Anti-tumor necrosis factor α: originators versus biosimilars, comparison in clinical response assessment in a multicenter cohort of patients with inflammatory arthropathies

OBJECTIVE

To compare etanercept and adalimumab biosimilars (SB4 and ABP501) and respective bioriginators in terms of safety and efficacy in a real-life contest.

METHODS

We consequently enrolled patients affected by rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, treated with SB4, and ABP501, or with corresponding originators, belonging to the main biological prescribing centers in the Lazio region (Italy), from 2017 to 2020. Data were collected at recruitment and after 4, 8, 12, and 24 months of therapy.

RESULTS

The multicenter cohort was composed by 455 patients treated with biosimilars [SB4/ABP501 276/179; female/male 307/146; biologic disease-modifying anti-rheumatic drug (b-DMARD) naïve 56%, median age/ interquartile range 55/46-65 years] and 436 treated with originators (etanercept/adalimumab 186/259, female/ male 279/157, b-DMARD naïve 67,2%, median age/interquartile range 53/43-62 years). No differences were found about safety, but the biosimilar group presented more discontinuations due to inefficacy (p<0.001). Female gender, being a smoker, and being b-DMARD naïve were predictive factors of reduced drug survival (p=0.05, p=0.046, p=0.001 respectively). The retention rate at 24 months was 81.1% for bioriginators and 76.5% for biosimilars (median retention time of 20.7 and 18.9 months, respectively) (p=0.002). Patients with remission/low disease activity achievement at 4 months showed a cumulative survival of 90% to biosimilar therapy until 24 months (p=0.001); early adverse reactions instead represented a cause of subsequent drug discontinuation (p=0.001).

CONCLUSIONS

Real-life data demonstrated a similar safety profile between biosimilars and originators, but a reduced biosimilar retention rate at 24 months. Biosimilars could be considered a valid, safe, and less expensive alternative to originators, allowing access to treatments for a wider patient population.

Janus kinase inhibitors: between prescription authorization and reimbursability

Following the restrictions on the reimbursability of Janus kinase inhibitors introduced by the Italian Medicines Agency, the Italian Society of Rheumatology has drafted this document to shed light on the clinical conditions and reimbursability criteria set out in the prescription forms.

Factors Associated With Genotypic Resistance and Outcome Among Solid Organ Transplant Recipients With Refractory Cytomegalovirus Infection

Genotypically resistant cytomegalovirus (CMV) infection is associated with increased morbi-mortality. We herein aimed at understanding the factors that predict CMV genotypic resistance in refractory infections and disease in the SOTR (Solid Organ Transplant Recipients) population, and the factors associated with outcomes. We included all SOTRs who were tested for CMV genotypic resistance for CMV refractory infection/disease over ten years in two centers. Eighty-one refractory patients were included, 26 with genotypically resistant infections (32%). Twenty-four of these genotypic profiles conferred resistance to ganciclovir (GCV) and 2 to GCV and cidofovir. Twenty-three patients presented a high level of GCV resistance. We found no resistance mutation to letermovir. Age (OR = 0.94 per year, IC95 [0.089-0.99]), a history of valganciclovir (VGCV) underdosing or of low plasma concentration (OR= 5.6, IC95 [1.69-20.7]), being on VGCV at infection onset (OR = 3.11, IC95 [1.18-5.32]) and the recipients' CMV negative serostatus (OR = 3.40, IC95 [0.97-12.8]) were independently associated with CMV genotypic resistance. One year mortality was higher in the resistant CMV group (19.2 % versus 3.6 %, p = 0.02). Antiviral drugs severe adverse effects were also independently associated with CMV genotypic resistance. CMV genotypic resistance to antivirals was independently associated with a younger age, exposure to low levels of GCV, the recipients' negative serostatus, and presenting the infection on VGCV prophylaxis. This data is of importance, given that we also found a poorer outcome in the patients of the resistant group.

Patients with systemic lupus erythematosus and their experience with vaccination against COVID-19: a descriptive and explanatory study

Not available

POS1266 MULTICENTER RETROSPECTIVE STUDY EVALUATING THE SAFETY OF ANTI-SARS-CoV-2 VACCINE IN A COHORT OF PATIENTS WITH SYSTEMIC VASCULITIS

Background

Vaccinations against SARS-CoV-2 represent a fundamental tool in controlling the pandemic. To date, data on the safety of anti-SARS-CoV-2 vaccines in patients with rare rheumatic diseases, such as systemic vasculitis, are limited.

Objectives

In this study we aimed at evaluating the safety of anti-SARS-CoV-2 vaccines in a multicentric cohort of patients with systemic vasculitis.

Methods

Patients with systemic vasculitis from two Rheumatology centres who had received anti-SARS-CoV-2 vaccine were retrospectively examined. The primary outcome was to evaluate, in this multi-centric cohort, the occurence of a disease flare after the administration of the vaccine, defined as development of clinical manifestations related to vasculitis with a concomitant increase in serum inflammatory markers. As a secondary outcome we aimed at evaluating, in a monocentric cohort of patients with vasculitis, the occurrence of adverse events (AEs) following vaccine administration compared to healthy controls (HC).

Results

We examined 111 patients with systemic vasculitis (n=69 female, n=42 male), with a mean age of 64.3 (± 13) years. Sixty had ANCA-associated vasculitis (AAV), fourty-two had Giant-Cell Arterities (GCA), five had Periarteritis Nodosa, four had Takayasu’s arteritis. One-hundred and five patients received a mRNA vaccine and six a viral vector one. A disease flare occurred in only 2 patients (1.8%) after the first dose of a mRNA vaccine: both had AAV (microscopic poliangioitis) and developed a pulmunary disease flare (respiratory failure requiring hospitalization and treatment with high-dose glucocorticoids). Of note, one of these patients had multiple previous comorbidities, including a severe COPD. Multivaried analysis, adjusted for age and sex, performed in a single monocentric cohort of patients with systemic vasculitis [n=60 (39 AAV, 21 GCA), 37 female, 23 male, mean age 71 (± 12.5) years] demonstrated a statistically significant higher frequency of AEs in vasculitis patients compared to HC (p=0.015) after the first dose of vaccination. No significant differences in the frequency of AEs in vasculitis patients compared to HC after the second dose were detected. All the AEs were mild in both groups (malaise was the most frequently reported); no serious AEs were reported.

Conclusion

Our data show a very low incidence of disease flares after the administration of anti-SARS-CoV-2 vaccines in patients with systemic vasculitis. Patients with systemic vasculitis seem more prone to develop mild AEs after the first dose of the vaccine. Taken together, this data suggest a good risk profile for anti-SARS-CoV-2 vaccine in patients with systemic vasculitis.

Disclosure of Interests

None declared

POS0475 ROLE OF IL-33/ST2 AXIS IN SYSTEMIC SCLEROSIS PATIENTS WITH ELECTROCARDIOGRAPHIC ABNORMALITIES

Background

Electrocardiographic (EKG) abnormalities are described in 25-75% Systemic Sclerosis (SSc) patients and they are associated with other systemic manifestations1 as well as with a worse prognosis.2 There is an increasing need for clinical and laboratory biomarkers to ameliorate the diagnostic approaches to patients with EKG abnormalities.3

In the last decade, many studies focused on the components of the interleukin (IL)-33/ST2 axis. Under physiological conditions, IL-33 is released by apoptotic cardiac cells, promoting a protective mechanism of cell survival, thanks to the binding with its transmembrane receptor ST2.4 During pathological cardiovascular events, an abnormal secretion of the IL-33 soluble receptor (sST2) by Th2 cells occurs. It binds IL-33 not allowing the physiological mechanism driven by the IL-33/ST2 binding previously described.4 For these reasons, sST2 has been proposed as a biomarker of cardiac injury in a variety of diseases.5

Objectives

Aim of this study was to analyse clinical and demographical parameters in a group of SSc patients, trying to define any possible feature associated with EKG abnormalities. Furthermore, the role of IL-33/ST2 axis components as biomarkers of cardiac injury in patients with SSc-related EKG abnormalities was evaluated, also assessing the possible correlation with serum concentration of NT-pro-BNP, a well-known cardiac injury biomarker in SSc.

Methods

Data from 277 SSc patients, fulfilling the 2013 ACR/EULAR classification criteria,6 attending our Scleroderma Clinic were retrospectively analysed. We selected patients with EKG trace and a blood sample available, collected after the SSc diagnosis. The sera levels of sST2 (ELISA Kit, Abcam), IL-33 (ELISA kit, RayBiotech) and NT-pro-BNP (ELISA Kit, Abcam) were measured. Patients with a history of heart diseases occurring before the diagnosis of SSc or features of secondary cardiac involvement (pulmonary arterial hypertension, severe interstitial lung disease or renal disease) were excluded.

Results

Forty-six SSc patients showed significant EKG abnormalities (rhythm and conduction disorders). Thirty-one SSc patients without pathologic finding at EKG traces were recruited as the control group.

From the analysis of the clinical characteristic of the disease at the moment of serum collection, patients with EKG anomalies have more frequently both a diffuse form of disease (n°-%: 23-50 vs 7-23; p 0.01), with a mean value of mRSS higher than controls (11±9 vs 6±6; p 0.01), and a scleroderma “late” pattern at the nailfold capillaroscopy (n°-% 23-50 vs 6-19; p 0.027).

Significantly higher median values of serum levels of sST2 in SSc patients with EKG disorders compared to the control group (4289pg/mL, IQR 2383 vs 2560 pg/mL, IQR 1455; p 0.0002) were detected, while opposite results were found analyzing serum levels of IL-33 (2.89 pg/mL IQR 101 vs 9 pg/mL IQR 277; p 0.032) (Graph 1). Serum NT-pro-BNP median values were significantly higher in the group of patients with EKG abnormalities than in the control group (149 pg/mL, IQR 354 vs 26 pg/mL, IQR 62; p 0.0007). These values correlated with sST2 serum levels (rho Spearman correlation 0.37; p 0.0006).

Conclusion

SSc patients with EKG abnormalities showed an increased skin and vascular involvement with respect to the control group. These associations could help clinicians in clinically stratifying SSc patients at risk of EKG abnormalities. To our knowledge, this is the first report evaluating the serum concentration of sST2 in SSc patients. Based on these results, we can speculate on the role of this molecule as potential biomarkers of early cardiac injury during SSc, although further studies involving a larger cohort of patients are needed.

References

[1]Vacca et al. Rheumatol 2014

[2]Tyndall et al. Ann Rheum Dis 2010

[3]Muresan et al. Clin Rheumatol 2018

[4]Vianello et al. Int J Biochem Cell Biol 2019

[5]Dudek et al. Adv Clin Exp Med 2020

[6]van den Hoogen et al. Arthritis Rheum 2013

Figure 1:

Graph 1. Serum sST2 (a) and IL-33 (b) concentrations in patients with EKG abnormalities (EKG+) vs control group (EKG)

Disclosure of Interests

None declared.

POS1253 THE COURSE OF COVID-19 IN A COHORT OF SPONDYLOARTHRITIS PATIENTS: A CASE-CONTROL PROSPECTIVE STUDY

Background

With the outbreak of the SARS-CoV-2 pandemic, the rheumatologists’ attention was directed at understanding whether infected patients could have a less favorable outcome. Available data seem to indicate that the course in rheumatic patients is not dissimilar from that in the general population. However, data on the outcome of COVID-19 in patients with spondyloarthritis (SpA) are scant.

Objectives

To describe the outcome of COVID-19 in patients with SpA in terms of hospitalization, need of oxygen therapy, and symptoms compared to a control group. The variation in disease activity before and after COVID-19 was also assessed.

Methods

We enrolled adult patients with psoriatic arthritis (PsA) and ankylosing spondylitis (AS) classified according to standard criteria, that received a diagnosis of COVID-19 through molecular or rapid antigen swab tests between September 2020 and January 2022. Demographic and clinical data, including age, body mass index (BMI), smoking habit, comorbidities, rheumatic treatment at diagnosis of COVID-19, date of COVID-19 diagnosis, symptoms and additional therapy during the infection and vaccination status were collected through a questionnaire and recorded on an electronic database. Disease activity, assessed by DAPSA in PsA patients and by BASDAI and ASDAS in AS patients, was evaluated before and at the first visit after the infection. As controls, individuals with COVID-19 but with no known diagnosis of rheumatic/autoimmune disease were recruited using the “best friend” system.

Results

Sixty-two patients were enrolled [43 with PsA and 19 with AS; F:M=40:22; median age 51 years, 25th-75th percentile 39.5-61; median BMI 25.5, 25th-75th percentile 21.75-28; median disease duration 90 months, 25th-75th percentile 36-192; 6 (9.7%) smokers, 37 (59.7%) non-smokers, 19 (30.6%) past smokers; 15 (24.2%) only treated with one conventional DMARD, 27 (43.5%) with bDMARDs and 20 (32.3%) with both; 44 (71%) had received no vaccine, 18 (29%) one or more doses of vaccine]. Forty-eight controls were also recruited [F:M=29:19; median age 48 years, 25th-75th percentile 41.5-57; median BMI 23.86, 25th-75th percentile 20.69-28.03; 10 (20.83%) smokers, 28 (58.33%) non-smokers, 10 (20.83%) past smokers; 43 (89.6%) had received no vaccine, 5 (10.4%) one or more doses of vaccine]. Among patients, 10 (16.1%) were hospitalized, of whom 8 (80%) required noninvasive oxygen therapy. Among controls, 7 (14.5%) were hospitalized, of whom 5 (71.4%) required noninvasive oxygen therapy. No differences were observed compared to the control group in terms of hospitalization and need for oxygen support. Likewise, the two groups did not bear any statistically significant difference in terms of symptoms (fever, dysgeusia, dyspnoea) and cardiovascular and respiratory comorbidities. BMI and smoking habit did not influence the outcome of COVID-19 in SpA patients, while a BMI of 25 or above was associated with hospitalization in the control group (p=0.0004, RR 3.417). Baseline treatment with immunosuppressants did not influence the disease outcome. DAPSA, ASDAS, and BASDAI did not significantly change after the infection (Table 1). We did not record any COVID-19-related death in either group.

Table 1.

Disease activity before and after COVID-19

Last visit before COVID-19First visit after COVID-19*PsA (n=43)AS (n=19)PsA (n=43)AS (n=19)Remission/low disease activity, n (%)19 (44.2%)17 (89.5%)23 (53.5%)14 (73.7%)Moderate/high disease activity, n (%)11 (25.6%)0 (0%)7 (16.3%)1 (5.3%)NA 13 (30.2%)NA 2 (10.5%)NA 13 (30.2%)NA 4 (21%)

* Reassessment of patients was performed 2 months (median) after COVID-19, 25th-75th percentile 1-4 months

PsA, psoriatic arthritis; AS, ankylosing spondylitis; NA, not available

Conclusion

Our data show that patients with SpA do not face a worse prognosis of COVID-19 than subjects without rheumatic/autoimmune diseases and that demographic and clinical features did not influence the course of the disease.

Disclosure of Interests

None declared

POS0246 SEQUENTIAL RITUXIMAB AND MEPOLIZUMAB IN EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS

Background

Rituximab (RTX) is an effective remission-induction treatment in ANCA-associated vasculitides (AAVs). Some reports have suggested that it might be effective also in Eosinophilic Granulomatosis with Polyangiitis (EGPA), to induce and maintain remission of vasculitic manifestations [1,2]. However, its effects for preventing respiratory relapses seem to be poor. Mepolizumab (Mepo) (both 100 and 300mg/month) is effective in improving respiratory manifestations and lung function, while partially controlling also systemic activity [3,4]. Isolated case reports further indicate that the sequential therapy with RTX and Mepo might be effective [5-7].

Objectives

The study aimed to investigate the efficacy and safety of a therapeutic regimen based on sequential RTX and Mepo for the control of EGPA.

Methods

A multicenter, retrospective, cohort study was conducted on adult patients diagnosed with EGPA according to the ACR classification criteria [8] or MIRRA trial criteria [3]. Only patients who received induction therapy with RTX (any dosage), and subsequent treatment with Mepo (100-300 mg/4 weeks) within 12 months from last RTX administration were included. Patients receiving other induction therapies between RTX and Mepo were excluded. The effectiveness of sequential RTX and Mepo was assessed in terms of disease activity (by the Birmingham Vasculitis Activity Score, BVAS) and daily corticosteroid dosage. Safety data were also collected.

Results

Thirty-four EGPA patients treated with sequential RTX and Mepo were included (59% females, median age of 51 years (IQR 40-58); 41% ANCA positive).

In most cases (26/34; 76%), RTX was started at the dosage of 1g q2w, and all except two patients had active disease at time of RTX beginning [median BVAS of 9 (IQR 6-14)]. Specifically, most patients started RTX for the control of systemic manifestations (19/34; 56%), or of both systemic and respiratory symptoms (11/34; 32%). All except one patient were receiving oral corticosteroids, at a median dosage of 25 mg/day (10-38).

Mepo was started after a median of 14 months (6-23) from RTX initiation and after a median of 5 months (IQR 3-11) from the last RTX administration. Mepo was used at the dosage of 100mg/4 weeks in 32/34 (94%), mostly for the control of respiratory manifestations (25/34, 74%). At the time of starting Mepo, the median BVAS was 4 (2-8), and median prednisolone dose 10 mg/day (7-15). After a median follow-up of 28 months (IQR 23-33) from starting Mepo, the median BVAS decreased to 1.5 (IQR 0-4) and the median corticosteroid dosage to 5 mg/day (2.5-5), with 7/34 (21%) patients being off steroids. At last follow-up, most patients were off-RTX (28/34), typically due to stable disease remission (20/34; 59%).

Both RTX and Mepo were well-tolerated; 5 patients had adverse events on RTX (none serious), and 5 on Mepo (including one serious infection).

Conclusion

Sequential use of RTX and Mepo seems to be effective for remission induction and maintenance in EGPA.

References

[1]Emmi, Ann Rheum Dis, 2018

[2]Teixeira, RMD Open, 2019 3. Wechsler, NEJM, 2017

[4]Bettiol, Arthritis Rheumatol, 2021

[5]Shiroshita, Respir Med Case Rep, 2018

[6]Higashitani, Mod Rheumatol Case Rep, 2021

[7]Afiari, Cureus 2020

[8]Masi, Arthritis Rheum, 1990

Table 1.

Effectiveness of sequential RTX and Mepo in the 34 patients included in the study

RTX beginningMepo beginningLast follow-upMedian time elapsed (IQR)-14 months (6-23) from RTX beginning28 months (23-33) from Mepo beginningDosage1g q2w (26/34);100mg/4 weeks (32/34)6 patients off Mepo; 28 patients off RTX375mg/m2 for 4 weeks (8/34)300mg/4 weeks (2/34)Reason for treatment beginning (manifestations)Systemic (19/34);Respiratory (25/34);-Systemic + respiratory (11/34);Systemic (4/34);Only respiratory (3/34);Remission maintenance (5/34)Other (1/34)BVAS (median, IQR)9 (6-14)4 (2-8)1.5 (0-4)Prednisolone dosage (median, IQR), mg/day25 (10-38)10 (7-15)5 (2.5-5)

Disclosure of Interests

Alessandra Bettiol: None declared, Maria Letizia Urban: None declared, Federica Bello: None declared, Davide Fiori: None declared, Irene Mattioli: None declared, Giuseppe Lopalco: None declared, Florenzo Iannone: None declared, Allyson Egan: None declared, Luca Moroni: None declared, Lorenzo Dagna Consultant of: Consultation honoraria from GSK outside the current work, Marco Caminati: None declared, Simone Negrini: None declared, Paolo Cameli: None declared, Marco Folci: None declared, Paola Toniati: None declared, Roberto Padoan: None declared, Oliver Flossmann: None declared, Roser Solans-Laqué: None declared, Laura Losappio: None declared, Jan Schroeder Consultant of: Advisory Board fees from AstraZeneca and GSK, Marc André: None declared, Laura Moi: None declared, paola parronchi Consultant of: Consultation honoraria from GSK and Novartis, Fabrizio Conti: None declared, Savino Sciascia: None declared, David Jayne Consultant of: Consultant for Astra-Zeneca, Aurinia, BMS, Boehringer-Ingelheim, Chemocentryx, Chugai, CSL, GSK, Infla-RX, Janssen, Novartis, Roche/Genentech, Takeda and Vifor, Augusto Vaglio Consultant of: Consultation honoraria from GSK outside the current work, Giacomo Emmi Consultant of: Consultation honoraria from GSK outside the current work

AB0441 PREDICTORS OF CLASI RESPONSE OVER TIME IN A MULTICENTRIC REAL LIFE COHORT OF SLE PATIENTS TREATED WITH BELIMUMAB

Background

Over 80% of patients affected with SLE experience skin involvement. The anti-BLyS drug belimumab was shown effective in ameliorating mucocutaneous SLE manifestations in clinical trials and real-life studies. Cutaneous response is quantified through the CLASI (cutaneous lupus erythematosus area and severity index). Clinically relevant improvements are defined as decreases of ≥50% (CLASI50) or 70% (CLASI70) from baseline values.

Objectives

To assess rates and predictors of CLASI50 and CLASI70 in the Berliss multicentric SLE cohort1 of patients treated with belimumab.

Methods

Baseline and ongoing features of patients with baseline active skin involvement (CLASI>0) were assessed in relationship to the chosen outcomes CLASI50 and CLASI70 at 24 and 52 weeks. A subanalysis on patients with CLASI≥5 was as well conducted. Logistic regression was employed to identify predictors of response.

Results

172 patients displayed skin involvement at baseline (CLASI>0). Of those, 124 displayed at least a 12-month-follow-up and were included in the analysis. Seventy-seven (62.1%) patients reached CLASI50 at 24 weeks and 91 (77.8%) at 52 weeks; 87 (70.2%) reached CLASI70 at 24 and 99 (79.8%) at 52 weeks. Baseline predictors of CLASI50 at 24 weeks were CLASI-damage (CLASI-d) (OR [95%CI], p; 0.79 [0.65-0.98] 0.03) and disease duration (0.93[0.86-0.99], 0.011). No baseline predictors of CLASI70 at 24 weeks emerged, however having achieved a CLASI50 response at 24 weeks portended CLASI50 and 70 response through week 52 (p<0.01, Table 1). In the subgroup of patients with CLASI≥5, longer disease and increased CLASI-d at baseline confirmed as negative predictors of CLASI50 at 24 weeks. In this subset, use of antimalarials and active smoking at baseline predicted CLASI70 at 24 weeks (Table 1).

Table 1.

Predictors of CLASI-A Response at Week 24 and 52 by Baseline CLASI-A at 50% and 70% Response Thresholds

TimepointOutcomeVariableOR[95%CI] pCLASI>024 weeksCLASI50CLASI-d0.79 [0.65-0.98] 0.030Disease duration0.93[0.86-0.99], 0.011CLASI70CLASI-d0.93 [0.74-1.16], 0.51Disease duration0.97 [0.97-1.02], 0.1852 weeksCLASI50CLASI50 at 24 weeks14.3[4.88-44.42], <0.001CLASI70CLASI50 at 24 weeks6.22 [2.00-19.34], 0.002CLASI≥524 weeksCLASI50CLASI-d0.72 [0.53-0.98], 0.037Disease duration0.93 [0.66-1.00], 0.071CLASI70Antimalarials6.61 [1.20-36.29] 0.032Smoking0.15 [0.03-0.83], 0.03452 weeksCLASI50CLASI50 at 24 weeks22.0 [2.47-196.05], 0.006CLASI70CLASI50 at 24 weeks1.24 [0.06-25.08], 0.88

CLASI, cutaneous lupus erythematosus area and severity index; CLASI-d, CLASI damage; CLASI50 and CLASI70: decrease ≥50% or ≥70% in CLASI from baseline. OR and 95%CIs are estimated using a logistic regression model with stratification factors as covariates (SLEDAI-2K at baseline, baseline prednisone dosage).

Conclusion

Earlier use of belimumab favors achievement of skin response among SLE patients and attainment of a prompt response predicts further response. Use of antimalarials reinforces while smoking hampers a more profound CLASI improvement over time.

References:

[1]Gatto M, et al. Arthritis Rheumatol. 2020 Aug;72(8):1314-1324

Disclosure of Interests

Mariele Gatto Speakers bureau: GSK, Grant/research support from: GSK, Roberto Depascale: None declared, Angela Tincani: None declared, Giacomo Emmi: None declared, Salvatore Scarpato: None declared, Fabrizio Conti: None declared, Marcello Govoni: None declared, Marta Mosca: None declared, Maria Gerosa: None declared, Enrica Bozzolo: None declared, Valentina Canti: None declared, Armando Gabrielli: None declared, Elisa Gremese: None declared, Salvatore De Vita: None declared, francesco ciccia: None declared, Carlo Salvarani: None declared, Maurizio Rossini: None declared, Paola Faggioli: None declared, Antonella Laria: None declared, Amato De Paulis: None declared, Roberto Gerli: None declared, Enrico Brunetta: None declared, Alessandro Mathieu: None declared, Carlo Selmi: None declared, Rossella De Angelis: None declared, Simone Negrini: None declared, Margherita Zen: None declared, Andrea Doria Speakers bureau: GSK, Eli Lilly, Roche, Grant/research support from: GSK, Luca Iaccarino Speakers bureau: GSK, Grant/research support from: GSK

AB0455 DRUGS, AUTOANTIBODIES AND GENES CONTRIBUTE TO THE DEVELOPMENT OF CHRONIC DAMAGE IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Genetic contribution to development of chronic damage have been scarcely investigated in systemic lupus erythematosus (SLE). In fact, whereas most studies have looked for an association between genetic variants and SLE susceptibility or disease phenotypes, only few have focused on the relationship between these biomarkers and damage development.

Objectives

Moving from these premises, we firstly analyzed the distribution of organ damage in a cohort of SLE patients and secondly we evaluate the role of clinical and genetic factors in determining the development of chronic damage.

Methods

Caucasian SLE patients, diagnosed according with 1997 ACR criteria, were enrolled, and clinical and laboratory data were collected. Based on literature data, we selected a panel of 17 SNPs of following genes STAT4, IL10, IRAK1, HCP5, MIR146a, ATG16L1, IRGM, ATG5, MIR124, MIR1279, TNFSF4, CD40. Genotyping was performed by allelic discrimination assays. A phenotype-genotype correlation analysis was performed by evaluating specific domains of SLICC Damage Index (SDI).

Results

Among 175 Caucasian SLE patients, 105 (60%) exhibited damage (SDI ≥1) with a median value of 1.0 (IQR 3.0). The musculoskeletal (26.2%), neuropsychiatric (24.6%) and ocular domains (20.6%) were involved most frequently. The presence of damage was associated with higher age, longer disease duration, neuropsychiatric (NP) manifestations, anti-phospholipid syndrome and the positivity of anti-dsDNA antibodies. Concerning therapies cyclophosphamide, mycophenolate mofetil and glucocorticoids resulted associated with the development of damage. The genotype/phenotype correlation analysis showed an association between renal damage, identified in 6.9% of patients, and rs2205960 of TNFSF4 (p=0.001; OR 17.0). This SNP resulted significantly associated with end-stage renal disease (p= 0.018, OR 9.68) and estimated GFR<50% (p=0.025, OR 1.06, Figure 1). The rs1463335 of MIR1279 gene was associated with the development of NP damage (p=0.029; OR 2.783). The multivariate logistic regression analysis confirmed the associations between TNFSF4 rs2205960 SNP and renal damage (p=0.020, r=2.53) and between NP damage and rs1463335 of MIR1279 gene (p=0.013, r=1.26)].

Figure 1.

Association between renal damage and rs2205960 of TNFSF4 (p=0.001). In addition, this SNP resulted significantly associated with the development of two specific items of SDI renal domain: estimated glomerular filtration rate (GFR) <50% and end-stage renal disease (ESRD) (p=0.025, p=0.018 respectively).

Conclusion

We showed the role of age, drugs, and autoantibody profile in determining chronic damage.

Our data suggest a possible role of genetic background in determining the development of renal and neuropsychiatric damage, as demonstrated by the association with polymorphisms of TFNSF4 and MIR1279, respectively. These results agree with previous studies suggesting the involvement of TNFSF4 in Lupus nephritis and microRNA in neuroinflammation.

Disclosure of Interests

None declared

POS0428 PATHOGENETIC ROLE OF MICROPARTICLES IN RHEUMATOID ARTHRITIS

Background

Microparticles (MPs) are fragments of surface membranes of activated eukaryotic cells. They are characterized by different dimensions (from 0.1 to 1μm) and expression of surface antigens, depending on their origin. MPs are important mediators of cell-to-cell communication as they can be internalized in a dose-dependent manner by macrophages, endothelial cells and other cell types, influencing both functional and phenotypic characteristics of the target cells. Even if MPs formation is enhanced by cell activation or apoptosis, constitutive exocytosis is a continuous ongoing process in vivo for many cells, and MPs originating from different cells can be always found in the plasma. In various autoimmune diseases, it has been found an increased number of MPs derived from activated platelets, leukocytes, vascular endothelium cells and other cell types. In Rheumatoid Arthritis (RA) an excessive production of MPs may predispose to autoimmune manifestations. Moreover, it has been speculated that MPs can stimulate the production, secretion, and transport of inflammatory factors in RA.

Objectives

We investigated the presence on the surface of RA-MPs of antigens derived from post-translationally modified proteins (citrullinated peptides and carbamylated peptides). We assumed that these specific antigens carried on the surface of RA-MPs could participate in RA pathogenetic process.

Methods

We enrolled 20 RA patients naïve for biological therapy fulfilling the 2010 American College of Rheumatology RA criteria and 20 healthy controls (HC), matched for age and sex. For each patient, laboratory and clinical data were recorded and clinical indexes were measured (TJ, SJ, CDAI, VAS pain, CDAI, SDAI, DAS28). A fasting blood sample, obtained from RA patients and HC, was centrifugated in order to obtain platelet-poor plasma (PPP), rich in MPs. Thereafter, MPs in RA patients and HC were measured using nanoparticle tracking analysis. Later on, MPs were incubated with unconjugated anti-citrullinated/carbamylated proteins antibodies and processed by flow cytometry and western blot to evaluate the surface expression of citrullinated/carbamylated antigens.

Results

Nanoparticle tracking analysis revealed a significant increase of number of MPs in RA compared to HC. Moreover, densitometric analysis showed a significative higher expression of citrullinated antigens on MPs’ surface in RA than controls (p < 0.0001), while no substantial difference was found in the expression of carbamylated antigens. The data obtained were confirmed with the western blot which identified the cytoskeletal protein vimentin, the cytoplasmatic glycolytic enzyme alpha-enolase1 and type II collagen as the main citrullinated and carbamylated proteins carried by MPs. Finally, a relevant correlation between the expression of citrullinated and carbamylated antigens and disease activity was found (Figure 1).

Figure 1.

The figure shows: (A) concentration of MPs in RA patients and HC (nanoparticle tracking analysis); (B) expression of citrullinated and carbamylated antigens on MPs’ surface in RA patients (flow cytometry analysis); (C) expression of citrullinated antigens in RA patients and HC and correlation between expression of citrullinated and carbamylated antigens on MPs’ surface in RA patients and DAS28, CDAI, SDAI; (D) cytoskeletal protein vimentin, cytoplasmatic glycolytic enzyme alpha-enolase1 and collagen type II (western blot).

Conclusion

The results of this study confirm an important role of MPs in the pathogenesis of RA not only as markers of disease activity but also as possible inducers of autoimmunity.

Disclosure of Interests

None declared.

POS0410 THE ROLE OF IL-6 IN ENDOTHELIAL DYSFUNCTION: RHEUMATOID ARTHRITIS AND COVID-19, TWO PATHOGENIC MODELS IN COMPARISON

Background

Rheumatoid arthritis (RA) is the most common systemic autoimmune disease that primarily affects joints but is also often characterized by extra-articular involvement1. Cardiovascular diseases are the most important causes of sudden death in these patients, which present a risk of developing cardiovascular events increased by 48%2. The causes of increased cardiovascular risk are several and not completely understood, but recent evidence supports the key role of endothelial dysfunction in pathogenesis. In this complex scenario, it is known that IL-6 receptors are present at the endothelial level and can be activated leading to endothelial dysfunction. SARS-Cov-2 is a coronavirus responsible for the disease called ‘coronavirus disease 2019’ (CoViD-19) characterized by clinical manifestations ranging from a flu-like syndrome up to severe lung damage associated with systemic hyper cytokine syndrome that can lead to multiple organ failure and death. Therefore, both RA and Covid-19 are associated with an increased pro-thrombotic and cardiovascular risk and IL-6 might be crucial in the pathophysiological mechanisms of both diseases.

Objectives

The main hypothesis of this study was to evaluate the possible role of IL-6 as a promoter of endothelial dysfunction in RA and CoViD-19.

Methods

In vitro experiments were conducted on the endothelial cell line EA. hy926. Cells were treated for 24 h with fetal bovine serum (FBS), a pool of RA patients’ sera or a pool of CoViD-19 patients’ sera. The expression levels of adhesion molecules (V-CAM1/CD-106, I-CAM/CD-54, p-selectine/CD-62, tissue factor/CD-142) and apoptosis were analyzed using cytofluorimetric technique. In addition, the autophagy level, using the autophagy markers p62 and LC3II, were evaluated through a western-blot analysis. The same experiments were conducted co-treating cells with the same pool of sera in addition to tocilizumab (TCZ), an anti-IL-6 drug, to verify the reversibility of the process and test the role of the aforementioned cytokine. Data are reported as interquartile median values. The Kruskal Wallis test was used for unpaired samples and the Mann-Whitney test for paired samples. P<0.05 values were considered statistically significant.

Results

EA. hy926 cells, when treated with both RA and CoViD-19 patients’ sera, showed increased levels of activation molecules and apoptosis compared to FBS treated cells. In addition, we observed increased levels of both p62 and LC3 proteins after both rheumatoid arthritis and CoViD-19 patients’ sera treatment. All these findings were reversible in the presence of TCZ. The results are presented in Figure 1.

Figure 1.

Figures show the adhesion molecules levels (A), apoptosis levels (B), p62 and LC3II levels (C), in all experimental conditions. FBS 10% (cells treated with FBS at 10% concentration), S AR (cells treated with a pool of RA patients’ sera); S Covid (cells treated with a pool of COVID-19 patients’ sera); FBS 10%+toci (cells co-treated with FBS at 10% concentration and TCZ); S AR+toci (cells co-treated with a pool of RA patients’ sera and TCZ); S Covid+toci (cells co-treated with a pool of CoViD-19 patients’ sera and TCZ).

Conclusion

Our data showed that treatment with RA and CoViD-19 patients’ sera increase the activation and death of endothelial cells in vitro. The increased level of cells death is possibly due to a block of autophagy. The reversibility of the process after blocking IL-6 with TCZ co-treatment confirms the hypothesis that IL-6 can play a key role in the pathogenesis of endothelial damage in patients with RA and CoViD-19.

References

[1]Bordy R et al. Microvascular endothelial dysfunction in rheumatoid arthritis. Nat Rev Rheumatol. 2018 Jul;14(7):404-420.

[2]Avina-Zubieta et al. Risk of incident cardiovascular events in patients with rheumatoid arthritis: a meta-analysis of observational studies. Ann. Rheum. Dis. 2012; 71:1524–1529.

Disclosure of Interests

None declared.

POS1058 BIOLOGICAL DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS IN PSORIATIC ARTHRITIS: PREDICTORS OF TREATMENT SURVIVAL IN A REAL-LIFE SETTING

Background

Psoriatic arthritis (PsA) is a chronic, immune-mediated, inflammatory arthropathy, distinctively involving joints and enthesis. The improved understanding of PsA pathogenesis has enabled the development of biological disease-modifying anti-rheumatic drugs (bDMARDS) targeting specific cytokines and signalling pathways. The availability of these drugs deeply modified PsA history, by preventing disease progression and by improving quality of life. Nevertheless, bDMARDS are not effective in all the patients who may experience primary or secondary inefficacy or adverse events development.

Objectives

In a real-life scenario, we evaluated the bDMARDs retention rate in a large PsA cohort. In detail, we compared drug survival of the first and second biological drug and we investigated the presence of factors associated with the bDMARDs treatment withdrawal.

Methods

We longitudinally evaluated adult PsA patients (2016 CASPAR criteria) treated with at least one bDMARD during disease history. For each PsA patient, the clinical and laboratory data, including demographics, past medical history with the date of diagnosis and treatments, clinical disease phenotypes, were collected in a standardized, computerized and electronically filled form. The retention rate was estimated by using the Kaplan-Meier method. Predictors for bDMARDs withdrawal were investigated in univariate and multivariate Cox proportional hazards analysis, adjusted for relevant variables.

Results

The present analysis included 223 PsA patients [M/F 91/132; median age 57 years (IQR 17); median disease duration 120 months (IQR 132)]. Adalimumab and Etanercept were the most frequently prescribed bDMARDs (41.5% and 41.0%, respectively). The retention rate of the first prescribed bDMARD as reported in Figure 1A: in detail, we found a 12-months retention rate of 79.8%. The comparison between etanercept and adalimumab showed a similar 12-months retention rate, but significantly higher for etanercept at 24 months (82.4% versus 69.5%, p=0.0034, Figure 1B). Out of 223 enrolled PsA patients, 109 (48.9%) received only one bDMARDs, while the remaining 114 (51.1%) received at least 2 drugs. When comparing these two groups of patients, drug survival at 24 months was significantly higher in patients treated with one bDMARD in comparison with those treated with at least two drugs (67.7% versus 52.2%, p=0.03, Figure 1C). Finally, female sex and anxiety-depressive disorders were significantly associated with the treatment with at least two dDMARDs (p=0.005 and p=0.01, respectively).

Conclusion

The results of the present study demonstrated a higher retention rate in the first-line bDMARDs treatment in comparison with second-line. Female sex and anxiety-depressive disorders may negatively affect drug retention rate.

Disclosure of Interests

None declared

POS0721 ASSOCIATION BETWEEN PRECONCEPTION COMPLEMENT LEVELS AND USE OF HYDROXYCHLOROQUINE WITH PREGNANCY OUTCOME IN PATIENTS WITH PRIMARY ANTIPHOSPHOLIPID SYNDROME AND CARRIERS OF ANTIPHOSPHOLIPID ANTIBODIES: AN INTERNATIONAL MULTICENTER STUDY

Background

Antiphospholipid Syndrome (APS) is a rare autoimmune disease characterized by thrombotic events and/or pregnancy morbidities in the presence of confirmed positivity for antiphospholipid antibodies (aPL). Complement was demonstrated to be involved in aPL-related pregnancy loss in animal models and several groups investigated the significance of complement levels in human disease. C3 and C4 serum levels were assessed in several cohorts of pregnant patients with APS and/or aPL positivity in order to relate complement consumption with adverse pregnancy outcome (APO).

According to some authors, hydroxychloroquine (HCQ) can control the activation of the complement system, improve pregnancy outcome and reduce aPL title.

Objectives

This study was designed to verify the effect of HCQ in addition to low dose aspirin (LDA) + low molecular weight heparin (LMWH) treatment in a multicenter cohort of primary APS (PAPS) and aPL carriers pregnant women and the possible correlation with preconception serum C3/C4 levels.

Methods

Medical records of pregnant women with confirmed positivity for aPL antibodies attending twelve referral centers from January 2010 to December 2020 were retrospectively evaluated. We considered as aPL-related APO: spontaneous abortions (<10 weeks of gestation), fetal loss (≥10 weeks of gestation), neonatal death (death of a formed fetus alive at birth in the first 28 days of life), preterm delivery before 37 weeks of gestation, preeclampsia, eclampsia or HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet).

Results

We have analyzed 164 singleton PAPS/aPL carrier pregnancies (22 aPL carriers - 13%) in 128 patients: all were treated with combination therapy (LDA+LMWH), and in 30 HCQ was added. 58 pregnancies (43%) had low levels of preconception C3/C4. A triple aPL positivity was observed in 54 pregnancies, 14 of them were treated with combination therapy + HCQ. When considering the whole cohort, the addition of HCQ had not significantly improved the gestational outcome. Further stratification was performed on the basis of complement consumption. In the group of patients with preconception low C3/C4 levels the addition of HCQ had not significantly improved pregnancy outcome. We have lastly evaluated 40 pregnancies with a high-risk profile (triple aPL positivity and complement consumption), in which we have found that HCQ significantly improved gestational outcome (p=0.018, Table 1).

Table 1.

Relationship between APO, therapy during pregnancy and risk profile.

All pregnancies (n=164)Reduced C3/C4 (n=58)Triple aPL+ and reduced C3/C4 (n=40)LDA+LMWH (n, %)LDA+LMWH+HCQ (n, %)pLDA+LMWH (n, %)LDA+LMWH+HCQpLDA+LMWHLDA+LMWH+HCQp(n, %)(n, %)(n, %)APO62 (46%)16 (53%)ns32 (68%)4 (36%)ns23 (77%)3 (30%)0.018No APO72 (54%)14 (47%)15 (32%)7 (64%)7 (23%)7 (70%)Total1343047113010

This observation could not be confirmed in patients with single or double aPL positivity.

Conclusion

The study shows that administering HCQ in addition to combination therapy can improve gestational outcome in aPL/PAPS high-risk patients. This observation confirms that HCQ exerts a beneficial effect on aPL pregnancies by complement inhibition as it was shown in animal models. In addition, our results provide the clinicians a useful tool to implement conventional treatment in patients at high risk of pregnancy complication or loss.

References

[1]De Carolis S, et al. Is there any role for the hydroxychloroquine (HCQ) in refractory obstetrical antiphospholipid syndrome (APS) treatment? Autoimmun Rev 2015;14:760-2.

[2]Mekinian A, et al. The efficacy of hydroxychloroquine for obstetrical outcome in antiphospholipid syndrome: data from a European multicenter retrospective study. Autoimmun Rev 2015;40:498-502.

[3]Mekinian A et al. Obstetrical APS: is there a place for hydroxychloroquine to improve the pregnancy outcome? Autoimmun Rev 2015;14:23-9.

Disclosure of Interests

None declared

AB1355 NAILFOLD CAPILLAROSCOPY CHANGES IN PATIENTS WITH PSORIATIC ARTHRITIS AND RHEUMATOID ARTHRITIS

Background

In psoriatic arthritis (PsA) and rheumatoid arthritis (RA) systemic inflammation is known to cause endothelial dysfunction(1). Nailfold videocapillaroscopy (NVC) analyzes in vivo blood vessels, looking for alterations due to microvascular damage, and its application in these pathologies often highlights interesting abnormalities. PsA is characterized by lower mean capillary length and density and abnormal morphology, such as tight terminal convolutions. In RA typically elongated and dilated capillaries and prominent subpapillary plexus are described(2, 3). Differences between RA and PsA NCV patterns are known but not well defined yet(3).

Objectives

Aim of our study was to evaluate the microvascular features circulation by NVC in patients affected by PsA and RA, looking for possible differences that may characterize the two diseases.

Methods

We recruited outpatients affected by PsA or RA classified according to standard criteria(4, 5) referring to the Rheumatology Unit at Sapienza University of Rome. Healthy controls (HCs) without known risk factors for nailfold capillary alterations(6) were also recruited. Patients and HCs underwent NVC with a 200x magnification lens. The following morphological parameters were considered: number of capillaries per square millimeter, alterations in length, dimension, morphology and distribution of the capillary; presence of ectatic loops, hemorrhages, flux abnormalities(7, 8). A semi-quantitative rating scale was adopted to score these changes, according to previous studies(9). The mean score for each subject was obtained by analyzing all fingers, except the thumbs.

For the statistical analysis, Chi-square and Mann-Whitney tests were used. All tests were two-sided with a significance level set at p<0.05.

Results

We recruited 34 patients (20 with PsA and 14 with RA) and 30 HCs. For patients, the mean age was 61,7 years (SD 15,4), median disease duration was 184 months (SD 204) and males were 18 (53%). Active or past smokers were 11 (18%), 9 (15%) suffered from arterial hypertension and 2 (0.03%) from type 2 diabetes mellitus. Raynaud’s phenomenon was present in 4 patients with PsA (20%) and 6 with RA (43%).

The most frequent morphological changes were tortuous capillaries (90% in PsA and 100% in RA), single-crossing shape (90% and 86%) and bizarre capillaries (30% in both groups) while multiple crossing and ramified capillaries were present in 50% and 21 % RA patients only.

With respect to HCs, we found significantly more frequent changes concerning morphology, ectatic loops, presence of hemorrhages and capillary plexus visibility in both PsA and RA patients. Moreover, patients with RA showed significantly more frequent abnormalities of the blood flow with respect to HCs. These results are shown in Table 1.

Table 1.

Comparison of the main NVC changes in patients and HCs.

NVC ChangesHCPsARAN (%)N (%)P value vs HCsN (%)P value vs HCsMorphology3 (10%)14 (70%)p<0.000112 (86%)p<0.0001Ectatic loops0 (0%)11 (55%)p<0.00018 (57%)p<0.0001Hemorrhages2 (0.07%)1 (5%)p<0.016 (43%)p<0.0058Plexus19 (63%)10 (50%)p<0.027 (50%)p<0.02Flux abnormalities3 (10%)6 (30%)p>0.055 (36%)p<0.026

The presence of hemorrhages was significantly higher in RA rather than in PsA patients (p<0.01). No significant differences were found in number, length, and distribution of capillaries between PsA/RA cases and HCs.

Conclusion

Our study confirms and completes the frame of NCV alterations in PsA and RA. We described for the first time alterations in the capillary morphology and the presence of hemorrhages in both groups of patients with respect to HCs. It remains to evaluate how these findings can reflect the microvascular environment of chronic arthritis.

References

[1]Fromm, S et al. Arthritis Res Ther 2019

[2]Lambova SN, Müller-Ladner U. Microvasc Res 2012

[3]Graceffa D, et al. Arthritis 2013

[4]Taylor W, et al. Arthritis Rheum 2006

[5]Aletaha D, et al. Ann Rheum Dis 2010

[6]Ciaffi J, et al. Microvasc Res 2020

[7]Maricq HR. Arthritis Rheum 1981

[8]Smith V, et al. Autoimmun Rev. 2020

[9]Cutolo M, et al. J Rheumatol 2000

Disclosure of Interests

None declared

OP0236 JAK-STAT INHIBITION RESTORES EPITHELIAL CELLS’ HOMEOSTASIS IN PRIMARY SJOGREN’S SYNDROME

Background

Although salivary gland epithelial cells (SGECs) are key players in the pathogenesis of autoimmune epithelitis that characterizes primary Sjӧgren’s Syndrome (pSS), the mechanisms sustaining SGECs activation in pSS remain largely undetermined. Therefore, therapeutic strategies to counteract SGECs activation in pSS are also lacking. In previous studies, we revealed that maladaptive autophagy sustains survival and pro-inflammatory activation of SGECs in pSS (1).

Objectives

To determine the therapeutic potential of JAK/STAT inhibition with baricitinib to restore homeostatic regulation of SGECs in pSS, by reducing autophagy, survival, and expression of adhesion molecules.

Methods

Primary SGECs were isolated from minor salivary glands (SG) of large cohort of patients with pSS or sicca syndrome and subjected to mechanistic and functional studies including flow-cytometry, immunoblotting, and immunofluorescence to assess autophagy (autophagic-flux, LC3IIB, p62, LC3B+/LAMP1+ staining), apoptosis (annexin V/PI, Caspase-3) and activation (ICAM, VCAM). Focus score and germinal centers were determined in homologous SG biopsies to assess correlations of findings with histological disease severity. Primary SGECs of patients with pSS were treated with Baricitinib (1 mM) for 24 prior to assessment of autophagy, apoptosis and activation.

Results

SGECs from pSS patients (n=29) exhibited increased autophagy (as determined by autophagic-flux p=0.001; LC3IIB p=0.02; p62 p=0.064; LC3IIB/LAMP1+ staining), increased expression of anti-apoptotic molecules (Bcl2 p=0.006), and reduced apoptosis (Annexin-V/PI p=0.002, Caspase-3 p=0.057) compared to sicca (n=16). Induction of autophagy in pSS SGECs correlated with histologic disease severity. Treatment of pSS SGECs with baricitinib ex vivo suppressed autophagy, increased apoptosis, and reduced expression of adhesion molecules.

Conclusion

SGECs in the inflammatory milieu of pSS are characterized by induction of autophagy and pro-survival mechanisms, and by expression of adhesion molecules. These changes correlate with SG infiltration with immune cells and with histologic disease severity. Among clinically available therapies, the JAK/STAT inhibitor baricitinib effectively reduced autophagy, countered the state of maladaptive activation of SGECs, and restored epithelial cell homeostasis. Transcriptomics and metabolomics studies are ongoing to dissect the specific mechanisms responsible for these beneficial effects.

References

[1]Colafrancesco S, et al. Maladaptive autophagy in the pathogenesis of autoimmune epithelitis in Sjӧgren’s Syndrome. Arthritis Rheumatol 2021.

Disclosure of Interests

Serena Colafrancesco Speakers bureau: Novartis

Sobi, Grant/research support from: Eli Lilly, cristiana barbati: None declared, Roberta Priori: None declared, Federico Giardina: None declared, angelica gattamelata: None declared, raffaella izzo: None declared, Bruna Cerbelli: None declared, Carla Giordano: None declared, Susanna Scarpa: None declared, Massimo Fusconi: None declared, Francesca Romana Spinelli Speakers bureau: Eli Lilly

Pfizer

Abbvie, Giulio Cavalli: None declared, cristiano alessandri: None declared, Fabrizio Conti: None declared

POS0741 REPORT FROM THE APS STUDY GROUP OF THE ITALIAN SOCIETY FOR RHEUMATOLOGY (SIR-APS) ON aPL NEGATIVIZATION

Background

The rate of antiphospholipid antibodies (aPL)negativization in antiphospholipid syndrome (APS) patients is uncertain, but it is estimated to be as high as 8%. aPL disappearance seems to be more frequent in patients positive for one single aPL test and appears to be related with the immunosuppressant/immunomodulatory treatment undertaken by the patient. Currently, a consensus definition of aPL negativization is lacking, as well as international recommendations on how to approach treatment in patients with a persistent aPL negative seroconversion.

Objectives

The aim of our work was to evaluate the clinical approach and the level of consensus among experts from the APS Study Group of the Italian Society for Rheumatology (SIR-APS) in different clinical scenario addressing aPL negativization and its definition.

Methods

Experts of SIR-APS were contacted using a survey methodology.

Results

A structured survey was circulated among 30 experts.Up to 90% of the interviewed experts agreed on defining aPL negativization as the presence of two negative determinations, one year apart (90%).Almost ful lconsensus exist among experts in some clinical settings, including: a) the role of aPL negativitation in the management of a thrombotic event determined by concomitant presence of cardiovascular risk factors, both modifiable and not modifiable (90%): b) approach to young patients with triple aPL positivity who experienced pulmonary arterial thrombotic event and tested negative for aPL detection after five year of vitamin K antagonist (VKA) treatment (90%); c)the use of “extra criteria” aPL antibodies testing before pondering VKA suspension (93%).

Conclusion

Consensus is needed to support the management of patients with APS in areas where controlled data are missing. A substantial agreement exists among expert in defying aPL negativization as the presence of two negative determinations, one year apart. On the contrary, VKA suspension should be embraced with extreme caution when it comes to APS patients, particularly if they experienced arterial thrombotic events and/or tested positive for triple aPL. Nevertheless, VKA cessation might be considered when risk factors are carefully monitored/treated and the presence for “extra criteria” aPL is ruled out.

References

[1]Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, Derksen RHWM, DE, Groot PG, Koike T, Meroni PL, Reber G, Shoenfeld Y, Tincani A, Vlachoyiannopoulos PG, Krilis SA. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost 2006; 4: 295–306.

[2]Coloma Bazán E, Donate López C, Moreno Lozano P, Cervera R, Espinosa G.

Discontinuation of anticoagulation or antiaggregation treatment may be safe in patients with primary antiphospholipid syndrome when antiphospholipid antibodies became persistently negative. Immunol Res Immunol Res; 2013; 56: 358–61.

[3]Radin M, Schreiber K, Sciascia S, Roccatello D, Cecchi I, Aguirre Zamorano MÁ, Cuadrado MJ. Prevalence of Antiphospholipid Antibodies Negativisation in Patients with Antiphospholipid Syndrome: A Long-Term Follow-Up Multicentre Study. Thromb Haemost 2019; 119: 1920–6.

Acknowledgements

Italian Society of Rheumatology

Disclosure of Interests

None declared

POS0634 SAFETY PROFILE OF b/tsDMARD IN RHEUMATOID ARTHRITIS PATIENTS WITH IMPAIRED GLOMERULAR FILTRATION RATE. AN ANALYSIS FROM THE GISEA REGISTRY

Background

In real-life setting, a greater number of elderly rheumatoid arthritis (RA) patients with impaired glomerular filtration rate (GFR) needs treatment with biologic or target synthetic disease-modifying anti-rheumatic drugs (b/tsDMARD) to achieve disease control and reduce NSAIDs intake. Long-term observational data from the real-life on the use of b/tsDMARD in these patients are scarce.

Objectives

The aim of this study was to evaluate the retention rate of b/tsDMARD in RA patients with impaired GFR in real-life setting.

Methods

Data of RA patients treated with at least one b/tsDMARD were retrospectively analyzed form the national Italian GISEA registry from January 2016 to December 2021. Estimated-GFR (eGFR) was calculated with the Cockcroft-Gault equation at the time of any b/tsDMARD prescription. For the purpose of this study, patients were divided in two groups, patients with impaired GFR (eGFR ≤60) and patients with normal GFR (eGFR >60). The retention rate was calculated by the Kaplan-Meier method and compared between these two groups by a log-rank test.

Results

The study population included 2443 treatment-line with b/tsDMARD from 1888 patients (female 80.4%, age 57±12 years, mean baseline CDAI 17±12, FR/ACPA+ 69.5%) who started a new b/tsDMARD. Disease characteristics are shown in Table 1. 288 treatments with b/tsDMARD were started in patients with impaired eGFR and 2155 in patients with normal eGFR. Compared to patients with eGFR >60, patients with eGFR ≤60 showed higher HAQ-DI (1.3±0.8 vs 1±0.8, p<0.001) at the start of b/tsDMARD treatment. Glucocorticoids were more prescribed in patients with impaired eGFR (80.2% vs 72.8%, p<0.01), while csDMARDs were more prescribed in association with b/tsDMARD in patients with normal eGFR (83.1% vs 76.4%, p<0.01). Of note, CTLA4-Ig treatment was more prescribed in patients with impaired eGFR (26% vs 17.1%, p<0.05), while no difference in b/tsDMARD prescription was observed for other mechanism of actions. Drug survival was similar between RA patients with impaired eGFR [58.2%, mean survival time 35 months (CI95% 31-39)]and RA patients with normal eGFR [55%, mean survival time 34.4 months (CI95% 33-36), log rank: 0.88] (Figure 1). Cox regression model adjusted for age, sex and b/tsDMARD showed no impact of eGFR on drug survival [HR: 0.9 (CI95%: 0.7-1.2).

Conclusion

Our data show that impaired eGFR seems to not influence the persistence of b/tsDMARD treatment in RA patients.

Disclosure of Interests

None declared

AB0499 LYMPHOID ORGANIZATION IN LUPUS NEPHRITIS: EVALUATING POSSIBLEAUTO ANTIGENS

Background

Lupus nephritis (LN) represent one of the most frequent organ manifestations and one the major cause of morbidity in Systemic Lupus Erythematosus (SLE) patients. Tubule-interstitial infiltrate (TII) represents an independent prognostic factors of renal outcome1.

Objectives

The aim of the study was to evaluate the inflammatory infiltrates organization in kidney biopsies obtained from LN patients and to investigate possible autoantigens for in situ immune response.

Methods

Paraffin embedded kidney specimens collected since 2017 from SLE patients who underwent a renal biopsy for diagnostic purpose were re-evaluated2. Clinical, laboratory and histological data were collected in a standardized, computerized and electronically filled form, including demographics and past medical history. Disease activity was assessed by using SLEDAI-2K and remission in response to therapy was defined as a score 0 of renal item of the SLEDAI3. The cellular infiltrate were assessed by hematoxylin-eosin and by immunohistochemistry with a staining of sequential sections for monoclonal antibodies to CD3, CD20, CD21. Staining for detections of LL-37, vimentin and citrulline was made4. Serological levels of CXCL13 and anti-vimentin antibodies (AVAs) were evaluated in a subgroup of patients.

Results

Eighteen paraffin embedded renal specimens with TII, from LN patients were re-evaluated (F:M = 17:1, median age at biopsy-SD years 37-23; median disease duration at date of biopsy-IQR 3-4 years). A histo-morphologic grading score was performed based on the total count of TI lymphocytes and the presence of ectopic lymphoid structures-ELSs (grade 3-G3) (Figure 1). A correlation was found between G3 structures and the absence of renal remission with conventional immunosuppressive therapy (P=0.0026). Samples with G3 foci showed significantly higher intensity of LL37 (P=0.013) and LL37 co-localization (P=0.006) compared to the other lymphocytic infiltrates. No correlation was found among the intensity of vimentin and citrulline and the grade of lymphoid aggregates. A statistically significant inverse correlation between AVAs serum levels and response to therapy was found (P=0.0048). Moreover, higher level of AVAs and CXCL13 were found in patients with G3 structures. To note, two patients underwent anti-CD20 therapy but renal remission was achieved only in the patients displaying G3 structure.

Figure 1.

Conclusion

The study demonstrated that tubule-interstitium involvement is associated with the presence of lymphoid aggregation and poor renal outcome. For the first time we demonstrated that patients with G3 structures had a significant decreased response to immunosuppressant conventional therapies compared to those without ELSs. These results suggest a possible phatogenetic, prognostic and therapeutical role of lymphocytic aggregates. In addiction, LL37, thus NETosis, could have a possible role in inducing the formation of lymphocytic structures. Moreover, patients with a G3 foci showed high serological levels of AVAs and CXCL13, thus, promoting their possible role as circulating biomarkers of the presence of ELSs.

References

[1]Bajema, I. M. et al. Revision of the International Society of Nephrology/Renal Pathology Society classification for lupus nephritis: clarification of definitions, and modified National Institutes of Health activity and chronicity indices. Kidney Int. 93,789–796 (2018).

[2]Weening JJ et al. International Society of Nephrology Working Group on the Classification of Lupus Nephritis; Renal Pathology Society Working Group on the Classification of Lupus Nephritis. The classification of glomerulonephritis in systemic lupus erythematosus revisited. Kidney Int. 2004 Feb;65(2):521-30.

[3]Gladman DD et al. Systemic lupus erythematosus disease activity index 2000. J Rheumatol 2002; 29:288-91.

[4]Bombardieri M et al. Ectopic lymphoid neogenesis in rheumatic autoimmune diseases. Nat Rev Rheumatol. 2017 Mar;13(3):141-154.

Disclosure of Interests

None declared

AB0436 EFFECTIVENESS OF BELIMUMAB IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS: A REAL-LIFE ANALYSIS

Background

Efficacy and safety of belimumab (BLM) in Systemic Lupus Erythematosus (SLE) patients with active disease have been demonstrated by RCTs [1,2] and confirmed by several observational studies [3-8]. Most of these data have been obtained by the use of BLM intravenous formulation (IV); on the contrary, very few findings are available on the use of the drug subcutaneous formulation (SC).

Objectives

Efficacy and drug survival of BLM have been assessed in a monocentric cohort of SLE patients, exploring any difference between the two routes of administration, IV or SC.

Methods

A longitudinal study on SLE patients (according to ACR 1997 classification criteria [9]) candidates for treatment with BLM has been performed. Demographic, clinical-laboratory and therapeutic data - including glucocorticoid dosage in prednisone-equivalent - have been collected. Disease activity has been assessed by SLEDAI-2k [10]; in patients with inflammatory articular involvement, DAS28-PCR [11] has been used. In compliance with the study protocol, patients were assessed at baseline and at 3 and 12 months after starting treatment.

Results

A total of 85 patients treated with BLM were enrolled, most of whom were female (male/female 2/83), with a median age of 48 years (IQR 13) and a median disease duration of 127 months (IQR 151). Fifty-one patients (60%) were treated with IV formulation and the remaining 34 (40%) with SC route. BLM was prescribed due to the following clinical manifestations: joint involvement (61.2%), cutaneous manifestations (20.0%), renal involvement (for residual proteinuria, 5.9%), haematological modifications (5.9%), constitutional involvement (3.5%), pericarditis (1.2%), headache (1.2%). In both the formulations, joint involvement was the most frequent indication of BLM (IV: 64.7%, SC: 58.8%). Median treatment duration was 15 months (IQR 24). Moving on drug efficacy, after 3 and 12 months of follow-up BLM has determined a significant reduction of SLEDAI-2k median values (p=0.001, p<0.001 respectively, Figure 1A) as well as of daily prednisone dose (p=0.009, p<0.0001 respectively, Figure 1B). In patients treated because of musculoskeletal manifestations, DAS28-PCR reduced significantly at 3 and 12 months after treatment (p<0.0001). Drug survival at 12 months was 70% in the total cohort (Figure 1C) and was higher in patients treated with SC formulation than with IV route (75.8% versus 66.5%, p=ns). During the period of follow-up, 39 patients (45.9%) discontinued BLM: 38.4% of patients due to adverse events, 41% for primary or secondary inefficacy, 15% lost to follow-up, 5.1% for pregnancy. BLM withdrawal for adverse events was more frequent in the group of patients treated with IV formulation than SC one (25.9% versus 5.9%, p=0,0001). 11 patients switched from IV formulation to SC one after a median period of 40 months (IQR 20) without loss of efficacy or adverse events.

Conclusion

Our results confirm BLM efficacy also in a real-life setting. Notably, our data highlight a better drug survival in patients treated with SC formulation, mainly secondary to a less frequency of adverse events.

References

[1]Furie R et al. Arthritis Rheum. 2011;63(12):3918-3930.

[2]Navarra SV et al. Lancet. 2011;377(9767):721-731.

[3]Andreoli L et al. Isr Med Assoc J. 2014;16(10):651-653.

[4]Hui-Yuen JS et al. J Rheumatol. 2015;42(12):2288-2295.

[5]Collins CE et al. Lupus Sci Med. 2016;3(1):e000118.

[6]Touma Z et al. Rheumatol Int. 2017;37(6):865-873.

[7]Iaccarino L et al. Arthritis Care Res (Hoboken). 2017;69(1):115-123.

[8]Gatto M et al. Arthritis Rheumatol. 2020;72(8):1314-1324.

[9]Hochberg M.C. Arthritis Rheum. 1997;40:1725.

[10]Gladman DD et al. J Rheumatol. 2002;29(2):288-291.

[11]Prevoo ML et al. Arthritis Rheum. 1995;38(1):44-48.

Disclosure of Interests

None declared

POS0879 LUNG ULTRASOUND FOR INTERSTITIAL LUNG DISEASE DETECTION IN A COHORT OF SYSTEMIC SCLEROSIS PATIENTS: ROLE OF B-LINE AND PLEURAL LINE MODIFICATIONS

Background

Lung ultrasound (LUS) is a technique that showed a high diagnostic accuracy for interstitial lung disease (ILD) detection in systemic sclerosis (SSc) patients and currently in progress of standardization. Traditionally, B-lines represented the finding of ILD, with the ≥10 total cut-off reported by Tardella et al. resulting to be closely related to moderate ILD detected on high resolution chest computed tomography (HRCT). Recently, Fairchild et al. proposed novel LUS criteria for the evaluation of pleural line, disclosing high accuracy and reproducibility.

Objectives

To compare B lines cut-off with novel pleural line criteria and the respectively associated variables.

Methods

We enrolled 55 consecutive patients affected by SSc according to ACR/EULAR 2013 criteria who underwent respiratory functional tests (RFTs) during 2021, excluding smokers and those with arterial pulmonary hypertension. Twenty-four of them carried out a HRCT during a ± 6-months’ time. In the same day of RFTs, two certified blinded operators performed LUS for each patient applying the 14-areas technique proposed by Gutierrez et al., looking for the presence of total ≥10 cumulative B lines and the fulfilling of Fairchild’s criteria for pleural line. A 3-13 MHz operating linear probe was used. Clinical-demographic data and ongoing therapies were collected.

Results

Among 55 total SSc patients, the agreement between the two operators for Fairchild’s criteria was almost perfect (Cohen’s kappa (k) =0.81) and substantial for ≥10 cumulative B-lines count (k=0.74). Fairchild’s criteria showed a higher diagnostic accuracy compared with ILD detected on HRCT, with an overall specificity (SP) and a positive predicted value (PPV) of 100% (Table 1). A negative correlation emerged between total lung capacity values (TLC%) and both B lines cut-off [first operator (IO): p 0.04, r -0.27; second operator (IIO): p 0.042, r-0.28] and pleural line criteria (IO: p 0.009, r -0.35; IIO: p 0.08, r – 0.36), but only the latter negatively correlated also with forced vital capacity values (FVC%) (IO: p 0.04, r – 0.27; IIO p 0.03, r -0.28). The ≥10 total B lines amount correlated positively with concurrent mycophenolate therapy (IO: p 0.09, r 0.28; IIO: p 0.005, r 0.37) and negatively with anti-centromere antibodies (IO: p 0.002, r -0.3; IIO p 0.009, r -0.34). The presence of digital ulcers showed a positive correlation with pleural line criteria (IO: p 0.03, r 0.29; IIO: p 0.005, r 0.37), with a significant association on multivariate analysis (IO: p 0.03, IIO: p 0.01).

Table 1.

Overall sensitivity, specificity, positive predictive value, negative predictive value of LUS compared to ILD detected on HRCT. C.I. 95% confidence interval.

SE (C.I.)SP (C.I.)PPV (C.I.)NPV (C.I.)Fairchild’s criteria fulfilling0.91 (0.76 - 0,97)1 (0.78 – 1.000)1 (0.88 -1.00)0.82 (0,59 – 0.94)≥10 cumulative B-lines count0.73 (0.56 – 0.85)0.8 (0.55 – 0.93)0.89 (0.72 – 0.96)0.57 (0.36 – 0.75)

Conclusion

We confirmed the feasibility and reliability of Fairchild’s recently proposed pleural line LUS criteria, that showed a higher diagnostic accuracy versus ≥10 cumulative B-lines count for ILD detected on HRCT, presenting SP and PPV values of 100% in SSc. Furthermore, these LUS features seem to differently associate with other aspects of the disease such as autoantibody specificity and vascular lesions, thus deserving future deeper evaluations. For the first time, we found that Fairchild’s criteria were associated with a clinical variable such as digital ulcers. Our results highlight the relevance of pleural line evaluation for ILD detection in SSc on LUS and its possible role towards a standardization of this diagnostic technique.

References

[1]Gutierrez M et al., Radiol Med, 2019.

[2]Xie, H.Q et al. Arthritis Res Ther, 2019.

[3]Tardella M et al., Medicine (Baltimore), 2018.

[4]Fairchild R et al. Arthritis Care Res, 2021.

Disclosure of Interests

None declared

AB0380 ANTI-TNFα: ORIGINATORS vs BIOSIMILARS, COMPARISON IN CLINICAL RESPONSE ASSESSMENT IN A MULTICENTER COHORT OF PATIENTS WITH INFLAMMATORY ARTHROPATHIES

Background

Tumor necrosis factor (TNF)-α is one of principal proinflammatory cytokines involved in pathogenesis of different inflammatory arthropathies as Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) and Ankylosing Spondylitis (AS). Biotechnological drugs, represented among others by monoclonal antibodies directed against TNF-α, lead to a revolution in RA and spondylarthritis treatment. They were the first biological drugs used to treat these diseases, with good results in terms of safety and efficacy. Also because of high cost of these drugs, for some years biosimilars have been introduced in clinical practice. Biosimilars are less expensive (in Italy, less of 30% than bioriginators); they underwent to a severe process of “comparability” to assess safety and efficacy like their originators. In Italy, AIFA authorized SB4 (etanercept biosimilar), SB5 and ABP501 (adalimumab biosimilars) after passing III-phase randomized clinical trials; but real-life data and registers are lacking.

Objectives

Aim of this study is to compare biosimilars and bioriginators in terms of safety and efficacy in a real-life contest.

Methods

We consequently enrolled patients, affected by inflammatory arthropathies (RA, PsA, AS) and treated with biosimilars (SB4, ABP501), belonging to any of the main biological prescribing centers in the Lazio region, from 2017 to 2020. Moreover, we enrolled patients, affected by same inflammatory diseases, but treated with corresponding originator. Clinical and laboratory data as well as disease activity indices, were collected at recruitment (T0) and after 4 (T1), 8 (T2), 12 (T3) and 24 (T4) months of therapy. Adverse events were registered.

Results

The multicenter cohort was composed by 455 patients treated with biosimilars (SB4/ABP501 276/179; F/M 307/146; naïve 56%, median age/IQR 55/46-65) and 436 treated with originators (etanercept/adalimumab 186/259, F/M 279/157, naïve 67,2%, median age/IQR 53/43-62). No differences were found about safety, but biosimilar group presented a higher number of discontinuations due to inefficacy (p<0.001), observed at all time-points. Female gender, to be smoker and b-DMARDs naïve, the initial non-response to the drug were predictive factors of reduced drug survival (p=0,05, p=0,046, p=0,001 respectively). Retention rate at 24 months was 81.1% for bioriginators and 76.5% for biosimilars (with a median retention time of 20.7 and 18.9 months, respectively) (p=0.002). Patients with remission/low disease activity achievement at T1 showed a cumulative survival of 90% to biosimilar therapy until at T4 (p=0.001); early adverse reactions instead represented an important cause of subsequent drug discontinuation (p=0.001).

Conclusion

Real-life data demonstrated the same safety between biosimilars and originators but a reduced biosimilar retention rate at 24 months, about 76%. Despite their loss efficacy, biosimilars could be considered valid and safe, and a good and less expensive alternative to the originators, allowing access to these innovative treatments to a wider patient population.

References

[1]Feldmann, M. & Maini, R. N. Anti-TNFα therapy of rheumatoid arthritis: what have we learned? Annu. Rev. Immunol. 2001;19, 163–196.

[2]McInnes IB, Schett G (2007) Cytokines in the pathogenesis of rheumatoid arthritis. Nat Rev Immunol 7:429–442

[3]Velayudhan J, Chen YF, Rohrbach A, Pastula C, Maher G, Thomas H, et al. Demonstration of functional similarity of proposed biosimilar ABP 501 to adalimumab. BioDrugs. 2016;30(4):339– 51.

[4]Emery P, Vencovsky ́ J, Sylwestrzak A et al. Long-term safety and efficacy of SB4 (etanercept biosimilar) in patients with rheumatoid arthritis: comparison between continuing SB4 and switching from etanercept reference product to SB4. Ann Rheum Dis 2016; 75:236.

Figure 1.

Disclosure of Interests

None declared

AB0087 THE EFFECT OF BARICITINIB ON STAT1 PHOSPHORYLATION IN MONOCYTES FROM RHEUMATOID ARTHRITIS PATIENTS

Background

Baricitinib is a Janus kinase (JAK)1/JAK2 inhibitor approved for the treatment of rheumatoid arthritis (RA)1-2. STAT proteins bind JAK kinase dimers coupled with cytokine receptors and regulate gene transcription. The JAK/STAT system is responsible for the intracellular signaling of different cytokines contributing to the activation process of the monocyte lineage, therefore the use of JAK inhibitors can affect cell functionality3-6.

Objectives

The aim of the present study was to verify the effects of baricitinib on STAT phosphorylation in peripheral mononuclear cells (PBMCs) of RA patients and to evaluate any correlation between STAT phosphorylation and response to therapy.

Methods

At baseline (BL) and after 4 weeks (w4) of treatment, we evaluated patients’ disease activity (DAS28PCR, CDAI and SDAI), dividing them into responders and non-responders according to the Minimal Clinically Important Difference for DAS28PCR (1.2 points) at w4. The phosphorylation of STAT1, STAT4 and STAT5 was analyzed at BL and w4 in gated monocytes, Treg, CD8 + and CD4 + lymphocytes from 4 responder and 4 non-responder patients through flow cytometry, at basal conditions and after IL2, IFNα and IL6 stimulation.

Results

Baseline clinical and demographic characteristics of patients are reported in Table 1. We showed that monocyte count decreased from BL to w4 mostly in responders. Basal pSTAT1 phosphorylation tent to be higher in monocytes of non-responder patients; after 4 weeks of treatment, the reduction of the cytokine-induced pSTAT1 was significantly greater in monocytes from responders compared to non-responders (Figure 1). The phosphorylation of STAT4 and STAT5 was not affected by treatment in any cell type and at any time point. We further studied the STAT1 phosphorylation pathway isolating the effect of stimulation with IFNα and stratifying monocytes according to their surface marker expression of CD14 and CD16 in classical, intermediate and non-classical. We observed the same pattern with a significant greater reduction of pSTAT1 in monocytes from responder patients, compared to non-responders, after the treatment with baricitinib.

Table 1.

Clinical and demographic characteristics of Rheumatoid Arthritis patients.

Clinical and demographic characteristicsN=8Age (years), median (IQR)59 (8)Female:Male7:1Etnicity-Caucasian n (%)6 (75)-Hispanic n (%)2 (25)Disease duration (months), median (IQR)156 (201)Rheumatoid Factor, n (%)3 (37.5)ACPA, n (%)4 (50)Number of previous csDMARDs, n (%)-12 (25)-21 (12.5)-31 (12.5)-≥ 44 (50)Number of previous bDMARDs, n (%)-12 (25)-22 (25)-31 (12.5)-≥ 43 (37.5)Baricitinib in monoterapy, n (%)5 (62.5)Daily PDN dose, median (IQR)5 (6)

ACPA: anti-citrullinated protein antibodies; csDMARDs: conventional syntetic disease-modifying antirheumatic drugs; bDMARDs: biological disease-modifying antirheumatic drugs; PDN: prednisone.

Figure 1.

STAT1 phosphorylation in responder (R) and non-responder (NR) patients at basal conditions (before stimulation) (a), and after cytokine (IL2, IFNα and IL6) stimulation (b) at baseline and at T1 (week 4).

Conclusion

These results may suggest that monocyte count and STAT1 phosphorylation in circulating monocytes could represent early markers of response to baricitinib therapy.

References

[1]Gadina M, et al. Janus kinases to jakinibs: from basic insights to clinical practice. Rheumatology (Oxford). 2019

[2]Gadina M, et al. Translating JAKs to Jakinibs. J Immunol. 2020

[3]Kubo S, et al. The JAK inhibitor, tofacitinib, reduces the T cell stimulatory capacity of human monocyte-derived dendritic cells. Ann Rheum Dis. 2014

[4]Kubo S, et al. Janus Kinase Inhibitor Baricitinib Modulates Human Innate and Adaptive Immune System. Front Immunol. 2018

[5]Ikari Y, et al. Peficitinib Inhibits the Chemotactic Activity of Monocytes via Proinflammatory Cytokine Production in Rheumatoid Arthritis Fibroblast-Like Synoviocytes. Cells. 2019

[6]Yang X, et al. Tofacitinib inhibits ox-LDL-induced adhesion of THP-1 monocytes to endothelial cells. Artif Cells Nanomed Biotechnol. 2019

Disclosure of Interests

Cristina Garufi Consultant of: Lilly, Gloria Tucci: None declared, Ilenia Pacella: None declared, Marta Zagaglioni: None declared, Alessandra Pinzon Grimaldos: None declared, Fulvia Ceccarelli: None declared, Silvia Piconese: None declared, Francesca Romana Spinelli Consultant of: Lilly, Fabrizio Conti Consultant of: Lilly

POS0120 NEUROLOGICAL INVOLVEMENT IN A MONOCENTRIC COHORT OF PATIENTS WITH SERONEGATIVE ANTIPHOSPHOLIPID SYNDROME

Background

The nervous system is affected in a relevant number of patients with antiphospholipid syndrome (APS), being responsible for high morbidity and mortality rates. The identification of neurological manifestations is crucial since those symptoms may benefit from anticoagulation treatment. Noteworthy, the prevalence and the characteristics of neurological manifestations in the subset of patients with “seronegative APS” (SN-APS) still need to be investigated.

Objectives

The aim of this study was to assess the neurological involvement in patients with SN-APS. Secondly, association between non-conventional antiphospholipid antibodies (aPL) and clinical characteristics were investigated.

Methods

We included all consecutive patients referred to the Lupus Clinic and to the Stroke Unit of our Hospital, presenting clinical features consistent with a diagnosis of APS despite the evidence of persistently negative tests for anti-cardiolipin antibodies (aCL), anti-β2 glycoprotein I, and lupus anticoagulant. Patients with an identified cause of thrombosis and/or pregnancy morbidity were excluded. Patients’ sera were analyzed for the detection of aCL using thin layer chromatography (TLC), while ELISA test was used to detect antibodies directed against the anti-vimentin/cardiolipin complex (aVim/CL).

Results

From January 2015 to October 2019, 40 patients with SN-APS and neurological involvement were enrolled. Clinical and demographic characteristics are reported in Table 1. Thirty-three patients (82.5%) resulted positive for at least one non-conventional test (62.5% positive on two occasions) while 17.5% were negative. The occurrence of aCL by TLC immunostaining was 33/40 (82.5%), while a Vim/CL were found in 10/40 (25%). Double positivity for aCL by TLC-immunostaining and aVim/CL was observed in 8/40 patients (20%). Patients who tested positive for non-conventional aPL on two occasions had a five-fold increased risk of developing venous thrombosis (LR 5.24; p=0.022). The positivity for aCL by TLC immunostaining determined an augmented risk of sinus vein thrombosis (LR 5.49; p=0.019) while positivity for aVim/CL raised the likelihood of epilepsy (LR 4.133; p=0.042). Almost all (16/18, 88%) patients with ischemic stroke resulted positive at least one test, 15 tested positive for aCL by TLC-immunostaining and 3 for aVim/CL. In this subset of patients, the positivity for non-conventional aPL on two occasions determined an increased risk of venous thrombosis (LR 8.905; p=0.003) and recurrent stroke (LR 6.321; p=0.012). In particular, those who tested positive for aVim/CL were at higher risk of developing recurrent stroke (LR 6.659; p=0.01).

Table 1.CharacteristicsPatients N= 40 (%)Female/Male35/5Mean age in years (S.D.)48 (12.5)Thrombosis34 (85)  Arterial23 (57.5) Venous17 (42.5) Recurrent13 (32.5)Pregnancy morbidity12 (34.3) Recurrent miscarriage11 (31.4) Foetal deaths2 (5.7) Premature births2 (5.7)Thrombosis + Pregnancy morbidity6 (17.1)Neurological manifestations Stroke18 (45) Recurrent stroke7 (17.5) Transient ischemic attack4 (10) Venous sinus thrombosis5 (12.5) Headache18 (45) Epilepsy7 (17.5) Transverse myelitis2 (5)Other manifestations Livedo reticularis5 (12.5) Low platelets3 (7.5)

Conclusion

The nervous system is one of the most frequently affected in APS, however only few data exist about prevalence, characteristics and outcome of its involvement in SN-APS patients. In this work, using TLC immunostaining and ELISA for aVim/CL, we identified non-conventional aPL antibodies in 62,5% SN-APS patients. This subset of patients presented a wide spectrum of neurological manifestations, with frequencies and features that resemble those observed in APS patients. Furthermore, we demonstrated the association between non-conventional aPL and neurological manifestations, such as sinus vein thrombosis, recurrent stroke and epilepsy. In conclusion, testing for non-conventional aPL antibodies may contribute to the evaluation of the stratification of risk for neurological manifestations in SN-APS.

Disclosure of Interests

None declared

AB0507 IMPACT OF CAFFEINE CONSUMPTION ON ENDOTHELIAL PROGENITOR CELLS SURVIVAL IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS

Background

Circulating endothelial progenitor cells (EPCs) are widely demonstrated biomarkers of endothelial function. Their frequency and function varied in systemic lupus erythematosus (SLE) patients, with a significant association with subclinical atherosclerosis1. Caffeine, one of the most widely consumed products in the world, seems to interact with multiple components of the immune system by acting as a non-specific phosphodiesterase inhibitor, and it seems to be able to activate autophagy2-3. In terms of cardiovascular disease (CVD), data from the literature showed a U-shaped association between habitual coffee intake and CVD4. In this view, Spyridopoulos et al. demonstrated a significant improvement in endothelial cells and EPCs migration after coffee consumption in coronary artery disease both in mouse models and in patients5. Finally, we demonstrated the impact of caffeine on SLE disease activity, in terms of SLEDAI2k values and serum cytokine levels. Moreover, patients with a low caffeine intake seemed to have a more severe disease phenotype6.

Objectives

The aim of this study was to evaluate the role of caffeine intake on endothelial function in SLE patients, by assessing its effect on number and function of EPCs both ex vivo in SLE patients and in vitro in healthy donors (HD) treated with SLE sera.

Methods

We performed a cross-sectional study enrolling consecutive SLE patients (revised 1997 ACR criteria), referring to the Sapienza Lupus Clinic. Patients with history of traditional CV risks factors were excluded. Caffeine intake was evaluated using a 7-day food frequency questionnaire. At the end of questionnaire filling circulating EPCs were detected by using a flow cytometry analysis defined as CD34+KDR+ cells. Subsequently, EPCs pooled from 6 HD were co-cultured with caffeine at 0.5 mM and 1 mM with and without SLE sera. After 7 days, we evaluated the cells morphology and the ability to form colonies. Moreover, we analyzed for the percentage of annexin V-positive (AV) apoptotic cells by flow cytometry analysis and for levels of autophagy and apoptotic markers LC3-II, p62 and Bcl2 by western blot.

Results

We enrolled 31 SLE patients (F:M 30:1, median age 43 years, IQR 18; median disease duration 144 months, IQR 180). The median intake of caffeine was 166 mg/day (IQR 194). We found a EPCs median percentage of 0.03% (IQR 0.04) observing a positive correlation between caffeine intake and EPCs percentage (p=0.03, r=0.4). Moving on in vitro experiments, after 7 days of cell cultures, HD EPCs treated with SLE sera and caffeine showed an improvement in morphology and in number of EPCs-CFU in comparison with those incubated with SLE sera without caffeine (p=0.0003). Moreover, the colonies treated with SLE sera were poorly organized in comparison with HD; the addition of caffeine restored the colony structure. After treated HD-EPCs with SLE sera we observed an increase in AV positive cells and p62 and LC3-II values and a reduction of Bcl2 values; the addition of caffeine was able to significantly reduce AV positive cells and p62 and LC3-II values and to significantly increased Bcl2 values, without any significant differences between caffeine 0.5 mM and 1 mM treatment (Figure 1A-D).

Conclusion

Our data demonstrated the ability of caffeine in increasing the number of circulating EPCs in SLE patients. Moreover, in vitro experiments seem to suggest a protective role of caffeine on EPCs survival and vitality through the promotion of autophagy and the inhibition of apoptosis.

References

[1]Westerweel et al. Ann Rheum Dis 2007;

[2]Aronsen et al. Europ Joul of Pharm 2014;

[3]Li et al. Theranostics 2018;

[4]Ding et al. Circulation 2015;

[5]Spyridopoulos et al. Art. Thromb Vasc Biol. 2008;

[6]Orefice et al. Lupus 2020.

Disclosure of Interests

None declared

POS0553 NEW BIOMARKERS IN RHEUMATOID ARTHRITIS: ROLE OF HOMOCYSTEINYLATED ANTI-ALPHA1 ANTITRYPSIN ANTIBODIES

Background

Rheumatoid Arthritis (RA) is a multifactorial, chronic, systemic, inflammatory disease that can lead to progressive joint destruction (Alamanos et al, Autoimmun Rev 2005). Positivity for Rheumatoid Factor (RF) and antibodies against citrullinated proteins (ACPA) is useful for diagnostic and prognostic purposes. Nevertheless, in about 20% of patients, it is not possible to detect the presence of these autoantibodies. This has led to the identification of new antibody specificities, such as antibodies directed against carbamylated proteins (Mastrangelo A et al, J Immunol Res 2015) and, more recently, against homocysteinylated alpha 1 antitrypsin (anti-HATA) (Colasanti T et al, J Autoimmun 2020).

Objectives

To evaluate the prevalence of anti-HATA in a large cohort of patients with RA and their correlation with serological, clinical and erosive bone damage assessed by musculo-skeletal ultrasound (US).

Methods

Consecutive outpatients with RA, diagnosed according to the 2010 ACR/EULAR criteria, were enrolled. Demographic and clinical-laboratory data were recorded, including FR and ACPA determination. Disease activity was assessed by DAS28. The presence of anti-HATA antibodies was investigated by homemade ELISA using native alpha 1 antitrypsin modified in vitro to obtain homocysteinylated alpha 1 antitrypsin. US assessment was performed at the level of bilateral metacarpophalangeal and proximal interphalangeal joints; the presence of erosions and inflammatory features was identified according to OMERACT definitions (Wakefield RJ et al, J Rheumatol 2005).

Results

The present analysis included 91 RA patients (M/F 22/69; mean age 62 years; mean disease duration 12.5 years). Overall, the prevalence of anti-HATA was 69.2%. Anti-HATA antibodies were found in 63/91 (69.2%) of the entire patient cohort, whereas 68/91 (74.3%) patients were positive for ACPA and 63/91 (69.4%) for FR. 41.4% of patients had concomitant positivity for the three autoantibodies (FR, ACPA, anti-HATA). The analysis of patients with triple positivity for related arthritis antibodies (FR, ACPA, anti-HATA) was particularly interesting: indeed, in this subgroup, 80% of patients presented erosive damage, compared to 42.1% of patients who did not present simultaneously the three autoantibodies (p=0.0001). Patients with simultaneous positivity for RF, ACPA and anti-HATA showed a more aggressive disease phenotype (p=0.0001). Finally, a positive correlation was also found between disease activity (expressed by DAS28) and total inflammatory and erosive ultrasonographic score (p=0.005 and p=0.001, respectively).

Conclusion

The results of the present study confirm a high prevalence of anti-HATA in RA patients; furthermore, patients with concomitant presence of anti-HATA, ACPA and RF showed a more aggressive disease phenotype, in terms of erosive damage. Our analysis underlines as the characterization of new antibody specificities in RA could help in the early diagnosis of this disease and in the characterization of the different severity degrees.

References

[1]Alamanos Y, Drosos AA. Epidemiology of adult rheumatoid arthritis. Autoimmun Rev. 2005 Mar;4(3):130-6.

[2]Mastrangelo A, Colasanti T, Barbati C, Pecani A, Sabatinelli D, Pendolino M, Truglia S, Massaro L, Mancini R, Miranda F, Spinelli FR, Conti F, Alessandri C. The Role of Posttranslational Protein Modifications in Rheumatological Diseases: Focus on Rheumatoid Arthritis. J Immunol Res. 2015;2015:712490;

[3]Colasanti T, Sabatinelli D, Mancone C, Giorgi A, Pecani A, Spinelli FR, Di Giamberardino A, Navarini L, Speziali M, Vomero M, Barbati C, Perricone C, Ceccarelli F, Finucci A, Celia AI, Currado D, Afeltra A, Schininà ME, Barnaba V, Conti F, Valesini G, Alessandri C. Homocysteinylated alpha 1 antitrypsin as an antigenic target of autoantibodies in seronegative rheumatoid arthritis patients. J Autoimmun. 2020 Sep;113:102470.

[4]Wakefield RJ, Balint PV, Szkudlarek M, et al. Musculoskeletal ultrasound including definitions for ultrasonographic pathology. J Rheumatol 2005; 32: 2485-2487.

Disclosure of Interests

None declared.

AB1487 VALIDATION AND CULTURAL ADAPTATION OF THE QUALISEX QUESTIONNAIRE IN WOMEN WITH SJÖGREN’S SYNDROME IN ITALY

Background

The quality of sexual life (QSL) is a complex and multimodal experience influenced by endogenous and external factors, including age, gender, and cultural environment. Rheumatic diseases, with their burden of pain, fatigue, organ damage, and disability, can severely impair sexual life and this is true also for Sjögren’s Syndrome, where simple tools to assess the QSL in everyday clinical practice are needed.

Objectives

To translate ad adapt into Italian the Qualisex, a new brief questionnaire originally created for Rheumatoid Arthritis patients, for women with primary Sjögren’s Syndrome (pSS) and evaluate the impact of the disease on their sexuality.

Methods

Consecutive sexually active pSS (according to ACR/EULAR 2016 criteria) patients aged >18 were asked to participate in this study approved by the local bioethics committee. With the permission of the developer, the French original version of the Qualisex questionnaire (consisting of 10 items, the higher the score, the greater the negative impact of the disease on the QSL) was translated and adapted into Italian according to current guidelines. In the absence of a gold standard assessment for sexuality in pSS, face and content validity was assessed cross-sectionally by correlations with other disease aspects such as anxiety and depression measured by Hospital Anxiety and Depression Scale (HADS), EULAR SS patient-reported index (ESSPRI), and quality of the relationship. As a measure of reliability, internal consistency was assessed through Cronbach’s Alpha coefficient. A Cronbach’s value >0.7 is generally regarded as satisfactory. The feasibility of the scale was indirectly assessed through missing data. To assess the factorial structure of the Italian version of the questionnaire an Exploratory Factor Analysis (EFA) was carried out. Moreover we also assessed the level of redundancy by means of intra-item correlation of the Qualisex questionnaire. ESSDAI (EULAR Sjögren’s Syndrome Disease Activity Index), and SSDDI (Sjogren’s Syndrome Disease Damage Index) were assessed as well. Analyses were carried out with IBM SPSS Statistics for Macintosh, version 22.0 (IBM Corp., Armonk, NY, USA).

Results

40 sexually active women with pSS and a median age of 53 (IQR 45.25-57.25) were enrolled. The EFA showed that the model with a single factor appeared to be highly significant (Chi235= 2943.10; p<0.05); the average inter-item correlation was found to be 0.392 (Min -0.479; Max 0.834) which is an acceptable value as for redundancy. There were no missing answers. Cronbach’s alpha coefficient resulted to be 0.86 which indicates an adequate internal consistency. The median Qualisex score was 4.65 (IQR 2.13–6.2). As far as correlations, age (Rho=0.39; p<0.05), menopause (Rho=0.41; p<0.05), relationship quality (Rho=0.55; p<0.05), anxiety (HADS-A; Rho=0.38; p<0.05), and depression (HADS-D; Rho=0.47; p<0.05) appeared to be positively correlated with Qualisex score. Also, a positive correlation with ESSPRI (Rho=0.43; p<0.05), and drug use (Rho=0.37; p<0.05) was demonstrated. On the contrary no significant correlation was found with education (Rho=-0.07; p=0.64), systemic disease activity (Rho=0.14; p=0.39), and damage (Rho=0.06; p=0,74).

Conclusion

The Italian version of the Qualisex questionnaire is a valid, reliable and useful tool to assess the quality of sexual life in pSS. QSL in pSS women has an inverse relationship with age, menopause, drug use, ESSPRI, mood disorders, and dissatisfaction with the partner, while, as previously reported, no correlation was found with disease activity, damage, and educational status. This further highlights the impact of subjective symptoms such as dryness, pain, fatigue, and the overall psychological well-being on patients’ life. Thus, it is critical for the physician to consider patients’ perspective.

Disclosure of Interests

None declared

AB0118 PORPHYROMONAS GINGIVALIS AMOUNT IN THE TONGUE BIOFILM IS ASSOCIATED WITH EROSIVE ARTHRITIS IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Several data have demonstrated the occurrence of erosive arthritis in Systemic Lupus Erythematosus (SLE) patients. However, few studies have focused on the pathogenic mechanisms involved in this feature. The implication of oral pathogens has been proved in Rheumatoid Arthritis: in particular, Porphyromonas gingivalis (Pg), by inducing citrullination, could trigger autoimmune response.

Objectives

We evaluated amount of Pg of the tongue in a cohort of SLE patients with arthritis, focusing on the association with the erosive phenotype.

Methods

SLE patients with arthritis were enrolled. We evaluated the presence of ACPA and RF by using commercially enzyme-linked immunosorbent assay kits. SLEDAI-2k was applied to assess disease activity and DAS28 to assess joint inflammatory status. Erosive damage was evaluated by ultrasound at level of metacarpophalangeal and proximal interphalangeals joints. All subjects underwent a tongue cytologic swab in order to quantify the amount of Pg (real-time PCR). The bacterium expression was obtained from the ratio between the patient’s DNA amount and that obtained from healthy subjects.

Results

The present analysis included 33 SLE patients (M/F 3/30; median age 47 years, IQR 17; median disease duration 216 months, IQR 180). Concerning activity at the time of the enrollment, we found a median DAS28 value of 3.8 (IQR 2.8) and a median SLEDAI-2k of 4 (IQR 5). Twelve patients (36.4%) showed US-detected erosive damage in at least one joint, significantly associated with ACPA positivity (p<0.0001). Furthermore, patients with erosive damage showed significantly higher median DAS28 values in comparison with those without [4 (IQR 3.1) versus 3.2 (IQR 2.1), p=0.03]. Moving on the oral pathogen analysis, we found a mean Pg ratio of 19.7±31.1 (median 6.6, IQR 22.3). When dividing patients according to the presence of erosive damage, we found higher Pg amount in SLE patients with this phenotype in comparison with those without (31.4±44.3 versus 12.9±19.2, p=ns; Figure 1A). Thus, we used Pg mean values as threshold, identifying two groups of patients, namely highPg and lowPg. In a receiver operating characteristic curve analysis (ROC), this threshold resulted in the most sensitive and specific one (sensitivity of 85%; specificity of 50%). As reported in Figure 1B, erosive damage was significantly more frequent in highPg patients in comparison with lowPg (60.0% versus 26.0%, p=0.001). Furthermore, highPg patients showed higher prevalence of skin manifestations, serositis and neurological involvement compared to lowPg patients (p=0.005, p=0.03, p=0.0001, respectively).

Conclusion

The possible contribution of oral microbiota in SLE erosive arthritis was here evaluated for the first time, finding a significant association between erosive damage and higher expression of Pg at tongue level.

Disclosure of Interests

None declared

AB0119 ROLE OF COSTIMULATORY MOLECULES IN SYSTEMIC LUPUS ERYTHEMATOSUS: FOCUS ON CD137

Background

Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease characterized by a wide autoantibodies production. The traditionally concept of a B-cell driven disease has been changed in the last years due to the evidence demonstrating the crucial role of T cells in SLE pathogenesis. In particular, regulatory (Treg) and memory T cells seem act through co-stimulatory and co-inhibitory molecules, such as CD137, PD1-1 and CTLA4. The over-expression of this molecules on lymphocytes may contribute to immune system dysregulation.

Objectives

The primary objective of the present case-control study was to evaluate the expression of CD137, PD1-1 and CTLA4 on T cell surface of SLE patients by using flow-cytometry. Secondly, we evaluated the percentage of Treg and memory T cells.

Methods

We enrolled patients SLE patients (2019 ACR/EULAR criteria) and sex/age-matched healthy subjects (HS). Demographic, clinical, and laboratory data were collected in a standardized computerized electronically filled form. Disease activity was assessed by SLEDAI-2k. Each subject underwent peripheral blood sample collection. By using flow-cytometry we evaluated the expression of FOXP3, CD137, PD1-1 and CTLA4, CD45, CD25, CCR7 to determine the percentage of Treg and memory T cells.

Results

The present analysis included 21 SLE patients [M/F 1/20 median age 48 years (IQR 17), median disease duration 144 months (IQR 204)]. The Treg percentage was significantly lower in SLE compared to HS [median 4.2 (IQR 0.32) versus 2.5 (IQR 2.44); p=0.001, Figure 1A]. Moving on effector Treg (eTreg), SLE patients with high disease activity (SLEDAI > 4) showed a significantly higher prevalence for these cells compared to patients with SLEDAI ≤ 4 [1.16 (IQR 0.51) versus 0.53 (IQR 0.8), p=0.014, Figure 1B]. Moreover, inverse correlation was found between eTreg percentage and SLEDAI-2k [p=0.029, r=-0.47 (CI 0.75 – 0.04) Figure 1C]. The evaluation of CD137 expression was significantly higher in SLE patients compared to HS on CD3+ cells [median 5.32 (IQR 6.11) versus 3.3 (IQR 1.7), p=0.001, Figure 1F]. On CD4+ cells, CD137 expression positively correlated with disease activity [p=0.0082, r=0.58 (CI 0.15-0.82)]. Finally, when analysing memory T cells subpopulations, inverse correlation has been found between effector memory T cells (TEM, CD45RA-CCR7-) and SLEDAI-2k when considering CD3+ [p=0.029, r=-0.56 (CI 0.81 – 0.12)] and CD4+ cells [p=0.016, R=-0.54 (CI -0.80 - -0.1)]. Of note, CD137 expression on T central memory cells (TCM, CD45RA-CCR7+) positively correlated with SLEDAI-2k [(p=0.019, r=0.52 (CI 0.09 – 0.79)].

Figure 1.

A) Comparison of the percentage of Treg in HS and SLE patients. B) Comparison of the percentage of eTreg in SLE patients with high disease activity and low disease activity C) Correlation between % eTreg and SLEDAI-2k. D) Comparison of the percentage of CD3+CD137+ cells in HS and SLE patients. E) Comparison of % of CD4+CD137+ cells in SLE patients with high disease activity and low disease activity F) Correlation between % of CD4+CD137+ cells and SLEDAI-2k.

Conclusion

Our results suggest a possible role of CD137-CD137L axis in SLE pathogenesis. The stimulatory role of this molecule is indicated by the positive correlation between SLEDAI-2k values and surface expression of CD137. Moreover, inverse correlation between SLEDAI-2k and eTreg percentage suggests a possible Treg dysregulation in SLE.

Table 1.

SLE cohort features

Clinical and Laboratory FeaturesMucocutaneous80.9%Articular76.1%Serositis19.0%Kidney23.8%Haematological48.2%CNS/PNS9.5%Thrombotic events4.7%anti-dsDNA68.4%anti-SSA/anti-SSB47.6%anti-RNP19.0%anti-Sm33.0%Antiphospholipid antibodies14.2%Low C3/C457.1%Previous TherapyGlucocorticoid90.5%Hydroxychloroquine95.2%Methotrexate23.8%Mofetil Mycophenolate33.3%Ciclosporin28.5%Cyclophosphamide9.5%Azathioprine33.3%Rituximab14.3%Antiplatelet23.8%Anticoagulant therapy4.7%

Disclosure of Interests

None declared

Material effects on dynamics in triple-nozzle gas-puff Z pinches

The gas-puff Z pinch has a long history with myriad applications as an efficient neutron or x-ray source. Its simplicity as a load configuration makes it suitable for studying fundamental plasma physics phenomena such as instabilities and energy transport. For example, the implosion of cylindrical shells onto a fusion fuel are inherently susceptible to instability growth on their external surfaces; if such instabilities are unmitigated, then the consequences in terms of degraded performance can be substantial. Similarly, mitigating heat transport from a hot fuel to its colder surrounding container can make fusion conditions more easily achievable. Here we have conducted a systematic study of triple-nozzle (outer liner, inner liner, fuel) gas puffs using two-dimensional (2D) magnetohydrodynamic simulations to investigate the effect of load material on the relevant dynamics. Analogous to past studies on spherical blast waves and converging shock waves, a trend emerges linking increased radiative cooling, lower adiabatic index, and increased magneto-Rayleigh-Taylor instability growth. Notably, our results suggest that, for the present configuration, Ar radiates less than both Ne and Kr during the early stages of the implosion while mass is being swept up and perturbations begin to seed instability growth. Consequently, pinches with Ar on the outer surface exhibit more stable 2D behavior. Here we also present a parameter scan of thermonuclear neutron yield, Y, as a function of peak current, I_{pk} and dopant concentration with Ne or Ar, depending on the inner liner material. Above 6 MA, our results suggest Y∝I_{pk}^{5} and even substantial mixing (10% by volume) of Ne into the fuel does not drastically reduce yield, suggesting an Ar/Ne/fuel configuration may reliably achieve DD thermonuclear yields of 10^{13}-10^{14}/cm in the 10-20 MA range.

Tofacitinib Decreases Autophagy of Fibroblast-Like Synoviocytes From Rheumatoid Arthritis Patients

The pathway of Janus tyrosine kinases (JAKs) has a central role in the pathogenesis of Rheumatoid Arthritis (RA) by regulating multiple immune functions and cytokine production. The JAK inhibitor tofacitinib is effective in RA patients not responding to methotrexate or TNF-inhibitors. Since hyperactive autophagy has been associated with impaired apoptosis of RA fibroblast-like synoviocytes (FLS), we aimed to investigate the role of tofacitinib in modulating autophagy and apoptosis in these cells. FLS isolated from RA biopsies were cultured with tofacitinib in presence of autophagy inducer rapamycin and in serum deprivation condition. Levels of autophagy, apoptosis, and citrullinated proteins were analyzed by western blot, flow cytometry, immunocytofluorescence, and Real-Time PCR. Rapamycin induced an increase in RA-FLS autophagy while the levels of autophagy marker LC3-II were reduced after in vitro treatment with tofacitinib. The analysis of autophagic flux by specific fluorescence dye confirmed the reduction of autophagy in RA FLS. The treatment with tofacitinib did not influence apoptosis of RA FLS. Modulation of the autophagic process by tofacitinib did not significantly change citrullination. The results of this study demonstrate that tofacitinib is able to modulate autophagy of FLS contributing to its effectiveness in RA patients.

Maladaptive autophagy in the pathogenesis of autoimmune epithelitis in Sjӧgren's Syndrome

OBJECTIVE

Salivary gland epithelial cells (SGECs) are key cellular drivers in the pathogenesis of primary Sjӧgren's Syndrome (pSS); however, the mechanisms sustaining SGECs activation in pSS remain undetermined. The aim of this study is to determine the role of autophagy in the survival and activation of SGECs in pSS.

METHODS

Primary SGECs isolated from minor salivary glands (SG) of patients with pSS or sicca syndrome were evaluated by flow-cytometry, immunoblotting, and immunofluorescence to assess autophagy (autophagic-flux, LC3IIB, p62, LC3B+/LAMP1+ staining), apoptosis (annexin V/PI, Caspase-3) and activation (ICAM, VCAM). Focus score and germinal centers presence was assessed in SG from the same patients to correlate with histological severity. Human salivary gland (HSG) cells were stimulated in vitro with PBMCs and serum from pSS patients in the presence or absence of autophagy inhibitors to determine changes in autophagy and epithelial cell activation.

RESULTS

SGECs from pSS patients (n=24) exhibited increased autophagy (autophagic-flux p=0.001; LC3IIB p=0.02; p62 p=0.064; LC3IIB/LAMP1+ staining), increased expression of anti-apoptotic molecules (Bcl2 p=0.006), and reduced apoptosis (Annexin-V/PI p=0.002, Caspase-3 p=0.057) compared to sicca (n=16). Autophagy correlated with histologic disease severity. In vitro experiments on HSG cells stimulated with serum and PBMCs from pSS patients confirmed activation of autophagy and expression of adhesion molecules, which was reverted upon pharmacologic inhibition of autophagy.

CONCLUSIONS

In pSS SGECs, inflammation induces autophagy and pro-survival mechanisms, which promote SGEC activation and mirror histological severity. These findings indicate that autophagy is a central contributor to the pathogenesis of pSS and a new therapeutic target.

Mitigation of magneto-Rayleigh-Taylor instability growth in a triple-nozzle, neutron-producing gas-puff Z pinch

The gas-puff Z-pinch is a well-known source of x-rays and/or neutrons, but it is highly susceptible to the magneto-Rayleigh-Taylor instability (MRTI). Approaches to MRTI mitigation include density profile tailoring, in which nozzles are added or modified to alter the acceleration trajectory, and axial pre-magnetization, in which perturbations are smoothed out via magnetic field line tension. Here, we present two-dimensional magnetohydrodynamic simulations of loads driven by an 850 kA, 160 ns driver that suggest these mitigation strategies can be additive. The initial axial magnetic field, B_{z0}, to stabilize a 2.5-cm-radius Ne gas liner imploding onto an on-axis deuterium target can be reduced from 0.7 T to 0.3 T by adding a second liner with a radius of 1.25 cm. Because MRTI mitigation tends to increasingly lower yield with higher B_{z0}, the use of a lower field is advantageous. Here, we predict a reduction in yield penalty from >100× with the single liner to <10× with a double liner. A premagnetized, triple nozzle gas puff could therefore be an attractive source for intense neutrons or other fusion applications.

Durability of Dolutegravir-Based Regimens: A 5-Year Prospective Observational Study

This study evaluates the frequency and causes of dolutegravir (DTG) discontinuation along 5 years of follow-up, in both antiretroviral treatment (ART)-naive and experienced people living with HIV (PLWH). This is a prospective multi-center cohort study enrolling PLWH on DTG from July 2014 until November 2020. DTG-durability was investigated using the Kaplan-Meier survival curve. The Cox proportional-hazards model was used for estimating the hazard ratio (HR) of DTG discontinuation for any cause, and for adverse events (AEs). Nine hundred sixty-three PLWH were included, 25.3% were women and 28.0% were ART-naive. Discontinuations for any causes were 10.1 [95% confidence interval (95% CI) 8.9-11.5] per 100 person-years, similar in most regimens, with the apparent exception of tenofovir alafenamide/emtricitabine+DTG (p < 0.0001). In the multivariable Cox regression model, non-Caucasian ethnicity, age ≥50 years, and lower estimated glomerular filtration rate (eGFR) were associated with a higher probability of DTG interruption. The incidence rate of virological failure was 0.4 (95% CI 0.2-0.7) per 100 person-years, while the estimated discontinuation rate for AEs was 4.0 (3.2-4.9) per 100 person-years. Thirty-four DTG interruptions were due to grade ≥3 events (10 central nervous system, 6 hypersensitivity, 3 renal, 3 myalgia/asthenia, 3 abdominal pain, 2 gastrointestinal, and 7 other events). People with lower body mass index, age ≥50 years, and lower eGFR were at higher risk of AEs, while dual combinations were protective (HR 0.41 compared with abacavir/lamivudine/DTG, 95% CI 0.22-0.77). In this prospective observational study, we found high DTG durability and a low rate of virological failures. Dual therapies seemed protective toward AEs and might be considered, when feasible, a suitable option to minimize drug interactions and improve tolerability.

Identification of lenvatinib prognostic index via recursive partitioning analysis in advanced hepatocellular carcinoma

BACKGROUND

After the advent of new treatment options for advanced hepatocellular carcinoma (HCC), the identification of prognostic factors is crucial for the selection of the most appropriate therapy for each patient.

PATIENTS AND METHODS

With the aim to fill this gap, we applied recursive partitioning analysis (RPA) to a cohort of 404 patients treated with lenvatinib.

RESULTS

The application of RPA resulted in a classification based on five variables that originated a new prognostic score, the lenvatinib prognostic index (LEP) index, identifying three groups: low risk [patients with prognostic nutritional index (PNI) >43.3 and previous trans-arterial chemoembolization (TACE)]; medium risk [patients with PNI >43.3 but without previous TACE and patients with PNI <43.3, albumin-bilirubin (ALBI) grade 1 and Barcelona Clinic Liver Cancer stage B (BCLC-B)]; high risk [patients with PNI <43.3 and ALBI grade 2 and patients with PNI <43.3, albumin-bilirubin (ALBI) grade 1 and Barcelona Clinic Liver Cancer stage C (BCLC-C)]. Median overall survival was 29.8 months [95% confidence interval (CI) 22.8-29.8 months] in low risk patients (n = 128), 17.0 months (95% CI 15.0-24.0 months) in medium risk (n = 162) and 8.9 months (95% CI 8.0-10.7 months) in high risk (n = 114); low risk hazard ratio (HR) 1 (reference group), medium risk HR 1.95 (95% CI 1.38-2.74), high risk HR 4.84 (95% CI 3.16-7.43); P < 0.0001. The LEP index was validated in a cohort of 127 Italian patients treated with lenvatinib. While the same classification did not show a prognostic value in a cohort of 311 patients treated with sorafenib, we also show a possible predictive role in favor of lenvatinib in the low risk group.

CONCLUSIONS

LEP index is a promising, easy-to-use tool that may be used to stratify patients undergoing systemic treatment of advanced HCC.

AB0079 ENDOTHELIAL FUNCTION IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS: IMPACT OF CAFFEINE CONSUMPTION ON ENDOTHELIAL PROGENITOR CELLS

Background:

As widely demonstrated, circulating endothelial progenitor cells (EPCs) could be considered biomarkers of endothelial dysfunction. Their frequency and function varied in systemic lupus erythematosus (SLE) patients, with a significant association with subclinical atherosclerosis1. Caffeine, one of the most widely consumed products in the world, seems to interact with multiple components of the immune system by acting as a non-specific phosphodiesterase inhibitor2. In terms of cardiovascular disease (CVD), data from the literature showed a U-shaped association between habitual coffee intake and CVD3. In this view, Spyridopoulos et al. demonstrated a significant improvement in mature endothelial cells and EPCs migration in relation to coffee consumption in coronary artery disease both in mouse models and in patients4. Finally, caffeine seems to play a positive effect on SLE disease activity status, as demonstrated by the inverse association between its intake and SLE Disease Activity Index 2000 (SLEDAI-2K) and the serum levels of inflammatory cytokines5. At the best of our knowledge, there are no data about the effect of caffeine on cardiovascular risk in SLE patients.

Objectives:

The aim of this study was to evaluate the possible role of caffeine intake on endothelial function in SLE patients, by evaluating its effect on circulating EPCs.

Methods:

We performed a cross-sectional study enrolling SLE patients, fulfilling the revised 1997 ACR criteria. According with the protocol study, we excluded patients with history of smoking, CVD, chronic kidney failure, dyslipidaemia, and/or diabetes. At recruitment, the clinical and laboratory data were collected and disease activity was assessed using the SLEDAI-2k. Caffeine intake was evaluated using a 7-day food frequency questionnaire, previously employed in SLE cohort5. At the end of questionnaire filling, blood samples were collected. EPCs were isolated from peripheral blood mononuclear cells (PBMC) by a flow cytometry analysis and they were defined as early EPCs CD34+KDR+CD133+ cells and late EPCs CD34+KDR+CD133-, expressed as a percentage within the lymphocyte gate.

Results:

We enrolled 19 patients (F:M 18:1, median age 45 years, IQR 15; median disease duration 240 months, IQR 168). In this cohort, we observed a mean±SD SLEDAI-2k value of 1.3±3.3 and the most frequent disease-related feature was joint involvement (73.7%). Concerning treatment at the time of enrolment, the majority of patients were receiving treatment with hydroxychloroquine (78.9%) and seven with glucocorticoids (36.8%). The median intake of caffeine was 163 mg/day (IQR 138) and we used this value as cut-off to categorize SLE patients in 2 groups: group 1 (N=10, caffeine intake ≤ 163 mg/day) and group 2 (N=9, caffeine intake > 163 mg/day). Patients with less intake of caffeine showed a significantly more frequent history of lupus nephritis (p=0.03), haematological manifestations (p=0.0003) and anti-dsDNA positivity (p=0.0003). Moving on EPCs, a positive correlation between caffeine intake and EPCs percentage was observed (p=0.04, r=0.4) (Figure 1A). Moreover, patients with more caffeine intake showed higher levels of early EPCs (p=0.02) (Figure 1B).

Conclusion:

This is the first report analysing the impact of caffeine on EPCs frequency in SLE patients. We found a positive correlation between its intake and both early and late EPCs percentage, suggesting a caffeine influence on endothelial function in SLE patients. Nonetheless, these results support the possible impact of dietary habits on autoimmune diseases.

References:

[1]Westerweel et al. Ann Rheum Dis 2007.

[2]Aronsen et al. Europ Joul of Pharm 2014.

[3]Ding et al. Circulation 2015.

[4]Spyridopoulos et al. Art. Thromb Vasc Biol. 2008.

[5]Orefice et al. Lupus 2020.

Disclosure of Interests:

None declared

AB0234 SURVIVAL OF ABATACEPT IN RHEUMATOID ARTHRITIS PATIENTS: A REAL-LIFE STUDY

Background:

Abatacept (ABA) is a biological drug approved for the treatment of rheumatoid arthritis (RA) patients that, by working on CTLA4, can inhibit T-cell activation. Randomized controlled trials have demonstrated both the efficacy and a good safety profile, characterized by a lower infectious risk in comparison with other biological DMARDs, in RA patients. In a real-life setting, the drug retention rate could be considered as a surrogate of drug effectiveness. Data from the literature reported a retention rate of ABA ranging from 55 to 76% at 12 months and from 54 to 64% at 24 months (1-3).

Objectives:

In the present longitudinal analysis, we evaluated the retention rate of ABA in a large monocentric RA cohort.

Methods:

We enrolled consecutive RA patients starting treatment with intravenous (IV) or subcutaneous (SC) ABA according to the standard of care. All the patients fulfilled the 2010 ACR/EULAR classification criteria for RA. For each patient, we collected demographic parameters, serological status, previous and concomitant treatments, and disease activity by DAS28 with C reactive protein (DAS28-CRP). All the patients were assessed at baseline, and after 4 and 12 months (T4 and T12, respectively). The reasons for withdrawal of treatment were registered and classified as primary or secondary inefficacy or adverse events (AEs). Kaplan-Meier statistical analysis has been done to evaluate the survival of the treatment in patients with at least 12 months follow-up.

Results:

We evaluated 161 patients [M/F 21/140; median age 67 years (IQR 21.7), median disease duration 180 months (IQR 161)]. RF was positive in 70.3% of patients, ACPA in 66.4%. ABA was the first biological DMARD in 66 patients (41%). At baseline, the median DAS28-CRP was 4.3 (IQR 1.6) and ABA was administered in association with MTX in 96 patients (59.6%). One hundred-eleven patients (68.9%) started SC ABA [M/F 16/95; median age 64.5 years (IQR 21.5), median disease duration 156 months (IQR 132)], the remaining 50 IV ABA [M/F 5/45, median age 71 years (IQR 60.2), median disease duration 187 months (IQR 157)]. Median age and disease duration were significantly higher in patients receiving IV in comparison with SC ABA (p=0.008 and p=0.03, respectively). We found a significant reduction of DAS28-CRP values during the follow-up in comparison with baseline [4 months: median 3.5 (IQR 1.9), p<0.0001; 12 months: median 3.2 (IQR 1.4), p<0.0001]. Seven patients were lost to follow-up, in the remaining 154 patients a median treatment duration of 33 months (IQR 49) was registered. Data on drug survival are reported in Figure 1A: at 12 months, 92% of patients persisted on treatment; this percentage decreased to 78.2% at 24 months and to 67.9% at 36 months. Furthermore, we did not find any differences in drug survival either with respect to SC vs IV administration (12 months: 93.7% versus 88.6%; 24 months 78.9% versus 72.6%; 36 months 63.7% versus 72.6%; Figure 1B) or according to the association with MTX. Concerning the withdrawal reasons, 46 patients (29.9%) stopped ABA due to inefficacy (primary in 28, secondary in 18), 11 patients (7.1%) due to AEs, and 7 for inadequate adherence (4.5%). Finally, 10 patients switched from IV to SC administration, due to patient’s preference.

Conclusion:

In our monocentric RA cohort, we have observed a high retention rate of ABA at both 12 and 24 months, confirming the good profile of this drug in terms of effectiveness and safety, irrespective of the route of administration and association with MTX.

References:

[1]Cagnotto, Arthritis Res Ther 2020; (2) Salmon, J Clin Med 2020; Westhovens, Rheumatol Int 2020.

Acknowledgements:

I would like to acknowledge Dr. F. Ceccarelli, for her patience.

Disclosure of Interests:

None declared

POS0783 LUPUS NEPHRITIS: HISTOLOGICAL FEATURES AND LONG TERM OUTCOMES IN A LARGE SINGLE-CENTRE COHORT

Background:

In Systemic Lupus Erythematosus (SLE) patients the incidence of lupus nephritis (LN) is about 40% (1). The rate of progression to end stage renal disease (ESRD) is 4.3-10.1% (2) and renal involvement is a strong predictor of morbidity and mortality.

Objectives:

To describe clinical, histological features and renal outcomes of LN patients included in our single-center registry reporting data from more than 30 years. Moreover, we examined the correlation between clinical features at LN diagnosis and therapeutic lines used during the course of a 24 years follow-up.

Methods:

A total of 71 patients were diagnosed with LN from 1989 to 2020. Demographic features and laboratory abnormalities (serum creatinine, 24 hours urine protein, urinary sediment, ds-DNA) at the time of LN diagnosis and at last available follow-up, were evaluated. We also examined renal biopsy performed and the histological classes (proliferative vs non-proliferative). We considered the increase number of therapeutic lines adopted as a negative prognostic factor in response to therapy.

Mean (SD) or median (IQR) were used according the variable distribution. T-test and Chi square and Mann-Whitney were used and p-value <0.05 were considered significant.

Results:

Among 71 patients with LN, 63 (88.7%) were females and 8 (11.3%) males, with a F/M ratio of 6. Median SLE duration was 180 (162) months. The median age at the onset of nephritis was 28 (19.5) years and occurred in median after 12 (60) months from SLE diagnosis.

Sixty patients underwent a biopsy: the histology showed class III or IV prolipherative glomerulonephritis in 49 patients (81.6%) and a non-proliferative class in 11 (18.3%) (p< 0.0001). Median serum creatinine value, 24 hours urine protein, urinary sediment, anti-ds-DNA at LN onset are reported in Table 1. Induction therapy was performed with cyclofosfamide in 14.5% of cases, mycophenolate in 21.1%, rituximab in 1.3%, cyclosporine A in 1.9% and azathioprine in 4.6%. The lines of therapies adopted during the follow-up ranged between a minimum of 0 and a maximum of 6 lines with a median value of 1.

Overall, the median follow-up was 180 (111) months and 30 (21.3%) patients had at least 120 months of follow-up. Median serum creatinine value, 24 hours urine protein, urinary sediment and eGFR last available follow-up are reported in Table 1.

Three patients underwent dialysis and 3 kidney transplantation.

Eight patients underwent a re-biopsy: 7 (87.5%) had a proliferative class and 1 (12.5%) had a membranous class (p=0.01). Median serum creatinine value, 24 hours urine protein, urinary sediment at re-biopsy are reported in Table 1. In re-bioptized subgroup patients, induction therapies were cyclofosfamide in 50% of cases, mycophenolate in 12.5%, cyclosporine A in 25% and azathioprine in 12.5%.

There were not statistically significant differences among the age on LN onset, the time from renal onset to the onset of the disease and the number of therapeutic lines adopted (Figure 1).

Conclusion:

Among patients with LN the proliferative classes are the most common. At the 15-year follow-up 2,1% had renal transplantation and 2,1% dyalisis. We did not detect any association between age at diagnosis, time from renal impairment and the number of therapeutic lines.

References:

[1]Fanouriakis A et al. Update EULAR/ERA–EDTA recommendations for the management of lupus nephritis. Ann Rheum Dis 2019.

[2]Hanly JG et al. The frequency and outcome of lupus nephritis: results from an international inception cohort study. Rheumatology 2016.

Table 1.

Laboratory features in SLE patients at LN onset, at last available follow-up and in re-bioptized patients.

LN onset(n 71)AFTER 10 years long FOLLOW-UP(n 30)P valueRe-bioptized patients(n 8)Serum creatinine (mg/dl)0.81 (+/- 0.4)0.87 (+/- 0.60)0,071.05 (0.45)24 hours urine protein (mg/24 h)3000 (+/- 3707)330 (+/- 793)<0,000015068 (2392)Active urinary sediment64 patients (45,44%)2 patients (6.66%)<0,000018 patients (100%)Anti-ds-DNA +30 patientseGFR <50ml/h12 patients (3.6%)

Disclosure of Interests:

None declared

POS0685 MYCOPHENOLATE MOFETIL IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS: FIVE-YEARS DRUG SURVIVAL IN RENAL AND NON-RENAL INVOLVEMENT

Background:

The updated EULAR recommendations for the management of systemic lupus erythematosus (SLE) underline the use of Mycophenolate Mofetil (MMF) in the treatment of different disease related manifestations (1). Several randomized controlled trials have demonstrated the efficacy of MMF in lupus nephritis (LN) patients but only case series and open-labelled trials have analyzed the use of this drug in other than LN features. Moreover, no data are available about the MMF retention rate in a real-life setting.

Objectives:

The present study aims at evaluating the 5-years drug retention rate (DRR) of MMF in a large monocentric SLE cohort. Secondly, we investigated the influence of MMF in disease activity changes and chronic damage progression.

Methods:

We performed a longitudinal study including all the SLE patients (ACR 1997 criteria) starting MMF treatment in our Lupus Clinic. Data about indications, mean dosage, duration of treatment and reasons for drug withdrawal were registered. The DRR was estimated using the Kaplan–Meier method. Disease activity and chronic damage were assessed by SLE Disease Activity Index 2000 (SLEDAI-2K) and SLICC Damage Index (SDI), respectively.

Results:

The present analysis included 162 SLE patients (M/F 22/140, median age at the disease diagnosis 25.5 years, IQR 13). At the beginning of MMF treatment, we registered a median age of 34 months (IQR 21) and a median disease duration of 72 months (IQR 123). The most frequent indications for prescribing MMF were LN (101 patients, 62.3%) and musculoskeletal manifestations (39, 24.1%), followed by neuropsychiatric involvement (10, 6.2%), and others disease related manifestations (12, 7.4%; in particular skin involvement, hematological features, myositis, vasculitis). MMF was administered at a mean daily dosage of 2.1±0.6 grams; no differences in dosage were found between the different indications (p=ns).

At the longitudinal analysis, we registered a median treatment duration of 30 months (IQR 55). Figure 1 reported data about DRR: in particular, at 60 months follow-up we observed a DRR of 61.1% for LN patients, which was similar to that registered for patients without renal involvement (NLN) (60.5%; p=ns). Interestingly, the DRR at 60 months was higher in the subgroup of patients treated for joint involvement (75.4%), even without reaching a statistically significant difference. During the observation period, 92 patients (59.2%) discontinued MMF (median treatment duration at discontinuation 25 months, IQR 35). Interestingly, the main cause of withdrawal was the achievement of persistent remission, observed in 20 patients (21.7%), followed by loss of efficacy (19 patients, 20.5%), drug intolerance and pregnancy planning (17 patients for both reasons, 18,4%). Furthermore, our analysis confirmed MMF efficacy, as demonstrated by the significant reduction in SLEDAI-2k values after 4, 12 and 24 months of treatment (p< 0.0001 for all the time-points in comparison with baseline). In addition, MMF resulted able to control chronic damage progression, as demonstrated by the lack of significant increase in SDI values (baseline: 0.6, IQR 1; last observation: 0.93, IQR 1; p=ns).

Conclusion:

The evaluation of a large SLE cohort demonstrated a good retention rate for MMF. In particular, our results demonstrated that MMF is also a safe and effective drug for SLE manifestation other than LN, in particular for joint involvement. Moreover, it is able to control disease activity and to prevent the progression of chronic damage.

References:

[1]Fanouriakis A et al. Ann Rheum Dis. 2019 Jun;78(6):736-745.

Disclosure of Interests:

None declared

POS0737 LOW PRECONCEPTIONAL COMPLEMENT LEVEL IS RELATED WITH ADVERSE OBSTETRIC OUTCOME IN A MULTICENTRIC COHORT OF PREGNANCY IN PATIENTS WITH APS AND APL POSITIVITY

Background:

The role of complement in the antiphospholipid (aPL) related pathology has been widely studied in animal models. Antiphospholipid antibodies can induce fetal loss in experimental animals but mice deficient in specific complement components (C4, C3, C5) appear somehow protected. In addition, in pregnant mice injected with aPL, antibody deposition has been found at decidual level causing focal necrosis, apoptosis and neutrophil infiltrates and supporting aPL pathogenetic potential. On the other hand, human studies did find hypocomplementemia associated to pregnancy complications in patients with obstetric antiphospholipid syndrome (APS). These results, however, are not unanimously confirmed and, in addition, some studies only show increased levels of complement activation products (i.e. Bb) and not decreased levels of C3 and/or C4. A recently study focusing on complement level in early pregnancy and before pregnancy showed a significant correlation with pregnancy complications and loss in a large cohort of primary APS.

Objectives:

To investigate if the simple detection of low C3 and/or C4 could be considered a risk factor for adverse pregnancy outcome in APS and aPL carriers pregnancies.

Methods:

We performed a multicentric study including patients from 10 Italian and 1 Russian Centers. Data on pregnancies in women with primary APS (n=434) and asymptomatic carriers with persistently positive aPL but not fulfilling clinical criteria for APS (n=218) were retrospectively collected. Serum C3 and C4 levels were evaluated by nephelometry; hypocomplementemia was defined by local laboratory reference values. Statistical analysis was performed using GraphPad.

Results:

Preconceptional complement levels and gestational outcome were available for 107 (25%) pregnancies in APS out of 434 and for 196 (90%) pregnancies in aPL carriers women out of 218. In pregnancies with low preconceptional C3 and/or C4, a significantly higher prevalence of pregnancy losses was observed (p=0.019). A subgroup analysis focusing on triple aPL positive patients was also performed. Preconceptional low C3 and/or C4 levels were found to be associated with an increased rate of pregnancy loss (p = 0.027) in this subgroup also. Otherwise, adverse pregnancy outcomes in single or double aPL positive women were not related to preconception complement levels (p = 0.44) (Table 1). Of note, all the pregnancy losses in the triple positive group occurred in patients treated with low dose aspirin and low molecular weight heparin from the time of positive pregnancy test.

Conclusion:

Our findings confirm that decreased complement levels before pregnancy are associated with increased risk of adverse outcome. This has been seen only in in women with triple aPL positivity, indeed single or double positivity does not show this trend. Complement levels are cheap and easy to be measured therefore they could represent a useful aid to identify patients at increased risk of pregnancy loss. test positivity.

References:

[1]De Carolis S, et al. Complementemia and obstetric outcome in pregnancy with antiphospholipid syndrome. Lupus (2012) 21:776–8.

[2]Kim MY, et al. Complement activation predicts adverse pregnancy outcome in patients with systemic lupus erythematosus and/or antiphospholipid antibodies. Ann Rheum Dis (2018) 77:549–55.

[3]Fredi M, et al. Risk Factors for Adverse Maternal and Fetal Outcomes in Women With Confirmed aPL Positivity: Results From a Multicenter Study of 283 Pregnancies. Front Immunol. 2018 May 7;9:864.

Triple aPL positivitySingle or double aPL positivityGestational outcomeLow C3/C4 (n=49)Normal C3/C4(n=17)pLow C3/C4 (n=57)Normal C3/C4(n=165)pTerm live birth (>37w)15 (31%)6 (35%)ns34 (60%)110 (67%)nsPreterm live birth (≤37w)22 (45%)11 (65%)ns15 (26%)38 (23%)nsPregnancy losses (abortion and miscarriages)12 (24%)0 (0%)0.0278 (14%) 17 (10%)ns

Disclosure of Interests:

None declared

POS1021 THE PsABio STUDY IN ITALY: A REAL-WORLD COMPARISON OF THE PERSISTENCE, EFFECTIVENESS AND SAFETY OF USTEKINUMAB AND TUMOUR NECROSIS FACTOR INHIBITORS IN PATIENTS WITH PSORIATIC ARTHRITIS

Background:

There are still unmet needs in the treatment of psoriatic arthritis (PsA), including in terms of treatment persistence, which is a function of effectiveness, safety and patient satisfaction. Ustekinumab (UST) was the first new biologic drug to be developed for the treatment of PsA after tumour necrosis factor inhibitors (TNFi).

Objectives:

To compare treatment persistence, effectiveness and safety of UST and TNFi in Italian patients within the PsABio cohort.

Methods:

PsABio (NCT02627768) is an observational study of 1st/2nd/3rd-line UST or TNFi treatment in PsA in 8 European countries. The current analysis set includes 222 eligible patients treated in 15 Italian centres, followed to Month 12 (±3 months). Treatment persistence/risk of stopping was analysed using Kaplan−Meier (KM) and Cox regression analysis. Proportions of patients reaching minimal disease activity (MDA)/very low disease activity (VLDA) and clinical Disease Activity Index for PsA (cDAPSA) low disease activity (LDA)/remission were analysed using logistic regression, including propensity score (PS) adjustment for imbalanced baseline covariates, and non-response imputation of effectiveness endpoints if treatment was stopped/switched before 1 year. Last observation carried forward data are reported.

Results:

Of patients starting UST and TNFi, 75/101 (74.3%) and 77/121 (63.6%), respectively, persisted with treatment at 1 year. The observed mean persistence was 410 days for UST and 363 days for TNFi. KM curves and PS-adjusted hazard ratios confirmed significantly higher persistence (hazard ratio [95% confidence interval (CI)]) for UST versus TNFi overall (0.46 [0.26; 0.82]; Figure 1). Persistence was also higher for UST than TNFi in patients receiving monotherapy without methotrexate (0.31 [0.15; 0.63]), in females (0.41 [0.20; 0.83]), and in patients with body mass index (BMI) <25 kg/m2 (0.34 [0.14; 0.87]) or >30 kg/m2 (0.19 [0.06; 0.54]). There was no significant difference in persistence between treatments in patients with BMI 25−30 kg/m2. While patients receiving 1st- and 3rd-line UST or TNFi showed similar risk of discontinuation (0.60 [0.27; 1.29] and 0.36 [0.10; 1.25], respectively), patients receiving 2nd-line UST showed better persistence than those receiving 2nd-line TNFi (0.33 [0.13; 0.87]). Other factors added to the PS-adjusted Cox model did not show significant effects. In patients with available follow-up data, the mean (standard deviation) baseline cDAPSA was 26.3 (15.4) for UST and 23.5 (12.3) for TNFi; at 1-year follow-up, 43.5% of UST- and 43.6% of TNFi-treated patients reached cDAPSA LDA/remission. MDA was reached in 24.2% of UST- and 28.0% of TNFi-treated patients, and VLDA in 12.5% of UST- and 10.2% of TNFi-treated patients. After PS adjustment (stoppers/switchers as non-responders), odds ratios (95% CI) at 1 year did not differ significantly between UST and TNFi groups for reaching cDAPSA LDA/remission (1.08 [0.54; 2.15]), MDA (0.96 [0.45; 2.05]) or VLDA (0.98 [0.35; 2.76]). In total, 23 (20.4%) patients reported ≥1 treatment emergent adverse event with UST and 30 (22.2%) with TNFi; 6 (5.3%) and 10 (7.4%) patients, respectively, discontinued treatment because of an adverse event.

Conclusion:

In the Italian PsABio cohort, UST had better overall persistence compared with TNFi, as well as in specific subgroups: females, patients on monotherapy without methotrexate, with BMI <25 or >30 kg/m2, and patients receiving UST as 2nd-line treatment. At 1 year, both treatments showed similar effectiveness, as measured by cDAPSA responses and MDA/VLDA achievement.

Acknowledgements:

This study was funded by Janssen. Contributing author: Prof. Piercarlo Sarzi-Puttini, ASST Fatebenefratelli-Sacco, University of Milan, Italy

Disclosure of Interests:

Elisa Gremese: None declared, Francesco Ciccia Speakers bureau: AbbVie, Abiogen, Bristol-Myers Squibb, Celgene, Janssen, Lilly, Novartis, Pfizer, Roche, Consultant of: Celgene, Janssen, Lilly, Novartis, Pfizer, Roche, Grant/research support from: Celgene, Janssen, Novartis, Pfizer, Roche, Carlo Selmi Speakers bureau: AbbVie, Alfa-Wassermann, Amgen, Biogen, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, Sanofi-Genzyme, Consultant of: AbbVie, Alfa-Wassermann, Amgen, Biogen, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, Sanofi-Genzyme, Grant/research support from: AbbVie, Amgen, Janssen, Pfizer, Giovanna CUOMO: None declared, Rosario Foti Speakers bureau: AbbVie, Bristol-Myers Squibb, Celgene, Lilly, MSD, Janssen, Roche, Sanofi, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Lilly, MSD, Janssen, Roche, Sanofi, Marco Matucci Cerinic Speakers bureau: Actelion, Biogen, Janssen, Lilly, Consultant of: Chemomab, Grant/research support from: MSD, Fabrizio Conti Consultant of: AbbVie, Bristol-Myers Squibb, Galapagos, Lilly, Pfizer, Enrico Fusaro Speakers bureau: AbbVie, Amgen, Lilly, Grant/research support from: AbbVie, Pfizer, Giuliana Guggino Speakers bureau: AbbVie, Celgene, Novartis, Pfizer, Sandoz, Grant/research support from: Celgene, Pfizer, Florenzo Iannone Speakers bureau: AbbVie, Bristol-Myers Squibb, Celgene, Lilly, MSD, Novartis, Pfizer, Sanofi, UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Lilly, MSD, Novartis, Pfizer, Sanofi, UCB, Andrea Delle Sedie: None declared, Roberto Perricone: None declared, Luca Idolazzi Speakers bureau: AbbVie, Eli Lilly, Janssen, MSD, Novartis, Sandoz, Paolo Moscato: None declared, Elke Theander Employee of: Janssen, Wim Noel Employee of: Janssen, Paul Bergmans Shareholder of: Johnson & Johnson, Employee of: Janssen, Silvia Marelli Employee of: Janssen, Laure Gossec Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Biogen, Celgene, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Samsung Bioepis, Sanofi-Aventis, UCB, Grant/research support from: Amgen, Galapagos, Janssen, Lilly, Pfizer, Sandoz, Sanofi, Josef S. Smolen Speakers bureau: AbbVie, Amgen, AstraZeneca, Astro, Bristol-Myers Squibb, Celgene, Celltrion, Chugai, Gilead, ILTOO, Janssen, Lilly, MSD, Novartis- Sandoz, Pfizer, Roche, Samsung, Sanofi, UCB, Grant/research support from: AbbVie, AstraZeneca, Lilly, Novartis, Roche.

AB0704 TELEMEDICINE AT THE TIME OF COVID-19: THE EXPERIENCE WITH RA PATIENTS TREATED WITH JAK-INHIBITORS

Background:

The spread of COVID-19, the lockdown, the limited access to care reevaluated the role of tele-consultation and self-assessment.

Objectives:

Our aim was to evaluate in a cohort of Rheumatoid Arthritis (RA) patients treated with JAK-inhibitors (JAKi): the self-assessed disease activity during lockdown, the lockdown impact on fatigue, anxiety, depression and the prevalence of Covid-19.

Methods:

We enrolled RA patients treated with baricitinib or tofacitinib. At baseline (BL) and follow-up we collected: patients’ demographic data, composite disease activity indices (CDAI, DAS28CRP), global assessment (PGA), pain visual analogue scale (VAS), FACIT (functional assessment of chronic illness therapy) and a self-rating scale for disease impact on anxiety and depression (Zung-A/D). Patients were instructed on how to perform self-assessment through video-material and fulfilled the online form of “Rheumatoid Arthritis Impact of Disease” (RAID)1 and “RA Disease Activity Index” (RADAI). To capture the pandemic effect, we compared patients in different status (remission, low, moderate and high-disease activity) at the last in-person visit (preCoV) through the DAS28CRP and CDAI, to the tele-health visit (THV), measured by the RAID. BL and pre-CoV ZUNG-A, ZUNG-D, FACIT questionnaires were compared with the online results during the pandemic. Exposure, tests and symptoms of Covid-19 were recorded. Data were expressed as mean±standard deviation or median(IQR) according to distribution.

Results:

Twenty patients (median age 58.2±11.9 and mean disease duration 153.5 ± 112.7 months) were treated with tofacitinib and 27 with baricitinib. The median time-lapse between the pre-CoV visit and the THV was 12 (IQR 4) weeks. DAS28CRP and CDAI significantly decreased from BL to pre-CoV visit. During the last in-person visit, 21 patients (48.83%) were in remission, 9 (20.93%) in low disease activity; according to the RAID, 15 (31.91%) and 7 (14.89%) patients were respectively in remission and low disease activity during the THV (Table A). PGA and pain significantly decreased from BL to pre-Cov visit but worsened during the lockdown (Table A). FACIT remaining stable during THV. At THV, we detected a significant improvement of anxiety from BL (Zung-A) and a tendency to lower depression scores compared to BL (Table A). JAKi showed a good safety profile considering Covid-19 symptoms, none of the patients was diagnosed with SarsCoV2 infection.

Conclusion:

This is the first study on virtual assessment in RA patients treated with JAKi. The unique social experiment of the pandemic impaired the clinical response already achieved before the lockdown, without a collateral worseling of FACIT, anxiety and depression.

References:

[1]Gossec L, et al. Ann Rheum Dis. 2009

[2]Stucki G, et al. Arthritis Rheum. 1995

Table A.

DAS28, CDAI, RAID scores and patient-reported outcomes assessment at baseline and during the follow-up

BLpre-CoVTHVDISEASE ACTIVITYN (%)N (%)N (%)REMISSIONDAS280 (0%)21 (48.8%)CDAI0 (0%)10 (22.7%)RAID15 (31.9%)LOW DISEASEDAS281(2.1%)9 (20.9%)CDAI7(14.8%)23 (52.2%)RAID7 (14.9%)MODERATEDAS2833 (70.2%)12 (27.9%)CDAI17 (37.1%)8 (18.1%)RAID13 (27.6%)HIGHDAS2813 (27.6%)1 (2.3%)CDAI23 (48.9%)3 (6.8%)RAID12 (25.5%)GH70 (30)20 (49.5)*45 (45)*#Pain70 (28)25 (45.5)*40 (48.5)*#Zung A37 (9)37 (10.2)35 (14)*Zung-D39 (17)39 (13)*38 (12)FACIT11.5 (17.2)8 (19.5)7(15)

* p≤0.001 vs BL

# p ≤0.04vs preCoV

Data expressed as median (IQR)

Disclosure of Interests:

Cristina Garufi: None declared, Francesca Romana Spinelli Speakers bureau: Abbvie, Eli Lilly, Consultant of: Gilead/Galapagos, Eli Lilly, Grant/research support from: Pfizer, Silvia Mancuso: None declared, Fulvia Ceccarelli: None declared, Fabrizio Conti Speakers bureau: Abbvie, Eli Lilly, Sanofi, Pfizer, Consultant of: Gilead/Galapagos

POS1240 HYDROXYCHLOROQUINE CARDIOTOXICITY: A CASE-CONTROL STUDY COMPARING PATIENTS WITH COVID19 AND PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Antimalarials have been associated with QT prolongation in COVID19 patients but are generally safe in patients with rheumatologic disease.

Objectives:

Aim of the study was to compare the prevalence of QTc prolongation between COVID19 and Systemic Lupus Erythematosus (SLE) patients treated with hydroxychloroquine (HCQ).

Methods:

We included consecutive patients with SARS-CoV-2 infection confirmed by nasopharyngeal swab and patients taking HCQ for SLE. A prolonged QTc was defined as an increase in QTc intervals >60 ms (compared with baseline) or as a QTc of ≥500 ms.

Results:

We enrolled 58 COVID19 patients (median age 70.5 years, IQR 25). HCQ, without or with azithromycin, was given to 26 (44.8%) and 15 patients (25.9%), respectively; 17 (29.3%) had not received either drug. The median baseline QTc was 432 (IQR 36) and prolonged QTc was observed in 15 (26%) patients (12 QTc≥500 ms and 3 patients ΔQTc>60 ms). We didn’t find significant differences in QTc prolongation among the three treatment groups. Baseline QTc (OR 111.5) and D-dimer (OR 78.3) were independently associated to QTc prolongation.

Compared to the 50 SLE patients (median age of 38.5 years, IQR 22), chronically treated with HCQ, patients with COVID19 showed significantly longer QTc (p < 0.001) (Table 1).

Conclusion:

This is the first study demonstrating that, differently from COVID19 patients, patients with SLE are not susceptible to HCQ-induced long QT syndrome and arrhythmia. The combined arrhythmogenic effect of SARS-CoV-2 infection and HCQ could account for the excess of QTc prolongation and fatal arrhythmias described in patients with COVID19.

Table 1.

Difference in clinical and demographic features between Systemic Lupus Erythematosus and COVID19 patients.

Demographic FeaturesSLE patientsCovid-19 patientsp-ValueN°5058Female4323< 0.001Age (years)45 (17)70.5 (25)< 0.001Comorbidities N %Hypertension15 (30)24 (48)0.2Cardiovascular diseses8 (16)13 (22.4)0.4COPD1 (2)9 (15.5)0.016Thyroid disease8 (16)8 (13.8)0.75Chronic kidney disease4 (8)5 (8.6)0.91Population characteristics Median (IQR)HCQ (mg/die)400 (125)400< 0.001HCQ Time (days)3255 (5790)7< 0.001QTc (ms)SLEDAI-2KSDI432 (36.25)0 (4)0395 (80)--< 0.001--

Disclosure of Interests:

None declared

AB0269 ARE INTERFERON-GAMMA RELEASE ASSAYS RELIABLE TO DETECT TUBERCULOSIS INFECTION IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH JANUS KINASE INHIBITORS?

Background:

The therapeutic armamentarium for patients with rheumatoid arthritis (RA) has recently been enriched with the family of Janus kinase (JAK) inhibitors. Because the risk of reactivation of latent tuberculosis infection (LTBI) following the use of these drugs seems to be similar to that seen with anti-TNF agents, screening for LTBI is recommended in patients with RA before starting treatment with JAK inhibitors. Interferon(IFN)-gamma release assays (IGRAs) are increasingly used for this purpose. However, JAK inhibitors tend to decrease the levels of IFNs, questioning the reliability of IGRAs during treatment with this novel class of drugs.

Objectives:

To compare the performance of the QuantiFERON-TB Gold Plus (QFT-Plus) test with that of QuantiFERON-TB Gold In-tube (QFT-GIT) assay in RA patients before and during treatment with JAK inhibitors.

Methods:

A longitudinal, prospective study has been performed in RA patients (ACR/EULAR 2010 criteria) candidates for tofacitinib or baricitinib treatment. All patients underwent QFT-Plus and QFT-GIT at baseline (T0), and after 3 (T3) and 9/12 months (T9/12) of treatment with JAK inhibitors. The agreement of the two tests was calculated at all timepoints. The agreement between IGRAs and tuberculin skin test (TST) or chest radiography at baseline was also determined. Lastly, the variability of QTF-Plus results was assessed during follow-up.

Results:

Twenty-nine RA patients (F/M 23/6; median age/IQR 63/15.5 years; median disease duration/IQR 174/216 months) were enrolled: among them, 22 were to start baricitinib (75.9%) and 7 tofacitinib (24.1%). A perfect agreement was found between QFT-Plus and QFT-GIT at all times of observation (κ=1). At baseline, no agreement was recorded between IGRAs and TST (κ=-0.08) and between TST and chest radiography (κ=-0.07), while a low agreement was found between QFT-Plus and chest radiography (κ=0.17). A variation of 33.3% in the results of the QFT-Plus test was recorded at T3 compared to T0, of 29.4% at T9/12 compared to T0, and of 11.8% at T9/12 compared to T3. The median levels of IFN-γ produced by lymphocytes in response to the mitogen of QFT-Plus decreased after 3 months of treatment (1.59/4.72 IU/ml vs 3.08/7.68 IU/ml at baseline), followed by an increase after 9/12 months (2.25/4.61 IU/ml), but these differences were not significant. No significant change in the median number of circulating lymphocytes such as to explain the variation of the QFT-Plus results after 3 months of JAK inhibitor therapy was documented (1815/690/mm3 vs 2140/750/mm3 at baseline). At baseline, both QFT-Plus and QFT-GIT showed positive results in 5 patients (17.2%), negative in 19 (65.5%), and indeterminate in 5 (17.2%). Glucocorticoids intake was associated with a higher probability of negative or indeterminate result of IGRAs at baseline (p<0.0001).

Conclusion:

Our data show that a response to IGRAs is detectable in the course of treatment with JAK inhibitors. However, similarly to what has been observed during treatment with TNF antagonists, the results of QFT-GIT and QFT-Plus show some variability when longitudinally repeated. These fluctuations occur in the absence of correlation with clinical outcome, thus challenging their interpretation. Since we do not have a sufficiently sensitive test capable of detecting TB infection, an integrated evaluation of risk factors, clinical manifestations and multiple diagnostic tests should be considered for a proper evaluation of the risk of TB infection in immunosuppressed patients.

Disclosure of Interests:

None declared