POS0886 EFFICACY AND SAFETY OF RITUXIMAB IN AUTOIMMUNE DISEASE–ASSOCIATED INTERSTITIAL LUNG DISEASE: A PROSPECTIVE COHORT STUDY

Background

Interstitial lung disease (ILD) is a common condition in patients with connective tissue disease (CTD). It is associated with increased morbidity and mortality. Rituximab (RTX) has been approved for treatment of RA and some recent retrospective studies suggest that it could be an alternative treatment for patients with CTD-ILD, even in cases that prove refractory to conventional immunosuppressants.

Objectives

To analyze the efficacy and safety of RTX in connective tissue disease associated with interstitial lung disease (CTD-ILD).

Methods

We performed a multicenter, prospective, observational study of patients with CTD-ILD receiving RTX between 2015 and 2020. Patients who had worsening of respiratory symptoms or decline in the pulmonary function tests (PFT) compared to the time of ILD diagnosis were treated with rituximab. The patients were assessed using high-resolution computed tomography and PFT baseline, at 12 months, and at the end of follow-up. The main outcome measure at the end of follow-up was forced vital capacity (FVC)>10% or diffusing capacity of the lungs for carbon monoxide (DLCO)>15% and radiological progression or death. We recorded clinical characteristics, time to initiation of RTX, concomitant treatment, infections, and hospitalization. A Cox regression analysis was performed to identify factors associated with worsening of ILD.

Results

We included 37 patients with CTD-ILD treated with RTX for a median (IQR) of 38.2 (17.7-69.0) months (Table 1). At the end of the follow-up, disease had improved or stabilized in 23 patients (62.1%) and worsened in 7 (18.9%); 7 patients (18.9%) died. Mean PFT values decreased significantly at the start of RTX compared to the date of ILD diagnosis in FVC (72.2[21.3]vs 73.5 [16.9] mg/l;p=0.040) and DLCO-SB (55.9 [15.7] vs 58.3 [16.1] mg/l; p=0.041). No significant decline was observed in median FVC (72.2 vs 70.8; p=0.530) or DLCO (55.9 vs 52.2; p=0.100). The multivariate analysis showed the independent predictors for worsening of CTD-ILD to be baseline DLCO (OR [95% CI], 0.904 [0.8-0.9]; p=0.015), time to initiation of RTX (1.01 [1.001-1.02]; p=0.029), and mycophenolate (0.202 [0.04-0.8]; p=0.034). The infection incidence rate was 0.21 patient-years.

Table 1.

Baseline demographic and clinical characteristics of 37 patients with CTD-ILD receiving rituximab.

VariableTotal n=37RAn=19SSn=14IMn=4p ValueFemale sex, n (%)27 (73.0)13 (68.4)11 (78.6)3 (75.0)0.806Age in years, mean (SD)62.8 (9.9)67.7 (9.7)57.9 (7.9)56.6 (5.5)0.001Smoking0.147Never smoked, n (%)20 (54.1)9 (47.4)7 (50.0)4 (100.0)Smoked at some time, n (%)17 (45.9)10 (52.6)7 (50.0)0 (0.0)Duration of CTD, months, median (IQR)107.8 (49.5-188.8)151.0 (8.,0-240.5)89.6 (51.3-184.4)35.1 (25.1-49.0)0.017Duration of ILD, months, median (IQR)65.4 (31.1-110.3)82.2 (37.4-120.1)64.5 (35.5-107.1)25.9 (25.0-36.0)0.136Time to initiation of RTX, median (IRQ)12.0 (6.5-48.2)25.1 (7.0-57.6)11.4 (3.9-43.6)7.4 (7.0-10.4)0.455Duration of treatment with RTX, median (IQR)38.2 (23.4-69.9)45.3 (22.2-79.9)52.5 (24.7-63.3)22.8 (17.7-36.2)0.291Combined with csDMARDs, n (%)15 (40.5)9 (47.4)5 (35.7)1 (25.0)0.637Methotrexate, n (%)5 (13.5)2 (10.5)3 (21.4)0 (0.0)0.468Leflunomide, n (%)2 (5.4)2 (10.5)0 (0.0)0 (0.0)0.367Sulfasalazine, n (%)1 (2.7)1 (5.3)0 (0.0)0 (0.0)0.615Hydroxychloroquine, n (%)7 (18.9)4 (21.1)2 (14.3)1 (25.0)0.840Combination with immunosuppressants, n (%)20 (54.1)7 (36.8)9 (64.3)4 (100.0)0.044Mycophenolate, n (%)19 (51.4)6 (31.6)9 (64.3)4 (100.0)0.021Azathioprine, n (%)1 (2.7)1 (5.3)0 (0.0)0 (0.0)0.615Corticosteroids, n (%)25 (67.6)14 (73.7)7 (50.0)4 (100.0)0.121Doses of corticosteroids, median (IQR)5.0 (0.0-10.0)5.0 (0.0-10.0)2.5 (0.0-7.5)10.0 (8.1-10.5)0.519

Conclusion

Lung function improved or stabilized in more than half of patients with CTD-ILD treated with RTX. No significant increase in infection rates was observed. Early treatment and combination with mycophenolate could reduce the risk of progression of ILD.

Disclosure of Interests

None declared

POS0211 PREDICTORS OF PROGRESSION AND MORTALITY IN PATIENTS WITH PREVALENT RHEUMATOID ARTHRITIS AND INTERSTITIAL LUNG DISEASE: A PROSPECTIVE COHORT STUDY

Objectives:

To analyze the effect of disease-modifying antirheumatic drugs (DMARDs) and identify risk factors associated with disease progression and mortality in patients with rheumatoid arthritis associated with interstitial lung disease (RA-ILD).

Methods:

We performed a multicenter, prospective, observational study of patients with RA-ILD receiving DMARDs between 2015 and 2020. The patients were assessed using high-resolution computed tomography and pulmonary function tests at baseline and at 60 months. The main outcome measure at 60 months was worsening of FVC >10% or DLCO >15% and radiological progression or death. We recorded demographic and clinical characteristics, lung function, and the incidence of adverse events. A Cox regression analysis was performed to identify factors associated with worsening of ILD.

Results:

After 60 months, lung disease had stabilized in 66 patients (56.9%), improved in 9 (7.8%), and worsened in 23 (19.8%). Eighteen patients (15.5%) died, with a mean survival of 71.8 (1.9) months. Baseline characteristics of 116 with RA-ILD treated with DMARDs is in table 1.The Cox multivariate analysis revealed the independent predictors of worsening of RA-ILD to be usual interstitial pneumonia (HR, 2.6 [95%CI, 1.0-6.7]), forced vital capacity (%) (HR, 3.8 [95%CI, 1.5-6.7]), anticitrullinated protein antibody titers (HR, 2.8 [95%CI, 1.1-6.8]), smoking (HR, 2.5 [95%CI, 1.1-6.2]), and treatment with abatacept, tocilizumab, or rituximab (HR, 0.4 [95%CI, 0.2-0.8]). During follow-up, 79 patients (68%) experienced an adverse event, mostly infection (61%).

Conclusion:

Lung function is stable in most patients with RA-ILD receiving treatment with DMARDs, although one third of patients die. Identifying factors of worsening in RA-ILD is important for clinical management.

Table 1.

Baseline characteristics of 116 with RA-ILD treated with DMARDs

VariableTotal=116Epidemiological characteristicsFemale sex, n (%)63 (54.3)Age, years, mean (SD)68.3 (9.9)Clinical and analytical characteristicsCurrent smokerNonsmoker, n (%)57 (49.1)Smoker, n (%)23 (19.8)Exsmoker, n (%)36 (31.0)Time since diagnosis of RA, months, median (p25-p75)148.5 (71.5-217.8)Diagnostic delay, months, median (p25-p75)8.5 (4.9-16.8)Time since diagnosis of ILD, months, median (p25-p75)27.5 (9.8-60.0)Positive rheumatoid factor (>10), n (%)111 (95.7)Positive ACPA titer (>20), n (%)100 (86.2)Erosive disease, n (%)76 (65.5)Treatment Synthetic DMARD100 (86.2) Methotrexate, n (%)51 (44.0) Leflunomide, n (%)30 (25.9) Sulfasalazine, n (%)9 (7.8) Hydroxychloroquine, n (%)21 (18.1)Biologic DMARD50 (43.1) Infliximab, n (%)1 (0.9) Etanercept, n (%)6 (5.2) Adalimumab, n (%)3 (2.6) Golimumab, n (%)3 (2.6) Certolizumab, n (%)3 (2.6) Tocilizumab, n (%)6 (5.2) Abatacept, n (%)15 (12.9) Rituximab, n (%)13 (11.2) Immunosuppressants11 (9.5) Mycophenolate, n (%)7 (6.0) Azathioprine, n (%)4 (3.4) Antifibrotic agents, nintedanib, n (%)1 (0.9) Baseline corticosteroids, n (%)69 (60.0) Dose of baseline corticosteroids, median (p25-p75)5.0 (0.0-7.5)

Abbreviations. RA: rheumatoid arthritis; ILD: interstitial lung disease; ACPA: anticyclic citrullinated protein antibody; DMARD: disease-modifying antirheumatic drug; SD: standard deviation.

Acknowledgements:

Grant for Medical Researchers of the “Fundación Española de Reumatología” 2019. declare.

Disclosure of Interests:

None declared

SAT0621-HPR EVALUATION OF THE SOCIAL IMPACT OF THE DISEASE IN PATIENTS WITH REUMATOID ARTHRITIS, ANQUILOSING SPONDYLITIS, AND SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Objectives:

To describe the impact of the disease on patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) or ankylosing spondylitis (EA) on the social health of people who suffer from it.

Methods:

Cross section of a consecutive sampling of patients with AS, RA or SLE. Selection criteria: age ≥18 years with AS (ASAS criteria), AR (EULAR / ACR 2010 criteria) and SLE (ACR-EULAR criteria) able to understand and willing to perform the questionnaires. Protocol: All patients who attended a consultation between October and December 2019 were offered to participate in the study. After their approval and verification of the inclusion criteria, they conducted a battery of PROMIS platform questionnaires focused on assessing their social health. Likewise, data on their disease, comorbidities and socio-labor profile were collected. All participants signed an informed consent and the study was approved by the CEIC of the referral hospital.

Main outcomes:

The variables collected by the questionnaires evaluate social health in several areas: mobility, depression, satisfaction with social relationships, social isolation, company, ability to participate in social activities, emotional support, instrumental support and support through information. Statistical analysis: Descriptive, bivariate analysis using t-student, ANOVA and χ2;, followed by multivariate linear regression (RLM) (Vd: ability to participate in continuous social activities 7-35).

Results:

151 patients participated: 50 with RA (90% women, mean age 55.12 ± 13.64 years), 51 with AS (51% women, 52.59 ± 12.15 years) and 50 patients with SLE (96 % women, mean age 47.14 ± 11.3 years). The most frequent comorbidities were: arthritis, visual impairment, anxiety and depression (table 1). These results present a greater tendency to depression and anxiety patients of SLE. No significant differences were observed in most of the social questionnaires analyzed between groups (table 2), except in a worse mobility in patients with RA and AD compared to SLE (p = 0.017). About half of the patients in all groups had depression (43%) and reduced mobility (63.6%). All groups are satisfied with their social role 128 (85.3%), have the capacity to participate in social activities 140 (94%) and feel accompanied 147 (97.4%). On the contrary, the social isolation figure is 42 (28%). Social isolation implies an affectation of the serious social role in patients who claim to be accompanied, so it is not secondary to loneliness or lack of family support.

In the multivariate analysis it was observed that the independent variables that were associated with the ability to participate in social activities were satisfaction with social relations (β = 0.349 [p = <0.001]), mobility (β = 0.309 [p = < 0.001]), depression (β = -0.186 [p = <0.011]) and social isolation (β = -0.195 (p = 0.001)). This model would explain 32% of the variability in the ability to participate in social activities. (R2 = 0.32).

Conclusion:

The predictors of the ability to participate in social activities in patients with RA, AD and SLE were: depression, mobility deficit, social isolation and satisfaction with social activities. Patients with RA, AD and SLE present similar data, so there are no differences due to pathologies in the social role, highlighting that they have a good social support and despite this there is social isolation being able to be associated with the deficit in mobility and high rates of depression.

Disclosure of Interests:

None declared

FRI0496 FRECUENCY OF POLYAUTOIMMUNITY IN RHEUMATOID ARTHRITIS AND SYSTEMIC LUPUS ERITHEMATOSUS

Background:

Objectives:

To study the frequency of polyautoinmunity and multiple autoinmune syndrome (MAS) in patients with rheumatoid arthritis (RA) and systemic lupus erithematosus (SLE).

Methods:

Study design: We performed a cross-sectional study in patients with RA and SLE, and compared them with healthy subjects. Cases: RA patients classified by ACR/EULAR 2010 criteria and SLE patients classified by ACR/EULAR 2019 criteria. SLE and RA patients were compiled consecutively from a rheumatology clinic of the Regional University hospital of Malaga. Controls: subjects without rheumatologic autoimmune disease (AD) from the same population area. Protocol: All subjects filled out a predesigned questionnaire for the collection of polyautoimmunity data on the cut-off date. Main variables: polyautoimmunity was defined as co-occurrence of SLE or RA and other AD. Secondary variables: Rheumatologic, cutaneous, endocrine, digestive and neurological AD. MAS was defined as presence of three or more AD. Family history of SLE, RA and other autoimmune diseases were also collected. Statistic analysis: descriptive analysis, bivariate analysis and multivariable analysis were done. (Dependent variable: Polyautoimmunity).

Results:

We recruited 109 patients with RA, 105 with SLE and 88 controls. Fifteen patients with RA (13.8%), 43 with SLE (41%) and 2 controls (2.2%) reported polyautoimmunity. Table 1 describes the epidemiological characteristics, comorbidities and polyautoimmunity in study population. The most frequent AD associated with RA was Sjögren’s syndrome (SS) (53.3%) and SS (55.8%) followed by the antiphospholipid syndrome (30.2%) were associated with SLE. Hashimoto’s thyroiditis and psoriasis were the next most frequent AD. According to family history, 5 patients with RA (33.3%) and 12 with SLE (27.9%) had a family history of first degree of other AD. Obesity was associated with polyautoimmunity in RA (OR = 3,362, p = 0.034). In SLE, joint damage (OR = 2.282, p = 0.038) and anti-RNP antibodies (OR = 5.095, p = 0.028) were factors associated with polyautoimmunity and taking hydroxychloroquine was a protective factor (OR = 0.190, p = 0.004).

Conclusion:

Polyautoimmunity in RA and especially in SLE is frequent. It was associated with obesity in RA and in SLE with joint damage and anti-RNP antibodies. The hydroxychloroquine appeared as a protective factor.

VariablesRA(N=109)SLE(N=105)Controls(N=88)P valueEpidemiological characteristicsSex: female, n (%)85 (78.0)99 (94.3)68 (77.3)0.001Age, mean (SD), years56.5 (10.8)50.8 (13.2)57.1 (10.6)0.133Caucasic race, n (%)107 (98.2)105 (100)88 (100)0.168ComorbiditiesSmoking0.001 No smoking, n (%)55 (50.5)78 (74.3)56 (63.6) Smoking history, n (%)54 (49.5)27 (25.7)32 (36.4)Obesity, n (%)38 (34.9)21 (20.0)22 (25.0)0.044Dyslipidemia, n (%)24 (22.0)22 (21.2)17 (19.3)0.896Hypertension, n (%)27 (24.8)28 (26.7)23 (26.1)0.746Diabetes mellitus, n (%)7 (6.4)1 (1.0)1 (1.1)0.031Polyautoimmunity, n (%)15 (13.8)43 (41)2 (2.2)<0.001MAS, n (%)1 (0.9)9 (8,6)0 (0.0)<0.001FH polyautoimmunity, n (%)19 (17.6)26 (24.8)15 (17.0)0.060

RA: rheumatoid arthritis; SLE: systemic lupus erithematosus; SD: standard desviation; MAS: multiple autoinmune syndrome; FH:Family history

Disclosure of Interests:

None declared

Effects of silymarin MZ-80 on hepatic oxidative stress in rats with biliary obstruction

This study was designed to evaluate the effects of three pharmaceutical forms of silymarin (silymarin MZ-80, silybinin-beta-cyclodextrin, and silybinin) on the liver oxidative status in vitro and after oral administration to rats with extrahepatic biliary obstruction (EBO) and sham-operated animals. We evaluated thiobarbituric acid-reactive substances (TBARS), glutathione (GSH + GSSG) and their related enzyme activities (GSH peroxidase, GSSG reductase and GSH transferase). All three compounds inhibited the in vitro production of TBARS (IC(50) 56-533 micromol/l). These compounds, mainly silymarin MZ-80, also increased GSH peroxidase and GSH transferase activities. In EBO rats we found increases in TBARS production which was inhibited by 50-70% after treatment. Glutathione was reduced by 55% and elevated by silymarin MZ-80. GSH transferase increased in the group given silymarin MZ-80. We conclude that all three derivatives of silymarin show a clear ability to reduce lipid peroxidation in the liver. Silymarin MZ-80 was the only compound that enhanced the glutathione antioxidant system.

Comparison of the cervical cytology test using the PAPNET method and conventional microscopy

From August 1994 to June 1995, laboratories in 28 Mexican states and the Federal District submitted a total of 10098 diagnosed Pap test slides to Mexico's National Institute of Epidemiologic Diagnosis and Reference (INDRE) for reexamination by conventional methods and also by the automated PAPNET system in Suffern, New York, U.S.A. The aim was to determine the degree of agreement obtained by these various methods. Most of the slides examined (at least 78%) yielded negative results or merely indicated an inflammatory process; 8% to 14% indicated mild or moderate cervical dysplasia; and 2% to 3% indicated conditions ranging from severe dysplasia to invasive cervical cancer. Comparison of the state laboratory and INDRE diagnoses yielded a Kappa correlation coefficient of 0.62, near the lower limit of agreement, the agreement being poorest in cases where it was necessary to distinguish between degrees of abnormality. Although state laboratory underestimation appeared lowest with respect to cases of atypia and of mild, moderate, and severe dysplasia (between 12% and 20%), these percentages are alarming because it is at these stages that the patient may be treated to prevent evolution to carcinoma. While the Kappa correlation coefficient was better (0.80) when the INDRE and PAPNET diagnoses were compared, PAPNET showed only limited ability to distinguish between various pathologic alterations, and the percentages of underestimates (false negatives) obtained with PAPNET were also high. Overall, the results indicate a need to improve the quality of cervical cytology diagnoses at state public health laboratories in Mexico through stepped-up training and supervision. They also indicate that the use of PAPNET involves greater difficulty than does manual microscopic examination of cervical smears, and that a way still needs to be found to detect and review the false negative results generated by PAPNET before approving use of this technology.