Early Osteoarthritis Questionnaire (EOAQ): a tool to assess knee osteoarthritis at initial stage

Background

Early stage of osteoarthritis (OA) is characterized by joint stiffness and pain as well as by subclinical structural changes that may affect cartilage, synovium, and bone. At the moment, the lack of a validated definition of early osteoarthritis (EOA) does not allow to make an early diagnosis and adopt a therapeutic strategy to slow disease progression. Also, no questionnaires are available to evaluate the early stage, and therefore this remains an unmet need.

Objective

Therefore, the purpose of the technical experts panel (TEP) of 'International Symposium of intra-articular treatment' (ISIAT) was to create a specific questionnaire to evaluate and monitor the follow-up and clinical progress of patients affected by early knee OA.

Design

The items for the Early Osteoarthritis Questionnaire (EOAQ) were identified according to the following steps: items generation, items reduction, and pre-test submission.

Methods

During the first step, literature has been reviewed and a comprehensive list of items about pain and function in knee EOA was drafted. Then, during the ISIAT (5th edition 2019), the draft has been discussed by the board, which reformulated, deleted, or subdivided some of the items. After the ISIAT symposium, the draft was submitted to 24 subjects affected by knee OA. A score based on the importance and the frequency was created and the items with a score ⩾0.75 were selected. After intermediate evaluation made by a sample of patients, the second and final version of the questionnaire EOAQ was submitted to the whole board for final analysis and acceptance in a second meeting (29 January 2021).

Results

After an exhaustive elaboration, the final version of the questionnaire contains two domains (Clinical Features and Patients Reported Outcome) with respectively 2 and 9 questions, for a total of 11 questions. Questions mainly explored the fields of early symptoms and patients reported outcomes. Marginally, the need of the symptoms treatment and the use of painkillers were investigated.

Conclusions

Adoption of diagnostic criteria of early OA is strongly encouraged and a specific questionnaire for the whole management of the clinical features and patients' outcome might really improve the evolution of OA in the early stages of the disease, when the treatment is expected to be more effective.

AB1001 OSTEOARTHRITIS AND OBESITY: RELATIONSHIPS AND EFFICACY OF THERAPY

Background

Osteoarthritis (OA) is the most common joint disease. The most important factor not only in the development but also in the progression of OA is obesity. Higher incidence of OA in obese patients is associated with several factors. One of them is a large volume of fat mass, which increases the mechanical load on the joints. On the other hand, in obesity, hyperexpression of pro-inflammatory mediators (cytokines, adipokines) is observed, which negatively affect joint tissues, as well as provoke the development of low-level metabolic inflammation. Thus, the problem of OA and obesity is very relevant in modern rheumatology.

Objectives

To determine features of clinical manifestations of OA in obesity and evaluate the effectiveness of obesity therapy in OA.

Methods

The study included 73 patients (women) with knee OA (according to the ACR criteria) II-III X-ray stage by Kellgren-Lawrence: obese 50 (body mass index (BMI) > 30 kg/m2) and non-obese 23 (control group). Obese patients were divided into 2 groups: 1 group (n = 25) - received orlistat 120mg 3 times a day for 6 months in combination with non-medicamentous methods of controlling excess body weight and 2 group (n = 25), whose patients were recommended a diet and dosed exercise for 6 months. Monthly visits evaluated anthropometric measures, articular status, WOMAC. Initially and after 6 months, laboratory scores were evaluated in obese patients (determination of leptin, TNF-α, IL-6, CRP in peripheral blood).

Results

In patients with OA and obesity, a more severe course of OA is determined compared to the control group (Table 1).

Table 1.

Comparative characteristics of obese and non-obese knee OA patients

ParametersObese patients (n = 50), BMI > 30 kg/m2Non-obese patients (n = 23),BMI < 30 kg/m2рThe mean age, y.o.,(М ± δ)56.5 ± 5.8658.69 ± 5.430,13The mean age of OA onset, y.o., (М ± δ)49.33 ± 6.1455.17 ± 4.88< 0.001Average duration of OA, years, (М ± δ)7.43 ± 3.933.52 ± 1.47< 0.001BMI of onset OA, kg/m2, (М ± δ)36.53 ± 4.3525.8 ± 2.0< 0.001The mean body weight, kg, (М ± δ)102.97 ± 14.5770.87 ± 8.84< 0.001WOMAC pain, mm, (М ± δ)227.9 ± 85.15168.35 ± 49.170.006WOMAC stiffness, mm, (М ± δ)94.44 ± 49.471.52 ± 25.710.039WOMAC functional insufficiency, mm, (М ± δ)846.8 ± 337.57692.69 ± 121.990.037Total WOMAC, mm, (М ± δ)1170.28 ± 437.85932.61 ± 159.090.014

After 6 months of drug therapy of obesity in patients of group 1, a significant decrease in body weight by 10.07% (p < 0.05) was achieved. In patients of group 2, body weight decreased by 0.84% (p > 0.05). In patients of group 1, the indicators of the WOMAC index improved: pain decreased by 52.5% (p < 0.05), stiffness by 47.98% (p < 0.05), functional insufficiency by 51.55% (p < 0.05). In patients of group 2, there was also a decrease in the WOMAC index, however, these changes were worse than in patients with greater body weight loss. Analyzing laboratory data, in group 1 there was a significant decrease in the level of leptin (p = 0.05) and IL-6 (p < 0.05), in contrast to patients of group 2 (p = 0.64; p = 1.0, respectively). In the study of TNF-α, no significant changes in the two groups were determined. CRP level in 1 group of patients decreased by 23.74% (p > 0.05) compared to baseline data, in 2 group of CRP increased by 24.54% (p > 0.05). Correlation analysis revealed a direct relationship between a decrease in leptin level and a decrease in body weight (r = 0.5, p = 0.02) in patients with greater weight loss. Direct correlations of leptin reduction and WOMAC index decline (pain, stiffness, functional insufficiency, total WOMAC) (r = 0.5, p = 0.01; r = 0.4, p = 0.04; r = 0.4, p = 0.03; r = 0.5, p = 0.01, respectively).

Conclusion

The results of our study demonstrated a more severe clinical course of OA in obese patients. Drug therapy for obesity in patients with knee OA and obesity not only leads to a decrease in the presentation of clinical symptoms of OA, but also entails changes at the metabolic level: a decrease in leptin, IL-6 and CRP, which indicates a decrease in the intensity of metainflammation in obese patients. Thus, therapeutic interventions aimed at reducing body weight should be an integral part of knee OA therapy.

Disclosure of Interests

None declared

AB0995 Metabolic phenotype of knee osteoarthritis: characteristic biochemical and imaging features

Objectives

to outline specific biochemical and imaging features of metabolic phenotype of knee osteoarthritis (OA) in a multicenter prospective study.

Methods

284 female patients with knee OA (according to the ACR criteria) aged 40-78 were included in this prospective multicenter study. OA radiologic stages in the study group varied from I to III (Kellgren & Lawrence) and all the patients signed an informed consent. Mean age was 58.5 ± 9.5 years, disease duration was 5 (2-10) years. BMI was 29.6 ± 5.6 kg/m2, with hip (HC) – 109.3 ± 10.4 cm and waist circumference (WC) – 92.5 ± 12.5 cm. Physicians filled out individual case report forms, which included anthropometric information, history and physical assessment data. All patients performed lab tests, ultrasonography and x-ray of the knee, as well as proximal femur and lumbar spine DEXA.

Results

Metabolic phenotype was diagnosed in 52.4% of patients. Participants were then divided in two groups. Patients with metabolic phenotype of osteoarthritis were older (61 (57-68) vs 52 (43-58), respectively, p<0.0001), had higher BMI (31.6 (28.6-35.4) vs 26.4 (23.4-30.3), p<0.0001) and had more intense VAS knee pain while walking on flat surface (50 (40-60) vs 35 (10-50), p<0.0001). There were also statistically significant differences when we analyzed the imaging results (Table 1). Patients with metabolic phenotype of knee OA had higher chances of grade III K&L (ОR=4.4, 95% CI 1.3-14.2, р=0.01) and more significant medial joint space narrowing, bigger tibial osteophytes; knee ultrasound revealed thinner cartilage and thicker synovium. DEXA showed higher total hip BMD. Patients with metabolic phenotype had higher levels of CRP, HbA1c, uric acid, cholesterol, LDL, triglycerides, ALT, AST, glucose, leptin and COMP.

Table 1.

Comparison of patients depending on phenotype

IndexMetabolic phenotype(n=149)No metabolic phenotype(n=135)pK&L radiologic grade0.01I grade13.6%56.7%II grade62.7%36.7%III grade23.7%6.6%Posterior lateral tibial cartilage, mm, Me1.5 (1.4-1.8)1.7 [1.6;1.8]0.05Posterior medial tibial cartilage, mm, Me1.6 (1.3-1.8)1.7 [1.6;1.8]0.014Medial knee joint space, mm, Me2.6 (1-4.6)3.6 [3;4.3]0.023Osteophytes of the medial tibial condyle, mm, Me1 (1-2)0 [0;0]0.025Osteophytes of the lateral tibial condyle, mm, Me1 (1-2)0[0;1]0.042Synovium thickness, mm, Me3.1 (2.9-3.5)2.9 (2.6-3.1)0.02Total hip BMD, (g/cm2), mm, Me0.95 (0.87-1.02)0.87 (0.77-0.99)0.03CRP, mg/l, Me2.8 (1.4-5.1)1.1 (0.49-2.0)0.0001HbA1c, %, Me5.7 (5.4-5.9)5.2 (4.9-5.6)0.0001Uric acid, mcmol/l, Me312 (268-391)269.7 (233.9-324.5)0.0002Cholesterol, mmol/l, Me6.4 (5.33-6.85)5.4 (4.78-5.82)0.002LDL, mmol/l, Me4 (3.38-4.59)3.1 (2.6-3.89)0.0009Triglycerides, mmol/l, Me1.6 (1.19-2.44)1.1 (0.76-1.48)<0.0001ALT/AST, units/l, Me21 (17.15-28.9)/ 20.6 (17.6-25)15.9 (11.4-19.8)/ 18.1(14.9-21.6)0.0006Glucose, mmol/l, Me5.6 (5.1-6,155)5.2 (4.97-5.53)0.001Leptin, ng/ml, Me35.6 (25.5-55.6)20 (14.7-31)<0.001COMP, ng/ml, Me1415 (1115-2100)712.2 (484.5-1015)<0.001IL-6, pg/ml, Me0.55 (0.25-0.8)0.03 (0.01-0.4)<0.005

Spearman correlation analysis showed positive correlations (p <0.05) between the metabolic phenotype and OA radiologic stage (r=0.44), size of tibial osteophytes (r=0.31), synovium thickness (r=0.28), hsCRP (r=0.44), HbA1c (r=0.45), cholesterol (r=0.29), LDL (0.3), triglycerides (r=0.36), uric acid (r=0.3), leptin (r=0.46), IL-6 (r=0.38), COMP (r=0.51). Negative correlations (p <0.05) were established with medial joint space (via X-ray): (r=-0.24) and cartilage thickness (via ultrasound) (r=-0.25).

Conclusion

Comprehensive examination of patients with the use of imaging and biochemical methods showed that metabolic phenotype of osteoarthritis is more severe (with correction for age taken into account). Patients with metabolic phenotype showed higher levels of hsCRP, leptin, IL-6, COMP, which possibly demonstrate a more active form of low-grade inflammation (the underlying mechanism of OA pathogenesis) and more significant cartilage damage

Disclosure of Interests

None declared

POS1136 OSTEOARTHRITIS AND METHOTREXATE: EFFICACY AND SAFETY

Background

One of the common phenotypes of osteoarthritis (OA) is the “inflammatory phenotype,” which is characterized by persistent synovitis of knee joints, small joints of the hands, the development of the erosive hand OA (EOA), and insufficient effectiveness of standard OA therapy. In the inflammatory OA phenotype, changes observed in the synovial sheath have similar features to rheumatoid arthritis, so baseline anti-inflammatory drugs used in RA may be considered as possible treatments for OA. The literature presents few studies with mixed results on the use of methotrexate (MTX) in patients with OA.

Objectives

To examine the efficacy and safety of MTX use in patients with inflammatory knee OA and hand EOA.

Methods

The study included 40 patients (women) with OA (according by ACR criteria) and insufficient effectiveness of previous OA standard therapy: with knee OA (47.5%), hand EOA (25%) and a combination of these 2 localizations (27.5%). The clinical characteristics are shown in Table 1. For 24 weeks, patients received MTX subcutaneously with a dose escalation of 10mg to 15mg per week combined with folic acid 5mg per week and meloxicam 15mg “on demand.” The efficacy of MTX therapy was assessed by WOMAC and AUSCAN, by the OMERACT-OARSI criteria. During the study, laboratory indicators were monitored (clinical, biochemical, immunological blood tests, general urine test).

Table 1.

Clinical characteristic of patients.

ParametersValuesAge, y.o., Me [25%; 75% percentiles]62.5 [58;69]Аge of OA onset, y.o., Me [25%; 75% percentiles]51.0 [46;58]Duration of disease, years, Me [25%; 75% percentiles]9.53 [5;15]Kellgren-Lawrence grades of knee OAII grade, %73.3%III grade, %26.7%BMI, kg/m2 (М ± δ)30.68±6.48WOMAC pain, mm, Me [25%; 75% percentiles]328 [236; 360]WOMAC stiffness, mm, Me [25%; 75% percentiles]100 [87;121]WOMAC functional insufficiency, mm, Me [25%; 75% percentiles]776 [610; 1019]Total WOMAC, mm, Me [25%; 75% percentiles]1220 [819; 1640]AUSCAN pain, mm, Me [25%; 75% percentiles]235 [191;313]AUSCAN stiffness, mm, Me [25%; 75% percentiles]56 [35;66]AUSCAN functional insufficiency, mm, Me [25%; 75% percentiles]430 [334;580]Total AUSCAN, mm, Me [25%; 75% percentiles]671 [392;912]ESR, mm/h, Me [25%; 75% percentiles]11 [7;13]CRP, mg/l, Me [25%; 75% percentiles]1.3 [0.8;2.5]

Results

As a result of 24 weeks of MTX therapy, there was a statistically significant decrease in pain, stiffness and functional insufficiency in the small joints of the hand on the AUSCAN index and in the knee joints on the WOMAC index (Figure 1). In hand EOA, there was a decrease in pain by 40.21%, stiffness by 48.21%, functional insufficiency by 23.72%. In knee OA, there was a reduction in pain by 50.45%, stiffness by 49%, and functional failure by 42.7%. 85.5% of patients with knee OA and 72.5% of patients with hand EOA became responders to therapy according to the OMERACT-OARSI criteria. The best clinical effect was achieved in knee OA (89.9% of patients). As a result of MTX therapy, the need for non-steroidal anti-inflammatory drugs (NSAID) decreased: initially, 85% of patients took NSAID daily or more than 3 times a week, and after 6 months of MTX therapy, only 15% of patients took NSAID daily. In general, the tolerability of MTX was satisfactory. The study of 7 patients was stopped: 4 (10%) due to nausea, 3 (8%) due to a moderate increase in transaminases, one of these patients (3%) had one episode of neutropenia up to 1.82x10*9/l (norm 2.04 - 5.80 x10*9/l). There were no serious adverse events.

Figure 1.

Conclusion

The results demonstrated a good symptomatic effect of MTX in patients with knee OA and hand EOA. There was a statistically significant decrease in pain, stiffness and functional insufficiency in knee joints and small joints of the hands, a decrease in the need for NSAID throughout MTX therapy. The best clinical effect was achieved in patients with knee OA. Thus, the study showed that MTX has a good clinical effect in OA and a satisfactory safety profile.

Disclosure of Interests

None declared

POS1129 MAIN PREDICTORS OF STRUCTURAL PROGRESSION IN PATIENTS WITH METABOLIC PHENOTYPE OF OSTEOARTHRITIS

Objectives

to determine the main predictors of structural progression in patients with metabolic phenotype of knee osteoarthritis (OA).

Methods

82 female patients with metabolic phenotype of knee OA (diagnosis of OA according to the ACR criteria, radiologic stages varying I-III Kellgren & Lawrence) aged 40-75 were included in this prospective study. Mean age was 59.1 ± 8.5 years (42-74), BMI was 32.5 ± 3.48 kg/m2, disease duration was 13 (7-19) years. Individual case report forms, which included history of the disease, physical assessment data, VAS knee pain, WOMAC, joint status, comorbidities and previous medications, were filled out for each patient. All patients performed plain knee radiography, ultrasound and MRI (WORMS).

Results

13 patients (15.9%) showed structural progression at two years of follow-up. When comparing groups with (n=13, group 1) and without (n=69, group 2) structural progression, there were no differences in terms of age, age of disease onset and disease duration. However, in the progression group patients had higher bodyweight: 99 ± 12.9 vs 82.5 ± 8.1 kg (р = 0.0003), they also had higher VAS knee pain (69 (66-73) vs 54 (34-66) mm (p=0.0009), and WOMAC (359 (339-381) vs 255 (200-316) mm (p=0.003)). More patients from the progression group had hypertension (92.3% vs 79.7%) and type 2 diabetes (100% vs 4.3%). MRI showed significant intergroup differences in terms of both frequency and severity of cartilage damage. Cartilage defects (via WORMS) were more frequent in the medial tibial compartment of group 1: 50% vs 4.9%, RR=10.2, 95% CI 2.9-35.1, p=0.0004. Identical trend was found when evaluating bone marrow lesions (BMLs) in the medial (75% vs 27.9%, RR=2.7, 95% CI 1.6-4.5, p=0.003) and lateral (50% vs 16.4%, RR=3.05, 95% CI 1.4-6.8, p=0.02) tibial compartments. Synovitis was verified via MRI in 100% of group 1 patients vs 56.5% (RR=1.8, 95% CI 1.4-2.2, p=0.007).

Correlation analysis confirmed the relationship (p<0.05 for all) between metabolic phenotype structural progression and the following parameters: bodyweight (r=0.39), WOMAC pain (r=0.37), type 2 diabetes (r=0.27), synovium thickness via ultrasound (r=0.32), medial (r=0.44) and lateral (r=0.32) tibial compartment subchondral BMLs, medial tibial cartilage defects (r=0.42), presence of subchondral bone cysts in the medial tibial compartment (r=0.38) and femur (r=0.37); lateral tibial (r=0.28) compartment and femur (r=0.28) and also synovitis (r=0.32).

Discriminant analysis has shown that the most significant risk factors for structural progression of the metabolic phenotype of knee OA were high WOMAC pain, synovitis, type 2 diabetes and medial tibial compartment BMLs. Based on the selected factors and their coefficients, we have created a formula that allows to predict the risk of structural progression of metabolic OA.

Table 1.

Discriminant function coefficients to create a model of structural progression of metabolic knee osteoarthritis

FactorsDiscriminant function coefficientsROC-curveWOMAC pain0.00608XXXXType 2 diabetes2.11052BMLs in the medial tibial comparment1.3734Synovitis1.19864Constant6.34279AUC=0.802 (0.650-0.954)

Model accuracy – 89%

Conclusion

this prospective trial has shown that the main predictors for metabolic knee OA phenotype progression are high WOMAC pain, type 2 diabetes, MRI-detected synovitis and BMLs in the medial tibial compartment. These risk factors may serve as a basis for further personalized therapeutic and preventive approaches.

Disclosure of Interests

None declared

POS1135 METABOLIC OSTEOARTHRITIS: THE ROLE OF THE NUMBER OF COMPONENTS OF METABOLIC SYNDROME AND EXPRESSION OF CARTILAGE TISSUE DESTRUCTION GENES

Background

Osteoarthritis (OA) associated with metabolic syndrome (MS) or its components is considered as the metabolic phenotype of OA. It is well known that obesity and other components of MS affect the clinical picture, course and progression of OA. The cumulative effect of metabolic disorders has an effect on the course and outcomes of OA. The study of molecular genetic relationships between the expression of cartilage tissue destruction genes and metabolic OA is one of the little-studied and relevant directions in rheumatology.

Objectives

To determine the role of MS component count and gene expression associated with cartilage tissue destruction in metabolic OA.

Methods

The study included women (n = 117) 45-75 y.o with knee OA (according by ACR criteria) I-III X-ray stage by Kellgren-Lawrence with different numbers of MS components. The duration of the study was 2 years. The clinic conducted visits 1 times a year. At each visit, anthropometric patient scores, articular status, VAS for knee pain, WOMAC and comorbidities were recorded. Patients underwent a laboratory examination (biochemical blood examination: glucose, total cholesterol, LDL, HDL, TG, isolation of blood RNA to determine the level of expression of cell proliferation genes - m-TOR and cartilage destruction - cathepsin K), instrumental examination (X-ray of knee joints) 1 once a year.

Results

All patients with knee OA included in the study (n = 117) showed an abdominal type of obesity (waist circumference > 80 cm in women), which is the main criterion for MS. With frequency analysis in 5.5% of patients, 1 component of MS was detected, in 13.5% - 2 components of MS, in 70.2% - 3 components of MS, in 10.8% - 4 components of MS. Median (Me, 25%; 75% percentile) duration of knee OA disease was greater in patients with 2 or more MS components and was 7.3 years (6.0-8.0) compared to patients with 1 MS component, in whom the duration of OA was 5.4 years (2.0-11.0), p < 0.05. Spearman correlation analysis showed significant relationships between MS component count and OA duration, age, BMI, VAS for knee pain, WOMAC (Table 1).

Table 1.

Analysis of the relationship between the number of MS components and OA by Spearman.

ParametersNumber of MS componentsрAger=0,57<0,05Duration of knee OAr=0,56<0,05X-ray stage by Kellgren-Lawrence of knee OAr=0,24<0,05BMIr=0,48<0,05VAS for knee painr=0,36<0,05WOMAC painr=0,47<0,05WOMAC stiffnessr=0,42<0,05WOMAC functional insufficiencyr=0,47<0,05Total WOMACr=0,46<0,05

Patients showed high expression rates of m-TOR cell proliferation regulator (11.08 (4.27-15.5)) and cathepsin K articular cartilage destruction (9.34 (3.66-12.5)). In analysis of Spearman correlations of cell metabolism gene expression with clinical manifestations of OA and MS components, direct positive correlations with VAS for knee pain were found (p < 0.001, r = 0.95), body weight (p < 0.001, r = 0.92), the number of MS components (p < 0.001, r = 0.78) and WOMAC pain (p < 0.001, r = 0.76).

Conclusion

In our work, it has been demonstrated that 3 or more components of MS in patients with knee OA are observed at pronounced X-ray stages of OA with longer disease duration and a long history of obesity. There are positive correlations between the number of MS components and the clinical course of OA, X-ray severity of OA, hyperexpression of cell proliferation and cartilage destruction genes.

Disclosure of Interests

None declared

AB0974 Association between diabetes mellitus as part of metabolic syndrome and osteoarthritis (preliminary data)

Background

There are more evidence that diabetes mellitus (DM) aggravates the course of osteoarthritis (OA).

Objectives

At multicenter study to evaluate impact of DM as part of metabolic syndrome on course of knee OA.

Methods

The enrolled patients had knee OA based on ACR criteria with x-ray confirmation with stage I-III (Kellgren and Lawrence (K&L). Mean disease duration was 5 (2-10) years. Patients were evaluated by report form, using the anthropometric parameters, questionnaires, disease history and comorbidity, clinical examination data, assessment of knee joints pain, standard X-ray, ultrasound signs of OA, DXA three sites the L1-L4 lumbar spine, femoral neck, and total hip. All participants were signed an informed consent form.

Results

At prospective study were enrolled 253 women with mean age 58.3 ± 9.5 years (40-75) years, with knee OA. Compensated DM type 2 was diagnosed in 26 (10.3%) patients with knee OA. All patients with knee OA were divided into two groups:1st group was with DM and 2nd group without DM (Table 1). Patients with DM were older, had higher weight and BMI. In patients with DM was harder course of OA based on clinical and instrumental data: higher pain by WOMAC score; at X-ray were more frequent confirmed III stage (K&L) (ОR=3.1, 95%CI 1.1-8.7, р= 0.01). At X-ray investigation narrow of medial joint space and at ultrasound thickness of the cartilage were also smaller at 1st group (р<0.05). Bone mineral density (BMD) in site total hip was also higher at DXA at 1st group. More often comorbidity at 1st group was hypertension (OR=3.5 (95%CI 1.2-10.6), р= 0.01), metabolic syndrome (MS) (OR=10.2 (95%CI 2.3-44), р=0.0002) and nonalcoholic steatohepatitis as part of MS (OR=33.9 (95%CI 3.22-356.8), р=0.003).

Table 1.

Comparative characteristics of patients with OA with or without DM.

Parameters1 group (n=26)2 group (n=227)pAge, years, Me65.5 (60- 68)59 (52- 65)0.002BMI, кg/m2, Me33.5 (29.4- 35.8)28.7 (25.6- 32.3)0.0006OA duration, years, Ме11 (7- 18)4 (2-10)0.0032Generalized ОА, %5024.50.009WOMAC pain, mm, Ме199 (158- 230)120 (45- 190)0.005X-ray stage (K&L), %I8.732.50.04II65.257.3III26.110.2Medial knee joint space, mm, Ме2 (0.6- 3.1)3.4 (2.2- 4.5)0.03Cartilage thickness in posterior-lateralis area of knee joint, mm, Ме1.5 (1.4-1.7)1.7 (1.6- 1.9)0.05HbA1c, %; Ме7.2 (5.4-7.7)5.4 (5-5.7)0.01Glucosae, mmol/l, Ме6.6 (5.1-6,9)5.3 (4.9- 5.7)0.003Hypertension, %84.660.80.01Metabolic syndrome, %92.354.20.0002Medial knee joint space, mm, Ме2 (0.6- 3.1)3.4 (2.2- 4.5)0.03Cartilage thickness in posterior-lateralis area of knee joint, mm, Ме1.5 (1.4-1.7)1.7 (1.6- 1.9)0.05BMD total hip, g/cm2, Ме0.966 (0.955-1.054)0.878 (0.801-0.944)0,04Number of components of MS, %0021.10.0009I10.532.8II47.436.7III and more41.29.4Nonalcoholic steatohepatitis, %18.80.80.003

In the Spearman correlation analysis are confirmed positive associations between DM and more difficult and prolonged course of OA. We found out that higher WOMAC pain subscale (r=0.18), total hip BMD at DXA (r=0.25), smaller size of medial joint space (r=-0.24) and thickness of the cartilage at ultrasound (r= -0.13) are associated with DM (р<0.05 for all parameters). Positive relationships also are indicated with BMI (r=0.21), hypertension (r=0.15), MS (r=0.24), type, such as nonalcoholic steatohepatitis (r=0.26) and number of components of MS (r=0.39).

Conclusion

The patients with OA are high frequent comorbidity with DM (10.3%). Association OA and DM lead to severe OA and higher comorbidity.

References

None

Disclosure of Interests

None declared

POS0127 ASSOCIATION BETWEEN HYPERURICEMIA AND OSTEOARTHRITIS

Background:

Objectives:

To evaluate the relationship of hyperuricemia (GU) with the course of knee osteoarthritis (OA) and the components of metabolic syndrome (MS).

Methods:

The prospective study included 107 women aged 40-75 y.o, with a reliable diagnosis of I-III Kellgren J. - Lawrence J. stage of knee OA (ACR), who signed an informed consent. The average age of patients was 59.1 ± 8.9 y.o. (from 38 to 74), the duration of the disease was 9 (4-12) years. The average values of the body mass index (BMI) corresponded to obesity (30.6 ± 5.7 kg / m2), waist circumference (WC) - 93.9 ± 12.1 cm. An individual card was filled out for each patient, including anthropometric parameters, anamnesis and clinical examination data, an assessment of knee joint pain according to VAS, and concomitant diseases. All patients underwent standard X-ray of the knee joints, DEXA scan of the lumbar spine and total hip, and laboratory examination.

Results:

Hyperuricemia was diagnosed in 26.2% of patients. Patients with GU had a higher BMI and WC (p<0.05). X-ray examination revealed significantly larger sizes of osteophytes (p = 0.02) and smaller sizes of the medial space of the knee joint (p = 0.02), while the patients of both groups were comparable in age and duration of OA (Table 1). Patients with GU had a statistically significantly higher bone mineral density (BMD) values were observed in L1-L4 and total hip (p<0.05). MS was almost 2 times more often diagnosed in patients with GU (83.3% vs. 49.2%, RR=1.71, 95%Cl 1.21-2.36, p=0.01). Higher levels of CRP, COMP, leptin, triglycerides (TG), creatinine, ALT and AST were determined in patients with GU (Table 1). Spearman rank ordered correlation coefficients between GU and BMI (r=0.22, p=0.03), WC (r=0.26, p=0.02), MS (r=0.29, p=0.01), and CHD (r=0.21, p=0.04). There were a correlation between GU and the stage of knee OA (X-ray) (r=0.34, p=0.02), the size of medial osteophytes in the femur (mm) (r=0.37, p=0.01) and the medial space of the knee joint (mm) (r=-0.27, p=0.01), BMD L1-L4 (r=0.37, p=0.03) and the total hip (r=0.37, p=0.04). There were also significant positive associations with the following laboratory parameters: CRP (r=0.27, p=0.007), COMP (r=0.25, p=0.05), leptin (r=0.29, p=0.03), creatinine (r=0.45, p<0.0001), TG (r=0.44, p=0.0001), ALT (r=0.32, p=0.002), AST (r=0.25, p=0.02).

Table 1.

Comparative characteristics of OA patients with and without GU

ParameterOA Patients with GU (n = 28)OA Patients without GU (n = 79)pAge, y.o.61 (53-68)60 (54-66)0.33Duration OA, years10 (6-14)7.5 (3-12)0.06WC, сm99.3 ± 12.892.2 ± 11.40.02BMI, kg/m233.5 ± 5.630 ± 5.60.04The size of the medial space of joint according to X-ray, mm2.3 (1.2-3.3)3.2 (2.0-4.3)0.02The size of the osteophytes of the femur, mm5.8 (3.7-6.3)2.9 (1.7-4.5)0.02BMI L1-L4, g/сm21.18 (1.12-1.24)1.0 (0.86-1.15)0.04BMI total hip, g/сm21.05 (1.0-1.13)0.9 (0.82-0.98)0.04CRP, mg/l2.8 (1.9-6.2)1.9 (1.2-3.6)0.007COMP, ng/ml31.9 (27.6-45)24.2 (18.9-38.7)0.05Leptin, ng/ml46.2 (36.5-72)30.5 (19.5-45.6)0.03TG, mmol/l1.97 (1.61-2.41)1.26 (0.87-1.63)0.002Creatinine, mmol/l79 (74.9-86)68 (62-74)0.0001ALT, mmol/l26.5 (17.2-32.9)17.9 (13.2-21.7)0.003АST, mmol/l22.5 (18.5-27.8)18.9 (16.8-21.9)0.02

Conclusion:

GU may be an aggravating predictor of not only MS-associated diseases such as obesity, dyslipidemia, but also OA. Thus, at high levels of uric acid, more advanced radiological stages of OA, high values of the BMD of the axial skeleton and increased values of CRP, COMP are noted. In this connection, therapeutic interventions of OA in patients with GU should also be aimed at reducing the concentration of uric acid, which may provide a slowdown in the progression of the disease. Further study of this issue is needed.

Disclosure of Interests:

None declared

AB0603 THE NEW POSSIBILITIES OF USING CHONDROITIN SULFATE IN PATIENTS WITH KNEE OSTEOARTHRITIS

Background:

Administration of Chondroitin Sulfate for treatment of osteoarthritis included treatment types include systemic and parenteral therapies. The benefits of local therapies between difference route is ambivalent.

Objectives:

To evaluate effectiveness and safety of Chondroitin Sulfate (CS) by intramuscular and concomitant (intramuscular and intraarticular) route of administration in patients with knee osteoarthritis (OA).

Methods:

In total 150 patients with knee OA according by ACR criteria and with radiological stages 2 and 3 according to Kellgren-Lawrence were enrolled. Patients were divided by 2 groups: 75 patients (R) received course of 25 intramuscular injection every other day: at the first 3 injection’s in dose 100 mg, and in continue in dose 200 mg, 75 patients in 2nd group (N) received 5 intra-articular injections in target knee in dose 200 mg once per 3 days, in continue 16 intramuscular injections every other day in dose 200 mg. All patients received NSAID - meloxicam in stable dose 15 mg per day. All patients were checked by WOMAC, pain by visual analog scale (VAS), McGiIl Pain Questionnaire (MPQ). At the baseline, standard clinical examination for all patients were blood tests, urine test, coagulation panel and ECG.

Results:

After comparing of two groups by the end of course the intensity of pain by VAS was significantly greater in R group (21,88±13,24 vs 16,81±13,49; р<0,0001). There were no significant differences between groups in improvement of WOMAC, WOMAC subscales and MPQ from baseline. Serious adverse events (AE) were absent. 11 AE’s were detected 3,3% (5/150), but in 100% of cases AE’s were resolved by the end of course.

Conclusion:

CS is effective decreased intensity of pain and stiffness, improved functional ability of joints both intramuscular and concomitant route of administration. However, significantly greater results at pain intensity by VAS shows combination: pain intensity by the end of course was significantly lower in group with concomitant intramuscular and intra-articular injections. Probably, it was associated with faster resolution of synovitis by intraarticular route of administration, that leads to choose this route for patients with comorbidity.

Disclosure of Interests:

None declared.

POS0358 EVALUATION OF THE EFFECT OF mTOR EXPRESSION ON THE CLINICAL MANIFESTATIONS OF KNEE OSTEOARTHRITIS IN OBESE AND NORMAL WEIGHT PATIENTS

Background:

Currently, a large number of molecular biological and genetic markers are known to be involved in the development of osteoarthritis (OA). The mammalian target of rapamycin (mTOR) signaling pathway is responsible for chondrocyte proliferation, cartilage matrix production, and cell growth. OA is characterized by increased mTOR synthesis, which is accompanied by an increase in proliferative activity and destruction of chondrocytes. Obesity is an important factor in the progression of knee OA. The study of mTOR expression in patients with OA and obesity is an urgent task in the development of personalized OA therapy.

Objectives:

To determine the expression of mTOR in patients with knee OA in combination with obesity and normal body weight. To evaluate the effect of mTOR on the clinical manifestations of OA in patients with different body mass index (BMI).

Methods:

The study included 73 female patients aged 45-65 y.o. with Kellgren-Lawrence stage II-III knee OA. The patients were divided into 2 groups: group 1 (n=50) with obesity (BMI > 30 kg / cm2) and group 2 (n=23) with normal or increased body weight (BMI < 30 kg/cm2). The average age of patients with obesity is 56.5 ± 5.87 years, without obesity - 58.7 ± 5.43 years. Clinical manifestations were evaluated by a WOMAС. RNA was isolated from the patients ‘ blood samples, which was used to determine the expression of mTOR.

Results:

Patients with knee OA with and without obesity did not differ in age. OA develops at an earlier age in obese patients, than in non-obese patients (p < 0.001). Patients from 1 group had a high BMI > 30 kg/m2 at the onset of OA. Obese patients had more severe knee OA is significantly more often detected: Kellgren-Lawrence stage III was determined in 10% of obese patients and in 4.35% - without obesity (p < 0.001). Significantly higher values of the WOMAC index pain, stiffness, joint functional failure, and total WOMAC were observed in obese patients (p = 0.006, p = 0.039, p = 0.037, and p = 0.014, respectively). Obese patients had higher VAS pain scores (p < 0.05) compared to patients with a lower BMI. Obese patients had a higher mTOR expression (p < 0.05) of 8.02±8.62, compared to non-obese patients. High mTOR expression was associated with VAS knee pain (r=0.78; p < 0.05) and WOMAC pain (r=0.89; p<0.05) in obese patients (Table 1).

Table 1.

Correlation of m-TOR

ParametersmTOR (1 group, n=50)mTOR (2 group, n=23)Body weightр > 0,05р > 0,05Pain (VAS)r=0,78; р<0,05p = 0,07; r = 0,45Pain (WOMAC)r=0,89; р<0,05р > 0,05Total WOMACр > 0,05р > 0,05

Conclusion:

Our study showed that patients with obesity and knee OA have higher rates of mTOR expression, compared to patients with normal body weight. High mTOR expression correlates with the severity of knee pain in obese patients. Thus, the evaluation of mTOR expression in obese patients and knee OA plays an important role in predicting the severity of clinical manifestations of OA, and may influence the choice of personalized therapy tactics for such patients.

Disclosure of Interests:

None declared

OP0197 EVALUATION OF THE RELATIONSHIP OF LEPTIN WITH THE METABOLIC PHENOTYPE OF KNEE OSTEOARTHRITIS IN THE CONTEXT OF OBESITY THERAPY

Background:

Obesity and components of the metabolic syndrome (MS) play a key role in the pathogenesis of the metabolic phenotype of osteoarthritis (OA). Obesity is a process meta inflammation due to the synthesis of proinflammatory mediators (adipokines and adipocytokines). The severity of OA depends on the presence of obesity, adipokine activity, comorbidity, and the presence of MS. The problem of treatment of metabolic OA and obesity is very relevant, in connection with the obesity pandemic.

Objectives:

To evaluate the relationship of leptin with the clinical manifestations of OA and various components of MS in the context of obesity therapy.

Methods:

The study included 50 female patients aged 45-65 y.o. with Kellgren-Lawrence stage II-III knee OA and obesity (body mass index (BMI)>30kg/m2). The average age of the patients was 56.5 ± 5.86 years, the average duration of the disease was 7.43 ± 3.93 years. 62% of patients were diagnosed MS. Patients were randomly divided into 2 groups for the treatment of obesity. Patients from group 1 (n=25) took orlistat 120mg 3 times a day in combination with a hypocaloric diet and exercise for 6 months. Patients from group 2 (n=25) were on a hypocaloric diet in combination with exercise for 6 months. The groups were comparable in clinical parameters. The clinical course of OA was determined by the WOMAC and VAS. Anthropometric data (height, weight) were determined. All patients underwent a laboratory examination at 2 points (initially and after 6 months): a biochemical blood test, leptin was determined by PCR in peripheral blood.

Results:

8% of patients had 1 MS component, 34% - 2 MS components, 34% - 3 MS components, 22% - 4 MS components, and 2% - 5 MS components at the beginning of the study. High leptin levels (p=0.001) were determined in patients with more than 3 MS components. The correlation analysis showed direct correlations of high leptin levels with the severity of knee WOMAC pain (r=0.36, p=0.02) and VAS pain (r=0.51, p=0.01). A positive correlation was determined between high leptin levels and body weight (r=0.56, p<0.01) and waist circumference (r=0.38, p<0.01). Patients from group 1 had a significant decrease of body weight by 10.07% (p<0.05), the indicators of the WOMAC index improved: pain decreased by 52.5% (p<0.05), stiffness by 47.98% (p<0.05), joint functional failure by 51.55% (p<0.05) after 6 months of drug therapy for obesity. Patients of group 2 had a not significant decrease of body weight by 0.84% (p>0.05), and they were worse indicators of clinical manifestations of OA according to WOMAC compared to group 1 (p<0.05). 24% of patients from group 1 showed a decrease in the number of MS components. 12% of patients from group 2 had a decrease in the number of MS components and 12% patients increase in MS components. Patients from 1 group with a significant decrease in body weight, there was a decrease in the level of leptin (p = 0.05) (graphic 1), in contrast to patients without weight loss on the background of non-drug therapy (p = 0.64). We found direct correlations between a decrease in leptin levels and a decrease in the WOMAC index (pain, stiffness, joint functional failure, total WOMAC) (r=0.5, p=0.01; r=0.4, p=0.04; r=0.4, p=0.03; r=0.5, p=0.01, respectively). Patients with a decrease in the number of MS components had a significantly lower leptin levels (p=0.01).

Graphic 1.

Dynamic of leptin.

Conclusion:

Leptin is a predictor of a worse course of the metabolic phenotype of OA associated with MS and obesity. High levels of leptin were observed with more MS components, and were associated with the severity of knee pain and body weight. We observed a decrease in the level of leptin, a decrease in the number of MS components, and an improvement in the clinical manifestations of OA against the background of a significant decrease in body weight. Thus, the treatment of obesity in patients with the metabolic phenotype of OA and other interventions aimed at reducing the level of leptin may contribute to reducing the progression of knee OA.

Disclosure of Interests:

None declared

POS1094 SYNOVITIS IS FACTOR OF OSTEOARTHRITIS KNEE PROGRESSION IN PATIENTS WITH LESS THAN 5 YEARS OF DISEASE DURATION

Background:

There are many studies about investigation of risk factors (RF) of knee osteoarthritis (OA) radiologic progression. Especially, in patients with small disease duration. At the moment, there are ambivalent of results of previous studies, lead to uncertain role of synovitis.

Objectives:

The aim of study is to investigate relationship between knee OA synovitis and progression risk in patients with small disease duration during a follow-up period of 5 years.

Methods:

Eligible patients had knee OA based on ACR criteria with x-ray confirmation; baseline (BL) disease duration less than 5 years. Patients were evaluated at BL and at 5-year follow-up, using the questionnaires, clinical examination, knee joints pain by visual analog scale (VAS), musculoskeletal ultrasound and X-ray. Unadjusted p-values are presented.

Results:

Among 52 adults with knee OA (mean age ± standard deviation, 59.11 ± 8.95 years; 100% female) had the proportion of patients at BL 42.3% (n=22), 46.2 % (n=24), 11.5% (n=6) by disease stage 1,2 and 3, respectively. Patients were categorized into 2 groups by progression during 5 years from BL based on changes of radiological stage. After 5-years follow-up period the progression of knee OA was established in 14 patients (1 group) and in 38 patients (2 group) the progression by radiological stage was absent. BL patients’ characteristics were similar across 1st and 2nd groups: mean age 58.29±7.68 vs 56.05±8.74, р>0.05; disease duration 3.43±1.34 vs 3.47±1.33, р>0.05. Individuals with knee OA progression had worse knee joints pain during walking (60.36±18.33 vs 48.71±17.81, р=0.043), higher body mass index (BMI) (34.45±4.60 vs 28.92±4.92 kg/m2, р=0.001), higher frequency of knee synovitis by clinical examination (42.9% vs 10.5%, RR=4.07; 95%Cl (1,3-12,3), р=0.01) and by musculoskeletal ultrasound (57.1% vs 18.4%, RR=3.1; 95%CI (1.38-6.96), р=0.009). At 5-years follow-up knee pain was significantly greater for 1st group (69.64±18,49 vs 55.76±12.76, р = 0.003), higher BMI (35.74±5.83 vs 30.64±4.64, р = 0.002), also higher frequency of knee synovitis by clinical examination (57.1% vs 10.5%, RR = 5.4 (95%Cl 1.9-15.2), р=0.001) and by musculoskeletal ultrasound (50% vs 13.2%, RR=3.8 (95%Cl 1.4-10.0), р=0.009). Spearman correlation coefficients between radiologic stage and OA progression factors were indicated: between radiologic stage and knee pain during walking (r = 0.34, p<0.05), BMI (r = 0.46, p<0.01), knee synovitis by musculoskeletal ultrasound (r = 0.41, p<0.01). Multivariate (discriminant) analysis was determined that synovitis is a significant predictor of radiographic progression (p < 0.05).

Conclusion:

The proportion of patients with knee synovitis by clinical examination and musculoskeletal ultrasound data increased by 5-year follow-up from BL. Synovitis is a significant predictor of radiographic progression of knee OA in patients with small disease duration.

Disclosure of Interests:

None declared.

Figure 1.

POS0130 ASSOCIATION BETWEEN HYPERTENSION AND OSTEOARTHRITIS

Background:

Objectives:

To evaluate the relationship between arterial hypertension (AH) and the course of knee osteoarthritis (OA).

Methods:

The prospective study included 109 women aged 38-75 y.o., of I-III Kellgren J. - Lawrence J. stage of knee OA (ACR), who signed an informed consent. The average age was 59.3 ± 8.7 y.o. (from 38 to 74), the average duration of the OA was 7 (4-12) years. The average values of the body mass index (BMI) corresponded to obesity (30.9 ± 5.4 kg / m2), waist circumference (WC) – 94.4 ± 11.7 cm. An individual card was filled in for each patient, including anthropometric parameters, anamnesis and clinical examination data, assessment of knee joint pain according to VAS, WOMAC, KOOS and DN4 indices, and concomitant diseases. All patients underwent standard X-ray of the knee joints, laboratory examination.

Results:

AH was diagnosed in 69.7 % patients with OA. Patients were divided into 2 groups, according to the presence or absence of AH (Table 1). Patients with AH were older, had a higher BMI, WC, a longer duration of menopause and significantly earlier its onset (p<0.05). Patients with OA and AH had a more severe course of OA: higher values of pain in VAS, total WOMAC and all its components, DN4, worse indicators of total KOOS (p<0.05). X-ray examination showed a tendency to a more significant narrowing of the medial space of the knee joints (p = 0.07). Laboratory examination showed higher values of CRP, ESR, IL-6, and leptin (p < 0.05).

Table 1.

Comparative characteristics of OA patients with and without AH

ParametersPatients with AH(n=76)Patients without AH(n=33)pAge, y.o.61 (57-68)55.5 (49-58)<0.01WC, cm92 (90-105)86.5 (84-90)<0.01Age of menopause, y.o.50 (47-52)55.5 (49-58)0.02Duration of menopause, years14 (7.5-19)7 (4-8)<0.01Duration of OA, years10 (5-15)4 (1-6)0.001VAS pain score, mm49 (40-57)42 (24-50)0.02WOMAC pain, mm189.5 (140-250)140 (108-162)0.001WOMAC stiffness, mm77.5 (42-100)56 (33.5-71.5)0.01WOMAC functional impairment (FI), mm651 (547-902)546.5 (320-663.5)0.002Total WOMAC, mm899 (728-1280)734 (526.5-882)0.001KOOS, points0.47 (0.36-0.57)0.6 (0.53-0.75)<0.01DN4, points2 (1-3)1 (0-2)0.01Overall health status, mm45 (35-55)36.5 (28.5-48.5)0.02The size of the medial space of joint according to X-ray, mm2.45 (1.35-4.35)3.6 (2.8-4.3)0.07CRP, mg/l2.38 (1.47-4.85)1.21 (0.69-2.53)<0.01Leptin, ng/ml37.4 (26.5-53.3)23.6 (15.1-40.2)0.01IL-6, pg/ml0.7 (0.4-1.2)0.45 (0.3-0.7)0.03ESR, mm/h14 (7-18)7 (6-12)0.02

We founded positive (р <0.05) associations between AH and a more severe, prolonged course of OA (r=-0.39, p<0.01) in the the Spearman rank-order correlation coefficient analysis. Thus, patients with AH had higher values of VAS pain (r=0.31, p<0.01), total WOMAC (r=0.31, p<0.01) and all its components (pain (r=0.33, p<0.01), FI (r=0.3, p<0.01) and stiffness (r=0.24, p<0.01), DN4 (r=0.24, p=0.01), worse indicators of total KOOS (r=-0.42, p<0.01) and overall health status (r=0.23, p=0.02), more often detected more advanced stage of OA (r=0.24, p=0.03) and synovitis (r=0.23, p=0.01). In addition, positive relationships were found with CRP (r=0.31, p<0.01), IL - 6 (r=0.3, p=0.03), ESR (r=0.3, p=0.02). Positive relationships were confirmed between AH and age (r=0.39, p<0.01), menopause duration (r=0.39, p<0.01), WC (r=0.37, p<0.01), leptin (r=0.35, p=0.01), the presence of hypertriglyceridemia (r=0.35, p=0.01) and cardiovascular risks according to SCORE (r=0.26, p=0.02), considering traditional risk factors for cardiovascular diseases (CVD).

Conclusion:

Thus, we found that AH in patients with knee OA is affected by a variety of variables, both related to traditional CVD factors and to OA itself, and the correlations found are approximately equal in strength. The results obtained require further study, and it is possible that preventive measures aimed at reducing the traditional risk factors of diseases of the circulatory system, or correcting existing CVD, will contribute to a more favorable course of OA.

Disclosure of Interests:

None declared

AB0599 EFFICACY AND SAFETY OF COMBINATION THERAPY WITH NSAIDS AND ANTICONVULSANT, COMPARED WITH NSAID MONOTHERAPY FOR CHRONIC PAIN IN PATIENTS WITH OSTEOARTHRITIS OF THE KNEE JOINTS

Background:

In 20-44% of patients with osteoarthritis of the knee joints neuroplastic changes occur due to central sensitization (1,2), which is the rationale for complex therapy, including centrally acting drugs, for more effective pain control.

Objectives:

To evaluate the efficacy and safety of combination therapy with NSAID and anticonvulsant in comparison with NSAID monotherapy in patients with osteoarthritis of the knee joints and signs of central sensitization or nocyplastic pain

Methods:

The study included 60 women with osteoarthritis of the knee joints (OAK) with signs of nocyplastic pain. Nocyplastic pain were revealed by neuropathic scales (DN4 questionnaire > 4 points), subject to the absence of patients lesions of the somatosensory nervous system. All patients were randomized into two age- and sex-matched groups: group I (n=30) received combination therapy with aceclofenac and pregabalin, group II (n=30) - monotherapy with aceclofenac. The observation period was 42 days and included three visits. All patients underwent a clinical and neurological examination, we assessed the overall WOMAC index, pain intensity at rest with the visual analogue scale (VAS), nocyplastic pain (DN4 and Pain DETECT questionnaires), anxiety and depression (HADS questionnaire) and the quality of life (EQ-5D questionnaire).

Results:

The intensity of pain at rest according to VAS in patients of group I significantly decreased after 14 days (visit 2) and even further after 42 days (visit 3) (64.0 [50.0; 72.0] vs 49.0 [33.0; 55.0] vs 33.5 [22.0; 49.0] p = 0.006). In group II the intensity of pain at rest also decreased after 14 days (visit 2) (63.0 [41.0; 72.0] vs 48.0 [35.0; 58.0] p <0.001), however, did not change significantly from visit 2 to 3 (48.0 [35.0; 58.0] vs 44.0 [35.0; 60.0]) (p = 0.57).

The dynamics of neuropathic pain indicators according to the DN4 and Pain DETECT questionnaires was as follows: group I (visit 1-3) DN4 (6.0 [5.0; 7.0] vs 3.0[1.0; 4.0], p=0.001) and Pain DETECT (17.0 [16.0;20.0] vs 8.0 [5.0; 14.0], p=0.001). Group II DN4 (6.0[5.0;6.0] vs 5,0 [3,0; 6,0],p=0,05), Pain DETECT (17,0 [15,0; 19,0] vs 16.0 [14,0; 19,0],p=0,53).

The overall WOMAC index decreased significantly in both groups.

Significant positive dynamics in terms of the level of anxiety (9.0 [7.0;14.0] vs 7.0 [4.0;10.0], p=0.001), depression (8.0 [5.0;10.0] vs 6.5 [4.0;9.0], p= 0.03) and quality of life (0.52 [-0.02;0.52] vs 0.52 [0.52;0.59], p=0.01) was observed compared to baseline in group I but not in group II. Before the start of therapy, the groups were comparable in the studied parameters, however, after 42 days, anxiety (7.0 [4.0;10.0]vs 9.0 [7.0;12.0], p=0.02) and depression levels (6.5 [4.0;9.0] vs 8.0 [6.0;9.0], p=0.05) were statistically different. Moreover, the median anxiety and depression levels still exceeded 7 points in group II, indicating the presence of anxiety and depression.

Conclusion:

Combination therapy of chronic pain with signs of nocyplastic pain with pregabalin and aceclofenac in patients with knee osteoarthritis has been shown to be effective in terms of pain intensity, the presence of neuropathic descriptors and the severity of anxiety compared with aceclofenac alone.

References:

[1]Hochman JR, French MR, Bermingham SL, Hawker GA. The nerve of osteoarthritis pain. Arthritis Care Res (Hoboken). 2010;62:1019–23.

[2]Hochman JR, Gagliese L, Davis AM, Hawker GA. Neuropathic pain symptoms in a community knee OA cohort. Osteoarthr Cartil. 2011;19:647–54.

Disclosure of Interests:

None declared.

AB0604 FACTORS ASSOCIATED WITH PAIN IN EARLY KNEE OSTEOARTHRITIS (PRELIMINARY DATA)

Background:

Objectives:

To identify factors associated with pain in patients with early knee osteoarthritis fulfilling ESKOA criteria [1].

Methods:

50 patients (46 women (92%); 4 men (8%)) fulfilling ESKOA criteria were enrolled in the trial, every participant signed up the consent form. Median age of patients was 47 ± 8 yrs (36 – 63 yrs), body mass index (BMI) was 28.5 ± 4.9 kg/m2 (40% of patients had obesity). Every patient, after signing the standard informed consent form, was addressed to a physician, who would fill in an individual case report form (CRF), including anthropometric parameters, history of OA, comorbidities and physical examination data. Knee pain was also assessed with the use of visual analog scale (VAS). All participants underwent knee X-ray according to the standardized fixed flexion protocol with the use of positioning frame [2].

Results:

Most of the patients (70%) were between the ages of 35 and 50 and only 15 of them (30%) were older than 50 years. Median knee pain duration was found to be 16 (12-20) weeks, intensity of VAS – knee pain was 46 mm (42-50). Median number of episodes of knee pain (in the last 6 months) was 3 (2-6); 30 participants (60%) had episodes of knee pain lasting less than a week, 8 of them (6%) had pain lasting for around a week, 12 of them (24%) had episodes of pain lasting more than one week. In most patients (74%) pain relieved with time, without any additional therapy. Most of the patients had episodes of knee pain linked to increased overload (48 (96%)), when squatting (41 (82%)), most of the patients also reported pain when climbing up and down the stairs (80%) and short joint stiffness when starting movement (76%). Knee pain after sitting was reported in 54% of cases and 20 participants (40%) also reported some walking limitations due to knee discomfort.

Knee X-ray revealed that most of the patients had I Kellgren&Lawrence (K&L) stage knee OA (picture 1). All the included participants had ESR (7 (5-10 mm/hr)) and CRP (1.24 (0.8-2.2 mg/l)) within normal range.

Picture 1 – Radiological knee OA stage (K&L) distribution in the study group

In the Spearman correlation analysis, we have estimated the factors, which may be associated with more severe pain in patients with early knee OA fulfilling the ESKOA criteria. We found out that higher BMI (r=0.38, р=0.02), presence of metabolic syndrome (r=0.37, р=0.008) and hypertension (r=0.29, р=0.04), as well as walking limitations (r=0.33, р=0.008) are associated with knee pain.

Conclusion:

The use of ESKOA criteria in patients with short duration of knee pain can facilitate diagnosis of osteoarthritis on an early stage. In addition, the acquired data show that timely diagnosis and correction of certain components of metabolic syndrome may be beneficial for the course of knee pain intensity in patients with early knee OA, further continuation of this trial is necessary.

References:

[1]Migliore A et al. Rheumatol Int. 2017 Aug;37(8):1227-1236.

[2]Mazzuca SA et al. Osteoarthritis Cartilage. 2008 Dec;16(12):1555-9.

Disclosure of Interests:

None declared.

AB0884 METABOLIC UNHEALTHY PHENOTYPE OF OBESITY IN PATIENTS WITH KNEE OSTEOARTHRITIS: THE EFFECTIVENESS OF ORLISTAT

Background:

Obesity is an important socio-medical problem of mankind. Since the number of obese people in the world is increasing by about 1% per year, the immediate prospects do not look optimistic. One of the important risks of the development and progression of osteoarthritis (OA) is the metabolically unhealthy phenotype of obesity, which is accompanied by a violation of lipid and carbohydrate metabolism, a violation of cytokine regulation. An important step in the treatment of patients with obesity and OA of the knee joints is weight loss.

Objectives:

To evaluate the effectiveness of complex therapy of metabolic unhealthy phenotypes of obesity using orlistat (an intestinal lipase inhibitor) in the clinical manifestations of knee OA, dynamic markers of lipid and carbohydrate metabolism, dynamic CRP and leptin.

Methods:

The study included 50 female patients with knee OA Kellgren-Lawrence stage II-III and obesity (body mass index (BMI)>30kg/m2), aged 45-65yo. Group 1 (25 patients) was administered orlistat at 120 mg (1 capsule) 3 times a day for 6 month combined with low-calorie diet and therapeutic physical exercise. Group 2 (25 patients) was administered only life-modifying therapy for 6 month. The clinical parameters of the course of knee OA (WOMAC), an assessment of the quality of life (EQ-5D) were assessed at initially and after 6 months. Also initially and after 6 months a laboratory study of peripheral blood was performed glucose, HDL, LDL, TG, CRP, leptin, and the index of visceral obesity (IVO) was calculated.

Results:

Initially, all patients had signs of a metabolically unhealthy phenotype of obesity: waist circumference (WC) > 88cm, high IVO, dyslipidemia, arterial hypertension, hyperleptinemia. After 6 months of complex therapy of obesity using orlistat in patients of group 1, a significant decrease in body weight by 10.07% (p <0.05), a decrease in WC by 8 cm (p <0.05), a significantly significant decrease were achieved IVO (p <0.05), glucose (p <0.05). Analysis of cytokines showed a significant decrease in leptin (p <0.05) and CRP (p <0.05) in patients with a weight loss of more than 10%. The reduction in body weight in group 1 patients reduced pain by 52% (p <0.05), stiffness by 51% (p <0.05), improved joint functional failure by 51% (p <0.05) and improved quality life by 52% (p <0.05). In patients of group 2, against the background of non-drug therapy of obesity, body weight decreased by 0.84% (p> 0.05), slightly decreased WC (p> 0.05). Indicators of lipid metabolism, IVO, glucose, leptin remained unchanged (p> 0.05). The increase in CRP in patients of the 2nd group was determined by 24.54% (p <0.05).

Conclusion:

The results of our study demonstrate the effectiveness of the use of a comprehensive drug regimen for the treatment of metabolically unhealthy phenotype of obesity for the clinical manifestations of osteoarthritis of the knee joints; it contributes to the improvement of metabolic parameters: a decrease in WC, lipid and carbohydrate metabolism, CRP and leptin. Thus, the use of complex therapy using orlistat in patients with osteoarthritis and obesity leads to a decrease in the metabolic activity of adipose tissue, helps to reduce cardiometabolic risk and to improve the clinical course of osteoarthritis.

Disclosure of Interests:

None declared

AB1112 THE DIAGNOSTIC OF THE OSTEOARTHRITIS OF THE HANDS BY CONVENTIONAL RADIOGRAPHY

Background:

The most severe phenotype of osteoarthritis (OA) is currently considered to be an inflammatory or erosive phenotype (EOA). There is currently no reliable x-ray picture of this disease in the literature, and the question of whether it is an independent form of OA, a natural more pronounced stage of progression, or a separate nosology is debated in the literature.

Objectives:

To identify the localization, frequency, and severity of pain and radiological symptoms in patients with EOA and non-erosive (NOA) disease in the interphalangeal (DIP and PIP) and metacarpal (MCP) joints of the hands.

Methods:

64 women with diagnosis of OA of the hand (HOA) joints according to the ACR criteria were included into study after signing the informed consent form. Mean age was 65.28 ± 6.82 years (48-77), mean BMI 27,7 ± 4,4 kg/m2, mean disease duration 12 ± 8,1 years. Individual patient’s medical record included relevant anthropometric data, records from case history and clinical examination, AUSCAN scores, patient’s articular status. Instrumental diagnostic methods included plain radiography of the hand joints in an anterior-posterior projection. The images were described in accordance with the Kellgren&Lawrence (K&L) system.

When evaluating radiographs of 64 patients with HOA, the most common was stage II (49%) according to K&L, and the most common symptoms in distal (DIP), proximal (PIP) interphalangeal and MCP were joint space narrowing (JSN) (100%, 100%, and 95%, respectively) and osteophytes (OP) (88%, 70%, and 45%, respectively). Subchondral osteosclerosis (SO) (5%), erosions (8%), and subluxations (3%) in MCP, as well as subluxation in PIP (6%) were less common. Statistica 10.0 was used for statistical analysis.

23 patients had EOA, 37 had NOA. Depending on the presence of erosions in interphalangeal joints patients were divided into 2 groups comparable in terms of age, age of OA onset and duration of disease (the average age of patients with EOA interphalangeal joints was 68 + 6.15 years, and mean disease duration 18,34 + 7.11 years; in the group without erosive changes in the average age amounted to 65,13±5.43 years, mean disease duration of 16.56±8.4 years).

Results:

EOA DIP and PIP was detected in 15 (23%) with radiological changes corresponding to stages III-IV of HOA and in 8 people (12%) with stage II on the K&L scale. Patients with stage I according to standard radiography had no erosive process.

In DMFs OP (100% and 78%, OR=1.28, 95%, CI [1.08-1.5], p=0.02), SO (74% and 11%, OR=6.8, 95%, CI [2.6-17.8], p<0,0001), subchondral cysts (SC) (61% and 24%, OR=2.5, 95%, CI [1.3-4.82], p=0.005) and subluxations (43% and 14%, OR=3.2, 95%, CI [1.3-8.23], p=0.01) were significantly more often found in patients with EOA. In PIPs SO (43% AND 5%, OR=8.04, 95%, CI [1.93-33.5], p=0.0005), SC (52% and 27%, OR=1.93, 95%, CI [0.1-3.73], p=0.045) and subluxations (17% and 0%, p=0.01) were significantly more frequently detected in patients with EOA compared to the non-erosive group. According to the results of the AUSCAN questionnaire, a significantly greater severity of pain was found in patients with EOA (65%) in comparison with the non-erosive (30%) form of HOA (OR=2.19, 95%, CI [1.23-3.9], p=0.008).

Conclusion:

DIPs is most often affected in OA of interphalangeal joints, less often PIPs, the most common symptoms are JSN and OP. At EOA in addition to more frequent detection OP, cysts, SO, subluxations in DIPs, SO, cysts and subluxations in PIPs, there is also significantly more pronounced pain according to AUSCAN data, it can be concluded that EOA is more severe in comparison with the non-erosive form of HOA.

Disclosure of Interests:

Danil Kudinsky: None declared, Ludmila Alekseeva Grant/research support from: Bayer, Alexander Smirnov: None declared, Alexander Volkov: None declared, Olga Alekseeva: None declared, Elena Taskina: None declared, Anastasiia Sukhinina: None declared

AB0885 EFFECTIVENESS AND SAFETY OF GLUCOSAMINE AND CHONDROITIN COMBINATION IN PATIENTS WITH KNEE AND HIP OSTEOARTHRITIS: INTERIM ANALYSIS RESULTS OF AN OBSERVATIONAL STUDY

Background:

Combined treatment with oral glucosamine hydrochloride (GH) and chondroitin sulfate (CS) was shown to be efficient for pain relief and function improvement in osteoarthritis patients with moderate to severe knee pain [1,2].

Objectives:

To investigate demographic and clinical characteristics, changes in pain, functions of daily living, quality of life and treatment satisfaction of patients with knee osteoarthritis (KOA) or hip osteoarthritis (HOA) receiving long-term treatment with oral GH and CS combination in routine clinical practice.

Methods:

An open-label, multicenter, observational prospective study is being conducted in the Russian Federation. Patients of both sexes with KOA or HOA (Kellgren and Lawrence grades I-III) who receive GH 500 mg+CS 400 mg capsules three times a day for the first 3 weeks of treatment, then twice daily, are included in the study. The interim analysis has been conducted after the first 550 enrolled patients (50% of the total sample size) had completed the first follow-up visit (Week 16-24 after the start of treatment).

Results:

The study group included 406 (73.8%) patients with KOA and 144 (26.2%) patients with HOA enrolled in 43 centers in Russia. The mean age of the patients was 61.1 years; most patients were women (88.7%). The predominant risk factors for OA were non-genetic causes (excess weight, hormonal disorders, malformations of bones and joints, joint operations) (52.8% of patients), exogenous risk factors (professional activity, trauma, sports) and hereditary diseases of bones and joints were reported in 15.5% and 4.1% of patients, respectively.

Interim analysis showed clinically significant improvement in each of the KOOS and HOOS subscales at 4-6 months after the start of treatment. In patients with KOA, the mean score increase was 15.7 for the Pain subscale, 14.6 for the Quality of Life subscale, 13.8 for the Physical function (KOOS-PS), and 11.7 for the Symptoms subscale. The percentage of patients who rated the pain frequency as ‘always’ or ‘daily’ decreased from 60% to 25%.

In patients with HOA, the mean score increase was 16.0 for the Pain subscale, 14.3 for the Quality of Life subscale, 16.1 for the Physical function (HOOS-PS), and 10.3 for the Symptoms subscale. The percentage of patients who rated the pain frequency as ‘never’ or ‘monthly’ increased from 34% to 60%.

Most patients (89.1%) were receiving the medicinal product for ≥3 months. Treatment-related AEs were reported in 16 (3.0%) patients and mainly included gastrointestinal tract disorders (in 12 (2.2%) patients).

Conclusion:

The results obtained at 4-6 months after the start of treatment demonstrate clinically significant reduction of frequency and intensity of pain and other OA symptoms, as well as improvement of functions in daily living and quality of life in patients with KOA or HOA after the first course of treatment with GH + CS capsules. The majority of patients (72.5%) were satisfied with the treatment. The incidence of drug-related AEs was low, and the nature of AEs was consistent with known safety profile of GH and CS combination.

References:

[1]Clegg DO, Reda DJ, Harris CL, et al. Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med. 2006 Feb 23;354(8):795-808.

[2]Hochberg MC, Martel-Pelletier J, Monfort J, et al. Combined chondroitin sulfate and glucosamine for painful knee osteoarthritis: a multicentre, randomised, double-blind, non-inferiority trial versus celecoxib. Ann Rheum Dis. 2016 Jan;75(1):37-44.

Disclosure of Interests:

Kirill Telyshev: None declared, Ludmila Alekseeva Grant/research support from: Bayer, Alexander Lila: None declared, Andrey Baranov Grant/research support from: Bayer, Evgeny Trofimov Grant/research support from: Bayer

Treat-to-target strategy for knee osteoarthritis. International technical expert panel consensus and good clinical practice statements

Background:

In this work, we aimed to establish a clinical target in the management of knee osteoarthritis (KOA) and to propose good clinical practice (GCP) statements for carrying out a treat-to-target strategy.

Methods:

A steering committee of seven experts had formulated a provisional set of recommendations that were exposed for discussion and modification to a technical expert panel (TEP) of 25 multidisciplinary experts from Europe, North America, South America and Asia. The level of evidence and strength of each recommendation was discussed. The TEP formulated overarching principles and GCP statements based on the level of agreement for each item with a vote using a 10-point numerical scale.

Results:

Two overarching principles and 10 GCP statements were formulated by the TEP. These GCP statements suggest: treatment should achieve clinical improvement bringing the patient to the Patient Acceptable Symptom State (PASS); pharmacological and nonpharmacological treatment should begin as early as possible, with an early diagnosis of symptomatic KOA; the patient should be evaluated every 3–6 months; risk factors of KOA progression should be identified and managed with patients at the beginning of the treatment and monitored regularly; treatment should be adapted according to patient phenotype and disease severity; healthy lifestyle must be promoted and monitored. The level of agreement average ranged from 8.7 to 9.6 on scale.

Conclusions:

The proposed overarching principles and GCP statements have the aim of involving patients, general practitioners and multidisciplinary specialists in sharing a therapeutic treat-to-target strategy for KOA management based on the best evidence and expert opinions.

EULAR evidence-based recommendations for the diagnosis of hand osteoarthritis: report of a task force of ESCISIT

Objectives:

To develop evidence-based recommendations for the diagnosis of hand osteoarthritis (OA).

Methods:

The multidisciplinary guideline development group, representing 15 European countries, generated 10 key propositions regarding diagnosis using a Delphi consensus approach. For each recommendation, research evidence was searched for systematically. Whenever possible, the sensitivity, specificity and likelihood ratio (LR) were calculated; relative risk and odds ratios were estimated for risk factors for hand OA. Quality of evidence was categorised using the European League Against Rheumatism (EULAR) hierarchy, and strength of recommendation was assessed by the EULAR visual analogue scale.

Results:

Diagnostic topics included clinical manifestations, radiographic features, subgroups, differential diagnosis, laboratory tests, risk factors and comorbidities. The sensitivity, specificity and LR varied between tests depending upon the cut-off level, gold standard and controls. Overall, no single test could be used to define hand OA on its own (LR <10) but a composite of the tests greatly increased the chance of the diagnosis. The probability of a subject having hand OA was 20% when Heberden nodes alone were present, but this increased to 88% when in addition the subject was over 40 years old, had a family history of nodes and had joint space narrowing in any finger joint.

Conclusion:

Ten key recommendations for diagnosis of hand OA were developed using research evidence and expert consensus. Diagnosis of hand OA should be based on assessment of a composite of features.

EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)

OBJECTIVES

To develop evidence based recommendations for the management of hand osteoarthritis (OA).

METHODS

The multidisciplinary guideline development group comprised 16 rheumatologists, one physiatrist, one orthopaedic surgeon, two allied health professionals, and one evidence based medicine expert, representing 15 different European countries. Each participant contributed up to 10 propositions describing key clinical points for management of hand OA. Final recommendations were agreed using a Delphi consensus approach. A systematic search of Medline, Embase, CINAHL, Science Citation Index, AMED, Cochrane Library, HTA, and NICE reports was used to identify the best available research evidence to support each proposition. Where possible, the effect size and number needed to treat were calculated for efficacy. Relative risk or odds ratio was estimated for safety, and incremental cost effectiveness ratio was used for cost effectiveness. The strength of recommendation was provided according to research evidence, clinical expertise, and perceived patient preference.

RESULTS

Eleven key propositions involving 17 treatment modalities were generated through three Delphi rounds. Treatment topics included general considerations (for example, clinical features, risk factors, comorbidities), non-pharmacological (for example, education plus exercise, local heat, and splint), pharmacological (for example, paracetamol, NSAIDs, NSAIDs plus gastroprotective agents, COX-2 inhibitors, systemic slow acting disease modifying drugs, intra-articular corticosteroids), and surgery. Of 17 treatment modalities, only six were supported by research evidence (education plus exercise, NSAIDs, COX-2 inhibitors, topical NSAIDs, topical capsaicin, and chondroitin sulphate). Others were supported either by evidence extrapolated from studies of OA affecting other joint sites or by expert opinion. Strength of recommendation varied according to level of evidence, benefits and harms/costs of the treatment, and clinical expertise.

CONCLUSION

Eleven key recommendations for treatment of hand OA were developed using a combination of research based evidence and expert consensus. The evidence was evaluated and the strength of recommendation was provided.

Immune response modulation by recombinant peptides expressed in virus-like particles

Aspergillus fumigatus, a ubiquitous fungus, is implicated in the pathogenesis of a number of clinically different allergic diseases in man, including allergic bronchopulmonary aspergillosis. Peptide-based immunotherapy may offer an alternative treatment strategy for the management of allergic disease. The objective of this study was to alter the allergen-specific immune response using dominant T cell epitopes of a major A. fumigatus allergen, Asp f2, expressed in yeast as virus-like particles (VLP). The T cell epitopes of Asp f2, recognized in mice with an H-2d background, were determined by producing T-cell hybridomas. Two dominant T cell epitopes, aa60--71 and aa235--249, were identified and expressed in a yeast VLP system. To induce tolerance VLP-peptides were injected subcutaneously into mice previously immunized with recombinant Asp f2. The T cell immune response was abrogated totally in 3 weeks following a single injection of VLP but was restored 2 months later following intranasal antigen exposure. T-cell depletion resulted in the reduction of 20-30% of all antigen-specific immunoglobulin classes. Thus, recombinant peptides expressed in the VLP system can be used successfully in the modulation of Asp f2-induced immune response in mice, although a single administration is not sufficient to maintain a state of tolerance for a long period of time.

Prevention of experimental septic shock by pretreatment of mice with muramyl peptides

Muramyl peptides, immunostimulators with macrophage as a main target cell, are used for protecting mice from LPS-lethality (the experimental model of septic shock). Different protocols of pretreatment mice by muramyl peptides lead to opposite results. LPS and glycopeptides act synergistically in the induction of lethal shock, when mice receive peptides 1 day prior to lethal dose of LPS. However, extension of the period between the peptide and LPS injections to 6 days cancels the effect of synergism. Moreover, a 14-day interval between the same injections leads to protection of 70-90% animals from the toxic effect of LPS. Lipophilic analogs require 10-100 lower concentrations to protect the animals than the parent highly hydrophilic glycopeptides. Production of TNF, IL-1 and phagocytosis by macrophages was studied within the periods corresponding to "synergism" and LPS-resistance. High level of macrophage activity was observed during the "synergism" period. Low TNF production and reduced macrophage phagocyte activity corresponded to LPS-resistant state. These results partly explain the LPS-unresponsiveness in mice after their pretreatment by muramyl peptides.

Intravenous injection of major and cryptic peptide epitopes of ribotoxin, Asp f 1 inhibits T cell response induced by crude Aspergillus fumigatus antigens in mice

Aspergillus fumigatus, a ubiquitous fungus, is implicated in the pathogenesis of a number of clinically different allergic diseases in man. Peptide-based immunotherapy may offer an alternative in patient care and management. The purpose of this study was to evaluate the role of T cell epitopes of A. fumigatus ribotoxin, Asp f 1 in inducing tolerance in mice exposed to A. fumigatus antigen. The epitope analysis in BALB/c mice using synthetic peptides of Asp f 1 demonstrated both cryptic and dominant epitopes detected from 42 through 54 and 155 through 167 aa, accordingly. Intravenous injection of these peptides markedly inhibited the response induced by the exposure to crude A. fumigatus extract in mice as evidenced by the in vitro interleukin-2 (IL-2) production and proliferation of T-lymphocytes. Cytokine transcription studies indicate that, when stimulated with the peptides in immunogenic conditions, the major peptide (aa 155-167) specific T cell clone produced only IFN-gamma, but not IL-4. The ability of both dominant and cryptic peptide epitopes of a single molecule to induce tolerance against the immune response to a multi-molecular allergen complex has significant implication for peptide-based immunotherapy.

Plasmapheresis in the treatment of posttransplant cardiomyopathy

After heart transplantation a number of factors such as pre- and postoperative hypoxia of the myocardium, myocardial failure of the early postoperative period, acute rejection episodes, cytomegalovirus infection, and finally the progressive atherosclerosis of the coronary arteries lead to the development of transplanted heart failure. Severe alterations of the myocardial function at this end stage of the process correspond to incurable cardiomyopathy. The target of plasmapheresis in this case is to decrease the extent of the disturbances in the lipoprotein contents and blood rheology for the improvement of the coronary perfusion of the transplanted heart. Nine patients with 3-7 year survival periods after heart transplantations underwent plasmapheresis twice a year using the Haemonetics PCS-plus machine. 2,100-2,700 ml of plasma was removed. Biochemical data, rheology and coagulation, and the concentration of Sandimmune (Sandoz Pharma Ltd., Basel, Switzerland) were controlled, and radionuclide scintigraphy of the myocardium, coronarographia, and transesophageal ultrasound investigations were completed for these patients. The result was the significant improvement of the coronary perfusion of the myocardium. The level of immunosuppression after the plasmapheresis procedures did not change and therefore did not demand any correction. Thus, we think that plasmapheresis can be an effective method of treatment of posttransplantation cardiomyopathy; the improvement of coronary perfusion decreases the extent of chronic ischemia. Further studies are necessary to answer the question as to whether it is possible to prolong the time before retransplantation with the help of plasmapheresis.