Modulating the wayward T cell: New horizons with immune checkpoint inhibitor treatments in autoimmunity, transplant, and cancer

The T-cell response is regulated by the balance between costimulatory and coinhibitory signals. Immune checkpoints are essential for efficient T-cell activation, but also for maintaining self-tolerance and protecting tissues from damage caused by the immune system, and for providing protective immunity. Modulating immune checkpoints can serve diametric goals, such that blocking a coinhibitory molecule can unleash anti-cancer immunity whereas stimulating the same molecule can reduce an over-reaction in autoimmune disease. The purpose of this review is to examine the regulation of T-cell costimulation and coinhibition, which is central to the processes underpinning autoimmunity, transplant rejection and immune evasion in cancer. We will focus on the immunomodulation agents that regulate these unwanted over- and under-reactions. The use of such agents has led to control of symptoms and slowing of progression in patients with rheumatoid arthritis, reduced rejection rates in transplant patients, and prolonged survival in patients with cancer. The management of immune checkpoint inhibitor treatment in certain challenging patient populations, including patients with pre-existing autoimmune conditions or transplant patients who develop cancer, as well as the management of immune-related adverse events in patients receiving antitumor therapy, is examined. Finally, the future of immune checkpoint inhibitors, including examples of emerging targets that are currently in development, as well as recent insights gained using new molecular techniques, is discussed. T-cell costimulation and coinhibition play vital roles in these diverse therapeutic areas. Targeting immune checkpoints continues to be a powerful avenue for the development of agents suitable for treating autoimmune diseases and cancers and for improving transplant outcomes. Enhanced collaboration between therapy area specialists to share learnings across disciplines will improve our understanding of the opposing effects of treatments for autoimmune disease/transplant rejection versus cancer on immune checkpoints, which has the potential to lead to improved patient outcomes.

Adherence to Mediterranean diet and patient perception of rheumatoid arthritis

OBJECTIVE

To evaluate the association between the adherence to Mediterranean diet (MD) and disease impact, activity, and comorbidities in patients with rheumatoid arthritis (RA).

DESIGN

Consecutive patients with RA were enrolled in this cross-sectional study. For each patient, Disease Activity Score on 28 joints (DAS28), Simple Disease Activity Index (SDAI), RA Impact of Disease (RAID), Health Assessment Questionnaire (HAQ), patient global assessment (PGA) and general health (GH) and a self-reported questionnaire called MD score were recorded.

RESULTS

205 RA patients (median age 53 years, female 80.49 %) were enrolled. An association between MD score and HAQ (p-value = 0.033), PGA and GH (p-value 0.023 both) was observed. RAID total score had a statistically significant negative relationship with MD score (p-value = 0.016). A statistically significant negative association was found for pain (p-value = 0.025), functional disability (p-value<0.001), sleep (p-value = 0.041), physical well-being (p-value = 0.027) and coping (p-value = 0.008). Multiple regression analysis to evaluate the relationship between significant RAID items and MD score did not show any statistical significance as all items are strongly related to each other. A negative trend, although not statistically significant was found for DAS28 and SDAI. The only comorbidity associated with MD score was arterial hypertension (OR = 0.94).

CONCLUSIONS

In this Italian RA cohort, the adherence to MD was significantly associated with a better RAID, PGA and GH, but higher MD score was not significantly associated with lower disease activity. Our study suggests an overall potential beneficial effect of MD in RA patients.

Ideal food pyramid for patients with rheumatoid arthritis: A narrative review

Emerging literature suggests that diet plays an important modulatory role in rheumatoid arthritis (RA) because diet is an environmental factor that affects inflammation, antigen presentation, antioxidant defense mechanisms and gut microbiota. Patients with RA frequently ask their doctors about which diets to follow, and even in the absence of advice from their physicians, many patients are undertaking various dietary interventions. Given this background, the aim of this review is to evaluate the evidence to date regarding the ideal dietary approach for management of RA in order to reduce the counteracting inflammation, and to construct a food pyramid for patients with RA. The pyramid shows that carbohydrates should be consumed every day (3 portions of whole grains, preferably gluten free), together with fruits and vegetables (5 portions; among which fruit, berries and citrus fruit are to be preferred, and among the vegetables, green leafy ones.), light yogurt (125 ml), skim milk (200 ml), 1 glass (125 ml) of wine and extra virgin olive oil; weekly, fish (3 portions), white meat (3 portions), legumes (2 portions) eggs (2 portions), seasoned cheeses (2 portions), and red or processed meats (once a week). At the top of the pyramid, there are two pennants: one green means that subjects with RA need some personalized supplementation (vitamin D and omega 3) and one red means that there are some foods that are banned (salt and sugar). The food pyramid allows patients to easily figure out what to eat.

The burden of air pollution and temperature on Raynaud's phenomenon secondary to systemic sclerosis

OBJECTIVES

to evaluate the effect of air pollution (ozone - O3 and particulate matter <=10 μm and <=2.5 μm - PM10 and PM2.5) on the severity of Raynaud's phenomenon (RP) secondary to systemic sclerosis (SSc).

DESIGN

cross-sectional, observational, and single centre study.

SETTING AND PARTICIPANTS

all consecutive SSc patients residing in Lombardy (Northern Italy) were enrolled. PM10, PM2.5, and O3 concentrations were calculated for each patient at municipality resolution in the week before the evaluation. Similar considerations were made for meteorological variables (temperature and humidity).

MAIN OUTCOME MEASURES

patients were asked to assess RP severity during the week before the evaluation according to a visual analogue scale (VAS). Ordinal logistic regression models were fitted to evaluate the short-term effect of temperature and air pollution with respect to RP. A univariate linear regression model was created to consider the association between temperature and pollutants.

RESULTS

in this study, 87 SSc patients were enrolled. Temperature was confirmed to strongly influence RP severity. PM10 and PM.5 were found to significantly worsen RP severity for the first four days before the evaluation, including the day of the visit, and as mean up to six days before the evaluation. O3 seemed to exert a protective effect on RP severity that was significant for the first four days before the evaluation, including the day of the visit, and as mean up to seven days before the evaluation.

CONCLUSIONS

since the overwhelming effect of temperature on RP, final conclusions about the exact contribution of pollutants on RP severity cannot be drawn because of the strong inter-correlation between air pollution and temperature.

Incidence of COVID-19 in Patients With Rheumatic Diseases Treated With Targeted Immunosuppressive Drugs: What Can We Learn From Observational Data?

Objective

To describe the incidence and severity of coronavirus disease 2019 (COVID‐19) in patients with rheumatic diseases treated with targeted synthetic or biologic disease‐modifying antirheumatic drugs (DMARDs) compared with that in the general population living in the same Italian region.

Methods

Patients followed up at 2 rheumatology referral centers in Lombardy from February 25, 2020 to April 10, 2020 were invited to participate in a survey designed to identify patients who had confirmed COVID‐19, close contact with others with confirmed COVID‐19, or symptoms of the infection, and to detect changes in work, behavior, and disease management made in an attempt to prevent infection. The incidence of COVID‐19 in the Lombardy population was obtained from the National Institute of Statistics. COVID‐19 cases were confirmed by nasopharyngeal swab.

Results

The survey was given to 955 patients (531 patients with rheumatoid arthritis, 203 patients with psoriatic arthritis, 181 patients with spondyloarthritis, and 40 patients with connective tissue diseases, vasculitides, or autoinflammatory diseases). These patients had a mean age of 53.7 years, and 67.4% were women. The rate of response to the survey was 98.05%, and the incidence of confirmed COVID‐19 cases was consistent with that in the general population (0.62% versus 0.66%; P = 0.92). None of the patients had severe complications or required intensive care treatment, and all of the patients who tested positive for COVID‐19 temporarily discontinued ongoing targeted synthetic drug or biologic DMARD therapy. Almost all patients took precautions to prevent the COVID‐19 infection (90.6%), and almost all continued treatment with targeted synthetic drugs or biologic DMARDs (93.2%). Disease activity remained stable in 89.5% of patients.

Conclusion

Our results reflected the attitude of patients with rheumatic diseases regarding the prevention of the infection while maintaining their long‐term treatment regimens. The incidence and severity of COVID‐19 in patients treated with targeted synthetic drugs or biologic DMARDs was not significantly different from that in the general population in the same region.

New Rheumatoid Arthritis Treatments for 'Old' Patients: Results of a Systematic Review

INTRODUCTION

In the last 20 years, biologic and targeted synthetic disease-modifying antirheumatic drugs (DMARDs) have become available for treating rheumatoid arthritis (RA), and a treat-to-target strategy has been introduced. We hypothesise that these advances should have resulted in changes to the characteristics of patients with RA participating in clinical trials of the newest therapies. This study determined whether the baseline characteristics of patients with RA enrolled in clinical trials have changed in the past decade versus patients participating in earlier RA studies.

METHODS

This secondary analysis was based on randomised controlled trials (RCTs) identified in a systematic literature review. Baseline characteristics of patients with RA with inadequate response to conventional synthetic DMARDs were compared between RCTs published in 1999-2009 and those published in 2010-2017 using random-effects meta-analyses.

RESULTS

Forty RCTs were analysed: 22 from 1999-2009 and 18 from 2010-2017. No significant difference between the two timeframes and no obvious trend over time were observed for age, gender, disease duration, rheumatoid factor status, tender and swollen joint counts, physician and patient global assessments of disease activity, and pain scores. Variability between RCTs was high. Similar results were observed for Disease Activity Scores and Health Assessment Questionnaire-Disability Index scores, but with low variability between RCTs.

CONCLUSION

The baseline characteristics of patients with RA participating in RCTs do not appear to have changed in the last decade despite the availability of new treatments and a different treatment approach. Further research should determine the impact of baseline patient characteristics on patients' response to RA treatments.

Thrombocytopenia in idiopathic inflammatory myopathies: a case series analysis

Idiopathic inflammatory myopathies (IIM) are a group of rare connective tissue diseases (CTDs) deeply affecting patients' prognosis. Extra-muscular involvement is not rare and skin, joints and lung are the most common targets. However, also dyserythropoiesis has been described, carrying relevant issues on patients' management and follow-up, as for example, lymphopenia has been associated with an increased risk of rapid progressive interstitial lung disease in anti-MDA5 positive dermatomyositis. Conversely to systemic lupus erythematosus, thrombocytopenia has only been rarely described in IIM and very few authors focused on its potential prognostic implications. We describe five cases of thrombocytopenia in IIM patients positive for myositis specific (MSA) or associated (MAA) autoantibodies. These reports extend the spectrum of haematological features associated to IIM, focusing also on potential risk factors for thrombocytopenia occurrence.

Factors Predicting Early Failure of Etanercept in Rheumatoid Arthritis: An Analysis From the Gruppo Italiano di Studio sulla Early Arthritis (Italian Group for the Study of Early Arthritis) Registry

Objectives

This study aims to investigate the factors associated with early discontinuation (within one year) of etanercept (ETA) in rheumatoid arthritis (RA) patients who began ETA as first biologic disease-modifying antirheumatic drug (bDMARD) and who were entered into the Gruppo Italiano di Studio sulla Early Arthritis (Italian Group for the Study of Early Arthritis; GISEA) registry.

Patients and methods

This registry-based cohort study included 477 RA patients (95 males, 382 females; median age 53 years; range 18 to 83 years) who began ETA as first bDMARD. Patient demographics, disease features and drugs were re-evaluated after 12 months. Baseline predictors of ETA discontinuation were estimated by univariate and multivariate analyses using Cox regression model.

Results

Seventy patients (14.7%) discontinued ETA during the first year (for inefficacy in 55.8%, adverse events in 28.6%, and other reasons in 6.5%). Concurrent conventional synthetic DMARDs (csDMARDs) were reported in 54.3% of patients, mainly methotrexate (MTX), while 52.4% of subjects took low doses of glucocorticoids. Patients stopping ETA more frequently showed one or more comorbidities, mainly cardiovascular diseases (28.6% vs. 15.7% in patients stopping and continuing ETA, respectively, p=0.009). The presence of comorbidities and a combination therapy with csDMARDs other than MTX were independent factors associated with early discontinuation of ETA at multivariate Cox analysis.

Conclusion

Although ETA demonstrated a high persistence in biologic-naïve RA patients, about 15% of patients discontinued the treatment within 12 months. The presence of comorbidities and a combination therapy with csDMARDs other than MTX were the main factors for an early withdrawal of the drug.

Relevant non-pharmacologic topics for clinical research in rheumatic musculoskeletal diseases: The patient perspective

OBJECTIVE

The research approach on rheumatic musculoskeletal diseases (RMDs) is challenging and patient involvement is an emerging issue to obtain relevant information to research. Despite growing interest in non-pharmacologic aspects of clinical research in RMDs, the patients' perspectives are currently poorly explored.

METHODS

A cross-sectional no-profit online survey was devised to identify and rank the priorities for clinical research in RMDs according to patients' perspectives. Patients were asked to rate the following topics: food/nutrition, air pollution, smoking, work activity, social participation, physical activity, emotional well-being/stress, alternative medicine, and patient-physician relationship. The survey was disseminated by ALOMAR (Lombard Association for Rheumatic Diseases) between June and October 2019.

RESULTS

Two hundred RMD patients completed the survey. The topic most rated 188 (94%) was the doctor-patient relationship, considered very or extremely important. Other topics rated as follows: psychological well-being 185 (92.5%), physical activity 155 (77.5%), nutrition, eating habits 150 (75%), alternative therapies 144 (72%), work activity 144 (72%), environmental pollution 134 (67%), social life 121 (60.5%) and cigarette smoke 119 (59.5%). The topics considered relevant were perceived to be able to influence disease symptoms. Environmental pollution and smoking were considered the most important for RMD prevention in 43.3% and 48.7% respectively.

CONCLUSIONS

This survey highlights the relevance of several unmet needs and indicates that active patient involvement is essential to design successful translational studies and improve clinical outcomes.

Golimumab effectiveness in biologic inadequate responding patients with rheumatoid arthritis, psoriatic arthritis and spondyloarthritis in real-life from the Italian registry GISEA

OBJECTIVE

To evaluate the clinical effectiveness of golimumab in biologic inadequate responder (IR) patients with Rheumatoid arthritis (RA), Spondyloarthritis (SpA), and Psoriatic arthritis (PsA).

METHODS

We analyzed 1424 patients on golimumab from the GISEA registry. Drug survival was estimated by Kaplan-Meier analysis in biologic-naïve, 1-biologic IR, ≥2-biologics IR patients. Hazard ratios (HRs) of discontinuing golimumab at 2 years were assessed by multivariate Cox regression. Patients achieving CDAI based low disease activity (LDA) or BASDAI<4 were calculated at 6 and 12 months.

RESULTS

In RA (n.370), the 2-years survival on golimumab was 61.4% in 1-biologic IR, 51.9% in≥2-biologics IR, and 73.1% in biologic-naive patients (P=0.002 vs≥2-biologics IR). In SpA (n.502), the survival was similar among 1-biologic IR (80%), ≥2-biologics IR (76.5%), and biologic-naive (74.6%) patients (P>0.05). In PsA (n.552) the survival was 72% in 1-biologic IR, 72.5% in≥2-biologics IR, and 71.8% in naïve-biologic (P>0.05). Predictors of golimumab discontinuation were monotherapy (HR 1.65) for RA, female gender for SpA (HR 2.48) and PsA (HR 1.57). In RA, patients on CDAI-LDA were lower in 1-biologic IR (40%) or≥2 biologics IR (40%) than in biologic-naïve (60%) group at 6 months (P=0.02), but no difference was observed at 12 months. In PsA and SpA, the percentage of patients on CDAI-LDA or BASDAI<4 at 6 months was almost identical across the subgroups.

CONCLUSIONS

Golimumab had similar effectiveness in biologic-failure and biologic-naïve SpA and PsA, but seems to be less effective in multi-failure RA patients, especially as monotherapy. The best outcomes were seen in male patients.

Multicentre, randomised, open-label, parallel-group study evaluating the efficacy and safety of ixekizumab versus adalimumab in patients with psoriatic arthritis naïve to biological disease-modifying antirheumatic drug: final results by week 52

Objectives

SPIRIT head-to-head (H2H) is a 52-week (Wk) trial comparing ixekizumab (IXE) with adalimumab (ADA) for simultaneous American College of Rheumatology (ACR)50 and Psoriasis Area and Severity Index (PASI)100 responses in 566 patients (distributed evenly across both groups) with psoriatic arthritis (PsA). IXE was superior to ADA for this primary end point at Wk24. We aimed to determine the final efficacy and safety results through Wk52 including a prespecified subgroup analysis of concomitant conventional synthetic disease-modifying anti-rheumatic drugs (csDMARD) use.

Methods

SPIRIT-H2H is a Wk52 multicentre, open-label, blinded-assessor study comparing IXE and ADA in bionaïve patients with PsA. Patients were randomised 1:1 to IXE or ADA with stratification by concomitant csDMARD use and presence of moderate-to-severe plaque psoriasis. Prespecified end points at Wk24 and Wk52 included musculoskeletal, psoriasis, quality-of life outcomes, subgroup analyses and safety.

Results

A significantly higher proportion of patients treated with IXE versus ADA simultaneously achieved ACR50 and PASI100 (39% vs 26%, p<0.001), PASI100 (64% vs 41%, p<0.001) at Wk52. Efficacy of IXE and ADA was similar at Wk52 for ACR50 (49.8% vs 49.8%, p=0.924), treat-to-target outcomes, enthesitis and dactylitis resolution. Responses to IXE were consistent irrespective of concomitant csDMARD use. Significantly more patients on IXE monotherapy versus ADA monotherapy had simultaneous ACR50 and PASI100 (38% vs 19%, p=0.007), and PASI100 responses (66% vs 35%, p<0.001) at Wk52. There were no new safety findings for IXE or ADA.

Conclusions

IXE provided significantly greater simultaneous joint and skin improvement than ADA through Wk52 in bionaïve patients with PsA. IXE showed better efficacy on psoriasis and performed at least as well as ADA on musculoskeletal manifestations. IXE efficacy was consistent irrespective of concomitant csDMARD use.

Trial registration number

NCT03151551.

COVID-19 in rheumatic diseases in Italy: first results from the Italian registry of the Italian Society for Rheumatology (CONTROL-19)

OBJECTIVES

Italy was one of the first countries significantly affected by the coronavirus disease 2019 (COVID-19) epidemic. The Italian Society for Rheumatology promptly launched a retrospective and anonymised data collection to monitor COVID-19 in patients with rheumatic and musculoskeletal diseases (RMDs), the CONTROL-19 surveillance database, which is part of the COVID-19 Global Rheumatology Alliance.

METHODS

CONTROL-19 includes patients with RMDs and proven severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) updated until May 3rd 2020. In this analysis, only molecular diagnoses were included. The data collection covered demographic data, medical history (general and RMD-related), treatments and COVID-19 related features, treatments, and outcome. In this paper, we report the first descriptive data from the CONTROL-19 registry.

RESULTS

The population of the first 232 patients (36% males) consisted mainly of elderly patients (mean age 62.2 years), who used corticosteroids (51.7%), and suffered from multi-morbidity (median comorbidities 2). Rheumatoid arthritis was the most frequent disease (34.1%), followed by spondyloarthritis (26.3%), connective tissue disease (21.1%) and vasculitis (11.2%). Most cases had an active disease (69.4%). Clinical presentation of COVID-19 was typical, with systemic symptoms (fever and asthenia) and respiratory symptoms. The overall outcome was severe, with high frequencies of hospitalisation (69.8%), respiratory support oxygen (55.7%), non-invasive ventilation (20.9%) or mechanical ventilation (7.5%), and 19% of deaths. Male patients typically manifested a worse prognosis. Immunomodulatory treatments were not significantly associated with an increased risk of intensive care unit admission/mechanical ventilation/death.

CONCLUSIONS

Although the report mainly includes the most severe cases, its temporal and spatial trend supports the validity of the national surveillance system. More complete data are being acquired in order to both test the hypothesis that RMD patients may have a different outcome from that of the general population and determine the safety of immunomodulatory treatments.

Ultrasound assessment of lacrimal glands: a cross-sectional study in healthy subjects and a preliminary study in primary Sjögren's syndrome patients

OBJECTIVES

This study aimed to: i) perform an ultrasonographic (US) evaluation of the lacrimal glands (LGs) in healthy subjects in order to define the sonographic elementary lesions which could be identified in the LGs and describe their frequencies in healthy subjects; ii) test the intra and inter-rater agreement between four rheumatologists; iii) preliminary assess whether the elementary lesions of the LGs let us differentiate healthy subjects from primary Sjögren's syndrome (pSS) patients.

METHODS

A consensus meeting was held to define the sonographic lesions to be evaluated. Healthy subjects and pSS patients underwent lacrimal glands ultrasound (LGUS) examinations in two Italian Rheumatology Clinics. A web-based reliability exercise was performed on healthy subjects' images by four rheumatologists. Afterward, images of pSS patients were evaluated for the presence of the sonographic lesions previously defined and compared to the US findings in healthy subjects.

RESULTS

Fifty-seven healthy subjects and 17 pSS patients were evaluated. The intra and inter-rater reliability score was good-excellent for almost all the agreed US features assessed (glandular parenchyma visibility, size, homogeneity, hypoechoic areas, hyperechoic spots, fibrous gland appearance, fatty deposition). Among the LGUS elementary lesions in pSS patients compared with healthy subjects, we detected a significantly difference in glandular inhomogeneity [13/33 (39.4%) vs. 9/63 (14.3%), p=0.01], and in fibrous gland appearance [3/33 (9.1%) vs. 0/63 (0%), p=0.04].

CONCLUSIONS

In this preliminary study, LGUS proved to have a good-excellent intra and inter-rater reliability. The glandular parenchyma inhomogeneity and the fibrous gland appearance could help differentiate pSS patients from healthy subjects.

THU0204 A SUBGROUP ANALYSIS OF LOW DISEASE ACTIVITY AND REMISSION FROM PHASE 3 STUDY OF FILGOTINIB IN PATIENTS WITH INADEQUATE RESPONSE TO BIOLOGIC DMARDS

Background:

Despite effective treatments, many patients (pts) with rheumatoid arthritis (RA) have inadequate responses to biologic DMARDs (bDMARD-IR), highlighting an unmet need. It is unclear whether prior bDMARD use affects efficacy of the oral, selective JAK-1 inhibitor filgotinib (FIL).

Objectives:

To explore clinical response to FIL in bDMARD-IR pts stratified by mode of action (MOA) and number of prior bDMARDs.

Methods:

The global, phase 3 FINCH-2 (NCT02873936) study treated 448 bDMARD-IR pts with active RA.1Pts were randomised 1:1:1 to once-daily FIL 200 mg, FIL 100 mg, or placebo (PBO) for 24 weeks. Efficacy was assessed by percent of pts achieving low disease activity (LDA) or remission at week (W)24 as measured by CDAI and DAS28(CRP) stratified by number and MOA of prior bDMARDs. Comparisons were not adjusted for multiplicity. Nonresponder imputation was used.

Results:

In total, 448 bDMARD-IR pts were included, 105 with prior experience with ≥3 bDMARDs (Table). At W24, pts receiving FIL were in LDA at a higher proportion vs PBO, irrespective of number of prior bDMARDs or MOA (Figure 1). For pts receiving FIL 200 vs PBO, DAS28(CRP) ≤3.2 was achieved at W24 by 52% vs 26%, 51% vs 22%, and 38% vs 9% of pts with 1, 2, or ≥3 prior bDMARDs, respectively, and 49% vs 21% and 50% vs 13% of pts exposed to TNF or IL-6 inhibitors; for all subgroups, rates were significantly higher vs PBO (Figure 1). Delta between FIL 200 mg and PBO was maintained irrespective of number or type of prior bDMARDs. At W24, pts receiving FIL achieved remission at numerically higher rates vs PBO (Figure 2). For pts receiving FIL 200 mg vs PBO, DAS28(CRP) <2.6 was achieved at W24 by 36% vs 14%, 30% vs 14%, and 22% vs 6% of pts with 1, 2, and ≥3 prior bDMARDs, respectively, and 31% vs 14% and 29% vs 9% of pts exposed to TNF or IL-6 inhibitors (Figure 2). Delta between FIL 200 mg and PBO was maintained irrespective of number or type of prior bDMARDs. Treatment-emergent adverse events across subgroups were consistent with overall study population.

Table.

Number and MOA of prior bDMARDs

FIL 200 mgn = 147FIL 100 mgn = 153PBOn = 148TotalN = 448Prior bDMARDs 173 (49.7)86 (56.2)77 (52.0)236 (52.7) 237 (25.2)33 (21.6)36 (24.3)106 (23.7) ≥337 (25.2)34 (22.2)34 (23.0)105 (23.4)LOE ≥1 bDMARD125 (85.0)129 (84.3)126 (85.1)380 (84.8)Intolerance ≥1 bDMARD36 (24.5)34 (22.2)32 (21.6)102 (22.8)Prior TNFi121 (82.3)134 (87.6)124 (83.8)379 (84.6) LOE ≥1 TNFi97 (66.0)113 (73.9)103 (69.6)313 (69.9) Intolerance ≥1 TNFi25 (17.0)24 (15.7)24 (16.2)73 (16.3)Prior non-TNFi73 (49.7)62 (40.5)75 (50.7)210 (46.9) LOE ≥1 non-TNFi52 (35.4)43 (28.1)56 (37.8)151 (33.7) Intolerance ≥1 non-TNFi13 (8.8)13 (8.5)11 (7.4)37 (8.3)Prior IL-6i34 (23.1)35 (22.9)32 (21.6)101 (22.5) LOE ≥1 IL-6i25 (17.0)22 (14.4)21 (14.2)68 (15.2) Intolerance ≥1 IL-6i5 (3.4)10 (6.5)5 (3.4)20 (4.5)

Data presented as n (%).

i, inhibitor; LOE, lack of efficacy.

Conclusion:

Treatment with FIL vs PBO led to higher rates of LDA and remission in pts with IR to IL-6 or TNF inhibition, or to 1, 2, or ≥3 prior bDMARDs, with a similar safety profile to the overall study population. A significantly higher proportion of pts overall receiving FIL 200 mg vs PBO were in LDA at W24. Improved efficacy of FIL vs PBO in pts who previously failed multiple bDMARDs indicates distinct benefits of selective JAK-1 inhibition with FIL.

References:

[1]Genovese, et al.JAMA2019;322(4):315–25.

Disclosure of Interests: :

Jacques-Eric Gottenberg Grant/research support from: BMS, Pfizer, Consultant of: BMS, Sanofi-Genzyme, UCB, Speakers bureau: Abbvie, Eli Lilly and Co., Roche, Sanofi-Genzyme, UCB, Maya H Buch Grant/research support from: Pfizer, Roche, and UCB, Consultant of: Pfizer; AbbVie; Eli Lilly; Gilead Sciences, Inc.; Merck-Serono; Sandoz; and Sanofi, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB, Grace C. Wright Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Exagen, Eli Lilly, Myriad Autoimmune, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Sanofi Genzyme, UCB, Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Exagen, Eli Lilly, Myriad Autoimmune, Novartis, Regeneron Pharmaceuticals, Inc., Sanofi Genzyme, UCB, Tsutomu Takeuchi Grant/research support from: Eisai Co., Ltd, Astellas Pharma Inc., AbbVie GK, Asahi Kasei Pharma Corporation, Nippon Kayaku Co., Ltd, Takeda Pharmaceutical Company Ltd, UCB Pharma, Shionogi & Co., Ltd., Mitsubishi-Tanabe Pharma Corp., Daiichi Sankyo Co., Ltd., Chugai Pharmaceutical Co. Ltd., Consultant of: Chugai Pharmaceutical Co Ltd, Astellas Pharma Inc., Eli Lilly Japan KK, Speakers bureau: AbbVie GK, Eisai Co., Ltd, Mitsubishi-Tanabe Pharma Corporation, Chugai Pharmaceutical Co Ltd, Bristol-Myers Squibb Company, AYUMI Pharmaceutical Corp., Eisai Co., Ltd, Daiichi Sankyo Co., Ltd., Gilead Sciences, Inc., Novartis Pharma K.K., Pfizer Japan Inc., Sanofi K.K., Dainippon Sumitomo Co., Ltd., Kenneth Kalunian Grant/research support from: Pfizer, Lupus Research Alliance, Sanford Consortium, Consultant of: Genentech, Nektar, BMS, Janssen, AstraZeneca, Biogen, Vielabio, Equillium, Eli Lilly, ILTOO, Abbvie, Amgen, Roche, Gilead, Alena Pechonkina Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Ying Guo Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Shangbang Rao Shareholder of: Gilead Sciences Inc., Employee of: Gilead Sciences Inc., YingMeei Tan Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Robin Besuyen Shareholder of: Galapagos, Employee of: Galapagos, Mark C. Genovese Grant/research support from: Abbvie, Eli Lilly and Company, EMD Merck Serono, Galapagos, Genentech/Roche, Gilead Sciences, Inc., GSK, Novartis, Pfizer Inc., RPharm, Sanofi Genzyme, Consultant of: Abbvie, Eli Lilly and Company, EMD Merck Serono, Genentech/Roche, Gilead Sciences, Inc., GSK, Novartis, RPharm, Sanofi Genzyme

FRI0234 A HIGH NEMO SCORE IN VIDEOCAPILLAROSCOPY IS PREDICTIVE OF FUTURE DEVELOPMENT OF DIGITAL ULCERS IN PATIENTS WITH SYSTEMIC SCLEROSIS

Background:

Nailfold videocapillaroscopy (NVC) is a feasible method that allows the observation and follow-up of the microvascular changes that mark the course of Systemic Sclerosis (SSc). In previous studies, we demonstrated that the NEMO score, namely the cumulative Number of microhaEMOrrhages and microthromboses, is a good indicator of the steady state level and over time changes of disease activity (DA) in SSc (1-3).

Objectives:

To verify whether a high NEMO score, and then a high level of active microvascular derangement in the fingers may be predictive of the subsequent development of ischemic digital ulcers (IDUs).

Methods:

The NEMO score was assessed at baseline (T0) in 98 patients affected by SSc, according to the ACR-EULAR criteria. Out of them, 90 were females, 48 had the limited form and 50 the diffuse cutaneous variant of SSc. ACA and anti-Scl-70 antibodies were positive in 42 and 50 patients, respectively. The NVC pattern was early, active and late in 16, 42 and 40 patients, respectively.

Afterwards, patients were closely followed up for 3 years, and the appearance of new IDUs was recorded in any time of the follow up.

The T0-NEMO score values of patients who developed IDUs were compared to those of patients who did not. A receiver operating curve (ROC) was constructed, and the area under the curve (AUC) calculated, by plotting the sensitivity and 1-specificity of the different NEMO score values in predicting the development of IDUs.

Results:

During the follow up, 38 out of 98 patients developed one or more DUs. The NEMO score at T0 was significantly higher in those who developed IDUs with respect to those who did not [median 14.5 (CI 11.0-21.5), and 4.5 (CI 4.0-6.0), respectively, p<.0001]. The AUC was 0.79 (CI 0.69-0.86, p<0.0001). A NEMO score of 12 or more had a sensitivity of 83.3 (CI 71.5-91.7), and a specificity of 63.2 (CI 46.0-78.2), with positive (P) and negative (N) predictive values (PV) of 59.1 (CI 44.9-72.3), and 85.6 (CI 71.7-94.3), respectively. A NEMO score of 16 or more had a sensitivity of 95.0 (CI 86.1-99.0), and a NPV of 93.3 (CI 77.4-99.2).

Conclusion:

NEMO score is not only a valid tool to assess the level of DA in the course of SSc, but this NVC parameter could also be used as a good predictor of the future development of IDUs in patients with this disease.

References:

[1]Sambataro et al. Arthritis Res Ther 2014;16:462-69

[2]Andracco et al. Arthritis Res Ther 2017;19:133-41

[3]Pignataro et al. Arthritis Res Ther. 2019;21(1):258

Disclosure of Interests:

Nicoletta Del Papa: None declared, Francesca Pignataro: None declared, Wanda Maglione: None declared, Antonina Minniti: None declared, Domenico Sambataro: None declared, Gianluca Sambataro: None declared, Gabriele Valentini Grant/research support from: BMS, MSD, NOVARTIS, LILLY, PFIZER, ABBVIE, CELGENE, Claudio Vitali: None declared, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB

AB0671 PREVALENCE OF EXTRA-ARTICULAR MANIFESTATIONS AND IMPACT ON TARGETED DRUG PRESCRIPTION IN PATIENTS WITH SPONDYLOARTHRITIS: A RETROSPECTIVE ANALYSIS OF A REAL-LIFE COHORT

Background:

Extra-articular manifestations (EAMs), such as uveitis, inflammatory bowel diseases (IBD), and psoriasis (PSO) can frequently complicate the disease course of patients with spondyloarthritis (SpA), although prevalence data on this regard are still controversial. The occurrence of EAMs may influence the decision to introduce a targeted therapy and also drive the choice of the most appropriate drug.

Objectives:

The aim of this study is to retrospectively evaluate the prevalence of EAMs in a real-life cohort of SpA patients who were eligible to receive a targeted therapy and to investigate their impact in the choice of targeted treatment.

Methods:

Clinical data of SpA (axial SpA [axSpA], peripheral SpA, and psoriatic arthritis [PsA]) patients treated with a biologic or targeted synthetic Disease-Modifying Anti-Rheumatic Drug (DMARD) between December 1999 and December 2019 were extracted from a local registry. Prevalence of main SpA-related EAMs (uveitis, IBD and PSO) was calculated at the time of drug prescription, evaluating their distribution according to treatment subgroups. Comparisons between disease and treatment subgroups were made using the Fisher’s test.

Results:

The study included 629 patients with SpA (axSpA 26%, peripheral SpA 24%, PsA 50%), 266 [42%] women, mean age [±SD] 52 [±13.2] years, mean disease duration 7.8 [±7.9] years), receiving a total of 1106 lines of targeted treatment (I-line n=629, II-line n=258, ≥ III-line n=219) with etanercept (n=177), anti-TNF monoclonal antibodies (397 infliximab, 273 adalimumab, 38 certolizumab pegol, and 130 golimumab), secukinumab (n=46), ustekinumab (n=28), or apremilast (n=18). At the time of drug introduction, 13% of SpA patients showed at least one EAM. The prevalence of uveitis was higher in axSpA (11.8%) compared with both peripheral SpA (5.5%, p=0.01) and PsA (2.8%, p<0.0001), while IBD was more frequent in peripheral SpA (15.6%) than in axSpA (8.1%, p=0.008) and PsA (4.7%; p<0.0001). The prevalence of PSO was similar in axial and peripheral SpA (8.4 versus 6.3%, respectively; p=0.41). In the overall population, the baseline presence of at least one EAM was associated with a more frequent prescription of anti-TNF monoclonal antibodies rather than etanercept (14.4% versus 6.7%, respectively; p=0.004). Moreover, we observed a numerically, although not statistically significant, higher proportion of EAMs in patients treated with anti-TNF monoclonal antibodies rather than secukinumab (6.5%), ustekinumab (7.1%), and apremilast (5.9%).

Conclusion:

In our real-life cohort of SpA patients treated with targeted therapies, EAMs were highly represented at baseline, especially uveitis in axSpA and IBD in peripheral SpA. The presence of extra-articular involvement was associated with a preferential prescription of anti-TNF monoclonal antibodies rather than etanercept or drugs with different mechanisms of action.

References:

[1]Erol K, et al. Extra-articular manifestations and burden of disease in patients with radiographic and non-radiographic axial spondyloarthritis. Acta Reumatol Port. 2018;43(1):32-39.

[2]Molto A, Sieper J. Peripheral spondyloarthritis: Concept, diagnosis and treatment. Best Pract Res Clin Rheumatol. 2018;32(3):357-368.

[3]van der Heijde D, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis. 2017 Jun;76(6):978-991.

Disclosure of Interests:

Martina Biggioggero: None declared, Ennio Giulio Favalli Consultant of: Consultant and/or speaker for BMS, Eli-Lilly, MSD, UCB, Pfizer, Sanofi-Genzyme, Novartis, and Abbvie, Speakers bureau: Consultant and/or speaker for BMS, Eli-Lilly, MSD, UCB, Pfizer, Sanofi-Genzyme, Novartis, and Abbvie, Antonio Marchesoni Speakers bureau: Abbvie, Pfizer, UCB, Novartis, Celgene, Eli Lilly, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB

AB0153 ADIPOSE-DERIVED STROMAL/STEM CELLS FROM SYSTEMIC SCLEROSIS PATIENTS SUCCESSFULLY EXERT A PARACRINE ANTI-FIBROTIC ACTIVITY AND INDUCE A PRO-ANGIOGENIC PHENOTYPE OF SCLERODERMA FIBROBLASTS IN VITRO

Background:

Adipose-derived stromal/stem cells (ADSCs) are multipotential non-hematopoietic progenitor cells with anti-inflammatory, immunomodulatory and regenerative effects. They have the advantage of accessibility and potent pro-angiogenic effects when compared with other stem cells, such as bone-marrow derived stem cells. Recent studies have shown that autologous fat grafting may be effective in the treatment of fibrotic and vascular complications in systemic sclerosis (SSc), despite a pro-fibrotic signature.

Objectives:

Aim of the study was to better characterize the proliferative and secretive profile of ADSCs in normoxic and hypoxic conditions, and to evaluate the mechanisms by which ADSCs exert these observed clinical effects.

Methods:

Adipose tissue samples were obtained by liposuction from 12 SSc patients and 10 healthy donors (HD). ADSCs were purified according to their adherence to the plastic and characterized to express specific MSC surface antigens by flow cytometry analysis. Proliferation of ADSCs from SSc patients and normal controls was evaluated in normoxic and hypoxic conditions. Fibroblasts and ADSCs derived from SSc patients were co-cultured in direct and indirect culture systems and compared to HD. Fibroblasts proliferation, mRNA expression and protein secretion of VEGF and known fibrotic mediators including TGF β-1, TGFR, CTGF, Collagen type I (Col I) were analyzed in the same conditions.

Results:

Normoxic and hypoxic culture conditions did not modify the proliferation rate of both normal and SSc ADSCs. Hypoxia significantly increased mRNA expression of VEGF by HD and SSc ADSCs but had no effect on the mRNA expression of pro-fibrotic mediators, ie TGFβ and TGFR. Normal and SSc fibroblast proliferation was significantly reduced in both co-culture systems (p < 0.001) and by treatment with normoxic and hypoxic conditioned medium (CM) (p=0.001 and p=0.002). In the same conditions, mRNA expression and protein secretion of TGF-β1, CTGF and Col I were significantly reduced (p = 0.003, p =0.02, p=0.04). These results were confirmed when normal and SSc fibroblasts were cultured in the presence of ADSCs normoxic and hypoxic CM (p=0.02 and p=0.01). Furthermore, a significant increase in mRNA expression and production of VEGF was observed in SSc fibroblasts cultured in the presence of normoxic and hypoxic CM (p = 0.002 and p< 0.0001, respectively).

Conclusion:

We found that treatment with the medium from normoxic and hypoxic preconditioned ADSCs has an anti-fibrotic effect through both the inhibition of fibroblast proliferation and key mediators of fibrosis. The increased expression of VEGF by SSc fibroblasts in the presence of normoxic and, even more, hypoxic ADSCs CM, suggests that ADSCs can induce a paracrine pro-angiogenic phenotype, even in fibroblasts with a pro-fibrotic signature. Altogether these data show that ADSCs may exert their anti-fibrotic and pro-angiogenetic effects on SSc fibroblasts by the secretion of paracrine factors, partly explaining the mechanisms underlining beneficial clinical results of fat graft in SSc patients.

Disclosure of Interests:

Nicoletta Del Papa: None declared, Maurizio Lorini: None declared, Vincenzo Carbonelli: None declared, Antonina Minniti: None declared, Francesca Pignataro: None declared, Wanda Maglione: None declared, Gabriele Di Luca: None declared, Nicola Montano: None declared, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB

FRI0273 EFFECTIVENESS AND RETENTION RATE OF SECUKINUMAB FOR PSORIATIC ARTHRITIS AND AXIAL SPONDYLOARTHRITIS: REAL-LIFE DATA FROM THE ITALIAN LORHEN REGISTRY

Background:

Observational data on the use of secukinumab for the treatment of spondyloarthritides are still lacking. Large population-based registries that allow long-term follow-up have been increasingly used to investigate the performance of biologic drugs in a real life setting.

Objectives:

The aim of this study is to evaluate the effectiveness and the retention rate of secukinumab in psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA) patients in a real-life setting over a 3-year follow-up period.

Methods:

Data of all PsA and axSpA patients (diagnosed according to CASPAR and ASAS criteria, respectively) treated with secukinumab were prospectively collected in the Italian multicentric LORHEN registry. Effectiveness was measured as the mean change from baseline of Disease Activity in PSoriatic Arthritis score (DAPSA) in PsA and Ankylosing Spondylitis Disease Activity Score (ASDAS) in axSpA patients. Rates of DAPSA remission and ASDAS inactive disease were also computed. The 3-year retention rate was calculated by the Kaplan-Meier method and compared between PsA and axSpA by a log-rank test. A descriptive analysis of reasons for discontinuation was performed.

Results:

The study population included 195 PsA (55.4% females, mean age 50.7 [±11.8] years, mean disease duration 10 [±7.8] years, mean baseline DAPSA 23.12 [±12.3]) and 94 axSpA (61.7% males, mean age 49.1 [±12.7] years, mean disease duration 10.4 [±9.4] years, mean baseline ASDAS 3.41 [±1.1]) patients who received secukinumab as first (26.5 and 33%, respectively) or subsequent biologic agent. Compared with baseline, the 3-, 6- and 12-month mean values of both DAPSA (12.6 [±9], 11.2 [±10.5] and 9.3 [±7.5], respectively) and ASDAS (2.23 [±0.9], 2.15 [±0.9], and 1.84 [±0.9], respectively) were significantly decreased (p<0.001 for all the timepoints). The 3-, 6-, and 12-month rates of remission/inactive disease were 15.5, 25.4, and 30.5% in PsA and 18, 23.7, and 28.6% in axSpA group, respectively. One- and 3-year retention rate (figure 1) were respectively 79.4% and 66.6% in PsA and 72.3% and 70.1% in axSpA patients, with no significant difference between the two groups (p=0.517). The most frequent reason for withdrawal was inefficacy in both PsA (n=41) and axSpA (n=20), whereas only 8 PsA and 6 axSpA patients discontinued secukinumab because of adverse events.

Conclusion:

Our data confirmed in a real-life setting the 1-year clinical efficacy and the 3-year survival of secukinumab in both PsA and axSpA. The safety profile of secukinumab was very favorable for both the indications. No significant differences were observed in the performance of secukinumab between ax-SpA and PsA.

References:

[1]Deodhar A, et al. Arthritis Research & Therapy; 2019.

[2]Mease PJ, et al. RMD Open. BMJ Specialist Journals; 2018;4(2):e000723.

[3]Baraliakos X, et al. Clin Exp Rheumatol. 2018 Jan;36(1):50–5.

Disclosure of Interests:

Ennio Giulio Favalli Consultant of: Consultant and/or speaker for BMS, Eli-Lilly, MSD, UCB, Pfizer, Sanofi-Genzyme, Novartis, and Abbvie, Speakers bureau: Consultant and/or speaker for BMS, Eli-Lilly, MSD, UCB, Pfizer, Sanofi-Genzyme, Novartis, and Abbvie, Antonio Marchesoni Speakers bureau: Abbvie, Pfizer, UCB, Novartis, Celgene, Eli Lilly, Silvia Balduzzi: None declared, Carlomaurizio Montecucco: None declared, Claudia Lomater Consultant of: Advisory board for Sanofi, Novartis, Abbvie, Gloria Crepaldi Consultant of: Advisory board for Sanofi and Celgene, Speakers bureau: BMS, MSD, Silvia Talamini: None declared, Chiara Bazzani: None declared, Enrico Fusaro: None declared, Marta Priora: None declared, Aurora Iannello: None declared, Giuseppe Paolazzi: None declared, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB

AB0229 SHORT-TERM EXPOSURE TO OUTDOOR AIR POLLUTANTS AND RHEUMATOID ARTHRITIS ACTIVITY IN METROPOLITAN AREAS IN THE NORTH OF ITALY

Background:

Air pollution is believed to cause oxidative stress and systemic inflammation, that could trigger autoimmunity in rheumatoid arthritis (RA). Several epidemiological studies investigated the possible role of air pollution in the outbreak of RA with controversial results. As far as we know, studies on the effects on disease activity of short-term exposure have not been published.

Objectives:

To evaluate the impact of short-term exposure to air pollutants (daily mean PM10, PM2.5, NO2and O3) on disease activity in patients with RA.

Methods:

Consecutive patients with RA (ACR/EULAR Criteria 2010) resident in Lombardy (Italy) were enrolled. In each patient Disease Activity Score on 28 joints (DAS28), Simple Disease Activity Index (SDAI) were assessed. Daily PM10, PM2.5, NO2and O3concentrations, estimated by Regional Environmental Protection Agency at municipality resolution, were used to assign short-term exposure from day of visit back to 14 days. Multivariable linear regression models were performed to identify the day of the pollutants independently associated with disease activity indices, adjusting for the variables significant at the univariate analysis. β coefficients were reported for 1 μg/m3increments of pollutants’ concentrations.

Results:

422 RA patients were enrolled in the study between January and June 2018: 81.5% females, mean age 58.2±13.3 years, mean disease duration 16.1±11.5 years, 27.3% current smokers, 59.5% RF positivity, 54.5% ACPA positivity. Sparse punctual statistically significant negative associations emerged at the multivariate analysis between PM10, PM2.5, NO2and the outcomes, although with very low estimates, whereas positive associations resulted for O3.

Afterwards patients were stratified in 3 subgroups according to their ongoing treatment (no therapy, n=25, conventional synthetic Disease Modifying anti-Rheumatic Drugs -DMARDs-, n=108 and biological or targeted synthetic DMARDs, n=289). A statistical significance was found by analysing the influence of therapy on the interaction between PM2.5and DAS28 (Figure below): a positive trend between PM2.5and DAS28 appeared in the first two groups (no therapy, 0.013±0.007, p=0.06 and csDMARDs, 0.006±0.004, p=0.17), whereas a statistically significant inverse association was seen in the b/tsDMARDs group (-0.005±0.002, p=0.01). Therapy interaction was particularly evident in several days before the visit also for O3.

Conclusion:

The changes of the outcome measures related to the increase of the pollutants’ levels did not reach the minimal clinically important difference, therefore air pollution seems barely relevant on disease activity once the loss of tolerance is established in RA. O3and PM/NO2always exhibit an opposite performance having inversely proportional atmospheric concentrations, whereas the biological role of this substance is still matter of debate and will need further understanding. Therapy seems to be able to interact with the relation between air pollutants and the parameters considered.

Disclosure of Interests:

Francesca Ingegnoli: None declared, Tania Ubiali: None declared, Tommaso Schioppo: None declared, Valentina Longo: None declared, Simona Iodice: None declared, Ennio Giulio Favalli Consultant of: Consultant and/or speaker for BMS, Eli-Lilly, MSD, UCB, Pfizer, Sanofi-Genzyme, Novartis, and Abbvie, Speakers bureau: Consultant and/or speaker for BMS, Eli-Lilly, MSD, UCB, Pfizer, Sanofi-Genzyme, Novartis, and Abbvie, Orazio De Lucia: None declared, Antonella Murgo: None declared, Valentina Bollati: None declared, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB

AB0922 BUROSUMAB (ANTI-FGF23 MONOCLONAL ANTIBODY) IN THE TREATMENT OF A PATIENT WITH RECURRENT TUMOR INDUCED OSTEOMALACIA

Background:

Tumor-induced Osteomalacia (TIO) is a rare paraneoplastic syndrome caused by tumoral overproduction of fibroblast growth factor 23 (FGF23), resulting in hyperphospaturia, hypophosphatemia and osteomalacia. Surgery is the only curative treatment, but tumor can locally recur, even after years from primary surgery. Furthermore, some tumors cannot be removed by surgery due to their location.

Objectives:

To describe a case of a 53-year-old woman affected by recurrent TIO after three surgical attempts of removal treated with Burosumab.

Methods:

We describe the case of a 53 years old woman with TIO treated with Burosumab, an anti-FGF-23 monoclonal antibody at present approved for X-linked hypophosphatemic rickets only.

Results:

A 46-year-old Caucasian female was referred to our Bone Unit after experiencing several fractures in different sites. She reported being in good health until three years prior consultation. At the time of symptoms onset, she experienced a progressive muscle pain, enabling her to stand for a long period. During imaging evaluation for atraumatic fracture of right great trochanter, the MRI abdomen and18FDG- PET-CT showed a metabolic pre-sacral lesion. She unsuccessfully underwent to an exploratory laparotomy of that lesion. Then, she suffered from atraumatic intertrochanteric fracture of right femur, surgically treated, and after 3 months, she had an insufficiency dyaphiseal fracture of the left femur, surgically treated. Furthermore, she experienced several ribs fractures. At the time of first evaluation, lab works showed: serum-Phosophate (PS) 1.2 mg/dL (reference range (RR) 2.5-4.5 mg/dL), urinary-phosphate of 24h (PU) 842 mg/24h, alkaline phosphatase (ALP) 565 UI (RR<300), 1,25(OH)2vitamin D327 ng/L (RR 25-86.5), PTH 24 (RR<75 pg/mL), intact-FGF-23 117 (RR 25-45 pg/mL), normal serum and 24h-urinary Calcium. Patient underwent to68Ga-DOTATATE-PET-CT that showed a pre-sacral lesion, who was studied with MRI and CT before surgery. In 2013 patient underwent surgical excision of the pre-sacral region. After 18 months of well-being, patient complained worsening of articular pain and muscle weakness, and further ribs fractures. Another68Ga-DOTATATE-PET-CT reported a relapse of the previous pre-sacral lesion (32x12x47 mm) with an increase of FGF-23levels (54.6 pg/mL). Even the subsequent surgery was not able to remove the tumor. Since 2015, patient was maintained in phosphorus supplements and 1,25(OH)2vitamin D3, but PS levels never normalized. We asked for compassionate use of Burosumab and, after ethical committee approval, in September 2019 she was started on Burosumab, at a dose of 30 mg per month (0.3 mg/kg). At baseline, she had PS 1.2 mg/dL, PU 1874 mg/24h, TRP 25.96%. After two months, she improved in pain symptom (VAS reduction from 65 to 12 mm), which allow her to walk and stand without crutches. She did not normalize her PS levels (1.3 mg/dL), while PU reduced to 1000 mg/24h. We titred Burosumab dose at 40 mg per month (0.6 mg/kg) and patient is still under therapy, waiting for next blood works.

Conclusion:

This is the first European patient affected by TIO treated with Burosumab. Burosumab could be a promising therapy in the medical treatment of TIO refractory or not eligible for definitive surgery. Further data are needed to standardize the proper dose regimen.

Disclosure of Interests:

Chiara Crotti: None declared, Francesca Zucchi: None declared, Piergiorgio Messa: None declared, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB, Massimo Varenna: None declared

THU0159 THE ADDITIONAL VALUE OF INTERLEUKIN-6 INHIBITORS ON PATIENT REPORTED OUTCOMES IN THE MANAGEMENT OF RHEUMATOID ARTHRITIS FAILURES TO A PREVIOUS ANTI-TUMOR NECROSIS FACTOR INHIBITOR: RETROSPECTIVE ANALYSIS FROM A LOCAL REGISTRY

Background:

To date the better strategy for the management of tumor necrosis factor inhibitor (TNFi) failures in rheumatoid arthritis (RA) is still under debate. At the same time, the patient’s perspective is becoming increasingly important in the management of RA and the use of patient reported outcomes (PROs) is becoming more and more frequent in daily practice.

Objectives:

To evaluate the additional value of PROs in the measure of comparative clinical response in a real-life local cohort of patients treated with different alternative mechanisms of action after the failure of a first-line TNFi.

Methods:

Data were retrospectively extracted from the registry of the ASST Gaetano Pini-CTO Institute, which include all RA patients treated with biologic drugs between December 1999 and December 2019. The analysis was limited to patients who failed a first-line TNFi and the study population was stratified according to the prescribed second-line mechanism of action (MoA). In each treatment subgroup the 6- and 12-month clinical response was evaluated as the mean change from baseline of Clinical Disease Activity Index (CDAI) score, Patient Global Assessment (PGA), and pain VAS. The rates of patients achieving CDAI remission/low disease activity (LDA) and an acceptable level of pain (pain VAS ≤20) were also calculated. The comparison between treatment subgroups was performed by using the t-test and the Fischer’s test for continuous and dichotomous variables, respectively.

Results:

A total of 405 patients (192 treated with a second TNFi, 87 with interleukin-6 inhibitors [IL-6is], 70 with abatacept, and 56 with rituximab) were included in the study. In the overall population 352 patients (86.9%) were female, mean (±standard deviation) age was 55.7±13.1 years, mean disease duration 14.3±9.1 years, RF and ACPA were positive in 76.4% and 79.3% of patients, respectively. We observed a clear trend toward the superiority of IL-6is over TNFis in the 12-month mean change from baseline of CDAI score (-13.9 vs -9.2, p=0.06) and in remission/LDA rates (58.7 vs 45.1%; p=0.048). In the evaluation of PROs, we found a statistically significant superiority of IL-6 over TNF inhibitors in the 12-month mean change from baseline of PGA (-34.5 vs -22.6%, p=0.02) and pain VAS (-35.4 vs -19.3%, p=0.01), and a significantly greater rate of acceptable pain level (42.1 vs 25.6%, p=0.01). No significant difference was observed in any of the evaluated items between a second TNFi and abatacept or rituximab.

Conclusion:

In a RA cohort of real-life insufficient responders to a first TNFi, we observed an overall better clinical response to IL-6is compared to a second TNFi. This effect is much more evident in the measure of PROs rather than composite indices as a possible result of the involvement of IL-6 in the pathways leading to pain and fatigue development in RA.

References:

[1]Choy EHS, Calabrese LH. Neuroendocrine and neurophysiological effects of interleukin 6 in rheumatoid arthritis. Rheumatology (Oxford). 2018;57(11):1885–1895.

[2]Crotti C, Biggioggero M, Becciolini A, Favalli EG. Sarilumab: patient-reported outcomes in rheumatoid arthritis. Patient Related Outcome Measures. 2018;9:275–84.

Disclosure of Interests:

Ennio Giulio Favalli Consultant of: Consultant and/or speaker for BMS, Eli-Lilly, MSD, UCB, Pfizer, Sanofi-Genzyme, Novartis, and Abbvie, Speakers bureau: Consultant and/or speaker for BMS, Eli-Lilly, MSD, UCB, Pfizer, Sanofi-Genzyme, Novartis, and Abbvie, Martina Biggioggero: None declared, Elena Agape: None declared, Antonio Marchesoni Speakers bureau: Abbvie, Pfizer, UCB, Novartis, Celgene, Eli Lilly, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB

AB1192 THE UNDERWORLD OF DEPRESSIVE SYMPTOMS IN RHEUMATIC DISEASES: OVERLOOKED, UNRECOGNIZED OR UNPERCEIVED?

Background:

The concomitant presence of depressive symptoms and rheumatic diseases (RDs) impose a considerable economic and social burden on the communities as they are associated with numerous deleterious outcomes such as increased mortality, work disability, higher disease activity and worsening physical function, higher pain levels and fatigue. Despite growing interest on depressive symptoms burden in RDs, current patient perception on this topic is unknown.

Objectives:

Italian patients with RDs were invited to participate in an online study gauging the presence and the perception of depressive symptoms using the Patient Health Questionnaire (PHQ-9).

Methods:

This was a cross-sectional no-profit online study to screen the presence and the perception of depressive symptoms in RDs patients. All participants gave their consent to complete the PHQ-9 and they were not remunerated. Completion was voluntary and anonymous. The PHQ-9 rates the frequency of symptoms over the past 2 weeks on a 0-3 Likert-type scale. It contains the following items: anhedonia, depressed mood, trouble sleeping, feeling tired, change inappetite, guilt or worthlessness, trouble concentrating, feeling slowed down or restless, and suicidal thoughts. Patients were stratified as: <4 not depressed, 5-9 sub-clinical or mild depression, 10-14 moderate depression, 15-19 moderately severe depression and 20-27 severe depression. The survey was disseminated by ALOMAR (Lombard Association for Rheumatic Diseases) between June and October 2019.

Results:

192 patients took part in the study: 170 female with median age 50 years. Among respondents only 35 (18.2%) were not depressed. Depression was sub-clinical or mild in 68 (35.4%), moderate in 42 (21.9%), moderately severe in 30 (15.6%), and severe in 17 (8.9%). 16 (8.3%) of respondents declared to have depressive symptoms and 7 of 16 were under psychiatric therapy.

Moreover, patients were grouped according to diagnosis.

124 respondents had inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis). 23 (18.5%) were not depressed. Depression was sub-clinical or mild in 41 (33%), moderate in 26 (21%), moderately severe in 21 (17%), and severe in 13 (10.5%). Among them, 8 (6.5%) declared to have depressive symptoms depressed and 3 of 8 were under psychiatric therapy.

49 respondents had a connective tissue disease or vasculitis. 11 (22.5%) were not depressed. Depression was sub-clinical or mild in 19 (38.8%), moderate in 13 (26.5%), moderately severe in 2 (4%), and severe in 4 (8.2%). Among them, 3 (6%) declared to have depressive symptoms and 1 of 6 were under psychiatric therapy.

19 respondents had other rheumatic diseases. 1 (5.3%) was not depressed. Depression was sub-clinical or mild in 8 (42.1%), moderate in 3 (15.8%), moderately severe in 7 (36.8%). Among them, 5 (26.3%) declared to be depressed and 3 of 5 were under psychiatric therapy.

Conclusion:

Our study confirmed that the overall real-life burden of depressive symptoms is relevant in all RDs. At the same time, these results highlighted that depressive symptoms are overlook by physicians and unperceived by patients since fewer that half of respondents (46.4%) had a clinical depression (PHQ-9>10). These results suggested that screening for depression should form part of the routine clinical assessment of RD patients.

Acknowledgments:

We thank the Lombard Association of Rheumatic Diseases (ALOMAR) for its contribution to design and disseminate the survey, the group that sustain systemic sclerosis (GILS), and the IT service of the University of Milan.

Disclosure of Interests:

Francesca Ingegnoli: None declared, Tommaso Schioppo: None declared, Tania Ubiali: None declared, Valentina Bollati: None declared, Silvia Ostuzzi: None declared, Massimiliano Buoli: None declared, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB