Three-month tapering and discontinuation of long- term, low-dose glucocorticoids in senior patients with rheumatoid arthritis is feasible and safe: placebo-controlled double blind tapering after the GLORIA trial

OBJECTIVE

The randomised placebo-controlled GLORIA (Glucocorticoid LOw-dose in RheumatoId Arthritis) trial evaluated the benefits and harms of prednisolone 5 mg/day added to standard care for 2 years in patients aged 65+ years with rheumatoid arthritis (RA). Here, we studied disease activity, flares and possible adrenal insufficiency after blinded withdrawal of study medication.

METHODS

Per protocol, patients successfully completing the 2-year trial period linearly tapered and stopped blinded study medication in 3 months. We compared changes in disease activity after taper between treatment groups (one-sided testing). Secondary outcomes (two-sided tests) comprised disease flares (DAS28 (Disease Activity Score 28 joints) increase >0.6, open-label glucocorticoids or disease-modifying antirheumatic drug (DMARD) increase/switch after week 4 of tapering) and symptoms/signs of adrenal insufficiency. In a subset of patients from 3 Dutch centres, cortisol and ACTH were measured in spot serum samples after tapering.

RESULTS

191 patients were eligible; 36 met treatment-related flare criteria and were only included in the flare analysis. Mean (SD) DAS28 change at follow-up: 0.2 (1.0) in the prednisolone group (n=76) vs 0.0 (1.2) in placebo (n=79). Adjusted for baseline, the between-group difference in DAS28 increase was 0.16 (95% confidence limit -0.06, p=0.12). Flares occurred in 45% of prednisolone patients compared with 33% in placebo, relative risk (RR) 1.37 (95% CI 0.95 to 1.98; p=0.12). We found no evidence for adrenal insufficiency.

CONCLUSIONS

Tapering prednisolone moderately increases disease activity to the levels of the placebo group (mean still at low disease activity levels) and numerically increases the risk of flare without evidence for adrenal insufficiency. This suggests that withdrawal of low-dose prednisolone is feasible and safe after 2 years of administration.

Changes in body weight and body composition in patients with active rheumatoid arthritis aged 65+ treated with 2-year low-dose add-on prednisolone in the randomised double-blind placebo-controlled GLORIA trial

OBJECTIVES

To investigate the effect of 2 years of add-on prednisolone 5 mg/day on body weight and composition in patients with active rheumatoid arthritis (RA) aged 65+ and the relation with disease activity.

METHODS

The Glucocorticoid Low-dose Outcome in RheumatoId Arthritis trial, a pragmatic, placebo-controlled, double-blind, randomised controlled trial investigated the balance of benefit and harm of 2 years of prednisolone 5 mg/day added to standard care in 451 patients with active RA aged 65+. In the current study, 449 patients were included, and body weight and Disease Activity Score of 28 Joints were measured at baseline and after 3, 6, 12, 18 and 24 months. In 57 patients, body composition was assessed at baseline and after 2 years with dual-energy X-ray absorptiometry. Data were analysed with longitudinal mixed models.

RESULTS

The mean (95% CI) change in body weight was 0.9 (0.3 to 1.6) kg in the prednisolone group and -0.4 (-1.1 to 0.2) kg in the placebo group (difference 1.3 (0.5-2.2), (p<0.01)). The treatment effect was independent of disease activity suppression and comprised mostly increase in (appendicular) lean mass after 2 years. There was no significant increase in total fat mass, nor redistribution of fat mass from peripheral to central tissues.

CONCLUSIONS

Patients with active RA aged 65+ treated with prednisolone 5 mg/day for 2 years gained about 1 kg in weight, compared with minimal-non-significant-weight loss on placebo. Our data suggest that the small increase in weight is mostly lean mass, rather than increase or redistribution of fat mass traditionally associated with glucocorticoid treatment.

POS1012 PATIENT CHARACTERISTICS AND CLINICAL ASSESSMENTS ASSOCIATED WITH PROGRESSION FROM NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS TO ANKYLOSING SPONDYLITIS

Background

Part of the patients with non-radiographic spondyloarthritis (nr-axSpA) will progress to ankylosing spondylitis (AS). Varying factors are reported to be predictive of this progression of which the presence of elevated CRP and active sacroliitis on MRI are most often found1.

Objectives

To explore patient characteristics and clinical assessments associated with progression from nr-axSpA to AS up to 6 years follow-up in daily clinical practice.

Methods

Patients from the ongoing Groningen Leeuwarden axial SpA (GLAS) cohort classified as nr-axSpA enrolled into the cohort (baseline) between 2009 and 2018 were included in the analyses. Nr-axSpA was defined as sacroiliitis of ≥ 2 grade bilaterally or ≥ 3 unilaterally on the AP view of pelvic radiographs, according to the modified New-York (mNY) criteria. Baseline and available radiographs at 2 (n=85), 4 (n=53) and 6 years (n=30) of follow-up were randomized with radiographs of patients with AS and scored with known time sequence according to the mNY criteria by 2 trained readers (SK and RW). In case of disagreement in classification, the score of a third independent reader (AS) was used. Progression to AS was defined as progression in mNY sacroiliitis score to a score of ≥2 bilaterally or ≥3 unilaterally at any time during the 6-year follow-up period. Patient characteristics and clinical assessments at baseline were compared between patients who did and did not progress from nr-axSpA to AS, using chi-squared tests, Mann-whitney U tests or independent t-tests when appropriate.

Results

85 patients were classified as nr-axSpA at baseline. Mean age was 39±11 years, 52% was male, median symptom duration was 6 (IQR 3-17) years, 75% was HLA-B27+, and mean ASDAS was 2.7±1.1.

After 2, 4 and 6 years, 9/85 (10.6%), 4/47 (8.5%) and 2/24 (8.3%) of nr-axSpA patients progressed to AS. In total, 15 patients progressed to AS and 31 and 19 patients did not yet reach follow-up at 4 and 6 years, respectively.

Patients with nr-axSpA progressing to AS were significantly more often current smokers (62% vs. 21%, p=0.003) and had more often a history of uveitis (47 vs. 11%, p=0.001). Furthermore, patients with nr-axSpA progressing to AS tended to have higher CRP (and therefore ASDAS), more entheseal involvement, and worse lumbar spinal mobility then non-progressors; however, due to the relatively low number of progressors during the analyzed follow-up period, significance could not be reached (Table 1).

Table 1.

Comparison of baseline characteristics between patients with nr-axSpA who did and did not progress to AS. Values presented as mean ± SD, median (IQR) and n (%) for normally distributed, non-normally distributed and categorical variables, respectively. *p<0.05.

Baseline characteristicsAll patients (n=85)No progression (n=70)Progression (n=15)pMale sex44 (52%)39 (56%)5 (33%)0.115Age38.6 ± 10.838.4 ± 10.239.5 ± 13.80.774Symptom duration6 (3 – 17)7 (3 – 16)4 (2 – 20)0.663HLA-B27+62 (75%)52 (74%)10 (67%)0.758Currently smoking22 (28%)14 (21%)8 (53%)0.003*BMI26.1 ± 4.426.2 ± 4.525.8 ± 4.20.750History of uveitis15 (18%)8 (11%)7 (47%)0.001*History of IBD7 (8%)6 (9%)1 (8%)0.808History of psoriasis12 (14%)10 (15%)2 (13%)0.923ASDAS2.7 ± 1.12.6 ± 1.13.2 ± 1.00.107- ASDAS >2.151 (72%)41 (68%)10 (91%)0.126BASDAI5.3 (3.4 – 6.7)5.4 (3.2 – 6.8)4.7 (3.6 – 6.7)0.538CRP ≥5.021 (27%)16 (25%)5 (39%)0.320Start TNFi (during first 2 years of follow-up)27 (32%)23 (33%)4 (27%)0.640Chest expansion (cm)5.2 ± 2.15.3 ± 2.14.7 ± 2.10.367Lateral spinal flexion (cm)14.4 (10.5 – 17.5)14.5 (10.7 – 17.7)11.3 (9.0 – 17.5)0.163mSchober (cm)14.1 ± 1.314.1 ± 1.313.7 ± 1.30.308

Conclusion

In our cohort, active smoking and a history of uveitis were independently associated with the progression of nr-axSpA to AS. Combining data of different cohorts will help to assess a more robust picture of axSpA features and patient characteristics associated with progression to AS.

References

[1]Protopopov M, Poddubnyy D. Expert Rev Clin Immunol. 2018;14(6):525-533

Acknowledgements

The GLAS cohort has received unrestricted grants from Novartis.

Disclosure of Interests

Stan Kieskamp: None declared, Rick Wilbrink: None declared, Mark Siderius: None declared, Freke Wink: None declared, Reinhard Bos: None declared, Hendrika Bootsma Speakers bureau: Bristol-Myers Squibb, Novartis, Consultant of: Bristol-Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Grant/research support from: Unrestricted grants from Bristol-Myers Squibb and Roche, Suzanne Arends: None declared, Anneke Spoorenberg Paid instructor for: Abbvie, Consultant of: AbbVie, Novartis Pharma, Pfizer, UCB Pharma, Lilly, Grant/research support from: Novartis Pharma, Pfizer

POS1438 FRYQ QUESTIONNAIRE DISTINGUISHES INFLAMMATORY FROM NON-INFLAMMATORY DISEASE IN NEWLY REFERRED PATIENTS

Background

Inflammatory Rheumatic Diseases (IRDs) affect 5% of the general population, while 35% of the population experiences Musculoskeletal Complaints (MSCs) [1]. IRDs cause early disability, reduced life-expectancy and considerable health care costs. Early diagnosis is essential to prevent long-term damage, similarly important is the early identification of patients with MSCs without IRDs to prevent unnecessary health care expenses. Of the population referred to the rheumatologist, 60% have non-inflammatory MSCs while only 20% of patients with an IRD see a rheumatologist within three months of symptom onset [2]. The need for digital predictive (triage) tools for Rheumatic and Musculoskeletal Diseases led to the development of the Frysian Questionnaire for differentiation of MSK complaints (FRYQ).

Objectives

To assess if FRYQ questionnaire can distinguish inflammatory rheumatic disease from non-inflammatory MSCs in newly referred patients.

Methods

The Frysian Questionnaire for differentiation of MSK complaints (FRYQ) is an 87 item questionnaire (consisting of 20 open questions and 67 closed questions), which is used in regular care in the rheumatology outpatient clinic of the Medical Center Leeuwarden to triage newly referred patients. Results of FRYQ, referral work diagnosis, resulting diagnoses and demographic data of 854 patients were collected. Elastic Net regularization was used to extract the most informative questions. The data was split: 75% to construct the elastic net and 25% to perform an independent validation. The classification performance was evaluated according to the area under the ROC-curve.

Results

The group consisted of 287 males (33%) and 570 (66%) females. Table 1 shows the characteristics of the 854 studied referrals.

Table 1.Table 1Referral orwork diagnosisNumber (%)Diagnosis by rheumatologist Number (%)Correct work diagnosis GPNumber (%)Rheumatoid arthritis146 (16.9)87 (10.1)53 (36.3)Psoriatic arthritis41 (4.8)29 (3.4)17 (41.5)Spondylarthropathy64 (7.4)52 (6.0)30 (46.9)Undifferentiated oligoarthritis97 (11.2)10 (1.2)5 (5.2)Polymyalgia rheumatica55 (6.4)27 (3.1)22 (40.0)Gout55 (6.4)49 (5.7)40 (72.7)Calcium pyrophosphate deposition4 (0.5)13 (1.5)2 (50.0)Sarcoidosis10 (1.2)10 (1.2)5 (50.0)Arthralgia124 (14.4)0 (0) Varied: mostly non inflammatoryNAClinically suspect arthralgia018 (2.1)NAReactive arthritis2 (0.2)12 (1.4)1 (50.0)Sjögrens’ syndrome14 (1.6)6 (0.7)2 (14.3)Systemic sclerosis3 (0.3)5 (0.6)2 (66.7)Systemic lupus erythematosus8 (0.9)5 (0.6)3 (37.5)GPA vasculitis01 (0.1)0 (0)Suspicion systemic auto immune disease57 (6.6)0 (varied: mostly non inflammatory)0 (0)Tendomyalgia27 (3.1)117 (13.6)10 (37.0)Fibromyalgia79 (9.2)110 (12.7%)57 (72.2)Osteoarthritis29 (3.4)153 (17.7%)22 (75.9)Hypermobility syndrome023 (2.7)0 (0)Unknown60NAOther33 (3.9)127* (14.8)NAtotal854 (100)854 (100)NAInflammatory293 (34.3 %)*Non-inflammatory560 (65.7 %)*

*including missing data

After elastic net regularization the 87 items could be reduced to 33 items that were able to differentiate inflammatory disease from non-inflammatory disease with an AUC of 0.70 in the ROC curve below (Figure 1).

Figure 1.

ROC-curve highlighting performance of FRYQ after regularization in the validation set

Conclusion

FRYQ questionnaire can differentiate inflammatory rheumatic disease from non-inflammatory musculoskeletal complaints. To officially validate FRYQ a prospective cohort study is needed.

References

[1]van der Linden, M.W, Westert G.P, de Bakker, D.H et al. Tweede Nationale Studie naar ziekten en verrichtingen in de huisartspraktijk. https://www.nivel.nl/sites/default/files/bestanden/ns2_rapport1.pdf. Utrecht/Bilthoven: NIVEL/RIVM, 2004.

[2]Stack RJ, Nightingale P, Jinks C, et al. Delays between the onset of symptoms and first rheumatology consultation in patients with rheumatoid arthritis in the UK: an observational study. BMJ Open 2019;9:e024361,2018-024361.

Acknowledgements

We thank our data managers and outpatient clinic secretariat.

Disclosure of Interests

None declared

OP0263 FAVORABLE BALANCE OF BENEFIT AND HARM OF LONG-TERM, LOW-DOSE PREDNISOLONE ADDED TO STANDARD TREATMENT IN RHEUMATOID ARTHRITIS PATIENTS AGED 65+: THE PRAGMATIC, MULTICENTER, PLACEBO- CONTROLLED GLORIA TRIAL

Background

Low-dose glucocorticoid (GC) therapy is widely used in RA but the true balance of benefit and harm is still unknown.

Objectives

We studied the effects of prednisolone (5 mg/day, 2 years) in RA patients aged 65+, requiring adjustment of antirheumatic therapy (DAS28≥2.60).

Methods

Pragmatic double-blind placebo-controlled randomized trial; all co-treatments and changes therein were allowed during the trial except long-term open label GC; Ca/D supplementation was advised in all patients. Minimal exclusion criteria were tailored to seniors.

Harm outcome: the number of patients with ≥1 serious adverse event (SAE), or ≥1 ‘other adverse event of special interest’ (other AESI). Other AESI comprised any AE (except worsening of RA) causing study discontinuation, and GC-specific events (Table 1).

Table 1.

Adverse events of special interest (AESI).*

prednisolone (n=224)placebo (n=225)Events by protocol-defined categorySAEother AESISAEother AESI Infection261241691  Urinary tract449429  Pneumonia217213  Other20581049 Cardiovascular8260 Symptomatic fracture21146 New onset  Hypertension1407  Diabetes mellitus0201  Cataract0726  Glaucoma0103 Other†43433526Total8019463140

*AESI: Comprises serious adverse events (SAE) and other AESI, defined by protocol.

†‘Other’ other AESI: non-serious AE outside of the above predefined categories, but associated with premature discontinuation.

Benefit outcomes: improvement in disease activity (DAS28) and joint damage progression (Sharp/van der Heijde).

Longitudinal mixed models analyzed the data. Given prior knowledge we report one-sided 95% confidence limit (95%CL) and statistical tests, performed only for the main outcomes.

Results

We randomized 451 RA patients in 7 EU countries, 449 received the intervention; of these 63% prednisolone vs 61% placebo patients completed 2 years of follow up. Discontinuations were similar in both groups: for AE (14%) and active disease (4%); the remainder mostly for ‘trial fatigue’ and covid-related access issues (20%). Mean time on study drug was 19 (SD 8) months.

70% of patients were female, mean age was 72 (max 88) years, RA duration 11 years; 67% were RF+, 56% ACPA+, 96% had joint damage on radiographs: mean score 20, median 8. Mean DAS28 was 4.5. Most patients (79%) were on current DMARD treatment, including 14% on biologics; 47% had previously used GC, 14% changed DMARD therapy at baseline. Patients had mean 2.1 active comorbidities, and used median 7 drugs.

Benefit: Disease activity rapidly declined to stabilize after 1 year (Figure 1), and was lower on prednisolone (adjusted mean difference in DAS28 over 2 years: 0.37, 95%CL 0.23, p<0.0001). The contrast in early (3-month) response was larger in 331 patients adherent to protocol on stable treatment: mean difference in DAS28 0.62 (95%CL 0.44), more responders on prednisolone (Figure 1). Significant time-treatment interaction in secondary analyses suggested a decrease in contrast after the first year, most likely caused by significantly more changes in DMARD treatment on placebo. Joint damage progression over 2 years was significantly lower on prednisolone: mean 0.6 (SD 1.9) v 1.8 (6.4) score points on placebo, difference 1.2 (95%CL 0.2, p=0.02).

Harm: 60% prednisolone vs 49% placebo patients experienced the harm outcome: adjusted RR 1.24, 95%CL 1.04, p=0.02; number needed to harm 9.5 (Table 1). During the study 1 vs 2 patients died, and 3 vs 0 died within 5 months of discontinuation. Per 100 patient-years, AE totaled 278 in prednisolone vs 206 in placebo patients, and the difference was most marked for infections (Table 1); these were mostly mild or moderately severe. Other GC-specific AESI were rare without relevant differences.

Conclusion

Add-on low dose prednisolone has beneficial long-term effects on disease activity and damage progression in senior RA patients on standard treatment. The tradeoff is a 24% increase in patients with mostly mild to moderate AE, suggesting a favorable balance of benefit and harm.

Acknowledgements

Trial registration: NCT02585258 (clinicaltrials.gov).

The trial is part of a larger project funded by the European Union’s Horizon 2020 research and innovation program under grant agreement No. 634886.

Apart from the listed authors and centers, the GLORIA Trial Consortium comprises:

L.M. Middelink, Middelinc BV The Netherlands, Operational Lead;

V. Dekker, Amsterdam UMC, Vrije Universiteit, Financial Lead;

Partners:

Trial operations: N. van den Bulk, CR2O BV, The Netherlands;

Study Medication (Development, Manufacturing & Supply): R.M.A. Pinto,

Bluepharma – Indústria Farmacêutica, S.A., Portugal;

Data management: L. Doerwald, Linical Netherlands BV, The Netherlands; S. Manger, Department of Epidemiology & Data Science, Amsterdam UMC, Vrije Universiteit, The Netherlands.

Adherence monitoring: J. Redol, BeyonDevices LDA, Portugal;

Safety monitoring: K. Prinsen, Clinfidence BV, The Netherlands;

Patient partner: M. Scholte-Voshaar, Stichting Tools (Tools2Use), The Netherlands.

Investigators (other recruiting centers):

T.L.T.A. Jansen, VieCuri – location Venlo, The Netherlands;

C. Codreanu, Clinical Center for Rheumatic Diseases, Bucarest, Rumania;

R.M.Zandhuis-Mooij, MSc, Gelre Ziekenhuis, Apeldoorn, The Netherlands;

E. Molenaar, Groene Hart Ziekenhuis, Gouda, The Netherlands;

J.M. van Laar, UMC Utrecht, The Netherlands;

Y.P.M. Ruiterman, Haga Ziekenhuis, Den Haag, The Netherlands;

A.E.R.C.H. Boonen, MUMC, Maastricht, The Netherlands;

M. Micaelo, Instituto Português de Reumatologia, Lisboa, Portugal;

J. Costa, Hospital de Ponte Lima, Portugal;

M. Sieburg, Rheumatologische Facharztpraxis Magdeburg, Germany;

J.P.L. Spoorenberg, UMC Groningen, The Netherlands;

U. Prothmann, Knappschaftsklinikum Saar GbmH, Puettlingen, Germany;

M.J. Saavedra, Hospital de Santa Maria, Lisboa, Portugal;

I. Silva, Hospital de Egas Moniz, Lisboa, Portugal;

M.T. Nurmohamed, Reade, Amsterdam, The Netherlands;

J.W.G. Jacobs, UMC Utrecht, The Netherlands; and

S.W. Tas, Amsterdam UMC, University of Amsterdam, The Netherlands.

Scientific Advisory Committee:

J.W.J. Bijlsma, UMC Utrecht, The Netherlands;

R. Christensen, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark;

Y.M. Smulders, Amsterdam UMC, VU University, The Netherlands; and

S.H. Ralston, University of Edinburgh, Edinburgh, UK.

Radiographic assessment:

D.M.F.M. van der Heijde (Imaging Rheumatology BV, the Netherlands)

coordinated the reading of the hand and foot x-rays.

A.F. Marsman and W.F. Lems scored the spine X-rays.

Patient panel:

C. Rusthoven and M. Bakkers, The Netherlands

E. Frazão Mateus, and G. Mendes, Portugal

C. Elling-Audersch and D. Borucki, Germany

A. Cardone, Italy

P. Corduta and O. Constantinescu, Romania

P. Richards, United Kingdom

G. Aanerud, Norway

Disclosure of Interests

Maarten Boers Consultant of: Novartis, Linda Hartman: None declared, Daniela Opris-Belinski Consultant of: Abbvie, Pfizer, MSD, Novartis, Eli Lilly, Ewo Pharma, UCB, Reinhard Bos: None declared, Marc R Kok: None declared, José Antonio P. da Silva: None declared, Eduard N. Griep: None declared, Ruth Klaasen: None declared, Cornelia Allaart: None declared, Paul Baudoin: None declared, Hennie Raterman Consultant of: Abbvie, Pfizer, MSD, Novartis, Eli Lilly, Ewo Pharma, UCB, Zoltán Szekanecz: None declared, Frank Buttgereit Consultant of: Abbvie, AstraZeneca, Gruenenthal, Horizon Therapeutics, Mundipharma, Pfizer, Roche, Pavol MASARYK: None declared, Thomas Klausch: None declared, Sabrina Paolino: None declared, Annemarie M. Schilder Consultant of: Eli Lilly, Novartis, Genzyme, WIllem Lems Consultant of: Pfizer, Galapagos, Lilly, Amgen, UCB., Maurizio Cutolo: None declared

OP0270 TAPERING OF LONG-TERM, LOW-DOSE GLUCOCORTICOIDS IN SENIOR RHEUMATOID ARTHRITIS PATIENTS: FOLLOW-UP OF THE PRAGMATIC, MULTICENTRE, PLACEBO-CONTROLLED GLORIA TRIAL

Background

Guidelines suggest glucocorticoids (GC) should be used as bridge therapy in rheumatoid arthritis (RA), but many patients are treated chronically with low doses. The effects of withdrawal in such patients has not been studied extensively.

Objectives

To study disease activity score (DAS28), disease flares and signs of adrenal insufficiency after withdrawal of blinded trial medication (prednisolone 5 mg/day or placebo for 2 years).

Methods

The 2-year, double-blind GLORIA trial evaluated the long-term benefits and harms of low dose GC added to standard care (see main GLORIA trial abstract). Senior RA patients (≥ 65 years) were randomly assigned to prednisolone 5 mg/day or placebo.

After the final trial visit study medication was linearly tapered to zero in 3 months by adding a stop day every two weeks, and patients were reassessed. Those who successfully completed the trial and did not receive open-label GC during the 4 weeks after the final trial visit were included in this follow-up study.

The primary outcome was change in DAS28 at follow-up compared to the final trial visit. Secondary outcomes included the occurrence of disease flares (DAS28 increase > 0.6 or open-label GC between week 4 and 12 of the taper phase) and signs of adrenal insufficiency, assessed by 9 items selected from the 57-symptom list from the MDHAQ questionnaire (1) and hypotension (systolic RR < 90 or diastolic RR < 60). In a subset of patients from 3 Dutch centres, cortisol and ACTH were measured in spot serum samples during the follow-up visit.

Analysis of covariance assessed the change in DAS28. Linear regression and chi-square test were used for the remaining outcomes.

Results

278 participants completed the GLORIA study, 21 received GC within 4 weeks after the end of the trial, 58 had missing data, leaving 199 patients eligible for this study.

34 patients received open label GC after 4 weeks and were excluded for the primary analysis. In the remaining 165 patients (80 prednisolone, 85 placebo), mean (SD) DAS28 was higher on placebo: 3.14 (1.04) vs 2.92 (1.13) prednisolone at the final trial visit. After tapering, disease activity increased significantly (p=0.02) in the prednisolone group to 3.18 (1.20) but was stable in placebo (3.14). The difference in the increase of DAS28 between the groups was 0.21 (95%CI –0.05;0.47; p=0.11).

For signs of adrenal insufficiency, 33 out of 165 had missing data, leaving 60 in the prednisolone group and 72 in placebo (Table 1). Mean (SD) number of signs for prednisolone was 1.1 (1.1) versus 0.9 (1.3) for placebo at final trial visit and 0.8 (1.2) versus 0.8 (1.0) at follow-up. Difference in the change of the number of signs was –0.1 (95%CI –0.4;0.3; p=0.66).

Table 1.

Adrenal insufficiency signs and symptoms.

prednisolone (n=60)placebo(n=72)end of trialchange after 3 monthsend of trialchange after 3 monthsFatigue (unusual)15113–1Appetite loss5–144Muscle weakness7–26–2Dizziness32101Stomach pain3431Muscle pain19–619–1Nausea5–322Vomiting1001Diarrhoea5–23–2Hypotension*2–14–2Sum**1.1 (1.1)–0.2 (1.3)0.9 (1.3)0.0 (1.3)

* Systolic RR < 90 or diastolic RR < 60.

**Mean (SD)

No differences were seen in ACTH or cortisol levels: mean (SD) ACTH was 5.8 (4.1) in 23 prednisolone patients, and 5.1 (3.7) in 24 placebo patients; cortisol 296 (113) v 310 (166), cortisol/ACTH 67 (40) v 77 (54). Two prednisolone and one placebo patient had cortisol levels below 80. None developed clinical hypoadrenalism during further follow-up.

199 patients qualified for the disease flares sample, 99 prednisolone and 100 placebo; 44 patients flared on prednisolone tapering vs 31 on placebo, relative risk 1.43 (95%CI 0.99; 2.07; p=0.07).

Conclusion

Tapering prednisolone moderately increases disease activity to placebo levels (mean still at low disease activity levels) and numerically increases the risk of flare without any evidence of adrenal insufficiency. This suggests that withdrawal of low dose prednisolone is feasible after 2 years of administration.

References

[1]DeWalt DA et al. Clin Exp Rheumatol. 2004;22:453-61.

Acknowledgements

The GLORIA trial is registered at clinicaltrials.gov under NCT02585258.

The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‘’Personalizing Health and Care’’, grant agreement No 634886.

Disclosure of Interests

Abdullah Almayali: None declared, Maarten Boers Consultant of: Novartis, Linda Hartman: None declared, Daniela Opris-Belinski Consultant of: Abbvie, Pfizer, MSD, Novartis, Eli Lilly, Ewo Pharma, UCB, Reinhard Bos: None declared, Marc R Kok: None declared, José Antonio P. da Silva: None declared, Eduard N. Griep: None declared, Ruth Klaasen: None declared, Cornelia Allaart: None declared, Paul Baudoin: None declared, Hennie Raterman Consultant of: AbbVie, Amgen, Celgene, Roche, Sandoz, Sanofi Genzyme and UCB, Zoltán Szekanecz: None declared, Frank Buttgereit Consultant of: Abbvie, AstraZeneca, Gruenenthal, Horizon Therapeutics, Mundipharma, Pfizer, Roche, Pavol MASARYK: None declared, WIllem Lems Consultant of: Pfizer, Galapagos, Lilly, Amgen, UCB., Maurizio Cutolo: None declared, Marieke ter Wee: None declared

POS1402 COST-EFFECTIVENESS AND COST-UTILITY OF ADD-ON, LOW-DOSE PREDNISOLONE IN RA PATIENTS AGED 65+: THE PRAGMATIC, MULTICENTER, PLACEBO-CONTROLLED GLORIA TRIAL

Background

Rheumatoid arthritis (RA) is a disease with substantial impact on quality of life, healthcare and societal costs [1]. Current treatment strategies, especially biologic drugs, result in high costs [2]. Previous studies have already found that a combination treatment strategy of disease-modifying antirheumatic drug(s) with initially medium-to-high doses of prednisolone resulted in better effects and lower costs compared to the treatment strategies without prednisolone [3, 4]. However, to our knowledge the cost-effectiveness of low-dose glucocorticoids (GCs), and that of GC overall in established RA has not been examined separately.

Objectives

To evaluate the cost-effectiveness and cost-utility of low-dose prednisolone in RA patients aged 65+.

Methods

The economic evaluation was performed as part of the placebo-controlled GLORIA trial of RA patients aged 65+ with a disease activity score in 28 joints (DAS28) ≥2.60. Eligible patients were randomized to 2 years 5 mg/day prednisolone or placebo. Patients were recruited from 28 clinical centers in seven European countries. All co-treatment, except for chronic oral GC, was allowed.

The economic evaluation had a societal perspective with a time horizon of two years. Cost data were collected with questionnaires and from recorded events, and valued with unit prices of 2017. The primary effectiveness outcome was the DAS28. For cost-utility, quality-adjusted life years (QALYs) were estimated from the EuroQol-5 Dimension (EQ-5D) questionnaire.

Standard regression models were used to estimate incremental costs and effects between the treatment groups. Bootstrapping assessed the uncertainty around the average differences in costs and health outcomes.

Results

In total, 444 of 451 randomized patients were included in the modified-intention-to-treat analysis (see main GLORIA study abstract). Patients were on average 72 years and had median 4 active comorbidities at baseline. Mean total costs over 2 years were k€10.8 in the prednisolone group, k€0.4 (95% CI –3.7; 1.9) lower than in the placebo group. Total direct medical costs were k€0.5 (95% CI –4.0; 1.5) lower in the prednisolone group. The mean number of QALYs was similar in both groups (difference 0.02 [–0.03; 0.06] in favor of prednisolone). The DAS28 was 0.38 lower in the prednisolone group than in the placebo group (0.19;0.56).

The cost-effectiveness plane shows that the majority of the bootstrapped cost-effect pairs was situated in the southwest quadrant of the plane confirming the larger effects (i.e. decrease in DAS28) and non-significant lower costs in the prednisolone group (Figure 1). The cost-utility plane shows that the number of QALYs was similar for both groups and that the bootstrapped cost-utility pairs were slightly more located in the southeast quadrant confirming a very small increase in QALYs and slightly lower costs in the prednisolone group (Figure 1).

Conclusion

With greater effectiveness at non-significantly lower costs, low-dose, add-on prednisolone is cost-effective for RA compared to placebo over two years. QALYs were equal in both groups, most likely due to the impact of multiple comorbidities.

References

[1]Kobelt G. Elsevier. 2009;83-9.

[2]Souliotis K et al. PLoS One. 2019;14:e0226287.

[3]Ter Wee MM et al. RMD Open. 2017;3:e000502.

[4]Verhoeven AC et al. Br J Rheumatol. 1998;37:1102-9.

Acknowledgements

The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‘’Personalizing Health and Care’’, grant agreement No 634886.

Disclosure of Interests

Linda Hartman: None declared, Mohamed El Alili: None declared, Maurizio Cutolo: None declared, Daniela Opris-Belinski Speakers bureau: Abbvie, Pfizer, MSD, Novartis, Eli Lilly, Ewo Pharma, UCB, José Antonio P. da Silva: None declared, Zoltán Szekanecz: None declared, Frank Buttgereit Speakers bureau: Abbvie, AstraZeneca, Gruenenthal, Horizon Therapeutics, Mundipharma, Pfizer, Roche, Pavol MASARYK: None declared, Reinhard Bos: None declared, Marc R Kok: None declared, Sabrina Paolino: None declared, Veerle M. H. Coupé: None declared, WIllem Lems Speakers bureau: Pfizer, Galapagos, Lilly, Amgen, UCB, Maarten Boers Speakers bureau: BMS, Novartis, Pfizer

POS1010 SPINAL RADIOGRAPHIC PROGRESSION AND ITS ASSOCIATION WITH PROGRESSION TO ANKYLOSING SPONDYLITIS IN PATIENTS WITH NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS

Background

Prevention of structural damage of the axial skeleton is an important goal of treatment in axial spondyloarthritis (axSpA)1. Most studies concerning spinal radiographic progression focused on ankylosing spondylitis (AS). Data on spinal radiographic progression in patients with non-radiographic (nr)-axSpA is limited and data on the relation between spinal and sacroiliac radiographic progression in this population is lacking.

Objectives

To assess long-term spinal radiographic progression in patients with nr-axSpA. Secondly, to explore the association between radiographic progression to AS and spinal radiographic progression in these patients.

Methods

Patients enrolled in the ongoing Groningen Leeuwarden Axial SpA (GLAS) cohort, classified as nr-axSpA at baseline, with pelvic and spinal (lumbar and cervical) radiographs available at baseline and at least one follow-up visit at 2, 4 or 6 years were selected for analyses. Progression from nr-axSpA to AS was defined as progression to modified New York (mNY) sacroiliitis score ≥2 bilaterally or ≥3 unilaterally. Radiographs of nr-axSpA patients were randomized with radiographs of AS patients and scored in known time sequence by two trained readers blinded for patient characteristics. SK and RW scored the SI joints and in case of disagreement in axSpA classification, the score of a third independent reader (AS) was used. SK and MS scored the spinal radiographs according to the modified stoke ankylosing spondylitis spinal score (mSASSS; 0-72), and the mean of both total scores was calculated. In case of >5 points discrepancy between both readers, the mSASSS of a third independent reader (FM) together with the closest of the scores of the primary readers was used. The mSASSS change of nr-axSpA patients who did en did not progress to AS was compared with Mann-Whitney U tests.

Results

Included were 60 patients with a clinical diagnosis of nr-axSpA, confirmed by their sacroiliac radiographic score at baseline. Mean age was 37±10 years, 53% were male, median symptom duration was 9 (IQR 2-17) years, 75% were HLA-B27+, and mean ASDAS was 2.6±1.1.

In total 15 patients progressed to AS. Median mSASSS at baseline was 1.5 (IQR 0.5 – 4.4). Median change in mSASSS from baseline was 0.0 (IQR 0.0 – 1.0) vs. 1.0 (IQR 0.0 – 1.5) at 2 years; 1.2 (IQR 0.3 – 3.5) vs. 2.0 (0.5 – 2.7) at 4 years; and 1.8 (1.0 – 3.8) vs. 2.5 (0.5 – 3.5) at 6 years for non-AS progressors and AS progressors, respectively (Figure 1). These mSASSS changes weres were not significantly different at any timepoint (p = 0.456, p=0.814, p=0.929 for 2-, 4-, and 6-year follow-up, respectively).

Figure 1.

Comparison of mSASSS progression between patients with and without progression to AS during the first 6 years of follow-up.

Conclusion

In our observational cohort of patients with nr-axSpA with up to 6 years of follow-up, mSASSS progression was low (< 1 mSASSS unit/year) and was not different between patients who did and did not progress to AS.

References

[1]Van der Heijde D. et al. Ann Rheum Dis. 2017;76(6):978-991.

Acknowledgements

The GLAS cohort was supported by an unrestricted grant from Novartis.

Disclosure of Interests

Stan Kieskamp: None declared, Mark Siderius: None declared, Rick Wilbrink: None declared, Fiona Maas: None declared, Freke Wink: None declared, Reinhard Bos: None declared, Hendrika Bootsma Speakers bureau: Bristol-Myers Squibb, Novartis, Consultant of: Bristol-Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Grant/research support from: Unrestricted grants from Bristol-Myers Squibb and Roche, Suzanne Arends: None declared, Anneke Spoorenberg Paid instructor for: Abbvie, Consultant of: Abbvie, Novartis Pharma, Pfizer, UCB Pharma, Lilly, Grant/research support from: Novartis Pharma, Pfizer

AB0884 Disease outcomes in patients with psoriatic arthritis completing 12 months of apremilast treatment - Real-world data from the REWARD study

Background

Patients with moderately active psoriatic arthritis (PsA) and limited joint involvement have considerable disease burden1,2. Recent data shows these patients have a high likelihood of achieving treatment goals if treated with apremilast3. This is the first report of outcomes in patients with PsA who received apremilast for 12 months in Dutch clinical practice.

Objectives

We report disease outcomes, including the PsA Impact of Disease (PsAID) 12-item questionnaire, swollen joint count (SJC), tender joint count (TJC), dactylitis and enthesitis, among patients in the prospective, multicenter, observational REWARD study who completed 12 months of apremilast treatment.

Methods

The ongoing REWARD study enrolled patients who had initiated apremilast for the treatment of PsA in the Netherlands between 13 April 2017 and 24 March 2021, and includes up to 12 months follow-up1,4. We report interim data from patients with data available as of 16 September 2021. Baseline data are summarized separately for patients who discontinued apremilast before their month 12 study visit (stoppers) and patients still receiving apremilast at their month 12 visit (completers). Post baseline data are summarized for completers. Continuous data are summarized using mean and SD, categorical data are summarized using n and percent.

Results

98 patients were included in this interim analysis; 32 had completed 12 months of apremilast treatment (completers), 54 had discontinued apremilast before month 12 (stoppers), 12 were ongoing in the study. Compared with stoppers, completers were more likely to be biologic naïve and have dactylitis, and had lower BSA. All other baseline characteristics were similar (Table 1). Among completers, all PsAID domains improved after 3 months of apremilast treatment and these improvements were maintained through month 12 (Figure 1). Mean SJC and TJC decreased between baseline and month 12 (SJC, 4.2 and 1.0 at baseline and month 12, respectively; TJC, 7.1 and 3.3, respectively). The proportion of completers with SJC, TJC, enthesitis and dactylitis scores of 0 increased from baseline to month 12 (Figure 1B). The proportion of completers reporting at least one adverse event (AE) was comparable to the overall study population (14/32 [44%] and 48/98 [49%], respectively); the reported adverse events were similar to the known safety profile of apremilast.

Table 1.

Baseline characteristics

All=all patients included in this interim analysis; Completers= patients that received apremilast for 12 months; Stoppers= patients that stopped apremilast treatment prior to 12 months.

BMI=Body Mass Index, PsO=Psoriasis, BSA PsO= Body Surface Area Psoriasis, SJC=Swollen Joint Count, TJC=Tender Joint Count, PsAID=Psoriatic Arthritis Impact of Disease, VAS=Visual Analog Scale, CRP= C-reactive protein, cDAPSA=Clinical Disease Activity in Psoriatic Arthritis, Rem=Remission, Mod=Moderate, PsA= Psoriatic Arthritis

Figure 1.

(A) PSAID scores in completers and (B) percentage of completers with no swollen joints, no tender joints, no dactylitis and no enthesitis at baseline (BSL), month 3, 6 and 12 (M3, M6, M12).

Conclusion

In this interim analysis of the REWARD study, patients completing 12 months of apremilast treatment were more likely to be biologic naïve than patients who discontinued apremilast within 12 months of initiation, and had significant decreases in TJC, SJC, dactylitis and enthesis during apremilast treatment. Completed patients also reported decreased PsAID scores during apremilast treatment, indicating improvements in their quality of life.

References

[1]Jansen TL, et al. Ann Rheum Dis. 2019; 78:913 [abstract FRI0442]

[2]Wervers et al. J Rheumatol. 2018;45:1526.

[3]Mease PJ, et al. Arthritis Care Res. 2020; 72, 6, 814–821

[4]Bos R, et al. Ann Rheum Dis. 2021; 80:805 [POS1053]

Acknowledgements

Sylvia de Jong and Claire Desborough, Amgen employees, provided medical writing and editorial assistance.

Disclosure of Interests

Reinhard Bos Consultant of: AbbVie BV, Genzyme Europe, Grant/research support from: Galapagos, Tim Jansen Speakers bureau: Grunenthal, Sobi, Consultant of: AbbVie, Celgene Corporation, Grant/research support from: ReumaNederland, Olatec, Grunenthal, Ian Bridges Shareholder of: Amgen, Employee of: Amgen, Sylvia de Jong Shareholder of: Amgen, Employee of: Amgen, Novartis, Marijn Vis Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Grant/research support from: Novartis, Pfizer

Low dose, add-on prednisolone in patients with rheumatoid arthritis aged 65+: the pragmatic randomised, double-blind placebo-controlled GLORIA trial

Background

Low-dose glucocorticoid (GC) therapy is widely used in rheumatoid arthritis (RA) but the balance of benefit and harm is still unclear.

Methods

The GLORIA (Glucocorticoid LOw-dose in RheumatoId Arthritis) pragmatic double-blind randomised trial compared 2 years of prednisolone, 5 mg/day, to placebo in patients aged 65+ with active RA. We allowed all cotreatments except long-term open label GC and minimised exclusion criteria, tailored to seniors. Benefit outcomes included disease activity (disease activity score; DAS28, coprimary) and joint damage (Sharp/van der Heijde, secondary). The other coprimary outcome was harm, expressed as the proportion of patients with ≥1 adverse event (AE) of special interest. Such events comprised serious events, GC-specific events and those causing study discontinuation. Longitudinal models analysed the data, with one-sided testing and 95% confidence limits (95% CL).

Results

We randomised 451 patients with established RA and mean 2.1 comorbidities, age 72, disease duration 11 years and DAS28 4.5. 79% were on disease-modifying treatment, including 14% on biologics. 63% prednisolone versus 61% placebo patients completed the trial. Discontinuations were for AE (both, 14%), active disease (3 vs 4%) and for other (including covid pandemic-related disease) reasons (19 vs 21%); mean time in study was 19 months. Disease activity was 0.37 points lower on prednisolone (95% CL 0.23, p<0.0001); joint damage progression was 1.7 points lower (95% CL 0.7, p=0.003). 60% versus 49% of patients experienced the harm outcome, adjusted relative risk 1.24 (95% CL 1.04, p=0.02), with the largest contrast in (mostly non-severe) infections. Other GC-specific events were rare.

Conclusion

Add-on low-dose prednisolone has beneficial long-term effects in senior patients with established RA, with a trade-off of 24% increase in patients with mostly non-severe AE; this suggests a favourable balance of benefit and harm.

Trial registration number

NCT02585258.

Central sensitization has major impact on quality of life in patients with axial spondyloarthritis

INTRODUCTION

Persistent pain has large potential impact on quality of life (QoL). During the course of the disease, many patients with axial spondyloarthritis (axSpA) report persistent pain. Central sensitization (CS) may explain part of this chronic pain. However, the role of CS in relation to QoL has been sparsely studied in axSpA. Therefore, our aim was to explore the relationship between CS and QoL in patients with axSpA.

METHODS

Consecutive outpatients from the Groningen Leeuwarden axSpA (GLAS) cohort completed the Central Sensitization Inventory (CSI; range 0-100) and the AS Quality of Life (ASQoL; range 0-18). Multivariable linear regression analysis was used to explore the relationship between CSI and ASQoL scores correcting for potential confounders.

RESULTS

Of the 178 included axSpA patients, mean CSI score was 38.0 ± 14.1 and 45% scored ≥40, which indicates a high probability of CS. Mean ASQoL score was 6.0 ± 5.3 and mean ASDAS_CRP 2.1 ± 1.0. A CSI score ≥40 was significantly associated with higher ASQoL score (mean 9.7 vs. 3.3), higher ASDAS_CRP (mean 2.6 vs. 1.7), female gender (60% vs. 29%) and more often entheseal involvement (61% vs. 26%). In univariable analysis, CSI score explained a large proportion of the variation in ASQoL (B = 0.06, 95%CI: 0.05-0.07; R²=0.46). This association remained significant after correction for ASDAS_CRP, gender, entheseal involvement, comorbidities, symptom duration, smoking status, BMI class and educational level (B = 0.04, 95%CI: 0.03-0.05).

CONCLUSION

CS is strongly related to patient-reported QoL in patients with axSpA independently from other patient- and disease-related aspects.

Intravenous pegylated liposomal prednisolone outperforms intramuscular methylprednisolone in treating rheumatoid arthritis flares: A randomized controlled clinical trial

Glucocorticoids (GCs) are potent anti-inflammatory drugs but their use is limited by systemic exposure leading to toxicity. Targeted GC delivery to sites of inflammation via encapsulation in long-circulating liposomes may improve the therapeutic index. We performed a randomized, double-blind, active-controlled, multi-center study in which intravenously (i.v.) administered pegylated liposomal prednisolone sodium phosphate (Nanocort) was compared to equipotent intramuscular (i.m.) methylprednisolone acetate (Depo-Medrol®; i.e. a current standards-of-care for treating flares in rheumatoid arthritis patients). We enrolled 172 patients with active arthritis who met all eligibility criteria, eventually resulting in 150 patients randomized in three groups: (1) Nanocort 75 mg i.v. infusion plus i.m. saline injection; (2) Nanocort 150 mg i.v. infusion plus i.m. saline injection; and (3) Depo-Medrol® 120 mg i.m. injection plus i.v. saline infusion. Dosing in each group occurred at baseline and on day 15 (week 2). Study visits occurred at week 1, 2, 3, 4, 6, 8 and 12, to assess both efficacy and safety. The primary endpoint was the "European League Against Rheumatism" (EULAR) responder rate at week 1. Safety was determined by the occurrence of adverse events during treatment and 12 weeks of follow-up. Treatment with Nanocort was found to be superior to Depo-Medrol® in terms of EULAR response at week 1, with p-values of 0.007 (good response) and 0.018 (moderate response). Treatments were well tolerated with a comparable pattern of adverse events in the three treatment groups. However, the Nanocort groups had a higher incidence of hypersensitivity reactions during liposome infusion. Our results show that liposomal Nanocort is more effective than Depo-Medrol® in treating patients with rheumatoid arthritis flares and has similar safety. This is the first clinical study in a large patient population showing that i.v. administered targeted drug delivery with a nanomedicine formulation improves the therapeutic index of glucocorticoids.

Medication adherence in older people with rheumatoid arthritis is lower according to electronic monitoring than according to pill count

Objectives

Suboptimal medication adherence is a serious problem in the treatment of chronic inflammatory diseases. To measure medication adherence, electronic monitoring is regarded as superior to pill count. GLORIA is an ongoing two-year trial on the addition of low-dose (5 mg/d) prednisolone or placebo to standard care in older people (65+ years) with RA. During the entire trial, adherence is measured with electronic caps, and with pill counts. The objective is to describe medication adherence patterns, and to compare the adherence results of the two methods.

Methods

The recorded adherence patterns of patients (blinded for treatment group) were classified according to descriptive categories. The cutoff for good adherence was set at 80% of prescribed pills taken.

Results

Trial inclusion closed in 2018 at 451 patients, but trial follow-up is ongoing; the current dataset contains adherence data of 371 patients. Mean number of recorded 90-day periods per patient was 4 (range 1–8). Based on pill count over all periods, 90% of the patients had good adherence; based on cap data, only 20%. Cap data classified 30% of patients as non-user (<20% of days an opening) and 40% as irregular user (different adherence patterns, in or between periods).

Conclusion

In our trial of older people with RA, the majority appeared to be adherent to medication according to pill count. Results from caps conflicted with those of pill counts, with patterns suggesting patients did not use the bottle for daily dispensing, despite specific advice to do so.

Trial registration

NCT02585258. ClinicalTrials.gov (https://www.clinicaltrials.gov/)

Central sensitization, illness perception and obesity should be considered when interpreting disease activity in axial spondyloarthritis

OBJECTIVES

Many patients with axial spondyloarthritis (axSpA) report persistent pain even when treated with anti-inflammatory agents. Our aim was to explore the presence of central sensitization (CS) and different types of illness perceptions in patients with axSpA, and to assess their associations with disease activity assessments.

METHODS

Consecutive outpatients from the Groningen Leeuwarden Axial Spondyloarthritis (GLAS) cohort were included. Besides standardized assessments, patients filled out the Central Sensitization Inventory (CSI), Illness Perception Questionnaire (IPQ-R) and Pain Catastrophizing Scale (PCS). Univariable and multivariable linear regression analyses were used to investigate the association between questionnaire scores, patient characteristics and disease activity assessments ASDASCRP, BASDAI and CRP.

RESULTS

We included 182 patients with a mean symptom duration of 21.6 years. Mean ASDASCRP was 2.1, mean BASDAI 3.9, and median CRP 2.9. Mean CSI score was 37.8 (scale 0-100) and 45% of patients scored ≥40, indicating a high probability of CS. CSI score, IPQ-R domain identity (number of symptoms the patient attributes to their illness), and IPQ-R domain treatment control (perceived treatment efficacy), and obesity were significantly and independently associated with both ASDASCRP and BASDAI, explaining a substantial proportion of variation in these disease activity scores (R2=0.35 and R2=0.47, respectively). Only obesity was also independently associated with CRP.

CONCLUSION

CS may be common in patients with long-term axSpA. CS, as well as specific illness perceptions and obesity were all independently associated with the widely used (partially) patient-reported disease activity assessments ASDASCRP and BASDAI. Treating physicians should take this into account in the follow-up and treatment of their patients.

Extra-skeletal manifestations in axial spondyloarthritis are associated with worse clinical outcome despite the use of TNF blocking therapy

OBJECTIVE

To investigate the prevalence and 4-year incidence of acute anterior uveitis (AAU), inflammatory bowel disease (IBD) and psoriasis, and to explore associations of newly developed extra-skeletal manifestations (ESMs) with clinical disease outcome in a large cohort of axial spondyloarthritis (SpA) patients.

METHODS

All consecutive patients included in the Groningen Leeuwarden Axial SpA (GLAS) cohort between 2004 and 2011 were analysed. History of ESMs at baseline and newly developed ESMs during 4-year follow-up were only recorded when diagnosis by an ophthalmologist, gastroenterologist or dermatologist was present.

RESULTS

Of the 414 included axial SpA patients, 31.5% had a positive history of one or more ESMs: 24.9% AAU, 9.4% IBD, and 4.4% psoriasis. History of psoriasis was significantly associated with more radiographic damage, especially of the cervical spine. Of the 362 patients with 4-year follow-up data, 15.7% patients developed an ESM: 13.3% patients with AAU, of which 3.6% had a first episode and 9.7% had recurrent AAU, 1.9% developed IBD, and 0.8% developed psoriasis. Patients who newly developed ESMs (without history of ESMs) had worse ASQoL score (mean 10.0 vs. 5.9, p=0.001), larger occiput to wall distance (median 6.3 vs. 2.0, p=0.021) and more limited modified Schober test (mean 12.6 vs. 13.6, p=0.014) after 4 years of follow-up. The majority of patients developing an ESM used anti-TNF therapy.

CONCLUSION

History of ESMs was present at baseline in one-third of axial SpA patients. The 4-year incidence of ESMs was relatively low, but patients who developed a new ESM reported worse quality of life.

AB0160 HIGH NUMBER OF CONCOMITANT MEDICATIONS AND COMORBIDITIES AT BASELINE IN THE GLUCOCORTICOID LOW-DOSE OUTCOME IN RHEUMATOID ARTHRITIS (GLORIA) STUDY: AN OLDER POPULATION WITH RHEUMATOID ARTHRITIS

Background:

Treatment with low-dose glucocorticoids (GCs) (≤7.5 mg prednisolone) in combination with standard care is highly effective in rheumatoid arthritis (RA), but despite 70 years of clinical experience, evidence-based information on its balance of benefit and harm is incomplete. This leads to an ongoing debate, with under- and over-use of GCs as result. The GLORIA pragmatic trial was developed to assess harm, benefit and costs of low-dose GCs added to the standard treatment of older RA patients.

Objectives:

The objective of this abstract is to document the baseline status and frequency of comorbid conditions in the GLORIA study population. The results of the unblinded data will be submitted as late-breaking abstract.

Methods:

This double-blind, randomized, placebo-controlled, multicenter trial (1) was open for patients with RA according to the 1987 or 2010 (2) criteria, age ≥65 years, and disease activity score of 28 joints (DAS28) of ≥2.6. Patients were recruited from rheumatology clinics in Germany, Hungary, Italy, The Netherlands, Portugal, Romania and Slovakia. Eligible patients were randomized to two years of treatment with daily 5 mg prednisolone or matching placebo. All other medication was allowed, except for GCs. The presented data are blinded because the database is not closed yet.

Results:

The population consists of 451 patients with mean disease duration 10.6 (Q1-Q3: 3-15) years. The majority (70%) is female, mean age is 72.5 (Q1-Q3: 68-76, range: 65-88) years, 66% were positive for rheumatoid factor and 56% for ACPA. Patients had a mean of 4.3 (SD 2.8) comorbidities besides RA (3.4 active) and therefore used multiple concomitant medications (3.9 (SD 3.4)) (Table 1). The most common comorbidities (provisional data of 161 patients with complete coding) in this older population are: vascular disorders (58%), musculoskeletal and connective tissue disorders (57%) and a history of surgical and medical procedures (45%). Patients were most frequently on beta blocking agents (22%, mainly metoprolol) and HMG CoA reductase inhibitors (20%, mainly simvastatin). Most patients also have an extensive history of anti-rheumatic treatment. At the start of the trial most patients (82%) were on cDMARD treatment; 15% were on bDMARDs/tsDMARDs. Almost half of the patients previously had been treated with GCs, with a mean duration of 3.4 years and a mean last dose of 4.6 mg/day.

Conclusion:

The baseline data shows that we have an older study population who have relatively many other comorbidities next to RA and who are almost all treated with multiple concomitant medications in addition to the study medication. Therefore, we expect to report a high adverse event rate. Research among older patients is urgently needed, but the frailty of this population as represented by the multiple comorbidities and concomitant medications have to be taken into account in the analyses and interpretation of the results.

References:

[1]Hartman L, Rasch LA, Klausch T, Bijlsma HWJ, Christensen R, Smulders YM, et al. Harm, benefit and costs associated with low-dose glucocorticoids added to the treatment strategies for rheumatoid arthritis in elderly patients (GLORIA trial): study protocol for a randomised controlled trial. Trials. 2018;19:67.

[2]Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO, et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010;62:2569-81.

Table 1.

Comorbidities and concomitant medications at baseline in the GLORIA trial.

MeanSDRangeComorbidities 4.32.8 0-15 Active 3.4 Past 1.9Concomitant medications (count) 3.93.4 0-15 Beta blocking agents (%)22 HMG CoA reductase inhibitors (%)20 Platelet aggregation inhibitors (%)16 ACE inhibitors (%)12 Angiotensin II antagonists (%)11DAS28 4.521.05DAS28CRP 4.060.97HAQ (0-3) 1.20.7RA treatmentCurrent (%)Previous (%) cDMARD8492 bDMARD/tsDMARD1522 NSAID5129 Glucocorticoids 049

Acknowledgements:

The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‘’Personalizing Health and Care’’, grant agreement No 634886.

Disclosure of Interests:

None declared

POS1053 COMPARISON OF BASELINE CHARACTERISTICS BETWEEN PATIENTS CONTINUING OR DISCONTINUING APREMILAST AT TWELVE MONTHS IN THE REWARD STUDY (THE NETHERLANDS)

Background:

Previous analysis of the REWARD study reported that patients with limited joint involvement have a considerable burden of disease1. Recent data suggest that patients with moderately active psoriatic arthritis (PsA) and a limited joint involvement have a high likelihood of achieving treatment goals when treated with apremilast2. According to EULAR recommendations a PDE4 inhibitor may be considered in patients with mild disease and an inadequate response to at least one csDMARD, in whom neither a bDMARD nor a JAK inhibitor is appropriate and the value of apremilast may be found in treating patients with relatively mild disease (oligoarticular)3.

Objectives:

The objective of this prospective, multicentre, non-interventional study is to describe patient reported outcomes, effectiveness and real-life use of apremilast in patients with PsA. Patients will be followed up for a maximum of 12 months. This interim analysis compared the baseline characteristics and experience on apremilast for two subgroups of patients, those remaining on apremilast versus the ones that discontinued.

Methods:

In this interim analysis we included patients with data available at cut-off date of 03 November 2020. Patient enrollment and follow up of current subjects is ongoing. Descriptive statistics (n’s and percents for categorical data, means for continuous data) were used to summarize the baseline data by subgroup. Kaplan Meier plots are presented to show patients’ experience on apremilast by subgroup.

Results:

85 patients were included in the analysis. 30 patients have completed the study, 39 patients have discontinued and 16 are ongoing. At baseline 22 (26%) patients were biologic experienced and 62 (74%) were biologic naïve. Both groups had a comparable disease activity measured with clinical disease activity in psoriatic arthritis (cDAPSA) scores. Biologic experienced patients had a longer disease duration compared to biologic naïve patients (mean 9.7 vs 6.2 years). Inefficacy of previous medication was the main reason for starting apremilast in both subgroups. Overall, 86% (n=69) of patients were still receiving apremilast at month 3, 60% (n=46) at month 6, and 41% (n=26) at month 12 (Figure 1). Drug survival (length of time until discontinuation of apremilast) for biologic naïve patients was 93% at month 3, 73% at month 6 and 58% at month 12. Drug survival of biologic experienced patients was 67%, 20%, and 0% at months 3, 6, and 12, respectively. At baseline mean values of body mass index (BMI), swollen joint count (SJC), tender joint count (TJC), psoriatic arthritis impact of disease (PsAID) were comparable between both groups (Table 1). Reasons for discontinuation were mainly lack of efficacy (49%) and adverse events (44%). In this analysis the nature and frequency of adverse events is in line with the known profile of apremilast.

Conclusion:

In this interim analysis, patients who were biologic naïve had a better probability to remain on treatment than those who were biologic experienced. Baseline characteristics were similar between the two groups, apart from disease duration that was longer in the biologic experienced group. Best drug survival is achieved when apremilast is prescribed earlier in the PsA treatment course, before biologics and after csDMARDs, as per apremilast EU label.

References:

[1]Jansen TL, et al. Ann Rheum Dis. 2019;78:913 [abstract FRI0442]

[2]Mease PJ, et al. Arthritis Care Res 2020 72 6 814–821

[3]Gossec L, et al. Ann Rheum Dis 2020;79:700–712

Disclosure of Interests:

Reinhard Bos Consultant of: AbbVie BV, Genzyme Europe, Janssen-Cilag, Novartis, Pfizer, Grant/research support from: Galapagos, Tim Jansen Consultant of: AbbVie, Celgene Corporation – consultant, Speakers bureau: Grunenthal, Sobi – speakers bureau, Grant/research support from: ReumaNederland, Olatec, Grunenthal – grant/research support, Sylvia de Jong Shareholder of: Employee of Amgen Inc, Employee of: Employee of Amgen Inc, Antonio Castiglia Shareholder of: Employee of Amgen Inc, Employee of: Employee of Amgen Inc, Marijn Vis Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Grant/research support from: Novartis, Pfizer, AbbVie, Celgene Corporation, Eli Lilly, Novartis, Pfizer.

POS1014 CENTRAL SENSITIZATION HAS MAJOR IMPACT ON QUALITY OF LIFE IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background:

Maintaining optimal health-related quality of life (QoL) is the ultimate goal of treatment in axial spondyloarthritis (axSpA). Chronic pain has a large potential impact on QoL. Central sensitization (CS) may explain part of the chronic pain in axSpA. However, the role of central sensitization (CS) herein has only been studied to a limited degree and current axSpA guidelines pay little attention to identification and treatment of CS.

Objectives:

To explore the relationship between CS and QoL in axSpA.

Methods:

Consecutive outpatients with axSpA from the Groningen Leeuwarden Axial Spondyloarthritis (GLAS) cohort were included. CS was assessed with the Central Sensitization Inventory (CSI; 0-100), QoL with the AS Quality of Life questionnaire (ASQoL; 0-18) and disease activity with the AS Disease Activity Score (ASDASCRP). A high probability of CS was defined as CSI score ≥40 and active disease as ASDASCRP score ≥2.1. Patient characteristics and clinical assessments were compared between groups with CSI score <40 and ≥40.(1) Multivariable regression analysis was conducted to investigate the relationship between CSI and ASQoL scores, correcting for potential confounders.

Results:

Of the 178 axSpA patients with available CSI score, 149 completed the ASQoL. Mean age of the 178 included patients was 47.4 ± 14.1 years, 78 (44%) were female, mean symptom duration was 21.4 ± 13.6 years and 88 (52%) were using bDMARDS. Mean CSI score was 38.0 ± 14.1, mean ASQoL 6.0 ± 5.3 and mean ASDASCRP 2.1 ± 1.0. CSI score ≥40 was significantly associated with higher mean ASQoL (9.7 vs. 3.3), higher mean ASDASCRP (2.6 vs. 1.7), female gender (60% vs. 29%) and more often entheseal involvement (61% vs. 26%) (Table 1).

Table 1.

Selection of patient characteristics, disease activity and clinical outcome variables for patients with axSpA, divided in subgroups for CSI score with a cutoff point of 40.

CharacteristicsAll patientsn = 178CSI<40n = 98 (55%)CSI≥40n = 80 (45%)Age (years)47.4 ± 14.148.7 ± 15.045.8 ± 12.7Female78 (44)27 (29)44 (60)*Symptom duration (years)21.4 ± 13.621.5 ± 13.521.2 ± 13.8HLA-B27+133 (79)70 (79)54 (79)Smoker45 (27)28 (32)15 (23)BMI (kg/m2)26.7 ± 5.026.2 ± 4.427.5 ± 5.8Completed higher education181 (71)48 (70)34 (76)Biological use88 (52)49 (52)39 (51)RDCI (0-9)0.0 (0.0 – 1.0)0.0 (0.0 – 1.0)0.0 (0.0 – 1.8)Peripheral arthritis210 (6)5 (6)5 (8)Entheseal involvement364 (40)23 (26)38 (61)*ASDASCRP2.1 ± 1.01.7 ± 0.92.6 ± 1.0*CRP (mg/ml)2.9 (1.1 – 6.8)2.6 (1.1-6.0)3.6 (1.4 – 7.0)ASQoL (0-18)6.0 ± 5.33.3 ± 3.69.7 ± 4.9*CSI (0-100)38.0 ± 14.128.0 (23 – 34)50.0 (43.0 –56.0)N/A

Values are n (%), mean ± SD or median (IQR).

1International Standard Classification of Education (ISCED) level >4; 2Swollen Joint Count >0; 3Maastricht Ankylosing Spondylitis Enthesitis Score >0. *p<0.001. ASDASCRP: Ankylosing Spondylitis Disease Activity Score; ASQoL: Ankylosing Spondylitis Quality of Life questionnaire; CRP: C-reactive protein; CSI: Central Sensitization Inventory; RDCI: Rheumatic Disease Comorbidity Index.

Patients with low ASDASCRP (<2.1) and also low CSI score (<40) showed good QoL (median ASQoL 1.1). Patients with low ASDASCRP combined with high CSI score (≥40) and patients with high ASDASCRP (≥2.1) combined with low CSI score reported worse QoL (median ASQoL 5.6 and 4.1, respectively). Patients with high ASDASCRP and also high CSI score reported the worst QoL (median ASQoL 12.0). (Figure 1).

Figure 1.

ASQoL score in patients with axSpA with CSI score ≥40 and <40, divided for ASDASCRP (cutoff 2.1)

Additionally, in univariable analysis, the CSI score explained a large proportion of the variation of the ASQoL (R2=0.46). This association remained significant after correction for ASDASCRP, gender, symptom duration, entheseal involvement, smoking status, BMI category, educational level and comorbidities in multivariable analysis (CSI p<0.001).

Conclusion:

In daily clinical practice, CS seems strongly related to patient-reported QoL in patients with long-term axSpA.

References:

[1]Neblett R et al. J Pain. 2013;14:438–45.

Acknowledgements:

The authors would like to thank all patients who participated in the GLAS cohort. Furthermore, the authors wish to acknowledge Mrs. B. Burmania, Mrs. B. Hollander, Mrs. S. Katerbarg, Mrs. S. Lange, Mrs. E. Markenstein, Mrs. R. Rumph and Mrs. M. de Vries-Veldman for their contribution to clinical data collection.

Disclosure of Interests:

Stan Kieskamp: None declared, Davy Paap: None declared, Marlies Carbo: None declared, Freke Wink Consultant of: Abbvie, Reinhard Bos: None declared, Hendrika Bootsma Grant/research support from: Roche, Suzanne Arends Grant/research support from: Pfizer, Anneke Spoorenberg Consultant of: Abbvie, Pfizer, MSD, UCB, Lilly, Novartis, Grant/research support from: Abbvie, Pfizer, UCB, Novartis.

Effectiveness and safety over 3 years after the 2-year U-Act-Early trial of the strategies initiating tocilizumab and/or methotrexate

Objectives

U-Act-Early was a 2-year, randomized placebo controlled, double-blind trial, in which DMARD-naïve early RA patients were treated to the target of sustained remission (SR). Two strategies initiating tocilizumab (TCZ), with and without methotrexate (MTX), were more effective than a strategy initiating MTX. The aim of the current study was to determine longer-term effectiveness in daily clinical practice.

Methods

At the end of U-Act-Early, patients were included in a 3-year post-trial follow-up (PTFU), in which treatment was according to standard care and data were collected every 3 months during the first year and every 6 months thereafter. Primary end point was disease activity score assessing 28 joints (DAS28) over time. Mixed effects models were used to compare effectiveness between initial strategy groups, correcting for relevant confounders. Between the groups as randomized, proportions of patients were tested for DMARD use, SR and radiographic progression of joint damage.

Results

Of patients starting U-Act-Early, 226/317 (71%) participated in the PTFU. Over the total 5 years, mean DAS28 was similar between groups (P > 0.20). During U-Act-Early, biologic DMARD use decreased in both TCZ initiation groups and increased in the MTX initiation group, but during follow-up this trend did not continue. SR was achieved at least once in 99% of patients. Of the 226 patients, only 30% had any radiographic progression over 5 years, without significant differences between the groups.

Conclusion

Although in the short-term the strategies initiating TCZ yielded the most clinical benefit, in the longer-term differences in important clinical outcomes between the strategies disappeared, probably due to continuation of the treat-to-target principle.

Bone mineral density improves during 2 years of treatment with bisphosphonates in patients with ankylosing spondylitis

Aims

To evaluate whether 2 years of treatment with bisphosphonates in combination with calcium/vitamin D supplements has an effect on lumbar spine and hip bone mineral density (BMD) in ankylosing spondylitis (AS) patients starting tumour necrosis factor‐α inhibitors or receiving conventional treatment. Secondly, to explore the development of radiographic vertebral fractures.

Methods

Patients from the Groningen Leeuwarden AS cohort receiving bisphosphonates based on clinical indication and available 2‐year follow‐up BMD measurements were included. BMD of lumbar spine (L1–L4) and hip (total proximal femur) were measured using dual‐energy X‐ray absorptiometry. Spinal radiographs (Th4–L4) were scored for vertebral fractures according to the Genant method.

Results

In the 20 included patients (median 52 years, 14 males), lumbar spine and hip BMD Z‐scores increased significantly; median from −1.5 (interquartile range [IQR] −2.2 to 0.4) to 0.1 (IQR −1.5 to 1.0); P < .001 and median from −1.0 (IQR −1.6 to −0.7) to −0.8 (IQR −1.2 to 0.0); P = .006 over 2 years, respectively. In patients also treated with tumour necrosis factor‐α inhibitors (n = 11), lumbar spine and hip BMD increased significantly (median 2‐year change +8.6% [IQR 2.4 to 19.6; P = .009] and +3.6% [IQR 0.7–9.0; P = .007]). In patients on conventional treatment (n = 9), lumbar spine BMD increased significantly (median 2‐year change +3.6%; IQR 0.7 to 9.0; P = .011) and no improvement was seen in hip BMD (median −0.6%; IQR −3.1 to 5.1; P = .61). Overall, younger AS males with limited spinal radiographic damage showed most improvement in lumbar spine BMD. Four mild radiographic vertebral fractures developed in 3 patients and 1 fracture increased from mild to moderate over 2 years in postmenopausal women and middle‐aged men.

Conclusion

This explorative observational cohort study in AS showed that 2 years of treatment with bisphosphonates in combination with calcium/vitamin D supplements significantly improves lumbar spine BMD. Mild radiographic vertebral fractures still occurred.

AB1165 MEDICATION ADHERENCE DATA IN A RANDOMIZED TRIAL: LARGE CHALLENGES TO COME FROM RAW DATA TO A WORKABLE AND RELIABLE DATASET

Background:

Medication adherence in the GLORIA trial, among elderly patients with rheumatoid arthritis, is measured with caps that register openings of the medication bottle. At each study visit, one or two medication bottles with cap (kits) are dispensed, each containing 90 capsules. Multiple steps are needed to come to a workable dataset to describe adherence.

Objectives:

To describe the steps that are needed to come from raw data to a workable dataset to analyze adherence data that are recorded by electronic caps.

Methods:

The medication bottle contains a cap with the ability to register cap openings. The raw dataset from the caps consist of an excel file with one opening event per row, recorded as date and time. One cap yields approximately 90 rows. First, the kit numbers were matched to the corresponding patient numbers, that are recorded in another excel file. Instances where two kits were dispensed were recorded with two kit numbers in one cell and need to be copied to two cells with one kit number. Second, the VLOOKUP function was used to combine dates and kit numbers. One row now contains all openings from one kit. Then, the number of days between first opening and each next opening date was calculated. A range of 90 days was made to calculate how many times the bottle was opened on each day of the 90-days period. The results were color-coded to visualize instances of zero, one or ≥two openings on a day.

Results:

The colored calendar matrix (Figure 1) can now be used to categorize adherence patterns.

Conclusion:

A monitoring cap seems a simple instrument to measure adherence. However, multiple steps and a lot of time are needed to come to a workable dataset for the study of adherence patterns.

Acknowledgments:

The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‟Personalizing Health and Care’’, grant agreement No 634886.

Disclosure of Interests:

Linda Hartman: None declared, Elisa Alessandri: None declared, Reinhard Bos: None declared, Daniela Opris-Belinski Speakers bureau: as declared, Marc R Kok Grant/research support from: BMS and Novartis, Consultant of: Novartis and Galapagos, Hanneke Griep-Wentink: None declared, Ruth Klaasen: None declared, Cornelia Allaart: None declared, George Bruyn: None declared, Hennie Raterman Grant/research support from: UCB, Consultant of: Abbvie, Amgen, Bristol-Myers Sqibb, Cellgene and Sanofi Genzyme, Marieke Voshaar Grant/research support from: part of phd research, Speakers bureau: conducting a workshop (Pfizer), Nuno Gomes: None declared, Rui Pinto: None declared, Thomas Klausch: None declared, WIllem Lems Grant/research support from: Pfizer, Consultant of: Lilly, Pfizer, Maarten Boers: None declared

FRI0581 IN ELDERLY PATIENTS, CAPS THAT RECORD MEDICATION BOTTLE OPENINGS ARE UNRELIABLE AND THUS NOT THE GOLD STANDARD FOR ADHERENCE

Background:

Adherence is a serious problem in treatment of inflammatory diseases. To measure adherence, caps that record medication bottle openings may be superior to capsule counts (1). In the ongoing two-year GLORIA trial on the addition of low-dose (5 mg) prednisolone or placebo to standard of care in elderly patients (65+ years) with rheumatoid arthritis, adherence was measured in both ways during the whole trial.

Objectives:

To describe adherence patterns, and to compare adherence as assessed with adherence caps and with capsule counts in the GLORIA trial.

Methods:

The recorded adherence patterns of patients (blinded for treatment group) were classified according to descriptive categories. Overall adherence according to number of bottle openings was compared with adherence according to the capsule count. Good adherence was defined as 80%: i.e. for caps 80% of days one opening recorded, and for counts less than 20% of prescribed tablets returned at the subsequent visit. Each patient has a maximum of 8 periods of 90 days.

Results:

Trial inclusion has closed in 2018 at 452 patients; the current dataset contains adherence data of 385 patients. Mean number of recorded 90-day periods per patient was 4 (range 1-8). Based on capsule counts over all periods, 90% of the patients met the 80% threshold of adherence; based on cap data only 31% met this criterion.

The four adherence patterns are shown in a calendar matrix, with yellow for zero, green for one and blue for ≥two openings on a day (Figure 1). Bottles were supposed to be opened once a day.

Patients were categorized according to the opening pattern seen in at least 50% of assessed periods:

32% non-use(<20% of the days an opening);26% stable use(≥80% of the days 1 opening);40% irregular use(different adherence patterns, in or between periods);2% weekly use(1 opening per week).

Conclusion:

In our trial of elderly rheumatoid arthritis patients, patients appeared to be mostly adherent according to conventional capsule counts. Results from adherence caps were highly discrepant with the capsule counts, with patterns suggesting patients did not use the bottle for daily dispensing, despite specific advice to do so.

References:

[1] El Alili M, Vrijens B, Demonceau J, Evers SM, Hiligsmann M. A scoping review of studies comparing the medication event monitoring system (MEMS) with alternative methods for measuring medication adherence. Br J Clin Pharmacol 2016;82:268-79.

Acknowledgments:

The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‘’Personalizing Health and Care’’, grant agreement No 634886.

Disclosure of Interests:

Linda Hartman: None declared, Sabrina Paolino: None declared, Reinhard Bos: None declared, Daniela Opris-Belinski Speakers bureau: as declared, Marc R Kok Grant/research support from: BMS and Novartis, Consultant of: Novartis and Galapagos, Hanneke Griep-Wentink: None declared, Ruth Klaasen: None declared, Cornelia Allaart: None declared, George Bruyn: None declared, Hennie Raterman Grant/research support from: UCB, Consultant of: Abbvie, Amgen, Bristol-Myers Sqibb, Cellgene and Sanofi Genzyme, Marieke Voshaar Grant/research support from: part of phd research, Speakers bureau: conducting a workshop (Pfizer), Nuno Gomes: None declared, Rui Pinto: None declared, Thomas Klausch: None declared, WIllem Lems Grant/research support from: Pfizer, Consultant of: Lilly, Pfizer, Maarten Boers: None declared

OP0080 CENTRAL SENSITIZATION AND ILLNESS PERCEPTIONS SHOULD BE TAKEN INTO ACCOUNT WHEN INTERPRETING DISEASE ACTIVITY IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background:

Up to 40% of ankylosing spondylitis patients report persistently high pain scores of >4 (scale of 0-10) even after responding to long-term TNF-alpha blocking therapy.[1] In other rheumatic diseases, nociplastic pain (due to altered functioning of the nervous system leading to peripheral and central sensitization) is common.[2] In axial spondyloarthritis (axSpA), patient illness and pain perceptions were shown to influence disease outcome.[3] Therefore, we hypothesized that central sensitization and patients’ illness perceptions are associated with persistently high disease activity in axSpA.

Objectives:

To investigate to what extent central sensitization, pain catastrophizing and patients’ perceptions play a role in axSpA and to explore associations with disease activity.

Methods:

Between April and September 2019, consecutive outpatients from the Groningen Leeuwarden axSpA (GLAS) cohort,[4] an ongoing large prospective cohort, were included in this study. Besides the standardized assessments, patients filled out three additional questionnaires: Central Sensitization Inventory (CSI), Pain Catastrophizing Scale (PCS) and Revised Illness Perception Questionnaire (IPQ-R). Univariable and multivariable linear regression analyses were used to investigate the association of CSI, PCS and each of the eight subscales of the IPQ-R, and disease activity assessments ASDAS-CRP, BASDAI, and CRP. We corrected for the following potential confounders: gender, symptom duration, BMI, educational level, smoking status and HLA-B27 status.

Results:

Of 171 included patients, 58% were male, 79% were HLA-B27 positive, median symptom duration was 21 (IQR 10-32), mean ASDAS-CRP 2.1 ± 1.0, mean BASDAI 3.9 ± 2.2 and median CRP 2.9 (IQR 1.2-6.3). Mean CSI score was 37.8 ± 14.1 (scale of 0-100), and 44% of patients scored ≥40 on the CSI.[5] Median PCS score was 15 (IQR 7-22) (scale of 0-52), median IPQ-R illness identity subscore 3 (IQR 2-4) (scale of 0-14) and mean IPQ-R treatment control subscore 18.1 ± 3.4 (scale of 5-25). In univariable regression analysis, CSI and PCS scores and IPQ-R subscores all showed significant associations with ASDAS-CRP, and all except the IPQ-R subscale personal control showed significant associations with BASDAI. Only IPQ-R treatment control was significantly associated with CRP. Central sensitization, two IPQ-R subscales (perceived treatment control and the number of symptoms patients attributed to their axSpA: illness identity) and BMI were independently associated with disease activity assessments BASDAI (R2=0.46) and ASDAS-CRP (R2=0.36) (Figure 1).

Conclusion:

In this axSpA population with long-term disease, 44% scored above the CSI cutoff point of 40, indicating a high probability of central sensitization. CSI score, illness identity and treatment control were independently associated with disease activity assessments.

References:

[1]Arends Set al.Clin Exp Rheumatol 2017;35(1):61-8.

[2]Meeus Met al.Semin Arthritis Rheum 2012;41(4):556-67.

[3]Van Lunteren Met al. Arthritis Care Res (Hoboken) 2018;70(12):1829-39.

[4]Arends Set al.Arthritis Res Ther 2011;13(3):R94.

[5]Neblett Ret al.J Pain 2013;14(5):438-45.

Disclosure of Interests:

Stan Kieskamp: None declared, Davy Paap: None declared, Marlies Carbo: None declared, Freke Wink Consultant of: Abbvie, Janssen, Reinhard Bos: None declared, Hendrika Bootsma Grant/research support from: Unrestricted grants from Bristol-Myers Squibb and Roche, Consultant of: Consultant for Bristol-Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Speakers bureau: Speaker for Bristol-Myers Squibb and Novartis., Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Anneke Spoorenberg: None declared

SAT0285 VISUALISATION OF THE ACTIVE CALCIFICATION PROCESS WITH 18-F SODIUM FLUORIDE PET/CT IN LIMITED CUTANEOUS SYSTEMIC SCLEROSIS WITH CALCINOSIS CUTIS IS FEASIBLE: A PILOT STUDY

Background:

Calcinosis cutis is a major daily challenge to patients with longstanding systemic sclerosis (SSc), negatively affecting their quality of life. Unfortunately, treatment options are very limited due to lack of understanding of the pathogenetic process. Currently, calcinosis cutis is only detected at its irreversible end-stage. Early detection of calcinosis cutis could putatively allow early disease-modifying interventions and monitor treatment effects.

Objectives:

The aim of the current study is to assess the feasibility of visualising “active” micro-calcifications with 18-F Sodium Fluoride (NaF) PET scanning, compared to low-dose CT in patients with clinically overt calcinosis cutis.

Methods:

This was a cross-sectional, observational, pilot study. All patients met 2013 ACR/EULAR criteria for SSc. Patients underwent a whole body NaF PET/low-dose CT scan, scanned 90 minutes post-injection. (Sub)cutaneous calcifications were described and assessed on NaF PET, which was compared to CT images by two independent investigators.

Results:

A total of 10 female patients with limited cutaneous SSc [median age 56 years (IQR 52-66), median disease duration 17 years (8-19), PAH 10%, ILD 20%] were included, and compared to 10 controls [70 years (65-73)]. NaF uptake showed normal distribution throughout the skeletal bones, arterial tree, and visceral organs, which was comparable between patients and controls. Additionally, NaF uptake was visible in the skin of all SSc patients, but in none of the controls. Cutaneous NaF uptake largely correlated with clinical calcifications. Most common sites of cutaneous NaF uptake were fingers (6 patients) and knees (7 patients). Only 5% of the NaF positive lesions were not accompanied by visible calcifications on CT. Furthermore, of all calcified lesions seen on CT, 51% showed uptake on NaF PET. Small lesions (<1 cm), were generally only visible on CT, due to lower resolution of NaF PET.

Conclusion:

Imaging of “active” calcinosis cutis in limited cutaneous systemic sclerosis is feasible using NaF PET scanning. Most clinically overt calcifications and half of those seen on CT were positive for NaF uptake. Whether these “active” calcifications behave differently in terms of faster progression, clinical complaints, and infection risk, and whether these are potentially suitable for disease modifying interventions is subject to future study.

Disclosure of Interests:

None declared

Treatment of resistant Raynaud's phenomenon with single-port thoracoscopic sympathicotomy: a novel minimally invasive endoscopic technique

Objective

To assess the minimally invasive single-port thoracoscopic sympathicotomy feasibility and efficacy in patients with treatment-resistant RP.

Methods

Single-port thoracoscopic sympathicotomy was performed unilaterally on the left side in eight patients with RP (six males, two females, with a median age of 45.2 years). Five patients had primary and three had secondary RP. Perfusion effects in the hands were assessed at baseline and after 1 month by using a cooling and recovery procedure, and by using laser speckle contrast analysis. Number and duration of RP attacks were reported over a 2-week period.

Results

Patient satisfaction was 100% after surgery. After surgery, a unilateral improvement in perfusion was observed in the left hand compared with the right hand, with cooling and recovery (P = 0.008) and with laser speckle contrast analysis (P = 0.023). In addition, the number and duration of the attacks in the left hand decreased compared with the right hand (both P = 0.028). No serious adverse events occurred in a follow-up period of at least 10 months.

Conclusion

Single-port thoracoscopic sympathicotomy is feasible and can be effective in improving hand perfusion in patients with RP. However, long-term efficacy needs to be established.

Clinical trial registration number

NCT02680509.

Effectiveness of TOcilizumab in comparison to Prednisone In Rheumatoid Arthritis patients with insufficient response to disease-modifying antirheumatic drugs (TOPIRA): study protocol for a pragmatic trial

Background

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease, predominantly affecting joints, which is initially treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). In RA patients with insufficient response to csDMARDs, the addition of prednisone or tocilizumab, a biological DMARD (bDMARD), to the medication has been shown to be effective in reducing RA symptoms. However, which of these two treatment strategies has superior effectiveness and safety is unknown.

Methods

In this multicenter, investigator-initiated, open-label, randomized, pragmatic trial, we aim to recruit 120 RA patients meeting the 2010 ACR/EULAR classification criteria for RA, with active disease defined as a Clinical Disease Activity Index (CDAI) > 10 and at least one swollen joint of the 28 assessed. Patients must be on stable treatment with csDMARDs for ≥ 8 weeks prior to screening and must have been treated with ≥ 2 DMARDs, of which a maximum of one tumor necrosis factor inhibitor (a class of bDMARDs) is allowed. Previous use of other bDMARDs or targeted synthetic DMARDs is not allowed. Patients will be randomized in a 1:1 ratio to receive either tocilizumab (subcutaneously at 162 mg/week) or prednisone (orally at 10 mg/day) as an addition to their current csDMARD therapy. Study visits will be performed at screening; baseline; and months 1, 2, 3, 6, 9, and 12. Study medication will be tapered in case of clinical remission (CDAI ≤ 2.8 and ≤ 1 swollen joint at two consecutive 3-monthly visits) with careful monitoring of disease activity. In case of persistent high disease activity at or after month 3 (CDAI > 22 at any visit or > 10 at two consecutive visits), patients will switch to the other strategy arm. Primary outcome is a change in CDAI from baseline to 12 months. Secondary outcomes are additional clinical response and quality of life measures, drug retention rate, radiographically detectable progression of joint damage, functional ability, and cost utility. Safety outcomes include tocilizumab-associated adverse events (AEs), glucocorticoid-associated AEs, and serious AEs.

Discussion

This will be the first randomized clinical trial comparing addition of oral prednisone or of tocilizumab head to head in RA patients with insufficient response to csDMARD therapy. It will yield important information for clinical rheumatology practice.

Trial registration

This trial was prospectively registered in the Netherlands Trial Register on October 7, 2019 (NL8070). The Netherlands Trial Register contains all items from the World Health Organization Trial Registration Data Set.

Improvement of AOAC Official Method 984.27 for the Determination of Nine Nutritional Elements in Food Products by Inductively Coupled Plasma-Atomic Emission Spectroscopy After Microwave Digestion: Single-Laboratory Validation and Ring Trial

A single-laboratory validation (SLV) and a ring trial (RT) were undertaken to determine nine nutritional elements in food products by inductively coupled plasma-atomic emission spectroscopy in order to improve and update AOAC Official Method 984.27. The improvements involved optimized microwave digestion, selected analytical lines, internal standardization, and ion buffering. Simultaneous determination of nine elements (calcium, copper, iron, potassium, magnesium, manganese, sodium, phosphorus, and zinc) was made in food products. Sample digestion was performed through wet digestion of food samples by microwave technology with either closed or open vessel systems. Validation was performed to characterize the method for selectivity, sensitivity, linearity, accuracy, precision, recovery, ruggedness, and uncertainty. The robustness and efficiency of this method was proved through a successful internal RT using experienced food industry laboratories. Performance characteristics are reported for 13 certified and in-house reference materials, populating the AOAC triangle food sectors, which fulfilled AOAC criteria and recommendations for accuracy (trueness, recovery, and z-scores) and precision (repeatability and reproducibility RSD and HorRat values) regarding SLV and RT. This multielemental method is cost-efficient, time-saving, accurate, and fit-for-purpose according to ISO 17025 Norm and AOAC acceptability criteria, and is proposed as an improved version of AOAC Official Method 984.27 for fortified food products, including infant formula.

Ankylosing spondylitis disease activity score is related to NSAID use, especially in patients treated with TNF-α inhibitors

Background

Non-steroidal anti-inflammatory drugs (NSAIDs) are regarded as the cornerstone of conventional treatment for AS. However little is known about concomitant NSAID use during treatment (with TNF-α inhibitors) in daily clinical practice.

Methods and findings

Consecutive patients from the GLAS cohort were included. NSAID use and ASAS-NSAID index were evaluated at group level and at individual patient level during 52 weeks of follow-up. Analyses were stratified for treatment regimen. Generalized estimating equations (GEE) was used to evaluate NSAID use in relation to assessments of disease activity over time. In patients starting TNF-α inhibitors (n = 254), 79% used NSAIDs at baseline and this proportion decreased significantly to 38% at 52 weeks. ASAS-NSAID index also decreased significantly from median 65 to 0. In patients on conventional treatment (n = 139), 74% used NSAIDs at baseline with median ASAS-NSAID index of 50 and this remained stable during follow-up. At each follow-up visit, approximately half of the patients changed their type or dose of NSAIDs. GEE analysis over time showed that NSAID use was associated with AS disease activity score (p<0.05). This relation was more pronounced in patients treated with TNF-α inhibitors compared to conventional treatment (B = 0.825 vs. B = 0.250).

Conclusions

In this observational cohort of established AS patients, there was no difference in baseline NSAID use between patients with and without indication for TNF-α inhibitors. NSAID use decreased significantly after starting TNF-α inhibitors. During conventional treatment, NSAID use remained stable at group level. However, NSAID use changed frequently at individual patient level and was significantly associated with disease activity.

A New Enzyme Immunoassay for Soluble Fibrin in Plasma, with a High Discriminating Power for Thrombotic Disorders

Fibrin formation is a multistep process initiated by thrombin. At first thrombin converts fibrinogen to fibrin molecules which in vivo form soluble complexes with fibrinogen. Soluble fibrin is considered to be an early biochemical marker for intravascular fibrin formation and impending thrombotic events, such as deep venous thrombosis (DVT), pulmonary embolism (PE) and disseminated intravascular coagulopathy (DIC).

A new enzyme immunoassay (EIA) was developed on the basis of a monoclonal antibody directed against a fibrin specific neo-epitope located on the gamma-chain of fibrinogen; γ-(312-324). In addition, it was possible to prepare a lyophilized reference material of thrombin-generated soluble fibrin, that allowed for full antigen recovery after reconstitution with buffer. Assay conditions, e.g. solid phase-Ig concentration and buffer composition, sample and conjugate dilution, and incubation times were optimised.

The present assay was found to be specific (no interference of homologous antigens) and reproducible (intra-assay CV 4-8%, inter-assay CV 4-9%), and therefore highly suited for measuring soluble fibrin levels in a plasma milieu. The median normal value for soluble fibrin was determined in plasma samples obtained from apparently healthy volunteers (n = 81) and found to be 0.040 μg/ml, with a range (10-90 percentiles) of 0.026-0.059 μg/ml.

A retrospective study showed that soluble fibrin levels were highly significantly increased in patients with a confirmed diagnosis of DIC (median 1.042 μg FEU/ml, range 0.160-2.319 μg/ml, n = 21, P <0.0001 vs normal), PE (median 0.527 μg FEU/ml, range 0.084-1.234 μg/ml, n = 29, P <0.0001 vs normal) and DVT (median 0.126 μg FEU/ml, range 0.059-0.878 μg/ml, n = 36, P <0.0001 vs normal), as determined by the Mann-Whitney U-Test.

Diseases due to unhealthy environments: an updated estimate of the global burden of disease attributable to environmental determinants of health

Background

The update of the global burden of disease attributable to the environment is presented. The study focuses on modifiable risks to show the potential health impact from environmental interventions.

Methods

Systematic literature reviews on 133 diseases and injuries were performed. Comparative risk assessments were complemented by more limited epidemiological estimates, expert opinion and information on disease transmission pathways. Population attributable fractions were used to calculate global deaths and global disease burden from environmental risks.

Results

Twenty-three percent (95% CI: 13-34%) of global deaths and 22% (95% CI: 13-32%) of global disability adjusted life years (DALYs) were attributable to environmental risks in 2012. Sixty-eight percent of deaths and 56% of DALYs could be estimated with comparative risk assessment methods. The global disease burden attributable to the environment is now dominated by noncommunicable diseases. Susceptible ages are children under five and adults between 50 and 75 years. Country level data are presented.

Conclusions

Nearly a quarter of global disease burden could be prevented by reducing environmental risks. This analysis confirms that eliminating hazards and reducing environmental risks will greatly benefit our health, will contribute to attaining the recently agreed Sustainable Development Goals and will systematically require intersectoral collaboration to be successful.

Stopping Tumor Necrosis Factor Inhibitor Treatment in Patients With Established Rheumatoid Arthritis in Remission or With Stable Low Disease Activity: A Pragmatic Multicenter, Open-Label Randomized Controlled Trial

OBJECTIVE

Tumor necrosis factor inhibitor (TNFi) biologic agents are an effective treatment for rheumatoid arthritis (RA). It is unclear whether patients whose disease is in remission or who have stable low disease activity need to continue use of TNFi or can stop this treatment. This study was undertaken to assess whether patients with established RA who are in remission or have stable low disease activity can effectively and safely stop their TNFi therapy.

METHODS

The study was designed as a pragmatic multicenter, open-label randomized controlled trial. Inclusion criteria were a diagnosis of RA according to the American College of Rheumatology 1987 classification criteria, as well as use of a TNFi for at least 1 year along with a stable dose of disease-modifying antirheumatic drugs and a Disease Activity Score in 28 joints (DAS28) of <3.2 over the 6 months preceding trial inclusion. Patients were randomized in a 2:1 ratio to either stop or continue treatment with their current TNFi. Flare was defined as a DAS28 of ≥3.2 during the 12-month follow-up period and an increase in score of ≥0.6 compared to the baseline DAS28.

RESULTS

In total, 531 patients were allocated to the stop group and 286 to the TNFi continuation group. At 12 months, more patients had experienced a flare in the stop group (272 [51.2%] of 531) than in the continuation group (52 [18.2%] of 286; P < 0.001). The hazard ratio for occurrence of a flare after stopping TNFi was 3.50 (95% confidence interval [95% CI] 2.60-4.72). The mean DAS28 in the stop group was significantly higher during the follow-up period compared to that in the continuation group (P < 0.001). Of the 195 patients who restarted TNFi treatment after experiencing a flare and within 26 weeks after stopping, 165 (84.6%) had regained a DAS28 of <3.2 by 6 months later, and the median time to a regained DAS28 of <3.2 was 12 weeks (95% Cl 10.7-13.3). There were more hospitalizations in the stop group than in the continuation group (6.4% versus 2.4%).

CONCLUSION

Stopping TNFi treatment results in substantially more flares than does continuation of TNFi in patients with established RA in remission or with stable low disease activity.

Ankylosing spondylitis patients at risk of poor radiographic outcome show diminishing spinal radiographic progression during long-term treatment with TNF-α inhibitors

Objective

To investigate the influence of patient characteristics on the course of spinal radiographic progression in a large prospective longitudinal cohort study of ankylosing spondylitis (AS) patients treated long-term with TNF-α inhibitors.

Methods

Consecutive patients from the Groningen Leeuwarden AS (GLAS) cohort starting TNF-α inhibitors with spinal radiographs at least available at baseline and 6 years of follow-up were included. Radiographs were scored using mSASSS by two independent readers. Generalized estimating equations (GEE) were used to explore the associations between baseline characteristics and spinal radiographic progression. The course of radiographic progression in patients with and without risk factors for poor radiographic outcome was investigated using different time models (linear and non-linear). Single linear imputation was used in case of missing radiographic data at the intermediate (2 or 4 years) follow-up visits.

Results

80 AS patients were included with mean baseline mSASSS 8.7±13.3. Baseline syndesmophytes, male gender, older age, longer symptom duration, smoking, and higher BMI were significantly associated with more radiographic damage over time. GEE analysis in patients with these risk factors revealed that radiographic progression followed a non-linear course with mean mSASSS progression rates reducing from max. 2.8 units over 0–2 years to min. 0.9 units over 4–6 years. The GEE model revealed a linear course with overall very low progression (≤1 mSASSS units/2yrs) in patients without risk factors. Complete case analysis in 53 patients showed similar results.

Conclusion

AS patients at risk of poor radiographic outcome showed the highest but diminishing spinal radiographic progression during long-term treatment with TNF-α inhibitors.

Late onset cardiomyopathy as presenting sign of ATTR A45G amyloidosis caused by a novel TTR mutation (p.A65G)

OBJECTIVE

The clinical description of a novel TTR gene mutation characterized by a late onset amyloid cardiomyopathy.

METHODS AND RESULTS

A 78-year-old man of Dutch origin with recent surgery for bilateral carpal tunnel syndrome (CTS) was admitted to our hospital because of heart failure with preserved ejection fraction (55%). Cardiac ultrasound showed thickened biventricular walls, and cardiac magnetic resonance imaging also showed late gadolinium enhancement. Early signs of a polyneuropathy were found by neurophysiological testing. A few months later, his 72-year-old sister was admitted to an affiliated hospital because of heart failure caused by a restrictive cardiomyopathy. In both patients, a subcutaneous abdominal fat aspirate was stained with Congo red and DNA was analyzed by direct sequencing of exons 1 to 4 of the transthyretin (TTR) gene. Both fat aspirates revealed transthyretin-derived (ATTR) amyloid. ^99mTc-diphosphonate scintigraphy further confirmed cardiac ATTR amyloidosis in the male patient. DNA analysis of both patients showed a novel TTR mutation c.194C>G that encodes for the gene product TTR (p.A65G) ending up as the mature protein TTR A45G. The 56-year-old daughter of the male patient had the same TTR mutation. A full diagnostic workup did not reveal any signs of amyloidosis yet.

CONCLUSIONS

A novel amyloidogenic TTR mutation was found in a Dutch family. The clinical presentation of ATTR A45G amyloidosis in the affected family members was heart failure due to a late-onset cardiomyopathy. The systemic nature of this disease was reflected by bilateral CTS and by early signs of a polyneuropathy in the index patient.

Incorporating assessment of the cervical facet joints in the modified Stoke ankylosing spondylitis spine score is of additional value in the evaluation of spinal radiographic outcome in ankylosing spondylitis

Background

To aim was to investigate the additional value of incorporating the de Vlam cervical facet joint score in the modified ankylosing spondylitis (AS) spine score (mSASSS) for the evaluation of spinal radiographic outcome in AS.

Method

Baseline and 4-year radiographs from 98 consecutive patients from the Groningen Leeuwarden AS (GLAS) cohort, who had AS treated with TNF-α inhibitors, were scored by two readers; the vertebral bodies were assessed according to the mSASSS (0–72) and cervical facet joints (C2–C7) were assessed according to the method of de Vlam (0–15). The combined AS spine score (CASSS) was calculated as the sum of both total scores (range 0–87) and compared with the original mSASSS according to three aspects of the Outcome Measures in Rheumatology Clinical Trials (OMERACT) filter: feasibility, discrimination, and truth.

Results

Feasibility: the CASSS was calculated in 91% of the patients. No additional radiographs were necessary and the assessment took only a few extra minutes. Discrimination: both scoring methods had excellent inter-observer reliability (intra-class correlation coefficient (ICC) status scores >0.99, progression scores 0.92). Incorporating the cervical facet joints did not result in an increase in measurement error. The CASSS detected more patients with definite damage (61% vs. 57%) and definite progression (55% vs. 48%). Truth: higher CASSS scores at baseline and higher progression scores were seen in 41 (46%) and 22 (25%) patients, respectively. Cervical rotation correlated better with cervical CASSS than with cervical mSASSS (Spearman’s rho = 0.68 vs. 0.59).

Conclusions

The CASSS is a relevant and easy modification of the mSASSS. It captures more patients with AS who have spinal radiographic damage and progression, which is of great additional value in the evaluation of radiographic outcome in this heterogeneous and overall slowly progressing disease.

Early rheumatoid arthritis treated with tocilizumab, methotrexate, or their combination (U-Act-Early): a multicentre, randomised, double-blind, double-dummy, strategy trial

BACKGROUND

For patients with newly diagnosed rheumatoid arthritis, treatment aim is early, rapid, and sustained remission. We compared the efficacy and safety of strategies initiating the interleukin-6 receptor-blocking monoclonal antibody tocilizumab with or without methotrexate (a conventional synthetic disease-modifying antirheumatic drug [DMARD]), versus initiation of methotrexate monotherapy in line with international guidelines.

METHODS

We did a 2-year, multicentre, randomised, double-blind, double-dummy, strategy study at 21 rheumatology outpatient departments in the Netherlands. We included patients who had been diagnosed with rheumatoid arthritis within 1 year before inclusion, were DMARD-naive, aged 18 years or older, met current rheumatoid arthritis classification criteria, and had a disease activity score assessing 28 joints (DAS28) of at least 2·6. We randomly assigned patients (1:1:1) to start tocilizumab plus methotrexate (the tocilizumab plus methotrexate arm), or tocilizumab plus placebo-methotrexate (the tocilizumab arm), or methotrexate plus placebo-tocilizumab (the methotrexate arm). Tocilizumab was given at 8 mg/kg intravenously every 4 weeks with a maximum of 800 mg per dose. Methotrexate was started at 10 mg per week orally and increased stepwise every 4 weeks by 5 mg to a maximum of 30 mg per week, until remission or dose-limiting toxicity. We did the randomisation using an interactive web response system. Masking was achieved with placebos that were similar in appearance to the active drug; the study physicians, pharmacists, monitors, and patients remained masked during the study, and all assessments were done by masked assessors. Patients not achieving remission on their initial regimen switched from placebo to active treatments; patients in the tocilizumab plus methotrexate arm switched to standard of care therapy (typically methotrexate combined with a tumour necrosis factor inhibitor). When sustained remission was achieved, methotrexate (and placebo-methotrexate) was tapered and stopped, then tocilizumab (and placebo-tocilizumab) was also tapered and stopped. The primary endpoint was the proportion of patients achieving sustained remission (defined as DAS28 <2·6 with a swollen joint count ≤four, persisting for at least 24 weeks) on the initial regimen and during the entire study duration, compared between groups with a two-sided Cochran-Mantel-Haenszel test. Analysis was based on an intention-to-treat method. This trial was registered at ClinicalTrials.gov, number NCT01034137.

FINDINGS

Between Jan 13, 2010, and July 30, 2012, we recruited and assigned 317 eligible patients to treatment (106 to the tocilizumab plus methotrexate arm, 103 to the tocilizumab arm, and 108 to the methotrexate arm). The study was completed by a similar proportion of patients in the three groups (range 72-78%). The most frequent reasons for dropout were adverse events or intercurrent illness: 27 (34%) of dropouts, and insufficient response: 26 (33%) of dropouts. 91 (86%) of 106 patients in the tocilizumab plus methotrexate arm achieved sustained remission on the initial regimen, compared with 86 (84%) of 103 in the tocilizumab arm, and 48 (44%) of 108 in the methotrexate arm (relative risk [RR] 2·00, 95% CI 1·59-2·51 for tocilizumab plus methotrexate vs methotrexate, and 1·86, 1·48-2·32 for tocilizumab vs methotrexate, p<0·0001 for both comparisons). For the entire study, 91 (86%) of 106 patients in the tocilizumab plus methotrexate arm, 91 (88%) of 103 in the tocilizumab arm, and 83 (77%) of 108 in the methotrexate arm achieved sustained remission (RR 1·13, 95% CI 1·00-1·29, p=0·06 for tocilizumab plus methotrexate vs methotrexate, 1·14, 1·01-1·29, p=0·0356 for tocilizumab vs methotrexate, and p=0·59 for tocilizumab plus methotrexate vs tocilizumab). Nasopharyngitis was the most common adverse event in all three treatment groups, occurring in 38 (36%) of 106 patients in the tocilizumab plus methotrexate arm, 40 (39%) of 103 in the tocilizumab arm, and 37 (34%) of 108 in the methotrexate arm. The occurrence of serious adverse events did not differ between the treatment groups (17 [16%] of 106 patients in the tocilizumab plus methotrexate arm vs 19 [18%] of 103 in the tocilizumab arm and 13 [12%] of 108 in the methotrexate arm), and no deaths occurred during the study.

INTERPRETATION

For patients with newly diagnosed rheumatoid arthritis, strategies aimed at sustained remission by immediate initiation of tocilizumab with or without methotrexate are more effective, and with a similar safety profile, compared with initiation of methotrexate in line with current standards.

FUNDING

Roche Nederland BV.

Tapering and discontinuation of methotrexate in patients with RA treated with TNF inhibitors: data from the DREAM registry

Objectives

To study the number of patients that taper or discontinue concomitant methotrexate (MTX) in daily practice in patients with rheumatoid arthritis (RA) treated with tumour necrosis factor inhibitor (TNFi) and to analyse the effects of that adaption on disease activity and drug survival.

Methods

Data were collected from the Dutch Rheumatoid Arthritis Monitoring (DREAM) registry. Patients who started their first TNFi were included in the study. Treatment effectiveness after MTX tapering or discontinuation was analysed using Disease Activity Score of 28 joints (DAS28). Drug survival of the TNFi was analysed using the Cox proportional hazard model with a time-dependent covariate.

Results

In 458 patients (34%), MTX was tapered, 126 patients (10%) discontinued MTX and 747 patients (56%) continued MTX at the same dose. On average, DAS28 improved after tapering MTX (−0.40, −0.45) and after stopping MTX (−0.28, −0.12) at 6 and 12 months. In the taper group, 21% of the patients relapsed (DAS28 increase >0.6), and in the discontinuation group this was 21% and 24% at 6 and 12 months, respectively. Patients who taper and discontinue MTX have a similar DAS28 score over time as patients who continue MTX. Moreover, there was no influence of tapering or discontinuation of MTX on long-term drug survival of TNFi.

Conclusions

In daily practice, tapering or discontinuation of concomitant MTX in patients with RA treated with TNFi frequently occurs and it does not seem to influence the average DAS28 over time or the long-term TNFi drug survival. It appears that in daily clinical practice the correct patients are selected to taper or discontinue MTX.

Patient-tailored dose reduction of TNF-α blocking agents in ankylosing spondylitis patients with stable low disease activity in daily clinical practice

OBJECTIVES

Tumour necrosis factor-alpha (TNF-α) blocking agents are very effective in controlling systemic inflammation and improving clinical assessments in ankylosing spondylitis (AS). In view of potential side effects and high costs of long-term treatment, our aim was to investigate whether dose reduction of TNF-α blocking agents is possible without loss of effectiveness in AS patients in daily clinical practice.

METHODS

Patients from the prospective observational GLAS cohort, fulfilling the modified New York criteria for AS, with active disease before start of TNF-α blocking therapy and stable (≥6 months) low disease activity on the conventional dose regimen, who started with dose reduction of TNF-α blocking therapy before June 2011 were studied. Dose reduction was patient-tailored (step-by-step approach) and consisted of lowering the dose and/or extending the interval between doses.

RESULTS

Between June 2005 and March 2011, 58 AS patients started dose reduction of etanercept (n=39), infliximab (n=10), or adalimumab (n=9). Of all patients, 74%, 62%, and 53% maintained their reduced dose or dosing frequency after 6, 12, and 24 months, respectively. The mean dose of TNF-α blocking therapy over time corresponded to 62% of the standard dose regimen. Disease activity remained low in the majority of patients who maintained dose reduction after 24 months (94% had BASDAI<4). If there was recurrence of disease symptoms, patients achieved good clinical response after returning to the conventional regimen (88% reached BASDAI<4).

CONCLUSIONS

In this observational cohort, patient-tailored dose reduction of TNF-α blocking agents was successful preserving stable low disease activity over 24 months in approximately half of the AS patients.