POS1358 THE EFFECTS AND SAFETY OF APREMILAST AND CYTOKINE EXPRESSION IN BEHCET’S DISEASE PATIENTS

Background:

Apremilast, the small-molecule phosphodiesterase (PDE) -4 inhibitor, was approved for the treatment of recurrent oral ulcers associated with Behcet’s disease (BD) in Japan from September 2019, following the success of the phase 3 RELIEF study (1). However, the efficacy of apremilast on domains other than oral ulcers in BD patients is unclear. On the other hand, it has been reported that apremilast may decrease the production of proinflammatory cytokine and increase the production of anti-inflammatory mediators in psoriasis (PS) and psoriatic arthritis (PsA) (2).

Objectives:

To evaluate the effects and safty of apremilast on clinical symptoms and the changing of serum cytokine expression.

Methods:

BD patients who had treated with apremilast for active oral ulcers were included in the study. We investigated the improvement rate of oral and genital ulcers, skin lesions, arthritis. In addition, serum cytokines (IFN-γ, IL-10, IL-8, and TNF-α) before and after apremilast treatment were measured using a multiplex immunoassay (Luminex Assay, R&D Systems).

Results:

Fourteen patients (3 males and 11 females) were enrolled in this study. The mean age was 46.6 ± 13.0 years and the mean duration of disease was 10.2 ± 8.8 years. All patients had active oral ulcers, five had genital ulcers, six had skin lesions, and four had arthritis. Three months after the treatment with apremilast, oral ulcers improved in 13 patients (92.9%). The improvement rates of genital ulcers, skin lesions and arthritis were 60%, 25% and 25%, respectively. Changes in serum cytokines were different from those previously reported in PS. Adverse events were gastrointestinal symptoms such as nausea and diarrhea in 6 patients and sensorineural deafness in 1 patient. Medication was reduced in 2 patients, and discontinued in 1 patient due to nausea and diarrhea.

Conclusion:

Apremilast is useful not only for oral ulcers, but also for other lesions in BD patients. The effect of apremilast for other domain such as genital ulcers, skin lesions, arthritis was not comparable to that of active oral ulcers. Additionally, BD may have different cytokine profile from PS and PsA.

References:

[1]Hatemi G, Mahr A, Ishigatsubo Y, et al. Trial of Apremilast for Oral Ulcers in Behcet’s Syndrome. N Engl J Med. 2019;381(20):1918-28

[2]Schafer P. Apremilast mechanism of action and application to psoriasis and psoriatic arthritis. Biochem Pharmacol. 2012;83(12):1583-1590

Disclosure of Interests:

None declared

POS0556 USEFULNESS OF FDG-PET/CT FOR PREDICTING SPONTANEOUS REGRESSION IN MTX ASSOCIATED LYMPHOPROLIFERATIVE DISORDER WITH RHEUMATOID ARTHRITIS

Background:

Recently, there are many reports from Japan about methotrexate associated lymphoproliferative disorder (MTX-LPD). We are investigating the predictive factor of spontaneous regression (SR) in MTX-LPD. On the other hand, FDG-PET/CT is used for diagnosis of LPD including malignant lymphoma. In addition, it was reported that imaging biomarkers such as metabolic tumor volume (MTV) and total lesion glycolysis (TLG) could predict the prognosis of malignant tumor (1, 2). However, there is no report that these imaging biomarkers could predict the SR of MTX-LPD.

Objectives:

We investigate the usefulness of FDG-PET/CT for predictive factor of SR in MTX-LPD.

Methods:

We enrolled 24 RA patients who diagnosed MTX-LPD and performed FDG-PET/CT from 2005 to 2019. We divided these cases into spontaneous regression cases (SR group; 15 cases) and cases that treated with chemotherapy after MTX discontinuation (CTx group; 9 cases), and compared the difference as follow subjects between two groups; clinical data including histopathological findings, SUVmax to evaluate malignant tumor activity by FDG-PET/CT, MTV and TLG which refer to metabolically active volume of the tumor segmented FDG-PET/CT. In addition, we analyzed cut off levels, sensitivity and specificity using statistical software JMP.

Results:

Diffuse large B cell lymphoma (DLBCL) and Hodgkin lymphoma (HL) were 5 and 1 cases in SR group, and 1 and 5 cases in CTx group. In addition, MTV and TLG by FDG-PET/CT was significantly lower in SR group, although SUVmax is no difference between two groups (figure 1). Cut off levels of MTV and TLG were 103.12 ml (sensitivity; 88.9%, specificity; 86.7%) and 361.75 ml (sensitivity; 88.9%, specificity; 86.7%), respectively.

Conclusion:

We suggested that MTV and TLG were useful for predict of SR in MTX-LPD.

References:

[1]Chen HH, Chiu NT, Su WC. et al. Prognostic value of whole-body total lesion glycolysis at pretreatment FDG PET/CT in non-small cell lung cancer. Radiology. 2012 Aug;264(2):559-66.

[2]Chu KP, Murphy JD, La TH. et al. Prognostic value of metabolic tumor volume and velocity in predicting head-and-neck cancer outcomes. Int J Radiat Oncol Biol Phys. 2012 Aug 1;83(5):1521-7.

Figure 1.

Comparison of the level of MTV(a) and TLG (b).

Disclosure of Interests:

None declared

AB0443 BIOMARKER SUCH AS IL-17, IL-21 AND TIMP-1, IS USEFUL FOR PREDICTING THE PATHOPHYSIOLOGY OF CONNECTIVE TISSUE DISEASE-ASSOCIATED PULMONARY HYPERTENSION

Background:

Connective tissue disease-associated pulmonary hypertension (CTD-PH) is constructed by a variety of pathologies, including cardiac, pulmonary, and vascular involvement, as well as immune abnormalities. Because of its various constructs, it is difficult for many respiratory physicians, cardiologists, and rheumatologists to determine a treatment strategy for CTD-PH. In addition, CTD-PH has different pathologies from iPAH, and there are cases in which immunosuppressive therapy is effective. These suggests that the two PAHs may have different pathogenesis, including inflammation in the pulmonary artery. However, there are not enough biomarkers to distinguish pathologies. On the other hand, it has been reported that various cytokines such as TIMP-1, Interleukin (IL)-6, IL-17, and IL-21 are involved in the pathogenesis of CTD-PH or vasculitis. (1,2) However, the relationship between these cytokine expression and the pathogenesis or treatment of CTD-PH has not been fully clarified.

Objectives:

To clarify the relationship between cytokine profile and clinical features, change in cytokines and hemodynamics by treatment, association with the effectiveness of immunosuppressive therapy.

Methods:

Patients suspected PH was included. At the time of cardiac catheterization(RHC), sera in pulmonary pre and post-capillary were collected and TIMP-1, MCP-1, IL-17 and IL-21, IL-12p70 and IL-6 were analyzed by ELISA(ABCAM UK, Ella simple plex USA). The following clinical data were collected: age, gender, underlying disease, complication of interstitial lung disease, treatment (immunosuppressant and pulmonary vasodilator), hemodynamics. Furthermore, we investigated the relationship between cytokines and clinical data.

Results:

15 cases of CTD-PH, 13 cases of non-CTD-PH, and 6 cases of non-PH were analyzed. (SSc 12 cases, MCTD 7cases, SLE 2 cases, and others 13 cases) 28 cases were diagnosed with PH by RHC. There was a positive correlation between IL-6 and mean pulmonary arterial pressure in all PH case. In addition, MCP-1, IL-6, and TIMP-1 tend to be high in SSc-PH cases. On the other hand, in Non-SSc-PH, IL-12p70 and IL-17 were high. In cases who pulmonary vascular hemodynamics improved by treatment, IL-17, IL-21, and TIMP-1 decreased.

Conclusion:

Biomarker profiles in pulmonary capillaries may differ depending on the disease. Furthermore, it suggested that IL-17, IL-21 and TIMP-1 may be biomarkers of therapeutic effect.

References:

[1]Hashimoto-Kataoka T. et al. Proc Natl Acad Sci U S A. 2015 May 19;112(20):E2677-86.

[2]Jun Ishizaki et al. Arthritis Res Ther. 2017 Sep 29;19(1):218.

Disclosure of Interests:

None declared.

AB0287 EFFECTS OF HYDROXYCHLOROQUINE ON PERIPHERAL BLOOD CYTOKINE EXPRESSION ASSOCIATED WITH ATHEROSCLEROSIS IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

In systemic lupus erythematosus(SLE), a higher frequency of atherosclerotic lesions is associated with a poor life prognosis (1). Hydroxychloroquine (HCQ) has been reported to improve the prognosis of life and dyslipidemia in SLE (2), and the mechanism has been unclear.

Objectives:

To determine the effect of HCQ treatment on serum cytokines associated with atherosclerosis in SLE.

Methods:

SLE patients who received additional HCQ and maintained low disease activity between January 2016 and September 2020 were included in this study. Disease activity was assessed by SLEDAI, CLASI and LLDAS, and serum complement titers, anti-ds-DNA antibodies, serum insulin and serum cytokines (adiponectin, resistin and leptin) were analyzed before and after HCQ treatment.

Results:

Fifty-four patients (3 males, 51 females, mean age 41.9±12.8 years) were included (Table 1). Thirty-two patients achieved LLDAS at baseline. Serum adiponectin and insulin levels were significantly increased after 3 months of HCQ treatment compared to baseline, and serum resistin levels were significantly lower (Figure 1). Patients with a history of renal disease had greater degree of changes in serum adiponectin and resistin levels. Among SLE patients who did not achieve LLDAS at baseline, those who still did not achieve LLDAS after 3 months had significantly lower serum leptin levels before HCQ treatment than those who achieved it after 3 months.

The change of serum resistin levels correlated with those of serum S100A8 levels (r=0.5, p=0.0001).

Conclusion:

Additional HCQ treatment in SLE patients improves lipid abnormalities. HCQ may improve prognosis by controlling disease activity in SLE and reducing risk factors for atherosclerosis.

References:

[1]Gregory Katz, et al. Systemic Lupus Erythematosus and Increased Prevalence of Atherosclerotic Cardiovascular Disease in Hospitalized Patients. Mayo Clin Proc. 2019; 94:1436-1443.

[2]Laura Durcan, et al. Longitudinal Evaluation of Lipoprotein Parameters in Systemic Lupus Erythematosus Reveals Adverse Changes with Disease Activity and Prednisone and More Favorable Profiles with Hydroxychloroquine Therapy. J Rheumatol. 2016; 43: 745–750.

Table 1.

Characteristics of SLE patients enrolled in this study

Characteristicsn=54, no.(%)Female, no(%)51(94)Age, years, mean±SD41.9±12.8Disease duration, years, mean±SD15.1±11.1Past involvementRenal involvement23 (43)NPSLE5 (9)ComplicationAPS10 (19)Dyslipidemia2 (4)Diabetes 1 (2)Concomitant immunosuppressive treatmentsPrednisone No.(%)46 (85) Median Dosage, mg/day (range)5.0 (1-10)Disease activitySLENA-SLEDAI score3.9±2.0 Current skin involvement30 (56) anti-dsDNA positive, no(%)21 (39)low complement, no(%)29 (54)

Anti-dsDNA positive means anti ds-DNA titer increases over 12 IU/ml

Low complement means any of C3, C4 and CH50 decreases to less 68mg/dl, less 12mg/dl, 30U/ml.

APS: Anti-phospholipid antibody syndrome, NPSLE: neuropsychiatric SLE,

Disclosure of Interests:

None declared

AB0390 CHARACTERISTICS AND PROGNOSIS OF AGE-DEPENDED ANCA-ASSOCIATED VASCULITIS IN JAPAN

Background:

It is known that most of ANCA-associated vasculitis (AAV) patients are elderly. A cohort study showed that the mean age of onset was 71.1 years, especially in patients with microscopic polyangiitis (MPA)1). However, the characteristics and prognosis of age-depended AAV patients are still unclear.

Objectives:

To clarify the differences in age-related characteristics and prognosis between Japanese patients with AAV.

Methods:

We enrolled 44 patients with AAV who underwent remission induction therapy at our hospital from January 2016 to December 2020. They were divided with under 70 years old group (<70 yo group, n=12) and over 70 years old group (≥70 yo group, n=32). We investigated between two groups as follows; clinical characteristics and laboratory data at diagnosis, rates of complete remission (CR) at 6 months, defined as Birmingham Vasculitis Activity Score (BVAS)=0 and prednisone ≤7.5 mg/day, adverse events, and relapse free survival.

Results:

Mean age were 61.9 ± 9.74 years old in <70 yo group and 77.5 ± 4.61 years old in ≥70 yo group (p<0.01). There were significantly fewer newly diagnosed cases in the <70 yo group, and half of the patients with relapsing disease. There was no difference in the type of ANCA, organ involvement, or BVAS. Remission induction therapy was performed with CY or RTX, and no difference was observed between these two groups. In addition, there was also no difference in maintenance therapy (Table 1). CR rate in <70 yo group and in ≥70 yo group were 55% and 46 % respectively (p=0.73). Severe infections occurred with no patient (0%) in <70 yo group and with 5 patients (16%) in ≥70 yo group (p=0.30). 5 patients of relapse were observed in the <70 yo group and 1 patient in the ≥70 yo group, and relapse free survival was significantly lower in the <70 yo group (p=0.001) (Figure 1).

<70 yo (n=12)≥70 yo (n=32)p valueAge (year)61.9 ± 9.7477.5 ± 4.61< 0.01*Female, n (%)10 (83)28 (87)0.66AAV typeMPA, n (%) / GPA, n (%)6 (50) / 6 (50)26 (81) / 6 (19)0.06Newly diagnosed, n (%)6 (50)27 (84)0.045*ANCA positivity MPO, n (%) / PR3, n (%)11 (92) / 0 (0)30 (94) / 3 (9)1 / 0.55 negative, n (%)1 (8)1 (3)0.48CRP (mg/dl)3.34 ± 4.018.15 ± 6.860.03*eGFR (mL/min)55.8 ± 25.357.7 ± 24.70.93BVAS12.0 ± 8.014.8 ± 6.80.23Remission induction therapyCY, n (%) / RTX, n (%)5 (42) / 7 (58)16 (50) / 16 (50)0.74Maintenance therapy AZA, n (%)7 (58)14 (44)0.50 RTX, n (%)1 (8)6 (19)0.65 others, n (%)2 (17)3 (9)0.60 without IS, n (%)2 (17)9 (28)0.70

The p-value was estimated using Fisher’s exact or Wilcoxson rank sum test. yo, years old; AAV, ANCA-associated vasculitis; MPA, microscopic polyangiitis; GPA, granulomatosis with polyangiitis; CY, cyclophosphamide; RTX, rituximab; AZA, azathioprine; IS, immunosuppressants. *p<0.05

Conclusion:

There was no difference in remission rate between two groups. Severe infections were observed only in the ≥70 yo group. We suggest that younger AAV patients need attention to relapse after the remission because of lower relapse free survival in <70 yo group.

References:

[1]Sada KE, et al. Arthritis Res Ther 2014; 16: R101.

Figure 1.

Relapse free survival Relapse free survival was calculated by Kaplan-Meier method and compared by log-rank test. *p<0.05

Disclosure of Interests:

None declared

POS0863 DIFFERENTIATING THE DOMINANCE OF PULMONARY VASCULAR DISEASE OR INTERSTITIAL LUNG DISEASE ON HEMODYNAMIC ABNORMALITIES IN SYSTEMIC SCLEROSIS AND CLARIFYING EACH CHARACTERISTIC BY USING QUANTITATIVE EVALUATION OF CHEST CT

Background:

Group 1 and 3 pulmonary hypertension (PH) develop through different pathological mechanisms but have similar hemodynamic abnormalities. Systemic sclerosis (SSc) is associated with both pulmonary vascular disease (PVD) and interstitial lung disease (ILD), making it challenging to differentiate group 1 and 3 PH in those patients. A previous study using quantitative evaluation of chest computed tomography (CT) demonstrated that normal lung volume was inversely correlated with mean pulmonary arterial pressure (mPAP) in patients with group 3 PH (1).

Objectives:

In this study, we aimed to assess the dominance of PVD or ILD in SSc patients by quantitative evaluation of chest CT and to evaluate each characteristic.

Methods:

A total of 76 SSc patients who underwent right heart catheterization (RHC) were included. Chest CT was evaluated by using a software (Synapse Vincent Ver.3.0, Fujifilm) which quantified normal and total area of the lung. Then, we calculated abnormal area by drawing normal area from total area in the lung (%). Pulmonary function test (PFT) and serum biomarkers, such as KL-6 and LDH, were also evaluated. The dominance of PVD or ILD was defined as divergent or parallel change between the first and last assessments, respectively, in mPAP and abnormal area in the lung calculated using the software. Increase or decrease by over 10% in the last assessment compared to the first assessment was considered as a significant change in mPAP or abnormal area in the lung. P values were calculated by Mann-Whitney U test, and correlation coefficients were calculated by direct regression variance.

Results:

The median [range] values of mPAP and abnormal area in the lung at baseline were 23 [9-65] mmHg and 30.2 [0-100] %, respectively. Of 37 SSc and PH patients, 18 were defined as having PVD dominance while 19 as ILD dominance. Abnormal area in the lung at baseline was greater in patients with ILD dominance compared to those with PVD dominance (39.1 [16.3-98.3] v.s. 14.0 [0-99] %, p=0.002), whereas mPAP was higher in patients with PVD dominance than those with ILD dominance (42.5 [23.0-65.0] v.s. 26.0 [16.0-42.0] mmHg, p=0.002). PFT parameters including forced vital capacity were not different between the two groups. The ratio of mPAP/KL-6 showed a great difference between the two groups with its significant elevation in patients with PVD dominance (p=0.007).

Conclusion:

Quantitative evaluation of chest CT showed great efficiency in differentiating the dominance of PVD or ILD in patients with SSc and PH. In addition, the ratio of mPAP/KL-6 may easily be used as a parameter for dominance evaluation.

References:

[1]Iwasawa T, Kato S, Ogura T, Kusakawa Y, Iso S, Baba T, et al. Low-normal lung volume correlates with pulmonary hypertension in fibrotic idiopathic interstitial pneumonia: computer-aided 3D quantitative analysis of chest CT. AJR Am J Roentgenol. 2014;203(2):W166-73.

Disclosure of Interests:

None declared

AB0826 IMPORTANCE OF PRECONCEPTION CARE AND PLANNING FOR PREGNANCY IN WOMEN OF CHILDBEARING AGE COMPLICATED WITH CONNECTIVE TISSUE DISEASES

Background:

Previous reports showed that connective tissue disease (CTD) have a high risk for adverse pregnancy outcomes (APOs) such as preterm birth, light-for-date, or preeclampsia1). It was revealed that these APOs were associated with high disease activity or treatment agents, particularly in glucocorticoid2). Some patients, who have no or insufficient preconception care and became unplanned pregnant, exacerbate the underlying disease, and lead to disappointing pregnancy outcomes. Therefore, preconception care and planning for pregnancy is very important to control disease activities and manage the appropriate treatment agents, including glucocorticoid, immunosuppressants, biologics, hydroxychloroquine, and anticoagulants3).

Objectives:

We investigate whether the presence or absence of preconception care before pregnancy affects clinical disease course and pregnancy outcomes.

Methods:

We examined 200 CTD women who delivered their newborns in our institution from March 2006 to January 2021. We analyzed the association between preconception care and the clinical course of underlying diseases during pregnancy or pregnancy outcomes.

Results:

Of all 200 cases, 133 (55.9%) cases had preconception care in our institution, while the others had no or insufficient preconception care. We showed the comparison of treatment agents and pregnancy outcomes between the cases with and without preconception care in Table 1. There was no significant difference in the rate of glucocorticoid use and the mean prednisolone dose during pregnancy between these two groups. However, the rate of increased dose of glucocorticoid or pulse therapy was significantly higher in the cases without preconception care. As for pregnancy outcomes, there was no significant difference in the live birth rate. On the other hand, the gestational weeks at delivery were significantly shorter, and the rate of preterm birth was higher in the cases without preconception care. In addition, the rate of the hospitalization of neonatal intensive care unit (NICU) was also significantly higher in the cases without preconception care.

Conclusion:

We revealed that preconception care before pregnancy reduced the need for intensified treatment such as increasing dose of glucocorticoid or pulse therapy. The rate of preterm birth and NICU hospitalization was also shown to decrease. Therefore, it is important for our rheumatologists to provide an appropriate preconception care for CTD women of childbearing age and to make a plan for pregnancy.

References:

[1]Tsuda S, Sameshima A, Sekine M, Kawaguchi H, Fujita D, Makino, et al. Mod Rheumatol 2019:24;1-10.

[2]Clowse ME, Magder LS, Petri M. J Rheumaotol 2011;38:1012-1016.

[3]Sammaritano LR, Bermas BL, Chakravarty EE, Chambers C, Clowse MEB, Lockshin MD, et al. Arthritis Care Res 2020;72:461-488.

Table 1.

Comparison of treatment agents and pregnancy outcomes between the cases with and without preconception care

Preconception care (+) (n=113)Preconception care (-) (n=89)P valueTreatment agents during pregnancy Glucocorticoid use (n (%))64 (56.6)50 (56.2)1.00  Mean glucocorticoid dose (mg/day)6.3±3.98.4±6.10.09  Dose-up of glucocorticoid (n (%))11 (9.7)26 (29.2)<0.01*  Glucocorticoid pulse therapy (n (%))0 (0)8 (9.0)0.01* Immunosuppressant (n (%))14 (12.5)4 (4.5)0.08 Hydroxychloroquine (n %))7 (6.2)6 (6.7)1.00 Anticoagulant therapy (n (%))21 (18.8)16 (17.8)1.00Pregnancy outcome Spontaneous abortion (n (%))8 (7.1)6 (6.7)1.00 Live birth (n (%))100 (88.5)78 (87.6)1.00  Gestational weeks at delivery (week)38.7±1.437.3±3.50.01*  Birth weight of newborn (gram)2888.8±453.72678.4±732.60.25 Adverse pregnancy outcomes (n (%))26 (26.0)28 (35.0)0.20  Preterm birth (n (%))5 (5.0)19 (23.8)<0.01*  Light-for-date (n (%))10 (10.0)9 (11.3)0.81  Hypertensive disorder (n (%))5 (5.0)8 (10.0)0.25  NICU management (n (%))13 (13.0)24 (30.0)<0.01*

Disclosure of Interests:

None declared

Is warfarin associated with higher risk of thrombus in left atrial appendage than direct oral anticoagulants?

Funding Acknowledgements

Type of funding sources: None.

Background

Thrombus in left atrial appendage (LAA) is associated with cardiogenic ischemic stroke, and anticoagulation therapy is utilized to prevent thromboembolism.

Purpose

This study is to investigate the incidence of thrombus in left atrial appendage detected by transoesophageal echocardiography (TOE) under anticoagulation therapy with warfarin or direct oral anticoagulants (DOAC).

Methods

Between 2005 and 2016, the patients who underwent TOE under anticoagulation therapy due to atrial fibrillation more than one month were enrolled in this study. The patients were divided into 2 groups according to whether treated with warfarin or DOAC and baseline characteristics and incidence of LAA thrombus were assessed.

Results

Among the 313 study patients, 243 (78%) were treated with warfarin. The patients treated with warfarin were elder (median 73 y vs. 67 y [interquartile range 66 – 78 y vs. 58 – 72 y], P &lt; 0.01), the body mass index was lower (23.2 vs. 24.0 [21.0 – 25.4 vs. 21.3 – 26.9], P = 0.03). The prevalence of male sex (64% vs. 71%, P = 0.26) were similar between the 2 groups. The previous history of hypertension (69% vs. 59%, P = 0.10), diabetes (24% vs. 19%, P = 0.32), vascular disease (30% vs. 26%, P = 0.52), and ischemic stroke were similar between the 2 groups (30% vs. 23%, P = 0.22). The prevalence of CHA2DS2-VASc score &gt; 1 (84% vs. 59%, P &lt; 0.01) and the d-dimer level (0.7 vs. 0.5 mcg/ml [0.5 – 1.8 vs. 0.5 – 0.5 mcg/ml], P &lt; 0.01) were higher in the warfarin groups than those of the DOAC. The velocity of LAA was slower in the warfarin group than those of DOAC (35 vs. 55 cm/s [21 – 54 vs. 38 – 68 cm/s], P &lt; 0.01). The incidence of detection of LAA thrombus was 19% in the warfarin group and 3% in the DOAC group (P &lt; 0.01). In the warfarin group, the PT-INR were lower in the patients with LAA thrombus (1.38 vs. 1.66 [1.11 – 1.92 vs. 1.34 – 2.03], P = 0.03).

Conclusions

The higher risk of ischemic stroke and out of range PT-INR may be the cause of the higher incidence of LAA thrombus in the patients treated with warfarin than those with DOAC.

Abstract Figure.

Serum interleukin-17A/interferon-gamma ratio as a predictor for the severity of atrial low voltage in atrial fibrillation: from FIB-MARK study

Background

Atrial fibrosis is hallmark of structural remodeling in atrial fibrillation (AF), but the inflammatory mechanism remains unclear. The purpose of the present study was to identify the specific inflammatory biomarkers to atrial fibrosis evaluated by atrial low voltage (LV) in AF patients for clarification of the mechanism.

Methods

Forty inflammatory biomarkers were quantified in 16 consecutive AF patients measured left atrial low voltage during catheter ablation.

Results

Median %LV area was 17%. In Pearson's correlation analysis, interleukin (IL)-17A and interferon (IFN)-γ was the most significant positive and negative correlation with %LV (R=0.35 and 0.43, P&lt;0.001). Furthermore, there was a significant correlation between IL-17A/IFN-γ ratio and %LV (R=0.65, P=0.007). The area under the receiver operator characteristics curve of IL-17A/IFN-γ ratio for significant LV (%LV &gt;10% as a reference standard) was 0.88. IL-17A/IFN-γ ratio was significantly higher in patients with significant LV than those without (1.41 versus 0.97, P=0.01), Furthermore, the sensitivity, specificity, and accuracy for detecting significant LV were 60%, 100%, and 75.0% at the cutoff value of 1.3. The event free survival from recurrent atrial tachyarrhythmias was not significantly different between patients with and without IL-17A/IFN-γ ratio &gt;1.3 (83.3% versus 80.0% at 1-year, P=0.81).

Conclusions

Among inflammatory biomarkers, IL-17A/IFN-γ ratio was a significant predictor for the severity of left atrial low voltage n AF patients. Further study is needed to reveal the association between IL-17A and IFN-γ for development of fibrosis in AF.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): JSPS KAKENHI GrantNumber JP19K17594

Long-term outcomes evaluated by device-monitored physical activity in patients with implantable cardiac defibrillator or cardiac resynchronization therapy device

Background

The patients with implantable cardiac defibrillator (ICD) or cardiac resynchronization therapy device (CRT) have high risk of cardiac events, and lower physical activity has been thought to be associated with higher rate of cardiac events. On the other hand, cardiovascular implantable electronic devices can monitor physical activity through a built-in accelerometer. This study aimed to analyze long-term outcomes by device-based monitoring of physical activity in patients with ICD or CRT.

Methods

We retrospectively reviewed 89 patients with ICD/CRT, (56 males, 66.5 years old; ICD 45, CRT-D 42, CRT-P 2) who survived longer than 6 months after implantation in our institution. We analyzed physical activity by devices at 6th month and divided to 2 groups; In Low activity group (group L; n=38), their physical activity (moving time above 70 steps/min walk level) is less than 2 hours/day, and in Normal activity group (group N; n=51), physical activity is more than 2 hours/day. We evaluated their background characteristics in each group, physical activity at 12th month, and composite outcomes of hospitalization due to worsening of heart failure (HF) and death of any cause.

Results

Mean follow-up period was 57.4 months (median 40 months). In group L, they had higher age (71.1 y.o. vs. 63.2 y.o.; p=0.0003), higher rate of low EF (76.3% vs. 54.9%; p=0.035), and lower rate of attendance to outpatient cardiac rehabilitation program (10.5% vs 27.5%; p=0.043) compared with group N. 85.7% of patients in group L stayed in low physical activity at 12th month, and 87.8% of patient in group N stayed in normal physical activity. Composite outcomes of HF hospitalization and death occurred significantly higher in group L (Log-rank p&lt;0.0001; 29.0% vs. 5.9% at 1 year, and 68.7% vs. 16.2% at 3 year: Figure 1) than in group N. Each event, HF hospitalization and death of any cause were shown significantly higher in group L (Log-rank p&lt;0.0001). In group L, mortality rate of patients who could improve their physical activity from 6th month to 12th month was significantly lower than patients who stayed in low physical activity (Log-rank p=0.038).

Conclusions

Lower level of device-monitored physical activity was associated with higher mortality and higher rate of HF hospitalization in patients with ICD or CRT. Most of the patient in lower physical activity could not improve their activity from 6th month to 12th month. Early and continuous intervention is necessary especially for high risk patients such as high age or low EF.

Figure 1

Funding Acknowledgement

Type of funding source: None

Prognosis and cause of death in patients with left atrial appendage thrombus treated with or without anticoagulation therapy

Background

Thrombus in left atrial appendage (LAA) is associated with cardiogenic ischemic stroke; however, little is known about prognosis of patients with LAA thrombus detected by transoesophageal echocardiography (TOE).

Purpose

This study is to investigate the prognosis of patients with LAA thrombus and their cause of death.

Methods

Between 2005 and 2016, the patients who were performed TOE in our hospital were enrolled in this retrospective observational study. Five-year stroke free and survival curves were constructed by Kaplan-Meir method and cause of death were assessed.

Results

Among the 1263 study patients, LAA thrombus was detected in 146 (12%) patients. The patients with LAA thrombus were elder (74 y [66–79 y] vs. 70 y [62–76 y], P&lt;0.001), than those without LAA thrombus, respectively. The prevalence of male sex (67% vs. 69%, P=0.63) were similar between the 2 groups. The prevalence of CHA2DS2-VASc score ≥2, d-dimer (1.7 mcg/ml [0.9–3.5 mcg/ml] vs. 0.8 mcg/ml [0.5–2.2 mcg/ml], P&lt;0.001), and plasma brain natriuretic peptide (315 pg/ml [128–515 pg/ml] vs. 126 pg/ml [47–284 pg/ml], P&lt;0.001) were higher in the patients with LAA thrombus than those without (89% vs. 78%, P=0.003). The LAA velocity was slower in the patients with LAA thrombus than those without (23 cm/s [15–34 cm/s] vs. 51 cm/s [35–72 cm/s], P&lt;0.001). The prevalence of receiving anticoagulation therapy before (34% vs. 24%, P=0.01) and after (98% vs. 66%, P&lt;0.001) TOE 1 month were higher in the patients with LAA thrombus than those without. The 5-year stroke free rate was lower in the patients with LAA thrombus than those without (82% vs. 93%, P&lt;0.001); however, the 5-year survival were similar between the 2 groups (84% vs. 84%, P=0.93) (Figure). The cause of death as ischemic stroke was only 7% (1/14) and 3% (3/94), (P=0.43); the cardiac cause (14% vs. 43%, P=0.07) and the malignancy (35% vs. 29%, P=0.75) were the frequent cause of death in the patient with LAA thrombus and those without, respectively.

Conclusions

The patients who were detected thrombus in the LAA had higher incidence of ischemic stroke; however, the 5-y survival were similar. The ischemic stroke was not major cause of death in the patients with and without LAA thrombus. The higher rate of receiving anticoagulation therapy may be one of the causes of the discrepancy.

Figure 1

Funding Acknowledgement

Type of funding source: None

Equine non-invasive time-lapse imaging and blastocyst development

In this study we examined the timeline of mitotic events of invitro-produced equine embryos that progressed to blastocyst stage using non-invasive time-lapse microscopy (TLM). Intracytoplasmic sperm injection (ICSI) embryos were cultured using a self-contained imaging incubator system (Miri®TL; Esco Technologies) that captured brightfield images at 5-min intervals that were then generated into video for retrospective analysis. For all embryos that progressed to the blastocyst stage, the initial event of extrusion of acellular debris preceded all first cleavages and occurred at mean (±s.e.m.) time of 20.0±1.1h after ICSI, whereas 19 of 24 embryos that did not reach the blastocyst stage demonstrated debris extrusion that occurred at 23.8±1.1h, on average 4h longer for this initial premitotic event (P<0.05). Embryos that failed to reach the blastocyst stage demonstrated a 4-h delay compared with those that reached the blastocyst stage to reach the 2-cell stage (P<0.05). All embryos that reached the blastocyst stage expressed pulsation of the blastocyst with visible expansion and contraction at approximate 10-min intervals, or five to six times per hour. Using a logit probability method, we determined that 2- and 8-cell stage embryos could reasonably predict which embryos progressed to the blastocyst stage. Together, the results indicate that TLM for equine embryo development is a dynamic tool with promise for predicting successful embryo development.

Integrative and Complementary Health Practices Building a New Health Paradigm

This work arose from the need to broaden the therapeutic approach and offer a differentiated health intervention proposal based on the understanding that the illness process has repercussions on all integrated systems of Being. Since 2019, the Health Center for the Elderly in Blumenau (SC-Brasil), specialized multi-professional service, offering support for biopsychoenergetic transformation with the practice of Yoga and Meditation, through a holistic and comprehensive view of health. It begins with the Multidimensional Assessment of the Elderly, with a guideline in welcoming and qualified listening, which considers the subject and all subjectivity. From there, the expanded diagnosis and the Singular Therapeutic Project are built and the consultations with the team and the 'Re-Conhecer group' begin. The activity is weekly, aimed at the elderly and their family, takes place in an appropriate place and lasts two hours. Welcoming, pranayama, mantras, kriyas and meditation are made, as well as reflections on free themes. The professionals who conduct the practice are the dentist, trained in yoga, and the social worker, the welcoming process continues individually after the activity. Due to subjectivity, results are routinely collected in a qualitative way from the participants' report. There is a perception on the part of the participants, therapists and members of the multidisciplinary team that this work provides improvement in cognitive abilities, self-care, well-being, self-confidence, creativity, improved sleep, autonomy, balance, strengthening bonds, joy, vitality.

Key messages

This initiative builds new models of health care, transcending the traditional biomedical model, according to the operational guideline for comprehensiveness, universal access and equity. Provokes reflections and builds a new perspective of life with quality and participation of the elderly as subjects of their health.

AB0787 EFFECTIVENESS OF IL-17 INHIBITORS REVEALED BY MINIMAL DISEASE ACTIVITY (MDA) ACHIEVEMENT OF PSORIATIC ARTHRITIS PATIENTS

Background:

Recently, several type of biologics such as TNF inhibitors, IL-17 inhibitors, IL-12/23 (p40) inhibitors and IL-23 (p19) inhibitors are approved for PsA. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) 2015 Treatment Recommendation suggests the treat-to-target strategy for PsA1), however, this recommendation does not indicate how to determine which biologics to use. Recent reports revealed that IL-17 inhibitors were as effective as TNF inhibitors2). On the other hand, based on the Tight Control of Psoriatic Arthritis (TICOPA) study, present treatment strategies for PsA aim to reach on minimal disease activity (MDA)3).

Objectives:

We investigate the effectiveness of IL-17 inhibitors focusing on MDA achievement which were administered for the Psoriatic Arthritis (PsA) patients in our institution.

Methods:

We examined 46 patients whom were diagnosed and treated in our institution. We analyzed DAS28-CRP as the evaluation of arthritis and Minimal Disease Activity (MDA) achievement as that of overall disease activity.

Results:

Biologics were administered in 30 cases (65.2%) of all 46 cases. In 30 cases, 19 cases (63.3%) initiated TNF inhibitors (TNFi) and 7 cases (23.3%) were IL-17 inhibitors (naïve group). In 9 cases, TNFi were switched into Il-17 inhibitors (switch group), 7 cases continued TNFi (TNFi group). Patients characteristics in the cases which could collect the data were shown in Table 1. As for arthritis, DAS28-CRP has significantly improved at fourth weeks in naïve and TNFi group. In switch group, DAS28-CRP has not demonstrated significant improvement, however, IL-17 inhibitors were effective for the cases to which they were initiated for arthritis. As for MDA, 71% and 78% have also achieved MDA at twentieth weeks in both naïve and switch groups. In the TNFi group, 67% have not achieved MDA at twentieth weeks because of no improvement of rash (Figure 1). In switch group, all cases to which IL-17 inhibitors were initiated for either arthritis or rash have achieved MDA, however, 40% of cases which were introduced for both arthritis and rash have not achieved MDA.

Table 1.

Comparison of clinical characteristics at baseline in 3 groups.

Il-17 naïve group (n=7)IL-17 switch group (n=9)TNF group (n=7)p valueAge, year60.7 ± 18.953.8 ± 15.450.7 ± 13.6N.SDisease duration, year20.3 ± 25.817.4 ± 9.59.9 ± 12.4N.SMale, n (%)3 (43)6 (67)5 (71)N.SMTX, n (%)2 (29)4 (44)5 (71)N.SCRP(mg/dl)0.41 ± 0.501.87 ± 3.131.07 ± 1.77N.SSwollen joint count6.7 ± 7.33.6 ± 4.26.2 ± 6.9N.STender joint count6.6 ± 7.02.2 ± 2.66.9 ± 9.0N.SPatient pain VAS55.7 ± 22.347.1 ± 34.935.4 ± 13.6N.SBSA (%)12.5± 17.37.7 ± 14.87.4 ± 7.2N.SBiologics, nSecukinumab: 2Ixekizumab: 5secukinumab: 3Ixekizumab: 5Brodalumab: 1Infliximab: 3Adalimumab:3Etanercept:1

TNF: Tumor Necrosis Factor, MTX: Methotrexate, VAS: visual analog scale, BSA: body surface area, N.S: not significant

Conclusion:

In our study, IL-17 inhibitors could bring high rate of MDA achievement for both naïve and switch from TNFi. We suggest that TNFi should be switched into IL-17 inhibitors rapidly in the case of ineffective for TNFi.

References:

[1]Coates LC, Kavanaugh A, Mease PJ, et al. Arthritis Rheumatol. 2016;68:1060-71.

[2]Miyagawa I, Nakayamada S, Tanaka Y. Curr Rheumatol Rep. 2019 20;21:21.

[3]Coates LC, Moverley AR, McParland L, et al. Lancet. 2015 19;386:2489-98.

Disclosure of Interests:

None declared

FRI0065 CLINICAL FEATURES OF METHOTREXATE ASSOCIATED LYMPHOPROLIFERATIVE DISORDER IN RHEUMATOID ARTHRITIS PATIENTS AND INFLUENCE OF CD8 POSITIVE LYMPHOCYTE INFILTRATION

Background:

Lymphoproliferative disorders (LPD) that develop in rheumatoid arthritis (RA) patients treated with MTX (MTX-LPD) is one of the important complications for RA patients. We have previously epidemiologically demonstrated an association between MTX and the development of LPD in RA patients1). MTX-LPD has varied pathologies including various clinical symptom and histological finding. Therefore, we need more information about MTX-LPD. In addition, it is one of the characteristics for MTX-LPD that spontaneous regression (SR) after MTX discontinuation. However, the mechanism of SR is not clarified.

Objectives:

We collect the information such as clinical symptom and histological finding of MTX-LPD with RA patients, and clarify the clinical features of MTX-LPD. In addition, we investigated the difference between SR cases and cases that treated with chemotherapy after MTX discontinuation (CTx cases).

Methods:

We enrolled 90 MTX-LPD patients from Kagawa Prefecture, Japan between June 2005 and December 2019. Patients were diagnosed according to American College of Rheumatology (ACR) 1987 classification criteria or ACR/European League Against Rheumatism (EULAR) 2010 classification criteria, and treated with disease modifying antirheumatic drugs (DMARDs) including MTX. We collected as follow information; age, gender, duration of RA, laboratory data (lymphocyte counts and sIL-2R) and treatment of MTX-LPD. In addition, we divided 16 MTX-LPD cases diagnosed histological into two groups (SR:CTx group; n=10:6), and analyzed the histological findings (CD4, CD8, CD163 and CD47) using the staining in immunohistochemistry (IHC) between the two groups. Each positive cell analyzed using virtual viewer soft ImageScope.

Results:

Characteristics of 90 MTX-LPD patients are as follow; mean age 66.5±11.2 years,63 female, duration of RA 18.5±19.4 years. 65 patients (72.2%) were spontaneously improved by discontinuing MTX. 58 patients (64.4%) were proven MTX-LPD histologically. In these patients, diffuse large B-cell lymphoma (DLBCL) was the most frequent histological type of MTX-LPD (56.9%). Infiltration of CD8 positive lymphocyte in the lesion was significant less in the SR cases than in the CTx cases (Figure 1). However, CD4, CD163 and CD47 positive cells had no significant difference between two groups.

Figure 1.

CD8 positive lymphocytes in the specimen of lesion using the staining in immunohistochemistry (IHC) between SR and CTxgroup.

Conclusion:

We revealed clinical features of MTX-LPD with RA patients. In addition, CD8 positive lymphocytes are involved in tumor immunity. In this study, we suggested that the extent of CD8 positive lymphocyte infiltration may predict SR of MTX-LPD. Further study is necessary on revealing the mechanism of SR in MTX-LPD.

References:

[1]Kameda T. et al. Arthritis Care Res (Hoboken). 2014 Sep;66(9):1302-9.

Disclosure of Interests:

None declared

AB0391 EFFECT OF HCQ ON LLDAS ACHIEVEMENT IN SLE PATIENTS

Background:

HCQ for SLE in Japan has been administered in many cases after approval. Therefore, the effect of additional administration of HCQ on low disease activity of SLE was considered to be clearer.

Objectives:

To clarify the effect of HCQ treatment on the control of disease activity in SLE patients.

Methods:

All SLE patients with low disease activity (LDA) enrolled in this study started additional HCQ treatment from January 2016. All patients with LDA enrolled in this study started HCQ treatment and had been receiving oral HCQ continuously for at least 3 months without using other immunosuppressive treatments or glucocorticoids. Disease activity was evaluated by SLEDAI, CLASI, and LLDAS, and serum complement values, anti-DNA antibodies, and pro-inflammatory cytokines were analyzed as immunological biomarkers before and after HCQ treatment.

Results:

52 of 100 patients were enrolled in this study (M:F; 4:48, average age; 40.6±13.4). 24 lupus nephritis patients were in sustained remission. 29 patients (56%) achieved LLDAS and 3 patients (6%) achieved clinical remission (CR) before HCQ administration.

Of the 20 patients (38%) who did not achieve LLDAS before HCQ administration, the LLDAS achievement rates at 3, 6, and 12 months after additional HCQ were 47%, 59%, and 81% (including 12.5% of CR achievement rates), respectively.

Serum levels of MRP8, MRP14, TNF-α, IL-6, VEGF-A, IL-1ra, MIP-1a and IL-2 decreased significantly 3 months after additional HCQ treatment. In addition, serum levels of MRP8, MRP14, TNF-α, IL-6 and IL-2 also decreased significantly 3 months after additional HCQ treatment despite achieving LLDAS or CR. The expressions of IFN-α didn’t decrease significantly in 9 cases that could be detected.

The magnitude of the changes in serum MRP8, MRP14, IL-8 and Il-1ra levels in patients with a history of LN was significantly higher than in those without a history of LN. The magnitude of the reduction in serum MCP-1 levels in patients not achieving LLDAS with a history of LN was significantly higher than in those without a history of LN(p=0.046).

The change of CLASI activity score was correlated with the change in serum levels of MRP14 and MCP-1 with univariate analysis (MRP14: r=-0.41, p=0.017, MCP-1: r=-0.58, p=0.0006). The change of serum C3 levels had a negative correlation with MCP-1(r=-0.33, p=0.022).

The magnitude of the change in serum levels of MRP14, TNF-α, IL-8, MCP-1, MIP-1a and IL-1ra in patients achieving LLDAS were correlated with the change of CLASI activity score with univariate analysis (MRP14: r=-0.49, p=0.041, TNFα: r=0.74, p=0.0038, IL-1ra: r=0.66, p=0.038, MIP-1a: r=0.63, p=0.037, Figure 1). Moreover, the change of serum C3 and C4 levels in them had a negative correlation with the change of serum MCP-1 levels (Figure 2).

Figure 1.

Correlation between change of CLASI activity scores and serum MCP-1 levels in SLE patients with LLDAS (IL-8: r=0.77,p=,0.0007, MCP-1: r=0.80,p=,0.0001).

Figure 2.

Correlation between change of serum C3 and C4 levels and serum MCP-1 levels in SLE patients with LLDAS (C3: r=-0.40, p=0.028, C4: r=-0.37, p=0.047).

Conclusion:

Additional administration of HCQ is useful for cytokine control even in LLDAS-achieved cases, and particularly contributes to the improvement of skin lesion.

In addition, regulation of IL-8 and MCP-1 is important for control of renal lesions of SLE, and more control of the activity of SLE

The effect of HCQ on IL-8 and MCP-1 is related to the control of renal lesions in SLE, so that disease activity of more SLE patients might be more controlled disease activity.

References:

[1]R Wakiya, et al. Hydroxychloroquine modulates elevated expression of S100 proteins in systemic lupus erythematosus. Lupus. 2019;28:826-833

Disclosure of Interests:

None declared

FRI0254 SERUM IL-17 AND IL-21 AFFECT THE HEMODYNAMICS IN CONNECTIVE TISSUE DISEASE ASSOCIATED-PULMONARY HYPERTENSION

Background:

Pulmonary hypertension associated with connective tissue disease (CTD-PH) has complicated pathology including immune abnormalities, cardiac and pulmonary lesions. Therefore, it is difficult for rheumatologist to manage CTD-PH. We hesitate to use immunosuppressants in addition to pulmonary vasodilators to treat CTD-PH. Although there is a report that the cytokine such as Interleukin (IL)-6, IL-17 and IL-21 are involved in the development of PH1), changes in the hemodynamics of theses cytokines with treatment are not clear.

Objectives:

We investigate serum cytokine profile and clinical appearance in CTD-PH, and clarify the relationship between change in cytokines and hemodynamics before and after treatment.

Methods:

14 cases of CTD-PH (8 cases in Scleroderma; SSc-PH group, 4 cases in Mixed connective tissue disease; MCTD-PH group, 2 cases in Systemic lupus erythematosus; SLE-PH group), 6 cases in Other-PH group, and 2 cases of SSc without PH as controls were included. The following clinical data were collected: age, gender, underlying disease, complication of interstitial lung disease, treatment (immunosuppressant and pulmonary vasodilator). Serum samples in pre- and post-capillary before and after treatment were collected during cardiac catheterization examination. Serum cytokines (MCP-1, IL-6, IL-17 and IL-21) of these samples were measured by ELISA (ABCAM, UK).

Results:

Serum MCP-1, IL-6, and IL-21 levels were higher in SSc-PH group than in the other groups. Conversely, serum IL-17 levels tended to be higher in non-SSc group compared to SSc-PH group. Additionally, serum MCP-1 levels in SSc-PH group decreased in post-capillary as compared to pre-capillary. Furthermore, patients with decreased serum IL-17 and IL-21 levels before and after treatment showed improved pulmonary hemodynamics.

Conclusion:

SSc-PH had a different cytokine profile compared with non-SSc-PH. We suggested that the serum IL-17 and IL-21 levels effect the hemodynamics in CTD-PH.

References:

[1]Hashimoto-Kataoka T. et al. Proc Natl Acad Sci U S A. 2015 May 19;112(20):E2677-86.

Disclosure of Interests:

None declared

AB0392 THE EFFECT OF HYDROXYCHLOROQUINE ON THE RISK FACTORS FOR ATHEROSCLEROSIS DEVELOPMENT

Background:

Systemic lupus erythematosus(SLE) patients, especially patients with lupus nephritis have poor vascular endothelial function and increased cardiovascular(CV) mortality.

Meanwhile, several studies showed hydroxychloroquine(HCQ) has effect on reduction in lipids and thrombosis(1), but the mechanism is unclear.

Objectives:

We examined effect of HCQ on adipocytokine expression in SLE patients.

Methods:

52 SLE patients with low disease activity started with HCQ were analyzed before and 3 months after HCQ treatment. 21 SLE patients has past history of lupus nephritis. Serum S100 proteins and adipocytokines were measured by ELISA, and serum inflammatory ctytokine levels were evaluated by Multiplex assay (TNF-α, IL-6, VEGF-A).

Results:

Serum adiponectin level was increased significantly 3 months after HCQ treatment compared with those at baseline (mean change 1.35, Figure 1). SLE patients who achieved LLDAS had a greater increase than those who did not. Additionally, the changes of serum adiponectin levels were associated with those of TNF-α, IL-6, VEGF-A and S100A9 protein, which plays an important role of SLE pathogenesis.

Figure 1.

Serum adiponectin levels at baseline were compared with levels after 3 months of HCQ treatment. Serum adiponectin levels significantly decreasing during HCQ treatment in SLE patients. For statistical analyses *p<0.0001,Pvalue: Wilcoxon signed-rank test

Conclusion:

A HCQ could reduce the risk factors for atherosclerosis along with control of SLE disease activity.

References:

[1]Wallace DJ, et al. Cholesterol-lowering effect of hydroxychloroquine in patients with rheumatic disease: reversal of deleterious effects of steroids on lipids. Am J Med. 1990; 89: 322-6.

Disclosure of Interests:

None declared

AB0493 COMPARISON OF EFFICACY AND SAFETY BETWEEN RITUXIMAB AND CYCLOPHOSPHAMIDE IN REMISSION INDUCTION THERAPY FOR JAPANESE ANCA-ASSOCIATED VASCULITIS(AAV) PATIENTS; A SINGLE CENTER RETROSPECTIVE ANALYSIS

Background:

Rituximab(RTX) and Cyclophosphamide(CY) has been indicated for ANCA-associated vasculitis(AAV) as remission induction therapy. However, older age and renal disfunction were independent predictor of treatment related adverse effects in remission induction with CY in recent reports1). Japanese AAV patients are characterized by the predominance of elderly, and the study about comparison of efficacy and safety between RTX and CY in elderly Japanese AAV patients are limited.

Objectives:

To compare the efficacy and safety between RTX versus CY as remission induction therapy in Japanese AAV patients.

Methods:

We analyzed 40 cases (20 cases received RTX and 20 cases received CY) who received remission induction therapy in our hospital between January 2016 and August 2019. Clinical and laboratory variables at diagnosis, rates of complete remission(CR) at 6 months, defined as Birmingham Vasculitis Activity Score (BVAS)=0 and prednisone 7.5 mg/day, AAV relapse at 12 months, and adverse effects were investigated.

Results:

Of 40 patients, mean age was 73.5±9.6 years (6 males and 34 females). Diagnosis of MPA and GPA were 30 cases and 10 cases, respectively. 37 cases (93%) were positive for MPO-ANCA. Treatment regimen was determined by attending physician. Baseline characteristic of each group (RTX group and CY group) are shown in Table1. Baseline charactor, disease activity, organ involvement, and the proportion of patients with relapsing disease were similar in the two treatment groups. At 6 months, there was no difference of remission rate between two groups (RTX: CY = 62%: 44%, p=0.35) (Figure 1). However, mean PSL dosage at 3 months was significantly lower in RTX group (10.0±4.6mg/day) as compared to CY group (15.8±9.5mg/day; p=0.025) (Figure 2). At 12 months, 1 case in CY group and no case in RTX group had relapse. Adverse effects through 12 months are shown in Table 2. 8 infections (30%) in CY group and 7 infections (35%) occurred in RTX group (p=0.64), respectively. 1 case in RTX group had died due to renal failure.

Table 1.

Comparison of clinical characteristics at baseline between RTX and CY groups.

RTX(n=20)CY(n=20)p valueDeath, n (%)1 (5)0 (0)0.50Infections, n (%)7 (35)8 (30)0.46Serious (grade 3), n (%)4 (15)3 (10)0.50Malignancy, n (%)1 (5)0 (0)0.50VTE, n (%)1 (5)0 (0)0.50AMI, n (%)1 (5)0 (0)0.50Leukopenia, n (%)3 (15)3 (10)0.70Necrosis of femoral head, n (%)0 (0)1 (5)0.50Mediastinal emphysema0 (0)1 (5)0.50

VTE: venous thrombotic emboli, AMI: acute myocardial infarction

Conclusion:

We indicated that PSL was tapered more rapidly in RTX group, although there was no difference of remission rate at 6 months and infection at 12 months between RTX and CY therapy. Therefore, remission induction therapy with RTX might be more safety for elderly Japanese AAV patients.

References:

[1]Little MA, Nightingale P, Verburgh CA, Hauser T, et al. Ann Rheum Dis 2010; 69:1036–1043.

Table 2.

Adverse effects through 12 months. % = patients with 1 effects

RTX(n=20)CY(n=20)p valueAge, year72.3 ± 11.074.8 ± 8.010.55female, n (%)16 (80)18 (90)0.33AAV type0.14 MPA, n (%)13 (65)17 (85) GPA, n (%)7 (35)3 (15)Newly diagnosis, n (%)7 (35)4 (20)0.24ANCA positivity MPO, n (%)20 (100)17 (85)0.12 PR3, n (%)1 (5)2 (10)0.50 negative, n (%)0 (0)2 (10)0.24 eGFR (mL/min)55.0 ± 29.558.1 ± 21.50.45Organ involvement General, n (%)14 (70)19 (95)0.046* Cutaneous, n (%)1 (5)3 (15)0.30 Eyes, n (%)4 (20)1 (5)0.17 ENT, n (%)5 (25)5 (25)1.00 Pulmonary, n (%)14 (70)15 (75)0.50 Renal, n (%)14 (70)13 (65)0.50 Neurologic, n (%)8 (40)4 (20)0.15BVAS13.8 ± 6.614.1 ± 7.60.73

RTX: Rituximab, CY: Cyclophosphamide, ANCA: antineutrophil cytoplasmic autoantibody, AAV: ANCA-associated vasculitis, GPA: granulomatosis with polyangiitis, MPA: microscopic polyangiitis, ENT: Ear, Nose, and Throat, BVAS Birmingham Vasculitis Activity Score, * p <0.05

Disclosure of Interests:

None declared

SAT0057 PREDICTING INADEQUATE RESPONSE TO JAK INHIBITORS BY CLUSTER ANALYSIS IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Oral Janus kinase inhibitors (JAKi) have dramatically altered outcomes in patients with rheumatoid arthritis (RA). However, there remains some proportion of patients who respond to inadequately JAKi treatment (JAKi-IR) [1,2]. The characteristics in RA patients associated with JAKi-IR have not been fully demonstrated.

Objectives:

To clarify the characteristics of JAKi-IR in patients with RA by cluster analysis.

Methods:

This retrospective study comprised 120 RA patients who were treated with JAKi (Tofacitinib or Baricitinib) between July 2013 and September 2019 in five facilities. The disease status at the baseline, at 12 weeks after JAKi treatment and at the time point of withdrawing JAKi was assessed using the Disease Activity Score (DAS28) and the American College of Rheumatology (ACR) response criteria. JAKi-IR was defined as follows, primary non-response at 12 weeks after JAKi treatment: withdrawal of JAKi with ACR20 non-response or non-improvement in DAS28-CRP (ΔDAS28-CRP<1.2 from baseline), secondary non-response: withdrawal of JAKi without clinical remission after 12 weeks. Hierarchical cluster analysis was performed with the following variables: gender, age, disease duration, bone erosion, ACR functional classification (Class ≥3), comcomitant rheumatoid arthritis related interstitial lung disease (RA-ILD) or other autoimmune disease (AID), anti-citrullinated protein antibody (ACPA) positivity, rheumatoid factor (RF) at baseline, use/dose of methotrexate (MTX) and prednisolone (PSL), serum ESR/CRP, tender/swollen joint counts (TJC/SJC), visual analog scale by patients (VAS-Pt), and prior of biologic DMARDs.

Results:

The 120 enrolled patients were classified into 4 groups by cluster analysis(Figure1), The characteristics of each group are as follows, Group A(n=21): female + bone erosion + RF/ACPA positive + AID + MTX non-user, Group B(n=36): male + older age + RA-ILD + RF/ACPA positive + MTX non-user, Group C(n=35): RF/ACPA positive + absence of RA-ILD + MTX user, Group D (n=28): seronegative + MTX user + absence of RA-ILD + history of biologic DMARDs failure. The rate of JAKi-IR was A:9%, B:8%, C:20%, D:32%, and the significant difference between Group B and D was identified (p=0.02). In multiple comparison of 4 groups, no significant difference was identified (p=0.06) (Figure2).

Conclusion:

JAKi-IR would be more likely to be seronegative, MTX use, absence of RA-ILD and history of biologic DMARDs failure. Cluster analysis is an exploratory tool that aids in the analysis of huge amount of data.

References:

[1] Takeuchi T, Yamanaka H, Yamaoka K, Arai S, Toyoizumi S, DeMasi R, et al. Efficacy and safety of tofacitinib in Japanese patients with rheumatoid arthritis by background methotrexate dose: A post hoc analysis of clinical trial data. Mod Rheumatol. 2019;29(5):756-66.

[2] Tanaka Y, Atsumi T, Amano K, Harigai M, Ishii T, Kawaguchi O, et al. Efficacy and safety of baricitinib in Japanese patients with rheumatoid arthritis: Subgroup analyses of four multinational phase 3 randomized trials. Mod Rheumatol. 2018;28(4):583-91.

Disclosure of Interests:

Masanari Sugawara: None declared, Yuichiro Fujieda: None declared, Atsushi Noguchi: None declared, Shun Tanimura: None declared, Yuka Shimizu: None declared, Ikuma Nakagawa: None declared, Michihito Kono: None declared, Masaru Kato: None declared, Kenji Oku: None declared, Tatsuya Atsumi Grant/research support from: Eli Lily Japan K.K., Alexion Pharmaceuticals, Inc., Bristol-Myers Squibb Co., AbbVie Inc., Daiichi Sankyo Co., Ltd., Pfizer Inc., Chugai Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Astellas Pharma Inc., Consultant of: Gilead Sciences, Inc., Eli Lilly Japan K.K., UCB Japan Co. Ltd., AbbVie Inc., Daiichi Sankyo Co., Ltd., Pfizer Inc., Chugai Pharmaceutical Co., Ltd., Speakers bureau: Eli Lilly Japan K.K., UCB Japan Co. Ltd., Bristol-Myers Squibb Co., AbbVie Inc., Eisai Co. Ltd., Otsuka Pharmaceutical Co., Ltd., Daiichi Sankyo Co., Ltd., Pfizer Inc., Chugai Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Takeda Pharmaceutical Co., Ltd., Astellas Pharma Inc.