The history of antiphospholipid syndrome

Antiphospholipid Syndrome (APS) is an autoimmune disease which was defined in the early 1980s. The principal features include thromboembolic events and/or pregnancy losses in association with antiphospholipid antibodies (aPL). As an historical note, the full-blown picture of the syndrome resembles the illness suffered by Anne Stuart, Queen of England in the XVIII century, whose repeated miscarriages caused the end of the royal Stuart line and the Hanoverian succession. The identification of aPL started in the early XX century and was linked to the introduction of the serological test for the diagnosis of syphilis. This involves a reaction between an antibody (reagin) and a phospholipid antigen derived from bovine heart (cardiolipin). Later on, it was observed that not all subjects with a positive test had syphilis, and that the so called "false positive reaction" was often reported in patients with systemic lupus erythematosus. Different tests for the identification of aPL were subsequently developed: first lupus anticoagulant (1971) and then immunoassays for anticardiolipin (1983) and anti-beta2 glycoprotein I (1990) antibodies. In the same period the association between the presence of circulating aPL and thrombotic and obstetric events was established, both in patients with autoimmune diseases and in otherwise healthy subjects, leading to the identification of APS as a distinct autoimmune disease. This has allowed better diagnosis and more targeted treatment for many patients.

AB0441 PREDICTORS OF CLASI RESPONSE OVER TIME IN A MULTICENTRIC REAL LIFE COHORT OF SLE PATIENTS TREATED WITH BELIMUMAB

Background

Over 80% of patients affected with SLE experience skin involvement. The anti-BLyS drug belimumab was shown effective in ameliorating mucocutaneous SLE manifestations in clinical trials and real-life studies. Cutaneous response is quantified through the CLASI (cutaneous lupus erythematosus area and severity index). Clinically relevant improvements are defined as decreases of ≥50% (CLASI50) or 70% (CLASI70) from baseline values.

Objectives

To assess rates and predictors of CLASI50 and CLASI70 in the Berliss multicentric SLE cohort1 of patients treated with belimumab.

Methods

Baseline and ongoing features of patients with baseline active skin involvement (CLASI>0) were assessed in relationship to the chosen outcomes CLASI50 and CLASI70 at 24 and 52 weeks. A subanalysis on patients with CLASI≥5 was as well conducted. Logistic regression was employed to identify predictors of response.

Results

172 patients displayed skin involvement at baseline (CLASI>0). Of those, 124 displayed at least a 12-month-follow-up and were included in the analysis. Seventy-seven (62.1%) patients reached CLASI50 at 24 weeks and 91 (77.8%) at 52 weeks; 87 (70.2%) reached CLASI70 at 24 and 99 (79.8%) at 52 weeks. Baseline predictors of CLASI50 at 24 weeks were CLASI-damage (CLASI-d) (OR [95%CI], p; 0.79 [0.65-0.98] 0.03) and disease duration (0.93[0.86-0.99], 0.011). No baseline predictors of CLASI70 at 24 weeks emerged, however having achieved a CLASI50 response at 24 weeks portended CLASI50 and 70 response through week 52 (p<0.01, Table 1). In the subgroup of patients with CLASI≥5, longer disease and increased CLASI-d at baseline confirmed as negative predictors of CLASI50 at 24 weeks. In this subset, use of antimalarials and active smoking at baseline predicted CLASI70 at 24 weeks (Table 1).

Table 1.

Predictors of CLASI-A Response at Week 24 and 52 by Baseline CLASI-A at 50% and 70% Response Thresholds

TimepointOutcomeVariableOR[95%CI] pCLASI>024 weeksCLASI50CLASI-d0.79 [0.65-0.98] 0.030Disease duration0.93[0.86-0.99], 0.011CLASI70CLASI-d0.93 [0.74-1.16], 0.51Disease duration0.97 [0.97-1.02], 0.1852 weeksCLASI50CLASI50 at 24 weeks14.3[4.88-44.42], <0.001CLASI70CLASI50 at 24 weeks6.22 [2.00-19.34], 0.002CLASI≥524 weeksCLASI50CLASI-d0.72 [0.53-0.98], 0.037Disease duration0.93 [0.66-1.00], 0.071CLASI70Antimalarials6.61 [1.20-36.29] 0.032Smoking0.15 [0.03-0.83], 0.03452 weeksCLASI50CLASI50 at 24 weeks22.0 [2.47-196.05], 0.006CLASI70CLASI50 at 24 weeks1.24 [0.06-25.08], 0.88

CLASI, cutaneous lupus erythematosus area and severity index; CLASI-d, CLASI damage; CLASI50 and CLASI70: decrease ≥50% or ≥70% in CLASI from baseline. OR and 95%CIs are estimated using a logistic regression model with stratification factors as covariates (SLEDAI-2K at baseline, baseline prednisone dosage).

Conclusion

Earlier use of belimumab favors achievement of skin response among SLE patients and attainment of a prompt response predicts further response. Use of antimalarials reinforces while smoking hampers a more profound CLASI improvement over time.

References:

[1]Gatto M, et al. Arthritis Rheumatol. 2020 Aug;72(8):1314-1324

Disclosure of Interests

Mariele Gatto Speakers bureau: GSK, Grant/research support from: GSK, Roberto Depascale: None declared, Angela Tincani: None declared, Giacomo Emmi: None declared, Salvatore Scarpato: None declared, Fabrizio Conti: None declared, Marcello Govoni: None declared, Marta Mosca: None declared, Maria Gerosa: None declared, Enrica Bozzolo: None declared, Valentina Canti: None declared, Armando Gabrielli: None declared, Elisa Gremese: None declared, Salvatore De Vita: None declared, francesco ciccia: None declared, Carlo Salvarani: None declared, Maurizio Rossini: None declared, Paola Faggioli: None declared, Antonella Laria: None declared, Amato De Paulis: None declared, Roberto Gerli: None declared, Enrico Brunetta: None declared, Alessandro Mathieu: None declared, Carlo Selmi: None declared, Rossella De Angelis: None declared, Simone Negrini: None declared, Margherita Zen: None declared, Andrea Doria Speakers bureau: GSK, Eli Lilly, Roche, Grant/research support from: GSK, Luca Iaccarino Speakers bureau: GSK, Grant/research support from: GSK

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Table 1.

AEs and disease exacerbations per disease

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

Acknowledgements

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

Disclosure of Interests

None declared

POS0151 PREGNANCIES IN PATIENTS WITH SPONDYLOARTHRITIS: DATA FROM 2 EUROPEAN CENTERS

Background

There is growing interest in reproductive issues in patients with Spondyloarthritis (SpA) and Psoriatic arthritis (PsA).

Objectives

To describe a real-life cohort of prospectively-followed pregnancies in SpA and PsA patients, focusing on obstetric outcome and on flare during pregnancies and post-partum.

Methods

Data on SpA and PsA pregnancies prospectively-followed in 2 European pregnancy clinics from 2010 to 2021 were retrospectively analysed.

Disease activity was assessed using ASDAS-CRP or DAS28-CRP according to the main involvement (peripheral or axial). Disease flare was defined as the need to treatment modification (introduction or increase ≥5mg/day of prednisone, introduction of cDMARD or bDMARD). Miscarriages were excluded from the analysis of flares.

Results

Data on 122 pregnancies (53 PsA and 69 ‘other SpA’: 39 axialSpA, 20 undifferentiated SpA, 6 IBD-related SpA, 4 reactive arthritis) in 102 patients (median age at conception: 34 [IQR: 31-36] years; median disease duration: 72 [24-132] months) were collected.

We recorded 98 (86%) live births and 16 (14%) miscarriages (8 missing data).

Cesarean section was performed in 15/98 (15%) cases. Median week of gestation at delivery was 39 [38-40]; 8 preterm births (<37 week of gestation) and 2 severe preterm births (<34 week of gestation) occurred. There was no difference between PsA or ‘other-SpA’ concerning pregnancy outcome and route of delivery.

Fourty-two pregnancies (40%) had at least 1 flare during pregnancy; 7 pregnancies had more than 1 flare. Overall, there were 13, 24 and 12 flares in the 1st, 2nd and 3rd trimester, respectively.

A higher frequency of patients with axial involvement was observed in the ‘flare’ group as compared to pregnancies without flare (83% vs 59%, p=0.02) (Table 1).

Table 1.

Comparison between ‘flare’ and ‘without flare’ groups.

FLARE (42)WITHOUT FLARE (64)pAge at conception (years)33 (31-37)33 (31-35)0.88Disease duration at conception (months)71 (24-120)60 (24-137)0.74PsA13 (31%)31 (48%)0.11‘Other SpA’29 (69%)33 (52%)0.11Axial involvement35 (83%)38 (59%)0.02Peripheral involvement30 (%)54 (%)0.17bDMARD useAny time before pregnancy16 (38%)19 (30%)0.49Stop at + pregnancy test/1st trimester8 (19%)4 (6%)0.09Start/continue 1st trimester7 (17%)10 (16%)0.89Start in 2ndtrimester5 (12%)00.02Start in 3rd trimester2 (5%)00.30Post-partum flare11/34 (32%)22/49 (45%)0.36

Continuous variables were compared using Mann-Whitney test; categorical variables were compared using Chi-square with Yates’ correction or Fisher’s exact test.

Medications resumed to treat flare were steroids (29 pregnancies), csDMARDs (14 pregnancies) and TNF-inhibitors (7 pregnancies: 5 during the 2nd and 2 during the 3rd trimester).

A post-partum flare was registered in 33/83 (40%) of cases, without difference between ‘flare’ group vs ‘without flare’ group (Table 1), as well as between PsA vs ‘other SpA’ pregnancies (47% vs 33%, p=0.2).

Conclusion

In this cohort of SpA pregnancies, 40% experienced a flare during pregnancy and 40% during post-partum. Flares occurred more frequently in the 2nd trimester and especially in patients with axial involvement, requiring the start of a TNF-inhibitor during the 2nd or the 3rd trimester in 7 pregnancies. Having a flare during pregnancy was not associated with a post-partum flare.

Disclosure of Interests

None declared

AB0925 Advantages of combined Derma-Rheumatological evaluation in Early Psoriatic Arthritis

Background

Psoriatic Arthritis (PsA) is a challenging diagnosis both for the absence of specific biomarkers and for its clinical heterogeneity, especially in its initial phases. Early onset of PsA is mostly characterized by mono-oligoarthritis, enthesitis, dactylitis, onychopathy, modest cutaneous involvement. At least 50% of early-PsA patients initially come at dermatologist’s attention because they carry only few musculoskeletal symptoms such as enthesitis and dactylitis. Rheumatological evaluation and ultrasound (US) demonstration of articular and entheseal inflammation allows to augment the probability of an early diagnosis in a short period of time.

Objectives

We described patients referred to our derma-rheumatological clinic. We focused our attention on the main affected domain and on the advantages of a combined evaluation in terms of diagnosis, access to advanced therapies and short-term outcome.

Methods

All patients referred to our derma-rheumatological clinic by dermatologists from July 2017 to July 2019 for suspected PsA were considered in the present study. 55% of them were studied with US, according to clinical necessity. All the suspected domains were studied using both B-mode and Power Doppler.

Results

81 patients, sent to our attention for suspected PsA, were included. In 18 (37%) of them diagnosis was confirmed (Caspar criteria were satisfied). In these patients oligoarthritis (80%), enthesitis (40%), dactylitis (23%), sometimes in combination, were the most frequent presentations. In 25% of cases enthesitis was the only clinical feature. Articular disease activity was low to moderate in most of patients (DAPSA 14,83 ± 10,08). Disease duration at the diagnosis was 12 months in 90% of cases and the time occurring between symptoms and the first advanced therapy was 18 months in 50% of cases. US study allowed to redefine disease status in 30% of cases. Arthritis and enthesitis were the main domains where US evaluation gave more diagnostic value.

Conclusion

literature reports a mean time to diagnosis and to start advanced pharmacological therapy respectively of 1,5 and 5 years. In our report, time to start advanced therapy was much lower than expected, falling in the so-called window of opportunity. US study importantly contributed to reach this target, allowing us to identify as soon as possible sub-clinical and pauci-symptomatic forms (low disease activity, prevailing entheseal domain), which could otherwise be misdiagnosed or have an important diagnostic delay. The attention of dermatologist and integrated evaluation allowed us to optimize our diagnostic-therapeutic work-up in patients affected by early PsA, allowing them to receive sooner advanced therapies, according to recent EULAR and GRAPPA recommendations.

References

[1]Lubrano E, et al. Residual Disease Activity and Associated Factors in Psoriatic Arthritis. J Rheumatol. 2020 Oct 1;47(10):1490-1495. Clinical Rheumatology (2020)

[2]GRAPPA Treatment Recommendations: An Update From the 2020 GRAPPA Annual Meeting LC Coates et al. The Journal of Rheumatology Feb 2021, jrheum.201681.

Disclosure of Interests

None declared

POS0721 ASSOCIATION BETWEEN PRECONCEPTION COMPLEMENT LEVELS AND USE OF HYDROXYCHLOROQUINE WITH PREGNANCY OUTCOME IN PATIENTS WITH PRIMARY ANTIPHOSPHOLIPID SYNDROME AND CARRIERS OF ANTIPHOSPHOLIPID ANTIBODIES: AN INTERNATIONAL MULTICENTER STUDY

Background

Antiphospholipid Syndrome (APS) is a rare autoimmune disease characterized by thrombotic events and/or pregnancy morbidities in the presence of confirmed positivity for antiphospholipid antibodies (aPL). Complement was demonstrated to be involved in aPL-related pregnancy loss in animal models and several groups investigated the significance of complement levels in human disease. C3 and C4 serum levels were assessed in several cohorts of pregnant patients with APS and/or aPL positivity in order to relate complement consumption with adverse pregnancy outcome (APO).

According to some authors, hydroxychloroquine (HCQ) can control the activation of the complement system, improve pregnancy outcome and reduce aPL title.

Objectives

This study was designed to verify the effect of HCQ in addition to low dose aspirin (LDA) + low molecular weight heparin (LMWH) treatment in a multicenter cohort of primary APS (PAPS) and aPL carriers pregnant women and the possible correlation with preconception serum C3/C4 levels.

Methods

Medical records of pregnant women with confirmed positivity for aPL antibodies attending twelve referral centers from January 2010 to December 2020 were retrospectively evaluated. We considered as aPL-related APO: spontaneous abortions (<10 weeks of gestation), fetal loss (≥10 weeks of gestation), neonatal death (death of a formed fetus alive at birth in the first 28 days of life), preterm delivery before 37 weeks of gestation, preeclampsia, eclampsia or HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet).

Results

We have analyzed 164 singleton PAPS/aPL carrier pregnancies (22 aPL carriers - 13%) in 128 patients: all were treated with combination therapy (LDA+LMWH), and in 30 HCQ was added. 58 pregnancies (43%) had low levels of preconception C3/C4. A triple aPL positivity was observed in 54 pregnancies, 14 of them were treated with combination therapy + HCQ. When considering the whole cohort, the addition of HCQ had not significantly improved the gestational outcome. Further stratification was performed on the basis of complement consumption. In the group of patients with preconception low C3/C4 levels the addition of HCQ had not significantly improved pregnancy outcome. We have lastly evaluated 40 pregnancies with a high-risk profile (triple aPL positivity and complement consumption), in which we have found that HCQ significantly improved gestational outcome (p=0.018, Table 1).

Table 1.

Relationship between APO, therapy during pregnancy and risk profile.

All pregnancies (n=164)Reduced C3/C4 (n=58)Triple aPL+ and reduced C3/C4 (n=40)LDA+LMWH (n, %)LDA+LMWH+HCQ (n, %)pLDA+LMWH (n, %)LDA+LMWH+HCQpLDA+LMWHLDA+LMWH+HCQp(n, %)(n, %)(n, %)APO62 (46%)16 (53%)ns32 (68%)4 (36%)ns23 (77%)3 (30%)0.018No APO72 (54%)14 (47%)15 (32%)7 (64%)7 (23%)7 (70%)Total1343047113010

This observation could not be confirmed in patients with single or double aPL positivity.

Conclusion

The study shows that administering HCQ in addition to combination therapy can improve gestational outcome in aPL/PAPS high-risk patients. This observation confirms that HCQ exerts a beneficial effect on aPL pregnancies by complement inhibition as it was shown in animal models. In addition, our results provide the clinicians a useful tool to implement conventional treatment in patients at high risk of pregnancy complication or loss.

References

[1]De Carolis S, et al. Is there any role for the hydroxychloroquine (HCQ) in refractory obstetrical antiphospholipid syndrome (APS) treatment? Autoimmun Rev 2015;14:760-2.

[2]Mekinian A, et al. The efficacy of hydroxychloroquine for obstetrical outcome in antiphospholipid syndrome: data from a European multicenter retrospective study. Autoimmun Rev 2015;40:498-502.

[3]Mekinian A et al. Obstetrical APS: is there a place for hydroxychloroquine to improve the pregnancy outcome? Autoimmun Rev 2015;14:23-9.

Disclosure of Interests

None declared

POS0741 REPORT FROM THE APS STUDY GROUP OF THE ITALIAN SOCIETY FOR RHEUMATOLOGY (SIR-APS) ON aPL NEGATIVIZATION

Background

The rate of antiphospholipid antibodies (aPL)negativization in antiphospholipid syndrome (APS) patients is uncertain, but it is estimated to be as high as 8%. aPL disappearance seems to be more frequent in patients positive for one single aPL test and appears to be related with the immunosuppressant/immunomodulatory treatment undertaken by the patient. Currently, a consensus definition of aPL negativization is lacking, as well as international recommendations on how to approach treatment in patients with a persistent aPL negative seroconversion.

Objectives

The aim of our work was to evaluate the clinical approach and the level of consensus among experts from the APS Study Group of the Italian Society for Rheumatology (SIR-APS) in different clinical scenario addressing aPL negativization and its definition.

Methods

Experts of SIR-APS were contacted using a survey methodology.

Results

A structured survey was circulated among 30 experts.Up to 90% of the interviewed experts agreed on defining aPL negativization as the presence of two negative determinations, one year apart (90%).Almost ful lconsensus exist among experts in some clinical settings, including: a) the role of aPL negativitation in the management of a thrombotic event determined by concomitant presence of cardiovascular risk factors, both modifiable and not modifiable (90%): b) approach to young patients with triple aPL positivity who experienced pulmonary arterial thrombotic event and tested negative for aPL detection after five year of vitamin K antagonist (VKA) treatment (90%); c)the use of “extra criteria” aPL antibodies testing before pondering VKA suspension (93%).

Conclusion

Consensus is needed to support the management of patients with APS in areas where controlled data are missing. A substantial agreement exists among expert in defying aPL negativization as the presence of two negative determinations, one year apart. On the contrary, VKA suspension should be embraced with extreme caution when it comes to APS patients, particularly if they experienced arterial thrombotic events and/or tested positive for triple aPL. Nevertheless, VKA cessation might be considered when risk factors are carefully monitored/treated and the presence for “extra criteria” aPL is ruled out.

References

[1]Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, Derksen RHWM, DE, Groot PG, Koike T, Meroni PL, Reber G, Shoenfeld Y, Tincani A, Vlachoyiannopoulos PG, Krilis SA. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost 2006; 4: 295–306.

[2]Coloma Bazán E, Donate López C, Moreno Lozano P, Cervera R, Espinosa G.

Discontinuation of anticoagulation or antiaggregation treatment may be safe in patients with primary antiphospholipid syndrome when antiphospholipid antibodies became persistently negative. Immunol Res Immunol Res; 2013; 56: 358–61.

[3]Radin M, Schreiber K, Sciascia S, Roccatello D, Cecchi I, Aguirre Zamorano MÁ, Cuadrado MJ. Prevalence of Antiphospholipid Antibodies Negativisation in Patients with Antiphospholipid Syndrome: A Long-Term Follow-Up Multicentre Study. Thromb Haemost 2019; 119: 1920–6.

Acknowledgements

Italian Society of Rheumatology

Disclosure of Interests

None declared

AB1109 EVALUATION OF THE POTENTIAL INDUCTION OF AUTOANTIBODIES AFTER THE ANTI-SARS-COV2-VACCINATION IN A COHORT OF PATIENTS WITH TRIPLE POSITIVITY FOR ANTIPHOSPHOLIPID ANTIBODIES

Background

Anti-SARS-CoV2 vaccines showed a good efficacy in prevention of severe COVID-191. Their potential in induction of autoantibodies (abs) has not been well established1. One recent study demonstrated an increase of abs’ titre after anti-SARS-CoV2 vaccination only in patients with already pre-existing positivity2.

Objectives

To evaluate the potential induction of abs after anti-SARS-CoV2 vaccination in a triple positive antiphospholipid antibodies (aPL) cohort.

Methods

18 subjects were enrolled [M/F= 17/1; median age=52 years; 5 Primary Antiphospholipid Syndrome (PAPS), 5 Systemic Lupus Erythematosus (SLE) with associated APS and 8 aPL carriers (1 Behçet Disease, 1 SLE, 4 Undifferentiated Connective Tissue Disease, 2 with no diagnosis of systemic autoimmune disease)]. Serum samples were collected before the first (T0) and at least one month after the second administration (T1) of the anti-SARS-CoV2 vaccine (16 BNT162b2, 1 mRNA-1273, 1 Gam-COVID-Vac).

A wide panel of abs were evaluated through routinely methods.

Results

None developed any additional sign of autoimmune diseases upon vaccination. Patients majority did not display any new autoantibody positivity (Table 1). Changes were observed in 3 patients: 1) one aPL carrier patient who was antinuclear antibodies (ANA) negative at T0 was found to be ANA positive at T1 [negative anti-double stranded DNA and anti-extractable nuclear antigen (ENA)]; this patient was actually ANA positive in her clinical history; 2) one aPL carrier patient affected by SLE, who was IgM and IgG aCL and IgG aB2GPI positive at T0, turned positive for IgM and IgA aB2GPI; 3) one aPL carrier patient affected by Behçet Disease, who was positive for IgM aCL and for IgM aB2GPI at T0, turned positive for IgA aCL and IgA aB2GPI.

Table 1.

Autoantibodies’ titre pre (T0) and post (T1) anti-SARS-CoV2 vaccination.

AutoantibodiesLevel at T0Level at T1p-value*Patients positive at T0Patients positive at T1p-value°Anti-dsDNA28.7 (21.8-64.5)25.8 (15.9-68.5)0.1637/18 (38.9%)6/18 (33.3%)0.729(n.v. <27 IU/ml)aCL IgG88.1 (27.1-218.9)68.2 (18.8-181.3)0.11815/18 (83.3%)13/18 (72.2%)0.691(n.v. <20 CU)aCL IgG11.9 (11.2-77.2)11.2 (11.2-24.5)0.4329/18 (50%)7/18 (38.9%)0.502(n.v. <12 IU/ml)aCL IgM20.8 (5.9-35.9)8.9 (3.3-21.6)0.0069/18 (50%)5/18 (27.8%)0.171(n.v. <20 CU)aCL IgM30.4 (18.1-170.8)23.8 (11.2-82.3)0.02914/18 (77.8%)12/18 (66.7%)0.457(n.v. <12 IU/ml)aCL IgA11.7 (11.2-30.9)11.2 (11.2-17.6)0.0298/18 (44.4%)6/18 (33.3%)0.494(n.v. <12 IU/ml)aβ2GPI IgG230.4 (110.1-971.1)242.3 (33.7-652.9)0.08316/18 (88.9%)14/18 (77.8%)0.658(n.v. <20 CU)aβ2GPI IgG9.3 (9.3-128.1)19.4 (9.3-126.9)0.8448/18 (44.4%)9/18 (50%)0.738(n.v. <20 IU/ml)aβ2GPI IgM16.9 (3.6-51.3)6.8 (1.5-23.1)0.0417/18 (38.9%)5/18 (27.8%)0.480(n.v. <20 CU)aβ2GPI IgM19.8 (11.1-78.8)9.9 (9.3-52.4)0.1098/18 (44.4%)7/18 (38.9)0.735(n.v. <20 IU/ml)aβ2GPI IgA20.8 (9.3-39.9)9.3 (9.3-37.8)0.08010/18 (55.6%)7/18 (38.9%)0.317(n.v. <20 IU/ml)

Antiphospholipid antibodies were determined with chemiluminescence (CU) and home-made ELISA (IU/ml) methods of detection. Pre and post-vaccine values are expressed as median (IQR). In bold, statistically significant comparisons. *Wilcoxon signed-rank test for paired variables was applied. °Chi-square test or Fisher’s exact test were applied.

dsDNA=double-stranded DNA; aCL: anti-cardiolipin; aβ2GPI: anti-beta2-glycoprotein I; n.v.: normal value.

All emerging aPL were low titre. None of the patients displayed raising aPL titres from low to medium-high.

Conclusion

Anti-SARS-CoV2 vaccination did not induce any clinical signs of autoimmunity in a cohort of patients with triple aPL positivity. Serology for autoantibodies remained stable in the majority of patients. Few patients experienced the emergence of low titre aPL, possibly as an expected inter-assay variation rather than an evolving “serological flare”.

References

[1]Ishay Y et al. Int Immunopharmacol. 2021;

[2]Thurm C et al. medRxiv 2021.

Disclosure of Interests

None declared

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

Background

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

Objectives

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

Methods

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

Results

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

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

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

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

Conclusion

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

Disclosure of Interests

None declared

AB0686 THE IMPACT OF SYSTEMIC SCLEROSIS (SSc) ON WOMEN’S HEALTH EVALUATED WITH A NEW SSc-SPECIFIC PATIENT-REPORTED QUESTIONNAIRE

Background

Systemic Sclerosis (SSc) can strongly affect the quality of life of affected women. We aimed at designing a SSc-specific, patient-reported questionnaire to explore different aspects of women’s health.

Objectives

The questionnaire was created together with Obstetricians-Gynecologists (70 questions, 5 sections) and administered to consecutive patients with SSc (2013 ACR/EULAR classification criteria) regularly attending our Clinic in May-December 2021. The Female Sexual Function Index (FSFI) questionnaire was also administered.

Methods

The questionnaire was created together with Obstetricians-Gynecologists (70 questions, 5 sections) and administered to consecutive patients with SSc (2013 ACR/EULAR criteria) regularly attending our Clinic in the period May-December 2021. The Female Sexual Function Index (FSFI) questionnaire was also administered.

Results

Questionnaires were proposed to 114 patients; among 100 who accepted to participate (median age 59.0 [43.0-67.0], median disease duration 11.0 [6.0-17.0] years), 48% had received SSc diagnosis during reproductive age (<45 years). The cutaneous involvement was limited in 75% and anti-centromere were positive in 44%. A regular gynecological follow-up was not declared by 60% of the patients. Considering patients with SSc-diagnosis in reproductive age: 73% never discussed contraceptive methods with their SSc-Clinicians; 63% desired a pregnancy after diagnosis, but 30% did not satisfied the desired family size; about 50% reported they did not know whether a woman with SSc could experience disease worsening or take safe medications during pregnancy, and have children also affected by SSc. 77% of patients declared improvement or stability of SSc manifestations during pregnancy. Table 1 shows the comparison of pregnancies before and after SSc diagnosis, based on data reported by the patients. Regarding sexuality, 59% reported that SSc negatively affected it by vaginal dryness (67%), digital ulcers (37%), gastro-intestinal disease (37%) and dyspnea (20%). Among 39 patients completing FSFI, 67% had sexual dysfunction.

Table 1.

Results are presented as median [IQR] or number/number available data (%) based on patients answering the question. Continuous variables were compared with Mann-Whitney test; categorical variables with Fisher’s exact test.

Total pregnancies (n= 189)Pregnancies after diagnosis (n= 42)Pregnancies before diagnosis (n= 147)p-value OR [95% CI]Maternal age at conception, years28.0 [24.0-32.0]32.0 [28.0-39.0]27.0 [23.0-30.0]< 0.001Live births152/189 (80.4)31/42 (73.8)121/147 (82.3)0.221Cesarean sections36/135 (26.7)17/31 (54.8)19/104 (18.3)< 0.0015.43 [2.30-12.9]Preterm births <37 weeks32/109 (29.4)7/32 (21.9)25/77 (32.5)0.269Preterm births <34weeks7/32 (21.8)2/7 (28.6)5/25 (20.0)0.632Birth weight, kilograms3.3 [2.8-3.6]3.1 [2.5-3.5]3.3 [3.0-3.7]0.049≥ 1 Adverse Pregnancy Outcomes15/113 (13.3)8/31 (25.8)7/82 (8.5)0.0163.73 [1.22-11.39]Gestational hypertension4/113 (3.5)3/31 (9.7)1/82 (1.2)0.062Preeclampsia1/113 (0.9)1/31 (3.2)0/82 (0.0)0.274Eclampsia0/113 (0.0)0/31 (0.0)0/82 (0.0)1.000HELLP syndrome1/113 (0.9)0/31 (0.0)1/82 (1.2)1.000Gestational diabetes3/113 (2.7)2/31 (6.5)1/82 (1.2)0.182Intra Uterine Growth Restriction4/113 (3.5)2/31 (6.5)2/82 (2.4)0.302Perinatal deaths2/134 (1.5)0/32 (0.0)2/102 (1.9)1.000Neonatal Intensive Care Unit Admission11/134 (8.2)6/32 (18.8)5/102 (4.9)0.0224.48 [1.27-15.84]Perinatal infections8/134 (8.2)3/32 (9.4)5/102 (4.9)0.396Breastfeeding92/132 (69.7)22/32 (68.8)70/100 (70.0)0.893

Conclusion

The newly created specific questionnaire was instrumental to facilitate physician-patient communication about ‘women’s health’, particularly in the field of sexuality which is characterized by a high frequency of dysfunction. Adverse outcomes are possible during SSc pregnancies and should be discussed during the multidisciplinary preconception counselling, along with measures to possibly reduce their risk.

Acknowledgements

GILS (Gruppo Italiano Lotta Sclerodermia) is kindly acknowledged for supporting the study with a grant.

Disclosure of Interests

None declared

AB0661 NEUROPSYCHOLOGICAL OUTCOME OF CHILDREN BORN TO WOMEN WITH SYSTEMIC SCLEROSIS ASSESSED THROUGH A SELF-ADMINISTERED MULTIDISCIPLINARY QUESTIONNAIRE: RESULTS FROM A MONOCENTRIC COHORT

Background

In the last years, the rate of successful pregnancies has significantly increased in Systemic Sclerosis (SSc)1 women. However, the long-term outcome of their children remains an unexplored issue.

Objectives

To evaluate the neuropsychiatric (NP) outcome of children born to SSc mothers.

Methods

An ad-hoc questionnaire, regarding different aspects of child’s neurodevelopment (ND) (3 sections: childhood [0-5 years]; scholar age [6-11 years]; adolescence [12-18 years]), was created and administered to female SSc patients (ACR/EULAR 2013 criteria) attending our outpatient clinic during 2021 and who had at least 1 child. Children’s NP characteristics were compared between 3 subgroups: A) born >10 years before SSc diagnosis; B) born ≤10 years before SSc diagnosis; C) born after SSc diagnosis. Results below are expressed as number/total number of answers collected for each question.

Results

100 SSc women reported 189 pregnancies: 152 resulted in 154 live births (2 twin pregnancies).

At least one NP alteration was reported in 42/119 (35%) subjects, more frequently in group B (57%), as compared to group A (31%, p:0.07) and group C (30%, p:0.09) although not statistically significant (Figure 1). Sleep irregularities were the most frequently reported disorder (15/42, 36%). Comparisons between the 3 subgroups for every NP outcome evaluated are shown in Table 1: overall, a higher rate of NP alterations were reported in children belonging to group B.

Table 1.

Analysis of NP outcomes: comparison of the 3 subgroups.

A n=103B n=19C n=32N° of subjects evaluated forDISORDERS IN CHILDHOOD103/10319/1932/32Sleep irregularities6/79 (8)*4/13 (31)*5/27 (19)Motor difficulties0/77 (3)°2/13 (15)°2/26 (8)Difficulty in relationships0/78 (0)1/11 (9)2/26 (8)Difficulty in non-verbal communication skills0/78 (0)1/11 (9)2/26 (8)Difficulty in verbal communication skills1/77 (1)1/12 (8)2/26 (8)Difficulty in social integration6/77 (8)3/12 (25)1/25 (4)Cognitive difficulties0/77 (0)1/12 (8)0/26 (0)N° of subjects evaluated forDISORDERS IN SCHOLAR AGE103/10317/1917/32Difficulty in school lessons/homework7/77 (9)3/12 (25)0/15 (0)Behavioral problems during school period4/76 (5)1/12 (8)1/15 (7)School year repetition11/76 (15)2/13 (15)0/15 (0)N° of subjects evaluated forDISORDERS IN ADOLESCENCE101/10314/1911/32Difficulty in managing anger and aggression4/75 (5)0/11 (0)0/10 (0)Behavioral alterations0/75 (0)0/11 (0)0/10 (0)Difficulty in conduct2/73 (3)0/11 (0)2/10 (20)Mood alterations1/73 (1)1/11 (9)0/10 (0)Alterations of the feeding behavior1/75 (1)0/11 (0)0/10 (0)Anxiety problems1/75 (1)1/10 (10)0/10 (0)

Results are presented as number/total number (%) of answers collected for each question. Variables were compared with Chi Squared/exact Fisher test. *p=0.03; °p=0.02.

Figure 1.

Children with ≥1 NP alteration: comparison of the 3 subgroups.

In addition, SSc mothers declared that 7/123 (6%) children underwent a NP evaluation leading to a diagnosis in 3 cases: 1 cognitive delay, 1 learning disorder (LD) and 1 autism spectrum disorder (ASD). These children were born 1 and 5 years before and 3 years after SSc diagnosis, respectively. The prevalence of these diagnoses (0.8%) does not differ from general pediatric population.

Conclusion

Children born to SSc mothers, had prevalence of major NP alterations (cognitive deficits, LDs, ASDs) similar to general pediatric population. A higher frequency of minor ND disorders, especially sleep irregularities, was observed in children within 10 years before maternal diagnosis, compared to the other groups, possibly suggesting an impact of maternal chronic disease on the relationship with child in the first years of life. To confirm these self-reported preliminary data, the extension of the study will consist in a systematic NP evaluation proposed to all the offspring of SSc mothers aged ≤18 years.

References

[1]Blagojevic J et al. 2019. J Rheumatol.

Acknowledgements

GILS (Gruppo Italiano Lotta Sclerodermia) is kindly acknowledged for supporting the study with a grant.

Disclosure of Interests

None declared

OP0125 THE MANAGEMENT OF PREGNANCY IN AUTOIMMUNE RHEUMATIC DISEASES: ANALYSIS OF 758 PREGNANCIES FROM THE PROSPECTIVE NATIONWIDE P-RHEUM.IT STUDY (THE ITALIAN REGISTRY OF PREGNANCY IN THE RHEUMATIC DISEASES)

Background

Pregnancy is a topic of fundamental importance for women living with autoimmune rheumatic diseases (ARD). Efforts at national and international levels have been put in the collection and harmonization of data in order to implement an evidence-based management of pregnant patients.

Objectives

The P-RHEUM.it study was designed as a nationwide, web-based longitudinal observational cohort study to collect data about pregnancy in ARD in 26 centers in Italy. The study started in May 2018 and has been supported by the Italian Society for Rheumatology.

Methods

Pregnant patients with a definite rheumatic disease according international criteria were enrolled up to gestational week (GW) 20. The course of maternal disease activity, the use of medications, fetal and maternal complications, and the quality of life (EuroQoL questionnaire) were collected for each trimester, as well as pregnancy outcome, mode of delivery, neonatal complications, and maternal and children’s follow-up to 6 months after delivery, including the screening for post-partum depression by means of EPDS (Edinburgh Postnatal Depression Scale).

Results

As of December 2021, 758 pregnancies had been enrolled, 205 (27%) ongoing and 553 (73%) with outcome. Pregnancy loss occurred in 54 (9.8%) cases (40 spontaneous miscarriages; 6 voluntary terminations). Live births were 495 (89.5%), perinatal death occurred in 4 (0.7%) cases. Table 1 reports on the group of 495 live births, along with subgroups of Rheumatoid Arthritis (RA) and Systemic Lupus Erythematosus (SLE), the two most represented diseases. Regarding treatments, 166 (30%) pregnancies were exposed to corticosteroids, 239 (43%) to hydroxychloroquine, 59 (10.7%) to csDMARDs, 84 (15.2%) to TNF inhibitors, 1 (0.2%) to non-TNFi bDMARDs, 299 (54%) to low dose acetylsalicylic acid, and 126 (22.8%) to heparin.

Table 1.PREGNANCIES WITH LIVE BIRTHS, EXCLUDING PERINATAL DEATHSTotal pregnancies (n=495)RA pregnancies (n=69)SLE pregnancies (n=93)Age at conception (years)34 (31 - 37)34.5 (32 - 38)34 (31 - 36)Disease duration (years)6.1 (2.2 - 11.1)7.1 (4.3 - 11.6)9.3 (5.9 - 15.9)Caucasian431 (87.8%)53 (79.1%)75 (80.6%)Never smokers358 (73.8%)53 (80.3%)66 (71.7%)Body Mass Index >3045 (9.5%)7 (10.3%)5 (5.6%)Arterial Hypertension6 (1.2%)0 (0%)2 (2.2%)Time to pregnancy (months)3 (1 - 6)3 (1 - 6)3 (0 - 10)Physician-reported flares in the 12 months prior to conception107 (23%)22 (34.4%)13 (14.8%)Physician global assessment at enrolment (VAS 0-100)5 (0 - 17)5 (0 - 20)4 (0 - 10)Patient global health at enrolment (VAS 0-100)18 (7 - 30)10 (5 - 29)10 (5 - 25)EuroQoL at enrolment (-1.6 – 1)1 (0.8 - 1)1 (0.8 - 1)1 (0.8 - 1)Flares during pregnancy35 (7.1%)6 (8.7%)7 (7.5%)Hypertensive disturbances*8 (1.7%)1 (1.6%)6 (6.6%)Delivery at term (≥37 GW)410 (85.1%)53 (77.9%)74 (80.4%)Spontaneous vaginal delivery173 (35.9%)23 (33.8%)23 (25.3%)Congenital malformations11 (2.4%)2 (3.1%)1 (1.1%)Small for gestational age (SGA) neonate24 (4.9%)1 (1.4%)9 (9.9%)Breastfeeding in the first 4 weeks after delivery341 (79.7%)45 (77.6%)59 (76.6%)EPDS score at risk for post-partum depression22 (14.1%)0 (0%)3 (10.3%)

Continuous variables are expressed as median (interquartile range); *gestational hypertension/preeclampsia/HELLP syndrome/eclampsia.

Conclusion

Multiple factors may have contributed to the high rate of live births, including good disease control before and during pregnancy thanks to the use of anti-rheumatic drugs and low frequency of general risk factors. SLE pregnancy was affected by a higher frequency of complications (hypertensive disturbances, SGA babies) as compared to RA pregnancy. Nearly 80% of patients breastfed in the first month after delivery. For the first time, data about the screening questionnaire for post-partum depression were collected, showing at least 1 out 10 patients can be at risk.

References

[1]Meissner Y et al. Arthritis Res Ther;21(1):241; Ann Rheum Dis. 2021;80(1):49-56.

Acknowledgements

P-RHEUM.it study is supported by the Italian Society for Rheumatology (SIR). All the Investigators are acknowledged for their contribution.

Disclosure of Interests

None declared

POS0764 EULAR RECOMMENDATION-BASED QUALITY INDICATORS (QIS) FOR SYSTEMIC LUPUS ERYTHEMATOSUS (SLE): ELABORATION, FINAL SET, PERFORMANCE AND INITIAL VALIDATION

Background:

Targets of therapy and quality of care are receiving increased attention in systemic lupus erythematosus (SLE).

Objectives:

To develop Quality Indicators (QIs) for the care of SLE patients based on the EULAR recommendations, and assess their performance.

Methods:

Using the published EULAR recommendations for SLE, we developed 44 candidate QIs. These were independently rated for validity and feasibility by 12 experts, analysed by a modified RAND/UCLA model and further scrutinized based on the scorings and expert opinion. (Fig.1) Adherence to the final set of QIs was tested in a cohort of 220 SLE patients combined with an assessment on its impact on disease outcomes such as flares, hospitalizations and organ damage.

Results:

The panel rated 18 QIs as valid and feasible. These involve diagnosis; disease and damage assessment; monitoring for lupus nephritis and drug toxicity; therapy and targets of therapy; fertility and pregnancy; and adjunct therapy (preventive measures for osteoporosis, vaccination, cardiovascular disease). On average, SLE patients received 54% (95%CI 52–56%) of the indicated care with adherence ranging from 41% for QIs related to monitoring to 88% for treatment-related QIs. Regarding targets of therapy, sustained remission or low disease activity were achieved in 27%, while 94% of patients received low-dose glucocorticoids, and 92% the recommended hydroxychloroquine dose. Dependent upon individual QI tested, adherence for lupus nephritis-related QIs was 88% for receiving appropriate adjunct therapy (ACE inhibitors) to 100% for being treated with the indicated immunosuppressive treatment. In contrast, adherence to QIs related to preventive measures and other adjunct therapies was moderate to low. Notably, patients who were eligible for cardiovascular risk modification, vaccination, and osteoporosis management received lower quality of care (40.5%, 47.7% and 45.5% respectively) while 91.4% had sunscreen protection. In reference to laboratory work-up and monitoring, complete laboratory work-up at diagnosis was performed in 48%, while disease activity and damage, were fully assessed only in 14.1% (in three consecutive visits) and 28.6% (annually) respectively, Similarly, reproductive health and pregnancy counselling adherence rates were modest estimated at 50% and 62% respectively. Higher adherence to the indicated care during follow-up (monitoring QIs) was associated with reduced risk for adverse outcomes during the last year of observation (OR 0.97, 95%CI 0.96-0.99). Patients who achieved sustained remission or LLDAS, exhibited fewer flares (OR=0.15, p-value<0.001) and damage accrual (OR=0.35, p-value<0.001). Of interest, patients who received low-dose of GCs or were appropriately vaccinated, had a lower risk of experiencing a flare (OR=0.23 and 0.46 respectively).

Conclusion:

A set of 18 QIs based on the EULAR recommendations for SLE was developed to be used towards improving care in SLE. Initial real-life data suggest variable degree of adherence with higher adherence resulting in reduced adverse outcomes.

References:

[1]Fanouriakis, et al., 2019 Update of the EULAR recommendations for the management of systemic lupus erythematosus. In Annals of the Rheumatic Diseases (Vol. 78, Issue 6, pp. 736–745). BMJ Publishing Group. https://doi.org/10.1136/annrheumdis-2019-215089.

[2]Nikolopoulos, D., et al., Evolving phenotype of systemic lupus erythematosus in Caucasians: low incidence of lupus nephritis, high burden of neuropsychiatric disease and increased rates of late-onset lupus in the ‘Attikon’ cohort. Lupus, 29(5), 514–522. https://doi.org/10.1177/0961203320908932.

Acknowledgements:

This project has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (grant agreement No 742390)

Disclosure of Interests:

None declared

POS0737 LOW PRECONCEPTIONAL COMPLEMENT LEVEL IS RELATED WITH ADVERSE OBSTETRIC OUTCOME IN A MULTICENTRIC COHORT OF PREGNANCY IN PATIENTS WITH APS AND APL POSITIVITY

Background:

The role of complement in the antiphospholipid (aPL) related pathology has been widely studied in animal models. Antiphospholipid antibodies can induce fetal loss in experimental animals but mice deficient in specific complement components (C4, C3, C5) appear somehow protected. In addition, in pregnant mice injected with aPL, antibody deposition has been found at decidual level causing focal necrosis, apoptosis and neutrophil infiltrates and supporting aPL pathogenetic potential. On the other hand, human studies did find hypocomplementemia associated to pregnancy complications in patients with obstetric antiphospholipid syndrome (APS). These results, however, are not unanimously confirmed and, in addition, some studies only show increased levels of complement activation products (i.e. Bb) and not decreased levels of C3 and/or C4. A recently study focusing on complement level in early pregnancy and before pregnancy showed a significant correlation with pregnancy complications and loss in a large cohort of primary APS.

Objectives:

To investigate if the simple detection of low C3 and/or C4 could be considered a risk factor for adverse pregnancy outcome in APS and aPL carriers pregnancies.

Methods:

We performed a multicentric study including patients from 10 Italian and 1 Russian Centers. Data on pregnancies in women with primary APS (n=434) and asymptomatic carriers with persistently positive aPL but not fulfilling clinical criteria for APS (n=218) were retrospectively collected. Serum C3 and C4 levels were evaluated by nephelometry; hypocomplementemia was defined by local laboratory reference values. Statistical analysis was performed using GraphPad.

Results:

Preconceptional complement levels and gestational outcome were available for 107 (25%) pregnancies in APS out of 434 and for 196 (90%) pregnancies in aPL carriers women out of 218. In pregnancies with low preconceptional C3 and/or C4, a significantly higher prevalence of pregnancy losses was observed (p=0.019). A subgroup analysis focusing on triple aPL positive patients was also performed. Preconceptional low C3 and/or C4 levels were found to be associated with an increased rate of pregnancy loss (p = 0.027) in this subgroup also. Otherwise, adverse pregnancy outcomes in single or double aPL positive women were not related to preconception complement levels (p = 0.44) (Table 1). Of note, all the pregnancy losses in the triple positive group occurred in patients treated with low dose aspirin and low molecular weight heparin from the time of positive pregnancy test.

Conclusion:

Our findings confirm that decreased complement levels before pregnancy are associated with increased risk of adverse outcome. This has been seen only in in women with triple aPL positivity, indeed single or double positivity does not show this trend. Complement levels are cheap and easy to be measured therefore they could represent a useful aid to identify patients at increased risk of pregnancy loss. test positivity.

References:

[1]De Carolis S, et al. Complementemia and obstetric outcome in pregnancy with antiphospholipid syndrome. Lupus (2012) 21:776–8.

[2]Kim MY, et al. Complement activation predicts adverse pregnancy outcome in patients with systemic lupus erythematosus and/or antiphospholipid antibodies. Ann Rheum Dis (2018) 77:549–55.

[3]Fredi M, et al. Risk Factors for Adverse Maternal and Fetal Outcomes in Women With Confirmed aPL Positivity: Results From a Multicenter Study of 283 Pregnancies. Front Immunol. 2018 May 7;9:864.

Triple aPL positivitySingle or double aPL positivityGestational outcomeLow C3/C4 (n=49)Normal C3/C4(n=17)pLow C3/C4 (n=57)Normal C3/C4(n=165)pTerm live birth (>37w)15 (31%)6 (35%)ns34 (60%)110 (67%)nsPreterm live birth (≤37w)22 (45%)11 (65%)ns15 (26%)38 (23%)nsPregnancy losses (abortion and miscarriages)12 (24%)0 (0%)0.0278 (14%) 17 (10%)ns

Disclosure of Interests:

None declared

POS0476 CAN LOW-DOSE ASPIRIN DURING PREGNANCY PREVENT THE DEVELOPMENT OF ADVERSE PREGNANCY OUTCOMES IN WOMEN WITH ARTHRITIS? DATA FROM THE P-RHEUM.it STUDY

Background:

In rheumatic diseases, specifically in chronic inflammatory arthritis (IA), there are no data about the effectiveness of LDA in preventing pregnancy complications.

Objectives:

To assess the potential benefit of LDA administration during pregnancy to prevent adverse pregnancy outcomes (APO) in IA.

To compare pregnancy outcomes in IA pregnancies treated during pregnancy with LDA with those untreated.

Methods:

Italian P-RHEUM.it register is designed as a nationwide, web-based longitudinal observational cohort study collecting data on pregnancies in inflammatory rheumatic diseases. At baseline, socio-demographic parameters, obstetric history, comorbidities and clinical/laboratoristic characteristics are registered. During pregnancy, the course of maternal disease, medications, development of fetus and complications are collected for each trimester.

Results:

From May 2018 to May 2020, 349 patients were enrolled. Forty-five patients with IA had completed their pregnancy with known outcome (20 Rheumatoid Arthritis, 10 Psoriatic Arthritis, 6 Ankylosing spondylitis, 5 Juvenile Idiopathic Arthritis, 4 Undifferentiated Arthritis): 13 (28.89%) treated with LDA during pregnancy and 32 (71.11%) without LDA prophylaxis. LDA was used with a higher frequency in women with previous APO, anti-phospholipid positivity and on biological DMARDs even if it’s not statistically significant (Table 1). All the LDA-treated women had a live-birth rate of 100%, whereas among women not treated with LDA the live birth rate was of 84.4% with 27 live-birth pregnancies, 3 early miscarriages, 1 fetal loss and 1 stillbirth observed. There were no significant differences between the LDA and the not LDA groups regarding pregnancy/peripartum obstetric complications (p=0.14), although less adverse pregnancy/peripartum outcomes were registered in LDA patients’ group (Table 1).

Conclusion:

The preliminary data of this prospective cohort study show that LDA improve pregnancy outcome in IA even if women treated with LDA had more risk factors for APO. The extension of this cohort will allow us to further investigate these important results.

References:

[1]Roberge S, et al. AmJObstetGynecol.2017;216:110-120.e6.

[2]Andreoli L et al. Annals of the Rheumatic Diseases 2017;76: 476–85.

[3]Sammaritano L et al. Arthritis & Rheumatology 2020; 72: 529–56.

Table 1.

Comparison between inflammatory arthritis pregnancies treated with low-dose aspirin and those untreated.

LDA (n 19)Not LDA (n 39)pMaternal age at conception, median (IQR)33 (30.5 - 36.5)33 (28.2 - 35)BMI, median (IQR)25.4 (22.9 - 28.5)22.5 (20.4 - 24.5)Smoking, n (%)3 (15.8%)4/36 (11.1%)0.68Previous APO, n (%)7/11 (63.7%)7/13 (56.1%)0.34aPL+, n (%)3 (15.8%)1/36 (2.8%)0.1CRP+, n (%)5/15 (33.3%)11/27 (40.7%)0.75GC at baseline, n (%)9 (47.4%)15/34 (44.1%)0.82cDMARDs at baseline, n (%)1 (5.3%)3/34 (8.8%)1bDMARDs at baseline, n (%)6 (31.6%)11 (28.2%)0.79Live-birth pregnancy, n (%)18 (94.7%)32 (82.1%)0.25Pregnancy loss, n (%)1 (5.3%)7 (17,9%)0.25Hypertensive disorders, n (%)2/18 (11.1%)6/38 (15,8%)1HELLP syndrome, n (%)0 (0%)0 (0%)1PROM, n (%)0 (0%)3/38 (7.9%)0.54Preterm delivery, 34-37 GW, n (%)2 (10.5%)2 (5.2%)0.59Preterm delivery, <34 GW, n (%)1 (5.3%)1 (2.6%)1IUGR, n (%)0 (0%)3 (7.8%)0.54SGA, n (%)0 (0%)0 (0%)1Pregnancy/Peripartum complications, n (%)3 (15.8%)11 (28.9%)0.35

Legend: aPL, Antiphospholipid syndrome; bDMARDs, biological disease-modifying antirheumatic drugs; BMI, Body mass index; cDMARDs, Conventional disease-modifying antirheumatic drugs; CRP, C-reactive protein; GC, Glucocorticoids; GW, gestational week; HELLP, haemolysis, elevated liver enzymes, and low platelets; Hypertensive disorder defined as gestational hypertension, preeclampsia and eclampsia; IQR, Interquartile range; IUGR, intrauterine growth restriction; LDA, Low-dose Aspirin; Pregnancy loss defined as early fetal-loss, miscarriage and still-birth; PROM, Premature rupture of membranes; SGA, Small for gestational age.

Acknowledgements:

I would like to acknowledge the Epidemiology Unit of the Italian Society for Rheumatology and the Investigators of the Italian Registry.

Disclosure of Interests:

None declared

POS0760 MONITORING C3 AND C4 VARIATIONS IN SYSTEMIC LUPUS ERYTHEMATOSUS PREGNANCIES IS USEFUL TO RECOGNIZE COMPLICATIONS. DATA FROM 2 ITALIAN CENTERS

Background:

In SLE pregnancies adverse pregnancy outcomes (APO) are more frequent than in general obstetric population (GOP). In clinical practice, low C3 and C4 levels are associated with active disease and, during pregnancy, complement activation products are shown to be associated with APO.

Objectives:

To analyse complement variations during SLE pregnancies, focusing on disease flares and APO.

Methods:

Data on SLE pregnancies prospectively-followed by multidisciplinary team in 2 Italian Centers from 1987 to 2018 were retrospectively analysed. C3 and C4 normal levels were calculated in general obstetric population (GOP) as previously described1, and related to maternal and fetal outcome. Non categorical variables were compared using Mann-Whitney test or Wilcoxon test when appropriate.

Results:

Two hundred forty-six pregnancies in 172 SLE patients were analysed (mean age at conception 31.3 ±4.9 years; mean disease duration 8.3 ±7.1). Anti-Ro antibodies were positive in 64 patients (37%) and anti-phospholipid antibodies (aPL) were positive in 84 (48%), with single positivity in 54%, double in 24% and triple in 21%; 9 patients (5%) had also a diagnosis of obstetric-antiphospholipid syndrome (APS) and 8 (4%) had thrombotic-APS. Seventy-one patients (41%) had history of Lupus Nephritis.

Thirty-five flares were recorded in 30 pregnancies (12%). APO occurred in 47 pregnancies (19%) and were: 27 fetal loss (20 early miscarriage <10th week and 7 intrauterine fetal death), 11 severe preterm birth (<34th week) and 15 hypertensive disorder (11 pre-eclampsia and 5 pre-eclampsia+HELLP syndrome).

In GOP, C3 progressively increased throughout pregnancy and C4 increase from the 1st trimester to the 2nd trimester, as well as in SLE pregnancies without flares and without APO, from preconception (Fig 1). In the other SLE groups, C3 and C4 showed a different trend: in pregnancies with flares, they did not increase from preconception to the 1st trimester; in fetal losses and severe pre-term births, they remained stable throughout pregnancy; in hypertensive disorders they increased only between preconception and the 1st trimester.

C3 and C4 levels were higher in GOP than in all SLE pregnancies groups (including those without flares and without APO) in each trimester. SLE pregnancies without flares showed higher C3 and C4 levels than pregnancies with flares, at preconception and in each trimester. SLE pregnancies without APO had higher C3 and C4 levels than pregnancies with fetal death at 2nd trimester, higher C3 levels than severe pre-term births in each trimester and higher C4 at 3rd trimester (Fig.1).

At preconception, pregnancies with flares showed a higher frequency of low C3 and of low C4 than in pregnancies without flares (76% vs 42%, p=0.01; 76% vs 26%, p<0.001, respectively). Using the normality range previously calculated in GOP, SLE pregnancies with flares had higher frequency of low C4 in every trimester as compared with pregnancies without flares (1st: 82% vs 48%, p=0.003; 2nd: 82% vs 64%, p=0.01; 3rd: 64% vs 30%, p=0.002). At multivariate analysis, low C4 at preconception was associated with flare (OR [95% CI]: 10.34 [2.52-42.39]; p=0.001).

Figure 1.

Variations of C3 and C4 median levels (mg/dL) throughout pregnancy in GOP1 and in SLE pregnancies without and with flare (a) and without and with APO (b).

* p <0.05

^as compared with SLE groups: p<0.05; § as compared with SLE pregnancies without flare: p<0.05; + as compared with SLE pregnancies without APO: p<0.05

Conclusion:

In SLE pregnancies, monitoring of C3 and C4 is important: its failure to increase can be useful to recognize potential risk situations which deserve particular monitoring.

References:

[1]Reggia R. et al. Rheumatology 2012;51:2186-2190.

Disclosure of Interests:

None declared

AB0822 BREASTFEEDING AMONG WOMEN WITH RHEUMATIC DISEASES: ANALYSIS OF DATA FROM THE P-RHEUM.IT STUDY

Background:

The World Health Organization recommends that infants should be exclusively breastfed until the age of 6 months. The aim of this study was to assess the ratio of breastfeeding patients with Rheumatic Diseases (RD) and to identify possible causes of its discontinuation.

Objectives:

The aim of this study was to assess the ratio of breastfeeding patients with Rheumatic Diseases (RD) and to identify possible causes of its discontinuation.

Methods:

This study was embedded in the P-RHEUM.it register, as a nationwide prospective cohort study collecting data of pregnancies in inflammatory RD. Pregnancies, enrolled until the 20th week of pregnancy, are followed from pregnancy until 6 months postpartum. At baseline, sociodemographic parameters, obstetric history, comorbidities are reported. During pregnancy, the course of maternal disease, development of foetus and complications are reported. After delivery, the pregnancy outcome, data on lactation and child development are collected.

Results:

From May 2018 to May 2020 data of 349 patients were available. Data on lactation were available in 44 pregnancies. Two months after delivery 37 were continuing breastfeeding (n=26) or mixed feeding (n=11), while 7 were using formula feeding. Among patients using formula feeding 2 had a diagnosis of rheumatoid arthritis (RA), 1 of juvenile idiopathic arthritis, 1 of undifferentiated arthritis (UA), 1 of anti-phospholipid syndrome (APS), 1 of vasculitis and 1 of systemic lupus erythematosus. The reasons of formula feeding were the following: 2 for agalactia, 2 for personal preferences, 3 for drug-related concerns (1 for physician’s decision in a patient with APS; 2 for maternal concerns about drugs in patients with RA and UA treated respectively with Adalimumab and Tocilizumab). At 6 months 30 continued breastfeeding (n=23) or mixed feeding (n=7) and 14 formula feeding. The reasons of formula feeding were available in 9 patients: 3 for agalactia, 2 for personal preferences, 2 for physician’s decision in a patient with APS and in a patient positive for anti-phospholipid antibodies; 2 for maternal concerns about drugs.

Conclusion:

Preliminary data of this prospective study demonstrate a high percentage of breastfeeding/mixed feeding after delivery and after 6 months among women with RD. Drug related concerns are the main reason of discontinuation of breastfeeding, although medication results compatible with lactation. Using our results, strategies supporting patients with RD whishing to breastfeed may be developed.

References:

[1]Carina Gotestam Sporken et al. The EULAR points to consider for use of antirheumatic drugs before pregnancy, and during pregnancy and lactation. Ann Rheum Dis 2016.

[2]Sammaritano et al. 2020 American College of Rheumatology Guideline for the management of reproductive health in rheumatic and muscoloskeletal diseases, Arthritis Rheumatol. 2020.

Acknowledgements:

Authors would like to thank SIR study center and all patients who accepted to partecipate to our study

Disclosure of Interests:

None declared

POS0702 PREGNANCY IN SLE PATIENTS TREATED WITH BELIMUMAB: EXPERIENCE FROM 3 ITALIAN CENTERS

Background:

Belimumab (BEL) is a monoclonal antibody approved for SLE treatment but few data are available about its use before or during pregnancy.

Objectives:

Our study aims to describe pregnancies in SLE patients who have discontinued BEL before conception, at positive pregnancy test or during pregnancy.

Methods:

Data from prospectively-followed pregnancies (2014-2020) in SLE patients treated with BEL in 3 Italian centers where retrospectively collected, focusing on maternal disease activity, obstetric and neonatal outcome. Continuous data are expressed as median [min-max].

Results:

Thirteen SLE pregnancies were analyzed (median age at conception 32 [24-41] years; 77% spontaneous, 69% primigravidae). All patients had positive ANA and anti-dsDNA antibodies; 4 had anti-Ro antibodies (31%); 4 had anti-phospholipid antibodies (aPL; 1 single, 2 double and 1 triple positivity). Seven patients (54%) had a history of lupus nephritis (LN); 2 patients (15%) had a concomitant diagnosis of antiphospholipid syndrome (1 thrombotic-APS and 1 thrombotic+obstetric-APS).

Ten (77%) pregnancies were planned and the use of BEL with regard to pregnancy was agreed with the patient during preconception counseling. At preconception visit, 8 patients were in remission while 5 had active disease (median SLEDAI 3 [0-8]).

BEL (11 intravenous, 2 subcutaneous) was stopped in 2 cases before conception, in 7 at positive pregnancy test and in 4 during pregnancy (2 at 11th week, 1 at 22nd, 1 at 24th); median duration of treatment at discontinuation was 29 [4-68] months. Other treatments during pregnancy were: oral prednisone in 12 cases (92%); intravenous methylprednisolone in 1 (8%); hydroxychloroquine in 10 (77%); chloroquine in 1 (8%); azathioprine in 5 (39%); calcineurin inhibitors in 5 (39%); low-dose acetylsalicylic acid in 10 (77%); low molecular weight heparin in 9 (69%).

Three flares occurred during the 3rd trimester in patients who stopped BEL at positive pregnancy test.

Live-births occurred in 92% of the pregnancies. A patient with thrombotic+obstetric-APS and LN, underwent assisted reproductive technology (embryo donation) and developed eclampsia (25thweek), an urgent cesarean section was performed and the newborn died after 3 days. One pre-eclampsia occurred in a patient with history of LN, double aPL positivity and active disease. One miscarriage at 11th week occurred; no early miscarriages (<10th week) were recorded. Pregnancy complications and outcomes are reported in Table 1.

Table 1.

Pregnancy complications and outcomes according to the timing of discontinuation of BEL.

BEL STOPPED PRECONCEPTIONALLY(2)BEL STOPPED AT POS PREGNANCY TEST(7)BEL STOPPED DURING PREGNANCY(4)Pre-eclampsia0/20/71/4 (25%)Eclampsia0/20/71/4* (25%)Gestational Diabetes0/21/7 (14%)0/4IUGR0/21/7 (14%)1/4* (25%)pPROM/PROM0/20/71/4 (25%)Live birth1/2 (50%)7/7 (100%)4/4 (100%)Severe pre-term birth(≤ 34thweek)0/20/71/4* (25%)Late pre-term birth(35th- 37thweek)0/23/7 (43%)0/4Small for Gestational age neonate0/24/7 (54%)1/4 (25%)Late miscarriage (>10thweek)1/2 (50%)0/70/4Perinatal death0/20/71/4* (25%)

IUGR: IntraUterine Growth Restriction; PROM: Premature Rupture of Membrane; pPROM: pretermPROM; *in the same patient (history of thrombotic and obstetric-APS and lupus nephritis) who underwent Assisted Reproductive Technologies (embryo donation).

No malformations were recorded. Two newborns were transferred to the Intensive Care Unit (1 for milk protein intolerance and 1 for desaturation).

Eight newborns received vaccinations according to national schedule (missing data for 3). Five newborns were breastfed, 1 received formula milk and 5 mixed-feeding. BEL was resumed in 7/13 patients after pregnancy (in 4 cases for flare), after a median period of 5 [4-22] months.

Conclusion:

While more data are needed, this small series suggests that BEL might be a therapeutic option for SLE patients during pregnancy planning, similarly to other biological drugs used in chronic forms of arthritis.

Disclosure of Interests:

None declared

POS0693 EFFICACY AND SAFETY OF BELIMUMAB IN PATIENTS WITH LUPUS NEPHRITIS IN REAL-LIFE SETTING: RESULTS FROM A LARGE, NATIONWIDE, MULTICENTRIC, PROSPECTIVE COHORT

Background:

LN is still a severe manifestation of Systemic lupus erythematosus (SLE) and multitarget therapy is needed to control the disease especially in refractory cases.

Objectives:

To evaluate renal response in SLE patients with glomerulonephritis (GN) treated with Belimumab in real-life setting.

Methods:

Patients with proteinuria >0.5 g/24 h and/or active sediment at baseline enrolled in a multicentre Italian cohort of SLE patients (BeRLiSS study), treated with monthly iv Belimumab 10 mg/kg plus standard of care were considered in this study. Complete renal response (CRR) was defined as proteinuria <0.5 g/24 h, estimated glomerular filtration rate (eGFR)≥90ml/min/1.73m2 and no rescue therapy. Primary efficacy renal response (PERR) was defined as proteinuria ≤0.7 g/24 h, eGFR ≥60ml/min/1.73m2 and no rescue therapy. Prevalence and predictive factors of CRR and PERR at 12 and 24 months after Belimumab initiation were analyzed by multivariate logistic regression analysis.

Results:

A total of 91 patients were considered in this study, 79 female, mean age 40.51±9.03 years, mean disease duration 12.18±8.15 years, median follow-up time after Belimumab initiation 22 months. Twenty patients had baseline proteinuria ≥0.5 <1 g/day, 17 ≥1 <2 g/day, 13 ≥2 g/day. Belimumab was started at GN onset in 20 (22%) patients and at the time of a renal flare in all other cases. Seventy-five patients underwent a renal biopsy: 1 class I, 4 class II, 14 class III, 47 class IV and 9 class V. Baseline serum creatinine was 82.44±29.26 umol/L; 15 patients showed eGFR<60ml/min/1.73m2 at baseline. Immunosuppresants were taken by 70 (76.9%) patients: 47 micofenolate, 15 azathioprine and 5 ciclosporine. Sixty patients (65.9%) were on antimalarials. During follow-up 34 (37.4%) patients achieved CRR. Among them 5 (14.7%) patients relapsed and 29 (85.3%) patients maintained remission. Mean time to achieved CRR was 9.71±5.91 months.

High levels of baseline proteinuria were a negative independent predictor of CRR and PERR at 6 months (OR 0.044 CI95% 0.006-0.320 p=0.002 and OR 0.232 CI95% 0.091-0.596 p=0.002) and 12 months (OR 0.029 CI95% 0.002-0.556 p=0.019 and OR 0.056 CI95% 0.009-0.327 p=0.001). High levels of baseline creatinine were a negative independent predictor of renal response. Renal response at 6 months was a strong predictive factor of renal response at 12 and 24 months.

Conclusion:

Belimumab is an effective add-on therapy in the treatment of GN in real-life practice setting.

Disclosure of Interests:

None declared

POS0724 GENDER DIFFERENCES IN THROMBOTIC PRIMARY ANTIPHOSPHOLIPID SYNDROME IN A LARGE COHORT OF PATIENTS FROM FOUR EUROPEAN CENTERS

Background:

Autoimmune diseases occur more frequently in females and their course and severity can be affected by gender. Antiphospholipid syndrome (APS) is a systemic autoimmune disorder in which antiphospholipid antibodies (aPL) exert a pathogenic role resulting in vascular thrombosis and/or pregnancy morbidities. Data about gender differences in thrombotic APS (t-APS) are still scarce1,2.

Objectives:

To evaluate the differences in frequency, disease expression and severity between females and males affected by primary t-APS.

Methods:

Retrospective study enrolling subjects with a formal diagnosis of primary APS (Miyakis 2006) with vascular thrombosis at onset. Women who presented with obstetric events as first aPL-related manifestation were excluded. All the patients were followed from 1967 to 2019 in four European centers: three French centers and one Italian center.

Results:

The study included 433 patients (68% females, 32% males). Median age at t-APS onset [31 (24-46) vs 41 (29-53) years, p<0.001] and at diagnosis [34 (27-50) vs 46 (34-57) years, p<0.001] was significantly lower in females.

The most common presenting manifestations were venous thrombosis (60%) followed by arterial events (37%) and catastrophic APS (3%). Venous events were more frequent in women as compared to men (64% vs 51% p:0.012 OR:1.7 [1.1-2.5]). Sites of venous thrombosis included: limbs (35%), pulmonary (17%), cerebral (3%), portal and inferior cava (2%) and retinal (1%) veins, without gender differences. The arterial events were more frequent among men (43% vs 34% p:0.053). Strokes (27%) and myocardial infarctions (4%) were the most frequent manifestations, followed by thrombosis of limbs (2%), retina (2%) and abdominal organs (1%). Noteworthy, only men presented with visceral ischemia.

During the follow-up, new thrombosis occurred in 41% of patients (179/433). 33% out of them had at least two episodes and these occurred especially among males (22% vs 10% p:0.001 OR:2.5 [1.3-4.8]). New events were mostly of the same type, but ⅓ of patients presented a switch from venous to arterial side and viceversa, with no gender differences.

Complete aPL profile was available in 357 subjects: 33% had single aPL positivity, 24% double positivity and 43% triple positivity, with no differences between women and men. About 80% of the patients had a concomitant risk factor (RF) for thrombosis. Established cardiovascular RFs were more represented among men as shown in table 1. In women, estrogenic exposure was the main RFs, present in almost 40% of them.

Table 1.MALESn= 137FEMALESn= 296POR [IC 95%]Traditional cardiovascular RFs, n (%)Smoke66 (48)81 (27)<0.0012.5 [1.6-3.8]Arterial hypertension59 (43)75 (25)<0.0012.2 [1.5-3.4]Dyslipidemia52 (38)72 (24)0.0041.9 [1.2-2.9]Diabetes16 (12)15 (5)0.0142.5 [1.8-5.1]Obesity13 (10)38 (13)nsOther thrombophilic factors, n (%)Estrogenic stimuli*0116 (39)-Trauma / surgery / immobilization21 (15)32 (11)nsCongenital thrombophilia9/94 (10)33/204 (16)ns

Data were compared using contingency tables, p value was calculated with Chi-Squared or Fisher exact test. *= hormonal therapy, pregnancy, post-partum

Conclusion:

This gender-oriented analysis of patients with primary t-APS showed that women had the first vascular event at a younger age and mostly on the venous side, while men presented mainly with arterial events, later in life and suffered from more recurrent events. No differences were observed in the distribution of the aPL profile. The different frequency of arterial and venous events in the two groups could be attributed mainly to the presence of additional RFs rather than to biological gender-specific issues. However, it should be underlined that some RFs, such as the use of estrogens or classic cardiovascular RFs, are exclusive or more represented in one gender rather than the other, making it difficult to assess the link of causality between gender and manifestations of t-APS.

References:

[1]JF de Carvalho. Rheumatol Int. 2011.

[2]LJ Jara. Lupus. 2005.

Disclosure of Interests:

None declared

POS0751 COMORBIDITY AND LONG-TERM OUTCOME IN PATIENTS WITH CONGENITAL HEART BLOCK: PRELIMINARY DATA OF THE ITALIAN REGISTRY ON THE IMMUNE-MEDIATED CONGENITAL HEART BLOCK

Background:

Congenital heart block (CHB) is due to placental transfer of maternal anti-Ro/SSA autoantibodies to the fetus. The prevalence of CHB has been estimated as 1-2% in anti-Ro/SSA women while the recurrence rate is 16-19% (1). This condition is associated with a high rate of fetal/neonatal mortality and most of the cases requires pacemaker (PM) pacing. Given the rarity of CHB, limited data are available regarding the long-term follow-up of the offspring other than the cardiovascular complications.

Objectives:

The results of the Italian Registry of the autoimmune congenital heart block were recently described (2). A peculiarity of this cohort was that most of the mothers had an established diagnosis of systemic autoimmune disease at CHB detection, in contrast with other registries where CHB was mostly incidentally detected in healthy women. Here we report an update, with the preliminary data regarding the long-term outcome of patients with CHB, their unaffected siblings and health controls born from mothers positive for Ro/SSA.

Methods:

Data regarding demography, treatment, maternal, neonatal outcome, and follow-up were collected through an online electronic datasheet. A dedicated questionnaire was created with the aim to investigate general health, cardiovascular follow-up, and frequency of autoimmune diseases.

Results:

One-hundred and five cases of CHB in 99 patients were included from 1969 to December 2020. CHB was mostly detected in utero (97 cases, 92.3%) with 8 neonatal cases. Third degree CHB occurred in 71 cases (67.6%). Child mortality was observed in 29 (27.6%) cases: 20 in utero, 7 during neonatal period and 2 during childhood. Overall, a PM was implanted in 54 out of the 85 live births (63.5%). Then, our cohort was divided into 2 subgroups: pregnancy that occurred before (N=61) and after 2010 (N=44) with the aim to evaluate possible differences among the subgroups. Whereas mortality, PM, CHB degree were similar, CHB more frequently occurred in the last 10 years among Ro/SSA asymptomatic carriers than in the group of pregnancies before 2010 (53.6% vs 32.8%, p=0.038). Questionnaires from 14 surviving CHB cases, 8 unaffected siblings 12 controls born from mothers Ro/SSA positive were collected. Among CHB cases, 6 were males and 8 females, median age 12 years (range 6-28). All presented a third degree CHB, 10 required a neonatal PM pacing and one had an implantable ECG recorder. PM was substituted at least once in 9 patients, the oldest patient had to change it four times. No dilated cardiomyopathy occurred and most of the patients maintain an annual follow-up. Two cases of autoimmune diseases were registered among CHB cases, one idiopathic juvenile arthritis and one Cogan’s vasculitis, both born from mothers with Sjogren Syndrome. Four cases of neurodevelopmental disorders occurred: three cases of learning disabilities (one in each group) and one case of speech disorder in the sibling group. In addition, a CHB case presented a stress disorder linked to frequent hospitalizations.

Conclusion:

This registry is an ongoing project aiming at collecting all Italian CHB. Moreover, here we reported the preliminary data concerning the evaluation of long-term follow-up of CHB patients. Our data, even if need to be confirmed in larger cohort, seems reassuring: no differences were reported comparing CHB patients with unaffected siblings or controls.

References:

[1]Brito-Zéron et al. Nat Rev Rheumatol 2015;11:301-312.

[2]Fredi M et al. Front Cardiovasc Med. 2019 Feb 28;6:11.

Disclosure of Interests:

None declared

FRI0217 SENSITIVITY AND SPECIFICITY OF 2019 DCVAS DRAFT CLASSIFICATION CRITERIA FOR GIANT CELLS ARTERITIS AND TAKAYASU ARTERITIS IN A MONOCENTRIC COHORT OF PATIENTS WITH CLINICAL DIAGNOSIS OF LARGE VESSEL VASCULITIS

Background:

Recently, a new set of classification criteria for Giant Cells Arteritis (GCA) and Takayasu Arteritis (TA) has been developed by the DCVAS project and presented as draft criteria at the 19th International Vasculitis and ANCA Workshop held in Philadelphia in 2019.

Objectives:

The purpose of the present study is to analyze the performance of the 2019 DCVAS Draft Classification Criteria in differentiating GCA and TA in a cohort of patients with Large Vessel Vasculitis (LVV), comparing their sensitivity and specificity to 1990 ACR Classification Criteria.

Methods:

2019 DCVAS Draft Criteria and 1990 ACR Criteria were retrospectively applied to a cohort of 130 consecutive patients with Large Vessel Vasculitis. In all patients the diagnosis of vasculitis was histologically and/or radiologically confirmed.

Results:

One-hundred patients had a clinical diagnosis of GCA, 25 patients of TA and 5 patients of other form of LVV, different from GCA and TA (idiopathic isolated aortitis n:2, aortitis with retroperitoneal fibrosis n:2, isolated pulmonary arteritis n:1).

Among the 100 patients clinically diagnosed as GCA (F/M: 68/32, age: 74 (60-83)) only 82 fulfilled the 1990 ACR Criteria for GCA, while all of them fulfilled the 2019 DCVAS Draft Criteria for GCA.

Instead, among the 25 patients with a clinical diagnosis of TA (F/M: 21/4, age: 34 (16-48)), 22 (88%) could be classified as TA according to the 1990 ACR Criteria, 25 (100%) according to 2019 DCVAS Draft Criteria.

In the group of patients diagnosed with other form of LVV (F/M: 2/3, age: 56 (38-71)) 4 patients (80%) fulfilled the 2019 DCVAS Draft Criteria for GCA, while none of them fulfilled the 2019 DCVAS Draft Criteria for TA or the 1990 ACR Criteria for GCA or TA. One of these patients did not fulfilled any classification criteria.

On the contrary, one GCA patient could be classified both as GCA or TA according to the 2019 DCVAS Draft Criteria but didn’t fulfilled the 1990 ACR Criteria for GCA or TA.

For GCA, 2019 DCVAS Draft Criteria shown a sensitivity of 100% and a specificity of 80%, compared to 82% and 100% of 1990 ACR Criteria. For TA, 2019 DCVAS Draft Criteria shown a sensitivity of 100% and a specificity of 99%, compared to 88% and 100% of 1990 ACR Criteria.

For GCA the agreement between the two different sets of criteria was 85.5% (Cohen’s k coefficient: 0.64), for TA the agreement was 85.1% (k: 0.58).

Conclusion:

The new draft classification criteria shown a lower specificity if compared to the older ones, but also a higher sensitivity: in particular 2019 DCVAS Draft Criteria can better identify GCA patients with extracranial involvement, historically excluded from the 1990 ACR criteria.

both GCA and TA 2019 DCVAS Draft Criteria, demonstrating that this classification well performs in differentiating GCA and TA.

Table 1:GCA (n:100)TA (n:25)Other LVV (n:5)Morning stiffness in shoulders or neck43 (43%)3 (12%)0 (0%)Sudden visual loss33 (33%)2 (8%)0 (0%)Jaw or tongue claudication35 (35%)0 (0%)0 (0%)New headache/Scalp tenderness77 (77%)/30 (30%)5 (20%)/0 (0%)1 (20%)/0 (0%)Temporal Artery Exam: pathological findings34 (34%)0 (0%)0 (0%)Elevated ESR or CRP100 (100%)16 (64%)5 (100%)Temporal Artery Biopsy: vasculitis53 (53%)0 (0%)0 (0%)Temporal Artery halo sign (US)/Bilateral axillary involvement11 (11%)/11 (11%)0 (0%)/4 (16%)0 (0%)/0 (0%)FDG-PET activity throughout aorta32 (32%)13 (52%)4 (80%)Angina or ischemic cardiac pain5 (5%)4 (16%)1 (20%)Arm or leg claudication5 (5%)12 (48%)0 (0%)Arterial bruit2 (2%)19 (76%)1 (20%)Reduced pulse in upper extremity1 (1%)15 (60%)0 (0%)Carotid: reduced pulse or tenderness0 (0%)8 (32%)0 (0%)SBP difference in arms: >10/ >20 mmHg0 (0%)/1 (1%)14 (56%)/6 (24%)0 (0%)/0 (0%)Pathological Angiography or AngioCT:number of affected arteries: 1/2/>319 (19%):7/3/922 (88%):0/1/195 (100%):3/0/2Paired branch arteries involvement7 (7%)20 (80%)2 (40%)Abdominal aorta with renal or mesenteric involvement0 (0%)17 (68%)0 (0%)

Disclosure of Interests:

None declared

FRI0154 SHOULD BE OLDER PATIENTS TESTED FOR ANTIPHOSPHOLIPID ANTIBODIES? 695 CASES FROM THE RETROSPECTIVE SERIES HIBISCUS

Background:

Although guidelines do not recommend antiphospholipid antibodies testing after 60 yo, recent data reported late onset antiphospholipid syndrome (APS).

Objectives:

To comparatively analyse the clinical, laboratory features and outcomes in 695 cases with primary APS between patients older and younger than 70 yo.

Methods:

we have performed an international study within the framework of the International Registry of primary APS patients treated with Hydroxychloroquine, HIBISCUS (an ongoing retrospective and prospective register launched in 2016). 28 centres from 17 countries participate. Data about late onset APS were analysed in 695 patients and were obtained from a standardized form registered in the database containing 66 items with respect to demographics, clinical and biological features.

Results:

Arterial events and especially stroke represented the main initial and recurrent clinical manifestation in 40 primary APS patients older than 70 yo. There were not statistically significant differences with respect to cardiovascular risk factors between the two groups of patients. A significant male predominance, a familial APS history, a higher prevalence of triple positivity, lower complement levels, and anticardiolipin antibodies (aCL) IgA isotype were found in older patients. Low anticoagulation regimens were safe and efficient, with a low relapse rate in older patients.

Conclusion:

we suggest that the detection of aPL antibodies should be included into the initial screening panel tests in elderly with thrombotic events, especially arterial, in particular those with recurrent stroke and familial APS.

Our study further suggests that lower intensity anticoagulation regimens could be a therapeutic option in older APS patients, as no differences in outcomes and relapse rate were found between patients with high and low intensity anticoagulation regimens.

References:

[1]Grimaud F et al. Rheumatology. 2019;58:1006-10.

[2]Goldman-Mazur S et al. Thromb Res. 2019;176:67-73.

[3]Hirmerova J et al. 2017;36:167-73.

Disclosure of Interests:

Cristina Belizna: None declared, Omar Latino: None declared, Ljudmila Stojanovich: None declared, Patrick Saulnier: None declared, Katrien Devreese: None declared, Sebastien Udry: None declared, Natasa Stanisavljevic: None declared, Aleksandra Djokovic Speakers bureau: KRKA, Astra Zeneca, Actavis, Jaume Alijotas-Reig: None declared, Enrique Esteve-Valverde: None declared, Raquel Ferrer-Oliveras: None declared, Angela Tincani: None declared, Laura Andreoli: None declared, Francesca Regola: None declared, Maarten Limper: None declared, Alexander Makatsariya: None declared, Jamilya Khizroeva: None declared, Viktoria Bitsadze: None declared, Cecilia Chighizola: None declared, Francesca Pregnolato: None declared, Maria Orietta Borghi: None declared, Pier Luigi Meroni: None declared

AB0423 NEUROPSYCHIATRIC OUTCOME OF CHILDREN BORN TO WOMEN WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) WOMEN AND EXPOSED IN UTERO TO AZATHIOPRINE: A CASE-CONTROL STUDY

Background:

A possible increase in neurodevelopmental (ND) and learning disorders (LD) in the offspring of mothers affected by SLE have been suggested in some studies, along with the identification of different possible risk factors. Azathioprine (AZA) is commonly used during pregnancy, based on its non-teratogenicity and extended experience in women with different diseases. However, a few small studies suggested an association between in utero exposure to AZA and possible increased frequency of ND/LD in children, indirectly derived from increased request of supportive educational services.

Objectives:

To evaluate the medium-long term outcome in terms of ND/LD in children of school age (≥6 years) born to SLE women treated with AZA during pregnancy, as compared to that of children born to SLE mothers not treated with AZA during pregnancy.

Methods:

Data from our Pregnancy Clinic registry were collected for prospectively followed pregnancies of SLE women treated with AZA (cases) and compared to pregnancies of SLE women not treated with AZA (controls), that were matched for age at pregnancy, presence of renal involvement and aPL positivity. SLE patients (cases and controls) were interviewed by phone to collect data about their children, focusing on the presence of ND/LD certified by Neuropsychiatrists.

Results:

Data were collected for 14 SLE mothers in the AZA group and 31 in the control group, with similar age at pregnancy (30.3±5.21 vs 31.4±4.70 years, p:0.45) and frequency of renal involvement (50.0% vs 44.1%, p:0.77), aPL positivity (33.3% vs 29.4%, p:0.76) and anti-Ro/SSA positivity (27.8% vs. 26.5%, p:0.55). A SLE flare during pregnancy was more frequently recorded in the AZA group (27.8% vs. 2.94%, p:0.02). Other medications included HCQ (55.6% vs. 70.6%, p:0.36) and corticosteroids (100% vs 79.4%, p:0.08).

We collected data for 18 children in the AZA group and 34 children in the control group, that had a similar mean age at the time of the interview (12.7±4.80 vs. 12.9±5.61 years, p:0.91). The two groups had also similar gestational age (37.4±2.20 weeks vs. 38.0±1.29 weeks, p:0.23), birth weight (3003±433 g vs 3011±453 g, p:0.95) and rate of male sex (61.1% vs 44.1%, p:0.38).

We recorded similar frequency of ND/LD in the two groups. In particular, a ND was present in 2/18 (11.1%) of children exposed to AZA vs. 2/34 (5.88%) in the control group (p:0.60). A LD was present in 1/18 cases (5.56%) and 6/34 controls (17.6%) (p:0.40).

Conclusion:

The medium-long term outcome of children born to SLE mothers in the whole cohort was characterized by the presence of ND in 4/54 (7.69%) and LD in 7/52 (13.5%). ND/LD do not seem to be related to in utero exposure to AZA.

Disclosure of Interests:

None declared

SAT0202 C4 LEVELS AS PREDICTOR OF DISEASE FLARES AND ADVERSE PREGNANCY OUTCOMES IN SYSTEMIC LUPUS ERYTHEMATOSUS PREGNANCIES

Background:

SLE pregnancies have an increased risk of Adverse Pregnancy Outcomes (APO). In clinical practice, low C3 and C4 levels are associated with active disease and, during pregnancy, complement activation products are shown to be associated with APO.

Objectives:

To analyse potential association between C3 and C4 variations and disease flares and APO during SLE pregnancies.

Methods:

Demographic, clinical and laboratory data on SLE pregnancies prospectively-followed by a multidisciplinary team in a pregnancy clinic from 1987 to 2015 were retrospectively analysed at preconception and at each trimester. Hypocomplementemia was defined according to the normality range calculated in healthy pregnancies by Reggia et al1. APO were defined as: early miscarriage (<10thweek), intrauterine fetal death (>10thweek), perinatal death (<30thday of life), pre-eclampsia (PE), severe preterm birth (<34thweek).

Results:

134 pregnancies in 98 SLE patients were analysed. APO occurred in 22 (16%) pregnancies: 9 early miscarriages, 4 intrauterine fetal deaths, 3 severe preterm births, 6 PE (hesitated in 1 intrauterine fetal death, 1 perinatal death; 2 preterm birth between 34thand 37thweeks and 2 term births). 13 flares (2 renal, 4 articular, 6 cutaneous and 1 neurological) were recorded in 11 (8%) pregnancies.

The mean C3 and C4 levels at each trimester are shown in table 1.

Table 1.

C3 and C4 mean levels (mg/dL) at pre-conceptional visit (T0), 1sttrimester (T1), 2ndtrimester (T2) and 3rdtrimester (T3).

C3 T0C3 T1C3 T2C3 T3p T0-T1p T1-T2p T2-T3Pregnancies with flares73.282.283.897.50.040.020.06Pregnancies without flares85.391.8104.4114.7<0.001<0.001<0.001Pregnancies with APO*84.791.598.5106.30.030.030.89Pregnancies without APO*84.590.9102.8112.8<0.001<0.001<0.001C4 T0C4 T1C4 T2C4 T3p T0-T1p T1-T2p T2-T3Pregnancies with flares8.611.810.911.40.010.430.27Pregnancies without flares13.214.716.316.6<0.001<0.0010.98Pregnancies with APO**13.116.115.914.70.010.30.13Pregnancies without APO**12.914.215.816.1<0.001<0.0010.42

Comparison of C3 and C4 mean levels between pregnancies with APO vs without APO:

* T0, T1, T2, T3: ns; ** T0, T1, T2, T3: ns

Both in pregnancies with flares and with APO, there was no increase of C3 between the 2ndand the 3rdtrimester and of C4 between the 1stand the 2ndtrimester.

At preconception, mean levels of C4 were lower in pregnancies with flares compared to those without flares (images 1 and 2); during the 2ndand the 3rdtrimesters the mean levels of both C3 and C4 were lower in pregnancies with flares.

In pregnancies with APO, the variation of C4 levels between the 2ndand the 3rdtrimester was lower than in pregnancies without APO (-3.18 vs 0.27; p=0.01).

A higher frequency of low C4 was observed at pre-conceptional visit, 1sttrimester and 3rdtrimester (6/7 vs 25/103 p=0.002; 8/9vs56/106 p=0.04; 9/11 vs 33/96 p=0.003) in pregnancies with flare as compared with pregnancies without flares.

Figure 1.

Image 1: comparison of C3 mean levels between pregnancies with faresvswithout flares

Figure 2.

Image 2: comparison of C4 mean levels between pregnancies with faresvswithout flares

Conclusion:

In our cohort of prospectively-followed SLE pregnancies, low C4 levels at preconception seems to predict flares during pregnancy. Low increase of C4 levels between the 2ndand the 3rdtrimester could predict an APO.

References:

[1]Reggia R. et al. Rheumatology 2012;51:2186-90

Disclosure of Interests:

None declared

AB0678 RISK FACTORS FOR ADVERSE PREGNANCY OUTCOMES IN SPONDYLOARTHRITIS: DISEASE PHENOTYPE AND DISEASE ACTIVITY MAY PLAY A ROLE

Background:

Pregnant patients (pts) with spondyloarthritis (SpA) seem at increased risk for adverse pregnancy outcomes (APO), however limited and conflicting data have been published so far and risk factors for APO in these pts remain poorly understood.

Objectives:

To assess APO and identify possible risk factors for those in a cohort of SpA pregnant pts.

Methods:

Data on SpA pts prospectively-followed in a pregnancy clinic from 2010 to 2019 were retrospectively analysed before conception and during each trimester. Pregnancies complicated by APO were compared with those that were uneventful for demographic and clinical variables. Active disease was defined as a DAS-28-CRP>3.2 or an ASDAS-CRP ≥ 2.1 according to peripheral or axial dominant disease respectively.

Results:

56 pregnancies (mean age 34±5 years; median disease duration 60 months, IQR 24-123) in 47 pts were analysed: 37 psoriatic arthritis, 7 axial SpA, 6 undifferentiated SpA, 3 enteropathic SpA, 2 reactive arthritis and 1 enthesitis-related juvenile idiopathic arthritis. APO were recorded in 23/56 (41%) pregnancies: 5 (9%) early miscarriages, 1 (2%) medical abortion (central nervous system malformation), 3 (5%) preterm births (≥34 gestational week, all for preterm premature rupture of membranes - PROM); 2 (4%) PROM; 7 (13%) small for gestational age newborns (SGA); 3 gestational diabetes and 2 cholestasis of pregnancy. Table 1 displays the comparison between pregnancies with and without APO. A higher number of pts with active disease were detected during the 2ndtrimester in both groups, however differences between those were only significant at the 3rdtrimester (p=0.03). History of inflammatory bowel symptoms (IBS) was also associated with an increased risk for APO (p=0.02). Although not reaching statistical significance, APO occurred more frequently in pts with a previous use of > 1 conventional synthetic (cs) or biological (b) disease-modifying antirheumatic drug (DMARD) (p=0.05), suggesting a more difficult to treat phenotype. Likewise, pts with APO were less often treated with low dose aspirin (LDA) during pregnancy.

Conclusion:

SGA was the main APO recorded. History of IBS, a more difficult to treat phenotype and the presence of active disease during pregnancy influenced APO in this cohort, reinforcing the need for tight disease control before and during pregnancy. Larger and prospective data are warranted to confirm these results and to assess the potential protective role of LDA.

References:

[1]Molto 2018; Zbinden 2018.

Table 1.

Differences between patients with and without APO

Pregnancieswith APOPregnancies without APOpN, %23, 41.133, 58.9Maternal age at conception,mean±SD (years)33.8±533.8±4.9NSHx previous APO– N, %4,17.43, 9.1NSDisease duration,median (IQR), (months)96 (36-132)48 (24-96)NSAxial dominant disease– N, %6, 26.16, 18.2NSPeripheral dominant disease –N, %11, 47.820, 60.6NSHx enthesitis– N, %9, 39.113, 39.4NSHx dactylitis– N, %5, 21.711, 33.3NSHx psoriasis– N, %10, 43.518, 54.5NSHx uveitis–N, %1, 4.34, 12.1NSHx inflammatory bowel symptoms– N, %4, 17.40, 00.02HLA-B27– N, %8, 34.87, 21.2NS>1 cs or bDMARDs before conception –N, %13, 56.510, 30.30.05LDA during pregnancy– N, %7, 30.417, 51.5NSActive disease before conception- N, %5, 21.72, 6.1NSActive disease 1sttrimester- N, %1, 4.34, 12.1NSActive disease 2ndtrimester- N, %6, 26.15, 15.2NSActive disease 3rdtrimester- N, %3, 130, 00.03

Legend: Hx – history of; NS – non significant.

Disclosure of Interests:

None declared

FRI0239 ANTI-NXP2 ANTIBODIES: CLINICAL AND SEROLOGICAL ASSOCIATIONS IN A MULTICENTRIC ITALIAN STUDY

Background:

anti-NXP2 antibodies is considered a serological marker of dermatomyositis (DM), with calcinosis, severe myositis and, in some series, cancer. Historically, these associations have been detected with immunoprecipitation (IP), but in the last few years commercial lineblot (LB) assay have been released.

Objectives:

to analyze the clinical features associated to anti-NXP2 antibodies, including the onset of concomitant cancers, both with LB and homemade IP

Methods:

clinical and serological data from medical charts of 213 patients with a diagnosis of inflammatory miosidites without anti-NXP2 (NXP2-), followed-up by two third-level Centers, and 61 anti-NXP2+ patients from 10 Rheumatological centers were analyzed. Anti-myositis specific (MSA) and anti-myositis associated antibodies (MAA) were detected in single centers by LB (Euroimmun Autoimmune Inflammatory Myopathies 16 antigens). Anti-NXP2 was confirmed by protein and RNA IP, as previously described (1)

Results:

clinical diagnosis of anti-NXP2+ positive with LB were 42 DM, 11 PM, inclusion body myositis (IBM) 4, necrotizing myositis and overlap (OM) 1 each. Anti-NXP2+ showed a lower age at onset (p<0.0001) more frequent diagnosis of DM (68.8%vs30%,OR5.2) and IBM (6.5%vs0.49%,OR14.8), typical skin manifestations, myositis (93%vs79% OR3.3), concomitant presence of another MSA (12.7%vs2%, OR6.41) and lower rate of features associated with OM or anti-synthetase syndrome. Serum from 49 NXP2+ was available and IP analysis was made with the confirmation of NXP2 in 31 sera (63.2%) with the following diagnosis: DM 27 cases, PM 3, IBM 1. Whilst the majority of the associations were confirmed comparing NXP2LB+/IP+ with the IIM NXP2-, some peculiar associations were found significant only for the double positive patients: dysphagia (53%vs 30%,OR 2.56) and calcinosis (22%vs6.5% OR4) whereas IBM diagnosis and the presence of concomitant MSA antibodies were lost. Survival time from cancer onset is shown in figure.

IP did not confirmed anti-NXP2 antibodies in 18 sera: in 4 cases at least one MSA/MAA was identified by IP; these 18 patients did not show differences when compared with 213 anti-NXP2-.

Conclusion:

Protein IP confirmed anti-NXP2 antibodies in 63% of LB+ sera. Double positive cases showed more typical DM features and rarely occurred in IIM not DM. Anti-NXP2 positivity by LB should be confirmed by other methods in order to correctly diagnose and characterize IIM patients.

References:

[1]Arthritis Res Ther 2012,30;14:R97

Acknowledgments:

Forum Italiano per la Ricerca Malattie Autoimmuni (FIRMA)

Disclosure of Interests:

Micaela Fredi: None declared, Ilaria Cavazzana: None declared, Angela Ceribelli: None declared, Maria Grazia Lazzaroni: None declared, Simone Barsotti: None declared, Maurizio Benucci: None declared, Lorenzo Cavagna: None declared, Ludovico De Stefano: None declared, Andrea Doria Consultant of: GSK, Pfizer, Abbvie, Novartis, Ely Lilly, Speakers bureau: UCB pharma, GSK, Pfizer, Janssen, Abbvie, Novartis, Ely Lilly, BMS, Giacomo Emmi: None declared, Marco Fornaro: None declared, Federica Furini: None declared, Roberto Gerli: None declared, Maria Grazia Giudizi: None declared, Marcello Govoni: None declared, Anna Ghirardello: None declared, Luca Iaccarino Speakers bureau: GSK, Pfizer, Janssen, Novartis, 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, Maria Infantino: None declared, Alessandro Mathieu: None declared, Emiliano Marasco: None declared, Paola Migliorini: None declared, Boaz Palterer: None declared, paola parronchi: None declared, Matteo Piga: None declared, Federico Pratesi: None declared, Antonella Radice: None declared, Carlo Selmi: None declared, Valeria Riccieri: None declared, Marilin Tampoia: None declared, Giovanni Zanframundo: None declared, Angela Tincani: None declared, Franco Franceschini: None declared

FRI0105 EVALUATION OF CXCL13 AND ICAM1 SERUM LEVELS AS PREDICTORS OF CLINICAL RESPONSE TO ABATACEPT IN RHEUMATOID ARTHRITIS

Background:

Soluble intercellular adhesion molecule 1 (ICAM1) and C-X-C motif chemokine 13 (CXCL13) were described as differentially associated with two major subtypes of synovitis in rheumatoid arthritis (RA). Raised serum levels of ICAM1 (which is upregulated in synovial fibroblasts in response to TNFα), and of CXCL13 (which is expressed by synovial follicular dendritic cells and activated mature antigen-experienced T-helper cells), are associated with a myeloid or lymphoid synovial phenotype, respectively (1). It has been suggested that a preferential clinical response to anti-TNFα, as compared to anti-IL-6R monotherapy, can be predicted by measuring these two biomarkers (2). No information is available on the possible utility of these biomarkers in RA patients treated with abatacept (ABA), a T-cell co-stimulation blocker.

Objectives:

To analyze the effect of ABA on ICAM1 and CXCL13 serum levels in RA and to verify whether they predict the response to the drug.

Methods:

63 RA patients [F/M=51/12; median (10th-90thpercentile) age=60 (41-72) years; CRP-DAS28=4.6 (3.3-5.8); ACPA positive: 86%], before and after 6 months of treatment with ABA + methotrexate and 22 sex and age-matched healthy controls (HC) were evaluated. Serum ICAM1 and CXCL13 levels were dosed by commercial ELISA (Life Technologies and R&D). Response to treatment was defined with the EULAR criteria.

Results:

CXCL13 serum levels were higher in RA at baseline than in HC [136 (42-325) vs 32 (19-57) pg/ml, p<0.01], while no difference was observed in ICAM1 [186 (125-276) vs 184 (153-246) ng/ml, p=0.9]; positive correlations between ICAM1 and CRP (r:0.28; p=0.03) and CXCL13 levels and CRP (r:0.40; p<0.01) and CRP-DAS28 values (r:0.27, p=0.05) were found. After therapy with ABA, a reduction of CXCL13 was observed [136 (42-325) vs 94 (29-319) pg/ml, p<0.01], both in responders [n: 37: 151 (57-462) vs 97 (26-329) pg/ml; p<0.01] and non-responders (n: 14: 142 (68-293) vs 89 (42-198) pg/ml; p=0.01]. Not significant variation of ICAM1 serum levels was found in the entire cohort [186 (125-276) vs 190 (113-252) ng/ml, p=0.06]. However, a significant decrease was observed in non-responders [222 (169-302) vs 186 (110-233) ng/ml, p=0.02]. At baseline, no significant difference was found among patients seropositive for ACPA if compared with the negative ones [ACPA+ vs ACPA- for ICAM1 [187 (123-280) vs 177 (134-258) ng/ml; p=0.7] and for CXCL13 [143 (42-368) vs 113 (56-270) pg/ml; p=0.4]].

Conclusion:

Our results confirmed that CXCL13 serum levels are directly correlated with disease activity and demonstrated that ABA therapy induces their reduction. These findings suggest that the co-stimulation blockade at central level and/or in the synovium lead to a reduced production of CXCL13. We could not demonstrate that CXCL13 levels predict the clinical response to ABA in this cohort of patients.

References:

[1]Rosengren S, Rheumatology 2011;2.Dennis G, Arthritis Res Ther 2014

Acknowledgments:

Bristol-Myers-Squibb Italy provided an unrestricted research grant for the study conduction.

Disclosure of Interests:

None declared

FRI0155 Α MULTICENTER “AT-RISK” COHORT FOR THE DISCOVERY OF ENVIRONMENTAL, CLINICAL AND MOLECULAR PREDICTORS FOR THE TRANSITION INTO SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Background:

SLE onset is preceded by a preclinical phase evidenced by the presence of anti-nuclear and other autoantibodies (autoAbs), which however, have low predictive value for development of clinical SLE.

Objectives:

To define the subgroup of autoAbs-positive individuals who are at high risk for progression into SLE by integrating environmental, clinical/serological, genetic and transcriptome data.

Methods:

A multicenter, across five European countries, inception cohort of autoAbs-positive individuals or first-degree relatives (FDRs) of SLE patients who are monitored prospectively over five years for possible transition to SLE according to the classification criteria. Structured data collection on demographics, family and medical history, clinical (criteria and selected non-criteria manifestations) and serological parameters, use of medications, hydroxyvitamin D levels and lifestyle (tobacco, alcohol use, physical activity, adherence to Mediterranean diet). Blood samples are stored for RNA-sequencing and genotyping.

Results:

A total 254 at-risk individuals (93% women, 99% Caucasians, aged [mean ± standard deviation] 36 ± 12 years) have been included and enrolment/monitoring is still ongoing. Forty individuals (16%) have FDR with SLE and 88 individuals (35%) have FDR with another autoimmune disorder. The frequency of active and past use of tobacco was 28% and 20%, respectively. Sedentary lifestyle (moving only for necessary chores or outdoor activity 1-2 times/week) was reported by 54% and adherence to the Mediterranean diet was low (3.4 ± 2.3, maximum score: 9). At enrolment, individuals had 1.9 ± 1.1 ACR-1997 classification criteria, with anti-nuclear antibodies (ANA) being the most frequent (88%), followed by synovitis (39%), photosensitivity (33%) and immunologic disorder (30%) (Table 1). During follow-up of 15.2 ± 7.2 months, a total 15 individuals (5.9%) have progressed into classified SLE, including cases with severe hematological and neurological disease.

Table 1.

Baseline characteristics of the at-risk for SLE cohort

N (%) or mean ± SDACR 1997 classification criteria1.9 ± 1.1 Malar rash68 (27%) Discoid rash29 (11%) Photosensitivity83 (33%) Mucosal ulcers49 (19%) Synovitis100 (39%) Serositis30 (12%) Renal disorder28 (11%) Neurologic disorder31 (12%) Hematologic disorder58 (23%) Immunologic disorder77 (30%) ANA222 (88%)SLICC 2012 classification criteria Clinical criteria1.0 ± 0.9 Immunological criteria1.3 ± 0.9

Conclusion:

Among individuals with positive autoAbs or FDRs with SLE, the short-term risk for transition into clinical SLE is low. Following the study completion, clinical and lifestyle data will be combined with blood transcriptome to define a high-risk subgroup of individuals for progression into SLE.

Acknowledgments:

The study is supported by the Foundation for Research in Rheumatology (FOREUM; preclin016)

Disclosure of Interests:

Christina Adamichou: None declared, Dionysis Nikolopoulos: None declared, Myrto Nikoloudaki: None declared, Zahra Rahme: None declared, Micaela Fredi: None declared, Antigoni Pieta: None declared, ARGYRO REPA: None declared, Alice Parma: None declared, Eleni Kalogiannaki: None declared, Nestor Avgustidis: None declared, Nikolaos Kougkas: None declared, Aggelos Banos: None declared, Anastasios Eskitzis: None declared, Alessandra Bortoluzzi: None declared, Søren Jacobsen: None declared, Prodromos Sidiropoulos: None declared, Emmanouil Dermitzakis: None declared, Marta Mosca: None declared, Luís Inês: None declared, Laura Andreoli: None declared, Angela Tincani: None declared, Antonis Fanouriakis Paid instructor for: Paid instructor for Enorasis, Amgen, Speakers bureau: Paid speaker for Roche, Genesis Pharma, Mylan, George Bertsias Grant/research support from: GSK, Consultant of: Novartis

AB0522 GENDER DIFFERENCES IN GIANT CELLS ARTERITIS: ANALYSIS OF A MONOCENTRIC COHORT OF 100 PATIENTS

Background:

Giant Cells Arteritis (GCA) is the most common primary vasculitis in adults and usually occurs in patients older than 50 years. Epidemiological studies shown a higher prevalence of the disease in women compared to man. However, differences in clinical presentation between men and women have not been demonstrated, even if some distinctions have been suggested (1,2).

Objectives:

The purpose of the present study is to analyze differences in the clinical presentation of GCA according to sex.

Methods:

We collected retrospectively clinical data of a monocentric cohort of 100 consecutive GCA patients. Mann Whitney test was used to compare continuous variables, while Chi-square test and Fisher’s exact test were applied for comparison between qualitative variables.

Results:

One-hundred patients with a clinical diagnosis of GCA were enrolled in the study (68 women, 32 men). In all patients the diagnosis of vasculitis was histologically and/or radiologically confirmed. Main clinical data are reported in the table.

Patients were classified according to vascular involvement in three groups: temporal arteritis (C-GCA), extracranial large vessel vasculitis (LV-GCA) and both cranial and extracranial vasculitis (LV-C-GCA). No significant differences in vascular distribution of the disease were found according to sex, even if large vessel involvement seems to be more frequent in women (43% vs 28%; p: ns).

Male and female patients presented at diagnosis a similar clinical picture, with the same frequency of systemic symptoms (fever, fatigue, weight loss), polymyalgia rheumatica, visual symptoms and claudication. However, male patients complained more often temporal headache (90% vs 71%, p: 0.01), even no significant differences were found in the incidence of pathological findings at temporal artery physical examination (38% vs 32%; p: ns) and biopsy (59% vs 50%).

On the contrary, in female patients a longer time to diagnosis was recorded (8 (2-49 vs 4 (0-35) months; p: 0.01).

Conclusion:

In our cohort of GCA patients, clinical presentation was similar in male and female patients, with no significant differences in clinical, radiological and laboratory findings. However, male patients presented more often temporal headache, the most typical symptom of GCA, and this could explain a shorter time to diagnosis, if compared to female.

References:

[1]Sturm A et al. Clin Exp Rheum, 2016

[2]Nir-Paz R et al. J of Rheum, 2002

All GCA(n:100)WOMAN (n:68)MAN(n:32)Age: median (10th-90thpercentile)76 (62-80)73 (60-83)76 (62-80)Time to diagnosis (weeks) *8 (1-42)8 (2-49)4 (0-35)C-GCA61 (61%)38 (56%)23 (72%)LV-C-GCA16 (16%)13 (20%)3 (9%)LV-GCA23 (23%)17 (25%)6 (20%)New temporal headache*77 (77%)48 (71%)29 (90%)Visual symptoms39 (39%)24 (35%)15 (47%)Jaw or tongue claudication35 (35%)23 (34%)12 (38%)Fever39 (39%)24 (35%)15 (47%)Fatigue71 (71%)48 (71%)23 (72%)Weight loss49 (49%)34 (50%)15 (47%)Polymyalgia rheumatica43 (43%)33 (49%)10 (31%)Arm or leg claudication5 (5%)2 (3%)3 (9%)Positive temporal artery biopsy53 (53%)34 (50%)19 (59%)Pathological findings at temporal artery physical examination34 (34%)22 (32%)12 (38%)CRP (C-reactive protein)83 (22-160)89 (21-159)78 (23-155)ESR (erythrocyte sedimentation rate)72 (34-109)79 (37-113)54 (32-100)FDG-PET activity throughout aorta32 (32%)25 (37%)7 (22%)

*: p ≤ 0.05

Disclosure of Interests:

None declared

SAT0207 ANTI-SSA/RO POSITIVITY AND CONGENITAL HEART BLOCK: OBSTETRIC AND FETAL OUTCOME IN A COHORT OF ANTI-SSA/RO POSITIVE PREGNANT WOMEN WITH AND WITHOUT AUTO-IMMUNE DISEASES FROM THREE ITALIAN TERTIARY REFERRAL CENTERS

Background:

neonatal lupus syndrome (NLS) is an acquired disease caused by the trasplacental passage of anti-SSA antibodies. Congenital heart block (CHB) represents the most serious manifestation of NLS. The rate of CHB in Anti-SSA positive pregnant women ranges from 1 to 5% in different studies

Objectives:

to retrospectively assess the prevalence of CHB in a cohort of anti-SSA positive pregnant women followed in 3 Italian tertiary centers

Methods:

pregnancies of anti-SSA positive women attending the pregnancy clinic of ASST Pini CTO/Policlinico Mangiagalli, Rheumatology Division of Spedali Civili, Brescia and Rheumatology Division of Ospedale S Matteo, Pavia from 2009 to 2019 were included. Patients underwent monthly clinical examination. Fetal heart rate was assessed weekly by Doppler ultrasound from 14thto 26thgestational week. On week 14 and 26, a fetal echocardiography was performed. A EKG was performed at birth

Results:

351 prospectively followed pregnancies in 292 anti-SSA/Ro positive women were included. Table 1 reports diagnosis. None of the prospectively followed pregnancies were complicated by complete CHB. Seven additional patients were referred to our clinics after diagnosis of CHB and were subsequently found to be anti-SSA positive, reporting no symptoms of diseases. Considering the 7 additional pregnancies, the incidence of CHB was 1.9%. We observed 3 neonates (0.8%) with cutaneous NLS and 1 case of transient increase of liver enzymes. In another neonate, a 1thdegree A-V block was found after birth. A complete analysis of maternal and fetal outcome was possible in 244 cases (Table 2) and compared with 3158 unselected healthy controls. Among these 244 cases, 65% were taking hydroxychloroquine

Table 1.

patients diagnosis

n%Sjogren’s Syndrome58`20Systemic lupus erythematosus7626UCTD7425Asymptomatic Ro carriers5619Other2810292100Table 2.

maternal and fetal outcome

healthy controls N=3158Anti-SSA/Ro ptsN=244P valuePrevious CHB n (%)2 (0.8)Anti-SSB pos n (%)46 (18.8)aPL pos n (%)49 (20)PregnancyLive births3158241Preeclampsia, n (%)43 (1.1)2 (0.8)nsDeliveryDelivery <37 wks, n (%) / < 34 wks n (%)401 (12.6) /201 (6)35 (15.6) / 14 (6)ns / nsCesarean Section, n (%)897 (29.3)115 (47.5)<0.001

Conclusion:

none of the patients prospectively followed in our centers before and during pregnancy developed complete CHB. If the 7 cases of anti-SSA positivity diagnosed after CHB detection were included in the analysis, the incidence of CHB was comparable to previous reports. Our data suggest that a strict follow up and proper treatment of anti-SSA positive patients with or without an autoimmune disease before and during pregnancy can reduce the risk of NLS. Further studies are warranted to confirm a possible protective role of anti-rheumatic treatments, including HCQ

References:

[1]Fredi M. Front Cardiovasc Med. 2019

Disclosure of Interests:

Maria Gerosa: None declared, Micaela Fredi: None declared, Laura Andreoli: None declared, Cecilia Chighizola: None declared, Lorenza Maria Argolini: None declared, Davide Donzelli: None declared, Tamara Vojinovic: None declared, Véronique Ramoni: None declared, Elisa Bellis: None declared, Laura Trespidi: None declared, Federica Gazzola: None declared, Enrico Ferrazzi: None declared, Sonia Zatti: None declared, Fausta Benvenuti: None declared, Pier Luigi Meroni: None declared, Franco Franceschini: None declared, Carlomaurizio Montecucco: None declared, Rolando Cimaz: None declared, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB, Angela Tincani: None declared

SAT0368 PREGNANCY IN WOMEN WITH SPONDYLOARTHRITIS: WHO ARE THE PATIENTS AT RISK OF DISEASE FLARE?

Background:

Patients with Spondyloarthritis (SpA) can experience flares during pregnancy and postpartum even though the available data are limited and not conclusive.

Objectives:

To assess disease activity and treatment modification during pregnancy and postpartum in patients with SpA and to identify risk factors for disease flare.

Methods:

Data on SpA pregnancies prospectively-followed in a pregnancy clinic from 2010 to 2019 were retrospectively analysed. Disease activity was assessed during each trimester and postpartum using ASDAS-CRP or DAS28-CRP. Flare was defined as an increase of disease activity leading to treatment modification (introduction or increase ≥5mg/day of prednisone, introduction of cDMARD or bDMARD)1.

Results:

Data on 50 pregnancies in 46 patients were collected (mean age at conception 33±4.7 years; median disease duration: 60 months (IQR 24-132); 33 psoriatic arthritis, 6 axialSpA, 2 reactive arthritis, 2 IBD-related SpA; 6 undifferentiated SpA, 1 juvenile idiopathic arthritis). Six pregnancies ended in miscarriage, so they weren’t considered for the analysis of flares during pregnancy (table 1). Fifteen out of 44 (34%) pregnancies had at least one flare during pregnancy (6, 7 and 4 during 1st, 2ndand 3rdtrimester respectively; 2 pregnancies had multiple flares). A higher rate of flare was observed in pregnancies of patients with axial involvement (p=0.01), on treatment with bDMARDs at preconceptional visit (p=0.03) and who stopped TNFi at positive pregnancy test (p=0.03). Peripheral involvement was associated with a lower rate of flares (p=0.02). Medications resumed during pregnancy were steroids (in 6 pregnancies), cDMARDs (2 sulfasalazine, 1 cyclosporine) and bDMARDs (4 certolizumab, 4 etanercept). During postpartum period flares were recorded in 46% of patients.

Table 1.

clinical features, medication and disease activity in pregnancies with flare vs without flare

CLINICAL FEATURESFLARE (15)NO FLARE (29)pAxial involvement, n (%)11/15 (73)9/29 (31)0.01Peripheral arthritis, n (%)8/15 (53)26/29 (90)0.02Enthesitis, n (%)5/15 (33)14/29 (48)nsDactilitis, n (%)3/15 (20)8/29 (28)nsPsoriasis, n (%)6/15 (40)17/29 (59)nsIBD, n (%)2/15 (13)0nsUveitis, n(%)1/15 (7)3/29 (10)nsHLAB27 +7/11 (64)5/12 (42)nsMEDICATION HISTORYbDMARDs, n (%)11/15 (73)7/29 (24)0.003bDMARDs at preconception visit, n (%)8/15 (53)6/29 (21)0.04bDMARDs stopped at positive pregnancy test, n (%)7/15 (47)4/29 (14)0.03cDMARDs, n (%)12/15 (80)25/29 (86)nsDISEASE ACTIVITYACTIVE DISEASE* preconception visit, n(%)3/14 (21)4/23 (17)nsACTIVE DISEASE 1sttrimester, n(%)6/15 (40)1/29 (3)0.004ACTIVE DISEASE 2ndtrimester, n(%)8/15 (47)2/29 (7)0.001ACTIVE DISEASE 3rdtrimester, n(%)2/15 (13)1/29 (3)ns

*DAS28-CRP>3.2 or ASDAS-CRP≥2.1

Conclusion:

In our cohort of prospectively-followed SpA pregnancies, 34% experienced a flare during pregnancy and 46% during postpartum. Flares occurred especially in those patients who discontinued TNFi early in pregnancy and with axial involvement. When resumed during pregnancy, TNFi was able to control the disease. At preconception counselling, the continuation of TNFi during pregnancy should be considered to ensure a better control of disease.

References:

[1]Fischer-Betz R et al.Arthritis Rheumatol. 2015; 67.

Disclosure of Interests: :

None declared

Autoantibodies' titre modulation by anti-BlyS treatment in systemic lupus erythematosus

OBJECTIVE

The objective of this study was to analyse autoantibodies' titres modulation during belimumab treatment in 50 patients with systemic lupus erythematosus (SLE).

METHODS

Sera were collected at belimumab start (T0) and every six months until the 24th month. Disease activity index (SLEDAI-2K) was analysed at every timepoint. High avidity anti-dsDNA was detected by radioimmunological method, anti-ENA, anti-cardiolipin antibodies (aCL), anti-β2 glycoprotein I (anti-β2GPI) were analysed by ELISA.

RESULTS

Fifty patients with SLE (mean SLEDAI-2K: 7.18 ± :3), mean age of 39 ± 11 years and mean follow-up of 13 ± 7.8 years were enrolled. A significant decrease of anti-dsDNA and anti-β2GPI IgM titres was observed at all timepoints. IgG aCL titre showed significant decrease only at T18. Anti-dsDNA negativization was detected in 21%, anti-β2GPI IgG in 33% and aCL IgG in 30% of sera, mostly at T6. Anti-ribosomal showed a significant titre decrease at T6 and T12, with negative seroconversion at T18. Anti-Sm titre significantly dropped down at T6, then remained stable during the time. Significant correlations were found between anti-dsDNA and anti-ribosomal titre and between SLEDAI ratio (SLEDAI value/SLEDAI T0) and anti-ribosomal titre ratio (value/value T0).

CONCLUSIONS

Belimumab treatment induced a significant reduction of SLE-specific autoantibodies titre and IgM anti-β2GPI. Anti-ribosomal titre decrease correlates with anti-dsDNA titre and disease activity improvement.

Detection of Anti-Phospholipid and Anti-DNA Antibodies and their Idiotypes in Newborns of Mothers with Anti-Phospholipid Syndrome and Sle

The titers, isotypes and idiotypes of antiphospholipid and anti-dsDNA antibodies were determined in seven pairs of mothers with antiphospholipid syndrome (APLS) and their offspring, in 11 pairs of SLE mothers and their matched infants and in seven respective pairs of healthy subjects. In addition, maternal as well as fetal sera were evaluated for the presence of anti-SSA (Ro), anti-SSB (La) and anti-70 kd RNP autoantibodies.

In the sera from APLS patients, as well as in the sera from their offspring, the mean antibody titer of IgG aCL was found to be significantly higher then the corresponding value in the control group (P < 0.01). Highly significant increased titers of IgG anti-DNA antibodies were found in the sera of SLE mothers and their matched offspring (P < 0.0008).

The prevalance of anti-SSA, anti-SSA, and anti-7OKd RNP antibodies was lower then that of antiphospholipid and anti-dsDNA antibodies. Only one of the respective offspring had increased levels of these antibodies.

The quantity of maternal antibodies transferd to the fetus was depended on their concentration in the maternal circulation, as well as on their type and specificity. Follow-up of newborn sera showed a progressive decrease in the antiphospholipid antibody titers during 3 months. After 6 months it was undetected.

Our results point to a transplacental transfer of aCL and anti-DNA antibodies, a phenomenon which is not necessarily associated with respective clinical manifestations, in contrast to the classical humoral mediated autoimmune diseases (e.g. myasthenia gravis).

Relationship between endothelial dysfunction, videocapillaroscopy and circulating CD3+CD31+CXCR4+ lymphocytes in systemic lupus erythematosus without cardiovascular risk factors

OBJECTIVE

The objective of this paper is to analyse whether digital capillary morphology, analysed by nailfold videocapillaroscopy (NVC), and the number of circulating CD3 + CD31 + CXCR4 + lymphocytes (angiogenic T cells) could be markers of endothelial dysfunction (ED) in systemic lupus erythematosus (SLE) without cardiovascular disease (CVD) and CV risk factors.

METHODS

Nineteen consecutive SLE patients, according to Systemic Lupus International Collaborating Clinics Classification Criteria, with a disease duration less than five years, low disease activity, without CVD and CV risk factors (diabetes, chronic renal disease, uncontrolled systemic arterial hypertension, smoking, hypercholesterolemia, obesity), statin or beta-blocker use were enrolled. Each patient and sex- and age-matched healthy control (HC) underwent Doppler echocardiogram, an endothelial function study by peripheral arterial tonometry technique, NVC and peripheral blood immunophenotyping.

RESULTS

SLE ED+ more frequently showed NVC abnormalities compared with HCs ( p < 0.0001) in terms of minor alterations ( p = 0.017), lower capillary numbers ( p = 0.0035) and major alterations. SLE ED + showed a higher rate of CD3 + CD31 + CXCR4 + lymphocytes compared with SLE ED- and with HCs. NVC + SLE showed a significantly reduced rate of total CD3 + cells, but a higher rate and absolute number of CD3 + CD31 + CXCR4 + , compared with NVC- SLE.

CONCLUSION

NVC alterations are frequent in SLE without any CV risk factors and CVD. They are associated with ED and increased circulating CD3 + CD31 + CXCR4 + lymphocytes. These findings demonstrate a clear microvascular perturbation in patients with short disease duration, low disease activity and no CV risk factors.

Antinuclear antibodies in Frontotemporal Dementia: the tip's of autoimmunity iceberg?

Recent studies suggest a role of the autoimmune system dysregulation in Frontotemporal dementia (FTD). In the present study, we performed a broad immunological screening in a large sample of sporadic FTD patients. We reported a significant increase of antinuclear autoantibodies (ANA) positivity in 100 FTD patients as compared to 100 healthy controls (HC) (60% vs. 13%, p < .001). In FTD, ANA-positive and ANA-negative patients did not differ for any clinical feature. These data extend and further confirm autoimmune dysregulation in FTD. However, it still remains to be clarified whether these antibodies have a potential pathogenic role or represent simply an epiphenomenon.

Utilization of Dilute Russell’s Viper Venom Time to Detect Autoantibodies against β2-Glycoprotein I which Express Anticoagulant Activity in the Presence but not in the Absence of Exogenous Phospholipids

Lupus anticoagulant (LA) is a general term to define immunoglobulins interfering with phospholipid-dependent coagulation tests. It is now clear that the phospholipid-dependence of some LA is related to the presence of the phospholipid-binding plasma protein β2-glycoprotein I β2-GPI) and that autoantibodies to β2-GPI might represent a specific category of LA. To verify this hypothesis we have purified IgG autoantibodies to β2-GPI from plasma of 6 patients with antiphospholipid antibody syndrome, by means of agarose-immobilized human β2-GPI. All 6 preparations tested positive in anti-β2-GPI IgG antibody ELISA and showed a marked LA activity by prolonging dilute Russell Viper Venom Time (dRVVT) from a minimum of 5.3 s in patient # 1 to a maximum of 41.1 s in patient # 3. These IgG preparations behaved as typical LA, with this activity tending to disappear in the presence of increasing phospholipid (PL) concentrations. Moreover, the LA activity of the IgG preparations was not detectable in the absence of PL, in which case the ratio between dRVVT obtained in the presence and absence of IgG autoantibodies to β2-GPI was close to 1. This pattern was confirmed by using plasma from patients with antiphospholipid antibody syndrome testing positive for anti-β2-GPI IgG antibodies. These findings suggest that dRVVT performed both in the presence and absence of PL might constitute a sensitive screening test to detect specific antibodies with LA activity.

Macrophage activation syndrome in adult systemic lupus erythematosus: report of seven adult cases from a single Italian rheumatology center

The aim was to describe the macrophage activation syndrome (MAS), a life-threatening syndrome characterized by excessive immune activation that can be triggered by conditions affecting immune homeostasis, in a cohort of adult Italian patients with systemic lupus erythematosus (SLE). This was a monocentric retrospective evaluation. The utility of the H-score, developed to estimate the individual risk of having reactive MAS in adult patients, was assessed. Among 511 patients with SLE, 7 cases (1.4%) of MAS (all females) were identified and their medical records reviewed. In all cases, MAS was simultaneous to the onset of SLE. All patients had fever, lymphadenopathy, hematological involvement, and high titer of anti-dsDNA antibodies. Workup for infections and malignancies was negative. In all cases, the H-score was higher than the cut-off suggested for the classification of reactive MAS. All cases required hospital admission, and 2 patients were admitted to the intensive care unit. Most patients were treated successfully with high doses of corticosteroids and with immunosuppressive drugs, whereas the full therapeutic regimen developed for primary hemophagocytic lymphohistiocytosis HLH was used only in one case. No death from MAS was observed. MAS is a rare and severe disorder that complicated the onset of SLE in our cohort. The H-score may be useful in the classification of these patients.

Early Lupus Project: one-year follow-up of an Italian cohort of patients with systemic lupus erythematosus of recent onset

Objective

To describe the clinical and serological features of a prospectively followed cohort of early diagnosed systemic lupus erythematosus (SLE) patients during a one-year follow-up period.

Methods

SLE patients with disease duration less than 12 months were consecutively enrolled in a multicentre, prospective study. At study entry and then every 6 months, a large panel of data was recorded.

Results

Of 260 patients enrolled, 185 had at least 12 months of follow-up; of these, 84.3% were female, 92.4% were Caucasians. Mean diagnostic delay was about 20 months; higher values of European Consensus Lupus Activity Measurement (ECLAM) and of organs/systems involved were both associated with shorter diagnostic delay. Clinical and serological parameters improved after study entry. However, patients' quality of life deteriorated and cardiovascular risk factors significantly increased. About one-third of patients with active disease at study entry went into remission (ECLAM = 0). Negative predictors for remission were: oral ulcers, arthritis, low C4, anti-SSB (Ro) antibodies and therapy with mycophenolate. There was a widespread use of glucocorticoids both at baseline and during follow-up.

Conclusion

Clinical symptoms and serological parameters improve during the first period after diagnosis. However, patients’ quality of life deteriorates. The widespread use of glucocorticoids is probably the reason for the early significant increase of some cardiovascular risk factors.

Antiphospholipid syndrome and IgA anti-beta2-glycoprotein I antibodies: when Cinderella becomes a princess

IgA anti-beta2-glycoprotein I (IgA-aB2GPI) antibodies are currently not included as a laboratory criterion of antiphospholipid syndrome (APS). In the 13th International Congress on Antiphospholipid Antibodies, Galveston, TX, (USA) in 2010, these antibodies were accepted as an APS laboratory criterion in patients who had clinical manifestations of APS but were negative for "consensus" antiphospholipid antibodies (aPL) (IgG and IgM isotypes). Consequently, individuals with thrombotic events who are negative for consensus aPL may be undiagnosed for APS. The most recent publications have confirmed that IgA-aB2GPI antibodies are a risk factor for thrombotic events. In this viewpoint, we propose that IgA-aB2GPI antibodies should be included as an APS consensus criterion and that we have to help Cinderella become a princess.

The inter-observer reading variability in anti-nuclear antibodies indirect (ANA) immunofluorescence test: A multicenter evaluation and a review of the literature

Recently there has been an increase demand for Computer-Aided Diagnosis (CAD) tools to support clinicians in the field of Indirect ImmunoFluorescence (IIF), as the novel digital imaging reading approach can help to overcome the reader subjectivity. Nevertheless, a large multicenter evaluation of the inter-observer reading variability in this field is still missing. This work fills this gap as we evaluated 556 consecutive samples, for a total of 1679 images, collected in three laboratories with IIF expertise using HEp-2 cell substrate (MBL) at 1:80 screening dilution according to conventional procedures. In each laboratory, the images were blindly classified by two experts into three intensity classes: positive, negative, and weak positive. Positive and weak positive ANA-IIF results were categorized by the predominant fluorescence pattern among six main classes. Data were pairwise analyzed and the inter-observer reading variability was measured by Cohen's kappa test, revealing a pairwise agreement little further away than substantial both for fluorescence intensity and for staining pattern recognition (k=0.602 and k=0.627, respectively). We also noticed that the inter-observer reading variability decreases when it is measured with respect to a gold standard classification computed on the basis of labels assigned by the three laboratories. These data show that laboratory agreement improves using digital images and comparing each single human evaluation to potential reference data, suggesting that a solid gold standard is essential to properly make use of CAD systems in routine work lab.

Effector T-cells are expanded in systemic lupus erythematosus patients with high disease activity and damage indexes

Background and objectives T-cell activation may be one of the pathogenic mechanisms of systemic lupus erythematosus (SLE). After repeated antigenic stimulation, T-cells undergo different modifications, leading to the differentiation into effector memory T-cells (CCR7-CD45RA-) and terminally differentiated effector memory (TDEM) T-cells (CCR7-CD45RA+). Similarly, down-modulation of CD28 may lead to the expansion of the CD28- T-cells, a subpopulation with peculiar effector activities. The aim of this study was the characterization of T-cell phenotype in a cohort of patients with SLE according to disease activity and damage index. Materials and methods Phenotypic analysis of peripheral blood T lymphocytes of 51 SLE patients and 21 healthy controls was done by flow-cytometry. SLE disease activity was evaluated by SLE Disease Activity Index-2000 (SLEDAI-2K) and damage by the Systemic Lupus International Collaborating Clinics/American College of Rheumatology damage index (SDI). The variations between different groups were evaluated by Mann-Whitney test. Bonferroni correction was applied to adjust for multiple comparisons ( p^adj). Spearman rank test was used to evaluate the correlations between quantitative variables. Results CD4+ lymphopenia was found among SLE patients. Patients showed a trend for a higher percentage of TDEM among the CD4+ T-cell subpopulation in comparison with healthy controls ( p = .04). SLE patients were divided into two groups according to disease activity: patients with SLEDAI-2K ≥ 6 ( n = 13) had a higher percentage of circulating CD4+ T-cells with CD28- phenotype ( p^adj= .005) as well as those with an effector memory ( p^adj= .004) and TDEM ( p^adj= .002) phenotype and a trend of decrease of regulatory T-cells (TREGs) ( p = .02), in comparison with patients with low disease activity ( n = 38). Patients with damage (SDI ≥ 1) tended to show an expansion of TDEM among CD4+ T-cells as compared with patients with no damage ( p = .01). In SLE patients an inverse correlation was found between the percentages of TREGs and those of TDEM ( p < .01) or CD4 + CD28- ( p < .01) T-cells. Conclusions CD4+ T-cell subpopulations displaying phenotype characteristics of effector lymphocytes are proportionally expanded in patients with active SLE and a higher damage index. These findings may suggest a role of effector T-cells in the pathogenesis of the disease and in the mechanisms of damage in SLE.