OP0027 ASSOCIATION BETWEEN BASELINE CARDIOVASCULAR RISK AND INCIDENCE RATES OF MAJOR ADVERSE CARDIOVASCULAR EVENTS AND MALIGNANCIES IN PATIENTS WITH PSORIATIC ARTHRITIS AND PSORIASIS RECEIVING TOFACITINIB

Background

Common comorbidities of psoriatic arthritis (PsA) and psoriasis (PsO) are cardiovascular (CV) disease and metabolic syndrome (MetS).1,2 Risk of CV disease may be associated with increased risk of future malignancies.3 Tofacitinib is a JAK inhibitor for treatment of PsA and has been investigated for treatment of PsO.

Objectives

To examine baseline (BL) CV risk and its association with incidence rates (IRs) of major adverse CV events (MACE) and malignancies in tofacitinib-treated patients (pts) with PsA and PsO.

Methods

Analysis included data from 3 (Phase [P]3/long-term extension [LTE]) trials of pts with PsA and 7 (P2/3/LTE) trials of pts with PsO receiving ≥1 dose of tofacitinib (5 or 10 mg twice daily). IRs (pts with events/100 pt-yrs) for MACE and malignancies (excluding non-melanoma skin cancer) were stratified by: history of coronary artery disease (HxCAD [≥1 of myocardial infarction, coronary heart disease, coronary artery procedure or stable angina pectoris]); BL 10-yr atherosclerotic CV disease (ASCVD) risk (ASCVD-pooled cohort equations calculator [only in pts without HxCAD]); and BL MetS (≥3 of hypertension, raised triglycerides, reduced high-density lipoprotein cholesterol, high waist circumference or high fasting glucose levels).

Results

Of 783 and 3663 pts with PsA and PsO, total tofacitinib exposure was 2038 and 8950 pt-yrs, and median duration of exposure was 3.0 and 2.4 yrs, respectively. In pts with PsA and PsO, 5.0% and 2.5% had HxCAD, respectively; in those without HxCAD, >20% had intermediate/high BL 10-yr ASCVD risk (Figure 1). At BL, 40.9% and 32.7% of pts with PsA and PsO had MetS, respectively. IRs of MACE were greatest in pts with PsA and PsO who had HxCAD/high BL 10-yr ASCVD risk (Table 1). In the PsA cohort, 5/6 pts with MACE had BL MetS. IRs of malignancies in pts with PsA were greatest in those with intermediate/high BL 10-yr ASCVD risk; 8/9 pts with malignancies in these risk categories had BL MetS (Table 1). In the PsO cohort, IR of malignancies was notably greater in those with high vs low/intermediate BL 10-yr ASCVD risk (Table 1).

Table 1.

IRs of MACE and malignancies in pts with PsA and PsO receiving tofacitinib, stratified by HxCAD, BL 10-yr ASCVD risk and BL MetS

MACEMalignanciesPsAPsOPsAPsOn/N[n1]IR (95% CI)n/N[n1]IR (95% CI)n/N[n1]IR (95% CI)n/N[n1]IR (95% CI)HxCADYes1/39[0]0.97 (0.02, 5.38)3/93[0]1.49 (0.31, 4.36)0/39[0]0.00 (0.00, 3.52)0/93[0]0.00 (0.00, 1.83)No5/744[5]0.25 (0.08, 0.59)20/3570[10]0.22 (0.13, 0.34)15/744[10]0.75 (0.42, 1.24)60/3570[26]0.66 (0.51, 0.85)BL 10-yr ASCVD risk categoryHigh risk (≥20%)1/35[1]1.26 (0.03, 7.01)7/179[4]1.67 (0.67, 3.43)1/35[1]1.26 (0.03, 7.03)15/179[10]3.57 (2.00, 5.89)Intermediate risk(≥7.5–<20%)2/121[2]0.62 (0.07, 2.23)9/716[6]0.50 (0.23, 0.95)8/121[7]2.46 (1.06, 4.86)23/716[9]1.28 (0.81, 1.92)Borderline risk(≥5–<7.5%)1/91[1]0.42 (0.01, 2.32)2/400[0]0.19 (0.02, 0.67)2/91[1]0.83 (0.10, 3.01)5/400[1]0.47 (0.15, 1.09)Low risk (<5%)1/487[1]0.08 (0.00, 0.42)2/2241[0]0.03 (0.00, 0.13)4/487[1]0.30 (0.08, 0.77)17/2241[6]0.30 (0.17, 0.47)BL MetSYes5/3200.60 (0.20, 1.40)10/11970.34 (0.16, 0.63)10/3201.20 (0.58, 2.21)26/11970.89 (0.58, 1.31)No1/4630.08 (0.00, 0.44)13/24660.20 (0.11, 0.35)5/4630.40 (0.13, 0.92)34/24660.54 (0.37, 0.75)

Follow-up time calculated up to the day of the first event and subject to risk period of 28 days beyond the last dose of study drug.

CI, confidence interval; N, total pts; n, pts with MACE/malignancies; n1, pts with MACE/malignancies and BL MetS.

Conclusion

In tofacitinib-treated pts with PsA and PsO, raised CV risk and MetS at BL were potentially associated with higher IRs of MACE and malignancies. Our findings support assessing CV risk in pts with PsA and PsO and enhanced monitoring for malignancies in those with raised CV risk.

References

[1]Karmacharya et al. Ther Adv Musculoskel Dis 2021; 13: 1-15.

[2]Garshick et al. J Am Coll Cardiol 2021; 77: 1670-1680.

[3]Lau et al. JACC CardioOncol 2021; 3: 48-58.

Acknowledgements

Study sponsored by Pfizer Inc. Medical writing support was provided by Emma Mitchell, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests

Lars Erik Kristensen Speakers bureau: AbbVie, Amgen, Biogen, Bristol-Myers Squibb, Eli Lilly, Janssen, MSD, Novartis, Pfizer Inc and UCB, Grant/research support from: Biogen, Janssen, Novartis and UCB, Bruce Strober Speakers bureau: AbbVie, Amgen, Eli Lilly, Janssen and Ortho Dermatologics, Consultant of: AbbVie, Almirall, Amgen, Arcutis, Arena, Aristea, Boehringer Ingelheim, Bristol-Myers Squibb, Cara, Celgene, Dermavant, Dermira, Eli Lilly, GlaxoSmithKline, Janssen, Leo, Meiji Seika Pharma, Novartis, Ortho Dermatologics, Pfizer Inc, Regeneron, Sanofi-Genzyme, Sun Pharma and UCB, Denis Poddubnyy Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer Inc and UCB, Consultant of: AbbVie, BIOCAD, Gilead Sciences, GlaxoSmithKline, Eli Lilly, MSD, Novartis, Pfizer Inc, Samsung Bioepis and UCB, Grant/research support from: AbbVie, MSD, Novartis and Pfizer, Ying Ying Leung Consultant of: AbbVie, Eli Lilly, Janssen and Novartis, Hyejin Jo Consultant of: Pfizer Inc, Employee of: Syneos Health, Kenneth Kwok Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Ivana Vranic Shareholder of: Pfizer Inc, Employee of: Pfizer Ltd, Dona Fleishaker Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Lara Fallon Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Arne Yndestad Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Dafna D Gladman Consultant of: AbbVie, Amgen, Celgene, Eli Lilly, Galapagos, Gilead Sciences, Janssen, Novartis, Pfizer Inc and UCB.

OP0152 A DEEP LEARNING FRAMEWORK FOR MRI DETECTION OF ACTIVE INFLAMMATORY AND STRUCTURAL CHANGES IN THE SACROILIAC JOINT CONSISTENT WITH AXIAL SPONDYLOARTHRITIS: AN INTERNATIONAL COLLABORATIVE STUDY

Background

Magnetic resonance tomography (MRI) plays a key role in the early diagnosis of axial spondyloarthritis (axSpA). However, the detection of changes indicative of axSpA requires specific expertise, which poses a challenge to non-specialized centers. Deep learning (an advanced machine learning method) based on training an artificial neural network may facilitate and support diagnostics in clinical practice.

Objectives

To create a reliable deep learning tool for the detection of active inflammatory and structural changes indicative of axSpA on MRI of sacroiliac joints.

Methods

In this study, MRIs of sacroiliac joints from 477 patients from four cohorts (GESPIC-AS, GESPIC-Crohn, GESPIC-Uveitis and OptiRef comprising 266 patients with and 211 without axSpA) were used to develop a deep learning framework (randomly divided into training, n=404, and validation, n=73, datasets). MRIs from the ASAS cohort (n=116) were used for independent testing (test dataset). Each examination in the training/validation dataset was evaluated for the presence of active inflammatory and structural changes indicative of SpA by six experienced, trained and calibrated readers and by seven expert readers in the test dataset. The presence of the changes was defined as the majority vote amongst readers. Discordant cases in the training/validation dataset underwent consensus reading. In addition, the test dataset was evaluated by three radiologists not specifically trained in SpA. Diagnostic performance was evaluated using the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity and specificity.

Results

The prevalence of positive imaging findings for active inflammatory/structural changes indicative of axSpA was 41%/51% in the training/validation dataset and 22%/22% in the test dataset. The model for the detection of active inflammatory changes showed an AUC of 0.91 (0.83 – 0.97) – Figure 1 – and an accuracy of 84% on the validation dataset; the corresponding sensitivity and specificity were 96% and 76%, respectively. Despite a substantially lower prevalence of active inflammatory changes in the test dataset, the model showed good generalization with an AUC of 0.91 (0.84−0.97) and an accuracy of 75%; the sensitivity and specificity were 88% and 71%, respectively. The model demonstrated a similar performance on the validation and test datasets for the detection of active inflammatory changes fulfilling the ASAS definition. The model for the detection of structural changes indicative of axSpA showed good performance on the validation dataset with an AUC of 0.90 (0.82-0.96) for the detection of structural changes and an overall accuracy of 85%. The associated sensitivity and specificity were 95% and 75%, respectively. The model showed reasonable generalization to new data with an AUC of 0.89 (0.81−0.96) and an accuracy of 79%; the sensitivity and specificity were 85% and 78%, respectively. Overall, the model performed close to the individual human experts - Figure 1.

Conclusion

The developed framework allowed the detection of active inflammatory and structural changes indicative of axSpA on MRI. This approach may be used as an assistant tool in the diagnostic workflow.

Acknowledgements

GESPIC-AS has been financially supported by the German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung - BMBF). GESPIC-Crohn has been supported by the Clinical Research Unit grant from the Berlin Institute of Health (BIH). GESPIC-Uveitis has been supported by a research grant from AbbVie. OptiRef has been supported by a research grant from Novartis. The Assessment of Spondyloarthritis International Society (ASAS) has supported the project with a research grant and provided access to the MRI images of the ASAS calssifiaction cohort.

We want to thank colleagues who performed annotation of the images from the ASAS classification cohort: Pedro Machado, Mikkel Ostergaard, Suzanne Juhl Pedersen, Ulrich Weber. Further, we thank Torsten Karge for the development of the MRI reading interface for GESPIC and OptiRef images, Joel Paschke for development of the scoring interface for ASAS images.

LCA is grateful for her participation in the BIH Charité–Junior Clinician and Clinician Scientist Program and KKB is grateful for his participation in the BIH Charité Digital Clinician Scientist Program all funded by the Charité–Universitätsmedizin Berlin and the Berlin Institute of Health. JR is grateful for her participation in the BIH Charité–Junior Clinician and Clinician Scientist Program.

Disclosure of Interests

None declared

OP0017 RECAPTURE RATES WITH IXEKIZUMAB AFTER WITHDRAWAL OF THERAPY IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS: RESULTS AT WEEK 104 FROM A RANDOMIZED PLACEBO-CONTROLLED WITHDRAWAL STUDY

Background

COAST-Y is the first study to evaluate the effect of continuing vs withdrawing an IL-17A antagonist, Ixekizumab (IXE) on the maintenance of disease control in patients (pts) with ankylosing spondylitis and non-radiographic axial spondyloarthritis through 104 Weeks (wks).

Objectives

Here, we describe the final results of pts re-randomized to either placebo (PBO; IXE Withdrawal) or IXE, who experienced flare, and recaptured response before or after open label retreatment during COAST-Y.

Methods

COAST-Y (NCT03129100) is a Phase 3, long-term extension study that included a double-blind, PBO-controlled, randomized withdrawal-retreatment period (RWP). Eligible pts who completed an originating study (COAST-V, -W, or -X) entered a 24-Week (Wk) lead-in period and received 80 mg IXE every 2 (Q2W) or 4 wks (Q4W) (the treatment regimen at the end of the originating study); pts receiving PBO at the end of COAST-X were assigned to IXE Q4W in COAST-Y. Pts who achieved remission (Ankylosing Spondylitis Disease Activity Score (ASDAS) <1.3 (inactive disease; ID) at least once at Wk 16 or 20, and <2.1 (low disease activity; LDA) at both visits) were randomized 2:1 at Wk 24 to continue IXE (as per lead-in period) or withdrawn to PBO. Pts who subsequently experienced flare (ASDAS ≥2.1 at 2 consecutive visits or ASDAS >3.5 at any visit) were switched to open label IXE Q2W or Q4W at the next visit (same as lead-in period). Time to first flare was analyzed using the Kaplan-Meier method with treatment comparison performed using log-rank test. The observed proportion of pts who recaptured ASDAS LDA and ID were summarized for pts who experienced flare and were retreated with open label IXE.

Results

A total of 155 pts met the criteria for remission and entered the RWP (PBO [IXE withdrawal], N=53; IXE Q4W, N=48; IXE Q2W, N=54) and 138 completed Wk 104. At Wk 104, significantly more pts in the combined IXE group (75.5%, p<0.001, IXE Q4W: 75.0%, p<0.001; IXE Q2W: 75.9%, p<0.001) remained flare free through Wk 104 vs PBO (Figure 1). Notably, 35.8% of pts on PBO (IXE Withdrawal) never experienced flare. Of the PBO pts who experienced flare and were retreated during Wk 24-104 (N=28), 4 recaptured LDA before switching to open label IXE retreatment, while 23 recaptured LDA and 19 met ID after switching (Table 1). Of the continuously treated IXE pts (N=13), 7 recaptured LDA before switching to open label IXE retreatment, while 5 recaptured LDA and 4 met ID after.

Figure 1.

The proportion (%) of patients who remained flare free through 104 weeks. ‡p<0.001, †p<0.01, *p<0.05 vs PBO (IXE Withdrawal).

Table 1.

Recapture of first treatment response before or after switching to open label IXE through 104 weeks among placebo (ixekizumab withdrawal)-treated patients who experienced a flare and retreated

Total patients who flared and were switched to open-label ixekizumab retreatmentPlacebo (ixekizumab withdrawal)(N=28)ASDAS disease activity statusLDAIDRecaptured response before open label ixekizumab retreatment41Recaptured response with open label ixekizumab retreatment (≤16 weeks)2314Recaptured response with open label ixekizumab retreatment (>16 weeks)05Total patients who recaptured response at week 10427/28 (96%)20/28 (71%)

Data are presented as n, (%) for the total row and n only for all other rows. In each column, the denominator is 28. ASDAS, Ankylosing Spondylitis Disease Activity Score; ID, inactive disease; LDA, low disease activity including ID; N, number of patients in the analysis population.

Conclusion

Pts continuously treated with IXE were less likely to experience flare vs pts on PBO (IXE withdrawal). The vast majority of pts withdrawn from IXE to PBO recaptured at least LDA and over half met ID with IXE retreatment. This may provide support for pts who require interruption in therapy.

Acknowledgements

This study was sponsored by Eli Lilly and Company. Medical writing services were provided by Edel Hughes, PhD and Sumeet Sood, PhD of Eli Lilly and Company, and was funded by Eli Lilly and Company.

Disclosure of Interests

Robert B.M. Landewé Consultant of: Rheumatology Consultancy BV, AbbVie, UCB, Pfizer, Eli Lilly and Company, Novartis, and Celgene, Denis Poddubnyy Speakers bureau: AbbVie, Bristol Myers Squibb, Celgene, Eli Lilly and Company, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Roche, and UCB Pharma, Consultant of: AbbVie, Bristol Myers Squibb, Celgene, Eli Lilly and Company, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Roche, and UCB Pharma, Grant/research support from: AbbVie, Eli Lilly and Company, Merck Sharp & Dohme, Novartis, and Pfizer, Proton Rahman Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, and UCB, Rebecca Bolce 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, Jeffrey Lisse Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Ann Leung: None declared, So Young Park Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Lianne S. Gensler Consultant of: AbbVie, Eli Lilly and Company, Grant/research support from: Novartis, Pfizer, and UCB.

OP0149 RADIOGRAPHIC PROGRESSION FROM NON-RADIOGRAPHIC TO RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS: RESULTS FROM A 5-YEAR MULTICOUNTRY PROSPECTIVE OBSERVATIONAL STUDY

Background

Patients (pts) with axial spondyloarthritis (axSpA) are classified into radiographic axSpA (r-axSpA) and non-radiographic axSpA (nr-axSpA) based on the presence or absence of radiographic sacroiliitis. Approximately 20% to 80% of newly diagnosed axSpA pts have nr-axSpA and 8% to 40% progress to r-axSpA over the next 2 to 10 years.

Objectives

To evaluate progression from nr-axSpA to r-axSpA over 5 years in a prospective multicentre cohort.

Methods

PROOF was a global, real-world, prospective, observational study conducted in rheumatology clinical practices in 29 countries across 6 different geographic regions.1 The study enrolled adults with chronic back pain for ≥3 months and onset before 45 years of age. This analysis included pts diagnosed with axSpA who also fulfilled the Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axSpA. Study visits occurred at baseline (BL) and yearly thereafter. Baseline and follow-up radiographs of sacroiliac joints (SIJ) were evaluated for pts with initial nr-axSpA diagnosis independently by 2 central readers according to the modified New York criteria. In the case of disagreement on the classification (nr- or r-axSpA), images were adjudicated by a third reader. Radiographic progression from nr-axSpA to r-axSpA over 5 years was evaluated by Kaplan-Meier analysis. Cox proportional hazards regression analyses for time to radiographic progression from nr-axSpA to r-axSpA were conducted. For model 1, ‘imaging arm vs clinical arm’ was used as an independent variable, and for model 2, ‘active inflammation on magnetic resonance imaging highly suggestive of sacroiliitis associated with SpA’ was used. Further, potential predictive factors included in the models were age, gender, back pain duration, number of SpA parameters, smoking status, CRP, good response to NSAIDs, HLA-B27 status, and current use of NSAIDs and TNF inhibitors.

Results

Among 2633 enrolled pts, 2165 (82%) were diagnosed with axSpA and fulfilled the ASAS classification criteria. Among these, 1612 (74%) were classified as having r-axSpA (1050 [65%]) or nr-axSpA (562 [35%]) by central reading. The majority of nr-axSpA pts (77%) fulfilled the ASAS classification criteria due to positive findings on imaging (plus ≥1 SpA feature) and 23% were classified according to the clinical arm. A total of 246 nr-axSpA pts who had ≥1 follow-up SIJ radiograph were included in this analysis. Among these 246 pts, progression from initial nr-axSpA to r-axSpA at any of the follow-up visits was observed in 40 pts (16%) over 5 years. Mean time to radiographic progression was 2.4 years (ranging from 0.9 to 5.1 years) in descriptive analysis (Kaplan-Meier curve shown in Figure 1). In model 1 of the Cox regression analysis, male gender (hazard ratio [HR]: 3.16 [95% CI: 1.22–8.17]; P=0.0174), fulfilment of the imaging arm (HR: 6.64 [1.37–32.25]; P=0.0188), and good response to NSAIDs, (HR: 4.66 [1.23–17.71]; P=0.0237), were significantly associated with progression to r-axSpA (Figure 1). In model 2, HLA-B27 positivity showed a significant association with progression (HR: 3.99 [1.10–14.49]; P=0.0353; Figure 1).

Conclusion

In this study, 16% of nr-axSpA pts progressed to r-axSpA within 5 years. The mean time to disease progression was 2.4 years. Predictors of radiographic progression were male gender, good response to NSAIDs, and fulfilment of the imaging arm as well as HLA-B27 positivity.

References

[1]Poddubnyy D. et al, Rheumatology (Oxford). 2021; doi: 10.1093/rheumatology/keab901

Disclosure of Interests

Denis Poddubnyy Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Biocad, Eli Lilly, Gilead, GlaxoSmithKline, MSD, Novartis, Pfizer, Samsung Bioepis, and UCB, Grant/research support from: AbbVie, Eli Lilly, MSD, Novartis, and Pfizer, Joachim Sieper Speakers bureau: AbbVie, Janssen, Merck, Novartis, Pfizer, Roche, and UCB, Consultant of: AbbVie, Janssen, Lilly, Merck, Novartis, Pfizer, and UCB, Servet Akar Speakers bureau: AbbVie, Lilly, MSD, Novartis, Pfizer, Roche, Janssen, and UCB, Consultant of: AbbVie, Lilly, MSD, Novartis, Pfizer, Roche, Janssen, and UCB, Grant/research support from: AbbVie, Lilly, MSD, Novartis, Pfizer, Roche, Janssen, and UCB, Santiago Muñoz-Fernández Speakers bureau: AbbVie, BMS, Galapagos, Janssen, MSD, Novartis, Pfizer, Roche, and UCB., Consultant of: AbbVie, BMS, Galapagos, Janssen, MSD, Novartis, Pfizer, Roche, and UCB., Grant/research support from: AbbVie, BMS, Galapagos, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Hildrun Haibel Speakers bureau: AbbVie, Janssen, MSD, Pfizer, Sobi, Novartis, and Roche, Consultant of: Boehringer, Janssen, MSD, Novartis, and Roche, Torsten Diekhoff Paid instructor for: Novartis, MSD, Canon MS, Consultant of: Eli Lilly, Mikhail Protopopov: None declared, Elisabeth Altmaier Consultant of: AbbVie, Fabiana Ganz Shareholder of: Owns AbbVie stock or stock options., Employee of: AbbVie, Robert Inman Consultant of: AbbVie, Amgen, Janssen, Lilly, Novartis, Pfizer, and Sandoz, Grant/research support from: AbbVie, Amgen, and Janssen

OP0021 TREATMENT WITH NON-STEROIDAL ANTI-INFLAMMATORY DRUGS IS ASSOCIATED WITH RETARDATION OF RADIOGRAPHIC SPINAL PROGRESSION IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS: 10-YEAR RESULTS FROM THE GERMAN SPONDYLOARTHRITIS INCEPTION COHORT

Background

There are conflicting data regarding effect of nonsteroidal anti-inflammatory drugs (NSAID) on radiographic spinal progression in axial spondyloarthritis (axSpA). The analysis of the first 2-year of the GErman SPondyloarthritis Inception Cohort (GESPIC) showed that higher NSAID intake may retard new bone formation in r-axSpA. It remained, however, unclear, whether cyclooxygenase-2 selective inhibitors (COX2i) might have a stronger effect than non-selective (NS) ones and if the effect could be observed also in nr-axSpA.

Objectives

To investigate the effect of NSAIDs (COX2i and NS) intake on radiographic spinal progression in patients with r-axSpA and nr-axSpA.

Methods

Based on availability of at least two sets of spinal radiographs during 10-year follow-up, 243 patients with early axSpA (130 and 113 nr- and r-axSpA, respectively) from GESPIC were included in this analysis. The patients contributed a total of 540 2-year radiographic intervals. Radiographs were scored by 3 trained and calibrated readers according to modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). Final mSASSS was calculated as a mean of 3 readers, and progression was defined as absolute mSASSS change score over 2 years. NSAID type, daily dose, and frequency of intake were recorded at visits. The ASAS index of NSAID intake (0-100) counting both dose and duration of intake was calculated for intervals. The association between NSAID intake (NSAID type and NSAID score) and radiographic spinal progression over 2 years was analysed using longitudinal generalized estimated equations (GEE).

Results

At baseline, 161 (66.3%) patients were treated with NSAIDs. While 289 (53.5%) and 128 (23.7%) 2-year radiographic intervals were covered by NS and COX-2i respectively, 123 (22.8%) intervals were not covered by NSAID. The significant association between higher NSAID intake and retardation of radiographic spinal progression was found in adjusted multivariable longitudinal GEE analysis. This effect was mostly attributable to patients with r-axSpA (Table 1). mSASSS progression was numerically lower in patients taking COX2i (irrespectively of dose) as compared to patients treated with NS-NSAIDs; in stratified analysis, however, there was no clear dose-dependency (as reflected by NSAID index) in both groups (Figure 1, Table 1).

Table 1.

The association between radiographic spinal progression (mSASSS change score) and NSAID intake in patients with axSpA in multivariable longitudinal GEE

All axSpA β (95% CI)* (n=461)nr-axSpA β (95% CI)*(n=244)r-axSpA β (95% CI)* (n=217)NSAID intake score, per 10 points-0.04 (-0.09, 0.00)-0.02 (-0.06, 0.02)-0.07 (-0.13, 0.00)NSAID type§ NS inhibitors vs No NSAID0.30(-0.07, 0.66)0.25(-0.07, 0.57)0.26(-0.40, 0.92) COX2i vs No NSAID0.17(-0.19, 0.54)0.15(-0.15, 0.46)0.18(-0.49, 0.85) COX2i vs NS inhibitors-0.12(-0.37, 0.12)-0.10(-0.28, 0.09)-0.08(-0.57, 0.40)Analysis stratified according to NSAID typeNon-selective NSAID intake score, per 10 points-0.06(-0.12, 0.00)-0.04(-0.09, 0.01)-0.07(-0.17, 0.03)COX2 selective NSAID intake score, per 10 points-0.06(-0.13, 0.02)-0.03(-0.07, 0.02)-0.09(-0.18, 0.01)

axSpA: axial spondyloarthritis; COX2i, cyclooxygenase-2 selective inhibitors; n, number of current 2-year radiographic intervals in multivariable analyses; NS, non-selective COXi; NSAID, non-steroidal anti-inflammatory drugs.

*All multivariable models were adjusted for sex, symptom duration at the beginning of the interval, time-averaged ASDAS the interval, classification as radiographic axSpA, smoking in the interval, mSASSS at the beginning of theinterval, and TNFi use in the interval.

§NSAID intake score was added in this model.

Conclusion

Higher NSAID intake is associated with lower radiographic spinal progression, particularly in r-axSpA patients. COX2i might possess a stronger inhibitory effect on radiographic progression as compared to NS-NSAIDs.

Disclosure of Interests

Murat Torgutalp: None declared, Valeria Rios Rodriguez Consultant of: AbbVie, Grant/research support from: Falk e.V, Ani Dilbaryan: None declared, Fabian Proft Speakers bureau: Novartis, Lilly, UCB AbbVie, AMGEN, BMS, Hexal, MSD, Pfizer, Roche and Janssen, Grant/research support from: Novartis, Lilly and UCB, Mikhail Protopopov Consultant of: Novartis and UCB, Maryna Verba: None declared, Judith Rademacher Consultant of: Novartis and UCB, Hildrun Haibel Consultant of: Boehringer, Janssen, MSD, Novartis, Sobi, Roche, Pfizer, AbbVie, and Sobi, Joachim Sieper Speakers bureau: Abbvie, Janssen, Lilly, Merck, Novartis, UCB, Consultant of: AbbVie, Lilly, Merck, Novartis, UCB, Martin Rudwaleit Speakers bureau: AbbVie, Boehringer Ingelheim, Celgen, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, UCB., Consultant of: AbbVie, Boehringer Ingelheim, Celgen, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, UCB., Denis Poddubnyy Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, and UCB., Consultant of: AbbVie, Biocad, Eli Lilly, Gilead, GlaxoSmithKline, Janssen, MSD, Novartis, Pfizer, Samsung Bioepis, and UCB, Grant/research support from: AbbVie, Eli Lilly, MSD, Novartis, Pfizer.

OP0050 INTRAARTICULAR MORPHINE IN CHRONIC KNEE-ARTHRITIS – RESULTS OF A RANDOMIZED PLACEBO-CONTROLLED TRIAL

Background

Patients with chronic inflammatory arthritis (e.g. rheumatoid arthritis; RA) or inflammatory exacerbations of chronic degenerative joint diseases (e.g. osteoarthritis; OA) suffer from recurrent pain, restricted function and reduction of daily activities. The current standard of intraarticular (i.a.) therapy is the injection of steroids, which can increase risk of infection, cartilage degenerations, and other well-known systemic side effects. A novel approach without such complications could be the activation of peripheral opioid receptors, e.g. by i.a. application of small, systemically inactive doses of morphine.

Objectives

The aim of this randomized placebo-and active drug controlled double blind trial was to investigate reduction of pain in chronic knee arthritis patients following i.a. injections of morphine, a standard steroid (triamcinolone), or placebo. The primary hypothesis was that i.a. morphine results in significantly lower pain scores than placebo. The primary outcome parameter was reduction of the Visual Analogue Scale (VAS) pain at day 7.

Methods

Adult patients with chronic knee arthritis because of osteoarthritis (OA) or inflammatory arthritis (IA, rheumatoid arthritis, psoriatic arthritis, spondyloarthritis, oligoarthritis or monarthritis) and a high level of pain (VAS pain ≥ 4 out of 10) at baseline received a single dose of either morphine 3 mg i.a., or triamcinolone 40 mg i.a., or placebo (NaCl 0.9%) i.a., Patients were monitored closely throughout the entire study period with a total of 4 visits over weeks and documented pain in the morning and evening in a patient´s diary. Safety data was collected during the whole study period. P-values were calculated using two-sided T-tests.

Results

114 patients were screened, 93 were treated and 89 (96%) completed day 7. Of these n= 61 (66%) were diagnosed with OA and n= 32 (34%) with IA 48 (52%) patients were female, mean age was 58.5 (SD 14 years) and mean disease duration 6.7 years (median 2 years, range <1 year – 42 yearss, IQR <1 – 10 years). The mean VAS pain improvement at day 7 for morphine, triamcinolone and placebo was -22.8, -37.7, and -19.8 respectively. The differences were not significant (p=0.69) for placebo vs. morphine, but significant for placebo vs. triamcinolone and for triamcinolone vs. morphine (p=0.013 and p=0.006). Mean improvements of the everyday pain documentation are shown in Figure 1. During the study period, there were no serious adverse events and 45 adverse events, most of them were mild.

Figure 1.

Mean VAS pain over one week in patients with chronic knee arthritis treated with morphine, triamcinolone or placebo as a single intraarticular injection.

Conclusion

In this randomized, placebo and active controlled double blind trial a single dose of 3 mg i.a. administered morphine did not lead to significant improvements in comparison to placebo and was inferior to triamcinolone at day 7. The same was true during the first 7 days as shown in the pain documentation in patient diaries. These data does not support the use of i.a. morphine for pain reduction in patients with chronic arthritis.

Disclosure of Interests

Hildrun Haibel Speakers bureau: AbbVie, MSD, Janssen, Roche and Pfizer, Consultant of: Roche, Boehringer, Janssen, MSD, Novartis, and Sobi, Grant/research support from: BMBF Neuroimpa 01EC1403F, Joachim Sieper Speakers bureau: Abbvie, Janssen, Lilly, Merck,Novartis, UCB, Consultant of: Abbvie, Lilly, Merck, Novartis, UCB, Denis Poddubnyy Speakers bureau: AbbVie, Bristol Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Biocad, Eli Lilly, Gilead, GlaxoSmithKline, MSD, Novartis, Pfizer, Samsung Bioepis, and UCB, Grant/research support from: AbbVie, Eli Lilly, MSD, Novartis, and Pfizer, Valeria Rios Rodriguez: None declared, Fabian Proft Speakers bureau: Abbvie, BMS, MSD, Novartis, Pfizer, Roche and UCB, Consultant of: Abbvie, BMS, MSD, Novartis, Pfizer, Roche and UCB, Grant/research support from: Novartis, Judith Rademacher: None declared, Sabrina Igel: None declared, Peter Martus: None declared, Christoph Stein Grant/research support from: BMBF Neuroimpa 01EC1403F.

OP0018 COMPARISON OF THE EFFECT OF TREATMENT WITH NSAIDs ADDED TO ANTI-TNF THERAPY VERSUS ANTI-TNF THERAPY ALONE ON PROGRESSION OF STRUCTURAL DAMAGE IN THE SPINE OVER TWO YEARS IN PATIENTS WITH ANKYLOSING SPONDYLITIS (CONSUL) – AN OPEN-LABEL, RANDOMIZED CONTROLLED, MULTICENTER TRIAL

Background

There is some evidence that NSAIDs, in particular celecoxib (CEL), might possess not only symptomatic efficacy but also disease-modifying properties in radiographic axial spondyloarthritis (r-axSpA) formerly known as ankylosing spondylitis, retarding progression of structural damage in the spine if taken continuously. For biological disease-modifying antirheumatic drugs (bDMARDs), retardation of structural damage progression has also been demonstrated, but at least 4 years of treatment seem to be necessary (at least for tumour necrosis factor inhibitors – TNFi) to see such an effect. Therefore, a combination of an NSAID with a TNFi might bring additional benefits in terms of retardation of structural damage progression especially in high-risk patients.

Objectives

The aim of this RCT was to evaluate the impact of treatment with the COX-II-selective NSAID (CEL) when added to a TNFi (golimumab - GOL) compared with TNFi (GOL) alone on progression of structural damage in the spine over 2 years in patients with r-axSpA.

Methods

Eligible patients had r-axSpA and high disease activity (BASDAI ≥4), NSAID failure and risk factors for radiographic spinal progression: C-reactive protein >5 mg/l and/or ≥1 syndesmophyte(s). The trial consisted of two phases: a 12-week run-in phase, in which all included patients received treatment with GOL 50 mg every 4 weeks sc, followed by a 96-week controlled treatment period, in which patients who achieved a BASDAI improvement of ≥2 points were randomly assigned to GOL + CEL 200 mg bid or GOL alone arms. The primary endpoint was radiographic spinal progression as assessed by the change in the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) after 108 weeks in the intent-to-treat population, read by 3 independent readers blinded for the treatment arm and the time-point.

Results

Of the 157 screened patients, 81.5% (n=128) were enrolled into the run-in phase. 109 patients fulfilled the BASDAI response criterion at w12 and were randomized 1:1 (54 vs. 55) to GOL+CEL or GOL alone; 97 (45 vs. 52) patients completed the study at w108. Clinical characteristics of the randomized patients are shown in Tab. 1. The mSASSS change after w108 was 1.1 (95%CI 0.2; 2.0) vs. 1.7 (95%CI 0.8; 2.6) in the GOL+CEL vs. GOL alone groups, respectively, p=0.79. Figure 1 shows the cumulative probability of the mSASSS change in both treatment arms. New syndesmophytes in the opinion of three readers occurred in 11% vs. 25% of the patients in the GOL+CEL vs. GOL alone groups, respectively, p=0.12. During the study, a total of 14 serious adverse events (SAE) were reported (7 in the GOL+CEL group, 5 in the GOL alone group and 2 during the run-in phase).

Figure 1.

Cumulative probability plot of mSASSS progression over 108 weeks of treatment.

Conclusion

In this study, a combined therapy with GOL+CEL did not show significant superiority over GOL monotherapy in retarding radiographic spinal progression over two years in r-axSpA patients.

However, the observed numerical reduction in radiographic spinal progression associated with the combined treatment might be, however, clinically relevant for patients at high risk for progression.

Table 1.

Baseline characteristics of randomized patients

ParametersGOL+CEL N=54GOL alone N=55All patients N=109validnvaluevalidnvaluevalidnvalueSex, malen (%)5440 (74.1)5541 (74.5)10981 (74.3)Age, yearsMean (SD)5439.9 (9.9)5537.5 (10.8)10938.7 (10.4)Smokern (%)5319 (35.8)5522 (40)10841 (38)HLA-B27 positivityn (%)5445 (83.3)5147 (92.2)10592 (87.6)BASDAIMean (SD)546.2 (1)556.1 (1.1)1096.1 (1.1)BASMIMean (SD)542.6 (1.9)542.9 (1.4)1082.8 (1.6)CRP > 5 mg/Ln (%)5438 (70.4)5538 (69.1)10976 (69.7)ASDAS-CRPMean (SD)543.6 (0.6)553.7 (0.9)1093.7 (0.8)Prior bDMARDsn (%)5417 (31.5)559 (16.4)10926 (23.9)Presence of ≥ 1 syndesmophyte(s)n (%)5427 (50)5528 (50.9)10955 (50.5)mSASSSMean (SD)5413.5 (16.9)5510.3 (13.2)10911.9 (15.2)

Acknowledgements

The CONSUL study has been supported by a grant from the German Ministry of Education and Research (BMBF), grant number FKZ 01KG1603 and study medication (golimumab) was provided free of charge by MSD Sharp & Dohme GmbH, Munich, Germany.

Furthermore we would like to thank Anne Weber, Bianca Mandt, Claudia Lorenz, Hildrun Haibel, Judith Rademacher, Laura Spiller, Petra Tietz as well as all participating rheumatologist and included patients.

Disclosure of Interests

Fabian Proft Speakers bureau: AMGEN, AbbVie, BMS, Celgene, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Consultant of: Novartis, Grant/research support from: Novartis, UCB, Lilly, Burkhard Muche Speakers bureau: UCB Pharma, AMGEN, Consultant of: UCB Pharma, AMGEN, Valeria Rios Rodriguez Speakers bureau: AbbVie, Falk e.V., Murat Torgutalp: None declared, Mikhail Protopopov Consultant of: Novartis, Joachim Listing: None declared, Maryna Verba: None declared, Uta Kiltz: None declared, Jan Brandt-Juergens: None declared, Maren Sieburg: None declared, Swen Holger Jacki: None declared, Joachim Sieper Speakers bureau: AbbVie, Janssen, Merck, Novartis, Consultant of: Abbvie, Janssen, Lilly, Merck, Novartis, UCB, Denis Poddubnyy Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Biocad, Eli Lilly, Gilead, GlaxoSmithKline, Janssen, MSD, Novartis, Pfizer, Samsung Bioepis, and UCB, Grant/research support from: AbbVie, Eli Lilly, MSD, Novartis, and Pfizer.

OP0106 SOLUBLE PD-1 PROMOTES LOCAL IL-17A PRODUCTION IN THE INFLAMED MICROENVIRONMENT IN SpA

Background

Programmed death 1 (PD-1) is an immune checkpoint receptor expressed by activated T-cells. Activation of the PD-1 pathway reduces T cell activation and inflammation. Targeting PD-1 in cancer can result in autoimmune disease, which highlights the importance of this pathway in balancing inflammation. Both PD-1 and its ligands are present in soluble (s) forms, and we have previously showed that sPD-1 is associated to bone erosions in rheumatoid arthritis. Spondyloarthritis (SpA) is characterized by both bone erosions and bone formation. Current evidence suggests an important interaction between the PD-1 pathway and the proinflammatory cytokine IL-17A. IL-17A is central in promoting inflammation in SpA and direct osteoclast activation leading to bone erosion. We have previously demonstrated that the PD-1 ligand, PD-L2, reduces osteoclast formation under inflammatory conditions.

Objectives

We aimed at investigating the interplay between the PD-1 pathway and IL-17A in relation to inflammation and bone homeostasis in patients with SpA.

Methods

From early SpA patients, plasma was collected at baseline and after 1 year of treatment with Adalimumab. From chronic SpA patients, plasma, synovial fluid (SF), peripheral blood mononuclear cells (PBMCs) and synovial fluid mononuclear cells (SFMCs) were collected. Plasma and PBMCs were also collected from healthy controls (HC) for comparison. Disease activity was measured by ASDAS and progression by inflammation and new bone formation in the total spine.

Facet joint biopsies were collected from SpA patients during surgery for correction of rigid hyperkyphosis. Levels of sPD-1 and sPD-L2 were measured in plasma and SF. Surface expression of PD-1 and CCR6 was evaluated on PBMCs and SFMCs. Levels of IL-17A were measured in the supernatant from stimulated PBMC cultures with recombinant human (rh)PD-1. Facet joint biopsies were stained for the presence of PD-1, PD-L1, PD-L2 and CCR6.

Results

Plasma levels of sPD-1 and sPD-L2 were equally increased in both early and chronic SpA compared to HC. Plasma levels of sPD-1 and sPD-L2 did not change following one year of treatment. In chronic SpA patients, sPD-1 levels were higher in SF than in plasma. Levels of sPD-1 and sPD-L2 in plasma and SF did not correlate with any disease activity scores or progression. Expression of PD-1 on the cell surface of PBMCs from SpA patient was comparable to healthy controls. On SFMCs, PD-1 expression was increased, supporting continuous T-cell activation in the local microenvironment. After stimulation with anti CD3/CD28, SpA PBMCs produced more IL-17A when cultured with rhPD-1 compared to healthy control PBMCs.

PD-1 and CCR6 were highly present in facet joint biopsies, but PD-L2 and PD-L1 could not be detected. This supports the PD-1 pathway to play a role at the actual site of pathology.

Conclusion

Plasma levels of the PD-1 family is unaffected by addition of anti-TNFα antibody treatment in SpA. The early SpA cohort had a low degree of progression in structural changes in the observation period, which could explain the lack correlation with sPD-1 and sPD-L2 and disease progression. Soluble PD-1 is high in the inflamed microenvironment, where it may result in increased IL-17A production. Collectively, these data suggest that the PD-1 pathway could play a role in the pathogenesis of SpA, acting in the inflamed microenvironment.

Disclosure of Interests

None declared

OP0016 EFFICACY AND SAFETY OF UPADACITINIB IN PATIENTS WITH ACTIVE NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS: A DOUBLE-BLIND, RANDOMIZED, PLACEBO-CONTROLLED PHASE 3 TRIAL

Background

Janus kinase (JAK) inhibitors have been recognized as a potential therapeutic option in ankylosing spondylitis (AS), also known as radiographic axial spondyloarthritis (r-axSpA).1 Upadacitinib (UPA), a JAK inhibitor, has demonstrated efficacy and safety in the treatment of AS2; however, no JAK inhibitor studies have been conducted in non-radiographic axSpA (nr-axSpA) to date.

Objectives

To assess the efficacy and safety of UPA in patients (pts) with active nr-axSpA.

Methods

SELECT-AXIS 2 (NCT04169373) was conducted under a master protocol comprising two independent studies, one in an AS population with an inadequate response to biologic disease-modifying antirheumatic drugs and one in an nr-axSpA population. The nr-axSpA study is a randomized, double-blind, placebo(PBO)-controlled, phase 3 trial that enrolled adults ≥18 years with a clinical diagnosis of nr-axSpA (who also fulfilled 2009 ASAS classification criteria for axSpA but did not meet the radiologic criterion of modified New York criteria), who had objective signs of active inflammation consistent with axSpA on MRI of the sacroiliac (SI) joints and/or high sensitivity C-reactive protein (hs-CRP) >upper limit of normal (2.87 mg/L) at screening, and who had BASDAI and pt’s assessment of total back pain scores ≥4 based on a 0 to 10 numeric rating scale at study entry. Pts were randomized 1:1 to receive oral UPA 15 mg once daily (QD) or PBO during a 52-week (wk) double-blind treatment period. The primary endpoint was ASAS40 response at wk 14. Multiplicity-controlled secondary endpoints assessed at wk 14 included BASDAI50, ASDAS ID (<1.3), ASDAS LDA (<2.1), ASDAS PR, and ASAS20, and the change from baseline (Δ) in ASDAS (CRP), SPARCC MRI SI joint inflammation score, total and nocturnal back pain, BASFI, ASQoL, ASAS HI, BASMI, and MASES. Treatment-emergent adverse events (TEAEs) are reported through wk 14 for pts who received ≥1 dose of study drug.

Results

Of 314 pts randomized at baseline, 313 received study drug (UPA 15 mg, n=156; PBO, n=157) and 295 (94%) received study drug through wk 14. Baseline demographic and disease characteristics were balanced across treatment groups and consistent with an active nr-axSpA population (58% female; mean age 42.1 years; mean BASDAI 6.9; mean hs-CRP 12.1 mg/L). A significantly higher ASAS40 response rate at wk 14 was achieved with UPA vs PBO (45% vs 23%; P<0.0001; Figure 1). Statistical significance was also achieved in the first 12 of the 14 multiplicity-controlled secondary endpoints (ie, all endpoints except BASMI and MASES) at wk 14 for UPA compared with PBO (P<0.01; Figure 1). The proportion of pts who experienced a TEAE was similar between treatment groups (UPA, 48%; PBO, 46%). Serious TEAEs and TEAEs leading to discontinuation were reported in 4 (2.6%) pts treated with UPA and 2 (1.3%) pts treated with PBO, respectively. Few pts had serious infection or herpes zoster (each 2 [1.3%] pts on UPA; each 1 [0.6%] pt on PBO, respectively). Uveitis was reported in 1 (0.6%) pt on UPA who had a history of uveitis and none on PBO. No malignancy other than non-melanoma skin cancer, major adverse cardiovascular events, venous thromboembolic events, inflammatory bowel disease (IBD), or death were reported in the study; 1 event of basal cell carcinoma occurred with PBO.

Conclusion

UPA 15 mg QD demonstrated significantly greater improvements in disease activity, pain, function, quality of life, and MRI-detected SI joint inflammation than PBO after 14 wks of treatment in pts with active nr-axSpA. The safety profile of UPA was consistent with what has been observed with other inflammatory musculoskeletal diseases,3–5 and no new risks were identified. These results support the potential use of UPA in pts with active nr-axSpA.

References

[1]Ward MM, et al. Arthritis Rheumatol. 2019;71(10):1599–63.

[2]van der Heijde D, et al. Arthritis Rheumatol. 2021;73(suppl 10).

[3]Cohen SB, et al. ARD. 2021;80:304–311.

[4]Burmester G, et al. Rheumatol Ther. 2021;1–19.

[5]van der Heijde D, et al. Lancet. 2019;394(10214):2108–2117.

Acknowledgements

AbbVie funded this study and participated in the study design, research, analysis, data collection, interpretation of data, review, and approval of the abstract. No honoraria or payments were made for authorship. Medical writing support was provided by Julia Zolotarjova, MSc, MWC, of AbbVie.

Disclosure of Interests

Atul Deodhar Consultant of: AbbVie, Amgen, Aurinia, BMS, Celgene, GSK, Janssen, Lilly, MoonLake, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, GSK, Lilly, Novartis, Pfizer, and UCB, Filip van den Bosch Speakers bureau: AbbVie, Celgene, Janssen, Lilly, Merck, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Celgene, Janssen, Lilly, Merck, Novartis, Pfizer, and UCB, Denis Poddubnyy Speakers bureau: AbbVie, BMS, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, and UCB, Consultant of: AbbVie, BMS, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Walter P Maksymowych Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Novartis, and Pfizer, Désirée van der Heijde Consultant of: AbbVie, Bayer, BMS, Cyxone, Eisai, Galapagos, Gilead, GSK, Janssen, Lilly, Novartis, Pfizer, UCB, Employee of: Director of Imaging Rheumatology BV, Tae-Hwan Kim Speakers bureau: AbbVie, Celltrion, Kirin, Lilly, and Novartis, Mitsumasa Kishimoto Consultant of: AbbVie, Amgen Astellas BioPharma, Asahi-Kasei Pharma, Astellas, Ayumid Pharma, BMS, Chugai, Daiichi Sankyo, Eisai, Gilead, Janssen, Kyowa Kirin, Lilly, Novartis, Ono Pharma, Pfizer, Tanabe-Mitsubishi, Teijin Pharma, and UCB, Yuanyuan Duan Shareholder of: May own AbbVie stock or options, Employee of: AbbVie, Yihan Li Shareholder of: May own AbbVie stock or options, Employee of: AbbVie, Aileen Pangan Shareholder of: May own AbbVie stock or options, Employee of: AbbVie, Peter Wung Shareholder of: May own AbbVie stock or options, Employee of: AbbVie, In-Ho Song Shareholder of: May own AbbVie stock or options, Employee of: AbbVie.

OA35 Efficacy of secukinumab and HLA-B27 subtypes: results from a Phase 3b randomised controlled trial in axial SpA

Background/Aims

Human Leukocyte Antigen (HLA)-B is strongly associated with axial spondyloarthritis (axSpA); over 100 subtypes of HLA-B27 are currently recognized and designated as HLA-B∗2701 to HLA-B∗27106. The association of these subtypes with clinical features of axSpA patients or their response to therapy has not been determined. This post hoc analysis explored the potential association of the HLA-B27 subtypes with the effect of secukinumab in axSpA patients from the SKIPPAIN trial (NCT03136861).

Methods

SKIPPAIN, a 24-week, randomised, double-blind, placebo-controlled, multicentre trial, enrolled adult axSpA patients with active disease fulfilling ASAS classification criteria (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI] score ≥4 and average spinal pain numerical rating scale [NRS] score &gt;4 at baseline) and inadequate response to ≥ 2 NSAIDs for ≥4 weeks. Patients were randomised (3:1) to receive subcutaneous secukinumab 150 mg or placebo weekly followed by every 4 weeks (q4w) starting at Week 4. At Week 8, placebo patients were re-randomised to secukinumab 150 or 300 mg q4w up to Week 24. HLA-B27 subtypes were tested by PCR-reverse sequence-specific oligonucleotide probe on a baseline blood sample. Average spinal pain scores were analysed using a repeated measures analysis of covariance model.

Results

Overall, 380 patients with axSpA (269 [70.8%] AS; 111 [29.2%] nr-axSpA) were randomised to secukinumab 150 mg (n = 285) or placebo (n = 95). Most patients were HLA-B27 positive in both treatment groups (233 [81.8%] SEC vs 76 [80.0%] placebo). Distribution of HLA subtypes was consistent with what is expected in a typical European population, with HLA-B*27:05:02G as the most common allele (secukinumab 150 mg, n = 172 [60.4%]; placebo, n = 48 [50.5%]). In the HLA-B*27 homozygous group, a higher proportion of patients had uveitis, peripheral arthritis, enthesitis and a family history of spondyloarthritis versus the heterozygous group; disease severity or burden of disease was similar between the two groups. Male predominance was more evident in the HLA-B*27 homozygous group, who were younger by 1 year and reported longer duration of symptoms by an average of 8 months. Disease severity was comparable while disease burden was higher in the B*27:05:02G versus the B27:02:01G heterozygous group. There was a significant least square (LS) mean difference (standard error [SE]) in back pain response between secukinumab and placebo in HLA-B27 positive patients (-0.9 [±0.27], 95% confidence interval [CI] -1.47 to -0.42, P = 0.0004) and HLA-B27 heterozygous (B*27:05:02G) patients (-0.9 [±0.37], 95% CI − 1.62 to -0.17, P = 0.0152), differences in other HLA-B27 subtypes were non-significant.

Conclusion

Although secukinumab has shown efficacy in both HLA-B27 positive and negative patients, presence of HLA-B27 and homozygosity had a distinct positive effect on response. Further studies or pooled analyses are warranted to investigate associations of HLA-B27 subtypes with the clinical features of axSpA or of less prevalent HLA-B27 subtypes with treatment response.

Disclosure

H. Marzo-Ortega: Consultancies; AbbVie, Amgen, BMS, Biogen, Celgene, Gilead, Janssen, Lilly, Novartis, Pfizer, Samsung Bioepis, Sanofi-Aventis, UCB. Grants/research support; Amgen, Lilly, Janssen, Pfizer, Sandoz, Sanofi, Galapagos. D. Poddubnyy: Consultancies; AbbVie, Biocad, BMS, Eli Lilly, MSD, Novartis, Pfizer, Samsung Bioepis, UCB, Gilead. Member of speakers’ bureau; AbbVie, BMS, Lilly, MSD, Novartis, Pfizer, UCB. Grants/research support; AbbVie, MSD, Eli Lilly, Novartis, Pfizer. E. Pournara: Shareholder/stock ownership; Novartis. Other; Employee of Novartis. B. Schulz: Other; Employee of Novartis. A. Deodhar: Consultancies; AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, GSK, Janssen, Novartis, Pfizer, UCB. Member of speakers’ bureau; AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb, Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB. Grants/research support; AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB. X. Baraliakos: Consultancies; AbbVie, BMS, Celgene, Chugai, Galapagos, Gilead, MSD, Novartis, Pfizer, UCB. Member of speakers’ bureau; AbbVie, BMS, Celgene, Chugai, MSD, Novartis, Pfizer, UCB. Grants/research support; AbbVie, Novartis.

Treatment with Tumour Necrosis Factor Inhibitors is Associated with a Time-Shifted Retardation of Radiographic Sacroiliitis Progression in Patients with Axial Spondyloarthritis: 10-year Results from the German Spondyloarthritis Inception Cohort

OBJECTIVES

To investigate the longitudinal association between radiographic sacroiliitis progression and treatment with tumour necrosis factor inhibitors (TNFi) in patients with early axial Spondyloarthritis (axSpA) in a long-term inception cohort.

METHODS

We included patients from the German Spondyloarthritis Inception Cohort who had baseline plus at least one sacroiliac radiograph during follow-up. Two central readers scored the radiographs according to modified New York criteria. The sacroiliac sum score was calculated as a mean of both readers. TNFi use was assessed according to exposure in the current and/or previous 2-year radiographic interval. The association between TNFi use and radiographic sacroiliitis progression was examined by longitudinal generalized estimating equations analysis with adjustment for potential confounders.

RESULTS

In total, 301 axSpA patients (166 non-radiographic [nr-axSpA] and 135 radiographic [r-axSpA]) contributed 737 radiographic intervals. While receiving ≥12 months TNFi in the previous interval was associated with a significant decrease in the sacroiliitis sum score (β=-0.09 [95% CI -0.18, -0.01], adjusted for age, sex, symptom duration, HLA-B27 status, Bath Ankylosing Spondylitis Disease Activity Index [BASDAI], C-reactive protein [CRP], and Non-steroidal anti-inflammatory drugs [NSAIDs] intake), this was not the case in patients who received TNFi in the current interval (β=0.05 [95% CI -0.05, 0.14]). This effect was stronger in patients with nr-axSpA as compared to patients with r-axSpA (β=-0.16 [95% CI -0.28, -0.03] vs β=-0.04 [95% CI -0.15, 0.07], respectively).

CONCLUSION

TNFi was associated with reduction of radiographic sacroiliitis progression in patients with axSpA. This effect became evident between 2 and 4 years after treatment initiation.

Validation of the ASDAS with a quick quantitative CRP assay (ASDAS-Q) in patients with axial SpA: a prospective multicentre cross-sectional study

Objectives:

The objective of the study was to validate the Ankylosing Spondylitis Disease Activity Score (ASDAS) based on a quick quantitative C-reactive protein (qCRP) assay (ASDAS-Q) in a multicentre, prospective, cross-sectional study in patients with axial spondyloarthritis (axial SpA).

Methods:

Disease activity assessment was performed in prospectively recruited patients with axial SpA. Routine laboratory CRP was determined in the central laboratory of each study centre, while quick qCRP and erythrocyte sedimentation rate (ESR) were measured locally. Consequently, ASDAS-CRP, ASDAS-Q using the qCRP and ASDAS-ESR were calculated. The absolute agreement on the disease activity category ascertainment was analysed with cross-tabulations and weighted Cohen’s kappa. Bland–Altman plots and intraclass correlation coefficients (ICCs) were used to analyse the criterion validity.

Results:

Overall, 251 axial SpA patients were included in the analysis. The mean qCRP value (6.34 ± 11.13 mg/l) was higher than that of routine laboratory CRP (5.26 ± 9.35 mg/l). The ICC for routine laboratory CRP versus qCRP was 0.985 [95% confidence interval (CI): 0.972–0.991]. Comparing ASDAS-Q with ASDAS-CRP, 242 of 251 (96.4%) patients were assigned to the same disease activity categories with a weighted Cohen’s kappa of 0.966 (95% CI: 0.943–0.988) and ICC of 0.997 (95% CI: 0.994–0.999).

Conclusions:

ASDAS-Q showed an almost perfect agreement with ASDAS-CRP in the assignment to specific disease activity categories. Consequently, ASDAS-Q using the qCRP value can be applied as an accurate and quickly available alternative to ASDAS-CRP, thus facilitating the implementation of the treat-to-target concept in clinical trials and clinical routine.

[Low back pain from a rheumatological point of view]

Low back pain is the leading symptom of a family of inflammatory rheumatic diseases grouped under the umbrella term "spondyloarthritides". This paper discusses the main clinical, laboratory, and imaging features of spondyloarthritides in the diagnostic context of low back pain. It also highlights the current therapeutic principles of axial spondyloarthritis.

Controversies in rheumatology: Imaging of enthesitis in spondyloarthritis - does it mean anything for treatment decisions?

Enthesitis is considered a hallmark manifestation of spondyloarthritis including axial spondyloarthritis and psoriatic arthritis. Detection of enthesitis might be challenging in both diagnostic and classification processes. In this debate, we discuss the controversy on the role of imaging in the detection of enthesitis including the relevance for treatment decisions in spondyloarthritis.

CT-like images in MRI improve specificity of erosion detection in patients with hand arthritis: a diagnostic accuracy study with CT as standard of reference

OBJECTIVE

To compare the diagnostic accuracy of susceptibility-weighted imaging (SWI), standard T1-weighted (T1w) images and high-resolution 3D-gradient echo sequences (volumetric interpolated breath-hold examination (VIBE)) for detection of erosions in patients with peripheral arthritis using CT as standard of reference.

MATERIALS AND METHODS

A total of 36 patients were included in the study. All patients underwent CT and MRI, including SWI, VIBE and T1w sequences of the clinically more affected hand. Two trained readers scored all imaging datasets separately for erosions in a blinded fashion. Specificity, sensitivity and diagnostic accuracy of MRI sequences were calculated on a per-patient level.

RESULTS

CT was positive for erosion in 16 patients and 77 bones (Rheumatoid Arthritis MRI Score >0), T1w in 28 patients, VIBE in 25 patients and SWI in 17 patients. All MRI sequences performed with comparably high sensitivities (T1w 100%, VIBE 94% and SWI 94%). SWI had the highest specificity of 90%, followed by VIBE (50%) and T1w (40%). Both T1w and VIBE produced significantly higher sum scores than CT (341 and 331 vs 148, p<0.0001), while the sum score for SWI did not differ from CT (119 vs 148; p=0.411).

CONCLUSION

Specificity for erosion detection remains a challenge for MRI when conventional and high-resolution sequences are used but can be improved by direct bone depiction with SWI. Both T1w and VIBE tend to overestimate erosions, when CT is used as the standard of reference.

Fractal analysis of perfusion imaging in synovitis: a novel imaging biomarker for grading inflammatory activity based on assessing angiogenesis

Objectives

The mutual and intertwined dependence of inflammation and angiogenesis in synovitis is widely acknowledged. However, no clinically established tool for objective and quantitative assessment of angiogenesis is routinely available. This study establishes fractal analysis as a novel method to quantitatively assess inflammatory activity based on angiogenesis in synovitis.

Methods

First, we established a pathophysiological framework for synovitis including fractal analysis of software perfusion phantoms, which allowed to derive explainability with a known and controllable reference standard for vascular structure. Second, we acquired MRI datasets of patients with suspected rheumatoid arthritis of the hand, and three imaging experts independently assessed synovitis analogue to Rheumatoid Arthritis MRI Scoring (RAMRIS) criteria. Finally, we performed fractal analysis of dynamic first-pass perfusion MRI in vivo to evaluate angiogenesis in relation to inflammatory activity with RAMRIS as reference standard.

Results

Fractal dimension (FD) achieved highly significant discriminability for different degrees of inflammatory activity (p<0.01) in software phantoms with known ground-truth of angiogenic structure. FD indicated increasingly chaotic perfusion patterns with increasing grades of inflammatory activity (Spearman’s ρ=0.94, p<0.001). In 36 clinical patients, fractal analysis quantitatively and objectively discriminated individual RAMRIS scores (p≤0.05). Area under the receiver-operating curve was 0.84 (95% CI 0.7 to 0.89) for fractal analysis when considering RAMRIS as ground-truth. Fractal analysis additionally identified angiogenesis in cases where RAMRIS underestimated inflammatory activity.

Conclusions

Based on angiogenesis and perfusion pathophysiology, fractal analysis non-invasively enables comprehensive, objective and quantitative characterisation of inflammatory angiogenesis with subjective and qualitative RAMRIS as reference standard. Further studies are required to establish the clinical value of fractal analysis for diagnosis, prognostication and therapy monitoring in inflammatory arthritis.

Corticosteroids as risk factor for COVID-19-associated pulmonary aspergillosis in intensive care patients

PURPOSE

Corticosteroids, in particular dexamethasone, are one of the primary treatment options for critically ill COVID-19 patients. However, there are a growing number of cases that involve COVID-19-associated pulmonary aspergillosis (CAPA), and it is unclear whether dexamethasone represents a risk factor for CAPA. Our aim was to investigate a possible association of the recommended dexamethasone therapy with a risk of CAPA.

METHODS

We performed a study based on a cohort of COVID-19 patients treated in 2020 in our 13 intensive care units at Charité Universitätsmedizin Berlin. We used ECMM/ISHM criteria for the CAPA diagnosis and performed univariate and multivariable analyses of clinical parameters to identify risk factors that could result in a diagnosis of CAPA.

RESULTS

Altogether, among the n = 522 intensive care patients analyzed, n = 47 (9%) patients developed CAPA. CAPA patients had a higher simplified acute physiology score (SAPS) (64 vs. 53, p < 0.001) and higher levels of IL-6 (1,005 vs. 461, p < 0.008). They more often had severe acute respiratory distress syndrome (ARDS) (60% vs. 41%, p = 0.024), renal replacement therapy (60% vs. 41%, p = 0.024), and they were more likely to die (64% vs. 48%, p = 0.049). The multivariable analysis showed dexamethasone (OR 3.110, CI95 1.112-8.697) and SAPS (OR 1.063, CI95 1.028-1.098) to be independent risk factors for CAPA.

CONCLUSION

In our study, dexamethasone therapy as recommended for COVID-19 was associated with a significant three times increase in the risk of CAPA.

TRIAL REGISTRATION

Registration number DRKS00024578, Date of registration March 3rd, 2021.

What amount of structural damage defines sacroiliitis: a CT study

OBJECTIVES

To propose a data-driven definition for structural changes of sacroiliac (SI) joints in the context of axial spondyloarthritis (axSpA) imaging on a large collective of CT datasets.

METHODS

546 individuals (102 axSpA, 80 non-axSpA low back pain and 364 controls without back pain) with SI joint CTs were evaluated for erosions, sclerosis and ankylosis using a structured scoring system. Lesion frequencies and spatial distribution were compared between groups. Diagnostic performance (sensitivity (SE), specificity (SP), positive predictive values, negative predictive values and positive and negative likelihood ratios) was calculated for different combinations of imaging findings. Clinical diagnosis served as standard of reference.

RESULTS

Ankylosis and/or erosions of the middle and dorsal joint portions yielded the best diagnostic performance with SE 67.6% and SP 96.3%. Inclusion of ventral erosions and sclerosis resulted in lower diagnostic performance with SE 71.2%/SP 92.5% and SE 70.6%/SP 90.0%, respectively.

CONCLUSIONS

Sclerosis and ventrally located erosions of SI joints have lower specificity on CT of the SI joint in the context of axSpA imaging. Ankylosis and/or erosions of the middle and dorsal joint portions show a strong diagnostic performance and are appropriate markers of a positive SI joint by CT.

[Spondyloarthritis in childhood and adulthood]

Axial spondylarthritis in adulthood (SpAA) is frequently initially manifested as a sacroiliitis, whereas this not true for enthesitis-related arthritis (EAA), which begins in childhood and adolescence. Classically, EAA begins with peripheral arthritis and only a part transitions into a juvenile SpA (jSpA) or SpAA. The criteria used for classification of SpAA and EAA are currently being validated and revised. For the first time imaging is included for EAA. For both diseases nonsteroidal anti-inflammatory drugs (NSAID) are initially used therapeutically, followed by biologicals or synthetic targeted disease-modifying drugs in refractory courses. Steroids should be avoided in long-term treatment. For optimal transition and further care in adulthood, a close cooperation between internistic and pediatric rheumatologists is necessary.

[Perioperative management of treatment of patients with inflammatory rheumatic diseases : Updated recommendations of the German Society of Rheumatology]

BACKGROUND

Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014.

METHODS

After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added.

RESULTS

The glucocorticoid dose should be reduced to as low as possible 2-3 months before elective surgery (in any case <10 mg/day) but should be kept stable 1-2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1-2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3-4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing.

CONCLUSION

Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.

Axial Involvement in Psoriatic Arthritis cohort (AXIS): the protocol of a joint project of the Assessment of SpondyloArthritis international Society (ASAS) and the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)

BACKGROUND

Involvement of the axial skeleton (sacroiliac joints and spine) is a relatively frequent manifestation associated with psoriatic skin disease, mostly along with involvement of peripheral musculoskeletal structures (peripheral arthritis, enthesitis, dactylitis), which are referred to as psoriatic arthritis (PsA). Data suggest that up to 30% of patients with psoriasis have PsA. Depending on the definition used, the prevalence of axial involvement varies from 25% to 70% of patients with PsA. However, there are currently no widely accepted criteria for axial involvement in PsA.Objective: The overarching aim of the Axial Involvement in Psoriatic Arthritis (AXIS) study is to systematically evaluate clinical and imaging manifestations indicative of axial involvement in patients with PsA and to develop classification criteria and a unified nomenclature for axial involvement in PsA that would allow defining a homogeneous subgroup of patients for research.

DESIGN

Prospective, multicenter, multinational, cross-sectional study.

METHODS AND ANALYSES

In this multicenter, multinational, cross-sectional study, eligible patients [adult patients diagnosed with PsA and fulfilling Classification Criteria for Psoriatic Arthritis (CASPAR) with musculoskeletal symptom duration of ⩽10 years not treated with biological or targeted synthetic disease-modifying anti-rheumatic drugs] will be recruited prospectively. They will undergo study-related clinical and imaging examinations. Imaging will include radiography and magnetic resonance imaging examinations of sacroiliac joints and spine. Local investigators will evaluate for the presence of axial involvement based on clinical and imaging information which will represent the primary outcome of the study. In addition, imaging will undergo evaluation by central review. Finally, the central clinical committee will determine the presence of axial involvement based on all available information.

ETHICS

The study will be performed according to the ethical principles of the Declaration of Helsinki and International Council for Harmonisation Good Clinical Practice guidelines. The study protocol will be approved by the individual Independent Ethics Committee / Institutional Review Board of participating centers. Written informed consent will be obtained from all included patients.Registration: ClinicalTrials.gov ID: NCT04434885.

Characteristics of Patients With Axial Spondyloarthritis by Geographic Regions: PROOF Multicountry Observational Study Baseline Results

Objectives

To compare demographic and clinical characteristics of patients with axial SpA (axSpA) across geographic regions.

Methods

Patients With Axial Spondyloarthritis: Multicountry Registry of Clinical Characteristics (PROOF) is an observational study that enrolled recently diagnosed (≤1 year) axSpA patients fulfilling the Assessment of SpondyloArthritis international Society classification criteria from rheumatology clinical practices in 29 countries across six geographic regions. Demographics and disease-related parameters were collected. Here we present baseline data for patients who were classified as radiographic axSpA (r-axSpA) or non-radiographic axSpA (nr-axSpA) confirmed by central reading.

Results

Of the 2170 patients enrolled, 1553 were classified based on central evaluation of sacroiliac radiographs [r-axSpA: 1023 (66%); nr-axSpA: 530 (34%)]. Patients with nr-axSpA had a significantly higher occurrence of enthesitis (40% vs 33%), psoriasis (10% vs 5%) and IBD (4% vs 2%) vs r-axSpA patients. Significant differences in axSpA characteristics were observed between geographic regions. The highest occurrence of peripheral arthritis (60%), enthesitis (52%) and dactylitis (12%) was in Latin America, and the lowest was in Canada (9%, 9% and 2%, respectively). The occurrence of uveitis and psoriasis was highest in Canada (18% and 14%, respectively) and lowest in China (6% and <1%, respectively). IBD was highest in Arabia (21%), and no cases were observed in China. In multivariable analysis adjusted for factors potentially affecting peripheral and extramusculoskeletal manifestations, geographic regions still exhibited significant differences in frequencies of uveitis (P < 0.01), psoriasis (P < 0.0001) and peripheral arthritis (P < 0.0001).

Conclusion

The multinational PROOF study of axSpA patients showed significant regional differences in peripheral and extramusculoskeletal manifestations of SpA, which could be considered in management guidelines and clinical trials.

Efficacy of tofacitinib in reduction of inflammation detected on MRI in patients with Psoriatic ArthritiS presenTing with axial involvement (PASTOR): protocol of a randomised, double-blind, placebo-controlled, multicentre trial

INTRODUCTION

Psoriatic arthritis (PsA) is an inflammatory disease characterised by synovitis, enthesitis, dactylitis and axial involvement. The prevalence of axial involvement ranges from 25% to 70% in this patient group. Treatment recommendations for axial PsA were mainly extrapolated from guidelines for axial spondyloarthritis, and the main treatment options are non-steroidal anti-inflammatory drugs and biological disease-modifying antirheumatic drugs (tumour necrosis factor, IL-17 and IL-23 inhibitors). Tofacitinib was approved for the treatment of PsA and its efficacy on axial inflammation has been demonstrated in a phase II study of ankylosing spondylitis (AS). This prospective study aims to evaluate the efficacy of tofacitinib in reducing inflammation in the sacroiliac joints (SIJs) and spine on MRI in patients with axial disease of their PsA presenting with active axial involvement compatible with axial PsA.

METHODS AND ANALYSES

This is a randomised, double-blind, placebo-controlled, multicentre clinical trial in patients with axial PsA who have evidence of axial involvement, active disease as defined by a Bath AS Disease Activity Index score of ≥4 and active inflammation on MRI of the SIJs and/or spine as assessed by and independent central reader. The study includes a 6-week screening period, a 24-week treatment period, which consist of a 12-week placebo-controlled double-blind treatment period followed by a 12-week active treatment period with tofacitinib for all participants, and a safety follow-up period of 4 weeks. At baseline, 80 subjects shall be randomised (1:1) to receive either tofacitinib or matching placebo for a 12-week double-blind treatment period. At week 12, an MRI of the whole spine and SIJs will be performed to evaluate the primary study endpoint.

ETHICS AND DISSEMINATION

The study will be performed according to the ethical principles of the Declaration of Helsinki and the German drug law. The independent ethics committees of each centre approved the ethical, scientific and medical appropriateness of the study before it was conducted.

TRIAL REGISTRATION NUMBER

NCT04062695; ClinicalTrials.gov and EudraCT No: 2018-004254-22; European Union Clinical Trials Register.