THU0363 EFFECTS OF NINTEDANIB IN PATIENTS WITH SYSTEMIC SCLEROSIS-ASSOCIATED ILD (SSC-ILD) AND NORMAL VERSUS ELEVATED C-REACTIVE PROTEIN (CRP) AT BASELINE: ANALYSES FROM THE SENSCIS TRIAL

Background:

In the SENSCIS trial in patients with SSc-ILD, nintedanib reduced the rate of decline in forced vital capacity (FVC) over 52 weeks. Elevated CRP is a marker of an inflammatory phenotype and has been associated with a greater rate of decline in FVC and higher mortality in patients with SSc.

Objectives:

To assess the effects of nintedanib in subgroups by CRP at baseline in the SENSCIS trial.

Methods:

Patients with SSc-ILD with onset of first non-Raynaud symptom <7 years and ≥10% fibrosis of the lungs on HRCT were randomised to receive nintedanib or placebo. We analysed the rate of decline in FVC (mL/year) over 52 weeks, the proportion of patients with an absolute increase in FVC ≥3% predicted (proposed as the minimal clinically important difference for improvement in FVC in patients with SSc-ILD), and absolute change from baseline in mRSS at week 52 in subgroups with normal vs elevated high-sensitivity CRP (≤4.99 vs >4.99 mg/L) at baseline.

Results:

Of patients with available data, 78/270 (28.9%) and 74/261 (28.4%) in the nintedanib and placebo groups, respectively, had CRP >4.99 mg/L at baseline. Compared with patients with lower CRP, those with CRP >4.99 mg/L included a similar proportion of patients who were ATA-positive (61.8% vs 60.2%, respectively), a greater proportion with diffuse cutaneous SSc (63.2% vs 49.3%) and had a higher mean mRSS (13.7 vs 10.2) and lower mean FVC % predicted (68.6% vs 73.9%). The adjusted annual rate of decline in FVC in the placebo group was numerically greater in patients with CRP >4.99 than ≤4.99 mg/L at baseline (-106.6 [SE 27.6] vs -83.0 [17.1] mL/year). The effect of nintedanib vs placebo on reducing the rate of decline in FVC was numerically more pronounced in patients with CRP >4.99 than ≤4.99 mg/L at baseline but the treatment-by-time-by-subgroup interaction p-value did not indicate heterogeneity in the effect of nintedanib between subgroups (p=0.70) (Figure). In the nintedanib and placebo groups, respectively, the proportions of patients with an absolute increase in FVC ≥3% predicted at week 52 were 20.4% and 15.0% in those with CRP ≤4.99 mg/L and 24.4% and 14.9% in those with CRP >4.99 mg/L at baseline (treatment-by-subgroup interaction p=0.59); adjusted mean changes in mRSS at week 52 were -2.2 (SE 0.3) and -2.1 (0.3) in those with CRP ≤4.99 mg/L (difference -0.1 [95% CI -1.0, 0.8]) and -2.3 (0.5) and -1.0 (0.5) in those with CRP >4.99 mg/L at baseline (difference -1.2 [-2.7, 0.2]; treatment-by-visit-by-subgroup interaction p=0.20).

Conclusion:

In the SENSCIS trial, the rate of decline in FVC over 52 weeks in the placebo group was numerically greater in patients with elevated CRP at baseline. Nintedanib reduced the rate of decline in FVC both in patients with normal and elevated CRP at baseline, with a numerically greater effect in patients with elevated CRP.

Disclosure of Interests:

Gabriela Riemekasten Consultant of: Cell Trend GmbH, Janssen, Actelion, Boehringer Ingelheim, Speakers bureau: Actelion, Novartis, Janssen, Roche, GlaxoSmithKline, Boehringer Ingelheim, Pfizer, Patricia Carreira Grant/research support from: Actelion, Roche, MSD, Consultant of: GlaxoSmithKline, VivaCell Biotechnology, Emerald Health Pharmaceuticals, Boehringer Ingelheim, Roche, Speakers bureau: Actelion, GlaxoSmithKline, Roche, Lesley Ann Saketkoo Grant/research support from: Corbus Pharmaceuticals, United Therapeutics, Consultant of: Boehringer Ingelheim, Eicos Sciences, Speakers bureau: Boehringer Ingelheim, Martin Aringer Consultant of: Boehringer Ingelheim, Roche, Speakers bureau: Boehringer Ingelheim, Roche, Lorinda Chung Grant/research support from: United Therapeutics, Boehringer Ingelheim, Consultant of: Bristol-Myers Squibb, Boehringer Ingelheim, Mitsubishi Tanabe, Eicos Sciences, Janet Pope Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly & Company, Merck, Roche, Seattle Genetics, UCB, Consultant of: AbbVie, Actelion, Amgen, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Eicos Sciences, Eli Lilly & Company, Emerald, Gilead Sciences, Inc., Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Speakers bureau: UCB, Corinna Miede Employee of: Employee of Boehringer Ingelheim, Susanne Stowasser Employee of: Employee of Boehringer Ingelheim, Martina Gahlemann Employee of: Employee of Boehringer Ingelheim, Margarida Alves Employee of: Employee of Boehringer Ingelheim, Dinesh Khanna Shareholder of: Eicos Sciences, Inc./Civi Biopharma, Inc., Grant/research support from: Dr Khanna was supported by NIH/NIAMS K24AR063120, Consultant of: Acceleron, Actelion, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Corbus Pharmaceuticals, Horizon Therapeutic, Galapagos, Roche/Genentech, GlaxoSmithKline, Mitsubishi Tanabe, Sanofi-Aventis/Genzyme, UCB

AB0584 DOES ANTI-ACID TREATMENT INFLUENCE DISEASE PROGRESSION IN SYSTEMIC SCLEROSIS INTERSTITIAL LUNG DISEASE (SSC-ILD)? DATA FROM THE GERMAN SSC-NETWORK

Background:

Gastroesophageal reflux (GER) is common in SSc and thus treatment with anti-acid therapy (AAT) is frequent. An association between GER and the development / progression of SSc-ILD has been hypothesized. However, outcomes of AAT on disease progression in SSc-ILD has only sparsely been studied.

Objectives:

Methods:

The German Network for Systemic Scleroderma (DNSS), which includes SSc pts. prospectively, was analyzed for SSc-ILD. Those without progression at ILD 1stdiagnosis were categorized in AAT vs. no-AAT users and disease outcome was assessed.

Results:

SSc-ILD was reported in 1165 (28.2%) out of 4131 pts. 712 of SSc-ILD pts had no disease progression at ILD 1stdiagnosis. 567 used AAT while 145 did not. Baseline characteristics were similar between groups with regards to age (mean 54.7 years), BMI, time since SSc diagnosis and immunosuppressant use. Significant differences in no-AAT vs. AAT were found for gender (male 18% vs. 25%, p=0.05), SSc subtype (p=0.002, diffuse more common in AAT), lung function (DLCO 66% vs. 58%, p=0.001; FVC 86% vs. 77%, p=0.001), mRSS (8 vs. 11.5, p<0.01), esophageal involvement (32% vs. 56%, p<0.01) and steroid use (30% vs. 43%, p=0.005). While mortality did not differ between groups (3.9%, p= 0.59), disease progression was more common in the AAT group than in no-AAT users (24.5% vs. 13%, p=0.03). Furthermore, there was a significant difference in decline of FVC≥10% with 30% in the AAT compared to 14% in no-AAT (p=0.018); a decline in DLCO≥15% was more common in the AAT group by trend (23% vs. 14%, p=0.087).

Conclusion:

While results may have partially been biased by differences in baseline characteristics, this current analysis disfavors the approach of AAT use for SSc-ILD.

Disclosure of Interests:

Michael Kreuter Grant/research support from: Roche, Boehringer, Consultant of: Roche, Boehringer, Speakers bureau: Boehringer, Roche, Francesco Bonella Grant/research support from: Boehringer, Consultant of: Boehringer, Roche, Bristol MS, Galapagos, Speakers bureau: Boehringer, Roche, Gabriela Riemekasten Consultant of: Cell Trend GmbH, Janssen, Actelion, Boehringer Ingelheim, Speakers bureau: Actelion, Novartis, Janssen, Roche, GlaxoSmithKline, Boehringer Ingelheim, Pfizer, Ulf Müller-Ladner Speakers bureau: Biogen, Jörg Henes Grant/research support from: Novartis, Roche-Chugai, Consultant of: Novartis, Roche, Celgene, Pfizer, Abbvie, Sanofi, Boehringer-Ingelheim,, Elise Siegert Grant/research support from: Actelion, Consultant of: AEC, Speakers bureau: NA, Claudia Guenther: None declared, Ina Koetter Grant/research support from: Novartis, Roche, Speakers bureau: Abbvie, Actelion, Celgene, MSD, UCB, Sanofi, Lilly, Pfizer, Novartis, Chugai, Roche, Boehringer, Norbert Blank Speakers bureau: Actelion, Roche, Boehringer, Pfizer, Chugai, Christiane Pfeiffer: None declared, Marc Schmalzing: None declared, Gabriele Zeidler: None declared, PETER KORSTEN Grant/research support from: Novartis, Juarms GmbH, Consultant of: Abbvie, Pfizer, Lilly, BMS, Speakers bureau: Abbvie, Pfizer, chugai, BMS, Lilly, Sanofi aventis, Laura Susok: None declared, Aaron Juche: None declared, Margitta Worm Consultant of: Mylan Gemany, Bencard Allergie, BBV Technologies S.A., Novartis, Biotest, Sanofi, Aimmune Therapies, Regeneron, Speakers bureau: ALK-Abello, Novartis, Sanofi, Biotest, Mylan, Actelion, HAL Allergie, Aimmune Bencard Allergie, Ilona Jandova: None declared, Jan Ehrchen: None declared, Cord Sunderkoetter: None declared, Gernot Keyszer: None declared, Andreas Ramming Grant/research support from: Pfizer, Novartis, Consultant of: Boehringer Ingelheim, Novartis, Gilead, Pfizer, Speakers bureau: Boehringer Ingelheim, Roche, Janssen, Tim Schmeiser Speakers bureau: Actelion, UCB, Pfizer, Alexander Kreuter Speakers bureau: Sanofi, Abbvie, Merck Sharp&Dohme, Boehringer, Kathrin Kuhr: None declared, Hanns-Martin Lorenz Grant/research support from: Consultancy and/or speaker fees and/or travel reimbursements: Abbvie, MSD, BMS, Pfizer, Celgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, Astra-Zeneca, Lilly. Scientific support and/or educational seminars and/or clinical studies: Abbvie, MSD, BMS, Pfizer, Celgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, Astra-Zeneca, Lilly, Baxter, SOBI, Biogen, Actelion, Bayer Vital, Shire, Octapharm, Sanofi, Hexal, Mundipharm, Thermo Fisher., Consultant of: see above, Pia Moinzadeh: None declared, Nicolas Hunzelmann Speakers bureau: Actelion, Boehringer

SAT0329 IS THE RATE OF LUNG FUNCTION DECLINE THE SAME IN PATIENTS WITH SYSTEMIC SCLEROSIS-ASSOCIATED ILD (SSC-ILD) WHO EXPERIENCE WEIGHT LOSS? DATA FROM THE SENSCIS TRIAL

Background:

In the SENSCIS trial, nintedanib reduced the progression of SSc-ILD vs placebo, as shown by a lower rate of decline in forced vital capacity (FVC). The adverse event (AE) profile of nintedanib was characterised mainly by gastrointestinal (GI) events, including weight loss.

Objectives:

Assess FVC decline and AEs in subgroups by weight loss ≤5% vs >5% over 52 weeks in the SENSCIS trial.

Methods:

Patients with SSc-ILD with first non-Raynaud symptom <7 years before screening and ≥10% fibrosis of the lungs on an HRCT scan were randomised to nintedanib or placebo. In a non-randomised comparison, we analysed the rate of decline in FVC (mL/year) and AEs over 52 weeks in subgroups by weight loss (≤5% vs >5%) over 52 weeks.

Results:

In the nintedanib (n=288) and placebo (n=288) groups, respectively, 112 (38.9%) and 43 (14.9%) patients had weight loss >5% over 52 weeks. At baseline, patients with weight loss >5% over 52 weeks had a higher mean age (57.0 vs 52.9 years), greater proportion of females (81.3% vs 72.9%), and similar mean BMI (26.5 vs 25.7 kg/m2, respectively) and FVC % predicted (71.0% vs 73.1%, respectively) vs patients with weight loss ≤5%. In the placebo group, the mean (SE) annual rate of decline in FVC was similar between patients who had weight loss ≤5% and >5% over 52 weeks (-92.7 [14.7] mL/year and -96.4 [34.9] mL/year, respectively). The estimated annual rate of decline in FVC was lower in patients treated with nintedanib than placebo, with between-group differences in patients who had weight loss ≤5% and >5% of 49.9 mL/year [95% CI 4.2, 95.6]) and 30.2 mL/year [95% CI -50.5, 110.9]), respectively, with no evidence of heterogeneity between subgroups by weight loss (p=0.68 for interaction). Standardised differences in baseline values of potential confounders were <0.2 (indicating negligible differences). The most frequent AEs in patients treated with nintedanib were diarrhoea (74.4% and 77.7% of patients with weight loss ≤5% and >5%, respectively), nausea (30.1% and 33.9%, respectively) and vomiting (19.3% and 33.3%, respectively). In the nintedanib and placebo groups, respectively, AEs leading to discontinuation of study drug occurred in 17.0% and 8.6% of patients with weight loss ≤5%, and 14.3% and 9.3% of patients with weight loss >5% over 52 weeks.

Conclusion:

In the SENSCIS trial in patients with SSc-ILD, a greater proportion of patients treated with nintedanib than placebo had weight loss >5% over 52 weeks. The rate of decline in FVC was numerically lower in the nintedanib group than in the placebo group both in patients with weight loss ≤5% and >5% over 52 weeks. AEs leading to discontinuation of nintedanib were not more frequent in patients with weight loss >5% vs ≤5%.

References:

Disclosure of Interests: :

Alain LESCOAT: None declared, Stéphane Jouneau Grant/research support from: AIRB, Boehringer Ingelheim, LVL Medical, Novartis, Roche, Bellorophon Therapeutics, Biogen, Fibrogen, Galecto Biotech, Gilead Sciences, Pharm-Olam, Pliant Therapeutics, Savara Pharmaceuticals/Serendex Pharmaceuticals, Consultant of: Actelion, AIRB, AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Chiesi, Genzyme, GlazoSmithKline, LVL Medical, Mundipharma, Novartis, Pfizer, Roche, Sanofi, Bruno Crestani Grant/research support from: AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Novartis, Roche, Sanofi, Consultant of: AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Roche, Sanofi, Speakers bureau: AstraZeneca, Boehringer Ingelheim, Roche, Sanofi, Gabriela Riemekasten Consultant of: Cell Trend GmbH, Janssen, Actelion, Boehringer Ingelheim, Speakers bureau: Actelion, Novartis, Janssen, Roche, GlaxoSmithKline, Boehringer Ingelheim, Pfizer, Yasuhiro Kondoh Consultant of: Boehringer Ingelheim, Asahi Kasei Pharma, Janssen, Shionogi, Speakers bureau: Boehringer Ingelheim, Asahi Kasei Pharma, Janssen, Eisai, KYORIN, Mitsubishi Tanabe Pharma, Novartis, Shionogi, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl, Nina Patel Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Speakers bureau: Genentech, John Huggins Consultant of: I was a site PI for the SENSCIS trial for Boehringer Ingelheim, Christian Stock Employee of: Employee of Boehringer Ingelheim, Martina Gahlemann Employee of: Employee of Boehringer Ingelheim, Margarida Alves Employee of: Employee of Boehringer Ingelheim, Christopher Denton Grant/research support from: GlaxoSmithKline, CSL Behring, and Inventiva, Consultant of: Medscape, Roche-Genentech, Actelion, GlaxoSmithKline, Sanofi Aventis, Inventiva, CSL Behring, Boehringer Ingelheim, Corbus Pharmaceuticals, Acceleron, Curzion and Bayer

FRI0001 NEUTROPHILS IN GRANULOMATOSIS WITH POLYANGIITIS DISPLAY FEATURES OF PYROPTOSIS

Background:

Granulomatosis with polyangiitis (GPA) is characterized by extravascular necrotizing granulomatous inflammation and systemic ANCA – associated (AAV) vasculitis with neutrophils as a key player in the pathogenesis (1). We and others have shown that neutrophil-related cell death mechanisms contribute to chronic inflammatory processes in AAV (2, 3). Recently, another form of inflammatory cell death primarily described in monocytes called pyroptosis was also discovered in neutrophils (4). A cardinal feature of pyroptosis is the activation of the NLRP3 inflammasome, a sensor of different pathogen- and damage-associated molecular patterns (PAMP, DAMP), following caspase-1-mediated processing and secretion of IL-1beta (5).

Objectives:

The aim of this study was to investigate, if neutrophils from GPA patients express pyroptosis-related components NLRP3, active caspase 1 and cleaved IL-1beta.

Methods:

Polymorphonuclear leukocytes (PMN) were isolated from peripheral blood of GPA patients and healthy controls (HC) (n = 10 each). Expression of NLRP3, inactive/active caspase 1 and active IL-1beta was determined by western blot. In addition, peripheral blood mononuclear cells (PBMC) were isolated from GPA and HC. mRNA expression ofnlrp3andil1bwas determined by qPCR. To exclude false-positive results by contamination with monocytes we performed flow cytometry analysis of whole blood samples with markers CD3, CD14, CD15, CD66b and NLRP3.

Results:

PMN from GPA patients showed markedly increased expression of NLRP3, active caspase 1 and active IL-1beta compared to HC. In contrast, there was no difference between GPA and HC on the mRNA level of neithernlrp3noril1bin PBMC. In addition, we confirmed by flow cytometry increased expression of NLRP3 in PMN from GPA, but not in monocytes.

Conclusion:

Here we provide evidence, that neutrophils from GPA undergo pyroptosis, demonstrated by increased NLRP3, active caspase 1 expression as well as IL-1beta processing. Neutrophils are present in high numbers at the site of granulomatous lesions of inflamed tissue in GPA and IL-1beta is increased in GPA sera (2). Therefore, neutrophils represent a potential source of IL-1beta in GPA. Given the fact that GPA-associated features such as massive release of necrosis-related DAMP or microbial agents such asStaphylococcus aureus(6) can activate the NLRP3-inflammasome, we identified here a potential relevant mechanism of neutrophils contributing to chronic inflammation of GPA.

References:

[1]Jennette, J.C., and Falk, R.J. (2014). Pathogenesis of antineutrophil cytoplasmic autoantibody-mediated disease. Nat. Rev. Rheumatol.10, 463–473.

[2]Millet, A., Martin, K.R., Bonnefoy, F., Saas, P., Mocek, J., Alkan, M., Terrier, B.,Kerstein,A., Tamassia, N., Satyanarayanan, S.K., et al. (2015). Proteinase 3 on apoptotic cells disrupts immune silencing in autoimmune vasculitis. J. Clin. Invest. 125, 4107–4121.

[3]Schreiber, A., Rousselle, A., Becker, J.U., von Mässenhausen, A., Linkermann, A., and Kettritz, R. (2017). Necroptosis controls NET generation and mediates complement activation, endothelial damage, and autoimmune vasculitis. Proc. Natl. Acad. Sci. 201708247.

[4]Tourneur, L., and Witko-Sarsat, V. (2019). Inflammasome activation: Neutrophils go their own way. J. Leukoc. Biol.105, 433–436.

[5]Bergsbaken, T., Fink, S.L., and Cookson, B.T. (2009). Pyroptosis: Host cell death and inflammation. Nat. Rev. Microbiol.7, 99–109.

[6]Lamprecht, P.,Kerstein, A., Klapa, S., Schinke, S., Karsten, C.M., Yu, X., Ehlers, M., Epplen, J.T., Holl-Ulrich, K., Wiech, T., et al. (2018). Pathogenetic and Clinical Aspects of Anti-Neutrophil Cytoplasmic Autoantibody-Associated Vasculitides. Front. Immunol.9, 1–10.

Disclosure of Interests:

Anja Kerstein-Staehle: None declared, Nadja Leinung: None declared, Jannik Meyer: None declared, Silke Pitann: None declared, Antje Müller: None declared, Gabriela Riemekasten Consultant of: Cell Trend GmbH, Janssen, Actelion, Boehringer Ingelheim, Speakers bureau: Actelion, Novartis, Janssen, Roche, GlaxoSmithKline, Boehringer Ingelheim, Pfizer, Peter Lamprecht: None declared

AB0496 AUTOANTIBODIES TARGETING COMPLEMENT RECEPTORS 3A AND 5A1 ARE DECREASED IN ANCA-ASSOCIATED VASCULITIS AND CORRELATE WITH HIGHER RELAPSE RATE

Background:

Activation of the alternative and final common pathways have been shown in ANCA-associated vasculitis (AAV) (1). Circulating titers of C5a are elevated and correlate with disease activity in AAV. Binding to the corresponding G protein-coupled receptor (GPCR) C5aR1 enhances the influx of neutrophils, leading to ROS generation and severe necrotizing of vascular walls (2). Moreover, subsequent interaction of C5a with C5aR1 may represent a proinflammatory amplification loop (3). Blocking of the receptor is protective in a murine model in AAV (4). In humans, avacopan, a C5aR1-inhibitor showed promising results as glucocorticoid-sparing agent in two randomized phase II and one ongoing phase III clinicals trials in AAV (NCT02994927). Notably, disease-specific anti-GPCR autoantibody (aab) signatures have been found in different autoimmune diseases (5).

Objectives:

The aim of the present study was to examine whether (patho)physiological anti-C3aR and anti-C5aR1 aabs correlate with clinical findings in AAV, and whether this is linked to the clinical outcome.

Methods:

Sera and plasma of AAV patients [granulomatosis with polyangiitis (GPA), n=64; microscopic polyangiitis (MPA), n=26; eosinophilic granulomatosis with polyangiitis (EGPA), n=11] were measured by Elisa for circulating autoantibodies against complement receptors C3a (anti-C3aR aab) and C5a (anti-C5aR1 aab) and plasma levels of C3a and C5a. Expression of C3aR and C5aR1 on T-cells was determined using flow cytometry. Clinical data were assessed at the time of serum sampling and during follow-up for 48 months

Results:

GPA displayed low titers of anti-C3aR aab (GPA:5.33±2.54vs. HD:6.47±2.61, P=0.0031). Anti-C5aR1 aab were decreased in AAV, especially in GPA (GPA:1.02±1.07vs. HD:6.63±2.91, P=<0.0001). Plasma levels of C5a and anti-C5aR aab yielded an inverse correlation in AAV (r=-0.6813, P=0.0127). C5aR1 expression was increased on T-cells in GPA (CD4+C5aR1+T-cells: GPA:10.76±2.55%vs. HD:3.44±0.68%, P=0.0021; CD8+C5aR1+T-cells GPA:9.74±2.10%vs.HD:4.11±0.92%, P=0.0198). Reduced titers of anti-C5aR1 aab <0.45U/ml displayed an increased relapse risk for major organ involvement in GPA (HR 12.85, P=0.0014).

Conclusion:

As potential diagnostic marker, anti-C5aR1 aab titer may additionally be useful to monitor disease activity in AAV.

References:

[1]Chen M et al.Complement deposition in renal histopathology of patients with ANCA-associated pauci-immune glomerulonephritis.Nephrol Dial Transpl. 2009;24:1247-1252

[2]Schreiber A et al.C5a receptor mediates neutrophil activation an ANCA-induced glomerulonephritis.J Am Soc Nephrol. 2009; 20:289-298

[3]Lamprecht P et al.: Pathogenetic and clinical aspects of Anti-Neutrophil Cytoplasmic Autoantibody-associated vasculitides.Front Immunol.2018 Apr 9;9-680

[4]Xiao H et al.C5a receptor (CD88) blockade protects against MPO-ANCA GN.J Am Soc Nephrol. 2014;25(2):225-31

[5]Klapa S et al. Decreased endothelin receptor A autoantibody levels are associated with early ischaemic events in patients with giant-cell arteritis.Ann Rheum Dis2019 Oct;78(19):1443-1444

Disclosure of Interests:

Sebastian Klapa Grant/research support from: Actelion, Consultant of: Pfizer, Abbvie, Antje Müller: None declared, Andreas Koch: None declared, Anja Kerstein-Staehle: None declared, Wataru Kaehler: None declared, Harald Heidecke Shareholder of: Cell Trend GmbH, Employee of: Cell Trend GmbH, Speakers bureau: Cell Trend GmbH, Susanne Schinke Speakers bureau: Pfizer, Markus Huber-Lang: None declared, Martin Nitschke: None declared, Silke Pitann: None declared, Christian Karsten: None declared, Gabriela Riemekasten Consultant of: Cell Trend GmbH, Janssen, Actelion, Boehringer Ingelheim, Speakers bureau: Actelion, Novartis, Janssen, Roche, GlaxoSmithKline, Boehringer Ingelheim, Pfizer, Peter Lamprecht: None declared

AB0166 IMMUNOGLOBULIN G DERIVED FROM PATIENTS WITH SYSTEMIC SCLEROSIS IMPRINTS A PRO-INFLAMMATORY AND PRO-FIBROTIC PHENOTYPE IN MONOCYTE-LIKE THP-1 CELLS

Background:

Regulatory IgG autoantibodies directed against diverse G protein-coupled receptors (GPCR),i.e.antibodies with agonistic or antagonistic activity are abundant in human serum. The serum titers of autoantibodies targeting angiotensin II receptor 1 (AT1) and endothelin receptor A (ETA) are specifically altered in autoimmune diseases such as systemic sclerosis (SSc). Disease-promoting mechanisms regulated by anti-AT1and anti-ETAIgG are still elusive, but induction of pro-inflammatory and pro-fibrotic chemokines (CXCL8, CCL18) has been suggested to be one of them.

Objectives:

To determine the cytokine and phospho-kinase profiles induced in monocyte-like cells by IgG derived from SSc patients (SSc-IgG) enriched with anti-AT1and anti-ETAantibodies in comparison to IgG derived from healthy donors (IgG-HD).

Methods:

A monocyte-like cell line (THP-1) was culturedin vitroand stimulated with IgG (1 mg/ml) derived from SSc patients or HD in the presence of various inhibitors/blockers for 24h. Then, supernatants were analyzed by a human cytokine/chemokine array. Data were analyzed using bio-mathematical tools such as generalized t-test including the robust regression method from R/Bioconductor package LIMMA. In addition, THP-1 cells were culturedin vitroand stimulated with IgG (1 mg/ml) derived from SSc patients or HD for up to 30 minutes. Thereafter, cell lysates were assayed for the kinome employing a human phospho-kinase array. To validate potential effects of transcription factor inhibition, release of CXCL8 and CCL18 into the supernatant was measured by Elisa.

Results:

In general, SSc-IgG induced the release of most cytokines by THP-1 cells more pronouncedly than HD-IgG. The bio-mathematical analysis suggested that stimuli, responsible for the shift of the THP-1 cell cytokine profile, are more abundant in SSc-IgG than in HD-IgG. Based upon these findings a gene set enrichment analysis for transcription factors yielded the transcription factors NF-κB, AP-1, and PRDM1 (Blimp-1) as putative major regulatory hubs for the response of THP-1 cells to SSc-IgG. Further, SSc-IgG altered the phosphorylation status of several proteins, indicative of an involvement of MAPK and/or JAK/STAT pathways. Interestingly, a role for AP-1 was also proposed by the inhibition of CXCL8 and CCL18 release following pretreatment of THP-1 cells with an AP-1 blocker.

Conclusion:

Herein, we demonstrate that IgG of SSc patients, enriched with anti-AT1and anti-ETAautoantibodies drives THP-1 cells towards a general pro-inflammatory and pro-fibrotic phenotype, which is reflected by broad changes in the secretome and kinome of these cells. Furthermore, our results highlight AP-1 as critical regulator of gene transcription of CXCL8 and CCL18 in a monocyte-like cell line.

References:

[1]Cabral-Marques O, Marques A, Giil LM, De Vito R, Rademacher J, Günther J, Lange T, Humrich JY, Klapa S, Schinke S, et al. GPCR-specific autoantibody signatures are associated with physiological and pathological immune homeostasis.Nat Commun(2018)9:5224. doi:10.1038/s41467-018-07598-9

[2]Günther J, Kill A, Becker MO, Heidecke H, Rademacher J, Siegert E, Radi M, Burmester G-R, Dragun D, Riemekasten G. Angiotensin receptor type 1 and endothelin receptor type A on immune cells mediate migration and the expression of IL-8 and CCL18 when stimulated by autoantibodies from systemic sclerosis patients.Arthritis Res Ther(2014)16:R65. doi:10.1186/ar4503

Disclosure of Interests:

Anja Dalmann: None declared, Sripriya Murthy: None declared, Melanie Wannick: None declared, Georgios Eleftheriadis: None declared, Antje Müller: None declared, Detlef Zillikens: None declared, Hauke Busch: None declared, Christian Sadik: None declared, Gabriela Riemekasten Consultant of: Cell Trend GmbH, Janssen, Actelion, Boehringer Ingelheim, Speakers bureau: Actelion, Novartis, Janssen, Roche, GlaxoSmithKline, Boehringer Ingelheim, Pfizer

THU0025 MICRO-RNA DIFFERENTIALLY REGULATE THE ALTERNATIVE PRTN3-MRNA IN GRANULOMATOSIS WITH POLYANGIITIS

Background:

Micro-RNAs (miRNA) are short non-coding RNAs that regulate inflammation mostly by translational repression. Previously, we screened 847 miRNAs in nasal tissue from GPA patients and found a disease associated alteration of miRNA expression compared to healthy controls and chronic rhinosinusitis. MiR-184 was most over expressed in nasal tissue from GPA (13.4x). The dual-luciferase reporter assay confirmed a significant reduction of Proteinase-3 (PRTN3) expression by miR-184 (1).

PRTN3 transcripts with an alternative 3’ untranslated region (UTR) have been described in GPA (2). The pathophysiological relevance of this alternative transcript remains unclarified.

Objectives:

To identify new miRNA targets of potential pathophysiological relevance in GPA, we validated the effect of the 21 most dysregulated miRNAs on the mRNA of PRTN3. Further, we included the alternative PRTN3 mRNA in our screen to look for new regulatory differences.

Methods:

The inhibitory capacity of miRNAs on Proteinase-3 mRNA was estimated by a dual-luciferase reporter system. The sequences of the alternative (132bp longer) and the regular 3’UTR-PRTN3 were cloned and inserted into the pmirGLO vector and co-transfected with 21 miRNA mimics into HeLa cells. Co-transfection withCaenorhabditis elegansmiRNA 67 mimic (cel-miR-67) was used as negative control. Statistical significance was evaluated by students t-test adjusted for multiple comparisons (Holm-Sidak).

Results:

For 18 of 21 investigated miRNAs no effects could be observed on the alternative and the regular 3’UTR-PRTN3. But there were remarkable differential effects of let-7f, miR-184 and miR-708. Let-7f (-29,2%) and miR-708 (-23,6%) both showed a suppression of the alternative 3’UTR-PRTN3 but no effect on the regular 3’UTR-PRTN3 while miR-184 only suppressed the regular 3’UTR (-17,5 %) and not the alternative variant (fig. 1-2).

Fig. 1.

Dual-luciferase reporter assay with the regular 3’UTR of PRTN3 cloned into the pmirGLO vector compared to empty vector (NTC). Significant effect for miR-184 (17,5 %), miR-708 no effect and let-7f small but not significant reduction in luciferase activity (12,3 %). Data represent 3 independent experiments with triplicate measurements. miR-184 was tested 6 times. *P<0.05; ns = not significant; error bars display standard deviation.

Fig. 2.

Dual-luciferase reporter assay with the alternative 3’UTR of PRTN3. Significant effects of let-7f (29,2 %) and miR-708 mimic (23,6 %) but no significant effects of miR-184 of luciferase activity. 3 independent experiments with triplicate measurements. *P<0.05

Conclusion:

Disease specific miRNA signatures together with an increased PRTN3 level and in alternative PRTN3 mRNA in GPA suggest a dysregulation of PRTN3 expression in GPA. To our knowledge this is the first analysis in GPA showing that miRNAs can differentially regulate the expected and the alternative 3’UTR variants of PRTN3-mRNA. As miR-184 is markedly upregulated in GPA, a repression of PRTN3 is to be anticipated, possibly as a reaction to previous neutrophil activation with PRTN3 overexpression. Our findings also strengthen the potential pathophysiological role of the alternative PRTN3 mRNA.

References:

[1]Schinke S et alPROTEINASE-3 REGULATING MICRO-RNA IN GRANULOMATOSIS WITH POLYANGIITIS. Ann Rheum Dis 2019 (78 Suppl 2):437

[2]McInnes E et alDysregulation of Autoantigen Genes in ANCA-Associated Vasculitis Involves Alternative Transcripts and New Protein Synthesis J Am Soc Nephrol. 2015 26(2): 390–399

Acknowledgments:

Vasculitis foundation for funding

Disclosure of Interests:

Nick Reichard: None declared, Anja Kerstein-Staehle: None declared, Antje Müller: None declared, Gabriela Riemekasten Consultant of: Cell Trend GmbH, Janssen, Actelion, Boehringer Ingelheim, Speakers bureau: Actelion, Novartis, Janssen, Roche, GlaxoSmithKline, Boehringer Ingelheim, Pfizer, Peter Lamprecht: None declared, Susanne Schinke Speakers bureau: Pfizer

AB0159 INTERLEUKIN-16 PLAYS A ROLE IN THE PATHOGENESIS OF SYSTEMIC SCLEROSIS

Background:

Systemic sclerosis (SSc) is an autoimmune disorder with chronic and persistent inflammation. Interleukin-16 was originally described as a factor that could attract activated T cells in humans [1]. Elevated amounts of IL-16 have been demonstrated in SSc [2].

Objectives:

This study was undertaken to find out if IL-16 is associated with clinical characteristics of SSc.

Methods:

IL-16 was measured by Elisa in serum of patients with SSc (n=119) and healthy controls (n=50). Further, the presence of active IL-16 in mononuclear cells from peripheral blood of SSc patients (n=10) was examined by Western blot. Statistical analyses were done employing Graph Pad prism software (v 8). Patients with SSc were characterized based upon epidemiological and clinical parameters.

Results:

The serum concentration of IL-16 was higher in patients with SSc than in healthy controls (272.7±165.4 vs 172.8±64.84 pg/ml, p<0.0001). Further, the difference in the IL-16 serum concentration was more prominent in females (265.6±174.2 vs 160.1±53.37 pg/ml, p=0.0002) than in males (287.1±144.1 vs 187.6±74.64 pg/ml, p=0.0034). In addition, the concentration of IL-16 was elevated in patients with diffuse SSc compared to limited SSc (p=0.0206). The concentration of IL-16 in serum of SSc patients positively correlated with CRP (n=115, r=0.49, p<0.0001). There was a weak positive correlation between IL-16 in serum of SSc patients and the mRSS (n=112, r=0.22, p=0.0175). Noteworthy, the concentration of IL-16 was heightened in SSc patients with lung fibrosis compared to SSc patients without lung fibrosis (p=0.009). The ROC value of SSc patients with lung fibrosis was 0.64 (95%CI: 0.58-0.83). Moreover, active IL-16 derived from peripheral blood mononuclear cells (PBMC) of SSc patients with lung fibrosis was present in higher amounts compared to PBMC of SSc patients without lung fibrosis (5 vs 5, p=0.0557).

Conclusion:

Our results confirm and extend previous data by showing not only an increased concentration of IL-16 in the circulation of SSc patients, but new findings pointing towards a role of IL-16 for contributing to lung fibrosis in SSc.

References:

[1]Cruikshank, W. and D.M. Center, Modulation of lymphocyte migration by human lymphokines. II. Purification of a lymphotactic factor (LCF). J Immunol, 1982. 128(6): p. 2569-74.

[2]Kawabata, K., et al., IL-16 expression is increased in the skin and sera of patients with systemic sclerosis. Rheumatology (Oxford), 2019.

Disclosure of Interests:

Jiao Luo: None declared, Anja Kerstein-Staehle: None declared, Sara Comduehr: None declared, TatjanaKathleen Dreyer: None declared, Antje Müller: None declared, Susanne Schinke Speakers bureau: Pfizer, Gabriela Riemekasten Consultant of: Cell Trend GmbH, Janssen, Actelion, Boehringer Ingelheim, Speakers bureau: Actelion, Novartis, Janssen, Roche, GlaxoSmithKline, Boehringer Ingelheim, Pfizer

ACE inhibitors in SSc patients display a risk factor for scleroderma renal crisis-a EUSTAR analysis

Objectives

To investigate the effect of ACE inhibitors (ACEi) on the incidence of scleroderma renal crisis (SRC) when given prior to SRC in the prospectively collected cohort from the European Scleroderma Trial and Research Group (EUSTAR).

Methods

SSc patients without prior SRC and at least one follow-up visit were included and analyzed regarding SRC, arterial hypertension, and medication focusing on antihypertensive medication and glucocorticoids (GC).

Results

Out of 14,524 patients in the database, we identified 7648 patients with at least one follow-up. In 27,450 person-years (py), 102 patients developed SRC representing an incidence of 3.72 (3.06–4.51) per 1000 py. In a multivariable time-to-event analysis adjusted for age, sex, disease severity, and onset, 88 of 6521 patients developed SRC. The use of ACEi displayed an increased risk for the development of SRC with a hazard ratio (HR) of 2.55 (95% confidence interval (CI) 1.65–3.95). Adjusting for arterial hypertension resulted in a HR of 2.04 (95%CI 1.29–3.24). There was no evidence for an interaction of ACEi and arterial hypertension (HR 0.83, 95%CI 0.32–2.13, p = 0.69). Calcium channel blockers (CCB), angiotensin receptor blockers (ARB), endothelin receptor antagonists, and GC—mostly in daily dosages below 15 mg of prednisolone—did not influence the hazard for SRC.

Conclusions

ACEi in SSc patients with concomitant arterial hypertension display an independent risk factor for the development of SRC but are still first choice in SRC treatment. ARBs might be a safe alternative, yet the overall safety of alternative antihypertensive drugs in SSc patients needs to be further studied.

Evaluation of choroidal substructure perfusion in patients affected by systemic sclerosis: an optical coherence tomography angiography study

Objective: Vasculopathy in systemic sclerosis (SSc) is characterized by the obliteration of arterioles and a reduced capillary density in various tissues. In SSc, atrophic alterations of the choroid have been suggested based on morphological data acquired by optical coherence tomography (OCT). In this study, we aimed to assess the choroid in eyes of patients with SSc from a microcirculatory, dynamic point of view by adding optical coherence tomography angiography (OCTA) to the diagnostic spectrum.Method: SSc patients were enrolled, and age- and gender-matched healthy subjects were used as controls. In addition to basic ophthalmological and rheumatological examinations, individuals underwent enhanced-depth imaging OCT and OCTA. Subfoveal thicknesses of the choroid as well as all three choroidal vascular sublayers were measured and submacular perfusion values were evaluated.Results: In total, 12 patients with SSc and 12 matched controls were included. The median age of participants was 64 years. Submacular perfusion was significantly lower in the choriocapillaris (Δ = 0.72%; p = 0.045), Sattler's layer (Δ = 2.87%; p = 0.001), and Haller's layer (Δ = 2.69%; p = 0.018) of SSc patients compared to controls. Subfoveal thicknesses of Sattler's layer (Δ = 15 µm; p = 0.026) and Haller's layer (Δ = 41 µm; p = 0.045) were also significantly smaller in the SSc group.Conclusion: Choroidal microcirculation is impaired in SSc, even in patients without ophthalmological symptoms. Choroidal OCT and OCTA may offer additional biomarkers for SSc activity.

Association between baseline clinical and imaging findings and the development of digital ulcers in patients with systemic sclerosis

Objective

Systemic sclerosis (SSc) can lead to ischemic complications such as digital ulcers (DUs). The aim of the study was to find predictors of DUs by clinical and new imaging methods.

Patients and methods

All 79 SSc patients included in the study received a clinical, colour Doppler ultrasound (CDUS), fluorescence optical imaging (FOI) and capillaroscopy examination at baseline, and their capacity to predict new DU development was analysed in 76 patients at 12 months follow-up.

Results

Twenty-two of 76 patients (28.9%) developed new ulcers during follow-up (diffuse SSc 48.1%; limited SSc 18.4%). Receiver operating characteristic (ROC) curve analysis revealed an area under the curve of 0.7576 for DU development, with a specificity of 87% and a sensitivity of 54.6% (p = 0.0003, OR = 8.1 [95%CI 2.5–25.6]) at a cut-off of ≥ 21 points (ACR/EULAR classification criteria for SSc). Capillaroscopy and CDUS had high sensitivity (100% and 95.5%) but low specificity (28.9% and 22.2%) for ulcer occurrence when used alone, but better specificity (46.3%) when combined (OR = 18.1 [95%CI 2.3–144.4]; p = 0.0004). Using FOI, fingers with pathologic staining had a higher risk for new ulcer development in the same finger (p = 0.0153). General future DU (i.e. DU also in other fingers) was associated with a missing FOI signal in the right digit III at baseline (p = 0.048).

Conclusion

New imaging modalities can predict digital ulcer development in SSc patients with high sensitivity for capillaroscopy and CDUS and enhanced specificity when combined. A missing signal of FOI in the right digit III at baseline was associated with general future DU.

Classification, categorization and essential items for digital ulcer evaluation in systemic sclerosis: a DeSScipher/European Scleroderma Trials and Research group (EUSTAR) survey

BACKGROUND

A consensus on digital ulcer (DU) definition in systemic sclerosis (SSc) has been recently reached (Suliman et al., J Scleroderma Relat Disord 2:115-20, 2017), while for their evaluation, classification and categorisation, it is still missing. The aims of this study were to identify a set of essential items for digital ulcer (DU) evaluation, to assess if the existing DU classification was useful and feasible in clinical practice and to investigate if the new categorisation was preferred to the simple distinction of DU in recurrent and not recurrent, in patients with systemic sclerosis (SSc).

METHODS

DeSScipher is the largest European multicentre study on SSc. It consists of five observational trials (OTs), and one of them, OT1, is focused on DU management. The DeSScipher OT1 items on DU that reached ≥ 60% of completion rate were administered to EUSTAR (European Scleroderma Trials and Research group) centres via online survey. Questions about feasibility and usefulness of the existing DU classification (DU due to digital pitting scars, to loss of tissue, derived from calcinosis and gangrene) and newly proposed categorisation (episodic, recurrent and chronic) were also asked.

RESULTS

A total of 84/148 (56.8%) EUSTAR centres completed the questionnaire. DeSScipher items scored by ≥ 70% of the participants as essential and feasible for DU evaluation were the number of DU defined as a loss of tissue (level of agreement 92%), recurrent DU (84%) and number of new DU (74%). For 65% of the centres, the proposed classification of DU was considered useful and feasible in clinical practice. Moreover, 80% of the centres preferred the categorisation of DU in episodic, recurrent and chronic to simple distinction in recurrent/not recurrent DU.

CONCLUSIONS

For clinical practice, EUSTAR centres identified only three essential items for DU evaluation and considered the proposed classification and categorisation as useful and feasible. The set of items needs to be validated while further implementation of DU classification and categorisation is warranted.

TRIAL REGISTRATION

Observational trial on DU (OT1) is one of the five trials of the DeSScipher project (ClinicalTrials.gov; OT1 Identifier: NCT01836263 , posted on April 19, 2013).

[De-escalation of therapy in ANCA-associated vasculitides]

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) require a differentiated therapeutic approach depending on the degree of organ dysfunction and disease activity. In organ dysfunction and life-threatening AAV cyclophosphamide and rituximab are recommended for the induction of remission. For remission induction with a lack of organ dysfunction and non-life-threatening AAV, methotrexate or mycophenolate mofetil are recommended. For remission maintenance therapy azathioprine or methotrexate are used. In the case of contraindications, intolerance or previous failure of azathioprine and methotrexate treatment, rituximab, leflunomide or mycophenolate mofetil may be used as alternatives. Maintenance therapy is usually continued for at least 2 years. De-escalation of therapy requires continuous clinical monitoring while the glucocorticoid medication and immunosuppressive therapy is tapered; however, every de-escalation of therapy carries a risk of relapse.

Systemische Sklerose

Die systemische Sklerose gehört zu den rheumatischen Erkrankungen mit dem höchsten Einfluss auf die Prognose und Lebensqualität. Organmanifestationen wie die interstitielle Lungenfibrose, die pulmonale arterielle Hypertonie (PAH) und die Herzbeteiligung bestimmen die Mortalität, während Schmerzen, Bewegungseinschränkungen und digitale Ulzerationen häufig die Lebensqualität beeinflussen. Mangelernährung, Sarkopenie, Depression, Osteoporose, kardiovaskuläre Erkrankungen und Tumorerkrankungen treten möglicherweise bedingt durch die chronische Aktivierung des Immunsystems gehäuft auf. Es gibt derzeit erste Ansätze, Krankheitsmechanismen und die Beziehung zwischen der obliterativen Vaskulopathie und der variabel vorhandenen Fibrose zu verstehen. Die Therapie sollte frühzeitig beginnen. Eine Reihe von Substanzen beeinflusst die Raynaud-Symptomatik und die obliterative Gefäßerkrankung. Leider werden diese Therapien oftmals nicht ausreichend genutzt. Immunsuppressiva wie Cyclophosphamid, MMF oder eine autologe Stammzelltransplantation haben zu einer deutlichen Verbesserung der inflammatorischen Fibrose in klinischen Studien geführt. Neue Therapieansätze, die Krankheitsmechanismen beeinflussen und nebenwirkungsärmer sind, erscheinen erfolgversprechend und könnten künftig zu einer Zulassung führen. Derzeit wird eine Vielzahl von Studien durchgeführt. Die konsequente zielorientierte und individuelle Therapie stellt einen wichtigen Schlüssel zum Therapieerfolg dar.

Interstitial lung disease increases mortality in systemic sclerosis patients with pulmonary arterial hypertension without affecting hemodynamics and exercise capacity

Published data suggest that coexisting interstitial lung disease (ILD) has an impact on mortality in patients with systemic sclerosis (SSc) and pulmonary arterial hypertension (PAH), but there is scarce knowledge if this is reflected by hemodynamics, exercise capacity, autoantibody profile, or pulmonary function. In this partially retrospective study, 27 SSc-PAH patients were compared to 24 SSc-PAH patients with coexisting ILD respecting to survival, pulmonary function, hemodynamics, exercise capacity, and laboratory parameters. Survival was significantly worse in SSc-PAH-ILD patients than in SSc patients with isolated PAH (1, 5, and 10-year survival rates 86, 54, and 54% versus 96, 92, and 82%, p = 0.013). Compared to isolated SSc-PAH patients, patients with SSc-PAH-ILD revealed lower forced expiratory volume after 1 s (FEV1) values at the time of PAH diagnosis as well as 1 and 2 years later (p = 0.002) without significant decrease in the PAH course in both groups. At PAH diagnosis, diffusion capacity for carbon monoxide (DLCO) values were lower in the ILD-PAH group. Coexisting ILD was not associated with lower exercise capacity, different FEV1/forced vital capacity (FVC) ratio, higher WHO functional class, or reduced hemodynamics. Higher levels of antibodies against angiotensin and endothelin receptors predict mortality in all SSc-PAH patients but could not differentiate between PAH patients with and without ILD. Our study confirmed an impact of ILD on mortality in SSc-PAH patients. Pulmonary function parameters can be used to distinguish PAH from PAH-ILD. The higher mortality rate cannot be explained by differences in hemodynamics, exercise capacity, or autoantibody levels. Mechanisms of mortality remain to be studied.

[Risk stratification and follow-up assessment of patients with pulmonary arterial hypertension: Recommendations of the Cologne Consensus Conference 2016]

The 2015 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension are also valid for Germany. The guidelines contain detailed information about the diagnosis of pulmonary hypertension, and furthermore provide novel recommendations for risk stratification and follow-up assessments. However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to risk stratification and follow-up assessment of patients with PAH. This manuscript summarizes the results and recommendations of this working group.

[Digital ulcers in systemic sclerosis : A retrospective heath service study analysing treatment with bosentan and other vasoactive therapies]

BACKGROUND

Digital ulcers (DU) affect up to 60 % of patients with systemic sclerosis (SSc) and have a considerable impact on quality of life and morbidity. It is unclear to what extent authorised medicines are used, and if therapy guidelines are implemented in everyday practice.

METHOD

This retrospective health care study examined current standards of treatment for therapy and prevention of SSc-associated DU in an online survey with 83 physicians. Additionally, data from 161 case studies of SSc patients with DU were analysed, and the effect of DU treatment on the course of the disease determined.

RESULTS

For treatment and prevention of active DU, physicians predominantly indicated topical therapies, calcium channel blockers, iloprost and endothelin receptor antagonists. According to the case studies, 90 % of episodes with acute DU were treated with bosentan and iloprost in mono- or combination therapy. Preventive treatment was only administered during 50 % of episodes without DU, even after three or more phases with active DU. For the prevention of new DU, bosentan was used in mono- or combination therapy in 57 % of episodes without DU. Bosentan therapy during prevention shortened the following acute phase by 32 %. Additionally, continuous treatment with bosentan in acute and prevention phases reduced the duration of the following acute phase and increased the time to onset of new DU by 16 %. Moreover, bosentan stabilised the number of new DU.

CONCLUSION

In summary, these data confirm the efficacy of bosentan in preventing new DU when used in DU-free episodes and possibly also in phases of acute DU. Therapy recommendations for the treatment of DU are currently not fully implemented. In the future, even more attention should be paid to DU therapy.