Dual targeted therapy in patients with psoriatic arthritis and spondyloarthritis: a real-world multicenter experience from Spain

Dual targeted therapy (DTT) has emerged as a promising approach in patients with refractory spondyloarthritis (SpA) or psoriatic arthritis (PsA) and extra-musculoskeletal manifestations of both diseases, but its effectiveness/safety ratio still remains unclear. This is a retrospective, real-world multicenter study in refractory SpA and PsA patients with simultaneous use of two biological or synthetic targeted agents. Effectiveness was assessed using Ankylosing Spondylitis Disease Activity Score with C-reactive protein (ASDAS-CRP) and Disease Activity in Psoriatic Arthritis (DAPSA) Score. We identified 39 different DTT combinations in 36 patients (22 SpA; 14 PsA), 25 of them with concomitant inflammatory bowel disease. The most commonly used combinations were TNF inhibitor plus antagonist of the IL12/23 pathway, followed by TNF inhibitor plus IL-17 antagonist. During a median exposure of 14.86 months (IQR 8-20.2), DTT retention rate was 69.4% (n=25/36; 19 SpA, 6 PsA). Major clinical improvement (change in ASDAS-CRP > 2 or improvement > 85% in DAPSA) was achieved in 69.4% of patients (n=25/36 therapeutical combinations; 17/21 SpA, 8/15 PsA), with a 58.3% (n=21/36 combinations; 15/20 SpA, 6/13 PsA) low-activity/remission rate. Of the patients who were receiving glucocorticoids, 55% managed to withdraw them during follow-up. Interestingly, only four serious adverse events in three patients were observed, leading to DTT discontinuation.

AB0498 CONCENTRATIONS OF ADVANCED GLYCATION END PRODUCTS (AGEs) CORRELATE WITH INDEXES OF ACTIVITY AND DAMAGE ACCRUAL IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Background

It has been postulated that AGES could have a relevant role as inducers in the chronic inflammatory pathway present in various diseases1; among them, in immune-mediated diseases such as SLE, as well as that its concentration could be related to some parameters of the disease such as activity 2 or accumulated damage 3, showing studies discrepant results to date.

Objectives

To describe correlations between the concentrations of AGEs measured by cutaneous autofluorescence and various parameters related to the disease in a population of SLE patients.

Methods

AGE concentrations were measured by skin autofluorescence (Age Reader Mu Connect from Diagnoptics Technologies BV) in 66 SLE Caucasian patients and correlations with demographic and clinical data were analyzed, after adjusting for age, smoking and corticosteroids as possible confounding factors, according to previous data. Previous validation studies have shown that skin autofluorescence is strongly related to AGE levels in skin biopsies4. The indices were analyzed both as quantitative and categorized variables according to previously established categories or to medians/tertiles/quartiles depending on the distribution of the variable in our population.

Results

Table 1 shows some descriptive characteristics of our cohort. There were clinically and statistically significant differences in the values of AGEs according to the patient’s SLEDAI and SLICC. Specifically, it was observed that AGEs’ values in the population with severe activity according to SLEDAI was 0.61 (95% CI 0.85-2.046; p=0.045) points > than in those in remission (p=0.045); as well as AGEs‘ values in patients with SLICC ≥1 was 1.23 (95% CI 0.49-1.98; p=0.030) points > than in the group without cumulative damage. In all the models, the values of AGEs increased significantly with age, smoking and current treatment with corticosteroids, except for the model including the SLICC variable. Interactions in said model were explored, and it was observed that the concentration of AGES depended on the interaction between the value of SLICC and the intake of corticosteroids, so that differences were only observed between SLICC groups in those who took corticosteroids.

Table 1.

Descriptive characteristics of the cohort. c: categorized.

AverageSD%Age5415BMI25.364.68SmokerNo68.2Yes31.8AGEs2.60.7Disease duration (years)1611DAS282.221.16cDAS28remission71.2low9.1moderate15.2high4.5SLEDAI54cSLEDAIremission21.2low16.7moderate51.5high10.6SLICC11cSLICC00.0148.5>130.3321.2FACIT Fatigue Scale1810Patient global assessment (PGA)3.02.4cPGA0-131.82-328.8>339.4Physician global assessment1.71.3cPhysician global assessment0-147.0>153.0Visual Analogue Scale (VAS)3.13.1cVAS034.81-430.3>434.8Health Assessment Questionnaire (HAQ)0.5270.551cHAQ033.30-0.7536.4>0.7530.3CorticoidsYes27.3No72.7

Conclusion

A correlation with elevated values of AGEs was observed in those SLE patients with higher scores in the indexes of activity (SLEDAI) and damage accrual (SLICC). The fact that the differences in SLICC are only observed in those patients treated with corticosteroids suggests that, maybe, only the accumulated damage related to taking corticosteroids could be mediated by AGEs.

References

[1]Medzhitov R. Origin and physiological roles of inflammation. Nature 2008;454:428–435.

[2]Vytášek R, Šedová L, Vilím V. Increased concentration of two different advanced glycation end-products detected by enzyme immunoassays with new monoclonal antibodies in sera of patients with rheumatoid arthritis. BMC Musculoskelet Disord 2010;11:83.

[3]leeuw K de, Graaff R, Vries R de, Dullaart RP, Smit AJ, Kallenberg CG, Bijl M. Accumulation of advanced glycation endproducts in patients with systemic lupus erythematosus. Rheumatology 2007;46:1551–1556.

[4]Meerwaldt R, Links T, Graaff R, Thorpe SR, Baynes JW, Hartog J, Gans R, Smit A. Simple noninvasive measurement of skin autofluorescence. Ann N Y Acad Sci 2005;1043:290-298.

Disclosure of Interests

None declared

OP0104 EXPANDED CD8+ T CELL CLONES FROM HLA-B*27-POSITIVE PATIENTS WITH SPONDYLOARTHRITIS SHOW SIGNS OF ANTIGEN-EXPERIENCE

Background

The pathogenesis of Spondyloarthritis (SpA) remains unknown but its strong association with some alleles of HLA-B*27 is peculiar. The arthritogenic antigen hypothesis assumes the existence of specific peptides presented by risk-conferring HLA-B*27 alleles to antigen-specific CD8+ T cells, which then initiate or sustain autoimmune reactions. Several studies analyzing T cell receptor (TCR) repertoire found preferred Variable TCR chains and motifs in the hypervariable complementary determining region (CDR) 3, but analyzed only TCR β-chains in bulk analyses1,2.

Objectives

To analyze full sequence information of TCR including matching α- and β-chains from single CD8+ T cells and characterize the transcriptomes of expanded and non-expanded clonotypes in synovial fluid (SF) of SpA patients.

Methods

We included 17 patients with active gonarthritis: 10 patients with HLA-B27 positive (B27pos) SpA, 4 with HLA-B27 negative (B27neg) SpA and 3 rheumatoid arthritis (RA) patients. Antigen-experienced CD8+ T cells were sorted out of SF by flow cytometry. Single cell sequencing was performed for all patients to analyze matching TCR α- and β-chains. For 7 patients (3 B27pos SpA, 2 B27neg SpA, 2 RA), additionally whole transcriptome analyses were performed.

Results

We found strong biases when analyzing α and β chains of TCR Variable regions and CDR1 and CDR2 sequences (Figure 1 a,b): AV21, AV12-2, and AV17 were highly enriched in B27pos SpA as compared to B27neg subjects. Amongst the highest expressed clones, we could confirm enrichment for previously described TRBV genes as BV19, BV5-1 and BV6-2. We examined TCR α/β combinations and focused on those detected in at least three different B27pos SpA but not in any of the B27neg patients (Figure 1 c-f). The combinations TRBV19/TRAV21 and TRBV6-2/TRAV21 were most likely specific for B27pos SpA and might reflect interaction of these TCR chains with HLA-B*27. Sequences of CDR3 loops, which predominantly interact with HLA-bound antigenic peptides, revealed striking common structural motifs in α- and β-chains. Focusing on the most prominent TRAV21 chains pairing with TRBV19, 5-1 and 6-2 chains, revealed identical sequences in different patients and striking common structural motifs in α- and β-CDR3 sequences in other patients. Such marked similarities in the antigen-recognition loops of the β-chains associated with TRAV21 suggest common or highly similar antigens. Gene expression levels provided evidence that expanded cell populations had tissue resident memory (TRM) phenotypes (elevated expression of activation, migration and tissue retention markers, downregulated genes characteristic for T cell egress), while this phenotype was not very pronounced in non-expanded cells. Furthermore, markers for T cell exhaustion and apoptosis were elevated in expanded cells of B27pos SpA patients.

Figure 1.

Distinct TCRαβ V chain usage in expanded clones from HLA-B27 positive SpA patients. A,B Mean number of all productive TRAV (A) and TRBV (B) genes used in expanded, antigen-experienced CD8 T cell clones (>1% of all cells) from SF of 10 B27pos SpA, 4 B27neg SpA and 3 B27neg RA patients. C-F TRAV chains paired with TRBV19 (C), TRBV5-1 (D), TRBV6-2 (E), or TRBV chains paired with TRAV21 (F) with corresponding TRAJ spanning partners in expanded cells (frequency ≥2) from all 10 B27pos SpA. Number of chains are 1250 (C), 886 (D), 1220 (E), and 4006 (F).

Conclusion

Analysis of single antigen experienced CD8+ T cells from SF of B27pos SpA patients revealed significant clonal expansions and common motifs in the CDR loops. Two of the four CDR1 and CDR2 loops were highly homologous suggesting that these loops interact with α-helices of HLA-B*27. Common motifs in CDR3 loops of expanded clonotypes suggest recognition of a limited set of antigenic peptides presented by HLA-B*27. Many of the expanded clonotypes showed a TRM phenotype, were exhausted and on the way to become apoptotic, which suggests that these clones had sustained contact to specific antigens.

References

[1]Komech, et al. Rheumatology 2018

[2]Hanson, et al. A&R 2020

Acknowledgements

We thank all patients included in this study for their participation. This work was funded by the German Research Foundation (DFG) through grants DO 420/4 to KDo, PO 2124/2-1 to DP, and SyNergy (EXC 2145 SyNergy – ID 390857198) to KDo. Judith Rademacher and Katharina Deschler contributed equally. JR is participant in the BIH-Charité Clinician Scientist Program funded by the Charité –Universitätsmedizin Berlin and the Berlin Institute of Health. The authors would like to thank Martina Seipel for excellent technical assistance, Sabrina Sron for patient recruitment and study coordination, and Hildrun Haibel, Mikhail Protopopov, Fabian Proft, Valeria Rios Rodriguez and Laura Spiller for recruiting patients for this study.

Disclosure of Interests

None declared

POS1350 UVEITIS DUE TO IMMUNE-MEDIATED INFLAMMATORY DISEASES TREATED WITH CERTOLIZUMAB PEGOL. MULTICENTER STUDY OF 80 PATIENTS

Background

Adalimumab remains the only biologic approved by the EMA and FDA for the treatment of non-infectious uveitis [1-6]. The reports on efficacy of other anti-TNF drugs such as Certolizumab Pegol (CZP) are scarce.

Objectives

to determine the efficacy and safety of CZP in refractory uveitis secondary to Immune-mediated Inflammatory Diseases (IMIDs).

Methods

national multicenter study of 80 patients with uveitis due to IMID refractory to glucocorticoids and conventional immunosuppressants treated with CZP. Efficacy was assessed with the following ocular parameters: best corrected visual acuity (BCVA), anterior chamber cells, vitritis, macular thickness and presence of retinal vasculitis. The efficacy of CZP was compared between the baseline visit, 1st week, 1st and 6th month, and 1st year. Statistical analysis was performed with IBM SPSS Statistics v.23.

Results

we studied 80 patients/111 affected eyes (33 men/47 women) with a mean age of 41.6±11.7 years. The IMIDs included were: spondyloarthritis (n=43), Behçet’s disease (10), psoriatic arthritis (8), Crohn’s disease (4), sarcoidosis (2), JIA (1), reactive arthritis (1), rheumatoid arthritis (1), relapsing polychondritis (1), TINU (1), pars planitis (1), Birdshot (1) and idiopathic uveitis (6). Anterior was the most frequent uveitis pattern (n=61).

In 20 patients, besides the presence of refractory uveitis, desire of pregnancy was the reason for CZP initiation.

Prior to CZP, patients had received: methotrexate (n=38), sulfasalazine (28), azathioprine (14), cyclosporine (10), leflunomide (3), mycophenolate mofetil (4), and cyclophosphamide (1). Previous biologic therapy was administered in 52 patients (63%), with a median [IQR] of 2 [1-3] drugs per patient. The most used biologic was adalimumab (n=48), followed by infliximab (32), golimumab (15), tocilizumab (5), etanercept (7), rituximab (1), anakinra (1) and secukinumab (1). CZP was administered as monotherapy in 39 patients.

After 24 [12-36] months of follow-up, all parameters analyzed showed a rapid and maintained improvement (Table 1). A decrease in the mean number of uveitis flares was observed before and after CZP, (2.6±2.3 vs. 0.6±0.4, p<0.001). CZP was discontinued in 16 patients due to: ocular remission (n=3), insufficient ocular response (4) and incomplete response of extraocular manifestations (9). No serious adverse effects were found.

Table 1.

main ocular parameters analyzed in 80 patients with uveitis due to IMID and treated with CZP.

Baseline1st week1st month3rd month6th month1st yearBCVA (mean±SD)0.68±0.270.73±0.26*0.79±0.26*0.82±0.25*0.85±0.24*0.86±0.23*Tyndall improvement, n (%)Patients with Tyndall + at baseline (n=57)-23 (40.3)45 (78.9)47 (82.4)57 (100)57 (100)Vitritis improvement, n (%)Patients with Vitritis at baseline (n=14)-5 (35.7)8 (57.1)13 (92.8)14 (100)14 (100)OCT (µm) (mean±SD)297.5±48.1297.1±45.5286.5±39.8*277.6±43.3*271.5±38.6*269.0±38.8*Choroiditis, affected eyes, n (%)3 (2.4)3 (2.4)2 (1.6)2 (1.6)1 (0.8)1 (0.8)Retinal vasculitis, affected eyes, n (%)3 (2.4)2 (1.6)1 (0.8)0 (0)0 (0)0 (0)

*p<0.01

Conclusion

CZP seems to be effective and safe in the control of uveitis associated to different IMIDs.

References

[1]Jaffe GJ, et al. N Engl J Med 2016;375:932-43. doi: 10.1056/NEJMoa1509852.

[2]Nguyen QD, et al. Lancet 2016;388:1183-92. doi: 10.1016/S0140-6736(16)31339-3.

[3]Martín-Varillas JL, et al. Ophthalmology 2018; 125:1444-1451 doi: 10.1016/j.ophtha.2018.02.020

[4]Martín-Varillas JL, et al. J Rheumatol. 2021;48:741-750. doi: 10.3899/jrheum.200300

[5]Atienza-Mateo B. Arthritis Rheumatol. 2019;71:2081-2089. doi: 10.1002/art.41026.

[6]Vegas-Revenga N et al Am J Ophthalmol. 2019;200:85-94. doi: 10.1016/j.ajo.2018.12.019

Disclosure of Interests

None declared

AB1310 JANUS KINASE INHIBITORS IN SEVERE AND REFRACTORY INFLAMMATORY OCULAR PATHOLOGY. CASES REPORTS AND LITERATURE REVIEW

Background

Inflammatory ocular pathology (IOP) includes internal and external involvement. IOP may be severe ocular conditions refractory to conventional immunosuppressants and even biological therapy. Janus Kinase inhibitors (JAKINIB) had shown efficacy in refractory cases of different immune-mediated inflammatory diseases (IMID).

Objectives

In patients with refractory IOP treated with JAKINIB our aims were a) to assess the patients of Spanish referral centers, b) Literature review.

Methods

Multicenter study of 6 patients with refractory IOP treated with JAKINIB. For Literature review a search was conducted in PubMed, Embase and the Cochrane library from their inception to 1st January 2022, and conference proceedings from four major rheumatology conferences. In addition, a therapeutical approach of refractory IOP is proposed.

Results

We have identified 6 cases in five University Hospitals and 11 cases in the literature review. These 17 patients (14 women/ 3 men) (24 affected eyes), mean age 35.5±23.4 years had different refractory IOP (uveitis=11; scleritis= 3, PUK= 3).

Most of IOP were associated with IMID (n=13, 76.5%). The main underlying IMID were juvenile idiopathic arthritis (n=5, 29.4%), rheumatoid arthritis (n=2, 11.8%) and spondyloarthritis (n=2; 11.8%) (Table 1).

Table 1.

Cases reports and Literature review

Study, yearCasesAge/ SexUnderlying IMIDJAKINIBOcular involvementPrevious immunosuppressive treatmentOcular Improvement(Ref)Meadow et al. 2014159, FRATOFAPUKMTX, ABA, ivMPPartial (PI)(1)Bauermann et al. 2018122, FJIATOFAA. uveitis, CMEMTX, ADA, RTX, GOLI, IFX, CsA, TCZ, MMFComplete (CI)(2)Paley et al. 201921.40, F1.Idiopathic1.TOFA1.Scleritis1.MTX, MMF, AZA, CYP1.CI(3)2.45, F2.Idiopathic2.TOFA2.A. uveitis, CME2.MTX, LFN, AZA, MMF, ADA, IFX, CZP, intravitreal fluocinolone ac.2.CILiu J et al. 2020130, MBehçet disTOFAScleritisSSZ, MTX, AZA, LFN, THD, COL, GLMPI(4)Majumder et al. 2020126, FVogt-Koyanagi- Harada disTOFAP. uveitisivMPCI(5)Miserocchi et al. 202041. 9, FJIA1. TOFA1. Panuv1. IFX, ADA, LFN, ABA, RTX, TCZ.1. CI2. 1, F2. BARI2. Panuv2. MTX, ADA, IFX, RTX, ABA.2. CI(6)3. 2, F3. BARI3. Panuv3. MTX, AZA, IFX, ADA, TCZ.3. CI4. 10, M4. BARI4. Panuv4. ETN, MTX, CsA, IFX, ADA, ABA, TCZ, RTX.4. CIPyare et al. 2020145, FIdiopathicTOFANecrotizing scleritisMMFCI(7)Present study, 202261. 25, F1. Blau Syndrome1. TOFA/BARI1. Panuv1.MTX, ETN, ANA, ABA1. CI2. 85, F2. RA2. BARI2. PUK2.MTX, LFN, CZP, ADA, iv MP.2. CI3. 41, F3. Relapsing polychondritis3. BARI3. PUK3. MTX, CsA, SSZ, MMF, AZA, IFX, TCZ, CZP, ABA, ADA.3. CI4. 65, F4. Idiopathic4. BARI4. Panuv4. MTX, AZA4. CI5. 59, M5. AS5. UPA5. A. uveitis5. MTX, ADA5. CI6. 40, F6. SpA and ulcerative colitis6. TOFA6. A. uveitis6. MTX, AZA, ADA6. CI

Uveitis (n=11) followed by ocular surface pathology (n=6) were the most frequent subtypes of IOP. Patterns of uveitis were panuveitis (n=6), anterior uveitis (n=4; 2 of them with Cystoid macular edema) and posterior (n=1). Ocular surface pathology was due to scleritis (n=3) and PUK (n=3).

Besides systemic corticosteroids, before JAKINIB, conventional (n= 16; 94.1%) and biological immunosuppressive drugs (n=13; 76.5%) were required. The JAKINIB most widely used was tofacitinib (n= 10; 58.8%) followed by baricitinib (n=7; 41.2%). In only one patient with Blau Syndrome and uveitis, tofacitinib was switched to baricitinib due to severe lymphopenia.

After starting JAKINIB treatment, all patients presented clinical improvement, complete (n=15, 88.2%) or partial (n= 2; 11.8%).

Based on these data a therapeutical approach of refractory IOP was proposed (Figure 1).

Figure 1.

Therapeutical approach

Conclusion

JAKINIB may be an effective and safe therapy in IOP refractory to conventional or even biological immunosuppressive therapy.

References

[1]Meadow PB. Case Rep Rheumatol. 2014.

[2]Bauermann P. Ocul Immunol Inflamm. 2019.

[3]Paley MA. Am J Ophthalmol Case Reports. 2019.

[4]Liu J. Ann Rheum Dis. 2020.

[5]D Majumder. Indian J Ophthalmol. 2020.

[6]Miserocchi E. Clin Rheumatol. 2020.

[7]Pyare E. Indian J Ophtalmol, 2020.

Disclosure of Interests

None declared

Sustained low disease activity measured by ASDAS slow radiographic spinal progression in axial spondyloarthritis patients treated with TNF-inhibitors: data from REGISPONSERBIO

Background

To evaluate the influence of the disease activity on radiographic progression in axial spondyloarthritis (axSpA) patients treated with TNF inhibitors (TNFi).

Methods

The study included 101 axSpA patients from the Spanish Register of Biological Therapy in Spondyloarthritides (REGISPONSERBIO), which had clinical data and radiographic assessment available. Patients were classified into 2 groups based on the duration of TNFi treatment at baseline: (i) long-term treatment (≥4 years) and (ii) no long-term treatment (< 4 years). Radiographs were scored by two readers according to the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) with known chronology. Disease activity differences between patients’ groups at each time point were assessed using a linear mixed-effect model.

Results

Radiographic progression was defined as an increase in ≥2 mSASSS units. At inclusion, approximately half of the patients (45.5%) were receiving long-term treatment with TNFi (≥4 years). In this group of subjects, a significant difference in averaged Ankylosing Spondylitis disease Activity Score (ASDAS) across follow-up was found between progressors and non-progressors (2.33 vs 1.76, p=0.027, respectively). In patients not under long-term TNFi treatment (54.5%) though, no significant ASDAS differences were observed between progressors and non-progressors until the third year of follow-up. Furthermore, no significant differences were found in progression status, when disease activity was measured by Bath Ankylosing spondylitis Disease Activity Index (BASDAI) and C reactive protein (CRP).

Conclusions

Patients on long-term TNFi treatment with a mean sustained low disease activity measures by ASDAS presented lower radiographic progression than those with active disease.

Intravenous methylprednisolone induces rapid improvement in non-infectious uveitis: a multicentre study of 112 patients

OBJECTIVES

Rapid control of intraocular inflammation in non-infectious uveitis (NIU) is mandatory to avoid irreversible structural and functional damage. In this study, we assessed the efficacy and safety of intravenous methylprednisolone (IVMP) pulses in the treatment of NIU.

METHODS

A retrospective case series of 112 patients who received IVMP for the treatment of NIU, either isolated or associated with different underlying diseases, was studied. Intraocular inflammation (anterior chamber cells and vitritis) was the primary outcome measure. Secondary outcome measures were macular thickness and best corrected visual acuity (BCVA). Patients were assessed at baseline visit, and at days 2-5, 7, 15 and 30 after initiation of IVMP pulse therapy.

RESULTS

A total of 112 patients (mean age 42±14.5 yrs) were assessed. An underlying immune-mediated disease was diagnosed in 73 patients. Inflammatory ocular patterns were panuveitis (n=68), posterior uveitis (n=30), anterior uveitis (AU) (n=12), and intermediate uveitis (n=2). Additionally, patients presented cystoid macular oedema (CME) (n=50), retinal vasculitis (n=37), and exudative retinal detachment (n=31). Therapies used before IVMP included intraocular glucocorticoids (n=4), high-dose oral systemic glucocorticoids (n=77), and conventional (n=107) or biologic (n=40) immunosuppressive drugs. IVMP dose ranged from 80 to 1,000 mg/day for 3-5 consecutive days. Improvement was observed in AU, vitritis, BCVA, CME, and retinal vasculitis. At first month evaluation, total remission was achieved in 19 patients. Side effects of IVMP were respiratory infections (n=3), uncontrolled hyperglycaemia (n=1), herpes zoster (n=1), and oral candidiasis (n=1).

CONCLUSIONS

IVMP pulse therapy was effective and safe, and achieved rapid control of NIU.

Tocilizumab in Behçet's disease with refractory ocular and/or neurological involvement: response according to different clinical phenotypes

OBJECTIVES

Anti-IL6R tocilizumab (TCZ) therapy has proved to be useful in the treatment of refractory ocular and/or neurological involvement of Behçet's disease (BD). However, TCZ efficacy in other BD manifestations remains unclear. In this study we aimed to assess the efficacy of TCZ in the different clinical phenotypes of BD.

METHODS

This is a multicentre study of BD patients treated with TCZ, due to refractivity to standard systemic treatment.

RESULTS

We studied 16 patients (10 men/6 women); mean age 36.5±18.2 years. The main clinical manifestations at TCZ onset were ocular, oral and/or genital ulcers, arthritis, folliculitis and/or neurological involvement. Before TCZ, they had received several conventional and/or biological immunosuppressants, such as methotrexate, cyclosporine, adalimumab or infliximab. TCZ was used in monotherapy or combined with conventional immunosuppressive drugs. The main indications for TCZ prescription were refractory uveitis (n=14) and refractory neurobehçet (n=2). After a median [IQR] follow-up of 20 [9-45] months using TCZ, neurological and ocular domains improved in most cases with complete remission in most patients with uveitis. Articular and peripheral venous manifestations also experienced a favourable evolution. However, oral/genital ulcers, skin lesions and intestinal manifestations followed a torpid course.

CONCLUSIONS

TCZ is effective in BD with major clinical involvement. However, it does not seem to be effective in oral/genital ulcers or skin lesions.

AB0542 EVALUATION OF APREMILAST USE IN THE ROUTINE CLINICAL PRACTICE IN PATIENTS WITH PSORIATIC ARTHRITIS NAÏVE TO BIOLOGICAL TREATMENTS

Background:

Apremilast is a non-biologic systemic agent approved for the treatment of plaque psoriasis, oral ulcers of Behcet’s disease and PsA with proven efficacy in clinical trials [1,2]. However, more real-world evidence of apremilast use and effectiveness is needed to identify the patient profile most likely to benefit from this treatment [3].

Objectives:

To evaluate the persistence of apremilast treatment in patients with PsA naïve to biological treatments in routine clinical practice and assess its effectiveness. Baseline clinical characteristics on patients who started apremilast were also evaluated.

Methods:

Observational, prospective, multicenter (20 centers) study including consecutive adult patients with PsA naïve to biological therapies who had started treatment with apremilast during the previous 5 to 7 months and were followed-up during 12 months. Variables recorded were persistence of treatment with apremilast at 6 months (6mo) and number of swelling joints, presence of enthesitis and dactylitis, and disease activity, measured by the Disease Activity in Psoriatic Arthritis (DAPSA) score and Physician Global Assessment (PGA) of psoriasis, collected at baseline (BL) (i.e., apremilast treatment start) and 6mo; comorbidities were retrospectively collected at BL. Categorical and quantitative variables were compared using McNemar’s and Wilcoxon test, respectively. Data sets analyzed included all assessable patients.

Results:

Of the 60 patients recruited at the time of this interim analysis, 54 (90.0%) [mean (SD) age 53.4 (13.9) years] were assessable; 41 (75.9%) of these continued treatment with apremilast at 6mo. At BL, 34 (63.0%) patients had at least one comorbidity, the most frequent being cardiovascular disease (n=15, 27.8%), including hypertension (n=8, 14.8%), metabolic/endocrine disease (n=18, 33.3%), including obesity (n=8, 14.8%) and dyslipidemia (n=10, 18.5%). Psychiatric disease (i.e., depression) (n=5, 9.3%) and neoplasia (n=8, 14.8%) were also observed. The number of swelling joints decreased from median (Q1, Q3) 4.0 (2.0, 7.0) at BL to 1.5 (0.0, 4.0) at 6mo (p=0.0012). Patients with dactylitis and enthesitis decreased from 19 (35.2%) and 16 (29.6%) at BL to 10 (18.5%) and 9 (16.7%) at 6mo (p=0.0225 and p=0.0391), respectively. The distribution of patients in the different disease activity categories according to DAPSA scale changed between BL and 6mo, indicating a favorable disease evolution (Figure 1 next page). According to PGA, at BL (n=53), disease activity was categorized as mild in 18.0%, as moderate in 72.0%, and as severe in 10% of patients and, at 6mo (n=54), as mild in 70.6%, as moderate in 25.5%, and as severe in 3.9% of patients. Fifteen (27.8%) patients interrupted treatment permanently (n=13, 24.1%) or temporarily (n=2, 3.7%), due to no/partial response (n=8, 14.8%), tolerability issues leading to adverse events (n=3, 5.6%), patient decision (n=2, 3.7%), and other reasons (n=2, 3.7%) after a mean (SD) treatment of 3.05 (2.20) months.

Conclusion:

Forty-one (75.9%) patients with PsA naïve to biological therapies were treated with apremilast during ≥6 months. After treatment, the number of swelling joints, and dactylitis and enthesitis decreased and changes in disease activity according to DAPSA and PGA pointed to a favorable disease evolution. Apremilast treatment provides a clinical benefit to patients with PsA treated in clinical practice.

References:

[1]Gossec L, Smolen JS, Ramiro S, et al. European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update. Ann Rheum Dis. 2016 Feb 10;75(3):499 LP-510

[2]Torres T and Puig L. Apremilast: A novel oral treatment for psoriasis and psoriatic arthritis. Am J clin Dermatol. 2018 Feb;19(1):23-32

[3]Coates LC, Kavanaugh A, Mease PJ et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis 2015. Treatment Recommendations for Psoriatic Arthritis. Arthritis Rheumatol. 2016;68(5):1060– 71.

Disclosure of Interests:

Jordi Gratacos-Masmitja Speakers bureau: MSD, Pfizer, AbbVie, Janssen Cilag, Novartis, Celgene y Lilly., Consultant of: MSD, Pfizer, AbbVie, Janssen Cilag, Novartis, Celgene y Lilly., José Luis Álvarez Vega Speakers bureau: Abbvie, Amgen, MSD, Lilly, Roche, Esteve, UCB, Menarini, Pfizer, GSK, BMS, Janssen, Novartis, Gebro., Consultant of: Abbvie, Amgen, MSD, Lilly, Roche, Esteve, UCB, Menarini, Pfizer, GSK, BMS, Janssen, Novartis, Gebro., Grant/research support from: Abbvie, Amgen, MSD, Lilly, Roche, Esteve, UCB, Menarini, Pfizer, GSK, BMS, Janssen, Novartis, Gebro., Emma Beltrán Speakers bureau: Abbvie, Bristol, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Consultant of: Abbvie, Bristol, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, ANA URRUTICOECHEA-ARANA: None declared., C. Fito-Manteca: None declared., Francisco Maceiras: None declared., Joaquin Maria Belzunegui Otano Speakers bureau: Lilly, Amgen, Novartis, Abbvie, Janssen., J. Fernández-Melón Speakers bureau: Amgen SL, Eugenio Chamizo Carmona: None declared., Abad Hernández Speakers bureau: MSD, Abbvie, Pfizer, Kern, Novartis, Biogen, Sandoz, Amgen, Sanofi, Lilly, Roche and Janssen-Cilag, Consultant of: MSD, Abbvie, Pfizer, Kern, Novartis, Biogen, Sandoz, Amgen, Sanofi, Lilly, Roche and Janssen-Cilag, Grant/research support from: MSD, Abbvie, Pfizer, Kern, Novartis, Biogen, Sandoz, Amgen, Sanofi, Lilly, Roche and Janssen-Cilag, Inmaculada Ros Consultant of: Amgen, Grant/research support from: MSD, Roche, Novartis, lilly, Pfizer, Amgen, Eva Pascual Shareholder of: Amgen, Employee of: Amgen, Juan Carlos Torre Speakers bureau: Amgen, Lilly, Novartis, Janssen, Pfizer, Consultant of: Amgen, Lilly, Novartis, Janssen, Pfizer, Grant/research support from: Amgen, Lilly, Novartis, Janssen, Pfizer.

POS0978 DISEASE CONTROL IN PSORIATIC ARTHRITIS PATIENTS WITH OR WITHOUT AXIAL MANIFESTATIONS IN REAL CLINICAL PRACTICE IN SPAIN: RESULTS FROM THE MIDAS STUDY

Background:

MIDAS study assessed the disease activity in psoriatic arthritis (PsA) patients treated in clinical practice in Spain.

Objectives:

This sub-analysis compared disease activity between PsA patients with or without axial manifestations.

Methods:

MIDAS is an observational, non-interventional, cross-sectional, multicenter study conducted in Spain. Patients included were ≥18 years old with ≥6 months since diagnosis, were classified by CASPAR criteria and had initiated treatment ≥3 months. Disease activity was measured by Disease Activity in Psoriatic Arthritis (DAPSA) and Minimal Disease Activity (MDA). Axial involvement was defined according to the presence of inflammatory back pain assessed by rheumatologist.

Results:

312 evaluable PsA patients were included in this analysis, 12.2% of which presented with axial involvement. PsA patients with axial manifestations reported longer time from onset of symptoms to diagnosis and disease duration, higher presence of concomitant diseases, HLA-B*27+ status, C-reactive protein (CRP) levels, perception of uncontrolled disease and presence of swollen and tender joints compared to patients without axial involvement. A higher proportion of PsA patients with axial manifestations were treated with a biologic compared with those without axial involvement 68.4% vs 57.3% (Table 1). Patients with axial involvement showed a higher impairment of their quality of life compared to those without axial manifestations by a worse higher mean (SD) Psoriatic Arthritis Impact of Disease 12-item questionnaire (PSAID12) score (5.0 [2.4] vs 2.7 [2.2], respectively). In terms of disease control more patients with axial manifestations presented with moderate to high disease activity (DAPSA>14: 65.7% vs 36.8%, respectively) and did not meet the MDA criteria for remission (89.5% vs 42.7%, respectively) (Figure 1).

Conclusion:

PsA patients with axial manifestations presented with a higher burden of disease and showed a worse disease control compared to those without axial involvement.

Table 1.

Baseline demographic and clinical characteristics

With axial manifestations(n=38)Without axial manifestations (n=274)PsA(n=312)Age (years), mean (SD)53.1 (10.4)54.1 (12.4)54.0 (12.2)Sex (male), n (%)17 (44.7%)153 (55.8%)170 (54.5%)Time since diagnosis (years), mean (SD)13.6 (10.1)10.1 (8.8)10.5 (9.0)Time from onset of symptoms to diagnosis (years), mean (SD)4.3 (6.1)2.8 (4.8)3.0 (5.0)Presence of concomitant diseases, mean (SD)26 (68.4%)166 (60.6%)192 (61.5%)Anemia, n (%)3 (7.9%)7 (2.6%)7 (2.2%)Anxiety, n (%)6 (15.8%)9 (3.3%)1 (0.3%)Asthma, n (%)2 (5.3%)7 (2.6%)1 (0.3%)Depression, n (%)6 (15.8%)1 (0.4%)1 (0.3%)Dyslipidemia, n (%)3 (7.9%)8 (2.9%)9 (2.9%)Hypertension, n (%)3 (7.9%)7 (2.6%)9 (2.9%)Others (excluding skin psoriasis, uveitis, or IBD), n (%)3 (7.9%)17 (6.2%)19 (6.1%)Presence of HLA-B*27+, n (%)6 (15.8%)28 (10.2%)34 (10.9%)CRP levels (mg/l), mean (SD)7.3 (11.3)4.6 (6.5)4.9 (7.3)Patient perceived disease control (PASS), n (%)30 (78.9%)228 (83.5%)258 (83.0%)Presence of swollen (SJC≥1), n (%)22 (57.9%)117 (42.7%)139 (44.6%)Presence of tender joints (TJC≥1), n (%)14 (36.8%)74 (27.0%)88 (28.2%)Patients treated with biological26 (68.4%)157 (57.3%)183 (58.7%)

COPD, chronic obstructive pulmonary disease; CRP, C-reactive protein; HLA-B*27, human leukocyte antigen B27; IBD, inflammatory bowel disease; PASS, patient acceptable symptom state; PsA, psoriatic arthritis; SD, standard deviation; SJC, swollen joint counts; TJC, tender joint counts.

Figure 1.

Disease status according to clinical phenotype of PSA A) Disease activity according to DAPSA B) Disease activity according to MDA DAPSA, Disease Activity in Psoriatic Arthritis; MDA, Minimal Disease Activity; PsA, psoriatic arthritis.

Acknowledgements:

We thank to MIDAS group investigators and patients included in the study.

Disclosure of Interests:

Eugenio de Miguel Speakers bureau: AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi., Paid instructor for: Janssen, Novartis, Roche, Consultant of: AbbVie, Novartis, Pfizer, Galapagos, Grant/research support from: Abbvie, Novartis, Pfizer, Jordi Gratacos-Masmitja Speakers bureau: During the course of the year I have received funding in relation to courses and / or conferences, and / or have participated as a speaker or in advisory boards from: MSD, Pfizer, AbbVie, Janssen Cilag, Novartis, Lilly and Amgen., Consultant of: During the course of the year I have received funding in relation to courses and / or conferences, and / or have participated as a speaker or in advisory boards from: MSD, Pfizer, AbbVie, Janssen Cilag, Novartis, Lilly and Amgen., Grant/research support from: During the course of the year I have received a private grand from Pfizer.

I have not received any private influence in the elaboration of the contents of this talk., Ana Paula Cacheda: None declared, José M. Rodríguez-Heredia Speakers bureau: Amgen, Novartis, Sanofi, Consultant of: Amgen, Biogen, Fresenius, MSD, Janssen, Roche, Novartis, Pfizer, Sanofi, Adela Gallego Speakers bureau: During the course of the year I have received funding in relation to courses and / or conferences, and / or have participated as a speaker or in advisory boards from: MSD, Pfizer, AbbVie, Janssen, Novartis, Lilly, Amgen and Sanofi.

I have not received any private influence in the elaboration of the contents of this talk., Grant/research support from: During the course of the year I have received funding in relation to courses and / or conferences, and / or have participated as a speaker or in advisory boards from: MSD, Pfizer, AbbVie, Janssen, Novartis, Lilly, Amgen and Sanofi.

I have not received any private influence in the elaboration of the contents of this talk., Emma Beltrán Speakers bureau: Abbvie, Bristol, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Consultant of: Abbvie, Bristol, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Beatriz Font Ramos Employee of: Novartis employee, Carlos Sastré Employee of: Novartis employee, Cristina Sanabra Employee of: Novartis employee.

OP0060 COMPARATIVE STUDY ON ANTI-TNF VS TOCILIZUMAB FOR TREATMENT OF REFRACTORY UVEITIC CYSTOID MACULAR EDEMA DUE TO BEHCET’S DISEASE. MULTICENTER STUDY OF 49 PATIENTS

Background:

Posterior segment involvement is the most serious affection of uveitis in Behçet’s disease (BD), with cystoid macular edema (CME) being the leading cause of blindness. Anti-TNF, especially adalimumab (ADA) and infliximab (IFX), have demonstrated efficacy as first-line biologic agents in BD-related uveitis [1,2]. Moreover, the anti-IL6R tocilizumab (TCZ) has shown excellent results in highly refractory BD-uveitis and noninfectious uveitic CME [3-6].

Objectives:

To compare the efficacy of ADA vs IFX vs TCZ in patients with refractory CME due to BD.

Methods:

Observational multicenter study of patients with BD-associated CME refractory to conventional and/or biological immunosuppressive drugs. From a cohort of 177 patients treated with anti-TNF and 14 patients treated with TCZ, we selected those with CME at baseline. CME was defined as macular thickness > 300μm (measured by optic coherence tomography). We analyzed in the 3 groups of treatment (ADA, IFX, TCZ) from baseline up to 4 years the evolution of macular thickness (main outcome) and best-corrected visual acuity (BCVA). Differences between basal and final follow-up were evaluated. Multivariable linear regression was used to assess the differences between the 3 groups.

Results:

A total of 49 patients were included. ADA was used in 25 patients (40 eyes with CME), IFX in 15 (21 eyes with CME) and TCZ in 9 (11 eyes with CME). No statistically significant baseline differences were observed between the 3 groups (Table) except for previous anti-TNF therapy, which was used only in patients treated with TCZ (5 patients received ADA, 1 received IFX and 2 received both ADA and IFX, in different times). Most patients from all groups had received several conventional immunosuppressive drugs. Biological therapy was used in monotherapy or combined with azathioprine (n=10, 5 and 1 in ADA, IFX and TCZ group, respectively), cyclosporine A (n=10, 5 and 1) or methotrexate (n=4, 2 and 3). Macular thickness progressively decreased in the 3 groups, with no signs of CME after 1 year of treatment. Similarly, BCVA improvement and inflammatory ocular remission was reached in all groups (Figure).

Table 1.

Demographic and clinical characteristics of 49 patients with cystoid macular edema due to Behçet’s disease receiving ADA, IFX or TCZ.

ADA (n=25)IFX (n=15)TCZ (n=9)Eyes with cystoid macular edema, n402111Age, years41 ± 1138 ± 943 ± 16Sex, men/women12/137/85/4HLA–B51 +, n19106Duration of uveitis before anti-TNF/ anti-IL6R, months30 [12-82]15 [8-60]32 [24-144]Ocular features at start of anti-TNF/anti-IL6R Macular thickness, μm432 ± 118483 ± 126417 ± 113 Visual acuity, BCVA0.4 ± 0.20.3 ± 0.20.2 ± 0.2 Tyndall, inflammation grade2 [1-3]1 [0-1.5]1 [0-1.5] Vitritis, inflammation grade2.5 [1.5-3]1 [0-2]2 [1-2]Previous treatment, n Oral glucocorticoids // i.v. pulse methylprednisolone18 // 134 // 97 // 8 MTX //CsA //AZA13 // 22 // 148 // 13 // 88 // 6 // 2 ADA // IFX0 // 00 // 07 // 3Prednisone dosage at start of anti-TNF/anti-IL6R, mg/day45 [30-60]30 [20-60]30 [30-30]Combined treatment, n CsA // AZA // MTX10 // 10 // 45 // 5 // 21 // 1 // 3

Data are presented as mean ± SD or median [IQR] when data were not normally distributed. ADA, adalimumab; AZA, azathioprine; CsA, cyclosporine A; MTX, methotrexate; IFX, infliximab; TCZ, tocilizumab.

Figure 1.

Evolution of ocular parameters in 49 patients with cystoid macular edema due to Behçet’s disease receiving ADA, IFX or TCZ.

Conclusion:

Refractory CME associated to BD’s uveitis can be effectively treated with ADA, IFX or TCZ. Moreover, TCZ is effective in patients resistant to anti-TNF therapy.

References:

[1]Arthritis Rheumatol. 2019;71(12):2081-2089. doi: 10.1002/art.41026

[2]Ophthalmology. 2018;125(9):1444-1451. doi: 10.1016/j.ophtha.2018.02.020

[3]Rheumatology (Oxford). 2018;57(5):856-864. doi: 10.1093/rheumatology/kex480

[4]Am J Ophthalmol.2019;200:85-94. doi: 10.1016/j.ajo.2018.12.019

[5]Clin Exp Rheumatol. 2014;32(4 Suppl 84): S54-7. PMID: 25005576

[6]Clin Exp Rheumatol. 2016;34(6 Suppl 102): S34-S40. PMID:27054359

Disclosure of Interests:

None declared

POS1340 MULTICENTER STUDY OF 71 PATIENTS WITH REFRACTORY UVEITIS RELATED TO IMMUNE-MEDIATED INFLAMMATORY DISEASES ON CERTOLIZUMAB PEGOL TREATMENT

Background:

Prognosis of non-infectious refractory uveitis has improved markedly with biologic therapy (BT) (1-5). Most data are with monoclonal anti-TNF drugs, especially Adalimumab (ADA) and Infliximab (IFX). However, there is not enough evidence for the use of Certolizumab Pegol (CZP).

Objectives:

To evaluate the efficacy and safety of CZP in refractory uveitis secondary to Immune-Mediated Inflammatory Diseases (IMID).

Methods:

Multicenter study of 71 patients with uveitis due to IMID refractory to glucocorticoids and conventional immunosuppressants. Efficacy was assessed with the following ocular parameters: best corrected visual acuity (BCVA), anterior chamber cells, vitritis, macular thickness and presence of retinal vasculitis. These outcomes were compared between baseline, 1st week, 1st and 6th month, and 1st and 2nd year. Statistical analysis was performed with IBM SPSS Statistics v.23.

Results:

71 patients/100 affected eyes (29 men/42 women) with mean age of 40.0±11.3 years were studied. Underlying IMIDs were: spondyloarthritis (n=38), Behçet (10), psoriatic arthritis (8), Crohn disease (3), sarcoidosis (2), JIA (1), reactive arthritis (1), rheumatoid arthritis (1), relapsing polychondritis (1), TINU (1), pars planitis (1), Birdshot (1) and idiopathic uveitis (3). Uveitis pattern was anterior (n=55), posterior (6), panuveitis (6) and intermediate (4).

Prior to CZP, patients had received: methotrexate (37), sulfasalazine (26), azathioprine (14), cyclosporine (10), leflunomide (3), mycophenolate mofetil (3) and cyclophosphamide (1). Previous BT was administered in 48 (67.6%) patients, with a mean of 1.4±1.3 drugs per patient as follows: ADA (n=56), IFX (27), golimumab (14), tocilizumab (5) and etanercept (3). Pregnancy was the reason for prescribing CZP in 19 patients. CZP was administered in monotherapy (n=39) or combined with conventional immunosuppressants (n=32).

After a mean follow-up of 27.1±21.1 months, most of the ocular variables showed a rapid and significantly improvement (Table 1). A decrease in the median number [IQR] of flares of uveitis before and after CZP, (3 [1-4] vs. 0 [0-1], p<0.001) was observed. CZP was discontinued in 15 patients due to remission (n=2), ocular insufficient response (2) and incomplete response of extraocular manifestations (11). No serious adverse events were reported.

Conclusion:

CZP seems to be effective and safe in patients with refractory uveitis due to IMID.

References:

[1]Martín-Varillas JL, et al. Ophthalmology 2018; 125:1444-1451. doi: 10.1016/j.ophtha.2018.02.020.

[2]Atienza-Mateo B, et al. Arthritis Rheumatol 2019; 71:2081-2089. doi: 10.1002/art.41026.

[3]Santos-Gómez M, et al. Clin Exp Rheumatol 2016; 34(6 Suppl 102):S34-S40. PMID: 27054359

[4]Vegas-Revenga N, et al. Am J Ophthalmol 2019; 200:85-94. doi: 10.1016/j.ajo.2018.12.019

[5]Calvo-Río V, et al. Clin Exp Rheumatol. 2014; 32 (4 Suppl 84):S54-7. PMID: 25005576

Table 1.Baseline1stweek1stMonth6thMonth1styear2ndyearBCVA (mean±SD)0.68±0.270.72±0.27*0.79±0.25*0.84±0.24*0.85±0.25*0.87±0.22*Improvement in AC Cells, n (%)Patients with AC cells at baseline (n=48)-21 (43.7)30 (62.5)*41 (85.4)*48 (100)*48 (100)*Improvement in Vitritis, n (%)Patients with vitritis at baseline (n=13)-3 (23.1)8 (61.5)*11 (84.6)*13 (100)*13 (100)*OCT (µ) (mean±SD)292.5±47.7294±47.4286.7±41.9*274.7±38.7*272.8±38.9*266.31±36.2*Choroiditis; affected eyes, n, (%)3 (4.2)3 (4.2)2 (2.8)2 (2.8)1 (1.4)0 (0)Retinal Vasculitis; affected eyes, n, (%)2 (2.8)0 (0)1 (1.4)0 (0)0 (0)0 (0)

*p<0.001

Disclosure of Interests:

None declared

AB0771 HIGH DOSE INTRAVENOUS METHYLPREDNISOLONE INDUCES RAPID IMPROVEMENT OF VISUAL ACUITY IN NON-INFECTIOUS UVEITIS OF DIFFERENT IMMUNE MEDIATED INFLAMMATORY DISEASES

Background:

Rapid and effective remission-inducing therapy is mandatory in uveitis to avoid irreversible structural and functional damage. In some severe cases biological agents might be required (1-6).

High-dose intravenous methylprednisolone (IVMP) may achieve prompt control of inflammation in most immune mediated inflammatory diseases (IMID), including non-infectious uveitis (NIU).

Objectives:

To evaluate the efficacy and safety of IVMP pulse therapy in NIU of different IMID.

Methods:

Multicentre study of 71 patients with severe uveitis who received IVMP. The underlying diseases were: Vogt Koyanagy Harada disease (VKHD) (n=24), Behçet disease (BD) (19), Sarcoidosis (5) and idiopathic NIU (23). The main outcome variable was Best-Corrected Visual Acuity (BCVA) estimated using the Snellen chart. BCVA that was assessed at 0 (basal), 2-5, 7, 15 and 30 days after IVMP.

The results are expressed as mean ±SD in normally distributed variables, or as median [IQR] when are not. Comparison of continuous variables was performed using the Wilcoxon test.

Results:

We studied 46♀/ 25♂ patients. The main features are shown in Table 1. IVMP dose ranged from 250 to 1000 mg/day administered for 3-5 consecutive days, the dose was established according to the presence or not of other systemic manifestations apart from uveitis. All of them had active intraocular inflammation at the moment of the study. BCVA values improved considerably after 1 month (Figure 1). No major side effects were observed.

Figure 1.

Improvement of best corrected visual acuity (BCVA).

Conclusion:

High-dose IVMP pulse therapy is useful and safe for a prompt control of BCVA regardless of the underlying IMID.

References:

[1]Vegas-Revenga N, et al. Am J Ophthalmol. 2019; 200:85-94. doi: 10.1016/j.ajo.2018.12.019

[2]Calvo-Río V, et al. Clin Exp Rheumatol. 2014;32(4 Suppl 84): S54-7. PMID: 25005576

[3]Santos-Gómez M, et al. Clin Exp Rheumatol. 2016;34(6 Suppl 102): S34-S40. PMID:27054359

[4]Atienza-Mateo B, et al. Rheumatology (Oxford) 2018;57(5):856-864. doi: 10.1093/rheumatology/kex480.

[5]Atienza-Mateo B, et al. Arthritis Rheumatol. 2019; 71(12):2081-2089. doi: 10.1002/art.41026.

[6]Martín-Varillas JL, et al. Ophthalmology. 2018;125(9):1444-1451. doi: 10.1016/j.ophtha.2018.02.020

Table 1.

Main features of 71 patients with NIU. Data are of affected eyes.

VKHD(n=24)Idiophatic(n=23)Behcet’s disease (n=19)Sarcoidosis(n=5)Overall(n=71)Men/Women, n5/199/149/102/371Mean age (years) ±SD42 ±1147 ± 1533±1042 ± 22-Unilateral/Bilateral NIU, n (%)2 (8.3)/22(91.7)10 (43.5)/13(56.5)4 (21)/15 (79)3(60)/2(40)19/52NIU patterns, n (%) Posterior uveitis6 (25)9 (39.1)3 (15.8)1 (20)19 Panuveitis18 (75)14 (60.9)16 (84.2)4 (80)52Laboratory data, n (%) ANA2 (8.34)2 (8.7)0 (0)1 (20)5 HLA B270 (0)4 (17.4)0 (0)0 (0)4 HLA B290 (0)1 (4.3)0 (0)0 (0)1 HLA B510 (0)5 (21.7)8 (42)3 (60)16 Angiotensin Converting Enzyme (ACE)1 (4.17)2 (8.7)0 (0)1 (20)4

Disclosure of Interests:

None declared

Long-term Follow-up and Optimization of Infliximab in Refractory Uveitis Due to Behçet Disease: National Study of 103 White Patients

OBJECTIVE

In a large series of White patients with refractory uveitis due to Behçet disease (BD) being treated with infliximab (IFX), we assessed (1) long-term efficacy and safety of IFX, and (2) IFX optimization when ocular remission was achieved.

METHODS

Our multicenter study of IFX-treated patients with BD uveitis refractory to conventional immunosuppressant agents treated 103 patients/185 affected eyes with IFX as first biologic therapy in the following intervals: 3-5 mg/kg intravenous at 0, 2, 6, and then every 4-8 weeks. The main outcome variables were analyzed at baseline, first week, first month, sixth month, first year, and second year of IFX therapy. After remission, based on a shared decision between patient and clinician, IFX optimization was performed. Efficacy, safety, and cost of IFX therapy were evaluated.

RESULTS

In the whole series (n = 103), main outcome variables showed a rapid and maintained improvement, reaching remission in 78 patients after a mean IFX duration of 31.5 months. Serious adverse events were observed in 9 patients: infusion reactions (n = 4), tuberculosis (n = 1), Mycobacterium avium pneumonia (n = 1), severe oral ulcers (n = 1), palmoplantar psoriasis (n = 1), and colon carcinoma (n = 1). In the optimization subanalysis, the comparative study between optimized and nonoptimized groups showed (1) no differences in clinical characteristics at baseline, (2) similar maintained improvement in most ocular outcomes, (3) lower severe adverse events, and (4) lower mean IFX costs in the optimized group (€4826.52 vs €9854.13 per patient/yr).

CONCLUSION

IFX seems to be effective and relatively safe in White patients with refractory BD uveitis. IFX optimization is effective, safe, and cost-effective.

SAT0264 LONG TERM FOLLOW-UP AND OPTIMIZATION OF INFLIXIMAB IN REFRACTORY UVEITIS DUE TO BEHÇET’S DISEASE. MULTICENTER STUDY OF 103 CAUCASIAN PATIENTS

Background:

Biologic therapy has improved prognosis of Behçet Disease (BD) uveitis (1-5). Although infliximab (IFX) is approved in Japan, most data in Caucasian patients comes from small series. No data on optimization has been published

Objectives:

In a large series of Caucasian patients with refractory uveitis of BD, we assess:a) long-term efficacy and safety;b) IFX optimization when ocular remission was achieved

Methods:

Multicenter study of IFX-treated patients with BD uveitis refractory to conventional immunosuppressants.103 patients were treated with IFX as 1st biologic as follows: 3-5 mg/kg i.v. at 0, 2, 6 and every 4-8 weeks. The main outcomes were anterior chamber cells, vitritis, retinal vasculitis, macular thickness, visual acuity, and glucocorticoids sparing effect; analysed at baseline, 1st week, 1st and 6th months and 1st and 2nd years. After remission, IFX optimization was performed

Results:

In whole series (n=103), main outcomes showed a rapid and maintained improvement, reaching remission in 78 patients after a mean IFX duration of 31.5 months. Severe side-effects were observed in 9 patients.

Comparative study between optimized and non-optimized groups showed:a) no differences in clinical baseline characteristics;b) similar maintained improvement in most ocular outcomes;c) lower severe adverse events andd) lower IFX cost in optimized group (4826.52 vs 9854.13 euros/patient/year)(Table)

Conclusion:

IFX seems effective and safe in Caucasian patients with refractory BD uveitis. IFX optimization is effective, safe, and cost-effective

References:

[1]Martín-Varillas JL. Ophthalmology 2018;125:1444-1451.

[2]Atienza-Mateo B: Arthritis Rheumatol. 2019;71:2081-2089

[3]Santos-Gómez M. Clin Exp Rheumatol. 2016;34 (6 Suppl 102): S34-S40

[4]Urruticoechea-Arana A. Rheumatol Int. 2019;39:47-58.

[5]Atienza-Mateo B. Rheumatology (Oxford). 2018 1;57:856-864

Table.OptimizedN=18Non OptimizedN=42PPatients/eyes affected, n/n18/3442/77Age, mean (SD), years39.5 (9.8)38.8 (10.5)0.82Men, %55.659.50.78Duration of uveitis before IFX, median [IQR] months38 [18-119]35 [10-48]0.11Ocular features at time of IFX onset-AC cells count, median [IQR]2 [1-4]2 [1-2]0.29-Vitritis, median [IQR]2 [1.5-3]2 [1-2]0.02-BCVA, mean (SD)0.32 (0.21)0.37 (0.26)0.51-OCT, mean (SD)303.5 (23.3)397.7 (155.7)0.12-Retinal vasculitis, n (%)9 (50)26 (66.7)0.23Uveitis pattern, n (%)-Bilateral/unilateral16/2 (88.9/11.1)35/7 (83.3/16.7)0.71-Anterior0 (0)6 (14.3)0.17-Posterior5 (27.8)8 (19.0)0.50-Panuveitis13 (72.2)28 (66.7)0.67Prednisone dose at IFX onset, mean (SD), mg/d40.3 (20.6)41.4 (15.5)0.81IFX therapyMonotherapy/combined treatment, n (%)15 (83.3)30 (71.4)0.33-AZA5 (27.8)4 (9.5)0.11-CsA9 (33.3)8 (19.0)0.32-MTX4 (22.2)15 (35.7)0.30Follow-up on IFX therapy, median [IQR], months48 [33-60]24 [6-60]0.007-Relapses, median (IQR)0 [0-1]0 [0-2]-Remission, %10075.60.46-Severe side effects, n (per 100 patients/year)0 (0)3 (0.78)0.02-Cost (mean), euros per year4826.529854.130.55–

Disclosure of Interests:

José Luis Martín-Varillas Grant/research support from: AbbVie, Pfizer, Janssen and Celgene, Speakers bureau: Pfizer and Lilly, Belén Atienza-Mateo: None declared, Vanesa Calvo-Río Grant/research support from: MSD and Roche, Speakers bureau: AbbVie, Lilly, Celgene, Grünenthal, UCB Pharma, Emma Beltrán: None declared, Alfredo Adan: None declared, Elena Aurrecoechea: None declared, Santos Castañeda: None declared, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD, J. Luis Hernández: None declared, Ricardo Blanco Grant/research support from: AbbVie, MSD, and Roche, Speakers bureau: AbbVie, Pfizer, Roche, Bristol-Myers, Janssen, and MSD

Comparative Study of Infliximab Versus Adalimumab in Refractory Uveitis due to Behçet's Disease: National Multicenter Study of 177 Cases

OBJECTIVE

To compare the efficacy of infliximab (IFX) versus adalimumab (ADA) as a first-line biologic drug over 1 year of treatment in a large series of patients with refractory uveitis due to Behçet's disease (BD).

METHODS

We conducted an open-label multicenter study of IFX versus ADA for BD-related uveitis refractory to conventional nonbiologic treatment. IFX or ADA was chosen as the first-line biologic agent based on physician and patient agreement. Patients received 3-5 mg/kg intravenous IFX at 0, 2, and 6 weeks and every 4-8 weeks thereafter, or 40 mg subcutaneous ADA every other week without a loading dose. Ocular parameters were compared between the 2 groups.

RESULTS

The study included 177 patients (316 affected eyes), of whom 103 received IFX and 74 received ADA. There were no significant baseline differences between treatment groups in main demographic features, previous therapy, or ocular sign severity. After 1 year of therapy, we observed an improvement in all ocular parameters in both groups. However, patients receiving ADA had significantly better outcomes in some parameters, including improvement in anterior chamber inflammation (92.31% versus 78.18% for IFX; P = 0.06), improvement in vitritis (93.33% versus 78.95% for IFX; P = 0.04), and best-corrected visual acuity (mean ± SD 0.81 ± 0.26 versus 0.67 ± 0.34 for IFX; P = 0.001). A nonsignificant difference was seen for macular thickness (mean ± SD 250.62 ± 36.85 for ADA versus 264.89 ± 59.74 for IFX; P = 0.15), and improvement in retinal vasculitis was similar between the 2 groups (95% for ADA versus 97% for IFX; P = 0.28). The drug retention rate was higher in the ADA group (95.24% versus 84.95% for IFX; P = 0.042).

CONCLUSION

Although both IFX and ADA are efficacious in refractory BD-related uveitis, ADA appears to be associated with better outcomes than IFX after 1 year of follow-up.

Long-term etanercept survival in patients with psoriatic arthritis: a multicenter retrospective analysis in daily clinical practice in Spain

Although several randomized clinical trials and observational studies have evaluated the effectiveness, safety and drug survival of etanercept (ETN) in the treatment of psoriatic arthritis (PsA), long-term data regarding these aspects are currently scarce. For this reason, we sought to investigate the long-term survival and safety of ETN in PsA patients in 4 tertiary care Spanish hospitals over a 13-year observation period (from 2004 to 2017). The records of 85 PsA patients were reviewed. ETN showed an excellent survival profile, with rates of treatment discontinuation at 1, 3, 5 and 10 years of 15, 37, 46 and 59%, respectively. In our cohort, a trend toward longer drug survival in patients with shorter disease duration and those who were treated with ETN as their first biologic agent was observed. On the other hand, combination therapy with conventional disease-modifying antirheumatic drugs did not provide greater improvement on the long-term drug survival. Only 12% of the patients reported adverse events (AEs) during therapy, being most of them of mild to moderate intensity, and in only 7% AEs led to drug discontinuation. To the best of our knowledge, the present study shows the largest follow-up period of ETN-treated population analyzed in a real-life setting, and these results demonstrate the positive safety profile and long-term effectiveness of this biologic agent in the management of PsA patients.

Anti-interleukin 6 receptor tocilizumab in refractory uveitis associated with Behçet's disease: multicentre retrospective study

Objective

To assess the efficacy of tocilizumab (TCZ) in refractory uveitis of Behçet's disease (BD).

Methods

Multicentre study of patients with BD-associated uveitis. Patients were refractory to conventional and biologic immunosuppressive drugs. The main outcome measures were intraocular inflammation, macular thickness, visual acuity and corticosteroid-sparing effects.

Results

We studied 11 patients (7 men) (20 affected eyes); median age 35 years. Uveitis was bilateral in nine patients. The patterns of ocular involvement were panuveitis (n = 8, with retinal vasculitis in 4), anterior uveitis (n = 2) and posterior uveitis (n = 1). Cystoid macular oedema was present in seven patients. The clinical course was recurrent (n = 7) or chronic (n = 4). Before TCZ, patients had received systemic corticosteroids, conventional immunosuppressants and the following biologic agents: adalimumab (n = 8), infliximab (n = 4), canakimumab (n = 1), golimumab (n = 3), etanercept (n = 1). TCZ was used as monotherapy or combined with conventional immunosuppressants at 8 mg/kg/i.v./4 weeks (n = 10) or 162 mg/s.c./week (n = 1). At TCZ onset the following extraocular manifestations were present: oral and/or genital ulcers (n = 7), arthritis (n = 4), folliculitis/pseudofolliculitis (n = 4), erythema nodosum (n = 2), livedo reticularis (n = 1) and neurological involvement (n = 2). TCZ yielded rapid and maintained improvement in all ocular parameters of the patients, with complete remission in eight of them. However, this was not the case for the extraocular manifestations, since TCZ was only effective in three of them. After a mean (s.d.) follow-up of 9.5 (8.05) months, TCZ was withdrawn in two cases, due to a severe infusion reaction and arthritis impairment, respectively.

Conclusion

TCZ could be a therapeutic option in patients with BD and refractory uveitis.

Brief Report: IRF4 Newly Identified as a Common Susceptibility Locus for Systemic Sclerosis and Rheumatoid Arthritis in a Cross-Disease Meta-Analysis of Genome-Wide Association Studies

OBJECTIVE

Systemic sclerosis (SSc) and rheumatoid arthritis (RA) are autoimmune diseases that have similar clinical and immunologic characteristics. To date, several shared SSc-RA genetic loci have been identified independently. The aim of the current study was to systematically search for new common SSc-RA loci through an interdisease meta-genome-wide association (meta-GWAS) strategy.

METHODS

The study was designed as a meta-analysis combining GWAS data sets of patients with SSc and patients with RA, using a strategy that allowed identification of loci with both same-direction and opposite-direction allelic effects. The top single-nucleotide polymorphisms were followed up in independent SSc and RA case-control cohorts. This allowed an increase in the sample size to a total of 8,830 patients with SSc, 16,870 patients with RA, and 43,393 healthy controls.

RESULTS

This cross-disease meta-analysis of the GWAS data sets identified several loci with nominal association signals (P < 5 × 10(-6) ) that also showed evidence of association in the disease-specific GWAS scans. These loci included several genomic regions not previously reported as shared loci, as well as several risk factors that were previously found to be associated with both diseases. Follow-up analyses of the putatively new SSc-RA loci identified IRF4 as a shared risk factor for these 2 diseases (Pcombined  = 3.29 × 10(-12) ). Analysis of the biologic relevance of the known SSc-RA shared loci identified the type I interferon and interleukin-12 signaling pathways as the main common etiologic factors.

CONCLUSION

This study identified a novel shared locus, IRF4, for the risk of SSc and RA, and highlighted the usefulness of a cross-disease GWAS meta-analysis strategy in the identification of common risk loci.

The effect of biologic therapy different from infliximab or adalimumab in patients with refractory uveitis due to Behçet's disease: results of a multicentre open-label study

OBJECTIVES

To assess the efficacy of other biologic therapies, different from infliximab (IFX) and adalimumab (ADA), in patients with Behçet's disease uveitis (BU).

METHODS

Multicenter study of 124 patients with BU refractory to at least one standard immunosuppressive agent that required IFX or ADA therapy. Patients who had to be switched to another biologic agent due to inefficacy or intolerance to IFX or ADA or patient's decision were assessed. The main outcome measures were the degree of anterior and posterior chamber inflammation and macular thickness.

RESULTS

Seven (5.6%) of 124 cases (4 women/3 men; mean age, 43 (range 28- 67) years; 12 affected eyes) were studied. Five of them had been initially treated with ADA and 2 with IFX. The other biologic agents used were golimumab (n=4), tocilizumab (n=2) and rituximab (n=1). The ocular pattern was panuveitis (n=4) or posterior uveitis (n=3). Uveitis was bilateral in 5 patients (71.4%). At baseline, anterior chamber and vitreous inflammation were present in 6 (50%) and 7 (58.3%) of the eyes. All the patients (12 eyes) had macular thickening (OCT>250μm) and 4 of them (7 eyes), cystoid macular edema (OCT>300 μm). Besides reduction anterior chamber and vitreous inflammation, we observed a reduction of OCT values, from 330.4±58.5 μm at the onset of the biological agent to 273±50 μm at month 12 (p=0.06). Six patients achieved a complete remission of uveitis.

CONCLUSIONS

The vast majority of patients with BU refractory to standard immunosuppressive drugs are successfully controlled with ADA and/or IFX. Other biologic agents appear to be also useful.

Sponyloarthritis features forecasting the presence of HLA-B27 or sacroiliitis on magnetic resonance imaging in patients with suspected axial spondyloarthritis: results from a cross-sectional study in the ESPeranza Cohort

Introduction

Chronic back pain (CBP) is frequently the presenting symptom in patients with suspected axial spondyloarthritis (axSpA). Presence of sacroiliitis on magnetic-resonance-imaging (MRI) or HLA-B27 adds to diagnostic certainty. However, these costly tests cannot be applied in all patients with CBP. This study aims to investigate which SpA features increase the likelihood of a positive HLA-B27 or positive MRI of the sacroiliac-joints (MRI-SI) in patients with suspected axSpA.

Methods

Data from 665 patients with CBP within the ESPeranza Programme were analysed. Diagnostic utility measures (LR+, LR−) for a positive MRI-SI or HLA-B27 were calculated for various definitions of inflammatory back pain (IBP), their separate items and for other SpA features.

Results

Pretest probabilityies of a positive result was 41 % for MRI-SI and 40 % for HLA-B27. For a positive MRI-SI result the most useful IBP characteristic was alternating buttock pain (LR + =2.6). Among the IBP-criteria, fulfillment of the ‘ASAS criteria’ (LR + =2.1) was most contributory. Interestingly, the addition of alternating buttock pain to the Calin/ASAS-IBP criteria (LR + =6.0 and 5.5, respectively) or the addition of awakening at second half of night to the Calin-IBP criteria (LR + =5.5) increased the pre-test probability of MRI-sacroiliitis from 41 % to 79–80 %. Dactylitis (LR + =4.1) and inflammatory bowel disease (IBD) (LR + =6.4) increased this probability to 73 % and 81 %, respectively. To forecast HLA-B27 positivity, awakening at the second half of the night, fulfillment of the ASAS-IBP definition and uveitis were the most useful, but only marginally predictive (LR + = 1.3, 1,6 and 2.6, respectively).

Conclusions

If patients with suspected axial SpA have either 1) IBP according to Calin/ASAS definition plus alternating buttock pain, or 2) IBP according to Calin definition plus awakening at night, or 3) dactylitis or 4) IBD, the probability of finding a positive MRI-SI increases significantly.

Anti-TNF-α therapy in patients with refractory uveitis due to Behçet's disease: a 1-year follow-up study of 124 patients

OBJECTIVE

The aim of this study was to assess the efficacy of anti-TNF-α therapy in refractory uveitis due to Behçet's disease (BD).

METHODS

We performed a multicentre study of 124 patients with BD uveitis refractory to conventional treatment including high-dose corticosteroids and at least one standard immunosuppressive agent. Patients were treated for at least 12 months with infliximab (IFX) (3-5 mg/kg at 0, 2 and 6 weeks and then every 4-8 weeks) or adalimumab (ADA) (usually 40 mg every 2 weeks). The main outcome measures were degree of anterior and posterior chamber inflammation, visual acuity, macular thickness and immunosuppression load.

RESULTS

Sixty-eight men and 56 women (221 affected eyes) were studied. The mean age was 38.6 years (s.d. 10.4). HLA-B51 was positive in 66.1% of patients and uveitis was bilateral in 78.2%. IFX was the first biologic agent in 77 cases (62%) and ADA was first in 47 (38%). In most cases anti-TNF-α drugs were used in combination with conventional immunosuppressive drugs. At the onset of anti-TNF-α therapy, anterior chamber and vitreous inflammation was observed in 57% and 64.4% of patients, respectively. In both conditions the damage decreased significantly after 1 year. At baseline, 50 patients (80 eyes) had macular thickening [optical coherence tomography (OCT) >250 μm] and 35 (49 eyes) had cystoid macular oedema (OCT>300 μm) that improved from 420 μm (s.d. 119.5) at baseline to 271 μm (s.d. 45.6) at month 12 (P < 0.01). The best-corrected visual acuity and the suppression load also showed significant improvement. After 1 year of follow-up, 67.7% of patients were inactive. Biologic therapy was well tolerated in most cases.

CONCLUSION

Anti-TNF-α therapy is effective and relatively safe in refractory BD uveitis.

Immunochip analysis identifies multiple susceptibility loci for systemic sclerosis

In this study, 1,833 systemic sclerosis (SSc) cases and 3,466 controls were genotyped with the Immunochip array. Classical alleles, amino acid residues, and SNPs across the human leukocyte antigen (HLA) region were imputed and tested. These analyses resulted in a model composed of six polymorphic amino acid positions and seven SNPs that explained the observed significant associations in the region. In addition, a replication step comprising 4,017 SSc cases and 5,935 controls was carried out for several selected non-HLA variants, reaching a total of 5,850 cases and 9,401 controls of European ancestry. Following this strategy, we identified and validated three SSc risk loci, including DNASE1L3 at 3p14, the SCHIP1-IL12A locus at 3q25, and ATG5 at 6q21, as well as a suggested association of the TREH-DDX6 locus at 11q23. The associations of several previously reported SSc risk loci were validated and further refined, and the observed peak of association in PXK was related to DNASE1L3. Our study has increased the number of known genetic associations with SSc, provided further insight into the pleiotropic effects of shared autoimmune risk factors, and highlighted the power of dense mapping for detecting previously overlooked susceptibility loci.

A multicenter study confirms CD226 gene association with systemic sclerosis-related pulmonary fibrosis

Introduction

CD226 genetic variants have been associated with a number of autoimmune diseases and recently with systemic sclerosis (SSc). The aim of this study was to test the influence of CD226 loci in SSc susceptibility, clinical phenotypes and autoantibody status in a large multicenter European population.

Methods

A total of seven European populations of Caucasian ancestry were included, comprising 2,131 patients with SSc and 3,966 healthy controls. Three CD226 single nucleotide polymorphisms (SNPs), rs763361, rs3479968 and rs727088, were genotyped using Taqman 5'allelic discrimination assays.

Results

Pooled analyses showed no evidence of association of the three SNPs, neither with the global disease nor with the analyzed subphenotypes. However, haplotype block analysis revealed a significant association for the TCG haplotype (SNP order: rs763361, rs34794968, rs727088) with lung fibrosis positive patients (P_Bonf = 3.18E-02 OR 1.27 (1.05 to 1.54)).

Conclusion

Our data suggest that the tested genetic variants do not individually influence SSc susceptibility but a CD226 three-variant haplotype is related with genetic predisposition to SSc-related pulmonary fibrosis.

[Rituximab in rheumatoid arthritis-associated peripheral ulcerative keratitis]

CLINICAL CASE

We report two cases of patients affected by longstanding rheumatoid arthritis who developed a severe form of peripheral ulcerative keratitis (PUK). Neither of them had an optimal biological and clinical control of their systemic illness despite being treated with several disease-modifying antirheumatic drugs (DMARDs) and biologic therapy. High-dose systemic corticosteroids were given to treat the PUK without any success. Rituximab resulted in a favourable response with resolution of the corneal lesions and optimal control of their systemic illness.

DISCUSSION

Rituximab may be an additional tool to arrest progressive rheumatoid arthritis-associated PUK that is refractory to other drugs.

Assessment of nailfold capillaroscopy by x 30 digital epiluminescence (dermoscopy) in patients with Raynaud phenomenon

BACKGROUND

Dermoscopy is a useful tool for dermatologists to study melanocytic lesions. Its possible usefulness in the assessment of capillary nailfold morphological changes (capillaroscopy) has recently been advocated.

OBJECTIVES

To assess the practical utility of digital epiluminescence microscopy as a capillaroscopic instrument in patients with Raynaud phenomenon (RP). To compare the sensitivity and specificity rates obtained by epiluminescence microscopy with those previously reported with conventional capillaroscopic devices.

METHODS

Fifty-six consecutive patients with primary RP (PRP; n = 5) or secondary RP (SRP; n = 51) (11 men and 45 women in total) were included in the study. A control group of 10 healthy subjects was also evaluated. Twenty-six patients (46%) had systemic sclerosis (SS), 12 (21%) presystemic sclerosis (pre-SS), one (2%) dermatopolymyositis-SS, one (2%) mixed connective tissue disease, two (4%) Sjögren syndrome, two (4%) an overlap syndrome, one (2%) rheumatoid arthritis and six (11%) other connective tissue diseases. Capillary nailfold changes were studied using a nonportable digital epiluminescence device (magnification x 30). Following a systematized protocol, capillary nailfold morphology, density and distribution were evaluated. Several capillaroscopic patterns were identified (normal, sclerodermic, nonspecific, nondiagnostic) as previously defined. A possible relationship between capillary nailfold changes and the intensity of RP or the presence of associated autoimmune diseases was assessed.

RESULTS

The sclerodermic pattern showed a sensitivity of 76.9% and a specificity of 90.9% in SS. A typical capillaroscopic SS pattern was observed in 73% of cases of limited SS and in 82% of cases of diffuse SS. Patients with Sjögren syndrome and dermatopolymyositis-SS showed a nonspecific capillaroscopic pattern. All patients with PRP presented a normal capillaroscopic pattern. A normal capillaroscopic pattern was also observed in 11 of 12 patients with pre-SS. In one of two patients presenting severe sclerodactyly and in all patients showing hand oedema (three of 56), capillaroscopic changes could not be evaluated. Avascular areas correlated significantly with severe RP (P < 0.002), bone resorption (P < 0.007) and diffuse SS (P < 0.008).

CONCLUSIONS

Digital epiluminescence seems to be a useful and reliable technique in the evaluation of capillary nailfold morphological changes. This technical variation allows the identification of specific capillaroscopic patterns associated with connective tissue diseases. It also permits us to differentiate PRP from SRP. The results obtained with this technique are similar to those previously reported using standard capillaroscopy devices.

Dental services, costs, and factors associated with hospitalization for Medicaid-eligible children, Louisiana 1996-97

OBJECTIVE

This study compared types and costs of dental services rendered to children who had received care in a hospital operating room (H) with children who had not (NH).

METHODS

The study population consisted of all children aged 1-5 years who received a dental service reimbursed by the Louisiana Medicaid EPSDT program from October 1996 through September 1997. Claim files were provided by the Louisiana Bureau of Health Services Financing. A treatment intensity index [TII = 3 x (# extractions) + 2 x (# pulpotomies + # crowns) + # simple restorations] was calculated for H children (n = 2, 142) and NH children (n = 38,423). Using logistic regression, a dichotomous hospitalization variable (H vs NH) was regressed against treatment intensity and selected personal and parish (county) characteristics for each of the five age groups. Total and average reimbursement per child were calculated for both groups of children, by age.

RESULTS

The mean treatment intensity scores for H and NH children were 24.02 (SD = 11.82) and 2.16 (SD = 4.78), respectively. For all age groups, children with treatment intensity scores greater than 8 were at least 132 times more likely to be hospitalized than were children with scores less than or equal to 8. The mean cost for care provided to H children was $1,508 compared with $104 for NH. Total costs for dental care rendered to H children (5% of the study population) were $3,229,851 (45% of total dental costs for the study population).

CONCLUSION

Reducing severe caries through early interventions could provide substantial cost savings.

Subendometrial contractility in menstrual phase visualized by transvaginal sonography in patients with endometriosis

OBJECTIVE

To describe the propagation direction of the subendometrial myometrial contractile wave in menstrual phase sonographically assessed in patients with and without endometriosis.

DESIGN

Prospective study.

SETTING

Patients and normal volunteers in a university hospital.

PATIENTS

Sixteen women with (study group) and 21 without (control group) endometriosis.

INTERVENTIONS

Patients were examined by transvaginal sonography (midsaggital plane of the uterus) and recorded on videotape for a 5-minute period.

MAIN OUTCOME MEASURE

Direction of propagation of contraction waves.

RESULTS

The endometriosis group showed a predominant retrograde pattern whereas the control group showed a normal antegrade.

CONCLUSION

This abnormal cervix-to-fundus myometrial activity could well increase the amount of peritoneal shedding of endometrial menstrual debris, increasing the probabilities of its heterotopic implantation.