Retinal microvascular alterations in patients with active rheumatoid arthritis without cardiovascular risk factors: the potential effects of T cell co-stimulation blockade

Background

The evaluation of microvascular alterations might provide clinically useful information for patients with an increased cardiovascular (CV) risk, such as those with rheumatoid arthritis (RA), being the small artery remodeling the earliest form of target organ damage in primary CV diseases, such as arterial hypertension. The evaluation of retinal arterioles is a non-invasive technique aimed to identify an early microvascular damage, represented by the increase of the wall-to-lumen ratio (WLR) index. Abatacept (ABA), a T-cell co-stimulator blocker, is used to treat RA. A CV protective action was hypothesized for its peculiar mechanism of action in the modulation of T-cells, potentially involved in the pathogenesis of CV comorbidity. The study aimed to non-invasively investigate morphological characteristics of retinal arterioles in a cohort of RA patients treated with ABA.

Materials and methods

Seventeen RA patients [median (25th-75thpercentile) age = 58 (48-64) years, baseline 28-joint Disease Activity Score DAS28-C-reactive protein (DAS28-CRP) = 4.4 (3.9-4.6), body mass index (BMI) = 24.2 (23.4-26) kg/m2, rheumatoid factor positive:52.9%, anti-citrullinated peptide autoantibodies positive:76.5%] without known CV risk factors (arterial hypertension, diabetes, hypercholesterolemia, previous CV events, smoking) were evaluated by the adaptive optics imaging system of retinal arterioles before and every 6 months of therapy with ABA (T0, T6 and T12). Office blood pressure evaluation, 24-h ambulatory blood pressure monitoring and tissue-doppler echocardiography were also performed.

Results

A progressive significant reduction of the WLR of retinal arterioles was observed [T0 = 0.28 (0.25-0.30), T6 = 0.27 (0.24-0.31), T12 = 0.23 (0.23-0.26); p T0 vs. T6 = 0.414; p T6 vs. T12 = 0.02; p T0 vs. T12 = 0.009], without significant variations in other parameters. The T0-T12 reduction of WLR was correlated with that of DAS28-CRP (r:0.789; p = 0.005). Moreover, a significant reduction of diastolic office blood pressure and a trend for reduction of daily pressure measured by ambulatory monitoring were observed.

Conclusion

In a cohort of RA patients without known CV risk factors, a reduction of retinal microvascular alterations was demonstrated after treatment for 12 months with ABA, in parallel with the reduction of disease activity. These results might suggest the possibility of microvascular abnormalities regression induced by the immune system modulation.

Pregnancy in antiphospholipid syndrome: what should a rheumatologist know?

This review focuses on the management of reproductive issues in women who have antiphospholipid syndrome (APS) or are carriers of antiphospholipid antibodies (aPL). The importance of aPL detection during preconception counselling relies on their pathogenic potential for placental insufficiency and related obstetric complications. The risk of adverse pregnancy outcomes can be minimized by individualized risk stratification and tailored treatment aimed at preventing placental insufficiency. Combination therapy of low-dose acetylsalicylic acid and heparin is the mainstay of prophylaxis during pregnancy; immunomodulation, especially with hydroxychloroquine, should be considered in refractory cases. Supplementary ultrasound surveillance is useful to detect fetal growth restriction and correctly tailor the time of delivery. The individual aPL profile must be considered in the stratification of thrombotic risk, such as during assisted reproduction techniques requiring hormonal ovarian stimulation or during the follow-up after pregnancy in order to prevent the first vascular event.

Validation of the Italian version of the ANCA-associated vasculitis patient-reported outcome (AAV-PRO) questionnaire

Objectives

The primary objective of this study was the translation and validation of the ANCA-associated vasculitis patient-reported outcome (AAV-PRO) questionnaire into Italian, denoted as AAV-PRO_ita. The secondary objective was to evaluate the impact of ANCA-associated vasculitis (AAV) on quality of life (QoL) and work impairment in a large cohort of Italian patients.

Methods

The study design took a prospective cohort study approach. First, the AAV-PRO was translated into Italian following the step guidelines for translations. The new AAV-PRO_ita questionnaire covered three disease domains: organ-specific and systemic symptoms and signs; physical function; and social and emotional impact. Second, Italian-speaking AAV patients were recruited from 17 Italian centres belonging to the Italian Vasculitis Study Group. Participants completed the AAV-PRO_ita questionnaire at three time points. Participants were also requested to complete the work productivity and activity impairment: general health questionnaire.

Results

A total of 276 AAV patients (56.5% women) completed the questionnaires. The AAV-PRO_ita questionnaire demonstrated a good internal consistency and test-retest reliability. Female AAV patients scored higher (i.e. worse) in all thee domains, especially in the social and emotional impact domain (P < 0.001). Patients on glucocorticoid therapy (n = 199) had higher scores in all domains, especially in the physical function domain (P < 0.001), compared with patients not on glucocorticoid therapy (n = 77). Furthermore, patients who had at least one relapse of disease (n = 114) had higher scores compared with those who had never had one (n = 161) in any domain (P < 0.05). Finally, nearly 30% of the patients reported work impairment.

Conclusion

The AAV-PRO_ita questionnaire is a new 29-item, disease-specific patient-reported outcome measuring tool that can be used in AAV research in the Italian language. Sex, glucocorticoids and relapsing disease showed the greatest impact on QoL.

Early and Late Response and Glucocorticoid-Sparing Effect of Belimumab in Patients with Systemic Lupus Erythematosus with Joint and Skin Manifestations: Results from the Belimumab in Real Life Setting Study-Joint and Skin (BeRLiSS-JS)

AIM

To assess the efficacy of belimumab in joint and skin manifestations in a nationwide cohort of patients with SLE.

METHODS

All patients with skin and joint involvement enrolled in the BeRLiSS cohort were considered. Belimumab (intravenous, 10 mg/kg) effectiveness in joint and skin manifestations was assessed by DAS28 and CLASI, respectively. Attainment and predictors of DAS28 remission (<2.6) and LDA (≥2.6, ≤3.2), CLASI = 0, 1, and improvement in DAS28 and CLASI indices ≥20%, ≥50%, and ≥70% were evaluated at 6, 12, 24, and 36 months.

RESULTS

DAS28 < 2.6 was achieved by 46%, 57%, and 71% of patients at 6, 12, and 24 months, respectively. CLASI = 0 was achieved by 36%, 48%, and 62% of patients at 6, 12, and 24 months, respectively. Belimumab showed a glucocorticoid-sparing effect, being glucocorticoid-free at 8.5%, 15.4%, 25.6%, and 31.6% of patients at 6, 12, 24, and 36 months, respectively. Patients achieving DAS-LDA and CLASI-50 at 6 months had a higher probability of remission at 12 months compared with those who did not (p = 0.034 and p = 0.028, respectively).

CONCLUSIONS

Belimumab led to clinical improvement in a significant proportion of patients with joint or skin involvement in a real-life setting and was associated with a glucocorticoid-sparing effect. A significant proportion of patients with a partial response at 6 months achieved remission later on during follow-up.

Circulating immune-complexes of IgG/IgM bound to B2-glycoprotein-I associated with complement consumption and thrombocytopenia in antiphospholipid syndrome

Background

Antiphospholipid syndrome (APS) is a multisystemic autoimmune disorder characterized by thrombotic events and/or gestational morbidity in patients with antiphospholipid antibodies (aPL). In a previous single center study, APS-related clinical manifestations that were not included in the classification criteria (livedo reticularis, thrombocytopenia, leukopenia) were associated with the presence of circulating immune-complexes (CIC) formed by beta-2-glycoprotein-I (B2GP1) and anti-B2GP1 antibodies (B2-CIC). We have performed a multicenter study on APS features associated with the presence of B2-CIC.

Methods

A multicenter, cross-sectional and observational study was conducted on 303 patients recruited from six European hospitals who fulfilled APS classification criteria: 165 patients had primary APS and 138 APS associated with other systemic autoimmune diseases (mainly systemic lupus erythematosus, N=112). Prevalence of B2-CIC (IgG/IgM isotypes) and its association with clinical manifestations and biomarkers related to the disease activity were evaluated.

Results

B2-CIC prevalence in APS patients was 39.3%. B2-CIC-positive patients with thrombotic APS presented a higher incidence of thrombocytopenia (OR: 2.32, p=0.007), heart valve thickening and dysfunction (OR: 9.06, p=0.015) and triple aPL positivity (OR: 1.83, p=0.027), as well as lower levels of C3, C4 and platelets (p-values: <0.001, <0.001 and 0.001) compared to B2-CIC-negative patients. B2-CIC of IgM isotype were significantly more prevalent in gestational than thrombotic APS.

Conclusions

Patients with thrombotic events and positive for B2-CIC had lower platelet count and complement levels than those who were negative, suggesting a greater degree of platelet activation.

POS0805 GLUCOCORTICOID-RELATED ADVERSE EVENTS IN GIANT CELL ARTERITIS: APPLICATION OF THE GLUCOCORTICOID TOXICITY INDEX IN A MONOCENTRIC COHORT OF 140 PATIENTS

Background

Oral glucocorticoids (GC) are the mainstay of treatment for giant cell arteritis (GCA) but chronic exposure to GC is associated with serious comorbidities.

Objectives

The objective of this study was to determine the GC exposure and risk of GC-related adverse events (AEs) in GCA, validating the Glucocorticoid Toxicity Index (GTI) (1,2) in a cohort of real-world patients.

Methods

140 consecutive patients with GCA were enrolled in this retrospective monocentric study. All patients were older than 50 years of age, met the 1990 ACR criteria for GCA and/or had the evidence of a large vessel vasculitis at FDG-PET/CT scan. Patients’ clinical data were collected from clinical charts, calculating GC cumulative dose and GTI at baseline and in the following 5 years.

Results

140 patients were enrolled in the study: median (IQR) age at diagnosis 74 (67-79), Female: 97 (69%), Male: 43 (31%). According to vascular involvement patients were classified in cranial-GCA (C-GCA, n:91), large vessel-GCA (LV-GCA, n:21) and cranial and large vessel-GCA (LV-C-GCA, n:28). Furthermore, 50 (36%) patients were treated with only GC, 44 (31%) with GC+methotrexate (MTX), 46 (33%) with GC+tocilizumab (in 20 cases TCZ was started in the first 3 months after diagnosis: early-TCZ, in 26 cases after 3 months for relapses or AEs: late-TCZ).

During the follow up, 57 (41%) patients presented at least one relapse. In the GC group 22 relapses in 18 patients were reported, in MTX group 33 relapses in 25 patients (with 15 relapses before and 18 after MTX start), in early-TCZ group no relapses were reported, in late-TCZ group 21 relapses in 14 patients (with 17 relapses before and 4 after TCZ start) were reported.

Median cumulative GC doses after 1 and 5 years were respectively 7.9 (6.3-9.8) gr and 16.5 (13.8-18.9) gr in GC group, 8.7 (5.9-10.0) gr and 16.5 (13.2-20.7) gr in MTX group, 7.1 (5.5-8.0) gr and 13.3 (12.8-13.7) gr in early-TCZ and 7.7 (6.2-11.1) gr and 19.7 (12.2-23.8) gr in late-TCZ.

Eighty-eight percent of patients developed at least one GC-AE, with infections and hypertension being the most common reported AEs (42% e 44%, respectively). Median GTI-CWS (Cumulative Worsening Score) after 1 year was 65 (20-137) in GC, 63 (10-95) in MTX, 51 (33-116) in TCZ-early, 44 (0-91) in TCZ-late. Median GTI-CWS after 5 years was 219 (118-240) in GC, 137 (65-206) in MTX, 147 (146-147) in TCZ-early, 200 (121-231) in TCZ-late. A correlation between GTI-CWS and the GC cumulative dose was found (after 5 years r: 0.295, p: 0.026).

Conclusion

Chronic GC treatment is associated with a high risk of developing comorbidities. GTI score demonstrated to be an effective tool to assess GC-related AEs and proved to correlate with GC cumulative dose.

TCZ confirmed its efficacy in reducing relapse rate, both in early and late-TCZ groups (3). TCZ showed for the first time in a real-life cohort a GC sparing effect, with a 19% reduction in GC cumulative dose and a 33% reduction in GTI-CWS in 5 years (comparing GC group vs early-TCZ group).

References

[1]Glucocorticoid Toxicity Index (Copyright © 2016, 2018. Massachusetts General Hospital. All rights reserved.)

[2]Miloslavsky EM et al. Ann Rheum Dis. 2017 doi: 10.1136/annrheumdis-2016-210002.

[3]Stone JH et al. N Engl J Med. 2017 doi: 10.1056/NEJMoa1613849.

Disclosure of Interests

None declared

AB1471 EVALUATION OF CXCL13 SERUM LEVELS IN A COHORT OF PATIENTS WITH PERIPHERAL PSORIATIC ARTHRITIS IN COMPARISON WITH RHEUMATOID ARTHRITIS

Background

The research of circulating biomarkers in the field of chronic arthritis is still an unmet need, especially for the subgroup of seronegative arthritis [e.g., negative for anti-citrullinated peptides autoantibodies (ACPA) and/or rheumatoid factors (RF)]. In fact, in this clinical subset, there is a lack of soluble molecules which could help for a diagnostic or prognostic purpose, and the differential diagnosis between psoriatic arthritis (PsA) and seronegative rheumatoid arthritis (RA) is still a challenge. C-X-C motif chemokine 13 (CXCL13) is one of the most promising biomarkers recently identified, because of its association with active synovitis (1) and with a poor prognosis in RA (2), although there are still inadequate results to justify its routine use. No data are available of the determination of CXCL13 serum levels in PsA.

Objectives

To analyze CXCL13 serum levels in a cohort of PsA patients with a history of peripheral involvement in comparison with RA.

Methods

Cross sectional analysis of consecutive patients with peripheral PsA [n:81; male/female=44/37; median age (25°-75° percentile)=54 (46-62) years; 28-joint Disease Activity Score-C Reactive Protein (CRP-DAS28)=1.9 (1.6-2.5); active psoriasis=43%; DAPSA (Disease Activity in PSoriatic Arthritis) score=8 (3-14)] and RA [n:143; male/female=30/113; age =62 (50-70) years; seropositive=67%; CRP-DAS28=2.1 (1.5-2.8)] was performed. 100 sex and age-matched healthy controls (HC) were enrolled. CXCL13 serum levels were assessed through commercial ELISA test (R&D).

Results

CXCL13 serum levels were higher in all the subgroups of patients [PsA: 50.9 (34.5-80.2) pg/mL, p<0.01; RA: 77.2 (52.9-107.7) pg/mL, p<0.01; RA ACPA+: 77.7 (55.9-110.7) pg/mL, p<0.01; RA ACPA-: 69.5 (49.3-104) pg/mL, p<0.01] than in HC (22.3 (17.7-33.8) pg/mL). No significant differences were found among RA patients according with their seropositivity (p=0.378). CXCL13 serum levels were lower in PsA patients than in RA patients, independently from their seropositivity [vs RA ACPA+, p<0.01; vs RA ACPA-, p=0.012]. CXCL13 serum levels were positively correlated with CRP in PsA patients (r=0.30; p=0.008), but not with DAPSA score.

Conclusion

These results confirm the value of CXCL13 as a biomarker in the field of chronic arthritis. Its higher levels in seronegative RA than in PsA suggests its possible value in the differential diagnosis of these two subsets of arthritis.

References

[1]Bechman et al. BMC Rheumatology 2020;

[2]Bugatti et al. Rheumatology 2014.

Disclosure of Interests

None declared

AB1309 ANALYSIS OF A MONOCENTRIC COHORT OF IgG4-RELATED DISEASE PATIENTS: GREATER REDUCTION OF THE RESPONDER INDEX IN PHARMACOLOGICALLY-TREATED PATIENTS AS COMPARED TO UNTREATED ONES

Background

IgG4-related disease (IgG4-RD) is a systemic disease characterized by lymphoplasmocellular infiltration and storiform fibrosis. Pancreas, biliary tract, lacrimal and salivary glands, lymph nodes and retroperitoneum are frequently involved, although the clinical presentation may vary [1].

Objectives

The aim of this study is to retrospectively describe the clinical manifestations of a monocentric cohort of patients with IgG4-RD and analyze their clinical course by applying the validated IgG4-Related Disease Responder Index (RI) [2].

Methods

We enrolled 22 IgG4-RD patients classified with 2011 diagnostic criteria [3] and/or 2019 classification criteria [4].

Results

22 IgG4-RD patients (M/F=3.4/1), mostly Caucasian (91%), were diagnosed at a mean age of 59 years (44-74) with a median IgG4 concentration at diagnosis of 239 mg/dl (IQR 106-391 mg/dL). 14/22 (64%) patients fulfilled the 2011 classification criteria, while 8/22 (36%) were classified as possible (2), probable (5) or definitive (1) according to the diagnostic criteria of 2011. Organ involvement at diagnosis (T0) is described in Table 1. The organs most involved were lymph nodes, salivary glands and retroperitoneum. Patients were followed for a median of 49 months (IQR 16-88). Three patients were lost to follow-up. One patient died for pneumonia 96 months after diagnosis. During the follow-up 5 (23%) patients didn’t receive specific treatment, 1 (5%) was treated surgically, 6 (27%) with steroid only, 10 (45%) with steroid and immunosuppressants (with methotrexate and/or rituximab, tocilizumab, mycophenolate, cyclosporine, hydroxychloroquine, azathioprine) and/or surgical resection. A statistically significant reduction in RI between T0 and last follow-up (TLF) was observed in all the patients [from 6 (3-6) to 3 (1-4) p=0.010]. A significant reduction was also observed in the group of pharmacologically treated patients [from 6 (3-6) to 3 (1-4) p=0.035] but not in the group of patients without drug treatment (p = 0.174).

Table 1.

Organ involvement at diagnosis

Organ involvement T0N. Patients (%)Pancreas2 (9)Lymph nodes14 (64)Salivary glands13 (59)Lungs1 (5)Aorta and large blood vessels4 (18)Retroperitoneum, mediastinum, mesentery6 (27)Bile duct and liver3 (14)Kidneys2 (9)Pachymeninges1 (5)Orbits and lacrimal glands3 (14)Paranasal sinuses and / or nasal mucosa5 (23)

Conclusion

In our cohort, patients were predominantly male with mean age at diagnosis of 59 years, consistent with literature data [1]. A statistically significant reduction in disease activity defined by reduction of RI was observed in patients who received immunosuppressive therapy. No significant reduction was observed in patients not pharmacologically treated.

References

[1]Dai Inoue et al. Medicine, 2015

[2]Carruthers M.N. et al. Int J Rheumatol, 2012

[3]Umehara H. et al. Mod Rheumatol, 2012

[4]Wallace Z.S. et al. Ann Rheum Dis, 2020

Disclosure of Interests

None declared

Novel Therapies in Takayasu Arteritis

Takayasu Arteritis (TAK) is a large-vessel vasculitis that preferentially involves the aorta and its primary branches. Cardiac involvement is frequent in TAK and is a major determinant of the patient's outcome. Glucocorticoids (GC) are the mainstay of therapy for TAK, with high doses of GC effective to induce remission. However, relapses are common and lead to repeated and prolonged GC treatments with high risk of related adverse events. Potential GC toxicity is a major concern, especially because patients with TAK are young and need to be treated for several years, often for the whole life. Conventional immunosuppressive drugs are used in patients with severe manifestations but present some limitations. New therapeutic approaches are needed for patients with refractory disease or contraindications to conventional therapies. Fortunately, major progress has been made in understanding TAK pathogenesis, leading to the development of targeted biotherapies. In particular, IL-6 and TNF-α pathways seems to be the most promising therapeutic targets, with emerging data on Tocilizumab and TNF inhibitors. On the other hand, new insights on JAK-Inhibitors, Rituximab, Ustekinumab and Abatacept have been explored in recent studies. This review summarizes the emerging therapies used in TAK, focusing on the most recent studies on biologics and analyzing their efficacy and safety.

Novel Targets for Drug Use in Eosinophilic Granulomatosis With Polyangiitis

Eosinophilic Granulomatosis with Polyangiitis (EGPA) is a rare autoimmune disease characterized by medium and small vessels inflammation. Cardiac vasculitic involvement is one of the most severe manifestations with a significant impact on patients' long-term prognosis: anyway, a specific therapeutic approach for heart involvement in EGPA has not been explored yet. Current regimen consists of a long-term therapy with high dose of glucocorticoids, causing the well-known related-adverse events; immunosuppressive drugs are used in patients with severe manifestations, with some limitations. New therapeutic approaches are needed for patients with refractory disease or contraindications to conventional therapies. The quest for the ideal therapy is going toward a more and more personalized approach: on the one hand, efforts are made to use already existing therapies in the most appropriate way; on the other hand, new insights into EGPA pathogenesis allow the discovery of new targets, as demonstrated by mepolizumab and rituximab, targeting eosinophils, and B-cell compartments. This review summarizes the emerging therapies used in EGPA, focusing on the most recent studies on biologics and analyzing their efficacy and safety.

Durable renal response and safety with add-on belimumab in patients with lupus nephritis in real-life setting (BeRLiSS-LN). Results from a large, nationwide, multicentric cohort

BACKGROUND

Belimumab was recently approved for treatment of lupus glomerulonephritis (LN).

AIM

To evaluate renal response and its predictors in LN patients receiving belimumab in real-life.

PATIENTS AND METHODS

We considered all patients fulfilling the SLEDAI-2K renal items and/or having estimated glomerular filtration rate (eGFR)≤60 ml/min/1.73 m², with positive anti-dsDNA and/or low C3/C4 enrolled in the multicentre Italian lupus cohort BeRLiSS (BElimumab in Real LIfe Setting Study), treated with monthly IV Belimumab 10 mg/kg over standard treatment. Primary efficacy renal response (PERR), defined as proteinuria ≤0.7 g/24 h, eGFR≥60 ml/min/1.73 m² without rescue therapy, was considered as primary outcome. Complete renal response (CRR; proteinuria <0.5 g/24 h, eGFR≥90 ml/min/1.73 m²) was considered as secondary outcome. Prevalence and predictors of PERR were evaluated at 6, 12, 24 months by multivariate logistic regression.

RESULTS

Among the 466 SLE patients of BeRLiSS, 91 fulfilled the inclusion criteria, 79 females, median age 41.0 (33.0-47.0) years, median follow-up 22.0 (12.0-36.0) months. Sixty-four (70.3%) achieved PERR, of whom 38.4% reached CRR. Among patients achieving PERR at 6 months, 86.7% maintained response throughout the follow-up. At multivariable analysis, hypertension (OR [95%CI]: 0.28 [0.09-0.89], p = 0.032), high baseline serum creatinine (0.97 [0.95-0.99], p = 0.01) and high baseline proteinuria (0.37, [0.19-0.74], p = 0.005) negatively predicted PERR. Positive predictors of PERR at 12 and 24 months were baseline anti-Sm positivity (OR [95%CI]: 6.2 [1.21-31.7], p = 0.029; 19.8 [2.01-186.7], p = 0.009, respectively) and having achieved PERR at 6 months (14.4 [3.28-63.6]; 11.7 [2.7-48.7], p = 0.001 for both).

CONCLUSIONS

Add-on therapy with belimumab led to durable renal response in patients with LN in a real-life setting.

POS0811 EULAR RECOMMENDATIONS ON GIANT CELL ARTERITIS IN REAL LIFE

Background:

GCA is the most frequent systemic vasculitis in patients older than 50 years involving medium-sized and large arteries. On July 2019 EULAR published its updated recommendations for the management of large vessel vasculitis, including GCA.

Objectives:

To analyze how the application of the updated EULAR recommendations changed clinical practice in GCA patients in our Hospital.

Methods:

All patients with a new diagnosis of GCA between January 1st, 2018 and December 31st, 2020 were enrolled in this study. Two cohorts were analyzed: patients who received GCA diagnosis in the eighteen months before EULAR recommendations publication (between January 1st, 2018 and June 30th, 2019: cohort A) and patients who received GCA diagnosis in the following eighteen months (between July 1st, 2019 and December 31st, 2020: cohort B). Data are expressed as median (IQR).

Results:

70 patients were enrolled in the study (F: 47, M: 23, age: 76 (69-79) years): 39 patients in cohort A, 31 in cohort B. Table 1 summarize main clinical features and treatment of patients. Sixteen patients of cohort A (41%) and eleven patients of cohort B (35%) presented large vessel involvement demonstrated by FDG-PET/CT. Thirty-one patients in cohort A (79%) and twenty-seven in cohort B (87%) presented cranial symptoms and were studied with temporal arteries ultrasound (US) and/or biopsy (TAB). More specifically, in cohort A US was performed in 42% of patients with cranial symptoms and TAB in 58% of them. After EULAR recommendations publication (cohort B) the percentage of patients with cranial symptoms who performed US increased to 56% and the percentage of TAB decreased to 52%.

After EULAR recommendations publication, time between symptoms onset and first rheumatologic evaluation was reduced by 30% (from 61 (23-131) to 43 (22-92) days).

No difference in treatment regiments were found between groups, whether in glucocorticoid initial dose or DMARDs adjunctive therapy.

Conclusion:

After EULAR recommendations publication, two major improvement were achieved in our cohort. EULAR suggests GCA patients should be urgently referred to a specialist team. Consistently with this recommendation, time between symptoms onset and first rheumatologic evaluation was markedly reduced. Moreover, EULAR suggests always confirming GCA diagnosis by imaging or TAB, with US as first choice. In line with these recommendations, in our cohort US became more and more frequently performed and progressively preferred over TAB. On the other hand, no differences in treatment regiments were found over time, with EULAR recommendations satisfied both before and after their publication.

References:

[1]Hellmich B, et al. Ann Rheum Dis 2019.

ALL GCA(n: 70)Before EULAR recommendations(n: 39)After EULAR recommendations (n: 31)Time between symptoms onset and first rheumatologic evaluation (days)53 (22-110)61 (23-131)43 (22-92)Temporal artery US28/58 (48%)13/31 (42%)15/27 (56%)Temporal artery biopsy32/58 (55%)18/31 (58%)14/27 (52%)Large vessel involvement (FDG-PET/CT)27 (39%)16 (41%)11 (35%)Glucocorticoid initial dose (mg/die prednisone equivalent)50 (47-50)50 (50-50)50 (38-50)DMARDs43 (61%)24 (61%)19 (61%)

Disclosure of Interests:

None declared

POS0107 TAPERING BELIMUMAB IN PATIENTS WITH SLE: A SINGLE CENTER EXPERIENCE

Background:

In Italy, the use of belimumab has been authorized since 2013, in patients with active systemic lupus erythematosus (SLE) with positive anti–double-stranded DNA and low C3 or C4 levels, despite standard therapy. Belimumab is effective in reducing disease activity and number of flares and in blocking damage progression. To our knowledge, no data are available on dose tapering of belimumab in SLE patients chronically treated with it.

Objectives:

The aim of this retrospective study was to analyse prevalence of tapering in a single cohort and to evaluate disease activity after tapering.

Methods:

Patients, who received intravenous belimumab (10mg/kg) for at least 12 months between June 2013 and December 2020 were enrolled. The Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K), the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC-SDI), Physician Global Assessment (PGA), C3 and C4 levels, and prednisone daily dose were recorded at baseline and every six-months. Follow-up was stopped when patients switched to subcutaneous belimumab or when it was discontinued for more than 6 months (interrupted). Dose tapering was defined as the prolongation of the regular dose interval, after initial treatment based on the registered dosage.

Results:

Between June 2013 and December 2020, 48 patients received intravenous belimumab for at least 12 months (100% Caucasians, 94% females). All patients received standard belimumab dosage of 10mg/Kg every 4 weeks. Fourteen (29.1%) of 48 patients lengthened the dosing interval to 5 weeks; a subsequent lengthening of the interval occurred in 7 patients every 6 weeks and in 1 patient belimumab was gradually tapered to every 13 weeks.

Twelve months (T12) after belimumab introduction, 3 patients (6.2%) were receiving a tapered dosage; at T24, 9 out of the 37 (24.3%), at T36 9 out of 21 (42.8%), and at T48 8 out of 18 (44.4%). Differences in disease activity, damage, concomitant medications, disease duration at belimumab introduction (baseline) were evaluated among patients that maintained the standard interval versus the group that received a tapered dose. Notably, no differences were found among the two groups (standard dose vs tapering) concerning median age at baseline (41, IQR 31-47.5 vs 38, IQR 32.2-51.5), disease duration (median 11, IQR 7.2-16 vs 9, IQR 5.5-14.5), median prednisone daily dosage (7.1mg, IQR 5-11.9 versus 11mg, IQR 7.6-17.5) and median SLEDAI-2K (8, IQR 6-9.75 vs 8, IQR 5-10). Differences in concomitant medications or clinical manifestations are reported in Figure 1A.

Among the group that received the standard dose, 7 patients discontinued the treatment (20.6%), specifically 2 renal flares and one adverse event occurred. Whereas, in the reduced dose group, 2 discontinuations occurred (14.3%) due to a pregnancy and a renal flare. Noteworthy, the patient with the renal flare resumed subcutaneous belimumab 12 months after the flare. Finally, the disease activity was analysed in the 12 months after the first drug reduction (Figure 1B-E), with no sign of worsening of evaluated parameters (Figure 1B-1E), but with a significant reduction of steroids and SLEDAI-2K, 6 months after tapering.

Conclusion:

In our single retrospective cohort, we have demonstrated that belimumab tapering seems to be safe and not associated with a worsening disease activity over the following months. However, further studies are required to identify eligibility criteria and to determine the optimal dose-tapering strategy both for the intravenous and the subcutaneous formulations.

Figure 1.

Disclosure of Interests:

None declared

AB0822 BREASTFEEDING AMONG WOMEN WITH RHEUMATIC DISEASES: ANALYSIS OF DATA FROM THE P-RHEUM.IT STUDY

Background:

The World Health Organization recommends that infants should be exclusively breastfed until the age of 6 months. The aim of this study was to assess the ratio of breastfeeding patients with Rheumatic Diseases (RD) and to identify possible causes of its discontinuation.

Objectives:

The aim of this study was to assess the ratio of breastfeeding patients with Rheumatic Diseases (RD) and to identify possible causes of its discontinuation.

Methods:

This study was embedded in the P-RHEUM.it register, as a nationwide prospective cohort study collecting data of pregnancies in inflammatory RD. Pregnancies, enrolled until the 20th week of pregnancy, are followed from pregnancy until 6 months postpartum. At baseline, sociodemographic parameters, obstetric history, comorbidities are reported. During pregnancy, the course of maternal disease, development of foetus and complications are reported. After delivery, the pregnancy outcome, data on lactation and child development are collected.

Results:

From May 2018 to May 2020 data of 349 patients were available. Data on lactation were available in 44 pregnancies. Two months after delivery 37 were continuing breastfeeding (n=26) or mixed feeding (n=11), while 7 were using formula feeding. Among patients using formula feeding 2 had a diagnosis of rheumatoid arthritis (RA), 1 of juvenile idiopathic arthritis, 1 of undifferentiated arthritis (UA), 1 of anti-phospholipid syndrome (APS), 1 of vasculitis and 1 of systemic lupus erythematosus. The reasons of formula feeding were the following: 2 for agalactia, 2 for personal preferences, 3 for drug-related concerns (1 for physician’s decision in a patient with APS; 2 for maternal concerns about drugs in patients with RA and UA treated respectively with Adalimumab and Tocilizumab). At 6 months 30 continued breastfeeding (n=23) or mixed feeding (n=7) and 14 formula feeding. The reasons of formula feeding were available in 9 patients: 3 for agalactia, 2 for personal preferences, 2 for physician’s decision in a patient with APS and in a patient positive for anti-phospholipid antibodies; 2 for maternal concerns about drugs.

Conclusion:

Preliminary data of this prospective study demonstrate a high percentage of breastfeeding/mixed feeding after delivery and after 6 months among women with RD. Drug related concerns are the main reason of discontinuation of breastfeeding, although medication results compatible with lactation. Using our results, strategies supporting patients with RD whishing to breastfeed may be developed.

References:

[1]Carina Gotestam Sporken et al. The EULAR points to consider for use of antirheumatic drugs before pregnancy, and during pregnancy and lactation. Ann Rheum Dis 2016.

[2]Sammaritano et al. 2020 American College of Rheumatology Guideline for the management of reproductive health in rheumatic and muscoloskeletal diseases, Arthritis Rheumatol. 2020.

Acknowledgements:

Authors would like to thank SIR study center and all patients who accepted to partecipate to our study

Disclosure of Interests:

None declared

POS0693 EFFICACY AND SAFETY OF BELIMUMAB IN PATIENTS WITH LUPUS NEPHRITIS IN REAL-LIFE SETTING: RESULTS FROM A LARGE, NATIONWIDE, MULTICENTRIC, PROSPECTIVE COHORT

Background:

LN is still a severe manifestation of Systemic lupus erythematosus (SLE) and multitarget therapy is needed to control the disease especially in refractory cases.

Objectives:

To evaluate renal response in SLE patients with glomerulonephritis (GN) treated with Belimumab in real-life setting.

Methods:

Patients with proteinuria >0.5 g/24 h and/or active sediment at baseline enrolled in a multicentre Italian cohort of SLE patients (BeRLiSS study), treated with monthly iv Belimumab 10 mg/kg plus standard of care were considered in this study. Complete renal response (CRR) was defined as proteinuria <0.5 g/24 h, estimated glomerular filtration rate (eGFR)≥90ml/min/1.73m2 and no rescue therapy. Primary efficacy renal response (PERR) was defined as proteinuria ≤0.7 g/24 h, eGFR ≥60ml/min/1.73m2 and no rescue therapy. Prevalence and predictive factors of CRR and PERR at 12 and 24 months after Belimumab initiation were analyzed by multivariate logistic regression analysis.

Results:

A total of 91 patients were considered in this study, 79 female, mean age 40.51±9.03 years, mean disease duration 12.18±8.15 years, median follow-up time after Belimumab initiation 22 months. Twenty patients had baseline proteinuria ≥0.5 <1 g/day, 17 ≥1 <2 g/day, 13 ≥2 g/day. Belimumab was started at GN onset in 20 (22%) patients and at the time of a renal flare in all other cases. Seventy-five patients underwent a renal biopsy: 1 class I, 4 class II, 14 class III, 47 class IV and 9 class V. Baseline serum creatinine was 82.44±29.26 umol/L; 15 patients showed eGFR<60ml/min/1.73m2 at baseline. Immunosuppresants were taken by 70 (76.9%) patients: 47 micofenolate, 15 azathioprine and 5 ciclosporine. Sixty patients (65.9%) were on antimalarials. During follow-up 34 (37.4%) patients achieved CRR. Among them 5 (14.7%) patients relapsed and 29 (85.3%) patients maintained remission. Mean time to achieved CRR was 9.71±5.91 months.

High levels of baseline proteinuria were a negative independent predictor of CRR and PERR at 6 months (OR 0.044 CI95% 0.006-0.320 p=0.002 and OR 0.232 CI95% 0.091-0.596 p=0.002) and 12 months (OR 0.029 CI95% 0.002-0.556 p=0.019 and OR 0.056 CI95% 0.009-0.327 p=0.001). High levels of baseline creatinine were a negative independent predictor of renal response. Renal response at 6 months was a strong predictive factor of renal response at 12 and 24 months.

Conclusion:

Belimumab is an effective add-on therapy in the treatment of GN in real-life practice setting.

Disclosure of Interests:

None declared

POS0797 LARGE VESSEL-GCA: A DIAGNOSTIC CHALLENGE

Background:

GCA is the most frequent systemic vasculitis in patients older than 50 years involving medium-sized and large arteries. Inflammation of the extracranial branches of the carotid artery gives rise to the classic symptoms of GCA. However, in almost two-thirds of patients GCA involves also the aorta and its major branches (1,2). Large vessel involvement leads to a different atypical clinical picture which can be challenging to diagnose (3,4). More information on clinical presentation and vessel involvement in large-vessel GCA are needed to better diagnose it.

Objectives:

To analyze clinical presentation of large-vessel GCA compared to classical cranial disease.

Methods:

100 consecutive patients with a clinical diagnosis of GCA were enrolled in this retrospective study. All patients were older than 50 years of age, met the ACR criteria for GCA or had a positive biopsy of the temporal artery or evidence of large vessel vasculitis at FDG-PET/CT scan.

Results:

Based on vascular involvement, patients were classified into three group: 61 patients with only cranial arteritis (C-GCA), 16 patients with only extracranial large vessel vasculitis (LV-GCA) and 23 patients with both cranial and large vessel involvement (LV-C-GCA).

Compared to C-GCA, patients with large vessel involvement (LV-GCA and LV-C-GCA) were younger and more frequently women, and the difference was further significant for patients with isolated LV-GCA. Patients with isolated LV-GCA had also the longer duration of symptoms at GCA diagnosis [LV-GCA 20(16-82) vs LV-C-GCA 12(4-16) vs C-GCA 4(3-12) weeks; p<0.001]. Systemic symptoms, as fever and fatigue, were associated with large vessel involvement, both in LV-GCA and LV-C-GCA groups. Polymyalgia rheumatica was equally reported in all three cohorts of patients and no significant differences were found in inflammatory markers levels according to vessel involvement.

In patients with large vessels involvement (LV-GCA and LV-C-GCA) thoracic aorta, subclavian arteries and abdominal aorta were the most frequently involved arteries.

Conclusion:

GCA is not a single entity but includes several patterns of disease. Female gender, younger age and systemic symptoms are associated with large vessel involvement, regardless the presence or absence of cranial symptoms. The different clinical manifestations of large vessel GCA lead to a longer time to diagnosis if compared to C-GCA. For these reasons, in patients with the aforementioned characteristics, a large vessel involvement should be considered in order to reduce the time to diagnosis.

References:

[1]De Boysson H, et al. Clin Exp Rheumatol 2019.

[2]Prieto-González S, et al. Ann Rheum Dis 2012.

[3]Brack A, et al. Arthritis Rheum 1999.

[4]Muratore F, et al. Rheumatol 2015.

GCA(n: 100)C-GCA(n: 61)LV-C-GCA(n: 23)LV-GCA(n: 16)pAge: median (IQR)76 (67-79)75 (71-80)74 (69-77)63 (59-72)0.001Female/ Male68 (68%) /32 (32%)38 (62%) / 23 (38%)17 (74%) /6 (26%)13 (81%) /3 (19%)0.276Time between symptom onset and diagnosis (weeks)8 (4-20)4 (3-12)12 (4-16)20 (16-82)<0.001Cranial symptoms (overall)84 (84%)61 (100%)23 (100%)0 (0%)<0.001New temporal headache77 (77%)58 (95%)19 (83%)0 (0%)<0.001Visual symptoms39 (39%)34 (56%)5 (22%)0 (0%)<0.001Jaw or tongue claudication35 (35%)27 (44%)8 (35%)0 (0%)0.004Fever48 (48%)23 (38%)14 (61%)11 (69%)0.032Fatigue75 (75%)40 (66%)21 (91%)14 (88%)0.023Weight loss52 (52%)28 (46%)13 (57%)11 (69%)0.235Polymyalgia rheumatica43 (43%)27 (44%)13 (57%)3 (19%)0.061Arm or leg claudication5 (5%)0 (0%)4 (17%)1 (6%)0.005CRP (C-reactive protein)83 (45-127)77 (39-115)89 (50-134)95 (20-124)0.461ESR (erythrocyte sedimentation rate)72 (47-96)70 (46-88)75 (28-105)66 (44-91)0.711Cranial arteries84 (84%)61 (100%)23 (100%)0 (0%)<0.001Carotid arteries19 (19%)0 (0%)12 (52%)7 (44%)<0.001Subclavian and upper limb arteries21 (21%)0 (0%)10 (43%)11 (69%)<0.001Thoracic aorta29 (29%)0 (0%)15 (65%)14 (88%)<0.001Abdominal aorta21 (21%)0 (0%)10 (43%)11 (69%)<0.001Iliac and inferior limb arteries10 (10%)0 (0%)6 (26%)4 (25%)<0.001

Disclosure of Interests:

None declared

Characterization of B- and T-Cell Compartment and B-Cell Related Factors Belonging to the TNF/TNFR Superfamily in Patients With Clinically Active Systemic Lupus Erythematosus: Baseline BAFF Serum Levels Are the Strongest Predictor of Response to Belimumab after Twelve Months of Therapy

Background: Patients with systemic lupus erythematosus (SLE) show increased serum levels of tumor necrosis factor (TNF)/TNF receptor (R) superfamily member, e.g. BAFF (B lymphocyte stimulator). Belimumab, a monoclonal antibody against soluble BAFF, is used for treatment of SLE. Although B cells are the main target, a BAFF-dependent T-cell activation pathway also plays a role. High levels of anti-DNA antibodies and low complement at baseline are known predictors of response to Belimumab.

Objectives: To explore the association of circulating lymphocytes and serum levels of B- cell related TNF/TNFR superfamily members with response to Belimumab in SLE patients.

Methods: Twenty-one SLE patients received Belimumab. Clinical evaluation and laboratory tests were performed at baseline, at 6 and 12 months. TNF super-family members (BAFF, APRIL, sBCMA, sCD40L, sTACI, TWEAK) were tested by high-sensitivity ELISA in all patients, and lymphocyte immunophenotyping was performed by flow cytometry in ten subjects. SLE-disease activity was assessed by SLEDAI-2K score. Linear regression modeling was used to investigate parameters influencing SLEDAI-2K and anti-dsDNA antibody titers over time and for predictive models.

Results: Clinical improvement was observed in all patients. A global reduction of circulating B cells, especially naïve, was detected, without variation in the T-cell compartment. All TNF family members decreased, whereas APRIL remained constant. The increase in serum levels of C3 (p = 0.0004) and sTACI (p = 0.0285) was associated with a decrease of SLEDAI-2K. The increase of C4 (p = 0.027) and sBCMA (p = 0.0015) and the increase of CD8⁺ T cells (p = 0.0160) were associated with a decrease, whereas an increase of sCD40L in serum (p = 0.0018) and increased number of CD4⁺ T cells (p = 0.0029) were associated with an increase, in anti-dsDNA antibody titers, respectively. Using stepwise forward inclusion, the minimal model to predict SLEDAI-2K response at 12 months included BAFF (p = 3.0e − 07) and SLEDAI-2K (p = 7.0e − 04) at baseline. Baseline APRIL levels also showed an association, although the overall model fit was weaker.

Conclusion: In our real-life cohort, baseline serum levels of BAFF were the best predictor of response to Belimumab, confirming post-hoc results of the BLISS study and suggesting the utility of this particular biomarker for the identification of patients who are more likely to respond.

POS0593 THE REDUCTION OF RETINAL MICROVASCULAR ALTERATIONS AND THE DECREASE OF A POTENTIALLY RELATED T-CELL SUBSET IN PATIENTS WITH ACTIVE RHEUMATOID ARTHRITIS TREATED WITH ABATACEPT

Background:

T-cells play a pivotal role in the pathogenesis of rheumatoid arthritis (RA) and in its cardiovascular (CV) comorbidities, acting at microvascular level [1]. Since small artery remodeling is the earliest form of target organ damage in hypertension, the evaluation of microvascular alterations might provide clinically useful information. The evaluation of retinal arterioles is a non-invasive technique to identify a precocious microvascular damage, which is related to an increase of the wall-to-lumen ratio (WLR) [2]. CD3+CD31+CXCR4+ T-cells may be involved in damaged endothelium repair and are increased in patients with morphological microvascular alterations [3]. In addition to its effect on disease activity, abatacept (ABA), a co-stimulator blocker which is approved for the treatment of RA, may have specific CV protective action, modulating the numbers of certain subtypes of lymphocytes [4].

Objectives:

To non-invasively investigate morphological characteristics of retinal arterioles and to evaluate CD3+CD31+CXCR4+T-cells in a cohort of RA patients treated with ABA.

Methods:

Eleven RA patients [median (25th-75thpercentile) age=58 (50-65) years, baseline C-reactive protein (CRP)-DAS28=4.4 (3.8-4.6), body mass index (BMI)=23.4 (21.6-25.6) kg/m2, rheumatoid factor (RF) positive:45%, anti-citrullinated peptide autoantibodies (ACPA) positive:73%] without known CV risk factors (arterial hypertension, diabetes, hypercholesterolemia, previous CV events, smoking) were evaluated by adaptive optics, a validated technique quantifying microvascular damage [5], before and every 6 months of therapy with ABA (T0, T6 and T12). Phenotypic analysis of peripheral blood T lymphocytes was made by flow-cytometry in 5 patients of the cohort at T0 and T6.

Results:

A progressive significant reduction of the WLR of retinal arterioles was observed [T0=0.28 (0.25-0.30), T6=0.27 (0.24-0.31), T12=0.23 (0.23-0.26); p T0 vs T6=0.4; p T6 vs T12=0.01; p T0 vs T12=0.01] (Figure 1), without significant variations in the other parameters [internal diameter: T0=94.4 (84.1-104.0), T6=94.8 (84.6-107.7), T12=99.2 (89.1-109.1) µm; external diameter: T0=125.8 (111.1-131.0), T6=122.4 (109.1-134.5), T12=125.6 (113.9-134.4) µm; wall thickness: T0=13.2 (12.2-14.4), T6=13.4 (11.7-14.4), T12=12.5 (11.6-13.0) µm; wall cross-sectional area: T0=4581.0 (3788.7-5263.7), T6=4563.3 (3788.5-5295.2), T12=4099.7 (3899.0-5145.7) µm2)]. In 5 patients evaluated also for T-cell immunophenotyping a negative correlation was observed between CD3+CD31+CXCR4+ T-cell number and the retinal wall thickness at baseline (R=0.871;p=0.05). After ABA therapy a trend for reduction of CD3+CD31+CXCR4+T-cells [19.0 (13.8-38.3) vs 12.4 (5.2-18.0) % of CD3+], was observed as well as of significant reduction of retinal wall cross-sectional area [5123.3 (4385.0-5470.3) vs 4852.3 (4118.3-5228.0) µm2;p=0.04].

Conclusion:

In a cohort of RA patients without known CV risk factors, a reduction in retinal microvascular alterations arterioles was demonstrated after treatment for 12 months with ABA. CD3+CD31+CXCR4+T-cell number was inversely related to the possible presence of subclinical CV involvement. These results may suggest the possibility of microvascular abnormalities regression induced by the immune system modulation.

References:

[1]Dessein PH, J Rheumatol 2005.

[2]Rizzoni D, Am J Hypertens. 2018.

[3]Hur J, Circulation 2007.

[4]Kallikourdis M, Nat Commun 2017.

[5]De Ciuceis C, J Hypertens 2018.

Acknowledgements:

Bristol-Myers-Squibb Italy provided an unrestricted research grant for the study conduct.

Figure 1.

Disclosure of Interests:

None declared

Tocilizumab for the treatment of severe COVID-19 pneumonia with hyperinflammatory syndrome and acute respiratory failure: A single center study of 100 patients in Brescia, Italy

A hyperinflammatory syndrome (HIS) may cause a life-threatening acute respiratory distress syndrome (ARDS) in patients with COVID-19 pneumonia. A prospective series of 100 consecutive patients admitted to the Spedali Civili University Hospital in Brescia (Italy) between March 9th and March 20th with confirmed COVID-19 pneumonia and ARDS requiring ventilatory support was analyzed to determine whether intravenous administration of tocilizumab (TCZ), a monoclonal antibody that targets the interleukin 6 (IL-6) receptor, was associated with improved outcome. Tocilizumab was administered at a dosage of 8 mg/kg by two consecutive intravenous infusions 12 h apart. A third infusion was optional based on clinical response. The outcome measure was an improvement in acute respiratory failure assessed by means of the Brescia COVID Respiratory Severity Score (BCRSS 0 to 8, with higher scores indicating higher severity) at 24-72 h and 10 days after tocilizumab administration. Out of 100 treated patients (88 M, 12 F; median age: 62 years), 43 received TCZ in the intensive care unit (ICU), while 57 in the general ward as no ICU beds were available. Of these 57 patients, 37 (65%) improved and suspended noninvasive ventilation (NIV) (median BCRSS: 1 [IQR 0-2]), 7 (12%) patients remained stable in NIV, and 13 (23%) patients worsened (10 died, 3 were admitted to ICU). Of the 43 patients treated in the ICU, 32 (74%) improved (17 of them were taken off the ventilator and were discharged to the ward), 1 (2%) remained stable (BCRSS: 5) and 10 (24%) died (all of them had BCRSS≥7 before TCZ). Overall at 10 days, the respiratory condition was improved or stabilized in 77 (77%) patients, of whom 61 showed a significant clearing of diffuse bilateral opacities on chest x-ray and 15 were discharged from the hospital. Respiratory condition worsened in 23 (23%) patients, of whom 20 (20%) died. All the patients presented with lymphopenia and high levels of C-reactive protein (CRP), fibrinogen, ferritin and IL-6 indicating a HIS. During the 10-day follow-up, three cases of severe adverse events were recorded: two patients developed septic shock and died, one had gastrointestinal perforation requiring urgent surgery and was alive at day 10. In conclusion, our series showed that COVID-19 pneumonia with ARDS was characterized by HIS. The response to TCZ was rapid, sustained, and associated with significant clinical improvement.

FRI0217 SENSITIVITY AND SPECIFICITY OF 2019 DCVAS DRAFT CLASSIFICATION CRITERIA FOR GIANT CELLS ARTERITIS AND TAKAYASU ARTERITIS IN A MONOCENTRIC COHORT OF PATIENTS WITH CLINICAL DIAGNOSIS OF LARGE VESSEL VASCULITIS

Background:

Recently, a new set of classification criteria for Giant Cells Arteritis (GCA) and Takayasu Arteritis (TA) has been developed by the DCVAS project and presented as draft criteria at the 19th International Vasculitis and ANCA Workshop held in Philadelphia in 2019.

Objectives:

The purpose of the present study is to analyze the performance of the 2019 DCVAS Draft Classification Criteria in differentiating GCA and TA in a cohort of patients with Large Vessel Vasculitis (LVV), comparing their sensitivity and specificity to 1990 ACR Classification Criteria.

Methods:

2019 DCVAS Draft Criteria and 1990 ACR Criteria were retrospectively applied to a cohort of 130 consecutive patients with Large Vessel Vasculitis. In all patients the diagnosis of vasculitis was histologically and/or radiologically confirmed.

Results:

One-hundred patients had a clinical diagnosis of GCA, 25 patients of TA and 5 patients of other form of LVV, different from GCA and TA (idiopathic isolated aortitis n:2, aortitis with retroperitoneal fibrosis n:2, isolated pulmonary arteritis n:1).

Among the 100 patients clinically diagnosed as GCA (F/M: 68/32, age: 74 (60-83)) only 82 fulfilled the 1990 ACR Criteria for GCA, while all of them fulfilled the 2019 DCVAS Draft Criteria for GCA.

Instead, among the 25 patients with a clinical diagnosis of TA (F/M: 21/4, age: 34 (16-48)), 22 (88%) could be classified as TA according to the 1990 ACR Criteria, 25 (100%) according to 2019 DCVAS Draft Criteria.

In the group of patients diagnosed with other form of LVV (F/M: 2/3, age: 56 (38-71)) 4 patients (80%) fulfilled the 2019 DCVAS Draft Criteria for GCA, while none of them fulfilled the 2019 DCVAS Draft Criteria for TA or the 1990 ACR Criteria for GCA or TA. One of these patients did not fulfilled any classification criteria.

On the contrary, one GCA patient could be classified both as GCA or TA according to the 2019 DCVAS Draft Criteria but didn’t fulfilled the 1990 ACR Criteria for GCA or TA.

For GCA, 2019 DCVAS Draft Criteria shown a sensitivity of 100% and a specificity of 80%, compared to 82% and 100% of 1990 ACR Criteria. For TA, 2019 DCVAS Draft Criteria shown a sensitivity of 100% and a specificity of 99%, compared to 88% and 100% of 1990 ACR Criteria.

For GCA the agreement between the two different sets of criteria was 85.5% (Cohen’s k coefficient: 0.64), for TA the agreement was 85.1% (k: 0.58).

Conclusion:

The new draft classification criteria shown a lower specificity if compared to the older ones, but also a higher sensitivity: in particular 2019 DCVAS Draft Criteria can better identify GCA patients with extracranial involvement, historically excluded from the 1990 ACR criteria.

both GCA and TA 2019 DCVAS Draft Criteria, demonstrating that this classification well performs in differentiating GCA and TA.

Table 1:GCA (n:100)TA (n:25)Other LVV (n:5)Morning stiffness in shoulders or neck43 (43%)3 (12%)0 (0%)Sudden visual loss33 (33%)2 (8%)0 (0%)Jaw or tongue claudication35 (35%)0 (0%)0 (0%)New headache/Scalp tenderness77 (77%)/30 (30%)5 (20%)/0 (0%)1 (20%)/0 (0%)Temporal Artery Exam: pathological findings34 (34%)0 (0%)0 (0%)Elevated ESR or CRP100 (100%)16 (64%)5 (100%)Temporal Artery Biopsy: vasculitis53 (53%)0 (0%)0 (0%)Temporal Artery halo sign (US)/Bilateral axillary involvement11 (11%)/11 (11%)0 (0%)/4 (16%)0 (0%)/0 (0%)FDG-PET activity throughout aorta32 (32%)13 (52%)4 (80%)Angina or ischemic cardiac pain5 (5%)4 (16%)1 (20%)Arm or leg claudication5 (5%)12 (48%)0 (0%)Arterial bruit2 (2%)19 (76%)1 (20%)Reduced pulse in upper extremity1 (1%)15 (60%)0 (0%)Carotid: reduced pulse or tenderness0 (0%)8 (32%)0 (0%)SBP difference in arms: >10/ >20 mmHg0 (0%)/1 (1%)14 (56%)/6 (24%)0 (0%)/0 (0%)Pathological Angiography or AngioCT:number of affected arteries: 1/2/>319 (19%):7/3/922 (88%):0/1/195 (100%):3/0/2Paired branch arteries involvement7 (7%)20 (80%)2 (40%)Abdominal aorta with renal or mesenteric involvement0 (0%)17 (68%)0 (0%)

Disclosure of Interests:

None declared

FRI0154 SHOULD BE OLDER PATIENTS TESTED FOR ANTIPHOSPHOLIPID ANTIBODIES? 695 CASES FROM THE RETROSPECTIVE SERIES HIBISCUS

Background:

Although guidelines do not recommend antiphospholipid antibodies testing after 60 yo, recent data reported late onset antiphospholipid syndrome (APS).

Objectives:

To comparatively analyse the clinical, laboratory features and outcomes in 695 cases with primary APS between patients older and younger than 70 yo.

Methods:

we have performed an international study within the framework of the International Registry of primary APS patients treated with Hydroxychloroquine, HIBISCUS (an ongoing retrospective and prospective register launched in 2016). 28 centres from 17 countries participate. Data about late onset APS were analysed in 695 patients and were obtained from a standardized form registered in the database containing 66 items with respect to demographics, clinical and biological features.

Results:

Arterial events and especially stroke represented the main initial and recurrent clinical manifestation in 40 primary APS patients older than 70 yo. There were not statistically significant differences with respect to cardiovascular risk factors between the two groups of patients. A significant male predominance, a familial APS history, a higher prevalence of triple positivity, lower complement levels, and anticardiolipin antibodies (aCL) IgA isotype were found in older patients. Low anticoagulation regimens were safe and efficient, with a low relapse rate in older patients.

Conclusion:

we suggest that the detection of aPL antibodies should be included into the initial screening panel tests in elderly with thrombotic events, especially arterial, in particular those with recurrent stroke and familial APS.

Our study further suggests that lower intensity anticoagulation regimens could be a therapeutic option in older APS patients, as no differences in outcomes and relapse rate were found between patients with high and low intensity anticoagulation regimens.

References:

[1]Grimaud F et al. Rheumatology. 2019;58:1006-10.

[2]Goldman-Mazur S et al. Thromb Res. 2019;176:67-73.

[3]Hirmerova J et al. 2017;36:167-73.

Disclosure of Interests:

Cristina Belizna: None declared, Omar Latino: None declared, Ljudmila Stojanovich: None declared, Patrick Saulnier: None declared, Katrien Devreese: None declared, Sebastien Udry: None declared, Natasa Stanisavljevic: None declared, Aleksandra Djokovic Speakers bureau: KRKA, Astra Zeneca, Actavis, Jaume Alijotas-Reig: None declared, Enrique Esteve-Valverde: None declared, Raquel Ferrer-Oliveras: None declared, Angela Tincani: None declared, Laura Andreoli: None declared, Francesca Regola: None declared, Maarten Limper: None declared, Alexander Makatsariya: None declared, Jamilya Khizroeva: None declared, Viktoria Bitsadze: None declared, Cecilia Chighizola: None declared, Francesca Pregnolato: None declared, Maria Orietta Borghi: None declared, Pier Luigi Meroni: None declared

AB0523 TAKAYASU ARTERITIS AND SACROILIITIS: A CASE-CONTROL STUDY

Background:

A possible shared immunopathogenesis between Spondyloarthritis (SpA) and Takayasu Arteritis (TA) has been hypothesized and some clinical cases about SpA in TA patients have been reported (1). In clinical practice the diagnosis of sacroiliitis may be performed by X-ray, Computed Tomography (CT) or Magnetic Resonance Imaging (MRI). In particular, CT findings of sacroiliitis include contour irregularities, joint space alterations, joint erosion, subcondral bone changes (osteoporosis or sclerosis), enthesitis, ankylosis. Meanwhile, TA patients performe routinely FDG-PET/CT scans for monitoring disease activity.

Objectives:

This study aims to understand if there is an increased incidence of sacroiliitis in TA patients.

Methods:

We collected retrospectively imaging data from FDG-PET/CT scans of 28 TA patients and 28 controls, matched for sex and age. Controls were selected among patients performing FDG-PET/CT in our Nuclear Medicine Unit, excluding patients with bone tumors, bone metastasis and thyroid cancers. The majority of controls were affected by lymphoma in complete remission. An expert rheumatologist read the CT-scans of sacroiliac joints.

Results:

No patients or controls demonstrated FDG-uptake in sacroiliac joints. In the control group we detected sacroiliac sclerosis in two cases: one due to degenerative changes, one to sacroiliitis (1/28, 4%). In the TA group four patients presented CT alterations suggestive for sacroiliitis: one bilateral erosion, one bilateral sclerosis, two monolateral sclerosis (4/28, 14%). One of these patients complained an inflammatory back pain.

Conclusion:

In our cohort of TA patients we demonstrated an increased prevalence of sacroiliitis, diagnosed by CT scan. Only one patient reported an inflammatory back pain, while three patients had radiological signs of previous sacroiliitis. These findings highlight the importance of looking for spondyloarthropathy in TA patients even if asymptomatic.

References:

[1]Guzel Esen S, Joint Bone Spine, 2019

Disclosure of Interests:

None declared

FRI0105 EVALUATION OF CXCL13 AND ICAM1 SERUM LEVELS AS PREDICTORS OF CLINICAL RESPONSE TO ABATACEPT IN RHEUMATOID ARTHRITIS

Background:

Soluble intercellular adhesion molecule 1 (ICAM1) and C-X-C motif chemokine 13 (CXCL13) were described as differentially associated with two major subtypes of synovitis in rheumatoid arthritis (RA). Raised serum levels of ICAM1 (which is upregulated in synovial fibroblasts in response to TNFα), and of CXCL13 (which is expressed by synovial follicular dendritic cells and activated mature antigen-experienced T-helper cells), are associated with a myeloid or lymphoid synovial phenotype, respectively (1). It has been suggested that a preferential clinical response to anti-TNFα, as compared to anti-IL-6R monotherapy, can be predicted by measuring these two biomarkers (2). No information is available on the possible utility of these biomarkers in RA patients treated with abatacept (ABA), a T-cell co-stimulation blocker.

Objectives:

To analyze the effect of ABA on ICAM1 and CXCL13 serum levels in RA and to verify whether they predict the response to the drug.

Methods:

63 RA patients [F/M=51/12; median (10th-90thpercentile) age=60 (41-72) years; CRP-DAS28=4.6 (3.3-5.8); ACPA positive: 86%], before and after 6 months of treatment with ABA + methotrexate and 22 sex and age-matched healthy controls (HC) were evaluated. Serum ICAM1 and CXCL13 levels were dosed by commercial ELISA (Life Technologies and R&D). Response to treatment was defined with the EULAR criteria.

Results:

CXCL13 serum levels were higher in RA at baseline than in HC [136 (42-325) vs 32 (19-57) pg/ml, p<0.01], while no difference was observed in ICAM1 [186 (125-276) vs 184 (153-246) ng/ml, p=0.9]; positive correlations between ICAM1 and CRP (r:0.28; p=0.03) and CXCL13 levels and CRP (r:0.40; p<0.01) and CRP-DAS28 values (r:0.27, p=0.05) were found. After therapy with ABA, a reduction of CXCL13 was observed [136 (42-325) vs 94 (29-319) pg/ml, p<0.01], both in responders [n: 37: 151 (57-462) vs 97 (26-329) pg/ml; p<0.01] and non-responders (n: 14: 142 (68-293) vs 89 (42-198) pg/ml; p=0.01]. Not significant variation of ICAM1 serum levels was found in the entire cohort [186 (125-276) vs 190 (113-252) ng/ml, p=0.06]. However, a significant decrease was observed in non-responders [222 (169-302) vs 186 (110-233) ng/ml, p=0.02]. At baseline, no significant difference was found among patients seropositive for ACPA if compared with the negative ones [ACPA+ vs ACPA- for ICAM1 [187 (123-280) vs 177 (134-258) ng/ml; p=0.7] and for CXCL13 [143 (42-368) vs 113 (56-270) pg/ml; p=0.4]].

Conclusion:

Our results confirmed that CXCL13 serum levels are directly correlated with disease activity and demonstrated that ABA therapy induces their reduction. These findings suggest that the co-stimulation blockade at central level and/or in the synovium lead to a reduced production of CXCL13. We could not demonstrate that CXCL13 levels predict the clinical response to ABA in this cohort of patients.

References:

[1]Rosengren S, Rheumatology 2011;2.Dennis G, Arthritis Res Ther 2014

Acknowledgments:

Bristol-Myers-Squibb Italy provided an unrestricted research grant for the study conduction.

Disclosure of Interests:

None declared

AB0522 GENDER DIFFERENCES IN GIANT CELLS ARTERITIS: ANALYSIS OF A MONOCENTRIC COHORT OF 100 PATIENTS

Background:

Giant Cells Arteritis (GCA) is the most common primary vasculitis in adults and usually occurs in patients older than 50 years. Epidemiological studies shown a higher prevalence of the disease in women compared to man. However, differences in clinical presentation between men and women have not been demonstrated, even if some distinctions have been suggested (1,2).

Objectives:

The purpose of the present study is to analyze differences in the clinical presentation of GCA according to sex.

Methods:

We collected retrospectively clinical data of a monocentric cohort of 100 consecutive GCA patients. Mann Whitney test was used to compare continuous variables, while Chi-square test and Fisher’s exact test were applied for comparison between qualitative variables.

Results:

One-hundred patients with a clinical diagnosis of GCA were enrolled in the study (68 women, 32 men). In all patients the diagnosis of vasculitis was histologically and/or radiologically confirmed. Main clinical data are reported in the table.

Patients were classified according to vascular involvement in three groups: temporal arteritis (C-GCA), extracranial large vessel vasculitis (LV-GCA) and both cranial and extracranial vasculitis (LV-C-GCA). No significant differences in vascular distribution of the disease were found according to sex, even if large vessel involvement seems to be more frequent in women (43% vs 28%; p: ns).

Male and female patients presented at diagnosis a similar clinical picture, with the same frequency of systemic symptoms (fever, fatigue, weight loss), polymyalgia rheumatica, visual symptoms and claudication. However, male patients complained more often temporal headache (90% vs 71%, p: 0.01), even no significant differences were found in the incidence of pathological findings at temporal artery physical examination (38% vs 32%; p: ns) and biopsy (59% vs 50%).

On the contrary, in female patients a longer time to diagnosis was recorded (8 (2-49 vs 4 (0-35) months; p: 0.01).

Conclusion:

In our cohort of GCA patients, clinical presentation was similar in male and female patients, with no significant differences in clinical, radiological and laboratory findings. However, male patients presented more often temporal headache, the most typical symptom of GCA, and this could explain a shorter time to diagnosis, if compared to female.

References:

[1]Sturm A et al. Clin Exp Rheum, 2016

[2]Nir-Paz R et al. J of Rheum, 2002

All GCA(n:100)WOMAN (n:68)MAN(n:32)Age: median (10th-90thpercentile)76 (62-80)73 (60-83)76 (62-80)Time to diagnosis (weeks) *8 (1-42)8 (2-49)4 (0-35)C-GCA61 (61%)38 (56%)23 (72%)LV-C-GCA16 (16%)13 (20%)3 (9%)LV-GCA23 (23%)17 (25%)6 (20%)New temporal headache*77 (77%)48 (71%)29 (90%)Visual symptoms39 (39%)24 (35%)15 (47%)Jaw or tongue claudication35 (35%)23 (34%)12 (38%)Fever39 (39%)24 (35%)15 (47%)Fatigue71 (71%)48 (71%)23 (72%)Weight loss49 (49%)34 (50%)15 (47%)Polymyalgia rheumatica43 (43%)33 (49%)10 (31%)Arm or leg claudication5 (5%)2 (3%)3 (9%)Positive temporal artery biopsy53 (53%)34 (50%)19 (59%)Pathological findings at temporal artery physical examination34 (34%)22 (32%)12 (38%)CRP (C-reactive protein)83 (22-160)89 (21-159)78 (23-155)ESR (erythrocyte sedimentation rate)72 (34-109)79 (37-113)54 (32-100)FDG-PET activity throughout aorta32 (32%)25 (37%)7 (22%)

*: p ≤ 0.05

Disclosure of Interests:

None declared

Long-term treatment with tocilizumab in giant cell arteritis: efficacy and safety in a monocentric cohort of patients

Objective

The efficacy of tocilizumab (TCZ) in GCA is supported by two randomized controlled studies, in which TCZ allowed remission to be achieved after 52 weeks of treatment. However, after discontinuation of treatment, half of the patients relapsed. The aim of this study was to analyse the efficacy and safety of long-term treatment with TCZ and the role of fluorodeoxyglucose (FDG)-PET/CT scanning in the follow-up of these patients.

Methods

We collected the clinical data of a monocentric cohort of GCA patients retrospectively.

Results

Thirty-two patients were treated with TCZ [25 males and 7 females; age = 74 (59–81) years]. Most of them achieved and maintained clinical remission (1 month: 69%; 3 months: 91%; 6 months: 96%; 12 months: 100%), with serological and FDG-PET/CT scan improvement and a reduction of concomitant glucocorticoid therapy. Nineteen patients were treated for >52 weeks, and in 13 of them a dose tapering was performed, whereas in 2 cases TCZ was suspended for disease remission. Only two patients relapsed: one during TCZ tapering and one after TCZ discontinuation. Ten cases of mild infections and a case of urinary sepsis were reported; in patients treated for >1 year there was no increase in the incidence of side effects compared with patients treated for <12 months.

Conclusion

In our cohort of patients, we confirmed the efficacy of TCZ in the induction and maintenance of remission of GCA, demonstrating an important steroid-sparing effect and a good safety profile. Long-term treatment seems to prevent relapse of the disease, suggesting that TCZ treatment can be continued for >52 weeks with efficacy and safety.

Association Between Changes in BLyS Levels and the Composition of B and T Cell Compartments in Patients With Refractory Systemic Lupus Erythematosus Treated With Belimumab

Introduction: Belimumab is a monoclonal antibody against soluble BLyS used for treatment of refractory Systemic Lupus Erythematosus (SLE). Although B cells are the main target of this therapy, a BLyS-dependent T cell activation pathway has also been demonstrated. The aim of the study is to analyze B and T cells phenotype modifications in a cohort of SLE patients treated with belimumab in correlation with serum BLyS levels.

Materials and Methods: Fourteen SLE patients were enrolled in the study. Lymphocyte immunophenotyping by flow cytometry and determination of serum BLyS levels by high sensitivity ELISA were performed before the first infusion of belimumab, after 6 and 12 months of treatment. Sex and age-matched healthy controls were enrolled for the comparisons.

Results: Baseline number of total B cells, especially switched memory B cells, were lower in SLE patients compared to control subjects. After 6 months of treatment, the total number of B cells, particularly, naive and transitional B cells, was significantly reduced in correlation with the reduction of BLyS levels. No significant association was found between baseline counts of B cells and reduction of SLEDAI-2K over time. In terms of response prediction, a significant association between SLEDAI-2K improvement at 12 months and the decrease of total number of B cells within the first 6 months of therapy was observed. Concerning the T cell compartment, the baseline percentage number of CD8+ effector memory was associated with SLEDAI-2K at baseline and with its improvement after 12 months of therapy. Furthermore, T cell lymphopenia and low number of circulating recent thymic emigrants were also observed compared to control subjects measured at baseline.

Discussion: The effects of belimumab on B cell subpopulations could be explained by the direct blockage of soluble BLyS, while the mild effects on T cells might be explained indirectly by the reduction of disease activity by means of therapy. B cell immunophenotyping during belimumab might be useful for monitoring the response to treatment.

Incidence and prevalence of systemic sclerosis in Valcamonica, Italy, during an 18-year period

Objectives:

To investigate the epidemiology of systemic sclerosis in Valcamonica, an Italian Alpine valley, during an 18-year-long period.

Methods:

Patients with systemic sclerosis living in Valcamonica between 1999 and 2016 were identified by capture/recapture method using: (1) clinical databases of the only secondary Rheumatology Unit present in the valley and of the tertiary referral center for this area; (2) administrative data, extracting records with the International Classification of Diseases, 10th Revision, code for systemic sclerosis. Patients were included in the analysis when either the 1980 American Rheumatism Association classification criteria for systemic sclerosis or the 2013 American College of Rheumatology/European League Against Rheumatism criteria were satisfied. To study temporal changes, mean yearly incidence during three different 6-year interval was calculated. Prevalence rates were estimated at four different time points.

Results:

General population with age over 14 years living in Valcamonica varied during the evaluated period between 85,168 and 91,245 inhabitants. A total of 65 patients with systemic sclerosis were identified (female 84.6%, limited cutaneous systemic sclerosis: 84.6%; anticentromere: 64.6%). Systemic sclerosis incidence and prevalence increased during the study period (p = 0.029 and p < 0.0001, respectively). The increase of incidence was accounted for by cases satisfying only the 2013 criteria, with limited cutaneous systemic sclerosis, and with anticentromere, whereas the incidence of systemic sclerosis cases classified according to the 1980 criteria did not significantly increase. The prevalence at 31 December 2016 was 58.6 (95% confidence interval, 44.8–76.6) per 100,000 persons aged >14 years. Survival at 10 years after systemic sclerosis diagnosis was 83.0% (standard error, 5.6).

Conclusion:

Systemic sclerosis incidence and prevalence increased over time in this area, due to the increased recruitment of patients with milder forms of the disease.

Effector T-cells are expanded in systemic lupus erythematosus patients with high disease activity and damage indexes

Background and objectives T-cell activation may be one of the pathogenic mechanisms of systemic lupus erythematosus (SLE). After repeated antigenic stimulation, T-cells undergo different modifications, leading to the differentiation into effector memory T-cells (CCR7-CD45RA-) and terminally differentiated effector memory (TDEM) T-cells (CCR7-CD45RA+). Similarly, down-modulation of CD28 may lead to the expansion of the CD28- T-cells, a subpopulation with peculiar effector activities. The aim of this study was the characterization of T-cell phenotype in a cohort of patients with SLE according to disease activity and damage index. Materials and methods Phenotypic analysis of peripheral blood T lymphocytes of 51 SLE patients and 21 healthy controls was done by flow-cytometry. SLE disease activity was evaluated by SLE Disease Activity Index-2000 (SLEDAI-2K) and damage by the Systemic Lupus International Collaborating Clinics/American College of Rheumatology damage index (SDI). The variations between different groups were evaluated by Mann-Whitney test. Bonferroni correction was applied to adjust for multiple comparisons ( p^adj). Spearman rank test was used to evaluate the correlations between quantitative variables. Results CD4+ lymphopenia was found among SLE patients. Patients showed a trend for a higher percentage of TDEM among the CD4+ T-cell subpopulation in comparison with healthy controls ( p = .04). SLE patients were divided into two groups according to disease activity: patients with SLEDAI-2K ≥ 6 ( n = 13) had a higher percentage of circulating CD4+ T-cells with CD28- phenotype ( p^adj= .005) as well as those with an effector memory ( p^adj= .004) and TDEM ( p^adj= .002) phenotype and a trend of decrease of regulatory T-cells (TREGs) ( p = .02), in comparison with patients with low disease activity ( n = 38). Patients with damage (SDI ≥ 1) tended to show an expansion of TDEM among CD4+ T-cells as compared with patients with no damage ( p = .01). In SLE patients an inverse correlation was found between the percentages of TREGs and those of TDEM ( p < .01) or CD4 + CD28- ( p < .01) T-cells. Conclusions CD4+ T-cell subpopulations displaying phenotype characteristics of effector lymphocytes are proportionally expanded in patients with active SLE and a higher damage index. These findings may suggest a role of effector T-cells in the pathogenesis of the disease and in the mechanisms of damage in SLE.