POS1014 CENTRAL SENSITIZATION HAS MAJOR IMPACT ON QUALITY OF LIFE IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background:

Maintaining optimal health-related quality of life (QoL) is the ultimate goal of treatment in axial spondyloarthritis (axSpA). Chronic pain has a large potential impact on QoL. Central sensitization (CS) may explain part of the chronic pain in axSpA. However, the role of central sensitization (CS) herein has only been studied to a limited degree and current axSpA guidelines pay little attention to identification and treatment of CS.

Objectives:

To explore the relationship between CS and QoL in axSpA.

Methods:

Consecutive outpatients with axSpA from the Groningen Leeuwarden Axial Spondyloarthritis (GLAS) cohort were included. CS was assessed with the Central Sensitization Inventory (CSI; 0-100), QoL with the AS Quality of Life questionnaire (ASQoL; 0-18) and disease activity with the AS Disease Activity Score (ASDASCRP). A high probability of CS was defined as CSI score ≥40 and active disease as ASDASCRP score ≥2.1. Patient characteristics and clinical assessments were compared between groups with CSI score <40 and ≥40.(1) Multivariable regression analysis was conducted to investigate the relationship between CSI and ASQoL scores, correcting for potential confounders.

Results:

Of the 178 axSpA patients with available CSI score, 149 completed the ASQoL. Mean age of the 178 included patients was 47.4 ± 14.1 years, 78 (44%) were female, mean symptom duration was 21.4 ± 13.6 years and 88 (52%) were using bDMARDS. Mean CSI score was 38.0 ± 14.1, mean ASQoL 6.0 ± 5.3 and mean ASDASCRP 2.1 ± 1.0. CSI score ≥40 was significantly associated with higher mean ASQoL (9.7 vs. 3.3), higher mean ASDASCRP (2.6 vs. 1.7), female gender (60% vs. 29%) and more often entheseal involvement (61% vs. 26%) (Table 1).

Table 1.

Selection of patient characteristics, disease activity and clinical outcome variables for patients with axSpA, divided in subgroups for CSI score with a cutoff point of 40.

CharacteristicsAll patientsn = 178CSI<40n = 98 (55%)CSI≥40n = 80 (45%)Age (years)47.4 ± 14.148.7 ± 15.045.8 ± 12.7Female78 (44)27 (29)44 (60)*Symptom duration (years)21.4 ± 13.621.5 ± 13.521.2 ± 13.8HLA-B27+133 (79)70 (79)54 (79)Smoker45 (27)28 (32)15 (23)BMI (kg/m2)26.7 ± 5.026.2 ± 4.427.5 ± 5.8Completed higher education181 (71)48 (70)34 (76)Biological use88 (52)49 (52)39 (51)RDCI (0-9)0.0 (0.0 – 1.0)0.0 (0.0 – 1.0)0.0 (0.0 – 1.8)Peripheral arthritis210 (6)5 (6)5 (8)Entheseal involvement364 (40)23 (26)38 (61)*ASDASCRP2.1 ± 1.01.7 ± 0.92.6 ± 1.0*CRP (mg/ml)2.9 (1.1 – 6.8)2.6 (1.1-6.0)3.6 (1.4 – 7.0)ASQoL (0-18)6.0 ± 5.33.3 ± 3.69.7 ± 4.9*CSI (0-100)38.0 ± 14.128.0 (23 – 34)50.0 (43.0 –56.0)N/A

Values are n (%), mean ± SD or median (IQR).

1International Standard Classification of Education (ISCED) level >4; 2Swollen Joint Count >0; 3Maastricht Ankylosing Spondylitis Enthesitis Score >0. *p<0.001. ASDASCRP: Ankylosing Spondylitis Disease Activity Score; ASQoL: Ankylosing Spondylitis Quality of Life questionnaire; CRP: C-reactive protein; CSI: Central Sensitization Inventory; RDCI: Rheumatic Disease Comorbidity Index.

Patients with low ASDASCRP (<2.1) and also low CSI score (<40) showed good QoL (median ASQoL 1.1). Patients with low ASDASCRP combined with high CSI score (≥40) and patients with high ASDASCRP (≥2.1) combined with low CSI score reported worse QoL (median ASQoL 5.6 and 4.1, respectively). Patients with high ASDASCRP and also high CSI score reported the worst QoL (median ASQoL 12.0). (Figure 1).

Figure 1.

ASQoL score in patients with axSpA with CSI score ≥40 and <40, divided for ASDASCRP (cutoff 2.1)

Additionally, in univariable analysis, the CSI score explained a large proportion of the variation of the ASQoL (R2=0.46). This association remained significant after correction for ASDASCRP, gender, symptom duration, entheseal involvement, smoking status, BMI category, educational level and comorbidities in multivariable analysis (CSI p<0.001).

Conclusion:

In daily clinical practice, CS seems strongly related to patient-reported QoL in patients with long-term axSpA.

References:

[1]Neblett R et al. J Pain. 2013;14:438–45.

Acknowledgements:

The authors would like to thank all patients who participated in the GLAS cohort. Furthermore, the authors wish to acknowledge Mrs. B. Burmania, Mrs. B. Hollander, Mrs. S. Katerbarg, Mrs. S. Lange, Mrs. E. Markenstein, Mrs. R. Rumph and Mrs. M. de Vries-Veldman for their contribution to clinical data collection.

Disclosure of Interests:

Stan Kieskamp: None declared, Davy Paap: None declared, Marlies Carbo: None declared, Freke Wink Consultant of: Abbvie, Reinhard Bos: None declared, Hendrika Bootsma Grant/research support from: Roche, Suzanne Arends Grant/research support from: Pfizer, Anneke Spoorenberg Consultant of: Abbvie, Pfizer, MSD, UCB, Lilly, Novartis, Grant/research support from: Abbvie, Pfizer, UCB, Novartis.

POS1002 BASELINE CALPROTECTIN AND VISFATIN LEVELS PREDICT RADIOGRAPHIC SPINAL PROGRESSION AFTER 2 YEARS IN ANKYLOSING SPONDYLITIS PATIENTS ON TNF INHIBITOR THERAPY

Background:

Radiographic spinal progression determinates functional status and mobility in ankylosing spondylitis (AS)1.

Objectives:

To analyse whether biomarker of inflammation, bone turnover and adipokines at baseline or their change after 3 months or 2 years can predict spinal radiographic progression after 2 years in AS patients treated with TNF-α inhibitors (TNFi).

Methods:

Consecutive AS patients from the Groningen Leeuwarden Axial Spondyloarthritis (GLAS) cohort2 starting TNFi between 2004 and 2012 were included. The following serum biomarkers were measured at baseline, 3 months and 2 years of follow-up with ELISA:

 - Markers of inflammation: calprotectin, matrix metalloproteinase-3 (MMP-3), vascular endothelial growth factor (VEGF)

 - Markers of bone turnover: bone-specific alkaline phosphatase (BALP), serum C-terminal telopeptide (sCTX), osteocalcin (OC), osteoprotegerin (OPG), procollagen typ I and II N-terminal propeptide (PINP; PIINP), sclerostin.

 - Adipokines: high molecular weight (HMW) adiponectin, leptin, visfatin

Two independent readers assessed spinal radiographs at baseline and 2 years of follow-up according to the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). Radiographic spinal progression was defined as mSASSS change ≥2 units or the formation of ≥1 new syndesmophyte over 2 years. Logistic regression was performed to examine the association between biomarker values at baseline, their change after 3 months and 2 years and radiographic spinal progression. Multivariable models for each biomarker were adjusted for mSASSS or syndesmophytes at baseline, elevated CRP (≥5mg/l), smoking status, male gender, symptom duration, BMI, and baseline biomarker level (the latter only in models with biomarker change).

Results:

Of the 137 included AS patients, 72% were male, 79% HLAB27+; mean age at baseline was 42 years (SD 10.8), ASDAScrp 3.8 (0.8) and mSASSS 10.6 (16.1). After 2 years of follow-up, 33% showed mSASSS change ≥2 units and 24% had developed ≥1 new syndesmophyte. Serum levels of biomarkers of inflammation and bone formation showed significant changes under TNFi therapy, whereas adipokine levels were not altered from baseline (Figure 1).

Univariable logistic regression revealed a significant association of baseline visfatin (odds ratio OR [95% confidence interval] 1.106 [1.007-1.215]) and sclerostin serum levels (OR 1.006 [1.001-1.011]) with mSASSS progression after 2 years. Baseline sclerostin levels were also associated with syndesmophyte progression (OR 1.007 [1.001-1.013]). In multivariable logistic analysis, only baseline visfatin level remained significantly associated (OR 1.465 [1.137-1.889]) with mSASSS progression. Furthermore, baseline calprotectin showed a positive association with both, mSASSS (OR 1.195 [1.055-1.355]) and syndesmophyte progression (OR 1.107 [1.001-1.225]) when adjusting for known risk factors for radiographic progression.

Univariable logistic regression showed that change of sclerostin after 3 months was associated with syndesmophytes progression (OR 1.007 [1.000-1.015), change of PINP level after 2 years was associated with mSASSS progression (OR 1.027 [1.003-1.052]) and change of visfatin after 2 years was associated with both measures of radiographic progression – mSASSS (OR 1.108 [1.004-1.224]) and syndesmophyte formation (OR 1.115; [1.002-1.24]). However, those associations were lost in multivariable analysis.

Conclusion:

Independent of known risk factors, baseline calprotectin and visfatin levels were associated with radiographic spinal progression after 2 years of TNFi. Although biomarkers of inflammation and bone formation showed significant changes under TNFi therapy, these changes were not significantly related to radiographic spinal progression in our cohort of AS patients.

References:

[1]Poddubnyy et al 2018

[2]Maas et al 2019

Acknowledgements:

Dr. Judith Rademacher is participant in the BIH-Charité Clinician Scientist Program funded by the Charité –Universitätsmedizin Berlin and the Berlin Institute of Health.

Disclosure of Interests:

Judith Rademacher: None declared, Mark Siderius: None declared, Laura Gellert: None declared, Freke Wink Consultant of: AbbVie, Maryna Verba: None declared, Fiona Maas: None declared, Lorraine M Tietz: None declared, Denis Poddubnyy: None declared, Anneke Spoorenberg Consultant of: Abbvie, Pfizer, MSD, UCB, Lilly and Novartis, Grant/research support from: Abbvie, Pfizer, UCB, Novartis, Suzanne Arends Grant/research support from: Pfizer.

POS0034 RADIOGRAPHIC ENTHESEAL LESIONS AT HIP AND PELVIC REGION ARE ASSOCIATED WITH LONGER DISEASE DURATION, HIGHER BMI AND MORE SEVERE SPINAL AND HIP RADIOGRAPHIC DAMAGE IN PATIENTS WITH ANKYLOSING SPONDYLITIS

Background:

Enthesitis is an important feature of ankylosing spondylitis (AS) and structural and inflammatory entheseal lesions (EL) are frequently present on ultrasound. Plain radiographs also provide good imaging of structural entheseal involvement1. Until now, little is known about the presence of structural EL at the hip and pelvic region and the association with patient characteristics in AS.

Objectives:

Our aim was to investigate the prevalence of radiographic EL at the hip and pelvic region in AS patients compared to age and sex matched control subjects and to explore the relation with AS patient characteristics.

Methods:

AS patients from the Groningen Leeuwarden Axial SpA (GLAS) cohort, included between November 2004 and December 2010, with available anteroposterior (AP) pelvis radiographs at baseline were included. All patients fulfilled the modified New York criteria for AS. Additionally, 100 randomly selected AP pelvis radiographs from age and sex matched control subjects were obtained from the radiology department of the University Medical Center Groningen. The sacroiliac joints of all radiographs were blinded and radiographs were scored independently by two trained observers unaware of patient characteristics and treatment. The entheseal sites scored were: trochanter major, trochanter minor, os ischium, crista iliaca, both left and right side. The following 3 EL were scored: erosion/cortical irregularity, calcification and enthesophyte. Only lesions with absolute agreement between both observers were used for analyses. Radiographic spinal involvement was scored according to the modified Stoke AS Spine Score (mSASSS; range 0-72) and radiographic hip involvement according to the Bath AS Radiology Index (BASRI)-hip (range 0-4). Independent samples t test, Mann-Whitney U test, Chi-Square test, and Fisher Exact test were used to compare patient characteristics between patients with and without radiographic EL.

Results:

Of the 167 included AS patients, 117 (70%) were male, mean age was 43 ± 11 years, 133 (80%) were HLA-B27 positive and median symptom duration was 16 years (range 1-53). 127 (76%) AS patients and 58 (58%) controls showed EL, with 501 lesions in total of which 377 (75%) in AS patients. AS patients showed significantly more lesions than controls at all 5 locations. Os ischii showed the most lesions in both AS patients and controls (66% vs 53%, p<0.05). The most prevalent type of lesion in both groups was erosion/cortical irregularity (72% vs 51%, p<0.005). Enthesophytes were also more often observed in AS patients than in controls (31% vs 21%, p=0.07). Prevalence of calcifications was low in both groups and not significantly different (5% vs 2%, p=0.22). AS patients with EL were significantly older (mean 45.2 vs 35.1 yrs, p<0.005) and had longer symptom duration (median 18 vs 7.5 yrs, p<0.005) than patients without EL. Furthermore, patients with BMI >25 had significantly more often enthesophytes (42% vs 16%, p<0.05) than patients with a normal BMI. Additionally, AS patients with EL had significantly more often radiographic spinal damage than patients without EL with median mSASSS total score 8.7 vs 1.0 (p<0.005) and a trend toward significance for radiographic hip involvement (BASRI-hip score ≥2; p=0.06).

Conclusion:

Radiographic EL at hip and pelvic region are significantly more prevalent in AS patients than in age and sex matched controls. AS patients with EL were significantly older, had longer symptom duration and more spinal radiographic damage than patient without EL. Furthermore, BMI >25 was associated with a higher prevalence of enthesophytes. These new findings contribute to the knowledge of entheseal involvement in AS.

References:

[1]Voudouris et al. J Musculoskelet Neuronal Interact. 2003;3(1):89-100.

Disclosure of Interests:

Freke Wink Consultant of: Abbvie, Thomas Diemel: None declared, Suzanne Arends: None declared, Anneke Spoorenberg Consultant of: Abbvie, Pfizer, MSD, UCB, and Novartis, Grant/research support from: Abbvie, Pfizer, UCB and Novartis.

OP0130 COMPOSITE OF RELEVANT ENDPOINTS IN SJÖGREN’S SYNDROME (CRESS): A COMPREHENSIVE TOOL FOR CLINICAL TRIALS

Background:

Several large randomised controlled trials (RCTs) in primary Sjögren’s syndrome (pSS) failed to demonstrate drug efficacy.1-4 Many of these trials used ESSDAI as primary endpoint, showing large but similar response rates in active treatment and placebo groups.1,3,4 Given the heterogeneous nature of pSS, there is need for a composite endpoint including multiple clinically relevant parameters.

Objectives:

To develop and validate the Composite of Relevant Endpoints in Sjögren’s Syndrome (CRESS).

Methods:

A multidisciplinary team of pSS experts selected clinically relevant items and measurements to include in the CRESS. Definition of response of CRESS items was based on clinical relevance, previously defined minimal clinically important improvement (MCII) and data of the single-centre ASAP-III (abatacept) trial.1 CRESS was validated in three independent RCTs: TRACTISS (rituximab) trial2, multi-centre abatacept trial3 and ETAP (tocilizumab) trial4. CRESS response rates were assessed at the primary endpoint visit of all four trials.

Results:

Five complementary items were selected to form CRESS: systemic disease activity, patient-reported symptoms, tear gland, salivary gland and serological item. Definition of response per item is presented in Table 1. Total CRESS response was defined as response on ≥3 of 5 items. Since not all trials have ocular staining score or salivary gland ultrasonography (SGUS) available, the concise CRESS (cCRESS) was developed simultaneously, leaving Schirmer’s test and unstimulated whole saliva flow for the tear and salivary gland items, respectively. In the ASAP-III trial, CRESS response rates were 24/40 (60%) for abatacept vs. 7/39 (18%) for placebo at week 24 (p<0.001).

Table 1.

CRESS items and definition of response

ItemsMeasurementsDefinition of responseSystemic disease activityClinESSDAIScore<5 (low disease activity)Patient-reported symptomsESSPRIDecrease of ≥1 point or ≥15%Tear gland*Schirmer/OSS**-If abnormal Schirmer (≤5 mm) at baseline: increase of ≥5 mm in Schirmer-Or if abnormal OSS (≥3 points) at baseline: decrease ≥2 points in OSS-Or if both Schirmer/OSS normal scores at baseline: no change to abnormal in bothSalivary gland*UWS/SGUSIncrease of ≥25% in UWS (or if score is 0 at baseline, any increase)Or decrease of ≥25% in total Hocevar score (SGUS)SerologicalRF/IgGDecrease of ≥25% in RFOr decrease of ≥10% in IgGCRESS responderResponder on ≥3 of 5 items

Ocular Staining Score (OSS), Unstimulated whole salivary flow (UWS), Salivary gland ultrasonography (SGUS), Rheumatoid factor (RF), Immunoglobuline G (IgG)

*Concise CRESS (cCRESS): CRESS without OSS and SGUS, leaving Schirmer and UWS for tear and salivary gland items, respectively

**Mean of both eyes

In the external validation trials, cCRESS response rates for TRACTISS were: 33/67 (49%) rituximab vs. 20/66 (30%) placebo at week 48 (p=0.026). CRESS response rates (without SGUS) for the multi-centre abatacept trial were: 41/92 (45%) abatacept vs. 30/95 (32%) placebo at week 24 (p=0.067). cCRESS response rates (without rheumatoid factor) for ETAP were: 10/55 (18%) tocilizumab vs. 13/55 (24%) placebo at week 24 (p=0.482) (Figure 1A-D). Compared to ESSDAI MCII of ≥3 points decrease, CRESS was able to approximately halve placebo response rates in RCTs with high baseline ESSDAI scores (>5) (Figures 1E-H).

Conclusion:

CRESS shows lower placebo response rates compared to ESSDAI MCII, which is crucial for demonstrating treatment efficacy. With the CRESS, higher response rates in abatacept and rituximab treated patients compared to placebo were found in RCTs which previously showed negative primary endpoint results. CRESS confirmed that no differences were found for almost all outcome measures between tocilizumab and placebo,4 with low response rates. The CRESS is a well-balanced, feasible, composite endpoint for use in clinical trials in pSS patients.

References:

[1]Van Nimwegen 2020;9913(19):1–11

[2]Bowman 2017;69(7):1440–50

[3]Baer (doi:218599)

[4]Felten (doi:21846)

Acknowledgements:

The authors would like to acknowledge all contributors of the included trials.

Disclosure of Interests:

Suzanne Arends: None declared, Liseth de Wolff: None declared, Jolien F. van Nimwegen Speakers bureau: Bristol Myers Squibb, Consultant of: Bristol Myers Squibb, Gwenny M. Verstappen: None declared, Jelle Vehof: None declared, Michele Bombardieri Consultant of: MedImmune, GlaxoSmithKline, Grant/research support from: MedImmune, Simon J. Bowman Consultant of: AstraZenecea/MedImmune, Bristol Myers Squibb, Celgene, Eli Lilly, Glenmark, GlaxoSmithKline, MTPharma, Novartis, Ono, Pfizer, Takeda, UCB, XTLBio, Elena Pontarini: None declared, Alan Baer Consultant of: Bristol Myers Squibb, Sanofi, VielaBio, Novartis, Marleen Nys Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Jacques-Eric Gottenberg Grant/research support from: Bristol Myers Squibb, Pfizer, Renaud FELTEN: None declared, Neelanjana Ray Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Arjan Vissink: None declared, Frans G.M. Kroese Speakers bureau: Bristol Myers Squibb, Roche and Janssen-Cilag, Consultant of: Bristol Myers Squibb, Grant/research support from: Unrestricted grants from Bristol Myers Squibb, Hendrika Bootsma Speakers bureau: Bristol Myers Squibb and Novartis, Consultant of: Bristol Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Grant/research support from: Unrestricted grants from Bristol Myers Squibb and Roche

Adalimumab and infliximab survival in patients with hidradenitis suppurativa: a daily practice cohort study

BACKGROUND

Biologics are often required for the treatment of hidradenitis suppurativa (HS). However, data on the drug survival of biologics in daily practice are currently lacking.

OBJECTIVES

To assess the drug survival of antitumour necrosis factor biologics in a daily practice cohort of patients with HS and to identify predictors for drug survival.

METHODS

A retrospective multicentre study was performed in two academic dermatology centres in the Netherlands. Adult patients with HS using biologics between 2008 and 2020 were included. Drug survival was analysed with Kaplan-Meier survival curves and predictors of survival with univariate Cox regression analysis.

RESULTS

The overall drug survival of adalimumab (n = 104) at 12 and 24 months was 56·3% and 30·5%, respectively, which was predominantly determined by infectiveness. Older age (P = 0·02) and longer disease duration (P < 0·01) were associated with longer survival time. For infliximab (n = 44), overall drug survival was 58·3% and 48·6% at 12 and 24 months, respectively, and was predominantly determined by infectiveness and side-effects. Surgery during treatment was associated with a longer survival time (P = 0·01).

CONCLUSIONS

Survival rates were comparable for adalimumab and infliximab at 12 months, and were mainly determined by ineffectiveness. Age, disease duration (adalimumab) and surgery (infliximab) are predictors for longer survival.

Low body weight and involuntary weight loss are associated with Raynaud's phenomenon in both men and women

Objectives: Low body weight is an easily assessable cause of Raynaud's phenomenon (RP), and is frequently overlooked by clinicians. We aim to investigate the association of low body weight (body mass index < 18.5 kg/m²), involuntary weight loss, and nutritional restrictions with the presence of RP.Method: Participants from the Lifelines Cohort completed a validated self-administered connective tissue disease questionnaire. Subjects who reported cold-sensitive fingers and biphasic or triphasic colour changes were considered to suffer from RP. Patient characteristics, anthropometric measurements, and nutritional habits were collected. Statistical analyses was stratified for gender.Results: Altogether, 93 935 participants completed the questionnaire. The prevalence of RP was 4.2% [95% confidence interval (CI) 4.1-4.4%], and was three-fold higher in women than in men (5.7% vs 2.1%, p < 0.001). Subjects with RP had a significantly lower daily caloric intake than those without RP. Multivariate analysis, correcting for creatinine level, daily caloric intake, and other known aetiological factors associated with RP, revealed that low body weight [men: odds ratio (OR) 5.55 (95% CI 2.82-10.93); women: 3.14 (2.40-4.10)] and involuntary weight loss [men: OR 1.32 (1.17-1.48); women: 1.31 (1.20-1.44)] were significantly associated with the presence of RP. Low-fat diet was also associated with RP in women [OR 1.27 (1.15-1.44)].Conclusion: Low body weight and prior involuntary weight loss are associated with an increased risk of RP in both men and women. This study emphasizes that low body weight and weight loss are easily overlooked risk factors for RP, and should be assessed and monitored in subjects with RP.

SAT0170 COMPOSITE OF RELEVANT ENDPOINTS FOR SJÖGREN’S SYNDROME (CRESS)

Background:

Defining a primary study endpoint that is able to discriminate between active treatment and placebo is crucial for clinical trials in primary Sjögren syndrome (pSS). Recent trials used the validated ESSDAI as primary endpoint, but found large ‘response rates’ in the placebo group too. Since pSS is a very heterogenous disease, a composite endpoint including multiple aspects (i.e., systemic, patient-reported, functional and biological) may be more appropriate to demonstrate clinical efficacy.

Objectives:

To develop a composite endpoint for pSS based on expert opinion and analysis of trial data.

Methods:

Based on expert opinion, 5 items were found to be most relevant to assess the effect of treatment in pSS patients: ESSDAI, ESSPRI, OSS, SWS and RF/IgG (Figure 1). These items were tested using data at week 24 of the randomized, double blind, placebo-controlled ASAP-III trial.1ROC analysis was used to assess the discrimination of effect between the abatacept (n=40) and placebo (n=39) treatment groups. The optimal cut-off point per item was defined by the highest sum of sensitivity and specificity. The percentage of patients responding to the individual items (Figure 1) and the composite endpoint (named CRESS) was calculated.

Results:

For ESSDAI, ROC analysis showed that both absolute and relative change in ESSDAI were not able to discriminate between treatment groups (AUC 0.536 and 0.559) and no optimal cut-off point could be identified. According to an in SLE developed endpoint and based on expert opinion, it was decided to aim for the validated definition of low disease activity (ESSDAI<5)2.

For ESSPRI, ROC analysis (AUC 0.629) showed an optimal cut-off point of -13.8%. Therefore, the validated definition of ESSPRI response (≥-15% or 1 point)2was used. For OSS and SWS, ROC analysis (AUC 0.555 for OSS>3 at baseline and AUC 0.556 for SWS>0 at baseline) could not identify an optimal cut-off point, so the definitions based on expert opinion were kept (Figure 1).

For serological items, ROC analysis (AUC 0.861 for RF>0 at baseline and 0.615 for IgG) showed optimal cut-off points of -23% and -2.2%, respectively. It was decided to round these numbers to ≥25% decrease in RF or ≥5% decrease in IgG. Responding to ≥3 of the 5 items discriminated best between the abatacept and placebo groups. The final response rate to our composite endpoint (CRESS responders) was 55% vs. 13% in the abatacept and placebo groups, respectively (P<0.001). Further analysis of how many patients who met the composite endpoint also met the single endpoints and vice versa demonstrated that all individual items contributed to the overall response rate.

Conclusion:

This concept of the new ‘Composite of Relevant Endpoints for Sjögren’s Syndrome’ (CRESS) is developed. With this composite endpoint, it is possible to discriminate between abatacept and placebo response in pSS patients. Additional validation analyses in independent, global, multi-center, placebo-controlled trials of biological DMARDs in pSS and NECESSITY will be performed.

References:

[1]van Nimwegen et al. Lancet Rheumatol.Published online 31-01-2020.

[2]Seror et al. Ann Rheum Dis. 2016;75(2):382-9.

Acknowledgments:

The authors would like to thank Raphaele Seror for initial discussions on potential components and criteria to be explored in the creation of a composite pSS endpoint. The authors would also like to acknowledge valuable discussions with Marleen Nys, Miroslawa Nowak, Dennis Grasela, Antoine Sreih and Subhashis Banerjee.

Disclosure of Interests:

Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Jolien F. van Nimwegen Consultant of: Bristol-Myers Squibb, Speakers bureau: Bristol-Myers Squibb, Gwenny M. Verstappen: None declared, Arjan Vissink: None declared, Neelanjana Ray Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Frans G.M. Kroese Grant/research support from: Unrestricted grant from Bristol-Myers Squibb, Consultant of: Consultant for Bristol-Myers Squibb, Speakers bureau: Speaker for Bristol-Myers Squibb, Roche and Janssen-Cilag, Hendrika Bootsma Grant/research support from: Unrestricted grants from Bristol-Myers Squibb and Roche, Consultant of: Consultant for Bristol-Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Speakers bureau: Speaker for Bristol-Myers Squibb and Novartis.

THU0376 THE EFFECT OF 8 YEARS OF TNF-Α BLOCKING THERAPY ON BONE MINERAL DENSITY IN PATIENTS WITH ANKYLOSING SPONDYLITIS

Background:

Ankylosing spondylitis (AS) is a chronic inflammatory disease that mainly affects the axial skeleton. Bone loss reflected by low bone mineral density (BMD) is a common feature of AS and can already be observed at early stages of the disease. A recent cohort study of 135 AS patients reported 7.2% improvement in lumbar spine BMD and 2.2% improvement in hip BMD after 4 years of tumor necrosis factor-alpha (TNF-α) blocking therapy.1

Objectives:

To assess the effect of 8 years of TNF-α blocking therapy on BMD of the lumbar spine and hip in AS patients.

Methods:

Included in this study were consecutive AS outpatients from the Groningen-Leeuwarden Axial SpA (GLAS) cohort who received TNF-α blocking therapy for at least 8 years. A maximum of one switch to another TNF-α inhibitor was allowed. Patients were excluded when they used bisphosphonates at baseline or during follow-up. BMD of the lumbar spine (anterior-posterior projection L1-L4) (LS-BMD) and hip (total proximal femur) (hip-BMD) was measured at baseline, 1 year, 2 years and then bi-annually using dual-energy X-ray absorptiometry (Hologic QDR Discovery (UMCG) or Hologic QDR Delphi (MCL), Waltman, MA, USA). Z-scores, the number of SD from the normal mean corrected for age and gender, were calculated using the NHANES reference database. Low BMD was defined as lumbar spine and/or hip BMD Z-score ≤1. Generalized estimating equations were used to analyze BMD over time within subjects. Pairwise contrast were used to compare baseline and follow-up visits. P values <0.05 were considered statistically significant.

Results:

In total, 131 AS patients were included; 73% were male, 83% HLA-B27+, mean age was 41.3 ± 10.8 years, median symptom duration 14 years (IQR 7-24), median CRP levels 13 mg/L (IQR 6-22), and 28% had poor vitamin 25(OH)D3 status (<50) at baseline. 27% of patients switched to a second TNF-α inhibitor during follow-up and disease activity improved significantly during treatment: mean ASDASCRP3.8 ± 0.8 at baseline and 2.1 ± 0.9 after 8 years (P<0.001). At baseline, low BMD at the lumbar spine and hip was present in 34% and 19% patients, respectively. Both LS-BMD and hip BMD Z-scores were significantly improved during TNF-α blocking therapy at all follow-up visits compared to baseline. Significant improvement compared to the previous time point was found up to and including 4 years for the lumbar spine and up to and including 2 years for the hip. Thereafter, flattening of improvement was observed. Median percentage of improvement in absolute BMD after 8 years of TNF-α blocking therapy compared to baseline was 7.1% (IQR 0.8-13.5) for the lumbar spine and 1.6% (IQR -3.5-5.5) for the hip (Figure 1).

Conclusion:

In AS patients with established disease, both lumbar spine and hip BMD improved significantly at group level during 8 years of TNF-α blocking therapy. This effect was most pronounced in the lumbar spine, which corresponds to the disease process in AS. Main improvements in lumbar spine BMD were observed during the first 4 years of treatment.

References:

[1]Beek et al. J Bone Miner Res. 2019; jun;34(6):1041-8

Disclosure of Interests:

Mark Siderius: None declared, Freke Wink Consultant of: Abbvie, Janssen, Anneke Spoorenberg: None declared, Suzanne Arends Grant/research support from: Grant/research support from Pfizer

FRI0300 ARE COPING STRATEGIES, ANXIETY AND DEPRESSION ASSOCIATED WITH DAILY PHYSICAL ACTIVITY IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS?

Background:

Patients with axial spondyloarthritis (axSpA) who are more physically active experience less pain and better physical functioning.1Psychological factors such as anxiety and depression are associated with physical functioning and reduction of Quality of Life (QoL).2Furthermore, evasive coping strategies are commonly used in health-related coping.3However, as far as we know, no data is available regarding the influence of coping strategies, anxiety and depression on daily physical activity in axSpA.

Objectives:

To determine if coping strategies, anxiety and depression are associated with daily physical activity in patients with axSpA.

Methods:

Consecutive outpatients from the Groningen Leeuwarden AxSpA cohort (GLAS) participated in this study. Additionally to the standardized follow-up assessments, patients filled out the axSpA-Short Questionnaire to assess health-enhancing physical activity (axSpA-SQUASH), the Coping with Rheumatic Stressors (CORS) and the Hospital Anxiety and Depression Scale (HADS). Univariable and multivariable linear regression analyses were performed to explore associations of copings strategies, anxiety and depression, and patient- and disease related factors with daily physical activity. Additionally, patients were stratified into three tertiles of physical activity: low, intermediate and high. To identify group differences, Kruskal-Wallis test or Chi-Square test were used with post-hoc testing.

Results:

In total 85 patients were included; 59% were male, mean age was 49±14, median symptom duration 19.5 years (IQR 12.0-31.0), 71% were HLA-B27 positive and mean ASDAS was 2.1±1.0. Median axSpA-SQUASH total physical activity score was 9406.3 (IQR 5538.8–12081.3). Median scores of HADS-Anxiety (scale 7-28) and HADS-Depression (scale 7-28) were scores of 12 (IQR 10.0-14.0) and 10(IQR 9.0-12.5). The mostly frequently used coping strategie was comforting cognitions (for pain, range 9-36); median of 25.5 (IQR 22.0-28.0).

Univariable analysis showed that lower daily physical activity was significantly associated with gender (female), higher disease activity (BASDAI), worse physical function (BASFI), worse quality of life (ASQoL), coping strategies ‘decreasing activities’ and ‘pacing’, higher depression score (HADS) and higher perceived influence of axSpA on general well-being. In multivariable analysis, only the coping strategy “decreasing activity” was independently associated with physical activity (β: -419.3, R2: 0.155, P<0.001). Additionally, patients in the highest physical activity tertile were significantly more often male, had higher working status, lower BASDAI and ASDAS, better BASFI and ASQoL and scored lower on the coping strategy “decreasing activities”.

Conclusion:

In this cross-sectional study in axSpA patients with established disease, multiple patient and disease related factors were associated with daily physical activity. The evasive coping strategy ‘decreasing activities’ was the only independently associated factor. These findings suggest that to improve daily physical activity in axSpA patients attention should be paid not only on targeting disease activity, but also to other patient and disease related aspects, especially coping strategies used.

References:

[1]Regel A et al.RMD Open. 2017;3(1):e000397.

[2]Kilic G et al.Med (United States). 2014;93(29):e337.

[3]Peláez-Ballestas I et al.Med (United States). 2015;94(10):e600.

Acknowledgments:

The authors would like to thank all patients who participated in the GLAS cohort.

Disclosure of Interests:

Marlies Carbo: None declared, Laura Overbeeke: None declared, Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Yvo Kamsma: None declared, Freke Wink Consultant of: Abbvie, Janssen, Davy Paap: None declared, Anneke Spoorenberg: None declared

THU0402 SERUM MARKERS OF BONE RESORPTION, FORMATION, AND MINERALIZATION DURING 8 YEARS OF TNF-Α BLOCKING THERAPY IN PATIENTS WITH ANKYLOSING SPONDYLITIS

Background:

Ankylosing spondylitis (AS) is a chronic inflammatory disease, characterized by both excessive bone formation and bone loss. The bone turnover marker (BTM) bone-specific alkaline phosphatase (BALP) plays a central role in bone mineralization. Our previous study demonstrated that 3 years of TNF-α blocking therapy results in a significant increase in BALP.1However, longer follow-up is needed to investigate whether BALP stays elevated during TNF-α blocking therapy and also to explore the course of other BTM, osteocalcin (OC), procollagen type 1 N-terminal peptide (PINP) and serum type 1 collagen C-telopeptide (sCTX) in AS.

Objectives:

To evaluate serum markers of bone resorption, formation, and mineralization during 8 years of TNF-α blocking therapy in AS patients.

Methods:

Included were consecutive AS outpatients from the University Medical Center Groningen (UMCG) attending the Groningen-Leeuwarden Axial SpA (GLAS) cohort and who were treated with a maximum of 2 TNF-α blockers for at least 8 years. Patients were excluded when they used bisphosphonates at baseline or during follow-up. Data for a specific visit was coded as missing when patients either had experienced a fracture or received systemic corticosteroids within 1 year of that particular visit. Clinical and laboratory measurements were performed at baseline (before start of TNF-α blocking therapy), 3 and 6 months as well as 1, 2, 4, 6 and 8 years. Markers of bone formation OC, PINP and BALP, and marker of bone resorption sCTX were measured in serum. Z-scores of BTM were calculated using matched 10-years-cohorts of a Dutch reference group to correct for the normal influence that age and gender have on bone turnover. Serum levels of 25-hydroxyvitamin D (25(OH)D3) were assessed yearly. Generalized estimating equations were used to analyze BTM Z-scores over time within patients. Simple contrast was used to compare follow-up visits to baseline. P-values <0.05 were considered statistically significant.

Results:

In total, 37 AS patients were analyzed; 62% were male, 86% HLA-B27+, mean age was 38.6 ± 10.4 years, median symptom duration 14 years (IQR 10-25), median CRP 13 mg/L (IQR 6-25), and 30% had low vitamin 25(OH)D3 status (<50) at baseline. 35% of patients switched to a second TNF-α inhibitor during follow-up. ASDASCRPimproved significantly during treatment, from mean 3.8 ± 0.9 at baseline to 1.9 ± 0.9 after 8 years of follow-up (P<0.001). 25(OH)D3 levels were stable at group level, median 58 nmol/L (IQR 45-70) at baseline and 60 nmol/L (IQR 50-70) after 8 years. Bone regulation marker OC Z-score was found to be significantly increased only after 3 months of TNF-α blocking therapy compared to baseline. No significant changes during follow-up were found for collagen resorption marker sCTX Z-score. Collagen formation marker PINP Z-score was significantly increased after 3 and 6 months as well as 2 years of TNF-α blocking therapy. Bone mineralization marker BALP Z-score was significantly increased at all time points up to and including 2 years and returned to baseline levels during 4 to 8 years of TNF-α blocking therapy (Figure 1).

Conclusion:

In this subgroup of AS patients with established and active disease responding to TNF-α blocking therapy, we observed that the bone turnover balance favored bone formation during the first years of TNF-α blocking therapy, which corresponds to previously reported improvement in bone mineral density, especially at the lumbar spine.1New finding of our study is that after 8 years of treatment, markers of bone resorption, formation, and mineralization were all comparable to baseline values.

References:

[1]Arends et al. Arthritis Res Ther. 2012;14(2):R98

Disclosure of Interests: :

Mark Siderius: None declared, Anneke Spoorenberg: None declared, Suzanne Arends Grant/research support from: Grant/research support from Pfizer

OP0162 ABATACEPT TREATMENT FOR PATIENTS WITH EARLY ACTIVE PRIMARY SJÖGREN’S SYNDROME: OPEN-LABEL EXTENSION PHASE OF A RANDOMIZED CONTROLLED PHASE III TRIAL

Background:

Abatacept (CTLA-4-Ig) targets the CD80/CD86:CD28 co-stimulatory pathway required for full T-cell activation and T-cell dependent activation of B-cells. The Abatacept Sjögren Active Patients phase III (ASAPIII) trial is a mono-center, investigator-initiated, placebo controlled study with an open-label extension phase (NCT02067910), which assessed the efficacy and safety of weekly subcutaneous abatacept (125mg) in patients with early active primary Sjögren’s syndrome (pSS). Previous analyses of the double blind phase showed no significant effect of abatacept treatment compared to placebo on the primary endpoint, difference in EULAR Sjögren’s syndrome disease activity index (ESSDAI) at week 24.1

Objectives:

To evaluate the efficacy and safety of extended (48 weeks) open label abatacept treatment in pSS patients.

Methods:

Included patients had biopsy-proven pSS, fulfilled the AECG and ACR-EULAR criteria, had disease duration ≤7 years (median 2 years), ESSDAI ≥5, and 89% were anti–SSA positive. All 40 patients who received abatacept (ABA) in week 0-24 were subsequently treated with abatacept from week 24-48. Of the 40 patients who received placebo (PLB) in week 0-24, 2 were lost to follow up, and 38 were treated with abatacept from week 24-48. Systemic disease activity (ESSDAI), patient reported symptoms (ESSPRI), serological outcomes (RF and IgG), ocular staining score (OSS) and unstimulated whole salivary flow (UWS) were assessed. We evaluated whether outcomes improved within treatment groups, from week 0 to subsequent visits and from week 24 to subsequent visits:

GEE modeling was used to test significance of changes over time. Missing data were not imputed.

Results:

ESSDAI and ESSPRI were improved within ABA/ABA patients between week 0-48 with additional efficacy after week 24, and within PLB/ABA patients after switching to ABA. Significant decreases in ESSDAI and ESSPRI were also seen within PLB treated patients between week 0-24 (Figure 1). IgG and RF were improved within ABA/ABA patients between week 0-48 with additional efficacy after week 24, and within PLB/ABA patients after switching to ABA. OSS was improved within ABA/ABA treated patients between week 0-48. UWS only showed significant improvement in week 36 within ABA/ABA treated patients. No changes in IgG, RF, OSS or UWS were seen within PLB treated patients. No deaths occurred. One serious adverse event possibly related to intervention occurred during ABA treatment.

Conclusion:

ESSDAI and ESSPRI improved significantly during 48-week treatment with abatacept. Placebo treated patients also showed significant improvement in both indices and further improvement occurred after switching to abatacept. Biological activity was decreased by abatacept treatment. 48-week abatacept treatment improved OSS, and might improve UWS. Abatacept was well tolerated by pSS patients.

References:

[1]van Nimwegen et al. Lancet Rheumatol.Published online 31-01-2020

Acknowledgments:

This study was funded by Bristol-Myers Squibb. We thank all patients for participation in the ASAP-III trial.

Disclosure of Interests:

Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Jolien F. van Nimwegen Consultant of: Bristol-Myers Squibb, Speakers bureau: Bristol-Myers Squibb, Esther Mossel: None declared, Greetje S. van Zuiden Speakers bureau: Roche, Konstantina Delli: None declared, Alja J. Stel: None declared, Bert van der Vegt Consultant of: Advisory board member for Philips and Visiopharm., Erlin A. Haacke: None declared, Lisette Olie: None declared, Leoni Los: None declared, Gwenny M. Verstappen: None declared, Sarah A. Pringle: None declared, Fred K.L. Spijkervet: None declared, Frans G.M. Kroese Grant/research support from: Unrestricted grant from Bristol-Myers Squibb, Consultant of: Consultant for Bristol-Myers Squibb, Speakers bureau: Speaker for Bristol-Myers Squibb, Roche and Janssen-Cilag, Arjan Vissink: None declared, Hendrika Bootsma Grant/research support from: Unrestricted grants from Bristol-Myers Squibb and Roche, Consultant of: Consultant for Bristol-Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Speakers bureau: Speaker for Bristol-Myers Squibb and Novartis.

AB0662 TREATMENT AND FOLLOW-UP OF AXIAL SPONDYLOARTHRITIS IN DAILY CLINICAL PRACTICE - A SURVEY AMONG DUTCH RHEUMATOLOGISTS

Background:

ASAS-EULAR have developed management recommendations for axial spondyloarthritis (axSpA) to provide guidance to the management of patients with axSpA1. However, there is limited insight into how rheumatologists treat axSpA patients in daily clinical practice and if these recommendations are used.

Objectives:

To get insight into the management of axSpA patients in daily practice in the Netherlands.

Methods:

We performed a survey among rheumatologists in the Netherlands with 21 multiple choice questions; 5 general questions on characteristics of their practice and 16 questions addressing treatment and follow-up of axSpA patients in daily practice. The questionnaire was taken during structured face-to-face interviews by employees of the medical department of Novartis NL Rheumatologists in the Netherlands were invited to participate, aiming to get a sample of rheumatologists varying in geographical location and hospital type, as well as a mix of SpA-experts and non-SpA-experts. Rheumatologists gave approval for anonymous use of the data, which were entered in a database and analyzed using descriptive statistics.

Results:

Between October 15 2019 and January 16 2020, 36 rheumatologists participated; 6 from university hospitals, 27 from general hospitals and 3 from private care centers.

81% of the rheumatologists referred most of their axSpA patients (76-100%) after diagnosis for information and education concerning axSpA, exercise and lifestyle to a specialized nurse practitioner. Furthermore, 53% of rheumatologists referred most of their axSpA patients (76-100%) to a physiotherapist for exercise therapy. At diagnosis, approximately 55% of axSpA patients used the daily maximum dose of NSAIDs, compared to 25% for patients on biological treatment.

The reported level of importance of different axSpA related aspects for starting a biological was largely similar for AS and nr-axSpA, although some differences could be observed (Figure 1): Most rheumatologists graded insufficient response to 2 NSAIDs during 4 weeks (94% for AS and 92% for nr-AxSpA) and bone marrow edema on MRI (75% and 89%) as important for starting a biological. About 60% of rheumatologists considered active disease using ASDAS/BASDAI important for the decision to start a biological, which was similar to the importance of the level of pain. For nr-axSpA, more rheumatologists graded elevated CRP and bone marrow edema on MRI as important for starting a biological, than for AS.

Most rheumatologists (67%) do not base a decision that a biological is ineffective on ASDAS or BASDAI. To assess disease activity in axSpA, 86% of the rheumatologists always measured C-reactive protein (CRP), compared to 42% and 31% for BASDAI and ASDAS, respectively. 77% of rheumatologists reported to follow the 2016 ASAS-EULAR treatment recommendations for axSpA for treatment and follow-up of axSpA patients.

Conclusion:

This survey among Dutch rheumatologists suggests that ASDAS and BASDAI are as important for starting a biological in axSpA as is the level of pain. Moreover, in contrast to ASAS-EULAR treatment recommendations, most rheumatologists do not use validated disease activity instruments to assess biological ineffectiveness, which may be a topic for increasing awareness and education.

References:

[1]Van der Heijde D et al, Ann Rheum Dis 2017;76:978-91.

Acknowledgments:

We would like to thank all participating rheumatologists.

Disclosure of Interests:

Anneke Spoorenberg: None declared, Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Reindert Bruin Employee of: Current employee of Novartis Pharma B.V., Marjolein de Hair Employee of: Current employee of Novartis Pharma B.V.

FRI0568 MEASURING DAILY PHYSICAL ACTIVITY IN AXSPA PATIENTS: CONTENT VALIDITY AND MEASUREMENT PROPERTIES OF THE NEW AXSPA-SQUASH

Background:

The ASAS-EULAR recommendations for management of axial Spondyloarthritis (axSpA) includes that patients should be encouraged to exercise.1So far, there is no validated instrument for measuring daily physical activity in axSpA. Our previous study recommends to adapt the Short QUestionnaire to Assess Health-enhancing physical activity (SQUASH) to improve the validity in axSpA patients.2

Objectives:

AxSpA-disease specific adaptation of the physical activity questionnaire SQUASH to improve content validity and measurement properties.

Methods:

This study was conducted according to the OMERACT-filter within the Groningen Leeuwarden AxSpA (GLAS) cohort and was performed in two parts. Part 1: adaptation and evaluation of content validity using a qualitative stepwise approach with in-depth interviews with different healthcare professionals (n=9) and patients (n=8), field testing in patients (n=10), and consensus meeting for final adaptations. Thereafter, content validity (n=45) was tested by filling out axSpA-SQUASH and SQUASH in random order two weeks apart. Part 2: measurement properties were tested using the International Physical Activity Questionnaire (IPAQ) as comparator. Criterion validity (n=40): Spearman’s correlation with accelerometer as golden standard and classification accuracy of intensity. Construct validity (n=106): Spearman’s correlation with disease activity, physical functioning and quality of life as clinical outcome with expected fair to moderated associations. Test-retest reliability (n=45): intraclass correlation coefficients (ICC) after 2 weeks. Responsiveness (n=47): standardized response mean (SRM) after 3 months stratified by Ancor method.

Results:

In total 156 patients were included: mean age 48±13 years, 56% males, 72% HLA-B27 positive, symptom duration 21±13.3 years and ASDAS 2.0±1.0. Part 1: main adaptations were better explanation of intensities, adding answer option “not applicable”, examples were modernized, physiotherapy and activity “shopping” were added. Compared to the original SQUASH, the adapted axSpA-SQUASH measured a systematically higher activity count and had less missing values (8% vs. 32%). Part 2: criterion validity: axSpA-SQUASH correlated better with accelerometer compared to IPAQ (ρ=0.51 vs. ρ=0.35). Classification accuracy: accelerometer defined most activity as light (97%), whereas axSpA-SQUASH and IPAQ defined most activity as moderate intensity (55% and 62% resp.). Construct validity: correlations were low to moderate and strongest for axSpA-SQUASH compared to IPAQ. Construct validity: correlations were low to moderate and stronger for axSpA-SQUASH compared to IPAQ (BASDAI -0.27 vs -0.15, BASDAI –0.27 vs. -0.15, ASDAS -0.24 vs -0.09, BASFI -0.39vs. -0.21, ASQoL -0.39 vs. -0.35). Test-retest reliability: ICC axSpA-SQUASH: 0.80. Responsiveness: axSpA-SQUASH changed over time in the corresponding direction (Table 1). Feasibility: considered comprehensible and average completion time was 7 minutes.

Table 1.

Responsiveness of the axSpA-SQUASH versus change in BASDAI

SRM95% CIBASDAI T1BASDAI T2Improved (n=12)-0.36-0.99 to 0.285.01 (2.10)3.93 (1.60)Stable (n=21)0.28-0.18 to 0.733.76 (2.05)3.76 (2.05)Decreased (n=14)0.750.18 to 1.334.71 (1.96)5.79 (2.42)

Conclusion:

The new axSpA-SQUASH resulted in improved content validity and measurement properties. It seems the most appropriate questionnaire and can be used to assess daily physical activity in patients with axSpA.

References:

[1] Van Der Heijde D et al.Ann Rheum Dis. 2017;76:978-91.

[2] Arends S et al.Arthritis Res Ther. 2013;15:R99.

Acknowledgments:

We thank the ASAS for the reserch grant that supported this work.

Disclosure of Interests:

Marlies Carbo: None declared, Davy Paap: None declared, Fiona Maas: None declared, Anna Jetske Baron: None declared, Laura van Overbeeke: None declared, Mark Siderius: None declared, Freke Wink Consultant of: Abbvie, Janssen, Hendrika Bootsma Grant/research support from: Unrestricted grants from Bristol-Myers Squibb and Roche, Consultant of: Consultant for Bristol-Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Speakers bureau: Speaker for Bristol-Myers Squibb and Novartis., Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Anneke Spoorenberg: None declared

OP0080 CENTRAL SENSITIZATION AND ILLNESS PERCEPTIONS SHOULD BE TAKEN INTO ACCOUNT WHEN INTERPRETING DISEASE ACTIVITY IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background:

Up to 40% of ankylosing spondylitis patients report persistently high pain scores of >4 (scale of 0-10) even after responding to long-term TNF-alpha blocking therapy.[1] In other rheumatic diseases, nociplastic pain (due to altered functioning of the nervous system leading to peripheral and central sensitization) is common.[2] In axial spondyloarthritis (axSpA), patient illness and pain perceptions were shown to influence disease outcome.[3] Therefore, we hypothesized that central sensitization and patients’ illness perceptions are associated with persistently high disease activity in axSpA.

Objectives:

To investigate to what extent central sensitization, pain catastrophizing and patients’ perceptions play a role in axSpA and to explore associations with disease activity.

Methods:

Between April and September 2019, consecutive outpatients from the Groningen Leeuwarden axSpA (GLAS) cohort,[4] an ongoing large prospective cohort, were included in this study. Besides the standardized assessments, patients filled out three additional questionnaires: Central Sensitization Inventory (CSI), Pain Catastrophizing Scale (PCS) and Revised Illness Perception Questionnaire (IPQ-R). Univariable and multivariable linear regression analyses were used to investigate the association of CSI, PCS and each of the eight subscales of the IPQ-R, and disease activity assessments ASDAS-CRP, BASDAI, and CRP. We corrected for the following potential confounders: gender, symptom duration, BMI, educational level, smoking status and HLA-B27 status.

Results:

Of 171 included patients, 58% were male, 79% were HLA-B27 positive, median symptom duration was 21 (IQR 10-32), mean ASDAS-CRP 2.1 ± 1.0, mean BASDAI 3.9 ± 2.2 and median CRP 2.9 (IQR 1.2-6.3). Mean CSI score was 37.8 ± 14.1 (scale of 0-100), and 44% of patients scored ≥40 on the CSI.[5] Median PCS score was 15 (IQR 7-22) (scale of 0-52), median IPQ-R illness identity subscore 3 (IQR 2-4) (scale of 0-14) and mean IPQ-R treatment control subscore 18.1 ± 3.4 (scale of 5-25). In univariable regression analysis, CSI and PCS scores and IPQ-R subscores all showed significant associations with ASDAS-CRP, and all except the IPQ-R subscale personal control showed significant associations with BASDAI. Only IPQ-R treatment control was significantly associated with CRP. Central sensitization, two IPQ-R subscales (perceived treatment control and the number of symptoms patients attributed to their axSpA: illness identity) and BMI were independently associated with disease activity assessments BASDAI (R2=0.46) and ASDAS-CRP (R2=0.36) (Figure 1).

Conclusion:

In this axSpA population with long-term disease, 44% scored above the CSI cutoff point of 40, indicating a high probability of central sensitization. CSI score, illness identity and treatment control were independently associated with disease activity assessments.

References:

[1]Arends Set al.Clin Exp Rheumatol 2017;35(1):61-8.

[2]Meeus Met al.Semin Arthritis Rheum 2012;41(4):556-67.

[3]Van Lunteren Met al. Arthritis Care Res (Hoboken) 2018;70(12):1829-39.

[4]Arends Set al.Arthritis Res Ther 2011;13(3):R94.

[5]Neblett Ret al.J Pain 2013;14(5):438-45.

Disclosure of Interests:

Stan Kieskamp: None declared, Davy Paap: None declared, Marlies Carbo: None declared, Freke Wink Consultant of: Abbvie, Janssen, Reinhard Bos: None declared, Hendrika Bootsma Grant/research support from: Unrestricted grants from Bristol-Myers Squibb and Roche, Consultant of: Consultant for Bristol-Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Speakers bureau: Speaker for Bristol-Myers Squibb and Novartis., Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Anneke Spoorenberg: None declared

SAT0392 DIAGNOSIS OF AXIAL SPONDYLOARTHRITIS IN DAILY CLINICAL PRACTICE – A SURVEY AMONG DUTCH RHEUMATOLOGISTS

Background:

Since publication of the ASAS classification criteria for axial spondyloarthritis (axSpA) in 20091and the development of ASAS-endorsed recommendation for early referral of patients with a suspicion of axSpA,2awareness for non-radiographic (nr-) axSpA besides Ankylosing Spondylitis (AS) has increased. Still there is limited information of how nr-AxSpA is addressed in daily clinical practice.

Objectives:

To get insight into the diagnostic phase of axSpA in daily rheumatologic practice in the Netherlands, and to explore if nr-axSpA is addressed differently from AS.

Methods:

We set up a 21 multiple choice question survey for rheumatologists in the Netherlands with 5 general questions about their practice and 16 questions addressing the diagnostic phase of axSpA. The questionnaire was taken by representatives of the medical department of Novartis NL during structured face-to-face interviews. Rheumatologists in the Netherlands were invited to participate, aiming to get a sample of rheumatologists varying in geographical location and hospital type, as well as a mix of SpA-experts and non-SpA-experts. Rheumatologists gave approval for anonymous use of the data, which were entered in a database and subsequently analyzed using descriptive statistics.

Results:

From October 15th2019 until January 16th2020, 36 Dutch rheumatologists participated in the face-to-face survey; 6 from university hospitals, 27 from general hospitals and 3 from private care centers. Most of axSpA patients (61%) were referred by the general practitioner and mean time between referral and first visit was 2-6 weeks. More than 50% of rheumatologists reported a mean symptom duration of >1 year and in 30% even >2 years before first visit. For diagnosing axSpA rheumatologists performed in almost all cases X-pelvis (mean 100% (SD 0%) for both AS and nr-axSpA), CRP/ESR (91% (26%) for AS; 94% (22%) for nr-axSpA) and HLA-B27 (74% (40%) for AS; 86% (26%) for nr-axSpA. MRI of the SI joints was performed in 31% and 82% of patients, respectively, and about 60% of the rheumatologists used of classification criteria for diagnosing axSpA. In addition, rheumatologists marked the level of importance of several (SpA) clinical features for making the diagnosis AS or nr-axSpA (Figure 1). Most rheumatologists graded inflammatory back pain, arthritis/enthesitis/dactylits and uveitis as very important for contributing to the diagnosis. Functional impairment of the spine and male sex were mostly graded neutral or not important for making a diagnosis of axSpA. All features were graded of similar importance for the diagnosis AS and nr-axSpA, except for backpain starting before the age of 45, which was considered more important for diagnosing AS.

Conclusion:

This survey among Dutch rheumatologists showed that in 30% of patients referred with possible suspicion of axSpA, symptom duration still was >2 years. Almost 60% of rheumatologists make use of the ASAS classification criteria for diagnosing nr-axSpA. Therefore, for early referral awareness of axSpA in first line should enhance. Furthermore, rheumatologists should become aware that classification criteria are not similar to diagnostic criteria and cannot be used as a tick box for diagnosis.

References:

[1]Rudwaleit M et al, Ann Rheum Dis 2009;68:777-83, 2. Poddubnyy D et al, Ann Rheum Dis 2015;74:1483–7

Acknowledgments:

We would like to thank all participating rheumatologists.

Disclosure of Interests:

Anneke Spoorenberg: None declared, Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Mark Sinnige Employee of: Current employee of Novartis Pharma B.V., Marjolein de Hair Employee of: Current employee of Novartis Pharma B.V.

Longitudinal analysis of varicella-zoster virus-specific antibodies in systemic lupus erythematosus: No association with subclinical viral reactivations or lupus disease activity

Systemic lupus erythematosus (SLE) patients are at high risk of herpes zoster. Previously, we found increased immunoglobulin (Ig)G levels against varicella-zoster virus (VZV) in SLE patients compared to controls, while antibody levels against diphtheria and cellular immunity to VZV were decreased. We aimed to test our hypothesis that increased VZV-IgG levels in SLE result from subclinical VZV reactivations, caused by stress because of lupus disease activity or immunosuppressive drug use.

Presence of anticitrullinated protein antibodies in a large population-based cohort from the Netherlands

OBJECTIVES

To determine the prevalence of anticitrullinated protein antibodies (ACPAs) and their association with known rheumatoid arthritis (RA) risk factors in the general population.

METHODS

Lifelines is a multidisciplinary prospective population-based cohort study in the Netherlands. Cross-sectional data from 40 136 participants were used. The detection of ACPA was performed by measuring anti-CCP2 on the Phadia-250 analyser with levels ≥6.2 U/mL considered positive. An extensive questionnaire was taken on demographic and clinical information, including smoking, periodontal health and early symptoms of musculoskeletal disorders. RA was defined by a combination of self-reported RA, medication use for the indication of rheumatism and visiting a medical specialist within the last year.

RESULTS

Of the total 40 136 unselected individuals, 401 (1.0%) had ACPA level ≥6.2 U/mL. ACPA positivity was significantly associated with older age, female gender, smoking, joint complaints, RA and first degree relatives with rheumatism. Of the ACPA-positive participants, 22.4% had RA (15.2% had defined RA according to our criteria and 7.2% self-reported RA only). In participants without RA, 311 (0.8%) were ACPA-positive. In the non-RA group, older age, smoking and joint complaints remained significantly more frequently present in ACPA-positive compared with ACPA-negative participants.

CONCLUSIONS

In this large population-based study, the prevalence of ACPA levels ≥6.2 U/mL was 1.0% for the total group and 0.8% when excluding patients with RA. Older age, smoking and joint complaints were more frequently present in ACPA-positive Lifelines participants. To our knowledge, this study is the largest study to date on ACPA positivity in the general, mostly Caucasian population.