randomised 20-week, multicentre trial. The trial comprises three parts. In the induction phase (A1) lasting from week 0 to week 12, participants are randomised 1:1 to repeat infusions of 30 ml ACHIM or placebo at week 0 and 2 by gastro-duodenoscopy. In the maintenance phase (A2), all study participants will receive 30 ml ACHIM at week 12 and are followed continued blinded until week 20.

For longer-term data on intervention effects and safety, the participant will be followed for a maximum extended monitoring period of 16 weeks (part B).

The primary endpoint is change from baseline to week 12 in UCLA GIT scores on bloating or diarrhoea, depending on the worst symptom at baseline evaluated separately for each patient. Secondary endpoints are changes in UCLA GIT scores (bloating, diarrhoea and total) and safety measures.

Results:

We aim to enrol 70 SSc patients based on the power calculations for the primary endpoint “change in worst symptom from baseline to week 12”, with a considered drop out rate of 10%. This number of patients is expected to give a power of 80% of detecting a change in mean (p=0.05, two-sided) of -5.0 (or higher) if the relating standard deviation is 0.70 or lower. The patient screening started in September 2020, and we expect the study to be completed in May 2022.

Conclusion:

The ReSScue-study is to our knowledge the first FMT-study in SSc. This trial will assess the safety and efficacy of FMT in SSc patients with lower GI-symptoms, possibly leading to a novel treatment approach in SSc patients.

Disclosure of Interests:

Håvard Fretheim Grant/research support from: Received travel bursaries from Actelion, and remuneration from Bayer., Imon Barua: None declared, Vikas Sarna: None declared, Maylen N Carstens: None declared, Oliver Distler Speakers bureau: Below, Consultant of: Below, Grant/research support from: OD has/had consultancy relationship and/or has received research funding in the area of potential treatments for systemic sclerosis and its complications from (last three years): Abbvie, Acceleron Pharma, Amgen, AnaMar, Arxx, Baecon Discovery, Blade, Bayer, Boehringer Ingelheim, ChemomAb, Corbus, CSL Behring, Galapagos NV, Glenmark, GSK, Horizon (Curzion), Inventiva, iQvia, Italfarmaco, iQone, Kymera, Lilly, Medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Novartis, Pfizer, Roche, Sanofi, Serodapharm, Topadur, Target Bioscience and UCB. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Dinesh Khanna Consultant of: Abbvie, Actelion/Janssen, Acceleron Pharma, Amgen, Bayer, Boehringer Ingelheim, CSL Behring, GSK, Horizon Pharmaceuticals, Mitsubishi Tanabe Pharma, Pfizer, Roche, Sanofi, United Therapeutics. DK is chief medical officer of Eicos Sciences, Inc., Grant/research support from: Abbvie, Actelion/Janssen, Acceleron Pharma, Amgen, Bayer, Boehringer Ingelheim, CSL Behring, GSK, Horizon Pharmaceuticals, Mitsubishi Tanabe Pharma, Pfizer, Roche, Sanofi, United Therapeutics. DK is chief medical officer of Eicos Sciences, Inc., Elizabeth Volkmann Consultant of: Boehringer Ingelheim, Grant/research support from: Corbus, Forbius, Boehringer Ingelheim, Øyvind Midtvedt Shareholder of: Son of owner of ACHIM., Henriette Didriksen Speakers bureau: Travel bursary - GSK, Alvilde Dhainaut: None declared, Anna-Kristine H Halse: None declared, Gunnstein Bakland: None declared, Inge Christoffer Olsen: None declared, Maiju E Pesonen: None declared, Øyvind Molberg: None declared, Anna-Maria Hoffmann-Vold Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Medscape, Merck Sharp & Dohme, Lilly and Roche., Grant/research support from: Actelion, ARXX, Bayer, Boehringer Ingelheim, Medscape, Merck Sharp & Dohme, Lilly and Roche.

OP0174 SUBCLINICAL INTERSTITIAL LUNG DISEASE IS FREQUENT AND PROGRESSES ACROSS DIFFERENT CONNECTIVE TISSUE DISEASES

Background:

Based on the argument that symptoms define disease, physicians commonly apply the terms “preclinical” or “subclinical” disease to describe patients with disease-related findings but no accompanying symptoms for connective tissue disease associated interstitial lung disease (CTD-ILD). The term subclinical frequently applies to patients with mild ILD changes on high resolution chest tomography (HRCT), normal forced vital capacity (FVC), and without respiratory symptoms. Previous work in systemic sclerosis (SSc)-ILD did show that patients with even minor extent of ILD at baseline often progressed and had increased mortality risk, suggesting that it is not appropriate to define these patients as “subclinical.”

Objectives:

To identify the prevalence of subclinical ILD across CTD diagnoses, and assess the rate of progression of lung fibrosis compared to CTD without ILD and with clinical ILD.

Methods:

All CTD patients, including SSc, anti-synthetase syndrome (ASS) and mixed connective tissue disease (MCTD) from the Oslo University Hospital diagnosed before 2015 and assessed for the presence of ILD by HRCT were included. The year 2015 was chosen to secure an observation time of at least five years from ILD diagnosis to study end on 01.01.2021 or time of death. All patients fulfilled the respective CTD classification criteria. Subclinical ILD was defined as an ILD extent <5% by semi-quantitative assessment of baseline HRCT, preserved lung function with FVC >80% predicted and without respiratory symptoms. Clinical ILD was defined as >5% extent of ILD or <5% extent of ILD on HRCT with respiratory symtoms or FVC<80%. The outcome was ILD progression, defined as increasing extent of ILD from basline to follow-up HRCT by semi-quantitative assessment. Vital status was available in all patients and mortality was evaluated. Descriptive statistical analyses were conducted and time to ILD progression determined by Kaplan-Meier estimates.

Results:

We identified 525 CTD patients, including 296 with SSc, 135 with MCTD and 94 with ASS who had conducted a baseline HRCT. Of these, 227 (43%) had no ILD, 67 (13%) subclinical and 231 (44%) clinical ILD (Table). Of the 67 subclinical ILD patients, 45 (15%) had SSc, 13 (10%) MCTD and 9 (10%) ASS of thespecific cohorts. Over a median time of 4.5 years between baseline and follow-up HRCT, 95/395 (24%) showed progression of ILD, including 72 (26%) SSc and 23 (19%) MCTD patients. Disease progression frequently occurred in both subclinical ILD (38%) and clinical ILD (51%) patients (Figure). Age, gender, underlying CTD, and baseline lung function were not predictive for the progression of lung fibrosis. Progression was too infrequent to allow for meaningful multivariable regression analyses. After a median observation period of 12 years, 153 (29%) of the patients died. The 1-, 5- and 10-year survival rates in those without ILD, subclinical and clinical ILD were 97%/97%/99%, 88%/91%/82%, and 82%/85%/68% (p<0.001), respectively.

Table 1.

Clinical characteristics, demographics and outcome

No ILD (n=227)Subclinical ILD (n=67)Clinical ILD (n=231)Age, y (SD)50 (15.4)51 (14.4)52 (15.3)Male sex, n (%)89 (39)22 (33)111 (48)Deceased, n (%)50 (22)12 (18)91 (39)Observation period, y median (range)13.7 (18.6)13.9 (17.9)11.5 (17.1)FVC% (SD)97 (18.6)99 (17.9)81 (20.9)FVC decline% (SD)-0.70 (11.1)-0.81 (16.5)-1.61 (15.9)DLCO% (SD)73 (19.4)73 (16.9)55 (17.4)Extent of ILD% (SD)0 (0)2.3 (1.5)19.3 (16.8)ILD progression% (SD)0.08 (1.0)3.1 (6.2)3.6 (9.9)ILD progressors, n (%)3 (2)20 (38)72 (51)Figure 1.

Time to ILD progression in CTD without ILD, with subclinical and clinical ILD

Conclusion:

Subclinical ILD is frequently present across CTDs and progresses over time in a substantial subgroup of patients, comparable to patients with clinical ILD. Our findings question the terms sub- and preclinical ILD, which may potentially lead to a suboptimal “watchful waiting management strategy”. Monitoring all CTD patients with any ILD is of high importance to identify disease progression early.

Disclosure of Interests:

Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Roche, Merck Sharp & Dohme, Lilly and Medscape, Consultant of: Actelion, Boehringer Ingelheim, Bayer, ARXX, and Medscape, Grant/research support from: Boehringer Ingelheim, Helena Andersson: None declared, Silje Reiseter: None declared, Håvard Fretheim Consultant of: Actelion, Bayer., Imon Barua: None declared, Torhild Garen: None declared, Øyvind Midtvedt: None declared, Ragnar Gunnarsson: None declared, Mike Durheim Speakers bureau: Boehringer Ingelheim and Roche, Consultant of: Boehringer Ingelheim, Grant/research support from: Boehringer Ingelheim, Trond M Aaløkken: None declared, Øyvind Molberg: None declared

THU0348 ALTERED IMMUNE RECOGNITION OF SPECIFIC GUT BACTERIA BY IMMUNOGLOBULINS IN EARLY SYSTEMIC SCLEROSIS

Background:

Gastrointestinal tract (GIT) involvement is highly prevalent in systemic sclerosis (SSc) and associates with GIT symptoms that are present early and progress over time. Changes in gut microbiota are often reported in inflammatory disease settings but whether GIT symptoms associate with altered immune recognition of specific gut bacteria in early SSc is unknown.

Objectives:

Here, we profiled Ig coating patterns of gut bacteria in early disease from two well-characterized SSc cohorts to determine if the pattern and extent of bacterial immunoglobulin (Ig) coating differs in early SSc.

Methods:

We collected fecal material from early SSc patients (<36 months from time of diagnosis) at Oslo and Lund University Hospitals and from healthy age and gender matched controls (HC). To assess whether adaptive immunity was triggered against gut microbiota in early disease, we sorted and sequenced IgA, IgM and IgG coated bacteria from fecal samples by flow cytometry and performed 16s rRNA sequencing to compare the relative Ig coating of early SSc patients to HC. Data was resolved to the family level, rarefied to 5101 reads and converted to relative abundance. Taxonomic profiles, relative abundance, IgA, IgM and IgG coating patterns and extent of Ig coating were assessed. Unadjusted p-values <0.05 were defined as significant.

Results:

We included 50 SSc patients (26 from Oslo, 24 from Lund) with early SSc and 9 gender and age matched HC. Mean age of SSc patients at time of inclusion was 53 years, mean time since diagnosis was 13 months; 82% were female, 61% had limited cutaneous SSc and 43% were anti-centromere antibody positive. In all, 82% were treatment naïve while 18% had received either cyclophosphomide or mycophenolate mofetil immunosuppressants. We found increased relative abundance of IgA coated Desulfovibrionaceae in both SSc cohorts compared to HC and increased IgM and IgG coating of Veillonellaceae and Streptococcaceae (Figure 1). All of these bacteria have previously been associated with other autoimmune diseases or pro-inflammatory status; Desulfovibrionaceae to immune activation in the gut, and Veillonellaceae and Streptococcaceae to other chronic inflammatory and fibrotic conditions. While abundance of IgA coated Desulfovibrionaceae was higher in cyclophosphomide or mycophenolate mofetil-treated SSc patients than untreated patients, Veillonellaceae and Streptococcaceae were not affected by treatment. A lower abundance of IgA and IgM coated Akkermansiaceae; and IgM and IgG coated Bifidobacteriaceae was detected in treated compared to treatment naïve early SSc patients (Figure 2).

Conclusion:

We find the pattern and extent of Ig coating to inflammatory-associated gut bacteria differs between treatment-naïve, early SSc patients treated with cyclophosphomide or mycophenolate mofetil and HC which suggests immunosuppressive treatments may modify gut microbiota in SSc. Overall these findings support the involvement of altered immune recognition of specific gut bacteria in early SSc.

Disclosure of Interests:

Anna-Maria Hoffmann-Vold Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Actelion, Bayer, GlaxoSmithKline, Speakers bureau: Boehringer Ingelheim, Actelion, Roche, Kristofer Andréasson: None declared, Simen Hyll Hansen: None declared, Simon Midtvedt: None declared, Håvard Fretheim: None declared, Henriette Didriksen Consultant of: Actelion, Torhild Garen: None declared, Espen Bækkevold: None declared, Øyvind Midtvedt: None declared, Roger Hesselstrand: None declared, Brian K Chung: None declared, Øyvind Molberg: None declared

SAT0348 CLINICAL SPECTRUM TIME COURSE OF ANTISYNTHETASE SYNDROME PATIENTS POSITIVE FOR ANTICENTROMERE ANTIBODIES

Background:

ASSD is characterized by antisynthetase antibodies (ARS) and the triad arthritis/myositis/Interstitial Lung Disease (ILD). ASSD and systemic sclerosis (SSc) may share features, like Raynaud’s phenomenon (RP), capillaroscopic alterations, and also some SSc specific autoantibodies.

Objectives:

To evaluate the characteristics of ASSD + for anticentromere antibodies (ACA).

Methods:

Retrospective analysis of clinical and laboratory characteristics of ACA + ASSD. Patients were identified in an established international cohort, randomly matched 1:1 for sex, age, disease duration and ARS positivity with a group of ACA - ASSD.

Results:

18 ACA + ASSD (15 females, 83%, 15 anti-Jo1, 2 anti-PL7, 1 anti-PL12 ARS) patients were identified. In comparison to ACA - group, no differences were observed in disease clinical presentation and evolution. Though, 9 ACA + patients (50%) satisfied the ACR/EULAR 2013 classification criteria for SSc and only 1 in ACA - group (p=0.007) (Table 1).

An incomplete ASSD (lack of at least one triad finding) was observed in 15 patients in both ACA + and – group (p=1). Among these patients, 13 ACA + and 11 ACA – developed de-novo triad finding during disease course (p=0.651). In ACA + group, a de-novo arthritis was observed in 4 patients (vs 1, p=0.565), a de-novo myositis in 8 (vs 5, p=1), and a de-novo ILD in 7 (vs 10, p=1). The prevalence of complete forms was similar between ACA + and – group at both disease onset (3 vs 3, 17%, p=1) and last follow-up, (10 vs 11, 56% vs 61%, p=1). Of note, only 1 patient (6%) for each group died (p=1).

Conclusion:

The clinical spectrum time course of ACA+ and - ASSD is similar, even when ACA + patients could be classified as SSc. By considering the high prevalence of arthritis and myositis we observed, we suggest that ACA+ patients with arthritis and myositis, should be tested for ARS antibodies even when an ASSD is not clearly suspected.

References:

[1]Mirrakhimov AE. Curr Med Chem 2015;22:1963–75

[2]Cavagna L. J Clin Med 2019;8:E2013

[3]Sebastiani M. J Rheum 2019:46:279-84

[4]van den Hoogen F. Ann Rheum Dis 2013;72:1747-55

Table 1.

Patients characteristics. IQR, interquartile range; ILD, interstitial Lung Disease; SSc, systemic sclerosis

ACA+ (18)ACA - (18)pAge (years) at disease onset (median, IQR)47 (37-63)47 (39-63)0.834Disease duration (months) (median, IQR)81 (62-169)77 (58-165)0.486anti Ro52antibody (%)12(67)11 (61)1Arthritis onset10 (56)13 (72)0.489Arthritis last follow-up (%)14 (78)14 (78%)1Myositis onset (%)7 (39)11 (61)0.318Myositis last follow-up (%)15 (83)16 (89)1ILD onset (%)9 (50)6 (33)0.5ILD last follow-up (%)16 (89)16 (89)1Complete form onset (%)3 (17)3 (17)1Complete form last follow-up (%)10 (56)11 (61)1Raynaud phenomenon (%)13 (72)9 (50)0.305Mechanic’s hands (%)6 (33)7 (38)1Teleangectasias (%)2 (11)0 (0)0.486Cutaneous sclerosis (%)510.177Acral ulcers (%)1 (6)0 (0)1Scleroderma pattern at NVC8 (44)7 (39)1Pulmonary arterial hypertension (%)3 (17)2 (11)12013 ACR/EULAR SSc classification criteria9 (50)1 (6)0.007

Disclosure of Interests:

Giovanni Zanframundo: None declared, Gianluca Sambataro: None declared, Veronica Codullo: None declared, Alessandro Biglia: None declared, Emanuele Bozzalla Cassione: None declared, Elena Bravi: None declared, Florenzo Iannone Consultant of: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Speakers bureau: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Marco Fornaro: None declared, Konstantinos Triantafyllias: None declared, Alberto Pesci: None declared, Paola Tomietto: None declared, Øyvind Molberg: None declared, Salvatore Scarpato: None declared, Reinhard Voll: None declared, Marco Matucci-Cerinic Grant/research support from: Actelion, MSD, Bristol-Myers Squibb, Speakers bureau: Acetelion, Lilly, Boehringer Ingelheim, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD, Carlomaurizio Montecucco: None declared, Lorenzo Cavagna: None declared

THU0327 EFFECT OF IMMUNOSUPPRESSIVE MEDICATION ON GASTRO-INTESTINAL INVOLVEMENT IN SYSTEMIC SCLEROSIS PATIENTS STRATIFIED FOR DISEASE DURATION

Background:

Gastrointestinal tract (GIT) involvement is associated with high morbidity in systemic sclerosis (SSc) but the data on its impact from unselected and well characterized SSc cohorts are scarce. Currently, the effect of immunosuppressive (IS) treatment on GIT involvement is largely unknown.

Objectives:

To evaluate the severity and worsening of GIT involvement in two prospective SSc cohorts. To assess factors associated with severity of GIT involvement, stratified for disease duration. To evaluate effect of IS treatment on worsening of GIT involvement.

Methods:

All SSc patients fulfilling the 2013 SSc classification criteria from two SSc cohorts were evaluated. Incident SSc was defined as disease duration since first symptom non-Raynaud < 24 months at first presentation. GIT involvement was assessed by the UCLA GIT 2.0 score at baseline and after one year to assess worsening of GIT involvement. Worsening was defined as change > minimal clinical important difference for total score and for each of the seven subdomains. GIT involvement was defined as present if the patients reported symptoms resulting in a score of ≥0.01 and was segregated into mild ≥0.01 (<0.5 or for fecal incontinence and distention/bloating <1.01), moderate (≥0.5 or for fecal incontinence and distention/bloating ≥1.01) or severe GI symptoms (> 1.01 or for distension/bloating > 1.61 or for fecal soiling > 2.01). Logistic regression was applied to identify risk factors associated with GIT involvement at baseline. The effect of IS treatment on worsening on each of the subdomains after one year was evaluated with logistic regression, with adjustment for baseline disease duration and severity.

Results:

In total, 834 SSc patients were included; 236 (28%) had incident disease (table 1). Incident cases (IC) showed comparable severity of GIT involvement compared to non-incident cases (NIC) except for significantly less severe reflux and distension/bloating (figure 1). Logistic regression showed female sex (OR 8.5(1.1-36.01)) and smoking (OR 2.9(1.2-7.3)) to be associated with GIT severity at baseline in IC; in NIC anti-centromere antibody (OR 1.7(1.3-2.2)) was additionally associated with GIT severity. The use of IS at baseline did not associate with GI severity at baseline. In total n = 685 (82% never had IS treatment (83% NIC, 81% IC); of these 258 (38%) started with IS after baseline assessment (52% IC, 32% NIC, p =0.02). When comparing change of GIT involvement after one year between those who started IS and those who did not, worsening of GI symptoms occurred more frequently in patients who started IS treatment (figure 2), but notably, patients in this group were also more frequently anti-topoisomerase positive, had ILD, and diffuse disease subset compared to the patients without IS treatment; age and sex were comparable. In the logistic regression with adjustment for disease duration and severity, there were no significant associations between IS treatment and worsening on GIT involvement.

Conclusion:

Regardless disease duration, about 1/3 of all SSc patients had moderate-severe GIT involvement. Disease duration and treatment initiation with IS did not have a significant influence on worsening of GIT involvement.

Table:

Baseline characteristicsNon-inception cohort(n=598)Inception cohort(n=236)Female, n(%)504 (85)180 (76)Age, mean(SD)55 (13)56 (14)Disease duration non Raynaud-Phenomenon, median (IQR)8.8 (4.8-14.4)0.7 (0.3-1.2)Diffuse cutaneous subset, n(%)119 (20)67 (28)Interstitial lung disease, n(%)233 (39)71 (30)Anti-centromere, n(%)296 (50)96 (41)Immunosuppresive treatment at baseline, n(%)102 (17)44 (19))Duration of treatment at baseline in years, mean (SD)4.1 (4.8)1.2 (2.9)Methotrexate, n(%)54 (9)24 (10)Mycophenolate mofetil, n(%)25 (4)13 (6)Hydroxycholoquine, n(%)20 (3)7 (3)Cyclofosfamide, n(%)1 (1)10 (4)Azathioprine, n(%)11 (2)2 (1)Corticosteroids, n(%)58 (10)27 (11)

Acknowledgments:

NA

Disclosure of Interests:

Nina van Leeuwen: None declared, Håvard Fretheim: None declared, Øyvind Molberg: None declared, Thomas Huizinga Grant/research support from: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Consultant of: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Jeska de Vries-Bouwstra: None declared, Anna-Maria Hoffmann-Vold Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Actelion, Bayer, GlaxoSmithKline, Speakers bureau: Boehringer Ingelheim, Actelion, Roche

THU0331 INTERSTITIAL LUNG DISEASE IN SYSTEMIC SCLEROSIS: DECLINE IN FORCED VITAL CAPACITY DOES NOT PREDICT FURTHER PROGRESSION IN THE FOLLOWING PERIOD

Background:

In systemic sclerosis (SSc) patients with interstitial lung disease (ILD) approximately 30% show progressive ILD. It is unknown whether a progressive ILD period is followed by further lung function decline. In clinical practice, treatment is frequently initiated after observation of lung function decline over 6-12 months and lung function stabilization at follow up is often interpreted as treatment effect.

Objectives:

Assess the predictive ability of lung function decline over 12 months for further deterioration adjusted for known risk factors for ILD and treatment in two large and well characterized SSc cohorts.

Methods:

Patients with SSc-ILD by HRCT, fulfilling SSc classification criteria, from the Oslo and Zurich University Hospital were included. The first period with three consecutive annual forced vital capacity (FVC) measurements (i.e. at 0, 12 and 24 months, +/- 3 months) was used. Lung function decline was assessed by absolute changes in FVC% predicted. Moderately progressive ILD was defined as FVC decline of >5-<10% and significantly progressive ILD as FVC decline ≥10% in 12 months. Candidate predictors by experts (including SSc subtype, autoantibodies, disease duration, baseline and FVC decline in the first period, extent of lung and skin (mRSS) fibrosis, CRP, reflux, tendon friction rubs, O2 desaturation, dyspnea) for FVC decline in the second period were tested using logistic regression analysis. Treatment included low dose corticosteroids, mycophenolate mofetil; and other immunosuppressive treatment (cyclophosphamide, Rituximab and Tocilizumab).

Results:

In total, 240 SSc-ILD patients met the inclusion criteria (table). Of these 69 (29%) SSc-ILD patients showed progressive ILD in the first 12 months period; 34 (14%) with moderate (5-10%) and 35 (15%) with significant FVC decline (≥10%). Independent of FVC changes in the first period, 77 (32%) showed progressive ILD in the second period; 44 (18%) moderate and 33 (14%) significant FVC decline. Only 21 (9%) SSc-ILD patients had two progressive periods, and 115 (48%) were stable in the two 12 month’s periods; all independent of treatment. In multivariable logistic regression, progressive ILD in the first period (moderate, significant or combined FVC decline) was not predictive for progression in the following period. Of all applied risk factors, only mRSS was significantly predictive for further FVC decline, also when adjusted for age, gender and treatment (OR 1.03, 95%CI 1.00-1.08, p=0.035).

Conclusion:

Decline of FVC in one 12 months period did not predict further ILD progression in the following 12 months independent of treatment. These results have important clinical implications. Firstly, a decline of lung function in one period seems not to be the right indicator for initiating treatment. Secondly, stabilization of lung function under treatment initiated after ILD progression cannot necessarily be interpreted as a treatment response on the individual patient level.

Table:

First periodBoth periodsSSc-ILD (n=240)ILD progression (n=69)ILD progression (n=21)Stable ILD (n=115)Age, years (SD)48 (14.7)49 (13.8)50 (14.3)46 (15.3)Male, n (%)57 (24)18 (26)5 (24)27 (24)Disease duration yrs, mean (SD)10.2 (11.4)9.8 (10.2)8.8 (11.0)10.8 (12.3)Disease duration <3 years, n (%)68 (28)22 (32)8 (38)29 (25)Diffuse cutaneous SSc, n (%)95 (40)30 (44)11 (52)43 (27)Anti-topoisomerase I Ab, n (%)84 (35)27 (40)9 (43)42 (37)mRSS, mean (SD)10 (9.3)11 (10.2)16 (13.0)8 (8.3)CRPml, mean (SD)3.6 (7.2)3.3 (6.2)4.4 (9.1)3.1 (5.1)GERD, n (%)148 (62)44 (64)15 (74)70 (61)FVC % predicted90 (20.3)90 (21.9)92 (21.7)89 (19.3)DLCO% predicted64 (17.9)64 (16.6)70 (11.3)65 (17.5)Lung fibrosis >20%, n (%)55 (23)16 (23)4 (19)27 (24)Mycophenolate Mofetil, n (%)47 (20)15 (22)5 (24)23 (20)Other immunosuppression, n (%)79 (33)22 (32)9 (43)42 (37)Corticosteroids, n (%)62 (26)18 (26)8 (38)28 (24)

Disclosure of Interests:

Anna-Maria Hoffmann-Vold Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Actelion, Bayer, GlaxoSmithKline, Speakers bureau: Boehringer Ingelheim, Actelion, Roche, Håvard Fretheim: None declared, Britta Maurer Grant/research support from: AbbVie, Protagen, Novartis, congress support from Pfizer, Roche, Actelion, and MSD, Speakers bureau: Novartis, Mike Durheim Grant/research support from: BI, Consultant of: BI, Speakers bureau: BI, Øyvind Midtvedt: None declared, Mike O. Becker: None declared, Rucsandra Dobrota: None declared, Øyvind Molberg: None declared, Suzana Jordan: None declared, Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche

Assessing the relative impact of lupus nephritis on mortality in a population-based systemic lupus erythematosus cohort

OBJECTIVE

There is limited knowledge on the relative impact of lupus nephritis (LN) on morbidity and mortality in population-based systemic lupus erythematous (SLE) cohorts. Here, the primary aim was to compare mortality rates between patients with and without LN in a population-based SLE cohort.

METHODS

The study cohort included all SLE patients resident in the city of Oslo during 1999-2008. Follow-up time was median 14 (0-15) years. Presence of LN was defined according to the 1987 American College of Rheumatology classification criteria for SLE. LN class was determined by renal biopsy. Data on kidney function, including presence of end-stage renal disease (ESRD), were obtained from patient charts. Standardized mortality ratios (SMRs) were estimated by comparing deaths in the SLE cohort with age- and gender-matched population controls.

RESULTS

We found that 98/325 SLE patients (30%) developed LN, 92% of whom had occurrence within the first five years from disease onset. Incidence rate of ESRD was 2.3 per 1000 patient-years. A total of 56 deaths occurred during the study period, corresponding to an overall SMR in the SLE cohort of 2.1 (95% confidence interval (CI) 1.2-3.4). Estimated SMR for LN patients was 3.8 (95% CI 2.1-6.2), and for SLE patients without LN it was 1.7 (95% CI 0.9-2.7).

CONCLUSION

In this population-based SLE cohort, we found that LN was associated with increased morbidity and mortality, whereas SLE patients who did not develop LN had good overall prognoses regarding survival.

Plasma vitamin D levels and inflammation in the aortic wall of patients with coronary artery disease with and without inflammatory rheumatic disease

OBJECTIVES

Vitamin D modulates inflammation, and this may explain the observed associations between vitamin D status and disorders driven by systemic inflammation, such as coronary artery disease (CAD) and inflammatory rheumatic diseases (IRDs). The aims of this study were to assess vitamin D status in patients with CAD alone and in patients with CAD and IRD, and to explore potential associations between vitamin D status and the presence of mononuclear cell infiltrates (MCIs) in the aortic adventitia of these patients.

METHOD

Plasma levels of 25-hydroxyvitamin D₃ [(25(OH)D₃] were determined by radioimmunoassay and 1,25-dihydroxyvitamin D₃ [1,25(OH)₂D₃] by enzyme immunoassay in the 121 patients from the Feiring Heart Biopsy Study (FHBS) who had available histology data on adventitial MCIs; 53 of these had CAD alone and 68 had CAD and IRD.

RESULTS

In the crude analysis, vitamin D levels were similar in CAD patients with and without IRD. After adjustment for potential confounders, IRD was associated with an increase of 8.8 nmol/L [95% confidence interval (CI) 1.0-16.6; p = 0.027] in 25(OH)D₃ and an increase of 18.8 pmol/L (95% CI 4.3-33.3; p = 0.012) in 1,25(OH)₂D₃, while MCIs in the aortic adventitia were associated with lower levels of 1,25(OH)₂D₃ (β = -18.8, 95% CI -33.6 to -4.0; p = 0.014).

CONCLUSIONS

IRD was associated with higher levels of both 25(OH)D₃ and 1,25(OH)₂D₃. These findings argue against the hypothesis that patients with high systemic inflammatory burden (CAD+IRD) should have lower vitamin D levels than those with less inflammation (CAD only). Of note, when controlled for potential confounders, low 1,25(OH)₂D₃ levels were associated with adventitial aortic inflammation.

Serum IgG antibodies to peptidylarginine deiminase 4 predict radiographic progression in patients with rheumatoid arthritis treated with tumour necrosis factor-alpha blocking agents

BACKGROUND

Peptidylarginine deiminase 4 (PAD4) may generate epitopes targeted by anticitrullinated protein antibodies in rheumatoid arthritis (RA). A subset of patients with RA has serum autoantibodies to human recombinant PAD4 (hPAD4). Here, we assessed whether anti-hPAD4 status in RA predicted disease outcome after antitumour necrosis factor (anti-TNF)-alpha therapy.

METHODS

We analysed RA sera obtained at baseline (n = 40) and after 1 year on anti-TNF-alpha therapy (n = 33) for anti-hPAD4 IgG. Association analyses between baseline anti-hPAD status and disease progression were performed.

RESULTS

We found that 17 of 40 patients (42.5%) were serum anti-hPAD4 positive at baseline, and the anti-hPAD4 IgG levels were stable over 1 year on anti-TNF-alpha therapy. At baseline, there were indications that anti-hPAD4 positive patients had more severe disease than the negative patients. After 1 year on anti-TNF-alpha therapy, the anti-hPAD4 positive patients displayed a persistently elevated disease activity score using 28 joint counts score and increased progression in the van der Heijde-modified Sharp erosion score. Accordingly, more anti-hPAD4 positive than negative patients presented an increase in van der Heijde-modified Sharp erosion scores >0 over 1 year.

CONCLUSIONS

Anti-hPAD4 IgG can be detected in a subset of RA sera and the levels are stable after initiation of anti-TNF-alpha therapy. Serum anti-hPAD4 may predict persistent disease activity and radiographic progression in patients with RA receiving anti-TNF-alpha therapy.

Surface Expression of Transglutaminase 2 by Dendritic Cells and its Potential Role for Uptake and Presentation of Gluten Peptides to T Cells

Celiac disease is a chronic small intestinal inflammation driven by gluten-reactive T cells of the intestinal mucosa. These T cells are HLA-DQ2 or -DQ8 restricted, and predominantly recognize gluten peptides that are deamidated by the enzyme transglutaminase 2 (TG2). Our recent results strongly suggest that duodenal CD11c(+) dendritic cells (DC) are directly involved in T cell activation in the celiac lesion. The aim of this study was to investigate whether surface-associated TG2 could be involved in receptor-mediated endocytosis of gluten peptides, a process that may contribute to the preferential recognition of deamidated peptides. We found that both monocyte-derived DC and local CD11c(+) DC in the duodenal mucosa expressed cell surface-associated TG2. As phenotypic characterization of CD11c(+) DC in the celiac lesion suggests that these cells may be derived from circulating monocytes, we used monocyte-derived DC in functional in vitro studies. Using a functional T cell assay, we obtained evidence that cell surface-associated TG2 is endocytosed by monocyte-derived DC. However, we were unable to obtain evidence for a role of surface TG2 in the loading and subsequent generation of deamidated gluten peptides in these cells.