Efficacy of local injection therapy for heel pain in rheumatic inflammatory diseases: A systematic review

Heel pain or achillodynia is one of the most common manifestations in patients with rheumatic inflammatory diseases (RID) and particularly spondyloarthritis (SpA). It can be associated with inflammation at the bone insertion of tendon, ligament, bursa or fascia. However, treatment is still a challenge for rheumatologists. Several findings highlighted the proven benefit of nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), and recently, tumor necrosis factor (TNF)-α inhibitors. However, only limited data about the efficacy of local therapy such as glucocorticoid and anti-TNF injections are available. The aim of this systematic review was to assess the efficacy and safety of local therapies in heel pain and to make recommendations for further studies. Five studies discussing the effectiveness of local treatments of heel pain in RID were included. All studies recognized that the ultrasonography (US)-guided local corticosteroid or etanercept injections were effective and safe modalities for the treatment of inflammatory heel enthesitis, tendinitis, and retrocalcaneal bursitis (RCB) in patients with RID. Pain relief at the local site was associated with a reversion of the acute inflammatory changes in the heel. Furthermore, US-guided injection in RCB with a lateral approach was beneficial in terms of preventing side effects.

[The changing face of rheumatoid arthritis]

Rheumatoid arthritis (RA) is a heterogeneous disease in terms of presentation and evolution. In recent years, a change in the face of this disease has been noticed. RA appears to be less lethal than before, with a larger decline in cardiovascular mortality. Patient hospitalization and orthopedic surgery appear to be declining. Today's RA also seems less active and less destructive. These documented changes, especially over the last decade, are attributable not only to the emergence of biotherapies, but also to more rigorous management strategies by rheumatologists as well as increased patient awareness.

AB0261 IMPACT OF COMORBIDITIES IN THE DISEASE ACTIVITY OF PATIENTS WITH SPONDYLOARTHRITIS AND RHEUMATOID ARTHRITIS: TUNISIAN REGISTRY (BINAR)

Background:

Comorbidities can be associated with rheumatoid arthritis (RA) and spondyloarthritis (SpA). This association can be fortuitous but can also be secondary to rheumatism itself or to the effects of the treatments used. These comorbidities can worsen the disease and even increase patient mortality.

Objectives:

To assess the prevalence of comorbidities in RA or SpA patients from the Tunisian BIologics National Registry (BINAR) and to focus on their influence on the disease activity.

Methods:

BINAR is a multicenter non-interventional and prospective study, conducted in Tunisia with 80 rheumatologists over a period of three years. It included patients with RA (ACR / EULAR 2010 criteria) or SpA (ASAS 2009 criteria). Data were collected and analyzed through an electronic platform managed by DACIMA. They included demographic data, smoking status and types of comorbidities (cardiovascular disease, diabetes, dyslipidemia, osteoporosis, high blood pressure (HBP), neoplasia, gastrointestinal ulcer, depression and fibromyalgia). RA activity was evaluated by the DAS28-VS score and SpA activity by the BASDAI and ASDAS-CRP scores.

Results:

We included 298 patients (175 PR and 123 SpA) making the mean sex ratio 0.6 and mean age 49.18 years ± 14.1 [18-79]. Mean BMI was 27.0 ± 5.5 kg / m2[15 -45] and 17.7% of the patients were current smokers. Concerning disease activity, mean DAS28-VS in RA was at 4.9 ± 1.5 [1.1 - 8.1 and mean BASDAI and ASDAS-CRP, in SpA, were respectively 4.1 ± 1.8 and 2.8 ± 1.1. Comorbidities were noted in 54% of patients (62.1% in SpA and 37.9% in RA), with an average of 1.7 comorbidities per patient.

The most common comorbidities were osteoporosis (38.8%), cardiovascular disease (20.1%), diabetes (16.8%), HBP (18.1%), dyslipidemia (6.7%) and GIU (6.0%). Depression, fibromyalgia and neoplasia were mentioned in 1.7%, 1% and 1%, respectively.

No correlation was found between the number of comorbidities and the activity level of RA: DAS28-VS (p=0.12), nor the activity level of SpA: BASDAI(p=0.07), ASDAS-CRP(p=0.15). Correlations were studied between each comorbidity and activity disease parameters of RA and SpA, they are specified in Table 1. We found that only the presence of osteoporosis was associated with SpA activity, (ASDAS-CRP; p = 0.02).

Tableau n°1:

Relation between comorbidities and the disease activity parameters of rheumatoid arthritis and Spondyloarthritis

DAS 28 ESRBASDAIASDAS CRPDiabetesp = 0.737p = 0.633p = 0.652High Blood pressurep = 0.252p = 0.998p = 0.323Obesityp = 0.565p = 0.585p = 0.904Dyslipidemiap = 0.332p = 0.349p = 0.997Osteoporosisp = 0.372p = 0.989p = 0.020Gastrointestinal ulcerp = 0.829p = 0.286p = 0.910

DAS: disease activity score; BASDAI: Bath Ankylosing Spondylitis Disease Activity Index; ASDAS: Ankylosing Spondylitis Disease Activity Score

Conclusion:

According to this study, in patients with RA and SpA associated comorbidities may occur more frequently than expected (54%). However, they had no relation to the activity of the disease according to their frequencies or their types, except osteoporosis which was significantly associated with the SpA activity. Identifying these comorbidities may affect the management and treatment decisions for these patients to ensure an optimal clinical outcome.

Acknowledgments:

none

Disclosure of Interests:

None declared

AB0969 GAINED WEIGHT DURING PREGNANCY AND LOW BACK PAIN: IS IT REALLY ASSOCIATED?

Background:

Back pain is known to be a common complaint during pregnancy explained by gained weight in this period. Besides, the incidence of low back pain (LBP) in postpartum has also been quoted to be non-negligible even after delivery.

Objectives:

The aim of our study was to assess if the development of LBP during the post-partum period was correlated to gained weight after delivery.

Methods:

In this prospective study, we assessed a survey of 60 women under the age of 35 for back pain symptoms during the postpartum period from day 1 to 18 months. A structured questionnaire using Google form was used. Data from this survey were then correlated with gained weight and pregnancy outcome, as well as women’s history of LBP.

Results:

We interviewed 60 women during their post-partum period. The mean age was 27,9 years old [24, 35 years]. Women were on average at 9 months of post-partum [1, 18 months]. The median height was 1,6 meters [1,54-1,74m]. The median weight at the moment of the study was 63,2 kilograms [48-80kg]. Before pregnancy, body mass index was 23,5 Kg/m2[17-34 Kg/m2]. The total gained weight at the end of pregnancy was 14 kg [12-29 kg]. Only 20% gained more than 15kg. LBP was experienced in 35% of cases with a mean delay of 3,2 months post-partum [1-8 months]. The prevalence of persistent LBP was noted in 26% of cases. However, no correlation was found between LBP and gained weight (p=0,07). Sixty five percent reported one or more significant episodes of back pain during their pregnancy. Significantly, more patients suffering from pain in pregnancy had history of previous back pain episodes when not pregnant (p<0,001), as well as during previous pregnancies (p<0,001).

Conclusion:

No correlation was found between gained weight and occurrence of LBP. The main factors associated with the development of back pain were previous episodes of back pain while non-pregnant or pregnant.

Disclosure of Interests:

None declared

AB0668 CLINICAL CHARACTERISTICS OF RADIOGRAPHIC AND NON RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS IN A GROUP OF TUNISIAN SPONDYLOARTHRITIS

Background:

In the literature, non radiographic axial Spondyloarthritis (nr-SpA) is predominantly female with a shorter period of evolution and similar peripheral manifestations to radiographic axial spondyloarthritis (r-SpA). However, we do not have Tunisian studies comparing the two groups of axial spondyloarthritis (ax-SpA).

Objectives:

The aim of this study was to assess the epidemiological and clinical differences between nr-SpA and r-SpA in a group of Tunisian ax-SpA.

Methods:

Two hundred patients with ax-SpA (ASAS 2009 criteria) were retrospectively included and classified as r-Spa characterized by the presence of radiographic sacroiliitis and nr-SpA defined by the presence sacroiliitis only on MRI or HLA B27 antigen with other clinical features. The different demographic and clinical parameters were compared between the nr-SpA and r-SpA groups.

Results:

One hundred thirty-eight men and 62 women were included with a sex ratio of 2,2. The mean age was 43,3 ± 11,2 years and the mean period of evolution was 10,7 ± 8,4 years. The patients were divided to r-SpA in 80% of cases (n = 160) and nr-SpA in 20% of cases (n = 40).

Women were more present in the nr-SpA group with 47,5% of women versus 26.8% of women in the r-SpA group (p = 0,01). The patients with nr-SpA were younger with a mean age of 39,4 ± 13,4 years versus 44,3 ± 10,4 years in patients with r-SpA (p = 0,03). The mean period of evolution was shorter in nr-SpA group (5,8 ± 4,9 years vs 11.9 ± 8.5; p <0.001). The family history of SpA was more frequent in nr-SpA group (17.5% vs 4.3%, p = 0.004). Arthritis were more frequent in nr-SpA (42.5% vs 13.7%; p <0.0001). Similarly, enthesitis were more frequent in nr-SpA group (45% vs 15.6%; p <0.0001).

No statistically significant differences were found in the following parameters: age at onset of symptoms, diagnostic delay, HLA B-27 antigen and dactylitis.

Conclusion:

The clinical features were different in the 2 groups of ax-SpA: Patients with nr-SpA were more female and had more peripheral manifestations while patients with r-SpA were older and with longer period of evolution.

References:

[1]de Winter JJ, et al. Arthritis Res Ther 2016; 18:196

[2]Malaviya AN, et al. Int J Rheum Dis 2015; 18(7):736–41

Disclosure of Interests:

None declared

FRI0329 ASSOCIATION BETWEEN PERITENON EXTENSOR TENDON INFLAMMATION AND ENTHESITIS IN TUNISIAN PATIENTS WITH PSORIATIC ARTHRITIS

Background:

Ultrasonography (US) is a useful tool in assessing psoriatic arthritis (PsA) by detecting synovitis and Power Doppler (PD) activity. Enthesitis is well known as a cornerstone of PsA physiopathology. Recently, more specific US features of PsA have emerged, such as peritenon extensor tendon inflammation (PTI) and edema of soft tissues, with value in the positive diagnosis of the disease.

Objectives:

The aim of our study was to determine the association between PTI, edema and enthesitis in PsA patients.

Methods:

Patients with peripheral PsA responding to the Classification Criteria for Psoriatic Arthritis (CASPAR) were included. US examination was performed by an experimented rheumatologist blinded to clinical data using a machine type Esaote MyLAb 60 with a linear probe of 6-18 MHz. Wrists, metacarpo-phalangeal (MCP), proximal inter-phalangeal (PIP) and distal inter-phalangeal (DIP) joints were assessed in mode B and PD. PTI was defined as a hypoechoic image surrounding the digitorum tendon with or without PD signal in the dorsal aspect of MCP joints. Soft tissue edema was defined as a diffuse enlargement of soft tissue around the flexor tendon, with an increased PD signal, from finger pad to MCP joint and was evaluated by volar scan. Enthesitis of the digitorum extensor tendon at the dorsal aspect of DIP joint and synovitis were defined according to the OMERACT definitions.

A p<0.05 was considered statistically significant.

Results:

A total of 600 joints were assessed in 20 PsA patients, 8 men and 12 women, with a mean age of 55 ± 11 [33-77] years old. The mean disease duration was of 10±8 [1-34] years. Clinically, 25% of joints were tender and 6% were swollen. The mean DAPSA (Disease Activity in PSoriatic Arthritis) score was of 32±27 [4-112].

On US examination, synovitis was detected in 54 joints (9%), with PD signal in 53% of them. The sites of synovitis by decreasing order of frequency were: MCP in 38%, wrists in 26%, PIP in 19% and PID in 13% of cases.

PTI was noted in 24 MCP joints (12%) with PD signal in one case, and soft tissue edema in 6 MCP joints (3%).

Enthesitis was noted in 59 DIP joints (37%). The elementary lesions recorded were: enthesophytes in 64 %, erosions in 20 %, calcifications in 13 % and thickened and/or hypoechoic tendon in 12 % of cases. However, no PD signal at the enthesis was found.

PTI and soft tissue edema had no association with enthesitis (p=0.399 and p=0.374 respectively). PD synovitis showed a significant association with enthesitis (p=0.034), but not with PTI and soft tissue edema. GS synovitis had no association with any of these lesions.

Conclusion:

Our study found PTI and soft tissue edema not to be associated with enthesitis as opposed to PD synovitis. A larger sample size is necessary to support the role of PTI as an enthesis related lesion in PsA patients.

Disclosure of Interests:

None declared

AB0635 HOW ARE NON STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAID) PRESCRIBED IN AXIAL SPONDYLOARTHRITIS?

Background:

For decades, NSAID have been used as the first-line drugs to treat axial spondyloarthritis (ax-SpA). However, the NSAID prescription strategy is not clearly detailed and it varies from one clinician to another.

Objectives:

The aim of this study was to assess the NSAID prescription modalities adopted in ax-SpA and the differences between these modalities.

Methods:

This is a descriptive study including 200 cases of ax-SpA fulfilling the ASAS 2009 criteria and diagnosed between January 2000 and October 2019. The demographic and clinical features of the ax-SpA were collected and the modalities of prescription of NSAID were retrospectively assessed.

Results:

Our population consists of 138 men and 62 women with a mean age of 43,3 ± 11,2 years. The HLA B-27 antigen was present in 50,8% of cases. The ax-SpA was a pure axial form in 67% of patients, associated with peripheral arthritis, enthesitis and dactylitis in 19%, 21,5% and 1,5% respectively.

One hundred eighty patients (90%) had been treated with NSAIDs. The NSAIDs used were: the Diclofenac (57.5%), Indomethacin (37.5%), Piroxicam (36%), clecoxib (34%), Naproxen (29.5%) and ketoprofen (13%). Seventy-three patients (36.5%) had used at least 3 NSAIDs.

Among the 180 patients treated with NSAID, 88 patients (48,8%) were treated with conventional synthetic DMARDs (csDMARDs) in association with NSAID: Salazopyrine (43,3%) and Methotrexate (13,3%). Seventy-one patients (39,4%) had necessitated the use of anti-TNF alpha.

NSAIDs were used continuously in 115 patients (63.8%) and the maximum dose of NSAIDs was used in 78 patients (43.3%). By comparing patients who used maximum doses of NSAIDs and those who used NSAID continuously with other patients, we noticed that the use of biological treatments was more frequent in those groups (p = 0,01 and p=0,004 respectively).

In addition, while comparing the group of patients co-treated with csDMARDs with other patients treated with NSAID on monotherapy, we noted that this group of patients had more arthritis (p<0,0001), enthesitis (p=0,02), psoriasis (p=0,04) and necessitated more biological treatments (p=0,01).

Conclusion:

Our results suggest that maximal doses and/or continuous prescription of NSAID were mainly used if there was no response to that treatment. The csDMARDs were more prescribed if there were peripheral manifestations or psoriatic arthritis and those forms were also more candidates to biological treatments.

References:

[1]Wang R, et al. Arthritis Rheumatol Hoboken NJ. 2019;

Disclosure of Interests:

None declared

AB0669 PARTICULARITIES OF TUNISIAN FEMALE AXIAL SPONDYLOARTHRITIS

Background:

Axial spondyloarthritis (ax-SpA) is a chronic rheumatic disease that mainly affects men. However, the female form of ax-SpA remains insufficiently studied.

Objectives:

The aim of this study was to determine the clinical characteristics, the disease activity and the functional impact of female ax-SpA in comparison with male ax-SpA.

Methods:

This is a retrospective study including patients diagnosed with ax-SpA fulfilling the criteria of the Assessment of SpondyloArthritis international Society (ASAS) 2009.

Clinical parameters, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Bath ankylosing spondylitis disease activity index (BASDAI) and Bath ankylosing spondylitis functional index (BASFI) were compared between groups of female and male ax-SpA.

Results:

Two hundred ax-SpA patients were included with 31% of female (n=62) and a mean age of 43,3 ± 11,2 years.

The mean age at onset of symptoms was 31,8 ± 8,9 years for women and 25,3 ± 9,1 years for men (p <0,0001). The mean age at diagnosis was 36,4 ± 9,6 years for women and 31,7 ± 10,4 years for men (p = 0,003). Ax-SpA with juvenile onset was noted in 1,7% of women and 12,1% of men (p = 0,02). Male ax-SpA were significantly more smokers (46.8% vs 5.4%; p <0.001). The mean duration of morning stiffness was 11,3 ± 9,2 minutes for women versus 21,6 ± 19,3 minutes for men (p = 0,005).

The mean ESR was 42,4 ± 29,8 mm for women and 28,3 ± 23,4 mm for men (p = 0,001). Radiographic sacroiliitis was present in 69,3% of women versus 84,7% of men (p = 0,01). The use of anti-TNF alpha was less frequent in women (29% vs 48,5%; p = 0,01).

Our study didn’t found a statistically significant difference in peripheral manifestations, extraarticular manifestations, CRP, BASDAI and BASFI between the two groups.

Conclusion:

Female ax-SpA seems to have a better prognosis than male with older age in disease onset, less inflammation, less radiographic sacroiliitis and less use of biological treatments.

References:

[1]Rusman T, et al. Curr Rheumatol Rep. 2018; 20(6).

[2]Siar N, et al. Curr Rheumatol Rev. 2019;

Disclosure of Interests:

None declared

AB0201 IMPACT OF TREATMENT INITIATION DELAY ON DISEASE ACTIVITY DURING RHEUMATOID ARTHRITIS

Background:

During rheumatoid arthritis (RA), initiating conventional synthetic Disease Modifying Anti-Rheumatic Drug (csDMARD) at the early stages of the disease is a mandatory condition to achieve DMARD-free sustained remission (1). Limited data studying the relationship between RA treatment delay and disease activity are available.

Objectives:

The aim of this study was to assess the impact of csDMARD initiation delay during RA on disease activity.

Methods:

This is a cross-sectional study including patients with RA (ACR/EULAR criteria).Delays were collected from patients’ interview and were represented respectively by D1, D2 and D3. D1 stands for the lag time separating the first RA symptom onset and rheumatologist consultation. D2 stands for the lag time separating the first RA symptom onset and RA diagnosis. D3 stands for lag time separating the first RA symptom onset and csDMARD initiation. Disease activity was evaluated by: Visual Analogue Scale for pain (VAS), number of tender joints, number of swollen joints, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and Disease Activity Score28 (DAS28).The data were analyzed with descriptive statistics, Student’s t test, chi (2) test, and Spearman correlation using the SPSS statistical package. A p value < 0.05 was considered significant.

Results:

The study included 100 RA patients (86 women and 14 men), with a mean age of 56.5 ± 12.4 years. The mean age at the onset of RA was 47.5 ± 12.4 years. Median D1, D2 and D3 were respectively 12 months [0-242], 15.7 months [2-252] and 18 months [2-270].Methotrextate was prescribed in 86% of cases. At RA diagnosis, the median values for the following parameters were: VAS 80 [30-100], number of tender joints 10[0-28], number of swollen joints 5 [0-17], ESR 43mm/hour [6-133], CRP 14.1 mg/l [1-120], DAS28 (ESR) 5.22 [2-7.52] and DAS28 (CRP) 4.6 [1-6.93]. After one year of follow-up, the median parameters of the disease activity were respectively: VAS 60 [0-100], number of tender joints 6[0-28], number of swollen joints 2 [0-22], ESR 32 mm/hour [2-106], CRP 7.5 mg/l [1.2-94], DAS28 (ESR) 4.1 [1.4-7.1] and DAS28 (CRP) 3.7 [1.68-6.22]. Significant positive correlation was found between delays in csDMARD initiation and DAS28 (CRP) scores over the first year (p=0.02, r=0.29).

Conclusion:

In this study, delays in treatment were associated with higher DAS28 (CRP) scores after one year of follow-up. Our results suggest that early identification and treatment of RA leads to improved outcomes and even improved rates of drug-free remission.

References:

[1]Van Nies JA, Krabben A, Schoones JW, et al. What is the evidence for the presence of a therapeutic window of opportunity in rheumatoid arthritis? A systematic literature review. Ann Rheum Dis 2014;73:861–70.

Disclosure of Interests:

None declared

AB0636 MODALITIES OF PRESCRIPTION OF ANTI-TNF ALPHA IN AXIAL SPONDYLOARTHRITIS: ON MONOTHERAPY OR COMBINED WITH CONVENTIONAL SYNTHETIC DMARDS

Background:

The advent of biologics targeting tumor necrosis factor-alpha (anti-TNF alpha) has revolutionized the treatment of spondyloarthritis (SpA). Their association with conventional synthetic disease-modifying antirheumatic drugs (cs-DMARD), although effective and used in clinical practice for the treatment of peripheral rheumatic diseases, is not clearly assessed in axial spondyloarthritis (ax-SpA).

Objectives:

The aim of this study was to assess the strategy of prescription of anti-TNF alpha in a population of ax-SpA and to compare patients treated with anti-TNF alpha on monotherapy with those who had combined therapy with cs-DMARDs.

Methods:

This is a retrospective descriptive study including 85 cases of ax-SpA diagnosed between January 2000 and October 2019 and treated with anti-TNF alpha.

The clinical features, the erythrocyte sedimentation rate (ESR), the C-reactive protein (CRP), Bath ankylosing spondylitis disease activity index (BASDAI) and Bath ankylosing spondylitis functional index (BASFI) were compared between groups of anti-TNF alpha on monotherapy or combined therapy with csDMARDs.

Results:

Of 85 ax-SpA, 67 were males (78,8%) and the mean age was 44,4 ± 10,9 years. The mean period of evolution was 12,3 ± 9,1 years and 52,2% of patients were HLA-B27 positive. The ax-SpA was a pure axial form in 74,1% of patients, associated with peripheral arthritis, enthesitis and dactylitis in 17,6%, 17,6% and 1,2% respectively.

The ant-TNFs were administrated with a men delay of 78 ± 70,8 months. The anti-TNFs used were: Infliximab (41,1%), Etanercept (32,9%), Adalimumab (23,5%) and Golimumab (2,3%). Fifty-nine patients (69,4%) were treated with anti-TNF alpha on monotherapy and 26 patients (30,6%) had combined therapy. The csDMARDs prescribed were the Salazopyrine (22,4%) and the Methotrexate (7,1%).

While comparing the groups of anti-TNFs combined therapy and monotherapy, we noticed that the arthritis were present in 30,7% of patients from the group of combined therapy versus 11,8% of patients from the group of monotherapy (p=0,03). The psoriasis also was more present in the group of combined therapy (11,5% vs 1,6%; p=0,04).

There was no statically significant difference between the two groups in the following parameters: age, gender, HLA B27, enthesitis, dactylitis, uveitis, inflammatory bowel diseases, ESR, CRP, BASDAI and BASFI.

Conclusion:

Our results suggest that the concomitant use of csDMARDs with anti-TNFs is frequent in clinical practice in ax-SpA, but mainly justified by the presence of arthritis or psoriasis.

References:

[1]Engel-Nitz NM, et al. Rheumatol Ther. 2015;2(2):127–39.

Disclosure of Interests:

None declared

AB0637 EFFICACY OF COMEDICATION OF CONVENTIONAL SYNTHETIC DMARDS WITH TNF BLOCKERS IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background:

Tumour necrosis factor blockers (anti-TNFs) are typically used in axial spondyloarthritis (ax-SpA) when the disease has not responded adequately to conventional therapy. However, the effects of the comedication conventional synthetic disease modifying antirheumatic drugs (csDMARDs) with anti-TNFs are inconclusive.

Objectives:

The aim of this study was to evaluate the efficacy of comedication csDMARD and anti-TNF compared with anti-TNFs on monotherapy.

Methods:

A descriptive retrospective study including 85 patients with ax-SpA according to the criteria of the group ASAS on 2009 and having received anti-TNFs between January 2000 and October 2019.

The patients were divided on two groups, those who had received combined therapy with cs-DMARDs and those who had received anti-TNFs on monotherapy.

The response to treatment was assessed with the ASAS 40 response and partial remission at 3 and 6 months of treatment and was compared between the two groups.

Results:

Our populations consists of 67 men and 18 women with a mean age of 44,4 ± 10,9 years. The mean period of evolution was 12,3 ± 9,1 years and 52,2% of patients were HLA-B27 positive. The ax-SpA was associated with peripheral arthritis, enthesitis and dactylitis in 17,6%, 17,6% and 1,2% respectively.

Fifty-nine patients (69,4%) were treated with anti-TNF alpha on monotherapy and 26 patients (30,6%) had combined therapy. The ASAS 40 response was achieved in 45,6% of patients at 3 months and 64,1 % of them at 6 months of anti-TNFs treatment. Among them, 7,4% had obtained partial remission at 3 months and 20,3% at 6 months of treatment.

There was statically significant difference between the two groups on the ASAS 40 response or the partial remission at 3 and 6 months of treatments.

Conclusion:

The comedication therapy with csDMARDs does not influence the efficacy of anti-TNFs in ax-SpA patients suggesting no benefit in the concomitant use of these drugs in clinical practice.

References:

[1]Simone Det al. J Rheumatol Suppl. 2015;93:65–9.

Disclosure of Interests:

None declared

AB0319 DRUG SURVIVAL OF BIOLOGICS IN RHEUMATOID ARTHRITIS: PRELIMINARY DATA FROM THE TUNISIAN BINAR REGISTRY

Background:

The arrival of Biotherapy has changed the management and prognosis of rheumatoid arthritis (RA). However, drug survival of the first biotherapy is changing according to the studies.

Objectives:

We aimed to report the data on the drug survival of biotherapies in RA, collected from the Tunisian BIologics National Registry (BINAR)

Methods:

BINAR is a multicenter non-interventional and prospective study, conducted in Tunisia with 80 rheumatologists over a period of three years. It included patients with RA (ACR / EULAR 2010 criteria) and refractory to conventional background treatments (csDMARDs), who required the use of biological treatment of anti TNF, anti IL6 or Rituximab type. Data were collected and analyzed through an electronic platform managed by DACIMA. Sociodemographic data (age, gender, body mass index (BMI), smoking) and characteristics of RA (duration of evolution, erosive character) were collected. RA activity was studied by the DAS28-VS score and drug survival was evaluated by the duration of the biologics.

Results:

We included 175 patients with a sex ratio of 5.7 and a mean age of 54.1 ± 12.6 years [19-79]. Patients were smoking in 6.7% of cases and mean BMI was 27.9 ± 5.2 kg/m2[15.1-45.2]. RA was erosive in 73.1% of cases and the mean disease duration was 6.7±3.5 years. Disease activity was moderate (mean DAS28vs: 4.9±1.5). Concerning the treatments, 139 (79.4%) of the patients received TNFα inhibitor, 31 (17.7%) of the patients were on IL6 inhibitor and 15 (8.6%) were on Rituximab.

The mean duration of drug survival for TNFα inhibitor agents was 15.2 months, 18 months for anti IL6 and 16.3 months for Rituximab. The drug was discontinued by 19 patients (10.8%). The causes of discontinuation were primary failure in 31.8% (7 subjects), secondary escape in 9.1% (4 subjects), the occurrence of adverse effects in 31.8% (7 subjects), intolerance to drug in 9.1% (2 subjects), non-compliance for one patient and for other reasons in one case.

The drug survival of TNF inhibitor was not associated with socio-demographic data (gender (p=0.9), age (p=0.4), smoking (p=0.9), BMI (p=0.9)), nor with the characteristics of the disease duration (p = 0.5), DAS28 vs (p = 0.9), association with a csDMARDs (p = 0.2)) except the presence of erosion (p = 0.013).

Also, drug survival of IL6 inhibitor drugs was not associated with socio-demographic parameters (gender (p = 0.1), age (p= 0.6), smoking (p= 0.6), BMI (p = 0.4)) and the characteristics of the disease (duration (p = 0.9), erosive character (p = 0.6), DASvs (p = 0.1), association with a csDMARDs (p = 0.2)).

Similarly, drug survival of Rituximab was not associated with socio-demographic data (gender (p = 0.6), age (p = 0.7), BMI (p = 0.7)) or with the characteristics of RA (duration of evolution (p= 0.5), erosive character (p = 0.6), DASvs (p = 0.08), association with a csDMARDs (p = 0.5))

Conclusion:

Our study demonstrated that IL6 inhibitor had the longest duration of drug survival (18 months). The major causes of cessation were dominated by primary failure and the occurrence of an adverse event. Finally, the drug survival of TNF inhibitor agents was associated with the erosive character.

Acknowledgments:

none

Disclosure of Interests:

None declared

AB0747 SPECIFIC ULTRASOUND LESIONS IN PSORIATIC ARTHRITIS: PREVALENCE AND CORRELATION WITH DISEASE ACTIVITY

Background:

Psoriatic arthritis (PsA) is a systemic inflammatory disease with articular and extra-articular features. In recent years, Ultrasonography (US) is playing an important role in the diagnosis and monitoring of this disease. Specific US features of PsA have been reported such as enthesitis, peritenon extensor tendon inflammation (PTI) and soft tissue edema.

Objectives:

The aims of this study were to evaluate the prevalence of these US signs in PsA patients and to determine their association with disease duration and activity.

Methods:

Patients with peripheral PsA responding to the Classification Criteria for Psoriatic Arthritis (CASPAR) were enrolled. Clinical and biological data were extracted, and then US examination was performed by an experimented rheumatologist blinded to clinical data using a machine type Esaote MyLAb 60 with a linear probe of 6-18 MHz. The following US features were evaluated: PTI at the dorsal aspect of metacarpo-phalangeal (MCP) joints, soft edema at the volar aspect of MCP joints and enthesitis of the digitorum extensor at the dorsal aspect of distal inter-phalangeal (DIP) joints.

A p<0.05 was considered statistically significant.

Results:

We included twenty PsA patients, 8 men and 12 women, with a mean age of 55 ± 11 [33-77] years old. The mean disease duration was of 10±8 [1-34] years. A family history of PsA or psoriasis was reported in 53% of cases.

Oral corticosteroids were used in 21% of patients, at a mean daily posology of 7 mg [5-10] of Prednisone equivalent, Methotrexate in 84% of cases at a mean posology of 15 mg [10-20] per week, Sulfasalazine in 10% of cases and a biological DMARD in 32% of cases (Etanercept=4, Infliximab=1, Adalimumab=1).

The mean number of tender and swollen joints were respectively of 8 [0-16] and 2 [0-8]. The mean rate of patient global evaluation and visual analogue scale was of 5 [0-9].

The mean DAPSA (Disease Activity in PSoriatic Arthritis) score was of 32±27 [4-112].

US examination demonstrated that all patients had at least one of the three specific signs that we were looking for. At MCP level, PTI was noted in 11% of joints with Power Doppler (PD) signal in one case and soft tissue edema was noted in 3% of joints.

At DIP level, enthesitis of digitorum extensor tendon was noted in 39% of joints. The elementary lesions reported were: enthesophyte in 25%, erosion in 8%, calcification in 5% and thickened or hypoecoic tendon in 4% of joints. However, no PD signal was detected at the enthesis.

A positive association was found between DAPSA score and soft tissue edema (p=0.000), but not with PTI (0.668) and enthesitis (0.137). No relation was found between these three lesions and the disease duration.

Conclusion:

The presence of soft tissue edema, enthesitis and/or PTI on US can be an argument for the diagnosis of PsA. Soft tissue edema is shown to be associated with disease activity.

Disclosure of Interests:

None declared

AB0182 EVALUATION OF THE SOCIO-PROFESSIONAL IMPACT OF ANKYLOSING SPONDYLITIS AND RHEUMATOID ARTHRITIS IN TUNISIA: DATA FROM THE BINAR REGISTRY

Background:

Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are disabling and common chronic inflammatory rheumatic diseases.

Objectives:

The aim of our study was to evaluate the socio-professional impact of RA and AS.

Methods:

Using the Biological National Registry (BINAR) data, which includes ten tunisian rheumatology centers,we identified patients≥18 years with AS and RA according to the ACR and EULAR 2010 criteria(RA) and ASAS 2009 (AS), receiving biotherapy for less than two years.

Results:

298 patients were included in the study. The percentage of patients with RA was 58.7 % and those with AS 41.3%. The sex ratio was 0.6. The average age of the onset of the disease was 49.1 years ± 14.1 years [18–79]. For marital status, 72% were married, single (25%), widowed (2.6%) and divorced (0.4%). 22.4% of patients were illiterate, 32.7 % (primary), 28.3% (secondary) and 16.6% had an university level. For the RA population, a high disease activity (DAS28-ESR >5.1) was detected in 36% of patients, an erosive arthritis in 73.1% and 7.2% had a coxitis. In the AS group, an elevate BASDAI (BASDAI≥4) was detected in 56.9% of patients and 39% had coxitis. All patients have received Biological therapy concomitant with corticosteroids (59.1%), methotrexate (42.6%), salazopirine (20.8%) and leflunomide (4.7%). 54% of patients had a comorbidity, of which 1.7% was depression. More than half of our patients (54.3%) were unemployed, 40 % were professionally active, and 5.7% were retired due to the rheumatic condition. Absence from work was observed in 15.1% of cases with a total duration exceeding three months in 55.5% of cases. 37.9 % of patients were physically active: regularly (9.8%), irregularly (28.1%) and (62.1%) were sedentary. For the functional impact, HAQ score was 1.31± 0.7 for RA and BASFI was 5.2 ± 4.8 for AS. The working abandonment is significantly associated to: marital status (p=0.039), low level of education (p=0.04),depression (p<0.001), high activity of AS (p=0.004) and BASFI>4 (p=0,001).

Conclusion:

RA or AS requiring biotherapy have a high socio-economic impact and are responsible for absenteeism at work and even for early working abandonment. Early therapeutic management and a global assessment are essential in order to improve quality of life and working conditions. Longitudinal studies are needed to assess the effect of biological therapy on the socio-professional impact of these chronic inflammatory rheumatic disease.

Disclosure of Interests:

None declared

AB0300 SEVERITY FACTORS IN RHEUMATOID ARTHRITIS AND SPONDYLOARTHRITIS IN NEWLY TREATED PATIENTS WITH BIOLOGICS: SURVEY OF THE BINAR REGISTRY

Background:

Rheumatoid arthritis (RA) and spondyloarthritis (SA) are two heterogeneous diseases but both being major causes of disability in our practice. Biologic treatments have changed miraculously the course of these diseases in the past two decades.

Objectives:

To determine severity factors in RA and SA patient newly treated with biologics.

Methods:

A survey using results of the Tunisian registry BINAR including ten rheumamtology centers was conducted. Adults of 18 years or more were included. Only those meeting the ACR/EULAR 2010 critera for RA or the ASAS 2009 criterea for SA and treated with biologics for 2 years or less were included.

Results:

Two hundred and ninety-eight patientd were enrolled including 111 males and 187 females (sexe ratio H/F of 0.6. The mean age was 49.1 years ± 14.1. The mean disease duration was 6.7 years ± 3.5 for RA and 6.5 years ±3.6 for SA. All patients were prescribed biologics for poor response under NSAIDS or conventional DMARDS. Smoking was reported in 17.7% patients. High disease activity defined as a DAS 28 VS score>5,1 in RA and was reported in 36% of cases. HAQ>2 was present in 14.3%, erosive forms were reported in 73.1% of cases. Rheumatoid factor (RF) and anti cetrullinated peptide antibodies were highly positive (>3x normal rates) in 71,2% and 62.4% of cases respectively. As for AS, active disease was defined by ASDAS CRP or ASDAS VS>2,1 or BASDAI>4 and was reported in 39%, 39.8% and 56.9 % of cases respectively. The functional score BASFI>4 was reported in 54.5% of cases. On the whole, a coxitis was noted in 48.8% of cases and extra articular manifestations (EAM) were present in 59.3 % of cases. Statistical analysis for SA patients didn’t show an association between active disease (ASDAS>2,1 and different parameters (genre (p=0.205), smoking (p=0.120), inflammation in biology (p=0.481), uveitis (p=0.241) and the presence of coxitis (p=0.375)). Nevertheless, RA patients with severe disease were more likely men (p= <0.001). Other features for RA patients showed no significant statistical difference (age (p= 0.253), inflammation on biology (p=0.963), positive RF (p=0.789), ACPA positive (p=0.258), présence de EAM (p=0.382), erosive forms (p=0.203) and HAQ≥2 (p =0.219).

Conclusion:

It’s important to determine clinical, biological and radiographic factors in RA and SA patients as well as activity scores in order to recognize patients potentially at risk of poor progression and for better therapeutic management and biologic treatment may have an influence on these factors.

References:

[1]Wagner E, Ammer K, Kolarz G, Krajnc I, Palkonyai E, Scherak O, et al. Predicting factors for severity of rheumatoid arthritis: a prospective multicenter cohort study of 172 patients over 3 years. Rheumatol Int. 1 sept 2007;27(11):1041‑8.

Disclosure of Interests:

None declared

AB1128 ULTRASOUND SYNOVITIS AND SQUEEZE TEST: IS THERE A RELATIONSHIP?

Background:

The squeeze test or the Gaenslen’s test is an easy and rapid method to identify arthritis in metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints. It’s characterized by tenderness upon lateral compression of MCP or MTP joints. This is a useful clinical exam for the early diagnosis of Rheumatoid Arthritis (RA).

Objectives:

The aim of our study is to assess the real value of that test and its association with synovitis.

Methods:

A prospective study including RA patients (2010 ACR/EULAR criteria) was conducted at the Rheumatology Department of Mongi Slim Hospital Tunis.

US examination was performed by an experimented rheumatologist blinded to clinical data using a machine type Esaote MyLAb 60 with a linear probe of 6-18 MHz. MCP joints were assessed in dorsal longitudinal view, in mode B and Power Doppler.

Synovitis was defined and Flexor digitorum Tenosynovitis was defined according to OMERACT.

A p<0.05 was considered statistically significant.

Results:

Forty-three cases of RA were included. The mean age was 58.92 years [27 - 81]. The sex ratio was 0.16. Among our patients, 46.5% of cases were receiving methotrexate with a mean dose of 15,875 mg / week [7.5 - 22.5]. Corticosteroids were used in 55.8% of our patients with a mean dose of 8.65 mg / day [2.5 - 30]. Moreover, 23.25% of the patients were on biologics.

The mean value of morning stiffness was 37 min [0 - 150], the mean value of the global assessment of the disease by the patient was 5/10 [1 - 8]. The Gaenslen’s test was positive bilaterally in 25,6% of cases, in the right hand and in the left one in respectively 39.5% and 27.9% of the patients. Tenosynovitis of the flexors were found clinically in 11.6% case.

The mean CRP was 29.7 mg / L [0.2 - 275] and the mean ESR was 65 mm [3 - 120]. The mean value of DAS28 and DAS28CRPwere respectively 5.20 ± 1.43 [2.69 – 9.00] and 4.33 ± 1.43 [1.35 – 8.32]. Overall, 430 joints and 430 flexor tendons were assessed by Ultrasound. Ninety-one synovitis were detected with a mean of 2.56 synovitis in MCP per patient [0 - 10]. Flexor tenosynovitis was found in 53.5% of patients.

A statistically significant correlation was found between the squeeze test and presence of ultrasound synovitis of the MCP whatever the site of the synovitis; on the right side (r = 0.507; p < 10-3), or the left one (r = 0.607; p < 10-3) but no correlation between the clinically detected tenosynovitis and the ultrasound tenosynovitis (p = 0.364). We found a significant correlation between the Gleason test and ultrasound tenosynovitis on both side with r = 0.368 and p = 0.015 on the right hand and r = 0.441 and p = 0.003 on the left one.

Conclusion:

The squeeze test seems to be a very useful and practical clinical examination to easily detect synovitis and aid in the early diagnosis of RA

Disclosure of Interests:

None declared

AB1260 ARE THERMAL CURE AND REHABILITATION EFFECTIVE FOR RELIEVING LOW BACK PAIN? RESULTS OF A RANDOMIZED CONTROLLED TRIAL

Background:

Low back pain (LBP) is a major health problem around the world. It affects almost 80% of the population. Patient with LBP suffer from a heavy pain which is associated to long time incapacity. Different methods of treatment are applied in the objective of reducing pain and thus improving functional capacities of patients.

Objectives:

Our study aimed to compare the benefits, with regard to LBP symptoms, of a thermal cure and a rehabilitation treatment.

Methods:

It is a randomized therapeutic trial including patients with LBP, randomly divided into two groups: thermal cure and physical rehabilitation. Both of them were conducted in the same spa center of Djbal El Ouest. Outcome measures were visual analogic scale of pain (VAS), Oswestry Disability Index (ODI), Short Form-36 (SF36) questionnaire and schober test. Evaluation was carried out at day 18, 3 months, 6 months and 12 months following treatment.

Results:

Seventy-four patients were included, divided into 2 groups: thermal group (n=37) and dry rehabilitation group (n=37). Seventy patients performed the full treatment.

In the group of patients treated with thermal cure treatment (n=37), a significant improvement of VAS of pain, ODI and SF 36 was noted in day 18, 3 months,6 months and 12 months (Table 1).

Table 1.

Tendencies of the clinical indexes after treatment by thermal cure

D0(n=37)D18(n=37)3months(n=35)6months(n=32)12months(n=36)VAS ± SD68,2 ± 16,235,8 ± 26,555 ± 1960,2 ± 18,156,1 ± 19P0,0000,0000,0080,002ODI ± SD38,3 ± 14,129 ± 17,532 ± 14,130,2 ± 14,128,5 ± 13,6P0,030,030,070,000SF 36 physical mean score ± SD34,4 ± 14,364,2 ± 1845,9 ± 1950 ± 21,847,9 ± 18,5P0,0000,0000,0000,001SF36 mental mean score ± SD38,9 ± 16,371 ± 21,655,1 ± 20,456,4 ± 19,952,2 ± 20,8P0,0000,0000,0000,000Scober test ± SD3,1 ± 1,33,5 ± 1,32,8 ± 13 ± 1,13,2 ± 1,5P0,0370,3220,8120,657

VAS: visual analog scale; ODI: Oswestry Disability Index; SF36: short form 36

In the group of patients treated with physical rehabilitation (n=33), a significant improvement of the VAS of pain and of the physical mean score of SF36 was noted only on day 18 (Table 2). A significant improvement of the mental mean score of SF 36 was noted on day 18 and 6 months (Table 2).

Table 2.

Tendencies of the clinical indexes after treatment by physical rehabilitation

D0(n=37)D18(n=33)3 months(n=28)6 months(n=29)12 months(n=25)VAS ± SD64 ± 19,547,4 ± 24,655,7 ± 18,150,5 ± 27,562,2 ± 22,2P0,0020,0910,0570,567ODI ± SD34,3 ± 12,331,1 ± 17,331,9 ± 15,630,3 ± 18,831,1 ± 12P0,2680,2580,2960,150SF 36 physicalmean score ± SD38,1 ± 16,153,8 ± 2242,6 ± 16,445,1 ± 18,742,6 ± 16,2P0,0020,2840,2020,185SF36 mentalmean score ± SD39,3 ± 17,561,6 ± 23,545,1 ± 18,949,6 ± 24,646,9 ± 22,1P0,0000,1300,0330,09Schober test ± SD3,2 ± 1,43,5 ± 1,33,4 ± 1,42,7 ± 1,22,9 ± 1,3P0,8450,9830,0910,346

VAS: visual analog scale; ODI: Oswestry Disability Index; SF36: short form 36

Comparison of the two types of tested treatments showed a certain number of statistically significant differences. The VAS and physical mean score of SF 36 at day 18 and mental mean score of SF-36 at 3 months were significantly lower on the thermal cure group, while schober test at 3 months was significantly lower in the physical rehabilitation group.

Conclusion:

Our study suggests a superiority of thermal cure in relieving pain and improving quality of life at short term among patient with LBP and a comparable efficacy in improving lumbar spine function. However, the effectiveness of physical rehabilitation was greater on spine mobility.

Disclosure of Interests:

None declared

AB0287 HEMATOLOGICAL SIDE EFFECTS OF BIOLOGICAL THERAPY IN RHEUMATOLOGY: DATA FROM THE TUNISIAN REGISTER

Background:

During the last decade, the treatment of chronic inflammatory rheumatism (CIR) has been greatly improved with the advent of biotherapy.However, the use of biological treatment can lead to a number of side effects including abnormalities in the blood count.

Objectives:

The aim of this study was to assess the different hematological side effects of biological treatment in patients with rheumatoid arthritis (RA) and spondyloarthitis (SA).

Methods:

This study included patients with RA (ACR/EULAR 2010) and SA (ASAS 2009) registred with the Tunisian Biologic National Registry (BINAR).Patients were followed and treated with biologics for 2 years of less. Clinical data relative to biological treatment, including haematological side effects, have been collected.

Results:

Two hundred and ninety-eight patients (178 women and 111 men) were included in the study.

The mean age was 49.2 ± 14.1 years. The male/female ratio was 0.6. The mean diseases durations for RA and SA were respectively 6.7 ± 3.5 years and 6.5 ±3.6 years.

Anti-TNFα agents were prescribed in 87.9% of patients (n = 263) with respectively: Infliximab (20.4%) Etanercept (23.1%), Adalimumab (24.6%) and Certolizumab (26.5%).

Tocilizumab and Rituximab were prescribed in 10.4% and 5% of the patients, respectively.

Blood count abnormalities were noted in 15.4 % of patients (n=46).

Neutropenia was the most frequently anomaly met on the hemogram (9.1%) followed by anemia (3.4%) and thrombocytopenia (3%). Pancytopenia was found in 11.4% of patients (n=34).

The median time between biological therapy initiation and the onset of hematologic manifestations was 4.8 months [1-12]. Biological treatment was interrupted in two patients.

In the other cases, the biological treatment was maintained with close monitoring of blood cell count. No case of death related to these hematological disturbances has been reported.

Conclusion:

In our registry, hematological side effects of biological treatment were found in 15.4% of cases and were noted with a median delay of 4.8 [1-12] months after the treatment initiation. Further studies are needed to confirm our preliminary results.

Disclosure of Interests:

None declared

AB0946 PARTICULARITY OF MULTIFOCAL INFECTIOUS SPONDYLODISCITIS

Background:

Infectious spondylodiscitis is an infection of the intervertebral disc with damage to the vertebrae. Multiple stage involvement may lead to serious complications. Better understand of this infection is mandatory for optimal management.

Objectives:

The objective of our study was to describe the clinical, biological aspects and the course of this disease.

Methods:

This is a retrospective study including cases of infectious spondylodiscitis collected in a single rheumatology center between 2002 and 2018. Multi focal spondylodiscitis was defined as an attainment of 2 or more disc levels. Clinical, biological and evolution of this disease were reported.

Results:

Among the 52 cases of infectious spondylodiscitis collected, thirteen patients had multi-stage involvement of the spine. The sex ratio M/F in this group = 0.44 with an average age of 52 ± 14.32 years [31 – 76 years]. Diabetes mellitus was observed in 3 patients, chronic renal failure in one case and immunosuppressive therapy in one case. At the moment of the diagnosis, inflammatory back pain was present in all patients, fever was noted in 8 patients (61.5%), neurological deficit in 2 patients (15.4%) and weight loss in 4 cases (30.8%). The diagnosis time delay was 22 ± 15.9 weeks [2 – 60 weeks]. The mean CRP was 70.16 mg / L ± 55.5 [3.4 - 178] and the ESR was on average 79 mm ± 31.28 [6 - 125]. Diagnosis was confirmed by MRI in all cases. A prevertebral abscess was observed in 7 cases (%), an epiduritis in 5 patients (38.5%) and a psoas abscess in two cases (15.2%). The cervical spine was affected in 3 cases, the dorsal spine as well as the lumbar spine were affected in 12 cases. The involvment of 2 vertebral sites was the most frequent with 7 cases. A maximum of 5 site was noted in 3 cases. The thoracolumbar spine was the most affected with 11 cases (84.6%), the cervico-thoraco-lumbar involvement was found in only one case (7.7%). The bacteriological diagnosis was done by the disco-vertebral biopsy in 6 cases (46.2%), the brucellar serology in 3 cases (26.1%) and a strong presumption of tuberculosis (with positive IDR or Quantiferon) in 4 cases (30.8%). Mycobaterium tuberculosis was isolated in 8 patients (61.5%), brucella melitensis in 3 patients (23.1%) and staphylococcus aureus was found in 2 cases (15.4%). The outcome was favorable in all patients with appropriate antibiotic therapy after an average follow-up of 10.9 months ± 2.19.

Conclusion:

Multifocal infectious spondylodiscitis is a serious disorder which mainly affects immunocompromised patients and the specific germs are the most incriminated.

Disclosure of Interests:

None declared

AB0277 PREVALENCE OF HEPATITIS MARKERS IN PATIENTS TREATED WITH BIOLOGICAL DISEASE-MODIFYING ANTIRHEUMATIC DRUGS: RESULTS OF THE TUNISIAN REGISTRY BINAR

Background:

In the recent decades, biological disease-modifying antirheumatic drugs (bDMARDs) have significantly improved management and quality of life in patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA).

However, bDMARDs have also a strong influence on the immune system, leading to a risk of serious infection. Reactivation of hepatitis B (HBV) and C (HCV) virus is one of the most redoubtable complications of these immunosuppressive agents.

Objectives:

The aims of this study were to determine the screening rate for hepatitis B and C before starting a biological treatment and to examine the prevalence of their markers in patients with RA or SpA.

Methods:

Our study evaluated all patients included in the Tunisian registry BINAR (Biologic National Registry) since 2018 who had RA (ACR/EULAR 2010) or SpA (ASAS criteria) aged with more than eighteen years old and receiving their first bDMARDs during the two past years.

The following information were retrieved from the registry: demographic data on the patients, disease parameters, medication, HBV surface antigen (HBs Ag), antibody to HBs Ag (Anti HBs), antibody to HBV core antigen (Anti HBc), HBV-DNA, antibody to HCV (anti HCV) status and liver function tests (AST: aspartate aminotransferase; ALT:alanine aminotransferase).

Results:

A total of 298 patients was included, 111 men and 178 women, with a mean age of 49.2 ± 14.1 years old [18-79]. Among them, 58.7% were diagnosed with RA and 41.3% were diagnosed with SpA. The mean disease duration was 6.7±3.5 years [1-12] in patients with RA and 6.5±3 [1-12] in patients with SpA. The mean Disease Activity Score (DAS28) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) were respectively of 4.9±1.5 [1-8] and 4.1±1.8 [0-9].

Therapeutically, 167 patients (56%) were on Prednisone at a mean daily posology of 8.2±5.4 mg [4-60] and 70.3% on conventional synthetic disease modifying antirheumatic drug (csDMARD) in association with bDMARDs. It was about Tumor Necrosis Factor alpha antibodies (anti TNF a) in 87.9% of cases, Tocilizumab in 10.4% of cases and Rituximab in 5% of cases.

A screening of HBV was performed in 286 patients (96%). Ag HBs was positive in two cases (0.7%), and anti-HBc was positive in 16 cases (6.4%) which indicate a prior HBV infection. Fifteen patients (6%) were immunized with positive anti HBs. HBV-DNA was measured in 177 cases (66.8%) and was positive in 15 patients (6%).

HCV infection was searched in 282 patients (94.6%) and anti-HCV was negative in all cases.

AST and ALT mean rates were respectively of 18.3 [2-108] and 17.9 UI/l [2-74]. A perturbation of these liver function tests was observed in 13 patients (4.4%).

Conclusion:

Screening for hepatitis B and C were performed respectively in 96% and 94% of our Tunisian patients before receiving any bDMARDs. This should be systematic to avoid HBV reactivation which can lead to fulminant hepatic failure with a severe prognosis.

Disclosure of Interests:

None declared

AB0314 VIRAL HEPATITIS B REACTIVATION UNDER BIOLOGICAL THERAPY: SCREENING AND PREVENTION MODALITIES IN RHEUMATIC AND INFLAMMATORY BOWEL DISEASE PATIENTS

Background:

Viral hepatitis B reactivation (VHBr) is a serious complication of immunomodulatory therapy and in particular biological therapy (BT), which can be life-threatening, whence the adoption by societies of screening and prevention strategies based on the risk of VHBr which depends on serological status and the treatment used.

Objectives:

The objective of our study was to determine the modalities of HBV screening, to describe the prevalence of HBV infection in this group of patients, and to evaluate the VHBr prevention strategies adopted in our country.

Methods:

This was a retrospective, 8-year [2011-2018], single-centre, descriptive, retrospective study conducted in two departments: Rheumatology and Hepato-Gastroenterology. Patients under BT were included. Records with missing data were excluded. The modalities of screening and prevention of VHBr were determined and the prevalence of HBV markers was investigated.

Results:

One hundred patients were included: 85 followed up for chronic inflammatory rheumatic disease: rheumatoid arthritis (n=40), ankylosing spondylitis (n=41), juvenile idiopathic arthritis (n=4) and 15 patients followed up for inflammatory bowel disease (11 Crohn’s disease and 4 ulcerative colitis). The mean age was 44 years with a predominance of females (59%). The BTs prescribed were: anti-TNFα, anti-IL6 and antiCD20 in 83%, 11% and 7% respectively.

HBV screening was done in 89% of cases: HBsAg was tested in 89%, anti-HBc in 64% and anti-HBs in 43%. Complete B serology (HBsAg, anti-HBc and anti-HBs) was performed in 40%.

One patient had chronic hepatitis B on Entecavir for 3 years before starting anti-CD20 (HBsAg(+),anti-HBc(+)). A previous contact with HBV as evidenced by isolated anti-HBs(+) positivity was noted in 13 patients (20%).

A negative B serology was noted in 30 patients (30%). The vaccination rate was 10%.

Prophylaxis with Entecavir was indicated in 2 patients at high risk of viral B reactivation (candidates for anti-CD20 therapy and having anti-HBc(+) with undetectable viral load).One patient at moderate risk of reactivation (candidate for anti-TNF therapy and having anti-HBc(+)) was placed on Lamivudine for prophylaxis. Pre-emptive therapy based on monitoring of alanine aminotransferase (ALT) and HBV DNA levels every 1 to 3 months was indicated in 10 patients (with anti-HBc (+) and candidates for BT other than anti-CD20) but correctly applied in only 2 patients (20%). The remaining eight patients were monitored only for ALT levels. No cases of viral reactivation B were objectified.

Conclusion:

In our study, viral hepatitis B screening was done correctly in 40% of the cases. The rate of VHB vaccination was low (10%) despite the low cost of the vaccine. Prophylactic and pre-emptive treatment for viral reactivation were correctly applied in 100 and 20% of cases respectively. This underlines the difficulties encountered in applying pre-emptive treatment when access to HBV DNA level determination is limited and warrants more vigilance prior to the prescription of BT.

Disclosure of Interests:

None declared