POS0956 MEDITERRANEAN DIET IN AXIAL SPONDYLOARTHRITIS: A NUTRITIONAL INTERVENTION STUDY

Background:

Mediterranean diet (MD) proved to be beneficial on disease activity in patients affected by rheumatoid arthritis. A few data are available in other rheumatic conditions.

Objectives:

A prospective monocentric study was conducted to evaluate the effect of a nutritional intervention based on the MD and to investigate the impact of such modification on disease activity of axial spondyloarthitis (ax-SpA).

Methods:

Patients affected by ax-SpA randomized to a nutritional intervention arm (N) or a control arm (C) and were assessed at baseline (T0) and at month 6 (T6). Patients in N underwent a nutritional evaluation and received suggestions for dietary modification at T0, and then every 2 months. Adherence to the MD was evaluated with the PREDIMED questionnaire (range 0-10) [1]. A multivariable regression analysis was conducted to identify independent predictors of PREDIMED and of ASDAS-CRP improvement at T6.

Results:

Eligible patients (161) were randomized to either N (81) or C (80); 47 in N and 63 in C completed the study. No relevant change of anthropometric or laboratory measures was observed at T6 in either group. A ≥20%PREDIMED improvement was more frequent in N (22/47, 46.8%) compared to C (13/63, 20.6%) (p<0.01). Also, a ≥20%ASDAS-CRP improvement was more frequent in N (8/47, 57.1%) compared to C (39/63, 40.6%) (p=0.020); and especially in those who achieved a ≥20%PREDIMED improvement (12/35, 34.3%) vs those who did not (2/73, 2.7%) (p<0.01). The nutritional intervention, a higher age, and a lower BMI increased the odds of achieving a ≥20%PREDIMED improvement; the ≥20%PREDIMED improvement was associated higher odds of achieving a ≥20%ASDAS-CRP improvement; psoriasis was negatively associated to the ASDAS-CRP improvement (Figure 1).

Conclusion:

A nutritional intervention is effective in improving adherence to the MD in ax-SpA. A higher adherence to the MD may have a beneficial impact on activity of ax-SpA. Patients with psoriasis may have a limited benefit from the dietary improvement.

References:

[1]Martínez-González, M.A. et al. A 14-item mediterranean diet assessment tool and obesity indexes among high-risk subjects: The PREDIMED trial.PLoS One2012,7.

Table 1.

Characteristics of the patients.

All patientsNutritionControlsAll patientsNutritionControlsBaselineMonth 6Females, n, (%)40 (36.4)18 (38.3)22 (34.9)Age, years, mean±SD51.7±1.353.0±1.349.6±1.3HLA-B27 positivity, n (%)58 (52.7)22 (46.8)37 (57.1)Psoriasis, n (%)58 (50.7)26 (55.3)32 (50.8)Disease duration (years), mean±SD15.3±9.715.7±1015±9.5Duration of b/tsDMARD treatment overall, years, mean±SD5±4.15.8±4.54.5±3.8NSAID, n (%)76 (69.1)30 (63.8)46 (73)csDMARD, n (%)14 (12.7)5 (10.6)9 (14.3)BMI, Kg/meters2, mean±SD26.5±5.426.5±4.326.6±6.126.4±5.326.3±426.6±6.1ASDAS-CRP, mean±SD2.1±12.1±0.92.1±12±1.11.8±0.92.1±1.2BASDAI, mean±SD37.6±2337.4±23.237.7±22.939.3±24.137.3±23.641.2±24.6BASFI, mean±SD20.5±21.421.6±19.219.7±2319.8±19.619.1±18.820.5±20.4BASMI, mean±SD1.6±21.9±2.21.4±1.71.8±2.11.9±2.41.7±1.9Tender joint count, mean±SD1.1±2.30.8±2.11.4±2.50.9±20.8±20.9±1.9Swollen joint count, mean±SD0.3±1.30.4±20.1±0.50.2±1.30.3±1.80.2±0.8Leeds Enthesitis Index, mean±SD0.2±0.80.3±10.2±0.61.1±21.3±2.21±1.8CRP, mg/L, mean ±SD3.4±6.23.2±3.93.7±7.43.5±5.62.6±3.14.1±6.9LDL-c, mg/dl, mean ±SD130.8±36.5132.3±35129.7±38.4130.6±34.7125.7±34.8134.4±34.5PREDIMED score, mean ±SD6.7±1.87±2.16.6±1.67.6±2.18.6±1.96.8±2

b/tsDMARD biological/targeted synthetic DMARDs; csDMARD conventional DMARDs. PREDIMED questionnaire to assess adherence to the Mediterranean diet.

Disclosure of Interests:

None declared.

FRI0093 FACTORS ASSOCIATED WITH REFRACTORY RHEUMATOID ARTHRITIS (RRA) ACCORDING TO THREE AVAILABLE DEFINITIONS: TWO CROSS-SECTIONAL ANALYSES IN A LARGE ITALIAN MONOCENTRIC COHORT

Background:

Three definitions of refractory rheumatoid arthritis (RRA) have been proposed: Buch’s (B-RRA), i.e. failure of ≥1 anti-cytokine and ≥1 cell-targeted bDMARD [1]; Kearsley-Fleet’s (KF-RRA), i.e. exposure to ≥3 bDMARDs classes [2]; De Hair’s (DH-RRA), i.e. signs and/or symptoms of RA activity and failure of ≥1 csDMARD and ≥2 bDMARDs [3].

Objectives:

To evaluate the rate of RRA according to the three definitions in a monocentric cohort with two cross-sectional analyses in 2012 and 2019. We investigated also the major determinants of each definition. Secondary objective was to evaluate the most frequent treatments in RRA patients.

Methods:

Patients affected by RA followed at Padova University Hospital were included at two different time points. In the 2012 cohort patients on bDMARDs on 31stDecember 2012 and in the 2019 cohort patients on b/target synthetic DMARDs (tsDMARD) on 1stMarch 2019. Factors independently associated with RRA definitions were tested with multivariable regression analysis, including all variables achieving a p<0.10 in the univariate analysis.

Results:

We included 260 patients in the 2012 cohort and 571 in the 2019 cohort. Rate of RRA in 2012 cohort was: 23 (8.8%) B-RRA, 57 (21.9%) KF-RRA and 12 (4.6%) DH-RRA; rate of RRA in 2019 cohort was: 165 (28.9%) B-RRA, 96 (16.8%) KF-RRA and 57 (10%) DH-RRA. Following multivariate regression analysis, in the 2012 cohort a significant association was found between number of bDMARDs treatment and all RRA definitions [Tab.1]. Also in the 2019 cohort the variable associated with all RRA definitions was the number of bDMARDs treatment [Tab.2]. Both in 2012 and 2019, IL6-inhibitors were more frequently prescribed in RRA patients; instead TNF inhibitors were less frequently prescribed in RRA.

Conclusion:

Rate of RRA in the 2019 cohort was 10-30% which is higher compared to the 2012 cohort. This might be explained by the fact that RRA definitions are mainly affected by the number of bDMARDs. Thus, an accurate RRA definition should consider not only the number of treatments but also the current disease activity.

References:

[1]Buch MH. Ann Rheum Dis 2018;77:966–969

[2]Kearsley-Fleet L, et al. Ann Rheum Dis 2018;77:1405–1412

[3]De Hair MJH et al. Rheumatology 2018;57:1135-1144

Table 1.

Factors associated with three definitions of RRA in the 2012 cohort, multivariate analysis

CharacteristicsOR (95% C.I.)p valueB-RRACRPper mg/L increase0,81 (0,68-0,95)0,011HAQper unit increase3,28 (0,85-12,54)0,84Combination with any csDMARD4,61 (0,65-32,59)0,124bDMARD treatment durationper year increase0,58 (0,52-1,03)0,114No bDMARDs91,0 (7,87-1055,58)<0,001Model constant0,009KF-RRAPDNper mg increase1,49 (0,87-2,56)0,144DAS28per unit increase4,22 (1,4-12,71)0,011No bDMARDs- (0-0)0,99Model constant0,989DH-RRACombination with any csDMARD6,24 (0,69-56,61)0,614Comorbidity12,82 (0,46-1122,91)0,065No bDMARDsper unit increase6,25 (2,75-121,39)0,003Model constant0,002

B-RRArefractory RA according to Buch,KF-RRArefractory RA according to Kearsley-Fleet,DH-RRArefractory RA according to De Hair

Table 2.

Factors associated with three definitions of RRA in the 2019 cohort, multivariate analysis

CharacteristicsOR (95% C.I.)p valueB-RRANo. bDMARDs18.77 (11.06;31.85)p<0.001PDN daily doseper 5 mg increase2.15 (1.17;2.15)0.014Model Constantp<0.001KF-RRABMIper 5 unit increase0.61 (0.35;1.05)0.072No. bDMARDs8.69 (5.16;14.64)p<0.001bDMARD treatment start yearper year increase0.92 (0.84;1.01)0.087Model Constant0.069DH-RRANo. bDMARDs3.9 (2.67;5.71)p<0.001bDMARD treatment start yearper year increase0.91 (0.83;0.99)0.026DAS28per 0.6 unit increase5.55 (3.34;9.23)p<0.001RX progression2.7 (1.21;6.03)0.015Model Constant0.04

B-RRArefractory rheumatoid arthritis according to Buch,KF-RRArefractory rheumatoid arthritis according to Kearsley-Fleet,DH-RRArefractory rheumatoid arthritis according to De Hair,RX progression(mTSS ≥0,5 over the last 24 months)

Disclosure of Interests:

LARA FRISO: None declared, Francesca Ometto: None declared, DAVIDE ASTORRI: None declared, Costantino Botsios: None declared, Andrea Doria Consultant of: GSK, Pfizer, Abbvie, Novartis, Ely Lilly, Speakers bureau: UCB pharma, GSK, Pfizer, Janssen, Abbvie, Novartis, Ely Lilly, BMS

AB1315-HPR HYPERBARIC OXYGEN THERAPY IN FIBROMYALGIA PATIENTS – DOUBLE-BLIND PROSPECTIVE CLINICAL TRIAL

Background:

Hyperbaric Oxygen Therapy (HOT) proved effective in improving of symptoms of patients affected by fibromyalgia syndrome (FMS) [1].

Objectives:

The objective of the present study was to evaluate the effectiveness of HOT compared to hyperbaric treatment with no oxygen therapy (PBO) in the symptoms and working ability in FMS.

Methods:

We conducted a prospective trial in employed patients with FMS, randomly assigned to HOT or PBO. Patients and evaluating clinicians were blinded to the treatment. HOT arm comprised 40 sessions, 5 days/week, 120 minutes, 100% oxygen at 2ATA; PBO comprised the same sessions without oxygen. Evaluations were at baseline, after 4 (T1) and 8 weeks (T2). Parameters considered were: socio-demographics, biochemistry, clinical evaluation and patient-reported outcomes (PROs). Baseline assessment included questions BELIEF (how much do you hope to improve with this treatment) and HOPE (how much do you expect to improve with this treatment), with VAS response. Spearman’s, Mann-Whitney’s, Kruskal-Wallis and Fisher’s Exact test were used.

Results:

12 patients were included and completed the study, 6 in each arm (Tab. 1). No significant difference was observed in clinical measures or PROs at T1 and T2 between HOT and PBO arms, except for Working Productivity and Activity Impairment Questionnaire (WPAI) (result III) (Tab. 2). In both arms, disease duration was associated with worse PROs (Widespread pain index r=0.59,p=0.037, Severity Score r=0.81,p=0.025); higher BMI with improvement in function at T2 (r=0.63,p=0.027); higher baseline scores in BELIEF with reduction symptoms number (r=-0.67, p=0.021), higher scores in HOPE with reduction in Health Assessment Questionnaire (r=-0.057, p=0.039)

Table 1.

Patients characteristics

AllHOTPBONumber1266Age*55,5 (44;59,75)55,5 (47,75;60)51 (41;58,75)Females**6 (100)6 (100)6 (100)Disease duration *10 (8,25;26,75)9,5 (7,5;20,75)15 (10;26,75)BMI*25,5 (22,25;31)25 (22,75;28)28,5 (23;31,75)Smoke**0,5 (0;1)0 (0;1)1 (0,25;1)HOPE score*0 (0;1)0,5 (0;1)0 (0;0)>=80**9 (64,3)5 (62,5)4 (66,7)BELIEF score*70 (60;80)75 (67,5;83,75)62,5 (60;68,75)>=70**8 (57,1)6 (75)2 (33,3)

*median (IQR); **number (%)

Table 2.

Change from baseline in clinical measures and PROs at T2.

Medians (IQR)P value≧20 Percentage amelioration No. (%)P valueAllHOTPBOAllHOTPBOShort Form-36 - Physical1 (-1;4)3 (-1;5,5)0,5 (-0,75;3,25)ns0 (0)0 (0)0 (0)nsSF-36 - Mental4 (-1;8)6 (2,5;9,5)1 (-1,75;5,25)ns0 (0)0 (0)0 (0)nsSeverity score - total-13 (-15;-2)-15 (-17;-13,5)-3 (-5,5;-0,5)ns2 (18,2)2 (40)0 (0)nsNumber symptoms-3 (-4;0)-4 (-4,5;-1,5)-2 (-3;-0,25)ns2 (18,2)2 (40)0 (0)nsSASP score-1 (-3;0)-2 (-3,5;-0,5)-1 (-1,75;-0,25)ns1 (9,1)0 (0)1 (16,7)nsWidespread pain index0 (-2;0)0 (-2;0)-0,5 (-1,75;0)ns2 (18,2)2 (40)0 (0)nsTender Points Count (0-18-2 (-3;-0,5)-2 (-3,5;-1)-1,25 (-2;-0,13)ns3 (27,3)2 (40)1 (16,7)NsHealth Assessment Questionnaire0 (0;0)0 (-0,5;0,5)0 (0;0)ns3 (27,3)1 (20)2 (33,3)nsFibromyalgia Impact Questionnaire10 (0;15)10 (7,5;15)2,5 (-3,75;12,5)ns1 (9,1)0 (0)1 (16,7)nsWPAI result-2-0,5 (-1,25;-0,13)-1,5 (-2;-0,5)-0,25 (-0,5;0,19)ns3 (21,4)0 (0)3 (37,5)nsWPAI result-30 (-2,38;0)-2,75 (-3,88;-2)0 (0;0)ns5 (35,7)0 (0)5 (62,5)P=0.008WPAI result-1-1 (-3,25;-0,38)-3,5 (-4,75;-1,5)-0,5 (-1;0,38)ns6 (42,9)2 (33,3)4 (50)ns

Conclusion:

8-week HOT treatment does not substantially improve symptoms in FMS compared to PBO. All patients on hyperbaric treatment may experience amelioration of symptoms: other factors should be considered, including beliefs and expectations on the treatment.

References:

[1]DOI:10.1371/journal.pone.0127012

Disclosure of Interests:

None declared

AB0274 USE OF TNF-INHIBITORS BIOSIMILARS IN CHRONIC INFLAMMATORY ARTHRITIDES: A THREE-YEAR EXPERIENCE IN A LARGE MONOCENTRIC COHORT OF PATIENTS FROM THE NORTH-EAST ITALY

Background::

In recent years several biosimilars (BS) of tumour necrosis factor inhibitors (TNF-i) were introduced. At the Padova University Hospital the first BS of etanercept (bsETN) was available in October 2016 and the BS of adalimumab (bsADA) was available in November 2018.

Objectives:

The objectives of the study were to evaluate the rate of bioriginator-biosimilar (BO-BS) switch in all patients with rheumatoid arthritis (RA), psoriatic arthritis (PSA) and axial spondiloarthritis (axSpA) in the cohort of the Padova University Hospital and to examine factors favouring BO-BS switch. Secondly, we investigated survival of BO-BS switch and BO treatment and factors associated with longer treatment survival.

Methods:

We considered all patients on ETN originator (boETN) treatment when the first bsETN was available (1st October 2016) and all patients on ADA originator (boADA) when bsADA was available (1st November 2018). Patients were followed until 30 August 2019 and were classified as BO-BS switchers if they underwent a switch from either boETN or boADA to BS during the follow-up, otherwise they were considered as continuing BO treatment. Factors associated with BO-BS switch were tested with a multivariable regression analysis. To test the survival of the BO-BS switch and of the BO treatment, Cox regression analysis was used including all variables achiving a p<0.10 in univariate analysis tested with Log-rank test and Kaplan-Meier curves.

Results:

Among 1208 patients (553 RA, 433 PSA, 215 axSpA), 560 (46.3%) patients switched to bsETN (391) or bsADA (169). Mean disease duration was 16 (14.2) years and mean duration of the bDMARD treatment was 96.3 (56.8) months. After adjustment for potential confounders, factors associated with BO-BS switch were a longer disease duration, a shorter duration of previous bDMARD treatments and diagnosis (Tab.1) RA patients had almost a 3 fold increased likelihood of being switched to BS compared to PSA and axSPA, while difference between PSA and axSPA was not significant.

Following Cox regression analysis we observed a longer drug survival in BO-BS switchers compared to those continuing with BO (HR 1.38; 95% C.I. 1.2-1.58; p<0.001) (Fig. 1). A longer drug survival was also associated with a longer disease duration (.15years: HR 1.75; 95% C.I. 1.5-2; p<0.001), longer mean duration of previous bDMARDs (.5years: HR 4.1; 95% C.I. 3.5-4.7; p<0.001), and diagnosis (RA vs PSA: HR 1.22; 95% C.I. 1.02-1.47; p=0.030; RA vs axSpA: HR 0.89 95% C.I. 0.067-0.97; p=0.023; PSA vs axSpA: HR 0.66; 95% C.I. 0.57-0.77; p<0.001) (Fig 2).

Figure 1.

Kaplan-Meier curves for treatment survival, Log-rank test.

Figure 2.

Kaplan-Meier curves for treatment survival in all patients, Log-rank tes

Conclusion:

BO-BS switch was undertaken in almost half of the patients. Patients with longer disease duration and longer bDMARD duration, were the most likely to be switched successfully to BS. BO-BS switching does not affect the survival of the treatment, indeed, it provides sustained effectiveness particularly if undertaken in patients with stable disease activity.

Table 1.

Factors associated with BO-BS switch, multivariate regression analysis.

Disclosure of Interests:

DAVIDE ASTORRI: None declared, Francesca Ometto: None declared, LARA FRISO: None declared, BERND RAFFEINER: None declared, Costantino Botsios: None declared, Andrea Doria Consultant of: GSK, Pfizer, Abbvie, Novartis, Ely Lilly, Speakers bureau: UCB pharma, GSK, Pfizer, Janssen, Abbvie, Novartis, Ely Lilly, BMS

Diagnostic and prognostic role of renal histopathology in rheumatic diseases

The objective was to evaluate renal involvement in several rheumatic diseases (i.e. rheumatoid arthritis, systemic lupus erythematosus, Sjögren syndrome, systemic sclerosis, systemic vasculitides). The method chosen was to define histopathological profiles reported in renal biopsies performed on patients with renal involvement due to different rheumatic diseases. Renal involvement observed in patients with rheumatic disease can be the direct result of the disease per se and/or a complication of drugs used in the disease treatment. The clinical-pathological correlations derived from the study of renal tissues can be useful for differential diagnosis, prognosis assessment and therapeutic decisions. Renal biopsy should be considered as an important tool for the management of nephropathies in patients with systemic rheumatic diseases.

Inclusion of Saccharina latissima in conventional anaerobic digestion systems

Loading macroalgae into existing anaerobic digestion (AD) plants allows us to overcome challenges such as low digestion efficiencies, trace elements limitation, excessive salinity levels and accumulation of volatile fatty acids (VFAs), observed while digesting algae as a single substrate. In this work, the co-digestion of the brown macroalgae Saccharina latissima with mixed municipal wastewater sludge (WWS) was investigated in mesophilic and thermophilic conditions. The hydraulic retention time (HRT) and the organic loading rate (OLR) were fixed at 19 days and 2.1 g l^-1 d^-1 of volatile solids (VS), respectively. Initially, WWS was digested alone. Subsequently, a percentage of the total OLR (20%, 50% and finally 80%) was replaced by S. latissima biomass. Optimal digestion conditions were observed at medium-low algae loading (≤50% of total OLR) with an average methane yield close to [Formula: see text] and [Formula: see text] in mesophilic and thermophilic conditions, respectively. The conductivity values increased with the algae loading without inhibiting the digestion process. The viscosities of the reactor sludges revealed decreasing values with reduced WWS loading at both temperatures, enhancing mixing properties.

[TNFalpha blockers and infectious risk in rheumatoid arthritis]

Patients suffering from rheumatoid arthritis have increased risk of infections when compared with general population. The risk depends directly from disease activity and severity. Furthermore, risk increases with aging, immunosuppressive agents and comorbidities such as diabetes, pulmonary and cardiac diseases. In particular corticosteroids, even at low doses, are a major risk factor. Due to disease related risk it is difficult to separate the risk deriving from the use of TNF alpha blockers. Data from clinical trials, meta-analysis and national registers are somewhat contradictory. In patients with rheumatoid arthritis on routine follow-up, treatment with TNF alpha blockers seems to carry an increased risk of infections compared to traditional DMARDs but not associated with increased risk of overall serious infection. Physicians should carefully monitor for signs of infection when using TNF alpha blockers, particularly shortly after treatment initiation.