Flemish network on rare connective tissue diseases (CTD): patient pathways in systemic sclerosis. First steps taken

Despite the low prevalence of each rare disease, the total burden is high. Patients with rare diseases encounter numerous barriers, including delayed diagnosis and limited access to high-quality treatments. In order to tackle these challenges, the European Commission launched the European Reference Networks (ERNs), cross-border networks of healthcare providers and patients representatives. In parallel, the aims and structure of these ERNs were translated at the federal and regional levels, resulting in the creation of the Flemish Network of Rare Diseases. In line with the mission of the ERNs and to ensure equal access to care, we describe as first patient pathways for systemic sclerosis (SSc), as a pilot model for other rare connective and musculoskeletal diseases. Consensus was reached on following key messages: 1. Patients with SSc should have multidisciplinary clinical and investigational evaluations in a tertiary reference expert centre at baseline, and subsequently every three to 5 years. Intermediately, a yearly clinical evaluation should be provided in the reference centre, whilst SSc technical evaluations are permissionably executed in a centre that follows SSc-specific clinical practice guidelines. In between, monitoring can take place in secondary care units, under the condition that qualitative examinations and care including interactive multidisciplinary consultations can be provided. 2. Patients with early diffuse cutaneous SSc, (progressive) interstitial lung disease and/or pulmonary arterial hypertension should undergo regular evaluations in specialised tertiary care reference institutions. 3. Monitoring of patients with progressive interstitial lung disease and/or pulmonary (arterial) hypertension will be done in agreement with experts of ERN LUNG.

POS0240 WHICH FACTORS DRIVE THE CHOICE BETWEEN A 1ST AND 2ND GENERATION tsDMARD THERAPY IN RA THERAPY?

Background

Tofacitinib and Baricitinib are Janus Kinase Inhibitors (JAKi) considered first generation targeted synthetic DMARD (tsDMARDs) for the treatment of Rheumatoid Arthritis (RA). The second generation of JAKi (Upadacitinib and Filgotinib) seem to target JAK1 more selectively. Choice of JAKi is left to the treating rheumatologist as no head-to head-study or guidelines exist on this choice in RA.

Objectives

To investigate differences in demographics and clinical variables of patients with RA receiving either a 1st or a 2nd generation JAKi in daily practice.

Methods

Patients were included from the electronic platform “Tool for Administrative Reimbursement Drug Information Sharing” (TARDIS). Data from all Belgian RA patients on biologic (b) and tsDMARDs are here collected for drug reimbursement. Patients were selected for this analysis if starting a JAKi in 2021. Differences in demographic and clinical data were compared by χ2-tests and t-tests. Stepwise logistic regression models with tsDMARD choice as dependent variable was constructed with variables with p<0.05 in univariate analyses. Sensitivity analyses for bionaïve and bioexperienced patients were performed.

Results

In total, 1643 patients with RA starting JAKi therapy in 2021 were included. Of these, 433 (26.4%) were 1s generation and 1210 (73.6%) were 2nd generation. Patients starting a 1st generation JAKi were older, had higher Health Assessment Questionnaire (HAQ) scores, had a higher erythrocyte sedimentation rate (ESR), and less patients starting a 1st generation JAKi were bioexperienced (Table 1).

Table 1.

Comparison of baseline demographic and clinical characteristics between 1st and 2nd generation tsDMARDs

All populationBionaïve patientsBioexperienced patients1st generation tsDMARDs2nd generation tsDMARDs1st generation tsDMARDs2nd generation tsDMARDs1st generation tsDMARDs2nd generation tsDMARDsnumber4331210207482226728Age (years)60.8 ± 12.6*57.5 ± 13.1*60.5 ± 12.5*57.9 ± 13.5*60.8 ± 12.8*57.2 ± 12.7*Gender (women)304 (72.6%)833 (74.6%)137 (66.2%)344 (71.4%)175 (77.4%)550 (75.6%)Weight (kg)73.3 ± 15.374.2 ± 15.374.7 ± 16.474.2 ± 14.472.4 ± 13.874.6 ± 16.1Disease duration (years)9.0 ± 8.910.0 ± 9.75.6 ± 6.65.7 ± 7.111.9 ± 9.712.5 ± 10.1HAQ (0-3)1.9 ± 0.6*1.3 ± 0.8*1.8 ± 0.71.4 ± 0.71.9 ± 0.5*1.2 ± 0.8*PGA (0-100)63.5 ± 19.263.0 ± 21.565.0 ± 17.666.0 ± 20.162.0 ± 21.061.0 ± 21.8CRP (mg/l)12.8 ± 11.011.7 ± 10.716.3 ± 19.513.3 ± 15.410.5 ± 16.010.1 ± 13.5ESR (mm/h)25.3 ± 20.1*22.5 ± 18.3*28.1 ± 20.2*23.7 ± 17.5*21.9 ± 19.321.4 ± 19.3TJC288.8 ± 5.58.4 ± 5.78.7 ± 5.29.4 ± 5.48.9 ± 5.9*7.7 ± 5.8*SJC286.1 ± 4.65.9 ± 4.66.1 ± 4.16.6 ± 4.16.1 ± 4.95.5 ± 4.8DAS284.8 ± 1.04.7 ± 1.15.0 ± 0.95.0 ± 4.94.7 ± 1.1*4.5 ± 1.2*Bio-Experienced (yes)226 (51.1%) *728 (60.2%) *----N previous b/tsDMARDs2.0 ± 1.9*2.3 ± 2.2*--2.8 ± 1.0*3.1 ± 1.4*

Number given are mean ± SD or number, proportion. b=biologic; ts= targeted synthetic, HAQ= health assessment questionnaire, PGA= Patient Global assessment; CRP= C-reactive protein; ESR= erythrocyte sedimentation rate; TJC= tender joint count; SJC= Swollen joint Count; DAS28 = disease activity score based on the 28joints; N= number. * Signifies p<0.05.

The final logistic regression model included older age (OR(95%) =1.0(1.0-1.0)) and number of previous b/ts DMARDs ((OR(95%) =0.9(0.8-0.9))) as predictors of choice of 1st generation tsDMARDs (Table 2). In bionaive patients, only ESR (OR(95%) =1.0(1.0-1.0)) was predictive. In bioexperienced patients, older age (OR(95%) =1.0(1.0-1.0)), number of previous b/ts DMARDs ((OR(95%) =0.8(0.7-0.9)) and TJC (OR(95%) =1.0(1.0-1.1)) were predictors for choice of 1st generation tsDMARDs. HAQ was not included as it was missing in 90% of patients.

Conclusion

The high uptake of 2nd generation JAKi, just launched in 2021, is remarkable. Some variables effecting the choice of JAKi were found, yet these effects seemed to be small-sized. These drug choices could also be driven by other factors such as socio-economic status, illness perceptions or other patient reported outcomes, and also by marketing and sales.

Disclosure of Interests

None declared

AB0169 EARLY REMISSION AT 6 MONTHS AS A PREDICTOR OF LONGTERM REMISSION IN NEW ONSET RHEUMATOID ARTHRITIS

Background

Early therapeutic intervention is crucial for patients with early rheumatoid arthritis (ERA). The goal of remission is achievable in a large proportion of ERA patients.

Objectives

To evaluate the rate of patients in remission at 6 months and to correlate the 36 and 60 months remission rate in the Belgian CAP48 cohort and the UCLouvain Brussels cohort. To identify baseline characteristics differences between patients achieving remission or not.

Methods

We included patients with ERA from the CAP48 cohort and from the UCLouvain Brussels cohort who met the ACR/EULAR 2010 RA classification criteria. All patients were naïve to csDMARDs therapy. We collected patient characteristics at baseline and clinical response was analysed at 6, 36 and 60 months.

Results

287 RA patients from our UCLouvain Brussels Cohort and the CAP48 cohort were analysed (211 Females, 76 Males, mean age 46.2 years, 43.4% with baseline erosion, 70.1% with ACPA, 70.3% with Rheumatoid Factor, mean HAQ 1.16, mean DAS28-CRP 4.67, mean SDAI 24.9 and mean CDAI 24.1).

Table 1.

The clinical results are summarized in the Table.

DAS28-CRPMean(±SD)SDAIMean(±SD)CDAIMean(±SD)Remission(DAS28-CRP), %HAQMean(±SD)Baseline n=2874.67 (±1.38)26.5 (±15.5)24.1 (±14.4)/1.16 (±0.70)Months 6 n=2872.97 (±1.34)11.3(±12.3)10.5 (±11.8)44,9%0.60 (±0.62)Months 36 n=2872.24 (±1.04)7.5(±8.6)6.2 (±7.8)71,1%0.52 (±0.59)Months 60 n=1962.41 (±1.00)6.4(±6.5)5.7 (±6.2)66,3%0.56 (±0.63)

We divided the patients according to whether they achieved remission DAS28-CRP < 2.6 (group 1), or not (group 2) at 6 months.

Patient baseline characteristics were similar in the two groups respectively: age (46.7 vs 45.4 yrs); female (68.5 vs 77.3%); smoker (25.6 vs 27.0%); ACPA positive (70.1 vs 75.4%); baseline X-ray erosion (45.0 vs 54.7%).

DAS28-CRP, SDAI and CDAI at 6 months could predict long-term remission at 36 and 60 months, Figure:

Figure 1.

In group 1 global remission (DAS28-CRP<2.6, HAQ<0.5 and no X-ray progression) was observed in 75.6% at 60 months. The majority of these patients (69.4%) are still treated with Methotrexate, the others were treated with combination therapy.

Conclusion

Early and long term remission is an achievable goal in our two cohorts. Early diagnosis is critical in standard of care. At 6 months, all remission index criteria are good predictor for long term remission and could be used in daily care.

Disclosure of Interests

None declared

POS0694 WHAT TREATMENT GIVES THE BEST CLINICAL RESPONSE AFTER CESSATION OF JAKi THERAPY IN PATIENTS WITH RA? DATA OF THE TARDIS-RA REGISTRY, A NATIONWIDE BELGIAN BIOLOGIC REGISTRY

Background

JAKi represent a new important class in Rheumatoid Arthritis (RA) treatment options. It is unknown which specific bDMARD or mode of action should be selected after stopping a JAKi.

Objectives

To study if clinical response differs between advanced therapies that are initiated after stopping a JAKi.

Methods

Patients were included from the electronic platform “Tool for Administrative Reimbursement Drug Information Sharing” (TARDIS). Data from all Belgian RA patients on biologic and targeted therapy are collected here for drug reimbursement. Patients were selected for this analysis if they had stopped JAKi therapy and initiated a subsequent therapy. Patients were grouped by TNFi, T/B cell therapy, IL6i or JAKi therapy. The DAS28 response and proportion of patients in remission at the first follow-up (between 3 and 6 months) were compared between groups. Remission was defined as DAS28<2.6. Analyses were repeated in patients who were prescribed the stopped JAKi as first-line or as subsequent line therapy. Data were compared via χ2, Anova and t-tests.

Results

In total, 1238 patients who had stopped JAKi therapy were included. TNFi, T/B cell therapy, IL6i or JAKi therapy was initiated in 36% (441/1238), 19% (233/1238), 18% (227/1238) and 27% (337/1238) respectively. Most baseline demographic and clinical characteristics differed between groups (Table 1).

Table 1.TNFiB/T cellIL6iJAKip-valueNumber441 (36%)233 (19%)227 (18%)337 (27%)Age (years)55 ± 1457 ± 1355 ± 1459 ± 12<0.001Gender (women)323 (73%)177 (76%)186 (82%)257 (76%)0.100Weight (kg)74 ± 1579 ± 1775 ± 1575 ± 150.111Disease duration (years)9 ± 810 ± 911 ± 911 ± 90.002HAQ (0-3)1.6 ± 0.71.8 ± 0.61.5 ± 0.71.5 ± 0.80.353PGA (0-100)65 ± 2068 ± 2167 ± 2157 ± 24<0.001CRP (mg/l)10 ± 1614 ± 2016 ± 2811 ± 170.003ESR (mm/h)22 ± 2124 ± 1927 ± 2125 ± 220.117TJC288 ± 68 ± 69 ± 67 ± 60.001SJC285 ± 46 ± 56 ± 45 ± 50.006DAS284.7 ± 1.14.8 ± 1.14.9 ± 1.24.4 ± 1.3<0.0012nd line of therapy after initial JAKi therapy211 (48%)56 (24%)52 (23%)112 (33%)<0.001

Numbers given are mean ± SD or number, proportion. TNFi = tumour necrosis factor inhibitor, ts= targeted synthetic, HAQ= health assessment questionnaire, PGA= Patient Global assessment; CRP= C-reactive protein; ESR= erythrocyte sedimentation rate; TJC= tender joint count; SJC= Swollen joint Count; DAS28 = disease activity score based on the 28joints

The clinical response could be studied in 577 patients. Patients on rituximab were excluded as these were retreated on flare, following Belgian reimbursement criteria. TNFi, Tcell therapy, IL6i or JAKi therapy was initiated in 37% (211/577), 13% (76/577), 18% (102/577) and 33% (188/577) of these patients respectively. DAS28 decreased on average with 1.7 ± 1.5, 1.6 ± 1.4, 2.4 ± 1.6* and 1.3 ± 1.6 for patients on TNFi, T cell therapy, IL6i or JAKi therapy respectively (*p<0.001). Remission was reached in 42%, 41%, 56%* and 39% for patients on TNFi, T cell therapy, IL6i or JAKi therapy respectively (*p=0.045).

Before switching, JAKi therapy was the first advanced therapy in 35% (204/577). In this “naïve” subgroup, DAS28 decreased on average with 1.9 ± 1.5, 1.9 ± 1.3, 2.4 ± 1.8 and 1.0 ± 1.7* for patients on TNFi, Tcell therapy, IL6i or JAKi therapy respectively (*p=0.001). Remission was reached in 44%, 48%, 58% and 35% for patients on TNFi, Tcell therapy, IL6i or JAKi therapy respectively (p=0.279).

In the “experienced” subgroup, who started JAKi therapy as subsequent line therapy in 65% (373/577), DAS28 decreased on average with 1.5 ± 1.6, 1.5 ± 1.4, 2.3 ± 1.6* and 1.4 ± 1.6 for patients on TNFi, Tcell therapy, IL6i or JAKi therapy respectively (*p<0.001). Remission was reached in 40%, 38%, 55% and 41% for patients on TNFi, Tcell therapy, IL6i or JAKi therapy respectively (p=0.118).

Conclusion

Our results show clearly that IL6 inhibitors have a better clinical response after JAKi cessation compared to other mode of actions, including other JAKi. However, considerable baseline differences existed, that could influence our results.

Disclosure of Interests

None declared

Tapering of Etanercept is feasible in patients with Rheumatoid Arthritis in sustained remission: a pragmatic randomized controlled trial

Objective: In patients with rheumatoid arthritis (RA) in sustained remission, tapering of biological disease-modifying anti-rheumatic drugs can be considered. Tapering has already been investigated, but its feasibility remains to be determined. Therefore, we explored the feasibility of tapering etanercept in RA in a setting close to practice.Method: Patients with RA in 28-joint Disease Activity Score (DAS28) remission (≥ 6 months) and treated with etanercept 50 mg weekly (≥ 1 year) were included in the pragmatic 1 year open-label multicentre randomized controlled TapERA (Tapering Etanercept in Rheumatoid Arthritis) trial. Patients were assigned to continue etanercept weekly or to taper to every other week (EOW). Patients who lost remission [DAS28-C-reactive protein (CRP) ≥ 2.6] were re-escalated to etanercept weekly. The primary outcome was the proportion of patients maintaining DAS28-CRP remission for 6 months.Results: Sixty-six patients were randomized to etanercept weekly (n = 34) or EOW (n = 32). After 6 months, 26/34 patients (76%) in the weekly and 19/32 (59%) in the EOW group maintained disease control (p = 0.136). In the EOW group, 20/32 patients (63%) remained on their tapered treatment during the trial. Two patients reintroduced weekly etanercept themselves. Ten patients were re-escalated to etanercept weekly by the rheumatologist, after a median (interquartile range) interval of 3.0 (2.0-6.0) months. Among these patients, 7/10 regained remission after re-escalation, four of them at the next study visit.Conclusions: Although non-inferiority could not be demonstrated, tapering of etanercept to EOW appeared feasible in patients in sustained remission.

POS1203 EFFECT OF THE COVID19 PANDEMIC ON RHEUMATOLOGIST PRESCRIPTION BEHAVIOUR OF NEW ADVANCED THERAPY: DATA OF THE TARDIS-RA REGISTRY, A NATIONWIDE BELGIAN BIOLOGIC REGISTRY

Background:

Belgium suffered considerably from the COVID19 pandemic with high hospitalisation rates during 2 periods: a first wave in March and April 2020, and a second starting from October until the end of 2020. Measures of lowering social interaction were taken throughout 2020 and intensified during the first and second wave when needed. This pandemic could have influenced the access to care and advanced therapies for patients with Rheumatoid Arthritis (RA). In the electronic platform “Tool for Administrative Reimbursement Drug Information Sharing” (TARDIS), data from all Belgian RA patients on biologic and targeted therapy are collected during the submission of a request for initiation and prolongation of reimbursement for these drugs.

Objectives:

to investigate the effect of the COVID19 pandemic on the monthly prescription behaviour of a new advanced therapy in 2020 by comparing it to 2019.

Methods:

Patients were selected for this analysis if they started a new TNFi, B/T cell therapy, IL6 inhibitors or tsDMARD therapy in the TARDIS registry in 2019 or in 2020. Rheumatologists request reimbursement via the online TARDIS tool, which is considered here as a new drug prescription. Prescription behaviour was compared between 2019 and 2020, between bionaive and bioexperienced patients, and between the different drug classes

Results:

In 2019, 2949 patients were prescribed any new advanced therapy, including 1153 TNFi, 469 B/T cell therapy, 436 IL6 inhibitors and 891 tsDMARDs. In 2020, 2998 patients were prescribed any new advanced therapy including 1233 TNFi, 382 B/T cell therapy, 496 IL6 inhibitors and 887 tsDMARDs.

On a monthly basis, on average 246 and 250 new advanced therapies were prescribed in 2019 and 2020 respectively. Monthly deviations from this average in 2019 ranged from -19% to +16%. Monthly deviations from this average in 2020 ranged from -50% to +30%. Figure 1A shows the monthly prescription of new advanced therapies in 2019 and 2020.

For bionaive and bioexperienced patients, the same trend can be noted. Monthly deviations in bionaive patients in 2020 ranged from -60% to +38%, compared to -18% to +21% in 2019. Monthly deviations in bioexperienced patients ranged from -40% to +25%, compared to -19% to +17% in 2019.

Comparison per drug class in 2020 show similar trends. IL6 inhibitors show a slightly different timeline than other drugs classes with other periods of less or more prescriptions changes compared to the other drugs classes. See Figure 1B.

Conclusion:

The COVID19 pandemic did affect reimbursement requests for patients starting new advanced therapies in March and April 2020, especially for bionaive patients. The latter half of 2020 was apparently used to catch up with reimbursement requests for patients in need for advanced therapies resulting in similar total numbers of patients treated with advanced therapy in 2019 and 2020. The choice for a particular drug type was not clearly influenced by the pandemic. IL6 inhibitor use did seem to be affected differently by the pandemic, yet caution is warranted as these relatively large differences in proportional changes parallel small differences in actual drug numbers.

In sum, the observed effect of the pandemic on initiating advanced therapy during the first wave corresponds with Belgian governmental measures that restricted non-essential care which was less observed in the latter half of 2020.

Disclosure of Interests:

None declared.

Antibodies against carbamylated proteins: prevalence and associated disease characteristics in Belgian patients with rheumatoid arthritis or other rheumatic diseases

Objectives: Anti-carbamylated protein antibodies (anti-CarP) are reported to be associated with increased disease activity and with more severe joint damage in rheumatoid arthritis (RA) patients. The present study investigated the presence of anti-CarP in various rheumatic diseases, and their specific clinical significance in RA, in Belgian rheumatology patients.Method: We tested sera from 254 RA patients, 56 healthy controls, and 153 patients with different rheumatic conditions: juvenile idiopathic arthritis (JIA), axial spondyloarthritis, systemic sclerosis, and Sjögren's syndrome (SS). An in-house enzyme-linked immunosorbent assay was used to detect immunoglobulin G antibodies against carbamylated foetal calf serum.Results: Anti-CarP were detected in 88 RA patients (34.6%), of whom 82% were also positive for anti-citrullinated protein antibodies (ACPAs) and 81% were also rheumatoid factor (RF) positive. Of note, 11 anti-CarP single-positive patients were detected (4.3%). The previously reported association with joint erosions was not detected. However, in ACPA- and RF-negative RA patients, the presence of anti-CarP was associated with higher disease activity and disability. Fifteen per cent of JIA patients and 30% of SS patients also tested positive for anti-CarP and their antibody levels did not differ significantly from those of anti-CarP-positive RA patients. Anti-CarP levels were, however, significantly higher in ACPA- or RF-positive patients.Conclusion: Anti-CarP antibodies were detected in the sera of a cohort of Belgian RA patients. Moreover, they were also detected in primary SS patients and in JIA patients. In the seronegative subset of RA patients, anti-CarP antibodies showed prognostic value.

The importance of skin manifestations, serology and nailfold (video)capillaroscopy in morphea and systemic sclerosis: current understanding and new insights

Since the field around morphea and systemic sclerosis (SSc) is evolving rapidly, this review approaches conventional as well as more recent clinical developments from a dermatological point of view. Skin manifestations are critical in sub-classifying these diseases ensuring a correct prognosis for these patients. They can be discretely present, and therefore, diagnosis can be challenging sometimes, implicating a thorough dermatological examination is mandatory. Furthermore, a growing amount of dermatologists perform nailfold videocapillaroscopy (NVC), a more recent reliable non-invasive imaging technique used for in vivo assessment of the microcirculation at the nailfold. After all, specific NVC-changes are present in a majority of patients with SSc. This way, dermatologists not only take part in the diagnosis process through clinical investigation but also through the use of a modern state of the art imaging technique that is becoming the golden standard in SSc multidisciplinary workup. In this review, current understandings for NVC in morphea and SSc are revised. So far, the role of NVC in the diagnosis/prognosis/classification of morphea patients has not been thoroughly investigated to make proper conclusions. As for SSc, it is well known that NVC contributes to the diagnosis and can make a fundamental difference especially when obvious clinical SSc signs are absent. This review emphasizes the (somewhat underestimated) role of dermatologists in the process of diagnosis and follow-up, and thus, the difference we can make for our patients and fellow colleagues in the multidisciplinary workup of SSc and morphea.

[The new classification criteria for spondylarthritis: implications in clinical practice]

" Spondyloarthritis" consists of a group of several diseases sharing clinical, radiological and genetic similarities. Ankylosing spondylitis is the main representative of this group and is characterized by a predominant axial involvement. The presence of radiographic sacroiliitis is essential for the diagnosis of ankylosing spondylitis according to the modified New York criteria. Because the occurence of radiographic sacroiliitis takes 8 to 11 years, the diagnosis of spondyloarthritis is often delayed. Magnetic resonance imaging can depict sacroiliac joint inflammation before the appearance of radiographic damage thereby defining the concept of " non-radiographic axial spondylo-arthritis". This entity was defined by the axial spondyloarthritis classification criteria published by the Assessment of SpondyloArthritis international Society (ASAS). Some factors, such as elevated levels of C-reactive protein at baseline, have been identified as predictors of radiographic sacroiliitis progression, leading to a definite diagnosis of ankylosing spondylitis. These two entities show similar clinical expression (clinical features and activity levels), suggesting continuity between the two diseases. Non-radiographic forms most often affect women and patients with recent symptoms, and are therefore considered as a pre-radiographic status. If the use of magnetic resonance imaging is necessary for the identification of non-radiographic axial spondyloarthritis according to the ASAS criteria, the presumptive diagnosis is mainly based on complaints of inflammatory back pain. The presence of other typical clinical features, such as HLA B27 positivity and/or radiographic sacroiliitis increases the diagnostic probability and indicates the need for referral to a specialist.

[Early diagnosis of rheumatoid arthritis]

Rheumatoid arthritis is the most common chronic inflammatory rheumatic disorder, and is characterized by inflammation of the joint, which can lead to irreversible bone damage, joint deformity and disability, if not diagnosed timely or treated adequately. New classification criteria were developed in 2010 in order to identify patients at risk of developing persistent or erosive arthritis, and requiring early therapy. In order to detect early arthritis or bone erosions before their appearance on X-rays, ultrasound and magnetic resonance imaging are now routinely used by clinicians, and also seem to deliver prognostic information about the disease. Synovial biopsies are potentially interesting in case of early arthritis to identify markers of diagnosis, prognosis or therapeutic response. Genetic or environmental risk factors were described to play a role in the development or maintenance of the disease; they could also help to screen early RA. A rapid diagnosis is eventually based on the right information and a tight collaboration between the primary care physician and the rheumatology care specialist.

sIL7R concentrations in the serum reflect disease activity in the lupus kidney

OBJECTIVES

Evaluation of disease activity in systemic lupus erythematosus (SLE) nephritis is a challenge, and repeated renal biopsies are usually needed in order to confirm a suspicion of flare. In a previous cross-sectional study, we reported that serum soluble form of the interleukin-7 receptor (sIL7R) levels is strongly associated with nephritis in SLE patients. In the present study, we wanted to confirm the association between changes in serum sIL7R concentrations and renal disease activity in a large longitudinal cohort of SLE nephritis patients.

METHODS

Sera were harvested longitudinally in 105 SLE nephritis patients. Serum sIL7R cut-off value for the detection of SLE nephritis activity was determined as the mean sIL7R concentration in non-nephritis SLE patients + 2 SDs using data collected in our previous study. Patients with glomerular filtration rate (GFR) <60 mL/min/1.73 m(2) (n=17) were excluded from the study due to persistently elevated serum sIL7R values.

RESULTS

Serum sIL7R concentrations above the renal cut-off value were observed in 25 (out of 88) patients with a normal GFR. These patients had significantly higher serum double-stranded DNA (dsDNA) Ab and urinary protein to creatinine (UPC) ratio. Strikingly, 12 of them developed a renal British Isles Lupus Assessment Group index (BILAG) A within the next 3 months, while this was only the case in four out of the 63 other patients (p<0.0001). The test had 75.0% sensitivity and 81.9% specificity for the detection of a renal BILAG A. Combination of serum sIL7R with any of the classical tests (anti-dsDNA Ab titres, UPC ratio, serum C3) resulted in an increased specificity for the detection of a renal flare. Administration of immunosuppressive therapy resulted in a significant decrease in serum sIL7R concentrations.

CONCLUSIONS

Serum sIL7R is a sensitive and specific marker of renal disease activity in SLE. Elevated serum sIL7R values in SLE patients are associated with or predict the occurrence of an SLE nephritis flare.

Anti-cyclic citrullinated peptide antibodies: a comparison of different assays for the diagnosis of rheumatoid arthritis

OBJECTIVES

Anti-cyclic citrullinated peptide (anti-CCP) antibodies are highly specific markers of rheumatoid arthritis (RA). Considering the heterogeneity of the target antigens involved, and the test platforms and conjugates proposed in commercial anti-CCP assays, we assessed the diagnostic performances of four fully automated anti-CCP assays in a cohort of patients with RA compared to patients with other autoimmune and inflammatory disorders. We also evaluated the agreement between the qualitative results of these immunoassays.

METHOD

We evaluated three anti-CCP2 assays [Eurodiagnostica enzyme-linked immunosorbent assay (ELISA), Elecsys electrochemiluminescence immunoassay (ECLIA) on the Modular E170 Analyzer, and Zenit chemiluminescence immunoassay (CLIA) on the Zenit RA Analyzer] and one anti-CCP3 assay (Inova ELISA). ELISAs were performed on an automated workstation. Samples from 112 patients with RA and a disease control group of 136 patients (53 with autoimmune diseases, 65 non-autoimmune disorders, and 18 infectious diseases) were studied (included 161 samples submitted consecutively to the laboratory).

RESULTS

At a fixed specificity of 92%, the anti-CCP3 assay presented the highest sensitivity (75%) compared to the anti-CCP2 assays evaluated (63-72%). The Zenit anti-CCP2 assay gave the most false-positive results (especially in patients with viral infections and connective tissue diseases). The agreement between assays ranged from 86.3% to 95.2% and Kappa coefficients ranged from 0.724 to 0.899.

CONCLUSIONS

Recently released automated workstations provide a valuable alternative to ELISA to diagnose RA. However, differences in diagnostic performances are highlighted in our experience, especially for the Zenit assay. In our cohort, the anti-CCP3 assay gave slightly better performances than the anti-CCP2 assays (with the exception of the Zenit assay).

Rheumatoid arthritis synovial fibroblasts produce a soluble form of the interleukin-7 receptor in response to pro-inflammatory cytokines

We previously demonstrated that baseline synovial overexpression of the interleukin-7 receptor α-chain (IL-7R) is associated with poor response to tumour necrosis factor (TNF) blockade in rheumatoid arthritis (RA). We found that IL-7R gene expression is induced in fibroblast-like synovial cells (FLS) by the addition of TNF-α, IL-1β and combinations of TNF-α+ IL-1β or TNF-α+ IL-17, thereby suggesting that these cytokines play a role in the resistance to TNF blockade in RA. Because FLS and CD4 T cells also produce a soluble form of IL-7R (sIL-7R), resulting from an alternative splicing of the full-length transcript, we wondered whether expression of sIL-7R is similarly regulated by pro-inflammatory cytokines. We also investigated whether sIL-7R is detectable in the serum of RA patients and associated with response to TNF blockade. RA FLS were cultured in the presence of pro-inflammatory cytokines and sIL-7R concentrations were measured in culture supernatants. Similarly, sIL-7R titres were measured in sera obtained from healthy individuals, early untreated RA patients with active disease and disease-modifying anti-rheumatic drug (DMARD)-resistant RA patients prior to initiation of TNF-blockade. Baseline serum sIL-7R titres were correlated with validated clinical measurements of disease activity. We found that exposure of RA FLS to pro-inflammatory cytokines (TNF-α, IL-1β and combinations of TNF-α and IL-1β or TNF-α and IL-17) induces sIL-7R secretion. Activated CD4 T cells also produce sIL-7R. sIL-7R serum levels are higher in RA patients as compared to controls. In DMARD-resistant patients, high sIL-7R serum concentrations are strongly associated with poor response to TNF-blockade. In conclusion, sIL-7R is induced by pro-inflammatory cytokines in RA FLS. sIL-7R could qualify as a new biomarker of response to therapy in RA.

Spontaneous coronary artery dissection: favorable outcome illustrated by angiographic data

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction. It typically occurs in young women receiving oral contraceptive therapy or during the peripartum period. In the case presented here, spontaneous complete healing at angiography and the favorable outcome may support the role of conservative treatment in such patients.