HLA-B27 did not protect against COVID-19 in patients with axial spondyloarthritis - data from the ReumaCov-Brasil Registry

BACKGROUND

Some studies have suggested the HLA-B27 gene may protect against some infections, as well as it could play a benefit role on the viral clearance, including hepatitis C and HIV. However, there is lack of SARS-CoV-2 pandemic data in spondyloarthritis (SpA) patients.

AIM

To evaluate the impact of HLA-B27 gene positivity on the susceptibility and severity of COVID-19 and disease activity in axial SpA patients.

METHODS

The ReumaCoV-Brasil is a multicenter, observational, prospective cohort designed to monitor immune-mediated rheumatic diseases patients during SARS-CoV-2 pandemic in Brazil. Axial SpA patients, according to the ASAS classification criteria (2009), and only those with known HLA-B27 status, were included in this ReumaCov-Brasil's subanalysis. After pairing them to sex and age, they were divided in two groups: with (cases) and without (control group) COVID-19 diagnosis. Other immunodeficiency diseases, past organ or bone marrow transplantation, neoplasms and current chemotherapy were excluded. Demographic data, managing of COVID-19 (diagnosis, treatment, and outcomes, including hospitalization, mechanical ventilation, and death), comorbidities, clinical details (disease activity and concomitant medication) were collected using the Research Electronic Data Capture (REDCap) database. Data are presented as descriptive analysis and multiple regression models, using SPSS program, version 20. P level was set as 5%.

RESULTS

From May 24th, 2020 to Jan 24th, 2021, a total of 153 axial SpA patients were included, of whom 85 (55.5%) with COVID-19 and 68 (44.4%) without COVID-19. Most of them were men (N = 92; 60.1%) with mean age of 44.0 ± 11.1 years and long-term disease (11.7 ± 9.9 years). Regarding the HLA-B27 status, 112 (73.2%) patients tested positive. There were no significant statistical differences concerning social distancing, smoking, BMI (body mass index), waist circumference and comorbidities. Regarding biological DMARDs, 110 (71.8%) were on TNF inhibitors and 14 (9.15%) on IL-17 antagonists. Comparing those patients with and without COVID-19, the HLA-B27 positivity was not different between groups (n = 64, 75.3% vs. n = 48, 48%, respectively; p = 0.514). In addition, disease activity was similar before and after the infection. Interestingly, no new episodes of arthritis, enthesitis or extra-musculoskeletal manifestations were reported after the COVID-19. The mean time from the first symptoms to hospitalization was 7.1 ± 3.4 days, and although the number of hospitalization days was numerically higher in the B27 positive group, no statistically significant difference was observed (5.7 ± 4.11 for B27 negative patients and 13.5 ± 14.8 for B27 positive patients; p = 0.594). Only one HLA-B27 negative patient died. No significant difference was found regarding concomitant medications, including conventional or biologic DMARDs between the groups.

CONCLUSIONS

No significant difference of COVID-19 frequency rate was observed in patients with axial SpA regarding the HLA-B27 positivity, suggesting a lack of protective effect with SARS-CoV-2 infection. In addition, the disease activity was similar before and after the infection.

TRIAL REGISTRATION

This study was approved by the Brazilian Committee of Ethics in Human Research (CONEP), CAAE 30186820.2.1001.8807, and was registered at the Brazilian Registry of Clinical Trials - REBEC, RBR-33YTQC. All patients read and signed the informed consent form before inclusion.

AB1173 INCIDENT CASES OF COVID-19 AND VACCINATION ADHERENCE IN A MULTICENTRIC COHORT OF INFLAMMATORY ARTHRITIS IN BRAZIL

Background

The SARS-CoV-2 virus has caused a worldwide health crisis. Patients with inflammatory arthritis are at higher risk of hospitalization and death by COVID-19 due to comorbidities or immunosuppressive treatments. Vaccination is one the most important strategies to control the pandemic.

Objectives

To evaluate the incident cases of SARS-CoV-2 infection in a multicentric cohort of inflammatory arthritis in Brazil.

Methods

BiobadaBrasil is a multicentric registry-based cohort study of Brazilian patients with rheumatic diseases starting their first bDMARD or tsDMARD (1). The present analysis is a retrospective evaluation of adult patients with inflammatory arthritis (rheumatoid arthritis – RA, spondylarthritis -SpA and psoriatic arthritis-PsA) that were alive since the beginning of the COVID-19 pandemics in Brazil in February 2020. We evaluated the incidence and severity of COVID-19 infection and the adherence to anti- SARS-CoV-2 vaccines schedules, up to January 2022.

Results

A total of 300 patients were interviewed and 69 (23.0%) reported confirmed anti-SARS-CoV infection and 5 (1.7%) had a second infection. Among known infected patients, 18.8% need hospitalization and oxygen support, 7.2% were admitted at ICU, and 5.8% died. After COVID-19 infection, 31.8% reported worsening of disease activity but only 6.1% had modification in medication due to disease activity. Distribution of cases followed the pattern of waves observed in Brazil (Figure 1). Regarding vaccination, 285 (95%) reported to have received at least one dose of any anti-SARS-CoV-2 vaccine: 43% received the first with the adenovirus ChAdOx1 nCoV-19 (AstraZeneca) adenovirus vaccine, 32% received the Sinovac-CoronaVac inactivated vaccine, 22% received the BNT162b2 (Pfizer-BioNtech) mRNA vaccine and 3% received the BNT162b2 (Pfizer-BioNtech) adenovirus vaccine. Almost all (98.1%) of these patients had already received the second dose of vaccine and after the first and second vaccine doses, 6% and 4% of patients, respectively, reported worsening of articular disease activity, while, after the third dose, no patient reported disease activity worsening.

Figure 1.

Conclusion

During the pandemics, patients with inflammatory arthritis had a pattern of distribution of cases very similar to general population. Adherence to vaccination is high and well tolerated.

References

[1]Bredemeier et al. J Rheumatol 2021;48:1519-27

Disclosure of Interests

None declared

POS0677 CONSISTENCY IN TIME TO RESPONSE WITH UPADACITINIB AS MONOTHERAPY OR COMBINATION THERAPY AND ACROSS PATIENT POPULATIONS WITH RHEUMATOID ARTHRITIS

Background

Upadacitinib (UPA) has demonstrated efficacy in patients with moderate-to-severe rheumatoid arthritis (RA) across various patient populations.1–4

Objectives

This post hoc analysis aimed to evaluate the consistency in time to achieving meaningful clinical response with UPA 15 mg + conventional synthetic (cs) DMARDs in biologic (b) DMARD-inadequate responder (IR) versus csDMARD-IR patients with RA as well as with UPA 15 mg monotherapy versus UPA 15 mg + csDMARDs in csDMARD-IR patients.

Methods

Patients originally randomized to UPA 15 mg once daily from four Phase 3 trials were included in this analysis: SELECT-BEYOND1 and SELECT-CHOICE2 (UPA 15 mg + csDMARDs in bDMARD-IR patients), SELECT-NEXT3 (UPA 15 mg + csDMARDs in csDMARD-IR patients), and SELECT-MONOTHERAPY4 (UPA 15 mg monotherapy in methotrexate-IR patients). Time to response was estimated using the Kaplan–Meier method for clinical outcomes over 24 weeks (26 weeks in SELECT-MONOTHERAPY). Clinical outcomes included achievement of 28-joint Disease Activity Score with C-reactive protein (DAS28[CRP]) ≤3.2; low disease activity (LDA) defined as Clinical Disease Activity Index (CDAI) ≤10 and Simple Disease Activity Index (SDAI) ≤11; and 50% improvement in American College of Rheumatology (ACR) core components and morning stiffness (MS) duration/severity. Data presented were as observed.

Results

Overall, 905 patients were included (SELECT-BEYOND: n=164; SELECT-CHOICE: n=303; SELECT-NEXT: n=221; SELECT-MONOTHERAPY: n=217). csDMARD-IR patients had a mean disease duration of 7.3 (SELECT-NEXT) or 7.5 years (SELECT-MONOTHERAPY); bDMARD-IR patients had a mean disease duration of 12.4 years, with a more refractory population (≥3 prior bDMARDs) in SELECT-BEYOND (23%) than SELECT-CHOICE (10%). In general, the median time to DAS28(CRP) ≤3.2, CDAI LDA, 50% improvement in ACR core components, and 50% improvement in MS duration/severity were consistent across the studies in bDMARD-IR and csDMARD-IR patients. For SELECT-BEYOND, SELECT-CHOICE, SELECT-NEXT, and SELECT-MONOTHERAPY, the median (95% CI) time to achieve DAS28(CRP) ≤3.2 was 12 (12, 16), 12 (8, 12), 12 (8, 12), and 14 (8, 14) weeks, respectively (Figure 1), and the median time to achieve CDAI LDA was 20 (12, 24), 16 (12, 16), 16 (12, 16), and 20 (14, 20) weeks, respectively (Figure 2). A longer median (95% CI) time to achieve SDAI LDA was observed with UPA monotherapy (20 [14, 20] weeks) versus UPA + csDMARDs (12 [12, 16] weeks) in csDMARD-IR patients. Among bDMARD-IR patients, the median (95% CI) time to 50% improvement in pain was longer in SELECT-BEYOND versus SELECT-CHOICE (16 [12, 20] versus 8 [8, 12] weeks).

Conclusion

In diverse patient populations with RA, patients treated with UPA 15 mg, as monotherapy or with csDMARDs, generally demonstrated consistent time to achieving DAS28(CRP) ≤3.2, CDAI LDA, and 50% improvement in clinical outcomes.

References

[1]Genovese MC, et al. Lancet 2018;391:2513–24.

[2]Rubbert-Roth A, et al. N Engl J Med 2020;383:1511–21.

[3]Burmester GR, et al. Lancet 2018;391:2503–12.

[4]Smolen JS, et al. Lancet 2019;393:2303–11.

Acknowledgements

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data. No honoraria or payments were made for authorship. Medical writing support was provided by Amy Wilson, MSc, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests

Andrea Rubbert-Roth Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Chugai, Eli Lilly, Gilead, Janssen, Novartis, Roche, and Sanofi, Bernard Combe Speakers bureau: AbbVie, Bristol-Myers Squibb, Celltrion, Eli Lilly, Gilead/Galapagos, Janssen, Merck, Novartis, Pfizer, Roche/Chugai, and Sanofi, Consultant of: AbbVie, Bristol-Myers Squibb, Celltrion, Eli Lilly, Gilead/Galapagos, Janssen, Merck, Novartis, Pfizer, Roche/Chugai, and Sanofi, Zoltán Szekanecz Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Gedeon Richter, MSD, Pfizer, Roche, Sanofi, and UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Gedeon Richter, MSD, Pfizer, Roche, Sanofi, and UCB, Stephen Hall Speakers bureau: Eli Lilly, Janssen, Merck, Novartis, Pfizer, and UCB; and research grants from AbbVie, Janssen, Merck, and UCB, Consultant of: Eli Lilly, Janssen, Merck, Novartis, Pfizer, and UCB; and research grants from AbbVie, Janssen, Merck, and UCB, Boulos Haraoui Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, and UCB, Suzan Attar: None declared, Anna-Karin H Ekwall Consultant of: AbbVie and Pfizer, Yanna Song Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Tim Shaw Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Orsolya Nagy Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Ricardo Xavier Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Janssen, Novartis, Pfizer, and UCB

AB0079 THERAPEUTIC EFFECT OF ANTIGEN B, A PROTEIN FROM ECHINOCOCCUS GRANULOSUS, IN EXPERIMENTAL ARTHRITIS

Background

Antigen B (AgB) is a lipoprotein secreted in the hydatic cyst by Echinococcus granulosus larval stage and seems to be responsible for regulating the immune balance of host via Th2 response to promote survival of the parasite. A Th2 response can suppress the pro-inflammatory Th1 response generated in several immunopathologies, such as rheumatoid arthritis.

Objectives

To evaluate the anti-inflammatory and immunomodulatory effects of AgB in mice models of Zymozan-induced arthritis (ZIA), Antigen-induced arthritis (AIA) and Collagen-induced arthritis (CIA).

Methods

In all models, mice were divided into three groups: vehicle (saline), AgB 2 μg and AgB 10 μg (intraperitoneal once a day). In ZIA, arthritis was induced in Balb/c mice with an intra-articular (ia) injection of zymosan in the left knee joint thirty minutes after treatment. Nociception was analyzed over a 6h period and mice were euthanized 6h after arthritis induction to assess leukocyte migration into the joint. In AIA, Balb/C mice were sensitized by subcutaneous (sc) injection of methylated bovine serum albumin (mBSA) on day 0. Booster was administered on days 7 and 14. On day 21, arthritis was induced by ia injection of mBSA in the left knee joint. The treatment was performed 24h and 30min before the ia injection of mBSA. Nociception was analyzed over a 24h period and mice were euthanized 24h after arthritis induction to assess leukocyte migration into the joint. Male DBA/1J mice had CIA by subcutaneous injection of an emulsion containing Freund’s adjuvant and bovine collagen type II on days 0 and 18. The treatment took place between the 18th and 45th day after induction, as well as the evaluation of clinical arthritis score and nociception. Serum concentrations of IL-2, IL-4, IL-6, IL-10, IL-17, IFN-γ and TNF were evaluated in AIA and CIA.

Results

In ZIA, both doses of AgB diminished leukocytes migration to the knee joint compared with vehicle (AgB 2µg: 5.8±2.7; AgB 10µg: 5.6±2.7; vehicle: 4.8±3.1, p<0.05), but did not affect nociception. In AIA, both doses of AgB reduced nociception (AgB 2µg: 7.3±1.6; AgB 10µg: 7.2±1.6; vehicle: 6.0±2.1, p<0.01). Moreover, treatment with 2 μg of AgB inhibited in 70% the neutrophils migration (12.0±9.0, p<0.001) as well as it was reduced in mice treated with 10 μg of AgB as much as 58% (8.9±7.5, p<0.001), compared with control/vehicle (55.9±30.9). In addition, both doses reduced serum levels of IL-6 (AgB 2µg: 2.85±2.63; AgB 10µg: 3.10±3.18; vehicle: 27.07±30.28, p<0.01) and the dosage of 2 μg reduced the levels of IFN-γ (AgB 2µg: 0.53±0.27; vehicle: 1.47±0.46, p<0.05). In CIA, AgB treatment did not affected clinical score of arthritis (AgB 2µg: 4.6±3.8; AgB 10µg: 2.6±2.9; vehicle: 4.8±3.8, p>0.05), but the 2 μg dose improved nociception at day 32 after disease induction (7.1±1.2, p<0.05) and diminished serum levels of IL-6 (AgB 2µg: 68.9±71.8; vehicle: 475.7±362.3, p<0.05;) and TNF (AgB 2µg: 49.3±31.1; vehicle: 115.9±19.58; p<0.01), while the dose of 10 μg improved nociception at days 25, 32 and 34 after CIA induction (7.2±1.2, p<0.05).

Conclusion

These results suggest an effect of AgB on the initial pathophysiology of arthritis, reducing the influx of inflammatory cells to the knee joints of mice with acute arthritis. It also showed analgesic and anti-inflammatory potential on murine models of rheumatoid arthritis, highlighting the immunomodulatory role of parasitic helminth proteins on immune-mediated diseases.

References

[1]Monteiro KM, Cardoso MB, Follmer C, da Silveira NP, Vargas DM, Kitajima EW, et al. Echinococcus granulosus antigen B structure: subunit composition and oligomeric states. PLoS Negl Trop Dis. 2012.

[2]Mesquita Júnior, D. et al. Immune system - part II: basis of the immunological response mediated by T and B lymphocytes. Revista Brasileira De Reumatologia, v. 50, n. 5, p. 552–580, 2010.

Acknowledgements

We thank the Animal Experimentation Unit from the Hospital de Clínicas de Porto Alegre (HCPA) for their help during animal experimentation.

Disclosure of Interests

None declared

AB0173 MORPHOLOGICAL PARAMETERS ASSESSED BY ULTRASOUND IN QUADRICEPS MUSCLE WERE ASSOCIATED WITH CLINICAL FEATURES, MUSCLE STRENGTH, FUNCTIONAL CAPACITY AND PHYSICAL FUNCTION OF RHEUMATOID ARTHRITIS PATIENTS

Background

Rheumatoid arthritis (RA) patients usually present extra-articular manifestations (1,2), which affect muscle mass and, consequently, physical function (3). Among the various methods to assess muscle mass we tested muscle morphology by ultrasound (MU) to verify the associations of the quadriceps muscle with clinical features, muscle strength, functional capacity and physical function.

Objectives

To assess the MU of the quadriceps muscle and verify the muscle quality assessed by the pennation angle and its associations with clinical features, muscle strength, functional capacity and physical function in RA patients.

Methods

RA women, age ≥18years and who met 2010 American College of Rheumatology (ACR) criteria were included. Morphological parameters in quadriceps muscle consisted of the pennation angle of rectus femoris (RF), vastus intermedius (VI) and vastus lateralis (VL). RA activity was measured by 28-joint disease activity score (DAS28), muscle strength by handgrip and chair stand tests, functional capacity by health assessment questionnaire (HAQ), and physical function by timed-up-and-go (TUG) test and short physical performance battery (SPPB). Pearson’s or Spearman’s correlation coefficients were explored. The significance level was set at p ≤ 0.05 for all analyzes.

Results

Eighty-one patients were included (age: 58.64±9.52 years old; DAS28: 3.24±1.34). Smaller pennation angle in rectus femoris (RF) were associated with lower handgrip strength (r= 0.224, p=0.044), chair stand test (r= -0.372, p=0.004), HAQ (r= -0.404, p=0.001), SPPB (r= 0.262, p=0.047), as well as higher disease activity by DAS-28 (r= -0.415, p<0.0001) and age (r= -0.290, p=0.009). Smaller pennation angle in vastus intermedius (VI) were associated with worse chair stand (r= -0.281, p=0.033), HAQ (r= -0.302, p=0.015) and higher disease activity by DAS-28 (r= -0.304, p=0.006). Lastly, smaller pennation angle in vastus lateralis (VL) were associated with worse chair stand (r= -0.290, p=0.027), as well as higher DAS-28 (r= -0.237, p=0.033) and age (r= -0.272, p=0.014).

Conclusion

The pennation angles of the quadriceps muscle evaluated by ultrasound (RF, VI and VL muscles) were associated with chair stand test and DAS-28. In addition, the level of disease activity assessed by DAS-28 also appears to be affecting the quadriceps muscle. Finally, MU may be a useful method to evaluate the impact of the disease on skeletal muscle.

References

[1]Summers GD, Deighton CM, Rennie MJ, Booth AH. Rheumatoid cachexia : a clinical perspective. 2008;(April):1124–31.

[2]da Rocha OM, Batista A de AP, Maestá N, Burini RC, Laurindo IMM, Kayser C. Sarcopenia in rheumatoid cachexia: Definition, mechanisms, clinical consequences and potential therapies. Rev Bras Reum. 2009;49, 294–30.

[3]de Santana FS, da Cunha Nascimento D, de Freitas JPM, Miranda RF, Muniz LF, Neto LS, et al. Assessment of functional capacity in patients with rheumatoid arthritis: Implications for recommending exercise. Rev Bras Reumatol. 2014;54(5):378–85.

Table 1.

Associations between the quadriceps muscle morphology by ultrasound (pennation angle) with clinical features, muscle strength, functional capacity and physical function in rheumatoid arthritis patients.

VariablesnComponents of the quadriceps muscleRp-valueAge (y)81RF-0.2900.009VINSNSVL-0.2720.014Disease duration (y)81RFNSNSVINSNSVLNSNSDas-28 (CRP)81RF-0.415<0.0001VI-0.3040.006VL-0.2370.033Handgrip strength test (kg)81RF0.2240.044VINSNSVLNSNSChair stand test (s)58RF-0.3720.004VI-0.2810.033VL-0.2900.027HAQ (score)65RF-0.4040.001VI-0.3020.015VLNSNSTUG test (s)68RFNSNSVINSNSVLNSNSSPPB (score)58RF0.2620.047VINSNSVLNSNS

RF: rectus femoris; VI: vastus intermedius; VL: vastus lateralis; n: number; y: years; s: seconds; kg: kilogram; DAS28: Disease Activity Score 28; CRP: C-reactive protein; TUG: Timed-up-and-go; SPPB: Short Physical Performance Battery; NS: Not significant.

Acknowledgements

We thank the Coordination for the Improvement of Higher Level Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—CAPES) institution, the Foundation for Research Support of the Rio Grande do Sul State (Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul-FAPERGS), the Research and Events Incentive Fund (Fundo de Incentivo à Pesquisa e Eventos-FIPE) of HCPA and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico—CNPq).

Disclosure of Interests

None declared

AB0681 The 2-year impact of COVID-19 pandemic on muscle strength and physical performance in patients with systemic sclerosis: a cohort study

Background

Systemic sclerosis (SSc) patients are particularly prone to developing loss of muscle strength and worsening of physical performance due to decreased physical activity1. The lifestyle changes imposed by the SARS-CoV-2 outbreak have increased the incidence of sarcopenia in at-risk individuals2. However, the literature is scarce on the impacts of the COVID-19 pandemic on muscle strength and physical performance of SSc patients.

Objectives

(1) To assess the impact of the COVID-19 pandemic on muscle strength and physical performance of SSc patients and (2) to verify the associations of muscle strength and physical performance with inflammatory markers in a cohort study.

Methods

SSc patients who met the ACR / EULAR 2013 classification criteria were included. Patients followed between 2019 and 2021. Muscle strength was measured by handgrip strength (kg) and sit and stand (SST, seconds) tests. Physical performance was measured by timed up and go (TUG, seconds) and short physical performance battery (SPPB, points). Inflammatory markers were measured by C-reactive protein (CRP). T test for independent samples, Mann-Whitney U test of independent samples and Spearman’s correlation coefficients were explored. The significance level was set at p ≤ 0.05 for all analyses.

Results

Forty SSc patients concluded this study. At baseline, the mean age was 59 ±11.1 years old and the median disease duration was 13.1 (6.4-19.2) years. Patients had a median of 4.5 clinic visits (3.0-6.0) over the 2 years. The majority of patients were women (37, 92.5%). Ten patients (25%) had diffuse cutaneous disease, 30 patients (75%) non-diffuse cutaneous disease [25 patients (62.5%) had limited cutaneous disease, and 5 (12.5%) had sine scleroderma SSc]. The median of CRP was 2.9 (1.2-5.3). The median of handgrip strength was 20.0 (10.3-25.8) kg to the right hand and 19.0 (12.0-22.8) kg to the left hand. The median of SST was 14.4 (11.9-18.7) seconds. The median of TUG was 8.6 (7.7-9.5) seconds and the median of SPPB was 9.8 (9.0-11.0) points. The CRP was positively associated with SST (r=0.3, p=0.047) and TUG (r=0.3, p=0.029), and negatively with SPPB (r=-0.4, p=0.016). After 2 years of follow-up, the patients showed improvement in the left handgrip strength test (p=0.049) and SST (p=0.001). In physical performance, they showed improvement in the TUG test (p=0.005) and SPPB (p=0.001). The CRP was associated positively with TUG (r=0.4, p=0.033), no other associations were found.

Conclusion

Despite the COVID-19 pandemic and the restrictions imposed, in this population of patients with SSc, we did not detect any worsening in muscle strength and physical performance. Some of these parameters of muscle strength and physical performance were associated with the inflammatory marker CRP. More investigations are needed to assess the actual impact and possible associations.

Table 1.

Baseline comparison and after 2 years of patients with SSc

BaselineAfter 2 yearspCRP (mg/L),median (IQR)2.9 (1.2-5.3)2.3 (1.0-5.1)0.361Handgrip (kg),right, median (IQR)20.0 (10.3-25.8)20.5 (14.3-27.0)0.072left, median (IQR)19.0 (12.0-22.8)19.0 (14.0-26.0)0.049*SST (seconds),median (IQR)14.4 (11.9-18.7)11.6 (9.9-13.1)0.001*TUG (seconds),median (IQR)8.6 (7.7-9.5)7.9 (7.1-9.2)0.005*SPPB (points),median (IQR)9.8 (9.0-11.0)11.0 (10.0-12.0)0.001*

SSc: systemic sclerosis; IQR: interquartile range; mg: milligram; L: liter; kg: kilograms grams; TUG: timed and up go; SST: sit and stand test; SPPB: short physical performance battery; PCR: C-reactive protein; and * significant difference of ≤0.05.

References

[1]Zaghlol, Rabab S et al. “Functional Disability Among Systemic Sclerosis Patients: Relation to Disease Characteristics and Quality of Life Parameters.” Current rheumatology reviews, 2021.

[2]Bakaloudi, Dimitra Rafailia et al. “Impact of the first COVID-19 lockdown on body weight: A combined systematic review and a meta-analysis.” Clinical nutrition (Edinburgh, Scotland), 2021.

Disclosure of Interests

None declared

POS0845 ASSESSING FRAILTY IN SYSTEMIC SCLEROSIS: A CROSS-SECTIONAL STUDY COMPARING FRAIL AND EDMONTON FRAILTY SCALES WITH PHYSICAL FRAILTY PHENOTYPE

Background

Systemic sclerosis (SSc) is a chronic disease characterized by autoimmunity, vasculopathy and fibrosis. During the disease course, patients with SSc are prone to accumulate multiple organ damage, increasing their vulnerability to adverse outcomes in comparison with individuals of the same age: a phenomenon called frailty. One of the most used definitions of frailty is the physical frailty phenotype (PFP) by Fried, et al. The PFP consists of 5 components: unintentional weight loss, exhaustion, muscle weakness, slow walking speed, and low physical activity. There is scarce data about frailty in patients with SSc.

Objectives

To study the prevalence and clinical aspects of PFP in a sample of patients with SSc. Also, we aim to investigate the diagnostic accuracy of the Fatigue, Resistance, Ambulation, Illness and Loss of weight (FRAIL) scale and the Edmonton frailty scale (EFS) using the PFP as the reference standard.

Methods

Cross-sectional study, including patients with SSc according to the 2013 ACR-EULAR classification criteria or the criteria suggested by Le Roy and Medsger for early disease. PFP assessment was according to the original definition, except for physical activity domain, assessed with the International Physical Activity Questionnaire (IPAQ). Patients were classified according to Fried’s criteria in robust (0), pre-frail (1-2), and frail (≥3). FRAIL scale and EFS were also applied to the same individuals. The FRAIL score ranges from 0 to 5 and patients were classified as robust (0), pre-frail (1-2), or frail (≥3). The EFS score ranges from 0–17 and categorizes patients as not frail (0–4), vulnerable (5–6), mild frailty (7–8), moderate frailty (9–10), and severe frailty (≥11). For the diagnostic assessment of FRAIL scale and EFS, we estimated the area under the receiver operating characteristic curve (AUC), considering PFP as the reference standard and dichotomizing the results in frail vs. non-frail.

Results

Between March and December 2019, 82 SSc patients were consecutively included. The mean age and disease duration were 60.4 (±10.6) and 13.4 (±8.2) years, respectively; 91.5% were women, and 19.5% with diffuse cutaneous SSc. The PFP distribution was: 8 (9.8%) robust, 47 (57.3%) pre-frail and 27 (32.9%) frail patients. The PFP domains´ frequencies were: low physical activity in 57 (69.5%), muscle weakness in 41 (50%), exhaustion in 34 (41.5%), unintentional weight loss in 15 (18.3%) and slow walking speed in 8 (9.8%) patients. Using the FRAIL scale, 44 (53.7%) patients were considered pre-frail and 25 (30.5%) frail. According to the EFS, 26 patients (31.7%) were classified as vulnerable and 12 (14.6%) as frail: mild in 6 (7.3%), moderate in 4 (4.9%) and severe in 2 (2.4%). The AUC against PFP was: 0.871 (95% CI 0.789-0.954, p<0.001) for FRAIL scale and 0.870 (95% CI 0.791-0.948, p<0.001) for EFS (Figure 1).

Conclusion

Frailty is prevalent in patients with long-standing SSc, and most of them are considered pre-frail or vulnerable. Low physical activity, muscle weakness and exhaustion are among the most frequent clinical aspects of the frailty phenotype. Both FRAIL scale and EFS showed overlapping diagnostic accuracy against PFP as the reference standard, and FRAIL scale seems to be more feasible than EFS.

References

[1]Rockwood MR, MacDonald E, Sutton E, Rockwood K, Baron M. Frailty index to measure health status in people with systemic sclerosis. J Rheumatol. 2014;41(4):698-705.

[2]Morley JE, Vellas B, Abellan van Kan G, et al. Frailty consensus: a call to action. J Am Med Dir Association. 2014;14(6):392-7.

[3]Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56.

[4]van Kan GA, Rolland YM, Morley JE, Vellas B. Frailty: Toward a Clinical Definition. J Am Med Dir Assoc. 2008;9(2):71-2.

[5]Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006;35(5):526-9.

Disclosure of Interests

None declared

AB0080 GDF-11 AND GDF-8 INVOLVEMENT IN MUSCLE IMPAIRMENT OF COLLAGEN-INDUCED ARTHRITIS MODEL

Background

Rheumatoid arthritis is an autoimmune, inflammatory disease which affects primarily synovial joints and can induce skeletal muscle wasting (1). It is known that growth differentiation factors 8, 11 plays an important role in muscle homeostasis (2-3).

Objectives

Evaluate muscle mRNA and protein expression of GDF-8, GDF-11 in early and established stages of collagen-induced arthritis.

Methods

DBA1/J mice, were randomized into 5 groups: baseline animals (BL=6); control animals evaluated at days 25 and 50 (CO25=8, CO50=8) and collagen-induced arthritis mice evaluated at day 25 and 50 (CIA 25=8; CIA 50=8). Clinical score, paw edema, and body weight were evaluated. Clinical score, hind paw edema, and body weight were assessed. Grip strength, nociception, fatigue time, and walking speed were assessed on days 0, 18, 25, 50 of experimentation. Animals were euthanized on days zero (BL group), 25 (CIA 25 and CO 25) and 50 (CIA 50 and CO 50) after disease induction. TA muscle was used to myofiber cross-sectional and GA muscle was used to evaluate gene expression of GDF-8, GDF-11 levels via qRT-PCR. Protein expression of GDF-8, GDF-11 levels in GA muscle was performed by ELISA.

Results

RA in the early CIA 25 and established CIA 50 groups was confirmed by high values of clinical score, nociception, paw edema and histological score when compared to the respective controls (p<0.0001; p=0.001; p=0.001). There was a decrease in grip strength in the CIA 25 group and a worsening in this decrease at CIA 50 (p=0.0021, p=0.007). Fatigue time was shorter in CIA 25 compared to CO 25 (p= 0.002) and maintained in CIA 50 (p= 0.006). Walking speed showed a decrease in both time points (p=0.001; p=0.000). After normalization by body weight, only the GA muscle had weight loss in CIA 50 when compared to CO 50 (-34.5%). Similarly, the CSA TA muscle myofiber showed a reduction of 14.04% only at CIA 50 group compared to the CO 50 (p=0.026). The GA muscle GDF-11 mRNA levels were higher in the CIA 25 group compared to the CO 25 and BL groups (p=0.004; p=0.0087, respectively); in CIA 50, there was a trend towards increased muscle GDF-11 mRNA levels (p=0.07). The protein expression of GDF-11 in serum samples did not show differences between the analyzed groups; however, in GA muscle, GDF-11 protein expression showed differences at the CIA 25 (p=0.0023) and the CIA 50 group (p=0.017) compared with the respective controls and a significant difference in muscle protein expression between the CIA 25 groups and CIA 50 (p=0.0138). There was a decreased of mRNA content GDF-8 on muscle, in CIA 50 and a decreased between the CIA 25 and CIA 50 in GA muscle (p= 0.0377; p= 0.0019); GA muscle had an increase of GDF-8 protein levels comparing the CIA 25 and CIA 50 group (p=0.001), while protein levels in serum of GDF-8 were decreased in CIA 50 compared with CO 50 (p= 0.037). Low muscle strength was associated with higher protein levels of GDF-11 in GA muscle (r= -0.64, p=0.01) and decreased walking speed (r=-0.534, p=0.04). Higher serum levels of GDF-8 were associated with higher muscle strength (r= 0.74, p=0.02) and increased walking speed (r= 0.64, p=0.01).

Conclusion

At early arthritis, GDF-11 mRNA and protein expressions were increased and are related to the physical impairment, while GDF-8 expression is reduced at established disease and increased in serum over time in CIA model, possibly as GDF-8 had a more systemic role in inflammatory arthritis. Thus, the GDFs may have a role in muscle outcomes in the CIA model and can be involved in muscle atrophy and loss of physical function in RA.

References

[1]Aletaha D, Smolen JS. Diagnosis and Management of Rheumatoid Arthritis: A Review. JAMA - J Am Med Assoc. 2018;320(13):1360–72.

[2]Sinha M, Jang YC, Oh J, Khong D, Wu EY, Manohar R, Miller C, Regalado SG, Loffredo FS, Pancoast JR, et al (2014) Restoring systemic GDF11 levels reverses age-related dysfunction in mouse skeletal muscle. Science 344: 649–52.

[3]Trendelenburg AU, Meyer A, Rohner D, Boyle J, Hatakeyama S & Glass DJ (2009) Myostatin reduces Akt/TORC1/p70S6K signaling, inhibiting myoblast differentiation and myotube size. Am J Physiol Physiol 296: C1258–C1270.

Acknowledgements

We thank the Animal Experimentation Unit from the Hospital de Clínicas de Porto Alegre (HCPA) for their help during animal experimentation.

Disclosure of Interests

None declared

POS0650 THE IMPACT OF OLD AGE ON THE PERSISTENCE AND SAFETY OF TREATMENT WITH BIOLOGIC AGENTS OR JAK INHIBITORS IN RHEUMATOID ARTHRITIS

Background

The effect of age on persistence and safety of treatment with biologic disease modifying anti-rheumatic drugs (bDMARDs) in rheumatoid arthritis has been a subject to research interest. Two recently published studies did not observe significantly different survival of treatment with bDMARDs among older age (≥ 65 years) individuals (1,2); incidence of serious adverse events was higher in these patients (2).

Objectives

to evaluate association of the age with treatment survival and overall safety among patients receiving one or multiple courses of bDMARDs or targeted synthetic (ts-) DMARDs.

Methods

BiobadaBrasil is a multicentric registry-based cohort study of Brazilian patients with rheumatic diseases starting their first bDMARD or tsDMARD (3). The present analysis includes RA patients recruited from Jan 2009 to Oct 2019, followed-up over one or multiple (up to six) courses of treatment necessarily involving a bDMARD or tsDMARD (latest date, Nov 19, 2019). Treatment course is defined as a period during which the medication scheme does not change, except for dose adjustments. Primary outcome was the incidence treatment interruption for any reason (except for pregnancy or disease remission), while interruption due to adverse events (AEs; including death) and due to inefficacy served as secondary outcomes. Incidence of serious adverse events (SAEs) also served as a secondary outcome. Extended (frailty) multivariate Cox proportional hazards models and negative binomial regression with generalized estimating equations (to calculate incidence rate ratios [IRRs]) were used for statistical analyses (both types of analyses including time-varying covariates over multiple courses of treatment).

Results

In total, 1316 patients (2335 treatment courses, 6508 patient-years [PY]) were enrolled. Of these, 160 patients (643 PY; 237 treatment courses) were ≥ 65 years old, mean age at starting treatment = 71 ± 5 yrs (84% female). Old age was not significantly associated with treatment interruption for any reason, but presented higher risk of interruption due to adverse events (after multivariate adjustment) and lower risk of stopping because of inefficacy (see Table 1). Older patients presented higher incidence of SAEs than younger ones (16.0 vs 8.4/100 PY, respectively; multivariate IRR: 2.06, 95% CI: 1.51 to 2.80, P<0.001). Among old patients, tocilizumab (HR: 2.73, 95% CI: 1.13 to 6.64, P=0.026), etanercept (2.13, 1.12 to 4.07, P=0.022), and infliximab (2.39, 1.19 to 4.79, P=0.014) presented higher risk of treatment termination as compared with adalimumab. In this subgroup (age ≥65 yrs), there was no significant difference in the risk of SAEs between different bDMARDs/tsDMARDs.

Table 1.

Univariate and multivariate hazard ratios (HRs) of interruption of treatment course comparing older (≥65 years) versus younger patients (reference category). Results are HRs, 95% CIs, and P values.

Cause of interruption (n of events)Crude analysisAdjusted covariates*Interruption - any reason (1321)0.96 (0.75 to 1.23), P=0.7601.09 (0.82 to 1.43), P=0.550Interruption - adverse events (368)1.33 (0.75 to 0.89), P=0.1601.59 (1.07 to 2.35), P=0.020Interruption - inefficacy (680)0.56 (0.39 to 0.80), P=0.0020.57 (0.38 to 0.87), P=0.009

* Age, baseline DAS28, disease duration, gender, smoking, RF or anti-CCP, previous malignancy, interstitial lung disease, diabetes, hypertension, hypercholesterolemia, renal failure, ischemic cardiomyopathy, COPD, heart failure, concomitant use of each cs-, b-, and tsDMARDs, corticosteroids, starting year, osteoporosis, hepatitis B,C, treatment sequence.

Conclusion

The overall risk of treatment interruption with biologic or targeted synthetic DMARDs is not higher in older patients. Higher risk of interruption due to AE was balanced by a lower risk of stopping treatment due to inefficacy. Older patients had a higher incidence of SAEs.

References

[1]Mathieu et al. Rheumatol Int 2021;41:879-85.

[2]Freitas et al. Drugs Aging 2020;37:899-907.

[3]Bredemeier et al. J Rheumatol 2021;48:1519-27.

Disclosure of Interests

None declared

POS1285 IMMUNOGENICITY AND SAFETY OF THE CHADOX 1 COVID-19 VACCINE IN PATIENTS WITH AUTOIMMUNE DISEASES AND HEALTHY CONTROLS: DATA FROM SAFER STUDY

Background

Patients with autoimmune inflammatory diseases (AID) have been prioritized for urgent vaccination to mitigate COVID-19 risk. However, few studies in the literature assessed the immunogenicity and safety of the COVID-19 vaccine in patients with AID.

Objectives

In this context, the present study aims to evaluate the immunogenicity and safety of the vaccine against COVID-19 in patients with AID.

Methods

These data are from “Safety and efficacy on COVID-19 Vaccine in Rheumatic Disease” - SAFER study, a Brazilian multicentric prospective phase IV study to evaluate COVID-19 Vaccine in AID, in the real-life, in Brazil. Immunogenicity and adverse events (AE) from a single center were assessed, after 2 doses of ChAdOx1 (Oxford/AstraZeneca), 8 weeks of interval, in patients with AID and healthy controls (HC). Inclusion criteria were age ≥ 18 years and fulfilling criteria according to international classification for AID. Exclusion criteria: pregnancy, previous severe AE to any vaccine, other immunosuppression causes. Stratification of post-vaccination AE was performed using a diary, filled out daily and returned at the end of 28 days for each dose. Participants were followed up through blood collection for measurement of IgG antibodies against SARS-CoV-2 spike receptor-binding domain by chemiluminescence (SARS-CoV-2 IgG II Quant assay, Abbott Laboratories, Abbott Park, IL, USA) at baseline and 28 days after the second dose. The seropositivity was defined for titers ≥50 AU/mL. Quantitative analyses were presented as observed frequency, percentage, central tendency, and variability measurements. The sample’s normal distribution was verified through the Shapiro-Wilk test. The Kruskal-Wallis test and the post-hoc Dwass-Steel-Critchlow-Fligner pairwise comparisons test were used to compare the IgG-S titers between the groups through the evaluation period. Categorical data were addressed using the Fisher´s exact or Chi-squared (χ2) test. An alpha level of 5% significance was used in all analyses.

Results

A total of 377 volunteers with AID and 50 HC were included in the study. Patients with spondyloarthritis (N=64), systemic lupus erythematosus (N=63), rheumatoid arthritis (N=61), primary Sjögren’s syndrome (N=61), vasculitis (N=31), systemic sclerosis (N=14), inflammatory myopathy (N=9), Crohn´s disease (N=49), ulcerative colitis (N=11) and other systemics AID (N=12) were evaluated. Both groups had female predominance (73.5% vs. 74.0%, p=0.937) and were homogeneous for age (43.5 vs. 41.7,p=0.308). The seroconversion among those not reactive (IgG-S negative at baseline) (46 HC and 191 AID), 28 days after second dose was 97.1% for spondyloarthritis (p=0.425), systemic lupus erythematosus 88.2% (0.006), rheumatoid arthritis 93.5% (0.158), primary Sjögren’s syndrome 92.6% (0.133), systemic sclerosis or inflammatory myopathy 47.1% (0.001), inflammatory bowel disease 100% (0.999) and vasculitis 80% (0.006), while in healthy control was 100%. In comparison with HC, there was a statistically significant difference in IgG-S titles only in systemic sclerosis or inflammatory myopathy (1.694 AU/ml vs. 3.719 AU/ml; p=0.006). Both groups only presented mild AE. Pain at the injection (85.7% vs. 78.4%, p=0.239), headache (67.3% vs. 53.8, p=0.074) and fatigue (59.2% Vs. 46.2%, p=0.089) were more common in HC than AID. Overall, reactions like arthralgia (52.6 vs. 22.4%, p<0.001), hematoma (14.1 vs. 4.1%, p=0.05), cutaneous rash (9.5 vs. 0%, p=0.024) were more frequent in AID. Most participants related that they felt safer after receiving a COVID-19 vaccination, and 52.4% did not reported a worse patient global assessment (PGA) index.

Conclusion

In conclusion, our data indicated that ChAdOx1 vaccine is safe and induced high titers and seroconversion rate in AID. More severe AID, such as vasculitis, systemic lupus erythematosous, and systemic sclerosis and myositis showed a lower seroconversion rate. Further analysis will explore the association between immunossupressant and reactivity, and booster dose.

Acknowledgements

Acknowledgements to DECIT/MS and ICEPI/SESA for supporting the study.

Disclosure of Interests

None declared

POS0693 IMPACT OF UPADACITINIB VERSUS ABATACEPT ON INDIVIDUAL DISEASE OUTCOMES IN PATIENTS WITH RHEUMATOID ARTHRITIS AND INADEQUATE RESPONSES TO BIOLOGIC DMARDS

Background

The phase 3 SELECT-CHOICE trial of patients with rheumatoid arthritis (RA) and prior inadequate response to biologic DMARD(s) (bDMARD-IR) demonstrated superiority of the JAK inhibitor upadacitinib (UPA) vs abatacept (ABA) in the mean change from baseline (BL) in DAS28(CRP) and in the proportion achieving DAS28(CRP) <2.6 at week (wk) 12, with higher incidence of serious adverse events reported in the UPA treatment group.

Objectives

To evaluate the impact of UPA vs ABA on individual components of composite measures of disease activity in SELECT-CHOICE.

Methods

In SELECT-CHOICE, a double-blind phase 3 trial, bDMARD-IR patients were randomly assigned to UPA 15 mg once daily or ABA, each with background conventional synthetic DMARDs, for 24 wks. For this post hoc analysis, the proportions of patients achieving improvement from BL through wk 24 in ACR core variables (including SJC, TJC, Patient Global Assessment [PtGA], Physician Global Assessment [PhGA], pain, HAQ-DI, and hsCRP) and Boolean remission criteria were evaluated. Differences in the cumulative distributions of CDAI, DAS28(hsCRP), SDAI, and ACR-n (the lowest of percent change in TJC, percent change in SJC, or median of the other 5 ACR components) were determined using the Kolmogorov-Smirnov test and are reported as observed. For all other variables, non-responder imputation was applied for missing data. Nominal P values are provided throughout.

Results

A total of 616 bDMARD-IR patients with moderate to severe RA were randomized in SELECT-CHOICE (UPA 15 mg, n=303; ABA, n=309). BL demographic and disease characteristics were generally comparable between treatment groups, with a mean disease duration of approximately 12 years and mean CDAI of 39.6. At wk 12, more patients receiving UPA vs ABA achieved ≥50% improvements from BL in TJC68, PtGA, and hsCRP, with comparable proportions observed between UPA and ABA for the remaining ACR components (Figure 1). At wk 24, similar proportions of patients receiving UPA and ABA achieved ≥50% improvements in all but the hsCRP component. Overall, 15% and 26% of patients on UPA compared with 6% and 15% on ABA demonstrated ≥50% improvements across all ACR components at wks 12 and 24, respectively. At wks 12 and 24, Boolean remission was achieved by 6% and 14% of patients on UPA vs 2% and 10% of patients on ABA, respectively; the proportion of patients in both treatment groups achieving the individual Boolean components were also reported (Table 1). While comparable at BL, cumulative distributions of CDAI, SDAI, DAS28(hsCRP), and ACR-n were improved on UPA vs ABA at wk 12 (all nominal P <0.05); differences persisted for most measures at wk 24.

Table 1.

Proportions of Patients Achieving Boolean Remission and Its Components at Week 12 and 24 (NRI)

Week 12Week 24n (%)UPA 15 mgABAUPA 15 mgABA(N=303)(N=309)(N=303)(N=309)Boolean Remission19 (6)***5 (2)42 (14)*30 (10) PtGA ≤1054 (18)***29 (9)80 (26)*66 (21) TJC ≤189 (29)***64 (21)134 (44)*115 (37) SJC ≤1127 (42)**106 (34)169 (56)*152 (49) hsCRP ≤1 mg/dL257 (85)***209 (68)244 (81)***199 (64)

Nominal ***P <.001, **P <.01, *P <.05 for UPA vs ABA. ABA, abatacept; PtGA, Patient’s Global Assessment of disease severity; UPA, upadacitinib.

Conclusion

In this post hoc analysis of bDMARD-IR RA patients, improvements in components of disease measures were reported for both UPA and ABA through 24 weeks, with numeric differences noted for several components. Nominally higher attainment of Boolean remission and its components were observed for UPA over ABA.

References

[1]Rubbert-Roth A, et al. N Engl J Med 2020; 383:1511-21.

Acknowledgements

AbbVie and the authors thank the patients, study sites, and investigators who participated in these clinical trials. AbbVie funded these studies and participated in the study design, research, analysis, data collection, interpretation of data, reviewing, and approval of the publication. All authors had access to relevant data and participated in the drafting, review, and approval of this publication. No honoraria or payments were made for authorship. Medical writing support was provided by Matthew Eckwahl, PhD, of AbbVie.

Disclosure of Interests

Ronald van Vollenhoven Speakers bureau: AbbVie, Galapagos, GSK, Janssen, Pfizer, R-Pharma, UCB, Consultant of: AbbVie, AstraZeneca, Biogen, BMS, Galapagos, Janssen, Miltenyi, Pfizer, UCB, Grant/research support from: Research: BMS, GSK, UCB; Educational programs: MSD, Pfizer, Roche, Andrea Rubbert-Roth Speakers bureau: AbbVie, Pfizer, Sanofi, UCB, BMS, Lilly, Gilead, Roche, Consultant of: AbbVie, Gilead, Lilly, BMS, Sanofi, R-Pharm, Stephen Hall Consultant of: AbbVie, BMS, Lilly, Janssen, Pfizer, UCB, Novartis, Grant/research support from: AbbVie, BMS, Lilly, Janssen, Pfizer, UCB, Novartis, Ricardo Xavier Consultant of: AbbVie, Amgen, BMS, Lilly, Janssen, Novartis, Pfizer, UCB, Anna Shmagel Shareholder of: AbbVie, Employee of: AbbVie, Yanna Song Shareholder of: AbbVie, Employee of: AbbVie, Samuel Anyanwu Shareholder of: AbbVie, Employee of: AbbVie, Vibeke Strand Consultant of: AbbVie, Amgen, Arena, AstraZeneca, Bayer, BMS, Boehringer Ingelheim, Chemocentryx, BMS, Celltrion, Lilly, Genentech/Roche, Gilead, GlaxoSmithKline, Ichnos, Inmedix, Janssen, Kiniksa, Lilly, Merck, Myriad Genetics, Novartis, Pfizer, Regeneron Pharmaceuticals, Rheos, R-Pharma, Samsung, Sandoz, Sanofi, Scipher, Setpoint, Sorrento, Spherix, UCB

POS0607 IMPROVING TREAT-TO-TARGET IMPLEMENTATION IN RHEUMATOID ARTHRITIS: A SYSTEMATIC LITERATURE REVIEW OF BARRIERS, FACILITATORS, AND INTERVENTIONS

Background

Treat-to-target (T2T) is integral to international recommendations for managing patients with rheumatoid arthritis (RA),1,2 but its implementation in clinical practice is suboptimal.3 Understanding T2T barriers and facilitators may inform strategies for improving T2T implementation in RA.

Objectives

To review published evidence on barriers to and facilitators of T2T implementation in RA, and interventions designed to improve T2T implementation.

Methods

Two systematic literature searches were conducted to identify barriers to or facilitators of, and interventions designed to improve, T2T implementation in RA (Jan 1, 2015–Mar 1, 2021 and Jan 1, 2010–Jul 1, 2021, respectively). The quality of each study was assessed using the appropriate Critical Appraisal Skills Programme (CASP) checklist.4 Barriers/facilitators and interventions were grouped into categories and summarized descriptively.

Results

The barriers/facilitators literature search retrieved 235 articles. Seventy-seven of these, which described primary studies mentioning a total of 331 T2T barriers/facilitators in RA, were included in the analysis. The interventions literature search identified 451 articles, including 70 primary studies reporting a total of 56 unique interventions to improve T2T implementation in RA. The quality of the studies varied; however, most addressed at least half of the information evaluated in the CASP checklists. Barriers/facilitators were categorized into 18 key target areas for patients (n=7), healthcare professionals (HCPs; n=6), or patients and HCPs (n=5). These related to: HCPs’ or patients’ knowledge or perceptions; patients’ clinical or social conditions; patient–HCP communication or alignment; and time or resources (Figure 1). The 56 interventions were grouped into 18 types (Table 1). More than half of the interventions (n=30; 53.6%) were designed to improve or streamline disease activity or patient-reported outcome assessments or increase patient–HCP alignment on disease activity. Interventions designed to improve shared decision-making were also common (n=23; 41.1%); these included patient and HCP education (n=15), decision aids (n=7), and shared decision-making prompts (n=3). Of the 56 interventions, 20 (35.7%) reported improvements in T2T implementation and/or patient outcomes in RA. However, as most interventions were evaluated in single centers, their effectiveness, feasibility, and generalizability across other regions or healthcare settings were unclear.

Table 1.

Interventions for improving T2T implementation in RA, by type

Type of interventionNumber of unique interventions (n=56)aElectronic disease assessment recording11Disease assessment process/quality improvement initiative8Allied HCP-supported T2T strategy8Patient educational tools7Patient decision aid7HCP performance feedback7Integrated PRO assessment6Ultrasound assessment5HCP learning collaborative (structured learning sessions + performance feedback)4Patient PRO dashboard/visual feedback tool4Telehealth monitoring3HCP T2T/shared decision-making prompt3Nurse-led patient education3Multidisciplinary team program3HCP training2Patient telehealth education2HCP decision-making tool1Patient group sessions1

aInterventions may be assigned to more than one category

PRO, patient-reported outcome

Conclusion

While practical methods designed to improve T2T implementation in RA are available, their effectiveness and feasibility will likely vary by region and healthcare setting. More primary research is required to identify the most relevant barriers/facilitators and prioritize the most appropriate interventions to optimize T2T implementation both globally and locally.

References

[1]Smolen JS, et al. Ann Rheum Dis 2020;79:685–99

[2]Smolen JS, et al. Ann Rheum Dis 2016;75:3–15

[3]Yu Z, et al. Arthritis Care Res 2018;70:801–6

[4]Critical Appraisal Skills Programme 2019. https://casp-uk.net/casp-tools-checklists/ (Last accessed November 2021)

Acknowledgements

AbbVie funded the evidence synthesis and had the opportunity to review and comment on the publication prior to submission. However, decisions regarding the final publication content were made solely by the authors. Medical writing support was provided by Hilary Wong, PhD, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests

Laure Gossec Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Galapagos, Gilead, GSK, Janssen, Lilly, Novartis, Pfizer, Samsung Bioepis, Sanofi-Aventis, and UCB, Grant/research support from: Amgen, Galapagos, Lilly, Pfizer, and Sandoz, Louis Bessette Consultant of: AbbVie, Celgene, Fresenius Kabi, Gilead, Lilly, Novartis, Pfizer, Sandoz, and UCB, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Gilead, Janssen, Lilly, Novartis, Pfizer, and UCB, Ricardo Xavier Speakers bureau: AbbVie, Janssen, Lilly, Novartis, Pfizer, and Roche, Consultant of: AbbVie, Janssen, Lilly, Novartis, Pfizer, and Roche, Grant/research support from: AbbVie, Janssen, Lilly, and Pfizer, Ennio Giulio Favalli Speakers bureau: AbbVie, Bristol-Myers Squibb, Celltrion, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Sanofi-Genzyme, and UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celltrion, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Sanofi-Genzyme, and UCB, Andrew Ostor Consultant of: AbbVie, Bristol-Myers Squibb, Gilead, Janssen, Lilly, Novartis, Paradigm, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Bristol-Myers Squibb, Gilead, Janssen, Lilly, Novartis, Paradigm, Pfizer, Roche, and UCB, Maya H Buch Consultant of: AbbVie, Boehringer Ingelheim, Galapagos, Gilead, Lilly, and Pfizer (consulting fees paid to the host institution and travel honoraria), Grant/research support from: Pfizer and UCB

POS0546 URINARY METABOLOMIC BIOMARKER CANDIDATES FOR SKELETAL MUSCLE WASTING IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Rheumatoid arthritis (RA) is an autoimmune disease that affects the joints, leading to chronic synovial inflammation and local tissue destruction. Extra-articular manifestations may also occur, such as changes in body composition. Skeletal muscle wasting is often observed in patients with RA, but methods for assessing loss of muscle mass are expensive and not widely available, limiting their use in clinical practice and their evaluation in longitudinal studies. Metabolomic analysis has shown great potential for identifying changes in the metabolite profile of patients with autoimmune diseases and can advance our understanding of pathogenic mechanisms, early diagnosis, treatment, and follow-up. In this setting, urine metabolomic profiling in patients with RA may be a useful tool to identify skeletal muscle wasting.

Objectives

To evaluate the urinary metabolomic profile of patients with rheumatoid arthritis and associate it with skeletal muscle loss.

Methods

We recruited patients aged 40–70 years with RA according to the 2010 ACR/EULAR classification criteria. We measured disease activity by the Disease Activity Score in 28 joints using the C-reactive protein level (DAS28-CRP). We determined muscle mass according to DXA-derived appendicular lean mass index (ALMI) by summing the lean mass measurements for both arms and legs and dividing them by height squared (kg/height2). We performed urine metabolomic analysis by nuclear magnetic resonance (NMR) spectroscopy using the BAYESIL and MetaboAnalyst software packages. We performed principal component analysis (PCA) and partial least squares-discriminant analysis (PLS-DA), followed by Spearman’s correlation analysis. We set the significance level at p<0.05 for all analyses. We combined Receiver Operating Characteristic Curve (ROC) and logistic regression analyses to establish a diagnostic model.

Results

We included 90 patients with RA. Most patients were women (86.7%), with a mean age of 56.5 (SD, 7.3) years and a median DAS28-CRP of 3.0 (IQR, 1.0–3.0). We identified 15 metabolites that showed high variable importance in projection (VIP scores) by MetaboAnalyst. Of these, dimethylglycine (r=0.205; p=0.053), oxoisovalerate (r= −0.203; p=0.055) and isobutyric acid (r= −0.249; p= 0.018) were significantly correlated with ALMI. Based on low muscle mass (ALMI ≤6.0 kg/m2 for women and ≤8.1 kg/m2 for men), we established a diagnostic model with dimethylglycine (Area Under the Curve - AUC=0.65), oxoisovalerate (AUC=0.49) and isobutyric acid (AUC=0.83), with significant sensitivity and specificity.

Conclusion

Isobutyric acid, oxoisovalerate and dimethylglycine from urine samples were associated with low skeletal muscle mass in patients with RA. These findings suggest that this group of metabolites may be further tested as biomarkers for identification of skeletal muscle wasting.

References

[1]Cruz-Jentoft, Alfonso J. et al. Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing, v. 48, n. 1, p. 16-31, 2019.

[2]Teixeira, VOM, Filippin, VL, Xavier, MR. Mecanismos de perda muscular da sarcopenia,Rev. Bras. Reumatol. 52 (2), 2012.

[3]S.P. Young, S.R. Kapoor, M.R. Viant, J.J. Byrne, A. Filer, C.D. Buckley, G.D. Kitas, K. Raza, The Impact of Inflammation on Metabolomic Profiles in Patients With Arthritis. Arthritis and Rheumatism 65(8), 2015-2023, 2013.

[4]Alabarse, PV, Santos, RE, Silva, J, Oliveira, MS, Xavier, R. Metabolomic Biomarker Candidates For Skeletal Muscle Loss In The Collagen-Induced Arthritis (Cia) Model. Journal Of Personalized Medicine 11(9):837, 2021.

Figure 1.

Disclosure of Interests

None declared.

AB0352 IMPACT OF SEROLOGIC STATUS ON CLINICAL RESPONSES TO UPADACITINIB OR ABATACEPT IN PATIENTS WITH RHEUMATOID ARTHRITIS AND PRIOR INADEQUATE RESPONSE TO BIOLOGIC DMARDs: SUB-GROUP ANALYSIS FROM THE PHASE 3 SELECT-CHOICE STUDY

Background

In patients with RA who had a prior inadequate response or intolerance to biologic DMARDs, the oral Janus kinase inhibitor, upadacitinib (UPA), demonstrated superiority in change from baseline in DAS28(CRP) and DAS28(CRP)<2.6 at week 12 and improved responses across additional endpoints compared to abatacept (ABA) in the phase 3 SELECT-CHOICE study. Seropositive patients have been reported to respond better to treatment than seronegative patients.

Objectives

To evaluate clinical responses with UPA versus ABA among RA patients based on serologic status.

Methods

In SELECT-CHOICE (24-week, phase 3, double-blind, controlled trial), RA patients were randomized to oral UPA (15 mg once daily) or intravenous (IV) ABA (at day 1 and weeks 2, 4, 8, 12, 16, and 20; <60 kg, 500 mg; 60-100 kg, 750 mg; >100 kg, 1000 mg).1 UPA patients also received IV placebo and ABA patients also received oral placebo. All patients continued stable background conventional synthetic DMARDs. Starting at week 12, background RA medications were adjusted or added if patients did not experience ≥20% improvement compared to baseline in tender and swollen joint counts at two consecutive visits. For this sub-group analysis, patients were categorized as follows: RF+ and ACPA+, RF+ and/or ACPA+, and RF- and ACPA-. Mean change from baseline in DAS28(CRP), Clinical Disease Activity Index (CDAI), ACR responses, HAQ-DI, patient’s assessment of pain, and Functional Assessment of Chronic Illness Therapy - Fatigue scale (FACIT-F) were evaluated at weeks 12 and 24. Statistical inference was conducted using Chi-square tests or analysis of covariance (ANCOVA) with non-responder imputation or multiple imputation used for missing data and nominal P-values shown.

Results

Of the total population (N=612), the majority of patients were seropositive for RF and/or ACPA at baseline (80.4%) (Table 1). Most patients were female (~80%), ~55 years old, and one-third had previously experienced ≥2 biologic DMARDs. Mean change from baseline in DAS28(CRP) and CDAI were numerically higher with UPA vs ABA at weeks 12 and 24 across all sub-groups (Figure 1). Regardless of serologic status, UPA demonstrated numerically higher responses vs ABA for ACR 20/50/70 and proportions of patients in low disease activity and remission at both timepoints (Table 1). Mean change from baseline in the HAQ-DI and the patient’s assessment of pain was numerically higher with UPA compared to ABA across all sub-groups and timepoints (data not shown). Clinical responses were generally numerically higher at week 24 compared to week 12, and for the seropositive groups compared to the seronegative group, with both UPA and ABA.

Table 1.

Clinical Responses with UPA 15 mg or ABA in RA Patients Across Serologic Status Sub-Groups at Weeks 12 and 24

RF+ and ACPA+ (n=390)RF+ and/or ACPA+ (n=492)RF- and ACPA- (n=120)UPA n=189ABA n=201UPA n=242ABA n=250UPA n=61ABA n=59Proportion of Patients (%) (NRI)† WeekACR201281*7179*71624724847882776759ACR501251*4051**4026*122463*5363*544432ACR7012231624*151172439*2840**282520DAS28(CRP) ≤3.21254***3454***3333**102465**4965**505437DAS28(CRP) <2.61232***1733***1518*52446**3348***333925CDAI ≤10124239433933*1724595560565134CDAI ≤2.81210*310**3202423*1423**141112

*P<0.05; **P<0.01; ***P<0.001 UPA vs. ABA; nominal P-values are presented and not adjusted for multiple comparisons

†NRI was used for missing data

Conclusion

Across serologic statuses, clinical responses with UPA 15 mg vs ABA were numerically higher at weeks 12 and 24 among RA patients with prior inadequate response or intolerance to biologic DMARDs. In addition, clinical responses were numerically higher for seropositive patients compared to seronegative patients across all endpoints assessed, although the seronegative group had a smaller sample size in this post-hoc analysis.

Acknowledgements

AbbVie funded these studies and participated in the study design, research, analysis, data collection, interpretation of data. No honoraria or payments were made for authorship. Medical writing support was provided by Monica R.P. Elmore, PhD of AbbVie.

Disclosure of Interests

Andrea Rubbert-Roth Speakers bureau: AbbVie, BMS, Chugai, Roche, Gilead, Janssen, Lilly, Sanofi, Amgen, Novartis, Consultant of: AbbVie, BMS, Chugai, Roche, Gilead, Janssen, Lilly, Sanofi, Amgen, Novartis, Jeffrey Sparks Consultant of: Bristol-Myers Squibb, Gilead, Inova Diagnostics, Optum, and Pfizer., Arnaud Constantin Speakers bureau: AbbVie, BMS, Galapagos, Janssen, Lilly, Novartis, Pfizer, Sanofi, and UCB, Consultant of: AbbVie, BMS, Galapagos, Janssen, Lilly, Novartis, Pfizer, Sanofi, and UCB, Ricardo Xavier Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Janssen, Novartis, Pfizer, and UCB, Yanna Song Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Jessica Suboticki Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Roy M. Fleischmann Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, GSK, Janssen, Novartis, Pfizer Inc, Sanofi-Aventis, and UCB, Grant/research support from: AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Genentech, Janssen, Novartis, Pfizer Inc, Regeneron, Roche, Sanofi-Aventis and UCB

POS0242 THE EFFECT OF ANTIMALARIALS ON THE OVERALL SAFETY AND PERSISTENCE OF TREATMENT WITH BIOLOGIC AGENTS OR JAK INHIBITORS IN RHEUMATOID ARTHRITIS

Background

Antimalarials (AM) are frequently part of the initial scheme of conventional synthetic DMARDs in the treatment of rheumatoid arthritis (RA), and have been associated with lower incidence of diabetes and better lipid profile in these patients (1). However, the role of AM in schemes involving biologic (b-) or targeted synthetic (ts-) DMARDs has been much less extensively studied. In addition, a recent large scale study (2) and a consensus article (1) casted doubt on the long-term cardiovascular safety of AM.

Objectives

To evaluate the association of concomitant use of AM with the overall safety and survival of

treatment course among patients receiving one or multiple courses of bDMARDs or tsDMARDs

Methods

BiobadaBrasil is a multicentric registry-based cohort study of Brazilian patients with rheumatic diseases starting their first bDMARD or tsDMARD (3). The present analysis includes RA patients recruited from Jan 2009 to Oct 2019, followed-up over one or multiple (up to six) courses of treatment (latest date, Nov 19, 2019). A treatment course is defined as a period during which the medication scheme does not change. The primary outcome was the incidence of serious adverse events (SAEs). Total and system-specific adverse events (AEs), treatment interruption for any reason, interruption due to AEs and due to inefficacy served as secondary outcomes. Negative binomial regression with generalized estimating equations (to calculate the incidence rate ratios [ÌRRs]) and extended (frailty) Cox proportional hazards models were used for statistical analyses (both types of analyses including time-varying covariates over multiple courses of treatment).

Results

In total, 1316 patients (2335 treatment courses, 6711 patient-years [PY]) were enrolled. The overall incidence of serious adverse events was 9.2/100 PY. AM were used over 354 courses (1254.5 PY) of therapy. The IRRs for the primary and secondary outcomes are presented in Table 1. AM were also associated with better treatment course survival (Figure 1), reducing the risk of interruption due to AEs (multivariate hazard ratio: 0.56, 95% CI: 0.39 to 0.81, P=0.002) and inefficacy (0.65, 0.48 to 0.87, P=0.003).

Figure 1.Table 1.

Univariate and multivariate incidence rate ratios (IRRs) of adverse events comparing use versus non-use (reference category) of antimalarials. Results are IRRs, 95% CIs, and P values.

Type of adverse event (n of events)Crude analysisAdjusted covariates*Serious adverse events (617)0.60 (0.41 to 0.87), P=0.0070.51 (0.37 to 0.69), P<0.001Any adverse event (3494)0.65 (0.54 to 0.77), P<0.0010.68 (0.57 to 0.81), P<0.001Cardiovascular‡Serious (52)1.04 (0.49 to 2.20), P=0.9241.06 (0.45 to 2.50), P=0.891Total (163)0.90 (0.59 to 1.38), P=0.6420.93 (0.59 to 1.45), P=0.737InfectionsSerious (277)0.78 (0.44 to 1.39), P=0.4040.53 (0.34 to 0.83), P=0.006Total (1400)0.77 (0.61 to 0.98), P=0.0330.75 (0.60 to 0.94), P=0.014Hepatic‡Total (66)0.20 (0.07 to 0.64), P=0.0070.16 (0.04 to 0.57), P=0.005Glicemic control-relatedTotal (34)0.74 (0.29 to 1.92), P=0.5400.73 (0.26 to 2.00), P=0.535DyslipidemiaTotal (83)0.60 (0.31 to 1.13), P=0.1140.55 (0.28 to 1.06), P=0.074

*Age, baseline DAS28, disease duration, gender, smoking, seropositivity (RF or anti-CCP), previous malignancy, interstitial lung disease, diabetes, hypertension, hypercholesterolemia, renal failure, ischemic cardiomyopathy, COPD, heart failure, concomitant use of each cs-, b-, and tsDMARDs, corticosteroids, starting year, osteoporosis, hepatitis B and C, and treatment sequence. ‡ Excluding infections.

Conclusion

Among RA patients on treatment with bDMARDs or tsDMARDs, concomitant use of antimalarials reduced the incidence of serious and total AEs, including infections and hepatic AEs, and prolonged treatment course survival. No significant increase in the risk of cardiovascular AEs was observed.

References

[1]Desmarais et al. Arthritis Rheumatol 2021;73:2151-60.

[2]Lane et al. Lancet Rheumatol 2020;2:e698–e711

[3]Bredemeier et al. J Rheumatol 2021;48:1519-27.

Disclosure of Interests

None declared

POS0676 SURVIVAL OF THE FIRST COURSE OF BIOLOGIC OR JAK INHIBITOR IN RHEUMATOID ARTHRITIS: ASSOCIATION WITH THE CHOICE OF AGENT AND CONCOMITANT CONVENTIONAL SYNTHETIC DMARDS

Background:

After failure of conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) in the therapy of rheumatoid arthritis (RA), treatment may be escalated to biologic (bDMARDs) or JAK inhibitors (JAKi) (1). Analysis of drug survival can provide useful information on the effectiveness of these therapeutic schemes.

Objectives:

to evaluate the association of the choice of therapeutic agent with the survival of treatment course in RA patients receiving their first bDMARD or JAKi.

Methods:

BiobadaBrasil is a multicentric registry-based cohort study of Brazilian patients starting their first bDMARD/JAKi (2). This analysis includes RA patients recruited from Jan 2009 to Oct 2019, followed-up over the first course of treatment with a bDMARD/JAKi until censoring (latest date, Nov 19, 2019) or occurrence of the outcome of interest. A treatment course is defined as a period during which the medication scheme does not change, except for dose adjustments. The primary outcome was the interruption of treatment course for any reason (except for pregnancy or disease remission); interruption of treatment due to adverse events (AEs) or death and due to inefficacy served as secondary outcomes. Multivariate Cox proportional hazards models were used for analyses.

Results:

In total, 1177 patients (3800 patient-years [PY]) were enrolled. The overall incidence of treatment interruption was 17.5/100 PY. Adalimumab was the most frequently prescribed agent, followed by infliximab (n= 267). The hazards ratios (HR) of the primary and secondary outcomes are presented in Table 1. Figure 1 compares the survival of treatment curves of different bDMARDs/JAKi.

Table 1.

Hazard ratios (HR) of interruption of therapy course of each therapeutic agent (the reference category for bDMARDs/ JAKi is infliximab). Results are HR, 95% CIs, and P values*.

Agent (number of patients)Interruption for any reason (665 events)Interruption due to adverse events or death (196 events)Interruption due to inefficacy (319 events)Adalimumab (354)0.83 (0.68 to 1.01), P= 0.0620.68 (0.48 to 0.96), P=0.0291.08 (0.80 to 1.44), P=0.621Etanercept (257)0.81 (0.66 to 1.01), P=0.0630.56 (0.37 to 0.83), P=0.0040.93 (0.68 to 1.29), P=0.674Certolizumab (80)0.74 (0.47 to 1.16), P=0.1850.33 (0.13 to 0.86), P=0.0241.32 (0.74 to 2.35), P=0.350Golimumab (53)0.86 (0.53 to 1.38), P=0.5300.46 (0.18 to 1.19), P=0.1111.07 (0.53 to 2.15), P=0.849JAKi (tofacitinib) (59)0.54 (0.30 to 0.99), P=0.0470.19 (0.04 to 0.82), P=0.0260.89 (0.41 to 1.96), P=0.779Rituximab (48)0.87 (0.55 to 1.37), P=0.5400.48 (0.20 to 1.18), P=0.1090.58 (0.26 to 1.34), P=0.205Abatacept (30)0.52 (0.25 to 1.07), P=0.0770.46 (0.14 to 1.56), P=0.2150.46 (0.14 to 1.52), P=0.203Tocilizumab (29)0.29 (0.14 to 0.63), P=0.0020.40 (0.12 to 1.30), P=0.1260.28 (0.09 to 0.90), P=0.033Methotrexate (792)0.95 (0.79 to 1.14), P=0.5610.86 (0.62 to 1.19), P=0.3620.98 (0.75 to 1.28), P=0.860Leflunomide (497)1.17 (0.99 to 1.39), P=0.0611.44 (1.06 to 1.96), P=0.0201.02 (0.80 to 1.30), P=0.856Sulfasalazine (48)1.18 (0.80 to 1.75), P=0.4011.94 (1.07 to 3.54), P=0.0300.85 (0.45 to 1.59), P=0.605Antimalarials (230)0.80 (0.65 to 0.98), P=0.0270.67 (0.45 to 0.99), P=0.0430.67 (0.50 to 0.92), P=0.011

* All tests adjusted for other variables presented in the table and for age, baseline DAS28, disease duration, gender, smoking, seropositivity (RF/anti-CCP), previous malignancy, diabetes, hypertension, hypercholesterolemia, renal failure, ischemic cardiomyopathy, COPD, heart failure, use of corticosteroids, starting year, hypercholesterolemia, osteoporosis, hepatitis B and C.

Conclusion:

In our study, infliximab was related to an overall higher hazard of treatment course interruption than tolicizumab and tofacitinib, and higher hazard of interruption due to AEs than most other anti-TNF agents and tofacitinib. Maintaining antimalarials in patients receiving advanced therapies for RA may reduce interruption of treatment due to inefficacy and AEs.

Disclosure of Interests:

None declared

POS0671 CLINICAL RESPONSES TO UPADACITINIB OR ABATACEPT IN PATIENTS WITH RHEUMATOID ARTHRITIS BY TYPE OF PRIOR BIOLOGIC DISEASE-MODIFYING ANTIRHEUMATIC DRUG: DATA FROM THE PHASE 3 SELECT-CHOICE STUDY

Background:

In the phase 3 double-blind SELECT-CHOICE study of patients (pts) with prior inadequate response (IR) or intolerance to biologic disease-modifying antirheumatic drugs (bDMARDs), upadacitinib (UPA) showed superiority to abatacept (ABA) in change from baseline in 28-joint Disease Activity Score using C-reactive protein (DAS28[CRP]) and in the proportion of pts achieving DAS28(CRP) <2.6 at Week 12.

Objectives:

To describe clinical responses in pts receiving UPA or ABA by number and mechanism of action of prior bDMARDs.

Methods:

612 pts were randomized to once-daily UPA 15 mg or monthly intravenous ABA (<60 kg, 500 mg; 60–100 kg, 750 mg; >100 kg, 1000 mg). All pts continued background therapy with stable conventional synthetic DMARDs. From Week 12, pts who did not achieve ≥20% improvement in both tender and swollen joint counts vs baseline at 2 consecutive visits had background medication(s) adjusted or added. In this post hoc analysis, pts were grouped by the number and/or type of bDMARD received prior to enrollment: 1) lack of efficacy (LoE) to ≥1 tumor necrosis factor (TNF) inhibitor; 2) LoE to ≥1 interleukin-6 (IL-6) inhibitor; 3) intolerance to prior bDMARDs; 4) number of prior bDMARDs (1, 2, or ≥3). Mean change from baseline in DAS28(CRP) and DAS28(CRP) <2.6 and other clinical endpoints were evaluated at Weeks 12/24.

Results:

Most pts had LoE to ≥1 TNF inhibitor (536, 87.6%); 96 (15.7%) had LoE to an IL-6 inhibitor; 79 (12.9%) had intolerance to prior bDMARDs; 408 (66.7%), 134 (21.9%), and 64 (10.5%) had received 1, 2, or ≥3 prior bDMARDs, respectively. Mean change from baseline in DAS28(CRP) was generally greater with UPA vs ABA across the different pt subgroups at Weeks 12/24 (Figure 1). Across endpoints, regardless of prior bDMARD therapy (except in those who failed ≥3 prior bDMARDs), UPA and ABA demonstrated similar responses at Week 12 compared with those observed for the overall treatment groups, even with more stringent criteria such as ACR70 and Clinical Disease Activity Index (CDAI) ≤2.8 (Table 1. below) Responses at Week 24 followed a similar trend to those at Week 12 for DAS28(CRP) <2.6 and other endpoints (Table 1). The safety profile across subgroups was consistent with each respective treatment in the overall study population (data not shown).

Table 1.

Efficacy endpoints by prior bDMARD subgroup (Week 12 [top] and Week 24 [bottom])a

ACR20ACR50ACR70DAS28(CRP)≤3.2DAS28(CRP) <2.6CDAI ≤10CDAI ≤2.8HAQ-DIMCIDbLoE to ≥1 TNF inhibitorUPA 15 mg n=26375.377.944.959.722.838.849.061.230.446.840.758.69.122.875.574.3ABAn=27364.572.933.748.413.224.927.546.512.529.733.749.82.212.565.266.3LoE to ≥1 IL-6 inhibitorUPA 15 mg n=4870.885.437.566.720.829.245.866.725.041.741.758.36.316.778.378.3ABAn=4877.179.241.756.322.927.125.043.814.629.227.152.12.110.475.075.0Intolerance to prior bDMARDsUPA 15 mgn=4783.076.653.257.417.027.753.257.431.929.844.744.78.514.980.073.3ABAn=3262.571.928.150.00.031.321.956.36.331.321.956.33.19.461.367.71 priorbDMARDUPA 15 mgn=20677.281.151.963.121.838.852.466.032.547.641.761.29.220.979.676.6ABAn=20267.377.735.153.515.833.729.251.512.435.636.155.93.016.366.771.72 priorbDMARDsUPA 15 mgn=6478.176.634.456.323.439.151.662.526.650.045.354.74.723.473.870.5ABAn=7064.364.328.642.94.311.427.141.411.424.328.644.31.48.655.755.7≥3 prior bDMARDsUPA 15 mg n=2955.265.524.144.817.224.127.641.420.727.627.648.310.317.258.672.4ABAn=3565.771.440.040.020.017.128.637.120.020.037.140.02.98.677.174.3

aMissing information was imputed using NRI. bHAQ-DI MCID=reduction from baseline of ≥0.22

ACR20/50/70, 20/50/70% improvement in ACR criteria; HAQ-DI, Health Assessment Questionnaire-Disability Index

Conclusion:

Although sample sizes were small for some subgroups, treatment with UPA led to greater clinical responses vs ABA at Week 12, including in pts with LoE to TNF or IL-6 inhibitors, and those with IR or intolerance to 1, 2, or ≥3 prior bDMARDs.

Acknowledgements:

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and participated in the writing, review, and approval of the abstract. No honoraria or payments were made for authorship. Medical writing support was provided by Grant Kirkpatrick, MSc of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests:

Andrea Rubbert-Roth Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Chugai, Eli Lilly, Gilead, Janssen, Novartis, Roche, and Sanofi, Ricardo Xavier Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Janssen, Novartis, Pfizer, and UCB, Boulos Haraoui Consultant of: AbbVie, Amgen, Eli Lilly, Gilead, MSD, Pfizer, Sandoz, and UCB, Herbert S.B. Baraf Consultant of: Gilead, Janssen, and UCB, Grant/research support from: AbbVie, Eli Lilly, Genentech, Gilead, and Janssen, Maureen Rischmueller Consultant of: AbbVie, Bristol-Myers Squibb, CSL Behring, Eli Lilly, Gilead, Janssen, Pfizer, Sanofi, and UCB, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Janssen, Novartis, Pfizer, Sanofi, and UCB, Naomi Martin Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Yanna Song Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Jessica Suboticki Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, John Cush Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, and Novartis.

POS0654 IMPACT OF CONCOMITANT GLUCOCORTICOIDS ON THE CLINICAL EFFICACY AND SAFETY OF UPADACITINIB IN PATIENTS WITH RHEUMATOID ARTHRITIS: AN AD HOC ANALYSIS OF DATA FROM THREE PHASE 3 STUDIES

Background:

Glucocorticoid (GC) therapy has strong anti-inflammatory effects and helps slow radiographic progression in RA1; however, GCs can be associated with adverse events (AEs) such as infection, especially with long-term use and higher doses.

Objectives:

To evaluate the impact of baseline GCs on the efficacy and safety of upadacitinib (UPA) with or without concomitant conventional synthetic DMARDs (csDMARDs).

Methods:

In this ad hoc analysis of three Phase 3 studies, patients with inadequate response to MTX (MTX-IR) receiving UPA 15 mg once daily (QD) or placebo (PBO) + csDMARDs in SELECT-NEXT, and MTX-IR/MTX-naïve patients receiving UPA 15 mg QD monotherapy or MTX monotherapy in SELECT-MONOTHERAPY/SELECT-EARLY, respectively, were included. Efficacy outcomes, including measures of remission and low disease activity (LDA) determined by DAS in 28 joints using CRP (DAS28[CRP]; <2.6/≤3.2) and Clinical Disease Activity Index (CDAI; ≤2.8/≤10), were assessed and stratified by baseline GC use. Patients were permitted to receive oral GCs ≤10 mg/day (prednisone equivalent) at baseline with no adjustment permitted until Week 24/26/48. Safety was reported as number and proportion of patients with AEs. Data were analyzed descriptively with no statistical comparisons between groups or doses.

Results:

Of 1,506 patients included in the analysis, 737 (48.9%) were receiving baseline GCs (mean dose 6.2 mg/day). Baseline characteristics were broadly similar across treatment groups; SELECT-EARLY, which enrolled MTX-naïve patients, generally had the shortest duration of RA and higher CRP levels. Across UPA treatment groups, concomitant GCs generally did not influence the proportions of patients achieving remission (Figure 1). In SELECT-NEXT, clinical responses with UPA 15 mg in combination with csDMARDs were similar irrespective of concomitant GC use (Figure 1). Within SELECT-MONOTHERAPY, responses in patients receiving UPA 15 mg without concomitant csDMARDs or GCs were higher than those in patients receiving MTX alone, but were numerically lower than in those receiving UPA 15 mg with GCs (Figure 1). However, this was not observed within SELECT-EARLY, where clinical responses in patients receiving UPA 15 mg monotherapy without GCs were higher than in those patients receiving UPA 15 mg with GCs for both DAS28(CRP) <2.6 (40.6% vs 29.9%, respectively) and CDAI ≤2.8 (20.0% vs 11.6%, respectively) (Figure 1). A similar trend was observed for LDA. Serious AEs, AEs leading to discontinuation, and AEs of special interest, including infections (such as herpes zoster), were broadly similar in the UPA groups irrespective of concomitant GC use (table of safety data will be presented).

Conclusion:

UPA 15 mg in combination with csDMARDs or as monotherapy was effective in achieving remission and LDA, irrespective of concomitant GC use. Safety of UPA, including incidence of infection, appeared largely unaffected by concomitant GC use.

References:

[1]Kirwan JR, et al. Cochrane Database Syst Rev 2007;1:CD006356.

Acknowledgements:

AbbVie funded this study and participated in the study design, research, analysis, data collection, interpretation of data, reviewing, and approval of the publication. All authors had access to relevant data and participated in the drafting, review, and approval of this publication. No honoraria or payments were made for authorship. Medical writing assistance was provided by Frances Smith, PhD, of 2 the Nth, which was funded by AbbVie.

Disclosure of Interests:

Bernard Combe Speakers bureau: AbbVie, Eli Lilly, Gilead, Janssen, Merck, Novartis, Pfizer, Roche-Chugai, Sanofi, and UCB Pharma, Consultant of: AbbVie, Eli Lilly, Gilead, Janssen, Merck, Novartis, Pfizer, Roche-Chugai, Sanofi, and UCB Pharma, Frank Buttgereit Speakers bureau: AbbVie, Eli Lilly, Pfizer, and Roche, Andrew Ostor Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Gilead, Janssen, Novartis, Paradigm, Pfizer, Roche, and UCB Pharma., Ricardo Xavier Speakers bureau: AbbVie, Eli Lilly, Janssen, Novartis, Pfizer, Roche, and UCB Pharma, Consultant of: AbbVie, Eli Lilly, Janssen, Novartis, Pfizer, Roche, and UCB Pharma, Alain Saraux Speakers bureau: AbbVie, Bristol-Myers Squibb, Chugai, Eli Lilly, Nordic, Sanofi, and UCB Pharma, Consultant of: AbbVie, Bristol-Myers Squibb, Chugai, Eli Lilly, Nordic, Sanofi, and UCB Pharma, Capucine DARIDON Shareholder of: AbbVie, Employee of: AbbVie, Kirsten Famulla Shareholder of: AbbVie, Employee of: AbbVie, Yanna Song Shareholder of: AbbVie, Employee of: AbbVie, Ivan Lagunes-Galindo Shareholder of: AbbVie, Employee of: AbbVie, Gerd Rüdiger Burmester Speakers bureau: AbbVie, Eli Lilly, Gilead, Janssen, Merck, Pfizer, Roche, and UCB Pharma, Consultant of: AbbVie, Eli Lilly, Gilead, Janssen, Merck, Pfizer, Roche, and UCB Pharma

POS0222 PREDICTORS OF RESPONSE: BASELINE CHARACTERISTICS AND EARLY TREATMENT RESPONSES ASSOCIATED WITH ACHIEVEMENT OF REMISSION AND LOW DISEASE ACTIVITY AMONG UPADACITINIB-TREATED PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Upadacitinib (UPA) 15 mg once daily (QD) has demonstrated efficacy in phase 3 studies of patients with rheumatoid arthritis (RA).1–4 Early prediction of response to treatment with UPA could help to optimize therapy.

Objectives:

To identify baseline (BL) characteristics or Week (Wk) 12 disease activity measures that may predict the achievement of remission (REM) or low disease activity (LDA) at 6 months in patients with RA receiving UPA 15 mg.

Methods:

This ad hoc analysis included patients who were randomized to UPA 15 mg QD, as monotherapy in methotrexate (MTX)-naïve patients (SELECT-EARLY) or in combination with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), in patients with an inadequate response (IR) to MTX (SELECT-COMPARE) or ≥1 tumor necrosis factor inhibitors (TNFis) (SELECT-BEYOND and SELECT-CHOICE). The association of BL characteristics (including age, disease duration, prior/concomitant treatments, C-reactive protein [CRP], seropositivity, and disease activity) and Wk 12 disease activity parameters with the achievement of Clinical Disease Activity Index (CDAI) REM (≤2.8) or LDA (≤10) at Wk 24 (or Wk 26 in SELECT-COMPARE) was assessed by concordance statistics (C-statistics), or area under the receiver operator characteristic curve. C-index values and 95% confidence intervals were calculated by fitting a univariate logistic regression model for: demographic and BL characteristics, Wk 12 disease activity measures, and change from BL at Wk 12 in disease activity measures. A multivariate logistic regression with stepwise model selection was also performed. The proportion of patients achieving Wk 24/26 CDAI REM/LDA was stratified by ≥50% improvement from BL in swollen and/or tender joint count in 66/68 joints (SJC66/TJC68).

Results:

A total of 1377 patients were included in the analysis. Across the 4 studies, CDAI REM and LDA were achieved in 11.0–28.4% and 50.0–58.6% of patients, respectively (Table 1). BL demographics and disease characteristics were weakly predictive (C-index <0.70) of Wk 24/26 CDAI REM (C-index 0.49–0.69) or LDA (C-index 0.47–0.65), with the exception of BL Health Assessment Questionnaire-Disability Index in SELECT-BEYOND, which was moderately predictive of CDAI REM (C-index 0.73). Changes from BL in disease activity measures at Wk 12 were weakly or moderately predictive of Wk 24/26 CDAI REM (Figure 1) or LDA. CDAI value at Wk 12 was strongly predictive (C-index >0.80) of Wk 24/26 CDAI REM or LDA. Disease Activity Score in 28 joints using CRP and pain at Wk 12 were strongly predictive of Wk 24/26 CDAI REM (except in SELECT-CHOICE). Physician’s global assessment at Wk 12 was the only common predictor in the multivariate regression models for CDAI REM/LDA at Wk 24/26 across the 4 studies. A greater proportion of patients achieving ≥50% improvement in SJC66 and TJC68 at Wk 12 achieved CDAI REM (16.5–37.8% vs 0–9.4%) or LDA (66.0–72.8% vs 20.9–35.7%) at Wk 24/26 than those who did not.

Table 1.

Achievement of CDAI LDA and REM at Wk 24/26a

SELECT-EARLYSELECT-COMPARESELECT-BEYONDSELECT-CHOICEPatient populationMTX-naïveMTX-IRTNFi-IRTNFi-IRTreatmentUPA 15 mg monotherapy (n=317)UPA 15 mg + MTX(n=651)UPA 15 mg + csDMARD(n=146)UPA 15 mg + csDMARD(n=263)Efficacy at Wk 24/26a, n (%)CDAI REM (≤2.8)90 (28.4)150 (23.0)16 (11.0)60 (22.8)CDAI LDA (≤10)178 (56.2)343 (52.7)73 (50.0)154 (58.6)

a Wk 26 for SELECT-COMPARE only

Conclusion:

BL characteristics did not strongly predict response to UPA, but composite disease activity scores at Wk 12 predicted Wk 24/26 REM/LDA with UPA 15 mg QD across MTX-naïve, MTX-IR, and TNFi-IR patients. ≥50% improvement in SJC/TJC at Wk 12 was also associated with Wk 24/26 REM/LDA.

References:

[1]van Vollenhoven R, et al. Arthritis Rheumatol 2020;72:1607–20; 2. Genovese MC, et al. Lancet 2018;391:2513–24; 3. Fleischmann R, et al. Arthritis Rheumatol 2019;71:1788–800; 4. Rubbert-Roth A, et al. N Engl J Med 2020;383:1511–21.

Acknowledgements:

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and participated in the writing, review, and approval of the abstract. No honoraria or payments were made for authorship. Medical writing support was provided by Laura Chalmers, PhD, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests:

Arthur Kavanaugh Consultant of: Janssen, Grant/research support from: Janssen, Zoltán Szekanecz: None declared, Edward C. Keystone Speakers bureau: Abbott, Amgen, AstraZeneca, Biotest, Bristol-Myers Squibb, Eli Lilly, Genentech, Janssen, MSD, Novartis, Pfizer, Roche, Sanofi, and UCB, Consultant of: Abbott, Amgen, AstraZeneca, Biotest, Bristol-Myers Squibb, Eli Lilly, Genentech, Janssen, MSD, Novartis, Pfizer, Roche, Sanofi, and UCB, Grant/research support from: Abbott, Amgen, AstraZeneca, Biotest, Bristol-Myers Squibb, Eli Lilly, Genentech, Janssen, MSD, Novartis, Pfizer, Roche, Sanofi, and UCB, Andrea Rubbert-Roth Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Chugai, Eli Lilly, Janssen, Novartis, Pfizer, Roche, and Sanofi, Stephen Hall Grant/research support from: Pfizer, Ricardo Xavier: None declared, Joaquim Polido-Pereira: None declared, In-Ho Song Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Naomi Martin Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Yanna Song Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Samuel Anyanwu Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Peter Nash Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, Roche, Sanofi, and UCB.

POS1252 COVID-19 IN PATIENTS WITH RHEUMATIC DISEASES ON CHRONIC USE OF HYDROXYCHLOROQUINE IN A LARGE BRAZILIAN COHORT – A 24-WEEK PROSPECTIVE STUDY

Background:

The role of chronic use of hydroxychloroquine (HCQ) in rheumatic disease (RD) patients during the SARS-CoV-2 pandemic is still subject of discussion.

Objectives:

To compare the occurrence of COVID-19 and its outcomes between RD patients on HCQ use with individuals from the same household not taking the drug during community viral transmission in an observational prospective multicenter study in Brazil.

Methods:

Participants were enrolled and monitored through 24-week (From March 29th to Sep 30th, 2020) regularly scheduled phone calls performed by trained medical professionals. Epidemiological and demographic data, as well as RD disease activity status and current treatment data, specific information about COVID-19, hospitalization, need for intensive care, and death was recorded in both groups and stored in the Research Electronic Data Capture (REDCap) database. COVID-19 was defined according to the Brazilian Ministry of Health (BMH) criteria. The statistical analysis was performed using IBM-SPSS v.20.0 software. Group comparisons were made using the Man-Whitney, Chi-Square and Fisher Exact Test, as well as multivariate regression models adjusted to confounders. Survival curves were performed using Kaplan-Meier analysis.

Results:

A total of 10,427 participants mean age (SD) of 44.04 (14.98) years were enrolled, including 6004 (57.6%) rheumatic disease patients, of whom 70.8% had systemic lupus erythematosus (SLE), 6.7% rheumatoid arthritis (RA), 4% primary Sjögren’s syndrome (pSS), 1.8% mixed connective tissue disease (DMTC), 1% systemic sclerosis (SSc) and others (15.9), including overlap syndromes. In total, 1,132 (10.8%) participants fulfilled criteria for COVID-19, being 6.7% RD patients and 4.1% controls (p=0.002). A recent influenza vaccination had a protective role (p<0.001). Moderate and severe COVID-19 included the need for hospitalization, intensive care, mechanical ventilation or death. Infection severity was not different between groups (p=0.391) (Table 1). After adjustments for multiple confounders, the main risk factors significantly associated with COVID-19 were higher education level (OR=1.29 95%CI 1.05-1.59), being healthcare professionals (OR=1.91; 95%CI 1.45-2.53), presence of two comorbidities (OR=1.31; 95%CI 1.01-1.66) and three or more comorbidities associated (OR=1.69; 95%CI 1.23-2.32). Interestingly, age >=65 years (OR=0.20; 95%CI 0.11-0.34) was negatively associated. Regarding RD, the risk factors associated with COVID-19 diagnosys were SLE (OR= 2.37; 95%CI 1.92-293), SSc (OR=2.25; 95%CI 1.05-4.83) and rituximab use (OR=1.92; 95%CI 1.13-3.26). In addition, age >=65 years (OR=5.47; 95%CI 1.7-19.4) and heart disease (OR=2.60; 95%CI 1.06-6.38) were associated with hospitalization. Seven female RD patients died, six with SLE and one with pSS, and the presence of two or more comorbidities were associated with higher mortality rate.

Conclusion:

Chronic HCQ use did not prevent COVID-19 in RD compared to their household cohabitants. Health care profession, presence of comorbidities LES, SSc and rituximab were identified as main risk factors for COVID-19 and aging and heart disease as higher risk for hospitalization. Our data suggest these outcomes could be considered to manage them in clinical practice.

Table 1.

Frequency and severity of COVID-19 in patients with rheumatic diseases on chronic use of hydroxychloroquine compared to their household controls

COVID-19 outcomesTotal(%)GroupsPPatients(%)Controls (%)DiagnosisNo9256 (89.1)5300 (88.3)3956 (90.2)0.002Yes1132 (10.9)704 (11.7)428 (9.8)SeverityMild1059 (93.6)662 (94.0)397 (92.8)0.391Moderate52 (4.6)32 (4.5)20 (4.7)Severe21 (1.9)10 (1.4)11 (2.6)

HCQ: hydroxychloroquine.

Moderate and severe COVID-19 included the need for any of the following: hospitalization, intensive care, mechanical ventilation or death.

Acknowledgements:

To the Brazilian Society of Rheumatology for technical support and rapid nationwide mobilization.

To all the 395 interviewers (medical students and physicians) who collaborated in the study and the participants

To CNPq (Number 403442/2020-6)

Disclosure of Interests:

None declared

THU0074 ANTI-ARTHRITIC EFFECT OF RECOMBINANT CYSTATIN 3 FROM FASCIOLA HEPATICA IN COLLAGEN-INDUCED ARTHRITIS

Background:

Cystatins are cysteine proteases-inhibitors secreted byFasciola hepaticain order to modulate the host immune response to promote survival of the parasite. These molecules are able to inhibit different mammal cathepsins, to regulate the immune balance via Th2 and T regulatory responses, to downregulate antigen presentation and the release of pro-inflammatory cytokines (1,2) – mechanisms that are important in the development and maintenance of several immunopathology, as rheumatoid arthritis (RA) (3).

Objectives:

To evaluate the therapeutic effect of recombinants cystatin 1 and cystatin 3 fromFasciola hepaticain a mice model of collagen-induced arthritis (CIA).

Methods:

Twenty-seven DBA/1J mice were induced with CIA by an injection of collagen type-II and Freund’s adjuvant at days 0 and 18. Animals were randomly divided into three groups: vehicle (n=9, treated with phosphate-buffered saline), cystatin 1 (n=9, treated with 100 µg/dose of recombinant cystatin 1) and cystatin 3 (n=9, treated with 100 µg/dose of recombinant cystatin 3). Treatment started after day 18 by intraperitoneal injection once a day until the end of the experiment, at day 45 after CIA induction. Clinical arthritis score, nociception, paw edema, body and spleen weight were evaluated. Lymphocytes were isolated from lymph nodes and CD4+CD25+Foxp3+ T regulatory subset was assessed by flow cytometry. Data are expressed as mean ± SEM and were evaluated by one-way or two-way ANOVA followed by Bonferroni post-test.

Results:

Treatment with cystatin 1 did not alter any of the analyzed parameters. On the other hand, cystatin 3 was able to reduce clinical arthritis score from day 38 with 32% of reduction at day 45 (9.22±1.22) compared to vehicle (13.56±0.73) (p<0.05). In addition, treatment with cystatin 3 diminished nociception (cystatin 3: 4.0±0.36g, vehicle: 2.7±0.32g) (p<0.05) and paw edema (cystatin 3: 0.051±0,012ml, vehicle: 0.093±0.007ml) (p<0.05). Moreover, the treatment did not alter body weight (cystatin 3: 21.67±0.31g, vehicle: 21.05±0.38g) and spleen weight (cystatin 3: 7.04±0.31, vehicle: 7.16±0.38), as well as the T regulatory population (cystatin 3: 63.38±3.66%; vehicle: 58.31±6.77%).

Conclusion:

Treatment with cystatin 3 improved collagen-induced arthritis by attenuating the disease score, nociception and paw edema. Moreover, the treatment did not induce body weight loss or spleen weight alteration. These results suggest that recombinant cystatin 3 fromFasciola hepaticahas the potential as a treatment for inflammatory and autoimmune diseases such as RA.

References:

[1]Klotz C, Ziegler T, Daniłowicz-Luebert E, Hartmann S. Cystatins of parasitic organisms. Adv Exp Med Biol. 2011;712:208-21.

[2]Vray B, Hartmann S, Hoebeke J. Immunomodulatory properties of cystatins. Cell Mol Life Sci. 2002 Sep;59(9):1503-12.

[3]Smolen JS, Aletaha D, McInnes IB. Rheumatoid arthritis. Lancet. 2016 Oct 22;388(10055):2023-2038.

Disclosure of Interests:

Mirian Farinon: None declared, Renata Ternus Pedo: None declared, Thales Hein da Rosa: None declared, Barbara Jonson Bartikoski: None declared, Thaís Karnopp: None declared, Martin Cancela: None declared, Henrique Bunselmeyer Ferreira: None declared, Ricardo Xavier Consultant of: AbbVie, Pfizer, Novartis, Janssen, Eli Lilly, Roche

OP0269-HPR ASSOCIATION OF SARC-F PERFORMANCE WITH COMORBIDITIES, PHYSICAL DISABILITY AND LOWER ALBUMIN LEVELS IN SYSTEMIC SCLEROSIS PATIENTS

Background:

Systemic sclerosis (SSc) is a multisystem autoimmune disease of complex etiopathogeny, heterogeneous in its phenotypic expression and with a limited prognosis (1). The loss of muscle mass is a serious consequence of many chronic diseases and also is observed in SSc (2). This body composition alterations results in weakness, limitations and physical disability (3). SARC-F simple questionnaire, validated, is a key diagnostic feature for the fast assessment of geriatric syndromes associated with skeletal muscle wasting. However, there is no data about the SARC-F in SSc.

Objectives:

To assess the association between the SARC-F questionnaire with clinical features in patients with systemic sclerosis (SSc).

Methods:

Ninety-four patients diagnosed with systemic sclerosis were recruited and evaluated. Sarcopenia was assessed by the SARC-F questionnaire. Clinical features as disease duration time, comorbidities, body mass index (BMI), functional capacity by the Health Assessment Questionnaire (HAQ), inflammatory markers (C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), creatine phosphokinase (CPK), hemoglobin, creatinin and albumin) were medical record. Frequency analysis, descriptive analysis and Pearson’s correlation were performed. Statistical significance was considered as p<0,05.

Results:

Of the 94 patients analyzed, most were women (87/94;92.6%) with mean age of 60.5±10.3 years, median disease duration time of 11.2 (7.5-18.9) and median number of comorbidities was 1.00 (1.00-2.00). The mean of BMI was 25.9±4.7 Kg/m2. Twenty-one of the patients were classified as active or passive smokers, thirty-five said they were former smokers and thirty-eight never smoked. Sixty-nine (80, 2%) out of the ninety-four patients in the study had at least one type of comorbidity (mean 1, 44±1, 04). Eighty-three patients (88.3%) showed a SARC-F score without signs suggestive of sarcopenia (0-5) and eleven patients (11.7%) showed suggestive to sarcopenia (6-10). In HAQ, fifty-seven (60.6%) patients had mild incapacity, thirty-five (37.2%) had moderate incapacity, and two patients (2.2%) had severe incapacity. Higher SARC-F scores were associated with greater number of comorbidities (r=0.2; p=0.027), higher physical disability by HAQ (r= 0.5;p=0.000) and lower albumin levels (r= -0.3; p= 0.048). On other hand, SARC-F was not associated with time of diagnosis, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), creatine Phosphokinase (CPK), hemoglobin, hematocrit and creatinine.

Conclusion:

SARC-F scores were associated with comorbidities, physical disability and lower albumin levels in systemic sclerosis patients. Considering that comorbidities, physical disability and the albumin deficit enhances the patient’s muscle loss, SARC-F appears to be a good tool to screen sarcopenia risk factors in systemic sclerosis patients. Longitudinal studies are necessary to validate the SARC-F questionnaire in this population.

References:

[1]Hochberg MC et al. Sixth edit. (Elsevier, ed.). Philadelphia; 2015;

[2]Sakuma K et al. Pflügers Arch - Eur J Physiol. 2017;469(5-6):573-591.

[3]Caimmi C, et al. Clin Rheumatol. 2018;37(4):987-997.

Acknowledgments:

We thank the Coordination for the Improvement of Higher Level Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—CAPES) institution, the Foundation for Research Support of the Rio Grande do Sul State (Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul—FAPERGS), the Research and Events Incentive Fund (Fundo de Incentivo à Pesquisa e Eventos—FIPE) of HCPA and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico—CNPq).

Disclosure of Interests:

Leonardo Santos: None declared, Rafaela Cavalheiro do Espírito Santo: None declared, Vanessa Hax: None declared, Rafael Mendonça da Silva Chakr: None declared, Ricardo Xavier Consultant of: AbbVie, Pfizer, Novartis, Janssen, Eli Lilly, Roche

FRI0243 SARCOPENIA IS ASSOCIATED WITH MALNUTRITION IN PATIENTS WITH SYSTEMIC SCLEROSIS

Background:

Sarcopenia is one of the major health problems in older patients and is defined as a progressive decrease in muscle mass and function1. Sarcopenia has only rarely been studied in systemic sclerosis (SSc) and its impact in clinical characteristics of SSc is poorly investigated.

Objectives:

To evaluate the associations between sarcopenia and clinical features in SSc patients.

Methods:

Cross-sectional study, including 82 patients who met the ACR/EULAR 2013 classification criteria for SSc. Dual-energy X-ray absorptiometry, handgrip strength, and short physical performance battery were used to assess sarcopenia according the European Working Group on Sarcopenia in Older People’s (EWGSOP) diagnostic criteria updated in 20191. Malnutrition was evaluated according to the European Society of Clinical Nutrition and Metabolism (ESPEN)2, using the Malnutrition Universal Screening Tool (MUST) to screen risk for malnutrition.

Results:

The mean age was 60.4 years and 91.5% were women (table 1). Sarcopenia was identified in 15 (18.3%) SSc patients. Malnutrition was diagnosed in 12 (14.6%) and was more common in patients with sarcopenia (P=0.038). Also, there were significant differences between patients with and without sarcopenia regarding Body Mass Index (P=0.001), Fat Free Mass Index (P<0.001), knee extension strength (P=0.049), and Timed Up and Go test (P=0.041). There were no differences regarding age, disease duration, Rodnan skin score (mRSS), FVC and DLCO.

Table 1.

Clinical characteristics of SSc patients with and without sarcopenia. Data presented as number (%) of patients, except when indicated otherwise.

Patients featuresWhole(n=82)SSc patients without sarcopenia(n=67)SSc patients with sarcopenia(n=15)PvalueFemales75 (91.5)62 (92.5)13 (86.6)0.606Caucasian68 (82.9)53 (79.1)15 (100)0.258Age (years)b60.4 (10.6)60.2 (10.3)61.5 (12.3)0.678Diffuse skin involvement16 (19.5)16 (23.8)0 (0)0.082Disease duration (years)a12.8 (7.5, 19.2)12.7 (7.1,19.2)13.4 (8.9, 19.8)0.324Rodnan skin scorea4.0 (2.0, 10.0)5.0 (2.0, 10.0)2.0 (2.0,10.0)0.076Interstitial lung disease on HRCT32 (39.5)25 (37.3)7 (10.4)0.737FVC (% predicted)b88.4 (16.6)88.4 (16.9)88.3 (15.3)0.991DLCO (% predicted)b63.7 (11.9)63.6 (12.2)64.2 (11.2)0.855BMI (kg/m2)b25.6 (4.6)26.5 (4.4)21.8 (4.1)0.001FFMI (kg/m2)b15.6 (1.7)16.1 (1.6)13.8 (1.2)<0.001FMI (kg/m2)b9.5 (3.7)9.9 (3.6)7.5 (3.5)0.023Malnutrition12 (14.6)7 (10.4)5 (33.3)0.038MUST - Low risk58 (70.7)51 (76.1)7 (46.7)0.046Moderate and high risk24 (29.3)16 (23.9)8 (53.3)HAQb0.778 (0.591)0.797 (0.575)0.833 (0.576)0.825Timed Up and Go test (s)a8.41 (7.41, 10.59)8.39 (7.5, 9.4)10.23 (7, 14)0.041Knee extension strength (kgf)a21.40 (15.65, 27.52)21.70 (18.05, 28.35)14.82 (9.5, 24)0.049

aMedian (25, 75thpercentiles)

bMean (standard deviation)

Abbreviations: BMI: body mass Index; DLCO: diffusion capacity of carbon monoxide; FFMI: fat free mass index; FMI: fat mass index; FVC: forced vital capacity; HAQ: Health Assessment Questionnaire; HRCT: high-resolution computed tomography; MUST: Malnutrition Universal Screening Tool; SSc: systemic sclerosis.

Conclusion:

Sarcopenia is relatively common and is associated with malnutrition in patients with SSc. In our population, sarcopenia was not associated with other features related to a more severe disease. The role of sarcopenia in the prognosis of SSc needs to be better understood in longitudinal studies.

References:

[1]Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Sarcopenia: Revised European consensus on definition and diagnosis. Age Ageing. 2019;48(1):16-31.

[2]Cederholm T, Bosaeus I, Barazzoni R, et al. Diagnostic criteria for malnutrition - An ESPEN Consensus Statement. Clin Nutr. 2015;34(3):335-40

Disclosure of Interests:

Vanessa Hax: None declared, Rafaela Cavalheiro do Espírito Santo: None declared, Emerson Pena: None declared, Luísa Rodrigues: None declared, Renata Ternus Pedo: None declared, Jordana Miranda de Souza Silva: None declared, Nicole Pamplona Bueno de Andrade: None declared, Andrese Aline Gasparin: None declared, Ricardo Xavier Consultant of: AbbVie, Pfizer, Novartis, Janssen, Eli Lilly, Roche, Rafael Mendonça da Silva Chakr: None declared

SAT0151 EFFICACY AND SAFETY OF UPADACITINIB VERSUS ABATACEPT IN PATIENTS WITH ACTIVE RHEUMATOID ARTHRITIS AND PRIOR INADEQUATE RESPONSE OR INTOLERANCE TO BIOLOGIC DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (SELECT-CHOICE): A DOUBLE-BLIND, RANDOMIZED CONTROLLED PHASE 3 TRIAL

Background:

Upadacitinib (UPA) is an oral, reversible, selective JAK 1 inhibitor approved for the treatment of moderate to severe rheumatoid arthritis (RA). The efficacy/safety of UPA has been demonstrated in phase 3 studies, including superiority to adalimumab in patients (pts) with prior inadequate response (IR) to methotrexate.1-4

Objectives:

To assess the efficacy/safety of UPA vs abatacept (ABA) in pts with prior IR or intolerance to biologic DMARDs (bDMARDs).

Methods:

Pts were randomized to once daily UPA 15 mg or intravenous ABA (at Day 1, Weeks [Wks] 2, 4, 8, 12, 16 and 20 [< 60 kg: 500 mg; 60-100 kg: 750 mg; >100 kg: 1,000 mg]), with all pts continuing background stable csDMARDs. The study was double-blind for 24 wks. Starting at Wk 12, pts who did not achieve ≥20% improvement from baseline (BL) in both tender and swollen joint counts at two consecutive visits, had background medication(s) adjusted or initiated. The primary endpoint was change from BL in DAS28(CRP) at Wk 12 (non-inferiority). The non-inferiority of UPA vs ABA was tested using the 95% CI of treatment difference against a non-inferiority margin of 0.6. The two key secondary endpoints at Wk 12 were change from BL in DAS28(CRP) and the proportion of pts achieving clinical remission (CR) based on DAS28(CRP), defined as DAS28(CRP) <2.6. Both endpoints were to demonstrate the superiority of UPA vs. ABA. Treatment-emergent adverse events (TEAEs) are reported up to Wk 24 for all pts who received at least one dose of study drug.

Results:

Of 612 pts treated; 67% of pts had received 1 prior bDMARD, 22% received 2 prior bDMARDs, and 10% received ≥ 3 prior bDMARDs. 549 (90%) completed 24 wks of treatment. Common reasons for study drug discontinuation were AEs (UPA, 3.6%; ABA, 2.6%) and withdrawal of consent (UPA, 1.7%; ABA, 2.6%).

Non-inferiority and superiority were met for UPA vs ABA at Wk 12 for change from BL in DAS28(CRP) (-2.52 vs -2.00; -0.52 [-0.69, -0.35]; p <0.001 for UPA vs ABA). UPA also demonstrated superiority to ABA in achieving DAS28(CRP) <2.6 (30.0% vs 13.3%; p <0.001 for UPA vs ABA; Figure 1). Improvements in disease activity and remission rates were maintained through Wk 24. The proportions of pts achieving low disease activity (defined as DAS28(CRP) ≤3.2), ACR20, ACR50, and ACR70 responses were greater with UPA compared with ABA at Wk 12 (nominal p <0.05). More stringent outcome measures – CR, ACR50, and ACR70 responses - remained higher with UPA than ABA through Wk 24 (nominal p <0.05). Incidence of serious TEAEs, AEs leading to discontinuation, hepatic disorders, and CPK elevations were numerically higher with UPA versus ABA (Figure 2). Eight cases of herpes zoster were reported (4 in each treatment arm). No malignancies were reported. One case of adjudicated MACE, two adjudicated cases of VTE (1 pt with DVT and 1 pt with PE; both pts had at least one risk factor for VTE), and one treatment-emergent death were reported with UPA.

Conclusion:

In RA pts with a prior IR or intolerance to bDMARDs, UPA demonstrated superior improvement in signs and symptoms vs ABA based on change in DAS28(CRP) and in achieving CR at Wk 12. The safety profile of UPA was consistent with the phase 3 RA studies with no new risks identified.

References:

[1]Burmester GR, et al. Lancet. 2018;391(10139):2503-12

[2]Fleischmann R, et al. Arthritis Rheumatol. 2019;71(11):1788-800

[3]Genovese MC, et al. Lancet. 2018;391(10139):2513-24

[4]Smolen JS, et al. Lancet. 2019;393(10188):2303-11

Disclosure of Interests:

Andrea Rubbert-Roth Consultant of: Abbvie, BMS, Chugai, Pfizer, Roche, Janssen, Lilly, Sanofi, Amgen, Novartis, Jeffrey Enejosa Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Aileen Pangan Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Ricardo Xavier Consultant of: AbbVie, Pfizer, Novartis, Janssen, Eli Lilly, Roche, Boulos Haraoui Grant/research support from: Abbvie, Amgen, Pfizer, UCB, Grant/research support from: AbbVie, Amgen, BMS, Janssen, Pfizer, Roche, and UCB, Consultant of: Abbvie, Amgen, Lilly, Pfizer, Sandoz, UCB, Consultant of: AbbVie, Amgen, BMS, Celgene, Eli Lilly, Janssen, Merck, Pfizer, Roche, and UCB, Speakers bureau: Pfizer, Speakers bureau: Amgen, BMS, Janssen, Pfizer, and UCB, Maureen Rischmueller Consultant of: Abbvie, Bristol-Meyer-Squibb, Celgene, Glaxo Smith Kline, Hospira, Janssen Cilag, MSD, Novartis, Pfizer, Roche, Sanofi, UCB, Nasser Khan Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Ying Zhang Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Naomi Martin Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Mark C. Genovese Grant/research support from: Abbvie, Eli Lilly and Company, EMD Merck Serono, Galapagos, Genentech/Roche, Gilead Sciences, Inc., GSK, Novartis, Pfizer Inc., RPharm, Sanofi Genzyme, Consultant of: Abbvie, Eli Lilly and Company, EMD Merck Serono, Genentech/Roche, Gilead Sciences, Inc., GSK, Novartis, RPharm, Sanofi Genzyme

THU0610-HPR PREDICTION EQUATION FOR MUSCLE MASS OVERESTIMATES MUSCLE MASS IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Rheumatoid Arthritis (RA) is a chronic, progressive, inflammatory autoimmune disease characterized by systemic manifestations. Often is observed in RA patients changes in body composition, such as reduced muscle mass (sarcopenia) with stable or increased fat mass (FM) [1]. Total-body skeletal muscle mass (SMM), specifically appendicular skeletal muscle, is a key diagnostic feature for the assessment of geriatric syndromes associated with skeletal muscle wasting, such as sarcopenia [2]. Estimation of SMM can be accomplished by a variety of methods, but the majority that considered the gold standard for this purpose are high cost. Due high cost, this methods are unfeasible in population studies and increases the difficulty of use in different clinical contexts. Predictive equations have been developed for estimation of whole-body skeletal muscle mass on the basis of anthropometric data, which can be collected in a more affordable manner, in an attempt to make SMM calculation easier and enable its use in epidemiological research and in clinical settings [3]. However, these equations were not developed for RA populations.

Objectives:

To compare the anthropometric equation that estimate SMM with body composition measurements derived from DXA in RA patients.

Methods:

Ninety patients diagnosed with RA according to ACR/EULAR criteria were recruited. Body composition was assessed by total body dual-energy x-ray absorptiometry (DXA) for measurement of appendicular lean mass index (ALMI, kg/m2). The prediction equation for muscle mass proposed by Lee et al (variables included: body weight, height, age, sex and race) was used to generate estimates of SMM, stratified by BMI. Frequency analysis, independent student’s t test and intraclass correlation coefficients (ICC) were performed. Statistical significance was considered as p<0.05

Results:

Of the 90 patients analyzed, most were women (86.7%; 78/91), with mean age of 56.5±7.3 and median disease duration time of 8.5 (3-18) years. The mean of BMI was 27.39±5.14. Thirty (33.3%) RA patients had normal weight, forty patients (44.4%) were overweight and twenty patients (22.2%) were obese. In normal weight patients, just like overweight and obese patients, the estimates of SMM obtained by Lee equation were higher than those obtained by DXA measurements(Obese: Lee 10.66±1.19 vs DXA 7.10±0.73; Overweight: Lee 8.63±0.99 vs DXA 6.57±0.82; Normal weight: Lee 7.14±0.85vs DXA 6.03±0.71; p<0.05). The Lee equation estimates showed ICC of 0.78 (0.66 - 0.85) with DXA measurements. When stratified by BMI, Lee equation showed ICC of 0.87 (0.72 - 0.94) for normal weight, 0.83 (0.68 - 0.91) for overweight and 0.77 (0.42 - 0.90) for obese with DXA.

Conclusion:

The muscle mass index by Lee equation overestimates the muscle mass in overweight or obese RA patients compared to DXA. Thus, sarcopenic RA patients may be wrongly classified as normal by the equation. This is probably related to the obese cachexia that these patients often present. More studies are necessary to analysis to better prediction equations for muscle mass in RA patients.

References:

[1]Smolen JS et al. Nat Rev Dis Prim. 2018;4:18001; [2] Kim J et al. Am J Clin Nutr 2002; 76: 378–83.; [3] Lee RC et al. Am J Clin Nutr 2000;72:796-803.

Acknowledgments:

We thank the Coordination for the Improvement of Higher Level Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—CAPES) institution, the Foundation for Research Support of the Rio Grande do Sul State (Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul—FAPERGS), the Research and Events Incentive Fund (Fundo de Incentivo à Pesquisa e Eventos—FIPE) of HCPA and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico—CNPq).

Disclosure of Interests:

Rafaela Cavalheiro do Espírito Santo: None declared, Leonardo Santos: None declared, Lidiane Filippin: None declared, Priscila Lora: None declared, Ricardo Xavier Consultant of: AbbVie, Pfizer, Novartis, Janssen, Eli Lilly, Roche

THU0217 UPADACITINIB MONOTHERAPY IN METHOTREXATE-NAÏVE PATIENTS WITH RHEUMATOID ARTHRITIS: RESULTS AT 72 WEEKS FROM SELECT-EARLY

Background:

Upadacitinib (UPA), an oral JAK inhibitor, demonstrated significant improvements in signs, symptoms, and structural inhibition as monotherapy vs methotrexate (MTX) in a randomized, controlled trial (RCT) of MTX-naive RA patients (pts) through 48 weeks (wks).1

Objectives:

To present the safety and effectiveness of UPA through 72 wks in an ongoing long-term extension (LTE) of the SELECT-EARLY RCT.

Methods:

SELECT-EARLY included 2 study periods: (1) a 48-wk double-blind, active comparator-controlled, with pts randomized to UPA monotherapy 15 or 30 mg once daily or MTX (titrated to 20 mg/wk by Wk8); (2) an LTE, up to 4 years. Pts received open-label treatment once the last pt reached Wk48. Rescue therapy was added (MTX, for UPA groups; UPA, for MTX group) to pts not achieving CDAI remission (≤2.8) at Wk26. Non-responder imputation (NRI) was used for missing data as well as for pts receiving rescue therapy. Treatment-emergent adverse events (TEAEs) are summarized per 100 pt yrs (PY) through the cut-off date of 21 Feb 2019, when all pts had reached Wk72. Data are censored at the time of MTX or UPA addition among rescued patients.

Results:

Of 945 pts randomized and treated, 781 (83%) completed Period 1. Of these, 775 entered the LTE, including 57 rescued pts (MTX, 33; UPA 15 mg, 17; UPA 30 mg, 7). A total of 52 (7%) pts discontinued during the LTE through the cut-off date (primary reasons: AEs [n=16, 2.1%]; consent withdrawal [n=12, 1.5%]; lost to follow-up [n=10, 1.3%]). Cumulative exposures to monotherapy with MTX, UPA 15 mg, and UPA 30 mg were 350.6, 389.5, and 383.9 PYs, respectively. Both UPA 15 mg and 30 mg as monotherapy was associated with continued statistically significant improvements in disease activity measures vs MTX monotherapy through 72 wks (Table). The safety profiles of the UPA 15 and 30 mg groups were comparable for total TEAEs and numerically higher than MTX. Serious TEAEs and TEAEs leading to discontinuation of study drug were comparable across all groups (Figure). Most AEs of special interest were comparable across MTX and UPA groups, with the exception of higher rates of herpes zoster, opportunistic infections, and elevated creatine phosphokinase among the UPA groups. Two pts receiving MTX monotherapy experienced a venous thromboembolic event, with one event reported on UPA 30 mg and none on UPA 15 mg. There were 12 deaths (including 3 non-treatment-emergent) due to varied causes.

Table.

Proportion of Patients at Week 72 (NRI)

Parameter (%)MTXMonotherapyUPA 15 mg QDMonotherapyUPA 30 mg QDMonotherapyACR20/50/7050/39/2671***/62***/47***72***/67***/54***DAS28(CRP) ≤3.2/<2.638/2863***/52***69***/61***CDAI ≤10/≤2.842/1960***/35***69***/44***Boolean Remission1329***33***

***,P<0.001 for differences between MTX and UPA 15 and UPA 30 mg groups.

MTX, methotrexate; UPA, upadacitinib; QD, once daily; ACR, American College of Rheumatology; DAS28(CRP), 28-joint disease activity index based on C-reactive protein; CDAI, clinical disease activity index.

Figure.

Treatment-emergent Adverse Events Through ≥72 Weeks (E/100 PYs, 95% CI).

Conclusion:

Long-term UPA monotherapy was associated with continued improvements in RA signs and symptoms vs MTX monotherapy through 72 wks, and only a small proportion of pts required MTX addition at Wk26. Through 72 wks of treatment, the safety profile of UPA monotherapy remained consistent with data reported through 48 wks.1

References:

[1]van Vollenhoven R,et al.Ann Rheum Dis2019;78(S):376.

Disclosure of Interests: :

Ronald van Vollenhoven Grant/research support from: AbbVie, Arthrogen, Bristol-Myers Squibb, GlaxoSmithKline, Lilly, Pfizer, and UCB, Consultant of: AbbVie, AstraZeneca, Biotest, Bristol-Myers Squibb, Celgene, GSK, Janssen, Lilly, Medac, Merck, Novartis, Pfizer, Roche, and UCB, Tsutomu Takeuchi Grant/research support from: Eisai Co., Ltd, Astellas Pharma Inc., AbbVie GK, Asahi Kasei Pharma Corporation, Nippon Kayaku Co., Ltd, Takeda Pharmaceutical Company Ltd, UCB Pharma, Shionogi & Co., Ltd., Mitsubishi-Tanabe Pharma Corp., Daiichi Sankyo Co., Ltd., Chugai Pharmaceutical Co. Ltd., Consultant of: Chugai Pharmaceutical Co Ltd, Astellas Pharma Inc., Eli Lilly Japan KK, Speakers bureau: AbbVie GK, Eisai Co., Ltd, Mitsubishi-Tanabe Pharma Corporation, Chugai Pharmaceutical Co Ltd, Bristol-Myers Squibb Company, AYUMI Pharmaceutical Corp., Eisai Co., Ltd, Daiichi Sankyo Co., Ltd., Gilead Sciences, Inc., Novartis Pharma K.K., Pfizer Japan Inc., Sanofi K.K., Dainippon Sumitomo Co., Ltd., Maureen Rischmueller Consultant of: Abbvie, Bristol-Meyer-Squibb, Celgene, Glaxo Smith Kline, Hospira, Janssen Cilag, MSD, Novartis, Pfizer, Roche, Sanofi, UCB, Ricardo Blanco Grant/research support from: Abbvie, MSD and Roche, Consultant of: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen and MSD, Speakers bureau: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen, Lilly and MSD, Ricardo Xavier Consultant of: AbbVie, Pfizer, Novartis, Janssen, Eli Lilly, Roche, Mark Howard Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Alan Friedman Shareholder of: AbbVie Inc, Employee of: AbbVie Inc, Yanna Song Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Vibeke Strand Consultant of: AbbVie, Amgen, Biogen, Celltrion, Consortium of Rheumatology Researchers of North America, Crescendo Bioscience, Eli Lilly, Genentech/Roche, GlaxoSmithKline, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Sanofi, UCB

THU0346 SARC-F PERFORMANCE FOR SARCOPENIA SCREENING IN PATIENTS WITH SYSTEMIC SCLEROSIS

Background:

Because the method of diagnosing sarcopenia is complex and is considered to be difficult to introduce into routine practice, the European Working Group on Sarcopenia in Older People’s (EWGSOP) recommends use of the SARC-F questionnaire as a way to introduce assessment and treatment of sarcopenia into clinical practice1. Only recently, some studies have focused their attention on the presence of sarcopenia in systemic sclerosis (SSc) and there is no data about the performance of SARC-F in this population.

Objectives:

To test the diagnostic properties of the SARC-F questionnaire for sarcopenia screening in SSc patients.

Methods:

Cross-sectional study, including 94 SSc patients assessed by clinical evaluation, laboratory and pulmonary function tests. Sarcopenia was evaluated using the EWGSOP diagnostic criteria updated in 2019 (EWGSOP2): dual-energy X-ray absorptiometry, handgrip strength, and short physical performance battery (SPPB)1. Participants also completed the SARC-F questionnaire. The questionnaires’ performances were evaluated through receiver operating characteristic (ROC) curves and standard measures of diagnostic accuracy were computed using the EWGSOP2 criteria as the gold standard for diagnosis of sarcopenia.

Results:

Sarcopenia was identified in 15 (15,9%) SSc patients by the EWGSOP2 criteria. Area under the ROC curve of SARC-F screening for sarcopenia was 0.588 (95% confidence interval (CI) 0.482, 0.688) (figure 1). The results of sensitivity, specificity, positive likelihood ratio (PLR) and negative likelihood ratio (NLR) with the EWGSOP2 criteria as the reference standard were 35.71 [95% CI, 12.76-64.86], 81.01 (95% CI, 70.62-88.97), 1.88 (95% CI, 0.81-4.35) and 0.79 (95% CI, 0.53-1.19), respectively. The optimal cut-off point of SARC-F in our sample was ≥ 4 (Youden index: 0.21), the same cut-off point recommended in the literature2,3. Only 6 (40%) out of the 15 participants with sarcopenia were identified by the SARC-F questionnaire in our population. However, the SARC-F properly identified 4 out of 5 patients who had severe sarcopenia.

Conclusion:

This is the first study to evaluate the performance of SARC-F questionnaire for sarcopenia screening in patients with SSc. Although it appropriately identifies severe cases of sarcopenia, the SARC-F alone may not be an adequate screening tool in high-risk populations, such as SSc, that may benefit from early intervention and treatment.

References:

[1]Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Sarcopenia: Revised European consensus on definition and diagnosis. Age Ageing. 2019;48(1):16-31.

[2]Malmstrom TK, Morley JE. SARC-F: A simple questionnaire to rapidly diagnose sarcopenia. J Am Med Dir Assoc. 2013;14(8):531-532.

[3]Ida S, Kaneko R, Murata K. SARC-F for Screening of Sarcopenia Among Older Adults: A Meta-analysis of Screening Test Accuracy. J Am Med Dir Assoc. 2018;19(8):685-689.

Disclosure of Interests:

Vanessa Hax: None declared, Rafaela Santo: None declared, Leonardo Santos: None declared, Mirian Farinon: None declared, Marianne de Oliveira: None declared, Guilherme Levi Três: None declared, Andrese Aline Gasparin: None declared, M Bredemeier: None declared, Ricardo Xavier Consultant of: AbbVie, Pfizer, Novartis, Janssen, Eli Lilly, Roche, Rafael Mendonça da Silva Chakr: None declared

AB0185 PROSPECTIVE PROFILE OF URINE METABOLOME IN RHEUMATOID ARTHRITIS

Background:

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by increased mortality and associated with metabolic disorders. Since the metabolomic profile is known to vary in response to different inflammatory conditions, metabolome analysis could substantially improve diagnosis and prognosis of RA.

Objectives:

To analyze the urine metabolome profile in RA patients and correlate it with disease activity changes over 12 months

Methods:

Seventy-nine RA patients, according to ACR/EULAR 2010 classification criteria, between 40 and 70 years old, were recruited and followed for 12 months. Metabolome analysis was performed by Nuclear Magnetic Resonance spectroscopy (NMR), resulting in the identification of 93 metabolites in urine collected at the baseline and after 12 months. Frequency analysis, Pearson Correlation and Multivariate data analysis with orthogonal projections to latent structures (OPLS) method were performed and a statistical significance was considered as p<0.05.

Results:

The study population was characterized by the majority of women (86.7%), mean age of 56 years old, around 80% with positive anti-CCP or Rheumatoid Factor. During the one year of follow-up, there was no substantial variation in the DAS28 measurement (baseline: 3.8, after 12 months: 4.0). There was no significant correlation between the metabolome pattern and DAS28 score (p>0.05) over time. However, multivariate analysis (OPLS-DA) demonstrated an adequate differentiation of the population with 0.92 of accuracy (Q2: 0.72 and R2: 0.89).There was a significant increase of L-cysteine, choline, L-Phenylalanin, creatine, L-histidine, oxalacetic acid and xanthine, and a decrease of L-threonine, taurine, butyric and gluconic acid (p<0.05) during the follow-up, metabolites that are involved in the skeletal muscle metabolism.

Conclusion:

The observed biomarkers indicate,as expected, that the RA metabolic profile is associated with inflammation injury and skeletal muscle amino acid metabolism. Correlations with disease activity changes was compromised by the stable disease status during the 12 months. More studies evaluating correlations with skeletal muscle function and mass are underway.

Acknowledgments:

Disclosure of interest: Marianne Oliveira: None declared, Rafaela Santo: None declared, Mirian Farinon: None declared, Ricardo Xavier Consultant of: Abbvie, Pfizer, Novartis, Janssen, Lilly, Roche

Disclosure of Interests:

Marianne de Oliveira: None declared, Paulo Vinicius Alabarse: None declared, Mirian Farinon: None declared, Rafaela Cavalheiro do Espírito Santo: None declared, Ricardo Xavier Consultant of: AbbVie, Pfizer, Novartis, Janssen, Eli Lilly, Roche

AB0086 NEW METHOD TO ASSESS SKELETAL MUSCLE ATROPHY IN COLLAGEN INDUCED ARTHRITIS (CIA) MODEL

Background:

Muscle quality in rheumatoid arthritis (RA) is a new concept that involves morphological features and function. A measurement that associates cell morphology with clinical and physical parameters has not been reported in the literature. CIA is a RA mice model characterized by loss of muscle mass similar to human RA, thereby it is a convenient model to study the disease impact in muscle physiology.

Objectives:

Develop an index to measure the morphometry of muscle fibers and correlate the morphological features with the muscle functional performance in CIA.

Methods:

18 DBA/1J mice were induced using complete Freund’s adjuvant and a booster after 18 days induction. Along experimental phase, we evaluated muscle strength using grip strength test and clinical disease score after onset of disease. 16 healthy mice were used as control. After 25 days CIA induction, 8 CIA and 8 controls were euthanized for muscle evaluation in mild disease and, at day 50, 8 CIA and 8 control mice were euthanized for evaluation in severe disease. Tibialis anterior were collected for myofiber histological analysis. Using the Image Pro Plus software (Media Cybernetics, China), we segmented muscle fibers and assessed its area and its regularity (the last through an index named Muscle Fiber Irregularity Index, MFII). The index works as a threshold to set to screen the degree of normal, atrophic and hypertrophic based on the morphometry if muscle fibers. Values are compared to area and shape of control (healthy) fibers. Frequency analysis and Pearson Correlations were used and statistical significance was considered as p<0.05.

Results:

We found 1.5% atrophic muscle fibers in control animals. Mild CIA showed the same atrophic muscle fibers percentage compared to control. However, severe CIA showed 11.8% of atrophic muscle fibers. Decrease muscle strength in CIA over time were associated with a greater atrophic muscle fiber proportion (r=-0.8, p=0.021) and increased disease score (r=-0.8; p=0.019).

Conclusion:

Here we developed a new, objective method applied to screen for muscle quality through the morphometry of muscle fibers. Muscular Morphometric Analysis (MusMA) has potential to be used in combination with clinical parameters in several human pathophysiological analysis. Besides that, we can speculate that although muscle strength is associated with atrophic cell percentage, loss of strength does not only depend of atrophy, but disease activity also seems to influence muscle strength reduction.

References:

[1].Turesson C, Matterson EL. – Management of extra-articular disease manifestations in rheumatoid arthritis. Curr Opin Rheumatol. 2004; 16(3) 206-11

[2]Mielants H, Van den Bosch 2. – Extra-articular manifestations. Clin Exp Rheumatology 2009; 27(Suppl. 55): S56-S61

[3]Bouchard DR, Janssen I. Dynapenic-obesity and physical function in older adults. The journals of gerontology Series A, Biological sciences and medical sciences. 2010; 65(1):71–7.

[4]MANINI, T. M.; CLARK, B. C. Dynapenia and aging: An update. Journals of Gerontology - Series A Biological Sciences and Medical Sciences, v. 67 A, n. 1, p. 28–40, 2012. ISSN 10795006. Citado na página 19.

Disclosure of Interests:

Bárbara Bartikoski: None declared, Jordana Miranda de Souza Silva: None declared, Eduardo Chiela: None declared, Ricardo Xavier Consultant of: AbbVie, Pfizer, Novartis, Janssen, Eli Lilly, Roche

Spreader grafts: functional or just aesthetical?

OBJECTIVE

Spreader grafts are commonly used in rhinoplasty to achieve an aesthetic improvement of the nose or a functional improvement of the nasal airway. Currently, the aesthetic role of spreader grafts is well established. The functional effect of these grafts, however, has been controversial due to the lack of studies clearly demonstrating an increase on nasal airflow assigned to spreader grafts. The purpose of this study is to evaluate the effect of spreader grafts on nasal breathing.

METHODS

Nasal breathing of 72 consecutive patients undergoing rhinoplasty was evaluated by measuring peak nasal inspiratory flow (PNIF) before surgery and six months after surgery.

RESULTS

The mean preoperative PNIF of the 72 patients included in this study was 79.44 l/min and the mean postoperative PNIF was 110.42 l/min (p < 0.001). In 37 patients of this study no spreader grafts were used. In this group of patients the mean PNIF values changed from 73.24 l/min before surgery to 99.46 l/min after surgery. In the group of 35 patients in whom spreader grafts were used the mean PNIF values changed from 86.00 l/min before surgery to 122.00 l/min after surgery. The increase in the mean PNIF value after rhinoplasty was slightly higher in the group of patients with spreader grafts than in the group of patients without spreader grafts. The difference in the postoperative increase of PNIF between these two groups of patients, however, is not statistically significant.

CONCLUSIONS

This study suggests that patients undergoing rhinoplasty have a statistically significant improvement in nasal breathing after surgery. However, patients receiving spreader grafts in a non-randomized way do not have statistically significant greater benefit than those who do not.

Sexology population characterization – a two years’ experience at a Lisbon specialized centre

Introduction

Within psychiatry, sexology is a very particular area of expertise both by the nature and specificity of its diagnosis, as by the various difficulties and challenges their patients place. Sexology is a sub-specialty niche, but also a vast universe that covers such diverse conditions as paraphilia, gender dysphoria or sexual dysfunction. The sexology consultation of Santa Maria Hospital (HSM) is one of the biggest centers specialized in sexual disorders in the country. Consultations depend on the collaboration of a sexologist psychiatrist and psychiatry residents in close connection with endocrinology, urology and plastic surgery services.

Objective

We intend to conduct a characterization of the population observed in the HSM sexology consultation, in a period of 2 years, from the analyses of different general and diagnosis-specific relevant variables.

Methods

We intent to make a descriptive analysis of the population that attended the sexology consultation over the last 2 years. The sample study refers to all patients who have been specifically referred to sexology department or that directly requested access to this consultation. Data will be collected from medical computer records.

Results

Through systematic evaluation of different variables we can possibly conclude by some putative associations. A comprehensive characterization of this particular population is a possible method for a better and deeper insight on the diagnosis itself.

Conclusions

The purpose of this work is to increase peers’ sensitivity both to sexology and to the patients sexology serves.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

About an exhibitionism clinical case: Entity's review and state of the art exposure

Introduction

Exhibitionistic disorder may be present when there is sexual arousal from the exposure of one's genitals to an unsuspecting and nonconsenting person. This disorder prevalence is unknown but we know it is highly unusual in females. It generally starts at adolescence and its course is likely to vary with age. There are temperamental and environmental risk factors.

Most of what we know about exhibitionistic disorder is largely based on research with individuals convicted for criminal acts involving genital exposure, and this may represent an important bias. From a clinical case of exhibitionism, the authors intend to review this type of paraphilia from an historical, conceptual and etiologic point of view.

Objective

To review the concept behind this diagnosis and its evolution, the comprehensive theories that attempt to justify and frame it, as well as the type of intervention currently considered to be the state of the art.

Methods

Patient's observation and assessment, along with an extensive review of the relevant literature.

Conclusions

Starting from a real clinical case, the authors present a general theoretical review on the subject.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Identification of an anti-inflammatory protein from Faecalibacterium prausnitzii, a commensal bacterium deficient in Crohn's disease

BACKGROUND

Crohn's disease (CD)-associated dysbiosis is characterised by a loss of Faecalibacterium prausnitzii, whose culture supernatant exerts an anti-inflammatory effect both in vitro and in vivo. However, the chemical nature of the anti-inflammatory compounds has not yet been determined.

METHODS

Peptidomic analysis using mass spectrometry was applied to F. prausnitzii supernatant. Anti-inflammatory effects of identified peptides were tested in vitro directly on intestinal epithelial cell lines and on cell lines transfected with a plasmid construction coding for the candidate protein encompassing these peptides. In vivo, the cDNA of the candidate protein was delivered to the gut by recombinant lactic acid bacteria to prevent dinitrobenzene sulfonic acid (DNBS)-colitis in mice.

RESULTS

The seven peptides, identified in the F. prausnitzii culture supernatants, derived from a single microbial anti-inflammatory molecule (MAM), a protein of 15 kDa, and comprising 53% of non-polar residues. This last feature prevented the direct characterisation of the putative anti-inflammatory activity of MAM-derived peptides. Transfection of MAM cDNA in epithelial cells led to a significant decrease in the activation of the nuclear factor (NF)-κB pathway with a dose-dependent effect. Finally, the use of a food-grade bacterium, Lactococcus lactis, delivering a plasmid encoding MAM was able to alleviate DNBS-induced colitis in mice.

CONCLUSIONS

A 15 kDa protein with anti-inflammatory properties is produced by F. prausnitzii, a commensal bacterium involved in CD pathogenesis. This protein is able to inhibit the NF-κB pathway in intestinal epithelial cells and to prevent colitis in an animal model.

Antibacterial activity of ovary extract from sea urchin Diadema setosum

OBJECTIVE

Sea urchin gonad is considered as a highly prized delicacy in several countries. It is also rich in valuable bioactive compounds including polyunsaturated fatty acids (PUFAs) and β-carotene. This study was undertaken to examine the antimicrobial properties of the ovary extract from sea urchin Diadema setosum against selected Gram-negative and Gram-positive bacteria.

MATERIALS AND METHODS

The ovary extract was obtained using two different solvents such as methanol and chloroform. The obtained extract was used to examine its potential antimicrobial properties against the following 11 bacterial species using the disc diffusion method: Gram-negative bacteria (Salmonella typhi, Salmonella typhimurium, Shigella flexneri, Pseudomonas aeruginosa, Aeromonas hydrophila, Acinetobacter sp, Citrobacter freundii and Klebsiella pneumonia) and Gram-positive bacteria (Bacillus subtilis, Staphylococcus epidermidis and Staphylococcus aureus). The activity was measured in terms of zone of inhibition (mm).

RESULTS

The methanol extract exhibited a higher zone of inhibition against all the bacteria taken for examination. Whereas, the ovary extract obtained by chloroform did not show any antimicrobial activity against S. typhi, S. epidermidis, C. freundii and K. pneumonia. The results indicated that the ovary extract obtained by methanol extracts are capable of inhibiting the growth of pathogenic microbes taken for analysis. Moreover, the result indicates the presence of antimicrobial agents in sea urchin ovary.

CONCLUSIONS

The study suggests that the ovary extract of D. setosum may be a potential source of antimicrobial agent for pathogenic microorganisms.

The intestinal microbiome in type 1 diabetes

Few concepts in recent years have garnered more disease research attention than that of the intestinal (i.e. 'gut') microbiome. This emerging interest has included investigations of the microbiome's role in the pathogenesis of a variety of autoimmune disorders, including type 1 diabetes (T1D). Indeed, a growing number of recent studies of patients with T1D or at varying levels of risk for this disease, as well as in animal models of the disorder, lend increasing support to the notion that alterations in the microbiome precede T1D onset. Herein, we review these investigations, examining the mechanisms by which the microbiome may influence T1D development and explore how multi-disciplinary analysis of the microbiome and the host immune response may provide novel biomarkers and therapeutic options for prevention of T1D.