AB0231 OUTCOMES IN RHEUMATOID ARTHRITIS PATIENTS UNDER TOCILIZUMAB AS FIRST bDMARD: A REAL-LIFE MONOCENTRIC COHORT STUDY

Background:

Rheumatoid arthritis (RA) is one of the most frequent systemic inflammatory rheumatic diseases, being constantly assessed regarding new disease activity monitoring tools and new therapeutic targets and therapies. Tocilizumab (TCZ) is one of the latest biological disease-modifying antirheumatic drugs (bDMARDs) approved for RA’s treatment, usually as a second line agent in daily clinical practice.

Objectives:

Evaluate the different disease and patient reported outcomes in patients undergoing treatment with tocilizumab as the first biologic therapy.

Methods:

All patients with a definite RA diagnosis who had undergone treatment with TCZ as the first biologic therapy at a tertiary hospital’s rheumatology department were included in this analysis. Diverse socio-demographic data, as well as disease and patient related outcomes were assessed at baseline, 6 and 12 months of treatment with TCZ, and posteriorly extracted from the Portuguese register of rheumatic diseases (Reuma.PT). Statistical analysis included non-parametric tests such as Wilcoxon test and univariate analysis using linear and logistic regression models.

Results:

Fifty-one patients were included, 88.2% females, with a median age at introduction of TCZ of 53.5 +/- 10.4 years; mainly seropositive for either rheumatoid factor (66%) or anti citrullinated peptide antibody (ACPA; 68%), with an erosive disease (75.6%) and concomitantly treated with a conventional synthetic disease modifying anti-rheumatic drug (csDMARD) (70.5%). During follow-up there was a statistically significant reduction at 6 and 12 months of TCZ treatment regarding DAS28 (4 variables) (4v) and DAS28(4V)-CRP scores (p < 0.001), SDAI (p < 0.001), CDAI (p < 0.001), 68/66 tender and swollen joint counts (TJC/SJC) (p < 0.001), ESR and CRP (p < 0.001), patient and physician VAS (p < 0.001) and HAQ score (p = 0.01 at 6 months and p < 0.001 at 12 months). Rheumatoid factor and ACPA serum levels weren’t statistically different at 6 and 12 months of treatment with TCZ compared to the initial assessment, as well as the ACR responders at the same 6 months versus those at 12 months. A majority of patients showed good EULAR response at 6 (52.6%) and 12 (56.3%) months, as well as moderate to high mean improvement in ACR core set measures at 6 (53.3±22.7) and 12 (54.3±25.2) months. Assessment of subsequent therapeutic maintenance showed that 75% of patients remained under tocilizumab with an average treatment duration of 48.8±37.7 months. Reasons for switch ranged from adverse effects (63.6%) to primary failure (18.2%) and secondary failure (18.2%). There was a significant reduction in DAS28(4V), DAS28(4V)-CRP, CDAI, SDAI, TJC and SJC, ESR, CRP, patient and physician VAS and HAQ scores between 6 and 12 months of therapy (p < 0,001). ACR and EULAR responses didn’t differ significantly between assessments at 6 and 12 months. In the absence of a representative number of RA patients on TCZ monotherapy, it wasn’t possible to draw conclusions about the need to use combined therapy with a csDMARD for better clinically significant response.

A higher degree of ACR response at 6 months was associated with higher serum rheumatoid factor levels (OR 1.13, p < 0.05) at baseline, while a lower degree of response was seen with higher TJC (p = 0.05) and HAQ score (p < 0.01). ACR response at 12 months was lower in patients with erosive disease at baseline (p < 0.05). Regarding EULAR response criteria at 6 months, there was a negative association with higher TJC (p < 0.05), while at 12 months the negative trend was associated with ESR levels (p < 0.05) and HAQ scores (p < 0.05) at baseline.

Conclusion:

There seems to be evidence of good therapeutic response to TCZ in bDMARD naïve RA patients assessed at 6 months from baseline, without evidence of significant improvement of response measures further down the line. Basal serum rheumatoid factor levels, TJC, HAQ scores and the presence of erosive disease may have some predictive value on the therapeutic response. Further studies comparing TCZ as the first bDMARD in naïve RA patients against TNF inhibitors are needed.

Disclosure of Interests:

None declared

AB0536 EFFICACY OF TNF INHIBITORS IN MONOTHERAPY VERSUS COMBINATION THERAPY WITH csDMARDs IN PORTUGUESE PATIENTS WITH PSORIATIC ARTHRITIS: A REAL-WORLD STUDY

Background:

Tumor necrosis factor inhibitors (TNFi) are a key therapeutic weapon in psoriatic arthritis (PsA), and can be used as monotherapy or in combination with other csDMARDs, which are usually used as first line therapy in these patients, although its efficacy is not as well documented as in other rheumatic diseases. The optimal use of iTNF in PsA, as monotherapy or in combination therapy with csDMARDs, is still under debate.

Objectives:

We aimed to compare the response to treatment with TNFi in monotherapy and combined with csDMARDs, as first biologic, in patients with PsA.

Methods:

Retrospective study that included PsA patients followed at our Rheumatology department under TNFi as first biologic, fulfilling CASPAR classification criteria and registered in Reuma.pt. Clinical and laboratory data were collected at the start of the first iTNF and in the last visit of 2019. Disease activity was assessed using CDAI, SDAI, DAS28(4V), BASDAI, ASDAS, and the response measured using the BASDAI50, ASDAS, ASAS, ACR and PsARC responses. Comparison between groups was performed using the chi-square test, Mann-Whitney U/t-test (categorical and continuous variables, respectively). Logistic regression analyses were performed to determine predictors of bDMARD failure, and survival analysis to measure persistence under the first bDMARD regarding csDMARD status at baseline.

Results:

We included 99 patients, 47 (47.5% females) with a mean age of 47.9 ± 11.7 years at the start of the first iTNF. Fifty-one patients (51.5%) had symmetric polyarthritis, 26 (26.3%) spondyloarthritis, 16 (16.2%) asymmetric oligoarthritis, 3 (3.0%) distal arthritis and 1 (1.0%) arthritis mutilans. Sixty-three percent were under corticosteroid therapy and 77.8% under csDMARD therapy at the start of the first iTNF (mostly methotrexate, in 55.6% of patients under csDMARD). Etanercept (41, 41.4%), golimumab (25, 25.3%), adalimumab (22, 22.2%), infliximab (9, 9.1%) and certolizumab (2, 2.0%) were the iTNF started in these patients.

Patients who started iTNF as monotherapy had more frequent involvement of axial skeleton compared with combined therapy (54.5% vs 19.5%, p=0.001), were less exposed to corticosteroids (26.3% vs 72.6%, p<0.001) and had higher mean BASMI (3.7±1.8 vs 3.0±0.8, p=0.021) and BASFI (6.7±1.3 vs 4.7±2.5, p=0.036). Patients who were on iTNF monotherapy at the last consultation (43.4%) had lower mean tender (1.0±1.5 vs 3.6±4.3, p=0.002) and swollen (0.2±0.7 vs 0.8±1.0, p=0.012) joint counts, median patient VAS (30±46 vs 50±44, p=0.023), mean CDAI (5.6±4.4 vs 8.7±4.9, p=0.019), SDAI (6.2±4.6 vs 9.1±5.1, p=0.032), and DAS28(4V) (2.2±0.8 vs 2.7±0.9, p=0.047). iTNF failure was not significantly different in both groups. In the regression models, we found that basal DAS28(4V) (OR 1.874, 1.147-3.062 95%CI; p=0,012) was a predictor of first iTNF failure; there were no differences regarding csDMARD status.

When evaluating only patients without spondyloarthritis, we found that, at the last visit, iTNF monotherapy patients still had less exposure to corticosteroids (26.9% vs 54.3%, p=0.002), fewer mean tender (0.7±1.0 vs 2.6±4.4, p=0.006) and swollen (0.2±0.7 vs 1.1±2.5, p=0.025) joint counts, with no other differences observed. In the regression models, we found no differences regarding csDMARD status in these patients, while adalimumab (OR 0.009, 0.001-0.139 95% CI; p=0.009) was a negative predictor of bDMARD failure. Survival analysis revealed no differences between mono- and combined therapy.

Conclusion:

We can conclude that the differences observed regarding csDMARD status in patients with PsA are mainly due to different patterns of arthritis, namely, predominance of axial involvement. In patients without spondyloarthritis, iTNF monotherapy did not differ significantly in terms of response to treatment and disease activity measures, nor does monotherapy predict bDMARD failure and treatment response. These results suggest that iTNF monotherapy is possible in PsA without compromising treatment response.

Disclosure of Interests:

None declared.

AB0327 DRUG-INDUCED LUPUS ERYTHEMATOSUS SECONDARY TO ANTI-TNF-Α AGENTS IN PATIENTS WITH SPONDYLOARTHRITIS AND PSORIATIC ARTHRITIS

Background:

Induction of autoantibodies is frequently observed in patients treated with TNF-α antagonist and the possible development of drug-induced lupus erythematosus (DILE) remains a matter of concern. The prevalence of DILE secondary to anti-TNF-α therapy is estimated around 0.5-1% and clinical features include arthritis/arthralgia, rash, serositis, fever, myalgias, cytopenias, among others. According to the literature, DILE secondary to anti-TNF-α agents differs in several ways from the clinical and laboratory findings typically associated with classic DILE.

Objectives:

To estimate the incidence of induction of antinuclear antibodies (ANA) and DILE in a monocentric cohort of patients with spondyloarthritis and psoriatic arthritis treated with anti-TNF-α agents. To describe the clinical and laboratorial features and outcomes of patients with DILE.

Methods:

We performed a retrospective analysis of patients with spondyloarthritis and psoriatic arthritis treated with anti-TNF-α agents, from our University Hospital, who have been registered on the Portuguese Rheumatic Diseases Register (Reuma.pt) between July 2001 and December 2020. Patients with positive ANA (titer > 1/100) before the anti-TNF-α therapy were excluded. Because specific criteria for the diagnosis of DILE have not been established, we considered the diagnosis in case of a temporal relationship between clinical manifestations and anti-TNF-α treatment and fulfillment of ACR/EULAR 2019 classification criteria for SLE. In patients with DILE, clinical features, laboratory findings, systemic therapies and outcome after discontinuation of medication were collected from reuma.pt and medical records. For the clinical and demographic predictors, continuous variables were analyzed using a two-sided t-test and categorical variables using a Fisher’s exact test. P-value <0.05 was considered statistically significant.

Results:

In the spondyloarthritis group, 290 patients were included (44.8% females, mean age at diagnosis of 33.3 ± 11.5 years and mean disease duration of 15.1 ± 10.4 years) and in the psoriatic arthritis group, 116 patients were included (50.0% females, mean age at diagnosis of 40.1 ± 11.0 years and mean disease duration of 13.1 ± 6.8 years). In our study, we observed high serology conversion rates (positive ANA in 67.9% and 58.6% of patients with Spondyloarthritis and Psoriatic Arthritis, respectively), with similar conversion rates between different anti-TNF drugs. Three patients with spondyloarthritis (1.0%) and 1 patient with psoriatic arthritis (0.9%) developed DILE. Etanercept was the causative agent in 2 cases, infliximab and adalimumab in 1 case, each. Peripheral arthritis (new onset or abrupt worsening) occurred in 2 patients, serositis in 1 patient, constitutional symptoms in 2 patients, subnephrotic proteinuria in 1 patient, lymphopenia in 2 patients and hypocomplementemia in 1 patient. Specific treatment was prescribed to the 4 patients (oral corticosteroids) and they achieved complete recovery. After anti–TNF-α treatment interruption, no patient had recurrent disease. We observed that patients with DILE had a significantly longer disease duration (> 8.4 years; p=0.04) and a significantly longer duration of therapy with anti-TNF (> 4.0 years; p=0.04) when compared to patients without DILE.

Conclusion:

Despite the frequent induction of autoantibodies, the development of DILE secondary to anti–TNF-α agents is rare. Our study demonstrates an incidence rate similar to other studies reported before. The clinical and laboratorial characteristics of our patients with DILE attributable to anti–TNF-α agents differ significantly from DILE due to more traditional agents, as is described in literature. Overall, patients in this study had mild disease that improved after therapy discontinuation, without recurrence of the disease. It seems that a longer disease duration and a longer period under anti-TNF-α therapy may increase the risk of DILE development.

Disclosure of Interests:

None declared

POS1113 ANTIRESORPTIVE THERAPY AFTER TERIPARATIDE DISCONTINUATION – WHEN IS THE BEST TIME TO STARTING IT?

Background:

Treatment with teriparatide (TPTD) is associated with reduction of fracture risk in patients with severe osteoporosis. This drug can only be used for up to 2 years. After that a treatment course with antiresorptives should be considered, in order to prevent the rebound of bone turnover observed after TPTD discontinuation. In this regard, interest in sequential osteoporosis therapy has grown in recent years but the ideal timing for starting another treatment after TPTD is not well established.

Objectives:

The aim of this study is to assess if the timing of onset of antiresorptive therapy after TPTD discontinuation has implications in total hip bone mineral density (BMD) and in fracture risk.

Methods:

We performed a retrospective cohort study that included patients with severe osteoporosis treated with TPTD 20mcg/day for 24 months and followed for at least 2 more years in the rheumatology department of a tertiary university hospital. For analysis, demographic and clinical data and results of dual-energy X-ray absorptiometry (DXA) after cessation of teriparatide were used. For comparison between groups Mann-Whitney U test was used.

Results:

Fifty-five patients with osteoporosis, with a median age of 68 (32-85) years, were included. Forty-nine patients were female (89.1%). Nineteen patients (34.5%) had primary osteoporosis and 36 (65.5%) glucocorticoid-induced osteoporosis. The median time for initiating antiresorptive treatment was 7 (0-35) months after cessation of TPTD. Forty-three patients (78.2%) started a bisphosphonate, 6 denosumab (10.9%) and 6 patients did not receive any other treatment. The most prescribed bisphosphonate was zoledronate (69.8%). All patients received calcium and vitamin D supplementation. After completion of TPTD regimen 8 patients experienced at least one fragility fracture (14.5%). At follow-up, 37 (67.3%) of patients underwent DXA on average 30.0±15.4 months after starting antiresorptive agents. The median total hip BMD in patients who started antiresorptive therapy in the first 12 months (inclusive) after cessation of TPTD regime was 0,738 (0.587-0.993) g/cm2 and the median total hip BMD of patients who started therapy after one year of discontinuation of TPTD was 0.683 (0.390-0.813) g/cm2. This difference is marginally significant (p=0.067). The median time in starting antiresorptive treatment is higher in patients with new fragility fractures after TPTD than in patients without new fractures however this difference was not statistically significant (10.0 [2-35] vs 6.0 [0-35] months; p=0.393, respectively).

Conclusion:

Although this study is unable to show that anti-resorptive treatment should be started in the first year after discontinuation of TPTD, it is promising since the difference between the medians in the total hip BMD values obtained until one year and after one year are marginally significant. These results can be linked to the small sample size and highlight the need for further studies in this area.

References:

[1]Napoli N, Langdahl BL, Ljunggren Ö, Lespessailles E, Kapetanos G, Kocjan T, Nikolic T, Eiken P, Petto H, Moll T, Lindh E, Marin F. Effects of Teriparatide in Patients with Osteoporosis in Clinical Practice: 42-Month Results During and After Discontinuation of Treatment from the European Extended Forsteo® Observational Study (ExFOS). Calcif Tissue Int. 2018 Oct;103(4):359-371. doi: 10.1007/s00223-018-0437-x. Epub 2018 Jun 16. PMID: 29909449; PMCID: PMC6153867.

Disclosure of Interests:

None declared.

POS0488 THE IMPACT OF ANTINUCLEAR ANTIBODIES INDUCED BY ANTI-TUMOUR NECROSIS FACTOR ALPHA AGENTS ON THE LONG-TERM TREATMENT OUTCOMES IN RHEUMATOID ARTHRITIS PATIENTS

Background:

The seroconversion of antinuclear antibodies (ANA) induced by anti-tumour necrosis factor alpha (anti-TNF-α) therapy remains a matter of concern in various inflammatory conditions namely rheumatoid arthritis. However, evidence is still scarce regarding the impact of these autoantibodies on the clinical response to treatment in these patients.

Objectives:

This study aimed to explore the impact of ANA induced by anti-TNF-α therapy on the outcomes of treatment in patients with rheumatoid arthritis over two years of follow-up.

Methods:

An observational retrospective cohort study was conducted with two years of follow-up. Patients diagnosed with rheumatoid arthritis, according to the American College of Rheumatology (ACR) criteria, and registered on the Rheumatic Diseases Portuguese Register (Reuma.pt) who started their first anti-TNFα agent as first biologic between 2003 and 2018 were included. Patients with positive ANA (titer ≥100) and/or positive anti-double stranded DNA (anti-dsDNA) antibodies and/or with a diagnosis of SLE at their first visit were excluded. Demographic, clinical and laboratory data were obtained by consulting Reuma.pt. Disease Activity Score for 28 joints (DAS28), DAS28 delta, Health Assessment Questionnaire (HAQ), HAQ delta were assessed at baseline, 6, 12, 18 and 24 months. Clinical response was evaluated by EULAR criteria and three response categories were defined: good, mild and no response. The rate of switch of biological treatment was assessed over 24 months. To examine the differences between groups with and without ANA seroconversion independent samples t test for normally distributed continuous data, Mann-Whitney U-tests for non-normally distributed continuous data and Chi-square tests for categorical data were used. Logistic regression models were used to assess the effects of ANA seroconversion on clinical response to treatment over 6, 12, 18 and 24 months.

Results:

A total of 185 patients (mean age of 49.3±10.9 years old; 85.4% female) with a median follow-up of 7 [4-14] years were included. We found an ANA seroconversion rate (titer ≥100) of 77.3% (n=143) with median time of 36 [15-72.3] months. There were no differences among groups regarding age, gender, disease duration, be seropositivity or not (for rheumatoid factor and/or anti-citrullinated protein antibodies) and have an erosive disease or not. DAS28 delta was significantly different (p=0.035) between group with positive ANA (2.01±1.29) and negative ANA (1.15±1.51) at 6 months. DAS28 was significantly different (p=0.014) between group with positive ANA (5.06±3.39) and negative ANA (3.99±1.43) at 12 months. No statistically significant differences were found in the DAS28, DAS28 delta, HAQ, HAQ delta at 18 and 24 months and in the EULAR response at any time. Switch rate was significantly different between patients with ANA seroconversion (median 1[0-1]) versus absence of seroconversion (median 0[0-1]), p=0.025. In the regression model ANA seroconversion did not predict switch rate and EULAR response over time.

Conclusion:

This study showed that the majority of patients with rheumatoid arthritis treated with an anti-TNF-α agent developed ANA and that their presence may be associated with worse clinical results (DAS28) at 6 and 12 months. In fact, previous research suggested that a decrease in anti-TNF-α drug concentration due to the production of autoantibodies may lead to worse outcomes of treatment. Moreover, our data demonstrated that patients with ANA seroconversion had a higher switch rate. Despite these results, there are no differences in the EULAR response between the two groups and ANA seroconversion did not predict this response over time. Therefore, ANA induced by anti-TNF-α agents should be monitored in patients with rheumatoid arthritis and its impact on treatment must be considered. Further research is needed to explore these results through large-scale prospective studies.

Disclosure of Interests:

None declared

POS0914 IS THERE AN ASSOCIATION BETWEEN AUTOANTIBODIES INDUCTION AND LOSS OF THERAPEUTIC EFFICACY IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS AND PSORIATIC ARTHRITIS TREATED WITH ANTI-TNF-α AGENTS?

Background:

Induction of autoantibodies is frequently observed in patients treated with a TNF-α blocker. According to other authors, the incidence of induction of antinuclear antibodies (ANA) and anti-double stranded DNA antibodies (anti-dsDNA) varies between 23-57% and 9-33%, respectively. However, it is unknown whether the induction of these autoantibodies affects the pharmacokinetics and bioavailability of biotherapy and, consequently, reduces the efficacy and safety of the drug.

Objectives:

To analyze if there is an association between autoantibodies induction and therapeutic efficacy in a monocentric cohort of patients with axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) treated with anti-TNF-α agents.

Methods:

The authors performed a retrospective analysis of patients with axSpA and PsA treated in our University Hospital with a TNF-α blocker as first biologic agent, and analysed the autoantibodies induction rate after 12 (T12) and 24 (T24) months of therapy. Then, they investigated the influence of autoantibodies in therapeutic efficacy at T12 and T24. Clinical evaluation, laboratory findings including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) and disease activity and functional scores (Bath Ankylosing Spondylitis Disease Activity Index – BASDAI, AS Disease Activity Score with CPR - ASDAS-CRP, Bath AS Functional Index - BASFI) were collected from reuma.pt and medical records. For PsA patients, Disease Activity Score-28-CRP (DAS28-CRP), Simple Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI) and Health Assessment Questionnaire (HAQ) scores were also collected. Patients with positive ANA (titer > 1/100) prior to anti-TNF-α therapy were excluded. Continuous variables were analyzed using a t-test and categorical variables using a Chi-square test. P-value <0.05 was considered statistically significant.

Results:

In the axSpA group, 235 patients were included, 44.5% were females, mean age at diagnosis of 42.3 ± 12.4 years and median disease duration of 11.5 (IQR 6.0-21.0) years. Positive ANA were observed in 16.9% at T12 and 26.3% at T24 and positive anti-dsDNA in 3.4% at T12 and 3.8% at T24, with similar conversion rates between different anti-TNF drugs and no significant gender difference. A significant difference in ASDAS-CPR was found in axSpA patients with and without ANA at T12 (p=0.047). ASDAS-CPR was 1.16 times higher in patients with ANA comparing to patients without them. However, no difference was found in the others disease activity and functional scores at T12. Furthermore, no significant difference, including ASDAS-CPR, was found at T24. Also, there was no significant difference found when comparing patients with and without anti-dsDNA.

In the PsA group, 94 patients were included, 46.8% were females, mean age at diagnosis of 46.7 ± 11.7 years and median disease duration of 11.5 (IQR 6.5-16.5) years. Positive ANA were found in 14.9% at T12 and 21.3% at T24 and positive anti-dsDNA in 2.1% at T12 and 3.2% at T24. When comparing the groups with and without ANA and with and without anti-dsDNA at T12 and T24, no significant difference in disease activity and functional scores was found.

Conclusion:

This study revealed high rates of serology conversion, similar to the rates described before. The authors found that ASDAS-CPR was higher in axSpA patients with ANA after 12 months of therapy. However, this difference was no longer evident after 24 months. No other significant difference was found between patients with and without ANA or with and without anti-dsDNA. The authors consider that the induction of autoantibodies may interfere with the response to anti-TNF-α therapy in a short and initial period of time. Long-term follow-up data are lacking to say whether that influence will disappear consistently over the long run, as they observed after 12 months of therapy. However, they can state that, a priori, seroconversion should not lead to treatment suspension because of concerns about loss of efficacy.

Disclosure of Interests:

None declared

POS0872 CLINICAL FEATURES AND OUTCOME OF 1054 PATIENTS WITH SYSTEMIC SCLEROSIS: AN ANALYSIS OF THE PORTUGUESE REUMA.PT REGISTRY FOR SCLERODERMA (REUMA.PT/SSC)

Background:

Systemic sclerosis (SSc) may present distinctive manifestations and survival in different ethnic and geographic groups.

Objectives:

To describe the clinical features, treatments, and survival of adult SSc patients registered in Reuma.pt/SSc.

Methods:

Demographic features, SSc subsets, fulfilment of classification criteria, clinical and immunologic characteristics, comorbidities, medication and deaths were reviewed. Survival was calculated for patients included in the registry within the first 2 years of diagnosis.

Results:

In total, 1054 patients were included, 87.5% female, mean age at diagnosis 52.7 ± 14.8 years. The most common subset was limited cutaneous (lc)SSc (56.3%), followed by diffuse cutaneous (dc)SSc (17.5%), preclinical SSc (13%), overlap syndrome (9.8%) and SSc sine scleroderma (3.3%). Raynaud’s phenomenon (93.4%) and skin thickening (76.9%) were the most observed manifestations. Gastrointestinal (62.8% vs 47.8%), pulmonary (59.5% vs 23%) and cardiac (12.8% vs 6.9%) involvement were significantly more prevalent in dcSSc compared to lcSSc (Table 1). 52.5% of patients were ACA positive and 21% anti-topoisomerase positive, with significant differences between lcSSc and dcSSc. One third of patients was treated with immunomodulators, 53.6% with vasodilators, 23% received glucocorticoids and 2.3% biologics.

During the median follow-up 12.4 years, 83 deaths (7.9%) were verified. The overall 1, 2 and 5 years survival was 98.0%, 96.8% and 92.6% respectively, without significant differences between lcSSc and dcSSc (Figure 1).

Conclusion:

Reuma.pt/SSc register is useful in routine patient monitoring and contributes to improve knowledge about this rare and complex disease. Clinical features of Portuguese SSc patients are similar to what has been described in other populations although the overall 5-year survival in recently diagnosed patients appears to be higher than previously reported.

Table 1.

Cumulative clinical and immunologic characteristics of Portuguese SSc patients

Clinical and immunologic featuresTotalN=1054Limited cutaneous SScN= 576 (56.3%)Diffuse cutaneous SScN=180 (17.5%)P valueSkin involvement – N(%) N=987688 (90.6)525 (90.7)180 (100)<0.01Skin thickening * – N (%) N= 962680 (76.9)512 (88.9)180 (100)<0.01Digital ulcers – N (%) N=970325(33.5)186 (34.7)4 (51.5)<0.01Raynaud’s Phenomenon – N (%) N=1010943 (93.4)539 (95.7)157 (92.4)0.06Musculoskeletal involvement – N(%) N=972346 (45.6)247 (42.7)99 (55)<0.01Cardiac involvement –N(%) – N=92471 (7.7)36 (6.9)19 (12.8)0.02Renal involvement –N(%) – N= 91717 (1.9)8!1.5)6 (4.1)0.07Gastrointestinal involvement - N(%) N=933508 (48.2)277 (47.8)113 (62.8)<0.01Pulmonary involvement – N(%) N=915261 (28.5)119 (23)88 (59.5)<0.01PAH – N(%) N= 87114 (1.6)10 (2)1 (0.7)0.23Intersticial lung disease – N(%) N=765218 (28.5)100 (22.7)75 (57.7)<0.01Antinuclear antibodies - N(%) N=1040934 (89.8)522 (90.2)154 (88.5)0.57Anti-centromere – N(%) N= 1027540 (52.6)383 (67.1)16 (9.5)<0.01Anti-Scl70 – N(%) N=1020214 (21)12 (3.3)104 (60.1)<0.01Anti-RNA polymerase III – N(%) N=71025 (3.5)12 (3.3)7 (5.6)0.38ComorbiditiesHypertension – N(%) N=431117 (27.1)76 (29.7)67 (20.7)0.1Hyperlipidemia – N(%) N=43171 (13.4)72 (12.2)24 (15.9)0.08Neoplasia – N(%) N=105429 (2.8)12 (2.1)7 (3.9)0.14

PDE-5 (phosdiasterase-5); PPIs (proton pump inhibitors); PAH-Pulmonary arterial hypertension confirmed by right heart catheterization. Immunomodulators includes Metothrexate, Leflunomide, Hydroxycloroquine; Azathioprine, Mycophenolate Mofetil and Cyclophosphamide; * Does not include sclerodactyly.

Figure 1.

Panel A - Survival in years from diagnosis of patients with SSc included in Reuma.pt in the first 2 years of disease (N=472). Panel B - survival according to SSc subset (lcSSc and dcSSC).

Disclosure of Interests:

None declared

AB0478 IN PREVIOUSLY BIOLOGIC-NAÏVE RHEUMATIC PATIENTS WITH DRUG INDUCED LUPUS SECONDARY TO A FIRST ANTI-TNF THERAPY, IS IT SAFE TO SWITCH TO A SECOND ANTI-TNF-α AGENT?

Background:

Drug-induced lupus erythematosus (DILE) secondary to anti-TNF-α agents results from an immunogenicity phenomena not yet fully understood and is a rare condition. Withdrawal of anti-TNF- α therapy usually leads to total resolution of symptoms, however sometimes immunosuppression is needed. It is not clear if this condition is drug specific or class related. Therefore, there are doubts about the safety of switching to a second TNF inhibitor: will a further anti-TNF-α agent increase the risk of DILE recurrence?

Objectives:

To analyze the outcomes in patients with DILE secondary to an anti-TNF-α agent that switch to a second anti-TNF-α agent.

Methods:

We performed a retrospective analysis of patients with spondyloarthritis, psoriatic arthritis and rheumatoid arthritis from our University Hospital, who developed DILE secondary to an anti-TNF-α agent as a first biologic and switch to a second anti-TNF-α agent. Because specific criteria for the diagnosis of DILE have not been established, DILE diagnosis was considered when a temporal relationship between clinical manifestations and anti-TNF alpha treatment was found and ACR/EULAR 2019 classification criteria for SLE were fulfilled. Clinical and laboratorial features and outcomes were collected from the Portuguese Rheumatic Diseases Register (Reuma.pt) and medical records.

Results:

Six of 617 patients developed DILE secondary to anti-TNF-α agents (2 secondary to etanercept, 2 to adalimumab and 2 to infliximab). These patients had total resolution of symptoms and autoantibodies (ANA and anti-DNAds), induced by the therapy, disappeared after withdrawal of the anti-TNF-α agent implied.

Afterwards, 4 of these 6 patients switched to a second anti-TNF-α agent: 1 to etanercept, 1 to certolizumab, 1 to adalimumab and another to golimumab. The time interval between the two therapies was 2,0 ± 0,8 months. Regarding the outcomes, in all four patients, no DILE recurrence or autoantibodies induction recurrence was observed. These patients have a good response to the new biotherapy, without side effects reported, and a significant clinical improvement was observed.

Conclusion:

Our study results are in agreement with the literature described before. It seems that exist a low rate of DILE recurrence with an alternative anti-TNF-α agent. Thus, this condition seems to be drug specific rather than class related. Therefore, it seems secure to use a second anti-TNF-α agent, even in a short period of time after DILE development. There is no evidence about the best or securest second TNF inhibitor, so any anti-TNF-α agent can be prescribed. A carefully monitoring of symptoms of relapse should be ensured. In conclusion, DILE secondary to a TNF inhibitor should not be an absolute contraindication to the use of a subsequent anti-TNF-α agent.

Disclosure of Interests:

None declared.

AB0112 TNF INHIBITOR MONOTHERAPY IN RHEUMATOID ARTHRITIS: IS THERE REALLY A DIFFERENCE IN COMPARISON WITH COMBINATION THERAPY WITH CSDMARDS IN REAL-LIFE?

Background:

In Rheumatoid Arthritis (RA), tumor necrosis factor inhibitors (TNFi) in combination with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) has shown advantages concerning efficacy and immunogenicity in comparison with monotherapy. However, in clinical practice, up to 40% of patients under biological DMARDs (bDMARDs) are on monotherapy.

Objectives:

To compare the efficacy outcomes of TNFi in monotherapy and in combination therapy in a RA monocentric cohort.

Methods:

Retrospective, cross-sectional study including all the RA patients under TNFi followed at our Rheumatology Department and registered in the national database. Demographic, clinical and laboratorial data and disease activity measures were collected at the last visit of 2019 from each patient. Mann-Whitney U and chi-square tests were used to the comparison analysis between the two groups (continuous and categorical variables, respectively).

Results:

A total of 144 patients were included: 84% were females; at the last visit of 2019, the mean age was 56.3±10.9 years and the mean disease duration was 18.3±10.2 years; 73.6% were positive for rheumatoid factor (RF), 81.9% for anti-citrullinated protein autoantibodies (ACPA) and 45.1% had erosive disease. There were no statistically significant differences in these variables between the monotherapy and the combination therapy groups (table 1).

Table 1.

Demographic and disease-related variables in the monotherapy and the combination therapy group.

Monotherapy(n=31)Combination therapy (n=113)Age - mean±SD59.1±14.0 years55.5±9.8 yearsDisease duration - mean±SD20.5±11.2 years17.7±9.7 yearsRF positive - n (%)20 (60.4%)86 (76.8%)ACPA positive - n (%)25 (80.6%)93 (85.3%)Erosive disease - n (%)15 (48.4%)50 (44.6%)

Thirty-one patients (21.5%) were under monotherapy with TNFi and etanercept was the most frequent TNFi in both groups (54.8% vs 50.0%; monotherapy and combination therapy groups, respectively). At the start of the first bDMARD, the monotherapy group had a higher disease activity score 28 - 4 variables (DAS 28 4V; 6.083±0.930 vs 5.605±1.043, p=0.039) and a higher simple disease activity score (SDAI; 36.12±11.77 vs 28.76±9.98, p=0.035); also, in the monotherapy group more patients had already started the bDMARD in monotherapy (22.6% vs 2.7%, p<0.001), less patients were under (38.7% vs 73.2%, p=0.001) or had already been treated with (77.4% vs 93.8%, p=0.007) methotrexate, in comparison with the combination group therapy.

At the last visit of 2019, the monotherapy group had a higher mean years of duration of iTNF treatment (5.5±5.8 vs 3.4±4.5, p=0.048), a higher mean patient global assessment - visual analogue scale (PGA-VAS; 49±18 vs 39±25, p=0.023), a higher mean prednisolone equivalent dose in mg/day (7.6±6.3 vs 5.6±3.2, p=0.045) and a lower proportion of American College of Rheumatology 50 and 70 responses (ACR 50: 12.9% vs 17.0%, p=0.023; ACR 70: 3.2% vs 10.7%, p=0.045) in comparison with the combination therapy group.

Conclusion:

In line with the literature, our real-life results demonstrate some direct (higher PGA-VAS and lower ACR 50 and 70 responses) and indirect (higher current prednisolone equivalent dose) data that suggest that patients with TNFi monotherapy may have a worst disease activity control in comparison with combination therapy.

Disclosure of Interests:

None declared

POS0100 VITAMIN D LEVEL IN RHEUMATOID ARTHRITIS PATIENTS STARTING A BIOLOGIC DISEASE-MODIFYING DRUG AND ITS CORRELATION WITH DISEASE ACTIVITY AND RESPONSE TO TREATMENT

Background:

Vitamin D, a fat soluble vitamin that is mainly involved in the regulation of calcium/phosphate metabolism, has a increasingly understood role in immunomodulatory activity, both in innate and adaptive immune system. In rheumatoid arthritis (RA), vitamin D showed to suppress the proliferation of synoviocytes and to reduce the production of proinfammatory cytokines, in vitro. (1) Recently the hypothesis has been raised that vitamin D has a negative association with RA activity. (2)

Objectives:

This study aimed to evaluate the relationship between the 25-hydroxyvitamin D (25(OH) vitD) level, RA activity and response to a first biologic disease-modifying drug (bDMARD).

Methods:

This is a longitudinal, retrospective study including consecutive patients with the diagnosis of RA followed at our rheumatology department. Demographic, clinical, and laboratorial data were collected from our national database at baseline, 6 and 12 months after initiation of a first bDMARD. Statistical analysis was performed using SPSS 23.0. Correlations between variables were studied using Spearman correlation analysis and comparison between groups was performed using Wilcoxon and Kruskal-Wallis tests; p<0.05 was considered statistically significant.

Results:

Mean age of patients (n=236) was 51.5 ± 11.2 years old, 192 (81.4%) were females with a median disease duration of 10.1 [4.7, 16.7] years. Seropositivity for anti-citrullinated protein antibodies was present in 192 (81.4%) patients and for rheumatoid factor in 175 (74.2%). The majority exhibited a very high or high disease activity at baseline (median DAS28 5.75 [4.99 – 6.63]) and 90% (n=212) of them were concomitantly using corticosteroids and/or other disease-modifying anti-rheumatic drugs (117 with methotrexate (MTX), 62 with leflunomide and 32 with sulfasalazine). Regarding bDMARD, 56.8% (n=134) initiated an TNF alpha inhibitor.

After 6 and 12 months from a bDMARD initiation there was a significant reduction of ESR, CRP levels, TJCs, SJCs and DAS28 (all p-values < 0.001), as expected. Median baseline serum 25(OH) vitD concentrations was 25.5 [16.5, 30.0] ng/ml; notably, 34.2% of our sample was affected by hypovitaminosis D at baseline (25(OH) vitD< 20 ng/mL).

Among our study population 42.5% patients were responders to first bDMARD (23.8% good and 18.7% moderate responders) according to the EULAR response criteria. Disease remission (DAS28 < 2.6) was achieved by 17.6% of patients.

The percentage of good responders was significantly lower in the subgroup of patients with hypovitaminosis D compared to subjects with normal 25(OH) vitamin D levels at baseline (p=0.002), as it was for the percentage of disease remission (p=0.015).

The bivariate correlation analyses showed that 25(OH) vit D levels at baseline correlated with CRP levels and good response to RA treatment after 12 months (Spearman’s coefficient -0.201, p = 0.028; Spearman’s coefficient 0.255, p < 0.019, respectively). 25(OH) vit D levels at baseline, 6 and 12 months after bDMARD initiation did not correlate with age, BMI, ESV, number of tender or swollen joints, DAS28, HAQ or with SDAI or CDAI at 6 or 12 months of treatment.

Conclusion:

In patients with RA, basal 25(OH) vit D levels correlated with response to a bDMARD. These results suggest a role of basal vitamin D status in the prediction of disease evolution and support the hypothesis that vitamin D has an immunomodulatory potential.

References:

[1]Huhtakangas JA, Veijola J, Turunen S et al. 1,25(OH)2D3 and calcipotriol, its hypocalcemic analog, exert a long-lasting anti-infammatory and anti-proliferative effect in synoviocytes cultured from patients with rheumatoid arthritis and osteoarthritis. J Steroid Biochem Mol Biol 2017; 173: 13- 22.

[2]Lee YH, Bae SC. Vitamin D level in rheumatoid arthritis and its correlation with the disease activity: a meta-analysis. Clin Exp Rheumatol. 2016 Sep-Oct;34(5):827-833. Epub 2016 Apr 6. PMID: 27049238.

Disclosure of Interests:

None declared

POS0204 AUTOANTIBODIES AND SYSTEMIC LUPUS ERYTHEMATOSUS INDUCED BY ANTI-TUMOUR NECROSIS FACTOR ALPHA THERAPY IN RHEUMATOID ARTHRITIS

Background:

Anti-tumour necrosis factor alpha (anti-TNF-α) therapy is commonly used to treat inflammatory conditions such as rheumatoid arthritis (RA). Autoantibodies namely antinuclear antibodies (ANA) induced by these treatments are well established. However, anti-TNF-α-induced systemic lupus erythematosus (SLE) is rarely described and its incidence is yet unknown.

Objectives:

This study aimed to determine the prevalence of ANA seroconversion and to characterize the development of SLE induced by anti-TNF-α therapy in patients with RA over time.

Methods:

An observational retrospective cohort study was conducted with at least one year of follow-up. Patients with diagnosis of RA, according to American College of Rheumatology criteria (ACR), and registered on Rheumatic Diseases Portuguese Register (Reuma.pt) who started their first anti-TNFα between 2003 and 2019 were included. Patients with positive ANA (titer ≥100) and/or positive double-strand DNA (dsDNA) antibodies and/or with a diagnosis of SLE at their first visit were excluded. Demographic, clinical and laboratory data were obtained by consulting Reuma.pt. As there are no recognized criteria for drug-induced SLE, the diagnosis of SLE induced by anti-TNF-α was considered if there is a temporal relationship between clinical manifestations and anti-TNF-α-therapy, the presence of at least 1 serologic ACR criteria (ANA or anti-dsDNA) and at least 1 nonserologic ACR criteria (arthritis, serositis, hematologic disorder or malar rash) [1]. Continuous variables are presented with mean, standard deviation, median, quartile 1 and quartile 3. Categorical variables are presented with absolute and relative frequencies.

Results:

A total of 211 patients (mean age of 49.9±10.9 years old; 84.4% female) were included with a median follow-up time of 6 [3-14] years. We found a seroconversion rate for ANA of 75.4% (n=159) with median treatment duration of 31 [8.5-70.5] months. The most common titre was 1/100 with diffuse and speckled patterns. ANA seroconversion was higher for etanercept (47.8%, n=76) than with adalimumab (23.9%, n=38), infliximab (13.8%, n=22), golimumab (12.6%, n=20) or certolizumab (1.9%, n=3). SLE induced by anti-TNF-α occurred in two patients (0.9%) with erosive and seropositive (rheumatoid factor and anti-citrullinated protein antibodies) RA previously treated with two conventional synthetic disease-modifying antirheumatic drugs, including methotrexate. The first patient, a female with 66 years old and 17 years of disease duration, developed SLE after 16 months of infliximab, with constitutional symptoms, abrupt worsening of polyarthritis, ANA titer of 1/320 diffuse pattern and positive dsDNA (248 UI/mL) antibodies. The second patient, a woman with 43 years old and 11 years of disease duration, developed SLE after 41 months of adalimumab with malar rash and ANA titer of 1/320 diffuse pattern, positive dsDNA (285 UI/mL), positive anti-histone antibodies and hypocomplementemia. In these two cases, anti-TNF-α therapy was stopped and recovery was spontaneous without treatment. The first patient switched to adalimumab and the second switched to golimumab without recurrence of SLE for more than ten years.

Conclusion:

We found a high rate of ANA seroconversion induced by anti-TNFα therapy in patients with RA. However, similar to previous literature, only 0.9% of patients developed SLE with mild manifestations without major organ involvement. Although the drug with the highest ANA seroconversion rate was etanercept, those responsible for induced SLE were infliximab and adalimumab. Patients improved after discontinuation of therapy and tolerated an alternative anti-TNF-α drug without recurrence of induced SLE over time. Therefore, ANA and SLE induced by anti-TNF-α should be considered and reported in the follow-up of RA patients. Further research is needed to explore the impact of this adverse event on the outcomes of treatment over time.

References:

[1]Hochberg MC. Arthritis Rheum. 1997;40(9):1725.

Disclosure of Interests:

None declared

AB0483 CAN WE PREDICT WHICH PATIENTS WITH SPONDYLOARTHRITIS WILL NEED DOSE ESCALATION OF SECUKINUMAB TO 300 mg MONTHLY?

Background:

Secukinumab is a fully human monoclonal antibody against interleukin-17A, approved in several countries for the treatment of ankylosing spondylitis (AS) and psoriatic arthritis. It is known that some patients benefit from increasing the monthly dose of secukinumab from 150mg, the most commonly used dose, to 300mg. However, the baseline clinical characteristics that differentiate these patients are not yet fully understood.

Objectives:

This study aimed to investigate whether there are any variables at the beginning of biologic therapy that might predict a greater probability of having to increase the dose of secukinumab to 300mg in order to obtain a response to treatment.

Methods:

This is a retrospective cohort study, including all the spondyloarthritis and psoriatic arthritis patients under secukinumab at our Rheumatology Department and registered in the national database (Reuma.pt).

Demographic, clinical and laboratorial characteristics and disease activity measures were collected from the first visit before the patient began secukinumab. For comparison between the 2 groups, continuous variables were analyzed using Mann-Whitney U and T-tests and categorical variables were analyzed using a Chi-square test. Multivariate regression analyses assessed the impact of selected variables on the need to increase the dose of secukinumab to 300mg.

Results:

Thirty-two patients with a mean age of 53±11.96 years were included, 19 (58%) were females and 16 (48.5%) had psoriasis. Twenty-seven (81.8%) patients were under a nonsteroidal anti-inflammatory drug (NSAID), 11(33.3%) were under corticosteroid and 11(33.3%) were under conventional synthetic disease-modifying antirheumatic drug (csDMARD); 25 (75,8%) had previously been treated with a biological disease-modifying antirheumatic drug (bDMARD). The mean patient baseline VAS and physician baseline VAS were 74,39±19,77 and 47,55±23,38, respectively; the mean erythrocyte sedimentation rate (ESR) and C-Reactive Protein (CRP) were 26,33±22,62 mm/hr and 10,81±16,88 mg/dL, respectively; the mean swollen joint count (SJC) and tender joint count (TJC) were 1,30±1,63 and 3,67±3,14, respectively; the mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Ankylosing Spondylitis Disease Activity Score (ASDAS) were 6,18±2,06 and 3,41±0,84, respectively; the mean Bath Ankylosing Spondylitis Metrological Index (BASMI) and Bath Ankylosing Spondylitis Functional Index (BASFI) were 4,22±1,58 and 6,28±2,53, respectively; the mean Maastrich Ankylosing Spondylitis Enthesitis Score (MASES) was 2,85±3,23.

Nineteen patients (57.6%) had the dose of secukinumab increased to 300mg. At the baseline visit, the group of patients which had their secukinumab monthly dose increased to 300mg were more frequently men (12 vs 2, p=0.005) and had psoriasis (12 vs 4, p=0.049). On the other hand, these patients also exhibited lower MASES values (2±1.089 VS 4±0.501, p=0.022).

A regression analysis was conducted, estimating the relationships between the outcome binary variable of the monthly dose of secukinumab and the following predictors: gender, psoriasis, MASES value and use of corticosteroid. Female gender (OR 0.070, CI95% 0.005-0.890; p=0.040) and absence of psoriasis (OR 0.104, CI95% 0.011-0.952; p=0.045) were predictors for maintaining secukinumab at a dose of 150mg monthly.

Conclusion:

Our data suggest that the most common characteristics of patients in need of increasing the monthly dose of secukinumab from 150 to 300 mg to achieve a better treatment response are: male gender, coexistence of psoriasis and lower MASES value at baseline. The first two variables remained statistically significant in a multivariate model of regression analysis. Nonetheless, we insist it is of paramount importance to conduct larger studies to confirm these findings.

References:

[1]Deodhar A, et all. Long-term safety of secukinumab in patients with moderate-to-severe plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis. Arthritis Res Ther. 2019 May 2;21(1):111.

Disclosure of Interests:

None declared.

AB0816 PREDICTORS OF RESPONSE TO THE FIRST BDMARD IN BIOLOGIC-NAÏVE PATIENTS WITH SPONDYLOARTHRITIS: A COHORT STUDY

Background:

Several markers of response to biologic disease-modifying antirheumatic drugs (bDMARDs) have been identified in Rheumatoid Arthritis. However, data on predictors of response in Spondyloarthritis (SpA) are more limited.

Objectives:

To identify predictors of response to bDMARDs in a SpA population.

Methods:

Monocentric retrospective study including all the SpA patients (ASAS classification criteria) followed at our Rheumatology Department, registered in the national database and treated with bDMARD between July 2001 and August 2020. Demographic, clinical and laboratorial data at baseline and disease activity measures at 6 and 12 months of bDMARD were collected. Mann-Whitney U test and chi-square tests were used to the comparison analysis between groups (continuous and categorical variables, respectively) and univariate logistic regression was used in the prediction analysis.

Results:

A total of 325 patients were included, 178 (54.8%) males, 76 (23.4%) smokers and 164 (50.5%) HLA-B27 positive. Concerning SpA subtypes: 236 (72.6%) had Ankylosing Spondylitis, 31 (9.5%) had Inflammatory Bowel Disease Associated SpA and 58 (17.9%) had Undifferentiated SpA. The mean age at the start of the first bDMARD was 41.7 years (±12.2) and the median disease duration was 12.1 years (0.5-52.7). The mean ASDAS-CPR (Ankylosing Spondylitis Disease Activity Score with C-reactive protein) was 4.0 (±0.8) and most patients (57.2%) exhibited very high disease activity at baseline as evaluated by ASDAS-CRP. Ninety-five (29.2%) patients were taking NSAIDs (nonsteroidal anti-inflammatory drugs) and 131 (40.3%) were under csDMARDs (conventional synthetic disease-modifying antirheumatic drugs), being sulfasalazine the most frequent (28.3%). All patients started iTNF (tumor necrosis factor inhibitors): adalimumab (30.2%) and golimumab (24.6%) were the most frequently started bDMARDs.

At 6 and 12 months of bDMARD, 63.5% and 65.7% of the patients had ASDAS response (clinically important improvement or major improvement). Variables that showed statistically significant differences at baseline between those different groups are presented at Table 1.

Table 1.

Baseline characteristics that showed statistically significant differences at baseline between groups of patients with vs without ASDAS responses at 6 and 12 months of bDMARD. (bDMARD: biologic disease-modifying antirheumatic drug; BMI: body mass index; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate).

ASDAS response at 6 monthsASDAS response at 12 monthsyesnop-valueyesnop-valueAge at start of bDMARD (mean±SD)39.6±12.2 years44.2±10.7 yearsp=0.01240.7±12.8 years44.2±10.9 yearsp=0.035Age at SpA diagnosis (mean±SD)32.2±11.1 years35.8±11.9 yearsp=0.02331.3±10.7 years35.4±11.2 yearsp=0.010BMI (mean±SD)25.7±4.3kg/m228.7±6.0 kg/m2p=0.04525.6±4.3 kg/m228.5±5.7 kg/m2p=0.005CRP (mean±SD)3.2±3.5 mg/dL1.1±1.2 mg/dLp<0.0013.4±3.5 mg/dL1.4±1.6 mg/dLp<0.001ESR (mean±SD)36±2225±20p<0.00138±2427±17p=0.001ASDAS-CRP(mean±SD)4.1±0.83.5±0.4p<0.0014.2±0.83.6±0.8p<0.001HLA-B27+61.5%26%p=0.00660.1%44.4%p=0.033Males62.3%35.7%p=0.00462.3%37.5%p=0.001

Body mass index (BMI) (OR 0.89 [0.80-0.99], 95% CI) and ASDAS-CRP at baseline (OR 2.8 [1.2-6.6], 95% CI) predicted ASDAS response at 6 months; moreover, only BMI (OR 0.91 [0.83-0.99], 95% CI) predicted ASDAS response at 12 months of bDMARD.

Conclusion:

Our results demonstrate that a higher baseline disease activity predicts the response to bDMARDs in SpA. Interestingly, BMI at baseline also predicts ASAS response at 6 and 12 monthes of treatment with bDMARD, in line with some data that suggest an association between BMI and disease activity in SpA.

Disclosure of Interests:

None declared

The effect of polymorphisms in FSHR and FSHB genes on ovarian response: a prospective multicenter multinational study in Europe and Asia

STUDY QUESTION

Does the presence of single nucleotide polymorphisms (SNPs) in the FSH receptor gene (FSHR) and/or FSH beta subunit-encoding gene (FSHB) influence ovarian response in predicted normal responders treated with rFSH?

SUMMARY ANSWER

The presence of FSHR SNPs (rs6165, rs6166, rs1394205) has a statistically significant impact in ovarian response, although this effect is of minimal clinical relevance in predicted normal responders treated with a fixed dose of 150 IU rFSH.

WHAT IS KNOWN ALREADY

Ovarian reserve markers have been a breakthrough in response prediction following ovarian stimulation. However, a significant percentage of patients show a disproportionate lower ovarian response, as compared with their actual ovarian reserve. Studies on pharmacogenetics have demonstrated a relationship between FSHR or FSHB genotyping and drug response, suggesting a potential effect of individual genetic variability on ovarian stimulation. However, evidence from these studies is inconsistent, due to the inclusion of patients with variable ovarian reserve, use of different starting gonadotropin doses, and allowance for dose adjustments during treatment. This highlights the necessity of a well-controlled prospective study in a homogenous population treated with the same fixed protocol.

STUDY DESIGN, SIZE, DURATION

We conducted a multicenter multinational prospective study, including 368 patients from Vietnam, Belgium, and Spain (168 from Europe and 200 from Asia), from November 2016 until June 2019. All patients underwent ovarian stimulation followed by oocyte retrieval in an antagonist protocol with a fixed daily dose of 150 IU rFSH until triggering. Blood sampling and DNA extraction was performed prior to oocyte retrieval, followed by genotyping of four SNPs from FSHR (rs6165, rs6166, rs1394205) and FSHB (rs10835638).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Eligible were predicted normal responder women <38 years old undergoing their first or second ovarian stimulation cycle. Laboratory staff and clinicians were blinded to the clinical results and genotyping, respectively. The prevalence of hypo-responders, the number of oocytes retrieved, the follicular output rate (FORT), and the follicle to oocyte index (FOI) were compared between different FSHR and FSHB SNPs genotypes.

MAIN RESULTS AND THE ROLE OF CHANCE

The prevalence of derived allele homozygous SNPs in the FSHR was rs6166 (genotype G/G) 15.8%, rs6165 (genotype G/G) 34.8%, and rs1394205 (genotype A/A) 14.1%, with significant differences between Caucasian and Asian women (P < 0.001). FSHB variant rs10835638 (c.-211 G>T) was very rare (0.5%). Genetic model analysis revealed that the presence of the G allele in FSHR variant rs6166 resulted in less oocytes retrieved when compared to the AA genotype (13.54 ± 0.46 vs 14.81 ± 0.61, estimated mean difference (EMD) -1.47 (95% CI -2.82 to -0.11)). In FSHR variant rs1394205, a significantly lower number of oocytes was retrieved in patients with an A allele when compared to G/G (13.33 ± 0.41 vs 15.06 ± 0.68, EMD -1.69 (95% CI -3.06 to -0.31)). A significantly higher prevalence of hypo-responders was found in patients with the genotype A/G for FSHR variant rs6166 (55.9%, n = 57) when compared to A/A (28.4%, n = 29), ORadj 1.87 (95% CI 1.08-3.24). No significant differences were found regarding the FORT across the genotypes for FSHR variants rs6166, rs6165, or rs1394205. Regarding the FOI, the presence of the G allele for FSHR variant rs6166 resulted in a lower FOI when compared to the A/A genotype, EMD -13.47 (95% CI -22.69 to -4.24). Regarding FSHR variant rs6165, a lower FOI was reported for genotype A/G (79.75 ± 3.35) when compared to genotype A/A (92.08 ± 6.23), EMD -13.81 (95% CI -25.41 to -2.21).

LIMITATIONS, REASONS FOR CAUTION

The study was performed in relatively young women with normal ovarian reserve to eliminate biases related to age-related fertility decline; thus, caution is needed when extrapolating results to older populations. In addition, no analysis was performed for FSHB variant rs10835638 due to the very low prevalence of the genotype T/T (n = 2).

WIDER IMPLICATIONS OF THE FINDINGS

Based on our results, genotyping FSHR SNPs rs6165, rs6166, rs1394205, and FSHB SNP rs10835638 prior to initiating an ovarian stimulation with rFSH in predicted normal responders should not be recommended, taking into account the minimal clinical impact of such information in this population. Future research may focus on other populations and other genes related to folliculogenesis or steroidogenesis.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by an unrestricted grant by Merck Sharp & Dohme (MSD). N.P.P. reports grants and/or personal fees from MSD, Merck Serono, Roche Diagnostics, Ferring International, Besins Healthcare, Gedeon Richter, Theramex, and Institut Biochimique SA (IBSA). N.L.V. and M.T.H. report consultancy and conference fees from Merck, Ferring, and MSD, outside the submitted work. P.D. has received honoraria for lecturing and/or research grants from MSD, Ferring International, and Merck. D.S. reports grants and/or personal fees from MSD, Ferring International, Merck Serono, Cook, and Gedeon Richter. A.R.N., B.A.M., C.S., J.M., L.H.L., P.Q.M.M., H.T., and S.G. report no conflict of interests.

TRIAL REGISTRATION NUMBER

NCT03007043.

Continuous saline bladder irrigation after blue light transurethral resection of bladder tumor increases recurrence-free survival in low- to intermediate-risk non-muscle invasive bladder cancer

OBJECTIVES

To evaluate the efficacy of Continuous Saline Bladder Irrigation (CSBI) after blue light transurethral resection of bladder tumor (TURBT) to prevent recurrence of low- to intermediate-risk Non-Muscle Invasive Bladder Cancer (NMIBC).

PATIENTS AND METHODS

We conducted a retrospective study including patients with low- to intermediate-risk NMIBC who underwent TURBT in two urological centers between January 2017 and December 2018. Each TURBT was performed using blue light after intravesical instillation of hexaminolaevulinic acid. The experimental group included patients who received CSBI while the control group included patients without CSBI. When practice, CSBI was started immediately after the surgery and was interrupted 24 hours thereafter. Low-risk NMIBC had a surveillance while intermediate NMIBC had 8 adjuvant endovesical instillations of Mitomycin. The primary endpoint was bladder tumor recurrence free-survival which was defined as the time between the initial TURBT and the date of TURBT for bladder recurrence.

RESULTS

A total of 167 patients (median age: 71 years) were included: 20% female, 15% low-risk, 85% intermediate-risk NMIBC. CSBI was performed in 95 cases (57%). No complication related to irrigation was reported. Bladder recurrence was observed in 55 cases (32.9%): 22 (23.1%) in the CSBI group vs. 33 (45.8%) in the control group (P=0.002). Multivariate stepwise logistic regression analysis with backward selection revealed that CSBI (HR 0.47 [0.27-0.81]; P=0.006) and MMC (HR 0.55 [0.31-0.95]; P=0.034) were significantly associated with reduced risk of bladder recurrence.

CONCLUSIONS

Continuous saline bladder irrigation reduced the risk of bladder recurrence after blue light TURBT in patients with low- to intermediate-risk NMIBC while being safe. Prospective randomized study is needed to confirm these results.

LEVEL OF EVIDENCE

3.

Computed tomography derived left ventricular global longitudinal strain associate with clinical outcomes in patients undergoing transcatheter aortic valve replacement

Funding Acknowledgements

Type of funding sources: None.

Background

Computed tomography angiography (CTA) is key imaging modality for procedure planning for transcatheter aortic valve replacement (TAVR). Functional assessment by CTA with LV global longitudinal strain (LVGLS) has recently shown to be feasible. However, there is limited data on its prognostic value in patients with severe aortic stenosis (AS) who treated with TAVR.

Purpose

To evaluate the association of baseline CTA-LVGLS with post-TAVR outcome.

Methods

 Patients who underwent contrast multiphasic gated CTA for TAVR planning were studied. LVGLS was measured using dedicated feature-tracking software (Medis®). Cox regression analysis evaluated the association of baseline LVGLS with a composite outcome of all-cause death and heart failure hospitalization after TAVR.

Results

A total of 431 patients were included (median [IQR] age, 83 [77,87]years; 44% female); the society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score, 3.3 [2.3,5.1]%; CTA-LVGLS, -18.0 [-21.6,-14.2]%; LV ejection fraction was preserved at 60 [55,65]%. After a median follow-up of 19 [13,27] months, 99 composite outcomes occurred after TAVR. On multivariable Cox regression analysis, LVGLS was associated with the risk of composite outcome even after adjustment for baseline characteristics (Figure A). Patients with reduced LVGLS (above the median &gt;-18.0%) had higher risk of the composite outcome than those with preserved GLS (p = 0.003; Figure B).

Conclusion

Baseline CTA-LVGLS was associated with the risk of death or heart failure hospitalization over the clinical and echocardiographic characteristics in severe AS patients undergoing TAVR.

Abstract Figure.

Computed tomography characteristics of patients with functional MR receiving MitraClip

Funding Acknowledgements

Type of funding sources: None.

Background

Percutaneous leaflet repair with the MitraClip device (Abbott Vascular, Menlo Park, CA) is safe and effective in patients with severe functional mitral regurgitation (FMR). Residual or recurrent MR may occur in up to 40% of patients and is associated with persistent symptoms and impaired survival. The anatomical characteristics associated with residual or recurrent MR after MitraClip are not well defined by computed tomography angiography (CTA) in FMR population.

Methods

A retrospective analysis of patients with significant FMR, who underwent retrospective-gated CTA at Minneapolis Heart Institute between July 2015 to January 2020, identified those who underwent percutaneous leaflet repair with MitraClip. Anatomical and functional parameters were assessed by pre-procedure CTA and compared between those with and without residual (≥2) MR.

Results

  A total of 25 patients were included (median[Q1, Q3]; age, 80[75, 85]; 44% men) and classified into ventricular FMR (V-FMR, n = 12) and atrial FMR (A-FMR, n = 13) according to anatomical and functional characteristics by CTA. 50% of V-FMR and 38% of A-FMR had residual/worsening MR. Among V-FMR patients with residual/worsening MR, shorter coaptation length was observed (2.2[2, 2.3] mm vs. 3.5[3, 4], p = 0.006) (Figure). No differences in anatomical or functional characteristics were seen in A-FMR patients.

Conclusion

Longer coaptation length in V-FMR is predictive of successful MitraClip procedure, whereas mitral annulus size and cardiac volumes are not.

&lt;Ventricular FMR&gt; Total (N = 12) No residual/no worsening MR (N = 6) Residual/worsening MR (N = 6) P value Septal-lateral diameter, mm 31.9 (30.5, 37.9) 32.2 (30.1, 39.8) 31.9 (29.5, 35) 0.749 Annulus area, cm&sup2; 11.2 (10.4, 13.6) 11.3 (10.1, 14.6) 11.1 (9.6, 12.6) 0.631 Tenting area, cm&sup2; 1.6 (1.3, 2.1) 1.6 (1.2, 2.2) 1.7 (1.2, 2.3) 0.873 Tenting height, mm 8.5 (6.5, 9.7) 8.5 (6.6, 9.3) 8.3 (6.3, 10.1) 0.749 Coaptation length, mm 2.6 (2.1, 3.5) 3.5 (3.0, 4.0) 2.2 (2.0, 2.3) 0.006 &lt;Atrial FMR&gt; Total (N = 13) No residual/no worsening MR (N = 8) Residual/worsening MR (N = 5) P value Septal-lateral diameter, mm 32.3 (29.5, 39.0) 32.0 (29.2, 39.9) 34.3 (30.8, 39.02) 0.464 Annulus area, cm&sup2; 10.3 (9.2, 14.7) 10.2 (9.0, 14.6) 12.4 (9.4, 14.7) 0.661 Tenting area, cm&sup2; 1.2 (0.8, 1.8) 1.1 (0.7, 2.2) 1.3 (0.7, 1.8) 0.884 Tenting height, mm 5.5 (4.1, 6.9) 6.3 (4.1, 8.7) 4.6 (3.7, 5.8) 0.213 Coaptation length, mm 2.3 (1.5, 2.8) 2.5 (1.4, 3.5) 1.9 (1.5, 2.6) 0.464 Comparison of baseline CT parameters between no residual/ no worsening MR and residual/ worsening MR Abstract Figure.

Prevalence, incidence and risk factors for foot pressure ulcers in hospitalized elderly patients. An observational and prospective study

BACKGROUND

Incidence and clinical characteristics of foot pressure ulcers (FPU) in hospitalized elderly patients are not well known. The aim of the study was to determine the incidence of FPU during hospitalization, to describe main FPU characteristics and to assess main risk factors for FPU in hospitalised elderly subjects.

METHODOLOGY

An observational prospective study was performed in which patients 65 years or older admitted to Vascular Surgery, Orthopaedic or Geriatric departments were followed from admission to discharge. Trained nurses evaluated all recruited patients on a daily basis for possible FPU. Main characteristics of the patient (age, sex and co-morbidities) and the ulcer (location, grade) were registered.

RESULTS

299 patients were recruited (62.2% women, mean age 82.3 years, mean number of co-morbidities 2.8). Prevalence of FPU was 30.1% at admission and 73.9% at discharge. Incidence of FPU during hospitalization was 9.5 new FPU/100 person-day. 97.0% of the new FPU were grade 1 (erythema) and the most common locations were in the heel (57.6%), the external lateral part of the foot (13.1%), and the hallux of the fist toe (11.8%). Apart from immobility, main risk factors for FPU are age, geriatric residence origin and not able to outdoor life.

CONCLUSIONS

FPU has a high incidence among hospitalised elderly patients; most of them are grade 1 and located in the heel. More attention must be paid in the prevention of pressure ulcers in hospitalized frail subjects.

Dry eye disease symptoms and quality of life in perimenopausal and postmenopausal women

OBJECTIVE

This study aimed to evaluate dry eye disease (DED) symptoms and quality of life (QoL) in a group of perimenopausal and postmenopausal women, based on the Ocular Surface Disease Index (OSDI) questionnaire.

METHODS

An observational study was performed in a group of 1947 perimenopausal and postmenopausal women, aged between 45 and 79 years. The personal data collected were age, menopause status, age at menopause, and OSDI score.

RESULTS

The mean age of the group was 54.18 ± 6.84 years, with a mean age at menopause of 49.45 ± 4.02 years. The average OSDI score was 29.20 ± 19.4. The overall prevalence of DED symptoms was 79%, increasing significantly in postmenopausal women, 76.4% vs. 80.5% (p = 0.029). In our group, 37.7% had severe DED symptoms. Ocular symptoms, vision-related functions, and environmental trigger scores were higher in postmenopausal women, leading to a lower QoL. The severity of OSDI score increases with age (β coefficient: 0.15 [95% confidence interval: 0.02; -0.28]), while the severity of OSDI score decreases with a later onset age of menopause (β coefficient: -0.27 [95% confidence interval: -0.55; -0.01]).

CONCLUSIONS

DED symptoms are highly prevalent in perimenopausal and postmenopausal women. Postmenopausal women had a higher prevalence of symptoms and higher OSDI scores than perimenopausal women. The severity of DED symptoms and vision-related functions leads to poorer QoL.

Clinical and molecular practice of European thoracic pathology laboratories during the COVID-19 pandemic. The past and the near future

Background

This study evaluated the consequences in Europe of the COVID-19 outbreak on pathology laboratories orientated toward the diagnosis of thoracic diseases.

Materials and methods

A survey was sent to 71 pathology laboratories from 21 European countries. The questionnaire requested information concerning the organization of biosafety, the clinical and molecular pathology, the biobanking, the workload, the associated research into COVID-19, and the organization of education and training during the COVID-19 crisis, from 15 March to 31 May 2020, compared with the same period in 2019.

Results

Questionnaires were returned from 53/71 (75%) laboratories from 18 European countries. The biosafety procedures were heterogeneous. The workload in clinical and molecular pathology decreased dramatically by 31% (range, 3%-55%) and 26% (range, 7%-62%), respectively. According to the professional category, between 28% and 41% of the staff members were not present in the laboratories but did teleworking. A total of 70% of the laboratories developed virtual meetings for the training of residents and junior pathologists. During the period of study, none of the staff members with confirmed COVID-19 became infected as a result of handling samples.

Conclusions

The COVID-19 pandemic has had a strong impact on most of the European pathology laboratories included in this study. Urgent implementation of several changes to the organization of most of these laboratories, notably to better harmonize biosafety procedures, was noted at the onset of the pandemic and maintained in the event of a new wave of infection occurring in Europe.

•

Biosafety measures used in the first wave of the COVID-19 crisis were heterogeneous in 53 European pathology laboratories.

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A dramatic decrease of the workload in pathology laboratories was noted.

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No case of healthcare workers contaminated with SARS-CoV-2 associated with samples handling was identified.

Frequency and clinical impact of different definitions of moderate aortic stenosis

Background

Current echocardiographic guidelines recommend five parameters to define severity of aortic stenosis (AS): peak velocity (PV), mean gradient (MG), aortic valve area (AVA), index AVA (AVAi), and dimensionless index (DI). However, the clinical utility of these parameters for patients with moderate AS largely remain unknown.

Objective

To investigate the clinical profiles and outcomes of patients with moderate AS according to five different definitions for severity.

Methods

Using standard echocardiographic definitions, we identified patients with moderate AS who were evaluated in our health care system from 2011 to 2012. Patient demographics, morbidities, and adverse events were reviewed, including death, heart failure (HF) admission, and aortic valve replacement (AVR).

Results

We enrolled 1,042 patients (age, 75±12 yrs; 40% women). Very few patients (4%) met all five criteria for moderate AS, while 49% had only one or two criteria met. DI was the most common parameter for defining moderate AS, employed in 93% of patients. Patients with area-based indices (i.e., AVA, AVAi, DI) had lower stroke volume index, lower mean gradients, lower peak velocities, and more morbidities in comparison to those flow-based definitions of severity (i.e., PV, MG). During a median follow-up of 5.7 years, overall survival was poor with all-cause mortality of 62.8%. Notably, there was no difference in the rates of mortality (range, 56.4 to 63.3%) or HF hospitalization (range, 28.9 to 32.2%) for groups defined by the five parameters, though patients with flow-based definitions more likely had AVR in follow-up.

Conclusions

Most patients with moderate AS meet the definition for severity with one or few criteria. Regardless of the method of definition for severity, a high rate of mortality and morbidity can occur in patients with moderate AS. Further study to optimize the clinical outcomes of patients with moderate AS is warranted.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Minneapolis Heart Institute Foundation

Quality indicators of a cardiac rehabilitation program in women with coronary heart disease

Introduction

Cardiac rehabilitation programs (CRP) are well known to improve functional status and prognosis after a cardiovascular event. This programs are class IA recommendation. However, many studies have demonstrated that women are less likely to stick to a CRP.

Purpose

To compare baseline characteristics between men and women participating in a cardiac rehabilitation program and to determine whether there are gender differences in the benefits obtained after the program.

Methods

Using data from our Department of CRP, we analysed a total of 1091 patients referred between 2015 and 2018 to our center CRP after a cardiovascular diagnosis. Clinical, analytical and echocardiographic outcomes were collected. We defined benefit as the achievement of the target levels established for each cardiovascular risk factor (CVRF) as well as improvement in the exercise capacity. This capacity was evaluated with exercise tests and maximum O2 uptake at the beginning and at the end of the CPR.

Results

Between 2015 and 2018, 189 (17.3%) of them women with a mean age of 62 years were enrolled in the CRP. There were no significant gender differences in mean age or incidence of CVRF. Likewise, there weren't differences in cardiovascular diagnosis, risk stratification, left ventricular ejection fraction or exercise test performed before the program.

In the results after CRP there were no important gender differences in the percentage of patients who achieved the quality indicators described as HbA1c &lt;7.0%, systolic arterial pressure &lt;140 mmHg, diastolic arterial pressure &lt;90 mmHg. Percentage of LDL cholesterol &lt;70 mg/dl was significantly higher in male patients. Both in men and women an improvement of the second exercise test result was observed.

Conclusions

1. Men and women who suffer from a coronary heart disease have similar clinical characteristics.

2. Among patients with coronary heart disease who attended a cardiac rehabilitation program there were no significant gender differences in the benefits obtained after the program.

Funding Acknowledgement

Type of funding source: None

Advanced High-Temperature CO2 Sorbents with Improved Long-Term Cycling Stability

Developing novel sorbents with maximum carbonation efficiency and good cycling stability for CO₂ capture is a promising route to sequester anthropogenic CO₂. In this work, we have employed a green synthesis method to synthesize CaO-based sorbents suitably stabilized by MgO and supported by in situ generated carbon under inert atmosphere. The varied amounts (10-30 wt %) of MgO were used to stabilize the CaO. The supported mixed metal oxide (MMO) sorbents were screened for high-temperature CO₂ capture under CO₂ rich (86% CO₂) and lean (14% CO₂) gas streams at 650 °C and atmospheric pressure. The MMO sorbents captured 53-63 wt % of CO₂ per gram of sorbent under 86 and 14% CO₂, accounting for about 98% carbonation efficiency, which outperforms the CO₂ capture capacity of limestone derived CaO (L-CaO) sorbents (22.8 wt %). All of the synthetic MMO sorbents showed greater capture capacity and cyclic stability when compared to benchmark L-CaO. Because of the high carbonation efficiency and cycling stability of g-Ca_0.69Mg_0.3O sorbent, it was tested for 100 carbonation/regeneration cycles of 5 min each under CO₂ lean conditions. The g-Ca_0.69Mg_0.3O sorbent showed exceptional CO₂ capture capacity and cycling stability and retained about 65% of its initial capture capacity after 100 cycles.