Outcome of refractory to conventional and/or biologic treatment adult Still's disease following canakinumab treatment: Countrywide data in 50 patients

OBJECTIVE

To assess the efficacy and safety of the IL-1b inhibitor canakinumab in all adults with refractory Still's disease identified from the National Organization For Medicines for off-label drug use.

METHODS

In a retrospective longitudinal multicenter cohort of 50 patients (median age 39 years) with active Still's disease despite treatment with corticosteroids (n = 11), conventional and synthetic (n = 34) and/or biologic disease modifying anti-rheumatic drugs (n = 30), we assessed the efficacy of canakinumab 150-300 mg administered every 4 (n = 47) or 8 weeks (n = 3) as combination therapy or monotherapy (n = 7) during a median follow-up of 27 (3-84) months.

RESULTS

Α complete response was initially observed in 78% of patients within 3 months (median), irrespective of age at disease onset. A partial response was evident in 20%. One patient had resistant disease. Treatment de-escalation was attempted in 15 of 39 complete responders and a complete drug discontinuation in 21 patients for 8 months (median). Eleven patients (22%) relapsed during treatment, one during de-escalation process, and 11 after treatment discontinuation. Overall, 9 of 11 relapses were successfully treated with canakinumab treatment intensification or re-introduction. At last visit, 18% of patients were off treatment due to remission and 26% due to disease activity. Canakinumab had a significant corticosteroid sparing effect allowing weaning in 21 of 41 cases. Infections (20%, severe 4%) and leucopenia (6%) led to treatment cessation in one patient.

CONCLUSION

High rates of sustained remission were observed in this, largest so far, real-life cohort of adult patients with refractory Still's disease treated with canakinumab.

FRI0493 THE INTERLEUKIN-1B INHIBITOR CANAKINUMAB FOR REFRACTORY STILL’S DISEASE: LONG-TERM EXPERIENCE IN 50 CONSECUTIVE PATIENTS

Background:

Interleukin-1 (IL-1) is a major mediator of the inflammatory cascade in Still’s disease and an established therapeutic target.

Objectives:

To assess the efficacy and safety of the IL-1b inhibitor canakinumab in adolescent and adult patients with refractory Still’s disease.

Methods:

We conducted a retrospective longitudinal outcome study of 50 consecutive patients aged 39 years (median, range 14-72), fulfilling the Yamaguchi disease classification criteria, with active disease despite treatment with corticosteroids (CS) (n=11) and/or methotrexate (n=9) and/or biologics (n=30) [tumor necrosis factor inhibitors (n=13), IL-6 blockade (n=7), abatacept (n=2), anakinra (n=24); ≥1 biologics (n=13)]. Canakinumab 150-300 mg was administered sc, starting every 4 (n=48) or 8 weeks (n=2), for a median of 24 months (range 3-84). Concomitant treatment included CS (n=41), methotrexate (n=12) and leflunomide (n=3).

Results:

Complete remission was initially achieved in 78% of patients within a median time of 3 months, irrespective of age at disease onset. Partial clinical and laboratory response was evident in 20%. Canakinumab was discontinued in one patient with resistant disease (primary failure) and in 6 out of 10 initial responders, who relapsed during treatment (secondary failure). Of 39 patients in complete remission, increase in drug administration interval and/or drug dose reduction was attempted in 7, of which only 1 relapsed, whereas drug discontinuation was attempted in 19 patients for a median time of 8 months (range 3-68), of which 8 relapsed. Overall, in half of all disease flares, canakinumab re-introduction or intensification was successful. Canakinumab had a significant CS sparing effect permitting weaning in 21 of 41 cases. Infections (20%, severe 4%) and leucopenia (6%) led to treatment cessation in one patient.

Conclusion:

In this largest so far real-life patient cohort with refractory Still’s disease, high rates of sustained remission were induced by canakinumab both in adolescent and adult patients.

Disclosure of Interests:

Katerina Laskari: None declared, Panagiotis Athanassiou Grant/research support from: MSD, Genesis pharma, Janssen, Consultant of: Roche, Genesis pharma, Janssen, Speakers bureau: MSD, Janssen, Roche, Genesis pharma, Athanasios Georgiadis: None declared, Charalampos Gerodimos: None declared, Georgia Gkoni: None declared, Dimitrios Daoussis: None declared, Theodoros Dimitroulas: None declared, Despoina Dimopoulou: None declared, Chrysoula Iliou: None declared, Ioannis Kallitsakis Grant/research support from: MSD, Speakers bureau: Genesis pharma, Bristol-Myers Squibb, Dimitrios Karamitsos: None declared, Christina Katsiari: None declared, Stamatis-Nick Liossis: None declared, Clio Mavragani: None declared, CHARALAMPOS PAPAGORAS: None declared, Dimitrios Pikazis: None declared, Ioannis Raftakis: None declared, Theodosios Sarikoudis: None declared, Loukas Settas: None declared, Prodromos Sidiropoulos: None declared, Despoina Soukera: None declared, Evangelos Theodorou: None declared, Panagiota Tsatsani: None declared, Eleni Tsiakou: None declared, Dimitrios Vassilopoulos: None declared, PANAYIOTIS VLACHOYIANNOPOULOS: None declared, Georgios Vosvotekas: None declared, Paraskevi V. Voulgari: None declared, Marina Zakalka: None declared, Maria Tektonidou Grant/research support from: AbbVie, MSD, Novartis and Pfizer, Consultant of: AbbVie, MSD, Novartis and Pfizer, Petros Sfikakis Grant/research support from: Grant/research support from Abvie, Novartis, MSD, Actelion, Amgen, Pfizer, Janssen Pharmaceutical, UCB

FRI0147 PREVALENCE OF COMORBIDITIES IN ANTIPHOSPHOLIPID SYNDROME VERSUS RHEUMATOID ARTHRITIS: A MULTICENTRE, AGE- AND SEX-MATCHED STUDY

Background:

Comorbidities in rheumatic diseases (RDs) have been associated with increased morbidity and mortality. Evidence on prevalence of comorbidities in antiphospholipid syndrome (APS) and its difference from high comorbidity burden RDs is limited.

Objectives:

To compare the prevalence of common comorbidities between APS [primary (PAPS) and Systemic lupus erythematosus (SLE)-APS] and Rheumatoid arthritis (RA) patients.

Methods:

326 APS patients from the Greek registry (237 women, mean age 48.7±13.4 years, 161 PAPS) were matched 1:2 for age and sex with 652 RA patients from Greek RA Registry. Prevalence of cardiovascular (CV) risk factors, stroke, coronary artery disease (CAD), osteoporosis, diabetes mellitus (DM), Chronic obstructive pulmonary disease (COPD), depression and neoplasms were compared between APS and RA using logistic regression analysis.

Results:

Regarding CV burden, hyperlipidemia and obesity (ΒMI≥30) were comparable while hypertension, smoking, CAD and stroke were more prevalent in APS compared to RA patients (Table 1). Osteoporosis and depression were more frequent in APS while DM, COPD and neoplasms were comparable between two groups. Comparison of APS subgroups to 1:2 matched RA patients revealed that smoking and stroke were more prevalent in PAPS and SLE-APS vs RA. Hypertension, CAD and osteoporosis were more prevalent only in SLE-APS vs. RA while DM was less prevalent in PAPS vs. RA patients.

Table 1.

Comparison of comorbidities between Antiphospholipid syndrome (APS) vs. matched Rheumatoid Arthritis (RA) patients and between primary APS (PAPS) or Systemic Lupus Erythematosus-APS (SLE-APS) vs matched RA patients

APSRAOR*PAPSRAORSLE-APSRAORn (%)326652161322165330Hypertension97 (29.8)136 (21)1.61 (1.19-2.18)40 (25)75 (23.3)1.09 (0.70-1.69)57 (34.6)61 (18.5)2.33 (1.52-3.56)Smoking175 (53.7)264 (40.5)1.70 (1.30-2.22)87 (54)142 (44)1.49 (1.02-2.18)88 (53.3)122 (37)1.95 (1.33-2.85)Hyperlipidemia79 (24.2)135 (20.7)1.23 (0.89-1.68)40 (24.8)62 (19.3)1.39 (0.88-2.18)39 (23.6)73 (22)1.09 (0.70-1.70)Obesity48 (20.5)105 (19.5)1.06 (0.73-1.56)20 (17)51 (19)0.86 (0.49-1.52)28 (24)54 (19.7)1.28 (0.76-2.15)Stroke±66 (20.3)9 (1.4)13.8 (6.5-29.1)36 (22.4)4 (1.2)19.9 (6.6-59.9)30 (18.2)5 (1.5)7.8 (2.7-22.6)Coronary disease±16 (4.9)13 (2)3.14 (1.17-8.45)2 (1.2)7 (2.2)0.46 (0.04-4.77)14 (8.5)6 (1.8)10.9 (2.7-44.3)Osteoporosis×66 (20.3)92 (14)1.45 (1.01-2.06)19 (11.8)42 (13)0.96 (0.54-1.73)47 (28.5)50 (15)1.91 (1.20-3.05)Diabetes×18 (5.5)58 (9)0.58 (0.33-1.01)5 (3)29 (9)0.34 (0.13-0.89)13 (8)29 (9)0.88 (0.44-1.79)COPD≠11 (3.4)14 (2.2)1.26 (0.56-2.84)3 (1.9)6 (2)0.96 (0.23-4.0)8 (5)8 (2.4)1.28 (0.44-3.72)Depression#53 (16.3)66 (10)1.70 (1.15-2.53)23 (14)30 (9.3)1.69 (0.93-3.05)30 (18.2)36 (10.9)1.65 (0.96-2.84)Neoplasms˅14 (4.3)27 (4.1)1.05 (0.54-2.06)5 (3)12 (3.7)0.84 (0.28-2.52)9 (5.5)15 (4.6)1.31 (0.55-3.1)

*OR: Odds ratio, crude or adjusted for:

 ± age, sex, smoking, hypertension, hyperlipidemia, BMI, corticosteroid (Cs) duration

 × Cs duration

 ≠ smoking, Cs duration

 #sex, disease duration, Cs duration

 ˅ age, disease duration

Conclusion:

Comorbidity burden in APS (PAPS and SLE-APS) is comparable or even higher to that in RA, entailing a high level of diligence for CV risk prevention, awareness for depression and corticosteroid exposure minimization.

Disclosure of Interests:

Stylianos Panopoulos: None declared, Konstantinos Thomas: None declared, Georgios Georgiopoulos: None declared, Dimitrios Boumpas Grant/research support from: Unrestricted grant support from various pharmaceutical companies, Christina Katsiari: None declared, George Bertsias Grant/research support from: GSK, Consultant of: Novartis, Alexandros Drosos: None declared, Kyriaki Boki: None declared, Theodoros Dimitroulas: None declared, Alexandros Garyfallos Grant/research support from: MSD, Aenorasis SA, Speakers bureau: MSD, Novartis, gsk, Charalambos Papagoras: None declared, PELAGIA KATSIMPRI: None declared, Apostolos Tziortziotis: None declared, Christina Adamichou: None declared, Evripidis Kaltsonoudis: None declared, Evangelia Argyriou: None declared, GEORGIOS VOSVOTEKAS Grant/research support from: MSD, Janssen, Consultant of: MSD, Novartis, Roche, UCB pharma, Bristol-Myers Squibb, AbbVie, Speakers bureau: UCB pharma, Menarini, Bristol-Myers Squibb, MSD, Petros Sfikakis Grant/research support from: Grant/research support from Abvie, Novartis, MSD, Actelion, Amgen, Pfizer, Janssen Pharmaceutical, UCB, Dimitrios Vassilopoulos: None declared, Maria Tektonidou Grant/research support from: AbbVie, MSD, Novartis and Pfizer, Consultant of: AbbVie, MSD, Novartis and Pfizer

Anti-C1q autoantibodies are frequently detected in patients with systemic sclerosis associated with pulmonary fibrosis

BACKGROUND

Anti-C1q autoantibodies (autoAbs) are associated with systemic lupus erythematosus (SLE), but their presence in other rheumatic diseases has not been adequately investigated.

OBJECTIVES

We aimed to assess anti-C1q autoAbs and circulating immune complexes (CICs) in systemic sclerosis (SSc).

METHODS

In total 124 patients with SSc were studied; 106 were female and the median age was 59·4 years (range 25-81·4). Overall 75 (60·5%) had limited cutaneous SSc and 49 (39·5%) had diffuse cutaneous SSc. Also included were 25 patients with Sjögren syndrome (SjS), 29 with rheumatoid arthritis (RA), 38 with SLE and 53 healthy controls. Enzyme-linked immunosorbent assays with high- and low-salt buffers were used to measure anti-C1q antibodies and CICs. The former allows only anti-C1q antibody binding to C1q and the latter also allows IgG Fc to bind to C1q.

RESULTS

Anti-C1q antibodies were present in 20 of 124 (16·1%) patients with SSc: five had high levels (> 80 RU mL^-1 ) and 10 (50%) had moderate levels (40-80 RU mL^-1 ). Anti-C1q antibodies were also present in one of 25 (4%) patients with SjS, one of 29 (3%) with RA (P < 0·05 for both) and three of 53 (6%) healthy controls (P < 0·01). Anti-C1q antibodies were detected in 13 of 38 (34%) patients with SLEs. Anti-C1q antibodies were more frequent in male than female patients with SSc (P = 0·005); this association remained after multivariate regression analysis. Anti-C1q antibody level was the most important factor in predicting the presence of pulmonary fibrosis, and the second most important in predicting pulmonary arterial hypertension. Fourteen patients with SSc (11·3%) had CICs.

CONCLUSIONS

Anti-C1q autoAbs were frequently detected in patients with SSc, and their high levels predict the co-occurrence of pulmonary fibrosis or pulmonary arterial hypertension.

Cadherin-11 mRNA transcripts are frequently found in rheumatoid arthritis peripheral blood and correlate with established polyarthritis

Rheumatoid arthritis (RA) synovial fibroblasts hyperexpress the mesenchymal cadherin-11, which is involved also in tumor invasion/metastasis, whereas anti-cadherin-11 therapeutics prevent and reduce experimental arthritis. To test the hypothesis that cadherin-11 is aberrantly expressed in RA peripheral blood, 100 patients (15 studied serially) and 70 healthy controls were analyzed by real-time reverse transcription-PCR. Cadherin-11 mRNA transcripts were detected in 69.2% of moderately/severely active RA, versus 31.8% of remaining patients (p=0.001), versus 17.1% of controls (p<0.0001). Notably, cadherin-11 positivity correlated significantly and independently only with established (>1year) polyarthritis (>4 swollen tender joints), by multivariate logistic regression analysis including various possible clinical/laboratory factors. Rare cells of undefined nature, detected by flow cytometry following CD45(-) enrichment, strongly expressed surface cadherin-11 (estimated 10-50cells/ml of blood) in 5/6 patients with polyarticular established disease versus 1/6 patients with early RA. Studies on the potential pathogenic role of circulating cells expressing cadherin-11 in RA are warranted.

Aortic stiffness in systemic sclerosis is increased independently of the extent of skin involvement

OBJECTIVE

To study the stiffness of large arteries in relation to the extent of skin and lung fibrosis, aortic distensibility was examined in patients with diffuse and limited systemic sclerosis (SSc).

METHODS

Consecutive patients (55 with diffuse and 51 with limited SSc) without signs and symptoms of heart failure or a previous history of arterial hypertension underwent echocardiography and lung function tests. Aortic stiffness was determined non-invasively by aortic distensibility and aortic strain measurements in all patients and in 50 healthy subjects, matched for age and gender.

RESULTS

Aortic distensibility in patients with either diffuse (2.03 +/- 0.26 x 10(-6) cm(2) dyn(-1)) or limited SSc (2.12 +/- 0.33) was similarly decreased compared with controls (2.49 +/- 0.36, P<0.001). Moreover, aortic strain was significantly reduced in both patient groups compared with controls, confirming that aortic stiffness is increased in SSc independently of the extent of skin involvement. Left ventricular performance was similar between patients and controls, while left ventricular mass and tricuspid systolic gradient were significantly increased in both SSc groups, the latter being associated with aortic stiffness in multivariate analysis. No association with serum levels of C-reactive protein or lung function abnormalities indicative of pulmonary fibrosis were found.

CONCLUSIONS

Stiffness of the aorta is increased in patients with established SSc regardless of the extent of the inflammatory fibrotic process in the skin and lungs, suggesting that additional pathogenetic mechanisms contribute to the compromise of large arteries.