[Is complete immunity against measles a realistic target for patients with rheumatic diseases and how can it possibly be achieved?]

Measles outbreaks occur rather frequently in Germany. Patients with chronic inflammatory diseases are often treated with immunosuppressants. A recent study showed that about 7% of such patients are not protected against measles according to the lack of documentation in the vaccination card or the absence of protective antibodies. The Standing Committee on Immunization (STIKO) recommends a first vaccination against measles as a measles-mumps-rubella combined vaccination (MMR) in children aged 11-14 months and a second vaccination at 14-23 months. For adults born after 1970, vaccination against measles is recommended if they have not yet been vaccinated against measles or have only been vaccinated once against measles or if their vaccination status is unclear. In April 2019, STIKO published instructions for vaccinations recommended for immunodeficiency. Since March 1, 2020, measles vaccination have been compulsory in Germany.

Characteristics of the Diffuse Astrophysical Electron and Tau Neutrino Flux with Six Years of IceCube High Energy Cascade Data

We report on the first measurement of the astrophysical neutrino flux using particle showers (cascades) in IceCube data from 2010-2015. Assuming standard oscillations, the astrophysical neutrinos in this dedicated cascade sample are dominated (∼90%) by electron and tau flavors. The flux, observed in the sensitive energy range from 16 TeV to 2.6 PeV, is consistent with a single power-law model as expected from Fermi-type acceleration of high energy particles at astrophysical sources. We find the flux spectral index to be γ=2.53±0.07 and a flux normalization for each neutrino flavor of ϕ_{astro}=1.66_{-0.27}^{+0.25} at E_{0}=100  TeV, in agreement with IceCube's complementary muon neutrino results and with all-neutrino flavor fit results. In the measured energy range we reject spectral indices γ≤2.28 at ≥3σ significance level. Because of high neutrino energy resolution and low atmospheric neutrino backgrounds, this analysis provides the most detailed characterization of the neutrino flux at energies below ∼100  TeV compared to previous IceCube results. Results from fits assuming more complex neutrino flux models suggest a flux softening at high energies and a flux hardening at low energies (p value ≥0.06). The sizable and smooth flux measured below ∼100  TeV remains a puzzle. In order to not violate the isotropic diffuse gamma-ray background as measured by the Fermi Large Area Telescope, it suggests the existence of astrophysical neutrino sources characterized by dense environments which are opaque to gamma rays.

[How well are patients with inflammatory rheumatic diseases protected against measles?]

Hintergrund

Patienten mit entzündlich rheumatischen Erkrankungen haben aufgrund ihrer Autoimmunerkrankung, aber auch bedingt durch die immunsuppressive Medikation ein erhöhtes Infektrisiko. Obwohl Impfungen in der Primärprophylaxe von Infektionen bekanntermaßen effektiv sind, ist die Impfrate in Deutschland generell zu niedrig. Wegen des zuletzt zunehmenden, teils epidemieartigen Auftretens von Masern ist die Lebendimpfung gegen Masern in Deutschland seit Kurzem gesetzlich vorgeschrieben.

Fragestellung

Wie viele Patienten mit entzündlich rheumatischen Erkrankungen sind aktuell ausreichend gegen Masern geschützt?

Methode

Patienten mit entzündlich rheumatischen Erkrankungen des Rheumazentrums Ruhrgebiet wurden zwischen Dezember 2017 und Oktober 2018 prospektiv und konsekutiv eingeschlossen. Dabei wurden Daten zu Erkrankung und Therapie auf Ebene von Substanzklassen sowie die Impf- und Infektanamnese erhoben. Alle Angaben zu Impfungen wurden im Impfpass kontrolliert. Antikörpertiter gegen Masern wurden mit ELISA bestimmt. Als Schwellenwert für einen ausreichenden Schutz gegen Masern wurden 150 mIU/ml festgelegt.

Ergebnis

Von 975 Patienten konnten 540 (55,4 %) einen Impfausweis vorlegen. Bei 201 Patienten mit Ausweis (37,2 %) lagen dokumentierte Impfungen seit Geburt vor. Insgesamt hatten 45 von 267 nach 1970 geborene Patienten (16,9 %) einen suffizienten Impfschutz gegen Masern. Die anamnestischen Angaben zu einer Masernerkrankung in der Kindheit differenzierten nicht zwischen Patienten mit und ohne protektiven Masern-IgG-Antikörpern. Protektive Masern-IgG-Antikörper wurden bei 901 Patienten von 928 Patienten mit Messung der Masern-IgG-Antikörperspiegel (97,1 %) nachgewiesen. Die unterschiedlichen Wirkprinzipien der aktuellen immunsuppressiven Therapie hatten darauf keinen Einfluss.

Diskussion

Diese Daten zeigen, dass mindestens 2,9 % der Patienten keinen ausreichenden Schutz gegen Masern haben. Interessanterweise hatte die Mehrheit der nach 1970 geborenen Patienten protektive Antikörper trotz fehlenden Impfschutzes gegen Masern. Die Anstrengungen sowohl im primär- als auch im fachärztlichen Bereich sollten dringend verstärkt werden, um eine adäquate Infektionsprophylaxe bei besonders gefährdeten Patienten gewährleisten zu können.

[Delegation of medical tasks in rheumatology]

Modern rheumatology enables better and earlier diagnosis and therapy of inflammatory rheumatic system diseases. At the same time, the requirements for the care of rheumatologic patients have risen considerably for non-medical assistant professions and specialists for nursing professions. Since 2006 there has been established an education curriculum "Rheumatological Specialist Assistant DGRh-BDRh" (RFA) with the training to become a "Rheumatological Specialist Assistant (DGRh-BDRh)". In Europe and in parallel in Germany, assistant professions are increasingly involved in the early detection and care of patients with rheumatic diseases and entrusted with tasks.In this work, the overarching principles for delegation of medical tasks to RFA and recommendations for the delegation are published by the Commission for Delegation of the German Society for Rheumatology (DGRh). These recommendations are based on the requirements of the German Medical Association and have been legally evaluated. With the extension of the training of the RFA board certification is aimed for "MFA for Rheumatology". These recommendations enable more transparency and security for delegating doctors and the delegated RFA's.

[Is it possible to delegate medical services to qualified nurses specialized in rheumatology when evaluating patients with suspicion of ankylosing spondylitis?-Results of the PredAS study]

Hintergrund

Der oft langsame Beginn einer axialen Spondyloarthritis (axSpA), die initial zum Teil wenig spezifischen Symptome (Rückenschmerzen), aber auch begrenzte Ressourcen und die damit verbundenen Verzögerungen in der rheumatologischen Versorgung sind Faktoren, die zu verspäteter Diagnose und Therapie dieser meist jungen Patienten mit beitragen. Rheumatologische Fachassistenten (RFA) können zur Verbesserung der Versorgung beitragen, indem sie vom Rheumatologen delegierte ärztliche Leistungen übernehmen.

Ziel der Arbeit

Ziel ist, zu untersuchen, ob geschulte RFA bei Patienten mit chronischem Rückenschmerz und noch unklarer Diagnose mithilfe eines strukturierten Fragebogens anamnestische und klinische Befunde wie Rheumatologen erheben können.

Material und Methoden

In der multizentrisch durchgeführten PredAS-Studie wurden bei Patienten mit dem Leitsymptom chronischer Rückenschmerz demografische Basisdaten, Anamnese und patientenberichtete Endpunkte mittels strukturierter Fragebögen von RFA und Rheumatologen unabhängig voneinander erfasst. Zudem wurden Funktion (BASFI) und Wirbelsäulenbeweglichkeit (BASMI) standardisiert gemessen. Um die mögliche Erleichterung durch Nutzung digitaler Medien zu testen, wurden 2 Patientengruppen getrennt untersucht: Die Ergebnisse der einen Kohorte wurden mittels papierbasierter Case Report Forms (CRF) und die Ergebnisse der anderen elektronisch mittels iPad dokumentiert. Die Konkordanz der Dokumentationen zwischen RFA und Rheumatologen wurde als Kappa-Koeffizient, als prozentuale Übereinstimmung und auf individueller Patientenebene berechnet.

Ergebnisse

Bei fast drei Viertel der 141 Patienten mit chronischen Rückenschmerzen wurden Charakteristika des entzündlichen Rückenschmerzes identifiziert. Die Konkordanz bei Dokumentation durch RFA und Arzt war bei den anamnestischen Angaben zum Rückenschmerz höher als bei der Angabe zur Lokalisation des Rückenschmerzes. Bei der Erhebung des BASMI zeigte sich kein Unterschied zwischen RFA und Arzt (ICC 0,925) (95 %-CI 0,879–0,953). Der Zeitaufwand für die strukturierte Dokumentation betrug beim Arzt 20 ± 6,7 min und bei der RFA 28,5 ± 13 min.

Diskussion

Die Ergebnisse sprechen dafür, dass geschulte RFA die Rheumatologen bei der anamnestischen Aufarbeitung und ersten körperlichen Untersuchung im Rahmen der Diagnosestellung erheblich und qualifiziert unterstützen können.

OP0086 THE DEGREE OF BONE MARROW EDEMA AS DETECTED BY MAGNETIC RESONANCE IMAGING IN THE SACROILIAC JOINTS AND THE SPINE SUSPICIOUS OF AXIAL SPONDYLOARTHRITIS IN THE GENERAL POPULATION IS ASSOCIATED WITH DIFFERENT FACTORS

Background:

Taking advantage of a large population-based study we have recently reported that the frequency of bone marrow edema (BME) and fatty lesions (FL) in the sacroiliac joints (SIJ) and the spine of individuals <45 years detected by magnetic resonance imaging (MRI) suggestive of axial spondyloathritis (axSpA) is higher than expected.

Objectives:

To identify and compare factors associated with the extension of MRI lesions in the spine and the SIJ in the general population.

Methods:

All available spinal- (sagittal T1/T2 sequences) and SIJ- (semicoronal STIR sequences) MRIs were evaluated by two trained readers blinded to clinical data. BME (SIJ and spine) suggestive of axSpA were recorded. The extension of BME was quantified using the Berlin MRI score. Discrepancies were resolved by consensus. Degenerative lesions of the Modic type were excluded. The association of age (increase per decade), sex, HLA-B27 and hsCRP positivity, smoking (ever smoker vs. no smoker), spinal pain (yes vs. no in last 3 months), body mass index (BMI) categories (WHO definition), physically demanding job, and giving birth within the last 12 month with the severity of BME were examined. Associations between clinical factors and the Berlin MRI score were analyzed by negative binomial regression models resulting in incidence rate ratios (IRRs).

Results:

MRIs of 793 volunteers from the general population, mean age 37.3±6.3 years, 49.4% male, 8.9% HLA B27+, 7% CRP-positive, 56.9% with back pain in the last 3 months (28.8% with back pain NRS ≥4/10), 35.7% reported physically heavy work, 55% with BMI > 25 kg/m2, 16.2% current smokers, and 5% of females with pregnancy in the last year before MRI examination, were evaluated.

For BME on SIJ-MRIs, significant associations (IRR, 95% confidence level) were found for pregnancy in the last year (3.82, 1.17-14.24), HLA-B27+ (2.42, 1.33-4.55), BMI (25-30 vs. <25; 2.09 (1.33-3.31)) and presence of back pain in the last 3 months (1.54, 1.02-2.33).

For BME on spinal MRIs, significant associations were found for age per decade increase (1.45, 1.10-1.91) and physically demanding work (1.45, 1.04-2.00), while HLA-B27+ (1.32, 0.79-2.24), BMI (>30: 0.84, 0.53-1.32 (<25 reference)) and back pain in the last 3 months (1.29, 0.95-1.77) showed no association. Overall, spinal BME was more frequent than SIJ BME in the participants working at a desktop (61.5% vs. 54.4%), while smokers (66.9% vs. 63.8%) and participants with back pain in the last 3 months (62.5% vs. 56.9%) had more often SIJ BME than spinal BME, respectively.

Conclusion:

In this population-based study, individuals aged <45 years, HLA-B27+, women with pregnancy in the last year and presence of back pain were associated with the extent of BME in the SIJ, while age and physically demanding work were associated with the extent of BME in the spine. These data support the hypothesis of a mechanic origin of BME in the general population aged <45 years, while HLA B27 is a severity but not a susceptibility factor for BME in the SIJ.

Acknowledgments:

n/a

Disclosure of Interests:

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, Adrian Richter: None declared, Daniel Feldmann: None declared, Anne Ott: None declared, Robin Buelow: None declared, Carsten Schmidt: None declared, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma

AB0824 WHICH PARAMETERS ARE RELEVANT IN THE IDENTIFYING AXIAL INVOLVEMENT IN PSORIATIC ARTHRITIS? – RESULTS OF A SURVEY AMONG ASAS AND GRAPPA MEMBERS

Background:

Inflammatory involvement of the axial skeleton (sacroiliac joints and / or spine) is one of the relatively frequent musculoskeletal manifestations associated with psoriasis / psoriatic arthritis (PsA). There is an urgent need for an evidence-based definition for axial involvement in PsA that would identify a subgroup of patients within the heterogeneous PsA population to conduct observational, interventional and translational studies. ASAS and GRAPPA embarked on a collaborative initiative to develop a definition of axial involvement in PsA.

Objectives:

To perform a survey to identify variables relevant in the identification of the presence of axial involvement in PsA among members of ASAS and GRAPPA.

Methods:

The online survey utilized thePAPRIKAmethodology (PotentiallyAllPairwiseRanKings of all possibleAlternatives) that determines decision-makers’ part-worth utilities representing the relative importance of the attributes. Participants were exposed to number of clinical scenarios and were prompted to decide which of the scenarios is more compatible with axial involvement in PsA unless they are equal (Figure). The constant stem of each scenario was “a patient diagnosed with psoriatic arthritis fulfilling the CASPAR criteria”; the variable part included 13 common spondyloarthritis variables (Table). Variables were ranked according to their relative importance.

Results:

The survey was completed by 186 ASAS/GRAPPA members (63 ASAS only, 80 GRAPPA only, and 43 both societies). The ranking of the variables is presented inTable. The highest ranked parameters indicative of axial involvement in a patient with PsA were presence of typical radiographic or MRI changes in the sacroiliac joints and/or spine followed by the presence of chronic back pain and then inflammatory back pain. A separate analysis of ASAS and GRAPPA members provided the similar results concerning the relevance of the variables.

Conclusion:

Objective signs of inflammatory involvement of the axial skeleton are the most important indicators of axial disease in PsA in the opinion of the experts. A prospective cohort study is currently being planned to address the value of these and other variables in defining axial involvement in PsA.

Table.

Ranking of the parameters relevant to deciding on the presence of axial involvement in a PsA patient in the opinion of ASAS and GRAPPA members (n=186).

NParametersMedian rankMean rank1Presence of structural damage on an X-ray of SIJ22.82Presence of structural damage on an X-ray of spine3.54.13Presence of subchondral BME / osteitis on MRI of SIJ compatible with SpA44.54Presence of BME / osteitis on MRI of spine compatible with SpA455History or current presence of back pain5.55.86History of or current presence of inflammatory back pain5.567Good response of back pain to non-steroidal anti-inflammatory drugs87.88HLA-B2788.19Family history for SpA9.5910Elevated C-reactive protein109.311Presence of peripheral arthritis and/or enthesitis and/or dactylitis109.412Presence of anterior uveitis109.513Presence of inflammatory bowel disease109.6

BME=bone marrow edema, MRI=magnetic resonance imaging, SIJ=sacroiliac joints, SpA=spondyloarthritis

Disclosure of Interests:

Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Philip J Mease Grant/research support from: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – grant/research support, Consultant of: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – consultant, Speakers bureau: Abbott, Amgen, Biogen Idec, BMS, Eli Lilly, Genentech, Janssen, Pfizer, UCB – speakers bureau, Filip van den Bosch Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Speakers bureau: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Alice Gottlieb Grant/research support from: Boehringer Ingelheim, Incyte, Janssen, Novartis, UCB, Xbiotech, Consultant of: AbbVie, Allergan, Avotres Therapeutics, Beiersdorf, Boehringer Ingelheim, BMS, Celgene, Dermira, Incyte, Eli Lilly, Janssen, LEO Pharma, Novartis, Reddy Labs, Sun Pharmaceutical Industries, UCB, Valeant, Xbiotech, Laura C Coates: None declared, Vinod Chandran Grant/research support from: Abbvie, Celgene, Consultant of: Abbvie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lily, Janssen, Novartis, Pfizer, UCB, Employee of: Spouse employed by Eli Lily, Philip Helliwell: None declared, Deepak Jadon: None declared, Joachim Sieper Consultant of: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Speakers bureau: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, 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, Dafna D Gladman Grant/research support from: AbbVie, Amgen Inc., BMS, Celgene Corporation, Janssen, Novartis, Pfizer, UCB – grant/research support, Consultant of: AbbVie, Amgen Inc., BMS, Celgene Corporation, Janssen, Novartis, Pfizer, UCB – consultant

SAT0391 DEPRESSIVE SYMPTOMS ARE ASSOCIATED WITH HIGHER DISEASE ACTIVITY AND WORSE FUNCTIONAL STATUS IN AXSPA: A CROSS-SECTIONAL ANALYSIS FROM RABBIT-SPA

Background:

Axial spondyloarthritis (axSpA) is a potentially severe chronic inflammatory disease with impact on function and quality of life. About 20-30% of axSpA patients show symptoms of depression or are diagnosed with depression [1]. Depression may influence outcome, especially patient reported outcomes.

Objectives:

To assess differences in baseline characteristics and outcome parameters between patients with and without symptoms of depression using WHO-5 score.

Methods:

RABBIT-SpA is a prospective longitudinal cohort study including axSpA patients enrolled at start of a new conventional treatment (including NSAID) or bDMARD. WHO-5 score was used to identify depressive symptoms categorised into 3 groups using validated cut-offs: moderate to severe depressive symptoms <=28, mild depressive symptoms 29-50, good well-being >50. Baseline values of patients categorised as having moderate to severe depressive symptoms were compared with the rest of the patients using t-test. Spearman correlation coefficient was calculated to analyse the relationship between WHO-5 score and other outcome parameters.

Results:

A total of 848 axSpA patients were included in this analysis (table 1). Moderate to severe depressive symptoms were found in 221 patients (30%), 226 (31%) had mild depressive symptoms and 285 (39%) reported a good well-being. Percentages of patients with inflammatory back pain, peripheral arthritis or enthesitis as well as the number of affected joints (44 JC) and entheseal sites (using SPARCC) were higher in the group of patients with moderate to severe depressive symptoms.

Table 1.ParameterWHO-5 (<=28)Moderate severeN=221WHO-5 (29-50/>50)Mild/well-beingN=511Age, mean43.844.1Female, n (%)100 (45.2)229 (44.8)Disease duration, years, mean6.86.5Inflammatory back pain, n (%)195 (88.6)416 (81.6)Enthesitis, n (%)49 (22.3)78 (15.4)Peripheral arthritis (44 JC), n (%)64 (29.1)134 (26.3)Uveitis, n (%)45 (20.4)76 (15)IBD, n (%)13 (5.9)31 (6.1)Psoriasis, n (%)35 (15.8)58 (11.4)CRP positive (≥5mg/l), n (%)115 (59)243 (55.1)HLA-B27, n (%)151 (72.6)354 (74.2)BMI≥30, n (%)66 (30)117 (23.6)Comorbidities ≥3, n (%)50 (22.6)89 (17.4)Current smoking, n (%)102 (47.2)185 (36.7)

All analysed outcome parameters (e.g. ASDAS, ASAS-HI, BASDAI, BASFI, patient global, physician global, pain, sleep) were significantly worse in the group of patients with moderate to severe depressive symptoms versus the other patients (table 2). This includes physician-reported, patient-reported and composite scores.

Table 2.ParameterWHO-5 (<=28)Moderate severeN=221WHO-5 (29-50/>50)Mild/well-beingN=511p-valuePhysGA (NRS 0-10)6.2 (1.6)5.4 (1.9)0.0001ASDAS6.1 (1.6)4.2 (1.8)0.0001BASDAI (NRS 0-10)3.5 (0.8)2.9 (0.9)0.0001BASFI (NRS 0-10)5.5 (2.2)3.2 (2.2)0.0001ASAS-HI (0-17)9.8 (3.1)5.8 (3.1)0.0001PatGA (NRS 0-10)7 (1.8)5.4 (2.3)0.0001PatPain (NRS 0-10)6.9 (1.9)5.2 (2.3)0.0001PatSleep (NRS 0-10)7.2 (2.4)4.6 (2.9)0.0001

Results are presented as mean ± SD.

WHO-5 was highly correlated with all outcome parameters regardless of gender. Figure 1 shows the correlation of BASDAI and WHO-5 stratified for gender.

Figure 1.

Conclusion:

Almost one third (30%) of axSpA patients in this analysis reported scores indicative of depressive symptoms and depression. The strong correlation of WHO-5 scores with patient and physician reported outcomes may be relevant for the management of patients with axSpA.

References:

[1]Redeker I, et al. Ann Rheum Dis 2018;0:1–8. doi:10.1136

Acknowledgments:

RABBIT-SpA is supported by a joint, unconditional grant from AbbVie, Amgen, Janssen-Cilag, Lilly, MSD, Mylan, Novartis, Pfizer, and UCB.

Disclosure of Interests:

Anne Regierer Speakers bureau: Novartis, Celgene, Janssen-Cilag, Anja Weiß: 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, Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Ilka Schwarze: None declared, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Joachim Sieper Consultant of: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Speakers bureau: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Angela Zink Speakers bureau: AbbVie, Amgen, BMS, Gilead, Hexal, Janssen, Lilly, MSD, Pfizer, Roche, Sanofi Aventis, UCB, Anja Strangfeld Speakers bureau: AbbVie, BMS, Pfizer, Roche, Sanofi-Aventis

SAT0365 EFFECTS OF ANTI-TNF-THERAPY ON OSTEOBLASTIC ACTIVITY IN ANKYLOSING SPONDYLITIS – RESULTS FROM A PROSPECTIVE STUDY USING PET-MRI OF SIJ AND SPINE

Background:

The clinical efficacy of tumor necrosis factor inhibitors (TNFi) in patients with axial spondyloarthritis (axSpA) is well established but its effect on new bone formation is still unclear (1). Positron emission tomography (PET) using bone-seeking18F-Fluoride [18F]F in combination with magnetic resonance imaging ([18F]F /MRI) has been shown to depict not only bone marrow edema (BME) but also shows the quantity of tracer uptake in the late phase of perfusion suggestive of remodeling and osteoblastic activity, not only in radiographic axSpA (r-axSpA) (2).

Objectives:

Assess the effect of TNFi on bone remodeling processes in the axial skeleton of r-axSpA patients using [18F]F/MRI prior (baseline, BL) and 4 months after (follow-up, FU) treatment.

Methods:

Patients (11 male, 5 female, mean age 38.6±12.0 years) with clinically active r-axSpA (BASDAI>4, failure of NSAIDs, no previous biologics) prospectively underwent 3-Tesla and [18F]F PET/MRI (40 minutes after injection of a mean activity of 157 MBq [18F]F). Images of the SIJ (n=16 patients) and the whole spine (n=10 patients) were performed at BL and FU. Three readers (1 for [18F]F/MRI and 2 for conventional MRI) evaluated all images independently and blinded to timepoint allocation. Only lesions on which all readers agreed on were used for further analyses. Inflammation (bone marrow edema, BME), structural lesions (fat deposition (FD), sclerosis, erosions and ankylosis) and focal [18F]F uptake were recorded on the level of SIJ (SIJ-Q) and vertebral quadrants (V-Q), with each SIJ or vertebral body consisting of 4 VQs (superior and inferior sacral and iliac for the SIJ, and superior and inferior, anterior and posterior for the vertebral bodies).

Results:

A total of 128 SIJ-Q and 920 VQs were analyzed at both BL and FU. In the SIJs, 75 (58.6%), 120 (93.8%), 69 (53.9%), 99 (77.3%) and 16 (12.5%) SIJ-Q showed BME, FD, sclerosis, erosions and ankylosis, while 111 (86.7%) SIJ-Q showed focal [18F]F-uptake at BL. Association with increased [18F]F-uptake was found most frequently in SIJ-Q with BME (70/75 SIJ-Q, 93.3%), sclerosis (65/69 SIJ-Q, 94.2%) and FD (105/120 SIJ-Q, 87.5%). At FU, 37 SIJ-Q still showed BME (improvement by 50.7%), while almost no changes were observed in chronic lesions. In comparison, improvement of focal [18F]F-uptake was found in all lesion combinations, with improvement of focal [18F]F-lesions associated with BME by 62.9%, with sclerosis by 33.8% and with FD by 22.9% of SIJ-Q.

In the spine, only 41 (4.5%), 61 (6.6%), 14 (1.5%) V-Q showed BME, FD and sclerosis, respectively, while 77 V-Q (8.4%) showed focal [18F]F-uptake. An association to increased [18F]F-uptake was found most frequently with sclerosis (7/14 V-Q, 50%) and FD (25/61 V-Q, 41%). At FU, 12 V-Q still showed BME (improvement by 70.7%), while, similar to SIJ, almost no changes were observed in the chronic lesions. The largest improvement was found in focal [18F]F-lesions associated with BME 81.8% and with FD by 22.9% of V-Q.

Conclusion:

In this first prospective study on whole spine and SIJ [18F]F/MRI in patients with r-axSpA, a significant decrease of osteoblastic activity was observed over 4 months of continuous anti-TNF treatment. The effect of treatment was observed not only at sites with inflammatory lesions (BME) but also at sites with pre-existing chronic structural lesions, while some osteoblastic activity remained visible at 4 months. These data support a short-term effect of anti-TNF treatment on osteoblastic activity, while the long-term effects need to be further studied.

References:

[1]Van der Heijde D et al, Ann Rheum Dis 2017

[2]Buchbender C et al, J Rheumatol 2015

This work was supported by an unrestricted Grant by MSD GmbH, Germany

Disclosure of Interests:

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, Styliani Tsiami: None declared, Christoph Rischpler: None declared, Nils-Martin Bruckmann: None declared, Wolfgang Fendler: None declared, Julian Kirchner: None declared, Ken Hermann: None declared, Lino Sawicki: None declared, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma

AB1144 DAILY CLINICAL CARE OF PATIENTS WITH MUSCULOSKELETAL COMPLAINTS – HOW HELPFUL IS A TRIAGE SYSTEM FOR EARLY RECOGNITION OF INFLAMMATORY RHEUMATIC DISEASES?

Background:

Early diagnosis and treatment are important for the management of inflammatory rheumatic diseases (RMD). However, the availability of rheumatologists is limited in most European countries and selection strategies lack sensitivity and/or specificity.

Objectives:

To evaluate a triage strategy that offers the possibility to see patients within 4 weeks for short term appointments in order to check the probability of an inflammatory RMD and the necessity to further evaluate the patients in due time.

Methods:

Physician’s and patient’s information who called our tertiary rheumatology department´s outpatient clinic for a date in the triage system were included in this analysis. The time to first appointment as assessed by a nurse (Step 1), the short evaluation by a rheumatologist in the triage (Step 2) and the patient´s complaints and the diagnoses after an extensive diagnostic evaluation (Step 3) were documented.

Results:

In a period of 9 months in 2018, a total of 982 patients presented. A total of 62 patients (6.3%) were considered urgent (appointment within 3 days), while 240 (24.4%) were appointed within 4 weeks at Step 2. Of the former 46 (19.2%), and of the latter 151 patients (62.9%) were diagnosed with inflammatory RMD at Step 3.

In total, 334 patients (34.0%) were diagnosed with inflammatory RMD at Step 3, including 126 with RA (37.7%), 71 with axSpA/PsA (21.3%), 95 with connective tissue disease/vasculitis (28.4%) and 20 with gout (6.0%). The diagnosis suspected in Step 2 was confirmed in Step 3 in 77.9% of cases. In 217 patients, the diagnosis suspected in Step 2 was not confirmed in Step 3. Of them, 34 (15.7%) had unclear findings at Step 2 but an inflammatory RMD was found at Step 3, while 148 (68.2%) had a suspected inflammatory RMD at Step 2 but this was not confirmed at Step 3.

The most frequent musculoskeletal complaint at the time point of referral was pain in small peripheral joints (hands and/or feet) in 858 patients (87.4%), in large peripheral joints (knees, shoulders and/or hips) in 780 patients (79.4%) and back pain in 682 patients (69.5%). Fever, night sweats and unclear weight loss was reported by 50 patients (5.1%), while 210 patients (24.5%) presented with findings suspicious of inflammatory RMD such as elevated CRP of unclear origin, and 43 patients (4.8%) because of a threat of organ damage such as unclear elevation of creatinine, as reported by the referring physician. In addition, 167 patients (17.0%) had received glucocorticoids prior to referral, 87 (52.1%) of which finally did not receive the diagnosis of inflammatory RMD at Step 3, while 737 patients (75.1%) were receiving NSAIDs prior to referral.

Conclusion:

In this prospective evaluation of a triage system where all patients were pre-screened by a nurse and were seen within 4 weeks by a rheumatologist, clinical differentiation could be performed timely due to a successfully structured triage system. The initially suspected diagnosis was finally confirmed in ≥75% of cases, while ≥1/3 of patients had a definite inflammatory RMD.

This work was supported by an unrestricted Grant from Abbvie

Disclosure of Interests:

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, Imke Redeker: None declared, Maria Zacharopoulou: None declared, Styliani Tsiami: None declared, Konstantia Tsiaousi: None declared, Doris Morzeck: None declared, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma

SAT0579 SYSTEMATIC GERIATRIC ASSESSMENT IN OLDER PATIENTS WITH RHEUMATIC DISEASES - THE RheuMAGIC PILOT STUDY

Background:

Current demographic data predict that the number of older adults with rheumatic diseases will considerably increase in the coming years. Geriatric patients differ from younger adults in many ways including their clinical presentation, co-morbidities and response to medication. The management of such patients is often challenging due to the presence of multi-morbidity, polypharmacy and geriatric syndromes (i.e. conditions in which symptoms result from impairments in multiple systems rather than a discrete disease). To systematically assess geriatric patients, specific tools have been developed; however, they are not routinely utilized by rheumatologists. Using these tools could improve patient management and satisfaction in rheumatologic care.

Objectives:

To examine the prevalence of 17 common geriatric health problems using validated geriatric assessment tools in older patients with rheumatic and musculoskeletal diseases.

Methods:

Adults 65 years and older who presented to a tertiary rheumatologic hospital were included after informed consent. All patients recruited were assessed using theMAngableGeriatrICAssessment (MAGIC) which addresses 14 common geriatric health problems. In addition, polypharmacy (≥ 5 medication), muscle function using the Short Physical Performance Battery and frailty applying the Fried definition were assessed. Disability was quantified with the “Funktionsfragebogen Hannover” (FFbH), a validated tool for patients with rheumatologic diseases that can be easily converted to Health Assessment Questionnaire (HAQ) scores. Primary outcome was the frequency of the selected 17 geriatric health problems; the correlation of the total number of problems with HAQ scores was a secondary outcome.

Results:

Of the 300 individuals included 67% were female with a mean age of 73±6.6 years; 85% (> 50% with rheumatoid arthritis) had a rheumatologic diagnosis. The remaining participants had either a chronic pain syndrome or degenerative joint/spine disease. On average participants had 7 out of 17 assessed geriatric problems. Females had more such problems than males (8 vs. 6, p<0.0001). Chronic pain and polypharmacy were most common but several others were also seen in more than 50% of patients (see Table). The mean HAQ Score was 1.67±0.79. There was a positive correlation (see Graph) between the number of problems and the HAQ Score (R2= 0.44, p<0.0001).

Conclusion:

A systematic geriatric assessment can be successfully used to discover and quantify geriatric health problems in older patients with rheumatic and musculoskeletal diseases. These problems appear to be very common and importantly, patients with more problems had poorer functional status. Frailty, depression, incomplete vaccination status, cognitive impairment or polypharmacy are all known to negatively impact patient care. Recognizing and addressing geriatric problems has the potential to lead to health care improvements including adherence and medication side effects and might increase patient satisfaction and functional status independent of disease activity.

References:

[1]Buehring, B. and S. Barczi, Assessing the Aging Patient, in Spine Surgery in an Aging Population, N. Brooks and A. Strayer, Editors. 2019, Thieme: New York. p. 208.

[2]Cleutjens F, Boonen A, van Onna MGB. Geriatric syndromes in patients with rheumatoid arthritis: a literature overview. Clin Exp Rheumatol 2019;37(3):496-501

Geriatric Problem% presentProblems with Daily Activities67Problems with Vision28Problems with Hearing38Problems with Falls11Problems with Urinary Incontinence38Problems with Depression57Lack of Social Support10Incomplete Vaccinations53Problems with Cognition31Problems with Chronic Pain90Problems with Dizziness44Problems with Mobility41Problems with Unintentional Weight Loss30Inappropriate Medications present17Polypharmacy present81Frailty present46Short Physical Performance Battery low57

Acknowledgments:

None

Disclosure of Interests:

Anna Berrisch: None declared, Ioana Andreica: None declared, Styliani Tsiami: None declared, David Kiefer Grant/research support from: Novartis, Uta Kiltz Grant/research support from: AbbVie, Amgen, Biogen, Novartis, Pfizer, Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer, Roche, UCB, 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, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Bjoern Buehring Grant/research support from: GE/Lunar, Kinemed, Consultant of: Gilead, Abbvie, Lilly, GE/Lunar, Janssen, Amgen, Speakers bureau: UCB

FRI0521 EARLY RECOGNITION OF PATIENTS WITH AXIAL SPONDYLOARTHRITIS BY USING A PRACTICAL REFERRAL SYSTEM – EVALUATION OF THE RECENTLY PROPOSED 2-STEP STRATEGY

Background:

Chronic back pain (CBP) of the inflammatory type (IBP) is frequently reported in axSpA but also in the general population.

Objectives:

We evaluated a recently proposed two-step referral system for early recognition of axSpA (concentrating on patients ≤45 years with chronic back pain who present with buttock pain, improvement by movement, psoriasis, positive testing for HLA-B27) in primary care and compare it to other combinations of symptoms and SpA-related items.

Methods:

Consecutive patients ≤45 years who presented in PC to general practitioners or orthopedic surgeons working in PC with back pain lasting ≥2 months who had not been diagnosed before received questionnaires (Q1) relevant for the referral process. Thereafter, the PC physician asked the same questions in a separate questionnaire (Q2), including the decision on HLA-B27 testing. All patients were then referred to two experienced rheumatologists in a tertiary center who performed a complete workup including clinical, laboratory and imaging with radiographs and magnetic resonance imaging (MRI) examinations before their final diagnosis of axSpA or non-SpA (Q3).

Results:

A total of 320 patients (mean age 35.9±10.3 years) was recruited. The proposed referral strategy (prS) was fulfilled by 127 patients in Q1 (39.7%), 160 in Q2 (50%), 102 by both, Q1 and Q2 (31.9%), and 83 with either Q1 or Q2 (25.9%). Overall, 47 patients were diagnosed with axSpA by the rheumatologist at Q3 (14.7%), 66% of which were male, mean age 34.7±10.1 years, 70.2% HLA-B27 positive, mean CRP 0.8±1.4mg/dl, mean ASDAS 3.2±0.8, mean BASDAI 5.1±2.0. Of these, 37 patients had fulfilled the prS in Q1 or Q2 (78.7%), and 31 in both Q1 and Q2 (66%), respectively. In the latter, the HLA-B27 prevalence was significantly higher (27/31, 87.1%) as compared to patients diagnosed with axSpA at Q3 but who did not fulfill the prS in Q1 and Q2 (5/16, 31.3%) (p<0.001).

The sensitivity and specificity of the prS was 78.7% and 69.2% in Q1, 78.7% and 62.2% in Q2, and in both, Q1 and Q2, 66% and 74%, respectively.

AxSpA patients correctly identified by the prS in Q1 and Q2, were significantly more frequently positive for HLA-B27 and CRP and fulfilled more frequently the ASAS definition of inflammatory back pain in Q3.

Conclusion:

A simple two-step referral strategy using a combination of clinical features for identifying axSpA patients in PC without laboratory and imaging examinations was confirmed in a large population from daily practice. This strategy performed well as selection for referral at the patient and PC physician level.

This work was supported by an unrestricted Grant by Novartis Pharma GmbH, Germany

Table 1.OR (95% CI)Overall P valueInpatient stay duration0.87 (0.82, 0.93)<0.001Opioids prescribed at discharge0.23 (0.09, 0.55)0.001Patient’s location before admission:0.02Home1.0 (réf.)A&E Department0.25 (0.10, 0.65)Other Department0.35 (0.05, 2.53)Charlson comorbidity index0.76 (0.82, 0.93)Main diagnosis (only significant conditions displayed):0.03Low back pain, sciatica1.0 (réf.)Abarticular conditions0.03 (0.002, 0.47)Osteoporotic fracture0.17 (0.05, 0.52)

Predictors of home discharge. Multivariate logistic regression analysis. N=223.

Disclosure of Interests:

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, Styliani Tsiami: None declared, Doris Morzeck: None declared, Kirill Fedorov: None declared, Uta Kiltz Grant/research support from: AbbVie, Amgen, Biogen, Novartis, Pfizer, Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer, Roche, UCB, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma

OP0106 SECUKINUMAB 150 MG SIGNIFICANTLY IMPROVED SIGNS AND SYMPTOMS OF NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS: 52-WEEK RESULTS FROM THE PHASE III PREVENT STUDY

Background:

Axial spondyloarthritis (axSpA) spectrum covers radiographic axSpA and non-radiographic axSpA (nr-axSpA). PREVENT (NCT02696031) is the first phase III, placebo (PBO) controlled study evaluating secukinumab (SEC) 150 mg with (LD) or without loading (NL) dose, in patients (pts) with nr-axSpA.1The study had 2 independent analysis plans as per EU (Wk 16) and US (Wk 52) regulatory requirements.

Objectives:

To report efficacy through Wk 52 and safety up to two years for the PREVENT study.

Methods:

555 pts fulfilling ASAS criteria for axSpA plus abnormal CRP and/or MRI, without evidence of radiographic changes in sacroiliac (SI) joints according to modified New York Criteria for AS were enrolled. All images were assessed centrally before inclusion. Pts were randomised (1:1:1) to SEC 150 mg with LD, NL, or PBO at baseline (BL). LD pts received SEC 150 mg at Wks 1, 2, 3, and 4, and then every 4 wks (q4wk) starting at Wk 4. NL pts received SEC 150 mg at BL and PBO at Wks 1, 2, and 3, and then 150 mg q4wk. Switch to open-label (OL) SEC 150 mg or standard of care (SoC) was permitted after Wk 20. Primary endpoint was ASAS40 at Wk 16 (LD) and at Wk 52 (NL) in anti-TNF-naïve pts. Secondary endpoints (overall population) included ASAS40, BASDAI50, SI joint bone marrow edema (BME) score by MRI at Wks 16 and 52 and ASDAS-CRP inactive disease (ID) at Wk 52. Endpoints were analysed according to statistical hierarchy. Analysis used non responder imputation through Wk 52. Safety analyses included all pts who received ≥1 dose of study treatment.

Results:

Overall, 481 pts completed 52 wks with no major differences in retention across groups: 84.3% (156/185; LD), 89.7% (165/184; NL) and 86.0% (160/186; PBO). BL characteristics were similar across groups; 90% pts were anti-TNF-naïve, 56-58% pts had elevated CRP, 71-75% pts had evidence of SI joint inflammation by MRI. Proportion of pts who switched to OL or SoC between Wks 20 and 48 was 52.1% (LD), 49.2% (NL), and 67.4% (PBO). Primary endpoints at Wk 16 and Wk 52 were met (Table). SEC 150 mg LD or NL significantly improved secondary endpoints at Wk 16 and 52 vs PBO (Table). SEC significantly reduced SI joint MRI BME score vs PBO at Wk 16 (-1.68 and -1.03 vs -0.39;P= 0.0197 and 0.026, LD and NL respectively). No unexpected safety signals were reported.

Conclusion:

SEC 150 mg provided significant and sustained improvement in signs and symptoms of pts with nr-axSpA through Wk 52. MRI BME scores were reduced accordingly. There was no major difference between LD and NL. Safety of SEC was consistent with previous reports.2

References:

[1]Deodhar A, et al.Arthritis Rheumatol. 2019;71(suppl 10).

[2]Deodhar A, et al. Arth Res Ther. 2019;21:111.

TableEndpoints, % respondersWkSEC150 mg LD(N = 185)SEC150 mg NL(N = 184)PBO(N = 186)PrimaryASAS40 in anti-TNF-naïve pts1641.5‡42.2‡29.25235.4‡39.8‡19.9SecondaryASAS401640.0‡40.8‡28.05233.5‡38.0‡19.4BASDAI501637.3‡37.5‡21.05230.8‡35.3‡19.9ASDAS-CRP ID1620.5†21.7†8.15215.723.9‡10.2

†P< 0.001;‡P< 0.05 vs PBO (Pvalues are adjusted for multiplicity of testing at Wks 16 and 52. UnadjustedPvalue for ASDAS-CRP ID at Wk 16). Missing values were imputed as non-response.

N, number of randomised pts

Disclosure of Interests:

Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Ricardo Blanco Grant/research support from: AbbVie, MSD, Roche, Consultant of: Abbvie, Eli Lilly, Pfizer, Roche, Bristol-Myers, Janssen, UCB Pharma and MSD, Speakers bureau: Abbvie, Eli Lilly, Pfizer, Roche, Bristol-Myers, Janssen, UCB Pharma. MSD, Eva Dokoupilova Grant/research support from: Eli Lilly, AbbVie, Novartis, Lianne S. Gensler Grant/research support from: Pfizer, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, GSK, Novartis, UCB, Alan Kivitz Shareholder of: AbbVie, Amgen, Gilead, GSK, Pfizer Inc, Sanofi, Consultant of: AbbVie, Boehringer Ingelheim, Flexion, Genzyme, Gilead, Janssen, Novartis, Pfizer Inc, Regeneron, Sanofi, SUN Pharma Advanced Research, UCB, Paid instructor for: Celgene, Genzyme, Horizon, Merck, Novartis, Pfizer, Regeneron, Sanofi, Speakers bureau: AbbVie, Celgene, Flexion, Genzyme, Horizon, Merck, Novartis, Pfizer Inc, Regeneron, Sanofi, Stephen Hall Grant/research support from: Abbvie, UCB, Janssen, Merck, Hideto Kameda Grant/research support from: Abbvie, Asahi-Kasei, Chugai, Eisai, Mitsubishi-Tanabe and Novartis, Consultant of: Abbvie, Boehringer, Celgene, Eli Lilly, Janssen, Novartis, Sanofi, UCB, Speakers bureau: Abbvie, Asahi-Kasei, BMS, Chugai, Eisai, Eli Lilly, Janssen, Mitsubishi-Tanabe, Novartis and Pfizer, Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Marleen van de Sande Grant/research support from: Novartis, Eli Lilly, Boehringer Ingelheim, Janssen, Consultant of: Abbvie, Novartis, Eli Lilly, Speakers bureau: Novartis, MSD, 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, Anna Wiksten Shareholder of: Novartis, Employee of: Novartis, Brian Porter Shareholder of: Novartis, Employee of: Novartis, Hanno Richards Shareholder of: Novartis, Employee of: Novartis, Sibylle Haemmerle Shareholder of: Novartis, Employee of: Novartis, Atul Deodhar Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB

AB1245 DAILY MANAGEMENT OF PATIENTS WITH AXIAL SPONDYLOARTHRITIS: SELF-MONITORING OF DISEASE ACTIVITY WITH A SMARTPHONE APP IS FEASIBLE – A PROOF OF CONCEPT STUDY

Background:

Assessment and monitoring of disease activity and functioning is of major importance for the course of axial spondyloarthritis (axSpA). This is equally important for patient monitoring in daily routine as also for tight control strategies. Even though there is evidence that a closer monitoring of patients is better than routine care, more intensive treatment schedules are often not realized in daily practice for several reasons including shortage of time and personal resources. Using application software devices (apps) in clinical routine for the recording of disease-specific patient reported outcomes (PRO) may facilitate monitoring and improve clinical decision processes but there is a lack of data on the use of apps.

Objectives:

To investigate the use of such App technology in respect to usability, feasibility and equivalence of data in daily care of patients with axSpA. In more detail, it will be first determined how many patients are capable and ready to use the technology in a routine setting. Furthermore, the usage and behavior of patients using the app will be studied, the usability of the app and the equivalence of the collected parameters as well as the adherence to the documentation of disease activity over time.

Methods:

Patients diagnosed with axSpA were consecutively included in this ongoing monocentric prospective cohort study. In addition to patient and disease characteristics, information on previous experience with digital health apps was collected. Patients were asked to submit BASDAI and BASFI scores regularly every 2 weeks. The free to use AxSpA Live App is available for Android and iOS as a Class I certified medical device.

Results:

Out of 103 axSpA patients asked, 69 patients with axSpA (mean age 41.5 ± 11.3, 58% male, 76.8% use of bDMARDs, BASDAI 4.3 ± 2.0, BASFI 3.8 ± 2.5) out of 103 patients (67%) agreed to use participate, while 5 did not have a smartphone, 1 was unable to download the app for technical reasons, 28 reported other personal reasons). Of the 69, 62 patients (89.9%) reported using electronic media frequently and had used digital health apps (mean apps used 1.0 ± 1.3) in everyday life before. There were no systematic differences between pain levels documented on paper or by app at baseline (ICC 0.9 (95%CI 0.82 – 0.93). Out of 55 patients who completed week 2, only 33 patients (60%) used the App regularly to transmit their BASDAI/BASFI responses within the first two weeks (60%). Patients who started a new drug treatment because of high disease activity, reported BASDAI values more often than patients without a treatment change within a follow-up period of 5.5± 2.4 weeks (Table).

Conclusion:

The majority of patients with axSpA were able to use the AxSpA Live App. Most patients report scores regularly. The current disease activity seems to influence the adherence to reporting.

Patients without change in their medication (n=53)Patients with change in their medication (n=16)Age, years42.0 (11.9)39.8 (9.3)Sex, male (%)62.343.8BASDAI, baseline4.1 (2.1)4.9 (1.7)BASFI, baseline3.8 (2.6)3.8 (2.3)Time of follow-up, in weeks5.4 (2.4)5.6 (2.5)Number of transmitted BASDAI values at week 222 (41%)11 (69%)Median number of transmitted BASDAI values during follow up1.0(3.6)1.5 (1.4)

This work was supported by an unrestricted Grant by Novartis Pharma GmbH, Germany

Acknowledgments:

n/a

Disclosure of Interests:

Uta Kiltz Grant/research support from: AbbVie, Amgen, Biogen, Novartis, Pfizer, Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer, Roche, UCB, Robin Kempin: None declared, Anna Schlegel: 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, Styliani Tsiami: None declared, Bjoern Buehring Grant/research support from: GE/Lunar, Kinemed, Consultant of: Gilead, Abbvie, Lilly, GE/Lunar, Janssen, Amgen, Speakers bureau: UCB, David Kiefer Grant/research support from: Novartis, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma

AB1171 Effects of successive switches of two different biosimilars of etanercept on outcomes in inflammatory rheumatic diseases in daily practice

Background:

A single switch from an originator to a biosimilar product has been shown to be safe and effective in the treatment of rheumatic musculoskeletal diseases (RMDs). The availability of biosimilars has created a financial incentive to encourage switching to cheaper products (“non-medical switch”). This is naturally associated with multiple switches. However, the effect of multiple switching between biosimilars of the same reference product has not been thoroughly investigated to date.

Objectives:

To assess the effectiveness and safety of systematic non-medical switching from innovator etanercept (ETN) to biosimilar ETN (SB4) and successive to another biosimilar ETN (GP2015) in adult patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) or axial spondyloarthritis (axSpA) in a real-life setting.

Methods:

This retrospective study was performed in a tertiary center in adult patients with RA, PsA or axSpA who had been treated with the innovator ETN and who had been switched to two ETN biosimilars for economic reasons thereafter. The first switch from innovator ETN to the first biosimilar ETN occurred between February-May 2017 and the second switch from the first to the second biosimilar ETN occurred between September-December 2017. The end of the observation period was October 2019. Disease activity, function and adverse events (AE) were regularly assessed, and any changes in outcome were recorded during the follow-up period. The scores documented at week 12 week after the second switch were taken as primary outcome.

A total of 100 patients (54 RA, 27 axSpA, 19 PsA, mean age 54.3±15.1, 46% male) who switched twice to those ETN biosimilars over a follow-up period of 21.1±7.4 months were included. The retention rate after the second ETN biosimilar switch was 89% about 6 months after the second switch. While 2 patients were lost to follow-up and 1 patient died (cardiac arrest), 7 patients discontinued due to inefficacy or AE, including one pancreatic cancer. One patient was withdrawn due to pregnancy. Overall, 14 AEs were reported in 8 patients. Among them, 4 patients switched back to originator etanercept in month 6, 1 patient re-administered GP2015 successfully in month 3 after suffering from mucosal erosions and in 3 patients another mode of action was prescribed. The scores at week 12 of both, disease activity and function, remained unchanged (Table 1).

Table 1.

Patient characteristics

AssessmentBaseline(n=100)SB4 Follow-up 12 weeks(n=100)SB 4 Follow-up 24 weeks(n=100)Second switch to GP2015(n=100)GP2015 Follow-up 12 weeks(n=97)GP2015 Follow-up 24 weeks(n=89)RADAS283,0 (1,2)2,9 (1,4)3,1 (1,2)2,8 (1,4)3,4 (2,5)3,0 (1,4)HAQ1,4 (0,8)1,6 (0,9)1,0 (0,9)1,5 (0,8)1,5 (0,8)1,6 (0,9)PsADAS283,8 (1,4)1,9 (1,4)2,8 (1,5)3,1 (1,1)4,5 (2,6)3,6 (2,6)HAQ1,2 (0,9)1,0 (0,9)0,9 (0,9)1,0 (0,8)1,0 (0,9)1,2 (0,8)axSpABASDAI5,1 (2,7)4,5 (2,6)5,1 (3,8)4,1 (2,2)4,6 (2,5)4,3 (2,4)ASDAS3,4 (0,8)2,5 (0,8)2,7 (0,8)3,2 (1,8)2,7 (1,2)2,5 (0,9)BASFI4,4 (2,7)4,3 (2,7)4,3 (3,2)4,6 (2,6)4,5 (2,7)4,8 (3,0)

*Values are mean ± standard deviation

Disclosure: Hexal funded this research

Conclusion:

The retention rate after multiple switches from innovator ETN to two ETN biosimilars was close to 90%. No major changes in disease activity and function were observed in all three indications.

OP0104 THE IMPACT OF PERSISTENT INFLAMMATORY CHANGES ON PREVALENCE OF FATTY LESIONS IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS TREATED WITH CERTOLIZUMAB PEGOL: 4-YEAR MRI RESULTS FROM RAPID-AXSPA

Background:

Axial spondyloarthritis (axSpA) is a chronic disease characterised by inflammation in the sacroiliac joints and spine, causing severe back pain and stiffness. Emerging evidence suggests chronic spinal inflammation may be associated with osteoproliferation leading to syndesmophyte formation and spinal ankylosis, with subsequent worsening of patient mobility and function.1Fatty lesions (FLs) on magnetic resonance imaging (MRI) T1 sequences are considered to be post-inflammatory precursors to these changes. Certolizumab pegol (CZP), an Fc-free, PEGylated tumour necrosis factor inhibitor (TNFi), has proven efficacy in treating the signs and symptoms of axSpA.2,3CZP has also been shown to decrease spinal and sacroiliac joint MRI inflammation, and limit radiographic progression of the spine over 4 years of treatment.4

Objectives:

To report the effect of early post-baseline (BL) inflammatory changes on fatty lesion prevalence over 4 years in a broad axSpA patient population treated with CZP.

Methods:

RAPID-axSpA (NCT01087762) was a phase 3 trial which was double-blind and placebo (PBO)-controlled to Week (Wk) 24, dose-blind to Wk 48 and open-label to Wk 204. CZP-randomised axSpA patients (Wk 0 CZP: 200 mg every 2 wks [Q2W] or 400 mg Q4W) continued their assigned dose throughout; PBO-randomised axSpA patients (Wk 0 PBO) received CZP from Wk 24, or if non-responders, from Wk 16 onwards. Blinded spinal MRI scans at Wks 0, 12, 48, 96 and 204 were assessed by 2 central readers to evaluate FL and inflammatory lesions in vertebral edges (VEs). Changes in FL prevalence are reported as odds ratios (OR; FL+/FL-) between time points or inflammation states, with nominal 95% confidence intervals (CI), for Wk 0 CZP. ORs were estimated from a logistic regression model for VE level data with random effects for patient and VE (within patient). The fixed model effects included time point, inflammatory status of VEs at BL and Wk 12, FL status at BL, and interactions if appropriate.

Results:

Of 325 axSpA patients, 89 and 47 initially randomised to CZP or PBO, respectively, had a BL and ≥1 post-BL MRI and therefore were eligible for these analyses. In these patients, a total of 3,127 of VEs were assessed at BL; inflammation was observed in 21.6% and FL in 29.3% of VEs, equating to mean counts of 5.0 and 6.7 per patient; 10.5% of VEs had both inflammation and FL at BL. At BL, FLs were relatively more often observed in inflamed VEs vs non-inflamed VEs: OR (95% CI) of 3.30 (1.94, 5.61). This difference increased over time, as the OR of FL at Wk 204 vs BL was 2.82 (1.70, 4.66) in VEs that were inflamed at BL compared with 1.08 (0.79, 1.48) in VEs that were not inflamed at BL (Figure 1A). Resolution of inflammation by Wk 12 appeared to lower the risk of FL prevalence over 4 years. When adjusted for BL VE status with respect to inflammation and FL, if inflammation prevailed at Wk 12, the OR of FL vs no FL was 1.80 (0.93, 3.49) at Wk 48, 2.54 (1.32, 4.91) at Wk 96 and 3.91 (1.87, 8.15) at Wk 204 (Figure 1B).

Conclusion:

This is the first report from a clinical interventional PBO-controlled study in a broad axSpA population showing that inflammation that prevailed after the start of TNFi treatment was associated with increased FL prevalence over 4 years. Reduction of inflammation by Wk 12 mitigated the risk of FL over the long-term, indicating the importance of early, effective and long-term treatment targeting inflammation. Similarly, a complete and persistent reduction of inflammation appears to be critical in these patients.

References:

[1]Maksymowych WP. Ann Rheum Dis 2013;72:23–8;2.Van der Heijde D. Rheumatology (Oxford) 2017;56:1498–509;3.Deodhar A. Arthritis Rheumatol 2019;71:1101–11;4.Van der Heijde D. Ann Rheum Dis 2018;77:699–705.

Acknowledgments:

This study was funded by UCB Pharma. Editorial services were provided by Costello Medical.

Disclosure of Interests:

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, Sebastian Kruse: None declared, Simone Auteri Shareholder of: UCB Pharma, Employee of: UCB Pharma, Natasha de Peyrecave Employee of: UCB Pharma, Tommi Nurminen Employee of: UCB Pharma, Thomas Kumke Employee of: UCB Pharma, Bengt Hoepken Employee of: UCB Pharma, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma

FRI0278 IXEKIZUMAB IMPROVES SELF-REPORTED OVERALL FUNCTIONING AND HEALTH AS MEASURED BY THE ASAS HEALTH INDEX IN PATIENTS WITH NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS: 52-WEEK RESULTS OF A PHASE 3 RANDOMIZED, ACTIVE AND PLACEBO-CONTROLLED TRIAL (COAST-X)

Background:

Ixekizumab has demonstrated efficacy in treating signs and symptoms of patients with non-radiographic axial spondyloarthritis (nr-axSpA).1The Assessment of SpondyloArthritis International Society Health Index (ASAS HI) is a composite measure consisting of 17 dichotomous items to assess overall functioning and health in patients with spondyloarthritis.2

Objectives:

To assess health outcomes using ASAS HI in patients with nr-axSpA treated with ixekizumab (IXE) for 52 weeks.

Methods:

COAST-X (NCT02757352) was a 52-week, randomized, double-blind, placebo (PBO)-controlled study enrolling adults with an established diagnosis of axSpA (ASAS classification criteria, but not modified New York criteria for sacroiliitis), had Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score ≥4, back pain score ≥4, inflammation (sacroiliitis on magnetic resonance imaging [MRI] per ASAS criteria) or an elevated C-reactive protein [CRP] level >5 mg/L), and inadequate response or intolerance to nonsteroidal anti-inflammatory drugs. Patients were randomized 1:1:1 to receive PBO or 80 mg IXE every 4 weeks (Q4W) or every 2 weeks (Q2W). Changing background medications or switching to open-label IXE Q2W, or both, was allowed after week 16 at investigator discretion. Change from baseline in ASAS HI (score 0-17 with higher score indicating worse health) was analyzed using logistic regression analysis at Weeks 0, 4, 8, 16, 36, and 52. For the ASAS HI, the smallest detectable change was calculated as 3.0. Patients having an ASAS HI score ≤5 were defined as being in a good health state.3Comparisons between IXE treatments and PBO were made using logistic regression analysis. Non-responder imputation was used for missing data. Patients who switched to open label IXEQ2W were considered non-responders after they switched.

Results:

At baseline, ASAS HI scores were similar between the three groups (PBO 9.0 ± 3.7; IXE Q4W 8.6 ± 3.4; IXE Q2W 9.6 ± 3.4). Significantly more patients receiving IXE Q4W versus PBO achieved ASAS HI score ≤5 at Week 16 (p<0.05; Fig. A). From Week 36 to 52, significantly more patients receiving IXE Q4W and Q2W achieved ASAS HI score ≤5 (p<0.05; Fig. A). Significantly more patients receiving IXE Q2W versus PBO achieved a clinically meaningful improvement in ASAS HI score ≥3 at Week 16 (p<0.05; Fig. B). From Week 36 to 52 significantly more patients receiving IXE Q4W and Q2W achieved a clinically meaningful improvement in ASAS HI score ≥3 compared with PBO (p<0.05; Fig. B).

Figure.

Improvement in ASAS HI scores through Week 52.A: Proportion of patients who achieved an ASAS HI score ≤5 in patients with baseline ASAS HI score >5. B: Proportion of patients who achieved ≥3-point improvement in ASAS HI in patients with baseline ASAS HI score ≥3. ***p<0.001, **p<0.01, *p<0.05 versus PBO. Asterisk color indicates which IXE treatment group was compared with PBO. ASAS HI= Assessment of SpondyloArthritis International Society Health Index; IXE=ixekizumab; PBO=placebo; Q2W=every 2 weeks; Q4W=every 4 weeks

Conclusion:

Ixekizumab improves overall functioning and health in patients with nr-axSpA as assessed by ASAS HI, with significantly more patients achieving good health status.

References:

[1]Deodhar A, van der Heijde D, Gensler LS, et al.Lancet. 2020; 395(10217):53-64.

[2]Kiltz U, van der Heijde D, Boonen A, et al.Ann Rheum Dis. 2015;74(5):830-5.

[3]Kiltz U, van der Heijde D, Boonen A, et al.Ann Rheum Dis. 2018;77(9):1311-7.

Disclosure of Interests:

Uta Kiltz Grant/research support from: AbbVie, Amgen, Biogen, Novartis, Pfizer, Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer, Roche, UCB, Jessica A. Walsh Grant/research support from: AbbVie, Pfizer, Janssen, Consultant of: AbbVie, Novartis, Eli Lilly and Company, UCB, Ruben Burgos Vargas: None declared, Theresa Hunter Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Rebecca Bolce Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, David Sandoval Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Soyi Liu Leage Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Ann Leung: None declared, Xiaoqi Li Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Emily Blue Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma

OP0238 RISK OF HERPES ZOSTER IN PATIENTS WITH RHEUMATOID ARTHRITIS UNDER BIOLOGICAL, TARGETED SYNTHETIC, AND CONVENTIONAL SYNTHETIC DMARD TREATMENT

Background:

The risk of herpes zoster (HZ) is higher in patients with rheumatoid arthritis (RA) than in the general population. This risk is further increased with biologic disease-modifying anti-rheumatic drugs (bDMARDs) such as tumour necrosis factor inhibitors (TNFi) and targeted synthetic (ts)DMARDs such as Janus kinase inhibitors (JAKi) compared to patients taking conventional synthetic (cs)DMARDs such as methotrexate (MTX).

Objectives:

To compare incidence rates of HZ in RA patients under treatment with bDMARDs, tsDMARDs and csDMARDs with different modes of action and to find potential risk factors.

Methods:

Data of patients enrolled in the German biologics register RABBIT from 2007 onwards with the start of a bDMARD, tsDMARD or a change in csDMARD treatment were analysed. Patients were included when at least one follow-up documentation was available. All HZ events reported until 30 April 2019 were identified and assigned to treatments administered within the 3 month period prior to the HZ event. Crude incidence rates (IR) of HZ were calculated per 1,000 patient years (py). Cox regression was applied to investigate risk factors for the occurrence of HZ with and without inverse probability weights (IPW) to adjust for confounding by indication.

Results:

Data of 12,470 patients (53,218 py of observation) were included in the analysis. A total of 452 HZ cases in 433 patients were reported, of which 52 events were serious. The crude IRs per 1,000 py are illustrated by Figure. Adjusted for age, sex, and glucocorticoid use, a significantly increased risk was observed for treatment with monoclonal TNF antibodies (hazard ratio [HR], 1.55 [95% CI, 1.21-2.00]), B-cell targeted therapies (HR, 1.45 [95% CI, 1.07-1.97]), and tsDMARDs (HR, 3.55 [95% CI, 2.33-5.41]). Treatment with soluble TNF receptors, T-cell co-stimulation modulator, and IL-6 inhibitors were not significantly associated (Table). Adjustment with IPW amplified the effect and treatment with T-cell co-stimulation modulator and IL-6 inhibitors were also significantly associated with a higher risk compared to csDMARD treatment (Table).

Conclusion:

This is the first analysis in a European prospective cohort study comparing the incidence rates and risk of HZ in RA patients under treatment with six different modes of action within one cohort to csDMARD treatment. We found a significant association between HZ and treatment with JAKi. Our results also confirm a higher risk for monoclonal TNF antibodies and show a similar result for the T-cell co-stimulation modulator and B-cell targeted therapies. This study clearly supports systematic HZ vaccination of RA patients.

Table.

Acknowledgments:

RABBIT is supported by a joint, unconditional grant from AbbVie, Amgen, BMS, Fresenius Kabi, Hexal, Lilly, MSD, Mylan, Pfizer, Roche, Samsung Bioepis, Sanofi-Aventis and UCB

Disclosure of Interests:

Anja Strangfeld Speakers bureau: AbbVie, BMS, Pfizer, Roche, Sanofi-Aventis, Imke Redeker: None declared, Jörn Kekow Speakers bureau: BMS, MSD, Pfizer, Roche, Gerd Rüdiger Burmester Consultant of: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Speakers bureau: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Angela Zink Speakers bureau: AbbVie, Amgen, BMS, Gilead, Hexal, Janssen, Lilly, MSD, Pfizer, Roche, Sanofi Aventis, UCB

OP0060 MACHINE LEARNING BASED BERLIN SCORING OF MAGNETIC RESONANCE IMAGES OF THE SPINE IN PATIENTS WITH ANKYLOSING SPONDYLITIS FROM THE MEASURE 1 STUDY

Background:

Magnetic resonance imaging (MRI) offers a non-invasive and objective method of early diagnosis and classification, monitoring disease burden and treatment response for patients (pts) with axial spondyloarthritis (axSpA) including ankylosing spondylitis (AS).1Numerous scoring schemes such as the AS Spine MRI Activity (ASspiMRIa) score are available for the quantitative assessment of MRI, but are subject to intra- and inter-rater variability, labor intensive and costly. Nevertheless, quantification of MRI changes has become an important tool to demonstrate treatment success of biologic drugs in axSpA.

Objectives:

To evaluate the performance of machine learning (ML) based software for automated Berlin grading of spinal MRI bone marrow oedema in pts with AS and compare with expert scoring.

Methods:

Fully automated ML software (Figure) was developed to detect and label 23 vertebrae, define vertebral units (VU) as per the Berlin modification of the ASspiMRIa score, and score each VU as either 0 (score of 0) or 1 (score of 1, 2 or 3). The ML algorithm was based on the previously developed SpineNet software.2Analysis included 108 pts from the secukinumab MEASURE 1 study3, in which imaging was done using T1 and STIR sagittal MRI at baseline and Weeks 16, 52, 104, 156 and 208. Two expert readers, blinded to treatment and visit, evaluated all images by ASspiMRIa score. The scores from Reader 2 (R2) were binned into two groups: 0 vs 1, 2, or 3. As a result of multiple pt time points and expert reading sessions, the complete dataset comprised of 10,988 VU. Ten-way cross-validation at per-VU was used to train and validate the ML software. The dataset was split into 10 randomly selected subsets, ensuring that each pt appears in only one subset, after which 8 subsets were used for training the ML software, 1 was used to check for correct training and 1 was used for validation. The process was repeated ten times such that all 10 subsets were used for validation. Accuracy weighted for the frequency of each category, sensitivity and specificity were calculated using scores from R2 as reference. Intra-reader accuracy was also calculated.

Results:

Accuracy of the software in relation to expert reader scores was 67% with a sensitivity of 0.63 and specificity of 0.70. The intra-reader accuracy was 71% and 77% for R1 and R2, respectively. Individual VU scoring of the Software vs. R2 are presented in the Table as a confusion matrix.

Conclusion:

Automated scoring of MR images in AS pts provided moderate agreement to that of expert reader-based assessments. ML software has potential to provide an automated guided-reading approach to scoring MR images, which may enable further clinical insights.

References:

[1]Lukas C, et al. J Rheumatol. 2007;34:862-70.

[2]Jamaludin A, et al. Eur Spine J. 2017;26:1374-83.

[3]Baeten D, et al. N Engl J Med. 2015;373,2534-48.

Figure.

Processing pipeline of automated Berlin scoring software

Table.

Confusion matrix between the software and R2

SoftwareScore = 0SoftwareScore = 1, 2 or 3Total VU scoredR2 Score = 07199 (70%)3068 (30%)10,267R2 Score = 1, 2 or 3251 (35%)475 (65%)7267,4503,54310,993

Percentages calculated as a fraction over the total in each row. Overall accuracy is the average of the highlighted percentages.

Disclosure of Interests:

Amir Jamaludin: None declared, Rhydian Windsor: None declared, Sarim Ather: None declared, Timor Kadir: None declared, Andrew Zisserman: None declared, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Lianne S. Gensler Grant/research support from: Pfizer, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, GSK, Novartis, UCB, Pedro Machado Consultant of: Abbvie, Celgene, Janssen, Lilly, MSD, BMS, Novartis, Pfizer, Roche and UCB, Speakers bureau: AbbVie, Centocor, Eli Lilly, Janssen, MSD, Novartis, Pfizer and UCB Pharma, 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, Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Thibaud Coroller Shareholder of: Novartis, Employee of: Novartis, Brian Porter Shareholder of: Novartis, Employee of: Novartis, Shephard Mpofu Shareholder of: Novartis, Employee of: Novartis, Aimee Readie Shareholder of: Novartis, Employee of: Novartis

SAT0135 COMPARISON OF THE EFFICACY AND SAFETY OF TWO BRIDGING SCHEDULES OF PREDNISOLONE IN EARLY ACTIVE RHEUMATOID ARTHRITIS (CORRA): A DOUBLE-BLIND, RANDOMISED, PLACEBO-CONTROLLED TRIAL

Background:

Rheumatoid arthritis (RA) is a chronic inflammatory joint disease potentially leading to disability, impaired functioning, and premature death. Most treatment strategies include the early use of disease-modifying antirheumatic drugs (DMARDs) such as methotrexate (MTX) which is considered as an established ‘anchor’ therapy. Since it takes some weeks until MTX shows clinical efficacy, glucocorticoids (GC) are widely used for bridging.

Objectives:

The aim of the study “Comparison of the efficacy and safety of two starting dosages of prednisolone in early active RA” (CORRA) is to compare the efficacy and safety of two standard GC bridging schedules vs. placebo in addition to MTX, following a treat-to-target regimen, in early RA.

Methods:

CORRA is an investigator-initiated, randomised, multi-center, double-blind, placebo-controlled trial. Adult RA patients who were eligible for inclusion in the trial if they had a disease duration of less than 3 years and moderate or high disease activity were recruited in one hospital and 18 rheumatology practices in Germany. Patients were randomised (1:1:1) to receive 60 mg or 10 mg prednisolone (Pred) orally once daily (tapered down to 5 mg Pred within 8 weeks) or placebo. The duration of the intervention was 12 weeks, followed by an open observational phase for another 40 weeks. All patients were also treated with MTX (usually starting with 15mg/week followed by a treat-to target scheme). The primary efficacy endpoint was the progression of the radiographic joint damage after one year compared to baseline as determined by the van der Heijde modification of the Sharp score (SHS). Patients, physicians and readers of radiographs were unaware of the treatment assignments. For the comparison of the two GC groups, a non-inferiority margin of 1.3 points of the SHS was set. This trial was registered at ClinicalTrials.gov, numberNCT02000336.

Results:

Between February 2014 and February 2017, 395 patients were included in the trial, 381 of which had sufficient data also of follow-up visits. A total of 129 patients were assigned to the 60 mg Pred group, 124 to 10 mg Pred and 128 to the placebo group. At baseline, mean age was 58 years, 58% were female, 55% were rheumatoid factor and 52% ACPA positive. The mean number of swollen joints was 12.8 out of 28, mean ESR was 33.6 mm/h, mean CRP 2.2 mg/dL, mean DAS 28 6.0. Radiographic damage was 4.9 as measured by the SHS. In the 60 mg, 10 mg Pred group and in the placebo group, the DAS 28 was 2.6, 3.1, 4.5 at week 4 (p<0.001), 3.1, 2.8, 3.6 at week 12 (p<0.001), and 2.7, 2.6, 2.8 at week 52 (p=0.411), respectively. After 12 months the radiographic progression could be determined in 375 patients. In the 60 mg, 10 mg Pred group, and in the placebo group, the mean progression after 1 year was 1.0, 1.0, 1.1 for the total SHS and 0.5, 0.6, 0.7 for the erosion score of the SHS, respectively. Statistical analysis showed non-inferiority of the 10 mg Pred and of the placebo group in comparison to the 60 mg Pred group. Regarding safety issues, there were 10, 5, 6 serious adverse events and 31, 16, 20 adverse events in the MedDRA system organ class “infections and infestations” for the 60 mg Pred, 10 mg Pred, and the placebo group, respectively.

Conclusion:

The bridging schedule starting with 60 mg Pred reduced disease activity better than the 10 mg schedule or placebo only for a short time. The primary outcome structural damage was non-inferior in the 10 mg Pred and the placebo group in comparison to the 60 mg Pred group. Initial advantages of the higher dose may have been compromised by the long follow-up with the possible escalation of therapy due to the treat-to-target regimen.

Disclosure of Interests:

Dietmar Krause Grant/research support from: Pfizer and AbbVie (Abbott), Anna Mai: None declared, Nina Timmesfeld: None declared, Ulrike Trampisch: None declared, Renate Klaassen-Mielke: None declared, Henrik Rudolf: 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, Elmar Schmitz: None declared, Claas Fendler: None declared, Claudia Klink: None declared, Stephanie Boeddeker: None declared, Ertan Saracbasi: None declared, Jochen Christoph: None declared, Manfred Igelmann: None declared, Hans Juergen Menne: None declared, Albert Schmid: None declared, Hans J Trampisch: None declared, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma