Relationship between sex and clinical and imaging features of early axial spondyloarthritis: results from a 48 month follow-up (Italian arm of the SPondyloArthritis Caught Early (SPACE) study)

OBJECTIVES

To assess the association between sex and clinical and disease activity indices, and X-rays and magnetic resonance imaging (MRI) features, in early-stage axial spondyloarthritis (axSpA).

METHOD

Baseline data analysis was conducted on the Italian SPACE cohort, including patients with chronic back pain (duration ≥ 3 months and ≤ 2 years; onset < 45 years). Patients underwent MRI and X-rays of the sacroiliac joints (SIJs) to establish the diagnosis of axSpA, according to Assessment of SpondyloArthritis international Society criteria and physician's judgement. Clinical features, disease activity and functional indices, and images were collected at baseline and yearly during 48 months. Spinal and SIJ X-rays and MRI images were scored by two readers following Spondyloarthritis Research Consortium of Canada (SPARCC), modified Stoke Ankylosing Spondylitis Spinal Score, and modified New York criteria. Characteristics of axSpA patients according to sex (male/female) were compared over time using descriptive statistics.

RESULTS

Ninety-one patients had axSpA (83.5% non-radiographic; 16.5% radiographic); 47.3% were male. Males were younger, with shorter duration of axial symptoms, and more frequently had HLA-B27 positivity, radiographic sacroiliitis with a bilateral/symmetric pattern, and more signs of spondylitis. Females more frequently showed peripheral/entheseal involvement and the non-radiographic phenotype. Males showed increased pelvic/spinal radiographic progression and more often had active sacroiliitis on MRI. Although the frequency of inflammatory corner lesions did not differ between males and females, localization varied, with more cervical/thoracic MRI-spine lesions in females and more lumbar lesions in males. We observed a significant downward trend of SPARCC SIJ/spine scores in all patients, irrespective of sex. More fat lesions were observed on MRI-spine in females and on MRI-SIJ in males.

CONCLUSION

Sex was associated with distinct axSpA features: females showed low-grade radiographic sacroiliitis and spinal progression, and a higher prevalence of cervical and thoracic spine MRI signs.

AB0806 Gender and Imaging Progression in early Axial Spondyloarthritis: Results from a 48-month follow-up (Italian arm of SPACE study)

Background

Gender differences in disease presentation and imaging features of early axial-spondyloarthritis (axSpA) have not been thoroughly investigated.

Objectives

To assess the influence of gender on spinal/pelvic radiographic progression and magnetic-resonance-imaging (MRI) features in early-stage axSpA.

Methods

Baseline data from the Italian arm of SPondyloArthritis-Caught-Early-cohort, including patients with chronic-back-pain (CBP;duration≥3 months and ≤2 years;onset<45 years) were analyzed.Patients underwent a diagnostic work-up, including MRI and X-rays of the sacroiliac joints (SIJ), to establish a diagnosis of axSpA (according ASAS criteria). Clinical features, disease-activity and functional indices, imaging were collected at baseline (T0) and yearly during 48-months.Spinal and SIJ X-rays and MRIs were performed every 2-years and scored independently by 2 readers following Stoke Ankylosing Spondylitis Spinal Score System modified by Creemers (mSASSS) (score 0-72),modified New York criteria grading system (mNY-criteria) (score 0-4 per each joint) and Spondyloarthritis Research Consortium of Canada (SPARCC) (score of 0–40 for SIJ and of 0-92 for the spine). Characteristics of axSpA patients according the gender (male/female) were compared over-time with descriptive-statistics; multivariate-logistic-regression model was constructed to assess predictors of spinal and SIJ radiographic progression at 48-months.

Results

Out of 98 CBP patients, 91 had axSpA (83.5% non-radiographic;16.5% radiographic);47.3% were male. At T0 males were younger with less axial symptoms duration (p=0.04);had more frequently human-leukocyte-antigen (HLA)-B27+ (p=0.02),radiographic sacroiliitis with bilateral/symmetric pattern (p<0.02) and more signs of spondylitis (p=0.03).Females presented more frequently an associated peripheral/entheseal involvement (p=0.04) and a non-radiographic form (p=0.03). Functional and disease-activity indices decreased with slightly higher Maastricht Ankylosing Spondylitis Enthesitis Score (MASES),Visual Analogue Scale of pain (VAS),Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Functional Index (BASFI) values in females (p<0.04). Males showed a slight increased for both pelvic and spinal radiographic progression than females (Figure 1 A-E).At T0, 62 (68.1%) axSpA patients presented inflammatory lesions on MRI-SIJ, with more signs of active sacroiliitis in males (83.7% vs. 54.2%;p<0.05).Fifty-seven (62.6%) patients showed inflammatory-corner-lesions on MRI-spine: the frequency of these lesions no differed between males and females, while the localization varied:prevalently cervical/thoracic lesions were observed in females, instead lumbar lesions in males (p<0.05).We also found a higher prevalence of signs of active anterior spondylitis without active sacroiliitis on MRI in females (29.2% vs. 14.0%;p=0.03).Signs of enthesitis were found in 68.1% patients, with slightly higher prevalence of these lesions in thoracic area in females (p=0.04).Significant downtrend of SPARCC SIJ/spine scores was found, regardless the gender.More fat lesions were observed on MRI-spine in females, while more fat lesions were observed on MRI-SIJ in males (Figure 1F-G).Skin psoriasis was a predictor of spinal progression in all patients (OR=0.18; 95%CI:0.04-0.78).

Conclusion

The gender was associated with distinct axSpA features.Males had an increased pelvic and spinal radiographic progression and more frequently active sacroiliitis on MRI.Female axSpA showed a higher prevalence of cervical and thoracic spine-MRI signs (inflammatory-corner-lesions and fat lesions).

Disclosure of Interests

Mariagrazia Lorenzin: None declared, Augusta Ortolan: None declared, Stefania Vio: None declared, Giacomo Cozzi: None declared, Vanna Scapin: None declared, Giorgio De Conti: None declared, Andrea Doria Grant/research support from: AD has received honoraria and speaker fees from Novartis, Abbvie, Pfizer, MSD, Janssen., Roberta Ramonda Grant/research support from: RR has received honoraria and speaker fees from Novartis, Abbvie, Pfizer, MSD, Janssen.

POS0297 EFFECTIVENESS AND SAFETY OF SECUKINUMAB IN AXIAL SPONDYLOARTHRITIS: A 24-MONTH PROSPECTIVE, MULTICENTER REAL-LIFE STUDY

Background

Axial Spondyloarthritis (axSpA) can be distinguished in radiographic axSpA (r-axSpA) and non-radiographic (nr-axSpA). Secukinumab (SEC) is a novel treatment for axSpA, but data from real-life are still missing.

Objectives

To evaluate, in a multicentric-Italian-cohort of axSpA patients on SEC followed for 24-months: a)the long-term effectiveness and safety of SEC; b)the drug-retention-rate and low-disease-activity (LDA) measured as BASDAI<4/ASDAS<2.1 and very-low-disease-activity (VLDA) measured as BASDAI<2/ASDAS<1.3; c)any differences in outcomes according to: line of biological treatment (naïve/non-naïve), gender (male/female), subtype of axSpA (r-axSpA/nr-axSpA).

Methods

Consecutive patients with active axSpA (diagnosis according Assessment of SpondyloArthritis International Society ASAS criteria), who started SEC treatment, were evaluated prospectively. Data on disease characteristics, previous/ongoing treatments and imaging were collected. Disease-activity/functional/clinical scores and biochemical values were recorded at baseline (T0), at 6 (T6), 12 (T12), and 24 (T24) months. Effectiveness was evaluated over-time with descriptive statistics; multivariate Cox and logistic regression models were used to evaluate predictors of drug-discontinuation and LDA at T6. Infections, adverse events were recorded.

Results

249 patients (47.8% male; median age 51 years) were enrolled; 40.9% had HLA-B27; 53.8% had r-axSpA and 46.2% nr-axSpA. SEC was prescribed in 28.9% naïve and in 71.1% non-naïve patients. SEC effectiveness was shown as an improvement in several outcomes, such as ASDAS [T0=3.5(2.9-4.4) vs. T24=1.9(1.2-2.4);p=0.02] and BASDAI [T0=6.5(5.0-7.5) vs. T24=2.8(1.8-4.0);p=0.03]. After 24-months of treatment, 90.7% of naïve and 75.3% of non-naïve patients achieved LDA (BASDAI<4). At T24 naïve-patients showed better physical-functioning and lower disease-activity than non-naïve (Table 1). Similarly, at T24 we observed better physical functioning and lower inflammatory activity in males vs. females and in nr-axSpA vs. r-axSpA subjects. Retention-rate at T24 was 75% in the whole population, with some difference depending on gender (log-rank 9.319; p=0.002) (Figure 1). Treatment was discontinued in 61 patients (24.5%), mainly due to primary/secondary loss of effectiveness events (20 and 24 subjects, respectively), and only 17 patients (6.8%) due to adverse events (7 for reactions at the injection site or skin manifestations, 1 for gastro-intestinal complications, 1 for relapsing uveitis, 1 for hypertransaminasemia, 4 for severe recurrent infections, 3 due to the onset of new cancer).

Table 1.

Clinical, functional, disease activity and serological parameters of naïve (n=72) and non-naïve (n=177) axSpA patients during the 24-month follow-up

T0T6T12T24BASMI [0-10], median (IQR)naïve2.0 (1.0-4.0)2.0 (0.0-3.3)1.0 (0.0-2.8)1.0 (0.0-2.0)non-naïve4.0 (1.0-7.0)4.0 (1.0-7.0)2.0 (1.0-4.0)2.0 (1.0-3.0)pp=0.03p=0.04nsnsHAQ-S [0-8], median (IQR)naïve0.8 (0.5-1.3)0.5 (0.0-1.0)0.3 (0.0-1.0)0.1 (0.0-0.5)non-naïve1.1 (0.8-1.5)1.0 (0.4-1.3)0.6 (0.4-0.9)0.7 (0.1-0.9)pp=0.04p=0.04p=0.04p=0.04ASDAS [0-6], median (IQR)naïve3.3 (2.7-3.9)2.1 (1.6-2.7)2.0 (1.2-2.8)1.3 (1.0-2.2)non-naïve3.7 (2.9-4.7)2.9 (2.0-3.7)2.1 (1.9-3.1)2.3 (1.6-2.3)pnsnsnsp=0.04ESR [0-25](mm/h), median (IQR)naïve14.0 (6.0-27.0)10.0 (4.0-19.5)8.0 (3.1-12.8)5.0 (2.0-15.0)non-naïve18.5 (10.0-31.3)15.0 (8.0-25.0)12.0 (6.0-20.0)12.0 (6.0-19.0)pp=0.04p=0.04p=0.04p=0.04

Legend: BASMI: Bath Ankylosing Spondylitis Metrology Index; HAQ: Health Assessment Questionnaire modified for spondyloarthritis; ASDAS: Ankylosing Spondylitis Disease Activity Score; ESR: erythrocyte sedimentation rate

Conclusion

In a real-life clinical-setting, SEC proved to be safe and effective in axSpA, mainly in naïve-patients, with a notable drug-retention-rate. No differences were observed between r-axSpA and nr-axSpA.

Acknowledgements

Contributing authors of the Spondyloartritis and Psoriatic Arthritis SIR Study Group “Antonio Spadaro”: Alberto Cauli, MD, PhD, Rheumatology Unit, Department of Medical Sciences, AOU and University of Cagliari, Cagliari, Sardegna, Italy; Angelo Semeraro, MD, Rheumatology Unit, Martina Franca-ASL Taranto, Puglia, Italy; Leonardo Santo, MD, Rheumatology Unit, ASL BT Andria – DSS4 Barletta, Italy, Barletta-Andria-Trani, Puglia, Italy; Emanuela Praino, MD, Rheumatology Unit, ASL BT Andria – DSS4 Barletta, Italy, Barletta-Andria-Trani, Puglia, Italy; Giorgio Amato, MD, Rheumatology Unit, A.O.U. Policlinico S. Marco, Catania, Sicilia, Italy; Nicolò Girolimetto, MD, Rheumatology Unit, Department of Internal Medicine, Azienda USL-IRCCS, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Emilia Romagna, Italy.

Disclosure of Interests

Giacomo Cozzi: None declared, Mariagrazia Lorenzin: None declared, Maria Sole Chimenti: None declared, Salvatore D’Angelo: None declared, Antonio Marchesoni: None declared, Carlo Salvarani: None declared, Ennio Lubrano: None declared, Luisa Costa: None declared, Ylenia Dal Bosco: None declared, Elena Fracassi: None declared, Augusta Ortolan: None declared, Mario Ferraioli: None declared, Antonio Carriero: None declared, elisa visalli: None declared, RICCARDO BIXIO: None declared, Francesca Desiati: None declared, ALBERTO BERGAMINI: None declared, elisa pedrollo: None declared, Andrea Doria Grant/research support from: Novartis, Abbvie, Pfizer, MSD, Janssen, Rosario Foti: None declared, Antonio Carletto: None declared, Roberta Ramonda Grant/research support from: Novartis, Abbvie, Pfizer, MSD, Janssen

POS0952 THE IMPACT OF DIET ON DISEASE ACTIVITY IN SPONDYLOARTHRITIS: A SYSTEMATIC LITERATURE REVIEW

Background

Diet is thought to have a role in inflammatory diseases development and course. However, at present, no recommendations can be given to spondyloarthritis (SpA) patients regarding a specific type of diet/dietary supplement, as evidence on the topic is sparse.

Objectives

To review the evidence about the effect of diet/dietary supplements on SpA disease activity

Methods

A systematic literature review (SLR) was conducted in MEDLINE and SCOPUS according to the “PEO” format (Population: SpA, axial or peripheral, including Psoriatic Arthritis-PsA; Exposure: any kind of diet/dietary supplement; Outcome: any available disease activity measurement). Inclusion criteria were: adult patients, Randomized Controlled Trials (RCTs) and longitudinal studies (so that a pre-and post-intervention assessment were available), papers in English. Risk of bias (RoB) was independently judged by 2 authors (AO, MF) and conducted with different tools according to the study design: Newcastle Ottawa Scale (NOS) for observational studies, the ROBINS-1 tool for non-randomized studies, and the Cochrane risk of Bias tool 2.0 for RCTs.

Results

Literature search yielded 286 publications. After exclusion of 59 duplicates, 171 titles/abstract, and 44 full-texts, we included 8 interventional and 3 observational studies (Table 1). Among the former, 2 RCTs, one at unclear and one at low RoB, failed to show benefit of probiotics in SpA. One RCT at unclear RoB showed that weight loss, but not hypocaloric diet, was associated to MDA achievement in PsA. The other RCT, as well as the 4 quasi-interventional studies, were at high/serious RoB respectively. Among the observational studies, one study on Mediterranean diet demonstrated an association of diet adherence and a>=20% decrease of ASDAS in axSpA. Two other studies were judged of poor quality.

Table 1.

Characteristics of the included studies

Author yearPopula- tionInterven tionStudy designRando-mizedControlledSample sizeFollow-up (weeks)Primary outcomeMale Sex (%)Mean Age (years)Concomitant medications besides symptomaticsExperimental designLassus 1990PsAPU ethyl ester lipids supplementationQuasi-expNoNo808NR5049stable csDMARDsAppelboom 1994ASMilk product deprivationQuasi-expNoYes (AS vs RA)25/106NRNRNR28% on stable csDMARDsSundström 2006ASOmega 3 fatty acidsRCTYesYes (high vs low dose)2421NR61NRNo csDMARDsDi Minno 2014Obese/ overweight PsAHypocaloric dietRCTYesYes (hypocaloric vs free diet)13824MDA (+)3645All patients started anti-TNF; concomitant MTX in 29%Klinberg 2019Obese PsAHypocaloric dietQuasi-expNoNo4612-16MDA (+)3656100% on stable cs/bDMARDsKlinberg 2020Obese PsAHypocaloric dietQuasi-expNoYes (PsA vs controls)7420NR3656100% on stable cs/bDMARDsBrophy 2008SpAProbioticsInternet- based RCTYesYes (probiotics vs placebo)14712Satisfaction of CONSORT statement (+)644410% on stable b/csDMARDsJenks K 2010SpAProbioticsRCTYesYes (probiotics vs placebo)6312BASFI (-)634328.5% on csDMARDsObservational DesignAdawi 2018PsAIntermittent fastingcohort-No374NR3743100% on stable cs/bDMARDsBen Nessib 2020SpAFasting-refeedingcohort-No1228NR454740% on stable cs/ bDMARDsOmetto 2021axSpAMediterra-nean dietcohort-Yes (Mediterra-nean vs free diet)16124NR6551100% on stable cs/bDMARDs

PsA: Psoriatic arthritis, AS ankylosing spondylitis, SpA spondyloarthritis, ax: axial; RA Rheumatoid Arthritis, PU polyunsaturated; RCT Randomized Controlled Trial; exp=experimemntal; MDA Minimal Disease Activity; CONSORT CONsolidated Standards of Reporting Trials; BASFI Bath Ankylosing Spondylitis Functional Index; (+) or (-) indicate whether the primary outcome of the study was met or not

Conclusion

weight loss seems to be able to impact disease activity in SpA, while probiotics were not effective in the available RCTs so far. Adherence to Mediterranean diet might play a role in reducing disease activity. Evidence for effectiveness of dietary behaviors in SpA is quite heterogeneous and high quality studies are warranted to better understand the role of diet in SpA.

Disclosure of Interests

Augusta Ortolan: None declared, Mara Felicetti: None declared, Mariagrazia Lorenzin: None declared, Giacomo Cozzi: None declared, Giovanni Striani: None declared, Andrea Doria Speakers bureau: Novartis, AbbVie, Pfizer, MSD, Janssen, GSK, Consultant of: Novartis, AbbVie, Pfizer, MSD, Janssen, GSK, Roberta Ramonda Speakers bureau: honoraria and speaker fees from Novartis, AbbVie, Pfizer, MSD, Janssen, Consultant of: Novartis, AbbVie, Pfizer, MSD, Janssen

POS0956 MEDITERRANEAN DIET IN AXIAL SPONDYLOARTHRITIS: A NUTRITIONAL INTERVENTION STUDY

Background:

Mediterranean diet (MD) proved to be beneficial on disease activity in patients affected by rheumatoid arthritis. A few data are available in other rheumatic conditions.

Objectives:

A prospective monocentric study was conducted to evaluate the effect of a nutritional intervention based on the MD and to investigate the impact of such modification on disease activity of axial spondyloarthitis (ax-SpA).

Methods:

Patients affected by ax-SpA randomized to a nutritional intervention arm (N) or a control arm (C) and were assessed at baseline (T0) and at month 6 (T6). Patients in N underwent a nutritional evaluation and received suggestions for dietary modification at T0, and then every 2 months. Adherence to the MD was evaluated with the PREDIMED questionnaire (range 0-10) [1]. A multivariable regression analysis was conducted to identify independent predictors of PREDIMED and of ASDAS-CRP improvement at T6.

Results:

Eligible patients (161) were randomized to either N (81) or C (80); 47 in N and 63 in C completed the study. No relevant change of anthropometric or laboratory measures was observed at T6 in either group. A ≥20%PREDIMED improvement was more frequent in N (22/47, 46.8%) compared to C (13/63, 20.6%) (p<0.01). Also, a ≥20%ASDAS-CRP improvement was more frequent in N (8/47, 57.1%) compared to C (39/63, 40.6%) (p=0.020); and especially in those who achieved a ≥20%PREDIMED improvement (12/35, 34.3%) vs those who did not (2/73, 2.7%) (p<0.01). The nutritional intervention, a higher age, and a lower BMI increased the odds of achieving a ≥20%PREDIMED improvement; the ≥20%PREDIMED improvement was associated higher odds of achieving a ≥20%ASDAS-CRP improvement; psoriasis was negatively associated to the ASDAS-CRP improvement (Figure 1).

Conclusion:

A nutritional intervention is effective in improving adherence to the MD in ax-SpA. A higher adherence to the MD may have a beneficial impact on activity of ax-SpA. Patients with psoriasis may have a limited benefit from the dietary improvement.

References:

[1]Martínez-González, M.A. et al. A 14-item mediterranean diet assessment tool and obesity indexes among high-risk subjects: The PREDIMED trial.PLoS One2012,7.

Table 1.

Characteristics of the patients.

All patientsNutritionControlsAll patientsNutritionControlsBaselineMonth 6Females, n, (%)40 (36.4)18 (38.3)22 (34.9)Age, years, mean±SD51.7±1.353.0±1.349.6±1.3HLA-B27 positivity, n (%)58 (52.7)22 (46.8)37 (57.1)Psoriasis, n (%)58 (50.7)26 (55.3)32 (50.8)Disease duration (years), mean±SD15.3±9.715.7±1015±9.5Duration of b/tsDMARD treatment overall, years, mean±SD5±4.15.8±4.54.5±3.8NSAID, n (%)76 (69.1)30 (63.8)46 (73)csDMARD, n (%)14 (12.7)5 (10.6)9 (14.3)BMI, Kg/meters2, mean±SD26.5±5.426.5±4.326.6±6.126.4±5.326.3±426.6±6.1ASDAS-CRP, mean±SD2.1±12.1±0.92.1±12±1.11.8±0.92.1±1.2BASDAI, mean±SD37.6±2337.4±23.237.7±22.939.3±24.137.3±23.641.2±24.6BASFI, mean±SD20.5±21.421.6±19.219.7±2319.8±19.619.1±18.820.5±20.4BASMI, mean±SD1.6±21.9±2.21.4±1.71.8±2.11.9±2.41.7±1.9Tender joint count, mean±SD1.1±2.30.8±2.11.4±2.50.9±20.8±20.9±1.9Swollen joint count, mean±SD0.3±1.30.4±20.1±0.50.2±1.30.3±1.80.2±0.8Leeds Enthesitis Index, mean±SD0.2±0.80.3±10.2±0.61.1±21.3±2.21±1.8CRP, mg/L, mean ±SD3.4±6.23.2±3.93.7±7.43.5±5.62.6±3.14.1±6.9LDL-c, mg/dl, mean ±SD130.8±36.5132.3±35129.7±38.4130.6±34.7125.7±34.8134.4±34.5PREDIMED score, mean ±SD6.7±1.87±2.16.6±1.67.6±2.18.6±1.96.8±2

b/tsDMARD biological/targeted synthetic DMARDs; csDMARD conventional DMARDs. PREDIMED questionnaire to assess adherence to the Mediterranean diet.

Disclosure of Interests:

None declared.

OP0223 DEVELOPMENT AND PRELIMINARY VALIDATION OF ULTRASONOGRAPHIC DISEASE ACTIVITY AND DAMAGE SCORES IN PSORIATIC ARTHRITIS PATIENTS: RESULTS FROM THE UPSTREAM (ULTRASOUND IN PSORIATIC ARTHRITIS TREATMENT) STUDY

Background:

The UPSTREAM (NCT03330769) is a 24-month multi-center prospective cohort study that primarily aims to evaluate the additional value of musculoskeletal ultrasound (msk-US) over clinical examination in predicting 6-month minimal disease activity in Psoriatic Arthritis (PsA). (1)

Objectives:

To develop and preliminarily validate an activity msk-US score and a damage msk-US score for PsA using the UPSTREAM database.

Methods:

Patients classified with PsA according to CASPAR criteria and starting a new course of therapy for clinically active peripheral joint disease were eligible. The information regarding objectives, study design, clinical and US assessment has already been published (1). The msk-US examination was performed in 42 joints, 36 tendons, 12 entheses and 2 bursae defined through a web-based exercise (2). The sonographic elementary lesions were allocated to disease activity [i.e. synovitis (sy), tenosynovitis (ts), peritendinitis (pt), bursitis (bs) all evaluated both in Grey Scale (GS) and Power Doppler (PD) and active enthesitis (en)] and to damage (i.e. joint erosion, bone proliferation, tendon tear, enthesophyte, calcification and irregular enthesis bone profile). Hands and feet X-ray were assessed using the modified Sharp-Van der Heijde (mSVH) score. A principal component (PC) analysis (PCA) was performed for each score and the number of PCs was defined by means of parallel analysis using baseline data. Each PC was normalized (n) taking into account the proportion between the observed value (e.g. sy-GS count) and the maximum expected value (e.g. 42 for sy-GS). Spearman’ correlation was used to investigate the construct and discrimination validity of the new scores.

Results:

Between February 2017 and May 2020, 312 PsA patients (155 men), with a mean (SD) age of 52.8 13.4, were enrolled from 19 centers; 22 expert sonographers were involved with substantial agreement for US lesions evaluated (k ≥0.7). The median [IQR] disease duration was 1.3 [0.1-6.1] years and the median [IQR] tender joint and swollen joint counts were 6 [3-13] and 2 [1-5], respectively. The weight derived from PCA for each sonographic lesions and the final equation for calculating the scores are reported in Figure 1 (1A activity and 1B damage). The final msk-US activity score [n(ts-GS + ts-PD)*2.87] + [n(bs-GS + bs-PD)*1.76] + [n(pt-GS + pt-PD)*1.43] + [n(active en)*1.00] + [n(sy-GS)*0.83] + [n(sy-PD)*0.45] has the best construct and discrimination validities according to a significant correlation with all clinical variables usually related to clinical activity (Table 1). The msk-US damage score correlated with mSVH score, HAQ and other clinical variables (Table 1).

Table 1.VariablesMsk-US activity scoreMsk-US damage scoreSpearman correlationP-valueSpearman correlationP-valueESR0.1960.0020.0750.235CRP0.209<0.0010.0680.254TJC0.338<0.0010.286<0.001SJC0.338<0.0010.0720.221Dactylitis count0.284<0.001-0.0610.306LEI0.1940.0010.214<0.001Physician GA0.150.0120.0160.793Patient GA activity0.1380.018-0.0730.221Patient GA pain0.1990.001-0.0270.648HAQ0.238<0.0010.1460.014BASDAI0.237<0.0010.1750.003PSAID-90.70.0040.1480.013DAPSA0.392<0.0010.228<0.001Sharp van Der Heijde score0.1150.20.2660.003Figure 1.

Conclusion:

These newly developed and preliminary validated msk-US activity and damage scores could be used in patients with PsA in the context of observational and controlled trials.

References:

[1]Canzoni M et al. BMJ Open. 2018;8:e021942.

[2]Zabotti A et al. Ann Rheum Dis 2018;77:1537–1538.

Acknowledgements:

Alberto Batticciotto; Oscar Massimiliano Epis; Luisa Arcarese; Luca Navarini; Marta Caprioli; Mirco Magnani; Roberta Ramonda; Marco Amedeo Cimmino

Disclosure of Interests:

Alen Zabotti: None declared, Matteo Piga: None declared, Anna Zanetti: None declared, Marco Canzoni: None declared, nicola boffini: None declared, valentina picerno: None declared, Giovanni Zanframundo: None declared, Ettore Silvagni: None declared, Ivan Giovannini: None declared, BERND RAFFEINER: None declared, Palma Scolieri: None declared, Paola Mancini: None declared, Simone Parisi: None declared, Alessandra Bortoluzzi Grant/research support from: GSK, Garifallia Sakellariou Consultant of: Consultant for Abbvie and Novartis, Orazio De Lucia: None declared, Ilaria Tinazzi: None declared, Fabiana Figus: None declared, Luca Idolazzi Speakers bureau: Received grants as speaker for Eli Lilly, UCB, Celgene, MSD, Abbvie, Novartis, Paid instructor for: Paid instructor for UCB during Product specialist Meeting, Mariagrazia Lorenzin: None declared, Sara Zandonella Callegher: None declared, Alberto Cauli: None declared, Greta Carrara: None declared, Carlo Alberto Scirè: None declared, Annamaria Iagnocco: None declared

POS1221 SARS-COV2 SEROLOGY SCREENING IN SPONDYLOARTHRITIS PATIENTS IN NORTH-EASTERN ITALY: A PILOT STUDY

Background:

Serology could help defining the real extent of Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS-CoV2) diffusion in the population, especially in individuals considered at higher risk of SARS-CoV2 infection (COVID-19), such as Spondiloarthritis (SpA) patients undergoing immunosuppressive therapy or health care workers (HCW). In fact, COVID-19 detection is complicated by the fact that many patients can be asymptomatic. In these cases, it has also been suggested that a weaker immune response might be elicited.

In this context, the role of anti-cytokine targeted therapy –commonly used as treatment in SpA- is uncertain, as it is not clear whether it is detrimental or protective towards severe disease forms.

Objectives:

The aim of the study was to explore the potential role of serology in detecting previous contact with SARS-CoV2 in SpA patients and HCW, and compare the frequency of positive findings with a control population.

Methods:

Consecutive patients affected by axial or peripheral SpA, classified according to Assessment of SpondyloArthritis international Society (ASAS) criteria and undergoing cytokine-targeted therapy, as well as HCW and controls from the pre-COVID-19 era (control group, 2015) were recruited. In SpA patients, disease activity was assessed by Ankylosing Spondylitis Disease Activity Score (ASDAS) and Disease Activity Score on 28-joint-count (DAS28).

Sera from all patients were analysed through chemiluminescent analytical system (CLIA) for the presence of IgG and IgM anti-SARS-CoV2. Patients with a positive serological test (either IgM or IgG) additionally underwent real time Polymerase Chain Reaction (RT-PCR) in nasopharyngeal swabs in order to test for active infection. In SpA patients, serology was repeated after 3 months. Data across the 3 groups were compared by ANOVA or Chi-square, while comparison between 2 groups were conducted by Wilcoxon signed rank test or Chi-Square, for continuous and categorical data respectively. P ≤ 0.05 were considered as significant.

Results:

A total of 396 patients were recruited: 200 SpA, 95 HCW and 101 healthy controls. SpA patients were mostly (54%) males, with mean age 49.6 ±14.7 years, and all were treated with anti-TNFα (78%), anti-IL-17 (9%) and anti-IL-23 drugs (7%), or small molecules (6%). Their disease activity level was moderate-low as assessed by ASDAS (1.95 ±0.98) and DAS28 (2.33 ±2.02). Among HCW and controls, 35% and 62% were male, with mean age 46.7 ±12.9 and 50.6±10.6 respectively.

Positive serology (IgM or IgG, or both) was found in 12.5% SpA patients, 8.4% HCW, 0% controls (p=0.001). Among these, IgM titres were higher in the SpA group than in HCW (2.76±2.94 versus 0.80±0.67 KU/L, p= 0.016), while IgG mean titres were lower in the SpA group than in HCW (0.88±3.18 KU/L versus 1.05±0.88, p= 0.035). SpA patients with positive serology more frequently reported COVID-19 like symptoms than those with negative serology (20% vs 4%, p=0.009) and 2 had COVID-19 as confirmed by RT-PCR, none with a severe disease course. None of the HCW reported symptoms or tested positive by RT-PCR. In the SpA patients, at 3 months, the mean IgM titre decreased from 2.76±2.93 to 2.38±2.95 (p=0.001), while the IgG titres decreased from 0.89±3.25 to 0.31±0.87 (p=ns). Interestingly, the IgM or IgG titer at a single-patient level did not seem to change much in terms of absolute value (Figure 1), except in one patient, with documented COVID-19 (positive RT-PCR), in whom IgG level even decreased at 3 months.

Conclusion:

Serology revealed that exposure to COVID-19 in SpA patients, as well as HCW, was higher than expected based on reported symptoms. Targeted anti-cytokine therapy could act as a protective factor for a severe disease course in SpA patients. However, in this population, IgG and IgM titres did not change in a clinically significant manner at 3 months, and patient did not seem to develop an immune profile consistent with durable response. This result could be due to a weaker immune response in mild infections, but further studies are warranted to clarify the pathophysiology beyond these observations.

Figure 1.

Disclosure of Interests:

Augusta Ortolan: None declared, Chiara Cosma: None declared, Mariagrazia Lorenzin: None declared, Giacomo Cozzi: None declared, Andrea Doria Speakers bureau: Novartis, Abbvie, Pfizer, MSD, Janssen, Glaxosmithkline, Mario Plebani: None declared, Roberta Ramonda Speakers bureau: Novartis, Abbvie, Pfizer, MSD, Janssen

POS0927 EFFECTIVENESS AND SAFETY OF SECUKINUMAB IN NAïVE OR TNF-INHIBITORS FAILURE AXIAL SPONDYLOARTHRITIS PATIENTS IN REAL LIFE: A 24-MONTHS PROSPECTIVE MULTICENTRIC STUDY

Background:

Axial Spondyloarthritis (axSpA) can be distinguished in radiographic axSpA (r-axSpA) and non-radiographic (nr-axSpA). Secukinumab (SEC) is a novel treatment for axSpA, but data from real-life are still missing.

Objectives:

1)to evaluate the effectiveness and safety of a wide cohort of axSpA patients on SEC followed in 8 Italian Rheumatologic centers for 24-months;2)to compare the features and disease-activity indices of SEC-treated axSpA patients subdivided in naïve biological drugs (group A) and in TNF-inhibitors failure patients (group B).

Methods:

Consecutive patients with active axSpA (diagnosis according Assessment of SpondyloArthritis International Society ASAS criteria), who started SEC treatment, were evaluated prospectively.Data on disease characteristics, previous/ongoing treatments and imaging were collected. Disease-activity/functional/clinical scores and biochemical values were recorded at baseline (T0), at 6 (T6), 12 (T12), and 24 (T24) months. Effectiveness was evaluated over-time with descriptive statistics. Anova (Kruskal Wallis) and generalized linear models were used to compare variables over-time. Infections,adverse events were collected.

Results:

One-hundred-seven patients [49.53% men; median age 49years; median treatment duration 18.5years] were enrolled;53(49.53%) had HLA-B27, 47.66% were r-axSpA and 52.34% nr-axSpA. Signs of sacroiliitis were present on MRI in 97 (90.65%) and X-rays in 51 (47.66%). SEC was prescribed as first line biologic treatment in 32 (29.9%) patients and as second or more line biological treatment in 75 (70.1%) patients (Figure 1). In all population significant decrease was achieved in:Visual Analogue Scale of pain and general-health; Leeds Enthesitis Index;Health Assessment Questionnaire modified for spondyloarthritis (HAQ-s);Bath Ankylosing Spondylitis Functional Index (BASFI);C-reactive protein. Bath Ankylosing Spondylitis Metrology Index and Erythrocyte-sedimentation-rate not significantly decreased. Effectiveness was associated to an improvement in Ankylosing Spondylitis disease activity score (ASDAS) [T0=3.4 (2.9-3.9) vs T24=1.9 (1.2-2.7);p=0.02] and in Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) [T0=6.6 (5.0-7.8) vs T24=3.2 (2.0-5.0);p=0.03].At T0 group B had a longer disease duration (p=0.04),a greater prevalence of peripheral arthritis (p=0.02),enthesitis (p=0.04) and psoriasis (p=0.05) and was mostly male (p=0.05),while no significant difference was observed for functional and disease-activity indices and signs of sacroiliitis on MRI/X-rays. At T24 group A showed better physical functioning and lower disease activity compared to group B [HAQs A vs. B=0.1(0.0-0.5) vs 0.3(0.1-0.8); BASFI A vs B=1.6(0.8-4.8) vs 4.0(2.5-4.6); BASDAI A vs B=2.2(1.0-3.8) vs 3.9(2.7-5.0);ASDAS A vs B=1.3(1.0-2.2) vs 2.1(1.6-2.9)].After T24 of treatment 70.2% of Group A and 68.4% of Group B had a low disease activity,accordingly to ASDAS<2.1. Twenty-three patients (21.5%) stopped the treatment during the follow-up mainly because of primary (7) or secondary loss of efficacy (9).Only 7 patients suspended SEC because of adverse events.A low number of episodes of mild infections (19) occurred;SEC was instead permanently discontinued in 4 cases for:oral refractory mucositis (2);recurrent aphthosis (1);recurrent broncopneumoniae (1).The retention rate at t24 was good in the whole population (73%).Survival curves for Group A and B were similar (log-rank test=0.81;p=0.69).

Conclusion:

In a real-life clinical setting,SEC was safe and effective in axSpA, as shown by a significant decrease of BASDAI and ASDAS over a 24-months follow-up.

Disclosure of Interests:

Mariagrazia Lorenzin: None declared, Augusta Ortolan: None declared, Maria Sole Chimenti: None declared, Antonio Marchesoni Grant/research support from: AM has received honoraria and speaker fees from Abbvie, Pfizer, MSD, UCB, Novartis, Janssen, Eli-Lilly., Ennio Lubrano: None declared, Leonardo Santo Speakers bureau: Speaker from Jansen, Novartis, Pfizer, UCB, MSD, Sanofi, Angelo Semeraro: None declared, Carlo Salvarani: None declared, Nicolò Girolimetto: None declared, Emanuela Praino: None declared, Giulia Lavinia Fonti: None declared, Rosario Foti: None declared, Antonio Carletto: None declared, Andrea Doria Grant/research support from: ADhas received honoraria and speaker fees from Novartis, Abbvie, Pfizer, MSD, Janssen., Roberta Ramonda Grant/research support from: RR has received honoraria and speaker fees from Novartis, Abbvie, Pfizer, MSD, Janssen.

AB0549 PREDICTIVE FACTORS FOR SWITCHING IN PATIENTS WITH PSORIATIC ARTHRITIS UNDERGOING ANTI-TNFα, ANTI-IL12/23 OR ANTI-IL17 DRUGS: A FIFTEEN-YEAR MONOCENTRIC REAL-LIFE STUDY

Background:

Biological Disease-Modifying Anti-Rheumatic Drugs (bDMARDs) targeting Tumor Necrosis Factor (TNF) alpha, Interleukin (IL) 12/23 and IL17, have been approved for Psoriatic Arthritis (PsA) treatment, in this chronological order.

Objectives:

The aims of our study were to evaluate 1) predictors of first bDMARD failure, including mechanism of action 2) factors associated to failure of multiple (>=2) therapies.

Methods:

Consecutive patients attending our Rheumatology Unit, classified as PsA according to CASPAR criteria and beginning treatment with bDMARDs in the period 2004-2020, were enrolled. Disease characteristics, previous/ongoing treatments, comorbidities and follow-up duration were recorded. Demographic, clinical and laboratory data, disease-activity and functional indexes [including Disease Activity in PSoriatic Arthritis (DAPSA), PASI (Psoriasis Area and Severity Index) and Health Assessment Questionnaire (HAQ)], were recorded at baseline and yearly and were compared between switchers (>=1 switch/swap) and non-switchers. Date and reason for switching were collected. Effectiveness was evaluated over-time with descriptive statistics. A multivariable Cox-Proportional-Hazard (PH) model was built to evaluate the influence of mechanism of action (anti-TNFalpha/anti-IL12/23/anti-IL17) and of negative prognostic factors for drug response on time to first bDMARD discontinuation. Furthermore, a multivariable logistic regression model was built to assess the association between negative prognostic factors for drug response (independent variables) and failure of>=2 bDMARDs (“multifailure”, outcome). Kaplan-Meier curves were used to assess differences in time-to-first bDMARD discontinuation according to the targeted cytokine. P values <=0.05 were considered significant. Infections and adverse events were recorded.

Results:

Our study included 264 patients, 117 (44.32%) females, mean age 56±12 years, mean PsA duration 15±3 years;117 (44.32%) switched bDMARDs at least once. Switchers were mostly females, with higher PASI and worse HAQ at baseline (Figure 1). Mean time-to-first bDMARD discontinuation was 72 months; 2-year and 5-year retention rate was 75% and 60%, respectively. Survival curves for anti-TNFalpha/anti-IL12/23/anti-IL17 were similar (log-rak test=0.83;p=0.66). Main reasons for switching were inefficacy (79) and adverse events (38). The Cox PH model showed that female sex was independently associated to a higher risk of first bDMARD discontinuation (HR=2.39; 95%CI:1.50-3.81), while initiating therapy before 2015 was protective (HR=0.40; 95%CI:0.22-0.73). Other independent variables, including mechanism of action (HR=0.76; 95%CI:0.30-1.74 for anti-IL17; HR=0.53; 95%CI 0.15-1.86 for anti-IL12/23; reference: anti-TNFalpha), age (HR=1.00; 95%CI:0.99-1.03), baseline DAPSA (HR=0.98; 95%CI:0.96-1.00), PASI (HR=0.95; 95%CI:0.86-1.04), HAQ (HR=1.29; 95%CI:0.91-1.83), Body Mass Index BMI (HR=1.02; 95%CI:0.98-1.07) and comorbidities (HR=1.10; 95%CI:0.92-1.31) were not associated to the outcome. In the logistic regression model, only female sex was significantly associated to failure of>=2 therapies (OR=1.99, 95%CI:1.07-3.69); bDMARD mechanism of action, age, and initiating therapy before 2015 were instead not independently associated.

Conclusion:

Survival rate was good for anti-TNFalpha and other bDMARDs. Female sex was a predictor of first bDMARD discontinuation, unlike mechanism of action, comorbidities and BMI.

Figure 1.

Disclosure of Interests:

Mariagrazia Lorenzin: None declared., Augusta Ortolan: None declared., Giacomo Cozzi: None declared., Antonia Calligaro: None declared., Maria Favaro: None declared., Teresa Del Ross: None declared., Andrea Doria Grant/research support from: AD has received honoraria and speaker fees from Novartis, Abbvie, Pfizer, MSD, Janssen., Roberta Ramonda Grant/research support from: RR has received honoraria and speaker fees from Novartis, Abbvie, Pfizer, MSD, Janssen.

SARS-CoV-2 infection in patients with autoimmune rheumatic diseases in northeast Italy: A cross-sectional study on 916 patients

Background

Whether patients with autoimmune rheumatic diseases (ARD) have a higher risk for SARS-CoV-2 infection (COVID-19) and how SARS-CoV-2 pandemic impacts on adherence to therapy has not been fully elucidated. We assessed the rate and clinical presentation of COVID-19, and adherence to therapy in a large cohort of patients with ARD followed-up in a tertiary University-Hospital in Northeast Italy.

Methods

Between April 9th and April 25th^, 2020, after SARS-CoV-2 infection peak, a telephone survey investigating the impact of COVID-19 on patients with systemic lupus erythematosus (SLE), systemic sclerosis (SSc), rheumatoid arthritis (RA), ANCA-associated vasculitis (AAV), and idiopathic inflammatory myopathies (IIM) was administered. Demographics, disease activity status, therapy, occupational exposure, and adherence to social distancing advise were also collected.

Results

916 patients (397 SLE, 182 AAV, 176 SSc, 111 RA, 50 IIM) completed the survey. 148 patients developed at least one symptom compatible with COVID-19 (cough 96, sore throat 64, fever 64, arthromyalgias 59, diarrhea 26, conjunctivitis 18, ageusia/hyposmia, 18). Among the 916 patients, 65 (7.1%) underwent SARS-CoV-2 nasopharyngeal swab (18 symptomatic and 47 asymptomatic), 2 (0.21%) tested positive, a proportion similar to that observed in the general population of the Veneto region. No deaths occurred. 31 patients (3.4%) withdrew ≥1 medication, mainly immunosuppressants or biologics. Adoption of social distancing was observed by 860 patients (93.9%), including 335 (36.6%) who adopted it before official lockdown.

Conclusions

COVID-19 incidence seems to be similar in our cohort compared to the general population. Adherence to therapy and to social distancing advise was high.

•

SARS-CoV-2 infection rate in ARDs seems to be similar to that of the general population.

•

Adoption of social distancing measures was prevalent among different ARD groups.

•

Earlier social distancing was more common in unremitted patients, treated with multiple drugs.

•

Therapy discontinuation due to COVID-related concerns was rare, but undertaken even by active patients.

•

Therapeutic regimens based on ≥3 drugs were associated with therapy discontinuation in our cohort.

FRI0284 EFFECTIVENESS AND SAFETY OF SECUKINUMAB IN NAÏVE OR TNF-INHIBITORS FAILURE PSORIATIC ARTHRITIS PATIENTS IN REAL LIFE: A 24-MONTHS PROSPECTIVE MULTICENTER STUDY

Background:

Secukinumab (SEC) is a novel treatment for psoriatic arthritis (PsA),but data from real life are still missing.

Objectives:

1)to evaluate the effectiveness and safety of a wide cohort of PsA patients on SEC followed in 7 Italian rheumatologic centers for 24 months;2)to compare the features and disease activity indices of SEC-treated PsA patients subdivided in naïve biological drugs (group A) and in TNF-inhibitors (TNFi) failure patients (group B).

Methods:

Consecutive patients with moderate-severe PsA,who begun SEC treatment were evaluated prospectively.Data on disease characteristics,previous and ongoing treatments,comorbidities and duration of follow-up were collected.Disease activity,functional and clinimetric scores and biochemical values were recorded at baseline (t0),at 6 (t6),12 (t12),and 24 (t24) months.Anova (Kruskal Wallis) and generalized linear models were used to compare variables over time.Infections and adverse events were also collected.

Results:

PsA345patients [38.84% men;mean age 52.9 (11.27) years] were enrolled;mean treatment duration was 18.53 (9.97) years.SEC was prescribed as first line biologic treatment in 133 (38.55%) patients and as second or more line biological treatment in 212 (61.45%) patients. Enthesitis was present as a prominent manifestation in 61.44% of patients (Figure 1).In all population significant decrease in tender/swollen joints;Visual Analogue Scale of pain (VASp) and general health (VASgh);Psoriasis Area Severity Index (PASI);Leeds Enthesitis Index (LEI);number of dactylitis;Health Assessment Questionnaire modified for spondyloarthritis (HAQ-S);Bath Ankylosing Spondylitis Disease Activity Index (BASDAI);Bath Ankylosing Spondylitis Functional Index (BASFI);C-reactive protein (CRP) was achieved.Effectiveness of all PsA patients was associated to an improvement in Ankylosing Spondylitis disease activity score (ASDAS) [t0=3.45 (0.69) vs t24=1.48 (0.23);p<0.01] and in Disease Activity in PsA (DAPSA) [t0=29.52 (12.56) vs t24=11.41 (7.63);p<0.001].At t0group Bhad a more erosive (p=0.04) and polyarticular pattern (p=0.04),a longer disease duration (p=0.001),a greater prevalence (p=0.04) of psoriasis and dactylitis (p=0.01),a higher PASI score (p=0.01),while no significant difference was observed for uveitis,inflammatory bowel diseases,enthesitis.At t24group Ashowed better physical functioning and lower disease activity compared togroup B[HAQs A vs B=0.03 (0.16) vs 0.69 (0.73);BASDAI A vs B=2.37 (0.66) vs 4.27 (2.33);ASDAS A vs B=1.4 (0.62) vs 1.99 (0.86);CRP A vs B=2.03 (1.94) vs 3.11 (1.55) mg/L;DAPSA A vs B=7.03 (3.57) vs 12.41 (8.05)].After t24 of treatment 74.6% ofGroup Aand 72.8% ofGroup Barticular had an inactive\low disease activity (MDA),accordingly to ASDAS and DAPSA respectively.Forty-three patients (12.46%) stopped the treatment during the follow-up mainly because of primary or secondary loss of efficacy (29 and 24, respectively).Only 14 patients suspended SEC because of adverse events (of which 9 for reactions at site of injection).A low number of episodes of mild infections (16) occurred;SEC was instead permanently discontinued in 7 cases for:oral refractory mucositis (3);recurrent aphthosis (2);diverticulitis (2).The retention rate at t24 was good in the whole population.Interestingly no differences were found betweenGroup AandB(p=0.815).

Conclusion:

In a real life clinical setting,SEC was safe and effective in PsA. as shown by a significant decrease of DAPSA and ASDAS over a 24-months follow up.

Disclosure of Interests:

Mariagrazia Lorenzin: None declared, Antonio Carletto: None declared, Rosario Foti Consultant of: lilly, sanofi, MSD, Janssen, Abbvie, BMS, celgene, roche, Speakers bureau: lilly, sanofi, MSD, Janssen, Abbvie, BMS, celgene, roche, Maria Sole Chimenti: None declared, Angelo Semeraro: None declared, Luisa Costa: None declared, Leonardo Santo: None declared, Elena Fracassi: None declared, Ilaria Montanari: None declared, Mara Felicetti: None declared, Giulia Lavinia Fonti: None declared, Francesco Caso: None declared, Andrea Doria Consultant of: GSK, Pfizer, Abbvie, Novartis, Ely Lilly, Speakers bureau: UCB pharma, GSK, Pfizer, Janssen, Abbvie, Novartis, Ely Lilly, BMS, Augusta Ortolan: None declared, Roberta Ramonda Speakers bureau: Novartis, Celgene, Janssen, Pfizer, Abbvie, Lilly

AB0640 LONG-TERM EFFECTIVENESS AND DRUG SURVIVAL OF GOLIMUMAB IN PATIENTS AFFECTED BY PSORIATIC ARTHRITIS WITH CUTANEOUS INVOLVEMENT

Background:

Psoriatic arthritis (PsA) is a chronic immune-mediated disease associated with psoriasis (PsO). Overexpression of inflammatory cytokines such as tumor necrosis factor (TNF)-α plays a key role in the pathogenic mechanisms. Golimumab (GLM) is a fully human monoclonal antibody IgG1k neutralizing TNF-α approved for PsA and PsO, but effectiveness evaluation in real life remains a crucial issue.

Objectives:

In a real-life setting, to determine the survival rate of GLM (drug survival) at 48 months in the global population, in different clinical settings, and the effectiveness of GLM in improving joint symptoms and cutaneous manifestations in patients affected by moderate to severe PsA with cutaneous involvement.

Methods:

We collected retrospectively from 1 January 2014 to 31 December 2019 data from 105 patients affected by PsA, according to the Classification for Psoriatic Arthritis (CASPAR) criteria, who started treatment with GLM. Inclusion criteria were age > 18 years and had a diagnosis of PsA > 6 months, the presence of peripheral arthritis (at least one active joint) and active PsO. Relevant anamnestic, clinical, biochemical data and biological treatment line were collected at baseline (T0) and after 6 (T6), 12 (T12), 24 (T24) and 48 (T48) months of GLM treatment. Comparisons between baseline and 48 months continuous variables were performed using a paired t-test or a Wilcoxon signed-rank test for paired samples. The drug survival rates were analyzed using Kaplan-Meier estimates. Drug survival rates were read from the Kaplan-Meier survival curves. Differences in drug survival between groups were analyzed using a log-rank (Mantel-Cox) test, by stratifying for sex, BMI, smoking habit and line of treatment. A p-value <0.05 was considered as statistically significant.

Results:

Peripheral arthritis was present in 67 (63.8%) cases, axial disease in 37 (35.3%), enthesitis and PsO as prominent manifestations in 82 (78%) and 84 (80%) patients respectively. Erosive disease was present in 38 (36.2%) of patients at baseline. The most frequent comorbidities were MetS described in 20 (19%) patients and cardiovascular disease described in 33 (31.4%) patients, probably due to the high incidence of smokers (33 (31.4%) of patients) and to the elevate BMI score (27.1±6.0). At 48 months, the 42% (44 of 105) (figure 1A) of the patients have discontinued therapy; the most frequent reason was insufficient response/loss of efficacy (30 patients (28.6%) out of 105). Unexpectedly, no statistical significant difference emerged according to gender (p=0.652), BMI (p=0.655), smoking habit (p=0.466) and line of treatment (p=0.208) (figure 1B-E). Finally, the effectiveness of GLM in improving joint symptoms and cutaneous manifestations was confirmed once again, with a statistical significant improvement at 48 months in clinical (BASDAI p<0.0001; PASI p<0.01; DAPSA p<0.0001) and biochemical (CRP<0.05) data.

Conclusion:

This multicentric study revealed a high drug persistence of GLM in real-life patients, although the presence of comorbidities. Unlike what is known in literature, our study population presented no differences in terms of clinical response and efficacy between male and female, smokers and no-smokers, obese and health-weight patients, different line of treatment. On the other hand, efficacy and safety of GLM has been demonstrated once again also in real-life treatments.

References:

No references.

Disclosure of Interests:

giulia lavinia fonti: None declared, Maria Sole Chimenti: None declared, Arianna D’Antonio: None declared, miriam teoli: None declared, Francesco Caso: None declared, Luisa Costa: None declared, marco tasso: None declared, Augusta Ortolan: None declared, Mariagrazia Lorenzin: None declared, Paola Conigliaro: None declared, paola triggianese: None declared, Raffaele Scarpa: None declared, Roberto Perricone: None declared, Roberta Ramonda Speakers bureau: Novartis, Celgene, Janssen, Pfizer, Abbvie, Lilly

FRI0319 DO OBESITY AND OVERWEIGHT INFLUENCE DISEASE ACTIVITY MEASURES IN AXIAL SPONDYLOARTHRITIS? A SYSTEMATIC REVIEW AND META-ANALYSIS

Background:

obesity is apparently related with worse treatment response in axial spondyloarthritis (axSpA). However, it is unclear whether obesity or overweight per se are associated to higher disease activity scores compared to non-obese individuals, and what is the effect size of this difference.

Objectives:

to investigate whether overweight/obesity are associated to higher disease activity as measured by Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) or Ankylosing spondylitis disease activity score (ASDAS) in axSpA patients.

Methods:

MEDLINE, PubMed and Web of Science were searched using key terms corresponding to population (axSpA), exposure (overweight/obesity) and outcome (BASDAI, ASDAS). Predefined inclusion criteria were: 1) adult axSpA patients, both radiographic and non-radiographic 2) exposure classified according to Body Mass Index-BMI-; 3) BASDAI/ASDAS reported for each BMI group; 4) observational studies. Patients classified according to CASPAR or Moll&Wright criteria for psoriatic arthritis were excluded. Newcastle-Ottawa Scale for cohort, cross-sectional and case-control studies was used for quality check. BASDAI and ASDAS estimates were reported as mean difference (MD) and standard deviation (SD) between the normal BMI axSpA patients and the overweight or obese patients. The statistical heterogeneity of meta-analysis was assessed using the I2statistic. Random-effects meta-analysis was used to pool results.

Results:

A total of 330 references were generated by the database search. After removing duplicates, 250 references remained and were assessed for eligibility. A further 206 articles were excluded by titles and abstracts’ reading, 44 articles were examined full text. Only 11 articles fulfilled inclusion/exclusion criteria. Following quality check, 10 articles were finally included in the meta-analysis (Table). Among these, 4 studies reported two BMI groups (normal vs overwight+obese), while 6 studies reported three (normal, overweight, obese). In the studies reporting 3 BMI group, weighted means and standard deviation were calculated to create a merged overweight+obese group. The mean difference (MD) between pooled BASDAI and ASDAS of normal BMI patients and those of overweight+obese patients were respectively -0.38 (95%CI: -0.56, -0.21) and -0.19 (95%CI: -0.29, -0.09). In the articles reporting 3 BMI groups, the MD between BASDAI of normal BMI and overweight only patients was -0.09 (95% CI: -0.33; 0.15); between normal BMI and obese only patients MD was -0.77 (95%CI -1.07; -0.48, p<0.0001) (Figure). Heterogeneity statistics revealed low estimates, though with wide CI across all the groups (Figure).

Conclusion:

disease activity scores of normal BMI axSpA patients tend to be lower than overweight or obese patients. However, this difference seems to be relevant in practice especially when normal BMI patients are compared to truly obese patients (BMI ≥ 30).

Table.

Charactheristics of studies included in the meta-analysis and of the studied patients

Author and yearDesignCountryN° of patientsAge (years)Male sexHLAB27+Disease duration (years)Al-Osami 2018cohortIran17036.1 (9.0)158 (93)68(40)8.3 (5.9)Durcan 2012cross-sectionalIreland4645.1(11.2)35 (76)N/D12.9 (10.9)Hernandez-Breijo 2019cohortSpain/Netherlands18047.0 (12.7)107 (59)131 (73)8.0 (5.9)Lee 2017cross-sectionalChina19438.7 (13.7)150 (77)159 (82)7.1 (8.6)Maas 2016cross-sectionalNetherlands46145.3 (12.8)303 (66)361 (80)17 (15.2)Micheroli 2017cohortSwitzerland62439.4 (11.6)388 (62)487 (78)13 (10.9)O’Shea 2015cross-sectionalIreland26747.8 (N/D)212 (79)N/D21.7 (N/D)Ottaviani 2012cohortFrance15543.1 (12.4)98 (63)96 (65)8.0 (4.8)Rosas 2017cross-sectionalSpain/Mexico5747.1 (10.4)37 (65)44 (77)9.8 (9.3)Rubio-Vargas 2016cross-sectionalNetherlands16830.2 (8.2)81 (48.2)156 (93)N/D

Legend.Results are expressed as mean (SD) or number of patients (%). HLA= Human Leukocyte Antigen; N/D= not determined

Disclosure of Interests:

Augusta Ortolan: None declared, Mariagrazia Lorenzin: None declared, Mara Felicetti: None declared, Roberta Ramonda Speakers bureau: Novartis, Celgene, Janssen, Pfizer, Abbvie, Lilly

SAT0245 RENAL INVOLVEMENT AT ONSET IN ANTI-NEUTROPHIL CYTOPLASMIC ANTIBODY (ANCA)-ASSOCIATED VASCULITIS: A MAJOR INDEPENDENT RISK FACTOR FOR RENAL RELAPSE

Background:

In ANCA-associated vasculitis (AAV), renal relapses are cause for concern as they are unpredictable and predictors of end-stage renal disease (ESRD).

Objectives:

We aimed to assess the frequency of major renal (MR) relapses in AAV in our cohort and identify independent predictors of the first MR relapse at diagnosis.

Methods:

We performed a retrospective monocentric observational study in our Vasculitis clinic from January 2000 to August 2019. Inclusion criteria were: 1) granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and limited kidney disease (LKD) diagnosis fulfilling EMA algorithm criteria; 2) achievement of a stable remission, defined as absence of vasculitis symptoms or signs and adherence to the prednisone taper during remission-induction treatment. We excluded patients who developed ESRD before remission and those with incomplete data during the follow-up. Major renal (MR) relapses were defined as occurrence of at least one major item of renal Birmingham Vasculitis Activity Score version 3 (BVASv3).

All remitted patients were allocated in two subgroups: patients without MR relapse and patients with MR relapse. Univariate and multivariable analysis of first MR relapse predictors was performed with Fine and Gray (F&G) sub distribution hazards model to assess all competitive risks (progression to ESRD without MR relapse and death before MR relapse). Due to the relatively low frequency of events and the risk of overfitting, we performed several multivariable models with three variables, as recommended by Peduzzi e al1. The best multivariable model was selected accordingly to the Akaike information criterion (AIC).

Results:

96 (53% females) patients met the inclusion criteria: 74 GPA, 21 MPA and 1 LKD. Median age at diagnosis was 54 (44-64) years. ANCA testing was present in 94 patients, 85 were ANCA positive: 56 c-ANCA/PR3, 28 p-ANCA/MPO and 1 double positivity.

During a median follow-up (FU) of 54.5 months (29.3-96.5), we observed 19 MR relapses in 17 patients while 2 patients progressed to ESRD, 3 died without events and 76 reported no MR relapse. Density-incidence of MR relapses since remission was 3.6/100 person-year (CI 95% 2.2-5.6). Median time to first MR relapse after remission was 33 months (14-67.5).

At first MR relapse, 8 (53.3%) patients were on steroids while 10 (66.7%) were on immunosuppressant (5 azathioprine, 5 mycophenolate). In 2 cases, data about remission-maintenance treatment was not available.

MR relapses were observed only in ANCA positive patients with a significantly higher frequency of skin, kidney and nerve involvement at diagnosis (41.2% vs 17.7%, p=0.034, 94.1% vs 57.0% p=0.004, and 52.9% vs 25.3% p=0.024, respectively); while Ear, Nose and Throat (ENT) involvement was significantly lower (35.3% vs 62.0% p=0.043). Mean BVASv3 at diagnosis scored significantly higher in MR relapse group (24.1±6.2 vs 18.1±8.1. p=0.007).

At multivariable analysis with F&G model, renal involvement and induction treatment without cyclophosphamide and/or Rituximab at diagnosis were independent predictors of MR relapse (sHR 20.4 (2.6-158.2), p=0.004 and sHR 4.2 (1.5-12.0), p=0.007, respectively). Moreover, there was a trend of higher risk of MR relapse in PR3-ANCA (sHR 2.5 (0.9-7.1), p=0.091).

Conclusion:

Renal involvement at diagnosis and milder remission-induction treatment regimens resulted in a significantly higher risk of MR relapse during the FU in our cohort. PR3-ANCA specificity was not an independent predictor of MR relapse, even if we observed a trend of higher MR relapse risk with this covariate.

References:

[1]Peduzzi P et al. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996;49(12):1373-9.

Disclosure of Interests:

Mara Felicetti: None declared, Augusta Ortolan: None declared, Anna Chiara Frigo: None declared, Roberto Padoan: None declared, Michela Gasparotto: None declared, Mariagrazia Lorenzin: None declared, Andrea Doria Consultant of: GSK, Pfizer, Abbvie, Novartis, Ely Lilly, Speakers bureau: UCB pharma, GSK, Pfizer, Janssen, Abbvie, Novartis, Ely Lilly, BMS, Roberta Ramonda Speakers bureau: Novartis, Celgene, Janssen, Pfizer, Abbvie, Lilly, Franco Schiavon: None declared

AB0060 STING AND PROINFLAMMATORY CYTOKINES IN SYNOVIAL FLUID OF PATIENTS WITH DIFFERENT ARTHRITIDES

Background:

STING (stimulator of interferon genes) is a cytosolic protein that is found in endoplasmic reticulum (ER) membrane, mitochondria and mitochondria-associated membranes. Although it is well established that STING plays an important role in innate immune responses, its potential involvement in rheumatic disease processes remains to be clarified (1).

Objectives:

The aims of this study were to evaluate the levels of STING and its relationship with local inflammation in the synovial fluid (SF) of patients with psoriatic arthritis (PsA), rheumatoid arthritis (RA), gout, calcium pyrophosphate (CPP) crystal-induced arthritis (CPP-IA), osteoarthritis (OA) and OA with CPP crystals (OA+CPP).

Methods:

SF was collected from the knees of 60 untreated patients: 10 with PsA, 10 with RA, 10 with gout, 10 with CPP-IA, 10 with OA and 10 with OA+CPP. SF was examined under optical light microscopy. White cell count (WBC) and the polymorphonuclear cell (PMN) percentage were determined in SF according to standard procedures. SF IL-8, IL-6, IL-1β and extra- and intra-cellular STING levels were assayed by ELISA.

Results:

The levels of WBC were higher in SFs from gouty patients (27.7±20.56 103/mm3), while OA and OA+CPP patients showed the lowest WBC count (0.34±0.3 103/mm3, 0.3±0.28 103/mm3). SFs from inflammatory arthritis contained elevated percentages of PMN (gout: 85.5±10.86%, CPP-IA: 84±11.31%, RA: 80.33±8.14%, PsA: 42.6±35.97%). Extracellular STING was determined in OA (440±413.31 pg/ml), OA+CPP (225±205.06 pg/ml) and CPP-IA (475±7.07 pg/ml) SF, while was not detectable in RA, PsA and gout. Intracellular STING levels were similar and the highest in SFs from gout (96.4±35.44 pg/ml) and RA (90.64±23.13 pg/ml), while remained under detection limit only in SFs from PsA. SF concentration of IL-6 was lower in OA (354.87±377.56 pg/ml) and OA+CPP (389.56±104.14 pg/ml) as compared with inflammatory arthritides (PsA: 3807.14±489.86 pg/ml; RA: 17354±2334.87 pg/ml; gout: 19359±84.85 pg/ml; CPP-IA: 20389.56±104.14 pg/ml). The patients with gout and RA had the highest levels of IL-8 (2159.54±347.09 pg/ml; 2039.6±97.74 pg/ml) and IL-1β (35.93±20.46 pg/ml; 44.36±23.16 pg/ml), while OA showed the lowest concentrations (IL-8: 23.21±11.32 pg/ml; IL-1β: 0.47±0.13 pg/ml). In the total group of patients, we found a negative correlation between extracellular STING and IL-8 (r=-0.53; p=0.004) and IL-1β (r=-0.47; p=0.012). There was a positive correlation between intracellular STING and IL-8 (r=0.54; p=0.017), IL-1β (r=0.77; p<0.001) and IL-6 (r=0.69 p=0.009).

Conclusion:

This study is the first to define the presence of STING in SF of different arthritides. The high levels of extracellular STING in OA, OA+CPP and CPP-IA SFs may be due to the activation of factors that reduce its interaction with the ER. The effect of downregulating factors in PsA might explain the low concentration of intracellular STING in these patients.

References:

[1]Barber GN. STING: infection, inflammation and cancer. Nat Rev Immunol 2015;15:760-70.

Disclosure of Interests:

Anna Scanu: None declared, Roberto Luisetto: None declared, Francesca Oliviero: None declared, Paola Galozzi: None declared, Augusta Ortolan: None declared, Mariagrazia Lorenzin: None declared, Mara Felicetti: None declared, Andrea Doria Consultant of: GSK, Pfizer, Abbvie, Novartis, Ely Lilly, Speakers bureau: UCB pharma, GSK, Pfizer, Janssen, Abbvie, Novartis, Ely Lilly, BMS, Roberta Ramonda Speakers bureau: Novartis, Celgene, Janssen, Pfizer, Abbvie, Lilly

Biomarkers, imaging and disease activity indices in patients with early axial spondyloarthritis: the Italian arm of the SpondyloArthritis-Caught-Early (SPACE) Study

The study aimed to evaluate biomarkers facilitating early diagnosis of axial spondyloarthritis (axSpA) and correlations between them and disease activity parameters and imaging indexes. Patients with low back pain (LBP) (≥3 months, ≤2 years, onset ≤45 years) participating in the Italian arm of the SpondyloArthritis-Caught-Early SPACE study underwent a physical examination, questionnaires, laboratory tests, X-rays and MRI of the spine and sacroiliac joints (SIJ). An expert rheumatologist formulated axSpA diagnosis in accordance with Assessment of SpondyloArthritis International Society (ASAS) criteria. Disease activity and physical functioning were assessed using imaging, clinical and serological indices. Spine and SIJ MRI and X-rays were scored independently by 2 readers using the SPARCC, mSASSS and NY-criteria. Patients were classified as: subjects with signs of radiographic sacroiliitis (r-axSpA), subjects with signs of sacroiliitis on SIJ-MRI but not on X-rays (nr-axSpA MRI SIJ+) or subjects with no signs of sacroiliitis on MRI/X-rays but with >2 SpA features and signs of bone oedema on MRI spine (nr-axSpA MRI SIJ-/undifferentiated SpA). Significant differences were found in the prevalence of radiographic sacroiliitis, active sacroiliitis on MRI and SPARCC SIJ scores. Biomarker levels were not significantly increased in any of the patient groups. The correlations between IL-17 and IL-23 and other indices were not significant; correlations were found between IL-22 and BASFI, BASG1, HAQ, VAS pain, between mSASSS and MMP3, and between the latter and hsCRP. Although not significantly higher in any of the three groups, IL-22, MMP3 and hsCRP values were correlated with some disease activity indexes and with mSASSS. Large observational studies are required to confirm these preliminary findings.

Presence of multiple spondyloarthritis (SpA) features is important but not sufficient for a diagnosis of axial spondyloarthritis: data from the SPondyloArthritis Caught Early (SPACE) cohort

Objectives

Concerns have been raised about overdiagnosis of axial spondyloarthritis (axSpA). We investigated whether patients with chronic back pain (CBP) of short duration and multiple SpA features are always diagnosed with axSpA by the rheumatologist, and to what extent fulfilment of the Assessment of SpondyloArthritis International Society (ASAS) axSpA criteria is associated with an axSpA diagnosis.

Methods

Baseline data from 500 patients from the SPondyloArthritis Caught Early cohort which includes patients with CBP (≥3 months, ≤2 years, onset <45 years) were analysed. All patients underwent full diagnostic workup including MRI of the sacroiliac joints (MRI-SI) and radiograph of sacroiliac joints (X-SI). For each patient, the total number of SpA features excluding sacroiliac imaging and human leucocyte antigen B27 (HLA-B27) status was calculated.

Results

Before sacroiliac imaging and HLA-B27 testing, 32% of patients had ≤1 SpA feature, 29% had 2 SpA features, 16% had 3 SpA features and 24% had ≥4 SpA features. A diagnosis of axSpA was made in 250 (50%) of the patients: 24% with ≤1 SpA feature, 43% with 2 SpA features, 62% with 3 SpA features and 85% with ≥4 SpA features. Of the 230 patients with a positive ASAS classification 40 (17.4%) did not have a diagnosis of axSpA. HLA-B27 positivity (OR 5.6; 95% CI 3.7 to 8.3) and any (MRI-SI and/or X-SI) positive imaging (OR 34.3; 95% CI 17.3 to 67.7) were strong determinants of an axSpA diagnosis.

Conclusions

In this cohort of patients with CBP, neither the presence of numerous SpA features nor fulfilment of the ASAS classification criteria did automatically lead to a diagnosis axSpA. Positive imaging was considered particularly important in making a diagnosis of axSpA.

Spine and sacroiliac joints on magnetic resonance imaging in patients with early axial spondyloarthritis: prevalence of lesions and association with clinical and disease activity indices from the Italian group of the SPACE study

Our aim was to determine the prevalence of spine and sacroiliac joint (SIJ) lesions on magnetic resonance imaging (MRI) in patients with early axial spondyloarthritis (axSpA) and their correlation with disease activity indices. Sixty patients with low back pain (LBP) (≥3 months, ≤2 years, onset ≤45 years), attending the SpA-clinic of the Unità Operativa Complessa Reumatologia of Padova [SpondyloArthritis-Caught-Early (SPACE) study], were studied following a protocol including physical examination, questionnaires, laboratory tests, X-rays and spine and SIJ MRI. Positive spine and SIJ MRI and X-rays images were scored independently by 2 readers using the SPARCC method, modified Stoke ankylosing spondylitis spine score and New York criteria. The axial pain and localization of MRI-lesions were referred to 4 sites: cervical/thoracic/lumbar spine and SIJ. All patients were classified into three groups: patients with signs of radiographic sacroiliitis (r-axSpA), patients without signs of r-axSpA but with signs of sacroiliitis on MRI (nr-axSpA MRI SIJ+), patients without signs of sacroiliitis on MRI and X-rays (nr-axSpA MRI SIJ-). The median age at LBP onset was 29.05±8.38 years; 51.6% of patients showed bone marrow edema (BME) in spine-MRI and 56.7% of patients in SIJ-MRI. Signs of enthesitis were found in 55% of patients in the thoracic district. Of the 55% of patients with BME on spine-MRI, 15% presented presented a negative SIJMRI. There was a significant difference between these cohorts with regard to the prevalence of radiographic sacroiliitis, active sacroiliitis on MRI and SPARCC SIJ score. The site of pain correlated statistically with BME lesions in thoracic and buttock districts. Since positive spine-MRI images were observed in absence of sacroiliitis, we can hypothesize that this finding could have a diagnostic significance in axSpA suspected axSpA.

[Subclinical atherosclerosis in patients with psoriatic arthritis: a case-control study. Preliminary data]

OBJECTIVE

The aim of this study was to evaluate the prevalence of subclinical atherosclerosis in patients with psoriatic arthritis (PsA), correlated with some traditional risk factors of atherosclerosis and with PsA-related disease factors.

METHODS

Forty-one patients and 41 healthy subjects were evaluated for intima-media thickness (IMT) and flow-mediated dilation (FMD), using carotid duplex scanning. IMT values were expressed like IMT mean (cumulative mean of all the IMT mean) and M-MAX (cumulative mean of all the higher IMT). Subclinical atherosclerosis markers were correlated with age, body mass index (BMI) and blood pressure in both groups, with duration of arthritis, duration of psoriasis, tender and swollen joints, BASDAI (Bath Ankylosing Spondylitis Disease Activity Index), BASFI (Bath Ankylosing Spondylitis Functional Index), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in patients.

RESULTS

IMT mean and M-MAX were both higher in PsA patients compared with controls (0.7+/-0.15 vs 0.62+/-0.09 mm; p<0.01 and 0.86+/-0.21 vs. 0.74+/-0.13 mm; p<0.01 respectively). FMD was smaller in patients than in controls (5.9+/-2 vs 7.5+/-2.8%; p<0.01). Univariate analysis showed a correlation between IMT mean and SBP (r=0.217; p=0.05) and a correlation between M-MAX and age (r=0.392; p<0.001), BMI (r=0.252; p<0.05), SBP (r=0.446; p<0.001) in both groups. In PsA patients M-MAX resulted correlated with ESR (r=0.338; p<0.05) and BASDAI (r=0.322; p<0.05).

CONCLUSIONS

PsA patients exhibited endothelial dysfunctions which is an early marker of subclinical atherosclerosis, as well as an higher IMT. An interesting correlation between M-MAX and PsA activity index (ESR and BASDAI) was found.