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Fernández-Ávila DG, Patiño-Hernández D, Moreno-Luna S, Brance L, Arbeláez Á, Vilar AC, Lozada C, Ríos C, Toro C, Ramírez C, Pons-Estel G, Ugarte-Gil M, Narváez M, Albanese M, Roa O, Ruiz O, Burgos P, Xavier R, Fuentes Y, Soriano E. Development of a novel clinimetric tool: PAtient Reported Disease Activity Index in Rheumatoid Arthritis (PARDAI-RA) by PANLAR, for the assessment of patients living with rheumatoid arthritis. Clin Rheumatol 2024; 43:1277-1285. [PMID: 38355831 PMCID: PMC10944809 DOI: 10.1007/s10067-024-06868-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/13/2023] [Accepted: 01/04/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND Clinical experience has shown that a single measure is not sufficient to assess disease activity in rheumatoid arthritis (RA). Various clinimetric tools are necessary to address the many clinical situations that can arise. METHODS In order to develop a comprehensive measurement tool, the Pan American League of Associations for Rheumatology searched for the most frequent measures of disease activity applied in RA by means of a semi-systematic review of the available literature. RESULTS We found that the most frequently reported measures of disease activity were the 28-joint Disease Activity Score, C-reactive protein, and the erythrocyte sedimentation rate, followed by patient-reported measures of pain and stiffness and many other composite indices and patient-reported outcome measures. The most frequent physician-reported sign of disease was the swollen joint count, and the most frequently self-reported feature was the increase in disease activity or flares. CONCLUSION In this article, we present a new clinimetric tool developed based on expert consensus and on data retrieved from our search. Disease activity can be better assessed by combining various data sources, such as clinical, laboratory, and self-reported outcomes. These variables were included in our novel clinimetric tool. Key Points • The goal of treatment of RA is to achieve the best possible control of inflammation, or even remission; therefore, disease management should include systematic and regular evaluation of inflammation and health status. • Clinimetric tools evaluate a series of variables (e.g., symptoms, functional capacity, disease severity, quality of life, disease progression) and can reveal substantial prognostic and therapeutic differences between patients. • Our clinimetric tool, which is based on a combination of data (e.g., clinical variables, laboratory results, PROMs), can play a relevant role in patient assessment and care.
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Affiliation(s)
- Daniel G Fernández-Ávila
- Rheumatology Division, Pontificia Universidad Javeriana - Hospital Universitario San Ignacio, Bogotá, Colombia.
| | | | | | - Lorena Brance
- Rheumatology Division, Universidad Nacional de Rosario, Santa Fe, Argentina
| | | | | | - Carlos Lozada
- Rheumatology Division, University of Miami, Coral Gables, USA
| | - Carlos Ríos
- Universidad de Especialidades Espíritu Santo, Guayaquil, Ecuador
| | - Carlos Toro
- Centro de Referencia en Osteoporosis y Reumatología, Cali, Colombia
| | | | - Guillermo Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | | | | | | | - Orlando Roa
- Rheumatology Division Keralty, Bogotá, Colombia
| | - Oscar Ruiz
- Rheumatology Division Keralty, Bogotá, Colombia
| | - Paula Burgos
- Clinic Immunology and Rheumatology Department, Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
| | - Ricardo Xavier
- Rheumatology Service Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | | | - Enrique Soriano
- Rheumatology Division, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Yelnik CM, Erton ZB, Drumez E, Cheildze D, de Andrade D, Clarke A, Tektonidou MG, Sciascia S, Pardos-Gea J, Pengo V, Ruiz-Irastorza G, Belmont HM, Pedrera CL, Fortin PR, Wahl D, Gerosa M, Kello N, Signorelli F, Atsumi T, Ji L, Efthymiou M, Branch DW, Nalli C, Rodriguez-Almaraz E, Petri M, Cervera R, Shi H, Zuo Y, Artim-Esen B, Pons-Estel G, Willis R, Barber MRW, Skeith L, Bertolaccini ML, Cohen H, Roubey R, Erkan D. Thrombosis recurrence and major bleeding in non-anticoagulated thrombotic antiphospholipid syndrome patients: Prospective study from antiphospholipid syndrome alliance for clinical trials and international networking (APS ACTION) clinical database and repository ("Registry"). Semin Arthritis Rheum 2024; 65:152347. [PMID: 38185079 DOI: 10.1016/j.semarthrit.2023.152347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/13/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Long-term anticoagulant therapy is generally recommended for thrombotic antiphospholipid syndrome (TAPS) patients, however it may be withdrawn or not introduced in routine practice. OBJECTIVES To prospectively evaluate the risk of thrombosis recurrence and major bleeding in non-anticoagulated TAPS patients, compared to anticoagulated TAPS, and secondly, to identify different features between those two groups. PATIENTS/METHODS Using an international registry, we identified non-anticoagulated TAPS patients at baseline, and matched them with anticoagulated TAPS patients based on gender, age, type of previous thrombosis, and associated autoimmune disease. Thrombosis recurrence and major bleeding were prospectively analyzed using Kaplan-Meier method and compared using a marginal Cox's regression model. RESULTS As of June 2022, 94 (14 %) of the 662 TAPS patients were not anticoagulated; and 93 of them were matched with 181 anticoagulated TAPS patients (median follow-up 5 years [interquartile range 3 to 8]). The 5-year thrombosis recurrence and major bleeding rates were 12 % versus 10 %, and 6 % versus 7 %, respectively (hazard ratio [HR] 1.38, 95 % confidence interval [CI] 0.53 to 3.56, p = 0.50 and HR 0.53; 95 % CI 0.15 to 1.86; p = 0.32, respectively). Non-anticoagulated patients were more likely to receive antiplatelet therapy (p < 0.001), and less likely to have more than one previous thrombosis (p < 0.001) and lupus anticoagulant positivity (p = 0.01). CONCLUSION Fourteen percent of the TAPS patients were not anticoagulated at recruitment. Their recurrent thrombosis risk did not differ compared to matched anticoagulated TAPS patients, supporting the pressing need for risk-stratified secondary thrombosis prevention trials in APS investigating strategies other than anticoagulation.
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Affiliation(s)
- Cecile M Yelnik
- Univ. Lille, CHU Lille, Département de Médecine Interne et d'Immunologie Clinique, INSERM, UMR 1167, F-59000 Lille, France.
| | | | - Elodie Drumez
- Univ. Lille, CHU Lille, Département de Médecine Interne et d'Immunologie Clinique, INSERM, UMR 1167, F-59000 Lille, France
| | - Dachi Cheildze
- Hospital for Special Surgery, New York, NY, USA; Yale New Haven Hospital, New Haven, CT, USA
| | | | - Ann Clarke
- University of Calgary, Calgary, Alberta, Canada
| | | | | | | | | | | | | | | | - Paul R Fortin
- Centre ARThrite - CHU de Québec- Université Laval, Quebec, QC, Canada
| | - Denis Wahl
- Université de Lorraine, Inserm DCAC, and CHRU-Nancy, Nancy, France
| | | | - Nina Kello
- Northwell Health, New Hyde Park, NY, USA
| | | | | | - Lanlan Ji
- Peking University First Hospital, Beijing, China
| | | | - D Ware Branch
- University of Utah and Intermountain Healthcare, Salt Lake City, UT, USA
| | | | | | - Michelle Petri
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Hui Shi
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Zuo
- University of Michigan, Ann Arbor, MI, USA
| | | | - Guillermo Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas del Grupo Oroño (GO-CREAR), Rosario, Argentina
| | - Rohan Willis
- University of Texas Medical Branch, Galveston, TX, USA
| | | | | | | | - Hannah Cohen
- University College London, London, United Kingdom
| | | | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
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3
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Yazdany J, Ware A, Wallace ZS, Bhana S, Grainger R, Hachulla E, Richez C, Cacoub P, Hausmann JS, Liew JW, Sirotich E, Jacobsohn L, Strangfeld A, Mateus EF, Hyrich KL, Gossec L, Carmona L, Lawson-Tovey S, Kearsley-Fleet L, Schaefer M, Ribeiro SLE, Al-Emadi S, Hasseli R, Müller-Ladner U, Specker C, Schulze-Koops H, Bernardes M, Fraga VM, Rodrigues AM, Sparks JA, Ljung L, Di Giuseppe D, Tidblad L, Wise L, Duarte-García A, Ugarte-Gil MF, Colunga-Pedraza IJ, Martínez-Martínez MU, Alpizar-Rodriguez D, Xavier RM, Isnardi CA, Pera M, Pons-Estel G, Izadi Z, Gianfrancesco MA, Carrara G, Scirè CA, Zanetti A, Machado PM. Impact of Risk Factors on COVID-19 Outcomes in Unvaccinated People With Rheumatic Diseases: A Comparative Analysis of Pandemic Epochs Using the COVID-19 Global Rheumatology Alliance Registry. Arthritis Care Res (Hoboken) 2024; 76:274-287. [PMID: 37643903 DOI: 10.1002/acr.25220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/03/2023] [Accepted: 08/17/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE Approximately one third of individuals worldwide have not received a COVID-19 vaccine. Although studies have investigated risk factors linked to severe COVID-19 among unvaccinated people with rheumatic diseases (RDs), we know less about whether these factors changed as the pandemic progressed. We aimed to identify risk factors associated with severe COVID-19 in unvaccinated individuals in different pandemic epochs corresponding to major variants of concern. METHODS Patients with RDs and COVID-19 were entered into the COVID-19 Global Rheumatology Alliance Registry between March 2020 and June 2022. An ordinal logistic regression model (not hospitalized, hospitalized, and death) was used with date of COVID-19 diagnosis, age, sex, race and/or ethnicity, comorbidities, RD activity, medications, and the human development index (HDI) as covariates. The main analysis included all unvaccinated patients across COVID-19 pandemic epochs; subanalyses stratified patients according to RD types. RESULTS Among 19,256 unvaccinated people with RDs and COVID-19, those who were older, male, had more comorbidities, used glucocorticoids, had higher disease activity, or lived in lower HDI regions had worse outcomes across epochs. For those with rheumatoid arthritis, sulfasalazine and B-cell-depleting therapy were associated with worse outcomes, and tumor necrosis factor inhibitors were associated with improved outcomes. In those with connective tissue disease or vasculitis, B-cell-depleting therapy was associated with worse outcomes. CONCLUSION Risk factors for severe COVID-19 outcomes were similar throughout pandemic epochs in unvaccinated people with RDs. Ongoing efforts, including vaccination, are needed to reduce COVID-19 severity in this population, particularly in those with medical and social vulnerabilities identified in this study.
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Affiliation(s)
| | - Anna Ware
- National Center for Collaborative Healthcare Innovation, Palo Alto Department of Veterans Affairs Healthcare System, Palo Alto, California
| | | | | | - Rebecca Grainger
- University of Otago Wellington and Te Whatu Ora, Health New Zealand Capital, Coast and Hutt Valley, Wellington, New Zealand
| | - Eric Hachulla
- Service de Médecine Interne et Immunologie Clinique, Centre Hospitalier Universitaire (CHU) de Lille, pour la Filière des maladies Auto-Immunes et Autoinflammatoires Rares, Lille, France
| | - Christophe Richez
- Service de Rhumatologie, Centre de référence des maladies autoimmunes systémiques rares de l'Est et du Sud-Ouest de France, CHU de Bordeaux, pour la Société Française de Rhumatologie, Bordeaux, France
| | - Patrice Cacoub
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Société Nationale Française de Médecine Interne, Paris, France
| | - Jonathan S Hausmann
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jean W Liew
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | | | | | - Anja Strangfeld
- German Rheumatism Research Center and Charité University Hospital, Berlin, Germany
| | - Elsa F Mateus
- Portuguese League Against Rheumatic Diseases, Lisbon, Portugal, and European Alliance of Associations for Rheumatology, Kilchberg, Switzerland
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Laure Gossec
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique and AP-HP, Pitié-Salpêtrière hospital, Paris, France
| | | | - Saskia Lawson-Tovey
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, and NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Lianne Kearsley-Fleet
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | | | | | | | - Rebecca Hasseli
- University Hospital Munster, Munster, Germany, and Justus Liebig University Giessen, Kerckhoff, Germany
| | | | | | | | - Miguel Bernardes
- University of Porto and Centro Hospitalar e Universitário de São João, Porto, Portugal
| | | | - Ana Maria Rodrigues
- Sociedade Portuguesa de Reumatologia and Comprehensive Health Research Centre, Nova Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Jeffrey A Sparks
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lotta Ljung
- Karolinska Institutet and Academic Specialist Centre, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | | | | | - Leanna Wise
- Keck School of Medicine, University of Southern California, Los Angeles
| | | | - Manuel F Ugarte-Gil
- Grupo Peruano de Estudio de Enfermedades Autoinmunes Sistémica, Universidad Científica del Sur and Hospital Nacional Guillermo Almenara Irigoyen - EsSalud, Lima, Peru
| | | | | | | | - Ricardo Machado Xavier
- Universidade Federal do Rio Grande do Sul, Serviço de Reumatologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | | | - Mariana Pera
- Hospital Angel C. Padilla, San Miguel de Tucuman, Tucuman, Argentina
| | - Guillermo Pons-Estel
- Universidad Nacional de Rosario, Rosario, Argentina, and College of Physicians of the Province of Santa Fe 2nd, Santa Fe, Argentina
| | | | | | | | - Carlo Alberto Scirè
- Italian Society for Rheumatology and School of Medicine, University of Milano-Bicocca, Milan, Italy
| | | | - Pedro M Machado
- University College London, NIHR University College London Hospitals Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, and Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
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Casares-Marfil D, Martínez-Bueno M, Borghi MO, Pons-Estel G, Reales G, Zuo Y, Espinosa G, Radstake T, van den Hoogen LL, Wallace C, Guthridge J, James JA, Cervera R, Meroni PL, Martin J, Knight JS, Alarcón-Riquelme ME, Sawalha AH. A genome-wide association study suggests new susceptibility loci for primary antiphospholipid syndrome. medRxiv 2023:2023.12.05.23299396. [PMID: 38405993 PMCID: PMC10889036 DOI: 10.1101/2023.12.05.23299396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Objectives Primary antiphospholipid syndrome (PAPS) is a rare autoimmune disease characterized by the presence of antiphospholipid antibodies and the occurrence of thrombotic events and pregnancy complications. Our study aimed to identify novel genetic susceptibility loci associated with PAPS. Methods We performed a genome-wide association study comprising 5,485 individuals (482 affected individuals) of European ancestry. Significant and suggestive independent variants from a meta-analysis of approximately 7 million variants were evaluated for functional and biological process enrichment. The genetic risk variability for PAPS in different populations was also assessed. Hierarchical clustering, Mahalanobis distance, and Dirichlet Process Mixtures with uncertainty clustering methods were used to assess genetic similarities between PAPS and other immune-mediated diseases. Results We revealed genetic associations with PAPS in a regulatory locus within the HLA class II region near HLA-DRA and in STAT4 with a genome-wide level of significance. 34 additional suggestive genetic susceptibility loci for PAPS were also identified. The disease risk allele in the HLA class II locus is associated with overexpression of HLA-DRB6 , HLA-DRB9 , HLA-DPB2 , HLA-DQA2 and HLA-DQB2 , and is independent of the association between PAPS and HLA-DRB1*1302 . Functional analyses highlighted immune and nervous system related pathways in PAPS-associated loci. The comparison with other immune-mediated diseases revealed a close genetic relatedness to neuromyelitis optica, systemic sclerosis, and Sjögren's syndrome, suggesting colocalized causal variations close to STAT4 , TNPO3 , and BLK . Conclusions This study represents a comprehensive large-scale genetic analysis for PAPS and provides new insights into the genetic basis and pathophysiology of this rare disease.
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Quintana RM, García M, Garcia L, Gobbi C, Alba P, Bellomio V, Roverano S, Alvarez AP, Graf CE, Pisoni C, Spindler A, Gomez C, Figueredo HM, Papasidero S, Paniego R, de la Vega MC, Civit E, Gonzalez Lucero L, Martire MV, Aguila Maldonado R, Gordon S, Micelli M, Nieto R, Rausch G, Alarcón GS, Pons-Estel B, Pons-Estel G. Active lupus in Argentina: Results of a multicenter and national registry. Lupus 2023; 32:1555-1560. [PMID: 37936393 DOI: 10.1177/09612033231209601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
OBJECTIVE To evaluate the association between patients' characteristics and disease activity in an Argentine lupus registry. METHODS Cross-sectional study. Disease activity was stratified into: Remission off-treatment: SLEDAI = 0, without prednisone and immunosuppressive drugs. Low disease activity Toronto Cohort (LDA-TC): SLEDAI ≤2, without prednisone or immunosuppressive drugs. Modified lupus low disease activity (mLLDAS): SLEDAI score of ≤4, with no activity in major organ systems and no new features, prednisone of ≤10 mg/day and/or immunosuppressive drugs (maintenance dose) and Active disease: SLEDAI score of >4 and prednisone >10 mg/day and immunosuppressive drugs. A descriptive analysis and logistic regression model were performed. RESULTS A total of 1346 patients were included. Of them, 1.6% achieved remission off steroids, 0.8% LDA-TC, 12.1% mLLDAS and the remaining 85.4% had active disease. Active disease was associated with younger age (p ≤ 0.001), a shorter time to diagnosis (p ≤ 0.001), higher frequency of hospitalizations (p ≤ 0.001), seizures (p = 0.022), serosal disease (p ≤ 0.001), nephritis (p ≤ 0.001), higher SDI (p ≤ 0.001), greater use of immunosuppressive therapies and higher doses of prednisone compared to those on mLLDAS. In the multivariable analysis, the variables associated with active disease were the presence of pleuritis (OR 2.1, 95% CI 1.2-3.9; p = 0.007), persistent proteinuria (OR 2.5, 95% CI 1.2-5.5; p ≤ 0.011), nephritis (OR 2.5, 95% CI 1.2-5.6; p = .018) and hospitalizations (OR 8.9, 95% CI 5.3-16.0; p ≤ 0.001) whereas age at entry into the registry was negatively associated with it (OR 0.9, 95% CI 0.9-1.0; p = 0.029). CONCLUSION Active disease was associated with shorter time to diagnosis, worse outcomes (SDI and hospitalizations) and renal, neurological and serosal disease.
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Affiliation(s)
- Rosana M Quintana
- Grupo Oroño, Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Mercedes García
- Department of Reumatologia, HIGA General San Martin, La Plata, Argentina
| | - Lucila Garcia
- Department of Reumatologia, HIGA General San Martin, La Plata, Argentina
| | - Carla Gobbi
- Department of Reumatologia, Sanatorio Allende, Córdoba, Argentina
| | - Paula Alba
- Department of Reumatologia, Hospital Córdoba, Córdoba, Argentina
| | - Verónica Bellomio
- Department of Reumatologia, Hospital Angel C. Padilla, Tucumán, Argentina
| | - Susana Roverano
- Department of Reumatologia, Hospital J.M. Cullen, Santa Fe, Argentina
| | | | | | | | - Alberto Spindler
- Department of Reumatologia, Centro de Investigaciones Médicas Tucumán, Tucumán, Argentina
| | - Catalina Gomez
- Department of Reumatologia, Hospital Central de Formosa, Formosa, Argentina
| | - Heber Matias Figueredo
- Department of Reumatologia, Hospital de Alta Complejidad Pte. Juan Domingo Perón, Formosa, Argentina
| | - Silvia Papasidero
- Department of Reumatologia, Hospital General de Agudos Dr Enrique Tornú, Buenos Aires, Argentina
| | - Raul Paniego
- Department of Reumatologia, CePReR, Santa Rosa, La Pampa, Argentina
| | | | - Emma Civit
- Department of Reumatologia, Hospital del Carmen, Godoy Cruz, Argentina
| | | | | | | | - Sergio Gordon
- Department of Reumatologia, HIGA Dr Alende, Mar del Plata, Argentina
| | - Marina Micelli
- Department of Reumatologia, Hospital General de Agudos José María Ramos Mejía, Buenos Aires, Argentina
| | - Romina Nieto
- Hospital Provincial de Rosario, Rosario, Argentina
| | - Gretel Rausch
- Department of Reumatologia, Consultorio Privado, Rio Grande, Tierra del Fuego, Rio Grande, Argentina
| | - Graciela S Alarcón
- Division of Clinical Immunology and Rheumatology, Department of Medicine, Marnix E Heersink School of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bernardo Pons-Estel
- Grupo Oroño, Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Guillermo Pons-Estel
- Grupo Oroño, Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
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Barbhaiya M, Zuily S, Naden R, Hendry A, Manneville F, Amigo MC, Amoura Z, Andrade D, Andreoli L, Artim-Esen B, Atsumi T, Avcin T, Belmont HM, Bertolaccini ML, Branch DW, Carvalheiras G, Casini A, Cervera R, Cohen H, Costedoat-Chalumeau N, Crowther M, de Jesus G, Delluc A, Desai S, De Sancho M, Devreese KM, Diz-Kucukkaya R, Duarte-Garcia A, Frances C, Garcia D, Gris JC, Jordan N, Leaf RK, Kello N, Knight JS, Laskin C, Lee AI, Legault K, Levine SR, Levy RA, Limper M, Lockshin MD, Mayer-Pickel K, Musial J, Meroni PL, Orsolini G, Ortel TL, Pengo V, Petri M, Pons-Estel G, Gomez-Puerta JA, Raimboug Q, Roubey R, Sanna G, Seshan SV, Sciascia S, Tektonidou MG, Tincani A, Wahl D, Willis R, Yelnik C, Zuily C, Guillemin F, Costenbader K, Erkan D. The 2023 ACR/EULAR Antiphospholipid Syndrome Classification Criteria. Arthritis Rheumatol 2023; 75:1687-1702. [PMID: 37635643 DOI: 10.1002/art.42624] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/14/2023] [Accepted: 05/30/2023] [Indexed: 08/29/2023]
Abstract
OBJECTIVE To develop new antiphospholipid syndrome (APS) classification criteria with high specificity for use in observational studies and trials, jointly supported by the American College of Rheumatology (ACR) and EULAR. METHODS This international multidisciplinary initiative included 4 phases: 1) Phase I, criteria generation by surveys and literature review; 2) Phase II, criteria reduction by modified Delphi and nominal group technique exercises; 3) Phase III, criteria definition, further reduction with the guidance of real-world patient scenarios, and weighting via consensus-based multicriteria decision analysis, and threshold identification; and 4) Phase IV, validation using independent adjudicators' consensus as the gold standard. RESULTS The 2023 ACR/EULAR APS classification criteria include an entry criterion of at least one positive antiphospholipid antibody (aPL) test within 3 years of identification of an aPL-associated clinical criterion, followed by additive weighted criteria (score range 1-7 points each) clustered into 6 clinical domains (macrovascular venous thromboembolism, macrovascular arterial thrombosis, microvascular, obstetric, cardiac valve, and hematologic) and 2 laboratory domains (lupus anticoagulant functional coagulation assays, and solid-phase enzyme-linked immunosorbent assays for IgG/IgM anticardiolipin and/or IgG/IgM anti-β2 -glycoprotein I antibodies). Patients accumulating at least 3 points each from the clinical and laboratory domains are classified as having APS. In the validation cohort, the new APS criteria versus the 2006 revised Sapporo classification criteria had a specificity of 99% versus 86%, and a sensitivity of 84% versus 99%. CONCLUSION These new ACR/EULAR APS classification criteria were developed using rigorous methodology with multidisciplinary international input. Hierarchically clustered, weighted, and risk-stratified criteria reflect the current thinking about APS, providing high specificity and a strong foundation for future APS research.
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Affiliation(s)
- Medha Barbhaiya
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Stephane Zuily
- Vascular Medicine Division, French National Referral Center for Systemic and Autoimmune Diseases, Université de Lorraine, Inserm, DCAC, and CHRU-Nancy, F-54000, Nancy, France
| | - Ray Naden
- Department of Medicine and Obstetrics, Auckland City Hospital, Auckland, New Zealand
| | - Alison Hendry
- Department of General Medicine, Middlemore Hospital, Counties Manukau Health District, Auckland, New Zealand
| | - Florian Manneville
- CIC Clinical epidemiology, CHRU Nancy, Inserm, Université de Lorraine, Nancy, France
| | - Mary-Carmen Amigo
- Department of Internal Medicine, Service of Rheumatology, ABC Medical Center, Mexico DF, Mexico
| | - Zahir Amoura
- French National Reference Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome, Service de Medecine Interne 2, Hopital Pitie-Salpetriére; Centre d'Immunologie et des Maladies Infectieuses, Sorbonne Universite, Paris, France
| | - Danieli Andrade
- Department of Rheumatology, University of Sao Paulo, Sao Paulo, Brazil
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Department of Clinical and Experimental Science, University of Brescia, Brescia, Italy
| | - Bahar Artim-Esen
- Department of Rheumatology, Istanbul University School of Medicine, Istanbul, Turkey
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology, and Nephrology, Hokkaido University, Sapporo, Japan
| | - Tadej Avcin
- Department of Allergology, Rheumatology, and Clinical Immunology, Children's Hospital, University Medical Center, University of Ljubljana, Ljubljana, Slovenia
| | - H Michael Belmont
- Department of Rheumatology, Hospital for Joint Disease, New York University, New York, New York
| | - Maria Laura Bertolaccini
- Academic Department of Vascular Surgery, School of Cardiovascular and Metabolic Medicine & Sciences, King's College, London, UK
| | - D Ware Branch
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Graziela Carvalheiras
- Unidade de Imunologia Clínica, Departamento de Medicina Interna, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Alessandro Casini
- Division of Angiology and Hemostasis, University Hospital of Geneva, Geneva, Switzerland
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Hannah Cohen
- Department of Haematology, University College London, London, UK
| | - Nathalie Costedoat-Chalumeau
- Service de médecine interne, Centre de reference maladies autoimmunes et systémiques rares Île de France, APHP, Hopital Cochin, Université de Paris, Centre de recherche épidémiologie et biostatistiques de Sorbonne Paris Cité, F-75004 Paris, France
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Guilherme de Jesus
- Department of Obstetrics, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Aurelien Delluc
- Department of Medicine, University Ottawa, and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sheetal Desai
- Division of Rheumatology, University of California, Irvine, California
| | - Maria De Sancho
- Division of Hematology and Oncology, Weill Cornell Medicine, New York, New York
| | - Katrien M Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, and Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Reyhan Diz-Kucukkaya
- Department of Molecular Biology and Genetics, Istanbul University School of Science, Istanbul, Turkey
| | | | - Camille Frances
- Department of Dermatology-Allergology, Tenon Hospital, Paris, France
| | - David Garcia
- Department of Hematology, University of Washington, Seattle, Washington
| | - Jean-Christophe Gris
- Department of Hematology, CHRU-Nimes, UMR UA11 INSERM-University of Montpellier, France
| | - Natasha Jordan
- Department of Rheumatology, Addenbrooke's Hospital, Cambridge, UK
| | - Rebecca K Leaf
- Department of Hematology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nina Kello
- Division of Rheumatology, Northwell Health, Great Neck, New York
| | - Jason S Knight
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan
| | - Carl Laskin
- Division of Rheumatology, University of Toronto, TRIO Fertility, Toronto, Canada
| | - Alfred I Lee
- Department of Hematology, Yale School of Medicine, New Haven, Connecticut
| | - Kimberly Legault
- Division of Rheumatology, McMaster University, Hamilton, Ontario, Canada
| | - Steve R Levine
- Downstate Stroke Center, State University of New York Downstate Health Sciences University, Kings County Hospital Center, and Maimonides Medical Center/Jaffe Stroke Center, Brooklyn, New York
| | - Roger A Levy
- Department of Rheumatology, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil, and GlaxoSmithKline, Collegeville, Pennsylvania
| | - Maarten Limper
- Department of Medicine and Clinical Immunology, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Michael D Lockshin
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | | | - Jack Musial
- Department of Medicine, Jagiellonian University School of Medicine, Krakow, Poland
| | - Pier Luigi Meroni
- Immunorheumatology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | | | - Thomas L Ortel
- Division of Hematology, Duke University Medical Center, Durham, North Carolina
| | - Vittorio Pengo
- Department of Cardiology, University Hospital, Padova, Italy
| | - Michelle Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Guillermo Pons-Estel
- Department of Rheumatology, Grupo Oroño-Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | | | - Quentin Raimboug
- Department of Nephrology, Bichat University Hospital, Paris, France
| | - Robert Roubey
- Department of Rheumatology, University of North Carolina, Chapel Hill, North Carolina
| | - Giovanni Sanna
- Department of Rheumatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Surya V Seshan
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases, Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy, and University of Turin, Torino, Italy
| | - Maria G Tektonidou
- Joint Academic Rheumatology Program, First Propaedeutic and Internal Medicine Program, National and Kapodistrian University of Athens, Athens, Greece
| | - Angela Tincani
- Department of Rheumatology, Istanbul University School of Medicine, Istanbul, Turkey
| | - Denis Wahl
- Vascular Medicine Division, French National Referral Center for Systemic and Autoimmune Diseases, Université de Lorraine, Inserm, DCAC, and CHRU-Nancy, F-54000, Nancy, France
| | - Rohan Willis
- Antiphospholipid Standardization Laboratory, University of Texas Medical Branch, Galveston, Texas
| | - Cecile Yelnik
- Department of Internal Medicine and Immunology, Université de Lille, CHU Lille, INSERM, UMR 1167, F-59000 Lille, France
| | - Catherine Zuily
- Department of Obstetrics, Université de Lorraine, Inserm, DCAC, and CHRU-Nancy, F-54000, Nancy, France
| | - Francis Guillemin
- CIC Clinical epidemiology, CHRU Nancy, Inserm, Université de Lorraine, Nancy, France
| | - Karen Costenbader
- Department of Rheumatology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
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7
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Barbhaiya M, Zuily S, Naden R, Hendry A, Manneville F, Amigo MC, Amoura Z, Andrade D, Andreoli L, Artim-Esen B, Atsumi T, Avcin T, Belmont HM, Bertolaccini ML, Branch DW, Carvalheiras G, Casini A, Cervera R, Cohen H, Costedoat-Chalumeau N, Crowther M, de Jesús G, Delluc A, Desai S, Sancho MD, Devreese KM, Diz-Kucukkaya R, Duarte-García A, Frances C, Garcia D, Gris JC, Jordan N, Leaf RK, Kello N, Knight JS, Laskin C, Lee AI, Legault K, Levine SR, Levy RA, Limper M, Lockshin MD, Mayer-Pickel K, Musial J, Meroni PL, Orsolini G, Ortel TL, Pengo V, Petri M, Pons-Estel G, Gomez-Puerta JA, Raimboug Q, Roubey R, Sanna G, Seshan SV, Sciascia S, Tektonidou MG, Tincani A, Wahl D, Willis R, Yelnik C, Zuily C, Guillemin F, Costenbader K, Erkan D. 2023 ACR/EULAR antiphospholipid syndrome classification criteria. Ann Rheum Dis 2023; 82:1258-1270. [PMID: 37640450 DOI: 10.1136/ard-2023-224609] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/21/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE To develop new antiphospholipid syndrome (APS) classification criteria with high specificity for use in observational studies and trials, jointly supported by the American College of Rheumatology (ACR) and EULAR. METHODS This international multidisciplinary initiative included four phases: (1) Phase I, criteria generation by surveys and literature review; (2) Phase II, criteria reduction by modified Delphi and nominal group technique exercises; (3) Phase III, criteria definition, further reduction with the guidance of real-world patient scenarios, and weighting via consensus-based multicriteria decision analysis, and threshold identification; and (4) Phase IV, validation using independent adjudicators' consensus as the gold standard. RESULTS The 2023 ACR/EULAR APS classification criteria include an entry criterion of at least one positive antiphospholipid antibody (aPL) test within 3 years of identification of an aPL-associated clinical criterion, followed by additive weighted criteria (score range 1-7 points each) clustered into six clinical domains (macrovascular venous thromboembolism, macrovascular arterial thrombosis, microvascular, obstetric, cardiac valve, and hematologic) and two laboratory domains (lupus anticoagulant functional coagulation assays, and solid-phase enzyme-linked immunosorbent assays for IgG/IgM anticardiolipin and/or IgG/IgM anti-β2-glycoprotein I antibodies). Patients accumulating at least three points each from the clinical and laboratory domains are classified as having APS. In the validation cohort, the new APS criteria vs the 2006 revised Sapporo classification criteria had a specificity of 99% vs 86%, and a sensitivity of 84% vs 99%. CONCLUSION These new ACR/EULAR APS classification criteria were developed using rigorous methodology with multidisciplinary international input. Hierarchically clustered, weighted, and risk-stratified criteria reflect the current thinking about APS, providing high specificity and a strong foundation for future APS research.
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Affiliation(s)
- Medha Barbhaiya
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Stephane Zuily
- Vascular Medicine Division, French National Referral Center for Systemic and Autoimmune Diseases, Université de Lorraine, Inserm, DCAC, and CHRU-Nancy, Nancy, France
| | - Ray Naden
- Department of Medicine and Obstetrics, Auckland City Hospital, Auckland, New Zealand
| | - Alison Hendry
- Department of General Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Florian Manneville
- CIC Clinical Epidemiology, CHRU Nancy, Inserm, Université de Lorraine, Nancy, France
| | - Mary-Carmen Amigo
- Department of Internal Medicine, Service of Rheumatology, ABC Medical Center, Mexico, Mexico
| | - Zahir Amoura
- French National Reference Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome, Service de Medecine Interne 2, Hopital Pitie-Salpetriére; Centre d'Immunologie et des Maladies Infectieuses, Sorbonne Universite, Paris, France
| | - Danieli Andrade
- Department of Rheumatology, University of Sao Paulo, Sao Paulo, Brazil
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Department of Clinical and Experimental Science, University of Brescia, Brescia, Italy
| | - Bahar Artim-Esen
- Department of Rheumatology, Istanbul University School of Medicine, Istanbul, Turkey
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology, and Nephrology, Hokkaido University, Sapporo, Japan
| | - Tadej Avcin
- Department of Allergology, Rheumatology, and Clinical Immunology, Children's Hospital, University Medical Center, University of Ljubljana, Ljubljana, Slovenia
| | - H Michael Belmont
- Department of Rheumatology, Hospital for Joint Disease, New York University, New York, New York, USA
| | - Maria Laura Bertolaccini
- Academic Department of Vascular Surgery, School of Cardiovascular and Metabolic Medicine & Sciences, King's College, London, UK
| | - D Ware Branch
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
| | - Graziela Carvalheiras
- Unidade de Imunologia Clínica, Departamento de Medicina Interna, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Alessandro Casini
- Division of Angiology and Hemostasis, University Hospital of Geneva, Geneva, Switzerland
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Hannah Cohen
- Department of Haematology, University College London, London, UK
| | - Nathalie Costedoat-Chalumeau
- Service de médecine interne, Centre de reference maladies autoimmunes et systémiques rares Île de France, APHP, Hopital Cochin, Université de Paris, Centre de recherche épidémiologie et biostatistiques de Sorbonne Paris Cité, Paris, France
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Guilherme de Jesús
- Department of Obstetrics, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Aurelien Delluc
- Department of Medicine, University Ottawa, and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sheetal Desai
- Division of Rheumatology, University of California, Irvine, California, USA
| | - Maria De Sancho
- Division of Hematology and Oncology, Weill Cornell Medicine, New York, New York, USA
| | - Katrien M Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Reyhan Diz-Kucukkaya
- Department of Molecular Biology and Genetics, Istanbul University School of Science, Istanbul, Turkey
| | | | - Camille Frances
- Department of Dermatology-Allergology, Tenon Hospital, Paris, France
| | - David Garcia
- Department of Hematology, University of Washington, Seattle, Washington, USA
| | - Jean-Christophe Gris
- Department of Hematology, CHRU-Nimes, UMR UA11 INSERM-University of Montpellier, Montpellier, France
| | - Natasha Jordan
- Department of Rheumatology, Addenbrooke's Hospital, Cambridge, UK
| | - Rebecca K Leaf
- Department of Hematology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nina Kello
- Division of Rheumatology, Northwell Health, Great Neck, New York, New York, USA
| | - Jason S Knight
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Carl Laskin
- Division of Rheumatology, University of Toronto, TRIO Fertility, Toronto, Ontario, Canada
| | - Alfred I Lee
- Department of Hematology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kimberly Legault
- Division of Rheumatology, McMaster University, Hamilton, Ontario, Canada
| | - Steve R Levine
- Downstate Stroke Center, State University of New York Downstate Health Sciences University, Kings County Hospital Center, and Maimonides Medical Center/Jaffe Stroke Center, Brooklyn, New York, USA
| | - Roger A Levy
- Department of Rheumatology, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
- GlaxoSmithKline, Collegeville, Pennsylvania, USA
| | - Maarten Limper
- Department of Medicine and Clinical Immunology, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Michael D Lockshin
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | | | - Jack Musial
- Department of Medicine, Jagiellonian University School of Medicine, Krakow, Poland
| | - Pier Luigi Meroni
- Immunorheumatology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Giovanni Orsolini
- Department of Rheumatology, University Hospitals of Verona, Verona, Italy
| | - Thomas L Ortel
- Division of Hematology, Duke University Medical Center, Durham, North Carolina, USA
| | - Vittorio Pengo
- Department of Cardiology, University Hospital, Padova, Italy
| | - Michelle Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Guillermo Pons-Estel
- Department of Rheumatology, Grupo Oroño-Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | | | - Quentin Raimboug
- Department of Nephrology, Bichat University Hospital, Paris, France
| | - Robert Roubey
- Department of Rheumatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Giovanni Sanna
- Department of Rheumatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Surya V Seshan
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Savino Sciascia
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases, SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy
- University of Turin, Torino, Italy
| | - Maria G Tektonidou
- Joint Academic Rheumatology Program, First Propaedeutic and Internal Medicine Program, National and Kapodistrian University of Athens, Athens, Greece
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Department of Clinical and Experimental Science, University of Brescia, Brescia, Italy
| | - Denis Wahl
- Vascular Medicine Division, French National Referral Center for Systemic and Autoimmune Diseases, Université de Lorraine, Inserm, DCAC, and CHRU-Nancy, Nancy, France
| | - Rohan Willis
- Antiphospholipid Standardization Laboratory, University of Texas Medical Branch, Galveston, Texas, USA
| | - Cécile Yelnik
- Department of Internal Medicine and Immunology, Université de Lille, CHU Lille, INSERM, UMR 1167, Lille, France
| | - Catherine Zuily
- Department of Obstetrics, Université de Lorraine, Inserm, DCAC, and CHRU-Nancy, Nancy, France
| | - Francis Guillemin
- CIC Clinical Epidemiology, CHRU Nancy, Inserm, Université de Lorraine, Nancy, France
| | - Karen Costenbader
- Department of Rheumatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
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8
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Connelly K, Eades LE, Koelmeyer R, Ayton D, Golder V, Kandane-Rathnayake R, Gregory K, Brunner H, Burke L, Arnaud L, Askanase A, Aranow C, Vital E, Pons-Estel G, Dantata K, Andersen J, Cornet A, Buie J, Sun Y, Tanaka Y, Simon L, Lahoud Y, Friedman A, Kalunian K, Zuraw Q, Werth V, Garces S, Morand EF. Towards a novel clinical outcome assessment for systemic lupus erythematosus: first outcomes of an international taskforce. Nat Rev Rheumatol 2023; 19:592-602. [PMID: 37433880 DOI: 10.1038/s41584-023-00993-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2023] [Indexed: 07/13/2023]
Abstract
Systemic lupus erythematosus (SLE) is a disease of high unmet therapeutic need. The challenge of accurately measuring clinically meaningful responses to treatment has hindered progress towards positive outcomes in SLE trials, impeding the approval of potential new therapies. Current primary end points used in SLE trials are based on legacy disease activity measures that were neither specifically designed for the clinical trial context, nor developed according to contemporary recommendations for clinical outcome assessments (COAs), such as that substantial patient input should be incorporated into their design. The Treatment Response Measure for SLE (TRM-SLE) Taskforce is a global collaboration of SLE clinician-academics, patients and patient representatives, industry partners and regulatory experts, established to realize the goal of developing a new COA for SLE clinical trials. The aim of this project is a novel COA designed specifically to measure treatment effects that are clinically meaningful to patients and clinicians, and intended for implementation in a trial end point that supports regulatory approval of novel therapeutic agents in SLE. This Consensus Statement reports the first outcomes of the TRM-SLE project, including a structured process for TRM-SLE development.
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Affiliation(s)
- Kathryn Connelly
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.
| | - Laura E Eades
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Rachel Koelmeyer
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Darshini Ayton
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Vera Golder
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | | | - Kate Gregory
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Hermine Brunner
- Division of Rheumatology, Cincinnati Children's Hospital, University of Cincinnati, Cincinatti, OH, USA
| | | | - Laurent Arnaud
- Department of Rheumatology, National Reference Center for Autoimmune Diseases (RESO), Hopitaux Universitaires de Strasbourg, Strasbourg, Alsace, France
| | - Anca Askanase
- Lupus Center, Columbia University Medical Center, New York City, NY, USA
| | - Cynthia Aranow
- Lupus Centre of Excellence, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Ed Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Guillermo Pons-Estel
- Departamento de Medicina Interna, Centro Regional de Enfermedades Autoinmunes y Reumáticas de Grupo Oroño (GO CREAR), Rosario, Argentina
| | | | | | | | - Joy Buie
- Lupus Foundation of America, Washington, DC, USA
| | - Ying Sun
- Merck Healthcare KGaA, Darmstadt, Hesse, Germany
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Fukuoka, Japan
| | | | | | | | - Kenneth Kalunian
- Division of Rheumatology, Allergy and Immunology, University of California, San Diego, CA, USA
| | - Qing Zuraw
- Janssen Research and Development, Spring House, PA, USA
| | - Victoria Werth
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Eric F Morand
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
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9
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Maguire S, Al-Emadi S, Alba P, Aguiar MC, Lawati TA, Alle G, Bermas B, Bhana S, Branimir A, Bulina I, Clowse M, Cogo K, Colunga I, Cook C, Cortez KJ, Dao K, Gianfrancesco M, Gore-Massey M, Gossec L, Grainger R, Hausman J, Hsu TYT, Hyrich K, Isnardi C, Kawano Y, Kilding R, Kusevich DA, Lawson-Tovey S, Liew J, McCarthy E, Montgumery A, Moyano S, Nasir N, Padjen I, Papagoras C, Patel NJ, Pera M, Pisoni C, Pons-Estel G, Quiambao AL, Quintana R, Ruderman E, Sattui S, Savio V, Sciascia S, Sencarova M, Morales RS, Siddique F, Sirotich E, Sparks J, Strangfeld A, Sufka P, Tanner H, Tissera Y, Wallace Z, Werner ML, Wise L, Worthing AB, Zell J, Zepa J, Machado PM, Yazdany J, Robinson P, Conway R. Obstetric Outcomes in Women with Rheumatic Disease and COVID-19 in the Context of Vaccination Status. Rheumatology (Oxford) 2022; 62:1621-1626. [PMID: 36124987 DOI: 10.1093/rheumatology/keac534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 08/30/2022] [Accepted: 09/04/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To describe obstetric outcomes based on COVID-19 vaccination status, in women with rheumatic and musculoskeletal diseases (RMDs) who developed COVID-19 during pregnancy. METHODS Data regarding pregnant women entered into the COVID-19 Global Rheumatology Alliance registry from 24 March 2020-25 February 2022 were analysed. Obstetric outcomes were stratified by number of COVID-19 vaccine doses received prior to COVID-19 infection in pregnancy. Descriptive differences between groups were tested using the chi -square or Fisher's exact test. RESULTS There were 73 pregnancies in 73 women with RMD and COVID-19. Overall, 24.7% (18) of pregnancies were ongoing, while of the 55 completed pregnancies 90.9% (50) of pregnancies resulted in livebirths. At the time of COVID-19 diagnosis, 60.3% (n = 44) of women were unvaccinated, 4.1% (n = 3) had received one vaccine dose while 35.6% (n = 26) had two or more doses. Although 83.6% (n = 61) of women required no treatment for COVID-19, 20.5% (n = 15) required hospital admission. COVID-19 resulted in delivery in 6.8% (n = 3) of unvaccinated women and 3.8% (n = 1) of fully vaccinated women. There was a greater number of preterm births (PTB) in unvaccinated women compared with fully vaccinated 29.5% (n = 13) vs 18.2%(n = 2). CONCLUSION In this descriptive study, unvaccinated pregnant women with RMD and COVID-19 had a greater number of PTB compared with those fully vaccinated against COVID-19. Additionally, the need for COVID-19 pharmacological treatment was uncommon in pregnant women with RMD regardless of vaccination status. These results support active promotion of COVID-19 vaccination in women with RMD who are pregnant or planning a pregnancy.
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Affiliation(s)
- Sinead Maguire
- Department of Rheumatology, St James's Hospital, Dublin, Ireland.,School of Medicine, Trinity College Dublin, Ireland
| | - Samar Al-Emadi
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Paula Alba
- Hospital Cordoba, Rheumatology Unit, Cordoba, Argentina.,Universidad Nacional de Cordoba, School of Medicine, Cordoba, Argentina
| | | | - Talal Al Lawati
- Department of Rheumatology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Gelsomina Alle
- Department of Rheumatology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Suleman Bhana
- Department of Rheumatology, Crystal Run Healthcare, Middleton, New York, USA
| | - Anic Branimir
- School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia.,University of Zagreb, Division of Immunology and Rheumatology, Department of Internal Medicine, Zagreb, Croatia
| | - Inita Bulina
- Department of Rheumatology, Paul Stradins Clinical University Hospital, Riga, Latvia.,Department of Internal Diseases, Riga Stradins University, Riga, Latvia
| | - Megan Clowse
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Karina Cogo
- Department of Rheumatology, Hospital Interzonal Luis Guemes, Buenos Aires, Argentina.,Hospital San Juan De Dios, Department of Rheumatology, Buenos Aires, Argentina
| | - Iris Colunga
- Hospital Universitario Dr Jose Eleuterio Gonzalez, Department of Rheumatology, Monterrey, Mexico
| | - Claire Cook
- Division of Rheumatology, Massachusetts General Hospital, Allergy & Immunology, Boston, Massachusetts, USA
| | - Karen J Cortez
- Baguio General Hospital and Medical Center, Department of Rheumatology, Baguio City, Philippines
| | - Kathryn Dao
- UT Southwestern Medical Center, Dallas, Texas, USA
| | - Milena Gianfrancesco
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | | | - Laure Gossec
- Sorbonne Universite, Paris, France.,Pitie-Salpetriere Hospital, Paris, France
| | - Rebecca Grainger
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Jonathon Hausman
- Department of Pediatric Rheumatology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Rheumatology and Clinical Immunology, Beth Isreal Deaconess Medical Center, Boston, Massachusetts, USA
| | - Tiffany Y T Hsu
- Brigham and Women's Hospital, Division of Rheumatology, Inflammation and Immunity, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Kimme Hyrich
- The University of Manchester, Centre for Epidemiology Versus Arthritis, Manchester, UK.,Department of MSK Research, Manchester Academic Health Science Centre, Manchester, UK.,Department of Biomedical Research, UK and National Institute of Health Research Manchester, Manchester, UK
| | - Carolina Isnardi
- Argenitine Society of Rheumatology, Research Unit, Buenos Aires, Argentina
| | - Yumeko Kawano
- Brigham and Women's Hospital, Division of Rheumatology, Inflammation and Immunity, Boston, Massachusetts, USA
| | - Rachael Kilding
- Department of Rheumatology, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Daria A Kusevich
- Nasonova Research Institute of Rheumatology, Department of Rheumatology, Vidnoe, Russia
| | - Saskia Lawson-Tovey
- Department of MSK Research, Manchester Academic Health Science Centre, Manchester, UK.,UK and National Institute of Health Research Manchester, Department of Biomedical Research, Manchester, UK.,University of Manchester, Centre for Musculoskeletal Research, Centre for Genetics and Genomics Versus Arthritis, Manchester, UK.,Department of Biomedical Research, Manchester University NHS Foundation Trust, Manchester, UK
| | - Jean Liew
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Eoghan McCarthy
- Department of Rheumatology, Beaumont Hospital, Dublin, Ireland
| | - Anna Montgumery
- University of California San Francisco, Division of Rheumatology, Department of Medicine, San Francisco, California, USA.,VA Medical Center, Department of Health Research, San Francisco, California, USA
| | - Sebastian Moyano
- Department of Rheumatology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Noreen Nasir
- The Aga Khan University Hospital, Section of Internal Medicine, Department of Medicine, Karachi, Pakistan
| | - Ivan Padjen
- School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia.,University of Zagreb, Division of Immunology and Rheumatology, Department of Internal Medicine, Zagreb, Croatia
| | - Charalampos Papagoras
- Democritus University of Thrace, First Department of Internal Medicine, Alexandroupolis, Greece
| | - Naomi J Patel
- Massachusetts General Hospital, Division of Rheumatology, Allergy & Immunology, Boston, Massachusetts, USA
| | - Mariana Pera
- Hospital Angel C Padilla, Department of Rheumatology, Tucuman, Argentina
| | - Cecilia Pisoni
- CEMIC, Rheumatology and Immunology Section, Department of Internal Medicine, Buenos Aires, Argentina
| | - Guillermo Pons-Estel
- Sheffield Teaching Hospitals, NHS Foundation Trust, Department of Rheumatology, Sheffield, UK
| | - Antonio L Quiambao
- East Avenue Medical Center, Department of Rheumatology, Quezon City, Philippines
| | - Rosana Quintana
- Argenitine Society of Rheumatology, Research Unit, Buenos Aires, Argentina
| | - Eric Ruderman
- Northwestern University Feinberg School of Medicine, Department of Medicine/Rheumatology, Chicago, Illinois, USA
| | - Sebastian Sattui
- University of Pittsburgh, Department of Rheumatology, Pittsburgh, Pennsylvania, USA
| | | | - Savino Sciascia
- Osedale San Giovanni Bosco, Centro Multidisciplinare de Recerche di Immunopatologia e Documentazione su Malattie Rare (C.M.I.D.), Turin, Italy
| | - Marieta Sencarova
- Univerzitna Nemocnica L Pasteura, Department of Rheumatology, Slovakia
| | - Rosa Serrano Morales
- Centro Regional de Enfermedades Autoinmunes y Reumaticas (GO-CREAR), Rosario, Argentina
| | - Faizah Siddique
- Department of Rheumatology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Emily Sirotich
- McMaster University, Department of Health Research, Evidence and Impact, Hamilton, Ontario, Canada
| | - Jeffrey Sparks
- Brigham and Women's Hospital, Division of Rheumatology, Inflammation and Immunity, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Anja Strangfeld
- German Rheumatism Research Centre, Epidemiology Unit, Berlin, Germany
| | - Paul Sufka
- Healthcare Partners, St Paul, Minnesota, USA
| | - Helen Tanner
- Royal Brisbane and Women's Hospital, Department of Rheumatology, Queensland, Australia.,University of Queensland, Royal Brisbane Clinical Unit, Queensland, Australia
| | | | - Zachary Wallace
- Massachusetts General Hospital, Division of Rheumatology, Allergy & Immunology, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Marina L Werner
- Hospital Nacional de Clinicas, Department of Rheumatology, Cordoba, Argentina
| | - Leanna Wise
- University of Southern California, Keck School of Medicine, Los Angelos, California, USA
| | - Angus B Worthing
- Department of Rheumatology, Arthritis and Rheumatism Associates PC, Washington, DC, USA.,Georgetown University Medical Center, Washington, DC, USA
| | - JoAnn Zell
- Division of Rheumatology, University of Colorado Health, Aurora, Colorado, USA
| | - Julija Zepa
- Department of Rheumatology, Paul Stradins Clinical University Hospital, Latvia, Riga.,Riga Stradins University, School of Medicine, Latvia, Riga
| | - Pedro M Machado
- Centre for Rheumatology & Department of Neuromuscular Diseases, University College London, London, UK.,National Institute for Health Research (NIHR) University College London Hospitals (UCLH) Biomedical Research Centre (BRC), London, UK.,Department of Rheumatology, Northwick Park Hospital, London, UK
| | - Jinoos Yazdany
- University of California San Francisco, Division of Rheumatology, Department of Medicine, San Francisco, California, USA
| | - Philip Robinson
- Royal Brisbane and Women's Hospital, Department of Rheumatology, Queensland, Australia.,University of Queensland, Royal Brisbane Clinical Unit, Queensland, Australia.,Metro North Hospital & Health Service, Herston, Queensland, Australia
| | - Richard Conway
- Department of Rheumatology, St James's Hospital, Dublin, Ireland.,School of Medicine, Trinity College Dublin, Ireland
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Izadi Z, Gianfrancesco MA, Schmajuk G, Jacobsohn L, Katz P, Rush S, Ja C, Taylor T, Shidara K, Danila MI, Wysham KD, Strangfeld A, Mateus EF, Hyrich KL, Gossec L, Carmona L, Lawson-Tovey S, Kearsley-Fleet L, Schaefer M, Al-Emadi S, Sparks JA, Hsu TYT, Patel NJ, Wise L, Gilbert E, Duarte-García A, Valenzuela-Almada MO, Ugarte-Gil MF, Ljung L, Scirè CA, Carrara G, Hachulla E, Richez C, Cacoub P, Thomas T, Santos MJ, Bernardes M, Hasseli R, Regierer A, Schulze-Koops H, Müller-Ladner U, Pons-Estel G, Tanten R, Nieto RE, Pisoni CN, Tissera YS, Xavier R, Lopes Marques CD, Pileggi GCS, Robinson PC, Machado PM, Sirotich E, Liew JW, Hausmann JS, Sufka P, Grainger R, Bhana S, Gore-Massy M, Wallace ZS, Yazdany J. Environmental and societal factors associated with COVID-19-related death in people with rheumatic disease: an observational study. Lancet Rheumatol 2022; 4:e603-e613. [PMID: 35909441 PMCID: PMC9313519 DOI: 10.1016/s2665-9913(22)00192-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Differences in the distribution of individual-level clinical risk factors across regions do not fully explain the observed global disparities in COVID-19 outcomes. We aimed to investigate the associations between environmental and societal factors and country-level variations in mortality attributed to COVID-19 among people with rheumatic disease globally. Methods In this observational study, we derived individual-level data on adults (aged 18-99 years) with rheumatic disease and a confirmed status of their highest COVID-19 severity level from the COVID-19 Global Rheumatology Alliance (GRA) registry, collected between March 12, 2020, and Aug 27, 2021. Environmental and societal factors were obtained from publicly available sources. The primary endpoint was mortality attributed to COVID-19. We used a multivariable logistic regression to evaluate independent associations between environmental and societal factors and death, after controlling for individual-level risk factors. We used a series of nested mixed-effects models to establish whether environmental and societal factors sufficiently explained country-level variations in death. Findings 14 044 patients from 23 countries were included in the analyses. 10 178 (72·5%) individuals were female and 3866 (27·5%) were male, with a mean age of 54·4 years (SD 15·6). Air pollution (odds ratio 1·10 per 10 μg/m3 [95% CI 1·01-1·17]; p=0·0105), proportion of the population aged 65 years or older (1·19 per 1% increase [1·10-1·30]; p<0·0001), and population mobility (1·03 per 1% increase in number of visits to grocery and pharmacy stores [1·02-1·05]; p<0·0001 and 1·02 per 1% increase in number of visits to workplaces [1·00-1·03]; p=0·032) were independently associated with higher odds of mortality. Number of hospital beds (0·94 per 1-unit increase per 1000 people [0·88-1·00]; p=0·046), human development index (0·65 per 0·1-unit increase [0·44-0·96]; p=0·032), government response stringency (0·83 per 10-unit increase in containment index [0·74-0·93]; p=0·0018), as well as follow-up time (0·78 per month [0·69-0·88]; p<0·0001) were independently associated with lower odds of mortality. These factors sufficiently explained country-level variations in death attributable to COVID-19 (intraclass correlation coefficient 1·2% [0·1-9·5]; p=0·14). Interpretation Our findings highlight the importance of environmental and societal factors as potential explanations of the observed regional disparities in COVID-19 outcomes among people with rheumatic disease and lay foundation for a new research agenda to address these disparities. Funding American College of Rheumatology and European Alliance of Associations for Rheumatology.
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Affiliation(s)
- Zara Izadi
- Division of Rheumatology, School of Medicine, University of California, San Francisco, CA, USA
| | - Milena A Gianfrancesco
- Division of Rheumatology, School of Medicine, University of California, San Francisco, CA, USA
| | - Gabriela Schmajuk
- Division of Rheumatology, School of Medicine, University of California, San Francisco, CA, USA
- San Francisco VA Medical Center, San Francisco, CA, USA
| | - Lindsay Jacobsohn
- Division of Rheumatology, School of Medicine, University of California, San Francisco, CA, USA
| | - Patricia Katz
- Division of Rheumatology, School of Medicine, University of California, San Francisco, CA, USA
| | - Stephanie Rush
- Division of Rheumatology, School of Medicine, University of California, San Francisco, CA, USA
| | - Clairissa Ja
- Division of Rheumatology, School of Medicine, University of California, San Francisco, CA, USA
| | - Tiffany Taylor
- Division of Rheumatology, School of Medicine, University of California, San Francisco, CA, USA
| | - Kie Shidara
- Division of Rheumatology, School of Medicine, University of California, San Francisco, CA, USA
| | - Maria I Danila
- Division of Clinical Immunology and Rheumatology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Katherine D Wysham
- VA Puget Sound Health Care System and Division of Rheumatology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Anja Strangfeld
- German Rheumatism Research Center, Epidemiology and Health Care Research, Berlin, Germany
| | - Elsa F Mateus
- Portuguese League Against Rheumatic Diseases, Lisbon, Portugal
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK
- National Institute of Health Research Manchester Biomedical Research Centre, University of Manchester-NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Laure Gossec
- INSERM, Sorbonne Universites, Groupe Hopital Universitaire Pitie Salpetriere, AP-HP, Paris, France
- Rheumatology Department, Sorbonne Universites, Groupe Hopital Universitaire Pitie Salpetriere, AP-HP, Paris, France
| | | | - Saskia Lawson-Tovey
- Centre for Genetics and Genomics Versus Arthritis, University of Manchester, Manchester, UK
- Centre for Musculoskeletal Research, University of Manchester, Manchester, UK
- National Institute of Health Research Manchester Biomedical Research Centre, University of Manchester-NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | | | - Martin Schaefer
- German Rheumatism Research Center, Epidemiology and Health Care Research, Berlin, Germany
| | | | - Jeffrey A Sparks
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tiffany Y-T Hsu
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Naomi J Patel
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Leanna Wise
- University of Southern California, Los Angeles, CA, USA
| | - Emily Gilbert
- Division of Rheumatology, Mayo Clinic, Jacksonville, FL, USA
| | - Alí Duarte-García
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | | | - Manuel F Ugarte-Gil
- School of Medicine, Universidad Científica del Sur, Lima, Peru
- Rheumatology Department, Hospital Guillermo Almenara Irigoyen, EsSalud, Lima, Peru
| | - Lotta Ljung
- Department of Public Health and Clinical Medicine and Department of Rheumatology, Umeå University, Umeå, Sweden
- Division of Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Carlo A Scirè
- Epidemiology Research Unit, Italian Society for Rheumatology, Milan, Italy
| | - Greta Carrara
- Epidemiology Research Unit, Italian Society for Rheumatology, Milan, Italy
| | - Eric Hachulla
- INSERM, CHU Lille, Service de Médecine Interne et Immunologie Clinique, Centre de référence des maladies autoimmunes systémiques rares du Nord et Nord-Ouest de France, U1286-INFINITE-Institute for Translational Research in Inflammation, Université de Lille, Lille, France
| | - Christophe Richez
- Department of Rheumatology, Hôpital Pellegrin, Centre Hospitalier Universitaire de Bordeaux, Bordeux, France
- UMR-CNRS 5164, ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - Patrice Cacoub
- INSERM 959, Sorbonne Universites, Groupe Hopital Universitaire Pitie Salpetriere, AP-HP, Paris, France
| | - Thierry Thomas
- Département de Médecine Interne et Immunologie Clinique, Sorbonne Universites, Groupe Hopital Universitaire Pitie Salpetriere, AP-HP, Paris, France
- Centre National de Références Maladies Autoimmunes systémiques rares, Sorbonne Universites, Groupe Hopital Universitaire Pitie Salpetriere, AP-HP, Paris, France
- Centre National de Références Maladies Autoinflammatoires et Amylose Inflammatoire, Sorbonne Universites, Groupe Hopital Universitaire Pitie Salpetriere, AP-HP, Paris, France
- Inflammation-Immunopathology-Biotherapy Department, Sorbonne Universites, Groupe Hopital Universitaire Pitie Salpetriere, AP-HP, Paris, France
- Department of Rheumatology, Hôpital Nord, Centre Hospitalier Universitaire Saint-Etienne, INSERM U1059, Lyon University, Saint-Etienne, France
| | - Maria J Santos
- Rheumatology Department, Hospital Garcia de Orta, Almada, Portugal
- Instituto de Medicina Molecular, Faculdade Medicina Lisboa, University of Lisbon, Lisbon, Portugal
| | - Miguel Bernardes
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
- Rheumatology Department, Centro Hospitalar-Universitário de São João, Porto, Portugal
| | - Rebecca Hasseli
- Department of Rheumatology and Clinical Immunology, Justus-Liebig University Giessen, Germany
| | - Anne Regierer
- German Rheumatism Research Center, Epidemiology and Health Care Research, Berlin, Germany
| | - Hendrik Schulze-Koops
- Division of Rheumatology and Clinical Immunology, Department of Medicine IV, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Ulf Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Justus-Liebig University Giessen, Germany
| | | | - Romina Tanten
- Hospital Francisco Lopez Lima, General Roca, Argentina
| | - Romina E Nieto
- Department of Rheumatology, Grupo Oroño-Centro Regional de Enfermedades Autoinmunes y Reumáticas, Rosario, Santa Fe, Argentina
| | - Cecilia N Pisoni
- Rheumatology and Immunology Section, Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno", Buenos Aires, Argentina
| | - Yohana S Tissera
- Servicio de Clínica Médica, Unidad de Reumatología del Hospital Córdoba and Sanatorio Parque de Córdoba, Córdoba, Argentina
| | - Ricardo Xavier
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | - Philip C Robinson
- University of Queensland Medical School, Brisbane, QLD, Australia
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Herston, QLD, Australia
| | - Pedro M Machado
- University College London, University College London Hospitals NHS Foundation Trust, Northwick Park Hospital, London North-West University Healthcare NHS Trust, London, UK
| | - Emily Sirotich
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Canadian Arthritis Patient Alliance, Toronto, ON, Canada
| | - Jean W Liew
- Boston University School of Medicine, Boston, MA, USA
| | - Jonathan S Hausmann
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Boston Children's Hospital, Boston, MA, USA
| | | | - Rebecca Grainger
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | | | | | - Zachary S Wallace
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jinoos Yazdany
- Division of Rheumatology, School of Medicine, University of California, San Francisco, CA, USA
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Isnardi CA, Roberts K, Quintana R, Kreimer J, Echeverria C, Luna PC, Virasoro BM, Exeni IE, Kogan N, Correa MDLA, Pereira DA, Zelaya D, Tissera Y, Pisoni C, Gálvez Elkin MS, Alonso CG, Cogo AK, Cosatti M, Garcia L, Retamozo C, Severina M, Nieto R, Rosemffet M, Mussano ED, Bertoli A, Delavega M, Savio V, Cosentino V, Roldan B, Maldonado Ficco H, Maid P, Calle Montoro C, Fernandez L, Leguizamón ML, Gómez Vara AB, Alfaro MA, Landi M, Herscovich N, Maldini C, De la Vega Fernandez SS, Velozo E, Giorgis P, Sattler ME, Reyes Gómez C, Perrotat L, Reimundes C, Ezquer RA, Saurit V, Flores Trejo J, Cerda OL, Crespo Rocha MG, Carrizo Abarza V, Strusberg I, Rojas Tessel R, Verna G, Bande JM, Farfan P, Berbotto G, Pons-Estel G, Schneeberger EE. AB1094 SAFETY AND EFFICACY OF VACCINES FOR SARS-CoV-2 IN PATIENTS WITH RHEUMATIC AND IMMUNE-MEDIATED INFLAMMATORY DISEASES: DATA FROM THE ARGENTINEAN REGISTRY SAR-CoVAC. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundCurrently there is little information on the efficacy and safety of SARS-CoV-2 vaccination in patients with immune-mediated diseases and/or under immunosuppressive treatment in our country, where different types of vaccines and mix regimens are used. For this reason, the Argentine Society of Rheumatology (SAR) with the Argentine Society of Psoriasis (SOARPSO) set out to develop a national register of patients with rheumatic and immune-mediated inflammatory diseases (IMIDs) who have received a SARS-CoV-2 vaccine in order to assess their efficacy and safety in this population.ObjectivesTo assess SARS-CoV-2 vaccine efficacy and safety in patients with rheumatic and IMIDs.MethodsSAR-CoVAC is a national, multicenter and observational registry. Adult patients with a diagnosis of rheumatic or IMIDs who have been vaccinated for SARS-CoV-2 were consecutively included between June 1st and September 17th, 2021. Sociodemographic data, comorbidities, underlying rheumatic or IMIDs, treatments received and their modification prior to vaccination and history of SARS-CoV-2 infection were recorded. In addition, the date and place of vaccination, type of vaccine applied, scheme and indication will be registered. Finally, adverse events (AE), as well as SARS-CoV-2 infection after the application of the vaccine were documentedResultsA total of 1234 patients were included, 79% were female, with a mean age of 57.8 (SD 14.1) years. The most frequent diseases were rheumatoid arthritis (41.2%), osteoarthritis (14.5%), psoriasis (12.7%) and spondyloarthritis (12.3%). Most of them were in remission (28.5%) and low disease activity (41.4%). At the time of vaccination, 21% were receiving glucocorticoid treatment, 35.7% methotrexate, 29.7% biological (b) Disease Modifying Anti-Rheumatic Drugs (DMARDs) and 5.4% JAK inhibitors. Before vaccine application 16.9% had had a SARS-CoV-2 infection.Regarding the first dose of the vaccine, the most of the patients (51.1%) received Gam-COVID-Vac, followed by ChAdOx1 nCoV-19 (32.8%) and BBIBP-CorV (14.5%). In a lesser proportion, BNT162b2 (0.6%), Ad26.COV2.S (0.2%) and CoronaVac (0.2%) vaccines were used. Almost half of them (48.8%) completed the scheme, 12.5% were mix regimenes, the most frequent being Gam-COVID-Vac / mRNA-1273. The median time between doses was 51days (IQR 53).More than a quarter (25.9%) of the patients reported at least one AE after the first dose and 15.9% after the second. The flu-like syndrome and local hypersensitivity were the most frequent manifestations. There was one case of mild anaphylaxis. No patient was hospitalized. Altogether, the incidence of AE was 246.5 events/1000 doses. BBIBP-CorV presented significantly lower incidence of AE in comparison with the other types of vaccines. (118.5 events/1000 doses, p<0.002 in all cases)Regarding efficacy, 63 events of SARS-CoV-2 infection were reported after vaccination, 19% occurred before 14 days post-vaccination, 57.1% after the first dose (>14 days) and 23.8% after the second. In most cases (85.9%) the infection was asymptomatic or had an outpatient course and 2 died due to COVID-19.ConclusionIn this national cohort of patients with rheumatic and IMIDs vaccinated for SARS-CoV-2, the most widely used vaccines were Gam-COVID-Vac and ChAdOx1 nCoV-19, approximately half completed the schedule and in most cases homologously. A quarter of the patients presented some AE, while 5.1% presented SARS-CoV-2 infection after vaccination, in most cases mild.Disclosure of InterestsNone declared
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Savio V, Maldini C, Alba P, Saurit V, Berbotto G, Pisoni C, Tissera Y, Nieto R, Maldonado F, Ornella S, Gobbi C, Baños AR, Vivero F, Exeni IE, Cusa A, Bellomio VI, Perez Alamino R, Gomez G, Zelaya D, Risueño F, Quaglia MI, Correa MDLA, Rojas Tessel R, Delavega M, Lazaro MA, Mercé AL, Finucci P, Matellan CE, Romeo C, Martire V, Moyano S, Martin ML, Picco E, Goizueta C, Tralice ER, Tamborenea MN, Subils GC, Gallo R, Pineda Vidal SI, Velasco Zamora JL, Lloves Schenone N, Cosentino V, Rodriguez F, Diaz MP, Viola M, Mamani Ortega ML, Buschiazzo E, Gómez G, Roberts K, Quintana R, Isnardi CA, Pons-Estel G. POS1199 IS PSORIATIC ARTHRITIS A RISK FACTOR FOR SEVERE COVID -19 INFECTION? DATA FROM THE ARGENTINIAN REGISTRY SAR-COVID. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundComorbidities, particularly cardio-metabolic disorders, are highly prevalent in patients with psoriatic arthritis (PsA) and they were associated with an increased risk of atherosclerotic cardiovascular disease, which have been associated with higher morbidity and mortality. Whether PsA enhances the risk of SARS-CoV-2 infection or affects the disease outcome remains to be ascertained.ObjectivesTo describe the sociodemographic, clinical and treatment characteristics of patients with PsA with confirmed SARS-CoV-2 infection from the SAR-COVID registry and to identify the variables associated with poor COVID-19 outcomes, comparing them with those with rheumatoid arthritis (RA).MethodsCross-sectional observational study including patients ≥18 years old, with diagnosis of PsA (CASPAR criteria) and RA (ACR / EULAR 2010 criteria), who had confirmed SARS-CoV-2 infection (RT-PCR or serology) from the SAR-COVID registry. Recruitment period was between August 13, 2020 and July 31, 2021. Sociodemographic variables, comorbidities, and treatments were analyzed. To assess the severity of the infection, the ordinal scale of the National Institute of Allergy and Infectious Diseases (NIAID)1 was used, and it was considered that a patient met the primary outcome, if they presented criteria of categories 5 or higher on the severity scale. For this analysis, Chi2 test, Fisher’s test, Student’s test or Wilcoxon test, and binomial logistic regression using NIAID>=5 as dependent variable were performed.ResultsA total of 129 PsA patients and 808 with RA were included. Clinical characteristics are shown in Table 1. Regarding PsA treatment, 12.4% of PsA were receiving IL-17 inhibitors, 5.4% IL12-23 inhibitors, one patient apremilast and one abatacept. The frequency of NIAID≥5 was comparable between groups (PsA 19.5% vs RA 20.1%; p=0.976). (Figure 1).Table 1.Characteristics of patients with PsA and RA who presented COVID-19 in the SAR-COVID registry.Psoriatic arthritis (n=129)Rheumatoid arthritis (n=808)P valueTotal (n=937)Age (years), mean (SD)51.7 (12.7)53.1 (12.9)0.23952.9 (12.9)Female72 (55.8)684 (84.7)<0.001756 (80.7)Comorbidities65 (50.4)355 (43.9)0.203420 (44.8) Obesity (BMI ≥30)19 (15.2)102 (13.4)0.692121 (13.7) Morbid obesity (BMI ≥40)1 (0.8)10 (1.3)111 (1.25) Hypertension35 (28.5)205 (26.8)0.783240 (27.0) Diabetes16 (13.0)67 (8.8)0.18883 (9.39) Dyslipidemia24 (19.5)102 (13.5)0.106126 (14.4) Cardiovascular or cerebrovascular disease5 (11.4)32 (3.9)0.03337 (4.2)Two or more comorbidities55 (42.6)219 (27.1)<0.001274 (29.2)Current smoking4 (3.6)60 (8.4)0.7964 (7.7)High disease activity0 (0)29 (3.8)0.02729 (3.23)Glucocorticoids treatment5 (20.0)95 (60.1)<0.001100 (54.6)Conventional DMARDs47 (36.4)443 (54.8)<0.001490 (52.3)Biologic DMARDs60 (46.5)193 (23.9)<0.001253 (27.0)JAK inhibitors4 (3.10)72 (8.9)0.03876 (8.1)Full recovery of COVID-19105 (84.0)644 (81.7)0.127749 (82.0)COVID-19 complications16 (12.5)68 (8.7)0.22784 (9.2)Death due to COVID-191 (0.8)34 (4.3)0.07435 (3.8)Notes=values n (%) unless otherwise indicated; BMI: Body Mass Index; DMARDs: disease-modifying antirheumatic drugs; JAK inhibitors: Janus kinase inhibitors.PsA patients with NIAID≥5 in comparison with NIAID<5 were older (58.6±11.4 vs 50±12.5; p=0.002), had more frequently hypertension (52.2% vs 23%; p=0.011) and dyslipidemia (39.1% vs 15%; p=0.017). In the multivariate analysis, age (OR 1.06; 95% CI 1.02–1.11) was associated with a worse outcome of the COVID-19 (NIAID≥5) in patients with PsA, while those who received methotrexate (OR 0.34; 95% CI 0.11–0.92) and biological DMARDs (OR 0.28; 95% CI 0.09–0.78) had a better outcome.ConclusionAlthough PsA patients have a higher frequency of cardiovascular and metabolic comorbidities than those with RA, the COVID-19 severity was similar. Most of the patients had mild SARS-CoV-2 infection and a low death rate.References[1]Beigel JH, et al. Remdesivir for the Treatment of Covid-19 - Final Report. N Engl J Med. 2020 Nov 5;383(19):1813-1826.Disclosure of InterestsNone declared
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Cosatti M, D´ Angelo ME, Petkovic IE, Correa MDLA, Zelaya D, Gálvez Elkin MS, Cogo AK, Retamozo C, Nieto R, Mussano ED, Cavillon EM, Savio V, Roldan B, Maid P, Fernandez L, Muñoz L, Leguizamón ML, Herscovich N, Alfaro MA, Maldini C, Giorgis P, Reyes Gómez C, Reimundes C, Saurit V, Cerda OL, Crespo Rocha MG, Strusberg I, Verna G, Quaglia MI, Picco E, Catalan Pellet S, Galan M, Troyano Z, Perandones M, Kreimer J, Luna PC, Echeverria C, Virasoro BM, Roberts K, Isnardi CA, Schneeberger EE, Pons-Estel G, Pisoni C. POS1204 SARS-CoV-2 INFECTION AFTER VACCINATION IN PATIENTS WITH RHEUMATIC DISEASES FROM ARGENTINA. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundPatients with rheumatic diseases (RD) have been excluded from SARS-CoV-2 vaccine trials. Though data appear to show safety and efficacy, mostly evidence remains in mRNA vaccines. However in our country, adenovirus and inactivated vaccines, as well as heterologous schemes are frequently used.ObjectivesTo describe clinical characteristics and outcomes of SARS-CoV-2 infection after vaccination in patients with RD from de the SAR-CoVAC registry and to compare them with patients who got infected before vaccination. Additionally, factors associated with COVID-19 unfavorable outcome were assessed.MethodsAdult patients with RD who have been vaccinated for SARS-CoV-2 were consecutively included between June 1st and December 21st, 2021. Confirmed SARS-CoV-2 infection (RT-PCR o serology) was reported by the treated physician. Infection after an incomplete scheme was defined when the event was diagnosed at least 14 days after first dose; and after a complete scheme when it occurred > 14 days after second dose. Homologous scheme is defined by two same doses of vaccine and heterologous by two different doses. Patients with previous SARS-CoV-2 infection were excluded. To compare SARS-CoV-2 infection characteristics in not vaccinated patients, subjects from the SAR-COVID registry, which includes patients with RD and SARS-CoV-2 infection, were matched 2:1 by gender, age and RD.WHO-Ordinal Scale ≥5 was used to define unfavorable infection outcome. Descriptive statics, Chi2 test, Fischer test, T test and ANOVA were used.ResultsA total of 1350 patients from the SAR COVAC registry were included, 67 (5%) presented SARS-CoV-2 infection after vaccination. The later were mostly (72%) females with a mean age of 57 (SD 15) years old. The most frequent RD were rheumatoid arthritis (41%), psoriatic arthritis (12%) and systemic lupus erythematosus (10%). At vaccination, most of them (75%) had low disease activity or remission, 19% were taking steroids, 39% methotrexate, 27% bDMARDs and 6% JAK inhibitors.A total of 11 (16%) patients had SARS-CoV-2 infection <14 days after the first vaccine dose, 39 (58%) after an incomplete scheme and 17 (25 %) following a complete one. In the incomplete scheme group, 59% received Gam-COVID-Vac, 31% ChAdOx1 nCov-19 and 10% BBIBP-CorV; and in patients with complete scheme 47%, 24% and 29%, respectively. No event was reported after a complete heterologous scheme. No significant differences regarding sociodemoghraphic characteristics, RD, disease treatment, type of vaccine and regimen was found between in those with infection and those without it.After vaccination only 8 (12%) of the patients who got infected had an unfavorable course, 88% of them following an incomplete scheme (5 received Gam-COVID-Vac, 1 ChAdOx1 nCov-19 and 1 BBIBP-CorV) and one subject after a complete homologous Gam-COVID-Vac scheme. Having an unfavorable outcome of SARS-CoV-2 infection was associated to: male gender [63% vs 24%, p=0.036], older age [mean 70 years (SD 7) vs 55 years (SD 15), p=0.005], being Caucasian [100% vs 54%, p=0.018], higher education [mean 17 years (SD 4) vs 12 years (SD 4), p=0.010], the presence of comorbidities [100% vs 39%, p=0.001, having pulmonary disease [37% vs 5%, p=0.019], dyslipidemia [63% vs 17%, p=0.011] and arterial hypertension [63% vs 24%, p=0.036], RD, treatments, disease activity and types of vaccines received were comparable between groups.When comparing patients with and without vaccination prior SARS-CoV-2 infection, those who received at least one dose of vaccine had less frequently severe COVID-19 (12% vs 24%, p=0.067) and presented lower mortality due to COVID-19 (3% vs 6%, p=0.498). However these differences did not reach statistical significance.ConclusionIn the SAR-CoVAC registry 5% of the patients had SARS-CoV-2 infection after vaccination, most of them mild and 25% after a complete scheme. Any vaccine was associated with severe COVID-19. When comparing with non-vaccinated patients, those with at least one dose, had less frequently severe disease and died due COVID-19.Disclosure of InterestsNone declared
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Bertoli A, Muñoz L, López Pérez MJ, Sanchez Freytes L, Castaño MS, Saurit V, Berbotto G, Alle G, Severina M, Nieto R, Maldonado F, Pera M, Cogo AK, Baños AR, Vivero F, Pereira DA, Cosatti M, Savio V, Perez Alamino R, Medina MA, Schmid M, Risueño F, Quaglia MI, Pendon GP, Casalla L, Delavega M, Lazaro MA, Finucci P, Morbiducci J, Romeo C, Cucchiaro N, Moyano S, Barbich T, Conti SM, Goizueta C, Tralice ER, Maldini C, Rebak J, Gallo R, Maid P, Velasco Zamora JL, Lloves Schenone N, Porta S, Morales NS, Diaz MP, Viola M, Buschiazzo E, Gómez G, Roberts K, Quintana R, Isnardi CA, Pons-Estel G, Matellan CE. POS1200 DIFFERENCES BETWEEN THE FIRST AND THE SECOND WAVE OF SARS-COV-2 INFECTION IN PATIENTS WITH IMMUNE-MEDIATED INFLAMMATORY DISEASES IN ARGENTINA: DATA FROM THE SAR-COVID REGISTRY. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundIn Argentina we have witnessed two COVID 19 waves between 2020 and 2021. The first wave occurred during the spring of 2020 and it was related to the wild type of the virus, the second occurred during the fall/winter of 2021 when the gamma variant showed a clear predominance. During the first wave, patient with rheumatic diseases showed a higher frequency of hospitalization and mortality (4% vs 0.26%) when compared to the general population1; at that time, however, vaccination was not yet available.ObjectivesTo compare sociodemographic and disease characteristics, course and outcomes of SARS-CoV-2 infection in patients with immune-mediated/autoinflammatory diseases (IMADs) during the first and second waves in Argentina.MethodsSAR-COVID is a national, multicenter, longitudinal and observational registry, in which patients ≥18 years of age, with a diagnosis of a rheumatic disease who had confirmed SARS-CoV-2 infection (RT-PCR or positive serology) were consecutively included since August 2020. For the purpose of this report, only patients with IMADs who had SARS-CoV-2 infection during the first wave (defined as cases occurred between March 2020 and March 2021) and the second wave (cases occurred between April and August 2021) were examined. Sociodemographic characteristics, disease diagnosis and activity, comorbidities, immunosuppressive treatment and COVID 19 clinical characteristics, complications and outcomes: hospitalization, intensive care unit (ICU) admission, use of mechanical ventilation and death were compared among groups. Descriptive statistical analysis was performed. Variables were compared with Chi squared test and Student T test or Mann Whitney test. Multivariable logistic regression models with forward and backward selection method, using hospitalization, ICU admission and death as dependent variables were carried out.ResultsA total of 1777 patients were included, 1342 from the first wave and 435 of the second one. Patients had a mean (SD) age of 50.7 (14.2) years and 81% were female. Both groups of patients were similar in terms of socio-demographic features, disease diagnosis, disease activity, the use of glucocorticoids ≥ 10 mg/day and the immunosuppressive drugs (Table 1 below). Patients infected during the first wave have higher frequency of comorbidities (49% vs 41%; p= 0.004). Hospitalizations due to COVID 19 (31% vs 20%; p <0.001) and ICU admissions (9% vs 5%; p= 0.009) were higher during the first wave. No differences in the use of mechanical ventilation (16% vs 16%; p= 0.97) nor in the mortality rate (5% vs 4%; p= 0.41) were observed. In the multivariable analysis, after adjusting for demographics, clinical features and immunosuppressive treatment, patients infected during the second wave were 40% less likely to be hospitalized (OR= 0.6, IC95% 0.4-0.8) and to be admitted to the ICU (OR= 0.6, IC95% 0.3-0.9).Table 1.Variable (% or Mean – SD)First wave(n=1342)Second wave(n=435)p ValueFemale gender81800.7Age (years)51.0 (14.5)50.0 (13.3)0.2Disease diagnosis Rheumatoid arthritis46461 Ankylosing spondylitis10110.8 Systemic lupus erythematosus171850.9 Systemic Scleroderma551 Sjögren´s syndrome650.7 Inflammatory myopathies330.5 Vasculitis430.4Disease activity High430.5Use of immune modulatorsDMARDcs53560.2DMARDts460.1DMARDb82821Use of glucocorticoids ≥10 mg12120.9Comorbidities49410.004ConclusionThe impact of COVID 19 in Argentina, in terms of mortality in patients with IMADs was still higher compared to the general population during the second wave. However, the frequency of hospitalizations and ICU admissions was lower. These findings could be explained by the introduction of the SARS COV 2 vaccination and, probably, by the cumulative knowledge and management improvement of this infection among physicians.References[1]Isnardi CA et al. Epidemiology and outcomes of patients with rheumatic diseases and SARS-COV-2 infection: data from the argentinean SAR-COVID Registry. Ann Rheum Dis, 2021, suppl 1, 887.Disclosure of InterestsNone declared
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Quintana R, Garcia L, Alba P, Roverano S, Alvarez A, Graf C, Pisoni C, Spindler A, Gomez C, Figueredo HM, Papasidero S, Paniego RH, Delavega M, Civit De Garignani EE, Gonzalez Lucero L, Martire V, Águila Maldonado R, Gordon S, Gobbi C, Nieto R, Rausch G, Góngora V, D’amico MA, Dubinsky D, Orden AO, Zacariaz J, Romero J, Pera MA, Rillo O, Baez R, Arturi V, Gonzalez A, Vivero F, Schmid M, Caputo V, Larroude MS, Gomez G, Rodriguez G, Marin J, Collado MV, Jorfen M, Bedran Z, Sarano J, Zelaya D, Sacnun M, Finucci P, Rojas Tessel R, Sattler ME, Machado Escobar M, Astesana P, Paris UV, Allievi A, Vandale JM, Pons-Estel B, Pons-Estel G, García M. POS0707 POTENTIAL USE OF BELIMUMAB IN LUPUS PATIENTS FROM ARGENTINE COHORT ACCORDING DISEASE ACTIVITY STATE. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundThe goal of targeted treatment in patients with Systemic Lupus Erythematosus (SLE) is to achieve clinical remission or low disease activity, with the best quality of life, low damage rates and better survival 1-4. RELESSAR is a multicenter, cross-sectional study registry of ≥18 years SLE (ACR 97) patients 5.ObjectivesTo describe demographic, clinical characteristics and treatments in SLE patients according to disease activity state. To evaluate the proportion of SLE and refractory SLE patients that are potentially candidates for Belimumab treatment (Active SLE despite standard treatment including increased acDNA autoantibodies and low complement).MethodsWe evaluated demographic and clinical data, treatments, score of damage (SLICC), activity (SLEDAI) and comorbidity (Charlson), hospital admissions and severe infections. The patients were compared according to disease activity: remission (SLEDAI = 0 and without corticosteroids), low disease activity (LDA, SLEDAI> 0 and ≤4 and without corticosteroids) and non-optimal control (SLEDAI> 4 and any dose of corticosteroids). Refractory SLE was defined according to Rituximab (RTX) use, non-response to cyclophosphamide or two or more immunosuppressant or splenectomized patients. Potential use of Belimumab according approved prescription in Argentina was analyzed.ResultsOverall, 1277 patients were analyzed: 299 (23.4%) were in remission, 162 (12.7%) in LDA and 816 (63.9%) with non-optimal control of the disease.Patients in non-optimal control group were younger, less frequently female and they showed less time of disease and lower socioeconomic status (p < 0.001). They were also more prevalent mestizos (p= 0.004), had higher SLEDAI and SLICC indexes (p <0.001) and higher use of immunosuppressant therapy (p <0.001). There was no difference regarding biologic treatment (RTX p= 0.547 and Belimumab p= 0.08). This group had higher proportion of hospital admissions and severe infections (p<0.001, respectively).Two hundred and one SLE patients fulfilled the use of Belimumab prescription criteria but only 45/201 patients (22,3%) received it in the last visit. Malar rash was the only clinical variable associated with the use of Belimumab (72.7% vs 29.8% p= 0.005).Seventy-six patients classified as refractory SLE (15.7%) and 56/76 (75.7%) never received Belimumab. Patients on Belimumab therapy were associated to treatment with lower doses of corticoids (p= 0.018) and lower rate of hospital admission caused by SLE flare (p= 0.027).ConclusionA high percentage of patients had uncontrolled disease upon entry into the registry and were potential candidates for treatment with Belimumab. The patients who received biologic treatment showed the benefit of requiring fewer doses of corticosteroids and having a lower rate of hospitalizations.References[1]Mok CC. Treat-to-target in systemic lupus erythematosus: Are we there yet? Expert Rev Clin Pharmacol. 2016;9(5).[2]Morand EF, Mosca M. Treat to target, remission and low disease activity in SLE. Vol. 31, Best Practice and Research: Clinical Rheumatology. 2017.[3]Golder V, Tsang-A-Sjoe MWP. Treatment targets in SLE: Remission and low disease activity state. Rheumatol (United Kingdom). 2020;59.[4]Ruiz-Irastorza G, Bertsias G. Treating systemic lupus erythematosus in the 21st century: new drugs and new perspectives on old drugs. Vol. 59, Rheumatology (United Kingdom). 2021.[5]Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum [Internet]. 1997;40(9):1725. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9324032Disclosure of InterestsRosana Quintana: None declared, Lucila Garcia: None declared, Paula Alba: None declared, Susana Roverano: None declared, Analia Alvarez: None declared, Cesar Graf: None declared, Cecilia Pisoni: None declared, Alberto Spindler: None declared, Catalina Gomez: None declared, Heber Matias Figueredo: None declared, Silvia Papasidero: None declared, Raul Horacio Paniego: None declared, Maria DeLaVega: None declared, Emma Estela Civit De Garignani: None declared, Luciana Gonzalez Lucero: None declared, Victoria Martire: None declared, Rodrigo Águila Maldonado: None declared, Sergio Gordon: None declared, Carla Gobbi: None declared, Romina Nieto: None declared, Gretel Rausch: None declared, Vanina Góngora: None declared, Maria Agustina D´Amico: None declared, Diana Dubinsky: None declared, Alberto Omar Orden: None declared, Johana Zacariaz: None declared, Julia Romero: None declared, Mariana Alejandra Pera: None declared, Oscar Rillo: None declared, Roberto Baez: None declared, Valeria Arturi: None declared, Andrea Gonzalez: None declared, Florencia Vivero: None declared, Marcela Schmid: None declared, Victor Caputo: None declared, Maria Silvia Larroude: None declared, Graciela Gomez: None declared, Graciela Rodriguez: None declared, Josefina Marin: None declared, Maria Victoria Collado: None declared, Marisa Jorfen: None declared, Zaida Bedran: None declared, Judith Sarano: None declared, David Zelaya: None declared, MONICA SACNUN: None declared, Pablo Finucci: None declared, Romina Rojas Tessel: None declared, Maria Emilia Sattler: None declared, MAXIMILIANO MACHADO ESCOBAR: None declared, Pablo Astesana: None declared, Ursula Vanesa Paris: None declared, Alberto Allievi: None declared, Juan Manuel Vandale: None declared, Bernardo Pons-Estel: None declared, Guillermo Pons-Estel: None declared, Mercedes García Grant/research support from: GSK grant
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Gonzalez Gomez CA, Cosatti M, Castro Coello VV, Haye M, Tissera Y, Reyes AA, Albiero JA, Ornella S, Alba P, Gobbi C, Gamba MJ, Exeni IE, Cusa A, Gallino Yanzi J, Bellomio VI, Gomez G, Zelaya D, Takashima L, Carlevaris L, Correa MDLA, Rojas Tessel R, García M, German N, Mercé AL, Bertoli A, Aguero SE, Calvo ME, Martire V, Mauri M, Martin ML, Picco E, Castrillon Bustamante D, Ibañez Zurlo L, Tamborenea MN, Subils GC, Vasquez DL, Soares de Souza S, Herscovich N, Raiti L, Cosentino V, Rodriguez F, Ledesma C, Diaz MP, Mamani Ortega ML, Castaño MS, Gómez G, Roberts K, Quintana R, Isnardi CA, Pons-Estel G, Pisoni C. AB1101 PREVALENCE OF LONG COVID IN RHEUMATIC DISEASE PATIENTS: ANALYSIS OF SAR COVID REGISTRY. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.1021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundPersistent symptoms after acute COVID have been described previously. Main symptoms reported are fatigue, arthralgias, myalgias and mental sickness. Definition and methods vary widely.1ObjectivesTo asses prevalence and related factors to long COVID in a retrospective cohort of patients with rheumatic diseases from Argentina.MethodsA total of 1915 patients were registered from August 18th, 2020 to July 29th, 2021. Patients > 18 years old, with rheumatic disease and confirmed infection by SARS-CoV-2 (antigen or RT-PCR) were included. Those dead, with unknown outcome, wrong date or missing data were excluded. Demographic data, comorbidities, rheumatic disease, and characteristics of SARS-CoV-2 infection were recorded.Long COVID was defined according to NICE guidelines (persistent symptoms for more than 4 weeks, without alternative diagnosis). Long COVID symptoms were defined by rheumatologist. Severity of infection was classified according to WHO ordinal scale.We used descriptive statistics, univariate model (Student’s test, chi square test, ANOVA) and multivariate logistic regression analysis.Results230 (12%) had long COVID. Median age was 51 (IQR 40-61]) years, 82% were females, 51% were not caucasian. Median of education was 13.3 years (IQR 12 – 16), 79 % had private health insurance and 55 % were employed. Nearly half (n=762, 46%) had comorbidities, the most prevalent was hypertension (n=396, 24%).The most frequent rheumatic diseases were rheumatoid arthritis (n=719, 42%) and systemic lupus erythematosus (n=280, 16 %). Most were in low activity/remission (79%), used Conventional DMARD (n=773 patients, 45%) and steroids (n=588, 34%) at low dose (n=415, 71%).Main laboratory findings were abnormal D-dimer (n=94, 28%) and leukopenia (n=93, 26%). Most patients had a WHO ordinal scale < 5 (n=1472, 86%). Median of hospitalization at intensive care unit (ICU) was 8 days [IQR 5, 13]. Treatment for SARS-CoV-2 infection (steroids, anticoagulation, azithromycin, convalescent plasma) was used in 461 (27%) patients.Most of long COVID (n= 152, 69%) reported 1 symptom, the most frequent was fatigue (n= 55, 22%). Figure 1.Univariate analysis is presented in Table 1. In multivariate logistic regression analysis non-caucasian ethnicity OR 1.44 (1.07-1.95), years of education OR 1.05 (1-1.09), treatment with cyclophosphamide OR 11.35 (1.56-112.97), symptoms of COVID – 19 OR 13.26 (2.75-242.08), severity scale WHO ≥ 5 OR 2.46 (1.68-3.57), and ICU hospitalization days OR 1.09 (1.05-1.14) were factors associated to long COVID.Table 1.Univariate analysis of long COVID syndrome in SAR – COVID registryVariableAcute COVID n=1486Long COVID n=221P valueAge, years, median [IQR]51 [40, 60]54 [42, 62]0.032Caucasian, n (%)744 (48)132 (53)0.227Female sex, n (%)1242 (80)215 (86)0.066Education, years, median [IQR]12 [10, 17]13 [12, 16]-Private health insurance, n (%)1161 (79)181 (82)0.325Smoking, n (%)381 (25)71 (29)0.224Comorbidities, n (%)650 (45)108 (52)0.066Dyslipidemia, n (%)173 (12)39 (19)0.008Hypertension, n (%)332 (23)60 (29)0.053Low activity/remission disease, n (%)1140 (80)179 (77)1Rheumatoid arthritis, n (%)623 (42)96 (42)1Systemic lupus erythematosus, n (%)243 (16)37 (16)0.996DMARD, n (%)664 (45)109 (47)0.486Cyclophosphamide, n (%)3 (0.2)3 (1)0.035Rituximab, n (%)19 (1)9 (34)0.008Lymphocyte66 (23)19 (30)0.011<1.500 / mm3, n (%)Ferritin > 2000 ng/ml, n (%)32 (11)16 (25)0.011ICU hospitalization, days,7 [4, 10]10 [8, 24]<0.001median [IQR]Treatment for COVID-19, n (%)394 (27)91 (41)<0.001ConclusionPrevalence of long COVID was 12%. Non-caucasian ethnicity, higher education, treatment with cyclophosphamide, symptoms of COVID – 19, severe disease and ICU hospitalization days were related to long COVID.References[1]Cabrera Martimbianco AL, Pacheco RL, Bagattini ÂM, Riera R. Frequency, signs and symptoms, and criteria adopted for long COVID-19: A systematic review. Int J Clin Pract.Disclosure of InterestsNone declared
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Isnardi CA, Cerda OL, Schneeberger EE, Landi M, Calle Montoro C, Alfaro MA, Roldan B, Gómez Vara AB, Giorgis P, Ezquer RA, Crespo Rocha MG, Reyes Gómez C, Correa MDLA, Rosemffet M, Carrizo Abarza V, Catalan Pellet S, Perandones M, Reimundes C, Cruces L, Yesica L, Turk G, Quiroga F, Laufer N, Quintana R, Delavega M, Maid P, Pons-Estel G, Citera G. AB1123 EFFICACY AND SAFETY OF SARS-CoV-2 THIRD VACCINE IN PATIENTS WITH RHEUMATOID ARTHRITIS WHO DID NOT RESPOND AFTER PRIMARY TWO-DOSE REGIMEN. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.2953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundVaccination for COVID-19 is an essential tool to fight the pandemic. Evidence suggests that patients with immune mediated inflammatory diseases (IMIDs) have less response. The application of a booster shot is a strategy that has been implemented in this population, however there is scarce information about its efficacy.ObjectivesTo assess the humoral and cellular immune response after a third dose of SARS-CoV-2 vaccine in patients with rheumatoid arthritis (RA) with undetectable antibodies titles after primary regimen of two doses.MethodsObservational study. Patients with RA (ACR/EULAR 2010 criteria) from two rheumatology centers, ≥18 years old, with no seroconversion after two doses of SARS-CoV-2 vaccine, who received a third dose of either mRNA or vector-based vaccines (BNT162b2 or ChAdOx1 nCoV-19) were included. Anti-SARS-CoV-2 IgG antibodies, neutralising activity and T cell responses were assessed between 21 and 40 days after the third dose. Sociodemographic data, comorbidities, treatment, vaccine applied and the presence of adverse events (AE) were recorded. Statistical analysis: descriptive analysis. Chi2 or Fischer test and T test.ResultsA total of 21 non-responder patients were included, all of them females with a mean age of 63.7 years (SD 11,6) and mean disease duration of 15.8 years (SD 8). Most of them (81%) reported comorbidities, being the most frequent arterial hypertension, obesity and dyslipidemia. At vaccination time, 6 (28.6%) were receiving glucocorticoids, 3 of them ≥10 mg/day, 17 c-DMARDs (methotrexate 57.1%) and 18 (85.1%) b-DMARDs, 6 abatacept (ABT) and 4 rituximab (RTX).Regarding the primary vaccination regimen, 13 (61.9%) received two doses of BBIBP-CorV, 3 (14.3%) Gam-COVID-Vac, 3 (14.3%) ChAdOx1 nCoV-19 and 2 (9.5%) a mix regimen of Gam-COVID-Vac/mRNA-1273. The majority (95.2%) received BNT162b2 vaccine and only one of them ChAdOx1 nCoV-19, with a mean time between the second and third dose of 151,4 days (SD 46,4). After the third dose, 90.5% of the patients presented detectable anti-SARS-CoV-2 IgG and 76.2% presented neutralizing activity. The median of neutralizing antibodies titers was 1/12 (IQR 1/7-1/48). Both patients who did not present detectable antibodies were obese, recieved BBIBP-CorV during the primary regimen and BNT162b2 as the third dose, one of them was taking methotrexate and ABT and the other one RTX. Compared to other treatments, ABT and RTX was associated with no neutralizing activity in 4 (80%) patients and lower titers of neutralizing antibodies [median 1/3 (IQR 0-1/20) vs median 1/8 (IQR 1/4-1/128), p=0.197].A T-cell response was present in 41.2% of all patients after the second dose, increasing to 75% after the third dose. The use of ABT was associated with a lower frequency of T-cell response (80% vs 20%, p=0.014).Sixteen (76.1%) patients reported at least one AE, 66.7% injection site reaction and 25% flu-like syndrome.ConclusionIn this RA cohort who failed to seroconvert after two doses of SARS-CoV-2 vaccine, 90.5% presented detectable anti-SARS-CoV-2 IgG and 75% T-cell responce after a third dose. The use of ABT was associated with a lower frequency of T-cell response. This data highlights the importance of a third vaccine in this group of patients.Disclosure of InterestsNone declared
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Gómez Vara AB, Barbich T, Isnardi CA, Schneeberger EE, Citera G, Castro Coello VV, Baez R, Haye M, Reyes AA, Albiero JA, Tanten R, Velozo E, Alba P, Gamba MJ, Alonso CG, Maldonado Ficco H, Gallino Yanzi J, Savio V, Asnal C, Matellan C, Takashima L, Carlevaris L, Gálvez Elkin MS, Scafati J, García M, German N, Werner ML, Aeschlimann C, Aguero SE, Calvo ME, Gonzalez Lucero L, Rodriguez Gil GF, Mauri M, Petruzzelli S, Castrillon Bustamante D, Ibañez Zurlo L, Alonso D, Tomas JL, Vasquez DL, Soares de Souza S, Herscovich N, Raiti L, Mareco JM, Guaglianone D, Ledesma C, Diaz MP, Bedoya ME, Kisluk B, Gómez G, Roberts K, Quintana R, Pons-Estel G. POS1238 GLUCOCORTICOIDS, RITUXIMAB AND THE PRESENCE OF INTERSTITIAL LUNG DISEASE ARE ASSOCIATED WITH POOR OUTCOMES OF THE SARS-COV-2 INFECTION IN PATIENTS WITH RHEUMATOID ARTHRITIS: DATA FROM THE NATIONAL REGISTRY SAR-COVID. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.3000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundHigh disease activity, treatment with glucocorticoids (GC) and rituximab (RTX), have been related to worse outcomes of COVID-19.ObjectivesTo assess the clinical characteristics and severity of the SARS-CoV-2 infection in patients with rheumatoid arthritis (RA) included in the SAR-COVID registry and to identify factors associated with poor outcomes.MethodsSAR-COVID is a national, longitudinal and observational registry. Patients of ≥18 years old, with diagnosis of RA (ACR-EULAR criteria 2010) who had confirmed SARS-CoV-2 infection (RT-PCR or positive serology) were included between 13-8-20 and 31-7-21. Sociodemographic and clinical data, comorbidities, disease activity and treatment at the moment of the SARS-CoV-2 infection were collected. Additionally, infection symptoms, complications, medical interventions and treatments for COVID-19 were registered. Infection severity was assessed using the WHO-ordinal scale (WHO-OS)1. A cut-off value of ≥5 identified patients with severe COVID-19 and those who died.Statistical analysis: Descriptive statistics. Chi2 or Fischer test, Student T test or Mann-Whitney and Kruskal Wallis or ANOVA, as appropriate. Multiple logistic regression model.ResultsA total of 801 patients were included, with a mean age of 53.1 ± 12.9 years, most of them were female (84.5%) and the median (m) disease duration was 8 years (IQR 4-14). One third were in remission and 46.4% had comorbidities, being the most frequent, hypertension (26.9 %), dyslipidemia (13.5 %), obesity (13.4 %) and diabetes (8.9%). Moreover, 3.2% had interstitial lung disease (ILD) associated with RA. At SARS-CoV-2 diagnosis, 42.5% were receiving glucocorticoids (GC), 73.9% conventional (c) disease modifying antirheumatic drugs (DMARD), 24% biologic (b) DMARD and 9.1% targeted synthetic (ts) DMARD. Among bDMARD, the most frequently used were TNF inhibitors (17%), followed by abatacept (2.8%), IL-6 inhibitors (2.4%) and rituximab (RTX) (2.1%). During the SARS-CoV-2 infection, 95.8% had symptoms, 27% required hospitalization, 7.9% presented complications and 4.4% died due to COVID-19. Severe disease and death (WHO-OS≥5) was present in 7.5% of the patients. They were older (62.9±12.5 vs 52.2±12.7, p<0.001), and they had more frequently ILD (18.5% vs 2%, p<0.001), comorbidities (82.5% vs 43.7%, p<0.001), ≥2 comorbidities (60.3% vs 25.8%, p<0.001), treatment with GC (61% vs 40.7%, p=0.04) and RTX (8.3% vs 1.6%, p=0.007). Conversely, the use of cDMARD and TNF inhibitors was more frequent in patients with WHO-OS<5, nevertheless this difference was not significant. Disease activity was comparable between groups. In multivariable analysis, older age, the presence of diabetes, ILD, the use of GC and RTX were significantly associated with WHO-OS≥5 (Figure 1). Furthermore, older age (65.7±10.8 vs 52.4±12.8, p<0.001), the presence of comorbidities (87.9% vs 44.7%, p<0.001), chronic obstructive pulmonary disease (21.9% vs 5.2%, p=0.002), diabetes (30.3% vs 7.9%, p<0.001), hypertension (57.6% vs 25.6%, p<0.001), cardiovascular disease (15.6% vs 3.2%, p=0.005), cancer (9.1% vs 1.3%, p=0.001), ILD (23.3% vs 2.4%, p<0.001) and the use of GC (61.8% vs 41.4%, p=0.02) were associated with mortality. Older age [OR 1.1 IC95% 1.06-1.13] and the use of GC 5-10 mg/day [OR 4.6 IC95% 1.8-11.6] remained significantly associated with death due to COVID-19.Figure 1.Factors associated with severe disease and death due to COVID-19 (WHO-OS≥5) in patients with rheumatoid arthritis. Multivariable analysis. (ref.: reference; PDN: prednisone; OR: odds ratio; CI: confidence interval)ConclusionTreatment with RTX and GC, as well as older age, the presence of diabetes and ILD were associated with poor COVID-19 outcomes in this national cohort of patients with RA. Older patients and those taking GC had a higher mortality rate.References[1]World Health Organization coronavirus disease (COVID-19) Therapeutic Trial Synopsis Draft 2020.Disclosure of InterestsNone declared
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Cosatti M, D´ Angelo ME, Petkovic IE, Kogan N, Pereira DA, Tissera Y, Toledo MV, Alonso CG, Garcia L, Severina M, Rosemffet M, Bertoli A, Delavega M, Cosentino V, Maldonado Ficco H, Calle Montoro C, De la Vega Fernandez SS, Berbotto G, Rollano Perasso A, Gómez Vara AB, Landi M, Velozo E, Sattler ME, Perrotat L, Ezquer RA, Flores Trejo J, Farfan P, Rojas Tessel R, Carrizo Abarza V, Bande JM, Hernandez B, Papagno MJ, Rodriguez LA, Martin Koller V, Montoya F, Kreimer J, Luna PC, Echeverria C, Virasoro BM, Roberts K, Isnardi CA, Schneeberger EE, Pons-Estel G, Pisoni C. POS1201 SAFETY OF SARS-COV-2 VACCINES IN PATIENTS WITH RHEUMATIC DISEASES: DATA FROM THE NATIONAL REGISTRY SAR-CoVAC FROM ARGENTINA. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundPatients with rheumatic diseases (RD) have been excluded from SARS-CoV-2 vaccine trials, though data appear to show safety and efficacy, mostly evidence remains in mRNA vaccines. In our country, adenovirus-vector, inactivated and heterologous scheme vaccines are frequently used.ObjectivesTo describe the safety of SARS-CoV-2 vaccines in patients with RD from the national registry SAR-CoVAC and to assess sociodemographic and clinical factors associated to AE and disease flares after vaccination.MethodsAdult patients with RD who have been vaccinated for SARS-CoV-2 from de Argentine Society of Rheumatology Vaccine Registry (SAR-CoVAC) were consecutively included between June 1st and December 21st, 2021, This is a national multicentric observational registry that includes patients that have received at least one dose of any SARS-CoV-2 available vaccines in Argentina. Data is voluntarily collected by the treating physician. Naranjo scale was use to assess the association between the AE and vaccination.Homologous and heterologous schedules were defined according to whether both vaccines received were the same or different, respectively. Descriptive statics, Chi2 test, Fischer test, T test, ANOVA and multivariate regression logistic model were used.ResultsA total of 1679 patients, with 2795 SARS-CoV-2 vaccine doses were included. Vaccines more frequently used were: Gam-COVID-Vac (1227 doses, 44%), ChAdOx1 nCov-19 (872 doses, 31%), BBIBP-CorV (482 doses, 17%) and mRAN-1273 (172 doses, 6%). Altogether, 510 EA were experienced by 449 (27%) patients. Pseudo-flu syndrome was the most frequent (11%), followed by injection site reaction (7%). They were significantly more frequent after the first dose in comparison to the second one (13% vs 7% and 9% vs 5%, respectively, p<0.001 in both cases). All were mild or moderate and no patient was hospitalized due to an AE. One case of moderate anaphylaxis was reported by a patient who received Gam-COVID-Vac. No cases of vaccine-induced thrombotic thrombocytopenia were observed. There were 25 disease flares reported, 17 (68%) cases of arthritis. Among patients with two doses, those with heterologous schedule presented AE more frequent after the second dose (39% vs 17%).Total incidence of EA was 182.5 events/10 00 doses, it was significantly lower for BBIBP-CorV (105.9 events/1000 dosis, p<0.002 for all cases). The higher incidence of AE was observed for mRAN-1273 (261.6 events/1000 doses) and ChAdOx1 nCov-19 (232.8 events/1000 doses).Patients with AE were younger [mean 55 years (SD 14) vs 59 years (SD 14), p <0.010], not Caucasian ethnicity [48% vs 35%, p<0.001], had higher education level [mean 13.8 years (SD 4) vs 11.9 years (SD 5), p<0.001], were more frequently employed [54% vs 44%, p<0.001], lived mostly in urban area [99% vs 95% p <0.001, had more frequently dyslipidemia [38% vs 28% p 0.012], and less frequently arterial hypertension [49% vs 65%, p<0.001]. Systemic lupus erythematosus [11% vs 7%, p=0.039] and Sjögren syndrome [6% vs 1.8%, p<0.001] were more frequent among them, while non inflammatory diseases were less prevalent [19% vs 31%, p<0.001]. They were taking steroids [24 vs 18%, p=0.007], antimalarials [17% vs 10%, p<0.001] and methotrexate [41% vs 31%, p <0.001] more frequently.In the multivariable analysis, mRAN-1273 and ChAdOx1 nCov-19 were associated with AE, while BBIBP-CorV with lower probability of having one. (Figure 1)Figure 1.Variables associated with the development of AE. Multivariate logistic regression modelConclusionThe incidence of AE was 1825 events/1000 doses, were significantly higher for mRAN-1273 and ChAdOx1 nCov-19 and lower for BBIBP-CorV. Most common AE was pseudo-flu syndrome. Female sex, being younger, higher education level, ChAdOx1 nCov-19 and mRAN-1273 vaccines, the use of methotrexate and antimalarials were related of EA in patients with RD.References[1]Sattui SE et al. Early experience of COVID-19 vaccination in adults with systemic rheumatic diseases: results from the COVID-19 Global Rheumatology Alliance Vaccine Survey. RMD Open 2021;7.Disclosure of InterestsNone declared
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Brigante A, Isnardi CA, Gómez G, Quintana R, Haye M, Roberts K, García M, Gomez G, Gobbi C, Casado G, Rebak J, Dapeña JM, Berbotto G, Viola M, Saurit V, Petkovic IE, Bertoli A, Giorgis P, Diaz MP, Catay E, Exeni IE, Pons-Estel B, Paira S, Bovea Castelblanco G, De La Sota ME, Larroude MS, Pereira DA, Granel AB, Medina G, Pisoni C, Alvarez A, Aguero SE, Fernandez L, Sacnun M, Soares de Souza S, Velozo E, Aste N, Castro C, Lazaro A, Kerzberg E, Gallardo MDLÁ, Savio V, Gamba J, Secco A, Citera G, Soriano E, Graf C, Pons-Estel G, Delavega M. POS0655 SURVIVAL AND SAFETY OF BIOLOGICAL AND TARGETED SYNTHETIC THERAPIES AS REGARDS TO AGE GROUPS. BIOBADASAR 3.0 REGISTRY. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.3326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundAdvances in rheumatology and new therapeutic options have certainly impacted patient survival, changing the age range, from youth to seniors. The differences between the age groups could influence the evolution of the disease and the adverse events (AEs) related to the treatments. There are few real-world data on the safety and efficacy of treatments in different age groups.ObjectivesTo evaluate the frequency of AEs and the survival of treatments according to the age in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) or ankylosing spondylitis (AS).MethodsRetrospective, observational, multicenter study of real-life data of patients included in the BIOBADASAR 3.0 registry; exposed and not exposed to original biological treatments (b-DMARDs), biosimilars, targeted synthetic drugs (ts-DMARDs). The unexposed group received treatment with conventional disease-modifying drugs (cDMARDs). A Kaplan-Meier and Log Rank Test analysis was performed to study AEs-free survival and treatment in different age groups (young people <25; young adults 25-34; mature adults 34-65; old adults >65). Factors related to treatment survival were evaluated using Cox regression models.Results5,297 patients were included, 80.3% female, mean age 43.7 years (SD 15.6) and median disease progression 14.3 [IQR 11.5]. RA 4658 (87.9%); APs 490 (9.25%) and EA 149 (2.8%). The main reason for treatment discontinuation was ineffectiveness, in 624 patients in the exposed group and in 53 (2.5%) patients in control group, followed by the presence of AEs in 352 (11.2%) and 83 (3.9%), respectively (p=0.001).A mean Charlson Score of 0.268 (SD 0.6) in the exposed group and 0.306 (SD 0.7) in the control group (p=0.095). Median EAs-free survival in the exposed group was 12.5 years [IQR 16.6] while in controls was 28 years [IQR 11], p<0.0001. Median AEs-free survival was 12 years (IQR 11) in young people, 11.5 years [IQR: 4.9] in young adults, 10 years [IQR: 3.25] in mature adults and 7.6 years [IQR: 6] in old adults with a difference statistically significant (p>0.017). The exposed group presented a median treatment survival in years of 11.25 years [IQR: 10] in young people; 12.5 years [IQR: 4.7] in young adults, 7.5 years [IQR: 12.1] in mature adults and 4.5 years [IQR: 1.14] in old adults (p>0.0001). Considering only the first line of treatment, a median survival of 11.5 years [IQR: 10] was evidenced in the age group <25; 12 years [IQR: 2.6] between 25-34 years old, 10 years [IQR: 12] in the group between 34-65 years old and 5.5 years [IQR: 1.14] in the group > 65 years old (p>0.004). (Figure 1). Considering the second line of treatment, the differences between the groups were not statistically significant (p=0.57). In the multivariate regression model for patients with RA, the factors with the greatest impact on treatment survival were female sex (HR 1.3, 95% CI 1.2-1.4), old age (HR 1.01, 95% CI 1.008-1.01), treatment with steroids (HR 1.19, 95% CI1.1-1.2) and longer disease duration (HR 1.01, 95% CI1.01 – 1.02).ConclusionIn the present study we were able to demonstrate a greater occurrence of AEs in old adults and mature adults compared to young people and young adults. Conversely, survival for b-DMARDs and ts-DMARDs were greater in youth and young adults. In patients with RA, female sex, corticosteroid therapy, old aged and longer disease duration were associated with treatment discontinuation.References[1]Souto A, et al. Rate of discontinuation and drug survival of biologic therapies in rheumatoid arthritis: a systematic review and meta-analysis of drug registries and health care databases. Rheumatology (Oxford). 2016;55(3):523–34.[2]Ray D, et al. Immune senescence, epigenetics and autoimmunity. Clin Immunol. 2018 Nov;196:59-63. doi: 10.1016/j.clim.2018.04.002. Epub 2018 Apr 11.[3]Vela P, et al. Influence of age on the occurrence of adverse events in rheumatic patients at the onset of biological treatment: data from the BIOBADASER III register. Arthritis Res Ther. 2020 Jun 15;22(1):143. doi: 10.1186/s13075-020-02231-x.Disclosure of InterestsNone declared
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Porta SV, Ugarte-Gil MF, García-de la Torre I, Bonfá E, Gómez-Puerta JA, Arnaud L, Cardiel MH, Alarcón GS, Pons-Estel BA, Pons-Estel G. Controversies in Systemic Lupus Erythematosus: Are We Treating Our Patients Adequately? J Clin Rheumatol 2022; 28:e651-e658. [PMID: 34897194 DOI: 10.1097/rhu.0000000000001803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Systemic lupus erythematosus (SLE) is characterized by great clinical heterogeneity. The objectives of its management are to make a timely diagnosis and to initiate treatment as promptly as possible so organ damage can be avoided while at the same time exposure to potentially toxic drugs is minimized so that its overall course and outcome improve. In reviewing the current literature, it became quite clear that there are specific topics in which controversies do exist. These include how to treat patients with incomplete lupus erythematosus, the real possibility of abandoning altogether the use of oral glucocorticoids, and the pros and cons of the use of cyclophosphamide and mycophenolate mofetil for the induction treatment of lupus nephritis. Herein we discuss different points of view regarding these still unresolved issues; these comments represent a debate that took place during the PANLAR Virtual Congress (Pan American League of Associations for Rheumatology) and that was organized by the PANLAR Lupus study group, GLADEL (Grupo Latino Americano De Estudio del Lupus) on September 19, 2020.
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Affiliation(s)
- Sabrina Valeria Porta
- From the Rheumatology Department, J. M. Ramos Mejía Hospital, Buenos Aires, Argentina
| | - Manuel F Ugarte-Gil
- Universidad Científica del Sur, Hospital Guillermo Almenara Irigoyen, EsSalud, Lima, Perú
| | - Ignacio García-de la Torre
- Department of Immunology and Rheumatology, Hospital General de Occidente de la Secretaría de Salud, Universidad de Guadalajara, Guadalajara, México
| | - Eloísa Bonfá
- Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Laurent Arnaud
- Department of Rheumatology, Hôpitaux Universitaires de Strasbourg, National Reference Center for Rare Auto-immune and Systemic Diseases (CRMR RESO); Strasbourg, France
| | - Mario H Cardiel
- Centro de Investigación Clínica de Morelia, SC, Morelia, Mich, México
| | - Graciela S Alarcón
- Division of Rheumatology and Clinical Immunology, The University of Alabama at Birmingham, Birmingham, AL; Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Bernardo A Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Guillermo Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
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22
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van Vollenhoven RF, Bertsias G, Doria A, Isenberg D, Morand E, Petri MA, Pons-Estel BA, Rahman A, Ugarte-Gil MF, Voskuyl A, Arnaud L, Bruce IN, Cervera R, Costedoat-Chalumeau N, Gordon C, Houssiau FA, Mosca M, Schneider M, Ward MM, Alarcon G, Aringer M, Askenase A, Bae SC, Bootsma H, Boumpas DT, Brunner H, Clarke AE, Coney C, Czirják L, Dörner T, Faria R, Fischer R, Fritsch-Stork R, Inanc M, Jacobsen S, Jayne D, Kuhn A, van Leeuw B, Limper M, Mariette X, Navarra S, Nikpour M, Olesinska MH, Pons-Estel G, Romero-Diaz J, Rubio B, Schoenfeld Y, Bonfá E, Smolen J, Teng YKO, Tincani A, Tsang-A-Sjoe M, Vasconcelos C, Voss A, Werth VP, Zakharhova E, Aranow C. 2021 DORIS definition of remission in SLE: final recommendations from an international task force. Lupus Sci Med 2021; 8:8/1/e000538. [PMID: 34819388 PMCID: PMC8614136 DOI: 10.1136/lupus-2021-000538] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 11/04/2021] [Indexed: 11/12/2022]
Abstract
Objective To achieve consensus on a definition of remission in SLE (DORIS). Background Remission is the stated goal for both patient and caregiver, but consensus on a definition of remission has been lacking. Previously, an international task force consisting of patient representatives and medical specialists published a framework for such a definition, without reaching a final recommendation. Methods Several systematic literature reviews were performed and specific research questions examined in suitably chosen data sets. The findings were discussed, reformulated as recommendations and voted on. Results Based on data from the literature and several SLE-specific data sets, a set of recommendations was endorsed. Ultimately, the DORIS Task Force recommended a single definition of remission in SLE, based on clinical systemic lupus erythematosus disease activitiy index (SLEDAI)=0, Evaluator’s Global Assessment <0.5 (0–3), prednisolone 5 mg/day or less, and stable antimalarials, immunosuppressives, and biologics. Conclusion The 2021 DORIS definition of remission in SLE is recommended for use in clinical care, education, and research including clinical trials and observational studies.
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Affiliation(s)
- Ronald F van Vollenhoven
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Heraklion, Greece
| | - Andrea Doria
- Division of Rheumatology, University of Padova, Padova, Italy
| | - David Isenberg
- Centre for Rheumatology, University College London, London, UK
| | - Eric Morand
- Monash Medical Centre, Melbourne, Victoria, Australia
| | - Michelle A Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Anisur Rahman
- Medicine (Rheumatology), University College London, London, UK
| | | | | | - Laurent Arnaud
- Department of Rheumatology, Strasbourg University Hospitals, Strasbourg, France.,Strasbourg Federation of Translational Medicine (FMTS), University of Strasbourg, Strasbourg, France
| | - Ian N Bruce
- The University of Manchester, Manchester, UK
| | | | | | - Caroline Gordon
- Rheumatology Research Group, University of Birmingham, Birmingham, UK
| | - Frédéric A Houssiau
- Pole of Rheumatic Pathologies, Catholic University of Louvain, Institute for Experimental and Clinical Research, Brussels, Belgium.,Rheumatology Department, Saint-Luc University Clinics, Brussels, Belgium
| | | | - Matthias Schneider
- Policlinic for Rheumatology & Hiller Research Centre for Rheumatology, Heinrich-Heine-University, Düsseldorf, Germany
| | | | | | | | - Anka Askenase
- Columbia University Medical Center, New York, New York, USA
| | - Sang-Cheol Bae
- Rheumatology, Hanyang University Seoul Hospital, Seoul, Korea (the Republic of)
| | | | | | - Hermine Brunner
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Cindy Coney
- Lupus Foundation of America, Washington, District of Columbia, USA
| | - László Czirják
- Department of Rheumatology and Immunology, University of Pecs, Pecs, Hungary
| | - Thomas Dörner
- Charite University Hospitals Berlin, Berlin, Germany
| | - Raquel Faria
- Clinical Immunology Unit, Porto Hospital and University Center, Porto, Portugal
| | - Rebecca Fischer
- Rheumatology, Heinrich-Heine-University, Duesseldorf, Germany
| | | | - Murat Inanc
- Internal Medicine Rheumatology, University of Istanbul, Istanbul, Turkey
| | - Søren Jacobsen
- Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - David Jayne
- Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | | | | | - Maarten Limper
- Rheumatology & Clinical Immunology, UMC Utrecht, Utrecht, The Netherlands
| | - Xavier Mariette
- Public Assistance, Paris Hospitals, Paris Saclay University, Le Kremlin-Bicetre, France
| | - Sandra Navarra
- Rheumatology, University of Santo Tomas Hospital, Manila, Philippines
| | - Mandana Nikpour
- Medicine and Rheumatology, University of Melbourne, Fitzroy, Victoria, Australia
| | | | - Guillermo Pons-Estel
- Regional Center for Autoimmune and Rheumatic Diseases (GO-CREAR), Rosario, Argentina
| | - Juanita Romero-Diaz
- Immunology and Rheumatology, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico
| | | | - Yehuda Schoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Eloisa Bonfá
- Rheumatology, University of Sao Paulo Faculty of Medicine, Sao Paulo, Brazil
| | | | - Y K Onno Teng
- Nephrology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Michel Tsang-A-Sjoe
- Rheumatology, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | | | - Anne Voss
- Department of Rheumatology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | - Victoria P Werth
- Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elena Zakharhova
- Rheumatology, A I Yevdokimov Moscow State University of Medicine and Dentistry of the Ministry of Healthcare of the Russian Federation Faculty of Dentistry, Moskva, Russian Federation
| | - Cynthia Aranow
- Autoimmune and Musculoskeletal Disease, The Feinstein Institute for Medical Research, Manhasset, New York, USA
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Reyes AA, Alle G, Tanten R, Scolnik M, Soriano E, Berbotto G, Haye M, Gamba MJ, Nieto R, García M, Savio V, Gonzalez Lucero L, Alba P, Takashima L, Risueño F, Casalla L, Cucchiaro N, Bertoli A, Porta S, Maldini C, Gallo R, Goizueta C, Picco E, Quintana R, Roberts K, Isnardi CA, Pons-Estel G. POS1188 COVID-19 IN PATIENTS WITH RHEUMATIC DISEASES: COMPARISON OF DATA FROM THE ARGENTINE REGISTRY (SAR-COVID), WITH THE LATIN AMERICAN AND GLOBAL REGISTRY (GLOBAL RHEUMATOLOGY ALLIANCE). Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.1458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:SARS CoV-2 infection has recently burst onto the global scene, and the knowledge of the course of this infection in patients with rheumatic diseases receiving immunomodulatory treatment is still insufficient. The Argentine Society of Rheumatology (SAR) designed a national registry called SAR-COVID in order to get to assess our reality.Objectives:To identify the particular characteristics of patients with rheumatic diseases and COVID-19 in Argentina (SAR-COVID Registry), and to compare them with the data reported at the Latin American and Global level (Global International Alliance Rheum-COVID Registry).Methods:A national, multicenter, prospective and observational registry was carried out. Patients older than 18 years, with a diagnosis of rheumatic disease and SARS-CoV-2 infection by PCR or serology, were included between August 13, 2020 and January 17, 2021. Demographic data, underlying rheumatic disease (activity of the disease, current treatment), comorbidities, clinical-laboratory characteristics of the SARS-CoV-2 infection, as well as received treatments (pharmacological, oxygen therapy / ventilatory support) and outcomes (hospitalization, mortality) were recorded. The characteristics of the included patients were compared with the data reported at the Latin American and global level. Descriptive statistics were performed. Comparisons between groups were made using ANOVA, chi2 or Fisher’s test, according to the type of variable.Results:Four hundred sixty-five patients from Argentina, 74 patients from Latin America and 583 from the rest of the world were included, mostly women (79.6%, 73% and 71% respectively), with a mean age of 50.2 (SD 15.3), 53.5 (DE 15.6) and 55.8 (15.5), years respectively. The most frequent rheumatic diseases in the three groups were rheumatoid arthritis (43.9%, 35%, and 39%) and systemic lupus erythematosus (16.1%, 22%, and 14%) (Table 1).In Argentina, fewer patients received specific pharmacological treatment for COVID-19 (40.9%, 68% and 43% respectively, p <0.0001), and there was a lower requirement of NIMV / IMV (Non-Invasive Mechanical Ventilation/Invasive Mechanical Ventilation) than in the rest of Latin America and the world (10.5% vs 31% vs 13%, p <0.0001).Hospitalization was lower in Argentina than in the rest of Latin America (37.4% vs 61% p 0.0002) and of the world (37.4% vs 45% p 0.0123), and mortality was numerically lower in Argentina, but without statistically significant differences between the three groups (6.9%, 12% and 11%; p 0.6311). Most of the patients, (86.9%) did not present any complications in Argentina, with a statistically significant difference with the rest of the groups (62% and 77%, p <0.0001) (Graph 1).Conclusion:The patients with rheumatic diseases and SARS-CoV-2 infection reported in this argentinian registry received less specific pharmacological treatment for COVID-19, presented fewer complications and required less ventilatory support, than those reported in the Latinoamerican and Global registry. However, no statistically significant differences were observed in terms of mortality.Graph 1.Main outcomes and evolution of patients with rheumatic disease and COVID-19.References:[1]Stokes, Erin K, Zambrano, Laura D, Anderson, Kayla N, et al. Coronavirus Disease 2019 Case Surveillance - United States, January 22-May 30, 2020. MMWR Morb Mortal Wkly Rep; 69(24): 759-765, 2020 Jun 19.[2]Mehta P, McAuley DF, Brown M, et al. COVID-19: consider cytokine storm síndromes and immunosuppression. Lancet 2020;395:1033–4.[3]Gianfrancesco M, et al. Characteristics associated with hospitalisation for COVID-19 in people with rheumatic disease: data from the COVID-19 Global Rheumatology Alliance physician-reported registry. Ann Rheum Dis 2020;79:859–866.[4]Manuel F. Ugarte-Gil, et al. Characteristics associated with Covid-19 in patients with Rheumatic Disease in Latin America. Global Rheumatology. Septiembre 2020.Disclosure of Interests:Alvaro Andres Reyes Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Gelsomina Alle Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Romina Tanten Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Marina Scolnik Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Enrique Soriano Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Guillermo Berbotto Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Maria Haye Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, María Julieta Gamba Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Romina Nieto Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Mercedes García Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Veronica Savio Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Luciana Gonzalez Lucero Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Paula Alba Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Lorena Takashima Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, FABIAN RISUEÑO Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Luciana CASALLA Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Natalia Cucchiaro Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Ana Bertoli Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Sabrina POrta Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Carla Maldini Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Rosana Gallo Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Cecilia Goizueta Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Eugenia Picco Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Rosana Quintana Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Karen Roberts Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Carolina Ayelen Isnardi Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”, Guillermo Pons-Estel Grant/research support from: “Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.”
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Ugarte-Gil MF, Alarcon GS, Seet A, Izadi Z, Reategui Sokolova C, Clarke AE, Wise L, Pons-Estel G, Santos MJ, Bernatsky S, Mathias L, Lim N, Sparks J, Wallace Z, Hyrich K, Strangfeld A, Gossec L, Carmona L, Mateus E, Lawson-Tovey S, Trupin L, Rush S, Schmajuk G, Katz P, Jacobsohn L, Al Emadi S, Gilbert E, Duarte-Garcia A, Valenzuela-Almada M, Hsu T, D’silva K, Serling-Boyd N, Dieudé P, Nikiphorou E, Kronzer V, Singh N, Wallace B, Akpabio A, Thomas R, Bhana S, Costello W, Grainger R, Hausmann J, Liew J, Sirotich E, Sufka P, Robinson P, Machado P, Gianfrancesco M, Yazdany J. OP0286 CHARACTERISTICS ASSOCIATED WITH SEVERE COVID-19 OUTCOMES IN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE): RESULTS FROM THE COVID-19 GLOBAL RHEUMATOLOGY ALLIANCE (COVID-19 GRA). Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.2984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:An increased risk of severe COVID-19 outcomes may be seen in patients with autoimmune diseases on moderate to high daily doses of glucocorticoids, as well as in those with comorbidities. However, specific information about COVID-19 outcomes in SLE is scarce.Objectives:To determine the characteristics associated with severe COVID-19 outcomes in a multi-national cross-sectional registry of COVID-19 patients with SLE.Methods:SLE adult patients from a physician-reported registry of the COVID-19 GRA were studied. Variables collected at COVID-19 diagnosis included age, sex, race/ethnicity, region, comorbidities, disease activity, time period of COVID-19 diagnosis, glucocorticoid (GC) dose, and immunomodulatory therapy. Immunomodulatory therapy was categorized as: antimalarials only, no SLE therapy, traditional immunosuppressive (IS) drug monotherapy, biologics/targeted synthetic IS drug monotherapy, and biologic and traditional IS drug combination therapy. We used an ordinal COVID-19 severity outcome defined as: not hospitalized/hospitalized without supplementary oxygen; hospitalized with non-invasive ventilation; hospitalized with mechanical ventilation/extracorporeal membrane oxygenation; and death. An ordinal logistic regression model was constructed to assess the association between demographic characteristics, comorbidities, medications, disease activity and COVID-19 severity. This assumed that the relationship between each pair of outcome groups is of the same direction and magnitude.Results:Of 1069 SLE patients included, 1047 (89.6%) were female, with a mean age of 44.5 (SD: 14.1) years. Patient outcomes included 815 (78.8%) not hospitalized/hospitalized without supplementary oxygen; 116 (11.2) hospitalized with non-invasive ventilation, 25 (2.4%) hospitalized with mechanical ventilation/extracorporeal membrane oxygenation and 78 (7.5%) died. In a multivariate model (n=804), increased age [OR=1.03 (1.01, 1.04)], male sex [OR =1.93 (1.21, 3.08)], COVID-19 diagnosis between June 2020 and January 2021 (OR =1.87 (1.17, 3.00)), no IS drug use [OR =2.29 (1.34, 3.91)], chronic renal disease [OR =2.34 (1.48, 3.70)], cardiovascular disease [OR =1.93 (1.34, 3.91)] and moderate/high disease activity [OR =2.24 (1.46, 3.43)] were associated with more severe COVID-19 outcomes. Compared with no use of GC, patients using GC had a higher odds of poor outcome: 0-5 mg/d, OR =1.98 (1.33, 2.96); 5-10 mg/d, OR =2.88 (1.27, 6.56); >10 mg/d, OR =2.01 (1.26, 3.21) (Table 1).Table 1.Characteristics associated with more severe COVID-19 outcomes in SLE. (N=804)OR (95% CI)Age, years1.03 (1.01, 1.04)Sex, Male1.93 (1.21, 3.08)Race/Ethnicity, Non-White vs White1.47 (0.87, 2.50)RegionEuropeRef.North America0.67 (0.29, 1.54)South America0.67 (0.29, 1.54)Other1.93 (0.85, 4.39)Season, June 16th 2020-January 8th 2021 vs January-June 15th 20201.87 (1.17, 3.00)Glucocorticoids0 mg/dayRef.0-5 mg/day1.98 (1.33, 2.96)5-10 mg/day2.88 (1.27, 6.56)=>10 mg/day2.01 (1.26, 3.21)Medication CategoryAntimalarial onlyRef.No IS drugs2.29 (1.34, 3.91)Traditional IS drugs as monotherapy1.17 (0.77, 1.77)b/ts IS drugs as monotherapy1.00 (0.37, 2.71)Combination of traditional and b/ts IS1.00 (0.55, 1.82)Comorbidity BurdenNumber of Comorbidities (excluding renal and cardiovascular disease)1.39 (0.97, 1.99)Chronic renal disease2.34 (1.48, 3.70)Cardiovascular disease1.93 (1.34, 3.91)Disease Activity, Moderate/ high vs Remission/ low 2.24 (1.46, 3.43)IS: immunosuppressive. b/ts: biologics/targeted syntheticsConclusion:Increased age, male sex, glucocorticoid use, chronic renal disease, cardiovascular disease and moderate/high disease activity at time of COVID-19 diagnosis were associated with more severe COVID-19 outcomes in SLE. Potential limitations include possible selection bias (physician reporting), the cross-sectional nature of the data, and the assumptions underlying the outcomes modelling.Acknowledgements:The views expressed here are those of the authors and participating members of the COVID-19 Global Rheumatology Alliance and do not necessarily represent the views of the ACR, EULAR) the UK National Health Service, the National Institute for Health Research (NIHR), or the UK Department of Health, or any other organization.Disclosure of Interests:Manuel F. Ugarte-Gil Grant/research support from: Pfizer, Janssen, Graciela S Alarcon: None declared, Andrea Seet: None declared, Zara Izadi: None declared, Cristina Reategui Sokolova: None declared, Ann E Clarke Consultant of: AstraZeneca, BristolMyersSquibb, GlaxoSmithKline, Exagen Diagnostics, Leanna Wise: None declared, Guillermo Pons-Estel: None declared, Maria Jose Santos: None declared, Sasha Bernatsky: None declared, Lauren Mathias: None declared, Nathan Lim: None declared, Jeffrey Sparks Consultant of: Bristol-Myers Squibb, Gilead, Inova, Janssen, and Optum unrelated to this work., Grant/research support from: Amgen and Bristol-Myers Squibb, Zachary Wallace Consultant of: Viela Bio and MedPace, Grant/research support from: Bristol-Myers Squibb and Principia/Sanofi, Kimme Hyrich Speakers bureau: Abbvie, Grant/research support from: MS, UCB, and Pfizer, Anja Strangfeld Speakers bureau: AbbVie, MSD, Roche, BMS, Pfizer, Grant/research support from: AbbVie, BMS, Celltrion, Fresenius Kabi, Lilly, Mylan, Hexal, MSD, Pfizer, Roche, Samsung, Sanofi-Aventis, and UCB, Laure Gossec Consultant of: Abbvie, Biogen, Celgene, Janssen, Lilly, Novartis, Pfizer, Sanofi-Aventis, UCB, Grant/research support from: Lilly, Mylan, Pfizer, Loreto Carmona: None declared, Elsa Mateus Grant/research support from: Pfizer, Abbvie, Novartis, Janssen-Cilag, Lilly Portugal, Sanofi, Grünenthal S.A., MSD, Celgene, Medac, Pharmakern, GAfPA, Saskia Lawson-Tovey: None declared, Laura Trupin: None declared, Stephanie Rush: None declared, Gabriela Schmajuk: None declared, Patti Katz: None declared, Lindsay Jacobsohn: None declared, Samar Al Emadi: None declared, Emily Gilbert: None declared, Ali Duarte-Garcia: None declared, Maria Valenzuela-Almada: None declared, Tiffany Hsu: None declared, Kristin D’Silva: None declared, Naomi Serling-Boyd: None declared, Philippe Dieudé Consultant of: Boerhinger Ingelheim, Bristol-Myers Squibb, Lilly, Sanofi, Pfizer, Chugai, Roche, Janssen unrelated to this work, Grant/research support from: Bristol-Myers Squibb, Chugaii, Pfizer, unrelated to this work, Elena Nikiphorou: None declared, Vanessa Kronzer: None declared, Namrata Singh: None declared, Beth Wallace: None declared, Akpabio Akpabio: None declared, Ranjeny Thomas: None declared, Suleman Bhana Consultant of: AbbVie, Horizon, Novartis, and Pfizer (all <$10,000) unrelated to this work, Wendy Costello: None declared, Rebecca Grainger Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, Cornerstones, Jonathan Hausmann Consultant of: Novartis, Sobi, Biogen, all unrelated to this work (<$10,000), Jean Liew Grant/research support from: Pfizer outside the submitted work, Emily Sirotich Grant/research support from: Board Member of the Canadian Arthritis Patient Alliance, a patient run, volunteer based organization whose activities are largely supported by independent grants from pharmaceutical companies, Paul Sufka: None declared, Philip Robinson Speakers bureau: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer and UCB (all < $10,000), Consultant of: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer and UCB (all < $10,000), Pedro Machado Speakers bureau: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, all unrelated to this study (all < $10,000)., Consultant of: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, all unrelated to this study (all < $10,000), Milena Gianfrancesco: None declared, Jinoos Yazdany Consultant of: Eli Lilly and AstraZeneca unrelated to this project
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Serrano Morales R, Nieto R, Porta S, Roberts K, Lema L, Maldini C, Tissera Y, Albiero JA, Savio V, Goizueta C, Lobo V, Broll A, Cucchiaro N, ¨perez S, Izaguirre P, Estevez A, Abalo AI, Etcheverry M, Bellomio VI, Leguizamón ML, Antoniol N, Perandones C, Pisoni C, De la Torre ML, García M, Velloso MS, Sacnun M, Gobbi C, Guaglione D, Vivero F, Saurit V, Benzaquen N, Nemman V, Remondino G, Machado Escobar M, Scolnik M, Danielsen C, Gomez G, Babini AM, Brigante A, Luissi A, Castro Coello VV, Sorrentino L, Berman H, Alba P, Pons-Estel G. AB0342 OBSTETRIC AND THROMBOTIC ANTIPHOSPHOLIPID SYNDROME: ARE THEY DIFFERENT ENTITIES? Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.3842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:Several studies showed two main clinical phenotypes of antiphospholipid syndrome (APS): thrombotic (TAPS) and obstetric APS (OAPS). Although they have the same autoantibody profile, one of them developed thrombosis and other one obstetric morbidity.Objectives:To study clinical, demographic and antibody profile in patients with TAPS and OAPS.Methods:we retrospectively evaluated TAPS and OAPS patients who were included in Argentine Antiphospholipid antibodies registry. We studied clinical, demographic and antibody profile in both groups.Results:238 patients were included in the registry. 201 (84.81%) of them were female. 122 (60.69 %) of them fullfilled APS Sydney classification criteria, 47 (38.52%) TAPS and 52 (42.62%) OAPS. 23 (18.85%) patients had both thrombotic and obstetric events so they were excluded in this analysis.Arterial Hypertension (HBP) and Hyperlipidemia were more frequent in TAPS versus OAPS. Older age was found in TAPS as well as in association with Systemic lupus erythematosus (SLE). There was no difference in antibody profile between the 2 groups, and the Global Antiphospholipid Syndrome Score (aGAPSS) was higher in TAPS than OAPS.18 (38.3%) of TAPS patients had at least 1 pregnancy. Mean number of pregnancies of TAPS was 2.5 (1.10) and 3.84 (1.86) in OAPS. Thrombotic events were not found in TAPS during pregnancy and puerperium. HBP and gestational diabetes (GD) and other pregnancy related comorbidities were found in TAPS.OAPS (n=52)TAPS (n=47)POAPS(n=52)TAPS(n=18)SLE, n (%)11 (21.2)28 (59.6)0.0002N% (DE)N % (DE)aGAPSS, mean (RIQ)4 (5)8 (5)<0.0001Abortions (<10 weeks)3338.4 (36.2)826.5 (35.3)Age, mean (DE)39.3 (6.24)43.1 (13.5)<0.0001Live Birth3633.5 (28.1)1672.2 (34.7)HBP, n (%)5 (9.6)15 (31.9)0.0121 >37 weeks2116.4 (2.38)1661.1 (31.7)Hyperlipidemia, n (%)4 (7.7)12(25.5)0.0267Prematurity <37 >34 weeks118.76 (1.97)0-GD, n (%)3(5.8)2(4.3)0.9999Prematurity <34 weeks96.37 (1.49)11.39 (5.89)Obesity, n (%)8 (15.4)4 (8.5)0.2912Pre eclampsia >34-<37 weeks10.490 (0.0350)24.63 (0.138)Smoking, n (%)11 (21.1)13 (27.6)0.4019Placental Hematoma31.86 (8.18)12.78 (11.8)Sedentary lifestyle, n (%)16 (30.8)17 (36.2)0.8486Abruptio Placentae21.96 (9.80)24.17 (12.9)Triple Positivity59.648.50.8323 Normal delivery2017.8 (27.9)1447.7 (33.9)Double Positivity11.936.4Cesarean section2217.2 (21.6)211.1 (32.3)Simple Positivity2938.51940.4Urgent Cesarean section139.80 (20.3)412.5 (24.6)GD21.37 (7.49)12.78 (11.8)HBP63.46 (10.3)310.2 (26.3)Conclusion:Antibody profile was similar in TAPS and OAPS. However, clinical manifestations and cardiovascular risk were different. These results should be evaluated in prospective studies.Disclosure of Interests:None declared
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Isnardi CA, Quintana R, Roberts K, Castro Coello VV, Reyes AA, Tissera Y, Cosatti M, Rojas Tessel R, Scafati J, Barbich T, Gálvez Elkin MS, Rodriguez Gil GF, Moyano S, Werner ML, Rebak J, Morbiducci J, Martire V, Castaño MS, Dieguez C, Subils GC, Pons-Estel G. POS1208 EPIDEMIOLOGY AND OUTCOMES OF PATIENTS WITH RHEUMATIC DISEASES AND SARS-CoV-2 INFECTION: DATA FROM THE ARGENTINEAN SAR-COVID REGISTRY. Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.2250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:In the last time, many papers about SARS-CoV-2 have been published in the world. However, data from latinamerican patients is still scarce. In order to assess the impact of SARS-CoV-2 infection in patients with rheumatic diseases in our country and contribute to the global knowledge about the effect of immunosuppressive therapies in this group, the Argentine Society of Rheumatology has developed the National Registry of Patients with Rheumatic Diseases and COVID-19 (SAR-COVID).Objectives:The aim of this study was to evaluate clinical characteristics and outcomes of SARS-CoV-2 infection in patients with rheumatic diseases, treated or not with immunomodulators and/or immunosuppressants.Methods:SAR-COVID is a national, multicenter, prospective and observational registry, in which patients, ≥18 years of age, with a diagnosis of a rheumatic disease who had SARS-CoV-2 infection (PCR or positive serology) are consecutively included between August 13, 2020 and January 17, 2021. Sociodemographic data, comorbidities, underlying rheumatic disease and treatment, clinical characteristics, complications, laboratory and treatment of the SARS-CoV-2 infection were recorded. Hospitalization, mechanical ventilation requirements and death were assessed to evaluate COVID-19 outcome. Statistical analysis: Descriptive analysis. Chi2 or Fischer test and T test or Mann-Whitney U test or ANOVA, as appropriate. Multiple logistic regression.Results:A total of 525 patients were included, 80.4% were female, with a median age of 52 years (IQR 40-62). Comorbidities were reported in half of them (53.3%). The most frequent rheumatological diseases were rheumatoid arthritis (40.4%) and systemic lupus erythematosus (14.9%). At the time of the infection, most of them were in remission or in minimal/low disease activity (68.2%) and 72.9% were receiving immunosuppressive or immunomodulatory treatment.Symptoms were present in 96% of the patients, the most frequent being fever (56.2%), cough (46.7%) and headache (39.2%). During infection, 35.1% received some pharmacological treatment, dexamethasone (20%) the most frequently used. One third (35.1%) of the patients were hospitalized, 11.6% were admitted to the ICU, 10.1% needed mechanical ventilation and 6.9% died due to COVID-19. Complications were reported in 12.4%, being acute respiratory distress syndrome the most prevalent (8.8%).Patients over 65 years of age were more frequently hospitalized, admitted to the ICU, needed mechanical ventilation and died due to COVID-19 (50% vs 31.4%, 22% vs 9%, 16.3% vs 5.2%, 14% vs 5%, respectively; p<0.001 in all cases). Similar results were seen in patients with vasculitis (57.7% vs 33.9%, 46.2 vs 9.8%, 34.6% vs 6 %; 30.8% vs 5.6%, respectively; p< 0.001 in all cases) and those with moderate/high disease activity (55.7% vs 26.5%, 21.3 vs 7.8%, 17.2% vs 4.2 %; 17.2% vs 4.2 %, respectively; p< 0.001 in all cases). Patients with APS were more frequently admitted to the ICU (29.4% vs 11%, p= 0.037). The presence of comorbidities was associated with higher hospitalization (46% vs 22.6%, p<0.001), admission to the ICU (17.2% vs 5.9%, p<0.001) and mechanical ventilation (10.2% vs 4.6%, p= 0.028). Immunosuppressive treatment was not associated with worse outcomes.Conclusion:In this cohort of patients with a wide distribution of rheumatic diseases, we have found clinical characteristics similar to those reported by other international cohorts. Compared with national data, the mortality reported in these patients is higher. However, it should be noted that these are early data collected during isolation and that there may be an underreporting of asymptomatic patients or with mild symptoms who do not attend the rheumatologist.Older patients, those with comorbidities, with vasculitis and with higher disease activity showed poor COVID-19 outcomes.Disclosure of Interests:Carolina Ayelen Isnardi Speakers bureau: Janssen, BMS, Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., Rosana Quintana Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., Karen Roberts Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., Vanessa Viviana Castro Coello Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., Alvaro Andres Reyes Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., Yohana Tissera Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., Micaela Cosatti Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., Romina Rojas Tessel Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., Julia Scafati Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., Tatiana Barbich Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., María Soledad Gálvez Elkin Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., Gustavo Fabian Rodriguez Gil Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., Sebastian Moyano Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., Marina Laura Werner Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., Jonathan Rebak Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., Julieta Morbiducci Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., Victoria Martire Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., María Sol Castaño Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., Carolina Dieguez Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., Gisela Constanza Subils Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data., Guillermo Pons-Estel Grant/research support from: Unrestricted grants: Pfizer, Abbvie, Elea Phoenix. None of them have access to patient data.
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Ugarte-Gil MF, Mendoza Pinto C, Pons-Estel G, Reategui Sokolova C, Van Vollenhoven R, Bertsias G, Alarcon GS, Pons-Estel B. AB0448 IMPACT OF REMISSION ON DAMAGE ACCRUAL IN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) PATIENTS: A SYSTEMATIC LITERATURE REVIEW (SLR). Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.2037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:Treat-to-target strategy with remission as the target has been proposed for the management of SLE. However, there is not a uniform definition of remission.Objectives:To determine the protective value of remission state on organ damage accrual in SLE patients through a SLR.Methods:Two independent reviewers identified studies in Medline and Cochrane Library. Data on remission definitions and rates as well as damage accrual (assessed by the SLICC/ACR damage index [SDI]) were extracted. Definitions of remission included disease activity indices (SLEDAI and its variants and PGA), serological activity, prednisone (PDN) daily dose (mg/day), immunosuppressive (IS) drugs, antimalarial (AM) use and duration of remission. The quality of the studies was evaluated with the Newcastle-Otawa Scale (NOS).Results:Eight manuscripts were included comprising more than 6,000 patients from America, Europe and Asia Pacific. All the studies were longitudinal. The majority of the studies reached more than seven out nine points in the NOS. Remission rates ranged between 10 and almost 50%; they tend to be lower in America as compared to Asia Pacific and Europe. All definitions required a clinical SLEDAI=0, and allowed antimalarial use. However, there were differences regarding the inclusion of serological activity, PGA, prednisone or immunosuppressive drug use as well as minimum remission duration required. Even less stringent definition of remission prevented damage accrual. The risk of damage accrual was two to five-fold lower in those patients on remission.AuthorsCountry/ RegionPatientsRemissionAchieving remission (%)Damage: remission vs not remissionNOSZen et alItaly224SLEDAI=0Serologic= allowedPGA= NRPDN ≤ 5IS=YesAM=YesDuration=5 years37.5%Unremitted diseaseOR=2.53; p=0.0087Tani et alItaly115SLEDAI=0SerologicPGA= NRPDN ≤ 5IS=YesAM=YesDuration=NR49.6%ΔSLICC 0.12 vs 0.48,p= 0.0188Ugarte-Gil et alLatin America1,350SLEDAI=0Serologic= not allowedPGA= NRPDN ≤ 5IS=YesAM=YesDuration=NR20.2%New damageHR 0.60 p=0.0042Severe new damageHR 0.32 p=0.00338Tsang-A-Sjoe et alNetherlands224SLEDAI=0Serologic= allowedPGA= NRPDN ≤ 5IS=YesAM=YesDuration>5 years37.6%OR=0.20; p=0.0018Mok et alChina769SLEDAI=0Serologic= AllowedPGA<0.5PDN ≤ 5IS=YesAM=YesDuration≥5years25.1%Not being on remission for at least 5 yearsOR: 2.42; p<0.0017Tselios et alCanada267SLEDAI=0Serologic= AllowedPGA=NRPDN no restrictionIS no restrictionAM=YesDuration≥5years10.1%SDI after 10 years: 0.96 vs 1.53 (not on remission, not on LDAS), p for trend =0.0297Petri et alUS1,356SLEDAI=0Serologic= NRPGA<0.5PDN ≤ 5IS=YesAM=YesDuration= NRNRRate ratio per percentage of follow-upRR(<25%)=0.54; p<0.0001RR(25-49%)=0.47; p<0.0001RR(50-74%)=0.43; p<0.0001RR(>75%)=0.45; p=0.00197Golder et alAsia Pacific1,707SLEDAI=0Serologic=YesPGA<0.5PDN ≤ 5IS=YesAM=YesDuration= NR35.8%HR=0.55; p<0.00016NR: Not recorded. OR: Odds Ratio. HR: Hazard ratio. RR: Rate ratioConclusion:In SLE patients, achieving remission, even with less stringent definitions, prevented damage accrual.Disclosure of Interests: :Manuel F. Ugarte-Gil Grant/research support from: Jannsen, Pfizer, Claudia Mendoza Pinto: None declared, Guillermo Pons-Estel Grant/research support from: JANSSEN and GSK, Consultant of: JANNSEN, GSK and SANOFI, Speakers bureau: PFIZER, JANNSEN and GSK, Cristina Reategui Sokolova: None declared, Ronald van Vollenhoven Grant/research support from: AbbVie, Arthrogen, Bristol-Myers Squibb, GlaxoSmithKline, Lilly, Pfizer, and UCB, Consultant of: AbbVie, AstraZeneca, Biotest, Bristol-Myers Squibb, Celgene, GSK, Janssen, Lilly, Medac, Merck, Novartis, Pfizer, Roche, and UCB, George Bertsias Grant/research support from: GSK, Consultant of: Novartis, Graciela S Alarcon: None declared, Bernardo Pons-Estel Grant/research support from: GSK, Janssen, Consultant of: GSK, Janssen, Speakers bureau: GSK, Janssen
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Ugarte-Gil MF, Mendoza Pinto C, Reategui Sokolova C, Pons-Estel G, Van Vollenhoven R, Bertsias G, Alarcon GS, Pons-Estel B. AB0449 IMPACT OF REMISSION AND LOW DISEASE ACTIVITY (LDA) ON HEALTH-RELATED QUALITY OF LIFE (HRQOL) IN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) PATIENTS: A SYSTEMATIC LITERATURE REVIEW (SLR). Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.3995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Treat-to-target strategy has been proposed in SLE. Achieving remission/LDAS should prevent damage, reduce mortality and improve HRQoL.Objectives:To determine the protective value of remission or LDA states on HRQoL in SLE using a SLR.Methods:Two independent reviewers identified studies in Medline and Cochrane library and extracted data on remission, LDA and HRQoL. Remission and LDA definitions included disease activity (SLEDAI and its variants, SLAM and PGA), serological activity, new organ/system, prednisone (PDN) dose (mg/day), immunosuppressives (IS) drugs, antimalarial (AM) use and remission duration. The quality of the studies was assessed with the Newcastle-Otawa Scale (NOS).Results:Three manuscripts (1059 patients) for remission and 4 (2385 patients) for LDA were included (America, Europe & Asia Pacific). All the studies reached seven out of nine NOS points. Remission rates ranged 25-39%; and LDA: 42-62%. Even less stringent remission or LDA definitions predicted/were associated with a better HRQoL. Physical rather than mental domains were more associated with remission or LDA.Table 1.Association between remission and HRQoLAuthorsCountry/RegionPatientsRemissionRemission (%)Domains positively associated or predicted by remissionMok et al*China769SLEDAI=0Serologic= AllowedPGA<0.5PDN ≤ 5IS=YesAM=YesDuration≥5years25.1Remission>5 years vs not on remissionSF-36:Role physical, bodily pain, general health, vitality, social functioning, role emotional, PCS and MCSLupusPRO:Symptoms, medications, procreation, physical health, pain, emotional, image, HRQoL totalTsang-A-Sjoe et al#Netherlands154SLEDAI=0Serologic= allowedPGA ≤2/10PDN ≤ 5IS=YesAM=YesDuration=NR39.0 at baselineRemission on- or off-therapy predicted a better SF-36 PCS but not MCSMargiotta et al*Italy136SLEDAI=0Serologic= allowedPGA= NRPDN ≤ 5IS=YesAM=YesDuration>5 years39.0Remission >5years vs unremitted or remission<5 yearsSF-36:Physical health, role physical, bodily pain, general health, social functioningPCS: Physical component summary. MCS: Mental component summary. *Cross-sectional #LongitudinalTable 2.Association between LDA and HRQoLAuthorsCountry/RegionPatientsLDALDA (%)Domains positively associated or predicted by LDASGolder et al*Asia Pacific1422SLEDAI≤ 4PGA≤ 1PDN ≤ 7.5IS=YesAM=YesNew manifestations: NoDuration=NR42.0SF-36:Role physical, bodily pain, general health, vitality, social functioning, role emotional, mental health, PCS and MCSUgarte-Gil et al#USA483SLAM≤ 3PGA=NRPDN ≤ 7.5IS=NoAM=YesNew manifestations: NRDuration=NRNRSF-36:Physical function, role physical, bodily pain, general health, vitality, social functioning, role emotional, mental health, PCS and MCSUgarte-Gil et al#Peru243SLEDAI≤ 4PGA=NRPDN ≤ 7.5IS=YesAM=YesNew manifestations: NRDuration=NR48.6 at baselineLupusQoLPhysical health, pain, planning, burden to others, emotional health, fatiguePoomsalood et al*Thailand237SLEDAI≤ 2Serologic= allowedPGA=NRPDN ≤ 7.5IS=YesAM=YesNew manifestations: NRDuration=NR61.6SLEQoLUnivariable:physical, activities, symptom, treatment, mood, self-image and total.Multivariable: Better global QoLPCS: Physical component summary. MCS: Mental component summary. *Cross-sectional #LongitudinalConclusion:In SLE patients, achieving remission or LDA, is associated with a better HRQoL.Disclosure of Interests:Manuel F. Ugarte-Gil Grant/research support from: Jannsen, Pfizer, Claudia Mendoza Pinto: None declared, Cristina Reategui Sokolova: None declared, Guillermo Pons-Estel Grant/research support from: JANSSEN and GSK, Consultant of: JANNSEN, GSK and SANOFI, Speakers bureau: PFIZER, JANNSEN and GSK, Ronald van Vollenhoven Grant/research support from: AbbVie, Arthrogen, Bristol-Myers Squibb, GlaxoSmithKline, Lilly, Pfizer, and UCB, Consultant of: AbbVie, AstraZeneca, Biotest, Bristol-Myers Squibb, Celgene, GSK, Janssen, Lilly, Medac, Merck, Novartis, Pfizer, Roche, and UCB, George Bertsias Grant/research support from: GSK, Consultant of: Novartis, Graciela S Alarcon: None declared, Bernardo Pons-Estel Grant/research support from: GSK, Janssen, Consultant of: GSK, Janssen, Speakers bureau: GSK, Janssen
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Quintana R, Pons-Estel G, Roberts K, Sacnún M, Berbotto G, Garcia MA, Saurit V, Barile-Fabris L, Acevedo-Vazquez EM, Tavares Brenol JC, Sato EI, Iglesias A, Uribe O, Alarcon G, Pons-Estel BA. Jaccoud’s arthropathy in SLE: findings from a Latin American multiethnic population. Lupus Sci Med 2019; 6:e000343. [PMID: 31478011 PMCID: PMC6703282 DOI: 10.1136/lupus-2019-000343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/22/2019] [Accepted: 07/26/2019] [Indexed: 11/17/2022]
Abstract
Objective To compare the clinical, laboratory and outcome features of SLE patients with and without Jaccoud’s arthropathy (JA) from the Grupo Latino Americano De Estudio del Lupus (GLADEL) cohort. Methods 1480 patients with SLE [(34 centres, 9 Latin American countries with a recent diagnosis (≤2 years)] constitute the GLADEL cohort. JA was defined as reducible deformity of the metacarpophalangeal axis, without radiographic erosions at any time. Within this cohort, a nested case–control study was carried out. Control was matched for age, gender and centre in a 1:3 proportion. The variables included were: sociodemographic, clinical and immunological features, disease activity, damage and mortality. Comparisons were performed with Wilcoxon and χ2 tests for continuous and categorical variables, respectively. ORs and 95% CIs and Kaplan-Meier survival curve were estimated. Results Of 1480 patients, 17 (1.1%) JA patients were identified; 16 (94.1%) of them were women, mean age: 31.0 years (SD 12.0). Five (29.4%) patients presented JA at SLE diagnosis and 12 (70.6%) after. The median follow-up time and all disease features were comparable in both groups except for a higher frequency of pneumonitis in the patients with JA [4 (23.5) vs 1 (2.0); p=0.012; (OR: 15.4; 95% CI 1.6 to 149.6)]. The SLE disease activity index, Systemic Lupus International Collaborating Clinics/American College of Rheumatology damage Index and the Kaplan-Meier survival curve were similar in both groups. Conclusion JA may tend to appear early in the course of SLE; it seems not to have an impact on disease activity, damage accrual or in survival.
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Affiliation(s)
- Rosana Quintana
- Department of Internal Medicine, Centro Regional de Enfermedades Autoinmunes y Reumáticas (CREAR), Rosario, Argentina
| | - Guillermo Pons-Estel
- Department of Internal Medicine, Centro Regional de Enfermedades Autoinmunes y Reumáticas (CREAR), Rosario, Argentina
| | - Karen Roberts
- Department of Rheumatology, Hospital Provincial de Rosario, Rosario, Argentina
| | - Monica Sacnún
- Department of Rheumatology, Hospital Provincial de Rosario, Rosario, Argentina
| | - Guillermo Berbotto
- Department of Rheumatology, Hospital Escuela Eva Perón, Granadero Baigorria, Argentina
| | - Mercedes A Garcia
- Department of Rheumatology, Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina
| | - Veronica Saurit
- Department of Rheumatology, Hospital Privado, Cordoba, Cordoba, Argentina
| | - Leonor Barile-Fabris
- Department of Rheumatology, Hospital Angeles del Pedregal, Ciudad de México, Ciudad de Mexico, Mexico
| | | | - João C Tavares Brenol
- Department of Rheumatology, Hospital das Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Emilia I Sato
- Department of Rheumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Antonio Iglesias
- Department of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
| | - Oscar Uribe
- Department of Rheumatology, Universidad de Antioquia, Hospital Universitario “Fundación San Vicente”, Medellin, Colombia
| | - Graciela Alarcon
- Department of Medicine, Division of Clinical Immunology and Rheumatology, School of Medicine, The University of Alabama at Birmingham, Birmingham, England, USA
- Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Bernardo A Pons-Estel
- Department of Internal Medicine, Centro Regional de Enfermedades Autoinmunes y Reumáticas (CREAR), Rosario, Argentina
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Alarcón GS, Ugarte-Gil MF, Pons-Estel G, Vilá LM, Reveille JD, McGwin G. Remission and low disease activity state (LDAS) are protective of intermediate and long-term outcomes in SLE patients. Results from LUMINA (LXXVIII), a multiethnic, multicenter US cohort. Lupus 2019; 28:423-426. [PMID: 30678605 DOI: 10.1177/0961203319826693] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of this report is to determine the impact of remission and low disease activity state (LDAS) on damage accrual and mortality in systemic lupus erythematosus (SLE) patients. PATIENTS AND METHODS Visits from the Lupus in Minority populations: Nature vs. Nurture (LUMINA) cohort were categorized into remission (Systemic Lupus Activity Measure (SLAM) score = 0 and prednisone ≤ 5 mg/day and no immunosuppressants), LDAS ((not on remission), SLAM score ≤ 3, prednisone ≤ 7.5 mg/day, no immunosuppressants), or neither: active. Remission and LDAS visits were combined because of the relatively small number of remission visits. Their impact on damage accrual and mortality were examined by Poisson and logistic multivariable regressions adjusting for variables known to affect these outcomes. RESULTS A total of 3879 visits for 558 patients (28% Caucasian, 37% African descent, 35% Hispanic) were studied. These visits corresponded to 71 in remission, 585 in LDAS, and 3223 active. The longer the percentage of time the patients were in remission/LDAS, the less damage accrual observed (rate ratio 0.1773 (95% confidence interval (CI) 0.1216 to 0.2584) p < 0.0001). A trend was observed in terms of mortality although statistical significance was not reached (odds ratio 0.303 (95% CI 0.063 to 1.456), p = 0.1360). CONCLUSIONS The longer the patient's state on Remission/LDAS, the less damage accrual that occurs. The protective effect on mortality was not statistically significant.
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Affiliation(s)
- G S Alarcón
- 1 The University of Alabama at Birmingham, Birmingham, USA.,2 Universidad Peruana Cayetano Heredia, Lima, Perú
| | - M F Ugarte-Gil
- 3 Hospital Guillermo Almenara, EsSalud, Lima, Perú.,4 Universidad Científica del Sur, Lima, Perú
| | - G Pons-Estel
- 5 Hospital Provincial de Rosario, Rosario, Argentina.,6 Grupo Oroño-Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Sanatorio Parque Rosario, Santa Fe, Argentina
| | - L M Vilá
- 7 University of Puerto Rico Medical Sciences Campus, San Juan, USA
| | - J D Reveille
- 8 The University of Texas Health McGovern Medical School, Houston, USA
| | - G McGwin
- 1 The University of Alabama at Birmingham, Birmingham, USA
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Quintana R, Goñi M, Mathern N, Jorfen M, Conti S, Nieto R, Sanabria A, Prigione C, Silvestre AMR, García V, Pons-Estel G, Cervera R, García C, Peláez-Ballestas I, Alarcón GS, Pons-Estel BA. Rheumatoid arthritis in the indigenous qom population of Rosario, Argentina: aggressive and disabling disease with inadequate adherence to treatment in a community-based cohort study. Clin Rheumatol 2018; 37:2323-2330. [DOI: 10.1007/s10067-018-4103-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 04/06/2018] [Accepted: 04/10/2018] [Indexed: 11/29/2022]
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Silvariño R, Sant F, Espinosa G, Pons-Estel G, Solé M, Cervera R, Arrizabalaga P. Nephropathy associated with antiphospholipid antibodies in patients with systemic lupus erythematosus. Lupus 2011; 20:721-9. [PMID: 21486929 DOI: 10.1177/0961203310397410] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nephropathy associated with antiphospholipid antibodies (aPL) has been proposed as a risk factor of worse renal prognosis in patients with systemic lupus erythematosus (SLE). The purpose of the current study was to evaluate the prevalence of aPL-associated nephropathy (aPLN) among patients with lupus nephritis and to describe their functional renal outcome. METHODS A total of 79 renal biopsies from 77 patients followed at the Hospital Clinic, Spain were analysed. Each renal biopsy was evaluated by a pathologist who was blinded to the aPL status. Thrombotic microangiopathy (TMA), fibrous intimal hyperplasia (FIH), fibrocellular arterial occlusion (FAO), focal cortical atrophy (FCA), and tubular thyroidization as lesions suggestive of aPLN were identified. RESULTS aPLN was found in nine (11.4%) biopsies. TMA was found in three (33.3%) cases whereas chronic aPLN, represented by FIH and FCA, was found in four (44.4%) and three (33.3%) cases, respectively. A significant association between the presence of aPL and aPLN was found (p = 0.003). Patients with lupus anticoagulant (LA) plus IgG anticardiolipin antibodies (aCL) showed an increased prevalence of aPLN (OR: 3.61, 95% CI 1.28-5.14; p = 0.002). Creatinine levels were significantly increased in patients with aPLN compared with those with aPL without aPLN (p = 0.038). However, no significant difference in complete remission, partial remission, not response, and established renal damage between groups was observed at the end of follow-up. CONCLUSIONS The aPL have an important role in the pathogenesis of renal lesions in SLE patients. Prospective studies are needed to address the role of aPLN in the long-term outcome of SLE patients with positive aPL.
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Affiliation(s)
- R Silvariño
- Department of Autoimmune Diseases, Hospital Clínic-Institut d'Investigacions Biomèdiques Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Catalonia, Spain
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Cervera R, Bucciarelli S, Plasín MA, Gómez-Puerta JA, Plaza J, Pons-Estel G, Shoenfeld Y, Ingelmo M, Espinos G. Catastrophic antiphospholipid syndrome (CAPS): Descriptive analysis of a series of 280 patients from the “CAPS Registry”. J Autoimmun 2009; 32:240-5. [PMID: 19324520 DOI: 10.1016/j.jaut.2009.02.008] [Citation(s) in RCA: 171] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2009] [Accepted: 02/11/2009] [Indexed: 02/08/2023]
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