Can the Dose of Belimumab be Reduced in Patients with Systemic Lupus Erythematosus?

OBJECTIVES

The aims of this study were to investigate the prevalence of dose reduction in patients with SLE treated with belimumab (BEL) in Spain, analyze treatment modalities, and determine impact on control of disease activity.

METHODS

Retrospective longitudinal and multicentre study of SLE patients treated with BEL. Data on disease activity, treatments and outcomes were recorded before and after reduction (6-12 months), and they were compared.

RESULTS

A total of 324 patients were included. The dose was reduced in 29 patients (8.9%). The dosing interval was increased in 9 patients receiving subcutaneous BEL and in 6 patients receiving intravenous BEL. The dose per administration was reduced in 16 patients.Pre-reduction status was remission (2021 DORIS) in 15/26 patients (57.7%) and LLDAS in 23/26 patients (88.5%). After reduction, 2/24 patients (8.3%) and 3/22 patients (13.6%) lost remission at 6 months and 12 months, respectively (not statistically significant [NS]). As for LLDAS, 2/23 patients (8.7%) and 2/21 patients (9.5%) lost their status at 6 and 12 months, respectively (NS). Significantly fewer patients were taking glucocorticoids (GCs) at their 12-month visit, although the median dose of GCs was higher at the 12-month visit (5 [0.62-8.75] vs 2.5 [0-5] at baseline).

CONCLUSION

Doses of BEL can be reduced with no relevant changes in disease activity-at least in the short term-in a significant percentage of patients, and most maintain the reduced dose. However, increased clinical or serologic activity may be observed in some patients. Consequently, tighter post-reduction follow-up is advisable.

There and back again: analyzing the effect of outpatient readmission on the quality of life of patients attending a rheumatology clinic

Aims:

The aim of this study was to assess the effect of “outpatient readmissions” on the health-related quality of life (HR-QoL) of outpatients from a rheumatology clinic, meaning the effect of the patient’s return to the outpatient clinic after having received care and been discharged.

Methods:

We conducted an observational longitudinal retrospective study, with patients selected from the Hospital Clínico San Carlos Musculoskeletal cohort, based on having received at least one discharge from the outpatient clinic and having returned (readmission) at least once after the discharge. The main outcomes were the patients’ baseline HR-QoL (measured on the first visit of each episode) and the ΔHR-QoL (difference between the HR-QoL in the last and the first visit of each episode). Successive episodes of admission and readmission were chronologically ordered, paired and analyzed using nested linear mixed models, nested by patients and by admission–readmission tandem. We carried out bivariable and multivariable analyses to assess the effect of demographic, clinical, treatment and comorbidity-related variables in both main outcomes.

Results:

For the first main outcome, 5887 patients (13,772 episodes) were analyzed. Based on the multivariable level, readmission showed no significant marginal effect on the baseline HR-QoL (p-value = 0.17). Conversely, when analyzing the ΔHR-QoL, we did observe a negative and significant marginal effect (p-value = 0.028), meaning that readmission was associated with a lower gain in the HR-QoL during the follow-up, compared with the previous episode.

Conclusion:

In the outpatient setting, readmission exerts a deleterious effect in patients undergoing this process. Identification of outpatients more likely to be readmitted could increase the value of the care provided.

POS1215 INFLUENCE OF CONFINEMENT CARRIED OUT BY PATIENTS WITH AUTOIMMUNE AND IMMUNE- MEDIATED INFLAMMATORY DISEASE WITH BIOLOGICAL TREATMENT ON COVID-19 INFECTION

Background:

The disease caused by SARS-CoV-2 is a potentially serious infection. The autoimmune and immune-mediated inflammatory disease (AI/IMID) itself, its activity, the immunosuppression and the presence of comorbidities are associated with an increased risk of serious infections. At this moment the literature shows a similar risk of infection and severity compared to the general population. Some reports noted that these patients might adopt stricter measures of self-care protection than general population which could contribute to an incidence of infection lower than expected.

Objectives:

To assess the incidence and clinical presentation of SARS-CoV-2 infection in our cohort of patients with AI/IMID treated with biological agents (BA) or Janus Kinasa (JAK) inhibitors. To analyse the association of the incidence and the type of confinement between the AI/IMID group and the general population.

Methods:

A case-control study nested within a retrospective observational study was conducted from March 13th until April 23th, 2020 in Althaia, Xarxa Assistencial Universitària de Manresa. Subjects: cohort of AI/IMID patients followed by Rheumatology (inflammatory arthritis), Dermatology (psoriasis) and Digestology (inflammatory bowel disease) treated with BA/JAK inhibitors. Controls were selected from our Primary Care Centers. Main outcome: Type of confinement: strict: <1 outing / week with safety measures (SM), regular (2-3 outings with SM), lax (> 3 outings or face-to-face work with SM) and without confinement (without SM). Secondary outcome: SARS-CoV-2 infection: confirmed (PCR and/or positive serology), probable (severe illness requiring admission without PCR/serology or mild moderate with epidemiological contact) and possible (mild infection without microbiological check nor epidemiological contact); as well as severity according to the WHO.

Results:

367 patients and 193 controls were included. 45.2% of patients were men, with a mean age of 52 (SD 14.6). 47.4% were patients with rheumatologic disease, 25.3% from dermatology and 27.2% from digestive. 95.6% received a BA (66.6% anti-TNF and 33.4% non-anti-TNF) and the remaining 4.4% received JAK inhibitors. 43.3% patients had at least a risk factor compared to 37.8% in the control group (p=0.761). The Table 1 shows the incidence of COVID divided into confirmed and cumulative cases (confirmed and possible), with no significant differences. One patient (0.3%) in the case group and 3 patients (1.6%) in the control group required hospital admission (p=0.121). In relation to the type of confinement we had significant differences (p=0.013) within the AI/IMID group versus the control group in lax confinement. There were no differences in the incidence of COVID between the different confinement types.

Table 1.Case (n=367)Control (n=193)p-valueSARS-CoV-2 infectionCumulative COVID10.1 (7.2-13.6)13.5 (9.0-19.1)0.228Confirmed COVID3.3 (1.7-5.6)5.7 (2.9-10.0)0.169Probable2.2 (0.9-4.2)3.1 (1.1-6.6)0.572Possible4.6 (2.7-7.3)4.7 (2.1-8.7)0.987Type of confinementOR (95% CI)Strict59.1 (53.8-64.2)50.3 (43.0-57.5)0.0591.40 (0.99-1.99)Regular15.4 (11.8-19.5)14.4 (9.9-203)0.8131.06 (0.65-1.73)Lax25.0 (20.6-29.4)34.7 (28.0-41.9)0.0130.62 (0.42-0.91)No confinement0.5 (0.1-1.9)0.5 (0.01-0.03)1.0001.05 (0.09-11.7)

CI: confidence interval; OR: Odds ratio

Conclusion:

The incidence of COVID-19 infection in our cohort is similar to that reported in other series of AI/IMID patients and in general population, both for confirmed cases (3.3% vs 5.7%) as well as for cumulative cases (10.1% vs 13.5%). None of our patients developed a severe form of the infection. We observed that strict confinement was predominant in both groups, being higher in the AI/IMID patients (59.1% vs 50.3%). Furthermore, lax confinement was more frequent in the control group. Although the difference was not statistically significant, the incidence of infection was higher in the control group, especially in the subjects who performed lax confinement.

Disclosure of Interests:

None declared.

The SADDEN DEATH Study: Results from a Pilot Study in Non-ICU COVID-19 Spanish Patients

Introduction: The worldwide pandemic, coronavirus disease 2019 (COVID-19) is a novel infection with serious clinical manifestations, including death. Our aim is to describe the first non-ICU Spanish deceased series with COVID-19, comparing specifically between unexpected and expected deaths. Methods: In this single-centre study, all deceased inpatients with laboratory-confirmed COVID-19 who had died from March 4 to April 16, 2020 were consecutively included. Demographic, clinical, treatment, and laboratory data, were analyzed and compared between groups. Factors associated with unexpected death were identified by multivariable logistic regression methods. Results: In total, 324 deceased patients were included. Median age was 82 years (IQR 76–87); 55.9% males. The most common cardiovascular risk factors were hypertension (78.4%), hyperlipidemia (57.7%), and diabetes (34.3%). Other common comorbidities were chronic kidney disease (40.1%), chronic pulmonary disease (30.3%), active cancer (13%), and immunosuppression (13%). The Confusion, BUN, Respiratory Rate, Systolic BP and age ≥65 (CURB-65) score at admission was >2 in 40.7% of patients. During hospitalization, 77.8% of patients received antivirals, 43.3% systemic corticosteroids, and 22.2% full anticoagulation. The rate of bacterial co-infection was 5.5%, and 105 (32.4%) patients had an increased level of troponin I. The median time from initiation of therapy to death was 5 days (IQR 3.0–8.0). In 45 patients (13.9%), the death was exclusively attributed to COVID-19, and in 254 patients (78.4%), both COVID-19 and the clinical status before admission contributed to death. Progressive respiratory failure was the most frequent cause of death (92.0%). Twenty-five patients (7.7%) had an unexpected death. Factors independently associated with unexpected death were male sex, chronic kidney disease, insulin-treated diabetes, and functional independence. Conclusions: This case series provides in-depth characterization of hospitalized non-ICU COVID-19 patients who died in Madrid. Male sex, insulin-treated diabetes, chronic kidney disease, and independency for activities of daily living are predictors of unexpected death.

Outpatient Readmission in Rheumatology: A Machine Learning Predictive Model of Patient's Return to the Clinic

Our objective is to develop and validate a predictive model based on the random forest algorithm to estimate the readmission risk to an outpatient rheumatology clinic after discharge. We included patients from the Hospital Clínico San Carlos rheumatology outpatient clinic, from 1 April 2007 to 30 November 2016, and followed-up until 30 November 2017. Only readmissions between 2 and 12 months after the discharge were analyzed. Discharge episodes were chronologically split into training, validation, and test datasets. Clinical and demographic variables (diagnoses, treatments, quality of life (QoL), and comorbidities) were used as predictors. Models were developed in the training dataset, using a grid search approach, and performance was compared using the area under the receiver operating characteristic curve (AUC-ROC). A total of 18,662 discharge episodes were analyzed, out of which 2528 (13.5%) were followed by outpatient readmissions. Overall, 38,059 models were developed. AUC-ROC, sensitivity, and specificity of the reduced final model were 0.653, 0.385, and 0.794, respectively. The most important variables were related to follow-up duration, being prescribed with disease-modifying anti-rheumatic drugs and corticosteroids, being diagnosed with chronic polyarthritis, occupation, and QoL. We have developed a predictive model for outpatient readmission in a rheumatology setting. Identification of patients with higher risk can optimize the allocation of healthcare resources.