Therapy satisfaction and health literacy are key factors to improve medication adherence in systemic sclerosis

OBJECTIVE

Although medication adherence (MA) contributes to therapeutic outcome in systemic sclerosis (SSc), research data are scarce. Factors influencing MA in SSc are hardly known.

METHOD

We conducted a monocentric, cross-sectional study on 85 patients with SSc at the University of Lübeck, Germany, using the Compliance Questionnaire of Rheumatology as the main measurement tool of MA. We also used the Scleroderma Health Assessment Questionnaire, Illness Perception Questionnaire - Revised, Health Literacy Questionnaire, Lübeck Medication Satisfaction Questionnaire (a novel instrument created for this study), and patients' demographic and clinical data, to find factors contributing to MA.

RESULTS

Good MA was seen in 51.8% of patients. MA was positively associated with therapy satisfaction (p < 0.001), modified Rodnan Skin Score (p = 0.032), age (p = 0.025), intake of micronutrients (p = 0.033), number of prescribed drugs (p = 0.014), and some dimensions of health literacy. Negative associations were found for patients with weight loss attributed to SSc (p = 0.009) and the perception that the disease is caused by the patient's personality (p = 0.011) or emotional state (p = 0.037).

CONCLUSION

Although most SSc patients display good MA, non-adherence remains a major problem. Patients should be assessed for non-adherence. The factors affecting MA identified herein could help to improve therapeutic outcomes.

AB0137 SERA DERIVED EXTRACELLULAR VESICLES FROM SYTEMIC SCLEROSIS PATIENT AND AUTOANTIBODIES MEDIATE PERIPHAL BLOOD MONOCYTES ACTIVATION

Background

In SSc, autoantibodies (abs) directed against G protein-coupled receptors (GPCR) are prominent and for example induce release of inflammatory and profibrotic proteins by monocytes (1-3). Increased levels of autoantibodies against angiotensin II type 1 receptor (AT1R abs) have been found in patients with renal involvement in systemic sclerosis (SSc) (4-5). The elevated amount of anti-GPCR abs is accompanied by increased secretion of extracellular vesicles (EVs) in SSc (6). The importance of EVs in the pathogenesis is also based on packing and horizontal transfer of AT1R to different tissues and immune cells, exemplary shown by activated cardiomyocytes leading to higher responsiveness to Angiotensin II of recipient cells and vessels (7). Taken together, the relevance of studying anti-GPCR abs together with GPCR-EVs in SSc pathogenesis becomes evident (8). Interestingly, CCL18 is found to be upregulated in SSc patients and suggested to be upregulated by AT1R abs (9), indicating CCL18 and CCR8 cross-talk via EVs plays an essential role in the pathogenesis of SSc.

Objectives

Unravel the immune response of peripheral blood monocytes mediated by anti-AT1R abs and EVs to gain new insights into the pathomechanism in SSc.

Methods

Human peripheral blood monocytes of healthy donors were stimulated by the endogenous AT1R ligand angiotensin II as well as by a monoclonal anti-human AT1R ab and, in comparison, by purified IgG from HD (HD IgG) versus those from SSc (SSc IgG). Further, human peripheral blood monocytes of HD were treated with EVs derived from sera of SSc patients versus sera of HD, in the presence or absence of a monoclonal recombinant anti-AT1R ab. Monoclonal AT1R ab has been generated by hybridoma technique, sequenced and recombinantly expressed in HEK cells. The specificity of AT1R abs was tested by using an AT1R blocker (telmisartan, TEL). EVs were isolated from sera by differential centrifugation to exclude large particles and microvesicles and further by one-step polymer precipitation procedure utilising ExoQuick Exosome Precipitation Solution (System Biosciences, Palo Alto, CA) and subsequent purification by size exclusion. Further, primary human peripheral blood monocytes of HD (n=6) were treated with EVs derived from sera of SSc patients (n=6) versus sera of HD (n=6), in the presence or absence of a monoclonal recombinant anti-AT1R ab. The response of the monocytes was measured via CCL18 secretion by ELISA.

Results

The recombinant monoclonal anti-human AT1R antibody induced secretion of CCL18, a profibrotic cytokine, by primary monocytes derived from HD. Similarly, the purified IgG fractions derived from SSc patients also induced an increased CCL18 release by monocytes compared to IgG fractions derived from HD. Further, complete amelioration of the AT1R ab effect on CCL18 secretion was found, when monocytic AT1R expression was blocked with TEL. In addition, antagonistic effects of Angiotensin II to the monoclonal AT1R ab were observed. In line, enhanced CCL18 secretion of human monocytes stimulated with SSc-EVs alone and together with the monoclonal AT1R ab was induced.

Conclusion

The secretion of pro-fibrotic CCL18 by human monocytes in response to a monoclonal AT1R antibody as well as to SSc IgG indicates that anti-AT1R abs are involved in the SSc pathogenesis. Further, this effect could also be due to SSc-EVs potentially presenting anti-GPCR abs to their receptors on immune cells.

References

[1]Cabral-Marques O, et al. Nat Commun. 2018;9(1):5224.

[2]Murthy S, et al. Rheumatology (Oxford). 2021;60(6):3012-22.

[3]Günther J, et al. Arthritis Res Ther. 2014;16(2):R65.

[4]Kill A, Riemekasten G. Curr Rheumatol Rep. 2015;17(5):34.

[5]Xia Y, Kellems RE. Circ Res. 2013;113(1):78-87.

[6]Guiducci S, et al. Arthritis Rheum. 2008;58(9):2845-53.

[7]Pironti G, et al. Circulation. 2015;131(24):2120-30.

[8]Kalluri R, LeBleu VS. Science. 2020;367(6478).

[9]Prasse A, et al. Arthritis Rheum. 2007;56(5):1685-93.

Disclosure of Interests

None declared

POS0829 SPECTRUM OF ANCA-SPECIFICITIES IN EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS IN A RETROSPECTIVE MULTICENTER STUDY

Background

Anti-neutrophil cytoplasmic autoantibodies specific for myeloperoxidase (MPO-ANCA) are found in 10-70% of the patients with eosinophilic granulomatosis with polyangiitis (EGPA) depending on disease activity, methodological aspects and cohort examined [1-3]. Recently, a higher prevalence of anti-pentraxin 3 (PTX3)-ANCA has been reported in EGPA compared to granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) [4].

Objectives

To investigate the spectrum of ANCA specificities in a multicenter cohort of patients with EGPA and identify novel ANCA antigens.

Methods

We conducted a retrospective analysis of 73 patients with EGPA treated between 2015 and 2020 in 3 tertiary referral centers. In addition to in-house ANCA testing with indirect immunofluorescence (IFT) on fixed human granulocytes and antigen-specific enzyme-linked immunosorbent assays (ELISA), ANCA specificities were determined using a cell-based assay (CBA; Euroimmun, Lübeck, Germany). Diagnosis was based on Chapel Hill consensus conference definitions, ACR- and MIRRA-criteria for EGPA. Patient characteristics and clinical manifestations were evaluated and compared based on ANCA status. Fisher`s exact test was employed for comparison of patient groups.

Results

ANCA findings are summarized in Table 1. MPO- and proteinase 3 (PR3)-ANCA positive patients (13.7%) had a higher prevalence of peripheral neuropathy (70% vs. 44.4%, p = 0.0003) and glomerulonephritis (20% vs. 14.3%, not significant). MPO- and PR3-ANCA-negative patients (86.3%) had a higher prevalence of heart (10% vs. 46%, p <0.0001), central nervous system (CNS) (0% vs. 14.3%, p <0.0001) and gastrointestinal (10% vs. 22.2%, p = 0.0327) involvement. PTX3-ANCA were associated with a higher prevalence of ear-nose-throat (ENT) (100% vs. 85.3%, p <0.0001), lung (100% vs. 89.7%, p = 0.0015), gastrointestinal involvement (60% vs. 17.6%, p <0.0001) and peripheral neuropathy (100% vs. 48.5%, p <0.0001). Kidney (0% vs. 16.2%, p <0.0001) and CNS involvement (0% vs. 13.2%, p = 0.0002) occurred less frequently in PTX3-ANCA positive patients. The 2 olfactomedin 4 (OLM4)-ANCA positive patients presented with ENT, lung and kidney involvement, and polyneuropathy, respectively.

Table 1.

ANCA in EGPA cohort (n = 73). BPI = bactericidal permeability-increasing protein.

IFT / ELISANo. of patients (%)P-ANCA11 (15.1)C-ANCA5 (6.8)MPO-ANCA8 (10.9)PR3-ANCA2 (2.7)BPI-ANCA1 (1.4)PTX3-ANCA5 (6.8)OLM4-ANCA2 (2.7)

Conclusion

We report on the detection of PTX3-, BPI- and OLM4-ANCA in addition to MPO- and PR3-ANCA in EGPA. OLM4-ANCA has been reported in 2 patients with non-vasculitic inflammatory symptoms previously [5]. Herein, detection of OLM4-ANCA in EGPA is reported for the first time. Our study shows that the presence of ANCA with various specificities other than MPO and PR3 contribute to a higher prevalence of ANCA in EGPA. Moreover, clinical manifestations differ between ANCA-negative EGPA and ANCA-positive EGPA, and between patients with different ANCA-specificities.

References

[1]Schönermarck U, et al. Prevalence and spectrum of rheumatic diseases associated with proteinase 3-antineutrophil cytoplasmic antibodies (ANCA) and myeloperoxidase-ANCA. Rheumatology 2001;40:178-84.

[2]Bremer P, et al. Getting rid of MPO-ANCA: a matter of disease subtype. Rheumatology 2013:752-4.

[3]Comarmond C, et al. Eosinophilic granulomatosis with polyangiitis (Churg-Strauss): clinical characteristics and long-term followup of the 383 patients enrolled in the French Vasculitis Study Group cohort. Arthritis Rheum 2013;65:270-81.

[4]Padoan R, et al. IgG anti-Pentraxin 3 antibodies are a novel biomarker of ANCA-associated vasculitis and better identify patients with eosinophilic granulomatosis with polyangiitis. J Autoimmun 2021;124:102725.

[5]Amirbeagi F, et al. Olfactomedin-4 autoantibodies give unusual c-ANCA staining patterns with reactivity to a subpopulation of neutrophils. J Leukoc Biol 2015;97:181-9.

Disclosure of Interests

None declared

AB0660 Long-term effect of combination therapy with rituximab and mycophenolic acid on cardiac manifestations, pulmonary function and skin fibrosis in systemic sclerosis

Background

Cardiac manifestations in systemic sclerosis (SSc) can be either due to the fibrotic and vascular process or secondary to pulmonary arterial hypertension (PAH), cardiac inflammation, or renal crisis. Despite being one of the leading causes of death in SSc, cardiac involvement and its therapeutic options have been poorly studied. According to the ACR/EULAR recommendations, therapy with cyclophosphamide (CP) is applied to patients with cardiac manifestations. However, in case of inadequate response to CP, there are no other therapeutics evaluated.

Objectives

The aim of this retrospective analysis was to explore the efficacy of a therapy with rituximab and mycophenolic acid (MPA), especially in cases of CP failure or therapy induced cardiac toxicity

Methods

14 Patients with SSc and cardiac involvement (defined as troponin T elevation plus right- or left ventricular systolic or diastolic dysfunction, myocarditis, pericarditis, right heart failure secondary to PAH, or arrhythmias) were analysed. Two patients each showed concomitant myositis and rheumatoid arthritis, respectively. Twelve patients were initially treated with CP and two patients with methotrexate (MTX). Due to a disease progress (either cardiac involvement, skin fibrosis or lung function) a therapy with rituximab and MPA was initiated [1] These patients were followed for up to five years.

Results

Before initiation of CP or MTX electrocardiogram showed arrhythmias (atrial fibrillation, conduction blocks, multifocal ventricular extrasystoles (VES)) in 9 patients. Echocardiography revealed abnormalities in 10 patients including reduced left-ventricular ejection fraction (LV-EF), diastolic dysfunction, mitral regurgitation, or aortic aneurysm. 3 patients had PAH, 2 patients were diagnosed with post capillary pulmonary hypertension. Cardiac MRI revealed signs of myocarditis in 4 patients. 4 patients required cardiac resynchronization therapy or pacemaker implantation. Moreover, body plethysmography showed a reduction in forced vital capacity (FVC) in 12 patients, suggestive of restrictive lung disease. Under therapy with CP 11 patients had suffered from disease progress, 1 patient developed relapsing pneumonias and the 2 patients with overlap rheumatoid arthritis developed cardiac disease manifestations on MTX monotherapy. Consequently, rituximab 1000 mg q12weeks and MPA 1000 mg bid were initiated. Under this combination troponin T decreased in all patients (p=0.0002), LV-EF improved in 5, remained normal in 7 and deteriorated in 2 patients. The rate of VES improved in 8 patients. In one patient, myocarditis resolved completely (MRI). Moreover, pulmonary artery systolic pressure, measured by echocardiography, improved in all patients diagnosed with PAH under stable therapy. The modified Rodnan skin score improved in all patients, FVC improved in 7 patients, remained stable in 6 and decreased in the patient with overlap myositis. Rituximab infusions could be extended (1000 mg q24weeks) after 24-36 months of treatment in 11 patients. All patients showed peripheral blood depletion of B cells without noticed severe IgG deficiency. While 11 patients did not develop severe complications 2 patients died during follow-up of pneumonia and cardiogenic shock (overlap myositis), respectively and one patient developed a relapse of lung cancer with cerebral metastasis.

Conclusion

Therapy with rituximab and MPA is a promising alternative. However, its use requires risk stratification of patients with respect to adverse side effects which needs to be explored in future studies.

References

[1]Rimar D, Rosner I, Slobodin G. Upfront Combination Therapy With Rituximab and Mycophenolate Mofetil for Progressive Systemic Sclerosis. J Rheumatol 2021;48:304–5. https://doi.org/10.3899/jrheum.200484.

Disclosure of Interests

None declared

POS0474 ACTIVATION AND HYPERSENSITIZATION OF THE ANGIOTENSIN II TYPE 1 AND ENDOTHELIN-1 TYPE A RECEPTORS BY AGONISTIC AUTOANTIBODIES CONTRIBUTES TO VASCULAR INJURY IN SCLERODERMA RENAL CRISIS

Background

Scleroderma renal crisis (SRC) is a vascular complication of systemic sclerosis (SSc) with substantial risks for end-stage renal disease and death. Activating autoantibodies (Abs) targeting the angiotensin II type 1 (AT1R) and the endothelin-1 type A receptor (ETAR) are suggested to contribute to the vasculopathy in SSc (1, 2).

Objectives

Here, we sought to determine their pathogenic significance for acute renal vascular injury.

Methods

IgG from patients with SRC was studied for AT1R and ETAR dependent biologic effects on isolated rat renal interlobar arteries and vascular cells including contraction, signaling, and mechanisms of receptor activation. A cohort of ten patients with refractory SRC received multimodal treatment including AT1R and ETAR inhibition and plasma exchange and was followed for improvement of kidney function.

Results

In myography experiments, patient IgG exerted vasoconstriction (mean 6.5% of KCl induced contraction [95% confidence interval (95 CI) 5.0-8.1]) whereas control IgG did not (0.6% [95 CI 0.3-1.0]). The response was sensitive to inhibition of AT1R (3.0% [95% CI 1.4-4.7]) and ETAR (1.0% [95 CI 0.6-1.3]) and relied on MEK-ERK signaling. Contraction induced by angiotensin II and endothelin-1 was amplified by anti-AT1R and anti-ETAR Abs with substantial crosstalk between both receptors implicating autoimmune receptor hypersensitization. Co-immunoprecipitation experiments indicated heterodimerization between both receptor types enabling functional interrelation by structural interactions. 30% of patients with refractory SRC had improved kidney function after multimodal therapy.

Conclusion

We provide experimental and clinical evidence that agonistic Abs may contribute to SRC. Novel therapies targeted at autoimmune hyperactivation of AT1R and ETAR might improve outcomes in severe cases of SRC.

References

[1]Riemekasten, G. et al. Involvement of functional autoantibodies against vascular receptors in systemic sclerosis. Ann. Rheum. Dis. 70, 530–536 (2011).

[2]Becker, M. O. et al. Vascular receptor autoantibodies in pulmonary arterial hypertension associated with systemic sclerosis. Am. J. Respir. Crit. Care Med. 190, 808–817 (2014).

Figure 1.

Contraction of isolated rat renal interlobar arteries in response to IgG isolated from patients with scleroderma renal crisis (SRC) is dependent on angiotensin II typ 1 (AT1R) and endothelin-1 type A receptors (ETAR). Small vessel myography of artery rings exposed to (a) different concentrations of IgG isolated from healthy controls (Control IgG) or patients with SRC (SRC IgG). n = 12. *P<0.001 for SRC IgG versus Control IgG, #P<0.01 for 1.0 mg/mL versus 0.25 mg/mL and P<0.05 for 1.0 mg/mL versus 0.5 mg/mL. (b) Myography of vessels exposed to 1.0 mg/mL Control IgG or SRC IgG after pretreatment with an AT1R blocker (AT1RB, valsartan), an ETAR blocker (ETARB, sitaxsentan) or a dual endothelin-1 type A and type B receptor blocker (ETA/BRB, bosentan). n = 12. **P<0.01, ***P<0.001. Contraction is expressed as % of the maximal contraction in response to 60 mM KCl of each individual vessel. Mean±SEM.

Figure 2.

Interdependence of the angiotensin II (AngII) type 1 receptor (AT1R) and endothelin-1 (ET-1) receptors (ETA/BR) in the contractile response of isolated rat renal interlobar arteries to AngII and ET-1 in the presence of anti- AT1R and anti-ETAR activating autoantibodies.

Small vessel myography of artery rings exposed to 1.0 mg/mL IgG isolated from healthy controls (Control IgG) or patients with scleroderma renal crisis (SRC IgG) and natural ligands with and without pretreatment with receptor blockers as indicated. (a) Additional stimulation with 1000 nM AngII ± ETA/BR blocker (ETA/BRB) bosentan. n = 11-18. (b) Additional stimulation with 100 nM ET-1 ± AT1R blocker (AT1RB) valsartan. n = 6-12. Contraction is expressed as % of the maximal contraction in response to 60 mM KCl of each individual vessel. Mean±SEM. **P<0.01, ***P<0.001.

Disclosure of Interests

None declared.

POS1287 INFLUENCES ON FIBROMYALGIA AND AUTOANTIBODIES DIRECTED TO NEURO- AND VASOREGULATORY MOLECULES NEED TO BE CONSIDERED IN BIOMARKER RESEARCH

Background

Fibromyalgia syndrome (FMS) is often present in autoimmune diseases but can also occur in its primary form. Biomarkers for FMS are currently missing. Systemic chronic inflammation, dysautonomia and metabolic dysfunction have been suggested to contribute to the disease. Recent studies indicate that FMS involves autoantibodies (abs), which bind to neurons, macrophages and endothelial cells.

Objectives

In the present study, we aimed to delineate changes in natural abs directed to neuro- and vasoregulatory molecules and potentially confounding factors, which could influence these abs and disease state.

Methods

Sera from 91 patients with primary FMS (pFMS), 24 patients with secondary FMS (sFMS) and 31 healthy controls (HC) were analysed for the presence of 27 different natural abs directed to e.g., cholinergic, opioid, cannabinoid, endothelin or complement receptors or angiotensin system molecules by individual ELISAs (CellTrend GmbH, Luckenwalde, Germany). All participants were characterized by several questionnaires to obtain demographic data and measures of disease state (using the Widespread Pain Index (WPI) and Symptom Severity Score (SSS)). Linear regression on log-transformed ab levels adjusted for potential confounders was used to compare ab levels between groups. Random forest analysis was applied to differentiate between pFMS and HC by measuring the Area Under the Curve Receiver operating characteristics (AUC-ROC).

Results

Compared to HC, patients with pFMS showed increased levels of abs directed to ACE II, the angiotensin receptor type-2 (AT2R), the cannabinoid receptor type 1 and 2 (Can1-R, Can2-R), the endothelin receptor type-B (ETBR), the opioid receptor κ (Op-k-R) and lower levels against the complement receptor 5a (C5a-R) and the muscarinergic acetylcholine receptor type 3 (M3)(Figure 1). After adjustment for age (linear and squared) and sex, differences in the ab levels remain significant for abs against ACE II, AT2R, ETBR and the Op-k-R. However, none of which remained significant after further adjustment for Body Mass Index (BMI). Random forest analysis of unadjusted ab levels revealed an AUC-ROC of 0.94 for pFMS compared to HC with an average accuracy of 0.85 and a kappa of 0.55. Again, after adjusting the ab levels for age, sex and the BMI, AUC-ROC to discriminate HC from pFMS patients decreased to 0.73 (accuracy = 0.79, kappa = 0.33).

Figure 1.

Boxplots of logarithmized abs levels between groups. *: p < .05 in unadjusted analysis and after adjusting for age and sex, ~: p < .05 only significant after adjusting for age and sex, +: p < .05 only in unadjusted analysis (all FDR-corrected within group comparisons across abs). Unadjusted Adjusted for age, sex and BMI

Conclusion

Abs might be potential biomarkers for pFMS. However, these results highlight the important role of correct covariate adjustment for research on biomarkers supposed to classify FMS or other diseases. In FMS, increase in BMI might be a cause or a consequence of FMS and it is also unknown how BMI and abs influence each other. Thus, BMI might or might not be a confounder so that adjusting for BMI might be correct or incorrect. However, these abs could provide a link to understand how acquired conditions interact with the immune system.

References

[1]Goebel A et al. Passive transfer of fibromyalgia symptoms from patients to mice. J Clin Invest. 2021 Jul 1;131(13):e144201.

[2]Cabral-Marques O et al. GPCR-specific autoantibody signatures are associated with physiological and pathological immune homeostasis. Nat Commun. 2018 Dec 6;9(1):5224.

Figure 2.

AUC ROC as detected by random forest analysis in pFMS patients versus HC for unadjusted ab levels as well as for ab levels adjusted for age, sex, and BMI.

Disclosure of Interests

None declared

AB0028 IL-2 DEPRIVED PHENOTYPE OF FOXP3+ REGULATORY T CELLS AND PHENOTYPIC ALTERATIONS CONVENTIONAL CD4+ T CELLS IN PATIENTS WITH INFLAMMATORY MYOPATHIES AND PRIMARY SJOGREN´S SYNDROME

Background

A defect in regulatory T cell (Treg) homeostasis due to an acquired deficiency of interleukin-2 (IL-2) plays an important role in the pathogenesis of systemic lupus erythematosus (SLE).1,2 However, it is still unclear whether a defect in the Treg-IL-2 axis is also involved in other connective tissue disease such as inflammatory myopathies or primary Sjogren´s syndrome (pSS).

Objectives

The aim of our study was to investigate whether Treg from patients with poly- and dermatomyositis (PM/DM) and pSS display typical features of IL-2 deficiency in parallel to phenotypic alterations of conventional CD4+ T cell (Tcon) subsets compared to healthy controls (HC).

Methods

PBMC were isolated from patients with PM/DM (n=22) and pSS (n=17) and from age- and sex-matched HC (n=19) using gradient density centrifugation. Treg and Tcon subsets were analyzed by using multicolor flow cytometry. Mann-Whitney test was used for statistical analyses.

Results

Frequencies of FoxP3+CD127lo Treg among CD3+CD4+T cells were higher in pSS compared to PM/DM patients (p<0.001) and to HC (p<0.05). However, in both, PM/DM and pSS patients, frequencies of CD25+ cells among FoxP3+CD127lo Treg were significantly lower compared to HC (PM/DM: p<0.05, pSS: p<0.0001), while the frequencies of Helios+ cells among the CD25- Treg subset were substantially higher in pSS patients compared to DM/PM and HC (both p<0.001). Conversely, we found lower frequencies of CXCR5+ follicular Treg only in PM/DM patients (p<0.05). In parallel, there were higher frequencies of CD45RO+CCR7- effector/memory cells (p<0.01) and of Ki67+ proliferating cells (p<0.05) among CD3+CD4+FoxP3- Tcon in pSS patients compared to HC, which was not observed in PM/DM patients.

Conclusion

The loss of the CD25+ Treg subset in PM/DM and pSS patients is similar to previous findings in SLE patients1 and represents a hallmark of IL-2 deficiency. This suggests that shortage of IL-2 is pathophysiologically relevant also in PM/DM and pSS providing a rationale for low-dose IL-2 therapy in these diseases. In addition, activation and expansion of effector/memory Tcon appears to be more pronounced in pSS compared to PM/DM. The different distribution of Treg and of Tcon subsets between pSS and PM/DM patients might reflect differences in the availability of IL-2 and in the regulation of Tcon responses in these diseases.

References

[1]von Spee-Mayer C, Siegert E, Abdirama D, et al. Low-dose interleukin-2 selectively corrects regulatory T cell defects in patients with systemic lupus erythematosus. Ann Rheum Dis. 2016; 75; 1407–1415.

[2]Humrich JY, von Spee-Mayer C, Siegert E, et al. Low-dose interleukin-2 therapy in refractory systemic lupus erythematosus: an investigator-initiated, single-centre phase 1 and 2a clinical trial. Lancet Rheumatol. 2019; 1; e44-e54

Disclosure of Interests

Luisa R. Monne: None declared, Sara Comduehr: None declared, Fynn Gerlach: None declared, Antje Müller: None declared, Gabriela Riemekasten: None declared, Jens Y. Humrich Speakers bureau: GSK, AstraZeneca, Pfizer, BMS, UCB, MSD, AbbVie, Consultant of: GSK, AstraZeneca, ILTOO Pharma, Selecta Biosciences, Janssen-Cilag, Grant/research support from: Sanofi

POS0914 LATE SKIN FIBROSIS IN SYSTEMIC SCLEROSIS: A STUDY FROM THE EUSTAR COHORT

Background

Skin fibrosis is a cardinal feature of systemic sclerosis (SSc) and associated with significant disability. The early trajectory of skin fibrosis provides insights into the course of the disease including mortality; however, little is known about late skin fibrosis in SSc.

Objectives

The aims of our study were to ascertain the prevalence and characteristics of late skin fibrosis in SSc.

Methods

We developed and tested three conceptual scenarios of late (>5 years after 1st non-RP sign or symptom) skin fibrosis (Figure 1):

Figure 1.

Conceptual models/scenarios of late skin fibrosis in SSc. A: worsening and then improvement (>3 mRSS) during the first 5 years, and then worsened again after 5 years. B: worsening for the first time after 5 years. C: worsening in the first 5 years and stayed high after 5 years (i.e., failure to improve).

A. Worsening and then improvement (>3 mRSS) during the first 5 years, and then worsened again after 5 years.

B. Worsening for the first time after 5 years.

C. Worsening in the first 5 years and stayed high after 5 years (i.e., failure to improve).

We defined skin worsening as modified Rodnan skin score (mRSS) ≥ 5 units or ≥ 25%. Using strict inclusion criteria including complete mRSS, we identified 1,043 (out of 19,115) patients within the EUSTAR database for our analysis. We further restricted analysis within 887 (out of 1,043) patients who had limited (lcSSc) or diffuse cutaneous SSc (dcSSc) at baseline.

Results

One-fifth of patients among the whole cohort (n=208/1043, 19.9%) including in patients with lcSSc or dcSSc at baseline (n=193/887, 21.8%) developed late skin fibrosis. This was largely due to new skin worsening or failure to improve. Patients with lower baseline mRSS and lcSSc were more likely to develop late skin fibrosis. Anti-Scl-70 antibodies (Table 1) were associated with progression from baseline lcSSc to dcSSc, and anticentromere antibodies were protective.

Table 1.

Impact of autoantibody status on progression from baseline limited to diffuse cutaneous SSc (dcSSc).

Skin worsening after 5 years (Scenario B) (n=70)Skin worsening within 5 years and failed to improve after 5-year window (Scenario C) (n=61)Progressed to dcSSc (n=23)Not progressed to dcSSc(n=47)P-valueProgressed to dcSSc (n=37)Not progressed to dcSSc(n=24)P-valueAnticentromere+ve2/22 (9.1%)19/42 (45.2%)0.00346/34 (17.6%)14/21 (66.7%)0.0002-ve20/22 (90.9%)23/42 (54.8%)28/34 (82.4%)7/21 (33.3%)Anti-Scl-70+ve15/23 (65.2%)14/44 (31.8%)0.008822/36 (61.1%)8/23 (34.8%)0.0485-ve8/23 (34.8%)30/44 (68.2%)14/36 (38.9%)15/23 (65.2%)Anti-RNA-Polymerase-III+ve0/12 (0.0%)1/22 (4.5%)1.00000/6 (0.0%)0/14 (0.0%)---ve12/12 (100%)21/22 (95.5%)6/6 (100%)14/14 (100%)

Conclusion

Late skin fibrosis affects approximately 20% of SSc patients >5 years after onset of disease. We have identified different patterns relevant to clinical practice and trial design. Late skin fibrosis is usually due to new worsening or failure of skin to improve. Progression from baseline limited to diffuse cutaneous SSc was associated with anti-Scl-70 antibodies, and anticentromere antibodies were protective. Late skin fibrosis is a neglected manifestation of SSc and warrants further investigation including to determine clinical outcomes and optimal therapeutic strategy.

Acknowledgements

On behalf of EUSTAR collaborators.

Disclosure of Interests

Michael Hughes Speakers bureau: Speaking fees from Actelion pharmaceuticals, Eli Lilly, and Pfizer, outside of the submitted work, Suiyuan Huang: None declared, Juan Jose Alegre Sancho Speakers bureau: Speaking and/or investigational fees from Actelion pharmaceuticals, Eli Lilly, Pfizer, Boehringer Ingelheim, Roche, and GSK, outside of the submitted work, Grant/research support from: Speaking and/or investigational fees from Actelion pharmaceuticals, Eli Lilly, Pfizer, Boehringer Ingelheim, Roche, and GSK, outside of the submitted work, Patricia Carreira: None declared, Merete Engelhart: None declared, Eric Hachulla Speakers bureau: Received consulting fees/meeting fees from Johnson & Johnson, Boehringer Ingelheim, Bayer, GSK, Roche-Chugai, Sanofi-Genzyme; speaking fees from Johnson & Johnson, GSK, Roche-Chugai; and research funding from CSL Behring, GSK, Roche-Chugai and Johnson & Johnson., Consultant of: Received consulting fees/meeting fees from Johnson & Johnson, Boehringer Ingelheim, Bayer, GSK, Roche-Chugai, Sanofi-Genzyme; speaking fees from Johnson & Johnson, GSK, Roche-Chugai; and research funding from CSL Behring, GSK, Roche-Chugai and Johnson & Johnson., Jörg Henes Speakers bureau: Lectures for CHUGAI, Boehringer-Ingelheim, Eduardo Kerzberg: None declared, Maria Rosa Pozzi: None declared, Gabriela Riemekasten: None declared, Vanessa Smith: None declared, Gabriella Szucs: None declared, Marie Vanthuyne: None declared, Elisabetta Zanatta: None declared, Oliver Distler: None declared, Armando Gabrielli: None declared, Anna-Maria Hoffmann-Vold: None declared, Viginia Steen: None declared, Dinesh Khanna Shareholder of: DK has stock options in Eicos Sciences, Inc., Consultant of: Consultant for Acceleron, Amgen, Boehringer Ingelheim, CSL Behring, Chemomab, Genentech/Roche, Horizon, Mitsubishi Tanabe Pharma, Prometheus, Talaris., Grant/research support from: Has received grants from Bayer, BMS, Horizon and Pfizer (to University of Michigan).

POS0387 RISK STRATIFICATION APPROACHES PERFORM DIFFERENTLY IN SSc-ASSOCIATED PAH IN EUSTAR

Background

Pulmonary arterial hypertension (PAH) is a major clinical challenge in systemic sclerosis (SSc), and is associated with high mortality. Risk stratification provides an estimate for individual patient risk of 1-year mortality. The aim is to detect patients with the worst prognosis to optimize management strategies. Nine risk stratification approaches have been proposed in PAH, but have not been validated in SSc-PAH.

Objectives

To assess four risk stratification models and their performance to predict 1- and 3- year mortality and to identify the best risk assessment approach for SSc-PAH.

Methods

We included all patients with SSc diagnosed with PAH by right heart catheterization (RHC) from the European scleroderma trial and research (EUSTAR) database from 2001 to February 2021. PAH was defined as mean pulmonary arterial pressure (mPAP) ≥25 mmHg, pulmonary artery wedge pressure (PAWP) ≤15mmHg, and pulmonary vascular resistance (PVR) >3 Wood units (WU) in the absence of significant interstitial lung disease. We applied four different approaches for risk stratification at time of PAH diagnosis. Risk parameters included New York Heart Association (NYHA) class, 6-minute walk distance (6MWD), NT-proBNP or BNP, and echocardiographic and hemodynamic parameters with cut-off values based on the 2015 ESC/ERS Guidelines. Model 1 and 2 stratified patients into low, intermediate and high-risk categories; while Model 3 and 4 stratified the patients into four categories (low, intermediate-low, intermediate-high and high).

Model 1: Patients with ≥ 1 high-risk parameter were considered at high risk; with ≥ 1 intermediate-risk parameter at intermediate risk, otherwise at low risk1

Model 2: Each variable was graded from 1 to 3 representing low to high risk. The mean of available risk parameters was rounded to the nearest integer to define the risk category2

Model 3: Equals Model 2, but the intermediate risk group was divided into intermediate-low and intermediate-high based on the mean score3

Model 4: Stratifies patients into four risk categories based on the proportion of low-risk parameters3

We performed analysis of 1- and 3- year mortality in patients with a minimum follow-up of 1 and 3 years, respectively.

Results

Of 911 patients who conducted RHC, 273 (30%) were diagnosed with SSc-PAH according to the inclusion criteria (Table 1). Median follow-up time was 2.8 years (IQR 1.3-5.3). The models varied in their ability to predict mortality (Figure 1). Model 1 and 4 either over- or underestimated mortality. Model 2 stratified patients according to the expected 1-year mortality of <5%, 5-10% and >10% suggested by the ESC/ERS Guidelines. Model 3, which divided the intermediate risk group in two different risk groups, segregated the risk of mortality further within this group.

Table 1.

Demographic and clinical characteristics of patients segregated by risk stratification (Model 3)

NAll patients (n=273)Low-risk (n=78)Intermediate-low (n=118)Intermediate-high (n=56)High-risk (n=21)Age, years (SD)27365 (10.7)65 (10.3)65 (10.7)65 (10.8)67 (12.8)Female sex, n (%)273230 (84)64 (82)98 (83)48 (86)20 (95)lcSSc, n (%)263221 (84)60 (80)99 (86)47 (90)15 (71)NYHA 3 or 4, n (%)261155 (59)12 (16)75 (68)49 (89)19 (95)NT-proBNP, pg/ml (IQR)1111941 (230-1485)215 (103-377)763 (325-1418)1926 (1051-5681)3314 (1129-6553)6MWD, m (SD)196321 (124.1)404 (119.7)314 (99.9)262 (128.6)215 (96.0)RHC:- mPAP, mmHg (SD)27340 (11.0)35 (8.8)41 (11.5)41 (10.8)45 (11.6)- PAWP, mmHg (SD)2739 (3.2)9 (3.0)9 (3.4)9 (3.2)8 (3.1)- Cardiac index, l/min/m2(SD)2602.8 (0.8)3.2 (0.7)2.7 (0.8)2.6 (1.0)2.0 (0.5)- PVR, WU (SD)2737.4 (4.1)5.3 (2.8)7.9 (4.0)7.9 (4.2)11.3 (4.7)Figure 1.

1- and 3-year mortality according to risk category in the four different models

Conclusion

Model 3 provides signals for a better risk stratification of patients with newly diagnosed SSc-PAH, with progressively increasing mortality across the categories. This may provide guidance for optimized management in clinical practice.

References

[1]Hoffmann-Vold, Rheum 2018

[2]Kylhammar, Eur Heart J 2018

[3]Kylhammar, ERJ open 2021

Acknowledgements

The authors thank all EUSTAR collaborators.

Disclosure of Interests

Hilde Jenssen Bjørkekjær: None declared, Cosimo Bruni Speakers bureau: Actelion, Consultant of: Boehringer-Ingelheim, Patricia Carreira: None declared, Paolo Airò Speakers bureau: Boehringer Ingelheim, Bristol-Myers-Squibb, Consultant of: Bristol-Myers-Squibb, Grant/research support from: Bristol-Myers-Squibb, Roche, Janssen, CSL Behring, Carmen Pilar Simeón-Aznar Speakers bureau: Janssen, Boehringer Ingelheim and MSD, Consultant of: Janssen, Boehringer Ingelheim, Marie-Elise Truchetet: None declared, Alessandro Giollo: None declared, Alexandra Balbir-Gurman: None declared, Mickael Martin: None declared, Christopher P Denton Speakers bureau: Boehringer Ingelheim; Janssen, Consultant of: Boehringer Ingelheim; GSK; Corbus; Sanofi; Roche; Horizon; CSL Behring; Acceleron, Grant/research support from: CSL Behring; Horizon; GSK; Servier, Armando Gabrielli: None declared, Håvard Fretheim Consultant of: Bayer, GSK, Actelion, Imon Barua: None declared, Helle Bitter Speakers bureau: Boehringer Ingelheim, Øyvind Midtvedt: None declared, Kaspar Broch: None declared, Arne Andreassen: None declared, Yoshiya Tanaka Speakers bureau: Gilead, Abbvie, Behringer-Ingelheim, Eli Lilly, Mitsubishi-Tanabe, Chugai, Amgen, YL Biologics, Eisai, Astellas, Bristol-Myers, Astra-Zeneca, Consultant of: Eli Lilly, Daiichi-Sankyo, Taisho, Ayumi, Sanofi, GSK, Abbvie, Grant/research support from: Asahi-Kasei, Abbvie, Chugai, Mitsubishi-Tanabe, Eisai, Takeda, Corrona, Daiichi-Sankyo, Kowa, Behringer-Ingelheim, Gabriela Riemekasten: None declared, Ulf Müller-Ladner: None declared, Marco Matucci-Cerinic: None declared, Ivan Castellví: None declared, Elise Siegert: None declared, Eric Hachulla Speakers bureau: Johnson & Johnson, GlaxoSmithKline, Roche-Chugai, Consultant of: Bayer, Boehringer Ingelheim, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Sanofi-Genzyme, Grant/research support from: CSL Behring, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Sanofi-Genzyme, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim

POS0854 BASELINE CHARACTERISTICS OF PATIENTS WITH IMPROVEMENT OR PROGRESSION OF SYSTEMIC SCLEROSIS-ASSOCIATED INTERSTITIAL LUNG DISEASE (SSc-ILD) DURING THE SENSCIS TRIAL

Background

The course of SSc-ILD is variable, and may include periods of stability or even improvement in forced vital capacity (FVC) as well as periods of decline.

Objectives

To investigate the baseline characteristics of patients with SSc-ILD in the placebo group of the SENSCIS trial whose ILD improved or progressed over 52 weeks.

Methods

The SENSCIS trial enrolled patients with SSc with first non-Raynaud symptom in the prior ≤7 years, extent of fibrotic ILD on high-resolution computed tomography (HRCT) ≥10% and FVC ≥40% predicted. Patients who had been taking a stable dose of mycophenolate for ≥6 months were allowed to participate. We investigated the baseline characteristics of patients in the placebo group whose ILD showed improvement (absolute increase in FVC ≥5% predicted), stability (absolute decline or increase in FVC <5% predicted), progression (absolute decline in FVC ≥5% predicted), or significant progression (absolute decline in FVC ≥10% predicted) over 52 weeks. P-values based on ANOVA or Chi-squared tests were used to compare the baseline characteristics of the patients who showed improvement, stability and progression.

Results

Of 288 patients, 21 (7.3%) showed improvement, 166 (57.6%) stability, and 101 (35.1%) ILD progression, of whom 37 (12.8% of all patients) had significant ILD progression over 52 weeks. Most baseline characteristics were similar across the groups based on progression, but there were differences in DLCO % predicted (p=0.02) and in the proportion of patients taking mycophenolate (p=0.09) among patients who showed improvement, stability and progression (Table 1).

Table 1.

Baseline characteristics of patients in the placebo group of the SENSCIS trial in subgroups based on course of SSc-ILD over 52 weeks.

Improvement (n=21)Stability (n=166)Progression (n=101)Significant progression (n=37) (subset of Progression)P-value for comparison of Improvement, Stability, ProgressionAge, years55.9 ± 12.053.2 ± 12.653.1 ± 12.855.3 ± 11.80.64Female71.475.970.373.00.59Years since first non-Raynaud symptom3.7 ± 1.73.5 ± 1.73.5 ± 1.93.6 ± 1.90.81Diffuse cutaneous SSc47.649.453.556.80.78Anti-topoisomerase I antibody positive61.958.466.356.80.44High sensitivity C-reactive protein, mg/L5.1 ± 8.97.8 ± 23.05.6 ± 9.94.2 ± 4.40.62Modified Rodnan skin score9.3 ± 7.310.5 ± 8.411.9 ± 9.712.7 ± 11.30.29History of gastroesophageal reflux disease (GERD)76.272.978.278.40.62Extent (%) of fibrotic ILD on HRCT*26.4 ± 16.235.5 ± 20.436.6 ± 21.840.8 ± 23.50.12Presence of honeycombing on HRCT14.316.815.526.50.94Presence of ground glass opacities on HRCT81.086.689.784.80.51FVC % predicted77.1 ± 18.071.7 ± 17.273.3 ± 15.274.2 ± 14.80.33DLco % predicted61.5 ± 14.953.4 ± 14.851.1 ± 15.147.3 ± 14.50.02Taking mycophenolate71.448.245.535.10.09

Data are mean ± SD or % at baseline. Missing data were excluded. *Assessed visually in whole lung to nearest 5%. The assessment did not include pure (non-fibrotic) ground glass opacities.

Conclusion

These findings suggest that in the SENSCIS trial, patients who had higher DLCO % predicted or who were taking mycophenolate at baseline were less likely to show progression of SSc-ILD over 52 weeks.

Acknowledgements

The SENSCIS trial was funded by Boehringer Ingelheim. Oliver Distler was a member of the SENSCIS trial Steering Committee.

Disclosure of Interests

Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Lilly, Medscape, Merck Sharp & Dohme, Roche, Paid instructor for: Boehringer Ingelheim, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Eric Hachulla Speakers bureau: Johnson & Johnson, GlaxoSmithKline, Roche-Chugai; and research funding from CSL Behring, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Consultant of: Bayer, Boehringer Ingelheim, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Sanofi-Genzyme, Grant/research support from: GlaxoSmithKline, Roche-Chugai, Sanofi-Genzyme, Ariane Herrick Speakers bureau: Janssen, Consultant of: Arena, Boehringer Ingelheim, Camurus, CSL Behring, Gesynta, Grant/research support from: Gesynta, Teng Moua: None declared, Gabriela Riemekasten Speakers bureau: Boehringer Ingelheim, Janssen, Consultant of: Boehringer Ingelheim, Janssen, Madelon Vonk Speakers bureau: Boehringer Ingelheim, Bristol-Myers Squibb, GlaxoSmithKline, Janssen, MSD, Novartis, Roche, Consultant of: Boehringer Ingelheim, Corbus, Janssen, Grant/research support from: Boehringer Ingelheim, Ferrer, Galapagos, Janssen, Alexandra James Employee of: Alexandra James is an employee of Elderbrook solutions GmbH that is contracted by Boehringer Ingelheim, Margarida Alves Employee of: Margarida Alves is employee of Boehringer Ingelheim, Oliver Distler Speakers bureau: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Speaker fee: Bayer, Boehringer Ingelheim, Janssen, Medscape

, Consultant of: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Consultancy fee: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur

OD has/had relationships with the following companies in the area of potential treatments for arthritides in the last three calendar years:

Consultancy fee: Abbvie

, Grant/research support from: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Research Grants: Boehringer Ingelheim, Kymera, Mitsubishi Tanabe

POS0471 INDUCED ANTIBODIES DIRECTED TO THE ANGIOTENSIN RECEPTOR TYPE 1 PROVOKE SKIN AND LUNG INFLAMMATION AND DERMAL FIBROSIS AND ACT SPECIES OVERARCHING

Background

Antibodies directed to the angiotensin receptor type 1 (AT1R) were found to be increased in patients with SSc ad they predict mortality and SSc complications (1, 2). In vitro studies suggested an involvement in the pathogenesis of systemic sclerosis (SSc).

Objectives

Here, we aim to determine the contribution and functions of AT1R autoantibodies (Abs) in vivo and in vitro as well as their capacity to recognize AT1R from different species.

Methods

C57BL/6J mice were immunized with membrane-embedded human AT1R or empty membrane as control. Phenotypic properties of various organs were examined by immunohistochemistry, immunofluorescence, and TUNEL apoptosis assay. A monoclonal (m)AT1R Ab was generated based upon this mouse model by hybridoma technology and transferred into C57BL/6J mice. Mice deficient for CD4+ and CD8+ T cells, B cells and AT1Ra/b served as controls. In vitro, Abs responses towards AT1R were measured using rat cardiomyocytes, human epithelial cells, AT1R-transfected HEK293 cells and primary human monocytes.

Results

AT1R-immunized mice developed perivascular skin and lung inflammation, lymphocytic alveolitis, weak endothelial apoptosis and skin fibrosis, not present in controls or mice deficient for CD4+ T and B cells. The contribution of AT1R Abs to skin manifestations and interstitial lung disease was demonstrated by application of a mAT1R Ab, which induced skin and lung inflammation, not observed in the AT1Ra/b knockout mice. IgG from immunized mice containing AT1R Abs and/or the mAT1R Ab activated rat cardiomyocytes and human monocytes. Treatment of AT1R-transfected HEK293 cells with the mAT1R Ab enhanced AT1R signaling in the presence of the endogenous agonist Angiotensin II.

Conclusion

Our immunization strategy successfully induced AT1R Abs, contributing to inflammation and most likely to fibrosis via activation of AT1R. Therefore, AT1R Abs are valuable targets for future therapies in SSc and possibly other AT1R Ab-related diseases.

References

[1]Riemekasten, G. et al. Involvement of functional autoantibodies against vascular receptors in systemic sclerosis. Ann. Rheum. Dis. 70, 530–536 (2011).

[2]Becker, M. O. et al. Vascular receptor autoantibodies in pulmonary arterial hypertension associated with systemic sclerosis. Am. J. Respir. Crit. Care Med. 190, 808–817 (2014).

Figure 1.

AT1R immunization and induction of AT1R Abs in C57BL/6J mice induced lymphocytic alveolitis in bronchoalveolar fluid (A), interstitial lung disease (B) with increased inflammatory score (C)

Figure 2.

AT1R immunization and induction of AT1R Abs in C57BL/6J mice induced skin fibroses (A) as determined by collagen content (B) and skin thickness (C).

Acknowledgements

This manuscript was founded by the German Research Council RI1056/11-1-3 and the Excellence Cluster Precision Medicine in Inflammation and by the BMBF-founded Mesinflame project.

Disclosure of Interests

None declared.

POS0140 PREDICTING OUTCOMES IN SYSTEMIC SCLEROSIS: STRATIFICATION BY AUTO-ANTIBODIES OUTPERFORMS CUTANEOUS SUBSETTING IN THE EUSTAR COHORT

Background

Risk-stratification is key in a heterogeneous disease like systemic sclerosis (SSc). Until now, SSc patients are stratified according to the extent of skin involvement into limited cutaneous, diffuse cutaneous and sine scleroderma subtypes. However, this classification remains inaccurate to capture disease heterogeneity. Autoantibodies are found in more than 90% of the patients and can be detected before onset of the disease. Among them, three predominant and specific antibodies are used: anti-centromere, anti-Scl70 and RNA polymerase III antibodies.

Objectives

To compare the performances of stratification into LeRoy’s cutaneous subtypes versus autoantibody status in SSc versus combination of cutaneous subtypes and autoantibodies status.

Methods

Patients from the EUSTAR database were classified either as (i) limited cutaneous, diffuse cutaneous or sine scleroderma (based on the recording made by the treating physician) or (ii) according to autoantibodies with the following subclassifications: (1) no specific autoantibodies, (2) isolated ANA, (3) anti-centromere antibodies, (4) anti-Scl70 antibodies and (5) anti-RNA polymerase III antibodies or (iii) according to combination of cutaneous subset and auto-antibodies. The respective performance of each model to predict overall survival (OS), progression-free survival (PFS), disease progression and different organ involvements was assessed and the three models were compared by the area under the receiver operating characteristic curve (AUC 95%CI) and the net reclassification improvement (NRI). Missing data were imputed through multiple imputation using chain equations.

Results

In all, 10’711 patients were included: 84.6% females, mean age: 54.4±13.8 years, mean disease duration: 7.9±8.2 years. In the prospective analysis (n= 6’467 to 7’829 according to the outcome), after a mean follow-up of 56 months and a mean of three visits per patient, we did not identify any difference in AUC between the cutaneous-based model and the antibody-based model for prediction of OS and disease progression. However, the NRI showed a significant improvement in prediction of OS (0.57 [0.46-0.71] vs. 0.29 [0.19-0.39]) and disease progression (0.36 [0.29-0.46] vs. 0.21 [0.14-0.28]) at 4 years using the antibody-based model. Regarding prediction of each organ involvement in longitudinal analyses, the antibody-based model showed better performance than the cutaneous-one for renal crisis (AUC: 0.719 [0.696-0.742] vs. 0.664 [0.643-0.685]), with the highest association observed with anti-RNA polymerase III (OR: 7.47 [1.63-34.24], p= 0.010). Similarly, the antibody-based model was better than the cutaneous model in predicting lung fibrosis (AUC 0.719 [0.715-724] vs. 0.653 [0.647-0.659]) and restrictive lung fibrosis (AUC 0.759 [0.749-0.766] vs. 0.711 [0.701-0.721]) which were both associated with anti-Scl70 antibodies (OR: 9.29 [8.17-10.55] and 7.92 [5.37-11.69], respectively, p<0.0001 for both). Although there was no difference in the AUC to predict digital ulcers, NRI showed an improvement using the antibody-based model (0.31 [0.29-0.33] vs. 0.24 [0.22-0.26]) with the highest association with anti-Scl70 antibodies (OR: 3.57 [2.68-4.75], p<0.0001). The two models had similar performances in assessing occurrence of intestinal involvement, heart dysfunction or elevated sPAP. Combining both antibody status and cutaneous subtype did not improve the performance of our models. In the exploratory analysis, there was no change using modified Rodnan skin score to define cutaneous form.

Conclusion

Auto-antibody status outperforms the common cutaneous subsetting to risk-stratify SSc patients in the EUSTAR cohort. This easily performed subclassification using autoantibodies specific status can be used by the clinicians to risk-stratify their patients and to adapt disease monitoring in routine practice.

Disclosure of Interests

Muriel Elhai Speakers bureau: BMS outside of the submitted work, Marouane Boubaya: None declared, Nanthara Sritharan: None declared, Alexandra Balbir-Gurman: None declared, Elise Siegert: None declared, Eric Hachulla: None declared, Jeska de Vries-Bouwstra: None declared, Gabriela Riemekasten: None declared, Jörg H.W. Distler: None declared, Douglas Veale: None declared, Edoardo Rosato: None declared, Francesco Del Galdo: None declared, Fabian A Mendoza: None declared, Daniel Furst Consultant of: Abbvie, Novartis, Pfizer, R-Pharm, Grant/research support from: Emerald, Kadmon, PICORI, Pfizer,Prometheus, Talaris, Mitsubishi, Carlos De la Puente Bujidos: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Armando Gabrielli: None declared, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Coralie Bloch-Queyrat: None declared, Yannick Allanore Consultant of: Actelion, Bayer, BMS, Boehringer-Ingelheim, Inventiva, Roche, Sanofi-Aventis, Grant/research support from: Actelion, Bayer, BMS, Boehringer-Ingelheim, Inventiva, Roche, Sanofi-Aventis

POS0063 PROGRESSIVE INTERSTITIAL LUNG DISEASE IS FREQUENT ALSO IN LATE DISEASE STAGES IN SYSTEMIC SCLEROSIS PATIENTS FROM EUSTAR

Background

Short disease duration is a predictor for progressive systemic sclerosis-associated interstitial lung disease (SSc-ILD), but studies assessing ILD progression in later disease stages are lacking. To individually tailor management of ILD in SSc patients in clinical practice it is, however, of high importance to understand disease behaviour also in patients with late disease.

Objectives

Analyse ILD progression in SSc-ILD patients from the EUSTAR cohort segregated by subgroups of disease duration.

Methods

We segregated SSc-ILD patients into four categories of disease duration (≤3 years, >3- ≤7 years, >7- ≤15 years and >15 years after onset of Raynaud’s phenomenon). We assessed progressive ILD, defined as forced vital capacity (FVC) decline >10% or FVC decline ≥10% and FVC decline 5–10% and diffusing capacity of the lungs for carbon monoxide (DLCO) decline ≥15% (composite decline) over the first and second 12+/-3 months period after first registration (baseline) into EUSTAR. Clinical characteristics, pulmonary involvement, treatment at first registration and ILD progression were evaluated by descriptive statistics.

Results

In total, 2258 SSc-ILD patients were included, with 469 (20.8%) having a disease duration ≤3 years, 550 (24.4%) between >3- ≤7 years, 752 (33.3%) between >7- ≤15 years and 488 (21.6%) of >15 years (Table 1). Baseline characteristics and treatment patterns differed between the four subgroups, with more younger male patients with diffuse cutaneous SSc, anti-topoisomerase I antibody and higher Rodnan skin score having ≤3 years disease duration. Lung function with FVC and DLCO were similar between the four groups (Table 1). Notably, in the first and second 12+/-3 months periods after first registration in the EUSTAR database, there were no significant difference in FVC decline >10% or composite FVC and DLCO decline within the four subgroups. For example, patients with disease duration >7- ≤15 years and >15 years frequently showed disease progression of FVC >10%: 41/347 (11.8%) and 32/228 (14%) compared to 38/244 (15.6%) and 33/273 (15.6%) for disease duration ≤3 years and >3- ≤7 years (P=0.529), respectively (Figure 1).

Table 1.

Demographics and baseline clinical characteristics of EUSTAR patients

Disease duration≤ years(n=460)>3- ≤7 years(n=550)>7- ≤15 years(n=752)>15 years(n=488)p-valueAge, years (SD)55 (13.5)55 (14.1)57 (13.1)61 (11.5)<0.001Male, n (%)123 (26.2)115 (20.9)112 (14.9)38 (7.8)<0.001DcSSc, n (%)228 (56.4)262 (45.8)311 (45.4)163 (31.2)<0.001ATA, n (%)236 (53.4)293 (55.9)374 (52.8)218 (48.0)0.099mRSS, mean (SD)12.3(10.1)10.4 (8.3)9.4 (8.1)8.7 (7.7)<0.001GERD, n/N (%)273 (58.7)353 (64.4)482 (64.4)344 (71.2)0.001ESR, mean (SD)26.9(21.7)24.2 (19.5)26.2 (19.9)28.3 (21.2)0.022MMF, n/N (%)33 (16.6)43 (25.2)37 (20.4)14 (9.3)0.002MTX, n/N (%)19 (10)17 (10.1)19 (10.6)8 (5.2)0.296Any IS, n/N (%)81 (38.6)89 (47.1)82 (40.8)46 (28.7)0.006FVC % pred, mean (SD)86 (20.9)87 (21.6)86 (21.4)87 (22.8)0.770DLCO % pred, mean (SD)58 (19.3)59 (19.3)59 (19.9)58 (19.7)0.405NYHA class 3&4, n (%)84 (18.6)78 (14.6)125 (17.5)22.6 (7.0)0.090Figure 1.

FVC decline >10% and composite FVC and DLCO decline in the first and second 12+/-3 months within the four subgroups segregated by disease duration

Conclusion

It was long believed that ILD burned out in late disease stages. In our analysis of ILD progression by four disease duration categories, we showed that ILD frequently progressed also in late disease stages. This has important implications for clinical practise, as SSc patients need to be regularly monitored for ILD progression independent of disease duration.

Disclosure of Interests

Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Cathrine Brunborg: None declared, Paolo Airò Speakers bureau: Bristol-Myers-Squibb, Boehringer Ingelheim, Consultant of: Bristol-Myers-Squibb, Grant/research support from: Bristol-Myers-Squibb, Roche, Jannsen, CSL Behring, Lidia P. Ananyeva Speakers bureau: Boehringer Ingelheim, Grant/research support from: Boehringer Ingelheim, László Czirják Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Actelion (now GSK), MSD, Novartis, Pfizer, Roche, Lilly, Grant/research support from: Boehringer Ingelheim, Actelion (now GSK), MSD, Novartis, Pfizer, Serena Guiducci: None declared, Eric Hachulla Speakers bureau: GSK, Roche-Chugai, Johnson & Johnson, Boehringer Ingelheim, Consultant of: CSL Behring, GSK, Roche-Chugai, Johnson & Johnson, Boehringer Ingelheim, Grant/research support from: CSL Behring, Boehringer Ingelheim, GSK, Roche-Chugai, Sanofi Genzyme, Mengtao Li: None declared, Carina Mihai Speakers bureau: MEDtalks Switzerland, Mepha, Grant/research support from: Roche, Boehringer Ingelheim, Janssen, Gabriela Riemekasten Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Petros Sfikakis Consultant of: Boehringer Ingelheim, Gabriele Valentini Consultant of: Boehringer Ingelheim, Grant/research support from: Sanofi/BMS, Otylia Kowal-Bielecka Speakers bureau: Boehringer Ingelheim, Novartis, Pfizer, Gilead Sciences, Janssen-Cilag, MEDAC, MSD, Abbvie, Sandoz, Consultant of: Boehringer Ingelheim, Health Care system Navigator, CSL Behring, MSD, Novartis, Grant/research support from: CSL Behring, Boehringer Ingelheim, Abbvie, Roche, MEDAC, Yannick Allanore Speakers bureau: Boehringer, Abbvie, Consultant of: Boehringer, Bayer, Astra-Zeneca, Prometheus, Sanofi, Genentech/Roche, Boehringer, Grant/research support from: Alpine Immunosciences, OSE Immunotherapeutics, Medsenic, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim

POS0872 SERUM LEVEL OF SOLUBLE INTERLEUKIN-2 RECEPTOR IS LINKED TO BETA2-MICROGLOBULINE, NT-PRO BNP AND HIGH-SENSITIVITY TROPONIN T AND MAY HELP TO IDENTIFY PATIENTS WITH EARLY CLINICAL PROGRESS IN SSc

Background

Systemic sclerosis (SSc) is characterized by chronic inflammation that leads to damage of the vascular endothelium and excessive collagen deposition in several target organs (1). The interaction of interleukin 2 (IL-2) with the corresponding receptor (IL-2R) is involved in the regulation of autoimmune processes (2). The shedding product of the IL-2R alpha chain, soluble IL-2 receptor (sIL-2R, CD25), is able to either reduce or enhance immune responses (2). Previously, elevated serum levels of sIL-2R were found in the bronchoalveolar lavage of SSc patients with interstitial lung disease (SSc-ILD) as well as serologically in patients with early SSc, and thus suggested to be a biomarker for clinical development of SSc (3,4).

Objectives

To examine concentrations of sIL-2 in patients with SSc and analyse their association with clinical and serological parameters.

Methods

To determine if serological levels of sIL-2R serve as predictor of clinical complications in SSc, sera were analysed [limited cutaneous SSc (lcSSc) n=160; diffuse cutaneous SSc (dSSc), n=137] using a sandwich ELISA. Clinical data (pulmonary fibrosis, PAH, mRSS, therapy) and serological markers (hs-CRP, NT-pro BNP, neutrophil counts, creatinine, hs-troponin T, creatinine kinase, beta2-microglobuline) were assessed at the time of serum sampling and up to 48 months after baseline. Clinical progress was defined by the need to change therapies.

Results

Patients with dSSc presented elevated levels of sIL-2R compared to SSc (dSSc: 673±428 U/ml vs. 646±473 U/ml, p=0.0001). In SSc general, sIL-2R levels correlated with beta2-microglobuline (r=0.6161, p<0.0001, ROC-AUC:0.8428), hs-CRP (r=0.4091, p<0.0001, ROC-AUC:0.7110), NT-proBNP (r=0.2610, p<0.0001, ROC-AUC:0.6793), neutrophil count (r=0.2749, p<0.0001) and hs-troponin T (r=0.4548, p<0.0001, ROC-AUC:0.8729). Further, sIL-2R levels discriminated normal from pathological levels of hs-troponin T (sensitivity 80.0%, specificity 80.1%). Using Log-rank test and Mantel-Cox proportional hazard models, we found that sIL-2R levels above 745.5 U/ml predicted early clinical progress in SSc (HR: 3.45, p=0.0070, Figure 1) within 12 months.

Figure 1.

Kaplan-Meier survival analysis for the complete group of patients with SSc. Soluble Il-2R levels above 745U/ml were associated with early progress in SSc.

Conclusion

In SSc, serum levels of sIL-2R could be of diagnostic value by identifying clinical progress. Its role in pathophysiology, especially with regard to disease manifestations such as cardiac involvement needs to be investigated in more detail.

References

[1]Blagojevic J et al. Use of vasoactive/vasodilating drugs for systemic sclerosis (SSc)-related digital ulcers (DUs) in expert tertiary centres: results from the analysis of the observational real.life DeSScipher study. Clin Rheumatol. 2020Jan;39(1):27-36.

[2]Damoiseaux J The Il-2-Il-2 receptor pathway in health and disease: The role of the soluble IL-2 receptor. Clin Immunol 2020;Sep;218:108515

[3]Martinez JA et al. Elevation of soluble interleukin-2 receptor levels in thebronchoalveolar lavage from patients with systemic sclerosis. Rheumatol Int. 2001 Nov;21(3):122-6

[4]Valentini G et al. Early systemic sclerosis: short-term disease evolution and factors predicting the development of new manifestations of organ involvement. Arthritis Res Ther 2012 Aug17;14(4):R188

Disclosure of Interests

None declared

OP0158 COHORT ENRICHMENT STRATEGIES FOR PROGRESSIVE INTERSTITIAL LUNG DISEASE IN SYSTEMIC SCLEROSIS FROM EUSTAR

Background

Enrichment strategies from clinical trials for progressive systemic sclerosis-associated interstitial lung disease (SSc-ILD) have been partly successful but have not been tested in a real life cohort.

Objectives

Analyse the efficacy, representativeness and feasibility of enrichment strategies in SSc-ILD patients from the EUSTAR cohort.

Methods

We applied the inclusion criteria of major recent SSc-ILD trials (focuSSced, SLS II and SENSCIS) in SSc-ILD patients and assessed progressive ILD, defined as absolute change in forced vital capacity (FVC) and as significant progression (FVC decline >10%) over time. Data were compared to all patients and patients not fulfilling any inclusion criteria.

Results

In total, 2258 SSc-ILD patients were included, with 31.2% meeting SENSCIS, 5.8% SLS II, 1.6% focuSSced criteria and 1529 (67.7%) not meeting any criteria (Table 1). In the first 12+/-3 months, a slow FVC% decline of –0.1% was seen in the total, unselected cohort and in patients fulfilling SENSCIS criteria. Patients fulfilling criteria from focuSSced showed a strong FVC decline of –3.7%. Notably, patients enriched for SLS II criteria showed FVC improvement of +2.3% (Figure 1). Similarly, compared to the total unselected cohort, the number of significant progressive events was numerically higher in patients fulfilling focuSSced criteria, the same for SENSCIS criteria and even slightly lower for patients fulfilling the SLS2 criteria.

Table 1.

Demographics and baseline clinical characteristics of EUSTAR patients

Not fulfilling any criteria (n=1529)focuSSced (n=36)SLS II (n=132)SENSCIS (n=704)Age, years (SD)58.4 (2.9)51.5 (12.2)†51.2 (12.7) †54.2 (13.8) †Male, n (%)231 (15.1)7 (19)35 (27)**156 (21)*Disease duration, months (SD)156.3 (99.4)16.1 (13.9)†40.7 (25.2) †39.4 (23.9) †DcSSc, n (%)597 (43.8)36 (100) †85 (65) †35 (52) †ATA, n (%)735 (51.1)24 (67)*85 (69) †370 (56)mRSS, mean (SD)9.5 (8.3)21 (6.5)*13 (9.6)*11 (9.2)GERD, n (%)1002 (65.9)25 (69)92 (70)430 (62)ESR, mean (SD)27 (20.5)43.1 (23) †29.6 (19.6) †24.7 (20.7)MMF, n (%)75 (16.5)0 (0) †0 (0) †52 (22) †MTX, n (%)42 (9.2)0 (0) †2 (5)20 (9)FVC % predicted, mean (SD)85.7 (22.5)88 (13.6)*66 (9.1) †88 (19.8)DLCO% predicted, mean (SD)58.9 (21.5)61 (12.7)49(14.6)†59 (14.2)NYHA class, n (%)3261 (17.8)6 (19)28 (21)72 (10)*440 (2.7)0 (0)3 (2)4 (1)*

*P-value: 0.001–0.05; †P<0.001, between focuSSced, SENSCIS or SLS compared with not fulfilling any study criteria.

In the second 12 months period, SENSCIS enriched patients had a further absolute FVC% decline as described for the total cohort. In contrast, patients fulfilling the focuSSced and SLS II inclusion criteria showed numerical improvement of lung function in the second period (Figure 1). There were no significant associations of enrichment criteria and ILD progression in the second period.

Over the mean observation period of 2.3 years, patients not fulfilling any inclusion criteria showed the same FVC decline of –0.9 (12.1) as observed for the total cohort (–0.9% (12.6)). There were numerical differences in FVC changes in the enriched patient cohorts, varying from –2.8% FVC decline in patients fulfilling the focuSSced criteria to +3.4% FVC improvement with SLS II criteria.

Conclusion

Application of enrichment criteria from previous clinical trials showed enrichment for progression with variable success but led to selected patient populations reducing feasibility of recruitment. These findings are important for future clinical trial design and interpretation of the results of published trials.

Acknowledgements

We thank all EUSTAR collaborators.

Disclosure of Interests

Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Cathrine Brunborg: None declared, Paolo Airò Speakers bureau: Bristol-Myers-Squibb, Boehringer Ingelheim, Consultant of: Bristol-Myers-Squibb, Grant/research support from: Bristol-Myers-Squibb, Roche, Jannsen, CSL Behring, Lidia P. Ananyeva Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, László Czirják Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Actelion (now GSK), MSD, Novartis, Pfizer, Roche, Lilly, Grant/research support from: Boehringer Ingelheim, Actelion (now GSK), MSD, Novartis, Pfizer, Serena Guiducci: None declared, Eric Hachulla Speakers bureau: GSK, Roche-Chugai, Johnson & Johnson, Boehringer Ingelheim, Consultant of: CSL Behring, GSK, Roche-Chugai, Johnson & Johnson, Boehringer Ingelheim, Grant/research support from: CSL Behring, Boehringer Ingelheim, GSK, Roche-Chugai, Sanofi Genzyme, Mengtao Li: None declared, Carina Mihai Speakers bureau: MEDtalks Switzerland, Mepha, Grant/research support from: Roche, Boehringer Ingelheim, Janssen, Gabriela Riemekasten Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Petros Sfikakis Consultant of: Boehringer Ingelheim, Gabriele Valentini Consultant of: Boehringer Ingelheim, Sanofi, Grant/research support from: BMS, Otylia Kowal-Bielecka Speakers bureau: Boehringer Ingelheim, Novartis, Pfizer, Gilead Sciences, Janssen-Cilag, MEDAC, MSD, Abbvie, Sandoz, Consultant of: Boehringer Ingelheim, Health Care system Navigator, CSL Behring, MSD, Novartis, Grant/research support from: CSL Behring, Boehringer Ingelheim, Abbvie, Roche, MEDAC, Yannick Allanore Speakers bureau: Boehringer, Abbvie, Consultant of: Boehringer, Bayer, Astra-Zeneca, Prometheus, Sanofi, Genentech/Roche, Boehringer, Grant/research support from: Alpine Immunosciences, OSE Immunotherapeutics, Medsenic, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim

POS0335 THE POTENTIAL ROLE OF IL13 IN VASCULOPATHY IN SYSTEMIC SCLEROSIS PATIENTS

Background:

Systemic sclerosis (SSc) is a heterogeneous disease characterized by fibrosis, vasculopathy and autoimmunity. Dysfunctions causing disease pathology are characterized by the activation and recruitment of immune cells, as well as the formation of autoantibodies and cytokines. Profibrotic cytokines, such as interleukin-(IL)13, IL4 or IL6 play a crucial role in collagen production and fibrosis development [1]. Preliminary data reveal IL13 as a main driver for obliterative vasculopathy characterized by severe Raynaud phenomenon, acral ulcers and pulmonary arterial hypertension (PAH). Particularly acral ulcerations lead to a severe impairment in functional capacity in everyday life. In addition, pulmonary arterial hypertension is one of the main causes of the high mortality rate in SSc [2].

Objectives:

To prove the impact of IL13 in the pathogenesis of systemic sclerosis and thus provide the rationale for the identification of a potential new therapeutic target, we investigated IL13 expression in CD4 and CD8 T cells in patients suffering from systemic sclerosis compared to healthy controls.

Methods:

Peripheral blood mononuclear cells (PBMC) obtained from systemic sclerosis (SSc, n=31) patients and healthy controls (HC, n=13) were cultured without or in the presence of phorbol myristate acetate and ionomycin to activate T cells for cytokine production. Brefeldin A was used as an inhibitor of cytokine secretion. The intracellular IL13 and IL4 expression of CD4 and CD8 positive T cells were measured by flow cytometry and were compared between the investigated subgroups.

To identify a disease phenotype mediated by IL13, the expression levels in the SSc group were correlated to clinical, laboratory and apparative parameters assessing organ dysfunction.

Results:

While there were no significant differences in IL4 expression between healthy and diseased individuals, analyses of IL13 positive CD4 and CD8 T cells showed significant differences compared to HC (CD8+IL13 p=0.048; CD4+IL13 p=0.0046) revealing the functional differences though high structural homology of the two interleukins. The increased expression of IL13 in T cells from patients with systemic sclerosis further supports the assumption of an interleukin mediated pathomechanism. Considering the IL13-mediated clinical phenotype, high levels were detected in patients showing signs for vasculopathy, correlation with sPAP (CD8+IL13 p=0.0392), NTproBNP (CD4+IL13 p=0.0461), creatinine (CD4+IL13 p=0.0227), angiotensin II receptor type I and endothelin receptor type A antibodies (CD4+IL13 p=0.0105, p=0.0042) was demonstrated. In addition, patients in the fourth quartile of CD4+IL13 expression showed a higher incidence of acral ulcers and pits than patients with low interleukin levels. Moreover, this group of patients had an increased cardiovascular comorbidity including atherosclerosis, coronary heart disease and arterial hypertension.

Conclusion:

Increased IL13 levels could be detected in patients with SSc, especially in patients with the phenotype of an obliterative vasculopathy. This indicates preliminary evidence for the use of IL13 blockers as a new therapeutic approach in systemic sclerosis.

References:

[1]Furue M, Mitoma C, Mitoma H, Tsuji G, Chiba T, Nakahara T, Uchi H, Kadono T. Pathogenesis of systemic sclerosis-current concept and emerging treatments. Immunol Res. 2017 Aug;65(4):790-797. doi: 10.1007/s12026-017-8926-y.

[2]Tyndall AJ, Bannert B, Vonk M, et alCauses and risk factors for death in systemic sclerosis: a study from the EULAR Scleroderma Trials and Research (EUSTAR) database Annals of the Rheumatic Diseases 2010;69:1809-1815. doi: 10.1136/ard.2009.114264

Disclosure of Interests:

None declared

POS0318 CLINICAL PHENOTYPE IN SCLERODERMA PATIENTS WITH ANTI-TOPOISOMERASE I POSITIVITY AND LIMITED CUTANEOUS FORM: DATA FROM THE EUSTAR DATABASE

Background:

There is renewed interest in the role of autoantibodies to predict outcomes in systemic sclerosis (SSc). Among the newly identified subsets, patients with limited cutaneous form (lcSSc) but anti-topoisomerase I antibodies (Scl70) positivity draw particular attention, and namely, assessing the risk of developing interstitial lung disease (ILD) —the main cause of death in SSc—to improve the management of Scl70-lcSSc patients.

Objectives:

We aimed to characterize patients with Scl70-lcSSc in the large multicenter European Scleroderma Trial and Research (EUSTAR) cohort.

Methods:

The EUSTAR database was locked in July 2019. We included all patients fulfilling 1980 ACR and/or 2013 ACR/EULAR criteria for SSc, with disease duration at database entry ≤3 yrs and known and stable skin form during the first 3 yrs. Patients with lcSSc were compared: Scl70-lcSSc (target group) vs. ACA-lcSSc and ANA-lcSSc (Step 1); and Scl70-lcSSc vs. Scl70-dcSSc (Step 2). In the ANA subgroup we included ANA+ patients with negative SSc-specific antibodies (Scl70, ACA, RNA polymerase III). In each step, we performed 5 generalized mixed models (GMM) for the risk of the new onset of ILD (defined by imaging), primary myocardial involvement (PMI), pulmonary hypertension (PH), “any severe” (ILD+PMI+PH+scleroderma renal crisis) and all-cause-mortality. An additional GMM assessed the risk of forced vital capacity (FVC) decline ≥10% vs. FVC value at ILD onset. Each GMM was adjusted for age, sex and confounders.

Results:

Overall, 1285 SSc patients were included: 1068 (83%) females, 860 (67%) lcSSc and 425 (33%) dcSSc. Among patients with lcSSc, 537 (62%) had ACA+, 194 (23%) Scl70+ and 129 (15%) ANA+; 425 patients had dcSSc and Scl70+. Median follow-up was similar in all 4 groups: 7.2 to 8.1 yrs.

Step 1: At baseline, Scl70-lcSSc patients had significantly shorter time from Raynaud’s phenomenon (RP) to SSc onset, higher mRSS (5.8±4.8 vs. 4.3±4, p=0.001), and higher rate of articular and muscular involvement vs. ACA-lcSSc patients (Figure 1). No differences were found between Scl70-lcSSc and ANA-lcSSc comparing the aforementioned variables. ILD was more frequent in Scl70-lcSSc (46%) than in ACA-lcSSc (10%) and ANA-lcSSc (25%), as well as restrictive lung disease. GMM showed that Scl70-lcSSc carries a higher risk of ILD than both ACA-lcSSc (HR 4.55, 95%CI 3.23-6.67) and ANA-lcSSc (HR 2.17, 95%CI 1.39-3.45), with a rate of FVC decline ≥10% over time similar to the other limited forms. In Scl70-lcSSc patients the risk of “any severe” organ involvement was similar to ANA-lcSSc and higher than ACA-lcSSc (HR 1.89, 95%CI 1.40-2.50). In particular, Scl70-lcSSc shows a risk of PMI similar to ANA-lcSSc and lower than ACA-lcSSc; no differences regarding PH risk. The mortality risk in patients with Scl70-lcSSc was similar to the other limited forms’.

Step 2: At baseline, time from RP to SSc onset was longer in patients with Scl70-lcSSc, with less frequent joint synovitis and tendon friction rubs vs. patients with Scl70-dcSSc. Conversely, the frequency of muscular, cardiac and pulmonary involvement was similar. The risk of ILD in Scl70-lcSSc patients was similar to Scl70-dcSSc, with a lower risk of FVC decline ≥10% over time. The risk of “any severe” involvement (HR 0.66, 95%CI 0.49-0.83), PMI and PH was lower and the mortality risk tended to be lower (HR 0.57, 95%CI 0.33-1.01, p=0.053) vs. Scl70-dcSSc.

Conclusion:

In our large multicenter EUSTAR cohort one quarter of lcSSc patients were Scl70+. We show a ranking for major organ involvement within lcSSc: Scl70 the most severe, ANA+ intermediate and ACA the milder form. Scl70-dcSSc patients present the most severe phenotype, and Scl70 positivity, more than the cutaneous subset, is strongly predictive of ILD, whereas other variables may influence progression. These results may provide new insight to improve the management of Scl70-lcSSc patients.

Disclosure of Interests:

Elisabetta Zanatta: None declared, Dörte Huscher: None declared, Paolo Airò: None declared, Alexandra Balbir-Gurman: None declared, Elise Siegert: None declared, Augusta Ortolan: None declared, Marco Matucci-Cerinic: None declared, Franco Cozzi: None declared, Gabriela Riemekasten: None declared, Anna-Maria Hoffmann-Vold: None declared, Oliver Distler Speakers bureau: has/had consultancy relationship and/or has received research funding in the area of potential treatments for systemic sclerosis and its complications from (last three years): Abbvie, Acceleron Pharma, Amgen, AnaMar, Arxx Therapeutics, Baecon Discovery, Blade Therapeutics, Bayer, Boehringer Ingelheim, ChemomAb, Corbus Pharmaceuticals, CSL Behring, Galapagos NV, Glenmark Pharmaceuticals, GSK, Horizon (Curzion) Pharmaceuticals, Inventiva, iQvia, Italfarmaco, iQone, Kymera Therapeutics, Lilly, Medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Novartis, Pfizer, Roche, Sanofi, Serodapharm, Topadur, Target Bioscience and UCB. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Consultant of: has/had consultancy relationship and/or has received research funding in the area of potential treatments for systemic sclerosis and its complications from (last three years): Abbvie, Acceleron Pharma, Amgen, AnaMar, Arxx Therapeutics, Baecon Discovery, Blade Therapeutics, Bayer, Boehringer Ingelheim, ChemomAb, Corbus Pharmaceuticals, CSL Behring, Galapagos NV, Glenmark Pharmaceuticals, GSK, Horizon (Curzion) Pharmaceuticals, Inventiva, iQvia, Italfarmaco, iQone, Kymera Therapeutics, Lilly, Medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Novartis, Pfizer, Roche, Sanofi, Serodapharm, Topadur, Target Bioscience and UCB. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Grant/research support from: Kymera Therapeutics, Mitsubishi Tanabe, Armando Gabrielli: None declared, Stefan Heitmann: None declared, Nicolas Hunzelmann: None declared, Carlomaurizio Montecucco: None declared, Jadranka Morovic-Vergles: None declared, Camillo Ribi: None declared, Andrea Doria: None declared, Yannick Allanore: None declared

OP0266 EFFICACY OF NINTEDANIB IN PATIENTS WITH SYSTEMIC SCLEROSIS-ASSOCIATED INTERSTITIAL LUNG DISEASE (SSC-ILD) AND INTERNAL ORGAN INVOLVEMENT: DATA FROM THE SENSCIS TRIAL

Background:

SSc is a heterogeneous autoimmune disease characterised by fibrosis of the skin and internal organs. In most patients with SSc-ILD, organs other than the lungs are also affected. In the SENSCIS trial in patients with SSc-ILD, nintedanib reduced the rate of decline in forced vital capacity (FVC) (mL/year) over 52 weeks by 44% versus placebo.

Objectives:

We investigated the extent of organ involvement related to SSc at baseline in patients in the SENSCIS trial and the effect of nintedanib versus placebo on the rate of FVC decline in subgroups by internal organ involvement.

Methods:

The SENSCIS trial enrolled patients with SSc-ILD with first non-Raynaud symptom ≤7 years before screening, extent of fibrotic ILD ≥10% on high-resolution computed tomography (HRCT) and FVC ≥40% predicted. Patients with clinically significant pulmonary hypertension were excluded. Patients were randomised to receive nintedanib or placebo until the last patient reached week 52 but for ≤100 weeks. In post-hoc analyses, we analysed the rate of decline in FVC (mL/year) over 52 weeks in subgroups with and without different types of SSc-related internal organ involvement (upper gastrointestinal; lower gastrointestinal; cardiovascular [CV]; peripheral vascular; muscular; joint). These subgroups were defined based on patients’ SSc-related medical history as reported in the case report form. A random slope and intercept model was used to assess the rate of decline in FVC (mL/year) and an interaction test applied to assess potential heterogeneity in the treatment effect of nintedanib between the subgroups.

Results:

Of 576 patients, 96.9% had peripheral vascular involvement, 75.5% had upper gastrointestinal and 39.8% lower gastrointestinal involvement, 45.7% had CV involvement, 40.6% had joint involvement, and 27.1% had muscular involvement at baseline. In the placebo group, the rate of decline in FVC (mL/year) was numerically greater in patients with than without upper gastrointestinal involvement and in patients without than with joint involvement or muscular involvement (Figure). The exploratory interaction p-values did not indicate heterogeneity in the treatment effect of nintedanib versus placebo on reducing the rate of decline in FVC (mL/year) between the subgroups based on organ involvement (p>0.05 for all treatment-by-time-by-subgroup interactions) (Figure).

Conclusion:

Patients in the SENSCIS trial had diverse complications related to SSc. There was no evidence of a differential treatment effect of nintedanib on reducing the rate of decline in FVC based on gastrointestinal, CV, joint, or muscular involvement at baseline.

Acknowledgements:

The SENSCIS trial was funded by Boehringer Ingelheim. Medical writing support was provided by FleishmanHillard Fishburn, London, UK. The authors meet criteria for authorship as recommended by the International Committee of Medical Journal Editors (ICMJE).

Disclosure of Interests:

Yannick Allanore Consultant of: Boehringer Ingelheim, Medsenic, Menarini and Sanofi, Grant/research support from: Alpine Pharmaceuticals, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Lilly, MSD and Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Lilly, Medscape, MSD and Roche, Grant/research support from: Boehringer Ingelheim, Maureen Mayes Consultant of: Paid consultant or member of Advisory Board/Steering Committee for Boehringer Ingelheim, Eicos, Galapagos and Mitsubishi Tanabe Pharma, Grant/research support from: Clinical trial research support from Boehringer Ingelheim, Corbus, Eicos and Galapagos, Madelon Vonk Speakers bureau: Boehringer Ingelheim, GlaxoSmithKline, Janssen and Roche, Consultant of: Boehringer Ingelheim and Janssen, Grant/research support from: Boehringer Ingelheim, Ferrer, Galapagos and Janssen, Corinna Miede Employee of: Currently an employee of mainanalytics GmbH, contracted by Boehringer Ingelheim, Margarida Alves Employee of: Currently an employee of Boehringer Ingelheim, Gabriela Riemekasten Speakers bureau: Actelion, Boehringer Ingelheim, Cellgene, GlaxoSmithKline, Janssen, Novartis and Roche, Consultant of: Actelion, Boehringer Ingelheim and Janssen, Grant/research support from: Janssen

POS1449 SEGMENTED SHORT-FORMAT ONLINE EDUCATION SIGNIFICANTLY INCREASES PREDICTION, PROGNOSIS, AND MANAGEMENT OF FIBROSING INTERSTITIAL LUNG DISEASE ASSOCIATED WITH CONNECTIVE TISSUE DISEASE

Background:

Identifying fibrosing interstitial lung disease (ILD) at the earliest opportunity remains one of the most urgent challenges for the effective management of this potentially rapidly progressive and burdensome condition, which is frequently associated with several connective tissue diseases (CTDs). However, knowledge on how to identify early hallmarks and predictors of fibrosing ILD, as well as knowing which steps to take next is frequently lacking in clinical practice.

Objectives:

This study was conducted to determine whether online independent medical education could improve rheumatologists’ and pulmonologists’ knowledge and competence in identifying and managing progressive fibrosing ILDs earlier in the disease course.

Methods:

Rheumatologists and pulmonologists participated in five ~10-min presentations about the early identification of fibrosing ILD in patients with or without CTDs and completed all pre- and post-questions.1 The effects of the education on knowledge and competence were assessed using a 3-question, repeated pairs, pre-assessment/post-assessment study design. For all questions combined, the chi-square test assessed differences from pre- to post-assessment. P values <.05 are statistically significant. The activity launched on October 9, 2020, and data were collected through December 18, 2020.

Results:

Overall significant improvements were seen after participation for both rheumatologists (average correct response rate of 28% at pre-assessment vs 74% at post-assessment; P<.001, representing a 165% relative percentage change [RPC]; N=39), and pulmonologists (average correct response rate of 39% at pre-assessment vs 67% at post-assessment; P<.001, representing a 72% RPC; N=102). Specifically, significant improvements were observed in clinicians’ knowledge of predictors of fibrosing ILD in patients with CTD, as well as competence in selecting the right HRCT parameters to assess prognosis and select a treatment approach to reduce the risk of disease progression (Figure 1).

Figure 1.

After participating in the activity, 59% of rheumatologists and 50% of pulmonologists had measurable improved confidence related to identifying early disease progression in patients with progressive fibrosing ILDs.

Given the very low rates of correct responses at baseline regarding predictors of fibrosing ILD and assessing prognosis, it will be important to continue to reinforce these learnings in ongoing educational programs.

Conclusion:

This study demonstrates the success of segmented online education in improving rheumatologists’ and pulmonologists’ knowledge and competence in evaluating risk and prognosis of fibrosing ILD and managing patients with CTD-ILDs. This could lead to earlier changes in therapeutic approach for those with signs of progression and result in improved overall outcomes for these patients.

References:

[1]Kolb M, Maher T, Smith V, Jacob J, Rimekasten G. Catching and Managing Progressive Fibrosing Interstitial Lung Disease Progression Earlier. Launched: Oct 9, 2020. Data as of Dec 18, 2020. Available at www.medscape.org/viewarticle/938826

Disclosure of Interests:

Christy Rohani-Montez: None declared, Marinella Calle: None declared, Chris Allen: None declared, Toby Maher Speakers bureau: Astra Zeneca, Bayer, Blade Therapeutics, Boehringer Ingelheim, Bristol-Myers Squibb, Galapagos, Galecto, GlaxoSmithKline R&D, Indalo, IQVIA, Pliant, Respivant, Roche and Theravance, Consultant of: Astra Zeneca, Bayer, Blade Therapeutics, Boehringer Ingelheim, Bristol-Myers Squibb, Galapagos, Galecto, GlaxoSmithKline R&D, Indalo, IQVIA, Pliant, Respivant, Roche and Theravance, Grant/research support from: Astra Zeneca and GlaxoSmithKline R&D, Vanessa Smith Speakers bureau: Boehringer-Ingelheim Pharma GmbH&Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH&Co, Grant/research support from: Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer-Ingelheim, Pharma GmbH&Co, and Janssen-Cilag NV, Joseph Jacob Speakers bureau: Boehringer-Ingelheim; Roche, Consultant of: Boehringer-Ingelheim, Grant/research support from: GlaxoSmithKline, Gabriela Riemekasten Speakers bureau: AbbVie; Actelion; Boehringer-Ingelheim, Consultant of: Actelion; CellTrend; Janssen, Grant/research support from: AbbVie; Actelion, Martin Kolb Speakers bureau: AstraZeneca; Boehringer-Ingelheim; Novartis; Roche, Consultant of: AbbVie Inc.; Algernon Pharma; AstraZeneca;, Boehringer-Ingelheim; Cipla; Covance; EPG Health; Galapagos NV; Gilead; GlaxoSmithKline; Indalo; MitoImmune Therapeutics Inc; Novartis; Pieris; Prometic (now Liminal Biosciences); Roche; Third Pole Inc.; TwoXAR Inc., Grant/research support from: Boehringer-Ingelheim; GlaxoSmithKline; Novartis; Prometic; Roche; Avalyn

OP0244 28 NEW AUTOANTIBODIES AGAINST GPCR, GROWTH FACTORS AND GROWTH FACTOR RECEPTORS ARE ASSOCIATED WITH DISEASE MANIFESTATIONS IN SYSTEMIC SCLEROSIS

Background:

The morbidity and mortality of systemic sclerosis (SSc) are largely determined by vascular and fibrotic pathologies. Levels of autoantibodies (ab) against G protein-coupled receptors (GPCR), growth factors (GF) and growth factor receptors (GFR) are altered in SSc compared to healthy controls (HC) 1. Thus, higher angiotensin II receptor type 1 - (AT1R) and endothelin receptor type A - (ETAR) ab levels are associated with severe disease and SSc-related mortality 2. CXC motiv chemokine receptor 3 - (CXCR3) and 4 - (CXCR4) ab have predictive value for deterioration of pulmonary fibrosis (PF) 3.

Objectives:

We used statistical methods to identify associations between disease manifestations and 28 new ab directed against GPCR, GF and GFR in SSc.

Methods:

Ab against the following targets were measured in sera from SSc patients (n = 177) and HC (n = 88): Adrenoceptors alpha-1 (ADRA1), alpha-2 (ADRA2), beta-1 (ADRB1), beta-2 (ADRB2); muscarinoceptors 1-5 (M1R - M5R); AT1R, ETAR, endothelin B receptor (ETBR); CXCR3, CXCR4; complement receptors 3a (C3aR) and 5a (C5aR); protease-activated receptors 1 (PAR1) and 2 (PAR2); vascular endothelial growth factor A (VEGFA) and its receptors 1 (VEGFR1) and 2 (VEGFR2), epithelial growth factor (EGF)/ - receptor (EGFR); hepatocyte growth factor (HGF)/ - receptor (HGFR), platelet-derived growth factor-AA (PDGFAA), placental growth factor (PlGF).

The organ involvement (PF, cardiac involvement, PAH, gastrointestinal tract) and quantitative markers (modified Rodnan skin score, SSc activity score, pulmonary function, cardiac enzymes and echocardiography, routine laboratory, autoimmune diagnostics) as well as demographic data were recorded retrospectively at the time of sample collection. Statistical analysis was performed using the Mann-Whitney U test (MWU), Pearson correlations, ROC analysis, and age-adjusted logistic regression models.

Results:

In SSc 20 of 28 measured ab levels are significantly altered compared to HC. According to the Pearson correlation matrix, the ab-levels are highly correlated and build a network that differs between HC and SSc. Furthermore, altered network signatures are formed in the differentiated analysis of several disease manifestations of SSc such as SSc-subtype or PF. Based on ROC analysis, FGF-ab, ADRB1-ab and PlGF-ab are well suited to predict SSc (Figure 1).

In addition, limited cutaneous SSc (lSSc) patients displayed lower levels of most ab than diffuse cutaneous SSc patients, whereas cardiac and pulmonary involvement are associated with higher ab levels. In the logistic regression lSSc is associated with lower levels of ab against M1R, M2R, C5aR, ETAR, AT1R, PAR1, EGFR. Higher levels for ab against M1R, M2R, ETBR, C5aR are associated with PF, higher levels of ab against complement receptors, adrenoreceptors and EGF with NT-proBNP elevation.

Conclusion:

The newly described antibodies against GPCR, GF and GFR are highly correlated. Associations with morbidity- and mortality-determining organ involvement indicate their possible functional relevance and novel pathophysiological mechanisms. As new biomarkers, some of the ab have prognostic value for SSc; for other manifestations, their value should be evaluated in further studies.

References:

[1]Cabral-Marques, O., Marques, A., Giil, L.M. et al. GPCR-specific autoantibody signatures are associated with physiological and pathological immune homeostasis. Nat Commun9, 5224 (2018). https://doi.org/10.1038/s41467-018-07598-9

[2]Riemekasten G, Philippe A, Näther M, et al. Involvement of functional autoantibodies against vascular receptors in systemic sclerosis Annals of the Rheumatic Diseases 2011;70:530-536.

[3]Weigold, F., Günther, J., Pfeiffenberger, M. et al. Antibodies against chemokine receptors CXCR3 and CXCR4 predict progressive deterioration of lung function in patients with systemic sclerosis. Arthritis Res Ther 20, 52 (2018). https://doi.org/10.1186/s13075-018-1545-8

Disclosure of Interests:

Kristina Sterner: None declared, Césaire J. K. Fouodo: None declared, Inke König: None declared, Axel Künstner: None declared, Hauke Busch: None declared, Harald Heidecke Shareholder of: Owner of CellTrend, Anja Schumann: None declared, Antje Müller: None declared, Gabriela Riemekasten: None declared, Susanne Schinke Grant/research support from: UCB sponsors EULAR registration fees

POS0834 LONG-TERM OUTCOME OF SSC ASSOCIATED ILD: IMPROVED SURVIVAL IN PPI TREATED PATIENTS

Background:

Gastroesophageal reflux disease (GERD) occurs frequently in patients with systemic sclerosis (SSc) and SSc-associated interstitial lung disease (SSc-ILD). PPI use has to been shown to improve survival in patients with idiopathic pulmonary fibrosis, whereas to date there are no data on the use of PPI in SSc-ILD.

Objectives:

This study was aimed to assess whether use of PPI is associated with progression of SSc-ILD and survival.

Methods:

We retrospectively analysed 1931 patients with SSc and SSc-ILD from the German Network for Systemic Sclerosis (DNSS) database (2003 onwards). Kaplan–Meier analysis compared overall survival (OS) and progression-free survival (PFS) in patients with vs. without GERD (SSc and SSc-ILD), and PPI vs. no PPI use (SSc-ILD only). Progression was defined as a decrease in either % predicted forced vital capacity ≥10% or single-breath diffusing capacity for carbon monoxide ≥15%, or death.

Results:

GERD was not associated with decreased OS or PFS in patients with either SSc or SSc-ILD. In patients with SSc-ILD, PPI use was associated with improved OS vs. no PPI use after 1 year (98.4% [95% confidence interval: 97.6–99.3]; n=760 vs. 90.8% [87.9–93.8]; n=290) and after 5 years (91.4% [89.2–93.8]; n=357 vs. 70.9% [65.2–77.1]; n=106; p<0.0001). PPI use was also associated with improved PFS vs. no PPI use after 1 year (95.9% [94.6–97.3]; n=745 vs. 86.4% [82.9–90.1]; n=278) and after 5 years (66.8% [63.0–70.8]; n=286 vs. 45.9% [39.6–53.2]; n=69; p<0.0001).

Conclusion:

GERD had no effect on survival in SSc or SSc-ILD. PPIs improved survival in patients with SSc-ILD; however, controlled, prospective trials are needed to confirm this finding.

Disclosure of Interests:

Michael Kreuter Speakers bureau: Boehringer, Consultant of: Boehringer, Grant/research support from: Boehringer, Francesco Bonella Speakers bureau: Boehringer, Roche, GSK, Consultant of: Boehringer, Roche, GSK, Grant/research support from: Boehringer, Kuhr Kathrin: None declared, Jörg Henes Speakers bureau: Abbvie, Boehringer, Chugai, Roche, Janssen, Novartis, SOBI, Pfizer and UCB, Consultant of: Boehringer, Celgene, Chugai, Roche, Janssen, Novartis, SOBI, Grant/research support from: Chugai, Roche, Janssen, Novartis, SOBI, Pfizer, Elise Siegert: None declared, Gabriela Riemekasten Speakers bureau: Novartis, Janssen, Roche, GSK, Boehringer, Consultant of: Janssen, Actelion, Boehringer, Norbert Blank Consultant of: Sobi, Novartis, Roche, UCB, MSD, Pfizer, Actelion, Abbvie, Boehringer, Grant/research support from: Novartis, Sobi, Christiane Pfeiffer: None declared, Ulf Müller-Ladner: None declared, Alexander Kreuter Speakers bureau: MSD, Boehringer, InfectoPharm, Paid instructor for: MSD, PETER KORSTEN Consultant of: Glaxo, Abbvie, Pfizer, BMS, Chugai, Sanofi, Lilly, Boehringer, Novartis, Grant/research support from: Glaxo, Aaron Juche: None declared, Marc Schmalzing Speakers bureau: Chugai Roche, Boehringer, Celgene, Medac, UCB, Paid instructor for: Novartis, Abbvie, Astra Zeneca, Chugai Roche, Janssen, Consultant of: Chugai Roche, Hexal Sandoz, Gilead, Abbvie, Janssen, Boehringer, Margitta Worm Speakers bureau: Boehringer, Ilona Jandova Speakers bureau: Boehringer, Novartis, Abbvie, Laura Susok Speakers bureau: MSD, Novartis, BMS, Sunpharma, Consultant of: MSD, Tim Schmeiser Consultant of: Abbvie, Boehringer, Novartis, UCB, Claudia Guenther Paid instructor for: Advisory Board Boehringer January 2020, Employee of: Novartis 2002-2005, Gernot Keyszer Consultant of: Boehringer, Jan Ehrchen Speakers bureau: Boehringer, Janssen, Chugai, Sobi, Employee of: Pfizer, Actelion (now Janssen), Andreas Ramming Speakers bureau: Boehringer, Gilead, Janssen, Pfizer, Roche, Consultant of: Boehringer, Pfizer, Grant/research support from: Novartis, Pfizer, Ina Kötter Speakers bureau: several companies, Consultant of: several companies, Grant/research support from: several companies, Hanns-Martin Lorenz Speakers bureau: Abbvie, Astra Zeneca, Actelion, Alexion Amgen, Bayer Vital, Baxter, Biogen, Boehringer, BMS, Celgene, Fresenius, Genzyme, GSK, Gilead, Hexal, Janssen, Lilly, Medac, MSD, Mundipharm, Mylan, Novartis, Octapharm, Pfizer, Roche Chugai, Sandoz, Sanofi, Shire SOBI, Thermo Fischer, UCB, Grant/research support from: basic research studies: Pfizer, Novartis, Abbvie, Gilead, Lilly, MSD, Roche Chugai, Pia Moinzadeh Speakers bureau: Boehringer, Actelion, Grant/research support from: Actelion, Nicolas Hunzelmann Speakers bureau: Boehringer Janssen, Roche, Sanofi, Consultant of: Boehringer

OP0054 NEW ROLE FOR PROTEINASE 3 IN IL-16 BIOACTIVITY CONTROL IN GRANULOMATOSIS WITH POLYANGIITIS

Background:

The immunomodulatory cytokine IL-16 is increased in several inflammatory and autoimmune diseases1. IL-16 recruits and activates CD4+ immune cells such as T cells, dendritic cells, or monocytes. IL-16 is produced by various immune and non-immune cells, but synthesis and storage of IL-16 is regulated differentially depending on the cell type and stimulation. For its biological activity, IL-16 cleavage by caspase-3 is required1. Necrotizing granulomatous inflammation is a hallmark of granulomatosis with polyangiitis (GPA) with neutrophil dysregulation as a central driver of chronic inflammation and autoimmunity2. Earlier studies showed a correlation between increased serum IL-16 and disease parameters in AAV, including GPA3, but functional evidence for a direct link between IL-16 and neutrophils in granulomatous inflammation is missing so far.

Objectives:

In this study we aim to identify a functional link between increased IL-16, neutrophils, and the autoantigen proteinase 3 (PR3) with regard to chronic inflammation and autoimmunity in GPA.

Methods:

IL-16 was measured in sera of GPA patients (n = 40) and healthy controls (HC, n = 50) by ELISA and correlated with clinical features, such as disease activity (BVAS), creatinine, GFR, VDI and PR3-ANCA status. IL-16 protein expression was analyzed in peripheral blood mononuclear cells (PBMC) and polymorphonuclear cells (PMN) from GPA patients and HC (n = 5, each) by SDS-PAGE and western blot. Binding affinity of recombinant pro-IL-16 to native human PR3 was assessed by microscale thermophoresis. Cleavage of pro-IL-16 by active human PR3 was performed at various time points at 37°C. Cleavage products were analyzed by SDS-PAGE and western blot.

Results:

Circulating IL-16 was significantly increased in GPA patients compared to HC. Elevated IL-16 positively correlated with BVAS, creatinine, VDI and PR3-ANCA status and negatively correlated with GFR. In PMBC and PMN from GPA and HC we identified different expression patters of precursor and active forms of IL-16. In healthy PBMC we found high amounts of precursor (80kD), pro-IL-16 (55kD) and active IL-16 (17kD). In contrast, PBMC from GPA patients had lower amounts of pro-IL-16 and no active IL-16, indicating activation and secretion of IL-16 due to inflammatory stimulation, as shown earlier5. In GPA PMN we detected no precursor IL-16, but pro-IL-16 and its active form, in contrast to very low amounts of all IL-16 forms in healthy PMN. Processing and release of IL-16 in neutrophils has been linked to apoptosis and secondary necrosis5. By interaction studies we demonstrated direct binding of pro-IL-16 to PR3 with a Kd of 10 nM. In a subsequent cleavage assay we confirmed IL-16 processing by PR3 in a time-dependent manner.

Conclusion:

Correlation of serum IL-16 with clinical features of GPA suggests that IL-16 is associated with markers of disease activity, tissue damage and autoreactivity. We showed that PBMC and PMN represent a source of IL-16 in GPA. By the identification of PR3 as an additional IL-16-activating enzyme we could demonstrate a potential link between excessive PR3 expression, cell death and IL-16-dependent mechanisms, contributing to chronic granulomatous inflammation and autoimmunity in GPA.

References:

[1]Glass, W. G. et al. Not-so-sweet sixteen: The role of IL-16 in infectious and immune-mediated inflammatory diseases. J. Interf. Cytokine Res. 26, 511–520 (2006).

[2]Millet, A. et al. Proteinase 3 on apoptotic cells disrupts immune silencing in autoimmune vasculitis. J. Clin. Invest. 125, 4107–4121 (2015).

[3]Yoon, T. et al. Serum interleukin-16 significantly correlates with the Vasculitis Damage Index in antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Res. Ther. 22, 1–6 (2020).

[4]Elssner, A. et al. IL-16 Is Constitutively Present in Peripheral Blood Monocytes and Spontaneously Released During Apoptosis. J. Immunol. 172, 7721–7725 (2004).

[5]Roth, S. et al. Secondary necrotic neutrophils release interleukin-16C and macrophage migration inhibitory factor from stores in the cytosol. Cell Death Discov. 1, 15056 (2015).

Disclosure of Interests:

None declared

[Reality of inpatient vasoactive treatment with prostacyclin derivatives in patients with acral circulation disorders due to systemic sclerosis in Germany]

Hintergrund

Das Raynaud-Phänomen und die damit häufig einhergehenden digitalen Ulzerationen stellen für Patienten mit systemischer Sklerose (Sklerodermie [SSc]) ein frühes und sehr belastendes Symptom mit bedeutenden Einschränkungen der Arbeitsfähigkeit und Lebensqualität dar. Der Einsatz vasoaktiver Medikamente (insbesondere intravenöser Prostazyklinderivate) soll helfen, das Risiko hypoxischer Gewebeschäden bis hin zum Verlust der Finger zu reduzieren.

Methoden

Um Aufschluss über die aktuelle Versorgung von Patienten mit Prostazyklinderivaten im klinischen Alltag in Deutschland zu erhalten, führten wir eine Umfrage unter den im Deutschen Netzwerk für systemische Sklerodermie (DNSS) zusammengeschlossenen Kliniken durch. Zusätzlich erfolgte eine separate Patientenbefragung über die Sklerodermie Selbsthilfe e. V., die sich nur auf die Symptome „Raynaud-Phänomen“ und „Digitale Ulzera“ und den Einsatz intravenöser Prostazyklinderivate bezog.

Ergebnisse

Von den befragten 433 Patienten gaben 56 % an, dass sie bereits aufgrund ihrer Erkrankung und Symptome mit Prostazyklinderivaten behandelt wurden. Insgesamt 61 % erhielten die Therapie aufgrund starker Raynaud-Symptomatik und 39 % aufgrund digitaler Ulzerationen. Die meisten Befragten erfuhren durch die Therapie nicht nur eine Verbesserung des Raynaud-Phänomens und der digitalen Ulzera, sondern auch eine wesentliche Verbesserung von Einschränkungen im Alltag. Sie gaben zudem an, wesentlich weniger fremde Hilfe in Anspruch genommen sowie wesentlich weniger Fehlzeiten bei der Arbeit gehabt zu haben.

Schlussfolgerung

Die Patienten empfanden durchweg einen positiven Effekt der Therapie mit Prostazyklinderivaten auf das Raynaud-Phänomen, ihre digitalen Ulzerationen, Schmerzen und Alltagseinschränkung und fühlten sich durch die stationäre Therapie gut und sicher betreut. Diese positiven Effekte in der Patientenwahrnehmung sind eine eindrückliche Stütze und bestätigen nachdrücklich die auf europäischer und internationaler Ebene erarbeiteten Therapieempfehlungen.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00393-019-00743-9) enthält die 2 Fragebögen, die für die Befragung verwendet wurden. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.

The first composite score predicting Digital Ulcers in systemic sclerosis patients using Clinical data, Imaging and Patient history-CIP-DUS

Background

Digital ulcers (DU) present a challenging complication in systemic sclerosis (SSc). The aim of this study was to combine clinical characteristics and imaging methods to a composite score for the prediction of DU in SSc patients.

Methods

Seventy-nine SSc patients received clinical examination, their patient history was taken and nailfold capillaroscopy (NC), colour Doppler ultrasonography (CDUS) and fluorescence optical imaging (FOI) of the hands were performed at baseline. Newly developed DU over a period of approximately 12 months were registered. We used criteria with area under the curve (AUC) of at least 0.6 in regard to the development of these new DU to create the score (CIP-DUS, clinical features, imaging, patient history—digital ulcer score).

Results

Twenty-nine percent of all SSc patients developed new DU during follow-up (48.1% diffuse, 18.4% limited SSc). Based on the cross-validated (cv) AUC, a weight (cvAUC > 0.6 and ≤ 0.65: 1; cvAUC > 0.65 and ≤ 0.7: 2; cvAUC > 0.7: 3) was assigned to each selected parameter. The performance of the final CIP-DUS was assessed with and without the CDUS/FOI component. For the scleroderma patterns in NC, three points were appointed to late, two to active and one point to early capillaroscopy pattern according to Cutolo et al. The CIP-DUS including the CDUS and FOI parameters resulted in a good diagnostic performance (AUC after cross-validation: 0.83, 95%CI 0.74 to 0.92) and was well calibrated (chi-square = 12.3, p = 0.58). The cut-off associated with the maximum of sensitivity and specificity was estimated at ≥ 10 points resulting in a sensitivity of 100% and specificity of 74% for new DU during follow-up. Excluding CDUS and FOI parameters leads to a non-statistically significant lower performance (AUC after cross-validation: 0.81, 95%CI 0.72 to 0.91). However, including CDUS and FOI resulted in a better classification of patients in respect to the outcome new DU in follow-up due to significantly better reclassification performance (NRI = 62.1, p = 0.001) and discrimination improvement (IDI = 9.7, p = 0.01).

Conclusion

A new score was introduced with the aim to predict digital ulcers. If applied correctly and with the new imaging techniques proposed, all patients at risk of digital ulcers throughout 12 months could be identified.