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

Background:

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

Objectives:

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

Methods:

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

Results:

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

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

Conclusion:

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

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

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

Conclusion:

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

Disclosure of Interests:

None declared.

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

Disclosure of Interests:

None declared

AB0488 SPONDYLOARTHRITIS DISEASE BURDEN AS PERCEIVED BY PATIENTS: BASELINE PATIENT-REPORTED OUTCOME DATA FROM THE ITALIAN PROSPECTIVE SIRENA STUDY

Background:

Previous studies have compared Patient-Reported Outcomes (PROs) in Spondyloarthritis (SpA); a recent one has found similarity in Psoriatic Arthritis (PsA) and axial patients1.

Objectives:

To describe PROs at SpA diagnosis (new or confirmed), by type of SpA and by gender.

Methods:

SIRENA is an Italian, prospective Registry of SpA patients diagnosed according to ASAS criteria and naïve to any DMARDs. At inclusion, patients were classified as predominant axial (AxSpA) or mainly peripheral (pSpA). PROs showed in the Table 1 were collected and analysed descriptively.

Table 1.

PhGA and PROs at diagnosis*

AxSpA*pSpAAll(n=123)Women(n=64)Men(n=58)All(n=227)Women(n=109)Men(n=118)PhGA, n1156054222105117mean (SD)50.2 (28.6)54.8 (26.7)45.0 (30.1)45.4 (25.9)49.9 (25.6)41.3 (25.6)median (min, max)52.0 (0-100)62.0 (0-100)43.5 (0-100)48.5 (0-100)50.0 (1.0-100)40.0 (0-95.0)PtGA, n1125952209102107mean (SD)56.4 (27.8)61.5 (25.8)50.3 (29.2)50.3 (26.2)56.4 (23.1)44.5 (27.7)median (min, max)63.0 (0-100)70.0 (2.0-100)50.0 (0-100)50.0 (0-100)58.5 (7.0-100)47.0 (0-100)Pain VAS score, n1136052207101106mean (SD)56.7 (28.3)61.1 (26.6)50.6 (29.1)51.9 (26.8)57.4 (25.3)46.8 (27.3)median (min, max)60.0 (0-100)69.5 (2.0-100)50.0 (0-100)53.0 (0-100)61.0 (0-100)48.5 (0-100)Sleep VAS score, n1136052211103108mean (SD)55.3 (29.3)57.4 (29.5)52.3 (29.2)44.0 (30.1)50.4 (29.8)37.9 (29.2)median (min, max)59.0 (0-100)61.5 (0-100)53.0 (0-100)44.0 (0-100)53.0 (0-100)34.0 (0-100)BASFI, n11058511336568mean (SD)4.6 (2.8)5.2 (2.6)3.9 (2.8)3.5 (2.6)4.0 (2.6)3.1 (2.4)median (min, max)5.1 (0-9.7)5.8 (0-9.4)3.6 (0-9.6)2.9 (0-10.0)3.9 (0-10.0)2.45 (0-8.9)BASDAI, n11259521397069mean (SD)5.2 (2.4)5.8 (2.3)4.5 (2.3)5.2 (2.3)5.8 (2.1)4.6 (2.3)median (min, max)5.5 (0-9.3)6.2 (0-9.3)4.5 (0.3-9.2)5.5 (0.2-10.0)6.1 (1.0-10.0)4.8 (0.2-9.2)HAQ-DI score, n109585020399104mean (SD)0.9 (0.7)1.1 (0.7)0.6 (0.6)0.7 (0.7)0.9 (0.7)0.6 (0.6)median (min, max)0.8 (0.0-2.5)1.1 (0-2.5)0.5 (0-2.3)0.6 (0.0-2.8)0.8 (0-2.8)0.4 (0-2.6)WPAI% work time missed, n4919301074562mean (SD)7.3 (21.4)4.2 (9.5)9.2 (26.3)8.8 (24.7)8.6 (25.6)8.9 (24.3)median (min, max)0 (0-100)0 (0-35.1)0 (0-100)0 (0-100)0 (0-100)0 (0-100)% impairment at work, n6733341346173mean (SD)48.2 (31.9)58.5 (26.6)38.2 (33.7)39.7 (31.4)45.4 (30.9)34.9 (31.2)median (min, max)50.0 (0-100)60.0 (0-100)25.0 (0-100)40.0 (0-100)50.0 (0-100)30.0 (0-100)% overall work impairment, n4819291064561mean (SD)44.1 (33.0)52.4 (27.9)38.7 (35.3)40.1 (33.0)45.1 (33.1)36.4 (32.7)median (min, max)45.0 (0-100)60.0 (0-100)20.0 (0-100)40.0 (0-100)50.0 (0-100)30.0 (0-100)% activity impairment, n10053461839390mean (SD)56.7 (28.6)63.4 (23.9)48.0 (31.0)48.5 (30.3)55.3 (28.7)41.4 (30.4)median (min, max)60.0 (0-100)70.0 (0-100)50.0 (0-100)50.0 (0-100)60.0 (0-100)40.0 (0-100)

* The sum does not add up to the total because of some missing values.

Results:

From 23 sites, 123 AxSpA and 227 pSpA patients were analysed. Diagnosis was new in 58% of AxSpA and 77% of pSpA. 85.5% of the pSpA had PsA, while in AxSpA the most frequent type was Ankylosing Spondylitis (48.8%). Time from symptom onset to diagnosis was higher in AxSpA than in pSpA (median 36 vs 24 months, respectively). At inclusion, composite disease activity measures showed high disease activity for AxSpA (mean ASDAS-CRP 3.1) and moderate disease activity for pSpA (mean DAS28 3.6; mean DAPSA 22.5). AxSpA patients had numerically worse values than pSpA in all the PROs collected, except for BASDAI score that was similar (mean 5.2). For both AxSpA and pSpA, all PROs were worse in women than men, except for the % of work time missed. PtGA scores were higher than PhGA, in each group and gender.

Conclusion:

At diagnosis, SpA patients perceive a slightly higher disease burden than assessed by Physicians. For PROs other than BASDAI, AxSpA reported a worse impact than pSpA. Overall, women showed a higher disease impact than men.

References:

[1]Michelsen B. et al. PLoS ONE 2015; 10(4): e0123582.

Disclosure of Interests:

Rosario Foti Speakers bureau: Speaker bureau honoraria from Eli Lilly, Sanofi, MSD, Janssen, AbbVie, Bristol-Myers Squibb, Celgene, Roche, Consultant of: Consultancy fees from Eli Lilly, Sanofi, MSD, Janssen, AbbVie, BMS, Celgene, Roche, Gabriella Cardinale: None declared., Luisa Costa: None declared., Franco Franceschini: None declared., Francesco Ciccia Speakers bureau: Speaker bureau honoraria from AbbVie, Abiogen, Bristol-Myers Squibb, Celgene, Janssen, Eli Lilly, Pfizer, Novartis, Roche, Consultant of: Consultancy fees from Novartis, Pfizer, Janssen, Eli Lilly, Roche, Celgene, Grant/research support from: Grant/research support from Pfizer, Novartis, Celgene, Janssen, Roche, Antonio Marchesoni: None declared., Giuliana Guggino Speakers bureau: Speaker bureau honoraria from Celgene, Sandoz, Pfizer, Grant/research support from: Grant/research support from Pfizer, Celgene, Maurizio Rossini: None declared., Ennio Lubrano Di Scorpaniello: None declared., Bruno Frediani: None declared., Maria Sole Chimenti: None declared., Gerolamo Bianchi: None declared., Giuseppe Galfo: None declared., Silvia Marelli Employee of: Employee of Janssen-Cilag SpA Italy, Ennio Favalli Speakers bureau: Consulting fees and/or speaking engagements from AbbVie, Bristol-Myers Squibb, Lilly, Merck Sharp & Dohme, Pfizer, Galapagos, Sanofi-Genzyme, and UCB.

POS1349 THE JOINT INVOLVEMENT IN ADULT ONSET STILL’S DISEASE IS CHARACTERISED BY A PECULIAR MAGNETIC RESONANCE IMAGING AND A SPECIFIC TRANSCRIPTOMIC PROFILE

Background:

Adult onset Still’s disease (AOSD) is a rare systemic autoinflammatory disease and joint involvement is one of its clinical manifestations [1]. Arthritis, either oligoarthritis or bilateral symmetrical rheumatoid arthritis-like polyarthritis, is another common clinical feature of AOSD, with a migrating pattern at the beginning and becoming stable over the time [1].

Objectives:

The aims of the study were to assess joint involvement in AOSD by using magnetic resonance imaging (MRI), to describe main patterns of involvement, and associated clinical characteristics, and to evaluate the global transcriptomic profile of synovial tissues in AOSD to elucidate possible pathogenic pathways involved with.

Methods:

AOSD patients, who underwent to magnetic resonance imaging (MRI) exam on joints, were assessed to describe patterns of joint involvement and associated clinical characteristics. Some synovial tissues were collected for RNA-sequencing purposes.

Results:

In this study, 31 patients with AOSD (mean age 42.3 ± 15.2 years, 54.8% male gender), who underwent to at least one MRI exam on joints, were assessed. The most common MRI finding was the presence of synovitis on 60.5%, mainly in peripheral affected joints. MRI revealed a mild to moderate proliferative synovitis, as thickening of the synovial membrane, with low to intermediate signal intensity on T1-weighted images and intermediate to high signal intensity on T2-fat saturated weighted and STIR images, suggesting the presence of a hyperplastic than of a hypertrophied synovial tissue. Bone oedema and bone erosions were reported on 34.9% and 25.6% MRI exams, respectively. In all patients but one, bone erosions were synchronous with bone oedema, overlapping completely the locations. Assessing clinical characteristics in patients with MRI-erosions, a higher prevalence of splenomegaly, a more frequent chronic disease course, lower levels of erythrocyte sedimentation rate and ferritin was observed.

Assessing the synovial tissues of some AOSD patients, a moderate perivascular mononuclear infiltrate in the sub-lining stroma of hip synovial tissues was observed, whereas the lining cells were relatively unremarkable. In addition, interleukin (IL)-1β, IL-6, TNF, and heavy ferritin subunit (FeH) were found on AOSD synovial tissues.

An RNA-sequencing analysis assessed the global transcriptomic profile of synovial tissues on AOSD patients and matched-controls. Assessing IL-1 pathway, we found an increased expression of il1a, il1b, il1rap, il1r1, il18r1, and Il18bp on AOSD tissues when compared with controls. In IL-6 pathway, we found an increased expression of il6 and il6st/gp130 on AOSD synovial tissues whereas an increased expression of il6r was shown on the controls. Among genes involved in TNF pathway, tnf, traf1, traf2, tnfaip3 and tnfrsf1a resulted to be more expressed in AOSD synovial tissues than in controls. Finally, fth1 and ftl were more expressed in AOSD patients than controls, when we explored the iron uptake and transport pathway.

Conclusion:

A peculiar MRI pattern of joint involvement in AOSD was reported; the most common finding was the presence of synovitis, characterised by intermediate to high signal intensity on T2-fat-saturated weighted and STIR images. Bone erosions and bone oedema were also observed. This MRI pattern was associated with a hyper-activation of IL-1, IL-6, and TNF pathways together with a hyper-expression of ferritin genes on AOSD synovial tissues.

References:

[1]Giacomelli R, Ruscitti P, Shoenfeld Y. A comprehensive review on adult onset Still’s disease. J Autoimmun. 2018;93:24-36.

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

References:

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

Disclosure of Interests:

None declared.

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

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

Conclusion:

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

Disclosure of Interests:

None declared

POS1270 MUSCULOSKELETAL MANIFESTATIONS IN A COHORT OF 234 INFLAMMATORY BOWEL DISEASE PATIENTS

Background:

Musculoskeletal symptoms represent the most common extraintestinal manifestations of inflammatory bowel disease (IBD) and a major cause of impaired quality of life in these patients. Spondyloarthritis (SpA) is classically associated with IBD, but other rheumatic manifestations may occur.

Objectives:

To characterize musculoskeletal symptoms and rheumatic diseases in an IBD cohort.

Methods:

Retrospective monocentric descriptive study including all the patients with IBD consecutively reffered from Gastroenterology to the Rheumatology Department between January of 2013 and December 2020 in a tertiary university hospital. Demographic and clinical data and musculoskeletal symptoms were collected at the time of the first visit in the Rheumatology outpatient center and the rheumatic diseases diagnosed during the entire follow-up were registered.

Results:

A total of 234 patients were included, 136 (58.1%) females, 20 (8.5%) smokers. At the first Rheumatology consultation the mean age was 43.6 (±13.7) years and the mean IBD duration was 11.7 (±9.7) years. Concerning IBD: 172 (73.5%) had Crohn’s disease and 62 (26.5%) had ulcerative colitis; azathioprine (39.7%), infliximab (28.2%) and mesalazine (26.5%) were the most frequently used drugs; eleven patients (4.7%) were taking glucocorticoids and 106 (45.3%) had already been treated with glucocorticoids.

Regarding musculoskeletal symptoms: 76 (32.5%) patients had peripheral symptoms and 98 (41.9%) had axial symptoms (Table 1).

Table 1.

Characterization of peripheral and axial musculoskeletal symptoms in patients with Inflammatory Bowel Disease.

N (%)Peripheral symptomsNo158 (67.5%)Arthritis / “inflammatory” joint pain24 (10.3%)“Mixed” rhythm joint pain15 (6.4%)“Mechanical” joint pain29 (12.4%)Enthesopathy8 (3.4%)Axial symptomsNo136 (58.1%)“Inflammatory” back pain46 (19.7%)“Mixed” rhythm back pain35 (14.9%)“Mechanical” back pain17 (7.3%)Total234 (100%)

Twenty-six (11.1%) patients had radiographic sacroiliitis, 14 (6.0%) had sacroiliitis in computed tomography and 9 (3.8%) in magnetic resonance. Forty-four (18.8%) patients fulfilled Assessment of SpondyloArthritis international Society (ASAS) criteria for axial SpA and 5 (2.1%) for peripheral SpA. Also of note, 16 (6.8%) patients had a previous diagnosis of psoriasis and 5 (2.1%) had uveitis in the past.

Concerning other rheumatic diagnosis, we observed: osteoarthritis in 64 (27.3%), osteoporosis in 16 (6.9%), diffuse idiopathic skeletal hyperostosis in 6 (2.6%), systemic lupus erythematosus in 4 (1.7%), rotator cuff tendinopathy in 2 (0.9%), rheumatoid arthritis, gout, calcium pyrophosphate deposition disease, fibromyalgia, drug-induced lupus, osteitis condensans ilii, Dupuytren’s contracture and avascular necrosis of the femoral head in 1 (0.4%), each.

Conclusion:

Our results demonstrate a high prevalence of musculoskeletal symptoms and rheumatic diseases in patients with IBD. These diagnoses are not limited to the group of SpA and osteoporosis, emphasizing the importance of rheumatologists being alert to other rheumatic diagnoses in patients with IBD.

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

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

Conclusion:

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

Disclosure of Interests:

None declared.

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Table 1.

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

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

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

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

Conclusion:

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

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

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

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

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

Conclusion:

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

References:

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

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

References:

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

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

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

Results:

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

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

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

Conclusion:

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

References:

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

Disclosure of Interests:

None declared.

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

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

Table 1.

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

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

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

Conclusion:

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

Disclosure of Interests:

None declared

Health impact assessment in Portugal

HIA can act as a catalyst for intersectoral involvement and embody the concept of Health in All Policies and the whole-of-governance approach. The National Institute of Health (INSA), with technical support of WHO, designed an HIA capacity-building program, to develop technical skills and instruments for HIA implementation. As products of this Training Program, two policy dialogues were held with stakeholders from various sectors to discuss the difficulties, barriers and opportunities for HIA institutionalization in Portugal. The absence of a common glossary was point out. In fact, different sectors, namely Health and Environment, have different languages that are reflected in the approaches, planning and methods used, which can be competing instead of complementary. To overcome this issue, it was highlighted the need for an intersectoral committee to define a common strategy for HIA. Other suggestion was the creation of a technical unit in the Ministry of Health in order to assume the coordination and quality of the Public Health response in this subject. The experts also recognized the importance of the adoption of common guidelines including a glossary, the definition of dedicated structures, the studies' scale and level of depth, the resources and technical skills required and a set of tools to support the development of studies. As an opportunity, it was identified the transposition of the European Directive 2014/24/EU, which made mandatory that EIA must assess the significant effects of a project in 'population and human health'. This requisite implies intersectoral dialogue and strait work in order to respond to legal demands. In addition, the new Law on Health Bases (2019) determines that the approval of national legislative measures, with relevant impact in Health, must be preceded by previous studies. These elements constitute a new impulse and an opportunity for intersectoral dialogue and HIA implementation in Portugal.

SAT0435 SECUKINUMAB EFFICACY In PsA PATIENTS IS DEPENDENT ON PATIENTS’ BODY MASS INDEX

Background:

Psoriatic arthritis (PsA) is a chronic inflammatory arthritis burdened by a series of metabolic comorbidities. Among them, obesity is very common in PsA, with a prevalence of 27%, as confirmed by a recent Spanish work (1). Obesity in PsA has been associated with higher disease activity and a worse effectiveness of biologic treatment in PsA. This has been certainly proven for anti-TNF-α as demonstrated by different studies reporting, in obese patients, a reduced treatment response and adherence. In particular, results coming from DAN-BIO and ICE-BIO registries, (2) point out that obesity is a risk factor for anti-TNF withdrawal due to poor response. Although a recent multi-centric, retrospective study in Spain has shown that obese subjects with psoriasis have a poor therapeutic response to secukinumab, (3) no data are currently available for secukinumab in PsA obese patients.

Objectives:

Our studies focused on the relationship between BMI and clinical response to secukinumab in PsA.

Methods:

We, retrospectively, analysed clinical data of 100 patients with PsA (57% female, median age 53 (49.2-55 years)) satisfying CASPAR criteria (4) for PsA, afferent to our clinic, who were treated with secukinumab. Patients were divided into 2 groups based on BMI (BMI<25 normal weight and BMI≥25 overweight/obese).

Results:

In the normal weight group 75% were female, median age was 50.5 (41-54.6), median BMI was 22 (20.2-23.3) and median DAPSA was 19.19 (15.6-24.2). The features of the overweight/obese patients were similar to the normal weight group (48% were female, median age 54 (50-59), median BMI 29 (27.4-30.1) and median DAPSA 21.2 (19-24.4)). Clinical response to therapy, evaluated as the achievement of low disease activity or remission according to DAPSA, was recorded 6 months after starting treatment. After 6 months of treatment, the variation of the DAPSA was inversely related to BMI: overweight/obese patients had in fact a better response to secukinumab compared to normal weight patients. By using a correlation coefficient (SPSS), to analyze the degree of association between BMI and DAPSA, we observed that BMI and DAPSA are inversely related in our PsA patients (p=0.05). Interestingly, analysis of serum levels of IL-17 in 20 obese patients compared to 20 non-obese patients, showed significantly higher serum levels of IL-17 in the former (Figure 1), indicating IL-17 as a key cytokine driving inflammation in PsA obese patients.

Conclusion:

These are the first data about clinical response to secukinumab in obese PsA patients. Our results support the relevance of IL-17 in driving systemic inflammation in obese PsA patients, also providing evidence that obese patients may have a better response to secukinumab compared to non-obese patients. Interestingly, this effect was not

References:

[1]Rubén Queiro, Lorenzo A, Tejón P et al. Obesity in psoriatic arthritis. Comparative prevalence and associated factors. Medicine 2019 Jul;98(28):e16400

[2]Pil Højgaard, Glintborg B, Kristensen LE et al. The influence of obesity on response to tumour necrosis factor-a inhibitors in psoriatic arthritis:results from the DANBIO and ICEBIO registries. Rheumatology (Oxford). 2016 Dec;55(12):2191-2199

[3]Jaime Notario, Deza G, Vilarrasa E et al. Treatment of patients with plaque psoriasis with secukinumab in a real-life setting: a 52-weeks, multicenter, retrospective study in Spain. Journ of Derm Treat 2019 Aug;30(5):424-429

[4]Taylor W, Gladman D, Helliwell P et al. Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum. 2006 Aug;54(8):2665-73.

[5]Lluís Puig. Cardiometabolic Comorbidities in Psoriasis and Psoriatic Arthritis. Int J Mol Sci. 2017 Dec 25;19(1).

Disclosure of Interests:

Ilenia Pantano: None declared, DANIELA IACONO Speakers bureau: PFIZER, BRISTOL MAYERS SQUIBB, SANOFI, ENNIO GIULIO FAVALLI: None declared, GIUSEPPE SCALISE: None declared, Luisa Costa: None declared, Francesco Caso: None declared, Giuliana Guggino Grant/research support from: Pfizer, Celgene, Speakers bureau: Celgene, Sandoz, Pfizer, Raffaele Scarpa: None declared, francesco ciccia Grant/research support from: pfizer, novartis, roche, Consultant of: pfizer, novartis, lilly, abbvie, Speakers bureau: pfizer, novartis, lilly, abbvie

FRI0284 EFFECTIVENESS AND SAFETY OF SECUKINUMAB IN NAÏVE OR TNF-INHIBITORS FAILURE PSORIATIC ARTHRITIS PATIENTS IN REAL LIFE: A 24-MONTHS PROSPECTIVE MULTICENTER STUDY

Background:

Secukinumab (SEC) is a novel treatment for psoriatic arthritis (PsA),but data from real life are still missing.

Objectives:

1)to evaluate the effectiveness and safety of a wide cohort of PsA patients on SEC followed in 7 Italian rheumatologic centers for 24 months;2)to compare the features and disease activity indices of SEC-treated PsA patients subdivided in naïve biological drugs (group A) and in TNF-inhibitors (TNFi) failure patients (group B).

Methods:

Consecutive patients with moderate-severe PsA,who begun SEC treatment were evaluated prospectively.Data on disease characteristics,previous and ongoing treatments,comorbidities and duration of follow-up were collected.Disease activity,functional and clinimetric scores and biochemical values were recorded at baseline (t0),at 6 (t6),12 (t12),and 24 (t24) months.Anova (Kruskal Wallis) and generalized linear models were used to compare variables over time.Infections and adverse events were also collected.

Results:

PsA345patients [38.84% men;mean age 52.9 (11.27) years] were enrolled;mean treatment duration was 18.53 (9.97) years.SEC was prescribed as first line biologic treatment in 133 (38.55%) patients and as second or more line biological treatment in 212 (61.45%) patients. Enthesitis was present as a prominent manifestation in 61.44% of patients (Figure 1).In all population significant decrease in tender/swollen joints;Visual Analogue Scale of pain (VASp) and general health (VASgh);Psoriasis Area Severity Index (PASI);Leeds Enthesitis Index (LEI);number of dactylitis;Health Assessment Questionnaire modified for spondyloarthritis (HAQ-S);Bath Ankylosing Spondylitis Disease Activity Index (BASDAI);Bath Ankylosing Spondylitis Functional Index (BASFI);C-reactive protein (CRP) was achieved.Effectiveness of all PsA patients was associated to an improvement in Ankylosing Spondylitis disease activity score (ASDAS) [t0=3.45 (0.69) vs t24=1.48 (0.23);p<0.01] and in Disease Activity in PsA (DAPSA) [t0=29.52 (12.56) vs t24=11.41 (7.63);p<0.001].At t0group Bhad a more erosive (p=0.04) and polyarticular pattern (p=0.04),a longer disease duration (p=0.001),a greater prevalence (p=0.04) of psoriasis and dactylitis (p=0.01),a higher PASI score (p=0.01),while no significant difference was observed for uveitis,inflammatory bowel diseases,enthesitis.At t24group Ashowed better physical functioning and lower disease activity compared togroup B[HAQs A vs B=0.03 (0.16) vs 0.69 (0.73);BASDAI A vs B=2.37 (0.66) vs 4.27 (2.33);ASDAS A vs B=1.4 (0.62) vs 1.99 (0.86);CRP A vs B=2.03 (1.94) vs 3.11 (1.55) mg/L;DAPSA A vs B=7.03 (3.57) vs 12.41 (8.05)].After t24 of treatment 74.6% ofGroup Aand 72.8% ofGroup Barticular had an inactive\low disease activity (MDA),accordingly to ASDAS and DAPSA respectively.Forty-three patients (12.46%) stopped the treatment during the follow-up mainly because of primary or secondary loss of efficacy (29 and 24, respectively).Only 14 patients suspended SEC because of adverse events (of which 9 for reactions at site of injection).A low number of episodes of mild infections (16) occurred;SEC was instead permanently discontinued in 7 cases for:oral refractory mucositis (3);recurrent aphthosis (2);diverticulitis (2).The retention rate at t24 was good in the whole population.Interestingly no differences were found betweenGroup AandB(p=0.815).

Conclusion:

In a real life clinical setting,SEC was safe and effective in PsA. as shown by a significant decrease of DAPSA and ASDAS over a 24-months follow up.

Disclosure of Interests:

Mariagrazia Lorenzin: None declared, Antonio Carletto: None declared, Rosario Foti Consultant of: lilly, sanofi, MSD, Janssen, Abbvie, BMS, celgene, roche, Speakers bureau: lilly, sanofi, MSD, Janssen, Abbvie, BMS, celgene, roche, Maria Sole Chimenti: None declared, Angelo Semeraro: None declared, Luisa Costa: None declared, Leonardo Santo: None declared, Elena Fracassi: None declared, Ilaria Montanari: None declared, Mara Felicetti: None declared, Giulia Lavinia Fonti: None declared, Francesco Caso: None declared, Andrea Doria Consultant of: GSK, Pfizer, Abbvie, Novartis, Ely Lilly, Speakers bureau: UCB pharma, GSK, Pfizer, Janssen, Abbvie, Novartis, Ely Lilly, BMS, Augusta Ortolan: None declared, Roberta Ramonda Speakers bureau: Novartis, Celgene, Janssen, Pfizer, Abbvie, Lilly