AB0571 DERIVATION AND INDEPENDENT VALIDATION OF THE LUPUS ARTHRITIS AND MUSCULOSKELETAL DISEASE ACTIVITY SCORE (LAMDA): A MORE SENSITIVE, SPECIFIC AND RESPONSIVE TOOL FOR LUPUS ARTHRITIS

Background

The MSK components of the BILAG and SLEDAI have limited sensitivity, specificity and responsiveness.

Objectives

To develop a better disease activity tool for MSK lupus.

Methods

“LAMDA” was derived using data from the multicentre USEFUL study (PMID:33792659); 133 patients with inflammatory MSK pain received intramuscular depomedrone then were assessed for 66/68 SJC/TJC, BILAG-2004, SLEDAI-2K, physician MSK-VAS, inflammatory markers, patient pain and disease-activity-VAS and MSK-ultrasound. Baseline variables were modelled against US using penalized (Lasso) regression. For validation we evaluated: (i) responsiveness at week 6 in USEFUL and (ii) association with quality of life and treatment decision in an independent study (n=100).

Results

LAMDA was a composite of SJC, patient-MSK-pain-VAS, physician-MSK-disease-activity-VAS and ESR ranging from 0 to 26.5. Response effect size was greater for the LAMDA (0.37) than the BILAG-MSK (0.31), SLEDAI-MSK (0.27) and total US score (0.33). With active US at baseline, LAMDA’s effect size was 0.42.

In the validation study LAMDA score correlated with better physical function (R = -0.49, p<0.001), pain (R = -0.44, p=0.002) and Burden to Others (R = -0.38, p=0.009). LAMDA was higher when therapy was increased (mean (95% CI) difference 12.9 (5.8, 19.9), p<0.001).

Conclusion

LAMDA is a continuous disease activity instrument for MSK lupus that is sensitive to imaging-synovitis without swelling, more responsive than other instruments and correlates with quality of life and treatment decision. LAMDA may improve the ability of clinicians to monitor and treat MSK lupus, and determine the efficacy of therapies in clinical trials.

Acknowledgements

Funding: Lupus UK and NIHR

Disclosure of Interests

Khaled Mahmoud: None declared, Ahmed Zayat: None declared, Md Yuzaiful Md Yusof: None declared, Lee-Suan Teh: None declared, Shah Khan: None declared, Chee-Seng Yee: None declared, David D’Cruz: None declared, Nora Ng: None declared, David Isenberg: None declared, Coziana Ciurtin: None declared, Philip G Conaghan: None declared, Paul Emery: None declared, Christopher John Edwards: None declared, Elizabeth Hensor: None declared, Edward Vital Speakers bureau: GSK, AstraZeneca, Consultant of: GSK, AstraZeneca, Roche, Aurinia, Lilly, ILTOO, Novartis, Grant/research support from: AstraZeneca, Sandoz

POS0893 FACTORS TO CONSIDER FOR MEASURING THE EFFECT OF LUNG FUNCTION ON PATIENT REPORTED OUTCOMES IN SYSTEMIC SCLEROSIS PATIENTS: ANALYSIS OF THE EUSTAR DATABASE

Background

Patient Reported Outcomes (PROs) are central to measure how patients feel and function especially when determining the effect of disease modifying agents. In patients with Systemic Sclerosis associated Interstitial Lung Disease (SSc-ILD), dyspnea is the main driver of HAQ decline but the effect of reduced lung function on both generic and specific measures of functional impairment is not well defined, and there are many potential confounding biases that could distort the apparent extent and direction of this relationship. Moreover, collider biases potentially induced by selection into the cohort and in clinical trials can also play a role.

Objectives

To define within the EUSTAR database, the correlation of Forced Vital Capacity (FVC) and functional impairment PROs and identify potential confounders to be considered in casual inference studies.

Methods

A cross-sectional analysis included for each patient with SSc-ILD (by X-ray and/or HRCT) in the EUSTAR registry the last visit with at least one PRO (Health Assessment Questionnaire Disability Index [HAQ-DI], Cochin hand function scale [CHFS] and/or dyspnoea visual analogue scale [VAS]) and % predicted FVC (%pFVC), if available. Patients with LVEF≤50% or pulmonary arterial hypertension at RHC were excluded. SSc-ILD with restricted lung volume was defined as %pFVC≤70 [1]. Spearman’s correlation analysis was performed. Results of this analysis and literature review were integrated to design a directed acyclic graph (DAG) and identify the appropriate confounder adjustment set for the total causal effect of FVC on functional impairment PROs.

Results

Among 17.338 SSc patients in the EUSTAR registry (extracted in November 2019), 727 SSc-ILD patients fulfilled the inclusion criteria (median %pFVC 90 (IQR 74-104), median %pDLCO 60 (IQR 47-52)). Patients with %pFVC<70 (n=149), as compared to those with %pFVC≥70 (n=578) had worse HAQ-DI, CHFS and VAS-dyspnoea scores (Table 1). In unadjusted analysis, %pFVC showed a weak correlation with HAQ-DI (r=-0.21) and CHFS (r=-0.17), but a stronger correlation with VAS dyspnoea (r=-0.33).

Table 1.

Results are reported as number/number available (%) for dichotomic variables, or as median (IQR) (n available) for continuous variables.

%pFVC≥70 (n=578)%pFVC<70 (n=149)Age at disease onset (years)60.6 (52.3-69.3) (546)52.5 (45.6-63-7) (137)Disease duration (months)134.4 (77.5-212.2) (546)110.3 (66.3-199.7) (137)Male sex84/578 (14.5)32/149 (21.5)Anti-Scl70+231/468 (40.7)81/122 (66.4)Smoker ever52/389 (13.4)17/107 (15.9)Caucasian ethnicity545/569 (95.8)131/145 (90.3)dcSSc167/559 (29.9)74/147 (50.3)Oesophageal symptoms319/571 (55.9)93/147 (63.3)Muscle weakness78/565 (13.8)37/149 (24.8)CRP elevation141/540 (26.1)53/134 (39.6)Elevated sPAP (ECHO)45/456 (9.9)21/121 (17.2)Pericardial effusion2/448 (0.4)4/110 (3.6)Diastolic function abnormality151/431 (35.0)31/102 (30.4)Conduction blocks78/480 (16.3)35/120 (29.2)%pDLCO62 (52-74) (527)42 (35-53) (118)CHFS7 (1-23) (493)16 (2-34.8) (114)HAQ-DI0.63 (0.13-1.13) (578)1.25 (0.38-2) (139)VAS dyspnoea (0-100)15 (10-45) (391)40 (20-70) (109)NYHA stage 3/447/561 (8.4)37/143 (25.9)

Subsequently, we created a DAG showing the proposed causal pathway considered relevant to the relationship between FVC and HAQ (Figure 1).

Conclusion

Lung function as measured by FVC appears to correlate with worse patient-reported function in our unadjusted analysis of the large multicentre EUSTAR dataset. However, to estimate the total causal effect we must consider a multitude of potentially confounding factors, which need to be integrated and analysed in a causal inference framework. The proposed DAG will inform the development of simulations of the potential impact of bias (confounding, collider and omitted variable) on effect estimates we could obtain from EUSTAR cohort.

References

[1]Goh NS, et al. Am J Respir Crit Care Med, 2008.

Disclosure of Interests

Maria Grazia Lazzaroni Grant/research support from: Research grant from Boehringer-Ingelheim, Michelle Wilson Grant/research support from: Research grant from Boehringer-Ingelheim, Elizabeth Hensor: None declared, Jörg H.W. Distler: None declared, Giovanna Cuomo: None declared, Elise Siegert: None declared, Ulf Müller-Ladner: None declared, Yannick Allanore: None declared, Maria Joao Salvador: None declared, Branimir Anic: None declared, Ulrich Walker: None declared, László Czirják: None declared, Camillo Ribi: None declared, Cristina-Mihaela Tanaseanu: None declared, Armando Gabrielli: None declared, Anna-Maria Hoffmann-Vold: None declared, Oliver Distler: None declared, Francesco Del Galdo: None declared

POS1269 THE UTILITY OF ULTRASOUND TO PREDICT PATIENT OUTCOMES IN SHOULDER PAIN: A PROSPECTIVE OBSERVATIONAL STUDY OF 500 PATIENTS

Background:

Shoulder pain is common and persistent, with a large socioeconomic burden. Ultrasound (US) scans are used for diagnosing and managing shoulder pain, but the extent to which it informs management and improves outcomes is unknown. A recent retrospective study identified groups with different patterns of US pathologies.

Objectives:

To confirm the existence of US-based groups of shoulder pain and determine if US-detected pathology (grouped or individual) predicts outcomes in the context of usual care. Response to local steroid injection was also evaluated.

Methods:

This was a 6 month, prospective, single centred, community based, observational cohort study. Inclusion: shoulder pain, ≥18 years, first shoulder US. Exclusion: shoulder surgery, inflammatory arthritis, steroid/physiotherapy in prior 6 weeks. Standardised reporting for 10 US pathologies was employed. Latent class analysis (LCA) identified pathology-based groups. Multiple linear regression analysis explored associations between baseline pathologies, subsequent treatment and 6-month Shoulder Pain and Disability Index (SPADI). Growth mixture modelling (GMM) identified groups with common trajectories of change.

Results:

Of 500 patients (mean age 53.6; 52% female), 330 completed follow-up. LCA identified 4 groups: bursitis without acromioclavicular joint degeneration (ACJD) (group 1), bursitis with ACJD (group 2), rotator cuff tear (group 3), no bursitis/tear (group 4). SPADI was higher at baseline for tears (55.1 vs. 49.7-51.3) (overall p=0.005), but groups did not differ at 6 months (p=0.379) (Table 1). No individual pathologies predicted 6-month outcomes. Response to baseline injection at week 2 did not differ between groups (p=0.423). GMM found 4 trajectories; the majority of patients followed trajectory 1 (little change), irrespective of US pathology group (79%, 77%, 87%, 70% of US groups 1-4 respectively) (Figure 1).

Conclusion:

This is the largest prospective study involving US of symptomatic shoulders, and the first to investigate groups with distinct patterns of US pathologies in predicting outcome. US-based classification of pathology (as groups or individually) did not predict 6-month outcomes with current treatments and there were no differences in short-term response to steroids between groups. The role of routine diagnostic US for shoulder pain needs consideration; it may be useful if evidence-based therapies for specific pathologies are established.

Table 1.

Predictors of SPADI score at 6 months

Baseline characteristicCoefficient* (95% CI), p-valuePathology group:Bursitis w/o ACJ degeneration (group 1)ReferenceBursitis with ACJ degeneration (group 2)0.08 (-5.15, 5.32), p=0.975RC tear (group 3)5.01 (-1.48, 11.50), p=0.130No bursitis, no RC tear (group 4)1.98 (-4.00, 7.96), p=0.516Injection at scan4.87 (0.40, 9.34), p=0.033Age, years-0.01 (-0.17, 0.15), p=0.898Female-1.51 (-5.42, 2.40), p=0.448Symptom duration, months0.00 (-0.04, 0.05), p=0.879Uses arms to rise from chair2.65 (-1.50, 6.81), p=0.210Physiotherapy before baseline-0.23 (-4.78, 4.31), p=0.9201 injection before baseline2.35 (-2.87, 7.56), p=0.377≥2 injections before baseline6.53 (-2.50, 15.57), p=0.156Total SPADI0.62 (0.35, 0.89), p<0.001Shoulder activity score-0.59 (-1.15, -0.04), p=0.037P-SEQ score-0.20 (-0.46, 0.07), p=0.141Brief IPQ score0.19 (-0.16, 0.54), p=0.298HADS score0.01 (-0.38, 0.41), p=0.947Constant**35.44 (29.50, 41.38), p<0.001

*Interpreted as unit difference in Rasch-transformed SPADI score per 1 additional unit of the independent variable **Estimated SPADI at 26 weeks in patients in the reference category for all categorical variables and with mean values for continuous covariates. ACJ=acromioclavicular joint; HADS=hospital anxiety and depression scale; IPQ=illness perception questionnaire; P-SEQ=pain self-efficacy questionnaire; RC=rotator cuff; SPADI=shoulder pain and disability index

Figure 1.

Trajectories of total SPADI over time by the pathology groups found and response to injections

Acknowledgements:

This research was funded by the National Institute for Health Research (NIHR) Leeds Biomedical Research Centre (BRC) and by a NIHR Doctoral Research Fellowship (GT; DRF-2016-09-159). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. This study was also part-funded through the Arthritis Research UK Leeds Experimental Osteoarthritis Treatment Centre (20083).

Disclosure of Interests:

None declared

OP0134 NOVEL INTERFERON GENE EXPRESSION SCORES PREDICT REFRACTORY SEVERE CUTANEOUS DISEASE FOLLOWING RITUXIMAB THERAPY IN SLE

Background:

We developed and validated two continuous interferon-stimulated gene (ISG) expression scores (IFN-Score-A and IFN-Score-B) that predict clinical outcomes in SLE. IFN-Score-A includes ISGs typically present in a global interferon signature while IFN-Score-B includes additional ISGs potentially responsive to multiple IFN subtypes [1].

We have previously shown that these scores associate with treatment response following rituximab (RTX) therapy within the British Isles Lupus Assessment Group (BILAG) Biologics Register (BILAG-BR), a UK wide study of patients treated with RTX for active SLE following cyclophosphamide and/ or mycophenolate mofetil treatment failure. Specifically, multivariable analysis showed higher baseline IFN-Score-B independently predicted BILAG response at 6 months post treatment [2].

We also showed that response of cutaneous lupus to RTX can be poor even when other organs respond well, and that interferons are enriched in the skin of patients with SLE where dysregulated keratinocytes are a source of IFNк [3]. MASTERPLANS is a consortium aimed at identifying therapeutic biomarkers in SLE.

Objectives:

To investigate how IFN-Score-A and -B associated with skin disease and response to RTX.

Methods:

Pre-treatment whole blood samples were collected in TEMPUS tubes from subjects undergoing first RTX treatment within BILAG-BR. IFN-Scores were derived using a custom Taqman array as previously described [1]. Clinical response was defined as improvement in BILAG-2004 disease activity, with a maximum of one domain showing persistent BILAG-2004 grade B disease, and no new BILAG grade A or B disease flares at 6 months. The mucocutaneous domain of BILAG was then analysed separately.

Results:

147 patients were studied, of whom 90 had follow up data available. Baseline BILAG-2004 grade A/B disease activity predominantly affected the mucocutaneous domain in 74/147 (50.3%), musculoskeletal in 61 /147 (41.5%) and renal domain 66/147 (37.4%).

At 6 months 59/90 (65.6%) achieved an overall treatment response. Responders showed significantly higher mean IFN-Score-B compared with non-responders (-1.8 vs -2.4, p = 0.04). Among those with active grade A/B BILAG-2004 mucocutaneous disease at baseline, 38/50 (76%) showed improvement within this domain at 6 months. However, among overall non-responders, 7/31 (22.6%) had new or residual BILAG-A mucocutaneous disease at 6 months post RTX, indicating it to be a substantial component of overall treatment failure. In contrast, persistent grade A musculoskeletal disease was seen in 9.7% of non-responders. BILAG-A mucocutaneous disease is characterised by severe manifestations including extensive rashes covering > 18% of body surface area, severe bullous lupus or panniculitis and disabling deep mucosal ulceration. Neither IFN-Score-A nor IFN-Score-B were significantly associated with the severity of mucocutaneous disease at baseline. However, individuals with persistent or new BILAG-A mucocutaneous disease at six months following RTX displayed significantly lower baseline IFN-Score-B than those with improving or residual less severe disease (-3.0 vs -2.1, p = 0.04) after RTX.

Conclusion:

Low IFN score-B status identified an endotype of severe mucocutaneous SLE which was resistant to RTX therapy in the BILAG-BR cohort. We previously showed that high IFN-score-B independently predicts overall therapeutic response to rituximab. Further work will aim to refine IFN status as overall and organ specific biomarkers in SLE.

References:

[1] El-Sherbiny et al., Sci. Rep. 2018; 8: 5793.

[2] Alase et al., ARD 2019;78:763-764

[3] Psarras et al., Nat Commun. 2020; 11: 6149

Acknowledgements:

We would like to thank the Medical Research Council, National Institute of Health Research, UK for funding the MASTERPLANS project

Disclosure of Interests:

Lucy Marie Carter: None declared, Adewonuola Alase: None declared, Zoe Wigston: None declared, Antonios Psarras: None declared, Agata Burska: None declared, Md Yuzaiful Md Yusof: None declared, Elizabeth Hensor: None declared, John Reynolds: None declared, Miriam Wittmann Consultant of: Abbvie, Celgene, Janssen, L’Oreal, Novartis and Pfizer, Ian N. Bruce Speakers bureau: GlaxoSmithKline, UCB Pharma, Consultant of: AstraZeneca, Eli Lilly, GlaxoSmithKline, ILTOO Pharma, MedImmune, Merck Serono, Grant/research support from: Genzyme Sanofi, GlaxoSmithKline, Edward Vital Consultant of: Roche, GSK and AstraZeneca, Grant/research support from: Roche, GSK and AstraZeneca

POS0746 THE ARTHRITIS COMPONENT OF THE SLEDAI SHOULD ONLY BE SCORED IF THERE IS JOINT SWELLING

Background:

SLE disease activity tools do not optimally define disease activity and response. The SLEDAI arthritis item is common, and sufficient to define SRI response. Lupus patients with arthralgia often have no swelling. Glossary definitions of arthritis in different versions of the SLEDAI have included: swelling, swelling between visits, effusion, tenderness, warmth and erythema. MSK ultrasound in SLE can identify synovitis without swelling, ultrasound synovitis is associated with worse symptoms and serology, predicts response to therapy, and is more responsive to therapy than clinical variables.

Objectives:

To validate different glossary definitions for SLEDAI arthritis using musculoskeletal ultrasound.

Methods:

We analysed baseline data from a multicentre longitudinal study. Physicians scored SLEDAI-2K in 133 patients with joint pain that was considered inflammatory, but not necessarily swelling. Stable immunosuppressants and prednisolone <=5mg were permitted. If the arthritis criterion was scored, we asked physicians to report which glossary features drove their decision. Musculoskeletal ultrasound of hands and wrists was performed on the same day, blinded to clinical findings. We defined abnormal grey-scale in joints as 1 joint with GS>=2, and in tendons as >=1 tendon with GS >=1, and abnormal power Doppler as >=1 joint or tendon with PD >=1.

Results:

78/133 patients had arthritis scored on SLEDAI-2K. In 21/78, swelling was not a reason for that decision. These 21 patients had either tenderness (16/21), swelling reported between visits (4/21) or both of these (1/21). No patient was scored for warmth, erythema or effusion alone. Comparison of SLEDAI definitions and ultrasound is shown in Table 1. Of 57 patients with SLEDAI arthritis scored due to swelling, 90% had an abnormal ultrasound. The positive predictive value was 89% (95% CI 79 – 94). Of 21 patients with SLEDAI arthritis scored without swelling, 48% had an abnormal ultrasound. The positive predictive value was 48% (95% CI 31 – 67). There was no substantive difference in clinical and serological variables comparing patients with SLEDAI arthritis without swelling and patients without SLEDAI arthritis. In contrast, patients with SLEDAI arthritis with swelling had worse ESR (p=0.0003), Physician MSK disease activity VAS (p<0.001) and patient EMS VAS (p=0.0019) and IgG (p=0.0625) compared to the other two groups.

Conclusion:

Although ultrasound proven synovitis in the absence of swelling is not uncommon, it is not reliably identified using other signs or symptoms. The arthritis item of the SLEDAI was likely to be associated with ultrasound synovitis if scored because of swelling, but not if scored because of tenderness or swelling between visits. Our results support raising the threshold criteria for arthritis so that it should only be scored when there is joint swelling. Previous clinical trial datasets could be re-analysed excluding SLEDAI arthritis scores not confirmed by a swollen joint count greater than one.

SLEDAI-2K at baselineUltrasound Abnormalities at BaselineTest statistics for any ultrasound abnormalityGS jointsn/N (%)PD jointsn/N (%)GS tendonsn/N (%)PD tendonsn/N (%)Any abnormalityn/N (%)Sensitivity% (95% CI)Specificity% (95% CI)PPV% (95% CI)NPV% (95% CI)All patients (n=133)77/133 (58)33/133 (25)36/133 (27)27/106 (20)83/133 (62)----MSK SLEDAI = No (n=55)20/55 (36)2/55 (4)9/55 (16)3/55 (6)22/55 (40)----MSK SLEDAI = Yes (n=78)57/78 (73)31/78 (40)27/78 (35)24/78 (31)61/78 (78)73 (62, 82)b66 (51, 78) b78 (70, 84) b60 (49, 69) b-Due to swelling (n=57)48/57 (84)28/57 (49)21/57 (37)19/57 (33)51/57 (90)61 (50, 71)c88 (75, 95) c89 (79, 94) c57 (50, 64) c-Without swelling (n=21)a9/21 (43)3/21 (14)6/21 (29)5/21 (24)10/21 (48)31 (16, 50) d75 (60, 87) d48 (31, 67) d60 (45, 68) d

Disclosure of Interests:

Khaled Mahmoud: None declared, Ahmed Zayat: None declared, Md Yuzaiful Md Yusof: None declared, Katherine Dutton: None declared, Lee-Suan Teh: None declared, Chee-Seng Yee: None declared, David d’cruz: None declared, Nora Ng: None declared, David Isenberg: None declared, Coziana Ciurtin: None declared, Philip G Conaghan: None declared, Paul Emery: None declared, Christopher John Edwards Shareholder of: Research grant support from; Abbvie, Biogen, Pfizer, Consultant of: Personal fee from; Abbvie, BMS, Biogen, Celgene, Celltrion, Fresenius, Gilead, GSK, Janssen, Lilly, Mundipharma, Pfizer, MSD, Novartis, Roche, Samsung, Sanofi, UCB, Grant/research support from: Research grant support from; Abbvie, Biogen, Pfizer, Elizabeth Hensor: None declared, Edward Vital Speakers bureau: AstraZeneca, Genentech, Aurinia, Lilly, Modus, Consultant of: AstraZeneca, Genentech, Aurinia, Lilly, Modus, Grant/research support from: Sandoz, AstraZeneca,

OP0179 USEFUL STUDY I: A MULTICENTRE LONGITUDINAL STUDY TO TEST WHETHER ULTRASOUND CAN IDENTIFY PATIENTS WITH MUSCULOSKELETAL SYMPTOMS OF LUPUS WITH BETTER RESPONSE TO THERAPY

Background:

In SLE, musculoskeletal manifestations impact on quality of life and trial outcomes. We previously showed that assessments based on joint swelling lack sensitivity, specificity and responsiveness compared to ultrasound (US).

Objectives:

To determine clinical features predicting US synovitis and whether patients with US synovitis respond better to therapy

Methods:

SLE patients were recruited if the referring physician deemed they had inflammatory pain warranting treatment. Swollen joints were not required. At baseline, physicians recorded features of inflammation, concurrent fibromyalgia and osteoarthritis. Stable doses of prednisolone (≤5mg/day), antimalarials or immunosuppressants were allowed. Participants received depomedrone 120mg IM then were assessed at 0, 2 and 6 weeks for 66/68 swollen and tender joint counts, BILAG-2004, SLEDAI-2K, physician global and MSK-VAS, inflammatory markers, patient pain and disease activity-VAS, HAQ-DI, LupusQoL, US of hands and wrists (blinded to patient and clinical assessor). An internal pilot determined the primary endpoint:(Early Morning stiffness-VAS (EMS-VAS) at 2 weeks (adjusted for baseline) between patients with US-synovitis (GS≥2 or PD≥1 in ≥1 joint) vs. normal US at baseline. 20% difference was considered clinically meaningful. Sensitivity analyses adjusted for prednisolone and immunosuppressants.

Results:

122/133 patients completed all visits. There was significant disagreement between clinical examination and US. 78/133 had US synovitis; 68% of these had ≥1 swollen joint. Of 66/133 patients with ≥ 1 swollen joint, 20% had normal US. US-synovitis was more likely with joint swelling, a symmetrical small joint distribution and active serology. Physician-determined EMS, other lupus features or prior response to therapy were not associated. Fibromyalgia or osteoarthritis did not reduce the probability of US synovitis.

In the full analysis set (n=133) there was no difference in EMS VAS at 2 weeks according to US synovial status at baseline (difference -8mm, 95% CI -19, 4mm, p=0.178). 32 patients had fibromyalgia. After excluding them, we found a statistically and clinically significantly better clinical response to depomedrone in patients with US-synovitis at baseline (baseline-adjusted EMS VAS at 2 weeks -12mm, 95% CI -24, 0mm, p=0.049). This difference was greater in the treatment-adjusted sensitivity analysis (-12.8 (95% CI -22, -3mm), p=0.007) and the per-protocol-adjusted sensitivity analysis (-14.8mm (95% CI -20.8, -8.8mm), p<0.001). Patient with US synovitis had higher rates of improvement in the MSK BILAG-2004 (56% vs. 26%, p=0.09) and SLEDAI-2K (37% vs. 15%, p=0.03).

Conclusion:

In lupus arthritis, distribution and serology, but not other features, help identify US-synovitis. US-synovitis was independent of features of fibromyalgia, but fibromyalgia confounded assessment of clinical response. US should be used to select SLE arthritis patients for therapy and clinical trials, especially when there are inflammatory symptoms without swollen joints.

Acknowledgments:

The Project was funded by Lupus-UK

Disclosure of Interests:

Khaled Mahmoud: None declared, Ahmed Zayat: None declared, Md Yuzaiful Md Yusof: None declared, Katherine Dutton: None declared, Lee-Suan Teh: None declared, Chee-Seng Yee: None declared, David d’cruz Grant/research support from: GlaxoSmithKline, Nora Ng: None declared, David Isenberg Consultant of: Study Investigator and Consultant to Genentech, Coziana Ciurtin Grant/research support from: Pfizer, Consultant of: Roche, Modern Biosciences, Philip G Conaghan Consultant of: AbbVie, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, GSK, Novartis, Pfizer, Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor), Christopher Edwards Grant/research support from: Abbvie, Biogen, Roche, Consultant of: Abbvie, Samsung, Speakers bureau: Abbvie, BMS, Biogen, Celgene, Fresenius, Gilead, Janssen, Lilly, Mundipharma, Pfizer, MSD, Novartis, Roche, Samsung, Sanofi, UCB, Elizabeth Hensor: None declared, Edward Vital Grant/research support from: AstraZeneca, Roche/Genentech, and Sandoz, Consultant of: AstraZeneca, GSK, Roche/Genentech, and Sandoz, Speakers bureau: Becton Dickinson and GSK

THU0522 DIFFERENCES IN MUSCLE PROPERTIES IN GCA PATIENTS COMPARED TO HEALTHY CONTROLS AS ASSESSED BY QUANTITATIVE MRI

Background:

Giant cell arteritis (GCA) is a systemic inflammatory vasculitis that often presents with headaches and visual symptoms. It is a medical emergency as it can lead to permanent sight loss. Prompt treatment with high doses of glucocorticoid therapy are often required. However, it has been shown that GCA patients on glucocorticoid therapy develop muscle weakness, known as glucocorticoid induced myopathy (1).

Quantitative MRI may be sensitive to detect the differences in muscle parameters between newly diagnosed GCA patients compared to healthy controls. MRI T2 is sensitive to fluid related to physiological changes at the molecular level, and is regarded as an indirect measure of muscle inflammation (2). MRI muscle fat fraction (FF) is useful for identifying myosteatosis (3). Diffusion tensor imaging (DTI) is sensitive to changes in muscle microstructure and may be useful in identifying changes to muscle fibres (4).

Objectives:

To obtain preliminary estimates of the extent to which quantitative MRI-based measurements of muscle T2, FF, DTI and volume differ between newly diagnosed GCA patients and healthy controls (HC) and how the muscle changes over 3- and 6-month intervals following glucocorticoid therapy.

Methods:

MRI of the mid-thigh were acquired using Dixon imaging to assess FF, Stimulated Echo Acquisition Mode echo planar imaging (STEAM-EPI) to measure diffusion, and a fat-suppressed multi-echo spin-echo to measure T2. Regions of interest were drawn around the quadriceps and hamstrings. All participants had knee extension and flexion torque measured on an isokinetic dynamometer, and isometric dynamometer to measure grip strength.

Results:

20 GCA patients (68.2±8.3 years, 14/20 female, mean ESR 26.9mm/h, mean CRP 39.6mg/L) were enrolled within 14 days of starting glucocorticoids: 15 returned at 3 months (mean ESR 17mm/h, mean CRP 5.7mg/L); 8 returned at 6 months (mean ESR 18 mm/h, mean CRP 6mg/L). 20 directly age- and gender-matched HC also were recruited. T2 and FF were higher and muscle volume lower in the GCA patients at baseline compared to HC (fig. 1 and 2). Within the hamstrings, the mean differences between GCA patients and HC for T2, FF and muscle volume were 2.2ms (95% CI 1, 4; p=0.09), 3.8% (95% 2, 5; p<0.001), and -166cm3 (95% CI 110, 210; p<0.001) respectively. There was no substantive difference in mean diffusivity or fractional anisotropy. Results in the quadriceps followed a similar trend. Following glucocorticoid treatment, there were no substantive changes in MRI measurements. Knee flexion/extension and handgrip strength were lower in the GCA patients at baseline compared to HC, with differences of -5.3Nm (95% CI -32.6, -7.4; p=0.003) and -4.4Nm (95% CI -56.7, -1.3; p=0.04) for flexion and extension respectively. Muscle strength did not change following glucocorticoid treatment.

Figure 1.

Quantitative MRI measurements of GCA patients and healthy controls in the hamstrings.

Conclusion:

This pilot study suggests for the first time that muscle health may be affected in newly diagnosed GCA patients compared to age and gender matched HC, as demonstrated by higher T2 and FF, and lower muscle volume and muscle strength. These preliminary results show that muscle changes may occur in the early stages of GCA and persist throughout the disease duration. If these findings are confirmed, it will be important to consider interventions to improve muscle health in the treatment pathway for GCA.

References:

[1]Proven A, et al. Arthritis and rheumatism. 2003;49(5):703-8.

[2]Maillard SM, et al. 2004;43(5):603-8.

[3]Grimm A, et al. The Journal of Frailty & Aging. 2018.

[4]Ran J, et al. 2016;263(7):1296-302.

Figure 2.

Quantitative muscle volume and muscle strength measurements of GCA patients and healthy controls.

Disclosure of Interests:

Matt Farrow: None declared, John Biglands: None declared, Steven Tanner: None declared, Elizabeth Hensor: None declared, Sarah Mackie Grant/research support from: Roche (attendance of EULAR 2019; co-applicant on research grant), Consultant of: Sanofi, Roche/Chugai (monies paid to my institution not to me), Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor), Ai Lyn Tan: None declared

FRI0599 USEFUL II: DERIVATION OF THE LUPUS ARTHRITIS AND MUSCULOSKELETAL DISEASE ACTIVITY SCORE (LAMDA) USING DATA FROM A MULTICENTRE LONGITUDINAL STUDY

Background:

Musculoskeletal (MSK) disease is the commonest manifestation of SLE. We showed that the MSK components of the BILAG index and SLEDAI have limited sensitivity, specificity and responsiveness compared to ultrasound (US) synovitis. The USEFUL study evaluated response to glucocorticoids in SLE patients with inflammatory pain.

Objectives:

To develop a disease activity tool for lupus MSK manifestations that is continuous, responsive, sensitive, and correlates with US-synovitis

Methods:

133 patients who received depomedrone 120mg IM were assessed at 0, 2 and 6 weeks for 66/68 swollen and tender joint counts, BILAG2004 index, SLEDAI-2K, physician global and MSK-VAS, inflammatory markers, patient pain and disease activity-VAS. Total US score (OMERACT-EULAR) in the hands and wrists was calculated blinded to patient and clinical assessor. Patients reported overall response using a Likert scale.

The LAMDA was developed by modelling a core set of clinical variables against total US score using penalized (Lasso) regression. Responsiveness was compared between LAMDA and other variables at week 6 using effect sizes. Minimum clinically important difference (MCID) was explored using the SEM and minimal disease activity threshold using ROC.

Results:

The variables selected for the LAMDA score were swollen joint count, patient MSK pain VAS, physician MSK disease activity VAS and ESR. A continuous score was derived. This had a theoretical range from 0 to 26.5 based on maximum ESR of 100. The highest value observed in USEFUL was 15. LAMDA was significantly higher in patients with active US (mean (SD) 5.71 (2.67), n=78) compared to patients with normal US (3.27 (1.77), n=55; difference (95% CI) -2.45 (-3.26, -1.63), t=-5.93, p<0.001). This difference remained significant in patients with no swollen joints (difference (95% CI) -0.71 (-1.40, -0.02), t=-2.06, p=0.044).

Effect size was greater for the LAMDA (0.37) than the BILAG-MSK (0.31), SLEDAI-MSK (0.27) and total US score (0.33). In patients with active US at baseline, LAMDA’s effect size was 0.42.

The MCID was 0.71 and correlated with patient-reported change in pain. A threshold for minimal disease activity of 3.23 optimized sensitivity (0.77 (0.65, 0.89)) and specificity (0.80 (0.68, 0.92)) against US score >0.

Conclusion:

The LAMDA score is a novel continuous disease activity instrument for MSK manifestations of SLE derived from variables familiar to rheumatologists. The LAMDA score is sensitive to imaging detected synovitis without swelling and more responsive than other instruments. . LAMDA may improve the ability of clinicians to accurately determine therapeutic efficacy in clinical trials and practice. Future work will validate the LAMDA score in independent cohorts and randomized trials.

Acknowledgements:

This project was funded by Lupus UK

Disclosure of Interests:

Khaled Mahmoud: None declared, Ahmed Zayat: None declared, Md Yuzaiful Md Yusof: None declared, Coziana Ciurtin Grant/research support from: Pfizer, Consultant of: Roche, Modern Biosciences, Chee-Seng Yee: None declared, David Isenberg Consultant of: Study Investigator and Consultant to Genentech, Lee-Suan Teh: None declared, Katherine Dutton: None declared, David d’cruz Grant/research support from: GlaxoSmithKline, Nora Ng: None declared, Philip G Conaghan Consultant of: AbbVie, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, GSK, Novartis, Pfizer, Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor), Christopher Edwards Grant/research support from: Abbvie, Biogen, Roche, Consultant of: Abbvie, Samsung, Speakers bureau: Abbvie, BMS, Biogen, Celgene, Fresenius, Gilead, Janssen, Lilly, Mundipharma, Pfizer, MSD, Novartis, Roche, Samsung, Sanofi, UCB, Elizabeth Hensor: None declared, Edward Vital Grant/research support from: AstraZeneca, Roche/Genentech, and Sandoz, Consultant of: AstraZeneca, GSK, Roche/Genentech, and Sandoz, Speakers bureau: Becton Dickinson and GSK

OP0332 MUSCLE DETERIORATION DUE TO RHEUMATOID ARTHRITIS: ASSESSMENT BY QUANTITATIVE MRI AND STRENGTH TESTING

Background:

As well as joint damage, rheumatoid arthritis (RA) is also associated with altered body composition known as rheumatoid cachexia (RC). RC is characterised by reduced skeletal muscle and increased (white) fat mass and decreased strength. RC is associated with increased disease severity and disability (1). It is unknown at what stage muscle involvement begins in RA, and if the muscle damage is modifiable when patients achieve disease control.

Quantitative MRI (qMRI) can measure the biomarkers associated with RC. MRI T2 is sensitive to fluid related to physiological changes at the molecular level, and is regarded as an indirect measure of muscle inflammation (2). MRI muscle fat fraction (FF) measurements are useful for identifying myosteatosis (3).

Objectives:

To obtain preliminary estimates of the extent to which muscle imaging phenotype differs between RA and healthy controls (HC); and to describe the RA phenotype at different levels of disease activity.

Methods:

39 RA patients (comprising three groups) and 13 age and gender directly matched HC had a MRI scan of their dominant thigh. The RA groups were:

[1]13 ‘New RA’ - newly diagnosed, treatment naïve

[2]13 ‘Active RA’ - diagnosed >1 year, persistent DAS28 >3.2 for >1 year

[3]13 ‘Remission RA’ - diagnosed >1 year, persistent DAS28 <2.6 for >1 year

MR images of the mid-thigh were acquired using Dixon imaging to assess FF and a fat-suppressed multi-echo spin-echo to measure T2. Regions of interest were drawn around the quadriceps and hamstrings. All participants had knee extension and flexion torque measured on an isokinetic dynamometer, and isometric dynamometer to measure grip strength. One-Way ANOVA with Dunnett’s post-hoc analysis provided preliminary indication of potential differences between T2, FF, muscle volume and strength measurements between the disease stages.

Results:

39 RA patients were recruited: 13 new RA (mean age [years] 63 ± 15, DAS28 5.2 ± 3), 13 active RA (mean age [years] 65 ± 10, DAS28 4.8 ± 3), 13 remission RA (mean age [years] 67 ± 19, DAS28 1.7 ± 0.7) and also 13 HC. T2 and FF were higher in RA patients compared to HC (fig. 1). Within the hamstrings for T2, the mean differences between HC versus new, active and remission patients were 4.5ms (95% CI 2.5, 6.4; p<0.001), 3ms (95% CI 1.1, 4.9; p=0.001), and 5.0ms (95% CI 3.0, 6.4; p<0.001) respectively. Quadriceps results were similar. For muscle volume, the mean differences between HC versus new, active and remission patients were -517.3cm3(95% CI -751, -283; p<0.001), -370.5cm3(95% CI -605, -136; p=0.001), and -312.3cm3(95% CI -546. -77; p=0.006) respectively (fig. 2). Knee flexion/extension and handgrip strength were lower in all 3 groups of RA patients compared to HC. For knee flexion, the mean differences between HC versus new, active and remission patients were 18.4Nm (95% CI -35, -1; p=0.03), 10.1Nm (95% CI -27, 7; p=0.3), and 13.3Nm (95% CI -33, 0; p=0.1) respectively.

Figure 1.

Quantitative T2 and FF MRI of RA patients and healthy controls

Conclusion:

This pilot study suggests muscle health may be adversely affected in RA patients compared to matched HC. Our results suggest that muscle changes occur in the earliest stages of RA and persist throughout the disease duration, even in clinical remission. If confirmed, these data imply the need for adjunctive muscle intervention to current RA treatment strategies in order to improve patient outcomes.

References:

[1]Giles JT, et al. Arthritis Care & Research. 2008

[2]Maillard SM, et al. Rheumatology (Oxford, England). 2004

[3]Grimm A, et al. The Journal of Frailty & Aging. 2018.

Figure 2.

MRI muscle volume in RA patients and healthy controls

Disclosure of Interests:

Matt Farrow: None declared, John Biglands: None declared, Steven Tanner: None declared, Elizabeth Hensor: None declared, Maya H Buch Grant/research support from: Pfizer, Roche, and UCB, Consultant of: Pfizer; AbbVie; Eli Lilly; Gilead Sciences, Inc.; Merck-Serono; Sandoz; and Sanofi, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor), Ai Lyn Tan: None declared

Disease-specific quality of life in multiple sclerosis: the effect of disease modifying treatment

Disease specific quality of life was measured in the Leeds Multiple Sclerosis (MS) Treatment Programme (n-/210) using the self-report Leeds MS Quality of Life (LMSQoL) scale. The results showed a significant and sustained increase in quality of life associated with ‘disease modifying’ treatment. This contrasts with the Expanded Disability Status Scores (EDSS), which showed no measurable improvement. An increase in the LMSQoL score did not correlate with baseline age, disease duration, disability or number of prior relapses. There was no significant difference in treatment effect between relapsing-remitting and secondary progressive MS patients, or between patients receiving different products. However, patients with a poor quality of life at baseline showed the most benefit from treatment. Those who had their treatment stopped due to progression, side-effects or lack of effect had significantly lower LMSQoL scores on treatment. In this study, the LMSQoL scale was responsive to change and was easy to administer in a clinical setting.

MRI and clinical findings in patients with ankylosing spondylitis eligible for anti-tumour necrosis factor therapy after a short course of etoricoxib

Objective:

To describe and assess the response to short-term etoricoxib as shown by MRI and clinical variables in patients with ankylosing spondylitis (AS) selected for eligibility for anti-tumour necrosis factor therapy.

Methods:

In a 6-week open-label study, 22 patients with AS and eligible for biological therapy were treated with 90 mg of etoricoxib daily. Clinical and laboratory parameters were obtained and MRI of the sacroiliac joints and the lower thoracic and lumbar spine performed at baseline and at week 6. The primary end point was the proportion of patients fulfilling the SpondyloArthritis international Society (ASAS) response criteria for biological therapies (ASASBIO) while secondary end points included the change in MRI-determined bone lesions.

Results:

Eight of 20 completers improved enough to meet the ASASBIO response criteria and most clinical variables improved significantly. Fifteen patients had a total of 63 MRI-detectable lesions; overall, 13/60 lesions with paired scans either resolved completely or improved, while five lesions worsened or appeared during treatment.

Conclusion:

Etoricoxib is an effective symptomatic treatment for patients with AS; however, its effect on MRI-detected lesions is small. Further studies are needed to determine the effect of etoricoxib on MRI-determined bone oedema.

The development of a preliminary ultrasonographic scoring system for features of hand osteoarthritis

OBJECTIVES

Painful osteoarthritis (OA) of the hand is common and a validated ultrasound (US) scoring system would be valuable for epidemiological and therapeutic outcome studies. US is increasingly used to assess peripheral joints, though most of the US focus in rheumatic diseases has been on rheumatoid arthritis. We aimed to develop a preliminary US hand OA scoring system, initially focusing on relevant pathological features with potentially high reliability.

METHODS

A group of experts in the fields of OA, US and novel tool development agreed on domains and suggested scaling of the items to be used in US hand OA scoring systems. A multi-observer reliability exercise was then performed to evaluate the draft items.

RESULTS

Synovitis (grey scale and Power Doppler) and osteophytes (representing activity and damage domains) were included and evaluated as the initial components of the scoring system. All three features were evaluated for their presence/absence and if present were scored using a 1-3 scale. The reliability exercise demonstrated intra-reader kappa values of 0.444-1.0, 0.211-1.0 and 0.087-1.0 for grey scale synovitis, power Doppler and osteophytes respectively. Inter-reader reliability kappa values were 0.398, 0.327 and 0.530 grey-scale synovitis, power Doppler and osteophytes respectively. Without extensive standardisation, both intra- and inter-reader reliability were moderately good.

CONCLUSIONS

The draft scoring system demonstrated substantive to almost perfect percentage exact agreement on the presence/absence of the selected OA features and moderate to substantive percentage exact agreement on semi-quantitative grading. This preliminary process provides a good basis from which to further develop an US outcome tool for hand OA that has the potential to be utilised in multicentre clinical trials.

The challenges of integrating ultrasonography into routine rheumatology practice: addressing the needs of clinical rheumatologists

OBJECTIVES

The practice of musculoskeletal ultrasonography (MSKUS) by UK rheumatologists remains limited, despite their reported enthusiasm. This study aimed to investigate factors that may encourage or limit future dissemination of rheumatologist-performed MSKUS and provide insights into perceived clinical importance and learning motivation relating to published recommendations by MSKUS experts.

METHODS

A written questionnaire study was conducted, involving 48 rheumatologists. Questions included the potential role of self-performed MSKUS, skills that they would be willing to learn and factors that may encourage or limit learning and practice. Competency recommendations proposed by imaging experts (142 skills in 7 anatomical areas) were reviewed, and quantitative and qualitative data collected regarding 'value to their practice' and 'learning motivation'.

RESULTS

Eighty-nine percent wished to learn MSKUS. Factors influencing learning and practice included time to achieve competency; relative-added clinical value of MSKUS examination; limited training infrastructure; access to existing imaging service; equipment funding. Skills offering greatest clinical utility were inflammatory arthritis assessment and guided procedures; least useful were evaluation of ligament/muscle lesions and soft tissue masses. There was a close correlation between clinical utility, learning motivation and competency standard.

CONCLUSIONS

A trade-off between added clinical value and time to achieve competency is the major factor influencing practice and training in MSKUS. Most rheumatologists report limited time to devote to training and therefore need to prioritize areas of importance for dedicated learning. Educational programmes need to be highly focused and relevant to clinical and job-plan requirements in order to encourage future dissemination of MSKUS practice by rheumatologists.

Presence of significant synovitis in rheumatoid arthritis patients with disease-modifying antirheumatic drug–induced clinical remission: Evidence from an imaging study may explain structural progression

OBJECTIVE

More timely and effective therapy for rheumatoid arthritis (RA) has contributed to increasing rates of clinical remission. However, progression of structural damage may still occur in patients who have satisfied remission criteria, which suggests that there is ongoing disease activity. This questions the validity of current methods of assessing remission in RA. The purpose of this study was to test the hypothesis that modern joint imaging improves the accuracy of remission measurement in RA.

METHODS

We studied 107 RA patients receiving disease-modifying antirheumatic drug therapy who were judged by their consultant rheumatologist to be in remission and 17 normal control subjects. Patients underwent clinical, laboratory, functional, and quality of life assessments. The Disease Activity Score 28-joint assessment and the American College of Rheumatology remission criteria, together with strict clinical definitions of remission, were applied. Imaging of the hands and wrists using standardized acquisition and scoring techniques with conventional 1.5T magnetic resonance imaging (MRI) and ultrasonography (US) were performed.

RESULTS

Irrespective of which clinical criteria were applied to determine remission, the majority of patients continued to have evidence of active inflammation, as shown by findings on the imaging assessments. Even in asymptomatic patients with clinically normal joints, MRI showed that 96% had synovitis and 46% had bone marrow edema, and US showed that 73% had gray-scale synovial hypertrophy and 43% had increased power Doppler signal. Only mild synovial thickening was seen in 3 of the control subjects (18%), but no bone marrow edema.

CONCLUSION

Most RA patients who satisfied the remission criteria with normal findings on clinical and laboratory studies had imaging-detected synovitis. This subclinical inflammation may explain the observed discrepancy between disease activity and outcome in RA. Imaging assessment may be necessary for the accurate evaluation of disease status and, in particular, for the definition of true remission.

The unmet need for anti-tumour necrosis factor (anti-TNF) therapy in ankylosing spondylitis

OBJECTIVES

Anti-tumour necrosis factor (anti-TNF) therapy is effective in the treatment of ankylosing spondylitis (AS), but guidelines are needed because of the cost. The primary aim of this study was to evaluate the proportion of patients with AS who meet the criteria for anti-TNF therapy as well as to explore the relationship between disease activity, health status and quality of life in patients with AS who would potentially meet the criteria compared with those who would not.

METHODS

All patients with a confirmed diagnosis of AS were identified via a search through the clinic correspondence database and sent postal questionnaires. Data captured included demographics, disease activity, aspects of functional impairment, activity limitation and quality of life using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), pain scores (using a visual analogue scale), the Bath Ankylosing Spondylitis Functional Index (BASFI), Health Assessment Questionnaire (HAQ), short-form 36 (SF-36) and the Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire. The unpaired Student's t-test, chi(2) test and Mann-Whitney U-test were performed for comparisons of groups where appropriate.

RESULTS

Out of 325 mailed questionnaires, 246 (76%) were returned. The mean age of the patients who replied to the questionnaire was 52 yr (+/-12 yr) and 25% (62) were females. Mean BASDAI was 49 (+/-24) and 64% had a BASDAI > or = 40. There were significant differences between the groups with a BASDAI above and below 40 in pain by VAS, functional ability (BASFI, HAQ), health status (SF-36) and quality of life (ASQoL). Almost two-thirds (64%) of patients would meet the criteria for anti-TNF therapy under recommended guidelines.

CONCLUSION

Patients with AS demonstrated poor functional status and poor quality of life. There is a large unmet need for effective therapy in AS, with almost two-thirds of patients meeting the proposed criteria for biological therapy. Patients with a BASDAI > or = 40 had a worse functional status and quality of life than those who have a BASDAI of <40. These results indicate that the need for effective intervention for AS is a priority area.

Infliximab in combination with methotrexate in active ankylosing spondylitis: a clinical and imaging study

OBJECTIVE

To examine the efficacy and safety of infliximab combined with methotrexate compared with methotrexate alone in the treatment of ankylosing spondylitis (AS) using MRI and DXA to monitor its impact on bone.

METHODS

In this single centre study 42 subjects with active AS were treated with methotrexate and were randomly assigned, in a ratio of 2:1, to receive five infusions of either 5 mg/kg infliximab or placebo over 30 weeks. The primary outcome was improvement in disease activity as shown by the BASDAI at week 30. MRI was used to assess the effect of treatments on sacroiliac and spinal enthesitis/osteitis and DXA to monitor bone mineral density.

RESULTS

Both therapeutic agents were well tolerated with no dropouts due to adverse events. A significantly greater improvement in mean BASDAI score was seen in the infliximab arm at week 10 (p = 0.017) than in the placebo arm, but this was not maintained by week 30 (p = 0.195), 8 weeks after the last infusion, at which stage disease flares were reported by some subjects. MRI showed that the mean number of lesions resolving for each subject from week 0 to week 30 was significantly greater in the combination group than in the methotrexate monotherapy group (p = 0.016).

CONCLUSIONS

Infliximab in combination with methotrexate was a safe and efficacious treatment in AS over 6 months and was associated with significant regression in enthesitis/osteitis as determined by MRI. However, disease flares were reported 8 weeks after the last infusion, indicating that addition of methotrexate failed to extend the infliximab dosing interval.