Sacroiliac joint radiographic progression in axial spondyloarthritis is retarded by the therapeutic use of TNF inhibitors: 12-year data from the SCQM registry

OBJECTIVES

To analyse the effect of tumour necrosis factor inhibitors (TNFi) on sacroiliac joint (SIJ) radiographic progression in axial spondyloarthritis (axSpA).

METHODS

Patients with axSpA in the Swiss Clinical Quality Management cohort with up to 12 years of follow-up and radiographic assessments every 2 years were included. SIJs were scored by two readers according to the modified New York criteria blinded to chronology. The relationship between TNFi use before or during a 2-year radiographic interval and SIJ progression was investigated using generalised estimating equation models with adjustment for potential confounding. Progression was defined as worsening of ≥1 grade in ≥1 SIJ and ignoring a change from 0 to 1 over 2 years, if both readers agreed. A third reading of radiographs was integrated in sensitivity analyses.

RESULTS

A total of 515 patients with axSpA contributed to data for 894 radiographic intervals (24 progression events). In patients with complete covariate data, prior use of TNFi reduced the odds of progression (OR 0.21, 95% CI 0.07 to 0.65). A comparable effect was found for use of TNFi for ≥1 year within a 2-year radiographic interval (OR 0.21, 95% CI 0.08 to 0.55). The inhibitory impact of TNFi was confirmed if progression was demonstrated in 2/3 readings: OR 0.50, 95% CI 0.28 to 0.89 and OR 0.46, 95% CI 0.27 to 0.78 for TNFi treatment before and for ≥1 year within the interval, respectively.

CONCLUSION

TNFi are associated with deceleration of SIJ radiographic progression in patients with axSpA if treatment is continued for ≥1 year.

Type of mRNA COVID-19 vaccine and immunomodulatory treatment influence humoral immunogenicity in patients with inflammatory rheumatic diseases

Patients with inflammatory rheumatic diseases (IRD) are at increased risk for worse COVID-19 outcomes. Identifying whether mRNA vaccines differ in immunogenicity and examining the effects of immunomodulatory treatments may support COVID-19 vaccination strategies. We aimed to conduct a long-term, model-based comparison of the humoral immunogenicity following BNT162b2 and mRNA-1273 vaccination in a cohort of IRD patients. Patients from the Swiss IRD cohort (SCQM), who assented to mRNA COVID-19 vaccination were recruited between 3/2021-9/2021. Blood samples at baseline, 4, 12, and 24 weeks post second vaccine dose were tested for anti-SARS-CoV-2 spike IgG (anti-S1). We examined differences in antibody levels depending on the vaccine and treatment at baseline while adjusting for age, disease, and past SARS-CoV-2 infection. 565 IRD patients provided eligible samples. Among monotherapies, rituximab, abatacept, JAKi, and TNFi had the highest odds of reduced anti-S1 responses compared to no medication. Patients on specific combination therapies showed significantly lower antibody responses than those on monotherapy. Irrespective of the disease, treatment, and past SARS-CoV-2 infection, the odds of higher antibody levels at 4, 12, and 24 weeks post second vaccine dose were, respectively, 3.4, 3.8, and 3.8 times higher with mRNA-1273 versus BNT162b2 (p < 0.0001). With every year of age, the odds ratio of higher peak humoral immunogenicity following mRNA-1273 versus BNT162b2 increased by 5% (p < 0.001), indicating a particular benefit for elderly patients. Our results suggest that in IRD patients, two-dose vaccination with mRNA-1273 versus BNT162b2 results in higher anti-S1 levels, even more so in elderly patients.

Long-term persistence of antibodies after diphtheria/tetanus vaccination in immunosuppressed patients with inflammatory rheumatic diseases and healthy controls

Many vaccines demonstrate high effectiveness for years. This prospective multicentre study was conducted in Switzerland to assess the long-term persistence of antibodies to the diphtheria/tetanus (dT)-vaccine in adult patients with rheumatic diseases (PRDs). 163 PRDs and 169 controls were included in the study. The median age of all participants was 50 years (range: 18-83 years) and 56% were female. After a median time interval of 16 years after vaccination, the median anti-vaccine antibody concentrations were lower in PRDs than in controls for tetanus (1.68 vs 2.01; p = 0.049) and diphtheria (0.05 vs 0.22; p = 0.002). Based on the currently accepted seroprotection threshold (antibody concentration ≥ 0.1 IU/ml), PRDs had lower proportions of short-term tetanus and diphtheria protection as demonstrated by crude odds ratios (OR) of 0.30 (p = 0.017) and OR: 0.52 (p = 0.004), respectively. After adjusting for 'age' and 'time since last dT vaccination', the strength of associations became weaker; for tetanus, borderline evidence remained for a true difference between PRDs and controls (OR: 0.36 [p = 0.098]), however, not for diphtheria (OR: 0.86 [p = 0.58]). We hypothesize that in the presence of rheumatic diseases and its immunosuppressive treatment, vaccine-specific long-lived plasma cells (LLPCs) may be diminished or competitively displaced by rheumatism-specific LLPCs, a process which may decrease the persistence of vaccine-specific antibodies. Novel studies should be designed by incorporating methodologies allowing to determine the attributable fraction of immunosuppressive/immunomodulatory medications and rheumatic disease itself on long-lasting vaccine-specific antibody persistence, as well as, further study the role of LLPCs.

OP0102 THE SYNOVIUM IN CHRONIC INFLAMMATORY JOINT DISEASES: COMPARISON OF CLINICAL, HISTOLOGICAL AND scRNA-SEQ Data BETWEEN RA, PsA, SpA AND UA

Background

The synovium is the primary location of inflammation in various rheumatic diseases. However, specific differences of joint inflammation have not been explored on a single-cell level so far.

Objectives

To characterize the synovium of rheumatoid arthritis (RA), psoriatic arthritis (PsA), spondyloarthritis (SpA) and undifferentiated arthritis (UA) based on clinical and histological characteristics and single-cell RNA sequencing (scRNA-seq).

Methods

We performed ultrasound (US) guided synovial biopsy in patients fulfilling classification criteria: 10 RA, 4 PsA, 4 SpA and 3 UA. 3 osteoarthritis (OA) samples were obtained from surgery. Clinical data were collected at time of biopsy. Histological analysis of the synovium included Krenn score [1], synovial pathotype [2], vascularization [3] and presence of lymphoid follicles. OA histology was not available. We prepared scRNA-seq libraries with 10X Genomics and sequenced on NovaSeq 6000. ScRNA-seq data was analysed with Cell Ranger, Seurat and Harmony R packages. We selected overexpressed genes using log2 ratio (>0.25) and FDR adjusted p value < 0.05.

Results

Patients showed typical disease characteristics. In RA, 6/10 were seropositive, 8/10 were female and median age was 59 years (IQR 12). Patients with PsA, SpA and UA were seronegative. 2/4 SpA and 1/4 PsA patients were HLA-B27 positive. Median age was 53 years in PsA (IQR 14.2), 52.5 in SpA (IQR 14.8) and 53 in UA (IQR 3.5). In PsA 3/4, SpA 2/4 and UA 1/3 patients were male.

RA joints had significantly higher B-Mode US scores compared to PsA and SpA joints (mean B-Mode Score: RA 2.7; PsA 2; SpA 2). Correspondingly, RA patients reported a significantly higher amount of swelling in the biopsied joint compared to PsA and SpA (mean “Swelling-Score”: RA 6.85; PsA 4.25; SpA 4).

Histology showed no clear differences in the cell composition; most joints showed a lympho-myeloid pathotype. Mean Krenn Score was highest in RA (4.78) and lowest in SpA (3.33). PD-Mode US score showed a significant positive association with histological vascularization. Lymphoid follicles were significantly more seen in RA compared to all other diseases.

Integration of scRNA-seq data revealed 16 cell clusters with respective marker gene: PRG4 synovial fibroblasts (SF), THY1 SF, ACTA2 smooth muscle cells, VWF endothelial cells, TPSB2 mastcells, IGHG plasma cells, CD79 B-cells, CD69 T-Cells, CCL5 natural killer cells, DMTN Treg-cells, CXC2 neutrophil granulocytes, TREM2 macrophages, CD48 macrophages, CLEC10A macrophages, CD4 dendritic cells, MKI67 proliferating cells. OA had the lowest and RA the highest number of inflammatory cells within the synovium. SpA synovium had the highest number of neutrophils. Re-Clustering of only SF revealed 4 subtypes: PRG4 SF (3578 cells), CXCL12 SF (4539 cells), POSTN SF (2387 cells) and MFAP5 SF (1734 cells). Top 5 marker genes are shown in the Table 1. Most differentially expressed genes in OA were found in PRG4 SF; the previously described OA specific gene CSN1S1 [3] was not only underexpressed in RA but also in other inflammatory joint diseases (Figure 1). PGF, a gene associated with pathological angiogenesis, was one of the top discriminator genes, highly expressed in PsA SF (mostly PRG4 SF). RA SF (mostly CXCL12 SF) showed a high expression of CHI3L1, which is a RA specific autoantigen. High expression of hemoglobin genes was found in SpA PRG4 SF; an unexplored but previously described finding [5, 6].

Table 1.

Top 5 synovial fibroblast (SF) marker genes.

ClusterGenePRG4 SFPRG4CSN1S1MMP3CRTAC1HTRA1CXCL12 SFAPOECXCL12CCL2PTGDSCD74POSTN SFCOMPCOL1A1POSTNCILPPTNMFAP5 SFMFAP5SFRP2APODCXCL14CFD

Conclusion

We were able to compare the synovium of the most common chronic inflammatory joint diseases on various levels for the first time. The findings set the path for future diagnostic, prognostic, and therapeutic approaches in inflammatory joint diseases.

References

[1]Krenn et al, Histopath. 2006

[2]Humby et al, ARD 2019

[3]Kennedy et al, AR 2010

[4]Galligan et al, GI 2007

[5]Yeremenko et al, A&R 2012

[6]Park et al, JRD 2016

Disclosure of Interests

None declared

OP0175 TYPE OF mRNA COVID-19 VACCINE AND TREATMENT INFLUENCE ANTIBODY KINETICS IN PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES

Background

Patients on immunomodulatory treatments mount an attenuated immune response following mRNA COVID-19 vaccination, yet long-term studies of vaccine-induced anti-SARS-CoV-2 antibody (Ab) kinetics are missing.

Objectives

In this prospective observational study, we mapped the humoral antibody response to mRNA COVID-19 vaccines up to 24 weeks post full vaccination in patients with inflammatory rheumatic diseases (IRDs). We aimed to assess differences due to treatment, age, past SARS-CoV-2 infection, and vaccine (BNT162b2 vs. mRNA-1273).

Methods

Adult patients from the SCQM cohort who assented to an mRNA COVID-19 vaccine were recruited between 3/21 – 9/21. Participants answered questionnaires via an app and received kits for the self-collection of capillary blood samples at baseline, 4, 12, and 24 weeks post full vaccination. Samples were tested for IgG Ab against the S1 domain of the SARS-CoV-2 spike protein (anti-S1-IgG) using the EUROIMMUN ELISA. To examine differences in Ab titres arising from the defined parameters, while accounting for inter-assay variability, mixed effects continuous outcome logistic regression models were applied at each timepoint.

Results

Samples were obtained from 570 patients: 67% female, mean age 53 y (SD 12 y) with 37% RA, 36% axSpA, 21% PsA, and 6% UA (undifferentiated arthritis), on no medication (no DMARDs & no glucocorticoids; 15%), csDMARDs (10%), TNFi (48%), IL-1/6/17/23i (14%), JAKi (6%), rituximab (RTX; 4%), or abatacept (ABA; 2%) in mono/combination therapy at the first vaccination. 10% of patients had a past SARS-CoV-2 infection, 54% received BNT162b2, 46% mRNA-1273.

For any Ab threshold, the odds of having a higher Ab titre at 4, 12, and 24 weeks post full vaccination were 3.3 – 4 times higher with mRNA-1273 compared to BNT162b2 (Table 1, Figure 1). TNFi, JAKi, RTX, and ABA as monotherapy resulted in significantly lower Ab levels compared to no medication at almost all timepoints. In combination therapy, TNFi, IL-1/6/17/23i, RTX, and csDMARDs led to consistently lower Ab titres at all timepoints compared to respective monotherapy.

Table 1.

The OR of being above a given Ab threshold, regardless of the threshold. Ref. levels: mean age, no medication, no past SARS-CoV-2 inf., BNT162b2. Included in model but not shown: diagnosis, infrequently used medication (all non-signif.)

Weeks post full vacc.41224OR (95% CI); pAge0.96 (0.94 – 0.97)****0.98 (0.96 – 0.996)*0.98 (0.97 – 1.00)mRNA-1273 (vs BNT162b2)3.28 (2.34 – 4.61)****3.96 (2.83 – 5.54)****3.94 (2.93 – 5.50)****Past COVID inf. (vs none)7.56 (4.32 – 13.2)****8.14 (4.78 – 13.86)****11.65 (6.62 – 20.50)****csDMARD†1.27 (0.67 – 2.41)1.78 (0.94 – 3.35)1.70 (0.86 – 3.36)TNFi†0.46 (0.28 – 0.71)****0.30 (0.19 – 0.48)****0.13 (0.081 – 0.22)****IL-1/6/17/23i†0.97 (0.54 – 1.75)1.04 (0.57 – 1.89)0.89 (0.49 – 1.64)JAKi†0.38 (0.16 – 0.91)*0.38 (0.16 – 0.91)*0.53 (0.22 – 1.28)RTX†0.078 (0.013 – 0.46)**0.078 (0.015 – 0.42)**0.16 (0.037 – 0.71)*ABA†0.14 (0.039 – 0.51)**0.087 (0.022 – 0.35)***0.068 (0.017 – 0.27)***Interactions§Age:vaccine‡1.04 (1.02 – 1.07)**1.02 (0.99 – 1.05)1.03 (1.0008 – 1.058)*csDMARD:combi0.12 (0.02 – 0.70)*0.17 (0.029 – 0.95)*0.11 (0.023 – 0.56)**TNFi:combi0.34 (0.20 – 0.59)***0.37 (0.22 – 0.61)***0.36 (0.21 – 0.62)***IL-1/6/17/23i:combi0.26 (0.09 – 0.78)*0.25 (0.085 – 0.70)**0.20 (0.071 – 0.58)**JAKi:combi1.76 (0.33 – 9.44)1.23 (0.32 – 4.70)0.95 (0.25 – 3.65)RTX:combi0.11 (0.01 – 0.87)*0.095 (0.012 – 0.73)*0.085 (0.0091 – 0.79)*ABA:combi1.75 (0.25 – 12.2)0.74 (0.096 – 5.75)0.51 (0.073 – 3.62)

* p < 0.05; ** p < 0.01; *** p < 0.001; **** p < 0.0001;

†Medication as monoth. vs no medication

‡Interaction terms showing how OR of mRNA-1273 (vs BNT162b2) increases with age

§Interaction terms with medications: medication in combination th. vs medication as monoth.

Conclusion

Compared to no medication, some immunomodulatory therapies resulted in markedly lower Ab levels at all timepoints. In IRD patients, a past SARS-CoV-2 infection resulted in strikingly increased immunogenicity, as did mRNA-1273 compared to BNT162b2.

Acknowledgements

This study is investigator-initiated and received independent financial support from Moderna Switzerland GmbH. The SCQM thanks the patients for their participation in this study. A list of rheumatology offices and hospitals that contribute to the SCQM registries can be found on www.scqm.ch/institutions. The SCQM is financially supported by pharmaceutical industries and donors. A list of financial supporters can be found on www.scqm.ch/sponsors.

Disclosure of Interests

Catherine Elizabeth Raptis Grant/research support from: The study presented in the abstract is investigator-initiated and received independent financial support from Moderna Switzerland GmbH. The SCQM is financially supported by pharmaceutical industries and donors. A list of financial supporters can be found on www.scqm.ch/sponsors, Diego Olivier Andrey: None declared, Christos Polysopoulos Grant/research support from: The study presented in the abstract is investigator-initiated and received independent financial support from Moderna Switzerland GmbH. The SCQM is financially supported by pharmaceutical industries and donors. A list of financial supporters can be found on www.scqm.ch/sponsors, Christoph Berger: None declared, Adrian Ciurea: None declared, Pierre Lescuyer: None declared, Tanja Maletic Grant/research support from: The study presented in the abstract is investigator-initiated and received independent financial support from Moderna Switzerland GmbH. The SCQM is financially supported by pharmaceutical industries and donors. A list of financial supporters can be found on www.scqm.ch/sponsors, Myriam Riek Grant/research support from: The study presented in the abstract is investigator-initiated and received independent financial support from Moderna Switzerland GmbH. The SCQM is financially supported by pharmaceutical industries and donors. A list of financial supporters can be found on www.scqm.ch/sponsors, Almut Scherer Grant/research support from: The study presented in the abstract is investigator-initiated and received independent financial support from Moderna Switzerland GmbH. The SCQM is financially supported by pharmaceutical industries and donors. A list of financial supporters can be found on www.scqm.ch/sponsors, Isabell von Loga Grant/research support from: The study presented in the abstract is investigator-initiated and received independent financial support from Moderna Switzerland GmbH. The SCQM is financially supported by pharmaceutical industries and donors. A list of financial supporters can be found on www.scqm.ch/sponsors, Judith Safford: None declared, Kim Lauper Speakers bureau: Kim Lauper reports consulting fees for Pfizer and speakers fees for Pfizer, Viatris and Celltrion outside of the submitted work., Consultant of: Kim Lauper reports consulting fees for Pfizer and speakers fees for Pfizer, Viatris and Celltrion outside of the submitted work., Burkhard Moeller: None declared, Nicolas Vuilleumier: None declared, Axel Finckh Speakers bureau: Axel Finckh has received consultancies or speaker honoraria for AbbVie, BMS, Eli-Lilly, Gilead, Pfizer, Sanofi, and UCB outside of the submitted work, Consultant of: Axel Finckh has received consultancies or speaker honoraria for AbbVie, BMS, Eli-Lilly, Gilead, Pfizer, Sanofi, and UCB outside of the submitted work, Grant/research support from: Axel Finckh has received research support from AbbVie, Eli-Lilly, Galapagos, and Pfizer outside of the submitted work, Andrea Rubbert-Roth: None declared

OP0020 SEX DIFFERENCES IN EFFECTIVENESS OF FIRST-LINE TUMOR NECROSIS FACTOR INHIBITORS IN AXIAL SPONDYLOARTHRITIS; RESULTS FROM FIFTEEN COUNTRIES IN THE EuroSpA RESEARCH COLLABORATION NETWORK

Background

Evidence reveals sex differences in physiology, disease presentation and response to treatment in axial spondyloarthritis (axSpA). Pooled data from four randomized controlled trials demonstrated reduced treatment efficacy of a tumor necrosis factor inhibitor (TNFi) in females compared to males with ankylosing spondylitis1. However, real-life evidence confirming these data in large cohorts is scarce. We sought to validate prior studies using data from a large multinational cohort based on real-life clinical practice.

Objectives

To investigate sex differences in treatment response and drug retention rates in clinical practice among patients with axSpA, treated with their first TNFi.

Methods

Data from biologic-naïve axSpA patients initiating a TNFi in the EuroSpA registries were pooled. In the primary analysis, propensity-score weighting was applied to assess the causal effect of sex on clinically important improvement (CII) according to ASDAS-CRP at 6 months. A generalized linear regression model was used to estimate the causal risk difference (RD) and relative risk (RR) of sex on CII. Possible covariates influencing the outcome were determined a priori and selected based on availability in the database (<20% missing). The final covariates included in the model were country, age and TNFi start year. In the secondary analysis, drug retention was assessed over 24 months of follow-up by Kaplan-Meier curves and log-rank test.

Results

In total, 6,451 axSpA patients with available data on ASDAS-CRP at baseline and 6 months were assessed for treatment response. Baseline characteristics are shown in the Table 1. In the adjusted analysis, the probability for females to have CII was 15% (RR, 0.85; 95% confidence interval [CI], 0.82 to 0.89) lower compared to males and the difference in probability for having CII was 9.4 percentage points (RD, 0.094; 95% CI, 0.069 to 0.12). The survival analysis included 28,608 axSpA patients with available data on retention rates. The TNFi 6/12/24-month retention rates were significantly lower in females (81%/69%/58%) compared to males (89%/81%/72%), see Figure 1.

Table 1.FemaleMaleMean (SD), Median [IQR] or percentagesMean (SD), Median [IQR] or percentagesAge (years)42.0 (12.1)41.4 (12.3)Fulfilment of mNYC66%80%Disease duration (years)2.0 [1.0, 7.0]3.0 [1.0, 9.0]TNFi start year Start 1999-20097.2%9.8% Start 2010-201326%27% Start 2014-201637%36% Start 2017-202030%27%BASDAI, mm59 (20)54 (21)BASFI, mm48 (25)46 (24)ASDAS, units3.5 (0.9)3.5 (1.0)CRP (mg/L)6.7 [2.5, 16.0]11.9 [4.0, 25.0]SJC (0-28)0 [0, 0]0 [0, 0]TJC (0-28)0 [0, 2]0 [0, 1]VAS pain, mm63 (22)59 (24)VAS fatigue, mm65 (25)59 (26)

mNYC, modified New York criteria; TNFi, tumor necrosis factor inhibitor; BASDAI, Bath Ankylosing Spondylitis Disease Activity Indexf; BASFI, Bath Ankylosing Spondylitis Functional Index; ASDAS, Ankylosing Spondylitis Disease Activity Score; CRP, C-reactive protein; SJC, swollen joint count; TJC, tender joint count; VAS, visual analogue scale.

Conclusion

Treatment efficacy and retention rates are lower among female patients with axSpA initiating their first TNFi. Females presented with lower C-reactive protein levels and higher scores on patient reported outcomes at baseline, reflecting differences in disease expression. Recognizing these sex differences is of relevance for customized patient care and may improve patient education.

References

[1]van der Horst-Bruinsma et al. Ann Rheum Dis. 2013 Jul;72(7):1221-4.

Acknowledgements

Novartis Pharma AG and IQVIA for supporting the EuroSpA collaboration.

Disclosure of Interests

Pasoon Hellamand Grant/research support from: Novartis, Marleen G.H. van de Sande Speakers bureau: UCB, Consultant of: Abbvie, Eli Lily, Novartis and UCB, Grant/research support from: Novartis, Janssen, UCB and Eli Lilly, Lykke Midtbøll Ørnbjerg Grant/research support from: Novartis, Thomas Klausch: None declared, Michael Nurmohamed Speakers bureau: Abbvie, Janssen and Celgene, Consultant of: Abbvie, Grant/research support from: Abbvie, Amgen, Pfizer, Galapagos, BMS, Ronald van Vollenhoven Consultant of: AbbVie, AstraZeneca, Biogen, BMS, Galapagos, Janssen, Miltenyi, Pfizer, UCB and speaker fees from Abbvie, Galapagos, GSK, Janssen, Pfizer, R-Pharma and UCB, Grant/research support from: BMS, GSK and UCB, Dan Nordström Consultant of: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Anna-Mari Hokkanen Grant/research support from: MSD, Maria Jose Santos Speakers bureau: Abbvie, AstraZeneca, Lilly, Novartis and Pfizer, Elsa Vieira-Sousa Speakers bureau: MSD, Celgene, Novartis, Janssen, Abbvie and Pfizer, Consultant of: MSD, Celgene, Novartis, Janssen, Abbvie and Pfizer, Grant/research support from: MSD, Celgene, Novartis, Janssen, Abbvie and Pfizer, Anne Gitte Loft Consultant of: AbbVie, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Grant/research support from: Novartis, Bente Glintborg Grant/research support from: Pfizer, Abbvie and BMS, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Merck, Celgene and Novartis, Ulf Lindström: None declared, Johan K Wallman Consultant of: AbbVie, Amgen, Celgene, Eli Lilly and Novartis, Brigitte Michelsen Grant/research support from: Novartis, Adrian Ciurea Speakers bureau: AbbVie and Novartis, Michael J. Nissen Speakers bureau: AbbVie, Eli Lilly, Janssens, Novartis and Pfizer, Consultant of: AbbVie, Eli Lilly, Janssens, Novartis and Pfizer, Catalin Codreanu Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Ewopharma, Lilly, Novartis and Pfizer, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Ewopharma, Lilly, Novartis and Pfizer, Corina Mogosan Speakers bureau: AbbVie, Ewopharma, Lilly, Novartis and Pfizer, Consultant of: AbbVie, Ewopharma, Lilly, Novartis and Pfizer, Gary Macfarlane Grant/research support from: GSK, Gareth T. Jones Grant/research support from: AbbVie, Pfizer, UCB, Amgen and GSK, Karin Laas Speakers bureau: Amgen, Janssen, Novartis and Abbvie, Ziga Rotar Speakers bureau: Abbvie, Novartis, MSD, Medis, Biogen, Eli Lilly, Pfizer, Sanofi, Lek and Janssen, Consultant of: Abbvie, Novartis, MSD, Medis, Biogen, Eli Lilly, Pfizer, Sanofi, Lek and Janssen, Matija Tomsic Speakers bureau: Abbvie, Amgen, Biogen, Eli Lilly, Janssen, Medis, MSD, Novartis, Pfizer, Sanofi and Sandoz-Lek, Consultant of: Abbvie, Amgen, Biogen, Eli Lilly, Janssen, Medis, MSD, Novartis, Pfizer, Sanofi and Sandoz-Lek, Isabel Castrejon Speakers bureau: Eli Lilly, BMS, Janssen, MSD and Abbvie, Consultant of: Eli Lilly, BMS, Janssen, MSD and Abbvie, Manuel Pombo-Suarez Consultant of: Abbvie, MSD and Roche, Björn Gudbjornsson Speakers bureau: Amgen and Novartis, Consultant of: Amgen and Novartis, Arni Jon Geirsson: None declared, Eirik kristianslund: None declared, Jiří Vencovský Speakers bureau: Abbvie, Argenx, Boehringer-Ingelheim, Eli-Lilly, Gilead, MSD, Novartis, Octapharma, Pfizer, Roche, Sanofi and UCB, Consultant of: Abbvie, Argenx, Boehringer-Ingelheim, Eli-Lilly, Gilead, MSD, Novartis, Octapharma, Pfizer, Roche, Sanofi and UCB, Lucie Nekvindova: None declared, Semih Gulle: None declared, Berrin Zengin: None declared, Merete Lund Hetland Grant/research support from: Abbvie, Biogen, BMS, Celltrion, Eli Lilly, Janssen Biologics B.V, Lundbeck Fonden, MSD, Medac, Pfizer, Roche, Samsung Biopies, Sandoz and Novartis, Irene van der Horst-Bruinsma Speakers bureau: BMS, AbbVie, Pfizer and MSD, Consultant of: Abbvie, UCB, MSD, Novartis and Lilly, Grant/research support from: MSD, Pfizer, AbbVie and UCB.

POS1020 BIOLOGICAL DMARD TREATMENT IN PSORIATIC ARTHRITIS IS LIKEWISE EFFECTIVE IN PATIENTS WITH HIGH AND WITH LOW JOINT COUNTS – RESULTS FROM THE SWISS CLINICAL QUALITY MANAGEMENT (SCQM) FOR RHEUMATIC DISEASES COHORT STUDY

Background

Biological and targeted synthetic (b/tsDMARDs) may be used in absent remission in psoriatic arthritis (PsA) independent of a defined number of affected joints. However, minimum three swollen and three tender joints are a common inclusion criterion in trials of b/tsDMARDs, and less is currently known about their effectiveness in PsA patients with low joint counts.

Objectives

To characterize PsA patients with low or high joint counts (LJC/HJC), analyze their drug treatment in routine care, and estimate the effectiveness of a first bDMARD in LJC and HJC patients.

Methods

We defined patients with less than three tender or swollen joints as LJC, and those with at least three tender and swollen joints as HJC patients. Patients were twice categorized according to their joint counts at registration in the registry, and at start of a first bDMARD (Table 1). We compared HJC and LJC at registration for current and future DMARD therapies, and at start of a first bDMARD for treatment effectiveness, using drug retention in univariate and in multivariable Cox regression models.

Table 1.

Selected characteristics of bDMARD naïve PsA patients with a low and with a high number of affected joints at start of their first bDMARD.

VariableLevelsHJC% highLJC% lowN allpbDMARD typeTNFi17692.617588.8351=0.22OMA147.42211.236csDMARD cotherapyyes11761.69045.7207<0.01csDMARD historynaive2312.15527.978<0.01tsDMARD_historynaive17592.117789.8352=0.47Dactylitis historyyes11560.56030.5175<0.01HLA B27yes1211.52823.340=0.02MDAYes00.0178.617<0.01DAPSA remission00.0126.112<0.01DactylitisYes9349.03316.8126<0.01EnthesitisYes6361.85547.0118=0.03BMImean (SD)27.65(5.05)26.58(4.72)333=0.046MASESmean (SD)2.86(3.93)1.61(2.47)219=0.005HAQ-DImean (SD)0.77(0.58)0.60(0.50)292=0.010EQ-5dmean (SD)62.22(20.63)67.22(16.27)294=0.022Patient globalmean (SD)5.93(2.41)4.83(2.58)288<0.001Tender joint countmean (SD)10.15(8.93)4.92(8.17)387<0.001Swollen joint countmean (SD)7.16(4.91)1.37(2.15)387<0.001Patient painmean (SD)5.96(2.47)4.85(2.51)290<0.001

Abbreviations: DAPSA: Disease activity of PsA. BMI: Body mass index, EQ-5d: European Quality of Life Measurement in five dimensions. HAQ-DI. Health assessment questionnaire disability index. HJC: High joint count, LJC: Low joint count, MASES: Maastricht ankylosing spondylitis enthesitis score, MDA: minimal disease activity, OMA: other mode of action than TNFi.

Results

We followed DMARD therapies for median (IQR) 3.2 (1.6, 5.0) in 675 LJC patients and for 3.4 (1.8, 5.2) years in 334 HJC patients. LJC patients at registration as well as at start of a first bDMARD were less often female, with less severe skin, enthesitis, dactylitis and nail involvement. Furthermore, LJC patients had lower disability indices and a more favorable health related quality of life. When defined at registration, LJC were as frequent as HJC patients on csDMARDs, but less often on bDMARDs. During their follow-up, a csDMARD, a first and a second bDMARD were less often and on average later commenced in LJC than in HJC patients. However, when defined at start of a first bDMARD, drug retention did not significantly differ between LJC and HJC patients (Figure 1).

Figure 1.

Multivariable adjusted Cox regression model for discontinuation of a first bDMARD. Abbreviation: JC_group_base: Low and high joint count groups at baseline.

Conclusion

The majority of Swiss PsA patients is in LJC status, which also means a better status in most PsA domains than in HJC patients. LJC status was associated with established bDMARD therapy and with slower treatment escalation. However, bDMARDs were likewise effective in bDMARD-naïve LJC and HJC patients, and should not withhold only for reasons of a low joint count.

References

[1]Gossec et al. 2020, Annals of the Rheumatic Diseases 79 (6): S700–712.

[2]Gladman et al. 2021, The Journal of Rheumatology 48 (12): 1824–29.

Acknowledgements

I acknowledge all patients, physicians and researchers of the Swiss Clinical Quality Management (SCQM) for rheumatic diseases Program, and Celgene for funding of this research.

Disclosure of Interests

Burkhard Moeller Speakers bureau: Novartis, MSD, Synergy, Eli Lilly, Bristol-Myers-Squibb, Janssen-Cilag, AbbVie and Pfizer, Grant/research support from: Celgene, Amgen, Vifor, Adrian Ciurea Speakers bureau: Abbvie and Novartis, Raphael Micheroli: None declared, Michael J. Nissen Speakers bureau: Abbvie, Celgene, Eli-Lilly, Janssen, Novartis and Pfizer, Eleftherios Papagiannoulis: None declared, Almut Scherer: None declared, Godehard Scholz: None declared, Nikhil Yawalkar Speakers bureau: Abbvie, Amgen, Celgene, Janssen, Lilly, Novartis, Pfizer

POS0001 CAN SINGLE IMPUTATION TECHNIQUES FOR BASDAI COMPONENTS RELIABLY CALCULATE THE COMPOSITE SCORE IN AXIAL SPONDYLOARTHRITIS PATIENTS?

Background

In axial spondyloarthritis (axSpA), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is a key patient-reported outcome. However, one or more of its components may be missing when recorded in clinical practice.

Objectives

To determine whether an individual patient’s BASDAI at a given timepoint can be reliably calculated with different single imputation techniques and to explore the impact of the number of missing components and/or differences between missingness of individual components.

Methods

Real-life data from axSpA patients receiving tumour necrosis factor inhibitors (TNFi) from 13 countries in the European Spondyloarthritis (EuroSpA) Research Collaboration Network were utilized [1]. We studied missingness in BASDAI components based on simulations in a complete dataset, where we applied and expanded the approach of Ramiro et al. [2]. After introducing one or more missing components completely at random, BASDAI was calculated from the available components and with three different single imputation techniques: possible middle value (i.e. 50) of the component and mean and median of the available components. Differences between the observed (original) and calculated scores were assessed and correct classification of patients as having BASDAI<40 mm was additionally evaluated. For the setting with one missing component, differences arising between missing one of components 1-4 versus 5-6 were explored. Finally, the performance of imputations in relation to the values of the original score was investigated.

Results

A total of 19,894 axSpA patients with at least one complete BASDAI registration at any timepoint were included. 59,126 complete BASDAI registrations were utilized for the analyses with a mean BASDAI of 38.5 (standard deviation 25.9). Calculating BASDAI from the available components and imputing with mean or median showed similar levels of agreement (Table 1). When allowing one missing component, >90% had a difference of ≤6.9 mm between the original and calculated scores and >95% were correctly classified as BASDAI<40 (Table 1). However, separate analyses of components 1-4 and 5-6 as a function of the BASDAI score suggested that imputing any one of the first four BASDAI components resulted in a level of agreement <90% for specific BASDAI values while imputing one of the stiffness components 5-6 always reached a level of agreement >90% (Figure 1, upper panels). As expected, it was observed that regardless of the BASDAI component set to missing and the imputation technique used, correct classification of patients as BASDAI<40 was less than 95% for values around the cutoff (Figure 1, lower panels).

Table 1.

Level of agreement between the original and calculated BASDAI and correct classification for BASDAI<40 mm

Level of agreement with Dif≤6.9 mm* (%)Correct classification for BASDAI<40 mm** (%)1 missing componentAvailable93.996.9Value 5073.996.3Mean94.296.8Median93.196.82 missing componentsAvailable83.794.8Value 5040.792.8Mean83.594.8Median82.894.73 missing componentsAvailable71.992.6Value 5028.187.3Mean72.292.6Median69.792.2

* The levels of agreement with a difference (Dif) of ≤6.9 mm between the original and calculated scores were based on the half of the smallest detectable change. Agreement of >90% was considered as acceptable. ** Correct classification of >95% was considered as acceptable.

Figure 1.

Level of agreement between the original and calculated BASDAI and correct classification for BASDAI<40 mm as a function of the original score

Conclusion

BASDAI calculation with available components gave similar results to single imputation of missing components with mean or median. Only when missing one of BASDAI components 5 or 6, single imputation techniques can reliably calculate individual BASDAI scores. However, missing any single component value results in misclassification of patients with original BASDAI scores close to 40.

References

[1]Ørnbjerg et al. (2019). Ann Rheum Dis, 78(11), 1536-1544.

[2]Ramiro et al. (2014). Rheumatology, 53(2), 374-376.

Acknowledgements

Novartis Pharma AG and IQVIA for supporting the EuroSpA collaboration.

Disclosure of Interests

Stylianos Georgiadis Grant/research support from: Novartis, Myriam Riek Grant/research support from: Novartis, Christos Polysopoulos Grant/research support from: Novartis, Almut Scherer Grant/research support from: Novartis, Daniela Di Giuseppe: None declared, Gareth T. Jones Speakers bureau: Janssen, Grant/research support from: AbbVie, Pfizer, UCB, Amgen, GSK, Merete Lund Hetland Grant/research support from: Abbvie, Biogen, BMS, Celltrion, Eli Lilly, Janssen Biologics B.V, Lundbeck Fonden, MSD, Medac, Pfizer, Roche, Samsung Biopies, Sandoz, Novartis, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, UCB, Grant/research support from: Abbvie, BMS, Merck, Celgene, Novartis, Simon Horskjær Rasmussen Grant/research support from: Novartis, Johan K Wallman Consultant of: AbbVie, Amgen, Celgene, Eli Lilly, Novartis, Bente Glintborg Grant/research support from: Pfizer, Abbvie, BMS, Anne Gitte Loft Speakers bureau: AbbVie, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Consultant of: AbbVie, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Karel Pavelka Speakers bureau: Pfizer, MSD, BMS, UCB, Amgen, Egis, Roche, AbbVie, Consultant of: Pfizer, MSD, BMS, UCB, Amgen, Egis, Roche, AbbVie, Jakub Zavada Speakers bureau: Abbvie, Elli-Lilly, Sandoz, Novartis, Egis, UCB, Consultant of: Abbvie, Elli-Lilly, Sandoz, Novartis, Egis, UCB, Merih Birlik: None declared, Ayten Yazici Grant/research support from: Roche, Brigitte Michelsen Grant/research support from: Novartis, Eirik kristianslund: None declared, Adrian Ciurea Speakers bureau: AbbVie, Eli Lilly, Merck Sharp & Dohme, Novartis, Pfizer, Consultant of: AbbVie, Eli Lilly, Merck Sharp & Dohme, Novartis, Pfizer, Michael J. Nissen Speakers bureau: AbbVie, Eli Lilly, Janssens, Novartis, Pfizer, Consultant of: AbbVie, Eli Lilly, Janssens, Novartis, Pfizer, Ana Maria Rodrigues Speakers bureau: Abbvie, Amgen, Consultant of: Abbvie, Amgen, Grant/research support from: Novartis, Pfizer, Amgen, Maria Jose Santos Speakers bureau: Abbvie, AstraZeneca, Lilly, Novartis, Pfizer, Gary Macfarlane Grant/research support from: GSK, Anna-Mari Hokkanen Grant/research support from: MSD, Heikki Relas Speakers bureau: Abbvie, Celgene, Pfizer, UCB, Viatris, Consultant of: Abbvie, Celgene, Pfizer, UCB, Viatris, Catalin Codreanu Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Ewopharma, Lilly, Novartis, Pfizer, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Ewopharma, Lilly, Novartis, Pfizer, Corina Mogosan: None declared, Ziga Rotar Speakers bureau: Abbvie, Novartis, MSD, Medis, Biogen, Eli Lilly, Pfizer, Sanofi, Lek, Janssen, Consultant of: Abbvie, Novartis, MSD, Medis, Biogen, Eli Lilly, Pfizer, Sanofi, Lek, Janssen, Matija Tomsic Speakers bureau: Abbvie, Amgen, Biogen, Eli Lilly, Janssen, Medis, MSD, Novartis, Pfizer, Sanofi, Sandoz-Lek, Consultant of: Abbvie, Amgen, Biogen, Eli Lilly, Janssen, Medis, MSD, Novartis, Pfizer, Sanofi, Sandoz-Lek, Björn Gudbjornsson Speakers bureau: Amgen, Novartis, Consultant of: Amgen, Novartis, Arni Jon Geirsson: None declared, Pasoon Hellamand Grant/research support from: Novartis, Marleen G.H. van de Sande Speakers bureau: Eli Lilly, Novartis, UCB, Janssen, Abbvie, Consultant of: Eli Lilly, Novartis, UCB, Janssen, Abbvie, Grant/research support from: Eli Lilly, Novartis, UCB, Janssen, Abbvie, Isabel Castrejon: None declared, Manuel Pombo-Suarez Consultant of: Abbvie, MSD, Roche, Bruno Frediani: None declared, Florenzo Iannone Speakers bureau: Abbvie, Amgen, AstraZeneca, BMS, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Consultant of: Abbvie, Amgen, AstraZeneca, BMS, Galapagos, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Lykke Midtbøll Ørnbjerg Grant/research support from: Novartis

POS0995 VALIDATION OF THE SPARCC MRI-RETIC E-TOOL FOR INCREASING SCORING PROFICIENCY OF MRI LESIONS IN AXIAL SPONDYLOARTHRITIS

Background

The web-based Spondyloarthritis Research Consortium of Canada (SPARCC) real-time iterative calibration (RETIC) modules for scoring MRI lesions in axial spondyloarthritis (axSpA) have been created by SPARCC developers to enable remote training of readers to appropriately use the SPARCC MRI inflammation and structural damage instruments and to attain adequate scoring proficiency.

Objectives

We aimed to test the performance of these modules in enhancing scoring proficiency in comparison to SPARCC developers.

Methods

The SPARCCRETIC SIJ inflammation and structural damage modules are each comprised of 50 DICOM axSpA cases with baseline and follow up scans and an online scoring interface based on SIJ quadrants. Continuous visual real-time feedback regarding concordance/discordance of scoring per SIJ quadrant with expert readers is provided by a color-coding scheme. Reliability is assessed in real-time by intra-class correlation coefficient (ICC), ICC data being provided every 10 cases, which are scored until proficiency targets for ICC are attained. In the present exercise, participants (n=15) from the EuroSpA Imaging project were randomized, stratified by reader expertise in scoring with SPARCC, to one of two reader training strategies (groups A and B) that each comprised 3 stages (25 patients per stage, 2 timepoints, blinded to chronology; independent assessment of Inflammatory and structural lesions): Group A. 1. Review of original SPARCC manuscript describing scoring method. 2. Review of PowerPoint summary of SPARCC method plus completion of SPARCCRETIC module. 3. Re-review of PowerPoint summary. Group B. Same 3-step strategy as A except SPARCCRETIC module completed at stage 3. The reliability of scoring was compared to an expert radiologist (SPARCC developer).

Results

Very good scoring proficiency for status and change scores was evident for SPARCC BME even by non-experienced readers with similar levels of reliability irrespective of prior expertise. The beneficial impact of the SPARCCRETIC module on scoring proficiency was most consistently evident for the scoring of structural lesions and for Strategy B, where the impact was evident for all structural lesions, level of reader expertise, and status as well as change scores (Table 1). Scoring proficiency improved the most for the least experienced readers (Figure 1).

Table 1.

Inter-rater reliability (Status/Change ICC) compared to radiologist SPARCC developer

MRI LesionReader expertiseStrategy AStrategy BStage 1 cases (n=25)Stage 2 cases (n=25)Stage 3 cases (n=25)Stage 1 cases (n=25)Stage 2 cases (n=25)Stage 3 cases (n=25)BMENone (n=4)0.91 / 0.940.83/0.820.77/0.780.82/0.880.65/0.820.88/0.90Intermediate (n=6)0.88/0.880.90/0.900.85/0.900.93/0.940.78/0.800.83/0.80Experienced (n=5)0.92/0.940.90/0.880.92/0.930.83/0.880.84/0.900.89/0.89ANKYLOSISNone (n=4)0.86/0.660.83/0.280.86/0.780.66/0.410.69/0.340.88/0.80Intermediate (n=6)0.89/0.570.83/0.370.92/0.810.82/0.680.74/0.470.93/0.84Experienced (n=5)0.96/0.760.93/0.640.94/0.860.97/0.240.83/0.410.91/0.79BACKFILLNone (n=4)-0.08/-0.050.38/0.220.59/0.380.64/0.130.05/-0.090.47/0.27Intermediate (n=6)0.41/0.130.44/0.420.69/0.390.50/0.220.30/0.300.70/0.42Experienced (n=5)0.82/0.380.55/0.400.91/0.640.65/0.240.21/0.260.71/0.30EROSIONNone (n=4)0.13/-0.080.67/0.420.51/0.330.34/0.330.23/0.080.38/0.37Intermediate (n=6)0.42/0.180.56/0.120.51/0.440.33/0.270.45/0.180.53/0.39Experienced (n=5)0.61/0.330.64/0.340.64/0.420.51/0.270.58/0.110.62/0.31FAT METAPLASIANone (n=4)0.62/0.540.30/0.170.57/0.290.43/0.530.38/0.070.83/0.63Intermediate (n=6)0.49/0.380.59/0.300.79/0.510.57/0.780.50/0.420.81/0.47Experienced (n=5)0.75/0.620.81/0.340.91/0.700.84/0.900.56/0.130.78/0.37

Conclusion

Attaining scoring proficiency for MRI structural lesions in axSpA is difficult but can be consistently improved by using the SPARCCRETIC module, even for experienced readers.

Figure 1.

Disclosure of Interests

Walter P Maksymowych Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, UCB, Consultant of: Abbvie, Boehringer Ingelheim, Celgene, Eli-Lilly, Galapagos, Novartis, Pfizer, UCB, Grant/research support from: Abbvie, Novartis, Pfizer, UCB, Anna Enevold Fløistrup Hadsbjerg Grant/research support from: Novartis, Mikkel Østergaard Consultant of: AbbVie, BMS, Boehringer-Ingelheim, Celgene, Eli Lilly and Company, Galapagos, Gilead, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, UCB, Grant/research support from: AbbVie, BMS, Merck, Celgene, Novartis, Raphael Micheroli: None declared, Susanne Juhl Pedersen Grant/research support from: Novartis, Adrian Ciurea: None declared, Nora Vladimirova Grant/research support from: Novartis, Michael J Nissen Speakers bureau: Eli-Lilly, Janssen, Novartis, Consultant of: Abbvie, Celgene, Eli-Lilly, Janssen, Novartis, Pfizer, Kristyna Bubova: None declared, Stephanie Wichuk: None declared, Manouk de Hooge: None declared, Ashish Jacob Mathew Grant/research support from: Novartis, Karlo Pintaric: None declared, Monika Gregová: None declared, Ziga Snoj: None declared, Marie Wetterslev: None declared, Karel Gorican: None declared, Joel Paschke: None declared, Iris Eshed: None declared, Robert G Lambert Paid instructor for: Novartis

Does tenosynovitis of the hand detected by B-mode ultrasound predict loss of clinical remission in rheumatoid arthritis? Results from a real-life cohort

Objective

The role of US-detected tenosynovitis (USTS) in the management of rheumatoid arthritis remains controversial. The aim of this study was to investigate whether tenosynovitis can predict a flare in rheumatoid arthritis patients in remission in a real-life cohort.

Methods

Rheumatoid arthritis patients from the Swiss Clinical Quality Management cohort were included in this study if they were in clinical remission, defined by 28-joint disease activity score (DAS28-ESR) <2.6, and had an available B-mode tenosynovitis score. The patients were stratified according to the presence or absence of tenosynovitis (USTS+ vs. USTS–). Cox proportional hazard models were used for time-to-event analysis until the loss of remission, after adjustment for multiple confounders. The impact of baseline US performed early in remission and the advent of flares at different fixed time periods after baseline were investigated in sensitivity analysis.

Results

Tenosynovitis was detected in 10% of 402 rheumatoid arthritis patients in remission. At baseline, USTS+ patients in remission had significantly higher DAS28-ESR (mean (SD): USTS– 1.8 (0.5) versus USTS+ 2.0 (0.5); p = 0.0019) and higher additional disease activity parameters, such as physician global assessment, and simplified- and clinical-disease activity index. Joint synovitis detected by B-mode US was associated with tenosynovitis (mean (SD) 7.2 (6.3) in USTS– versus 9.0 (5.4) in USTS+, respectively; p = 0.02). A disease flare was observed in 69% of remission phases, with no differences in the time to loss of remission between USTS+ and USTS– groups.

Conclusion

While US-detected tenosynovitis was associated with higher disease activity parameters in rheumatoid arthritis patients in clinical remission, it was not able to predict a flare.

Current differentiation between radiographic and non-radiographic axial spondyloarthritis is of limited benefit for prediction of important clinical outcomes: data from a large, prospective, observational cohort

OBJECTIVE

To compare disease characteristics and outcomes between patients with axial spondyloarthritis with non-radiographic disease (nr-axSpA), bilateral grade 2 sacroiliitis (r22axSpA) and unilateral/bilateral grade 3-4 sacroiliitis (r3+axSpA) according to the modified New York criteria.

METHODS

We included patients with axial spondyloarthritis with available pelvic radiographs from the Swiss Clinical Quality Management Cohort. Retention of a first tumour necrosis factor inhibitor (TNFi) was investigated with multiple adjusted Cox proportional hazards models. The proportion of patients reaching 50% reduction in the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI50) at 1 year was assessed with multiple adjusted logistic regression analyses. Spinal radiographic progression, defined as an increase in ≥2 mSASSS units in 2 years, was assessed in generalised estimating equation models.

RESULTS

From 2080 patients, those with nr-axSpA (n=485) and r22axSpA (n=443) presented with lower C reactive protein levels and less severe clinical spinal involvement compared with patients with r3+axSpA (n=1152). While TNFi retention was similar in r22axSpA and nr-axSpA, the risk of discontinuation was significantly lower in r3+axSpA (HR 0.60, 95% CI 0.44 to 0.82 vs nr-axSpA). BASDAI50 responses at 1 year were comparable in r22axSpA and nr-axSpA, with a better response associated with r3+axSpA (OR 2.05, 95% CI 1.09 to 3.91 vs nr-axSpA). Spinal radiographic progression was similar in r22axSpA and nr-axSpA and significantly higher in r3 +axSpA.

CONCLUSION

Patients with r22axSpA are comparable to nr-axSpA patients but differ from patients with more severe sacroiliac damage with regard to treatment effectiveness and spinal radiographic progression. Therefore, current differentiation between nr-axSpA and radiographic disease seems of limited use for outcome prediction.

Lessons learned from a pilot implementation of physical activity recommendations in axial spondyloarthritis exercise group therapy

Background

The Ankylosing Spondylitis Association of Switzerland (SVMB) aimed to implement physical activity recommendations (PAR) within their exercise groups (EGs). The PAR promote exercise in all fitness dimensions at the correct dose. To implement the PAR within EGs, they were translated into a new EG concept with five key activities: (a) training for supervising physiotherapists (PTs), (b) correctly dosed exercises in all fitness dimensions, (c) exercise counselling, (d) bi-annual fitness assessments, and (e) individual exercise training, in addition to EG. All these activities were realized in close coordination with SVMB management.

Objectives

To analyse the implementation success by evaluating adherence/fidelity, feasibility, and satisfaction at the patient, PTs, and organisational level.

Methods

The five key activities of the new EG concept were developed, executed, and assessed after 6 months. The primary outcomes for implementation success were adherence of patients to the recommended exercise behaviour, self-reported by electronic diary; fidelity of PTs to the new concept, self-reported by diary; SVMB organisational changes. Secondary outcomes were feasibility and satisfaction with the new EG concept at all three levels. The tertiary outcome, to evaluate the effectiveness of PAR, was patient fitness, assessed through fitness assessments.

Results

30 patients with axSpA (ten women, mean age 58 ± 9 years) and four PTs (three women, mean age 46 ± 9 years) participated. The patients' self-reporting of adherence to the PAR was insufficient (43%), possibly due to technical problems with the electronic dairy. The PTs' fidelity to the new EG concept was satisfactory. On all levels, the new concept was generally perceived as feasible and useful for supporting personalised exercise.The frequency of exercise counselling and the fitness assessments was found by patients and PTs to be too high and rigid. Patients' cardiorespiratory fitness [ES 1.21 (95%CI 0.59, 1.89)] and core strength [ES 0.61 (95%CI 0.18, 1.06)] improved over the 6 months.

Conclusions

The pilot implementation of PAR showed acceptance and satisfaction to be sufficient, thus confirming the need for evidence-based EGs, provided by a patient organisation in order to support active PA behaviour. However, adaptations are necessary to increase its feasibility for nationwide implementation.

Trial Registration: SNCTP, SNCTP000002880. Registered 31 May 2018, https://www.kofam.ch/en/snctp-portal/search/0/study/42491.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-021-00233-z.

TNFα induces endothelial dysfunction in rheumatoid arthritis via LOX-1 and arginase 2: reversal by monoclonal TNFα antibodies

AIMS

Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting joints and blood vessels. Despite low levels of low-density lipoprotein cholesterol (LDL-C), RA patients exhibit endothelial dysfunction and are at increased risk of death from cardiovascular complications, but the molecular mechanism of action is unknown. We aimed in the present study to identify the molecular mechanism of endothelial dysfunction in a mouse model of RA and in patients with RA.

METHODS AND RESULTS

Endothelium-dependent relaxations to acetylcholine were reduced in aortae of two tumour necrosis factor alpha (TNFα) transgenic mouse lines with either mild (Tg3647) or severe (Tg197) forms of RA in a time- and severity-dependent fashion as assessed by organ chamber myograph. In Tg197, TNFα plasma levels were associated with severe endothelial dysfunction. LOX-1 receptor was markedly up-regulated leading to increased vascular oxLDL uptake and NFκB-mediated enhanced Arg2 expression via direct binding to its promoter resulting in reduced NO bioavailability and vascular cGMP levels as shown by ELISA and chromatin immunoprecipitation. Anti-TNFα treatment with infliximab normalized endothelial function together with LOX-1 and Arg2 serum levels in mice. In RA patients, soluble LOX-1 serum levels were also markedly increased and closely related to serum levels of C-reactive protein. Similarly, ARG2 serum levels were increased. Similarly, anti-TNFα treatment restored LOX-1 and ARG2 serum levels in RA patients.

CONCLUSIONS

Increased TNFα levels not only contribute to RA, but also to endothelial dysfunction by increasing vascular oxLDL content and activation of the LOX-1/NFκB/Arg2 pathway leading to reduced NO bioavailability and decreased cGMP levels. Anti-TNFα treatment improved both articular symptoms and endothelial function by reducing LOX-1, vascular oxLDL, and Arg2 levels.

Role of synovial fibroblast subsets across synovial pathotypes in rheumatoid arthritis: a deconvolution analysis

OBJECTIVES

To integrate published single-cell RNA sequencing (scRNA-seq) data and assess the contribution of synovial fibroblast (SF) subsets to synovial pathotypes and respective clinical characteristics in treatment-naïve early arthritis.

METHODS

In this in silico study, we integrated scRNA-seq data from published studies with additional unpublished in-house data. Standard Seurat, Harmony and Liger workflow was performed for integration and differential gene expression analysis. We estimated single cell type proportions in bulk RNA-seq data (deconvolution) from synovial tissue from 87 treatment-naïve early arthritis patients in the Pathobiology of Early Arthritis Cohort using MuSiC. SF proportions across synovial pathotypes (fibroid, lymphoid and myeloid) and relationship of disease activity measurements across different synovial pathotypes were assessed.

RESULTS

We identified four SF clusters with respective marker genes: PRG4+ SF (CD55, MMP3, PRG4, THY1neg ); CXCL12+ SF (CXCL12, CCL2, ADAMTS1, THY1low ); POSTN+ SF (POSTN, collagen genes, THY1); CXCL14+ SF (CXCL14, C3, CD34, ASPN, THY1) that correspond to lining (PRG4+ SF) and sublining (CXCL12+ SF, POSTN+ + and CXCL14+ SF) SF subsets. CXCL12+ SF and POSTN+ + were most prominent in the fibroid while PRG4+ SF appeared highest in the myeloid pathotype. Corresponding, lining assessed by histology (assessed by Krenn-Score) was thicker in the myeloid, but also in the lymphoid pathotype + the fibroid pathotype. PRG4+ SF correlated positively with disease severity parameters in the fibroid, POSTN+ SF in the lymphoid pathotype whereas CXCL14+ SF showed negative association with disease severity in all pathotypes.

CONCLUSION

This study shows a so far unexplored association between distinct synovial pathologies and SF subtypes defined by scRNA-seq. The knowledge of the diverse interplay of SF with immune cells will advance opportunities for tailored targeted treatments.

European bio-naïve spondyloarthritis patients initiating TNFi: Time trends in baseline characteristics, treatment retention and response

OBJECTIVES

To investigate time trends in baseline characteristics and retention, remission and response rates in bio-naïve axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) patients initiating tumour necrosis factor inhibitor (TNFi) treatment.

METHODS

Prospectively collected data on bio-naïve axSpA and PsA patients from routine care in 15 European countries were pooled. Three cohorts were defined according to year of TNFi-initiation: A (1999-2008), B (2009-2014) and C (2015-2018). Retention, remission and response rates were assessed at 6, 12 and 24 months.

RESULTS

In total, 27 149 axSpA and 17 446 PsA patients were included.Cohort A patients had longer disease duration compared with B and C. In axSpA, cohort A had the largest proportion of male and HLA-B27 positive patients. In PsA, baseline disease activity was highest in cohort A.Retention rates in axSpA/PsA were highest in cohort A and differed only slightly between B and C.For all cohorts, disease activity decreased markedly from 0 to 6 months. In axSpA, disease activity at 24 months was highest in cohort A, where also remission and response rates were lowest. In PsA, remission rates at 6 and 12 months tended to be lowest in cohort A. Response rates were at all time points comparable across cohorts, and less between-cohort disease activity differences were seen at 24 months.

CONCLUSION

Our findings indicate that over the past decades, clinicians have implemented more aggressive treatment strategies in spondyloarthritis. This was illustrated by shorter disease duration at treatment initiation, decreased retention rates and higher remission rates during recent years.

Impact of assessing patient-reported outcomes with mobile apps on patient-provider interaction

Objective

To explore the effect of apps measuring patient-reported outcomes (PROs) on patient–provider interaction in the rheumatic diseases in an observational setting.

Methods

Patients in the Swiss Clinical Quality Management in Rheumatic Diseases Registry were offered mobile apps (iDialog and COmPASS) to track disease status between rheumatology visits using validated PROs (Rheumatoid Arthritis Disease Activity Index-5 score, Bath Ankylosing Spondylitis Disease Activity Index score, Routine Assessment of Patient Index Data-3 score and Visual Analogue Scale score for pain, disease activity and skin symptoms). We assessed two aspects of patient–provider interaction: shared decision making (SDM) and physician awareness of disease fluctuations. We used logistic regressions to compare outcomes among patients who (1) used an app and discussed app data with their physician (app+discussion group), (2) used an app without discussing the data (app-only group) or (3) did not use any app (non-app users).

Results

2111 patients were analysed, including 1799 non-app users, 150 app-only users and 162 app+discussion users (43% male; with 902 patients with rheumatoid arthritis, 766 patients with axial spondyloarthritis and 443 patients with psoriatic arthritis). App users were younger than non-app users (mean age of 47 vs 51 years, p<0.001). Compared with non-app users, the app+discussion group rated their rheumatologist more highly in SDM (OR 1.7, 95% CI 1.1 to 2.4) and physician awareness of disease fluctuations (OR 2.0, 95% CI 1.3 to 3.1). This improvement was absent in the app-only group.

Conclusion

App users who discussed app data with their rheumatologist reported more favourably on patient–provider interactions than app users who did not and non-app users. Apps measuring PROs may contribute little to patient–provider interactions without integration of app data into care processes.

Drug retention, inactive disease and response rates in 1860 patients with axial spondyloarthritis initiating secukinumab treatment: routine care data from 13 registries in the EuroSpA collaboration

OBJECTIVES

To explore 6-month and 12-month secukinumab effectiveness in patients with axial spondyloarthritis (axSpA) overall, as well as across (1) number of previous biologic/targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs), (2) time since diagnosis and (3) different European registries.

METHODS

Real-life data from 13 European registries participating in the European Spondyloarthritis Research Collaboration Network were pooled. Kaplan-Meier with log-rank test, Cox regression, χ² and logistic regression analyses were performed to assess 6-month and 12-month secukinumab retention, inactive disease/low-disease-activity states (Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) <2/<4, Ankylosing Spondylitis Disease Activity Score (ASDAS) <1.3/<2.1) and response rates (BASDAI50, Assessment of Spondyloarthritis International Society (ASAS) 20/40, ASDAS clinically important improvement (ASDAS-CII) and ASDAS major improvement (ASDAS-MI)).

RESULTS

We included 1860 patients initiating secukinumab as part of routine care. Overall 6-month/12-month secukinumab retention rates were 82%/72%, with significant (p<0.001) differences between the registries (6-month: 70-93%, 12-month: 53-86%) and across number of previous b/tsDMARDs (b/tsDMARD-naïve: 90%/73%, 1 prior b/tsDMARD: 83%/73%, ≥2 prior b/tsDMARDs: 78%/66%). Overall 6-month/12-month BASDAI<4 were observed in 51%/51%, ASDAS<1.3 in 9%/11%, BASDAI50 in 53%/47%, ASAS40 in 28%/22%, ASDAS-CII in 49%/46% and ASDAS-MI in 25%/26% of the patients. All rates differed significantly across number of previous b/tsDMARDs, were numerically higher for b/tsDMARD-naïve patients and varied significantly across registries. Overall, time since diagnosis was not associated with secukinumab effectiveness.

CONCLUSIONS

In this study of 1860 patients from 13 European countries, we present the first comprehensive real-life data on effectiveness of secukinumab in patients with axSpA. Overall, secukinumab retention rates after 6 and 12 months of treatment were high. Secukinumab effectiveness was consistently better for bionaïve patients, independent of time since diagnosis and differed across the European countries.

Site-specific resolution of enthesitis in patients with axial spondyloarthritis treated with tumor necrosis factor inhibitors

BACKGROUND

Enthesitis is a hallmark of spondyloarthritis (SpA) with a substantial impact on quality of life. Reports of treatment effectiveness across individual enthesitis sites in real-world patients with axial SpA (axSpA) are limited. We investigated the evolution of enthesitis following tumor necrosis factor inhibitor (TNFi) initiation in axSpA patients, both cumulatively and at specific axial and peripheral sites.

METHODS

AxSpA patients in the Swiss Clinical Quality Management Registry were included if they initiated a TNFi, had an available Maastricht Ankylosing Spondylitis Enthesitis Score, modified to include the plantar fascia (mMASES, 0-15), at start of treatment and after 6 and/or 12 months and ≥12 months follow-up. Logistic regression models were utilized to analyze explanatory variables for enthesitis resolution.

RESULTS

Overall, 1668 TNFi treatment courses (TCs) were included, of which 1117 (67%) had active enthesitis at baseline. Reduction in mMASES at the 6- and 12-month timepoints was experienced in 72% and 70% of TCs, respectively. Enthesitis resolution at 6/12 months occurred in 37.9%/43.0% of all TNFi TCs and 40.7%/50.9% of first TNFi TCs. At 6 months, a significant reduction in the frequency of enthesitis was observed at all sites, except for the Achilles tendon and plantar fascia among first TNFi TCs, while at 12 months, reduction was significant at all sites in both TC groups. Enthesitis resolved in 60.3-77% across anatomical sites, while new incident enthesitis occurred in 4.0-13.5% of all TNFi TCs at 12 months. Both baseline and new-incident enthesitis occurred most frequently at the posterior superior iliac spine and the fifth lumbar spinous process. Younger age and lower mMASES at baseline were predictors of complete enthesitis resolution, while female sex and second- or later-line TNFi treatment were associated with persistence of enthesitis at 12 months.

CONCLUSION

In real-world axSpA patients treated with a TNFi, enthesitis improved in the majority of patients across all anatomical sites. Significant improvement at the Achilles and plantar fascia entheses was observed only at 12 months. Complete and site-specific enthesitis resolution occurred in ≥40% and ≥60% of TCs evaluated at 12 months, with a low incidence of new site-specific enthesitis.

TRIAL REGISTRATION

Not applicable.

Effectiveness and treatment retention of TNF inhibitors when used as monotherapy versus comedication with csDMARDs in 15 332 patients with psoriatic arthritis. Data from the EuroSpA collaboration

Background

Comedication with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) during treatment with tumour necrosis factor inhibitors (TNFi) is extensively used in psoriatic arthritis (PsA), although the additive benefit remains unclear. We aimed to compare treatment outcomes in patients with PsA treated with TNFi and csDMARD comedication versus TNFi monotherapy.

Methods

Patients with PsA from 13 European countries who initiated a first TNFi in 2006–2017 were included. Country-specific comparisons of 1 year TNFi retention were performed by csDMARD comedication status, together with HRs for TNFi discontinuation (comedication vs monotherapy), adjusted for age, sex, calendar year, disease duration and Disease Activity Score with 28 joints (DAS28). Adjusted ORs of clinical remission (based on DAS28) at 12 months were calculated. Between-country heterogeneity was assessed using random-effect meta-analyses, combined results were presented when heterogeneity was not significant. Secondary analyses stratified according to TNFi subtype (adalimumab/infliximab/etanercept) and restricted to methotrexate as comedication were performed.

Results

In total, 15 332 patients were included (62% comedication, 38% monotherapy). TNFi retention varied across countries, with significant heterogeneity precluding a combined estimate. Comedication was associated with better remission rates, pooled OR 1.25 (1.12–1.41). Methotrexate comedication was associated with improved remission for adalimumab (OR 1.45 (1.23–1.72)) and infliximab (OR 1.55 (1.21–1.98)) and improved retention for infliximab. No effect of comedication was demonstrated for etanercept.

Conclusion

This large observational study suggests that, as used in clinical practice, csDMARD and TNFi comedication are associated with improved remission rates, and specifically, comedication with methotrexate increases remission rates for both adalimumab and infliximab.

POS1168 SELF-REPORTED SARS-CoV2 TESTING AND COVID-19 DISEASE IN PATIENTS WITH RHEUMATOID ARTHRITIS, AXIAL SPONDYLOARTHRITIS AND PSORIATIC ARTHRITIS IN A SWISS OBSERVATIONAL COHORT

Background:

Since the beginning of the pandemic in Switzerland, immunosuppressed people were strongly advised to be tested for SARS-CoV2 when symptomatic as it was conjectured that they might be more at risk for infection and/or severe disease. While patients with autoimmune diseases might be indeed more at risk of death from COVID-191, it remains unknown, whether there are differences in infection or complication rates between patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis (AxSpA), and whether this relates to their disease or their treatment. Additionally, the prevalence of SARS-CoV2 testing in this population is not known.

Objectives:

This study aimed to assess and compare the rate of COVID-19 and SARS-CoV2 testing in patients with RA, AxSpA and PsA, the potential association with their treatment and, for testing, the number of symptoms.

Methods:

We included patients with RA, AxSpA and PsA from the Swiss Clinical Quality Management register (SCQM) using a smartphone app (mySCQM) to record information between March and December 2020. The outcomes of interest were self-reported SARS-CoV2 testing, symptoms compatible with COVID-19 during the previous month and confirmed COVID-19 through PCR nasopharyngeal swab. Outcomes were evaluated over the complete length of the aforementioned period (i.e. the outcome has been reported at least once during the period). Outcomes were compared between diseases groups, using logistic regression. We also evaluated the association of baseline treatment (TNF-inhibitors, b/tsDMARDs with other modes of action (OMA), no b/tsDMARDs) on the odds of symptoms and testing and the association of the number of symptoms (0-9) on the odds of testing. The analyses of SARS-CoV2 testing and COVID-19 symptoms were additionally adjusted for age, gender, glucocorticoids and csDMARDs. Confirmed cases were not adjusted for treatment and other covariates considering the low number of events.

Results:

We included 927 patients with RA, 805 with AxSpa and 453 with PsA (Table 1). 1010 patients reported COVID-19-like symptoms (mostly fever, runny nose and cough), but only 455 of them (45%) reported being tested. 151 patients were tested without symptoms. In between March and December 2020, 7.6% of RA, 8.5% of AxSpA and 10.5% of PsA patients were tested positive for COVID-19 (p=0.678). The odds of testing, symptoms and confirmed COVID-19 were similar between diseases and not associated with treatment for testing and symptoms (Figure 1). The number of symptoms was associated with the odds of testing (OR 1.43, 95%CI 1.37-1.50 by symptom).

Table 1.RAaxSpAPsApn 927 805 453Age (mean, SD)56.4 (13)47.1 (12)52.7 (11)<0.001Genderfemale 705 (76) 403 (50) 230 (51)<0.001TreatmentTNFi 272 (29) 498 (62) 174 (38)<0.001OMA 355 (38) 71 (9) 137 (30)No b/tsDMARDs 300 (32) 236 (29) 142 (31)csDMARDs use 476 (51) 111 (14) 147 (33)<0.001Steroids use 93 (10) 11 (1) 19 (4)<0.001Disease duration14.2 (10)17.4 (11)14.8 (12)<0.001Testing for COVID-19All patients258 (28)231 (29)117 (26) 0.550Patients with symptoms189/427 (44)179/392 (46)87/191 (46) 0.911Presence of COVID-19 symptoms427 (46)392 (49)191 (42) 0.082Positive COVID-19 test* 18/237 (8) 19/223 (9) 11/105 (11) 0.678

N, % when not specified otherwise. *Missing data on test results in 41 patients χ2 test for categorical and t-test for continuous variables.

Figure 1.

Conclusion:

Prevalence of COVID-19 symptoms and confirmed cases was similar between diseases, and for symptoms, was not associated with treatment. Despite strong advice from health authorities, less than 50% of patients with inflammatory rheumatic diseases and COVID-19 symptoms were tested. This proportion was not significantly different between diseases and not influenced by type of treatment. Efforts should be made to improve rates of SARS-CoV2 testing in patients with rheumatic diseases.

References:

[1]Williamson, E. J. et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature 584, 430–436 (2020).

Acknowledgements:

This study was supported by Pfizer, Sanofi, Novartis, Gilead, Biogen and Bristol-Myers Squibb.

We thank all the patients and health professionals contributing to SCQM.

Disclosure of Interests:

Eleftherios Papagiannoulis: None declared, Adrian Ciurea Speakers bureau: Abbvie, Eli Lilly, MSD, Novartis, Pfizer, Diana Dan: None declared, Axel Finckh: None declared, Benoit GILBERT: None declared, Isabell von Loga Consultant of: Deloitte Consulting AG., Cathy Melong Pianta Taleng: None declared, Almut Scherer Consultant of: Pfizer, Employee of: BMS (2007-2008), Kim Lauper Consultant of: Gilead Galapagos, Grant/research support from: AbbVie. The SCQM foundation is supported by different companies https://www.scqm.ch/en/sponsoren/.

POS0027 SECULAR TRENDS IN BASELINE CHARACTERISTICS, TREATMENT RETENTION AND RESPONSE RATES IN 27189 BIO-NAÏVE AXIAL SPONDYLOARTHRITIS PATIENTS INITIATING TNFI – RESULTS FROM THE EUROSPA COLLABORATION

Background:

Knowledge of changes over time in baseline characteristics and tumor necrosis factor inhibitor (TNFi) response in bio-naïve axial spondyloarthritis (axSpA) patients treated in routine care is limited.

Objectives:

To investigate secular trends in baseline characteristics and retention, remission and response rates in axSpA patients initiating a first TNFi.

Methods:

Prospectively collected data on bio-naïve axSpA patients starting TNFi in routine care from 15 European countries were pooled. According to year of TNFi initiation, three groups were defined a priori based on bDMARD availability: Group A (1999–2008), Group B (2009–2014) and Group C (2015–2018). Retention rates (Kaplan-Meier), crude and LUNDEX adjusted1 remission (Ankylosing Spondylitis Disease Activity Score (ASDAS) <1.3, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) <20) and response (ASDAS Major and Clinically Important Improvement (MI/CII), BASDAI 50) rates were assessed at 6, 12 and 24 months. No statistical comparisons were made.

Results:

In total, 27189 axSpA patients were included (5945, 11255 and 9989 in groups A, B and C).

At baseline, patients in group A were older, had longer disease duration and a larger proportion of male and HLA-B27 positive patients compared to B and C, whereas disease activity was similar across groups.

Retention rates at 6, 12 and 24 months were highest in group A (88%/81%/71%) but differed little between B (84%/74%/64%) and C (85%/76%/67%).

In all groups, median ASDAS and BASDAI had decreased markedly at 6 months (Table 1). The ASDAS values at 12 and 24 months and BASDAI at 24 months were higher in group A compared with groups B and C. Similarly, crude remission and response rates were lowest in group A. After adjustments for drug retention (LUNDEX), remission and response rates showed less pronounced between-group differences regarding ASDAS measures and no relevant differences regarding BASDAI measures.

Conclusion:

Nowadays, axSpA patients initiating TNFi are younger with shorter disease duration and more frequently female and HLA-B27 negative than previously, while baseline disease activity is unchanged. Drug retention rates have decreased, whereas crude remission and response rates have increased. This may indicate expanded indication but also a stable disease activity threshold for TNFi initiation over time, an increased focus on targeting disease remission and more available treatment options.

References:

[1]Arthritis Rheum 2006; 54: 600-6.

Table 1.

Secular trends in baseline characteristics, treatment retention, remission and response rates in European axSpA patients initiating a 1st TNFi

Baseline characteristicsGroup A(1999–2008)Group B(2009–2014)Group C(2015–2018)Age, years, median (IQR)57 (49–66)51 (42–60)46 (37–56)Male, %666057HLA-B27, %877772Years since diagnosis, median (IQR)5 (1–12)2 (0–8)2 (0–7)Smokers, %232425ASDAS, median (IQR)3.5 (2.8–4.1)3.4 (2.8–4.1)3.5 (2.8–4.1)BASDAI, median, (IQR)57 (42–71)59 (43–72)57 (41–71)TNFi drug, % (Adalimumab /Etanercept / Infliximab /Certolizumab / Golimumab)22 / 35 / 43 / 0 / 037 / 21 / 20 / 4 / 1827 / 28 / 24 / 8 / 13Follow up6 months12 months24 monthsGr AGr BGr CGr AGr BGr CGr AGr BGr CRetention rates, %, (95% CI)88 (88–89)84 (83–85)85 (84–86)81 (80–82)74 (74–75)76 (75–76)71 (70–72)64 (63–65)67 (66–68)ASDAS, median, (IQR)1.8 (1.2–2.8)1.9 (1.2–2.8)1.8 (1.2–2.6)1.9 (1.3–2.6)1.7 (1.2–2.5)1.6 (1.1–2.4)1.9 (1.4–2.6)1.7 (1.1–2.4)1.5 (1.1–2.2)ASDAS inactive disease, %, c/L28 / 2528 / 2430 / 2624 / 1932 / 2434 / 2623 / 1634 / 2039 / 23ASDAS CII, %, c/L57 / 5159 / 5063 / 5461 / 5063 / 4767 / 5159 / 4168 / 4074 / 45ASDAS MI, %, c/L31 / 2732 / 2737 / 3232 / 2637 / 2741 / 3130 / 2042 / 2546 / 28BASDAI, median, (IQR)23 (10–40)26 (11–48)24 (10–44)21 (10–38)23 (10–42)20 (8–39)22 (9–40)20 (8–39)16 (6–35)BASDAI remission, %, c/L44 / 4040 / 3443 / 3645 / 3645 / 3450 / 3844 / 3048 / 2956 / 34BASDAI 50 response, %, c/L53 / 4750 / 4253 / 4557 / 4656 / 4258 / 4457 / 3960 / 3563 / 38

Gr, Group; c/L, crude/LUNDEX adjusted.

Acknowledgements:

Novartis Pharma AG and IQVIA for supporting the EuroSpA Research Collaboration Network.

Disclosure of Interests:

Lykke Midtbøll Ørnbjerg Grant/research support from: Novartis, Sara Nysom Christiansen Speakers bureau: BMS and GE, Grant/research support from: Novartis, Simon Horskjær Rasmussen: None declared, Anne Gitte Loft Speakers bureau: AbbVie, Janssen, Lilly, MSD, Novartis, Pfizer, UCB, Consultant of: AbbVie, Janssen, Lilly, MSD, Novartis, Pfizer, UCB, Grant/research support from: Novartis, Ulf Lindström: None declared, Jakub Zavada: None declared, Florenzo Iannone: None declared, Fatos Onen: None declared, Michael J. Nissen Speakers bureau: Novartis, Eli Lilly, Celgene, and Pfizer, Consultant of: Novartis, Eli Lilly, Celgene, and Pfizer, Brigitte Michelsen Consultant of: Novartis, Grant/research support from: Novartis, Maria Jose Santos Speakers bureau: AbbVie, Novartis, Pfizer, Gary Macfarlane Grant/research support from: GlaxoSmithKline, Dan Nordström Consultant of: Abbvie, BMS, MSD, Novartis, Pfizer, Roche, UCB, Manuel Pombo-Suarez: None declared, Catalin Codreanu Speakers bureau: AbbVie, Amgen, Egis, Novartis, Pfizer, UCB, Grant/research support from: AbbVie, Amgen, Egis, Novartis, Pfizer, UCB, Matija Tomsic Speakers bureau: Abbvie, Amgen, Biogen, Medis, MSD, Novartis, Pfizer, Consultant of: Abbvie, Amgen, Biogen, Medis, MSD, Novartis, Pfizer, Irene van der Horst-Bruinsma Speakers bureau: Abbvie, BMS, MSD, Novartis, Pfizer, Lilly, UCB, Björn Gudbjornsson Speakers bureau: Amgen and Novartis, Johan Askling: None declared, Bente Glintborg Grant/research support from: Pfizer, Biogen, AbbVie, Karel Pavelka Speakers bureau: AbbVie, Roche, MSD, UCB, Pfizer, Novartis, Egis, Gilead, Eli Lilly, Consultant of: AbbVie, Roche, MSD, UCB, Pfizer, Novartis, Egis, Gilead, Eli Lilly, Elisa Gremese: None declared, Nurullah Akkoc: None declared, Adrian Ciurea Speakers bureau: Abbvie, Eli-Lilly, MSD, Novartis, Pfizer, Eirik kristianslund: None declared, Anabela Barcelos: None declared, Gareth T. Jones Grant/research support from: Pfizer, AbbVie, UCB, Celgene, Amgen, GSK, Anna-Mari Hokkanen Grant/research support from: MSD, Carlos Sánchez-Piedra: None declared, Ruxandra Ionescu Speakers bureau: Abbvie, Amgen, Boehringer-Ingelheim Eli-Lilly,Novartis, Pfizer, Sandoz, UCB, Ziga Rotar Speakers bureau: Abbvie, Amgen, Biogen, Medis, MSD, Novartis, Pfizer, Consultant of: Abbvie, Amgen, Biogen, Medis, MSD, Novartis, Pfizer, Marleen G.H. van de Sande: None declared, Arni Jon Geirsson: None declared, Mikkel Østergaard Speakers bureau: AbbVie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Centocor, GSK, Hospira, Janssen, Merck, Mundipharma, Novartis, Novo, Orion, Pfizer, Regeneron, Schering-Plough, Roche, Takeda, UCB and Wyeth, Consultant of: AbbVie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Centocor, GSK, Hospira, Janssen, Merck, Mundipharma, Novartis, Novo, Orion, Pfizer, Regeneron, Schering-Plough, Roche, Takeda, UCB and Wyeth, Merete L. Hetland Speakers bureau: Abbvie, Biogen, BMS, Celltrion, Eli Lilly, Janssen Biologics B.V, Lundbeck Fonden, MSD, Pfizer, Roche, Samsung Biopies, Sandoz, Novartis.

Comparative effectiveness of antitumour necrosis factor agents, biologics with an alternative mode of action and tofacitinib in an observational cohort of patients with rheumatoid arthritis in Switzerland

Background

Multiple biologic and targeted synthetic disease-modifying rheumatic drugs (b/tsDMARDs) are approved for the management of rheumatoid arthritis (RA), including TNF inhibitors (TNFi), bDMARDs with other modes of action (bDMARD-OMA) and Janus kinase inhibitors (JAKi). Combination of b/tsDMARDs with conventional synthetic DMARDs (csDMARDs) is recommended, yet monotherapy is common in practice.

Objective

To compare drug maintenance and clinical effectiveness of three alternative treatment options for RA management.

Methods

This observational cohort study was nested within the Swiss RA Registry. TNFi, bDMARD-OMA (abatacept or anti-IL6 agents) or the JAKi tofacitinib (Tofa) initiated in adult RA patients were included. The primary outcome was overall drug retention. We further analysed secondary effectiveness outcomes and whether concomitant csDMARDs modified effectiveness, adjusting for potential confounding factors.

Results

4023 treatment courses of 2600 patients were included, 1862 on TNFi, 1355 on bDMARD-OMA and 806 on Tofa. TNFi was more frequently used as a first b/tsDMARDs, at a younger age and with shorter disease duration. Overall drug maintenance was significantly lower with TNFi compared with Tofa [HR 1.29 (95% CI 1.14 to 1.47)], but similar between bDMARD-OMA and Tofa [HR 1.09 (95% CI 0.96 to 1.24)]. TNFi maintenance was decreased when prescribed without concomitant csDMARDs [HR: 1.27 (95% CI 1.08 to 1.49)], while no difference was observed for bDMARD-OMA or Tofa maintenance with respect to concomitant csDMARDs.

Conclusion

Tofa drug maintenance was comparable with bDMARDs-OMA and somewhat higher than TNFi. Concomitant csDMARDs appear to be required for optimal effectiveness of TNFi, but not for bDMARD-OMA or Tofa.

Discontinuation of biologic DMARDs in a real-world population of patients with rheumatoid arthritis in remission: outcome and risk factors

OBJECTIVES

Data from randomized controlled trials have shown the feasibility of discontinuation of bDMARD therapy in patients with RA that have reached remission. Criteria for selecting patients that are likely to remain in remission are still incompletely defined.We aimed to identify predictors of successful discontinuation of bDMARD therapy in the Swiss Clinical Quality Management (SCQM) registry, a real-world cohort of RA patients.

METHODS

RA patients in DAS28-ESR remission who stopped bDMARD/tsDMARD treatment were included. Loss of remission was defined as a DAS28-ESR > 2.6 or restart of a bDMARD/tsDMARD. Time to loss of remission was the main outcome. Kaplan-Meier methods were applied and cox regression was used for multivariable analyses adjusting for confounding factors. Missing data were imputed using multiple imputation.

RESULTS

318 patients in a bDMARD/tsDMARD-free remission were followed between 1997 and 2017. 241 patients (76%) lost remission after a median time of 0.9 years (95%CI 0.7-1.0). The time to loss of remission was shorter in women, in patients with a longer disease duration >4yrs and in patients who did not meet CDAI remission criteria at baseline. Remission was longer in patients with csDMARD therapy during b/tsDMARD free remission (HR 0.8, p= 0.05, 95%CI 0.6-1.0).

CONCLUSION

In a real-world patient population the majority of patients who discontinued b/tsDMARD treatment lost remission within <1 year. Our study confirms that fulfilment of more rigorous remission criteria and csDMARD treatment increases the chance of maintaining b/tsDMARD free remission.

Reliability of an adapted core strength endurance test battery in individuals with axial spondylarthritis

OBJECTIVES

To adapt the core strength endurance test battery (aCSE), previously used for testing athletes, to a target group of patients with axial spondylarthritis (axSpA), to evaluate its intra-tester reliability and its associations with disease-specific factors.

METHODS

A cross-sectional study was conducted at axSpA exercise therapy groups, including both axSpA patients and the physiotherapist group leaders (PTs). The aCSE was used to measure the isometric strength endurance of the ventral, lateral, and dorsal core muscle chains (measured in seconds), as well as to assess the disease-specific factors of functional status, self-reported pain, and perceived strength performance. The aCSE was repeated after 7-14 days to measure intra-tester reliability for the same rater (PT group leader). Reliability was calculated as an intra-class correlation coefficient (ICC) using a nested design. The associations between ventral, lateral, and dorsal strength endurance and the disease-specific factors were calculated using Pearson correlation coefficients.

RESULTS

Study participants were 13 PT group leaders and 62 axSpA patients. The latter were all capable of performing the aCSE, with the exception of one individual. A moderate to substantial intra-rater reliability (ICCs (95%CI)) was found for the ventral (0.54 (0.35, 0.74)), lateral (0.52 (0.33, 0.70)), and dorsal (0.71 (0.58, 0.86)) core muscle chains. None of the aCSE measures correlated with the disease-specific factors.

CONCLUSION

The aCSE was found to be a reliable test battery for assessing core strength endurance in axSpA patients. Interestingly, aCSE performance was not associated with any disease-specific factors. Key Points • The adapted core strength endurance test battery measures the isometric strength of the ventral, lateral and dorsal core muscle chains. • The adapted core strength endurance test battery showed a moderate to substantial intra-rater reliability for all three muscle chains tested in axSpA patients. • No correlations were found between the adapted core strength endurance test battery and the disease-specific factors of self-reported pain, functional status and perceived strength performance.