Providing high-quality care remotely to patients with rare bone diseases during COVID-19 pandemic

During the COVID-19 outbreak, the European Reference Network on Rare Bone Diseases (ERN BOND) coordination team and Italian rare bone diseases healthcare professionals created the "COVID-19 Helpline for Rare Bone Diseases" in an attempt to provide high-quality information and expertise on rare bone diseases remotely to patients and healthcare professionals. The present position statement describes the key characteristics of the Helpline initiative, along with the main aspects and topics that recurrently emerged as central for rare bone diseases patients and professionals. The main topics highlighted are general recommendations, pulmonary complications, drug treatment, trauma, pregnancy, children and elderly people, and patient associations role. The successful experience of the "COVID-19 Helpline for Rare Bone Diseases" launched in Italy could serve as a primer of gold-standard remote care for rare bone diseases for the other European countries and globally. Furthermore, similar COVID-19 helplines could be considered and applied for other rare diseases in order to implement remote patients' care.

Different fracture risk profile in patients treated with anti-osteoporotic drugs in real-life

In this retrospective study, we intended to investigate the baseline fracture risk profile in patients who started treatment with different anti-osteoporotic medications. We analyzed retrospectively the fracture risk calculated with DeFRA, a validated FRAX derived tool, in women who started an anti-osteoporotic treatment from 2010 to 2017. We analyzed baseline data of 12,024 post-menopausal women aged over 50 years. Teriparatide initiators had a baseline 10-year risk of major osteoporotic fracture of 82.1% with a Standard Deviation (SD) of 66.5%. Denosumab initiators and zoledronic acid initiators had a greater 10-year baseline risk of fracture (54.3%, SD 46.5% and 47.0%, SD 42.0 respectively) than patients initiated on alendronate (24.9%, SD 34.6%) and patients initiated on risedronate (23.9%, SD 24.1%). Using DeFRA, a FRAX™ derived tool, we showed significantly different fracture risk profiles in women who were started on various therapeutic agents for the treatment of osteoporosis in routine clinical practice.

THU0640-HPR GENDER DISPARITY IN AUTHORSHIP OF CLINICAL PRACTICE GUIDELINES IN RHEUMATOLOGY

Background:

Women are generally less represented as first author among original medical researches and clinical guidelines. Indeed, women are first authors in only 30% of clinical guidelines published in high impact medical journals. It is not known if a comparable underrepresentation occurs also in rheumatologic guidelines.

Objectives:

The aim of the present analysis is to evaluate the representation of female authors in rheumatological guidelines over a period of time between 2004 and 2019.

Methods:

We searched PubMed for guidelines published in English in the rheumatological field from 1st January 2004 to 1st January 2019. Gender of each author (man or woman) was identified by use of a minimum of two resources (i.e., author’s name and an internet search to identify the author’s photograph or gender pronoun).

Results:

We found 366 guidelines published between 2004 and 2019 (Table 1: stratified by year of publication and Table 2: stratified by disease). Overall, the proportion of female first authors was 32.0% (95% CI, 28.0% - 35%). After stratification by year of publication the percentage of female first authors was lower in past years compared to recent years. The percentage of female first author increased substantially over the time (Figure 1).

Table 1.

Percentage of female and male first author of rheumatological guidelines stratified by years

Years% FEMALE%MALE2004 (n=14)21.478.62005 (n=21)23.876.22006 (n=25)32.068.02007 (n=32)37.562.52008 (n=43)20.979.12009 (n=18)33.366.72010 (n=15)6.793.32011 (n=27)25.974.12012 (n=27)25.974.12013 (n=20)48.351.72014 (n=20)25,075,02015 (n=13)46,253,82016 (n=20)45,055,02017 (n=29)51,748,32018 (n=22)40,959,1Table 2.

Percentage of female and male first author of rheumatological guidelines stratified by disease

Disease% FEMALE% MALEOsteoarthritis (n=34)26.573.5Rheumatoid arthritis (n=96)18.881.2Fibromyalgia (n=30)2080Lupus erythematosus (n=29)34.565.5Psoriatic arthritis and Spondyloarthritis (n=73)23.376.7Sjogren syndrome (n=5)4060Gout (n=19)10.589.5Systemic sclerosis (n=18)16.783.3Polymyalgia and Giant cells’ arteritis (n=12)0100Osteoporosis (n=26)30.869.2ANCA associated vasculitides (n=14)21.478.6Polymyositis and Dermatomyositis (n=6)5050Behcet’s disease (n=4)2575Figure 1.

Temporal trend of the percentage of first author gender from 2004 to 2019 (male in blue, female in pink)

Conclusion:

We found a prevalence of male as first authors of guidelines in the rheumatological field published between January 2004 and January 2019. The EULAR Task Force on Gender Equity in Academic Rheumatology (EULAR GEAR) has been recently established, making an important first step toward gender equity in the authorship of guidelines in the rheumatological fields. Indeed, in the last 15 years we have witnessed an increase in female representativeness. Notwithstanding, efforts should be made to improve the representation of female authors nationally and internationally.

Disclosure of Interests:

Giovanni Adami: None declared, Ombretta Viapiana: None declared, Elisabetta Vantaggiato: None declared, Camilla Benini: None declared, Denise Rotta: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work., Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB

AB1082 INFLUENCE OF THE VARIATION OF THE OPERATOR, PATIENT POSITION AND DEVICE ON THE MEASUREMENT PERFORMANCE OF RADIOFREQUENCY ECHOGRAPHIC MULTI SPECTROMETRY (REMS)

Background:

The monitoring of bone mineral density (BMD) is a key aspect for patients undergoing pharmacological treatments that might cause BMD changes at non-physiological rates. At present, the short-term follow-up of patients under treatment in terms of BMD change with time remains an unmet clinical need, since the current techniques, including the gold standard dual X-ray absorptiometry (DXA), require at least 1 year between two consecutive measurements [1]. Therefore, an effective strategy for the assessment of BMD should guarantee high accuracy, precision and repeatability of the measurements.

Objectives:

The aim is to assess the influence of the variation 1) in patient position, 2) operator (both intra- and inter-) and 3) device on the REMS performance at lumbar spine and femoral neck.

Methods:

210 women were enrolled, divided in 7 groups of 30-patient each for the assessment of the parameters of interest, i.e. inter-device, intra- and inter-operator repeatability for lumbar spine scans and inter-patient position, inter-device, intra- and inter-operator repeatability for femoral neck scans.

All patients underwent 2 REMS scans at lumbar spine or femoral neck, performed by the same operator or by 2 different operators or by the same operator using 2 different devices or in different patient position (i.e. supine without constraints or with a constrained 25°-rotation of the leg). The percentage coefficient of variation (CV%) with 95% confidence interval and least significant change for a 95% confidence level (LSC) have been calculated.

Results:

For lumbar spine, intra-operator repeatability resulted in CV%=0.37% (95%CI: 0.26%-0.48%), with LSC=1.02%, inter-operator repeatability resulted in CV%=0.55% (95% CI: 0.42%-0.68%), with LSC=1.52%, inter-device repeatability resulted in CV%=0.53% (95% CI: 0.40%-0.66%), with LSC=1.47%.

For femoral neck, intra-operator repeatability resulted in CV%=0.33% (95%CI: 0.23%-0.43%), with LSC=0.91%, inter-operator repeatability resulted in CV%=0.47% (95% CI: 0.35%-0.59%), with LSC=1.30%, inter-device repeatability resulted in CV%=0.42% (95% CI: 0.30%-0.51%), with LSC=1.16%, inter-patient position repeatability resulted in CV%=0.24% (95% CI: 0.18%-0.30%), with LSC=0.66%.

Conclusion:

REMS densitometry is highly precise for both anatomical sites, showing high performance in repeatability. These results suggest that REMS might be a suitable technology for short-term monitoring. Moreover, thanks to its ionizing radiation-free approach, it might be applied for population mass investigations and prevention programs also in paediatric patients and pregnant women.

References:

Note:Carla Caffarelli, Giovanni Adami§, Giovanni Arioli§, Gerolamo Bianchi§, Maria Luisa Brandi§, Sergio Casciaro§, Luisella Cianferotti§, Delia Ciardo§, Francesco Conversano§, Davide Gatti§, Giuseppe Girasole§, Monica Manfredini§, Maurizio Muratore§, Paola Pisani§, Eugenio Quarta§, Laura Quarta§, Stefano Gonnelli

§Equal contributors listed in alphabetical order

Disclosure of Interests:

Carla Caffarelli: None declared, Giovanni Adami: None declared, Giovanni Arioli *: None declared, Gerolamo Bianchi Grant/research support from: Celgene, Consultant of: Amgen, Janssen, Merck Sharp & Dohme, Novartis, UCB, Speakers bureau: Abbvie, Abiogen, Alfa-Sigma, Amgen, BMS, Celgene, Chiesi, Eli Lilly, GSK, Janssen, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi Genzyme, Servier, UCB, Maria Luisa Brandi: None declared, Sergio Casciaro: None declared, Luisella Cianferotti: None declared, Delia Ciardo: None declared, Francesco Conversano: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work., Giuseppe Girasole: None declared, Monica Manfedini: None declared, Maurizio Muratore: None declared, Paola Pisani: None declared, Eugenio Quarta: None declared, Laura Quarta: None declared, Stefano Gonnelli: None declared

THU0479 ASSOCIATION BETWEEN CENTRAL SENSITIZATION AND CLINICAL AND ULTRASONOGRAPHIC PARAMETERS IN INFLAMMATORY ARTHRITIDES

Background:

Central sensitization (CS) is an important feature of patients with chronic pain, especially rheumatoid arthritis (RA) and psoriatic arthritis (PsA) patients. CS might interfere with the clinical evaluation of inflammation. Central Sensitization Inventory (CSI) is a validated instrument for assessing central sensitization.

Objectives:

We seek to investigate the inference of central sensitization (assessed with the CSI) on clinical (disease activity scores) and ultrasound parameters (US 7-joints score) in RA and PsA patients.

Methods:

We conducted a cross-sectional analysis on patients with an established diagnosis of RA or polyarticular PsA. Demographic, anamnestic and clinical parameters were collected. Disease activity was measured with SDAI in RA patients and with DAPSA in PsA patients. The presence and severity of synovitis was measured with the US 7-joints score. Exclusion criteria included: diagnosis of fibromyalgia, depression and patients with PsA with enthesitis predominant and/or spondylitis subtypes. Differences between variables were analysed with t-test and ANOVA for multiple comparisons. Correlation between continuous variables was analysed with Pearson correlation. CSI was analysed either as positive\negative (threshold 40 points) or divided in four categories, i.e., subclinical (≤29), mild (30-39), moderate (40-49), severe (50-59) and extreme (≥60).

Results:

We enrolled 42 patients in the study. Descriptive characteristics of the study population are presented in table 1. We found no difference in clinical parameters between diseases, sex or age. Women had a higher CSI score compared to men (mean 39.3 vs 26.7 p=0.005). We found a correlation between CSI score and DAPSA (r20.39, p =0.001), number of tender joints (r20.13, p=0.02) and HAQ (r20.47, p<0.001) (Figure 1) while we found no correlation between CSI score and SDAI or other clinical parameters. We found a significant difference in DAPSA, tender joints count and HAQ between CSI categories (ANOVA p=0.01, p=0.02 and p<0.001 respectively). US 7-joints score was associated with SDAI (r20.33, p=0.03), number of swollen joints (r20.28, p=0.002) and disease duration (r20.35, p<0.001) but not with DAPSA or tender joints.

Table 1.

Descriptive characteristics of the study population

Age (mean, SD in years)55.9 (12.3)BMI25.9 (3.9)CSI questionnaire score (mean)35 (16)CSI categories (n, %)Subclinical18 (42.9%)Mild9 (21.4%)Moderate8 (19.0%)Severe4 (9.5%)Extreme3 (7.1%)Diagnosis (n, %)PsA 52.4%9 men 13 womenRA 47.6%2 men 18 womenCSI score in PsA (mean, SD)34.4 (16.5)CSI score in RA (mean, SD)34.8 (15.5)CRP (median, IQR in mg/L)1.85 (1.0-4.6)Tender joints (mean, SD)2 (2)Swollen joints (mean, SD)1 (2)SDAI categories (n, %)Remission4 (20.0%)Low disease activity8 (40.0%)Moderate disease activity7 (35.0%)Severe disease activity1 (5.0%)DAPSA categories (n, %)Remission6 (33.3%)Low disease activity4 (22.2%)Moderate disease activity7 (38.9%)Severe disease activity1 (5.6%)US 7-joints score (mean, SD)6 (7)HAQ (mean, SD)0.6 (0.6)Prednisone equivalent (mean, SD in mg/day)1.47 (3.2)Biological DMARD (n, %)No15 (35.7%)Yes27 (64.3%)Conventional DMARD (n, %)No13 (31.0%)Yes29 (69.0%)Figure 1.

Correlation between DAPSA score and CSI score and between HAQ and CSI score

Conclusion:

We found an association between CS and sex, functional disability, tender joints count and disease activity score in PsA patients while there was no correlation between RA disease activity and central sensitization. US 7-joints score was associated with swollen joints count, disease duration and disease activity in RA patients but not in PsA patients. In PsA patients, DAPSA might be more influenced by central sensitization, especially in female individuals.

Disclosure of Interests:

Giovanni Adami: None declared, Elisabetta Gerratana: None declared, Alessandro Giollo: None declared, Camilla Benini: None declared, Elisabetta Vantaggiato: None declared, Denise Rotta: None declared, Luca Idolazzi: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work., Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB, Angelo Fassio Speakers bureau: Angelo Fassio reports personal fees from: Abiogen and Novartis, outside the submitted work.

AB1094 SCAR IMAGING ECHOCARDIOGRAPHY WITH ULTRASOUND MULTI-PULSE SCHEME [eSCAR] FOR THE DETECTION OF MYOCARDIAL FIBROSIS IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: PRELIMINARY RESULTS

Background:

Myocardial fibrosis is a severe complication of immune-mediated diseases, occurring in up to 30% of systemic lupus erythematosus (SLE) patients. Cardiovascular magnetic resonance imaging allows myocardial scar detection in SLE patients, but it is costly, time consuming, and unfit for patients with renal disease. Scar imaging echocardiography with ultrasound multi-pulse scheme (eSCAR) is a novel and promising technique that proved to be effective in detecting ischemic myocardial scars in patients with coronary artery disease (CAD).

Objectives:

To evaluate if the eSCAR technique is feasible and to better characterize SLE patients with cardiac involvement by eSCAR.

Methods:

We recruited consecutive patients with SLE classified according to the 2019 EULAR/ACR recommendations. Patients with diabetes mellitus, obesity, prior cardiovascular (CV) disease or anti-phospholipid (aPL) syndrome were excluded. Eligible participants underwent a thorough clinical assessment and a full echocardiography examination, including the eSCAR technique. Data on clinical variables were collected; disease activity was estimated by the SLE Disease Activity Index (SLEDAI) score. Lupus flare was defined as new/worse clinical signs and symptoms and/or lab measurements and a change/increase in treatment. Patients were compared according to the presence or absence of eSCAR. In this preliminary report, only descriptive analyses are provided. Continuous data are reported as median [25th; 75thpercentile].

Results:

We enrolled fifteen patients diagnosed with SLE (age 45 years [36; 47], disease duration 14 years [12; 20]), 13 (87%) were females. Median SLEDAI was 5 [2; 8]. The most frequent disease involvement included arthritis (73%), skin and mucous membranes (60%), lupus nephritis (47%) and cytopenias (47%). Patients had received treatment for lupus with 5 drugs [5; 8]. Cumulative prednisone dosage was 25 g [20; 44], whilst the current daily dosage of prednisone was 4 mg [0.0; 5.0]. Hypertension was present in 4 (27%) and hypercholesterolemia in 2 (13%) subjects; 4 patients (27%) were current or past smokers. The eSCAR technique was feasible in all participants with no adverse effects. Myocardial scars were detected in 2 patients (eSCAR-positive 13%; figure and table); eSCAR positive patients were females and had no history of cardiovascular involvement (including pericarditis); they had at least one relapse within the prior 12 months before enrollment; at least one cardiovascular risk factor was found in both patients (one was a smoker and the other one had hypertension); none received prior treatment with cyclophosphamide or rituximab; they had no renal involvement; arthritis and cytopenia were the prominent features of disease; anti-dsDNA titer was higher than eSCAR-negative patients.

Conclusion:

Echocardiography allowed detection of myocardial scars in patients with SLE. Our preliminary data show that eSCAR is feasible and well tolerated in a SLE population. Further data from this ongoing study will help investigate whether eSCAR might improve risk stratification, by identifying myocardial involvement in SLE patients with a more active disease.

eSCAR positivePatient 1eSCAR positivePatient 2eSCAR negativeSLE patients (n=13)Age, years324545SexFemaleFemale11 F / 2 MESR mm/h29715CRP mg/L30.62Anti-dsDNA (IF)PositivePositivePositive 7 (47)Anti-dsDNA (CLIA)10514934 [7; 66]C3 (mg/L)618085 [70; 94]C4 (mg/L)41310 [9; 16]P-Cr (mg/dL)0.60.80.7 [0.6; 0.7]aPLPositiveNegative7 (47)Disease duration, years152814 [12; 15]SLEDAI1205 [2; 8]Lupus flare in the past 12 monthsyesyes5 (33)Cumulative prednisone dosage (g)606124 [19, 32]Previous use of cyclophosphamideNoNo3 (20)Previous use of rituximabNoNo1 (1)

Acknowledgments:

This study was granted by Gruppo LES Italia Onlus

Disclosure of Interests:

Alessandro Giollo: None declared, Giulia Vinco: None declared, Giovanni Orsolini: None declared, Giovanni Cioffi: None declared, Giovanni Adami: None declared, Angelo Fassio Speakers bureau: Angelo Fassio reports personal fees from: Abiogen and Novartis, outside the submitted work., Luca Idolazzi: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work., Flavio Luciano Ribichini: None declared, Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB, Ombretta Viapiana: None declared

SAT0455 RADIOFREQUENCY ECHOGRAPHIC MULTI SPECTROMETRY (REMS) FOR THE IDENTIFICATION OF FRAIL BONES

Background:

Radiofrequency Echographic Multi Spectrometry (REMS) is the first clinically available approach for direct non-ionizing measurement of bone mineral density (BMD) at lumbar spine (LS) and femoral neck (FN). Available scientific evidences describe BMD estimated by REMS as an accurate parameter for the diagnosis of osteoporosis [1].

Objectives:

To investigate the effectiveness of the T-score values provided by REMS scans at FN and LS in the identification of frail patients at risk for osteoporotic fractures and to compare the performance of REMS with the dual-energy X-ray absorptiometry (DXA) one.

Methods:

The patients underwent DXA and REMS scans at FN and at LS. Five clusters of fractures occurred during a median 3.5-year follow-up were identified whether involving the upper limb (forearm, elbow, humerus, wrist, hand), lower limb (tibia, ankle, metatarsus), thorax (shoulder blade, shoulder, rib), hip (femur or pelvis bones), or vertebrae. The ability of REMS and DXA T-score values to assess the incidence and site of fractures was evaluated through an analysis of covariance.

Results:

Seven hundred twenty-one Caucasian women were enrolled. Ninety-five fractures occurred, in particular 41 at upper limb, 16 at hip, 15 at thorax, 14 at lower limb, 9 at vertebrae. Patients characteristics are reported in table. Considering subcategories of fractured patients, there were not statistically significant differences for age, height, weight and BMI.

In the analysis of covariance including age and BMI as covariates, the difference of T-score values between fractured and non-fractured patients is statistically significant for REMS and DXA at both sites.

Lower FN T-score values were found for patients with fractures at hip or vertebra with respect to non-fractured patients both for REMS and DXA (p<0.001). Considering LS T-score, lower values were found for patients with fractures at hip, vertebra or upper limb with respect to non-fractured patients both for REMS and DXA (p<0.001, Figure).

Conclusion:

REMS T-score measured at axial sites is an effective parameter for identification of patients at the risk of incident fragility fractures, in particular occurring at hip, vertebra or upper limb in a population-based sample of female subjects.

References:

[1]Diez-Perez, Aging Clin Exp Res 2019;31(10):1375–89

Table 1.

Baseline patient characteristics, expressed as median (25th– 75thpercentiles).

Patients with incident fragility fracturePatients without incident fragility fracturep-value*Age [years]70 (60-73)59 (54-64)<0.001Height [cm]159 (155-164)160 (156-165)0.08Weight [kg]63 (58-70)62 (57-69)0.42BMI [kg/m2]24.97 (23.13-26.86)24.24 (22.22-26.59)0.04FN REMS T-score-2.3 (-2.8 – -1.7)-1.8 (-2.3 – -1.1)<0.001FN DXA T-score-2.2 (-2.8 – -1.6)-1.7 (-2.3 – -1.1)<0.001LS REMS T-score-3.0 (-3.5 – -2.0)-2.0 (-2.8 – -1.0)<0.001LS DXA T-score-2.8 (-3.4 – -1.8)-1.9 (-2.7 – -1.0)<0.001

* Wilcoxon ranksum test

Figure.

Boxplot of the distribution of T-score values estimated REMS and DXA at FN and LS among patients without incident fragility fracture and patients with incident fragility fractures at different sites.

Note:G. Adami, G. Arioli§, G. Bianchi§, M.L. Brandi§, C. Caffarelli§, L. Cianferotti§, G. Girasole§, S. Gonnelli§, M. Manfredini§, M. Muratore§, E. Quarta§, L. Quarta§, D. Gatti§ equal contributors listed in alphabetical order.

Disclosure of Interests:

Giovanni Adami: None declared, Giovanni Arioli *: None declared, Gerolamo Bianchi Grant/research support from: Celgene, Consultant of: Amgen, Janssen, Merck Sharp & Dohme, Novartis, UCB, Speakers bureau: Abbvie, Abiogen, Alfa-Sigma, Amgen, BMS, Celgene, Chiesi, Eli Lilly, GSK, Janssen, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi Genzyme, Servier, UCB, Maria Luisa Brandi: None declared, Carla Caffarelli: None declared, Luisella Cianferotti: None declared, Giuseppe Girasole: None declared, Stefano Gonnelli: None declared, Monica Manfedini: None declared, Maurizio Muratore: None declared, Eugenio Quarta: None declared, Laura Quarta: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work.

SAT0452 DIFFERENT PROFILE OF RISK OF FRACTURE IN PATIENTS TREATED WITH ANTI-OSTEOPOROTIC DRUGS IN ITALY USING A NEW ALGORITHM

Background:

A new algorithm for management of patients at low, high and very high risk of osteoporotic fractures has been recently proposed, has been also recommended treating those patients at very high risk of fracture with bone anabolics (1). A similar treatment algorithm has been applied in Italy since 2015, when the “Nota 79”, that regulates the reimbursability for osteoporosis medications, has been developed by the Italian Agency for Drugs (AIFA) (2).

Objectives:

In the present study, using a new mathematical and computerized algorithm, we seek to investigate the profile of risk of fracture of patients starting treatment with different anti-osteoporotic medications in Italy.

Methods:

We retrospectively analyzed the 10-year risk of major osteoporotic fracture calculated with the DeFRAcalc79 tool in postmenopausal women aged over 50 years that were initiating an anti-osteoporotic treatment (fully reimbursed according to the Nota 79). DeFRAcalc79 is a new web-based fracture risk-assessment tool (https://defra-osteoporosi.it) that arithmetically adjusts the risk based on the integration of multiple risk factors contemplated by the AIFA’s Nota 79, including: demographic and anthropometric data, femoral and/or lumbar spine BMD T-score, family history of femoral or vertebral fractures, number and site of previous osteoporotic fracture (including vertebral, femoral, and nonvertebral nonfemoral fractures), glucocorticoid treatment (> 3 or > 12 months, ≥5 mg prednisone or equivalent), adjuvant hormone therapy for breast or prostate cancer, and comorbidities that increase the risk (rheumatoid arthritis and other connective tissue diseases, chronic obstructive pulmonary disease, inflammatory bowel diseases, Parkinson’s disease, multiple sclerosis, HIV infection, diabetes, or severe physical handicap).

Results:

We retrieved data for 10,235 women prescribed with an anti-osteoporotic treatment.Figure 1shows the mean 10-year fracture risk estimated with DeFRAcalc79 tool at the time of the treatment initiation. Teriparatide users had the highest 10-year risk of fracture (67.4% Standard Deviation [SD] 21.5%). We found that in 2,231 patients starting denosumab, the 10-year baseline risk of fracture was 38.5%, SD 22.8%. In 5,759 patients initiating alendronate was 25.7%, SD 15.3% and in patients initiating risedronate was 27.9%, SD 26.9%. Patients prescribed with zoledronic acid had a mean 10-year risk of fracture of 35.6%, SD 21.6. P values between means were all <0.01.

Figure 1.

Mean 10-year risk of fracture estimated with DeFRAcalc79 tool at the time of treatment initiation, p< 0.01 between all means.

Conclusion:

The risk of fracture of Italian post-menopausal women initiating different anti-osteoporotic medications varies significantly. Teriparatide is prescribed to patients with greater risk of fracture. The Nota 79 correctly individuates patients at very high risk of fracture that merit treatment with a bone anabolic. Denosumab and zoledronic acid are prescribed to patients with a greater risk of fracture compared to oral bisphosphonates.

DeFRAcalc79 is a useful and practical tool for the integrated evaluation of the profile of risk of fracture.

References:

[1]Kanis JA et al. Algorithm for the management of patients at low, high and very high risk of osteoporotic fractures. Osteoporos Int 2019 31:1–12.https://doi.org/10.1007/s00198-019-05176-3

[2]Adami G et al. Comments on Kanis et al.: Algorithm for the management of patients at low, high, and very high risk of osteoporotic fractures. Osteoporos Int. 2020. doi: 10.1007/s00198-020-05302-6. [Epub ahead of print]

Disclosure of Interests:

Giovanni Adami: None declared, Angelo Fassio Speakers bureau: Angelo Fassio reports personal fees from: Abiogen and Novartis, outside the submitted work., Alessandro Giollo: None declared, Giovanni Orsolini: None declared, Ombretta Viapiana: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work., Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB

SAT0456 REAL-LIFE RISK OF FRACTURE AND TREATMENT PREVALENCE IN DRUG-INDUCED OSTEOPOROSIS IN ITALY USING A NEW ALGORITHM

Background:

Glucocorticoid-induced osteoporosis and osteoporosis induced by adjuvant hormone therapy for breast cancer are the most common forms of secondary osteoporosis.

Objectives:

The exact real-life prevalence of treatment with anti-osteoporotic drugs in women with drug-induced osteoporosis is not known. In the present study, using a new mathematical and computerized algorithm, we investigate the profile of risk of fracture of women with drug-induced osteoporosis and the prevalence of treatment with anti-osteoporotic drugs.

Methods:

We have retrospectively analyzed the 10-year risk of major osteoporotic fracture calculated with the DeFRAcalc79 tool in postmenopausal women aged over 50 years that were initiating an anti-osteoporotic treatment (fully reimbursed according to the Nota 79). DeFRAcalc79 is a new web-based fracture risk-assessment tool (https://defra-osteoporosi.it) that arithmetically adjusts the risk based on multiple risk factors contemplated by the Nota 79, which regulates the reimbursability for osteoporosis medications in Italy (Italian Agency for Drugs, AIFA), including demographic and anthropometric data, femoral and/or lumbar spine BMD T-score, family history of femoral or vertebral fractures, number and site of previous osteoporotic fracture (including vertebral, femoral, and non-vertebral non-femoral fractures), glucocorticoid treatment (> 3 or > 12 months, ≥5 mg prednisone or equivalent), adjuvant hormone therapy for breast cancer, and comorbidities that induce an increased risk of fracture (rheumatoid arthritis and other connective tissue diseases, chronic obstructive pulmonary disease, inflammatory bowel diseases, Parkinson’s disease, multiple sclerosis, human immunodeficiency virus infection, diabetes, or severe physical handicap). This is a sub-analysis of the cross-sectional observational study to validate and further develop the DeFRA algorithm for the estimation of the risk of osteoporotic fractures, promoted by Verona hospital with the unconditional support of Amgen Srl.

Results:

Among 208 women, 116 (55.8%) were treated with adjuvant hormone therapy for breast cancer and 92 (44.2%) were on glucocorticoid ≥5 mg/day. Women on glucocorticoids had a greater mean 10-year risk of fracture compared to women on adjuvant hormone therapy for breast cancer (67.0% vs 39.1% p<0.01). 50.7% of women on adjuvant hormone therapy for breast cancer used denosumab, 28.0% zoledronic acid and 17.3% alendronate. In glucocorticoid-induced osteoporosis, 17.6% of the women used teriparatide, 37.3% alendronate, 29.4% zoledronic acid and 13.7% denosumab.

Conclusion:

In our cohort of patients, treatment with adjuvant hormone therapy for breast cancer was slightly more common than glucocorticoids. Women with glucocorticoid-induced osteoporosis had a greater risk of fracture compared to patients treated with adjuvant hormone therapy for breast cancer. Half of the patients on adjuvant hormone therapy for breast cancer were prescribed with denosumab. One-fifth of the patients with glucocorticoid-induced osteoporosis was treated with teriparatide. DeFRAcalc79 is a useful and practical tool for the integrated evaluation of fracture risk in drug-induced osteoporosis.

Disclosure of Interests:

Giovanni Adami: None declared, Angelo Fassio Speakers bureau: Angelo Fassio reports personal fees from: Abiogen and Novartis, outside the submitted work., Alessandro Giollo: None declared, Giovanni Orsolini: None declared, Ombretta Viapiana: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work., Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB

AB0893 THE EFFECTS OF THREE DIFFERENT VITAMIN D3 SUPPLEMENTATION REGIMENS IN DEFICIENT SUBJECTS - A RANDOMIZED OPEN-LABEL PARALLEL GROUP STUDY

Background:

Currently, most experts agree that levels of serum 25OH-Vitamin D (25OHD) lower than 20 ng/mL represent an acceptable threshold for deficiency (1). However, recommendations for vitamin D supplementation vary between scientific societies, and the best regimen to treat deficient patients is still not clear (1).

Objectives:

The aim of our study was to compare the pharmacokinetic profile of three different regimes of cholecalciferol supplementation in terms of 25OHD exposure and their safety profiles.

Methods:

We evaluated, in healthy subjects affected by vitamin D deficiency (defined as 25OHD<20 ng/mL), 18 to 60 years of age, the efficacy of three different oral supplementation regimens: daily 10,000Iu administered for 8 weeks, weekly 50,000Iu for 12 weeks and biweekly 100,000Iu for 12 weeks. Serum 25OHD was dosed at baseline, at week 2, 4, 8 in all three groups and also at week 12 in the 50,000 and 100,000Iu groups (the blood sample was taken before the drug administration if scheduled on the same day). Baseline characteristics and 25OHD changes from baseline to the various observation points were tested with ANOVA and t-test. 25OHD was measured by the IDS-ISYSMulti-Discipline automated analyser (Immunodiagnostic System, Boldon, UK) based on chemiluminescence technology. The CV intra-assay measured in our laboratory was 6% (inter-assay CV 9%). The study was authorized by the local ethical committee (protocol DIBA/11. Supported by Abiogen Pharma, Italy).

Results:

A total of 75 subjects were randomized to receive one supplementation regimen. The descriptive of the sample at baseline and relative 25OHD levels at the various observation points are reported in table 1. 25OHD increased significantly already at week 2 in all three groups (p=0.000). At week 2, 100% of the subject of the daily regimen group presented 25OHD levels >20ng/mL, 96% in the weekly and 88% in the biweekly ones.

Table 1.

mean values ± SD at the different observation points.

ParameterDaily 10.000 Ui(N = 25)Weekly 50.000 Ui(n = 25)Biweekly 100.000 Ui(N = 25)p-valueM:F12:137:1812:13Age (years)30.2 ± 9.936.7 ± 8.735.4 ± 11.0*0.059Body Weight (kg)65.8 ± 13.267.8 ± 10.866.6 ± 13.7*NSHeight (m)1.7 ± 0.11.68 ± 0.11.7 ± 0.1*NSBMI22.55 ± 2.723.8 ± 2.222.8 ± 2.7*NSBaseline 25OHD (ng/mL)14.6 ± 3.912.8 ± 313.5 ± 4.1*NS25OHD week 232.3 ± 526.5 ± 3.425.6 ± 5a0.007b0.00025OHD week 455 ± 10.139.9 ± 4.236.9 ± 7.2a0.000b0.00025OHD week 879.1 ± 16.253.5 ± 7.246.4 ± 8.2a0.000b0.000c0.00125OHD week 12NA58.5 ± 7.850.6 ± 9.6b0.000c0.001

*ANOVA test.

aDaily 10.000 Ui vs weekly 50.000 Ui.

bDaily 10.000 Ui vs Biweekly 100.000 Ui.

cWeekly 50.000 Ui vs biweekly 100.000 Ui.

In addition, the 25OH levels of the daily regimen group at week 8 were higher than both the ones of the weekly and the biweekly regimen groups both at week 8 and week 12 (p<0.000 vs both groups).

No serious adverse event occurred.

Conclusion:

All the three different regimens proved to be effective in correcting vitamin D deficiency already after 1 months (2 weeks for the daily regimen). A more refracted approach seems to more effective than the bolus-based regimens. The safety profile was excellent in all groups.

References:

[1]R. Bouillon, Comparative analysis of nutritional guidelines for vitamin D, Nat. Rev. Endocrinol. 13 (2017) 466–479.https://doi.org/10.1038/nrendo.2017.31.

Disclosure of Interests:

Angelo Fassio Speakers bureau: Angelo Fassio reports personal fees from: Abiogen and Novartis, outside the submitted work., Giovanni Adami: None declared, Ombretta Viapiana: None declared, Giovanni Orsolini: None declared, Alessandro Giollo: None declared, Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work.

Pharmacokinetics of Oral Cholecalciferol in Healthy Subjects with Vitamin D Deficiency: A Randomized Open-Label Study

BACKGROUND

the aim of this study was to investigate the pharmacokinetic (PK) and safety profile of high-dose vitamin D supplementation, comparing different schedules (daily, weekly, or bi-weekly) in an otherwise healthy vitamin D-deficient population. Methods: single-center, open-label study on healthy subjects deficient in vitamin D (25 (OH)D < 20 ng/mL), randomized to receive cholecalciferol (DIBASE^®, Abiogen Pharma, Italy) using three different schedules: Group A: 10,000 IU/day for eight weeks followed by 1000 IU/day for four weeks; Group B: 50,000 IU/week for 12 weeks, Group C: 100,000 IU/every other week for 12 weeks. Total cumulative doses were: 588,000 IU, 600,000 IU, 600,000 IU. The treatment regimens corresponded to the highest doses allowed for cholecalciferol for the correction of vitamin D deficiency in adults in Italy.

RESULTS

mean 25 (OH)D plasma levels significantly increased from baseline 13.5 ± 3.7 ng/mL to peak values of 81.0 ± 15.0 ng/mL in Group A, 63.6 ± 7.9 ng/mL in Group B and 59.4 ± 12 ng/mL in Group C. On day 28, all subjects showed 25 (OH)D levels ≥ 20 ng/mL and 93.1% had 25 (OH)D levels ≥ 30 ng/mL. On day 56 and 84, all subjects had 25 (OH)D levels ≥ 30 ng/mL. No serious adverse events occurred during the study.

CONCLUSIONS

normalization of 25 (OH)D serum levels was quickly attained with all the studied regimens. A more refracted schedule provided a higher systemic 25 (OH)D exposure.

Incidence and predictors of adverse clinical events in patients with rheumatoid arthritis and asymptomatic left ventricular systolic dysfunction

OBJECTIVES

Patients with rheumatoid arthritis (RA) are exposed to impairment in left ventricular (LV) function, which is a prognosticator of poorer clinical outcomes. In this study we assessed prevalence and factors associated with adverse outcomes in patients with RA and asymptomatic LV systolic dysfunction (LVSD).

METHODS

We prospectively analysed 102 RA patients with asymptomatic LVSD consecutively selected by a pool of 418 RA patients referred to the Division of Rheumatology, University of Verona, between March 2014 and March 2015. LVSD was defined as impaired global longitudinal strain (GLS) measured by echocardiography. The pre-specified study end-points were all-cause death/hospitalisation, and death/hospitalisation for cardiovascular cause.

RESULTS

During a follow-up of 35 [13-54] months, all-cause death/hospitalisation occurred in 40 patients (39%). No patient died during the follow-up, 18 patients (18% of the study population) had a cardiovascular event which required hospitalisation, while 22 (22% of patients) required hospitalisation, but this was unrelated to CV. Multiple Cox regression analysis identified worse renal function, more frequent use and a higher number of biologic DMARDs used before enrolment as independent predictors of all-causes hospitalisation. The same variables together with higher LV mass predicted CV hospitalisation. Prognostic cut-off points were 90 ml/min/1.73 m2 for glomerular filtration rate and 49 g/m2.7 for LV mass.

CONCLUSIONS

RA patients with asymptomatic LVSD have a very high rate of all-cause and cardiovascular hospitalisation at mid-term follow-up, predicted by worse renal function, higher LV mass, more frequent use and higher number of biologic DMARDs used before enrolment, suggesting that biologic DMARDs refractory is a proxy of adverse events.

Radiofrequency echographic multi spectrometry for the prediction of incident fragility fractures: A 5-year follow-up study

PURPOSE

To investigate the effectiveness of the T-score values provided by Radiofrequency Echographic Multi Spectrometry (REMS) in the identification of patients at risk for incident osteoporotic fractures.

METHODS

A population of Caucasian women (30-90 years), enrolled from 2013 to 2016, underwent dual X-ray absorptiometry (DXA) and REMS scans at axial sites. The incidence of fragility fractures was assessed during a follow-up period up to 5 years. Afterwards, patients with and without incident fractures were stratified in two age-matched groups with a 1: 2 proportion (Group F' and Group NF', respectively). The performance of REMS T-score in discriminating between the two groups was quantitatively assessed and compared with DXA.

RESULTS

1516 patients were enrolled and 1370 completed the follow-up (mean ± SD: 3.7 ± 0.8 years; range: 1.9-5.0 years). Fracture incidence was 14.0%. Age-matched groups included 175 fractured patients and 350 non-fractured ones, respectively (median age 70.2 [interquartile range: 61.0-73.3] and 67.3 [65.4-69.8] years, p-value ns). The groups resulted also balanced for height, weight and BMI (p-values ns). As expected, the differences in REMS T-score (for vertebral site, -2.9 [-3.6 to -1.9] in Group F', -2.2 [-2.9 to -1.2] in Group NF') and DXA T-score (-2.8 [-3.3 to -1.9] in Group F', -2.2 [-2.9 to -1.4] in Group NF') were statistically significant (p-value <0.001). Analogous results were obtained for femoral neck. Considering the T-score cut-off of -2.5, REMS identified Group F' patients with a sensitivity of 65.1% and specificity of 57.7% of (OR = 2.6, 95%CI: 1.77-3.76, p < 0.001), whereas DXA showed a sensitivity of 57.1% and a specificity of 56.3% (OR = 1.7, 95%CI: 1.20-2.51, p-value = 0.0032). For femoral neck, REMS sensitivity and specificity were 40.2% and 79.9%, respectively, with an OR of 2.81 (95%CI: 1.80-4.39, p < 0.001). DXA, instead, showed a sensitivity and specificity of 42.3% and 79.3%, respectively, with an OR of 2.68 (95%CI: 1.71-4.21, p < 0.001).

CONCLUSIONS

REMS T-score resulted an effective predictor for the risk of incident fragility fractures in a population-based sample of female subjects, representing a promising parameter to enhance osteoporosis diagnosis in the clinical routine.

Disease Activity and Anticitrullinated Peptide Antibody Positivity Predict the Worsening of Ventricular Function in Rheumatoid Arthritis

Objective

This prospective study was designed to analyze the incidence and the factors associated with impairment in left ventricular systolic function (LVSF) overtime in patients with rheumatoid arthritis (RA) without overt cardiac disease. In particular, we verified the hypothesis that a relationship between worsening of LVSF and markers of RA disease activity exists.

Methods

One hundred forty outpatients with RA without overt heart disease underwent clinical, laboratory, and echocardiographic evaluation at baseline and after 35 (interquartile range [IQR] 23‐47) months of follow‐up. A clinical Disease Activity Index (CDAI) score greater than 10 indicated the presence of moderate‐high RA disease activity; data on anticitrullinated peptide antibody (ACPA) positivity were recorded at baseline. Stress‐corrected midwall fractional shortening (sc‐MFS) was used as a measure of LVSF and was considered impaired if less than 86.5%.

Results

At 36 (IQR 23‐47) months follow‐up, impaired sc‐MFS was detected in 60 of 140 (43%) patients, compared with 80 patients with normal sc‐MFS. Disease duration and activity, ACPA positivity, inflammatory markers, cardiovascular and antirheumatic therapies, and sc‐MFS were similar between the two groups at baseline. A multiple logistic regression analysis showed ACPA positivity, moderate‐high disease activity (CDAI greater than 10), and disease duration as independent predictors of impaired sc‐MFS at follow‐up. Finally, a simple clinical score to predict worsening of LVSF at midterm was built (area under the curve of 0.80, with a sensibility and specificity of 78% and 82%, respectively).

Conclusion

Disease duration, ACPA positivity, and moderate‐high disease activity are independent prognosticators of LVSF impairment in RA. Adverse changes in heart function could be prevented by good control of inflammation and modulation of autoimmunity.

Acute Effects of Glucocorticoid Treatment, TNFα or IL-6R Blockade on Bone Turnover Markers and Wnt Inhibitors in Early Rheumatoid Arthritis: A Pilot Study

Tumor Necrosis Factor (TNF)-α and Interleukin (IL)-6 play a fundamental role in bone loss in rheumatoid arthritis (RA), partly due to the inhibition of the Wnt canonical pathway. The aim of our study was to investigate the short-term effects of three different treatments on Wnt inhibitors (Dkk-1 and sclerostin) and on bone turnover markers (BTMs): N-propeptide of type I collagen (PINP) and C-terminal telopeptide of type I collagen (β-CTX-I). We performed a retrospective analysis of prospectively collected data. We enrolled women affected by early RA (< 12 months) with active disease (DAS28 ≥ 2.6) despite a 6-month treatment with methotrexate (10-15 mg/week), who then started certolizumab pegol, tocilizumab, or methyl-prednisolone (8 mg/daily). Patients were divided into three groups according to the treatment. Blood samples were collected at baseline, week 1, and week 4. We selected 14 patients treated with certolizumab pegol, 14 patients with tocilizumab, and 20 patients with methyl-prednisolone. No difference between any of the tested parameters was found at baseline. β-CTX-I, Dkk-1, and sclerostin decreased after 1 week of treatment with certolizumab pegol (- 27% ± 21.5, - 50% ± 13.2, and - 30% ± 30.4, respectively, p < 0.05). Methyl-prednisolone induced similar changes, albeit less marked, on β-CTX-I and Wnt inhibitors, with a decrease in PINP (- 16.1% ± 16.5, p < 0.05). Tocilizumab did not significantly affect BTMs or Wnt inhibitors. No significant changes were found for PTH and 25OHD. In the first four weeks of treatment, TNFα inhibition showed strong effects on BTMs and Wnt inhibitors, differently from IL-6 blockade. Glucocorticoids induced similar changes; nonetheless, they showed undesired effects on bone formation.

Vitamin D supplementation: much ado about nothing

The scientific interest and the number of papers dealing with vitamin D supplementation has greatly grown in the last decades. Unfortunately, expert consensus on many clinical aspects of this topic is still lacking. In addition, data coming from recent clinical trials and meta-analyses seem to strongly put into doubt the real benefit of vitamin D supplementation, on both skeletal and extra-skeletal outcomes. This is further confusing since they seem to completely contradict the considerable body of evidence provided from previous epidemiological studies. This paper aims to analyze these new data in order to shed light onto the debated issues.

Nonlinear pulse compression to 22 fs at 15.6 µJ by an all-solid-state multipass approach

We demonstrate nonlinear compression of pulses at 1.03 µm and repetition rate of 200 kHz generated by a ytterbium fiber laser using two cascaded all-solid-state multipass cells. The pulse duration has been compressed from 460 to 22 fs, corresponding to a compression factor of ∼21. The compressed pulse energy is 15.6 µJ, corresponding to an average power of 3.1 W, and the overall transmission of the two compression stages is 76%. The output beam quality factor is M² ∼1.2 and the excess intensity noise introduced by nonlinear broadening is below 0.05%. These results show that nonlinear pulse compression down to ultrashort durations can be achieved with an all-solid-state approach, at pulse energies much higher than previously reported, while preserving the spatial characteristics of the laser.

Osteoporosis in Rheumatic Diseases

Osteoporosis is a chronic disease characterized by an increased risk of fragility fracture. Patients affected by rheumatic diseases are at greater risk of developing osteoporosis. The purpose of the present review is to discuss the pathogenesis, epidemiology, and treatment of osteoporosis in patients affected by rheumatic diseases with special focus for rheumatoid arthritis, psoriatic arthritis, spondyloarthritis, systemic lupus erythematosus, systemic sclerosis, vasculitides, Sjogren syndrome, and crystal-induced arthritis.