A Proposal of a New Tool for the Assessment of Damage in Behçet Syndrome Uveitis: Cerrahpasa Ocular Damage Grading System

INTRODUCTION/OBJECTIVE

There is currently no tool available to assess the severity of damage in uveitis due to Behçet's syndrome (BS). In this preliminary study, we developed a new grading system to evaluate ocular damage and assessed it in a prospective cohort.

METHODS

A specialist in BS uveitis (YO) developed a grading system for ocular damage with five grades based on the extent of damage in the posterior segment. YO trained a senior and general ophthalmologist with sample fundus images. BS patients who had undergone color fundus photography during their routine visits in attack-free periods were included in the study. The color fundus photos of this prospective cohort were evaluated blindly by YO and his trainees using the new grading tool. Inter and intra-observer agreement between the graders were assessed by Cohen's kappa analysis. The evaluation of YO was considered as the gold standard.

RESULTS

One hundred eighty-five eyes of 108 (29 F/79 M) patients with BS uveitis were graded for damage by two investigators. Their mean age was 38,58 years and their median ocular disease duration was 13 years. The gold standard and the two investigators exhibited substantial concordance with the ocular damage grading system. The inter- and intra-observer agreement were also almost perfect.

CONCLUSION

The newly developed ocular damage grading system enables the standardization of damage severity in BS uveitis. It is imperative to conduct internal and external validations across diverse cohorts. Furthermore, future studies should investigate its correlation with other multimodal imaging methods such as fluorescein angiography and optical coherence tomography.

Anakinra in idiopathic recurrent pericarditis: a comprehensive case series and literature review

OBJECTIVE

Idiopathic recurrent pericarditis (IRP) is defined by recurring episodes of pericardial inflammation without a known cause. This study investigates the safety and efficacy of anakinra, an interleukin‑1 inhibitor, as a successful therapy for IRP in cases resistant to conventional treatment.

METHODS

A retrospective evaluation of patients treated at our autoinflammatory center between 2011 and 2023 was conducted. Patient files were examined for demographic, clinical, and treatment response data, including nonsteroid anti-inflammatory drugs (NSAIDs), corticosteroids, and colchicine. Monogenic autoinflammatory disease screening was performed for Mediterranean Fever (MEFV), tumor necrosis factor receptor-associated periodic syndrome (TRAPS), mevalonate kinase (MVK), nucleotide-binding domain, leucine-rich-containing family, pyrin domain-containing-3 (NLRP3), and nucleotide-binding oligomerization domain-containing protein 2 (NOD2). Patients who experienced multiple episodes of pericarditis were diagnosed with recurrent pericarditis. The study evaluated anakinra treatment in IRP patients unresponsive to conventional therapy.

RESULTS

The study included 21 participants, 9 (42.9%) female and 12 (57.1%) male. The average age of the participants was 43.1 ± 16.5 years. The MEFV mutation analysis revealed that 2 (9.5%) had a mutation in exon 10 and 4 (19.0%) had one in exon 2. Out of the 16 cases, 15 successfully discontinued steroid treatment. Four patients (19.0%) experienced injection site reactions. C‑reactive protein (CRP) levels were measured at an average of 196 ± 67.8 mg/l before and 2.6 ± 3.15 mg/l after anakinra treatment.

CONCLUSION

In conclusion, the study adds to the growing evidence for the efficacy of interleukin-1 inhibitors, such as anakinra, as a promising treatment modality for IRP in cases resistant to conventional treatment.

Mycophenolate mofetil may be an alternative for maintenance therapy of Behçet syndrome uveitis: a single-center retrospective analysis

Experience with mycophenolate in uveitis due to Behçet syndrome (BS) is limited. Twelve patients with panuveitis or posterior uveitis who were started mycophenolate were included. Data on demographic characteristics, therapies, ocular attacks, and adverse events were extracted from patient charts. Seven patients with BS uveitis were prescribed mycophenolate for remission induction, of which 6 were refractory/intolerant to conventional immunosuppressives. Mycophenolate was combined with anti-TNFs in 3 patients, resulting in no further ocular attacks. Mycophenolate had to be stopped in the fourth patient due to adverse events. The remaining 3 patients continued to have ocular attacks and were switched to other agents without any drop in visual acuity. Among the 5 patients who were prescribed mycophenolate for maintenance, 2 were relapse free, but 3 experienced ocular attacks. One patient had an exacerbation of mucocutaneous lesions, and 2 experienced adverse events. Mycophenolate monotherapy may not be adequate for remission induction of refractory BS uveitis, but it can be a safe and effective alternative when combined with a biologic agent. It may also be an option for maintenance therapy.

Secukinumab-induced IgA vasculitis in a patient with psoriatic arthritis

OBJECTIVES

Secukinumab (SEC) is an effective and widely used drug in psoriatic disease and axial spondyloarthritis. However, SEC has been found to be associated with inflammatory conditions and vasculitis. These inflammatory adverse effects may complicate the treatment of underlying disease, and clinicians may experience difficulties in recognizing and managing this unusual condition.

CASE REPORT

A man aged 56 years with psoriatic disease refractory to conventional disease-modifying antirheumatic drugs was given adalimumab for 6 weeks, then switched to SEC when his psoriatic lesions were exacerbated. After 3 weeks of SEC treatment, he developed systemic features of IgA vasculitis while his skin lesions and arthritis persisted.

CONCLUSIONS

Although SEC-related inflammatory adverse events, including vasculitis, are rarely encountered in clinical practice, it is essential to recognize them because they can be mistaken as a component of the underlying inflammatory disease. In addition, the dramatic improvement in many cases after the cessation of SEC underlines the importance of making an accurate diagnosis. Pathogenetically, these adverse events are likely to be paradoxical reactions, except for SEC-induced inflammatory bowel diseases. However, in many aspects, their pathogenesis is controversial and needs clarification.

Infliximab for vascular involvement in Behçet's syndrome

OBJECTIVE

Vascular involvement is an important cause of morbidity and mortality in patients with Behçet's syndrome (BS). We aimed to survey the efficacy and safety of infliximab (IFX) in BS patients with vascular involvement followed in a dedicated tertiary center.

METHODS

Charts of all BS patients who used IFX for vascular involvement between 2004 and 2022 were reviewed. Primary endpoint was remission at Month 6, defined as lack of new clinical symptoms and findings associated with vascular lesion, lack of worsening of the primary vascular lesion and a new vascular lesion on imaging, and CRP < 10 mg/L. Relapse was defined as development of a new vascular lesion or recurrence of the preexisting vascular lesion.

RESULTS

Among the 127 patients (102 men, mean age at IFX initiation: 35.8 ± 9.0 years) treated with IFX, 110 (87%) had received IFX for remission induction and 87 of these (79%) were already on immunosuppressives when the vascular lesion requiring IFX developed. The remission rate was 73% (93/127) at Month 6 and 63% (80/127) at Month 12. Seventeen patients experienced relapses. Remission rates were better among patients with pulmonary artery involvement and venous thrombosis compared to patients with non-pulmonary artery involvement and venous ulcers. Fourteen patients had adverse events leading to IFX discontinuation and 4 had died due to lung adenocarcinoma, sepsis, and pulmonary hypertension-related right heart failure due to pulmonary artery thrombosis (n = 2).

CONCLUSION

Infliximab seems to be effective in majority of BS patients with vascular involvement, even in those who are refractory to immunosuppressives and glucocorticoids.

INCREASED ARTERIAL STIFFNESS AND ACCELERATED ATHEROSCLEROSIS IN TAKAYASU ARTERITIS

INTRODUCTION

Cardiovascular diseases are the leading causes of morbidity and mortality in patients with Takayasu arteritis (TAK). Arterial stiffness and accelerated atherosclerosis have been reported in TAK, however, morphological changes in the arterial wall have not been adequately addressed. Shear wave elastography (SWE) is a new, non-invasive, direct and quantitative method of ultrasonography (US) that evaluates elasticity of biological tissues.

METHODS

A total of 50 patients with TAK (44F/6 M; mean age: 39.8 ± 8.2 years), 43 with systemic lupus erythematosus (SLE) (38F/5 M; 38.0 ± 7.9 years) and 57 healthy controls (HCs) (50F/7M: 39.5 ± 7.1 years) were studied using carotid B mode US and SWE. Carotid artery intima-media thickness (CCA IMT) and SWE were measured and the atherosclerotic plaques were recorded. Clinical characteristics and cardiovascular risk factors were determined. Intra and inter observer reproducibility was assessed and found good agreement.

RESULTS

The mean IMT in the right and left carotid arteries was significantly higher only among patients with TAK when compared to SLE and HCs. Carotid artery plaques were significantly increased only in patients with TAK. On the other hand, the mean SWE value was significantly increased among both TAK and SLE patients when compared to HCs, whereas patients with TAK had the highest value. These were also true after adjustments were made for atherosclerotic risk factors and after all those with atherosclerotic plaques were excluded from the analysis. TAK itself, diastolic blood pressure levels and IMT were independently associated with SWE.

CONCLUSIONS

Markedly increased CCA IMT and SWE values appear to be uniquely associated with TAK, suggesting that they could be used as diagnostic tools. Arterial stiffness occurs independently from atherosclerosis and is associated with arterial thickening. Further studies should investigate whether CCA SWE values could predict cardiovascular morbidity and mortality. Strong association with premature atherosclerosis could be also considered as a unique feature of TAK.

Frequency of AA amyloidosis has decreased in Behçet's syndrome: a retrospective study with long-term follow-up and a systematic review

OBJECTIVE

A decline in the frequency of AA amyloidosis secondary to RA and infectious diseases has been reported. We aimed to determine the change in the frequency of AA amyloidosis in our Behçet's syndrome (BS) patients and to summarize the clinical characteristics of and outcomes for our patients, and also those identified by a systematic review.

METHODS

We identified patients with amyloidosis in our BS cohort (as well as their clinical and laboratory features, treatment, and outcome) through a chart review. The primary end points were end-stage renal disease and death. The prevalence of AA amyloidosis was estimated separately for patients registered during 1976-2000 and those registered during 2001-2017, in order to determine whether there was any change in the frequency. We searched PubMed and EMBASE for reports on BS patients with AA amyloidosis. Risk of bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool.

RESULTS

The prevalence of AA amyloidosis was 0.62% (24/3820) in the earlier cohort and declined to 0.054% (3/5590) in the recent cohort. The systematic review revealed 82 cases in 42 publications. The main features of patients were male predominance and a high frequency of vascular involvement. One-third of patients died within 6 months after diagnosis of amyloidosis.

CONCLUSION

The frequency of AA amyloidosis has decreased in patients with BS, which is similar to the decrease observed for AA amyloidosis due to other inflammatory and infectious causes. However, AA amyloidosis is a rare, but potentially fatal complication of BS.

AB1308 MYCOPHENOLATE FOR THE TREATMENT OF EYE INVOLVEMENT IN PATIENTS WITH BEHÇET’S SYNDROME

Background

Experience with mycophenolate in uveitis associated with Behçet’s syndrome (BS) is limited.

Objectives

We aimed to report the efficacy and safety of mycophenolate mofetil (MMF) and mycophenolate sodium (MPA) in the treatment of BS uveitis.

Methods

All patients with panuveitis or posterior uveitis who used mycophenolate for eye involvement between 2016 and 2018 were included. Patient charts were reviewed and data on demographic features, previous immunosuppressives, concomitant therapies, ocular attacks and outcome, and adverse events were extracted. Follow up was ended on October 2021.

Results

We included 12 BS patients (M/W: 8/4, mean age: 35±7 years) treated with mycophenolate during a mean follow-up of 42±19 months (Table 1). All but 3 patients had bilateral eye involvement. IFX and INF-α had been discontinued due to adverse events in all patients, AZA in 10/12, and Cy-A in 7/10.

Table 1.

Demographic, treatment and outcome of the 12 patients

Age /genderPrevious therapiesRemission induction or Maintenance therapyConcomitant biologicTime to ocular attack (months)Treatment after ocular attackAt the end of the follow-upMMF duration (months)25/MAZA,Cy-ARemission inductionNone2ADA was addedADA and MPAa were switched to INF due to further ocular attacks3842/WAZA,Cy-A, INF, IFXRemission inductionIFXN/AN/AStill on IFX and MMF7237/MAZA,Cy-A, INF, IFX, ADARemission inductionADAN/AN/AStill on ADA and MMF2732/MAZARemission inductionNone12IFX was addedStill on IFX and MMF5233/WAZA, Cy-A, INF, ADA, IFXRemission inductionNoneN/AN/AMPAb was switched to certolizumab and MTX524/MAZARemission inductionIFXN/AN/AStill on MMF and IFX was stopped due to remission6337/MAZA, Cy-ARemission inductionNone6IFX was addedIFX and MMF were switched to INF due to further ocular attacks4136/WAZA,Cy-A, INFMaintenanceNone2ADA was addedStill on ADA and MMF5036/MAZA,Cy-A, INF, IFXMaintenanceIFXN/AN/AStill on IFX and MMF was stopped due to remission1749/WAZA,Cy-A, INFMaintenanceNoneN/AN/AStill on MMF3937/MAZA, INFMaintenanceNone31Cy-A was addedStill on MMF and Cy-A38 d31/MAZA, Cy-A, INFMaintenanceNone5IFX was addedOff treatment for 2 years38

a MMF was switched to MPA due to numbness in hands and feet, and MPA was stopped due to arthralgia.

b MMF was switched to MPA due to diarrhea

Seven patients were prescribed mycophenolate for remission induction. One of these patients had had his first uveitis attack while on AZA treatment due to gastrointestinal involvement. The remaining 6 patients were using other immunosuppressives and experienced relapses that led to mycophenolate use. MMF was added to a biologic agent in 2 patients (IFX and ADA) and was initiated in combination with IFX in 1 patient. These 3 patients did not experience further ocular attacks and IFX was stopped due to remission in 1 patient. In the fourth patient, MMF was switched to MPA due to numbness in hands and feet and MPA was stopped due to arthralgia. This patient did not experience ocular attacks during 5 months of MPA therapy. The remaining 3 patients had further uveitis attacks without decrease in visual acuity 2, 6, and 12 months after MMF initiation, and IFX was added in 2 patients, and ADA in 1 patient. Two of these patients were switched to INF-α due to uveitis relapses. MMF was switched to MPA for diarrhea in 1 patient.

Five patients had received MMF for maintenance. One of these was using IFX when MMF was started and these 2 agents were used together. This patient discontinued MMF due to remission 17 months after MMF initiation and is still on IFX monotherapy. The second patient is still on MMF for 39 months without further ocular attacks. ADA, IFX and Cy-A were added in the remaining 3 patients due to ocular attacks 2, 5 and 31 months after MMF initiation. One of these 3 patients stopped IFX and MMF due to remission and is off treatment for 2 years.

Conclusion

Mycophenolate may be an alternative treatment modality in addition to biologics for patients with eye involvement who are intolerant to conventional therapies. Further data is needed to show whether it would be effective when used alone.

Disclosure of Interests

Didar Ucar: None declared, Yilmaz Ozyazgan: None declared, Sinem Nihal Esatoglu Speakers bureau: Sinem Nihal Esatoglu has received honorariums for presentations from UCB Pharma, Roche, Pfizer, and Merck Sharp Dohme, Emir Cerme: None declared, Vedat Hamuryudan Speakers bureau: Vedat Hamuryudan has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma, Grant/research support from: Vedat Hamuryudan has received grant/research support from Celgene., Melike Melikoglu: None declared, Izzet Fresko: None declared, Sebahattin Yurdakul: None declared, Hasan Yazici: None declared, Gulen Hatemi Speakers bureau: Gulen Hatemi has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma., Grant/research support from: Gulen Hatemi has received grant/research support from Celgene.

AB1305 A SYSTEMATIC REVIEW OF AA AMYLOIDOSIS AMONG PATIENTS WITH BEHÇET’S SYNDROME

Background

Data on patients with Behçet’s syndrome (BS) complicated with AA amyloidosis is limited to case reports or case series with a small number of patients.

Objectives

In this study, we aimed to perform a systematic review (SR) of published reports on BS patients with AA amyloidosis.

Methods

PubMed and EMBASE were searched with the keywords “Behcet* AND amyloidosis”, without date and language restriction, until May 2020. Two independent reviewers (SNE, GK) performed title/abstract and full text screening and data extraction. A third reviewer (GH) made the final decision in case of disagreement between the two reviewers. Studies that reported patients who were reported by authors as having BS and AA amyloidosis were included. The risk of bias assessment was done using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool.

Results

The systematic literature search yielded 760 articles of which 703 were excluded after title and abstract review. After full-text review, we further excluded 15 duplicate articles and 1 article was added after handsearching the reference lists of the full texts. Finally, we included 43 articles reporting 96 cases. Among these articles, 38 were case reports and 5 were case series reporting between 6 and 14 patients. All patients but 8 were reported from Mediterranean countries. The quality of all articles according to GRADE was very low due to the lack of a control group.

The main features of the patients were male predominance (81/96, 84%), a high frequency of major organ involvement (62/80, 77.5%) especially vascular involvement (60%), a low frequency of comorbidities predisposing to AA amyloidosis (11/96, 11.5%), and a very low frequency of gastrointestinal involvement (3/72, 4%). All but 8 patients were diagnosed with BS and AA amyloidosis simultaneously. The most common presentation was nephrotic syndrome (60/81, 74%). Presenting symptoms other than proteinuria were diarrhea (n=2), acute renal failure (n=2), upper gastrointestinal bleeding (n=1), end stage renal disease (ESRD) (n=1), cardiac symptoms due to cor pulmonale (n=1), and hypertension (n=1). Renal biopsy (72%) and rectal biopsy (17%) were the most commonly used procedures to diagnose AA amyloidosis.

After diagnosing AA amyloidosis, colchicine was initiated in 58 patients, cyclophosphamide in 16, and biologics in 3 (1 anakinra and 2 tocilizumab). In the 67 patients with available data on follow-up, 43% of the patients were followed-up for ≤1 year and median follow-up duration was 20 months (IQR: 4-48). Among the 64 patients with available data, 30 (47%) had developed ESRD. Among the 72 patients with available data on survival status, 30 patients (42%) had died. Ten patients (33%) had died within 6 months, 15 had died after a median follow-up of 48 months (IQR: 24-150), and follow-up duration was not available in the remaining 5 patients including 3 patients whose diagnoses were made by autopsy. Reasons for death were infection (n=7), ESRD (n=6), intractable diarrhea (n=3), pulmonary embolism (n=1), cor pulmonale (n=1), hemorrhage due to pulmonary artery aneurysm (n=1), liver cirrhosis (n=1), gastric cancer (n=1), subarachnoid hemorrhage (n=1), and not reported (n=8).

Conclusion

Male gender and major organ involvement, especially vascular involvement, appear to be risk factors for the development of AA amyloidosis in BS patients. While BS patients complicated with AA amyloidosis have been reported rarely, it is a fatal complication of BS. One third of the patients had died within 6 months after AA amyloidosis diagnosis.

Disclosure of Interests

Güzin Karatemiz: None declared, Sinem Nihal Esatoglu Speakers bureau: Sinem Nihal Esatoglu has received honorariums for presentations from UCB Pharma, Roche, Pfizer, and Merck Sharp Dohme., Mert Gurcan: None declared, Yesim Ozguler Speakers bureau: Yesim Ozguler has received honorariums for presentations from UCB Pharma, Novartis, and Pfizer., Sebahattin Yurdakul: None declared, Vedat Hamuryudan Speakers bureau: Vedat Hamuryudan has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma., Grant/research support from: Vedat Hamuryudan has received grant/research support from Celgene., Izzet Fresko: None declared, Melike Melikoglu: None declared, Emire Seyahi Speakers bureau: Emire Seyahi has received honorariums for presentations from Novartis, Pfizer, AbbVie, and Gliead., Serdal Ugurlu: None declared, Huri Ozdogan: None declared, Hasan Yazici: None declared, Gulen Hatemi Speakers bureau: Gulen Hatemi has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma, Grant/research support from: Gulen Hatemi has received grant/research support from Celgene.

POS0816 DRUG SURVIVAL OF INFLIXIMAB IN BEHÇET’S SYNDROME PATIENTS WITH DIFFERENT TYPES OF INVOLVEMENT

Background

Infliximab (IFX) is an effective therapeutic option in the management of severe and refractory manifestations of Behçet’s syndrome (BS).

Objectives

We aimed to evaluate long term drug survival of IFX in a large cohort of BS patients.

Methods

We reviewed the charts of BS patients who received IFX between 2004 and June 2021 and noted demographic features, reasons for IFX use, IFX duration, and reasons for discontinuation.

Results

371 patients (290 men, mean age at IFX initiation: 35.5 ± 10 years) received IFX for uveitis (n=164), vascular involvement (n=114), central nervous system (CNS) involvement (n=55), arthritis (n=19), gastrointestinal (GI) involvement (n=15), mucocutaneous involvement (n=10), venous ulcers (n=13), and secondary amyloidosis (n=1). Twenty patients had more than one type of involvement requiring IFX.

During a median follow-up of 30 months (IQR: 13-52), 175 (47%) patients were still receiving IFX for a median period of 40 months (IQR: 22-66) while 196 (53%) patients had discontinued IFX after a median follow-up of 19 months (IQR: 8-34).

IFX retention rate was 50% for mucocutaneous involvement, 43% for uveitis, 49% for vascular involvement, 58% for CNS involvement, 37% for arthritis, 53% for GI involvement, and 31% for venous ulcer (Table 1).

Table 1.

Drug survival of infliximab and reasons for infliximab discontinuation

Mucocutaneous involvement (n=10)Uveitis (n=164)Vascular (n=114)CNS (n=55)Arthritis (n=19)GIS (n=15)Venous ulcer (n=13)Male (n, %)3 (30)127 (77)89 (78)49 (89)14 (74)9 (60)12 (92)Age at infliximab initiation (mean ± SD years)35.8 ± 9.334 ± 9.936 ± 9.136.2 ± 10.439.6 ± 10.743 ± 14.137.4 ± 8.2Number of patients who used concomitant immunosuppressives (n, %)5 (50)108 (66)86 (75)38 (69)5 (26)11 (73)7 (54)Duration of infliximab use (mean ± SD months)33 ± 3845 ± 3828 ± 2337 ± 2837 ± 3526 ± 2625 ± 25Number of patients who discontinued infliximab (n, %)5 (50)93 (57)58 (51)23 (42)12 (63)7 (47)9 (69)Due to remission-30212121Due to primary inefficacy157---5Due to secondary inefficacy212545--Due to adverse event1231211541Due to noncompliance11113--2Due to other reasons-1212311-

Reasons for discontinuation were adverse events in 56 (15%), remission in 54 (15%) patients, inefficacy in 45 (12%) (secondary inefficacy in 26 (7%), primary inefficacy in 19 (5%)), and lack of patient compliance in 18 (5%). Other reasons were preparation for surgical operation (n=4), pregnancy (n=4), lack of health insurance (n=4), preferring subcutaneous administration during the pandemic (n=3), due to prison sentence (n=3), willing to get pregnant (n=1), rejecting the treatment (n=1), and death (n=3).

Adverse events (n=56) leading to the cessation of IFX were infusion reactions (n=22), infections (n=7), tuberculosis (n=6), malignancy (n=6), palmoplantar psoriasis (n=5), hepatotoxicity (n=4), lichen planus (n=1), drug induced lupus (n=1), auricular chondritis (n=1), macrophage activation syndrome (n=1), splenic infarction (n=1) and a decrease in left ventricular ejection fraction (n=1).

At the end of the follow-up, 2 patients had died due to lung adenocarcinoma, 1 patient had died due to pneumosepsis, 1 due to severe parenchymal neurologic involvement and 1 with pulmonary artery involvement due to massive hemorrhage during IFX treatment. Additionally, 7 patients had died 9, 10 months, 3, 3, 4, 7 and 9 years after IFX discontinuation. The causes of death were severe nervous system involvement in 2 patients, right heart failure due to pulmonary hypertension, laryngeal adenocarcinoma, lung adenocarcinoma, sepsis and gastrointestinal bleeding in 1 patient each.

Conclusion

IFX seems to be effective for the treatment of organ and life-threatening manifestations in the majority of the patients. However, drug retention rate was not optimal, mainly due to adverse events, inefficacy and patient non-compliance.

Disclosure of Interests

Sinem Nihal Esatoglu Speakers bureau: Sinem Nihal Esatoglu has received honorariums for presentations from UCB Pharma, Roche, Pfizer, and Merck Sharp Dohme, Beyza Tukek: None declared, Sitki Safa Taflan: None declared, Yilmaz Ozyazgan: None declared, Didar Ucar: None declared, Vedat Hamuryudan Speakers bureau: Vedat Hamuryudan has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma, Grant/research support from: Vedat Hamuryudan has received grant/research support from Celgene., Yesim Ozguler Speakers bureau: Yesim Ozguler has received honorariums for presentations from UCB Pharma, Novartis, and Pfizer., Emire Seyahi Speakers bureau: Emire Seyahi has received honorariums for presentations from Novartis, Pfizer, AbbVie, and Gliead, Melike Melikoglu: None declared, Ugur Uygunoglu Speakers bureau: Ugur Uygunoglu has received speaker fees from F Hoffmann La-Roche, F Hoffmann La-Roche, Bayer, Merck-Serono, Novartis, Teva, and Biogen Idec/Gen Pharma of Turkey, Consultant of: Ugur Uygunoglu has received advisory board honorariums from F Hoffmann La-Roche, F Hoffmann La-Roche, Bayer, Merck-Serono, Novartis, Teva, and Biogen Idec/Gen Pharma of Turkey, Aksel Siva Speakers bureau: Aksel Siva received honorariums from Teva for speaking engagements., Consultant of: Aksel Siva received honorariums from Bayer-Schering AG, Biogen/Gen Ilac of Turkey, Genzyme, Merck-Serono, and Roche for consulting, fees from Novartis as a consultant and advisory committee member,., Grant/research support from: Aksel Siva received travel and registration reimbursements from Genzyme., Zekayi Kutlubay: None declared, Izzet Fresko: None declared, Sebahattin Yurdakul: None declared, Hasan Yazici: None declared, Gulen Hatemi Speakers bureau: Gulen Hatemi has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma., Grant/research support from: Gulen Hatemi has received grant/research support from Celgene.

POS0814 OUTCOME OF VASCULAR INVOLVEMENT OF BEHÇET’S SYNDROME TREATED WITH INFLIXIMAB: A RETROSPECTIVE COHORT STUDY

Background

Vascular involvement is the most common cause of mortality and an important cause of disability in patients with Behçet’s syndrome (BS). Cyclophosphamide has been the treatment choice for severe vascular involvement, but high frequency of adverse events such as infertility and infections cause concern. TNF inhibitors can be an alternative for BS patients with vascular involvement.

Objectives

To survey the efficacy and safety of infliximab (IFX) in BS patients with arterial and venous vascular involvement.

Methods

We reviewed the charts of BS patients who used IFX for vascular involvement. We extracted data on demographic and clinical features, type of vascular involvement, laboratory tests, imaging modalities, concomitant immunosuppressives, duration of IFX use, and outcome. The primary endpoint was remission, defined as the presence of all of the following 3 parameters: 1) lack of new clinical symptoms/findings associated with the vascular lesion 2) normalization of CRP level defined as <10 mg/dl) 3) lack of worsening of the primary vascular lesion or a new lesion vascular at another site on imaging. Remission was assessed at month 6 and month 12. Secondary endpoints were relapse, overall disease activity assessed with BDCAF at baseline and at the final visit, development of new organ involvement other than vascular involvement during IFX treatment, severe adverse events leading to discontinuation of IFX therapy, hospitalization or death, and death.

Results

Among the 371 patients who used IFX between 2004 and June 2021, 127 patients (102 men, 25 women, mean age 40 ± 8.7 years) had used it for vascular involvement. The types of vascular involvement that required IFX were venous thrombosis in 61 patients (48%), pulmonary artery involvement in 37 (29%), non-pulmonary artery involvement in 16 (13%), and venous ulcer in 13 (10%). Remission rate was 72% (92/127) at month 6 and 61% (71/117) at month 12. 17/99 (17%) patients experienced 22 relapses during a mean follow-up of 28.4±21 months of IFX therapy. Among the 22 relapses, 12 were the progression of the pre-existing vascular lesion and 10 were new vascular lesions. Overall disease activity improved with a decrease in mean BDCAF score from 1.76 ± 1.27 to 0.6 ± 0.8 at the final visit (p<0.001). Remission and relapse rates according to type of vascular involvement and causes of IFX discontinuation are presented in the Table 1. Adverse events leading to IFX discontinuation were infusion reactions in 5, tuberculosis, disseminated zona, lung adenocarcinoma, fibromyxoid sarcoma, heart failure, SLE, palmoplantar pustulosis, auricular chondritis, and aortic stent graft infection in 1 patient each.

Table 1.

The frequency of concomitant immunosuppressive use, duration of infliximab use and outcomes of BS patients with vascular involvement treated with IFX

Venous thrombosis (n=61)Pulmonary artery involvement (n=37)Non-pulmonary arterial involvement (n=16)Venous ulcers (n=13)Overall (n=127)Number of patients who used concomitant immunosuppressives48 (79)24 (65)14 (87)7 (54)93 (73)Duration of IFX use (mean ± SD months)24 ± 19.725 ± 19.335 ± 29.626 ± 2425 ± 21Remission rate at month 650 (82)31 (84)10 (63)1 (8)92 (72)Remission rate at month 12a40 (70)21 (64)8 (53)2 (17)71 (60)Relapse rate4 (7)4 (11)9 (60)017 (13)Number of patients who discontinued IFX31 (51)23 (62)5 (31)9 (69)68 (54)Due to remission1560122Due to inefficacy313411Due to relapse10102Due to adverse event741113Due to noncompliance340310Due to new organ development10001Due to other reasonsb18009Death22004

a Since 10 patients did not reach the 12th month yet, the percentages were calculated on 117 patients.

b Other reasons were preparation for surgical operation (n=2), not wanting to come to the infusion frequently during the pandemic (n=2), pregnancy (n=1), willing to get pregnant (n=1), lack of health insurance (n=1), due to prison sentence (n=1), and death (n=1).

Conclusion

Infliximab may be beneficial in BS patients with vascular involvement, even in those who are refractory to immunosuppressives and corticosteroids.

Disclosure of Interests

Gulen Hatemi Speakers bureau: Gulen Hatemi has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma, Grant/research support from: Gulen Hatemi has received grant/research support from Celgene, Beyza Tukek: None declared, Sinem Nihal Esatoglu Speakers bureau: Sinem Nihal Esatoglu has received honorariums for presentations from UCB Pharma, Roche, Pfizer, and Merck Sharp Dohme., Yesim Ozguler Speakers bureau: Yesim Ozguler has received honorariums for presentations from UCB Pharma, Novartis, and Pfizer., Sitki Safa Taflan: None declared, Melike Melikoglu: None declared, Serdal Ugurlu: None declared, Izzet Fresko: None declared, Zekayi Kutlubay: None declared, Sebahattin Yurdakul: None declared, Hasan Yazici: None declared, Vedat Hamuryudan Speakers bureau: Vedat Hamuryudan has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma, Grant/research support from: Vedat Hamuryudan has received grant/research support from Celgene.

Post-COVID-19 vaccination inflammatory syndrome: A case report

A previously healthy 24-year-old male patient was referred to our clinic with bilateral lower extremity pain and dark urine, which were developed 2 weeks after receiving the second dose of the BNT162b2 vaccine against severe acute respiratory coronavirus 2. Laboratory tests indicated rhabdomyolysis. Lower extremity magnetic resonance imaging was compatible with myositis. Myositis-related antibodies were negative. Biopsy taken from gastrocnemius muscle revealed muscle necrosis and striking expression of major histocompatibility complex class I antigen. He was successfully treated, and his complaints were resolved. One week later at follow-up, he reported new-onset exertional dyspnoea with palpitations. ST-segment depressions were spotted on electrocardiography. Troponin T was found elevated as 0.595 ng/ml (normal <0.014 ng/ml). Echocardiography showed a hypokinetic left ventricle with an ejection fraction of 40% and pericardial effusion of 2 mm. An appropriate treatment plan was formulated for the diagnosis of myocarditis, eventually, the patient recovered within 10 days. The BNT162b2 messenger ribonucleic acid (mRNA) vaccine was felt to cause the aforementioned condition since no other aetiology could be identified. Although it is known that BNT162b2 may induce myocarditis, myositis concomitant myocarditis appears to be a very rare adverse effect of this vaccine.

Emergence of New Manifestations During Infliximab Treatment in Behçet Syndrome

OBJECTIVES

Infliximab (IFX) is being increasingly used for the treatment of severe manifestations of Behçet syndrome (BS). However, emergence of new manifestations has also been occasionally reported during IFX treatment. We aimed to assess the frequency of new manifestations in our BS patients treated with IFX.

METHODS

A chart review was conducted to identify all BS patients treated with IFX in our clinic between 2004 and 2020. Demographic data, indications for IFX initiation, concomitant treatments, and outcomes were recorded. A new manifestation was defined as the emergence of a new organ involvement or mucocutaneous manifestation developing for the first time during IFX treatment or within 12 weeks after the last infusion of IFX.

RESULTS

Among our 282 patients who used IFX, 19 (7%) patients had developed a total of 23 new manifestations during a mean follow up of 20.0 ± 15.3 months. Patients with vascular involvement were more likely to develop a new manifestation (12/19, 63%). Initial manifestations that required IFX were in remission at the time of new manifestation in 14/19 patients. IFX treatment was intensified (n = 6) and/or glucocorticoids, immunosuppressives, or colchicine were added to IFX (n = 21). IFX was switched to another agent for the remaining manifestations (n = 8). These treatment modifications led to remission in 17/19 patients.

CONCLUSION

New manifestations developed during IFX treatment in 7% of our patients with BS. They could be managed by intensifying IFX treatment or adding other agents in majority of these manifestations.

The incidence, clinical characteristics, and outcome of COVID-19 in a prospectively followed cohort of patients with Behçet's syndrome

Initial case series of small number of patients at the beginning of the pandemic reported a rather guarded prognosis for Behçet’s syndrome (BS) patients infected with SARS-CoV-2. In this prospective study, we describe the incidence, clinical characteristics, disease course, management, and outcome in a large cohort of BS patients with laboratory-confirmed infection of SARS-CoV-2. We defined a cohort of 1047 registered BS patients who were aged between 16 and 60 years and seen routinely before the pandemic at the multidisciplinary outpatient clinic. We followed prospectively this cohort from beginning of April 2020 until the end of April 2021. During 13 months of follow-up, of the 1047 (599 M/448 F) patients, 592 (56.5%) were tested for SARS-CoV-2 PCR at least once and 215 (20.5%; 95% CI 0.18–0.23) were tested positive. We observed 2 peaks which took place in December 2020 and April 2021. Of the 215 PCR positive patients, complete information was available in 214. Of these 214, 14 (6.5%) were asymptomatic for COVID-19. In the remaining, the most common symptoms were anosmia, fatigue, fever, arthralgia, and headache. A total of 40 (18.7%) had lung involvement, 25 (11.7%) were hospitalized, 1 was admitted to the intensive care unit while none died. Favipiravir was the most prescribed drug (74.3%), followed by colchicine (40.2%), and hydroxychloroquine (20.1%) in the treatment of COVID-19. After COVID-19, 5 patients (2.3%) were given supplemental O₂ and 31 (14.5%) antiaggregant or anticoagulants. During COVID-19, of the 214 PCR positive patients, 116 (54.2%) decreased the dose of their immunosuppressives or stopped taking completely; 36 (16.8%) experienced a BS flare which was mostly oral ulcers (10.3%). None of the patients reported a thrombotic event. A total of 93 (43.5%) patients reported BS flares after a median 45 days of COVID-19 infection and this was found to be significantly associated with immunosuppressive drug discontinuation. Multiple regression analysis adjusted for age and gender indicated that smoking and using interferon-alpha decreased the likelihood of getting COVID-19. The incidence and severity of COVID-19 did not differ between those who were using colchicine or not. The cumulative incidence of COVID-19 in this prospectively followed cohort of BS patients was almost two folds of that estimated for the general population living in Istanbul, Turkey, however, the clinical outcome of COVID-19 was not severe and there was no mortality. The protective effect of smoking and interferon deserves further investigation. On the other hand, colchicine did not have any positive or negative effect against COVID-19. Significant number of patients flared after COVID-19, however, this was significantly associated with immunosuppressive discontinuation during the infection. Contrary to our previous observations, COVID-19 did not seem to exacerbate thrombotic events during or after the infection.

POS0828 CONSISTENT EFFICACY WITH APREMILAST IN MEN AND WOMEN TO TREAT ORAL ULCERS ASSOCIATED WITH BEHÇET’S SYNDROME: PHASE 3 RELIEF STUDY RESULTS

Background:

Painful, recurring oral ulcers (OU) associated with Behçet’s syndrome negatively affect quality of life (QoL). Differences across sexes were reported in the frequency of disease manifestations, disease course, and response to colchicine. The phase 3, randomized, double-blind, placebo (PBO)-controlled RELIEF study showed overall efficacy of apremilast (APR) for OU associated with Behçet’s syndrome, including improvements in OU pain, disease activity, and QoL.

Objectives:

To evaluate the consistency of efficacy with APR in men and women with Behçet’s syndrome.

Methods:

Adults with active Behçet’s syndrome and ≥3 OU at randomization or ≥2 OU at screening and randomization, without active major organ involvement, were randomized to APR 30 mg BID or PBO during the 12-wk PBO-controlled phase. Randomization was stratified by sex. The primary endpoint was area under the curve for the number of OU through Wk 12 (AUCWk0-12) to assess continued efficacy over the time period in a symptom that waxed and waned. Key secondary endpoints included OU pain, complete response (OU-free), maintenance of complete response, and QoL at Wk 12. Disease activity was also assessed using Behçet’s Syndrome Activity Score (BSAS) and Behçet’s Disease Current Activity Index Form (BDCAF). QoL was assessed using Behçet’s Disease QoL (BDQoL). Prespecified subgroup analyses in men and women were performed to assess treatment effect in primary and secondary endpoints.

Results:

Eighty men and 127 women were randomized and received ≥1 dose of study medication. Mean age was 38.7 yrs (men) and 40.8 yrs (women). Mean (SD) OU count at baseline was 3.4 (1.4) (PBO) and 3.7 (1.5) (APR) for men and 4.3 (3.2) (PBO) and 4.5 (4.5) (APR) for women. Greater improvements in favor of APR vs PBO were observed in AUCWk0-12 in men and women (Figure 1). Consistency in efficacy with APR was observed between men and women, with greater reduction in pain and achievement of OU complete response (OU-free) and maintenance of response at Wk 12 vs PBO (Table 1). In men and women, consistent treatment effects in favor of APR vs PBO were observed for disease activity and QoL measures, although moderate treatment differences were observed in BDCAI (men/women) and BDQoL (men) (Table 1).

Conclusion:

Consistent treatment effects in favor of APR vs PBO in clinically relevant outcomes, including OU number and pain, OU complete response, and disease activity measures, were observed in men and women with OU associated with Behçet’s syndrome.

Key Secondary Efficacy Outcomes at Wk 12MenWomenPBO(n = 40)APR(n = 40)Tx Difference[95% CI]PBO(n = 63)APR(n = 64)Tx Difference[95% CI]OU CR, n/N (%)8/40 (20.0)21/40 (52.5)32.6 [12.8, 52.4]15/63 (23.8)34/64 (53.1)29.3 [13.2, 45.4]OU CR 6 + 6*, n/N (%)1/40 (2.5)10/40 (25.0)22.8 [8.8, 36.8]4/63 (6.3)21/64 (32.8)26.5 [13.6, 39.3]Pain (VAS)†-12.0 (4.8)-37.6 (4.9)-25.6 [-37.2, -14.1]-17.4 (4.4)-41.5 (4.3)-24.1 [-34.9, -13.3]BSAS†-1.3 (2.4)-14.4 (2.4)-13.1 [-18.8, -7.3]-7.7 (2.4)-19.7 (2.4)-12.0 [-18.0, -6.0]BDCAF†BDCAI-0.1 (0.3)-0.5 (0.3)-0.4 [-1.1, 0.4]-0.7 (0.3)-1.3 (0.3)-0.6 [-1.2, 0.0]Patient’s Perception of Disease Activity-0.2 (0.3)-1.4 (0.3)-1.2 [-1.9, -0.5]-1.0 (0.2)-1.8 (0.2)-0.9 [-1.4, -0.3]Clinician’s Overall Perception of Disease Activity-0.2 (0.3)-1.5 (0.3)-1.3 [-1.9, -0.7]-1.0 (0.2)-1.7 (0.2)-0.7 [-1.3, -0.2]BDQoL†-0.7 (1.0)-2.2 (1.0)-1.5 [-3.8, 0.8]-0.3 (0.9)-4.4 (0.9)-4.1 [-6.3, -2.0]

LOCF analyses. *Proportion of patients achieving an OU CR by Wk 6, and remaining OU-free for ≥6 additional wks during the 12-wk PBO-controlled treatment phase. †LS mean (SE) change from baseline. BSAS = Behçet’s Syndrome Activity Scores; BDCAF = Behçet’s Disease Activity Form; CR = complete response; n = number of patients randomized to treatment; Tx = treatment.

Acknowledgements:

This study was funded by Celgene. Additional analyses were funded by Amgen Inc. Writing support was funded by Amgen Inc. and provided by Kristin Carlin, RPh, MBA, of Peloton Advantage, LLC, an OPEN Health company.

Disclosure of Interests:

Gulen Hatemi Speakers bureau: AbbVie, Novartis, and UCB, Grant/research support from: Celgene, Alfred Mahr Speakers bureau: Chugai and Roche, Consultant of: Celgene and Chugai, Mitsuhiro Takeno Speakers bureau: AbbVie, Esai, and Mitsubishi-Tanabe, Consultant of: Celgene, Grant/research support from: Novartis, Doyoung Kim: None declared, Melike Melikoglu: None declared, Sue Cheng Employee of: Amgen Inc., Sven Richter Employee of: Amgen Inc., Shauna Jardon Employee of: Amgen Inc., Maria Paris Employee of: Amgen Inc., Mindy Chen Employee of: Amgen Inc., Yusuf Yazici Consultant of: Bristol-Myers Squibb, Celgene, Genentech, and Sanofi

POS0819 EMERGENCE OF DE NOVO MANIFESTATIONS DURING INFLIXIMAB TREATMENT IN BEHÇET SYNDROME

Background:

Infliximab (IFX) is increasingly used in the management of severe, relapsing or refractory manifestations of Behçet Syndrome (BS). Emergence of de novo manifestations have been reported during IFX treatment, despite efficacy for the initial manifestation that required IFX use1.

Objectives:

We aimed to survey a sizeable cohort of BS patients treated with IFX for the development of de novo manifestations during treatment.

Methods:

A chart review was conducted to identify all BS patients who were given IFX in our Behçet Disease Research Center between 2004 and 2020. Demographic data, indications for IFX initiation, concomitant drugs, prior treatments, and outcomes were recorded. De novo manifestations were defined as new BS manifestations that had not occurred before IFX treatment.

Results:

A total of 252 patients used IFX with the main indications being uveitis in 122, vascular involvement in 82, parenchymal central nervous system involvement in 32, gastrointestinal involvement in 11, arthritis in 10, mucocutaneous involvement in 4, and secondary amyloidosis in 1. Of these patients, 17 (6%) had developed a total of 21 de-novo manifestations during a mean follow-up of 38.4 ± 92 (SD) months (Table 1). Vascular involvement was the main indication for IFX in the majority (n=12; 71%) of these 17 patients followed by eye involvement (n=3; 18%), central nervous system involvement (n=1), and joint involvement (n=1). Concomitant medications were prednisolone in 14 patients, azathioprine in 6 patients, mycophenolate mofetil, cyclosporine-A and methotrexate in 1 patient each. Thirteen patients (76%) were in remission for the main indication when de-novo manifestations emerged. In 10 patients IFX treatment was intensified either by increasing the dose to 10 mg/kg (2 patients) or by shortening the infusion intervals to 4 weeks (2 patients) along with the addition of corticosteroids or immunosuppressives. In the remaining 7 patients IFX was switched to another agent (cyclophosphamide in 5, adalimumab in 1 and anakinra in 1). At the time of this survey 8/17 patients were still on IFX for a mean follow-up of 32.5 ± 24.6 (SD) months, with concomitant low dose prednisolone in 5, azathioprine in 3 and mycophenolate mofetil in 3. In addition to the 7 patients who discontinued IFX at the time of de-novo manifestations, 2 more patients had discontinued IFX due to allergic reactions.

Conclusion:

De novo manifestations developed during IFX treatment in 6% of BS patients, despite efficacy for the initial manifestation. Appearance of de novo manifestations mostly in patients with vascular involvement is noteworthy. Intensification of IFX treatment was efficacious in managing de novo manifestations in more than half of these patients.

References:

[1]Hamuryudan V et al. Semin Arthritis Rheum. 2015;45(3):369-73.

Table 1.

Distribution of de novo manifestations that have emerged in 17 patients

De-novo manifestations21Pulmonary artery aneurysm1Pulmonary artery thrombosis2Coronary artery involvement3Superficial thrombophlebitis5Arthritis5Erythema nodosum3Gastrointestinal involvement1Central nervous system involvement1

Disclosure of Interests:

None declared

POS0814 DRUG RETENTION RATE, REASONS FOR DISCONTINUATION AND OUTCOME OF INFLIXIMAB USE IN BEHÇET SYNDROME

Background:

Infliximab (IFX) plays a key role in the management of severe and refractory manifestations of Behçet syndrome (BS). However we had previously shown that its sustained use may be limited due to adverse events and lack of patient compliance (1).

Objectives:

To assess the retention rate of IFX, adverse events, causes of discontinuation and outcome after cessation of IFX in a larger group of BS patients who were followed in a tertiary center.

Methods:

The charts of BS patients who were prescribed IFX between 2004 and 2020 were reviewed to determine demographic features, reasons for IFX use, previous and concomitant drugs, IFX duration, reasons for cessation of IFX and time to flare following cessation of IFX. Follow-up was censored on March 2020.

Results:

A total of 252 patients (195 men, mean age 40±10 years) received IFX for uveitis (n=122), vascular involvement (n=82), parenchymal neurologic involvement (n=32), gastrointestinal involvement (n=11), arthritis (n=10), mucocutaneous involvement (n=4), and secondary amyloidosis (n=1). Ten patients had more than 1 involvement requiring IFX.

During a median follow-up of 52 (IQR: 30-88) months, 122 (48%) patients were still receiving IFX for a median period of 33 (IQR: 15-56) months while 130 (52%) patients had discontinued IFX after a median follow-up of 17 (IQR: 7-31) months. Reasons for discontinuation were remission in 25 (19%) patients, adverse events in 39 (30%), lack of efficacy in 23 (18%) (4 primary and 19 secondary), lack of patient compliance in 36 (28%), pregnancy in 4, and preparation for surgery in 3 patients.

Adverse events (n=39) that required the cessation of IFX were infusion reaction (n=17), infection (n=7), hepatotoxicity (n=4), malignancy (n=4), palmoplantar psoriasis (n=3), lichen planus (n=1), drug induced lupus (n=1), splenic infarction (n=1), and a decrease in left ventricular ejection fraction (n=1).

Among the 25 patients who discontinued IFX due to remission, 5 (20%) had a relapse after 4, 21, 26, 29, 38 and 46 months. The remaining patients did not experience a relapse during a median follow-up of 35 (IQR: 24-68) months.

At the end of the follow-up, 2 patients had died due to lung adenocarcinoma during IFX treatment and 3 patients had died 1 year, 3 and 8 years after IFX discontinuation. The causes of death were with right heart failure due to pulmonary hypertension in 1, and severe nervous system involvement in 2 of the patients.

Conclusion:

Despite its successful use for the management of potentially organ and life-threatening manifestations in more than half of our patients with BS, long term maintenance was not possible in 42%, mainly due to adverse events, lack of patient compliance and inefficacy.

Reference:

[1]Esatoglu SN, Tukek B, Taflan SS, et al. SAT0258 Drug Retention Rate and Prognosis After Discontinuation of Infliximab in Patients with Behçet Syndrome. Annals of the Rheumatic Diseases 2020;79: 1071-1072.

Reasons for infliximab treatmentNo of patientsNo (%) of patients who were still receiving infliximabNumber (%) of patients who discontinued infliximabReasons for discontinuationDuration of infliximab use(median (IQR) months)Eye involvement12259 (48)63 (52)Remission (n=17)Inefficacy (n=10)Lack of patient compliance (n=19)Adverse event (n=12)Others (n)=5)28 (12.5-52)Vascular involvement8240 (49)42 (51)Remission (n=10)Inefficacy (n=7)Lack of patient compliance (n=12)Adverse event (n=12)Others (n=4)18.5 (9-33.5)Parenchymal neurologic involvement3221 (66)11 (34)Adverse event (n=8)Inefficacy (n=2)Lack of patient compliance (n=1)25 (14.5-50)Gastrointestinal involvement114 (36)7 (64)Remission (n=1)Inefficacy (n=1)Adverse event (n=2)Lack of patient compliance (n=4)7 (2-17)Joint involvement102 (20)8 (80)Inefficacy (n=1)Adverse event (n=5)Lack of patient compliance (n=2)20 (4-35)Mucocutaneous involvement431Inefficacy (n=1)6, 10, 12, 104 monthsAA amyloidosis101Inefficacy (n=1)6 years

Disclosure of Interests:

None declared

POS0820 INFLIXIMAB FOR VASCULAR INVOLVEMENT IN BEHÇET SYNDROME

Background:

Vascular involvement is an important cause of morbidity and mortality in patients with Behçet syndrome (BS). TNF inhibitors have been reported to be effective for almost all serious manifestations of BS but data on vascular involvement is still limited.

Objectives:

To survey the efficacy and safety of infliximab (IFX) in BS patients with vascular involvement followed in a dedicated tertiary center.

Methods:

We reviewed the charts of all BS patients who used IFX and identified those who used this drug for vascular involvement. A standard form was used for extracting data on demographic and clinical features, type of vascular involvement, concomitant immunosuppressives, duration of IFX use, relapses, adverse events and outcome.

Results:

83 patients (67 men, 16 women, mean age 39.5 ± 8.4 SD years) had used IFX for vascular involvement. The number of patients with each type of vascular involvement as the main indication for IFX, and previous treatment modalities right before IFX are presented in the Table 1. 33 patients had more than 1 type of vascular lesion. Additional organ manifestations were eye involvement in 32, central nervous system involvement in 4 and gastrointestinal involvement in 3 patients. All but one patient used IFX at a dose of 5 mg/kg every 6-8 weeks. All patients used concomitant prednisolone and 51 received pulse methylprednisolone during induction. Other concomitant medications were azathioprine in 21 and mycophenolate mofetil in 4 patients. Outcome of IFX treatment at the end of a mean follow-up of 25.9 months (range 1-103) is tabulated according to arterial and venous involvement (Table 1). Overall, 57/83 (68%) patients obtained remission with no further relapses and IFX could be stopped in 12 (14%) of them. IFX was discontinued due to adverse events in 15 patients. These were allergic reactions in 8, tuberculosis, disseminated zona, lung adenocarcinoma, fibromyxoid sarcoma, heart failure, systemic lupus erythematosus, and palmoplantar pustulosis in 1 patient each. Three patients had died. Causes of death were lung adenocarcinoma in one patient and pulmonary hypertension related right heart failure due to pulmonary artery thrombosis in 2 patients.

Conclusion:

Infliximab seems to be beneficial in Behçet syndrome patients with vascular involvement, even in those who are refractory to immunosuppressives and corticosteroids. No further relapses occurred in 68% of the patients, and adverse events leading to discontinuation were observed in 18%.

Arterial Involvement (n=36)Venous Involvement (n=47)Main reason for infliximab usePulmonary artery aneurysm and/or thrombosis, n=29Peripheral artery aneurysm, n=4Aortic aneurysm, n=3Vena cava superior and/or inferior thrombosis, n=5Lower extremity DVT, n=24Budd-Chiari syndrome, n=4Intracardiac thrombosis, n=2Dural sinus thrombosis, n=7Leg ulcer, n=5Previous treatmentFirst line infliximab413Corticosteroids3438Cyclophosphamide (CYC)25 (15/25 refractory to CYC; 10/25 for maintenance after CYC)11 (8/11 refractory to CYC; 3/11 for maintenance after CYC)Interferon-alpha-13Azathioprine2117Mycophenolate Mofetil12Cyclosporine A-2None due to non-compliance21OutcomeRemission, still on infliximab1623Discontinued due to remission48Discontinued due to adverse events59Discontinued due to relapse53Discontinued due to non-compliance53Died2 (1 had previously discontinued due to relapse)1

Disclosure of Interests:

None declared

POS1351 CAUSES OF HOSPITALIZATION IN BEHÇET SYNDROME

Background:

The causes of hospitalization may provide important information on the course of diseases and treatment-related adverse effects.

Objectives:

We aimed to determine the causes and outcome of hospitalizations among patients with Behçet Syndrome (BS) in a dedicated center.

Methods:

We surveyed hospitalization records in our clinic between January 2002 and December 2019 and identified those with a diagnosis of BS. The records of these patients were reviewed for demographic and clinical features, causes of hospitalization and outcome. We divided hospitalization causes into 2 as being BS related (organ involvement or deterioration) and non-BS related (treatment complication or others).

Results:

Three-hundred and thirty BS patients (75% men, mean age 37.7 ±11.4 SD years) were hospitalized for a total of 456 times during 18 years. The mean disease duration was 10.8± 8.8 SD years. Two-hundred and ninety-one (64%) patients were using immunosuppressives (IS) with or without corticosteroids (CSs) and 72 (16%) of them were under biologic treatment at the time of hospitalization. The mean duration of hospitalization was 12.7±10.7 SD days. The reasons for hospitalization were directly related to BS in 259 patients (57%) and non-related to BS in 191 (42%). Six patients were hospitalized for both BS and non-BS related reasons at the same time. The most common reasons were vascular involvement (n=169, 64%) for BS related reasons and infections (n=64, 32%) for non-BS related reasons (Table 1). Patients hospitalized for BS related causes were younger (35.2±10.6 vs 41.1±11.7, p<0.001), had short mean disease duration (8.5±7.5 vs. 13.6±9.4 years, p<0.001), stayed shorter in the hospital (11.6±8.6 vs 14.0±12.9 days p=0.03) and had less frequent IS±CSs use (59% vs 70%, p=0.02) compared to those with non-BS related hospitalizations. There were no differences between the groups regarding gender distribution (203 M/62 F vs. 143 M/54 F) and use of biologic agents (15% vs 17%). Three patients died during hospitalization. The reasons were malignancy, infection and right heart failure due to pulmonary artery thrombosis and pulmonary hypertension, respectively.

Conclusion:

Vascular involvement is the leading cause of hospitalization among BS patients, followed by infections. The predominance of men among hospitalized patients underlines the relatively severe course of BS in men. The retrospective design and inclusion of patients who were hospitalized only in the rheumatology unit are limitations of this study.

Table 1.

Distributions of BS related and non-BS related reasons of hospitalizations

BS patients hospitalized with BS related reasons(n of pts=195, n of hospitalizations=265)*BS patients hospitalized with non-BS related reasons(n of pts=170, n of hospitalizations=197)*Causes of hospitalizations (per hospitalization)Vascular inv. (n=169, 64 %)Pulmonary artery inv. (n=64, 24 %)Deep vein thrombosis (n=39, 15 %)Budd-Chiari synd. (n=24, 9%)Vena cava inf. thrombosis (n=19, 7 %)Peripheral artery inv. (n=15, 6 %)Vena cava sup. thrombosis (n=14, 5 %)Aorta inv. (n=14, 5%)Coronary artery inv. (n=4, 2 %)Infection (n=64, 32%)Pneumonia (n=17, 8%)Tuberculosis (n=8, 4%)Urinary tract inf (n=7, 4%)Gastroenteritis (n=4, 2%)Osteomyelitis (n=3, 2%)Septic arthritis (n=3, 2%)Aspergillosis (n=2, 1%)Nocardia (n=1, 1%)Salmonella (n=1, 1%)Others (n=18, 9%)Neurologic inv. (n=50, 19 %)Parenchymal inv. (n=37, 14%)Dural sinus thrombosis (n=13, 5%)Drug side effects other than infections (n=29, 15 %)Interferon (n=10, 5%)Azathioprine (n=7, 4%)Cyclosporine (n=5, 3%)Steroid (n=3, 2%)TNF antagonists (n=3, 2%)IVIG (n=1, 1%)GI inv. (n=18, 7%)Additional rheumatologic diseases (n=17, 9%)Joint inv. (n=12, 5%)Renal disease (n=16, 8 %)Mucocutaneous inv. (n=10, 4%)Cardiovascular dis. (n=12, 6%)Eye inv. (n=8, 3%)Avascular necrosis (n=4, 2%)Others (n=8, 3%)Malignancy (n=11, 6%)Others (n=40, 20%)

*Some patients were hospitalized more than one times and for both BS related and non-BS related reasons at different time and had more than one type of BS related and/or non-BS related reasons.

Disclosure of Interests:

None declared

POS0254 EFFICACY OF APREMILAST IN THE TREATMENT OF ORAL ULCERS OF BEHÇET’S SYNDROME: RESULTS FROM THE EUROPEAN SUBGROUP OF RELIEF

Background:

Behçet’s syndrome, a chronic, multi-system variable vessel vasculitis, is often characterized by painful oral ulcers (OU) affecting quality of life (QoL). Apremilast (APR), an oral PDE4 inhibitor, demonstrated efficacy in OU treatment in the phase 3 multinational RELIEF study.

Objectives:

To evaluate APR efficacy in OU treatment in patients with active Behçet’s syndrome in a prespecified subgroup of patients enrolled in 13 European RELIEF sites (France, Germany, Greece, and Italy).

Methods:

patients were adults with active Behçet’s syndrome and ≥3 OU at randomization or ≥2 OU at screening and randomization, without active major organ involvement. Patients were randomized (1:1) to APR 30 mg BID or PBO during a 12-week double-blind phase. The primary endpoint was area under the curve for the number of OU through Week 12 (AUCWk0-12). Other outcomes were OU pain visual analog scale (VAS); achievement of OU complete response (ie, OU-free) and maintenance of OU complete response (ie, complete response at Week 6 and remaining OU-free for ≥6 additional weeks); OU partial response (ie, OU reduction ≥50%); disease activity (Behçet’s Syndrome Activity Score [BSAS]; Behçet’s Disease Current Activity Form [BDCAF], including Behçet’s Disease Current Activity Index [BDCAI], and Patient’s and Clinician’s Perception of Disease Activity); and QoL (BDQoL; Short Form Health Survey version 2 [SF-36v2], including Physical Functioning [PF] scale and Physical and Mental Component Summary [PCS, MCS]).

Results:

Of 207 patients randomized and treated in RELIEF, 52 were in the European subgroup. Mean (±SD) age in the subgroup was 39 (±12) years; 54% were women. Baseline disease characteristics were similar between treatment groups (Table 1). Patients receiving APR achieved lower AUCWk0-12 for OU vs PBO (Figure 1) and greater reduction in pain. A greater proportion of patients receiving APR achieved complete, maintained, or partial OU responses at Week 12 vs those receiving PBO (Table 1). Consistent treatment effects favoring APR vs PBO were observed in disease activity, as shown by BSAS and BDCAF component scores at Week 12 (Table 1). Greater improvement in SF-36v2 MCS was observed favoring APR vs PBO at Week 12, and moderate treatment differences were seen for other QoL measures (BDQoL, SF-36v2 PF, and SF-36v2 PCS).

Conclusion:

In the European subgroup of patients with Behçet’s syndrome and OU in RELIEF, APR resulted in greater reduction in OU count, OU pain, and disease activity as well as favorable treatment effect on QoL measures than PBO. These results are consistent with the efficacy of APR treatment in the overall RELIEF population.

Baseline Disease Characteristics, Mean*PBO (n = 27)APR (n = 25)Duration of BD, years9.08.2OU count3.84.0OU pain (VAS 0-100)60.664.2BSAS (0-100)38.741.4BDCAI (0-12)3.53.6BDQoL (0-30)10.59.0Efficacy Outcomes at 12 Weeks*PBO (n = 27)APR (n = 25)Treatment Difference [95% CI]OU pain (VAS 0-100), mean†–17.7–48.7–31.0 [–44.7, –17.3]OU complete response, n (%)‡4 (14.8)16 (64.0)51.5 [29.8, 73.3]OU maintained response, n (%)‡1 (3.7)8 (32.0)26.7 [7.4, 46.0]OU partial response, n (%)‡11 (40.7)21 (84.0)46.0 [23.9, 68.0]BSAS (0-100)†,§–5.23–20.68–15.5 [–22.6, –8.3]BDCAI (0-12)†,§–0.0–1.4–1.4 [–2.2, –0.6]Patient’s Perception of Disease Activity†,§–0.4–1.6–1.2 [–2.1, –0.4]Clinician’s Overall Perception of Disease Activity†,§−0.6−1.7–1.0 [–1.7, –0.4]BDQoL (0-30)†,§–1.25–2.37–1.12 [–3.8, 1.5]SF-36v2 MCS (0-100)†,§–2.14.26.3 [2.2, 10.4]

*ITT population.†LS mean of the change from baseline at Week 12.‡Non-responder imputation for missing data.§LOCF approach. All efficacy endpoints (except BDQoL) were significant at the level of P<0.05.

Acknowledgements :

This study was funded by Celgene. Additional analyses were funded by Amgen Inc. Writing support was funded by Amgen Inc. and provided by Kristin Carlin, RPh, MBA, of Peloton Advantage, LLC, an OPEN Health company.

Disclosure of Interests:

Alfred Mahr Speakers bureau: Chugai; Roche, Consultant of: Celgene; Chugai, Gulen Hatemi Speakers bureau: AbbVie, Novartis, and UCB, Grant/research support from: Celgene, Mitsuhiro Takeno Speakers bureau: AbbVie, Esai, and Mitsubishi-Tanabe, Consultant of: Celgene, Grant/research support from: Novartis, Doyoung Kim: None declared, Melike Melikoglu: None declared, david Saadoun Consultant of: AbbVie, Celgene, Janssen, and Roche, Grant/research support from: AbbVie and Roche, Christos C. Zouboulis Speakers bureau: Amgen, Galderma, Pierre Fabre, PPM and Sobi, Consultant of: AbbVie, AccureAcne, Almirall, Bayer Healthcare, GSK/Stiefel, Incyte, Inflarx, Janssen, Novartis, PPM, Regeneron, and UCB, Grant/research support from: Celgene, NAOS-BIODERMA, and Relaxera, Sue Cheng Employee of: Amgen Inc, Sven Richter Employee of: Amgen Inc, Shauna Jardon Employee of: Amgen Inc, Maria Paris Employee of: Amgen Inc, Mindy Chen Employee of: Amgen Inc, Yusuf Yazici Consultant of: Bristol-Myers Squibb, Celgene, Genentech, and Sanofi

AB0364 DO PATIENTS PARTICIPATING IN MEETINGS REPRESENT THE ACTUAL PATIENT POPULATION IN BEHÇET SYNDROME?

Background:

The importance of patient involvement in healthcare research is increasingly emphasized. Patients participate as research partners in designing studies and development of management recommendations, measurement tools and outcome measures. However, ensuring representation of the general patient population by specific patient groups may be challenging for multisystem diseases with heterogenous phenotype.

Objectives:

We aimed to evaluate whether patients with Behcet syndrome (BS) participating in a patient convention represent the actual patient population attending the clinic.

Methods:

A questionnaire was applied to 104 BS patients (Meeting group) attending the patient convention which was held during the Cerrahpasa Behcet Disease Symposium in Istanbul in February 2020. Patients had been invited to the convention through posters, advertisement on our website and social media. The questionnaire was conducted with a keypad given to the patients and it consisted of 21 items including age, gender, education level, working status, disease duration, BS manifestations, and treatment. The same questionnaire was filled by 97 consecutive patients (Clinic group) who attended our rheumatology outpatient clinic for their routine controls. Chi-square test was used to compare the groups.

Results:

Table 1 shows demographic and disease characteristics of the patient groups. The groups were similar in terms of sex and education level. There were more men in both groups, probably reflecting the more severe disease course among men in BS. There were significantly more patients who were >40 years of age and had a disease duration more than 20 years in the Meeting group. Although there were more patients who had a job in Clinic group, the difference was not significant. Central nervous system involvement, vascular involvement, genital ulcers, erythema nodosum, and arthritis were significantly more common in patients in the Meeting group compared with those in the Clinic group. The frequency of eye involvement, gastrointestinal involvement and papulopustular lesions were similar in the two groups. Cyclophosphamide use was significantly more common in Meeting group compared to the Clinic group.

Table 1.

Demographics, clinical characteristics, and treatments

Meeting Group(n=104)(n/N, %) Clinic Group(n=97)(n, %)POral aphthous ulcers 88/97(91)94(97)0.13Genital ulcers86/104(83)68(70)0.045 Erythema nodosum77/103(75)47(48)0.0003 Papulopustular skin lesions 69/103(67)75(77)0.09Arthritis78/102(77)46(47)<0.0001Eye involvement51/103(50)53(55)0.48Vascular involvement42/98(43)25(26)0.036CNS involvement14/103(14)2(2)0.016GI involvement14/97(14)6(6)0.10Prednisolone - still using30/104(29)34(35)0.37Prednisolone - ever used88/104 (85)72(74)0.08Colchicine - still using43/100 (43)46(47)0.57Colchicine - ever used86/100(86)74(76)0.10AZA - still using45/100 (45)41(42)0.77AZA - ever used81/100 (81)74(76)0.49 CYC - still using1/96(1)0(0)NSCYC - ever used16/96(17)7(7)0.048bDMARDs - still using20/101(20) 26(27) 0.31bDMARDs - ever used28/101(28)32(33) 0.44

* Adjusted P-values by Bonferroni correction were <0.001.

BS: Behcet Syndrome, CNS: Central nervous system, GI: Gastrointestinal, AZA: Azathioprine, CYC: Cyclophosphamide; bDMARDs: Biologic disease-modifying anti-rheumatic drugs; NS: non-significant

Conclusion:

Patients in the Meeting group had more severe disease compared to the Clinic group. Patients with all types of involvement were adequately represented in the Meeting group.

Disclosure of Interests:

None declared

Long term follow-up of Behçet's syndrome patients treated with cyclophosphamide

OBJECTIVES

CYC remains an important treatment option for Behçet's syndrome (BS) patients with life-threatening manifestations. However, adverse events may occur with CYC and this has led to increased use of biologic agents in other vasculitides. We investigated short and long term adverse events associated with CYC use in BS patients.

METHODS

We conducted a retrospective chart review of all BS patients treated with CYC between 1972 and 2006. Patients were called in and a standard form was used for collecting demographic characteristics, indication for CYC, its cumulative dose and short term adverse events, defined as those causing discontinuation of CYC, hospitalization and/or death, long term adverse events, including infertility and malignancy, and outcome.

RESULTS

Of 5790 BS patients, 198 (3.4%) had used at least one dose of CYC. Main indications were vascular or neurological involvement. After a median follow-up of 17 years, 52 (26%) patients had died, 113 (57%) could be contacted, and 33 (17%) were lost to follow-up. Vascular involvement was the leading cause of death (n = 27). Seventeen (9%) patients experienced short term adverse events with haemorrhagic cystitis being the most common. After a median follow-up of 25 years (interquartile range: 15-26 years), 17 malignancies occurred in 15 (8%) patients. Infertility was experienced by 26 (30%) patients.

CONCLUSION

Long term adverse events such as malignancy and infertility were major problems in our BS patients treated with CYC. These results underline the need for safer treatment modalities that are at least as effective as CYC.

Clinical course of acute deep vein thrombosis of the legs in Behçet's syndrome

OBJECTIVES

Lower extremity deep vein thrombosis (LEDVT) is a serious complication of Behçet's syndrome. Management constitutes mainly of administration of immunosuppressives, but the predictors of relapse and the optimal choice of immunosuppressives remain unclear. In this prospective study, we aimed to detect the risk and predictors of relapse and treatment response to different modalities.

METHODS

All Behçet's syndrome patients who presented with a first episode of acute LEDVT between 2010 and 2014 were prospectively followed with a standard protocol. Acute LEDVT was confirmed by Doppler ultrasonography. Serial planned Doppler ultrasonography assessments were performed during follow-up and additionally repeated in case of clinical suspicion. Recanalization rate was assessed at each visit. Our first-line treatment strategy consisted of AZA and CSs. IFN-alpha was used in patients who were refractory to or could not tolerate AZA or had concomitant eye involvement requiring further treatment.

RESULTS

Thirty-three patients with LEDVT (26 M/7 F) were prospectively followed for 40.7 ± 13.4 months. Among the 33 patients, 23 relapses were observed in 15 patients. Relapse rates were 29%, 37% and 45% at 6, 12 and 24 months, respectively. Among the possible predictors of relapse, poor recanalization was the only significant factor [hazard ratio 4.34 (95% CI 1.96, 10.0)]. Overall 29 patients were treated with AZA and 17 with IFN-alpha. The relapse rate was lower and recanalization rate was higher with IFN-alpha compared with AZA (12% vs 45% and 86% vs 45%).

CONCLUSION

The relapse rate for LEDVT in Behçet's syndrome is high despite AZA treatment. IFN-alpha seems to be a promising agent for preventing LEDVT relapses and achieving good recanalization.

AB0481 EFFICACY OF APREMILAST FOR THE TREATMENT OF GENITAL ULCERS ASSOCIATED WITH ACTIVE BEHÇET’S SYNDROME: A COMBINED ANALYSIS OF TWO RANDOMIZED CONTROLLED TRIALS

Background:

Behçet’s syndrome is a chronic, multi-system inflammatory disorder characterized by painful, recurrent oral ulcers (OU) and genital ulcers (GU).1The GU associated with Behçet’s syndrome can contribute to difficulties with sexual activity, walking, and sitting2; may cause scarring1; and may impair quality of life.1,2Apremilast (APR), an oral phosphodiesterase 4 inhibitor, has demonstrated efficacy in the treatment of the OU associated with Behçet’s syndrome in the phase III, randomized RELIEF study (BCT-002).3

Objectives:

To describe the efficacy of APR for the treatment of GU associated with active Behçet’s syndrome in the RELIEF study and in a pooled data analysis of RELIEF and the phase II study.

Methods:

Adult patients (≥18 years of age) with active Behçet’s syndrome and ≥3 OU at randomization or ≥2 OU at screening and randomization, without active major organ involvement, were randomized (1:1) to APR 30 mg twice daily or placebo (PBO). In RELIEF, clinical improvement in GU was assessed by evaluating the time to the first GU recurrence after loss of complete response, the mean number of GU in patients without GU at baseline, and the proportion of patients who were GU-free (complete response) at Week 12 (regardless of baseline GU status). A pooled analysis of patients in RELIEF and a randomized, phase II study4were conducted to assess achievement of GU complete response in patients with GU at baseline. In patients with GU complete response before Week 12, the median time to the first GU recurrence after loss of complete response was based on Kaplan-Meier estimates. The mean number of GU was summarized descriptively using data as observed. Between-group differences in the proportion of patients who were GU-free at Week 12 were analyzed by Cochran-Mantel-Haenszel test using non-responder imputation to handle missing data. Statistical tests were 2 sided (α=0.05).

Results:

A total of 207 patients were randomized and received ≥1 dose of study medication (APR: n=104; PBO: n=103). In all, 17 patients in the APR group and 17 in the PBO group had GU at baseline, with mean GU counts of 2.9 (APR) and 2.6 (PBO). Among patients with GU at baseline in RELIEF, 12/17 (70.6% [APR]) and 7/17 (41.2% [PBO]) achieved GU complete response at Week 12 (P=0.110). The median time to first GU recurrence in these patients occurred earlier with PBO (6.1 weeks) vs. APR (not calculable). In the pooled analysis of RELIEF and the phase II study, a significantly greater proportion of patients with GU at baseline achieved GU complete response at Week 12 with APR vs. PBO (21/27 [77.8%] vs. 9/23 [39.1%];P=0.011) (Figure 1). The proportion of patients who were GU-free was significantly greater with APR (92/104 [88.5%]) vs. PBO (72/101 [71.3%]), regardless of baseline number of GU (P=0.002) (Figure 2).

Conclusion:

The number of patients with GU was low, but the totality of the data shows a favorable trend in the treatment effect of APR on GU. Greater proportions of APR-treated patients were GU-free at Week 12 vs. patients receiving PBO, and the time to the first GU recurrence occurred earlier with PBO vs. APR.

References:

[1]Kokturk A. Patholog Res Int. 2012;2012:690390. 2. Senusi A, et al. Orphanet J Rare Dis. 2015;10:117. 3. Hatemi G, et al. N Engl J Med. 2019;381:1918-1928. 4. Hatemi G, et al. N Engl J Med. 2015;372:1510-1518.

Disclosure of Interests:

Gulen Hatemi Grant/research support from: BMS, Celgene Corporation, Silk Road Therapeutics – grant/research support, Consultant of: Bayer, Eli Lilly – consultant, Speakers bureau: AbbVie, Mustafa Nevzat, Novartis, UCB – speaker, Alfred Mahr Consultant of: Celgene, Speakers bureau: Roche, Chugai, Mitsuhiro Takeno Speakers bureau: Esai, Tanabe-Mitsubishi – speaker; Celgene Corporation – advisory board, Doyoung Kim: None declared, Melike Melikoglu: None declared, Sue Cheng Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Shannon McCue Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Sven Richter Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Michele Brunori Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Maria Paris Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Mindy Chen Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of the conduct, Yusuf Yazici Consultant of: BMS, Celgene Corporation, Genentech, Sanofi – consultant, Consultant of: BMS, Celgene Corporation, Genentech, Sanofi – consultant

FRI0202 WHAT IS NOT NERVOUS SYSTEM INVOLVEMENT IN BEHÇET SYNDROME: A SURVEY OF PATIENTS WITH BEHÇET SYNDROME REFERRED TO NEUROLOGY

Background:

Nervous system involvement of Behçet syndrome (neuroBS) is a serious, but infrequent manifestation of Behçet syndrome (BS). Although many BS patients present with signs and symptoms related to the nervous system, several of these are diagnosed with conditions other than neuroBS. The differential diagnosis may be difficult in such patients.

Objectives:

To identify conditions mimicking neuroBS among patients with BS and to determine clinical, laboratory and imaging findings that may help the differential diagnosis.

Methods:

We retrospectively screened the charts of 500 BS patients who were registered to our clinic between February 2012 and April 2015, to identify those who were referred to neurology at any time during their follow-up. We follow our BS patients in a multidisciplinary clinic and all patients with a sign or symptom related to the nervous system are seen by one of the neurologist members of the clinic. The final diagnoses, as well as presenting signs and symptoms, laboratory and imaging results and results of any other diagnostic modalities were retrieved from patient charts. Patients who did not have a follow-up visit during the last 3 months were invited to the clinic for their final condition. Those who were not able to come, or one of their family members if they were not able to talk, were interviewed on the phone.

Results:

Among the 500 BS patients who were screened, 116 (23%) were referred to neurology (53 men, 63 women, mean age 32.8 (±9.8), 98 (84%) fulfilled ISG criteria). Among these, 29 (5.8%) were diagnosed with neuroBS, 30 (6%) had other conditions related to the nervous system, 46 (9.2%) were not diagnosed with a nervous system disorder and their symptoms disappeared and 11 (2.2%) were inconclusive and lost to follow-up. Of the 29 patients with neuroBS, 20 had parenchymal involvement, 7 had cerebral venous sinus thrombosis, 1 had concurrent parenchymal involvement and cerebral venous sinus thrombosis and 1 had atypical neuroBS. Of the 30 BS patients who were diagnosed with another nervous system condition, 14 (2.8%) had primary headache syndromes including tension type headache (n=5) and migraine (n=9), 6 (1.2%) had psychiatric disorders including psychotic disorder (n=1), depression (n=4) and somatization disorder (n=1), the remaining patients had other diagnoses which were entrapment neuropathy (n=2), epilepsy, glial tumor, multiple sclerosis, Meniere’s disease, optic neuritis, neuroretinitis, steroid myopathy and polyneuropathy in one patient each. Presentation features such as cerebellar symptoms, motor symptoms, visual problems, altered consciousness, seizure, fever and facial palsy were more common among patients with neuroBS, whereas sensory symptoms and isolated headache were more common among BS patients with other nervous system conditions (Table).

Table.

Clinical characteristics of patients with neuroBS versus other diagnoses

Clinical findings at presentationBS patients with nervous system involvement (neuroBS) (n=29)BS patients with other nervous system conditions (n=30)Only headache2 (7%)17 (56%)Cerebellar symptoms*8 (27%)4 (13%)Motor symptoms*4 (14%)2 (7%)Sensory symptoms*3 (10%)5 (17%)Visual problems*(diplopia, blurred vision)9 (31%)1 (3%)Cognitive symptoms*2 (7%)2 (7%)Other* (Alteration of consciousness, seizure, fever, facial palsy)9 (31%)1 (3%)

* Accompanying more than 1 symptom/sign

Conclusion:

Nervous system conditions other than neuroBS are common in patients with BS who present with nervous system findings. Caution is required to avoid misdiagnosis of these patients as neuroBS.

Disclosure of Interests:

Elif Dincses: None declared, E. Buse Caliskan: None declared, Z. Ece Kaya: None declared, Ugur Uygunoglu: None declared, Melih Tutuncu: None declared, Sabahattin Saip: None declared, Aksel Siva: None declared, Melike Melikoglu: None declared, Vedat Hamuryudan Speakers bureau: Pfizer, AbbVie, Amgen, MSD, Novartis, UCB, Gulen Hatemi Grant/research support from: BMS, Celgene Corporation, Silk Road Therapeutics – grant/research support, Consultant of: Bayer, Eli Lilly – consultant, Speakers bureau: AbbVie, Mustafa Nevzat, Novartis, UCB – speaker

OP0028 EFFICACY OF APREMILAST FOR THE PAIN OF ORAL ULCERS ASSOCIATED WITH ACTIVE BEHÇET’S SYNDROME: 12-WEEK RESULTS FROM THE RANDOMIZED, PHASE III RELIEF STUDY

Background:

Oral ulcers (OU) associated with Behçet’s syndrome are often painful, may interfere with the ability to eat and can negatively affect quality of life.1,2Apremilast (APR), an oral phosphodiesterase 4 inhibitor, demonstrated efficacy in the treatment of OU associated with Behçet’s syndrome in a phase III, multicenter, randomized, double-blind, placebo (PBO)-controlled study (RELIEF; BCT-002).3

Objectives:

To describe the efficacy of APR treatment in improving OU pain associated with Behçet’s syndrome in RELIEF.

Methods:

Patients were randomized (1:1) to APR 30 mg twice daily (APR 30 BID) or PBO twice daily for a 12-week PBO-controlled phase, followed by a 52-week active treatment extension. Eligible patients were ≥18 years of age and had active Behçet’s syndrome with ≥3 OU at randomization or ≥2 OU at screening and randomization and without active major organ involvement. Clinical improvement in OU was evaluated by the area under the curve for the number of OU through Week 12 (AUCWk0-12; primary efficacy endpoint) and by assessments of OU number. Patient-reported OU pain was evaluated by the 100-mm visual analogue scale (VAS). The statistical tests were 2-sided (α=0.05). The proportions of patients achieving the minimal clinically important difference (MCID) and higher rates of improvement, defined as ≥10-mm,4≥30-mm (3-fold MCID), ≥50-mm (5-fold MCID) improvements in OU pain VAS scores, respectively, were analyzed through Week 12. An ANCOVA model was used to analyze the primary endpoint and assessments of OU number and OU pain (VAS). The proportion of patients achieving improvement in OU pain VAS scores at Week 12 were summarized descriptively.

Results:

A total of 207 patients were randomized and received ≥1 dose of study medication (APR: n=104; PBO: n=103). At baseline, the mean (SD) number of OU was 4.2 (3.7) in the APR 30 BID group and 3.9 (2.7) in the PBO group, and the mean (SD) OU pain VAS scores were 61.2 (27.6) and 60.8 (26.9), respectively. At Week 12, significantly greater improvements were observed with APR 30 BID vs. PBO in AUCWk0-12(least-squares [LS] mean [SE]: 129.5 [15.9] vs. 222.1 [15.9];P<0.0001), number of OU (LS mean [SE]: 1.1 [0.2] vs. 2.0 [0.3];P=0.0003) and OU pain VAS scores (LS mean [SE] change from baseline: −40.7 [3.3] vs. −15.9 [3.3];P<0.0001). The proportion of patients who achieved the MCID of ≥10-mm improvement in OU pain VAS scores at Week 12 was greater with APR 30 BID vs. PBO; this pattern was also observed for the higher 3- and 5-fold improvements in MCID (Figure 1). Greater proportions of APR 30 BID vs. PBO patients achieved ≥10-mm and ≥30-mm improvements in OU pain VAS scores over 12 weeks. Notably, greater achievement of ≥50-mm improvement in OU pain VAS scores was observed with APR 30 BID vs. PBO as early as Week 1 and maintained up to Week 12 (Figure 2).

Conclusion:

For patients with active Behçet’s syndrome, APR 30 BID provided significantly greater improvements vs. PBO in OU number and OU pain at Week 12, including the greater proportion of patients achieving MCID and 3- and 5-fold MCID of OU pain in the APR 30 BID group vs. the PBO group. These results indicate a clinically meaningful treatment effect of APR 30 BID on the OU associated with Behçet’s syndrome.

References:

[1]Kokturk A.Patholog Res Int. 2012;2012:690390.

[2]Hatemi G, et al.Ann Rheum Dis. 2008;67:1656-1662.

[3]Hatemi G, et al.N Engl J Med. 2019;381:1918-1928. 4. Dworkin RH, et al.J Pain. 2008;9:105-121.

Disclosure of Interests:

Gulen Hatemi Grant/research support from: BMS, Celgene Corporation, Silk Road Therapeutics – grant/research support, Consultant of: Bayer, Eli Lilly – consultant, Speakers bureau: AbbVie, Mustafa Nevzat, Novartis, UCB – speaker, Alfred Mahr Consultant of: Celgene, Speakers bureau: Roche, Chugai, Mitsuhiro Takeno Speakers bureau: Esai, Tanabe-Mitsubishi – speaker; Celgene Corporation – advisory board, Doyoung Kim: None declared, Melike Melikoglu: None declared, Sue Cheng Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Shannon McCue Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Sven Richter Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Michele Brunori Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Maria Paris Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of study conduct, Mindy Chen Employee of: Amgen Inc. – employment; Celgene Corporation – employment at the time of the conduct, Yusuf Yazici Consultant of: BMS, Celgene Corporation, Genentech, Sanofi – consultant, Consultant of: BMS, Celgene Corporation, Genentech, Sanofi – consultant

SAT0258 DRUG RETENTION RATE AND PROGNOSIS AFTER DISCONTINUATION OF INFLIXIMAB IN PATIENTS WITH BEHÇET SYNDROME

Background:

Infliximab (IFX) has become an important treatment option for all manifestations of Behçet syndrome (BS). Adverse events, loss of efficacy, lack of patient compliance and cost may limit its sustained use in patients with BS.

Objectives:

We aimed to evaluate the drug retention rates, causes of discontinuation and outcome after cessation of IFX.

Methods:

We reviewed the charts of 850 patients with BS who were registered in our clinic between 2009 and 2013 and identified those who had used IFX. The charts of these patients were surveyed for demographic features, the reasons for IFX use, previous and concomitant drugs, IFX duration, reasons for discontinuation and time to flare after discontinuation of IFX. We defined flare as disease activity in the organ involvement that necessitated IFX use. New major organ involvement that developed during or after discontinuation of IFX were also be noted.

Results:

A total of 50/850 patients were treated with IFX (40 men, mean age 40±9.5 years), for uveitis (n=29), vascular involvement (n=11), parenchymal neurologic involvement (n=8), arthritis (n=1) and venous ulcer (n=1). Of these 50 patients, 22 (43%) are still receiving IFX for a median duration of 40 (IQR: 25-83) months. The remaining 28 (47%) patients had discontinued IFX after a median follow-up of 12 (IQR: 7-30) months. Reasons for discontinuation were remission in 7 patients, adverse events in 10, primary lack of efficacy in 2, and lack of patient compliance in 9 patients. Among the 7 patients who discontinued IFX due to remission, only 1 patient with uveitis had a flare, 11 months after discontinuation, while on azathioprine. The remaining 6 did not experience any flares during a median follow-up of 29.5 (IQR: 4-24) months. Five of these patients used azathioprine and 1 used mycophenolate mofetil for maintenance. Among the 10 patients who discontinued due to adverse events, IFX was switched to adalimumab in 3 patients and none experienced flares under adalimumab. The remaining 7 patients continued to receive azathioprine or mycophenolate mofetil without a biologic. Among these, 1 patient with uveitis 1 with arthritis experienced flares 6 months after discontinuing IFX. Among the 9 patients who discontinued IFX due to lack of patient compliance, 3 patients (2 with uveitis and 1 with arthritis) had flares after 5 months, 1 year and 1.5 years. IFX was re-initiated in all. The remaining 6 patients did not experience any flares after a mean follow up of 5±1.5 years. Two with uveitis and 2 with venous thrombosis used azathioprine for maintenance, while 2 patients did not receive further treatment. New major organ involvement was not observed. New BS manifestations developed in 2 patients under IFX, arthritis in one patient and both epididymitis and erythema nodosum in the other.

Conclusion:

Almost half of our patients with BS remained on IFX during a median follow-up of 5.4 years (IQR:2.4-7). Main reasons for discontinuation were adverse events, remission and lack of patient compliance. Our observations further support the efficiency of IFX in managing patients with BS.

Disclosure of Interests:

Sinem Nihal Esatoglu: None declared, Beyza Tukek: None declared, Sitki Safa Taflan: None declared, Yilmaz Ozyazgan: None declared, Didar Ucar: None declared, Emire Seyahi: None declared, Melike Melikoglu: None declared, Vedat Hamuryudan Speakers bureau: Pfizer, AbbVie, Amgen, MSD, Novartis, UCB, Ugur Uygunoglu: None declared, Aksel Siva: None declared, Izzet Fresko: None declared, Sebahattin Yurdakul: None declared, Hasan Yazici: None declared, Gulen Hatemi Grant/research support from: BMS, Celgene Corporation, Silk Road Therapeutics – grant/research support, Consultant of: Bayer, Eli Lilly – consultant, Speakers bureau: AbbVie, Mustafa Nevzat, Novartis, UCB – speaker

Outcome of invasive procedures for venous thrombosis in Behçet's syndrome: case series and systematic literature review

OBJECTIVES

Systemic therapy aimed at suppressing the diffuse inflammation in the vessel wall is the major treatment modality for venous thrombosis in Behçet's syndrome (BS). Endovascular and/or surgical interventions are also used. We here report five patients who were referred to our clinic after having such interventions and also present a literature review to assess the outcome of invasive procedures for venous thrombosis in BS.

METHODS

Our patients were presented and a literature search for endovascular and/or surgical interventions in Pub-Med was performed. Recanalisation, reocclusion or other complications were assessed as outcomes.

RESULTS

Five BS patients with lower extremity thrombosis were referred to our clinic with post thrombotic syndrome due to incomplete recanalisation or infectious complication after endovascular interventions. Twenty-one articles reporting on 36 patients were found suitable for review. There were totally 21 lower extremity venous intervention cases, 14 of which had failure such as complication, reocclusion or incomplete recanalisation. Reocclusions occurred in 10 patients and reinterventions to 8 of them could restore flow only in 4 cases. Ileal infarct and vena cava wall-duodenal perforation were major complications. Invasive procedures of 8 abdominal thrombosis cases resulted with death due to ileus in one patient, and reocclusion in another. Seven of the 12 upper extremity/superior vena cava thrombosis cases resulted with reocclusions.

CONCLUSIONS

Endovascular and surgical interventions seemed to be unsuccessful because of recurrent infectious and vascular complications in 22 (53.6%) of 41 patients with venous thrombosis. The indication of these procedures is controversial. Their economic burden on the healthcare system must be considered.

Biosimilar infliximab for Behçet's syndrome: a case series

OBJECTIVES

The efficacy and safety of biosimilar infliximab (bio-IFX) was shown in randomised controlled trials and it was approved for all indications of the reference product in several countries. However, a previous case series of 3 patients with Behçet's syndrome (BS) reported disappointing results. We aimed to share our experience with bio-IFX treatment in different types of organ involvement in patients with BS.

METHODS

We reviewed the charts of all BS patients who were prescribed reference infliximab (ref-IFX) or bio-IFX in our BS clinic. Among the 181 BS patients who were prescribed IFX since 2003, 6 (3%) were prescribed bio-IFX due to refractory disease despite conventional immunosuppressives.

RESULTS

A total of 6 patients (mean age: 32.1±6.2, mean disease duration: 5.3±1.8 years, 5 men and 1 woman) received bio-IFX for uveitis, nervous system, vascular and joint involvement. Four of the 6 patients obtained remission and stayed in remission during the 16±6.5 months they used bio-IFX. Among the 4 patients who obtained remission, 2 were switched to ref-IFX due to unavailability of bio-IFX infusion set and did not experience adverse events or loss of efficacy. However, relapses occurred during tapering. The other 2 patients are still in remission with bio- IFX. Among the remaining 2 patients, one had to be switched to ref-IFX after the first infusion, due to a change in the reimbursement policy and the other was non-responsive.

CONCLUSIONS

Our limited experience showed that bio-IFX may be a safe and effective alternative for patients with BS, refractory to conventional immunosuppressives.

Secukinumab induced Behçet's syndrome: a report of two cases

Secukinumab is a human monoclonal antibody against IL-17A that has been shown to be effective in psoriasis, psoriatic arthritis and ankylosing spondylitis (AS). On the other hand, in randomized controlled trials among patients with Crohn’s disease (CD) and uveitis due to Behçet’s syndrome (BS) treated with secukinumab, primary end points were not met and the drug caused more exacerbations compared to placebo. The drug fact sheet states that secukinumab should be used with caution in patients with CD; however, there are no warnings for those with BS. Here, we present two patients with AS treated with secukinumab; we observed exacerbation of BS in one and emergence of de novo BS in another. Although IL-17A is thought to contribute to the pathogenesis of BS, our observations suggest that it might have a protective role. Finally, we suggest caution is required with the inhibition of IL-17 in BS.

Re-initiation of biologics after the development of tuberculosis under anti-TNF therapy

The use of anti-TNF agents is associated with an increased risk of tuberculosis (TB) and anti-TNF agents are stopped when active TB develops. However, discontinuation of treatment can result in flare of the underlying disease. The charts of 22 patients who developed active TB among a cohort of 2754 patients using anti-TNF agents between 2001 and 2013 were reviewed retrospectively. Patients restarting biologics during further follow-up were identified. One patient with miliary TB died within 1 month. A biologic agent was restarted in 16 of the remaining 21 patients (76 %). The most frequently re-initiated biologic agent was etanercept (n = 6) followed by rituximab (n = 5) and interferon-alpha (n = 3). Biologic treatment was re-initiated during anti-TB treatment in four patients and after completing TB treatment in 12 patients. The median follow-up after restarting biologics was 53 (IQR: 40-75) months. TB re-occurred in one patient with Behçet's syndrome, who initially received etanercept due to severe sight-threatening uveitis at the third month of anti-TB treatment followed by canakinumab 15 months later along with methotrexate, cyclosporine and corticosteroids. After a second course of 9 months TB therapy this patient is currently stable on interferon-alpha for 33 months. Restarting of anti-TNF agents and other biologic agents, even during TB treatment, seems to be possible among patients who had previously developed TB under anti-TNF treatment. However, the risk of re-development of TB infection mandates careful follow-up.

Bronchial artery enlargement may be the cause of recurrent haemoptysis in Behçet's syndrome patients with pulmonary artery involvement during follow-up

OBJECTIVES

Haemoptysis occurring in a Behçet's syndrome (BS) patient with pulmonary artery involvement (PAI) during follow-up is usually regarded as PAI relapse. However, bronchial artery enlargement (BAE) may be the source of haemoptysis in some patients.

METHODS

A chart review at the end of December 2014 revealed 118 patients with PAI in our centre since 1979. Nine (all men) had recurrent haemoptysis during follow-up which could not be explained with relapse of PAI.

RESULTS

Haemoptysis recurred a median of 1.5 years (IQR: 9 months-5 years) during follow-up. Thorax CT scans did not show relapse of PAI or emergence of BAE. The patients were treated empirically but continued to complain of occasional haemoptysis thereafter. BAE was detected in 8 patients after a median follow-up of 9 years (IQR: 5-12 years). Six patients underwent bronchial artery embolisation that was repeated in 3. One patient with severe pulmonary hypertension died 3 weeks later. The remaining 5 are under follow-up for between 5 months-9 years. Pulmonary infarction and mild hemiparesis occurred in 2 patients after embolisation. One patient died with haemoptysis before undergoing embolisation. Another one with small BAE is under follow-up for 8 years without embolisation. The source of bleeding could not be determined in 1 patient who is now haemoptysis free for 5 years.

CONCLUSIONS

BAE may be the source of recurring and fatal haemoptysis in BS patients with PAI during follow-up. Embolisation appears to be a life-saving procedure.

Color Doppler analysis of female reproductive vasculature in Behçet's disease

Behçet's disease (BD) may affect female reproductive vasculature. We aimed to evaluate Doppler sonographic characteristics of female reproductive vasculature and also ovarian volume, endometrial thickness (EMT) and antral follicle count of BD patients in comparison with a healthy control group. Seventeen premenopausal women aged between 18-45 years with BD, and a control group of 31 age- and body mass index-matched healthy women was included in the study. Uterine, spiral and intraovarian artery blood flow were examined by Doppler sonography in the late follicular phase. Resistance index, pulsatility index and systolic/diastolic ratio were recorded together with ovarian volume, EMT and antral follicle count. In particular this is a pilot study including the evaluation of the spiral and uterine arteries in BD. Doppler sonographic parameters, ovarian volume, EMT and antral follicle count of BD patients and healthy controls were not found to be statistically different. As a result of our analysis, we found similar Doppler sonographic features of both BD patients and the control group. Further studies conducted on a larger sample population with more aggressive BD symptoms may reveal the actual effect of BD on the female reproductive system.

Clinical and Ultrasonographic Evaluation of Lower-extremity Vein Thrombosis in Behcet Syndrome: An Observational Study

Vascular involvement can be seen in up to 40% of patients with Behcet syndrome (BS), the lower-extremity vein thrombosis (LEVT) being the most common type. The aim of the current study was to compare venous Doppler findings and clinical features between BS patients with LEVT and control patients diagnosed as having LEVT due to other causes.All consecutive 78 patients (71 men, 7 women; mean age 38.6 ± 10.3 years) with LEVT due to BS and 50 control patients (29 men, 21 women; mean age 42.0 ± 12.5 years) who had LEVT due to other causes, or idiopathic, were studied with the help of a Doppler ultrasonography after a detailed clinical examination. Patterns of venous disease were identified by cluster analyses. Clinical features of chronic venous disease were assessed using 2 classification systems. Venous claudication was also assessed.Patients with BS were more likely to be men, had significantly earlier age of onset of thrombosis, and were treated mainly with immunosuppressives and less frequently with anticoagulants. Furthermore, they had significantly more bilateral involvement, less complete recanalization, and more frequent collateral formation. While control patients had a disorganized pattern of venous involvement, BS patients had a contiguous and symmetric pattern, involving all deep and superficial veins of the lower extremities, with less affinity for crural veins. Clinical assessment, as measured by the 2 classification systems, also indicated a more severe disease among the BS patients. In line, 51% of the BS patients suffered from severe post-thrombotic syndrome (PTS) and 32% from venous claudication, whereas these were present in 8% and 12%, respectively, among the controls. Among BS patients, a longer duration of thrombosis, bilateral femoral vein involvement, and using no anticoagulation along with immunosuppressive treatment when first diagnosed were found to be associated independently with severe PTS.Lower-extremity vein thrombosis associated with BS, when compared to LEVT due to other causes, had distinctive demographic and ultrasonographic characteristics, and had clinically a more severe disease course.

Apremilast for Behçet's syndrome--a phase 2, placebo-controlled study

BACKGROUND

Oral ulcers, the hallmark of Behçet's syndrome, can be resistant to conventional treatment; therefore, alternative agents are needed. Apremilast is an oral phosphodiesterase-4 inhibitor that modulates several inflammatory pathways.

METHODS

We conducted a phase 2, multicenter, placebo-controlled study in which 111 patients with Behçet's syndrome who had two or more oral ulcers were randomly assigned to receive 30 mg of apremilast twice daily or placebo for 12 weeks. This regimen was followed by a 12-week extension phase in which the placebo group was switched to apremilast and a 28-day post-treatment observational follow-up phase. The patients and clinicians were unaware of the study assignments throughout the trial. The primary end point was the number of oral ulcers at week 12. Secondary outcomes included pain from these ulcers (measured on a 100-mm visual-analogue scale, with higher scores indicating worse pain), the number of genital ulcers, overall disease activity, and quality of life.

RESULTS

The mean (±SD) number of oral ulcers per patient at week 12 was significantly lower in the apremilast group than in the placebo group (0.5±1.0 vs. 2.1±2.6) (P<0.001). The mean decline in pain from oral ulcers from baseline to week 12 was greater with apremilast than with placebo (-44.7±24.3 mm vs. -16.0±32.5 mm) (P<0.001). Nausea, vomiting, and diarrhea were more common in the apremilast group (with 22, 9, and 12 incidents, respectively, among 55 patients) than in the placebo group (with 10, 1, and 2 incidents, respectively, among 56 patients), findings that were similar to those in previous studies of apremilast. There were two serious adverse events in patients receiving apremilast.

CONCLUSIONS

Apremilast was effective in treating oral ulcers, which are the cardinal manifestation of Behçet's syndrome. This preliminary study was neither large enough nor long enough to assess long-term efficacy, the effect on other manifestations of Behçet's syndrome, or the risk of uncommon serious adverse events. (Funded by Celgene; ClinicalTrials.gov number, NCT00866359.).