AB0310 STUDY “AR-CAT INICI”: MANAGEMENT OF EARLY RHEUMATOID ARTHRITIS IN CATALONIA

Background

Given the progressive change in the management of inflammatory diseases,an observational study was conducted on the management of Early Rheumatoid Arthritis (ERA) in Catalonia.

Objectives

To know the management of ERA in Catalonia, to assess whether the recommendations of the EULAR/ACR guidelines are followed and to study the causes of management variability,to set improvement objectives.

Methods

An observational,descriptive,and cross-sectional study was conducted,with data collection from June 15 to 30, 2021.The rheumatologists’ partners of the Catalan Society of Rheumatology were the object of study. An online survey was conducted with 304 members on the management of the ERA. Variables related to the characteristics of the respondents,the derivation and variables of the disease including clinical variables,type of treatment and outcomes used for follow-up including the impact of the SARS-CoV2 pandemic were included.The univariate study was performed using a study of proportions with Pearson’s correlation.

Results

A total of 105 members (34.5%) responded to the survey.11.6%>60 y, only 7.8% <30y. 99% were in public assistance.The number of rheumatologists per service is 7.2[1-17],but 34.2% had< 5 rheumatologists,with a reference population of 200,000-300,000p in 42% of respondents.The number of weekly visits made is 67.5[20-130].42.2% do not have a monographic RA or ERA dispensary and 30.4%not have specialized nursing.Characteristics of ERA:77.5% are derived from primary care(PC),52% have been between 6 weeks,42.1%>3 months.54.9% make a first visit within 2-4 weeks of PC referral and 14.7%> 8 weeks.100%provide previous analysis,only 47% had had RX performed.98% were previously treated(50.4%NSAIDs + CG,36.1%NSAIDs,12.3% CG).4.3% had GC doses>10 mg/day,11.3%> to 20mg/day.The treatment:DMARDs of choice in 100% is MTX,44.1% start doses of 10mg/week and 3.9%7.5 mg/week.The route of choice is oral(55.9% vs 44.1%).92.2% associate GC and 31.7% have not withdrawn them after 6 m.57.8% consider the maximum of MTX 25mg/W.87.1% use doses<10 mg/day,with the most used dose being 5 mg/day(35.6%).Follow-up after the start of DMARDs is performed 72.5% between 4-6 weeks and 12.7% is performed by nursing.100% use DAS 28 and 53.5% also CDAI.31.4% perform PROs(HAQ 83.3%,RAPID 3 14.3%).The use of systematic ultrasound is collected in 33%, being himself who performs it in 59.9% and an expert rheumatologist in 46.1%.Finally, when asked about incidence of pandemic in the follow-up,53.3% consider that it is doing the same as before. 46.1% consider that telephone visits are not suitable for the follow-up of the ERAvs14.7% who consider that Yes.When questioning the situations in which they consider them to be appropriate,75.9% that it was adequate in the control after the beginning of the DMARDs.Regarding the treatment of ERA, 66% delayed the onset of biological DMARDs, 72.1% due to difficulty of follow-up and only 8.8% due to an increased risk of infection. When performing the univariate analysis, it is evident that having a monographic dispensary is associated with earlier onset of MTX(p< 0.001)and at doses≥15 mg/W(p = 0.05),greater nursing intervention(p< 0.001),greater use of PROs(p = 0.008)and there is a tendency to a shorter waiting time for first visits(p = 0.07).It is also associated with not considering telephone visits(p< 0.001), making them in less than 25%(p< 0.0001).Similarly,hospital level is directly proportional to initiation at higher doses of MTX(p< 0.0001),lower use of GC<10mg.Among the rest of the variables, no association has been found.

Conclusion

The recommendations of EULAR/ACR in the treatment and follow-up of ERA are consistently followed,although the wide use of MTX orally is striking.It is evident that the variable that most influences the early onset of FAME and at higher doses,is a monographic dispensary,as well as greater presence of nursing and performance of PROs.

Acknowledgements

Thanks to all the members of the Catalan society of reuamtology who participated in the survey

Disclosure of Interests

None declared

AB0196 ABATACEPT VERSUS HYDROXYCHLOROQUINE IN PALINDROMIC RHEUMATISM: A MULTICENTER RANDOMIZED CLINICAL TRIAL (PALABA STUDY): TRIAL DESIGN AND PATIENTS CHARACTERISTICS

Background

Many patients with palindromic rheumatism (PR), mainly those with positive autoantibodies, evolve to rheumatoid arthritis (RA). Management of PR is empirical, and hydroxychloroquine (HCQ) is the most used antirheumatic drug. Abatacept (ABA) has been investigated in preclinical RA with good results. There are no randomized clinical trials in PR.

Objectives

To present the design of a randomized clinical trial in PR (PALABA study). To describe the characteristics of the patients at study entry. The main objective is to test the hypothesis that ABA can reduce the progression of RA in seropositive (ACPA+ and/or RF+) PR patients in comparison with HCQ.

Methods

Phase IV multicenter open label randomized controlled clinical trial with 42 months duration. The enrollment period was 18 months and the open randomized period 24 months. Fourteen spanish centers were included. The sample size was 70 patients (35 per arm). ABA sc 125 mg/week first year, 125 mg eow second year and HCQ oral 5mg/Kg daily were administered, both therapies in monotherapy. The main inclusion criteria were age >18 years with PR according to Guerne and Weissman modified criteria and disease evolution >3 and <36 months. Positive ACPA (ELISA or chemiluminescence (CCP2) and/or RF tests are required. Patients with arthritis in ≥1 joint >1 week at baseline, with criteria of other rheumatic diseases, radiographic erosions or previous antirheumatic therapy with synthetic DMARDS were excluded. The main outcome measure is achievement of RA classification criteria (EULAR/ACR 2010) at any time during the 24-month follow-up. Secondary outcomes were the number and intensity of joint attacks, adverse events, and effects on serum ACPA and anti-carbamylated antibodies at 0,3,12,24 months of follow-up. STATISTICS: Modified Full Analysis Set and Per Protocol Population analysis.

Results

Patient one was included in June 2018. The inclusion period has been extended until April 2022 due to low recruitment rates, partly due to the COVID-19 pandemic. As of 15 Jan 2022, 51 patients have been randomized and 49 (37F/12M) have received at least one drug dose. The mean onset of symptoms was 9.9±6.3 months. In 22 patients the follow-up time was greater than 12 months. RF and ACPA (CCP2) were positive in 81.6% and 89.8% of patients respectively; 24 patients were included in the ABA arm and 25 in the HCQ arm. Seven patients withdrew from the study during follow-up due to: progression to RA (n=3), adverse events (n=2) and other reasons (n=2). The demographic, clinical and laboratory characteristics of PR patients at study entry are shown in Table 1. No significant differences in patients’ characteristics between arms were observed at enrollment except a higher prevalence of CCP2 in the HCQ arm.

Table 1

Baseline demographic, clinical and laboratory characteristics at study entry

Age, mean (sd)49.6 (11.2)49.8 (12.0)49.4 (10.7)NSFemale, n (%)37 (75.5)19 (79.2)18 (72)NSBody mass index, mean (sd)27.(5.7)26.6 (5.5)27.4 (5.9)NSMonth of symptom duration, mean (sd)9.9 (6.3)9.8 (6.8)9.9 (5.9)NSCurrent Smokers, mean (sd)15 (30.6)6 (25)9 (36)NSNumber attacks 6 months before inclusion, mean (sd)4.65 (4.07)4.24 (2.78)5.0 (5.0)NSPIP/MCP involvement n (%)35 (71.4)16 (66.7)19 (76)NSWrist involvement, n (%)32 (65.3)17 (70.8)15 (60.0)NSInvolvement of other joints, n (%)30 (61.2)14 (58.3)16 (64.0)NSESR (mm), mean (sd)20.71 (16.8)23.13 (18.8)18.30 (14.8)NSRF positive, n (%)40 (81.6)19 (79.2)21 (84)NSACPA (CCP2) positive, n (%)44 (89.8)19 (79.2)25 (100)0.022

PIP: proximal interphalangeal MCP: metacarpophalangeal

Conclusion

We present the design of the first randomized clinical trial in PR of the efficacy of antirheumatic drugs (ABA vs HCQ) to avoid progression towards RA in patients with a high risk (recent onset PR and positive autoantibody status) of persistent arthritis. The characteristics of patients included until now are similar to those reported in recent onset PR.

Acknowledgements

PALABA study investigators: Beatriz Frade-Sosa, Rosa Maria Morlà, Lola Tobalina, Maria López-Lasanta, Helena Borrell, Georgina Salvador, Andrea M Cuervo, Noemí Busquets, Eduard Graell, Carolina Pérez- García, Luciano Pocino, Delia Reina, Oscar Camacho, Hector Corominas Ana M Millan. Miquel Sala, Sonia Castell, Eduardo Kanterewicz, Josep R. Rodriguez Cros, Alejandro Escudero, Usansolo Irati, José Francisco Garcia, Francisco Javier Toro, Natividad Oreiro, Alejandro Olivé, Maria J Gómara, Cristina García-Moreno, Isabel Haro and Raimon Sanmarti.

Disclosure of Interests

Beatriz Frade-Sosa: None declared, Rosa Morlà: None declared, Lola Tobalina: None declared, Carolina Perez-Garcia: None declared, Isabel Haro: None declared, Raimón Sanmartí Speakers bureau: received speaker honorariafrom Abbvie, BMS, Gebro-Pharma, Lilly, MSD, Pfizer, Sanofi and Roche, Grant/research support from: investigation grants  from Abbvie, BMS, Gebro-Pharma, Lilly, MSD, Pfizer, Sanofi and Roche

AB0398 AURICULAR TRANSCUTANEOUS HI-FREQUENCY E-MMUNOTHERAPY SEQUENCES (ATHENS) FOR THE TREATMENT OF RHEUMATOID ARTHRITIS: 1-YEAR CHANGES IN SYNOVITIS, OSTEITIS, AND BONE EROSION

Background

Current pharmacological treatments remain inadequate for a significant proportion of patients with rheumatoid arthritis (RA), and thus alternative treatment approaches are needed. Prior results from the first 12 weeks of a proof-of-concept (POC) study showed that ATHENS, a non-invasive high-frequency vagus nerve therapy, was well-tolerated with meaningful reductions in RA disease severity as measured by the American College of Rheumatology response criteria (ACR) and the Disease Activity Score using 28 joints (DAS28)[1].

Objectives

The current analysis assessed long-term changes (52 weeks total follow-up) in disease activity as measured by ACR, DAS28, and the following MRI-assessed changes: synovitis, osteitis, bone erosion, and cartilage loss.

Methods

Following the completion of the 12-week POC study, patients achieving a reduction in DAS28-CRP of ≥1.2 were given the option to enroll in the 9-month open-label extension (OLE) study. During the extension phase, patients were to use the wearable device for 15 minutes per day. Adjustment of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or biologic disease-modifying antirheumatic drugs (bDMARDs) were allowed during the OLE. Changes from baseline were assessed at 12 weeks (end of initial POC) and 52 weeks (end of the OLE). Structural damage and disease progression were evaluated by standardized MRI of the wrist and hand, with and without intravenous gadolinium-based contrast. MRIs were evaluated by two independent, central readers, blinded to clinical information and visit-order of the images, and were scored for synovitis, osteitis and bone erosion using the OMERACT-RAMRIS method. Cartilage loss was also determined using the 9-point cartilage loss scale (CARLOS).

Results

Twenty-seven of 30 patients completed the initial 12-week study, of whom 19 consented and entered the OLE. Of those 19 patients, 4 (21%) discontinued due to lack of efficacy, while the remaining 15 completed the 9-month extension. Due to the COVID-19 pandemic, 7 patients were unable to complete a 52-week MRI scan; MRI evaluations at baseline, 12 weeks, and 52 weeks were available for 8 patients.

DAS28-CRP mean (standard deviation [SD]) change from baseline was -1.78 (1.01) at 12 weeks (n=19; p<0.0001) and -2.30 (1.22) at 52 weeks (n=15; p<0.0001). ACR20, ACR50, and ACR70 response rates were 68%, 42%, and 21% at 52 weeks (n=19; discontinued participants were deemed non-responders). MRI analysis of synovitis, osteitis, bone erosion, and cartilage loss showed no evidence of disease progression through 52 weeks compared with baseline (Table 1).

Table 1.

Change in MRI OMERACT-RAMRIS from baseline to week 52

ScoreBaseline (n=8)Week 12 (n=8)Week 52 (n=8)Change Week 12 vs BL (n=8)Change Week 52 vs BL (n=8)CARLOS, mean (SD)3.9 (5.6)3.9 (5.6)3.9 (5.6)0.0 (0.0)0.0 (0.0)Erosion, mean (SD)10.8 (10.3)10.5 (10.3)10.6 (10.3)-0.3 (0.4)-0.1 (0.8)Osteitis, mean (SD)2.8 (4.1)2.3 (3.7)1.0 (1.1)-0.5 (1.1)-1.8 (3.1)Synovitis, mean (SD)4.0 (4.2)4.1 (4.7)3.3 (4.0)0.1 (0.6)-0.7 (1.0)

CARLOS = Cartilage loss score; OMERACT = Outcome Measures in Rheumatology; RAMRIS = Rheumatoid Arthritis Magnetic Resonance Imaging Scoring System

During the 9-month extension study, two new adverse events were reported (cornea transplant and right hand dysesthesia) in 2 (11%) patients; neither was treatment-related and both resolved without intervention. No serious adverse events were reported.

Conclusion

In patients with an initial treatment response to the Nēsos ATHENS therapy in the 12-week POC study, reductions in DAS28-CRP were sustained through 52 weeks. Although results should be interpreted cautiously given the small sample size and lack of control arm, MRI evaluation of synovitis, osteitis, bone erosion, and cartilage loss suggested no disease progression.

References

[1]Marsal, S., The Lancet Rheumatology, 2021. 3(4): p. e262-e269.

Disclosure of Interests

Charles Peterfy Consultant of: Nesos Corp, Employee of: Spire Sciences, Héctor Corominas: None declared, Juan Jose de Agustin: None declared, Carolina Perez-Garcia: None declared, Maria Lopez Lasanta: None declared, Helena Borrell Paños: None declared, D Reina-Sanz: None declared, Raimón Sanmartí: None declared, J. Narváez: None declared, Jose Antonio Narvaez: None declared, Vivek Sharma Shareholder of: Nesos Corp., Employee of: Nesos Corp., Konstantinos Alataris Shareholder of: Nesos Corp., Employee of: Nesos Corp., Mark C. Genovese Shareholder of: Nesos Corp. and Gilead, Employee of: Gilead, Matthew Baker Shareholder of: Nesos Corp., Consultant of: Nesos Corp., Sara Marsal Consultant of: Nesos, Pfizer, Sandoz, Novartis, Gilead, Grant/research support from: Nesos, BMS, Celgene, Merck Sharp and Dohme, Pfizer, Sandoz, Novartis, Sanofi, Janssen, Union Chimique Belge Pharma

POS1439 CANCER IN PATIENTS WITH RHEUMATIC DISEASES EXPOSED TO DIFFERENT BIOLOGIC AND TARGETED SYNTHETIC DMARDS IN REAL-WORLD CLINICAL PRACTICE: DATA FROM A MULTICENTER REGISTER

Background

Extensive evidence has confirmed no increased risk of cancer associated to either conventional synthetic DMARDs or anti-TNF in patients with rheumatic diseases. The risk of cancer in biologic (bDMARDs) different to anti-TNF and targeted synthetic (tsDMARDs) is considerably less investigated. As new therapies are emerging, more data in real-world registries are needed to confirm safety in other treatment groups.

Objectives

To compare the risk of cancer of tsDMARDs and other bDMARDs versus anti-TNF in patients with rheumatic diseases.

Methods

Data of patients enrolled in BIOBADASER 3.0 up to October 2021 with the start of any bDMARD or tsDMARD were analyzed. For each group, demographic and clinical variables were estimated. Changes to therapy and occurrence of serious adverse events collected annually. Incident cancer was defined as any cancer during the exposure classified according to Meddra dictionary leading to therapy discontinuation. Incidence rate ratios of cancer per 1000 patients-year (PYs) and 95% confidence interval were estimated. Incidence rate ratio was calculated for each group versus anti-TNF.

Results

We identified 271 cancers in BIOBADASER 3.0, corresponding to a cancer incident rate of 7.4 (6.5-8.3) per 1000 PY of exposure. Patients exposed to anti-TNF and anti-IL17 were younger, with lower disease duration and comorbidity versus other groups. Proportionally more malignancies were identified in the anti-CTLA-4 group (3.4%) versus the anti-TNF group (2.9%). The rates of incident cancer ranged between 2.6 events/1000 PY in the anti-IL17 group and 15.3 events/1000 PY in the anti-CTLA-4 group. The rate of cancer did not differ significantly in patients exposed to JAKi [0.8 (95% CI 0.4-1.5)], anti CD20 [1.1 (95% CI 0.6-1.8)], or anti-IL6 [1.3 (95% CI 0.9-1.9)] versus anti-TNF; it was significantly lower in patients exposed to anti-Il17 [0.4 (95% CI 0.2-0.9)], and significantly higher in patients exposed to anti-CTLA-4 [2.2 (95% CI 1.4-3.2)]. The most frequent malignancy was non-melanoma skin cancer, followed by solid cancer (mainly breast cancer with 24 events and lung cancer with 14 events) and melanoma (13 events).

Table 1.

New Cancer Diagnosis Among Patients with anti-TNF versus other therapies

Anti-TNF (N=6356)JAKi (N=1079)Anti-CD20 (N=667)Anti-IL6 (N=1178)Anti-CTLA-4 (N=783)Anti-IL17 (N=1051)Female, n (%)3738 (58.8)868 (80.4)523 (78.4)947 (80.4)598 (76.4)492 (46.81)Mean age, (SD)54.8 (14.7)58.5 (12.4)60.9 (13.6)59.8 (15.1)64.0 (12.8)52.2 (11.6)Mean start age, (SD)49.1 (14.0)56.6 (12.3)57.9 (13.5)55.7 (15.2)59.7 (13.0)49.8 (22.2)Disease duration, median (IQR)6.2[2.2-13.0]10.4[4.7 -17.2]11.0[5.1-18.5]8.3[3.2-15.1]10.3[5.2-17.0]3.1[0.3-10.7]Charlton Index1.9 (1.3)2.4 (1.6)2.4 (1.7)2.4 (1.7)2.8 (1.9)1.8 (1.3)First line biologic, n (%)99 (53.2)2 (22.2)1 (7.1)6 (20.0)5 (18.5)2 (66.7)New cancer diagnosis, n (%)186 (2.9%)9 (0.8%)14 (2.1%)30 (2.5%)27 (3.4%)5 (0.5%)Median years of follow-up months4.2 [2.3-7.3]2.4 [1.4-3.2]1.0 [1.0-1.0]2.6 [1.3-6.6]4.4 [1.5-5.7]1.8 [1-5-2.2]Time of exposure, yrs26233.51652.71871.53196.71762.11921Cancer Incidence Rate (per 1000 PY) ancer Incide7.1 (6.1-8.2)5.4 (2.8-10.5)7.5 (4.4-12.6)9.4 (6.6-13.4)15.3 (10.5-22.3)2.6 (1.1-6.3) .6 (1.1-6.3).5.2 (4.4-6.1)6.3 (1.6-8.1)5.9 (3.3-10.6)7.5 (5-11.2)10.8 (6.9-16.9)1.6 (0.5-4.8) .6 (0.5-40.3 (0.2-0.6)0 (0-0)1.1 (0.3-4.3)0.3 (0-2.2)0.6 (0.1-4)0 (0-0) (0-0)1-4)3)9)) Rate (per1.6 (1.2-2.2)1.8 (0.6-5.6)0.5 (0.1-3.8)1.6 (0.7-3.8)4 (1.9-8.3)1 (0.3-4.2)Rate ratio (vs anti-TNF)NA0.8 (0.4-1.5)1.1 (0.6-1.8)1.3 (0.9-1.9)2.2 (1.4-3.2)0.4 (0.2-0.9)

Conclusion

In this register-based study, rates of incident cancer did not differ between patients treated with anti-TNF and other bDMARDs or tsDMARDs, with the possible exception of a potential increased risk in patients treated with anti-CTLA-4.

Acknowledgements

Thank you to all patients, rheumatologists, and to the research personnel from the Spanish Foundation of Rheumatology who made this study possible.

Disclosure of Interests

Isabel Castrejon: None declared, Juan Molina Collada: None declared, Carolina Perez-Garcia: None declared, Paloma Vela-Casasempere Speakers bureau: ROCHE, UCB, GSK, LILLY, Consultant of: PFIZER, BMS, LILLY, UCB, GSK, Abbvie, Fresenius Kabi, Grant/research support from: ROCHE, ABBVIE, PFIZER, BMS, LILLY, SANDOZ, AMGEN, Cesar Diaz-Torne: None declared, Cristina Bohórquez: None declared, J M Blanco: None declared, Fernando Sánchez-Alonso: None declared

OP0138 RISK OF CANCER AFTER BIOLOGIC AND TARGETED SYNTHETIC DMARDS INITIATION IN PATIENTS WITH RHEUMATIC DISEASES AND A HISTORY OF PRIOR MALIGNANCY: DATA FROM THE BIOBADASER REGISTRY

Background

Patients with a history of cancer are routinely excluded from randomized controlled trials. As consequence, data on the safety of biologic disease modifying antirheumatic drugs (bDMARDS) and targeted synthetic (ts) DMARDs are limited. Although real world data from various national registries have not provided evidence of increased cancer recurrence, additional data from real-world registries may help to confirm safety of non-TNFi bDMARDs and tsDMARDs regarding cancer recurrence to guide treatment decisions.

Objectives

To compare the risk of incident malignancy with exposure to different bDMARDs and tsDMARDs in patients with rheumatic diseases and a prior malignancy.

Methods

The study population comprised patients with a prior malignancy from the BIOBADASER 3.0 up to 2021. BIOBADASER is a large national drug safety registry of patients with rheumatic diseases starting treatment with any bDMARD or tsDMARD and followed thereafter at the time an adverse event or a change in biological therapy occurs. Incident cancer was defined as any cancer (new primaries, local recurrence or metastases) during the exposure classified according to Meddra dictionary. Incidence rate ratios of cancer per 1000 patients-year (PY) and 95% CI were estimated. Rates of incident cancer in tsDMARDs and other bDMARDs versus anti-TNF treated patients were compared.

Results

A total of 9,129 patients treated with bDMARDs and tsDMARDs are included in BIOBADASER 3.0 at the time of the study. Of them, 352 with a prior history of malignancy at time of enrollment were selected for analysis (Figure 1). Overall, there were 32 incident malignancies (17 solid cancer, 14 non-melanoma skin cancer and 1 melanoma). The overall rate of incident malignancy was 27.1 (95% CI 18.6-38.3) events/1,000 PY, ranging between none events/1000 PY in the anti-IL17 group to 51.7 events/1000 PY in the anti-CTLA-4 group (Table 1). The overall rate of incident cancer did not differ significantly in patients exposed to JAKi [0.6 (95% CI 0.1-2.5)], anti-CD20 [0.3 (95% CI 0.1-1.4)], anti-IL6 [1.2 (95% CI 0.5-3.4)] or anti-CTLA-4 [1.3 (95% CI 0.5-3.6) versus anti-TNF therapy. The rate of different types of cancer (melanoma, non-melanoma skin cancer or solid tumors) did not differ between the different treatment groups when compared to anti-TNF therapy (Table 1).

Table 1.

Baseline characteristics and rate of incident cancer.

Anti-TNF(n = 185)JAKi(n = 61)Anti-CD20(n= 61)Anti-IL6(n= 68)Anti-CTLA-4(n= 47)Anti-IL17(n= 39)Total(n=352)Female, n (%)129 (69.7)49 (80.3)43 (70.5)54 (79.4)34 (72.3)21 (53.9)247 (70.2)Age, mean (SD)64.4 (13.1)66.7 (13.1)67.8 (10.0)70.5 (11.6)71.8 (10.4)59.5 (14.6)65.3 (13.0)Start treatment age, mean (SD)60.0 (12.9)64.8 (12.8)65.7 (9.6)67.3 (11.3)62.8 (12.7)56.9 (14.5)61.6 (12.8)Disease duration, median (IQR)6.7 (3.0-13.1)12.3 (7.4-19.6)10.8 (6.3-19.4)8.5 (4.0-16.8)8.2 (4.1-16.6)8.4 (4.7-16.1)7.0 (2.9-15.5)Time of follow-up months, mean (SD)23.1 (25.3)15.9 (13.3)11.5 (2.5)16.8 (17.6)23.7 (22.6)18.4 (15.5)17.5 (18.2)Charlson comorbidity index4.9 (2.0)5.2 (2.2)5.1 (2.0)5.5 (2.1)6.1 (2.6)6.9 (2.6)5.2 (2.1)Prior malignancyNon-lymphoproliferative (solid or melanoma), n (%)174 (94.5)58 (95.1)54 (88.5)65 (95.6)46 (97.9)36 (92.3)331 (94.0)Lymphoproliferative, n (%)9 (4.9)3 (4.9)13 (21.3)4 (5.9)4 (8.5)5 (12.8)29 (8.2)Metastatic cancer, n (%)2 (1.1)2 (3.3)2 (3.3)1 (1.5)3 (6.4)0 (0.0)7 (2.0)Incident cancerNew cancer diagnosis, n (%)182255032Time of exposure, sum (years)470,191,6163104,996,863,81178,6Rate of incident cancer (per 1,000 PY)38.3 (24.1-60.8)21.8 (5.5-87.3)12.3 (3.1-49.1)47.7 (19.8-114.5)51.7 (21.5-124.1)0 (0-0)27.1 (18.6-38.3)Rate ratio of incident cancer (vs anti-TNF)-0.6 (0.1-2.5)0.3 (0.1-1.4)1.2 (0.5-3.4)1.3 (0.5-3.6)--Figure 1.

Flowchart of patients included.

Conclusion

The risk of incident cancer in patients with rheumatic diseases and a prior malignancy does not differ according to the type of bDMARD and tsDMARD exposure.

Disclosure of Interests

None declared

POS1416 THE IMPACT OF NON-PERSISTENCE ON RESOURCE UTILIZATION COSTS IN IMMUNE-MEDIATED RHEUMATIC DISEASES

Background:

Rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS) are chronic progressive immune-mediated rheumatic diseases (IMRD) that can cause a progressive disability and joint deformation and thus can impact in healthcare resource utilization (HCRU) and costs.

Objectives:

To describe the HCRU and treatment costs in IMRD patients initiating subcutaneous tumour necrosis factor-alpha inhibitors (SC-TNFi) therapy, based on treatment persistence.

Methods:

Retrospective cohort study including all naïve patients initiating SC-TNFi therapy for IMRD from 2015-2018 in a tertiary university hospital.

Patients were divided into two cohorts: persistent and non-persistent. Treatment persistence was estimated as the duration of time from SC-TNFi therapy initiation to discontinuation during one year of follow-up.

SC-TNFi therapy and HCRU costs (outpatient care, rheumatology specialized outpatient care, inpatient care, emergency care, laboratory testing and other non- biological therapies) were calculated one year before and after initiation of SC-TNFi and compared between persistence and non-persistence groups.

Results:

110 patients were identified.

Baseline characteristics: Non-persistent cohort (n=25) versus Persistent cohort (n=85): median age 48.6(12.7) vs 47.3(15.4) (p=0.692). Female (n=12;48%) vs (n=49;57.6%) (p=0.493). Race: Caucasian (n=22;88%), Asiatic (n=3;12%), Other (n=0;0%) vs Caucasian (n=75;88.2%), Asiatic (n=5;5.9%), Other (n=5;5.9%) (p=0.351).IMRD: RA (n=14;56%),PsA (n=2;8%), AS (n=4;16%), other spondyloarthropathy (n=5;20%) vs RA (n=34;40%),PsA (n=11;12.9%), AS (n=24;28.3%), other spondyloarthropathy (n=16;18.8%) (p=0.470). SC-TNFi therapy: adalimumab (n=4;16%), etanercept commercial (n=4;16%), etanercept biosimilar1 (n=5;20%), etanercept biosimilar2 (n=5;20%), golimumab (n=5;20%), certolizumab (n=2;8%) vs adalimumab (n=22;25.9%), etanercept commercial (n=11;12.9%), etanercept biosimilar1 (n=7;8.3%), etanercept biosimilar2 (n=10;11.8%), golimumab (n=24;28.2%), certolizumab (n=11;12.9%) (p=0.398).

Overall cost of SC-TNFi treatment: Non-persistent 11218.81€ (6444.32), persistent 10470.19€ (3465.48); p= 0.658.

Table 1.

HCRU costs

Non-persistent(n=25)Persistent(n=85)Total(n=110)PHCRU costs 12 months prior to SC-TNFi initiation,€(SD)Outpatient care243.48(828.86)87.17(293.61)122.70(471.20)0.204Rheumatology outpatient care216.39(169.88)174.79(101.06)184.24(120.55)0.224Inpatient care500.41(1542.93)170.34(846.47)245.36(1046.74)0.571Emergency care37.77(66.00)39.30(83.16)38.95(79.31) 0.850Laboratory testing376.12(195.59)388.20(207.07)385.46(203.70)0.458Other non-biological therapies10.77(39.83)36.79(250.55)30.88(221.01) 0.803Total1384.94(1816.17)896.60(1247.60)1007.59(1402.87)0.299HCRU costs 12 months post SC-TNFi initiation,€(SD)Outpatient care106.11 (172.85)76.67 (112.90)83.36 (128.67) 0.682Rheumatology outpatient care327.29(170.10)195.58(100.05)225.52(130.99)<0.001Inpatient care89.35(446.77)80.86(466.54)82.79(460.11) 0.969Emergency care89.14(171.89)36.06(106.23)48.12(125.31) 0.198Laboratory testing182.14(128.62)146.86(141.48)154.88(138.89) 0.061Other non-biological therapies3859.80(4043.86)25.89(116.05)897.24(2493.21)<0.001Total4653.84(4269.61)561.93(682.14)1491.91(2709.23)<0.001

Conclusion:

- Non-persistence was observed in less than a quarter of the patients.

- No differences in the costs of SC-TNFi treatment were observed between the persistent and non-persistent groups, leading us to believe that persistence may not be associated with SC-TNFi costs offsets for patients with IMRD.

- During the period post SC-TNFi initiation, the costs of rheumatologic outpatient care and treatment with other non-biological therapies as well as total costs were statistically significantly lower in the persistent cohort. These results suggest that persistence may be associated with HCRU cost savings for IMRD patients.

Disclosure of Interests:

None declared

AB0264 1-YEAR RESULTS OF A NON-INVASIVE AURICULAR VAGUS NERVE STIMULATION DEVICE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Despite the clinical benefits of current pharmacological treatments for rheumatoid arthritis (RA), there remains an unmet need for alternative treatment approaches. Initial results of a 12-week proof-of-concept study of non-invasive, vagus nerve stimulation (VNS) of the auricular branch of the vagus nerve from a wearable device to treat RA showed the device to be well-tolerated with significant reductions in the DAS28-CRP and RA disease severity1.

Objectives:

This analysis presents data from the 9-month extension of the original proof-of-concept study.

Methods:

Following the completion of the 12-week proof-of-concept study, responding patients (defined as achieving a reduction in DAS28-CRP of ≥1.2 from baseline and/or achievement of ACR20) were given the option to enroll in a 9-month extension study. Use of the wearable device continued daily for up to 30 minutes as in the first 12 weeks of the study. Alteration of baseline medication and addition of conventional synthetic disease-modifying antirheumatic drugs (DMARDs) and biologic DMARDs were allowed during the extension phase.

Results:

20/27 patients who completed the initial 12-week study met the enrollment criteria for the extension phase; 19 of those patients consented to participate. 4/19 patients (21%) discontinued the extension study due to lack of efficacy (1 patient after 1 month, 2 patients after 3 months, and 1 patient after 6 months in the extension); 15 patients completed the extension phase. 2/15 patients (13%) added biologic therapy to their treatment regimen. Mean DAS28-CRP reduction from baseline to the end of the extension (12 months total) in all patients completing the extension was 2.23 (95% CI: -1.60, -2.86). For patients who did and did not add biologic therapy, mean DAS28-CRP reduction was 2.98 and 2.11, respectively. Individual DAS28-CRP reductions are shown in the figure 1. Mean HAQ-DI reduction from baseline to the end of the extension in all patients was 0.70. 2 non-device related adverse events were reported in the study extension: one related to cornea transplant and one related to dysesthesia. No serious adverse events were reported during the study extension phase.

Conclusion:

Benefits from the use of the wearable device were maintained over longer periods of time from the initial 12-week proof-of-concept study, with few safety concerns as no additional side effects were observed.

References:

[1]Marsal S et al. Non-invasive Vagus Nerve Stimulation Improves Signs and Symptoms of Rheumatoid Arthritis: Results of a Pilot Study [in press]. The Lancet Rheumatol, 2021

Disclosure of Interests:

Sara Marsal Speakers bureau: BMS, Pfizer, UCB, Celgene, Roche, Sanofi, Consultant of: Pfizer, Abbvie, Roche, Celgene, Galapagos, MSD, UCB, BMS, Sanofi, Grant/research support from: Pfizer, Abbvie, Roche, Celgene, MSD, UCB, BMS, Novartis, Janssen, Sanofi, Héctor Corominas: None declared, Juan Jose de Agustin: None declared, Carolina Perez-Garcia: None declared, Maria Lopez Lasanta: None declared, Helena Borrell Paños: None declared, D Reina-Sanz: None declared, Raimón Sanmartí: None declared, J. Narváez: None declared, Clara Franco-Jarava: None declared, Charles Peterfy Speakers bureau: Novartis, Bristol Myers Squibb, Amgen, Consultant of: Multiple companies on behalf of Spire Sciences Inc., Jose Antonio Narvaez: None declared, Vivek Sharma Shareholder of: Nēsos Corp, Employee of: Nēsos Corp, Konstantinos Alataris Shareholder of: Nēsos Corp, Employee of: Nēsos Corp, Mark C. Genovese Shareholder of: Gilead Sciences, Nēsos Corp, Employee of: Gilead Sciences, Matthew Baker Shareholder of: Nēsos Corp, Consultant of: Nēsos Corp

Accuracy of 18F-FDG PET/CT in patients with the suspicion of cardiac implantable electronic device infections: good for pocket, not so good for endocarditis

Introduction

The usefulness of 18F-FDG PET/CT in the diagnosis of infective endocarditis (IE) associated with cardiac implantable electronic devices (CIED) is not well established.

Purpose

To assess the diagnostic yield of 18F-FDG PET/CT in patients with suspected CIED infections, placing special emphasis on differentiating between pocket infection (PI) and CIED-IE.

Methods

From 2013 to 2018, all patients (n=63) admitted to a tertiary care hospital with suspected CIED infection were prospectively recruited, undergoing a thorough diagnostic work-up that included blood cultures extraction, transthoracic (TTE) and transoesophageal echocardiography (TEE) and a PET/CT. When device explantation was required, material from the pocket, generator and leads were also cultured. The gold standard for the diagnosis of CIED-IE was a positive lead culture in the absence of PI when percutaneous extraction was performed or a positive culture from a surgically removed lead. In spite of negative lead cultures, the presence of typical TEE images of vegetations in a clinical context of positive blood cultures was also considered as CIED-IE.

Results

After the whole diagnostic process, 14 (22.2%) cases corresponded to isolated PI and 13 (20.6%) were categorized as CIED-IE. Considering radionuclide uptake in the intracardiac portion of the lead, values of sensitivity, specificity and global diagnostic accuracy of PET/CT for CIED-IE were 38.5%, 98.0% and 85.7%, respectively. Positive and negative likelihood ratio values, 19.2 and 0.6 respectively, suggest that a positive PET/CT is much more probable to correspond to a patient with CIED-IE, whereas it is not possible to exclude this diagnosis in case of a negative result. In the case of PI, fair sensitivity (72.2%) and good specificity values (95.6%) were obtained. Extracardiac lead SUVmax and SUVratio in PI were good, with an area under the ROC curve (AUC) of 0.870 and 0.879, respectively. However, semiquantitative analysis was not useful for the diagnosis of CIED-IE.

Conclusions

In patients with suspected CIED infection, the yield of 18F-FDG PET/CT differs depending on the site of infection, showing a very high specificity but poor sensitivity in CIED-IE; so negative studies must be interpreted with caution if the suspicion of CIED-IE is high.

ROC curves SUVmax and SUV ratio for PI

Funding Acknowledgement

Type of funding source: None

SAT0133 PILOT CLINICAL STUDY OF A NON-INVASIVE AURICULAR VAGUS NERVE STIMULATION DEVICE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Despite the clinical benefit of current pharmacological treatments for rheumatoid arthritis (RA), there remains an unmet need for alternative treatment approaches. Vagus nerve stimulation (VNS) via an implanted device has been shown to attenuate RA disease severity in patients resistant to therapy,1as evidenced by a reduction in the DAS28-CRP score following a month of daily stimulation.

Objectives:

This pilot study investigated the safety and efficacy of a wearable (non-invasive) device that attaches to the outer ear to treat RA via electrical stimulation of the auricular branch of the vagus nerve.

Methods:

Patients with active RA (≥4 tender/swollen joints based on a 28-joint count, Disease Activity Score-28 with C-reactive protein (DAS28-CRP) >3.8, active synovitis detected on ultrasound and MRI) and inadequate response to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), or csDMARD and biologic DMARDs (bDMARDs), were enrolled in this open-label study. Patients used the device for up to 30 minutes daily over the course of the 12-week study. The primary endpoint was the change in DAS28-CRP score at Week 12. Secondary endpoints included a safety analysis, proportion of patients achieving ACR20/50/70, the mean change in HAQ-DI and the proportion of patients achieving a HAQ-DI MCID of at least 0.22 over 12 weeks. Additionally, sleep scores were assessed using a visual analogue scale (0-100) at baseline and 12 weeks.

Results:

Thirty patients with active RA were enrolled, of which 27 patients completed the 12-week protocol. Three patients dropped out of the study: two patients decided to seek other treatment and one patient moved out of the country. Data for three additional patients was not included in this dataset as it was still being collected. Of the 24 patients with complete 12-week datasets, 88% were female, the average age was 54.9 years, mean disease duration was 7.3 years, and four patients had an inadequate response to one or two bDMARDs.

The mean change in DAS28-CRP from baseline to Week 12 was -1.43 (p<0.05; Figure 1) and ACR20/50/70 response rates were 58.3%, 37.5%, and 16.7%, respectively (Figure 2). HAQ-DI change from baseline was -0.50 (p<0.05) at 12 weeks, and 15 out of 24 patients achieved an overall HAQ-DI reduction of 0.22 (62.5%). VAS sleep scores were significantly improved over the 12-week study. Scores for trouble falling asleep, awakened by pain at night, and awakened by pain in morning decreased by 64%, 70%, and 60%, respectively (p<0.05, n = 23). Three study adverse events (AEs) were reported: two device related AEs due skin irritation at the earpiece insertion site and one AE due to mucous accumulation in the throat.

Figure 1Figure 2

Average DAS28-CRP is shown for each study visit. Error bars indicate standard error of mean. Percentage of subjects meeting ACR20/50/70 at 12 weeks.

Conclusion:

In this pilot study, auricular stimulation was well tolerated and daily use over 12 weeks attenuated RA disease severity. Further evaluation in larger controlled studies are needed to confirm whether a non-invasive wearable device might offer an alternative approach for the treatment of RA.

References:

[1]Koopman FA, et al. (2016) Vagus nerve stimulation inhibits cytokine production and attenuates disease severity in rheumatoid arthritis. Proc Nat Acad Sci 2016; 113: 8284–9.

Disclosure of Interests:

Sara Marsal: None declared, Héctor Corominas Speakers bureau: Abbvie, Lilly, Pfizer, Roche, Maria Lopez Lasanta: None declared, D Reina-Sanz: None declared, Carolina Perez-Garcia: None declared, Helena Borrell Paños Speakers bureau: Lilly, Novartis, MSD and Janssen, Raimón Sanmartí Speakers bureau: Abbvie, Eli Lilly, BMS, Roche and Pfizer, J. Narváez: None declared, Clara Franco-Jarava: None declared, Jose Antonio Narvaez: None declared, Juan Jose de Agustin: None declared, Vivek Sharma Shareholder of: Vorso Corp., Konstantinos Alataris Shareholder of: Vorso Corp., Mark C. Genovese Grant/research support from: Abbvie, Eli Lilly and Company, EMD Merck Serono, Galapagos, Genentech/Roche, Gilead Sciences, Inc., GSK, Novartis, Pfizer Inc., RPharm, Sanofi Genzyme, Consultant of: Abbvie, Eli Lilly and Company, EMD Merck Serono, Genentech/Roche, Gilead Sciences, Inc., GSK, Novartis, RPharm, Sanofi Genzyme, Matthew Baker Consultant of: Gilead, Vorso, Paid instructor for: Gilead

FRI0330 BODY MASS INDEX AND DISEASE ACTIVITY IN CHRONIC INFLAMMATORY RHEUMATIC DISEASES: RESULTS OF THE CARDIOVASCULAR IN RHEUMATOLOGY (CARMA) PROJECT

Objectives:

Since obesity has been associated with higher inflammatory burden and worse response to therapy in patients with chronic inflammatory joint diseases (CIJDs), we aimed to confirm the potential association between body mass index (BMI) and disease activity in a large series of patients with CIJDs included in the Spanish CARdiovascular in rheuMAtology (CARMA) registry.

Methods:

Baseline data assessment of patients included from the CARMA project, a 10-year prospective study of patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA) attending outpatient rheumatology clinics from 67 Spanish hospitals. Obesity was defined when BMI (kg/m2) was>30 according to the WHO criteria. Scores used to evaluate disease activity were DAS28 in RA, BASDAI in AS, and modified DAS for PsA.

Results:

Data from 2,234 patients (775 RA, 738 AS and 721 PsA) were assessed. The mean±SD BMI at the baseline visit were: 26.9±4.8 in RA, 27.4±4.4 in AS and 28.2±4.7 in PsA. Multivariate analyses shown a positive association between BMI and disease activity in patients with RA (β-coefficient: 0.029; 95% CI: 0.01-0.05; p=0.007) and in those with PsA (β-coefficient: 0.036; 95% CI: 0.015-0.058; p=0.001). By contrast, there was no significant association between BMI and disease activity in patients with AS (β-coefficient: 0.001; 95% CI: -0.026-0.03; p=0.926).

In patients with RA, female gender (β-coefficient: 0.546; 95% CI: 0.316-0.775; p<0.001) and rheumatoid factor status (seropositivity for RF) (β-coefficient: 0.328; 95% CI: 0.106-0.549; p=0.004) also showed a positive association with disease activity, while physical activity revealed a negative association with disease activity (β-coefficient: -0.280; 95% CI: -0.479-(- 0.081); p=0.006).

Besides BMI, female gender (β-coefficient: 0.720; 95% CI: 0.524-0.916; p<0.001), Psoriasis Area Severity Index (β-coefficient: 0.038; 95% CI: 0.012-0.066; p=0.005) and enthesitis (β-coefficient: 0.256; 95% CI: 0.199-0.313; p<0.001) were also positively associated with disease activity in PsA.

As observed in RA and PsA, female gender was also associated with disease activity patients with AS (β-coefficient: 0.565; 95% CI: 0.299-0.832; p<0.001).

Conclusion:

BMI is associated with disease activity in RA and PsA but not in AS. Since obesity is a potentially modifiable factor, disease activity was associated with female gender and RF status in RA and with Psoriasis Area Severity Index and enthesitis in PsA. Adequate control over body weight may improve the outcome of patients with CIJDs and, therefore, weight control should be included in the strategy of management of these patients.

Disclosure of Interests:

Ruth López-González: None declared, Jesús Alejandro Valero Jaimes: None declared, Maria Auxiliadora Martin-Martinez: None declared, Santos Castañeda: None declared, Carmen García Gomez: None declared, Fernando Sánchez-Alonso: None declared, Carlos Gonzalez Juanatey: None declared, Eva Revuelta-Evrad: None declared, Carolina Perez-Garcia: None declared, Vicenç Torrente Segarra: None declared, Trinidad Pérez Sandoval: None declared, Javier Llorca: None declared, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD

OP0276 CLINICAL PATTERNS AND FOLLOW-UP OF INFLAMMATORY ARTHRITIS AND OTHER IMMUNE-RELATED ADVERSE EVENTS INDUCED BY CHECKPOINT INHIBITORS. A MULTICENTER STUDY

Background:

Immune checkpoint inhibitors (ICI), such as anti-CTLA-4and anti-PD1/PD-L1 monoclonal antibodies, have produced impressive clinical results in different types of cancer. However, immune-related adverse events (irAEs) may develop a wide spectrum of disabling syndromes. Knowledge of different rheumatic irAEs induced by ICI is increasing over the last years, however clinical patterns, time to onset of different irAEs according to treatment and follow-up are less well known.

Objectives:

To describe different clinical patterns of rheumatic irAEs induced by ICI and their rheumatic and oncologic outcomes.

Methods:

We included consecutive patients with rheumatic irAEs from 3 different referral centers in Barcelona with special emphasis in articular irAEs. Four main clinical syndromes were identified: inflammatory arthritis (IA), non-inflammatory arthralgias (NIA), psoriatic arthritis (PsA)-like and polymialgia (PMR)-like. We conducted a baseline visit and then follow-up in order to determine their clinical pattern, treatment response and outcome. Longitudinal visits were done from January 2017 to January 2020. Patients with other non–articular diagnosis were not included in the follow-up analysis.

Results:

We included 55 patients. A total of 34 patients were male (61.8%) with a mean age of 65.0 ± 11.4 years. Oncologic underlying diagnosis was lung carcinoma in 24 (43.6%) patients, followed by melanoma in 17 (29%), urothelial cancer in 4 (7.3%), breast in 2 (3.6%) and 2 (3.6%) acute myeloid leukemia among others. Seven (12.7%) patients received ICI as combined therapy. Different ICI were used including: Pembrolizumab in 21 (38.2%), Nivolumab 13 (23.6 %), Atezolizumab 6 (10.9%), Nivolumab + ipilimumab 5 (9.0%), Durvalumab 3 (5.5%), Pembrolizumab + epacadostat in 2 (3.6%), 2 anti TIM3, Atezolizumab+ Ibatasertib, Avelumab and Ipilimumab in one case each. 12 out of 55 patients had an underlying rheumatic disease before ICI treatment. Eleven patients developed other irAEs before or at the same time as rheumatic syndromes (mainly colitis and thyroiditis). Main rheumatic irAE included: IA in 23 (41.8%), NIA in 16 (29.1%), PsA-like in 6 (10.9%), PMR-like in 5 (9.1%) among others. Time from ICI to irAEs was 8.3 ± 8.4 months(mo). irAE presented earlier in patients with combined ICI therapy than in patients with monotherapy (6.5 ± 4.0 vs 8.6 ± 8.9 mo, p=NS, Figure 1A). Time (in mo) from ICI initiation to irAE onset was different according to treatments. For Nivolumab 10.0 ± 10.6, Anti TIM3 10.0 ± 1.4, Durvalumab 9.0 ± 2.0, Ipilimumab 7.98 ± 9.21, Pembrolizumab 7.28 ± 7.53, Avelumab 6.0 and Atezolizumab 4.4 ± 5.38 mo (Figure 1B). Time from ICI initiation and onset also differs among rheumatic irAEs (Figure 2). Mean time follow-up was 13.4 ± 10.9 mo. At the last visit, 45% were under GC, mean dose of 3.6 mg/d (range 0-40). DMARD were needed in 15% of patients (6 patients MTX, 1 with LEF and 1 SFZ). At the last visit, 11 (22.9%) patients remain with persistent arthritis, 25% intermittent flares and 52% had a self-limited pattern. Regarding oncologic outcome, 30.2% were on remission, 30.2% in partial response and 39.6% with tumor progression. Eleven (20%) of patients died.

Conclusion:

We described different clinical patterns according treatment and irAEs. Combined ICI therapy and patients treated with Atezolizumab had earlier onset of symptoms. Vasculitis and PMR-like syndromes appear in earlier phases. After a mean follow-up of around 1 year, one-quarter of the patients remain with persistent arthritis and 15% require DMARD therapy.

Disclosure of Interests:

Jose A. Gómez-Puerta Speakers bureau: Abbvie, BMS, GSK, Lilly, Pfizer, Roche, Carolina Perez-Garcia: None declared, David Lobo Prat: None declared, Roberto Gumucio: None declared, Fabiola Ojeda: None declared, Ana Milena Millán Arciniegas: None declared, Sebastian Rodriguez Garcia: None declared, Virginia Ruiz Speakers bureau: Lilly, Pfizer, Héctor Corominas Speakers bureau: Abbvie, Lilly, Pfizer, Roche

FRI0111 TOCILIZUMAB MAY INDUCE SECONDARY HYPOGAMMAGLOBULINAEMIA. A RETROSPECTIVE CASE SERIES OF 42 PATIENTS

Background:

Tocilizumab (TCZ) is a recombinant humanized, anti-human monoclonal antibody of the immunoglobulin G1ksubclass directed against soluble and membrane-bound interleukin 6 receptors (IL-6R) [1].

Interleukin-6 (IL-6) has a pleiotropic effect on inflammation, immune response, and hematopoiesis. When it was first identified, it was named as B-cell-stimulating factor 2 (BSF-2) according to its ability to induce immunoglobulin production in Epstein-Barr virus-transformed B-cell lines or in Staphylococcus aureus Cowan 1-stimulated B cells [2-4].

Nowadays, it is known that IL-6 controls the survival, population expansion and maturation of B cells and plasmablasts. In that way, the regulation of Blimp-1 by STAT3 is linked to antibody secretion and is associated with long-lived plasma cells that produce large amounts of immunoglobulin. Furthermore, the ability of IL-6 to promote humoral immunity has been linked to its effects on follicular helper T cells where they promote B cell proliferation and immunoglobulin class switching [5].

Objectives:

Hypogammaglobulinaemia is a known complication of some immunosuppressive drugs, not previously described in patients who received therapy with monoclonal antibody against the IL-6R. We aimed to analyzed the prevalence of hypogammaglobulinaemia in our series of patients treated with tocilizumab after a carefully diagnostic workup which ruled out other causes and analyzed whether is associated with a higher risk of infection.

Methods:

We conducted a retrospective review from 2010 to 2019 of forty-two patients affected with a rheumatic disease and treated with TCZ at our centre. In those patients in whom we had no record of immunoglobulin levels, we determined them in the blood analysis performed by usual clinical practice.

Results:

42 patients were identified, from whom 38 had rheumatoid arthritis. A 31% had immunoglobulin levels prior to starting treatment with TCZ but no one had hypogammaglobulinaemia. 2 patients were excluded due to their underlying disease could justify the IgG level abnormalities. During the treatment’s follow-up, we identified that a 30% of the patients (12/40) had hypogammaglobulinaemia. Of those patients in whom immunoglobulin levels had been determined prior to starting treatment with TCZ, a 36.3% of them (4/11) developed hypogammaglobulinaemia during the follow-up. From the series, we observed a statistical significance tendency (p=0.0057) for infection risk in those patients with hypogammaglobulinaemia in contrast to those with normal IgG level (41.5% vs 14.3%, respectively).

Conclusion:

Secondary hypogammaglobulinaemia may occurs in patients receiving anti-IL6 agents such as tocilizumab and this could be associated with an increasing infection risk. The prevalence is not precisely known, in part because measurement of IgG prior to or during the treatment has not been a standard of care. No medical data have been previously disclosed about this possible adverse effect of anti-interleukin-6 agents. Nevertheless, ideally randomized trials are needed to assess this initial hypothesis.

References:

[1]Sheppard M, Laskou F, Stapleton PP, Hadavi S, Dasgupta B. Tocilizumab (Actemra). Hum Vaccin Immunother. 2017;13(9):1972–1988.

[2]Tanaka T, Kishimoto T. The biology and medical implications of interleukin-6. Cancer Immunol Res. 2014;2(4):288–294.

[3]Tanaka T, Narazaki M, Kishimoto T. IL-6 in inflammation, immunity, and disease. Cold Spring Harb Perspect Biol. 2014;6(10):a016295. Published 2014 Sep 4.

[4]Kishimoto T. Interleukin-6: discovery of a pleiotropic cytokine. Arthritis Res Ther. 2006;8 Suppl 2(Suppl 2):S2.

[5]Hunter CA, Jones SA. IL-6 as a keystone cytokine in health and disease [published correction appears in Nat Immunol. 2017 Oct 18;18(11):1271]. Nat Immunol. 2015;16(5):448–457.

Disclosure of Interests:

Francisco Vílchez-Oya: None declared, Ana Pros: None declared, Irene Carrión Barberà Grant/research support from: I received a grant from the Spanish Rheumatology Foundation (FER) and laboratories KERN PHARMA for a brief stay abroad., Juan Antonio Meraz Ostiz: None declared, Tarek Carlos Salman Monte: None declared, Carolina Perez-Garcia: None declared

Effect of oral yohimbine on withdrawal jumping behaviour of morphine-dependent mice

Acute administration of the alpha-2 adrenoceptor agonist clonidine and chronic administration of the alpha2 antagonist yohimbine both inhibit opioid withdrawal signs in experimental models of dependence and also in clinical studies with opiate abusers. There are exceptions to this general rule: restlessness or self-reported abstinence in humans and withdrawal-induced escape behaviour in rodents are resistant to inhibition by acute clonidine. We have explored the effect of the alpha-2 antagonist yohimbine on morphine withdrawal-induced escape behaviour in a mouse model that we have proposed to differentiate between the urge to escape (number of jumps) and non-specific sedative/motor actions (height of jumps). Morphine dependence was induced by s.c. administration of a sustained-release preparation (1 g/kg). Naloxone (1 mg/kg) was injected to precipitate withdrawal jumping 72 hours after morphine injection. Co-treatment with yohimbine dissolved in the tap water (70 mg/l) decreased the number of jumps upon naloxone challenge, an effect which did not seem to be related with a sedative or toxic effect of the drug. This result confirms previous data and suggests that yohimbine could prevent the development of opioid dependence being active to decrease withdrawal-induced escape behaviour. The mechanisms of this action are discussed.