SAT0501 EARLY START OF BIOLOGICAL TREATMENT IN JUVENILE IDIOPHATIC ARTHRITIS: DOES A THERAPEUTIC WINDOW EXIST IN REAL LIFE?

Background:

Biological therapy (BT) has changed the treatment and perspectives of JIA patients but little is known about when is the best moment to start BT and the impact of this prompt iniciation.

Objectives:

To analyze the response to BT of Juvenile Idiophatic Arthritis (JIA) patients according to the time when the BT was started.

Methods:

A retrospective, descriptive study was conducted on JIA patients followed up in a referal hospital that started BT up to 24 months after diagnosis from 2000 to 2018. Disease activity was measured, at 2 years after diagnosis, according to Wallace criteria for remission (absence of: active arthritis, active uveitis, fever, rash or any other manifestation attributable to JIA, normal CRP and ESR, PGA indicating no active disease) for at least 6 months.

Results:

55 JIA patients that started BT up to 24 months from diagnosis were analyzed. 69,1% were girls with a median age at diagnosis of 8 years old IQR(3-13), median age at the start of BT of 9 years old IQR(3-13). Regarding JIA categories: 25,5% were Oligoarticular Persistent (OligP), 18,2% Systemic JIA (sJIA), 16,4% Entesitis related Arthritis (ERA), 12,7% Psoriatic Arthritis (APso) and Polyarticular RF- (PolyRF-), 5,5% Oligoarticular Extended (OligE) and Polyarticular RF+ (PolyRF+), 3,6% Undifferentiated (Und). 20% of patients had uveitis during followup. Conventional DMARD (cDMARD) was indicated in 83,6% of patients (95,7% Methotrexate) at diagnosis [median 0 months IQR(0-2,3)]. At the end of followup (2 years) only 30,9% of patients continued with cDMARDs. The main causes of discontinuation were: adverse events (46,7%), remission (36,7%). TNF inhibitors were precribed in 81,8% of patients and 18,2% of patients recieved two BT during the first 2 years from diagnosis. 54,5% of BT were indicated during the first 6 months from diagnosis, 27,3% from 7 to 12 months, 12,7% from 13 to 18 months, 5,5% from 19 to 24 months.

After 2 years from diagnosis, 78,2% of patients were on remission and 21,8% active. Among patients with active disease: 75% had arthritis, 16,7% had uveitis and 8,3% had both. There were no differences regarding disease activity among patients with uveitis and neither taking cDMARDs. Regarding JIA categories: 66,7% of OligE, 57,1% of PolyRF- and 57,1% of APso patients were active at 2 years from diagnosis when compared to the other categories (p=0.004).

Patients on remission at 24 months from diagnosis started sooner the BT than active patients [CI 95% (0,46-8,29) p=0,029]. The time when the BT was started was correlated to the activity at 2 years (K= 0,294 p=0,029). When the BT was prescribed after 7,5months from diagnosis it was correlated, in a COR curve, with a higher probability of active disease at 2 years (S= 0,67 E= 0,63). There was a correlation, among patients on remission at 2 years, between prompt start of BT and less time to reach remission (K= -0,345 p=0,024). Patients with active disease at 2 years, regardless of moment of BT iniciation, required more BT during follow-up (p=0,002).

Conclusion:

Prompt iniciation of BT was correlated with a better outcome. JIA patients that started BT early after diagnosis had a higher probability of remission after 2 years. Starting BT after 7,5 months was correlated with a higher probability of active disease at 2 years. Active disease at 24 months was correlated with persistent active disease during follow-up.

Disclosure of Interests:

None declared

AB0653 SURVIVAL OF BIOLOGIC THERAPHY AS SECOND LINE IN PATIENTS WITH ANKYLOSING SPONDYLITIS. EXPERIENCE IN A TERTIARY CARE CENTRE

Background:

In ankylosing spondylitis (AS) patients with lack of response to a first line of biologic disease modifying antirheumatic drugs (bDMARD), switching to another bDMARD is recommended, aiming either to the same or different therapeutic target. In several previous studies a decrease in drug survival has been noted when tumor necrosis factor alfa inhibitors (TNFai) are used as second or third treatment line (1,2).

Objectives:

Primary endpoint: To evaluate survival of bDMARD as second line treatment in patients with AS non responding to TNFai either because of lack or loss of efficacy. Secondary: To evaluate the impact on drug survival of several variables such as sex, HLA, peripheral arthritis, radiologic sacroiliitis, CRP, BASFI, BASDAI or bDMARD class.

Methods:

Observational, longitudinal and retrospective observational study. We included 67 patients diagnosed with AS who received treatment on second line with bDMARD (TNFai or anti IL7) after discontinuation of TNFai as first line of treatment. We analyze patients older than 18 yo, with at least 3 months of continuous treatment before and after switch, seen in our Hospital from 2006 to 2019. Data were collected regarding to demographics, HLA B27 positivity and functionality and activity index, CRP and treatment with cDMARDs.

Results:

All 67 patients included were still on follow up after switching to second bDMARD. Median age was 37 yo, 56.7% were male and 31%, smokers. 35.8% patients had axial AS; 1.5% peripheral arthritis; 62.7%, mixed and 9%, dactilitis. 76.1% had radiographic sacroiliitis and 74.6%, HLA B 27+. As first bDMARD, the most common was Infliximab (IFX) (47.8%), followed by Adalimumab (ADA) (19.4%) and Etanercept (ETN 14.9%). Mean survival was 32.4 months (IFX, 37 months; ETN, 45; Golimumab, 32.3 and ADA, 24.1). The commonest cause of treatment suspension was loss of efficacy (LoE) (56.7%), followed by lack of efficacy (LaE) (17.6%) and adverse effects (AE) (16.4%).

As second bDMARD the most frequent was ADA (35.8%), followed by ETN (34.3%), Golimumab (9%), IFX (7.5%) and Secukinumab (6%) with a mean survival of 45 months (ETN 63.8, ADA 45.7, Golimumab 32). Treatment was discontinued in 47.8% of patients because of LoE (17.9%), LaE (17.9%) and EA (11.9%). A total of 16 AE were recorded, of which 6% were infections and 9%, allergic reactions. Regarding the analysis of the impact of other variables on drug survival, there was statistically significant differences on HLA B 27 carrier status (p=0.012), in which we observed an increase on survival when the patient is HLA B27 + and in whom BASDAI is higher before switching (p=0.02).

Conclusion:

In our study, we did not observe differences in survival of second line bDMARD in patients with AS regarding type of TNFai, case of discontinuation or type of radiographic involvement in the first line of treatment. Patients with HLA B27+ and high value of BASDAI at the beginning of second bDMARD showed an increased on drug survival. Contrary to literature, we did not see significant differences regarding CRP.

References:

[1]Glintborg B, Østergaard M, Krogh NS, Tarp U, Manilo N, Loft AGR, et al. Clinical response, drug survival and predictors thereof in 432 ankylosing spondylitis patients after switching tumour necrosis factor α inhibitor therapy: results from the Danish nationwide DANBIO registry. Ann Rheum Dis. 2013 Jul;72(7):1149–55.

[2]Deodhar A, Yu D. Switching tumor necrosis factor inhibitors in the treatment of axial spondyloarthritis. Semin Arthritis Rheum. 2017 Dec;47(3):343–50.

Disclosure of Interests:

None declared

AB1200 EARLY ARTHRITIS CLINICS IMPROVES THE EVOLUTION OF THE DISEASE AND DECREASES WORK ABSENTEEISM

Background:

Rheumatoid arthritis is the most common inflammatory arthritis, and a significant cause of morbidity and mortality. Several clinical studies have shown that treatment introduced at an early stage, referred to as a “window of opportunity”, is associated with long-term benefits in the form of long-term remission and even complete remission of the disease.

Objectives:

Assess the advantages of a Early Arthritis clinic (EAC) in the management of RA until remission is reached and its impact on work absenteeism.

Methods:

We included a cohort of patients with early RA (≤12 months symptoms) who fullfield the ACR 2010 criteria, in an early arthritis clinic (EAC) from a tertiary hospital, between 2016-2019, followed for at least 2 years. Demographic, clinical, analytical and radiographic variables were included, and the dates of the visits during the follow-up were noted. Work absenteeism days was recorded before and after the first visit. Estadistic description and regressión analysis was performed.

Results:

Eighty-four patients with early RA were included, with loss of follow-up of tweelve patients. Fifty-one (70,8%) were women with a mean age 50 years ±15,84. Fifty-one patients were FR positive (70,8%) and sixty-eigth were ACPA positive (94,4%). Nine subjects (13%) had erosions. Acute phase reactans elevation was observed in fifty-five patients (76,3%). Thirty-seven subjects (51,3%) were smokers. Mean swollen joint count was 4 ± 4,79 and mean DAS28 was 4.01 ± 1.28. Inflammatory arthralgia was reported since mean time 6.7 months before the first visit. Seventy patients (97%) were treated with methotrexate and forty-nine (70%) did not require other treatment during follow-up. Ten patients (14.3%) required DMARDb, and half received 2 or more drugs of this clase. The mean cumulative time of exposure to corticosteroids was 8.37 ±9,26 months. Mean time between the date of derivation to Rheumatologist and the first visit was 44 days. Forty-nine patients (81%) achieved remission during follow-up and mean time required for this goal was 299 days with a mean 4.7 visits. We found a significant correlation between the time to reach remission with DAS28, NAT and N° treatments prescribed (0.38, 0.39 and 0.70 respectively, p <0.05). Twenty work absenteeism periods (mean 40.55 days) were reported in fourteen patients before the first visit associated with activity of RA, and tweelve periods (mean 19,75 days) in ten patients after the first visit (p <0.05).

Conclusion:

In our EAC, patients with RA usually reach remission in less than a year, requiring approximately 4 visits to achieve this goal. A significant correlation was found between the time to reach remission, DAS28 and the number of treatments required. Most patients respond to Methotrexate and suspend corticosteroids in less than a year. We found a significant reduction of work absenteeism associated with RA activity, after the first visit during the follow-up.

References:

[1]Kolarz K. Early reumatoid arthritis. Wiad Lek. 2018;71(5):1061-1065.

[2]Nisar MK. Early arthritis clinic is effective for rheumatoid and psoriatic arthritides. Rheumatol Int. 2019 Apr;39(4):657-662.

Disclosure of Interests:

None declared

AB0280 SURVIVAL ANALYSIS ON SECOND BIOLOGIC THERAPY IN PATIENTS WITH RHEUMATOID ARTHRITIS OLDER THAN 65 YEARS

Background:

Patients with Rheumatoid Arthritis (RA) ≥65 years old constitute an important and not very well studied group. Even though the course of the disease may be similar to that of younger patients, treatment is usually less aggressive given the limited information on efficacy, especially of biological treatments, in this age group.

Objectives:

To describe the characteristics of patients with RA ≥65 years old who started a second biological agent. To compare the survival of this second-line treatment between patients ≥65 and <65 years old.

Methods:

Retrospective, observational and longitudinal study. Patients diagnosed of RA, who started a second biological agent between 2000 and 2019, who discontinued a first-line TNF inhibitor, were included. Demographic, clinical and analytical data were obtained. The sample was divided in 2 groups: <65 and ≥65 years old. Kaplan Meier and Log-rank survival analysis were performed, as well as Cox regression to identify related factors.

Results:

157 patients were identified, 42 (26.8%) were ≥65 years old. In this group, 73.8% were women, with a mean age at the beginning of second biological treatment of 71.43±4.76 years. Demographic and clinical data of ≥65 years old patients are shown in the table. The most frequent second biological agent was Rituximab (23.8%), followed by Adalimumab (21.4%) and Tocilizumab (19%). 76.2% of patients had a disease-modifying drug associated, being Methotrexate the most frequent (45.2%). Discontinuation of second biological agent occurred in 30 patients (71.42%) ≥65 years old, which is similar to the percentage found in patients <65 years old (66.96%; p=0.70). The main causes of withdrawal of second-line agent in patients ≥65 years were adverse effects (23.8%) and secondary failure (23.8%), whereas in <65 years were primary and secondary failure (18.3% in both). Infections were more frequent in patients ≥65 years (14.3%) in comparison with patients <65 years (6.1%). In the survival analysis of the second biological agent, patients ≥65 years presented a median survival of 45 months (IC-95%=14.10-75.90); while patients <65 years had a median survival of 47 months (IC-95%=29.55-64.46), without statistically significant differences (p=0.803) (See Figure). Among elderly patients no statistically significant differences were found after comparison of survival curves in the subgroups: 65-69, 70-74 and ≥75 years. Rituximab presented a higher survival rate in patients ≥65 years (84.3 months; p<0.001), followed by Abatacept (58.5 months). Smoking (HR=13.96; IC- 95%=2.12-91.93), erosions (HR=7.04; IC-95%=1.05-47.31) and diabetes mellitus (HR=13.37; IC-95%=1.25-143.46) were identified as risk factors for discontinuation of second biologic agent.

Conclusion:

The survival of second biological agent after the failure of a first TNF inhibitor in patients ≥65 years is similar to the survival in younger patients, although there was a higher percentage of adverse effects in the first group. Rituximab and Abatacept showed a higher survival in patients ≥65 years. Smoking, erosions and diabetes mellitus were associated with an increased risk for the withdrawal of the second-line biological therapy.

References:

[1]Richter M, Matteson E, DavisIII J, Achenbach S, Crowson C. Comparison of Biologic Discontinuation in Patients With Elderly-Onset Versus Younger-Onset Rheumatoid Arthritis. ACR Open Rheumatology. 2019; 1(10): 627–631.

Variablesn= 42 (mean ± SD or %)Age at diagnosis (years)56.48 ± 9.94Age at the beginning of the treatment (years)71.43 ± 4.76Women31 (73.8%)Smokers11 (26.2%)RF (+)35 (83.3%)ACPA (+)30 (71.4%)Erosions29 (69%)Arterial hypertension21 (50%)Diabetes mellitus4 (9.5%)Dyslipidemia11 (26.2%)Disease-modifying drugMethotrexate19 (45.2%)Leflunomide10 (23.8%)Sulfasalazine1 (2.4%)Hydroxychloroquine0 (0%)InfectionsRespiratory infection3 (7.1%)Skin/Soft tissues infections2 (4.8%)Herpes zoster1 (2.4%)

Disclosure of Interests:

None declared

FRI0467 DRUG SURVIVAL AND SAFETY OF BIOLOGICAL THERAPIES IN PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS

Background:

Biological treatment (BT) has changed perspectives of JIA patients. Increasing data from real life experience have been reported.

Objectives:

To compare drug survival, safety and efficacy of BT in patients with Juvenile Idiopathic Arthritis (JIA).

Methods:

A retrospective observational study was conducted on JIA patients followed in a referal hospital and who had received at least one BT between 1999 and 2019.

Results:

218 BT in 130 JIA patients were analyzed. 67.7% were women with a median age at diagnosis of 8 years old IQR (3-13) and a median age at the beginning of the BT of 15 years old IQR(7.8-21). 21.5% of the patients had uveitis during follow-up. BT were indicated due to: arthritis(73.9%), uveitis(10.1%), arthritis and uveitis(2.7%), systemic activity(8.3%) and macrophage activation syndrome (1,8%).There were 130 BT started in 1st line, 55 in 2nd line, 20 in 3rd line, 10 in 4th line and 3 in 5th line.

The 1st line BT most frequently indicated was Etarnecept(ETN) up to 40%, followed by 30% Adalimumab(ADA) and 16,2% Infliximab(INF). The median duration of the 1st line was 51 months IQR (14-109,3). However, 53.8% of the 1st line BT were swiched: 28.3% due to adverse events, 25.7% due to 1° failure and 25.7% due to 2° failure. The BT that were discontinued were: INF (76.2%) and Anakinra (ANAK) (75%) due to adverse events and ETN (59.6%) due to 1° and 2° failure. 55 patients started a 2nd BT: 43.6% received ADA and 20% Tocilizumab (TCZ) with a median duration of 43 months IQR (12-90). 22 of 55 BT required a change: 75% of ETN and 59% of INF prescribed in 2nd line were discotinued. The causes were: 40% 1° failure, 28% 2° failure and 12% remission. In 1st line 87,6% of patients received TNF inhibitors, 74% mantained the target in 2nd line. In 3rd line TCZ was the most frequent BT. 71.5% of patients continue on BT. BT was withdrawn in 20 of 130 patients due to remission (40%), adverse events (30%), and pregnancy (10%).

In the analysis by decades, 80 BT (36.7%) were started from 1999 to 2008 and 138 BT (63.3%) from 2009 to 2019. In the 1st decade ETN and INF were the most frequently prescribed and in the 2nd decade, ADA and TCZ (p <0.0001). The 1st BT in the 2nd decade were indicated sooner compared to the 1st decade (1st decade: mean 119.5months SD(109.2); 2nd decade: mean 53.9 months SD(99.7); p <0.0001). In 1st line BT, the BT prescribed in the 2nd decade had a shorter duration than those in the 1st decade (1st decade: mean 84.1 months SD(71.8); 2nd decade: mean 51.7 months SD(5); p <0.0001).

In the survival analysis, TCZ and ADA were the BT with the highest survival (p=0.001). Of the 31 patients that started TCZ, 61.3% continue on TCZ, with a median duration of 46 months IQR(25-99) and 36/68(52,9%) still on ADA with a median duration of 61,5 months IQR(30.5-98).

Conclusion:

42.3% of patients required more than one BT. Since the onset of the BT there has been a change in prescription, probably related to the emerge of new targets and the evidence provided by clinical trials and guidelines. TCZ and ADA were the BT with the highest survival rate. On the other hand, INF and ANAK were the ones with the lowest survival rate. The most common causes of BT change in 1st line were adverse events in relation to INF and ANAK. In 2nd line there was a high rate of change in those patients who maintained TNFi, related to 1° failure.

Disclosure of Interests:

None declared

FRI0250 “ARE MYOSITIS ANTIBODIES SPECIFIC FOR IDIOPATHIC INFLAMMATORY MYOPATHY DIAGNOSIS?” CLINICAL CORRELATION OF A COHORT OF PATIENTS POSITIVE FOR MYOSITIS ANTIBODIES

Background:

Idiopathic inflammatory myopathies (IIM) are a group of immune-mediated diseases characterized my muscle weakness, skin rash and systemic involvement. Myositis-specific antibodies (MSA) and myositis-associated antibodies (MAA) play a major role in IIM diagnosis, classification and prognosis. Nevertheless, MSA/MAA testing is not standardized and there very few studies addressing their relationship with other diseases.

Objectives:

To describe a cohort of patients tested positive for MSA/MAA, and to explore it´s relationship with IIM and other autoimmune diseases.

Methods:

We retrospectively review all the serum samples obtained from patients tested for MSA/MAA during 2019 in the Immunology department of Ramón y Cajal University Hospital (Madrid, Spain). These antibodies were tested by specific immunoblot (EUROLINE: Autoimmune Inflammatory Myopathies 16 Ag) with highly purified MSA/MAA. Positivity was stablished according to absorbance titer and adjusted by positive control of each test (arbitrary units, AU). Patients were diagnosed with IIM according to their clinician diagnosis. Diagnosis and classification were confirmed by an independent rheumatologist (JL) according to current understanding of IIM classification.

Results:

Three-hundred-seventy-five samples were tested for MSA during the study period. Two-hundred-seventy-nine were negative for all antibodies tested. Ninety-six samples were positive for one or more MSA/MAA, corresponding to 74 patients (11 patients had 2 different samples). Forty-nine (66.2%) of the patients who tested positive were female and 25 (33.8%) were male. Mean age was 58.65 years. Only 22 patients (29.7%) had a confirmed diagnosis of IIM, 24 (32.4%) had a diagnosis of other autoimmune disease, and 11 (14.9%) were diagnosed with interstitial lung disease (ILD) (Figure 1). Six ILD patients had anti-PM-Scl or anti-Ku antibodies, which are associated with scleroderma or overlap-CTD myositis, nevertheless, they remained classified as ILD as no other features were described in this group.

Seventeen patients were positive for more than 1 MAA or MSA, including 14 patients positive for anti Ro-52. Antibody titer was higher in the IIM group compared to non-myositis group (59.59 vs 44.16, p=0.015). Anti Mi-2 was positive in 4 ILD without any other myositis features, and high titer anti-SRP (n=4, mean 59.75 AU) was found in primary biliary cirrhosis (PBC) patients. Additionally, 5 patients positive for antiJo-1 using ELIA (Thermo Fisher) were diagnosed with antisynthetase syndrome. IIM diagnosis and its relationship with antibody titer is represented in table 1.

Table 1.

Autoantibody titer according to diagnosis.

Antibody (Number of patients)Number of samplesIIMIIM antibody titer (AU)Non-IIMNon-IIM antibody titer (AU)Other AI diseasesAnti Ro-52Anti Jo-1 (n=1)11 (100%)92.70-01 (100%)Anti PL-7 (n=8)113 (37.5%)29.595 (62.5%)25.595 (62.5%)2 (25%)Anti PL-12 (n=3)21 (33.3%)53.952 (66.6%)69.971 (33.3%)2 (50%)Anti EJ (n=1)11 (100%)99.460-01 (100%)Anti OJ (n=2)40-2 (100%)23.041 (50%)0Anti Ku (n=14)193 (21.4%)107.2511 (78.6%)31.855 (35.7%)0Anti Tif1gamma (n=5)63 (60%)40.122 (40%)23.841 (20%)0Anti NXP2 (n=2)30-2 (100%)13.991 (50%)1 (50%)Anti Mi2 (n=12)173 (25%)48.659 (75%)26.674 (33.3%)0Anti SAE (n=1)10-1 (100%)1800Anti MDA5 (n=2)32 (100%)30.5401 (50%)1 (50%)Anti SRP (n=9)124 (44.4%)42.695 (55.6%)68.165 (55.5%)2 (22.2%)Anti PM-Scl75 and PM-Scl100 (n=2)21 (50%)68.61 (50%)36.6700Anti PM-Scl75 (n=8)10016.268 (100%)22.723 (37.5%)1 (12.5%)Anti PM-Scl100 (n=4)50-4 (100%)23.622 (50%)0

Conclusion:

Only 28.7% of the patients that were MAA/MSA positive had a diagnosis of IIM. Other autoimmune diseases and ILD were commonly found in this group of MSA/MAA positive patients.

References:

[1]Damoiseaux J, Vulsteke JB, Tseng CW, Platteel ACM, Piette Y, Shovman O, et al. Autoantibodies in idiopathic inflammatory myopathies: Clinical associations and laboratory evaluation by mono- and multispecific immunoassays. Vol. 18, Autoimmunity Reviews. Elsevier B.V.; 2019. p. 293–305.

Disclosure of Interests:

None declared

AB0984 BIOLOGICAL THERAPIES IN JUVENILE IDIOPHATIC ARTHRITIS: ARE THERE ANY DIFFERENCES BETWEEN CATEGORIES?

Background:

Juvenile Idiopathic Arthritis (JIA) is a heterogeneous group of pediatric diseases. Different response to biological treatment (BT) has been reported according to disease subtype.

Objectives:

To analyze the prescription and withdrawal of BT in JIA patients with focus on JIA category.

Methods:

A retrospective observational study was conducted on JIA patients followed in a referal hospital and who had received at least one BT between 1999 and 2019.

Results:

130 JIA patients were analyzed: 29 (22,4%) were Oligoarticular Persistent (OligP), 22 (16,9%) Enthesitis related Arthritis (ERA), 20 (15,4%) Systemic (sJIA), 19 (14,6%) Polyarticular RF- (PolyRF-), 14 (10,8%) Polyarticular RF+(PolyRF+), 13 (10%) Oligoarticular-Extended (OligE), 11 (8,4%) Psoriatic Arthritis (APso) and 2 (1,5%) Undifferentiated (Und).

The main characteristics are summarized in table 1.

The first line BT most frequently indicated was Etanercept up to 40% in all the categories except for ERA, where the most frequent BT was Adalimumab and sJIA, where the most frequent BT was Anakinra. The time between diagnosis and start of BT was different among the categories (p=0,007). In the Und category, the time until BT was the shortest (median: 1 month), since both patients had coxitis, followed by APso [median: 9 months IQR(1-57)] and sJIA [median: 17,5 months IQR(0,3-146,8)].

The survival of the first BT was different among the categories (p=0,006): 94,7% of the ERA continue receiving the first BT, followed by 76,2% of OligP and 50% of PolyRF+ and APso. Only 42% of sJIA continue on the first BT prescribed [up to 53,3% were TNF inhibitors (TNFi)]. The categories with less retention of the first BT were: OligE (25%); PolyRF- (27,3%) and Und (0%). The most frequent cause of discontinuation, among these categories, was secondary failure.

In the survival analysis between categories, there were differences on OligP (p=0,004), OligE (p=0,042) and PolyRF- (p=0,017). Tocilizumab and Adalimumab were the BT with highest survival with regards to Infliximab, Etanercept, Rituximab (OligE, PolyRF-), Abatacept (OligE, PolyRF-) and Certolizumab (OligP). The survival rate of IL1 inhibitiors and IL6 inhibitiors was higher regarding to TNFi in sJIA patients (p=0,013).

Conclusion:

Taking into account JIA category is mandatory to choose BT and to understand the response and discontinuation of BT. OligE and PolyRF - showed a high rate of change of the first BT related to secondary failure of Etanercept and Infliximab when compared to Adalimumab and Tocilizumab, as described in the survival analysis. The category with the highest retention of the first BT was ERA. UND patients started sooner BT due to the presence of coxitis. In sJIA, IL1 inhibitors and IL6 inhibitors were superior to TNFi in the survival analysis, as reported in existing literature.

Table:

Disclosure of Interests:

None declared

FRI0582 GM-CSF PRODUCED BY CD4+ T CELLS AS A MARKER OF CLINICAL REMISSION IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH TNF INHIBITORS

Background:

According to the EULAR recommendations, the therapeutic target in patients with RA should be remission (REM). However, no more than 50% of the patients treated with TNF inhibitors (TNFi) attains this outcome. Previous investigations suggested the peripheral blood mononuclear cells (PBMC) as markers associated with the TNFi treatment success1,2. Granulocyte-monocyte colony-stimulating factor (GM-CSF) plays a relevant role in the pathogenesis of rheumatoid arthritis (RA) because it promotes the macrophage differentiation, survival and activation3.

Objectives:

To analyse the intracellular cytokine production by PBMC and its association with REM attainment after 6 months (m) of TNFi treatment in patients with RA.

Methods:

This was a prospective bi-center pilot study including 36 patients with RA. PBMC were isolated from patients at baseline and after 6m of treatment with TNFi and cryopreserved until studied. Intracellular cytokine production by PBMC was stimulated in the presence of 2µg/mL brefeldin as follow: monocytes were stimulated with 20ng/mL LPS during 4h; and simultaneously lymphocytes were stimulated with 50ng/mL phorbol 12-myristate 13-acetate (PMA) and 750ng/mL ionomycin during 4h at 37°C. To identify IL-10-producing B cells, PBMC were pre-incubated with 3µg/mL of CpG oligonucleotide during 20h at 37°C prior to stimulation in presence of 2µmol/L monensin. Intracellular cytokine production (TNFα, IL6, GM-CSF, IL10) by the different cell subsets (monocytes, CD4+and CD8+T cells, naïve and memory B cells) was analysed by flow-cytometry. Clinical activity at baseline and after 6m was assessed by DAS28. REM was defined as DAS28≤2.6 at 6m. The association between REM and the change in cytokine production (Δ, 6m-0m) by each PBMC subset was analysed through univariable and multivariable logistic regression models.

Results:

Seventy-eight percent of the patients were female. After 6m of TNFi treatment, 47% patients attained REM. Univariable analyses was performed to investigate the association between REM and the baseline variables. Male sex (OR: 12.6; 95% CI: 1.35-117.57; p=0.03) and having lower baseline DAS28 (OR: 0.4; 95% CI: 0.19-0.85; p=0.02) were independently associated with attaining REM after 6m of TNFi. In the multivariable analysis, only being male (OR: 19.7; 95% CI: 1.4-273.9; p=0.03) remained independently associated with REM after 6m of treatment. Therefore, further analyses were adjusted by sex. Decreased production of GM-CSF by CD4+T cells percentage was found after 6m of TNFi treatment in REM patients (0m: 6.07%; 6m: 3.87%; p=0.007) while no-REM patients did not show differences with the baseline (0m: 3.70%; 6m: 3.75%; p=0.9). The decrease was significantly associated with attaining REM (OR: 0.56; 95% CI: 0.33-0.95; p: 0.03). No significant association was found between any other analysed intracellular cytokine produced by the different PBMC subsets and REM.

Conclusion:

GM-CSF intracellular production by CD4+T cells was significantly decreased by TNFi treatment only in patients who attained REM. Therefore, our results suggest that GM-CSF production by CD4+T cells may be a useful marker of REM to TNFi in RA.

References:

[1] Sobrino C, et al. Ann Rheum Dis. 2019; 78 (S2): A1665.

[2] Hernández-Breijo B, et al. Ann Rheum Dis. 2019; 78 (S2): A711.

[3] Avci AB, et al. Clin Exp Rheumatol. 2016; 34 (S98), 39-44.

Figure. 1:

Association between the change in intracellular cytokine production (Δ, 6m-0m) by each PBMC subset and REM. Adjusted logistic regression analyses were performed for each cytokine.

Acknowledgments:

ISCIII (PI16/00474; PI16/01092)

Disclosure of Interests:

Borja Hernández-Breijo: None declared, Chamaida Plasencia: None declared, Carlota García-Hoz: None declared, Cristina Sobrino: None declared, Victoria Navarro-Compán Consultant of: Abbvie, Lilly, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Lilly, Novartis, Pfizer, UCB, ANA MARTÍNEZ-FEITO: None declared, Israel Nieto-Gañán: None declared, Paloma Lapuente-Suanzes: None declared, Javier Bachiller-Corral: None declared, Gemma Bonilla: None declared, Cristina Pijoan Moratalla: None declared, Garbiñe Roy: None declared, Mónica Vázquez Díaz: None declared, Alejandro Balsa Grant/research support from: BMS, Roche, Consultant of: AbbVie, Gilead, Lilly, Pfizer, UCB, Sanofi, Sandoz, Speakers bureau: AbbVie, Lilly, Sanofi, Novartis, Pfizer, UCB, Roche, Nordic, Sandoz, Luisa María Villar: None declared, DORA PASCUAL-SALCEDO Grant/research support from: Pfizer, Novartis & Progenika, Speakers bureau: Pfizer, Merck, Novartis, Takeda, Menarini & Grifols, Eulalia Rodríguez-Martín: None declared

Impact of Comorbidity on Physical Function in Patients With Ankylosing Spondylitis and Psoriatic Arthritis Attending Rheumatology Clinics: Results From a Cross-Sectional Study

OBJECTIVE

To evaluate the impact of comorbidities on physical function in patients with ankylosing spondylitis (AS) and psoriatic arthritis (PsA).

METHODS

This was a cross-sectional analysis of the baseline visit from the Cardiovascular in Rheumatology study. Multivariate models with physical function as the dependent variable (Bath Ankylosing Spondylitis Functional Index and Health Assessment Questionnaire for AS and PsA, respectively) were performed. Independent variables were a proxy for the Charlson Comorbidity Index (CCIp; range 0-27), sociodemographic data, disease activity (erythrocyte sedimentation rate [ESR] and Bath Ankylosing Spondylitis Disease Activity Index [BASDAI] in AS; Disease Activity Score in 28 joints [DAS28] using the ESR in PsA), disease duration, radiographic damage, and treatments. Results were reported as beta coefficients, 95% confidence intervals (95% CIs), and P values.

RESULTS

We included 738 patients with AS and 721 with PsA; 21% of patients had >1 comorbidity. Comorbidity burden (CCIp) was independently associated with worse adjusted physical function in patients with PsA (β = 0.11). Also, female sex (β = 0.14), disease duration (β = 0.01), disease activity (DAS28-ESR; β = 0.19), and the use of nonsteroidal antiinflammatory drugs (β = 0.09), glucocorticoids (β = 0.11), and biologics (β = 0.15) were associated with worse function in patients with PsA. A higher education level was associated with less disability (β = -0.14). In patients with AS, age (β = 0.03), disease activity (BASDAI; β = 0.81), radiographic damage (β = 0.61), and the use of biologics (β = 0.51) were independently associated with worse function on multivariate analyses, but CCIp was not.

CONCLUSION

The presence of comorbidities in patients with PsA is independently associated with worse physical function. The detection and control of the comorbidities may yield an integral management of the disease.

Influence of Antisynthetase Antibodies Specificities on Antisynthetase Syndrome Clinical Spectrum Time Course

Antisynthetase syndrome (ASSD) is a rare clinical condition that is characterized by the occurrence of a classic clinical triad, encompassing myositis, arthritis, and interstitial lung disease (ILD), along with specific autoantibodies that are addressed to different aminoacyl tRNA synthetases (ARS). Until now, it has been unknown whether the presence of a different ARS might affect the clinical presentation, evolution, and outcome of ASSD. In this study, we retrospectively recorded the time of onset, characteristics, clustering of triad findings, and survival of 828 ASSD patients (593 anti-Jo1, 95 anti-PL7, 84 anti-PL12, 38 anti-EJ, and 18 anti-OJ), referring to AENEAS (American and European NEtwork of Antisynthetase Syndrome) collaborative group’s cohort. Comparisons were performed first between all ARS cases and then, in the case of significance, while using anti-Jo1 positive patients as the reference group. The characteristics of triad findings were similar and the onset mainly began with a single triad finding in all groups despite some differences in overall prevalence. The “ex-novo” occurrence of triad findings was only reduced in the anti-PL12-positive cohort, however, it occurred in a clinically relevant percentage of patients (30%). Moreover, survival was not influenced by the underlying anti-aminoacyl tRNA synthetase antibodies’ positivity, which confirmed that antisynthetase syndrome is a heterogeneous condition and that antibody specificity only partially influences the clinical presentation and evolution of this condition.

Development of Macrocycle Kinase Inhibitors for ALK2 Using Fibrodysplasia Ossificans Progressiva-Derived Endothelial Cells

Fibrodysplasia ossificans progressiva (FOP) is an extremely rare congenital form of heterotopic ossification (HO), caused by heterozygous mutations in the activin A type I receptor (ACVR1), that encodes the bone morphogenetic protein (BMP) type I receptor ALK2. These mutations enable ALK2 to induce downstream signaling in response to activins, thereby turning them into bone-inducing agents. To date, there is no cure for FOP. The further development of FOP patient-derived models may contribute to the discovery of novel biomarkers and therapeutic approaches. Nevertheless, this has traditionally been a challenge, as biopsy sampling often triggers HO. We have characterized peripheral blood-derived endothelial colony-forming cells (ECFCs) from three independent FOP donors as a new model for FOP. FOP ECFCs are prone to undergo endothelial-to-mesenchymal transition and exhibit increased ALK2 downstream signaling and subsequent osteogenic differentiation upon stimulation with activin A. Moreover, we have identified a new class of small molecule macrocycles with potential activity against ALK2 kinase. Finally, using FOP ECFCs, we have selected OD36 and OD52 as potent inhibitors with excellent kinase selectivity profiles that potently antagonize mutant ALK2 signaling and osteogenic differentiation. We expect that these results will contribute to the development of novel ALK2 clinical candidates for the treatment of FOP. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Timing of onset affects arthritis presentation pattern in antisyntethase syndrome

OBJECTIVES

To evaluate if the timing of appearance with respect to disease onset may influence the arthritis presentation pattern in antisynthetase syndrome (ASSD).

METHODS

The patients were selected from a retrospective large international cohort of ASSD patients regularly followed-up in centres referring to AENEAS collaborative group. Patients were eligible if they had an antisynthetase antibody testing positive in at least two determinations along with arthritis occurring either at ASSD onset (Group 1) or during the course of the disease (Group 2).

RESULTS

445 (70%; 334 females, 110 males, 1 transsexual) out of the 636 ASSD we collected had arthritis, in the majority of cases (367, 83%) from disease onset (Group 1). Patients belonging to Group 1 with respect to Group 2 had an arthritis more commonly polyarticular and symmetrical (p=0.015), IgM-Rheumatoid factor positive (p=0.035), erosions at hands and feet plain x-rays (p=0.036) and more commonly satisfying the 1987 revised classification criteria for rheumatoid arthritis (RA) (p=0.004). Features such as Raynaud's phenomenon, mechanic's hands and fever (e.g. accompanying findings) were more frequently reported in Group 2 (p=0.005).

CONCLUSIONS

In ASSD, the timing of appearance with respect to disease onset influences arthritis characteristics. In particular, RA features are more common when arthritis occurs from ASSD onset, suggesting an overlap between RA and ASSD in these patients. When arthritis appears during the follow-up, it is very close to a connective tissue disease-related arthritis. Also, the different prevalence of accompanying features between these two groups is in line with this possibility.

REDOSER project: optimising biological therapy dose for rheumatoid arthritis and spondyloarthritis patients

Background

Reducing the dose of biological therapy (BT) when patients with immune-mediated arthritis achieve a sustained therapeutic goal may help to decrease costs for national health services and reduce the risk of serious infection. However, there is little information about whether such a decision can be applied universally. Therefore, the objective of this study was to develop appropriateness criteria for reducing the dose of BT in patients with rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), and peripheral spondyloarthritis (pSpA).

Methods

The RAND/UCLA appropriateness method was coordinated by experts in the methodology. Five rheumatologists with clinical research experience in RA and/or SpA selected and precisely defined the variables considered relevant when deciding to reduce the dose of BT in the 3 diseases, in order to define patient profiles. Ten rheumatologists with experience in prescribing BT anonymously rated each profile on a scale of 1 (completely inappropriate) to 9 (completely appropriate) after revising a summary of the evidence obtained from 4 systematic literature reviews carried out specifically for this project.

Findings

A total of 2,304 different profiles were obtained for RA, 768 for axSpA, and 3,072 for pSpA. Only 327 (14.2%) patient profiles in RA, 80 (10.4%) in axSpA, and 154 (5%) in pSpA were considered appropriate for reducing the dose of BT. By contrast, 749 (32.5%) patient profiles in RA, 270 (35.3%) in axSpA, and 1,243 (40.5%) in pSpA were considered inappropriate. The remaining profiles were considered uncertain.

Interpretation

Appropriateness criteria for reducing the dose of BT were developed in 3 inflammatory conditions. These criteria can help clinicians treating these disorders to optimize the BT dose. However, further research is needed, since more than 50% of the profiles were considered uncertain and the real prevalence of each profile in daily clinical practice remains unknown.

Visceral leishmaniasis in a patient with rheumatoid arthritis treated with methotrexate

A large number of complications have been associated with rheumatoid arthritis (RA), those of infectious etiology being of special relevance. Their high incidence is closely linked to the use of immunosuppressive medication. The spectrum of agents causing opportunistic infections in patients with RA is very broad; however, there are relatively few cases of Leishmania infection, especially in patients not being treated with biological drugs.

Osteochondromas in fibrodysplasia ossificans progressiva: a widespread trait with a streaking but overlooked appearance when arising at femoral bone end

Metaphyseal bony outgrowths are a well-recognized feature of fibrodysplasia ossificans progressiva (FOP) phenotype, but its genuine frequency, topographic distribution, morphological aspect, and potential implications are not fully established. To better ascertain the frequency and characteristics of osteocartilaginous exostoses in FOP disease, we conducted a cross-sectional radiological study based on all the traceable cases identified in a previous comprehensive national research. Metaphyseal exostoses were present in all the 17 cases of FOP studied. Although most often arising from the distal femoral (where metaphyseal exostoses adopt a peculiar not yet reported appearance) and proximal tibial bones, we have found that they are not restricted to these areas, but rather can be seen scattered at a variety of other skeletal sites. Using nuclear magnetic resonance imaging, we show that these exophytic outgrowths are true osteochondromas. As a whole, these results are in agreement with data coming from the literature review. Our study confirms the presence of metaphyseal osteochondromas as a very frequent trait of FOP phenotype and an outstanding feature of its anomalous skeletal developmental component. In line with recent evidences, this might imply that dysregulation of BMP signaling, in addition to promoting exuberant heterotopic ossification, could induce aberrant chondrogenesis and osteochondroma formation. Unveiling the molecular links between these physiopathological pathways could help to illuminate the mechanisms that govern bone morphogenesis.

Monostotic Paget's disease of the femur: a diagnostic challenge and an overlooked risk

BACKGROUND

Although radiological diagnosis of Paget's disease of bone (PD) is usually straightforward, monostotic cases may potentially raise specific problems which lead to performing invasive procedures. Therefore, the purpose of this study is to ascertain whether or not monostotic femoral Paget's disease (MFPD) presentation poses particular diagnostic difficulties which prompt excessive use of excisional biopsies.

METHODS

We retrospectively reviewed the medical records of 24 MFPD patients identified from a series of 412 patients; their clinical features were compared with those of the remaining 164 monostotic cases and the radiological images were systematically assessed.

RESULTS

When compared with the remaining monostotic cases, MFPD patients were more prone to having normal alkaline phosphatase levels (31.8% vs. 16.4%; 0.08) and a significantly higher percentage of patients have PD symptoms (75% vs. 51%; 0.02) and complain of bone pain (73.9% vs. 40.8%; 0.003). Six (25%) MFPD patients evidenced a fracture over the pagetic lesion. This incidence is higher than that of the monostotic cases of other locations (8.4%; p=0.02). The existence of PD lesion was not recognised initially in 10 cases and an excisional bone biopsy was performed in 7 (29%). One patient subsequently experienced a fracture through the biopsy site and another two experienced worsening of their previous bone pain.

CONCLUSION

The femur is a relatively common monostotic PD location which often causes diagnostic confusion, prompting a bone biopsy in many cases. Careful assessment of this lesion by X-ray examination may help attain an early appropriate diagnosis and avoidance of unnecessary surgical morbidity.

[Is there a place in primary care for rare diseases? The case of fibrodysplasia ossificans progressiva]

La fibrodisplasia osificante progresiva es una de las enfermedades constitucionales óseas más devastadoras, y supone un ejemplo válido para establecer el papel de la asistencia primaria en la atención a las enfermedades poco frecuentes. Aunque las enfermedades raras suelen presentar alteraciones llamativas pueden remedar síntomas y signos de trastornos comunes, con riesgo de pasar desapercibidas. Por ello, todos los profesionales sanitarios deberían proceder con un grado de sospecha razonable ante un paciente con una enfermedad aparentemente común con rasgos atípicos o evolución no convencional. En el seguimiento integral e individualizado, los cuidados dispensados por el equipo de atención primaria en coordinación con otros dispositivos asistenciales, son fundamentales. La calidad de la atención a enfermedades raras no puede ser inferior a la que se presta a los demás procesos crónicos, ya que –además de ser un imperativo de justicia y equidad– estos pacientes son, en esencia, el «paradigma de la cronicidad».