THU0640-HPR GENDER DISPARITY IN AUTHORSHIP OF CLINICAL PRACTICE GUIDELINES IN RHEUMATOLOGY

Background:

Women are generally less represented as first author among original medical researches and clinical guidelines. Indeed, women are first authors in only 30% of clinical guidelines published in high impact medical journals. It is not known if a comparable underrepresentation occurs also in rheumatologic guidelines.

Objectives:

The aim of the present analysis is to evaluate the representation of female authors in rheumatological guidelines over a period of time between 2004 and 2019.

Methods:

We searched PubMed for guidelines published in English in the rheumatological field from 1st January 2004 to 1st January 2019. Gender of each author (man or woman) was identified by use of a minimum of two resources (i.e., author’s name and an internet search to identify the author’s photograph or gender pronoun).

Results:

We found 366 guidelines published between 2004 and 2019 (Table 1: stratified by year of publication and Table 2: stratified by disease). Overall, the proportion of female first authors was 32.0% (95% CI, 28.0% - 35%). After stratification by year of publication the percentage of female first authors was lower in past years compared to recent years. The percentage of female first author increased substantially over the time (Figure 1).

Table 1.

Percentage of female and male first author of rheumatological guidelines stratified by years

Years% FEMALE%MALE2004 (n=14)21.478.62005 (n=21)23.876.22006 (n=25)32.068.02007 (n=32)37.562.52008 (n=43)20.979.12009 (n=18)33.366.72010 (n=15)6.793.32011 (n=27)25.974.12012 (n=27)25.974.12013 (n=20)48.351.72014 (n=20)25,075,02015 (n=13)46,253,82016 (n=20)45,055,02017 (n=29)51,748,32018 (n=22)40,959,1Table 2.

Percentage of female and male first author of rheumatological guidelines stratified by disease

Disease% FEMALE% MALEOsteoarthritis (n=34)26.573.5Rheumatoid arthritis (n=96)18.881.2Fibromyalgia (n=30)2080Lupus erythematosus (n=29)34.565.5Psoriatic arthritis and Spondyloarthritis (n=73)23.376.7Sjogren syndrome (n=5)4060Gout (n=19)10.589.5Systemic sclerosis (n=18)16.783.3Polymyalgia and Giant cells’ arteritis (n=12)0100Osteoporosis (n=26)30.869.2ANCA associated vasculitides (n=14)21.478.6Polymyositis and Dermatomyositis (n=6)5050Behcet’s disease (n=4)2575Figure 1.

Temporal trend of the percentage of first author gender from 2004 to 2019 (male in blue, female in pink)

Conclusion:

We found a prevalence of male as first authors of guidelines in the rheumatological field published between January 2004 and January 2019. The EULAR Task Force on Gender Equity in Academic Rheumatology (EULAR GEAR) has been recently established, making an important first step toward gender equity in the authorship of guidelines in the rheumatological fields. Indeed, in the last 15 years we have witnessed an increase in female representativeness. Notwithstanding, efforts should be made to improve the representation of female authors nationally and internationally.

Disclosure of Interests:

Giovanni Adami: None declared, Ombretta Viapiana: None declared, Elisabetta Vantaggiato: None declared, Camilla Benini: None declared, Denise Rotta: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work., Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB

THU0479 ASSOCIATION BETWEEN CENTRAL SENSITIZATION AND CLINICAL AND ULTRASONOGRAPHIC PARAMETERS IN INFLAMMATORY ARTHRITIDES

Background:

Central sensitization (CS) is an important feature of patients with chronic pain, especially rheumatoid arthritis (RA) and psoriatic arthritis (PsA) patients. CS might interfere with the clinical evaluation of inflammation. Central Sensitization Inventory (CSI) is a validated instrument for assessing central sensitization.

Objectives:

We seek to investigate the inference of central sensitization (assessed with the CSI) on clinical (disease activity scores) and ultrasound parameters (US 7-joints score) in RA and PsA patients.

Methods:

We conducted a cross-sectional analysis on patients with an established diagnosis of RA or polyarticular PsA. Demographic, anamnestic and clinical parameters were collected. Disease activity was measured with SDAI in RA patients and with DAPSA in PsA patients. The presence and severity of synovitis was measured with the US 7-joints score. Exclusion criteria included: diagnosis of fibromyalgia, depression and patients with PsA with enthesitis predominant and/or spondylitis subtypes. Differences between variables were analysed with t-test and ANOVA for multiple comparisons. Correlation between continuous variables was analysed with Pearson correlation. CSI was analysed either as positive\negative (threshold 40 points) or divided in four categories, i.e., subclinical (≤29), mild (30-39), moderate (40-49), severe (50-59) and extreme (≥60).

Results:

We enrolled 42 patients in the study. Descriptive characteristics of the study population are presented in table 1. We found no difference in clinical parameters between diseases, sex or age. Women had a higher CSI score compared to men (mean 39.3 vs 26.7 p=0.005). We found a correlation between CSI score and DAPSA (r20.39, p =0.001), number of tender joints (r20.13, p=0.02) and HAQ (r20.47, p<0.001) (Figure 1) while we found no correlation between CSI score and SDAI or other clinical parameters. We found a significant difference in DAPSA, tender joints count and HAQ between CSI categories (ANOVA p=0.01, p=0.02 and p<0.001 respectively). US 7-joints score was associated with SDAI (r20.33, p=0.03), number of swollen joints (r20.28, p=0.002) and disease duration (r20.35, p<0.001) but not with DAPSA or tender joints.

Table 1.

Descriptive characteristics of the study population

Age (mean, SD in years)55.9 (12.3)BMI25.9 (3.9)CSI questionnaire score (mean)35 (16)CSI categories (n, %)Subclinical18 (42.9%)Mild9 (21.4%)Moderate8 (19.0%)Severe4 (9.5%)Extreme3 (7.1%)Diagnosis (n, %)PsA 52.4%9 men 13 womenRA 47.6%2 men 18 womenCSI score in PsA (mean, SD)34.4 (16.5)CSI score in RA (mean, SD)34.8 (15.5)CRP (median, IQR in mg/L)1.85 (1.0-4.6)Tender joints (mean, SD)2 (2)Swollen joints (mean, SD)1 (2)SDAI categories (n, %)Remission4 (20.0%)Low disease activity8 (40.0%)Moderate disease activity7 (35.0%)Severe disease activity1 (5.0%)DAPSA categories (n, %)Remission6 (33.3%)Low disease activity4 (22.2%)Moderate disease activity7 (38.9%)Severe disease activity1 (5.6%)US 7-joints score (mean, SD)6 (7)HAQ (mean, SD)0.6 (0.6)Prednisone equivalent (mean, SD in mg/day)1.47 (3.2)Biological DMARD (n, %)No15 (35.7%)Yes27 (64.3%)Conventional DMARD (n, %)No13 (31.0%)Yes29 (69.0%)Figure 1.

Correlation between DAPSA score and CSI score and between HAQ and CSI score

Conclusion:

We found an association between CS and sex, functional disability, tender joints count and disease activity score in PsA patients while there was no correlation between RA disease activity and central sensitization. US 7-joints score was associated with swollen joints count, disease duration and disease activity in RA patients but not in PsA patients. In PsA patients, DAPSA might be more influenced by central sensitization, especially in female individuals.

Disclosure of Interests:

Giovanni Adami: None declared, Elisabetta Gerratana: None declared, Alessandro Giollo: None declared, Camilla Benini: None declared, Elisabetta Vantaggiato: None declared, Denise Rotta: None declared, Luca Idolazzi: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work., Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB, Angelo Fassio Speakers bureau: Angelo Fassio reports personal fees from: Abiogen and Novartis, outside the submitted work.

Changes in Dkk-1, sclerostin, and RANKL serum levels following discontinuation of long-term denosumab treatment in postmenopausal women

PURPOSE

The positive effects of denosumab (DMAb) on bone mineral density (BMD) are quickly reversible after its discontinuation. We investigated whether this rebound was associated with dysregulation of the Wnt canonical pathway and/or by the increase in the receptor-activator of nuclear factor-kappa B ligand (RANKL) serum levels.

METHODS

The study included patients (n = 15) with postmenopausal osteoporosis to whom DMAb was administered for 78 months and then discontinued. We collected BMD data at baseline/month 0 (M0), M60, M84 (6 months after last DMAb administration, coinciding when the next DMAb dose would typically be due), and after 3 and 12 months of follow-up (FU-M3 and FU-M12, respectively). Serum C-terminal telopeptide of type 1 collagen (CTX-I), Dickkopf-1 (Dkk-1), and sclerostin were measured at M0, M60, M84, FU-M3, and FU-M12. Serum N-terminal propeptide of type 1 procollagen (PINP) and RANKL were dosed at M60, M84, FU-M3, and FU-12.

RESULTS

We found a significant decrease in the T-score at all sites at FU-M12, when compared to M84 (-0.51 ± 0.91 at the lumbar spine; -0.72 ± 0.33 at the total hip; and -0.42 ± 0.27 at the femoral neck, p < 0.05). After DMAb discontinuation (M84 vs FU M12) CTX-I, PINP increased already at FU-M3 (+0.921 ± 0.482 ng/mL, +126.60 ± 30.36 ng/mL, respectively, p < 0.01), RANKL increased at FU-M12 (+0.041 ± 0.062 ng/mL, p < 0.05), while Dkk-1 and sclerostin decreased at FU-M12 (-10.90 ± 11.80 and - 13.00 ± 10.52 pmol/L, respectively, p < 0.01). No changes in BMD or any of the markers were found between M60 and M84.

CONCLUSIONS

RANKL serum levels progressively increased after discontinuation of long-term DMAb while Dkk-1 and sclerostin serum levels decreased. The increase in RANKL serum levels supports the hypothesis of a sudden loss of inhibition of the resting osteoclast line after DMAb clearance, with a hyperactivation of these cells. Our results suggest that the changes in serum Wnt inhibitors after DMAb suspension might represent a mere feedback response to the increased bone turnover.

Inhibition of tumor necrosis factor-alpha (TNF-alpha) in patients with early rheumatoid arthritis results in acute changes of bone modulators

OBJECTIVE

Dicckopf-1 (Dkk-1) is a potent inhibitor of the Wnt canonical pathway. In rheumatoid arthritis (RA), Dkk-1 is upregulated by tumor necrosis factor-α (TNF). Certolizumab pegol (CMZ) is a biologic TNF-inhibitor (TNFi) effective in RA and slows radiographic progression. Data on the immediate effects (≤1-8 weeks) of TNFi on Wnt modulators are lacking. This study investigated the acute influence of TNFi treatment on Wnt modulators (Dkk-1 and sclerostin) and bone turnover markers (BTM), including intact N-terminal propeptide of collagen type I (PINP) and C-terminal telopeptide of type I collagen (CTX-I).

METHODS

This longitudinal, uncontrolled study involved female RA patients with inadequate response to conventional methotrexate who underwent treatment with CMZ. ESR, Dkk-1, sclerostin, BTM, parathyroid hormone (PTH), and 25OH-vitamin D levels were evaluated at baseline, week 1, week 4, and week 8. Radiographs of the hands and feet were obtained at baseline and the total and erosion scores were assessed using the Simple Erosion Narrowing Score method (SENS).

RESULTS

Seventeen patients were enrolled. Dkk-1 and CTX-I significantly decreased after one week of treatment with CMZ (-49.1 ± 17.1% and -25.0 ± 20.6%, respectively, p < 0.01), whereas PINP increased (+43.2 ± 31.5%, p < 0.01). These changes persisted at week 4 and 8.

CONCLUSIONS

Our study showed that TNF-alpha inhibition with CMZ promptly results in a rapid decline of serum Dkk-1 levels, alongside decreased bone resorption and increased bone formation.