Consensus statement on the diagnosis and treatment of sclerosing diseases of the skin, Part 1: Localized scleroderma, systemic sclerosis and overlap syndromes

The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present consensus provides an update to the 2017 European Dermatology Forum Guidelines, focusing on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, updated strategies for the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 1 of this consensus provides clinicians with an overview of the diagnosis and treatment of localized scleroderma (morphea), and systemic sclerosis including overlap syndromes.

An engineered glove to follow finger function in rheumatoid arthritis: an observational prospective study

The engineered Hand Test System (HTS) glove has shown high reliability in assessing the baseline functional status of rheumatoid arthritis (RA) hand. Starting from this achievement, the aim of the present observational prospective study was to assess the functionality of the single fingers of rheumatoid hand at follow-up. Eighty RA patients performed HTS glove tests at baseline and among these fifty-six patients were re-tested after 7 months. The HTS glove parameters [Touch Duration (TD), Movement Rate (MR), Inter Tapping Interval (ITI)] were correlated with disease activity and disability clinimetric indexes [Disease Activity Score 28 joint count-C-reactive protein (DAS28-CRP), Clinical Disease Activity Index (CDAI), Simplified Disease Activity Index (SDAI), Health Assessment Questionnaire-Disability Index (HAQ-DI), grip strength, visual analogue scale of pain (VAS), patient global assessment (PGA)], and with laboratory values. HTS glove parameters (TD, ITI, and MR) showed statistically significant correlations with clinimetric and clinical indexes at both time points (p < 0.05). During follow-up, a statistically significant variation of all HTS glove parameters for the fingers that have performed both the worst or best HTS test at baseline was detected (p < 0.05), while the mean HTS glove parameter values by considering all fingers did not show a statistically significant variation over time, as well as the traditional clinimetric indexes. Besides the objective role in assessing the RA hand function by integrating the traditional clinimetric indexes, the HTS glove seems a useful tool for evaluating worst or best finger function during time by measuring the movement speed.

Emerging nailfold capillaroscopic patterns in COVID-19: from acute patients to survivors

The SARS-CoV-2 infection causing the Coronavirus disease-19 (COVID-19) is characterized by a broad range of clinical manifestations, implicating microvascular damage with endothelial dysfunction and different organ involvement.

Nailfold capillaroscopy in the rheumatological current clinical practice in Italy: results of a national survey

This cross-sectional online study was designed by the study group on Capillaroscopy and Microcirculation in Rheumatic Diseases (CAP) of the Italian Society of Rheumatology (SIR) to provide an overview of the management of nailfold capillaroscopy in Italian rheumatology centers. Therefore, SIR distributed the survey to its members in July 2021, and each center's physician with the most expertise in capillaroscopy completed the questionnaire. The survey was completed by 102 centers, with at least one representative from each Italian region. Ninety-three centers perform capillaroscopy, and 52 (56) conduct more than 200 investigations annually. Seventy-eight (84%) of respondents have more than five years of experience with the technique, and 75 centers (80.6%) have received certification from specific national or international training courses. In 85 centers, a videocapillaroscope with 200x magnification is employed (91.4%). The average waiting period for the examination is 2.4 months, and less than 3 months in 64 of the locations (68.8%). The study demonstrates that capillaroscopy is an integral part of both the diagnostic phase of Raynaud's phenomenon and the monitoring of autoimmune connective tissue diseases (CTDs). However, the reporting methods and timing of patient followup are heterogeneous.

POS1232 LONG-TERM OUTCOMES OF COVID-19 VACCINATION IN PATIENTS WITH RARE AND COMPLEX CONNECTIVE TISSUE DISEASES: AN AD-INTERIM ANALYSIS OF ERN-ReCONNET VACCINATE STUDY

Background

Since the COVID-19 vaccination campaign was launched all over Europe, there has been general agreement on how benefits of SARS-CoV2 vaccines outweigh the risks in patients with rare connective tissue diseases (rCTDs). Yet, there is still limited evidence regarding safety and efficacy of such vaccines in these patients, especially in the long-term. For this reason, in the framework of ERN-ReCONNET, an observational long-term study (VACCINATE) was designed in order to explore the long-term outcome of COVID-19 vaccination in rCTDs patients. The consent form was developed thanks to the involvement of the ERN ReCONNET ePAG Advocates (European Patients Advocacy Group).

Objectives

To evaluate the safety profile of COVID-19 vaccination in rCTDs patients and the potential impact on disease activity. Primary endpoints were the prevalence of adverse events (AEs) and of disease exacerbations post-vaccination. Secondary endpoints were the proportion of serious adverse events (SAEs) and adverse events of special interest for COVID-19 (adapted from https://brightoncollaboration.us/wp-content/uploads/2021/01/SO2_D2.1.2_V1.2_COVID-19_AESI-update-23Dec2020-review_final.pdf)

Methods

The first ad-interim analysis of the VACCINATE study involved 9 ERN-ReCONNET Network centres. Patients over 18 years of age with a known rCTD and who received vaccine against COVID-19 were eligible for recruitment. Demographic data and diagnoses were collected at the time of enrolment, while the appearance of AEs and potential disease exacerbations were monitored after one week from each vaccination dose, and then after 4, 12 and 24 weeks from the second dose. A disease exacerbation was defined as at least one of the following: new manifestations attributable to disease activity, hospitalization, increase in PGA from previous evaluation, addition of corticosteroids or immunosuppressants.

Results

A cohort of 300 patients (261 females, mean age 52, range 18-85) was recruited. Systemic lupus erythematosus (44%) and systemic sclerosis (16%) were the most frequent diagnoses, followed by Sjogren’s syndrome (SS,12%), idiopathic inflammatory myositis (IMM,10%), undifferentiated connective tissue disease (UCTD,8%), mixed connective tissue disease (MCTD,4%), Ehlers-Danlos’s syndrome (EDS,4%), antiphospholipid syndrome (APS,2%). AEs appearing 7 days after the first and second doses were reported in 93 (31%) and 96 (32%) patients respectively, mainly represented by fatigue, injection site reaction, headache, fever and myalgia. Otitis, urticaria, Herpes Simplex-related rash, stomatitis, migraine with aura, vertigo, tinnitus and sleepiness were reported with very low frequency. Less than 2% of patients experienced AEs within 24 weeks from the second dose. No SAEs or AEs of special interest were observed in the study period. There were 25 disease exacerbations (8%), 7 of which severe. The highest number of exacerbations was observed after 4 weeks from the second dose (12 within week 4, 6 within week 12 and 7 within week 24). Disease exacerbation was most frequent in patients with EDS (33%) and MCTD (25%).

Conclusion

This preliminary analysis shows that COVID-19 vaccination is safe in rCTDs patients. AEs appear most often early after vaccination and are usually mild. Disease exacerbations are not frequent, but can be potentially severe and tend to occur most frequently within the first month after vaccination. Exacerbations can also occur 3-6 months after vaccination, although a causal relationship with the vaccination remains to be established. Our present data underline the importance of long-term observational studies.

Table 1.

AEs and disease exacerbations per disease

DiagnosisPatients enrolled (%) (n=300)EAs after 1st and 2nd dose (%)Exacerbations (%)APS25714EDS45033IIM10527MCTD44225SS12598SLE44698SSC16492UCTD850-

Acknowledgements

VACCINATE is a study promoted by the European Reference Network on rare and complex connective tissue diseases, ERN ReCONNET. This publication was funded by the European Union’s Health Programme (2014-2020)

Disclosure of Interests

None declared

AB0092 CTLA4-Ig PROMOTES THE M1-M2 SHIFT IN CULTURED MACROPHAGES OF RHEUMATOID ARTHRITIS PATIENTS WITH ACTIVE DISEASE: IN VITRO STUDY

Background

In rheumatoid arthritis (RA), macrophages play an important role in modulating the immunoinflammatory response through their polarization into “classically” (M1) or “alternatively activated” (M2) phenotypes and the release of pro-inflammatory cytokines (1). In the active inflammatory phase of RA, circulating intermediate monocytes and synovial tissue macrophages show a M1 phenotype, whereas MerTK+M2 macrophages seem to characterize the synovial tissue of RA patients under remission (2-4). In RA, CTLA4-Ig fusion protein (abatacept) reduces the pro-inflammatory activity of macrophages by interacting with the costimulatory molecule CD86 on surface cell membrane of activated cells, including macrophages (2).

Objectives

The in vitro study investigated the efficacy of CTLA4-Ig treatment to induce the shift from the M1 phenotype into an M2 phenotype in cultured monocyte-derived macrophages (MDMs) obtained from active RA patients.

Methods

Cultured MDMs obtained from peripheral blood mononuclear cells of 5 active RA patients (mean age 54±13 years) and 5 age-matched healthy subjects (HSs) after overnight stimulation with phorbol myristate acetate (5ng/ml), were treated with CTLA4-Ig at the concentrations of 100mg/mL or 500mg/mL for 3, 12, 24 and 48 hours. A part of cultured RA-MDMs as wells as cultured HS-MDMs were maintained in growth medium (RPMI at 10% of fetal bovine serum) without any treatment and used as unstimulated cells. Gene expression of CD80, CD86 and toll-like receptor-4 (TLR4), as M1 markers, as well as macrophage scavenger receptors (CD163, CD204), mannose receptor-1 (CD206), as surface M2 markers, and MerTK (functional M2 marker) were evaluated by quantitative real-time polymerase chain reaction (qRT-PCR). Protein synthesis of surface M2 markers was investigated by Western blotting. The statistical analysis was performed by Wilcoxon t-test.

Results

Cultured RA-MDMs showed a high basal gene expression of TLR4, CD80 and CD86 compared to HS-MDMs, confirming to be activated M1 macrophages. In these macrophages, CTLA4-Ig treatment downregulated the gene expression of M1 markers at both concentrations and all timings, but significantly limited to TLR4 and CD80 markers (500mg/mL,12 hours: p<0.05). Conversely, both concentrations of CTLA4-Ig significantly upregulated the gene expression of CD163, MerTK and CD206 (p<0.05), whereas only the high concentration of CTLA4-Ig significantly upregulated CD204 gene expression (p<0.05). The protein synthesis of all M2 surface markers was increased after 24 hours of treatment primarily by the high concentration of CTLA4-Ig, and significantly for CD204 and CD206 (p<0.05).

Conclusion

CTLA4-Ig treatment seems to exert an important anti-inflammatory effect by promoting the shift from a M1 to an M2 phenotype in cultured RA macrophages The results suggest a further mechanism for CTLA4-Ig in the modulation of the RA synovitis (5).

References

[1]Yang X et al. Cell Prolif. 2020;53:e12854.doi:10.111/cpr.12854.

[2]Kumar RA et al. Int. Immunol.2018;65:348-59.

[3]Boutet MA et al. Autoimmun Rev.2021;20:102758. doi: 10.1016/j.autrev.2021.102758.

[4]Alivernini S et al. Nat Med. 2020;26:1295-306. 5. Cutolo M et al. Arthritis Res Ther. 2009;11:R176; doi: 10.1186/ar2865.

Disclosure of Interests

Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Celgene, Pfizer, Boehringer Ingelheim, Samuele Tardito: None declared, Emanuele Gotelli: None declared, Paola Montagna: None declared, Rosanna Campitiello: None declared, Sabrina Paolino: None declared, Carmen Pizzorni: None declared, Alberto Sulli Grant/research support from: Laboratories Baldacci, Vanessa Smith Grant/research support from: Boehringer Ingelheim, Janssen-Cilag, Stefano Soldano: None declared

AB1160 IMPACT OF COVID-19 TREATMENTS ON PERIPHERAL CAPILLARY DENSITY EVALUATED BY NAILFOLD VIDEOCAPILLAROSCOPY

Background

Human SARS-CoV-2 infection can induce a wide spectrum of organ dysfunctions, including microvascular impairment [1]. S1 subunit of viral receptor-binding domain binds to the angiotensin-converting enzyme 2 receptor on endothelium and S2 subunit allows the virus to enter endothelial cells. The resulting breakdown of barrier integrity drives a cascade of inflammatory and thrombotic events, that aggravate the course of COVID-19 together with other risk factors [2-4]. Up to date, a lower capillary density has been reported in several distinct body districts, using sublingual video microscopy, ocular optical coherence tomography angiography, skin functional laser Doppler perfusion imaging and nailfold videocapillaroscopy (NVC) [5-8]. NVC examination has been performed in adult COVID-19 patients, however, without a control group [8].

Objectives

To confirm the statistical significance of the reduction in capillary density per linear millimeter evaluated by NVC in comparison with primary Raynaud’s phenomenon (PRP) patients and control subjects (CNT) and to evaluate the impact of an aggressive therapy against COVID-19 on the sparing in the number of capillaries.

Methods

Sixty-one COVID-19 survivors, thirty-one PRP patients and thirty CNT age and sex-matched underwent NVC analysis. Demographic and clinical data of COVID-19 survivors were collected with special regard to concomitant therapies, that included antivirals, antibiotics, anticoagulants and anti-inflammatory/immunomodulant drugs (glucocorticoids, hydroxychloroquine, IL-6 receptor antagonist). COVID-19 survivors were divided in two subgroups according to the severity of the active infection: thirty-four survivors with past mild-moderate disease (either unneedy for oxygen supplementation or need for Venturi mask) and twenty-seven survivors with past severe disease (need for Continuous Positive Airways Pressure and/or mechanical ventilation). The same Rheumatologist performed NVC evaluations in all patients and controls, using an optical probe, equipped with a 200x magnification lens and connected to a picture analysis software (Videocap, DS Medica, Milan, Italy). Absolute capillary number per linear millimeter was counted.

Results

COVID-19 survivors underwent NVC examination after a mean period of 126±53 days from the disease onset. Multivariate analysis showed differences in absolute capillary number per linear millimeter (p<0.001) after adjusting for age, sex, body mass index, comorbidities and concomitant drugs. The mean (± standard deviation) absolute nailfold capillary number per linear millimeter was significantly lower in severe (8.2±1.15) and mild-moderate (8.4±0.75) COVID-19 survivors than in both PRP (8.7±0.68) and CNT subjects (9.3±0.53) (p<0.001). The analysis of the impact of treatments on capillary density in the severe COVID-19 patients showed a positive trend (preservation of the capillary number) with antivirals (no: 7.8±1.53; yes: 8.5±0.64; p=0.35) and anti-IL-6 receptor antagonist administration (no: 7.8±1.36; yes: 8.6±0.74; p=0.16), while none of the other drugs was shown to be effective (glucocorticoids p = 0.46; antibiotics = 0.52; anticoagulants not evaluable as they were used in all COVID-19 patients).

Conclusion

SARS-CoV-2 infection seems associated to a significant capillary loss as distinctive NVC feature and data concerning the comparison of capillary density pre COVID-19 and post COVID-19 are desirable to reinforce this observation. The positive trend in saving the number of capillaries induced by aggressive anti-inflammatory therapies in COVID-19 survivors needs larger cohorts of patients.

References

[1]Rovas A et al. Angiogenesis. 2021;24:145-157.

[2]Raghavan S et al. Front Cardiovasc Med. 2021;8:687783.

[3]Cutolo M et al. RMD Open. 2020;6:e001454.

[4]Sulli A et al. Nutrients. 2021;13(3):717.

[5]Kanoore Edul VS et al. J Crit Care. 2021;61:73-75.

[6]Teo KY et al. Am J Ophtalmol. 2021;235:98-110.

[7]Sabioni L et al. Microvasc Res. 2021;134:104119.

[8]Natalello G et al. Microvasc Res. 2021;133:104071.

Disclosure of Interests

Emanuele Gotelli: None declared, Alberto Sulli Grant/research support from: Laboratori Baldacci S.p.a., Pietro Francesco Bica: None declared, Irene Schiavetti: None declared, Teresita Aloe’: None declared, Marco Grosso: None declared, Emanuela Barisione: None declared, Carmen Pizzorni: None declared, Sabrina Paolino: None declared, Vanessa Smith Grant/research support from: Boehringer Ingelheim, Janssen-Cilag, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Celgene, Pfizer, Boehringer Ingelheim

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

Background

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

Objectives

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

Methods

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

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

Table 1.

Adverse events of special interest (AESI).*

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

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

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

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

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

Results

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

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

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

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

Conclusion

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

Acknowledgements

Trial registration: NCT02585258 (clinicaltrials.gov).

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

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

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

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

Partners:

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

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

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

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

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

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

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

Investigators (other recruiting centers):

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

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

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

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

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

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

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

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

J. Costa, Hospital de Ponte Lima, Portugal;

M. Sieburg, Rheumatologische Facharztpraxis Magdeburg, Germany;

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

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

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

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

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

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

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

Scientific Advisory Committee:

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

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

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

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

Radiographic assessment:

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

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

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

Patient panel:

C. Rusthoven and M. Bakkers, The Netherlands

E. Frazão Mateus, and G. Mendes, Portugal

C. Elling-Audersch and D. Borucki, Germany

A. Cardone, Italy

P. Corduta and O. Constantinescu, Romania

P. Richards, United Kingdom

G. Aanerud, Norway

Disclosure of Interests

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

AB1210 FIBROMYALGIA AND BODY MASS COMPOSITION IN POST-MENOPAUSAL WOMEN: PRELIMINARY RESULTS FROM A CROSS-SECTIONAL MONOCENTRIC STUDY

Background

Fibromyalgia (FM) is characterized by chronic musculoskeletal widespread pain, fatigue, sleep disturbances and functional symptoms.

Objectives

Our study aimed to determine if FM could affect body composition of post-menopausal women and to investigated potential correlations between disease severity and body mass variables.

Methods

Thirty post-menopausal FM female patients (median age 58 years, BMI = 25.8) were diagnosed according to either ACR 1990 fibromyalgia classification criteria or ACR 2010 preliminary diagnostic criteria. They underwent Dual-energy X-ray absorptiometry (DEXA) for clinical purposes (i.e. screening for osteoporosis). The parameters analyzed by a dedicated software (GE Lunar, USA) were the spine and femoral bone mineral density (BMD), the total lean mass and the total body fat (TBF), quantitative variables of bone, muscle and fat composition. Additionally, qualitative analysis of the bone was indexed by the trabecular bone score (TBS). All the variables were compared with the parameters of 30 healthy controls (median age 59 years, BMI = 24.4) matched for sex and age. For each patient, data on disease duration, comorbidities, current treatment and disease severity self-reported scores were collected. The last ones derived from the Italian Fibromyalgia Impact Questionnaire Revised (FIQ-R) version that each patient independently compiled before the medical visit: widespread pain index (WPI), symptom severity scale (SSS), polysymptomatic distress scale (PDS), modified fibromyalgia assessment status (modFAS) and the FIQ-R total score.

Results

The clinical features of the FM patients included in our cohort are reported in Table 1. No statistically significant differences were observed between femoral/spine BMD, TBS and muscle mass between patients and controls (p = 0.3, p = 0.06, p = 0.16, p = 0.8 respectively). Conversely, both total and central body fat were significantly higher in patients compared with healthy controls (29.4 kg vs 25.2 kg, 15.7 kg vs 13.2 kg, p = 0.006 and p = 0.01 respectively). No significant correlations were observed between body mass composition indexes with scores of disease severity. Body mass composition variables did not statistically differ when patients were sub-analyzed according to pharmacological treatment and comorbidities.

Table 1.

Clinical features of FM patients included in present cohort (please see text for explanations of terminology)

Patients,N = 30Age (range)58.0 [53.8, 69.2]BMI (range)25.8 [23.0, 28.4]Disease duration (years), Median [IQR]4.5 [2.2, 9.2]ModFAS, Median [IQR]24.5 [20.0, 29.2]PDS, Median [IQR]17.5 [16.0, 23.2]SSS, Median [IQR]8.0 [6.0, 9.0]WPI, Median [IQR]12.0 [7.8, 15.0]FIQ-R, Median [IQR]57.9 [32.4, 68.8]Current pharmacological treatment Cyclobenzaprine N (%)24 (80) Fluoxetine N (%)5 (16.6) Duloxetine N (%)4 (13.3) Gabapentinoids N (%)2 (6.6) Tizanidine N (%)2 (6.6) Benzodiazepines N (%)2 (6.6) Cannabinoids N (%)3 (10)Nson-pharmacological treatmentAerobic physical activity N (%)5 (16)Comorbidities Hypertension N (%)10 (33.3) Diabetes N (%)3 (10) Osteoarthritis N (%)10 (33.3) Anxiety/depression N (%)3 (10) Psoriasis N (%)3 (10)

Conclusion

Our preliminary results suggest that FM seems not associated with impaired bone mass and bone quality in post-menopausal women compared to matched healthy controls, in line with the majority of literature evidences [1]. However, total and central adipose tissue mass resulted higher in this cohort of FM patients compared with controls but not correlate with disease severity. This might be due to a disease-induced sedentary lifestyle and might reinforce the concept that physical activity represents the best preventive method of overweight and obesity, one of most reported comorbidities for FM patients[2].

References

[1]Mateos F et al. Osteoporos Int. 2014;25(2):525-33.

[2]D’Onghia et al. Seminars in Arthritis and Rheumatism. 2021;51(2):409-24.

Disclosure of Interests

None declared

AB1351 FULL LONGITUDINAL NAILFOLD VIDEOCAPILLAROSCOPY ANALYSIS OF MICROVASCULAR CHANGES DURING NORMAL PREGNANCY

Background

During pregnancy profound physiologic changes are required to ensure fetal development and meet maternal needs. Microvascular remodelling is one major responsible for pregnancy haemodynamic adaptation, still it is not routinely evaluated in the obstetric field [1–2].

Objectives

To investigate the role of nailfold capillaroscopy (NCV) as a gold-standard and safe technique in detecting microvascular changes during normal pregnancy and to explore its possible application in clinical obstetric setting.

Methods

A population of 30 healthy pregnant women was longitudinally followed performing clinical assessment and NVC evaluation at each trimester and post-partum. Thirty non-pregnant age-matched healthy women having received at least two NVCs with a minimum 9 to 12-month interval were selected as controls. All NVC images were evaluated by a qualitative and semi-quantitative assessment using current standardised approach [3]. Statistical analyses were conducted to explore NVC parameters trend throughout gestation and its possible association with pregnancy course and clinical macrovascular parameters (i.e., systemic blood pressure, umbilical artery Doppler ultrasound).

Results

A progressive significant increase of capillary neoangiogenesis and a specular reduction in capillary dilations was observed during pregnancy (p<0.05). These statistically significant variations were not found in age-matched controls, who showed stable NVC parameters over a similar time frame (p<0.05). Not any significant association was found between NVC changes and pregnancy course, delivery outcome or macrovascular parameters.

Conclusion

This first comprehensive longitudinal NVC evaluation during normal pregnancy reports significant physiological microvascular variations throughout gestation, suggesting NVC as a safe and promising technique for further investigate and define patterns of microvascular changes in pregnant patients with rheumatic diseases.

References

[1]Thevissen et al. Expert Rev Med Devices. 2017;14(12):961–7.

[2]Abdo et al. Physiol Res 2014;63:395–408.

[3]Smith et al. Autoimmun Rev 2020; 19(3):102458.

Disclosure of Interests

None declared

POS1382 AN OVERVIEW OF NAILFOLD CAPILLAROSCOPY IN ITALY: RESULTS FROM A NATIONAL SURVEY

Background

In May 2020, the executive committee of the Italian Society of Rheumatology (SIR) endorsed the Italian study group (SG) on capillaroscopy and microcirculation in rheumatic diseases (CAPSIR) that first convened at the virtual annual meeting the same year. Nowadays capillaroscopy is a well-established, non-invasive technique with useful clinical applications in the assessment of connective tissue diseases (CTDs) [1] and mandatory for the differential diagnosis of Raynaud’s phenomenon (Rp) [2]. Despite growing interest in the use of this imaging technique in clinical and research settings, data on its current usage to assess microcirculation in rheumatic diseases in Italy are not available.

Objectives

To obtain an insight into the current utilization of capillaroscopy in the assessment of rheumatic patients in the Italian clinical setting.

This survey aimed: 1) to obtain an overview on the usage of capillaroscopy in rheumatological clinical practice in Italy, and 2) to gauge expert’s attitudes on factors influencing its use and the potential critical issues.

Methods

This online survey was devised to evaluate the opinions of the members of the SIR about nailfold capillaroscopy. It was designed with the contributions of the steering committee of CAPSIR SG, and emails with a link to the survey were sent to physicians affiliated with the SIR between July and August 2021 on behalf of the CAPSIR SG. At the beginning of the survey, the physician most experienced in capillaroscopy was asked to complete the questionnaire on behalf of his/her center. Questions were about the use of this technique in clinical practice and its critical issues. Data were reported with a descriptive analysis.

Results

One hundred and one centers, with at least one representative for each of the twenty Italian Region, completed the survey. 51.5% of respondents were in non-university hospitals, and 70 (69.3%) centers perform more than 100 capillaroscopy per year. The respondents were mainly practicing capillaroscopy for more than 5 years (85%) and gained certification of national or international dedicated training courses (84%). 43% of respondents had at least one scientific publication on this topic. Videocapillaroscope with 200X magnification was the most used instrument (91%). In public health services, the waiting time to schedule capillaroscopy is less than 3 months in 62.4% of centers. The survey has identified attitudes toward the use of capillaroscopy in the assessment and management of CTDs. In the screening phase of Rp, it is performed every 12 (mean value) months in patients with antinuclear antibodies (ANA) negative and every 6 months for those with positive ANA. Capillaroscopy is performed every 12 months (mean value) as part of the staging of CTDs (including systemic sclerosis). In more than 60% of centers, there is no specific diagnostic program for the screening of Rp and there is no connection with the general practitioners. 70% of the centers use capillaroscopy to follow the effect of therapies at least in systemic sclerosis.

Conclusion

At least one center for each Italian Region participated in this national survey, thus ensuring good geographical coverage. Moreover, the personnel who perform the exam had certified training and experience thus supporting the reliability of results. This survey indicates that the Italian public health system allows an acceptable waiting time to schedule the exam (less than 3 months). Italian Rheumatologists prescribe capillaroscopy as part of the clinical routine in the screening of Rp and as part of the annual checkup of CTDs. Critical issues remain the lack of a specific program and network with the general practitioners. To have a wider vision on this topic, our survey could be further extended to other European countries.

References

[1]Cutolo M, Smith V. Detection of microvascular changes in systemic sclerosis. and other rheumatic diseases. Nat Rev Rheumatol 2021;17(11):665-677.

[2]van den Hoogen F, Khanna D, et al. 2013 classification criteria for systemic sclerosis: an ACR/EULAR collaborative initiative. Ann Rheum Dis 2013;72(11):1747-55.

Disclosure of Interests

None declared

AB0738 Do cosmetic silicone implants trigger systemic sclerosis?

Background

The pathogenesis of systemic sclerosis (SSc) is thought to result from interactions between epigenetic features and environmental factors, leading to the onset and progression of the disease in genetically susceptible patients (1). Case reports of women with silicone breast implants who developed SSc have been published, but case-control and prospective studies in connective tissue diseases often failed to find an increased risk of SSc associated with silicone cosmetic surgery (2,3). These studies have several limitations, including heterogeneous cohorts of enrolled patients not selective for SSc, non-homogeneous disease duration or disease stage at study entry. For these reasons, the possible effect of silicone implants as immune adjuvants is highly suspected but remains unclear (4).

Objectives

Retrospective study of SSc patients, to find out who developed SSc after silicone cosmetic surgery.

Methods

The clinical files of 140 female patients with systemic sclerosis were retrospectively evaluated and clinical data collected.

Results

Five patients showing a history of silicone cosmetic surgery (3.6%) before SSc development were identified. The brief clinical histories of the five patients are below reported, showing very similar outcomes after silicone implant. 1. TC 47-year-old female underwent cosmetic breast prosthesis: twelve months later she experienced Raynaud’s phenomenon (RP) and diffuse cutaneous SSc after 10 further months; antinuclear antibodies were positive with a speckled and nucleolar pattern, but specific SSc-related autoantibodies negative. 2. LS 28-year-old female underwent cosmetic breast prosthesis: twenty-two months later RP appeared and anticentromere antibodies (ACA) positive aggressive diffuse SSc was diagnosed one year later. 3. PJ 38-year-old female underwent cosmetic breast prosthesis: eleven months later she experienced RP and after 10 further months, aggressive diffuse cutaneous SSc; antinuclear antibodies were positive with a speckled patter, but specific SSc-related autoantibodies were negative. 4. CM 58-year-old female who underwent cosmetic lip silicone application: one year later she complained of simultaneous onset of RP and very aggressive diffuse cutaneous SSc with anti-topoisomerase positivity; she died during follow-up. 5. BS 33-year-old female who underwent cosmetic breast prosthesis: twenty months later she complained of RP and after ten further months, limited cutaneous SSc with ACA positivity; SSc clinical condition partially improved and its progression stopped after prosthesis removal. Globally, after silicone implant, RP occurred in a mean time of 15±5 months and SSc in 23±8 months.

Conclusion

This study reports a prevalence of 3.6% of silicone cosmetic surgery before SSc onset, interestingly with a close and similar temporal association between silicone implant and disease development. This finding suggests a possible role of silicone in SSc pathogenesis (ASIA syndrome). Specifically addressed large clinical studies or big-data studies need to rule out this matter.

References

[1]Denton C, et al. Lancet 2017; 390: 1685–99.

[2]Marie I et al. Semin Immunopathol 2015; 37:463–473.

[3]Coroneos CJ et al. Ann Surg. 2019 Jan;269(1):30-36.

[4]Watad A et al. Lupus. 2017; 26:675-681.

Disclosure of Interests

Adriano Lercara: None declared, Alberto Sulli: None declared, Carmen Pizzorni: None declared, Emanuele Gotelli: None declared, Sabrina Paolino: None declared, ANDREA CERE: None declared, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Celgene, Pfizer, Boehringer-Ingelheim

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

Background

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

Objectives

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

Methods

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

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

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

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

Results

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

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

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

Table 1.

Adrenal insufficiency signs and symptoms.

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

* Systolic RR < 90 or diastolic RR < 60.

**Mean (SD)

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

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

Conclusion

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

References

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

Acknowledgements

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

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

Disclosure of Interests

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

AB0675 Health related quality of life in patients with mixed connective tissue disease: A comparison with matched systemic sclerosis patients

Background

Mixed connective tissue disease (MCTD) is a systemic auto-immune disorder, being probably the least common among the connective tissue diseases. Symptoms can be severe and could affect health-related quality of life (HRQoL). Identification of the burden of MCTD patients is of key importance to provide appropriate pharmacological and non-pharmacological care. No reports on HRQoL have been published in adult patients with MCTD.

Objectives

To perform an explorative study to evaluate HRQoL and its main determinants in MCTD patients, and compare HRQoL between MCTD and matched systemic sclerosis (SSc) patients.

Methods

MCTD patients fulfilling the Kahn criteria and participating in the MCTD prospective follow-up cohort of the Leiden University Medical Center were included. In addition, SSc patients matched for age, gender and disease duration were included for comparison. Data on disease characteristics, functional disability and HRQoL were collected annually for both disease groups. HRQoL was evaluated using the 36-Item Short Form Health Survey (SF36) and EuroQol (EQ5D). At baseline, HRQoL, as reflected by SF36 mental component score (MCS), SF 36 physical component score (PCS) and EQ5D were compared between MCTD and SSc patients. For MCTD patients, factors associated with HRQoL at baseline were identified using linear regression and change in HRQoL over 3 years was evaluated using linear mixed models. In addition, characteristics of MCTD patients who showed worsening of MCS and/or had PCS superior to the minimal clinical important difference of three points were identified.

Results

Thirty-four MCTD patients (121 visits; 82% female, mean age 42 years, median disease duration 45 months) and 102 SSc patients (424 visits; 82% female, mean age 45 years, median disease duration 49 months) were included. At baseline, MCTD-patients more often had ILD (47% vs. 34%, p=0.027), cardiac involvement (30% vs. 2%, p<0.001), synovitis (26% vs. 11%, p=0.004) and myositis (15% vs. 1%, p=0.001) compared to SSc patients, whereas SSc patients more often used immunosuppressive treatments except for hydroxychloroquine (MCTD:18% vs. SSc:7%, p=0.007).

Baseline HRQoL in MCTD was comparable to HRQoL in SSc, with mean SF36-PCS of 40.2 (SD:9.1) and mean SF36-MCS of 44.9 (SD:9.9), which is (nearly) one standard deviation lower than the general Dutch population. The SF36 subscore “general health perception” was the most impacted in both groups (MCTD: 38.5 [SD:7.0], SSc: 39.9 [SD:8.9]). The median EQ5DNL was 0.38 (IQR:0.14 – 0.54) and comparable between SSc and MCTD.

At baseline, in MCTD, ILD was significantly associated with SF36-PCS (β:6.98, 95% CI: 1.10 to 12.86) and SF36-MCS (β:-8.10, 95% CI:-14.93 to -1.26). Sclerodactyly was significantly associated with EQ5DNL (β:0.006; 95% CI:0.002 to 0.010) and SF36-PCS (β:0.12, 95% CI:0.03 to 0.21). No other significant associations were identified.

Over time, in MCTD, both the SF36-MCS and SF36-PCS improved significantly (MCS: β:2.35/year [95% CI:0.58 to 4.13], PCS: β:1.34/year [95% CI:0.03 to 2.65), whereas EQ5DNL was stable. Explorative analyses did not reveal a specific clinical characteristic with significant impact on the change of HRQoL over time. With an MCID of 3 points on the MCS and PCS, 7 MCTD-patients worsened on the MCS and 3 on the PCS. Patients who showed worsening of MCS over time tended to be older, more often had ILD, sclerodactyly and GI complaints, and had worse exercise tolerance. All these differences did not reach statistical significance. The patients who decreased PCS more often had ILD (100% vs. 41%, p=0.015), and used glucocorticoids more often (33% vs. 0%, p=0.046), were slightly older and had a worse exercise tolerance as compared to those who showed a stable/improving PCS over time.

Conclusion

Like in SSc, HRQoL is significantly impaired in MCTD, especially the general health perception of patients. Cardiac involvement, ILD, age and worse functional disability might specifically impact HRQoL in MCTD. However, these associations need further evaluations in larger cohorts.

Disclosure of Interests

None declared

AB1370 MICROVASCULAR CAPILLAROSCOPIC ABNORMALITIES AND AUTOANTIBODY OCCURRENCE IN SARCOIDOSIS PATIENTS

Background

Sarcoidosis (S) is a granulomatous disease with multi-organ involvement displaying a mixed immune-mediated pathophysiology. Raynaud’s phenomenon (RP) has been occasionally reported in S patients [1] and serum positivity for autoantibodies has been detected in S patients but their significance is debated [2].

Objectives

We described nailfold videocapillaroscopy (NVC) findings and estimated the prevalence of serum anti-nuclear (ANA) and extractable nuclear antigen autoantibodies (ENA-Abs) in S patients, comparing them with age- and sex- matched healthy controls (HCs) and patients with primary Raynaud’s phenomenon (PRP). Secondarily, we analysed potential correlations between NVC findings with the occurrence of autoantibodies, immunomodulatory treatment, laboratory parameters, variables of pulmonary function and whole-body imaging.

Methods

Twenty-seven (27) S patients, classified according to WASOG criteria[3], were assessed through NVC examination, laboratory parameters (including serum concentrations of angiotensin-converting enzyme [ACE], C-reactive protein [CRP], calcium, phosphorus, albumin, 25-hydroxyvitamin D, parathormone, ANA and ENA), pulmonary function tests (PFTs), chest-X ray and positron emission tomography/computerized tomography (PET/CT).

Among NVC parameters, we analysed capillary dilations, giant capillaries, haemorrhages, nonspecific abnormalities, and capillary absolute number for mm [4].

Pulmonary involvement was classified by X-ray Scadding staging system (SSS) scoring S patients in 4 grades [5]. From PET data, the maximum standard uptake value (SUVmax) was quantified as a variable of tissue 18-fluorodeoxyglucose hyper-uptake: consequently, S patients were defined PET-positive when SUV value ≥ 2.5. NVC parameters and ANA/ENA dosage were recorded also in 30 PRPs and 30 HCs.

Results

We excluded, among the cohort of S patient, one participant having a systemic sclerosis in overlap with S. The remaining 26 S patients (mean age 56.5 ± 12.5 years, 53.8 % of females, disease duration 28.4 ± 55.1 months, 27% glucocorticoid-naïve) showed a significant higher rate of dilations and nonspecific abnormalities and a lower mean capillary absolute number than PRPs and HCs (p < 0.01 for all comparisons). (Figure 1)

The prevalence of ANA positivity was significantly higher in S patients compared with PRPs and HCs (p < 0.02 for both). Among the whole cohort of patients only one S patient displayed a positive ENA-Ab (Ro52).

In the analysis of S patients’ subgroup, a significant negative correlation was detected between serum ACE levels with the presence of capillary dilations (rho = -0.45, p = 0.04), between CRP and mean capillary absolute number (rho = -0.49, p = 0.02) and a positive correlation was also detected between the mean capillary absolute number and the forced vital capacity percentage (FVC%) (rho = 0.40, p = 0.04).

Conclusion

Our findings suggest a microvascular involvement in sarcoidosis whose investigation by NVC could be useful for the detection of an overlapping connective tissue disease and for the monitoring of the phenotypes of S patients displaying RP.

The positivity for autoantibodies in S patients is in line with literature data suggesting, at least partially, autoimmune features of the disease or the production of autoantibodies reactive to tissue damage.

The correlations between NVC findings with ACE levels and lung function variables generate hypotheses of a potential partial vascular impairment in sarcoidosis disease activity and lung involvement.

References

[1]Nigro A et al. Reumatismo 2004; 56: 278-81.

[2]Kobak S et al. Autoimmune Diseases 2014

[3]Judson M.A et al. Clin Rev Allergy Immunol 2015; 49: 63-78.

[4]Smith V et al. Autoimmun Rev 2020; 19: 102458.

[5]Scadding J.G. Br Med J 1961; 2: 1165-72.

Disclosure of Interests

None declared

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

Background

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

Objectives

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

Methods

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

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

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

Results

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

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

Conclusion

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

References

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

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

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

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

Acknowledgements

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

Disclosure of Interests

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

AB0739 Aminaphtone tolerability and safety in scleroderma patients: a four-year follow-up

Background

Recent studies show that Aminaphtone is effective in the treatment of Raynaud’s phenomenon (RP) symptoms in patients with systemic sclerosis (SSc), and an increase in peripheral blood perfusion was demonstrated by Laser speckle contrast analysis in treated patients (1,2). Unfortunately, the drug is only available in a few countries.

Objectives

To evaluate long-term tolerability and safety of Aminaphtone in SSc patients with secondary RP.

Methods

Seventy SSc patients (EULAR/ACR criteria) (mean disease duration 8±7 years, mean age 61±10 years) who started Aminaphtone treatment due to active RP were enrolled and followed for at least 4 years. Patients were also taking various concomitant treatments, including immunomodulators, cyclic intravenous iloprost, endothelin receptor antagonists and aspirin. None was taking sildenafil or selexipag. Survival of Aminaphtone in therapy was assessed along with possible drug-related side effect. The Raynaud condition score (RCS) to asses disease severity and blood examinations were routinely performed.

Results

The mean follow-up of patients was 49±11 months. Aminaphtone was orally administered at 75 mg twice daily, as standard initial posology in our clinical practice. During the follow-up, six patients (8,6%) referred headache as side effect and had to reduce Aminaphtone posology to 75 mg per day, while maintaining clinical benefits. No other side effect related to the drug was observed during the follow-up. Seven patients increased the posology to 75 mg three times daily due to poor effectiveness, and further seven patients increased the posology to 75 mg three times daily only during the colder months of the year. Conversely, thirty-five patients reduced the dosage to 75 mg once daily only during the hottest months of the year, due to partial remission of the RP. During follow-up, blood tests did not reveal any significant alteration ascribable to Aminaphtone. A subjective improvement of Raynaud’s symptoms (assessed by the RCS) was already evident after 1-2 months of treatment in fifty-six patients (80%). Globally, the patients referred a sustained improvement followed by stabilization of Raynaud’s symptoms during the follow-up.

Conclusion

During an average observation period of four years, Aminaphtone showed a good tolerability and safety profile along with sustained efficacy in patients with SSc-related RP, without disabling or serious side effects. A randomized controlled trial for Aminaphtone use in the management of SSc-related RP is desirable to better assess the clinical efficacy of the drug over time.

References

[1]Parisi S, et al. Am J Int Med. 2015;3:204–209. 2. Ruaro B et al. 2019. Front Pharmacol 10:293.

Disclosure of Interests

ANDREA CERE: None declared, Emanuele Gotelli: None declared, Adriano Lercara: None declared, Carmen Pizzorni: None declared, Sabrina Paolino: None declared, Elisa Alessandri: None declared, Maurizio Cutolo Grant/research support from: Bristol Myers Squibb, Celgene, Pfizer, Boehringer Ingelheim, Alberto Sulli: None declared

POS1410 DEVELOPMENT OF PREDICTION MODELS FOR SENIOR PATIENTS WITH RHEUMATOID ARTHRITIS AND COMORBIDITIES TREATED WITH CHRONIC LOW-DOSE GLUCOCORTICOIDS IN THE GLORIA TRIAL

Background

Rheumatoid arthritis (RA) is a systemic, inflammatory disease primarily located in the joints resulting in pain, joint damage, functional disability and reduced quality of life. Treatment of RA is essential to prevent these outcomes, but the treatment itself may also result in adverse events and comorbidity [1]. Although many investigators are working on personalized medicine [2], better models to predict harm and benefit from a certain drug need to be developed before they can be used in daily clinical practice [3].

Objectives

To develop prediction models for individual patient harm and benefit outcomes in senior patients with RA and comorbidities treated with chronic low-dose glucocorticoid therapy or placebo.

Methods

In the GLORIA trial 451 RA patients aged 65+ were randomized to 2 years 5 mg/day prednisolone or placebo. Eight prediction models were developed from the dataset in a stepwise procedure. In preparation, to limit excessive statistical testing and false positive results, possible predictors were grouped into five predictor sets based on prior knowledge (Table 1). The first set of four models disregarded study treatment and examined general predictive factors. The second set of four models was similar but examined the additional role of study treatment, as main factor and as interaction factor with other predictive variables. In each set two models focused on harm (1: occurrence of ≥1 adverse event of special interest (AESI); 2: number of AESIs per year) and two on benefit (3: early clinical response–disease activity; 4: lack of joint damage progression). AESI comprised all serious adverse events, events leading to discontinuation of study treatment, and events related to glucocorticoid exposure (see main GLORIA study abstract). Linear and logistic multivariable regression methods with backward selection were used to develop the models. The final models were assessed and internally validated with bootstrapping techniques, and their performance was evaluated with model fit and discrimination measures.

Table 1.

Predictor sets.

Personal factorsDisease factorsComorbiditiesAgeDAS28Active comorbidity: cont, dich,SexRA durationGC-relatedEducationRFPrior comorbidity: cont, dich,SmokingAnti-CCPGC-relatedAlcoholDamage (cont, dich)# comorbidity medicationsBMICoping RAJoint surgeryBlood pressureImpact RA# patient symptomsMedicationHealth and daily functioning# concomitant medicationsHAQPrevious use DMARD, bDMARD, GCQoLCurrent use bDMARDVAS healthAdherenceSF36 physical, mentalSwitch antirheumatic drugs

cont=continuous; dich=dichotomous; GC=glucocorticoid.

Results

Study treatment (i.e. prednisolone) was highly predictive as a main factor in models 5-8, increasing the risk of both benefit and harm. In addition, a few additional variables were slightly (but not relevantly) predictive for the outcome in one of the models (Figure 1). Their association was much weaker than that of study treatment. In three instances, prednisolone interacted with another predictive factor (see Figure 1). The quality of the prediction models was sufficient, the performance low to moderate: explained variance: 12-15%, AUC 0.67-0.69.

Conclusion

Baseline factors are not helpful to select senior RA patients for treatment with low-dose prednisolone given their low power to predict the chance of benefit or harm.

References

[1]Smolen JS et al. Lancet. 2016;388(10055):2023-38.

[2]Huizinga TWJ. J Intern Med. 2015;277(2):178-87.

[3]De Punder YMRVR et al. Journal of Rheumatology. 2015;42(3):391-7.

Acknowledgements

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

Disclosure of Interests

Linda Hartman: None declared, José Antonio P. da Silva: None declared, Frank Buttgereit Speakers bureau: Abbvie, AstraZeneca, Gruenenthal, Horizon Therapeutics, Mundipharma, Pfizer, Roche, Maurizio Cutolo: None declared, Daniela Opris-Belinski Speakers bureau: Abbvie, Pfizer, MSD, Novartis, Eli Lilly, Ewo Pharma, UCB, Zoltán Szekanecz: None declared, Pavol MASARYK: None declared, Marieke Voshaar: None declared, Martijn W. Heijmans: None declared, WIllem Lems Speakers bureau: Pfizer, Galapagos, Lilly, Amgen, UCB, Désirée van der Heijde: None declared, Maarten Boers Speakers bureau: BMS, Novartis, Pfizer

P190 CAROTID DOPPLER ULTRASONOGRAPHIC AND DAPAGLIFOZIN IN TYPE 2 DIABETIC PATIENTS

Background

Carotid Doppler ultrasonography (USG) is widely used to measure haemodynamic parameters, such as Intima–Media Thickness (IMT) and blood flow velocities (i.e. Peak–Systolic Velocity [PSV], End–Diastolic Velocity [EDV], and Resistive Index [RI]). Dapaglifozin (SGLT2i) have been shown to reduce the risk of cardiovascular disease in type 2 diabetes (T2DM) patients. SGLT2i is a sodium–glucose co–transporter 2 inhibitor that reduces renal glucose reabsorption, thus increasing urinary glucose excretion. This leads to sustained systolic and diastolic blood pressure reduction, through natriuresis. We hypothesized that this agent would also reduce arterial stiffness.

Aim

The purpose of this study was to evaluate cardiovascular disease risk indirectly through USG of carotid artery vascular markers in T2DM patients using dapagliflozin.

Methods and Results

40 patients presenting to our clinic between march 2019 and march 2021 and diagnosed with T2DM were included in the study. These were divided into two groups : 1) a dapagliflozin group of 20 patients and 2) 20 patients non–dapagliflozin control group. Velocity parameters were: peak–systolic velocity (PSV), end–diastolic velocity (EDV), pulsatility index (PI), resistive index (RI). Examination was performed on distal portion of CCA, and we took the mean of both CCA. The mean duration of follow–up was 2.0 years. Mean ages were 55 ± 10 years in the dapagliflozin group and 50 ± 10 in the control group. Common carotid artery, PSV, and EDV parameters were higher while RI was lower (p ˂ 0.01), in the dapagliflozin group than in the control group. Vascular resistance was lower in the group using dapagliflozin for diabetes management. In addition In the dapagliflozin group, the IMT decreased after dapagliflozin therapy (P &lt; 0.01).

Conclusions

haemodynamic parameters were better performing in the group using dapagliflozin for diabetes management. Finally SGLT2i can decrease the IMT in patients with T2DM, which is closely related to cardiovascular benefit in patients with T2DM.

POS0882 AMINAPHTONE LONG-TERM TREATMENT IN SYSTEMIC SCLEROSIS

Background:

Aminaphtone has been used since many years to treat microvascular disorders. Aminaphtone seems to improve clinical symptoms of Raynaud’s phenomenon (RP), either primary or secondary to systemic sclerosis (SSc) by increasing peripheral blood perfusion as assessed by Laser speckle contrast analysis (1).

Objectives:

To evaluate long-term survival and tolerability of Aminaphtone in SSc patients with secondary RP.

Methods:

Eighty SSc patients (mean age 64±12 years; mean disease duration 9±8 years) treated with Aminaphtone due to active RP were enrolled (ACR/EULAR 2013 criteria). Patients were taking also various concomitant treatments, including aspirin, cyclic intravenous iloprost, immunomodulators, endothelin receptor antagonists. SSc patients performed periodic clinical and laboratory assessments on average every four months per our clinical practice. Duration of Aminaphtone administration, side effects, and self-assessment of Raynaud Condition Score (RCS) with a scale from 0 (absence of pain) to 10 (maximal pain) were retrospectively assessed.

Results:

The observation period was between twelve and seventy months (mean 36±19 months). Aminaphtone was administered at 75 mg twice daily, as standard initial posology per our clinical practice. During the follow-up, five patients (6.2%) referred headache as side effect: three of them had to reduce Aminaphtone posology to 75 mg per day, while maintaining clinical benefits; two patients had to stop the treatment. No other side effects related to the drug appeared during the treatment period, and repeated blood tests did not reveal any significant alteration ascribable to Aminaphtone. After 3 months of treatment sixty-six patients (83%) referred a subjective improvement of RP (RCS 3.6±0.8, vs baseline RCS 7.4±0.8, p=0.032), whereas fourteen patients (17%) were clinically unsatisfied (RCS 6.1±0.4, p=0.12). In this last group of patients, Aminaphtone posology was increased to 75 mg three times a day with a satisfactory amelioration in further nine patients (94% of total) (RCS 4.0±0.6, p=0.04), while five patients (6.2%) definitively discontinued therapy for subjective ineffectiveness within six months. Patients referred a sustained improvement of RCS along the observational period (36±19 months) (last RCS 3.6±0.7 vs baseline, p=0.031).

Conclusion:

During an average observation period of three years, Aminaphtone showed a good tolerability profile along with sustained efficacy in 94% of patients with SSc-related RP, without disabling side effects. The absence of a placebo-control group, the retrospective design limit the results, and a randomized controlled trial for Aminaphtone use in the management of SSc-related RP is needed.

References:

[1]Ruaro B et al. 2019. Front Pharmacol 10:293.

Disclosure of Interests:

Alberto Sulli: None declared, Emanuele Gotelli: None declared, ANDREA CERE: None declared, Elvis Hysa: None declared, Greta Pacini: None declared, Carmen Pizzorni: None declared, Sabrina Paolino: None declared, Maurizio Cutolo Grant/research support from: Laboratori Baldacci s.p.a.

POS0330 NINTEDANIB (TYROSINE KINASE INHIBITOR) DOWNREGULATES THE TRANSITION OF CULTURED SYSTEMIC SCLEROSIS FIBROCYTES INTO MYOFIBROBLASTS AND THEIR PRO-FIBROTIC ACTIVITY

Background:

Fibroblast-to-myofibroblast transition is one of the fundamental steps involved in the fibrotic process that characterise systemic sclerosis (SSc) [1]. Myofibroblasts are α-smooth muscle actin (αSMA) positive cells that contribute to fibrosis through the excessive synthesis and deposition of extracellular matrix (ECM) proteins, primarily fibronectin (FN) and type I collagen (COL1) [2].

Among the cells involved in the fibrotic process of SSc, circulating fibrocytes seem to have an emerging role as an important source of fibroblasts and myofibroblasts [3].

Nintedanib is a tyrosine kinase inhibitor approved for the treatment of idiopathic pulmonary fibrosis that interferes with the signalling pathways involved in the pathogenesis of fibrosis (4). Nintedanib was recently demonstrated to have a beneficial effect in patients with interstitial lung disease (ILD) associated with SSc (5).

Objectives:

To investigate nintedanib effect in inhibiting the in vitro transition of circulating SSc fibrocytes into myofibroblasts and their pro-fibrotic activity.

Methods:

Circulating fibrocytes were obtained from 14 SSc patients (mean age 64±14 years), who fulfilled the 2013 ACR/EULAR criteria for SSc and that underwent complete disease staging in a day-hospital setting at the Rheumatology Division of Genoa University. Five age-matched healthy subjects (HSs) were also analysed. All SSc patients and HSs signed the informed consent and the local EC approved the study. Peripheral blood mononuclear cells were isolated by density gradient centrifugation and plated on FN-coated dishes. After overnight culture, non-adherent cells were removed, and adherent cells were maintained in growth medium for 8 days (T8) to obtain fibrocytes [6]. T8-cultured SSc fibrocytes were maintained in growth medium (untreated cells) or treated with nintedanib 0.1μM and 1μM for 3 and 24 hours. Fibroblast specific protein-1 (S100A4) and αSMA, as markers of fibroblast/myofibroblast phenotype, together with COL1 and FN, were investigated by qRT-PCR and Western blotting. Non-parametric Mann-Whitney and Wilcoxon tests were used for the statistical analysis.

Results:

Significantly elevated gene and protein expressions of αSMA, S100A4, COL1 and FN were observed in SSc fibrocytes compared to HS fibrocytes (gene: αSMA p<0.001; others p<0.0001; protein: all p<0.05). In accordance with the antibody positivity for Scl70 and the presence or absence of ILD at CT scan, SSc patients were grouped as either Scl70 positive patients with ILD (Scl70+ILD+) or Scl70 negative patients without ILD (Scl70-ILD-). Significant αSMA, S100A4, COL1 and FN gene expressions were found in fibrocytes from Scl70+ILD+ compared to HS fibrocytes (αSMA p<0.001; others p<0.0001). Moreover, fibrocytes from Scl70+ILD+patients showed a more significant gene expression of fibroblasts/myofibroblasts markers compared to Scl70-ILD-patients (p<0.01 for S100A4), whereas no differences were observed for ECM gene expression.

Nintedanib reduced the gene and protein expression of αSMA, COL1 and FN in SSc fibrocytes compared to untreated ones with different statistical significance.

Noteworthy, nintedanib significantly downregulated αSMA, S100A4, COL1 and FN gene expression (all p<0.05) in Scl70+ILD+fibrocytes, whereas only that of S100A4 and FN was significantly downregulated (p<0.05) in Scl70-ILD- fibrocytes compared to untreated cells.

Conclusion:

Nintedanib seems to downregulate in vitro the transition of fibrocytes into myofibroblasts and their pro-fibrotic activity, particularly in cells isolated from Scl70+ILD+SSc patients.

References:

[1]Cutolo M et al. Exp Rev Clin Immunol. 2019;15:753-64.

[2]Van Caam A et al. Front. Immunol. 2018;9:2452.doi:10.3389/fimmu.2018.02452.

[3]Distler JH et al. Arthritis Rheumatol. 2017;69:257-67.

[4]Distler O et al. New Eng J Med. 2019; 380:2518-28.

[5]Maher TB et al. Arthritis Rheumatol.2020.doi:10.1002/art.41576.

[6]Cutolo M et al. Arthritis Res Ther. 2018;20:157.doi:10.1186/s13075-018-1652-6.

Acknowledgements:

We thank Stefano-Lutz Willing for the scientific support through the study.

Disclosure of Interests:

Stefano Soldano: None declared, Paola Montagna: None declared, Emanuele Gotelli: None declared, Samuele Tardito: None declared, Sabrina Paolino: None declared, Claudio Corallo: None declared, Carmen Pizzorni: None declared, Alberto Sulli: None declared, Carlotta Schenone: None declared, Greta Pacini: None declared, Vanessa Smith: None declared, Maurizio Cutolo Grant/research support from: I received grant/research support from Bristol-Myers Squibb, Boehringer, Celgene

POS0850 NAILFOLD CAPILLARY DILATIONS IN RAYNAUD’S PHENOMENON: QUANTIFYING A PREDICTIVE THRESHOLD FOR THE ‘SCLERODERMA PATTERN’

Background:

Non-specific abnormalities could be detected by nailfold videocapillaroscopy (NVC) in subject with primary Raynaud’s Phenomenon (RP) several years before the clinical onset of connective tissue diseases (CTD)s [1]. Previous findings from our group proved that ≤30 μm capillary dilations in RP patients have a negative predictive value for developing the ‘scleroderma pattern’ during follow-up [2].

Objectives:

To investigate the role of NVC >30 μm capillary dilations as positive predictive factors of the ‘scleroderma pattern’ in RP patients later developing systemic sclerosis (SSc)-related RP.

Methods:

A 10-year retrospective NVC-based investigation evaluated the dataset of sequential NVCs of 18 RP patients later developing SSc (cases) and 19 sex- and age-matched RP patients later developing other CTDs (controls). Both cases and controls had ≥1 NVC performed before the ‘scleroderma pattern’/CTD diagnosis (basal NVC) showing >30 μm dilated capillaries. Each NVC was qualitatively and semi-quantitatively assessed, recording number of total capillaries, number and average/site-specific diameters (arterial, apical, venous) of >30 μm dilated capillaries [3]. Statistical analysis was performed to stratify the risk of developing the ‘scleroderma pattern’.

Results:

Significant differences of capillary diameters were observed between cases and controls both at basal NVC and during follow-up (p<0.001). The proportion of >30 μm dilated capillaries in basal NVC was the strongest predictor of ‘scleroderma pattern’ in a median 3-year time, with a 27% cut-off (PPV 0.79, 95%CI 0.54,0.94; p<0.001). Additional “Higher risk” NVC hallmarks for ‘scleroderma pattern’ development were apical diameter >40 μm (p<0.001), venous diameter >25 µm (p<0.05) and average diameter ≥35 µm (p<0.005). Conversely, CTDs patients showed a stable NVC ‘non-scleroderma pattern’ over a median 10-year time.

Conclusion:

This is the first study to show that NVC-detected homogeneous and progressive capillary loop dilations in RP patients significantly contribute to predict the ‘scleroderma pattern’ evolution within a median 3-year time, possibly providing a “very early” window of opportunity in SSc pre-clinical stages.

References:

[1]Cutolo M et al. Expert Rev Clin Immunol. 2019;15(7):753–64. [2] Trombetta AC et al. J Rheumatol 2016;43:599–606. [3] Smith et al. Autoimmun Rev 2020; 19(3):102458.

Disclosure of Interests:

None declared

POS1250 VITAMIN D DEFICIENCY IS MAINLY ASSOCIATED WITH SEVERE LUNG INVOLVEMENT, LONGER DISEASE DURATION AND RISK OF DEATH IN ELDERLY COVID-19 PATIENTS

Background:

Vitamin D regulates the innate and adaptive immune system responses and low vitamin D levels have been associated with the increased risk of respiratory tract infections (1). Vitamin D deficiency has been recently reported to interfere with the prognosis of COVID-19 (2,3).

Objectives:

The aim of this study was to correlate the 25OH-vitamin D serum levels with lung involvement and disease severity, in a cohort of elderly patients hospitalized for SARS-CoV-2 infection.

Methods:

Sixty-five COVID-19 patients (mean age 76±13 years) and sixty-five sex- and age-matched control subjects (CNT) were included in the study. Respiratory parameters (PaO2, SO2, PaCO2, PaO2/FiO2), clinical and laboratory parameters (including 25OH-vitamin D, D-dimer, C-reactive protein) and type of radiological pulmonary involvement were collected at hospital admission. Statistical analysis was performed by non-parametric tests.

Results:

Vitamin D sufficiency (>30 ng/ml), insufficiency (between 20 and 30 ng/ml), deficiency (between 10 and 20 ng/ml) and severe deficiency (<10 ng/ml) were observed respectively in 11, 11, 21 and 57 % of COVID-19 patients. Vitamin D serum levels were found significantly lower in COVID-19 patients than in CNT (median 8 vs 16 ng/ml, p=0.001). A statistically significant positive correlation was observed between vitamin D serum levels and SO2 (p=0.05), PaO2 (p=0.03), PaO2/FiO2 (p=0.02). A statistically significant negative correlation was found between vitamin D serum levels and severity of radiologic pulmonary involvement: vitamin D was significantly lower in COVID-19 patients with either diffuse/severe interstitial lung involvement (p=0.05) or multiple lung consolidations (p=0.0001) than in those with mild radiological lung involvement. Significantly lower vitamin D serum levels were found in COVID-19 patients who died during hospitalization, compared to those who survived (median 3 vs 8 ng/ml, p=0.05). Finally, a statistically significant negative correlation was found between vitamin D serum levels and D-dimer (p=0.04), C-reactive protein (p=0.04) and disease duration (p=0.05).

Conclusion:

This study confirms that severe vitamin D deficiency is associated with more severe lung involvement, longer disease duration and risk of death in elderly COVID-19 patients.

References:

[1]Cutolo M, et al. RMD Open. 2020; 6(3):e001454.

[2]Bilezikian JP, et al. Eur J Endocrinol. 2020; 183(5):R133-R147.

[3]Weir EK, et al. Clin Med (Lond). 2020; 20:e107-e108.

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

References:

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

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

Table 1.

Comorbidities and concomitant medications at baseline in the GLORIA trial.

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

Acknowledgements:

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

Disclosure of Interests:

None declared