Towards the Lowest Efficacious Dose: Results From a Multicenter Noninferiority Randomized Open-Label Controlled Trial Assessing Tocilizumab or Abatacept Injection Spacing in Rheumatoid Arthritis in Remission

OBJECTIVE

We assess the clinical and structural impact at two years of progressively spacing tocilizumab (TCZ) or abatacept (ABA) injections versus maintenance at full dose in patients with rheumatoid arthritis in sustained remission.

METHODS

This multicenter open-label noninferiority (NI) randomized clinical trial included patients with established rheumatoid arthritis in sustained remission receiving ABA or TCZ at a stable dose. Patients were randomized to treatment maintenance (M) at full dose (M-arm) or progressive injection spacing (S) driven by the Disease Activity Score in 28 joints every 3 months up to biologics discontinuation (S-arm). The primary end point was the evolution of disease activity according to the Disease Activity Score in 44 joints during the 2-year follow-up analyzed per protocol with a linear mixed-effects model, evaluated by an NI test based on the one-sided 95% confidence interval (95% CI) of the slope difference (NI margin 0.25). Other end points were flare incidence and structural damage progression.

RESULTS

Overall, 202 of the 233 patients included were considered for per protocol analysis (90 in S-arm and 112 in M-arm). At the end of follow-up, 16.2% of the patients in the S-arm could discontinue their biologic disease-modifying antirheumatic drug, 46.9% tapered the dose and 36.9% returned to a full dose. NI was not demonstrated for the primary outcome, with a slope difference of 0.10 (95% CI 0.10-0.31) between the two arms. NI was not demonstrated for flare incidence (difference 42.6%, 95% CI 30.0-55.1) or rate of structural damage progression at two years (difference 13.9%, 95% CI -6.7 to 34.4).

CONCLUSION

The Towards the Lowest Efficacious Dose trial failed to demonstrate NI for the proposed ABA or TCZ tapering strategy.

Serum calprotectin and renal function decline in ANCA-associated vasculitides: a post hoc analysis of MAINRITSAN trial

OBJECTIVE

Serum calprotectin appears to be an interesting biomarker associated with renal vascular disease activity in antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV). The aim of this study was to assess whether serum calprotectin levels can predict decline in renal function in AAV patients receiving maintenance therapy.

METHODS

Serum calprotectin levels were assessed at inclusion and month 6 in AAV patients, in complete remission after induction therapy, randomly assigned to rituximab or azathioprine. Renal function decline was defined as a 25% decrease in estimated glomerular filtration rate (eGFR) and a change in the eGFR category, or a decrease of 15 mL/min/1.73 m2. Relapse was defined as a Birmingham Vasculitis Activity Score >0 attributable to active vasculitis.

RESULTS

Seventy-six AAV were included. Serum calprotectin increased from baseline to month 6 in patients with renal function decline (7940 (-226.0, 28 691) ng/ml vs -4800 (-18 777, 3708) ng/ml; p<0.001). An increase of calprotectin level was associated with a higher risk of subsequent renal function decline even after adjustment (OR 6.50 (95% CI 1.7 to 24.9) p=0.006). A significantly higher risk of relapse was observed in proteinase 3- AAV patients with an increase of serum calprotectin levels (OR 5.6 (95% CI 1.0 to 31.2), p=0.03).

CONCLUSION

An increase in serum calprotectin by month 6 compared with inclusion during remission-maintenance therapy in AAV was associated with a higher risk of renal function decline in the following 12 months.

TRIAL REGISTRATION NUMBER

NCT00748644.

Survey of adolescents' needs and parents' views on sexual health in juvenile idiopathic arthritis

BACKGROUND

Although the advent of new therapeutics for juvenile idiopathic arthritis (JIA) patients has considerably lessened the impact of the disease and reduced its sequelae, the outcomes of JIA remain important in their lives. Disease repercussions and side effects of treatments may affect sexual health and cause psychological distress. This aim of the study was to determine the expectations of adolescent JIA patients and the perceptions of their parents regarding knowledge and communication with healthcare providers (HCPs) in the field of sexual health (SH).

METHODS

In France, from September 2021 to April 2022, a survey was conducted, using anonymous self-administered questionnaires, among JIA patients (adults (aged 18-45 years) to provide insights from their recollection of their adolescence) and their parents in nine rheumatology centers and three patient associations.

RESULTS

The responses to the 76 patient questionnaires and 43 parent questionnaires that were collected were analyzed. Half of the patients thought JIA impacted their romantic relationships, but the results were less clear-cut for their sexual activity; and 58.7% of the patients said they would be comfortable discussing the subject with HCPs, but only 26.3% had done so, mainly regarding biomedical issues. The patients and their parents thought that ideally, the topic should be addressed in an individual patient education session at the hospital (51.3% and 34.9%, respectively), in a regular consultation (47.4% and 53.5%), or in a dedicated consultation requested by the adolescent without the adolescent's parents being informed (38.2% and 20.9%). Most of the respondents thought HCPs should be proactive in SH (77.6% of the patients and 69.8% of their parents). More patients than parents said the following digital information tools must be used: videos (29.0% vs. 9.3%, p = 0.0127) and smartphone applications (25.0% vs. 9.3%, p = 0.0372).

CONCLUSION

HCPs should consider addressing the unmet need for SH discussions during their patient encounters. To meet this need, we propose concrete actions in line with the wishes of patients and parents.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04791189.

Gait and Axial Spondyloarthritis: Comparative Gait Analysis Study Using Foot-Worn Inertial Sensors

Background

Axial spondyloarthritis (axSpA) can lead to spinal mobility restrictions associated with restricted lower limb ranges of motion, thoracic kyphosis, spinopelvic ankylosis, or decrease in muscle strength. It is well known that these factors can have consequences on spatiotemporal gait parameters during walking. However, no study has assessed spatiotemporal gait parameters in patients with axSpA. Divergent results have been obtained in the studies assessing spatiotemporal gait parameters in ankylosing spondylitis, a subgroup of axSpA, which could be partly explained by self-reported pain intensity scores at time of assessment. Inertial measurement units (IMUs) are increasingly popular and may facilitate gait assessment in clinical practice.

Objective

This study compared spatiotemporal gait parameters assessed with foot-worn IMUs in patients with axSpA and matched healthy individuals without and with pain intensity score as a covariate.

Methods

A total of 30 patients with axSpA and 30 age- and sex-matched healthy controls performed a 10-m walk test at comfortable speed. Various spatiotemporal gait parameters were computed from foot-worn inertial sensors including gait speed in ms^–1 (mean walking velocity), cadence in steps/minute (number of steps in a minute), stride length in m (distance between 2 consecutive footprints of the same foot on the ground), swing time in percentage (portion of the cycle during which the foot is in the air), stance time in percentage (portion of the cycle during which part of the foot touches the ground), and double support time in percentage (portion of the cycle where both feet touch the ground).

Results

Age, height, and weight were not significantly different between groups. Self-reported pain intensity was significantly higher in patients with axSpA than healthy controls (P<.001). Independent sample t tests indicated that patients with axSpA presented lower gait speed (P<.001) and cadence (P=.004), shorter stride length (P<.001) and swing time (P<.001), and longer double support time (P<.001) and stance time (P<.001) than healthy controls. When using pain intensity as a covariate, spatiotemporal gait parameters were still significant with patients with axSpA exhibiting lower gait speed (P<.001), shorter stride length (P=.001) and swing time (P<.001), and longer double support time (P<.001) and stance time (P<.001) than matched healthy controls. Interestingly, there were no longer statistically significant between-group differences observed for the cadence (P=.17).

Conclusions

Gait was significantly altered in patients with axSpA with reduced speed, cadence, stride length, and swing time and increased double support and stance time. Taken together, these changes in spatiotemporal gait parameters could be interpreted as the adoption of a so-called cautious gait pattern in patients with axSpA. Among factors that may influence gait in patients with axSpA, patient self-reported pain intensity could play a role. Finally, IMUs allowed computation of spatiotemporal gait parameters and are usable to assess gait in patients with axSpA in clinical routine.

Trial Registration

ClinicalTrials.gov NCT03761212; https://clinicaltrials.gov/ct2/show/NCT03761212

International Registered Report Identifier (IRRID)

RR2-10.1007/s00296-019-04396-4

New-Onset Inflammatory Bowel Diseases Among IL-17 inhibitors-Treated Patients: Results From The Case-Control MISSIL Study

OBJECTIVES

To describe new-onset inflammatory bowel diseases (new IBD) in patients treated with interleukin 17 inhibitors (IL-17i), to assess their incidence and to identify their risk factors in real life.

METHODS

A French national registry (MISSIL) aimed to report all cases of new IBD in patients treated with IL-17i from January 2016 to December 2019. Using the estimated number of patients treated by IL-17 in France during the study period, the annual incidence rates of new IBD was reported in IL-17i-treated patients. A case-control study was performed with two controls per new IBD case matched by gender, age and underlying inflammatory disease.

RESULTS

31 cases of new IBD under IL-17i were collected: 27 patients treated for spondyloarthritis and 4 patients for psoriasis. All were observed with secukinumab (SEK). The median time to onset of new IBD symptoms was 4.0 (1.5-7.5) months. SEK was discontinued in all patients. The evolution was favourable with complete resolution (17/31), improvement (7/31) or stabilization (5/31). 2 patients died: one due to a massive myocardial infarction and one due to post-colectomy complications. The incidence of new IBD decreased from 0.69/100 PY (7/1010) in 2016, to 0.08/100PY (6/7951) in 2019. No previous treatment with etanercept (OR = 0.33, IC95% 0.14-0.80, p= 0.014) and low number of previous biological therapies (OR = 0.67, 95%CI 0.47-0.94, p= 0.021) were significantly associated with new IBD.

CONCLUSION

The incidence of new IBD was low and decreased from 2016 to 2019. The outcome was favourable in 24 out of 31 patients, but two patients died.

Human influence on brown trout juvenile body size during metapopulation expansion

Change in body size can be driven by social (density) and non-social (environmental and spatial variation) factors. In expanding metapopulations, spatial sorting by means of dispersal on the expansion front can further drive the evolution of body size. However, human intervention can dramatically affect these founder effects. Using long-term monitoring of the colonization of the remote Kerguelen islands by brown trout, a facultative anadromous salmonid, we analyse body size variation in 32 naturally founded and 10 human-introduced populations over 57 years. In naturally founded populations, we find that spatial sorting promotes slow positive changes in body size on the expansion front, then that body size decreases as populations get older and local density increases. This pattern is, however, completely different in human-introduced populations, where body size remains constant or even increases as populations get older. The present findings confirm that changes in body size can be affected by metapopulation expansion, but that human influence, even in very remote environments, can fully alter this process.

The effects of a secondary task on gait in axial spondyloarthritis

Studies on the effects of dual tasking in patients with chronic inflammatory rheumatic diseases are limited. The aim of this study was to assess dual tasking while walking in patients with axial spondyloarthritis (axSpA) in comparison to healthy controls. Thirty patients with axSpA and thirty healthy controls underwent a 10-m walk test at a self-selected comfortable walking speed in single- and dual-task conditions. Foot-worn inertial sensors were used to compute spatiotemporal gait parameters. Analysis of spatiotemporal gait parameters showed that the secondary manual task negatively affected walking performance in terms of significantly decreased mean speed (p < 0.001), stride length (p < 0.001) and swing time (p = 0.008) and increased double support (p = 0.002) and stance time (p = 0.008). No significant interaction of group and condition was observed. Both groups showed lower gait performance in dual task condition by reducing speed, swing time and stride length, and increasing double support and stance time. Patients with axSpA were not more affected by the dual task than matched healthy controls, suggesting that the secondary manual task did not require greater attention in patients with axSpA. Increasing the complexity of the walking and/or secondary task may increase the sensitivity of the dual-task design to axial spondyloarthritis.

Marine habitat use and feeding ecology of introduced anadromous brown trout at the colonization front of the sub-Antarctic Kerguelen archipelago

In 1954, brown trout were introduced to the Kerguelen archipelago (49°S, 70°E), a pristine, sub-Antarctic environment previously devoid of native freshwater fishes. Trout began spreading rapidly via coastal waters to colonize adjacent watersheds, however, recent and unexpectedly the spread has slowed. To better understand the ecology of the brown trout here, and why their expansion has slowed, we documented the marine habitat use, foraging ecology, and environmental conditions experienced over one year by 50 acoustically tagged individuals at the colonization front. Trout mainly utilized the marine habitat proximate to their tagging site, ranging no further than 7 km and not entering any uncolonized watersheds. Nutritional indicators showed that trout were in good condition at the time of tagging. Stomach contents and isotope signatures in muscle of additional trout revealed a diet of amphipods (68%), fish (23%), isopods (6%), and zooplankton (6%). The small migration distances observed, presence of suitable habitat, and rich local foraging opportunities suggest that trout can achieve their resource needs close to their home rivers. This may explain why the expansion of brown trout at Kerguelen has slowed.

Mediation of Interleukin-23 and Tumor Necrosis Factor-Driven Reactive Arthritis by Chlamydia-Infected Macrophages in SKG Mice

OBJECTIVE

ZAP-70^W163C BALB/c (SKG) mice develop reactive arthritis (ReA) following infection with Chlamydia muridarum. Since intracellular pathogens enhance their replicative fitness in stressed host cells, we examined how myeloid cells infected with C muridarum drive arthritis.

METHODS

SKG, Il17a-deficient SKG, and BALB/c female mice were infected with C muridarum or C muridarum luciferase in the genitals. C muridarum dissemination was assessed by in vivo imaging or genomic DNA amplification. Macrophages were depleted using clodronate liposomes. Anti-tumor necrosis factor (anti-TNF) and anti-interleukin-23p19 (anti-IL-23p19) were administered after infection or arthritis onset. Gene expression of Hspa5, Tgtp1, Il23a, Il17a, Il12b, and Tnf was compared in SKG mice and BALB/c mice.

RESULTS

One week following infection with C muridarum, macrophages and neutrophils were observed to have infiltrated the uteri of mice and were also shown to have carried C muridarum DNA to the spleen. C muridarum load was higher in SKG mice than in BALB/c mice. Macrophage depletion was shown to reduce C muridarum load and prevent development of arthritis. Compared with BALB/c mice, expression of Il23a and Il17a was increased in the uterine and splenic neutrophils of SKG mice. The presence of anti-IL-23p19 during infection or Il17a deficiency suppressed arthritis. Tnf was overexpressed in the joints of SKG mice within 1 week postinfection, and persisted beyond the first week. TNF inhibition during infection or at arthritis onset suppressed the development of arthritis. Levels of endoplasmic reticulum stress were constitutively increased in the joints of SKG mice but were induced, in conjunction with immunity-related GTPase, by C muridarum infection in the uterus.

CONCLUSION

C muridarum load is higher in SKG mice than in BALB/c mice. Whereas proinflammatory IL-23 produced by neutrophils contributes to the initiation of C muridarum-mediated ReA, macrophage depletion reduces C muridarum dissemination to other tissues, tissue burden, and the development of arthritis. TNF inhibition was also shown to suppress arthritis development. Our data suggest that enhanced bacterial dissemination in macrophages of SKG mice drives the TNF production needed for persistent arthritis.

Evaluation of the impact of a nurse-led program of patient self-assessment and self-management in axial spondyloarthritis: results of a prospective, multicentre, randomized, controlled trial (COMEDSPA)

OBJECTIVE

To evaluate the impact of a nurse-led program of self-management and self-assessment of disease activity in axial spondyloarthritis.

METHODS

Prospective, randomized, controlled, open, 12-month trial (NCT02374749). Participants were consecutive axial spondyloarthritis patients (according to the rheumatologist) and nurses having participated in a 1-day training meeting. The program included self-management: educational video and specific video of graduated, home-based exercises for patients; and self-assessment: video presenting the rationale of tight monitoring of disease activity with composite scores (Ankylosing Spondylitis Disease activity Score, ASDAS/Bath Ankyslosing Spondylitis Disease Activity Index, BASDAI). The nurse trained patients to collect, calculate and report (monthly) ASDAS/BASDAI. Treatment allocation was by random allocation to this program or a comorbidities assessment (not presented here and considered here as the control group).

RESULTS

A total of 502 patients (250 and 252 in the active and control groups, respectively) were enrolled (age: 46.7 (12.2) years, male gender: 62.7%, disease duration: 13.7 (11.0) years). After the one-year follow-up period, the adherence to the self-assessment program was considered good (i.e. 79% reported scores >6 times). Despite a lack of statistical significance in the primary outcome (e.g. coping) there was a statistically significant difference in favor of this program for the following variables: change in BASDAI, number and duration of the home exercises in the active group, and physical activity (international physical activity score, IPAQ).

CONCLUSION

This study suggests a short-term benefit of a nurse-led program on self-management and self-assessment for disease activity in a young axial spondyloarthritis population in terms of disease activity, exercises and physical activity.

Impact of disease activity and treatments on ovarian reserve in patients with rheumatoid arthritis in the ESPOIR cohort

OBJECTIVES

Patients with RA have a higher prevalence of infertility than the general population. This study sought to examine the impact of RA disease activity and treatments on ovarian reserve measured by serum anti-Müllerian hormone (AMH) levels in the ESPOIR cohort. We sought to better define the indications for fertility preservation.

METHODS

Patients and serum analysis data were derived from the French national cohort ESPOIR. Enrolled patients (n = 102; 18-37-year-olds) fulfilled ACR/EULAR 2010 criteria for RA. Serum AMH levels were measured at T0, T6, T12, T24 and T36 months post-diagnosis. The impacts of RA activity (DAS28 and CRP level) and treatments (MTX only or with other medications) were evaluated at each study visit.

RESULTS

A gradual decrease in patients' serum AMH levels was observed over time, in line with the descending curve described for healthy women. Serum AMH levels of RA patients in comparison with the values considered normal for age did not reveal any significant differences (P > 0.05). We did not observe any impact of RA treatments. We demonstrated an inverse correlation between AMH variation and disease activity (DAS28: r = -0.27, P = 0.003; CRP: r = -0.16, P = 0.06).

CONCLUSION

This is the first study to determine serum AMH levels of a large cohort of RA patients over 36 months. Rapid disease activity control appears to be required to limit changes in the ovarian reserve. Fertility preservation is not likely to be necessary if inflammation is promptly controlled.

CLINICALTRIALS.GOV IDENTIFIER

NCT03666091.

Cut-off value to identify a flare using the Flare Assessment in Rheumatoid Arthritis (FLARE-RA) questionnaire: analysis of the TOSCA study

OBJECTIVE

The Flare Assessment in Rheumatoid Arthritis (FLARE-RA) self-administered questionnaire aims to identify patients who had flare in the interval between 2 consultations. This study aimed to establish a threshold for FLARE-RA score to identify RA flare.

METHODS

The Tocilizumab SubCutAneous (TOSCA) study evaluated the efficacy and safety of subcutaneous Tocilizumab (TCZ) to patients with active RA. Disease activity was assessed with the DAS28ESR at baseline and at week 2 (W2), W4, W12, and W24. The FLARE-RA questionnaire was administered at W12 and W24. Patient satisfaction, assessed at baseline and W24 with the Patient Acceptable Symptom State (PASS), was used as a surrogate marker of no flare. A correlation was sought between the FLARE-RA score at W12 and W24 and the area under the receiver operating characteristic (ROC) curve (AUC) for monthly DAS28ESR. The optimal FLARE-RA cut-off below which patient satisfaction reached the PASS was explored with an ROC curve.

RESULTS

139 patients were included (mean age 57.3 ± 13.8 years, 74.1% women, mean RA duration 10.8 ± 9.2 years, mean DAS28ESR 5.8 ± 1.1). The correlation between the FLARE-RA score and DAS28ESR AUC was moderate at all times: rho = 0.41 at W12 (p<0.0001) and 0.51 at W24 (p<0.0001). The optimal cut-off for the FLARE-RA score to identify absence of flare (i.e. an acceptable situation based on the PASS) was 2.3 with an AUC of 0.81.

CONCLUSION

FLARE-RA and DAS28ESR assessment differ; we propose a FLARE-RA cut-off of 2.3, below which the situation (i.e. without flare) is acceptable for patients.

GlutenSpA trial: protocol for a randomised double-blind placebo-controlled trial of the impact of a gluten-free diet on quality of life in patients with axial spondyloarthritis

INTRODUCTION

Subclinical intestinal inflammation and gut dysbiosis have been reported in patients with spondyloarthritis (SpA). In common practice, rheumatologists are increasingly confronted with patients with inflammatory rheumatism who are on gluten-free diets (GFDs), despite the lack of reliable data from controlled studies. This study aims to determine the impact of a GFD on the quality of life of patients with axial SpA.

METHODS AND ANALYSIS

The GlutenSpA study is a 24-week, randomised, double-blinded, placebo-controlled, multicentre trial. Patients with axial SpA (n=200) will follow a 16-week GFD and be randomly assigned (1:1) to an experimental or control arm. In the experimental arm with receive at least 6 gluten-free breads per day + 200 g of gluten-free penne pasta per week + 6 rice flavour capsules per day. The control arm will receive at least 6 gluten-containing breads per day + 200 g of gluten-containing penne pasta per week + 6 vital gluten-containing capsules per day. The primary end-point is the variation in Assessment of SpondyloArthritis International Society-Health Index (ASAS-HI) questionnaire between week 16 and baseline. A second open-label period of 8 weeks will follow the intervention period, during which the patient will be free to decide whether they will follow the GFD. The secondary outcomes comprise several patient-reported outcomes (SpA activity (Bath Ankylosing Spondylitis Disease Activity Index)), fatigue (Functional Assessment of Chronic Illness Therapy), depression (Hospital Anxiety and Depression Scale), functional disability index (Bath Ankylosing Spondylitis Functional Index)), variations in body mass index and Homeostasis Model Assessment Index and variations in the abundance and type of bacterial species found in the gut microbiota for a subgroup of patients (n=40). The data will be analysed using the intention-to-treat principle.The regional ethics committee (CPP Nord-ouest IV) has approved the study (IDRCB 2018-A00309-46). The results of the trial will be submitted for publication in peer-reviewed journals. The authors have no relationship that may have influenced the submitted work.

TRIAL REGISTRATION NUMBER

NCT04274374.

Foot-Worn Inertial Sensors Are Reliable to Assess Spatiotemporal Gait Parameters in Axial Spondyloarthritis under Single and Dual Task Walking in Axial Spondyloarthritis

The aim of this study was (1) to evaluate the relative and absolute reliability of gait parameters during walking in single- and dual-task conditions in patients with axial spondyloarthritis (axSpA), (2) to evaluate the absolute and relative reliability of dual task effects (DTE) parameters, and (3) to determine the number of trials required to ensure reliable gait assessment, in patients with axSpA. Twenty patients with axSpa performed a 10-m walk test in single- and dual-task conditions, three times for each condition. Spatiotemporal, symmetry, and DTE gait parameters were calculated from foot-worn inertial sensors. The relative reliability (intraclass correlation coefficients-ICC) and absolute reliability (standard error of measurement-SEM and minimum detectable change-MDC) were calculated for these parameters in each condition. Spatiotemporal gait parameters showed good to excellent reliability in both conditions (0.59 < ICC < 0.90). The reliability of symmetry and DTE parameters was low. ICC, SEM, and MDC were better when using the mean of the second and the third trials. Spatiotemporal gait parameters obtained from foot-worn inertial sensors assessed in patients with axSpA in single- and dual-task conditions are reliable. However, symmetry and DTE parameters seem less reliable and need to be interpreted with caution. Finally, better reliability of gait parameters was found when using the mean of the 2nd and the 3rd trials.

Increased high molecular weight adiponectin and lean mass during tocilizumab treatment in patients with rheumatoid arthritis: a 12-month multicentre study

Background

Patients with rheumatoid arthritis (RA) have an increased risk of cardiovascular (CV) disease. Adiponectin is involved in the metabolism of glucose and lipids with favourable effects on CV disease, especially its high molecular weight (HMW) isoform. Body composition changes are described in RA with various phenotypes including obesity. The effects of tocilizumab on serum adiponectin and body composition, especially fat mass, in patients with RA are not well determined.

Methods

Patients with active RA despite previous csDMARDs and/or bDMARDs and who were tocilizumab naïve were enrolled in a multicentre open-label study. They were evaluated at baseline, 1, 3, 6 and 12 months. Clinical assessment included body mass index (BMI) and anthropometric measurements. Lipid and metabolic parameters, serum adiponectin (total and HMW), leptin, resistin and ghrelin were measured at each time point. Body composition (lean mass, fat mass, % fat, fat in the android and gynoid regions) was evaluated at baseline, 6 and 12 months.

Results

One hundred seven patients were included. Both total and HMW adiponectin significantly increased from baseline to month 3, peaking respectively at month 3 (p = 0.0105) and month 1 (p < 0.0001), then declining progressively until month 6 to 12 and returning to baseline values. Significant elevation in HMW adiponectin persisted at month 6 (p = 0.001). BMI and waist circumference significantly increased at month 6 and 12, as well as lean mass at month 6 (p = 0.0097). Fat mass, percentage fat and android fat did not change over the study period. Lipid parameters (total cholesterol and LDL cholesterol) increased while glycaemia, insulin and HOMA-IR remained stable. Serum leptin, resistin and ghrelin did not change during follow-up.

Conclusions

Tocilizumab treatment in RA patients was associated with a significant increase in total and HMW adiponectin, especially at the onset of the treatment. Tocilizumab also induced a significant gain in lean mass, while fat mass did not change. These variations in adiponectin levels during tocilizumab treatment could have positive effects on the CV risk of RA patients. In addition, tocilizumab may have an anabolic impact on lean mass/skeletal muscle.

Trial registration

The ADIPRAT study was a phase IV open-label multicentre study retrospectively registered on ClinicalTrials.gov under the number NCT02843789 (date of registration: July 26, 2016).

Efficacy, safety and cost-effectiveness of a web-based platform delivering the results of a biomarker-based predictive model of biotherapy response for rheumatoid arthritis patients: a protocol for a randomized multicenter single-blind active controlled clinical trial (PREDIRA)

BACKGROUND

Rheumatoid arthritis (RA) is one of the leading chronic inflammatory rheumatism. First-line therapy with synthetic disease-modifying antirheumatic drugs (sDMARD) is insufficiently effective in 40% of cases and these patients are treated with biotherapies. The increased use of these drugs each year is becoming a public health issue with considerable economic burden. This cost is 20 times higher than that of sDMARD. However, among patients treated with biotherapies, clinical practice shows that about one third will not respond to the selected drug. In nonresponse cases, practitioners currently have no choice but to perform an empirical switching between different treatments, because no tool capable of predicting the response or nonresponse to these molecules is currently available.

METHODS

The study is a prospective, phase III, controlled, multicenter, and randomized, single-blind (patient) clinical trial, including RA patients with a previous failure to anti-TNF therapies. The main objective is the analysis of the clinical and pharmacoeconomic impact after 6 months of treatment. Intervention arm: prescription of biotherapy (rituximab, adalimumab, abatacept) using SinnoTest® software, a prediction software based on proteomic biomarkers. Control arm: prescription of biotherapy based on current practice, without the SinnoTest® software (any biotherapy). In addition, a substudy will be carried out within this trial to generate a biobank and further analyze the proteomic profile of the patients and their modification throughout the study.

DISCUSSION

This clinical trial study will be the first validation study of a biotherapy response prediction software, bringing personalized medicine into the management of RA. We expect that the findings from this study will bring several benefits for the patient and the Health Care System.

TRIAL REGISTRATION

ClincalTrials.gov NCT04147026 . Registered on 31 October, 2019.

OP0031 AN INCREASE IN SERUM CALPROTECTIN LEVEL IN ANCA-ASSOCIATED VASCULITIDES PATIENTS DURING MAINTENANCE THERAPY IS ASSOCIATED WITH MORE RELAPSE AND ACCELERATED RENAL FUNCTION DECLINE

Background:

Calprotectin (S100A8/A9), a protein secreted by activated neutrophils and monocytes in inflammatory conditions, is upregulated in active ANCA-associated vasculitides. Serum calprotectin level variation during induction therapy is associated with disease relapse in PR3-ANCA-associated vasculitides (1). However, the place of this biomarker during maintenance therapy is unknown.

Objectives:

To demonstrate whether variation in serum calprotectin level during maintenance therapy could be used as a biomarker predicting subsequent relapse in ANCA-associated vasculitides.

Methods:

Patients with ANCA-associated vasculitides in complete remission (BVAS=0) after induction therapy with cyclophosphamide and included in the MAINRITSAN trial (2) were analyzed. Patients were randomized to receive rituximab or azathioprine as maintenance therapy. Relapse was defined as the re-occurrence or new onset of disease attributable to active vasculitis. Accelerated decline renal function (estimated Glomerular Filtration Rate (eGFR) assessed using the MDRD equation) was defined in concordance with NICE 2015 guideline (3) as “a decrease in eGFR of 25% or more and a change in GFR category or a sustained decrease in eGFR of 15 ml/min/1.73m2over 12 months”. Calprotectin was assessed in the serum at inclusion and 6 months by ELISA (IDK® Calprotectin ELISA kit, Immunodiagnostik). We defined an increase in serum levels of calprotectin as a positive variation of calprotectin level at M6 compared to baseline.

Results:

Of all, 96 patients (female 45.8%, mean age 55.3±13.5, 69.8% PR3+, 62.5% ANCA positive at inclusion) had at least a calprotectin dosage (86 at baseline, 86 at M6 and 76 patients at this 2 time-point). Calprotectin level at baseline or 6 months was not significantly different between relapsing patients and those without relapse after 18 months of follow-up, whereas the calprotectin variation at M6 compared to baseline was higher in relapsing patients (n=10) (mean (SD) 17991 (±28972) ng/ml) than in patients not experiencing any relapse (n=66) (9419 (±50002) ng/mL; p=0.03). An increase in serum calprotectin level at 6 months was significantly associated with an increased risk of relapse in PR3-ANCA patients (OR=5.6 (95%CI, 1.0-31.3; p=0,049) but not in the whole study group (OR=3.3 (95%CI, 0.8-14.1; p=0.1), and identified patients with accelerated renal function decline (all cohort: OR=10.6 (95%CI, 2.9-39.6; p=0.002; PR3+ patients: OR=5.909 (95%CI, 2.9-39.6; p=0.01)), whereas calprotectin level did not correlate with glomerular filtration rate (r = -0.07, p=0.35).

Conclusion:

An increase in serum calprotectin during the first 6 months of maintenance therapy in ANCA-associated vasculitides is a useful biomarker predicting vasculitis relapse and accelerated renal function deterioration in the following 12 months.

Increase calprotectin serum at 6 months identify relapser and accelerated decline renal function at 1 year.Kaplan-Meier survival curves of ANCA-associated vasculitis patients with an increase in serum calprotectin at 6 months (solid line) or not (dotted line) remaining total relapse-free or accelerated decline renal function-free. Gehan-Beslow-Wilcoxon test.

References:

[1]Pepper RJ et al. Arthritis Rheumatol. 2017;69(1):185-93.

[2]Guillevin L et al. N Engl J Med. 2014;371(19):1771-80.

[3]NIH. Chronic kidney disease 2014.

Acknowledgments:

Supported by a grant from the Programme Hospitalier de Recherche Clinique, French Ministry of Health (2008-002846-51).

Disclosure of Interests:

Xavier Romand Consultant of: Xavier ROMAND has received honorarium fees from Abbvie, Anais Courtier: None declared, Minh Vu Chuong Nguyen: None declared, Marie-Hélène Paclet: None declared, Philippe Gaudin Speakers bureau: Lilly, Loïc Guillevin: None declared, Benjamin Terrier: None declared, Athan Baillet Consultant of: Athan BAILLET has received honorarium fees from Abbvie for his participation as the coordinator of the systematic literature review

AB0665 VALVULOPATHY, SYSTOLIC AND DIASTOLIC DYSFUNCTION IN AXIAL SPONDYLOARTHRITIS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background:

Axial Spondyloarthritis (ax-SpA) displays an increased cardiovascular disease (CVD) risk compared with the general population. Although ischemic cardiac manifestations are well known, prevalence of non-ischemic manifestations such as myocardial dysfunction and valvulopathy is less clear.

Objectives:

To compare prevalence of myocardial dysfunction and valvulopathy by ultrasound in ax-SpA patients and versus healthy controls.

Methods:

Two investigators independently searched for studies indexed in PUBMED, Cochrane Library and EMBASE databases and published before January 17th 2020. The search was focused on ultrasound evaluation of myocardial function and valvulopathy, with two-dimensional, Doppler, tissue Doppler, and speckle tracking echocardiography. We included for meta-analysis all controlled studies including ax-SpA without previous cardiovascular disease. Data were pooled using appropriate random or fixed effects model.

Results:

Literature search retrieved of 186 abstracts. A total of 31 papers were included in the systematic review and 27 papers were analyzed in the meta-analysis (1,494 ax-SpA patients and 1,091 healthy controls). Studies displayed cross-sectional design and included ax-SpA without prevalent cardiovascular disease.

Ax-SpA was defined according to the modified New York criteria (24 studies) followed or the ASAS criteria (2 studies). HLA B27+ positivity ranged from 51 to 100%, mean age ranged from 26.7 to 55.7 years, disease duration ranged from 3.2 to 23.3 years and mean BASDAI ranged from 1.24 to 5.6.

Patients with ax-SpA displayed a lower diastolic function with a lower E/A ratio, a higher deceleration time, a higher isovolumetric relaxation time and a lower systolic function with a lower ejection fraction (figure 1). Left-ventricular end diastolic and systolic diameters were higher in ax-SpA patients with respectively mean difference 0.55 mm [CI95%; 0.19, 0.91] and 0.79 mm [CI95%; 0.40, 1.17]. We did not find any difference for left and posterior ventricular thickness, left atrial dimension, and left ventricular mass index.

Figure 1.

Systolic and diastolic dysfunction is slightly altered in ax-SpA patients compared to healthy individuals Diastolic dysfunction was assessed by (A) E/A ratio (m/s), (B) deceleration time (ms), (C) Isovolumetric relaxation time (ms) and (D) systolic function was assessed by ejection fraction (%).

A total of 15 articles reported prevalence of valvulopathy in ax-SpA. Prevalence of mitral regurgitation and aortic regurgitation were similar in ax-SpA patients and healthy individuals: OR=1.13 [CI95% 0.76, 1.68] and OR=1.18 [CI95% 0.68, 2.04].

Conclusion:

Prevalence of valvulopathy was similar in ax-SpA and healthy individuals. Diastolic and systolic function seems to be slightly altered in ax-SpA compared to healthy controls. However, this difference is unlikely clinically relevant. Usefulness of systematic echography remains to be determined in future longitudinal studies.

Disclosure of Interests:

Fanny Adeline: None declared, Xavier Romand Consultant of: Xavier ROMAND has received honorarium fees from Abbvie, Mickael Dalecky Consultant of: Mickael DALECKY has received honorarium fees from Abbvie, Arnaud Pfimlin Consultant of: Arnaud PFIMLIN has received honorarium fees from Abbvie, Daniel Wendling: None declared, Philippe Gaudin Speakers bureau: Lilly, Pascal Claudepierre Speakers bureau: Janssen, Novartis, Lilly, Maxime Dougados Grant/research support from: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Consultant of: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Speakers bureau: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Athan Baillet Consultant of: Athan BAILLET has received honorarium fees from Abbvie for his participation as the coordinator of the systematic literature review

THU0539 IMPACT OF BODY MASS INDEX ON THE AGREEMENT BETWEEN ULTRASOUND- AND CLINICAL ASSESSMENTS OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS: MULTICENTRE AND CROSS-SECTIONAL STUDY

Background:

Clinical assessment of swollen joint count (SJC) in rheumatoid arthritis (RA) might be affected by obesity in terms of obesity-related excess adipose tissue.

Objectives:

To compare the level of agreement between synovitis evaluated by Power Doppler ultrasound (PDUS) and clinical examination (SJC as component of SDAI) in obese (O) (i.e. Body Mass Index (BMI) >30) versus non-obese (NO) (BMI≤30) RA patients.

Methods:

RA patients ≥18 years fulfilling 2010 ACR-EULAR criteria were included in the cross-sectional multicentre (13 centres) French observational RABODI study (ClinicalTrials.gov Identifier:NCT03004651). Clinical synovitis was evaluated on 44 joints. ESR and CRP were collected and SDAI, DAS28, DAS were calculated. A standard US examination on 44 joints was performed by an independent investigator blinded to clinical data. US synovitis was defined by a synovial hypertrophy ≥1 and PD signal≥1 on a semi-quantitative scale according to the EULAR-OMERACT scoring system. Levels of agreement between number of synovitis defined by PDUS and clinical examination were compared in O versus NO patients using Chi2 test, and Kappas (k) and ORs were calculated. A patient was considered “discordant” if ≥1 joint was discordantly classified by PDUS and clinical examination. SDAI was calculated and compared, with SJC defined either by clinical examination or PDUS.

Results:

121 patients were included: mean (SD) age of 58.5 (12.7) years, mean disease duration of 11.1 (9.7) years. 81% were female, 84.3% anti-CCP positive, 63.6% had erosive disease. Mean SDAI was 12.6 (±10.2). 53 (43.8%) had a BMI >30 and 68 (56.2%) ≤30. 59 (48.7%) and 62 (51.2%) had a SDAI≤11 and >11, respectively. The 2 groups were comparable, except for weight (mean (SD) 65.4 (13.5) vs 96.7 (14.7) kg, p< 0.001), some comorbidities (diabetes, asthma and fibromyalgia more frequent in O patients), tender joint count (mean 4.04 (±5.23) in NO vs 7.38 (±8.64) in O, p=0.021). Mean number of SJC was 2.4 (3.3), and PDUS 6.7 (±6.3). Levels of agreement between clinical and PDUS findings were comparable in O vs. NO patients regarding SDAI and other scores (Table). Patients with ≥3 discordant joints were numerically higher in O patients compared to NO (26/53 (49.1%) vs 22/68 (32.4%), p=0.062). At the joint level, discordance was higher in O patients in MCP4 (p=0.057), wrist (p=0.089).

Table.

Level of agreement between PDUS synovitis and SJC in obese versus normally weighted RA patients

Score with PDUS vs. SJCBMI ≤ 30N=68BMI > 30N=53OR(95%CI)P*SDAINon-Discordant (ND)63461.92(0.57-6.42)0.28Discordant (D)57Kappa0.850.73DAS28ND62471.32(0.4-4.35)0.64D66Kappa0.810.77DAS44ND63520.24(0.03-2.14)0.23D51Kappa0.830.96≥1 synovitisND51351.54(0.7-3.4)0.28D1718Kappa0.500.32

Conclusion:

In RA patients, despite a perceived higher difficulty to clinically detect SJ in O patients, the discrepancy between clinically- and PDUS defined synovitis was not significantly higher than in NO patients, and did not impact the extend of the definition of disease activity level.

Disclosure of Interests:

Gael Mouterde: None declared, Federico Manna: None declared, Benoit Le Goff: None declared, Jean-David Albert: None declared, Sandrine Jousse-Joulin: None declared, Frederique Gandjbakhch: None declared, Damien LOEUILLE: None declared, Philippe Gaudin Speakers bureau: Lilly, Muriel PIPERNO: None declared, BANAL Frédéric: None declared, Bénédicte Jamard: None declared, Carine Salliot: None declared, Nicolas Molinari: None declared, Bernard Combe Grant/research support from: Novartis, Pfizer, Roche-Chugai, Consultant of: AbbVie; Gilead Sciences, Inc.; Janssen; Eli Lilly and Company; Pfizer; Roche-Chugai; Sanofi, Speakers bureau: Bristol-Myers Squibb; Gilead Sciences, Inc.; Eli Lilly and Company; Merck Sharp & Dohme; Pfizer; Roche-Chugai; UCB, Maria-Antonietta D’Agostino: None declared, Cédric Lukas: None declared

THU0393 INFLAMMATORY BOWEL DISEASES AMONG SECUKINUMAB-TREATED PATIENTS: 24 CASES FROM THE MISSIL REGISTRY

Background:

An alert regarding about the tolerance of Interleukin 17 (IL-17) inhibitors has been issued from data of randomized controlled trials showing cases of de novo inflammatory bowel diseases (IBD). In a recent analysis of pooled data from 21 clinical trials, cases of IBD events (including Crohn’s disease (CD), ulcerative colitis (UC) and inflammatory bowel disease unclassified (IBDU)) were uncommon (1). Yet, real-world data are lacking.

Objectives:

To describe real-world data about patients treated by IL-17 inhibitors developing new onset IBD (CD or UC).

Methods:

A French national registry called MISSIL was started in February 2018 to collect the cases of patients treated by IL-17 inhibitors developing new onset IBD. This registry is conducted by rheumatologist, dermatologist and gastroenterologist learned societies specialized on immune-mediated inflammatory diseases. In France, secukinumab (SEK) has been granted market authorization since June 2016 and ixekizumab since April 2018.

Results:

24 cases under SEK were reported between February 2018 and January 2020: 3 patients with psoriasis and 21 patients with spondylwoarthritis. There were 20 patients with new onset CD and 4 with UC. Mean age was 51.7 ± 15.7 years old and 12/24 were female; 10 presented an axial spondyloarthritis, 5 a peripheral spondyloarthritis and 6 both,13/17 were HLA-B27 positive,7/19 had a radiographic sacroiliitis and 11/17 a MRI sacroiliitis. Only 2 were biological Disease-modifying antirheumatic drug (bDMARD)-naïve. Crohn’s disease was mainly located at the ileum, colon and rectum. The median time to onset of symptoms was 2 (1-6) months. The main symptoms were diarrhea, nausea and vomiting and loss of weight. Median CRP at the onset of symptoms was 68 mg/L (41-140.5); 21 patients underwent biopsies, 12 were in favor of CD. IL-17 inhibitors were consistently stopped. Patients were treated by corticosteroids (16/24), mesalazine (7/24), methotrexate (3/24), thiopurines (2/24), infliximab (9/243), adalimumab (3/24), golimumab (2/24), ustekinumab (5/24). The evolution was favorable under treatment with complete resolution (4/24), improvement (11/24) or stabilization (5/24). 3 patients worsened under treatment and 1 died (massive myocardial infarction).

Conclusion:

IBD flare in patients treated with IL-17 inhibitors are rare and lead to discuss the potential iatrogenic role of IL-17 inhibitor drugs. Further cases are needed to better characterize this complication. A case-control study will be conducted to identify patients at risk to develop IBD under IL-17 inhibitor.

References:

[1]Reich et al. Incidence rates of inflammatory bowel disease in patients with psoriasis, psoriatic arthritis and ankylosing spondylitis treated with secukinumab: a retrospective analysis of pooled data from 21 clinical trials. Ann Rheum Dis. 2019;78:473-479

Disclosure of Interests:

Jean-Guillaume Letarouilly Grant/research support from: Research grant from Pfizer, Benjamin Pariente: None declared, Delphine Staumont-Sallé Speakers bureau: Lilly, Novartis, Philippe Goupille Grant/research support from: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Consultant of: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Speakers bureau: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Pascal Claudepierre Speakers bureau: Janssen, Novartis, Lilly, Stephane Varin: None declared, Sylvain Lanot: None declared, Emmanuelle Dernis Speakers bureau: Lilly, Novartis, Tristan Pascart Speakers bureau: Novartis, Lilly, Beatrice Banneville Speakers bureau: Lilly, Novartis, Pauline Baudart: None declared, Bruno Gombert: None declared, Elodie BAUER: None declared, Laurianne Plastaras: None declared, Sébastien Barbarot: None declared, Renaud FELTEN: None declared, Loïc Le Dantec: None declared, Nathalie Sultan-Bichat: None declared, Céline Girard: None declared, Arnaud Constantin Grant/research support from: Study was sponsored by Sanofi Genzyme, Consultant of: Consulting fees from Abbvie, BMS, Celgene, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, Daniel Wendling: None declared, Philippe Gaudin Speakers bureau: Lilly, Denis Jullien Speakers bureau: Lilly, Novartis, Thao Pham Speakers bureau: Novartis, Janssen, Lilly, Rene-Marc Flipo Speakers bureau: Novartis, Janssen, Lilly

Rheumatoid Meningitis a Rare Extra-Articular Manifestation of Rheumatoid Arthritis: Report of 6 Cases and Literature Review

Objectives. Central neurological manifestations of rheumatoid arthritis (RA) like rheumatoid meningitis (RM) are rare, little known and have a high rate of morbi-mortality. METHODS. We described six cases of RM that were directly related to RA activity after exhaustive assessment. RESULTS. They were mainly women, aged of 50 to 69. All were positive for anti-cyclic citrullinated peptide antibodies and half for rheumatoid factors. RA activity, duration, and treatments were heterogeneous including oral steroids, conventional synthetic disease modifying anti-rheumatic drugs (DMARDs) and biologic DMARDs. Symptoms were various, with acute or progressive beginning; main were: generalized or focal seizure (4/6), fever (3/6), headaches (3/6), and frontal syndrome (2/6). Imaging lesions were four leptomeningitis, one pachymeningitis, and one association of both. MRI usually showed hypersignal in various territories in T2-FLAIR (fluid attenuated inversion recovery) mode, and enhancement in T1-weighted mode after gadolinium injection. All patients had lumbar puncture that found sterile cerebrospinal fluid, no neoplasic cell, elevated cell count in 5/6 cases and elevated proteins concentration in 3/6 cases. Cerebral biopsy was possible for three patients, and definitively confirmed the diagnosis of aseptic lepto- or pachymenintis, excluding vasculitis and lymphoma. Different treatments were used like intravenous high dose steroids, immunoglobulins or biologic DMARDs, with variable clinical and imaging outcome: one death, one complete recovery, and four recoveries with sequelae. Conclusions. Clinical symptoms, imaging, lumbar puncture, and serological studies are often nonspecific, only histologic examination can confirm the diagnosis of RM. Any central neurological manifestation in RA patients, even in quiescent and ancient RA, should warn the physician.

Evaluation of the impact of a nurse-led program of systematic screening of comorbidities in patients with axial spondyloarthritis: The results of the COMEDSPA prospective, controlled, one year randomized trial

OBJECTIVE

To evaluate the impact of a nurse-led program of systematic screening for the management (detection/prevention) of comorbidities.

METHODS

Prospective, randomized, controlled, open, 12-month trial (NCT02374749).

PARTICIPANTS

consecutive patients with axial Spondyloarthritis (axSpA) (according to the rheumatologist) THE PROGRAM: A nurse collected data on comorbidities during a specific outpatient visit. In the event of non-agreement with recommendations, the patient was informed and a specific recommendation was given to the patient (orally and in a with a detailed written report). Patients were seen after one year in a nurse-led visit. TREATMENT ALLOCATION: random allocation (i.e. either this program or an educational program not presented here and considered here as the control group).

MAIN OUTCOME

change after one year of a weighted comorbidity management score (0 to 100 where 0= optimal management).

RESULTS

502 patients were included (252 and 250 in the active and control groups, respectively): age: 47±12 years, male gender: 63%, disease duration: 14±11y. After one year, no differences were observed in a weighted comorbidity management score. However, the number of patients in agreement with recommendations was significantly higher in the active group for vaccinations (flu vaccination: 28.6% vs. 9.9%, p<0.01; pneumococcal vaccination:40.0% vs. 21.1%,p=0.04), for cancer screening (skin cancer screening: 36.3% vs. 17.2%, p=0.04) and for osteoporosis (bone densitometry performed: 22.6% vs. 8.7%, p<0.01; Vitamin D supplementation initiation: 51.9% vs. 9.4%, p<0.01).

CONCLUSIONS AND RELEVANCE

This study suggests the short-term benefit of a single-visit nurse-led program for systematic screening of comorbidities for its management in agreement with recommendations, even in this young population of patients with axSpA.

Data to be collected for an optimal management of axial spondyloarthritis in daily practice: Proposal from evidence-based and consensual approaches

OBJECTIVE

To propose a list of variables to be collected right after the diagnosis has been made and during the follow-up of patients with axial spondyloarthritis (ax-SpA) for an optimal management in daily practice.

METHODS

The process comprised (1) the evaluation of the interest of 51 variables proposed for the assessment of ax-SpA by means of a systematic literature research; (2) a consensus process involving 78 hospital-based or office-based rheumatologists, considering the collection of each variable in a 4 grade scale from "not very useful/useless" to "mandatory"; (3) a consensus on the minimum interval of time for periodic assessment of the selected variables on a 5 grade scale from "at each visit" to "never to be re-collected".

RESULTS

The systematic literature research retrieved a total of 14,133 abstracts, of which 213 were included in the final qualitative synthesis. Data to be collected at the initial systematic review comprised 5 patient's self-administered questionnaires, 3 variables of the physician's interview, 2 variables of the physical examination, 2 variables of the specific ax-SpA imaging and 2 other investigations. Two variables were recommended to be systematically collected at each visit, 1 variable twice a year, 6 variables yearly and 1 variable every 2 years.

CONCLUSIONS

Using an evidence-based and an expert consensus approaches, this initiative defined a core set of variables to be collected and reported right after the diagnosis and during follow-up of patients with ax-SpA in daily practice.

Fetuin-A and thyroxin binding globulin predict rituximab response in rheumatoid arthritis patients with insufficient response to anti-TNFα

OBJECTIVES

Rheumatoid arthritis (RA) is a debilitating disease, but patient management and treatment have been revolutionized since the advent of bDMARDs. However, about one third of RA patients do not respond to specific bDMARD treatment without clear identified reasons. Different bDMARDs must be tried until the right drug is found. Here, we sought to identify a predictive protein signature to stratify patient responsiveness to rituximab (RTX) among patients with an insufficient response to a first anti-TNFα treatment.

METHODS

Serum samples were collected at baseline before RTX initiation. A proteomics study comparing responders and nonresponders was conducted to identify and select potential predictive biomarkers whose concentration was measured by quantitative assays. Logistic regression was performed to determine the best biomarker combination to predict good or nonresponse to RTX (EULAR criteria after 6 months' treatment).

RESULTS

Eleven biomarkers potentially discriminating between responders and nonresponders were selected following discovery proteomics. Quantitative immunoassays and univariate statistical analysis showed that fetuin-A and thyroxine binding globulin (TBG) presented a good capacity to discriminate between patient groups. A logistic regression analysis revealed that the combination of fetuin-A plus TBG could accurately predict a patient's responsiveness to RTX with an AUC of 0.86, sensitivity of 80%, and a specificity of 79%.

CONCLUSION

In RA patients for whom a first anti-TNFα treatment has failed, the serum abundance of fetuin-A and TBG before initiating RTX treatment is an indicator for their response status at 6 months. ClinicalTrials.gov identifier: NCT01000441. Key Points • Proteomic analysis revealed 11 putative predictive biomarkers to discriminate rituximab responder vs. nonresponder RA patients. • Fetuin-A and TBG are significantly differentially expressed at baseline in rituximab responder vs. nonresponder RA patients. • Algorithm combining fetuin-A and TBG accurately predicts response to rituximab in RA patients with insufficient response to TNFi.

Calprotectin discriminates septic arthritis from pseudogout and rheumatoid arthritis

OBJECTIVE

We aimed to determine whether calprotectin and α-defensins could discriminate septic from other inflammatory arthritides.

METHODS

Synovial fluids with a predominance of neutrophils from patients with septic arthritis, pseudogout and RA were prospectively collected. Neutrophil-related proteins calprotectin and human neutrophil α-defensins levels were assessed in synovial fluids. Demographic parameters and biomarkers with P-value ⩽0.05 for differentiating septic from non-septic arthritis were included in a multivariable model. Multivariable logistic regression with stepwise selection was performed to build the final combined model.

RESULTS

A total of 74 patients were included: septic arthritis (n = 26), pseudogout (n = 28) and RA (n = 20). Patients with septic arthritis were more likely to be male and young, and to display higher synovial neutrophil count. Calprotectin was significantly increased in patients with septic arthritis. The multivariable model included calprotectin, synovial fluid neutrophil count and gender. Calprotectin was the only biomarker that discriminated septic arthritis from non-septic inflammatory arthritides, with 76% sensitivity, 94% specificity and a positive likelihood ratio = 12.2 at the threshold for calprotectin of 150 mg/l.

CONCLUSION

Synovial fluid calprotectin is a relevant biomarker to discriminate septic arthritis from other inflammatory arthritides. This biomarker should be tested in an independent cohort.

X-ray Phase Contrast osteo-articular imaging: a pilot study on cadaveric human hands

X-ray Phase Contrast Imaging (PCI) is an emerging modality whose availability in clinics for mammography and lung imaging is expected to materialize within the coming years. In this study, we evaluate the PCI Computed Tomography (PCI-CT) performances with respect to current conventional imaging modalities in the context of osteo-articular disorders diagnosis. X-ray PCI-CT was performed on 3 cadaveric human hands and wrists using a synchrotron beam. Conventional CT, MRI and Ultrasound were also performed on these three samples using routine procedures as well as research protocols. Six radiologists and rheumatologists independently evaluated qualitatively and semi quantitatively the 3D images' quality. Medical interpretations were also made from the images. PCI-CT allows the simultaneous visualization of both the high absorbing and the softer tissues. The 6 reader evaluations characterized PCI-CT as a visualization tool with improved performances for all tissue types (significant p-values), which provides sharper outlines and clearer internal structures than images obtained using conventional modalities. The PCI-CT images contain overall more information, especially at smaller scales with for instance more visible micro-calcifications in our chondrocalcinosis case. Despite a reduced number of samples used, this pilot study highlights the possible medical benefits of PCI for osteo-articular disorders evaluation. Although PCI-CT is not yet available in hospitals, the improved visualization capabilities demonstrated so far and the enhanced tissue measurement quality let suggest strong diagnosis benefits for rheumatology in case of a widespread application of PCI.

Copper phytoavailability in vineyard topsoils as affected by pyoverdine supply

Pyoverdine (Pvd) is a bacterial siderophore produced by some Pseudomonads species that can bind copper in addition to iron in soil. Pvd is expected to alter the dynamics and the ecotoxicity of Cu in vineyard soils. This study investigated the extent to which the mobility and the phytoavailability of Cu varied among vineyard soils with different pH and how they were affected by a supply of Pvd. Pvd was supplied (or not) to ten vineyard topsoils with pH ranging from 5.9 to 8.6 before metal was extracted with 0.005 M CaCl₂. Cu mobility was assessed through its total concentration and Cu phytoavailability through its free ionic concentration measured in the CaCl₂ extract. Cu mobility varied by a factor of six and Cu phytoavailability by a factor of 5000 among the soil samples. In the CaCl₂ extract, the concentration of Cu²⁺ was not correlated with the concentration of total Cu but was correlated with pH. This revealed that Cu phytoavailability depends to a great extent on Cu complexation in soil pore water, the latter being highly sensitive to pH. Adding Pvd enhanced the mobility of Cu in the soils including in carbonate soils. The Pvd-mobilization factor for Cu varied from 1.4 to 8 among soils, linked to the availability of Fe and Al in the solid phase and to Pvd partitioning between the solid and the liquid phase. Adding Pvd reduced the concentration of Cu²⁺ in CaCl₂ extract, which challenges the idea of using Pvd-producing bacteria to promote Cu phytoextraction.

Two-year abatacept retention rate in clinical practice in the French ACTION cohort

OBJECTIVES

Abatacept retention rates were evaluated in the French cohort in the prospective ACTION study (2010-2013), which included patients with moderate-to-severe rheumatoid arthritis managed in everyday clinical practice and started on intravenous abatacept therapy.

METHODS

Two-year abatacept retention rates were evaluated in 455 patients classified according to treatment line, body mass index (BMI), and status for rheumatoid factor (RF) and anti-citrullinated peptide antibody (ACPA).

RESULTS

After 2 years, the overall abatacept retention rate was 44%. The retention rate was non-significantly higher in the patients with vs. without a history of unresponsiveness to at least one biologic (48.1% vs. 41.8%, respectively). No significant retention rate differences were found across BMI categories (444 patients; <25, 45.5%; ≥25 to <30, 48.9%; and ≥30, 36.6%). Neither were any significant differences demonstrated according to RF and ACPA status (RF+ and ACPA+, 45.7%; RF+ or ACPA+, 43.8%; and FR- and ACPA-, 39.1%).

CONCLUSION

The 44% 2-year retention rate in the French ACTION cohort supports the usefulness of abatacept therapy. In this study, retention was not associated with treatment line, BMI, or antibody status.

Short-term Efficiency and Tolerance of Ketoprofen and Methylprednisolone in Acute Sciatica: A Randomized Trial

OBJECTIVE

Although anti-inflammatory drugs are commonly used in acute discogenic sciatica, data regarding their efficacy are scarce and controversial. We compared the efficacy and safety of intravenous ketoprofen and methylprednisolone with placebo in sciatica.

DESIGN

Multicenter, double-blinded randomized controlled trial.

SUBJECTS

Patients with confirmed discogenic acute sciatica, without neurologic deficit, were randomized into three arms.

METHODS

Besides standard-of-care analgesic therapy, they received intravenous injections of methylprednisolone (60 mg/d) or ketoprofen (200 mg/d) or placebo for five days. The primary outcome was leg pain over five days. Secondary outcomes were clinical responses at days 3 and 5, lumbar pain, Straight Leg Raise Test and lumbar flexion index, analgesic consumption, realization of lumbar spine injections, and surgery during the study period.

RESULTS

Fifty-four patients were randomized, and 50 completed the study. In patients admitted to the hospital for pain control with acute lumbar radicular pain due to intervertebral disc herniation and receiving an oral analgesic protocol including paracetamol, nefopam, tramadol, and morphine, there was no additional analgesic effect seen between groups. There was no significant difference in leg pain between the three groups over the study period. In the methylprednisolone group, however, we observed a higher rate of clinically relevant responses at day 3. No difference was observed on other secondary efficacy outcomes and safety.

CONCLUSION

No significant difference in leg pain was observed between groups. However, there was a higher proportion of patients relieved with intravenous methylprednisolone at day 3, compared with ketoprofen or placebo.

Infliximab Induced a Dissociated Response of Severe Periodontal Biomarkers in Rheumatoid Arthritis Patients

OBJECTIVE

Rheumatoid arthritis and periodontal disease are associated together, but the effect of therapy provided for one disease to the second one remained under-investigated. This study investigated effect of infliximab therapy used to treat rheumatoid arthritis (RA) on various biomarkers of periodontal disease (PD) severity including serologies of Porphyromonas gingivalis and Prevotella intermedia and matrix metalloproteinase 3.

METHODS

Seventy nine RA patients were enrolled at the time to start infliximab therapy and the 28 joint disease activity score (DAS28), anti-cyclic citrullinated petides 2nd generation (anti-CCP2), anti-P. gingivalis antibody, and Matrix metalloproteinase 3 (MMP-3) were monitored before and at 6 months of infliximab therapy. Joint damage and severe periodontal disease were assessed at baseline. Anti-CCP2, anti-P. gingivalis antibody, and MMP-3 were determined by enzyme-linked immunosorbent assay (ELISA).

RESULTS

At baseline, anti-CCP2 titers were associated with anti-P. gingivalis lipopolysaccharide (LPS)-specific antibodies titers (p < 0.05). Anti-P. gingivalis antibodies were not significantly correlated with clinical, biological, or destruction parameters of RA disease. At 6 months of infliximab therapy, MMP-3 level decreased (from 119 ± 103 ng/mL to 62.44 ± 52 ng/mL; p < 0.0001), whereas P. gingivalis antibody levels remained at the same level. DAS28 and inflammation markers C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR) also decreased significantly during infliximab therapy (p < 0.05) as anti-CCP2 levels (p < 0.001). Only high MMP-3 level at baseline was associated with infliximab efficacy (p < 0.01).

CONCLUSION

MMP-3 level can be a useful marker of the efficacy of infliximab in RA patients. The treatment did not affect anti-P. gingivalis antibodies.

A randomised, double-blind, placebo-controlled study assessing the efficacy of high doses of vitamin D on functional disability in patients with rheumatoid arthritis

OBJECTIVES

To evaluate the short-term efficacy of vitamin D (cholecalciferol) supplementation on functional disability in RA patients.

METHODS

1) Patients: RA (ACR 1987 revised criteria) in non-remission (DAS28 >2.6) whose treatment was not expected to be changed over a 3-month period following inclusion and presenting with vitD deficits (serum 25OHD <30ng/mL). 2) Study design: prospective randomised placebo-controlled trial (NCT02243800). 3) Study arms: either vitD ampoules (cholecalciferol 100,000IU) or placebo. 4) Outcome measures: primary: improvement in patients' functional disability using the Health Assessment questionnaire (HAQ); secondary: improvement in DAS28ESR, DAS28CRP, ESR, CRP, RAID score, fatigue (EVA and FACIT), and SF36.

RESULTS

Overall, 59 patients were included, 83.1% females, aged 59.8±10.9 years on average, with RA for 17.0±9.7 years. Thirty patients received placebo and 29 vitD. At 6 months, HAQ scores tended to be increased in the placebo group (+0.08±0.25), while slightly numerically decreased in the vitD group (-0.03±0.23) (p=0.11). After adjusting for age, gender, season, and initial vitD status, the between-group difference achieved statistically significance (p=0.046). After adjusting for age, gender, season, and initial vitD status, there was no significant difference in the secondary criteria between the 2 groups except for ESR and CRP (p=0.002 and 0.04, respectively).

CONCLUSIONS

In this randomised, double-blind, placebo-controlled clinical trial in patients with RA and VitD deficiency, high doses of cholecalciferol resulted in a statistically significant improvement in functional disability at month 6, which, however, was clinically not relevant.

Moderate alcohol consumption is associated with increased radiological progression in women, but not in men, with early rheumatoid arthritis: results from the ESPOIR cohort (Étude et Suivi des Polyarthrites Indifférenciées Récentes)

OBJECTIVE

We conducted this study to determine whether alcohol consumption influences radiological progression in early rheumatoid arthritis (RA).

METHOD

Patients fulfilling the European League Against Rheumatism/American College of Rheumatology 2010 criteria in the early arthritis cohort ESPOIR (Étude et Suivi des Polyarthrites Indifférenciées Récentes) were included in this study. Alcohol consumption was collected at baseline and at each visit. We classified alcohol consumption into three groups: abstinent (0 g/day), moderate (≤ 20 g/day for women, ≤ 30 g/day for men), and abuse (> 20 g/day for women, > 30 g/day for men). The primary outcome was the occurrence of radiological progression, defined as an increase ≥ 5 points in the total Sharp/van der Heijde score. We investigated whether alcohol consumption is predictive of radiological progression at 1, 3, and 5 years by univariate and multivariate analysis adjusted for age, baseline erosion, rheumatoid factor, anti-citrullinated peptide antibody, smoking status, body mass index, and treatment with leflunomide or methotrexate and biologics.

RESULTS

The study included 596 patients. When considering the influence of gender on the interaction between alcohol consumption and radiological progression, we showed a deleterious effect of moderate consumption in women [odds ratio (OR) = 1.73, 95% confidence interval (CI) 1.01; 2.96, p = 0.045] and a trend towards a protective effect of moderate consumption in men (OR = 0.50, 95% CI 0.21; 1.16, p = 0.106) in multivariate analysis.

CONCLUSION

Our data suggest a deleterious effect of moderate consumption of alcohol on radiological progression in women, but not in men, with early RA.

A reassessment of the carnivorous status of salmonids: Hepatic glucokinase is expressed in wild fish in Kerguelen Islands

Salmonids belong to a high trophic level and are thus considered as strictly carnivorous species, metabolically adapted for high catabolism of proteins and low utilisation of dietary carbohydrates. However they conserved a "mammalian-type" nutritional regulation of glucokinase encoding gene and its enzymatic activity by dietary carbohydrates which remains puzzling regarding their dietary regime. The present study investigates the hypothesis that this conservation could be linked to a real consumption by trout of this nutrient in their natural habitat. To do so, brown trout were sampled in the sub-Antarctic Kerguelen Islands, a site presenting oligotrophic hydrosystems and no local freshwater fish fauna prior the introduction of salmonids fifty years ago. Qualitative and quantitative analysis of carbohydrate content within Kerguelen trout stomachs demonstrate that these animals are fed on food resources containing digestible carbohydrates. Additionally, glycaemia and more particularly gck mRNA level and gck enzymatic activity prove that Kerguelen trout digest and metabolise dietary carbohydrates. Physiological and molecular analyses performed in the present study thus strongly evidence for consumption of dietary carbohydrates by wild trout in natural environments. Investigating differences between Kerguelen individuals, we found that smaller individuals presented higher glycaemia, as well as higher carbohydrates contents in stomach. However no relationship between scaled mass index and any physiological indicator was found. Thus it appears that Kerguelen trout do not turn to carbohydrate diet because of a different condition index, or that the consumption of carbohydrates does not lead to a generally degraded physiological status. As a conclusion, our findings may explain the evolutionary conservation of a "mammalian-type" nutritional regulation of gck by dietary carbohydrates in these carnivorous fish.