POS1371 BIOLOGICAL THERAPY IN REFRACTORY NEUROBEHÇET’S DISEASE. MULTICENTER STUDY OF 42 PATIENTS

Background:

Neuro-Behçet’s disease (NBD) is a severe complication of Behcet’s disease (BD). Despite well-established therapies with glucocorticoids and conventional immunosuppressants (cIS), a significant proportion of patients are refractory.

Objectives:

To assess efficacy and safety of biologic therapy (BT) in NBD refractory to glucocorticoids and at least one cIS.

Methods:

Open-label multicenter study of refractory NBD from 23 different referral Spanish Hospitals. Main outcome was neurological response. Secondarily, analytical efficacy was measured by Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP) and Hemoglobin (Hb) at baseline, 6 months, 1 year and 2 years.

Results:

We studied 42 patients (21 women/ 21 men; mean age 40.4±10.8 years). HLA B51 was positive in 15 out of 37 (40.5%) patients tested. Non-neurological manifestations were oral ulcers (n=41, 97.6%), genital ulcers (n=31, 73.8%), skin lesions (n=28, 66.7%), arthralgia (n=27, 64.3%), uveitis (n=21, 50.0%), arthritis (n=9, 21.4%), venous thrombosis (n=9, 21.4%) and arterial thrombosis (n=4, 9.5%). The underlying neurologic manifestation were parenchymal (n=34, 81.0 %) and non-parenchymal (n=17, 40.5%) involvement (Table 1). The first BT used was infliximab (n=20), adalimumab (n=13), golimumab (n=3), tocilizumab (n=3) and etanercept (n=2).

After 58.2±51.4 months since initiation of BT, neurological response was complete (n=27; 64.3%), or partial (n=11, 26.1%) (Figure 1). Only 4 (9.5%) patients did not respond. After 6 months of BT, ESR improved from.31.5±25.6 to 15.3±11.9 mm/h (p=0.005), CRP from 1.4 [0.2-12.8] to 0.3[0.1-3] mg/dL (p= 0.002) and Hb from 13.1±1.6 to 13.8±1.3 g/dL (p=0.005).

Figure 1.

Neurological clinical response to biological therapy.

Primary failure was observed in 16 (38.1%) patients due to inefficacy (n=11, 68.8%) or adverse effects (n=5, 31.3%). Similarly, causes of secondary failure (n=6, 14.3%) were inefficacy (n=5, 83.3%) and adverse effects (n=1, 16.7%). No serious adverse effects were observed.

Conclusion:

BT, especially monoclonal anti-TNF drugs, seems to be effective and safe in refractory NBD.

Table 1.

Neurologic manifestation of 42 patients with refractory neurobehçet's disease treated with biologic therapy.

Parenchymal subtype, n (%)34 (81.0)-Hemiparesis8 (19.1)-Polineuropathy8 (19.1)-Encephalopathy6 (14.3)-Cognitive impairments4 (9.5)-Optic neuropathy4 (9.5)-Ophtalmoparesis4 (9.5)-Other cranial nerve involvement3 (7.1)-Hemihypoesthesia3 (7.1)-Cerebellar dysphasia1 (2.4)-Cerebellar involvement1 (2.4)-Non-steroidal psicosis1 (2.4)Non-parenchymal subtype, n (%)17 (40.5)-Aseptic meningitis12(28.6)-Thrombosis4 (9.5)-Intracranial hypertension1 (2.4)

Disclosure of Interests:

Alba Herrero-Morant: None declared, José Luis Martín-Varillas Grant/research support from: AbbVie, Pfizer, Lilly, Janssen, and Celgene, Santos Castañeda: None declared, Iñigo González-Mazón: None declared, Olga Maiz: None declared, Ana Blanco Speakers bureau: AbbVie, Julio Sánchez: None declared, Norberto Ortego: None declared, Enrique Raya Speakers bureau: MSD, Grant/research support from: AbbVie, Alejandro Olive: None declared, Anahy Brandy-Garcia: None declared, Águeda Prior-Español: None declared, Clara Moriano: None declared, Elvira Diez Alvarez: None declared, Rafael Melero: None declared, Jenaro Graña: None declared, Álvaro Seijas-López: None declared, ANA URRUTICOECHEA-ARANA: None declared, Angel Ramos Calvo: None declared, Concepción Delgado Beltrán: None declared, Marta Loredo Martínez: None declared, Eva Salgado-Pérez: None declared, Francisca Sivera: None declared, Ignacio Torre-Salaberri: None declared, J. Narváez Speakers bureau: Bristol-Myers Squibb, José Luis Andréu Sánchez: None declared, Olga Martínez González: None declared, Ricardo Gómez de la Torre: None declared, Sabela Fernández: None declared, Susana Romero-Yuste: None declared, Gerard Espinosa: None declared, Miguel Á. González-Gay Speakers bureau: AbbVie, Pfizer, Roche, Sanofi, Lilly, Celgene and MSD, Grant/research support from: AbbVie, MSD, Jansen and Roche, Ricardo Blanco Speakers bureau: AbbVie, Pfizer, Roche, Bristol-Myers, Janssen, Sanofi, Lilly and MSD, Grant/research support from: AbbVie, MSD, and Roche

POS0308 TRAJECTORIES OF FATIGUE IN EARLY RA OVER 10 YEARS: RESULTS FROM THE ESPOIR COHORT

Background:

Fatigue is one of the most prevalent symptom reported by persons with RA. RA-related fatigue is a complex concept with biological, psychological and social interactions.

Objectives:

In a cohort of early RA patients, to determine and characterize fatigue trajectories over 10 years of follow-up and identify predictors of trajectory membership.

Methods:

Patients fulfilling the 2010 ACR/EULAR criteria for RA included in the ESPOIR cohort. We used a cluster analysis to obtain fatigue (assessed by fatigue visual analogue scale) trajectories over the course of 10 years from enrolment. Chi-square tests or ANOVA were performed to evaluate differences of baseline variables between fatigue trajectories. Using a multinomial logistic regression we could identify predictors of trajectory membership.

Results:

We analysed 598 patients with mean disease duration at enrolment of 26.2 ± 40.9 days. Cluster analysis revealed 3 trajectories: high (18%), moderate (52%) and low fatigue (30%). Compared to patients with moderate or low fatigue trajectory, patients with high fatigue trajectory were predominantly women and reported significantly higher duration and intensity of morning stiffness, HAQ score, number of tender joints, levels of pain, number of awakenings due to arthritis, levels of physician and patient global assessment and more frequent sleep problems, and increased psychological distress. Female patients with pain, psychological distress and presence of sicca symptoms had higher risk of being in high trajectory group.

Conclusion:

These findings suggest that levels of fatigue are rather stable over time in each trajectory. Baseline clinical measures and baseline patient-reported measures of functional status better distinguished the three fatigue trajectories. We did not find differences between trajectories in baseline laboratory measures. Inflammatory activity was not a predictor of being in high trajectory fatigue group.

References:

[1]Pollard LC, Choy EH, Gonzalez J, Khoshaba B, Scott DL. Fatigue in rheumatoid arthritis reflects pain, not disease activity. Rheumatology (Oxford) 2006;45:885–9

[2]Repping-Wuts H, van Riel P, van Achterberg T. Fatigue in patients with rheumatoid arthritis: what is known and what is needed. Rheumatology (Oxford) 2009;48:207–9.

[3]Pilgaard T, hagelund L, Stallknecht SE, jensen HH, Esbensen BA. Severity of fatigue in people with rheumatoid arthritis, psoritic artrhitis and spondyoarthritis- Results of cross-sectional study. Plos One. 2019;14:e0211831

[4]Feldthusen C, Grimby-Ekman A, Forsblad-d’Elia H, Jacobsson L, Mannerkorpi K. Explanatory factors and predictors of fatigue in persons with rheumatoid arthritis: a longitudinal study. J Rehabil Med 2016 28;48:469–76.

[5]Madsen SG, Danneskiold-Samsøe B, Stockmarr A, Bartels EM. Correlations between fatigue and disease duration, disease activity, and pain in patients with rheumatoid arthritis: a systematic review. Scand J Rheumatol. 2016;45:255-61.

[6]Olsen CL, Lie E, Kvien TK, Zangi HA. Predictors of fatigue in rheumatoid arthritis patients in remission or in a low disease activity state. Arthritis Care Res (Hoboken) 2016;68:1043–8.

[7]Druce K, Jones GT, Macfarlane GJ, Verstappen SMM, Basu N. The longitudinal course of fatigue in rheumatoid arthritis: results from the Norfolk Arthritis Register. J Rheumatol 2015;42:2059–65.

Disclosure of Interests:

None declared

Pneumatosis intestinalis and intestinal perforation in a case of multisystem inflammatory syndrome in children

This case demonstrates pneumatosis intestinalis and small bowel perforation in a paediatric patient with multisystem inflammatory syndrome in children (MIS-C). Our patient presented with fever, abdominal pain and shortness of breath. She progressed to haemodynamic failure and small bowel perforation approximately 1 week after admission. Patients with suspected or confirmed MIS-C should be monitored closely for abdominal catastrophe, especially when critically ill in the intensive care unit.

THU0297 SERIOUS INFECTIONS IN 134 PATIENTS WITH GIANT CELL ARTERITIS WITH TOCILIZUMAB IN CLINICAL PRACTICE. FREQUENCY, TYPE AND CLINICAL ASSOCIATIONS

Background:

Infections are the most common adverse event of Tocilizumab (TCZ) in Giant Cell Arteritis (GCA). In GiACTA study(1),serious infections were observed in 7% (9.6/100 patient-years) of patients who received TCZ weekly. Randomized clinical trials (RCTs) are conducted under highly standardized design excluding some real-world patients. Therefore, adverse events may be underestimated in RCTs. In our series of real-life, serious infections occurred in 11.9% (10.6/100 patient-years)(2).

Objectives:

In a wide series of GCA of clinical practice treated with TCZ, we assess the frequency, type and predisposing factors of serious infections.

Methods:

Multicenter study of 134 patients diagnosed with GCA, all of them refractory to conventional therapy, treated with TCZ. Serious infection was considered when a life-threatening infection, fatal, or requiring hospitalization occurred, intravenous antibiotics were required, or the infectious process led to persistent or significant disability.

Results:

16 of 134 (11.9%, 10.6/100 patient-years) patients developed serious infections during follow-up. The most frequent infections were pneumonia (n=4), urinary tract infection (n=4), and facial herpes zoster (n=2). At TCZ onset, serious infections were more frequent in older patients (74.3±9.6 vs 72.9±8.7 years), with a longer GCA evolution (20 [4.3-45.6] vs 13 [5-29.3] months), with visual manifestations (43.75% vs 17.8%) and a higher dose of prednisone at TCZ onset (30.4±15.5 vs 21.1±16.1 mg/day) (TABLE). Presence of comorbidities were similar in both groups. 13 of the 16 patients who had infections received a dose of prednisone greater than 15 mg/day (16.3/100 patient-years) compared to 3 patients under treatment with less than 15 mg/day of prednisone (4.2/100 patient-years).

Conclusion:

The age, GCA duration, ocular involvement and the dose of glucocorticoids, at TCZ onset, seem to be predisposing factors related to an increased risk of developing serious infections in GCA patients.

References:

[1]Stone JH, et al. N Engl J Med. 2017; 377:317-28.

[2]Calderón-Goercke M et al. Semin Arthritis Rheum 2019 Aug;49(1): 126-135.

TABLESERIOUS INFECTIONS(n=16)WITHOUT SERIOUS INFECTIONS(n=118)pBASAL FEATURES AT TCZ ONSETGENERAL FEATURES Age, years, mean± SD74.3±9.672.9±8.70.552 Sex, female/male n(%)13/388/300.760 Time from GCA diagnosis to TCZ onset (months), median [IQR]20[4.3-45.6]13[5-29.3]0.604COMORBIDITIES Hypertension, n(%)9(56)86(73)0.551 Diabetes, n(%)3(19)39(33)0.677 Chronic kidney disease, n(%)3(19)27(23)0.512CLINICAL FEATURES OF GCA PMR, n(%)9(56.25)64(54.2)0.879 Aortitis, n(%)5(31.25)53(45)0.301 Visual manifestations, n(%)7(43.75)21(17.8)0.017CORTICOSTEROIDS AT TCZ ONSET Prednisone dose mg/d, mean (SD)30.4±15.521.1±16.10.031

Disclosure of Interests:

Monica Calderón-Goercke: None declared, D. Prieto-Peña: None declared, Santos Castañeda: None declared, Clara Moriano: None declared, Elena Becerra-Fernández: None declared, Marcelino Revenga: None declared, Noelia Alvarez-Rivas: None declared, Carles Galisteo: None declared, Águeda Prior-Español: None declared, E. Galindez: None declared, Cristina Hidalgo: None declared, Sara Manrique Arija: None declared, Eugenio de Miguel Grant/research support from: Yes (Abbvie, Novartis, Pfizer), Consultant of: Yes (Abbvie, Novartis, Pfizer), Paid instructor for: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi), Speakers bureau: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi), Eva Salgado-Pérez: None declared, Vicente Aldasoro Speakers bureau: Roche, Abbvie, MSD, UCB, Pfizer, Menarini, Grunenthal, Gebro, Novartis, Janssen, Ignacio Villa-Blanco Consultant of: UCB, Speakers bureau: Novartis, MSD, Lilly, Susana Romero-Yuste: None declared, J. Narváez: None declared, Catalina Gomez-Arango: None declared, Eva Perez-Pampín: None declared, Rafael Melero: None declared, Francisca Sivera: None declared, Carlos Fernández-Díaz Speakers bureau: Brystol Meyers Squibb, Alejandro Olive: None declared, María Álvarez del Buergo: None declared, Luisa Marena Rojas: None declared, Carlos Fernández-López: None declared, Francisco Navarro: None declared, Enrique Raya: None declared, Beatriz Arca: None declared, Roser Solans-Laqué: None declared, Arantxa Conesa: None declared, Carlos Vázquez: None declared, Jose Andrés Román-Ivorra: None declared, Pau Lluch: None declared, Paloma Vela-Casasempere: None declared, Carmen Torres-Martín: None declared, Juan Carlos Nieto Speakers bureau: Pfizer, Abbvie, MSD, Novartis, Janssen, Lilly, Nordic Pharma, BMS, Gebro, FAES Farma, Roche, Sanofi, Carmen Ordas-Calvo: None declared, Cristina Luna-Gomez: None declared, Francisco J. Toyos Sáenz de Miera: None declared, Nagore Fernández-Llanio: None declared, Antonio García: None declared, Carmen González-Vela: None declared, Javier García-Fernández: None declared, Patricia Vicente-Gómez: None declared, Ángel García-Manzanares: None declared, Norberto Ortego: None declared, Francisco Ortiz-Sanjuán: None declared, Montserrat Corteguera: None declared, J. Luis Hernández: None declared, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD, Ricardo Blanco Grant/research support from: AbbVie, MSD, and Roche, Speakers bureau: AbbVie, Pfizer, Roche, Bristol-Myers, Janssen, and MSD

THU0001 GENOME-WIDE ASSOCIATION STUDY ON JOINT EROSIONS IN RHEUMATOID ARTHRITIS SUPPORTS DIFFERENTIAL PATHOLOGICAL MECHANISMS ACCORDING TO ANTI-CCP STATUS

Background:

Joint damage is the pathological hallmark of rheumatoid arthritis (RA). To identify the genetic variation associated with a higher level of erosions has proven elusive.

Objectives:

The objective of the present study was to perform a genome-wide association study on joint damage in a cohort of RA patients of the Spanish population. Our aims were to provide independent validation of previously reported variants and to identify new candidate risk loci. A stratified analysis was performed based on positivity to ACPA status.

Methods:

A total of 1,135 patients diagnosed with RA using the ACR-EULAR criteria recruited by the IMID Consortium were genotyped using a 550,000 single-nucleotide polymorphism array. Additional SNPs were imputed using the 1KG genome data. Joint damage was performed using the S-score, a simplified radiographic erosion score that has a high correlation with the Sharp-van der Hejde score (1). Association testing of SNPs with joint damage was performed via linear regression with the addition of the years of evolution as covariate. The two main components of genetic variation were also added to adjust for potential population stratification. A total of 50 SNPs representing previously reported loci associated with joint damage were selected. Genetic association was also performed at the pathway level using Pascal.

Results:

45 out of 50 SNPs representing 31 previously reported loci for joint damage could be satisfactorily imputed. Association testing of the whole patient cohort replicated the association withIL2RAandTRAF1. Of relevance, after stratifying for anti-CCP five new loci were replicated:KIF5AandSOSTin ACPA-positive RA andCD40, DKK1andTNFin ACPA-negative RA.IL2RAwas only significant in the ACPA-positive group andTRAF1was not significant in either strata. GWAS on the ACPA-positive cohort and on the ACPA-negative group identified n=7 and n=18 loci with P-values < 1x10-5, respectively. From these, however, only 1 SNP showed nominal significant association in the other patient group. Based on this evidence, we performed a pathway-based analysis to understand the biological mechanisms underlying this difference. Pathway analysis showed 52 biological processes associated with joint damage in ACPA-negative RA and 32 pathways in the ACPA-positive group, with only two shared biological processes between the two groups. Fc Gamma receptor mediated phagocytosis was the topmost biological process associated with erosions specifically in ACPA-negative RA and Signalling by Fibroblast Growth Factor mutants was the top process specific for ACPA-positive patients.

Conclusion:

The results from our study provide suggestive evidence that the genetic basis for joint damage is different according to the presence of ACPA. Replication of the new candidate loci in an independent patient cohort is underway.

References:

[1]Lopez-Lasanta, M., Julià, A., Maymó, J., Fernández-Gutierrez, B., Ureña-Garnica, I., Blanco, F. J., ... & Tornero, J. (2015). Variation at interleukin-6 receptor gene is associated to joint damage in rheumatoid arthritis.Arthritis research & therapy,17(1), 242.

Disclosure of Interests:

Antonio Julià: None declared, Francisco Blanco: None declared, Benjamin Fernandez: None declared, Antonio Gonzalez: None declared, Juan D: None declared, Joan Maymó: None declared, Mercedes Alperi-López: None declared, Alejandro Olive: None declared, Héctor Corominas Speakers bureau: Abbvie, Lilly, Pfizer, Roche, Victor Martinez Taboada: None declared, Isidoro González-Álvaro Grant/research support from: Roche Laboratories, Consultant of: Lilly, Sanofi, Paid instructor for: Lilly, Speakers bureau: Abbvie, MSD, Roche, Lilly, Antonio Fernandez-Nebro: None declared, Alba Erra: None declared, Simon Sánchez Fernandez: None declared, Núria Palau: None declared, Maria Lopez Lasanta: None declared, Adrià Aterido: None declared, Jesús Tornero: None declared, Sara Marsal: None declared

FRI0182 RISK FACTORS ASSOCIATED WITH RENAL INVOLVEMENT IN PRIMARY SJÖGREN’S SYNDROME: DATA FROM THE SPANISH SJÖGRENSER COHORT

Objectives:

To investigate the prevalence, risk factors, and effects of primary renal disease on morbidity and mortality in patients with primary Sjögren’s syndrome (pSS).

Methods:

All patients in the SJÖGRENSER (registry of adult SSp patients of the Spanish Society of Rheumatology, cross-sectional phase) cohort were retrospectively investigated for the presence of clinically significant renal involvement directly related to pSS activity.

Results:

Of the 437 patients investigated, 39 (9%) presented overt renal involvement during follow-up. Severe renal disease necessitating kidney biopsy was relatively rare (23%).

Renal involvement may complicate pSS at any time during the disease course and is associated with severe disease (indicated by higher scores of involvement, activity, and damage), systemic multiorgan involvement, and a higher frequency of lymphoma. Multivariate analysis showed that older age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.00–1.07), higher European League Against Rheumatism Sjogren’s Syndrome Disease Activity Index scores (OR 1.1, CI 1.03–1.18), serum anti-La/SSB positivity (OR 6.44, CI 1.36–30.37), and non-vasculitic cutaneous involvement (OR 8.64, 1.33–55.90) were independently associated with this complication.

Chronic renal failure developed in 23 of 39 patients (59%); only 1 of them progressed to end-stage renal disease necessitating renal replacement therapy. Patients with renal disease showed higher Sjögren’s syndrome disease damage index scores (SSDDI), higher rates of hospitalization due to disease activity and higher rates of clinically relevant comorbidities.

Conclusion:

Renal involvement is an uncommon complication in pSS that was observed in 9% of patients. Although categorized as a non-negligible comorbidity, this condition shows a favorable prognosis.

Disclosure of Interests:

None declared

FRI0487 APREMILAST IN MONOTHERAPY OR COMBINED IN NON-ULCER MANIFESTATIONS OF BEHÇET’S DISEASE. NATIONAL MULTICENTER STUDY OF 34 REFRACTORY CASES OF CLINICAL PRACTICE

Background:

Apremilast (APR) has demonstrated efficacy in orogenital ulcers of Behçet´s disease (BD). Response of other clinical manifestations remains unknown.

Objectives:

To assess the efficacy and safety of APR in monotherapy or combined with disease-modifying anti-rheumatic drugs (DMARDs) in non-aphthous ulcers of BD.

Methods:

National multicenter open-label study on 34 BD patients treated with APR at maintained standard dose of 30 mg twice daily.

Results:

From a cohort of 51 patients with APR by refractory orogenital ulcers of BD, we selected 34 (24 women/10 men, mean age 43.8±14.3 years), cases with another clinical manifestation/s.

Excluding CTs, colchicine or NSAIDs, APR was given in monotherapy (n=21) or combined with conventional and/or biologic DMARDs in 13 cases (5 methotrexate, 3 azathioprine, 3 hydroxychloroquine, 1 sulfasalazine, 1 dapsone, 2 tocilizumab, 1 IFX). Other active manifestations present at APR onset were: arthralgia/arthritis (16, true arthritis in 5), folliculitis/pseudofolliculitis (14), erythema nodosum (3), furunculosis (2), paradoxical psoriasis by TNFi (2), intestinal ileitis (2), deep venous thrombosis (2), leg ulcers (1), erythematosus and scaly skin lesions (1), fever (1), unilateral anterior uveitis (1) and neurobehçet (1).

After a median follow-up of 6 [3-12] months, folliculitis and ileitis improved, neurobehçet remained stable and musculoskeletal manifestations evolved in a variable way.(TABLE)

TABLE.

Conclusion:

In addition of orogenital ulcers, APR in monotherapy or combined, seems to be useful in skin manifestations of BD

Disclosure of Interests:

Alba Herrero Morant: None declared, Belen Atienza Mateo: None declared, J. Loricera: None declared, Vanesa Calvo del Rio Grant/research support from: MSD and Roche, Speakers bureau: Abbott, Lilly, Celgene, Grünenthal, UCB Pharma, José Luis Martín-Varillas Grant/research support from: AbbVie, Pfizer, Janssen and Celgene, Speakers bureau: Pfizer and Lilly, Gerard Espinosa: None declared, Jenaro Graña: None declared, Clara Moriano: None declared, Trinidad Pérez Sandoval: None declared, Manuel Martín Martínez: None declared, Elvira Diez: None declared, María Dolores García-Armario: None declared, Esperanza Martínez: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, Patricia Moya Alvarado: None declared, Francisca Sivera: None declared, Jaime Calvo Grant/research support from: Lilly, UCB, Consultant of: Abbvie, Jansen, Celgene, Isabel de la Morena: None declared, Francisco Ortiz Sanjuán: None declared, José Andrés Román Ivorra: None declared, Ana Pérez Gómez: None declared, Alejandro Olive: None declared, Carolina Díez: None declared, Juan José Alegre: None declared, D Ybáñez-García Speakers bureau: Lilly, Roche, Sanofi, Ángels Martínez-Ferrer: None declared, Javier Narvaez: None declared, Ignasi Figueras: None declared, Ana Isabel Turrión: None declared, Susana Romero-Yuste: None declared, Pilar Trénor: None declared, Soledad Ojeda Speakers bureau: AMGEN, LILLY, GEBRO, Miguel Á. González-Gay Grant/research support from: AbbVie, MSD and Roche, Speakers bureau: AbbVie, MSD and Roche, Ricardo Blanco Grant/research support from: Abbvie, MSD and Roche, Consultant of: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen and MSD, Speakers bureau: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen, Lilly and MSD

AB0907 BONE METABOLISM ASSESSMENT IN PATIENTS WITH RECENT DIAGNOSIS OF GIANT CELL ARTERITIS

Background:

There are several studies assessing bone mass and osteoporosis (OP) development of patients with giant cell arteritis (GCA) during glucocorticoid treatment, however data at time of diagnosis is scarce.

Objectives:

To analyze bone metabolism, bone mineral density (BMD) and trabecular microarchitecture by measuring trabecular bone score (TBS) in patients with recent diagnosis of GCA.

Methods:

Retrospective observational study in which we included all patients with GCA and bone metabolism assessment at diagnosis. We recorded: risk factors for OP (previous fractures and anti-OP treatments), bone metabolism (calcium, phosphate, PTH, 25-vitaminD [25-OHD]) and the DXA results (Lunar, DPX) at the time of diagnosis and during the follow-up. The statistic analysis was made with SPSS.

Results:

36 patients (27 W: 9M) with a mean age of 76±9 years were included. The clinical characteristics of the GCA at diagnoses were: headache (81%), constitutional syndrome (58%), allodynia (42%), visual loss (42%, binocular in 2 patients), jaw claudication (39%), polymyalgic syndrome (28%), amaurosis fugax (25%) and lingular necrosis (n=1, 3%). Additional diagnosis tests included: temporal biopsy (86%, being pathologic in 55%), temporal ultrasound (97%, pathologic 34%), extra-cranial arteries ultrasound (81%, pathologic 7%) and PET/CT (19%, pathologic 86%). Up to 61% received three metilprednisolone bolus (mean dose 1700mg). 7 patients (19%) had previous OP and 3 had already suffered a fragility fracture (Colles, vertebral and femur). Only 4 patients were receiving anti-OP treatment (2 oral bisphosphonate, 2 zoledronate).

At time of diagnosis of GCA, the mean of 25OHD was 17±13ng/mL (88%, <30). BMD showed low bone mass in 80% of patients (47% with OP, 33% osteopenia). The mean TBS was 1.026±0.098 and up to 38% showed poor bone microarchitecture [values <1.23]). No significant differences were observed between patients with or without TBS <1.23. Up to 94% of patients received anti-OP treatment (26 zoledronate, 6 oral bisphosphonate, 1 denosumab, 1 teriparatide). 3 patients had incidental fractures during the follow-up, however no relation was found with BMD or TBS.

Conclusion:

Low bone mass and vitamin D insufficiency are frequent in patients with recent diagnoses of GCA and up to 38% have poor bone microarchitecture at baseline. Thus, it’s important to perform a bone mass assessment in all patients with recent diagnose of ACG and initiate therapeutic or preventive anti-OP treatment if required.

Disclosure of Interests:

None declared

THU0307 RESPONSE OF BEHÇET’S REFRACTORY ORAL AND/OR GENITAL ULCERS TO APREMILAST IN COMBINATION VS MONOTHERAPY. NATIONAL MULTICENTER STUDY OF 51 CASES OF CLINICAL PRACTICE

Background:

Apremilast (APR) has demonstrated efficacy in the treatment of oral and/or genital aphthous ulcers in Behçet´s disease (BD). Combination of APR to other disease-modifying anti-rheumatic drugs (DMARDs) has not been assessed.

Objectives:

To compare the efficacy and safety of APR in monotherapy or combined with DMARDs in refractory BD.

Methods:

National multicenter open-label study on 51 BD patients with oral and/or genital ulcers refractory to conventional treatment.

Results:

We included 51 patients (35 women/16 men), mean age 44.7±13.2 years. Before APR, all patients had received several systemic conventional drugs. The main clinical symptoms for starting APR were oral (n=19) and genital (2) aphthous ulcers or both (30).

Excluding corticosteroids, colchicine or NSAIDs, APR was given at standard dose of 30 mg twice daily in monotherapy (n=31), or combined with conventional DMARDs in 16 cases (6 azathioprine, 5 methotrexate, 4 hydroxychloroquine, 4 sulfasalazine, 1 dapsone) or with biologic DMARDs in 4 (2 tocilizumab, 1 adalimumab, 1 infliximab). There were not found statistically significant differences in demographic features, previous therapy, clinical manifestations or reported adverse effects.

After a median follow-up of 6 [3-12] months, most of the patients experienced improvement of the orogenital ulcers in both groups (89.8% in the first 2 weeks), without statistically significant differences.(TABLE)

Conclusion:

APR leads to a rapid and maintained improvement in most patients with refractory BD orogenital ulcers. APR seems as effective and safe in monotherapy as combined.

TABLE:Week 1-2Week 4Month 6Month 12Month 24Outcome of oral and/or genital ulcers n, (%)Cn=19Mn=30Cn=19Mn=26Cn=12Mn=17Cn=7Mn=6Cn=1Mn=1 Complete resolution8 (42.1)11 (36.7)12 (63.2)20 (77)7 (58.4)14 (82.4)3 (42.8)3 (50)1 (100)1 (100) Partial resolution9 (47.4)16 (53.4)7 (36.8)3 (11.5)5 (41.6)2 (11.7)4 (57.2)3 (50)00 No response2 (10.5)3 (9.9)03 (11.5)01 (5.9)0000p value0.90.10.10.80.7

Abbreviations: C= combined; M= monotherapy; n= available data.

Disclosure of Interests:

Alba Herrero Morant: None declared, Belen Atienza Mateo: None declared, J. Loricera: None declared, Vanesa Calvo del Rio Grant/research support from: MSD and Roche, Speakers bureau: Abbott, Lilly, Celgene, Grünenthal, UCB Pharma, José Luis Martín-Varillas Grant/research support from: AbbVie, Pfizer, Janssen and Celgene, Speakers bureau: Pfizer and Lilly, Jenaro Graña: None declared, Gerard Espinosa: None declared, Clara Moriano: None declared, Trinidad Pérez Sandoval: None declared, Manuel Martín Martínez: None declared, Elvira Diez: None declared, María Dolores García-Armario: None declared, Esperanza Martínez: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, Patricia Moya Alvarado: None declared, Francisca Sivera: None declared, Jaime Calvo Grant/research support from: Lilly, UCB, Consultant of: Abbvie, Jansen, Celgene, Isabel de la Morena: None declared, Francisco Ortiz Sanjuán: None declared, José Andrés Román Ivorra: None declared, Ana Pérez Gómez: None declared, Sergi Heredia: None declared, Alejandro Olive: None declared, Águeda Prior: None declared, Carolina Díez: None declared, Juanjo J Alegre-Sancho Consultant of: UCB, Roche, Sanofi, Boehringer, Celltrion, Paid instructor for: GSK, Speakers bureau: MSD, GSK, Lilly, Sanofi, Roche, UCB, Actelion, Pfizer, Abbvie, Novartis, D Ybáñez-García Speakers bureau: Lilly, Roche, Sanofi, Ángels Martínez-Ferrer: None declared, J. Narváez: None declared, Ignasi Figueras: None declared, Ana Isabel Turrión: None declared, Susana Romero-Yuste: None declared, Pilar Trénor: None declared, Soledad Ojeda Speakers bureau: AMGEN, LILLY, GEBRO, Miguel Á. González-Gay Grant/research support from: AbbVie, MSD and Roche, Speakers bureau: AbbVie, MSD and Roche, Ricardo Blanco Grant/research support from: Abbvie, MSD and Roche, Consultant of: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen and MSD, Speakers bureau: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen, Lilly and MSD

OP0033 OPTIMIZATION OF TOCILIZUMAB THERAPY IN GIANT CELL ARTERITIS. A MULTICENTER REAL-LIFE STUDY OF 134 PATIENTS

Background:

Tocilizumab (TCZ) is the only biological agent approved in Giant Cell Arteritis (GCA). There is general agreement on the initial and the standard maintenance dose of TCZ. However, information on duration and optimization of TCZ in GCA is scarce.

Objectives:

Our aim was to assess efficacy and safety of TCZ therapy optimization in an unselected wide series of GCA in clinical practice.

Methods:

Multicenter study, 134 patients with GCA who received TCZ due to inefficacy/adverse events of previous therapy. Once complete remission was reached and based on a shared decision between patient and physician TCZ was optimized in some cases. Optimization was done by decreasing the dose and/or prolonging the TCZ dosing interval progressively.

Results:

134 GCA patients treated with TCZ (101w/33m); mean age 73.0±8.8 years. TCZ was administered IV to 106 (79.1%) patients and SC to 28 (20.9%). TCZ was optimized in 43 (32.1%) patients. No demographic, clinical manifestations or laboratory data differences had been found at TCZ onset (TABLE). After a follow up of 12 [6-15.5] months, and a complete remission for 6 [3-12] months; the first TCZ optimization was performed. Median prednisone dose at first TCZ optimization was 2.5 [0-5] mg/day. TCZ IV was optimized from 8 to 4 mg/kg/4weeks in 12 of 106 (11.3%) and from 162 mg/SC/week to 162 mg/SC/2weeks in 9 of 28 (32.1%) cases. Five (11.6%) of the 43 optimized cases relapsed. In 4 cases, the relapses were treated increasing TCZ up to the pre-optimization dose, in 1 case the route of administration was change (4 mg/kg/4week to 162 mg/SC/week). In 8 of 43 optimized patients (18.6%), it was possible to withdraw TCZ after complete remission for 30 [16.25-45.75] months. Regarding adverse events and severe infections were similar in both groups. The mean TCZ treatment costs were lower in the optimized group.

Conclusion:

Once remission is reached in GCA patients under TCZ treatment, optimization of TCZ may be performed. Based on our experience it could be performed by reducing the dose with IV TCZ or by prolonging dosing interval with SC TCZ.

References:

[1]Calderón-Goercke M et al. Semin Arthritis Rheum 2019 Aug;49(1): 126-135.

TABLE.OPTIMIZED-TCZ GROUP (n=43)NON-OPTIMIZED TCZ GROUP (n=91)pBASAL FEATURES AT TCZ ONSETGENERAL FEATURESAge, years, mean± SD68.9±8.771.4±8.50.125Sex, female/male n(%)32/1068/240.779Time from GCA diagnosis to TCZ onset (months), median [IQR]19.5[7.75-45]10.5[4 – 25]0.047SYSTEMIC MANIFESTATIONSFever, n(%)1(2.4)8(8.7)0.176Constitutional syndrome, n(%)11(26.2)19(20.7)0.476PMR, n(%)18(42.9)56(60.9)0.052ISCHEMIC MANIFESTATIONSVisual involvement, n(%)5(11.9)23(25)0.084Headache, n(%)26(61.9)42(45.7)0.081Jaw claudication, n(%)1(2.4)11(12)0.072CORTICOSTEROIDS AT TCZ ONSETPrednisone dose, mg/d mean (SD)15.1±11.125±17.40.001FOLLOW-UP ON TCZ THERAPY (MONTHS), MEDIAN [IQR]24[18-27]6 [3-18]0.000Relapses, n(%)5(11.6)5(5.5)0.207End follow-up remission, n(%)40(93)84(92)0.99Severe side efects, n(%)14(32.6)22(24.2)0.307Seriuos infections, n(%)6(14)10(11)0.878Cost, (mean) euros per yearIVSC7 538.47 329.011 726.411 726.4--

Disclosure of Interests:

Monica Calderón-Goercke: None declared, D. Prieto-Peña: None declared, Santos Castañeda: None declared, Clara Moriano: None declared, Elena Becerra-Fernández: None declared, Marcelino Revenga: None declared, Noelia Alvarez-Rivas: None declared, Carles Galisteo: None declared, Águeda Prior-Español: None declared, E. Galindez: None declared, Cristina Hidalgo: None declared, Sara Manrique Arija: None declared, Eugenio de Miguel Grant/research support from: Yes (Abbvie, Novartis, Pfizer), Consultant of: Yes (Abbvie, Novartis, Pfizer), Paid instructor for: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi), Speakers bureau: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi), Eva Salgado-Pérez: None declared, Vicente Aldasoro Speakers bureau: Roche, Abbvie, MSD, UCB, Pfizer, Menarini, Grunenthal, Gebro, Novartis, Janssen, Ignacio Villa-Blanco Consultant of: UCB, Speakers bureau: Novartis, MSD, Lilly, Susana Romero-Yuste: None declared, J. Narváez: None declared, Catalina Gomez-Arango: None declared, Eva Perez-Pampín: None declared, Rafael Melero: None declared, Francisca Sivera: None declared, Alejandro Olive: None declared, María Álvarez del Buergo: None declared, Luisa Marena Rojas: None declared, Carlos Fernández-López: None declared, Francisco Navarro: None declared, Enrique Raya: None declared, Beatriz Arca: None declared, Roser Solans-Laqué: None declared, Arantxa Conesa: None declared, Carlos Vázquez: None declared, Jose Andrés Román-Ivorra: None declared, Pau Lluch: None declared, Paloma Vela-Casasempere: None declared, Carmen Torres-Martín: None declared, Juan Carlos Nieto Speakers bureau: Pfizer, Abbvie, MSD, Novartis, Janssen, Lilly, Nordic Pharma, BMS, Gebro, FAES Farma, Roche, Sanofi, Carmen Ordas-Calvo: None declared, Cristina Luna-Gomez: None declared, Francisco J. Toyos Sáenz de Miera: None declared, Nagore Fernández-Llanio: None declared, Antonio García: None declared, J. Luis Hernández: None declared, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD, Ricardo Blanco Grant/research support from: AbbVie, MSD, and Roche, Speakers bureau: AbbVie, Pfizer, Roche, Bristol-Myers, Janssen, and MSD

FRI0148 SEROLOGICAL PROFILES IN PRIMARY SJÖGREN SYNDROME, SJOGRENSER PROJECT

Objectives:

Primary Sjögren´s Syndrome (pSS) is characterized by hyperactivity of the B cell, with the consequent production of autoantibodies. The presence of anti-Ro and anti-La has been associated with extraglandular manifestations and lymphoma development. The aim of this study is to evaluate the frequency of different serological profiles in patients of SJOGRENSER registry and to assess whether the combination of antibodies and serological markers are associated with the development of systemic disease and the systemic illness and/or the development of systemic disease and complications.

Methods:

SJOGRENSER is a transversal multicenter study with pSS patients (patients who meet 2002 pSS classification criteria); it is collected demographic, clinical, serological data and the activity index: ESSDAI and ESSPRI. It was established three serological profiles: 1. ANA/Ro+ with La/RF-; 2. ANA/Ro/La+ with RF-; 3. ANA/Ro/La/RF+. A descriptive analysis was done, with means and standard deviations, frequencies and proportions. Student t for quantitative variables and Chi2 for qualitative ones were performed to evaluate differences between groups, it was considered a p <0.05 as significant. The association was analyzed by multinominal analysis.

Results:

Four hundred and thirty-seven patients were included, the most frequent serological patterns observed were: ANA/Ro/La/RF+ 221 patients (50.5%), ANA/Ro/La+ 61 patients (13.9%) and ANA/Ro+ 60 patients(13.7%). There were only two patients with ANA/La +. The ESSDAI score was significantly associated with the profile ANA/Ro/La/RF+ (6 vs 4, p=0.007) and the group with the ANA/Ro/La+ profile reached an ESSDAI<5 (79%, p=0.043) (Table 1).

Table 1.

Serological markers associated with the development of systemic disease

InvolvementProfile 1ANA +Anti-Ro +Anti-La -RF –n=60N° (%)Profile 2ANA +Anti-Ro +Anti-La +RF –n= 61N° (%)Profile3ANA +Anti-Ro +Anti-La +RF +n= 221N°(%)pESSDAI index4460.007ESSDAI<544 (73.3)48 (78.7)139 (63.2)0.043ESSPRI index6.15.35.00.007Constitutional syndrome5 (8.3)9 (14.8)51 (23.1)0.023Lymphadenopathy8 (13.3)9 (14.8)37 (16.7)0.790Glandular14 (23.3)16 (26.2)87 (39.4)0.024Articular49 (81.7)40 (65.6)187 (84.6)0.004Lung3 (5.0)4 (6.6)29 (13.2)0.100Kidney0 (0)5 (8.2)31 (14.1)0.006Peripheral nervous system5 (8.3)6 (9.8)18 (8.2)0.918Central nervous system4 (6.7)7 (11.5)13 (5.9)0.320Hematological24 (40.0)26 (42.6)147 (66.5)<0.001Biologic5 (8.3)4 (6.6)26 (11.8)0.428Lymphoma1 (1.7)2 (3.3)3 (1.4)0.598

In contrast to the ESSPRI index was lower significantly associated with the profile ANA/Ro/La/RF+ and higher in the ANA/Ro+ (5 vs 6.1, p=0.007). The presence of antiLa and/or RF to the profile ANA/Ro+ rises the percentage of patients with constitutional syndrome, glandular, kidney and hematological affectation with statistically significant differences. The percentage of patients with articular involvement it was similar in the profiles ANA/Ro+ and ANA/Ro/La/RF +.

The multinomial analysis showed that the profile ANA/Ro/La/RF+ was associated with higher ESSDAI values (OR=1.09 (1.01-1.17)). The hematological involvement was associated with the profiles ANA/Ro/La/FR+ (OR= 2.76 (1.46-5.22)). Higher scoring of ESSPRI was associated with the profile ANA/Ro+ (OR=0.79 (0.69-0.91)).

Conclusion:

The most frequent serological profile was ANA/Ro/La/RF+ and it was associated with higher ESSDAI score. The presence of antiLa and/or RF with an ANA/Ro+ increased the presence of systemic involvement. The ANA/Ro+ profile was associated with a higher level of ESSPRI.

Disclosure of Interests:

None declared

AB0738 SAPHO OR PSORIATIC ARTHRITIS?: EVALUATION OF CASPAR CRITERIA IN A COHORT WITH SAPHO

Background:

SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis and osteitis) is an acronym created with the aim of encompassing within the same entity the findings present in a heterogeneous group of patients with various osteoarticular and cutaneous disorders. For years it has been debated whether it is an entity itself or if, on the contrary, it is a specific phenotype of psoriatic arthritis.

Objectives:

Determine the relationship between SAPHO syndrome and psoriatic arthritis by comparing the classic criteria of SAPHO with CASPAR in patients previously diagnosed with SAPHO.

Methods:

A retrospective study where patients with a diagnosis of SAPHO in the same center (1984-2018) were reviewed. Of a total of 95 patients that met the criteria of Benhamou et al., 46 were excluded due to lack of information to complete the minimum necessary data, so 39 patients were finally included in the study. Demographic data were registered, age at diagnosis, CASPAR criteria (active psoriasis, history of own or familial psoriasis, nail psoriasis, negative RF, dactylitis and new formation/juxta-articular bone proliferation), classical criteria of SAPHO and HLAB27. For the statistical analysis, a Chi-square is applied to determine the differences between the groups with / without CASPAR criteria.

Results:

Of the sample of 39 subjects diagnosed with SAPHO, 15 patients (38%) met CASPAR criteria (4M/11W), with a median age at diagnosis of 42 years (range 21-50). Of them, 8 (60%) had active cutaneous psoriasis, 10 (73%) had a family or personal history of psoriasis, 6 (40%) had psoriatic nail dystrophy, 14 (93%) had negative FR, 3 (20%) had presented some episode of dactylitis and 10 (73%) had juxta-articular new bone formation. Of the 15 patients who met CASPAR criteria, 9 (67%) had synovitis, 2 (13%) acne, 4 (26%) pustulosis, 13 (87%) hyperostosis and 12 (80%) osteitis. HLAB27 was positive in 1 patient (2.5%) of the group that met CASPAR criteria. Of the patients who did not fulfill CASPAR criteria (9M/15W), the median age at diagnosis was 44.5 years (range 10-70). None of them had active cutaneous psoriasis, psoriatic nail distrophy or dactylitis, 1 (4%) had a family or personal history of psoriasis, all had RF- and 3 (12.5%) had juxta-articular bone new formation (Table 1). Synovitis was observed more frequently in patients who met CASPAR criteria than in those who did not (67% vs 25%, p 0.01). In contrast, osteitis was present more frequently in patients who did not meet CASPAR criteria (80% vs 96% p 0.05) and pustulosis, although it was not statistically significant (50% vs 26%, p 0.07). Among patients who did not meet CASPAR criteria only 1 met the 5 classic SAPHO criteria and another 3 met 4.

Table 1.

Conclusion:

Approximately one third (38%) of patients diagnosed with SAPHO meet criteria for psoriatic arthritis, the most notable variables being active psoriasis or a history of psoriasis. Synovitis manifests more frequently in patients with CASPAR criteria and osteitis more present in patients who did not meet them.

Acknowledgments:

Rheumatology Service of the Germans Trias i Pujol Hospital

Disclosure of Interests:

None declared

AB0428 ASSOCIATION BETWEEN GEOGRAPHIC AND CLIMATOLOGICAL CONDITIONS AND CUTANEOUS MANIFESTATIONS IN LUPUS PATIENTS FROM THE SPANISH RHEUMATOLOGY SOCIETY LUPUS REGISTRY (RELESSER) AND ARGENTINE RHEUMATOLOGY SOCIETY LUPUS REGISTRY (RELESSAR) COHORT

Background:

Climatological conditions and ethnicity impact on the course of the disease in systemic lupus erythematosus patients.

Objectives:

We carry out a study to analyze cutaneous manifestations in SLE patients from Argentina and Spain.

Methods:

Patients data from Spanish Rheumatology Society Lupus Registry (RELESSER) and Argentina Rheumatology Society Lupus Registry (RELESSAR) were retrospectively analyzed for presence of cutaneous lesions (alopecia, photosensitivity, malar rash, discoid lesions, oral ulcers and subacute lesions). RELESSER-T and RELESSAR-T are multicenter, hospital-based registries, with retrospective cross-sectional collection of data about patients with SLE attending Spanish and Argentinian rheumatology services from the public national health system. Data about climatological conditions throughout the Spanish and Argentinian geography were provided by the Spanish Meteorological Agency and Argentine Meteorological Services.

Results:

A total of 5604 patients were included, median age 44.6 ± 15.3, 90.4 % female. Current smokers were 28,9%. Other climatological, geographical, biological and clinical data are shown in table 1. In the multivariable model, the presence of cutaneous lesion were significantly associated with temperature OR 1.116 (95% CI:1.042-1.196 p=0,002), altitude OR 1.001 (95% CI:1.000-1.001, p=0.012), hemolytic anemia OR 1.401 (95% CI:1.017-1.931 p=0.039) and serositis OR 1.509 (95% CI:1.215-1.875 p=0.000). Negative associations were observed between females OR 0.392 (95% CI:0.297-0.518, p=0.000), latitude OR 0.994 (95% CI:0.988-0.999, p=0.000), oceanic climate OR 0.566 (95% CI:0.381-0.842, p=0.005), leukopenia OR 0.790 (95% CI:0.643-0.970, p=0.025), renal disorder OR 0.761 (95% CI:0.600-0.966, p=0.025), glucocorticoids treatment OR 0.571 (95% CI:0.456-0.715, p=0.000) and antimalarial drugs OR 0.439 (95% CI:0.342-0.563, p=0.000).

Table 1.

Geographical, climatological and clinical/laboratory variables.

No cutaneous manifestationsCutaneous manifestationspLatitude, median (interqualite range)40.47 (38.35-41.63)40.37 (-31.41-41.34)0.001Altitude, median (interqualite range)192.0 (37.0-698.0)156.0 (25.0-609.0)0.000Temperature, mean monthly ± SD15.2 ± 3.515.3 ± 3.60.000Humidity, mean monthly ± SD66.9 ± 7.267.4 ± 7.10.108Oceanic climate, n (%)307 (11)2406 (89)0.000Subhumid/altitude climate, n (%)17 (7)240 (93)0.002Mediterranean climate, n (%)292 (17)1434 (83)0.000Arthritis, n (%)523 (12)3722 (88)0,003Serositis, n (%)254 (16)1368 (84)0,000Renal disorder, ever, n (%)206 (11)1576 (89)0.015Hemolytic anemia, n (%)90 (17)426 (83)0,002Leukopenia, n (%)345 (11)2669 (89)0.000Thrombocytopenia, n (%)170 (15)986 (85)0.076Antiphospholipid antibodies, n (%)293 (15)1606 (85)0.000Anti DNA, n (%)522 (14)3279 (86)0.044Anti-Ro/SSA, n (%)189 (11)1563 (89)0.000Hypocomplementemia, n (%)510 (12)3736 (88)0.000Glucocorticoids mucocutaneous cause, ever, n (%)499 (11)3928 (89)0.000Antimalarial drug: ever, n (%)500 (11)4034 (89)0.000

Conclusion:

In the current analysis, taking RELESSAR and RELESSER data together, we observe positive association between higher temperature and skin lesion and negative association with living in southern hemisphere latitudes.

References:

Influence of Solar Radiation in Cutaneous Manifestations of Lupus: Data from the Gladel Cohort [abstract]. Arthritis Rheumatol. 2016; 68 (suppl 10).

Disclosure of Interests:

Raúl Menor-Almagro: None declared, Mercedes Argentina García: None declared, Iñigo Rua-Figueroa: None declared, Guillermo Pons Estel: None declared, Maria Auxiliadora Martin-Martinez: None declared, Alejandro Muñoz Jimenez.: None declared, María Galindo-Izquierdo: None declared, Jaime Calvo-Alen: None declared, Antonio Fernandez-Nebro: None declared, Alejandro Olive: None declared, Bernardo Pons-Estel Grant/research support from: GSK, Janssen, Consultant of: GSK, Janssen, Speakers bureau: GSK, Janssen, Jose M Pego-Reigosa: None declared

Pumpless arteriovenous extracorporeal membrane oxygenation: A novel mode of respiratory support in a lamb model of congenital diaphragmatic hernia

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is commonly required in neonates with congenital diaphragmatic hernia (CDH) complicated by pulmonary hypertension (PH). ECMO carries significant risk, and is contraindicated in the setting of extreme prematurity or intracranial hemorrhage. Pumpless arteriovenous ECMO (P-ECMO) may represent an alternative for respiratory support. The present study summarizes our initial experience with P-ECMO in a lamb model of CDH.

STUDY DESIGN

Surgical creation of CDH was performed at 65-75days' gestation. At term (135-145days), lambs were delivered into the P-ECMO circuit. Three animals were maintained on a low-heparin infusion protocol (target ACT 160-180) and three animals were maintained with no systemic heparinization.

RESULTS

Animals were supported by the circuit for 380.7 +/- 145.6h (range, 102-504h). Circuit flow rates ranged from 97 to 208ml/kg/min, with adequacy of organ perfusion demonstrated by stable serum lactate levels (3.0 +/- 1.7) and pH (7.4 +/- 0.3). Necropsy demonstrated no evidence of thrombogenic complications.

CONCLUSION

Pumpless extracorporeal membrane oxygenation achieved support of CDH model lambs for up to three weeks. This therapy has the potential to bridge neonates with decompensated respiratory failure to CDH repair with no requirement for systemic anticoagulation, and may be applicable to patients currently precluded from conventional ECMO support.

Comparison of Subcutaneous Unfractionated Heparin with a Low Molecular Weight Heparin (Fragmin®) in Patients with Venous Thromboembolism and Contraindications to Coumarin

Intravenous heparin followed by oral anticoagulant therapy (e. g. with coumarin) is still the most widely used treatment for deep venous thromboembolism. Self-administered subcutaneous injections of heparin have been thought of as a promising alternative to coumarin, but the high doses required for ongoing prophylaxis have raised concerns about the possible development of bone disease. Certainly, long-term heparin therapy has been reported to cause osteoporosis in both laboratory animals and humans.

This study aimed to compare the efficacy and safety of unfractionated (UF) heparin with that of a low molecular weight heparin (Fragmin®, Kabi Pharmacia) in the prevention of recurrent deep venous thrombosis (DVT) and pulmonary embolism (PE) in a consecutive series of patients with contraindications to coumarin therapy. The patients comprised 40 men and 40 women, aged between 19 and 92 years (mean age, 68 years). They had all previously been diagnosed as having acute DVT and had been treated with conventional doses of heparin while in hospital. All patients had at least one of the following conditions: recent blood loss (either spontaneous or during admission while receiving heparin therapy); active gastroduodenal ulcer disease; psychological or physical inability or unwillingness to understand and accept the need for regular laboratory monitoring during coumarin treatment; chronic alcoholism; dementia; pregnancy; recent neurosurgery, and pericardial effusion; or were over 80 years of age. They were randomly allocated to receive either UF heparin, 10,000 IU s.c. b.d., or Fragmin®, 5000 IU anti-Factor Xa s. c. b. d., for a period of 3-6 months.

Two patients taking UF heparin were readmitted to hospital 2 and 3 months after discharge, owing to symptomatic, scintigraphically proven recurrent PE. No patients receiving Fragmin® had recurrent PE. There were 10 reports of minor bleeding: six in patients receiving UF heparin and four in patients on Fragmin®. Furthermore, there were seven cases of spinal fracture: six in patients on UF heparin, and one in a patient taking Fragmin®.

We conclude that fixed doses of both UFH and Fragmin® appear to be quite effective and safe for use in patients with a high risk of bleeding. In our experience, however, UF heparin is associated with an unacceptably high incidence of spinal fracture.

An extra-uterine system to physiologically support the extreme premature lamb

In the developed world, extreme prematurity is the leading cause of neonatal mortality and morbidity due to a combination of organ immaturity and iatrogenic injury. Until now, efforts to extend gestation using extracorporeal systems have achieved limited success. Here we report the development of a system that incorporates a pumpless oxygenator circuit connected to the fetus of a lamb via an umbilical cord interface that is maintained within a closed 'amniotic fluid' circuit that closely reproduces the environment of the womb. We show that fetal lambs that are developmentally equivalent to the extreme premature human infant can be physiologically supported in this extra-uterine device for up to 4 weeks. Lambs on support maintain stable haemodynamics, have normal blood gas and oxygenation parameters and maintain patency of the fetal circulation. With appropriate nutritional support, lambs on the system demonstrate normal somatic growth, lung maturation and brain growth and myelination.

Induction of Immune Tolerance to Foreign Protein via Adeno-Associated Viral Vector Gene Transfer in Mid-Gestation Fetal Sheep

A major limitation to adeno-associated virus (AAV) gene therapy is the generation of host immune responses to viral vector antigens and the transgene product. The ability to induce immune tolerance to foreign protein has the potential to overcome this host immunity. Acquisition and maintenance of tolerance to viral vector antigens and transgene products may also permit repeat administration thereby enhancing therapeutic efficacy. In utero gene transfer (IUGT) takes advantage of the immunologic immaturity of the fetus to induce immune tolerance to foreign antigens. In this large animal study, in utero administration of AAV6.2, AAV8 and AAV9 expressing green fluorescent protein (GFP) to ~60 day fetal sheep (term: ~150 days) was performed. Transgene expression and postnatal immune tolerance to GFP and viral antigens were assessed. We demonstrate 1) hepatic expression of GFP 1 month following in utero administration of AAV6.2.GFP and AAV8.GFP, 2) in utero recipients of either AAV6.2.GFP or AAV8.GFP fail to mount an anti-GFP antibody response following postnatal GFP challenge and lack inflammatory cellular infiltrates at the intramuscular site of immunization, 3) a serotype specific anti-AAV neutralizing antibody response is elicited following postnatal challenge of in utero recipients of AAV6.2 or AAV8 with the corresponding AAV serotype, and 4) durable hepatic GFP expression was observed up to 6 months after birth in recipients of AAV8.GFP but expression was lost between 1 and 6 months of age in recipients of AAV6.2.GFP. The current study demonstrates, in a preclinical large animal model, the potential of IUGT to achieve host immune tolerance to the viral vector transgene product but also suggests that a single exposure to the vector capsid proteins at the time of IUGT is inadequate to induce tolerance to viral vector antigens.

Axillary lymphatic malformations: Prenatal evaluation and postnatal outcomes

BACKGROUND/PURPOSE

The purpose of this study is to describe the prenatal findings and postnatal outcomes of fetuses with axillary lymphatic malformations.

METHODS

Retrospective chart review of fetuses with the prenatal diagnosis of isolated axillary lymphatic malformation detected between 2009 and 2013.

RESULTS

There were 8 fetuses diagnosed with isolated axillary lymphatic malformation. Median gestational age at diagnosis was 20.5 (19-28) weeks. All fetuses were evaluated by serial ultrasound and ultrafast fetal MRI. Two pregnancies were electively terminated. All continued pregnancies reached term, and all fetuses were delivered by cesarean section. None of the fetuses developed polyhydramnios or hydrops fetalis. Only one patient had an associated malformation (coarctation of the aorta). All patients were evaluated postnatally by MRI. Treatment included sclerotherapy only (1), sclerotherapy followed by surgical resection (1), surgical resection only (3), and observation (1). The median postnatal hospital stay was 8 (6-15) days. Three cases recurred after the initial treatment, two after surgery and one after sclerotherapy. On a median follow up of 2.1 years, all patients have some degree of visible residual disease. There were no deaths.

CONCLUSIONS

Prenatal diagnosis of axillary lymphatic malformation is increasing with improved technology. Axillary lymphatic malformations are usually isolated developmental anomalies that do not affect fetal health. Postnatal management options include surgery, sclerotherapy, and observation. Recurrences and residual disease after all types of treatment are frequent. This should be communicated to the parents at the time of prenatal counseling.

Risk factors associated with secondary sarcomas in childhood cancer survivors: a report from the childhood cancer survivor study

PURPOSE

Childhood cancer survivors have an increased risk of secondary sarcomas. To better identify those at risk, the relationship between therapeutic dose of chemotherapy and radiation and secondary sarcoma should be quantified.

METHODS AND MATERIALS

We conducted a nested case-control study of secondary sarcomas (105 cases, 422 matched controls) in a cohort of 14,372 childhood cancer survivors. Radiation dose at the second malignant neoplasm (SMN) site and use of chemotherapy were estimated from detailed review of medical records. Odds ratios (ORs) and 95% confidence intervals were estimated by conditional logistic regression. Excess odds ratio (EOR) was modeled as a function of radiation dose, chemotherapy, and host factors.

RESULTS

Sarcomas occurred a median of 11.8 years (range, 5.3-31.3 years) from original diagnosis. Any exposure to radiation was associated with increased risk of secondary sarcoma (OR = 4.1, 95% CI = 1.8-9.5). A dose-response relation was observed, with elevated risks at doses between 10 and 29.9 Gy (OR = 15.6, 95% CI = 4.5-53.9), 30-49.9 Gy (OR = 16.0, 95% CI 3.8-67.8) and >50 Gy (OR = 114.1, 95% CI 13.5-964.8). Anthracycline exposure was associated with sarcoma risk (OR = 3.5, 95% CI = 1.6-7.7) adjusting for radiation dose, other chemotherapy, and primary cancer. Adjusting for treatment, survivors with a first diagnosis of Hodgkin lymphoma (OR = 10.7, 95% CI = 3.1-37.4) or primary sarcoma (OR = 8.4, 95% CI = 3.2-22.3) were more likely to develop a sarcoma.

CONCLUSIONS

Of the risk factors evaluated, radiation exposure was the most important for secondary sarcoma development in childhood cancer survivors; anthracycline chemotherapy exposure was also associated with increased risk.

Automatic capture verification by charge-neutral sensing

Automatic capture verification can prolong pulse generator longevity and increase patient safety. However, the detection of evoked response following pacing is complicated due to afterpotentials caused by polarization of electrodes. This study describes a new capture verification scheme, which neutralizes the charges between the pacing electrodes. The hypothesis of the charge-neutral sensing is that the afterpotentials in the ring and the tip are opposite in polarity when pacing in a bipolar mode between ring and tip. Summing the unipolar signals sensed at the tip and the ring should effectively cancel the afterpotentials. This scheme was implemented in an external computer based system and tested during pacemaker implant/replacement on 23 patients during VVI pacing (17 acutely implanted leads and 6 chronic leads). Surface ECG was recorded to provide a marker for capture and noncapture. The pacing voltage was gradually decreased until a noncapture beat was noted. To avoid fusion beats, the pacing rate was programmed approximately 50% higher than the intrinsic rate. The evoked response was high pass filtered and the integral average was calculated for both capture and noncapture beats. The system signal to noise ratio (SNR) was expressed as ratio of the minimum integral average of all capture beats to the maximum integral average of all noncapture beats. The system SNR was 8.6 +/- 1.3 (mean +/- S.E.M; range 1.5-22.8), indicating that the charge-neutral sensing method has, on average, a ninefold safety margin in providing capture verification. Further, evaluation is needed to fully assess this feature in patients with chronic leads.

G-CSF after autologous bone marrow transplantation for malignant diseases in children. Spanish Working Party for Bone Marrow Transplantation in Children

The use of recombinant human granulocyte-stimulating factor (G-CSF) has been shown to effectively accelerate granulocytic recovery after autologous bone marrow transplantation (BMT) in adults. The experience, however, is limited in children. We evaluated the hematopoietic reconstitution in 41 consecutive children undergoing autologous BMT for hematologic malignancies (21 acute lymphoblastic leukemia, five non-Hodgkin's lymphoma) and solid tumours (seven neuroblastoma, two brain tumor, three Ewing's sarcoma, two Wilms' tumor, one rhabdomyosarcoma). Their ages ranged from 2 to 16 years (mean 7.2 years). rhG-CSF was given at a dose of 10 micrograms/kg/day i.v. in a 2h infusion from day +1 until +28 or until the absolute neutrophil count (ANC) was > 1 x 10(9)/L. These patients were compared with a similar historical control group of 38 children who did not receive rhG-CSF after autologous BMT. The number of cells infused was similar in both groups. At the dose and schedule used in the present study, rhG-CSF was well tolerated and no side-effects were observed. The number of cell infused was similar in both groups. At the dose and schedule used in the present study, rhG-CSF was well tolerated and no side-effects were observed. Our data show that rhG-CSF accelerates engraftment and reduces the number of febrile days and antibiotic use. Furthermore, patients who were treated had less infections.

Comparison of subcutaneous unfractionated heparin with a low molecular weight heparin (Fragmin) in patients with venous thromboembolism and contraindications to coumarin

Intravenous heparin followed by oral anticoagulant therapy (e. g. with coumarin) is still the most widely used treatment for deep venous thromboembolism. Self-administered subcutaneous injections of heparin have been thought of as a promising alternative to coumarin, but the high doses required for ongoing prophylaxis have raised concerns about the possible development of bone disease. Certainly, long-term heparin therapy has been reported to cause osteoporosis in both laboratory animals and humans. This study aimed to compare the efficacy and safety of unfractionated (UF) heparin with that of a low molecular weight heparin (Fragmin, Kabi Pharmacia) in the prevention of recurrent deep venous thrombosis (DVT) and pulmonary embolism (PE) in a consecutive series of patients with contraindications to coumarin therapy. The patients comprised 40 men and 40 women, aged between 19 and 92 years (mean age, 68 years). They had all previously been diagnosed as having acute DVT and had been treated with conventional doses of heparin while in hospital. All patients had at least one of the following conditions: recent blood loss (either spontaneous or during admission while receiving heparin therapy); active gastroduodenal ulcer disease; psychological or physical inability or unwillingness to understand and accept the need for regular laboratory monitoring during coumarin treatment; chronic alcoholism; dementia; pregnancy; recent neurosurgery, and pericardial effusion; or were over 80 years of age. They were randomly allocated to receive either UF heparin, 10,000 IU s.c. b.d., or Fragmin, 5000 IU anti-Factor Xa s.c. b.d., for a period of 3-6 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Anti-intrinsic factor antibodies in systemic lupus erythematosus

As the co-existence of pernicious anaemia (PA) and systemic lupus erythematosus (SLE) has been repeatedly reported, we have investigated the presence of anti-intrinsic factor antibodies (IFAb), the immunological hallmark of PA, in patients diagnosed with SLE. Serum cobalamin levels and IFAb were determined in 30 women diagnosed with SLE as well as in 45 controls. Cobalamin levels were low in 7/30 patients. IFAb were detected in 3/30 sera from patients but in none of the control sera. The presence of IFAb was associated with a low cobalamin concentration, anaemia and macrocytosis in only one patient. There was no evident relationship between the presence of IFAb and serological markers of SLE. We conclude that IFAb may appear in SLE patients, although the cobalamin deficiency described in SLE seems to be due to the presence of IFAb in only a minority of cases.