Early and Late Response and Glucocorticoid-Sparing Effect of Belimumab in Patients with Systemic Lupus Erythematosus with Joint and Skin Manifestations: Results from the Belimumab in Real Life Setting Study-Joint and Skin (BeRLiSS-JS)

AIM

To assess the efficacy of belimumab in joint and skin manifestations in a nationwide cohort of patients with SLE.

METHODS

All patients with skin and joint involvement enrolled in the BeRLiSS cohort were considered. Belimumab (intravenous, 10 mg/kg) effectiveness in joint and skin manifestations was assessed by DAS28 and CLASI, respectively. Attainment and predictors of DAS28 remission (<2.6) and LDA (≥2.6, ≤3.2), CLASI = 0, 1, and improvement in DAS28 and CLASI indices ≥20%, ≥50%, and ≥70% were evaluated at 6, 12, 24, and 36 months.

RESULTS

DAS28 < 2.6 was achieved by 46%, 57%, and 71% of patients at 6, 12, and 24 months, respectively. CLASI = 0 was achieved by 36%, 48%, and 62% of patients at 6, 12, and 24 months, respectively. Belimumab showed a glucocorticoid-sparing effect, being glucocorticoid-free at 8.5%, 15.4%, 25.6%, and 31.6% of patients at 6, 12, 24, and 36 months, respectively. Patients achieving DAS-LDA and CLASI-50 at 6 months had a higher probability of remission at 12 months compared with those who did not (p = 0.034 and p = 0.028, respectively).

CONCLUSIONS

Belimumab led to clinical improvement in a significant proportion of patients with joint or skin involvement in a real-life setting and was associated with a glucocorticoid-sparing effect. A significant proportion of patients with a partial response at 6 months achieved remission later on during follow-up.

A new digital health tool for the telemonitoring of patients with scleroderma during iloprost administration: a feasibility and acceptability study

OBJECTIVE

To assess the feasibility of a new device for telemonitoring vital parameters during iloprost infusion.

MATERIALS AND METHODS

In a pilot study, patients with systemic sclerosis received iloprost infusion while being telemonitored with Umana T1 Heart Monitor, within the hospital, under the supervision of family/community nurses and rheumatologists. Patients were administered a questionnaire to obtain information on satisfaction, practicability, and compliance with the new monitoring device.

RESULTS

Data recorded by the device for blood pressure, heart rate, and oximetry were concordant with those registered directly by nurses. Most patients found the device useful and thought it could be used at home, even while working.

CONCLUSIONS

Umana Heart Monitor T1 could be a valuable aid in at-home iloprost therapy in patients with systemic sclerosis.

AB1269 SHULMAN’S DISEASE OR EOSINOPHILIC FASCIITIS, A RARE FIBROSING DISORDER: A CASE REPORT TREATED WITH TOCILIZUMAB

Background

Schulman eosinophilic fasciitis (EF) is a rare fibrosing disorder, typified by erythema, edema, and symmetric induration of the distal bilateral extremities (only proximal to the wrists and ankles) or/and trunk(1).The “groove sign” and/or a pseudocellulite appearance of the involved skin may be present(1), followed by joint contractures (1).Fascial biopsy is the gold standard for making a diagnosis.Systemic corticosteroids are first-line treatment(2).The use of c/bDMARDs is described in literature with clinical improvements(2).

Objectives

to evaluate efficacy of Tocilizumab in a patient affected by Shulman’s disease

Methods

A 54-year-old woman went to our observation for appearance of abrupt-onset simmetric edema followed by induration of the bilateral extremities and trunk. She has been feverish for about 2 weeks associated with diffuse arthromyalgia. On rheumatological examination: non-liftable skin in folds on the bilateral arms and forearms and lower limbs; absence of frank synovitis or lymphoglandular swellings. The blood tests performed showed an increase in acute phase reactants. The ferritin and electrophoretic picture, complement and immunoglobulin dosage were normal. The blood count showed a marked absolute eosinophilia accompanied by modest monocytosis and modest platelet disease. There was a slight increase in LDH and in serum beta2microglobulin. Serology for viral infections and autoimmunity were negative. Screening for celiac disease was negative. Coprocultures, parasitology and the search for the fecal H. pylori antigen are negative. Excluded lymphadenopathy or hepatosplenomegaly to the total body computed tomography. Modest non-buffering pericardial effusion was reported in CT scan. Nailfold capillary changes were absent. Chronic inflammatory bowel diseases were excluded. A skin biopsy of the left forearm confirmed the clinical diagnosis of EF. In particular, it documented thickening of the fascia, site of an inflammatory process that included small lymphocytes, plasma cells, histiocytes and some eosinophils, distributed both diffusely and around blood vessels.The underlying muscle tissue and the supra-fascial skin were free from alterations. Secondary fasciitis was excluded by 18 fluorodeoxyglucose (FDG)-positron emission tomography; this showed a diffusely accumulation of the radiopharmaceutical in the muscles of the forearms and of both lower limbs, compatible with eosinophilic fasciitis and confirmed the pericardial effusion. Immunophenotypic analysis on peripheral blood excluded the presence of a monoclonal cell population. Diagnosis of primary eosinophilic fasciitis was made and therapy was started with methylprednisolone 1 g intravenously for 3 days followed by another 3 boluses of methylprednisolon of 500 mg iv. Given the poor response, it was decided to set up therapy with Methotrexate 15 mg up to a dose of 20 mg intramuscularly per week associated with prednisone 25 mg/day. The rheumatological re-evaluation at 3 months showed a worsening of the fibrosis and diffuse skin edema with an obligatory kyphosis of the spine and limitation in the patient’s movements. Therefore it was decided to start off label infusion therapy with Tocilizumab 8 mg/kg/month.

Results

A complete resolution of the skin picture with disappearance of the pericardial effusion was documented 12 months after the start of the biological drug

Conclusion

There are currently no guidelines for the treatment of eosinophilic fasciitis. Tocilizumab has been shown to be effective when introduced in the early inflammatory stages of the disease, as in the case described.

References

[1]Lakhanpal S, Ginsburg WW, Michet CJ, Doyle JA, Moore SB. Eosinophilic fasciitis: clinical spectrum and therapeutic response in 52 cases. Semin Arthritis Rheum. 1988;17(4):221–31.

[2]Daniel R. Mazori & Alisa N. Femia & Ruth Ann Vleugels. Eosinophilic Fasciitis: an Updated Review on Diagnosis and Treatment Curr Rheumatol Rep (2017) 19: 74.

Disclosure of Interests

None declared

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

AB0645 Nintedanib in treatment of pulmonary fibrosis secondary to Connective Tissue Disease:

Background

Interstitial lung disease (ILD) is a common manifestation of systemic sclerosis and other Rheumatic Diseases, and is one of the major causes of mortality. Nintedanib, a tyrosine kinase inhibitor, has been shown to have antifibrotic and anti-inflammatory effects in preclinical models of systemic sclerosis and ILD.

Objectives

To evaluate efficacy and safety of Nintedanib in pulmonary fibrosis secondary to Connective Tissue Disease.

Methods

Ten patients with pulmonary fibrosis secondary to Connective Tissue Disease treated with Nintedanib were monitored at baseline, 6 and/or 12 months, with clinical assessment, chest CT scan and/or pulmonary function testing (PFT) with assessment of the diffusing capacity for CO (DLCO). 8/10 patients had a diagnosis of Progressive Systemic Sclerosis, while the remaining ones had Polydermatomyositis and Mixed Connectivitis. All patients were dyspnoic at baseline and presented with dry cough. All patients had pulmonary fibrosis according to high-resolution chest CT scan. All patients had been treated with at least one csDMARD or bDMARD (cyclophosphamide, azathioprine, cyclosporine, rituximab, tocilizumab), prior to receiving nintedanib. At baseline 2/10 patients were treated with Nintedanib monotherapy, 7/10 were in combination therapy with Mycophenolate, 1 patient received a combination therapy with cyclosporine.

Results

Compared to baseline values, 4/7 patients showed stationarity of the respiratory function parameters (DLCO), in 2/7 patients it was observed a significant improvement of the DLCO (with a change of 15%) while in only 1 patient there was a worsening over time. FVC remained stable over time except in 1 patient who got a significant improvement. In 5/9 patients cough improved (unchanged in the rest of patients). Dyspnea (NYHA scale) improved in 6/9 patients, remained stationary in 2/6 patients and became worse in 1 patient. 8/9 patients had a stable chest CT at 6 and / or 12 months, while only 1 patient witnessed a further worsening of the fibrosis. 50% of the patients showed good gastrointestinal tolerance to the full dose of nintedaninb. The other half had the dose reduced in order to improve gastrointestinal symptoms.

Conclusion

Our data show that patients with ILD associated with Rheumatic Diseases treated with nintedanib had a clinical benefit over dyspnea and cough symptoms and a stabilization of radiological findings 12 months after starting the treatment. Also, respiratory function parameters remained stable over time. Gastrointestinal adverse events, including diarrhea, were common in these patients, but therapeutic dose adjustment led to fast symptoms resolution and good tolerance.

References

[1]Kristin B Highland, Oliver Distler, Masataka Kuwana, Yannick Allanore, Shervin Assassi, Arata Azuma, Arnaud Bourdin, Christopher P Denton, Jörg H W Distler, Anna Maria Hoffmann-Vold, Dinesh Khanna, Maureen D Mayes, Ganesh Raghu, Madelon C Vonk, Martina Gahlemann, Emmanuelle Clerisme-Beaty, Mannaig Girard, Susanne Stowasser, Donald Zoz, Toby M Maher, SENSCIS trial investigators. Efficacy and safety of nintedanib in patients with systemic sclerosis-associated interstitial lung disease treated with mycophenolate: a subgroup analysis of the SENSCIS trial. Lancet Respir Med. 2021 Jan;9(1):96-106.

[2]Oliver Distler, Kristin B Highland, Martina Gahlemann, Arata Azuma, Aryeh Fischer, Maureen D Mayes, Ganesh Raghu, Wiebke Sauter, Mannaig Girard, Margarida Alves, Emmanuelle Clerisme-Beaty, Susanne Stowasser, Kay Tetzlaff, Masataka Kuwana, Toby M Maher, SENSCIS Trial Investigators. Nintedanib for Systemic Sclerosis-Associated Interstitial Lung Disease. N Engl J Med. 2019 Jun 27;380(26):2518-2528.

Disclosure of Interests

None declared

Interstitial Lung Disease in Rheumatoid Arthritis: A Practical Review

Rheumatoid arthritis (RA) is a systemic inflammatory disease, which primarily causes symmetric polyarthritis. An extrarticolar involvement is common, and the commonly involved organ is lungs. Although cardiac disease is responsible for most RA-related deaths, pulmonary disease is also a major contributor, accounting for ~10-20% of all mortality. Pulmonary disease is a common (60-80% of patients with RA) extra-articular complication of RA. Optimal screening, diagnostic, and treatment strategies of pulmonary disease remain uncertain, which have been the focus of an ongoing investigation. Clinicians should regularly assess patients with RA for the signs and symptoms of pulmonary disease and, reciprocally, consider RA and other connective tissue diseases when evaluating a patient with pulmonary disease of an unknown etiology. RA directly affects all anatomic compartments of the thorax, including the lung parenchyma, large and small airways, pleura, and less commonly vessels. In addition, pulmonary infection and drug-induced lung disease associated with immunosuppressive agents used for the treatment of RA may occur.

Immunotherapy of COVID-19: Inside and Beyond IL-6 Signalling

Acting on the cytokine cascade is key to preventing disease progression and death in hospitalised patients with COVID-19. Among anti-cytokine therapies, interleukin (IL)-6 inhibitors have been the most used and studied since the beginning of the pandemic. Going through previous observational studies, subsequent randomised controlled trials, and meta-analyses, we focused on the baseline characteristics of the patients recruited, identifying the most favourable features in the light of positive or negative study outcomes; taking into account the biological significance and predictivity of IL-6 and other biomarkers according to specific thresholds, we ultimately attempted to delineate precise windows for therapeutic intervention. By stimulating scavenger macrophages and T-cell responsivity, IL-6 seems protective against viral replication during asymptomatic infection; still protective on early tissue damage by modulating the release of granzymes and lymphokines in mild-moderate disease; importantly pathogenic in severe disease by inducing the proinflammatory activation of immune and endothelial cells (through trans-signalling and trans-presentation); and again protective in critical disease by exerting homeostatic roles for tissue repair (through cis-signalling), while IL-1 still drives hyperinflammation. IL-6 inhibitors, particularly anti-IL-6R monoclonal antibodies (e.g., tocilizumab, sarilumab), are effective in severe disease, characterised by baseline IL-6 concentrations ranging from 35 to 90 ng/mL (reached in the circulation within 6 days of hospital admission), a ratio of partial pressure arterial oxygen (PaO2) and fraction of inspired oxygen (FiO2) between 100 and 200 mmHg, requirement of high-flow oxygen or non-invasive ventilation, C-reactive protein levels between 120 and 160 mg/L, ferritin levels between 800 and 1600 ng/mL, D-dimer levels between 750 and 3000 ng/mL, and lactate dehydrogenase levels between 350 and 500 U/L. Granulocyte-macrophage colony-stimulating factor inhibitors might have similar windows of opportunity but different age preferences compared to IL-6 inhibitors (over or under 70 years old, respectively). Janus kinase inhibitors (e.g., baricitinib) may also be effective in moderate disease, whereas IL-1 inhibitors (e.g., anakinra) may also be effective in critical disease. Correct use of biologics based on therapeutic windows is essential for successful outcomes and could inform future new trials with more appropriate recruiting criteria.

Durable renal response and safety with add-on belimumab in patients with lupus nephritis in real-life setting (BeRLiSS-LN). Results from a large, nationwide, multicentric cohort

BACKGROUND

Belimumab was recently approved for treatment of lupus glomerulonephritis (LN).

AIM

To evaluate renal response and its predictors in LN patients receiving belimumab in real-life.

PATIENTS AND METHODS

We considered all patients fulfilling the SLEDAI-2K renal items and/or having estimated glomerular filtration rate (eGFR)≤60 ml/min/1.73 m², with positive anti-dsDNA and/or low C3/C4 enrolled in the multicentre Italian lupus cohort BeRLiSS (BElimumab in Real LIfe Setting Study), treated with monthly IV Belimumab 10 mg/kg over standard treatment. Primary efficacy renal response (PERR), defined as proteinuria ≤0.7 g/24 h, eGFR≥60 ml/min/1.73 m² without rescue therapy, was considered as primary outcome. Complete renal response (CRR; proteinuria <0.5 g/24 h, eGFR≥90 ml/min/1.73 m²) was considered as secondary outcome. Prevalence and predictors of PERR were evaluated at 6, 12, 24 months by multivariate logistic regression.

RESULTS

Among the 466 SLE patients of BeRLiSS, 91 fulfilled the inclusion criteria, 79 females, median age 41.0 (33.0-47.0) years, median follow-up 22.0 (12.0-36.0) months. Sixty-four (70.3%) achieved PERR, of whom 38.4% reached CRR. Among patients achieving PERR at 6 months, 86.7% maintained response throughout the follow-up. At multivariable analysis, hypertension (OR [95%CI]: 0.28 [0.09-0.89], p = 0.032), high baseline serum creatinine (0.97 [0.95-0.99], p = 0.01) and high baseline proteinuria (0.37, [0.19-0.74], p = 0.005) negatively predicted PERR. Positive predictors of PERR at 12 and 24 months were baseline anti-Sm positivity (OR [95%CI]: 6.2 [1.21-31.7], p = 0.029; 19.8 [2.01-186.7], p = 0.009, respectively) and having achieved PERR at 6 months (14.4 [3.28-63.6]; 11.7 [2.7-48.7], p = 0.001 for both).

CONCLUSIONS

Add-on therapy with belimumab led to durable renal response in patients with LN in a real-life setting.

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

Improvement of HbA1c in Patients with Type 2 Diabetes Mellitus and Rheumatoid Arthritis Treated with bDMARDs

Objective

The aim of our study was to evaluate the possible role of biological treatments for rheumatoid arthritis (RA) in improving the glycemic profile in patients affected not only by RA but also by type 2 diabetes mellitus (2TDM).

Methods

An observational retrospective study was conducted using data from patients referred to our Rheumatology Unit. Patients with active RA despite standard DMARDs therapy and concomitant 2TDM were selected into one of five exposure groups to first-line bDMARDs (adalimumab, golimumab, etanercept, tocilizumab, sarilumab) and observed for the outcome of CRP, ESR, DAS28CRP and glycated hemoglobin (HbA1c) variations.

Results

After the start of treatment, there was a significant reduction in the values of acute phase reactants ESR and CRP (p<0.01), DAS28-CRP (p<0.01) and HbA1C (p<0.05), in the absence of any confounding factors such as a reduction in BMI or a change in steroid doses. There was no statistically significant difference between the various treatments. Anti-IL6 drugs appear to be associated with a slightly greater reduction in HbA1c values, bordering on statistical significance (p=0.047).

Conclusion

Initiation of a bDMARD appears to be associated with an improvement in concomitant 2TDM in patients with active RA, which, in the first hypothesis, is linked with a reduction of the inflammatory milieu.

FRI0238 AUTOLOGOUS FAT GRAFTING IN THE TREATMENT OF FACIAL SCLERODERMA: A SINGLE - CENTRE EXPERIENCE

Background:

Systemic sclerosis (SSc) is a systemic autoimmune disease characterized by progressive cutaneous and internal organ fibrosis. Orofacial manifestations are disabling and treatment options are limited. Fat Tissue Grafting (FTG) can be used for treating facial manifestations of the fibrosis.

Objectives:

In this study, we aimed to assess the safety and efficacy of FGT of our cohort of patients with SSc.

Methods:

We enrolled 20 SSc (18 W, 2 M) patients, from 2016 to 2019, suffering from facial sclerosis and restricted mouth opening capacity. FTG was carried out in accord with modified Colemans’ procedure (1): fat tissue was taken from periumbilical or trochanteric areas and was injected in 8 different points around the mouth. No side effects or adverse reactions have been documented. Evaluations included mouth opening capacity by measuring interincisal distance, oral functionality (MHISS scale) and patient global satisfaction (by Global Health scale).

Results:

A 11 mm (8 - 18mm range) median increase of interincisal distance was reported at month 6 and in 80% of patients at month 12, too (p<0.03). A significant improvement in MHISS scale was also observed (p<003). The patient satisfaction questionnaire showed 95% positive results and 80% of the patient replied affirmatively to the question about the repetition of FTG but only 2 patients required new FTG after 12 months.

Conclusion:

Our results showed that FTG improved mouth opening capacity and that aesthetic and functional results were satisfying to about 90% of the patients; long-term effects of this type of treatment are currently unknown. However, our and litterature data at 12 months follow-up seems to confirm the benefits in long term, despite the filling effect is over.

This study – that’s one of the largest case series described right now (2) - supports the possible therapeutic role of autologous FTG in improving facial scleroderma both in aesthetic and in functional aspects.

References:

[1]Coleman SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg. 2006; 118: 108S-20S

[2]Fat Grafting for the Treatment of Scleroderma.Strong AL, Rubin JP, Kozlow JH, Cederna PS. Plast Reconstr Surg. 2019 Dec;144(6):1498-1507. doi: 10.1097/PRS.0000000000006291.

Disclosure of Interests:

None declared

AB0574 BENEFITS OF ILOPROST IN LONG – TERM STABILIZATION OR IMPROVEMENT IN NEOANGIOGENESIS IN SYSTEMIC SCLEROSIS: A 15 YEARS OBSERVATION COHORT

Background:

In Systemic Sclerosis (SSc) fibrosis is due to microcirculation damage with capillary necrosis, arteriolar intimal proliferation and local ischemia. loprost (ILO) is used IV for the treatment of severe Raynaud phenomenon (RP) and digital ulcers (DU) in (SSc). We have already described (1) an improvement of peripheral vascularization with ILO, observed after 3 years treatment by capillaroscopy with an increase in the capillary number and mild regression of avascular areas and pericapillar oedema

Objectives:

Our aim was to observe capillaroscopic changes in a cohort of 26 patients treated with ILO, once a month (25 – 50 ng each infusion) for an average time of 15 years

Methods:

We evaluated the initial and 2019 capillaroscopic picture of 26 SSc patients (24 W,2 M; median age 63.8Y) in continuous treatment with monthly infusion of ILO from 2004 to today. 6/26 were SCL70 positive;the remainder was positive for anticentromere Ab

Results:

We documented stability of capillaroscopic picture in 62% of patients,an improvement in 19% and a worsening (mainly from early to active pattern) in 19%. Low adherence to therapy was observed among the worsened patients. Out of 8 patients with onset ulcers, only 3 patients still have skin ulcers, all with late stable capillaroscopic picture from onset.We have not documented serious adverse events

Conclusion:

Our observations confirm the efficacy and safety of ILO in the treatment of SSc even after many years of treatment, resulting in a stabilization of microvascular damage, independent of disease severity.

References:

[1]Possible role of iloprost (stable analog of PG12) in promoting neoangiogenesis in systemic sclerosis. Faggioli P, Giani L, Mazzone A. Clin Exp Rheumatol. 2006 Mar-Apr;24(2):220-1. No abstract available

Disclosure of Interests:

None declared

THU0463 EFFICACY AND SAFETY OF NERIDRONATE IN BONE EDEMA SYNDROME

Background:

Bone Marrow Edema Syndrome (BMES) is a severely disabling pain syndrome without a definite treatment and refers to transient clinical conditions with unknown pathogenic mechanism, such as transient osteoporosis of the hip (TOH), regional migratory osteoporosis (RMO), and reflex sympathetic dystrophy (RSD). Magnetic resonance imaging is used for the early diagnosis and monitoring the progression of the disease. Early differentiation from other aggressive conditions with long-term sequelae is essential in order to avoid unnecessary treatment.

Objectives:

Aim of this monocentric trial was to test the efficacy and the safety of the amino-bisphosphonate neridronate in patients with BMES administered in two different regimens.

Methods:

192 patients with BMES secondary to osteoarthritis localized to knee, hip, wrist or foot were randomly assigned to I.V. infusion of 100 mg neridronate given four times over 10 days (Group A, 72 subjects) or alternatively to I.V. infusions of 100 mg every 21 days over 3 months (Group B, 120 subjects). At baseline and after 180 days we performed an MRI. We assessed a 0-100 mm pain VAS in each patient, too. Outcomes were to evaluate the MRI changes and the VAS changes. A control group (35 patients) was enrolled too, treated conservatively with NSAIDs and articular rest.

Results:

we observed a significant improvement in MRI with the resolution of bone marrow lesions present at the baseline (p<0.01), without a significant difference between Group A and Group B. Visual analogue scale (VAS) score decreased significantly during the study in both groups (p<0.05) without a significant difference between the two treatment groups (p>0.1). Both groups showed a significant clinical and radiologic improvement compared with control group (p<0.001).

Conclusion:

In patients with BMES, the infusions of neridronate 100 mg every 21 days over 3 months or alternately every 3 days over 10 days are associated with clinically relevant and persistent benefits without significant differences between the two treatment-schedules. These results provide conclusive evidence that the use of bisphosphonates, at appropriate doses, is the treatment of choice BMES.

Disclosure of Interests: :

None declared

AB0901 PREVALENCE OF OSTEOPOROSIS IN ITALIAN POSTMENOPAUSAL WOMEN ACCORDING TO DEFRA ALGORITHM

Background:

Osteoporosis is a recognized health problem and the burden of the disease is mostly associated with the occurrence of hip and vertebral fracture.

Objectives:

This study was aimed at evaluating the prevalence of osteoporosis in Italian postmenopausal women, defined by DeFRA calculation as a 10 years fracture risk equal or higher than 20%.

Methods:

This is a monocenter cohort study evaluating 1850 post-menopausal women aged 50 years and older. All the participants were evaluated as far as anthropometrics. Defra questionnaire was administered and calculated with bone mineral density (DXA) measured at lumbar spine and femoral neck.

Results:

The prevalence of osteoporosis as assessed by DeFRA was 29.8% in the whole population, according to literature. The frequency of a risk fracture equal or higher than 20% varied from 7.9% in the group aged 50-59 years to 35% in subjects aged >80. Among clinical risk factors for fracture, the presence of a previous fracture (spine primarily) was the most commonly observed.

Conclusion:

Our data showed that about one third of post-menopausal women aged 50 and older in Italy has osteoporosis on the basis of DeFRA algorithm, with a high 10 years fracture risk. A previous fracture is the most common risk factor. The data should be considered in relation to the need to increase prevention strategies and therapeutic intervention.

Disclosure of Interests:

None declared

Color duplex ultrasonography findings of temporal arteries in a case of giant cell arteritis: role in diagnosis and follow-up

Giant cell arteritis (GCA) is a systemic autoimmune disease that affects medium- and large-sized arteries. The diagnostic gold standard is the temporal artery biopsy, but it has limited sensitivity and some difficulties in reproducibility. Color duplex ultrasonography is a noninvasive, reproducible, and inexpensive method for diagnosis of temporal arteries involvement (temporal arteritis [TA]) in GCA with high sensitivity and specificity. We present the ultrasound findings at baseline and during follow-up in a case of TA in a patient with GCA.

The macrophages in rheumatic diseases

Macrophages belong to the innate immune system giving us protection against pathogens. However it is known that they are also involved in rheumatic diseases. Activated macrophages have two different phenotypes related to different stimuli: M1 (classically activated) and M2 (alternatively activated). M1 macrophages release high levels of pro-inflammatory cytokines, reactive nitrogen and oxygen intermediates killing microorganisms and tumor cells; while M2 macrophages are involved in resolution of inflammation through phagocytosis of apoptotic neutrophils, reduced production of pro-inflammatory cytokines, and increased synthesis of mediators important in tissue remodeling, angiogenesis, and wound repair. The role of macrophages in the different rheumatic diseases is different according to their M1/M2 macrophages phenotype.

Different T cells' distribution and activation degree of Th17 CD4+ cells in peripheral blood in patients with osteoarthritis, rheumatoid arthritis, and healthy donors: preliminary results of the MAGENTA CLICAO study

Objective

To determine distribution of T cells and activation degree of Th CD4+ cells in peripheral blood of patients with osteoarthritis (OA), rheumatoid arthritis (RA), and healthy donors.

Methods

Patients with established diagnosis of RA according to American College of Rheumatology/European League Against Rheumatism 2010 criteria, knee or hip OA according to American College of Rheumatology criteria, and healthy blood donor volunteers were eligible. Multi-channel flow cytometry and monoclonal antibodies against CD3, CD4, CD8, CCR6, CD38, CXCR3, and HLA DR were used to distinguish and evaluate T cells’ subpopulation.

Results

We analyzed blood samples of 15 patients with well-defined RA, 56 with hip or knee OA, and 20 healthy age matched controls. Blood samples from RA patients showed significantly higher counts of CD4+ CD38+ DR+ (activated CD4 T cells) and Th17 (CCR6+ CXCR3−) cells as compared to OA patients and control group (P<0.01). Furthermore the samples from the OA patients showed a higher percentage of activated CD4 T cells and Th17 cells as compared to control group (P<0.05). Interestingly there was no difference between Th1 (CD4+ CXCR3+ CCR6−) and Th2 (CD4+ CXCR3− CCR6−) between the three groups (P>0.1).

Conclusion

According to the latest view of OA disease pathogenesis, our preliminary results support the hypothesis that OA may also be a disease with an immunological/inflammatory involvement like RA. It seems that there is a quantitative but non-qualitative difference in Th17 cells’ profile, including the expression of activation markers, between RA and OA.

Calciphylaxis in a patient affected by rheumatoid arthritis, chronic renal failure, and hyperparathyroidism: a case report

Calciphylaxis, or calcific uremic arteriolopathy, is the tissue and vascular calcification that occurs mainly in chronic kidney disease. However, it can be secondary to parathyroid dysfunction and it has been described in rheumatic patients. We present a case of calciphylaxis in a woman with inactive rheumatoid arthritis, acute renal failure, and hyperparathyroidism.

User preference for a portable syringe pump for iloprost infusion

Purpose

Administration of intravenous iloprost – a first-line European League Against Rheumatism (EULAR)-recommended choice for the treatment of scleroderma (SSc)-related digital vasculopathy – requires repeated treatment cycles of 6 hours per day in a hospital setting. During the infusion, patient mobility is considerably restricted due to the size and fixity of traditional syringe pumps. The aim of this study was to evaluate the satisfaction level of patients and nurses, after the introduction of a new portable syringe pump (Infonde^®, Italfarmaco S.p.A., Milan, Italy) at the Department of Rheumatology, Magenta Hospital, Milan, Italy.

Patients and methods

Thirty-four consecutive SSc patients receiving stable therapy with iloprost, previously administered with a fixed pump, were treated using the portable Infonde^® pump. Patients (n=34) and nurses (n=4) were asked to answer a nine- and six-item questionnaire, respectively, to assess the satisfaction of the administration comparing the new device versus the previous one. The health care staff of the ward developed the questionnaire, and the response scores ranged from 0 (fixed device better) to 10 (portable device better); thus a score >5 indicates a preference for Infonde^®.

Results

Patients’ answers indicated a preference towards the new portable syringe pump, versus the previous fixed pump. Questionnaires administered to patients generated a total of 306 responses, with over 95% of the responses in the range 8–10, of which 89% had a score equal to 10. The responses of nurses showed a score equal to 10 in 100% cases. No significant adverse events were recorded, indicating no change in the tolerability profile of the drug.

Conclusion

Iloprost administration with Infonde^® pump was preferred by both patients and health care professionals, and was well tolerated. The possibility to perform daily activities and the freedom of movement suggest a positive impact of Infonde^® on the treatment, with a potential favorable effect on the quality of life of patients during the many hours spent receiving the infusion.

Recognizing and treating myocarditis in recent-onset systemic sclerosis heart disease: potential utility of immunosuppressive therapy in cardiac damage progression

OBJECTIVES

Scleroderma heart disease is a major risk of death in systemic sclerosis (SSc). Mechanisms underlying myocardial damage are still unclear. We performed an extensive study of SSc patients with recent-onset symptoms for heart disease and examined the efficacy of immunosuppressive therapy.

METHODS

A cohort of 181 SSc patients was enrolled. Of these, 7 patients newly developed clinical symptoms of heart disease (heart failure, chest pain, and palpitation); all of them showed mild but persistent increase in cardiac enzymes. These patients underwent Holter ECG, 2D-echocardiography, perfusional scintigraphy, delayed-enhancement-cardiac magnetic resonance (DE-CMR), coronary angiography, and endomyocardial biopsy. Patients were treated for at least 12 months and followed-up for 5 years.

RESULTS

Ventricular ectopic beats (VEBs) were found in 4 patients, wall motion abnormalities in 3, pericardial effusion in 6, and DE in CMR in 6 with T2-hyperintensity in 2. In all patients, histology showed upregulation of endothelium adhesion molecules and infiltration of activated T lymphocytes, with (acute/active myocarditis in 6) or without (chronic/borderline myocarditis in 1) myocyte necrosis. Parvovirus B19 genome was detected in 3. None showed occlusion of coronary arteries or microvessels. Compared with SSc controls, these patients more often had early disease, skeletal myositis, c-ANCA/anti-PR3 positivity, VEBs, pericardial effusion, and systolic and/or diastolic dysfunction. Immunosuppressive therapy improved symptoms and led to cardiac enzyme negativization; however, 2 patients died of sudden death during follow-up.

CONCLUSIONS

Myocarditis is a common finding in SSc patients with recent-onset cardiac involvement. Its early detection allowed to timely start an immunosuppressive treatment, preventing cardiac damage progression in most cases.

Systematic review of the literature and a case report informing biopsy-proven giant cell arteritis (GCA) with normal C-reactive protein

Giant cell arteritis (GCA) is a vasculitis of large- vessels. A markedly elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels are characteristics of GCA, although temporal artery biopsy remains the gold standard for the diagnosis. We describe a case of biopsy-proven GCA showing a heavy infiltration of CD68 macrophages and CD3 T cells and with normal ESR and CRP levels at diagnosis. Key points (1) GCA may occur with normal ESR in a percentage of about 4 to 15 % (although the American College of Rheumatology classification criteria for giant cell arteritis include an ESR of 50 mm/h or more), while it can occur with normal ESR and normal CRP in a percentage of about 0.8 %. So, the clinical suspicion must be confirmed with a positive biopsy. (2) GCA patients with ESR >40 mm/h are characterized by higher incidence of headache and jaw claudication compared to patients with normal ESR. In our case, it occurred with normal ESR. (3) Color duplex ultrasonography is a noninvasive, easy, and inexpensive method for supporting a diagnosis of TA, with a high sensitivity and specificity. It can predict which patient will need TAB.

ACR70-disease activity score remission achievement from switches between all the available biological agents in rheumatoid arthritis: a systematic review of the literature

Introduction

The aim of our analysis was to compare the gaining of a major response (disease activity score [DAS] remission or American College of Rheumatology 70% improvement criteria [ACR70]) by switching between all the available biological therapies in rheumatoid arthritis.

Methods

A systematic review was performed including studies, published before December 2008, in which a second biological agent was used and clinical outcomes were evaluated after a first biological failure.

Results

Nine articles were included. Switching from etanercept and/or infliximab to adalimumab is effective with an ACR70 response ranging from 5% to 33%. Rituximab may be slightly more effective than switching to a second anti-tumor necrosis factor-alpha (anti-TNFα), reaching an ACR70 or DAS remission response in 12% and 9%, respectively. Clinical trials confirmed the efficacy in switching to abatacept (gain of effect 10.2%). Tocilizumab allows DAS28 (DAS using 28 joint counts) remission in 30.1% but ACR70 only in 12.4% of patients refractory to anti-TNFα.

Conclusions

The efficacy of a second biological agent, irrespective of the mode of action, in reaching an ACR70 or DAS remission after a first biologic is observed from 5% to 15% and from 9% to 15.4%, respectively (except in two studies).