Defining criteria for disease activity states in systemic juvenile idiopathic arthritis based on the systemic Juvenile Arthritis Disease Activity Score

OBJECTIVE

To develop and validate cutoff values in the systemic Juvenile Arthritis Disease Activity Score 10 (sJADAS10) that distinguish the states of inactive disease (ID), minimal disease activity (MiDA), moderate disease activity (MoDA), and high disease activity (HDA) in children with systemic juvenile idiopathic arthritis (sJIA), based on subjective disease state assessment by the treating pediatric rheumatologist.

METHODS

The cutoffs definition cohort was composed of 400 patients enrolled at 30 pediatric rheumatology centers in 11 countries. Using the subjective physician rating as an external criterion, 6 methods were applied to identify the cutoffs: mapping, calculation of percentiles of cumulative score distribution, Youden index, 90% specificity, maximum agreement, and ROC curve analysis. Sixty percent of the patients were assigned to the definition cohort and 40% to the validation cohort. Cutoff validation was conducted by assessing discriminative ability.

RESULTS

The sJADAS10 cutoffs that separated ID from MiDA, MiDA from MoDA, and MoDA from HDA were ≤ 2.9, ≤ 10, and > 20.6. The cutoffs discriminated strongly among different levels of pain, between patients with or without morning stiffness, and between patients whose parents judged their disease status as remission or persistent activity/flare or were satisfied or not satisfied with current illness outcome.

CONCLUSION

The sJADAS cutoffs revealed good metrologic properties in both definition and validation cohorts, and are therefore suitable for use in clinical trials and routine practice.

Safety and efficacy of canakinumab treatment for undifferentiated autoinflammatory diseases: the data of a retrospective cohort two-centered study

Introduction

The blockade of interleukine-1 (anakinra and canakinumab) is a well-known highly effective tool for monogenic autoinflammatory diseases (AIDs), such as familial Mediterranean fever, tumor necrosis factor receptor-associated periodic syndrome, hyperimmunoglobulinaemia D syndrome, and cryopyrin-associated periodic syndrome, but this treatment has not been assessed for patients with undifferentiated AIDs (uAIDs). Our study aimed to assess the safety and efficacy of canakinumab for patients with uAIDs.

Methods

Information on 32 patients with uAIDs was retrospectively collected and analyzed. Next-generation sequencing and Federici criteria were used for the exclusion of the known monogenic AID.

Results

The median age of the first episode was 2.5 years (IQR: 1.3; 5.5), that of the disease diagnosis was 5.7 years (IQR: 2.5;12.7), and that of diagnostic delay was 1.1 years (IQR: 0.4; 6.1). Patients had variations in the following genes: IL10, NLRP12, STAT2, C8B, LPIN2, NLRC4, PSMB8, PRF1, CARD14, IFIH1, LYST, NFAT5, PLCG2, COPA, IL23R, STXBP2, IL36RN, JAK1, DDX58, LACC1, LRBA, TNFRSF11A, PTHR1, STAT4, TNFRSF1B, TNFAIP3, TREX1, and SLC7A7. The main clinical features were fever (100%), rash (91%; maculopapular predominantly), joint involvement (72%), splenomegaly (66%), hepatomegaly (59%), lymphadenopathy (50%), myalgia (28%), heart involvement (31%), intestinal involvement (19%); eye involvement (9%), pleuritis (16%), ascites (6%), deafness, hydrocephalia (3%), and failure to thrive (25%). Initial treatment before canakinumab consisted of non-biologic therapies: non-steroidal anti-inflammatory drugs (NSAID) (91%), corticosteroids (88%), methotrexate (38%), intravenous immunoglobulin (IVIG) (34%), cyclosporine A (25%), colchicine (6%) cyclophosphamide (6%), sulfasalazine (3%), mycophenolate mofetil (3%), hydroxychloroquine (3%), and biologic drugs: tocilizumab (62%), sarilumab, etanercept, adalimumab, rituximab, and infliximab (all 3%). Canakinumab induced complete remission in 27 patients (84%) and partial remission in one patient (3%). Two patients (6%) were primary non-responders, and two patients (6%) further developed secondary inefficacy. All patients with partial efficacy or inefficacy were switched to tocilizumab (n = 4) and sarilumab (n = 1). The total duration of canakinumab treatment was 3.6 (0.1; 8.7) years. During the study, there were no reported Serious Adverse Events (SAEs). The patients experienced non-frequent mild respiratory infections at a rate that is similar as before canakinumab is administered. Additionally, one patient developed leucopenia, but it was not necessary to stop canakinumab for this patient.

Conclusion

The treatment of patients with uAIDs using canakinumab was safe and effective. Further randomized clinical trials are required to confirm the efficacy and safety.

Efficacy and safety of canakinumab as a second line biologic after tocilizumab treatment failure in children with systemic juvenile idiopathic arthritis: A single-centre cohort study using routinely collected health data

Background

A significant number of systemic juvenile idiopathic arthritis (sJIA) patients discontinue biologic disease-modifying antirheumatic drugs (bDMARDs) due to lack of efficacy or safety concerns. Studies of biologic therapy switch regimens in sJIA are required.

Methods

Patients with sJIA who switched from tocilizumab (due to lack of efficacy or safety) to canakinumab (4 mg/kg every 4 weeks) and were hospitalized at the rheumatology department from August 2012 to July 2020 were included. Primary efficacy outcomes were 30% or greater improvement based on the paediatric criteria of the American College of Rheumatology (ACR30), achievement of inactive disease (JADAS-71 = 0) and clinical remission (ACR sJIA clinical inactive disease criteria). Follow-up from time first canakinumab dose administered was 12 months or the closest time point (not less than 6 and not more than 18 months). Data were extracted from electronic outpatient medical records.

Results

During the study period, 46 patients with sJIA switched from tocilizumab to canakinumab. Median age at baseline was 8.2 [interquartile range (IQR) 4.0-12.9] years, with the median sJIA duration being 1.8 (IQR 0.8-5.8) years; 37 (80%) patients received at least one conventional DMARD (cDMARD; oral corticosteroids, methotrexate and/or cyclosporine A). Study outcomes were followed up in 45 patients (one patient did not attend the follow-up for an unknown reason); median follow-up was 359 (IQR 282-404) days. During the follow-up, 1 patient discontinued canakinumab due to tuberculosis detection and the dose was reduced or the injection interval increased in 4 (9%) patients. In total, 27 (60%) patients continued to receive at least one cDMARD. Improvement according to the ACR30 criteria was achieved in 43 patients [96%; 95% confidence interval (CI) 85-99], inactive disease in 42 (93%; 95%CI 82-98), and remission in 37 (82%; 95% CI 69-91); after adjustment for actual time-at-risk, the rates were 83, 85 and 73 events per 100 person-years, respectively. During follow-up, 23 AEs (most frequently infections) were reported in 19/45 (42%) patients; 5/45 (11%) patients developed macrophage activation syndrome, with a favorable outcome in all cases.

Conclusions

One-year canakinumab therapy was found to be potentially effective as second-line biologic therapy after discontinuation of tocilizumab in patients with sJIA.

POS1321 FEATURES OF MACROPHAGE ACTIVATION SYNDROME IN SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS IN THE ERA OF BIOLOGIC THERAPY

Background

Macrophage activation syndrome (MAS) is a severe hyperinflammatory response that develops against the background of juvenile idiopathic arthritis (JIA). It is known that the clinical feature of MAS on biologic therapy has other clinical manifestations, different from biologically naive patients.

Objectives

To study the clinical and laboratory features of macrophage activation syndrome in patients with juvenile idiopathic arthritis with systemic onset (sJIA) on the biologic therapy.

Methods

The study included 100 patients with MAS (114 cases of MAS) who observed in the rheumatological department of the National Medical Research Center for Children’s health of Ministry of health. All patients met the criteria for the diagnosis of sJIA and MAS. There were children in our study who did not receive biologic therapy – 84 (74%) cases, and children who had MAS in the biologic therapy – 30 cases (26%). The drugs are distributed as follows: tocilizumab - 7 cases (6%), kanakinumab - 20 cases (17%), etanercept – 2 cases (2%), adalimumab – 1 case (1%). For pairwise intergroup comparisons of quantitative variables, the nonparametric Mann-Whitney test was used.

Results

In comparative analysis of biologic-naive and on biologic patients, the greatest differences were obtained for the following clinical manifestations: rash, lymphadenopathy, myalgia (p<0.05). Fever was the most common symptom in both groups and was present in almost all patients (99%). All patients had elevated level of ferritin in the blood serum (773 ng/ml to 130149 ng/ml). Laboratory picture of MAS in the group of on biologic patients differed significantly from the group of patients naive for biologic therapy (Table 1). The most significant differences were found among the following laboratory parameters: hemoglobin level, the number of erythrocytes and platelets, erythrocyte sedimentation rate (ESR), levels of C-raective protein (CRP), ferritin, lactatedehydrogenase (LDH), albumin.

Table 1.

Laboratory data of patients with MAS.

nReference valuesMedianMinimumMaximumMann-Whitney Criterion (p)Biologic-naive cases of MAS(n= 84)Hemoglobin, g/l84120-14596,5061,00145,000,008Red blood cells, 1012/l844,5-5,33,782,135,010,001Platelets, 109/l84150-440149,0041,00523,000,025White blood cells, 109/l844,5-11,54,420,6925,840,074ESR, mm/h842-2045,002,00111,000,001CRP, mg/l840-5111,567,54368,310,006Ferritin, ng/ml8414-1244195,21702,38130149,200,022LDH, U/l8491-295413,50162,005245,000,059Albumin, g/l8438-5429,0016,1063,000,001On biologic cases of MAS(n = 30)Hemoglobin, g/l30120-145104,5067,00163,000,008Red blood cells, 1012/l304,5-5,34,173,106,150,001Platelets, 109/l30150-440101,504,00362,000,025White blood cells, 109/l304,5-11,53,220,7015,580,074ESR, mm/h302-2017,502,0098,000,001CRP, mg/l300-555,771,86407,120,006Ferritin, ng/ml3014-1242319,59773,90121396,000,022LDH, U/l3091-295600,0010,602148,570,059Albumin, g/l3038-5432,8020,3051,900,001

Conclusion

On biologic patients may also develop MAS, which is often difficult to diagnose due to the poor clinical picture and low laboratory activity. In this case, hyperferritinemia remains as a highly specific marker of MAS.

References

[1]Crayne CB, Albeituni S, Nichols KE, Cron RQ. The Immunology of Macrophage Activation Syndrome. Front Immunol. 2019 Feb 1;10:119. doi: 10.3389/fimmu.2019.00119. PMID: 30774631; PMCID: PMC6367262.

[2]Henderson LA, Cron RQ. Macrophage Activation Syndrome and Secondary Hemophagocytic Lymphohistiocytosis in Childhood Inflammatory Disorders: Diagnosis and Management. Paediatr Drugs. 2020 Feb;22(1):29-44. doi:10.1007/s40272-019-00367-1. PMID: 31732958; PMCID: PMC7334831.

[3]Ravelli A, Davì S, Minoia F, Martini A, Cron RQ. Macrophage Activation Syndrome. Hematol Oncol Clin North Am. 2015 Oct;29(5):927-41. doi:10.1016/j.hoc.2015.06.010. Epub 2015 Aug 25 PMID: 26461152

Disclosure of Interests

Ivan Kriulin Speakers bureau: Speaker for Novartis., Ekaterina Alexeeva Speakers bureau: Speaker for Roche, AbbVie, Bristol-Myers, Squibb, MSD, Novartis and Pfizer., Grant/research support from: Financial grants from Roche, Pfizer, Centocor, Eli Lilly, AbbVie, Bristol-Myers Squibb, MSD, Sanofi, Amgen and Novartis., Tatyana Dvoryakovskaya Speakers bureau: Speaker for Roche, AbbVie, Bristol-Myers, Squibb, MSD, Novartis and Pfizer., Grant/research support from: Financial grants from Roche, Pfizer, Centocor, Eli Lilly, AbbVie, Bristol-Myers Squibb, MSD, Sanofi, Amgen and Novartis., Rina Denisova Speakers bureau: Speaker for Roche, AbbVie, MSD, Novartis., Grant/research support from: Financial grants from Roche, Pfizer, Centocor, Sanofi and Novartis., Ksenia Isaeva Grant/research support from: Financial grants from Roche, Novartis and Sanofi., Aleksandra Chomakhidze: None declared, Anna Mamutova Speakers bureau: Speaker for Novartis., Grant/research support from: Financial grants from Eli Lilly., Olga Lomakina Grant/research support from: Financial grants from Pfizer, Eli Lilly., Anna Fetisova Grant/research support from: Financial grants from Amgen., Marina Gautier: None declared, Kristina Chibisova: None declared, Elizaveta Krekhova Speakers bureau: Speaker for Novartis., Irina Tsulukiya: None declared

AB0372 BIOLOGIC THERAPY IN CHILDREN WITH SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS ACCORDING TO THE FEDERAL REGISTER OF THE RUSSIAN FEDERATION

Background

Systemic juvenile idiopathic arthritis (sJIA) is the rarest variant of juvenile idiopathic arthritis, characterized by severe course, frequent exacerbations, the development of life-threatening extra-articular manifestations and complications, which requires the use of expensive medications and frequent hospitalizations of patients. In the Russian Federation, the provision of medicines to patients with sJIA is carried out at the expense of the federal budget, in this regard, the Federal Register of sJIA was created in 2018.

Objectives

To analyze biologic therapy in patients with sJIA according to the data of the Federal Register of the Russian Federation.

Methods

Retrospective analysis of epicrisis of patients receiving biologic therapy with a diagnosis of sJIA included in the Federal Register of the Russian Federation. The analysis included patients receiving the following drugs of biologic therapy: tocilizumab, сanakinumab, etanercept, adalimumab.

Results

In 2018, 582 patients receiving biologic therapy were included in the Federal Register. Since 2019, the number of patients has steadily increased: in 2019 there were 796, in 2020 - 949, in 2021 - 1041 patients.

The Federal Register of the Russian Federation includes patients under the age of 18 (in 2018 – 471, in 2019 – 666, in 2020 – 806, in 2021 – 790 patients) and patients over the age of 18 (in 2018 – 111, in 2019 – 130, in 2020 – 143, in 2021 – 250 patients).

During the four-year follow-up, patients receiving tocilizumab predominate - on average 72.25% (in 2018 – 74%, in 2019 – 73.1%, in 2020 – 70.3%, in 2021 – 71.6% of patients).

Therapy with using of TNF-α inhibitors remains without statistically significant dynamics: in 2018 – 38 (6.5%) received etanercept, in 2019 – 42 (5.3%), in 2020 – 44 (4.6%), in 2021 – 46 (4.4%); in 2018 – 22 (3.8%) received adalimumab, in 2019 – 25 (3.1%), in 2020 – 27 (2.9%), in 2021 – 29 (2.8%) patients.

The number of patients receiving сanakinumab has more than doubled since 2018 (in 2018 – 91 (15%), in 2019 – 147 (18.5%), in 2020 – 210 (22.3%), in 2021 - 220 (21.1%) patients.

Conclusion

The number of patients receiving biologic therapy with sJIA in the Russian Federation has increased, which is due to the natural growth of the disease and more affordable provision of patients with sJIA by the state.

References

[1]Lee JJY, Schneider R. Systemic Juvenile Idiopathic Arthritis. Pediatr Clin North Am. 2018 Aug;65(4):691-709. doi: 10.1016/j.pcl.2018.04.005. PMID: 30031494.

Disclosure of Interests

Maria Botova: None declared, Ekaterina Alexeeva Speakers bureau: Speaker for Roche, AbbVie, Bristol-Myers, Squibb, MSD, Novartis and Pfizer.,, Grant/research support from: Financial grants from Roche, Pfizer, Centocor, Eli Lilly, AbbVie, Bristol-Myers Squibb, MSD, Sanofi, Amgen and Novartis.,, Tatyana Dvoryakovskaya Speakers bureau: Speaker for Roche, AbbVie, Bristol-Myers, Squibb, MSD, Novartis and Pfizer.,, Grant/research support from: Financial grants from Roche, Pfizer, Centocor, Eli Lilly, AbbVie, Bristol-Myers Squibb, MSD, Sanofi, Amgen and Novartis.,, Rina Denisova Speakers bureau: Speaker for Roche, AbbVie, MSD, Novartis.,, Grant/research support from: Financial grants from Roche, Pfizer, Centocor, Sanofi and Novartis.,, Anna Mamutova Speakers bureau: Speaker for Novartis.,, Grant/research support from: Financial grants from Eli Lilly.,, Ksenia Isaeva Grant/research support from: Financial grants from Roche, Novartis and Sanofi.,, Aleksandra Chomakhidze: None declared, Olga Lomakina Grant/research support from: Financial grants from Pfizer, Eli Lilly.,, Anna Fetisova Grant/research support from: Financial grants from Amgen.,, Marina Gautier: None declared, Kristina Chibisova: None declared, Elizaveta Krekhova Speakers bureau: Speaker for Novartis.,, Ivan Kriulin Speakers bureau: Speaker for Novartis.,, Irina Tsulukiya: None declared, Tatyana Kriulina: None declared, Natalya Kondratyeva: None declared

POS1322 DISCONTINUATION OF LONG-TERM ADALIMUMAB TREATMENT IN PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS-ASSOCIATED UVEITIS

Background

Uveitis is the most common extra-articular manifestation of JIA which may lead to sight-threatening ocular complications. Topical corticosteroids are still used in the initial treatment for JIA-associated uveitis. The goal of treatment in these patients should be topical corticosteroid-free remission and prevention of recurrences. The most commonly used corticosteroid-sparing immunomodulatory are TNF-α inhibitors (TNFi), especially adalimumab.

Currently, limited data are available about when or how to stop adalimumab when remission of JIA-associated uveitis is presumed.

Objectives

To evaluate rates of relapse after discontinuation adalimumab in patients with JIA-associated uveitis.

Methods

Medical records of 33 patients with JIA-associated uveitis who were successfully treated with adalimumab to a state of topical corticosteroid-free remission and discontinued adalimumab due to a long-term remission were analyzed retrospectively.

Remission of uveitis was defined as <1+ cells in the anterior chamber and <1 + vitreous haze grading; relapse was defined as ≥1 cell in the anterior chamber or ≥1 vitreous haze grading [1].

Results

Corticosteroid-sparing control of inflammation was achieved in all patients. Adalimumab was discontinued after 50 (range 12–120) months after initiation of adalimumab. Duration of remission prior to discontinuing adalimumab was 42 (range 6 – 114) months. The mean duration of remission after adalimumab discontinuation was 14 (range 1–59) months. 13 (40%) of patients had flares after less than 12 months after discontinuing adalimumab, 5 (15%) had flares after 12 – 24 months, 15 (45%) had not flared due to 24 months after discontinuation adalimumab and had had a long-term non-biological remission. Disease was successfully controlled in 11(33%) patients with non-biological DMARDs, 22 (66%) patients restarted biological therapy after flares, due to lack of improvement after non-biological DMARDs. All patients in whom biological therapy was reinitiated responded satisfactorily. None of the flared patients didn’t require restarting corticosteroids.

Conclusion

Corticosteroid-sparing control of inflammation was achieved in all patients. Data from our experience with adalimumab in patients with JIA-associated uveitis suggest that 45 % of patients can be successfully withdrawn from biologics for at least 24 months without disease recurrence.

References

[1]Jabs DA, Nussenblatt RB, Rosenbaum JT. Standardization of uveitis nomenclature for reporting clinical data: results of the First International Workshop. Am J Ophthalmol 2005;140: 509-16.

Disclosure of Interests

Irina Tsulukiya: None declared, Ekaterina Alexeeva Speakers bureau: Speaker for Roche, AbbVie, Bristol-Myers, Squibb, MSD, Novartis and Pfizer., Grant/research support from: Financial grants from Roche, Pfizer, Centocor, Eli Lilly, AbbVie, Bristol-Myers Squibb, MSD, Sanofi, Amgen and Novartis., Tatyana Dvoryakovskaya Speakers bureau: Speaker for Roche, AbbVie, Bristol-Myers, Squibb, MSD, Novartis and Pfizer., Grant/research support from: Financial grants from Roche, Pfizer, Centocor, Eli Lilly, AbbVie, Bristol-Myers Squibb, MSD, Sanofi, Amgen and Novartis., Rina Denisova Speakers bureau: Speaker for Roche, AbbVie, MSD, Novartis., Grant/research support from: Financial grants from Roche, Pfizer, Centocor, Sanofi and Novartis., Anna Mamutova Speakers bureau: Speaker for Novartis., Grant/research support from: Financial grants from Eli Lilly., Ksenia Isaeva Grant/research support from: Financial grants from Roche, Novartis and Sanofi., Aleksandra Chomakhidze: None declared, Olga Lomakina Grant/research support from: Financial grants from Pfizer, Eli Lilly., Anna Fetisova Grant/research support from: Financial grants from Amgen., Marina Gautier: None declared, Kristina Chibisova: None declared, Ivan Kriulin Speakers bureau: Speaker for Novartis., Elizaveta Krekhova Speakers bureau: Speaker for Novartis., Maria Botova: None declared

AB1261 THE ANALYSIS OF THE ONSET OF SYSTEMIC LUPUS ERYTHEMATOSUS IN PEDIATRIC POPULATION

Background

Systemic lupus erythematosus (SLE) is characterized by multiple autoantibodies associated with a multisystem illness where any organ can be targeted. There are different classification criteria for SLE. Sensitivity and specificity of three criteria have been debated and may vary in different populations and clinical settings.

Objectives

We aim to evaluate the clinical and laboratory symptoms of the onset of systemic lupus erythematosus in pediatric population.

Methods

A total of 116 SLE patients (female –92, male-24) were included into the study. We analyzed the primary diagnosis, the time before identification the SLE, clinical and laboratory symptoms, their combination, and fulfilling the classification criteria of SLE. All data is presented as Me (IQR).

Results

The age of the onset of SLE was 13.3 (10.7, 15.2) years. 55/116 patients had other diagnosis before the verification of SLE, the time before the verification was 10 (5, 26) months. The loss of weigh was in 63(54%) of patients, fever – in 83(72%) (febrile – 57, subfebrile -26), adenopathy in 55(47%), malar rash – in 45(39%), discoid rash – in 19(16%), alopecia – in 19 (16%), photosensitivity – in 39(34%), oral ulcers – in 38 (33%), nazal ulcers – in 11(9.5%), arthritis – in 31(27%), pleuritis- in 18(16%), pericarditis- in 20(17%), renal disorder – in 52(47%), seizures- in 7(6%), psychosis – in 1(0.9%), myelitis – in 2(1.7%), peripheral neuropathy – in 3(2.6%), cranial neuropathy – in 2(1.7%), hemolytic anemia – in 59(51%), leukopenia- in 62(53%), thrombocytopenia- in 27(23%), ANA positivity – in 100(86%), anti-dsDNA antibody positivity – in 91(78%), antiphospholipid antibody positivity– in 27 (25%), direct Coombs’ test- in 22(19%). SELENA–SLEDAI Score was 13 (9, 20): low activity- in 14(12%) patients, moderate activity- in 23(20%), high activity – in 42(36%), very high activity – in 37(32%).

96 (83%) patients met the eligibility criteria ELAR/ACR 2019, 112(97%) – ACR criteria modified in 1997, 106(91%) – SLICC in 2012.

Conclusion

In this cohort, although all three criteria have sufficient. Some SLE patients with a clinical diagnosis lacked sufficient number of criteria.

Disclosure of Interests

Rina Denisova Speakers bureau: Speaker for Roche, AbbVie, MSD, Novartis., Grant/research support from: Financial grants from Roche, Pfizer, Centocor, Sanofi and Novartis., Ekaterina Alexeeva Speakers bureau: Speaker for Roche, AbbVie, Bristol-Myers, Squibb, MSD, Novartis and Pfizer., Grant/research support from: Financial grants from Roche, Pfizer, Centocor, Eli Lilly, AbbVie, Bristol-Myers Squibb, MSD, Sanofi, Amgen and Novartis., Tatyana Dvoryakovskaya Speakers bureau: Speaker for Roche, AbbVie, Bristol-Myers, Squibb, MSD, Novartis and Pfizer., Grant/research support from: Financial grants from Roche, Pfizer, Centocor, Eli Lilly,AbbVie, Bristol-Myers Squibb, MSD, Amgen and Novartis., Ksenia Isaeva Grant/research support from: Financial grants from Roche, Novartis and Sanofi., Aleksandra Chomakhidze: None declared, Anna Mamutova Speakers bureau: Speaker for Novartis., Grant/research support from: Financial grants from Eli Lilly., Olga Lomakina Grant/research support from: Financial grants from Pfizer, Eli Lilly., Anna Fetisova Grant/research support from: Financial grants from Amgen., Marina Gautier: None declared, Kristina Chibisova: None declared, Ivan Kriulin Speakers bureau: Speaker for Novartis., Elizaveta Krekhova Speakers bureau: Speaker for Novartis., Irina Tsulukiya: None declared

AB0727 STUDY OF MEFV GENE MUTATIONS IN A COHORT OF CHILDREN: A SINGLE CENTER

Background:

Familial Mediterranean fever (FMF) is a monogenic autoinflammatory hereditary disease characterized by recurrent episodes of fever with sterile peritonitis, pleural inflammation, arthritis, and/or erysipelas-like rash. Among all variants of the MEFV gene, according to the literature, five pathogenic ones have been identified, which in 75% of cases lead to the development of a typical clinical presentation: V726A, M694V, M694I, M680I, and E148Q. Among them, the M694V variant is the most common and occurs in patients with FMF in 20-65% of cases. At the same time, approximately 10 to 20% of patients meeting the diagnostic criteria for FMF do not have pathogenic variants in the MEFV gene. Despite the fact that the molecular genetic, pathogenetic and clinical features of the disease have been studied detailed, the diagnosis remains difficult due to the lack of a clear correlation between the patient’s clinical and genetic data.

Objectives:

To analyze the obtained genetic data of patients with pathogenic variants in the MEFV gene.

Methods:

The study included 103 patients who are mainly observed at the rheumatology department of the National Medical Research Center of Children’s Health of Ministry of Health of the Russian Federation in Moscow. All patients underwent analysis of the MEFV gene using Sanger sequencing with further statistical processing of the data obtained.

Results:

Of 103 patients, the pathogenic variant of the MEFV gene was found in 93 patients (90.3%), in 10 patients (9.7%) - the pathogenicity of the revealed variant was contradictory. Of 93 patients with the pathogenic variant of MEFV, the clinical presentation of the disease fits to FMF in 37 patients (39.6%). 11 (29.7%) of them had a mutation in M694V. Out of 37 children who met the criteria for FMF diagnosis, 15 (40.5%) children had a homozygous pathogenic variant of MEVF, and 22 (59.5%) children had two mutations in a heterozygous state. 57 patients who do not have a typical clinical presentation, which is specifical for FMF are observed at the departments of rheumatology, cardiology and nephrology, 13 patients are on an outpatient observation, and 6 patients at the time of the study are over 18 years old. 8 (14%) of them had a mutation in M694V. Among 57 patients with pathogenic heterozygous variants in a, 22 patients (38.6%) are observed in the rheumatology department, among them:

• Enthesitis-related arthritis - 2 patients (9%);

• Systemic juvenile arthritis - 13 patients (59%);

• Oligoarthritis - 5 patients (23%);

• Polyarthritis- 2 patients (9%).

Conclusion:

Analysis of the obtained data showed that FMF is characterized by a combination of the clinical presentation and the pathogenic variant in the MEFV gene. However, the disease manifests itself not only in the homozygous pathogenic variant, but also in the combination of two mutations in heterozygous. The presence of one heterozygous mutation, generally, does not lead to the development of FMF.

References:

[1]Konstantopoulos, A. Kanta, C. Deltas, V. Atamian, D. Mavrogianni, A.G. Tzioufas, I. Kollainis, K. Ritis, H.M. Moutsopoulos, Familial Mediterranean fever associated pyrin mutations in Greece Ann. Rheum. Dis., 62 (2003), pp. 479-481, 10.1136/ard.62.5.479.

[2]Gershoni-Baruch R, Brik R, Zacks N, Shinawi M, Lidar M, Livneh A: The contribution of genotypes at the MEFV and SAA1 loci to amyloidosis and disease severity in patients with Mediterranean Fever,Seminars in Arthritis and Rheumatism,Volume 43, Issue 3, 2013, Pages 387-391familial Mediterranean fever. Arthritis Rheum 2003; 48: 1149–1155.

[3]Booty MG, Chae JJ, Masters SL, et al. Familial Mediterranean fever with a single MEFV mutation: where is the second hit? Arthritis Rheum 2009; 60:185.

Disclosure of Interests:

None declared

POS0085 EVALUATION OF DURATION OF CLINICAL REMISSION IN CHILDREN WITH NON-SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS AFTER WITHDRAWAL OF ANTI – TUMOR NECROSIS FACTOR - ALPHA THERAPY

Background:

Juvenile idiopathic arthritis (JIA) is the most common and prevalent rheumatic disease in childhood which is based on a chronic autoimmune inflammation. Inactive disease and remission are now the primary treatment goal in JIA and biologics have been playing an important role to reach this objective.

The biologics of the first choice for the treatment of non-systemic JIA are the Tumor Necrosis Factor - alpha (TNFα) inhibitors; on this therapy patients can achieve clinically inactive disease and long-term remission.

Currently, little is known about when or how to stop TNFα inhibitors, when a good clinical response is achieved, and therefore no guidelines are available.

Objectives:

To estimate the length of clinical remission after discontinuation of treatment with TNFα inhibitors in patients with non-systemic juvenile idiopathic arthritis.

Methods:

A total of 393 patients with JIA who were treated with TNFα inhibitors at the Rheumatology Department of the National Medical Research Center of Children’s Health (Moscow, Russia) were screened for inclusion in this retrospective study.

Patients were treated with etanercept 1 times a week, 0.8 mg per kg of body weight per dose, with adalimumab 24 mg/m2 body surface area administered every other week until the end of therapy.Treatment was terminated abruptly. Inactive disease was defined according to the preliminary criteria of Wallace et al.[1]

Results:

77 patients (27—male, 50—female) with a mean age at diagnosis of 4 years (range 1–18 years) were included in the analysis. Of those, 69 of them discontinued TNFα inhibitors due to a long-term remission on treatment, 8 patients as a result of side effects, and there were excluded from our study.:

allergic reaction (n = 5), development of uveitis (n = 1), alopecia (n = 1), recurrent infection (n=11).The clinical subtypes of JIA were RF-negative polyarticular JIA -28 (40,58%) oligoarthritis—38 (55,07%), enthesitis-related arthritis—3 (4,35%).

TNFα inhibitors were started after a mean 46,43 (range 1–144) months of disease. The mean duration of therapy with TNFα inhibitors were 46,63 (range 10-113) months, with a mean duration of remission on medication 40,63 (range 6-107) months before withdrawal of TNFα inhibitors.

40/69 (57,97 %) patients did not develop a disease exacerbation and remained in long-term remission off medication—more than 24 months.

Early flares, that is less than 6 months after termination of TNFα inhibitors, were observed in 4/69 (5,8%) patients.

29 (42,03%) patients restarted TNFα inhibitors after exacerbation, due to lack of improvement after no biological DMARDs. All patients in whom TNFα inhibitors were reinitiated responded satisfactorily.

Conclusion:

Among patients with JIA in whom TNFα inhibitors were discontinued after inactive disease was achieved, 57,97 % had disease in clinical remission more than 24 months after stopping anti-TNFα therapy. No association was observed between the duration of inactive disease prior to TNFα inhibitors cessation and the time to disease relapse. In addition, we also ob- served no correlation between the risk of flare and the length of anti-TNF α therapy after inactive disease was achieved. In our population, TNFα antagonists were withdrawn a median of 38 (4-107) months after inactive disease was achieved. Data from our experience with anti-TNF α agents in the treatment of JIA suggest that 57,97 % of patients can be successfully withdrawn from TNF α antagonists for at least 24 months.

References:

[1]Wallace CA, Giannini EH, Huang B, Itert L, Ruperto N, for the Childhood Arthritis and Rheumatology Research Alliance (CARRA), the Pediatric Rheumatology Collaborative Study Group (PRCSG), and the Paediatric Rheumatology Interna- tional Trials Organisation (PRINTO). American College of Rheumatology provisional criteria for defining clinical in- active disease in select categories of juvenile idiopathic arthritis. Arthritis Care Res (Hoboken) 2011;63:929–36.

Disclosure of Interests:

None declared.

OP0166 DISEASE ACTIVITY IN CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS AFTER SIMULTANEOUS PCV13 AND HIB VACCINATION: A COHORT STUDY

Background:

The safety of vaccination of children with rheumatic diseases is determined not only by the risk of adverse events but also by the risk of exacerbation of the disease. The simultaneous administration of several vaccines can increase the likelihood of these events.

Objectives:

To evaluate the clinical and laboratory signs of disease activity in children with juvenile idiopathic arthritis (JIA) after simultaneous vaccination against pneumococcal and Haemophilus influenzae type b (Hib) infections.

Methods:

We included hospitalized patients with JIA ages 2 through 18 without serious comorbidity, immunized with polysaccharide conjugate vaccines against pneumococcal (PCV13) and Hib infections. Vaccines were administered (0.5 ml each) concurrently subcutaneously into the deltoid area. In all children before and 3 weeks after vaccination, clinical (joints with active arthritis, uveitis activity) and laboratory signs (increased ESR, concentrations of highly sensitive C-reactive protein – hsCRP, and calprotectin) of JIA activity were assessed. Serum hsCRP and calprotectin were quantified by ELISA. The upper limit of the reference interval for hsCRP was considered (according to the manufacturer’s instructions) a value of 8.2 mg/L, for calprotectin – 2.9 μg/ml, and for ESR – > 10 mm/h.

Results:

The study included 430 patients with JIA (girls 60.9%), median (IQR) age – 11.1 years (7.3 to 14.4), onset of JIA – 4.7 years (2.4 to 8.6). Patients with persistent oligoarticular JIA numbered 149 (34.7%), polyarticular RF-negative – 148 (34.4%), systemic – 101 (23.4%), enthesitis-related – 20 (4.7%), and polyarticular RF-positive JIA – 12 (2.8%). Biologic disease-modifying antirheumatic drugs (DMARDs) were administered to 278 (64.7%), non-biologic DMARDs (mostly methotrexate) – 282 (65.6%), corticosteroids – 45 (10.5%), and NSAIDs – 18 (4.2%) patients. Three weeks after vaccination, out of 100 (23.3%) patients with initially active joints, signs of active arthritis remained in 96 patients, of which 16 patients had a decrease in the median (IQR) number of active joints by 4 (2 to 8). Among patients without active joints at baseline, signs of active arthritis were not subsequently detected. Before vaccination, 9 patients had uveitis in the exacerbation phase, 7 - in the subactive phase, and 41 - in the remission phase. After vaccination, exacerbation of uveitis persisted in 4 patients. There were no new cases of uveitis or its exacerbation. The dynamics of laboratory signs of JIA activity are presented in Table 1. Initially, the high concentration of calprotectin was found in 191 (44.4%) patients, and after vaccination – in 220 (51.2%) patients; the difference was 6.7% (95% CI 1.0 - 12.5); hsCRP - in 34 (7.9%) and 51 (11.9%) patients; the difference was 4.0% (95% CI 0.6 - 7.3); high ESR – in 76 (17.7%) and 41 (9.5%) patients; the difference was -8.1% (95% CI -11.6 to -4.7), respectively. An independent predictor of new cases of high concentration of hsCRP (n = 36), but not new cases of high concentration of calprotectin (n = 94), was the initial number of joints with active arthritis – odds ratio 2.37 (95% CI 1.14 - 4.93).

Table 1.

Laboratory signs of JIA activity after simultaneous administration of vaccines against pneumococcal (PCV13) and Hib-infections

VariablesBaselineAfter 3 weeksRatio*p**Geometric mean (95% CI)Calprotectin, μg/ml2.93 (2.70 – 3.17)3.15 (2.92 – 3.40)1.08 (0.99 – 1.17)0.087hsCRP, mg/L0.69 (0.60 – 0.78)0.79 (0.69 – 0.90)1.15 (0.99 – 1.33)0.073ESR, mm/h4.4 (4.0 – 4.8)3.7 (3.4 – 4.0)0.84 (0.78 – 0.90)0.001

Note. CI – confidence interval. * Ratios of paired observations (95% CI). ** P-value calculated in paired samples t-test.

Conclusion:

Simultaneous vaccination against pneumococcal (PCV13) and Hib-infections in children with JIA produced no negative dynamics of the traditional indicators of disease activity (joint activity, uveitis, high ESR). At the same time, 3 weeks after vaccination, an increase in the concentration of calprotectin and hsCRP was found in a small number of patients (<10%).

Disclosure of Interests:

None declared

POS1312 DRUG SURVIVAL FOR IL-6 INHIBITOR TOCILIZUMAB: DATA FROM A SINGLE-CENTER OBSERVATION

Background:

The efficacy of tocilizumab for treatment patients with systemic juvenile idiopathic arthritis (sJIA) was demonstrated before. We want to describe tocilizumab drug survival based on data from a single-center observation.

Objectives:

To analyze the drug survival of tocilizumab in patients with sJIA treated at the National Medical Research Center of Children`s health, Moscow, Russia.

Methods:

Medical records from sJIA patients treated with tocilizumab (TOC) were analyzed retrospectively from the National Medical Research Center of Children`s health, Moscow, Russia.

Results:

One hundred ninety-two patients presenting with sJIA were included in this observation, with a median age at treatment initiation of 7,2 (interquartile range, IQR 3,9-10,8) years and a median disease duration of 1,9 (IQR 0,4-5,9) years. All patients had been bio-naive. TOC therapy was highly effective in patients with sJIA. At 6 month of follow-up 148/172 (86%) patients achieved inactive disease according the criteria C. Wallace, disease activity persisted in 24/172 (14%) patients. At 1 year of medication 139/150 (92%) patients had inactive disease. We analyzed the reason of TOC withdrawal retrospectively. A total of 82/192 drug withdrawals were performed. TOC was discontinued due to primary ineffectiveness in 4 patients, due to secondary ineffectiveness in 39 patients. 33 patients achieved drug-free remission. Six patients developed side effects that required discontinuation of TOC therapy (4 patients had allergic reactions, 1 patient developed tuberculosis, 1 patient had severe neutropenia). 47/82 patients were switched on other biologic drug: on canakinumab (31), on TNF-inhibitors (11), on rituximab (5). In summary, TOC was canceled in 49/192 (25%) patients due to ineffectiveness or AEs in our cohort.

Conclusion:

These results demonstrated that TOC is highly effective as the first biologic drug in patients with sJIA. Our observations have shown a good tolerability and survival of the IL-6 inhibitor TOC in patients with sJIA treated in a real-world clinical setting.

Disclosure of Interests:

None declared

AB0721 CLINICAL AND LABORATORY CHARACTERISTICS, GENETIC FEATURES OF MACROPHAGE ACTIVATION SYNDROME IN CHILDREN WITH SYSTEMIC-ONSET JUVENILE IDIOPATHIC ARTHRITIS: A SINGLE CENTER EXPERIENCE

Background:

Macrophage activation syndrome (MAS) is a life-threatening complication of systemic-onset juvenile idiopathic arthritis (sJIA) characterized by fever, hepatosplenomegaly, lymphadenopathy, coagulopathy, and rapid development of multiple organ failure. MAS is triggered by viral and bacterial infections, most often Epstein-Barr viruses, cytomegalovirus, influenza and parainfluenza viruses, parvavirus B19, yersiniosis, salmonellosis, sepsis.

Despite modern diagnostic and treatment technologies, MAS still remains a formidable complication of sJIA, it is characterized by an aggressive course, a heterogeneous clinical presentation, especially in conditions of treatment with genetically engineered biological drugs, an ambiguous response to pathogenetic therapy and is accompanied by mortality in 5-10% of patients.

Objectives:

To analyze the clinical and laboratory features of MAS in children with sJIA and to study the genetic predisposition of this syndrome.

Methods:

The study included 24 patients with MAS who are being followed up in the rheumatology department of the National Medical Research Center of Children’s Health, Moscow. The clinical presentation and laboratory manifestations were assessed in 24, and genetic features were described in 7 patients using a new generation sequencing with further biostatistical processing of the obtained genetic data.

Results:

Of 24 patients, 23 (98%) had fever, 16 (68%) patients had rash, 17 (72%) - organomegaly, 4 (16%) - polyserositis, 2 (7%) - myalgia and myopathy. All 24 (100%) patients had an increase in ferritin level of more than 684 ng/ml, 98% of them had a high level of lactate dehydrogenase (LDH) and 97% - a high level of triglycerides. In CBC, cytopenia was found in 80% of children: in 54% - erythrocytopenia, in 74% - leukopenia, in 88% - thrombocytopenia, in 15% - sharp decrease in erythrocyte sedimentation rate. In a coagulogram of 24 patients, 90% had an increase in D-dimer, 85% had a decrease in fibrinogen. Hyponatremia presented in 95% of patients. Thus, 85% of patients met the diagnostic criteria of the HLH-2004 protocol, adapted for children with sJIA. Genetic characteristics were analyzed in 7 children out of 94 patients with MAS. They are presented in Table 1. These patients have rare and frequent variants, as well as genes polymorphisms that are associated with macrophage activation syndrome.

Table 1.

The number of genetic variants in children with MAS (n=7).

GenePatient № 1Patient №2Patient № 3Patient № 4Patient №5Patient №6Patient №7LYST02473464NLRC44444463NLRP12510644124NLRP31855575TNFAIP32220222UNC13D182510182618XIAP1100131

Conclusion:

The macrophage activation syndrome has a typical clinical presentation, there are clinical and laboratory manifestations: fever, hyperferritinemia, cytopenia, hyponatremia, increased levels of LDH and triglycerides, based on which, a diagnosis can be made. Patients with MAS at our center also had genetic characteristics that predisposed to the development of this condition.

References:

[1]Crayne CB, Albeituni S, Nichols KE, Cron RQ. The Immunology of Macrophage Activation Syndrome. Front Immunol. 2019 Feb 1;10:119. doi: 10.3389/fimmu.2019.00119. PMID: 30774631; PMCID: PMC6367262.

[2]Henderson LA, Cron RQ. Macrophage Activation Syndrome and Secondary Hemophagocytic Lymphohistiocytosis in Childhood Inflammatory Disorders: Diagnosis and Management. Paediatr Drugs. 2020 Feb;22(1):29-44. doi: 10.1007/s40272-019-00367-1. PMID: 31732958; PMCID: PMC7334831.

[3]Ravelli A, Davì S, Minoia F, Martini A, Cron RQ. Macrophage Activation Syndrome. Hematol Oncol Clin North Am. 2015 Oct;29(5):927-41. doi: 10.1016/j.hoc.2015.06.010. Epub 2015 Aug 25. PMID: 26461152.

Disclosure of Interests:

None declared

Early combination therapy with etanercept and methotrexate in JIA patients shortens the time to reach an inactive disease state and remission: results of a double-blind placebo-controlled trial

BACKGROUND

Remission is the primary objective of treating juvenile idiopathic arthritis (JIA). It is still debatable whether early intensive treatment is superior in terms of earlier achievement of remission. The aim of this study was to evaluate the effectiveness of early etanercept+methotrexate (ETA+MTX) combination therapy versus step-up MTX monotherapy with ETA added in refractory disease.

METHODS

A multi-centre, double-blind, randomized study in active polyarticular JIA patients treated with either ETA+MTX (n = 35) or placebo+MTX (n = 33) for up to 24 weeks, followed by a 24-week open-label phase. The efficacy endpoints included pedACR30 criteria improvement at week 12, inactive disease at week 24, and remission at week 48. Patients who failed to achieve the endpoints at week 12 or at week 24 escaped to open-label ETA+MTX. Safety was assessed at each visit.

RESULTS

By intention-to-treat analysis, more patients in the ETA+MTX group reached the pedACR30 response at week 12 (33 (94.3%)) than in the placebo+MTX group (20 (60.6%); p = 0.001). At week 24, comparable percentages of patients reached inactive disease (11 (31.4%) vs 11 (33.3%)). At week 48, 11 (31.4%) and eight (24.2%) patients achieved remission. The median (+/-IQR) times to achieve an inactive disease state in the ETA+MTX and placebo+MTX groups were 24 (14-32) and 32 (24-40) weeks, respectively. Forty-four (74/100 patient-years) adverse events (AEs) were reported, leading to treatment discontinuation in 6 patients.

CONCLUSIONS

Early combination therapy with ETA+MTX proved to be highly effective compared to the standard step-up regimen. Compared to those treated with the standard regimen, more patients treated with a combination of ETA+MTX reached the pedACR30 response and achieved inactive disease and remission more rapidly.

THU0506 LONG-TERM EFFECTIVENESS AND SAFETY OF CANAKINUMAB AS A SECOND BIOLOGIC AFTER TOCILIZUMAB IN CHILDREN WITH EARLY AND LATE JIA WITH ACTIVE SYSTEMIC FEATURES

Background:

Canakinumab (CAN) is often used as second biologics in juvenile idiopathic arthritis with active systemic features (sJIA). However, there are little information about its long-term efficacy and safety.

Objectives:

To evaluate the long-term effectiveness and safety of CAN as a second biologics after tocilizumab (TOC) in sJIA patients depending on the duration of the disease.

Methods:

Thirty-one patients were enrolled in this study: the group of early sJIA (with duration shorter than 2 years, 19 patients) and the group of late sJIA (with duration longer than 2 years, 12 patients). At the baseline, information was collected on the characteristics of the onset of the disease, previous therapy and its success. At each visit at least 1 time per year clinical and laboratory characteristics of sJIA severity were assessed. Response to therapy was assessed using the ACRPedi 30/50/70/90 criteria and the C.Wallace criteria for inactive disease (WID) and clinical remission.

Results:

The most common reason for withdrawal of previous TOC was secondary ineffectiveness (22 cases, 71%); in 6 cases (19.4%) allergic reaction was observed; in two cases (6.5%) primary non-effectiveness appeared; and in one case (3.2%) there was marked infusion reaction.

At CAN initiation, sJIA activity was as follows: 15 (12: 23) for JADAS-71; 45 (36.5: 72) and 58 (45: 81) for physician’s and patient’s global assessment VAS; and 0.25 (0: 0.62) for the CHAQ disability index.

After 12-month treatment, 22 (71%) patients reached WID: 21 on CAN therapy and 1 – after CAN withdrawal due to administrative reason and stable WID. ACR50/70/90 response was achieved by 84.2%/84.2%/64.7% patients in early arthritis group and in 83.3%/75%/75% patients in late arthritis group (p=0.792).

However, 42.1% of patients with early sJIA achieved remission in the first 1.5 years without any further relapse during all the studied period and only 16.7% of patients with late arthritis (p=0.239). In multivariable analysis, it was found that age of sJIA onset (OR (2.5-97.5 CI) 0.353 (0.13 - 0.72), p=0.015), number of joints with active arthritis at sJIA onset (2.308 (1.26-5.73), p=0.025), and JADAS-71 at sJIA onset (0.664 (0.44-0.88), p=0.016) were associated with successful treatment with rapid achievement of stable remission.

During the 76.7 patient-years follow-up period, 18 of 31 (58.1%) patients were able to achieve a stable clinical remission and 27 (87.1%) – WID. Two patients have achieved successfully drug-off remission. Serious adverse event (SAE) was reported in one (3.2%) patient (enteritis).

Conclusion:

Long-term canakinumab therapy proved to be effective and safe as a second biologics after tocilizumab for any duration of the disease. However, patients with early arthritis are more likely to quickly achieve stable remission without further relapse. Younger onset of sJIA with polyarthritis involvement and low disease activity are predictors of rapid and stable remission.

Disclosure of Interests:

Ekaterina Alexeeva Grant/research support from: Roche, Pfizer, Centocor, Novartis, Speakers bureau: Roche, Novartis, Pfizer., Elizaveta Krekhova: None declared, Tatyana Dvoryakovskaya: None declared, Ksenia Isaeva: None declared, Aleksandra Chomakhidze: None declared, Evgeniya Chistyakova: None declared, Olga Lomakina: None declared, Rina Denisova: None declared, Anna Mamutova: None declared, Anna Fetisova: None declared, Marina Gautier: None declared, Dariya Vankova: None declared, Meyri Shingarova: None declared, Alina Alshevskaya: None declared, Andrey Moskalev: None declared, Ivan Kriulin: None declared

FRI0464 GENOTYPING AND PHENOTYPING PATTERNS IN PATIENTS WITH CAPS IN RUSSIAN FEDERATION

Background:

Cryopyrine-associated periodic syndromes (CAPS) are a group of rare congenital auto-inflammatory diseases (AID) that include diseases such as familial cold auto-inflammatory syndrome (FCAS), Muckle-Wells syndrome (MWS), and CINCA/NOMID syndrome. At present, there are limited data on demographic and clinical features of children with CAPS in Russia.

Objectives:

To reveal demographic, genotype and phenotype characteristics in CAPS patients at the National Medical Research Center of Children`s health, Moscow, Russia.

Methods:

Retrospective study included 12 patients (7 females, 58.3%) with CAPS confirmed by next generation sequencing (NGS). Median age of disease onset was 5.7 (interquartile range (IQR) 0.5:12.8) years. Characteristics of disease onset as well as dynamics of disease activity during long-term treatment were evaluated.

Results:

At the onset, systemic features were as follows: fever in 11 (91.6%) patients, rash in 8 (66.7%), hepatosplenomegaly in 7 (58.3%) patients, and lymphadenopathy in 6 (50%). Active arthritis in the onset of the disease was in 9/12 patients (75%), presented by polyarthritis in 7/9 (77.8%), and oligoarthritis in 2/9 (22.2%). Two patients (16.7%) had cataract, one (8.3%) had bilateral uveitis, and one (8.3%) had optic atrophy. Sensorineural hearing loss was observed only in 3/12 (25%). Hydrocephalus was detected in 3/12 (25%). Delayed mental and psycho-speech development was observed in 6/12 (50%) patients. In 3/12 (25%), the development of MAS was recorded.

All patients had nucleotide variants inNLRP3gene. According to NGS results and clinical characteristics, 8/12 (66.7%) patients were diagnosed with MWS and 4/12 (33.3%) had CINCA/NOMID syndrome. In children with MWS, heterozygous variantc.2113C>AinNLRP3gene was the most common (5/8 (62.5%) patients). One of 8 (12.5%) patients with novel heterozygous variantc.2861C>Twas detected; also one child (12.5%) have heterozygous variantc.598G>Aand one (12.5%) – heterozygous variantc.943A>G. Four patients with CINCA/NOMID syndrome also had heterozygous variants inNLRP3gene:c.598G>A,c.2173C>A,c.1991T>Candc.796C>T.

Prior to genetic testing, 12/12 (100%) patients received NSAIDs; 6/12 (50%) were treated with oral glucocorticoids (GC), 3/12 (25%) – with intravenous GC, 2/12 (22.2%) – with methotrexate. Biologics treatment included: 5/12 (41.7%) CAN, 4/12 (33.3%) tocilizumab, and 1/12 (8.3%) etanercept. After genetic testing, 7/12 (58.3%) patients were successfully switched to CAN. Only 1/12 (8.3%) child with MWS developed secondary inefficiency on CAN treatment.

Conclusion:

Systemic manifestations were detected in 91.6% of children, while active arthritis was observed in 75% of patients, which can cause difficulties in the diagnosis and treatment of CAPS. The effectiveness of canakinumab therapy was estimated in 91.6% of patients. The most frequent variant of theNLRP3gene in MWS wasc.2113C>A. In patients with CINCA/NOMID syndrome all nucleotide variants were individual.

Disclosure of Interests:

Meyri Shingarova: None declared, Ekaterina Alexeeva Grant/research support from: Roche, Pfizer, Centocor, Novartis, Speakers bureau: Roche, Novartis, Pfizer., Tatyana Dvoryakovskaya: None declared, Kirill Savostyanov: None declared, Aleksander Pushkov: None declared, Evgeniya Chistyakova: None declared, Ksenia Isaeva: None declared, Aleksandra Chomakhidze: None declared, Olga Lomakina: None declared, Rina Denisova: None declared, Anna Mamutova: None declared, Anna Fetisova: None declared, Marina Gautier: None declared, Dariya Vankova: None declared, Elizaveta Krekhova: None declared, Ivan Kriulin: None declared, Natalia Zhurkova: None declared, Rustam Tepaev: None declared, Alina Alshevskaya: None declared, Andrey Moskalev: None declared

AB0971 LONG-TERM EFFICACY AND SAFETY OF CANAKINUMAB IN PATIENTS WITH SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS: RESULTS FROM A SINGLE-CENTER STUDY

Background:

Results from various phase 3 clinical studies have demonstrated the efficacy of canakinumab to treat patients with systemic juvenile idiopathic arthirtis (sJIA). However, limited information is available on the long-term efficacy and safety of this drug to treat children with sJIA.

Objectives:

To evaluate the long-term efficacy and safety of canakinumab in patients with sJIA treated at the National Medical Research Center of Children`s health, Moscow, Russia.

Methods:

This was a prospective, single-center study that included canakinumab (CAN)-naive patients diagnosed with sJIA following the International League of Associations for Rheumatology (ILAR) criteria and start receiving CAN treatment from 10/2012 to 03/2016. Patients included in this study also participated, for defined periods of time, in the clinical trialNCT02296424. Patients with active disease started treatment with canakinumab 4 mg/kg. A treat-to-target approach was used, canakinumab was discontinued in patients on clinical remission, either following theNCT02296424protocol or by investigator’s decision, and re-introduced in those patients who experienced a relapse afterwards. Disease characteristics and demographics were recorded at the time of diagnosis and initiation of treatment (study entry). Disease activity was evaluated periodically using the adaptedJIAACR core set measures, and percentages of patients with inactive disease and on clinical remission were calculated using the sJIA ACR criteria. Response to treatment was also evaluated by calculating modified ACR responses and JADAS-71 scores. Safety was assessed by collecting and classifying adverse events (AEs) at each visit.

Results:

Nineteen patients presenting with sJIA were included in this study, with a median age at treatment initiation of 9.6 (interquartile range, IQR 6.4-11.1) years and a median disease duration of 4.4 (IQR 1.2-7.0) years. Most patients (17/19) had been treated previously with one or more biologic agents for sJIA. As of 23 December of 2019, the median time of follow up was 55.5 (47-71.7) months, with all patients being followed for at least 3.5 years and 5 patients followed for more than 7 years. As it is shown in figure 1, most patients (16/19) were on clinical remission one year after starting therapy, and this effect was sustained at year 3.5 (17/19). ACR 90 responses were observed in 84.2% (16/19) patients at one year and 94.7% (18/19) patients at 3.5 years, whereas JADAS-71 scores decreased from 15 (14: 28.5) at baseline to 0 (0: 0) at one year with 4/19 patients maintained with JADAS-71 >0); at 3.5 years, only one patient had JADAS-71>0 (0.47, due to slight ESR increasing). Concerning the 5 patients with >7 years of follow up, three of them were in clinical remission for more than 3 years, including one who had discontinued therapy more than 2 years. Another patient had a relapse after attempting drug discontinuation, but recovered clinical remission after reintroducing canakinumab, and remained in this state for the last two years. The remaining patient has persistent low levels of disease activity during the last four years of follow up. AEs required hospitalization were reported in 36.8% (7/19) patients.

Conclusion:

Sustained clinical remission was observed in most patients with sJIA treated with canakinumab for up to 7 years, with no new or unexpected adverse events reported.

Disclosure of Interests:

Ekaterina Alexeeva Grant/research support from: Roche, Pfizer, Centocor, Novartis, Speakers bureau: Roche, Novartis, Pfizer., Elizaveta Krekhova: None declared, Tatyana Dvoryakovskaya: None declared, Ksenia Isaeva: None declared, Aleksandra Chomakhidze: None declared, Evgeniya Chistyakova: None declared, Olga Lomakina: None declared, Rina Denisova: None declared, Anna Mamutova: None declared, Anna Fetisova: None declared, Marina Gautier: None declared, Dariya Vankova: None declared, Meyri Shingarova: None declared, Ivan Kriulin: None declared, Alina Alshevskaya: None declared, Andrey Moskalev: None declared

FRI0458 EFFICACY AND SAFETY OF PCV13 VACCINATION IN JIA PATIENTS WITH SYSTEMIC MANIFESTATIONS ON TOCILIZUMAB AND CANAKINUMAB TREATMENT

Background:

The need for continuous use of immunosuppressive drugs leads to increased risk of developing infectious diseases in children with juvenile idiopathic arthritis with systemic manifestation (sJIA). Questions about choosing the optimal vaccination time and the effect of different classes of therapy on vaccination effectiveness are still open.

Objectives:

To study clinical and laboratory effectiveness of PCV13-vaccination in children with sJIA on tocilizumab (TOC) and canakinumab (CAN) treatment depending on disease activity stage.

Methods:

Prospective cohort study included 2 groups of sJIA patients: in stable remission (Remission group, n=53) receiving CAN (n=10) or TOC (n=43) treatment, and in acute stage of disease (Acute group, n=25) which started to received CAN (n=7) or TOC (n=18) either before vaccination (Acute Treated Before subgroup, n=17) or after vaccination (Acute Treated After subgroup, n=8). 0.5 ml of the 13-valent PCV was administered once subcutaneously. Efficacy was evaluated by achieving of protection level of anti-pneumococcal antibodies after 4 weeks and by clinical indicators after 6 month follow-up: frequency of acute respiratory infections, frequency of antibiotics treatment courses, frequency of temporary withdrawal of biologics treatment due to severe infections. Frequency of events were counted per patients-years.

Results:

Four weeks after vaccination, protection level of anti-pneumococcal antibodies was achieved by for 36 (67.9%) patients in Remission group, 16 (64%) patients in Acute group (intergroup p=0.932), and in 8 (47.06%) patients in Acute Treated Before subgroup and in 8 (100%) patients in Acute Treated After subgroup (intersubgroup p=0.022). PCV13 have shown high clinical effectiveness in both Remission group and Acute group. Reducing of acute respiratory infections frequency was as follows: from 4.57 to 2.15 episodes per patient-year in Remission group (p<0.001) and from 4.32 to 1.28 per patient-year in Acute group (p<0.001).

Duration of antibiotics treatment reduced from 2.31 to 0.81 weeks per 1 patient-year in Remission group (p<0.001) from 1.97 to 0.74 in Acute group (p<0.001). Among patients who were previously treated with biologics, frequency of therapy withdrawal reduced from 4.34 to 2.42 per patient-year in Remission group (p<0.001) and from 3.53 to 1.18 in Acute Treated Before subgroup (p=0.002). The incidence of reactions to vaccination of PCV13 (local hyperemia, pain, subfebrile temperature) was similar in groups (22 (41.5%) for Remission group and 7 (28%) for Acute group, p= 0.319).

Conclusion:

Vaccination with the 13-valent PCV has demonstrated high clinical efficacy and safety in children with sJIA both in the acute stage of the disease and during remission. Vaccination of patients in acute stage of sJIA before treatment has advantages over vaccination during remission or after prolonged immunosuppressive therapy in terms of achieving an adequate vaccine response.

Disclosure of Interests:

Dariya Vankova: None declared, Ekaterina Alexeeva Grant/research support from: Roche, Pfizer, Centocor, Novartis, Speakers bureau: Roche, Novartis, Pfizer., Tatyana Dvoryakovskaya: None declared, Ksenia Isaeva: None declared, Aleksandra Chomakhidze: None declared, Rina Denisova: None declared, Anna Mamutova: None declared, Anna Fetisova: None declared, Marina Gautier: None declared, Elizaveta Krekhova: None declared, Meyri Shingarova: None declared, Ivan Kriulin: None declared, Anastasiya Kontorovich: None declared, Olga Galkina: None declared, Tatyana Radygina: None declared, Irina Zubkova: None declared, Natalia Tkachenko: None declared, Yanina Orlova: None declared, Mariya Kurdup: None declared, Anna Ismailova: None declared, Alina Alshevskaya: None declared, Andrey Moskalev: None declared, Olga Lomakina: None declared

THU0502 EFFICACY AND SAFETY OF SECUKINUMAB TREATMENT IN JUVENILE IDIOPATHIC ARTHRITIS PATIENTS

Background:

Anti-IL-17A biologic drug secukinumab (SEC) proved to be effective for treatment of psoriatic arthritis. However data about its efficacy in juvenile idiopathic arthritis (JIA) are restricted to off-label experience.

Objectives:

To evaluate the effectiveness and safety of SEC in JIA patients in the National Medical Research Center of Children`s health, Moscow, Russia.

Methods:

25 patients started SEC therapy from 12/2017 to 11/2019 in single-center prospective study. 3 patients withdrew treatment: two patients (8%) due to AE (1 - allergy followed by MAS after first injection and 1 – leukopenia) and one patient (4%) – after 10 months of treatment due to secondary inefficacy. Among others, 14 patients which were successfully treated for 6 months or longer were included into analysis. At the baseline, information was collected on the characteristics of the onset of the disease, previous therapy and its success. Patients were monitored at least 1 time per year. At each visit, clinical and laboratory characteristics of JIA severity were assessed. Response to therapy was assessed using the ACRPedi 30/50/70/90 criteria, the C.Wallace criteria for inactive disease (WID) and clinical remission. AEs were assessed at each visit.

Results:

Among 14 patients received SEC for at least 6 months, 7 (50%) have enthesitis-related arthritis, one (7.1%) – persistent oligoarthritis, 4 (28.6%) – RF-negative polyarthritis, 2 (14.3%) – psoriatic arthritis. 6 patients (42.9%) were HLA-B27 positive. Median age of JIA onset was 8.8 (IQR 5:11), age at SEC initiation – 14 (9.9:16.1), disease duration before SEC start – 3.3 (2.7:5.8). 7 (50%) were biologics-naïve, 2 (14.3%) were previously treated with anti-TNF drug, 5 (35.7%) have 2 or more different biologics in anamnesis.

SEC demonstrated high efficacy after the first injection resulting in JADAS-71 decreasing in all patients by median 4.3 (1.6:7.1) points and 7/7/5/2 patients (50%/50%/35.7%/14.3%) achieved ACR Pedi 30/50/70/90 response.

After 6 months of treatment, WID was achieved by 7 (50%) patients, JADAS-71 decreased from baseline level 15.2 (12.7:20.5) to 0.8 (0:4.2) points, and 14/13/11/9 patients (100%/92.9%/78.6%/64.3%) achieved ACR Pedi 30/50/70/90 response. One patients who had active uveitis at SEC initiation remained with subactive uveitis; one patient with uveitis remission had not flare episodes during follow-up period. One patient (7.1%) had successfully treated evaluation of transaminases after 4-th injection.

Conclusion:

Secukinumab showed high effectiveness and safety in children with JIA and can be further used both as a first-line drug in JIA associated with HLA-B27, and as an alternative drug for the ineffectiveness of the standard treatment regimen with biologics. No serious adverse events were registered during follow-up period.

Disclosure of Interests:

Ivan Kriulin: None declared, Ekaterina Alexeeva Grant/research support from: Roche, Pfizer, Centocor, Novartis, Speakers bureau: Roche, Novartis, Pfizer., Tatyana Dvoryakovskaya: None declared, Ksenia Isaeva: None declared, Aleksandra Chomakhidze: None declared, Evgeniya Chistyakova: None declared, Olga Lomakina: None declared, Rina Denisova: None declared, Anna Mamutova: None declared, Anna Fetisova: None declared, Marina Gautier: None declared, Dariya Vankova: None declared, Elizaveta Krekhova: None declared, Meyri Shingarova: None declared, Alina Alshevskaya: None declared, Andrey Moskalev: None declared

Dynamics of concomitant therapy in children with juvenile idiopathic arthritis treated with etanercept and methotrexate

BACKGROUND

Both the steroid- and NSAID-sparing effects of biologics in juvenile idiopathic arthritis (JIA) treatment are key aspects of the dynamics of patient's condition. The proper selection of biologics enables maximum treatment effectiveness and reduction of the dosage of concomitant therapy. Our aim was to study the dynamics of concomitant therapy during etanercept (ETA) and methotrexate (MTX) treatment in patients with JIA.

METHODS

This analysis included 215 JIA patients (63.3% females) showing sufficient response to main therapy. One hundred patients received MTX as main therapy, 24 received ETA monotherapy, and 91 received ETA þ MTX combination therapy. The dynamics of concomitant therapy were analyzed after 1 month, every 3 months during the first year, and every 6 months during the long-term follow-up (up to 5 years).

RESULTS

At the baseline, 24 (11.2%) patients received concomitant oral glucocorticoids (orGCs) and NSAIDs; the remaining 191 (88.8%) patients were treated with concomitant NSAIDs only. Within 1-year treatment, NSAIDs were discontinued in 162 (75.3%) patients. There were no significant differences in the dynamics of withdrawal of NSAIDs in patients who received and did not receive concomitant MTX. However, the percentage of treatment discontinuation in the MTX group was significantly lower compared to the other two groups (p < 0.001). Oral GCs were discontinued completely in 4 children (16.7%), and the dose of oral GCs was reduced in another 4 patients (16.7%). By the end of the follow-up period, 44 of 115 patients (38.3%) treated with ETA in combination with any concomitant therapy could switch to ETA monotherapy.

CONCLUSION

Therapy with ETA makes it possible to reduce the dosage or completely discontinue most concomitant medications (orGCs, NSAIDs, MTX) in a significant percentage of patients. This reduces the risk of development of NSAID- and GC-induced pathological conditions, while the effectiveness of therapy of the underlying condition remains high.

Comparative Efficacy of Adalimumab and Etanercept in Children with Juvenile Idiopathic Arthritis Under 4 Years of Age Depending on Active Uveitis

Introduction:

In 2011, Etanercept (ETA) was approved for clinical application in patients with Juvenile Idiopathic Arthritis (JIA) older than 2 years of age; Adalimumab (ADA) was approved in 2013. However, the available data for these patients are not sufficient even in large-scale registers. In older children, uveitis is a factor taken into consideration when choosing anti-TNF therapy, so we believe that its onset at an early age may affect the efficacy of treatment with different anti-TNF drugs.

Objectives:

This study aimed to evaluate the comparative efficacy of ADA and ETA in children of young age depending on their uveitis status.

Methods:

Comparative analysis involved patients who had initiated ETA (n=49, no active uveitis) or ADA (n=25; 13 patients with active uveitis and 12 patients without uveitis) therapy at an age of ≤4 years. Treatment efficacy was evaluated according to the dynamics of clinical signs and laboratory values, the ACRPedi and Wallace criteria.

Results:

ETA and ADA proved very efficacious in children under 4 years of age already after the first month of therapy according to the disease activity scores, laboratory values, and morning stiffness duration. After 3 months of therapy, the number of affected joints was substantially reduced in all three groups (p<0.01). The percentage of patients who had achieved ACR50/70/90 by the end of the follow-up period was 42/41/38 (85.7/83.7/77.6%) in ETA group, 10/10/9 (76.9/76.9/69.2%) in ADA group with uveitis, and 9/7/5 (75/58.3/41.7) in ADA group without uveitis, respectively. A comparable proportion of ETA patients and ADA patients with uveitis achieved remission (26 (53.1%) and 7 (53.8%), respectively), while only 3 (25%) of ADA patients without uveitis achieved long-term clinical remission (p-values are insignificant).

Conclusion:

In children younger than 4 years, ADA shows higher efficacy in patients with uveitis as compared to those without uveitis. Children without uveitis show a better response to ETA, although there is a risk of de novo uveitis. Therefore, ADA is the drug of choice for children with uveitis under 4 years of age, while ETA is preferred in children without uveitis.

Comparative analysis of the etanercept efficacy in children with juvenile idiopathic arthritis under the age of 4 years and children of older age groups using the propensity score matching method

Objective: The aim of this study was to analyze the efficacy and safety of etanercept (ETA) in children with juvenile idiopathic arthritis (JIA) under the age of 4 years and to compare the data with those for older age groups. Methods: Three groups comprising 34 patients each (total of 102 patients) were selected using the propensity score matching (PSM) method. The study group (patients under the age of 4 years; the Junior group (JNR)) was compared with patients of the older age groups, adjusted for criteria such as gender, JIA category, JIA severity, and either age at disease onset (the Reference by Age of disease Onset (RAO) group) or disease duration (the Reference by Disease Duration (RDD) group). Results: All three groups showed a good response to ETA therapy. During the follow-up period, only 4 (3.9%) patients failed to reach American College of Rheumatology (ACR) Pediatric criteria improvement at ACR50 level. In the JNR group, 82.4% of patients achieved ACR90 within a median time of 3 months (IQR, 3-6 months), which was a better result compared to the other two groups: 61.8% (RAO group) and 58.8% (RDD group) of patients achieved ACR90 within 6 (Interquartile Range (IQR), 3-9) months (p = .028). Three (9%) patients in the JNR group and none of the RDD and RAO groups discontinued treatment because of clinical remission (p = .045). Conclusion: An analysis of the ETA efficacy in different age groups comparable in terms of the diagnosis and disease severity demonstrated a higher efficacy of earlier ETA therapy in children of the same age at disease onset. In children at the early stage of arthritis (≤ 2.5 years long), ETA was more efficient in those with an earlier disease onset.