Temporal deep learning framework for retinopathy prediction in patients with type 1 diabetes

The adoption of electronic health records in hospitals has ensured the availability of large datasets that can be used to predict medical complications. The trajectories of patients in real-world settings are highly variable, making longitudinal data modeling challenging. In recent years, significant progress has been made in the study of deep learning models applied to time series; however, the application of these models to irregular medical time series (IMTS) remains limited. To address this issue, we developed a generic deep-learning-based framework for modeling IMTS that facilitates the comparative studies of sequential neural networks (transformers and long short-term memory) and irregular time representation techniques. A validation study to predict retinopathy complications was conducted on 1207 patients with type 1 diabetes in a French database using their historical glycosylated hemoglobin measurements, without any data aggregation or imputation. The transformer-based model combined with the soft one-hot representation of time gaps achieved the highest score: an area under the receiver operating characteristic curve of 88.65%, specificity of 85.56%, sensitivity of 83.33% and an improvement of 11.7% over the same architecture without time information. This is the first attempt to predict retinopathy complications in patients with type 1 diabetes using deep learning and longitudinal data collected from patient visits. This study highlighted the significance of modeling time gaps between medical records to improve prediction performance and the utility of a generic framework for conducting extensive comparative studies.

Association Between the Tissue and Circulating Advanced Glycation End-Products and the Micro- and Macrovascular Complications in Type 1 Diabetes: The DIABAGE Study

INTRODUCTION

Type 1 diabetes is associated with an increased risk of vascular complications. We aimed to investigate the association between serum and tissue advanced glycation end-products (AGEs) and micro- and macrovascular complications in type 1 diabetes (T1D).

METHODS

We conducted a cross-sectional study on 196 adults with T1D (mean age 44.53 ± 16, mean duration of diabetes 22 ± 12 years, mean HbA1c 8 ± 1.2%). AGEs were measured in blood serum (i.e., carboxymethyllysine (CML), methylglyoxal-hydroimidazolone-1 (MGH1), and pentosidine) and by measurement of skin autofluorescence (SAF). Associations between AGEs levels and vascular complications were analyzed using binary logistic regression. Correlations between AGEs and pulse wave velocity (PWV) were also assessed by linear regressions. Significant differences were set for p values less than 0.05.

RESULTS

We found positive associations between different AGEs and vascular complications. SAF was associated with both microangiopathy (retinopathy: OR = 1.92, p = 0.011; neuropathy: OR = 2.02, p = 0.04; any microangiopathy: OR = 2.83, p < 0.0001) and macroangiopathy (coronaropathy: OR = 3.11, p = 0.009; any macroangiopathy: OR = 2.78, p = 0.003). For circulating AGEs, pentosidine was significantly associated with coronaropathy (OR = 1.61, p = 0.01) and any macroangiopathy (OR = 1.52, p = 0.005) while MGH1 was associated with nephropathy (OR 1.72, p = 0.03). Furthermore, a significant linear correlation was found between PWV and SAF (r = 0.43, p < 0.001), pentosidine (r = 0.28, p < 0.001), and MGH1 (r = 0.16, p = 0.031), but not for CML (r = 0.03, p = 0.598).

CONCLUSIONS

Skin autofluorescence appears to be a useful marker for investigating both micro- and macrovascular complications in T1D. In this study, pentosidine was associated with macroangiopathy and MGH1 with nephropathy among the circulating AGEs. Furthermore, the correlations between PWV and AGEs may suggest their value in early prediction of vascular complications in T1D.

POS0300 FACTORS ASSOCIATED WITH SECUKINUMAB (SEC) RETENTION IN AXIAL SPONDYLOARTHRITIS (axSpA): RESULTS OF THE FRENCH RETROSPECTIVE STUDY FORSYA

Background

While data on real-life SEC retention rate in patients (pts) with axSpA is accumulating, there are no data on predictive factors for this retention. Presence of objective sign of inflammation (OSI) are known to be predictive of efficacy of anti-TNFs and their retention in axSpA.

Objectives

To assess whether OSI were predictive of SEC retention at 1 year in axSpA.

Methods

French retrospective study collecting between October 2019 and September 2020 data from axSpA pts a) having initiated and received at least one dose of SEC between August 11th 2016 and August 31st 2018, b)with at least a one year follow-up period. Retention of SEC at 1 year was estimated by the Kaplan Meier (KM) method. OSI were defined by at least one of the following: CRP> N, MRI-inflammation at the sacroiliac or spine level. Preselected factors of SEC retention at 1 year (≥1 OSI, age, sex, BMI, smoking, HLA B27, non-radiographic vs radiographic axSpA, past or present uveitis / Inflammatory Bowel Disease (IBD) / psoriasis / arthritis or synovitis, diagnostic delay, disease duration, SEC line of biologic therapy, SEC maintenance dose, concomitant csDMARD / oral corticosteroids / proton pomp inhibitor, history of depression / fibromyalgia) were analyzed by multivariate cox model regression. Only variables with <20% missing data were included in the model after imputation and stepwise selection (significance level for entering variables = 20%; for removing variables = 10%). OSI was forced into the model whatever its significance level or rate of missing data.

Results

In total, 906 pts from 47 centers (male: 42.2%, mean age: 46.2 ± 11.7 years, mean disease duration: 9,3 ± 9.1 years), were included in the analysis. At initiation of SEC, 86.3% of pts had ≥ 1 OSI and respectively 8.0%, 14.9% and 77.1% were in 1st, 2nd and ≥ 3rd line (L) of biologic/targeted synthetic DMARD. The 1 year KM survival rate for SEC was 59% [95%CI:55%-62%] overall, 58% [54%-62%] and 63% [53%-73%] for pts with or without OSI, and was numerically greater in 1st L vs 2nd and ≥3rd L (70% [59%-81%], 62% [54%-70%], 57% [53%-61%] respectively). In multivariate analysis absence of OSI, lack of prior exposure to anti-TNF inhibitors, absence of IBD, and absence of history of depression were associated with a better SEC retention at 1 year (Table 1).

Table 1.

Predictive factors of SEC 1 year retention identified by multivariate cox regression analysis (multiple imputation + stepwise selection)

Predictive factors (* reference)Still on SEC at 1 Year (%)#HR [95% CI]p vs refp type III≥ 1 objective sign of inflammationNo (N=165)*65.3%yes (N=711)58.8%1.44 [1.08; 1.93]0.014SEC treatment line1st L (N=68)*72.2%0.0842nd L (N=132)62.7%1.53 [0.91; 2.57]0.107≥ 3rd L (N=676)57.6%1.67 [1.06; 2.62]0.028Past or present history of IBDNo (N=854)*59.8%Yes (N=22)40.9%1.76 [1.01; 3.07]0.047History of depression or anti-depressive concomitant treatmentNo (N=716)*60.8%Yes (N=160)54.5%1.25 [0.97; 1.60]0.090

# without imputation for missing data

Interpretation HR > 1: the hazard of discontinuation at 1 year is X times higher vs reference

Conclusion

The overall retention of SEC at 1 year in daily practice at the time of its launch in France was 59% for axSpA patients and OSI, prior exposure to TNF inhibitors, IBD and history of depression were identified as predictive factors of SEC retention.

Acknowledgements

Authors thank the participating investigators, centers and patients. NOVARTIS Pharma France financially supported this study.

Disclosure of Interests

Maxime Dougados Consultant of: Honorarium from Novartis Pharma France, Julien Lucas: None declared, Emilie Desfleurs Employee of: Novartis employee, Pascal Claudepierre Consultant of: Honorarium from Novartis Pharma France, Philippe Goupille Consultant of: Honorarium from Novartis Pharma France, Adeline Ruyssen-Witrand Consultant of: Honorarium from Novartis Pharma France, Alain Saraux Consultant of: Honorarium from Novartis Pharma France, Anne Tournadre Speakers bureau: AbbVie, Fresenius-Kabi, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, Sanofi, Consultant of: AbbVie, Fresenius-Kabi, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, Sanofi, Grant/research support from: AbbVie, Fresenius-Kabi, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, Sanofi, Daniel Wendling Consultant of: Honorarium from Novartis Pharma France, Cédric Lukas Consultant of: Honorarium from Novartis Pharma France

POS0700 IMPACT OF DELAYING INITIATION OF METHOTREXATE BY 1 MONTH ON THE OUTCOME OF RHEUMATOID ARTHRITIS AT 1 YEAR

Background

It is recommended that vaccinations should be performed prior to start methotrexate (MTX) knowing that delaying initiation of background therapy may have an impact on the progression of RA.

Objectives

To access the impact of delaying initiation of MTX by 1 month on the outcome of RA at 1 year.

Methods

The VACIMRA study is a prospective, randomized, parallel-group, multicenter trial comparing the vaccine protection obtained in patients with rheumatoid arthritis according to the 1-month delay between anti-pneumococcal vaccine PCV13 and methotrexate initiation in one arm, versus immediate introduction of MTX following vaccination in the other arm. We analyzed disease activity based on DAS28-ESR at baseline (M0), 1, 2, 3, 6 and 12 months between the 2 groups. For structural progression, we performed a radiographic analysis of 79 RA patients included in the Montpellier center at baseline, 6 and 12 months. This analysis was performed by the same physician two times, blinded to the patient’s group. Structural damage progression at 6 months and 1 year was assessed according to van-der-Heijde-modified Sharp score (vSHS) on radiographs performed at inclusion, at 6 and 12 months of follow-up. Comparisons of the means of activity scores and radiographic scores were made with the non-parametric Wilcoxon-Mann-Whitney test.

Results

Of the 276 patients randomized, 261 could be analyzed (131 in the IMMEDIATE group and 130 in the DELAY group). At inclusion, there were no significant differences in demographic, disease activity (DAS28-ESR), biological and radiographic characteristics between the 2 groups (Table 1).

Table 1.

Baseline characteristics

VariableModalityTotal populationGROUP IMMEDIATEGROUPE DELAYpGender, n(%)N=261n=131n=1300.97Man74 (28.35)37 (28.24)37 (28.46)Woman187 (71.65)94 (71.76)93 (71.54)Age (years)Mean (± SD)55.74 (± 14.68)55.31 (± 15.27)56.16 (± 14.11)0.76MTX true naive (n(% col))No13 (4.98)8 (6.11)5 (3.85)0.40yes248 (95.02)123 (93.89)125 (96.15)Age at diagnosis (years)Mean (± SD)N=205 55.86 (± 15.16)n=98 55.31 (± 16.07)n=107 56.37 (± 14.34)0.80Positive rheumatoid factorn(% col)166 (64.59)84 (65.12)82 (64.06)0.86Positive ACPAn(% col)174 (68.24)89 (68.99)85 (67.46)0.79CRP (mg/L)Mean (± SD)N=260 17.62 (± 24.87)n=131 15.36 (± 17.95)n=129 19.91 (± 30.23)0.65DAS28-ESRMean (± SD)N=249 5.01 (± 1.11)n=125 5.03 (± 1.13)n=12 4.98 (± 1.10)0.54Sharp modified VdH total radiographic scoreMean (± SD)N=93 1.53 (± 3.62)n=47 1.57 (± 3.68)n=46 1.48 (± 3.60)0.88

DAS 28-ESR evolution during 1 year of follow-up

There was a significant difference in the means of DAS28-ESR at 1 month between the DELAY and IMMEDIAT groups (3.96 ± 1.46 vs 3.41 ± 1.33; p<0.001, respectively). There was no significant difference in the means of DAS28-ESR between the 2 groups at 3 months (3.19± 1.46 in the 2 groups p<0.91), at 6 months (3.11 ± 1.42 vs 3.24 ± 1.43; p=0.46, respectively) and at 12 months (2.96 ± 1.34 vs 2.98 ± 1.26p=0.89) (Graphic). Similarly, there was no significant difference in mean radiographic scores at 6 months (2.00 ± 4.41 vs. 1.80 ± 4.03 p=0.81) or at 12 months (2.23 ± 4.86 vs. 2.00 ± 4.07 p=0.93).

There was no significant variation between radiographic scores at 6 months compared to baseline in either group (mean difference 0.21 ± 0.52 vs. 0.36 ± 1.01, p=0.90) nor at 12 months compared to baseline (mean difference 0.40 ± 1.06 vs. 0.62 ± 1.58, p=0.85).

Conclusion

In patients with rheumatoid arthritis, initiation of methotrexate 1 month after PCV13 vaccination has no significant impact on RA activity and structural outcome at 1 year. Performing vaccinations 1 month before starting MTX can be proposed without significant impact on RA outcome at 1 year.

Figure 1.

Disclosure of Interests

None declared

POS1000 MORE THAN 30 % OF WOMEN WITH SPONDYLOARTHRITIS HAVE AN UNFAVORABLE PREGNANCY OUTCOME MOST FREQUENTLY DUE TO SMALL FOR GESTATIONAL AGE: ANALYSIS OF THE PROSPECTIVE GR2 COHORT

Background

Spondyloarthritis (SpA) is one of the most common chronic inflammatory diseases and regularly affects women of childbearing age1. However, there is limited knowledge about the impact of the disease and its treatment on pregnancy.

Objectives

The aim of the study was to determine the factors associated with adverse pregnancy outcome in women with SpA.

Methods

All SpA patients (diagnosis according to the Rheumatologist) included in the national multicenter GR2 cohort from 2015 to June 2021 were included in the analysis. Patients could be included either with a pregnancy wish (i.e., preconceptional period) or because of a clinical pregnancy (<12 weeks of gestation). The main endpoint was favorable pregnancy outcome, a composite outcome defined as a live birth at term ≥ 37 gestation weeks of a healthy newborn with a weight greater than the 10th percentile. We performed a multilevel logistic regression model, in which we considered patient and center random effects (patient random effect for some women included in the cohort two times). Disease activity was defined by a BASDAI score ≥ 4 at least once during pregnancy. We used a multiple imputation to address missing data among the explanatory variables. Results are presented as an odds ratio (OR) with confidence interval (CI).

Results

Among the 207 pregnancies in women with SpA included in the GR2 cohort, 126 were retained for analysis of obstetrical outcome. Of these, 29 (23.0%), 14 (11.1%), 69 (54.8%) were exposed to corticosteroid, NSAID and biologics at least once during pregnancy, respectively. An active disease at least once during pregnancy was found in 47 (37.3%) pregnancies. A live birth was found in 116 (92.1%) women, including 110 (87.3%) full-term births. Early miscarriages and stillbirths were observed in 7 (0.06%) and 3 (0.02%) women, respectively. A caesarean section was performed in 20 (17.2%) cases.

A favorable pregnancy outcome was found in 80 (63.5%) of the women. Unfavorable pregnancy outcome was most frequently due to small for gestational age, observed in 22 (19%) pregnancies. The multivariate model adjusted for age, BMI, nulliparity, active disease during pregnancy, smoking, and exposure to NSAIDs and corticosteroids during pregnancy found an association between unfavorable pregnancy outcome with nulliparity (OR 2.63 95% CI [1.01-6.81] p = 0.05).

Conclusion

This study provides original results on pregnancy in women with SpA. It found a favorable pregnancy outcome in 63.5% of women. Unfavorable pregnancy outcome was most frequently due to small for gestational age, which should lead to a coordinated management with obstetricians for the follow-up of pregnancy in women with SpA.

References

[1]Van den Brandt S. Arthritis Res Ther. 2017;19(1):64.

Table 1.

Multilevel logistic regression model: factors associated with unfavorable pregnancy outcome in women with SpA.

Univariate analysesMultivariate analysesCrude OR 95% CIpAdjusted OR 95% CIpAge1.01 [0.92-1.10]0.8591.05 [0.95-1.17]0.297BMI0.99 [0.91-1.07]0.7960.99 [0.90-1.08]0.747Nulliparity2.16 [0.94-4.94]0.0712.63 [1.01-6.81]0.049Smoking0.84 [0.23-3.03]0.8050.84 [0.22-3.21]0.805Disease activity*0.98 [0.40-2.43]0.9641.15 [0.43-3.07]0.778Corticosteroids**1.09 [0.45-2.65]0.8761.15 [0.51-2.71]0.902NSAIDs**0.65 [0.18-2.33]0.1960.67 [0.18-2.56]0.565

* BASDAI score ≥ 4 at least once during pregnancy.

** Use at least once during pregnancy

Acknowledgements

The GR2 Cohort is supported by the French Society of Rheumatology, the French Internal Medicine Society, and unrestricted grants from UCB.

Disclosure of Interests

SABRINA HAMROUN: None declared, Marion Couderc: None declared, Rene-Marc Flipo: None declared, Jérémie SELLAM: None declared, Christophe Richez Speakers bureau: CR has received consulting/speaker’s fees from Abbvie, Amgen, Astra Zeneca, Biogen, BMS, Celltrion, Eli Lilly, Galapagos, GSK, MSD, Novartis, and Pfizer, all unrelated to this manuscript., Rakiba Belkhir: None declared, Laure Gossec: None declared, Hubert MAROTTE: None declared, Emmanuelle Dernis: None declared, Aline Frazier-Mironer: None declared, Elisabeth Gervais: None declared, Cédric Lukas: None declared, Valerie Devauchelle-Pensec: None declared, Laëtitia Dunogeant: None declared, Alban Deroux: None declared, Nathalie Costedoat-Chalumeau: None declared, Anna Moltó: None declared

AB0760 Factors associated with the retention of secukinumab (SEC) in patients with psoriatic arthritis (PsA) in real world practice: Results from the retrospective FORSYA study

Background

While data on real-life retention of SEC in patients (pts) with PsA is accumulating, there are no data on predictive factors for this retention.

Objectives

The primary objective of FORSYA study was to assess whether objective signs of inflammation (OSI) were predictive of SEC retention at 1 year.

Methods

French retrospective study collecting between October 2019 and September 2020 data from axSpA pts a) having initiated and received at least one dose of SEC between August 11th 2016 and August 31st 2018, b)with at least a one year follow-up period. Retention of SEC at 1 year was estimated by the Kaplan Meier (KM) method. OSI were defined by at least one of the following within the 3 months before initiation of SEC: CRP> N, confirmed clinical dactylitis, confirmed clinical synovitis or ultrasonography power-Doppler positive synovitis except on MTP of first toe. Preselected factors at initiation of SEC retention at 1 year (≥1 OSI, age, sex, BMI, smoking status, axial feature, past or present psoriasis / uveitis / Inflammatory Bowel Disease (IBD) / active arthritis or synovitis, diagnostic delay, disease duration, SEC line of biologic therapy, SEC maintenance dose, concomitant csDMARD, concomitant oral corticosteroids, ≥1 comorbidity) were analyzed by multivariate cox model regression. Only variables with <20% missing data were included in the model after imputation and stepwise selection (significance level for entering variables = 20%; for removing variables = 10%). OSI was forced into the model whatever its significance level or rate of missing data.

Results

In total, 475 pts (male: 40.2%, mean age: 51.9 ± 12.2 years, mean disease duration: 9.3 ± 8.6 years) from 48 centers were included in the analysis. At initiation of SEC, 62.2% of pts had ≥ 1 OSI and respectively 11.0%, 19.5% and 69.6% were in 1st, 2nd and ≥ 3rd line (L) of biologic/targeted synthetic DMARD. The overall 1 year KM survival rate for SEC was 63% [95%CI: 59%-68%] and was numerically greater in 1st L vs 2nd and ≥3rd L (82% [72%-93%], 62% [52-72%], 61% [56%-66%] respectively). The overall survival rates for PsA pts with or without OSI were 62% [56%-68%] and 71% [62%-80%]. In multivariate analysis, absence of OSI, longer disease duration and lack of prior exposure to anti-TNF inhibitors were associated with a better SEC retention at 1 year (Table 1).

Table 1.

Predictive factors of SEC 1 year retention of SEC identified by multivariate cox regression analysis (multiple imputation + Stepwise selection)

Predictive factors (* reference)HR [95% CI]p vs refp type IIIAt least one objective sign of inflammationNo (N=175)*Yes (N=295)1.46 [1.05; 2.02]0.023Disease duration (years)≤ 7.2 years (N=241)*> 7.2 years (N=229)0.69 [0.51; 0.94]0.017Secukinumab treatment line1st L (N=50)*0.0152nd L (N=92)2.43 [1.17; 5.05]0.018≥ 3rd L (N=328)2.72 [1.38; 5.36]0.004

Interpretation for predictor: HR> 1: the hazard of discontinuation at 1 year is X times higher in category vs reference.

Conclusion

The overall retention of SEC at 1 year in daily practice at the time of its launch in France was 63% for PsA patients and OSI, disease duration and prior exposure to TNF inhibitors were identified as predictive factors of SEC retention.

Acknowledgements

Authors thank all participating investigators, centers and patients. This study was financially supported by NOVARTIS Pharma France.

Disclosure of Interests

Adeline Ruyssen-Witrand Consultant of: honorarium fees from Novartis France, Julien Lucas: None declared, Emilie Desfleurs Employee of: Novartis, Pascal Claudepierre Consultant of: Honorarium fees from Novartis France, Maxime Dougados Consultant of: honorarium fees from Novartis France, Philippe Goupille Consultant of: honorarium fees from Novartis France, Cédric Lukas Consultant of: honorarium fees from Novartis France, Alain Saraux Consultant of: honorarium fees from Novartis France, Anne Tournadre Consultant of: honorarium fees from Novartis France, Daniel Wendling Consultant of: honorarium fees from Novartis France

POS0621 MORE THAN 40% OF WOMEN WITH RHEUMATOID ARTHRITIS HAVE A TIME-TO-CONCEPTION LONGER THAN 1 YEAR: ANALYSIS OF THE PROSPECTIVE GR2 COHORT

Background

Rheumatoid arthritis (RA) is one of the most common chronic inflammatory diseases and regularly affects women of childbearing age1. However, there is limited knowledge about the impact of the disease and its treatment on fertility.

Objectives

The aim of the study was to determine factors associated with time-to-conception in women with RA.

Methods

All RA patients (diagnosis according to the Rheumatologist) included in the national multicenter GR2 cohort from 2015 to June 2021 were included in the analysis. Patients could be included either with a pregnancy wish (i.e., preconceptional period) or because of a clinical pregnancy (<12 weeks of gestation): for this analysis, only patients included preconceptionally were included. The main endpoint was time-to-conception, and the secondary endpoints were the number of subfertile patients (i.e., time-to-conception >12 months or non-achievement of pregnancy), as well as the number exposed to csDMARDs and biologics in the preconception period. We performed survival analyses, using a Cox model including a random effect for the center to account for heterogeneity of practices among participating centers. We used a multiple imputation to address missing data among the explanatory variables. Results are presented as a hazard ratio (HR) with confidence interval (CI) to assess associations between the factors studied and time-to-conception.

Results

Among the 167 patients with RA included in the GR2 cohort, 78 were selected for the main analysis of time-to-conception. Of these, 40 (51.3%) had a clinical pregnancy during follow-up. Subfertility was observed in 33 (42.3%) women and median time-to-conception was 19.1 months; mean preconception DAS28-CRP score was 2.3 (+/- 1.2).

Patients were treated during the preconceptional period with NSAIDs, corticosteroids, csDMARDs and biotherapy in 10 (12.8%), 35 (44.9%), 24 (30.8%), and 32 (41.0%) cases, respectively. The multivariate model adjusted for age, BMI, DAS28-CRP, disease duration, ACPA positivity, and exposure to corticosteroids and biologics in the preconception period found an association between increased preconception delay and age (HR (per year) 1. 12 95% CI [1.04-1.16] p = 0.01) as well as disease duration (HR (per year) 1.06 95% CI [1.02-1.15] p = 0.03).

Conclusion

This study provides original results on fertility in women with RA. It found a median time-to-conception of 19.1 months, with a subfertility rate of 42.3%, which is significantly higher than the general population2. In this context, it seems essential to discuss this topic from the beginning of the disease in women of childbearing age.

References

[1]Van den Brandt S. Arthritis Res Ther. 2017;19(1):64.

[2]Junul S. Hum Reprod. 1999;14(5):1250-4.

Table 1.

Survival analyses (Cox model): factors associated with time-to-conception in women with RA.

Univariate analysesMultivariate analysesCrude HR 95% CIpAdjusted HR 95% CIpAge1.11 [1.04-1.18]0.0021.12 [1.04-1.16]0.015BMI1.06 [0.99-1.16]0.1031.08 [0.99-1.16]0.062ACPA positivity1.75 [0.90-3.39]0.1071.44 [0.65-2.86]0.310Disease duration1.03 [0.98-1.08]0.2671.06 [1.02-1.15]0.032DAS28-CRP score1.08 [0.81-1.45]0.5921.08 [0.92-1.32]0.170Corticosteroids0.91 [0.51-1.65]0.7690.86 [0.42-1.68]0.620Biologics1.52 [0.82-2.81]0.1891.30 [0.62-2.78]0.630Figure 1.

Cumulative incidence curves for pregnancies in women with RA.

Acknowledgements

The GR2 Cohort is supported by the French Society of Rheumatology, the French Internal Medicine Society, and unrestricted grants from UCB.

Disclosure of Interests

SABRINA HAMROUN: None declared, Marion Couderc: None declared, Laure Gossec: None declared, Rene-Marc Flipo: None declared, Hubert MAROTTE: None declared, Christophe Richez Speakers bureau: CR has received consulting/speaker’s fees from Abbvie, Amgen, Astra Zeneca, Biogen, BMS, Celltrion, Eli Lilly, Galapagos, GSK, MSD, Novartis, and Pfizer, all unrelated to this manuscript., Aline Frazier-Mironer: None declared, Jérémie SELLAM: None declared, Elisabeth Gervais: None declared, Valerie Devauchelle-Pensec: None declared, Alban Deroux: None declared, Rakiba Belkhir: None declared, AZEDDINE DELLAL: None declared, Laëtitia Dunogeant: None declared, Cédric Lukas: None declared, Emmanuel Chatelus: None declared, Nathalie Costedoat-Chalumeau: None declared, Anna Moltó: None declared

OP0127 UNFAVORABLE PREGNANCY OUTCOME IS SIGNIFICANTLY ASSOCIATED WITH CORTICOSTEROID EXPOSURE DURING PREGNANCY IN WOMEN WITH RHEUMATOID ARTHRITIS: ANALYSIS OF THE PROSPECTIVE GR2 COHORT

Background

Rheumatoid arthritis (RA) is one of the most common chronic inflammatory diseases and regularly affects women of childbearing age1. However, there is limited knowledge about the impact of the disease and its treatment on pregnancy.

Objectives

The aim of the study was to determine the factors associated with adverse pregnancy outcome in women with RA.

Methods

All RA patients (diagnosis according to the Rheumatologist) included in the national multicenter GR2 cohort from 2015 to June 2021 were included in the analysis. Patients could be included either with a pregnancy wish (i.e., preconceptional period) or because of a clinical pregnancy (<12 weeks of gestation). The main endpoint was favorable pregnancy outcome, a composite outcome defined as a live birth at term ≥ 37 gestation weeks of a healthy newborn with a weight greater than the 10th percentile. Disease activity was defined by a DAS28-CRP score > 3.2 at least once during pregnancy. We performed a multilevel logistic regression model, in which we considered patient and center random effects (patient random effect for some women included in the cohort two times). We used a multiple imputation procedure to address missing data among the explanatory variables. Results are presented as an odds ratio (OR) with confidence interval (CI).

Results

Among the 167 pregnancies in women with RA included in the GR2 cohort, 92 were retained for analysis of obstetrical outcome. Of these, 43 (46.2%), 8 (7.9%), 40 (43.5%) were exposed to corticosteroid, NSAID and biologics at least once during pregnancy, respectively. A moderate or severe disease activity at least once during pregnancy was found in 20 (21.8%) pregnancies. A live birth was found in 83 (90.2%) women, including 69 (83.1%) full-term births. Early miscarriages were observed in 9 (0.1%) women. A caesarean section was performed in 22 (23.9%) cases.

A favorable pregnancy outcome was found in 52 (56.5%) of the women. Unfavorable pregnancy outcome was mainly due to prematurity and small for gestational age, observed in 14 (16.9%) and 17 (20.5%), respectively. The multivariate model adjusted for age, BMI, nulliparity, active disease during pregnancy, smoking, and exposure to biologics and corticosteroids during pregnancy found an association between an unfavorable pregnancy outcome and nulliparity (OR 6.2 95% CI [2.1-17.8] p = 0.002), age (OR (per year) 1.1 95% CI [1.0-1.3] p = 0.02) and exposition to corticosteroids during pregnancy (OR 3.2 95% CI [1.1-9.6] p = 0.04).

Conclusion

This study provides original results on pregnancy in women with RA. It found a favorable pregnancy outcome in 56.5% of women. Unfavorable pregnancy outcome was associated with age, nulliparity and corticosteroids use during pregnancy, which argues for their careful use during pregnancy.

References

[1]Van den Brandt S. Arthritis Res Ther. 2017;19(1):64.

Table 1.

Multilevel logistic regression model: factors associated with unfavorable pregnancy outcome in women with RA.

Univariate analysesMultivariate analysesCrude OR 95% CIpAdjusted OR 95% CIpAge1.09 [1.01-1.19]0.0361.14 [1.02-1.28]0.019BMI0.93 [0.83-1.04]0.1960.91 [0.77-1.08]0.204Nulliparity4.18 [1.66-10.53]0.0036.16 [2.13-17.76]0.002Smoking1.08 [0.29-3.36]0.9961.65 [0.37-7.22]0.141Disease activity*1.06 [0.40-2.81]0.9110.98 [0.21-2.28]0.753Corticosteroids**2.45 [1.05-5.68]0.0393.22 [1.09-9.57]0.038Biologics**1.05 [0.11-3.54]0.5892.02 [0.70-4.12]0.194

* Moderate or severe disease activity at least once during pregnancy.

** Use at least once during pregnancy

Acknowledgements

The GR2 Cohort is supported by the French Society of Rheumatology, the French Internal Medicine Society, and unrestricted grants from UCB.

Disclosure of Interests

SABRINA HAMROUN: None declared, Marion Couderc: None declared, Rene-Marc Flipo: None declared, Laure Gossec: None declared, Christophe Richez Speakers bureau: CR has received consulting/speaker’s fees from Abbvie, Amgen, Astra Zeneca, Biogen, BMS, Celltrion, Eli Lilly, Galapagos, GSK, MSD, Novartis, and Pfizer, all unrelated to this manuscript., Rakiba Belkhir: None declared, Aline Frazier-Mironer: None declared, Valerie Devauchelle-Pensec: None declared, Hubert MAROTTE: None declared, Jérémie SELLAM: None declared, Elisabeth Gervais: None declared, Alban Deroux: None declared, Cédric Lukas: None declared, Emmanuelle Dernis: None declared, Emmanuel Chatelus: None declared, Nathalie Costedoat-Chalumeau: None declared, Anna Moltó: None declared

Characteristics of newly diagnosed type 1 diabetes in paediatric and adult population from Reims University Hospital, France from 1997 to 2019

French health insurance data showed that the incidence of type 1 diabetes mellitus (T1DM) in children increased over the years to 2015. The objective of our study was to assess the evolution of the number of incident cases of paediatric and adult type 1 diabetes in our institution, and to describe their clinical presentation and its evolution. All patients with T1DM managed at diagnosis at Reims University Hospital between 1997 and 2019 were included. The clinical and biological data were extracted from the Champagne-Ardenne Diabetes Network database. Included were 847 patients with a median age of 10.3 years. Diagnosis was established in 71% of cases before 15 years, 7.4% after 35 years. The number of newly diagnosed cases was 3.6-times higher in 2019 compared to 1997. Ketoacidosis, the frequency of which decreased with age (P < 0.0001), revealed diabetes in a total of 32% of cases and in 46% of children under 5 years. It was more severe in children than in adults (P = 0.03), and its frequency increased over the study period. Hypotrophy was found in 23% of children under 15 years of age, and was more pronounced before 5 years of age, with no improvement over time. We saw an increase in the frequency of obesity or overweight among adults. Our study showed an increase in incident cases of diabetes in our hospital that continued over time for both children and adults. Clinical features at diagnosis deteriorated during this period for those under 15 years of age with an increase in ketoacidosis frequency.

Lipomatous pancreas facilitates late onset of renal cell carcinoma metastases

BACKGROUND

Late metastasizing into pancreatic tissue is a special hallmark of renal cell carcinomas (RCC). A very low prevalence leads to scarce data about therapy, prognosis and spreading pathways. The aim of the study was to analyze whether a high fat content in the pancreas facilitates RCC metastases formation. A model for density measurement of pancreatic tissue has been developed and evaluated. Pancreatic fat content was measured comparing Hounsfield units (HU) of CT scans.

METHODS

In a consecutive single centre retrospective database of 3600 patients with pancreatic resections, only 12 patients (0.3%) cases of RCC metastases in the pancreas were found. HU were measured in 3 pancreatic regions: head, body and tail in patients' CT scans. HU values were compared to a control population and results aligned with recent literature.

RESULTS

We revealed a prevalence of pancreatic metastases of RCC in 0.3% of cases. The formation of RCC in the pancreas occurred within 14 ± 5.6 years after initial diagnosis of RCC. 83.3% of the patients were alive after a follow-up period of up to 48 months. Clinical data analysis revealed an affinity for metastatic formation to lipomatous pancreas. This could be objectivized by HU analysis in CT scans.

CONCLUSION

Pancreatic metastases occur late after the first diagnosis of renal carcinoma and show an affinity for lipomatous pancreatic tissues. Due to its rarity in occurrence, multicentric studies are highly recommended to further analyze this correlation between fatty pancreas and RCC.

AB0493 WHAT IS THE DIAGNOSTIC VALUE OF IMPAIRED SPINAL MOBILITY MEASUREMENTS IN INFLAMMATORY BACK PAIN PATIENTS? DATA FROM THE DESIR COHORT

Background:

The diagnostic process in a patient with early inflammatory back pain suggestive of axial spondyloarthritis (ax-SpA) requires assessment and integration of multiple aspects, including clinical examination, biological measurements and radiologic assessments. Among the physical examination features, alteration of spinal mobility is often observed in ax-SpA. However, whether mobility impairment might really increase diagnostic likelihood, and which of the measurements made have relevant diagnostic value remains unknown.

Objectives:

To describe the frequency and severity of mobility impairment in multiple traditional measurements in patients suspect of early ax-SpA at initial assessment time, and to analyze their individual diagnostic performances in reference to usual classification criteria applied after 2 years of follow-up.

Methods:

Data from the DESIR cohort, which included patients aged 18-50 with inflammatory back pain lasting for 3 months to 3 years and a clinical suspicion of ax-SpA diagnosis were used. Baseline measurements of Schober’s test (Schober), chest expansion (CEx), lateral spinal flexion (LatSpiFlex), cervical rotation (CervRot) and intermalleolar distance (IntMalDist) collected at baseline were classified according to reference data from the general population adjusted for age and -when appropriate- for height. Cutoffs were defined as above 2.5th, 5th, 10th and 25th percentiles. With ASAS classification for ax-SpA applied at 2 years follow-up visit as external reference, diagnostic performances (Sensitivity [Se], Specificity [Sp], Positive [PPV] and Negative [NPV] Predictive Values) were calculated.

Results:

Complete data were available for 575 patients (of whom 377 (66%) fulfilled the ASAS criteria at 2 years). Schober, CEx, LatSpiFlex, CervRot and IntMalDist were above 5th percentile in respectively 278 (48%), 82 (14%), 220 (38%) and 93 (16%) patients. None of the measurements showed a clinically relevant compromise between both Se and Sp, but Sp was highest for CEx-most impaired cutoffs (Figure 1). The highest PPV (73.6%) and NPV (39.4%) were observed for LatSpiFlex.

Conclusion:

Measures of mobility and their levels of impairment do not show sufficient individual diagnostic value for ax-SpA among patients with early inflammatory back pain. However, highest degrees of impairment when compared to general population are more specifically observed in patients finally classified with ax-SpA for CEx, which was –consistently- 1 of the 2 mobility measures that was retained in the modified New York criteria for ankylosing spondylitis.

Disclosure of Interests:

Cédric Lukas Speakers bureau: AbbVie; Lilly; Merck; Novartis; Pfizer; Roche-Chugai;, Consultant of: AbbVie; Bristol-Myers Squibb; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; UCB; Sanofi;, Grant/research support from: Pfizer: Novartis, Gisèle Khoury Grant/research support from: Pfizer, Maria-Antonietta d’Agostino: None declared., Bernard Combe Speakers bureau: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Consultant of: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Jacques Morel Speakers bureau: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Consultant of: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai.

POS1082 CATASTROPHIZING IN PATIENTS WITH PSORIATIC ARTHRITIS

Background:

Catastrophizing is a negative cognitivo-affective response to an anxiety-provoking stimulus, especially anticipated or actual pain. It can be quickly assessed using a validated questionnaire: the Pain Catastrophizing Scale (PCS)1. Catastrophizing plays a role in maintaining chronic pain and is associated with several pain-related outcomes in osteoarthritis and low back pain. To our knowledge, there are no data on catastrophizing in patients with psoriatic arthritis (PsA).

Objectives:

To assess the prevalence of catastrophizing and associated factors in PsA.

Methods:

We performed a bi-centric observational, prospective study. All patients aged 18 or over with PsA fulfilling the 2006 CASPAR criteria were consecutively included. Sociodemographic data, information on the disease and its treatments were collected as well as questionnaires for disease activity (BASDAI), function (HAQ, BASFI), quality of life (SF12, EQ5D), anxiety and depression (HADS, GAD7), fibromyalgia (FiRST), insomnia (ISI) and catastrophizing scores (PCS). Statistical analysis included samples T-test, one-way variance analysis, Spearman’s correlation coefficient, Chi2 test, Fisher’s exact test, Wilcoxon test, multivariate linear regression (considering catastrophizing as a continuous variable) and multivariate logistics regression (considering catastrophizing as a categorical variable: PCS ≥ 20 = high level catastrophizing).

Results:

From September 2019 to March 2020, 85 PsA patients were included: 54.1% were women, the median age was 54.0 years and 33 patients (39.8%) were professionally active. The majority of patients (88.2%) had a disease lasting for more than 2 years. Axial involvement was found for 39 patients (45.9%), almost all patients (98.8%) had peripheral involvement, 32 patients (37.7%) had enthesitic involvement and 14 patients (16.7%) had erosions. Median DAS28 CRP was 3.12 [2.13-4.46] and the median BASDAI score was 5.50 [4.30-6.70]. The prevalence of a PCS score ≥20 was 45.9% [35.3;56.5]. The median PCS score was 16 [6-29]. In multivariate logistics regression, high-level catastrophizing was significantly associated with the HADS anxiety score (OR=1.35 [1.15-1.61]) and pain VAS (OR=1.04 [1.02-1.06]). In multivariate linear regression, catastrophizing was significantly associated with the HADS anxiety score (p= 0.004), pain VAS (p=0.001), HADS depression score (p=0.018) and insomnia score (p=0.034).

Conclusion:

Almost half the patients with PsA were high catastrophizers. Catastrophizing is related to anxiety, pain, depression and insomnia. It may be interesting to detect catastrophizing in order to improve the care of our patients.

References:

[1]Sullivan MJL. et al. Psychological Assessment. 1995;7(4):524–32

Disclosure of Interests:

None declared.

POS1239 POSITIVE IMPACT OF THE FIRST LOCKDOWN IN PATIENTS WITH CHRONIC INFLAMMATORY RHEUMATISM

Background:

Since the beginning of 2020, the COVID-19 pandemic has caused a considerable amount of fear, worry and concern in the general population and among certain groups such as the elderly, healthcare providers and people with pre-existing conditions in particular. Our patients suffering from chronic inflammatory rheumatism (CIR), a group of autoimmune pathologies treated by immunosuppressant medication, are particularly concerned. Actions taken – particularly quarantine and its effects on the normal activities, habits or livelihoods of many people – also have a significant impact. There is little information on the impact of the lockdown in patients with CIR with data measured prospectively, in a standardized way, before and during the first lockdown period.

Objectives:

The objective of this ancillary study was to evaluate the psychological impact of the first lockdown period (anxiety, depression, sleep disorders, catastrophizing...) as well as the evolution of disease activity in patients suffering from CIR.

Methods:

At two French university hospitals, adult patients with rheumatoid arthritis (RA) according to the ACR-EULAR 2010 criteria, spondyloarthritis (SpA) fulfilling the ASAS 2009 criteria and psoriatic arthritis (PsA) according to the Caspar 2006 criteria were consecutively included in the Catastrophism in Chronic Inflammatory Rheumatism (CRIC) study from September 2019. Sociodemographic data, information on the disease and its treatments were collected as well as questionnaires on disease activity (DAS28, CDAI, BASDAI), function (HAQ), quality of life (SF12, EQ5D), anxiety and depression (HADS, GAD7), insomnia (ISI) and catastrophizing scores (PCS). These data were collected prospectively at baseline, 3, 6 and 12 months.

In this ancillary study, data from patients with an assessment before and during lockdown were analyzed. Statistical analyses were descriptive with a paired Student’s T-test.

Results:

In all, 140 patients (49 RA, 69 SpA and 22 PsA) were evaluated before and during lockdown. The median age was 53.5 [44-63] years and 60.7% were women; 74 patients (53.2%) were professionally active and 102 (72.9%) were living as couples. The majority of patients (92.9 %) had a disease lasting more than 2 years. Concerning treatments, 63 (45%) were treated by bDMARD monotherapy, 40 (28.5%) by bDMARD+ csDMARD, 17 (12.1%) by csDMARD monotherapy and 2 patients by tsDMARD; 90.7% were not taking any corticosteroids and 8.6% were taking ≤5 mg/d; 30% were on NSAIDs.

When comparing before and during lockdown, pain, tender joint count, swollen joint count, disease activity (CDAI, BASDAI) and function (HAQ, SF12 physical component) were similar. However, there was a significant improvement in psychological status, anxiety (HADS, GAD7), the mental component of SF12, catastrophizing and overall quality of life (EQ5D) (see Table 1 below).

Conclusion:

There are very few prospective, standardized data on the impact of lockdown in patients with CIR with an assessment before and during the first lockdown period. In patients with CIR, the first lockdown period had no impact on the activity of the disease and was well experienced psychologically with less anxiety and an improvement in quality of life.

Table 1.Outcome (N)140 CIR: 49 RA, 69 SpA, 22 PsABefore lockdownMean (SD)During lockdownMean (SD)Mean change(SD)PPain VAS (138)39.4 (25.3)39.4 (25.0)-0.28 (27.1)NSTJC (57)4.0 (6.8)4.7 (4.4)0.7 (5.9)NSSJC (56)1.0 (2.6)1.6 (1.7)0.5 (2.4)NSCDAI (36)11.7 (1.4)12.3 (7.5)1.2 (8.7)NSBASDAI (84)4.7 (1.9)4.9 (2.0)0.14 (1.4)NSHAQ (135)0.72 (0.57)0.72 (0.53)0.03 (0.33)NSSF12 mental(136)32.7 (8.7)36.2 (8.4)3.46 (8.01)<0.0001GAD-7 (anxiety) (135)7.7 (5.5)5.0 (5.3)-1.73 (0.40)<0.0001HADS anxiety(137)8.5 (3.9)7.8 (3.9)-0.64 (2.91)0.0113EQ5D(139)0.55 (0.31)0.61 (0.29)0.06 (0.24)0.0078PCS (catastrophizing) (137)18.9 (13.3)15.9 (11.1)-3.10 (9.60)0.0003

Disclosure of Interests:

None declared

OP0214 IMPACT OF A MULTI-MORBIDITY SCREENING AND PREVENTION PROGRAM IN CHRONIC INFLAMMATORY RHEUMATIC DISEASES ON THE ONE-YEAR HOSPITALIZATION RATE BASED ON AN ANALYSIS OF THE FRENCH NATIONAL HEALTH DATABASE

Background:

A screening program for multimorbidities started in 2014 at the Montpellier University Hospital for primary prevention in patients with chronic inflammatory rheumatic diseases (IRD).

Objectives:

The objective of this work was to assess the impact of this program on morbidity by comparing the hospitalization rate of those patients in the year following the screening to the one of patients with IRD who did not benefit from this program.

Methods:

Patients with IRD who benefit from the screening program in 2015, 2016 and 2017 were identified in the French national health database PMSI and matched to 3 controls living in the same area on age, sex, type of IRD, use of intravenous (IV) biologic (b) DMARDs and index date. The exclusion criteria were subjects in secondary prevention identified as history of myocardial infarction in the previous 5 years or use of antiplatelet therapy. The primary outcome was the rate of all-cause hospitalization in the following year. The secondary endpoints were hospitalizations for another reason than IRD (“non-IRD”) including those for cardiovascular [CV] events and major fractures. Hospitalization rates were compared between the two groups in the year after screening (or index date) and also between the year preceding screening and the year after for each group. Univariate and multivariate odds ratios (CI95%) were calculated, taking into account the medical history (hypertension, diabetes, heart failure, CV disease, COPD, major fractures in the 5 years preceding the index date) and hospitalizations in the previous year.

Results:

486 patients were identified and matched with 1458 controls. 67.08% had rheumatoid arthritis and 21.81% spondyloarthritis; 7% of them had IV bDMARDs. Unscreened patients had more hypertension (19% vs 10.1%), diabetes (9% vs 4.9%), heart failure (2.3% vs 0.4%) and “non-IRD” hospitalizations (78.5% vs 72.2%) in the 5 years preceding the index date. In the year following the index date, the percentages of “all causes” and “non-IRD” hospitalizations were significantly higher in non-screened than in screened patients (n = 1944, 64.8% versus 51%, Chi2 test, p <0.001; and 47.1% versus 37.9%, p <0.001 respectively). 17 (1.17%) cardiovascular events occurred in non-screened versus 2 (0.41%) in screened patients (n = 1944, Chi2 test, p = 0.14). There was no difference in the occurrence of CV events or major fractures between the 2 groups. In multivariate analysis, screening was associated with a 49% (0.51 [0.41-0.64]) reduction in “all causes” hospitalization and a 27% (0, 73 [0.58-0.91]) decrease in “non-IRD” hospitalization, with no difference for CV or fracture cardiological events. The risk factors associated with “non-IRD” hospitalization were: history of “non-IRD” hospitalization in the previous year (2.26 [1.63-3.13]), IV bDMARDs (1.69 [1, 14-2.53]) and age> 70 years (1.44 [1.02-2.03] vs <50 years). Hospitalization in the previous year for “all causes” or “non-IRD” was associated with rehospitalization in the following year in the non-screened group (p <0.001), but not in the screened group (p = 0.750 and p = 0.066 respectively).

Conclusion:

Our screening and prevention program was associated with a reduction in hospitalizations in the following year and a decrease in the risk of re-hospitalization compared to unscreened patients with IRD. This suggests a positive impact of performing systematic screening for multi-morbidities in IRD patients.

Acknowledgements:

We thank Pfizer for their financial support

Disclosure of Interests:

guillaume decarriere: None declared, Jenica PASTOR: None declared, David DEMOULIN: None declared, Gael Mouterde Speakers bureau: Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Pfizer, Cédric Lukas Speakers bureau: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, UCB, Consultant of: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, UCB, Grant/research support from: Pfizer, Novartis and Roche-Chugai, Bernard Combe Speakers bureau: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Consultant of: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Grégoire Mercier: None declared, Jacques Morel Speakers bureau: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Consultant of: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Claire Daien Speakers bureau: Pfizer, Roche-Chugai, Fresenius, BMS, MSD, Lilly, Novartis, Galapagos, Consultant of: Abivax, Abbbvie, BMS, Roche-Chugai, Grant/research support from: Pfizer, roche-chugai, fresenius, MSD

OP0053 IMPACT OF CORRECTING CRP THRESHOLD ACCORDING TO BMI ON DIAGNOSIS, DISEASE ACTIVITY, INDICATION OF BIOLOGICAL TREATMENT AND PREDICTION OF THERAPEUTIC RESPONSE, IN PATIENTS SUSPECTED OF AXIAL SPONDYLOARTHRITIS. RESULTS FROM DESIR COHORT

Background:

Acute phase reactants are crucial parameters to consider for management of chronic inflammatory back pain (IBP) patients suspect of axial spondyloarthritis (ax-SpA). Indeed, C-reactive protein (CRP) is part of ASAS classification criteria for SpA, impacts on assessment of disease activity by ASDAS-CRP score, and should be elevated when a bDMARD is discussed in patients without radiological sacroiliac lesions. Moreover, elevated CRP is regarded predictive of favorable therapeutic response. Obesity in otherwise healthy people is associated with high CRP values. An adjusted definition of normal CRP threshold based on gender and BMI has been proposed.

Objectives:

The aim of this study was to assess whether correcting CRP threshold with patient’s BMI would change classification according to ASAS criteria for ax-SpA, presence of clinically relevant activity according to ASDAS-CRP, indication for TNF inhibitor (TNFi) and, as primary endpoint, improve prediction of therapeutic response to first TNFi.

Methods:

The study was conducted in DESIR cohort, which included 708 patients with early IBP suspect of ax-SpA. We included all patients with available data on BMI and CRP. High CRP level was defined either according to usual threshold (5 mg/L) or to the formula using BMI for adjustment. With this formula, CRP could be considered “normal” or due to obesity if: ≤ 1 + (BMI-25)/25 for men and ≤ 1 + (BMI-25)/12.5 for women (with CRP in mg/dL). We reported distribution of CRP levels in patients with high level according to usual threshold but below BMI adjusted threshold, as it is potentially suggestive of false-positive CRP due to overweight/obesity. Among them, we identified those who had no objective sign of disease activity (defined as arthritis, dactylitis, active uveitis or inflammatory bowel disease). To evaluate the impact on classification/diagnosis, we examined HLAB27-positive patients with only 2 ASAS criteria, including high CRP (the second being IBP, since it was mandatory for inclusion in DESIR cohort). Then, we calculated ASDAS-CRP score. We presented proportions of patients with ASDAS- high or very high disease activity but high CRP level possibly due to BMI only, and among those, the number concerned by a change of disease activity level when adjusting ASDAS-CRP score with minimal value for CRP (2mg/l). Among patients treated by TNFi during first 24-month follow-up, we excluded those with sacro-iliitis, and studied in others, CRP levels at last visit before treatment initiation using both thresholds. We compared proportion of ASAS40 responders using logistic regression analysis, with abnormal CRP defined after correction for BMI in patients without any sign of activity, beside other classical predictive factor of therapeutic response (age, gender, sacro-iliitis, HLAB27, psoriasis, arthritis, smoking).

Results:

Data were available for 634 patients. 205 had a high CRP level using usual threshold, of which 73 (35.6%) had a high CRP possibly due to BMI alone as they had no objective sign of disease activity. There were no differences in diagnosis as no patient had as only ASAS criteria: HLAB27 associated with high CRP and IBP. ASDAS-CRP score could be calculated in 626 patients. By correcting ASDAS score for patients with high CRP possibly due to BMI, 95.3% remained with same activity level (kappa for the ASDAS levels was 0.93). For impact of CRP on indication of bDMARD, 178 patients were treated by TNFi during first 24 months of follow-up: 61% of patients had an indication of TNFi according to EMA, with usual CRP threshold, and 56% with the adjusted one. Regarding response to TNFi, there were no association between any of the 2 CRP thresholds and ASAS40 response. Only sacro-iliitis on MRI was associated with ASAS40 response.

Conclusion:

Adjustment of CRP threshold according to BMI has a very limited impact on diagnosis, evaluation of disease activity of SpA, indication of TNFi initiation and prediction of TNFi response.

Disclosure of Interests:

Odile Facorat: None declared, Jacques Morel Speakers bureau: Abbvie, Biogen, BMS, Fresenius Kabi, Lilly, Mylan, Novartis, Pfizer, Sanofi, Consultant of: Abbvie, BMS, Boerhinger Ingelheim, Galpaagos, GSK, Lilly, Novartis, Sanofi, Grant/research support from: Biogen, BMS, Lilly, Novartis, Pfizer, Sanofi, Servier, Bernard Combe Speakers bureau: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Consultant of: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Pascal Richette Consultant of: AbbVie, Amgen, Biogen, BMS, Celgene, Janssen-Cilag, Lilly, Medac, MSD, NORDIC Pharma, Novartis, Pfizer, Roche, SanofiAventis, UCB, Cédric Lukas Speakers bureau: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, UCB, Consultant of: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, UCB, Grant/research support from: Pfizer, Novartis and Roche-Chugai

AB0247 ANALYSIS OF THE IMPACT OF TOFACITINIB TREATMENT ON WEIGHT IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

A prior post hoc analysis of tofacitinib clinical trial data reported improvements in rheumatoid arthritis (RA) outcomes with tofacitinib vs placebo (PBO) through Month (M)6, regardless of baseline (BL) body mass index (BMI).1

Objectives:

To assess change from BL (Δ) in BMI, and disease activity by BL BMI status, in patients (pts) with moderate/severe RA receiving tofacitinib through M12.

Methods:

This post hoc analysis included data pooled from Phase 3 and 3b/4 studies of pts who were methotrexate-naïve (NCT01039688) or inadequate responders to conventional synthetic (cs) or biologic DMARDs (NCT00960440; NCT00847613; NCT00814307; NCT00856544; NCT00853385; NCT02187055; NCT02831855). Pts received ≥1 dose of tofacitinib 5 or 10 mg twice daily (BID) or 11 mg once daily (QD), ± csDMARDs, or PBO. Least squares (LS) mean ΔBMI (linear mixed model repeated measures; observed cases) was summarised for all treatment groups at M3/6/12 (M3/6 only for tofacitinib 11 mg QD and PBO). Other assessments at M3/6/12 included ΔBMI ± BL concomitant glucocorticoids (GCs) or antidepressants (descriptive statistics), LS mean ΔDAS28-4(ESR) stratified by BL BMI status (<25, ≥25–<30, ≥30), and correlations between LS mean ΔBMI and ΔDAS28-4(ESR).

Results:

In total, 2349, 1611, 694 and 681 pts received tofacitinib 5 mg BID, 10 mg BID, 11 mg QD or PBO, respectively. Demographics/baseline characteristics were generally similar across treatments, except for some numerical differences in the tofacitinib 11 mg QD group, eg fewer female pts, more White pts and fewer pts receiving concomitant GCs, compared with other treatment groups. At M3/6, LS mean BMI significantly increased from BL with all tofacitinib doses vs PBO (all p<0.05); LS mean ΔBMI was greatest with 10 mg BID and lowest with 11 mg QD (Figure 1a). LS mean ΔBMI was greater in pts receiving tofacitinib as monotherapy vs combination therapy at M3/6/12 (Figure 1b). ΔBMI was generally similar in pts receiving treatment ± concomitant GCs or antidepressants (data not shown). Improvements in DAS28-4(ESR) were observed in each BL BMI status group at M3/6/12 and were greatest with all tofacitinib doses vs PBO. LS mean ΔDAS28-4(ESR) was generally numerically highest for pts with BMI <25 and numerically lowest for pts with BMI >30, for all tofacitinib doses. LS mean ΔDAS28-4(ESR) was generally greatest with tofacitinib 10 mg BID and 11 mg QD vs 5 mg BID across BL BMI status groups (Figure 1c). Across treatments, model-adjusted associations between LS mean ΔDAS28-4(ESR) and ΔBMI were weak (correlation coefficients all <0.3; Table 1).

Table 1.

Correlations between LS mean ΔDAS28-4(ESR) and ΔBMI through M12

Tofacitinib5 mg BIDTofacitinib10 mg BIDTofacitinib11 mg QDPBONCorrelation coefficientNCorrelation coefficientNCorrelation coefficientNCorrelation coefficientM320210.116913480.12406410.09075540.0783M619180.130512700.13976110.04381500.1556M1214550.12138740.1826----

Slopes for associations between LS mean ΔBMI and ΔDAS28-4(ESR) were significantly different from 0 at M3/6/12 with tofacitinib 5 and 10 mg BID (all p<0.05). Correlations were analysed by a general linear model method, which included BL age, gender, race and RA duration. For pts receiving tofacitinib 11 mg QD in ORAL Shift (NCT02831855), only data to M6 were included. Pts who advanced from PBO to tofacitinib were not analysed post-advancement

DAS28-4(ESR), Disease Activity Score in 28 joints, erythrocyte sedimentation rate; N, number of pts analysed

Conclusion:

LS mean ΔBMI was greater with tofacitinib (all doses) vs PBO at M3/6, and with tofacitinib monotherapy vs combination therapy at M3/6/12. Improvements in DAS28-4(ESR) were seen across all BL BMI status groups. BMI increases with tofacitinib were only weakly associated with DAS28-4(ESR) improvements. The relationship between disease activity and ΔBMI requires further investigation.

References:

[1]Dikranian et al. Arthritis Rheumatol 2018; 69 (S10): Abs 2371.

Acknowledgements:

Study sponsored by Pfizer Inc. Medical writing support was provided by Anthony G McCluskey, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests:

Jürgen Wollenhaupt Speakers bureau: Pfizer Inc, Consultant of: Pfizer Inc, Jacques Morel Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Novartis, Pfizer Inc, Sanofi Genzyme, Grant/research support from: Bristol-Myers Squibb, Pfizer Inc, Claire Daien Consultant of: Abivax, Grant/research support from: AbbVie, Bristol-Myers Squibb, Chugai, Eli Lilly, MSD, Novartis, Pfizer Inc, Sandoz, Adeline Ruyssen-Witrand Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Mylan, Novartis, Pfizer Inc, Sanofi Genzyme, Grant/research support from: AbbVie, Amgen, Mylan, Pfizer Inc, Cédric Lukas Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer Inc, Sanofi Genzyme, UCB, Grant/research support from: Novartis, Pfizer Inc, Christophe Richez Consultant of: AbbVie, Amgen, AstraZeneca, Biogen, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Mylan, Pfizer Inc, Grant/research support from: Biogen, Eli Lilly, Glenmark, Nordic Pharma, Roche, Andrea Shapiro Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Douglass Chapman Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Magali CROS Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Jose Luis Rivas Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Gustavo Citera Consultant of: AbbVie, Amgen, Eli Lilly, Gema, Genzyme, Novartis, Pfizer Inc, Sanofi Genzyme, Grant/research support from: AbbVie, Amgen, Eli Lilly, Gema, Genzyme, Novartis, Pfizer Inc, Sanofi Genzyme

POS0641 INCIDENCE OF GASTRO-INTESTINAL COMPLICATIONS IN RHEUMATOID ARTHRITIS PATIENTS RECEIVING BIOLOGICAL DMARDS IN OBSERVATIONAL COHORT STUDIES: A SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS

Background:

Rheumatoid arthritis (RA) patients are at increased risk of gastro-intestinal (GI) perforations compared with non-RA patients, resulting in increased mortality. Clinical trials, post-marketing studies and registries have reported an increased risk of GI perforations in RA patients treated with tocilizumab.

Objectives:

The aim of our study was to assess the incidence of GI complications among RA patients receiving bDMARDs in observational cohort studies

Methods:

A systematic literature review was carried out through September 2020 on the Pubmed, Embase and international congress databases, selecting observational cohort studies assessing the incidence of GI complications, including perforations and diverticulitis, in RA patients receiving bDMARDS. Keywords were “gastrointestinal perforation”, “gastrointestinal disease”, “diverticulitis”, “biological DMARDs” and “rheumatoid arthritis” with no publication date limit. Studies were selected independently by two readers. Data were extracted by one investigator and independently checked by another. A meta-analysis was performed with Review Manager Software, with random-effects models, whenever methodologically possible and relevant.

Results:

The literature search revealed 232 articles and abstracts of potential interest, and further examination resulted in 7 studies fulfilling required criteria. Among bDMARDs, Tocilizumab was associated with an increased incidence of GI perforations, with an overall incidence of 2.40 per 1000 person-years (95% confidence interval [95% CI] 1.45-3.35). The overall incidences of GI perforations were 1.01 per 1000 PY [0.75-1.27] for TNF inhibitors, 1.07 per 1000 PY [0.53-1.62] for abatacept and 1.12 per 1000 PY [0.16-2.08] for rituximab (Figure 1). In RA patients treated with tocilizumab, most of the perforations were located in the lower GI tract, with an incidence of 2.24 per 1000 PY [1.24-3.52]. The incidences of upper GI perforations were similar across the different bDMARDs. The incidences of diverticulitis were 4.99 per 1000 PY [4.08-5.99] in RA patients receiving tocilizumab and 1.81 per 1000 PY [1.47-2.19] in those receiving TNF inhibitors.

Figure 1.

Meta-analysis of the incidences of gastro-intestinal perforations in RA patients receiving bDMARDs in observational cohort studies

Conclusion:

In our meta-analysis, focused in RA patients receiving bDMARDs in observational cohort studies, tocilizumab was associated with an increased incidence of GI perforations, mainly located in the lower GI tract. An history of diverticulitis and long-term corticosteroid therapy were associated with an increased risk of GI perforations.

Acknowledgements:

We cannot express enough thanks to PhD Constantin and PhD Morel for their support and encouragement.

We would like to address a special word of thanks to PhD Lukas for his accuracy.

Special Thanks to Claire Rempenault for her precious advices. You have been a role model for us.

Disclosure of Interests:

None declared

POS0308 TRAJECTORIES OF FATIGUE IN EARLY RA OVER 10 YEARS: RESULTS FROM THE ESPOIR COHORT

Background:

Fatigue is one of the most prevalent symptom reported by persons with RA. RA-related fatigue is a complex concept with biological, psychological and social interactions.

Objectives:

In a cohort of early RA patients, to determine and characterize fatigue trajectories over 10 years of follow-up and identify predictors of trajectory membership.

Methods:

Patients fulfilling the 2010 ACR/EULAR criteria for RA included in the ESPOIR cohort. We used a cluster analysis to obtain fatigue (assessed by fatigue visual analogue scale) trajectories over the course of 10 years from enrolment. Chi-square tests or ANOVA were performed to evaluate differences of baseline variables between fatigue trajectories. Using a multinomial logistic regression we could identify predictors of trajectory membership.

Results:

We analysed 598 patients with mean disease duration at enrolment of 26.2 ± 40.9 days. Cluster analysis revealed 3 trajectories: high (18%), moderate (52%) and low fatigue (30%). Compared to patients with moderate or low fatigue trajectory, patients with high fatigue trajectory were predominantly women and reported significantly higher duration and intensity of morning stiffness, HAQ score, number of tender joints, levels of pain, number of awakenings due to arthritis, levels of physician and patient global assessment and more frequent sleep problems, and increased psychological distress. Female patients with pain, psychological distress and presence of sicca symptoms had higher risk of being in high trajectory group.

Conclusion:

These findings suggest that levels of fatigue are rather stable over time in each trajectory. Baseline clinical measures and baseline patient-reported measures of functional status better distinguished the three fatigue trajectories. We did not find differences between trajectories in baseline laboratory measures. Inflammatory activity was not a predictor of being in high trajectory fatigue group.

References:

[1]Pollard LC, Choy EH, Gonzalez J, Khoshaba B, Scott DL. Fatigue in rheumatoid arthritis reflects pain, not disease activity. Rheumatology (Oxford) 2006;45:885–9

[2]Repping-Wuts H, van Riel P, van Achterberg T. Fatigue in patients with rheumatoid arthritis: what is known and what is needed. Rheumatology (Oxford) 2009;48:207–9.

[3]Pilgaard T, hagelund L, Stallknecht SE, jensen HH, Esbensen BA. Severity of fatigue in people with rheumatoid arthritis, psoritic artrhitis and spondyoarthritis- Results of cross-sectional study. Plos One. 2019;14:e0211831

[4]Feldthusen C, Grimby-Ekman A, Forsblad-d’Elia H, Jacobsson L, Mannerkorpi K. Explanatory factors and predictors of fatigue in persons with rheumatoid arthritis: a longitudinal study. J Rehabil Med 2016 28;48:469–76.

[5]Madsen SG, Danneskiold-Samsøe B, Stockmarr A, Bartels EM. Correlations between fatigue and disease duration, disease activity, and pain in patients with rheumatoid arthritis: a systematic review. Scand J Rheumatol. 2016;45:255-61.

[6]Olsen CL, Lie E, Kvien TK, Zangi HA. Predictors of fatigue in rheumatoid arthritis patients in remission or in a low disease activity state. Arthritis Care Res (Hoboken) 2016;68:1043–8.

[7]Druce K, Jones GT, Macfarlane GJ, Verstappen SMM, Basu N. The longitudinal course of fatigue in rheumatoid arthritis: results from the Norfolk Arthritis Register. J Rheumatol 2015;42:2059–65.

Disclosure of Interests:

None declared

POS0306 IMPACT OF MULTIMORBIDITY ON DISEASE MODIFYING ANTI-RHEUMATIC DRUG THERAPY IN EARLY RHEUMATOID ARTHRITIS: DATA FROM THE ESPOIR COHORT

Background:

Multimorbidity is frequent in rheumatoid arthritis (RA) and could interfere with the therapeutic response.

Objectives:

The aim of this study was to evaluate multimorbidity in the French cohort of early arthritis (ESPOIR cohort) and its possible impact on the therapeutic response.

Methods:

We included patients fulfilling 2010 ACR/EULAR criteria for RA. An adapted MultiMorbidity Index (aMMI) was developed [1]. Each patient was assigned scores of binary aMMI (0= no comorbidity, 1= at least 1 comorbidity) and counted and weighted aMMI. The primary endpoint was achievement of Clinical Disease Activity Index (CDAI) low disease activity after initiation of a first disease-modifying anti-rheumatic drug (DMARD) according to the aMMI. Secondary endpoints were other disease activity scores and response criteria. We collected data from the visit preceding the first DMARD initiation (baseline visit) and the visit after at least 3 months of treatment (follow-up visit). The impact of aMMI on therapeutic maintenance at 1, 3, 5 and 10 years was evaluated.

Results:

Analyses involved 472 patients: 302 (64%) had at least 1 comorbidity. Overall, 45.3% and 44.7% with binary aMMI= 0 or 1, respectively (p= 0.9), achieved CDAI low disease activity (Table 1). Similar results were found with counted and weighted aMMI. Use of other disease activity scores or response criteria did not show a significant impact of multimorbidity on the therapeutic response. Therapeutic maintenance was significantly better with binary aMMI = 1 than binary aMMI = 0. Increased counted aMMI was associated with increased probability of still being on the first initiated DMARD at each time point (Table 2).

Table 1.

Impact of aMMIs on CDAI, DAS28 and SDAI low disease activity (LDA) achievement at follow-up visit (univariate analyses)

LDA achievementCDAIpDAS28pSDAIpYesNoYesNoYesNoBinary aMMI, n (%)077 (45.3)93 (54.7)0.9*85 (50.0)85 (50.0)0.2*80 (47.1)90 (52.9)0.9*1135 (44.7)167 (55.3)131 (43.4)171 (56.6)141 (46.7)161 (53.3)Counted aMMI, mean (SD)1.0 (1.1)1.1 (1.1)0.71.0 (1.1)1.1 (1.1)0.21.1 (1.1)1.1 (1.1)1.0Weighted aMMI, mean (SD)4.1 (5.2)4.0 (4.7)0.94.0 (5.2)4.1 (4.7)0.34.0 (5.0)4.0 (4.9)1.0

aMMI= adapted MultiMorbidity Index; CDAI= Clinical Disease Activity Index; SDAI= Simplified Disease Activity Index

* Proportion of patients achieving LDA between patients with binary aMMI= 0 and binary aMMI= 1. Because of no statistically significant results, no multivariate analysis was performed.

Table 2.

Probability of first DMARD maintenance at 1, 3, 5 and 10 years (multivariate analysis)

Time pointFirst DMARD maintained or stoppedBinary aMMI#Counted aMMI§011 year(n= 530)Maintenance (n= 300)22981.71 (0.93)OR [95% CI]*> 999 [286.2->999]221.3 [84.0-583.0]Withdrawal (n= 230)205250.12 (0.37)3 years(n= 493)Maintenance (n= 285)102751.66 (0.94)OR [95% CI]*153.9 [73.0-324.5]26.1 [15.1-45.3]Withdrawal (n= 208)175330.22 (0.64)5 years(n= 459)Maintenance (n= 116)91071.72 (1.05)OR [95% CI]*10.9 [5.1-23.3]2.2 [1.8-2.7]Withdrawal (n= 343)1631800.82 (1.0)10 years(n= 415)Maintenance (n= 40)2381.58 (0.84)OR [95% CI]*14.0 [3.3-59.1]1.6 [1.2-2.0]Withdrawal (n= 375)1582170.99 (1.12)

#data are number of patients

§ data are mean (standard error)

* data are odds ratios (ORs) and 95% confidence intervals (95% CI) of still being on the first initiated DMARD at 1, 3, 5 and 10 years between patients with binary aMMI = 1 and binary aMMI = 0 and according to counted aMMI, per additional point.

Conclusion:

In the ESPOIR cohort, therapeutic response to a first DMARD was not affected by multimorbidity but therapeutic maintenance was better in multimorbid patients.

References:

[1]Radner H, Yoshida K, Mjaavatten MD, et al. Development of a multimorbidity index: Impact on quality of life using a rheumatoid arthritis cohort. Semin Arthritis Rheum 2015;45:167–73.

The variables included in multivariate analyses were sex, rheumatoid factor and/or anti-citrunillated peptide antibody positivity, age, CDAI at baseline visit, number of treatments at baseline visit.

Acknowledgements:

We are grateful to Nathalie Rincheval (Montpellier) for expert monitoring and data management and all the investigators who recruited and followed the patients (F. Berenbaum, Paris-Saint Antoine; MC. Boissier, Paris-Bobigny; A. Cantagrel, Toulouse; B. Combe, Montpellier; M. Dougados, Paris-Cochin; P. Fardellone and P. Boumier, Amiens; B. Fautrel, Paris-La Pitié; RM. Flipo, Lille; Ph. Goupille, Tours; F. Liote, Paris- Lariboisière; O. Vittecoq, Rouen; X. Mariette, Paris-Bicêtre; P. Dieude, Paris Bichat; A. Saraux, Brest; T. Schaeverbeke, Bordeaux; and J. Sibilia, Strasbourg).

Disclosure of Interests:

Aurélie BELTAI: None declared, Bernard Combe Speakers bureau: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Consultant of: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche, Amandine Coffy: None declared, Cécile Gaujoux-Viala: None declared, Cédric Lukas Speakers bureau: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai and UCB, Consultant of: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai and UCB, Grant/research support from: Pfizer, Novartis and Roche-Chugai, Alain Saraux Speakers bureau: AbbVie; Bristol-Myers Squibb; Lilly; Nordic; Novartis; Pfizer; Roche-Chugai; Sanofi and UCB, Consultant of: AbbVie; Bristol-Myers Squibb; Lilly; Nordic; Novartis; Pfizer; Roche-Chugai; Sanofi and UCB, Grant/research support from: AbbVie; Bristol-Myers Squibb; Lilly; Nordic; Novartis; Pfizer; Roche-Chugai; Sanofi and UCB, Maxime Dougados Speakers bureau: Pfizer, Abbvie, Lilly, UCB, Merck, BMS, Roche, Biogen, Sanofi, Novartis, Sandoz, Consultant of: Pfizer, Abbvie, Lilly, UCB, Merck, BMS, Roche, Biogen, Sanofi, Novartis, Sandoz, Grant/research support from: Pfizer, Abbvie, Lilly, UCB, Merck, BMS, Roche, Biogen, Sanofi, Novartis, Sandoz, Jean-Pierre DAURES: None declared, Charlotte Hua: None declared

POS1003 CATASTROPHIZING IN PATIENTS WITH SPONDYLOARTHRITIS

Background:

Catastrophizing is a negative cognitivo-affective response to an anxiety-provoking stimulus, especially anticipated or actual pain. It can be assessed quickly using a validated questionnaire: the Pain Catastrophizing Scale (PCS)1. Catastrophizing plays a role in maintaining chronic pain and is associated with several pain-related outcomes in osteoarthritis and low back pain. There is a lack of knowledge about catastrophizing in axial spondyloarthritis (AS) with only one study2 so far.

Objectives:

To assess the prevalence of catastrophizing and associated factors in spondyloarthritis.

Methods:

We performed an observational, prospective, bi-centric study. All patients aged 18 or over with AS fulfilling the 2009 Assessment in Spondyloarthritis International Society (ASAS) criteria were consecutively included. Sociodemographic data, information on the disease and its treatments were collected as well as questionnaires regarding disease activity (BASDAI), function (HAQ, BASFI), quality of life (SF12, EQ5D), anxiety and depression (HADS, GAD7), fibromyalgia (FiRST), insomnia (ISI) and catastrophizing scores (PCS). Statistical analysis included a samples t-test, one-way variance analysis, Spearman’s correlation coefficient, the Chi2 test, Fisher’s exact test, the Wilcoxon test, multivariate linear regression (considering catastrophizing as a continuous variable) and multivariate logistics regression (considering catastrophizing as a categorical variable: PCS ≥ 20 = high level catastrophizing).

Results:

From September 2019 to March 2020, 168 AS patients were included: 48.5% were women, the median age was 48.5 years and 100 patients (60.2%) were professionally active. Almost all patients (95.8%) had a disease lasting for more than 2 years; 110 (72%) were HLA-B27+; 84 (50%) had MRI sacroiliitis and 62 (37.6%) radiographic sacroiliitis. In all, 166 (98.8%) had axial involvement, 99 (58.9%) had peripheral involvement and 44 (26.2%) had enthesitic involvement. The median BASDAI score was 6.30 [Q1-Q3 4.65-6.30].

The prevalence of a PCS score ≥20 was 45.5% [38.0;53.0]. The median PCS score was 18 [7-27]. In multivariate logistics regression, high-level catastrophizing was significantly associated with the HADS anxiety score (OR=1.54 [1.22-2.0]), HADS depression score (OR=1.25 [1.10-1.43]) and disease activity (BASDAI OR=1.14 [1.01-1.26]). In multivariate linear regression, catastrophizing was also significantly associated with anxiety (p<0.0001), depression (p<0.0001) and disease activity (p=0.0008).

Conclusion:

Almost half the patients with AS were high catastrophizers. Catastrophizing is linked to anxiety, depression, and disease activity. It may be interesting to detect catastrophizing in order to improve the management of our patients.

References:

[1]Sullivan MJL. et al. Psychological Assessment. 1995;7(4):524–32

[2]Penhoat M. et al. Joint Bone Spine. 2014;81(3):235–9

Disclosure of Interests:

None declared.

OP0035 ASSESSMENT OF THE INTESTINAL PERMEABILITY IN PATIENTS WITH RHEUMATOID ARTHRITIS USING COLONIC TISSUES AND SERA

Background:

Patients with rheumatoid arthritis (RA) have an altered gut microbiota (dysbiosis) (1-3). This microbiota interacts with intestinal epithelium which can lead to an increased intestinal permeability, responsible for the passage of antigens and inflammatory molecules, and can therefore promote systemic inflammation. Gut microbiota tends to normalize with disease control (2), suggesting that systemic inflammation may directly influence the composition of microbiota and the gut barrier. It was shown in many inflammatory diseases that intestinal permeability is impaired, but to date there is very little data in RA.

Objectives:

In the present study, we evaluate the intestinal permeability in RA patients by analyzing tight junctions in colonic biopsies and serum markers.

Methods:

Colonic biopsies from 20 RA patients who underwent coloscopy for screening with normal histology were compared with those from 20 age and sex matched controls. ZO-1, occludin and claudin 2 junction proteins were evaluated by immunohistochemistry. The staining intensity was assessed by two blinded independent readers. The serum concentrations of LPS-binding protein (LBP), CD14s and zonulin were evaluated by ELISA in 25 patients naive of DMARDs, 41 patients before and after introduction of a DMARDs and 21 controls. Elevated zonulin in serum indicates an increase in intestinal permeability while LBP and CD14s indicate bacterial translocation.

Results:

ZO-1 expression was significantly lower in biopsies from patients with RA than controls (mean score ± SD of 1.6 ± 0.56 vs 2.0 ± 0.43; p = 0.01). Age, sex, disease duration and immunological status did not significantly influence the expression of colonic junction proteins. LBP and CD14s were higher in serum from RA patients naive of DMARDs than controls (p = 0.002 and p = 0.003). LBP, CD14s and zonulin levels significantly correlated with DAS28 (r = 0.61, p = 0.005; r = 0.51, p = 0.030 and r = 0.46, p = 0.049, respectively). After treatment, unlike non-responders, LBP and CD14s were significantly reduced in DMARD responders and variations in LBP and CD14s significantly correlated with changes in DAS28 (r = 0.46, p = 0.002 and r = 0, 33 and p = 0.030, respectively).

Conclusion:

This work is one of the first to explore intestinal permeability in RA and to show altered tight junction in colonic tissue from RA. This increased intestinal permeability appears to be related to the systemic inflammation. Improving the gut microbiota through food or probiotics could enhance the effect of treatments by limiting this amplification loop of inflammation.

References:

[1]Horta-Baas G, Romero-Figueroa MDS, Montiel-Jarquin AJ, Pizano-Zarate ML, Garcia-Mena J, Ramirez-Duran N. Intestinal Dysbiosis and Rheumatoid Arthritis: A Link between Gut Microbiota and the Pathogenesis of Rheumatoid Arthritis. J Immunol Res. 2017;2017:4835189.

[2]Zhang X, Zhang D, Jia H, Feng Q, Wang D, Liang D, et al. The oral and gut microbiomes are perturbed in rheumatoid arthritis and partly normalized after treatment. Nat Med. 2015;21(8):895-905.

[3]Maeda Y, Kurakawa T, Umemoto E, Motooka D, Ito Y, Gotoh K, et al. Dysbiosis Contributes to Arthritis Development via Activation of Autoreactive T Cells in the Intestine. Arthritis Rheumatol. 2016;68(11):2646-61.

Disclosure of Interests:

Rachel Audo: None declared, Pauline Sanchez: None declared, Julie Mielle: None declared, Laurence Macia: None declared, Benjamin Rivière: None declared, Cédric Lukas: None declared, Bernard Combe: None declared, Jacques Morel: None declared, Claire Daien Speakers bureau: Pfizer roche chugai fresenius BMS msd Novartis galapagos, Consultant of: Abivax abbbvie BMS roche chugai, Grant/research support from: Pfizer, roche-chugai, fresenius, msd

POS0566 CATASTROPHIZING IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Catastrophizing is conceptualized as a negative cognitive–affective response to an anxiety-provoking stimulus, especially anticipated or actual pain. Catastrophizing can be assessed quickly using a validated questionnaire: the Pain Catastrophizing Scale (PCS)1. Catastrophizing plays a role in maintaining chronic pain and is associated with several pain-related outcomes in osteoarthritis and low back pain.

Objectives:

To assess the prevalence of catastrophizing and associated factors in rheumatoid arthritis (RA).

Methods:

We performed an observational, prospective, bi-centric study. All patients aged 18 or over with RA and fulfilling the ACR-EULAR 2010 criteria were consecutively included. Sociodemographic data, information on the disease and its treatments were collected as well as questionnaires for disease activity (DAS28), function (HAQ), quality of life (SF12, EQ5D), anxiety and depression (HADS, GAD7), fibromyalgia (FiRST), insomnia (ISI) and catastrophizing scores (PCS). Statistical analysis included the samples t-test, one-way variance analysis, the Spearman’s correlation test, the Chi2 test, Fisher’s exact test, the Wilcoxon test, multivariate linear regression (considering catastrophizing as a continuous variable) and multivariate logistics regression (considering catastrophizing as a categorical variable: PCS ≥ 20 = high level catastrophizing).

Results:

From September 2019 to March 2020, 201 patients with RA were included: 78.1% were women and the median age was 63.0 years. In all, 64.1% of patients were RF+, 65.7% ACPA+, and 46% had erosive disease. Median DAS28 CRP was 2.9 [2.1-4.0]. with 45% of patients in remission, 14.8% with low, 31.2% moderate and 9 % high activity. The majority of patients (92 %) had a disease lasting for more than 2 years.

The prevalence of a PCS score ≥20 was 48.0% [41.0;54.9]. The median PCS score was 18 [7-28]. In multivariate logistics regression, high-level catastrophizing was significantly associated with DAS28-CRP (OR= 1.61 [1.18-2.20]), HADS anxiety score (OR=1.25 [1.11-1.40]) and the HADS depression score (OR=1.19 [1.07-1.33]). In multivariate linear regression, catastrophizing was significantly associated with the HADS anxiety score (p< 0.0001), HADS depression score (p=0.0055), HAQ (p=0.0015) and the ISI insomnia score (p=0.005).

Conclusion:

Almost half the patients with RA were high catastrophizers. Catastrophizing is linked to anxiety, depression, disease activity, function impairment and insomnia. It may be interesting to detect catastrophizing in order to improve the management of our patients.

References:

[1]Sullivan MJL. et al. Psychological Assessment. 1995;7(4):524–32

Disclosure of Interests:

None declared

OP0138 FEASIBILITY OF PROGRESSIVE ANTI-TNF TAPERING IN AXIAL SPONDYLOARTHRITIS PATIENTS IN LOW DISEASE ACTIVITY: RESULTS FROM THE MULTICENTER NON-INFERIORITY PROSPECTIVE RANDOMIZED CONTROLLED TRIAL SPACING

Background:

Anti-TNF treatments (TNFi) have shown high efficacy in axial spondyloarthritis (ax-SpA) with inadequate response to non-steroidal anti-inflammatory drugs (NSAIDs). However their effect remains predominantly symptomatic, and their long-term tolerance as well as significant societal cost justify investigation about a potential reduction in drug dosage, or –most feasible and comfortable for the patient– increase in intervals between doses.

Objectives:

To assess if a progressive and monitored reduction of administered TNFi by increase of intervals between injections results in a comparable proportion of patients remaining after 12 months (m) in low disease activity state despite a decreased cumulative treatment dose received.

Methods:

Non-inferiority randomized controlled trial, having included adult patients with ax-SpA fulfilling ASAS criteria, already treated by anti-TNF, and in stable low disease activity for at least 6 m (current and at least 6 m old BASDAI<4/10), who were randomized into 2 groups: either keeping on their usual treatment with stable doses (“unchanged” group), or progressive spacing of injections of their treatment (“spacing” group). Follow-up was done every 3 m during 12 m, with regular monitoring of disease activity and, in patients from the group “spacing”, modification of the rhythm of injections according to disease activity and predefined standardized protocol (either increase or decrease (step-back) of intervals between injections). The primary endpoint was the difference of proportions of patients having a low disease activity state (BASDAI<4/10) after 12 m of follow-up between the 2 groups. It was estimated on the ITT population after multiple imputation. The 90% confidence interval associated was calculated using the Farrington-Manning method and the lower bound was compared to the non-inferiority margin of -20%. With an expected proportion of 85% patients remaining in low disease activity in the unchanged group, and α and β risks at respectively 5% and 90%, the required number of patients was calculated at 358, and thus 398 had to be included with a 10% expected proportion of patients with unavailable data.

Results:

398 patients were randomized in 23 French rheumatology units (197 and 201 in the spacing and unchanged groups respectively), and 389 included in analyses (9 did not receive the allocated treatment). Mean (SD) age was 44.3 (12.4) years, 71.2% were males. Mean (SD) BASDAI at inclusion was 1.45 (1.02). TNFi used were etanercept (35.7%), adalimumab (33.9%), infliximab (20.6%), golimumab (9.3%) and certolizumab (0.5%). For the 373 patients with complete follow-up (93.7%), 162/184 (88.0%) had a low disease activity in the “spacing” group vs. 173/189 (91.5%) in the “unchanged” group at 12 m. After multiple imputation for the 16 patients with missing data, the difference of proportion between the two groups was estimated to -4.18% [CI90% -10.0; 1.7], thus confirming the non-inferiority of the “spacing” procedure. In the “spacing” group at 12 m, 134/162 (82.7%) patients in low disease activity were still receiving a lowered TNFi dose.

Conclusion:

In ax-SpA patients with BASDAI<4 for at least 6 months under TNFi, it is possible to increase intervals between injections while maintaining a low disease activity by adjusting treatment with quarterly monitoring of SpA activity.

Disclosure of Interests:

Cédric Lukas Speakers bureau: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, UCB, Consultant of: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, UCB, Grant/research support from: Pfizer, Novartis and Roche-Chugai, Anne Tournadre Speakers bureau: Abbvie, Fresenius, Janssen, MSD, Pfizer, Roche Chugai, Sanofi, Paid instructor for: Fresenius, Consultant of: Abbvie, Fresenius, Lilly, Novartis, Sanofi, Grant/research support from: Fresenius, Novartis, Pfizer, UCB, Marie Christine Picot: None declared, Erika Nogué: None declared, Emmanuelle Dernis Speakers bureau: Roche chugai, UCB, BMS, Novartis, Lilly, Mylan, Pfizer, Celgène, Consultant of: UCB, MSD, BMS, Lilly, Novartis, Philippe Goupille Speakers bureau: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Janssen, Lilly, Medac, MSD, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Consultant of: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Janssen, Lilly, Medac, MSD, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Grant/research support from: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Janssen, Lilly, Medac, MSD, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Bernard Combe Speakers bureau: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Consultant of: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Jacques Morel Speakers bureau: Abbvie, Biogen, BMS, Fresenius Kabi, Lilly, Mylan, Novartis, Pfizer, Sanofi, Consultant of: Abbvie, BMS, Boerhinger Ingelheim, Galpaagos, GSK, Lilly, Novartis, Sanofi

FRI0353 FACTORS ASSOCIATED WITH DISCORDANCE BETWEEN PATIENT AND RHEUMATOLOGIST ASSESSMENT OF DISEASE ACTIVITY IN PSORIATIC ARTHRITIS CONSIDERED IN REMISSION

Background:

Assessment of disease activity in psoriatic arthritis (PsA) requires evaluation of multiple aspects. Perception of disease activity by patient and physician is frequently discordant.

Objectives:

The aim of our study was to evaluate factors associated with persistence of disease activity evaluated by patients yet considered in remission by their rheumatologist.

Methods:

We performed a transversal monocentric study. PsA patients were included if they met the CASPAR criteria and if they were considered in remission. Disease activity was evaluated by scores: Disease Activity Score (DAS28-CRP), Simple Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI), Disease Activity in Psoriatic Arthritis (DAPSA), Minimal Disease Activity (MDA), modified Boolean remission criteria for PsA. We collected multiple Patient’s Reported Outcomes (PROs): Psoriatic Arthritis Impact of Disease (PsAID), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Health Assessment Questionnaire (HAQ), Dermatology Life Quality Index (DLQI), Beck Depression Inventory (BDI), Fibromyalgia Rapid Screening Tool (FiRST), Pain Catastrophizing Scale (PCS). Discordance was defined by a difference between patient’s and rheumatologist’s global assessment ≥30/100 on a Visual Analogue Scale (VAS). Univariate and multivariate analyses were performed to evaluate factors associated with the presence of discordance.

Results:

62 PsA patients were included. 40.3 % were women and the mean (SD) age was 55 (14) years. 61% patients were in remission (rheumatologist definition) for more than 12 months and 19% for less than 3 months. 50% met MDA, 63% DAS28-CRP < 2,6, 39% SDAI and CDAI remission, 27% DAPSA remission. 39% had a discordant disease activity assessment from their rheumatologist. In univariate analysis, factors associated with discordance were a history of depression, an associated fibromyalgia, a history of clinical enthesitis and a history of corticosteroid use (Table 1). All disease activity scores and PROs were higher in discordant group and were associated with discordance in univariate analysis. In multivariate analysis, discordance was associated with no previous corticosteroid use (OR 24.5 (95%CI 2.9-203.7), p=0.003), a higher BDI scale (OR 1.4 (95%CI 1.1-1.8) by supplementary point, p=0.017) and a higher DAPSA score (OR 1.5 (95%CI 1.2-2), p<0.001) by supplementary point.

Conclusion:

In this PsA cohort, discordance between patient and rheumatologist is very common. Discordance in assessment of disease activity was associated with no previous corticosteroid use, probably reflecting a less severe disease, presence of depressive symptoms and an increase of DAPSA, reflecting a more active disease.

Disclosure of Interests:

Marie Moly: None declared, Cédric Lukas: None declared, Jacques Morel: None declared, Bernard Combe Grant/research support from: Novartis, Pfizer, Roche-Chugai, Consultant of: AbbVie; Gilead Sciences, Inc.; Janssen; Eli Lilly and Company; Pfizer; Roche-Chugai; Sanofi, Speakers bureau: Bristol-Myers Squibb; Gilead Sciences, Inc.; Eli Lilly and Company; Merck Sharp & Dohme; Pfizer; Roche-Chugai; UCB, Gael Mouterde: None declared

Table 1.

Factors associated with discordance: Univariate analysis

Discordant group n=24Concordant group n=38OR (95%CI)PHistory of depression, n (%)9 (37.5)1 (2,6)22 (2.58-190.84)<0.001Fibromyalgia (ACR criteria), n (%)5 (20.8)1 (2.6)9.74 (1.06-89.4)0.028At least one enthesitis on the Leeds Enthesitis Index, n (%)14 (58.3)34 (89.5)0.17 (0.04-0.61)0.006TreatmentsPrevious corticosteroid use, n (%)8 (33.3%)26 (68.4%)0.23 (0.08-0.69)0.007Disease activity scores et Patients Reported Outcomes PROsDAS28-CRP > median (2.3), n (%)19 (79.2)12 (31.6)8.23 (2.48-27.32)<0.001SDAI > median (5.09), n (%)21 (87.5)10 (26.3)19.6 (4.79-80.18)<0.001DAPSA > median (7.97), n (%)22 (91.7)9 (23.7)35.4 (6.9-180.8)<0.001BDI > median (3), n (%)14 (58.3)10 (26.3)3.92 (1.32-11.62)0.012FiRST > median (2), n (%)17 (70.8)11 (28.9)5.95 (1.94-18.37)0.001BASDAI > median (2.45), n (%)19 (79.2)12 (31.6)8.23 (2.48-27.32)<0.001HAQ> median (0.1), n (%)16 (66.7)11 (28.9)4.91 (1.63-14.76)0.004PCS > median (9), n (%)18 (75)11 (28.9)7.36 (2.3-23.5)<0.001PsAID > median (2.1), n (%)18 (75)13 (34.2)5.77 (1.84-18.06)0.002

OP0022 RISK OF DIVERTICULITIS AND GASTRO-INTESTINAL PERFORATION IN RHEUMATOID ARTHRITIS TREATED WITH TOCILIZUMAB COMPARED TO RITUXIMAB AND ABATACEPT: A PROSPECTIVE PROPENSITY-MATCHED COHORT STUDY

Background:

There are discordant results regarding a potential increased risk of gastro-intestinal perforation (GIP) in rheumatoid arthritis (RA) patients treated with tocilizumab (TCZ) compared to conventional synthetic disease modifying anti rheumatic drugs (csDMARDs) or TNF inhibitors (TNFis) (1–3).

Objectives:

The aim of our study was to compare the risk of diverticulitis and GIP in RA patients treated with TCZ compared to rituximab (RTX) and abatacept (ABA).

Methods:

We conducted a multicentric study of patients with RA, prospectively followed in 3 observational French registries evaluating the effectiveness and safety of RTX (Autoimmunity and Rituximab (AIR)), ABA (Orencia and Rheumatoid Arthritis (ORA)), and TCZ (REGistry–RoAcTEmra (REGATE)). Using a propensity score approach, we compared the risk of diverticulitis or GIP during treatment with TCZ vs RTX and ABA. The following covariates were included in the propensity score: age, sex, history of diabetes and neoplasia, Charlson Comorbidity Index, number of previous csDMARDs and TNFi, history of TNFi, daily dose of glucocorticoids (GCs) at baseline, co-treatment with a csDMARDs, average DAS28 during follow-up, duration of RA, and exposure time to the considered bDMARDs.

Results:

4501 patients (1496 treated by TCZ, 1986 by RTX and 1019 by ABA) were included. 21 and 9 GIP occurred in the TCZ treated patients, compared to 10 and 8 in the RTX treated patients and 10 and 2 in the ABA treated patients (corresponding incidence rate (IR) are shown in table 1). Two deaths occurred in patients experiencing GIP: 1 (12.5%) due to undetermined rectal perforation among a RTX treated patient, and 1 (11.1%) due to a perforated ulcer among a TCZ treated patient. Based on inverse probability weighting (IPW), there was an increased risk of diverticulitis and GIP in the TCZ treated patients compared with RTX or ABA (table 1). In a subgroup analysis, we confirmed an increased risk of GIP due to diverticulitis but not to any other etiology. Older age (p=0.05), GCs at baseline (p=0.10) and average daily dose of GCs during follow-up (p=0.08) seemed associated with GIP only in univariate analysis. Compared to RTX and ABA, diverticulitis and GIP among TCZ patients occurred earlier after the last perfusion (p=0.01), with atypical clinical presentation (slow transit in 30%, p=0.04) and lower acute phase reactants when the event occurred (C-reactive protein: 31.2±58.4 vs 88.2±89.6 mg/L, p=0.005). Perforated diverticulitis seemed to have higher dose of GCs at the time of the event compared to diverticulitis without perforation in univariate analysis (p=0.06).

Table 1.

Incidence (/1000 PY) and risk of diverticulitis or GIP

AE (n)IRAE (n)IRAE (n)IRIPW analysisOR[95 CI]pOR[95 CI]pExposition (PY)TCZ (ref)3 990RTX6 322ABA2 389TCZ vs RTXTCZ vs ABADiverticulitis215.3101.6104.24.5[2.6-7.6]<0.00013.4[1.7-6.5]<0.0001GIP92.381.320.82.8[1.5-5.1]0.0015.4[1.4-19.9]0.01*Diverticular GIP61.530.520.83.8[1.7-8.5]0,0016.9[1.9-25.4]0.004*Due to another etiology30.750.8001.4[0.5-3.9]0.5--

AE=adverse events; PY=person-years

Conclusion:

TCZ was associated with an increased risk of diverticulitis, and GIP due to diverticulitis, compared to RTX and ABA. Our study confirms an increased risk of GIP in RA patients treated with TCZ, which might be explained by an increased risk of diverticulitis with misleading clinical presentation.

References:

[1]Strangfeld A et al. Ann Rheum Dis. 2016 Jul 12

[2]Xie F, Yun H et al. Arthritis Rheumatol. 2016 May 1

[3]Barbulescu A et al. OP0231, Ann Rheum Dis. 2018 Jun 1;77(Suppl 2):164–5.

Disclosure of Interests:

Claire Rempenault: None declared, Cédric Lukas: None declared, Bernard Combe Grant/research support from: Novartis, Pfizer, Roche-Chugai, Consultant of: AbbVie; Gilead Sciences, Inc.; Janssen; Eli Lilly and Company; Pfizer; Roche-Chugai; Sanofi, Speakers bureau: Bristol-Myers Squibb; Gilead Sciences, Inc.; Eli Lilly and Company; Merck Sharp & Dohme; Pfizer; Roche-Chugai; UCB, Thierry Schaeverbeke: None declared, Daniel Wendling: None declared, Thao Pham Speakers bureau: Novartis, Janssen, Lilly, Xavier Mariette Consultant of: BMS, Gilead, Medimmune, Novartis, Pfizer, Servier, UCB, Jacques-Eric Gottenberg Grant/research support from: BMS, Pfizer, Consultant of: BMS, Sanofi-Genzyme, UCB, Speakers bureau: Abbvie, Eli Lilly and Co., Roche, Sanofi-Genzyme, UCB, Jacques Morel: None declared

THU0539 IMPACT OF BODY MASS INDEX ON THE AGREEMENT BETWEEN ULTRASOUND- AND CLINICAL ASSESSMENTS OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS: MULTICENTRE AND CROSS-SECTIONAL STUDY

Background:

Clinical assessment of swollen joint count (SJC) in rheumatoid arthritis (RA) might be affected by obesity in terms of obesity-related excess adipose tissue.

Objectives:

To compare the level of agreement between synovitis evaluated by Power Doppler ultrasound (PDUS) and clinical examination (SJC as component of SDAI) in obese (O) (i.e. Body Mass Index (BMI) >30) versus non-obese (NO) (BMI≤30) RA patients.

Methods:

RA patients ≥18 years fulfilling 2010 ACR-EULAR criteria were included in the cross-sectional multicentre (13 centres) French observational RABODI study (ClinicalTrials.gov Identifier:NCT03004651). Clinical synovitis was evaluated on 44 joints. ESR and CRP were collected and SDAI, DAS28, DAS were calculated. A standard US examination on 44 joints was performed by an independent investigator blinded to clinical data. US synovitis was defined by a synovial hypertrophy ≥1 and PD signal≥1 on a semi-quantitative scale according to the EULAR-OMERACT scoring system. Levels of agreement between number of synovitis defined by PDUS and clinical examination were compared in O versus NO patients using Chi2 test, and Kappas (k) and ORs were calculated. A patient was considered “discordant” if ≥1 joint was discordantly classified by PDUS and clinical examination. SDAI was calculated and compared, with SJC defined either by clinical examination or PDUS.

Results:

121 patients were included: mean (SD) age of 58.5 (12.7) years, mean disease duration of 11.1 (9.7) years. 81% were female, 84.3% anti-CCP positive, 63.6% had erosive disease. Mean SDAI was 12.6 (±10.2). 53 (43.8%) had a BMI >30 and 68 (56.2%) ≤30. 59 (48.7%) and 62 (51.2%) had a SDAI≤11 and >11, respectively. The 2 groups were comparable, except for weight (mean (SD) 65.4 (13.5) vs 96.7 (14.7) kg, p< 0.001), some comorbidities (diabetes, asthma and fibromyalgia more frequent in O patients), tender joint count (mean 4.04 (±5.23) in NO vs 7.38 (±8.64) in O, p=0.021). Mean number of SJC was 2.4 (3.3), and PDUS 6.7 (±6.3). Levels of agreement between clinical and PDUS findings were comparable in O vs. NO patients regarding SDAI and other scores (Table). Patients with ≥3 discordant joints were numerically higher in O patients compared to NO (26/53 (49.1%) vs 22/68 (32.4%), p=0.062). At the joint level, discordance was higher in O patients in MCP4 (p=0.057), wrist (p=0.089).

Table.

Level of agreement between PDUS synovitis and SJC in obese versus normally weighted RA patients

Score with PDUS vs. SJCBMI ≤ 30N=68BMI > 30N=53OR(95%CI)P*SDAINon-Discordant (ND)63461.92(0.57-6.42)0.28Discordant (D)57Kappa0.850.73DAS28ND62471.32(0.4-4.35)0.64D66Kappa0.810.77DAS44ND63520.24(0.03-2.14)0.23D51Kappa0.830.96≥1 synovitisND51351.54(0.7-3.4)0.28D1718Kappa0.500.32

Conclusion:

In RA patients, despite a perceived higher difficulty to clinically detect SJ in O patients, the discrepancy between clinically- and PDUS defined synovitis was not significantly higher than in NO patients, and did not impact the extend of the definition of disease activity level.

Disclosure of Interests:

Gael Mouterde: None declared, Federico Manna: None declared, Benoit Le Goff: None declared, Jean-David Albert: None declared, Sandrine Jousse-Joulin: None declared, Frederique Gandjbakhch: None declared, Damien LOEUILLE: None declared, Philippe Gaudin Speakers bureau: Lilly, Muriel PIPERNO: None declared, BANAL Frédéric: None declared, Bénédicte Jamard: None declared, Carine Salliot: None declared, Nicolas Molinari: None declared, Bernard Combe Grant/research support from: Novartis, Pfizer, Roche-Chugai, Consultant of: AbbVie; Gilead Sciences, Inc.; Janssen; Eli Lilly and Company; Pfizer; Roche-Chugai; Sanofi, Speakers bureau: Bristol-Myers Squibb; Gilead Sciences, Inc.; Eli Lilly and Company; Merck Sharp & Dohme; Pfizer; Roche-Chugai; UCB, Maria-Antonietta D’Agostino: None declared, Cédric Lukas: None declared

FRI0101 EFFECTS OF IL6 INHIBITORS ON THE INCIDENCE OF MAJOR ADVERSE CARDIOVASCULAR EVENTS IN RHEUMATOID ARTHRITIS PATIENTS: A SYSTEMATIC REVIEW WITH META ANALYSIS

Background:

Rheumatoid arthritis (RA) is associated with a 2 fold increased risk of cardiovascular events (CVE) and mortality when compared to the general population. The systemic inflammation in RA seems to play a pivotal role by creating endothelial dysfunction and thus accelerating atherosclerosis. This long lasting inflammatory process potentiates the effects of additional classical cardiovascular risk factors. Since the 2000s, numerous therapeutic advances, in particular biologics, allow better control of this inflammation. Among these, IL6 inhibitors (IL6i) are known to provide rapid and sustained improvements in clinical, biological and radiographic outcomes. However, an increase in circulating lipid concentrations in patients treated with IL6i is usual. This raises the question of the risk -to -benefit ratio of IL6i.

Objectives:

The purpose of this systematic literature review and meta-analysis was to evaluate the impact of IL6i on the incidence of major adverse cardiovascular events in RA patients in comparison with TNFalpha inhibitors (TNFi), non TNFi bDMARDs or csDMARDS.

Methods:

A systematic literature search of MEDLINE (via PubMed), EMBASE and the Cochrane Library databases until February 2019 was performed. Included studies were observational studies or randomized controlled trials having reported relevant confirmed CVEs (death from CVE, myocardial infarction, heart failure and stroke) in patients with RA treated with IL6i, and a suitable control group. A meta-analysis of the relative risk for each CVE in RA patients treated with IL6i compared to patients in the control groups was performed. A random effect model was applied in case of substantial heterogeneity.

Results:

Of 6869 studies, 23 randomized controlled trials and 6 controlled cohorts could be included. IL6i were significantly associated with a reduction in the risk of myocardial infarction in comparison with TNFi (OR, 0.73; 95% CI [0.56 to 0.96]). No other significant effects were observed with regard to the risks of stroke, heart failure (HF), and death from CVE in comparison with csDMARDs, TNFi, or non-TNFi bDMARDs (table 1).

Table 1.

Pooled relative risks of cardiovascular events in RA patients treated with IL-6 inhibitors and respective control groups

Cs DMARDSTNFiNon TNFi bDMARDSMyocardial infarction1.44 [0.50;4.17]0.73 [0.56; 0.96]0.81 [0.48; 1.36]Stroke1.08 [0.40; 2.91]1.20 [0.82; 1.77]0.73 [0.39; 1.37]Heart failure0.17 [0.01; 4.08]1.51 [0.61; 3.70]1.19 [0.71; 1.98]Cardiovascular death1.59 [0.62; 4.11]1.13 [0.72; 1.78]NA

Our findings of a potentially protective effect of IL6i use on the risk of MI are reassuring. Although several beneficial effects might be involved, like the effective control of systemic inflammation, the anti-arrhythmia effect or the improvement of endothelial and left ventricle dysfunction, a potential indication bias with a decreased likelihood to prescribe these drugs in patients with high cardiovascular risk cannot be excluded.

Conclusion:

This review of the literature with meta-analysis provides reassuring results about the association between use of IL6i and CVE in RA patients. Data from long-term observational studies is however needful to confirm and ascertain this result.

Disclosure of Interests:

None declared

THU0538 IN PSORIATIC ARTHRITIS PATIENTS CONSIDERED IN REMISSION BY THEIR RHEUMATOLOGIST, CAN DISCORDANCE IN DISEASE ACTIVITY ASSESSMENT BETWEEN PATIENT AND RHEUMATOLOGIST BE EXPLAINED BY RESIDUAL INFLAMMATION AS MEASURED BY ULTRASONOGRAPHIC EXAMINATION?

Background:

Psoriatic arthritis (PsA) is a heterogeneous disease and its assessment is sometimes difficult. Perception of disease activity by patient and physician is frequently discordant in patients in clinical remission. Ultrasound (US) is an imaging technique, which can detect inflammation in PsA.

Objectives:

The aim of our study was to assess whether persistence of disease activity evaluated by the patient, considered in remission by his rheumatologist, was associated with inflammation measured by US.

Methods:

We performed a transversal monocentric study. PsA patients were included if they met the CASPAR criteria and were considered in remission by their rheumatologist. Demographic data, characteristics of the disease and treatments were collected. Discordance was defined by a difference between patient’s and rheumatologist’s global assessment ≥30/100 on a Visual Analogic Scale. An US examination was performed on 50 joints, 28 tendons and 14 entheses by an independent investigator. Synovial or tendon sheath hypertrophy and PD signal were evaluated on a semi-quantitative scale, B Mode and PD signal abnormalities on entheses were searched, according to the EULAR-OMERACT scoring system. US remission was defined by no power Doppler (PD) signal on joints, tendons and entheses and minimal US activity by maximum one PD signal on the same sites. Univariate and multivariate analyses were performed to evaluate factors associated with US abnormalities.

Results:

Sixty-two PsA patients were included. 40.3% were women, the mean (SD) age was 55 (14) years, 42% were in US remission and 71% in minimal US activity (Table 1), 19.4% had ≥1 PD synovitis and 88.7% had a B mode synovitis, 95.2% had a B mode abnormality on entheses and 51.6% had ≥1 PD signal on entheses. Thirty nine percent had a discordant disease activity assessment with their rheumatologist. In univariate analysis, discordance was not associated with US remission (OR=1.71 (95%CI 0.61-4.83), p=0.224) or US minimal disease activity (OR=0.99 (95%CI 0.32-3.05), p=0.602). In multivariate analysis, US remission was independently associated with female gender (OR=3.94 (95%CI 1.20-12.9), p=0.024) and younger age (OR=0.95 (95%CI 0.91-0.99), p=0.027). Minimal US activity was associated with history of enthesis lesion (OR=11.26 (95%CI 1.34-94.93), p=0.026) and age (OR=0.95 (95%CI 0.90-1), p=0.044).

Table 1.

Ultrasound characteristics of the 62 PsA patients.

N (%)Ultrasound remission26 (41.9)Ultrasound minimal disease activity44 (71)Patients with ≥1 grey scale synovitis55 (88.7)Patients with ≥1 Power Doppler synovitis12 (19.4)Patients with ≥1 grey scale tenosynovitis15 (24.2)Patients with ≥1 Power Doppler tenosynovitis1 (1.6)Patients with ≥1 grey scale enthesitis lesion (thickness, hypo echogenicity, calcification, enthesophyte, erosion, bursitis)59 (95.2)Patients with ≥1 Power Doppler enthesitis32 (51.6)

Conclusion:

Our study showed persistent inflammation evaluated by US in PsA patients considered in remission by their rheumatologist. However, prevalence of residual inflammation evaluated by US was not higher in patients with self-assessment of their disease discordant from their rheumatologist.

Disclosure of Interests:

Marie Moly: None declared, Cédric Lukas: None declared, Jacques Morel: None declared, Bernard Combe Grant/research support from: Novartis, Pfizer, Roche-Chugai, Consultant of: AbbVie; Gilead Sciences, Inc.; Janssen; Eli Lilly and Company; Pfizer; Roche-Chugai; Sanofi, Speakers bureau: Bristol-Myers Squibb; Gilead Sciences, Inc.; Eli Lilly and Company; Merck Sharp & Dohme; Pfizer; Roche-Chugai; UCB, Gael Mouterde: None declared

SAT0064 VACCINATION RATE AND RISK FACTORS FOR NON-VACCINATION IN RHEUMATOID ARTHRITIS: A CROSS-SECTIONAL PROSPECTIVE MULTICENTRIC OBSERVATIONAL STUDY

Background:

Rheumatoid arthritis (RA) patients are at increased risk of infections, some of which could be prevented in part by vaccination (1). Influenza and pneumococcal vaccines are recommended in RA (2). However, vaccination coverage of these patients remains very low. Five years ago, we found in a previous study that vaccination rates in France were 55% for pneumococcal and 60% for influenza vaccines (3).

Objectives:

The aim of our study was to evaluate the vaccination rate among RA patients, compare it with our previous results, and identify factors associated with non-vaccination.

Methods:

We conducted a cross sectional multicentric observational study in the rheumatology departments of 5 university hospitals in France. Data were collected from December 2018 to July 2019. Outpatients and hospitalized adult patients with RA according to the ACR/EULAR 2010 criteria were included. Data were collected during a single visit through an anonymous questionnaire completed by the patients. Pearson Chi-squared analysis and multivariable logistic regression were used to compare characteristics of vaccinated versus non vaccinated patients.

Results:

584 patients (77.9% of women, mean age 61.8±12.6 years old) were included. 81.7% were RF and/or ACPA positive, with a mean RA duration of 15.7±10.5 years, 58.2% were treated with methotrexate (MTX), and 68.6% with a biologic. Vaccination rate against pneumococcal was 78.9% (versus 55% in 2013, p<0.0001) and 60.4% for influenza (versus 60% in 2013). The main reason for non-vaccination was absence of vaccine proposal (59.2%) for pneumococcal, and fear of vaccines (56.7%) for influenza. In the multivariate analysis, a higher level of education (OR [CI95] 4.4 [2.3-8.4], p<0.0001), a very good opinion on vaccination (2.1 [1.1-4.1], p=0.003), vaccination against influenza done (2.3 {1.3-4.2], p=0.006), and exposure to biologics (4.0 [2.2-7.4], p<0.0001) were associated with vaccination against pneumococcal. Age over 65 years old (2.0 [1.2-3.2], p=0.006), participation in a patients’ association (3.6 [1.4-8.9], p=0.006), vaccination against pneumococcal done (2.4 [1.3-4.5], p=0.004), exposure to biologics (2.1 [1.2-3.7], p=0.006), a good (3.3 [1.4-8.9], p=0.03) and a very good opinion on vaccination (6.6 [2.8-15.6], p<0.0001) were associated with vaccination against influenza.

Conclusion:

Vaccination rate against pneumococcal increased over the last 5 years but remained stable for influenza vaccine in French RA patients. This could be improved with patient’s information and education, especially in patients age under 65, biologic naïve and with a bad opinion about vaccination.

References:

[1] Doran MF, Crowson CS et al. Arthritis Rheum. 2002 Sep;46(9):2287–93.

[2]van Assen S, Agmon-Levin N et al. Ann Rheum Dis. 2011 Mar;70(3):414–22.

[3] Hua C, Morel J et al. Rheumatol Oxf Engl. 2015 Apr;54(4):748–50.

Disclosure of Interests:

Claire Rempenault: None declared, Thomas Barnetche: None declared, Marion Magnol: None declared, Benjamin Castagne: None declared, marine pugibet: None declared, Eleonore Berard: None declared, Marie-Elise Truchetet: None declared, Pascale Vergne-Salle: None declared, Anne Tournadre: None declared, Adeline Ruyssen-Witrand Grant/research support from: Abbvie, Pfizer, Consultant of: Abbvie, BMS, Lilly, Mylan, Novartis, Pfizer, Sandoz, Sanofi-Genzyme, Cédric Lukas: None declared

THU0581 USE OF EHEALTH BY PATIENTS WITH RHEUMATOID ARTHRITIS: AN OBSERVATIONAL, CROSS SECTIONAL, MULTICENTER STUDY

Background:

The use of eHealth tools (internet, mobile applications, connected devices) in chronic diseases and in the field of rheumatoid arthritis (RA) is growing (1). eHealth may improve the overall care of patients suffering from chronic diseases (2,3).

Objectives:

The main objective of this study was to describe the use of eHealth by RA patients in France. The secondary objectives were to identify differences in demographic and disease characteristics between patients using eHealth tools or not. We also assessed patients’ expectations about digital devices.

Methods:

We conducted a cross-sectional, multicenter study. Patients with RA according to the ACR / EULAR 2010 criteria were recruited in 5 university hospitals (Bordeaux, Clermont-Ferrand, Limoges, Montpellier and Toulouse). Patients completed an anonymous self-questionnaire including demographic data, assessment about the use of eHealth (access, support, frequency of use, type of use, reason for use). The treating rheumatologist of the patient filled in an independent medical questionnaire collecting the disease characteristics, the activity of RA and the treatments. Data were collected from December 2018 to July 2019.

Results:

The questionnaires were completed by 575 patients, with an average age of 62±13 years, 78% of whom were women. 473 (82%) patients had access to eHealth through a computer (n=402, 86%), a tablet (n=188, 40%) and/or a smartphone (n=221, 47%). Among them, 36% (170/473) used internet for health in general and 29% (134/473) specifically for RA. Regarding the use of eHealth for RA, all patients used it to learn about their disease and 66% (89/134) as a tool to help monitoring RA. Most of them (n=87/125, 70%) had a paper medical record, 24/125 patients (19%) used a digital tool (spreadsheet n=10, 8% and / or mobile application n=9, 7% and / or website n=5, 4%) and 31/125 patients (25%) did not use any tool to monitor their RA. Few patients (16/126, 13%) used numeric reminders for their treatments. A specific application for RA was used by 27/127 patients (21%) using eHealth. Age, level of study, employment, treatment, comorbidities, membership of a patient association group and patient education program were associated with the use of eHealth for RA in univariate analysis. In multivariate analysis, membership of patient’s association (OR: 5.8 [3.0-11.2]), bDMARDs use (OR: 0.6 [0.4-1]) and comorbidities (OR: 0.7 [0.6-0.8]) remained associated with eHealth use for RA. According to the patients, recommendation by a doctor (n=225/330, 68%), ease of use (n=105/330, 32%) and data security (n=69/330, 21%) were the factors that would favor the use of eHealth.

Conclusion:

To date, few patients used eHealth for their disease. The use of a reliable and validated eHealth tool in RA could therefore be promoted by rheumatologist and might optimize the therapeutic adherence.

References:

[1]Mosa ASM, Yoo I, Sheets L. A systematic review of healthcare applications for smartphones. BMC Med Inform Decis Mak. 10 juill 2012;12:67.

[2]Lorig KR, Ritter PL, Laurent DD, Plant K. The internet-based arthritis self-management program: a one-year randomized trial for patients with arthritis or fibromyalgia. Arthritis Rheum. 15 juill 2008;59(7):1009‑17.

[3]Charpentier G, Benhamou P-Y, Dardari D, Clergeot A, Franc S, Schaepelynck-Belicar P, et al. The Diabeo software enabling individualized insulin dose adjustments combined with telemedicine support improves

Disclosure of Interests:

Marion Magnol: None declared, Eleonore Berard: None declared, Claire Rempenault: None declared, Benjamin Castagne: None declared, marine pugibet: None declared, Cédric Lukas: None declared, Anne Tournadre: None declared, Pascale Vergne-Salle: None declared, Thomas Barnetche: None declared, Marie-Elise Truchetet: None declared, Adeline Ruyssen-Witrand Grant/research support from: Abbvie, Pfizer, Consultant of: Abbvie, BMS, Lilly, Mylan, Novartis, Pfizer, Sandoz, Sanofi-Genzyme

Concurrent Vogt-Koyanagi-Harada disease and impressive response to immune checkpoint blockade in metastatic melanoma

Background: Vogt-Koyanagi-Harada disease (VKHD)-like symptoms have previously been reported in 11 melanoma patients treated with immune checkpoint inhibitors. Materials & methods: We report a female patient with multilocular metastatic melanoma who was treated with nivolumab. Results: Following the first nivolumab dose, she experienced bilateral blurry vision, hearing loss, vertigo and ataxia. Ocular ultrasound was consistent with the diagnosis of uveitis. Audiography revealed severe bilateral sensorineural hearing loss. A high-dose corticosteroid regimen was initiated under which the patient developed generalized vitiligo. Abdominal and thoracic CT scans showed an almost complete response to nivolumab therapy. This patient fulfilled all criteria of VKHD which is characterized pathogenetically by an antimelanocytic autoimmune process. Conclusion: The present case showed an impressive response to antimelanoma immunotherapy. Based on these data, the occurrence of VKHD in melanoma patients appears to be a strong indicator for immune checkpoint inhibitor efficacy.

Validation of mean upper cervical cord area (MUCCA) measurement techniques in multiple sclerosis (MS): High reproducibility and robustness to lesions, but large software and scanner effects

Introduction

Atrophy of the spinal cord is known to occur in multiple sclerosis (MS). The mean upper cervical cord area (MUCCA) can be used to measure this atrophy. Currently, several (semi-)automated methods for MUCCA measurement exist, but validation in clinical magnetic resonance (MR) images is lacking.

Methods

Five methods to measure MUCCA (SCT-PropSeg, SCT-DeepSeg, NeuroQLab, Xinapse JIM and ITK-SNAP) were investigated in a predefined upper cervical cord region. First, within-scanner reproducibility and between-scanner robustness were assessed using intra-class correlation coefficient (ICC) and Dice's similarity index (SI) in scan-rescan 3DT1-weighted images (brain, including cervical spine using a head coil) performed on three 3 T MR machines (GE MR750, Philips Ingenuity, Toshiba Vantage Titan) in 21 subjects with MS and 6 healthy controls (dataset A). Second, sensitivity of MUCCA measurement to lesions in the upper cervical cord was assessed with cervical 3D T1-weighted images (3 T GE HDxT using a head-neck-spine coil) in 7 subjects with MS without and 14 subjects with MS with cervical lesions (dataset B), using ICC and SI with manual reference segmentations.

Results

In dataset A, MUCCA differed between MR machines (p < 0.001) and methods (p < 0.001) used, but not between scan sessions. With respect to MUCCA values, Xinapse JIM showed the highest within-scanner reproducibility (ICC absolute agreement = 0.995) while Xinapse JIM and SCT-PropSeg showed the highest between-scanner robustness (ICC consistency = 0.981 and 0.976, respectively). Reproducibility of segmentations between scan sessions was highest in Xinapse JIM and SCT-PropSeg segmentations (median SI ≥ 0.921), with a significant main effect of method (p < 0.001), but not of MR machine or subject group. In dataset B, SI with manual outlines did not differ between patients with or without cervical lesions for any of the segmentation methods (p > 0.176). However, there was an effect of method for both volumetric and voxel wise agreement of the segmentations (both p < 0.001). Highest volumetric and voxel wise agreement was obtained with Xinapse JIM (ICC absolute agreement = 0.940 and median SI = 0.962).

Conclusion

Although MUCCA is highly reproducible within a scanner for each individual measurement method, MUCCA differs between scanners and between methods. Cervical cord lesions do not affect MUCCA measurement performance.

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Mean upper cervical cord area (MUCCA) was obtained with five different methods.

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MUCCA was determined in a unique scan-rescan multi-vendor MR study.

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Reproducibility: MUCCA did not differ between scan-rescan images for any method.

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Robustness: MUCCA differed between methods and between scanners.

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Performance of MUCCA methods was not affected by the presence of lesions.

Evidence for a white matter lesion size threshold to support the diagnosis of relapsing remitting multiple sclerosis

BACKGROUND

The number of white matter lesions (WML) in brain MRI is the most established paraclinical tool to support the diagnosis of multiple sclerosis (MS) and to monitor its course. Diagnostic criteria have stipulated a minimum detectable diameter of 3 mm per WML, although this threshold is not evidence-based. We aimed to provide a rationale for a WML size threshold for three-dimensional MRI sequences at 3 T by comparing patients with relapsing-remitting MS (RRMS) to control subjects (CS).

METHODS

We analyzed MR images from two cohorts, obtained at scanners from two different vendors, each comprising patients with RRMS and CS. Both cohorts were examined with FLAIR and T1w sequences. In total, 232 patients with RRMS (Expanded Disability Status Scale: mean = 1.6 ± 1.2; age: mean = 36 ± 10) as well as 116 age- and sex-matched CS were studied. We calculated odds ratios across WML volumes. The WML size threshold, which discriminated best between patients and CS, was estimated with receiver operating characteristic curve analysis.

RESULTS

In both cohorts, odds ratios increased continuously with increasing WML volumes, and discriminative power was highest at a WML size threshold corresponding to a diameter of about 3 mm.

CONCLUSION

The stipulated WML size threshold of 3 mm in diameter for the diagnostic criteria of MS seems a reasonable choice for three-dimensional MRI sequences at 3 T.

Risk of fracture and low bone mineral density in adults with inflammatory bowel diseases. A systematic literature review with meta-analysis

Inflammatory bowel diseases (IBDs) are associated with a decreased bone mineral density, but the impact on fractures is unknown. In our study, global risk of fracture is increased for patients with IBDs versus controls. This result will help to determine the appropriate assessment with early screening and management of osteoporosis. Inflammatory bowel diseases (IBDs), such as Crohn's disease (CD) and ulcerative colitis (UC), are associated with a decreased bone mineral density (BMD). However, the impact on fracture risk is unknown and data are contradictory across studies. In this systematic review and meta-analysis, we aimed to assess the risk of fracture and presence of low BMD in patients with IBDs compared to healthy controls. A systematic search of literature was conducted of MEDLINE, EMBASE, the Cochrane library and abstracts from appropriate scientific congresses. Studies were selected if they compared the incidence of fractures and/or BMD measurement by dual-energy X-ray absorptiometry in patients with IBDs and healthy sex- and age-matched controls. Data were extracted by two independent investigators. Meta-analysis was performed with the inverse variance approach to estimate pooled odds ratios (ORs) and risk ratios (RRs) with their 95% confidence intervals (CIs). Twenty-four studies met the inclusion criteria. On the basis of nine studies, global risk of fracture was increased for patients with IBDs versus controls (RR = 1.38, 95% CI 1.11-1.73; p = 0.005). Fracture risk with IBDs was significantly increased for vertebral fractures (OR = 2.26, 95% CI 1.04-4.90; p < 0.001), but not for any other site. The analysis of 16 studies evaluating BMD showed a significant decrease in mean BMD and Z-scores for IBD patients versus controls at all sites. In our meta-analysis, patients with IBDs have an increased risk of fractures, especially in the spine, and significant decreased BMD at all sites, which suggests the need for identifying high-risk individuals among this population.

Early predictors of diabetic retinopathy in type 1 diabetes: The Retinopathy Champagne Ardenne Diabète (ReCAD) study

AIMS

To determine the relationship between early markers of diabetes control and diabetic retinopathy (DR) in type 1 diabetes.

METHODS

A historic cohort study was conducted on 712 patients from the CARéDIAB database. HbA_1c and usual metabolic parameters were measured one year after diagnosis of diabetes. First occurrences of severe hypoglycemia and ketoacidosis during follow-up were selected as time-dependent markers of diabetes control. Data were analyzed in a Cox model using SPSS software to predict DR with significance level at p-value <0.05.

RESULTS

In multivariate regression, any diabetic retinopathy was predicted by HbA_1c (HR = 1.38; CI = 1.25-1.52; p < 0.0001), severe hypoglycemia (HR = 3; CI = 1.99-4.52; p < 0.0001), ketoacidosis (HR = 1.96; CI = 1.17-3.22; p = 0.009), and age at diagnosis (HR = 1.016; CI = 1.002-1.031; p = 0.02). Proliferative DR was predicted by HbA_1c (HR = 1.67; CI = 1.51-1.79; p < 0.0001), severe hypoglycemia (HR = 3.67; CI = 2.74-5.25; p < 0.0001), and ketoacidosis (HR = 2.37; CI = 1.56-3.18; p < 0.0001).

CONCLUSION

This study shows that the failure to achieve diabetes control after the first year of diagnosis as well as early episodes of acute diabetes complications may contribute to the occurrence of diabetic retinopathy in type 1 diabetes patients.

Cervical cord and ventricle affection in neuromyelitis optica

OBJECTIVES

Cervical cord involvement is common in neuromyelitis optica (NMO) and multiple sclerosis (MS), but its impact on disability in NMO has rarely been studied. Recent publications on NMO examined the periventricular system, areas of high aquaporin-4 expression, but not yet by using ventricle volumetry.

PURPOSE

To compare cervical cord atrophy, ventricular widening, and supra- and infratentorial brain measures between NMO and MS, and study their impact on clinical disability.

METHODS

Magnet resonance imaging-based volumetry of upper cervical cord, third and fourth lateral ventricles, grey matter, white matter, brainstem, cerebellum and clinical status of 18 NMO and 20 MS patients, was compared between the groups and with 26 healthy controls. Patterns of ventricular widening relative to healthy controls were inspected by voxel-based morphometry of the cerebrospinal fluid.

RESULTS

Cervical cord atrophy was similar in NMO and MS (75.2 ± 10.0 mm² , respectively, 76.5 ± 9.5 mm² vs 84.1 ± 8.6 mm² in controls).Third ventricle increase in both groups, and specific fourth ventricle widening in MS were detected. Patient groups differed in third to fourth ventricle ratio (P = 0.002). In NMO, white matter correlated inversely with the affected cord segments (P = 0.001) and with cervical cord area (P = 0.043). The disability status was explained by cervical cord area and third ventricle volume (R² =0.524) in NMO, and by grey matter and fourth ventricle volume (R² =0.565) in MS.

CONCLUSION

Cervical cord atrophy and third ventricular enlargement are both clinically relevant in NMO. Third and fourth ventricle volumetry shows differences between NMO and MS regarding the involvement of periventricular structures.

Prevalence and topographic distribution of spinal inflammation on MR imaging in patients recently diagnosed with axial spondyloarthritis

OBJECTIVE

The primary goal of this study was to determine the prevalence and topographic distribution of spinal lesions in lower thoracic and lumbar spine on magnetic resonance imaging (MRI) in patients with recently diagnosed with spondyloarthritis. The secondary goal was to identify variables associated with vertebral patterns consistent with spondyloarthritis on MRI.

PATIENTS AND METHODS

A total of 112 HLA-B27 positive patients with recently diagnosed spondyloarthritis were retrospectively included. There were 70 women and 42 men, with a mean age of 41 years±12 (SD) (range: 17-70years). Mean symptom duration was 1year (range: 0-7years). MRI examinations of sacroiliac joints and thoracolumbar spine were reviewed for the presence of bone marrow edema, chronic structural abnormalities, and vertebral patterns consistent with spondyloarthritis. Age, gender and disease duration of patients with vertebral patterns on MRI consistent with spondyloarthritis were compared with those without MRI signs of spondyloarthritis.

RESULTS

Thirty-six patients (32.1%) showed spinal patterns of spondyloarthritis, including 16 patients (14.3%) with no associated inflammatory sacroiliitis. Posterior inflammatory lesions were present in 20.5% of patients. Posterior spinal inflammatory lesions were significantly associated with vertebral corner inflammatory lesions (P=0.03). There were no differences in age, sex or mean duration of symptoms between the two groups of patients.

CONCLUSION

Spinal involvement is observed in 32.1% of HLA-B27 positive patients with recently diagnosed spondyloarthritis and is not associated with sacroiliitis in 14.3%. Age, gender or symptom duration are not associated with spinal involvement on MRI.

Association of environmental markers with childhood type 1 diabetes mellitus revealed by a long questionnaire on early life exposures and lifestyle in a case-control study

Background

The incidence of childhood type 1 diabetes (T1D) incidence is rising in many countries, supposedly because of changing environmental factors, which are yet largely unknown. The purpose of the study was to unravel environmental markers associated with T1D.

Methods

Cases were children with T1D from the French Isis-Diab cohort. Controls were schoolmates or friends of the patients. Parents were asked to fill a 845-item questionnaire investigating the child’s environment before diagnosis. The analysis took into account the matching between cases and controls. A second analysis used propensity score methods.

Results

We found a negative association of several lifestyle variables, gastroenteritis episodes, dental hygiene, hazelnut cocoa spread consumption, wasp and bee stings with T1D, consumption of vegetables from a farm and death of a pet by old age.

Conclusions

The found statistical association of new environmental markers with T1D calls for replication in other cohorts and investigation of new environmental areas.

Trial registration

Clinical-Trial.gov NCT02212522. Registered August 6, 2014. 

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3690-9) contains supplementary material, which is available to authorized users.

Association between RANK, RANKL and OPG polymorphisms with ACPA and erosions in rheumatoid arthritis: results from a meta-analysis involving three French cohorts

OBJECTIVES

The RANK/RANKL/osteoprotegerin (OPG) system plays a central role in the pathogenesis of bone erosions in rheumatoid arthritis (RA). The aim of this study was to test the association between 11 single-nucleotide polymorphisms (SNPs) located on RANK, RANKL and OPG genes and anticitrullinated peptide antibody (ACPA) presence or erosions in RA.

METHODS

PATIENTS

This work was performed on three independent samples of French patients with RA: the Etude de Suivi des PolyArthrites Indifférenciées Récentes (ESPOIR) (n=632), Rangueil Midi-Pyrénées (RMP) (n=249) and French Rheumatoid Arthritis Genetic Consortium (FRAGC) (n=590) cohorts. Genotyping: the genotyping of 11 SNPs located on RANK, RANKL and OPG were performed by PCR.

STATISTICAL ANALYSES

The association between the genotypes with ACPA or erosions was first tested in the ESPOIR cohort using a χ(2) test and, in the case of significant association, replicated in the RMP and FRACG cohorts. A meta-analysis on the three cohorts was performed using the Mantel-Haenszel method.

RESULTS

One SNP on RANK (rs8086340) and three SNPs on RANKL (rs7984870, rs7325635, rs1054016) were significantly associated with ACPA presence, while one SNP on OPG (rs2073618) and one SNP on RANKL (rs7325635) were significantly associated with erosions in the ESPOIR cohort. Following meta-analysis performed on the three samples, the SNP on RANK and the GGG haplotype of the three SNPs located on RANKL were both significantly associated with ACPA presence, while only the SNP on OPG remained significantly associated with erosions.

CONCLUSIONS

This study identified one SNP located on RANK, one haplotype on RANKL associated with ACPA presence, and one SNP located on OPG associated with erosions in three different samples of French patients with RA.

[Radiation-Induced Radiculopathy with Paresis of the Neck and Autochthonous Back Muscles with Additional Myopathy]

Radiation-induced tissue damage is caused by ionizing radiation mainly affecting the skin, vascular, neuronal or muscle tissue. Early damages occur within weeks and months while late damages may occur months or even decades after radiation.Radiation-induced paresis of the spine or the trunk muscles with camptocormia or dropped-head syndrome are rare but have already been described as long-term sequelae after treatment of Hodgkin's lymphoma. The differential diagnosis includes limb-girdle muscular dystrophy, fascioscapulohumeral muscular dystrophy (FSHD) or lysosomal storage diseases (e. g. Acid Maltase Deficiency). We present the case of a patient with long lasting diagnostics over many months due to different inconclusive results.

Factors associated with a bad functional prognosis in early inflammatory back pain: results from the DESIR cohort

Background

Spondyloarthritis (SpA) is a heterogeneous disease with hardly predictable potential courses. We aimed at determining prognostic factors of bad functional outcome at 2 years in patients with early inflammatory back pain (IBP).

Methods

Data from patients included in the French multicentre devenir des spondylarthropathies indifférenciées récentes (DESIR) cohort, that is, suffering from IBP starting before 50 years of age and lasting for 3–36 months, were used. A bad functional outcome at 24 months was defined as an increase in bath ankylosing spondylitis functional index (BASFI), or BASFI at 2 years higher than the 75th centile in the cohort. Demographic, clinical, biological and radiological data collected at inclusion were compared in patients with bad functional outcome versus others, by χ² test, then by a multivariate logistic regression model with stepwise selection of relevant factors.

Results

513 patients (54.4% females, 72.2% fulfilling ASAS criteria) were assessed. Of those, 130 (25.3%) fulfilled the aforementioned criteria of a bad functional outcome (BASFI increase ≥4 units or ≥36 at 2 years). Multivariate analysis revealed that not fulfilling ASAS criteria, female sex, age >33 years, lower educational level, active smoking status and high disease activity according to bath ankylosing spondylitis disease activity index (BASDAI) at baseline were independently associated with a bad functional outcome at 24 months. Sensitivity analyses restricted to patients fulfilling ASAS criteria for SpA resulted in similar results.

Conclusion

We observed, in a large prospective cohort of patients with early IBP, formerly described bad prognostic factors, especially a low educational level, an older age and a high disease activity at onset, and revealed that active smoking status and female sex were also independently associated with a poor outcome. Fulfilment of ASAS criteria, on the other hand, was predictive of a better outcome, most likely due to the more consensual management of a defined disease.

Multicenter Validation of Mean Upper Cervical Cord Area Measurements from Head 3D T1-Weighted MR Imaging in Patients with Multiple Sclerosis

BACKGROUND AND PURPOSE

Spinal cord atrophy is a common and clinically relevant characteristic in multiple sclerosis. We aimed to perform a multicenter validation study of mean upper cervical cord area measurements in patients with multiple sclerosis and healthy controls from head MR images and to explore the effect of gadolinium administration on mean upper cervical cord area measurements.

MATERIALS AND METHODS

We recruited 97 subjects from 3 centers, including 60 patients with multiple sclerosis of different disease types and 37 healthy controls. Both cervical cord and head 3D T1-weighted images were acquired. In 11 additional patients from 1 center, head images before and after gadolinium administration and cervical cord images after gadolinium administration were acquired. The mean upper cervical cord area was compared between cervical cord and head images by using intraclass correlation coefficients (ICC) for both consistency (ICCconsist) and absolute (ICCabs) agreement.

RESULTS

There was excellent agreement of mean upper cervical cord area measurements from head and cervical cord images in the entire group (ICCabs = 0.987) and across centers and disease subtypes. The mean absolute difference between the mean upper cervical cord area measured from head and cervical cord images was 2 mm(2) (2.3%). Additionally, excellent agreement was found between the mean upper cervical cord area measured from head images with and without gadolinium administration (ICCabs = 0.991) and between the cervical cord and head images with gadolinium administration (ICCabs = 0.992).

CONCLUSIONS

Excellent agreement between mean upper cervical cord area measurements on head and cervical cord images was observed in this multicenter study, implying that upper cervical cord atrophy can be reliably measured from head images. Postgadolinium head or cervical cord images may also be suitable for measuring mean upper cervical cord area.