Towards the Lowest Efficacious Dose: Results From a Multicenter Noninferiority Randomized Open-Label Controlled Trial Assessing Tocilizumab or Abatacept Injection Spacing in Rheumatoid Arthritis in Remission

OBJECTIVE

We assess the clinical and structural impact at two years of progressively spacing tocilizumab (TCZ) or abatacept (ABA) injections versus maintenance at full dose in patients with rheumatoid arthritis in sustained remission.

METHODS

This multicenter open-label noninferiority (NI) randomized clinical trial included patients with established rheumatoid arthritis in sustained remission receiving ABA or TCZ at a stable dose. Patients were randomized to treatment maintenance (M) at full dose (M-arm) or progressive injection spacing (S) driven by the Disease Activity Score in 28 joints every 3 months up to biologics discontinuation (S-arm). The primary end point was the evolution of disease activity according to the Disease Activity Score in 44 joints during the 2-year follow-up analyzed per protocol with a linear mixed-effects model, evaluated by an NI test based on the one-sided 95% confidence interval (95% CI) of the slope difference (NI margin 0.25). Other end points were flare incidence and structural damage progression.

RESULTS

Overall, 202 of the 233 patients included were considered for per protocol analysis (90 in S-arm and 112 in M-arm). At the end of follow-up, 16.2% of the patients in the S-arm could discontinue their biologic disease-modifying antirheumatic drug, 46.9% tapered the dose and 36.9% returned to a full dose. NI was not demonstrated for the primary outcome, with a slope difference of 0.10 (95% CI 0.10-0.31) between the two arms. NI was not demonstrated for flare incidence (difference 42.6%, 95% CI 30.0-55.1) or rate of structural damage progression at two years (difference 13.9%, 95% CI -6.7 to 34.4).

CONCLUSION

The Towards the Lowest Efficacious Dose trial failed to demonstrate NI for the proposed ABA or TCZ tapering strategy.

Serum calprotectin and renal function decline in ANCA-associated vasculitides: a post hoc analysis of MAINRITSAN trial

OBJECTIVE

Serum calprotectin appears to be an interesting biomarker associated with renal vascular disease activity in antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV). The aim of this study was to assess whether serum calprotectin levels can predict decline in renal function in AAV patients receiving maintenance therapy.

METHODS

Serum calprotectin levels were assessed at inclusion and month 6 in AAV patients, in complete remission after induction therapy, randomly assigned to rituximab or azathioprine. Renal function decline was defined as a 25% decrease in estimated glomerular filtration rate (eGFR) and a change in the eGFR category, or a decrease of 15 mL/min/1.73 m2. Relapse was defined as a Birmingham Vasculitis Activity Score >0 attributable to active vasculitis.

RESULTS

Seventy-six AAV were included. Serum calprotectin increased from baseline to month 6 in patients with renal function decline (7940 (-226.0, 28 691) ng/ml vs -4800 (-18 777, 3708) ng/ml; p<0.001). An increase of calprotectin level was associated with a higher risk of subsequent renal function decline even after adjustment (OR 6.50 (95% CI 1.7 to 24.9) p=0.006). A significantly higher risk of relapse was observed in proteinase 3- AAV patients with an increase of serum calprotectin levels (OR 5.6 (95% CI 1.0 to 31.2), p=0.03).

CONCLUSION

An increase in serum calprotectin by month 6 compared with inclusion during remission-maintenance therapy in AAV was associated with a higher risk of renal function decline in the following 12 months.

TRIAL REGISTRATION NUMBER

NCT00748644.

Survey of adolescents' needs and parents' views on sexual health in juvenile idiopathic arthritis

BACKGROUND

Although the advent of new therapeutics for juvenile idiopathic arthritis (JIA) patients has considerably lessened the impact of the disease and reduced its sequelae, the outcomes of JIA remain important in their lives. Disease repercussions and side effects of treatments may affect sexual health and cause psychological distress. This aim of the study was to determine the expectations of adolescent JIA patients and the perceptions of their parents regarding knowledge and communication with healthcare providers (HCPs) in the field of sexual health (SH).

METHODS

In France, from September 2021 to April 2022, a survey was conducted, using anonymous self-administered questionnaires, among JIA patients (adults (aged 18-45 years) to provide insights from their recollection of their adolescence) and their parents in nine rheumatology centers and three patient associations.

RESULTS

The responses to the 76 patient questionnaires and 43 parent questionnaires that were collected were analyzed. Half of the patients thought JIA impacted their romantic relationships, but the results were less clear-cut for their sexual activity; and 58.7% of the patients said they would be comfortable discussing the subject with HCPs, but only 26.3% had done so, mainly regarding biomedical issues. The patients and their parents thought that ideally, the topic should be addressed in an individual patient education session at the hospital (51.3% and 34.9%, respectively), in a regular consultation (47.4% and 53.5%), or in a dedicated consultation requested by the adolescent without the adolescent's parents being informed (38.2% and 20.9%). Most of the respondents thought HCPs should be proactive in SH (77.6% of the patients and 69.8% of their parents). More patients than parents said the following digital information tools must be used: videos (29.0% vs. 9.3%, p = 0.0127) and smartphone applications (25.0% vs. 9.3%, p = 0.0372).

CONCLUSION

HCPs should consider addressing the unmet need for SH discussions during their patient encounters. To meet this need, we propose concrete actions in line with the wishes of patients and parents.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04791189.

Gait and Axial Spondyloarthritis: Comparative Gait Analysis Study Using Foot-Worn Inertial Sensors

Background

Axial spondyloarthritis (axSpA) can lead to spinal mobility restrictions associated with restricted lower limb ranges of motion, thoracic kyphosis, spinopelvic ankylosis, or decrease in muscle strength. It is well known that these factors can have consequences on spatiotemporal gait parameters during walking. However, no study has assessed spatiotemporal gait parameters in patients with axSpA. Divergent results have been obtained in the studies assessing spatiotemporal gait parameters in ankylosing spondylitis, a subgroup of axSpA, which could be partly explained by self-reported pain intensity scores at time of assessment. Inertial measurement units (IMUs) are increasingly popular and may facilitate gait assessment in clinical practice.

Objective

This study compared spatiotemporal gait parameters assessed with foot-worn IMUs in patients with axSpA and matched healthy individuals without and with pain intensity score as a covariate.

Methods

A total of 30 patients with axSpA and 30 age- and sex-matched healthy controls performed a 10-m walk test at comfortable speed. Various spatiotemporal gait parameters were computed from foot-worn inertial sensors including gait speed in ms^–1 (mean walking velocity), cadence in steps/minute (number of steps in a minute), stride length in m (distance between 2 consecutive footprints of the same foot on the ground), swing time in percentage (portion of the cycle during which the foot is in the air), stance time in percentage (portion of the cycle during which part of the foot touches the ground), and double support time in percentage (portion of the cycle where both feet touch the ground).

Results

Age, height, and weight were not significantly different between groups. Self-reported pain intensity was significantly higher in patients with axSpA than healthy controls (P<.001). Independent sample t tests indicated that patients with axSpA presented lower gait speed (P<.001) and cadence (P=.004), shorter stride length (P<.001) and swing time (P<.001), and longer double support time (P<.001) and stance time (P<.001) than healthy controls. When using pain intensity as a covariate, spatiotemporal gait parameters were still significant with patients with axSpA exhibiting lower gait speed (P<.001), shorter stride length (P=.001) and swing time (P<.001), and longer double support time (P<.001) and stance time (P<.001) than matched healthy controls. Interestingly, there were no longer statistically significant between-group differences observed for the cadence (P=.17).

Conclusions

Gait was significantly altered in patients with axSpA with reduced speed, cadence, stride length, and swing time and increased double support and stance time. Taken together, these changes in spatiotemporal gait parameters could be interpreted as the adoption of a so-called cautious gait pattern in patients with axSpA. Among factors that may influence gait in patients with axSpA, patient self-reported pain intensity could play a role. Finally, IMUs allowed computation of spatiotemporal gait parameters and are usable to assess gait in patients with axSpA in clinical routine.

Trial Registration

ClinicalTrials.gov NCT03761212; https://clinicaltrials.gov/ct2/show/NCT03761212

International Registered Report Identifier (IRRID)

RR2-10.1007/s00296-019-04396-4

New-Onset Inflammatory Bowel Diseases Among IL-17 inhibitors-Treated Patients: Results From The Case-Control MISSIL Study

OBJECTIVES

To describe new-onset inflammatory bowel diseases (new IBD) in patients treated with interleukin 17 inhibitors (IL-17i), to assess their incidence and to identify their risk factors in real life.

METHODS

A French national registry (MISSIL) aimed to report all cases of new IBD in patients treated with IL-17i from January 2016 to December 2019. Using the estimated number of patients treated by IL-17 in France during the study period, the annual incidence rates of new IBD was reported in IL-17i-treated patients. A case-control study was performed with two controls per new IBD case matched by gender, age and underlying inflammatory disease.

RESULTS

31 cases of new IBD under IL-17i were collected: 27 patients treated for spondyloarthritis and 4 patients for psoriasis. All were observed with secukinumab (SEK). The median time to onset of new IBD symptoms was 4.0 (1.5-7.5) months. SEK was discontinued in all patients. The evolution was favourable with complete resolution (17/31), improvement (7/31) or stabilization (5/31). 2 patients died: one due to a massive myocardial infarction and one due to post-colectomy complications. The incidence of new IBD decreased from 0.69/100 PY (7/1010) in 2016, to 0.08/100PY (6/7951) in 2019. No previous treatment with etanercept (OR = 0.33, IC95% 0.14-0.80, p= 0.014) and low number of previous biological therapies (OR = 0.67, 95%CI 0.47-0.94, p= 0.021) were significantly associated with new IBD.

CONCLUSION

The incidence of new IBD was low and decreased from 2016 to 2019. The outcome was favourable in 24 out of 31 patients, but two patients died.

Human influence on brown trout juvenile body size during metapopulation expansion

Change in body size can be driven by social (density) and non-social (environmental and spatial variation) factors. In expanding metapopulations, spatial sorting by means of dispersal on the expansion front can further drive the evolution of body size. However, human intervention can dramatically affect these founder effects. Using long-term monitoring of the colonization of the remote Kerguelen islands by brown trout, a facultative anadromous salmonid, we analyse body size variation in 32 naturally founded and 10 human-introduced populations over 57 years. In naturally founded populations, we find that spatial sorting promotes slow positive changes in body size on the expansion front, then that body size decreases as populations get older and local density increases. This pattern is, however, completely different in human-introduced populations, where body size remains constant or even increases as populations get older. The present findings confirm that changes in body size can be affected by metapopulation expansion, but that human influence, even in very remote environments, can fully alter this process.

The effects of a secondary task on gait in axial spondyloarthritis

Studies on the effects of dual tasking in patients with chronic inflammatory rheumatic diseases are limited. The aim of this study was to assess dual tasking while walking in patients with axial spondyloarthritis (axSpA) in comparison to healthy controls. Thirty patients with axSpA and thirty healthy controls underwent a 10-m walk test at a self-selected comfortable walking speed in single- and dual-task conditions. Foot-worn inertial sensors were used to compute spatiotemporal gait parameters. Analysis of spatiotemporal gait parameters showed that the secondary manual task negatively affected walking performance in terms of significantly decreased mean speed (p < 0.001), stride length (p < 0.001) and swing time (p = 0.008) and increased double support (p = 0.002) and stance time (p = 0.008). No significant interaction of group and condition was observed. Both groups showed lower gait performance in dual task condition by reducing speed, swing time and stride length, and increasing double support and stance time. Patients with axSpA were not more affected by the dual task than matched healthy controls, suggesting that the secondary manual task did not require greater attention in patients with axSpA. Increasing the complexity of the walking and/or secondary task may increase the sensitivity of the dual-task design to axial spondyloarthritis.

Marine habitat use and feeding ecology of introduced anadromous brown trout at the colonization front of the sub-Antarctic Kerguelen archipelago

In 1954, brown trout were introduced to the Kerguelen archipelago (49°S, 70°E), a pristine, sub-Antarctic environment previously devoid of native freshwater fishes. Trout began spreading rapidly via coastal waters to colonize adjacent watersheds, however, recent and unexpectedly the spread has slowed. To better understand the ecology of the brown trout here, and why their expansion has slowed, we documented the marine habitat use, foraging ecology, and environmental conditions experienced over one year by 50 acoustically tagged individuals at the colonization front. Trout mainly utilized the marine habitat proximate to their tagging site, ranging no further than 7 km and not entering any uncolonized watersheds. Nutritional indicators showed that trout were in good condition at the time of tagging. Stomach contents and isotope signatures in muscle of additional trout revealed a diet of amphipods (68%), fish (23%), isopods (6%), and zooplankton (6%). The small migration distances observed, presence of suitable habitat, and rich local foraging opportunities suggest that trout can achieve their resource needs close to their home rivers. This may explain why the expansion of brown trout at Kerguelen has slowed.

Mediation of Interleukin-23 and Tumor Necrosis Factor-Driven Reactive Arthritis by Chlamydia-Infected Macrophages in SKG Mice

OBJECTIVE

ZAP-70^W163C BALB/c (SKG) mice develop reactive arthritis (ReA) following infection with Chlamydia muridarum. Since intracellular pathogens enhance their replicative fitness in stressed host cells, we examined how myeloid cells infected with C muridarum drive arthritis.

METHODS

SKG, Il17a-deficient SKG, and BALB/c female mice were infected with C muridarum or C muridarum luciferase in the genitals. C muridarum dissemination was assessed by in vivo imaging or genomic DNA amplification. Macrophages were depleted using clodronate liposomes. Anti-tumor necrosis factor (anti-TNF) and anti-interleukin-23p19 (anti-IL-23p19) were administered after infection or arthritis onset. Gene expression of Hspa5, Tgtp1, Il23a, Il17a, Il12b, and Tnf was compared in SKG mice and BALB/c mice.

RESULTS

One week following infection with C muridarum, macrophages and neutrophils were observed to have infiltrated the uteri of mice and were also shown to have carried C muridarum DNA to the spleen. C muridarum load was higher in SKG mice than in BALB/c mice. Macrophage depletion was shown to reduce C muridarum load and prevent development of arthritis. Compared with BALB/c mice, expression of Il23a and Il17a was increased in the uterine and splenic neutrophils of SKG mice. The presence of anti-IL-23p19 during infection or Il17a deficiency suppressed arthritis. Tnf was overexpressed in the joints of SKG mice within 1 week postinfection, and persisted beyond the first week. TNF inhibition during infection or at arthritis onset suppressed the development of arthritis. Levels of endoplasmic reticulum stress were constitutively increased in the joints of SKG mice but were induced, in conjunction with immunity-related GTPase, by C muridarum infection in the uterus.

CONCLUSION

C muridarum load is higher in SKG mice than in BALB/c mice. Whereas proinflammatory IL-23 produced by neutrophils contributes to the initiation of C muridarum-mediated ReA, macrophage depletion reduces C muridarum dissemination to other tissues, tissue burden, and the development of arthritis. TNF inhibition was also shown to suppress arthritis development. Our data suggest that enhanced bacterial dissemination in macrophages of SKG mice drives the TNF production needed for persistent arthritis.

Evaluation of the impact of a nurse-led program of patient self-assessment and self-management in axial spondyloarthritis: results of a prospective, multicentre, randomized, controlled trial (COMEDSPA)

OBJECTIVE

To evaluate the impact of a nurse-led program of self-management and self-assessment of disease activity in axial spondyloarthritis.

METHODS

Prospective, randomized, controlled, open, 12-month trial (NCT02374749). Participants were consecutive axial spondyloarthritis patients (according to the rheumatologist) and nurses having participated in a 1-day training meeting. The program included self-management: educational video and specific video of graduated, home-based exercises for patients; and self-assessment: video presenting the rationale of tight monitoring of disease activity with composite scores (Ankylosing Spondylitis Disease activity Score, ASDAS/Bath Ankyslosing Spondylitis Disease Activity Index, BASDAI). The nurse trained patients to collect, calculate and report (monthly) ASDAS/BASDAI. Treatment allocation was by random allocation to this program or a comorbidities assessment (not presented here and considered here as the control group).

RESULTS

A total of 502 patients (250 and 252 in the active and control groups, respectively) were enrolled (age: 46.7 (12.2) years, male gender: 62.7%, disease duration: 13.7 (11.0) years). After the one-year follow-up period, the adherence to the self-assessment program was considered good (i.e. 79% reported scores >6 times). Despite a lack of statistical significance in the primary outcome (e.g. coping) there was a statistically significant difference in favor of this program for the following variables: change in BASDAI, number and duration of the home exercises in the active group, and physical activity (international physical activity score, IPAQ).

CONCLUSION

This study suggests a short-term benefit of a nurse-led program on self-management and self-assessment for disease activity in a young axial spondyloarthritis population in terms of disease activity, exercises and physical activity.

Impact of disease activity and treatments on ovarian reserve in patients with rheumatoid arthritis in the ESPOIR cohort

OBJECTIVES

Patients with RA have a higher prevalence of infertility than the general population. This study sought to examine the impact of RA disease activity and treatments on ovarian reserve measured by serum anti-Müllerian hormone (AMH) levels in the ESPOIR cohort. We sought to better define the indications for fertility preservation.

METHODS

Patients and serum analysis data were derived from the French national cohort ESPOIR. Enrolled patients (n = 102; 18-37-year-olds) fulfilled ACR/EULAR 2010 criteria for RA. Serum AMH levels were measured at T0, T6, T12, T24 and T36 months post-diagnosis. The impacts of RA activity (DAS28 and CRP level) and treatments (MTX only or with other medications) were evaluated at each study visit.

RESULTS

A gradual decrease in patients' serum AMH levels was observed over time, in line with the descending curve described for healthy women. Serum AMH levels of RA patients in comparison with the values considered normal for age did not reveal any significant differences (P > 0.05). We did not observe any impact of RA treatments. We demonstrated an inverse correlation between AMH variation and disease activity (DAS28: r = -0.27, P = 0.003; CRP: r = -0.16, P = 0.06).

CONCLUSION

This is the first study to determine serum AMH levels of a large cohort of RA patients over 36 months. Rapid disease activity control appears to be required to limit changes in the ovarian reserve. Fertility preservation is not likely to be necessary if inflammation is promptly controlled.

CLINICALTRIALS.GOV IDENTIFIER

NCT03666091.

Cut-off value to identify a flare using the Flare Assessment in Rheumatoid Arthritis (FLARE-RA) questionnaire: analysis of the TOSCA study

OBJECTIVE

The Flare Assessment in Rheumatoid Arthritis (FLARE-RA) self-administered questionnaire aims to identify patients who had flare in the interval between 2 consultations. This study aimed to establish a threshold for FLARE-RA score to identify RA flare.

METHODS

The Tocilizumab SubCutAneous (TOSCA) study evaluated the efficacy and safety of subcutaneous Tocilizumab (TCZ) to patients with active RA. Disease activity was assessed with the DAS28ESR at baseline and at week 2 (W2), W4, W12, and W24. The FLARE-RA questionnaire was administered at W12 and W24. Patient satisfaction, assessed at baseline and W24 with the Patient Acceptable Symptom State (PASS), was used as a surrogate marker of no flare. A correlation was sought between the FLARE-RA score at W12 and W24 and the area under the receiver operating characteristic (ROC) curve (AUC) for monthly DAS28ESR. The optimal FLARE-RA cut-off below which patient satisfaction reached the PASS was explored with an ROC curve.

RESULTS

139 patients were included (mean age 57.3 ± 13.8 years, 74.1% women, mean RA duration 10.8 ± 9.2 years, mean DAS28ESR 5.8 ± 1.1). The correlation between the FLARE-RA score and DAS28ESR AUC was moderate at all times: rho = 0.41 at W12 (p<0.0001) and 0.51 at W24 (p<0.0001). The optimal cut-off for the FLARE-RA score to identify absence of flare (i.e. an acceptable situation based on the PASS) was 2.3 with an AUC of 0.81.

CONCLUSION

FLARE-RA and DAS28ESR assessment differ; we propose a FLARE-RA cut-off of 2.3, below which the situation (i.e. without flare) is acceptable for patients.

GlutenSpA trial: protocol for a randomised double-blind placebo-controlled trial of the impact of a gluten-free diet on quality of life in patients with axial spondyloarthritis

INTRODUCTION

Subclinical intestinal inflammation and gut dysbiosis have been reported in patients with spondyloarthritis (SpA). In common practice, rheumatologists are increasingly confronted with patients with inflammatory rheumatism who are on gluten-free diets (GFDs), despite the lack of reliable data from controlled studies. This study aims to determine the impact of a GFD on the quality of life of patients with axial SpA.

METHODS AND ANALYSIS

The GlutenSpA study is a 24-week, randomised, double-blinded, placebo-controlled, multicentre trial. Patients with axial SpA (n=200) will follow a 16-week GFD and be randomly assigned (1:1) to an experimental or control arm. In the experimental arm with receive at least 6 gluten-free breads per day + 200 g of gluten-free penne pasta per week + 6 rice flavour capsules per day. The control arm will receive at least 6 gluten-containing breads per day + 200 g of gluten-containing penne pasta per week + 6 vital gluten-containing capsules per day. The primary end-point is the variation in Assessment of SpondyloArthritis International Society-Health Index (ASAS-HI) questionnaire between week 16 and baseline. A second open-label period of 8 weeks will follow the intervention period, during which the patient will be free to decide whether they will follow the GFD. The secondary outcomes comprise several patient-reported outcomes (SpA activity (Bath Ankylosing Spondylitis Disease Activity Index)), fatigue (Functional Assessment of Chronic Illness Therapy), depression (Hospital Anxiety and Depression Scale), functional disability index (Bath Ankylosing Spondylitis Functional Index)), variations in body mass index and Homeostasis Model Assessment Index and variations in the abundance and type of bacterial species found in the gut microbiota for a subgroup of patients (n=40). The data will be analysed using the intention-to-treat principle.The regional ethics committee (CPP Nord-ouest IV) has approved the study (IDRCB 2018-A00309-46). The results of the trial will be submitted for publication in peer-reviewed journals. The authors have no relationship that may have influenced the submitted work.

TRIAL REGISTRATION NUMBER

NCT04274374.

Foot-Worn Inertial Sensors Are Reliable to Assess Spatiotemporal Gait Parameters in Axial Spondyloarthritis under Single and Dual Task Walking in Axial Spondyloarthritis

The aim of this study was (1) to evaluate the relative and absolute reliability of gait parameters during walking in single- and dual-task conditions in patients with axial spondyloarthritis (axSpA), (2) to evaluate the absolute and relative reliability of dual task effects (DTE) parameters, and (3) to determine the number of trials required to ensure reliable gait assessment, in patients with axSpA. Twenty patients with axSpa performed a 10-m walk test in single- and dual-task conditions, three times for each condition. Spatiotemporal, symmetry, and DTE gait parameters were calculated from foot-worn inertial sensors. The relative reliability (intraclass correlation coefficients-ICC) and absolute reliability (standard error of measurement-SEM and minimum detectable change-MDC) were calculated for these parameters in each condition. Spatiotemporal gait parameters showed good to excellent reliability in both conditions (0.59 < ICC < 0.90). The reliability of symmetry and DTE parameters was low. ICC, SEM, and MDC were better when using the mean of the second and the third trials. Spatiotemporal gait parameters obtained from foot-worn inertial sensors assessed in patients with axSpA in single- and dual-task conditions are reliable. However, symmetry and DTE parameters seem less reliable and need to be interpreted with caution. Finally, better reliability of gait parameters was found when using the mean of the 2nd and the 3rd trials.

Increased high molecular weight adiponectin and lean mass during tocilizumab treatment in patients with rheumatoid arthritis: a 12-month multicentre study

Background

Patients with rheumatoid arthritis (RA) have an increased risk of cardiovascular (CV) disease. Adiponectin is involved in the metabolism of glucose and lipids with favourable effects on CV disease, especially its high molecular weight (HMW) isoform. Body composition changes are described in RA with various phenotypes including obesity. The effects of tocilizumab on serum adiponectin and body composition, especially fat mass, in patients with RA are not well determined.

Methods

Patients with active RA despite previous csDMARDs and/or bDMARDs and who were tocilizumab naïve were enrolled in a multicentre open-label study. They were evaluated at baseline, 1, 3, 6 and 12 months. Clinical assessment included body mass index (BMI) and anthropometric measurements. Lipid and metabolic parameters, serum adiponectin (total and HMW), leptin, resistin and ghrelin were measured at each time point. Body composition (lean mass, fat mass, % fat, fat in the android and gynoid regions) was evaluated at baseline, 6 and 12 months.

Results

One hundred seven patients were included. Both total and HMW adiponectin significantly increased from baseline to month 3, peaking respectively at month 3 (p = 0.0105) and month 1 (p < 0.0001), then declining progressively until month 6 to 12 and returning to baseline values. Significant elevation in HMW adiponectin persisted at month 6 (p = 0.001). BMI and waist circumference significantly increased at month 6 and 12, as well as lean mass at month 6 (p = 0.0097). Fat mass, percentage fat and android fat did not change over the study period. Lipid parameters (total cholesterol and LDL cholesterol) increased while glycaemia, insulin and HOMA-IR remained stable. Serum leptin, resistin and ghrelin did not change during follow-up.

Conclusions

Tocilizumab treatment in RA patients was associated with a significant increase in total and HMW adiponectin, especially at the onset of the treatment. Tocilizumab also induced a significant gain in lean mass, while fat mass did not change. These variations in adiponectin levels during tocilizumab treatment could have positive effects on the CV risk of RA patients. In addition, tocilizumab may have an anabolic impact on lean mass/skeletal muscle.

Trial registration

The ADIPRAT study was a phase IV open-label multicentre study retrospectively registered on ClinicalTrials.gov under the number NCT02843789 (date of registration: July 26, 2016).

Efficacy, safety and cost-effectiveness of a web-based platform delivering the results of a biomarker-based predictive model of biotherapy response for rheumatoid arthritis patients: a protocol for a randomized multicenter single-blind active controlled clinical trial (PREDIRA)

BACKGROUND

Rheumatoid arthritis (RA) is one of the leading chronic inflammatory rheumatism. First-line therapy with synthetic disease-modifying antirheumatic drugs (sDMARD) is insufficiently effective in 40% of cases and these patients are treated with biotherapies. The increased use of these drugs each year is becoming a public health issue with considerable economic burden. This cost is 20 times higher than that of sDMARD. However, among patients treated with biotherapies, clinical practice shows that about one third will not respond to the selected drug. In nonresponse cases, practitioners currently have no choice but to perform an empirical switching between different treatments, because no tool capable of predicting the response or nonresponse to these molecules is currently available.

METHODS

The study is a prospective, phase III, controlled, multicenter, and randomized, single-blind (patient) clinical trial, including RA patients with a previous failure to anti-TNF therapies. The main objective is the analysis of the clinical and pharmacoeconomic impact after 6 months of treatment. Intervention arm: prescription of biotherapy (rituximab, adalimumab, abatacept) using SinnoTest® software, a prediction software based on proteomic biomarkers. Control arm: prescription of biotherapy based on current practice, without the SinnoTest® software (any biotherapy). In addition, a substudy will be carried out within this trial to generate a biobank and further analyze the proteomic profile of the patients and their modification throughout the study.

DISCUSSION

This clinical trial study will be the first validation study of a biotherapy response prediction software, bringing personalized medicine into the management of RA. We expect that the findings from this study will bring several benefits for the patient and the Health Care System.

TRIAL REGISTRATION

ClincalTrials.gov NCT04147026 . Registered on 31 October, 2019.

OP0031 AN INCREASE IN SERUM CALPROTECTIN LEVEL IN ANCA-ASSOCIATED VASCULITIDES PATIENTS DURING MAINTENANCE THERAPY IS ASSOCIATED WITH MORE RELAPSE AND ACCELERATED RENAL FUNCTION DECLINE

Background:

Calprotectin (S100A8/A9), a protein secreted by activated neutrophils and monocytes in inflammatory conditions, is upregulated in active ANCA-associated vasculitides. Serum calprotectin level variation during induction therapy is associated with disease relapse in PR3-ANCA-associated vasculitides (1). However, the place of this biomarker during maintenance therapy is unknown.

Objectives:

To demonstrate whether variation in serum calprotectin level during maintenance therapy could be used as a biomarker predicting subsequent relapse in ANCA-associated vasculitides.

Methods:

Patients with ANCA-associated vasculitides in complete remission (BVAS=0) after induction therapy with cyclophosphamide and included in the MAINRITSAN trial (2) were analyzed. Patients were randomized to receive rituximab or azathioprine as maintenance therapy. Relapse was defined as the re-occurrence or new onset of disease attributable to active vasculitis. Accelerated decline renal function (estimated Glomerular Filtration Rate (eGFR) assessed using the MDRD equation) was defined in concordance with NICE 2015 guideline (3) as “a decrease in eGFR of 25% or more and a change in GFR category or a sustained decrease in eGFR of 15 ml/min/1.73m2over 12 months”. Calprotectin was assessed in the serum at inclusion and 6 months by ELISA (IDK® Calprotectin ELISA kit, Immunodiagnostik). We defined an increase in serum levels of calprotectin as a positive variation of calprotectin level at M6 compared to baseline.

Results:

Of all, 96 patients (female 45.8%, mean age 55.3±13.5, 69.8% PR3+, 62.5% ANCA positive at inclusion) had at least a calprotectin dosage (86 at baseline, 86 at M6 and 76 patients at this 2 time-point). Calprotectin level at baseline or 6 months was not significantly different between relapsing patients and those without relapse after 18 months of follow-up, whereas the calprotectin variation at M6 compared to baseline was higher in relapsing patients (n=10) (mean (SD) 17991 (±28972) ng/ml) than in patients not experiencing any relapse (n=66) (9419 (±50002) ng/mL; p=0.03). An increase in serum calprotectin level at 6 months was significantly associated with an increased risk of relapse in PR3-ANCA patients (OR=5.6 (95%CI, 1.0-31.3; p=0,049) but not in the whole study group (OR=3.3 (95%CI, 0.8-14.1; p=0.1), and identified patients with accelerated renal function decline (all cohort: OR=10.6 (95%CI, 2.9-39.6; p=0.002; PR3+ patients: OR=5.909 (95%CI, 2.9-39.6; p=0.01)), whereas calprotectin level did not correlate with glomerular filtration rate (r = -0.07, p=0.35).

Conclusion:

An increase in serum calprotectin during the first 6 months of maintenance therapy in ANCA-associated vasculitides is a useful biomarker predicting vasculitis relapse and accelerated renal function deterioration in the following 12 months.

Increase calprotectin serum at 6 months identify relapser and accelerated decline renal function at 1 year.Kaplan-Meier survival curves of ANCA-associated vasculitis patients with an increase in serum calprotectin at 6 months (solid line) or not (dotted line) remaining total relapse-free or accelerated decline renal function-free. Gehan-Beslow-Wilcoxon test.

References:

[1]Pepper RJ et al. Arthritis Rheumatol. 2017;69(1):185-93.

[2]Guillevin L et al. N Engl J Med. 2014;371(19):1771-80.

[3]NIH. Chronic kidney disease 2014.

Acknowledgments:

Supported by a grant from the Programme Hospitalier de Recherche Clinique, French Ministry of Health (2008-002846-51).

Disclosure of Interests:

Xavier Romand Consultant of: Xavier ROMAND has received honorarium fees from Abbvie, Anais Courtier: None declared, Minh Vu Chuong Nguyen: None declared, Marie-Hélène Paclet: None declared, Philippe Gaudin Speakers bureau: Lilly, Loïc Guillevin: None declared, Benjamin Terrier: None declared, Athan Baillet Consultant of: Athan BAILLET has received honorarium fees from Abbvie for his participation as the coordinator of the systematic literature review