POS0214 ASSOCIATION BETWEEN C-REACTIVE PROTEIN AND 10-YEAR RISK OF CARDIOVASCULAR DISEASE IN RHEUMATOID ARTHRITIS USING THE ERS-RA SCORE: A CROSS-SECTIONAL ANALYSIS OF THE CORDIS COHORT

Background:

Rheumatoid arthritis (RA) is associated with an increased risk of atherosclerotic cardiovascular disease (CVD). The Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis (ERS-RA) estimates the 10-year risk of myocardial infarction, stroke or CVD-related death based on conventional and RA-specific (clinical disease activity index, CDAI, disease duration, glucocorticoid use) risk factors (1).

Objectives:

We evaluated the associations between ERS-RA 10-year risk of CVD, high-sensitivity C-reactive protein (hs-CRP) concentrations, and pharmacological treatment in 1,251 RA patients collected by the “Cardiovascular Obesity and Rheumatic Disease Study (CORDIS)” group of the Italian Society of Rheumatology (SIR).

Methods:

We assessed independent associations between ERS-RA risk score and each relevant variable using multivariate regression (ENTER approach; listwise deletion analysis). Given the relatively high number of missing hs-CRP data (n=385), regression analysis was also performed using multiple imputation (10 sets, Stata 16.1). Regression models were not adjusted for independent variables included in the ERS-RA score.

Results:

Among 1,251 RA patients [mean (SD) age 60.4(9.3), range (40-80) years; 78% female; mean (SD) disease duration, 11.6(8) years; mean (SD) CDAI, 9(9); mean (SD) HAQ, 0.77(0.7); mean (SD) hs-CRP, 6.8(12) mg/L] the estimated 10-year CVD risk was 11.6(0.9) % [mean (SD)]. Regarding treatment, 539(43%) received glucocorticoids, 676(54%) a biological or targeted synthetic disease-modifying anti-rheumatic drug (b/tsDMARD) (n missing=1), and 885(81%) at least one conventional synthetic DMARD (csDMARD). Ninety-three (7.4%) patients did not receive any treatment. After adjusting for the use of b/tsDMARD and csDMARD, hs-CRP concentrations were significantly associated with 10-year risk of CVD both in standard multiple regression (n=865; coefficient=0.005 for each 10 mg/L hs-CRP increment, 95% confidence interval (0.000-0.100), p=0.043) and after multiple imputation (n=1,251; coefficient=0.005 for each 10 mg/L hs-CRP increment, 95% confidence interval (0.000-0.114), p=0.035) (Table 1). This corresponds to an increase of 10-year CV risk of 1% for every 20 mg/L increase in hs-CRP concentrations.

Conclusion:

In a large cohort of RA patients, we observed a significant, positive, and independent association between hs-CRP concentrations and 10-year CV risk estimated by ERS-RA. The cross-sectional design of the study did not allow to establish a cause-effect relationship between hs-CRP and CV risk. Given that conventional CV risk factors and inflammation-related variables are accounted for in the ERS-RA risk score, other, unexplored, mechanisms may underlie the observed association between hs-CRP and CV risk.

References:

[1]Solomon, D. H., et al. “Derivation and internal validation of an expanded cardiovascular risk prediction score for rheumatoid arthritis: a Consortium of Rheumatology Researchers of North America Registry Study.” Arthritis & rheumatology 67.8 (2015): 1995-2003.

Table 1.

Multiple regression models

Model 1n= 865Model 2n= 1, 251ERS-RA scoreCoefficient95% CI, pCoefficient95% CI, phs-CRP, every 10 mg/L increment0.0050.000 to 0.100, 0.0430.0050.000 to 0.011, 0.035b/tsDMARD use-0.002-0.005 to 0.001, 0.199-0.000-0.002 to 0.002, 0.963csDMARD use0.002-0.003 to 0.007, 0.3940.002-0.002 to 0.006, 0.371Prob >F, model with only CRP0.030.03Prob >F, full model0.070.08

A multiple linear regression (ENTER method) was performed for the dependent variable ERS-RA score using a listwise deletion analysis (Model 1) and a multiple imputation analysis (Model 2).

Disclosure of Interests:

None declared

SAT0555 MUSCULOSKELETAL ULTRASOUND IN MONITORING RESPONSE TO JAKi IN RHEUMATOID ARTHRITIS PATIENTS: RESULTS FROM A LONGITUDINAL STUDY

Background:

Therapeutic approach of rheumatoid arthritis (RA) patients has been enriched by the introduction of small molecules. In particular Jak inhibitors (JAKi), baricitinib and tofacitinib, demonstrated their efficacy in patients naïve or resistant to biological treatments in randomized controlled trials. Moreover, these drugs seem to be able to prevent radiographic progression. To date few data are available from the real life context. Ultrasonographic (US) assessment has became a valid imaging tool in the management of RA patients in clinical practice, allowing the evaluation of joint inflammatory status. Together with clinimetric assessment, US could provide a comprehensive assessment of drug response.

Objectives:

In the present study we aimed at assessing the early response to JAKi treatment by using musculoskeletal US.

Methods:

In this prospective longitudinal study, we collected data about all consecutive active RA patients starting treatment with JAKi. RA was diagnosed according to the 2010 ACR/EULAR criteria. At each visit, clinical and laboratory data were collected in a standardized and computerized form, including demographics, past medical history, co-morbidities, previous and concomitant treatments. According with study protocol, all patients underwent clinical and US assessment at the following time-points: baseline (T0), 4 weeks (T1) and 12 weeks (T2). Clinical evaluation included tender and swollen joint counts (0-28), patients global health assessment. C-reactive protein (CRP) levels were registered and disease activity was calculated by disease activity score (DAS) in 28 joints by using CRP (DAS28-CRP). A systematic multiplanar grey-scale and power Doppler (pD) US examination was performed by using MyLab Eight Exp Machine (Esaote, Florence, Italy) at level of 22 joints (bilateral I-V metacarpophalangeal, I-V proximal interphalangeal, wrist). According with OMERACT definitions (1) we assessed the presence of synovial effusion, hypertrophy and pD, that were scored according to a semi-quantitative scale (0-3). A total US inflammatory score (0-198) was obtained by their sum.

Results:

We enrolled 91 patients [F/M 77/14; median age 60.0 years (IQR 15.5); median disease duration 144 months (IQR 126)]. Of these patients, 54 (59.3%) were treated by baricitinib and the remaining 37 by tofacitinib. At baseline we found a median US inflammatory score of 20 (IQR 18.7) and a median DAS28-CRP of 5.0 (IQR 1.56). US assessment demonstrated significant reduction in the median values of inflammatory score already at T1 [median 13 (IQR 14.7), p<0.0001], that was maintained at T2 [median 10 (IQR 11), p<0.0001]. These results are represented in figure 1. Similar to US inflammatory score, a significant reduction was registered for DAS28-CRP median values [T1 3.5 (IQR 1.73), p<0.0001; T2 3.3 (IQR 1.8), p<0.0001]. No significant differences were found when subgrouping patients according with different JAKi drug, in terms US and clinimetric assessment.

Conclusion:

In the present study, specifically designed to evaluate the US-detected efficacy of JAKi in RA patients, we demonstrated in a real life setting a significant, early and sustained improvement of inflammatory joint status.

References:

[1]Wakefield et al, J Rheumatol 2005

Disclosure of Interests:

enrica cipriano: None declared, Fulvia Ceccarelli: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, Cristina Garufi: None declared, Ilaria Duca: None declared, Silvia Mancuso: None declared, cristiano alessandri Grant/research support from: Pfizer, Manuela Di Franco: None declared, Roberta Priori: None declared, Valeria Riccieri: None declared, Rossana Scrivo: None declared, Carlo Perricone: None declared, Guido Valesini: None declared, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

FRI0134 EFFECT OF JAK INHIBITORS ON PAIN AND QUALITY OF LIFE IN RHEUMATOID ARTHRITIS PATIENTS

Background:

Pain control is considered a treatment priority from most patients with Rheumatoid Arthritis (RA). Despite the treat to target approach, residual pain is commonly reported by patients with RA. Treatment with JAK inhibitors (JAKi) has been associated to a rapid control of pain.

Objectives:

To investigate the effect of JAKi on pain and quality of life in a mono-centric real-life clinical setting.

Methods:

Patients candidate to baricitinib or tofacitinib were evaluated at baseline and after 12 and 24 weeks of treatment. Disease activity was assessed by Disease Activity Score (DAS)28 with C reactive protein (CRP). A reduction of ≥ 50% of pain visual-analogue scale (VAS) 0-100 mm was recorded as “very much improved, substantially improved” (1). Pain VAS score ≤ 10 mm was considered “no/limited pain” (2). Patients’ satisfaction was assessed by the Patient Acceptable Symptom State question (3). Data were expressed as mean (SD) or median (interquartile range) according to the variables’ distribution. Mann Witney test was use and p values <0.05 were considered statistically significant.

Results:

Overall 108 patients started a JAK inhibitor (baricitinib n=67, tofacitinib n=41). Eighty-four patients (baricitinib n=51; tofacitinib n=33) were followed-up for at least 3 months and were included in the analysis. Table 1 summarizes demographic and clinical characteristic of the cohort. After 12 and 24 weeks of treatment we detected a significant reduction of DAS28 compared with baseline [from 4.7 (1.5) to 3.2 (1.7) 2.9 (1.5) and 2.7 (1.1), respectively; p<0.001; p<0.00001 and p<0.00001). At week 4, 27% and 51.8% of patients achieved remission and low disease activity, respectively; the percentages increase to 32.1% and 60.7% at week 12 and 42.2% and 70.3% at week 24. When evaluating the extent of reduction of the single items included in the DAS28 composite index we found that number of tender (TJ) and swollen joints (SJ) decreased from 9 (7.8) to 5 (3.5) to 4 (5) and 1 (3) at week 4, 2 (4) and 1 (3) at week 12, and 2 (4) and 1 (3) at week 24, respectively (p<0.00001 for all); the median reduction of TJC and SJC at week 4, 12 and 24 was 60%, 77% and 88%, and 81%, 86% and 100%, respectively. GH decreased from 70(30) to 40(40) at week 4, 40(30) at week 12 and 37(40) at week 24 (p<0.00001) with a median reduction of 37.5%, 44% and 46%. C reactive protein decreased by 54.5% at week 4, 47% at week 12 and 55% at week 24. VAS pain was significantly reduced at week 4, 12 and 24 [from 70(25) to 40(40,)30(40) at the three timepoints, p<0.00001] decreasing by 37.5%, 50% and 54%, respectively. A substantial reduction (≥50%) in VAS pain was reported by 41.3%, 54.4% and 53.9% of patients after 4, 12 and 24 weeks, respectively. Limited/no pain was reported by 21.3%, 24.7% and 36.5% at weeks 4, 12 and 24, respectively. Overall, 81.8% of patients achieved the PASS after a median time of 10 (7-15) days.

Conclusion:

JAK inhibitors baricitinib and tofacitinib induce a rapid improvement of disease activity driven both by pain and inflammation control. Even if no/limited pain was described only by one third of the patients, most of them reported a rapid and sustained reduction of pain accounting for the achievement of a satisfactory health condition.

References:

[1]Dworkin RH et al. Pain 2008; 9:105–121.

[2]Well GA et al. J Rheumatol 2005; 32:2016–2024.

[3]Heiber T et al. Ann Rheum Dis 2008; 67:967-71.

Baricitinib (n=51)Tofacitinib (n=33)PF:M43: 826:7nsAge, mean (SD)59±1260±12nsDisease duration, mean (SD)163±101170±112nsBaseline DAS28(PCR), median (IQR)4.7 (4-5.6)4.7 (4.3-5.4)nsConcomitant methotrexate, n (%)27 (52.9)8 (24.2)<0.001Daily prednisone dose, median (IQR)5 (2.5-9.5)5 (1.88-9.9)nsN° of previous csDMRADs, median (IQR)3 (1-4)2.5 (2-3)nsN° of previous bDMRADs, median (IQR)2 (1-4)1 (0-2.5)ns

Disclosure of Interests:

Francesca Romana Spinelli Grant/research support from: Pfizer, Speakers bureau: Lilly, BMS, Celgene, Cristina Garufi: None declared, Fulvia Ceccarelli: None declared, Silvia Mancuso: None declared, Ilaria Duca: None declared, cristiano alessandri Grant/research support from: Pfizer, Manuela Di Franco: None declared, Roberta Priori: None declared, Valeria Riccieri: None declared, Rossana Scrivo: None declared, Guido Valesini: None declared, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

AB1265 GENDER DISTRIBUTION AND GENDER-RELATED ISSUES AMONG YOUNG RHEUMATOLOGISTS AND ACADEMIC POSITIONS IN RHEUMATOLOGY: A SNAPSHOT OF THE CURRENT SITUATION IN ITALY

Background:

The Italian Society for Rheumatology (SIR) comprises committees for Rheumatologists under the age of 40 (SIRyoung) and for Women in Rheumatology (Reumatologhe Donne – ReDO). As female representation is increasing in rheumatology worldwide [1], there has been interest in assessing gender-related issues.

Objectives:

To describe the gender distribution among young members of SIR and academic positions in Rheumatology in Italy. To assess the expectations and needs of young rheumatologists with regard to their career.

Methods:

SIRyoung members developed a web-based survey which was distributed among SIR members under the age of 40 during the spring of 2019. Responses were collected and analysed anonymously. ReDO retrieved and analysed the data regarding academic positions in Italy in September 2019 from official data by “Ministry of Education, University and Research” (www.miur.it).

Results:

Out of 478 SIR members under 40 (66.5% F), 113 (23.7%) completed the SIRyoung survey (62.1% F). Regarding career plans, male and female members responded: hospital physician (36.9% vs 37.8%), outpatient clinic physician (18.5% vs 28.3%), academic career (23.9% vs 22.8%), private practice (16.3% vs 9.4%), and industry (4.3 vs 1.6%), respectively. When asked about their interest in doing a fellowship in another national center or abroad, 60.8% of male and 72.8% of female respondents were interested but thought they could not afford it. Reasons reported by males and females were: working reasons, namely barriers to temporarily leave the workplace (61.3% vs 50.7%), family reasons (16.1% vs 25.4%), financial reasons (22.6% vs 16.5%), respectively. As for academic rheumatology in Italy, 113 positions were retrieved. Men held 64 positions (57%) and women 49 (43%). Full professors were mostly men (92%), while assistant professors were women in 65% of the cases (58% of those with a permanent position; 72% of those with a temporary position) (Figure) [2].

Conclusion:

Our study explored for the first time gender distribution and related issues in Rheumatology in Italy. Female representation accounts for two thirds of SIR members under 40. This could reflect the general trend of medical school being chosen more often by women than men. No differences were observed in the career expectations of male and female rheumatologists. Interestingly, nearly one fourth of female respondents were interested in academic career, confirming the trend toward female predominance observed for assistant professors. Therefore, it is likely that the next generation of full professors will have a balanced gender distribution, as it is already for associate professors. The choice of a fellowship is still hampered by several problems, but it seems that reasons for not pursuing such opportunities are similarly distributed in males and females. Although family reasons tend to be more frequent in female rheumatologists, this is not significant as compared to men. This could indicate that family affects career choices of both male and female rheumatologists. It is important that national societies promote surveys for the assessment of gender specific issues among their members, in order to identify unmet needs and design interventions for career support regardless of gender.

References:

[1]Andreoli L, et al. Joint, Bone, Spine: Revue du Rhumatisme. 2019;86(6):669-672.

[2]Bosello SL, et al. Reumatismo 2020; in press.

Acknowledgments:

SIRyoung and ReDO wish to thank the Steering Committee of SIR

Disclosure of Interests:

Laura Andreoli: None declared, Stefano Alivernini: None declared, Alessia Alunno: None declared, Silvia Laura Bosello: None declared, Cecilia Chighizola: None declared, Paola Conigliaro: None declared, Elisa Gremese Speakers bureau: Abbvie, BMS, Celgene, Jannsen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB, Cristina Iannuccelli: None declared, Luca Quartuccio Consultant of: Abbvie, Bristol, Speakers bureau: Abbvie, Pfizer, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, Marta Vadacca: None declared, Maria Sole Chimenti: None declared

THU0627-HPR JOINT INVOLVEMENT SIGNIFICANTLY INFLUENCES QUALITY OF LIFE OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Joint involvement is one of the most common features observed in Systemic Lupus Erythematosus (SLE), potentially involving up to 90% of patients [1]. Several patients’ reported outcomes (PROs) have been employed to measure Quality of life (QoL) in SLE patients, but frequently not specifically developed for SLE patients. More recently, the LupusQoL has been validated, a disease specific questionnaire[2,3].

Objectives:

We focused at assessing the relationship between musculoskeletal manifestations and QoL in a large SLE cohort, by using the LupusQoL.

Methods:

SLE patients with a clinical history of joint involvement (arthralgia/arthritis – group A) were enrolled in the present study. SLE diagnosis was performed according to the revised 1997 ACR criteria. As a control group, we enrolled SLE patients without history of joint involvement (group B).Disease activity was assessed by the SLE Disease Activity Index-2000 (SLEDAI-2k). The activity of joint involvement was assessed by using the disease activity score on 28 joints (DAS28ESR). The LupusQoL was administered to the enrolled patients (Group A and Group B). It consists of 34 items referring to eight domains: physical health (PH), pain (P), planning (PL), intimate relationships (IR), burden to others (BO), emotional health (EH), body image (BI) and fatigue (F).

Results:

Group A included 110 patients [M/F 8/102; median age 49 years (IQR 13), median disease duration 156 months (IQR 216)], while group B included 58 patients [M/F 11/47; median age 40 years (IQR 15), median disease duration 84 months (IQR 108)]. Group A showed a significantly lower disease duration and mean age in comparison with group B (P< 0.001 for both comparisons). As represented in figure 1, group A showed significantly lower values in all LupusQoL domains except for “burden to others” domain. Moreover, we observed an inverse correlation between DAS28ESRand all the LupusQoL domains in group A patients [PH (r=-0.5, P>0.0001), P (r=-0.5, P<0.0001), PL (r=-0.5, P<0.0001), IR (r=-0.2, P=0.006), BO (r=-0.4, P=0.0004), EH (r=-0.3, P=0.0009), BI (r=-0.4, P=0.001), F (r=-0.4, P<0.0001)]. Conversely, SLEDAI-2k values inversely correlated only with PL (r=-0.3, P=0.006), IR (r=-0.25, P=0.02), EH (r=-0.3, P=0.02).

Figure 1.

Conclusion:

In the present study, by using a disease specific PRO, we found a poorer QoL in SLE patients with joint involvement in comparison with those without this manifestation. Moreover,DAS28ESRsignificantly correlated with all LupusQol domains, differently from SLEDAI-2k, suggesting the need to evaluate joint involvement with a specific activity index.

References:

[1]Cervera R et al. Medicine 1993

[2]McElhone K. et al. Arthritis Rheum 2007.

[3]Conti F et al. Lupus 2014

Group (A)Group (B)pPH80,38 ± 21,4362,88 ± 23.28< 0.0001P82,36 ± 25.0862,30± 26.02< 0.0001PL83,04 ± 27.8270,58± 29.450.001IR84,49± 25.9965,36± 36.330.0005BO69,58 ± 28.4663,45± 28.950.129EH71,98 ± 24.6964,69± 23.050.0169F73,69 ± 24.2959,78±26.060.0004B78,14 ± 24.6156,28±30.14<0.0001

Disclosure of Interests:

Francesco Natalucci: None declared, Fulvia Ceccarelli: None declared, enrica cipriano: None declared, Giulio Olivieri: None declared, Carlo Perricone: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, Simona Truglia: None declared, Francesca Miranda: None declared, cristiano alessandri Grant/research support from: Pfizer, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi, Guido Valesini: None declared

THU0227 CAFFEINE INTAKE MODULATES DISEASE ACTIVITY AND CYTOKINES LEVELS IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS

Background:

Systemic lupus erythematosus (SLE) is an autoimmune disease mainly affecting women of childbearing age. The interplay between genetic and environmental factors may contribute to disease pathogenesis1. At today, no robust data are available about the possible contribute of diet in SLE. Caffeine, one of the most widely consumed products in the world, seems to interact with multiple components of the immune system by acting as a non-specific phosphodiesterase inhibitor2.In vitrodose-dependent treatment with caffeine seems to down-regulate mRNA levels of key inflammation-related genes and similarly reduce levels of different pro-inflammatory cytokines3.

Objectives:

We evaluated the impact of caffeine consumption on SLE-related disease phenotype and activity, in terms of clinimetric assessment and cytokines levels.

Methods:

We performed a cross-sectional study, enrolling consecutive patients and reporting their clinical and laboratory data. Disease activity was assessed by SLE Disease Activity Index 2000 (SLEDAI-2k)4. Caffeine intake was evaluated by a 7-day food frequency questionnaire, including all the main sources of caffeine. As previously reported, patients were divided in four groups according to the daily caffeine intake: <29.1 mg/day (group 1), 29.2-153.7 mg/day (group 2), 153.8-376.5 mg/day (group 3) and >376.6 mg/day (group 4)5. At the end of questionnaire filling, blood samples were collected from each patient to assess cytokines levels. These were assessed by using a panel by Bio-Plex assays to measure the levels of IL-6, IL-10, IL-17, IL-27, IFN-γ, IFN-α and Blys.

Results:

We enrolled 89 SLE patients (F/M 87/2, median age 46 years, IQR 14; median disease duration 144 months, IQR 150). The median intake of caffeine was 195 mg/day (IQR 160.5). At the time of the enrollment, 8 patients (8.9%) referred a caffeine intake < 29.1 mg/day (group 1), 27 patients (30.3%) between 29.2 and 153.7 mg/day (group 2), 45 patients (51%) between 153.8 and 376.5 mg/day (group 3) and 9 patients (10.1%) >376.6 mg/day (group 4). A negative correlation between the levels of caffeine and disease activity, evaluated with SLEDAI-2K, was observed (p=0.01, r=-0.26). By comparing the four groups, a significant higher prevalence of lupus nephritis, neuropsychiatric involvement, haematological manifestations, hypocomplementemia and anti-dsDNA positivity was observed in patients with less intake of caffeine (figure 1 A-E). Furthermore, patients with less intake of caffeine showed a significant more frequent use of glucocorticoids [group 4: 22.2%,versusgroup 1 (50.0%, p=0.0001), group 2 (55.5%, p=0.0001), group 3 (40.0%, p=0.009)]. Moving on cytokines analysis, a negative correlation between daily caffeine consumption and serum level of IFNγ was found (p=0.03, r=-0.2) (figure 2A); furthermore, patients with more caffeine intake showed significant lower levels of IFNα (p=0.02, figure 2B), IL-17 (p=0.01, figure 2C) and IL-6 (p=0.003, figure 2D).

Conclusion:

This is the first report demonstrating the impact of caffeine on SLE disease activity status, as demonstrated by the inverse correlation between its intake and both SLEDAI-2k values and cytokines levels. Moreover, in our cohort, patients with less caffeine consumption seems to have a more severe disease phenotype, especially in terms of renal and neuropsychiatric involvement. Our results seem to suggest a possible immunoregulatory dose-dependent effect of caffeine, through the modulation of serum cytokine levels, as already suggested byin vitroanalysis.

References:

[1]Kaul et alNat. Rev. Dis. Prim.2016; 2. Aronsen et alEurop Joul of Pharm2014; 3. Iris et alClin Immun.2018; 4. Gladman et al J Rheumatol. 2002; 5. Mikuls et alArth Rheum2002

Disclosure of Interests:

Valeria Orefice: None declared, Fulvia Ceccarelli: None declared, cristiana barbati: None declared, Ramona Lucchetti: None declared, Giulio Olivieri: None declared, enrica cipriano: None declared, Francesco Natalucci: None declared, Carlo Perricone: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, cristiano alessandri Grant/research support from: Pfizer, Guido Valesini: None declared, Fabrizio Conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

FRI0159 EROSIVE ARTHRITIS IN SYSTEMIC LUPUS ERYTHEMATOSUS: APPLICATION OF CLUSTER ANALYSIS

Background:

Systemic Lupus Erythematosus (SLE) related arthritis has been traditionally defined non-erosive and then considered a minor manifestation. Thanks to the application of more sensitive imaging techniques, such as ultrasonography (US), erosive damage has been identified in up to 40% of SLE patients with joint involvement, suggesting the need for more appropriate treatment (1). Antibodies directed against citrullinated and carbamilated proteins (ACPA and anti-CarP, respectively) have been associated with erosive damage and then proposed as biomarkers for this more aggressive phenotype (2).

Objectives:

Here, we evaluated a large SLE cohort with joint involvement by using cluster analysis, in order to identify the disease phenotype associated with erosive arthritis.

Methods:

For this analysis, we enrolled consecutive SLE patients (ACR 1997 criteria) with a clinical history of joint involvement (arthritis/arthralgia). Clinical and laboratory data were collected in a standardized computerized electronically filled form, including demographics, past medical history with the date of diagnosis, co-morbidities, previous and concomitant treatments, serological status. The presence of rheumatoid factor (RF), ACPA and anti-CarP was investigated by ELISA test. Erosive damage was assessed by ultrasonography at level of metacarpophalangeal, proximal interphalangeal and metatarsophalangeal joints (MyLab Eight Exp, Esaote, Florence, Italy). Data have been analysed by hierarchic cluster analysis (SPSS program, IBM).

Results:

We enrolled 203 patients [M/F 12/191, median age 46.0 years (IQR 18); median disease duration 120.0 months (IQR 108)]. Erosive damage was identified in 53 patients (26.1%), all of them referring at least one episode of arthritis during disease course. Moving on autoantibodies status, RF was positive in 29.5%, anti-CarP in 28.5% and ACPA in 11.2%. The univariate analysis demonstrated a significant association between US-detected erosive damage and anti-CarP (p=0.01), ACPA (p=0.03), and renal manifestations (p=0.03). In Figure 1 we reported the dendrogram obtained from cluster analysis, allowing the identification of four cluster. Positivity for ACPA, anti-CarP, erosive damage, Jaccoud’s arthropathy and renal manifestations were allocated in the same cluster. Interestingly, RF resulted allocated in a different cluster, including ENA, anti-SSA and anti-SSB antibodies.

Conclusion:

The application of cluster analysis allowed the identification of a specific SLE phenotype, characterized by erosive damage, renal manifestations and positivity for anti-CarP and ACPA. We could speculate about the presence of a shared pathogenic mechanism, involving NETosis, contributing to nephritis and erosive arthritis.

References:

[1]Ceccarelli F et al. Semin Arthritis Rheum 2017

[2]Ceccarelli F et al. Arthritis Res Ther 2018

Disclosure of Interests:

Fulvia Ceccarelli: None declared, Francesco Natalucci: None declared, Carlo Perricone: None declared, enrica cipriano: None declared, Carmelo Pirone: None declared, Giulio Olivieri: None declared, Tania Colasanti: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, cristiano alessandri Grant/research support from: Pfizer, Guido Valesini: None declared, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

AB0355 EFFECT OF TOFACITINIB IN TREG /TH17 BALANCE IN RHEUMATOID ARTHRITIS

Background:

Rheumatoid arthritis (RA) is a systemic chronic autoimmune disease that can cause progressive articular destruction (1). The imbalance between Tregs and Th17-cells - an effector T-cell subset acting as Treg antagonists – is closely linked to autoimmunity (2). A shift in the Th17/Treg balance towards the pro-inflammatory Th17 side has been reported in many autoimmune disorders including RA (4-5). Tofacitinib is the first janus kinases (JAK) inhibitor (JAKi) approved for the treatment of RA and it binds to and competitively inhibits the kinase domain of JAK3, JAK1 and, to a lesser degree, JAK2. Data on JAKi and Th17 cells/regulatory T cells (Tregs) are only available for ruxolitinib, a JAKi registered for myeloproliferative diseases (6).

Objectives:

Our project aimed at investigate the possible effect of Tofacitinib on the Treg/Th17 balance in RA patients.

Methods:

We isolated Peripheral Blood Mononuclear Cells (PBMCs) from patients affected by RA at baseline (T0) and after one month of Tofacitinib therapy (T1). By flow cytometry we characterized Treg and Th17 at T0 and T1. Clinical and laboratory data of the patients were collected in a standardized, computerized and electronically filled form. We assessed the disease activity by using DAS-28 (CRP). Data were expressed as mean(SD) or median (interquartile range, IQR) according to the variables’ distribution. Mann-Whitney and Spearman test were used. The values of P < 0.05 were considered statistically significant.

Results:

We isolated PBMCs from 9 patients with RA (F:M = 7:2, mean age±SD 60±17.4 years; mean disease duration±SD 20±6.6 years, DAS-28 median at T0 4.14 IQR 1.6; at T1 3.08 IQR 1.3). The median percentage of Treg and Th17 at T0 and T1 were respectively: T0 1.85 IQR 0.98 T1 3.12 IQR 1.37; T0 1.64 IQR 1.4, T1 0.6 IQR 1.1. Treg significantly increased after tofacitinib treatment while Th17 showed a tendency in decreasing without achieving a statistical difference (p= 0.003 and p=0.8, respectively) (figure 1). DAS-28 was negatively correlated with Treg number (r = -0.76565, p = 0.00021) and positively with Th17 numbers (r = 0.5816, p = 0.01135).

Conclusion:

This is the first study that investigated the role of JAKi on the Treg/Th17 balance in RA showing and increase in Treg cells with a concurrent tendency in decrease of Th17 cell population. The restore of the Treg/Th17 balance was associated with the reduction of DAS-28 (CRP).

References:

[1]McInnes IB et al. Lancet 2017

[2]Fasching P et al. Molecules 2017

[3]Han L et al. Front. Med. 2015

[4]Beringer A et al. Med. 2016

[5]Lippert E et al. Blood 2006

Disclosure of Interests:

viviana antonella pacucci: None declared, cristiana barbati: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Speakers bureau: Lilly, BMS, Celgene, Fulvia Ceccarelli: None declared, Silvia Mancuso: None declared, Cristina Garufi: None declared, cristiano alessandri Grant/research support from: Pfizer, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

FRI0121 STEROID-SPARING EFFECT OF JAK INHIBITORS IN RHEUMATOID ARTHRITIS PATIENTS FOLLOWED UP IN A REAL LIFE SETTING

Background:

Glucocorticoids (GCs) are a milestone of Rheumatoid Arthritis (RA) treatment; EULAR recommendations on the management of medium to high dose glucocorticoids remind to evaluate comorbidities and risk factors for adverse events when planning GCs treatment. Tofacitinib and Baricitinib are Janus kinases inhibitors (JAKi) registered for RA treatment. About 60% of patients enrolled in randomized clinical trials with JAKi were co-treated with GCs; however, little is known about tapering and percentage of withdrawal both in clinical trials and real life.

Objectives:

To evaluate the steroid-sparing effect of JAKi in patients with RA.

Methods:

We prospectively enrolled consecutive adult patients with RA starting JAKi. At baseline and after 4, 12 and 24 weeks we calculated C-Reactive Protein based Disease Activity score 28 (DAS28CRP). Daily dose of GCs was recorded at each visit as prednisone (PDN)-equivalent dose. Data are expressed as median (IQR). Continuous variables were compared by Mann Whitney test while dichotomous ones by Chi-square test. P values < 0.05 were considered statistically significant.

Results:

Between January 2018 and January 2020, 108 patients started JAKi: 67 patients Baricitinib, 41 patients Tofacitinib. The analysis was restricted to 64 RA patients (50 female, 14 male) who had at least 6 months of follow-up. Table 1 shows the demographic, clinical and clinimetric characteristics of the cohort. Patients treated with baricitinib and tofacitinib were comparable for age, disease duration, PDN dose and previous number of csDMARDS and bDMARDS; 30 patients (47.6%) were treated with JAKi in monotherapy. At baseline, the median daily PDN dose was 5 (7.25) mg; after 4, 12 and 24 weeks the median daily dose significant decreased to 5 (6.25) mg, 2.5 (5) mg and 0 (5) mg, respectively (p<0.0001). The percentage of patients treated with GC decreased from 81.5% to 63.5% at week 4, and to 48.4% at week 12 and 24. After 4, 12 and 24 weeks we detected a significant reduction of DAS28 (p<0.00001 compared to baseline). A similar percentage of patients who withdrew PDN compared to those who were still on PDN achieved remission after 12 and 24 months. Similarly, the reduction in DAS28 was comparable between the two groups at week 4 [4.8 (4.2) in those who withdrew vs 4.1 (1) in those who did not] at week 12 [4.8(1.6) for both] and at week 24 [3.7 (1.4) in those who withdrew vs 2.3 (0.7) in those who did not].

Table 1.

Demographic, clinic and clinimetric characteristics of the 64 patients

Baricitinib= 41Tofacitinib=23P valueFemale:male33:817:6P=nsAge, median (IQR), years58 (15)66 (14.5)P=nsDisease duration, median (IQR), months144 (144)150 (120)P=nsN° of previous csDMARDS3 (3)3 (1)P= nsN° of previous bDMARDs2 (3)1 (3)P= nsDAS28CRPat baseline4.7 (1.6)4.8 (2)P=nsPDN dose at baseline, median (IQR), mg5 (7.5)5 (5)P=nsPDN dose at 4 weeks, median (IQR), mg5 (7.5)5 (5)P=nsPDN dose at 12 weeks, median (IQR), mg2 (5)2.5 (4.7)P=nsPDN dose at 24 weeks, median (IQR), mg0 (5)2.5 (0)P=ns

IQR: interquartile range; DAS28CRP: Disease Activity Score 28 using C-Reactive Protein, csDMARDS: conventional synthetic Disease Modyfing anti-rheumatics drugs, bDMARDS: biotheconological Disease Modifying anti-rheumatics drugs PDN= prednisone

Conclusion:

The rapid reduction of disease activity determined by JAK inhibitors allows a fast tapering of PDN, as suggested by the last EULAR recommendations for the management of RA.

Disclosure of Interests:

Ilaria Duca: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Speakers bureau: Lilly, BMS, Celgene, Fulvia Ceccarelli: None declared, Cristina Garufi: None declared, Silvia Mancuso: None declared, cristiano alessandri Grant/research support from: Pfizer, Rossana Scrivo: None declared, Roberta Priori: None declared, Valeria Riccieri: None declared, Manuela Di Franco: None declared, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

AB0340 EFFECT OF BARICITINIB ON RANKL SERUM CONCENTRATION IN RHEUMATOID ARTHRITIS PATIENTS

Background:

RANKL (receptor activator of nuclear factor κB ligand) and osteoprotegerin, the main regulators of bone metabolism, are involved in osteoblasts/osteoclasts balance in inflammatory disease, such as Rheumatoid Arthritis (RA). Janus kinase (JAK) inhibitors (baricitinib and tofacitinib) can reduce the progression of structural damage in patients with moderate to severe RA. Previous studies suggest a link between JAK inhibition, production of RANKL and osteoclastogenesis1,2.

Objectives:

to investigate the effect of baricitinib on RANKL serum concentration in unselected RA patients.

Methods:

Patients affected by RA according to 2010 ACR criteria, starting treatment with baricitinib as clinically indicated, were consecutively enrolled. Demographic, clinical and laboratory data were collected at baseline (T0) and after three months of therapy (T3). RANKL serum concentration was analyzed by ELISA at the same timepoints. All patients underwent ultrasound (US) examination at T0 and T3. According with OMERACT definitions, the presence of synovial effusion, hypertrophy and power Doppler were assessed and scored on a semi-quantitative scale (0=absent, 1=mild, 2=moderate, 3=severe), obtaining a total US score (0-198), representing the joint inflammatory status (15); erosions were registered. Data were expressed as median (interquartile range); Mann-Whitney and Spearman tests were performed for comparisons and p values < 0.05 were considered statistically significant.

Results:

We prospectively followed up 33 RA patients starting treatment with baricitinib [M/F 8/25; age 58(9) years; disease duration 165(150) months; 22/33 (67%) ACPA-anti-citrullinated protein antibody positive; 24/33 patients (73%) RF-rheumatoid factor positive]. After three months of therapy we observed a significant reduction of DAS28CRP, CDAI and SDAI compared to baseline (p<0.0001). The US inflammatory score showed a significant improvement at T3 (p<0.0001). The serum concentration of RANKL showed a significant decrease after three months of therapy from 44 (25.9) to 27.5 (35.3) pg/ml,p=0.0256 (Figure 1). While in 67% of patients RANKL decreased after treatment, in 33% of patients no decrease or an increase of RANKL was detected. Those patients showing an increase of RANKL had similar DAS28CRP, CDAI, SDAI, but had significantly less swollen joints, compared to those in which RANKL decreased (p=0.0364). At baseline, the concentration of RANKL significantly correlated with the swollen joint count (p=0.0117) and ESR (p=0.0482), but not with DAS28CRP, CDAI, SDAI nor with the US inflammatory score. Nevertheless, the reduction of RANKL was not significantly associated with the achievement of low disease/remission after three months of treatment, with ACPA/RF positivity or the presence of erosions detected by US.

Conclusion:

This is the first study demonstrating that baricitinib reducesin vivothe serum levels of RANKL, regardless the correlation with disease activity indices. The discrepancy between the levels of RANKL and the clinical response is in line with previous data in the literature, demonstrating that, under treatment with anti-TNF and anti-IL1, the decrease of RANKL did not influence the local or systemic inflammatory parameters, even if still preventing bone loss3.

References:

[1]LaBranche T P et al. JAK inhibition with tofacitinib suppresses arthritic joint structural damage through decreased RANKL production. Arthritis Rheum 2012

[2]Murakami, KA Jak1/2 inhibitor, baricitinib, inhibits osteoclastogenesis by suppressing RANKL expression in osteoblasts in vitro. PLOS ONE 2017

[3]Stolina M et al. RANKL inhibition by osteoprotegerin prevents bone loss without affecting local or systemic inflammation parameters in two rat arthritis models: comparison with anti-TNFalpha or anti-IL-1 therapies. Arthritis Res Ther 2009

Disclosure of Interests:

Cristina Garufi: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, Fulvia Ceccarelli: None declared, Silvia Mancuso: None declared, cristiana barbati: None declared, Tania Colasanti: None declared, cristiano alessandri Grant/research support from: Pfizer, Fabrizio Conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

THU0257 ESTIMATED 10-YEARS CARDIOVASCULAR RISK IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS: PRELIMINARY RESULTS FROM THE “CARDIOVASCULAR OBESITY AND RHEUMATIC DISEASE (CORDIS)” STUDY GROUP OF THE ITALIAN SOCIETY OF RHEUMATOLOGY

Background:

Systemic lupus erythematosus (SLE) patients are at high risk for CV events, and EULAR recommends assessing the 10-year CV-risk using the Systematic Coronary Risk Evaluation (SCORE) [1]. The QRISK3, another score to assess CV-risk in UK population, considers different factors among which also SLE. The Progetto Cuore score (PCS) is validated to estimate CV risk in Italian people and largely replicates the SCORE project [2].

Objectives:

This cross-sectional study aimed to estimate CV-risk using SCORE, QRISK3 and, for the first time, PCS in a multicentric cohort of Italian SLE patients.

Methods:

During 2019 we evaluated 173 SLE patients (87.7% female; age 40±16 years; disease duration 138±105 months), fulfilling the 1997 ACR classification criteria. Clinical and laboratory data were registered, and individual CV-risk was calculated using suitable algorithms for the SCORE, QRISK3 and PCS. Statistical analysis was performed using Graphpad Instat 8.0 (San Diego, CA-USA).

Results:

In 13 (7%) SLE patients a previous CV event was recorded. Hypertension was present in 60 (37.5%) and diabetes in 27 (16.9%) patients. Mean total cholesterol was 184±39 mg/dL, HDLc 58±18 mg/dL, LDLc 124±37 mg/dL, triglycerides 105±63 mg/dL; dyslipidaemia was reported in 58 (36.2%) patients and 29 (18.1%) were on statin. Mean BMI was 24.9±5.3 Kg/sm, 60 (37.5%) and 23 (14.3%) patients were overweight and obese, while 25 (15.6%) patients were smokers. 87 (54.3%) SLE patients had a SLEDAI<4, 91% of patients were taken HCQ and 65% were on prednisone (mean dose 5.4±5.9 mg/day), but only 7.5% took >7.5 mg/day. The CV-risk of SLE patients according to SCORE, QRISK3 and PCS was 1.1±2.1%, 10.5±12.3% and 3.7±5.4%, respectively. Stratifying patients at low, moderate or high CV risk according to the PCS and SCORE a double proportion of patients was at moderate (8% vs 3.9%) or high (1.9% vs 0.9%) CV risk (p=0.03). Finally, CV-risk according to QRISK3 was higher than 20% (high risk) in 32/160 (20%) patients.

Conclusion:

This multicentre study demonstrated that the mean estimated CV-risk in SLE patients is globally low using the SCORE, QRISK3 and PCS. The PCS seems to better intercept those patients at moderate/high risk, at least in Italian SLE patients, while QRISK3 predicts the highest CV risk. The lack of disease-specific CV-risk factors (such as autoantibodies profile or organ involvement) probably account for the underestimation of CV risk using the SCORE and PCS.

References:

[1]ARD 2019;78(6):736-745.

[2]ARD 2019;0:1–2.doi:10.1136/annrheumdis-2019-215715

Disclosure of Interests:

Fabio Cacciapaglia Speakers bureau: BMS; Roche; Pfizer; Abbvie, Andreina Manfredi: None declared, Gianluca Erre: None declared, Elena Bartoloni Bocci: None declared, Garifallia Sakellariou Speakers bureau: Abbvie, Novartis, MSD, Ombretta Viapiana: None declared, Sergio Colella: None declared, Anna Abbruzzese: None declared, Marco Fornaro: None declared, Giacomo Cafaro: None declared, Maria Antonietta Fenu: None declared, Bianca Lucia Palermo: None declared, Martina Dessì: None declared, Adalgisa Palermo: None declared, Alessandro Giollo: None declared, Elisa Gremese Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Novartis, Sanofi, UCB, Roche, Pfizer, Speakers bureau: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Novartis, Sanofi, UCB, Roche, Pfizer, Francesca Romana Spinelli Grant/research support from: Pfizer, Speakers bureau: Lilly, BMS, Celgene, Fabiola Atzeni: None declared, Matteo Piga: None declared

OP0204 LUPUS COMPREHENSIVE DISEASE CONTROL IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS: APPLICATION OF A NEW INDEX

Background:

The main outcomes in SLE patients management are represented by the remission achievement and chronic damage prevention. Even though activity and damage are intimately connected, to date indices including both these outcomes are not available.

Objectives:

In the present study, we aimed at assessing the application of a new index, the Lupus comprehensive disease control (LupusCDC), including disease activity and chronic damage progression.

Methods:

We performed a longitudinal analysis, including SLE patients according to ACR 1997 criteria, followed-up in the period between January 2014 and December 2018, and with at least one visit per year. Disease activity was assessed by SLE Disease Activity Index 2000 (SLEDAI-2K) and three different remission levels were evaluated, as reported in Table 1 (1).

Table 1.

Remission levels considered in the study (1).

Remission levelDefinitionComplete Remission(CR)No clinical and serological activity (SLEDAI-2K=0) in corticosteroid-free and immunosuppressant-free patients (antimalarials allowed)Clinical remission off-corticosteroids(ClR-GCoff)Serological activity with clinical quiescent disease according to SLEDAI-2K in corticosteroid-free patients (stable immunosuppressive therapy and antimalarials allowed)clinical remission on-corticosteroids(ClR-GCon)Clinical quiescent disease according to SLEDAI-2K in patients on prednisone 1–5 mg/day (stable immunosuppressants and antimalarials allowed)

Chronic damage was registered according to SLICC damage index (SDI). All the patients were evaluated at baseline (T0) and every 12 months (T1, T2, T3, T4). At each time-point, we calculated the prevalence of LupusCDC, defined as remission achievement plus absence of chronic damage progression in the previous one year. We calculated this outcome including separately the different remission levels.

Results:

According with inclusion criteria, 172 SLE patients were evaluated in the present analysis [M/F 16/156, median age 49 years (IQR 16.7), median disease duration 180 months (IQR 156)]. At first assessment, we observed a mean±SD SDI value of 0.7±1.1. In details, 56 patients (32.5%) showed damage in at least one organ/system and the presence of damage was significantly associated with age (p<0.0001, r=0.3) and disease duration (p=0.0003, r=0.3). During the follow-up, we observed a significant increase in SDI values compared with T0 (T1: mean±DS 0.8±1.3, p<0.0001; T2: 0.8±1.4, p<0.0001; T3: 0.9±1.4 p=0.0001; T4: 1.0±1.5 p<0.0001).

In figure 1A and 1B we reported the proportion of patients achieving the different levels of remission and LupusCDC, respectively. In particular, the LupusCDC definition including CR was the most frequently detected in all time-points evaluated (T1: 18.0%; T2: 31.9%; T3: 27.9%; T4: 24.4%), with a significant difference at T2 [LupusCDC(CR)versusLupusCDC(ClR-GCoff), p=0.0002; LupusCDC(CR)versusLupusCDC(ClR-GCon) p=0.0002)], T3 [LupusCDC(CR)versusLupusCDC(ClR-GCoff), p=0.03; LupusCDC(CR)versusLupusCDC(ClR-GCon) p=0.006], T4 [LupusCDC(CR)versusLupusCDC(ClR-GCon), p=0.002]. No significant differences were found when comparing the prevalence of different remission levels and the prevalence of LupusCDC including the corresponding remission.

Conclusion:

In the present analysis we proposed for the first time a new index including disease activity and chronic damage, in order to evaluate the proportion of SLE patients reaching a comprehensive disease control. We found that CR is most frequently associated with the absence of damage progression.

References:

[1]Zen M et al. Ann Rheum Dis 2017.

Disclosure of Interests:

Fulvia Ceccarelli: None declared, Giulio Olivieri: None declared, Lorenzo Dominici: None declared, Alessandra Ida Celia: None declared, enrica cipriano: None declared, Cristina Garufi: None declared, Silvia Mancuso: None declared, Francesco Natalucci: None declared, Valeria Orefice: None declared, Carlo Perricone: None declared, Carmelo Pirone: None declared, viviana antonella pacucci: None declared, Francesca Morello: None declared, Simona Truglia: None declared, Francesca Miranda: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, cristiano alessandri Grant/research support from: Pfizer, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

SAT0092 CARDIOVASCULAR RISK ASSESSMENT IN PATIENTS WITH AUTOIMMUNE RHEUMATIC DISEASES: AN ITALIAN RHEUMATOLOGISTS’ SURVEY

Background:

Cardiovascular (CV) disease is the leading cause of morbidity and mortality in patients with inflammatory arthritis. The growing attention to the CV risk characterizing patients with autoimmune inflammatory disease led EULAR to provide recommendations on CV risk management (1). To date, there are no data on the adherence to EULAR recommendation among Italian rheumatologists.

Objectives:

Our objective was to measure the level of awareness and the attitude to manage CV risk.

Methods:

Italian rheumatologists were invited to anonymously answer a web-based questionnaire designed by the steering committee of the Cardiovascualr and Obesity in Rheumatic Diseases (CORDIS) study group of the Italian Society of Rheumatology. The first part of the questionnaire concerned demographic information; the subsequent questions concerned the attitude to assess CV risk and the limitations for not assessing, the specific CV risks considered in the clinical practice and their management. Data are presented using standard summary statistics and were expressed as mean+/-standard deviation or median (interquartile range) according to variables’ distribution.

Results:

One thousand-three hundred rheumatologists (of whom 500 are under 40 and 100 over 70 years of age) have been invited by email to complete the survey. The questionnaire has been filled by 102 rheumatologists (7.85%) (53 females and 49 males) with a median age of 38 years (32-48) and a median of 4 (0-15) years of specialization. Most of the physician who answered the questionnaire works in University Hospitals (67/102; 65.7%), 22 out of 102 (21.6%) in non-academic Hospitals, and the remaining 12,7% in territorial outpatient clinics.

When asked if they usually evaluate CV risk in patients with autoimmune rheumatic diseases, 67/102 (67.2%) answered positively, 18 no (17.6%) and 7 did not answer the question; 82% of those who routinely assess the CV do it by themselves. The barriers limiting the assessment of CV risk included: i) lack of time (79%); ii) complex management (12%); inadequate training (9%).

As for the CV risk factors, lipid profile, hypertension and diabetes are assessed by most of the rheumatologists (90%, 89% and 88%, respectively), family history by 78% and body mass index by 75.3% and waist circumference only by 25% of those who completed the survey.

Finally, only 18.6% stated that they manage by themselves CV risk in patients with autoimmune rheumatic diseases while 50% refer patients to other specialists and 23.4% to general practitioner.

Conclusion:

Despite the growing awareness on the CV risk characterizing patients with autoimmune rheumatic disease, about one third of young Italian rheumatologists does not strictly adhere to the EULAR recommendations on CV management, mostly due to insufficient time during the routine care visits.

References:

[1] Agca R et al. Ann Rheum Dis 2017; 76: 17-28.

Disclosure of Interests:

Francesca Romana Spinelli Grant/research support from: Pfizer, Speakers bureau: Lilly, BMS, Celgene, Fabio Cacciapaglia Speakers bureau: BMS; Roche; Pfizer; Abbvie, Fabiola Atzeni: None declared, Gianluca Erre: None declared, Andreina Manfredi: None declared, Elena Bartoloni Bocci: None declared, Matteo Piga: None declared, Garifallia Sakellariou Speakers bureau: Abbvie, Novartis, MSD, Ombretta Viapiana: None declared, Elisa Gremese Speakers bureau: Abbvie, BMS, Celgene, Jannsen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB

SAT0228 PREGNANCY OUTCOME IN SYSTEMIC LUPUS ERYTHEMATOSUS: A MONOCENTRIC COHORT ANALYSIS

Background:

Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease, affecting prevalently women in childbearing age. Thanks to pre-gestational counseling and multi-disciplinary approach, adopted in daily clinical practice, SLE patients are experiencing even more uncomplicated pregnancies.

Objectives:

Here, we evaluated pregnancy outcome in a large SLE cohort, compared to a control group including pregnant women without autoimmune diseases.

Methods:

Pregnant SLE patients (diagnosis made according to ACR 1997 criteria) were included in the present study, conducted in the context of a joint rheumatology/gynecology multi-disciplinary team. For each patient we collected demographic information, medical history, treatments, disease activity (SLEDAI-2K) chronic damage (SLICCdamage index), clinical and laboratory data, including serum complement level and autoantibodies. Pregnancy outcomes were reported longitudinally as well as disease relapses occurring during pregnancy and puerperium. Flares were defined as new onset or worsening disease-related manifestation in any organ/system.

Results:

Since 2008, 70 consecutive pregnancies occurred in 50 SLE patients [(median age at diagnosis 25 years (IQR 12.2), median age at first pregnancy 33 years (IQR 7), median disease duration 72 months (IQR 120)]. As controls, we evaluated 100 consecutive pregnancies in 100 women without autoimmune diseases [(median age 31 years (IQR 9)]. Table 1 reports the obstetric, fetal and neonatal outcomes of SLE patients compared to control group. A positive outcome in terms of live born infants was experienced in 88.6% of SLE pregnancies and in 88% of control group (p=NS). There were no statistically significant differences in any of the pregnancy outcomes evaluated; however, the percentage of small for gestational ages (SGA) was significantly higher in SLE group (22.8%versus11.0% P=0.003). A statistical association was found between SGA and positivity for anti-dsDNA, anti-SSA ed anti-SSB (p=0.0001, p=0.01, p=0.04 respectively). Miscarriage was significantly associated with disease-related serologic abnormalities [anti-dsDNA (p=0.0001), low C3 (p=0.0001) and low C4 (p=0.006)] and past smokinghabitus(p=0.0001); preterm birth was associated with anti-dsDNA, anti-CL and anti-B2GPI (p=0.001, p=0.0005, p=0.01 respectively). A disease flare was reported in 28 pregnancies (40%) and in 31 puerperium (44.3%). Figure 1 reports SLE relapses divided according to organ involvement. Flare during pregnancy was associated with positivity for anti-SSA (p=0.001), anti-SSB (p=0.01) and a-CL (p=0.006), whilepuerperiumrelapses were associated with previous renal involvement (p=0.0005), flare during pregnancy (p=0.01) and chronic damage (p=0.0001).

Table 1.

Pregnancy outcomes in 50 SLE and 100 controls.

LES(Pregnancies N=70)Controls(Pregnancies N=100)POBSTETRIC OUTCOMEPreterm birth N/%18/25.719/19NSGestational hypertension N/%5/7.13/3NSGestational diabetes N/%5/7.15/5NSPre-eclampsia N/%2/2.91/1NSFETAL OUTCOMEMiscarriages N/%8/11.412/12NSPR interval elongation N/%4/6.4––IUGR N/%3/51/1NSNEONATAL OUTCOMESGA< 10° centile N/%16/22.811/110.003Weight at birth median-I.Q.R.2850-6883250-8140.003Apgar 1’ median-I.Q.R.8-18-1NSApgar 5’ median-I.Q.R.9-110-1NSFigure 1.

Disease flares during and after 70 SLE pregnancies divided according to organ involvement.

Conclusion:

The present study confirms the role of pre-gestational counseling and a multi-disciplinary approach in the outcome of SLE pregnancies. Moreover, the high prevalence of disease relapse even more justifies the need for a combined rheumatology/gynecology multi-disciplinary approach.

Disclosure of Interests:

Carmelo Pirone: None declared, Fulvia Ceccarelli: None declared, Aikaterini Selntigia: None declared, Carlo Perricone: None declared, Simona Truglia: None declared, viviana antonella pacucci: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Speakers bureau: Lilly, BMS, Celgene, cristiano alessandri Grant/research support from: Pfizer, Guido Valesini: None declared, Giuseppina Perrone: None declared, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

THU0281 EXPLORING THE GENETIC DIVERSITY OF STAPHYLOCOCCUS AUREUS IN PATIENTS AFFECTED BY SYSTEMIC LUPUS ERYTHEMATOSUS: ASSOCIATION WITH DISEASE-RELATED FEATURES AND ACTIVITY

Background:

Infective factors play a central role in autoimmune diseases pathogenesis. It is possible to speculate that the host genotype could interact with genetic background of infective agents. We previously evaluated a large SLE cohort, observing the association between theS. Aureus(SA) carriage status and presence of a more active disease in terms of autoantibodies positivity.

Objectives:

We evaluated epidemiological, molecular characterization, genetic diversity and evolution of SA isolated from SLE patients by means of phylogenetic analysis.

Methods:

Consecutive SLE patients (ACR 1997 criteria) were enrolled: clinical/laboratory data were collected and nasal swab for SA identification was performed. On the basis of translation elongation factor (tuf) gene, a phylogenetic analysis was performed to investigate phylogenetic relationships and to assess significant clades in patients with persistent carriage status (nasal swab positive in two consecutive evaluation, performed 1 week apart). The first dataset was composed by seven SA tuf gene isolated from non-SLE individuals from different countries (downloaded from the GenBank database,https://www.ncbi.nlm.nih.gov/nucleotide/) and tuf gene SA collected from SLE patients enrolled in the present study.

Results:

We enrolled 118 patients (M/F 10/198; median age 45.5 years, IQR 13,2; median disease duration 120 months, IQR 144). Skin involvement is the most frequent disease manifestation (86 patients, 72.9%), followed by joint involvement (78 patients, 66.1%). Twenty-four patients (20.3%) were SA carriers (SA+), three of them resulted MRSA. SA+ patients showed a significantly higher prevalence of joint involvement (79.2%versus62.7%, P=0.01) and anti-dsDNA positivity (75.0%versus55.3%, P=0.004). Moreover, SA+ SLE showed a more active disease, in terms of SLEDAI-2k values [SA+: median 2 (IQR 3.75)versusSA-: median 0 (IQR 2), P=0.04). The phylogenetic analysis has been restricted on the 21 non-MRSA SA+ patients. The maximum likelihood phylogenetic tree of the first dataset revealed a statistically supported larger clade (A, N=17) and a smaller one (B, N=4; figure 1A). SLE patients located in the clade A showed a significantly higher prevalence of joint involvement (88.2%) in comparison with clade B (50.0%, P<0.0001) and SA- (62.7%, P<0.0001, figure 2B). Moreover, haematological manifestations were significantly more frequent in clade A patients (64.7%) compared with B (50.0%, P=0.004, figure 2C).

Conclusion:

The results of the present study confirmed the association between SA carriage status and disease activity, in terms of SLEDAI-2k values and anti-dsDNA positivity. The phylogenetic analysis ontufgene show a clustering ofSA+patients in two major clade (A and B). Interestingly thetufgenotype of clade A is significantly associated with a specific disease phenotype, characterized by joint involvement and positivity for anti-dsDNA. These findings support the hypothesis that bacterial genetic variants may be associated with specific disease features.

References:

[1]Rigante et al. Int J Mol Sci. 2015;

[2]Wertheim et al Lancet Infect Dis. 2005;

[3]Conti et al Arthritis Res Ther 2016;

[4]Tong et al Clin Microbiol Rev. 2015;

[5]Rhee et al Infect Control Hosp Epidemiol. 2015

Disclosure of Interests:

Giulio Olivieri: None declared, Fulvia Ceccarelli: None declared, Alessandra Lo Presti: None declared, silvia angeletti: None declared, Carlo Perricone: None declared, Giancarlo Iaiani: None declared, Lucia De Florio: None declared, francesca antonelli: None declared, Luigino Amori: None declared, Cristina Garufi: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Speakers bureau: Lilly, BMS, Celgene, cristiano Alessandri: None declared, Guido Valesini: None declared, Massimo Cicozzi: None declared, Fabrizio Conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

AB0085 MODULATION OF CIRCULATING SKELETAL STAMINAL CELLS IN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH TOFACITINIB

Background:

Rheumatoid arthritis (AR) is an autoimmune systemic inflammatory disease characterized by chronic synovial inflammation resulting in bone damage and erosions, with consequently functional disability. Currently, attempts for regenerative therapies for osteo-cartilage pathologies have proved unsuccessful. Recently, a “pool” of skeletal stem cells (hSSCs: human skeletal stem cells) able to generating bone cells, has been identified in human bone (1).

Objectives:

In light of these observations, we aim at characterizing skeletal stem cells in peripheral blood from RA patients candidate to Tofacitinib treatment.

Methods:

In this pilot study 4 RA patients [4F; mean age 65 years; mean disease duration 19 years] candidate to Tofacitinib treatment and 4 healthy donors (HD), matched by gender and age, were enrolled. Blood samples were collected from each subject of the study, at baseline (T0) and for RA patients, after 1 month of Tofacitinib (T1), to evaluatinghSSC(CD45-, CD146-, CD73+, PDPN+, CD164+) by flow cytometry. For this purpose, we performed on whole blood a negative magnetic selection for CD45 cells. Then, the eluate was labeled with antibodies anti CD146-PE, anti CD73-APC, anti CD164 - FITC and anti-Podoplanin (PDPN) PerCP/Cyanine5.5. The acquisition was performed using a FACS Calibur, which included 100,000 events per sample (Figure 1).

Results:

ThehSSCspercentage was significantly lower in RA patients than in HD (p = 0.0286). At T1, after treatment with Tofacitinib, meanhSSCspercentage significantly increased from 1.8% to 4.2 % (p = 0.016 vs RA T0) (Figure 2A). Correlation analysis showed a significant indirect relation between the percentage ofhSSCand disease activity measured by DAS28ESR, SDAI and CDAI (Figure 2B).

Conclusion:

The results of this study demonstrate, for the first time, circulating skeletal stem cells and their reduced expression in active RA patients. Tofacitinib treatment leads to a significant increase inhSSCspercentage. This evidence opens up new perspectives on bone repair mechanisms and on deepening of current therapeutic strategies.

References:

[1]Chan CKF, Gulati GS, Sinha R, Tompkins JV, Lopez M, Carter AC, Ransom RC, Reinisch A, Wearda T, Murphy M, Brewer RE, Koepke LS, Marecic O, Manjunath A, Seo EY, Leavitt T, Lu WJ, Nguyen A, Conley SD, Salhotra A, Ambrosi TH, Borrelli MR, Siebel T, Chan K, Schallmoser K, Seita J, Sahoo D, Goodnough H, Bishop J, Gardner M, Majeti R, Wan DC, Goodman S, Weissman IL, Chang HY, Longaker MT.Identification of the Human Skeletal Stem Cell.Cell. 2018 Sep 20;175(1):43-56.e21. doi: 10.1016/j.cell.2018.07.029.

Acknowledgments:

none

Disclosure of Interests:

cristiana barbati: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, cristina garufi: None declared, Ilaria Duca: None declared, fulvia ceccarelli: None declared, Tania Colasanti: None declared, Marta Vomero: None declared, cristiano alessandri Grant/research support from: Pfizer, Guido Valesini: None declared, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

SAT0223 TUBULO-INTERSTITIAL INFILTRATES IN LUPUS NEPHRITIS

Background:

Lupus nephritis (LN) occurs in up to 60% of patients affected by Systemic Lupus Erythematosus (SLE). The presence of inflammatory infiltrates in glomeruli and/or in tubulo-interstitium (TI) plays an important role in terms of prognosis (1). Ectopic lymphoid structures (ELSs) are clusters of organized lymphoid infiltrates forming at sites of chronic inflammation in non-lymphoid organs (2). Data on ELSs in kidneys of SLE patients are scant (3-5).

Objectives:

The aim of the study was to evaluate the tubule-interstitial infiltrates (TI-I) organization and to investigate the presence of ELSs.

Methods:

Kidney sections of SLE patients undergoing a renal biopsy for diagnostic purpose were studied; LN was diagnosed according to the 2003 International Society of Nephrology / Renal Pathology Society classification criteria. Clinical, laboratory and histological data were collected in a standardized, computerized and electronically filled form, including past medical history. The presence of lymphoid aggregates and ELS in the kidney sections were firstly evaluated by hematoxylin-eosin (HE). By using immunohistochemistry (IHC), we characterized the infiltrates by identification of T cells (CD3), B cells (CD20) and follicular dendritic cells (CD21).

Results:

By HE we evaluated 53 kidney samples from LN patients (F:M = 51:2, mean age at biopsy ± SD years 35±7.7; mean disease duration at date of biopsy ± SD 8±8.3 years). TI-I were found in 33 kidney specimens. By HE we identified a well-defined infiltrate pattern resembling ELS in 13 renal samples. In these samples, we confirmed the presence of organized infiltrates by IHC, with evidence of segregated T and B cells areas in most of them. In one sample, the CD21 staining was positive confirming the presence of ELS (Figure 1). Interestingly, this last patient, who failed ciclophosphamide and mycofenolate, responded to rituximab administration and is now in complete LN remission. Moreover TII was negatively correlated with renal remission after induction therapy (P=0.03) independent of the histological class and the induction treatment.

Figure 1.

Biopsy specimens showing tubulo-interstitial ELS by IHC (10x).

Conclusion:

Assessment and management of LN patients are greatly facilitated by information obtained by renal biopsy. In the present study the evaluation by HE of 53 kidney samples from patients with LN showed TI-I in 62% of the specimens and a well-defined infiltrate pattern with GC-like features in 39% of those specimens with TI-I, confirmed in IHC. The presence of TII was associated with a worse outcome in response to therapy. Our preliminary results obtained by IHC suggest that ELS could be considered as a biomarker of renal response to B-cell depleting therapy supporting the importance of TI disease.

References:

[1]Giannakakis K. & Faraggiana T. Histopathology of Lupus Nephritis. Clinic Rev Allerg Immunol 2011

[2]Bombardieri M et al. Ectopic lymphoid neogenesis in rheumatic autoimmune diseases. Nat Rev Rheumatol 2017

[3]Chang A et al. In situ B cell-mediated immune responses and tubulointerstitial inflammation in human lupus nephritis. J Immunol 2011

[4]Shen Y et al. Association of intrarenal B-cell infiltrates with clinical outcome in lupus nephritis: a study of 192 cases. Clin Dev Immunol 2012

[5]Neusser MA et al. Intrarenal production of B-cell survival factors in human lupus nephritis. Mod Pathol 2011

Disclosure of Interests:

viviana antonella pacucci: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Speakers bureau: Lilly, BMS, Celgene, Konsantinos Giannakakis: None declared, Serena Colafrancesco: None declared, Simona Truglia: None declared, Fulvia Ceccarelli: None declared, Cristina Garufi: None declared, cristiano alessandri Grant/research support from: Pfizer, Fabrizio Conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

FRI0376 EFFECT OF CARBAMYLATED LOW-DENSITY LIPOPROTEINS ON BONE CELLS HOMEOSTASIS

Background:

Carbamylation is a post-translational modification occurring under several conditions such as uremia, smoking and chronic inflammation as in rheumatoid arthritis (RA). Low-density lipoproteins (LDL) represent a target of carbamylation. Carbamylated-LDL (cLDL) have an increased inflammatory and atherogenic potential. Growing evidence supports an influence of modified lipids on bone cells homeostasis. However, the role of cLDL on bone cells physiology is still unknown.

Objectives:

Considering the rate of carbamylation and the role of anti-carbamylated proteins antibodies as markers of erosive disease in RA, the purpose of this study is to investigate the effect of cLDL on bone homeostasis.

Methods:

In-vitrocarbamylation of LDL was performed as previously described by Ok et al. (Kidney Int. 2005). Briefly, native LDL (nLDL) were treated with potassium cyanate (KOCN) for 4 hours, followed by excessive dialysis for 36 hours to remove KOCN. Both osteoclasts (OCs) and osteoblasts (OBLs) were treated at baseline with 20 μg/ml, 100 μg/ml and 200 μg/ml of cLDL or nLDL. To induce osteoclast differentiation, CD14+ monocytes were isolated from peripheral blood of healthy donors by magnetic microbeads separation and then cultured on a 96-wells plate in DMEM media supplemented with RANKL and M-CSF. After 10 days cells were fixed, stained for tartrate-resistant acid phosphatase (TRAP), a marker of OC differentiation, and counted. OBLs were isolated from bone specimens of 3 patients who had undergone to knee or hip arthroplasty for osteoarthritis and treated for 5 days with different concentrations of cLDL and nLDL. OBLs were fixed and stained for alkaline phosphatase positive activity (ALP), a marker of osteogenic differentiation. Total RNA was extracted from cell lysates. Copies of single-stranded complementary DNA (cDNA) were synthesized and analyzed by real-time PCR to evaluate RANKL and Osteoprotegerin (OPG) mRNA expression levels.

Results:

In OCLs culture, cLDL significantly decreased the number of OC compared to untreated cells (200 μg/ml p=0,0015) and nLDL treated cells (200 μg/ml p= 0,011; 20 μg/ml p= 0,0014) (Fig 1). Moreover, treatment with cLDL induced an increase of not terminally differentiated OCs, reduced dimensions of OCs, less intense TRAP staining and vacuolization (Fig 2). In OBLs culture, cLDL (20, 100 μg/ml) significantly reduced the ALP activity of OBLs compared with untreated cells (p<0.05) (Fig 3). nLDL did not affect the ALP expression. Treatment with cLDL stimulated RANKL mRNA expression in osteoblasts increasing the RANKL/OPG ratio (Fig 4).

Fig 1.Fig 2.Fig 3.Fig 4.

Conclusion:

cLDL induce a significant depression of OC and OBL differentiation. Moreover, cLDL increase RANKL expression in OBL, unbalancing bone tissue turnover towards bone resorption. Accordingly, cLDL could be implicated in the bone loss characterizing several conditions associated to an increased carbamylation, such as RA

Disclosure of Interests:

Bruno Lucchino: None declared, Martina Leopizzi: None declared, Tania Colasanti: None declared, Valeria Di Maio: None declared, cristiano alessandri Grant/research support from: Pfizer, Guido Valesini: None declared, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi, Manuela Di Franco: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly

THU0127 Estimated cardiovascular risk in a large cohort of rheumatoid arthritis patients from the “Cardiovascular Obesity and Rheumatic DISease (CORDIS)” Study Group of the Italian Society of Rheumatology

Background:

Rheumatoid arthritis (RA) patients present high cardiovascular (CV) morbidity and mortality and EULAR recommends estimating their CV-risk [1]. The Systematic Coronary Risk Evaluation (SCORE) algorithm is suggested if National Guidelines are lack, but few data are available about different strategies.

Objectives:

To estimate the 10-years CV-risk using different algorithms in RA compared to osteoarthritis (OA) patients, as control group.

Methods:

A total of 1467 RA patients (78.3% female; mean age 59.8±11.5 years; mean disease duration 131±109 months), fulfilling the 2010 EULAR/ACR classification criteria, and 342 age and sex matched patients with OA (79.8% female; mean age 58.7±11.5 years) were enrolled in this multicentre cross-sectional study during 2019. Clinical and laboratory data were registered, and individual CV-risk was calculated using: SCORE chart, “Progetto Cuore” model (PCM), QRisk3, Reynolds Risk Scores (RRS) and Expanded Risk Score in RA (ERS-RA), as stated by suitable algorithms. Statistical analysis was performed using the Statistical System Graphpad Instat 8.0 (San Diego, CA-USA).

Results:

In 46 (3%) RA patients a previous CV event was observed. Among traditional CV-risk factors, RA patients presented higher frequency of diabetes (9.9% vs 6.4%; p=0.04) and lower prevalence of dyslipidaemia (21.7% vs 32.5%; p<0.0001) compared to OA patients. Prevalence of hypertension was similar in both groups (40% vs 39.2%). Mean BMI (25.6±4.8 vs 26.6±4.4; p<0.0001) and prevalence of obesity (15% vs 21%; p=0.003) were significantly lower in RA patients. Finally, RA patients were more frequently smokers (20.4% vs 12.5% - p=0.002). 441 (30%) RA patients were in CDAI remission, 998 (68%) patients were on csDMARDs while a biologic agent was used in 617 (42%) patients. About 43% of RA patients were on a mean prednisone-dose of 4.5±3.5 mg/day. The 10-years CV-risk resulted 2 to 3-fold higher in RA compared to OA patients using the different algorithms. The QRisk3 estimated the highest CV risk in our cohort of patients, while the ERS-RA and RRS were significantly higher than PCM and SCORE.

Conclusion:

Our study demonstrates a higher estimated CV-risk in RA compared to OA patients. The commonly used algorithms to estimate CV-risk in clinical practice perform differently, evaluating different traditional CV-risk factors and disease specific characteristic, as for QRisk3 or ERS-RA. Rheumatologist should impact on both traditional and RA related modifiable CV-risk factors.

References:

[1]Agca R, et al. Ann Rheum Dis 2017;76:17–28.

Disclosure of Interests:

Fabio Cacciapaglia Speakers bureau: BMS; Roche; Pfizer; Abbvie, Matteo Piga: None declared, Gianluca Erre: None declared, Andreina Manfredi: None declared, Elena Bartoloni Bocci: None declared, Garifallia Sakellariou Speakers bureau: Abbvie, Novartis, MSD, Ombretta Viapiana: None declared, Sergio Colella: None declared, Anna Abbruzzese: None declared, Martina Dessì: None declared, Caterina Vacchi: None declared, Floriana Castagna: None declared, Giacomo Cafaro: None declared, Bianca Lucia Palermo: None declared, Alessandro GIollo: None declared, Marco Fornaro: None declared, Elisa Gremese Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Novartis, Sanofi, UCB, Roche, Pfizer, Speakers bureau: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Novartis, Sanofi, UCB, Roche, Pfizer, Francesca Romana Spinelli Grant/research support from: Pfizer, Speakers bureau: Lilly, BMS, Celgene, Fabiola Atzeni: None declared

FRI0145 FOLLOW-UP OF A MONOCENTRIC COHORT OF SERONEGATIVE ANTIPHOSPHOLIPID SYNDROME

Background:

Seronegative antiphospholipid syndrome (SN-APS) is the term proposed to describe patients with clinical signs highly suggestive of APS but persistently negative for conventional antiphospholipid antibodies (aPL) assays. Therefore, new antigenic targets or different methodological approaches have been investigated to detect aPL in SN-APS [1].

Objectives:

The aim of this study was to describe the clinical follow-up of a monocentric cohort of SN-APS patients.

Methods:

The study included all consecutive SN-APS patients examined from 2014 to 2018. In all patients other possible causes of thrombosis or obstetric morbidity were ruled out. APL were investigated through two tests: 1. anti-cardiolipin/vimentin antibodies (aCL/Vim) by enzyme-linked immunosorbent assay (ELISA) 2. anti-cardiolipin antibodies (aCL) by thin-layer chromatography (TLC)-immunostaining.

Results:

We enrolled 121 patients (all Caucasian except one Asian and one Hispanic women). Clinical and demographic characteristics are reported in Table 1.

Table 1.

Clinical and demographic characteristics

FeaturesSN-APSn= 121 (%)Male/Female14/107Mean age in years (from-to)42.58 (16-78)PAPS/SAPS78/43 (64.5/35.5)SLE28 (23.1)Others autoimmune diseases15 (12.4)Pregnancy morbidity56/107 (52.3) Spontaneous abortions49 (45.8) Normal fetus deaths22 (20.6) Premature births7 (6.54)Thrombosis72 (59.5) Arterial thrombosis36 (29.8) Venous thrombosis48 (39.7) Recurrent thrombosis28 (23.1)Thrombosis + Pregnancy morbidity8 (6.6)Non-criteria APS features45 (37.2) Livedo reticularis18 (14.9) Thrombocytopenia12 (9.9) Migraine19 (15.7) Seizures5 (4) Others11 (9)Cardiovascular risk factors50 (41.3) Hypercholesterolemia8 (6.6) Smoking22 (18.2) Hypertension22 (18.2) OC/HRT7 (5.8) Diabetes4 (3.3)

Sixty-nine out 121 patients (57%) resulted positive for at least one non-conventional test in two occasions more than 12 weeks apart (Figure 1). The agreement between first and second test resulted respectively of K=0,703 e K=0,655 (Cohen’s K test). Figure 2 shows the prevalence of aCL (TLC-immunostaining) and aCL/Vim. We found a significant correlation between aCL (by TLC-immunostaining) and aCL/Vim (p= 0.027), brain MRI ischemic changes (p= 0.012) and age (p= 0.023). ACL/Vim was significantly correlated with livedo reticularis (p = 0.015).

Patients with double positivity showed a higher prevalence of mixed thrombotic and obstetrical features than patients with single positivity (p < 0.001, likelihood positive ratio 8.2).

Non-conventional aPL positivity better supported the diagnosis of APS and, following the therapeutic changes implemented, in a median follow up of 41 months (IQR 39.5) only 3 cases of recurrent thrombosis (2 cases of arterial thrombosis during treatment with antiaggregant therapy and one case of venous thrombosis in treatment with new oral anticoagulant therapy) were observed. During the follow-up, 35 patients with obstetric morbidity who resulted positive for the tests had 20 pregnancies; 12 of them (60%) experienced a good outcome under conventional treatment for classical APS.

Conclusion:

The results demonstrate that new methods – TLC-immunostaining – or new antigens - CL/Vim – allow to detect aPL in so-called “SN-APS” patients and, consequently, to prescribe the most appropriate therapy.

References:

[1]Conti F et al. The Mosaic of “Seronegative” Antiphospholipid Syndrome. J Immunol Res. 2014;2014:389601

Disclosure of Interests:

Silvia Mancuso: None declared, Simona Truglia Speakers bureau: Lilly, BMS, Serena Recalchi: None declared, Gloria Riitano: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Speakers bureau: Lilly, BMS, Celgene, Fulvia Ceccarelli: None declared, Maurizio Sorice: None declared, cristiano alessandri Grant/research support from: Pfizer, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

Gender equality in Rheumatology

Not available.

Anti-D4GDI antibodies activate platelets in vitro: a possible link with thrombocytopenia in primary antiphospholipid syndrome

Background

Thrombocytopenia is a manifestation associated with primary antiphospholipid syndrome (PAPS), and many studies have stressed the leading role played by platelets in the pathogenesis of antiphospholipid syndrome (APS). Platelets are highly specialized cells, and their activation involves a series of rapid rearrangements of the actin cytoskeleton. Recently, we described the presence of autoantibodies against D4GDI (Rho GDP dissociation inhibitor beta, ARHGDIB) in the serum of a large subset of SLE patients, and we observed that anti-D4GDI antibodies activated the cytoskeleton remodeling of lymphocytes by inhibiting D4GDI and allowing the upregulation of Rho GTPases, such as Rac1. Proteomic and transcriptomic studies indicate that D4GDI is very abundant in platelets, and small GTPases of the RHO family are critical regulators of actin dynamics in platelets.

Methods

We enrolled 38 PAPS patients, 15 patients carrying only antiphospholipid antibodies without clinical criteria of APS (aPL carriers) and 20 normal healthy subjects. Sera were stored at − 20 °C to perform an ELISA test to evaluate the presence of anti-D4GDI antibodies. Then, we purified autoantibodies anti-D4GDI from patient sera. These antibodies were used to conduct in vitro studies on platelet activation.

Results

We identified anti-D4GDI antibodies in sera from 18/38 (47%) patients with PAPS, in sera from 2/15(13%) aPL carriers, but in no sera from normal healthy subjects. Our in vitro results showed a significant 30% increase in the activation of integrin αIIbβ3 upon stimulation of platelets from healthy donors preincubated with the antibody anti-D4GDI purified from the serum of APS patients.

Conclusions

In conclusion, we show here that antibodies anti-D4GDI are present in the sera of PAPS patients and can prime platelet activation, explaining, at least in part, the pro-thrombotic state and the thrombocytopenia of PAPS patients. These findings may lead to improved diagnosis and treatment of APS.

CD44v3 and CD44v6 isoforms on T cells are able to discriminate different disease activity degrees and phenotypes in systemic lupus erythematosus patients

BACKGROUND

Adhesion molecule CD44 contributes to T cell migration into target organs. A higher expression of CD44v3 and v6 isoforms has been identified on T cells from systemic lupus erythematosus (SLE) patients. The aim of this study was to investigate the expression of CD44v3/v6 on T cells of SLE patients in order to evaluate their correlation with clinical features.

METHODS

Sixteen healthy subjects (HSs) and 33 SLE female patients were enrolled. Fifteen patients were in remission (Systemic Lupus Erythematosus Disease Activity Index-2000 (SLEDAI-2K) = 0) and 18 patients had an active disease (SLEDAI-2K ≥ 4). Experiments were conducted by flow cytometry.

RESULTS

Expression of CD44v3 on CD4⁺ and CD8⁺ T cells was higher in active patients compared to HSs ( p = 0.0097 and p = 0.0096). CD44v3 on CD8⁺ T cells was also higher in active patients compared to patients in remission ( p = 0.038). CD44v6 was higher on CD4⁺ and CD8⁺ T cells from active patients compared to HSs ( p = 0.003 and p = 0.0036) and to patients in remission ( p = 0.01 and p = 0.02). In active patients the ratio CD44v3/v6 was unbalanced towards isoform v6 on both T cell populations. In a receiver operating characteristic curve analysis, CD44v6 on CD4⁺ T cells was the most sensitive and specific one (specificity of 81.8%, sensitivity of 75%). Expression of CD44v6 on CD4⁺ and CD8⁺ T cells correlated with the SLEDAI-2K ( p = 0.03, r = 0.38 and p = 0.02, r = 0.39). CD44v6 and CD44v3 on CD8⁺ T cells associated with nephritis and arthritis ( p = 0.047 and p = 0.023).

CONCLUSIONS

CD44v3/v6 can be used as biomarkers of disease activity and phenotypes; isoform v6 on CD4⁺ T cells can be useful as a diagnostic biomarker.

Usefulness of composite indices in the assessment of joint involvement in systemic lupus erythematosus patients: correlation with ultrasonographic score

Specific indices are not available to evaluate systemic lupus erythematosus (SLE) joint involvement; indeed, the application of indices validated for rheumatoid arthritis has been suggested. We evaluated the usefulness of organ specific composite indices, i.e. the Disease Activity Score on 28 joints (DAS28), Simplified Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI), and the ratio of swollen to tender joints (STR), to assess SLE joint activity by analyzing the correlation between these indices and ultrasonography (US) inflammatory status. We evaluated SLE patients with arthralgia and/or arthritis: the above-mentioned indices were calculated and the SLE Disease Activity Index 2000 (SLEDAI-2k) was applied to assess global disease activity. US of I-V metacarpophalangeal, I-V proximal interphalangeal, wrist, and knee bilateral was performed. Synovial effusion/hypertrophy and power Doppler findings were scored according to a semi-quantitative scale (0-3) to obtain an inflammatory total score (0-216). One hundred and six patients (M/F 7/99, median age 49.5 years (IQR 17.0), median disease duration 8.5 years (IQR 17.0)) were enrolled. We identified a positive correlation between US score and DAS28-CRP ( r = 0.3, p = 0.007), STR ( r = 0.42, p = 0.0005), SDAI ( r = 0.33, p = 0.02), CDAI ( r = 0.29, p = 0.03); US score reflected different levels of clinimetric joint activity. In conclusion, we suggest the ability of composite indices in detecting SLE joint inflammation and their possible real-life use.

Reduction of autophagy and increase in apoptosis correlates with a favorable clinical outcome in patients with rheumatoid arthritis treated with anti-TNF drugs

Background

Autophagy has emerged as a key mechanism in the survival and function of T and B lymphocytes, and its activation was involved in apoptosis resistance in rheumatoid arthritis (RA). To investigate whether the relationship between autophagy and apoptosis may impact the response to the therapy, we analyzed ex vivo spontaneous autophagy and apoptosis in patients with RA subjected to treatment with anti-tumor necrosis factor (TNF) drugs and in vitro the effects of TNFα and anti-TNF drugs on cell fate.

Methods

Peripheral blood mononuclear cells (PBMCs) from 25 RA patients treated with anti-TNF drugs were analyzed for levels of autophagy marker LC3-II by western blot and for the percentage of annexin V-positive apoptotic cells by flow cytometry. The same techniques were used to assess autophagy and apoptosis after in vitro treatment with TNFα and etanercept in both PBMCs and fibroblast-like synoviocytes (FLS) from patients with RA.

Results

PBMCs from patients with RA responsive to treatment showed a significant reduction in LC3-II levels, associated with an increased apoptotic activation after 4 months of therapy with anti-TNF drugs. Additionally, the expression of LC3-II correlated with DAS28. TNFα was able to induce autophagy in a dose-dependent manner after 24 h of culture in RA PBMCs and FLS. Moreover, etanercept caused a significant reduction of autophagy and of levels of citrullinated proteins.

Conclusions

Our results show how the crosstalk between autophagy and apoptosis can sustain the survival of immune cells, thus influencing RA progression. This suggests that inhibition of autophagy represents a possible therapeutic target in RA.

Electronic supplementary material

The online version of this article (10.1186/s13075-019-1818-x) contains supplementary material, which is available to authorized users.