Can the General Public Be a Proxy for an "At-Risk" Group in a Patient Preference Study? A Disease Prevention Example in Rheumatoid Arthritis

BACKGROUND

When selecting samples for patient preference studies, it may be difficult or impractical to recruit participants who are eligible for a particular treatment decision. However, a general public sample may not be an appropriate proxy.

OBJECTIVE

This study compares preferences for rheumatoid arthritis (RA) preventive treatments between members of the general public and first-degree relatives (FDRs) of confirmed RA patients to assess whether a sample of the general public can be used as a proxy for FDRs.

METHODS

Participants were asked to imagine they were experiencing arthralgia and had screening tests indicating a 60% chance of developing RA within 2 yrs. Using a discrete choice experiment, participants were offered a series of choices between no treatment and 2 unlabeled hypothetical treatments to reduce the risk of RA. To assess data quality, time to complete survey sections and comprehension questions were assessed. A random parameter logit model was used to obtain attribute-level estimates, which were used to calculate relative importance, maximum acceptable risk (MAR), and market shares of hypothetical preventive treatments.

RESULTS

The FDR sample (n = 298) spent more time completing the survey and performed better on comprehension questions compared with the general public sample (n = 982). The relative importance ranking was similar between the general public and FDR participant samples; however, other relative preference measures involving weights including MARs and market share differed between groups, with FDRs having numerically higher MARs.

CONCLUSION

In the context of RA prevention, the general public (average risk) may be a reasonable proxy for a more at-risk sample (FDRs) for overall relative importance ranking but not weights. The rationale for a proxy sample should be clearly justified.

HIGHLIGHTS

Participants from the general public were compared to first-degree relatives on their preferences for rheumatoid arthritis (RA) preventive treatments using a discrete choice experiment.Preferences were similar between groups in terms of the most important and least important attributes of preventive treatments, with effectiveness being the most important attribute. However, relative weights differed.Attention to the survey and predicted market shares of hypothetical RA preventive treatments differed between the general public and first-degree relatives.The general public may be a reasonable proxy for an at-risk group for patient preferences ranks but not weights in the disease prevention context; however, care should be taken in sample selection for patient preference studies when choosing nonpatients.

The Symptoms in Persons At Risk of Rheumatoid Arthritis (SPARRA) questionnaire: predicting clinical arthritis development

OBJECTIVE

There is a need to better define symptom characteristics associated with arthritis development in individuals at risk of rheumatoid arthritis (RA). We investigated whether reported symptoms in at-risk individuals could predict arthritis development and whether predictive symptoms differed between seropositive and seronegative at-risk individuals.

METHOD

At-risk individuals from four cohorts (Netherlands, UK, Sweden, and Switzerland) completed the Symptoms in Persons At Risk of Rheumatoid Arthritis (SPARRA) questionnaire. Participants had either (i) anti-citrullinated protein antibodies and/or rheumatoid factor, or (ii) relevant symptoms with or without RA antibodies. Follow up was ≥ 24 months or until clinical arthritis development. Stepwise forward selection created SPARRA prediction models for the combined group and for a seropositive subgroup.

RESULTS

Of 214 participants, the mean age was 50 years, 67% were female, and 27% (n = 58) developed clinical arthritis after a median time of 7 months. Four symptoms predicted arthritis development: self-reported joint swelling, joint pain moving from side to side (combined group only), feeling pins and needles in the joints, and often feeling fatigued (predicting non-arthritis).

CONCLUSION

Specific symptoms can provide useful information to estimate a person's RA risk. Differences in predictive symptoms between seropositive and seronegative at-risk individuals need to be further investigated. Future research is needed to determine whether changes in symptoms over time improve prediction and to determine the value of SPARRA in optimizing the selection of individuals who need to consult a rheumatologist.

Exploring preferences of at-risk individuals for preventive treatments for rheumatoid arthritis

OBJECTIVE

Some immunomodulatory drugs have been shown to delay the onset of, or lower the risk of developing, rheumatoid arthritis (RA), if given to individuals at risk. Several trials are ongoing in this area; however, little evidence is currently available about the views of those at risk of RA regarding preventive treatment.

METHOD

Three focus groups and three interviews explored factors that are relevant to first degree relatives (FDRs) of RA patients and members of the general public when considering taking preventive treatment for RA. The semi-structured qualitative interview prompts explored participant responses to hypothetical attributes of preventive RA medicines. Transcripts of focus group/interview proceedings were inductively coded and analysed using a framework approach.

RESULTS

Twenty-one individuals (five FDRs, 16 members of the general public) took part in the study. Ten broad themes were identified describing factors that participants felt would influence their decisions about whether to take preventive treatment if they were at increased risk of RA. These related either directly to features of the specific treatment or to other factors, including personal characteristics, attitude towards taking medication, and an individual's actual risk of developing RA.

CONCLUSION

This research highlights the importance of non-treatment factors in the decision-making process around preventive treatments, and will inform recruitment to clinical trials as well as information to support shared decision making by those considering preventive treatment. Studies of treatment preferences in individuals with a confirmed high risk of RA would further inform clinical trial design.

AB0034 INVESTIGATING THE ROLE OF ACCELERATED IMMUNESENESCENCE IN THE PATHOGENESIS OF RHEUMATOID ARTHRITIS

Background

Advancing age is recognised as a major risk factor for autoimmune inflammatory conditions, such as Rheumatoid Arthritis (RA). Despite strong associations with older age we understand little of the role ageing processes play in disease pathogenesis in RA. The immune system undergoes a dramatic remodelling with age, termed immunesenescence, which contributes towards increased risk of autoimmunity1. Previous research in patients with established RA has shown certain features of immunesenescence, such as thymic atrophy and telomere shortening in T cells, at a younger age2,3.

Objectives

In this study we aimed to determine if immunesenescence is seen in the very earliest stages of RA and therefore might be a contributor to RA pathogenesis rather than a result of the disease.

Methods

We have assessed aspects of the aged immune phenotype by immunostaining and flow cytometry4 in adults with arthralgia (n=25), undifferentiated arthritis (UA; n=41), confirmed RA of less than 3 months (n=25) and more than 3 months duration (n=78) and compared these to age and sex matched healthy controls (n=38). Nanostring methodology was used to determine gene expression changes associated with the development of RA.

Results

We observed increased features of T and B cell immunesenescence in DMARD-naïve recently diagnosed RA patients driven by reduced naïve T cells (p<0.01) and B cells (p<0.01), increased senescent (CD28-ve, CD57+ve, KLRG1+ve) T cells (p<0.01), an increased Th17/Treg ratio (p<0.01) and increased frequency of age-associated B cells (p<0.01). With the exception of naïve T cell frequency, which was reduced in UA patients (p<0.05), these changes were not seen in the very early stages of RA, namely patients with arthralgia and UA. These data suggest that immunesenescence only occurs once disease is established. Furthermore, using nanostring we have identified several biological ageing processes (DNA damage, autophagy) associated with this state of immunesenescence in RA.

Conclusion

Accelerated immune ageing is an early feature of RA and biological ageing processes represent novel targets to modulate disease progression.

References

[1]Duggal NA, Upton JA, Phillips AC, Sapey E, Lord JM (2013) An age-related numerical and functional deficit in CD19+CD24hiCD38hi B cells is associated with an increase in systemic autoimmunity. Aging Cell 12:873-881.

[2]Goronzy, J.J. and Weyand CM (2001). Thymic function and peripheral T-cell homeostasis in rheumatoid arthritis. Trends Immunol. 22(5):251-5.

[3]Steer SE, Williams FMK, Kato B, Gardner JP, Norman PJ, Hall MA, Kimra M, Vaughan R, Aviv A, Spector T (2007) Reduced telomere length in rheumatoid arthritis in independent of disease activity and duration. Ann Rheum Dis 66:476-480.

[4]Duggal NA, Pollock RD, Lazarus NR, Harridge S, Lord JM (2018). Major features of immunesenescence, including reduced thymic output, are ameliorated by high levels of physical activity in adulthood. Aging Cell 17:e12750

Disclosure of Interests

None declared

POS0591 TREATMENTS TO PREVENT RHEUMATOID ARTHRITIS IN FIRST DEGREE RELATIVES: DEMOGRAPHIC AND PSYCHOLOGICAL PREDICTORS OF RISK TOLERANCES

Background

There is a growing research focus on the development of interventions to reduce risk of rheumatoid arthritis (RA) in at-risk groups.(1) RA patients’ first-degree relatives (FDRs) have an elevated risk of developing RA and are potential candidates for preventive interventions. Recent studies have quantified the preferences of at risk groups for preventive treatments.(2-4) Little is known about predictors of preference heterogeneity in this context.

Objectives

Assess the extent to which FDR characteristics and beliefs predict risk tolerances for preventive treatments.

Methods

Adult FDRs of patients with confirmed RA in the UK were invited to take part in a web-based survey. FDRs enrolled in a UK prospective cohort (PREVeNT-RA) were also invited. Survey development, including attribute selection and presentation, was informed by qualitative research, ranking surveys, literature review, and expert opinion including patient research partners. Respondents received information about RA, questions to check comprehension, and an introduction to the survey. Participants were asked to imagine they were experiencing arthralgia and had positive autoantibody tests indicating a 60% chance of developing RA within two years. Using a probabilistic threshold technique, participants made choices between no treatment (no benefit and no risks) or a preventive treatment option. Treatment options were defined by a fixed level of benefit (reduction in risk of RA from 60% to 20%) and varying levels of risks (Table 1). For each treatment risk, participants made a series of choices where the risk was systematically increased or decreased until they switched their choice. This procedure was repeated for each of the remaining risks. Participants also completed items assessing demographics, perceived risk of developing RA, health literacy, subjective numeracy, the Brief Illness Perception Questionnaire (IPQ) and the Beliefs about Medicines Questionnaire General (BMQ-G). The maximum acceptable risk (MAR) respondents were willing to accept for a 40% (60% to 20%) point risk reduction in developing RA was summarized across participants using descriptive statistics. Associations between MARs and participants’ characteristics and illness/medication beliefs were assessed using interval regression. Independent variables were dichotomized and effects coded.

Table 1.

Attributes and levels of treatment options

Treatment attributeLevels describing no treatment optionLevels describing treatment optionChance of developing RA60%20%Chance of mild side effects0%2%; 4%; 5%; 7% or 10%Chance of a serious infection due to treatment0%1%; 1.5%; 2%; 3% or 5%Chance of a serious side effect that is potentially irreversible0%0.001%; 0.01%; 0.02%; 0.05% or 0.1%

Results

289 FDRs (80 male) responded. The mean (SE) MAR for mild side effects, serious infection, and serious side effects was 29.08 (1.52), 9.09 (0.60) and 0.85 (0.27), respectively. Participants aged over 60 years were less tolerant of risk of serious infection than average (mean MAR - 2.06 (0.78)) and younger participants were more tolerant of risk of serious infection than average (mean MAR + 2.06 (0.78)). Risk of mild side effects was less acceptable to participants who perceived they were likely/very likely to develop RA (mean MAR - 3.34 (1.55)) than to those who did not (mean MAR + 3.34 (1.55)). Education level, health literacy, numeracy, IPQ and BMQ-G subscales were not predictors of risk tolerance.

Conclusion

Age and perceived risk of RA had a significant impact on FDRs’ tolerance for specific, but not all, included risks. Cognitive ability and beliefs about RA/medicine did not explain preference heterogeneity. This is informative for drug development and the development of tailored risk communication resources to support preventive approaches.

References

[1]Mankia et al. Ann Rheum Dis. 2021;80(10):1286-98.

[2]Simons et al. Ann Rheum Dis. 2021;80:96-7.

[3]Harrison et al. Plos One. 2009; 14(4): e0216075.

[4]Finckh et al. Curr Rheumatol Rep. 2016;18: 51.

Acknowledgements

On behalf of the PREFER project. PREFER received funding from the IMI 2 Joint Undertaking (grant No. 115966), which receives support from the EU’s Horizon 2020 research and innovation program and European Federation of Pharmaceutical Industries and Associations (EFPIA). K. Raza is supported by the NIHR Birmingham Biomedical Research Centre.

Disclosure of Interests

Gwenda Simons: None declared, Ellen Janssen Shareholder of: Johnson & Johnson, Employee of: Janssen Research and Development, Jorien Veldwijk: None declared, Rachael DiSantostefano Shareholder of: Johnson & Johnson, Employee of: Janssen Research and Development, Matthias Englbrecht Speakers bureau: Abbvie, Chugai, Eli Lilly, Novartis, Roche, Sanofi, Mundipharma, Paid instructor for: Abbvie, Chugai, Roche, Consultant of: Abbvie, Novartis, Roche, Sanofi, Grant/research support from: Roche, Chugai, Christine Radawski Shareholder of: Eli Lilly, Employee of: Eli Lilly, Larissa Valor: None declared, Jenny Humphreys: None declared, Ian N. Bruce: None declared, Brett Hauber Shareholder of: Pfizer Inc., Employee of: Pfizer Inc., Karim Raza Consultant of: Abbvie, Sanofi, Grant/research support from: Bristol Myers Squibb, Marie Falahee: None declared.

POS0597 PREDICTORS OF PERCEIVED RISK IN FIRST DEGREE RELATIVES OF RHEUMATOID ARTHRITIS PATIENTS

Background

Risk of rheumatoid arthritis (RA) is 3-5 times higher in first-degree relatives (FDRs). Efforts are increasing to develop preventive interventions for this at risk group. Risk perception is a key predictor of health behaviours, including FDRs’ interest in predictive testing1 and preventive intervention for RA. Effective risk communication is essential for RA prevention studies and clinical translation2.

Objectives

To define variables associated with perceived risk of developing RA in FDRs of RA patients.

Methods

RA patients attending outpatient clinics (West Midlands, UK) were asked to invite their FDRs to complete a cross-sectional printed survey. Patients were also invited to complete a survey. Unique survey numbers enabled linkage of FDR and proband responses. FDRs’ perceived absolute risk, comparative risk, experiential risk, and worry about risk were assessed using 5-point Likert scales. Predictor variables included demographics, the Single Item Literacy Screener, Brief Illness Perception Questionnaire, Brief Approach/Avoidance Coping Questionnaire, Life Orientation Test Revised and the Short Health Anxiety Inventory. Patient predictors of FDR perceived risk included demographics, time since RA diagnosis and Rheumatoid Arthritis Impact of Disease Score.

Outcome measure responses were grouped into ‘low’ and ‘high’ for regression analyses. Univariable analysis used independent samples T-tests, chi-square tests and Mann-Whitney U Tests. Backwards stepwise binary logistic regression examined the relationship between FDR characteristics and perceived risk of RA. Generalised Estimating Equations assessed whether patient variables predicted FDR’s perceived risk.

Results

396 FDRs returned a survey. Paired data from 213 patients were available for 292 of these FDRs.

The distributions of risk perception scores are shown in Figure 1. All measures of perceived risk were inter-correlated (p<0.001; ranging from r=0.48 to r=0.80).

65.2% of FDRs perceived themselves to be ‘Likely’ or ‘Very Likely’ to develop RA in their lifetime. FDR’s ethnic group, deprivation index, employment status, education level, smoking status, cohabitation with index patient status, coping style and dispositional optimism were not significantly different between high and low perceived risk groups. Characteristics significant in univariable analyses were used in multivariable analyses (Table 1). Children were 3.89 times more likely than siblings to perceive themselves at high risk of RA. Higher health anxiety scores were associated with increased perceived risk. Female gender, and beliefs that RA would last a long time, and cause higher concern and negative emotional impact predicted increased risk perceptions. Higher perceptions of how well treatment would control RA was associated with a reduced likelihood of perceiving oneself at high risk.

Index patient characteristics did not associate with FDRs’ risk perceptions.

Table 1.

Multivariable analysis

FDR CharacteristicPerceived Risk [Odds Ratio (95% Confidence Interval)]AbsoluteComparativeExperientialWorry about RiskGender1.98 (1.19-3.27)* Male$ FemaleRelationship to index patient2.80 (1.70-4.61)***3.43 (2.04-5.78)***3.89 (2.24-6.75)***2.26 (1.30-3.94)** Child Sibling$Health Literacy1.50 (1.00-2.25)Illness Perceptions0.89 (0.79-0.99)*1.25 (1.05-1.48)*1.17 (0.99-1.38)0.84 (0.74-0.94)** Timeline0.91 (0.81-1.01)0.87 (0.77-0.98)*1.36 (1.13-1.63)** Treatment control1.20 (1.02-1.40)* Concern EmotionHealth Anxiety1.04 (1.01-1.07)*1.05 (1.01-1.07)*1.07 (1.03-1.11)**1.06 (1.02-1.09)**

*p<0.05, **p<0.01, ***p<0.001, $ Reference

Conclusion

FDRs’ perceived risk of RA was high. Key predictors included being a child of a patient with RA, higher health anxiety and lower perceptions of RA treatment control. An understanding of these predictors will inform the development of effective risk communication and preventive strategies.

References

[1]Wells et al. Rheumatology. 2021 doi: 10.1093/rheumatology/keab890

[2]Mankia et al. Ann Rheum Dis. 2021;80(10):1286-98

Acknowledgements

S. Bunnewell and I. Wells are joint first authors.

Disclosure of Interests

None declared

AB0091 INCREASED BIOLOGICAL AGE IN MALE PARTICIPANTS OF SWEDISH AND UK RHEUMATOID ARTHRITIS COHORTS IS NOT LINKED TO DISEASE

Background

Immunesenescence in the adaptive immune system, subsequent to thymic involution, results in compromised immunity and increased susceptibility to autoimmune disease and chronic inflammation. There are reports in the literature that immunesenescence, including thymic atrophy and telomere shortening, is accelerated in patients with rheumatoid arthritis (RA)1. What is unclear is whether RA includes accelerated biological ageing overall in addition to immune ageing which may help to explain the increased risk of age-related diseases in RA2. Recent studies have identified a set of DNA methylated sites across the genome that are highly correlated with chronological age and mortality, termed epigenetic clocks3,4 or DNAm age (DNAma), and can be used to determine an individual’s biological age.

Objectives

The aim of our study is to determine if the biological epigenetic clocks of RA patients are accelerated.

Methods

We evaluated the Horvath3 and Hannum4 epigenetic clocks of control and RA patients using published DNAm data sets, accessions GSE42861 (EIRA, Swedish cohort of 342 RA patients and 328 non-RA controls) and E-MTAB-6988 (77 RA discordant monozygotic twins).

Results

We did not detect significant differences between DNAma of RA and non-RA twins. Similarly, there were no significant differences between the DNAma of RA patients and controls from the Swedish EIRA cohort. However, we detected a significant acceleration in DNAma of male discordant twins, both RA and non-RA, by 5.4 years (p=3.29e-5) and 2.8 years (p=0.04) using the Hannum and Horvath clocks, respectively. Male participants, both control and RA patients, from the EIRA cohort also exhibited an accelerated DNAma, by 1.5 years (p=7.55e-5) using the Hannum clock but using the Horvath clock a significant DNAma acceleration, by 1.4 years (p=0.002) was detected in male RA patients from the EIRA cohort.

Conclusion

Overall, we detected a significant biological age acceleration in male participants from both RA and control groups and only found a significant difference between DNAma of Non-RA controls and RA patients for one of the epigenetic clocks. Further analysis using additional cohort data and biological clock algorithms is needed to confirm our findings.

References

[1]Goronzy, J.J. and Weyand CM (2001). Thymic function and peripheral T-cell homeostasis in rheumatoid arthritis. Trends Immunol. 22(5):251-5.

[2]Meune C, et al. (2009) Trends in cardiovascular mortality in patients with rheumatoid arthritis over 50 years: a systematic review and meta-analysis of cohort studies. Rheumatol 48:1309-1313.

[3]Horvath S (2013) DNA methylation age of human tissues and cell types. Genome Biol 14:R115.

[4]Hannum G, et al (2013) Genome-wide Methylation Profiles Reveal Quantitative Views of Human Aging Rates. Mol Cell 49:359-367.

Acknowledgements

The study was funded by FOREUM

Disclosure of Interests

None declared

OP0276 PREFERENCES FOR TREATMENTS TO PREVENT RHEUMATOID ARTHRITIS: DISCRETE CHOICE SURVEY OF RHEUMATOID ARTHRITIS PATIENTS’ FIRST-DEGREE RELATIVES IN THE UNITED KINGDOM AND GERMANY

Background

There is a growing research focus on the development of interventions to reduce risk of rheumatoid arthritis (RA) in at-risk individuals.(1) A recent survey of the general population asked to assume a 60% risk of RA established that hypothetical preventive treatments were acceptable to most participants.(2) However the preferences of individuals who actually have an elevated risk of RA, such as first-degree relatives (FDRs) of RA patients, are not well understood.

Objectives

To quantify FDRs’ preferences for preventive treatments for RA.

Methods

Adult FDRs in the UK and Germany were invited to take part in a web-based survey via patients with clinician-confirmed RA either during a rheumatology clinic visit or by mail. In addition, FDRs taking part in a UK-based prospective cohort (PREVeNT-RA) were invited via email. Participants received information about RA followed by questions to check comprehension, and an introduction to the survey including warm-up questions. They were asked to imagine they were experiencing arthralgia and had positive autoantibody tests indicating a 60% chance of developing RA in the next two years. Using a discrete choice experiment, participants were offered a series of 15 choices between no treatment and two unlabeled hypothetical treatments to reduce risk of RA. Treatments were defined by six attributes with varying levels, describing benefits, risks, and frequency/route of administration (Table 1). Attribute selection and presentation was informed by qualitative research, ranking surveys, systematic literature review, and expert opinion. Survey layout was informed by patient research partners and qualitative pre-testing. A two-class latent class analysis was used to estimate preferences and calculate relative importance of treatment attributes and predicted uptake. A panel mixed logit model was used to obtain maximum acceptable risk estimates.

Table 1.

Treatment attributes and levels

AttributeLevelsChance of developing RA reduced from 60% to10%; 20%; 30%; 40%How the treatment is takenA shallow injection under the skinA drip into the veinOne or two tabletsHow often the medication has to be takenDailyWeeklyMonthlyEvery 6 monthsChance of mild side effects2%; 5%; 10%Chance of a serious infection due to treatment0%; 1%; 5%Chance of a serious side effect that is potentially irreversible1 in 100,000 people20 in 100,000 people100 in 100,000 people

Results

356 FDRs (252 female, 289 in the UK) responded. While treatment effectiveness was the most important attribute in both classes (Figure 1), the importance of other attributes differed between classes, with method and frequency of treatment administration being more important in class 2 and risk of mild side effects only impacting treatment choice in class 1. Perceived risk of developing RA predicted class assignment; those with higher perceived risk were more likely to belong to class 1. On average, the predicted uptake of treatment profiles estimating prevention candidates: abatacept; atorvastatin; hydroxychloroquine; tolerogenic cell-based therapy; and no treatment would be 50%, 15%, 9%, 18% and 0%, respectively. Finally, the maximum acceptable risk participants were willing to accept were 81%, 25% and 3% point increases in risk of mild side effects, serious infection, and serious side effects, respectively, for medicines that would reduce their risk of developing RA in the upcoming two years from 60% to 20%.

Conclusion

Effective preventive treatments for RA were acceptable to FDRs asked to assume a 60% chance of developing RA. Mode and frequency of treatment administration had a greater impact on treatment choices for participants with a lower perceived risk of RA. These findings are informative for target product profile development, endpoint selection, benefit-risk assessment, regulatory approval, and development of informational resources for those at risk of RA.

References

[1]Mankia et al. Ann Rheum Dis. 2021;80(10):1286-98.

[2]Simons et al. Ann Rheum Dis. 2021;80:96-7.

Acknowledgements

On behalf of the PREFER project. PREFER received funding from the IMI 2 Joint Undertaking (grant No. 115966), which receives support from the EU’s Horizon 2020 research and innovation program and European Federation of Pharmaceutical Industries and Associations (EFPIA). This abstract and its contents reflect the view of the presenter and not the view of PREFER, IMI, the European Union or EFPIA. K. Raza is supported by the NIHR Birmingham Biomedical Research Centre.

Disclosure of Interests

Gwenda Simons: None declared, Jorien Veldwijk: None declared, Rachael DiSantostefano Shareholder of: Johnson & Johnson, Employee of: Janssen Research and Development, Matthias Englbrecht Speakers bureau: Abbvie, Chugai, Eli Lilly, Novartis, Roche, Sanofi, Munidpharma, Paid instructor for: Abbvie, Chugai, Roche, Consultant of: Abbvie, Novartis, Roche, Sanofi, Grant/research support from: Roche, Chugai, Christine Radawski Shareholder of: Eli Lilly & Company, Employee of: Eli Lilly & Company, Larissa Valor: None declared, Jenny Humphreys: None declared, Ian N. Bruce: None declared, Karim Raza Consultant of: Abbvie, Sanofi, Grant/research support from: Bristol Myers Squibb, Marie Falahee: None declared

POS0056 GLOBAL STEROID METABOLISM IN MACROPHAGES: SHAPING INFLAMMATORY FUNCTION AND DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS

Background

Macrophages are key drivers of joint destruction and disease pathophysiology in rheumatoid arthritis (RA), where their inflammatory function is influenced by steroid hormones such as androgens and glucocorticoids (GCs). Local bioavailability of these steroids is determined by both systemic adrenal/gonadal synthesis and local metabolism in peripheral target tissues. The inflammatory regulation and function of steroid hormone metabolism by key rate limiting enzymes in chronic inflammatory diseases such as RA remain poorly defined and could present new therapeutic targets.

Objectives

Characterise regulation of global steroid metabolism in macrophages in RA and determine its contribution to androgen and GC availability, macrophage function and disease activity.

Methods

Bulk and single cell RNA-sequencing of FACS-sorted macrophages were analysed using previously published datasets from RA patients (27 female, 8 male)(1, 2). Gene expression of rate limiting steroid metabolism enzymes were assessed in macrophages and their subsets and correlated to clinical parameters of disease activity. Primary human monocyte-derived macrophages were polarised to non-inflammatory (M-CSF 20ng/ml) and inflammatory activated (M-CSF 20ng/ml, IFNγ 20ng/ml, TNFα 10ng/ml) subsets and treated with active or inactive metabolites of GCs (cortisol/cortisone 100nmol/l) and androgens (androstenedione/testosterone/DHEA 100nmol/l; DHT 10nmol/l). Metabolism and functional effects were assessed in primary cultures and RA synovial fluids by liquid chromatography mass spectrometry, RT-qPCR and ELISA.

Results

Significant differentially expressed genes (DEGs) were identified in the GC and androgen metabolism pathways in synovial macrophages when stratified for high and low disease activity by DAS28-CRP. Expression of the GC-activating enzyme HSD11B1 and androgen activating enzyme SRD5A1 were significantly increased and positively correlated with disease severity. The androgen activating enzyme AKR1C3 was significantly suppressed and negatively correlated with disease severity. SRD5A1 and HSD11B1 expression were localised to S100A12pos and SPP1pos subsets associated with active RA, whilst AKR1C3 was primarily expressed by MerTKposTREM2high subsets associated with RA remission. Inflammatory activation of primary macrophages decreased AKR1C3, and increased HSD11B1 and SRD5A1 expression. This resulted in a shift in intracrine production of active GCs and androgens favouring increased levels of the active GC cortisol and the potent androgen DHT. The resulting changes in steroid ratios in inflammatory activated macrophages resulted in lower expression and release of the pro-inflammatory mediators TNFα, IL6 and IL12 indicating functional significance. In vivo, metabolic changes favouring increased GC activation and reduced androgen activation correlated with disease severity determined by DAS28-CRP.

Conclusion

We have shown for the first time a role for macrophages and their tissue subsets in the inflammatory metabolism and activation of GCs and androgens in RA, which influence macrophage function and disease activity. Targeting these key metabolic pathways represents a novel route to modifying and suppressing disease activity and joint destruction in chronic polyarthritis.

References

[1]Zhang F, Wei K, Slowikowski K, Fonseka CY, Rao DA, Kelly S, et al. Defining inflammatory cell states in rheumatoid arthritis joint synovial tissues by integrating single-cell transcriptomics and mass cytometry. Nature Immunology. 2019;20(7):928-+.

[2]Alivernini S, MacDonald L, Elmesmari A, Finlay S, Tolusso B, Gigante MR, et al. Distinct synovial tissue macrophage subsets regulate inflammation and remission in rheumatoid arthritis. Nature Medicine. 2020;26(8):1295-+.

Acknowledgements

This research was funded by the Wellcome Trust (ref: 215243/Z/19/Z)

Disclosure of Interests

None declared

OP0075 FIBROBLAST/MACROPHAGE CROSSTALK VIA LACTATE: NEW THERAPEUTIC TARGET IN RHEUMATOID ARTHRITIS

Background

The synovial membrane is the principal site of inflammation in rheumatoid arthritis (RA) and distinct subsets of fibroblasts and macrophages, with different effector functions, have been described within it1,2,3. Inflammation renders the RA synovial microenvironment hypoxic and acidic, with increased levels of lactate, the end product of glycolysis. Lactate acts as an immunomodulatory molecule within the synovium4, interacting with lactate transporters present on fibroblasts and macrophages to regulate their function, movement and metabolism.

Objectives

To test whether dysfunctional crosstalk between fibroblasts and macrophages, driven by lactate, promotes the persistence of synovial inflammation.

Methods

Synovial tissues (n = 8) from patients fulfilling the 2010 ACR/EULAR RA criteria were obtained by ultrasound-guided synovial biopsy. Osteoarthritis (OA) synovial tissues of subjects undergoing joint replacement were used as control group. Monocarboxylate transporter 1 (MCT)1 and MCT4 expression on fibroblasts and macrophages was assessed via confocal microscopy. We used RA synovial fibroblasts and monocyte-derived macrophages to test the effect of lactate in vitro. Migration was assessed in trans-well plates or via scratch test assays. Seahorse was used to evaluate metabolic pathways. IL6 production was measured by ELISA. Bioinformatic data were confirmed on publicly available scRNAseq datasets.

Results

We showed that: i) The expression of MCT1 and MCT4 which regulate lactate import and export respectively, is up-regulated upon inflammation. ii) Fibroblasts preferentially express MCT1, while MCT4 is more highly expressed by macrophages. iii) Lactate, at the concentration found in RA synovial fluid (10 mM), has divergent effects on the effector functions of these two cell types. In fibroblasts, lactate promotes IL6 production and cell motility; these effects are reduced by pre-treatment with a pan-lactate transporter inhibitor. In contrast macrophages respond to lactate by reducing migration, IL6 secretion and glycolysis.

Conclusion

The contrasting effects of lactate on macrophage and fibroblast migration, IL6 production and metabolism suggest that lactate represents a key metabolite ensuring linked choreography between fibroblast and macrophage movement in the synovium which may become uncoupled in disease. We propose that dysfunctional crosstalk between these two cell types due to high lactate levels, promotes inflammation and the establishment of persistent disease in RA. Targeting lactate/MCTs pathway may provide a novel therapeutic strategy, to restore cellular crosstalk and to reduce inflammation in RA patients.

References

[1]Croft et al, Nature 2019;570:246-251

[2]Culemann et al, Nature 2019;572:670-675

[3]Alivernini et al, Nat Med 2020;26:1295-1306

[4]Pucino et al, Cell Metab 2019;30:1055-1074.e8

Disclosure of Interests

Valentina Pucino: None declared, Meriam Nefla: None declared, Vincent Gauthier: None declared, Sally A Clayton: None declared, Andrew Filer Consultant of: Abbvie, Roche, Janssen, Grant/research support from: Roche, UCB, Nascient, Mestag, GSK, Janssen, Andy R Clark: None declared, Karim Raza: None declared, Christopher D Buckley Consultant of: GSK, Astra-Zenica, Roche, Pfizer, Lilly, Janssen Mestag, Grant/research support from: GSK, Roche, Pfizer, Janssen Mestag.

Correction to: Symptoms in first-degree relatives of patients with rheumatoid arthritis: evaluation of cross-sectional data from the symptoms in persons at risk of rheumatoid arthritis (SPARRA) questionnaire in the Preclinical EValuation of Novel Targets in RA (PREVeNT-RA) Cohort

An amendment to this paper has been published and can be accessed via the original article.

Design, Development and Evaluation of Thermal Properties of Polysulphone-CNT/GNP Nanocomposites

Polysulphone (PSU) composites with carbon nanotubes (PSU-CNT) and graphene nanoplatelets (PSU-GNP) were developed through the solution casting process, using various weight load percentages of 1, 3, 5, and 10 wt% of CNT and GNP nanofillers. The microstructural and thermal properties of the PSU-based composites were compared. The microstructural characterisation of both composites (PSU-CNTs and PSU-GNPs) showed a strong matrix–filler interfacial interaction and uniform dispersion of CNTs and GNPs in the PSU matrix. The analysis demonstrated that both the thermal conductivity and effusivity improved with the increase in the weight percentage (wt%) of CNTs and GNPs because of the percolation effect. The polysulphone-based composite containing 10 wt% CNTs showed a remarkably high thermal conductivity value of 1.13 (W/m·K), which is 163% times higher than pure PSU. While the glass transition temperature (Tg) was shifted to a higher temperature, the thermal expansion was reduced in all the PSU-CNT and PSU-GNP composites. Interestingly, the CNTs allowed homogeneous distribution and a reasonably good interfacial network of interaction with the PSU matrix, leading to better microstructural characteristics and thermal properties than those of the PSU-GNP composites. The findings highlight the importance of controlling the nature, distribution, and content of fillers within the polymeric matrix.

Symptoms in first-degree relatives of patients with rheumatoid arthritis: evaluation of cross-sectional data from the symptoms in persons at risk of rheumatoid arthritis (SPARRA) questionnaire in the PRe-clinical EValuation of Novel Targets in RA (PREVeNT-RA) Cohort

BACKGROUND

First-degree relatives (FDRs) of people with rheumatoid arthritis (RA) have a fourfold increased risk of developing RA. The Symptoms in Persons At Risk of Rheumatoid Arthritis (SPARRA) questionnaire was developed to document symptoms in persons at risk of RA. The aims of this study were (1) to describe symptoms in a cohort of FDRs of patients with RA overall and stratified by seropositivity and elevated CRP and (2) to determine if patient characteristics were associated with symptoms suggestive of RA.

METHODS

A cross-sectional study of FDRs of patients with RA, in the PREVeNT-RA study, who completed a study questionnaire, provided a blood sample measured for rheumatoid factor, anti-CCP and CRP and completed the SPARRA questionnaire. Moderate/severe symptoms and symmetrical, small and large joint pain were identified and described. Symptoms associated with both seropositivity and elevated CRP were considered suggestive of RA. Logistic regression was used to determine if symptoms suggestive of RA were associated with patient characteristics.

RESULTS

Eight hundred seventy participants provided all data, 43 (5%) were seropositive and 122 (14%) had elevated CRP. The most frequently reported symptoms were sleep disturbances (20.3%) and joint pain (17.9%). Symmetrical and small joint pain were 11.3% and 12.8% higher, respectively, in those who were seropositive and 11.5% and 10.7% higher in those with elevated CRP. In the logistic regression model, seropositivity, older age and feeling depressed were associated with increased odds of small and symmetrical joint pain.

CONCLUSIONS

This is the first time the SPARRA questionnaire has been applied in FDRs of patients with RA and has demonstrated that the presence of symmetrical and small joint pain in this group may be useful in identifying people at higher risk of developing RA.

POS1483-HPR A QUANTITATIVE ASSESSMENT OF THE LIKELIHOOD THAT PATIENTS WITH RHEUMATOID ARTHRITIS WILL COMMUNICATE INFORMATION ABOUT RHEUMATOID ARTHRITIS RISK TO RELATIVES

Background:

First-degree relatives (FDRs) of patients with rheumatoid arthritis (RA) are at increased risk of RA and are being recruited to studies of predictive and preventive approaches. Access to FDRs is usually via the proband with RA. Qualitative investigations have shown that communication of RA risk to FDRs is a complex and selective process. However, quantitative data are needed to develop a robust understanding of this process and its determinants to develop effective communication strategies and support for RA patients and their relatives.

Objectives:

To identify predictors of the RA patients’ reported likelihood of communicating RA risk information to their FDRs.

Methods:

Patients with RA were invited to anonymously complete a survey assessing patient characteristics including age, gender, duration of RA, information seeking and decision making preferences (Autonomy Preference Index1), interest in FDRs taking a predictive test for RA, dispositional openness, and the general functioning subscale of the McMaster Family Assessment Device2. Reported likelihood of communicating RA risk to each of the patients’ FDRs was assessed using a Likert scale ranging from extremely unlikely (0) to extremely likely (4). The median score across all FDRs was calculated for each patient. The association between patient characteristics and the median score was examined using univariate approaches.

Results:

Surveys were completed by 482 patients (median age 65 years, 72% female). Most patients reported being likely to communicate RA risk to their FDRs (median score=3). Those who reported their likelihood of communicating RA risk to both children and siblings were more likely to communicate risk to children than siblings (p<0.001). No significant difference was found for FDRs’ gender, or patients’ gender, on reported likelihood to communicate about RA risk (p=0.32 and p=0.87, respectively). Patients who were older and who had had RA for longer were less likely to communicate about RA risk with their relatives. Patients who had higher interest in their FDRs taking a predictive test for RA, information seeking preferences, openness to communicate, and family functioning were more likely to communicate about risk (Table 1).

Table 1.

Descriptive statistics and Spearman’s rank-order correlations for the association between patients’ characteristics and their median reported likelihood of communicating to their FDRs about RA risk

Patient characteristicsDescriptive statisticsAssociation with median likelihood to communicate risk to relativesTest statisticP valueAge; median (IQR)65 (55-72)-0.19<0.001*RA duration; median (IQR)10 (4-20)-0.180.001*Autonomy preferences Information seeking; median (IQR)84 (75-97)0.26<0.001* Decision making; median (IQR)54 (42-67)0.090.048Interest in children taking a test; median (IQR)3 (2-3)0.44<0.001*Interest in siblings taking a test; median (IQR)2 (2-3)0.44<0.001*Openness; median (IQR)2 (1-3)0.130.004*Family functioning; median (IQR)2 (2-3)0.23<0.001*

* p values significant at the Bonferroni adjusted value of 0.006.

Conclusion:

Respondents were willing to communicate RA risk to their FDRs, and were more likely to communicate about risk to their children than their siblings. Factors including information seeking preferences, dispositional openness, interest in FDRs taking a predictive test, and family functioning were associated with increased likelihood of communicating RA risk information to FDRs. Patients’ age and RA duration were associated with decreased likelihood. These findings increase understanding of communication about RA risk in families, and will inform the development of informational approaches to support family communication and access to FDRs.

References:

[1]Ende et al. Journal of General Internal Medicine. 1989; 4(1): 23-30.

[2]Epstein et al. Journal of Marital and Family therapy.1983; 9(2): 171-180.

Acknowledgements:

This work was supported by Versus Arthritis; Grant reference: 21560 and Riksbankens Jubileumsfond (The Swedish Foundation for Humanities and Social Sciences); Grant reference: M13-0260:1 ‘Mind the Risk’.

Disclosure of Interests:

Imogen Wells: None declared, Peter Nightingale: None declared, Gwenda Simons: None declared, Christian Mallen Grant/research support from: Keele School of Medicine have received funding to support BMS recruit to a non-pharmacological atrial fibrillation trial., Karim Raza Grant/research support from: KR reports grants from Abbvie and Pfizer, and personal fees from Abbvie, Pfizer, Sanofi, Lilly, Bristol Myers Squibb, UCB, Janssen, and Roche Chugai, all outside the submitted work., M. Falahee: None declared

OP0160-HPR PREFERENCES FOR TREATMENTS TO PREVENT RHEUMATOID ARTHRITIS: DISCRETE CHOICE SURVEY OF GENERAL POPULATIONS IN UNITED KINGDOM, GERMANY, AND ROMANIA

Background:

There is increasing research focus on intervention for rheumatoid arthritis (RA) at the earliest stages of disease development, including treatment to prevent RA in at-risk groups. Novel cellular therapies are in development, and the effectiveness of existing immunomodulatory agents to prevent RA in those at risk is under investigation. Quantitative evidence of likely uptake of preventive treatments, and preferences for benefits and risks of such treatments is limited.

Objectives:

To quantify preferences for preventive therapies for RA.

Methods:

A web-based survey (n = 2959) was administered to an age- and gender- stratified sample of adults in the general population from online survey panels in the UK, Germany, and Romania. After receiving information about RA, questions to check comprehension of background information, an introduction to the survey tasks and warm-up questions, participants were asked to imagine that they were experiencing arthralgia (without swelling) and had positive autoantibody tests indicating a 60% chance of developing RA in the next two years. Using a discrete choice experiment with a Bayesian D-efficient design, participants were offered a series of 15 choices between no treatment and two unlabeled hypothetical treatments to lower risk of RA development. Treatments were defined by six attributes with varying levels including benefits, risks, and frequency/route of administration (Table 1). One choice task with fixed levels described treatments representative of those under investigation for RA prevention (abatacept, hydroxychloroquine, atorvastatin and tolerogenic cell-based therapy). Attribute selection and presentation was informed by previous qualitative research, ranking surveys, systematic literature review, and expert opinion. Survey design was informed by patient research partners. The survey was pre-tested during qualitative interviews and revised. A pilot of the final survey with 100 respondents was conducted to obtain priors for the final experimental design. Random parameters logit (RPL) models were used to estimate relative importance of treatment attributes and likely treatment uptake rates in each country.

Table 1.

Treatment attributes and levels

AttributeLevelsChance of developing RA reduced from 60% to10%; 20%; 30%; 40%How the treatment is takenA shallow injection under the skinA drip into the veinOne or two tabletsHow often the medication has to be takenDailyWeeklyMonthlyEvery 6 monthsChance of mild side effects2%; 5%; 10%Chance of a serious infection due to treatment0%; 1%; 5%Chance of a serious side effect that is potentially irreversible1 in 100,000 people20 in 100,000 people100 in 100,000 people

Results:

Across all three countries, effectiveness was the treatment attribute that had most impact on treatment choice (Figure 1). Method of administration was second most important for respondents from the UK and Romania but less important for German respondents. Risks of serious infection and serious side effects were more important determinants of treatment choice for respondents in Romania than they were in the UK and Germany. Percentage choice of fixed profiles reflecting abatacept, atorvastatin, hydroxychloroquine, tolerogenic cell-based therapy and no treatment differed across countries (χ2=78.90; p<0.001): 28.3%, 20.6%, 22.2% 18.5% and 10.4% respectively in the UK; 31.3%, 18.8%, 11.2%, 23.4% and 15.3% in Germany; and 27.6%, 20.5%, 15.8%, 21.7% and 14.4% in Romania.

Conclusion:

This study suggests that effective preventive treatments for RA are acceptable to members of the general population told to assume up a 60% chance of developing RA. The relative importance of treatment attributes and likely uptake of fixed treatment profiles differed across countries. These findings are informative for the design of prevention trials, and the development of informational resources and efficient preventive strategies for those at risk of developing RA.

Acknowledgements:

On behalf of the PREFER project. PREFER received funding from the IMI 2 Joint Undertaking (grant No. 115966), which receives support from the EU’s Horizon 2020 research and innovation program and European Federation of Pharmaceutical Industries and Associations (EFPIA). K. Raza is supported by the NIHR Birmingham Biomedical Research Centre.

Disclosure of Interests:

Gwenda Simons: None declared, Jorien Veldwijk: None declared, Rachael Di Santostefano Shareholder of: Johnson & Johnson, Employee of: Janssen R&D (of Johnson & Johnson), Matthias Englbrecht Speakers bureau: AbbVie, Chugai, Eli Lilly, Novartis, Roche, Sanofi, Mundipharma, Paid instructor for: AbbVie, Chugai, Roche, Consultant of: AbbVie, Novartis, Roche, Sanofi, Grant/research support from: Roche, Chugai, Christine Radawski Shareholder of: Eli Lilly & Company, Employee of: Eli Lilly & Company, Larissa Valor: None declared, Karim Raza Consultant of: Personal fees from Abbvie, Pfizer, Sanofi, Lilly, Bristol Myers Squibb, UCB, Janssen, and Roche Chugai, Grant/research support from: Abbvie and Pfizer, M. Falahee: None declared

OP0264-HPR PERSPECTIVES ON APPROACHES TO PREDICT THE DEVELOPMENT OF RHEUMATOID ARTHRITIS: A QUANTITATIVE ASSESSMENT OF PATIENTS AND THEIR FIRST DEGREE RELATIVES

Background:

There is considerable interest within the medical research community in the identification of individuals at risk of developing rheumatoid arthritis (RA), to identify those who may benefit from preventive interventions. However, it is important to understand the views of those who may be candidates for such predictive tests, to inform the development of effective approaches. First degree relatives (FDRs) of patients with RA are at an increased risk of developing RA. RA patients can provide access to FDRs. Qualitative investigations have explored the views of these groups about predictive testing for RA1,2, but quantitative approaches are needed to develop a robust understanding.

Objectives:

To identify predictors of interest in predictive testing for FDRs and patients, and to assess the likelihood of patients communicating information about RA risk to their FDRs.

Methods:

Surveys were completed by 482 RA patients and 397 of their FDRs. Patients were invited to complete the survey and to provide another to their relatives. Spearman’s Rank Correlations were used to assess relationships between interest in predictive testing/ likelihood of risk communication and potential predictor variables.

Results:

FDRs had a median age of 41 years, 64% were female. 57% were definitely interested and 36% were probably interested in taking a predictive test for RA. Several predictors were found to be associated with interest (table 1).

Table 1.

Spearman’s correlations for relatives’ and patients’ interest in predictive testing. After applying a Bonferonni adjustment, p values were taken as statistically significant at p≤0.003.

FDRsPatientsPredictors of interest in predictive testingrsPrsPBrief Illness Perception Questionnaire0.110.030.090.05 Consequences0.16*0.002*0.100.03 Timeline0.090.07-0.050.28 Personal control-0.030.59-0.020.68 Treatment control-0.020.760.020.74 Identity0.090.090.120.01 Concern0.21*<0.001*0.16*<0.001* Coherence0.110.030.0070.88 Emotional0.120.020.110.02Information Seeking0.35*<0.001*0.22*<0.001*Decision making-0.050.330.070.13Health literacy0.030.520.020.62Health numeracy-0.060.23-0.020.72Brief Avoidance Coping Questionnaire0.120.02-0.010.76Optimism0.060.26-0.070.12Health anxiety0.16*0.001*--Perceived risk0.37*<0.001*--Rheumatoid Arthritis Impact of Disease--0.050.31

– not applicable

Patients had a median age of 65 years, 71% were female. 47% were definitely interested and 30% were probably interested in their children taking a predictive test. Several predictors were found to be associated with interest (table 1). On a Likert scale from extremely unlikely (0) to extremely likely (4), most patients indicated that they were likely to communicate RA risk information to their children (median score=3).

Conclusion:

Interest in predictive testing for RA was high amongst FDRs, and factors including information seeking preference, RA risk perception, concern about RA, perceived consequences of RA and health anxiety were significantly associated with interest. Patients were also willing to communicate information about RA risk to their children. These findings increase understanding of perceptual variation in those at risk of RA, and will inform the development of information to support decision making in individuals considering predictive tests and preventive interventions. We are currently extending this preliminary analysis by building multivariate models incorporating a range of attitudes about predictive testing, assessing predictors of patients’ likelihood of communicating to their FDRs about risk, and the relationship between patients’ and FDRs’ responses.

References:

[1]Stack RJ et al. BMJ open. 2016; 6(6):e010555.

[2]Falahee M et al. Arthritis care & research. 2017; 69(10):1558-65.

Acknowledgments:

This work was supported by Versus Arthritis; Grant reference: 21560.

Disclosure of Interests:

Imogen Wells: None declared, Gwenda Simons: None declared, Rebecca Stack: None declared, Christian Mallen Grant/research support from: My department has received financial grants from BMS for a cardiology trial., Peter Nightingale: None declared, Karim Raza Grant/research support from: KR has received research funding from AbbVie and Pfizer, Consultant of: KR has received honoraria and/or consultancy fees from AbbVie, Sanofi, Lilly, Bristol-Myers Squibb, UCB, Pfizer, Janssen and Roche Chugai, Speakers bureau: KR has received honoraria and/or consultancy fees from AbbVie, Sanofi, Lilly, Bristol-Myers Squibb, UCB, Pfizer, Janssen and Roche Chugai, M. Falahee: None declared

PARE0007 PATIENT AND PUBLIC INVOLVEMENT IN CLINICAL TRIAL DESIGN

Background:

Patient and public involvement (PPI) is gaining increasing recognition as important in ensuring research is relevant and acceptable to participants. Rheuma Tolerance for Cure (RTCure) is a 5 year international collaboration between academia and industry; focusing on earlier detection and prevention of rheumatoid arthritis (RA) through the use of immune-tolerising treatments.

Objectives:

To bring lived experience and insight into scientific discussions; and to evolve collaboration between lay representatives and academia/industry.

Methods:

9 Patient Research Partners (PRPs) from 5 European countries were recruited via the EULAR PARE Network and institutions within the RTCure Consortium (8 PRPs with RA and 1 ‘at risk’). They were asked to enter into a legal agreement with the Consortium. PRPs participated in teleconferences (TCs) and were invited to attend face-to-face (F2F) meetings at least annually. Requests for input/feedback were sent from researchers to PRPs via the project’s Patient Engagement Expert [SK].

Results:

PRP involvement has given researchers and industry partners a new perspective on patient priorities, and focused thought on the ethics of recruitment for and participation in clinical trials of people ‘at risk’ of developing RA. PRPs have helped define the target populations, given their thoughts on what types of treatments are acceptable to people ‘at risk’ and have aided the development of a survey (sent to EULAR PARE members) regarding the use of animal models in biomedical research. Positive informal feedback has been received from researchers and industry regarding the contribution of PRPs to the ongoing project (formal evaluation of PPI in RTCure will be carried out in 2020 and at the project end in 2022).

Challenges:

Legal agreements- Many PRPs refused to sign the Consortium’s complex PRP Agreement; feeling it unnecessary, incomprehensible and inequitable. After extensive consultation with various parties (including EULAR and the Innovative Medicines Initiative) no similar contract was found. Views for its requirement even varied between legal experts. After 2 years of intense discussion, a simple non-disclosure agreement was agreed upon. Ideally any contract, if required, should be approved prior to project onset.

Meeting logistics- Other improvements identified were to locate the meeting venue and accommodation on the same site to minimise travel, and to make it easier for PRPs to take breaks when required. This also facilitates informal discussions and patient inclusivity. We now have agreed a policy to fund PRPs extra nights before and after meetings, and to bring a carer if needed.

Enabling understanding– Future annual meetings will start with a F2F meeting between PRPs and Work Package Leads. Researchers will be encouraged to start presentations with a summary slide in lay language. Additionally, an RTCure Glossary is in development.

Enabling participation– SK will provide monthly project updates and PRP TCs will be held in the evening (as some PRPs remain employed). PRPs will be invited to all project TCs and F2F meetings. Recruitment is underway to increase the number of ‘at risk’ PRPs as their viewpoint is vital to this study.

Conclusion:

Currently PPI in RTCure is an ongoing mutual learning process. Universal guidance regarding what types of contracts are needed for PPI would be useful. Communication, trust and fruitful discussions have evolved through F2F meetings (both formal and informal) between PRPs, academia and industry. It is important that all parties can be open with each other in order to make PPI more meaningful.

Acknowledgments:

This work has received support from the EU/EFPIA Innovative Medicines Initiative 2 Joint Undertaking RTCure grant number 777357.

Disclosure of Interests:

Savia de Souza: None declared, Ruth Williams: None declared, Eva Johansson: None declared, Codruta Zabalan: None declared, Tom Esterine: None declared, Margôt Bakkers: None declared, Wolfgang Roth: None declared, Neil Mc Carthy: None declared, Meryll Blake: None declared, Susanne Karlfeldt: None declared, Martina Johannesson: None declared, Karim Raza Grant/research support from: KR has received research funding from AbbVie and Pfizer, Consultant of: KR has received honoraria and/or consultancy fees from AbbVie, Sanofi, Lilly, Bristol-Myers Squibb, UCB, Pfizer, Janssen and Roche Chugai, Speakers bureau: KR has received honoraria and/or consultancy fees from AbbVie, Sanofi, Lilly, Bristol-Myers Squibb, UCB, Pfizer, Janssen and Roche Chugai

OP0114 PREDICTING RHEUMATOID ARTHRITIS USING THE SYMPTOMS IN PERSONS AT RISK OF RHEUMATOID ARTHRITIS (SPARRA) QUESTIONNAIRE

Background:

Accurate prediction of rheumatoid arthritis (RA) development in persons at risk of RA can help to select individuals for early intervention trials. Currently, RA prediction mostly relies on biomarkers such as genetic factors, autoantibodies and imaging abnormalities, with symptoms being only a minor component1-3. However, at-risk individuals exhibit a high prevalence of diverse and often severe symptoms4,5and information on the predictive ability of individual symptoms or symptom complexes is still largely lacking.

Objectives:

We investigated the prevalence and predictive ability of symptoms in persons at-risk of RA, using the validated ‘Symptoms in Persons At Risk of Rheumatoid Arthritis’ (SPARRA) questionnaire.

Methods:

Individuals at-risk of RA from four different cohorts from the Netherlands (n=122), United Kingdom (N=90), Sweden (N=13) and Switzerland (N=20), were asked to fill out the SPARRA questionnaire, consisting of 69 questions (previously described6). Individuals were either defined as persons with anticitrullinated protein antibodies (ACPA) and/or rheumatoid factor (RF; n=193), having relevant symptoms (i.e. clinically suspect arthralgia with or without RA-specific antibodies, n=70) or being first degree relatives (FDR, n=20) of RA patients. All were followed for a minimum of 24 months or until clinical arthritis development. Univariable analyses were performed for possible predictor selection (p<0.2), followed by stepwise forward selection (by Cox regression, p<0.1) to create a multivariable prediction model.

Results:

The mean age of all participants was 49 years and 69% was female. In total, 56 persons (23%) developed clinical arthritis (n=22, 25, 7, 2 respectively in the 4 groups) after a median of 11.9 months (IQR 5.3 - 17.8). In total, 23 SPARRA questions were selected from the univariable analyses and entered in the stepwise forward selection procedure. Time to development of RA was predicted by the following questions: pain moving from joint to joint, having moderate or severe swelling in joints, feeling ≥1 days fatigue per month and feeling stiffness in joints of one and both feet (table 1).

Table 1.

Multivariable prediction model of SPARRA questions to predict clinical arthritis

HR (95% CI), pDoes your joint pain move from joint to joint?No; from arms to legs; from legs to arms (ref)1From ons side to the other2.96 (1.57; 5.57), p = 0.001Over the past month how much joint swelling have you had?None or mild (ref)1Moderate or severe3.04 (1.48; 6.25), p = 0.003Over the past month how many days of the month have you had fatigue?0 (ref)1≥ 10.32 (0.15; 0.67), p = 0.003Where did you feel joint stiffness?Neither feet (ref)One foot0.93 (0.42; 2.08), p = 0.865Both feet0.40 (0.17; 0.93), p = 0.032

Conclusion:

Asking persons at-risk of RA about joint pain, swelling and stiffness is common clinical practice. However, specific details such as pain moving from one side to the other or degree of joint swelling may provide useful additional information to estimate a person’s RA risk. The protective effect noted for fatigue and stiff feet may reflect an underlying pain syndrome rather than RA risk. We are currently performing analyses of the potential added value of SPARRA questions over the clinical prediction model by van der Stadt et al3which will help determine the final format of the SPARRA questionnaire.

References:

[1]de Hair MJ et al. Ann Rheum Dis. 2013;72(10):1654-8.

[2]Rakieh C et al. Ann Rheum Dis. 2015;74(9):1659-66.

[3]van de Stadt LA et al. Ann Rheum Dis. 2013;72(12):1920-6.

[4]Smolik I et al. J Rheumatol. 2013;40(6):818-24.

[5]Stack RJ et al. Arthritis Care Res (Hoboken). 2013;65(12):1916-26.

[6]van Beers-Tas MH et al. RMD Open. 2018;4(1):e000641.

Acknowledgments:

Supported by EULAR

Disclosure of Interests:

Laurette van Boheemen: None declared, Marieke ter Wee: None declared, M. Falahee: None declared, M.H. van Beers - Tas: None declared, Axel Finckh Grant/research support from: Pfizer: Unrestricted research grant, Eli-Lilly: Unrestricted research grant, Consultant of: Sanofi, AB2BIO, Abbvie, Pfizer, MSD, Speakers bureau: Sanofi, Pfizer, Roche, Thermo Fisher Scientific, Aase Hensvold: None declared, Karim Raza Grant/research support from: KR has received research funding from AbbVie and Pfizer, Consultant of: KR has received honoraria and/or consultancy fees from AbbVie, Sanofi, Lilly, Bristol-Myers Squibb, UCB, Pfizer, Janssen and Roche Chugai, Speakers bureau: KR has received honoraria and/or consultancy fees from AbbVie, Sanofi, Lilly, Bristol-Myers Squibb, UCB, Pfizer, Janssen and Roche Chugai, Dirkjan van Schaardenburg: None declared

Early rheumatoid arthritis is characterised by a distinct and transient synovial fluid cytokine profile of T cell and stromal cell origin

A study by Raza et al., published in this journal in 2005, identified that RA patients, within 3 months of symptom onset, had a synovial fluid cytokine profile that was distinct from that of patients with other inflammatory arthritides of similarly short duration. This profile, which was transient, was characterised by cytokines of stromal and T cell origin. These findings suggested that the first few months after symptom onset were associated with changes in the early RA joint that differed from those operating at later stages. The significance of this paper's methodological approach and its findings, and how they relate to subsequent literature, are discussed.

11β-HSD1 plays a critical role in trabecular bone loss associated with systemic glucocorticoid therapy

BACKGROUND

Despite their efficacy in the treatment of chronic inflammation, the prolonged application of therapeutic glucocorticoids (GCs) is limited by significant systemic side effects including glucocorticoid-induced osteoporosis (GIOP). 11β-Hydroxysteroid dehydrogenase type 1 (11β-HSD1) is a bi-directional enzyme that primarily activates GCs in vivo, regulating tissue-specific exposure to active GC. We aimed to determine the contribution of 11β-HSD1 to GIOP.

METHODS

Wild type (WT) and 11β-HSD1 knockout (KO) mice were treated with corticosterone (100 μg/ml, 0.66% ethanol) or vehicle (0.66% ethanol) in drinking water over 4 weeks (six animals per group). Bone parameters were assessed by micro-CT, sub-micron absorption tomography and serum markers of bone metabolism. Osteoblast and osteoclast gene expression was assessed by quantitative RT-PCR.

RESULTS

Wild type mice receiving corticosterone developed marked trabecular bone loss with reduced bone volume to tissue volume (BV/TV), trabecular thickness (Tb.Th) and trabecular number (Tb.N). Histomorphometric analysis revealed a dramatic reduction in osteoblast numbers. This was matched by a significant reduction in the serum marker of osteoblast bone formation P1NP and gene expression of the osteoblast markers Alp and Bglap. In contrast, 11β-HSD1 KO mice receiving corticosterone demonstrated almost complete protection from trabecular bone loss, with partial protection from the decrease in osteoblast numbers and markers of bone formation relative to WT counterparts receiving corticosterone.

CONCLUSIONS

This study demonstrates that 11β-HSD1 plays a critical role in GIOP, mediating GC suppression of anabolic bone formation and reduced bone volume secondary to a decrease in osteoblast numbers. This raises the intriguing possibility that therapeutic inhibitors of 11β-HSD1 may be effective in preventing GIOP in patients receiving therapeutic steroids.

Attitudes towards Oral Health in Patients with Rheumatoid Arthritis: A Qualitative Study Nested within a Randomized Controlled Trial

INTRODUCTION

Patients with rheumatoid arthritis (RA) present a higher incidence and severity of periodontitis than the general population. Our study, Outcomes of Periodontal Treatment in Patients with Rheumatoid Arthritis (OPERA), was a randomized waiting-list controlled trial using mixed methods. Patients randomized to the intervention arm received intensive periodontal treatment, and those in the control arm received the same treatment with a 6-mo delay.

AIM

The nested qualitative component aimed to explore patients' experiences and priorities concerning oral health and barriers and facilitators for trial participation.

METHODS

Using purposive sampling until thematic saturation was reached, we conducted 21 one-to-one semistructured interviews with randomized patients in either of the 2 treatment arms as well as with patients who did not consent for trial participation.

RESULTS

The patients described their experiences about RA, oral health, and study participation. Previous experiences with dental care professionals shaped patients' current perceptions about oral health and the place of oral health on their list of priorities compared with other conditions. Patients also highlighted some of the barriers and facilitators for study participation and for compliance with oral health maintenance. The patients, in the control arm, presented their views regarding the acceptable length of waiting time for the intervention.

CONCLUSION

The associations between periodontal and systemic health are increasingly recognized by the literature. Our study provided an insight into RA patients' experiences and perceptions about oral health. It also highlighted some of the barriers and facilitators for participating in a periodontal interventional study for this group. We hope that our findings will support the design of larger interventional periodontal studies in patients with RA. The complex challenges faced by the burden of RA and the associated multimorbidities in this patient group might highlight opportunities to improve access to oral health services in this patient population.

KNOWLEDGE TRANSFER STATEMENT

This article provided insights into the experiences and perceptions of rheumatoid arthritis patients about their oral health to improve patient participation in a definitive clinical trial.

Therapeutic glucocorticoids prevent bone loss but drive muscle wasting when administered in chronic polyarthritis

BACKGROUND

Patients with rheumatoid arthritis (RA) experience extra-articular manifestations including osteoporosis and muscle wasting, which closely associate with severity of disease. Whilst therapeutic glucocorticoids (GCs) reduce inflammation in RA, their actions on muscle and bone metabolism in the context of chronic inflammation remain unclear. We utilised the TNF-tg model of chronic polyarthritis to ascertain the impact of therapeutic GCs on bone and muscle homeostasis in the context of systemic inflammation.

METHODS

TNF-tg and wild-type (WT) animals received either vehicle or the GC corticosterone (100 μg/ml) in drinking water at onset of arthritis. Arthritis severity and clinical parameters were measured, serum collected for ELISA and muscle and bone biopsies collected for μCT, histology and mRNA analysis. In vivo findings were examined in primary cultures of osteoblasts, osteoclasts and myotubes.

RESULTS

TNF-tg mice receiving GCs showed protection from inflammatory bone loss, characterised by a reduction in serum markers of bone resorption, osteoclast numbers and osteoclast activity. In contrast, muscle wasting was markedly increased in WT and TNF-tg animals receiving GCs, independently of inflammation. This was characterised by a reduction in muscle weight and fibre size, and an induction in anti-anabolic and catabolic signalling.

CONCLUSIONS

This study demonstrates that when given in early onset chronic polyarthritis, oral GCs partially protect against inflammatory bone loss, but induce marked muscle wasting. These results suggest that in patients with inflammatory arthritis receiving GCs, the development of interventions to manage deleterious side effects in muscle should be prioritised.

11 Beta-hydroxysteroid dehydrogenase type 1 regulates synovitis, joint destruction, and systemic bone loss in chronic polyarthritis

OBJECTIVE

In rheumatoid arthritis, the enzyme 11 beta-hydroxysteroid dehydrogenase type 1 (11β-HSD1) is highly expressed at sites of inflammation, where it converts inactive glucocorticoids (GC) to their active counterparts. In conditions of GC excess it has been shown to be a critical regulator of muscle wasting and bone loss. Here we examine the contribution of 11β-HSD1 to the pathology of persistent chronic inflammatory disease.

METHODS

To determine the contribution of 11β-HSD1 to joint inflammation, destruction and systemic bone loss associated with persistent inflammatory arthritis, we generated mice with global and mesenchymal specific 11β-HSD1 deletions in the TNF-transgenic (TNF-tg) model of chronic polyarthritis. Disease severity was determined by clinical scoring. Histology was assessed in formalin fixed sections and fluorescence-activated cell sorting (FACS) analysis of synovial tissue was performed. Local and systemic bone loss were measured by micro computed tomography (micro-CT). Measures of inflammation and bone metabolism were assessed in serum and in tibia mRNA.

RESULTS

Global deletion of 11β-HSD1 drove an enhanced inflammatory phenotype, characterised by florid synovitis, joint destruction and systemic bone loss. This was associated with increased pannus invasion into subchondral bone, a marked polarisation towards pro-inflammatory M1 macrophages at sites of inflammation and increased osteoclast numbers. Targeted mesenchymal deletion of 11β-HSD1 failed to recapitulate this phenotype suggesting that 11β-HSD1 within leukocytes mediate its protective actions in vivo.

CONCLUSIONS

We demonstrate a fundamental role for 11β-HSD1 in the suppression of synovitis, joint destruction, and systemic bone loss. Whilst a role for 11β-HSD1 inhibitors has been proposed for metabolic complications in inflammatory diseases, our study suggests that this approach would greatly exacerbate disease severity.

Finite Element Analysis of Interfacial Debonding in Copper/Diamond Composites for Thermal Management Applications

Copper/diamond (Cu/D) composites are famous in thermal management applications for their high thermal conductivity values. They, however, offer some interface related problems like high thermal boundary resistance and excessive debonding. This paper investigates interfacial debonding in Cu/D composites subjected to steady-state and transient thermal cyclic loading. A micro-scale finite element (FE) model was developed from a SEM image of the Cu/20 vol % D composite sample. Several test cases were assumed with respect to the direction of heat flow and the boundary interactions between Cu/uncoated diamonds and Cu/Cr-coated diamonds. It was observed that the debonding behavior varied as a result of the differences in the coefficients of thermal expansions (CTEs) among Cu, diamond, and Cr. Moreover, the separation of interfaces had a direct influence upon the equivalent stress state of the Cu-matrix, since diamond particles only deformed elastically. It was revealed through a fully coupled thermo-mechanical FE analysis that repeated heating and cooling cycles resulted in an extremely high stress state within the Cu-matrix along the diamond interface. Since these stresses lead to interfacial debonding, their computation through numerical means may help in determining the service life of heat sinks for a given application beforehand.

Lumbar sympathetic chain: anatomical variation and clinical perspectives

The sympathetic and parasympathetic nervous systems constitute the autonomic nervous system which controls the entropy of the body and maintain the equilibrium. The sympathetic chain forms a definitive anatomic entity which is quite variable with respect to its position and the number of ganglia. The sympathetic nervous system causes vasoconstriction and thus forms the basis of Lumbar sympathetic surgeries being performed in patients with peripheral vascular diseases. The anatomic variations in this region hence gains immense importance for the operating surgeons and consulting radiologists. In the present study, the rami communicantes of either side of lumbar sympathetic chain crossed the common iliac arteries from lateral to medial side and united in front of first piece of sacrum. These rami communicantes encircled the right gonadal artery and could be a threat to the gonadal vascularity causing infertility. This was an unusual feature of the lumbar sympathetic chain and its rami communicantes that were noted in this particular case.

Unilateral Variation in Extensor digitorum longus muscle

During a routine dissection of an adult embalmed male cadaver for educational purpose in the department of anatomy at AIIMS, New Delhi, India, a rare unilateral variation of extensor digitorum longus (EDL) was found which is a muscle of anterior compartment of the leg. There was a split tendon of EDL muscle in the anterior compartment of left leg which became a common tendon in front of the ankle joint. This common tendon of EDL muscle again divided into four slips and were inserted in to the lateral four toes. In the upper part of the leg, the anterior tibial vessel and deep fibular nerve lie between the EDL and tibialis anterior. Knowledge of this type of anomaly is useful in diagnosis and treatment of compartmental syndrome. One of the tendon from the split tendon of EDL muscle can be used as a graft in tendon replacement surgeries. The split tendon may also be capable for some precise movements of the toes.

A feasibility study of educational tools for osteomalacia

Many people in the UK, particularly people of South Asian origin, are advised to supplement their vitamin D intake, yet most do not. This suggests an unmet educational need. The osteomalacia mind map was developed to meet this need. The mind map contains culturally sensitive images, translated into Urdu and made interactive on a DVD. This study explores the feasibility of a randomised controlled study to measure the effect of education on improving vitamin D knowledge and adherence. This was a pilot and feasibility study. Cluster randomisation was used to avoid inter person contamination. Two South Asian women's groups were recruited to receive information about osteomalacia either by interactive DVD or an Arthritis Research UK leaflet. Knowledge and compliance were tested before and after the educational interventions via a knowledge questionnaire and the measurement of vitamin D and parathormone levels. The groups were found to be mismatched for knowledge, educational attainment and language at baseline. There were also organisational difficulties and possible confounding due to different tutors and translators. The DVD group had high knowledge at baseline which did not improve. The leaflet group had low knowledge at baseline that did improve. The DVD group had lower parathormone which did not change. The leaflet group had an increase in vitamin D but parathormone remained high. Performing a randomised study with this population utilising an educational intervention was difficult to execute. If cluster randomisation is used, extreme care must be taken to match the groups at baseline.