Mortality and cardiovascular risk in vasculitis ANCA. Importance of hypertension and renal function. Experience from southern Spain

BACKGROUND

Cardiovascular disease (CVD) is one of the principal causes of death in antineutrophil cytoplasmic antibody-(ANCA)-associated vasculitis (AAV).

OBJECTIVES

To evaluate the mortality and it's causes and CVD and its vascular risk factors (VRFs) in AAV patients in Andalusia.

METHODS

A multicenter cohort of 220 AAV patients followed-up from 1979 until June 2020 was studied in Andalussia, south of Spain. The information, including socio-demographic and clinical data was recorded retrospectively through chart review. Data was analysed using Chi2, ANOVA and Cox proportional hazards regresion as uni and multivariate test with a 95% confidence interval (CI).

RESULTS

During a mean ± standard deviation follow-up of 96.79 ± 75.83 months, 51 patients died and 30 presented at least one CVE. Independent prognostic factors of mortality were age (HR 1.083, p=0.001) and baseline creatinine (HR 4.41, p=0.01). Independent prognostic factors of CVE were age [hazard ratio (HR) 1.042, p=0.005] and the presence of hypertension (HTN) six months after diagnosis (HR 4.641, p=0.01). HTN, diabetes and renal failure, all of these important VRFs, are more prevalent in AAV patients than it is described in matched general population.

CONCLUSIONS

Age and baseline renal function, but not CVEs, are predictors of mortality and age and early HTN are independent predictors for having a CVE. CVD screening in AAV patients is demanded.

Efficacy and safety of selexipag in real-life in patients with pulmonary arterial hypertension: early results of RAMPHA study

Background

Pulmonary arterial hypertension (PAH) is a syndrome characterized by marked remodeling of the pulmonary vasculature and leading to right heart failure and death. Selexipag, an oral prostacyclin IP receptor agonist, has been shown to decrease morbidity and mortality compared to patients treated with placebo.

Purpose

Our aim was to evaluate the efficacy and safety of Selexipag in patients with PAH in real-life.

Methods

The RAMPHA study was a multicenter, observational and retrospective trial of patients who had PAH and began taking Selexipag between 2017–2021. We analyzed baseline characteristics, risk profiles, clinical assessments that were used for risk stratification and events in follow-up time.

Results

29 patients aged 48±14 were initially studied. 23 (79%) were women. Within the pulmonary hypertension-classification, 10 (34,5%) had PAH associated-congenital heart disease, 9 (31%) had idiopathic HAP, 7 (24,1%) had PAH associated with connective tissue disease, 1 had PAH associated to HIV and 2 heritable PAH. The time from PAH diagnoses to the beginning of Selexipag treatment was 54 months (IQR 89).

89,7% (26) were in treatment with doubled combination therapy with PDE5i+ARE; Sildenafil was the most widely used PDE5i and bosentan (37,9%) the most used ARE. No patients were under treatment with intravenous prostacyclin analogue, but 3 were with Treprostinil (1 of them subcutaneous and 2 inhaled) and 2 patients with iloprost.

Most patients were categorized in intermediate risk profile (figure 1), using the risk stratification strategy of ESC/ERS PH guidelines. In the approach of risk assessment before start with Selexipag, clinical, functional, exercise (with 6MWT) and echocardiographic variables were used in all the patients. Biochemical variables with NT-proBNP were used in 93% of the patients. Only 15 patients had a right catheterization to get haemodynamic parameters before the treatment.

At follow up, 11 patients (38%) improved functional class, only 1 patient got worst (p=0,001). 3 patients improved risk-profile in the exercise test and, in the others, a quantitative improvement was found. NT-proBNP levels were not significant better (924ng/l IQR 1209 vs 760ng/l IQR 1397). There were not changes in RV function in the echocardiographic parameters.

Selexipag was well-tolerated, 86% of the patients experienced side effects, but none had to discountinue the treatment. The most common side effect was headache. The titration lasted 68 days (IQR 72) and 38% of the patients got maximum doses.

At the medium-term follow-up of 52 months, the free-event survival (worsening of PAH that resulted in hospitalization; initiation of parenteral prostanoid therapy or death to PAH; or any cause) was 80% (Figure 2).

Conclusion

Selexipag, added as triple combination therapy in patients with PAH intermediate risk, improved risk variables, was well tolerated and achieved a medium-long-term free-event survival greater than 80%.

Funding Acknowledgement

Type of funding sources: None.

[Caution with the use of dexamethasone in patients with COVID-19 in its initial phases]

INTRODUCTION

The effect of dexamethasone in the initial phase of infection by SARS-CoV-2 and its influence on COVID-19 is not well defined. We describe clinical-radiological characteristics, the cytokine storm parameters, and the clinical evolution of a series of patients treated with dexamethasone in the disease's initial phase.

METHOD

A study of 8 patients who received dexamethasone before the development of COVID-19. We evaluate clinical variables, imaging tests, cytokine release parameters, treatment used and patient evolution.

RESULTS

All patients received a 6 mg/day dose with a mean duration of 4.5 days before admission. High resolution computed tomography (HRCT) revealed that most of them presented a severe extension; most patients had a slightly elevated level of cytokine release parameters. Three patients required high-flow oxygen therapy due to respiratory failure; none required orotracheal intubation or died.

CONCLUSION

Dexamethasone in the early stages of SARS-CoV-2 infection appears to be associated with severe COVID-19.

Caution with the use of dexamethasone in patients with COVID-19 in its initial phases

Introduction

The effect of dexamethasone in the initial phase of infection by SARS-CoV-2 and its influence on COVID-19 is not well defined. We describe clinical-radiological characteristics, the cytokine storm parameters, and the clinical evolution of a series of patients treated with dexamethasone in the disease's initial phase.

Method

A study of 8 patients who received dexamethasone before the development of COVID-19. We evaluate clinical variables, imaging tests, cytokine release parameters, treatment used and patient evolution.

Results

All patients received a 6 mg/day dose with a mean duration of 4.5 days before admission. High resolution computed tomography (HRCT) revealed that most of them presented a severe extension; most patients had a slightly elevated level of cytokine release parameters. Three patients required high-flow oxygen therapy due to respiratory failure; none required orotracheal intubation or died.

Conclusion

Dexamethasone in the early stages of SARS-CoV-2 infection appears to be associated with severe COVID-19.

SAT0523 BIOLOGICAL THERAPY IN REFRACTORY ATYPICAL OPTIC NEURITIS. MULTICENTER STUDY

Background:

Optic Neuritis (ON) is an inflammation of the optic nerve. Its most common presentation is demyelinating typical ON. Atypical ON is rare, severe, non-demyelinating and can be isolated or associated to different diseases including autoimmune diseases. If it is not treated, it can lead to devastating visual results. Conventional treatment includes systemic corticosteroids and conventional immunosuppressants (CIS).

Objectives:

Our aim was to assess the efficacy of biological therapy in atypical ON refractory to conventional treatment.

Methods:

Open-label multicenter study including 19 patients diagnosed with atypical ON refractory to systemic corticosteroids and at least one CIS. The main outcomes assessed were Best Corrected Visual Acuity (BCVA) and optic nerve and ganglionar cells Optical Coherence Tomography (OCT). These outcome variables were recorded at baseline, 1 week, 2 weeks, 1 month, 3 months and 6 months and 1 year after biological therapy onset.

FIGURE

Results:

We studied 19 patients (12 women/7 men); mean age of 34.8 ± 13.9 years. The underlying diseases were idiopathic (n=7), Behçet´s disease (n=5), systemic lupus erythematosus (n=2), neuromyelitis optica (n=3), sarcoidosis (n=1) and relapsing polychondritis (n=1)(TABLE).Before biological therapy and besides systemic corticosteroids, patients had received different CIS. Biological therapy was adalimumab (n=6), rituximab (n=6), infliximab (n=5) and tocilizumab (n=4). After biological therapy, an improvement in ocular parameters was observed: BCVA [0.7±0.3 to 0.8±0.3; p= 0.03], optic nerve OCT [123.2±58.3 to 190.5±175.4; p= 0.11], and ganglionar cells OCT [369.6±137.4 to 270.7±23.2; p= 0.03] at one year(FIGURE). After a mean follow-up of 29.1 ±19.2 months, there were no severe adverse effects observed.

Conclusion:

Biological therapy may be effective in patients with refractory atypical ON.

TABLECaseGender/ AgeUnderlying diseaseLateralityIV steroids dose (g)Maximum prednisone oral dose (g)Conventional immunosuppressantsBiological therapyAdverse effects1F/29IdiopathicUnilateral460AZATCZNo2F/26IdiopathicBilateral5.530AZATCZNo3F/13IdiopathicBilateral-10MTXADANo4F/25IdiopathicBilateral460MTXIFX, TCZNo5F/24IdiopathicBilateral0.560MTX, AZAADANo6M/14IdiopathicBilateral-10MTXADANo7F/30Vasculitis ANCA+Unilateral360AZA, MMF, LFM, CFMRTXYes8M/21BehçetBilateral-60MTX, AZAADANausea Vomits9M/25BehçetUnilateral0.560MTX, CyAADANo10M/39BehçetUnilateral380MTX, MMFIFXNo11M/40BehçetUnilateral-80MMFIFXNo12M/37BehçetUnilateral-60CyAIFXNo13F/68NMOUnilateral2.530CFM, AZARTXNo14F/41NMOUnilateral360CFMRTXInfection15F/43NMOBilateral560AZARTXInfusion reaction16F/56SLEUnilateral-60HCQ, MMF, CFMRTXNo17F/47SLEUnilateral560HCQ, MMFRTXNo18F/43Relapsing polychondritisBilateral360MTX, CFMIFX, TCZNo19M/41SarcoidosisBilateral340AZAADANo

Disclosure of Interests:

Alba Herrero Morant: None declared, Carmen Álvarez Reguera: None declared, Vanesa Calvo del Rio Grant/research support from: MSD and Roche, Speakers bureau: Abbott, Lilly, Celgene, Grünenthal, UCB Pharma, Olga Maíz Alonso: None declared, Ana Blanco Speakers bureau: Abbvie, J. Narváez: None declared, Santos Castañeda: None declared, Esther Vicente Speakers bureau: BMS, Roche., Susana Romero-Yuste: None declared, Rosalía Demetrio-Pablo: None declared, ANA URRUTICOECHEA-ARANA: None declared, J. L. García Serrano: None declared, J. L. Callejas Rubio: None declared, Norberto Ortego: None declared, Julio Sánchez: None declared, Paula Estrada: None declared, Iñigo Rua-Figueroa: None declared, David Martínez-López: None declared, José Luis Martín-Varillas Grant/research support from: AbbVie, Pfizer, Janssen and Celgene, Speakers bureau: Pfizer and Lilly, Miguel Á. González-Gay Grant/research support from: AbbVie, MSD and Roche, Speakers bureau: AbbVie, MSD and Roche, Ricardo Blanco Grant/research support from: Abbvie, MSD and Roche, Consultant of: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen and MSD, Speakers bureau: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen, Lilly and MSD

Pyoderma gangrenosum and systemic lupus erythematosus: a report of five cases and review of the literature

Pyoderma gangrenosum (PG) is an uncommon, distinctive cutaneous ulceration which is usually idiopathic, but may be associated with many systemic disorders. The etiopathogenesis of PG is still not well understood. PG is part of the spectrum of the neutrophilic dermatoses and it has been proposed as a prototype of cutaneous autoinflammatory disease. PG usually has a good outcome under immunosuppressive treatment. Although PG has been associated with several systemic diseases, it has rarely been reported in association with systemic lupus erythematosus (SLE). In this article we report five cases of SLE-related PG and review the literature. Our findings support the possible relationship between active SLE and PG, although the mechanism remains unclear. Clinical manifestations, used treatments and outcomes of SLE-related PG do not differ from the described for the general population.

[Virus and systemic vasculitis]

The participation of genetic and environmental factors has always been invoked in the pathogenesis of the autoimmune systemic diseases, including the primary vasculitides. Among the environmental factors, infections, fundamentally those having a viral nature, have always been focused on, especially after the discovery of the close existing relationship between the polyarteritis nodosa and the hepatitis B virus, on the one hand, and mixed cryoglobulinemia and the hepatitis C virus, on the other. The present review summarizes data from the most recent literature related to associations between virus infections and primary vasculitides, following the Chapel-Hill vasculitis classification.

[Internet application for medical purposes in chronic patients cared in a systemic autoimmune diseases unit]

OBJECTIVE

In recent years Internet has become an important tool for medical information search, not only for physicians but also for the patients. Little is known about Internet patient's use in Spain. Our objective was to study the frequency with which patients with different chronic autoimmune diseases cared in our unit use Internet as a source of medical information, and to identify the factors associated with its use.

METHODS

A survey was carried out on Internet use to patients cared in a teaching hospital Systemic Autoimmune Diseases unit along three consecutive weeks.

RESULTS

Hundred thirty-eight patients completed the questionnaire. Eighty-seven (63%) were women. Fifty-four patients (39.1%) were older than 55 years. Mean disease progression was 34.2 +/- 39.2 months. 22% of the respondents were uneducated, 39% had elementary education level; 20% had average education level, and 20% had advanced education level. Forty-two patients (30.4%) used regularly Internet for any purpose. Factors associated to Internet use for medical purposes were regular Internet use (OR: 4.6; CI: 1.1-18.8;p = 0.03), and average or advanced educational degree (advanced education: OR: 22.9; CI: 2.6-202.7; p = 0.005; average education: OR: 8.5; CI: 1.2-59.6; p = 0.03). Eighty-one patients (58.7%) expressed their need of information on quality web pages.

CONCLUSIONS

Many patients use Internet for medical purposes in our environment and even more consider to use it in the future. It is important to be aware of this fact and facilitate information about quality web pages for interested patients.