Impact on patient outcomes of spondyloarthritis-inflammatory bowel disease multi-disciplinary meetings

OBJECTIVES

To assess the impact on patient outcomes of the spondyloarthritis (SpA) and inflammatory bowel disease (IBD) multidisciplinary team (MDT) meetings in a large university hospital.

METHODS

A single-centre retrospective observational case-note review was conducted assessing the outcome of all 226 cases discussed at the SpA-IBD MDT meetings in a large UK university hospital between 2017-2022.

RESULTS

A total of 226 patients were discussed. It was deemed that 97% of MDT meetings helped to improve communication between teams, and 100% were educational. A total of 57% of discussions led to an instant change of disease management, while 40% of discussions resulted in a treatment plan that avoided the use of dual advanced therapy. This improved patient safety by reducing immunosuppression. The MDT meetings were highly cost and time efficient; 125 referrals between specialists were avoided, and in 51 cases there was a significant chance of reducing future drug costs. A timely investigation or appointment was arranged following 50% of MDT discussions, helping to clarify the diagnosis and optimise patient care. 9% of meetings enabled drugs to be prescribed to patients that are not yet licenced for the other speciality, thereby improving treatment options available in the management of complex cases.

CONCLUSION

The MDT meetings have been beneficial for patients, the clinical team and the institution. This approach might be considered by other rheumatology and gastroenterology departments.

Proceedings of the Collaborative Research Network Meeting at the GRAPPA 2022 Annual Meeting

At the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) 2022 annual meeting, the Collaborative Research Network (CRN) met to present updates on several projects. These included the GRAPPA-Industry biomarker projects, Axial Psoriatic Arthritis Molecular and Clinical Characterisation Study, Axial Involvement in Psoriatic Arthritis Cohort (AXIS) study, and the Health Initiatives in Psoriasis and Psoriatic Arthritis Consortium European States (HIPPOCRATES). The meeting concluded with a discussion on pathways to further academia-industry collaboration.

The PROPER Study: A 48-Week, Pan-European, Real-World Study of Biosimilar SB5 Following Transition from Reference Adalimumab in Patients with Immune-Mediated Inflammatory Disease

BACKGROUND

The non-interventional PROPER study generated real-world evidence on clinical outcomes following transition in routine practice from reference adalimumab to the EMA-approved SB5 biosimilar adalimumab in patients with immune-mediated inflammatory disease.

METHODS

Adults with rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), Crohn's disease (CD), or ulcerative colitis (UC) were enrolled at 63 sites across Europe. Eligible patients received ≥ 16 weeks of routine treatment with reference adalimumab before transitioning to SB5, and were followed for 48 weeks post-transition. The primary objective was to evaluate candidate predictors (clinically relevant baseline variables with incidence ≥ 15% by indication cohort) associated with persistence on SB5 at 48 weeks post-initiation. Key primary outcome measures were persistence on SB5 (estimated by Kaplan-Meier methodology) and clinical characteristics and disease activity scores at the time of transition to SB5 treatment (baseline).

RESULTS

A total of 955 eligible patients were enrolled (RA, n = 207; axSpA, n = 127; PsA, n = 162; CD, n = 447; UC, n = 12), of whom 932 (97.6%) completed follow-up and 722 (75.6%) were still receiving SB5 at week 48. Kaplan-Meier estimates (95% confidence interval, CI) of persistence on SB5 at week 48 for RA, axSpA, PsA, and CD were 0.86 (0.80-0.90), 0.80 (0.71-0.86), 0.81 (0.74-0.86), and 0.72 (0.67-0.76), respectively. The single candidate predictor associated with probability of SB5 discontinuation before week 48 was female sex [RA, axSpA, and CD cohorts; HR (95% CI): 3.53 (1.07-11.67), 2.38 (1.11-5.14), and 2.21 (1.54-3.18), respectively]. Disease activity scores remained largely unchanged throughout the study, with proportions by cohort in remission at baseline versus week 48 being 59.2% versus 57.2%, 81.0% versus 78.0%, 94.7% versus 93.7%, and 84.0% versus 85.1% for patients with RA, axSpA, PsA, and CD, respectively. Similarly, the SB5 dosing regimen remained unchanged for the majority of patients from baseline to week 48, the most common regimen being 40 mg every 2 weeks. In total, 232 patients (24.3%) reported at least one adverse drug reaction, and most events were mild; eight patients (3.9%) in the RA cohort experienced nine serious adverse events (SAEs; two possibly related to SB5); eight patients (4.9%) in the PsA cohort experienced nine SAEs (one possibly related to SB5); 22 patients (4.9%) in the CD cohort experienced 27 SAEs (four possibly related to SB5); and no SAEs were observed in the UC cohort.

CONCLUSIONS

With the exception of female sex in RA, axSpA, and CD, none of the candidate predictors were associated with SB5 discontinuation. Persistence on SB5 was high, treatment effectiveness was maintained, and no safety signals were detected.

TRIAL REGISTRATION

This trial is registered with ClinicalTrials.gov: NCT04089514.

Proceedings of the GRAPPA 2022 Executive Retreat

The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) leadership congregated for a strategic planning meeting before the 2022 GRAPPA annual meeting in New York, USA. Meeting aims were to review GRAPPA's performance in relation to its 2016 goals and identify successes and areas for further improvement, identify key GRAPPA priorities and activities for the next 5 years, and explore committee structures to best support these aims.

Stratification of biological therapies by pathobiology in biologic-naive patients with rheumatoid arthritis (STRAP and STRAP-EU): two parallel, open-label, biopsy-driven, randomised trials

BACKGROUND

Despite highly effective targeted therapies for rheumatoid arthritis, about 40% of patients respond poorly, and predictive biomarkers for treatment choices are lacking. We did a biopsy-driven trial to compare the response to rituximab, etanercept, and tocilizumab in biologic-naive patients with rheumatoid arthritis stratified for synovial B cell status.

METHODS

STRAP and STRAP-EU were two parallel, open-label, biopsy-driven, stratified, randomised, phase 3 trials done across 26 university centres in the UK and Europe. Biologic-naive patients aged 18 years or older with rheumatoid arthritis based on American College of Rheumatology (ACR)-European League Against Rheumatism classification criteria and an inadequate response to conventional synthetic disease-modifying antirheumatic drugs (DMARDs) were included. Following ultrasound-guided synovial biopsy, patients were classified as B cell poor or B cell rich according to synovial B cell signatures and randomly assigned (1:1:1) to intravenous rituximab (1000 mg at week 0 and week 2), subcutaneous tocilizumab (162 mg per week), or subcutaneous etanercept (50 mg per week). The primary outcome was the 16-week ACR20 response in the B cell-poor, intention-to-treat population (defined as all randomly assigned patients), with data pooled from the two trials, comparing etanercept and tocilizumab (grouped) versus rituximab. Safety was assessed in all patients who received at least one dose of study drug. These trials are registered with the EU Clinical Trials Register, 2014-003529-16 (STRAP) and 2017-004079-30 (STRAP-EU).

FINDINGS

Between June 8, 2015, and July 4, 2019, 226 patients were randomly assigned to etanercept (n=73), tocilizumab (n=74), and rituximab (n=79). Three patients (one in each group) were excluded after randomisation because they received parenteral steroids in the 4 weeks before recruitment. 168 (75%) of 223 patients in the intention-to-treat population were women and 170 (76%) were White. In the B cell-poor population, ACR20 response at 16 weeks (primary endpoint) showed no significant differences between etanercept and tocilizumab grouped together and rituximab (46 [60%] of 77 patients vs 26 [59%] of 44; odds ratio 1·02 [95% CI 0·47-2·17], p=0·97). No differences were observed for adverse events, including serious adverse events, which occurred in six (6%) of 102 patients in the rituximab group, nine (6%) of 108 patients in the etanercept group, and three (4%) of 73 patients in the tocilizumab group (p=0·53).

INTERPRETATION

In this biologic-naive population of patients with rheumatoid arthrtitis, the dichotomic classification into synovial B cell poor versus rich did not predict treatment response to B cell depletion with rituximab compared with alternative treatment strategies. However, the lack of response to rituximab in patients with a pauci-immune pathotype and the higher risk of structural damage progression in B cell-rich patients treated with rituximab warrant further investigations into the ability of synovial tissue analyses to inform disease pathogenesis and treatment response.

FUNDING

UK Medical Research Council and Versus Arthritis.

GWAS meta-analysis of psoriasis identifies new susceptibility alleles impacting disease mechanisms and therapeutic targets

Psoriasis is a common, debilitating immune-mediated skin disease. Genetic studies have identified biological mechanisms of psoriasis risk, including those targeted by effective therapies. However, the genetic liability to psoriasis is not fully explained by variation at robustly identified risk loci. To move towards a saturation map of psoriasis susceptibility we meta-analysed 18 GWAS comprising 36,466 cases and 458,078 controls and identified 109 distinct psoriasis susceptibility loci, including 45 that have not been previously reported. These include susceptibility variants at loci in which the therapeutic targets IL17RA and AHR are encoded, and deleterious coding variants supporting potential new drug targets (including in STAP2, CPVL and POU2F3). We conducted a transcriptome-wide association study to identify regulatory effects of psoriasis susceptibility variants and cross-referenced these against single cell expression profiles in psoriasis-affected skin, highlighting roles for the transcriptional regulation of haematopoietic cell development and epigenetic modulation of interferon signalling in psoriasis pathobiology.

Protocol for the Psychosis Immune Mechanism Stratified Medicine (PIMS) trial: a randomised double-blind placebo-controlled trial of single-dose tocilizumab in patients with psychosis

INTRODUCTION

Evidence suggests a potentially causal role of interleukin 6 (IL-6), a pleiotropic cytokine that generally promotes inflammation, in the pathogenesis of psychosis. However, no interventional studies in patients with psychosis, stratified using inflammatory markers, have been conducted to assess the therapeutic potential of targeting IL-6 in psychosis and to elucidate potential mechanism of effect. Tocilizumab is a humanised monoclonal antibody targeting the IL-6 receptor to inhibit IL-6 signalling, licensed in the UK for treatment of rheumatoid arthritis. The primary objective of this study is to test whether IL-6 contributes to the pathogenesis of first episode psychosis and to examine potential mechanisms by which IL-6 affects psychotic symptoms. A secondary objective is to examine characteristics of inflammation-associated psychosis.

METHODS AND ANALYSIS

A proof-of-concept study employing a randomised, parallel-group, double-blind, placebo-controlled design testing the effect of IL-6 inhibition on anhedonia in patients with psychosis. Approximately 60 participants with a diagnosis of schizophrenia and related psychotic disorders (ICD-10 codes F20, F22, F25, F28, F29) with evidence of low-grade inflammation (IL-6≥0.7 pg/mL) will receive either one intravenous infusion of tocilizumab (4.0 mg/kg; max 800 mg) or normal saline. Psychiatric measures and blood samples will be collected at baseline, 7, 14 and 28 days post infusion. Cognitive and neuroimaging data will be collected at baseline and 14 days post infusion. In addition, approximately 30 patients with psychosis without evidence of inflammation (IL-6<0.7 pg/mL) and 30 matched healthy controls will be recruited to complete identical baseline assessments to allow for comparison of the characteristic features of inflammation-associated psychosis.

ETHICS AND DISSEMINATION

The study is sponsored by the University of Bristol and has been approved by the Cambridge East Research Ethics Committee (reference: 22/EE/0010; IRAS project ID: 301682). Study findings will be published in peer-review journals. Findings will also be disseminated by scientific presentation and other means.

TRIAL REGISTRATION NUMBER

ISRCTN23256704.

Horizon scan: State-of-the-art therapeutics for psoriatic arthritis

Psoriatic arthritis (PsA) is a common immune-mediated inflammatory disease (IMID) that can present with a heterogenous clinical phenotype. The advent of advanced therapies has substantially improved patient outcomes, but many patients still have suboptimal or unsustained response, resulting in morbidity, structural damage and functional impairment. There remains a need for better therapeutic options and precision medicine approaches to improve outcomes for patients with PsA. This review synthesises recently approved the state-of-the-art therapeutics for PsA, including inhibitors of IL-23, Janus kinase (JAK), tyrosine kinase 2 (TYK2) and dual-target IL-17A/F. The evidence base for emerging therapeutics, including MK-2 inhibitors, nano-IL-17 inhibitors, nanobodies and other dual-target therapies for PsA is also reviewed. Potential future therapeutic strategies and unmet research needs are discussed.

AB0348 THE PROPER STUDY: A 48-WEEK ANALYSIS OF A PAN-EU REAL-WORLD STUDY OF SB5 BIOSIMILAR FOLLOWING TRANSITION FROM REFERENCE ADALIMUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS, AXIAL SPONDYLOARTHRITIS OR PSORIATIC ARTHRITIS

Background

SB5, a biosimilar to reference adalimumab (ADL), received EU marketing authorisation in 2017, based on pre-clinical and clinical phase I and III studies that demonstrated bioequivalence and comparable efficacy, safety and immunogenicity to ADL.

Objectives

The real-world study ‘PROPER’ is designed to provide insights into outcomes of the transition from ADL to SB5 outside the randomised, controlled, clinical trial setting.

Methods

Under an umbrella design, 1000 patients with immune-mediated inflammatory disease were enrolled at centres in Belgium, Germany, Ireland, Italy, Spain and the UK, and followed for 48 weeks post-transition. Eligible patients with a diagnosis of rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), ulcerative colitis or Crohn’s disease had been transitioned to SB5 as part of routine treatment following a minimum of 16 weeks’ treatment with ADL. Data were captured from patient charts retrospectively for 24 weeks prior to and prospectively and/or retrospectively up to 48 weeks after SB5 initiation. This analysis of the rheumatology cohort reports clinical characteristics, disease scores, persistence on SB5, clinical management and safety up to the closing date of November 30th, 2021.

Results

Of the 496 patients included in this analysis, the majority were enrolled in UK (n=174), Germany (n=145) and Spain (n=73); Italy, Ireland and Belgium enrolled 45, 44 and 15 patients respectively. At study close, 487 patients had completed 48 weeks of follow-up; 397 of those remained on SB5 throughout.

Methotrexate was received as concomitant therapy by 37% of patients and 20% had received a biologic therapy prior to reference ADL. Most patients (89.3% of RA, 92.1% of axSpA, 97.3% of PsA) transitioned to SB5 at the same dose regimen received for ADL.

Clinical characteristics, SB5 dose and flare are detailed in Table 1, disease scores in Figure 1.

Table 1.

Patient clinical characteristics, SB5 dose, flare

RA (N=207)axSpA (N=127)PsA (N=162)Age at SB5 initiation (years), mean (SD); IQR60.1 (11.8)53.0, 68.050.3 (13.4)38.0, 61.053.3 (12.0)45.0, 62.0Duration of disease (years), mean (SD); IQR13.3 (11.4)5.0, 19.518.8 (13.5)9.0, 25.012.2 (9.9)4.0, 19.0n%n%n%Women15072.54031.57345.1Patients receiving SB5 40mg Q2WBaseline15273.411590.614992.0Week 4813272.59387.712491.9Episodes of Flare018790.310784.313985.81209.71814.22012.3200.021.631.9How was Flare diagnosedDisease score1155.0731.81038.5Patient-reported symptoms1995.022100.026100.0Secondary Loss of Response315.000.0726.9Action taken for FlareBiologic therapy dose adjusted420.029.1519.2Non-biologic therapy dose adjusted840.0313.6934.6Clinical investigation00.014.5311.5Other*945.01359.11661.5

*Includes cessation of therapy, prescription of corticosteroids, physical exercise, no action.

IQR, interquartile range; SD, standard deviation; Q2W once two-weekly.

Figure 1.

Disease scores (paired patients), mean (95% CI)

Fifteen patients each experienced one unrelated Serious Adverse Event (SAE): 2 in the axSpA cohort [tachycardia, intracranial haemorrhage]; 6 in the PsA cohort [myocardial infarct (2), breast carcinoma, COVID-19, gallbladder calculus, dyspnoea]; 7 in the RA cohort [facial numbness, depression, COVID-19, pneumonia, diverticulitis, parvovirus, coronary occlusion]. Two patients reported SAEs considered causally related to SB5: Herpes zoster and pneumonia (RA cohort), and ALS with worsening (PsA cohort).

Conclusion

This analysis of a large, contemporary cohort of EU patients with established RA, axSpA or PsA shows treatment effectiveness maintained at 48 weeks after switching from ADL to SB5, with most patients continuing on SB5 Q2W throughout. Episodes of flare were uncommon, and the importance of patient-reported symptoms in recognition of flare is evident. No new safety signals were observed.

Acknowledgements

Statistical services were provided by FGK Clinical Research GmbH, Munich, Germany. Data management services were provided by Worldwide Clinical trial, Research Triangle Park, NC, USA. Funding was provided by Biogen International GmbH.

Disclosure of Interests

Ulf Müller-Ladner Consultant of: Biogen, Grant/research support from: Biogen, Karl Gaffney Speakers bureau: Novartis, UCB, AbbVie, Lilly, Consultant of: Novartis, UCB, AbbVie, Lilly, Pfizer, Grant/research support from: NAAS, AbbVie, Pfizer, UCB, Novartis, Lilly, Cellgene, Celltrion, Janssen, Gilead, Biogen, Deepak Jadon Consultant of: AbbVie, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Oxford University Press, Pfizer, Roche, Sandoz, UCB, Grant/research support from: AbbVie, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Oxford University Press, Pfizer, Roche, Sandoz, UCB, Marco Matucci-Cerinic Consultant of: Chemomab, Biogen, Pfizer, Lilly, Behring, Janssen, MSD, Eugenio Chamizo Carmona Speakers bureau: Abbvie, Amgen, Biogen, BMS, Celgene, Eli Lilly, Fresenius-Kabi, Galapagos, Janssen, MSD, Novartis, Pfizer, and UCB, Consultant of: Abbvie, Amgen, Biogen, BMS, Celgene, Eli Lilly, Fresenius-Kabi, Galapagos, Janssen, MSD, Novartis, Pfizer, and UCB, Ulrich Freudensprung Shareholder of: May hold stock in Biogen, Employee of: Biogen, Janet Addison Shareholder of: May hold stock in Biogen, Employee of: Biogen

POS0965 MAGNETIC RESONANCE ENTEROGRAPHY AS A SCREENING TOOL FOR AXIAL SPONDYLOARTHRITIS IN CROHN’S DISEASE: A PROSPECTIVE SINGLE-CENTER CROSS-SECTIONAL OBSERVATIONAL STUDY USING MRE SCREENING FOLLOWED BY CLINICAL ASSESSMENT (ProSpA-CD)

Background

Patients with inflammatory bowel disease (IBD) have an excess burden of axial spondyloarthritis (axSpA) (1), but currently there are no reliable screening tools available. Magnetic resonance enterography (MRE) is an oral contrast MRI of the small bowel used to aid the diagnosis of Crohn’s disease (CD) (2). MRE also captures the sacroiliac joints (SIJs) but the radiological assessment of this is often overlooked. MRE scans therefore contain potentially valuable unreported data, which could be used to screen for axSpA in CD patients.

Objectives

To determine: (i) the validity, sensitivity, specificity and area under the receiver operating characteristic (ROC) curve (AUC) of MRE as a screening tool for axSpA in CD, using dedicated axial MRI scans with clinical assessment as the gold standard; (ii) the proportion of patients with evidence of axSpA on MRE who fulfill the 2009 Assessment of Spondyloarthritis International Society (ASAS) criteria for axSpA; (iii) whether the presence of extra-intestinal manifestations (EIMs) or CD location can predict the occurrence of axSpA in CD.

Methods

ProSpA-CD was a pair of linked prospective observational studies conducted at a large secondary care university hospital in the UK. In ProSpA-CD-Screen, patients who had undergone MRE between 2015-2019 were assessed for eligibility. The consenting participants‘ MRE images were evaluated by a rheumatologist and a radiologist, using a scoring system for evidence of axSpA. Participants with evidence of axSpA and a control group of participants without evidence of axSpA were invited to participate in ProSpA-CD-Assess, in which the performance of MRE as a screening test was assessed against a gold standard of clinical assessment, serological testing and dedicated MRI of the spine and pelvis of each participant. ROC curve and logistic regression analyses were performed.

Results

A total of 1344 MRE scans were performed between 2015-2019, of which 501 eligible patients were identified. For ProSpA-CD-Screen, 259 participants were recruited. MRE SIJ abnormalities were identified in 94/259 participants and from these, 90 cases were recruited to ProSpA-CD-Assess. For the control group, 71/165 participants with normal SIJs were recruited to ProSpA-CD-Assess (total cases + controls = 161). A clinical diagnosis of axSpA was made in 41/161 (25.47%) participants, of which 25/161 (15.53%) fulfilled ASAS criteria. We constructed a ROC curve to assess test performance using different thresholds on the MRE scoring system. The optimum threshold corresponded to a sensitivity of 0.60 (95%CI 0.39, 0.79) and specificity of 0.85 (95%CI 0.78, 0.91) for MRE as a screening tool for axSpA (ASAS criteria) with an AUC value of 0.78 (95%CI 0.65, 0.86, p<0.05). We did not find a significant association between axSpA and CD location. Multivariable logistic regression demonstrated significant associations between axSpA (ASAS criteria) and inflammatory back pain (OR 11.03; 95%CI 2.53, 48.10; p<0.05), HLA B27 (OR 9.94; 95%CI 1.84, 53.87; p<0.05), history of dactylitis (OR 51.01; 95%CI 1.07, 2423.90; p<0.05) and plantar fasciitis (OR 9.08; 95%CI 1.30, 63.55; p<0.05).

Conclusion

We have shown that MRE as a screening tool for axSpA in a cohort of CD patients has good specificity, but poor sensitivity, suggesting that its use as a screening tool is limited. There was no significant association between axSpA and CD location or CD EIMs.

References

[1]Garber A, Regueiro M. Extraintestinal Manifestations of Inflammatory Bowel Disease: Epidemiology, Etiopathogenesis, and Management. Curr Gastroenterol Rep. 2019;21(7):31.

[2]Rimola J, Ordas I, Rodriguez S, Garcia-Bosch O, Aceituno M, Llach J, et al. Magnetic resonance imaging for evaluation of Crohn’s disease: validation of parameters of severity and quantitative index of activity. Inflamm Bowel Dis. 2011;17(8):1759-68.

Figure 1.

MRE score ROC curve for participants fulfilling ASAS criteria for axial spondyloarthritis.

Acknowledgements

Acknowledgement is given to Dr Beverly Ng, Katherine Hodges and CARE for their contribution to this study.

Disclosure of Interests

Jobie Evans Grant/research support from: Clinical study (ProSpA-CD) funded by Merck, Sharpe and Dohme (MSD), Tim Raine: None declared, Scott McDonald: None declared, Ken Poole: None declared, Richard Samworth: None declared, Philippe Riede: None declared, Elliott Rees: None declared, Simona D’Amore: None declared, Miles Parkes: None declared, Deepak Jadon Grant/research support from: Clinical study (ProSpA-CD) funded by Merck, Sharpe and Dohme (MSD)

Comparative genetic analysis of psoriatic arthritis and psoriasis for the discovery of genetic risk factors and risk prediction modelling

Objectives

Psoriatic arthritis (PsA) has a strong genetic component, and the identification of genetic risk factors could help identify the ~30% of psoriasis patients at high risk of developing PsA. Our objectives were to identify genetic risk factors and pathways that differentiate PsA from cutaneous‐only psoriasis (PsC) and to evaluate the performance of PsA risk prediction models.

Methods

Genome‐wide meta‐analyses were conducted separately for 5,065 patients with PsA and 21,286 healthy controls and separately for 4,340 patients with PsA and 6,431 patients with PsC. The heritability of PsA was calculated as a single‐nucleotide polymorphism (SNP)–based heritability estimate (h²_SNP) and biologic pathways that differentiate PsA from PsC were identified using Priority Index software. The generalizability of previously published PsA risk prediction pipelines was explored, and a risk prediction model was developed with external validation.

Results

We identified a novel genome‐wide significant susceptibility locus for the development of PsA on chromosome 22q11 (rs5754467; P = 1.61 × 10⁻⁹), and key pathways that differentiate PsA from PsC, including NF‐κB signaling (adjusted P = 1.4 × 10⁻⁴⁵) and Wnt signaling (adjusted P = 9.5 × 10⁻⁵⁸). The heritability of PsA in this cohort was found to be moderate (h²_SNP = 0.63), which was similar to the heritability of PsC (h²_SNP = 0.61). We observed modest performance of published classification pipelines (maximum area under the curve 0.61), with similar performance of a risk model derived using the current data.

Conclusion

Key biologic pathways associated with the development of PsA were identified, but the investigation of risk classification revealed modest utility in the available data sets, possibly because many of the PsC patients included in the present study were receiving treatments that are also effective in PsA. Future predictive models of PsA should be tested in PsC patients recruited from primary care.

Clinical effectiveness of symptomatic therapy compared with standard step-up care for the treatment of low-impact psoriatic oligoarthritis: the two-arm parallel group randomised POISE feasibility study

Introduction

In psoriatic arthritis (PsA), treatment recommendations support first-line use of disease-modifying antirheumatic drugs (DMARDs). There are few treatment strategy trials, and no previous studies have investigated tailored treatment choice by disease severity. Studies in oligoarthritis (<5 inflamed joints) are limited but have suggested that some can be managed without DMARDs, preventing unnecessary side effects. This study aimed to assess the feasibility and acceptability of a study comparing standard DMARD treatment against symptomatic therapy in patients with mild psoriatic oligoarthritis.

Methods

This trial was embedded within the MONITOR-PsA cohort, which uses a Trials Within Cohorts (TWiCs) design. Patients with newly diagnosed psoriatic oligoarthritis, with low disease activity (PASDAS ⩽ 3.2) and the absence of poor prognostic factors [C reactive protein (CRP) < 5 mg/dL, HAQ < 1, no radiographic erosions] were randomised open-label to either standard care with 'step-up' DMARD therapy or to symptomatic therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) and local corticosteroid injections to inflamed joints. Key outcomes were the proportion of eligible cohort patients, consent and study completion rate.

Results

Over the 15-month study period, only one eligible patient was randomised. Although oligoarthritis patients represented 45% of patients in this early PsA cohort, the majority did not have mild disease (24% raised CRP, 51% moderate disease activity, 13% radiographic damage and/or poor function). Of those meeting trial inclusion criteria, many patients refused treatment in the observational cohort prior to an invitation into the trial as they did not wish to be treated with DMARDs.

Conclusion

The study was not feasible as designed. Oligoarthritis represents around half of initial PsA presentations, but the majority starting therapy have high-impact disease. A small proportion have mild oligoarticular disease but many are not keen on treatment with DMARDs, given the potential side effects of these medications. Further research is needed to support evidence-based treatment in this subgroup.

Trial registration number

- ClinicalTrials.gov (NCT03797872) and EudraCT (2018-001085-42).

Axial Involvement in Psoriatic Arthritis cohort (AXIS): the protocol of a joint project of the Assessment of SpondyloArthritis international Society (ASAS) and the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)

BACKGROUND

Involvement of the axial skeleton (sacroiliac joints and spine) is a relatively frequent manifestation associated with psoriatic skin disease, mostly along with involvement of peripheral musculoskeletal structures (peripheral arthritis, enthesitis, dactylitis), which are referred to as psoriatic arthritis (PsA). Data suggest that up to 30% of patients with psoriasis have PsA. Depending on the definition used, the prevalence of axial involvement varies from 25% to 70% of patients with PsA. However, there are currently no widely accepted criteria for axial involvement in PsA.Objective: The overarching aim of the Axial Involvement in Psoriatic Arthritis (AXIS) study is to systematically evaluate clinical and imaging manifestations indicative of axial involvement in patients with PsA and to develop classification criteria and a unified nomenclature for axial involvement in PsA that would allow defining a homogeneous subgroup of patients for research.

DESIGN

Prospective, multicenter, multinational, cross-sectional study.

METHODS AND ANALYSES

In this multicenter, multinational, cross-sectional study, eligible patients [adult patients diagnosed with PsA and fulfilling Classification Criteria for Psoriatic Arthritis (CASPAR) with musculoskeletal symptom duration of ⩽10 years not treated with biological or targeted synthetic disease-modifying anti-rheumatic drugs] will be recruited prospectively. They will undergo study-related clinical and imaging examinations. Imaging will include radiography and magnetic resonance imaging examinations of sacroiliac joints and spine. Local investigators will evaluate for the presence of axial involvement based on clinical and imaging information which will represent the primary outcome of the study. In addition, imaging will undergo evaluation by central review. Finally, the central clinical committee will determine the presence of axial involvement based on all available information.

ETHICS

The study will be performed according to the ethical principles of the Declaration of Helsinki and International Council for Harmonisation Good Clinical Practice guidelines. The study protocol will be approved by the individual Independent Ethics Committee / Institutional Review Board of participating centers. Written informed consent will be obtained from all included patients.Registration: ClinicalTrials.gov ID: NCT04434885.

Application of information theoretic feature selection and machine learning methods for the development of genetic risk prediction models

In view of the growth of clinical risk prediction models using genetic data, there is an increasing need for studies that use appropriate methods to select the optimum number of features from a large number of genetic variants with a high degree of redundancy between features due to linkage disequilibrium (LD). Filter feature selection methods based on information theoretic criteria, are well suited to this challenge and will identify a subset of the original variables that should result in more accurate prediction. However, data collected from cohort studies are often high-dimensional genetic data with potential confounders presenting challenges to feature selection and risk prediction machine learning models. Patients with psoriasis are at high risk of developing a chronic arthritis known as psoriatic arthritis (PsA). The prevalence of PsA in this patient group can be up to 30% and the identification of high risk patients represents an important clinical research which would allow early intervention and a reduction of disability. This also provides us with an ideal scenario for the development of clinical risk prediction models and an opportunity to explore the application of information theoretic criteria methods. In this study, we developed the feature selection and psoriatic arthritis (PsA) risk prediction models that were applied to a cross-sectional genetic dataset of 1462 PsA cases and 1132 cutaneous-only psoriasis (PsC) cases using 2-digit HLA alleles imputed using the SNP2HLA algorithm. We also developed stratification method to mitigate the impact of potential confounder features and illustrate that confounding features impact the feature selection. The mitigated dataset was used in training of seven supervised algorithms. 80% of data was randomly used for training of seven supervised machine learning methods using stratified nested cross validation and 20% was selected randomly as a holdout set for internal validation. The risk prediction models were then further validated in UK Biobank dataset containing data on 1187 participants and a set of features overlapping with the training dataset.Performance of these methods has been evaluated using the area under the curve (AUC), accuracy, precision, recall, F1 score and decision curve analysis(net benefit). The best model is selected based on three criteria: the ‘lowest number of feature subset’ with the ‘maximal average AUC over the nested cross validation’ and good generalisability to the UK Biobank dataset. In the original dataset, with over 100 different bootstraps and seven feature selection (FS) methods, HLA_C_*06 was selected as the most informative genetic variant. When the dataset is mitigated the single most important genetic features based on rank was identified as HLA_B_*27 by the seven different feature selection methods, consistent with previous analyses of this data using regression based methods. However, the predictive accuracy of these single features in post mitigation was found to be moderate (AUC= 0.54 (internal cross validation), AUC=0.53 (internal hold out set), AUC=0.55(external data set)). Sequentially adding additional HLA features based on rank improved the performance of the Random Forest classification model where 20 2-digit features selected by Interaction Capping (ICAP) demonstrated (AUC= 0.61 (internal cross validation), AUC=0.57 (internal hold out set), AUC=0.58 (external dataset)). The stratification method for mitigation of confounding features and filter information theoretic feature selection can be applied to a high dimensional dataset with the potential confounders.

AB0204 THE PROPER STUDY: INTERIM ANALYSIS OF A PAN-EU REAL-WORLD STUDY OF SB5 BIOSIMILAR FOLLOWING TRANSITION FROM REFERENCE ADALIMUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS, AXIAL SPONDYLOARTHRITIS, OR PSORIATIC ARTHRITIS

Background:

SB5, a biosimilar to reference adalimumab (ADL), received EU marketing authorisation in August 2017, based on the totality of evidence from pre-clinical and clinical Phase I and III studies that demonstrated bioequivalence, similar efficacy, and comparable safety and immunogenicity to the reference. This real-world study provides data on outcomes of the transition from reference to biosimilar ADL outside the controlled, randomised, clinical trial setting.

Objectives:

To evaluate candidate predictors of persistence on SB5 in EU patients (pts) across multiple indications.

Methods:

This ongoing observational study enrolled 1000 pts with rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), ulcerative colitis, or Crohn’s disease who initiated SB5 as part of routine clinical practice following a minimum of 16 weeks’ treatment with reference ADL, at clinics in Belgium, Germany, Ireland, Italy, Spain, and the UK. Data are captured from clinic records retrospectively for the 24 weeks prior to transition, and prospectively and/or retrospectively for 48 weeks following transition. Primary outcome measures include baseline clinical characteristics, disease activity scores and clinical management over time; data on COVID-19 infection has recently been captured. This interim analysis (IA) provides an overview of baseline characteristics, disease scores and dose regimen up to 48 weeks post-initiation of SB5, and COVID-19 infection reported to date, in subjects with RA, axSpA, or PsA enrolled at 35 specialist sites and followed up to the data extract date of 18th December 2020.

Results:

Of the 504 pts included in this IA, 201 have RA, 169 have PsA, and 134 axSpA. At time of data extract, 216 pts had completed 48 weeks on SB5, 73 pts had discontinued SB5, and 8 had discontinued the study.

RA (N=201)axSpA (N=134)PsA (N=169)Mean (SD)Q1, Q3Mean (SD)Q1, Q3Mean (SD)Q1, Q3Age at SB5 initiation (years)60.2 (11.7)53, 6850.5 (13.6)38, 6153.0 (12.2)43, 62Duration of disease (years)13.5 (11.7)4.5, 2018.7 (13.2)9, 2512.7 (9.9)4, 20n%n%n%Women14471.64130.67745.6SB5 Dosing regimen:Baseline 40 mg Q2W14974.112089.615692.3Week 48 40mg Q2W6977.56785.99892.5Baseline Other*5225.91410.4137.7Week 48 Other*2022.41114.187.5Disease Score(paired patients)DAS28FFbHBASDAITender Joint CountSwollen Joint CountBaseline, n, mean (95% CI)692.5 (2.3–2.7)2273.9 (65.6–82.1)422.8 (2.3–3.4)491.8 (0.1–3.0)490.6 (0.2–0.9)Week 48, n, mean (95% CI)692.6 (2.3–2.8)2272.1 (64.0–80.2)423.0 (2.4–3.7)491.9 (0.5–3.3)490.6 (0.1–1.1)Patient diagnosed with COVID-19 at any time on-study, n (%)No14295.39688.114098.6Yes32.010.910.7Unknown42.71211.010.7Imraldi regimen stopped or changed due to COVID-19, regardless of diagnosis, n (%)No13098.510697.2134100Yes21.532.800

SD standard deviation; Q1 1st quartile, Q3 3rd quartile; CI Confidence Interval

*Other includes all other reported doses and/or dosing intervals: 40mg QW, 80mg Q2W, and unspecified frequency

DAS28 Disease Activity Score 28; FFbH Hanover Functional Ability Questionnaire; BASDAI Bath Ankylosing Spondylitis Disease Activity Index

Conclusion:

This IA provides a first insight into clinical management of pts over 48 weeks, in a contemporary cohort of EU pts with established RA, axSpA and PsA, switched from reference to biosimilar ADL SB5 in clinical practice. The majority of pts showed no meaningful difference in disease score or dose regimen of SB5 by Week 48 post-transition. As of data extract date, the proportion of pts with a known positive COVID-19 test was low (1.3%) and a small minority (1.3%) had SB5 treatment changed or interrupted as a result of the COVID-19 pandemic. With follow-up of pts ongoing to Q4 2021, the study will continue to provide pertinent information about clinical outcomes of transition from reference to biosimilar ADL in real-world practice and in indications not investigated in controlled studies.

Acknowledgements:

Statistical services gave been provided by FGK Clinical Research GmbH, Munich, Germany. Data management services were provided by Worldwide Clinical trial, Research Triangle Park, NC, USA; funding was provided by Biogen International GmbH.

Disclosure of Interests:

Ulf Müller-Ladner Consultant of: Biogen, Grant/research support from: Biogen, Karl Gaffney Consultant of: AbbVie, Celgene, Gilead, Lilly, MSD, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Celgene, Gilead, Lilly, MSD, Novartis, Pfizer, and UCB, Deepak Jadon Consultant of: AbbVie, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Oxford University Press, Pfizer, Roche, Sandoz, UCB, Grant/research support from: AbbVie, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Oxford University Press, Pfizer, Roche, Sandoz, UCB, Ulrich Freudensprung Shareholder of: Biogen, Employee of: Biogen, Janet Addison Shareholder of: Biogen, Employee of: Biogen

OP0229 THE GROUP FOR RESEARCH AND ASSESSMENT OF PSORIASIS AND PSORIATIC ARTHRITIS (GRAPPA) TREATMENT RECOMMENDATIONS 2021

Background:

Since the 2015 GRAPPA treatment recommendations were published, therapeutic options and management strategies for psoriatic arthritis (PsA) have advanced considerably.

Objectives:

The goal of the GRAPPA recommendations update is to develop high quality, evidence-based recommendations for the treatment of PsA, including related conditions and comorbidities.

Methods:

GRAPPA rheumatologists, dermatologists and patient research partners (PRPs) updated overarching principles for the management of adults with PsA by consensus. Principles considering use of biosimilars and tapering/discontinuing of therapy were added to this update. Systematic literature searches based on data publicly available from three databases (MEDLINE, EMBASE, and Cochrane CENTRAL) were conducted from the end of the previous recommendations’ searches through August 2020. Additional abstract searches were performed for conference presentations in 2017-2020. Searches covered PsA treatments (peripheral arthritis, axial arthritis, enthesitis, dactylitis, skin, and nail disease). Additional searches were performed for related conditions (uveitis and IBD) and comorbidities evaluating their impact on safety and treatment outcomes. Individual groups assessed the risk of bias and applied the GRADE system to generate strong or conditional recommendations for therapies within the domain groups and for the management of comorbidities and related conditions. These recommendations were then incorporated into an overall treatment schema.

Results:

Updated, evidence-based treatment recommendations are shown (Table 1). Since 2015, many new medications have been incorporated. Additional results for older medications, such as methotrexate, have been published across PsA domains. Based on the evidence, the treatment recommendations developed by individual groups were incorporated into the overall schema including principles for management of arthritis, spondylitis, enthesitis, dactylitis, skin, and nail disease in PsA, and associated conditions (Figure 1). Choice of therapy for an individual should ideally address all of the domains that impact on that patient, supporting shared decision making with the patient involved. Additional consideration in the recommendations was given to key associated conditions and comorbidities as these often impact on therapy choice.

Conclusion:

These GRAPPA treatment recommendations provide up to date, evidence-based guidance to providers who manage and treat adult patients with PsA. These recommendations are based on domain-based strategy for PsA and supplemented by overarching principles developed by consensus of GRAPPA members.

IndicationStrongForConditional ForConditionalAgainstStrongAgainstInsufficient evidencePeripheral Arthritis DMARD NaïvecsDMARDs, TNFi, PDE4i, IL-12/23i, IL-17i, IL-23i, JAKiNSAIDs, oral CS, IA CS,IL-6i,Peripheral Arthritis DMARD IRTNFi, IL-12/23i, IL-17i, IL-23i, JAKiPDE4i, other csDMARD, NSAIDs, oral CS, IA CS,IL-6i,Peripheral ArthritisbDMARD IRTNFi, IL-17i, IL-23i, JAKi,NSAIDs, oral CS, IA CS, IL-12/23i, PDE4i, CTLA-4-IgIL-6i,Axial arthritis, Biologic NaïveNSAIDs, Physiotherapy, simple analgesia, TNFi, IL-17i, JAKiCS SIJ injections, bisphosphonatescsDMARDs, IL-6i,IL-12/23i, IL-23iAxial PsA, Biologic IRNSAIDs, Physiotherapy, simple analgesia, TNFi, IL-17i, JAKi csDMARDs, IL-6i,IL-12/23i, IL-23iEnthesitisTNFi, IL-12/23i, IL-17i, PDE4i, IL-23i, JAKiNSAIDs, physiotherapy, CS injections, MTXIL-6i,Other csDMARDsDactylitisTNFi IL-12/23i, IL-17i, IL-23i, JAKi, PDE4iNSAIDs, CS injections, MTXOther csDMARDsPsoriasisTopicals, phototherapy, csDMARDs, TNFi, IL-12/23i, IL-17i, IL-23i, PDE4i, JAKi AcitretinNail psoriasisTNFi, IL12/23i, IL17i, IL23i, PDE4iTopical CS, tacrolimus and calcipotriol combination or individual therapies, Pulsed dye laser, csDMARDs, acitretin, JAKiTopical Cyclosporine / Tazarotene, Fumarate, Fumaric Acid Esters, UVA and UVB Phototherapy, AlitretinoinIBDTNFi (not ETN), IL-12/23i, JAKiIL-17iUveitisTNFi (not ETN)

Disclosure of Interests:

Laura C Coates Speakers bureau: AbbVie, Amgen, Biogen, Celgene, Gilead, Eli Lilly, Janssen, Medac, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Amgen, Celgene, Eli Lilly, Pfizer, and Novartis, Enrique Soriano Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb,GSK, Genzyme, Janssen, Lilly, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb,GSK, Genzyme, Janssen, Lilly, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Grant/research support from: AbbVie, Janssen, Novartis Pharma, Pfizer, Roche, and UCB, Nadia Corp: None declared, Heidi Bertheussen Consultant of: Pfizer, Kristina Callis-Duffin Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Lilly, Janssen, Novartis, Pfizer, Sienna Biopharmaceuticals, Stiefel Laboratories, UCB, Ortho Dermatologics, Inc, Regeneron Pharmaceuticals, Inc., Anaptys Bio, Boehringer Ingelheim., Cristiano Barbosa Campanholo Speakers bureau: AbbVie, Eli Lilly, Janssen, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Janssen, Novartis, Pfizer, and UCB, Jeffrey Chau: None declared, Lihi Eder Consultant of: Abbvie, UCB, Janssen, Eli Lily, Pfizer, Novartis, Grant/research support from: Abbvie, UCB, Janssen, Eli Lily, Pfizer, Novartis, Daniel Fernandez Consultant of: Abbvie, UCB, Roche, Janssen, Pfizer, Amgen and Brystol, Grant/research support from: Abbvie, UCB, Roche, Janssen, Pfizer, Amgen and Brystol, Oliver FitzGerald Speakers bureau: AbbVie, Janssen and Pfizer Inc, Consultant of: BMS, Celgene, Eli Lilly, Janssen and Pfizer Inc, Grant/research support from: AbbVie, BMS, Eli Lilly, Novartis and Pfizer Inc, Amit Garg Consultant of: Abbvie, Amgen, Asana Biosciences, Bristol Myers Squibb, Boehringer Ingelheim, Incyte, InflaRx, Janssen, Pfizer, UCB, Viela Biosciences, Grant/research support from: Abbvie, Dafna D Gladman Consultant of: Abbvie, Amgen, BMS, Eli Lilly, Galapagos, Gilead, Jansen, Novartis, Pfizer and UCB, Grant/research support from: Abbvie, Amgen, Eli Lilly, Jansen, Novartis, Pfizer and UCB, Niti Goel: None declared, Suzanne Grieb: None declared, Philip Helliwell Speakers bureau: Janssen, Novartis, Pfizer, Consultant of: Eli Lilly, M Elaine Husni Consultant of: Abbvie, Amgen, Janssen, Novartis, Lilly, UCB, Regeneron, and Pfizer, Deepak Jadon Speakers bureau: AbbVie, Amgen, Celgene, Eli Lilly, Gilead, Healthcare Celltrion, Janssen, MSD, Novartis, Pfizer, Roche, Sandoz, UCB, Consultant of: AbbVie, Amgen, Celgene, Eli Lilly, Gilead, Healthcare Celltrion, Janssen, MSD, Novartis, Pfizer, Roche, Sandoz, UCB, Grant/research support from: AbbVie, Amgen, Celgene, Eli Lilly, Gilead, Healthcare Celltrion, Janssen, MSD, Novartis, Pfizer, Roche, Sandoz, UCB, Arnon Katz: None declared, Dhruvkumar Laheru: None declared, John Latella: None declared, Ying Ying Leung Speakers bureau: Novartis, AbbVie, Eli Lilly, Janssen, Consultant of: Pfizer and Boehringer Ingelheim, Grant/research support from: Pfizer and conference support from AbbVie, Christine Lindsay Shareholder of: Amgen, Employee of: Aurinia pharmaceuticals, Ennio Lubrano Speakers bureau: Alfa-Sigma, Abbvie, Galapagos, Janssen Cilag, Lilly., Consultant of: Alfa-Sigma, Abbvie, Galapagos, Janssen Cilag, Lilly., Luis Mazzuoccolo Speakers bureau: Abbvie, Amgen, Novartis, Elli Lilly, Jansen, Consultant of: Abbvie, Amgen, Novartis, Elli Lilly, Jansen, Roland McDonald: None declared, Philip J Mease Speakers bureau: AbbVie, Amgen, Eli Lilly, Janssen, Novartis, Pfizer and UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, Galapagos, Gilead Sciences, GlaxoSmithKline, Janssen, Novartis, Pfizer, SUN and UCB, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Galapagos, Gilead Sciences, Janssen, Novartis, Pfizer, SUN and UCB, Denis O’Sullivan: None declared, Alexis Ogdie Consultant of: AbbVie, Amgen, BMS, Celgene, Corrona, Gilead, Janssen, Lilly, Novartis, and Pfizer, Grant/research support from: Novartis and Pfizer and Amgen, Wendy Olsder: None declared, Lori Schick: None declared, Ingrid Steinkoenig: None declared, Maarten de Wit Consultant of: AbbVie, BMS, Celgene, Janssen, Lilly, Novartis, Pfizer, Roche, Danielle van der Windt: None declared, Arthur Kavanaugh Speakers bureau: AbbVie, Amgen, BMS, Eli Lilly, Gilead Janssen, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, BMS, Eli Lilly, Gilead Janssen, Novartis, Pfizer, UCB

Treatment of psoriatic arthritis with biologic and targeted synthetic DMARDs: British Society for Rheumatology guideline scope

The aim of this guideline is to provide an update on evidence-based recommendations for treatment of adult patients with PsA. The previous BSR guidelines for PsA were published in 2012 and since that time, there have been many new advanced therapies licensed for PsA. This update will provide practical guidance for clinicians on the optimal selection of advanced therapies taking into account different domains of PsA (arthritis, enthesitis, dactylitis, axial disease and psoriasis) and key associated comorbidities. It will also update guidance on treatment strategy including the use of a treat-to-target approach. The guideline will be developed using the methods and processes outlined in Creating Clinical Guidelines: Our Protocol. (1) This development process to produce guidance, advice and recommendations for practice has National Institute for Health and Care Excellence (NICE) accreditation.

A comparison of clinical examination and ultrasound enthesitis indices in patients with psoriatic arthritis, adjusted for concomitant fibromyalgia

Objectives:

To: (a) determine the extent of ultrasound (US)-detected peripheral enthesitis in a cohort of patients with psoriatic arthritis (PsA); (b) compare this with three clinical examination (CE) enthesitis indices; and (c) determine the effect of concurrent fibromyalgia on the evaluation of enthesitis.

Methods:

A prospective single-centre cross-sectional study of consecutive outpatients with established PsA undergoing clinical examination for enthesitis and US examination for inflammatory and structural lesions of enthesitis. Multivariable analyses tested for association between US scores, CE enthesitis indices and influence of concurrent fibromyalgia.

Results:

A total of 106 patients were assessed. Of these, 91/106 (85.8%) had CE enthesitis and 105/106 (99.1%) had ⩾1 US feature of enthesitis. There was a moderate correlation between US entheseal inflammation and both the Leeds Enthesitis Index (LEI) (Spearman rank, r = 0.36) and Spondyloarthritis Research Consortium of Canada Enthesitis Index (SPARCC) (r = 0.44). US entheseal damage did not correlate with CE enthesitis indices. Twenty-eight (26.4%) patients were classified as having concurrent fibromyalgia, in whom multivariable regression analyses demonstrated no correlation between US scores and CE enthesitis indices. PsA patients without fibromyalgia demonstrated a statistically significant association between both LEI (r = 0.48, p < 0.0001) and SPARCC (r = 0.62, p < 0.0001) and US entheseal inflammation.

Conclusion:

There is a moderate association between US entheseal inflammation, but not damage, and CE enthesitis indices in patients with PsA. The presence of concurrent fibromyalgia is linked with higher CE enthesitis scores, without an increase in US inflammation, suggesting that CE enthesitis indices should be used/interpreted with caution in these patients. Imaging, including US, should be the preferred modality to detect enthesitis in PsA patients with concurrent fibromyalgia.

Treating to target in psoriatic arthritis: assessing real-world outcomes and optimising therapeutic strategy for adults with psoriatic arthritis-study protocol for the MONITOR-PsA study, a trials within cohorts study design

Background

The Tight Control of psoriatic arthritis (TICOPA) trial confirmed improved clinical outcomes with a treat to target (T2T) strategy in psoriatic arthritis (PsA). This consisted of 4-weekly review and escalation of ‘step up’ therapy (single disease modifying therapy (DMARD), combination DMARDs and then biologics) based on remission criteria. Based on this, a T2T approach is supported by European PsA treatment recommendations. However, it is not commonly implemented in routine care primarily due to feasibility and cost concerns. In the TICOPA trial, the same treatment regime was used for all participants regardless of their disease profile. Despite the recognition of PsA as a highly heterogeneous condition, no studies have tailored which drugs are used depending on disease severity. The cohort will establish real world outcomes for the T2T approach in PsA and also form the basis of a trials within cohorts (TWiCs) design to test alternative therapeutic approaches within embedded clinical trials providing an evidence base for treatment strategy in PsA.

Methods

The Multicentre Observational Initiative in Treat to target Outcomes in Psoriatic Arthritis (MONITOR-PsA) cohort will apply a T2T approach within routine care. It will recruit newly diagnosed adult patients with PsA starting systemic therapies. The cohort is observational allowing routine therapeutic care within NHS clinics but a T2T approach will be supported when monitoring treatment within the cohort. Eligible participants will be adults (≥18 years) with active PsA with ≥ 1 tender or swollen joints or enthesis who have not previously had treatment with DMARDs for articular disease.

Discussion

This study is the first TWiC designed to support a fully powered randomised drug trial. The results from the observational cohort will be compared with those observed in the TICOPA trial investigating the clinical effectiveness and health care costs of the pragmatic T2T approach. Nested trials will provide definitive RCT evidence establishing the optimal management of PsA within the T2T approach. The TWiCs design allows robust generalizability to routine healthcare, avoids disappointment bias, aids recruitment and in future will allow assessment of longer-term outcomes.

Trial registration

ClinicalTrials.gov NCT03531073. Retrospectively registered on 21 May 2018.

AB0824 WHICH PARAMETERS ARE RELEVANT IN THE IDENTIFYING AXIAL INVOLVEMENT IN PSORIATIC ARTHRITIS? – RESULTS OF A SURVEY AMONG ASAS AND GRAPPA MEMBERS

Background:

Inflammatory involvement of the axial skeleton (sacroiliac joints and / or spine) is one of the relatively frequent musculoskeletal manifestations associated with psoriasis / psoriatic arthritis (PsA). There is an urgent need for an evidence-based definition for axial involvement in PsA that would identify a subgroup of patients within the heterogeneous PsA population to conduct observational, interventional and translational studies. ASAS and GRAPPA embarked on a collaborative initiative to develop a definition of axial involvement in PsA.

Objectives:

To perform a survey to identify variables relevant in the identification of the presence of axial involvement in PsA among members of ASAS and GRAPPA.

Methods:

The online survey utilized thePAPRIKAmethodology (PotentiallyAllPairwiseRanKings of all possibleAlternatives) that determines decision-makers’ part-worth utilities representing the relative importance of the attributes. Participants were exposed to number of clinical scenarios and were prompted to decide which of the scenarios is more compatible with axial involvement in PsA unless they are equal (Figure). The constant stem of each scenario was “a patient diagnosed with psoriatic arthritis fulfilling the CASPAR criteria”; the variable part included 13 common spondyloarthritis variables (Table). Variables were ranked according to their relative importance.

Results:

The survey was completed by 186 ASAS/GRAPPA members (63 ASAS only, 80 GRAPPA only, and 43 both societies). The ranking of the variables is presented inTable. The highest ranked parameters indicative of axial involvement in a patient with PsA were presence of typical radiographic or MRI changes in the sacroiliac joints and/or spine followed by the presence of chronic back pain and then inflammatory back pain. A separate analysis of ASAS and GRAPPA members provided the similar results concerning the relevance of the variables.

Conclusion:

Objective signs of inflammatory involvement of the axial skeleton are the most important indicators of axial disease in PsA in the opinion of the experts. A prospective cohort study is currently being planned to address the value of these and other variables in defining axial involvement in PsA.

Table.

Ranking of the parameters relevant to deciding on the presence of axial involvement in a PsA patient in the opinion of ASAS and GRAPPA members (n=186).

NParametersMedian rankMean rank1Presence of structural damage on an X-ray of SIJ22.82Presence of structural damage on an X-ray of spine3.54.13Presence of subchondral BME / osteitis on MRI of SIJ compatible with SpA44.54Presence of BME / osteitis on MRI of spine compatible with SpA455History or current presence of back pain5.55.86History of or current presence of inflammatory back pain5.567Good response of back pain to non-steroidal anti-inflammatory drugs87.88HLA-B2788.19Family history for SpA9.5910Elevated C-reactive protein109.311Presence of peripheral arthritis and/or enthesitis and/or dactylitis109.412Presence of anterior uveitis109.513Presence of inflammatory bowel disease109.6

BME=bone marrow edema, MRI=magnetic resonance imaging, SIJ=sacroiliac joints, SpA=spondyloarthritis

Disclosure of Interests:

Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Philip J Mease Grant/research support from: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – grant/research support, Consultant of: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – consultant, Speakers bureau: Abbott, Amgen, Biogen Idec, BMS, Eli Lilly, Genentech, Janssen, Pfizer, UCB – speakers bureau, Filip van den Bosch Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Speakers bureau: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Alice Gottlieb Grant/research support from: Boehringer Ingelheim, Incyte, Janssen, Novartis, UCB, Xbiotech, Consultant of: AbbVie, Allergan, Avotres Therapeutics, Beiersdorf, Boehringer Ingelheim, BMS, Celgene, Dermira, Incyte, Eli Lilly, Janssen, LEO Pharma, Novartis, Reddy Labs, Sun Pharmaceutical Industries, UCB, Valeant, Xbiotech, Laura C Coates: None declared, Vinod Chandran Grant/research support from: Abbvie, Celgene, Consultant of: Abbvie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lily, Janssen, Novartis, Pfizer, UCB, Employee of: Spouse employed by Eli Lily, Philip Helliwell: None declared, Deepak Jadon: None declared, Joachim Sieper Consultant of: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Speakers bureau: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Dafna D Gladman Grant/research support from: AbbVie, Amgen Inc., BMS, Celgene Corporation, Janssen, Novartis, Pfizer, UCB – grant/research support, Consultant of: AbbVie, Amgen Inc., BMS, Celgene Corporation, Janssen, Novartis, Pfizer, UCB – consultant

AB0839 RELIABILITY OF COMPOSITE MEASURES FOR THE ASSESSMENT OF PSORIATIC ARTHRITIS

Background:

Composite measures of disease activity have been developed for use in Psoriatic Arthritis (PsA) to capture the wide spectrum of disease but there is a lack of consensus regarding which to adopt for routine practice. It is recognised that more data is required to understand the measurement properties of existing instruments and consider the impact of modifications that may improve face validity, responsiveness or feasibility. It is important to have an estimate of a measurement instrument’s reliability in the setting of stable disease in order to understand measurement error and responsiveness. To our knowledge no data exists on the stability of composite measures in PsA.

Objectives:

To measure test re-test reliability of composite measures of disease activity in PsA.

Methods:

Clinical and patient reported outcomes to enable the calculation of composite measures were administered to 141 patients with PsA at five time points in a UK multicentre observational study. All patients fulfilled the CASPAR criteria. Twenty-nine patients with clinically stable disease and receiving no treatment intervention underwent repeat assessment by the same examiner within 2 weeks. Patients in high and low disease were included. Reliability was evaluated by intra-class correlation coefficient (ICC) and Bland Altman plots.

Results:

Of the 29 patients included 15 were male, the mean age was 52.4 years (SD 13.39), mean disease duration at T0was 9.2yrs (SD 8.11). The mean swollen joint count was 3.4 (SD 5.1), tender joint count 11.3 (SD 15.03) and PASI 1.0 (SD1.04). The ICC (95% CI) for tender and swollen joint counts were 0.94 (0.87-0.97) and 0.91 (0.80-0.96) respectively. The ICC for PASI was 0.95 (0.90-0.98). All composite measures demonstrated high levels of test-retest reliability with ICC >0.85, table. The most reliable measure was the PADAS ICC 0.98 (95% CI 0.954-0.991). The individual ICC for each composite measures are reported in the table and Bland Altman plots, figure.

Conclusion:

All composite measures show high levels of test-retest reliability in this cohort. The PASDAS was the most stable measure. Modifications to these instruments can now be tested and the impact compared to the original versions.

Table.

Funding:

This report is independent research funded by the National Institute for Health Research, Programme Grants for Applied Research [Early detection to improve outcome in patients with undiagnosed PsA (‘PROMPT’), RP-PG-1212-20007]. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Disclosure of Interests:

William Tillett Grant/research support from: AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer Inc, UCB, Consultant of: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, MSD, Pfizer Inc, UCB, Speakers bureau: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, Pfizer Inc, UCB, Philip Helliwell: None declared, Oliver FitzGerald: None declared, Robin Waxman: None declared, Anna Antony: None declared, Laura C Coates: None declared, Deepak Jadon: None declared, Paul Creamer: None declared, Suzanne Lane: None declared, Marco Massarotti: None declared, Charlotte Cavill: None declared, Mel Brooke: None declared, Jonathan Packham: None declared, Eleanor Korendowych: None declared, Anya Lissina: None declared, Neil McHugh: None declared

AB0311 THE PROPER STUDY: RESULTS OF THE FIRST INTERIM ANALYSIS OF A PAN-EU REAL-WORLD STUDY OF SB5 BIOSIMILAR FOLLOWING TRANSITION FROM REFERENCE ADALIMUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS, AXIAL SPONDYLOARTHRITIS OR PSORIATIC ARTHRITIS

Background:

SB5, a biosimilar to reference adalimumab (ADA), received EU marketing authorisation in August 2017, based on the totality of evidence from pre-clinical and clinical Phase I and III studies that demonstrated bioequivalence, similar efficacy, and comparable safety and immunogenicity to the reference. There are few published data on the transition from reference to biosimilar ADA outside the controlled, randomised, clinical trial setting.

Objectives:

To evaluate candidate predictors of persistence on SB5 in EU patients across multiple indications.

Methods:

This ongoing observational study will enrol approximately 1200 subjects with rheumatoid arthritis (RA), axial spondyloarthritis (axSpA) or psoriatic arthritis (PsA), who initiated SB5 as part of routine clinical practice following a minimum of 16 weeks’ treatment with reference ADA, at clinics in Belgium, Germany, Ireland, Italy, Spain and the UK. Data are captured from clinic records retrospectively for the 24 weeks prior to transition, and prospectively and/or retrospectively for 48 weeks following transition. The primary objective is to evaluate candidate predictors of persistence, and primary outcome measures include baseline clinical characteristics, disease activity scores, clinical management and patient satisfaction over time. This interim analysis provides an overview of baseline characteristics for subjects enrolled and followed up by the data extract date of 20thDecember 2019.

Results:

Of the 123 patients included in this interim analysis, 43 suffer from RA, 42 from axSpA and 38 from PsA.

Table 1.

Patient baseline characteristics

RA (N=43)axSpA (N=42)PsA (N=38)Mean (SD)Q1, Q3Mean (SD)Q1, Q3Mean (SD)Q1, Q3Age (years)58.7 (11.3)53, 6452.3 (13.3)41, 6353.7 (14.1)48, 63Duration of disease (years)6.8 (9.5)1, 622.0 (14.4)12.5, 32.513.8 (9.4)5.5, 22n%n%n%Women3172.11638.11642.1Dosing regimen ADA to SB5: 40mg Q2W: 40mg Q2W3485.03685.73489.5 Other*615.0614.3410.5Stable disease (physician opinion)3491.92765.93085.7Disease Activity Score:Mean (SD)95% CIMean (SD)95% CIMean (SD)95% CI DAS28 (n = 26)2.71 (0.88)2.36, 3.06---- BASDAI (n = 31)--3.71 (2.89)2.65, 4.77-- PsA scores (n = 23)0.3 (0.9)  Swollen joint2.9 (5.7)-0.1, 0.8  Tender joint0.4, 5.4Patient Awareness:n%n%n%Instructed in self-administration43100.03790.23594.6Know to remove SB5 from fridge 30 minutes pre-injection43100.03895.03697.3Know SB5 can be stored out of fridge <25oc for 28 days4297.73382.52875.7

DAS-28 Disease Activity Score 28; BASDAI Bath Ankylosing Spondylitis Disease Activity Index; SD standard deviation; Q1 1stquartile, Q3 3rdquartile; CI Confidence Interval

‘Other’ includes all other reported doses and/or dosing intervals: 40mg QW, 80mg Q2W, and unspecified frequency

Conclusion:

This interim analysis provides a first insight into a contemporary cohort of EU patients with established RA, axSpA and PsA, switched from reference to biosimilar ADA in clinical practice. The majority of patients have stable disease at transition, 85% or more of each cohort transitioned to the same dose regimen of biosimilar as received for the reference prior to transition, and most are aware of correct storage and self-administration of their biosimilar medication. With ongoing enrolment and longer follow-up, the study will provide pertinent information about clinical outcomes of transition from reference to biosimilar adalimumab in real-world practice and in indications not investigated in controlled studies.

Disclosure of Interests:

Ulf Müller-Ladner Speakers bureau: Biogen, Karl Gaffney Grant/research support from: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Consultant of: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Speakers bureau: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Deepak Jadon: None declared, Ulrich Freudensprung Shareholder of: Biogen International GmbH, Employee of: Biogen International GmbH, Janet Addison Shareholder of: Biogen Idec, Employee of: Biogen Idec

Prevalence and predictors of tumour necrosis factor inhibitor persistence in psoriatic arthritis

Objectives

To evaluate TNF-α inhibitor (TNFi) persistence when used as first- or second-line biologic therapy for the management of PsA, and to determine baseline clinical and laboratory parameters associated with TNFi persistence.

Methods

A retrospective single-centre cohort study was performed on all patients with PsA initiated on TNFi therapy between 2003 and 2015. Demographic, clinical and laboratory characteristics were compared with TNFi persistence, using Kaplan-Meier survival and Cox proportional hazards models.

Results

One hundred and eighty-eight patients with PsA were prescribed TNFi therapy as first-line biologic therapy over a period of 635 person-years [46% male, mean (s.d.) age 47.3 (11.4) years; median (interquartile range) disease duration 11 (7-16) years]. At 12 months of follow-up 79% of patients persisted with TNFi therapy, and 73% at 24 months. Of those discontinuing TNFi, 35% stopped due to primary inefficacy, 22% secondary inefficacy and 43% adverse events. Multivariable analysis identified female sex (hazard ratio (HR) 2.57; 95% CI: 1.26, 5.24; P = 0.01) and the presence of metabolic syndrome-related co-morbidities (HR = 2.65, 95% CI: 1.24, 5.69; P = 0.01) as predictors of lower persistence. Of 32 cases treated with a second TNFi, persistence at 12 months was 56%. TNFi persistence was 2-fold less likely in these 32 cases compared with first-line TNFi users (HR = 2.02, 95% CI: 1.20, 3.42; P = 0.01).

Conclusion

Patients with PsA who are female and have metabolic syndrome-related co-morbidities have lower TNFi persistence. Although persistence was lower in patients who had switched to a second TNFi, a substantial proportion of these cases responded, advocating switching to a second TNFi as a valid therapeutic strategy.

Novel Composite Radiographic Score for Longitudinal Observational Studies of Psoriatic Arthritis: A Proof-of-concept Study

Objective.

To devise a feasible composite radiographic score for use in observational studies of psoriatic arthritis (PsA).

Methods.

Radiographs from 50 patients with PsA were evaluated with the PsA-modified Sharp, Sharp/van der Heijde (SvdH), and Ratingen scores. Data reductions were made to devise a concise score.

Results.

The Reductive X-ray Score for Psoriatic Arthritis (ReXSPA) required the assessment of only 22 joints (234 points), including erosion, joint space narrowing, and osteoproliferation in the hands and feet. The ReXSPA accounted for 80% of change detected with the SvdH score.

Conclusion.

We report a proof-of-concept radiographic score for observational studies derived though data reduction.

Long-term remission following withdrawal of dopamine agonist therapy in subjects with microprolactinomas

OBJECTIVE

Reports suggest that up to 70% of patients with microprolactinomas treated with dopamine agonist therapy may achieve long-term normoprolactinaemic remission following drug withdrawal. Yet, there is no consensus on the duration of therapy nor is therapeutic interruption universally practised. We have assessed remission rates in a large cohort of treatment-naive subjects with microprolactinomas. Subjects received dopamine agonist (DA) therapy with either cabergoline or bromocriptine for a period of 2 to 3 years in the majority of cases, followed by a trial of treatment withdrawal.

DESIGN

Retrospective analysis of clinic records of 89 patients (mean age 32.7 +/- 8.4 years, 84 women and 5 men) who had received either cabergoline (n = 67) (0.5-3 mg weekly) or bromocriptine (n = 22) (2.5-10 mg daily) for a mean duration of 3.1 years.

RESULTS

Following withdrawal of therapy, 57 subjects developed recurrence (64%) and the mean time to recurrence was 9.6 months (range 1-44 months), while 32 subjects (36%) remained in remission beyond 1 year (mean 3.6 years, range 1-7 years). There was no difference in remission rates between subjects treated with cabergoline (n = 21) and bromocriptine (n = 11), but a direct relationship between pretreatment prolactin concentration and risk of recurrent symptomatic hyperprolactinaemia was observed. No subjects developed clinical features to suggest tumour expansion following therapeutic discontinuation.

CONCLUSIONS

This study confirms that abrupt withdrawal of chronic dopamine agonist therapy, following 2 to 3 years of treatment is safe and associated with long-term remission in 30-40% of subjects with microprolactinomas. This therapeutic strategy is convenient and applicable in clinical practice.