Neuropathic‐like pain symptoms in inflammatory hand osteoarthritis lower quality of life and may not decrease under prednisolone treatment

Background

Pain is common in hand osteoarthritis (OA) and multiple types may occur. We investigated the prevalence, associated patient characteristics, influence on health‐related quality of life (HR‐QoL) and response to anti‐inflammatory treatment of neuropathic‐like pain in inflammatory hand OA.

Methods

Data were analysed from a 6‐week, randomized, double‐blind, placebo‐controlled trial investigating prednisolone treatment in 92 patients with painful inflammatory hand OA. Neuropathic‐like pain was measured with the painDETECT questionnaire. Associations between baseline characteristics and baseline neuropathic‐like pain were analysed with ordinal logistic regression, association of baseline neuropathic‐like pain symptoms with baseline HR‐QoL with linear regression, painDETECT and visual analogue scale (VAS) change from baseline to week 6 and interaction of painDETECT with prednisolone efficacy on VAS pain change from baseline to week 6 with generalized estimating equations (GEE).

Results

Of 91 patients (79% female, mean age 64) with complete painDETECT data at baseline, 53% were unlikely to have neuropathic‐like pain, 31% were indeterminate and 16% were likely to have neuropathic‐like pain. Neuropathic‐like pain was associated with female sex, less radiographic damage and more comorbidities. Patients with neuropathic‐like pain had lower HR‐QoL (PCS‐6.5 [95% CI −10.4 to −2.6]) than those without. Neuropathic‐like pain symptoms remained under prednisolone treatment and no interaction was seen between painDETECT and prednisolone efficacy on VAS pain.

Conclusions

In this study, 16% of inflammatory hand OA patients had neuropathic‐like pain. They were more often female, had more comorbidities and had lower QoL than those without. Neuropathic‐like pain symptoms remained despite prednisolone treatment and did not seem to affect the outcome of prednisolone treatment.

Significance

Pain is the dominant symptom in hand OA, with an unclear aetiology. In this study, we found that neuropathic‐like pain may play a role in hand OA, that it showed associations with female sex, younger age and more comorbidities and that it lowered health‐related quality of life in hand OA. Neuropathic‐like pain in hand OA seems resistant to prednisolone therapy but did not seem to interfere with the treatment of inflammatory pain with prednisolone.

POS1408 AN ULTRASOUND NEGATIVE FOR SUBCLINICAL SYNOVITIS IN PATIENTS WITH ARTHRALGIA: IS IT HELPFUL IN IDENTIFYING THOSE WHO WILL NOT DEVELOP INFLAMMATORY ARTHRITIS? A LONGITUDINAL STUDY IN FOUR ARTHRALGIA COHORTS

Background

Ultrasound (US) has become an established method in the evaluation of joints and is often used in clinical practice to guide management decisions in arthralgia-patients. To date, studies on the prognostic value of MSUS in arthralgia focused on the positive predictive value of subclinical inflammation. However, also the absence of imaging-detected subclinical synovitis is now increasingly used in daily practice to exclude arthralgia-patients from further follow-up. Though, evidence on the value of a negative US in ruling out future IA development in arthralgia-patients (the negative predictive value) is mostly absent. According to the rules of Bayes, predictive values are highly dependent on the prior-risk of developing the disease. The NPV therefore, is strongly related to the prior-risk of not getting IA, which is quite considerable in arthralgia-patients.

Objectives

To investigate the negative predictive value (NPV) of musculoskeletal ultrasound (MSUS) in arthralgia patients at risk for developing inflammatory arthritis (IA).

Methods

An MSUS examination of hands and feet was performed in arthralgia-patients at risk for IA in four independent cohorts. Patients were followed for one-year on the development of IA. Subclinical synovitis was defined as greyscale≥2 and/or power Doppler≥1. NPVs were determined and compared with the prior risks of not developing IA. Outcomes were pooled using meta-analyses and meta-regression analyses. In sensitivity analyses, MSUS-imaging of tender joints only (rather than the full US-protocol) was analyzed and ACPA-stratification applied, the latter being in line with the use of US in daily care.

Results

After one-year 78%, 82%, 77% and 72% of patients in the four cohorts did not develop IA. The NPV of a negative US was 86%, 85%, 82% and 90%, respectively. The meta-analysis showed a pooled non-IA prevalence of 79%(95%CI: 75%-83%) and a pooled NPV of 86%(95%CI:81-89%) (Figure 1). Imaging tender joints only (as generally done in clinical practice) and ACPA-stratification showed similar results.

Figure 1.

Full US protocol; Prior risks of not developing IA (A) and negative predictive values of MSUS (B) in the four cohorts. For comparison, the pooled prior risk and confidence interval from A are depicted in the red column in B.

Conclusion

A negative US result in arthralgia has a high NPV for not developing IA, which is mainly due to the high a-priori risk of not developing IA. The added value of a negative US (<10% increase) was limited.

References

N.A.

Disclosure of Interests

Cleo Rogier: None declared, Giulia Frazzei: None declared, Marion Kortekaas: None declared, Marloes Verstappen: None declared, Sarah Ohrndorf: None declared, Elise van Mulligen: None declared, Ronald van Vollenhoven Speakers bureau: Speaker, for which institutional and/or personal honoraria were received: AbbVie, Galapagos, GSK, Janssen, Pfizer, UCB, Consultant of: Consultancy, for which institutional and/or personal honoraria were received: AbbVie, AstraZeneca, Biogen, Biotest, BMS, Galapagos, Gilead, Janssen, Pfizer, Sanofi, Servier, UCB, Vielabio, Grant/research support from:

Research Support (institutional grants): BMS, GSK, Lilly, UCB

Support for Educational programs (institutional grants): Pfizer, Roche

, Dirkjan van Schaardenburg: None declared, Pascal de Jong: None declared, Annette van der Helm-van Mil: None declared

POS0501 SEQUENTIAL ULTRASOUND IN ARTHRALGIA PATIENTS AT RISK FOR INFLAMMATORY ARTHRITIS; IS IT HELPFUL FOR RISK STRATIFICATION IN DAILY PRACTICE?

Background

Musculoskeletal Ultrasound (MSUS) is often used to assess the presence of subclinical joint inflammation in patients presenting with arthralgia suspicious for progression to inflammatory arthritis (IA). Even though evidence-based guidelines for these patients are still absent, presence or absence of subclinical joint inflammation often influences management decisions in daily clinical practice. Studies so far focused on MSUS results at presentation with arthralgia. However, it is unknown if and how MSUS results change over time, and whether repeating MSUS is helpful in demonstrating or ruling out impending RA with greater certainty.

Objectives

To investigate whether sequential imaging at 4-months, in addition to baseline evaluation, is helpful in the risk stratification of arthralgia-patients.

Methods

Arthralgia-patients suspicious for progression to IA were included in the Rotterdam clinically suspect arthralgia cohort. At baseline and at 4-months a bilateral MSUS-examination was performed of the joints and tendons in both hands and feet. Subclinical inflammation was defined as GS>1 and/or PD>0, this was scored according to the latest OMERACT- guidelines.(1, 2) Based on a large US study carried out in a symptom-free population, the cut-off value in MTP 2-3 was considered present if GS ≥3 and/or PD ≥1.(3) Patients were followed for one-year on development of IA, identified with joint examination by experienced rheumatologists. The value of MSUS was studied separately for patients with and without subclinical joint inflammation at baseline. In a sensitivity analysis, ACPA-stratification was applied.

Results

A total of 52 consecutive patients were studied; 29% developed IA after one year. At baseline, 25 patients had subclinical inflammation and 27 patients did not have subclinical inflammation. In these groups respectively 28% and 7% developed IA before the 4-month-visit and therefore did not have repeated MSUS (Figure 1 A/B). In the patients with a positive MSUS at baseline, 28% had a negative MSUS at four months, all these patients did not progress to IA, irrespective of tender joints count(Figure 1A). In the group of patients with a negative MSUS at baseline, 26% achieved a positive MSUS at 4-months. All patients with a negative MSUS at baseline and no tender joints at 4-months did not progress to IA, regardless of the MSUS results. Patients with a negative MSUS at baseline and tender joints at 4-months developed IA infrequently, without relevant differences between those that did or did not develop a positive MSUS at 4-monthts. Overall, only a minority of patients whose MSUS progressed from negative to positive indeed developed IA, whereas this repeated MSUS was falsely positive in most cases(Figure 1B). Despite the small numbers, ACPA-stratification was performed, this showed a similar trend.

Figure 1.

Sequential ultrasound at baseline and after 4-months of follow-up in arthralgia-patients at risk for inflammatory arthritis with subclinical inflammation at baseline (A) and without subclinical inflammation at baseline(B).

Conclusion

Within arthralgia patients with a positive MSUS at baseline, a negative MSUS after 4-months may be an incentive to exclude arthralgia-patients from further follow-up. Within the patients with a negative MSUS at baseline, repeating MSUS may induce more false positive than correct positive results.

References

[1]D’Agostino MA, Terslev L, Aegerter P et al. Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforce-Part 1: definition and development of a standardised, consensus-based scoring system. RMD Open. 2017;3(1):e000428.

[2]Naredo E, D’Agostino MA, Wakefield RJ et al. Reliability of a consensus-based ultrasound score for tenosynovitis in rheumatoid arthritis. Ann Rheum Dis. 2013;72(8):1328-34.

[3]Padovano I, Costantino F, Breban M et al. Prevalence of ultrasound synovial inflammatory findings in healthy subjects. Ann Rheum Dis. 2016;75(10):1819-23.

Disclosure of Interests

None declared.

POS0123 NEUROPATHIC PAIN SYMPTOMS IN INFLAMMATORY HAND OSTEOARTHRITIS(OA) LOWERS HEALTH RELATED PHYSICAL QUALITY OF LIFE AND MAY REQUIRE ANOTHER APPROACH THAN ANTI-INFLAMMATORY TREATMENT

Background:

Pain is a common, difficult to manage symptom in hand osteoarthritis (OA). Multiple pain mechanisms may play a role in hand OA.

Objectives:

To investigate presence of neuropathic pain symptoms in patients with inflammatory hand OA, characteristics of those patients, their impact on health related quality of life (HR-QoL), and the influence of anti-inflammatory treatment on neuropathic pain symptoms.

Methods:

Data from a randomised, double-blind, placebo-controlled trial of prednisolone including 92 patients with hand OA fulfilling ACR criteria were used. At baseline patients had signs of synovial inflammation, a VAS finger pain of ≥30 mm and who flared ≥20 mm upon NSAID washout. The primary endpoint was VAS finger pain (0-100) at week 6.

Neuropathic pain symptoms were measured at baseline and week 6 using the validated painDETECT questionnaire, consisting of questions on pain quality, pain intensity over time and radiating pain. Scores range -1 to 38 and patients are classified as having unlikely (<13), indeterminate (13-18) and likely (>18) neuropathic pain. HR-QoL was measured with physical component scale (PCS) of Short-Form 36 (SF36; 0-100), comorbidities with the Self-administered Comorbidities Questionnaire (SCQ; 0-45), radiographic severity with Kellgren-Lawrence (KL) sum score (0-120), and treatment response with OMERACT-OARSI responder criteria.

Association of patient characteristics with neuropathic pain symptoms was analysed with univariate and multivariate ordinal logistic regression, with painDETECT as dependent variable. Association of neuropathic pain symptoms with HR-QoL was analysed with multivariate linear regression, adjusted for age, sex, BMI, VAS finger pain, SCQ score and KL sum score, with PCS as dependent variable. Response of neuropathic pain symptoms and VAS pain to prednisolone was analysed with generalised estimating equations. Association of neuropathic pain symptoms at baseline with response to treatment was analysed using χ2-tests and GEE.

Results:

91 patients had complete painDETECT data at baseline (mean painDETECT score 12.8 [SD 5.9]). Scores were <13 in 53%, 13-18 in 31% and >18 in 16%. Higher painDETECT score categories were associated with less radiographic damage, more comorbidities, female sex and higher VAS finger pain in multivariate analysis. (table 1)

Table 1.

Ordinal logistic regression with painDETECT categories as dependent variable

VariablesMean (SD) N=91 (100%)Odds ratio (95% CI)Age64 (9)0.96 (0.90 to 1.02)Female sex; N (%)72 (79%)3.84 (1.19 to 12.39)*BMI; median (SD)27 (24 to 29)0.97 (0.89 to 1.06)SCQ score; median (SD)2 (1 to 5)1.04 (1.04 to 1.36)*VAS finger pain53.8 (2.1)1.02 (1.00 to 1.04)*KL sum score37 (16)0.96 (0.93 to 1.00)*

*p<0.05. BMI = body mass index. SCQ = Self-administered comorbidities questionnaire. VAS = visual analog scale. KL= Kellgren-Lawrence.

Patients with painDETECT scores >18 had a lower HR-QoL (PCS -6.5 [95%CI -10.4 to -2.6]) than those with painDETECT scores <13.

PainDETECT scores remained unchanged throughout the trial in both prednisolone-treated and placebo-treated patients, and there was no between-group difference at week 6. VAS pain improved more in the prednisolone group than in the placebo group (mean between-group difference -16.5 [95%CI -26.1 to -6.9]) (figure 1). No association between the presence of neuropathic pain symptoms at baseline and OMERACT-OARSI response to treatment was found.

Conclusion:

Patients with inflammatory hand OA and additional neuropathic pain symptoms are more often female and have more comorbidities, and report a lower QoL, than those without. Neuropathic pain symptoms seem unresponsive to anti-inflammatory therapy. Clinicians should be aware of neuropathic pain symptoms in their patients as they might benefit from additional, specific treatment.

Acknowledgements:

The authors thank all patients for their participation in the HOPE study, and participating rheumatologists for inclusion of patients in the HOPE study. We also thank research nurses B.A.M.J. van Schie-Geyer and S. Wongsodihardjo, and technicians J.C. Kwekkeboom and E.I.H. van der Voort, for their contributions.

Disclosure of Interests:

Coen van der Meulen: None declared, Lotte van de Stadt: None declared, Féline Kroon: None declared, Marion Kortekaas: None declared, Annelies Boonen Speakers bureau: Lecture for UCB; paid to department., Consultant of: Yes. Advisory board meetings at Galapagos, Eli Lilly and Abvvie; paid to department., Grant/research support from: Yes. Grants by Celgene and Abbvie; paid to department., Stefan Böhringer: None declared, Marieke Niesters: None declared, Monique Reijnierse: None declared, Frits Rosendaal: None declared, Naghmeh Riyazi: None declared, M. Starmans: None declared, Franktien Turkstra: None declared, Jende van Zeben: None declared, Cornelia Allaart: None declared, Margreet Kloppenburg Consultant of: For Abbvie, Pfizer, Levicept, GlaxoSmithKline, Merck-Serono, Kiniksa, Flexìon, Galapagos, Jansen, CHDR and local investigator of industry-driven trial (Abbvie). All fees were paid to the institution., Grant/research support from: Grant by the Dutch Arthritis Society

POS0258 REAL-TIME VERSUS STATIC SCORING IN MUSCULOSKELETAL ULTRASONOGRAPHY IN PATIENTS WITH INFLAMMATORY HAND OSTEOARTHRITIS

Background:

Ultrasound (US) is used in rheumatic musculoskeletal diseases (RMDs) such as hand osteoarthritis (OA) as outcome measure. Traditionally scoring is performed real-time, but central reading of static US images could avoid issues of inter-rater reliability. However, agreement between real-time and static assessment has not been studied

Objectives:

To study the agreement between real-time and static scoring of US in inflammatory hand OA.

Methods:

Ultrasound was performed of 30 joints obtained in 75 patients with hand osteoarthritis, treated with prednisolone or placebo in a randomized double-blind trial. Hand joints were assessed for synovial thickening, effusion, Doppler signal and osteophytes by ultrasound (score 0-3 per joint) at baseline and after treatment. Two ultrasonographers blinded for clinical data scored the live images together (simultaneously) in real-time. A consensus score for each joint was recorded. Representative images stored during scanning were scored by one ultrasonographer minimally 6 months after real-time scoring. For each patient, images of each visit were scored paired, with known chronological order.

Agreement between scoring methods was studied at joint level with quadratic weighted kappa. At patient level, intra-class correlations (ICC; mixed effect model, absolute agreement, with clustering taken into account) were calculated at both timepoints. ICCs were also calculated for the delta of sum scores. Responsiveness of scoring methods was analyzed with generalized estimating equations (GEE) with treatment as independent and ultrasonography findings as dependent variable.

Results:

Thirty-nine patients (52%) were treated with prednisolone and 36 (48%) were treated with placebo. Patient characteristics were well-balanced between treatment groups.

All patients had signs of synovial thickening and osteophytes as assessed by real-time ultrasonography, and almost all signs of effusion (99%) or a positive Doppler signal (95%) in at least one joint. Total ultrasonography sum score for osteophytes was high (mean 45 ±SD 12), whereas sum score was low for positive Doppler signal (mean 5.9 ±SD 4.4), with intermediate sum scores for synovial thickening and effusion (mean 16 ±SD 6.3 and 11 ±SD 6.0 respectively). Static sum scores were overall slightly higher (osteophytes mean 48 ±SD 10; Doppler mean 6.9 S±D 5.0; synovial thickening mean 20 ±SD 7.0 and effusion 13 ±SD 6.5)

Agreement at baseline was good to excellent at joint level (kappa 0.72-0.88) and moderate to excellent at patient level (ICC 0.59-0.86). Agreement for delta sum scores was poor to fair for synovial thickening and effusion (ICC 0.18 and 0.34 respectively), but excellent for Doppler signal (ICC 0.80) (Table 1).

Real-time ultrasonography showed responsiveness to prednisolone with a mean between-group difference of synovial thickening sum score of -2.5 (CI:-4.7 to-0.3). Static ultrasonography did not show a decrease in synovial thickening (Figure 1). No difference in ultrasonography scores was seen for the other ultrasonography features, neither with real-time nor static scoring.

Conclusion:

While cross-sectional agreement between real-time and static ultrasonography was good, agreement of delta sum scores was not and paired static ultrasonography measurement of synovial thickening did not show responsiveness to prednisone therapy where real-time ultrasonography did. Therefore, when using ultrasonography in clinical trials, real-time dynamic scoring should remain the standard.

Table 1.

Agreement on patient level

BaselineWeek 6Delta W6-BLICC (95% CI)ICC (95% CI)ICC (95% CI)Synovitis0.59 (0.26-0.76)0.58 (0.24-0.77)0.18 (0 - 0.40)Effusion0.84 (0.66-0.92)0.84 (0.75-0.89)0.34 (0.12-0.53)Osteophytes0.82 (0.50-0.92)0.78 (0.56-0.88)NDDoppler0.86 (0.75-0.92)0.91 (0.85-0.94)0.80 (0.70 -0.87)

ICC: intra-class correlation coefficient linear mixed model (random patient, fixed rating), absolute agreement. ND: Not Dertermined

Disclosure of Interests:

Lotte van de Stadt: None declared, Féline Kroon: None declared, Monique Reijnierse Grant/research support from: Dutch Arthritis Foundation, Désirée van der Heijde Consultant of: bbVie, Amgen, Astellas, AstraZeneca, Bayer, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma, Frits Rosendaal: None declared, Naghmeh Riyazi: None declared, R. de Slegte: None declared, Jende van Zeben: None declared, Cornelia Allaart: None declared, Margreet Kloppenburg Consultant of: Abbvie, Pfizer, Levicept, GlaxoSmithKline, Merck-Serono, Kiniksa, Flexion, Galapagos, Jansen, CHDR, Grant/research support from: MI-APPROACH, Marion Kortekaas: None declared

The role of anti-myelin (auto)-antibodies in the phagocytosis of myelin by macrophages

Plasma cells secreting antibodies directed to myelin components are present in CNS of MS patients and although the pathogenic role of such antibodies has yet to be established it is apparent from animal studies that anti-myelin antibodies are involved in myelin damage. In this study, we have investigated the effect of disease-promoting anti-myelin mAb on the phagocytosis of myelin by macrophages. Monoclonal antibodies directed to myelin basic protein (MBP)--clones 1, 12, 17, 22, 26, proteolipid protein (PLP), galactocerebroside (GalC) and myelin oligodendrocyte glycoprotein (MOG)--clones Y1, Y4, Y6, Y7, Y9, Y10, Y11 and Z12 were incubated with purified murine myelin labeled with DiI. The degree of phagocytosis of antibody-treated myelin by murine macrophages in vitro was determined using a quantitative flow cytometric assay. In comparison to untreated myelin pretreatment with myelin-specific mAb modified the degree of phagocytosis. The degree of opsonization of myelin was dependent on the isotype of antibody and the epitope recognized in addition to the ability of the mAb to fix complement. The greatest degree of opsonization of myelin was observed with the monoclonal antibody MOG Z12 that has previously been shown to enhance EAE and augment demyelination. These findings suggest a major role for anti-myelin antibodies, in particular antibodies directed to MOG, for the phagocytosis of myelin by macrophages in vitro. This may have relevance to the pathogenesis of myelin damage in vivo and provide a helpful tool for the classification of heterogeneous diseases such as MS.