Validation of the Italian version of the ANCA-associated vasculitis patient-reported outcome (AAV-PRO) questionnaire

Objectives

The primary objective of this study was the translation and validation of the ANCA-associated vasculitis patient-reported outcome (AAV-PRO) questionnaire into Italian, denoted as AAV-PRO_ita. The secondary objective was to evaluate the impact of ANCA-associated vasculitis (AAV) on quality of life (QoL) and work impairment in a large cohort of Italian patients.

Methods

The study design took a prospective cohort study approach. First, the AAV-PRO was translated into Italian following the step guidelines for translations. The new AAV-PRO_ita questionnaire covered three disease domains: organ-specific and systemic symptoms and signs; physical function; and social and emotional impact. Second, Italian-speaking AAV patients were recruited from 17 Italian centres belonging to the Italian Vasculitis Study Group. Participants completed the AAV-PRO_ita questionnaire at three time points. Participants were also requested to complete the work productivity and activity impairment: general health questionnaire.

Results

A total of 276 AAV patients (56.5% women) completed the questionnaires. The AAV-PRO_ita questionnaire demonstrated a good internal consistency and test-retest reliability. Female AAV patients scored higher (i.e. worse) in all thee domains, especially in the social and emotional impact domain (P < 0.001). Patients on glucocorticoid therapy (n = 199) had higher scores in all domains, especially in the physical function domain (P < 0.001), compared with patients not on glucocorticoid therapy (n = 77). Furthermore, patients who had at least one relapse of disease (n = 114) had higher scores compared with those who had never had one (n = 161) in any domain (P < 0.05). Finally, nearly 30% of the patients reported work impairment.

Conclusion

The AAV-PRO_ita questionnaire is a new 29-item, disease-specific patient-reported outcome measuring tool that can be used in AAV research in the Italian language. Sex, glucocorticoids and relapsing disease showed the greatest impact on QoL.

Age at diagnosis influences the clinical phenotype, treatment strategies and outcomes in patients with giant cell arteritis: results from the observational GCAGE study on a large cohort of 1004 patients

BACKGROUND

Immune and vascular ageing are proposed risk factors for giant cell arteritis (GCA). Data on the impact of age at diagnosis of GCA on the clinical presentation and course of the disease are scarce.

METHODS

Patients with GCA followed at referral centres within the Italian Society of Rheumatology Vasculitis Study Group were enrolled up to November 2021. Patients were grouped according to age at diagnosis: ≤64, 65-79 and ≥80 years old.

RESULTS

The study included 1004 patients, mean age 72.1±8.4, female 70.82%. Median follow-up duration was 49 (IQR 23-91) months. Patients in the oldest group (≥80 years) had significantly more cranial symptoms, ischaemic complications and risk for blindness compared with the groups 65-79 and ≤64 years (blindness: 36.98% vs 18.21% vs 6.19%; p<0.0001). Large-vessel-GCA was more frequent in the youngest group (65% of patients). Relapses occurred in 47% of patients. Age did not influence the time to first relapse, nor the number of relapses. Older age was negatively associated with the number of adjunctive immunosuppressants. Patients >65 years old had 2-3 fold increased risk for aortic aneurysm/dissection up to 60 months follow-up. Serious infections, but not other treatment-related complications (hypertension, diabetes, osteoporotic fractures), were significantly associated with older age. Mortality occurred in 5.8% of the population with age >65, cranial and systemic symptoms as independent risk factors.

CONCLUSIONS

The highest risk of ischaemic complications, aneurysm development, serious infections and the possible undertreatment make of GCA a very challenging disease in the oldest patients.

2022 American College of Rheumatology/EULAR Classification Criteria for Takayasu Arteritis

OBJECTIVE

To develop and validate new classification criteria for Takayasu arteritis (TAK).

METHODS

Patients with vasculitis or comparator diseases were recruited into an international cohort. The study proceeded in 6 phases: 1) identification of candidate criteria items, 2) collection of candidate items present at diagnosis, 3) expert panel review of cases, 4) data-driven reduction of candidate items, 5) derivation of a points-based classification score in a development data set, and 6) validation in an independent data set.

RESULTS

The development data set consisted of 316 cases of TAK and 323 comparators. The validation data set consisted of an additional 146 cases of TAK and 127 comparators. Age ≤60 years at diagnosis and imaging evidence of large-vessel vasculitis were absolute requirements to classify a patient as having TAK. The final criteria items and weights were as follows: female sex (+1), angina (+2), limb claudication (+2), arterial bruit (+2), reduced upper extremity pulse (+2), reduced pulse or tenderness of a carotid artery (+2), blood pressure difference between arms of ≥20 mm Hg (+1), number of affected arterial territories (+1 to +3), paired artery involvement (+1), and abdominal aorta plus renal or mesenteric involvement (+3). A patient could be classified as having TAK with a cumulative score of ≥5 points. When these criteria were tested in the validation data set, the model area under the curve was 0.97 (95% confidence interval [95% CI] 0.94-0.99) with a sensitivity of 93.8% (95% CI 88.6-97.1%) and specificity of 99.2% (95% CI 96.7-100.0%).

CONCLUSION

The 2022 American College of Rheumatology/EULAR classification criteria for TAK are now validated for use in research.

POS0838 INCIDENCE OF CANCER IS SIGNIFICANTLY INCREASED IN EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS PATIENTS: RESULTS FROM A MULTICENTRE STUDY

Background

No large assessment of the general cancer occurrence in eosinophilic granulomatosis with polyangiitis (EGPA) has been reported.

Objectives

The aim is to investigate the incidence of malignancies in EGPA patients and to examine the effect of immunosuppressive therapy on malignancy risk in these patients.

Methods

The occurrence of cancers was assessed in a cohort of 303 incident EGPA patients (54.8% female, 44% MPO-ANCA positive, 53 [41-61] years old at diagnosis), diagnosed between 1987 and 2019. Demographic, clinical and laboratory data, and the use of immunosuppressive drugs were assessed. Through linkage with Regional Italian Cancer Registries, information about any malignancy occurring before and after EGPA diagnosis was collected. For each patient, the person-years (PY) of follow-up was calculated till the first event: cancer occurrence, last follow-up or death. The PY was stratified by sex, age (in 5-year groups) and calendar-decades (2000-2009 and 2010-2019). Standardized incidence ratios (SIR) between observed and expected numbers (retrieved from the AIRTUM-AIOM database) of cancers were calculated with exact Poisson regression analysis and used as a measure of risk difference.

Results

Thirty patients developed a total of 42 malignancies during a median follow-up of 4.4 [2.1-8.5] years. After excluding patients with a diagnosis of cancer before EGPA onset, 20 first malignancies were observed in 1276 PY observation period. The SIR (95% Poisson CI) malignancy risk was 1.99 (1.22-3.08; p=0.007) for all cancers at all sites, and 1.86 (0.98-2.75; p= 0.025) for all cancers excluding non-melanoma skin cancers. Incidence rates were significantly higher in ANCA positive patients (SIR 2.43 [1.30-4.16]; p=0.007) when compared to ANCA negative, and in those treated with cyclophosphamide (SIR 2.42 [1.11-4.60]; p=0.030) when compared to other immunosuppressive agents. Median latency from EGPA onset and first cancer diagnosis was 5 (2-11) years, with 63.3% of patients developing cancer within 1 and 5 years. Malignancy-free survival at 2, 5, and 10 years of follow-up was 96%, 91%, and 70%, respectively. Of these malignancies, 30% were skin cancers, 25% prostate cancers and 20% breast cancers. Comparing patients who developed malignancies with those who did not, any significant difference was noted regarding sex, ANCA status, age at diagnosis, clinical manifestations, BVAS, FFS, environmental exposure, smoking habit and cancer familiarity. Type of treatment and cumulative doses of cyclophosphamide were not associated with higher incidence of cancers.

Conclusion

EGPA patients have a two-fold risk of overall malignancy than the general population. This cancer excess might be driven by a combination of already known treatment-associated factors and other unknown disease-associated factors, which should be further investigated

References

NA

Figure 1.

Disclosure of Interests

None declared

POS0813 GLUCOCORTICOIDS, CONVENTIONAL DMARDs AND TOCILIZUMAB DIFFERENTLY AFFECT 18F-FDG PET METABOLIC ACTIVITY IN GIANT CELL ARTERITIS PATIENTS

Background

Imaging role in large vessel vasculitis (LVV) patients is tremendously increased in recent years. However, the role of 18F-FDG PET in evaluating treatment response is still an unmet need.

Objectives

The aim of the present study is to evaluate the effect of different treatment regimens, namely glucocorticoids (GC), conventional disease modifying anti-rheumatic drugs (cDMARDs) and tocilizumab (TCZ), on clinical and metabolic activity of giant cell arteritis (GCA) with extra-cranial involvement.

Methods

Consecutive LVV inpatients and outpatients, classified as GCA, were prospectively enrolled. We included all patients who underwent to at least 2 consecutive 18F-FDG PET-CT or MR scan between October 2010 and October 2021. Demographic and clinical data as well as disease activity were assessed before every PET scan. Remission was defined absence of signs and symptoms attributable to GCA and normalization of ESR (<30 mm/Hr) and CRP (<1 mg/dL) [1].

GCA patients were compared according to current treatment regimen: GC monotherapy versus cDMARDs (methotrexate, azathiopirine) and versus TCZ (administered both subcutaneous and intravenous). For each PET scan the vessel’s metabolic activity was evaluated using the Meller’s grading [2] and the PETVAS score [3].

Results

The study included 47 patients (age 66 [60-70], 72.3% female) exposed to a total of 77 treatment regimens (n=37 GC monotherapy, n=26 cDMARDs, n=14 TCZ). A total of 181 PET scan were conducted (min 2 – max 6). Overall clinical remission rate during the follow-up was 75.7% in GC-treated patients, 69.2% in cDMARDs-treated and 85.7% in TCZ-treated (p=0.513).

Persistence was comparable among the different treatment regimens (GC 19±10 months vs cDMARDs 22±16 months vs TCZ 23±11 months, p=0.445).

All the treatment led to significant reduction of acute phase reactants (GC-treated: ESR 50vs20 mmh, p<0.001, ΔESR= -43.3%, CRP 13.6vs5.3 mg/L, p=0.001, ΔCRP= -87.7%; cDMARDs-treated: ESR 36vs27 mmh, p=0.134, ΔESR= -152%, CRP 13.6vs5.3 mg/L, p=0.038, ΔCRP= -66.3% and TCZ-treated: ESR 27vs3 mmh, p=0.017, ΔESR= -86.7%, CRP 11.4vs2.7 mg/L, p=0.023, ΔCRP= -80.2%).

Significant improvement in PETVAS was observed only in TCZ-treated patients (12vs4, p=0.002, ΔPETVAS -66.7%), while the other treatment approaches resulted not significant (GC treated 12vs5, p=0.052, ΔPETVAS= -50%; cDMARDs 11vs4, p=0.124, ΔPETVAS -52.4%).

Daily prednisone dose at last examination was 4.5 [0-5] mg/d in the cDMARDs group vs 1.25 [0-5] mg/d in the TCZ group (p=0.057). Interestingly, at last PET examination low-grade inflammation (Meller 1-2) was observed in 56.8% of GC-treated patients, 57.7% of cDMARDs-treated patients and 64.3% of TCZ-treated patients (p=0.884).

Conclusion

18F-FDG PET may be useful in assessing disease activity and monitoring response to therapy. Tocilizumab treatment significantly reduce vessel’s metabolic activity over time, when compared to conventional treatment. A persistent low-grade uptake during remission is common features in LVV patients, irrespectively of treatment regimens.

References

[1]Stone JH, Tuckwell K, Dimonaco S, Klearman M, Aringer M, Blockmans D, Brouwer E, Cid MC, Dasgupta B, Rech J, Salvarani C, Schett G, Schulze-Koops H, Spiera R, Unizony SH, Collinson N. Trial of Tocilizumab in Giant-Cell Arteritis. N Engl J Med. 2017 Jul 27;377(4):317-328. doi: 10.1056/NEJMoa1613849. PMID: 28745999.

[2]Meller J, Grabbe E, Becker W, Vosshenrich R. Value of F-18 FDG hybrid camera PET and MRI in early takayasu aortitis. Eur Radiol. 2003 Feb;13(2):400-5. doi: 10.1007/s00330-002-1518-8. Epub 2002 Jun 29. PMID: 12599007.

[3]Grayson PC, Alehashemi S, Bagheri AA, Civelek AC, Cupps TR, Kaplan MJ, Malayeri AA, Merkel PA, Novakovich E, Bluemke DA, Ahlman MA. 18 F-Fluorodeoxyglucose-Positron Emission Tomography As an Imaging Biomarker in a Prospective, Longitudinal Cohort of Patients With Large Vessel Vasculitis. Arthritis Rheumatol. 2018 Mar;70(3):439-449. doi: 10.1002/art.40379. Epub 2018 Feb 6. PMID: 29145713; PMCID: PMC5882488

Figure 1.

Disclosure of Interests

None declared

AB0627 Evaluation of internal consistency, feasibility, and reliability of the Italian version of ANCA-associated vasculitis patient-reported outcome (AAV-PRO_ita) questionnaire: preliminary results from a multicenter study on a large cohort of Italian patients

Background

The ANCA-associated vasculitis patient-reported outcome (AAV-PRO) questionnaire is a 29-item disease-specific PRO measure for AAV[1]. The Italian version of the AAV-PRO questionnaire (AAV-PRO_ita) was translated in collaboration with Oxford and Bristol University (UK) and was preliminarily tested on a single-center Italian cohort[2].

Objectives

The main objective of this multicentric study was to assess the internal consistency, feasibility, and reliability of the AAV-PRO_ita in a large cohort of Italian AAV patients. The secondary objective was to investigate the clinical characteristics of AAV patients associated with AAV-PRO_ita domains.

Methods

The AAV-PRO_ita is describes the following disease domains: (1) organ-specific and systemic symptoms and signs (SSS); (2) physical function (PF); (3) social and emotional impact (SEI). In this study, Italian-speaking AAV patients were recruited from Italian Centres (N=13) with a large experience in the diagnosis and treatment of systemic vasculitis, belonging to the Vasculitis Study Group of the Italian Society of Rheumatology. Inclusion criteria were: a confirmed diagnosis of GPA, MPA, or EGPA; ANCA positivity in at least once occasion or biopsy-proven AAV; and age ≥18 years old. Participants completed the AAV-PRO_ita at three different time-points: baseline, after 5-7 days, and at month 3.

Results

229 AAV-patients (56.3% women) with a median age of 61 (IQR 51-72) were recruited and completed the questionnaires. The subtype of AAV was mainly GPA (131, 57.2%), followed by EGPA (58, 25.3%), and MPA (40, 17.5%). Median BVASv3 at baseline was 0 (IQR 0-3), whereas the median BVASv3 at the onset of disease was 14 (IQR 9-20). Participants had a median duration of disease of 67 (IQR 24-126) months. Patients who experienced at least one relapse, one hospitalization, and one severe infection were 40.2%, 53.3%, and 24%, respectively. 83% of the patients were on immunosuppressant therapy and 71.6% were still receiving glucocorticoids (GC).

AAV-PRO_ita questionnaire had good internal consistency (Cronbach’s Alpha range 0.81-0.93) and good test-retest reliability (ICCs range 0.93-0.96). Item response rates were high overall (maximum 0.87% missing data), supporting the feasibility of the questionnaire.

Concerning the domains of the questionnaire, female AAV patients scored higher (i.e. worse) in all three domains, especially in the SEI domain (p-value<0.001). Older participants (≥65 years) scored higher in the PF domain (p-value<0.05) in all three times of self-completions of the questionnaire. The ongoing treatment also influenced the results. In fact, patients on GC showed higher scores in the PF domain (p-value=0.003) and SEI domain (p-value=0.021). The VDI value seemed to be related to AAV-PRO_ita scores more than disease duration or disease activity, especially in the SSS domain (ρ>0.3, p-value<0.001). Conversely, subtype of AAV did not influence the item scores.

Conclusion

The AAV-PRO_ita questionnaire is a new 29-item, disease-specific PRO measure for use in AAV in the Italian language. It is a self-administered Italian questionnaire with good internal consistency, feasibility, and reliability. AAV-PRO_ita proved to be a useful tool to explore the AAV patient’s perception of quality of life, and it could become an important way of measuring the unmet needs of AAV patients.

References

[1]Robson, J.C. et al. Validation of the ANCA-Associated Vasculitis Patient-Reported Outcomes (AAV-PRO) Questionnaire. Ann. Rheum. Dis.2018, 77, 1157–1164, doi:10.1136/annrheumdis-2017-212713.

[2]Treppo, E.; Palese, A.; Vita, S.D.; Quartuccio, L. AB0392 PRELIMINARY VALIDATION OF THE ITALIAN VERSION OF ANCA-ASSOCIATED VASCULITIS PATIENT-REPORTED OUTCOME (AAV-PRO_ita) QUESTIONNAIRE: FATIGUE AND CHRONIC PAIN AS UNMET NEEDS BY CURRENT TREATMENTS. Ann. Rheum. Dis.2021, 80, 1224–1224, doi:10.1136/annrheumdis-2021-eular.2123.

Acknowledgements

We thank the Italian Study Group on Systemic Vasculitis.

Disclosure of Interests

None declared

POS0837 EFFICACY OF ULTRA-LOW DOSE RITUXIMAB FOR REMISSION MAINTENANCE THERAPY IN ANCA-ASSOCIATED VASCULITIS

Background

Rituximab (RTX) achieved high remission-induction and sustained maintenance rates for patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) [1], [2]. However, RTX is an expensive medication, which may potentially lead to serious side effects. Defining the best dose regimen for maintenance in AAV is still an unmet need.

Objectives

The aim of the present study is to compare the effects of ultra-low dose RTX (500 mg or 1000 mg once per year) to standard low dose RTX (500 or 1000 mg twice per year) as remission-maintenance therapy in AAV patients.

Methods

We included consecutive AAV patients (classified as GPA and MPA [3]) referring to four different Rheumatology centers in Italy. We assessed all AAV patients who successfully achieved disease remission (BVASv3=0) with conventional RTX or cyclophosphamide regimens and have been subsequently treated with RTX for maintenance of remission. All included patients received at least three maintenance infusions with either 1000 mg or 500 mg, twice per year (standard low dose) or once per year (ultra-low dose). After a period of 18 months, we assessed the remission rate, damage (VDI), glucocorticoids intake, ANCA status, B-cells depletion and serum IgG levels.

Results

From January 2011 to December 2021, 83 AAV patients (mean age 51±16, 49.4% female, 95.2% ANCA positive, 65.8% anti PR3, 34.2% anti MPO), 61 classified as GPA and 22 MPA, achieved complete disease remission with conventional RTX induction regimen. After 7 [6-9] months, 29.9% patients started maintenance treatment with ultra-low dose RTX (once per year), while 70.1% patients with standard low dose (twice per year), for 18 months. No significant differences at baseline were noted between patients receiving ultra-low dose when compared to those treated with conventional low-dose.

At the end of observation period, a disease flare was observed in 22.7% of the low-dose group, and 21.2% in those treated with the standard dose (p=0.881). Relapse-free survival was comparable between the two group (log-rank p=0.818, Figure 1).

Figure 1.

When comparing AAV patients treated with ultra-low dose regimen to those treated with low-dose, no differences were noted in negative ANCA rate (72.2% vs 67.1%, p=0.262), ANCA titer (0 [0-7.8] vs 0 [0-50] UI/mL, p=0.232), B-cells depletion rate (70.6% vs 75%, p=0.725), mean serum IgG (811 [146-922] vs 680 [429-861] mg/dL, p=0.367), mean daily glucocorticoid dosage (2.5 [0-5] vs 3.75 [0-5] mg/d, p=0.647), VDI (4 [1-5] vs 2 [1-4], p=0.098), hypogammaglobulinaemia rate (31.8% vs 36.5%, p=0.697) and deaths (4.5% vs 5.8%, p=0.831).

Although not significant, patients treated with ultra-low dose had lower severe infection rate (10.5% vs 26.8%, p=0.154). Notably, in the all cohort 5 deaths were related to COVID19 pneumonia.

Conclusion

Reduced exposure to RTX was not associated with an impaired efficacy of maintenance therapy in patients with AAV. Remission maintenance with ultra-low dose RTX is a safe and more cost-effective option.

References

[1]B. Terrier et al., “ANCA-associated vasculitides: Recommendations of the French Vasculitis Study Group on the use of immunosuppressants and biotherapies for remission induction and maintenance,” Press. Medicale, vol. 49, no. 3, 2020, doi: 10.1016/j.lpm.2020.104031.

[2]S. V. Moiseev, N. M. Bulanov, A. S. Zykova, and P. I. Novikov, “Rituximab in ANCA-associated vasculitis: Fewer infusions or ultra low-dose maintenance therapy,” Ann. Rheum. Dis., vol. 78, no. 9, pp. 1–2, 2019, doi: 10.1136/annrheumdis-2018-213873.

[3]J. C. Jennette et al., “2012 Revised International Chapel Hill consensus conference nomenclature of vasculitides,” Arthritis Rheum., vol. 65, no. 1, pp. 1–11, 2013, doi: 10.1002/art.37715.

Disclosure of Interests

None declared

Biologic therapy in relapsing polychondritis: navigating between options

INTRODUCTION

Relapsing polychondritis (RP) is a rare systemic inflammatory disease of unknown etiology, primarily affecting cartilaginous tissue and proteoglycan-rich structures. Clinical manifestations vary from mild symptoms to occasional organ or life-threatening complications. Treatment can be challenging and is mostly based on experience or case reports/series.

AREAS COVERED

There is growing literature investigating the role of biologics in the management of RP. TNFα antagonists, abatacept, tocilizumab, rituximab, anakinra and tofacitinib have been prescribed in several RP patients, mainly as second-line treatment, after conventional immunosuppressive agents' failure.

EXPERT OPINION

: Glucocorticoids represent the gold standard treatment of RP. Conventional immunosuppressants should be administered in refractory patients or when a glucocorticoid-sparing effect is needed. Biologic therapy should be used after failure of conventional treatments or in severe manifestations. TNFα inhibitors are the most prescribed biologic agent, with partial or complete response in several cases; but loss of efficacy may occur over time. Infliximab and adalimumab should be preferred among TNFα antagonists. Abatacept and tocilizumab proved to be effective as second-line biologic agents, but frequent infections are reported with the former. Data on anakinra and rituximab are controversial, therefore they are not recommended as first-line biologic drugs. The use of JAK inhibitors is still anecdotal.

Health-Related Quality of Life in Patients With ANCA-Associated Vasculitis and Sinonasal Involvement: A Single-Center Cross-Sectional Study

BACKGROUND/OBJECTIVE

The aim of this study was to assess the impact of sinonasal morbidity on quality of life (QoL) in antineutrophil cytoplasmic antibody-associated vasculitis (AAV).

METHODS

This cross-sectional case-control study enrolled 71 patients-44 AAV cases with (ear, nose, and throat [ENT]-AAV) or without ENT involvement (non-ENT-AAV) undergoing multidisciplinary evaluations and 27 chronic rhinosinusitis (CRS) cases. Three validated QoL questionnaires (Sino-Nasal Outcomes Test-22 [SNOT-22], Nasal Obstruction Symptom Evaluation [NOSE], and Short-Form 36) were administered, and the 3 groups were compared.

RESULTS

The ENT-AAV patients were significantly younger (p = 0.01), with less antineutrophil cytoplasmic antibody positivity frequency (p = 0.035) and lower renal involvement (p = 0.003) than the non-ENT-AAV patients.The SNOT-22 questionnaire demonstrated significantly greater sinonasal morbidity in ENT-AAV patients compared with CRS patients (p < 0.001). The NOSE score of ENT-AAV patients was comparable to those of CRS patients, but higher than that of non-ENT-AAV patients (p < 0.001). The SNOT-22 and NOSE scores positively correlated with disease activity (p = 0.037; p = 0.004, respectively). Short-Form 36 domain-by-domain analysis revealed a significantly poorer QoL in ENT-AAV patients, especially with physical functioning being progressively impaired in CRS, non-ENT-AAV, and ENT-AAV patients (p < 0.001). No significant differences in QoL came to light when AAV patients were stratified according to current systemic o local treatments.

CONCLUSIONS

The QoL in AAV patients is significantly reduced, especially in the presence of ENT involvement. The AAV-related nasal morbidity is consistent and comparable to that reported by CRS patients. It significantly affects patients' QoL and in particular social functioning, leading to limitation in daily/work activities. Organ-focused questionnaires and multidisciplinary management are warranted to pursue a treat-to-target approach in these patients.

New onset and flare of rheumatic diseases following COVID-19 vaccination are mild and respond well to treatment: 9-month follow-up data from a single centre cohort

OBJECTIVES

Anti-COVID-19 vaccines have proved to be effective and well tolerated. Great attention is now being paid to the characterisation of possible adverse events associated to their administration. We report a case series of suspected rheumatic diseases (RDs) following anti-COVID-19 vaccination.

METHODS

We included patients evaluated at first-aid rheumatologic consultancy and at rheumatologic outpatient and inpatient clinic at Padova University Hospital between May and September 2021 presenting with a RD within 30 days after an anti-COVID-19 vaccine dose. Our selection was in accordance with the World Health Organisation guidelines for adverse event following immunisation (AEFI) surveillance. Patients were regularly re-evaluated by telemedicine or face-to-face visit.

RESULTS

We identified 30 cases of RD following vaccination: 24 (80.0%) new onsets and 6 (20.0%) flares. Most of patients (76.6%) received the BNT162b2 vaccine. The mean time to RD onset/flare was 12±9 days. The most common manifestations were inflammatory arthritis (40.0%), rheumatic polymyalgia (33.3%) and adult-onset Still's disease (13.3%). At the last FU visit (9.6±2.2 months), 83.3% of patients showed complete response to first- or second-line therapy, 13.3% a partial response and one patient (3.3%) was still experiencing an active disease.

CONCLUSIONS

Considering the amount of vaccine doses administered during the evaluation period we overall detected a limited number of cases. We noted a clear prevalence of autoinflammatory conditions and seronegative manifestations. The great majority of patients had mild features and showed a good response to therapy.

Current clinical and therapeutic approach to tumour-like mass lesions in granulomatosis with polyangiitis

Granulomatosis with polyangiitis (GPA) is a systemic autoimmune disorder classified among the anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and characterized by a triad of upper and lower respiratory tract disease, systemic vasculitis involving small-to-medium vessels and renal manifestations. Mass lesions, also described as inflammatory lesions, pseudotumor or tumour-like masses, are uncommon manifestations of GPA and are often called granuloma since histology examination shows granulomatous inflammation and rarely vasculitis. Masses could represent a localized manifestation of GPA or develop as part of a systemic disease. Unusual clinical presentation together with nonspecific radiological and histological features may delay the correct diagnosis leading to disease progression and organ damage. Diagnosis of GPA in such cases may be challenging and malignancy or infections must be considered as alternative diagnostic options. Here we reviewed all the different sites where mass lesions were reported in GPA, focusing on atypical localization, and summarized current therapeutic options and their different outcomes. We retrieved and discussed the cases reported since 2010, bearing in mind the advances in the therapeutic management of AAV patients in the last decade, namely biological therapy such as rituximab. Despite treatment regimens with glucocorticoids and immunosuppressive agents, mass lesions have a refractory course in a high proportion of patients. Invasive surgical procedures may be considered only when drug therapy fails.

IgG anti-Pentraxin 3 antibodies are a novel biomarker of ANCA-associated vasculitis and better identify patients with eosinophilic granulomatosis with polyangiitis

OBJECTIVE

To investigate prevalence of anti-Pentraxin 3 (PTX3) antibodies in sera of anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) patients.

METHODS

Anti-PTX3 and PTX3 levels were analysed by enzyme-linked immunosorbent assays in sera from unselected patients with AAV and compared with patients with systemic lupus erythematosus (SLE, n = 130), other connective tissue diseases (CTDs, n = 97) and matched healthy controls (n = 97). Optical density (OD) cut-off for positive anti-PTX3 antibodies was determined by ROC curve analysis and set as 0.234. Indirect immunofluorescence (IIF) on fixed human granulocytes was used to analyze the fluorescence pattern of anti-PTX3 antibodies. Liquid-phase inhibition tests were conducted to assess potential interferences.

RESULTS

We included 101 AAV patients (females 58%, median age 60[51-69] years) affected either with granulomatosis with polyangiitis (GPA, n = 51), microscopic polyangiitis (MPA, n = 12) or eosinophilic granulomatosis with polyangiitis (EGPA, n = 38). Anti-PTX3 antibodies were detected in 29.7% AAV patients, being significantly higher than in healthy controls (p < 0.001) and CTDs (p = 0.030) but lower than in SLE (p = 0.004). Anti-PTX3 antibody prevalence was 44.7% in EGPA, 25% in MPA and 19% in GPA (p = 0.034). Among ANCA negative patients, 35.7% displayed positive anti-PTX3 antibodies. Anti-PTX3 were associated with a lower prevalence of systemic (p = 0.002), ear-nose-throat (p = 0.006) and renal manifestations (p = 0.016). Anti-PTX3 antibodies were characterized by a specific IIF pattern on fixed granulocytes. PTX3 serum levels resulted lower in AAV than healthy controls (p < 0.001). PTX3 inhibited anti-PTX3 binding in a dose-dependent manner.

CONCLUSIONS

Anti-PTX3 autoantibodies appear a promising novel biomarker of AAV, especially EGPA.

Mepolizumab for Eosinophilic Granulomatosis with Polyangiitis (EGPA): a European multicenter observational study

OBJECTIVE

Mepolizumab proved efficacious for eosinophilic granulomatosis with polyangiitis (EGPA, former Churg-Strauss) at the dosage of 300mg/4 weeks in the randomized controlled MIRRA trial. Few successful real-life experiences with the dosage approved for severe eosinophilic asthma (100mg/4 weeks) were recently reported. We retrospectively assessed the effectiveness and safety of mepolizumab 100 and 300mg/4 weeks in a large European EGPA cohort.

METHODS

We included all EGPA patients treated with mepolizumab at the recruiting centres in 2015-2020. Treatment response was evaluated from month 3 through 24 (T3-T24) after mepolizumab starting. Complete response (CR) was defined as no disease activity (Birmingham Vasculitis Activity Score, BVAS=0) and a prednisone dose ≤4mg/day. Respiratory outcomes included asthma and ear-nose-throat (ENT) exacerbations.

RESULTS

We included 203 patients, of whom 191 at stable dosage (158 mepolizumab 100mg/4 weeks, 33 300mg/4 weeks). At T3, 25 patients (12.3%) had a CR. CR rates increased to 30.4% and 35.7% at T12 and T24 and were comparable between mepolizumab 100 and 300mg/4 weeks. Mepolizumab led to a significant reduction in BVAS, prednisone dose, eosinophil counts from T3 through T24, with no significant differences between 100 and 300 mg/4weeks. Eighty-two patients (40.4%) experienced asthma exacerbations [57/158 (36%) on 100mg/4 weeks; 17/33 (52%) on 300mg/4 weeks]. Thirty-one (15.3%) experienced ENT exacerbations. Forty-four patients (21.7%) experienced adverse events, most being non-serious (38/44).

CONCLUSION

Mepolizumab both at 100 and 300mg/4 weeks is effective for EGPA. The two dosages should be compared in the setting of a controlled trial.

Leukocytoclastic vasculitis associated with multifocal sensory neuropathy responsive to intravenous immunoglobulins: a case report

Leukocytoclastic vasculitis (LCV) is a common form of small-vessel vasculitis, which commonly presents as palpable purpura or petechiae, caused by deposition of circulating immune complexes on vessels walls that attracts granulocytes which damage the vascular endothelium and leading to erythrocytes extravasation. The skin is the most commonly involved organ, but also renal, gastrointestinal, pulmonary, cardiovascular and neurological systems may be affected. Skin lesions may be the initial signs of systemic vasculitis. Systemic symptoms may be present, such us fever, myalgia, abdominal pain and arthralgia. The presence of neuropathy/mononeuritis multiplex is expression of severe vasculitic involvement. Herein, we describe the case of a patient with leucocytoclastic vasculitis associated to sensitive neuropathy, responsive to intravenous immunoglobulins (IVIg) therapy, after the failure of classic systemic treatments.

Significance of PR3-ANCA positivity in eosinophilic granulomatosis with polyangiitis (Churg-Strauss)

OBJECTIVES

Only a third of patients with eosinophilic granulomatosis with polyangiitis (EGPA) are ANCA-positive, mainly directed against MPO. ANCA directed against PR3 are rarely found in EGPA. We aimed to examine the significance of PR3-ANCA in EGPA.

METHODS

We set up a retrospective European multicentre cohort including 845 patients. Baseline characteristics and outcomes were analysed and compared according to ANCA status.

RESULTS

ANCA status was available for 734 patients: 508 (69.2%) ANCA-negative, 210 (28.6%) MPO-ANCA and 16 (2.2%) PR3-ANCA. At baseline, PR3-ANCA patients, compared with those with MPO-ANCA and ANCA-negative, less frequently had active asthma (69% vs 91% and 93%, P = 0.003, respectively) and peripheral neuropathy (31% vs 71% and 47%, P < 0.0001), more frequently had cutaneous manifestations (63% vs 38% and 34%, P = 0.03) and pulmonary nodules (25% vs 10% and 8%, P = 0.046), and lower median eosinophil count (1450 vs 5400 and 3224/mm3, P < 0.0001). Vasculitis relapse-free survival was shorter for PR3-ANCA (hazard ratio 6.05, P = 0.005) and MPO-ANCA patients (hazard ratio 1.88, P = 0.0002) compared with ANCA-negative patients.

CONCLUSION

PR3-ANCA EGPA patients differ from those with MPO-ANCA and negative ANCA, and share clinical features with granulomatosis with polyangiitis. This suggests that PR3-ANCA EGPA could be a particular form of PR3-ANCA-associated vasculitis.

Nasal polyps in eosinophilic granulomatosis with polyangiitis: Structured histopathology and CD105 expression

PURPOSE

Distinguishing the prodromal nasal polyposis of eosinophilic granulomatosis with polyangiitis (EGPA) from chronic rhinosinusitis with nasal polyps (CRSwNP) is a challenge for rhinologists and rheumatologists. It has recently been reported that angiogenesis and CD105 expressed on vascular endothelial cells could have a role in the pathogenesis and development of nasal polyps. This exploratory study examined the structured histopathology of nasal polyps in patients with EGPA and CRSwNP, comparing CD105 expression in their nasal tissue with that of a control group with no chronic sinonasal inflammation.

METHODS

A structured histopathological study was performed on surgical specimens of nasal tissue from 32 adults (13 with EGPA, 14 with CRSwNP, 5 controls), considering CD105 as a marker to determine microvessel density (MVD).

RESULTS

The mean eosinophil count was higher in EGPA patients with tissue inflammation (p = .002), and in CRSwNP patients with sub-epithelial edema (p = .009). Neutrophil infiltration was significantly associated with severe tissue inflammation in EGPA patients (p = .04), but with the absence of fibrosis in CRSwNP patients (p = .04). In the EGPA group, CD105-MVD correlated with tissue eosinophil count (p = .05). Mean CD105-MVD was significantly higher in EGPA patients with mucosal ulceration (p = .004). In the CRSwNP group, a CD105-MVD correlated positively and significantly with tissue eosinophil count (p = .01).

CONCLUSION

Alongside the known abundance of eosinophils, other cells might contribute to inflammatory processes. Neutrophils may amplify inflammation, eosinophil recruitment and tissue damage. CD105 expression in CRSwNP and EGPA nasal polyps supports the hypothesized involvement of angiogenesis in the pathogenesis and development of nasal polyps.

Neutrophil infiltrates and eosinophil aggregates in chronic rhinosinusitis with nasal polyps and EGPA

INTRODUCTION/OBJECTIVES

The histopathological study of inflammatory cells and their tendency to form aggregates in chronic rhinosinusitis with nasal polyps (CRSwNP) has shown promising results in determining the pathogenesis and predicting clinical outcome. Bilateral nasal polyps also occur in over 70% of patients with eosinophilic granulomatosis with polyangiitis (EGPA). The study aim was to investigate neutrophil infiltrates and eosinophil aggregates in CRSwNP and EGPA tissues of Caucasian patients.

METHOD

A histopathological study was performed on surgical specimens of nasal polyps from 144 adults (15 with allergic fungal rhinosinusitis; 19 with nonsteroidal anti-inflammatory drugs-exacerbated respiratory disease (NERD); 16 with intrinsic asthma; 21 with extrinsic asthma; 21 with allergy; 22 with eosinophil CRSwNP (ECRSwNP); 17 with non-ECRSwNP; 13 with EGPA).

RESULTS

Focusing on the presence of tissue eosinophil aggregates, NERD and ECRSwNP were the sub-cohorts with the highest rate. Neutrophil infiltrate rate was significantly higher in EGPA sub-cohort than in all CRSwNP sub-cohorts apart from non-ECRSwNP.

CONCLUSIONS

Structured histopathology is increasingly identifying the different histotypes of CRSwNP. This analysis can be used to better understand CRSwNP endotypes and develop targeted therapies. The response to therapy and therefore control of CRSwNP relapses definitely depends on our ability to act on the underlying inflammatory pattern. Key points • Systematic analysis of how neutrophil infiltrates and eosinophilic aggregates are distributed in the different phenotypes of CRSwNP and EGPA. • Neutrophil infiltrates and eosinophil aggregates are strong risk factors for nasal polyps' refractoriness. • NERD and ECRSwNP are the sub-cohorts of CRSwNP with the highest rate of tissue eosinophil aggregates. • Neutrophil infiltrates are significantly higher in EGPA.

SARS-CoV-2 infection in patients with autoimmune rheumatic diseases in northeast Italy: A cross-sectional study on 916 patients

Background

Whether patients with autoimmune rheumatic diseases (ARD) have a higher risk for SARS-CoV-2 infection (COVID-19) and how SARS-CoV-2 pandemic impacts on adherence to therapy has not been fully elucidated. We assessed the rate and clinical presentation of COVID-19, and adherence to therapy in a large cohort of patients with ARD followed-up in a tertiary University-Hospital in Northeast Italy.

Methods

Between April 9th and April 25th^, 2020, after SARS-CoV-2 infection peak, a telephone survey investigating the impact of COVID-19 on patients with systemic lupus erythematosus (SLE), systemic sclerosis (SSc), rheumatoid arthritis (RA), ANCA-associated vasculitis (AAV), and idiopathic inflammatory myopathies (IIM) was administered. Demographics, disease activity status, therapy, occupational exposure, and adherence to social distancing advise were also collected.

Results

916 patients (397 SLE, 182 AAV, 176 SSc, 111 RA, 50 IIM) completed the survey. 148 patients developed at least one symptom compatible with COVID-19 (cough 96, sore throat 64, fever 64, arthromyalgias 59, diarrhea 26, conjunctivitis 18, ageusia/hyposmia, 18). Among the 916 patients, 65 (7.1%) underwent SARS-CoV-2 nasopharyngeal swab (18 symptomatic and 47 asymptomatic), 2 (0.21%) tested positive, a proportion similar to that observed in the general population of the Veneto region. No deaths occurred. 31 patients (3.4%) withdrew ≥1 medication, mainly immunosuppressants or biologics. Adoption of social distancing was observed by 860 patients (93.9%), including 335 (36.6%) who adopted it before official lockdown.

Conclusions

COVID-19 incidence seems to be similar in our cohort compared to the general population. Adherence to therapy and to social distancing advise was high.

•

SARS-CoV-2 infection rate in ARDs seems to be similar to that of the general population.

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Adoption of social distancing measures was prevalent among different ARD groups.

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Earlier social distancing was more common in unremitted patients, treated with multiple drugs.

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Therapy discontinuation due to COVID-related concerns was rare, but undertaken even by active patients.

•

Therapeutic regimens based on ≥3 drugs were associated with therapy discontinuation in our cohort.

FRI0214 PERSISTENT LOW-GRADE FDG-PET VASCULAR INFLAMMATION IN REMITTED LVV-GCA PATIENTS IS ASSOCIATED TO A SIGNIFICANT HIGH RISK OF RELAPSE

Background:

Persistent low-grade vascular inflammation in giant cell arteritis (GCA) with large vessel involvement (LVV) treated patients could represent the expression of persistent subclinical disease activity or post-inflammatory vascular remodelling. Whether these findings have any impact on future vascular outcomes is still an unmet need.

Objectives:

To evaluate the frequency and evolution of FDG-PET low-grade vascular inflammation in remitted LVV-GCA patients.

Methods:

We included all consecutive patients classified as GCA with LVV involvement, with a minimum disease duration of 12 months and clinically remitted, who underwent to at least one PET/MR scan between January 2015 and January 2020. For each scan vessel’s metabolic activity was assessed using the Meller’s grading1. Low-grade inflammation was defined as Meller 1 and 2 (inferior or equal to liver), as reported in previous studies. Demographic and clinical data, as well as disease remission or flares, were recorded and compared to vascular metabolic activity.

Results:

In total 88 PET scans were performed in 54 LVV-GCA patients, predominantly female (77.8%), aged 68[7,8] years, with a regular BMI (23.9[2.8]) and with a long-standing disease (27[32.6] months). A subsequent PET/MR scan was available in 34 patients (median time between the two scans 9[6.3] months).

At first PET examination, low-grade metabolic activity was reported in 68,5% of the cases, while complete remission in 15% and high metabolic activity in 25%. Comparing patients with low-grade vascular inflammation to those with complete remission (Meller 0), they had lower disease duration (28[25.9] vs 73[68] months, but without significance) and they were treated with higher daily prednisone dosage (5[3.8] vs 0[2.2], p=0.042). No significant differences were noted in age, acute phase reactants and type of treatment. Moreover, when compared to those with high metabolic activity (Meller 3), the latter had only significantly higher CRP levels (8.3[13.8] vs 4.1[3.9], p=0.03) and lower disease duration (19[20.6] vs 28[25.9] months, but without significance). While no significant differences were noted in age and type of treatment (both glucocorticoids and immunosuppressants).

Among all patients with low-grade vascular inflammation, 81% of them underwent to steroids or immunosuppressants tapering due to clinical remission. At the subsequent PET examination, a worsening of metabolic activity (Meller 3) was found in 4/20 patients, with 1 clinical flare. While in 14/20 patients the subsequent PET revealed a persistent metabolic activity. Only in 2/20 there was a complete metabolic remission. Change or increase of the treatment regimen led to an improvement (Meller 0 or 1) in all the cases. Low-grade metabolic activity was associated with a significant increased risk of worsening/flare at the subsequent PET examination (RR 5.29[1.87-16.11], p=0.002).

Conclusion:

Low-grade vascular inflammation at PET examination is a common feature in remitted patients. It is associated with older age, lower disease duration and clinical remission. Treatment tapering is associated with an increased risk of worsening/flare. Further research is urgently needed to address this issue.

References:

[1]J. Meller et al., “Early diagnosis and follow-up of aortitis with [(18)F]FDG PET and MRI.,” Eur. J. Nucl. Med. Mol. Imaging, vol. 30, no. 5, pp. 730–6, May 2003.

Disclosure of Interests:

Roberto Padoan: None declared, Alessandro Tomelleri: None declared, Mara Felicetti: None declared, Corrado Campochiaro Speakers bureau: Novartis, Pfizer, Roche, GSK, SOBI, Elena Baldissera Speakers bureau: Novartis, Pfizer, Roche, Alpha Sigma, Sanofi, Filippo Crimì: None declared, Pietro Zucchetta: None declared, Diego Cecchin: None declared, Maria Picchio: None declared, Lorenzo Dagna Grant/research support from: Abbvie, BMS, Celgene, Janssen, MSD, Mundipharma Pharmaceuticals, Novartis, Pfizer, Roche, SG, SOBI, Consultant of: Abbvie, Amgen, Biogen, BMS, Celltrion, Novartis, Pfizer, Roche, SG, and SOBI, Andrea Doria Consultant of: GSK, Pfizer, Abbvie, Novartis, Ely Lilly, Speakers bureau: UCB pharma, GSK, Pfizer, Janssen, Abbvie, Novartis, Ely Lilly, BMS, Franco Schiavon: None declared