Regional variations of cardiovascular risk in gout patients: a nationwide cohort study in Korea

Objective

The extent of regional variations in cardiovascular risk and associated risk factors in patients with gout in South Korea remains unclear. Therefore, we aimed to investigate the risk of major cardiovascular events in gout patients in different regions.

Methods

This was a nationwide cohort study based on the claims database of the Korean National Health Insurance and the National Health Screening Program. Patients aged 20 to 90 years newly diagnosed with gout after January 2012 were included. After cardiovascular risk profiles before gout diagnosis were adjusted, the relative risks of incident cardiovascular events (myocardial infarction, cerebral infarction, and cerebral hemorrhage) in gout patients in different regions were assessed.

Results

In total, 231,668 patients with gout were studied. Regional differences in cardiovascular risk profiles before the diagnosis were observed. Multivariable analysis showed that patients with gout in Jeolla/Gwangju had a significantly high risk of myocardial infarction (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [CI], 1.02~1.56; p=0.03). In addition, patients with gout in Gangwon (aHR, 1.38; 95% CI, 1.09~1.74; p<0.01), Jeolla/Gwangju (aHR, 1.41; 95% CI, 1.19~1.67; p<0.01), and Gyeongsang/Busan/Daegu/Ulsan (aHR, 1.37; 95% CI, 1.19~1.59; p<0.01) had a significantly high risk of cerebral infarction.

Conclusion

We found there were regional differences in cardiovascular risk and associated risk factors in gout patients. Physicians should screen gout patients for cardiovascular risk profiles in order to facilitate prompt diagnosis and treatment.

A retrospective observational study of the appropriate starting dose of febuxostat in patients with gout

BACKGROUND/AIMS

The occurrence of gout attacks at the start of uric acid lowering treatment worsens compliance. We aimed to determine the appropriate dose of febuxostat to reduce the occurrence of gout attacks during the initial treatment period.

METHODS

We retrospectively analyzed the data of patients diagnosed with gout who underwent treatment at Jeju National University Hospital between May 2018 and May 2020.

RESULTS

Two-hundred and twenty-seven patients were included, with a mean age of 53.2 ± 16.4 years, and 219 (96.5%) were male. The patients were divided into two groups according to the starting dose of febuxostat (20 mg vs. 40 mg). There were no significant differences in mean age, disease duration, colchicine, estimated glomerular filtration rate (eGFR), initial uric acid levels, and presence of subcutaneous tophi between the two groups. Gout attacks occurred more frequently in the 20 mg group than in the 40 mg group during the first 3 months of treatment (32.0% vs. 14.3%, p = 0.002), particularly during the first month (21.3% vs. 7.5%, p = 0.005). Multivariate logistic regression analysis was conducted adjusting for the effects of disease duration, the presence of subcutaneous tophi, eGFR, and initial uric acid levels. A febuxostat starting dose of 40 mg (odds ratio, 0.464; 95% confidence interval [CI], 0.246 to 0.862; p = 0.015) and anti-inflammatory prophylaxis (odds ratio, 0.359; 95% CI, 0.158 to 0.813; p = 0.014) were found to be independent factors associated with a gout attack.

CONCLUSIONS

Starting uric acid lowering treatment with febuxostat 40 mg rather than 20 mg may reduce the incidence of gout attacks in the early period of treatment in Korean patients with gout.

Incident and recurrent herpes zoster for first-line bDMARD and tsDMARD users in seropositive rheumatoid arthritis patients: a nationwide cohort study

BACKGROUND

There is limited information regarding disease-modifying antirheumatic drug (DMARD)-dependent risks of overall, incident, and recurrent herpes zoster (HZ) during first-line biologic DMARD (bDMARD) or targeted synthetic DMARD (tsDMARD) treatment among patients with seropositive rheumatoid arthritis (RA) in terms of HZ risk.

METHODS

A total of 11,720 patients with seropositive RA who were prescribed bDMARD or tofacitinib between January 2011 and January 2019 from the Korean Health Insurance Review & Assessment Service database were studied. A multivariate Cox proportional hazards regression model was adopted to evaluate the adjusted hazard ratio (aHR) with 95% confidence interval (CI) for the risk of HZ dependent on the choice of first-line bDMARDs or tsDMARD, including etanercept, infliximab, adalimumab, golimumab, tocilizumab, rituximab, tofacitinib, and abatacept.

RESULTS

During the 34,702 person-years of follow-up, 1686 cases (14.4%) of HZ were identified, including 1372 (11.7%) incident and 314 (2.7%) recurrent HZs. Compared with that of the abatacept group, tofacitinib increased the overall risk (aHR, 2.46; 95% CI, 1.61-3.76; P<0.001), incidence (aHR, 1.99; 95% CI, 1.18-3.37; P=0.011), and recurrence (aHR, 3.69; 95% CI, 1.77-7.69; P<0.001) of HZ. Infliximab (aHR, 1.36; 95% CI, 1.06-1.74; P=0.017) and adalimumab (aHR, 1.29; 95% CI, 1.02-1.64; P=0.032) also increased the overall HZ risk. Moreover, a history of HZ was found to be an independent risk factor for HZ (aHR, 1.54; 95% CI, 1.33-1.78; P<0.001).

CONCLUSIONS

HZ risk is significantly increased in RA patients with a history of HZ after the initiation of bDMARDs or tsDMARD. The risk of incident and recurrent HZ was higher after tofacitinib treatment in patients with RA than that after treatment with bDMARDs. Individualized characteristics and history of HZ should be considered when selecting bDMARDs or tsDMARD for RA patients considering HZ risks.

POS0389 MUSCULAR EXPRESSION OF CD163 AND MAJOR HISTOCOMPATIBILITY COMPLEX CLASS I AS DIAGNOSTIC MARKERS IN IDIOPATHIC INFLAMMATORY MYOPATHIES

Background

Various inflammatory markers have been suggested for detecting idiopathic inflammatory myopathies (IIMs); however, their diagnostic utility remains inconclusive.

Objectives

Muscle tissues from patients diagnosed with IIMs from January 2001 to March 2017 in a tertiary hospital were investigated. Muscular expression of CD3, CD4, CD8, CD20, CD68, CD163, MX1, MHC class I, MHC class II, and HLA-DR in muscle biopsy specimens from patients with IIMs and controls were evaluated using immunohistochemical staining. Classification and regression tree analyses were used to classify patients with IIMs who met the 2017 European League Against Rheumatism/American College of Rheumatology classification criteria for adult and juvenile idiopathic inflammatory myopathies (2017 EULAR/ACR criteria for IIMs) using various staining results as predictor variables.

Methods

Muscle tissues from patients diagnosed with IIMs from January 2001 to March 2017 in a tertiary hospital were investigated. Muscular expression of CD3, CD4, CD8, CD20, CD68, CD163, MX1, MHC class I, MHC class II, and HLA-DR in muscle biopsy specimens from patients with IIMs and controls were evaluated using immunohistochemical staining. Classification and regression tree analyses were used to classify patients with IIMs who met the 2017 European League Against Rheumatism/American College of Rheumatology classification criteria for adult and juvenile idiopathic inflammatory myopathies (2017 EULAR/ACR criteria for IIMs) using various staining results as predictor variables.

Results

Among the total 146 patients diagnosed with IIMs by expert neurologist or rheumatologist, 129 patients with IIMs met the 2017 EULAR/ACR criteria for IIMs. Histopathologic features consistent with IIMs using HE staining was observed in 104 of 129 (80.6%) patients who met the 2017 EULAR/ACR criteria for IIMs (dermatomyositis, n = 46/66, 69.7%; polymyositis n = 58/63, 92.1%; sensitivity 80.6%, specificity 100.0%). Muscular expression of CD163 (99.2% vs. 20.8%, p < 0.001) and MHC class I (87.6% vs. 23.1%, p < 0.001) were significantly higher in patients with IIMs who met the 2017 EULAR/ACR criteria for IIMs than in controls. Combined CD163 and MHC class I expression provided the most significant stratification for the control group (sensitivity 96.1%, specificity 94.5%). This combination was able to classify 16 of 17 (94.1%) patients who were diagnosed with IIMs by an expert physician but did not meet the 2017 EUALR/ACR criteria for IIMs.

Conclusion

Combined CD163 and MHC class I muscular expression may be useful in diagnosing IIMs.

Table 1.

Sensitivity, specificity, and predictive values of various inflammatory marker expressions and their optimal combinations for the diagnosis of idiopathic inflammatory myopathies.

SensitivitySpecificityPPVNPVPatients who were diagnosed by an expert physician but did not meet the 2017 EULAR/ACR classification criteria for IIMs are classified by each combinationMuscle biopsy features consistent with IIMs on H/E staining80.6%100.0%100.0%74.5%7/17 (41.2%)CD3 expression91.5%51.4%77.6%76.6%7/17 (41.2%)CD163 expression99.2%79.2%89.5%98.3%16/17 (94.1%)MHC class I on myofibers87.6%76.9%88.3%75.8%12/17 (70.6%)HLA-DR on myofibers69.8%81.5%88.2%57.6%8/17 (47.1%)MHC class II on myofibers13.2%72.3%45.6%29.6%6/17 (35.3%)Combination of CD163 pattern and MHC class I on myofibers96.1%94.5%96.9%93.2%16/17 (94.1%)Combination of histopathologic examination using HE staining, CD163 pattern, and MHC class I on myofibers97.7%94.5%95.8%96.5%16/17 (94.1%)

Acknowledgements

This work was supported by a research grant from the Jeju National University Hospital

Disclosure of Interests

None declared

POS0284 CHANGES OF ESTIMATED GLOMERULAR FILTRATION RATE AFTER LONG-TERM FEBUXOSTAT OR ALLOPURINOL TREATMENT IN GOUT PATIENTS

Background

Under the hypothesis that hyperuricemia is a potentially modifiable risk factor for progression of CKD, there has been numerous small, single-center studies that have shown that use of urate-lowering therapy (ULT) delayed CKD progression in patients with hyperuricemia or CKD. However, recent three multicenter, randomized controlled trials have not shown beneficial effect of ULT on the progression of CKD among CKD patients without gout and in DM patients with albuminuria.

Objectives

We investigated whether ULT may have a beneficial effect on the progression of CKD in gout patients.

Methods

Gout patients who took the study medication for more than 1 year were identified from the Cardiovascular Safety of Febuxostat or Allopurinol in Patients with Gout (CARES) trial, which is a large, multicenter, randomized controlled trial. We analyzed the estimated glomerular filtration rate (eGFR) slope (mL/min/1.73 m2 per year) using the CKD-EPI equation. Using logistic regression, we investigated risk factors for CKD progression, defined as eGFR slope of lower than 0 mL/min/1.73 m2 per year.

Results

During the study period [median (interquartile range, IQR) 3.1 (2.0-4.8) year], 4,144 patients performed median (IQR) 12 (9~15) creatinine tests, the GFR slope was analyzed as median (IQR) 0.5 (-0.8-1.6). The median (IQR) values of the GFR slope were -1.2 (-2.3--0.5) in the CKD progression group (n=1,590) and 1.3 (0.7-2.2) in the CKD progression delayed group (n=2,554). After adjusting well known factors associated with CKD progression, average level of serum uric acid ≥ 6 mg/dL during study period was significantly associated with CKD progression (adjusted odds ratio 1.73; 95% confidence interval 1.49-2.01, p < 0.0001).

Conclusion

This study showed that eGFR did not decrease in more than half of gout patients after long term febuxostat or allopurinol administration. ULT may have a beneficial effect on slowing the progression of CKD in gout patients.

Figure 1.

Changes of estimated glomerular filtration rate during febuxostat or allupurinol administration.

Acknowledgements

We were able to access the CARES trial data through the Vivli company, and re-analyzed data of the CARES trial without financial support from any company.

Disclosure of Interests

None declared

Expression of Inflammatory Markers in the Muscles of Patients with Idiopathic Inflammatory Myopathy According to the Presence of Interstitial Lung Disease

Background: Several studies have identified factors associated with the development of interstitial lung disease (ILD) in patients with idiopathic inflammatory myopathies (IIMs). However, few have assessed the association between ILD and muscle biopsy findings, including inflammatory marker expressions analyzed using immunohistochemistry (IHC). Methods: Muscle biopsies from patients who were newly diagnosed with IIMs between 2000 and 2017 were reviewed. ILD was diagnosed based on chest computed tomography findings at the time of diagnosis of IIMs. IHC staining was performed for CD3, CD4, CD8, CD20, CD68, CD163, MX1, MHC class I, and HLA-DR. The factors associated with the presence of ILD were evaluated by logistic regression analysis. Results: Of the 129 patients with IIM, 49 (38%) had ILD. In the muscle biopsy findings, CD4 expression, MX1 expression on immune cells, and expression of MHC class I and HLA-DR on myofibers were more common in patients with ILD than those without. In the logistic regression analysis, the HLA-DR expression on myofibers was significantly associated with the risk of ILD (OR, 2.39; 95% CI, 1.24–4.90, p = 0.012) after adjusting for pathologic findings, clinical features, and autoantibodies. Conclusion: The expression of HLA-DR on myofibers was associated with the presence of ILD in patients with IIM.

Effect of Low-Dose Corticosteroid Use on HBV Reactivation in HBsAg-positive Rheumatoid Arthritis Patients

Background:

It is well known that the use of corticosteroids (CS) results in increased viral replication and elevated alanine aminotransferase in hepatitis B virus (HBV) patients. However, only a few studies have investigated the effect of low-dose CS on HBV reactivation. In addition, there are few studies on the effects of synthetic disease-modifying anti-rheumatic drugs on HBV reactivation.

Objective:

We investigated the reactivation of HBV in rheumatoid arthritis (RA) patients treated with long-term low-dose corticosteroids. In addition, we analyzed factors affecting HBV reactivation, including disease-modifying anti-rheumatic drugs.

Methods:

We retrospectively reviewed medical records and analyzed the incidence of HBV reactivation in RA patients who were hepatitis B surface antigen (HBsAg) positive and who were receiving ≤10 mg of prednisolone over 4 weeks. Logistic regression analysis was performed to investigate the factors that increase the risk of HBV reactivation.

Results:

A total of 141 patients were included in the study, out of which 24 (17.0%) patients had HBV reactivation. The administration of low-dose corticosteroids did not affect HBV reactivation in HBsAg-positive RA patients (odds ratio: 0.807, 95% confidence interval: 0.143–4.546, p = 0.808), nor did the duration of corticosteroid administration, average daily corticosteroid dose, and cumulative corticosteroid dose. Administration of leflunomide was found to significantly increase the risk of HBV reactivation (odds ratio: 3.851, 95% confidence interval: 1.026–14.459, p = 0.046).

Conclusion:

The administration of low-dose corticosteroids did not affect the rate of HBV reactivation, suggesting that it can be used safely. Leflunomide may increase the risk of HBV reactivation; therefore, HBV patients should be carefully monitored when receiving this drug.

Association of first, second, and third-line bDMARDs and tsDMARD with drug survival among seropositive rheumatoid arthritis patients: Cohort study in A real world setting

OBJECTIVES

To determine the association of first, second, and third-line biologic disease-modifying antirheumatic drugs (bDMARDs) and tofacitinib with drug survival among seropositive rheumatoid arthritis (RA) patients.

METHODS

The study population was composed of 8,018 seropositive RA patients who were prescribed bDMARDs or tofacitinib between January 2014 and January 2019 from the Korean Health Insurance Review and Assessment Service database. First, second, and third-line choice of tumor necrosis factor inhibitors (TNFi) including etanercept, infliximab, adalimumab, and golimumab, as well as non-TNFi including tocilizumab, rituximab, tofacitinib, and abatacept were assessed. Multivariate Cox proportional hazards regression was used to determine the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for drug failure according to bDMARD or tofacitinib choice starting from the initial prescription date.

RESULTS

Compared to first etanercept users, patients with first tocilizumab (aHR 0.56, 95% CI 0.46-0.68), tofacitinib (aHR 0.27, 95% CI 0.18-0.42), or abatacept (aHR 0.83, 95% CI 0.69-0.99) had lower risk of drug failure. Second choice of tocilizumab (aHR 0.38, 95% CI 0.25-0.55), tofacitinib (aHR 0.23, 95% CI 0.15-0.37), or abatacept (aHR 0.54, 95% CI 0.35-0.84) was associated with lower drug failure risk compared to second etanercept users. Finally, third choice of tocilizumab (aHR 0.32, 95% CI 0.16-0.62) or tofacitinib (aHR 0.35, 95% CI 0.19-0.63) was associated with lower drug failure risk compared to third TNFi users.

CONCLUSION

First and second-line tocilizumab, tofacitinib, or abatacept may lead to improved drug survival. Third-line use of tocilizumab or tofacitinib may be beneficiary in reducing drug failure risk among seropositive RA patients.

POS0209 ASSOCIATION OF FIRST, SECOND, AND THIRD-LINE BDMARDS AND TSDMARD WITH DRUG SURVIVAL AMONG RHEUMATOID ARTHRITIS PATIENTS: A COHORT STUDY

Background:

Since tofacitnib is a tsDMARD with a different mechanism of action compared to bDMARDs, along with the fact that recent releases of bDMARDs or tsDMARDs have led to numerous possible switching patterns, there is a need for comparative studies of bDMARDs and tofacitinib with subsequent drug survival among RA patients.

Objectives:

To determine the association of first, second, and third-line biologic disease- modifying antirheumatic drugs (bDMARDs) and tofacitinib with drug survival among rheumatoid arthritis (RA) patients.

Methods:

The study population was composed of 8,018 seropositive RA patients who were prescribed bDMARDs or tofacitinib between January 2014 and January 2019 from the Korean Health Insurance Review and Assessment Service database. First, second, and third-line choice of tumor necrosis factor inhibitors (TNFi) including etanercept, infliximab, adalimumab, and golimumab, as well as non-TNFi including tocilizumab, rituximab, tofacitinib, and abatacept were assessed. Multivariate Cox proportional hazards regression was used to determine the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for drug failure according to bDMARD or tofacitinib choice starting from the initial prescription date.

Results:

Compared to first etanercept users, patients with first tocilizumab (aHR 0.56, 95% CI 0.46-0.68), tofacitinib (aHR 0.27, 95% CI 0.18-0.42), or abatacept (aHR 0.83, 95% CI 0.69- 0.99) had lower risk of drug failure. Second choice of tocilizumab (aHR 0.38, 95% CI 0.25- 0.55), tofacitinib (aHR 0.23, 95% CI 0.15-0.37), or abatacept (aHR 0.54, 95% CI 0.35-0.84) was associated with lower drug failure risk compared to second etanercept users. Finally, third choice of tocilizumab (aHR 0.32, 95% CI 0.16-0.62) or tofacitinib (aHR 0.35, 95% CI 0.19- 0.63) was associated with lower drug failure risk compared to third TNFi users.

Conclusion:

First and second-line tocilizumab, tofacitinib, or abatacept may lead to improved drug survival. Third choices of tocilizumab or tofacitinib may be beneficiary in reducing drug failure risk among RA patients.

References:

[1].Neovius M, Arkema EV, Olsson H, et al. Drug survival on TNF inhibitors in patients with rheumatoid arthritis comparison of adalimumab, etanercept and infliximab. Ann Rheum Dis 2015;74(2):354-60.

Table 1.

Risk of drug failure on rheumatoid arthritis patients according to first, second, and third choice of bDMARD or tofacitinib.

EventsPerson-yearsIncidenceaHR95% CIFirst-line choice (n=8,018) Etanercept2902,3961211.00reference Infliximab2361,4171671.361.14-1.62 Adalimumab4492,7181651.281.10-1.48 Golimumab2581,9551321.060.90-1.26 Tocilizumab1712,623650.560.46-0.68 Rituximab129340.290.04-2.08 Tofacatinib24502480.270.18-0.42 Abatacept2162,207980.830.69-0.99Second-line choice (n=1,645) Etanercept411512721.00reference Infliximab16513141.040.58-1.88 Adalimumab852753091.070.72-1.60 Golimumab412042010.790.51-1.23 Tocilizumab85918930.380.25-0.55 Rituximab4311290.520.18-1.46 Tofacatinib35484720.230.15-0.37 Abatacept462991540.540.35-0.84Third-line choice (n=353) Etanercept3191581.00reference Infliximab5105001.270.27-5.91 Adalimumab5172940.990.22-4.38 Golimumab13225912.230.60-8.25 Tocilizumab171271340.470.13-1.68 Rituximab3221360.600.12-3.09 Tofacatinib231621420.500.14-1.77 Abatacept17592881.110.31-3.96

Adjusted hazard ratios calculated by multivariate Cox proportional hazards regression after adjustments for age, sex, hospital type, number of csDMARDs, first bDMARDs or tofacitinib for second and third-line choice analysis, Charlson comorbidity index, and enrollment year.

Incidence calculated as the number of events per 1,000 person-years.

Acronyms: aHR, adjusted hazard ratio; CI, confidence interval.

Disclosure of Interests:

Byeongzu Ghang: None declared, Seulggie Choi: None declared, Eun Young Lee Grant/research support from: This work was supported by grants from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute, funded by the Ministry of Health and Welfare, Republic of Korea [HI14C1277] and Britol-Myers Squibb [IM101-735].

Cyr61 synthesis is induced by interleukin-6 and promotes migration and invasion of fibroblast-like synoviocytes in rheumatoid arthritis

Background

Interleukin-6 (IL-6) is involved in fibroblast-like synoviocyte (FLS) activation and promotes pannus formation and bone and cartilage destruction in rheumatoid arthritis (RA). Cysteine-rich 61 (Cyr61) protein regulates cell proliferation, migration, and differentiation. The aim of this study was to investigate the role of Cyr61 in RA-FLS migration and invasion after IL-6 stimulation.

Methods

Western blotting, immunohistochemistry, reverse transcription-polymerase chain reaction, and real time-polymerase chain reaction were used to examine protein and mRNA levels of Cyr61, matrix metalloproteinases (MMPs), and other signalling proteins. Knockdown of gene expression was performed with siRNA, and RNA sequencing was performed for differential gene analysis. Migration and invasion were assessed by wound healing and Boyden chamber assays.

Results

Cyr61 levels were elevated in FLSs from RA patients compared to those in osteoarthritis patients. Control and IL-6-treated FLSs showed differential gene expression. IL-6 stimulated protein synthesis of Cyr61, which was attenuated by the extracellular signal-related kinase 1/2 (ERK 1/2) inhibitor, PD98059, and knockdown of early growth response 3 (EGR3), but not of JUN. IL-6-induced Cyr61 protein synthesis increased expression of MMP2. Cyr61 promoted FLS migration and invasion in an autocrine manner. Knockdown of CYR61 and a neutralising antibody attenuated Cyr61 synthesis and IL-6-induced FLS migration.

Conclusions

By modulating the ERK/EGR3 pathway, IL-6 stimulated Cyr61 production and in turn increased invasiveness of FLS. Our data suggest that Cyr61 might be a potential target to prevent the progression of joint damage in RA.

OP0168 CARDIOVASCULAR EVENT ASSOCIATED WITH INITIATING ALLOPURINOL AND FEBUXOSTAT - ACUTE GOUT ATTACK AND CARDIOVASCULAR GOUT ATTACK

Background:

When serum uric acid rapidly increases or decreases due to such as alcohol consumption or fasting, free urate crystals are formed, which induce an acute joint inflammation referred to as an acute gout attack. In 86.4% of patients with gout, dual energy computed tomography demonstrated the deposition of urate crystals in vasculature, and urate crystals have been observed in coronary arteries and various tissues in 10.9% of patients with a heart transplant. However, whether hyperuricemia and urate crystal directly cause cardiovascular disease is not well known. We previously reanalyzed the CARES trial to calculate the mortality rates based on the median duration of exposure to study drugs and the median follow-up duration. A sharp increase in mortality was observed after allopurinol and febuxostat were discontinued. Even in view of the Sick-Stopper Effect, for about 40-fold increase in mortality following drug discontinuation, we postulated that the sharp increase in mortality may be associated with rapid changes in uric acid level (rebound hyperuricemia), and that withdrawal of hypouricemic agent leads to an acute inflammatory response due to an abrupt increase in serum uric acid level with subsequent free urate crystal formation in the cardiovascular system (cardiovascular gout attack)(1).

Objectives:

Based on this hypothesis that some cardiovascular events may be cardiovascular gout attacks, we investigated the association between the cardiovascular event and initiation of hypouricemic agent, when is accompanied by acute gout attack and/or fluctuation of uric acid, in gout patients.

Methods:

Using the Korean National Health Insurance Service (KNHIS) database, which covers the entire Korean population, we conducted a population-based cohort study among gout patients who initiated allopurinol or febuxostat between 2012 and 2018. The initiators were defined as those who had no prior dispensing of any urate-lowering therapy for at least 60 months before the first dispensing date (i.e. index date) of either allopurinol or febuxostat. We excluded patients with a diagnosis of cancer and patients treated with benzbromarone. We investgated a composite cardiovascular event of hospitalized myocardial infarction, ischemic stroke, and cerebral hemorrhage.

Results:

We identified hospitalizations for cardiovascular event (acute myocardial infarction (n = 3538), cerebral infarction (n = 5127), and cerebral hemorrhage (n = 1593)) that occurred within 2 year before and 2 year after initiation of allopurinol or febuxostat. Of these, 4333 cardiovascular event (0.014 per person-time, 95% confidence interval [CI], 0.014 to 0.015) occurred in 2 years before initiation of allopurinol or febuxostat, 1032 cardiovascular event (0.081 per person-time, 95% confidence interval [CI], 0.076 to 0.086) occurred in 30 days before initiation of allopurinol or febuxostat. And, 83 cardiovascular event (0.030 per person-time, 95% CI, 0.024 to 0.037) occurred in 7 days after initiation of allopurinol or febuxostat. (Figure)

Figure 1

Conclusion:

Initiation of febuxostat and allopurinol was significantly associated with acute myocardial infarction, cerebral infarction, and cerebral hemorrhage. Considering that allopurinol and febuxostat usually are initiated a few weeks after a acute gout attack. Acute gout attack and/or fluctuation of uric acid level might be significantly associated with cardiovascular event. Some of cardiovascular events might be cardiovascular gout attack.

References:

[1]Ghang B, Ahn SM, Kim J, Kim YG, Lee CK, Yoo B. Discontinuing febuxostat might cause more deaths than continuing febuxostat: the untold story from the CARES trial. Rheumatology (Oxford). 2019.

Disclosure of Interests:

None declared

FRI0485 RISK OF PROGRESSION OF IDIOPATHIC PULMONARY FIBROSIS TO CONNECTIVE TISSUE DISEASE

Background:

Connective tissue disease (CTD) may be observed during the course of idiopathic pulmonary fibrosis (IPF). However, clinical factors associated with the development of CTD in patients with IPF have not yet been identified. These factors might be valuable clues for determining the pathogenesis of pulmonary fibrosis in patients with CTD. We hypothesize that some IPF patients have a clinically significant association with autoimmunity, and that autoantibodies are important biomarkers for identifying these patients.

Objectives:

Based on this hypothesis, we investigated whether the serology criteria (anti-neutrophil cytoplasmic antibody (ANCA) or autoantibodies that met the serology criteria for interstitial pneumonitis with autoimmune features (IPAF)) were associated with the development of CTD during the clinical course of IPF in the patients from our previous study(1), with a particular focus on which antibodies have a significant association with the development of CTD.

Methods:

We retrospectively reviewed the records of 527 patients with a first diagnosis of IPF between January 2007 and March 2014, and investigated the length of time from first visit to the clinic for IPF diagnosis (baseline) to CTD diagnosis by an expert rheumatologist in patients with IPF. Multivariable Cox proportional-hazards models with backward elimination were used to investigate the risk factors for the development of CTD.

Results:

CTD developed in 15 patients at a median of 2.1 years (range 1.2 to 4.8) after IPF diagnosis. All these patients had ANCA or autoantibodies that met the serology criteria for IPAF. A significant number of IPF patients with high titers of RF, ACPA or MPO-ANCA tested at first visit to the clinic progressed to CTD(Figure 1). Survival duration for IPF patients with progression to CTD was 5.3 [3.8; 6.7] years, which was significantly longer than for the IPF patients without progression to CTD (2.9 [1.7; 4.8], p = 0.001). Independent risk factors for development of CTD in IPF patients included female gender (adjusted hazard ratio (HR) 5.319, p = 0.0082), titer of rheumatoid factor (RF) (adjusted HR 1.006, p = 0.022), titer of anti-citrullinated protein antibody (ACPA) (adjusted HR 1.009, p = 0.0011), and titer of myeloperoxidase (MPO) ANCA (adjusted HR 1.02, p < 0.0001).

Figure 1.

Connective tissue disease development in each autoantibody positive IPF patient. ACPA = anti–citrullinated protein antibody; ANA = antinuclear antibody; CTD = connective tissue disease; MPA = microscopic polyangiitis; PAN = polyarteritis nodosa; RA = rheumatoid arthritis; RF = rheumatoid factor; UCTD = Undifferentiated connective tissue disease; SjS = Sjögren’s syndrome.

Conclusion:

We observed development of CTD in IPF patients with ANCA or autoantibodies that met the IPAF serology criteria. Among these autoantibodies, RF, ACPA, and MPO-ANCA were significantly associated with the development of CTD in IPF patients. Progression to CTD is uncommon in IPF patients, but a significant number of IPF patients with high titers of RF, ACPA or MPO-ANCA progressed to connective tissue disease. IPF with high titers of RF, ACPA or MPO-ANCA might be the initial clinical manifestation of connective tissue disease. Further studies are needed to investigate the role of RF, ACPA, and MPO-ANCA in development of pulmonary fibrosis.

References:

[1]Ghang B, Lee J, Chan Kwon O, Ahn SM, Oh JS, Hong S, et al. Clinical significance of autoantibody positivity in idiopathic pulmonary fibrosis. Respir Med. 2019;155:43-8.

Disclosure of Interests:

None declared

Clinical features and prognoses of acute transverse myelitis in patients with systemic lupus erythematosus

BACKGROUND/AIMS

Acute transverse myelitis (ATM) is a severe complication of systemic lupus erythematosus (SLE). This study evaluated the clinical factors related to outcome in patients with SLE-associated ATM.

METHODS

The medical records of patients diagnosed with SLE-associated ATM between January 1995 and January 2015 were reviewed. The patients were divided into two groups based on improvement of neurological deficits after treatment: favorable response group and unfavorable response group. During follow-up, the recurrence of ATM was also analyzed.

RESULTS

ATM was identified in 16 patients with SLE. All of the patients were treated with high doses of methylprednisolone (≥ 1 mg/kg daily). Although 12 patients (75%) recovered (favorable response group), four (25%) had persistent neurologic deficits (unfavorable response group) after the treatment. Compared to the favorable response group, significantly higher Systemic Lupus Erythematosus Disease Activity Index-2000, lower complement levels and initial severe neurologic deficits were found in the unfavorable response group. Among the 12 favorable response patients, five (41.7%) experienced recurrence of ATM during the followup. Patients (n = 5) who experienced relapse had a shorter duration of high-dose corticosteroid treatment (13.2 days vs. 32.9 days, p = 0.01) compared to patients who did not relapse. The mean duration of tapering-off the corticosteroid until 10 mg per day was significantly longer in non-relapse group (151.3 ± 60.8 days) than in relapse group (63.6 ± 39.4 days, p = 0.013).

CONCLUSION

Higher disease activity in SLE and initial severe neurologic deficits might be associated with the poor outcome of ATM. Corticosteroid slowly tapering-off therapy might be helpful in preventing the recurrence of ATM.

Clinical features and risk of recurrence of acute calcium pyrophosphate crystal arthritis

OBJECTIVES

It is unclear whether attack recurrence rates are similar between acute calcium pyrophosphate (CPP) crystal arthritis and gout. This study compared the clinical features and recurrence rates of both conditions.

METHODS

In this retrospective study, we reviewed 106 patients with acute CPP crystal arthritis (based on the presence of CPP crystals and/or chondrocalcinosis) and 173 patients with gout (based on the presence of monosodium urate crystals). We analysed clinical variables and compared them between the two conditions. We identified factors associated with the recurrence of acute CPP crystal arthritis.

RESULTS

Patients with acute CPP crystal arthritis were older (76.5 vs. 62 years, p<0.001) and female (69.8% vs. 6.9%, p<0.001); they had a lower body mass index (22.3 vs. 23.7, p=0.002), lower renal insufficiency rate (27.4% vs. 41.6%, p=0.016), and higher rate of preceding infection (22.6% vs. 11.0%, p=0.009) than those with acute gout. Recurrence rates were similar between the groups (19.1% vs. 22.9%, p=0.562). Use of proton pump inhibitors (PPIs) [hazard ratio (HR), 5.625; 95% CI, 1.672-18.925; p=0.005] and warfarin (HR, 7.301; 95% CI, 1.930-27.622; p=0.003) or exposure to chemotherapy (HR, 5.663; 95% CI, 1.180-27.169; p=0.03) were associated with acute CPP crystal arthritis recurrence.

CONCLUSIONS

Acute CPP crystal arthritis was more common than acute gout in older women with preserved renal function. Physicians should be aware of the association between recurrence and PPI, warfarin, or chemotherapy use in these patients.

Surgical Outcomes in Behcet's Disease Patients With Severe Aortic Regurgitation

BACKGROUND

An optimal treatment for aortic regurgitation in Behcet's disease has not been established. We investigated the effect of operative technique, prosthetic material, and immunomodulation therapy on surgical outcomes.

METHODS

In this study, 23 patients with Behcet's disease surgically treated for aortic regurgitation were assessed. Significant postoperative events were defined as death, aortic valve or graft-related problem(s), infective endocarditis, disabling stroke, and aortic valve or root reoperation. Surgical procedures were classified as isolated aortic valve replacement, bioprosthetic root replacement, and mechanical root replacement. Allograft root replacements were included in the bioprosthetic root replacement group.

RESULTS

A total of 40 operations, including 39 aortic valve or root surgeries and 1 orthotopic heart transplantation, were performed on patients confirmed with Behcet's disease. However, the study only reviewed 35 of the 40 cases (4 cases with inadequately documented medical records and 1 heart transplantation case were excluded). Significant adverse events occurred in 8 of 11 (73%) isolated aortic valve replacement, 9 of 12 (75%) bioprosthetic root replacement (5 xenografts and 7 allografts), and 4 of 12 (33%) mechanical root replacement cases. Multivariate analysis revealed that the 1-month postdischarge C-reactive protein level and operative age were independent predictive factors for postoperative event-free survival. Mechanical root replacement was identified as the most significant predictive factor leading to positive outcomes (hazard ratio, 0.147; 95% confidence interval, 0.028 to 0.766; p = 0.023).

CONCLUSIONS

The findings suggest that mechanical root replacement combined with a low postoperative C-reactive protein level maintained through adjunctive immunomodulation therapy may lead to optimal surgical outcomes in Behcet's disease associated with severe aortic regurgitation.

IL-17A+GM-CSF+ Neutrophils Are the Major Infiltrating Cells in Interstitial Lung Disease in an Autoimmune Arthritis Model

Objective

To gain a better understanding of the pathogenesis of autoimmune arthritis-associated interstitial lung disease (ILD), we sought to identify the characteristics of lung-infiltrating cells in SKG mice with ILD.

Methods

We injected curdlan in SKG mice at 8 weeks of age, and identified the presence of ILD by PET-MRI at 20 weeks post-injection and histological analysis at 22 weeks post-injection. Lung-infiltrating cells were examined by flow cytometry. Analysis of serum cytokines by the Luminex multiplex cytokine assay was performed at 14 and 22 weeks post-injection, and cytokine profiles before and after the development of ILD were compared. Opal multiplexed immunofluorescent staining of lung tissue was also performed.

Results

At 20 weeks post-injection, curdlan-treated SKG mice developed not only arthritis but also lung inflammation combined with fibrosis, which was identified by PET-MRI and histological analysis. The majority of inflammatory cells that accumulated in the lungs of curdlan-treated SKG mice were CD11b⁺Gr1⁺ neutrophils, which co-express IL-17A and GM-CSF, rather than TNF-α. Compared with 14 weeks post-injection, serum levels of GM-CSF, MCP1, IL-17A, IL-23, TSLP, and soluble IL-7Rα had increased at 22 weeks post-injection, whereas those of IFN-γ, IL-22, IL-6, and TNF-α remained unchanged. Furthermore, IL-23, CXCL5, IL-17A, and GM-CSF, but not TNF-α, were observed in immunofluorescent-stained lung tissue.

Conclusion

We found that IL-17A⁺GM-CSF⁺ neutrophils represented the major inflammatory cells in the lungs of curdlan-treated SKG mice. In addition, GM-CSF and IL-17A appear to play a more important role than TNF-α in ILD development.

Nontuberculous mycobacterial infection in rheumatoid arthritis patients: a single-center experience in South Korea

BACKGROUND/AIMS

Nontuberculous mycobacteria (NTM) infection has been increasing worldwide in both general population and immunocompromised patients, which has also been reported in rheumatoid arthritis (RA) patients. This study aimed to identify the incidence and clinical characteristics of NTM infection in RA patients living in tuberculosis (TB) infection endemic area.

METHODS

We performed a retrospective analysis of NTM infection cases in our RA registry at a tertiary referral center from January 1995 to December 2013. The clinical features of them were compared to those of 52 TB infection patients from same registry.

RESULTS

Among 1,397 patients with RA, NTM infection was newly developed in 26 patients and the incidence of NTM infection was 164.8 per 100,000 patient-years. The Mycobacterium avium complex was the most frequent isolate (76.9%). None of the NTM infections had extrapulmonary involvement, which was rather common in TB infection (26.9%). Patients with NTM infection were older, received higher cumulative steroid doses, and had higher rates of past TB infection history and concomitant interstitial lung disease (ILD) than cases with TB infection.

CONCLUSIONS

In South Korea, NTM infection is not rare in RA patients, and infection rates are growing. Physicians should be cautious about NTM infection in patients with a history of TB infection or concomitant ILD, even living in TB endemic area.

CD14+ Cells with the Phenotype of Infiltrated Monocytes Consist of Distinct Populations Characterized by Anti-inflammatory as well as Pro-inflammatory Activity in Gouty Arthritis

It has been suggested that inflammasome-mediated IL-1β production in monocytic cells is responsible for the acute inflammatory response in gouty arthritis. However, phenotypical and functional analyses of monocytes during gouty arthritis have yet to be conducted. Therefore, we investigated the characteristics of monocytes/macrophages in the synovial fluid cells of patients with acute gout. The number and frequency of monocytes/macrophages in the synovial fluid mononuclear cells (SFMCs) of patients was examined. The expression of markers for monocyte recruitment and tissue-resident macrophages, the production of pro-inflammatory and anti-inflammatory cytokines, and phagocytosis were analyzed in the monocytes/macrophages of patients with acute gout attacks. The number and frequency of CD14⁺CD3⁻CD19⁻CD56⁻ monocytes/macrophages was markedly increased in the SFMCs of patients with gout compared to those of patients with rheumatoid arthritis (RA). CD14⁺ cells showed the phenotypes of infiltrated monocytes rather than tissue-resident macrophages, characterized by a high expression of CCR2, MRP8, and MRP14, but a low expression of MERTK and 25F9. These cells had the capacity to produce pro-inflammatory cytokines such as TNF-α and IL-1β after stimulation with lipopolysaccharides. In addition, anti-inflammatory features, including CD163 expression and IL-10 production from CD14⁺ cells, were significantly higher in patients with gout than in those with RA. CD14⁺ cells with phenotype of M2 macrophages had high phagocytic activity for monosodium urate crystals. Thus, our results indicate that monocytes/macrophages from patients with gout have the phenotype of infiltrated monocytes, and these cells consist of different populations characterized by anti-inflammatory activities as well as pro-inflammatory functions.

Risk of Colchicine-Associated Myopathy in Gout: Influence of Concomitant Use of Statin

OBJECTIVE

The purpose of this study was to investigate the risk of myopathy when statins are coadministered with colchicine in patients with gout.

METHODS

In gout patients who received colchicine with or without statin, clinical data collected included medications and history of hypertension, chronic kidney disease, and liver cirrhosis. Myopathy was defined as the presence of muscle symptoms with elevated creatine kinase or myoglobin. Multivariate analysis was performed to identify risk factors for myopathy. Inverse probability of treatment weighting (IPTW)-adjusted analysis was used to evaluate the influence of concomitant colchicine and statin use on myopathy.

RESULTS

Of 674 patients, 486 received colchicine alone and 188 also received statin. The incidence of myopathy was not significantly higher in those on both drugs than in those on colchicine alone (2.7% vs 1.4%, P = .330). On multivariate analysis, chronic kidney disease (hazard ratio [HR] 29.056; 95% confidence interval [CI], 4.387-192.450; P <.001), liver cirrhosis (HR 10.676; 95% CI, 1.279-89.126; P = .029), higher colchicine dose (HR 20.960; 95% CI, 1.835-239.481; P = .014), and concomitant CYP3A4 inhibitor (HR 12.027; 95% CI, 2.743-52.725; P = .001) were associated with increased risk of myopathy. Concomitant use of statins, however, was not, even after adjusting for confounders (HR 1.123; 95% CI, 0.262-4.814; P = .875; IPTW-adjusted HR 0.321; 95% CI, 0.077-1.345; P = .120).

CONCLUSION

Concomitant use of statin and colchicine was not associated with increased risk of myopathy. Thus, concomitant use of statin with colchicine seems to be safe from myotoxicity in gout patients.

Longterm Outcomes of Renal Artery Involvement in Takayasu Arteritis

OBJECTIVE

Takayasu arteritis (TA) involving the renal artery can result in hypertension (HTN), renal dysfunction, and premature death. The aim of this study was to investigate the longterm outcomes and factors that predict outcomes in patients with TA with renal artery stenosis.

METHODS

The medical records of patients diagnosed with TA between January 1997 and December 2014 were reviewed retrospectively. Renal artery involvement was based on computed tomography and/or angiography findings. Poor outcome was defined as refractory HTN, chronic renal insufficiency, or death.

RESULTS

Of the 62 TA patients with renal artery involvement, 11 (17.7%) underwent renal artery revascularization. Younger age, male sex, and more severe stenosis (> 70%) were associated with vascular intervention. After a median followup of 90.6 months, 11 (17.7%) of the 62 patients had refractory HTN and 6 (9.7%) had chronic renal insufficiency. Renal insufficiency [5/15 (33.3%) vs 3/47 (6.4%), p = 0.016] and bilateral involvement [12/15 (80.0%) vs 23/47 (48.9%), p = 0.041] were significantly more frequent in patients with poor than good outcomes. Multivariate Cox analysis revealed that renal insufficiency at presentation (HR 13.778, 95% CI 3.530-53.786, p < 0.001) and bilateral renal artery involvement (HR 5.053, 95% CI 1.179-21.661, p = 0.029) were significant risk factors for poor outcomes at followup, but performance of revascularization procedure was not (HR 0.663, 95% CI 0.176-2.498, p = 0.543).

CONCLUSION

Bilateral lesions and renal functional impairment at presentation, but not implementation of revascularization procedures, were significant factors for outcomes in TA patients with renal artery involvement.

Late-onset IgA vasculitis in adult patients exhibits distinct clinical characteristics and outcomes

OBJECTIVES

The aim of this study was to determine whether adult IgA vasculitis patients who developed the disease at an older age differ from early-onset patients in terms of clinical features and outcomes.

METHODS

All consecutive adult patients who were diagnosed with IgA vasculitis between January 1997 and December 2014 were reviewed retrospectively. Patients who developed the disease at an older age (≥60 years; late-onset) were compared with those with an earlier onset of disease (<60 years; early-onset). Renal insufficiency was defined as an estimated glomerular filtration rate <60 ml/minute.

RESULTS

In total, 100 adult patients were diagnosed with IgA vasculitis (mean age, 45.61 ± 17.24 years), of whom 31 (31%) had late-onset disease. Compared to early-onset patients, late-onset patients were less likely to have a preceding upper respiratory tract infection (0/31, 0.0% vs. 14/69, 20.3%; p=0.004), and more likely to have renal involvement at presentation (27/31, 87.1% vs. 43/69, 62.3%; p=0.017). At the last follow-up visit, late-onset patients were more likely to have chronic renal insufficiency, including end-stage renal disease (18/28, 64.3% vs. 7/62, 11.3%; p=0.000). Multivariate Cox analysis revealed that late-onset was a significant risk factor for renal insufficiency at follow-up (hazard ratio, 16.980, 95% confidence intervals, 4.380-65.830; p=0.000).

CONCLUSIONS

Patients with late-onset IgA vasculitis in adults exhibit distinct clinical features characterized by greater renal involvement and worse renal outcomes. Thus, watchful follow-up might be needed for adult IgA vasculitis patients, in particular those with late-onset disease.