Effectiveness and safety of filgotinib in rheumatoid arthritis patients: data from the GISEA registry

OBJECTIVES

The aim of this study was to evaluate the effectiveness and safety profile of filgotinib, a JAK1 preferential inhibitor, in rheumatoid arthritis (RA) patients included in Italian GISEA (Group for the Study of Early Arthritis) registry.

METHODS

Data from RA patients treated with filgotinib, recorded in the GISEA registry, were analysed. Disease activity scores and patient-reported outcomes (PROs) were assessed at baseline, as well as during 12-month follow-up. A difficult-to-treat (D2T) RA patient was defined according with EULAR criteria. Retention rate of filgotinib was estimated by the Kaplan-Meier method and factors influencing drug discontinuation were estimated by Cox regression models.

RESULTS

246 RA patients (female 89%, 57.6±12.2 years old) started filgotinib, mostly as second (22%) or further (43.9%) b/tsDMARDs line of treatment. At 3 and 12 months, 18.8% and 27.5% of patients achieved Clinical Diseases Activity Index based remission and 30.1% and 37.7% obtained a visual analogue scale of pain ≤20 (all p<0.01 vs. baseline). Filgotinib survival rate was 84.5% at the 6-month and 75.8% at 12-month follow-up, and was comparable either in monotherapy or combination therapy, and irrespective of glucocorticoid intake. b/tsDMARD naive patients had the lowest hazard ratio (HR) of filgotinib discontinuation (HR 0.29, 95%CI 0.14-0.64), while D2T-RA the highest (HR 1.82, 95%CI 1.01-3.3). Eight patients (3.3%) discontinued filgotinib due to adverse events.

CONCLUSIONS

In an Italian real-life setting, filgotinib is confirmed to be safe and with a good effectiveness profile both in monotherapy and without glucocorticoids.

Comorbidities in the Spondyloarthritis GISEA Cohort: an average treatment effect analysis on patients treated with bDMARDs

OBJECTIVES

We aimed to investigate the effectiveness of tumour necrosis factor inhibitors (TNFi), anti-interleukin-17 or interleukin-12/23 monoclonal antibodies (anti-IL) on comorbidities in a cohort of patients with spondyloarthritis (SpA), using an average treatment effect (ATE) analysis.

METHODS

SpA patients from the multicentre Italian GISEA Registry were divided into groups according to pharmacological exposure: no treatment (G0), TNFi (G1) and non-responders to TNFi switched to anti-IL (G2). In each group, we recorded the prevalence and incidence of infectious, cardiopulmonary, endocrinological, gastrointestinal, oncologic, renal and neurologic comorbidities. Each comorbidity was then fitted for ATE and baseline features were evaluated for importance.

RESULTS

The main findings of this study comprising 4458 SpA patients relate to cancer, other gastrointestinal diseases (OGID) and fibromyalgia. ATE showed no increased risk of solid cancer in G1 (0.42 95% CI 0.20-0.85) and G2 (0.26 95% CI 0.08-0.71) vs. G0, with significantly higher incidence in G0 (14.07/1000 patient-years, p=0.0001). Conversely, a significantly higher risk of OGID and fibromyalgia was found in G1 (1.56 95% CI 1.06-2.33; 1.69 95% CI 1.05-2.68, respectively) and G2 (1.91 95% CI 1.05-3.24; 2.13 95% CI 1.14-3.41, respectively) vs. G0. No treatment risk reduction was observed in haematological malignancies, cardiovascular events and endocrinological comorbidities.

CONCLUSIONS

Overall, our study confirms the safety of TNFi and anti-IL in SpA patients, albeit with some caveats pertaining to solid cancers, OGID and fibromyalgia. Furthermore, taking into consideration causality with observational data may yield more reliable and relevant clinical information.

COVID-19 illness: Different comorbidities may require different immunological therapeutic targets

BACKGROUND

The SARS-CoV-2 pandemic has led to more than 6,870.000 deaths worldwide. Despite recent therapeutic advances, deaths in Intensive Care Units still range between 34 and 72%, comprising substantial unmet need as we move to an endemic phase. The general agreement is that in the first few days of infection, antiviral drugs and neutralizing monoclonal antibodies should be adopted. When the patient is hospitalized and develops severe pneumonia, progressing to a systemic disease, immune modifying therapy with corticosteroids is indicated. Such interventions, however, are less effective in the context of comorbidities (e.g., diabetes, hypertension, heart failure, atrial fibrillation, obesity and central nervous system-CNS diseases) which are by themselves associated with poor outcomes. Such comorbidities comprise common and some distinct underlying inflammatory pathobiology regulated by differential cytokine taxonomy.

METHODS

Searching in the PubMed database, literature pertaining to the biology underlying the different comorbidities, and the data from the studies related to various immunological treatments for the Covid-19 disease were carefully analyzed.

RESULTS

Several experimental and clinical data have demonstrated that hypertension and atrial fibrillation present an IL-6 dependent signature, whereas diabetes, obesity, heart failure and CNS diseases may exhibit an IL-1a/b predominant signature. Distinct selective cytokine targeting may offer advantage in treating severe COVID-19 illness based on single or multiple associated comorbidities. When the patient does not immediately respond, a broader target range through JAKs pathway inhibitors may be indicated.

CONCLUSIONS

Herein, we discuss the biological background associated with distinct comorbidities which might impact the SARS-CoV-2 infection course and how these should to be addressed to improve the current therapeutic outcome.

Serum Albumin Levels: A Biomarker to Be Repurposed in Different Disease Settings in Clinical Practice

Serum albumin (ALB), one of the most important proteins in human physiology, has the main functions of maintaining plasma oncotic pressure and plasma volume, transporting hormones, vitamins, oligominerals and drugs, and exerting a powerful antioxidant-anti-inflammatory role. Its prognostic value in liver and malabsorption syndromes is well known. In this narrative review, an analysis of the most important studies evaluating the prognostic significance of low serum ALB levels in hospitalized patients was performed. Specifically, the risk in emergency medicine, cardiovascular diseases, Coronavirus Disease 19 (COVID-19) infection, nephrology, oncology, and autoimmune rheumatic diseases has been examined to fully explore its clinical value. ALB is a negative acute-phase reactant and the reduction in its serum levels represents a threatening parameter for long-term survival in several clinical settings, and a strong biomarker for a poor prognosis in most diseases. Therefore, clinicians should consider serum ALB as a valuable tool to assess the efficacy of specific therapies, both in hospitalized patients and in chronic follow-up.

Stricter treat-to-target in RA does not result in less radiographic progression: a longitudinal analysis in RA BIODAM

OBJECTIVES

To investigate whether meticulously following a treat-to-target (T2T)-strategy in daily clinical practice will lead to less radiographic progression in patients with active RA who start (new) DMARD-therapy.

METHODS

Patients with RA from 10 countries starting/changing conventional synthetic or biologic DMARDs because of active RA, and in whom treatment intensification according to the T2T principle was pursued, were assessed for disease activity every 3 months for 2 years (RA-BIODAM cohort). The primary outcome was the change in Sharp-van der Heijde (SvdH) score, assessed every 6 months. Per 3-month interval DAS44-T2T could be followed zero, one or two times (in a total of two visits). The relation between T2T intensity and change in SvdH-score was modelled by generalized estimating equations.

RESULTS

In total, 511 patients were included [mean (s.d.) age: 56 (13) years; 76% female]. Mean 2-year SvdH progression was 2.2 (4.1) units (median: 1 unit). A stricter application of T2T in a 3-month interval did not reduce progression in the same 6-month interval [parameter estimates (for yes vs no): +0.15 units (95% CI: -0.04, 0.33) for 2 vs 0 visits; and +0.08 units (-0.06; 0.22) for 1 vs 0 visits] nor did it reduce progression in the subsequent 6-month interval.

CONCLUSIONS

In this daily practice cohort, following T2T principles more meticulously did not result in less radiographic progression than a somewhat more lenient attitude towards T2T. One possible interpretation of these results is that the intention to apply T2T already suffices and that a more stringent approach does not further improve outcome.

Case report: crowned dens syndrome in a patient with seronegative rheumatoid arthritis

Chondrocalcinosis (CC) is the one of the most common crystal pyrophosphate disease associated arthritis in the elderly. It has been shown to coexist with seronegative and seropositive rheumatoid arthritis (RA), yet mostly with seronegative RA. Among the localisation of CC, the deposition in the ligaments surrounding the odontoid process may remain asymptomatic for years or may lead to and acute severe symptomatology, which may mimic several clinical illnesses among which meningitis (fever, severe pain, acute phase reactants). This is called the 'crowned dens syndrome (CDS)', which has been reported to represent an important percentage of acute neck pain needing hospital admission in neurosurgery units. In this case, the rapid demonstration of 'crowned dens' through CT scan may allow to avoid lumbar puncture and cerebrospinal fluid examination. The coexistence of RA and CDS is very rare, and rarely reported in the literature, yet it may represent a clinical challenge. We describe here one case that while on therapy with methotrexate (MTX) and naproxen (NPX) had an acute neck pain, and peripheral arthritis flare, that responded well to colchicine given along with MTX and NPX.

The forgotten key players in rheumatoid arthritis: IL-8 and IL-17 - Unmet needs and therapeutic perspectives

Despite the relevant advances in our understanding of the pathogenetic mechanisms regulating inflammation in rheumatoid arthritis (RA) and the development of effective therapeutics, to date, there is still a proportion of patients with RA who do not respond to treatment and end up progressing toward the development of joint damage, extra-articular complications, and disability. This is mainly due to the inter-individual heterogeneity of the molecular and cellular taxonomy of the synovial membrane, which represents the target tissue of RA inflammation. Tumor necrosis factor alpha (TNFα) and interleukin-6 (IL-6) are crucial key players in RA pathogenesis fueling the inflammatory cascade, as supported by experimental evidence derived from in vivo animal models and the effectiveness of biologic-Disease Modifying Anti-Rheumatic Drugs (b-DMARDs) in patients with RA. However, additional inflammatory soluble mediators such as IL-8 and IL-17 exert their pathogenetic actions promoting the detrimental activation of immune and stromal cells in RA synovial membrane, tendons, and extra-articular sites, as well as blood vessels and lungs, causing extra-articular complications, which might be excluded by the action of anti-TNFα and anti-IL6R targeted therapies. In this narrative review, we will discuss the role of IL-8 and IL-17 in promoting inflammation in multiple biological compartments (i.e., synovial membrane, blood vessels, and lung, respectively) in animal models of arthritis and patients with RA and how their selective targeting could improve the management of treatment resistance in patients.

Peripheral blood CD4posCD25posFoxP3pos cells and inflammatory cytokines as biomarkers of response in rheumatoid arthritis patients treated with CTLA4-Ig

BACKGROUND

Prognostic biomarkers of treatment response to distinct biologic disease-modifying anti-rheumatic drugs (b-DMARDs) are still lacking within the management of rheumatoid arthritis (RA).

METHODS

Thirty-four b-DMARDs naive RA patients, divided by disease duration into early (cohort 1) and long standing (cohort 2), received CTLA4-Ig. At study entry, and every 3 months for 1 year, each patient underwent peripheral blood (PB)-derived CD4^pos cell subpopulation assessment by flow cytometry, STAT3 and STAT5 expression by RT-PCR and IL-6, IL-12p70, TGFβ, and IL-10 serum levels by ELISA. The DAS and CDAI remission was assessed at 6 and 12 months.

RESULTS

DAS- and CDAI-defined remission within 12 months was achieved by 16 (47.1%) and 8 (23.5%) RA patients, respectively. Considering the whole RA cohort, CTLA4-Ig induced a significant decrease of IL-6 serum levels from baseline to 6 and 12 months, as well as of PB CD4^posCD25^posFoxP3^pos cells at 6 and 12 months, and of CD4^posIL17^pos cells after 12 months. PB CD4^pos cells of RA patients showed higher STAT3 and STAT5 expression than healthy controls, which remained unchanged within 12 months of treatment. At study entry, RA patients achieving DAS remission had significantly lower IL-6 serum levels than RA patients not achieving this outcome. In particular, having baseline IL-6 serum levels ≤ 8.4 pg/ml, significantly identified naïve to b-DMARDs RA patients more likely to achieve DAS-remission under CTLA4-Ig at 6 months (66.7%) compared to RA patients with baseline IL-6 serum levels > 8.4 pg/ml [15.4%, OR (95%Cis) 11.00 (1.75-55.82)]. Moreover, having CD4^posCD25^posFoxP3^pos cells rate ≥ 6.0% significantly identifies naïve to b-DMARDs early RA patients more likely to achieve DAS remission at 6 months (83.3%) compared to RA patients with baseline CD4^posCD25^posFoxP3^pos cells < 6.0% [16.7%, OR (95% Cis) 25.00 (1.00-336.81)].

CONCLUSIONS

Baseline IL-6 serum levels and peripheral blood-derived CD4^pos subpopulations are putative novel prognostic biomarkers of CTLA4-Ig response in RA patients.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Disclosure of Interests

None declared

POS0111 MORE METICULOUSLY FOLLOWING TREAT-TO-TARGET IN RA DOES NOT LEAD TO LESS RADIOGRAPHIC PROGRESSION: A LONGITUDINAL ANALYSIS IN BIODAM

Background

A Treat-to-Target approach (T2T) is broadly considered to lead to better clinical outcomes and recommended in patients with RA. However, very few studies have analyzed the effect of T2T on radiographic progression, and any such studies have provided inconsistent results.

Objectives

To investigate whether meticulously following a treat-to-target (T2T)-strategy in daily clinical practice leads to lower radiographic progression in RA.

Methods

Patients from the multicenter RA-BIODAM cohort with ≥2 consecutive visits with radiographs available were included. In RA-BIODAM patients were enrolled as they were initiating a new csDMARD/bDMARD treatment were followed-up with the intention to benchmark and intensify treatment. The primary outcome of this analysis was the change in Sharp-van der Heijde score (SvdH, 0-448), assessed every 6 months, using average scores from 2 readers (scores with known chronological order). Following a DAS44-T2T remission strategy, which was defined at each 3-month visit, was the main variable of interest. Patients were categorized based on the proportion of visits in which T2T was followed according to our definition: very low (≤40% of the visits, low (>40%, <62.5%), high (≥62.5%, ≤75%) and very high (>75%). Radiographic progression at 2 years was visualized across groups by cumulative probability plots. Per 3-month interval T2T could be followed zero, one or two times (in a total of 2 visits). Associations between the number of visits with T2T in an interval and radiographic progression, both in the same and in the subsequent 6-month interval, were analysed by generalised estimating equations, adjusted for age, gender, disease duration and country.

Results

In total, 511 patients were included (mean (SD) age: 56 (13) years; 76% female). After 2 years, patients showed on average 2.2 (4.1) units progression (median:1 unit). Mean (SD) 2-year progression was not significantly different across categories of T2T: very low: 2.1 (2.7)-units; low: 2.8 (6.0); high: 2.4 (4.5), very high: 1.6 (2.2) (Figure 1). Meticulously following-up T2T in a 3-month interval neither reduced progression in the same 6-month interval (parameter estimates (for yes vs no): +0.15 units (95%CI: -0.04 to 0.33) for 2 vs 0 visits; and +0.08 units (-0.06;0.22) for 1 vs 0 visits) nor did it reduce progression in the subsequent 6-month interval (Table 1).

Table 1.

Effect of following DAS44-remission-T2T strategy on 6-month radiographic progression over 2 years

Change in radiographic damage(regression coefficient (95% CI))N=506T2T during 3 months on radiographic progression in the same 6-month period 2 visits vs 0 followed0.15 (-0.04; 0.33) 1 visit vs 0 followed0.08 (-0.06; 0.22)T2T during 3 months on radiographic progression in the subsequent 6-month period 2 visits vs 0 followed-0.09 (-0.28; 0.10) 1 visit vs 0 followed-0.10 (-0.24; 0.05)Figure 1.

Cumulative probability plot with 2-year radiographic progression according to the proportion of 3-monthly visits with T2T followed

Conclusion

In this daily practice cohort, more meticulously following T2T principles did not result in more reduction of radiographic progression than a somewhat more liberal attitude toward T2T. One possible interpretation of these results is that the intention to apply T2T already suffices and that a more stringent approach does not further improve outcome.

Acknowledgements

BIODAM was financially supported by an unrestricted grant from AbbVie

Disclosure of Interests

Sofia Ramiro Speakers bureau: Eli Lilly, MSD, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, UCB, Sanofi, Grant/research support from: AbbVie, Galapagos, Novartis, Pfizer, UCB, Robert B.M. Landewé Speakers bureau: AbbVie, BMS, Gilead, Galapagos, GSK,Janssen, Lilly, Novartis, Pfizer, UCB, Consultant of: AbbVie, BMS, Gilead, Galapagos, GSK,Janssen, Lilly, Novartis, Pfizer, UCB

Dr Landewé owns Rheumatology Consultancy BV, Désirée van der Heijde Consultant of: AbbVie, Bayer, BMS, Cyxone, Eisai, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Lilly, Novartis, Pfizer, UCB Pharma. Director of Imaging Rheumatology bv., Alexandre Sepriano Speakers bureau: Novartis, Consultant of: UCB, Oliver FitzGerald Speakers bureau: Biogen, Novartis, AbbVie, BMS, Pfizer, Grant/research support from: BMS, Novartis, UCB, Pfizer, Lilly, Janssen, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Celgene, Eli-Lilly, Galapagos, Gilead, Janssen, Merck, Novartis, Orion, Pfizer, Roche and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, Amgen, BMS, Merck, Celgene and Novartis, Joanne Homik: None declared, Ori Elkayam Speakers bureau: Pfizer, Lilly, Novartis, Abbvie, BI, Janssen, Consultant of: Pfizer, Lilly, Novartis, Abbvie, BI, Janssen, Grant/research support from: Pfizer, Abbvie, Janssen, Carter Thorne Consultant of: Abbvie, Organon, Pfizer, Sandoz, Maggie Larché Speakers bureau: AbbVie, Actelion, Amgen, BMS, Boehringer-Ingelheim, Fresenius-Kabi, Gilead, Janssen, Mallinckrodt, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, Sobi, UCB, Grant/research support from: Abbvie, BMS, Gianfranco Ferraccioli Speakers bureau: SOBI, Consultant of: Abbivie, Marina Backhaus: None declared, Gilles Boire Speakers bureau: Abbvie Canada, BMS Canada, Lilly Canada, Janssen Canada, Merck Canada, Pfizer Canada, Viatris, Consultant of: Abbvie Canada, Amgen Canada, BMS Canada, Celgene, GileadSciences, Janssen Canada, Lilly Canada, Merck Canada, Mylan Canada, Novartis Canada, Pfizer Canada, Roche Canada, Samsung Bioepis, Sanofi Canada, Teva, Grant/research support from: Lilly Canada, BMS Canada, Pfizer, Sandoz Canada, UCB Canada, Merck Canada, Novartis Canada, Roche Canada, Bernard Combe Speakers bureau: Abbvie, BMS,Celltrion,Galapgos-Gilead, Janssen, Lilly, MERCK, Pfizer,Roche-Chugai, Consultant of: Abbvie, Celltrion,Galapgos-Gilead, Janssen, Lilly, MERCK, Roche-Chugai, Grant/research support from: Pfizer, Roche-chugai, Thierry Schaeverbeke: None declared, Alain Saraux Speakers bureau: Abbvie, Lilly, Nordic, Novartis, Pfizer, Roche-Chugai, Sanofi, UCB, Consultant of: Abbvie, Lilly, Nordic, Novartis, Pfizer, Roche-Chugai, UCB, Grant/research support from: Novartis, Fresenius, Lilly, Maxime Dougados Consultant of: Pfizer, AbbVie, UCB, Merck, Lilly, Novartis, BMS, Galapagos, Biogen, Roche, Grant/research support from: Pfizer, AbbVie, UCB, Merck, Lilly, Novartis, BMS, Galapagos, Biogen, Roche, Maurizio Rossini Speakers bureau: Amgen, Abbvie, BMS, Eli-Lilly, Galapagos,MSD, Novartis, Pfizer, Sandoz, Theramex, UCB, Marcello Govoni Speakers bureau: Abbvie, Pfizer, Galapagos, BMS, Eli-Lilly, Paid instructor for: Pfizer, Consultant of: Abbvie, BMS, Novartis, Astrazeneca, Pfizer, Luigi Sinigaglia: None declared, Alain Cantagrel Speakers bureau: Abbvie, Amgen, Biogen, BMS, Janssen, Lilly France, Médac, MSD France, Nordic-Pharma, Novartis, Pfizer, Sanofi Aventis, UCB, Consultant of: BMS, Janssen, Lilly France, MSD France, Sandoz, Grant/research support from: MSD France, Novartis, Pfizer, Cornelia Allaart: None declared, Cheryl Barnabe Speakers bureau: Sanofi Genzyme, Pfizer, Fresenius Kabi, Janssen, Consultant of: Gilead, Celltrion Healthcare, Clifton Bingham Consultant of: AbbVie, BMS, Eli Lilly, Janssen, Moderna, Pfizer, Sanofi, Grant/research support from: BMS, Dirkjan van Schaardenburg: None declared, Hilde Berner Hammer Speakers bureau: AbbVie, Novartis, Lilly, Rana Dadashova: None declared, Edna Hutchings: None declared, Joel Paschke: None declared, Walter P Maksymowych Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, UCB, Consultant of: Abbvie, Boehringer Ingelheim, Celgene, Eli-Lilly, Galapagos, Novartis, Pfizer, UCB, Grant/research support from: Abbvie, Novartis, Pfizer

Infectious agents breaking the immunological tolerance: The holy grail in rheumatoid arthritis (RA) reconsidered

Multiple Sclerosis (MS) has been shown to be linked to Epstein Barr Virus (EBV) infection, a virus that infects B cells inside the CNS. The seminal study raises a key interest into the infectious origin of several other autoimmune inflammatory diseases.We will discuss here the infectious agents that have been studied over the years in Rheumatoid Arthritis (RA), a crippling arthritis that was treated a century ago with gold salts (anti mycobacterial agent), with chloroquine (anti malarial agent), or sulphasalazine (an antibacterial-antiinflammatory agent). Several infectious agents have been taken into consideration i.e. Streptococcus group A, Proteus, Mycobacterium tuberculosis-MTB, Parvovirus B19, Epstein Barr virus, Porphyromonas gengivalis-Pg, Aggregatibacter actinomycetescomitans, and finally Haemophilus -Glaesserella parasuis-Hps. Of these agents only three satisfy the Witebski's criteria as possible pathogenetic causes of an autoimmune disease, MTB, Pg, Hps. We will discuss here how the immune tolerance might be broken, which could be the neoantigen or autoantigen involved, how the infectious agent was studied as a trigger capable of inducing arthritis in animal models. The preventive measures that should be adopted to lessen the impact of the infections, to prevent the burden and the severity of the illness are described.

Haemophilus parasuis (Glaesserella parasuis) as a Potential Driver of Molecular Mimicry and Inflammation in Rheumatoid Arthritis

Background:Haemophilus parasuis (Hps; now Glaesserella parasuis) is an infectious agent that causes severe arthritis in swines and shares sequence similarity with residues 261–273 of collagen type 2 (Coll_261−273), a possible autoantigen in rheumatoid arthritis (RA).

Objectives/methods: We tested the presence of Hps sequencing 16S ribosomal RNA in crevicular fluid, synovial fluids, and tissues in patients with arthritis (RA and other peripheral arthritides) and in healthy controls. Moreover, we examined the cross-recognition of Hps by Coll_261−273-specific T cells in HLA-DRB1^*04^pos RA patients, by T-cell receptor (TCR) beta chain spectratyping and T-cell phenotyping.

Results:Hps DNA was present in 57.4% of the tooth crevicular fluids of RA patients and in 31.6% of controls. Anti-Hps IgM and IgG titers were detectable and correlated with disease duration and the age of the patients. Peripheral blood mononuclear cells (PBMCs) were stimulated with Hps virulence-associated trimeric autotransporter peptide (VtaA10_755−766), homologous to human Coll_261−273 or co-cultured with live Hps. In both conditions, the expanded TCR repertoire overlapped with Coll_261−273 and led to the production of IL-17.

Discussion: We show that the DNA of an infectious agent (Hps), not previously described as pathogen in humans, is present in most patients with RA and that an Hps peptide is able to activate T cells specific for Coll_261−273, likely inducing or maintaining a molecular mimicry mechanism.

Conclusion: The cross-reactivity between VtaA10_755−766 of a non-human infectious agent and human Coll_261−273 suggests an involvement in the pathogenesis of RA. This mechanism appears emphasized in predisposed individuals, such as patients with shared epitope.

EULAR points to consider for the management of difficult-to-treat rheumatoid arthritis

OBJECTIVE

To develop evidence-based European Alliance of Associations for Rheumatology (EULAR) points to consider (PtCs) for the management of difficult-to-treat rheumatoid arthritis (D2T RA).

METHODS

An EULAR Task Force was established comprising 34 individuals: 26 rheumatologists, patient partners and rheumatology experienced health professionals. Two systematic literature reviews addressed clinical questions around diagnostic challenges, and pharmacological and non-pharmacological therapeutic strategies in D2T RA. PtCs were formulated based on the identified evidence and expert opinion. Strength of recommendations (SoR, scale A-D: A typically consistent level 1 studies and D level 5 evidence or inconsistent studies) and level of agreement (LoA, scale 0-10: 0 completely disagree and 10 completely agree) of the PtCs were determined by the Task Force members.

RESULTS

Two overarching principles and 11 PtCs were defined concerning diagnostic confirmation of RA, evaluation of inflammatory disease activity, pharmacological and non-pharmacological interventions, treatment adherence, functional disability, pain, fatigue, goal setting and self-efficacy and the impact of comorbidities. The SoR varied from level C to level D. The mean LoA with the overarching principles and PtCs was generally high (8.4-9.6).

CONCLUSIONS

These PtCs for D2T RA can serve as a clinical roadmap to support healthcare professionals and patients to deliver holistic management and more personalised pharmacological and non-pharmacological therapeutic strategies. High-quality evidence was scarce. A research agenda was created to guide future research.

POS0675 THE COMPARATIVE 3-YEAR RETENTION RATE OF TARGETED-SYNTHETIC AND BIOLOGIC DRUGS FOR RHEUMATOID ARTHRITIS: REAL-LIFE DATA FROM THE ITALIAN GISEA REGISTRY

Background:

Long-term observational data on the real-life use of JAK inhibitors (JAKis) for rheumatoid arthritis (RA) and their comparison with biological drugs are still very limited. Large population-based registries have been increasingly used to investigate the performance of targeted drugs in a real-life setting.

Objectives:

The aim of this study is to evaluate and compare the 3-year retention rate of JAKis, TNF inhibitors (TNFis) and biologic drugs with other mechanisms of action (OMAs) in the large cohort of RA patients included in the Italian national GISEA registry.

Methods:

Data of all RA patients treated with targeted synthetic or biologic drugs were prospectively collected in the Italian multicentric GISEA registry. The analysis was limited to patients who started a first- or second-line targeted drug in the period after the first JAKi was marketed in Italy (1st December 2017). The 3-year retention rate was calculated by the Kaplan-Meier method and compared between different drug classes by a log-rank test. A descriptive analysis of reasons for discontinuation was performed.

Results:

The study population included 1027 RA patients (79.8% females, mean age [±SD] 56.9 [±13.5] years, mean disease duration 9.8 [±9] years, mean baseline SDAI 17.5 [±11.9], ACPA positive 67.4%, RF positive 62.7%) who received JAKis (baricitinib or tofacitinib, n=297), TNFis (n=365), or OMAs (n=365) as first or second targeted drug. Main baseline characteristics of study population were overall well balanced between treatment groups. Retention rate was numerically but not statistically higher (p=0.18) in patients treated with JAKis compared with TNFis or OMAs (80.6, 78.9 and 76.4% at 1 year and 73, 56.8 and 63.8% at 3 years, respectively) (Figure 1). Drug survival was significantly higher in patients receiving concomitant methotrexate (MTX) compared with monotherapy only in TNFis (66.8 vs 47.1%, p=0.04) but not in JAKis (76.1 vs 70.1%, p=0.54) and OMAs (66.1 vs 61.9%, p=0.41) group. Therapy was discontinued in a total of 211 patients because of ineffectiveness (n=107), adverse events (n=88), or compliance/other reasons (n=16). The most frequent reason for treatment withdrawal was ineffectiveness in both JAKis (n=30 out of 56) and TNFis (n=45 out of 74) groups, whereas OMAs were discontinued more frequently because of adverse events (n=41 out of 81).

Conclusion:

Our data confirmed in a real-life setting a favorable 3-year retention rate of all available targeted mechanisms of action for RA therapy. As expected, concomitant MTX significantly impacted persistence on therapy of TNFis only. Discontinuations of JAKis for adverse events were infrequent overall, confirming the safety profile observed in randomized clinical trials.

Figure 1.

Three-year retention rate by treatment group

Disclosure of Interests:

None declared

Retention rate of a second line with a biologic DMARD after failure of a first-line therapy with abatacept, tocilizumab, or rituximab: results from the Italian GISEA registry

OBJECTIVES

EULAR recommendations do not suggest which biologic disease-modifying anti-rheumatic drug (bDMARD) should be preferred after failure of a first bDMARD in the treatment of rheumatoid arthritis (RA). In particular, few data are available regarding the effectiveness of a second-line bDMARD after failure of abatacept (ABA), tocilizumab (TCZ), and rituximab (RTX). The aim of this study was to analyze the retention rate of a second line with tumor necrosis factor inhibitors (TNFi) or other mechanisms of action (MoAs), after the failure of either RTX, TCZ, or ABA.

METHODS

Two hundred and seventy-eight RA patients from the Italian GISEA registry were included in the study. RTX was the first bDMARD in 18% of patients, ABA in 45.7%, and TCZ in 36.3%, while the second bDMARD was a TNFi (group 1) in 129 patients and an agent with a different MoA (group 2) in 149.

RESULTS

During a median follow-up of 22 months (IQR 68), 129 patients discontinued their treatment; patients of group 1 discontinued the treatment more frequently than patients of group 2 (p<0.001) with retention rates of 33.6±5.7% and 63.6±4.6% after 104 weeks for group 1 and group 2, respectively (p<0.001). At multivariate analysis, the mechanism of action was the only predictor for the maintenance in therapy.

CONCLUSIONS

According to our data, ABA, RTX, and TCZ seem to maintain a good retention rate also when used as a second-line therapy, suggesting their use after the failure of a non-TNFi as first-line therapy. However, specifically designed studies are needed to evaluate the more appropriate therapeutic strategies in RA, according to the first-line drug, including new targeted synthetic DMARDs. Key Points • A large proportion of rheumatoid arthritis patients fail the first biologic DMARD. • Few data are available about the efficacy of biologic DMARD after the failure of a non-TNF inhibitor. • Abatacept, rituximab, or tocilizumab seem to maintain a good retention rate after the failure of a first-course therapy with a non-TNF inhibitor.

Inclusion of Synovial Tissue-Derived Characteristics in a Nomogram for the Prediction of Treatment Response in Treatment-Naive Rheumatoid Arthritis Patients

Objective

This study applied a synovitis score obtained during routine care from ultrasound (US)–guided biopsies of synovial tissue (ST) in patients with rheumatoid arthritis (RA) and patients with other inflammatory and noninflammatory joint diseases to identify pretreatment synovial biomarkers associated with disease characteristics, and to integrate the findings into a multiparameter nomogram for use in baseline prediction of diagnosis and treatment response in treatment‐naive rheumatoid arthritis (RA) patients.

Methods

The study enrolled a total of 1,015 patients with various autoimmune diseases (545 patients with RA, 167 patients with psoriatic arthritis [PsA], 199 patients with undifferentiated peripheral inflammatory arthritis [UPIA], 18 patients with crystal‐induced arthritis, 26 patients with connective tissue diseases, and 60 patients with osteoarthritis [OA] [as part of the SYNGem cohort]). All patients underwent a US‐guided ST biopsy at baseline, and patients were then stratified according to disease phase. The KSS, along with disease characteristics and clinical outcomes, were incorporated into a nomogram for prediction of achievement of clinical remission in RA patients who were previously naive to treatment. In patients in whom a treat‐to‐target strategy was applied, remission was defined as change in the Disease Activity Score in 28 joints (DAS28) at 6 months after treatment initiation.

Results

The KSS significantly differed among RA patients, as well as PsA patients and UPIA patients, when compared to OA patients. In RA, the KSS directly correlated with the DAS28 and was related to autoantibody positivity in treatment‐naive RA patients. Moreover, at baseline, treatment‐naive RA patients achieving 6‐month remission according to DAS28 had a lower KSS, shorter duration of symptoms (very early RA [VERA]), and lower disease activity than treatment‐naive RA patients not achieving remission according to DAS28. Results of logistic regression analysis identified the following synergistic predictive factors of achievement of DAS28‐based disease remission at 6 months: having a short disease duration (VERA), not having high disease activity, and having a KSS of <5 at baseline. A nomogram integrating these baseline clinical and histologic characteristics in treatment‐naive RA patients yielded an up to 81.7% probability of achieving 6‐month remission according to the DAS28.

Conclusion

The KSS is a reliable tool for synovitis assessment on US‐guided ST biopsy, contingent on the phase of the disease and the autoimmune profile of each patient. This tool could be integrated within a therapeutic response–predictive nomogram for the prediction of treatment response in RA patients who were previously naive to treatment.

Systemic Bone Density at Disease Onset Is Associated With Joint Erosion Progression in Early Naive to Treatment Rheumatoid Arthritis: A Prospective 12-Month Follow-Up Open-Label Study

Objectives: Osteoporosis and bone erosions are hallmarks of rheumatoid arthritis (RA) since disease onset is underpinned by the inflammatory burden. In this observational study, we aimed to dissect the putative RA-related parameters and bone-derived biomarkers associated with systemic and focal bone loss at disease onset and with their progression.

Methods: One-hundred twenty-eight patients with early rheumatoid arthritis (ERA) were recruited at disease onset. At study entry, demographic, clinical, and immunological parameters were recorded. Each ERA patient underwent plain X-rays of the hands and feet at study entry and after 12 months to assess the presence of erosions. After enrollment, each patient was treated according to the recommendations for RA management and followed up based on a treat-to-target (T2T) strategy. At baseline, blood samples for soluble biomarkers were collected from each patient, and plasma levels of osteoprotegerin (OPG), receptor activator of nuclear factor κB ligand (RANKL), Dickkopf-1 (DKK1), and interleukin 6 (IL-6) were assessed by enzyme-linked immunosorbent assay (ELISA). Seventy-one ERA patients underwent bone mineral density (BMD) measurement at the left femoral neck and second to fourth lumbar spine vertebrae (L2–L4) by dual-energy X-ray absorptiometry (DXA).

Results: Among the whole cohort, 34 (26.6%) ERA patients with bone erosions at study entry had a higher disease activity (p = 0.02) and IL-6 plasma levels (p = 0.03) than non-erosive ones. Moreover, at DXA, 33 (46.5%) ERA patients had osteopenia, and 16 (22.5%) had osteoporosis; patients with baseline bone erosions were more likely osteopenic/osteoporotic than non-erosive ones (p = 0.03), regardless of OPG, RANKL, and DKK1 plasma levels. Obese ERA patients were less likely osteopenic/osteoporotic than normal weight ones (p = 0.002), whereas anti-citrullinated protein antibodies (ACPA) positive ERA patients were more likely osteopenic/osteoporotic than ACPA negative ones (p = 0.034). At logistic regression analysis, baseline Disease Activity Score measured on 44 joints (DAS44) [OR: 2.46 (1.11–5.44)] and osteopenic/osteoporosis status [OR: 7.13 (1.27–39.94)] arose as independent factors of erosiveness. Baseline osteopenic/osteoporotic status and ACPA positivity were associated with bone damage progression during the follow-up.

Conclusions: Bone erosions presence is associated with systemic bone loss since the earliest phases of RA, suggesting that the inflammatory burden and autoimmune biology, underpinning RA, represent crucial enhancers of bone remodeling either locally as at systemic level.

EULAR definition of difficult-to-treat rheumatoid arthritis

BACKGROUND

Despite treatment according to the current management recommendations, a significant proportion of patients with rheumatoid arthritis (RA) remain symptomatic. These patients can be considered to have 'difficult-to-treat RA'. However, uniform terminology and an appropriate definition are lacking.

OBJECTIVE

The Task Force in charge of the "Development of EULAR recommendations for the comprehensive management of difficult-to-treat rheumatoid arthritis" aims to create recommendations for this underserved patient group. Herein, we present the definition of difficult-to-treat RA, as the first step.

METHODS

The Steering Committee drafted a definition with suggested terminology based on an international survey among rheumatologists. This was discussed and amended by the Task Force, including rheumatologists, nurses, health professionals and patients, at a face-to-face meeting until sufficient agreement was reached (assessed through voting).

RESULTS

The following three criteria were agreed by all Task Force members as mandatory elements of the definition of difficult-to-treat RA: (1) Treatment according to European League Against Rheumatism (EULAR) recommendation and failure of ≥2 biological disease-modifying antirheumatic drugs (DMARDs)/targeted synthetic DMARDs (with different mechanisms of action) after failing conventional synthetic DMARD therapy (unless contraindicated); (2) presence of at least one of the following: at least moderate disease activity; signs and/or symptoms suggestive of active disease; inability to taper glucocorticoid treatment; rapid radiographic progression; RA symptoms that are causing a reduction in quality of life; and (3) the management of signs and/or symptoms is perceived as problematic by the rheumatologist and/or the patient.

CONCLUSIONS

The proposed EULAR definition for difficult-to-treat RA can be used in clinical practice, clinical trials and can form a basis for future research.

Rituximab Followed by Belimumab Controls Severe Lupus Nephritis and Bullous Pemphigoid in Systemic Lupus Erythematosus Refractory to Several Combination Therapies

Systemic lupus erythematosus (SLE) and bullous pemphigoid (BP) are chronic autoimmune diseases in which B cells play an important pathogenic role in the different stages of the disease. B cell-targeted therapies have been suggested as a new rational approach for treating SLE. Rituximab (RTX), an anti-CD20 chimeric monoclonal antibody, failed to achieve primary endpoints in two clinical trials (EXPLORER and LUNAR) despite multiple observational and retrospective studies showing its beneficial effect on SLE. Moreover, RTX is recommended in cases of BP that is unresponsive to conventional treatments. Belimumab (BLM), a human immunoglobulin G1 λ monoclonal antibody that inhibits soluble B-lymphocyte stimulator (BlyS)/B-cell activating factor (BAFF), is the only biological treatment approved for standard therapy of refractory autoantibody-positive active SLE. Animal models and a few case reports have supported the efficacy of the combined use of RTX followed by BLM as maintenance therapy in severe lupus nephritis (LN), suggesting that their combined use may be more effective than their single use, without compromising safety. In this study, we describe the clinical case of a SLE patient with predominant renal involvement in overlap with BP, refractory to conventional therapy including RTX alone, achieving significant steroid sparing and clinical remission under sequential treatment of RTX-BLM. Moreover, we describe the first case of BP successfully treated with BLM. This case report may encourage further clinical research studies in B lymphocyte targeted combination therapy in patients affected by SLE with major organ involvement or with refractory disease, suggesting that RTX and BLM sequential therapy may be a valid option for the treatment of SLE manifestations, including conventional therapy and RTX-resistant LN.

Basic immunology may lead to translational therapeutic rationale: SARS-CoV-2 and rheumatic diseases

COVID-19 pandemia is a major concern for patients and healthcare systems. The fear of infection by patients with concomitant rheumatic diseases (either adult or children) and connective tissue diseases is arising worldwide, because of their immunological background and immunological therapies. Analysing the basic biology of single diseases, the data suggest that there is an "immunological umbrella" that seems to protect against the infection, through IFN type 1 and NK cell function. To date, reports from China, United States and Europe did not reveal an higher risk of infection, either for rheumatoid arthritis, juvenile idiopathic arthritis nor for lupus erythematosus. Antimalarials, anti-IL6-Anti-IL6 receptor, anti-IL1, anti-GM-CSF receptor and JAK1/2/3 inhibitors, are under investigation in COVID-dedicated clinical trials to control the inflammation raised by SARS-CoV-2 infection. Initial reports on the occurrence of autoimmune phenomena in the convalescence phase of SARS-CoV-2 infection suggests that the immunological consequences of the infection need to be strictly understood. Reporting of the study conforms to broad EQUATOR guidelines (Simera et al January 2010 issue of EJCI).

Factors Predicting Early Failure of Etanercept in Rheumatoid Arthritis: An Analysis From the Gruppo Italiano di Studio sulla Early Arthritis (Italian Group for the Study of Early Arthritis) Registry

Objectives

This study aims to investigate the factors associated with early discontinuation (within one year) of etanercept (ETA) in rheumatoid arthritis (RA) patients who began ETA as first biologic disease-modifying antirheumatic drug (bDMARD) and who were entered into the Gruppo Italiano di Studio sulla Early Arthritis (Italian Group for the Study of Early Arthritis; GISEA) registry.

Patients and methods

This registry-based cohort study included 477 RA patients (95 males, 382 females; median age 53 years; range 18 to 83 years) who began ETA as first bDMARD. Patient demographics, disease features and drugs were re-evaluated after 12 months. Baseline predictors of ETA discontinuation were estimated by univariate and multivariate analyses using Cox regression model.

Results

Seventy patients (14.7%) discontinued ETA during the first year (for inefficacy in 55.8%, adverse events in 28.6%, and other reasons in 6.5%). Concurrent conventional synthetic DMARDs (csDMARDs) were reported in 54.3% of patients, mainly methotrexate (MTX), while 52.4% of subjects took low doses of glucocorticoids. Patients stopping ETA more frequently showed one or more comorbidities, mainly cardiovascular diseases (28.6% vs. 15.7% in patients stopping and continuing ETA, respectively, p=0.009). The presence of comorbidities and a combination therapy with csDMARDs other than MTX were independent factors associated with early discontinuation of ETA at multivariate Cox analysis.

Conclusion

Although ETA demonstrated a high persistence in biologic-naïve RA patients, about 15% of patients discontinued the treatment within 12 months. The presence of comorbidities and a combination therapy with csDMARDs other than MTX were the main factors for an early withdrawal of the drug.

Golimumab effectiveness in biologic inadequate responding patients with rheumatoid arthritis, psoriatic arthritis and spondyloarthritis in real-life from the Italian registry GISEA

OBJECTIVE

To evaluate the clinical effectiveness of golimumab in biologic inadequate responder (IR) patients with Rheumatoid arthritis (RA), Spondyloarthritis (SpA), and Psoriatic arthritis (PsA).

METHODS

We analyzed 1424 patients on golimumab from the GISEA registry. Drug survival was estimated by Kaplan-Meier analysis in biologic-naïve, 1-biologic IR, ≥2-biologics IR patients. Hazard ratios (HRs) of discontinuing golimumab at 2 years were assessed by multivariate Cox regression. Patients achieving CDAI based low disease activity (LDA) or BASDAI<4 were calculated at 6 and 12 months.

RESULTS

In RA (n.370), the 2-years survival on golimumab was 61.4% in 1-biologic IR, 51.9% in≥2-biologics IR, and 73.1% in biologic-naive patients (P=0.002 vs≥2-biologics IR). In SpA (n.502), the survival was similar among 1-biologic IR (80%), ≥2-biologics IR (76.5%), and biologic-naive (74.6%) patients (P>0.05). In PsA (n.552) the survival was 72% in 1-biologic IR, 72.5% in≥2-biologics IR, and 71.8% in naïve-biologic (P>0.05). Predictors of golimumab discontinuation were monotherapy (HR 1.65) for RA, female gender for SpA (HR 2.48) and PsA (HR 1.57). In RA, patients on CDAI-LDA were lower in 1-biologic IR (40%) or≥2 biologics IR (40%) than in biologic-naïve (60%) group at 6 months (P=0.02), but no difference was observed at 12 months. In PsA and SpA, the percentage of patients on CDAI-LDA or BASDAI<4 at 6 months was almost identical across the subgroups.

CONCLUSIONS

Golimumab had similar effectiveness in biologic-failure and biologic-naïve SpA and PsA, but seems to be less effective in multi-failure RA patients, especially as monotherapy. The best outcomes were seen in male patients.

Distinct synovial tissue macrophage subsets regulate inflammation and remission in rheumatoid arthritis

Immune-regulatory mechanisms of drug-free remission in rheumatoid arthritis (RA) are unknown. We hypothesized that synovial tissue macrophages (STM), which persist in remission, contribute to joint homeostasis. We used single-cell transcriptomics to profile 32,000 STMs and identified phenotypic changes in patients with early/active RA, treatment-refractory/active RA and RA in sustained remission. Each clinical state was characterized by different frequencies of nine discrete phenotypic clusters within four distinct STM subpopulations with diverse homeostatic, regulatory and inflammatory functions. This cellular atlas, combined with deep-phenotypic, spatial and functional analyses of synovial biopsy fluorescent activated cell sorted STMs, revealed two STM subpopulations (MerTKposTREM2high and MerTKposLYVE1pos) with unique remission transcriptomic signatures enriched in negative regulators of inflammation. These STMs were potent producers of inflammation-resolving lipid mediators and induced the repair response of synovial fibroblasts in vitro. A low proportion of MerTKpos STMs in remission was associated with increased risk of disease flare after treatment cessation. Therapeutic modulation of MerTKpos STM subpopulations could therefore be a potential treatment strategy for RA.

AB0102 SPECIALIZED PRO-RESOLVING MEDIATOR RECEPTORS AS INFLAMMATORY RESOLUTION BIOMARKERS IN RHEUMATOID ARTHRITIS

Background:

The regulation of inflammation is a dynamic process involving several molecules as lipid mediators. The Specialized Pro-resolving Mediators (SPMs), such as Resolvin (RvD and RvE), Protectins, Maresins and Lipoxin A4 (LXA4), are bioactive metabolites of omega-3 and omega-6 fatty acids which drive inflammatory resolution phase and promote tissue repair. ERV, ALX/FPR2 and BLT1 are SPM receptors. Although in Rheumatoid Arthritis (RA) lipid mediators role within pathophysiology is under definition, studies on SPMs receptors role are still lacking in this disease.

Objectives:

Purpose of this study is to define ERV, ALX/FPR2 and BLT1 expression in blood derived leukocytes and synovial cells and to correlate it to disease activity to define SPM receptors ad inflammatory resolution biomarkers in RA patients.

Methods:

A cohort of 52 RA patients was enrolled in the study of which 40 with active disease (DAS28= 5,35 (5,18-6,40)) and 12 in sustained remission status (DAS28= 2,1 (1,83-2,42)). Each enrolled patient underwent peripheral blood (PB) drawing and 46 of them underwent US-guided synovial tissue (ST) biopsy. FACS gating strategy was used for PB and ST processing to evaluate percentage of positive cells and the mean fluorescence intensity (MFI) of ERV+, ALX/FPR2+and BLT1+in CD45+CD3+, CD45+CD19+for PB and ST, CD45+CD14+and neutrophils for PB only and CD45-CD90+, CD45+CD64+CD11b+macrophages (distinct in CD206+and CD206-subpopulations) for ST only. Each included ST was stained with haematoxylin/eosin and categorized by a pathologist, blinded to clinical characteristics, using the Krenn Score (KS) to assess ST inflammation degree. As control group, 11 undifferentiated peripheral inflammatory arthritis (UPIA) patients were enrolled in the study.

Results:

Considering the whole RA cohort, DAS28 inversely correlated with BLT1+positive cells on ST-derived CD45+(r= -0.48; p= 0.048), CD3+(r= -0.56; p= 0.019) and CD19+(r= -0.49; p= 0.042) cells, in contrast with CD90+(r= 0.50; p= 0.041) cells. Similarly, both DAS28 and KS inversely correlated with ALX/FPR2+positive cells in ST-derived CD45+(r= -0.42, p= 0.050 and r= -0,41, p= 0,046 respectively) cells. Evaluating the MFI levels of the SPM receptors along all RA stages (naïve-to-treatment, resistant-to-treatment, sustained remission) compared with UPIA control group, interestingly ST-derived CD45+cells of remission RA were depleted of ERV1 compared to naïve-to-treatment RA (p=0.04), despite comparable ST inflammation. Furthermore, highest ERV1 expression was found in ST-derived CD45+CD3+and CD45+CD19+cells in naïve-to-treatment RA compared with UPIA patients (p= 0,045 and p= 0,012 respectively). Moreover, the lowest BLT1 level was found in remission RA CD3+cells compared with UPIA and naïve-to-treatment RA patients (p= 0,008 and p= 0,023 respectively).

Conclusion:

SPM receptors expression seem to be tightly related to disease activity in the synovial tissue, suggesting an important involvement in the inflammatory process in RA patient.

References:

[1]Serhan CN. Nature, 2014.

[2]Alivernini S, et al. Arthritis Res Ther 2016

[3]Krenn V et al. Histopathology, 2006.

Disclosure of Interests:

Simone Perniola: None declared, Stefano Alivernini: None declared, Barbara Tolusso: None declared, Maria Rita Gigante: None declared, Marco Gessi: None declared, Clara Di Mario: None declared, Luca Petricca: None declared, Annunziata Capacci: None declared, Anna Laura Fedele: None declared, Gianfranco Ferraccioli: None declared, Elisa Gremese Speakers bureau: Abbvie, BMS, Celgene, Jannsen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB

FRI0574 RENAL TISSUE EPIGENETIC BIOMARKERS’ CHARACTERIZATION IN PATIENTS WITH LUPUS NEPHRITIS AS PARAMETERS OF DISEASE ACTIVITY, REMISSION AND FLARE

Background:

Epigenetic factors such as non-coding RNA (miRNA) have been shown to be deregulated in Systemic Lupus Erythematosus (SLE). In particular, in mouse model (1), different miRNAs have been associated with lupus nephritis (LN), one of the most severe manifestations of the disease.

Objectives:

The aim of the study was to evaluate the expression of miR-155 and miR-34a in renal tissue as biomarkers of organ involvement and inflammatory tissue activity in patients with LN.

Methods:

Thirty-two LN patients with active renal involvement were enrolled (age: 32.2 ± 9.2 years). The nephritic onset of the disease (early-SLE) was present in 13 patients (41%), while 19 patients (59%) showed a renal involvement during the follow-up (long-SLE). Clinical, laboratory and demographic data were collected for each patient. Disease activity was recorded using SLEDAI-2K and renal activity, using the total SLEDAI-2K fraction including the items related to the renal involvement. Ultrasound-guided renal biopsy has been performed for each patients for the definition of the nephritic class according to the ISN / RPS classification of 2003 revised in 2018(2). The expression of miR-155 and miR-34a in renal tissue was carried out by extraction of total RNA from paraffin-preserved biopsies and after a retrotrascription protocol was evaluated using SYBR® Green-based real-time PCR by relative quantification considering the ΔCt (Ct miRNA- Ct housekeeping gene)(3).

Results:

Mir-155 and miR-34a expression in renal tissue were comparable in the different histological classes. Dividing patients on the base of nephritic onset, patients with early SLE showed lower expression of miR-155 (ΔCt 12.8 ± 10.8) and miR-34a (ΔCt 14.6 ± 9.9) than patients with long-SLE (miR-155: ΔCt 6.1 ± 8.7 p = 0.02; miR-34a: ΔCt 7.1 ± 9.0 p = 0.03). Furthermore, a direct correlation was observed between the expression of miR-155 and miR-34a (r = 0.91, p <0.001). Considering patients with early-SLE, the expression of miR-34a was slightly significant in patients who had relapsed (ΔCt 8.2 ± 11.4 vs ΔCt 18.4 ± 7.9 p = 0.08), although no correlation emerged between the expression of miR-155 and miR-34a both at the time of the biopsy and with the disease activity indices. At the histological evaluation, miR-155 and miR-34a were more expressed in Early-SLE patients who had wire loop lesions (miR-155: ΔCt 19.5 ± 7.7 vs ΔCt 7.3 ± 9.6 p = 0.05; miR-34a: ΔCt 21,7 ± 1.1 vs ΔCt 8,8 ± 9.7 p= 0.05) possibly associated with a greater activation of the inflammatory component.

Conclusion:

MiR-155 and miR-34a may represent tissue biomarkers of inflammatory activation in patients with LN in particular the higher expression of these miRNA in Long-SLE patients could indicate a possible role of these biomarkers in renal involvement in patients with SLE with later renal onset. The increased expression of miR-34a could give indications of a disease recurrence suggesting a closer monitoring of the patient.

References:

[1] Leiss H et al. Plosone 2017

[2] Bajema IM et al Kidney Int. 2018

[3] Alivernini S et al. Nat Commun 2018

Disclosure of Interests:

None declared

THU0287 EVALUATION OF PREDICTIVE FACTORS OF WORSE PROGNOSIS IN LUPUS NEPHRITIS: FOCUS ON NEW PATHOGENETIC PATHWAYS

Background:

cytokine dysregulation plays an important role in the pathogenesis of Lupus Nephritis (LN) representing an attractive field of research aiming to find new pathways for new targeted therapies. IL-17, IL-23 axis seems to have a great influence in the development of LN.

Objectives:

to evaluate the strongest prognostic factors in a cohort of patient with LN focusing on of the impact of IL-17, IL 23 axis as new pathogenetic pathway on renal outcome.

Methods:

91 patients with active LN at disease onset or disease flare were enrolled. Laboratory, immunological and disease activity data were collected at the baseline and at 6(T6),12(T12),24(T24) months and at the last follow-up(FU). 84 renal biopsies were evaluated according to ISN/RPS classification, assessing the activity and chronicity indexes and the active interstitial infiltrate using the BANFF score system. Baseline serum levels of IL-17 and IL-23 were assessed by ELISA in 37 patients.

Results:

among the 84 renal biopsies evaluated 77% belonged to class III and IV according to ISN/RPS; 41,8% of patients had an active interstitial infiltrate<5%, 35.2% between 5% and 25% and 15,4% above 25%. Regarding immunological data 35,2% of patients revealed a seropositivity for antiphospholipid antibodies(APL+). The median serum level of IL-17 and IL-23 were 0.12±0.15 pg/ml and 27.7±9.12 pg/ml respectively. Using the ROC curves analysis we found a cut off value of 25.89 pg/ml for IL-23 for remission at T6. Among the 10 patients with a IL-23 level above this cut-off none achieved remission at T6 and the univariate analysis shows that a serum level of IL-23 above the defined cut-off was associated with an active interstitial infiltrate>5% at renal biopsy and with the development of persistent proteinuria. The analysis of IL-17 could not let us to find a cut off value for renal damage progression since a too much high number of patients had a null value. Nevertheless patients with more elevated serum levels of IL-17 at the baseline showed more elevated level of interstitial infiltrate at renal biopsy and a worse renal outcome overall. Finally we conducted an univariate and multivariate analysis for each renal outcome considered. We found that an inflammatory interstitial infiltrate>5% at renal biopsy and APL+ were associated with worse renal outcome in terms of early and persistent remission, chronic damage, persistent proteinuria, and renal flare both in univariate and multivariate analysis. Higher serum level of IL-23 was associated with persistent proteinuria, renal flare and tended to be associated to chronic renal damage and persistent renal activity.

Conclusion:

interstitial inflammatory infiltrate and APL+ represent in our study the strongest predictors of worse renal outcome. An higher serum level of IL-23 was found to be a negative prognostic factor pointed out the possibility to consider the IL-17-IL 23 axis as a biomarkers of a more aggressive renal disease.

Disclosure of Interests:

None declared

Outcomes and Findings of the International Rheumatoid Arthritis (RA) BIODAM Cohort for Validation of Soluble Biomarkers in RA

OBJECTIVE

The Outcome Measures in Rheumatology Soluble Biomarker Working Group initiated an international, multicenter, prospective study, the Rheumatoid Arthritis (RA) BIODAM cohort, to generate resources for the clinical validation of candidate biomarkers predictive of radiographic progression. This first report describes the cohort, clinical outcomes, and radiographic findings.

METHODS

Patients with RA from 38 sites in 10 countries starting or changing conventional synthetic disease-modifying antirheumatic drugs and/or starting tumor necrosis factor inhibitors were followed for 2 years. Participating physicians were required to adhere to a treat-to-target strategy. Biosamples (serum, urine) were acquired every 3 months, radiography of hands and feet every 6 months, and ultrasound of hands and feet every 3 months in a subset. Primary endpoint was radiographic progression by the Sharp/van der Heijde score.

RESULTS

A total of 571 patients were recruited and 439 (76.9%) completed 2-year followup. At baseline, the majority was female (76%), mean age 55.7 years, and mean disease duration 6.5 years. Patients had a mean of 8.4 swollen and 13.6 tender joints, 44-joint count Disease Activity Score (DAS44) 3.8, 77.7% rheumatoid factor-positive or anticitrullinated protein antibody-positive. Percentage of patients in DAS and American College of Rheumatology remission at 2 years was 52.2% and 27.1%, respectively. Percentage of patients with radiographic progression (> 0.5) at 1 and 2 years was 38.2% and 59.9%, respectively.

CONCLUSION

The RA BIODAM prospective study succeeded in generating an extensive list of clinical, imaging (2343 radiographs), and biosample (4638 sera) resources that will be made available to expedite the identification and validation of biomarkers for radiographic damage endpoints. (Clinicaltrials.gov: NCT01476956, clinicaltrials.gov/ct2/show/NCT01476956).

SAT0224 ANTIPHOSPHOLIPID ANTIBODIES AND VASCULAR RENAL LESIONS AS PROGNOSTIC FACTORS IN LUPUS NEPHRITIS

Background:

Several studies have showed that antiphospholipid antibodies (aPL) positivity represents a predictor of worse renal outcome in patients with Lupus Nephritis (LN). In addition, an association between aPL positivity and the histological data of vascular lesions on the renal biopsies has been reported.

Objectives:

To determine the prognostic role of aPL and vascular renal lesions in the assessment of clinical outcome during the follow up period, in terms of time to achieve remission, number of renal flares and development of chronic renal damage in patients affected by LN.

Methods:

Among 120 patients affected by LN from our Rheumatology Unit, 91 patients (age 43.8 ± 12 years, 74 (81.3%) female, disease duration 7.1 ± 7.9 years) have been evaluated and the follow-up data have been collected at the baseline and at 6, 12, 24 months and at the last follow-up visit. Histopathological data of 41 patients were evaluated according to the 2016 revision of ISN/RPS classification.

Results:

Among the 91 LN patients, 31 (34.1%) were aPL positive (aPL+), 10 (32.2%) of them were affected by Antiphospholipid Antibodies Syndrome (APS), 53.3% showed a single aPL positivity, 23.1% double aPL positivity and 15.4% triple aPL positivity. At the last follow up visit a significant higher number of aPL+ patients showed a persistent complement consumption than aPL negative (aPL-) patients (p=0.001). Evaluating clinical outcome, we observed that aPL- patients showed a remission achievement time slightly earlier than aPL+ patients (13.6 ± 1.0 months vs 16.5 ± 1.5 months; log-rank test: p=0.06, Breslow test: p=0.08) and as expected, patients with a persistent complement consumption achieve remission later (18.2 ± 1.5 months vs 13.0 ± 1 months; log-rank test: p=0.002, Breslow test: p=0.003). Furthermore at the last follow up, a significant higher percentage of aPL+ patients developed persistent proteinuria (p=0.02) and chronic renal failure (p=0.04). Considering histologic features (activity and chronicity index, glomerulonephritis class, presence of mesangiolysis, glomerular wrinkling, glomerular thrombi, interstitial inflammatory infiltrates, interstitial fibrosis and tubular atrophy,tubulitis and vascular lesions) we didn’t observe significant differences between aPL+ and aPL- patients but we found two typical vascular lesions (mesangiolysis and vascular thrombi) only in aPL + patients.

Conclusion:

aPL positivity is a predictor of worse renal outcome but in our cohort of LN patients we didn’t find an association between aPL positivity and vascular renal lesions at renal biopsy. The worse renal outcome and the late time to achieve remission in aPL+ group can be related to a cumulative vascular damage over time as observed in other organ and systems.

Disclosure of Interests:

None declared

SAT0027 DEVELOPMENT AND VALIDATION OF A NOMOGRAM COMBINING CLINICAL AND HISTOPATHOLOGICAL SYNOVIAL FEATURES FOR PREDICTING EARLY TREATMENT RESPONSE IN NAIVE TO TREATMENT RHEUMATOID ARTHRITIS

Background:

Rheumatoid Arthritis (RA) is characterized by synovial tissue (ST) heterogeneity at disease onset in terms of inflammatory degree and microanatomical organization being related to treatment response.

Objectives:

To develop a multiparametric tool for baseline treatment response prediction including disease characteristics and histopathologic features of ST biopsies, using a large single center (SYNGem Unit) naive to treatment RA cohort.

Methods:

240 naive to treatment RA who underwent US-guided ST biopsy, at the first clinical evaluation, were enrolled. Clinical and immunological characteristics were recorded for each patient. All ST FFPE specimens were stained with H&E and classified by a pathologist, blinded to clinical characteristics, using the Krenn score [1] to assess the degree of ST inflammation. All naive to treatment RA were treated according to the T2T scheme and DAS remission rate at 6-12 months was recorded. On the basis of the regression analysis, a nomogram was constructed that incorporated the significant factors predicting the “achievement of DAS-Remission at 6 months follow-up” in naive RA. The performance of the nomogram was assessed by discrimination and calibration.

Results:

Univariate analysis showed that RA who achieved early (6 months) DAS-remission had, at baseline, significantly lower total Krenn score (p<0.001), shorter symptoms duration (p=0.005) and lower disease activity (p<0.001) than RA not achieving this clinical outcome. ROC curve analysis revealed that RA having, at baseline, a total Krenn score <4.5 [(AUC)95%C.I.: 0.67(0.60-0.74),p<0.001] achieved more likely DAS-remission at 6 months (53.1%) than RA with total Krenn score ≥4.5(28.9%,p<0.001). Interestingly, RA whose ST was biopsied within 3 months from joint symptoms beginning showed significantly lower ST inflammation as total Krenn score than RA whose ST was analyzed among 3-12 months (p=0.04) or after 12 months (p=0.002) since symptoms beginning. However, in terms of follicular structure presence, the microanatomical organization of the synovial inflammatory infiltrate did not differ comparing RA whose ST was biopsied within 3 months from joint symptoms beginning (44.4%) and RA whose ST was biopsied among 3-12 months (47.6%, p=0.74) or after 12 months (52.7%,p=0.33) since symptoms beginning.

Logistic regression analysis revealed that, at baseline, being VERA, not having HDA and having a total Krenn score <4.5 were synergistic factors of DAS-remission achievement at 6 months [OR:10.5(95%IC:2.28-48.01);p<0.05]. Based on the regression analysis, a nomogram integrating baseline clinical (disease activity and duration) and histological (total Krenn score) characteristics was developed in which the value of each of the variables was given a point score. A total score was calculated by adding each single point score and, by projecting the value of the “total points” score to the “probability” line up to 87.5%.

Conclusion:

Krenn score is a reliable tool for the semi-quantitative assessment of ST inflammation on US-guided ST biopsies being contingent to baseline disease characteristics and can be integrated within a nomogram to better predict the therapeutic response in naive to treatment RA.

References:

[1] Krenn V, et al. Histopathology 2006

Disclosure of Interests:

Stefano Alivernini: None declared, Barbara Tolusso: None declared, Marco Gessi: None declared, Maria Rita Gigante: None declared, Alice Mannocci: None declared, Luca Petricca: None declared, Simone Perniola: None declared, Clara Di Mario: None declared, Anna Laura Fedele: None declared, Laura Bui: None declared, Annunziata Capacci: None declared, Dario Bruno: None declared, Giuseppe La Torre: None declared, Francesco Federico: None declared, Gianfranco Ferraccioli: None declared, Elisa Gremese Speakers bureau: Abbvie, BMS, Celgene, Jannsen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB

Comprehensive review on intravertebral intraspinal, intrajoint, and intradiscal vacuum phenomenon: From anatomy and physiology to pathology

The term 'vacuum phenomenon' (VP), is characterized by gas-like density areas due to a rapid increase in the joint space volume ('acute VP') or represent a chronic gas collection. It can occur within a collapsed vertebral body, the spinal canal, joints but mainly the intervertebral disc. Studies support that VP is originated by a dynamic process involving the balance between tissues' liquid and gaseous components, influenced by the duration and the depth of mechanical and metabolic alterations, by the nature of neighboring tissues and the variability in both pressure and permeability of disc or vertebral or joint structures. Prevalence of VP in the general population is about 2%, reaching 20% in the elderly with disc degeneration. Although it's often a random finding in asymptomatic patients, VP is an eventually painful expression of disc degeneration, or disc or vertebral fracture, or bone lesions. In sporadic cases, intradiscal gas can be expelled (all-in-one or gradually), resulting in a gaseous cyst, causing pain and neurological symptoms. Considering that spontaneous resolution and recurrence after surgery are both possible, most of the authors recommend conservative treatment in patients with intradiscal and intravertebral VP; occasionally percutaneous CT(computed tomography) -guided aspiration or vertebral stabilization.

Gut microbiota analysis in systemic sclerosis according to disease characteristics and nutritional status

OBJECTIVES

Systemic sclerosis (SSc) is a rare multi-organ disorder with a prominent gastrointestinal (GI) involvement. Altered gut microbiota is now considered a pivotal factor associated with the development of immune-mediated and inflammatory diseases. We performed a 16S ribosomal RNA (rRNA) gene-sequencing analysis of fecal microbiota in a cohort of SSc patients and matched healthy controls (HCs), with the aim to obtain some hints about a possible role of dysbiosis in the onset, progression, and severity of the disease.

METHODS

We analysed stool samples from 63 SSc patients with different disease duration, phenotype, and nutritional status and from 17 HCs through 16S ribosomal RNA (rRNA) gene-sequencing.

RESULTS

Microbial richness was lower for patients with long-standing disease. A similar observation was made for patients with diffuse cutaneous SSc (dsSSc) compared to those with limited variant (lcSSc) and for patients who reported a recent weight loss. Consistent with previous reports, we noted a deviation of the intestinal microbial composition in patients with SSc compared to HCs, with a greater expression of Lactobacillus and Streptococcus and a depletion of Sutterella. Nutritional status, assessed using BMI as a surrogate, appeared to have a marked impact on the gut microbiota, with overweight patients showing lower richness compared both to underweight and normal-BMI patients.

CONCLUSIONS

Our findings expand the current knowledge of gut microbiota in SSc and could be useful to identify patients who would most benefit from treatments aimed at restoring the eu-biosis.

QT and QT dispersion intervals in long-standing and moderately active rheumatoid arthritis: results from a multicentre cross-sectional study

OBJECTIVES

To define the prevalence of prolonged QT interval and QT dispersion (QTd) in rheumatoid arthritis (RA) patients and in a control population.

METHODS

QT interval corrected by Bazett's formula (QTc) was calculated from standard 12-lead ECGs in 963 subjects free of previous cardiovascular events (646 RA patients and 317 controls strictly matched for age, sex and cardiovascular risk factors).

RESULTS

RA patients (59.6±9.6 years, 68.1% females) had a long mean disease duration (10.6 years) and moderate disease activity (DAS28=3.68±1.23). QTc was 5 msec longer in RA patients than in controls (412±9 vs. 407±28 msec, p=0.013). However, the prevalence of QTc prolongation in RA patients and controls was not significantly different (5.3% vs. 6.3%, p=0.50). On the contrary, RA patients had a significantly greater QTd (42±26 vs. 35±18 msec, p<0.001) and a higher prevalence of increased QTd (33.3% vs. 18.3%, p<0.001) than controls. Furthermore, RA was independently associated to increased QTd [OR(95%CI)= 2.21(1.58-3.08), p=0.0001]. In the RA population, male gender and older age were independently associated with a higher prevalence of prolonged QTd.

CONCLUSIONS

In this cohort of long-standing and moderately active RA patients, RA showed longer QTc but similar prevalence of prolonged QTc and an increased QTd with a 1.8-fold higher prevalence of increased QTd than the control population. Further studies in larger prospective cohorts are warranted to investigate whether QTd prolongation predicts sudden cardiac death and other adverse cardiovascular outcomes in RA.

O14 Semi-quantitative assessment of synovial inflammation on US guided synovial membrane biopsy is contingent to disease phase, autoimmune profile and treatment response in RA: a large single center experience

Background

Ultrasound (US)-guided minimally-invasive synovial tissue (ST) biopsy is a well-tolerated procedure for basic and translational studies on chronic inflammatory joint diseases as rheumatoid arthritis (RA), psoriatic arthritis (PsA) and spondyloarthritis (SpA). The aim of the study was to evaluate the utility of histopathologic criteria to differentiate US-guided ST biopsies in daily clinical care in relation to diagnosis, disease characteristics, US parameters and treatment response in a large single center ST biopsy unit.

Methods

1,064 patients [545 RA, 167 PsA, 75 SpA, 199 undifferentiated peripheral inflammatory arthritis (UPIA), 18 crystal arthritis, 26 connective tissue diseases and 34 osteoarthritis (OA) respectively] who underwent US-guided ST biopsy were enrolled. US parameters (Synovial Hyperthrophy and Power Doppler signal respectively) were recorded for each biopsied joint. RA, PsA and SpA patients were stratified based on disease activity phase (naive to DMARDs, DMARDs resistant and in sustained remission, respectively). Clinical, demographic and immunological characteristics were recorded for each patient. All ST FFPE specimens were routinely processed and stained with H&E and classified by a pathologist, blinded to clinical characteristics, using the Krenn score to assess the degree of ST inflammation. Moreover, the presence/absence of lymphocytes, plasmacells, granulocytes and oedema was assessed for each ST. All naive to treatment RA were treated according to the T2T scheme and followed for at least 12 months and DAS remission rate was recorded.

Results

In the cohort, the distribution of synovitis score was significantly different among patients with inflammatory chronic diseases (RA, PsA, SpA and UPIA respectively) compared to OA (ANOVA Test p &lt; 0.001). Moreover, Krenn score directly correlated with synovial hyperthrophy (R = 0.36; p &lt; 0.001) and Power Doppler signal (R = 0.40;p&lt;0.001) of the biopsied joint. Considering the RA cohort, naive RA showed a higher Krenn score compared to resistant RA (p &lt; 0.001) and RA in sustained clinical and US remission (p &lt; 0.001), directly correlating with DAS28 (R = 0.51; p &lt; 0.001). Moreover, ACPA and RF positivity was related to the Krenn score and to ST plasmacells presence at RA onset (p &lt; 0.05 and p &lt; 0.001, respectively) but not at the time of DMARDs-failure or sustained remission achievement (p &gt; 0.05 for both). Stratifying naive RA based on disease duration at ST biopsy, naive RA with symptoms duration &gt;1 year, showed higher Krenn score compared to those with symptoms duration &lt;3 months (p &lt; 0.001). Finally, logistic regression analysis revealed that Krenn score higher or equal to 4.5 at baseline is an independent factor of no DAS remission achievement within 12 months [OR(95%CI):0.37(0.20-0.67)p&lt;0.001] in naive RA.

Conclusion

Krenn score is a reliable tool for the semi-quantitative assessment of ST inflammation on US-guided ST biopsies being differentially distributed among various chronic inflammatory joint diseases and contingent to disease phase, autoimmune profile and therapeutic response in RA.

Disclosures

S. Alivernini None. B. Tolusso None. M. Gessi None. M. Gigante None. L. Petricca None. C. Di Mario None. S. Perniola None. A. Fedele None. G. Peluso None. L. Bui None. A. Capacci None. F. Federico None. G. Ferraccioli None. E. Gremese None.

P234 Characterisation of human synovial tissue dendritic cells in rheumatoid arthritis patients

Background

Dendritic cells (DCs) direct immune responses against pathogens while maintaining tolerance to self-antigens. However, their aberrant activation can lead to autoimmunity and inflammation. DCs consist of two subtypes: plasmacytoid and myeloid DCs. Recently, single-cell sequencing has revealed complex heterogeneity within myeloid DCs. These cells can be divided into CD141pos (DC1), DC2 defined as CD1highCD163neg and DC3 defined as CD1clowCD163high. In addition, a population of CD1cnegCD141negCD16pos (DC4), which share some gene expression with CD16pos monocytes, has been identified. To date, most studies of RA investigated DC precursors in circulation or synovial fluid (SF). However, DCs perform their functions within lymphoid or peripheral tissue. Therefore, in this study, we sought to characterise myeloid DC subsets in synovial tissue (ST) with the prospect of better understanding their role in driving autoimmunity in RA.

Methods

We developed a flow sorting strategy to characterise the phenotype of distinct myeloid DC subsets in multiple biological compartments (PB, SF, and ST). Ultrasound-guided ST biopsies (RA n = 9; Psoriatic arthritis n = 3 with active disease) were digested with liberase prior to analysis. PB DCs (RA n = 19, Psoriatic arthritis n = 16, healthy donors n = 12), and SF DC (n = 3) were used as comparators. ST, SF and PB DCs were sorted then microRNA, pro-inflammatory and regulatory cytokine expression analysed by amplified qPCR. To evaluate the role of miR-155 in RA CD1cpos DC activation, CD1cpos cells were computationally sub-setted from a scRNAseq synovial dataset comparing synovial tissues of healthy individuals (n = 4) with patients with active RA (n = 7) and those in sustained clinical and ultrasound remission (n = 7). To elucidate the role of miR-155, CD1cpos DC from RA patients (n = 10) were sorted then transfected with miR-155 mimic or control mimic and the cytokines expression and produced were evaluated using quantitative RT-PCR and Luminex, respectively.

Results

Our data revealed that whilst all myeloid DCs subsets can be present in inflamed RA synovium they occur with variable frequencies. CD1cpos (DC2/3) being the most abundant, followed by CD16pos DCs (DC4), whilst CD141pos DCs (DC1) occur in low numbers or are absent. CD1cpos DC sorted from RA ST express high levels of epigenetic regulators of inflammatory response miR-155, IL-6, TNF-a and IL-23 as compared to circulating cells.Unsupervised clustering of synovial CD1c cells identified 4 separate clusters including a distinctive miR155 positive CD1c cluster in RA patients. These cells showed significantly higher expression of pro-inflammatory cytokines and co-stimulatory molecules compared to other synovial CD1c clusters. Overexpression of miR-155 in CD1cpos leads to increased production of TNF-a and IL-23.

Conclusion

Our data show that miR-155 is strongly implicated as an epigenetic regulator of the pro-inflammatory synovial CD1cpos DCs sub-cluster and contributes to exacerbating RA.

Disclosures

A. Elmesmari None. L. MacDonald None. D. Vaughan None. B. Tolusso None. L. Bui None. M. Gigante None. F. Federico None. G. Ferraccioli None. E. Gremese None. I. B McInnes None. S. Alivernini None. M. Kurowska-Stolarska None.

Is treat-to-target really working in rheumatoid arthritis? a longitudinal analysis of a cohort of patients treated in daily practice (RA BIODAM)

OBJECTIVES

To investigate whether following a treat-to-target (T2T)-strategy in daily clinical practice leads to more patients with rheumatoid arthritis (RA) meeting the remission target.

METHODS

RA patients from 10 countries starting/changing conventional synthetic or biological disease-modifying anti-rheumatic drugs were assessed for disease activity every 3 months for 2 years (RA BIODAM (BIOmarkers of joint DAMage) cohort). Per visit was decided whether a patient was treated according to a T2T-strategy with 44-joint disease activity score (DAS44) remission (DAS44 <1.6) as the target. Sustained T2T was defined as T2T followed in ≥2 consecutive visits. The main outcome was the achievement of DAS44 remission at the subsequent 3-month visit. Other outcomes were remission according to 28-joint disease activity score-erythrocyte sedimentation rate (DAS28-ESR), Clinical Disease Activity Index (CDAI), Simplified Disease Activity Index (SDAI) and American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) Boolean definitions. The association between T2T and remission was tested in generalised estimating equations models.

RESULTS

In total 4356 visits of 571 patients (mean (SD) age: 56 (13) years, 78% female) were included. Appropriate application of T2T was found in 59% of the visits. T2T (vs no T2T) did not yield a higher likelihood of DAS44 remission 3 months later (OR (95% CI): 1.03 (0.92 to 1.16)), but sustained T2T resulted in an increased likelihood of achieving DAS44 remission (OR: 1.19 (1.03 to 1.39)). Similar results were seen with DAS28-ESR remission. For more stringent definitions (CDAI, SDAI and ACR/EULAR Boolean remission), T2T was consistently positively associated with remission (OR range: 1.16 to 1.29), and sustained T2T had a more pronounced effect on remission (OR range: 1.49 to 1.52).

CONCLUSION

In daily clinical practice, the correct application of a T2T-strategy (especially sustained T2T) in patients with RA leads to higher rates of remission.

European multicentre study validates enhanced liver fibrosis test as biomarker of fibrosis in systemic sclerosis

Objectives

To validate enhanced liver fibrosis (ELF) test and its components-amino-terminal propeptide of procollagen type III (PIIINP), tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) and HA-as biomarkers of fibrosis in SSc in an independent, international, multicentre cohort.

Methods

Two hundred and fifty-four SSc patients from six Rheumatology Centres were included. Sera were collected and stored according to EUSTAR biobanking recommendations and analysed through automated high throughput diagnostics. Statistical analysis was performed with SPSS software.

Results

Two hundred and forty-seven SSc patients (mean age 55.7 ± 13.9 years, 202 F) were analysed. ELF score, TIMP-1 and PIIINP levels were higher in males (P = 0.0197, P = 0.0107, P = 0.0108 respectively) and in dcSSc (P = 0.001, P = 0.0008, P < 0.0001 respectively). ELF score and the single markers significantly correlated with modified Rodnan skin score (r = 0.37, P < 0.0001), disease activity and severity (P < 0.0001 for all markers, except for HA P = 0.0001) and inversely with forced vital capacity, (FVC) % (TIMP-1, r = -0.21, P = 0.0012; PIIINP, r = -0.26, P = 0.0001), TLC% (ELF score, r = -0.20, P = 0.0036; TIMP-1, r = -0.32, P < 0.0001; PIIINP, r = -0.28, P < 0.0001), diffusion capacity of the lung for carbon monoxide (DLCO) % (P < 0.0001 for all markers, except for HA P = 0.0115). Multivariate analysis indicated that age (P < 0.001), modified Rodnan skin score (P < 0.001) and DLCO% (P = 0.005) were independently associated with ELF score.

Conclusion

Between the first and this validation studies, the value of the ELF score as independent marker of skin and lung involvement in SSc is confirmed in 457 patients. A longitudinal study is on-going to identify an SSc specific algorithm with predictive value for skin and lung progression.

The B side of rheumatoid arthritis pathogenesis

In the last years, a dramatic amount of research has been performedincreasing the knowledge about the biological mechanism underpinning Rheumatoid Arthritis (RA) inflammation, putting B lymphocytes in the center of RA pathogenesis. Nowadays, B cell phenotypes and autoantibodies positivity arose as important biomarkers in early and long-standing disease. Moreover, comparative analysis of peripheral blood and synovial tissue compartments enables the identification of novel physiopathological mechanisms promoting inflammation. In this narrative review we will discuss the biological relevance of B cell derived autoimmunity and in RA course, from disease onset to remission achievement.