Is intraoperative heparin during renal transplantation useful to reduce graft vascular thrombosis?

OBJECTIVES

The standard treatment for end-stage renal disease is renal transplantation. As vascular anastomoses are performed during the surgery, it may expose to a risk of vascular thrombosis. This raises the question of using intravenous heparin during the procedure. The purpose of this study was to compare the incidence of renal transplant vascular thrombosis in the perioperative period based on whether the patients received or not intraoperative heparin.

METHODS

A single center retrospective study was conducted on a cohort of consecutive patients who underwent renal transplantation between 2011 and 2015. Patients were divided into two groups: patients not receiving heparin vs. receiving heparin at the dose of 0.5mg/kg. A Doppler ultrasound was performed at day one postoperatively to assess the occurrence of vascular thrombosis. Hemorrhagic complications and the need for postoperative transfusion were also assessed.

RESULTS

In total, 261 patients were included. Fifty-one patients received heparin (19.5%). Patient's baseline characteristics were comparable between the groups. No significant difference was found regarding the incidence of vascular thrombosis (6% for both groups, P=1). In addition, no difference was found regarding hemorrhagic complications requiring surgical revision (P=1) as well as early postoperative transfusion rate (P=0.57).

CONCLUSIONS

Our results suggest that intraoperative IV heparin doesn't improve the risk of vascular thrombosis following renal transplantation. However, intraoperative IV heparin was not significantly associated with a higher rate of hemorrhagic complications suggesting that heparin can be safely used if required in some selected patients at higher risk of thrombosis.

LEVEL OF EVIDENCE

3.

A systematic review on the effect of DMARDs on fertility in rheumatoid arthritis

INTRODUCTION

Drug therapy could alter fertility in patients with rheumatoid arthritis (RA). We aimed to perform a systematic review to evaluate if Disease-modifying antirheumatic drug (DMARD) therapy influences fertility as this is an important point to consider in shared decision making on RA therapy.

METHODS

A search was conducted at 18/10/2019 in EMBASE, PubMed (including MEDLINE) and the Web of Science Core Collection. Our inclusion criteria were studies involving women or men diagnosed with RA, older than 18 years and on DMARD therapy, with as outcome a fertility parameter. Systematic reviews, meta-analyses, case reports, case series and animal studies were excluded. Studies not in English or Dutch or published before 2004 were excluded. Quality appraisal was performed by the CASP systematic review checklist.

RESULTS

After duplicate removal, 9030 references were identified. After title/abstract screening, 82 articles remained. After full text screening, 4 articles could be retained. No studies were found through backward snowballing. Only studies involving women could be retained. The included studies investigated the effect of methotrexate, certolizumab pegol, etanercept and sulfasalazine on fertility. No detrimental effects of these DMARDs on time-to-pregnancy, anti-Müllerian hormone serum level or presence of a history of infertility, were reported.

CONCLUSION

This systematic review underlines the gap in knowledge regarding the effect of DMARDs on fertility in women and especially men with RA. DMARD treatment, contrary to general belief, seemed to have no harmful effect on fertility, possibly because it resulted in better controlled disease activity. More research is needed to improve guidance for patients with RA with a child wish.

FRI0035 THE CHALLENGE OF ASSESSING WELL-BEING IN PATIENTS WITH EARLY RHEUMATOID ARTHRITIS

Background:

Advances in therapeutics and treatment strategies for Rheumatoid Arthritis (RA) have improved clinical outcomes. Although these advances also impact the well-being as shown in many patient-reported outcomes, still a sizeable number of patients in clinical remission report a reduced well-being.

Objectives:

To explore factors that contribute to well-being in patients with early RA.

Methods:

Patients from the 2-year pragmatic treat-to-target Care in Early Rheumatoid Arthritis (CareRA) trial were included. Patients were treated intensively, with a combination of csDMARDs and glucocorticoid remission induction schemes, except one group treated with MTX monotherapy.

Eight different validated questionnaires including the Arthritis Self-Efficacy Scale (ASES), the multidimensional Fatigue Inventory (MFI), the Pittsburgh Sleep Quality Index (PSQI) the Revised Illness Perception Questionnaire (IPQ-R), the Utrecht Coping List (UCL), the Short Form 36 (SF-36), RA Quality of Life questionnaire (RA-QOL) and the Social Support List (SSL) were taken. Questionnaires were obtained at baseline, at week 16, 52 and 104 except for the IPQ and UCL, which were only taken at baseline and week 16.

Three patients` groups were created including all patients, patients in remission (DAS28crp < 2.6) and not in remission. Regression models were constructed to define well-being at week 16, 52 and 104. The Patient Global Assessment (PGA) on a Visual Analogue Scale 0-100 (VAS) was chosen as a proxy for well-being (score 0-100). As predictors, all subscales of the 8 validated questionnaires, summing to 84 variables, with and without the VAS for Pain (VAS-Pain) were used in 18 models (3 patient groups, 3 time points, with/without VAS-Pain) in total. Data reduction used forward, backward and stepwise selection based on the Aikake information criteria. Data was checked for influential observations by Cook’s distance and for multicollinearity by variance inflation factors (threshold = 5). Influential observations were removed one observation every time. Highly correlated variables were deleted by backward selection (α=5%). Missing data was handled by multiple imputation using CART with 15 iterations.

Results:

In total, 379 patients were included. Table 1 gives the number of variables and the associated R2. In the 9 models defining well-being without VAS-Pain, 53 variables were used at least once. Most common variables were bodily pain (n=8) and social function (n=5) of the SF-36, and positive emotions (n=4) of the SSL. In the 9 models with VAS-Pain, 31 variables were used at least once. Most common variables were vitality (n=3) and social function (n=3) of the SF-36, and identity (n=3) of the IPQ-R. Model content was heterogenous regarding patient population and time.

R2and number of variables in each model of well-being

All patientsPatients in remissionPatients not in remissionR2#R2#R2#week 1652%1339%753%6week 16 with VAS-Pain78%469%680%5week 5244%844%757%12week 52 with VAS-Pain84%584%692%2week 10440%1339%862%10week 104 with VAS-Pain81%782%486%11

R2= coefficient of determination, the proportion of the variance in the dependent variable that is predictable from the independent variable(s). # = number of variables selected in regression model

Conclusion:

Well-being is apparently difficult to define uniformly as many factors contribute to it. As already known, well-being, defined by PGA, and VAS-Pain are highly associated, even in patients in remission where pain levels should be theoretically lower. Other well-being definitions could lead to different results and should be further explored.

Disclosure of Interests:

Diederik De Cock: None declared, Tianna Poffe: None declared, Geert Verbeke: None declared, Veerle Stouten: None declared, Sofia Pazmino: None declared, Delphine Bertrand: None declared, Johan Joly: None declared, Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, Patrick Verschueren Grant/research support from: Pfizer unrestricted chair of early RA research, Speakers bureau: various companies

AB1153 ANALGESIC AND ANTI-INFLAMMATORY DRUG USE IN PATIENTS WITH RHEUMATOID ARTHRITIS, PSORIATIC ARTHRITIS AND SPONDYLOARTHRITIS VERSUS CONTROLS IN A BELGIAN GENERAL PRACTITIONER REGISTRY

Background:

Rheumatoid arthritis (RA), psoriatic arthritis (PSA) and spondyloarthritis (SPA) are the most common inflammatory rheumatic diseases. Pain is the hallmark symptom in these conditions and pain relief is ranked first amongst preferred outcomes by patients. Level of analgesic and anti-inflammatory drug use is unknown in these populations in Belgium.

Objectives:

To compare analgesic and anti-inflammatory drug use in patient populations of RA, PSA and SPA versus controls in a General Practitioners (GP) setting in an era of expanding treatment possibilities in rheumatology.

Methods:

Data were obtained from Intego over a 13-year time interval from 1999 to 2012. Intego is a Flemish GP-based morbidity registration network hosted at the Academic Center for General Practice of the KU Leuven, covering 2% of the Flemish general population. Patients classified under the International Classification of Primary Care codes L88 (rheumatoid/seropositive arthritis) and L99 (musculoskeletal disease other) were selected for this study. Experienced rheumatologists verified if the keywords mapped to these codes corresponded to a diagnosis of RA/SPA/PSA. The date of these diagnoses in Intego was considered “baseline”. Controls were matched on age, gender, baseline date and GP practice in a 4:1 case ratio. Intego registers all electronic drug prescriptions by the GP. Anytime use of glucocorticoids, NSAIDs, opioids except tramadol, tramadol and paracetamol in the first 3 years after diagnosis is presented. Proportions of patients and controls on analgesic and anti-inflammatory drugs were compared by Chi-Square analyses.

Results:

Over a 13-year period, 738, 229 and 167 patients were included with a diagnosis of RA, SPA or PSA, respectively. Table 1 presents the medication use of these populations. The three conditions had statistically significantly more prescriptions for all types of analgesic and anti-inflammatory drugs compared to controls. Approximately 70% of patients with an inflammatory rheumatic condition received mild pain medication (NSAIDs, Tramadol and Paracetamol) in the first three years after diagnosis. To note is the high use of opioids, even excluding tramadol, in these populations ranging up to 15%.

Table 1.

3-year analgesic and anti-inflammatory drug use in RA, SPA and PSA patients versus controls

MedicationRARA ControlSPASPA ControlPSAPSA ControlNumber of patients7382952229916167668Glucocorticoids241(33%)348(12%)29(13%)70(8%)47(28%)67(10%)NSAIDs455(62%)1156(39%)161(70%)340(37%)114(68%)267(40%)Opioids109(15%)263(9%)31(14%)53(6%)24(14%)45(7%)Tramadol87(12%)150(5%)22(10%)28(3%)16(10%)26(4%)Paracetamol233(32%)598(20%)63(28%)165(18%)51(31%)141(21%)Total analgesic and anti-inflammatory drug use506(69%)1409(48%)172(75%)407(44%)121(72%)309(46%)

RA= Rheumatoid arthritis, PSA= psoriatic arthritis, SPA= spondyloarthritis. Total analgesic and anti-inflammatory drug is the sum of NSAIDs, Tramadol and Paracetamol. Anytime use of drugs are presented.

Conclusion:

Frequent analgesic and anti-inflammatory drug use in patients with a chronic inflammatory joint condition is to be expected, and underlined by the results of our study. Remarkably is the high use of opioids, even excluding tramadol, in patients with RA, PSA and SPA in an era of effective disease modifiers, as well in the control population. Our data shows that around 9% of the Belgian population receives at least once over a 3-year period an opioid prescription. As our data only registers electronic GP prescriptions, this is likely to be an underestimation of the true prescription proportion. Detailed analyses on dose and duration of analgesic and anti-inflammatory drugs will follow.

Disclosure of Interests:

Sofia Pazmino: None declared, Veerle Stouten: None declared, Patrick Verschueren Grant/research support from: Pfizer unrestricted chair of early RA research, Speakers bureau: various companies, Pavlos Mamouris: None declared, Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, Kurt de Vlam Grant/research support from: Celgene, Eli Lilly, Pfizer Inc, Consultant of: AbbVie, Eli Lilly, Galapagos, Johnson & Johnson, Novartis, Pfizer Inc, UCB, Delphine Bertrand: None declared, Kristien Van der Elst: None declared, Bert Vaes: None declared, Diederik De Cock: None declared

THU0089 TRENDS AND PREFERENCES IN RA CLINICAL SCORES WORLDWIDE

Background:

Different scores are used for patient management in rheumatoid arthritis (RA), including patient characterization such as ACR/EULAR criterion [1], disease activity monitoring by healthcare professionnals such as DAS28 [2], DAS28-CRP [2], CDAI [1], SDAI [3], or by patients such as HAQ-DI [4] or RAPID3 [5]. Most of these scores involve computations that are difficult to perform mentally (such as a square root function). Accordingly, several software tools have been designed over the years to help clinicians and patients compute these scores [6].

Objectives:

This work reports for the first time usage statistics for one of these software tools, the RheumaKit online platform, from 2016 to 2020, showing that it has become a standard tool used worldwide by the rheumatology community. It also investigates the increasing use of repeated measurements, as enabled by that platform. Finally, a comparison between different disease activity scores is proposed, and usage preferences are documented.

Methods:

Until January 2020, RheumaKit online portal has allowed users to compute scores without registering on the portal. In such cases, the computations and results are not stored, yet this activity is tracked by Google Analytics (as per explicit cookie policy). Users may also create an account, enabling storage and retrospective access to the computed results. Such entry recording in the RheumaKit database is only available for healthcare professionnals. The system then allows users to create individual patient files in which multiple scores and timepoints are recorded. These two data sources (Google Analytics and internal database) are used to perform this study: counts and trends are reported over the period ranging from 01 Jan 2016 to 31 Dec 2019.

Results:

RheumaKit online application had been accessed by 7,300 distinct users in 2016; this number has grown to 86,000 distinct users in 2019. User distribution has also evolved: in 2016, users were reported from Russia (13% of the 7,300 users), USA (12.2%), Belgium (9.7% – this figure being explained by the fact that the tool is developed in Belgium), France (7.3%), and UK (7.2%); wereas in 2019, users are from the USA (21.1% of the 86,000 users), France (14.4%), Germany (5.4%), Brazil (5.3%), UK (5.3%). With respect to scores, the usage ranking over 2016-2019 outlines a preference for DAS28-CRP (93,900 computations) followed by HAQ-DI (72,800), DAS28 (63,600), CDAI (56,500), SDAI (42,700), RAPID3 (33,800), and ACR-EULAR2010 (19,800). The tendency in registering scores is also increasing, as the number of registered healthcare professionnals went from 117 on the 1stof Jan 2016 to almost 1,200 on 31 Dec 2019.

Conclusion:

The use of computer-assisted clinical scoring for RA patients is an increasing trend observed worldwide, with dominance in Europe and America. The tendency to perform repeated, longitudinal measurements of these scores for a given patient is also increasing exponentially. DAS28-CRP and HAQ-DI are the most used scores among those available in this study.

References:

[1]Aletaha et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum 2010

[2]Prevoo et al. Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum 1995.

[3]Smolen et al. A simplified disease activity index for rheumatoid arthritis for use in clinical practice. Rheumatology (Oxford) 2003

[4]Bruce and Fries. The Stanford Health Assessment Questionnaire: Dimensions and Practical Applications. Health Qual Life Outcomes 2003

[5]Pincus et al. An index of only patient-reported outcome measures, routineassessment of patient index data 3 (RAPID3), in two abataceptclinical trials: similar results to disease activity score (DAS28) andother RAPID indices that include physician-reported measures. Rheumatology 2008.

[6]das-score.nl, DAS28.nl, Rheumakit.com, 4s-dawn.com, …

Disclosure of Interests:

Thibault Helleputte Shareholder of: DNAlytics, Damien Bertrand Employee of: DNAlytics.

FRI0566 THE FLARE-RA QUESTIONNAIRE CAN IDENTIFY OMERACT FLARES IN PATIENTS WITH RHEUMATOID ARTHRITIS INCLUDED IN THE TAPERA TRIAL

Background:

The Flare assessment in rheumatoid arthritis (FLARE-RA) questionnaire has been developed to identify flares in patients with rheumatoid arthritis (RA). The first version was published by Berthelot et al. (2012) and consisted of 13 questions on a Likert-scale of 1-6 ranging from ‘completely untrue’ to ‘completely true’. When the FLARE-RA questionnaire was validated by Fautrel et al., 2 questions were removed, and it was rescaled to 0–10. The questionnaires’ usefulness has been tested in few studies. Further external validation in a well-defined cohort of patients with RA is needed.

Objectives:

To externally validate the FLARE-RA questionnaire and determine cut-offs for identifying a flare in an established RA population in which biologicals are tapered.

Methods:

Patients who were in remission according to the DAS28CRP or ESR (≥6 months) and treated with etanercept 50 mg weekly (≥1 year), were enrolled between 2012 – 2014 in the pragmatic 1-year open-label randomised controlled TapERA (Tapering Etanercept in RA) trial. Patients were randomised to continue etanercept 50 mg weekly or taper to 50 mg every other week. The FLARE-RA questionnaire (version of 2012) was completed every 3 months. Outcomes were based on 3 versions of the questionnaire (13 questions (13q), 11 questions (11q) and 11 questions rescaled (r11q)). Per time point, the average of the answers was calculated to obtain a total score of the FLARE-RA questionnaire. The total scores were compared between patients in remission (DAS28CRP <2.6), low (DAS28CRP ≥2.6 - ≤3.2), moderate (DAS28CRP >3.2 - ≤5.1) and high disease activity (DAS28CRP >5.1) using the Kruskal-Wallis test and between patients with and without a flare according to the OMERACT definition (increase in DAS28 >1.2 compared to baseline or increase in DAS28 >0.6 and current DAS28 ≥3.2) using the Mann-Whitney U test. The total FLARE-RA scores of the different time points were combined to determine the receiver operating characteristics (ROC) curves, the corresponding cut-off values and the area under the curve (AUC) for identifying an OMERACT flare. An AUC of <0.5, between 0.5 and 0.7 and >0.7 stands for having no, moderate and a good predictive value, respectively.

Results:

FLARE-RA questionnaires of 66 patients (68% female, mean ± standard deviation (SD) age of 55 ± 11 years) were collected. The FLARE-RA score (13q) did increase when disease activity increased at month (M) 3 and M12 (p<0.01) (table 1). Patients presenting with an OMERACT flare had a statistically significantly higher total FLARE-RA score (13q) compared to patients without a flare, except at M12 (M3 and M6: p<0.05, M9: p<0.01). The AUC - ROC curve of the FLARE-RA questionnaire (13q) for identifying an OMERACT flare was 0.736 and the cut-off value was 2.3 (1-6 scale). The AUC - ROC curve was the same for the 11q and r11q version, namely 0.727. The cut-off values were 2.4 (1-6 scale) and 2.7 (0-10 scale), respectively (figure 1).

Table 1.

Comparison of the total FLARE-RA scores (13q) between the disease activity groups (DAS28CRP)

RemissionLDAMDAHDAP-valueBLPatients (n)62310FLARE Q1.8 ± 0.81.5 ± 0.31.30.800M3Patients (n)501150FLARE Q2.1 ± 1.03.0 ± 0.93.5 ± 1.40.004M6Patients (n)52590FLARE Q2.1 ± 0.83.1 ± 1.33.1 ± 1.90.057M9Patients (n)481071FLARE Q2.1 ± 0.92.8 ± 1.13.3 ± 1.62.40.079M12Patients (n)52860FLARE Q2.1 ± 1.03.1 ± 0.83.2 ± 1.00.002Figure 1.

ROC curves of the total FLARE-RA scores (13q, 11q and r11q version) for identifying a flare according to the OMERACT definition. FLARE Q is expressed in mean ± SD. M month, FLARE Q FLARE-RA questionnaire 13q, n number, LDA low disease activity, MDA moderate disease activity, HDA high disease activity

Conclusion:

The FLARE-RA scores seem to reliably discern between patients with and without an OMERACT flare. A cut-off of 2.7 on the current questionnaire (r11q) had the optimal sensitivity and specificity to identify an OMERACT flare.

Disclosure of Interests:

Delphine Bertrand: None declared, Veerle Stouten: None declared, Sofia Pazmino: None declared, Diederik De Cock: None declared, Anneleen Moeyersoons: None declared, Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, Johan Joly: None declared, Patrick Verschueren Grant/research support from: Pfizer unrestricted chair of early RA research, Speakers bureau: various companies

Développement professionnel continu (DPC) et émergence de la recertification en France. Évolution législative et commentaires

La formation médicale continue (FMC) est une obligation déontologique et légale en France. L’évaluation des pratiques professionnelles (EPP) a rejoint en 2004 l’obligation d’acquisition des connaissances pour devenir le développement professionnel continu (DPC) en 2009. Actuellement, le dispositif est complet : définition, organisation et validation. Mais l’obligation individuelle pour valider le DPC n’a jamais été appliquée. La recertification prévue par la loi de 2019 ne sera opérationnelle qu’en 2021, au plus tôt. Son pilier essentiel est le DPC. La mission de recertification qui a préparé la loi exclut toutes épreuves de vérification des connaissances. La recertification se fait par une valorisation du parcours professionnel comprenant, outre le DPC, une activité maintenue et régulière, une amélioration de la relation avec le patient, la prise en compte de la santé du médecin et l’absence d’évènements indésirables. L’Ordre veillant sur la compétence des médecins, c’est lui qui reçoit la validation du DPC, comme il recevra celle de la recertification.

FRI0020 CLINICAL TREATMENT RESPONSE STILL DOES NOT MATCH PATIENT REPORTED IMPROVEMENT, EVEN IN EARLY RHEUMATOID ARTHRITIS

Background:

Commonly used disease activity scores in rheumatoid arthritis (RA) include one patient reported outcome (PRO) -the patient’s global health assessment (PGA). Exploratory factor analysis (EFA) was performed on data from the 2 year Care in early Rheumatoid Arthritis (CareRA) trial to explain the evolution of disease burden extracting 3 factors.1

Objectives:

To assess the evolution and relative responsiveness over time of clinical, laboratory and patient assessments included in composite scores, together with other PROs like pain, fatigue and functionality in patients with early RA (≤1 year) treated to target (T2T) within the CareRA trial.

Methods:

DMARD naïve patients with early RA (n=379) were included, randomized to remission induction with COBRA-like treatment schemes (n=332) or MTX monotherapy (n=47) and T2T.

Components of disease activity scores (swollen/tender joint count (S/TJC), C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR), and physician (PhGH) or patient (PGA) global health assessment), pain and fatigue (both on 0-100 scale) and HAQ were recorded at every visit.

Missing data was handled with multiple imputation (n=15). Clustering was removed with multiple outputation (n=1000), then each of the 15 000 datasets was analyzed by EFA with principal component extraction and oblimin rotation. The analyses were combined after re-ordering the factors by maximizing factor congruence. The 3 extracted factors and their individual components (with their loadings) were: 1. Patient containing PGA (0.87), pain (0.86), fatigue (0.90) and HAQ (0.5) 2.Clinical with SJC (0.92), TJC (0.89) and PhGH (0.76) and 3.Laboratory with CRP(0.87) and ESR (0.78).1(Pazmino, ACR 2019 abstract, Table 3)

Afterwards, variables were first normalized to a 0-1 scale, then multiplied -weighted- by the factor loadings previously obtained.1For each Patient, Clinical and Laboratory severity score, the weighted variables belonging to each score were summed together and then re-scaled to 0-1 (higher values suggest more burden).

The percentage (%) improvement from baseline to week 104 and the area under the curve (AUC) across time points were calculated per factor.

Differences in % improvement and AUC were compared between patients not achieving and achieving early and sustained (week 16 to 104) disease activity score remission (DAS28CRP <2.6) with ANOVA. Bonferroni correction was used for multiple testing.

Results:

Severity scores of Patient, Clinical and Laboratory factors improved rapidly over time (Figure 1). In patients achieving sustained remission (n=122), Patient, Clinical and Laboratory scores improved 56%, 90% and 27% respectively. In patients not achieving sustained remission (n=257) the improvement was 32%, 78% and 9% respectively (p<0.001 only for clinical improvement).

Patients in CareRA who achieved sustained remission had an AUC of 15.1, 3.4 and 4.7 in Patient, Clinical and Laboratory scores respectively, compared to 32.3, 10.0, and 7.2 in participants not achieving sustained remission (p<0.001 for all comparisons).

Conclusion:

Patient, Clinical and Laboratory severity scores improved rapidly over time in patients achieving rapid and sustained disease control. However, overall, Patient burden seemed not to improve to the same extent as Clinical burden. Patient’s unmet needs in terms of pain, fatigue, functionality and overall well-being should thus be given more attention, even in patients in sustained remission.

References:

[1]Pazmino S,et al.Including Pain, Fatigue and Functionality Regularly in the Assessment of Patients with Early Rheumatoid Arthritis Separately Adds to the Evaluation of Disease Status [abstract]. ACR. 2019.

Disclosure of Interests:

Sofia Pazmino: None declared, Anikó Lovik: None declared, Annelies Boonen Grant/research support from: AbbVie, Consultant of: Galapagos, Lilly (all paid to the department), Diederik De Cock: None declared, Veerle Stouten: None declared, Johan Joly: None declared, Delphine Bertrand: None declared, Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, Patrick Verschueren Grant/research support from: Pfizer unrestricted chair of early RA research, Speakers bureau: various companies

FRI0023 TREATING EARLY AND INTENSIVELY IS ASSOCIATED WITH LOWER FATIGUE LEVELS ON THE LONG TERM, EVEN IN PATIENTS WITH EARLY RHEUMATOID ARTHRITIS CONSIDERED TO HAVE A FAVOURABLE RISK PROFILE

Background:

Fatigue is reported in up to 90% of patients with established Rheumatoid Arthritis (RA). Fatigue has a large impact on patient`s life and is perceived difficult to manage in many patients. The early disease course could constitute a window of opportunity to tackle fatigue.

Objectives:

To explore that, if RA can be controlled rapidly, complaints of fatigue could be less in the long run, even in patients considered at low risk to develop a severe disease course.

Methods:

Patients with a low risk profile recruited in the 2-year pragmatic Care in Early Rheumatoid Arthritis (CareRA) trial were used in this analysis. This low risk profile was based on the absence of erosions, rheumatoid factor, anti-citrullinated protein bodies or low disease activity status. The low-risk group was randomised to either a tight step-up starting with 15mg MTX weekly in monotherapy (MTX-TSU) or COBRA Slim, consisting of 15 mg MTX weekly and a prednisone step-down scheme starting at 30 mg. Fatigue was measured by the multi-dimensional fatigue inventory (MFI), a self-report instrument consisting of 20 questions with a Likert scale from 1-5 as answer. These 20 questions can be subdivided in five subscales (0-20) of four questions (higher scores indicating higher fatigue levels): general fatigue, mental fatigue, physical fatigue, reduced activity and reduced motivation. General fatigue means the general feeling of being tired. Mental fatigue implicates concentration and memory problems. Physical fatigue implicates a lack of energy and strength. Reduced activity means that patients can do less activities for example on one day. Reduced motivation means that patients don’t want to plan or do things due to lack of motivation. MFI was obtained at baseline, at week 16, week 52 and week 104. Cobra Slim was compared with MTX-TSU by Mann-Whitney-U test. The 5 domains of the MFI of the two groups were compared by a generalized estimating equation (GEE) over 2 years adjusting for baseline MFI domain score and DAS28.

Results:

Of the 90 patients recruited in the low-risk group, 80 (89%) patients completed the MFI at baseline. Randomisation was successful resulting in similar baseline characteristics and MFI levels between Cobra Slim (n=38) and MTX-TSU (n=42). After 2 years of treatment, DAS28CRP levels (Slim 1.9 ±0.8 - MTX-TSU 2.2 ±1.0, p=0.253) and DAS28CRP remission (Slim 81.5% - MTX-TSU 77.1%, p=0.677) did not differ between patients. However, general (Slim 9.8 ±4.1 – MTX-TSU 13.1 ±4.0, p=0.005) and mental (Slim 6.8 ±2.7 - MTX-TSU 10.0 ±4.9, p=0.022) fatigue levels on the MFI were lower in the Cobra Slim group at week 104. GEE analysis confirmed that groups differed in the general (p=0.026) and mental (p=0.013) fatigue scale over 2 years (Figure 1).

Figure 1.

DAS28CRP and MFI General Fatigue score over 2 years between groups

Conclusion:

Patients treated intensively have lower fatigue levels over 2 years compared to patients treated more conservatively, even if disease activity became similar in the two groups over time. This underlines the importance of initiating an optimal intensive treatment even in so called low-risk patients. Moreover, our results show that fatigue is a heterogeneous concept, with different interactions between treatment and type of fatigue. Although our study was limited by a small sample size, the data clearly shows how to improve fatigue levels significantly in early RA.

Disclosure of Interests:

Diederik De Cock: None declared, Amber Nooyens: None declared, Sofia Pazmino: None declared, Delphine Bertrand: None declared, Veerle Stouten: None declared, Johan Joly: None declared, Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, Patrick Verschueren Grant/research support from: Pfizer unrestricted chair of early RA research, Speakers bureau: various companies

THU0214 LONG-TERM EFFECTIVENESS OF METHOTREXATE WITH STEP DOWN GLUCOCORTICOID BRIDGING (COBRA SLIM) VERSUS OTHER CONVENTIONAL DMARD REGIMENS AS INITIAL RA THERAPY: 5-YEAR OUTCOMES OF THE CARERA TRIAL

Background:

The treat-to-target Care in Early Rheumatoid Arthritis (CareRA) trial demonstrated that remission induction with csDMARD combinations and step-down glucocorticoids (GCs) was not superior over methotrexate (MTX) monotherapy with step-down GCs (Cobra Slim) in RA patients with a high-risk profile (1). Moreover, Cobra Slim showed benefit over a tight step-up with MTX in monotherapy (TSU) in RA patients with a low-risk profile.

Objectives:

To compare the long term outcomes up to 5 years of different initial intensive treatment strategies in participants of the CareRA-plus study.

Methods:

In the CareRA trial, patients with DMARD naïve early RA were stratified in a high- or low-risk group based upon the presence of serummarkers, disease activity and erosive status. High-risk patients were randomised to Cobra Classic (MTX+sulphasalazine with highly dosed GC remission induction scheme), Cobra Avant-Garde (MTX+leflunomide with moderately dosed GC scheme) or Cobra Slim. Low-risk patients were randomised to Cobra Slim or TSU. Patients completing this trial were eligible for the CareRA-plus observational study. Here, patients were evaluated 6-monthly over 3 years. Therapy adaptation was left to the treating physician. Efficacy was assessed by DAS28-CRP and HAQ and compared between the originally allocated treatment arms. The 5-year evolution from CareRA baseline of DAS28-CRP and HAQ was assessed via linear mixed models. All adverse events (AEs), considered to be clinically relevant by investigators, and DMARD/GCs therapy were registered.

Results:

Of 322 eligible patients, 252 (78%) were included in CareRA-plus, of which 203 (81%) completed the study. Characteristics and outcomes at the CareRA closing visit (year 2) did not differ between patients entering CareRA-plus or not. DAS28-CRP<2.6 at year 5 in high-risk patients was 72%, 77% and 64% in the Classic, Slim and Avant-Garde group respectively (p=0.403). In the longitudinal analyses, all treatment arms in the high-risk group had comparable DAS28-CRP (p=0.921) and HAQ scores over time (p=0.540). In the low-risk population, 83% of patients in the Slim and 82% in the TSU arm had DAS28-CRP<2.6 at year 5 (p=0.945). Low-risk patients starting Cobra-Slim had lower DAS28-CRP scores over 5 years than those receiving TSU (p= 0.002). HAQ score over time did not differ (p=0.129). In high-risk patients, the total numbers of AEs throughout CareRA-plus, were 70 in 36 Classic, 95 in 48 Slim and 80 in 36 Avant-Garde patients (p=0.182). In the low-risk group there were 18 AEs in 10 Slim and 36 in 17 TSU patients (p=0.048). During the 5-year study, biologics were initiated in 22% of all patients: 23% of Classic, 23% of Slim high-risk, 25% of Avant-Garde, 17% of Slim low-risk, and 15% of TSU patients. At the year 5 visit, 71%, 61% and 50% of high-risk patients were on csDMARD monotherapy (mostly MTX) in Classic, Slim and Avant-Garde respectively. Of the low-risk group, 65% in COBRA-Slim and 62% in TSU were taking a single csDMARD. At the year 5 visit, 9% of all participants received chronic oral GC therapy (>3 months).

Conclusion:

All intensive treatment strategies resulted in excellent long-term clinical outcomes. Initial Cobra Slim therapy showed comparable 5-year effectiveness as Cobra Classic and Avant-Garde in high-risk early RA patients and better efficacy and safety than conservative step up treatment in low-risk patients.

Figure 1.

Mean disease activity by DAS28-CRP or mean functionality by HAQ index scores for high-risk or low-risk patients.

References:

[1]Stouten, V. et al. Effectiveness of different combinations of DMARDs and glucocorticoid bridging in early rheumatoid arthritis: two-year results of CareRA. Rheumatology (Oxford). (2019)doi:10.1093/rheumatology/kez213.

Disclosure of Interests: :

Veerle Stouten: None declared, Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, Diederik De Cock: None declared, Sofia Pazmino: None declared, Johan Joly: None declared, Delphine Bertrand: None declared, Kristien Van der Elst: None declared, Patrick Verschueren Grant/research support from: Pfizer unrestricted chair of early RA research, Speakers bureau: various companies

SAT0028 THE FLARE-RA QUESTIONNAIRE CAN PREDICT FLARES IN PATIENTS WITH ESTABLISHED RHEUMATOID ARTHRITIS PARTICIPATING IN THE TAPERA TRIAL

Background:

The Flare assessment in Rheumatoid Arthritis (FLARE-RA) questionnaire was developed to identify Rheumatoid Arthritis (RA) flares, but it is unknown if this questionnaire can also predict flares.

Objectives:

To identify if the FLARE-RA questionnaire has a predictive capacity for OMERACT flares in patients with established RA participating in a tapering trial.

Methods:

Patients, participating in the 1-year open-label pragmatic randomised controlled TapERA (Tapering Etanercept in RA) trial, were included in the analysis. Patients had to be in DAS28CRP or ESR remission (≥6 months) and treated with etanercept 50 mg weekly (≥1 year). Participants were randomised to continue etanercept 50 mg weekly or to taper to 50 mg every other week.

The FLARE-RA questionnaire was completed every 3 months in the trial. This questionnaire consists of 13 questions on a Likert-scale from 1 to 6 reflecting ‘completely untrue’ to ‘completely true’. Validation by Fautrel et al. leaded to elimination of 2 questions (‘steroid intake’ and ‘overall worsening of RA’) and rescaling to 0-10. Our outcomes were based on these 3 versions of the questionnaire, namely 13 questions (13q), 11 questions (11q) and rescaled 11 questions (r11q). The FLARE-RA questionnaire can be divided in 2 subscales: the FLARE-RA arthritis subscale (questions regarding morning stiffness, night disturbances, joint swelling, joint pain, analgesics) and FLARE-RA general symptoms subscale (questions regarding fatigue, functional limitation, irritability, mood disturbances, withdrawal, need for help).

The total FLARE-RA score was calculated by taking the average of all the questions per time point. A flare was defined according to the OMERACT definition, namely an increase in DAS28CRP > 1.2 compared to baseline or increase in DAS28CRP > 0.6 and current DAS28CRP ≥ 3.2. All the total FLARE-RA scores of the baseline, month 3, 6 and 9 visit were grouped and the mean ± standard deviation (SD) FLARE-RA score was compared between patients with or without an OMERACT flare on the next study visit using the Mann-Whitney U test. Logistic regressions using the total FLARE-RA score to predict an OMERACT flare 3 months later were carried out for the 13q, 11q and r11q versions and the FLARE-RA subscales. Missing data were imputed using expectation maximisation.

Results:

Sixty-six patients (68% female, mean ± SD age of 55 ± 11 years) completed the FLARE-RA questionnaire. This yielded 264 FLARE-RA scores, of which the total mean ± SD FLARE-RA score was 2.1 ± 1.0 and 2.7 ± 1.1 for patients without and with an OMERACT flare on the next study visit, respectively (p<0.01). This was comparable for the 11q and r11q versions (Table 1). For the total FLARE-RA score (13q), the odds ratio of having an OMERACT flare 3 months later is 1.6 (95% confidence interval (CI) 1.2 – 2.2, p=0.004). This was 1.5 (95% CI 1.1 – 2.1, p=0.006) for the 11q and 1.2 (95% CI 1.1 – 1.4, p=0.006) for the r11q version. The odds ratio of having an OMERACT flare on the next visit was 1.5 (95% CI 1.2 – 2.0, p=0.002) and 1.4 (95% CI 1.0 – 2.0, p=0.025) for the arthritis and general symptoms subscale, respectively.

Table 1.

Comparison of overall total FLARE-RA scores between patients with or without an OMERACT flare on the next visit

Questionnaire versionNo OMERACT flare on next visitOMERACT flare on next visitP-valueOverall total FLARE-RA score(mean ± SD)13q2.1 ± 1.02.7 ± 1.10.00211q2.2 ± 1.12.7 ± 1.10.004r11q2.3 ± 2.13.4 ± 2.20.004

Overall total FLARE-RA score was derived by grouping the total FLARE-RA scores of the baseline, month 3, 6 and 9 visit.

Conclusion:

Higher total FLARE-RA questionnaire scores seem to indicate a higher risk of an OMERACT flare 3 months later, regardless of which versions or subscales of the FLARE-RA questionnaire were used. Hence, our findings suggest that the FLARE-RA questionnaire could be used as a predictive tool for flares.

Disclosure of Interests:

Delphine Bertrand: None declared, Diederik De Cock: None declared, Veerle Stouten: None declared, Sofia Pazmino: None declared, Anneleen Moeyersoons: None declared, Johan Joly: None declared, Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, Patrick Verschueren Grant/research support from: Pfizer unrestricted chair of early RA research, Speakers bureau: various companies

Management of forearm bone loss with induced membrane technique

There are very few published studies describing the treatment of segmental bone defects of the forearm using the induced membrane technique. The objectives of this study were to evaluate the time to bone union, the function of the joints above and below the treated bone segment and the patients' quality of life over the long-term. We performed a retrospective study in all patients treated by the induced membrane for a forearm bone defect over at 13-year period. Demographics, bone union, complications, functional outcomes and occupational status were collected. Six patients were included: 2 posttraumatic injuries, 1 osteomyelitis, 1 septic arthritis, 1 aseptic nonunion, 1 tumor. The average defect length was 64mm (48-110). All defects were treated with internal fixation. Bone graft was harvested from the iliac crest in two patients, the femur (using the Reamer Irrigator Aspirator technique) in three patients and the radius in one patient. Five patients achieved bone union after a mean of 4months (3-6). Three complications were observed: 1 radioulnar instability, 1 infection of the fixation device, 1 abscess. At an average 8½ years' follow-up, the pain level on the VAS was 0.6 (0-3), the Mayo Elbow Performance Score was 98 (90-100), the Herzberg score was 108 (85.6-140) and the QuickDASH was 14.9 (2.7-35). All patients returned to work. Using the induced membrane technique avoids the complications associated with vascularized autograft and yields good functional outcome and quality of life.

Antithymocyte globulin-induced hemolytic anemia and thrombocytopenia after kidney transplantation

Antithymocyte globulin is the most widely used lymphocyte-depleting treatment in kidney transplantation. In spite of the frequency of side effects, including anemia and thrombocytopenia, their pathophysiological mechanisms are not clearly established. Here, we report the case of a 21-year-old patient who had a first kidney transplantation and received induction immunosuppressive therapy by thymoglobulin. Immediately after kidney transplantation, he developed a severe hemolytic anemia and thrombocytopenia with a subsequent perirenal hematoma, which lead to a second surgical procedure and a transfer to the intensive care unit. Our patients' anemia and thrombocytopenia had heteroimmune characteristics, and thymoglobulin therapy was suspected to be the cause, via an interaction with a common Fc-receptor epitope in the different cell lines.

Belatacept Rescue Therapy in Kidney Transplant Recipients With Vascular Lesions: A Case Control Study

Immunosuppression in kidney transplant recipients with decreased graft function and severe histological vascular changes can be particularly challenging. Belatacept could be a valuable option, as a rescue therapy in this context. We report a retrospective case control study comparing a CNI to belatacept switch in 17 patients with vascular damage and low eGFR to a control group of 18 matched patients with CNI continuation. Belatacept switch was performed on average 51.5 months after kidney transplantation (6.2-198 months). There was no difference between the two groups regarding eGFR at inclusion, and 3 months before inclusion. In the "CNI to belatacept switch group," mean eGFR increased significantly from 23.5 ± 6.7 mL/min/1.73m² on day 0, to 30.4 ± 9.1 mL/min/1.73 m² on month 6 (p < 0.001) compared to the control group, in which no improvement was observed. These results were still significant on month 12. Two patients experienced biopsy-proven acute rejection. One was effectively treated without belatacept discontinuation. Two patients needed belatacept discontinuation for infection. In conclusion, the remplacement of CNI with belatacept in patients with decreased allograft function and vascular lesions is associated with an improvement in eGFR.

Bose-Einstein condensation in chains with power-law hoppings: Exact mapping on the critical behavior in d-dimensional regular lattices

Recent experimental progress on the realization of quantum systems with highly controllable long-range interactions has impelled the study of quantum phase transitions in low-dimensional systems with power-law couplings. Long-range couplings mimic higher-dimensional effects in several physical contexts. Here, we provide the exact relation between the spectral dimension d at the band bottom and the exponent α that tunes the range of power-law hoppings of a one-dimensional ideal lattice Bose gas. We also develop a finite-size scaling analysis to obtain some relevant critical exponents and the critical temperature of the BEC transition. In particular, an irrelevant dangerous scaling field has to be taken into account when the hopping range is sufficiently large to make the effective dimensionality d>4.

Reduction of Extended-Release Tacrolimus Dose in Low-Immunological-Risk Kidney Transplant Recipients Increases Risk of Rejection and Appearance of Donor-Specific Antibodies: A Randomized Study

The aim of this study (ClinicalTrials.gov, NCT01744470) was to determine the efficacy and safety of two different doses of extended-release tacrolimus (TacER) in kidney transplant recipients (KTRs) between 4 and 12 mo after transplantation. Stable steroid-free KTRs were randomized (1:1) after 4 mo: Group A had a 50% reduction in TacER dose with a targeted TacER trough level (C₀ ) >3 μg/L; group B had no change in TacER dose (TacER C₀ 7-12 μg/L). The primary outcome was estimated GFR at 1 year. Of 300 patients, the intent-to-treat analysis included 186 patients (group A, n = 87; group B, n = 99). TacER C₀ was lower in group A than in group B at 6 mo (4.1 ± 2.7 vs. 6.7 ± 3.9 μg/L, p < 0.0001) and 12 mo (5.6 ± 2.0 vs. 7.4 ± 2.1 μg/L, p < 0.0001). Estimated GFR was similar in both groups at 12 mo (group A, 56.0 ± 17.5 mL/min per 1.73 m²; group B, 56.0 ± 22.1 mL/min per 1.73 m²). More rejection episodes occurred in group A than group B (11 vs. 3; p = 0.016). At 1 year, subclinical inflammation occurred more frequently in group A than group B (inflammation score [i] >0: 21.4% vs. 8.8%, p = 0.047; tubulitis score [t] >0: 19.6% vs. 8.7%, p = 0.076; i + t: 1.14 ± 1.21 vs. 0.72 ± 1.01, p = 0.038). Anti-HLA donor-specific antibodies appeared only in group A (6 vs. 0 patients, p = 0.008). TacER C₀ should be maintained >7 μg/L during the first year after transplantation in low-immunological-risk, steroid-free KTRs receiving a moderate dose of mycophenolic acid.