Having More Tender Than Swollen Joints Is Associated With Worse Patient-Reported Outcomes in Patients With Early RA

BACKGROUND/OBJECTIVE

In patients with rheumatoid arthritis (RA), high tender-swollen joint differences (TSJDs) have been associated with worse outcomes. A better understanding of the phenotype and impact of high TSJD on patient-reported outcomes (PROs) in early RA may lead to earlier personalized treatment targeting domains that are important to patients today. Our objectives were to evaluate the impact of TSJD on updated PROs in patients with early RA over 1 year and to determine differences in associations by joint size.

METHODS

This longitudinal cohort study followed patients with active, early RA enrolled in the Canadian Early Arthritis Cohort between 2016 and 2022, who completed clinical assessments and PROMIS-29 measures over 1 year. Twenty-eight joint counts were performed and TSJDs calculated. Adjusted associations between TSJD and PROMIS-29 scores were estimated using separate linear-mixed models. Separate analyses of large versus small-joint TJSDs were performed.

RESULTS

Patients with early RA (n = 547; 70% female; mean [SD] age, 56 [15] years; mean [SD] symptom duration, 5.3 [2.9] months) were evaluated. A 1-point increase in TSJD was significantly associated with worse PROMIS T-scores in all domains: physical function (adjusted regression coefficient, -0.27; 95% confidence interval [CI], -0.39, -0.15), social participation (adjusted regression coefficient, -0.34; 95% CI, -0.50, -0.19), pain interference (adjusted regression coefficient, 0.49; 95% CI, 0.35, 0.64), sleep problems (adjusted regression coefficient, 0.29; 95% CI, 0.16, 0.43), fatigue (adjusted regression coefficient, 0.34; 95% CI, 0.18, 0.50), anxiety (adjusted regression coefficient, 0.23; 95% CI, 0.08, 0.38), and depression (adjusted regression coefficient, 0.20; 95% CI, 0.06, 0.35). Large-joint TSJD was associated with markedly worse PROs compared with small-joint TSJD.

CONCLUSIONS

Elevated TSJD is associated with worse PROs particularly pain interference, social participation, and fatigue. Patients with more tender than swollen joints, especially large joints, may benefit from earlier, targeted therapeutic interventions.

Impact of filgotinib on pain control in the phase 3 FINCH studies

OBJECTIVE

This post hoc analysis of the FINCH 1-3 (NCT02889796, NCT02873936 and NCT02886728) studies assessed specific effects of filgotinib on pain control and their relationship with other aspects of efficacy in patients with rheumatoid arthritis (RA).

METHODS

Assessments included: residual pain responses of ≤10 and ≤20 mm on a 100 mm visual analogue scale (VAS); the proportion of patients who achieved VAS pain responses in addition to remission or low disease activity by Disease Activity Score-28 with C-reactive protein (DAS28-CRP) or Clinical Disease Activity Index (CDAI) criteria.

RESULTS

Across studies, filgotinib reduced pain from week 2, with responses sustained throughout the studies. In FINCH 1, at week 24, 35.8%, 25.0%, 24.6% and 11.6% of patients in the filgotinib 200 mg, filgotinib 100 mg, adalimumab and placebo arms (each plus methotrexate) achieved VAS pain ≤20 mm in addition to DAS28-CRP remission; 26.3%, 17.9%, 17.2% and 7.6% achieved VAS pain ≤10 mm in addition to DAS28-CRP remission. A similar pattern was seen for CDAI remission. Time during which VAS pain was ≤10 or ≤20 mm was longest with filgotinib 200 mg and comparable between adalimumab and filgotinib 100 mg. Similar findings were reported for filgotinib in FINCH 2 and 3.

CONCLUSION

In all RA populations studied, pain improvements occurred from week 2 and were sustained over time. In FINCH 1, filgotinib 100 mg provided similar pain amelioration to adalimumab, whereas filgotinib 200 mg resulted in greater pain improvement and higher proportion of patients with residual pain ≤10 or ≤20 mm and meeting DAS28-CRP remission criteria.

Having More Tender Than Swollen Joints is Associated With Worse Function and Work Impairment in Patients With Early Rheumatoid Arthritis

OBJECTIVE

Patients with early rheumatoid arthritis (RA) may present with more tender than swollen joints, which can persist. Elevated tender-swollen joint difference (TSJD) is often challenging, because there may be multiple causes and it may contribute to overestimating disease activity. Little is known about the phenotype and impact of TSJDs on patient function. Our objective was to evaluate the impact of TSJD on functional outcomes in early RA and to see whether associations vary by joint size.

METHODS

Data were from patients with active, early RA (≤12 months) enrolled in the Canadian Early Arthritis Cohort, who completed assessments of general function (Multidimensional Health Assessment Questionnaire [MDHAQ]), upper extremity (UE) function (Quality of Life in Neurological Disorders [Neuro-QoL] UE scale), and work/activity impairment (Work Productivity and Activity Impairment RA) over their first year of follow-up. A total of 28 joint counts were performed. TSJDs were calculated. Adjusted associations between TSJDs and functional outcomes were estimated in separate multivariable linear mixed effects models. Separate analyses were performed for large- versus small-joint TSJD.

RESULTS

Patients (N = 547) were 70% female, mean age 56 (SD 15) years, mean disease duration 5.3 (SD 2.9) months. At baseline, 287 (52%) had TSJD >0 (43% involved large joints and 34% small joints), decreasing to 32% at 12 months. A one-point increase in TSJD was significantly associated with worse function (MDHAQ: adjusted mean change 0.10, 95% confidence interval [CI] 0.08-0.13; Neuro-QoL UE function T score: adjusted mean change -0.59, 95% CI -0.76 to -0.43; and greater work impairment: adjusted mean change 1.95%, 95% CI 0.85%-3.05%). Higher large-joint TSJDs were associated with the worst functional outcomes.

CONCLUSION

Having more tender than swollen joints is common in early RA and is associated with worse function, most notably when involving large joints. Early identification and targeted intervention strategies may be needed.

Non-surgical local treatments of digital ulcers in systemic sclerosis: a systematic literature review

INTRODUCTION

Digital ulcers (DUs) are difficult to treat in patients with systemic sclerosis (SSc) and systemic (i.e., pharmacological) therapy is currently considered the 'standard of care'. Our aim was to examine the safety and efficacy of local, non-surgical treatment for SSc-DUs.

METHODS

A systematic literature review (SLR) of original research articles up to August, 29 2022 was performed according to the PICO framework. References were independently screened by two reviewers and risk of bias was assed using validated tools. Due to study heterogeneity narrative summaries are used to present data.

RESULTS

Among 899 retrieved references, 14 articles were included (2 randomised trials (RTs), and 12 observational (OBS) studies). The most frequently studied procedure (5 studies) was botulin A toxin (hand or single finger) injection with a reported healing rate (HR) of 71%-100%. Amniotic and hydrocolloid membranes were examined in one study each and associated with a good HR. Tadalafil 2% cream was studied in a single study with a reduction in the number of DUs. Vitamin E gel was associated with a reduction in ulcer healing time. Low-level light therapy, hydrodissection and corticosteroid injection, extracorporeal shock wave (ESW) and photobiomodulation were evaluated in a single study each and showed a positive trend. Dimethyl sulfoxide was associated with significant local toxicity.

CONCLUSIONS

A range of non-surgical, local treatments for SSc-DUs have been explored and showed efficacy to some extent. We have identified methodological flaws that should be avoided in the design of future studies to explore locally-acting treatments for SSc-DUs.

Systemic pharmacological treatment of digital ulcers in systemic sclerosis: a systematic literature review

OBJECTIVE

To evaluate the evidence concerning systemic pharmacological treatments for SSc digital ulcers (DUs) to inform the development of evidence-based treatment guidelines.

METHODS

A systematic literature review of seven databases was performed to identify all original research studies of adult patients with SSc DUs. Randomized controlled trials (RCTs) and prospective longitudinal observational studies (OBSs) were eligible for inclusion. Data were extracted, applying the patient, intervention, comparison, outcome framework, and risk of bias (RoB) was assessed. Due to study heterogeneity, narrative summaries were used to present data.

RESULTS

Forty-seven studies that evaluated the treatment efficacy or safety of pharmacological therapies were identified among 4250 references. Data from 18 RCTs of 1927 patients and 29 OBSs of 661 patients, at various RoB (total 2588 patients) showed that i.v. iloprost, phosphodiesterase-5 inhibitors and atorvastatin are effective for the treatment of active DUs. Bosentan reduced the rate of future DUs in two RCTs (moderate RoB) and eight OBSs at low to high RoB. Two small studies (moderate RoB) indicate that Janus kinase inhibitors may be effective for the treatment of active DUs, otherwise there are no data to support the use of immunosuppression or anti-platelet agents in the management of DUs.

CONCLUSION

There are several systemic treatments, across four medication classes, that are effective therapies for the management of SSc DUs. However, a lack of robust data means it is not possible to define the optimal treatment regimen for SSc DUs. The relatively low quality of evidence available has highlighted further areas of research need.

Surgical management of digital ulcers in systemic sclerosis: A systematic literature review

BACKGROUND

There is a strong rationale to develop locally-acting surgical treatments for digital ulcers (DUs) in patients with systemic sclerosis (SSc). Our aim was to examine the safety and efficacy of local surgical management for SSc-DU.

METHODS

A systematic literature review was carried out until to August 2022 using 7 different databases. Original research studies concerning adult patients with SSc-DUs, and local surgical treatments were analysed using the PICO framework. We included randomized controlled trials, prospective/retrospective studies, and case series (minimum of 3 patients) References were independently screened by two reviewers including assessment of the risk of bias using validated tools.

RESULTS

Out of 899, 13eligible articles were included. Autologous fat (adipose tissue AT) grafting was the surgical modality most identified (7 studies, 1 randomized controlled double blinded trial and 6 prospective open-label single arm studies). The healing rate (HR) with autologous fat grafting (4 studies) was 66-100 %. Three studies reported autologous adipose-derived stromal vascular fraction grafting: HR of 32-60 %. Bone marrow derived cell transplantation in a single study showed 100 % healing rate over 4-24 weeks. Surgical sympathectomy was examined in 3 studies, prospective without comparator with a median healing rate of 81 %. Two surgical studies (of direct microsurgical revascularisation and microsurgical arteriolysis) showed 100 % healing of ulcers, with no complications.

CONCLUSION

Several surgical approaches for SSc-DUs have demonstrated some degree of safety and effectiveness for DU healing. However, there are significant methodological issues. Future studies are warranted to rigorously investigate surgical interventions for SSc-DUs.

Phosphodiesterase 5 inhibitors (PDE5i) for the treatment of Raynaud's phenomenon

BACKGROUND

Raynaud's phenomenon is a vasodilatory phenomenon characterised by digital pallor, cyanosis, and pain of the extremities. Primary Raynaud's phenomenon has no underlying disease associated with it, while secondary Raynaud's phenomenon is associated with connective tissue disorders such as systemic sclerosis. Systemic sclerosis causes fibrosis and commonly affects the skin and internal organs such as the gastrointestinal tract, lungs, kidney, and heart. Phosphodiesterase 5 inhibitors (PDE5i) are a class of drugs that increases blood flow to the extremities and may be beneficial in the treatment of Raynaud's phenomenon.

OBJECTIVES

To assess the benefits and harms of PDE5i compared to placebo for the treatment of Raynaud's phenomenon.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and clinical trial registries up to June 2022. We did not apply any language restrictions. We searched the bibliographies of retrieved articles and contacted key experts in the field for additional and unpublished data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing PDE5i to placebo in people with primary and secondary Raynaud's phenomenon.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

This review included nine RCTs which ranged in duration from four to eight weeks and included a total of 411 participants. The majority had Raynaud's phenomenon secondary to systemic sclerosis. Tadalafil was assessed in four studies, sildenafil in three studies, vardenafil in one study, and a new PDE5 inhibitor known as "PF-00489791" in one study. Three studies were parallel design and six studies were cross-over. The frequency of attacks per week was 24 with placebo and PDE5i reduced the frequency of attacks by an average of three attacks per week (mean difference (MD) -3.07, 95% confidence interval (CI) -5.15 to -1.00; 8 studies; low-certainty evidence). The duration of attacks per day was 55 minutes with placebo and PDE5i reduced the duration of attacks by an average of five minutes (MD -5.31, 95% CI -8.90 to -1.71; 8 studies; low-certainty evidence). Very low-certainty evidence from one study with eight participants showed severity of Raynaud's attacks (assessed on a 10 cm visual analogue scale with lower scores indicating less severity) was 20% lower with a PDE5i (3.7 with placebo compared to 1.6 with treatment; MD -2.1, 95% CI -2.7 to 1.4; very low-certainty evidence). Pain and patient global assessment were assessed on a 10 cm visual analogue scale with lower scores indicating improvement. Low-certainty evidence showed that the use of PDE5i may result in little to no difference compared to placebo in reducing the average pain of Raynaud's attacks (3 to 2.9; MD -0.10, 95% CI -0.78 to 0.57; 4 studies). Global scores were 36% lower with the use of a PDE5i compared to placebo (9.2 to 5.6; MD -3.59, 95% CI -4.45 to -2.73; 1 study, 24 participants; low-certainty evidence). The rate of withdrawals during treatment with PDE5i ranged from 4% to 20% compared with 2% in the placebo group in five studies. Four studies reported no withdrawals due to adverse events. Seven studies reported no serious adverse events. The rate of serious adverse events reported in two studies ranged from 2% during treatment to 4% with placebo. The majority of the studies were judged as low or unclear risk of bias for selection, performance, and detection bias. Almost half were judged at high risk of attrition bias and unclear risk for selective reporting bias. We downgraded frequency of attacks, duration of attacks, pain intensity, and patient global assessment for small sample sizes and concerns about inconsistency and graded each as low certainty of evidence. We downgraded severity of attacks to very low certainty due to serious concerns about imprecision and publication bias. We downgraded withdrawals due to adverse events and serious adverse events to moderate certainty of evidence due to a low number of reported events.

AUTHORS' CONCLUSIONS

Based on low-certainty evidence, PDE5i may reduce the frequency of attacks of Raynaud's phenomenon by a small amount per week, result in a small reduction in the duration of attack, improve patients' global assessment of their disease, and result in little to no difference in pain. PDE5i probably result in little or no difference in serious adverse events but slightly increase the likelihood of withdrawing from treatment due to an adverse event.

Effectiveness of a treat-to-target strategy in patients with moderate to severely active rheumatoid arthritis treated with abatacept

BACKGROUND

To compare a treat-to-target (T2T) approach and routine care (RC) in adults with active to severely active rheumatoid arthritis (RA) initiating subcutaneous abatacept.

METHODS

A 12-month cluster-randomized trial in active RA patients treated with abatacept was conducted. Physicians were randomized to RC or T2T with a primary endpoint of achieving sustained Clinical Disease Activity Index (CDAI) low disease activity (LDA) at two consecutive assessments approximately 3 months apart. Additional outcomes included Simple Disease Activity Index (SDAI), Disease Activity Score 28-CRP (DAS28-CRP), Routine Assessment of Patient Index Data 3 (RAPID3), and the Health Assessment Questionnaire-Disability Index (HAQ-DI). Time to achieve therapeutic endpoints was assessed with survival analysis.

RESULTS

Among the 284 enrolled patients, 130 were in the T2T group and 154 in RC. Primary endpoint was achieved by 36.9% and 40.3% of patients in T2T and RC groups, respectively. No significant between-group differences were observed in the odds of achieving secondary outcomes, except for a higher likelihood of CDAI LDA in the T2T group vs. RC (odds ratio [95% confidence interval]: 1.33 [1.03-1.71], p = 0.0263). Compared with RC, patients in the T2T group achieved SDAI remission significantly faster (Kaplan-Meier-estimated mean [standard error]: 14.0 [0.6] vs. 19.3 [0.8] months, p = 0.0428) with a trend toward faster achievement of CDAI LDA/remission, DAS28-CRP remission, and HAQ-DI minimum clinically important difference.

CONCLUSIONS

Patients managed per T2T and those under RC experienced significant improvements in RA disease activity at 12 months of abatacept treatment. T2T was associated with higher odds of CDAI LDA and a shorter time to achieving therapeutic endpoints.

TRIAL REGISTRATION

Name of the registry: ClinicalTrials.gov.

TRIAL REGISTRATIONS

NCT03274141 . Date of registration: September 6, 2017.

Benefits of Autoantibody Enrichment in Early Rheumatoid Arthritis: Analysis of Efficacy Outcomes in Four Pooled Abatacept Trials

INTRODUCTION

The efficacy of abatacept is enhanced in anti-citrullinated protein antibody (ACPA) and rheumatoid factor (RF)-positive versus -negative patients with rheumatoid arthritis (RA). Four early RA abatacept trials were analyzed to understand the differential impact of abatacept among patients with SeroPositive Early and Active RA (SPEAR) compared to non-SPEAR patients.

METHODS

Pooled patient-level data from AGREE, AMPLE, AVERT, and AVERT-2 were analyzed. Patients were classified as SPEAR if they were ACPA +, RF +, disease duration < 1 year, and Disease Activity Score-28 (DAS28) C-reactive protein (CRP) ≥ 3.2 at baseline; non-SPEAR otherwise. Outcomes included: American College of Rheumatology (ACR) 20/50/70 at week 24; mean change from baseline to week 24 for DAS28 (CRP), Simple Disease Activity Index (SDAI), ACR core components; DAS28 (CRP) and SDAI remission. Adjusted regression analyses among abatacept-treated patients compared SPEAR and non-SPEAR patients, and in full trial population estimating how the efficacy of abatacept versus comparators [adalimumab + methotrexate, methotrexate] was modified by SPEAR status.

RESULTS

The study included 1400 SPEAR and 673 non-SPEAR patients; most were female (79.35%), white (77.38%), and with a mean age 49.26 (SD 12.86) years old. Around half with non-SPEAR were RF + and three-quarters ACPA +. Stronger improvements from baseline to week 24 were observed in almost all outcomes for abatacept-treated SPEAR versus non-SPEAR patients or versus SPEAR patients treated with comparators. Larger improvements were observed for SPEAR patients among the abatacept-treated population, and more strongly improved efficacy among SPEAR patients for abatacept than comparators.

CONCLUSIONS

This analysis, including large patient numbers of early-RA abatacept trials, confirmed beneficial treatment effects of abatacept in patients with SPEAR versus non-SPEAR.

Disproportionate articular pain is a frequent phenomenon in rheumatoid arthritis and responds to treatment with sarilumab

OBJECTIVES

In some patients with RA, joint pain is more severe than expected based on the amount of joint swelling [referred to as disproportionate articular pain (DP)]. We assessed DP prevalence and the effects of sarilumab, an IL-6 inhibitor, on DP.

METHODS

Data from RA patients treated with placebo or 200 mg sarilumab in the phase 3 randomized controlled trials (RCTs) MOBILITY and TARGET, adalimumab 40 mg or sarilumab 200 mg in the phase 3 RCT MONARCH and sarilumab 200 mg in open-label extensions (OLEs) were used. DP was defined as an excess tender 28-joint count (TJC28) over swollen 28-joint count (SJC28) of ≥7 (TJC28 - SJC28 ≥ 7). Treatment response and disease activity were determined for patients with and without DP.

RESULTS

Of 1531 sarilumab 200 mg patients from RCTs, 353 (23%) had baseline DP. On average, patients with DP had higher 28-joint DAS using CRP (DAS28-CRP) and pain scores than patients without DP, whereas CRP levels were similar. After 12 and 24 weeks, patients with baseline DP treated with sarilumab were more likely to be DP-free than those treated with placebo or adalimumab. In RCTs, more sarilumab-treated patients achieved low disease activity vs comparators, regardless of baseline DP status. In OLEs, patients were more likely to lose rather than gain DP status.

CONCLUSION

About one-quarter of patients with RA experienced DP, which responded well to sarilumab. These data support the concept that other mechanisms (potentially mediated via IL-6) in addition to inflammation may contribute to DP in RA.

TRIAL REGISTRATIONS

NCT01061736, NCT02332590, NCT01709578, NCT01146652.

Patient-level factors predictive of interstitial lung disease in rheumatoid arthritis: a systematic review

Objective Interstitial lung disease (ILD) is an important cause of mortality in some patients with rheumatoid arthritis (RA). Patient-level factors may predict which patients with RA are at the highest risk of developing ILD and are therefore candidates for screening for this complication of the underlying disease.Methods A systematic literature review was performed using PubMed, Embase and Scopus over a 10-year period up to July 2021. Publications reporting patient-level factors in patients with RA with and without ILD that were assessed before development of ILD (or were unchanged over time and therefore could be extrapolated to before development of ILD) were retrieved for assessment of evidence. Genetic variation in MUC5B and treatment with methotrexate were not included in the assessment of evidence because these factors have already been widely investigated for association with ILD.Results We found consistent associations of age, sex, smoking status and autoantibodies with development of ILD. For biomarkers such as Krebs von den Lungen 6, which have been shown to be diagnostic for ILD, there were no publications meeting criteria for this study.Conclusions This analysis provides an initial step in the identification of patient-level factors for potential development of a risk algorithm to identify patients with RA who may be candidates for screening for ILD. The findings represent a useful basis for future research leading to an improved understanding of the disease course and improved care for patients with RA at risk of development and progression of ILD.

Patient Disease Trajectories in Rheumatoid Arthritis Patients Treated with Baricitinib 4-mg in Four Phase 3 Clinical Studies

INTRODUCTION

We sought to identify and compare treatment response groups based on individual patient responses (rather than group mean response) over time on the Clinical Disease Activity Index (CDAI) for rheumatoid arthritis (RA), in patients treated with baricitinib 4-mg in 4 phase 3 studies.

METHODS

Trajectory subgroups were identified within each study using growth mixture modeling. Following grouping, baseline characteristics and disease measures were summarized and compared.

RESULTS

In each study, three response trajectories were identified. In the three studies of patients naïve to biological disease-modifying anti-rheumatic drugs (bDMARDs) patients had, on average, high disease activity, as measured by CDAI. In these studies, a group of rapid responders (65-71% of patients) had the lowest baseline CDAI scores and achieved mean CDAI ≤ 10 by week 16. Gradual responders (10-17%) had higher baseline CDAI, but generally achieved low disease activity (CDAI ≤ 10) by week 24. A group of partial responders (18-22%) had higher baseline CDAI and did not achieve mean CDAI ≤ 10. In bDMARD-experienced patients, the subgroups were rapid responders, who achieved mean CDAI ≤ 10 (42% of patients); partial responders, with mean CDAI decrease of ~ 15 points from baseline (42% of patients); and limited responders (15% of patients). Changes in modified total sharp score (mTSS; assessed only in biologic-naïve patients) were below the smallest detectable difference at 24/52 weeks for > 90% of patients in each group, excepting partial responders in RA-BEGIN (≥ 75% no detectable change).

CONCLUSION

In patients receiving baricitinib 4-mg, lower baseline CDAI was generally associated with rapid response, while higher baseline CDAI scores were generally seen for patients who either reached treatment targets more gradually, or who had a partial or limited response. Maintenance of response was observed with continued baricitinib treatment in all response groups and generally included maintenance of mTSS.

Safety of synthetic and biological DMARDs: a systematic literature review informing the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis

OBJECTIVES

To perform a systematic literature review (SLR) concerning the safety of synthetic(s) and biological (b) disease-modifying antirheumatic drugs (DMARDs) to inform the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis (RA).

METHODS

SLR of observational studies comparing safety outcomes of any DMARD with another intervention in RA. A comparator group was required for inclusion. For treatments yet without, or limited, registry data, randomised controlled trials (RCTs) were used.

RESULTS

Fifty-nine observational studies addressed the safety of DMARDs. Two studies (unclear risk of bias (RoB)) showed an increased risk of serious infections with bDMARDs compared with conventional synthetic (cs)DMARDs. Herpes zoster infections occurred more with JAKi than csDMARDs (adjusted HR (aHR): 3.66) and bDMARDs (aHR: 1.9-2.3) (four studies, two low RoB). The risk of malignancies was similar across bDMARDs (five studies) and with tofacitinib compared with bDMARDs (one study, low RoB). The risk of major adverse cardiovascular events (MACE) was similar with bDMARDs and tofacitinib (two studies, one low RoB). Thirty studies reported safety from RCTs, with one, designed to evaluate safety, showing that malignancies (HR (95% CI): 1.48 (1.04 to 2.09)) and MACE (HR (95% CI): 1.33 (0.91 to 1.94)) occurred numerically more frequently with tofacitinib (5 mg and 10 mg doses combined) than with TNFi in patients with cardiovascular risk factors. In this study, the risk of venous thromboembolism (VTE) was higher with tofacitinib 10 mg than with TNFi.

CONCLUSION

The safety profile of bDMARDs was further demonstrated. Whether the difference in incidence of malignancies, MACE and VTE between tofacitinib and TNFi applies to other JAKi needs further evaluation.

Impact of the COVID-19 pandemic on patients with rheumatoid arthritis: data from the Ontario Best Practices Research Initiative (OBRI)

Objective

The coronavirus disease 2019 (COVID-19) pandemic created challenges for patients with RA. We examined the potential impact of the pandemic on patient-reported outcomes (PROs), disease activity and medication profiles, comparing the periods pre-pandemic and during the pandemic.

Methods

Patients enrolled in the Ontario Best Practices Research Initiative were included if they had at least one visit to a physician or study interviewer within 12 months before and after the start of pandemic-related closures in Ontario (15 March 2020). Baseline characteristics, disease activity, PROs [i.e. health assessment questionnaire disability index, RA disease activity index (RADAI), European quality of life five-dimension questionnaire], medication use and changes were included. Student's paired two-sample t-tests and McNamar's tests were performed for continuous and categorical variables between time periods.

Results

The sample for analysis consisted of 1508 patients, with a mean (s.d.) age of 62.7 (12.5) years, and 79% were female. Despite decreases in the number of in-person visits during the pandemic, there was no significant negative impact on disease activity or PRO scores. The DASs in both periods remained low, with either no clinically significant differences or slight improvement. Scores for mental, social and physical health were either stable or improved. There were statistically significant decreases in conventional synthetic DMARD use (P < 0.0001) and increased Janus kinase inhibitor usage (P = 0.0002). Biologic DMARD use remained stable throughout the pandemic.

Conclusion

In this cohort, disease activity and PROs of RA patients remained stable during the COVID-19 pandemic. The longer-term outcomes of the pandemic warrant investigation.

Post-switch Effectiveness of Etanercept Biosimilar Versus Continued Etanercept in Rheumatoid Arthritis Patients with Stable Disease: A Prospective Multinational Observational Study

INTRODUCTION

To better inform clinicians about the use of etanercept biosimilar (SB4) in patients with rheumatoid arthritis (RA), COMPANION-B, a prospective real-world observational study, evaluated the effectiveness of the voluntary switch from originator (etanercept, ETN) to SB4 in patients with stable RA (low-disease activity/remission).

METHODS

The study recruited adult patients (18 years or older) with RA (2010 American College of Rheumatology criteria) prescribed ETN as their first or second biologic for at least 6 months across 14 sites in Canada and five in Australia. Patients had stable disease (Disease Activity Score-28 using erythrocyte sedimentation rate [DAS28-ESR] less than 3.2) at enrollment with no evidence of flare within the previous 3 months. Concomitant disease-modifying antirheumatic drugs (DMARDs) were permitted. Patients could elect to continue ETN or voluntarily switch to SB4 in consultation with their doctors. The primary effectiveness measure was the proportion of patients with disease worsening (defined as a DAS28-ESR increase of at least 1.2 from baseline and minimum score of at least 3.2 or a defined modification in RA treatment) during 12 months of follow-up. The secondary effectiveness measure was the proportion of patients with disease worsening at month 6. Serious adverse events (SAEs) and non-serious adverse reactions (NSARs) were recorded.

RESULTS

Of 163 patients enrolled, 109 elected to continue on ETN and 54 switched to SB4; 65.8% of patients received non-biologic DMARD(s), 52.6% methotrexate, and 10.5% oral corticosteroid(s). At month 12, the proportion of patients with disease worsening was comparable in the ETN group (22.8% [95% CI 15.0-32.2]) and SB4 group (17.6% [95% CI 8.4-30.9]). Similarly, the proportions of patients with disease worsening were also comparable at month 6 (ETN: 7.9% [95% CI 3.5-15.0]; SB4: 7.8% [95% CI 2.2-18.9]). SAEs were low and similar across both groups (ETN: 8.7%; SB4: 5.7%). NSARs were slightly higher in the SB4 vs. ETN group (13.2% vs. 2.9%).

CONCLUSIONS

SB4 demonstrated comparable effectiveness to ETN over 12 months in patients with stable RA who voluntarily switched to the biosimilar in a real-world setting.

AB1180 COVID-19 HAD DISPROPORTIONATE IMPACTS ON RA SYMPTOMS AND FUNCTION BY SEX AND AGE: RESULTS FROM THE CANADIAN EARLY ARTHRITIS COHORT (CATCH)

Background

During the COVID-19 pandemic, Canadians with RA faced considerable uncertainty due to greater risk of infection, hospitalization, changing access to RA medications, and very limited access to in-person RA care. Further, to reduce transmission of the virus and COVID-related hospitalizations, stringent mitigation measures were implemented across the country to greatly reduce social contacts including curfews, limits on private gatherings and business closures. Little is known about the impact of the COVID-19 pandemic and associated mitigation efforts in RA. We hypothesized that women and younger adults with RA would report greater impairments in HRQL.

Objectives

To compare changes in HRQL prior-to and during the COVID-19 pandemic by sex and age groups in real-world RA patients seen in routine practice settings.

Methods

Data were from patients in the Canadian Early Arthritis Cohort (CATCH) who completed a study visit in the year prior to the COVID-19 pandemic (Mar 2019 through Feb 2020) and a repeat assessment during the pandemic period (Mar 2020 – Jan 2022). RA disease activity was assessed using the RA Flare Questionnaire, a validated patient-reported measure of current RA disease symptoms (pain, stiffness, fatigue) and function (physical, participation). An RA-FQ score ≥ 20 was used to classify RA symptoms consistent with an RA inflammatory flare. HRQL was assessed using PROMIS-29 Adult Profiles. We compared changes in mean Physical (PHS) and Mental Health (MHS) scores, and the proportion of patients with impairments in each domain (i.e., scores ≥ 55 for pain interference, fatigue, anxiety, depression, and sleep and ≤45 for physical function and participation) before and during the COVID-19 pandemic across sex and age groups (<40, 40-64, ≥65 years).

Results

The 938 CATCH participants in the analytic sample with data available at both time periods had a mean (SD) age of 60 (13) and RA symptom duration of 5.8 (3.7) years; 72% were women, 88% were white, and 64% reported >high school education. Most (80%) were in CDAI REM/LDA at the most recent visit prior to start of pandemic. The proportion of patients with RA-FQ ≥20 were similar at both time periods. While physical and emotional RA symptom impacts remained stable in men prior to and during the COVID-19 pandemic, women reported significant increases in anxiety and depression during the pandemic period. Younger RA patients <40 reported increases in depression, and older RA patients (65+) reported increases in anxiety and greater impacts on participation.

Conclusion

Our results illustrate that while the proportions of patients with high inflammatory disease activity were similar prior to and during the COVID-19 pandemic, we observed disproportionate impacts on HRQL by sex and age with a higher proportion of women, adults <40, and those ≥65 years of age experiencing greater impairments in several HRQL domains.

Table 1.DomainWomen (N = 673)Men (N=265)Age <40 (N=84)Age 45-64 (N=492)Age 65+ (N= 362)BeforeDuringBeforeDuringBeforeDuringBeforeDuringBeforeDuringRA Flare >20%17%21%19%18%13%7%18%21%18%21%Anxiety34%*42%*23%23%42%55%32%35%28%*35%*Depression28%*34%*22%20%25%*42%*28%28%24%30%Fatigue36%38%24%23%43%43%36%33%26%32%Pain47%52%48%45%39%48%46%49%49%54%Physical function54%57%46%46%40%40%49%50%59%62%Participation42%47%34%36%37%38%40%41%40%*49%*Sleep30%34%18%22%26%29%29%33%23%28%

*p <0.05

Acknowledgements

CATCH is supported through unrestricted research grants from: Amgen and Pfizer Canada since 2007; AbbVie since 2011; Medexus since 2013; Sandoz Canada since 2019; Fresenius Kabi Canada since 2021 and; Organon Canada since 2021. Previous funding from Janssen Canada (2011-16); UCB Canada and Bristol-Myers Squibb Canada (2011-18); Hoffman La Roche (2011-21); Sanofi Genzyme (2016-17); Eli Lilly Canada (2016-20); Merck Canada (2017-21) and Gilead Sciences Canada (2020-21)

Disclosure of Interests

None declared

AB0720 Adult Onset Still’s Disease: Points to Consider

Background

Adult-onset Still’s disease (AOSD) is a rare and complex autoinflammatory disease of unknown etiology. AOSD has a heterogeneous presentation which can lead to diagnostic uncertainty with prolonged time prior to treatment. NSAIDs, glucocorticoids, conventional DMARDs, and biologics are used in the management of AOSD with varying results. Furthermore, factors associated with de-escalation of therapies remain unclear.

Objectives

To review the literature and create a consensus on points to consider in the diagnosis, prognosis, and treatment of AOSD.

Methods

A scoping review of the AOSD literature over the last 15 years was performed. MEDLINE and EMBASE were searched and studies included if they provided information regarding the epidemiology, differential diagnosis, diagnostic criteria, complications, prognosis, and initial, chronic, and refractory treatment approaches in AOSD. Following narrative information synthesis, a meeting was held with experienced clinicians across Canada for the creation of a consensus on points to consider in AOSD.

Results

The annual incidence and prevalence of AOSD is observed to be between 0.16 to 0.62 per 100,000 and 3.9 to 6.9 per 100,000, respectively. AOSD most commonly affects young adults and women. Women are more likely to have severe complications from AOSD including macrophage activation syndrome, disseminated intravascular coagulation, or thrombotic thrombocytopenic purpura. The Yamaguchi criteria remains the most widely used diagnostic tool with a sensitivity of 96.2% and specificity of 92.1%. Common presentation manifestations include intermittent high fevers (>39.0 degrees Celsius), arthralgias/arthritis, pharyngitis, lymphadenopathy, and a maculopapular rash. Other manifestations can variably involve the cardiovascular, respiratory, and GI systems. Common laboratory abnormalities include leukocytosis with neutrophilia, elevated ESR and CRP, elevated ferritin, and transaminitis. AOSD patients are most commonly ANA and Rf negative. Initial treatment includes NSAIDs, glucocorticoids, and conventional DMARDs. Disease refractory to initial therapy is managed through IL-1 and IL-6 inhibitors such as Anakinra or Tocilizumab. Elevated ESR, pericarditis, and non-response to corticosteroids are some of the factors associated with refractory and chronic disease requiring advanced therapies and long term follow-up.

Conclusion

AOSD is a multi-faceted autoinflammatory disease with a diverse presentation profile. Clinicians are recommended to consider AOSD, following exclusion of infections, malignancies, and autoimmune diseases, as a cause for fever of unknown etiology. Our review provides points to consider in the diagnosis and management of AOSD following expert consensus.

References

[1]Gerfaud-Valentin M, Maucort-Boulch D, Hot A, Iwaz J, Ninet J, Durieu I, et al. Adult-onset still disease: manifestations, treatment, outcome, and prognostic factors in 57 patients. Medicine. 2014 Mar;93(2).

[2]Sfriso P, Priori R, Valesini G, Rossi S, Montecucco CM, D’Ascanio A, et al. Adult-onset Still’s disease: an Italian multicentre retrospective observational study of manifestations and treatments in 245 patients. Clinical rheumatology. 2016 Jul;35(7).

Disclosure of Interests

None declared

POS0913 INCREASED HEALTH CARE UTILIZATION IN SYSTEMIC SCLEROSIS PATIENTS WHO HAVE DIGITAL ULCERS

Background

Systemic sclerosis is a multi-system autoimmune disease characterized by fibrosis of the skin and internal organs, and vasculopathy which manifests as pulmonary arterial hypertension and digital ulcers. Digital ulcers are debilitating and painful lesions most commonly present in the digit tips or extensor surfaces of the hands leading to significant morbidity and decreased quality of life. SSc patients with digital ulcers may require increased support and therefore may have greater healthcare resource utilization compared to those patients without digital ulcers.

Objectives

We assessed the impact of DUs on resource utilization including hospitalizations, outpatient visits and procedures within a large SSc Canadian registry.

Methods

A cohort of patients with SSc and digitals ulcers was derived from the Canadian Scleroderma Research Group registry and matched to controls individually based on sex, age (±3 years), SSc subtype, and disease duration (±2 years). Eligible patients met the 2013 ACR/EULAR criteria (confirmed by an experienced rheumatologist), were 18 years of age, had completed the Resource Utilization Questionnaire (RUQ), and had active digital ulcers at two consecutive annual visits (baseline study visit and at 1st year). The Medgser Disease Severity Scale was used to assess ulcer disease severity. Unadjusted and adjusted regression analyses compared the association between DUs and resource utilization.

Results

RUQs in 104 SSc patients with active DUs at two consecutive annual visits were compared with 104 patients without DUs matched 1:1 for age, sex, disease subtype and duration. Over one year, DUs were associated with a higher number of tests (p˂0.05) and visits to health professionals, especially to a rheumatologist (p˂0.0001) and internist (p=0.003), a greater need for an accompanying person (p˂0.05) and aids purchased/received (p˂0.05). Having DUs was associated with more severe disease, even after excluding the peripheral vascular domain from a total DSS (9.7±4.5 vs 5.6±2.7, p˂0.0001). After adjustment for disease severity in other organs, the presence of DUs remained a significant predictor of more frequent physician visits and more tests (all˂0.05) by linear regression analysis.

Conclusion

SSc patients with DUs utilized significantly more healthcare resources per annum even after adjustment for disease severity in other organ systems.

References

[1]Khimdas S, Harding S, Bonner A, Zummer B, Baron M, Pope J, Canadian Scleroderma Research Group. Associations with digital ulcers in a large cohort of systemic sclerosis: results from the Canadian Scleroderma Research Group registry. Arthritis care & research. 2011 Jan;63(1):142-9.

[2]Nihtyanova SI, Brough GM, Black CM, Denton CP. Clinical burden of digital vasculopathy in limited and diffuse cutaneous systemic sclerosis. Annals of the rheumatic diseases. 2008 Jan 1;67(1):120-3.

Disclosure of Interests

None declared

POS0888 NON-SURGICAL LOCAL TREATMENTS FOR DIGITAL ULCERS IN SYSTEMIC SCLEROSIS: A SYSTEMATIC LITERATURE REVIEW

Background

Digital ulcers(DUs) in systemic sclerosis(SSc) represent a major clinical challenge. There are no recommendations for the local management of SSc-DUs. Systemic therapy is considered the standard of care. However, there is a strong rationale for local approaches to DU by avoiding side effects from systemic therapies. The World Scleroderma Foundation DU Working Group intends to develop evidence-based recommendations for DU management including local, non-surgical treatment(ln-sT).

Objectives

To summarise the literature on the safety and efficacy of ln-sT for SSc-DUs.

Methods

A systematic literature review(SLR) of papers describing the use of ln-sT for DU in SSc was performed up to May 2021 according to the PICO framework. References were independently screened by two reviewers who independently assessed the full text of eligible articles and extracted data.

Results

Among 790 retrieved references, 12 were included. Median(range) number of patients per study was 9(7–84), mean age ranging from 37 to 62.5 years. In 5(41%) studies a control group was included. Background systemic therapies are summarized in Table 1. The most studied treatment was botulin toxin A(BTA). It was used as hand injection in 3 studies (median dose ranging from 90 to 150 U) and as 50 U single finger injection in 1 study. Healing rate after a median time of 8-49 weeks ranged from 71% to 100%. In 2 studies a reduction in VAS pain was observed from 20% to 100%. Transient muscle weakness was the most common side effect in 10% of patients. Amniotic(Am) and hydrocolloid membranes(HyM) were used in 1 study each. They were associated with a good healing rate, statistically significant for the HyM. Tadalafil 2% cream was studied in 1 study and was associated with a reduction in the median DU number from 1.6 to 1 per patient after a median time of 4 weeks and a reduction by 1.4 point in the 10-mm VAS scale. Vitamin E gel was shown to be associated with a statistically significant reduction in the healing time compared to SoC alone in 1 RCT(13.2 ± 2.7 versus 20.9 ± 3.6 weeks, P=<0.001). Low-level light therapy, hydrodissection and corticosteroid injection and extracorporeal shock wave(ESW) were evaluated in 1 study each. They were all associated with positive outcomes which was statistically significant only for the ESW. The only negative trial examined dimethyl sulfoxide and was associated with local toxicity.

Table 1.

Characteristics of the studies.

TreatmentType of studyPatientsBaseline DUBackground therapy (%) ETA CCB APA PG ARB ACE-I PDE-5i ISFollow-up (weeks)Healing rate(%)*Pain Reduction (VAS/10)ComparatorHydrodissection and corticosteroid injectionP1202334.4Rheumatoid ArthritisTadalafil 2% Vitamin E gelRRCT15131.6(1)3.5±2.30462700130704 241(1)Reduced time to heal**1.4SoCAmHyMRP67310001002800002817033143810090**SoCBTAMedian 90 U per handHigh-concentration hand100 U non-dominant handSingle finger 50 URRPP772010314571140718558551008514201001414718 4981277717510020%100%Untreated CHLow-level light therapyP8102537025378100ESWP9493355661144441**1.31Dimethyl sulfoxideDBRCT84No change, skin toxicity with 70% formulation

*Unless otherwise stated. **Statistically significant. ARB= angiotensin receptor antagonist. ACEi= ACE inhibitors. APA= anti-platelet agents. CCB= calcium channel blockers. CH= contralateral hand. DBRCT= double blind randomized-controlled trial. ETA = endothelin antagonist. IS= immunosuppression. PG= prostaglandins. PDE-5i= Phosphodiesterase type-5 inhibitors. P = prospective. R = retrospective. SoC= standard of care (as per local protocol).

Conclusion

Our SLR supports interest to develop ln-sTs for SSc-DUs. The number of studies is limited and mainly case reports and small single studies are present. Treatments were well tolerated and there was evidence of efficacy for BTA, vitamin E, ESW and HyM in refractory DUs. The evidence is not robust and confounding factors (vasodilators background therapies) could impact on the findings. Future research is indicated to conduct larger, well-designed studies.

Disclosure of Interests

Corrado Campochiaro: None declared, Yossra A. Suliman: None declared, Michael Hughes Speakers bureau: Actelion pharmaceuticals, Eli Lilly, and Pfizer, outside of the submitted work., Jan Schoones: None declared, Dilia Giuggioli: None declared, Pia Moinzadeh Speakers bureau: speaking fees from Actelion pharmaceuticals and Boehringer Ingelheim, Nancy Maltez: None declared, Laura Ross: None declared, Murray Baron: None declared, Lorinda Chung: None declared, Yannick Allanore: None declared, Christopher P Denton: None declared, Oliver Distler Speakers bureau: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Tracy Frech: None declared, Daniel Furst: None declared, Dinesh Khanna Speakers bureau: Janssen and Eicos Sciences, Inc., Thomas Krieg: None declared, Masataka Kuwana Speakers bureau: Speakers fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and Consultant fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida, outside of the submitted work., Marco Matucci-Cerinic: None declared, Janet Pope: None declared, Alessia Alunno: None declared

POS0898 SURGICAL MANAGEMENT OF DIGITAL ULCERS IN SYSTEMIC SCLEROSIS: A SYSTEMATIC LITERATURE REVIEW

Background

Management of digital ulcers (DUs) in systemic sclerosis (SSc) is a major clinical challenge. To date, systemic therapy is generally considered as the ‘standard of care’ for significant SSc-DUs. However, there is a strong rationale to develop local approaches to DUs, to avoid side effects from systemic therapies. World Scleroderma Foundation DU Working Group intends to develop practical, evidence-based recommendations for DU management including local, Surgical Treatment (L-ST).

Objectives

To summarize the literature on the safety and efficacy of L-ST for SSc-DUs.

Methods

A systematic literature review (SLR) was conducted up to May 2021. According to the PICO framework, eligibility criteria were defined and original research articles about surgical treatment of SSc DUs in adult patients were included. References were independently screened by 2 reviewers who assessed the full text of eligible articles and extracted data.

Results

Thirteen eligible articles out of 790 total publications were identified (Table 1). Due to the paucity of randomized controlled trials of surgical treatments for SSc-DU, we included retrospective studies and case series with at least 4 patients. Autologous fat (adipose tissue AT) grafting was the surgical modality mostly identified (7 studies of which 1 RCT and 6 prospective open label single arm). The healing rate (HR) with autologous fat grafting (4 studies) ranged from 66-100 %. In the RCT, two age and sex matched groups were included, adipose tissue (AT)group (n=25 pts) and sham procedure (SP) group (n=13), DU healing was reported in 23/25 in AT group versus 1/13 in the SP group in 8 wks, (p<0.0001), 12 pts in the SP group, received rescue AT injection, all of them healed after 8 wks. Three studies reported autologous adipose-derived stromal vascular fraction(SVF) grafting and the HR ranged from 32-60%, followed up to 12 months. Transient edema and paresthesia were reported in 2 studies, and amputation in 2 ulcers in 1 study, and no complications were reported in other studies. Surgical sympathectomy was reported in 3 studies, with a median healing rate of 81%. Bone marrow derived cell transplantation in a single study showed 87% healing rate over (4-24 wks). Two surgical studies (of direct microsurgical revascularization N=4, and microsurgical arteriolysis, N=6), showed 100% healing of ulcers, no complications reported.

Table 1.

Characteristics of the extracted studies.

StudydesignPatients (n)Baseline DU (n)Background therapy (%)Follow-upOutcomeHealed ulcers(%) Adipose tissue graftAutologous fat graftp9.15PG, CCB—100ETA 26PDE-5i 138-12 wks66Adipose tissue graftingRCT25 case13- Ctr25-case13- CtrPG- 100CCB 1008 wks92-case7-CtrAdipose tissue implantp1515no therapy7 wks100Adipose tissue graftp129PG,CCB-100ETA6 month88adipose derived SVFp1215PDE-5i, ccb, PG allowed22m6Adipose derived SVFp1215CCB 50ETA166 m63 Adipose derived SVFp1819CCB 50PG 27ETA 5IS 7124 wks32SympathectomySympathectomyR611CCB-10020 m81SympathectomyR1335PGCCBAPA35Sympathectomy, vascular bypass (+vein graftR1726Ccb 35APA 47PDE-i5 589 m100Bone marrow derived cells transplantation)p88PG-6236 m87Direct microsurgical revascularizationR44m100Limited microsurgical arteriolysisR61712 m100

SVF =stromal vascular fraction P = prospective. R = retrospective. RCT= double blind randomized-controlled trial. ETA = endothelin antagonist. CCB= calcium channel blockers. APA= anti-platelet agents. PG= prostaglandins. ARB= angiotensin receptor antagonist. ACEi= ACE inhibitors. PDE-5i= PDE-5 inhibitors. IS= immunosuppression. M=median. SoC= standard of care. HR= healing rate

Conclusion

Our SLR has identified several surgical modalities for SSc-DUs. L-STseemed generally effective and safe for DU healing, thus Significant methodological issues emerged including small numbers of pts, lack of comparator, failure to report confounders such as background therapies and variable follow up. Future research is warranted to rigorously investigate surgical interventions for Dus.

Disclosure of Interests

Yossra A. Suliman: None declared, Corrado Campochiaro: None declared, Michael Hughes Speakers bureau: speaking fees from Actelion pharmaceuticals, Eli Lilly, and Pfizer, outside of the submitted work, Jan Schoones: None declared, Dilia Giuggioli: None declared, Nancy Maltez: None declared, Pia Moinzadeh Speakers bureau:: speaking fees from Actelion pharmaceuticals and Boehringer Ingelheim, Laura Ross: None declared, Lorinda Chung: None declared, Yannick Allanore: None declared, Murray Baron: None declared, Christopher P Denton: None declared, Oliver Distler Shareholder of: Consultancy relationship with and/or has received research funding from and/or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Speakers bureau: Consultancy relationship with and/or has received research funding from and/or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Consultant of: Consultancy relationship with and/or has received research funding from and/or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Grant/research support from: Consultancy relationship with and/or has received research funding from and/or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Tracy Frech: None declared, Daniel Furst: None declared, Dinesh Khanna Speakers bureau: Janssen and Eicos Sciences, Inc., Paid instructor for: Janssen and Eicos Sciences, Inc., Consultant of: Janssen and Eicos Sciences, Inc., Thomas Krieg: None declared, Masataka KUWANA Speakers bureau: Speakers fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and Consultant fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida, outside of the submitted work., Paid instructor for: Speakers fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and Consultant fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida, outside of the submitted work., Consultant of: Speakers fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and Consultant fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida, outside of the submitted work., Marco Matucci-Cerinic: None declared, Janet Pope: None declared, Alessia Alunno: None declared

POS1361 THE CANADIAN RESEARCH GROUP OF RHEUMATOLOGY IN IMMUNO-ONCOLOGY (CanRIO): A NATIONWIDE MULTI-CENTER PROSPECTIVE COHORT

Background

Immune Checkpoint Inhibitors (ICI) have altered the landscape of cancer therapy. However, toxicities are common and up to 80% of patients will develop immune-related adverse events (irAE), including rheumatic irAEs (Rh-irAE), which can often limit their cancer treatment. Our knowledge of clinical manifestations and optimal management of patients with Rh-irAE continues to evolve as these agents are being used to treat a wider variety of cancers. Currently available data is limited to retrospective case series and case reports. There is also scarce data on the use of ICI in patients with pre-existing autoimmune disease (PAD) as these patients are often excluded from clinical trials.

Objectives

To describe the clinical presentation, management and early outcomes of patients exposed to ICI with Rh-irAE or PAD recruited and followed prospectively from multiple sites across Canada.

Methods

Adult patients with Rh-irAE from cancer immunotherapy (CTLA-4, PD-1 or PDL-1 inhibitors) or those with PAD exposed to cancer immunotherapy are prospectively recruited across 9 academic sites in Canada. Standardized clinical and biologic data are also collected. We describe clinical characteristics and management of patients recruited between January 2020 and October 2021, stratified based on the presence or absence of PAD.

Results

103 patients were recruited from 9 sites. From those, 85 had Rh-irAE, 47 had pre-existing musculoskeletal and rheumatic diseases, and 20 had other PAD. The most frequent Rh-irAE were joint manifestations (n = 73). Other Rh-irAE included muscle symptoms (n = 7), connective tissue disease (n = 6), vasculitis (n=2) and sarcoid (n = 3). Prednisone was the most common treatment (n = 53). Intraarticular corticosteroids were used in 7 patients. Eleven patients required conventional synthetic disease-modifying anti-rheumatic drugs (DMARD) and only one required biologic DMARD to control the Rh-irAE. Anti-PD-1 therapies were the most used ICI (56.3%), followed by combination therapy (35.9%). Response to index immunotherapy at 6 months was available for 21 patients. Most patients had partial response (57.1%) and only 4 patients had tumor progression (19.1%). The ICI was permanently discontinued due to an irAE in 21 patients (38.1% with PAD and 61.9% without PAD). There were no deaths related to Rh-irAE.

Conclusion

The initial sample of the CanRIO prospective national cohort suggests that demographic characteristics and tumor representation in people with PAD and without PAD is similar. Patients with PAD are less likely to receive combination therapy (n= 12 vs. n=25) and are less likely to have tumor progression on ICI (n=1) compared to those without PAD (n=3). Selection bias is noted in this initial sample since half of recruited patients have PAD. The CanRIO cohort provides valuable insight into real-world spectrum and management of Rh-irAE secondary to immunotherapy for cancer.

Disclosure of Interests

Shahin Jamal Grant/research support from: CanRIO has received financial support from BMS and Organon, Lourdes Gonzalez Arreola: None declared, Julia Tan: None declared, Carrie Ye: None declared, Janet Roberts: None declared, Aurore Fifi-Mah: None declared, Marie Hudson: None declared, Sabrina Hoa: None declared, Janet Pope: None declared, Ines Colmegna: None declared, C. Thomas Appleton: None declared

OP0308-HPR MORE THAN HALF OF RA PATIENTS WITH A LIFETIME HISTORY OF MOOD DISORDERS WERE ANXIOUS AND DEPRESSED DURING THE COVID-19 PANDEMIC: RESULTS FROM THE CANADIAN EARLY COHORT (CATCH) STUDY

Background

A growing number of studies indicate the considerable mental health impacts of the prolonged COVID-19 pandemic in the general population as chronic stress is a risk factor for the development of depression and anxiety. Mood disorders are more prevalent in RA and a history of anxiety or depressive disorders increases the risk of recurrence in the future.

Objectives

To compare trends in prevalence of anxiety and depressive symptoms, prior to and during the COVID-19 pandemic in RA patients with and without a lifetime history of mood disorders.

Methods

Data were from RA patients diagnosed and treated for RA in rheumatology clinics across Canada enrolled in the Canadian Early Arthritis Cohort (CATCH) Study. We estimated monthly trends in prevalence of clinically significant levels of anxiety and depression (PROMIS Depression and Anxiety 4a score 55+) from all visits between Mar 2019 and Jan 2022 and compared monthly trends in anxiety and depression in the year prior to (Mar 2019- Feb 2020) and during the pandemic (Mar 2020 to Jan 2022) stratified by lifetime history of mood disorders.

Results

4,148 visits were completed from Mar 2019 to Jan 2022 in 1,644 RA patients with a mean (SD) age of 60 (14) and disease duration of 6 (4) years. 73% were women, 84% white, 60% had completed some post-secondary education, and 77% were in CDAI REM/LDA at the visit closest to the start of pandemic. 253 (15%) reported a lifetime history of depression and 217 (13%) a lifetime history of anxiety; 8% reported prior treatment for either.

Patients with a history of mood disorders had higher levels of depression and anxiety prior-to and during the pandemic compared with patients without a history of mood disorders (Table 1). Proportions were highest during COVID waves in all and were substantially higher and more variable in people with a previous history of mood disorders as compared to those without a history (Figure 1). While depressive symptoms peaked early in the pandemic, anxiety increased with each wave, peaking in Wave 3 (May-Jun 2021).

Table 1.

Prevalence of depression and anxiety symptoms prior to and during the COVID-19 pandemic in RA patients with and without a history of mood disorders.

Period Prevalence (monthly range)DepressionAnxietyNo historyPrior HistoryNo HistoryPrior HistoryN observations35276213610538Prepandemic (3/19 - 2/20)21%(14%-30%)51%(29%-64%)27%(20%-35%)58%(31%-89%)Pandemic (3/20 - 1/22)22%(15%-29%)53%(33%-78%)28%(20%-43%)59%(33%-80%)Figure 1.

During the first 22 months of the COVID-19 pandemic, the proportion of patients with depression and anxiety increased in all groups. More than half of those with a history of emotional distress had clinically significant levels of depression and anxiety; proportions were highest during COVID waves in all and were substantially higher in people with previous history as compared to those without a history (see Figure 1). Whereas depressive symptoms peaked early in the pandemic, anxiety increased with each wave, peaking in Wave 3 (May-Jun 2021).

Conclusion

Symptoms of anxiety and depression were common in Canadian adults with RA prior to and after the onset of the COVID-19 pandemic. Whereas others have found that high levels of depression and anxiety occurred early in the pandemic but declined fairly rapidly in the general population1, emotional distress was not attenuated over time in this large cohort of RA patients. Individuals reporting lifetime history of mood disorders were more than twice as likely to report anxiety and depression, with depression peaking early in the pandemic and anxiety growing with each successive wave in the first year. The results demonstrate the importance of applying a lifetime perspective as previous episodes of anxiety and depression may be an important marker of increased vulnerability and recurrence in RA patients, particularly during the pandemic.

References

[1]Fancourt D et al. Trajectories of anxiety and depressive symptoms during enforced isolation due to COVID-19 in England. Lancet Psychiatry. 2021;8:141-9.

Acknowledgements

CATCH is supported through unrestricted research grants from: Amgen and Pfizer Canada since 2007; AbbVie Corporation since 2011; Medexus since 2013; Sandoz Canada since 2019; Fresenius Kabi Canada since 2021 and; Organon Canada since 2021. Previous funding from Janssen Canada (2011-16); UCB Canada and Bristol-Myers Squibb Canada (2011-18); Hoffman La Roche Limited (2011-21); Sanofi Genzyme (2016-17); Eli Lilly Canada (2016-20); Merck Canada (2017-21) and; Gilead Sciences Canada (2020-21)

Disclosure of Interests

None declared

AB0721 From Undifferentiated Connective Tissue Disease to Identifiable Disease: Precursors of Systemic Sclerosis and Systemic Lupus Erythematosus

Background

The pathogenesis of systemic lupus erythematosus and systemic sclerosis is characterized by derangements of the innate and adaptive immune systems, and inflammatory pathways leading to autoimmunity, chronic cytokine production, and chronic inflammation. Diagnosis is rooted in meeting established criteria. However, in pre-clinical states criteria is not fulfilled but biochemical and autoimmune derangements are present. Understanding the underlying processes responsible for disease pathogenesis in pre-clinical states, which place patients at increased risk for the development of established connective tissue diseases, presents a prognostic opportunity, and could enable timely treatment leading to limiting disease progression.

Objectives

We aim to describe the role of the innate and adaptive immune system in the pre-clinical states of UCTD-risk-SSc and prescleroderma, the underlying immune dysregulation in these pre-clinical states, and the evolution of antibodies from nonspecific antinuclear antibodies to specific prior to SLE development.

Methods

Our search strategy was developed alongside an experienced information specialist. We searched the databases EMBASE and MEDLINE with restrictions for the English language. Reference lists of all primary studies and review articles were searched for additional references. Studies reported in full-text and abstract formats were included.

Results

Multiple cytokines are observed to increase along a disease spectrum from UCTD-risk-SSc to classified SSc and include sICAM-1, CCL2, CXCL8, ang-2, CXCL16, e-selectin, and IL-13. The mechanism of action of these cytokines includes transmigration of lymphocytes endothelium, innate immune cell activation and signal propagation, and extracellular matrix deposition. The progressive nature of cytokine increase through a spectrum from pre-clinical to clinical emphasizes disease evolution and enables the discernment of patients who may warrant early intervention. Furthermore, there are disease markers which are observed to be predictive of established SSc and include sIL-2Rα, PIIINP, CXCL4, CXCL10, and CXCL11. Pre-clinical SLE is characterized by an evolving IFN signature and progressive SLE-specific antibody formation prior to disease classification.

Conclusion

The coordinated dysregulation of the innate and adaptive immune systems, and inflammatory signalling pathways leads to the pathogenesis of connective tissue disease. Our improved understanding of these underlying aberrations in pre-clinical stages of disease will serve to better identify patients at increased risk.

References

[1]Valentini G, Pope JE. Undifferentiated connective tissue disease at risk for systemic sclerosis: Which patients might be labeled prescleroderma? Autoimmunity reviews. 2020 Nov;19(11):102659.

[2]Lambers WM, Westra J, Bootsma H, de Leeuw K. From incomplete to complete systemic lupus erythematosus; A review of the predictive serological immune markers. Seminars in arthritis and rheumatism. 2021;51(1):43–8.

Disclosure of Interests

None declared

Nintedanib in Patients With Autoimmune Disease-Related Progressive Fibrosing Interstitial Lung Diseases: Subgroup Analysis of the INBUILD Trial

Objective

To analyze the efficacy and safety of nintedanib in patients with fibrosing autoimmune disease–related interstitial lung diseases (ILDs) with a progressive phenotype.

Methods

The INBUILD trial enrolled patients with a fibrosing ILD other than idiopathic pulmonary fibrosis, with diffuse fibrosing lung disease of >10% extent on high‐resolution computed tomography, forced vital capacity percent predicted (FVC%) ≥45%, and diffusing capacity of the lungs for carbon monoxide percent predicted ≥30% to <80%. Patients fulfilled protocol‐defined criteria for progression of ILD within the 24 months before screening, despite management deemed appropriate in clinical practice. Subjects were randomized to receive nintedanib or placebo. We assessed the rate of decline in FVC (ml/year) and adverse events (AEs) over 52 weeks in the subgroup with autoimmune disease–related ILDs.

Results

Among 170 patients with autoimmune disease–related ILDs, the rate of decline in FVC over 52 weeks was −75.9 ml/year with nintedanib versus −178.6 ml/year with placebo (difference 102.7 ml/year [95% confidence interval 23.2, 182.2]; nominal P = 0.012). No heterogeneity was detected in the effect of nintedanib versus placebo across subgroups based on ILD diagnosis (P = 0.91). The most frequent AE was diarrhea, reported in 63.4% and 27.3% of subjects in the nintedanib and placebo groups, respectively. AEs led to permanent discontinuation of trial drug in 17.1% and 10.2% of subjects in the nintedanib and placebo groups, respectively.

Conclusion

In the INBUILD trial, nintedanib slowed the rate of decline in FVC in patients with progressive fibrosing autoimmune disease–related ILDs, with AEs that were manageable for most patients.

Video Abstract

POS0900 SYSTEMIC PHARMACOLOGICAL TREATMENT OF DIGITAL ULCERS IN SYSTEMIC SCLEROSIS: A SYSTEMATIC LITERATURE REVIEW

Background

Digital ulcers (DU) are common in systemic sclerosis (SSc) and associated with reduced survival, high morbidity and poor quality of life. Recommendations have previously been proposed for DU management yet there remains significant unmet patient need. Therefore the World Scleroderma Foundation DU Working Group intends to develop practical evidence based recommendations for DU management.

Objectives

To summarise data on efficacy and safety of systemic treatments for SSc DU.

Methods

A systematic literature review to May 2021 was performed. PubMed, MEDLINE, Embase, Web of Science, Cochrane Library, Emcare (OVID) and Academic Search Premier databases were searched for original studies on adult patients with SSc DU treated with systemic pharmacological treatment. Based on the PICO framework, eligibility criteria were defined and references were independently screened by two reviewers. Reviewers independently assessed the full text of eligible articles. Owing to interstudy heterogeneity narrative summaries were used to present data.

Results

The search strategy identified 1271 references of which 45 eligible articles were included. Seventeen studies were randomised placebo controlled trials (RCT) pertaining to PDE5 antagonists (PDE5i) (n=3), endothelin receptor antagonists (ERA) (n=3), prostanoids (n=7), antiplatelet agents (n=1) and other (n=3) (Table 1). No head to head RCT was retrieved. All other studies were observational studies (OBS). Studies were highly heterogeneous with application of differing definition of DU, variable study eligibility criteria, clinical endpoints and follow up periods. This limited the calculation of effect size and comparison across studies.

Table 1.

Characteristics of placebo controlled randomised controlled trials

Author YearInterventionnFollow upOutcomeFavours interventionHachulla 2016Sildenafil8312 weeksTime to DU healing-Andrigueti 2017Sildenafil4112 weeksDU healing+Shenoy 2010Tadalafil246 weeksNew DU+Khanna 2016Macitentan55416 weeksNew DU-Matucci-Cerinic 2011Bosentan18832 weeksNew DU Time to healing of DU+-Korn 2004Bosentan12212 weeksNew DU+Kawald 2008IV iloprost5012 monthsDU healing-Wigley 1992IV iloprost3510 weeksDU healing+Wigley 1994IV iloprost739 weeks50% reduction in DU score-Seibold 2017Treprostinil14820 weeksNet DU burden-Vayssairat 1999Beraprost10725 weeks% patients with new DU-Denton 2017Selexipag7412 weeksNumber of new DU DU healing-Lau 1993Cicaprost334 weeksNumber of DU-Abou-Raya 2008Atorvastatin844 monthsNumber of DU+Au 2010Cyclophosphamide15812 monthsNumber of patients with DU-Beckett 1984Dipyridamole / aspirin412 yearsChange in general SSc-Nagaraja 2019Riociguat1732 weeksNet DU burden-

+ significantly superior to comparator

- non significantly different from comparator

DU: digital ulcers IV: intravenous SSc: systemic sclerosis

Several RCT found improved DU healing with treatment: two with PDE5i, one with iloprost and one showed improved DU healing and prevention with atorvastatin. Two RCT demonstrated effective prevention of new DU with bosentan. OBS studies with a total of 621 patients showed variable improvements in the healing of DU with CCB, PDE5i, ERA, statins, N-acetylcysteine, prostanoids and ketanserin and prevention of new DU with ERA.

Regarding safety, all treatments were generally tolerated with few serious adverse events. Treatment was ceased in 6.25-17.5% of patients in RCT due to treatment related side effects.

Conclusion

Despite several studies assessing the efficacy and safety of systemic pharmacological treatment of SSc DU, it is not possible to draw solid conclusions due to study heterogeneity. Small RCT have shown treatment benefit with PDE5i, iloprost and atorvastatin. Large studies demonstrated effective prevention of new DU with bosentan. Our results highlight the urgent need for improved clinical trial design to generate more robust evidence and novel therapies to guide the management SSc DU.

Acknowledgements

This work was supported by the World Scleroderma Foundation.

Disclosure of Interests

Nancy Maltez: None declared, Laura Ross: None declared, Michael Hughes Speakers bureau: Actelion Pharmaceuticals, Eli Lilly and Pfizer outside of the submitted work., Jan Schoones: None declared, Murray Baron: None declared, Lorinda Chung Consultant of: Eicos, Corrado Campochiaro: None declared, Yossra A. Suliman: None declared, Dilia Giuggioli: None declared, Pia Moinzadeh Speakers bureau: Actelion Pharmaceuticals, Boehringer Ingelheim, Yannick Allanore: None declared, Christopher P Denton: None declared, Oliver Distler Speakers bureau: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur., Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur., Grant/research support from: Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143), Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur., Tracy Frech: None declared, Daniel Furst: None declared, Dinesh Khanna Consultant of: Eicos Sciences Inc, Janssen, Thomas Krieg: None declared, Masataka Kuwana Speakers bureau: Speaker fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and consultancy fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida outside of the submitted work., Marco Matucci-Cerinic: None declared, Janet Pope: None declared, Alessia Alunno: None declared

Predictors of Influenza Vaccination in Early Rheumatoid Arthritis 2017-2021: Results From the Canadian Early Arthritis Cohort

Objective

Adults with rheumatoid arthritis (RA) are at a higher risk for infections, including influenza and related complications. We identified influenza vaccination coverage in adults newly diagnosed with RA and examined sociodemographic RA characteristics and attitudes associated with vaccination.

Methods

We used data from patients enrolled in the Canadian Early Arthritis Cohort between September 2017 and February 2021. At enrollment, participants reported their vaccination status in the previous year and completed the Beliefs About Medicines Questionnaire (BMQ). Clinical data were obtained from medical records. Logistic regression was used to identify predictors of vaccination in the year after RA diagnosis.

Results

The baseline analytic sample of 431 patients were mostly White (80%) women (67%) with a mean age of 56 (SD 14) years. Prediagnosis, influenza vaccine coverage was 38%, increasing to 46% post diagnosis in the longitudinal sample (n = 229). Participants with previous influenza vaccination (odds ratio [OR] 15.33; 95% confidence interval [CI] 6.37‐36.90), on biologics or JAKs (OR 5.42; 95% CI 1.72‐17.03), and with a higher change in BMQ Necessity‐Concerns Differential scores (OR 1.08; 95% CI 1.02‐1.15) had greater odds, whereas women (OR 0.32; 95% CI 0.14‐0.71), participants with a non‐White racial background (OR 0.13; 95% CI 0.04‐0.51), and participants currently smoking (OR 0.09; 95% CI 0.02‐0.37) had lower odds of influenza vaccine coverage.

Conclusion

Influenza vaccination coverage in patients with early RA remains below national targets in adults living with a chronic condition. Discussing vaccine history and medication attitudes at initial clinic visits with new patients with RA may enhance vaccine acceptance and uptake.

Randomized feasibility trial of the Scleroderma Patient-centered Intervention Network Self-Management (SPIN-SELF) Program

BACKGROUND

The Scleroderma Patient-centered Intervention Network (SPIN) developed an online self-management program (SPIN-SELF) designed to improve disease-management self-efficacy in people with systemic sclerosis (SSc, or scleroderma). The aim of this study was to evaluate feasibility aspects for conducting a full-scale randomized controlled trial (RCT) of the SPIN-SELF Program.

METHODS

This feasibility trial was embedded in the SPIN Cohort and utilized the cohort multiple RCT design. In this design, at the time of cohort enrollment, cohort participants consent to be assessed for trial eligibility and randomized prior to being informed about the trial. Participants in the intervention arm are informed and provide consent, but not the control group. Forty English-speaking SPIN Cohort participants from Canada, the USA, or the UK with low disease-management self-efficacy (Self-Efficacy for Managing Chronic Disease Scale [SEMCD] score ≤ 7) who were interested in using an online self-management program were randomized (3:2 ratio) to be offered the SPIN-SELF Program or usual care for 3 months. Program usage was examined via automated usage logs. User satisfaction was assessed with semi-structured interviews. Trial personnel time requirements and implementation challenges were logged.

RESULTS

Of 40 SPIN Cohort participants randomized, 26 were allocated to SPIN-SELF and 14 to usual care. Automated eligibility and randomization procedures via the SPIN Cohort platform functioned properly, except that two participants with SEMCD scores > 7 (scores of 7.2 and 7.3, respectively) were included, which was caused by a system programming error that rounded SEMCD scores. Of 26 SPIN Cohort participants offered the SPIN-SELF Program, only 9 (35%) consented to use the program. Usage logs showed that use of the SPIN-SELF Program was low: 2 of 9 users (22%) logged into the program only once (median = 3), and 4 of 9 (44%) accessed none or only 1 of the 9 program's modules (median = 2).

CONCLUSIONS

The results of this study will lead to substantial changes for the planned full-scale RCT of the SPIN-SELF Program that we will incorporate into a planned additional feasibility trial with progression to a full-scale trial. These changes include transitioning to a conventional RCT design with pre-randomization consent and supplementing the online self-help with peer-facilitated videoconference-based groups to enhance engagement.

TRIAL REGISTRATION

clinicaltrials.gov , NCT03914781 . Registered 16 April 2019.

Results from the 2020 Canadian Rheumatology Association's Workforce and Wellness Survey

Objective

The Canadian Rheumatology Association (CRA) launched the Workforce and Wellness Survey to update the Canadian rheumatology workforce characteristics.

Methods

The survey included demographic and practice information, pandemic impacts, and the Mini-Z questionnaire to assess burnout. French and English survey versions were distributed to CRA members electronically between 10/14/2020-3/5/2021. The number of full-time equivalent (FTE) rheumatologists per 75,000 population was estimated from the median proportion of time in clinical practice multiplied by provincial rheumatologist numbers from the Canadian Medical Association (CMA).

Results

Forty-four percent (183/417) of the estimated practicing rheumatologists (149 adult; 34 pediatric) completed the survey. The median age was 47 years, 62% were female, and 28% planned to retire within the next 5-10 years. Respondents spent a median of 65% of their time in clinical practice. FTE rheumatologists per 75,000 ranged between 0 and 0.70 in each province/territory and 0.62 per 75,000 nationally. This represents a deficit of 1 to 78 FTE rheumatologists per province/territory and 194 FTE rheumatologists nationally to meet the CRA's workforce benchmark. Approximately half of survey respondents reported burnout (51%). Women were more likely to report burnout (OR 2.86, 95%CI: 1.42-5.93). Older age was protective against burnout (OR 0.95, 95%CI: 0.92, 0.99). As a result of the pandemic, 97% of rheumatologists reported spending more time engaged in virtual care.

Conclusion

There is a shortage of rheumatologists in Canada. This shortage may be compounded by the threat of burnout to workforce retention and productivity. Strategies to address these workforce issues are urgently needed.

The Scleroderma Patient-centered Intervention Network Self-Management (SPIN-SELF) Program: protocol for a two-arm parallel partially nested randomized controlled feasibility trial with progression to full-scale trial

BACKGROUND

Systemic sclerosis (scleroderma; SSc) is a rare autoimmune connective tissue disease. We completed an initial feasibility trial of an online self-administered version of the Scleroderma Patient-centered Intervention Network Self-Management (SPIN-SELF) Program using the cohort multiple randomized controlled trial (RCT) design. Due to low intervention offer uptake, we will conduct a new feasibility trial with progression to full-scale trial, using a two-arm parallel, partially nested RCT design. The SPIN-SELF Program has also been revised to include facilitator-led videoconference group sessions in addition to online material. We will test the group-based intervention delivery format, then evaluate the effect of the SPIN-SELF Program on disease management self-efficacy (primary) and patient activation, social appearance anxiety, and functional health outcomes (secondary).

METHODS

This study is a feasibility trial with progression to full-scale RCT, pending meeting pre-defined criteria, of the SPIN-SELF Program. Participants will be recruited from the ongoing SPIN Cohort ( http://www.spinsclero.com/en/cohort ) and via social media and partner patient organizations. Eligible participants must have SSc and low to moderate disease management self-efficacy (Self-Efficacy for Managing Chronic Disease (SEMCD) Scale score ≤ 7.0). Participants will be randomized (1:1 allocation) to the group-based SPIN-SELF Program or usual care for 3 months. The primary outcome in the full-scale trial will be disease management self-efficacy based on SEMCD Scale scores at 3 months post-randomization. Secondary outcomes include SEMCD scores 6 months post-randomization plus patient activation, social appearance anxiety, and functional health outcomes at 3 and 6 months post-randomization. We will include 40 participants to assess feasibility. At the end of the feasibility portion, stoppage criteria will be used to determine if the trial procedures or SPIN-SELF Program need important modifications, thereby requiring a re-set for the full-scale trial. Otherwise, the full-scale RCT will proceed, and outcome data from the feasibility portion will be utilized in the full-scale trial. In the full-scale RCT, 524 participants will be recruited.

DISCUSSION

The SPIN-SELF Program may improve disease management self-efficacy, patient activation, social appearance anxiety, and functional health outcomes in people with SSc. SPIN works with partner patient organizations around the world to disseminate its programs free-of-charge.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04246528 . Registered on 27 January 2020.

A Bridge Too Far? Real-World Practice Patterns of Early Glucocorticoid Use in the Canadian Early Arthritis Cohort

OBJECTIVE

To describe patterns of glucocorticoid use in a large real-world cohort with early rheumatoid arthritis (RA) and assess the impact on disease activity and treatment.

METHODS

Data are from adults with new RA (≤1 year) recruited to the Canadian Early Arthritis Cohort (CATCH) and are stratified on the basis of whether a person was prescribed oral glucocorticoids within 3 months of study entry. Disease activity was compared over 24 months. Mixed-effects logistic regression was used for adjusted odds ratios (aORs) of escalation to biologics separately for 12 and 24 months, with random effects terms to account for prescribing patterns clustering by study site.

RESULTS

Among 1891 persons, 30% received oral steroids. Users were older, were less often employed, and had shorter disease duration and higher disease activity. Disease activity improved over time, with early glucocorticoid users starting at higher levels of disease activity. Participants with early oral glucocorticoids were more likely to be on a biologic at 12 months (aOR = 2.4; 95% confidence interval [CI], 1.5-3.7) and 24 months (aOR = 1.9; 95% CI, 1.3-3.0). Despite Canadian clinical practice guidelines to limit corticosteroid use to short-term or 'bridge' therapy, 30% of patients who used oral glucocorticoids still used them 2 years later.

CONCLUSION

Early steroids were prescribed sparingly in CATCH and were often indicative of more active baseline disease as well as the need for progression to biologics.

Prenatal mental and physical health, behaviours, and maternity care experiences during the COVID-19

Background

During pregnancy, women's mental and physical health, health behaviours, and experiences of maternity care can have significant implications for obstetric, maternal and child outcomes. These factors can be impacted by adverse life-events, such as the COVID-19 pandemic.

Aim

This study examined pregnant women's mental and physical health, health behaviours, and experiences of maternity care during the COVID-19 pandemic.

Methods

An international online survey was conducted in June and July 2020. Pregnant women self-reported levels of general stress, pregnancy-specific stress and COVID-19 related stress. Women also self-reported their mental and physical health, general health behaviours and COVID-19 related health behaviours. Maternity care experiences were reported using closed and open-ended questions. Descriptive statistics and thematic analyses were used for quantitative and qualitative data respectively.

Results

573 pregnant women from 15 countries participated. Women reported high levels of pregnancy-specific and COVID-19-related stress, and low levels of mental and physical health, during the pandemic. Women reported distress related to restrictions implemented in their maternity care that limited in-person interactions with healthcare professionals and partner attendance at antenatal appointments. Lack of information on COVID-19 and pregnancy also led to uncertainty for women about pregnancy and birth. Encouragingly, pregnant women reported high levels of adherence to public health advice and healthy prenatal behaviours.

Conclusions

The COVID-19 pandemic is having significant adverse effects on the mental and physical health of pregnant women. Population level interventions targeting pregnancy- and pandemic-specific stress are needed to better support the mental and physical health of women during the on-going pandemic and minimise adverse outcomes for women and children.

Key messages

The COVID-19 pandemic is significantly adversely impact the mental and physical health of pregnant women, indicating need for population level interventions for prenatal mental and physical health. Restrictions in maternity care and uncertainty about COVID-19 impacts are key determinant of adverse prenatal physical and mental health outcomes.

The frequency of uveitis in patients with adult versus childhood spondyloarthritis

Objectives

This meta-analysis investigated the frequency of ocular involvement in childhood and adult spondyloarthritis (SpA).

Methods

A systematic review of the literature was conducted. Medline, Web of Science and Cochrane databases were searched upto October 2018 identifying publications related to SpA, including ankylosing spondylitis (AS) with ocular conditions (OC) (uveitis, iritis, retinitis, chorioretinitis and other ocular involvement). The rates of OC were extracted and random effects models estimated their frequency. Heterogeneity was evaluated using I². Inclusion criteria were studies in SpA of either children or adults who included a frequency of OC.

Results

3164 studies were identified, and 41 analysed which included frequencies of uveitis/iritis. Other OC were too infrequent to analyse. A pooled random effects model showed that the prevalence of uveitis was 24% in adult AS (23 studies, 11 943 patients), 10% in adult psoriatic arthritis (PsA) (9 studies, 1817) and 17% in undifferentiated adult SpA (9 studies, 6568 patients). In juveniles with AS, the prevalence of uveitis was 27% (8 studies, 927 patients), in juvenile PsA it was 16% (5 studies, N=498) and in juvenile undifferentiated SpA, uveitis occurred in 7% (2 studies, 1531 patients). In all evaluated SpA subgroups, there were no statistical differences in the frequency of uveitis between juveniles and adults.

Conclusions

Uveitis in adult versus child-onset SpA is similar in AS but more common in adult-onset undifferentiated SpA, and less frequent in adult-onset PsA compared to child-onset PsA, but the differences were not significant.

Efficacy and safety of tofacitinib modified-release 11 mg once daily plus methotrexate in adult patients with rheumatoid arthritis: 24-week open-label phase results from a phase 3b/4 methotrexate withdrawal non-inferiority study (ORAL Shift)

OBJECTIVES

To report the efficacy, safety and patient-reported outcome measures (PROs) of tofacitinib modified-release 11 mg once daily plus methotrexate in patients with rheumatoid arthritis (RA) from the open-label phase of Oral Rheumatoid Arthritis Trial (ORAL) Shift.

METHODS

ORAL Shift was a global, 48-week, phase 3b/4 withdrawal study in patients with moderate to severe RA and an inadequate response to methotrexate. Patients received open-label tofacitinib modified-release 11 mg once daily plus methotrexate; those who achieved low disease activity (LDA; Clinical Disease Activity Index (CDAI)≤10) at week 24 were randomised to receive blinded tofacitinib 11 mg once daily plus placebo (ie, blinded methotrexate withdrawal) or continue with blinded tofacitinib 11 mg once daily plus methotrexate for another 24 weeks. Efficacy, PROs and safety from the open-label phase are reported descriptively.

RESULTS

Following screening, 694 patients were enrolled and received tofacitinib plus methotrexate in the open-label phase. At week 24, 527 (84.5%) patients achieved CDAI-defined LDA. Improvements from baseline to weeks 12 and 24 were generally observed for all efficacy outcomes (including measures of disease activity, and response, LDA and remission rates) and PROs. Adverse events (AEs), serious AEs and discontinuations due to AEs were reported by 362 (52.2%), 20 (2.9%) and 41 (5.9%) patients, respectively. No deaths were reported.

CONCLUSIONS

Tofacitinib modified-release 11 mg once daily plus methotrexate conferred improvements in disease activity measures, functional outcomes and PROs, with most (84.5%) patients achieving CDAI-defined LDA after 24 weeks of open-label treatment; the safety profile was generally consistent with the historic safety profile of tofacitinib.Funded by Pfizer Inc; NCT02831855.

OP0262-HPR THE NEURO-QOL UPPER EXTREMITY FUNCTION SCALE: NEW OPPORTUNITIES TO MORE RELIABLY AND PRECISELY MEASURE SELF-REPORTED HAND FUNCTION AND SELF-CARE ACTIVITIES IN PEOPLE WITH RA

Background:

RA is an inflammatory disease that results in pain and loss of function, especially in the hands and wrists. Brief self-assessment tools that can reliably and precisely quantify hand/wrist function are needed to assess inflammatory activity when a physical exam is not feasible and to capture day-to-day experience of living with RA. Neuro-QoL is part of the PROMIS family of self-report measures created using a patient-centred approach and IRT methodology. The Neuro-Qol Upper Extremity Function (UEF) scale measures ability across fine motor and ADLs involving digital, manual and reach-related function and self-care. Little is known about its performance in RA.

Objectives:

To evaluate the validity and responsiveness of the 8-item Neuro-QoL UEF in RA. We hypothesized scores would be strongly (r>.70) associated with MHAQ, MD-HAQ, and PROMIS PF, moderately (r=.4 to .7) to symptoms, disease activity, and QoL indicators, and be responsive to change in disease activity and PF.

Methods:

Data were from the 0 and 6-month visits of adults with early RA (sx <1 yr) enrolled in the Canadian Early Arthritis Cohort, a prospective real-world study at 16 sites across Canada. Participants completed the Neuro-QoL UEF, MHAQ, MDHAQ, PROMIS-29, and PT Global at each visit. Rheumatologists recorded joint counts and MD Global. To evaluate content validity, we examined descriptive statistics across CDAI disease activity levels, and Pearson correlations between the Neuro-QOL UEF, legacy measures, CRP & ESR. Responsiveness was assessed by correlating change scores from visits 0-6 between Neuro-QoL UEF, disease activity and legacy PF scores.

Results:

The 262 participants were mostly white (83%) women (71%) with a mean (SD) age of 55 (13). Summary statistics at 6-months are shown in Table 1. Neuro-QOL UEF was moderately-strongly correlated with MHAQ, MDHAQ, PROMIS-PF (|r|=.63-.75) and moderately correlated with pain and stiffness, (|r|=.59, -.64), and CDAI, SDAI, PT&MD Global, TJ & SJ (|r|=.39-.58). Neuro-QOL UEF was moderately correlated with PROMIS QoL domains Pain, Fatigue, Anxiety, Depression, Sleep & Participation (|r|=.39-.60).

Table 1.

Summary statistics of physical function and RA disease activity indices at 6 months.

MeanSDMdn25%75%(Min, Max)Physical FunctionNeuro-Qol UEF46.59.753.837.553.8(21.8, 53.8)MHAQ (0-3)0.290.430.130.000.38(0.00, 2.25)MD-HAQ (0-10)1.391.640.700.002.00(0.00, 8.00)PROMIS-PF46.48.546.239.556.0(23.3, 56.0)RA Disease ActivityCDAI9.39.96.03.013.0(0.0, 56.0)SDAI10.710.96.83.115.2(0.0, 57.0)Patient Global3.02.5315(0, 10)MD Global1.82.2103(0, 9)Swollen Joints (28)2.13.7002(0, 20)Tender Joints (28)2.43.9103(0, 24)

Neuro-QOL scores decreased in a dose-response manner across worsening CDAI DA states reflecting increasing impairment (Table 2). Persons with HDA reported the highest disability, scoring nearly 0.5 SD lower on the Neuro-QoL UEF than PROMIS PF. Change from baseline to 6 months in Neuro-QoL UEF was moderately correlated with changes in PROMIS PF, MHAQ, PT Global, and CDAI (|r|=.44-.65). The mean change and range from 0-6 months in Neuro-QoL was significantly larger than in PROMIS (8.9 [95% CI 7.5, 10.4] vs. 5.4 [95% CI 4.4, 6.4])(see Figure).

Table 2.

Mean scores (95% CI) at 6 months by CDAI level.

REMLDAMDAHADNeuroQol UEF52.8 (51.8, 53.7)48.1 (46.6, 49.7)42.0 (39.4, 44.6)33.8 (30.5, 37.1)MHAQ (0-3)0.05 (0.02, 0.09)0.19 (0.14, 0.24)0.45 (0.34, 0.57)0.90 (0.63, 1.17)MD-HAQ (0-10)0.31 (0.17, 0.46)1.11 (0.90, 1.32)2.15 (1.71, 2.59)3.56 (2.56, 4.56)PROMIS-PF52.8 (51.4, 54.2)46.8 (45.3, 48.2)42.3 (40.4, 44.2)38.0 (34.4, 41.6)

Conclusion:

Clinicians, researchers, and patients benefit from practical self-report tools that reliably and precisely monitor hand function in RA. Results offer initial evidence of validity and responsiveness and support use of Neuro-QoL UEF to self-assess inflammatory activity in the hands and day-to-day experiences of living with RA.

Acknowledgements:

The CATCH study was designed and implemented by the investigators and financially supported through unrestricted research grants from: Amgen and Pfizer Canada - Founding sponsors since January 2007; AbbVie Corporation and Hoffmann-LaRoche since 2011; Medexus Inc. since 2013;, Merck Canada since 2017, Sandoz Canada, Biopharmaceuticals since 2019,Gilead Sciences Canada since 2020 and Fresenius Kabi Canada Ltd. since 2021. Previously funded by Janssen Biotech from 2011-2016, UCB Canada and Bristol-Myers Squibb Canada from 2011-2018, Sanofi Genzyme from 2016-2017, and Eli Lilly Canada from 2016-2020.

Disclosure of Interests:

None declared

OP0172 BRENTUXIMAB VEDONTIN FOR SKIN INVOLVEMENT IN REFRACTORY DIFFUSE CUTANEOUS SYSTEMIC SCLEROSIS, INTERIM RESULTS OF A PHASE IIB OPEN-LABEL TRIAL

Background:

Systemic sclerosis (SSc) is an autoimmune disease affecting multiple organs causing morbidity and mortality. Treatments targeting SSc skin often have limited success. The presence of CD30+ lymphocytes in skin biopsies and increased levels of serum CD30 have been reported in SSc patients1. This could constitute a new therapeutic target.

Objectives:

To explore the efficacy and safety of brentuximab vedotin, a chimeric anti-CD30 antibody drug conjugate, in patients with severe active diffuse cutaneous SSc who failed multiple treatments.

Methods:

This Phase IIb, single center, open-label, investigator-initiated trial will recruit 10 patients. Brentuximab vedotin 0.6 mg/Kg was infused intravenously every 3 weeks for 48 weeks. Inclusion criteria were age ≥18 years, meeting the 2013 ACR/EULAR SSc classification criteria, modified Rodnan skin score (mRSS) ≥15 with <5 years since the first non-Raynaud’s symptom and/or skin worsening despite immunosuppression. Patients were allowed to continue their standard of care medications for SSc except for rituximab. Patients with severe cardiac or pulmonary SSc involvement, severe infections, significant peripheral neuropathy, or active malignancy were excluded. The primary objective was a decrease in mRSS of ≥8 at 48 weeks. The main secondary endpoint was MRSS at 24 weeks. Differences were assessed by paired t tests. Data were compared to 16 age, disease duration, mRSS and past/present use of immunosuppressors-matched controls (ratio 2-3:1) from the Canadian Scleroderma Research Group (CSRG) registry.

Results:

Eight of 10 patients have been recruited to date; two are in the first 8 weeks and one was withdrawn at her request after developing influenza at week 12. Five subjects (60% female) have reached week 24, and 3 have completed 48 weeks. The mRSS is shown in Table 1. The ΔMRSS for patients treated with brentuximab between weeks 0 and 24 was 8.2 ([CI 95% 2.8, 13.6], p = 0.013) and from 0 to 48 was 15.3 ([CI 95% 8.2, 22.5], p = 0.012). Whereas, the ΔMRSS for the CSRG controls was 3.1 ([CI 95% -2, 8.2], p = 0.211) at 48 weeks. Assuming that mRSS would at least be the same from week 24 to 48 in the 2 cases who are between 24 and 48 weeks with brentuximab, we compared the 5 cases vs controls (Figure 1). ΔMRSS for Brentuximab was 12.2 ([CI 95% 5.9, 18.5], p = 0.006. No cases have developed a peripheral neuropathy and only one SAE (influenza).

Table 1.N (SD)NAgeDisease durationmRSS week 0mRSS week 24mRSS week 48mRSS week 48**Case560.2 (9.3)4.5 (2.1)33 (5.2)24.8 (6)15.7 (3)20.8 (8.3)Control1658.5 (8.3)4.9 (2.1)31.3 (5.9)N/D28.1 (7.5)28.1 (7.5)p0.7310.7750.559N/D0.0130.079

mRSS = modified Rodnan skin score, N/D = no data, ** = comparisons including 5 cases, assuming stability in MRSS from week 24 to 48 in cases 5 and 6

Figure 1.

Conclusion:

Brentuximab vedontin already achieved the primary endpoint at 24 weeks, after half of the intended recruitment sample reached this landmark. A comparison with CSRG controls showed that mRSS only decreased significantly in patients treated with brentuximab. This interim report suggests that brentuximab vedontin might effectively improve skin involvement in patients with diffuse SSc and severe skin involvement.

References:

[1]Mavalia C, Scaletti C, Romagnani P, et al. Type 2 helper T-cell predominance and high CD30 expression in systemic sclerosis. Am J Pathol. 1997;151(6):1751-8.

Acknowledgements:

We would like to acknowledge the Canadian Scleroderma Research Group, Louise Vanderhoek, Sara Macdonald Hewitt and Jillian Bylsma for their collaboration

Disclosure of Interests:

Andreu Fernandez-Codina Consultant of: Bayer, Boehringer Ingelheim, Atheneum consulting, Tatiana Nevskaya: None declared, Janet Pope Speakers bureau: Actelion, Amgen, Abbie, Bayer, Boehringer Ingelheim, BMS, Eli Lilly, Galapagos, Gilead, Janssen, Medexus, Merck, Novartis, Pfizer, Roche, Samsung, Sandoz, Sanofi, Teva, UCB., Consultant of: Actelion, Amgen, Abbie, Bayer, Boehringer Ingelheim, BMS, Eli Lilly, Galapagos, Gilead, Janssen, Medexus, Merck, Novartis, Pfizer, Roche, Samsung, Sandoz, Sanofi, Teva, UCB., Grant/research support from: Actelion, Amgen, Abbie, Bayer, Boehringer Ingelheim, BMS, Eli Lilly, Galapagos, Gilead, Janssen, Medexus, Merck, Novartis, Pfizer, Roche, Samsung, Sandoz, Sanofi, Teva, UCB.

AB0419 ACCESS TO TREATMENT FOR RAYNAUD’S PHENOMENON AND DIGITAL ULCERS FOR PATIENTS WITH SYSTEMIC SCLEROSIS DOESN’T FOLLOW EULAR/EUSTAR GUIDELINES

Background:

Patients with Raynaud’s Phenomenon (RP) from systemic sclerosis (SSc) may experience severe complications. Digital ulcers (DUs), occur in approximately half the patients with SSc, and cause hand dysfunction, severe pain, and decreased quality of life. DUs lead to increased healthcare utilization and systemic economic burden through hospitalizations, ED visits, and ambulatory services (1). However, access to medications such as PDE5 inhibitors and prostacyclins that are within the EULAR/EUSTAR SSc guidelines (2) in a country with global health care but patchy pharmacare such as Canada has not been studied.

Objectives:

The purpose of this study was to elucidate the access to treatment of medications for RP and DU in patients with SSc in Canadian provinces through identifying the provincial and private insurance coverage of PDE5 inhibitors (PDE5i) and prostanoids, the timelines and procedures of requesting these medications, and the process of administering IV prostanoids if required for patient care.

Methods:

We designed an online survey and collected data through the Survey Monkey platform. The survey was administered to rheumatologists affiliated with the Canadian Scleroderma Research Group (CSRG) from December 2020 to January 2021. Responders were asked to report if the province or private insurance automatically provided PDE5i for patients with RP and DU or if a dedicated process was required to attain these medications. Additionally, responders were asked to describe the process of administering Iloprost, Epoprostenol and Alprostadil and the barriers inherent to their administration. Of note, there is no DIN number for Iloprost in Canada so every time it is used there must be an application to Health Canada.

Results:

The survey was completed by 100% of CSRG researchers (17/17), representing 8 provinces in Canada. None of the provincial governments provided coverage for PDE5i without special requests that were adjudicated on a case by case basis with approximately half the provinces paying for PDE5i upon special request if a patient was eligible for provincial drug insurance (ex elderly, youths, low income families). Two provinces, Quebec and Saskatchewan, provided PDE5i “all the time”. Whereas NS, MB, ON, BC, and AB provided them “sometimes”; NFLD provided them “never”. Provincial governments and private insurance fulfilled requests “within 1 month” 62% of the time and the other requests took longer to be answered. Private insurance approved coverage with special request in AB, MB, QC, ON, and NS. Respondents described administration of IV prostanoids as “inconsistent”, requiring “a lot of work”, and that patients in most jurisdictions be admitted as in-patients for provinces to cover these medications.

Conclusion:

Most jurisdiction within Canada do not provide coverage for PDE5i and the process to obtain access for patients is delayed, non-uniform, and often not approved. Intravenous prostanoid infusions are difficult to obtain and have system barriers. Advocacy and cost effectiveness data should be used to advocate for access to medications that are recommended within SSc recommendations.

References:

[1]Morrisroe K, et al. Digital ulcers in systemic sclerosis: their epidemiology, clinical characteristics, and associated clinical and economic burden. Arthritis research & therapy. 2019 Dec;21(1):1-2.

[2]Kowal-Bielecka O, et al. Update of EULAR recommendations for the treatment of systemic sclerosis. Annals of the rheumatic diseases. 2017 Aug 1;76(8):1327-39.

Disclosure of Interests:

None declared

AB0447 PREVALENCE OF PRIMARY BILIARY CIRRHOSIS IN SYSTEMIC SCLEROSIS AND SJÖGREN’S SYNDROME OVER TIME: A SYSTEMATIC REVIEW

Background:

Primary biliary cirrhosis (PBC) is a rare slowly progressive autoimmune disease characterized by inflammatory destruction and fibrosis of intrahepatic bile ducts. It is known to coexist together with rheumatological conditions such as Sjögren’s syndrome (SS) and systemic sclerosis (SSc). There is a wide range in reported prevalence of disease overlap with these entities; however, the exact prevalence rates remain unclear.

Objectives:

The objectives were to determine the prevalence of: 1) PBC in patients with SS and SSc (and the subsets of limited cutaneous SSc (lcSSc) and diffuse cutaneous SSc (dcSSc)), 2) SSc and SS in patients with PBC, and 3) to analyze changes in frequency over time. SSc occurs in 3/10,000 and PBC in 4-40/10,000 but these rare autoimmune diseases are known to coexist together. We speculated that there could be more cases diagnosed due to increasing availability of standardized antibody tests such as ANA, centromere antibodies, ENA and mitochondrial antibodies.

Methods:

A systematic review of the literature was performed using Medline, EMBASE, CINAHL, and the Cochrane Library databases up till June 16, 2020. Only full text articles in the English language with at least 40 patients were included. Cohorts, case series, cross-sectional studies, correspondences and registries with reported prevalence rates of both PBC in patients with SS and SSc as well as SSc and SS in patients with PBC were included. Data on frequency of co-existent diseases was studied by year of publication to determine if prevalence changed over time using linear regression. We used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist to assess the quality of the studies.

Results:

Of 2876 citations identified, 67 were included in the analysis (n=33 for PBC, 15 for SSc, 18 for SS and 1 for SSc/SS). STROBE checklist scores ranged from 7-21. The prevalence of PBC was 5% in patients with SSc. Within the subsets, the prevalence of PBC in lcSSc was 8% and in dcSSc was 1%. In patients with SS, the prevalence of PBC was 4%. The prevalence of SSc overall in those with PBC was 5% and, within the subsets was 6% in lcSSc and 0% in dcSSc. The prevalence of SS in PBC was 18%. There was also no significant association between year of publication and prevalence. There was a lack of standardized definitions so misclassification may have occurred.

Conclusion:

PBC is increased in SSc but mostly in the lcSSc subset. SS in PBC is common at nearly 1 in 5. Over the years, there was no change in the prevalence of PBC in SSc indicating stability over time.

Acknowledgements:

Meagan Stanley, Western University Librarian.

Disclosure of Interests:

None declared.

POS0474 SUBSTANTIAL IMPACT OF AUTOANTIBODY ENRICHMENT ON OUTCOMES IN EARLY RHEUMATOID ARTHRITIS TREATED WITH ABATACEPT: DATA FROM A LARGE POOLED ANALYSIS OF 4 RCTS

Background:

Biomarkers are commonly used as prognostic tools in rheumatoid arthritis (RA) and have additional potential to guide treatment decisions. Previous clinical trials of abatacept (ABA) such as the Early AMPLE trial (eAMPLE) and real-world data suggest differential treatment effects of ABA based on the presence of biomarkers and disease stage.1-4

Objectives:

To supplement evidence of enhanced efficacy of ABA among patients with enriched autoantibody biomarkers and early disease stage by applying key inclusion criteria from the eAMPLE trial retrospectively to historic ABA RCTs.

Methods:

Individual patient data (IPD) from four early-RA ABA trials (AGREE [NCT00122382], AMPLE [NCT00929864], AVERT [NCT01142726], AVERT-2 [NCT02504268]) were pooled. Patients were defined as enriched at baseline if they had: 1) RA disease duration ≤ 12 months, 2) DAS28-CRP ≥ 3.2, 3) ≥ 3 times the upper limit of normal on an anti-cyclic citrullinated peptide (anti-CCP) test, and 4) were rheumatoid factor positive (RF+). Patients were grouped according to treatment status (ABA [monotherapy or with methotrexate (MTX)] or non-ABA [MTX or adalimumab (ADA) plus MTX]). Outcomes included DAS28-CRP mean change from baseline to week 24, DAS28-CRP remission and ACR 20/50/70 at week 24. IPD mixed-effects meta-regressions were estimated with trial fixed effects, main effects and interaction of enrichment status and treatment type, trial-level random effects on the interaction, and baseline DAS28-CRP score for DAS28-CRP outcomes. These regressions were conducted in the full population and among ABA patients only. Sensitivity analyses defining enrichment using only criteria 3 and 4 were also conducted.

Results:

2,087 patients [1,328 (64%) enriched, 759 (36%) non-enriched] were included (AGREE 492 [24%], AMPLE 509 [24%], AVERT 339 [16%], AVERT-2 747 [36%]). Disease duration, RF+, and anti-CCP values differed as expected between the two groups, while DAS28-CRP was high regardless of enrichment status (Table 1). Among ABA-treated patients, outcomes were more favorable for enriched patients compared to non-enriched patients across all outcomes, either statistically or directionally (Figure 1, ABA treatment arm only analysis). The differences in outcomes between enriched vs. non-enriched patients were larger for ABA than for comparators across all outcomes with the exception of ACR 50, where the difference was directionally consistent (Figure 1, ABA vs. comparator analysis). The relative odds of improved efficacy of ABA vs. comparators ranged from 37% to 87% for remission and ACR responses. The results were consistent in the sensitivity analysis using only anti-CCP and RF seropositivity to define enrichment.

Figure 1.

Analysis results

Conclusion:

This post-hoc study corroborates previous evidence of improved outcomes among ABA-treated, seropositive early RA patients by applying eAMPLE inclusion criteria retrospectively to ABA RCTs. The findings support a differential treatment effect for costimulation blockade using ABA among enriched and double antibody positive early RA patients, suggesting a potential for patient-tailored RA treatment approaches.

References:

[1]Buckner J, et al. Arthritis Rheumatol. 2019; 71 (suppl 10).

[2]Huizinga T, et al Annals of the Rheumatic Diseases 2015;74:234-235.

[3]Harrold L, et al, Rheumatol Ther. 2019 Jun;6(2):217-230.

[4]Sokolove J, et al. Ann Rheum Dis 2016 Apr;75:709–714.

Table 1.

Baseline characteristics

All patientsNon-enriched patientsEnriched patientsAbataceptComparatorsAbataceptComparatorsN = 2,087N = 385N = 374N = 784N = 544DemographicsAge (years)49.3 ± 12.949.4 ± 12.650.6 ± 12.948.6 ± 12.549.2 ± 13.5Female79.3%81.3%83.4%77.2%77.9%Disease characteristicsDisease duration (months)8.5 ± 12.519.9 ± 15.918.3 ± 15.12.4 ± 2.82.4 ± 2.9RF Positive91.0%74.2%76.1%100%100%Anti-CCP Positive81.8%52.2%47.3%100%100%DAS28-CRP Score5.71 ± 1.135.72 ± 1.195.66 ± 1.205.68 ± 1.095.76 ± 1.08

Comparators included MTX and MTX+ADA.

Acknowledgements:

This study was sponsored by Bristol Myers Squibb.

Disclosure of Interests:

Kaleb Michaud Grant/research support from: Pfizer Aspire grant, Sarah (Sang Hee) Park Employee of: Bristol Myers Squibb, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, John Vaile Shareholder of: Amgen, Novartis, Bristol Myers Squibb, Regeneron, Employee of: Bristol Myers Squibb, Vadim Khaychuk Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Janet Pope Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, BI, Gilead, Galapagos, Janssen, Lilly, Medexus, Merck, Novartis, Pfizer, Sanofi, Sandoz, Consultant of: AbbVie, Amgen, Bristol Myers Squibb, BI, Celltrion, Gilead, Galapagos, Janssen, Lilly, Medexus, Merck, Novartis, Pfizer, Roche, Samsung, Sanofi, Sandoz, Teva, UCB, Grant/research support from: AbbVie, BMS, Merck, Pfizer, Roche, Seattle Genetics, Philip G Conaghan Speakers bureau: AbbVie, Novartis, Consultant of: Bristol Myers Squibb, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer

POS1459-HPR IDENTIFYING MEANINGFUL CHANGE IN THE RA FLARE QUESTIONNAIRE SCORES IN RHEUMATOID ARTHRITIS

Background:

The RA-FQ is a patient-reported measure of current disease activity in RA that can be used to identify disease flares. The RA-FQ queries pain, physical function, fatigue, stiffness, and participation and yields a score from 0-50. We previously reported on reliability, validity, and responsiveness.

Objectives:

To identify changes in RA-FQ that represent minimal and meaningful improvement or worsening from the perspective of people with RA, treating rheumatologists, and in relation to disease activity indices. We hypothesized that

Methods:

Data were from adults with early RA (sx <1 year) enrolled in the Canadian Early Arthritis Cohort, a prospective study of real-world patients treated across Canada. Participants completed the RA-FQ, Patient Global, and RA transition item since last visit (a little vs. a lot better or worse or same) between consecutive 3- and 6-month visits. Rheumatologists recorded joint counts, MD Global, and change in RA. We compared mean change across improvement and worsening using patient anchors and disease activity indicators.

Results:

The 808 adults were mostly white (84%) women (71%) with a mean (SD) age of 55 (15) and moderate-high CDAI level (85%) at enrollment. Most (79%) reported their RA had changed; 59% were better and 20% worse. Patients who were a lot worse had a mean increase of 8.9 points whereas those who rated themselves as a lot better had a -6.0 decrease on the RA-FQ (Figure 1). Minimal worsening and improvement were associated with 4.7 and -1.8 change in RA-FQ scores, respectively, while patients who rated their RA unchanged had stable RA-FQ scores (Table 1).

Similar changes were evident in CDAI, SDAI, and DAS indices (Table 1). Larger differences were observed with patient vs. physician global scores and tender vs. swollen joints. Across measures, the change associated with worsening was greater than for improvement. Results supported all prespecified hypotheses ab.

Table 1.

Spearman’s correlation coefficients of PsAQoL with the other parameters for construct validity

DomainA Lot Better(N=346; 43%)A Little Better(N=132; 16%)The Same(N=174; 21%)A Little Worse(N=94; 12%)A Lot Worse(N=62; 8%)Δ95% CISDΔ95% CISDΔ95% CISDΔ95% CISDΔ95% CISDRA-FQ Total (0-50)-6.0(-7.1, -4.9)10.3-1.8(-3.2, -0.3)8.4-0.1(-1.3, 1.1)8.14.7(2.9, 6.6)9.18.9(5.1, 12.7)15.0 Pain-1.2(-1.4, -0.9)2.4-0.4(-0.8, 0.0)2.30.0(-0.2, 0.3)1.81.3(0.8, 1.7)2.22.0(1.2, 2.9)3.3 Physical Function-1.3(-1.6, -1.1)2.4-0.3(-0.6, 0.1)2.10.0(-0.3, 0.3)2.10.9(0.4, 1.4)2.41.8(0.8, 2.7)3.7 Fatigue-1.1(-1.4, -0.8)2.6-0.4(-0.7, 0.0)1.90.0(-0.3, 0.3)2.10.7(0.3, 1.1)2.11.3(0.5, 2.1)3.2 Stiffness-1.1(-1.4, -0.9)2.4-0.4(-0.7, 0.0)2.0-0.1(-0.4, 0.2)2.01.1(0.6, 1.5)2.21.8(1.0, 2.7)3.3 Participation-1.2(-1.5, -1.0)2.5-0.1(-0.5, 0.3)2.1-0.1(-0.4, 0.2)2.20.8(0.4, 1.3)2.22.0(1.1, 2.8)3.4Disease ActivityCDAI*-5.3(-6.3, -4.3)9.1-3.3(-5.4, -1.3)11.5-0.8(-2.0, 0.5)8.11.7(-0.1, 3.5)8.86.8(3.7, 9.8)12.0SDAI-5.6(-6.8, -4.4)9.2-3.5(-6.1, -0.9)12.2-1.9(-3.6, -0.2)8.91.5(-0.7, 3.7)9.24.7(1.0, 8.4)12.2DAS28-CRP-0.7(-0.8, -0.6)1.01-0.5(-0.7, -0.2)1.2-0.2(-0.4, 0.0)1.00.3(0.1, 0.5)1.00.5(0.2, 0.9)1.2Patient Global (0-10)-1.3(-1.5, -1.0)2.7-0.5(-0.9, -0.1)2.1-0.1(-0.4, 0.2)2.11.3(0.8, 1.8)2.42.9(2.1, 3.6)3.1MD Global (0-10)-1.2(-1.4, -1.0)1.9-0.7(-1.1, -0.3)-0.1-0.1(-0.4, 0.2)1.90.1(-0.3, 0.5)2.80.7(0.0, 1.5)2.8Swollen Joints (28)-1.4(-1.7, 1.0)3.2-1.0(-1.8, -0.2)4.6-0.4(-0.9, 0.0)3.00.0(-0.7, 0.7)3.41.3(0.2, 2.5)4.6Tender Joints (28)-1.5(-1.9, -1.1)3.9-1.3(-2.2, -0.3)5.50.0(-0.7, 0.6)4.30.3(-0.7, 1.2)4.52.2(0.8, 3.5)5.4

Conclusion:

In this large cohort of adults with ERA, the RA-FQ was responsive to change and generally distinguish between minimal and meaningful improvement and worsening. These data add to a growing evidence demonstrating robust psychometric properties of the RA-FQ and offer initial guidance about the amount of change associated with improvement or worsening, supporting its use in RA care, research and decision-making.

Acknowledgements:

The CATCH study was designed and implemented by the investigators and financially supported through unrestricted research grants from: Amgen and Pfizer Canada - Founding sponsors since January 2007; AbbVie Corporation and Hoffmann-LaRoche since 2011; Medexus Inc. since 2013;, Merck Canada since 2017, Sandoz Canada, Biopharmaceuticals since 2019,Gilead Sciences Canada since 2020 and Fresenius Kabi Canada Ltd. since 2021. Previously funded by Janssen Biotech from 2011-2016, UCB Canada and Bristol-Myers Squibb Canada from 2011-2018, Sanofi Genzyme from 2016-2017, and Eli Lilly Canada from 2016-2020.

Disclosure of Interests:

None declared

POS0207 REAL-WORLD RETENTION OF JAK INHIBITORS IS LONGER THAN BDMARDS IN RHEUMATOID ARTHRITIS

Background:

Biological disease modifying anti-rheumatic drugs (bDMARDs) and Janus Kinase inhibitors (JAKi) are both recommended post conventional synthetic disease modifying anti-rheumatic drug (csDMARD) therapy failure in active rheumatoid arthritis (RA), but the data on long-term durability are limited.

Objectives:

The objective of this study is to analyze a database of patients at the Western University, Rheumatology Center who initiated a bDMARD or JAKi and compare the proportion and characteristics of patients associated with retention of a drug class.

Methods:

This was a single-center study of 215 adult RA patients (82.76 % females, age 59.8 ± 12.0 years, disease duration 15.5 ± 10.0 years; table 1) failing multiple csDMARDs prior to initiating either bDMARDs (TNF inhibitors, abatacept, rituximab, tocilizumab) or JAKi, between June 2014 (when tofacitinib was approved in Canada) and April 2020. All patients enrolled had failed traditional DMARDs, including methotrexate, hydroxychloroquine, sulfasalazine and/or leflunomide. Durability and predictors of discontinuation were analyzed by Kaplan-Meier and Cox regression analyses for all treatment trials, and for patients receiving bDMARDs/JAKi as a first line after csDMARDs failure.

Results:

In 215 patients, there were 320 treatment events (148 bDMARDs, 172 JAKi) and 142 discontinuations (53.5% bDMARDs, 46.5% JAKi). Figure 1 represents the Kaplan-Meier survival curve for time to therapy discontinuation in 215 patients receiving bDMARDs vs JAKi. The Cox proportional hazards model was significant with better retention for JAKi, with a hazard ratio (HR) for treatment discontinuation of JAKi compared with bDMARDs of 0.676 (95% CI 0.47-0.97, p=0.034), adjusted for gender, age, disease duration, and line of therapy (Table 1). Moreover, the analysis revealed better retention for both groups as first line advanced therapy compared to later lines of therapy; 57.6% of JAKi and 31.1% of bDMARDs were used as first line advanced therapy. HR for treatment discontinuation for first line vs later lines of therapy was 0.593 (95% CI 0.40-0.88, p=0.01), adjusted for drug class, gender, age, and disease duration (Table 1). The most common reasons for discontinuations were inefficacy (60%), side effects (22%), or other reasons (18%). Inefficacy (58% vs 62%, p=0.8) and side-effects (16% vs 27%, p=0.4) were equally common for bDMARDs and JAKi. Sex, age at treatment onset, and RA duration did not predict discontinuation by Cox regression analyses, and after sub-grouping into bDMARDs and JAKi.

Conclusion:

EULAR guidelines have placed bDMARDs equal to JAKi as post csDMARD failure therapy in active RA. However, this study demonstrates that JAKi has a greater durability than biologics regardless of gender, age, disease duration, and line of therapy. Therefore, JAKi may be considered as a preferable method of treatment post csDMARD failure in active RA.

Figure 1.

Kaplan-Meier survival curves for (A) time to discontinuation of therapy in all RA patients receiving bDMARDs versus JAKi; P-value represents Cox regression adjusted for gender, age, disease duration, and line of therapy (B) time to discontinuation of therapy in patients using bDMARDs/JAKi as first line of advanced therapy; P-value represents Cox regression adjusted for drug class, gender, age, and disease duration

Table 1.

Patient demographics and hazard ratios for discontinuation of bDMARDs versus JAKi by Cox regression model

CharacteristicJAKi (N=172)bDMARD (N=148)MeanAge (years)60.958.559.8Sex (% F)77.888.582.8Disease duration (years)15.315.815.5Line of advanced therapy (% first line)57.631.145.3Drug used (%)Tofacitinib: 93.5Rituximab: 26.4Etanercept: 19.6Adalimumab: 17.6Predictors of Drug DiscontinuationHR (95% CIs)P valuesCrude ModelJAKi vs bDMARDs0.60 (0.43, 0.84)0.003Adjusted modelJAKi vs bDMARDs0.68 (0.47, 0.97)0.034Male vs female0.77 (0.46, 1.31)0.342Age1.01 (0.99, 1.03)0.123RA duration0.99 (0.97, 1.01)0.500Treatment line 1 vs >10.59 (0.40, 0.88)0.010

Disclosure of Interests:

Karla Machlab: None declared, Samir M. Iskandar: None declared, Tatiana Nevskaya: None declared, Louise Vanderhoek: None declared, Jillian Bylsma: None declared, Sara Hewitt: None declared, Janet Pope Speakers bureau: AbbVie, Amgen, BMS, BI, Gilead, Galapagos, Janssen, Lilly, Medexus, Merck, Novartis, Pfizer, Sanofi, Sandoz, Consultant of: AbbVie, Amgen, BMS, BI, Celltrion, Gilead, Galapagos, Janssen, Lilly, Medexus, Merck, Novartis, Pfizer, Roche, Samsung, Sanofi, Sandoz, Teva, UCB, Grant/research support from: AbbVie, BMS, Merck, Pfizer, Roche, Seattle Genetics

POS0531 FACTORS ASSOCIATED WITH BASELINE HYPERTENSION IN EARLY RHEUMATOID ARTHRITIS: DATA FROM A REAL-WORLD LARGE INCIDENT COHORT

Background:

It is not well understood why hypertension (HTN) is so common in rheumatoid arthritis (RA) patients. Reported prevalence of HTN in RA patients ranges from 4-73%.(1)

Objectives:

This study explored the prevalence of HTN at time of RA diagnosis and which demographic, behavioural and clinical factors were associated with HTN.

Methods:

Data from the Canadian Early Arthritis Cohort (CATCH), a prospective inception cohort of patients with RA <1 year duration, were used to analyze baseline demographic, behavioural and clinical characteristics associated with HTN, which was reported by physicians. Univariate logistic regression models were created to explore associations with baseline HTN. A multivariate logistic regression model was built based on goodness of fit indicated by likelihood ratio tests. Variables included in the model were age, sex, race, body mass index (BMI), education, smoking, alcohol servings, seropositivity, disease activity and comorbidities.

Results:

In total, 2052 subjects were included with mean (±SD) age of 55 (±14) years and symptom duration 5.60(5.47, 5.73) months, 71% of subjects were female and 85% were Caucasian. HTN was reported in 26% of subjects at baseline. Hypertensive subjects were older and more likely to be male. Other factors significantly associated with HTN at baseline were lower education, ever smoking, high BMI, diabetes, hyperlipidemia, worse RA disease activity, longer duration of RA symptoms, being seropositive, as well as the use of NSAIDs and/or corticosteroids (Table 1). In multivariable analysis HTN was associated with older age, overweight and obese BMI, diabetes, and hyperlipidemia. Expression of anti-citrullinated protein antibodies was inversely associated with HTN (Table 1). Other RA disease factors and treatments were not significantly associated with HTN on multivariable analysis.

Table 1.

Results of univariate and multivariate logistic regression analyses exploring the association between baseline characteristics and HTN in early RA.

Univariate Logistic RegressionMultivariable Logistic RegressionVariableCrude OR (95% CI)Adjusted OR (95% CI)Socio-Demographic20-39 years old0.15 (0.07, 0.26)0.14(0.05, 0.34)40-59 years oldReference60-79 years old2.81 (2.26, 3.50)2.26(1.65, 3.11)80-99 years old5.87 (3.36,10.25)3.80(1.53, 9.41)Female0.55 (0.45, 0.68)1.10(0.78, 1.54)Lifestyle/BehaviouralNormal weight (18.5- 24.9kg/m2)ReferenceOverweight (25-29.9 kg/m2)2.33(1.74, 3.11)1.63(1.10, 2.43)Obese (30+ kg/m2)3.19(2.38, 4.27)2.84(1.91, 4.23Ever-smoking1.41(1.15, 1.73)1.02(0.75, 1.40)Post-secondary education0.58(0.47, 0.71)0.88(0.65, 1.20)Clinical CharacteristicsSymptom duration0.99(0.99, 0.99)1.00(1.00, 1.00)DAS-281.09(1.09, 1.17)1.02(0.92, 1.13)ACPA+0.68(0.56, 0.85)0.64(0.44, 0.92)Corticosteroid use pre-baseline1.37(1.04, 1.81)OmittedNSAID use at baseline0.68(0.55, 0.84)OmittedDiabetes5.62(4.09, 7.73)3.20(1.99, 5.15)Hyperlipidemia4.75(3.74, 6.03)2.80(1.94, 4.02),CVD15.59(3.35, 72.64)Omitted

DAS-28; Disease activity score 28, ACPA; Anti-citrullinated protein antibody, CVD; Cardiovascular disease. Pre-baseline is 29 to 365 days before entering the cohort. Baseline is within 28 days before entering the cohort. Omitted variables either failed likelihood ratio test or were colinear. Additional variables tested but found insignificant: race, alcohol servings, depression, RF+, and use of DMARDs.

Conclusion:

Approximately 1 in 4 diagnosed with RA had HTN reported by their rheumatologists, which is similar to that of the general population. This suggests that increased risk of HTN in RA patients may develop as RA disease or treatment time progresses. Factors that may be predictive of this excess risk will be explored in further analysis.

References:

[1]Panoulas VF, Metsios GS, Pace AV, et al. Hypertension in rheumatoid arthritis. Rheumatology (Oxford) 2008;47:1286-98.

Acknowledgements:

The CATCH study was designed and implemented by the investigators and financially supported through unrestricted research grants from: Amgen and Pfizer Canada - Founding sponsors since January 2007; AbbVie Corporation and Hoffmann-LaRoche since 2011; Medexus Inc. since 2013;, Merck Canada since 2017, Sandoz Canada, Biopharmaceuticals since 2019,Gilead Sciences Canada since 2020 and Fresenius Kabi Canada Ltd. since 2021. Previously funded by Janssen Biotech from 2011-2016, UCB Canada and Bristol-Myers Squibb Canada from 2011-2018, Sanofi Genzyme from 2016-2017, and Eli Lilly Canada from 2016-2020.

Disclosure of Interests:

Brook Hadwen: None declared, Saverio Stranges: None declared, Neil Klar: None declared, Kuriya Bindee: None declared, Janet Pope Speakers bureau: UCB, Consultant of: AbbVie, Actelion, Amgen, Bayer, BMS, Eicos Sciences, Eli Lilly & Company, Emerald, Gilead, Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB;, Grant/research support from: Abbvie, BMS, Eli Lilly & Company, Merck, Roche, Seattle Genetics, UCB, Susan J. Bartlett Consultant of: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie, Gilles Boire Speakers bureau: Merck, BMS, Pfizer, Janssen, Grant/research support from: Amgen, Abbvie, BMS, Eli Lilly, Merck, Novartis, Pfizer, Sandoz, Louis Bessette Speakers bureau: Amgen, BMS, Janssen, Roche, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Lilly, Novartis, Consultant of: Amgen, BMS, Janssen, Roche, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Lilly, Novartis., Grant/research support from: Amgen, BMS, Janssen, Roche, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Lilly, Novartis., Carol Hitchon Grant/research support from: Pfizer and UCB Canada, Glen Hazlewood: None declared, Edward Keystone Speakers bureau: Amgen, AbbVie, Bristol-Myers Squibb, F. Hoffmann-La Roche Inc., Janssen Inc., Merck, Pfizer Pharmaceuticals, Sanofi Genzyme, UCB, Consultant of:: AbbVie, Amgen, AstraZeneca Pharma, Bristol-Myers Squibb Company, Celltrion, Myriad Autoimmune, F. Hoffmann-La Roche Inc, Genentech Inc, Gilead, Janssen Inc, Lilly Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Sandoz, Sanofi-Genzyme, Samsung Bioepsis, Grant/research support from: AbbVie, Amgen, Gilead Sciences, Lilly Pharmaceuticals, Merck, Pfizer Pharmaceuticals, PuraPharm, Sanofi, Orit Schieir: None declared, Carter Thorne Speakers bureau: Medexus/Medac, Consultant of: Abbvie, Centocor, Janssen, Lilly, Medexus/Medac, Pfizer, Grant/research support from: Amgen, Pfizer, Abbvie, Celgene, CaREBiodam, Novartis, Diane Tin: None declared, Marie-France Valois: None declared, Vivian Bykerk Consultant of: Amgen, BMS, Gilead, Sanofi-Genzyme/Regeneron, Scipher, Pfizer Pharmaceuticals, UCB, NIH, Lillian Barra: None declared

Patient and Rheumatologist Perspectives on Tapering DMARDs in Rheumatoid Arthritis: A Qualitative Study

OBJECTIVES

To understand the perspectives of patients and rheumatologists for tapering DMARDs in RA.

METHODS

Using semi-structured interview guides, we conducted individual interviews and focus groups with RA patients and rheumatologists, which were audiotaped and transcribed. We conducted a pragmatic thematic analysis to identify major themes, comparing and contrasting different views on DMARD tapering between patients and rheumatologists.

RESULTS

We recruited 28 adult patients with RA (64% women; disease duration 1-54 years) and 23 rheumatologists (52% women). Attitudes across both groups towards tapering DMARDs were ambivalent, ranging from wary to enthusiastic. Both groups expressed concerns, particularly the inability to 'recapture' the same level of disease control, while also acknowledging potential positive outcomes such as reduced drug harms. Patient tapering perspectives (whether to and when) changed over time and commonly included non-biologic DMARDs. Patient preferences were influenced by lived experiences, side effects, previous tapering experiences, disease trajectory, remission duration, and current life roles. Rheumatologists' perspectives varied on timing and patient profile to initiate tapering, and were informed by both data and clinical experience. Patients expressed interest in shared decision making (SDM) and close monitoring during tapering, with ready access to their healthcare team if problems arose. Rheumatologists were generally open to tapering (not stopping), though sometimes only when requested by their patients.

CONCLUSION

The perspectives of patients and rheumatologists on tapering DMARDs in RA vary and evolve over time. Rheumatologists should periodically discuss DMARD tapering with patients as part of SDM, and ensure monitoring and flare management plans are in place.

A meta-analysis of the epidemiology of giant cell arteritis across time and space

INTRODUCTION

Giant cell arteritis (GCA) is a common large vessel vasculitis in those over age 50 years. This meta-analysis examined the geographical and temporal distribution of the incidence, prevalence, and mortality of GCA.

METHODS

A systematic review was conducted using EMBASE, Scopus, and PubMed from their inceptions until 2019. Studies were included if they reported at least 50 or more GCA patients and defined the location and time frame. Articles on mortality were included and standardized mortality ratio (SMR) was extracted where possible. Mean pooled prevalence, incidence, and SMR were calculated using a random effects model. Linear regression was used to explore correlations between latitude and incidence, prevalence, and mortality.

RESULTS

Of the 3569 citations identified, 107 were included. The pooled incidence of GCA was 10.00 [9.22, 10.78] cases per 100,000 people over 50 years old. This incidence was highest in Scandinavia 21.57 [18.90, 24.23], followed by North and South America 10.89 [8.78, 13.00], Europe 7.26 [6.05, 8.47], and Oceania 7.85 [- 1.48, 17.19]. Pooled prevalence was 51.74 [42.04, 61.43] cases per 100,000 people over age 50. Annual mortality was 20.44 [17.84, 23.03] deaths/1000. Mortality generally decreased over the years of publication (p = 0.0008). Latitude correlated significantly with incidence (p = 0.0011), but not with prevalence, or mortality.

CONCLUSIONS

GCA incidence varies nearly 3-fold between regions and is highest in Scandinavia but not significantly. Mortality may be improving over time.

The Key Comorbidities in Patients with Rheumatoid Arthritis: A Narrative Review

Comorbidities in patients with rheumatoid arthritis (RA) are often associated with poor health outcomes and increased mortality. Treatment decisions should take into account these comorbidities due to known or suspected associations with certain drug classes. In clinical practice, it is critical to balance potential treatment benefit against the possible risks for comorbidities as well as the articular manifestations of RA. This review summarises the current literature relating to prevalence and risk factors for the important comorbidities of cardiovascular disease, infections, lymphomas and nonmelanoma skin cancers in patients with RA. The impact on patient outcomes and the interplay between these comorbidities and the therapeutic options currently available, including tumour necrosis factor inhibitors and newer biological therapies, are also explored. As newer RA therapies are developed, and patients gain wider and earlier access to advanced therapies, in part due to the emergence of biosimilars, it is important to consider the prevention or treatment of comorbidities as part of the overall management of RA.

Changes in Market Share of Biologic and Targeted Synthetic Disease-Modifying Anti-Rheumatic Drugs for Treatment of Rheumatoid Arthritis: Results from the Ontario Best-Practice Research Initiative Database

OBJECTIVE

For patients with Rheumatoid Arthritis (RA) who do not achieve adequate clinical response with combined conventional synthetic disease-modifying anti-rheumatic drugs (cs- DMARDs), initiation of advanced therapies such as biologic DMARDs (bDMARDs) or targeted synthetic DMARDs (tsDMARDs) is recommended. Tumour necrosis factor inhibitors (TNFi) are the oldest and most commonly used subgroup of advanced therapies. In the last decade, new non-TNFi advanced therapy options have become available. We described the relative use of TNFi vs. non-TNFi in Ontario-based practices from 2008-2017.

METHODS

Adult patients with RA enrolled in the Ontario Best Practices Research Initiative (OBRI) database who started bDMARDs or tsDMARDs anytime during or within 30 days prior to enrollment were included. The proportion of patients treated with TNFi vs. non-TNFi agents between 2008 and 2017 was described for all patients and those initiating their first bDMARD/tsDMARD. All TNFi therapies were included. Non-TNFi included Abatacept, Rituximab, Tocilizumab, and Tofacitinib.

RESULTS

A total of 1,057 patients were included, of whom 72.0% were bDMARD/tsDMARD naïve. In 2008, the relative non-TNFi use was 5.4% in all patients while it was 0% in bDMARD/ts- DMARD-naïve patients. In 2017, the proportion of patients using non-TNFi increased to 33.8% among all patients and 33.3% in bDMARD/tsDMARD-naïve patients.

CONCLUSION

This descriptive analysis of data from the OBRI cohort reveals that TNFi are still used in the majority of cases; however, there has been an increase in the use of non-TNFi therapies both overall and as first-line advanced therapy. This trend towards non-TNFi therapies as first-line advanced therapy may be partially explained by the shift in guideline recommendations from TNFi as first-line to any of the advanced therapeutics.