Initial Treatment with Biological Therapy in Rheumatoid Arthritis

BACKGROUND

We aimed to analyse the effectiveness, efficiency, and safety of initial treatment with biological therapies in rheumatoid arthritis (RA).

METHODS

Qualitative study. A group of RA experts was selected. A scoping review in Medline was conducted to analyse the evidence of initial RA treatment with biological therapies. Randomised clinical trials were selected. Two reviewers analysed the articles and compiled the data, whose quality was assessed using the Jadad scale. The experts discussed the review's findings and generated a series of general principles: Results: Seventeen studies were included. Most of the included patients were middle-aged women with early RA (1-7 months) and multiple poor prognostic factors. Initial treatment with TNF-alpha inhibitors combined with methotrexate (MTX) and an IL6R inhibitor (either in mono or combination therapy) is effective (activity, function, radiographic damage, quality of life), safe, and superior to MTX monotherapy in the short and medium term. In the long term, patients who received initial treatment with biologicals presented better results than those whose initial therapy was with MTX.

CONCLUSIONS

Initial treatment of RA with biological therapies is effective, efficient, and safe in the short, medium, and long term, particularly for patients with poor prognostic factors.

Recommendations by the Spanish Society of Rheumatology on risk management of biological treatment and JAK inhibitors in patients with rheumatoid arthritis

OBJECTIVE

To present recommendations based on the available evidence and the consensus of experts, for risk management of biological treatment and JAK inhibitors in patients with rheumatoid arthritis.

METHODS

Clinical research questions relevant to the purpose of the document were identified. These questions were reformulated in PICO format (patient, intervention, comparison, outcome or outcome) by a panel of experts, selected based on their experience in the area. A systematic review of the evidence was carried out, grading according to the GRADE criteria (Grading of Recommendations Assessment, Development, and Evaluation). Specific recommendations were then formulated.

RESULTS

6 PICO questions were proposed by the panel of experts based on their clinical relevance and the existence of recent information regarding the risk of occurrence of serious infections, the risk of reactivation of the hepatitis B virus, the risk of reactivation of the virus varicella-zoster, the risk of appearance of skin (melanoma and non-melanoma) or haematological cancer, the risk of appearance of thromboembolic disease and the risk of progression of the human papilloma virus. A total of 28 recommendations were formulated, structured by question, based on the evidence found and the consensus of the experts.

CONCLUSIONS

The SER recommendations on risk management of treatment with biologic therapies and JAK inhibitors in rheumatoid arthritis are presented.

Healthcare Professional (HCP) and Patient Usability Evaluation and Preferences of Two Auto-injector Devices for Self-Injection of Biosimilars, SB4 and SB5: A Literature Review

BACKGROUND

Numerous biologic drugs, including etanercept and adalimumab, are administered subcutaneously. This study reviewed the evidence on the usability and preference of self-injection devices of SB4 and SB5 compared with the reference product injectors.

METHODS

A systematic search was conducted in PubMed using the search string "(Imraldi OR Hadlima OR SB5 OR Benepali OR Brenzys OR SB4) AND (preference) AND (device)" covering the period from 28 January 2016 (first introduction of SB4) to 31 May 2022. Only articles and abstracts on usability or preference-rating of SB4 and SB5 autoinjectors (AI) written in English were selected. Additional papers identified via manual search supplemented the retrieved papers.

RESULTS

A total of nine articles and one conference poster were selected (seven surveys, one observational study, and two phase II studies). Overall, participants of the studies included nurses and rheumatologists, as well as patients who were from three medical specialties where these medicines are most commonly used (rheumatology, gastroenterology, and dermatology). The majority of patients and healthcare professionals rated ease of use and ease of grip as the most important device attributes. SB4/Pen and SB5/Pen were mostly preferred over their prefilled syringes (PFS), Enbrel/Pen, and Humira/Pen.

CONCLUSION

The analyzed data on usability and device preference indicate that SB4/Pen and SB5/Pen were preferred over the other reference product autoinjectors, thanks to their button-free design, auditory and visual injection feedback, and overall ease of use. Therefore, they were preferred over the other reference product autoinjectors. Because user-friendly devices can improve treatment adherence, pharmaceutical companies should consider patient convenience when developing medical devices.

Screening criteria for interstitial lung disease associated to rheumatoid arthritis: Expert proposal based on Delphi methodology

OBJECTIVE

To develop a joint proposal for screening criteria of interstitial lung disease (ILD) in patients with rheumatoid arthritis (RA) and vice versa, which serves as a guidelines in patient referral between the Rheumatology and Pneumology departments to early detection of these patients.

METHODS

A systematic literature review was carried out on the risk factors for the development of ILD in RA patients, and for the referral criteria to Rheumatology for suspected early RA. Based on the available evidence, screening criteria were agreed using the Delphi method by a panel of pneumologists and rheumatologists with expertise in these pathologies.

RESULTS

Screening criteria for ILD in patients with RA and for the early detection of RA in cases with ILD of unknown etiology have been developed. In both cases, a detection strategy was based on clinical risk factors. Recommendations also included the complementary tests to be carried out in the different clinical scenarios and on the periodicity that screening should be repeated.

CONCLUSION

A selective screening strategy is recommended for the first time in the early diagnosis of patients with ILD-RA. This multidisciplinary proposal aims to solve some common clinical questions and help decision-making, although its usefulness to identify these patients with good sensitivity must be confirmed in a validation study.

Executive summary of the consensus statement of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), Spanish Society of Neurology (SEN), Spanish Society of Immunology (SEI), Spanish Society of Pediatric Infectology (SEIP), Spanish Society of Rheumatology (SER), and Spanish Academy of Dermatology and Venereology (AEDV), on the diagnosis, treatment and prevention of Lyme borreliosis

The diagnosis of Lyme borreliosis (LB) is based on the epidemiological history, clinical manifestations and microbiological findings in the early disseminated and late phases of the disease. Related to this fact, microbiological diagnostic techniques have recently appeared. Far from facilitating the diagnosis and the clinical-therapeutic management of LB patients, they are generating confusion. Herein, experts and representatives of Spanish Scientific Societies [Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), Spanish Society of Neurology (SEN), Spanish Society of Immunology (SEI), Spanish Society of Pediatric Infectology (SEIP), Spanish Society of Rheumatology (SER), and Spanish Academy of Dermatology and Venereology (AEDV)] exposed the executive summary after reviewing the epidemiology, clinical spectrum, available diagnostic techniques for the diagnosis of Borrelia burgdorferi infection, therapeutic and prevention options of LB. By consensus, recommendations for microbiological diagnosis are offered together with those supporting the therapeutic management and prophylaxis of infection.

Clinical Value of IL6R Gene Variants as Predictive Biomarkers for Toxicity to Tocilizumab in Patients with Rheumatoid Arthritis

Tocilizumab is a first-line biologic disease-modifying anti-rheumatic drug (bDMARD) that inhibits the interleukin-6 (IL-6) pathway by antagonizing the IL-6 receptor (IL-6R). Tocilizumab is widely used to treat rheumatoid arthritis (RA), a prevalent autoimmune disease that can cause irreversible joint damage and disability. Although many bDMARDs have been developed for RA, there is a lack of validated biomarkers which could guide personalized medicine strategies. To evaluate whether single-nucleotide polymorphisms (SNPs) in the IL6R gene could predict tocilizumab toxicity in patients with RA, we conducted a retrospective cohort study of 88 patients treated with tocilizumab. Six SNPs previously described in the IL6R gene were genotyped (rs12083537, rs11265618, rs4329505, rs2228145, rs4537545, and rs4845625). Using parametric tests, we studied the association between the SNPs and hepatotoxicity, infection, hypersensitivity, gastrointestinal, hematological, and dyslipidemia adverse events (AEs). We found associations between dyslipidemia and rs4845625 and between hematological AEs and rs11265618 and rs4329505. No further associations were found for the remaining SNPs and other AEs. Our findings support the potential clinical value of SNPs in the IL6R gene as predictive biomarkers for toxicity to tocilizumab in patients with RA.

Role of IL6R Genetic Variants in Predicting Response to Tocilizumab in Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a prevalent autoimmune disease characterized by chronic arthritis that may lead to irreversible joint damage and significant disability. Patients with RA are commonly treated with Tocilizumab (TCZ), an IL-6 receptor (IL-6R) antagonist, but many patients refractorily respond to this therapy. Identifying genetic biomarkers as predictors of TCZ response could be a key to providing a personalized medicine strategy. We aimed to evaluate whether functional single nucleotide polymorphisms (SNPs) in the IL6R gene could predict TCZ response in patients with RA. We retrospectively included 88 RA patients treated with TCZ. Six SNPs previously described in the IL6R gene (rs12083537, rs11265618, rs4329505, rs2228145, rs4537545, and rs4845625) were genotyped in DNA samples from these patients. Using parametric tests, we evaluated the association between these polymorphisms and clinicopathological features. Responses to treatments were assessed at six months using three variables: a quantitative improvement in Disease activity score including 28 joints (DAS28), a satisfactory European League Against Rheumatism (EULAR) response, and low disease activity (LDA) achievement. The three response variables studied were associated with genetic variant rs4845625, and no association was found with the other five SNPs. Our findings support the potential clinical value of SNPs in the IL6R gene as predictive biomarkers for TCZ response.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Acknowledgements

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

Disclosure of Interests

None declared

AB0608 TIME OF DIAGNOSIS AND INITIATION OF TREATMENT OF GIANT CELL ARTERITIS (GCA) ACCORDING TO CLINICAL PHENOTYPE AND REFERRAL ORIGIN

Background

Giant cell arteritis (GCA) presents two phenotypic patterns: cranial and extracranial. Cranial manifestations are relatively easier to recognize and to diagnose, however since the extracranial are more insidious and less known, it may lead to a delay in diagnosis and in treatment. The main treatment are glucocorticoids (GC) at high doses followed by a descending pattern. The time between the begin of the symptoms and the start of the treatment with GC it’s of vital importance in the prognosis of the disease.

Objectives

The present AUDIT describes our cohort’s clinical features, the time from symptom onset to rheumatology visit and diagnosis of GCA, as well as the differences in time according to the service originating the referral.

Methods

Audit retrospective, descriptive study of patients diagnosed with GCA by the CGA 1990 criteria. All patients diagnosed with GCA from 2011 to 2021, in a single hospital center and referred to the Rheumatology Service were included.

Patients were classified as: cranial phenotype, extracranial or mixed. Demographic and clinical variables and complementary examinations were collected. As well as the time from the first symptom until the patients are referred and diagnosed.

Results

Seventy patients were included in the study. Fifty-one patients (72.9%) were female, their clinical features are shown in Table 1. Twelve of them (17,39%) had a cranial phenotype, sixteen (23,18%) an extracranial phenotype and forty-one (60,42%) a mixed one.

Extracranial phenotype patients showed to be younger at the time of the diagnoses than the other groups. Cranial phenotype patients had a lower increase of the acute phase reactants than the other phenotypes (without finding statistically significant differences). In Table 2 are shown the other demographic, clinical and analytic data.

Table 1.

Disease Characteristics of the Patients at Baseline according to their phenotype

PHENOTYPECRANIALEXTRACRANIALMIXEDTOTALN=12N=17N=41N=70Age75.543 ± 7.4873.543 ± 8.176.356 ±7.4675.56 ±7.46Smoker8.3% (n=1)11.8% (n=3)14.6% (n=6)12.9% (n=9)Headache91.7% (n=11)0%90.2% (n=37)68.6% (n= 48)Ocular involvement58.3% (n=7)0%34.1% (n=14)30% (n=21)Fever of unknow origin0%29.4% (n=5)34.1% (n=14)27.1% (n=19)Polymyalgia rheumatica0%41.2% (n=7)53.7% (n=22)41.4% (n=29)Constitutional syndrome0%23.5% (n=4)36.6% (n=15)27.1% (n=19)Cutaneous hyperalgesia25% (n=3)0%31.7% (n=13)22.9% (n=16)Anaemia0%41.2% (n=7)46.3% (n=19)37% (n=26)C reactive protein51.33 ± 40.1677.83 ± 75.3085.55 ± 81.6777.58 ± 74.57Erythrocyte sedimentation rate60.64 ± 33.1376.20 ± 36.3577.93 ± 3574.65 ± 35.07

Patient referral were made from: Emergency room/ Internal Medicine hospitalization (30%, 21 patients), Primary Care (21.4%, 15 patients), Internal Medicine outpatient clinic (15.7%, 11 patients), Neurology (18.6%, 13 patients) and other specialties outpatient clinic (cardiology, vascular surgery, ophthalmology, hematology and gastroenterology).

The median of the time from the first symptom until the patients are diagnosed are 12,9, 13,97 and 7,91 weeks in the cranial, extracranial and mixed respectively.

The median of time from the first symptom until the patient referral to rheumatology are 9.34, 12.74 and 5.87 weeks in the cranial, extracranial and mixed respectively.

The median of time from patient referral to rheumatology to be assessed are 3.73, 5.59 and 3.43 weeks in the cranial, extracranial and mixed respectively.

75.7% of the patients received treatment with glucocorticoids before being referral to rheumatology.

Conclusion

In our cohort, most of the patients with CGA had a mixed phenotype. The patient referral to rheumatology is made mainly from the emergency room, internal medicine hospitalization and primary care.

Patients with mixed phenotype are diagnosed faster than the ones with an exclusively extracranial phenotype.

The time between the first symptom and the referral to rheumatology is still long.

Disclosure of Interests

None declared

POS1381 ULTRASONOGRAPHIC EVALUATION OF ENTHESOPATHY IN IDIOPATHIC DIFFUSED SKELETAL HYPEROSTOSIS. APPLICABILITY OF THE MASEI INDEX

Background

In Diffuse idiopathic Skeletal Hyperostosis (DISH) o Forestier-Rotés disease the enthesis is also the hallmark of extraspinal manifestations. Despite being a characteristic hallmark of the disease, it has been poorly investigated.

Objectives

To assess the usefulness of the Madrid Sonographic Enthesitis Index (MASEI) to classify patients with DISH and to analyse the ultrasound findings in hyperostotic entheses.

Methods

We recruited 35 patients with DISH, according to Resnick classification criteria, who were compared with 33 healthy patients age, sex and body mass index-matched. An ultrasound was performed strictly following the MASEI protocol. The ultrasound examiners, with extensive experience in musculoskeletal ultrasound (ECOCAT group), were blinded to the diagnosis of the patients. The interobserver reliability of MASEI index measured by an ICC was 0.97 (95%, CI 89-99) [1]. Demographic, cardiovascular risk factors, clinical, radiological and MASEI-related variables were collected. We categorized into MASEI- inflammatory (MASEI-I) and MASEI-damage (MASEI-D) as previously published [2]but also into MASEI-DISH, which included the variables of thickness, structure and calcification. In the statistical analysis, patients’ data were depicted by using descriptive statistics and the comparison between groups with the Chi-square test for categorical variables and the T-Student test for numerical variables. The validity of the index was examined using the area under the ROC curve and its corresponding 95% confidence interval (CI). The optimal cut-off point was defined as the one that maximizes sensitivity (S) and specificity. (Spe). The statistical program used was R software.

Results

In the analysis of the elemental lesions, the alterations in structure, thickness and calcification of the distal quadriceps (DQT) and Achilles tendons (AQT) stood out (p <0.05). In the total MASEI, the ultrasound score of ≥ 16.50 (S80%, Spe 85%), obtained with an AUC of 0.877 (95% CI, 0.79 to 0.96), was the best cut-off to differentiate patients from healthy subjects. In the categorized indices, MASEI-I: cut-off 5.50 (S 89%, Spe 76%) and AUC 0.835 (95% CI 0.73 to 0.94); MASEI-D: 7.50 (S 86%, Spe 76%) and AUC 0.850 (95% CI, 0.75 to 0.94) and MASEI-DISH: 16.50 (S 74%, Spe 91%) and AUC (95% CI 0.76 to 0.95). The total MASEI in the DISH group was 27.46 (SD 14.4) compared to 10.30 (SD 6.4) in healthy controls (p<0.001) as well as in those categorized as MASEI-I, MASEI-D or MASEI-DISH (p <0.001).

Conclusion

Entheses lesions of the AQT and the DQT mark the differences between DISH and healthy patients. The optimal cut-off point was 16.50, and we did not observe any advantages in establishing MASEI categorizations that could be useful in clinical practice. Although the MASEI is an index designed to classify patients with spondyloarthritis, our study shows that it also allows differentiating DISH patients from healthy subjects. It would also be interesting to analyse the capacity of the MASEI to distinguish DISH from spondyloarthritis.

References

[1]Moya Alvarado P, et al. Rheumatol Int. 2020.

[2]Eder L et al. J Rheumatol. 2014; 41(3): 466-72.

This study has received a grant from the Catalan Rheumatology Society (2019)

Acknowledgements

Investigation Unit Sociedad Española de Reumatología

Catalan Rheumatology Society (Grant)

Disclosure of Interests

Teresa Clavaguera Speakers bureau: 2021 Jansen, UCB, Novartis, Marta Valls Speakers bureau: 2021 Lilly, Nordic, Maria Buxó: None declared, MANEL PUJOL BUSQUETS Speakers bureau: abbvie, pfizer, lilly, UCB, Janssen, Novartis, Georgina Salvador Alarcon Speakers bureau: Lilly, Novartis, Roche, abbvie, Sanofi, Eulàlia Armengol Speakers bureau: Novartis, Jansen, Xavier González-Giménez: None declared, Mireia Moreno Speakers bureau: Many: Novartis, MSD, Marta Arévalo: None declared, Vicenç Torrente: None declared, Lourdes Mateo: None declared, Susana Holgado: None declared, Xabier Michelena: None declared, Juan José De Agustín De Oro: None declared, Meritxell Sallés Lizarzaburu Speakers bureau: Lilly, Sanofi, Sonia Mínguez: None declared, ANDRES PONCE FERNANDEZ: None declared, Rosa Morlà: None declared, Paula Estrada: None declared, D Reina-Sanz Speakers bureau: Novartis, UCB, Patricia Moya: None declared, Hector Corominas Speakers bureau: Gebro, Abbvie, Fresenius, Judith Font Urgellés: None declared, Patricia Reyner Speakers bureau: Lilly, Sanofi, Nordic

AB0868 PREVALENCE AND RISK FOR BUNDLE BRANCH BLOCK, ATRIOVENTRICULAR BLOCK AND PACEMAKER IMPLANTATION IN SPONDYLOARTHRITIS. A SYSTEMATIC REVIEW OF THE LITERATURE

Background

Inflammation of the valve attachment site may produce tissue degeneration near the atrioventricular node, which may lead to electrical conduction disturbances, that is to say atrioventricular block (AVB) and bundle branch block (BBB).

Objectives

To evaluate the evidence regarding the prevalence and risk of BB, AVB and pacemaker implantation (PMI) in patients with spondyloarthritis (SpA) compared to a control group without SpA.

Methods

A systematic review of the literature was performed using Pubmed (Medline), EMBASE (Elsevier) and Cochrane Library (Wiley) databases until December 2021. The risk for AVB, BBB and PMI were analyzed. Cohort, case control and cross-sectional studies in patients ≥18 years meeting the classification criteria for SpA were included. The Odds ratio (OR), risk ratio (RR) or Hazard ratio (HR) were considered as outcomes. Data was synthesized in a previously defined extraction form. The risk of bias was assessed by the Newcastle-Ottawa Scale.

Results

In total, eight out of 374 studies were included. As for low grade AVB and BBB, only indirect results comparing prevalences from low to medium quality studies were found. According to population based registries, the sex and age adjusted HR of AVB was 2.3 (95% CI 1.6 - 3.3) in ankylosing spondylitis, 2.9 (95% CI 1.8 - 4.7) in undifferentiated spondyloarthritis and 1.5 (95% CI 1.1 a 1.9) in psoriatic arthritis. The RR for PMI was 1.3 (95% CI 1.16 - 1.46) for groups aged between 65-69 years, 1.33 (95% CI 1.22 - 1.44) for 70-75 years, 1.24 (95% CI 1.55 - 1.33) for 75-79 years and 1.11 (95% CI 1.06 - 1.17) for groups older than 80 years.

AuthorStudy designPopulationSample numberTestOutcomesAdjustmentBaniaamam 2021[6]Cross sectionalAS and osteoarthritis between 50-75 years267ECGPrevalence of AVB, BBB and PMIControls matched for age, sex and smoking statusBengtsson 2017[12]CohortAS, uSpA, PsA, GPfrom the Swedish national registry294136ICD-10Prevalence, Incidence, HR, for AVB and PMI compared to GPAge, sexDik 2010[9]Cross sectionalAS131ECGPrevalence of AVB and BBB Association of PR interval with AS disease related variablesAge, sex, disease durationFeld 2008[10]Case controlPsA compared to non psoriatic nor arthritic patients184ECGPrevalence of AVB, BBB Correlation of PR interval with AS disease related variablesNoneFu 2016[8]Cross sectionalAS between 18-50y without cardiac disease122ECGPrevalence of AVB, BBB AS without kyphosisNoneGoulenok 2010[13]Cross sectionalSpA, RA and control group without known CV disease288ECGPrevalence AVB, BBNoneWard 2018[7]CohortAS from Medicare database older than 6542,327ICD-9Prevalence, incidence, OR of PMIAge, sex, raceYildrir 1999[11]Case controlAS88Holter and ECGPrevalence of AVBNone

Conclusion

The differences of prevalence in AVB and BBB were similar in SpA and control groups even though studies lacked the power. According to population registries there was an two fold-increased risk of high grade AVB in SpA patients. RR for PMI was higher in younger age groups.

Disclosure of Interests

Hye Sang Park: None declared, Ana Laiz Speakers bureau: A.L. has received speaker fees/honoraria from Abbvie, Lilly, Novartis, Pfizer and UCB, Petra Díaz del Campo Fontecha: None declared, Mª Auxiliadora Martín Martínez: None declared, Mercedes Guerra-Rodriguez: None declared, Concepción Alonso Martín: None declared, Jesus Sanchez-Vega: None declared, Hector Corominas Speakers bureau: H.C. has received speaker fees/honoraria from BMS, Gebro, MSD, Lilly, Novartis, Pfizer, Roche, Sanofi, and UCB, Consultant of: H.C. has participated in consulting for Abbvie, Amgen, Biogen, Celgene, Gilead, Kern, Pfizer and Sanofi.

AB0402 THERAPEUTIC ADHERENCE AND PERSISTENCE OF TOFACITINIB AND BARICITINIB IN RHEUMATOID ARTHRITIS PATIENTS IN DAILY CLINICAL PRACTICE

Background

The use of Janus kinase inhibitors (JAKi) is approved for adults with rheumatoid arthritis (RA) with moderate to severe activity. Although there is increasing data about baricitinib and tofacitinib in daily clinical practice, data about adherence and persistence in real-life is scarce.

Objectives

(i) To evaluate the adherence and persistence of tofacitinib and baricitinib in RA patients in a real-life setting. (ii) To assess the influence of treatment adherence to therapeutic persistence.

Methods

Retrospective longitudinal observational study that included all patients with RA who were treated with tofacitinib and/or baricitinib between 2017/10 and 2021/05 in a tertiary hospital. Demographic, clinical and pharmacological data were collected from electronic medical and pharmacy claim records. Kaplan-Meier survival analysis and log-rank test were performed to calculate and compare treatment persistence, respectively. Drug adherence was assessed with the Medication Possession Ratio (MPR). The effect of therapeutic adherence on treatment persistence was evaluated with a linear regression model.

Results

We included 136 cases: 30 treated with tofacitinib [28.6%], 44 with baricitinib [41.9%] and 31 with both [29.5%] corresponding to 105 RA patients. In our sample 86.7% of the patients were women with a mean age (± SD) of 63 (± 13) years. At the start of treatment, patients had a mean disease activity score DAS28-ESR (± SD) of 5.1 (± 1.2) and they had previously received a median (range) of 3 (0-8) biologic agents for RA.

During the study period, 40 (29.4%) and 38 (27.9%) patients treated with tofacitinib and baricitinib, respectively, discontinued the treatment.

Mean treatment persistence was 363 days (95%CI=2-1.282) in tofacitinib group and 406 days (CI95%=8-1.300) in baricitinib group. There were no statistical differences in treatment survival (HR=1.01 [95CI%=0.59-1.71]; p=0.97).

Mean MPR was 91% in both groups. There was no statistically significant correlation between therapeutic adherence and treatment persistence (p=0.21).

Conclusion

The results showed no significant differences between treatment persistence and adherence of tofacitinib and baricitinib in our patients with rheumatoid arthritis. In our cohort, therapeutic adherence was high and it did not influence treatment persistence.

Disclosure of Interests

None declared

AB1237 COMPARISON BETWEEN ENZYME IMMUNOASSAY AND CHEMILUMINESCENCE TO DETERMINE THE CONCENTRATION OF SERUM CALPROTECTIN AND ITS ASSOCIATION WITH CLINICAL VARIABLES IN PEDIATRIC RHEUMATOLOGY

Background

Serum calprotectin (SC) is an emerging biomarker in the measurement of inflammation. It can be determined by different techniques, such as enzyme immunoassay (EIA) or chemiluminescence (CLIA). However, there are no studies comparing whether there is a correlation between the two diagnostic methods in paediatric rheumatologic diseases.

Objectives

(i) To assess whether there are differences between serum calprotectin (SC) levels determined by EIA (Bühlmann) method and CLIA (QUANTA Flash) in pediatric age patients with systemic autoimmune rheumatic disease (SARD). (ii) To evaluate which clinical and analytical variables are associated with an increase of SC in each method.

Methods

Analytical cross-sectional study that included patients from a pediatric rheumatology specialized unit between 02/2017 and 05/2021. We included 41 patients with SARD who had at least one SC analysis determined by EIA in their routine controls (144 serum) and afterwards had SC determined again, this time using the CLIA method.

The collected variables were sex, age, remission according to clinical judgment, swollen joint count according to physical examination (PE Count) and ultrasound (US Count), Juvenile Arthritis Disease Activity Score according to physical examination (PE JADAS-27) and ultrasound (US JADAS-27), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).

As for the statistical analysis, intraclass correlation (ICC) and paired samples t-test were performed to compare the two methods. Univariate linear regression was performed to study the association between EIA, CLIA and both clinical and analytical variables.

Results

We included 41 patients, 50.1% were women with a mean age (± SD) of 13.1 (± 3.8) years. The details of their descriptive characteristics were: mean SC (EIA) of 3.1 (±1.8) µg/ml, mean SC (CLIA) of 2.5 (±1.6) µg/ml, mean CRP of 2.6 (± 6.5) mg/l, mean ESR of 10.1 (± 11) mm/h, and mean PE JADAS-27 of 2.8 (± 8). Most frequent diagnosis was oligoarticular juvenile idiopathic arthritis (JIA) (24.4%), followed by enthesitis-related (ERA) JIA (12.2%) and polyarticular JIA (12.2%), familial Mediterranean fever (FMF) (9.8%), psoriatic JIA (4.9%), systemic JIA (4.9%) and syndrome of periodic fever, aphtous stomatitis, pharyngitis, and cervical adenitis (PFAPA) (4.9%), vasculitis (4.8%), and undifferentiated JIA (2.4%). Clinical diagnosis was unspecific in 9.8% of the patients. In our sample, 66.7% were in clinical remission at the discretion of the specialist.

A statistically significant Pearson’s CCI of 0.77 (95%CI 0.70-0.83; p=0.00) was observed as a single measure between EIA and CLIA and with an average of 0.87 (95%CI=0.82-0.91; p=0.000). Figure 1 shows the dispersion of this correlation.

On the other hand, we observed a statistically significant difference in the mean between both methods of 0.58 (95%CI=0.40-0.77; p=0.000), observing a greater difference in SC (EIA) > 4 µg/ml.

A significant association was observed between EIA and clinical remission, joint count, JADAS and CRP; and also between CLIA and clinical remission, JADAS and CRP. The analysis performed is shown in Table 1.

Table 1.

Association between EIA and CLIA with clinical and analytical variables.

RemissionPE CountUS CountPE JADASUS JADASbpbpbpbpbpSC(EIA)0.430.0110.140.0270.080.0240.090.0000.060.000SC(CLIA)0.530.000-0.000.9450.310.3200.050.0210.040.015SexGenderESRCRPbpbpbpbpSC(EIA)0.000.9970.050.2070.000.4870.050.027SC(CLIA)-0.240.3620.010.7950.020.1050.080.000

b, regression coefficient; p, statistical significance.

Conclusion

There is a good correlation between EIA and CLIA methods to determine SC in pediatric patients with SARD. Significant differences were observed between both methods above the value of 4 µg/ml. This fact could be explained by methodological differences, since CLIA discriminates better at higher values than EIA.

An association was observed between both methods and variables of remission or disease activity.

Disclosure of Interests

None declared

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

Background

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

Objectives

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

Methods

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

Results

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

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

Table 1.

Change in MRI OMERACT-RAMRIS from baseline to week 52

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

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

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

Conclusion

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

References

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

Disclosure of Interests

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

Impact of the COVID-19 pandemic on rheumatology nursing consultation

OBJECTIVE

The COVID-19 pandemic has brought major changes to the model of patient care in Rheumatology. Our aim was to compare the change in the care delivered in a rheumatology nursing consultation before and during the pandemic.

MATERIAL AND METHODS

Descriptive and observational study. Patient care was registered before and during the COVID-19 outbreak. The variables collected were age, sex, prevalent rheumatic disease, type of visit and reason for consultation.

RESULTS

254 consecutive patients were included before the COVID-19 pandemic for 20 days and 251 patients during COVID-19 for 10 working days. The mean age was 61 years before and 57 during the pandemic. Of both groups, 74% were women. The most frequently attended pathologies before and during COVID-19 were rheumatoid arthritis and spondyloarthropathies. Scheduled face-to-face visits decreased during COVID-19 (46.5% versus 1.6%), with an increased number of phone scheduled visits (2.8% versus 52.2%) and spontaneous consultations either by phone or e-mail (28.3% versus 45%). The type of scheduled visits during COVID-19 were for stable diseases (20% versus 37%) and monitoring (12% versus 38%). The reason for spontaneous consultation increased during COVID-19 and were mainly doubts regarding prevention measures and treatment optimization (13.8% versus 31.1%).

CONCLUSIONS

The first wave of COVID-19 brought to rheumatology nursing consultation a global increase in all activities in the number of visits per day, in the number of stable patient controls, in monitoring and answering patient concerns.

Not all COVID-19 pandemic waves are alike

OBJECTIVE

We aimed to assess differences in patients' profiles in the first two surges of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic in Barcelona, Spain.

METHODS

We prospectively collected data from all adult patients with SARS-CoV-2 infection diagnosed at the Hospital de la Santa Creu i Sant Pau, Barcelona, Spain. All the patients were diagnosed through nasopharyngeal swab PCR. The first surge spanned from 1st March to 13th August 2020, while surge two spanned from 14th August to 8th December 2020.

RESULTS

There were 2479 and 852 patients with microbiologically proven SARS-CoV-2 infection in surges one and two, respectively. Patients from surge two were significantly younger (median age 52 (IQR 35) versus 59 (40) years, respectively, p < 0.001), had fewer comorbidities (379/852, 44.5% versus 1237/2479, 49.9%, p 0.007), and there was a shorter interval between onset of symptoms and diagnosis (median 3 (5) versus 4 (5) days, p < 0.001). All-cause in-hospital mortality significantly decreased for both the whole population (24/852, 2.8% versus 218/2479, 8.8%, p < 0.001) and hospitalized patients (20/302, 6.6% versus 206/1570, 13.1%, p 0.012). At adjusted logistic regression analysis, predictors of in-hospital mortality were older age (per year, adjusted odds ratio (aOR) 1.079, 95%CI 1.063-1.094), male sex (aOR 1.476, 95%CI 1.079-2.018), having comorbidities (aOR 1.414, 95%CI 0.934-2.141), ICU admission (aOR 3.812, 95%CI 1.875-7.751), mechanical ventilation (aOR 2.076, 95%CI 0.968-4.454), and coronavirus disease 2019 (COVID-19) during surge one (with respect to surge two) (aOR 2.176, 95%CI 1.286-3.680).

CONCLUSIONS

First-wave SARS-CoV-2-infected patients had a more than two-fold higher in-hospital mortality than second-wave patients. The causes are likely multifactorial.

AB0804 ONE YEAR FOLLOW-UP SAFETY AND EFFICACY RESULTS OF VACCINATION PROTOCOL FROM A RHEUMATOLOGY CLINIC

Background:

Patients with autoimmune inflammatory rheumatic diseases (AIIRD) have a higher burden of infectious diseases compared to the general population. This could be explained by the disturbances in their immune system response, comorbidities and immunosuppressive treatment.Vaccination is the most effective measure to prevent infections.

Objectives:

To describe a cohort of patients with AIIRD referred to the infectious disease´s unit according to the vaccination protocol.

Methods:

Restrospective and descriptive study of a cohort of 286 patients with AIIRD who were evaluated in the rheumatology service of a tertiary hospital in Barcelona and referred to the infectious disease´s unit according to the vaccination protocol among 1 year,between January 1rst December 31st, 2019. The vaccination protocol included serologies of human immunodeficiency virus,hepatitis A,B and C, varicella zoster,tuberculosis,measles,mumps and rubella virus.The recommended vaccines were H.influenzae b,S.pneumonia,influenza,hepatitis A and B(immunity absence),meningococcus c,tetanus – diphtheria (low antigenic load),poliomyelitis and human papillomavirus (not vaccinated).The patients included were diagnosed with a rheumatologic condition under immunosuppressive therapy. Demographic variables,diagnosis,treatment,vaccines administered,infections and adverse effects were collected.

Results:

Of 286 patients reviewed the mean age was 61, 4 (±14.4) years. The characteristics of the cohort are shown in Table 1. Most of the patients used csDMARDs 149 (52.1%), 77(26.9%) patients used combined treatment. Measles and rubella are part of the triple virus vaccines included in the systematic Spanish vaccination schedule, in our cohort 20 (7%) patients had negative serologies for measles and 26 (9%) for rubella. 57 (20%) patients had latent TB with positive Quantiferon.Forty-one (14.3%) were vaccinated before receiving immunosuppressive treatment. The less administered vaccine was influenza with 44.9% (vaccination rate in Spain in healthy population, in 2019-2020 was 51.2%).No serious adverse effects were reported in relation to the vaccination. The infectious complications during the follow-up period were bronchopneumonia in a patient with RA treated with certolizumab (1), herpes zoster infection in RA on adalimumab(1), recurrent otitis in RA on adalimumab(1), mycobacterium avium infection in RA on etanercept(1), TB reactivation in RA with GCs and csDMARDs(1) and Papilloma virus infection in SpA on ustekinumab (1).

Table 1.

CHARACTERISTICS OF COHORT OF PATIENTS

Sex n % (women/men)193/93 (67,5/32,5)Age, years ± DE61.4 ± 14.4Diagnoses AIIRD, n (%)Rheumatoid arthritis n (%)164 (57.3)Systemic lupus erythematosus n (%)6 (2.1)Sjögren´s syndrome n (%)9 (3.1)Systemic sclerosis n (%)1 (0.35)Inflammatory myopathie n (%)5 (1.7)Vasculitis n (%)36 (12.6)Polymyalgia rheumatica n (%)4 (1.4)Spondyloarthropathy n (%)46 (16.1)Others n (%)15 (5.2)Treatment AIIRDGCs n (%)116 (40.7)csDMARDs n (%)149 (52.1)bDMARDs n (%)80 (27.8)tsDMARDs n (%)7 (2.4)Others1 n (%)12 (4.2)GCs + csDMARDs n (%)59 (21)GCs + bDMARDs n (%)14 (4.9)GCs + csDMARDs + bDMARDs n (%)4 (1.4)VaccinesPCV 13 n (%)283 (99)PPSV23 n (%)265 (93)HiB n (%)265 (93)NM n (%)247 (86.7)Influenza n (%)128 (44.9)HBV n (%)121 (42.3)Vaccination before IS n (%)41 (14.3)Vaccination with IS n (%)244 (85.3)

Other: Behcet,Adult Stills,Relapsing polychondritis,IGg4 related disease,Sarcoidosis

Others1: Mycophenolic acid,cyclosporine and tacrolimus

Conclusion:

In our cohort, the vaccination protocol proved to be a good tool to improve the vaccination rate of rheumatological patients, despite this, the vaccination of Hepatitis B and specially of influenza, continues to have a lower prevalence to general population.The vaccines were effective since none of the preventable infections occurred during follow up, despite the use of an immunosuppressant. Vaccination showed a good safety profile, without reported serious adverse effects or worsening of the underlying disease.

Disclosure of Interests:

None declared

POS0132 IS THE INTERCRITICAL GOUT REALLY ASYMPTOMATIC? THE INFLAMMATORY ROLE OF THE SILENT URATE CRYSTAL DEPOSITION

Background:

Gout is the most prevalent inflammatory arthritis. Gout is chronic inflammatory deposition disease related to an increase of cardiovascular (CV) events and mortality. Subclinical chronic inflammation has been demonstrated in this patients but not its relation with the monosodium urate (MSU) crystal deposit size and the number of CV risk factors.

Objectives:

To study the subclinical inflammation in intercritical gout patients and its possible relation to the estimated size of the crystal deposition and the number of CV risk factors.

Methods:

To analyze subclinical inflammation we performed a secretome analysis and a cytokine and adiponektine plasma levels quantification (IL-1β, IL-18, IL-6, sIL-6R, TNFα, CXCL-5, RANTES, leptin, resistin and adiponectin) in a cohort of gout patients. As nowadays it is not feasible to determinate the whole body deposit of MSU crystals we created three different MSU crystal deposit size patient groups using an indirect clinical and analytical classification to estimate it. Then we compared cytokine levels between healthy donors and gout patients. We also compared cytokine levels between the different crystal size deposition groups and studied its association to the number of CV risk factors.

Results:

Ninety consecutive patients attending a Crystal Arthritis Unit were studied. Mean age was 68.27 (28-101) years. 81.1% were male. Clinical gout evolution was of 10.1±9.8 years. 77.5% were on urate lowering treatment. 24% had tophaceous gout. Mean uric acid was 6.3±2.1 mg/dl with 47.1% of them being on target. Hypertension was present in 68.9%, diabetes mellitus in 18.9%, dislipemia in 48.9%, BMI>30 in 32.9%, abdominal obesity in 50% and 16.1% suffered from ischemic heart disease. From the 102 molecules studied in the secretome analysis in 56 there was at least a 20% difference between donors group and any of the deposition groups. In 74% of them gout patients secreted lower levels. IL-18, sIL-6R, RANTES, leptin and adiponectin were higher in patients than in healthy donors. IL-18, sIL6-R, RANTES and CXCL5 levels were associated to the size of the crystal deposits. IL-18, sIL-6R, RANTES and leptin were higher in gout groups with CV risk factors. IL-18, sIL6-R, RANTES and leptin were higher in gout patients with no risk factors when compared to healthy donors with no risk factors. We found no differences when comparing urate lowering treated and non-treated patients.

Conclusion:

Our results demonstrate that some proinflammatory cytokines and metabolic proteins are raised in intercritical gout patients. Some of them are different from the flare/inflammasome expected ones. In some cytokines this elevation is related to the size of the monosodium urate crystal deposit and/or to the number of cardiovascular risk factors. This cytokine changes could help to explain the increase of the cardiovascular events in gout patients.

Disclosure of Interests:

Cesar Diaz-Torne Grant/research support from: Received a grant from Grünenthal, Maria Angels Ortiz: None declared, Sicylle Jeria Navarro: None declared, Andrea Garcia-Gullien: None declared, Lluis Sainz: None declared, Hector Corominas: None declared, Silvia Vidal: None declared

AB0129 IL-6R GENETIC VARIANTS AS PREDICTORS OF CLINICAL RESPONSE TO TOCILIZUMAB IN RHEUMATOID ARTHRITIS PATIENTS

Background:

Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory autoimmune disease of unknown etiology. Tocilizumab (TCZ) is a first-line biological disease-modifying anti-rheumatic drug (bDMARD) which inhibits Interleukin 6 (IL-6) pathway through blockade of its receptor. At present, there is a lack of evidence to recommend the treatment of one bDMARD over another.(1) Seeking for genetic biomarkers to predict response to treatment could be key towards a personalized treatment strategy in rheumatology.(2)

Objectives:

We aimed to evaluate whether functional single nucleotide polymorphisms (SNPs) in the IL6R gene could predict response and/or toxicity to TZC in Caucasian patients diagnosed with RA.

Methods:

Retrospective analytical preliminar study of a cohort of 31 patients diagnosed with RA (ACR/EULAR 2010 criteria) who received treatment with TCZ within the last 10 years. Epidemiological, clinical and laboratory data were collected. DNA was extracted from EDTA blood samples. Three SNPs in the IL-6 receptor gene (rs12083537, rs2228145, rs4329505) were genotyped by real-time PCR with TaqMan probes. The associations between polymorphisms and clinicopathological features were evaluated using parametric tests. Efficacy was assessed as the difference of DAS-28 CRP at 6 months. The toxicities recorded were hepatotoxicity, infections, hypersensibility, gastrointestinal, hematological and dyslipidemia.

Results:

The 31 DNA samples from patients included were mainly female (83.9%) and had a mean age at diagnosis of 46.8 years. The mean duration of treatment was 51.3 months and, previously to initiate TCZ, they received a mean of 2,6 csDMARD and 1,7 bDMARD.

The more frequent adverse effects were hypertransaminasemia (22.6%) and neutropenia (32.3%). Most relevant epidemiologic and clinical data is shown in Table 1.

Table 1.

Clinical characteristics. RA=Rheumatoid Arthritis. CCP= anti-Cyclic Citrullinated Peptides. RF=Rheumatoid factor. csDMARDs= conventional synthetic Disease-modifying antirheumatic drug. bDMARD= biological Disease-modifying antirheumatic drug. BMI=Body Mass Index. Sc=subcutaneous. Ev=endovenous. DAS28= Disease Activity Score in 28 joints

Sex (n=31), n (% women/men) 26/5 (83,9%/16,1%)Age at diagnosis (n=31), years +- SD 46,8+- 12,8Erosive RA (n=31), n(%) 14 (45,2%)Anti-CCP positive (n=31), n(%)UI+- SD 23 (74,2%)259,7 +- 137,3RF positive (n=31), n (%)UI+-SD 21 (67,7%)189,4+- 114Previous csDMARD (n=31), n°+-SD2,6 +-1,3Previous bDMARD (n=31), n°+- SD1,7 +- 1,4BMI (n=29), mean +- SD29,3+- 5,1Duration of treatment (n=31), months +-SD51,3 +- 36,3-Active treatment (n=12)-80,9+- 18,3-Finished treatment (n=19)-32,6+- 32,2Route of administration (n=31), n (%) sc/ev 11/20 (35,5/64,5)Basal DAS28 (n=30), mean+- SD5,3 +- 1,1DAS28 reduction at 6 months (n=28), mean+-SD2,9 +-1,1

The univariate analyses showed that the rs2228145 variant was statistically associated with differences in DAS28 reduction at 6 months (p=0.042). Regarding efficacy, we also found a trend with the SNP rs4329505 (p=0.173), which could achieve statistical significance with the projected inclusion of more patients. No associations were found regarding adverse effects.

Conclusion:

The rs2228145 polymorphisms in the IL6R gene may be considered as a pharmacogenetic biomarker of TCZ response in RA patients. More studies are required in order to investigate the clinical use of pharmacogenetic biomarkers in rheumatic diseases.

References:

[1]Smolen, Josef S., Robert B., et al. 2020. “EULAR Recommendations for the Management of Rheumatoid Arthritis with Synthetic and Biological Disease-Modifying Antirheumatic Drugs: 2019 Update.” Annals of the Rheumatic Diseases 79 (6): 685–99.

[2]Tarnowski, Maciej, Agnieszka Paradowska-Gorycka, et al. 2016. “The Effect of Gene Polymorphisms on Patient Responses to Rheumatoid Arthritis Therapy.” Expert Opinion on Drug Metabolism & Toxicology 12 (1): 41–55.

Disclosure of Interests:

None declared

POS0827 HEPATOTROPIC VIRUSES WITH HIGHER RHEUMATOID FACTOR, BUT NOT RHEUMATIC DISEASES LINK TO PREVALENT CRYOGLOBULINEMIA. CORRELATION OF CLINICAL AND SEROLOGICAL MARKERS WITH ETIOLOGICAL CAUSES

Background:

Cryoglobulinemia (CG) is a rare phenomenon, which is defined as the persistent presence in serum of abnormal immunoglobulins (Igs) that precipitate in vitro at less than 37°C and dissolve when the temperature rises again. Is related to hematological disorders, infections and autoimmunes diseases.

Objectives:

To describe the differential clinical features, serological and demographics in a cohort of patients diagnosed with CG.

Methods:

We describe a retrospective cohort of 252 cryoglobulin (Cg) positive samples, obtained from a database from the immunology laboratory of a tertiary hospital (November 2018-November 2019). We obtained 182 patients with CG, classified according to their etiology into 4 groups: 1)Rheumatic diseases (RD) that includes rheumatoid arthritis, Systemic lupus erythematosus, Sjögren´s syndrome and Systemic scleroderma, 2)Hepatotropic viruses (HV) with patients diagnosed with Hepatitis C virus, B virus and both, 3)Hematological diseases (HD) and 4)Essential cryoglobulinemia (CGE). Demographic variables, clinical and serological data were collected. A comparative analysis was performed with the Mann-Whitney U test and the multivariate Kruskal-Wallis test, nonparametric variables were compared using a Wilcoxon test. Ten patients, with more than one disease from 4 groups, were excluded from the study.

Results:

Out of 182 reviewed patients, 172 were included in the study. Mean age at diagnosis was 59.7(±14.0). Demographic, clinical and laboratory characteristics are described in table 1. Mixed CG was the predominant subtype, in 116 (67.4%) patients. The most prevalent CG-associated diseases were HV infection with 91(53%) patients. CGE mostly presented with cutaneous manifestations (p=0.0001), particularly purpura. In RD group the presence of Raynaud and non-erosive arthritis (p=0.0001) was relevant. Laboratory findings showed that CG titration varies according to the etiology, being HD the one with the highest values with 292.2 (±546.2). There is significant difference in terms of the average of rheumatoid factor (RF) being higher in the group by CGE. On other hand, the group HV presented more consumption of complement, and showed the lowest average p=0.0001, without more severe clinical manifestations.

RD (n=47)HV (n=91)HD (n=17)CGE (n=17)Gender,n(%) F42 (89.4)57 (62.6)7 (41.2)11 (64.7)Age at dg, years, (± SD)60.6 (±14)59.6 (±13.1)61.1(±16.6)56.3(±20.8)p=0.8CLINICAL CHARACTERISTICSSkin n (%)18 (38.3)10 (11.0)2 (11.8)9 (52.9)p<0.001Raynaud n (%)14 (29.8)1 (5.9)3 (17.6)p<0.001Purpura n (%)6 (12.8)9 (9.9)2 (11.8)6 (35.3)p=0.04Acrocyanosis n (%)6 (12.8)1 (5.9)p=0.0033Ulcers n (%)3 (6.4)2 (2.2) -2 (11.8)p=0.19Peripheric Neuro n (%)10 (21.3)9 (9.9)1 (5.9)4 (23.5)p=0.13N-E arthritis n (%)22 (46.8)8 (8.8)1 (5.9)4 (23.5)p<0.001GMN n (%)5 (10.6)3 (3.3)1 (5.9)3 (17.6)p=0.11LABORATORYCg (mg/dL) x (± SD)26.7 (±63.2)65.8 (±256.5)292.4 (±546.2)47.59 (±79.1)p<0.001Isotype IgG, n (%)G+M 26 (55.3)G+M 72 (79.1)M 8 (47.1)G+M 12 (70.6)β2M (≥1.8 mg/L), n (%)7/40 (17.5%)1/5 (20.0%)3/12 (25.0%)-p= 0.44RCP (mg/L) p 5010.3 (±26.2)3.9 (±3.0)13.4 (±18.3)8.5 (±12.0)p= 0.47ESR (mm/h) p5040.0 (±28.5)20.3 (±20.2)35.4 (±35.1)24.5 (±25.0)p= 0.0003RF + (>20UI/mL), n (%)19/46 (41.3)44/86 (51.2)5/11 (45.5)7/17 (41.2)p= 0.09p5090.6 (±175.9)161.0 (±219.5)94.8 (±135.6)284.5 (±619.3)p<0.001C3 (<85mg/dL), n %)20 (42.6)47 (51.6)3 (17.6)3 (17.6)p= 0.13x (± SD)90.1 (±28.6)68.5 (±10.8)99.1 (±29.0)114.8 (±12.7)p<0.001C4 (<12mg/dL), n (%)17 (36.2)36 (39.6) -3 (17.6)p= 0.02x (± SD)15.6 (±9.0)7.6 (±3.5)20.4 (±7.4)21.1 (±9.5)p<0.001

Conclusion:

In our cohort, not all patients with CG presented clinical manifestations being those associated with CGE and RD those with the highest skin and joint expression. The most prevalent association of CG continues to be the HV and we confirmed the characteristic decrease in C3 and C4 complement levels, together with the positivity for RF.

Disclosure of Interests:

None declared

POS0806 FINDINGS CONSISTENT WITH SUBCLINICAL VASCULITIS IN PATIENTS WITH NEW ONSET POLYMYALGIA: A SYSTEMATIC LITERATURE REVIEW AND A META-ANALYSIS OF COHORT DATA

Background:

GCA is characterized by cranial symptoms but imaging techniques show that patients with non-specific symptoms such as systemic inflammation or PMR may have undiagnosed large vessel (LV) GCA1. Although silent GCA in patients with clinically isolated PMR may have consequences for patients’ outcome, little is known about its prevalence and characteristics of affected patients.

Objectives:

To review data on the prevalence of silent GCA in newly diagnosed PMR patients without cranial GCA symptoms and to analyze which characteristics are associated with vascular involvement among PMR patients.

Methods:

We systematically screened PubMed, Embase and Web of Science databases and included studies screening for GCA in steroid naïve PMR patients without cranial symptoms consistent with GCA. Authors of the publications that used PET for vasculitis screening were invited to share their individual patient data (IPD) for a meta-analysis. We sought to define patient characteristics that were associated with vasculitis using univariable mixed effects logistic regression models with vascular involvement as the outcome, missing values were imputed using multilevel joint modeling multiple imputation. To fit a multivariable model with the candidate predictors we excluded variables that were hypothesized to have less medical relevance for the outcome and highly correlated inflammation markers (ESR, Lc).

Results:

Out of the 3047 studies screened independently by 2 authors (DG and TD), 13 fulfilled the inclusion criteria. These studies (published 1963-2019) reported on 543 PMR patients examined by temporal artery biopsy (n=175), ultrasound (n=110), PET or PET-CT (n=258). 115 PMR patients were diagnosed with GCA (21.2%), with prevalence ranging from 0-92%.

We collected IPD for 243 patients from 4 cohorts using PET and 3 using PET/CT for GCA diagnosis. The overall median age of patients was 72.3 years (IQR 66.4-78.0) and vasculitis was found in 65 patients (26.7%) (table 1).

Table 1.OverallPMRPMR+GCAn (%)243178 (73.3)65 (26.7)Female sex (%)146 (60.1)98 (55.1)48 (73.8)Shoulder girdle pain (%)236 (97.1)174 (97.8)62 (95.4)Pelvic girdle pain (%)174 (71.6)127 (71.3)47 (72.3)Inflammatory back pain (%)No107 (44.0)83 (46.6)24 (36.9)Yes106 (43.6)70 (39.3)36 (55.4)Lower limb pain (%)No87 (35.8)61 (34.3)26 (40.0)Yes81 (33.3)68 (38.2)13 (20.0)Weight loss (%)112 (46.1)78 (43.8)34 (52.3)CRP (mg/l) (median [IQR])46.0 [19.0, 77.7]44.0 [16.9, 74.2]52.0 [27.9, 85.0]ESR (mm/h) (mean (SD))65.2 (30.3)62.7 (30.2)72.3 (29.7)Hemoglobin (g/dl) (mean (SD))12.1 (1.5)12.2 (1.5)11.7 (1.6)Thrombocytes (1e+09/ml) (mean (SD))341.9 (106.3)323.9 (103.2)375.8 (104.6)

In the univariable analyses the following factors were most strongly associated with vasculitic PET findings: female sex (OR 2.31, CI 1.17-4.58), inflammatory back pain (OR 2.73, CI 1.32-5.64), temperature >37° (OR 1.83, CI 0.90-3.7), weight loss (OR 1.83, CI 0.96-3.51), thrombocytosis (i.e., patients with a thrombocyte count 1 SD above mean have an OR of 1.51, CI 1.05-2.18), anemia (i.e., 1 g/dl decrease in Hb below mean corresponds to an OR of 1.25, CI 1.00-1.56). Patients with lower limb pain were less likely to have vasculitis (OR 0.43, CI 0.19–0.95). The estimated ORs were very similar in the multivariable model although the 95%CIs became wider.

Conclusion:

Although the prevalence across published studies showed substantial variation, 6 out of 13 studies reported a prevalence of silent GCA in 18-40% of all PMR patients. The exploratory analysis of the collected IPD identified female sex, inflammatory back pain, fever, weight loss, absence of lower leg pain, thrombocytosis and anemia as factors associated with LV-GCA. These findings should be validated in future prospective cohort studies. The presence or absence of these factors may further aid in diagnosing LV-GCA in PMR patients.

References:

[1]Buttgereit F, Dejaco C, Matteson EL, Dasgupta B. Polymyalgia Rheumatica and Giant Cell Arteritis: A Systematic Review. JAMA. 2016 Jun 14;315(22):2442–58.

Acknowledgements:

The study is funded by the “Schweizerische Stiftung für die Erforschung der Muskelkrankheiten (SSEM)”.

Disclosure of Interests:

Daniele Silvio Gozzoli: None declared, Andrea Hemmig: None declared, Lars Hemkens: None declared, Laura Werlen: None declared, Hannah Ewald: None declared, Christoph Berger: None declared, Diego Kyburz Grant/research support from: DK reports personal fees from Abbvie, Gilead, Lilly, Novartis and Pfizer, outside of the submitted work, Stephan Imfeld: None declared, Markus Aschwanden: None declared, Mihaela Stegert: None declared, Dario Camellino: None declared, Marco Amedeo Cimmino: None declared, Corrado Campochiaro Grant/research support from: personal fees from Roche, Alessandro Tomelleri: None declared, Liesbet Henckaerts: None declared, Daniel Blockmans Speakers bureau: Paid speaker for Roche, Consultant of: Paid consultant for Roche, Patricia Moya: None declared, Hector Corominas: None declared, Russell Buchanan: None declared, Claire Owen Speakers bureau: CO has received speaking honoraria from Roche, Janssen, Novartis and Pfizer, and meeting sponsorship from Roche, UCB and Janssen, Yannick van Sleen: None declared, Elisabeth Brouwer Speakers bureau: E. Brouwer as an employee of the UMCG received speaker fees and consulting fees from Roche in 2017, 2018 which were paid to the UMCG, Consultant of: E. Brouwer as an employee of the UMCG received speaker fees and consulting fees from Roche in 2017, 2018 which were paid to the UMCG, Hiroyuki Ymashita: None declared, Thomas Daikeler: None declared

AB0384 IMPACT OF TEMPORAL ARTERY ULTRASOUND ON SURVIVAL OF PATIENTS WITH GIANT CELL ARTERITIS

Background:

Giant cell arteritis (GCA) is the most common primary systemic vasculitis in adults over 50 years of age. Its incidence increases with age, with a peak between 70-80 years and predominates in women, 3:1. It is a medical emergency that, if not diagnosed, can lead to irreversible complications. The delay in time from diagnosis to start of treatment is crucial to avoid possible serious outcomes on short, medium and long term. Survival in GCA is estimated between 60-90% at 5 years and 48-81% at 10 years. Efforts have been made to implement rapid diagnostic circuits to assess patients and initiate treatment without delay with good results both in reducing permanent vision loss and in reducing the costs of these patients due to emergency visits and admissions. The morbidity and mortality of this disease is high, but the use of efficient diagnostic strategies, such as ultrasound of superficial temporal arteries, has proven to be a useful, practical, cost-effective and, above all, quick tool to make the diagnostic approach.

Objectives:

Analyze the impact of early temporal artery ultrasound on survival for patients with GCA.

Methods:

Survival study of 48 patients with GCA, in two different “stages” in terms of diagnostic approach: Group A (n = 27), patients diagnosed between 2002 - 2011 using only ACR 1990 criteria and Group E (n = 21) diagnosed between 2010-2015 using ACR criteria and TAUS. TAUS was performed by Rheumatologists with extensive experience in ultrasound and within a period of no more than 7 days for these patients. The definitive diagnosis of GCA was based on the clinical criteria of the Rheumatologist within the clinical and analytical context and with the specific complementary examinations for each case (Ultrasound, PET-CT, biopsy). Demographic data, comorbidities, signs and symptoms at debut, analytical data, complementary examinations, treatment and evolution were obtained retrospectively through the electronic medical record of the patient, based on the database of our GCA cohort. A survival analysis was performed considering death as the main outcome. The statistic used was the Kaplan-Meier test. In addition, other complications related to treatment or pathology are collected.

Results:

The mean age at diagnosis of our patients was 79 + - 6 years, with a female: male ratio of 3: 1. The follow-up was between 2 and 16 years with a mean of 5.8 + - 3 years, until the last visit collected or until the outcome of death. Group A had a survival at 5 and 10 years of 53.4% and 36.7% respectively, while group E of 79.5% at both cut-off points. (Figure 1).

There is a significant difference between the survival of both groups, p <0.01, this being better in the group in which TAUS was implemented for rapid diagnosis (group E). The main causes of death were cardiovascular events, 30%, predominantly in group E (75%), and infection, 30%, predominantly in group A. The median from diagnosis to death was 3 years (range 1 - 13).

Figure 1.

Group A (red line) according to ACG 1990 criteria and Group B (green line) according to ACG criteria and implementing TAUS for rapid diagnosis

Conclusion:

The implementation of temporal artery ultrasound (TAUS) is associated with a significant improvement in the survival rate of patients with GCA and a reduction in treatment-related complications in patients who were diagnosed with ultrasound in less than 7 days compared to those diagnosed by the conventional healthcare attention routes.

References:

[1]Gonzalez-Gay MA, et al. Giant cell arteritis: epidemiology, diagnosis, and management. DOI: 10.1007/s11926-010-0135-9

[2]Patil P, et al. Fast track pathway reduces sight loss in giant cell arteritis: results of a longitudinal observational cohort study. PMID: 26016758

[3]Breuer GS, et al. Survival of patients with giant cell arteritis: a controversial issue. PMID: 31969222

[4]Diamantopoulos AP, et al. The fast-track ultrasound clinic for early diagnosis of giant cell arteritis significantly reduces permanent visual impairment: towards a more effective strategy to improve clinical outcome in giant cell arteritis? 10.1093/rheumatology/kev289

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

References:

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

Disclosure of Interests:

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

AB0666 PROGNOSTIC VALUE OF SERUM KREBS VON DEN LUNGEN-6 GLYCOPROTEIN CIRCULATING LEVELS IN COVID-19 PNEUMONIA: A PROSPECTIVE COHORT STUDY

Background:

Currently, there are no biomarkers to predict respiratory worsening in patients with Coronavirus infectious disease, 2019 (COVID- 19) pneumonia.

Objectives:

We aimed to determine the prognostic value of Krebs von de Lungen-6 circulating serum levels (sKL-6) predicting COVID- 19 evolving trends.

Methods:

We prospectively analyzed the clinical and laboratory characteristics of 375 COVID- 19 patients with mild lung disease on admission. sKL-6 was obtained in all patients at baseline and compared among patients with respiratory worsening.

Results:

45.1% of patients developed respiratory worsening during hospitalization. Baseline sKL-6 levels were higher in patients who had respiratory worsening (median [IQR] 303 [209-449] vs. 285.5 [15.8-5724], P=0.068). The best sKL-6 cut-off point was 408 U/mL (area under the curve 0.55; 33% sensitivity, 79% specificity). Independent predictors of respiratory worsening were sKL-6 serum levels, age >51 years, time hospitalized, and dyspnea on admission. Patients with baseline sKL-6 ≥ 408 U/mL had a 39% higher risk of developing respiratory aggravation seven days after admission. In patients with serial determinations, sKL-6 was also higher in those who subsequently worsened (median [IQR] 330 [219-460] vs 290.5 [193-396]; p<0.02).

Conclusion:

sKL-6 has a low sensibility to predict respiratory worsening in patients with mild COVID-19 pneumonia. Baseline sKL-6 ≥ 408 U/mL is associated to a higher risk of respiratory worsening. sKL-6 levels are not useful as a screening tool to stratify patients on admission but further research is needed to investigate if serial determinations of sKL-6 may be of prognostic use.

References:

[1]Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-62. 5.

[2]Tian W, Jiang W, Yao J, Nicholson CJ, Li RH, Sigurslid HH, et al. Predictors of mortality in hospitalized COVID-19 patients: A systematic review and meta-analysis. J Med Virol. 2020.

[3]Wang D, Li R, Wang J, Jiang Q, Gao C, Yang J, et al. Correlation analysis between disease severity and clinical and biochemical characteristics of 143 cases of COVID-19 in Wuhan, China: a descriptive study. BMC Infect Dis. 2020;20(1):519.

Disclosure of Interests:

None declared.

Phenotypic and Functional Consequences of PLT Binding to Monocytes and Its Association with Clinical Features in SLE

Platelets (PLTs) can modulate the immune system through the release of soluble mediators or through interaction with immune cells. Monocytes are the main immune cells that bind with PLTs, and this interaction is increased in several inflammatory and autoimmune conditions, including systemic lupus erythematosus (SLE). Our aim was to characterize the phenotypic and functional consequences of PLT binding to monocytes in healthy donors (HD) and in SLE and to relate it to the pathogenesis of SLE. We analyzed the phenotypic and functional features of monocytes with non-activated and activated bound PLTs by flow cytometry. We observed that monocytes with bound PLTs and especially those with activated PLTs have an up-regulated HLA-DR, CD86, CD54, CD16 and CD64 expression. Monocytes with bound PLTs also have an increased capacity for phagocytosis, though not for efferocytosis. In addition, monocytes with bound PLTs have increased IL-10, but not TNF-α, secretion. The altered phenotypic and functional features are comparable in SLE and HD monocytes and in bound PLTs. However, the percentages of monocytes with bound PLTs are significantly higher in SLE patients and are associated with undetectable levels of anti-dsDNA antibodies and hematuria, and with normal C3 and albumin/creatinine levels. Our results suggest that PLTs have a modulatory influence on monocytes and that this effect may be highlighted by an increased binding of PLTs to monocytes in autoimmune conditions.

Non-invasive vagus nerve stimulation for rheumatoid arthritis: a proof-of-concept study

BACKGROUND

Vagus nerve stimulation delivered with an implanted device has been shown to improve rheumatoid arthritis severity. We aimed to investigate the safety and efficacy of non-invasive stimulation of the auricular branch of the vagus nerve for the treatment of patients with moderately to severely active rheumatoid arthritis.

METHODS

This prospective, multicentre, open-label, single-arm proof-of-concept study enrolled patients aged 18-80 years with active rheumatoid arthritis who had an inadequate response to conventional synthetic disease-modifying antirheumatic drugs (DMARDs) and up to one biological DMARD. Biological DMARDs were stopped at least 4 weeks before enrolment and concomitant use was not allowed during the study. All eligible participants were assigned to use a non-invasive, wearable vagus nerve stimulation device for up to 30 min per day, which delivered pulses of 20 kHz. Follow-up visits occurred at week 1, week 2, week 4, week 8, and week 12 after the baseline visit. The primary endpoint was the mean change in Disease Activity Score of 28 joints with C-reactive protein (DAS28-CRP) at week 12 compared with baseline. Secondary endpoints included the mean change in the Health Assessment Questionnaire-Disability Index (HAQ-DI), the proportion of patients with a minimal clinically important difference of 0·22 on HAQ-DI, the proportion achieving American College of Rheumatology (ACR) 20, ACR50, and ACR70 response, and safety analysis. This study is registered with ClinicalTrials.gov (NCT04116866).

FINDINGS

Of 35 patients screened for eligibility, 30 (86%) were enrolled at six centres in Spain between Dec 27, 2018, and Oct 24, 2019, of whom 27 (90%) completed the week 12 visit. The mean change in DAS28-CRP at 12 weeks was -1·4 (95%CI -1·9 to -0·9; p<0·0001) from a mean baseline of 5·3 (SD 1·0). 11 (37%) of 30 patients reached DAS28-CRP of 3·2 or less, and seven (23%) patients reached DAS28-CRP of less than 2·6 at week 12. The mean HAQ-DI change was -0·5 (95%CI -0·7 to -0·2; p<0·0001) from a mean baseline of 1·6 (SD 0·7), and 17 (57%) patients reached a minimal clinically important difference of 0·22 or more. ACR20 responses were reached by 16 (53%) patients, ACR50 responses by 10 (33%) patients, and ACR70 by five (17%) patients. Four adverse events were reported, none of which were serious and all of which resolved without intervention.

INTERPRETATION

Use of the device was well tolerated, and patients had clinically meaningful reductions in DAS28-CRP. This was an uncontrolled, open-label study, and the results must be interpreted in this context. Further evaluation in larger, controlled studies is needed to confirm whether this non-invasive approach might offer an alternative treatment for rheumatoid arthritis.

FUNDING

Nēsos.

Impact of the COVID-19 Pandemic on Rheumatology Nursing Consultation

OBJECTIVE

The COVID-19 pandemic has brought major changes to the model of patient care in Rheumatology. Our aim was to compare the change in the care delivered in a rheumatology nursing consultation before and during the pandemic.

MATERIAL AND METHODS

Descriptive and observational study in 254 patients before and in 251 during the pandemic outbreak.

RESULTS

The type of scheduled face-to-face visit decreased during COVID-19 (46.5% vs. 1.6%), with the number of scheduled telephone visits increasing (2.8% vs. 52.2%) and spontaneous consultations over the phone or email (28.3% vs. 45%). The functions performed in the programmed ones were the stable patient control (20% vs. 37%) and management (12% vs. 38%). The reason for spontaneous consultation increased during COVID-19, especially doubts regarding prevention measures and treatment optimization (13.8% vs. 31.1%).

CONCLUSIONS

The first wave of COVID-19 brought to rheumatology nursing consultation a global increase in all activities in the number of visits per day, in the number of stable patient controls, in monitoring and answering patient concerns.

The four horsemen of a viral Apocalypse: The pathogenesis of SARS-CoV-2 infection (COVID-19)

The pathogenesis of coronavirus disease 2019 (COVID-19) may be envisaged as the dynamic interaction between four vicious feedback loops chained or happening at once. These are the viral loop, the hyperinflammatory loop, the non-canonical renin-angiotensin system (RAS) axis loop, and the hypercoagulation loop. Severe acute respiratory syndrome (SARS)-coronavirus (CoV)-2 lights the wick by infecting alveolar epithelial cells (AECs) and downregulating the angiotensin converting enzyme-2 (ACE2)/angiotensin (Ang-1-7)/Mas1R axis. The viral feedback loop includes evading the host's innate response, uncontrolled viral replication, and turning on a hyperactive adaptative immune response. The inflammatory loop is composed of the exuberant inflammatory response feeding back until exploding in an actual cytokine storm. Downregulation of the ACE2/Ang-(1-7)/Mas1R axis leaves the lung without a critical defense mechanism and turns the scale to the inflammatory side of the RAS. The coagulation loop is a hypercoagulable state caused by the interplay between inflammation and coagulation in an endless feedback loop. The result is a hyperinflammatory and hypercoagulable state producing acute immune-mediated lung injury and eventually, adult respiratory distress syndrome.

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

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

Figure 1Figure 2

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

Conclusion:

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

References:

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

Disclosure of Interests:

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

FRI0594 USE OF ANTI-DFS70 ANTIBODIES IN RHEUMATOLOGICAL PATIENTS WITH SUSPICION OF SYSTEMIC AUTOIMMUNE DISEASE

Background:

Positivity of dense fine speckles antibodies (anti-DFS70) has been associated with antinuclear antibodies positivity in people with no evidence of systemic autoimmune disease. They could be useful to distinguish patients with these characteristics that do not meet diagnostic and/or classifying criteria for any systemic autoimmune disease (SAD).

Objectives:

To evaluate the use of anti- DFS70 in patients with suspicion of SAD.

Methods:

A cross-sectional observational study was conducted at 2 tertiary-level hospitals. We included a cohort of patients visited in the last year by either rheumatology or other specialties, under suspicion of SAD, in which the IgG isotype anti-DFS70 was obtained by recombination with the Euroline Immunoblot of Euroimmun. Demographic, clinical and immunological variables were collected.

Results:

102 patients (78% women) were included, median age of 49 years old. The descriptive statistics are summarized in Table 1. All patients had ANA titters > 1/80. 37% were positive for anti-DFS70, with homogeneous, speckled and other patterns in 36%, 72% and 15% respectively.74% were visited by rheumatologists under the suspicion of systemic lupus erythematosus (SLE) in 27%, other SAD 25%, arthralgia 36% and fibromyalgia 12%. 13% presented high DNA titters, low C3/C4 levels in 14% and 9%. SLE’s symptoms were: arthritis 21%, arthralgia 41%, cutaneous 20% and oral ulcers 8%. Anti-DFS70(+) was related to the speckled pattern in 46% compared to other patterns (p=0,009), which had a negative association with anti-DFS70(p=0,003). Regarding the diagnoses, there was a negative association with SLE, other SAD and other rheumatologic diagnoses in 88%, 75% and 55% respectively(p=0,006). Anti-DFS70(-) was associated with oral ulcers (p=0,024), decreased C3/C4 levels (p=0,007/p=0,018), psoriatic arthritis (p=0,024) and cutaneous lupus (p=0,008), but not with drug-induced SLE (p=0,48) or lupus nephritis (p=0,067). There was no statistical significance between anti-DFS70(+) and arthralgia or fibromyalgia, but these patients don’t have a SAD diagnosis.

Table 1.RHEUMATOLOGY(n=75)OTHER SPECIALTIES(n=27)antiDFS70(+)n=25(100%)antiDFS70(-)n=50(100%)antiDFS70(+)n=13(100%)antiDFS70(-)n=14(100%)Women20(80)43(86)8(62)9(64)Age years (ED)47,1(±20,1)50,4(±15,5)45,1(±26,7)54,7(±15,6)ANAHomogeneous8(32)23(46)2(15)4(29)PatternSpeckled22(88)*30(60)12(92)9(64)IIFOther010(20)1(8)4(29)Final diagnosisArthralgia12(48)15(30)SpecialityFibromyalgia3(12)6(12)Dermatology4(31)7(49)Drug-induced SLE2(8)2(4)Gastroenterology3(23)3(21)SLE3(12)17(34)*Hematology1(8)2(14)Cutaneous lupus08(16)*Other5(38)2(14)PsA06(12)*Other6(25)16(32)SLEArthritis3(12)13(26)Arthralgia13(52)18(36)Cutaneous3(12)12(24)Oral ulcers0(0)6(12)*Leukopenia0(0)4(8)Thrombocytopenia0(0)1(2)Fever1(4)1(2)Pleuritis0(0)1(2)Pericarditis0(0)1(2)Nephritis0(0)4(8)Myositis1(4)0(0)

ANA (antinuclear antibody), IIF (indirect immunofluorescence), SLE (systemic lupus erythematosus), PsA (psoriatic arthritis), *p<0, 05.

Conclusion:

Our results suggest that patients with suspicion of SAD, especially SLE, presented a greater proportion of negative anti-DFS70 compared to other diagnoses, including SAD, along with a decrease in complement levels and the presence of oral ulcers, being useful at the initial study of these patients. More studies are needed to characterize this association.

Disclosure of Interests:

Jose Luis TANDAIPAN JAIME: None declared, Berta Magallares: None declared, Julia Bernardez: None declared, ELENA RIERA ALONSO: None declared, FRANCISCO PUJALTE: None declared, Laura Martínez-Martínez: None declared, ANDRES BAUCELLS: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, Hector Corominas: None declared, Silvia Martinez Pardo: None declared

AB0770 DESCRIBING A COHORT OF PATIENTS WITH PSORIATIC ARTHRITIS ACCORDING TO THE BODY MASS INDEX: EXPERIENCE IN A JOINT RHEUMATOLOGY-DERMATOLOGY CLINIC

Background:

Obesity is a predictor for the development of psoriatic arthritis (PsA) with a negative prognostic impact.

Objectives:

We aimed to describe and characterize patients with PsA according to the Body Mass Index (BMI) in a joint Rheumatology-Dermatology unit (PAIDER).

Methods:

We retrospectively reviewed patients diagnosed with PsA according to CASPAR criteria visited between May 2012 and May 2019 at the PAIDER clinic of our center. Data on demographic and anthropometric features, serologic findings, source of referral, cardiovascular risk factors and biological treatment were collected from clinical records. Patients were classified according to the WHO International Classification of nutritional status in normal weight (BMI 18.5-24.9 Kg/m2), overweight (BMI 25-29.9 Kg/m2) and obesity (BMI≥30 Kg/m2). A descriptive analysis was performed, and the differences between groups were evaluated using Chi2, T-Student and ANOVA tests. P-values <0.05 were accepted as significant.

Results:

During the study period 393 patients (50.6% women) with a mean age of 52.47 ± 13.21 years were evaluated. Baseline characteristics are shown in table 1.

Table 1.Baseline characteristicsTotaln=393Female, n (%)199 (50,6)Age, yrs, mean ±SD52,47 (13,21)Source of referral, n (%) Dermatology117 (29,8) Rheumatology219 (55,7) Primary Care and Others22 (5,6)Smoker, n (%)97 (25,8)High Blood Pressure (HBP), n (%)106 (27,7)Diabetes, n (%)48 (12,5)Hypercholesterolemia, n (%)98 (25,8)Hyperuricemia, n (%)32 (8,6)HLA-B27 positive, n (%)68 (21,6)BMI, Kg/m2, mean ±SD28,15 (5,87)Biological treatment, n (%)166 (43,2)

The mean BMI was 28.15 ± 5.87 kg/m2. 112 patients (32%) were overweight with a mean BMI of 27.46 ± 1.55 kg/m2and 118 patients (34%) were obese with a mean BMI of 34.42 ± 5.08 kg/m2. Of the obese patients, 80 (67.8%) had obesity grade 1, 28 (23.7%) grade 2 and 10 (8.5%) grade 3.

Characteristics of the patients according to BMI categories are shown in Table 2.

Table 2.Characteristics according to BMINormal weightn= 118Overweightn= 112Obesityn=118P valueFemale, n (%)66 (55,9)52 (46,4)62 (52,5)nsAge, yrs, mean ±SD47,92 (14,08)54,71 (11,75)54,48 (11,54)<0,001Source of referral, n (%)Ns Dermatology35 (33,7)37 (35,2)34 (30,9) Rheumatology63 (60,6)61 (58,1)70 (63,6) Primary Care and Others6 (5,8)7 (6,7)6 (5,5)Smoker, n (%)37 (33)23 (21,1)31 (26,7)nsHigh Blood Pressure (HBP), n (%)12 (10,5)37 (34,3)41 (35)<0,001Diabetes, n (%)7 (6)9 (8,3)30 (25,6)<0,001Hypercholesterolemia, n (%)19 (17)24 (22,2)45 (38,5)0,001Hyperuricemia, n (%)5 (4,4)7 (6,8)19 (16,7)0,004HLA-B27, n (%)27 (28,7)17 (17,9)13 (12,6)0,016BMI, Kg/m2, media ±DE22,58 (1,78)27,46 (1,55)34,42 (5,08)-Biological treatment, n (%)47 (41,2)45 (40,9)66 (55,9)0,032

We observed that mean age was significantly higher in obese patients (p <0.001), as well as the prevalence of cardiovascular risk factors such as HBP (p <0.001), Diabetes (p <0.001), dyslipidemia (p = 0.001) and hyperuricemia (p = 0.004). Obese patients also received more biological therapy (p=0.032). A higher prevalence of HLA-B27 was observed in patients with normal weight (p=0.016). No differences were found according to BMI regarding gender and source of referral.

Conclusion:

- Almost 70% of patients with PsA visited in the PAIDER clinic of our center have a BMI above normal and more than a third of them are obese, mostly grade 1.

- In our joint clinic there are no differences in BMI regarding the source of referral of the patients.

- Patients with obesity are older, have more cardiovascular comorbidities and receive more biological treatment significantly, which increases the complexity of their management and worsens the prognosis.

Disclosure of Interests:

Andrea García-Guillén: None declared, Ana Laiz: None declared, Anna Lopez-Ferrer: None declared, HyeSang Park: None declared, Patricia Moya: None declared, Berta Magallares: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, Ana Milena Millán Arciniegas: None declared, Cesar Díaz-Torné: None declared, Sicylle Jeria: None declared, Hector Corominas: None declared

THU0001 GENOME-WIDE ASSOCIATION STUDY ON JOINT EROSIONS IN RHEUMATOID ARTHRITIS SUPPORTS DIFFERENTIAL PATHOLOGICAL MECHANISMS ACCORDING TO ANTI-CCP STATUS

Background:

Joint damage is the pathological hallmark of rheumatoid arthritis (RA). To identify the genetic variation associated with a higher level of erosions has proven elusive.

Objectives:

The objective of the present study was to perform a genome-wide association study on joint damage in a cohort of RA patients of the Spanish population. Our aims were to provide independent validation of previously reported variants and to identify new candidate risk loci. A stratified analysis was performed based on positivity to ACPA status.

Methods:

A total of 1,135 patients diagnosed with RA using the ACR-EULAR criteria recruited by the IMID Consortium were genotyped using a 550,000 single-nucleotide polymorphism array. Additional SNPs were imputed using the 1KG genome data. Joint damage was performed using the S-score, a simplified radiographic erosion score that has a high correlation with the Sharp-van der Hejde score (1). Association testing of SNPs with joint damage was performed via linear regression with the addition of the years of evolution as covariate. The two main components of genetic variation were also added to adjust for potential population stratification. A total of 50 SNPs representing previously reported loci associated with joint damage were selected. Genetic association was also performed at the pathway level using Pascal.

Results:

45 out of 50 SNPs representing 31 previously reported loci for joint damage could be satisfactorily imputed. Association testing of the whole patient cohort replicated the association withIL2RAandTRAF1. Of relevance, after stratifying for anti-CCP five new loci were replicated:KIF5AandSOSTin ACPA-positive RA andCD40, DKK1andTNFin ACPA-negative RA.IL2RAwas only significant in the ACPA-positive group andTRAF1was not significant in either strata. GWAS on the ACPA-positive cohort and on the ACPA-negative group identified n=7 and n=18 loci with P-values < 1x10-5, respectively. From these, however, only 1 SNP showed nominal significant association in the other patient group. Based on this evidence, we performed a pathway-based analysis to understand the biological mechanisms underlying this difference. Pathway analysis showed 52 biological processes associated with joint damage in ACPA-negative RA and 32 pathways in the ACPA-positive group, with only two shared biological processes between the two groups. Fc Gamma receptor mediated phagocytosis was the topmost biological process associated with erosions specifically in ACPA-negative RA and Signalling by Fibroblast Growth Factor mutants was the top process specific for ACPA-positive patients.

Conclusion:

The results from our study provide suggestive evidence that the genetic basis for joint damage is different according to the presence of ACPA. Replication of the new candidate loci in an independent patient cohort is underway.

References:

[1]Lopez-Lasanta, M., Julià, A., Maymó, J., Fernández-Gutierrez, B., Ureña-Garnica, I., Blanco, F. J., ... & Tornero, J. (2015). Variation at interleukin-6 receptor gene is associated to joint damage in rheumatoid arthritis.Arthritis research & therapy,17(1), 242.

Disclosure of Interests:

Antonio Julià: None declared, Francisco Blanco: None declared, Benjamin Fernandez: None declared, Antonio Gonzalez: None declared, Juan D: None declared, Joan Maymó: None declared, Mercedes Alperi-López: None declared, Alejandro Olive: None declared, Héctor Corominas Speakers bureau: Abbvie, Lilly, Pfizer, Roche, Victor Martinez Taboada: None declared, Isidoro González-Álvaro Grant/research support from: Roche Laboratories, Consultant of: Lilly, Sanofi, Paid instructor for: Lilly, Speakers bureau: Abbvie, MSD, Roche, Lilly, Antonio Fernandez-Nebro: None declared, Alba Erra: None declared, Simon Sánchez Fernandez: None declared, Núria Palau: None declared, Maria Lopez Lasanta: None declared, Adrià Aterido: None declared, Jesús Tornero: None declared, Sara Marsal: None declared

AB0997 IS HEIGHT ADJUSTMENT NECESSARY IN PEDIATRIC DENSITOMETRY IN ALL CHILDREN?

Background:

The current guidelines of the International Society for Clinical Densitometry (1) recommend that in children with linear growth or maturational delay, Z score results should be adjusted. Height for age Z score (HAZ) adjustment is valid and can be calculated using the formula the formula proposed by Zemmel et al(2).

It is possible that pediatric populations without linear growth or maturational delay, also benefit from HAZ, to prevent bone size from influencing the final Z score.

Objectives:

To evaluate Z score variability adjusted and without adjusting for height for age.

Methods:

We analysed data from densitometry performed on patients 2-20 years of age, from 2016 to 2018, assessed in the pediatric rheumatology office of our hospital for presenting risk factors for low bone mass/osteoporosis. The HAZ was calculated according to Zemel’s formula.

Results:

Data from 103 patients are presented. Its characteristics are summarized in Table 1

Table 1.Mean age9,8 yearsFemale52,4%Height Percentil ≤ 36,8%Height Percentil ≥ 974,9%LBM (Z score ≤ -2) spine8,2%LBM HAZ spine6,4%LBM whole body10,5%LBM HAZ whole body7,2%

The table shows that the proportion of patients with BMD decreases in both the spine region and the whole body when adjusting for HAZ.

When evaluating the relationship between densitometric measurements we found that spine Z score (ZsS) and whole body Z score (ZsWB) had a correlation coefficient of 0,73 (p<0,001). There were no differences between their averages (p=0,170).

At the LBM cut-off point (Z score ≤ -2) there were discrepancies in 7%, where 5% presented LBM in ZsWB but not in ZsS. The concordance index at this point was 0,557.

When comparing these measures with their HAZ adjusted equivalents, we observe:

Conclusion:

There are discrepancies at the LBM cut-off point depending on the HAZ adjustment.

The pediatric population without linear growth or maturational delay, can also benefit from HAZ adjustment, especially those with high height percentiles in which their size can hide a diagnosis of LBM.

References:

[1]Weber DR, Boyce A, Gordon C, Hogler W, Kecskemethy HH, Misra M, et al. The Utility of DXA Assessment at the Forearm, Proximal Femur, and Lateral Distal Femur, and Vertebral Fracture Assessment in the Pediatric Population: 2019 ISCD Official Position. Journal of clinical densitometry: the official journal of the International Society for Clinical Densitometry. 2019;22(4):567-89.

[2]Zemel BS, Leonard MB, Kelly A, Lappe JM, Gilsanz V, Oberfield S, et al. Height adjustment in assessing dual energy x-ray absorptiometry measurements of bone mass and density in children. The Journal of clinical endocrinology and metabolism. 2010;95(3):1265-73.

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

Disclosure of Interests:

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

AB0998 TRABECULAR BONE SCORE IN PEDIATRICS, IS IT USEFUL?

Background:

Bone fragility depends not only on bone mineral density (BMD), but also on bone microarchitecture. In adults, Trabecular Bone Score (TBS) is being used as an indirect marker of bone microarchitecture

It is a software that applicated to the vertebral image obtained by conventional densitometry, informs about the thickness of the trabeculae, the trabecular connectivity and the space between them. A high score indicates a better bone microstructure. In adults, a TBS equal to or greater than 1,350 is considered to represent a normal microarchitecture

Objectives:

To evaluate the usefulness of TBS in pediatric population with risk factors for Low Bone Mass (LBM)

Methods:

TBS was assessed by analyzing vertebral densitometries performed on patients from 4 to 20 years of age, assessed in the pediatric rheumatology office of our hospital for presenting risk factors for LBM, consecutively from 2016 until 2018

Data were compared with normal pediatric population

Results:

Data from 83 patients are shown, with an average age of 11.2 years, 62% female, 80% Caucasian

The main risk factors for LBM were (%): Insufficient calcium intake (84,5), medications with osteopenizing potential (31), corticosteroids (39), sedentary lifestyle (13,6), fractures of long or vertebral bones (12,6) and hypovitaminosis D (8,1)

Table 1.

TBS por age groups and in patients with and without LBM

Age groupsnMeanSDMinimum-MaximumScholars (4-9a)221,3210,0931,119-1,502Adolescence (10-17a)541,3090,0881,073-1,493Youth (18-20a)61,3590,0851,258-1,460Spine Z scorenMean (SD)pMinimum-Maximum ≤-281,270 (0,075)0,1261,419-1,162 >-2741,321 (0,090)1,502-1,073Whole Body Z score ≤-291,246 (0,060)0,0121,323-1,145 >-2731,324 (0,089)1,502-1,073Table 2.

TBS in healthy population and study population for age

Healthy girls (n=2535)Healthy boys (n=1459)Study girls (n=47)Study boys (n=36)Age (y)Spine BMDTBSSpine BMDTBSTBSTBS1-20,401,3250,371,2722-30,511,3630,461,2671,1273-40,521,3460,511,2641,2044-50,601,3460,601,2671,2371,2435-60,601,2880,561,2691,3301,3686-70,651,2800,601,2321,3181,4227-80,671,2680,641,2441,3391,3458-90,711,2660,681,2281,2449-100,751,2780,701,2081,2531,34110-110,81,2850,731,2311,2291,29211-120,841,3370,761,2501,3031,31512-130,991,3550,811,2481,3811,36813-141,061,3860,891,2731,3941,33814-151,101,3980,991,3031,4741,28515-161,141,4051,081,3111,3681,40616-171,171,4051,151,3341,3321,37117-181,171,4041,201,3281,3741,28518-191,171,4041,161,314

Conclusion:

TBS was lower in the patients with LBM by whole body Z score, but not in those with LBM by spine Z score. We observed a decrease in TBS in adolescence, not corresponding with a decrease in BMD, and that should not be interpreted as a pathological finding

Similar results have been described in other pediatric populations (1, 2), but larger studies are needed to evaluate this phenomenon. We hypothesize that it may be due to a higher rate of growth in adolescence, with a lower rate of calcium apposition into the osteoid material

References:

[1]Del Rio DS, Winthenrieth R. BONE MICROARCHITECTURE (TBS) AND BONE MASS DEVELOPMENT DURING CHILDHOOD AND ADOLESCENCE IN A SPANISH POPULATION GROUP. . WCO-IOF-ESCEO; Seville2014.

[2]Shawwa K, Arabi A, Nabulsi M, et al. Predictors of trabecular bone score in school children. Osteoporosis international: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2016;27(2):703-10.

Disclosure of Interests:

None declared

AB0489 BETA 2 MICROGLOBULIN AS A PROGNOSTIC FACTOR IN CRYOGLOBULINEMIA NON ASSOCIATED WITH HEPATOTROPIC VIRUSES

Background:

Cryoglobulinemia (CG) is a rare phenomenon related to haematological disorders, infections and autoimmune diseases. Age and renal involvement are known prognostic markers.

Objectives:

To describe the differential clinical features and the prognostic factors in a cohort of patients diagnosed with CG non-associated with hepatotropic viruses.

Methods:

A descriptive, retrospective study of a cohort comprised of 252 cryoglobulin positive samples, obtained from the immunology laboratory database of a tertiary hospital attending 450,000 people over 1 year. 186 patients with CG positive samples were included, 87 of which were not associated with neither hepatitis B nor C virus. Demographic, clinical, serological and pathological data were collected. Nonparametric variables were compared using a Wilcoxon test.

Results:

Out of 186 reviewed patients, 87 (46.7%) are included in this study. The mean age at CG diagnosis was 60 (± 16) years. Mixed CG was the predominant subtype, detected in 66 (75.9%) patients, 10 of which (11.5%) were associated with glomerulonephritis (GN) with compatible biopsy, 17 (19.5%) with peripheral neuropathy (PN), 29 (33.3%) with non-erosive arthritis and 10 (11.5%) with leukocytoclastic vasculitis confirmed by skin biopsy. The clinical, epidemiological and serological characteristics of the sample are summarized in Table 1.

Figure 1.

Ing et al’s Nomogram of parsimonious model.

Table 1.

Clinical, epidemiological and serical characteristics of patients with CG

Sex, female / male, n (%)65/22 (74.7/25.3)Age at diagnosis, years ± SD60 ± 16CG subtype, n (%)- Type 1, n (%)27 (30)- Mixed, n (%)61 (70)ASSOCIATED DISEASES- pSS, n (%)37 (42,5)- LES, n (%)9 (10,3)- SSc, n (%)7 (8,05)CLINICAL CHARACTERISTICS- Skin, n (%)30 (34,5)- Purpura, n (%)14(16)- Ulcers, n (%)5 (5,7)- Acral ischemia, n (%)2 (2,3)- Acrocyanosis by cold, n (%)7 (8)- Raynaud, n (%)19 (21,8)- Peripheric Neuropathy, n (%)17 (19,5)- Non-erosive arthritis, n (%)29 (33,3)- Glomerulonephritis, n (%)10 (11,5)LABORATORY- β2M +(>1.8 mg/L) mean3.9- RCP (mg/L) p503.7- ESR (mm/hour) p5028- RF + (>20 UI/mL) p50124- Anti Ro52 + /Anti Ro60 + n, (%)42 (48.3)- Low C3 n, (%)48 (55.1)- Low C4 n, (%)36 (41.4)

In the comparative analysis of patients with CG and Beta 2 microglobulin (β2M), CG and rheumatoid factor (RF), those with high β2M (>1.8 mg / L) presented significantly more GN (p0.016) and PN (p0.013). However, the association of RF with either GN (p0.948) or PN (p0.645) was not significant. Also, high β2M was significantly related to complement consumption of C4 (p: 0.015) but not of C3 (p: 0.063). In the 30 (34.5%) patients with skin manifestations, high β2M showed no statistically significant association. The main systemic autoimmune diseases associated were primary Sjögren’s Syndrome (pSS) 37 (42.5%), Systemic Lupus Erythematosus (SLE) 9 (10.3%) and Systemic Sclerosis (SSc) 7 (8.05%).

Conclusion:

A direct association between presence of elevated levels of β2M and the existence of progression to glomerulonephritis and peripheral neuropathy is found in our cohort. No correlation is found between the presence of CG and other serological markers of autoimmunity except low C4. CG with elevated β2M does not associate with greater skin involvement or arthritis.

References:

[1]A.C. Desbois et al. Cryoglobulinemia: An update in 2019. Joint Bone Spine (2019)

[2]Cacoub P, Cryoglobulinemia Vasculitis, The American Journal of Medicine (2015)

Disclosure of Interests:

None declared

AB1356-HPR GOUT IN SPANISH PRIMARY HEALHCARE CENTERS: STILL A LONG WAY TO GO

Background:

Gout has a prevalence >2.5% in the Spanish adult population. It is a chronic disease that without proper treatment causes pain, joint deformity and increased cardiovascular risk and mortality. Recent advances have demonstrated that if correctly treated the disease can be controlled and even ‘cured’. Most gouty patients are diagnosed and treated by general practitioners (GPs). There is evidence that the management if these patients is not good neither at Rheumatology Units nor at Primary Healthcare (PHC) centers.Several causes of this mismanagement can be found in the literature.

Objectives:

Design and evaluation of the results of a questionnaire created from a bibliographic search focused on areas of improvement of gout management in PHC.

Methods:

A search was made in Pubmed to identify the main barriers described in the management of patients with gout in primary care. The terms used were: “Gout”, “primary healthcare” and “education”. A Google Form of gout knowledge and management questionnaire was designed, taking into account what is described in the literature. The Google Form was sent to all GP from an urban area via mail and to other contacts via WhatsApp and twitter.

Results:

Responses were obtained from 224 GPs; 69.5% were women; 73.1% had between 11 and 30 years of professional experience; 96.4% answered that gouty are mostly controlled in primary care; 99.6% performs the diagnosis of gout without analysis of synovial fluid and 17% diagnosed only by clinics without urate levels; 55.9% of GPs do not use any reference guide. Of those who use, the 73% use GUIPCLINGOT and 40% use SEMGs one; 80.5% have not done any gout course in the last 5 years; 26% did not have access to a rheumatologist to confirm the gout diagnosis; only 30.8% knew the therapeutic objective of the urate lowering therapy (ULT); 28.6% considered the beginning of ULT after the first attack; 62% believed that the most important part of the treatment was changing diet and lifestyles; 88.8% did not perform any specific education for these patients by the nurse; just 37.2% carried out a treat-to-target strategy to lower urate levels.

Conclusion:

The questionnaire identifies multiple points of improvement for the management of this pathology in accordance with the described in the literature. Most GPs are unaware of the therapeutic objective of the ULT.

Disclosure of Interests:

None declared

SAT0217 PERFORMANCE OF ACR/EULAR 2019, SLICC 2012 AND ACR 1997 CLASSIFICATION CRITERIA IN A COHORT OF SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS WITH LONGSTANDING DISEASE

Background:

Systemic lupus erythematosus (SLE) is an autoimmune disease with variable clinical features and a complex physiopathology. In 2019, EULAR and ACR have jointly developed new classification criteria with both high sensitivity and specificity. These criteria have the particularity of including the presence of ANA as an obligatory entry criterion and the existence of clinical and immunological domains with weighted scores.

Objectives:

To evaluate the performance and characteristics of the ACR/EULAR 2019, SLICC 2012 and ACR 1997 classification criteria in a cohort of SLE patients with longstanding disease.

Methods:

Descriptive observational study that enrolled a cohort of SLE patients with longstanding disease followed in a tertiary level hospital. Demographic and clinical data were gathered along with the fulfillment of classification criteria. The sensitivity of each classification criteria and the statistically significant associations between criteria fulfillment and clinical and immunological data were calculated. Statistical analyses were performed using the Chi2, T-student and ANOVA tests. Statistical significance was assumed in p values <0.05.

Results:

A total of 79 patients (88.6% women) with a mean age of 51.8±14 years, disease duration of 15.2±11.5 years and SLEDAI of 2.65±2.1 were included. The sensitivity of the different classification criteria was 51.9% for ACR 1997, 87.3% for SLICC 2012 and 86.1% for ACR/EULAR 2019 (Table 1).

Table 1.

Sensitivity and average scores.

ACR/EULAR 2019SLICC 2012ACR 1997Sensitivity (%)86.187.351.9Average score of patients classified as SLE(±SD)18.6±5.85.3±1.45±0.9Average score of patients NOT classified as SLE(±SD)6.1±2.52.8±0.42.8±0.8

51.9% of patients met all three classification criteria, 29.1% met SLICC 2012 and ACR/EULAR 2019, 5% only met SLICC 2012 and 3.7% exclusively met ACR/EULAR 2019. 11.4% of patients did not meet any classification criteria and were characterized by having a low SLEDAI (0.6±0.9) and fulfilling only skin domains (alopecia or oral ulcers), antiphospholipid antibodies or hypocomplementemia.

Statistically significant associations were found between meeting ACR/EULAR 2019 classification criteria and the presence of low C3 and C4 (p<0.04), DNA (p<0.001), lupus nephritis III-IV (p<0.05) and arthritis (p<0.001), highlighting that all patients with arthritis met these criteria.

In the SLICC 2012 evaluation, significant associations were found between meeting these criteria and the presence of arthritis (p<0.01), renal involvement (p<0.04), leukopenia/lymphopenia (p=0.05), DNA (p<0.03) and hypocomplementemia (p=0.02).

Fullfilment of ACR 1997 was associated to the presence of malar rash (p<0.001), discoid lupus (p<0.05), photosensitivity (p<0.001) and oral ulcers (p<0.04), as well as arthritis (p<0.001), serositis (p=0.02), renal (p<0.05) and hematologic (p=0.05) involvement.

The Kappa concordance coefficient among classification criteria is detailed in Table 2.

Table 2.

Kappa concordance coefficient.

ACR/EULAR 2019 - SLICC 2012ACR/EULAR 2019 - ACR 1997SLICC 2012 - ACR 1997Kappa concordance coefficient0.610.270.30

Conclusion:

The ACR/EULAR 2019 classification criteria maintain a high sensitivity similar to the SLICC 2012 in SLE patients with longstanding disease, both of which are much higher than ACR 1997. Patients with serological, articular or renal involvement are more likely to meet SLICC 2012 or ACR/EULAR 2019 criteria. It is noteworthy the relevance of dermatological manifestations in ACR1997 classification criteria against the increased weight that a better understanding of SLE physiopathology has provided to analytic and immunological criteria in the subsequent classification criteria.

Disclosure of Interests:

David Lobo Prat: None declared, Berta Magallares: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, HyeSang Park: None declared, Patricia Moya: None declared, Ignasi Gich: None declared, Ana Laiz: None declared, Cesar Díaz-Torné: None declared, Ana Milena Millán Arciniegas: None declared, Susana P. Fernandez-Sanchez: None declared, Hector Corominas: None declared

FRI0442 APPROPRIATE USE OF SEROLOGY TESTS FOR THE DIAGNOSIS OF LYME DISEASE. EXPERIENCE IN AN URBAN AREA

Background:

Lyme disease (LD) is a multisystemic animal-borne disease caused by spirochetes of theBorrelia burgdorferi s.lcomplex and transmitted by ticks of the speciesIxodes ricinus. In Spain, most cases occur in rural areas of the north-east region with a peak of maximum incidence between spring and early autumn. The diagnosis is based on a history of potential exposure to ticks, the recognition of characteristic clinical manifestations and serological testing.

Objectives:

To assess the suitability of serological study for the diagnosis of LD in an urban area.

Methods:

Retrospective observational study that included all LD serology tests made between April 2017 and September 2019 at a tertiary hospital in Barcelona covering a population of 450,000 people. Demographic data and the medical department that requested the serology test were collected along with serology test results. The medical records of patients with positive serology were consulted to identify which patients were finally diagnosed with LD along with their clinical manifestations, treatment and outcome.

Results:

A total of 574 serological tests were included and 78 (13.59%) of them were positive. Only 1.04% (6) of all serological tests belonged to patients finally diagnosed with LD. The department that made most requests was Neurology (37.3%) followed by Infectious Diseases (21%), Internal Medicine (14.5%), Emergency Medicine (4.7%), Dermatology (4.5%), Critical Care Medicine (2.3%) and Rheumatology (2.1%). 50% of the diagnosed patients were women with a mean age of 57.7±7.7DE years. In 50% of diagnosed cases, patients remembered a tick bite during activities in the mountain or rural areas. The most common clinical manifestations were erythema migrans (67%), non-inflammatory arthralgias (50%), fatigue and malaise (67%), together with one case of meningoencephalitis and one of knee monoarthritis. All diagnosed patients received antibiotic treatment with ceftriaxone (33%) or doxycycline (66%). Only one patient presented post-Lyme syndrome.

The serological test for LD in our center had a total individual cost of 15.75 eur, so the cost of the 574 requests was 9,040.5 eur. 7,812 eur corresponded to negative results and 1,134 eur to false positive results.

Conclusion:

Our study indicates the overuse of diagnostic testing for LD with implications for patient care and cost-effective health management. In the absence of a history of potential exposure to infected vector ticks or characteristic clinical manifestations, unnecessary microbiological tests should not be performed.

Disclosure of Interests:

David Lobo Prat: None declared, Luís Sainz Comas: None declared, Virginia Pomar: None declared, Ana Milena Millán Arciniegas: None declared, HyeSang Park: None declared, Andrea García-Guillén: None declared, Sicylle Jeria: None declared, Ana Laiz: None declared, Berta Magallares: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, Patricia Moya: None declared, Cesar Díaz-Torné: None declared, Susana P. Fernandez-Sanchez: None declared, Hector Corominas: None declared

Thrombospondin-1 mediates muscle damage in brachio-cervical inflammatory myopathy and systemic sclerosis

Objective

To describe the clinical, serologic and histologic features of a cohort of patients with brachio-cervical inflammatory myopathy (BCIM) associated with systemic sclerosis (SSc) and unravel disease-specific pathophysiologic mechanisms occurring in these patients.

Methods

We reviewed clinical, immunologic, muscle MRI, nailfold videocapillaroscopy, muscle biopsy, and response to treatment data from 8 patients with BCIM-SSc. We compared cytokine profiles between patients with BCIM-SSc and SSc without muscle involvement and controls. We analyzed the effect of the deregulated cytokines in vitro (fibroblasts, endothelial cells, and muscle cells) and in vivo.

Results

All patients with BCIM-SSc presented with muscle weakness involving cervical and proximal muscles of the upper limbs plus Raynaud syndrome, telangiectasia and/or sclerodactilia, hypotonia of the esophagus, and interstitial lung disease. Immunosuppressive treatment stopped the progression of the disease. Muscle biopsy showed pathologic changes including the presence of necrotic fibers, fibrosis, and reduced capillary number and size. Cytokines involved in inflammation, angiogenesis, and fibrosis were deregulated. Thrombospondin-1 (TSP-1), which participates in all these 3 processes, was upregulated in patients with BCIM-SSc. In vitro, TSP-1 and serum of patients with BCIM-SSc promoted proliferation and upregulation of collagen, fibronectin, and transforming growth factor beta in fibroblasts. TSP-1 disrupted vascular network, decreased muscle differentiation, and promoted hypotrophic myotubes. In vivo, TSP-1 increased fibrotic tissue and profibrotic macrophage infiltration in the muscle.

Conclusions

Patients with SSc may present with a clinically and pathologically distinct myopathy. A prompt and correct diagnosis has important implications for treatment. Finally, TSP-1 may participate in the pathologic changes observed in muscle.

Treat-to-target strategy in patients with rheumatoid arthritis: Audit of adherence from real world clinical data

INTRODUCTION

The current paradigm of the management of rheumatoid arthritis (RA) recommends achieving a state of remission or low disease activity through the treat-to-target strategy. Our study assesses adherence to this strategy.

METHOD

Patients with RA (ACR-EULAR 2010 criteria) were included. From each centre, 19 patients were randomly selected. Clinical histories (CH) were assessed by independent auditors, checking compliance with predefined quality criteria. The study was approved by ethics committees.

RESULTS

We included 856 patients (mean age 54 years; 71% women). The use of a combined index (CI) was recorded in 61% of cases. Visits were recorded every 4 weeks using a CI in 4% of CH while attempts were made to achieve remission. Monitoring of disease activity every 6-8 months after reaching the target was recorded in 73% of cases.

CONCLUSIONS

The implementation of the treat-to-target strategy is barely recorded in patients with RA in routine clinical practice.

A Combined Transcriptomic and Genomic Analysis Identifies a Gene Signature Associated With the Response to Anti-TNF Therapy in Rheumatoid Arthritis

Background: Rheumatoid arthritis (RA) is the most frequent autoimmune disease involving the joints. Although anti-TNF therapies have proven effective in the management of RA, approximately one third of patients do not show a significant clinical response. The objective of this study was to identify new genetic variation associated with the clinical response to anti-TNF therapy in RA.

Methods: We performed a sequential multi-omic analysis integrating different sources of molecular information. First, we extracted the RNA from synovial biopsies of 11 RA patients starting anti-TNF therapy to identify gene coexpression modules (GCMs) in the RA synovium. Second, we analyzed the transcriptomic association between each GCM and the clinical response to anti-TNF therapy. The clinical response was determined at week 14 using the EULAR criteria. Third, we analyzed the association between the GCMs and anti-TNF response at the genetic level. For this objective, we used genome-wide data from a cohort of 348 anti-TNF treated patients from Spain. The GCMs that were significantly associated with the anti-TNF response were then tested for validation in an independent cohort of 2,706 anti-TNF treated patients. Finally, the functional implication of the validated GCMs was evaluated via pathway and cell type epigenetic enrichment analyses.

Results: A total of 149 GCMs were identified in the RA synovium. From these, 13 GCMs were found to be significantly associated with anti-TNF response (P < 0.05). At the genetic level, we detected two of the 13 GCMs to be significantly associated with the response to adalimumab (P = 0.0015) and infliximab (P = 0.021) in the Spain cohort. Using the independent cohort of RA patients, we replicated the association of the GCM associated with the response to adalimumab (P = 0.0019). The validated module was found to be significantly enriched for genes involved in the nucleotide metabolism (P = 2.41e-5) and epigenetic marks from immune cells, including CD4+ regulatory T cells (P = 0.041).

Conclusions: These findings show the existence of a drug-specific genetic basis for anti-TNF response, thereby supporting treatment stratification in the search for response biomarkers in RA.

Correlation of fatigue with other disease related and psychosocial factors in patients with rheumatoid arthritis treated with tocilizumab: ACT-AXIS study

To assess the hypothesis if tocilizumab (TCZ) is effective on disease activity, and also its effect in fatigue and other clinical and psychological disease-related factors in patients with rheumatoid arthritis (RA) treated with TCZ.A 24-week, multicenter, prospective, observational study in patients with moderate to severe RA receiving TCZ after failure or intolerance to disease-modifying antirheumatic drugs or tumor necrosis factor-alpha was conducted.Of the 122 patients included, 85 were evaluable for effectiveness (85% female, 51.9 ± 12.5 years, disease duration 8.7 ± 7.4 years). Mean change in C-reactive protein level from baseline to week 12 was -11.2 ± 4.0 (P < .001). Mean Disease Activity Index score (DAS28) decreased from 5.5 ± 1.0 at baseline to 2.7 ± 1.3 (P < .001) at week 24. Mean change in Functional Assessment of Chronic Illness Therapy score was -5.4 ± 11.2 points at week 24. Multiple regression analysis showed that the improvement in DAS28, sleep, and depression explained 56% and 47% of fatigue variance at week 12 and 24, respectively.Tocilizumab is effective in reducing disease activity and results in a clinically significant improvement in fatigue, pain, swollen joint count, morning stiffness, sleepiness, depression, and DAS28; the last 3 were specifically identified as factors explaining fatigue variance with the use of TCZ in RA patients.

Genetic variation at the glycosaminoglycan metabolism pathway contributes to the risk of psoriatic arthritis but not psoriasis

OBJECTIVE

Psoriatic arthritis (PsA) is a chronic inflammatory arthritis affecting up to 30% of patients with psoriasis (Ps). To date, most of the known risk loci for PsA are shared with Ps, and identifying disease-specific variation has proven very challenging. The objective of the present study was to identify genetic variation specific for PsA.

METHODS

We performed a genome-wide association study in a cohort of 835 patients with PsA and 1558 controls from Spain. Genetic association was tested at the single marker level and at the pathway level. Meta-analysis was performed with a case-control cohort of 2847 individuals from North America. To confirm the specificity of the genetic associations with PsA, we tested the associated variation using a purely cutaneous psoriasis cohort (PsC, n=614) and a rheumatoid arthritis cohort (RA, n=1191). Using network and drug-repurposing analyses, we further investigated the potential of the PsA-specific associations to guide the development of new drugs in PsA.

RESULTS

We identified a new PsA risk single-nucleotide polymorphism at B3GNT2 locus (p=1.10e-08). At the pathway level, we found 14 genetic pathways significantly associated with PsA (p_FDR<0.05). From these, the glycosaminoglycan (GAG) metabolism pathway was confirmed to be disease-specific after comparing the PsA cohort with the cohorts of patients with PsC and RA. Finally, we identified candidate drug targets in the GAG metabolism pathway as well as new PsA indications for approved drugs.

CONCLUSION

These findings provide insights into the biological mechanisms that are specific for PsA and could contribute to develop more effective therapies.

Expert Recommendations on the Interleukin 6 Blockade in Patients with Rheumatoid Arthritis

OBJECTIVE

To draft recommendations on interleukin 6 (IL-6) blockade in rheumatoid arthritis (RA), based on best evidence and experience.

METHODS

A group of 10 experts on IL-6 blockade in RA was selected. The 2 coordinators formulated 23 questions about IL-6 blockade (indications, efficacy, safety, etc.). A systematic review was conducted to answer the questions. Using this information, inclusion and exclusion criteria were established, as were the search strategies (Medline, EMBASE and the Cochrane Library were searched). Two different reviewers selected the articles. Evidence tables were created. At the same time, European League Against Rheumatism and American College of Rheumatology abstracts were evaluated. Based on this evidence, the coordinators proposed preliminary recommendations that the experts discussed and voted on in a nominal group meeting. The level of evidence and grade of recommendation were established using the Oxford Centre for Evidence Based Medicine and the level of agreement with the Delphi technique (2 rounds). Agreement was established if at least 80% of the experts voted yes (yes/no).

RESULTS

The 8 preliminary recommendations were accepted after the Delphi process. They covered aspects such as the use of these therapies in monotherapy, in combination, in patients with refractory disease or intolerant patients, response evaluation, optimization and risk management.

CONCLUSIONS

The manuscript aims to solve frequently asked questions and aid in decision making strategies when treating RA patients with IL-6 blockade.