Abatacept as Monotherapy and in Combination With Methotrexate in Patients With Juvenile Idiopathic Arthritis: Analysis of 2 Phase III Trials

OBJECTIVE

To describe the efficacy and safety data of children with polyarticular-course juvenile idiopathic arthritis (pcJIA) treated with abatacept (ABA) + methotrexate (MTX) or ABA monotherapy when prior MTX use was either ineffective or not tolerated.

METHODS

Posthoc analysis of 2 phase III trials of subcutaneous (SC) and intravenous (IV) ABA over 2 years in patients with pcJIA (aged 2-17 years). Patients were stratified by treatment with ABA + MTX or ABA monotherapy and further by prior biologic use. Efficacy outcomes included JIA-American College of Rheumatology (JIA-ACR) responses, Juvenile Arthritis Disease Activity Score in 27 joints using C-reactive protein (JADAS27-CRP), and safety. Descriptive pharmacokinetic analyses were also performed.

RESULTS

Efficacy responses (JIA-ACR and JADAS27-CRP) were similar between patients receiving ABA + MTX (n = 310) or ABA monotherapy (n = 99) and persisted over 2 years. Clinical response rates were similar in biologic-naïve patients and prior biologic users; this was independent of MTX use. Across both studies, ABA + MTX and ABA monotherapy displayed similar safety profiles. Pharmacokinetic results revealed similar minimum steady-state trough ABA concentrations between studies. Further, baseline MTX did not influence ABA clearance and was not a significant predictor of JIA-ACR responses.

CONCLUSION

ABA monotherapy (SC and IV) was effective and well tolerated in children with pcJIA when prior MTX use was ineffective or not tolerated. Treatment effects of ABA appear to be independent of MTX coadministration. Consequently, ABA monotherapy can be considered for those with prior biologic therapy if MTX use is inappropriate. (ClinicalTrials.gov: NCT01844518 and NCT00095173).

POS0448 SYNOVIAL TRANSCRIPTOMIC PROFILES CORRELATE WITH DISEASE ACTIVITY IN EARLY UNTREATED RHEUMATOID ARTHRITIS

Background

Synovitis is the common feature across all individuals with a diagnosis of rheumatoid arthritis (RA). Yet, cellular and transcriptomic alterations occuring in RA synovium are highly variable amongst patients. So far, most data on clinical-tissue correlations either rely on hypothesis-driven approaches or are potentially biased by heterogeneous clinical characteristics (e.g. disease duration or disease-modifying antirheumatic drugs).

Objectives

We used transcriptomic profiling of synovial tissue from early, untreated rheumatoid arthritis patients (ERA) to 1/ identify the genes with the most variable expression amongst patients and 2/ explore the ability of unbiased (data-driven) approaches to define clinically relevant ERA subgroups.

Methods

Synovial biopsies were harvested from clinically involved joints of ERA patients using needle arthroscopy or ultrasound-guided biopsy. Data on disease activity were collected at inclusion. For each sample, 350ng total RNA was sent for RNAsequencing using a standardized protocol (Macrogen Europe). After quality control (Fast QC) and genome alignement (HiSat2), normalized read counts were analyzed on Qlucore Omics Explorer. To focus on inter-sample heterogeneity, genes were filtered based on variance (σ/σmax). Unbiased approaches (Principal Component Analysis, Unsupervised Clustering) were applied to define patients’ clusters. Pathway enrichment analysis were performed on Metascape. CibersortX was used to extrapolate the immune cell subsets relative composition from gene expression data. All other statistical analyses were performed on GraphPad Prism v9.

Results

Total RNA was obtained from synovial biopsies from 74 patients. We first applied variance filtering to identify the genes whose expression showed the greatest variation between patients (n = 894 most variable genes). PCA analysis on the level of expression of these genes did not divide samples into distinct groups, instead yielding a continuous distribution broadly associated with baseline disease activity, as measured by DAS28CRP. Consequently, we used unsupervised clustering to allow for unbiased definition of two patient clusters (PtC): PtC1 (n=52) and PtC2 (n=22) based on their expression of these 894 genes. Pathway analysis of these genes revealed significant enrichment of immune system genes, in the Inflammatory response and Rheumatoid Arthritis pathways (gene cluster 1: GC1), B cell & plasma cell-related pathways (GC2) and metabolic processes-related genes (GC3). Interestingly, PtC1 and PtC2 were characterized by very different clinical features. More specifically, patients from the group with a strong B & plasma cell signature (PtC1) displayed higher baseline indices of all disease activity score components (median DAS28CRP: 5.56 vs 4.09; p-value = 0.0003). They also had higher rates of baseline radiological erosions (erosive disease in 34.6 % vs 10%; p-value = 0.0252) but similar rates of seropositive disease. In line with our pathway analyses, we found a higher signature (inferred relative frequency) of B & plasma cells, T cells and M1-like macrophages in PtC1 compared to PtC2 synovia. PtC2 synovia instead had relatively higher M2-like macrophage and resting mast cell signatures.

Conclusion

In this large synovial biopsy study, we found that synovial transcriptomic profiles in ERA patients distribute continuously based on the expression of inflammatory and immune cell transcriptomic pathways. These synovial transcriptomic signatures correlate strongly with systemic disease activity.

Acknowledgements

This work was funded in part by unrestricted grants from Cap48 (RTBF), the Fonds de la Recherche Scientifique (FNRS), and the Fund for Scientific Research in Rheumatology (FWRO/FRSR), managed by the King Baudouin Foundation. CT is funded by the FNRS and Fondation Saint-Luc (Cliniques Universitaires Saint-Luc). NL is a chercheur qualifiée of the FNRS.

Disclosure of Interests

Clément Triaille: None declared, Tatiana Sokolova: None declared, Stéphanie de Montjoye: None declared, Adrien Nzeusseu Toukap: None declared, Laurent Meric de Bellefon: None declared, Axelle Loriot: None declared, Bernard Lauwerys Shareholder of: BL owns shares (<15000€) in DNALytics, Employee of: BL is currently employed at UCB Biopharma, Patrick Durez: None declared, Nisha Limaye: None declared.

OP0221 EFFICACY OF SECUKINUMAB IN ENTHESITIS-RELATED ARTHRITIS: RESULTS FROM A RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED, TREATMENT WITHDRAWAL, PHASE 3 STUDY (JUNIPERA)

Background

Enthesitis-related Arthritis (ERA) is a category of juvenile idiopathic arthritis (JIA) characterised by heterogeneous and insidious manifestations comprising axial and/or peripheral arthritis, and enthesitis.1 Secukinumab (SEC) demonstrated efficacy and safety in both ERA and juvenile psoriatic arthritis (JPsA) in the JUNIPERA trial.2

Objectives

To evaluate the rate of flare risk reduction and efficacy of SEC on axial and peripheral manifestations in patients (pts) with active ERA.

Methods

ERA pts (2 to <18 years of age) with active disease (both ≥3 active joints and ≥1 active enthesitis site) were included. In the open-label (OL) treatment-period (TP)1, s.c. SEC (75/150 mg in pts <50/ ≥50 kg) was administered at baseline (BL), and at Week (Wk) 1–4, 8 and 12. Pts who achieved at least JIA-ACR30 response at Wk 12 were randomised into the double-blinded TP2 to continue SEC or placebo (PBO) every 4 wk until a disease flare, or up to Wk 100. The primary endpoint was time to flare in ERA and JPsA pts. The juvenile spondyloarthritis disease activity Index (JSpADA) is a disease activity assessment tool that contains 8 items to measure axial and peripheral disease activity.3 Evaluation of axial and peripheral manifestations at the end of TP1 and TP2 in pts who experienced these symptoms at BL included modified Schober test (lumbar flexion), inflammatory back pain, FABER (Flexion, ABduction, External Rotation) test, JIA-ACR responses, Juvenile Arthritis Disease Activity Score (JADAS)-27, and resolution of enthesitis and dactylitis for peripheral disease. These outcomes were also used to assess JIA disease course at the end of TP2.

Results

A total of 52/86 (60.5%) pts with ERA were enrolled in the OL period TP1 (mean age, 13.7 years; male, 78.8%). In total, 51/52 (98.1%) pts completed TP1 and 41/44 (93.2%) completed TP2. At BL, mean JADAS-27 was 14.8, mean JSpADA index was 3.9, mean enthesitis and dactylitis counts were 2.7 and 0.4, respectively, mean number of active joints was 6.2 and of mean joints with limited range of motion 4.9. The relative risk reduction of experiencing a disease flare in TP2 was 55% (HR 0.45, 95% CI: 0.16–1.28, p=0.075) in ERA pts (Figure 1). The overall axial and peripheral disease symptoms improved over time and are presented in the Table 1. At the end of TP1, 84.6% (44/52) of pts achieved JIA-ACR 30 and 65.4% (34/52) achieved JIA-ACR 70. Clinically relevant reduction of functional ability as assessed by Childhood Health Assessment Questionnaire (CHAQ) also occurred (see Table 1).

Table 1.

Resolution of axial and peripheral disease symptoms and JIA ACR responses at the end of TP1 and 2

Clinical response, mean (SD) change from BL (unless otherwise stated)TP1-Wk 12End of TP2*SEC (N=52)SEC (N=22)PBO (N=22)JSpADA index−2.4 (1.7)−2.7 (1.7)−2.3 (2.1)JSpADA Schöber, %58.3100.0100.0Inflammatory back pain, %77.8100.050.0FABER test, %52.6100.083.3Clinical sacroiliitis, %53.3100.050.0Enthesitis−2.2 (1.9)−2.5 (2.1)−1.3 (1.8)Dactylitis−0.2 (0.8)−0.2 (1)−0.1 (0.4)JIA ACR30, %84.690.968.2JIA ACR50, %78.881.868.2JIA ACR70, %65.468.254.5JIA ACR90, %32.745.550.0JIA ACR100, %26.936.445.5Inactive disease, %38.550.050.0CHAQ−0.5 (0.5)−0.6 (0.7)−0.4 (0.5)CRP, median (SD) change from BL−1.8 (38.7)−5.8 (38.3)0 (35.9)JADAS-27−9.6 (7.5)−11.0 (8.9)−7.6 (8.9)Resolution of enthesitis#, %72.378.683.3Resolution of dactylitis#, %5066.70

*End of TP2 is based on individual pts’ last visit at TP2. #At BL, in TP1, enthesitis (n= 46); dactylitis (n=5). In TP2, no. of pts who had presence at BL and showed complete resolution at the end of TP2: enthesitis, SEC 14, PBO 18; dactylitis, SEC 3, PBO, 0. CRP, C-reactive protein

Conclusion

In pts with ERA, SEC demonstrated longer time to disease flare vs PBO and exhibited rapid and sustained improvement of axial and peripheral manifestations up to Wk 104.

References

[1]Pagnini I, et al. Front Med 2021;8:6673052.

[2]Brunner H, et al. Arthritis Rheumatol 2021;73 (suppl 10).

[3]Weiss PF, et al. Arthritis Care Res 2014;66:1775-82.

Disclosure of Interests

Nicolino Ruperto Speakers bureau: Eli Lilly, GlaxoSmith and Kline, Pfizer, SOBI and UCB, Paid instructor for: Eli Lilly and Pfizer, Consultant of: Ablynx, Amgen, Astrazeneca-Medimmune, Aurinia, Bayer, Bristol Myers and Squibb, Cambridge Healthcare Research (CHR), Celegene, Domain therapeutic, Eli Lilly, EMD Serono, GlaxoSmith and Kline, Idorsia, Janssen, Novartis, Pfizer, SOBI and UCB, Grant/research support from: Bristol Myers and Squibb, Eli Lilly, F Hoffmann-La Roche, Novartis, Pfizer and SOBI, Elena Chertok: None declared, Joke Dehoorne Speakers bureau: Abbvie, Roche, Consultant of: Abbvie, Roche, Pfizer, Grant/research support from: Abbvie, Roche, Gerd Horneff Speakers bureau: Novartis, Pfizer, Janssen, Grant/research support from: Pfizer, Novartis, Roche, MSD, Tilmann Kallinich Speakers bureau: Roche, Ingrid Louw Speakers bureau: Pfizer, Abbvie, BMS, Consultant of: Pfizer, Abbvie, Janssen, Amgen and Cipla, Sandrine Compeyrot-Lacassagne: None declared, Bernard Lauwerys Employee of: UCB Pharma, Neil Martin: None declared, Katherine Marzan Grant/research support from: Novartis, Sanofi, William Knibbe Speakers bureau: Novartis, Amgen, UCB, Abbvie, Ruvie Martin Shareholder of: Novartis, Employee of: Novartis, Xuan Zhu Shareholder of: Novartis, Employee of: Novartis, sarah whelan Shareholder of: Novartis, Employee of: Novartis, Luminita Pricop Shareholder of: Novartis, Employee of: Novartis, Alberto Martini Speakers bureau: Aurinia, Bristol Myers and Squibb, Eli Lilly, EMD, Janssen, Pfizer, Roche and Serono, Consultant of: Aurinia, Bristol Myers and Squibb, Eli Lilly and EMD, Daniel J Lovell Consultant of: Astra Zeneca, Boehringer Ingelheim, GSK, Hoffman LaRoche, Novartis, UBC, Grant/research support from: Astra Zeneca, Boehringer Ingelheim, GSK, Hoffman LaRoche, Novartis, UBC, Hermine Brunner Consultant of: Novartis, Grant/research support from: Novartis

OP0309 WES ANALYSIS OF RARE FAMILIES POINTS TO A PATHOGENIC ROLE FOR THE cGAS/STING-TYPE I IFN AXIS IN SSc

Background

Systemic sclerosis (SSc) is a rare (prevalence ±20/100,000), chronic condition characterized by vascular, immunological and connective tissue abnormalities. Genetic factors contribute to disease, as evidenced by a 15-fold increased relative risk in relatives of patients. Case-control studies have identified numerous associated loci; the identification and functional validation of risk alleles has however been elusive. No monogenic or oligogenic causes of SSc have been demonstrated, likely due to the infrequency of familial clustering (≤ 1.6% of cases) in this disease. We are fortunate to have access to DNA samples from five such families, with two affected first-degree relatives each: To our knowledge the only series of its kind.

Objectives

The goal of our research is to identify and functionally validate genes that drive SSc pathogenesis in these families, thereby shedding light on fundamental disease mechanisms. In light of the apparent lack of a multi-generational effect, we hypothesize that SSc may be transmitted as a di/oligogenic trait in these families, with two-to-a-few genes acting together to cause disease.

Methods

Whole exome sequencing (WES) was performed on all available blood-DNA (Figure 1). We filtered for variants that are (a) shared by both affected individuals within each family, (b) absent-to-rare in the general population, and (c) predicted to affect protein function by multiple in silico tools. Candidate gene prioritization and pathway analysis is followed by in vitro testing of a subset of SSc-variants, to assess for their effects on protein function. Where two strong candidate genes are identified in the same family, in vitro validation of both variants will be followed by the generation of single- vs. double- knock-in mice, to test for di/oligogenic effects of variant combinations on SSc-related phenotypes.

Figure 1.

SSc families. Filled symbols: affected. Arrows: WES on blood-DNA. lSSc: Limited SSc; lcSSc: Limited cutaneous SSc; dcSSC: Diffuse cutaneous SSc. cGAS/STING (red) and IFN I (black) - related candidate genes.

Results

WES yielded 23-45 genes per family with variants that satisfied the above criteria. Prioritization of candidates was based on systematic annotation of all 180 genes for expression pattern, function, and potential impact of the SSc-variants. Our data suggest familial SSc is genetically heterogeneous, with little sharing of candidates between families. We therefore assessed for pathways represented in gene-lists from multiple families, and found that participants in the cGAS/STING - type I-IFN axis are identified in all (Figure 1). This would suggest a unifying disease mechanism.

cGAS/STING is a sentinel system responsible for the production of anti-viral type I interferons (IFN-α/β) and pro-inflammatory cytokines in the presence of cytoplasmic double stranded DNA (dsDNA). cGAS/STING-dependent self-dsDNA sensing has been implicated in silica-induced inflammation: a risk factor in SSc and pulmonary fibrosis. A type I IFN-response signature is identified in SSc patients and correlates with disease severity. Mutations in two of our candidates cause Mendelian diseases with phenotypic overlaps with SSc, and all but one cause disease-relevant phenotypes when perturbed in mice. Finally, preliminary in vitro data suggest gain-of-function effects of the variant identified in TMEM173/STING, and loss-of-function effects in NT5E/CD73 and PRKD2 (the last with two different variants identified in two families; Figure 1). All would lead to increased IFN-I signaling.

Conclusion

We report, for the first time, WES analysis of a familial SSc series of unprecedented size for this rare disease. The identification of potential “driver” gene variants in cGAS/STING-type I IFN signaling regulators across all families points to an important pathogenic role for this pathway in SSc.

Disclosure of Interests

Pierre Maus: None declared, Vanessa Smith: None declared, Tessa Du Four: None declared, Marie Vanthuyne: None declared, Bernard Lauwerys Shareholder of: UCB Pharma, Employee of: Currently an employee of UCB Pharma, Nisha Limaye: None declared

Pharmacovigilance pregnancy data in a large population of patients with chronic inflammatory disease exposed to certolizumab pegol

Introduction:

Chronic inflammatory diseases (CIDs), including rheumatic diseases and other inflammatory conditions, often affect women of reproductive age. Tumor necrosis factor inhibitors (TNFi) are widely used to treat CID, but there is limited information on outcomes of TNFi-exposed pregnancies. We evaluated pregnancy outcomes from 1392 prospectively reported pregnancies exposed to certolizumab pegol (CZP), a PEGylated, Fc-free TNFi with no to minimal placental transfer.

Methods:

CZP-exposed pregnancies in patients with CID from the UCB Pharmacovigilance global safety database were reviewed from the start of CZP clinical development (July 2001) to 1 November 2020. To limit bias, the analysis focused on prospectively reported cases with known pregnancy outcomes.

Results:

In total, 1392 prospective pregnancies with maternal CZP exposure and known pregnancy outcomes (n = 1425) were reported; 1021 had at least first-trimester CZP exposure. Live birth was reported in 1259/1425 (88.4%) of all prospective outcomes. There were 150/1425 (10.5%) pregnancy losses before 20 weeks (miscarriage/induced abortion), 11/1425 (0.8%) stillbirths, and 5/1392 (0.4%) ectopic pregnancies. Congenital malformations were present in 30/1259 (2.4%) live-born infants, of which 26 (2.1%) were considered major according to the Metropolitan Atlanta Congenital Defects Program criteria. There was no pattern of congenital malformations.

Discussion and conclusion:

No signal for adverse pregnancy outcomes or congenital malformations was observed in CZP-exposed pregnancies. Although the limitations of data collected through this methodology (including underreporting, missing information, and absence of a comparator group) should be considered, these data provide reassurance for women with CID who require CZP treatment during pregnancy, and their treating physicians.

High p16INK4a, a marker of cellular senescence, is associated with renal injury, impairment and outcome in lupus nephritis

Objectives

Because a significant fraction of patients with lupus nephritis (LN) develops renal impairment, there is a need to better understand the mechanisms underlying disease progression. Here, we assessed for cellular senescence in the LN kidney, and its association with disease severity and outcome.

Methods

We enumerated the number of cells positive for p16^INK4a protein, a marker of cellular senescence, by immunohistochemistry followed by digital quantification, on renal biopsies from 40 patients with active LN. We tested for an association of p16^INK4a with renal fibrosis, CD8⁺ T cell infiltration, systemic disease and renal function at baseline and at 5 years.

Results

The presence of p16^INK4a-positive cells was significantly associated with lower estimated glomerular filtration rate at baseline and 5 years post-treatment, independently of patient demographics and systemic disease parameters. It was also associated with higher baseline renal fibrosis and CD8⁺ T cell infiltration. Interestingly, we observed marked spatial co-distribution of glomerular p16^INK4a-positive cells with CD8⁺ T cells.

Conclusion

We demonstrate, for the first time, that LN biopsies characterised by renal impairment display increased p16^INK4a-positive cells, associated with higher fibrosis and CD8⁺ T cell infiltration. Cellular senescence may represent a kidney-intrinsic disease mechanism and potentially, a novel therapeutic target in LN.

Serum calprotectin (S100A8/A9): a promising biomarker in diagnosis and follow-up in different subgroups of juvenile idiopathic arthritis

Introduction

In the management of juvenile idiopathic arthritis (JIA), there is a lack of diagnostic and prognostic biomarkers. This study assesses the use of serum calprotectin (sCal) as a marker to monitor disease activity, and as a classification and prognosis tool of response to treatment or risk of flares in patients with JIA.

Methods

Eighty-one patients with JIA from the CAP48 multicentric cohort were included in this study, as well as 11 non-paediatric healthy controls. An ELISA method was used to quantify sCal with a commercial kit.

Results

Patients with an active disease compared with healthy controls and with patients with inactive disease showed an eightfold and a twofold increased level of sCal, respectively. sCal was found to be correlated with the C-reactive protein (CRP) and even more strongly with the erythrocyte sedimentation rate. Evolution of DAS28 scores correlated well with evolution of sCal, as opposed to evolution of CRP. With regard to CRP, sCal could differentiate forms with active oligoarthritis from polyarthritis and systemic forms. However, sCal brought an added value compared with the CRP as a prognosis marker. Indeed, patients with active disease and reaching minimal disease activity (according to Juvenile Arthritis Disease Activity Score) at 6 months following the test had higher sCal levels, while patients with inactive disease had higher sCal levels if a flare was observed up to 3–9 months following the test.

Conclusions

This study confirms the potential uses of sCal as a biomarker in the diagnosis and follow-up of JIA.

POS0022 PHARMACOVIGILANCE PREGNANCY DATA IN A LARGE POPULATION OF PATIENTS WITH CHRONIC INFLAMMATORY DISEASE EXPOSED TO CERTOLIZUMAB PEGOL: PREGNANCY OUTCOMES AND CONFOUNDERS

Background:

Chronic inflammatory diseases (CID) in women of reproductive age are increasingly being treated with tumour necrosis factor inhibitors (TNFi), in line with recent guidelines.1 However, data on TNFi-exposed pregnancy outcomes are still limited. Certolizumab pegol (CZP), a PEGylated, Fc-free TNFi, has no/minimal placental transfer from mother to infant during the third trimester.2

Objectives:

To assess pregnancy outcomes from the UCB Pharmacovigilance safety database from over 1,300 prospectively reported pregnancies with maternal CZP exposure.

Methods:

Details of CZP-exposed pregnancies from the UCB Pharmacovigilance safety database were reviewed up to November 1, 2020. Analysis was limited to prospectively reported cases with known pregnancy outcomes to avoid potential reporting bias. Confounders (specific CID, non-biologic medications and maternal infection) were evaluated using a multivariate stepwise regression model; results from the confounders analysis are reported as odds ratios (OR) with 95% confidence intervals (CI). Patients with missing information about presence or absence of confounders were excluded from the model.

Results:

1,392 prospective pregnancies (1,425 fetuses) with maternal CZP exposure and known outcomes were reported (Figure 1). Mean (SD) maternal age was 31.9 (5.1) years. Of these, 1,021/1,392 (73.3%) pregnancies had at least first-trimester CZP exposure and 547/1,392 (39.3%) were exposed during all trimesters. Overall, there were 1,259/1,425 (88.4%) live births, 150/1,425 (10.5%) abortions (miscarriages and terminations), 11/1,425 (0.8%) stillbirths, and 5/1,425 (0.4%) ectopic pregnancies. Congenital malformations were reported in 35/1,425 fetuses (2.5%) and in 30/1,259 live-born infants (2.4%); 26 (2.1%) congenital malformations were major according to the Metropolitan Atlanta Congenital Defects Program criteria. There was no pattern of specific congenital malformations. Preterm births occurred in 124/1,259 (9.8%) live births, and 101/1,259 (8.0%) of infants had low birth weight (<2.5 kg). In the confounders analysis, reported corticosteroid use was independently associated with increased odds of preterm birth (OR [95% CI]: 2.1 [1.3–3.4]; p<0.005) and low birth weight (OR [95% CI]: 1.7 [1.0–2.9]; p<0.05), but decreased odds of abortion (OR [95% CI]: 0.5 [0.3–0.9]; p<0.05). Reported NSAID use was associated with increased odds of abortion (OR [95% CI]: 2.2 [1.2–4.0]; p<0.05), as was methotrexate/leflunomide use (OR [95% CI]: 3.2 [1.7–6.2]; p<0.0005). Maternal infections were associated with increased odds of preterm birth (OR [95% CI]: 1.9 (1.1–3.5; p<0.05). Finally, there was an association between a diagnosis of Crohn’s disease and odds of abortion (OR [95% CI]: 2.5 [1.5–4.1]; p=0.0005), and between rheumatoid arthritis and low birth weight (OR [95% CI]: 1.9 [1.1–3.3]; p<0.05).

Conclusion:

This prospective analysis, including more than 1,000 pregnancies with CZP exposure in at least the first trimester, represents one of the largest cohorts of pregnancies with known outcomes in patients with CID. Our data confirm the impact of specific CID, concomitant drugs or comorbidities on pregnancy outcomes. In particular, additional use of corticosteroids was highlighted as a risk factor for preterm birth and low birth weight in our cohort of CZP-treated patients. No increase in adverse pregnancy outcomes or specific congenital malformations was observed in CZP-exposed pregnancies, compared to the general population,3,4 which offers further reassurance for women of childbearing age considering CZP treatment.

References:

[1]Sammaritano LR. Arthritis Rheum 2020;72:529–56;

[2]Mariette X. Ann Rheum Dis 2018;77:228–33;

[3]Ventura SJ. Natl Vital Stat Rep 2012;60:1–21;

[4]Lee H. BMC Pregnancy Childbirth 2020;20:33.

Acknowledgements:

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

Disclosure of Interests:

Megan Clowse Consultant of: UCB Pharma, Grant/research support from: Janssen, Pfizer, Rebecca Fischer-Betz Consultant of: AbbVie, BMS, Celgene, Chugai, Eli Lilly, Janssen, Novartis, Pfizer, Sanofi, UCB Pharma, Catherine Nelson-Piercy Consultant of: Alliance Pharma, UCB Pharma, Angela Scheuerle Consultant of: Antiretroviral Pregnancy Registry, Harmony Biosciences, IQVIA, ICON, NovoNordisk, PPD, Roche, Sanofi-Genzyme, Syneos, UCB Pharma, ViiV, Thomas Kumke Shareholder of: UCB Pharma, Employee of: UCB Pharma, Bernard Lauwerys Employee of: UCB Pharma, Rachna Kasliwal Employee of: UCB Pharma, Frauke Förger Speakers bureau: Mepha, Roche, UCB Pharma, Grant/research support from: UCB Pharma.

OP0037 ABATACEPT AND OTHER DMARDS HAVE COMMON TRANSCRIPTOMIC EFFECTS ON RA SYNOVIAL TISSUE

Background:

Modes of action of DMARDs (disease-modifying antirheumatic drugs) in rheumatoid arthritis (RA) are not completely understood at the level of the synovium. Studying treatment-induced modifications in RA synovial tissue can provide unique insights into the pathways modulated downstream of different DMARDs.

Objectives:

Our goal was to assess histological and transcriptomic effects of Abatacept (ABA) on RA synovium, and to compare them with previously published data obtained by our group using the same study design on other DMARDs: Tocilizumab (TCZ), Rituximab (RTX), Methotrexate (MTX) and Adalimumab (ADA).

Methods:

Synovial tissue was obtained using ultrasound-guided biopsy from affected joints before (W0) and 16 weeks (W16) after treatment with subcutaneous Abatacept 125mg per week on a MTX background. Paraffin-sections were stained for CD3, CD20 and CD68 and scored by a pathologist for T cell, B cell and macrophage infiltration. Transcriptional profiling was performed using GeneChip Human Genome U133 Plus 2.0 arrays (Affymetrix), and analyzed on Genespring GX (Agilent). Pathway analyses were performed on Genespring GX, Metascape (https://metascape.org/) and EnrichR (https://maayanlab.cloud/Enrichr/). Protein-Protein Interaction (PPI) networks were generated on STRING (https://string-db.org/).

Results:

14 RA patients were included (female: 9, ACPA/RF positive: 8, erosive disease: 12, median disease duration in years (± SD): 11.7 (± 8.1), median DAS28CRP (± SD): 4.78 (± 1.11)). Median DAS28CRP significantly decreased between W0 and W16, as did US GS score. Evaluation of histological slides (n=11 pairs of samples) showed no significant effect of Abatacept on T cell, B cell or macrophage infiltration. Gene expression analysis (n=10 pairs of samples) identified 304 transcripts differentially expressed (129 downregulated, 175 upregulated) between W0 and W16 (FC≥1.5 and p<0.05, paired Mann-Whitney). Downregulated genes were significantly enriched for immune processes and included several key T cell regulatory genes (IL2RA, CD28, IL7, IL7R), strongly overlapping with data from previous studies on TCZ (n= 12 pairs), RTX (n=12 pairs), MTX (n=8 pairs) and ADA (n=8 pairs). Thus, each treatment shares 31 to 48% of its downregulated genes with the others, with genes downregulated by at least three involved in key RA-associated pathways such as leukocyte activation, NF-kappa B signaling, TNF signaling and JAK-STAT signaling. Given their seemingly overlapping effects, data were pooled across these studies, markedly improving power thanks to their paired-design. This revealed that genes downregulated by DMARDs (n=573, Benjamini-Hochberg corrected p-value<0.05, paired Mann-Whitney) were significantly enriched for both T cell and myeloid leukocyte activation pathways. Interestingly, DMARDs seem to have a coordinate effect on the two pathways (correlation of mean Log2FC: r=0.8558, p<0.0001), with a stronger impact (Log2FCW16-W0) in good responders to therapy (n=17) as compared to moderate (n=20) and to non-responders (n=13) (p<0.0001, Mann-Whitney). Finally, Transcription Factor enrichment and PPI network analyses point to a central role for molecules including JAK/STATs as mediators of all studied therapies.

Conclusion:

We provide evidence that the effects of five DMARDs on RA synovium culminate in the same pathways (namely, T cell and myeloid leukocyte activation). This confirms previous studies suggesting the existence of common mediators downstream of DMARDs, independent of their primary targets, and suggests attractive new therapeutic targets.

Acknowledgements:

This work was funded in part by unrestricted grants from Cap48 (RTBF) and Bristol-Myers Squibb. Clément Triaille is funded by the Fonds National de la Recherche Scientifique (FNRS, Communauté française de Belgique) and Fondation Saint-Luc (Cliniques Universitaires Saint-Luc).

Disclosure of Interests:

Clément Triaille: None declared, Tilman Gaelle: None declared, Tatiana Sokolova: None declared, Laurent Meric de Bellefon: None declared, Christine Galant: None declared, Patrick Durez Grant/research support from: unrestricted research grant from Bristol-Myers Squibb, Bernard Lauwerys Employee of: currently employed at UCB Biopharma, Nisha Limaye: None declared

AB0761 HISTOPATHOLOGY OF CHECKPOINT INHIBITORS INDUCED ARTHRITIS: RETROSPECTIVE ANALYSIS OF 3 CASES

Background:

Induced arthritis (IA) is a rare immune related adverse event occurring in 0.5 to 2% of patients exposed to Immune (irAEs) Checkpoint Inhibitors (CPI). In some patients, this condition may be severe and long lasting even after CPI cessation. Cross-reactivity between tumor- and self-antigens was considered in the etiology of several cases of irAEs but disease mechanisms in IA remain elusive.

We systematically collect synovial tissue of patients with IA (Ethical Committee B403201942386).

Objectives:

Here, we report the histopathological findings from ultrasound guided (USG) synovial biopsies from the 3 first patients of our cohort. The immune cell infiltration in CPI IA patients is compared to the histopathological findings in rheumatoid arthritis.

Methods:

Patients were referred through their oncologist after the onset of an arthritis in the context of a CPI therapy. The diagnostic of arthritis was confirmed by a rheumatologist and by ultrasound assessment. USG biopsies were performed before initiation of specific therapies.

Pathological and immunohistochemical analyses include semi quantitative scoring of the following: synovial hyperplasia, fibrinoid necrosis, chorion cellular infiltrate, vascular hyperplasia, CD3-, CD20-, CD68- and CD138-positive cells.

All patients gave written informed consent.

Results:

Three patients went through the USG biopsy procedure: 2 males and 1 female. No adverse events were recorded.

All patients had metastatic neoplasms and time-to-arthritis was on average 6.7 months after CPI initiation. The USG biopsies were performed from 1 week after the onset of the IA to 16 months. The target joints displayed strong synovial thickening on ultrasound. Histological and immunohistochemistry studies showed light to moderate synovial hyperplasia and inflammatory cell infiltration of the sublining by macrophages and T cells, but no or little B cells (Table 1).

Table 1.

Clinical Characteristics and histopathological analyses on synovial biopsies.

Patient 1Patient 2Patient 3CanceruterusbladderlungsBiopsied jointfirst metatarsophalangial jointwristkneeTime-to-synovial biopsy1 week2 months16 monthsGrey scale on ultrasound3/33/33/3Hematoxylin-eosin staining:synovial hyperplasiafibrinoid necrosischorion cellular infiltratevascular hyperplasia++++0+++++++00/+++Immunochemistry staining:CD3CD20CD68CD138++++000/+++0/+++000/+

Conclusion:

USG synovial biopsies have been safely performed and the histopathological analysis have confirmed the synovitis with mainly a macrophage infiltrate (myeloid pattern). IA synovitis is characterized by synovial hyperplasia and macrophage and T cell infiltration of the sublining. Increased collaboration between oncologists and rheumatologists is needed to create opportunities for referral of patients between the two specialties and optimize treatment. Further analyses (such as global or single-cell RNA sequencing) are needed to learn more about IA physiopathology.

References:

[1]Humby F, Lewis M, Ramamoorthi N & al. Synovial cellular and molecular signatures stratify clinical response to csDMARD therapy and predict radiographic progression in early rheumatoid arthritis patients. Ann Rheum Dis. 2019 Jun;78(6):761-772. doi: 10.1136/annrheumdis-2018-214539.

[2]Postow MA, Sidlow R, Hellmann MD. Immune-Related Adverse Events Associated with Immune Checkpoint Blockade. N Engl J Med. 2018 Jan 11;378(2):158-168. doi: 10.1056/NEJMra1703481. PMID: 29320654.

Disclosure of Interests:

Meric de Bellefon Laurent: None declared, Aspeslagh Sandrone: None declared, Di Romana Silvana: None declared, Cornelis Frank: None declared, Poncin Renaud: None declared, Christine Galant: None declared, Bernard Lauwerys Employee of: Bernard Lauwerys is currently employed at UCB Biopharma, Patrick Durez: None declared

POS0067 HIGH DEGREE OF INTER-PATIENT HETEROGENEITY IN SYNOVIOCYTE HYPERPLASIA AND IMMUNE CELLS INFILTRATION IN THE SYNOVIUM OF JUVENILE IDIOPATHIC ARTHRITIS PATIENTS

Background:

Increasing evidence indicates that synovial tissue analysis can deliver pathophysiological insights but also individual clinically-relevant information in adult-onset inflammatory arthritides. Little is known about synovial pathology in juvenile idiopathic arthritis, especially regarding inter-patient variability of histopathological features.

Objectives:

To assess the heterogeneity of main synovial features (synoviocyte hyperplasia and immune cells infiltration) in juvenile idiopathic arthritis (JIA) patients and a cohort of young adults (<30 years old) with early rheumatoid arthritis (RA).

Methods:

Synovial biopsies were sampled using needle arthroscopy or ultra-sound (US) guided biopsy during intra-articular joint injection. Tissue was embedded in paraffin then sections were stained with hematoxylin and eosin. Synoviocyte hyperplasia (SH) and immune cells infiltration (ICI) was assessed by an experienced pathologist on a 0 – 3 scale where 0 represents the absence of the feature and 3 the highest level.

Results:

34 JIA patients (age (median ±SD): 15.5±6.47 years, oligo-articular JIA n=28/34, polyarticular JIA n=6/34, ANA-RF-ACPA positivity=56%-10%-3%) and 22 RA (age (median ±SD): 24.3±2.6 years, ANA-RF-ACPA positivity=10%-36%-32%) patients were included. Synovial tissue was obtained from knee (n=49/56), wrist (n=4/56) or metacarpophalangeal/intercarpophalangeal joints (n=3/56), using US guided biopsy in 27% of patients and needle arthroscopy in 73%.

Individual scores of SH and ICI were correlated in both JIA (Spearman’s r=0.503, p value=0.0024) and RA (Spearman’s r=0.636, p value=0.0015). There was no significant difference in SH and ICI scores between the 2 groups (SH score (Q25-Q50-Q75) in JIA= 0.5-1.125-2 and in RA = 0.75-2-2; ICI score (Q25-Q50-Q75) in JIA= 1-2-2 and in RA = 0.75-2-2.25). Intra-group variability of the two assessed features was comparable between the 2 groups (SH coefficient of variation: 72.2% for JIA and 68.2% for RA; ICI coefficient of variation: 52.2% for JIA and 71.2% for RA). Within JIA patients, there was no significant difference in SH/ICI scores between groups based on ANA positivity, oligo or polyarticular involvement nor ongoing treatment.

Conclusion:

Studying main histological features of synovitis, we found no difference between JIA and young RA patients. Furthermore, we report a similar degree of inter-patient heterogeneity in synovial pathological features of JIA and RA patients. These variations were not explained by common clinical characteristics. Whether they relate to different molecular signatures as suggested in adult RA will be further investigated using bulk tissue RNA sequencing.

Acknowledgements:

This work was funded in part by Cap48 (RTBF). Clément Triaille is funded by the Fonds National de la Recherche Scientifique (FNRS, Communauté française de Belgique) and Fondation Saint-Luc (Cliniques Universitaires Saint-Luc).

Disclosure of Interests:

Clément Triaille: None declared, Cécile Boulanger: None declared, Tatiana Sokolova: None declared, Laurent Meric de Bellefon: None declared, Adrien Nzeusseu Toukap: None declared, Christine Galant: None declared, Nisha Limaye: None declared, Bernard Lauwerys Employee of: currently employed at UCB Biopharma, Patrick Durez: None declared.

Integrative Analysis Reveals a Molecular Stratification of Systemic Autoimmune Diseases

OBJECTIVE

Clinical heterogeneity, a hallmark of systemic autoimmune diseases, impedes early diagnosis and effective treatment, issues that may be addressed if patients could be classified into groups defined by molecular pattern. This study was undertaken to identify molecular clusters for reclassifying systemic autoimmune diseases independently of clinical diagnosis.

METHODS

Unsupervised clustering of integrated whole blood transcriptome and methylome cross-sectional data on 955 patients with 7 systemic autoimmune diseases and 267 healthy controls was undertaken. In addition, an inception cohort was prospectively followed up for 6 or 14 months to validate the results and analyze whether or not cluster assignment changed over time.

RESULTS

Four clusters were identified and validated. Three were pathologic, representing "inflammatory," "lymphoid," and "interferon" patterns. Each included all diagnoses and was defined by genetic, clinical, serologic, and cellular features. A fourth cluster with no specific molecular pattern was associated with low disease activity and included healthy controls. A longitudinal and independent inception cohort showed a relapse-remission pattern, where patients remained in their pathologic cluster, moving only to the healthy one, thus showing that the molecular clusters remained stable over time and that single pathogenic molecular signatures characterized each individual patient.

CONCLUSION

Patients with systemic autoimmune diseases can be jointly stratified into 3 stable disease clusters with specific molecular patterns differentiating different molecular disease mechanisms. These results have important implications for future clinical trials and the study of nonresponse to therapy, marking a paradigm shift in our view of systemic autoimmune diseases.

Molecular Signatures of Kidney Antibody-Secreting Cells in Lupus Patients With Active Nephritis Upon Immunosuppressive Therapy

OBJECTIVE

This study was undertaken to characterize kidney and urine antibody-secreting cells (ASCs) from patients with active lupus nephritis, before and after induction therapy.

METHODS

We included patients with biopsy-proven active lupus nephritis and performed anti-CD138 staining of kidney biopsy samples to visualize ASCs. We performed single-cell gene expression profiling on sorted ASCs from fresh biopsy samples using multiplex reverse transcriptase-polymerase chain reaction. We used a gene set that allowed for the study of ASC maturation from plasmablasts to long-lived plasma cells. We quantified urine ASCs from untreated patients with lupus nephritis at diagnosis and after 6 months of prospective follow-up during induction therapy.

RESULTS

The number of kidney CD138+ ASCs in 46 untreated patients with lupus nephritis was correlated with a low estimated glomerular filtration rate and with tubulointerstitial damage. Most kidney ASCs from 3 untreated patients had a plasmablast molecular signature; in contrast, in 4 patients with refractory lupus nephritis, the kidney ASCs were mainly long-lived plasma cells, representing an ASC transcriptional profile similar to that in the bone marrow of 2 healthy donors. Some urine ASCs with a plasmablast signature were detected in patients with untreated active lupus nephritis. The presence of urine ASCs at 6 months was associated with treatment failure.

CONCLUSION

Our results suggest potential for ASC-directed therapy in refractory lupus nephritis.

Rituximab versus tocilizumab in anti-TNF inadequate responder patients with rheumatoid arthritis (R4RA): 16-week outcomes of a stratified, biopsy-driven, multicentre, open-label, phase 4 randomised controlled trial

BACKGROUND

Although targeted biological treatments have transformed the outlook for patients with rheumatoid arthritis, 40% of patients show poor clinical response, which is mechanistically still unexplained. Because more than 50% of patients with rheumatoid arthritis have low or absent CD20 B cells-the target for rituximab-in the main disease tissue (joint synovium), we hypothesised that, in these patients, the IL-6 receptor inhibitor tocilizumab would be more effective. The aim of this trial was to compare the effect of tocilizumab with rituximab in patients with rheumatoid arthritis who had an inadequate response to anti-tumour necrosis factor (TNF) stratified for synovial B-cell status.

METHODS

This study was a 48-week, biopsy-driven, multicentre, open-label, phase 4 randomised controlled trial (rituximab vs tocilizumab in anti-TNF inadequate responder patients with rheumatoid arthritis; R4RA) done in 19 centres across five European countries (the UK, Belgium, Italy, Portugal, and Spain). Patients aged 18 years or older who fulfilled the 2010 American College of Rheumatology and European League Against Rheumatism classification criteria for rheumatoid arthritis and were eligible for treatment with rituximab therapy according to UK National Institute for Health and Care Excellence guidelines were eligible for inclusion in the trial. To inform balanced stratification, following a baseline synovial biopsy, patients were classified histologically as B-cell poor or rich. Patients were then randomly assigned (1:1) centrally in block sizes of six and four to receive two 1000 mg rituximab infusions at an interval of 2 weeks (rituximab group) or 8 mg/kg tocilizumab infusions at 4-week intervals (tocilizumab group). To enhance the accuracy of the stratification of B-cell poor and B-cell rich patients, baseline synovial biopsies from all participants were subjected to RNA sequencing and reclassified by B-cell molecular signature. The study was powered to test the superiority of tocilizumab over rituximab in the B-cell poor population at 16 weeks. The primary endpoint was defined as a 50% improvement in Clinical Disease Activity Index (CDAI50%) from baseline. The trial is registered on the ISRCTN database, ISRCTN97443826, and EudraCT, 2012-002535-28.

FINDINGS

Between Feb 28, 2013, and Jan 17, 2019, 164 patients were classified histologically and were randomly assigned to the rituximab group (83 [51%]) or the tocilizumab group (81 [49%]). In patients histologically classified as B-cell poor, there was no statistically significant difference in CDAI50% between the rituximab group (17 [45%] of 38 patients) and the tocilizumab group (23 [56%] of 41 patients; difference 11% [95% CI -11 to 33], p=0·31). However, in the synovial biopsies classified as B-cell poor with RNA sequencing the tocilizumab group had a significantly higher response rate compared with the rituximab group for CDAI50% (rituximab group 12 [36%] of 33 patients vs tocilizumab group 20 [63%] of 32 patients; difference 26% [2 to 50], p=0·035). Occurrence of adverse events (rituximab group 76 [70%] of 108 patients vs tocilizumab group 94 [80%] of 117 patients; difference 10% [-1 to 21) and serious adverse events (rituximab group 8 [7%] of 108 vs tocilizumab group 12 [10%] of 117; difference 3% [-5 to 10]) were not significantly different between treatment groups.

INTERPRETATION

The results suggest that RNA sequencing-based stratification of rheumatoid arthritis synovial tissue showed stronger associations with clinical responses compared with histopathological classification. Additionally, for patients with low or absent B-cell lineage expression signature in synovial tissue tocilizumab is more effective than rituximab. Replication of the results and validation of the RNA sequencing-based classification in independent cohorts is required before making treatment recommendations for clinical practice.

FUNDING

Efficacy and Mechanism Evaluation programme from the UK National Institute for Health Research.

Current laboratory and clinical practices in reporting and interpreting anti-nuclear antibody indirect immunofluorescence (ANA IIF) patterns: results of an international survey

Background

The International Consensus on Antinuclear Antibody (ANA) Patterns (ICAP) has recently proposed nomenclature in order to harmonize ANA indirect immunofluorescence (IIF) pattern reporting. ICAP distinguishes competent-level from expert-level patterns. A survey was organized to evaluate reporting, familiarity, and considered clinical value of ANA IIF patterns.

Methods

Two surveys were distributed by European Autoimmunity Standardization Initiative (EASI) working groups, the International Consensus on ANA Patterns (ICAP) and UK NEQAS to laboratory professionals and clinicians.

Results

438 laboratory professionals and 248 clinicians from 67 countries responded. Except for dense fine speckled (DFS), the nuclear competent patterns were reported by > 85% of the laboratories. Except for rods and rings, the cytoplasmic competent patterns were reported by > 72% of laboratories.

Cytoplasmic IIF staining was considered ANA positive by 55% of clinicians and 62% of laboratory professionals, with geographical and expertise-related differences.

Quantification of fluorescence intensity was considered clinically relevant for nuclear patterns, but less so for cytoplasmic and mitotic patterns. Combining IIF with specific extractable nuclear antigens (ENA)/dsDNA antibody testing was considered most informative.

Of the nuclear competent patterns, the centromere and homogeneous pattern obtained the highest scores for clinical relevance and the DFS pattern the lowest. Of the cytoplasmic patterns, the reticular/mitochondria-like pattern obtained the highest scores for clinical relevance and the polar/Golgi-like and rods and rings patterns the lowest.

Conclusion

This survey confirms that the major nuclear and cytoplasmic ANA IIF patterns are considered clinically important. There is no unanimity on classifying DFS, rods and rings and polar/Golgi-like as a competent pattern and on reporting cytoplasmic patterns as ANA IIF positive.

Efficacy and Safety of Canakinumab in Patients With Systemic Juvenile Idiopathic Arthritis With and Without Fever at Baseline: Results From an Open-Label, Active-Treatment Extension Study

OBJECTIVE

To evaluate the long-term efficacy and safety of canakinumab and explore prediction of response in patients with systemic juvenile idiopathic arthritis (JIA) with or without fever at treatment initiation.

METHODS

At enrollment, patients with active systemic JIA (ages 2 to <20 years) started open-label canakinumab (4 mg/kg every 4 weeks subcutaneously). Efficacy measures included the adapted American College of Rheumatology (ACR) Pediatric 50/70/90 criteria, the Juvenile Arthritis Disease Activity Score (JADAS), and clinically inactive disease and clinical remission on medication, evaluated by either the JADAS or ACR criteria.

RESULTS

Of the 123 patients (70 with fever and 52 without fever [fever status was not reported for 1 patient]), 84 (68.3%) completed the study (median duration 1.8 years). Comparable efficacy (adapted ACR Pediatric 50/70/90/100) was observed by day 15 in both subgroups (60.0%/48.6%/37.1%/24.3% in those with fever and 67.3%/48.1%/34.6%/19.2% in those without fever), and further increased thereafter. By month 6, clinical remission according to the JADAS or the ACR criteria was achieved in 17 (24.3%) and 26 (37.1%), respectively, of patients with fever and 9 (17.3%) and 12 (23.1%), respectively, of patients without fever. Median time to onset of clinical remission according to the JADAS or ACR criteria was 57 and 30 days, respectively, in those with fever, and 58 and 142 days, respectively, in those without fever. An adapted ACR Pediatric 50 response by day 15 was the strongest predictor of achieving clinical remission according to the JADAS (odds ratio [OR] 13 [95% confidence interval (95% CI) 4, 42]; P < 0.0001) or glucocorticoid discontinuation (OR 19 [95% CI 3, 114]; P = 0.002). Of the 71 of 123 patients (57.7%) who received glucocorticoids at study entry, 27 (38.0%) discontinued glucocorticoids and 21 (29.6%) reached a dose of <0.2 mg/kg/day, with no difference between those with and those without fever; 13 patients (10.6%) tolerated a sustained canakinumab dose reduction to 2 mg/kg every 4 weeks. No new safety findings were observed.

CONCLUSION

Canakinumab provided rapid and sustained improvement of active systemic JIA irrespective of the presence of fever at treatment initiation.

Bier anemic spots, cyanosis, and urticaria-like eruption (BASCULE) syndrome: Report of two new cases and literature review

We herein report two new adolescent cases of Bier anemic spots, cyanosis, and urticaria-like eruption (BASCULE) syndrome. This rare, recently described condition may be associated with postural orthostatic tachycardia syndrome (POTS) and other forms of orthostatic intolerance. This report provides details on two cases and a literature review.

Diagnostic performance of sacroiliac joint MRI and added value of spine MRI to detect active spondyloarthritis

PURPOSE

To investigate the diagnostic performance of sacroiliac joint (SIJ) magnetic resonance imaging (MRI) and the incremental value of spine MRI to "predict" clinical disease activity in patients with axial spondyloarthritis (axSpA).

MATERIALS AND METHODS

This cross-sectional study included adult patients with known axSpA according to the SpondyloArthritis International Society (ASAS) classification criteria, radiological arm. MRI disease activity was scored semi-quantitatively for SIJ and total spine MRI in each patient. Two cut-off levels (≥ 1.3 and ≥ 2.1) for ankylosing spondylitis disease activity score with C-reactive protein (ASDAS-CRP) were considered for clinical disease activity categorization. MRI scores were first evaluated individually. Then, SIJ score was combined with the score from a spine segment (lumbar, cervical, thoracic or total spine) to build a bi-parametric model using a classification tree. Receiver operating characteristic (ROC) curves were constructed to evaluate the classification performance according to disease activity category of these models.

RESULTS

Forty-four patients (30 men, 14 women; mean age, 37 years±10 [SD] [range: 17-64 years]) with a mean disease duration of 5 years±8 (SD) (range: 0-35 years) were included. Thirty-six patients (36/44; 82%) had ASDAS-CRP≥1.3 and 27 patients (27/44; 61%) had ASDAS-CRP≥2.1. The most frequently involved spinal segment was mid-thoracic (T7-T8). The SIJ MRI score was an informative model to identify active axSpA (AUC≥0.7, regardless of the cut-off level on ASDAS-CRP). Performance of bi-parametric models based on "SIJ+thoracic spine" (for detecting patients with ASDAS-CRP≥1.3) or "SIJ+total spine" (for detecting patients with ASDAS-CRP≥2.1) outperformed that of the individual SIJ score (P<0.05).

CONCLUSION

The combination of MRI of the SIJ and spine allows to accurately discriminate between active and inactive axSpA, outperforming SIJ MRI alone.

Proteomic analysis in lupus mice identifies Coronin-1A as a potential biomarker for lupus nephritis

BACKGROUND

Approximately 50% of systemic lupus erythematosus (SLE) patients develop nephritis, which is among the most severe and frequent complications of the disease and a leading cause of morbidity and mortality. Despite intensive research, there are still no reliable lupus nephritis (LN) markers in clinical use that can assess renal damage and activity with a high sensitivity and specificity. To this end, the aim of this study was to identify new clinically relevant tissue-specific protein biomarkers and possible underlying molecular mechanisms associated with renal involvement in SLE, using mass spectrometry (MS)-based proteomics.

METHODS

Kidneys were harvested from female triple congenic B6.NZMsle1/sle2/sle3 lupus mice model, and the respective sex- and age-matched C57BL/6 control mice at 12, 24 and 36 weeks of age, representing pre-symptomatic, established and end-stage LN, respectively. Proteins were extracted from kidneys, purified, reduced, alkylated and digested by trypsin. Purified peptides were separated by liquid chromatography and analysed by high-resolution MS. Data were processed by the Progenesis QIp software, and functional annotation analysis was performed using DAVID bioinformatics resources. Immunofluorescence and multiple reaction monitoring (MRM) MS methods were used to confirm prospective biomarkers in SLE mouse strains as well as human serum samples.

RESULTS

Proteomic profiling of kidney tissues from SLE and control mice resulted in the identification of more than 3800 unique proteins. Pathway analysis revealed a number of dysregulated molecular pathways that may be mechanistically involved in renal pathology, including phagosome and proximal tubule bicarbonate reclamation pathways. Proteomic analysis supported by human transcriptomic data and pathway analysis revealed Coronin-1A, Ubiquitin-like protein ISG15, and Rho GDP-dissociation inhibitor 2, as potential LN biomarkers. These results were further validated in other SLE mouse strains using MRM-MS. Most importantly, experiments in humans showed that measurement of Coronin-1A in human sera using MRM-MS can segregate LN patients from SLE patients without nephritis with a high sensitivity (100%) and specificity (100%).

CONCLUSIONS

These preliminary findings suggest that serum Coronin-1A may serve as a promising non-invasive biomarker for LN and, upon validation in larger cohorts, may be employed in the future as a screening test for renal disease in SLE patients.

THU0200 THE CHOICE OF BDMARD OR TSDMARD AS FIRST LINE THERAPY: DATA OF THE TARDIS-RA REGISTRY, A NATIONWIDE BELGIAN BIOLOGIC REGISTRY

Background:

The Tool for Administrative Reimbursement Drug Information Sharing (TARDIS) is an electronic platform combining data collection from all Belgian patients with Rheumatoid Arthritis (RA) on advanced therapy, together with a drug reimbursement request. Therapy choice after initial 2 classical synthetic DMARD failure is left to the treating rheumatologist in Belgium.

Objectives:

To investigate first-line therapy choices for tumor necrosis factor inhibitor (TNFi) biologic (b) DMARDs, non-TNFi bDMARDs or targeted synthetic (ts) DMARDs via patient characteristics and initial treatment response in the TARDIS-RA registry.

Methods:

All Belgian rheumatologist inserted patient data online when prescribing a b/tsDMARD. When data was entered for the first time, previous and current use of DMARD therapies was registered. Every next bDMARD or tsDMARD initiation, prolongation and discontinuation was registered electronically. First prolongation is 6 months for bDMARDs and 12 weeks for tsDMARDs, and yearly thereafter. Patients were selected for this analysis if they started a TNFi, non-TNFi or tsDMARD therapy between Jan 2018 and Jan 2019. Rituximab was excluded. Baseline characteristics of bionaive patients per therapy were compared with Mann-Whitney U or Chi2tests were appropriate. Regression analyses, adjusted for age, DAS28 baseline and disease duration, evaluated DAS28 change, remission (DAS28<2.6) and low disease activity (LDA, DAS28<3.2) between b/tsDMARDs at first TARDIS follow-up.

Results:

In 2018, 1263 bionaive RA patients were included. Table 1 describes this population. Time until 1stfollow-up differed between groups with 183 (181-184) days for bDMARD versus 84 (84-84) days for tsDMARD patients. Lineair regression showed an effect of therapy type on DAS28 change in bionaive patients (p=0.017). Logistic regression showed no difference per therapy for remission (p=0.090) nor low disease activity (p=0.123). Proportions of therapy prolongations at 1stfollow up visit did not differ per therapy type.

Table 1.

Baseline characteristics and treatment response of first-line TNFi, Non-TNFi or tsDMARDs

TNFiNon-TNFitsDMARDp-valueNumber patients696 (57%)293 (25%)215 (18%)Age (years)55, (45-64)58, (51-68)58, (49-66)<0.001Disease duration (years)3, (1-7)3, (1-9)5, (2-13)<0.001DAS28 Baseline4.8, (4.3-5.5)5.1, (4.4-5.7)4.7, (4.2-5.4)0.010DAS28 Change2.2 (1.0-3.0)2.2 (1.1-3.2)1.9 (0.9-2.7)0.014Remission296 (50%)123 (49%)78 (42%)0.143LDA377 (64%)153 (61%)105 (56%)0.196Prolongation therapy492 (82%)219 (87%)161 (86%)0.158

Number given are median, (IQR) or number (proportion). TNFi = tumour necrosis factor inhibitor, ts= targeted synthetic, DAS = disease activity score, DAS28 change = DAS28 at 1st follow up visit minus DAS28 at baseline, remission = DAS28<2.6), LDA = low disease activity = DAS28<3.2), Prolongation = therapy was continued at 1st follow-up visit. Mann-Whitney U or Chi square tests were used where appropriate.

Conclusion:

Initial therapy choices are partially driven by patient profile, although other factors such as patient preferences could not be verified. DAS28 change for tsDMARDs seemed less important versus bDMARDs, but can possibly be attributed to the preset evaluation moment being sooner for tsDMARDs versus bDMARDs aside of patient profile differences in age and disease duration. In contrast, proportion of remission, low disease activity and therapy prolongation did not differ by therapy.

Disclosure of Interests:

Diederik De Cock: None declared, Patrick Durez Speakers bureau: AbbVie, Bristol-Myers Squibb, Celltrion, Eli Lilly, Pfizer, Sanofi, Dirk Elewaut: None declared, Bernard Lauwerys: None declared, Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, Patrick Verschueren Grant/research support from: Pfizer unrestricted chair of early RA research, Speakers bureau: various companies

THU0367 INCIDENCE AND PREVALENCE OF SYSTEMIC SCLEROSIS-ASSOCIATED INTERSTITIAL LUNG DISEASE IN FLANDERS: A 12-YEARS COLLABORATIVE MULTICENTER PROSPECTIVE COHORT STUDY

Background:

Systemic sclerosis-associated interstitial lung disease (SSc-ILD) is the main cause of death in SSc and accounts for up to 30-35% of SSc-mortality (1-2). All SSc cases, irrespective of the extent of the skin disease, should be evaluated for ILD (3). The epidemiology of SSc-ILD in Belgium is unknown. In literature, the prevalence of ILD in SSc varies between 19% and 52%. However, different criteria were used to diagnose ILD (4). In 2008, Goh et al. proposed a flow diagram to diagnose SSc-ILD based on chest high-resolution CT-scan (HRCT) and pulmonary function tests (PFTs). Their categorization into limited or extensive ILD has prognostic value (5).

Objectives:

To determine the prevalence and incidence rate of SSc-ILD in Flanders.

Methods:

Up to 12-year follow-up data of consecutive SSc patients were obtained by 2 Flemish expert centres (University Hospitals Ghent and Leuven). Patients fulfilling the LeRoy and/or ACR-EULAR classification criteria were included consecutively in the prospective cohort (6). Patients received HRCT at baseline and on indication thereafter, as well as yearly PFT. All HRCTs were centrally analyzed (Ghent) and patients were categorized according to the Goh criteria as without ILD, with limited ILD (limILD) or with extensive ILD (extILD) (5).

Results:

Between 2006 and 2018, 797 SSc patients (557 Ghent/240 Leuven; 22% limited SSc (LSSc)/59% limited cutaneous SSc (LcSSc)/19% diffuse cutaneous SSc (DcSSc)) had baseline HRCT and PFT. The baseline characteristics are depicted in the table. The mean age (SD) was 53 +/-15 years and the majority of patients was female (76%).

272 SSc patients had ILD at baseline, implicating a baseline prevalence of 34% (272/797). The baseline prevalences were 35% and 55% for the LcSSc and DcSSc subgroups respectively. During a median follow-up of 39 months (IQR: 11-79 months), 44 patients were diagnosed with incidental SSc-ILD, resulting in an incidence rate of 21,0/1000 person-years (PY), 95% CI:15,2-28,1. The incidence rates were 21,7/1000 PY, 95%CI: 14,3-31,6 and 43.9/1000PY, 95%CI: 22.7-76.8 for the LcSSc and DcSSc subgroups respectively.

Table.

Baseline characteristics

SSc (n=797)LcSSc (n=470)DcSSc (n=149)age (years) °53+/-1554+/-1554+/-14♂/♀ *193(24%)/604(76%)109(23%)/361(77%)58(39%)/91(61%)Disease Duration (months) #for 718: 22 (5-72)for 443: 25 (5-80)for 145: 16 (7-52)LSSc/LcSSc/DcSSc *178(22%)/470(59%)/149(19%)follow-up (months) #39 (11-79)38.5 (9.75-81)44 (17.5-78)Anti-centromere antibodies§252/538 (47%)163/317 (51%)19/108 (18%)Anti-topoisomeraseI antibodies§119/519 (23%)66/297 (22%)45/112 (40%)ILD at baseline, *272 (34%)163 (35%)82 (55%)LimILD, *230 (29%)139 (30%)67 (45%)ExtILD, *42 (5%)24 (5%)15 (10%)New ILD during follow-up, §44/52527/30712/67

°: mean +/- standard deviation, *: number of patients (percent), #: median (interquartile range), §= number of patients/total number of patients with available data (%)

Conclusion:

In an unselected cohort of SSc patients, a third of the patients has ILD at baseline which is in line with previous prevalence reports. Importantly, this is the first study reporting incidence rates of SSc-ILD.

References:

[1]Steen VD and Medsger TA, Ann Rheum Dis 2007;66:940-4

[2]Elhai M et al. Ann Rheum Dis 2017;76:1897-1905

[3]Smith V et al. RMD Open 2019;4:e000782. doi:10.1136/rmdopen-2018-000782

[4]Bergamasco A et al. Clinical Epidemiology 2019;11:257-73

[5]Goh N et al. Am J Respir Crit Care Med 2008;177:1248-54

[6]van den Hoogen et al. Arthritis Rheumatol 2013;65:2737-47

Disclosure of Interests:

Els Vandecasteele Grant/research support from: my institution has received a research grant from the Research Foundation Flanders FWO), Speakers bureau: my institution has received speaker fees from Actelion, Karin Melsens: None declared, Daniel Blockmans Consultant of: yes, Speakers bureau: yes, Charlotte Carton: None declared, Filip De Keyser: None declared, Ellen De Langhe Consultant of: member of advisory board for Boehringer, Bernard Lauwerys: None declared, Yves Piette: None declared, Amber Vanhaecke: None declared, Koen Verbeke: None declared, Wim Wuyts Grant/research support from: my institution has received a grant from Boehringer Ingelheim and Roche, Consultant of: my institution has received payments for consultancy from Boehringer Ingelheim and Roche, Speakers bureau: my institution has received speaker fees from Boehringer Ingelheim and Roche, Guy Brusselle: None declared, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl

THU0032 MODIFIED PEPTIDES AS A NOVEL IMMUNOTHERAPY FOR RHEUMATOID ARTHRITIS

Background:

Rheumatoid arthritis (RA) is a highly prevalent and severe systemic autoimmune disease associated with permanent disability and strong socio-economic burdens. Currently, there is no therapeutic treatment and RA patients rely on lifelong, costly treatments. Imcyse develops modified peptides eliciting antigen specific cytolytic CD4 T cells (cCD4+) that induce apoptosis of antigen presenting cells (APC) in a contact dependent manner. cCD4+ also induce apoptosis of autoantigen-specific bystander T-cells, activated by the same APC thus eliminating the risk of general immunosuppression. Peptides consist of MHC class II T cell epitopes of a target autoantigen modified in their flanking region by the addition of an amino acid sequence containing a thiol-disulphide oxidoreductase active motif1.

Objectives:

The goal of this study was to synthesize modified peptides from a target RA autoantigen and test their potency to generatein vitrospecific and cytolytic CD4+ T cells from RA patients.

Methods:

We designed modified peptides from a target RA autoantigen after in silico and in vitro assessment to identify MHC II core binding region, HLA class II binding capacities and physiochemical properties.

CD4+ T cells were purified from PBMC of a newly diagnosed seropositive RA patient and co-cultured with autologous APC in the presence of the modified peptide. The CD4+ T cells were restimulated periodically. Peptide’s ability to generate specific CD4+ T cells was evaluated by flow cytometric analysis of the expression of surface activation marker CD154 (CD40L). The peptide specific CD4+ T cell lines were sorted based on their surface CD154 expression. Their pro-apoptotic activity was assessed after overnight (O/N) co-culture of CD4+ T cells with fluorescent tracer labelled autologous lymphoblastoid cells lines (LCL). Flow cytometry quantification of LCL apoptosis was measured by annexin V staining. MHC II restriction of CD4+ T cells was demonstrated by the addition of blocking antibodies against HLA-DR, DP or DQ molecules.

Results:

CD4+ T cells were in vitro expanded after six consecutive stimulations with the peptide. We investigated their specificity by flow cytometry and showed that 69% of CD4+ T cells that were stimulated O/N in the presence of the peptide expressed the activation marker CD154 versus 29% of CD4+ T cells that were stimulated in its absence. These cells were sorted based on CD154 expression following specific stimulation. Cell enrichment was then assessed by flow cytometric analysis. Data showed that more than 91% (background 3%) were peptide specific based on CD154 expression.

After co-culture of CD4+ T cells with LCL, in independent experiments, Annexin V binding was detected on peptide loaded LCL, ranging from 69% to 89%, while when LCL were kept unloaded these values were between 30% and 55%, respectively, indicating that when specifically activated, these CD4+ T cells had pro-apoptotic activity. When both the peptide and blocking antibodies against HLA-DR, DP or DQ molecules added in the co-culture the pro-apoptotic activity was inhibited by 68%, 20% and 25%, respectively.

Conclusion:

The preliminary but very promising data show that our modified peptide generates peptide-specific CD4+ T cells with lytic properties that lyse target APC in an HLA class II specific manner. Our plan is to show that these CD4+ T cells can also induce apoptosis in bystander T cells and to further validate our results in additional RA donors.

References:

[1]Carlier, V. A., Vanderelst, L., Janssens, W. & Jacquemin, M. G. Increased Synapse Formation Obtained by T Cell Epitopes Containing a CxxC Motif in Flanking Residues Convert CD4 + T Cells into Cytolytic Effectors.7, (2012).

Disclosure of Interests:

Eleni Araklioti Grant/research support from: This work was supported by Pfizer Inc. and by Walloon Region, Ludivine Herman Grant/research support from: This work was supported by Pfizer Inc. and by Walloon Region, Ngoc Quynh Nhu Nguyen Grant/research support from: This work was supported by Pfizer Inc. and by Walloon Region, Roxana Roohi Ahangarani Grant/research support from: This work was supported by Pfizer Inc. and by Walloon Region, Milos Erak Grant/research support from: This work was supported by Pfizer Inc. and by Walloon Region, Bernard Lauwerys: None declared, Patrick Durez Speakers bureau: AbbVie, Bristol-Myers Squibb, Celltrion, Eli Lilly, Pfizer, Sanofi, Vincent Geenen: None declared, Aaron Winkler Shareholder of: Shareholder of Pfizer, Inc, Employee of: Full time employee of Pfizer, Inc, Marcelle Van Mechelen Grant/research support from: This work was supported by Pfizer Inc. and by Walloon Region, Luc Vander Elst Grant/research support from: This work was supported by Pfizer Inc. and by Walloon Region, Vincent Carlier Grant/research support from: This work was supported by Pfizer Inc. and by Walloon Region

FRI0021 SHOULD WE USE GLUCOCORTICOID IN EARLY RHEUMATOID ARTHRITIS?: RESULTS AT 5 YEARS FROM THE ERA LOUVAIN BRUSSELS COHORT

Background:

The EULAR recommendations, updated in 2016, propose the initiation of glucocorticoid (GC) therapy in combination with cDMARDs background therapy for every patient with early rheumatoid arthritis (ERA).1

Objectives:

The aim of this study is to evaluate the proportion of patients with ERA who have been treated with GC in daily practice, to analyse the baseline characteristics of these patients, and to assess the clinical benefit and side effects of GC during 5 years of follow-up.

Methods:

We included patients with ERA from the UCLouvain Brussels cohort who met the ACR/EULAR 2010 classification criteria and were naïve to cDMARDs. Treatments were initiated based on the decision of a senior rheumatologist. We retrospectively collected patient characteristics prior to the introduction of cDMARDs with or without GC. Efficiency and serious adverse events were analysed at 6 months, 1 year, 3 years and 5 years.

Results:

Data from 474 eligible ERA patients were collected. The average age of the population is 48.9 years. 70.5% of the patients are women. 27.3% are smokers and 68.8% are positive for anti-citrullinated protein antibody (ACPA).

178 patients (37.7 %) initiated GC compared to 294 patients (62.3%) who received only NSAIDs and/or analgesics in combination with cDMARDs.

At baseline, the elevation of CRP is the main factor that favors the initiation of GC (CRP 2.9 vs 2.0 mg/dl, p = 0.015) followed by smoking habits (34.2% vs 23.3%, p = 0.018), the absence of ACPA (37.2% vs 27.6%, p = 0.037), the prescription of methotrexate as a monotherapy (70.6% vs 50.5%, p <0.001), and the age (50.6 vs 48.0, p = 0.050). Other parameters such as swollen joint count, tender joint count, DAS28-CRP, HAQ or baseline erosion were similar between groups.

5 years follow-up of DAS28-CRP, HAQ or VAS pain values did not differ between the two groups (Fig 1A).

Figure 1.

Comparison of DAS28-CRP and HAQ scores evolution.(A) in two groups of patients: treated with GC (BL-GC Yes) or without GC (BL_GC No) in combination with cDMARDs as first line treatment.(B) in two groups of patients: never treated with GC during 5 years follow-up (No GC/ 5 years) and those who received a high cumulative dose of GC ≥ 1 g/5years (GC>[1G/5years]).

Interestingly, patients not exposed at baseline to GC showed a higher remission rate (DAS28-CRP< 2.6) of 48.4% vs 44.3% at 6 months.

We also analysed a subgroup of patients (n=139) who received a cumulative dose of more than 1 g of prednisolone during the 5 years period. We confirmed the baseline differences for CRP, smoking habits, age and found in this subgroup more males (36.7% vs 28.2%, p=0.021) and higher DAS-28CRP values (5.0 vs 4.7, p=0.048).

During the 5 years follow up, DAS-28CRP, VAS pain and HAQ remained significantly higher leading to a higher number of bioDMARDs prescribed in this group (Fig 1B).

More severe infections were reported in this subgroup (11.5% vs 4.2%). Bone densitometry values, number of fractures, and cardiovascular profiles were similar between groups.

Conclusion:

In our ERA cohort, initiation of GC treatment does not add additional benefit for the short and long-term control of the disease.

GC were more prescribed in seronegative RA patients with higher level of inflammation and we confirm that patients exposed to higher cumulative doses of GC are at higher risk to develop severe infections.

Further studies are needed to support that GC induction therapy should not be offered to all ERA patients.

References:

[1]Smolen JS, Landewé R, Bijlsma J, et al., EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis. 2017 Jun;76(6):960-977.

Disclosure of Interests:

Emilie Sapart: None declared, Tatiana Sokolova: None declared, Stéphanie de Montjoye: None declared, Stephanie Dierckx: None declared, Adrien Nzeusseu Toukap Grant/research support from: AbbVie, Celgene Corporation, Janssen, Pfizer, UCB – grant/research support, Consultant of: AbbVie, Eli Lilly, Janssen, Novartis, UCB – consultant, Speakers bureau: AbbVie, Eli Lilly, Janssen, Novartis, UCB – advisory board member, Aleksandra Avramovska: None declared, Bernard Lauwerys: None declared, Patrick Durez Speakers bureau: AbbVie, Bristol-Myers Squibb, Celltrion, Eli Lilly, Pfizer, Sanofi

O07 Randomised, open labelled clinical trial to investigate synovial mechanisms determining response: resistance to rituximab versus tocilizumab in RA patients failing TNF inhibitor therapy

Background

Biologic therapies have transformed the outlook for RA but the significant health economic impact of these therapies has highlighted the need to define predictive markers of response. Rituximab (RTX) is licensed for use following failure of csDMARDs and TNF inhibitor (TNFi) therapy. However, in this increasing therapeutically resistant cohort only 30% of patients achieve an ACR50 response. The observation in early RA that 50% of patients show low/absence of synovial B-cells prompted us to test the hypothesis that in these patients a biologic agent targeting alternative pathways maybe more effective. We report results from the first pathobiology-driven randomised controlled trial (RCT) in RA (R4RA) evaluating whether patient stratification according to the synovial B-cell rich/poor status enriches for response/non response to RTX.

Methods

R4RA is a phase IV open-label RCT conducted in 19 European centres recruiting patients failing or intolerant to csDMARD therapy and at least one TNFi. Synovial tissue was obtained at trial entry and used to classify patients as B-cell rich or poor using both histological and RNA-seq classification criteria. Patients were randomised to receive RTX or tocilizumab (TCZ). The study was powered to test in the B cell poor population superiority of TCZ over RTX at 16 weeks. The primary and co-primary end-points were defined respectively as Clinical Disease Activity Index (CDAI) ≥50% improvement from baseline and Major Treatment response (MTR)= CDAI improvement ≥ 50% and CDAI ≤10.1.

Results

The trial recruited to target (n = 164) with a power of 89.5%. In the B cell poor cohort a numerically higher number of patients achieved the primary endpoint and a significantly higher number of patients achieved co-primary endpoint (MTR). Classification of patients as B cell poor/rich according to RNA-seq criteria enhanced the difference between TCZ and RTX, with a significantly higher number of TCZ treated patients reaching both CDAI 50% improvement and CDAI MTR in the B-cell poor group.

Conclusion

In a RA B cell poor population failing csDMARDs and TNFi therapy, TCZ is more effective than RTX. This first biopsy-driven RCT suggests clinical utility for integrating molecular pathology profiling into treatment algorithms to allocate targeted therapies.

Disclosures

F. Humby: Honoraria; Roche, Pfizer. Grants/research support; Pfizer. P. Durez: BMS,Bristol-Myers Squibb, Celltrion, Eli Lilly, Hospira, Mundipharma, Pfizer, Samsung, Sanofi, UCB. M. Buch: Consultancies; Pfizer, Roche, UCB, AbbVie, Eli Lilly, Sandoz, and Sanofi. Grants/research support; Pfizer, Roche, UCB, AbbVie, Eli Lilly, Sandoz, and Sanofi. M. Lewis: None. M. Bombardieri: None. H. Rizvi: None. S. Kelly: None. L. Fossati: None. R. Hands: None. G. Giorli: None. A. Mahto: None. C. Montecucco: None. B. Lauwerys: None. V.C. Romao: None. A.G. Pratt: Member of speakers’ bureau; Eli Lilly and Janssen-Cilag Ltd. Grants/research support; Pfizer. S. Bugatti: None. N. Ng: None. F. Rivellese: None. P. Ho: None. M. Bellan: None. P. Sainaghi: None. P. Verschueren: None. N. Gendi: None. B. Dasgupta: Abbvie, BMS, GSK, Roche, Roche Chugai, Sanofi, Sanofi Aventis, Sanofi-Aventis. A. Cauli: BMS, Celgene, Lilly, Lilly MSD, MSD, Novartis, Pfizer, Sanofi, Sigma Wesseumen, UCB. C. John: None. A. Nerviani: None. G. Thornborn: None. D. Holroyd: None. M. Congia: None. C. Thompson: None. P. Reynolds: None. J. Cañete: None. R. J. Moots: Biogen, Bristol-Myers Squibb, Chugai,

Novartis, Pfizer Inc, Roche, Sandoz, UCB. P.C. Taylor: AbbVie, Biogen, Celgene, Eli Lilly and Company, Fresenius, Fresenius SE & Co, Galapagos, Gilead. GlaxoSmithKline, Janssen, Lilly, Nordic Pharma, Pfizer, Pfizer Inc, Roche, Sanofi, UCB. C. Edwards: Abbvie, Biogen, BMS, Fresenius, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, UCB. J. Isaacs: None. P. Sasieni: None. J. E. Fonesca: None. E. Choy: AbbVie, Abbvie, Roche, Chugai, Amgen, Eli Lilly, Janssen, Novartis, Regeneron, R-Pharm and Sanofi, Amgen, Amgen, Roche, Chugai, Bristol-Myers Squibb, Eli-Lilly Janssen, Pfizer, Regeneron, Sanofi and UCB., AstraZeneca, Bio-Cancer, Bio-Cancer, Biogen, Novartis, Sanofi, Roche, Pfizer and UCB ,Biogen, BMS, Boehringer Ingelheim, Celgene, Chugai Pharma, Eli Lilly, Ferring Pharmaceuticals, GSK, Hospira, Janssen, Jazz Pharmaceuticals, Merck Sharp & Dohme, Merrimack Pharmaceutical, Napp, Novartis, Novimmune, ObsEva, Pfizer, Regeneron, Roche, R-Pharm, Sanofi, SynAct Pharma, Tonix, Union Chimique Belge. C. Pitzalis: None. NIHR have funded the study.

Serum GlycA Level is Elevated in Active Systemic Lupus Erythematosus and Correlates to Disease Activity and Lupus Nephritis Severity

Objective: Reliable non-invasive biomarkers are needed to assess disease activity and prognosis in patients with systemic lupus erythematosus (SLE). Glycoprotein acetylation (GlycA), a novel biomarker for chronic inflammation, has been reported to be increased in several inflammatory diseases. We investigated the relevance of serum GlycA in SLE patients exhibiting various levels of activity and severity, especially with regards to renal involvement. Methods: Serum GlycA was measured by nuclear magnetic resonance spectroscopy in samples from well characterized SLE patients and from both healthy controls and patients with other kidney diseases (KD). Disease activity was evaluated using the Systemic Lupus Erythematosus Activity Index 2000 (SLEDAI-2K). Renal severity was assessed by kidney biopsy. Results: Serum GlycA was elevated in active (n = 105) compared to quiescent SLE patients (n = 39, p < 10⁻⁶), healthy controls (n = 20, p = 0.009) and KD controls (n = 21, p = 0.04), despite a more severely altered renal function in the latter. GlycA level was correlated to disease activity (SLEDAI-2K, ρ = 0.37, p < 10⁻⁴), C-reactive protein, neutrophil count, triglyceride levels, proteinuria and inversely to serum albumin. In patients with biopsy-proven lupus nephritis (LN), GlycA levels were higher in proliferative (n = 26) than non-proliferative LN (n = 10) in univariate analysis (p = 0.04), and was shown to predict proliferative LN independently of renal parameters, immunological activity, neutrophil count and daily corticosteroid dosage by multivariate analysis (p < 5 × 10⁻³ for all models). In LN patients with repeated longitudinal GlycA measurement (n = 11), GlycA varied over time and seemed to peak at the time of the flare. Conclusions: GlycA, as a summary measure for different inflammatory processes, could be a valuable biomarker of disease activity in patients with SLE, and a non-invasive biomarker of pathological severity in the context of LN.

[Inflammatory arthritides pathotypes]

The pathophysiology of the inflammatory arthritides (IA) is complex and the result of interactions between genetic and environmental factors, leading to -in the case of seropositive rheumatoid arthritis-a breach of immune tolerance and subsequent development of joint and systemic manifestations. Regardless of the exact site of the initial immune dysregulation, the synovial membrane is the main target of IA. The heterogeneity of the clinical phenotypes is even more evident on the histological level (pathotypes), which in turn renders research on disease mechanisms more complicated. This article focusses on the various pathotypes of IA.

Correction to: Standardisation of synovial biopsy analyses in rheumatic diseases: a consensus of the EULAR Synovitis and OMERACT Synovial Tissue Biopsy Groups

Following publication of the original article [1], the authors reported an error in the spelling of the ninth author's name.

Standardisation of synovial biopsy analyses in rheumatic diseases: a consensus of the EULAR Synovitis and OMERACT Synovial Tissue Biopsy Groups

Background

The aim of this global collaboration was to develop a consensual set of items for the analysis of synovial biopsies in clinical practice and translational research through the EULAR Synovitis Study Group (ESSG) and OMERACT Synovial Tissue Biopsy Group.

Methods

Participants were consulted through a modified Delphi method. Three sequential rounds occurred over 12 months. Members were sent a written questionnaire containing items divided into two parts. Items were identified and formulated based on a scoping review. The first part of the questionnaire referred to synovial biopsies in clinical practice including five subsections, and the second part to translational research with six subsections. Every participant was asked to score each item on a 5-point Likert scale. Items with a median score above 3.5 and a ≥ 70% agreement were selected for the next round. The last round was conducted orally at EULAR in June 2017.

Results

Twenty-seven participants from 19 centers were contacted by email. Twenty participants from 17 centers answered. Response rates for next rounds were 100%. For the first part relating to clinical practice, 20/44 items (45.5%) were selected. For the second part relating to translational research, 18/43 items (41.9%) were selected for the final set.

Conclusions

We herein propose a consensual set of analysis items to be used for synovial biopsies conducted in clinical practice and translational research.

Electronic supplementary material

The online version of this article (10.1186/s13075-018-1762-1) contains supplementary material, which is available to authorized users.

Subcutaneous Abatacept in Patients With Polyarticular-Course Juvenile Idiopathic Arthritis: Results From a Phase III Open-Label Study

Objective

To investigate the pharmacokinetics, effectiveness, and safety of subcutaneous (SC) abatacept treatment over 24 months in patients with polyarticular‐course juvenile idiopathic arthritis (JIA).

Methods

In this phase III, open‐label, international, multicenter, single‐arm study, patients with polyarticular JIA (cohort 1, ages 6–17 years and cohort 2, ages 2–5 years) in whom treatment with ≥1 disease‐modifying antirheumatic drug was unsuccessful received weight‐tiered SC abatacept weekly: 10 to <25 kg (50 mg), 25 to <50 kg (87.5 mg), ≥50 kg (125 mg). Patients who had met the JIA–American College of Rheumatology 30% improvement criteria (achieved a JIA‐ACR 30 response) at month 4 were given the option to continue SC abatacept to month 24. The primary end point was the abatacept steady‐state serum trough concentration (C_minss) in cohort 1 at month 4. Other outcome measures included JIA‐ACR 30, 50, 70, 90, 100, and inactive disease status, the median Juvenile Arthritis Disease Activity Score in 71 joints using the C‐reactive protein level (JADAS‐71–CRP) over time, safety, and immunogenicity.

Results

The median abatacept C_minss at month 4 (primary end point) and at month 24 was above the target therapeutic exposure (10 μg/ml) in both cohorts. The percentage of patients who had achieved JIA‐ACR 30, 50, 70, 90, or 100 responses or had inactive disease responses at month 4 (intent‐to‐treat population) was 83.2%, 72.8%, 52.6%, 28.3%, 14.5%, and 30.1%, respectively, in cohort 1 (n = 173) and 89.1%, 84.8%, 73.9%, 58.7%, 41.3%, and 50.0%, respectively, in cohort 2 (n = 46); the responses were maintained to month 24. The median (interquartile range) JADAS‐71–CRP improved from baseline to month 4: cohort 1, from 21.0 (13.5, 30.3) to 4.6 (2.1, 9.4); cohort 2, from 18.1 (14.0, 23.1) to 2.1 (0.3, 4.4). Improvements were sustained to month 24, at which time 27 of 173 patients (cohort 1) and 11 of 22 patients (cohort 2) had achieved JADAS‐71–CRP remission. No unexpected adverse events were reported; 4 of 172 patients (2.3%) in cohort 1 and 4 of 46 (8.7%) in cohort 2 developed anti‐abatacept antibodies, with no clinical effects.

Conclusion

Weight‐stratified SC abatacept yielded target therapeutic exposures across age and weight groups, was well tolerated, and improved polyarticular JIA symptoms over 24 months.

Biomarkers of systemic lupus erythematosus identified using mass spectrometry-based proteomics: a systematic review

Advances in mass spectrometry technologies have created new opportunities for discovering novel protein biomarkers in systemic lupus erythematosus (SLE). We performed a systematic review of published reports on proteomic biomarkers identified in SLE patients using mass spectrometry‐based proteomics and highlight their potential disease association and clinical utility. Two electronic databases, MEDLINE and EMBASE, were systematically searched up to July 2015. The methodological quality of studies included in the review was performed according to Preferred Reporting Items for Systematic Reviews and Meta‐analyses guidelines. Twenty‐five studies were included in the review, identifying 241 SLE candidate proteomic biomarkers related to various aspects of the disease including disease diagnosis and activity or pinpointing specific organ involvement. Furthermore, 13 of the 25 studies validated their results for a selected number of biomarkers in an independent cohort, resulting in the validation of 28 candidate biomarkers. It is noteworthy that 11 candidate biomarkers were identified in more than one study. A significant number of potential proteomic biomarkers that are related to a number of aspects of SLE have been identified using mass spectrometry proteomic approaches. However, further studies are required to assess the utility of these biomarkers in routine clinical practice.

Drug repositioning in SLE: crowd-sourcing, literature-mining and Big Data analysis

Lupus patients are in need of modern drugs to treat specific manifestations of their disease effectively and safely. In the past half century, only one new treatment has been approved by the US Food and Drug Administration (FDA) for systemic lupus erythematosus (SLE). In 2014–2015, the FDA approved 71 new drugs, only one of which targeted a rheumatic disease and none of which was approved for use in SLE. Repositioning/repurposing drugs approved for other diseases using multiple approaches is one possible means to find new treatment options for lupus patients. “Big Data” analysis approaches this challenge from an unbiased standpoint whereas literature mining and crowd sourcing for candidates assessed by the CoLTs (Combined Lupus Treatment Scoring) system provide a hypothesis-based approach to rank potential therapeutic candidates for possible clinical application. Both approaches mitigate risk since the candidates assessed have largely been extensively tested in clinical trials for other indications. The usefulness of a multi-pronged approach to drug repositioning in lupus is highlighted by orthogonal confirmation of hypothesis-based drug repositioning predictions by “Big Data” analysis of differentially expressed genes from lupus patient samples. The goal is to identify novel therapies that have the potential to affect disease processes specifically. Involvement of SLE patients and the scientists that study this disease in thinking about new drugs that may be effective in lupus though crowd-sourcing sites such as LRxL-STAT ( www.linkedin.com/in/lrxlstat ) is important in stimulating the momentum needed to test these novel drug targets for efficacy in lupus rapidly in small, proof-of-concept trials conducted by LuCIN, the Lupus Clinical Investigators Network ( www.linkedin.com/in/lucinstat ).

Meta-Analysis from Gene Expression Profiles of Lupus Affected Tissues Reveals Novel Immune Cell Contributions

Immunologic mechanisms causing tissue damage in autoimmune diseases such as SLE are not fully understood. To gain additional insight, gene expression profiles obtained from lupus affected skin, synovium and kidney were obtained and compared to meta-analyzed data obtained from active lupus B, T and myeloid cells. More than 300 arrays from lupus patients and appropriate controls were analyzed to determine differentially expressed (DE) genes (8279 discoid lupus skin, 5465 synovium, 6381 glomerulus, 5587 tubulointerstitum). Notably, the majority of lupus affected tissue DE genes were detected in more than one tissue and 439 were differentially expressed in all tissues. A variety of approaches assessed the molecular pathways and cellular phenotypes accounting for these common lupus affected tissue DE genes. Curated STRING-based interaction analysis identified a number of pathways including co-stimulation of T cells, activation of B and myeloid cells, antigen presentation, TLR signaling and p38 activation; from a total of 193 IPA-documented pathways, 59 were common to all tissues including p38 signaling, TLR signaling, maturation of dendritic cells, B cell activation and ICOS-ICOSL in T cells. Novel bioinformatics approaches documented that more than 50% of the DE genes in the tissues were associated with immune cell function and 11–18% were unique to the immune system. Further analysis using LINCS and additional novel software highlighted specific molecular pathways of immune cell activation including the JAK/STAT and the IL12 pathways. These results demonstrate the value of comprehensive application of orthogonal curated bioinformatics tools in identifying the role of immune cells in lupus pathogenesis and tissue damage.

Evaluation of Minimally Invasive, Ultrasound-guided Synovial Biopsy Techniques by the OMERACT Filter--Determining Validation Requirements

OBJECTIVE

Because limited data currently support the clinical utility of peripherally expressed biomarkers in guiding treatment decisions for patients with rheumatoid arthritis, the search has turned to the disease tissue. The strategic aim of the Outcome Measures in Rheumatology (OMERACT) synovitis working group over the years has been to develop novel diagnostic and prognostic synovial biomarkers. A critical step in this process is to refine and validate minimally invasive, technically simple, robust techniques to sample synovial tissue, for use both in clinical trials and routine clinical practice. The objective of the synovitis working group (SWG) at OMERACT 12 (2014) was to examine whether recently developed ultrasound (US)-guided synovial biopsy techniques could be validated according to the OMERACT filter for future clinical use recommendation.

METHODS

The SWG examined whether current data reporting US-guided synovial biopsy of both large and small joints addressed the OMERACT filters of truth, discrimination, and feasibility.

RESULTS

There are currently limited data examining the performance of US-guided synovial biopsy, mainly from observational studies. Thus, it remains critical to evaluate its performance, within the clinical trials context, against the current gold standard of arthroscopic biopsy, with particular reference to: (1) synovial tissue yield, (2) capacity to determine treatment response as measured by a validated synovial biomarker, and (3) tolerability of the procedure.

CONCLUSION

We summarize the discrete work packages agreed to as requirements to validate US-guided synovial biopsy and therefore lead to a global consensus on the use of synovial biopsy for research and clinical practice.