Impact of the COVID-19 pandemic on the disease course of patients with inflammatory rheumatic diseases: results from the Swiss Clinical Quality Management cohort

OBJECTIVES

To investigate whether the transient reduction in rheumatology services imposed by virus containment measures during the COVID-19 pandemic was associated with disease worsening in axial spondyloarthritis (axSpA), rheumatoid arthritis (RA) or psoriatic arthritis (PsA).

METHODS

Patient-reported disease activity assessed during face-to-face visits and/or via a smartphone application were compared between three periods of each 2 months duration (before, during and after the COVID-19-wave) from January to June 2020 in 666 patients with axSpA, RA and PsA in the Swiss Clinical Quality Management cohort.

RESULTS

The number of consultations dropped by 52%, whereas the number of remote assessments increased by 129%. The proportion of patients with drug non-compliance slightly increased during the pandemic, the difference reaching statistical significance in axSpA (19.9% vs 13.2% before the pandemic, p=0.003). The proportion of patients with disease flares remained stable (<15%). There was no increase in mean values of the Bath Ankylosing Disease Activity Index, the Rheumatoid Arthritis Disease Activity Index-5 and the Patient Global Assessment in patients with axSpA, RA and PsA, respectively.

CONCLUSION

A short interruption of in-person patient-rheumatologist interactions had no major detrimental impact on the disease course of axSpA, RA and PsA as assessed by patient-reported outcomes.

Predictive value of anti-CarP and anti-PAD3 antibodies alone or in combination with RF and ACPA for the severity of rheumatoid arthritis

OBJECTIVES

The objective of this study was to analyse the predictive value of anti-carbamylated protein (anti-CarP) and anti-peptidyl-arginine deiminase type-3 (anti-PAD3) antibodies, alone or in combination with RF and ACPA, to identify patients at high risk of developing severe RA outcomes.

METHODS

Patients within the Swiss Clinical Quality Management registry with a biobank sample were tested for RF, ACPA, anti-CarP, and anti-PAD3 antibodies. We examined the association of each autoantibody with DAS28, HAQ and radiographic damage (Ratingen) at baseline and longitudinally.

RESULTS

Analyses included 851 established RA patients and 516 disease controls [axial spondyloarthritis (axSpA = 320) and PsA (196)]. Anti-CarP and anti-PAD3 antibodies were, respectively, present in 22.4% and 10.7% of the whole RA population, and in 13.2% and 3.8% of the RF and ACPA double seronegative patients. At baseline, RA patients with anti-PAD3 had higher DAS28 (4.2 vs 3.7; P= 0.005) and significantly more radiographic damage (14.9 vs 8.8; P= 0.02) than anti-PAD3-negative patients. In the ACPA-negative subgroup, baseline Ratingen scores were significantly higher in anti-PAD3-positive patients (P= 0.01). The combination of anti-PAD3, RF IgM, and ACPA was associated with significantly higher baseline radiographic scores than the double seropositive group (P= 0.04). The presence of any two of the previous autoantibodies was associated with significantly greater radiographic progression over 10 years than if all were absent (P= 0.02). There were no differences in RA outcome measures with regards to anti-CarP.

CONCLUSIONS

Anti-PAD3 antibodies are associated with higher disease activity and joint damage scores in RA patients.

Impact of discordance between patient's and evaluator's global assessment on treatment outcomes in 14 868 patients with spondyloarthritis

OBJECTIVES

To assess the impact of 'patient's minus evaluator's global assessment of disease activity' (ΔPEG) at treatment initiation on retention and remission rates of TNF inhibitors (TNFi) in psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA) patients across Europe.

METHODS

Real-life data from PsA and axSpA patients starting their first TNFi from 11 countries in the European Spondyloarthritis Research Collaboration Network were pooled. Retention rates were compared by Kaplan-Meier analyses with log-rank test and by Cox regression, and remission rates by χ2 test and by logistic regression across quartiles of baseline ΔPEG, separately in female and male PsA and axSpA patients.

RESULTS

We included 14 868 spondyloarthritis (5855 PsA, 9013 axSpA) patients. Baseline ΔPEG was negatively associated with 6/12/24-months' TNFi retention rates in female and male PsA and axSpA patients (P <0.001), with 6/12/24-months' BASDAI < 2 (P ≤0.002) and ASDAS < 1.3 (P ≤0.005) in axSpA patients, and with DAS28CRP(4)<2.6 (P ≤0.04) and DAPSA28 ≤ 4 (P ≤0.01), but not DAS28CRP(3)<2.6 (P ≥0.13) in PsA patients, with few exceptions on remission rates. Retention and remission rates were overall lower in female than male patients.

CONCLUSION

High baseline patient's compared with evaluator's global assessment was associated with lower 6/12/24-months' remission as well as retention rates of first TNFi in both PsA and axSpA patients. These results highlight the importance of discordance between patient's and evaluator's perspective on disease outcomes.

Differences between men and women with nonradiographic axial spondyloarthritis: clinical characteristics and treatment effectiveness in a real-life prospective cohort

BACKGROUND

Sex differences with regard to clinical manifestations and response to tumor necrosis factor inhibitors (TNFi) have been delineated for the radiographic form of axial spondyloarthritis (axSpA). More limited evidence for a differential effectiveness of treatment in genders exists for the nonradiographic disease state (nr-axSpA). The aim of the study was to compare demographics, clinical parameters, and response to TNFi in women versus men with nr-axSpA.

METHODS

We compared disease characteristics of 264 women and 231 men with nr-axSpA at inclusion in the prospective Swiss Clinical Quality Management Cohort. Response to a first TNFi was assessed in 85 women and 78 men without diagnosed co-morbid fibromyalgia. The primary outcome was the proportion of patients achieving the 40% improvement in the Assessment of SpondyloArthritis international Society criteria (ASAS40) at 1 year. Additional response outcomes were evaluated as secondary outcomes. Patients having discontinued TNFi were considered non-responders. Logistic regression analyses were adjusted for baseline differences, which might potentially mediate the effect of sex on treatment response.

RESULTS

Compared to men, women had a longer diagnostic delay, a higher level of perceived disease activity, and more enthesitis and were in a lower percentage HLA-B27 positive. An ASAS40 response was achieved by 17% of women and 38% of men (OR 0.34; 95% CI 0.12, 0.93; p = 0.02). A significantly lower response rate in women was confirmed in the adjusted analysis (OR 0.19; 95% CI 0.05, 0.62; p = 0.009) as well as for the other outcomes assessed.

CONCLUSION

Despite only few sex differences in patient characteristics in nr-axSpA, response rates to TNFi are significantly lower in women than in men.

EULAR/eumusc.net standards of care for rheumatoid arthritis: cross-sectional analyses of importance, level of implementation and care gaps experienced by patients and rheumatologists across 35 European countries

Objective

As part of European League against Rheumatism (EULAR)/European Musculoskeletal Conditions Surveillance and Information Network, 20 user-focused standards of care (SoCs) for rheumatoid arthritis (RA) addressing 16 domains of care were developed. This study aimed to explore gaps in implementation of these SoCs across Europe.

Methods

Two cross-sectional surveys on the importance, level of and barriers (patients only) to implementation of each SoC (0–10, 10 highest) were designed to be conducted among patients and rheumatologists in 50 European countries. Care gaps were calculated as the difference between the actual and maximum possible score for implementation (ie, 10) multiplied by the care importance score, resulting in care gaps (0–100, maximal gap). Factors associated with the problematic care gaps (ie, gap≥30 and importance≥6 and implementation<6) and strong barriers (≥6) were further analysed in multilevel logistic regression models.

Results

Overall, 26 and 31 countries provided data from 1873 patients and 1131 rheumatologists, respectively. 19 out of 20 SoCs were problematic from the perspectives of more than 20% of patients, while this was true for only 10 SoCs for rheumatologists. Rheumatologists in countries with lower gross domestic product and non-European Union countries were more likely to report problematic gaps in 15 of 20 SoCs, while virtually no differences were observed among patients. Lack of relevance of some SoCs (71%) and limited time of professionals (66%) were the most frequent implementation barriers identified by patients.

Conclusions

Many problematic gaps were reported across several essential aspects of RA care. More efforts need to be devoted to implementation of EULAR SoCs.

Travel patterns, risk behaviour and health problems of travellers with rheumatic diseases compared to controls: A multi-centre, observational study

BACKGROUND

Patients with chronic conditions travel around the world more than ever. Only few studies have examined travel patterns and health outcomes of patients with rheumatic diseases during international travel.

METHOD

We conducted a multi-centre prospective cohort study in Switzerland, in which we studied the immunogenicity and safety of vaccinations in patients with rheumatic diseases and travellers without rheumatic diseases (controls). Participants who travelled internationally received questionnaires 1 and 13 weeks post-travel. We compared travel patterns, risk behaviours, and travel-associated problems during and after the trips in both groups.

RESULTS

274 participants returned post-travel questionnaires (65 rheumatic patients, 209 controls). Controls more frequently travelled to subtropical/tropical destinations and stayed longer abroad. 64% of all participants experienced health problems during travel (74% rheumatic patients vs. 62% controls, P = 0.11). Pre-travel, patients reported a higher susceptibility to gastrointestinal infections . During travel, a higher percentage of rheumatic patients cancelled the day programme due to health problems (13% vs. 4%, P = 0.024). The main problems in rheumatic patients occurred due to the underlying rheumatic diseases, or were of psychological nature. Although not statistically significant, infectious disease symptoms (rhinitis, cough) occurred more frequently in controls. When only considering subtropical/tropical destinations, rheumatic patients more frequently had gastrointestinal problems during travel - and skin infections after the trip.

CONCLUSIONS

This study does not support the notion that patients with rheumatic diseases should avoid international travel for an increased risk of infections. In patients with subtropical/tropical destinations, however, gastrointestinal problems may be increased during travel - and skin infections post-travel.

Effectiveness of secukinumab versus an alternative TNF inhibitor in patients with axial spondyloarthritis previously exposed to TNF inhibitors in the Swiss Clinical Quality Management cohort

Objective

To compare effectiveness of treatment with secukinumab (SEC) with that of alternative tumour necrosis factor inhibitors (TNFis) in patients with axial spondyloarthritis (axSpA) after withdrawal from one or more TNFis.

Methods

Patients diagnosed as having axSpA in the Swiss Clinical Quality Management cohort were included if they had initiated SEC (n=106) or an alternative TNFi (n=284) after experiencing TNFi failure. Drug retention was investigated with matching weights propensity score (PS) analyses and multiple adjusted Cox proportional hazards models. Matching weights PS-based analyses and multiple-adjusted logistic regression analyses were used to assess the proportion of patients reaching 50% reduction in the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI50) at 1 year.

Results

SEC was more often used as third-line or later-line biological drug (76% vs 40% for TNFi). Patients starting SEC had higher BASDAI, Bath Ankylosing Spondylitis Functional Index, Bath Ankylosing Spondylitis Metrology Index and C reactive protein levels. A comparable risk of drug discontinuation was found for SEC versus TNFi (HR 1.14, 95% CI 0.78 to 1.68 in the PS-based analysis and HR 1.16, 95% CI 0.79 to 1.71 in the multiple-adjusted analysis). No significant difference in BASDAI50 responses at 1 year was demonstrated between the two modes of biological drug action, with CI of estimates being, however, wide (OR for SEC vs TNFi 0.76, 95% CI 0.26 to 2.18 and 0.78, 95% CI 0.24 to 2.48 in the PS-based and the covariate-adjusted model, respectively).

Conclusion

Our data suggest a comparable effectiveness of SEC versus an alternative TNFi after prior TNFi exposure.

OP0242 META-ANALYSIS OF SINGLE-CELL RNA SEQUENCING DATA OF THE SYNOVIUM TO DEFINE SYNOVIAL FIBROBLAST PHENOTYPES ACROSS JOINT LOCATION AND DISEASE

Background:

Up to now, three groups used single cell RNA sequencing (scRNA-seq) to analyse the synovium in arthritis using different methods and material to measure RNA expression on a single cell level: Ref. 1 used unsorted dissociated synovial cells and a droplet based method; Refs 2 and 3 performed scRNA-seq on sorted cell populations.

Objectives:

The aim of this study was to perform a meta-analysis of scRNA-seq data of the synovium in arthritis: 1) to define synovial fibroblast (SF) phenotypes, 2) to confirm differences across SF clusters between rheumatoid arthritis (RA) and osteoarthritis (OA) and 3) to analyse joint specific differences between SF phenotypes.

Methods:

In addition to the available count matrices [1-3], we used unsorted dissociated synovial cells from three patients with undifferentiated arthritis (UA) with a droplet-based method (10x Genomics). We followed a standard protocol [4] to integrate the datasets into a shared space, even in the presence of extensive technical and/or biological differences (“batch-corrected”). SF were selected as previously described (PDPN+,ISLR+,COL1A2+,PTPRC-) [1-3]. We used a minimum log2 FC of 0.25 for average expression of genes in a cluster relative to the average expression in all other clusters combined to define marker genes. R with Seurat, Monocle and clusterProfiler packages were used for scRNA-seq analysis, pseudotime trajectory analysis and pathway enrichement analysis, respectively. Quantitative PCR (qPCR) (n=6-14 per location and disease), immunohistochemistry (IHC) and Krenn synovitis score (n=5-15 per location and disease) were performed according to standard protocols.

Results:

Data from 29 RA, 3 UA and 6 OA patients were analysed. From a total of 29’448 cells, we identified 14’787 (50%) with a fibroblast phenotype. Of those, we determined 5 subpopulations (Fig. 1): 1)THY1-CD55hifibroblasts with high expression ofMMP1andMMP3(SF1), 2)THY1loCD34+fibroblasts expressing high levels ofPI16(SF2) 3)THY1hifibroblasts expressing high levels of periostin (POSTN) and collagens (e.g.COL1A1, COL3A1) (SF3), 4)THY1hifibroblasts expressingCXCL12(SF4) and 5)THY1lofibroblasts expressingCXCL12,NR4A1andCCL2(SF5). Fig. 2 shows pathway enrichment map of all marker genes; it organizes enriched terms into a network with edges connecting overlapping gene sets. Pseudotime trajectory axis derived from Monocle indicated that SF4 represent a state between SF3 and SF5. Pseudotemporal expression dynamics ofTHY1marked the progression of these three subtypes (Graph 1). SF1 and SF2 were proportionally underrepresented and SF3-5 overrepresented in RA (chi-squared = 37.18, p = 1.65e-07). The expression of POSTN, a signature gene of SF3, was not different between RA and OA tissues, but significantly correlated with the synovitis score (Spearman ρ = 0.55, p=0.02), in particular with pathological changes in the sublining. POSTN expression was higher in hand than in knee synovial tissues (mean ± SD IHC score: hand 8 ±2, knee 5 ±2) and in cultured SF (qPCR: 10-fold difference). Accordingly, SF3 was enriched in hand versus knee synovial tissues in the scRNA-seq dataset (chi-squared = 944.87, p < 2.2e-16).

Fig. 1Fig. 2

Graph 1

Conclusion:

In our meta-analysis, we found comparable subtypes of fibroblasts as in the individual analyses [1-3], showing the robustness of cell phenotype identification using scRNA-seq. The different SF phenotypes appear to be plastic cell states rather than fixed cell subtypes, whose development is controlled by an interrelation between pathological changes in the synovium and joint location.

References:

[1]Stephenson et al. Nat. Commun. 2018

[2]Mizoguchi et al. Nat. Commun. 2018

[3]Zhang et al. Nat Immunol. 2019

[4]Stuart, Butler, et al. Cell 2019

Disclosure of Interests:

Raphael Micheroli: None declared, Mojca Frank-Bertoncelj: None declared, Sam G. Edalat: None declared, Kerstin Klein: None declared, Tadeja Kuret: None declared, Kristina Buerki: None declared, Adrian Ciurea Consultant of: Consulting and/or speaking fees from AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Merck Sharp & Dohme, Novartis and Pfizer., Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche, Caroline Ospelt Consultant of: Consultancy fees from Gilead Sciences.

FRI0040 MULTI-VARIATE APPROACH INCLUDING SEROLOGY AND GENETICS FOR AN IMPROVED IDENTIFICATION OF PATIENTS AT RISK OF DEVELOPING RA

Background:

First-degree relatives of rheumatoid arthritis (RA) patients (FDR-RA) have a 3 - 5-fold increased prevalence of the disease [1]. RA development is triggered by an interaction between genetic and environmental factors.

As the field is moving towards prevention in pre-clinical stages of RA, it is key to identify individuals with imminent RA, prior to onset of symptoms, which will presumably rely on both the measurement of autoantibodies and genetic risk markers.

Objectives:

Assemble a pattern of serologic biomarkers in combination with genetics to improve the identification of individuals at high risk to develop RA.

Methods:

The cohort included 827 serum samples from 601 individuals, followed within the Swiss multicenter cohort study SCREEN-RA of FDR [2]. FDR-RA were categorized into four groups according to the presence of symptoms and systemic autoimmunity associated with RA; 1: asymptomatic FDR-RA without anti-CCP or symptoms, 416 (69%); 2: FDR-RA with clinically suspect arthralgia (CSA) [3] or with signs of arthritis, without anti-CCP, 72 (12%); 3: FDR-RAs with no signs of arthritis, positive anti-CCP test, 55 (9%); 4: FDR with signs of arthritis or CSA, positive anti-CCP-test, 58 (10%).

Serum samples were analyzed for the presence of anti-CCP (IgG, IgA), RF (IgM, IgA) and anti-RA33 (IgM, IgA, IgG) using the EliATMinstrument platform (Phadia AB, Uppsala, Sweden).

Genetic measurements were performed using the AmpliSeqTMtechnology on the Ion GeneStudioTMinstruments (Thermo Fisher Scientific, Carlsbad, USA), covered variants were analyzed using an algorithm focusing on the identification of RA patients.

Results:

The overall prevalence of biomarkers, considering results above cutoff values, was 1% for anti-CCP IgG and IgA, 10% and 2% for RF IgM and RF IgA, respectively, and 6-15% for all three anti-RA33 isotypes. Several individuals had multiple positive serology tests (Fig 1): 3.6% (22) were positive for 2 tests and 1% (6) were positive for 3 or more tests. Among the 28 individuals positive for ≥2 tests, 17 (61%) were symptomatic.

Figure 1.

Distribution of positive serology within the different groups. No positivity (none), positive for one (1), equal or more than 2 (2-5) of the serologic tests.

Nine of 604 FDR-RA subsequently developed classifiable RA and were positive for serologic biomarkers before date of RA diagnosis (Table 1). The RA converters had a mean age of 39 years (24-75 yrs) and an average follow-up time within the study of 3.6 years (1-7 yrs).

Table 1.

Biomarker status of subsequent RA converters before date of diagnosis.

RA convertersCCP IgGCCP IgARF IgMRF IgARA33 total1+++++2+−++−3−−+−+4−−+−−5−−+−−6−−−−+7−−−−+8−−−−−9−−−−−

Using an algorithm to analyze the RA-associated genetic SNPs, we could highlight 48 FDR-RA (8%) with an increased genetic risk to develop RA. 15 out of 48 individuals (31%) at high genetic risk reported CSA, and 12 out of 48 individuals (25%) displayed signs of systemic autoimmunity associated with RA.

Conclusion:

When looking at FDR it could help to not only include anti-CCP autoantibody testing but also additional biomarkers like RF and anti-RA33. Furthermore, looking at the genetic risk factors could give additional information. The combination with the multi-variate profile could even improve the early diagnosis of these patients.

References:

[1]Kuo et al. Rheumatology 2017; 56:928933

[2]Finckh et al. Ann Rheum Dis 2011; 70: S3–282

[3]van Steenbergen HW, et al. Ann Rheum Dis 2017; 76:491–496

Disclosure of Interests:

Maresa Grundhuber Grant/research support from: Thermo Fisher Scientific, Employee of: Thermo Fisher Scientific, Isabel Gehring Grant/research support from: Thermo Fisher Scientific, Employee of: Thermo Fisher Scientific, Céline Lamacchia Grant/research support from: Thermo Fisher Scientific partially supported this study, Pascale Roux-Lombard: None declared, Michael Nissen Grant/research support from: Abbvie, Consultant of: Novartis, Lilly, Abbvie, Celgene and Pfizer, Speakers bureau: Novartis, Lilly, Abbvie, Celgene and Pfizer, Ulrich Walker Grant/research support from: Ulrich Walker has received an unrestricted research grant from Abbvie, Consultant of: Ulrich Walker has act as a consultant for Abbvie, Actelion, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, MSD, Novartis, Pfizer, Phadia, Roche, Sandoz, Sanofi, and ThermoFisher, Paid instructor for: Abbvie, Novartis, and Roche, Speakers bureau: Abbvie, Actelion, Bristol-Myers Squibb, Celgene, MSD, Novartis, Pfizer, Phadia, Roche, Sandoz, and ThermoFisher, Burkhard Moeller: None declared, Diego Kyburz Grant/research support from: Abbvie, Roche, Consultant of: Abbvie, BMS, Novartis, Pfizer, Roche, UCB, Gilead, Sanofi, Speakers bureau: Pfizer, BMS, Novartis, Abbvie, Adrian Ciurea Consultant of: Consulting and/or speaking fees from AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Merck Sharp & Dohme, Novartis and Pfizer., Maryam Poorafshar Grant/research support from: Thermo Fisher Scientific, Employee of: Thermo Fisher Scientific, Axel Finckh Grant/research support from: Pfizer: Unrestricted research grant, Eli-Lilly: Unrestricted research grant, Consultant of: Sanofi, AB2BIO, Abbvie, Pfizer, MSD, Speakers bureau: Sanofi, Pfizer, Roche, Thermo Fisher Scientific

OP0075 SPINAL RADIOGRAPHIC PROGRESSION IN AXIAL SPONDYLOARTHRITIS AND THE IMPACT OF CLASSIFICATION AS NONRADIOGRAPHIC VERSUS RADIOGRAPHIC DISEASE

Background:

Data on spinal radiographic progression is more limited in nonradiographic axial spondyloarthritis (nr-axSpA) than in the radiographic disease state (r-axSpA). It remains unclear, whether radiographic sacroiliitis is by itself associated with progression of spinal structural damage.

Objectives:

To investigate whether spinal radiographic progression relates to structural damage at the sacroiliac level in axSpA by means of statistical mediation analyses in a large prospective real-life cohort of patients with axSpA.

Methods:

Patients from the Swiss Clinical Quality Management cohort were included if they fulfilled the ASAS classification criteria and could be classified as nr-axSpA or r-axSpA after central scoring of pelvis radiographs. Spinal radiographs performed every 2 years were scored according to the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). The relationship between classification status and spinal progression over 2 years was investigated using binomial generalized estimating equations models with adjustment for sex, ankylosing spondylitis disease activity score (ASDAS) and tumor necrosis factor inhibitor treatment. Baseline spinal damage was considered an intermediate variable and included in sensitivity analyses, as were additional variables potentially influencing radiographic progression.

Results:

In total, 88 nr-axSpA and 418 r-axSpA patients contributed to data for 725 radiographic intervals (Table 1). Mean (SD) mSASSS change over 2 years was 0.16 (0.62) units in nr-axSpA and 0.92 (2.78) units in r-axSpA, p=0.01. Nr-axSpA was associated with a significantly lower progression over 2 years (defined as an increase in ≥2 mSASSS units) in adjusted analyses (OR 0.33, 95%CI 0.13; 0.83), confirmed with progression defined as the formation of ≥1 syndesmophyte. Mediation analyses revealed that sacroiliitis exerted its effect on spinal progression indirectly by being associated with the appearance of a first syndesmophyte (OR 0.09, 95%CI 0.02; 0.36 for nr-axSpA vs r-axSpA) (Fig. 1 and 2). Baseline syndesmophytes were predictors of further progression.

Table 1.

Baseline characteristics at first radiograph.

ParameterN506nr-axSpAN = 88r-axSpAN = 418PFemale sex, %50654.533.7<0.001Age, y50639.5±11.140.4±11.00.52Symptom duration, y49810.0±9.914.0±9.8<0.001HLA-B27 positive, %45271.680.70.09BASDAI4274.6±2.04.2±2.30.26ASDAS4082.8±0.92.8±1.10.74Elevated CRP, %42230.640.60.14BASFI4332.8±2.23.1±2.50.71BASMI4351.1±1.42.2±2.0<0.001mSASSS5060.9±1.56.8±12.7<0.001Syndesmophytes, %5069.135.2<0.001On TNFi, %50619.336.40.002Fig. 1.

Modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) for individual patients plotted as a function of duration since symptom onset.

Fig. 2.

Two-year mSASSS progression depicted in a cumulative probability plot. Progression was defined as an increase in mSASSS of at least 2 units (dotted line) in 2 years.

Conclusion:

Spinal structural damage is mainly restricted to patients with r-axSpA, leading to relevant prognostic and therapeutic implications.

Disclosure of Interests:

Monika Hebeisen: None declared, Raphael Micheroli: None declared, Almut Scherer: None declared, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Manouk de Hooge: None declared, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Robert B.M. Landewé Consultant of: AbbVie; AstraZeneca; Bristol-Myers Squibb; Eli Lilly & Co.; Galapagos NV; Novartis; Pfizer; UCB Pharma, Kristina Buerki: None declared, Michael Nissen Grant/research support from: Abbvie, Consultant of: Novartis, Lilly, Abbvie, Celgene and Pfizer, Speakers bureau: Novartis, Lilly, Abbvie, Celgene and Pfizer, Burkhard Moeller: None declared, Pascal Zufferey: None declared, Pascale Exer: None declared, Adrian Ciurea Consultant of: Consulting and/or speaking fees from AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Merck Sharp & Dohme, Novartis and Pfizer.

THU0013 INTEGRATED ANALYSIS OF SYNOVIAL SINGLE CELL RNA SEQUENCING DATA DEEPENS THE CURRENT KNOWLEDGE OF SYNOVIAL PATHOLOGY IN ARTHRITIS

Background:

The heterogeneity of synovial tissues from patients with arthritis could contribute to the interpatient variability in disease course, prognosis and treatment response. Single-cell RNA sequencing (scRNA-seq) permits in-depth analysis of tissue heterogeneity, which could facilitate drug discovery and patient stratification for precision medicine.

Objectives:

To construct a comprehensive landscape of synovial cell types and molecular pathways in arthritis by integrating our and published scRNA-seq data, generated across different scRNA-seq technologies [Smart-seq2, Drop-seq], cell preparation protocols [dissociated unsorted, sorted cells] and types of arthritis [undifferentiated (UA), rheumatoid arthritis, osteoarthritis].

Methods:

Synovial tissues were obtained by ultrasound-guided biopsy from patients with UA [not fulfilling the classification criteria for a specific arthritis, n=3]. Biopsies were disintegrated [enzymatic and mechanical disruption] and cell viability assessed with trypan blue. ScRNA-seq libraries [2 per patient] were prepared with 10X Genomics Drop-Seq and sequenced on NovaSeq6000. Bioinformatics analysis of our and published [n=35] datasets1-3was performed using Seurat protocol4with correction for batch effects and filtering low-quality cells. Functional enrichment analysis of marker genes in clusters was done with STRING Protein-Protein networks. Synovitis was assessed with ultrasound and histology.

Results:

Our tissue disintegration protocol resulted in good cell yield and viability (92%, 72%, 100%). The synovial cellular heterogeneity detected by scRNA-seq reflected the histological findings [Krenn score, pathotype]. These were supported with the ultrasound and clinically assessed disease activity. The integrated analysis of 41 datasets from 38 donors yielded 41845 scRNA-seq cell profiles, 50% contributed by our dataset. An independent analysis of our data and their integration with published data showed that different scRNA-seq methods and protocols can identify all the major synovial cell types and their activation states (Figure 1) with large heterogeneity between donors. We identified a previously undescribed synovial cell population, which was located near the fibroblast cluster, was negative for canonical cell markers, but highly enriched in cell division genes (80% of marker genes). These cells comprised a mixed population of CD34-, podoplanin (PDPN)highor PDPNlowcells that were mostly negative for the sub-lining fibroblast marker THY. Furthermore, they appeared to be highly secretory (extracellular matrix components) and their gene expression profile was inclined towards cell migration, vascular development and insulin growth factor-dependent processes.

Figure 1.

Heatmap with top 20 cluster gene markers, gene enrichment analysis and UMAP plot of synovial cell clusters.

Conclusion:

By integrating synovial scRNA-seq data from 41845 cells, we identified a previously undescribed, highly proliferative and secretory synovial cell population in arthritis. We increased the number of known scRNA-seq synovial cell profiles in arthritis by two-fold and demonstrated the robustness of synovial scRNA-seq data outputs across different technologies and protocols. This broadens the current knowledge of synovial tissue heterogeneity and pathology in arthritis.

References:

[1]Stephenson W. et al. Nat Commun 2017.

[2]Mizoguchi F. et al. Nat Commun 2017.

[3]Zhang F. et al. Nat Immunol 2018.

[4]Stuart T et al. Cell 2019

Acknowledgments:

This work is supported by Vontobel Foundation and medAlumni University of Zurich

Disclosure of Interests:

Sam G. Edalat: None declared, Raphael Micheroli: None declared, Tadeja Kuret: None declared, Kristina Buerki: None declared, Chantal Pauli: None declared, Snežna Sodin-Šemrl: None declared, Adrian Ciurea Consultant of: Consulting and/or speaking fees from AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Merck Sharp & Dohme, Novartis and Pfizer., Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche, Caroline Ospelt Consultant of: Consultancy fees from Gilead Sciences., Gregor Rot: None declared, Mojca Frank-Bertoncelj: None declared

THU0383 GENDER DIFFERENCES IN NONRADIOGRAPHIC AXIAL SPONDYLOARTHRITIS: FROM CLINICAL CHARACTERISTICS TO EFFECTIVENESS OF TNF INHIBITORS

Background:

While a male predominance is found in radiographic axial spondyloarthritis (r-axSpA), an equal male to female distribution was repeatedly reported for the nonradiographic disease form (nr-axSpA). Some important differences in clinical manifestations and response to treatment with tumor necrosis factor inhibitors (TNFi) between the sexes have been delineated for r-axSpA. It remains unclear, whether comparable sex differences can be assumed for nr-axSpA. Indeed, existing data on gender differences in nr-axSpA is limited to subgroups and is particularly scarce regarding effectiveness of treatment.

Objectives:

To investigate sex differences with regard to demographics, clinical manifestations and response to TNFi in nr-axSpA after exclusion of patients with co-morbid fibromyalgia (FM).

Methods:

Response to a first TNFi was assessed in 85 women and 78 men with nr-axSpA and without concomitant FM in the Swiss Clinical Quality Management Cohort. The primary outcome was the proportion of patients achieving a 40% improvement in the Assessment of Spondyloarthritis international Society criteria (ASAS40) at 1 year. Additional response outcomes were evaluated as secondary outcomes. Patients having discontinued TNFi were considered nonresponders. Logistic regression analyses were adjusted for baseline differences (Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Maastricht ankylosing spondylitis enthesitis score (MASES), diagnostic delay, body mass index (BMI)).

Results:

Baseline characteristics of women and men are shown in Table 1. Significant differences were restricted to diagnostic delay, BASDAI, MASES and BMI. An ASAS40 response was achieved by 17% of women and 38% of men (OR 0.34, 95% CI 0.12; 0.93, p=0.02). A lower response rate in women was confirmed in the adjusted analysis (OR 0.19, 95% CI 0.05; 0.62, p=0.009) as well as for the other outcomes assessed (Table 2).

Table 1.

Baseline characteristics of women and men with nr-axSpA starting a first TNFi (after exclusion of patients with co-morbid FM).

ParameterN163MenN = 78WomenN = 85pAge, years16335.6±10.839.1±11.40.10Age at onset, years16227.9±8.628.1±8.50.66Diagnostic delay, years1624.1±7.67.8±9.90.005HLA-B27 positive, %14975.768.00.36Prior MRI sacroiliitis, %15470.868.30.86BASDAI1485.3±2.06.3±1.60.003ASDAS1403.3±1.03.4±0.70.29Elevated CRP, %15442.538.30.62BASFI1483.6±2.43.8±2.50.54BASMI1411.2±1.11.4±1.20.42EQ-5D14154.8±22.855.8±18.30.79Peripheral arthritis,%15941.652.40.20Enthesitis, %15880.585.20.53MASES1572.3±2.53.9±3.30.002csDMARDs ever, %16334.642.40.34Taking NSAIDs, %15092.986.20.29Current smoking, %13928.322.80.55BMI16025.9±4.224.0±4.4<0.001Table 2.

Response rates of women versus men after 1 year of treatment with a first TNFi.

Unadjusted analysesAdjusted analysesOutcomeWomen%Men%OR95% CIPOR95% CIPASAS4017380.340.12; 0.930.020.190.05; 0.620.009BASDAI5023500.300.11; 0.770.0070.190.05; 0.580.005ASDAS improv. ≥1.128580.290.10; 0.780.0080.260.08; 0.750.02ASDAS <2.127490.390.15; 1.000.030.180.04; 0.650.01ASDAS improv. ≥24260.130.01; 0.680.0050.040.00; 0.270.003ASDAS <1.38290.230.05; 0.820.010.070.01; 0.390.005

Conclusion:

Despite only few sex differences in patient characteristics in nr-axSpA, response rates to TNFi are significantly lower in women than in men.

Disclosure of Interests:

Regula Neuenschwander: None declared, Monika Hebeisen: None declared, Raphael Micheroli: None declared, Kristina Buerki: None declared, Pascale Exer: None declared, Karin Niedermann Schneider: None declared, Michael Nissen Grant/research support from: Abbvie, Consultant of: Novartis, Lilly, Abbvie, Celgene and Pfizer, Speakers bureau: Novartis, Lilly, Abbvie, Celgene and Pfizer, Almut Scherer: None declared, Adrian Ciurea Consultant of: Consulting and/or speaking fees from AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Merck Sharp & Dohme, Novartis and Pfizer.

THU0398 DRUG RETENTION RATES AND TREATMENT OUTCOMES IN 1860 AXIAL SPONDYLOARTHRITIS PATIENTS TREATED WITH SECUKINUMAB IN ROUTINE CLINICAL PRACTICE IN 13 EUROPEAN COUNTRIES IN THE EUROSPA RESEARCH COLLABORATION NETWORK

Background:

To determine the real-life 6- and 12-month secukinumab effectiveness in Europe overall, as well as stratified by prior biologic disease-modifying anti-rheumatic drug (bDMARD)/targeted synthetic (ts)DMARD use.

Objectives:

Real-life data from axSpA patients treated with secukinumab from 13 countries in the European Spondyloarthritis (EuroSpA) Research Collaboration Network were pooled. We calculated proportions of patients achieving Bath Ankylosing Spondylitis Disease Activity Score (BASDAI) <2/<4 and Ankylosing Spondylitis Disease Activity Score (ASDAS) <1.3/<2.1 at 6 and 12 months, including with LUNDEX adjustments (crude value adjusted for drug retention). Retention rates were compared between b/tsDMARD naïve, 1 prior and ≥2 prior b/tsDMARD users with Kaplan-Meier analyses with log rank test and disease states by Chi-square test.

Methods:

A total of 1860 axSpA patients were included (Table 1). Overall 6/12-month secukinumab retention rates were 82%/72% and higher in bionaïve patients (Table 2, Figure). Significant differences in retention rates in-between the registries were found. Inactive disease/low-disease-activity (LDA) were achieved more often in bionaïve patients (Table 2).

Table 1All patients (n=1860)b/tsDMARD naïve (n=414)1 prior b/tsDMARD (n=448)≥2 prior b/tsDMARDs (n=998)Age (years), mean (SD)47 (12)45 (12)47 (12)48 (12)Men, %57%68%58%49%Years since diagnosis, mean (SD)10 (9)8 (9)10 (9)11 (9)Current smokers, %25 %27%25%23%Patient’s global (0-100), median (IQR)70 (50-81)80 (60-90)64 (50-80)70 (50-82)Physician’s global (0-100), median (IQR)45 (25-63)64 (43-78)45 (22-60)40 (20-58)C reactive protein (mg/L), median (IQR)8 (3-25)15 (5-31)7 (3-25)6 (2-22)Erythrocyte sedimentation rate (mm/h), median (IQR)22 (9-44)30 (14-44)24 (8-45)18 (8-42)Pain (0-100), median (IQR)70 (50-81)80 (65-90)65 (49-80)70 (50-80)BASDAI, median (IQR)6.2 (4.6-7.6)6.8 (5.2-8.0)5.9 (4.2-7.2)6.1 (4.4-7.6)BASFI, median (IQR)5.5 (3.2-7.3)6.1 (3.2-7.6)4.8 (2.8-6.8)5.5 (3.3-7.2)ASDAS, median (IQR)3.6 (2.9-4.3)4.2 (3.5-4.8)3.5 (2.7-4.2)3.5 (2.8-4.2)Table 2MonthsAll patients (n=1860)b/tsDMARD naïve (n=414)1 prior b/tsDMARD (n=448)≥2 prior b/tsDMARDs (n=998)p-value*Secukinumab retention rate, % (95%CI)682% (80-84%)90% (87-93%)83% (79-86%)78% (76-81%)0.0011272% (69-74%)84% (81-88%)73% (69-78%)66% (63-69%)<0.001BASDAI <2, % Crude626373518<0.001 LUNDEX adjusted21342813<0.001 Crude1225412918<0.001 LUNDEX adjusted16311811<0.001BASDAI <4, % Crude651716040<0.001 LUNDEX adjusted40654730<0.001 Crude1251765639<0.001 LUNDEX adjusted32573623<0.001ASDAS <1.3, % Crude69131360.001 LUNDEX adjusted712115<0.001 Crude1211181570.002 LUNDEX adjusted713940.002ASDAS <2.1, % Crude6243226200.002 LUNDEX adjusted19292115<0.001 Crude1227442721<0.001 LUNDEX adjusted17331712<0.001

*Comparisons between b/tsDMARD naïve, 1 prior and ≥2 prior b/tsDMARD users were performed with Kaplan-Meier with log-rank test or Chi-Square test, as appropriate

Conclusion:

In this real-life study of 1860 patients with axSpA in 13 European countries secukinumab retention was high and significantly higher for bionaïve patients. Overall, a higher proportion of bionaïve than previous b/tsDMARD users achieved inactive disease/LDA.

Figure

Acknowledgments:

Novartis and IQVIA for supporting the EuroSpA RCN

Disclosure of Interests:

Brigitte Michelsen Grant/research support from: Research support from Novartis, Consultant of: Consulting fees Novartis, Ulf Lindström: None declared, Catalin Codreanu Consultant of: Speaker and consulting fees from AbbVie, Accord Healthcare, Alfasigma, Egis, Eli Lilly, Ewopharma, Genesis, Mylan, Novartis, Pfizer, Roche, Sandoz, UCB, Speakers bureau: Speaker and consulting fees from AbbVie, Accord Healthcare, Alfasigma, Egis, Eli Lilly, Ewopharma, Genesis, Mylan, Novartis, Pfizer, Roche, Sandoz, UCB, Adrian Ciurea Consultant of: Consulting and/or speaking fees from AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Merck Sharp & Dohme, Novartis and Pfizer., Jakub Zavada Speakers bureau: Abbvie, UCB, Sanofi, Elli-Lilly, Novartis, Zentiva, Accord, Anne Gitte Loft Grant/research support from: Novartis, Consultant of: AbbVie, MSD, Novartis, Pfizer and UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer and UCB, Manuel Pombo-Suarez Consultant of: Janssen, Lilly, MSD and Sanofi., Speakers bureau: Janssen, Lilly, MSD and Sanofi., Fatos Onen: None declared, Tore K. Kvien Grant/research support from: Received grants from Abbvie, Hospira/Pfizer, MSD and Roche (not relevant for this abstract)., Consultant of: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Paid instructor for: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Speakers bureau: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Ziga Rotar Consultant of: Speaker and consulting fees from Abbvie, Amgen, Biogen, Eli Lilly, Medis, MSD, Novartis, Pfizer, Roche, Sanofi., Speakers bureau: Speaker and consulting fees from Abbvie, Amgen, Biogen, Eli Lilly, Medis, MSD, Novartis, Pfizer, Roche, Sanofi., Maria Jose Santos Speakers bureau: Novartis and Pfizer, Florenzo Iannone Consultant of: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Speakers bureau: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Anna-Mari Hokkanen: None declared, Björn Gudbjornsson Speakers bureau: Novartis and Amgen, Johan Askling Grant/research support from: JA acts or has acted as PI for agreements between Karolinska Institutet and the following entities, mainly in the context of the ARTIS national safety monitoring programme of immunomodulators in rheumatology: Abbvie, BMS, Eli Lilly, Merck, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB Pharma, Ruxandra Ionescu Consultant of: Consulting fees from Abbvie, Eli-Lilly, Novartis, Pfizer, Roche, Sandoz, Speakers bureau: Consulting and speaker fees from Abbvie, Eli-Lilly, Novartis, Pfizer, Roche, Sandoz, Michael Nissen Grant/research support from: Abbvie, Consultant of: Novartis, Lilly, Abbvie, Celgene and Pfizer, Speakers bureau: Novartis, Lilly, Abbvie, Celgene and Pfizer, Karel Pavelka Consultant of: Abbvie, MSD, BMS, Egis, Roche, UCB, Medac, Pfizer, Biogen, Speakers bureau: Abbvie, MSD, BMS, Egis, Roche, UCB, Medac, Pfizer, Biogen, Carlos Sánchez-Piedra: None declared, Servet Akar: None declared, Joe Sexton: None declared, Matija Tomsic: None declared, Helena Santos Speakers bureau: AbbVie, Eli-Lilly, Janssen, Pfizer, Novartis, Marco Sebastiani: None declared, Jenny Osterlund: None declared, Arni Jon Geirsson: None declared, Gareth T. Jones Grant/research support from: Pfizer, AbbVie, UCB, Celgene and GSK., Irene van der Horst-Bruinsma Grant/research support from: AbbVie, Novartis, Eli Lilly, Bristol-Myers Squibb, MSD, Pfizer, UCB Pharma, Consultant of: AbbVie, Novartis, Eli Lilly, Bristol-Myers Squibb, MSD, Pfizer, UCB Pharma, Stylianos Georgiadis Grant/research support from: Novartis, Cecilie Heegaard Brahe Grant/research support from: Novartis, Lykke Midtbøll Ørnbjerg Grant/research support from: Novartis, Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB

OP0109 CO-MEDICATION WITH A CONVENTIONAL SYNTHETIC DMARD IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS IS ASSOCIATED WITH IMPROVED RETENTION OF TNF INHIBITORS: RESULTS FROM THE EUROSPA COLLABORATION

Background:

Axial spondylarthritis (axSpA) patients treated with a tumour necrosis factor inhibitor (TNFi) may receive a concomitant conventional synthetic disease-modifying anti-rheumatic drug (csDMARD), although the value of combination therapy remains unclear.

Objectives:

Describe the proportion and phenotype of patients with axSpA initiating their first TNFi as monotherapy compared to TNFi+csDMARD combination therapy, and to compare the 1-year TNFi retention between the two groups.

Methods:

Data from 13 European registries was collected. Two exposure treatment groups were defined: TNFi monotherapy at baseline (=TNFi start date) and TNFi+csDMARD combination therapy. TNFi retention rates were assessed with Kaplan-Meier curves for each country and combined. Hazard ratios (HR, 95% CI) for discontinuing the TNFi were obtained with Cox models: (i) crude; adjusted for (ii) country, and (iii) country, sex, age, calendar year, disease duration and BASDAI. Participating countries were dichotomized into two strata, depending on their 1-year retention rate being above (stratum A) or below (stratum B) the average retention rate across all countries.

Results:

22,196 axSpA patients were included with 34% on TNFi+csDMARD combination therapy. Baseline characteristics are presented in table 1. Overall, the crude TNFi retention rate was marginally longer in the combination therapy group (80% (79-81%)) compared to the monotherapy group (78% (77-79%)) and was primarily driven by differences in stratum B (fig. 1). TNFi retention rates varied significantly across countries (range:-11.0% to +11.3%), with a clear distinction between the 2 strata. The HRs for discontinuation over 1-year (reference=TNFi monotherapy) in the 3 models were: (i) 0.88 (0.82-0.93), (ii) 0.87 (0.82-0.92), (iii) 0.88 (0.82-0.93).

Table 1Baseline characteristicsAll patients(n=22196)Country stratum ACountry stratum BTNFi mono(n=4940)csDMARD + TNFi(n=2547)TNFi mono(n=9693)csDMARD + TNFi(n=5016)Age (years), mean (SD)42.6 (12.5)43.4 (12.0)42.8 (12.2)41.6 (12.7)43.7 (12.7)Females, %41.137.738.242.044.2Disease duration (yrs), mean (SD)5.7 (8.0)6.2 (7.7)6.7 (7.4)4.9 (8.2)6.1 (8.2)Enthesitis, %50.316.733.957.859.7SJC-28, median (IQR)0 (0-1)0 (0-0)0 (0-2)0 (0-0)0 (0-2)VAS pain (0-100), mean (SD)60.9 (24.5)63.3 (26.5)67.8 (23.3)60.2 (23.4)57.2 (24.3)CRP (mg/L), median (IQR)8 (3-20)7.8 (2-20)18 (6.7-32.6)6.0 (2.7-15)8.0 (3-22)BASDAI (0-10), mean (SD)5.7 (2.1)5.7 (2.2)6.2 (2.1)5.6 (2.0)5.4 (2.2)BASFI (0-10), mean (SD)4.4 (2.5)4.4 (2.6)4.9 (2.5)4.3 (2.4)4.2 (2.9)ASDAS, mean (SD)3.5 (1.1)3.7 (1.0)4.0 (1.0)3.3 (1.0)3.3 (1.1)On Infliximab, %25.721222436Baseline csDMARD use, %-Methotrexate045063-Sulfasalazine068033-Leflunomide0801

Conclusion:

Considerable differences were observed across countries in the use of combination therapy and TNFi retention in axSpA patients. The overall 1-year TNFi retention was higher with csDMARD co-therapy compared to TNFi monotherapy. TNFi monotherapy had a 12-13% higher risk of treatment discontinuation.

Acknowledgments:

Novartis Pharma AG and IQVIA

MN and BD participated equally

Disclosure of Interests:

Michael Nissen Grant/research support from: Abbvie, Consultant of: Novartis, Lilly, Abbvie, Celgene and Pfizer, Speakers bureau: Novartis, Lilly, Abbvie, Celgene and Pfizer, Bénédicte Delcoigne: None declared, Daniela Di Giuseppe: None declared, Lennart T.H. Jacobsson Consultant of: AbbVie, Eli Lilly, Janssen, Novartis and Pfizer, Karen Fagerli: None declared, Anne Gitte Loft Grant/research support from: Novartis, Consultant of: AbbVie, MSD, Novartis, Pfizer and UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer and UCB, Adrian Ciurea Consultant of: Consulting and/or speaking fees from AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Merck Sharp & Dohme, Novartis and Pfizer., Dan Nordström Consultant of: Abbvie, Celgene, Lilly, Novartis, Pfizer, Roche and UCB., Speakers bureau: Abbvie, Celgene, Lilly, Novartis, Pfizer, Roche and UCB., Ziga Rotar Consultant of: Speaker and consulting fees from Abbvie, Amgen, Biogen, Eli Lilly, Medis, MSD, Novartis, Pfizer, Roche, Sanofi., Speakers bureau: Speaker and consulting fees from Abbvie, Amgen, Biogen, Eli Lilly, Medis, MSD, Novartis, Pfizer, Roche, Sanofi., Florenzo Iannone Consultant of: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Speakers bureau: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Maria Jose Santos Speakers bureau: Novartis and Pfizer, Manuel Pombo-Suarez Consultant of: Janssen, Lilly, MSD and Sanofi., Speakers bureau: Janssen, Lilly, MSD and Sanofi., Björn Gudbjornsson Speakers bureau: Novartis and Amgen, Heřman Mann: None declared, Nurullah Akkoc: None declared, Catalin Codreanu Consultant of: Speaker and consulting fees from AbbVie, Accord Healthcare, Alfasigma, Egis, Eli Lilly, Ewopharma, Genesis, Mylan, Novartis, Pfizer, Roche, Sandoz, UCB, Speakers bureau: Speaker and consulting fees from AbbVie, Accord Healthcare, Alfasigma, Egis, Eli Lilly, Ewopharma, Genesis, Mylan, Novartis, Pfizer, Roche, Sandoz, UCB, Irene van der Horst-Bruinsma Grant/research support from: AbbVie, Novartis, Eli Lilly, Bristol-Myers Squibb, MSD, Pfizer, UCB Pharma, Consultant of: AbbVie, Novartis, Eli Lilly, Bristol-Myers Squibb, MSD, Pfizer, UCB Pharma, Brigitte Michelsen: None declared, Gary Macfarlane: None declared, Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis, Matija Tomsic: None declared, Burkhard Moeller: None declared, Pedro Ávila-Ribeiro Grant/research support from: Novartis, Carlos Sánchez-Piedra: None declared, Heikki Relas Grant/research support from: Abbvie., Consultant of: Abbvie, Celgene, and Pfizer., Speakers bureau: Abbvie, Celgene, and Pfizer., Arni Jon Geirsson: None declared, Lucie Nekvindova: None declared, Gozde Yildirim Cetin Speakers bureau: AbbVie, Novartis, Pfizer, Roche, UCB, MSD, Ruxandra Ionescu Consultant of: Consulting fees from Abbvie, Eli-Lilly, Novartis, Pfizer, Roche, Sandoz, Speakers bureau: Consulting and speaker fees from Abbvie, Eli-Lilly, Novartis, Pfizer, Roche, Sandoz, Niels Steen Krogh: None declared, Johan Askling Grant/research support from: JA acts or has acted as PI for agreements between Karolinska Institutet and the following entities, mainly in the context of the ARTIS national safety monitoring programme of immunomodulators in rheumatology: Abbvie, BMS, Eli Lilly, Merck, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB Pharma, Bente Glintborg Grant/research support from: Grants from Pfizer, Biogen and Abbvie, Ulf Lindström: None declared

FRI0283 CO-MEDICATION WITH CSDMARD HAS LITTLE EFFECT ON THE RETENTION OF TNF INHIBITORS IN PSORIATIC ARTHRITIS, RESULTS FROM THE EUROSPA COLLABORATION

Background:

Previous studies have suggested similar effectiveness, but longer treatment retention, for tumor necrosis factor inhibitors (TNFi), when used in combination with a conventional synthetic disease modifying anti-rheumatic drug (csDMARD) in psoriatic arthritis (PsA).

Objectives:

To describe patients with PsA initiating a first TNFi as monotherapy compared to combination therapy, and to explore 1-year treatment retention of TNFi in the two groups.

Methods:

Patients with PsA starting a first TNFi (2006-2017) were identified in biologics registers of 13 European countries, and data were pooled for analysis. Co-medication with csDMARD was determined at TNFi start.

Because of large inter-country variation in TNFi retention, countries were split into two strata, depending on each country’s 1-year retention rate for TNFi being above (stratum A) or below (stratum B) the average 1-year retention rate.

TNFi treatment retention was compared through Kaplan-Meier curves; the proportion remaining on the TNFi at one year; and hazard ratios (HR) during the first year: (i) crude; adjusted for (ii) country-strata, and (iii) country-strata, sex, age, calendar year, DAS28 and disease duration. In model (iii) only registers contributing >1000 patients or <33% missing data for DAS28 were included.

Results:

A total of 14778 patients with PsA starting a first TNFi were included. Baseline disease activity was similar within stratum B, but higher for the combination treatment group in stratum A (table 1).

Table 1.

Baseline characteristics

Country strataStratum AStratum BTNFimonotherapyN=2120TNFi/csDMARDcombinationN=2128TNFimonotherapyN=3369TNFi/csDMARDcombinationN=7161Females52%51%53%51%Age, years49.7 (12.2)48.7 (11.8)48.8 (13.0)48.9 (12.2)Disease duration, yrs6.4 (7.0)6.8 (6.8)5.9 (7.5)5.9 (7.1)Tender joints 285.5 (6.3)8.0 (6.3)5.6 (6.0)5.6 (5.7)Swollen joints 282.8 (4.3)5.6 (5.0)3.0 (3.8)3.3 (3.8)VAS pain54 (29)62 (24)59 (23)56 (24)DAPSA-2824.6 (18.6)36.2 (17.6)27.3 (15.6)27.2 (15.2)DAS28 (CRP)3.5 (1.4)4.7 (1.3)4.0 (1.2)4.0 (1.1)Concomitant csDMARDMethotrexate-76%-79%Sulfasalazine-15%-15%Other csDMARD-49%-25%

Numbers are means (sd) unless otherwise stated.

The Kaplan-Meier curves for the treatment groups were similar within each stratum (fig 1), as were the proportions remaining on TNFi after one year, stratum A: monotherapy 86% (95%CI: 85-88) vs. combination 86% (84-87), stratum B: 71% (69-72) vs. 73% (72-74). The HRs for TNFi discontinuation (ref=TNFi monotherapy) were: (i) 1.06 (0.98-1.13), (ii) 0.94 (0.87-1.01), (iii) 0.89 (0.83-0.96), including 13078 patients (9 countries) for model (iii).

Conclusion:

In this exploratory study no benefit in TNFi retention was observed for csDMARD combination therapy in crude analyses, while in adjusted analyses an 11% lower risk of TNFi discontinuation was found. These preliminary results offer limited support for use of combination therapy in PsA. Further analyses will explore to what extent the results are affected by inter-country heterogeneity and differences between TNFi.

Acknowledgments:

UL and DDG contributed equally.

Novartis Pharma AG and IQVIA support the EuroSpA collaboration.

Disclosure of Interests:

Ulf Lindström: None declared, Daniela Di Giuseppe: None declared, Bénédicte Delcoigne: None declared, Bente Glintborg Grant/research support from: Grants from Pfizer, Biogen and Abbvie, Burkhard Moeller: None declared, Manuel Pombo-Suarez Consultant of: Janssen, Lilly, MSD and Sanofi., Speakers bureau: Janssen, Lilly, MSD and Sanofi., Carlos Sánchez-Piedra: None declared, Kari Eklund Consultant of: Celgene, Lilly, Speakers bureau: Pfizer, Roche, Heikki Relas Grant/research support from: Abbvie., Consultant of: Abbvie, Celgene, and Pfizer., Speakers bureau: Abbvie, Celgene, and Pfizer., Björn Gudbjornsson Speakers bureau: Novartis and Amgen, Thorvardur Love: None declared, Gareth T. Jones Grant/research support from: Pfizer, AbbVie, UCB, Celgene and GSK., Adrian Ciurea Consultant of: Consulting and/or speaking fees from AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Merck Sharp & Dohme, Novartis and Pfizer., Catalin Codreanu Consultant of: Speaker and consulting fees from AbbVie, Accord Healthcare, Alfasigma, Egis, Eli Lilly, Ewopharma, Genesis, Mylan, Novartis, Pfizer, Roche, Sandoz, UCB, Speakers bureau: Speaker and consulting fees from AbbVie, Accord Healthcare, Alfasigma, Egis, Eli Lilly, Ewopharma, Genesis, Mylan, Novartis, Pfizer, Roche, Sandoz, UCB, Ruxandra Ionescu Consultant of: Consulting fees from Abbvie, Eli-Lilly, Novartis, Pfizer, Roche, Sandoz, Speakers bureau: Consulting and speaker fees from Abbvie, Eli-Lilly, Novartis, Pfizer, Roche, Sandoz, Lucie Nekvindova: None declared, Jakub Zavada Speakers bureau: Abbvie, UCB, Sanofi, Elli-Lilly, Novartis, Zentiva, Accord, Nuh Atas: None declared, Servet Yolbaş: None declared, Karen Fagerli: None declared, Brigitte Michelsen Grant/research support from: Research support from Novartis, Consultant of: Consulting fees Novartis, Ziga Rotar Consultant of: Speaker and consulting fees from Abbvie, Amgen, Biogen, Eli Lilly, Medis, MSD, Novartis, Pfizer, Roche, Sanofi., Speakers bureau: Speaker and consulting fees from Abbvie, Amgen, Biogen, Eli Lilly, Medis, MSD, Novartis, Pfizer, Roche, Sanofi., Matija Tomsic: None declared, Florenzo Iannone Consultant of: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Speakers bureau: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Maria Jose Santos Speakers bureau: Novartis and Pfizer, Pedro Ávila-Ribeiro Grant/research support from: Novartis, Lykke Midtbøll Ørnbjerg Grant/research support from: Novartis, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Lennart T.H. Jacobsson Consultant of: AbbVie, Eli Lilly, Janssen, Novartis and Pfizer, Johan Askling Grant/research support from: JA acts or has acted as PI for agreements between Karolinska Institutet and the following entities, mainly in the context of the ARTIS national safety monitoring programme of immunomodulators in rheumatology: Abbvie, BMS, Eli Lilly, Merck, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB Pharma, Michael Nissen Grant/research support from: Abbvie, Consultant of: Novartis, Lilly, Abbvie, Celgene and Pfizer, Speakers bureau: Novartis, Lilly, Abbvie, Celgene and Pfizer

Relationship between preterm birth and post-partum periodontal maternal status: a hospital-based Romanian study

PURPOSE

This cross-sectional case-control study of post-partum women aimed to estimate whether maternal periodontitis was a predictive contributor to preterm birth and to identify other risk factors associated with preterm birth in our target population.

METHODS

The case group included women who delivered preterm (74 cases) and the control group included women who had a normal term delivery (120 controls). Medical records, a 16-item questionnaire, and a full-mouth periodontal examination were used to collect information about socio-demographic characteristics, general health problems, birth-related information, behavioral factors and periodontal status. Logistic regression analysis was used to estimate the strength of the relationship between predictors and the categorical outcome variable, preterm birth.

RESULTS

The bivariate analysis revealed the significant associations between preterm birth and socio-demographic factors (educational level, p = 0.003), antepartum smoking habit (p = 0.001) and birth weight lower than 2500 g (p < 0.001). The multivariate analysis highlighted that the presence of post-partum maternal periodontitis and its severity remained independent risk factors of preterm birth in the presence of antepartum smoking habit and route of delivery [adjusted OR 2.26, 95% CI (1.06; 4.82), respectively, OR 3.46, 95% CI (1.08; 11.15)].

CONCLUSION

Post-partum maternal periodontal disease and its severity might, in part, be considered as contributor to preterm deliveries before 37 weeks of gestation.

Safety and immunogenicity of tetanus/diphtheria vaccination in patients with rheumatic diseases-a prospective multi-centre cohort study

OBJECTIVES

We aimed to assess the safety and immunogenicity of a diphtheria/tetanus vaccine booster dose in three different patient groups with rheumatic diseases on a variety of immunosuppressive/immunomodulatory medications compared with healthy controls (HCs).

METHODS

We conducted a multi-centre prospective cohort study in Switzerland. We enrolled patients with RA, axial SpA/PsA, vasculitis (Behçet's disease, ANCA-associated vasculitis) and HCs. Diphtheria/tetanus vaccination was administered according to the Swiss vaccination recommendations. Blood samples were drawn before vaccination, and 1 month and 3 months afterwards. Antibody concentrations against vaccine antigens were measured by ELISA. Immunogenicity was compared between patient and medication groups. A mixed model was applied for multivariate analysis. Missing data were dealt with using multiple imputation.

RESULTS

Between January 2014 and December 2015, we enrolled 284 patients with rheumatic diseases (131 RA, 114 SpA/PsA, 39 vasculitis) and 253 HCs. Of the patients, 89% were on immunosuppressive/immunomodulatory medication. Three months post-vaccination 100% of HCs vs 98% of patients were protected against tetanus and 84% vs 73% against diphtheria. HCs and SpA/PsA patients had significantly higher responses than RA and vasculitis patients. Assessing underlying diseases and medications in a multivariate model, rituximab was the only factor negatively influencing tetanus immunogenicity, whereas only MTX treatment had a negative influence on diphtheria antibody responses. No vaccine-related serious adverse events were recorded.

CONCLUSION

Diphtheria/tetanus booster vaccination was safe. Tetanus vaccination was immunogenic; the diphtheria component was less immunogenic. Vaccine responses were blunted by rituximab and MTX.

TRIAL REGISTRATION

ClinicalTrials.gov, http://clinicaltrials.gov, Identifier: NCT01947465.

Long-term immunogenicity after yellow fever vaccination in immunosuppressed and healthy individuals

BACKGROUND

The live-attenuated yellow fever vaccine (YFV) is generally contraindicated in immunosuppressed patients. Our aim was to investigate if immunosuppressive therapy impairs the long-term protection against yellow fever virus in patients who had received YFV prior to the start of their immunosuppressive therapy.

METHODS

Our study examined 35 healthy individuals and 40 immunosuppressed patients with autoimmune diseases or organ transplants. All individuals had received YFV prior to the onset of their immunosuppression. We analysed the long-term influence of the immunosuppressive therapy on the YFV protective immunity by measuring neutralising antibodies (NA) with the Plaque Reduction Neutralisation Test (PRNT). We assessed risk factors for a negative PRNT result (titre below 1: 10) and their influence on the magnitude of the NA.

RESULTS

A median time interval of 21.1 years (interquartile range 14.4-31.3 years) after the YFV in all patients, a total of 35 immunosuppressed patients (88%) were seropositive (PRNT ≥ 1:10) compared to 31 patients (89%) in the control group. The geometric mean titres of NA did not differ between the groups. The duration of an underlying rheumatic disease was the only risk factor found for a lower magnitude of NA. An insufficient level of NA was found in nine subjects (12%) who had received a single dose of YFV (in one subject, the number of YFV doses was unknown).

CONCLUSION

The use of an immunosuppressive drug started after the administration of the YFV did not affect long-term persistence of NA. A second dose of YFV may be necessary to secure long-term immunity.

Discordances between clinical and ultrasound measurements of disease activity among RA patients followed in real life

OBJECTIVE

Measurements of disease activity, such as the clinical disease activity score (DAS28) or ultrasound (US) scores, often yield discordant results. This study's objectives were to determine the proportion of disagreements between the two assessment methods in patients with rheumatoid arthritis (RA) and to describe factors associated with discrepancy in assessment.

METHODS

All RA patients in the Swiss registry for inflammatory arthritides (SCQM) with at least one concomitant DAS28 and US score, were included. Disease activity was categorized as remission, low-to-moderate, and high, based on previously established cut-offs, for both the DAS28 and the US score. A longitudinal analysis was performed among patients who underwent at least two assessments.

RESULTS

Of 2369 assessments included (1091 patients), 1196 (50.4%) were discordant. The US score both over- and under-estimated disease activity compared to the DAS28 score (23.5% and 26.8% respectively). Clinical and demographic factors significantly associated with discordant results were the individual components of the DAS28 score when US was used as the reference and age, disease duration, and the swollen joint count when the DAS28 was used as the reference. The main US-related factor associated with discordance was the presence of US tenosynovitis. In the longitudinal analysis of 1081 patients, the proportion of disagreements remained essentially unchanged.

CONCLUSION

Rates of disagreement between clinical and US assessments of disease activity among RA patients are high and remain high during follow-up, even when the US assessors were aware of the clinical examination findings. Both clinical- and ultrasound- related factors were associated with discordances.

Treatment response and drug retention rates in 24 195 biologic-naïve patients with axial spondyloarthritis initiating TNFi treatment: routine care data from 12 registries in the EuroSpA collaboration

Objective

To study drug retention and response rates in patients with axial spondyloarthritis (axSpA) initiating a first tumour necrosis factor inhibitor (TNFi).

Methods

Data from 12 European registries, prospectively collected in routine care, were pooled. TNFi retention rates (Kaplan-Meier statistics), Ankylosing Spondylitis Disease Activity Score (ASDAS) Inactive disease (<1.3), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) <40 mm and Assessment of SpondyloArthritis International Society responses (ASAS 20/40) were assessed at 6, 12 and 24 months.

Results

A first TNFi was initiated in 24 195 axSpA patients. Heterogeneity of baseline characteristics between registries was observed. Twelve-month retention was 80% (95% CI 79% to 80%), ranging from 71% to 94% across registries. At 6 months, ASDAS Inactive disease/BASDAI<40 rates were 33%/72% (LUNDEX-adjusted: 27%/59%), ASAS 20/40 response rates 64%/49% (LUNDEX-adjusted 52%/40%). In patients initiating first TNFi after 2009, 6097 patients was registered to fulfil ASAS criteria for axSpA, 2935 was registered to fulfil modified New York Criteria for Ankylosing Spondylitis and 1178 patients was registered as having non-radiographic axSpA. In nr-axSpA patients, we observed lower 12-month retention rates (73% (70%–76%)) and lower 6-month LUNDEX adjusted response rates (ASDAS Inactive disease/BASDAI40 20%/50%, ASAS 20/40 45%/33%). For patients initiating first TNFi after 2014, 12-month retention rate, but not 6-month response rate, was numerically higher compared with patients initiating TNFi in 2009–2014.

Conclusion

A large European database of patients with axSpA initiating a first TNFi treatment in routine care, demonstrated that 27% of patients achieved ASDAS inactive disease after 6 months, while 59% achieved BASDAI <40. Four of five patients continued treatment after 1 year.

Do patients with axial spondyloarthritis with radiographic sacroiliitis fulfil both the modified New York criteria and the ASAS axial spondyloarthritis criteria? Results from eight cohorts

Background

Patients with spondyloarthritis with radiographic sacroiliitis are traditionally classified according to the modified New York (mNY) criteria as ankylosing spondylitis (AS) and more recently according to the Assessment of SpondyloArthritis international Society (ASAS) criteria as radiographic axial spondyloarthritis (r-axSpA).

Objective

To investigate the agreement between the mNY criteria for AS and the ASAS criteria for r-axSpA and reasons for disagreement.

Methods

Patients with back pain ≥3 months diagnosed as axSpA with radiographic sacroiliitis (mNY radiographic criterion) were selected from eight cohorts (ASAS, Esperanza, GESPIC, OASIS, Reuma.pt, SCQM, SPACE, UCSF). Subsequently, we calculated the percentage of patients who fulfilled the ASAS r-axSpA criteria within the group of patients who fulfilled the mNY criteria and vice versa in six cohorts with complete information.

Results

Of the 3882 patients fulfilling the mNY criteria, 93% also fulfilled the ASAS r-axSpA criteria. Inversely, of the 3434 patients fulfilling the ASAS r-axSpA criteria, 96% also fulfilled the mNY criteria. The main cause for discrepancy between the two criteria sets was the reported age at onset of back pain.

Conclusion

Almost all patients with axSpA with radiographic sacroiliitis fulfil both ASAS and mNY criteria, which supports the interchangeable use of the terms AS and r-axSpA.

Comparison of drug survival on adalimumab, etanercept, golimumab and infliximab in patients with axial spondyloarthritis

Objectives

To compare drug survival in patients with axial spondyloarthritis treated with different TNF inhibitors in standard dosage.

Methods

Patients fulfilling the Assessment in SpondyloArthritis international Society classification criteria for axial spondyloarthritis in the Swiss Clinical Quality Management cohort were included in this study if a first TNF inhibitor on standard dosage was started after recruitment and if a baseline visit was available. Drug maintenance up to drug discontinuation or dose escalation was compared between TNF inhibitors with multiple adjusted Cox proportional hazards models and multiple imputation for missing baseline covariate data.

Results

A total of 966 patients were included (adalimumab 344, etanercept 237, golimumab 214, infliximab 171). Patients on certolizumab (n = 18) were excluded. Patients starting golimumab had lower disease activity as well as better physical function and quality of life in comparison to patients starting another drug. A higher proportion of patients starting infliximab had a history of extra-articular manifestations. Drug dosage was more often escalated during follow-up in patients treated with infliximab than with subcutaneously administered agents. However, no significant differences in time up to drug discontinuation or dose escalation were observed in multiple adjusted analyses if treatment was initiated after 2009, when all 4 TNF inhibitors were available: hazard ratio for infliximab versus etanercept 1.16 (95% confidence interval 0.80; 1.67), p = 0.44, for golimumab versus etanercept 0.80 (0.58; 1.10), p = 0.17 and for adalimumab versus etanercept 0.93 (0.69; 1.26), p = 0.66.

Conclusion

In axial spondyloarthritis, drug survival with standard doses of different TNF inhibitors is comparable.