Prognostic nutritional index as an indicator for the development of bone fragility fracture in patients with rheumatoid arthritis

OBJECTIVES

The validity of prognostic nutritional index (PNI) as an index of incident bone fragility fracture (inc-BFF) in rheumatoid arthritis (RA) patients was investigated.

METHODS

RA patients whom continuously followed up for >3 years were picked up. Patients were classified in accordance with inc-BFF positivity (BFF+ and BFF-). Their clinical background including PNI was statistically examined for inc-BFF. The background factors were compared between the two groups. Patients were narrowed into subgroups according to the factor that showed a significant difference between the two groups, and they were statistically examined according to the PNI for the inc-BFF. The two groups were narrowed with propensity score matching and compared to the PNI.

RESULTS

A total of 278 patients with 44 BFF+ and 234 BFF- were recruited. In the background factors, the presence of prevalent BFF and the simplified disease activity index remission rate had a significantly higher risk ratio. In a subgroup who comorbid lifestyle-related diseases, PNI had a significantly higher risk ratio for the inc-BFF. After the propensity score matching, the PNI showed no significant difference between the two groups.

CONCLUSIONS

PNI is available when patients with RA comorbid lifestyle-related diseases. PNI is not an independent key for the inc-BFF in RA patients.

Investigation of treatment continuity, usefulness, and nocebo effect in switching from the original etanercept to its biosimilar in patients with rheumatoid arthritis: A JET observational study in Japanese clinical practice

OBJECTIVES

To assess the usefulness and onset of nocebo effects after switching from the original etanercept (ETN) to a biosimilar (BS) in routine clinical practice at rheumatology clinics in Japan (13 sites).

METHODS

A total of 165 patients (87.0% women, age = 57.88 ± 15.07 years, and disease duration = 10.32 ± 7.71 years), whose low disease activity was maintained with the original ETN for ≥12 weeks, and who agreed to switch treatment to its BS, were included. The end-points were disease activity score 28 (DAS28)-C-reactive protein and DAS28-erythrocyte sedimentation rate.

RESULTS

No significant difference was observed between the changes in DAS28-C-reactive protein and DAS28-erythrocyte sedimentation rate >12 weeks before switching and >12 weeks after switching (P = 0.132 and 0.334, respectively). The treatment continuation rate during the 52 weeks after switching to BS was 97.3%. During this period, BS was discontinued in only four patients, and no nocebo effects were suspected in these four patients.

CONCLUSION

Switching from ETN to BS was effective even in routine clinical practice at rheumatology clinics in Japan, and no nocebo effects were observed. Sufficient explanations to patients by rheumatologists and the additional payment for drug costs between patients at hospital visits effectively improved the continuation rate without any nocebo effect.

Pain score as a predictor of subsequent fragility fracture in postmenopausal patients with rheumatoid arthritis: A retrospective case-control study

Objectives

Bone fragility fracture (BFF) is a serious incident in treating rheumatoid arthritis (RA). We hypothesized that pain degree during treatment RA correlated with incident BFF and validated how pain affects incident BFF (inc-BFF).

Methods

Postmenopausal RA patients treated for at least 3 years were recruited. The primary endpoint was the development of inc-BFF. Follow-up began with the first bone mineral density measurement (baseline) and continued until the development of the first BFF or termination of the study. Clinical indicators at baseline, including pain score using a visual analog scale (PS-VAS), were analyzed statistically using Cox regression analysis, receiver operation characteristics (ROC), Kaplan-Meier survival curve analysis (K-M), and chi-square test.

Results

A total of 239 patients were recruited. Using a multivariate Cox regression analysis, the baseline's PS-VAS and prevalent BFF (pr-BFF) demonstrated significantly higher risk ratios. For ROC, pr-BFF and PS-VAS had significant cutoff index (COI) (positive, 21.0) and an area under-curve of 0.692 (P < 0.001) and 0.616 (P < 0.01), respectively. PS-VAS > COI had a 2.24-fold higher hazard ratio than PS-VAS ≤ COI using K-M. When these 2 conditions were combined, patients with pr-BFF-positive and PS-VAS-positive had a sensitivity of 42.3% and a specificity of 88.8% for the inc-BFF. PS-VAS > COI had no statistical significance in the subgroup without pr-BFF, whereas the existence of pr-BFF had a significantly higher risk ratio in the PS-VAS ≤ COI.

Conclusions

The PS-VAS during RA treatment is a good indicator for predicting the inc-BFF in postmenopausal RA patients with pr-BFF.

The impact of time length to Boolean remission for tight disease activity control after acquisition in rheumatoid arthritis patients

Clinical importance of time length from initiation under treat-to-target (T2T) strategy to acquisition of clinical remission (TL) in treating patients with rheumatoid arthritis (RA) on disease activity control, daily activities, and quality of life maintenance was investigated. In patients who achieved Boolean remission once or more, relationship between TL and patients' background data at initiation, and relationship between TL and mean simplified disease activity score (SDAI), Health Assessment Questionnaire Disability Index (HAQ-DI) score, pain score with visual analog scale (PS-VAS), Sharp/van der Heijde Score (SHS) and quality of life score (QOLS) at the first remission and thereafter were evaluated statistically. Patients were divided into two groups whether TL was within 6 months or longer (G ≤ 6 and G > 6). Change of the parameters and Boolean remission rate (BRR) after the first remission between the two groups were compared statistically. In 465 patients, TL correlated significantly with the SDAI score, the HAQ score, PS-VAS, SHS, and the QOLS after the remission. The SDAI score and the BRR after the remission were significantly better in the G ≤ 6 than in the G > 6. TL is an important key to guarantee good and stable clinical course in treating under T2T.

Clinical significance of serum cystatin C-to-creatinine ratio as a surrogate marker for incident osteoporotic fracture predictions

Background

Detection of appropriate indicators is valuable for preventing incidental osteoporotic fractures. We statistically evaluated the significance of serum cystatin C-to-creatinine ratio (CysC/Cr) as a surrogate marker for incident major osteoporotic fractures (MOF) prediction.

Methods

Eligible patients with simultaneous measurement of CysC/Cr and bone mineral density in the lumbar spine and proximal femur were selected, and their fracture histories until 5 years after baseline were observed in the retrospective area cohort data. Patients who were followed up until termination or the first osteoporotic fracture were included, and loss of follow-up or death was excluded. Candidate risk factors for osteoporotic fractures were tested for risk ratios using a cox regression analysis. Receiver operating characteristic tests were performed on factors with significantly higher risk ratios and evaluated with Kaplan-Meier survival analysis to determine the hazard ratios of the factors.

Results

A total of 175 patients of whom 28 had incident MOF, 38 men, and 137 women, were enrolled. The mean age was 70.2 years. A significantly higher risk ratio was shown in the presence of prevalent MOF, hyper fall-ability, lifestyle-related diseases, chronic kidney diseases ≥ Grade3a, and higher CysC/Cr. All parameters had cutoff indices and showed significantly higher hazard ratios.

Conclusions

These results suggested that CysC/Cr may be a predictive marker of incident osteoporotic fractures. It might work as a screening tool for MOF risk.

Associations between clinical metrics of joint deformity, disease duration, disease activity, functional capacity, quality of life, pain, and fatigue in patients with rheumatoid arthritis

OBJECTIVES

Aim of this study is to clarify associations between metrics of patient's clinical status statistically using retrospective cohort data.

METHODS

Patients with RA who were followed up more than 3 years were recruited. Their EuroQol-5th dimension (EQ5D) as an index of quality of life (QOL), Health Assessment Questionnaire Disability Index (HAQ) as an index of functional capacity (FC), simplified disease activity index (SDAI), pain score using visual analog scale (PS-VAS), and fatigue score using visual analog scale (FS-VAS) were monitored every three months. Sharp/van der Heijde score (SHS) was calculated annually. Associations between average values of these factors at beginning of follow-up (baseline) and change from baseline to final year in follow-up (change), and patient's sex, age, and disease duration (DD) were evaluated statistically.

RESULTS

A total of 447 patients were analyzed. EQ5D score correlated significantly with HAQ score both at baseline and change of that, and FS-VAS. HAQ score correlated significantly with EQ5D and HAQ score at baseline. SDAI score correlated significantly with SHS and FS-VAS at baseline. SHS correlated significantly with the SHS at baseline. PS-VAS correlated significantly with the PS-VAS, EQ5D at baseline, change of theEQ5D and HAQ scores. FS-VAS correlated significantly with change of the EQ5D score and FS-VAS at baseline.

CONCLUSIONS

These results suggested that these clinical metrics are influenced by each variable at baseline. QOL and fatigue are correlated each other, as well as QOL and FC, whereas disease activity correlated with joint deformity level and fatigue. Key Points • It is questionable whether improvement of disease activity leads to improvements in functional capacity and QOL in treating rheumatoid arthritis. • We evaluated the association among metrics of clinical outcomes, such as EQ5D, HAQ, SDAI, SHS, pain score, and fatigue score using retrospective cohort data. • Results suggested that metrics are influenced by each items at baseline, and QOL and fatigue are correlated each other, as well as QOL and functional capacity.

Clinical Advantage of Attaining Index-Based Remission Prior to Composite Remission in Treating Rheumatoid Arthritis

BACKGROUND AND OBJECTIVES

The clinical advantage of targeting index-based remission prior to Boolean remission was evaluated retrospectively.

MATERIALS AND METHODS

A total of 578 patients with rheumatoid arthritis (RA), who were treated for more than three years, were recruited. Patients who were treated to targeted index-based remission and composite measure remission criteria such as Boolean remission from the first consultation were divided according to the turn of attaining Boolean remission and index-based remission: G-IBR, a group that matched index-based remission at the same time Boolean remission is attained or earlier; G-BR_IF, a group that attained Boolean remission followed by index-based remission or failed; G-IR_BF, a group that could not attain Boolean remission despite attaining index-based remission; G-BothF, a group that failed to attain either Boolean remission or index-based remission. Background factors were statistically compared among groups. The Boolean remission rate in patients who attained index-based remission (BRR) and the rate of failure to attain index-based remission in patients who failed to attain Boolean remission (BFR) were statistically evaluated.

RESULTS

Groups comprising 225, 231, and 482 in G-IBR; 160, 154, and 8 in G-BR_IF; 18, 18, and 75 in G-IR_BF; and 175, 175, and 13 in G-BothF when indexing the clinical disease activity index (CDAI), simplified disease activity index (SDAI), and 28-joints disease activity score with C-reactive protein (DAS28-CRP), respectively. Disease activity indices' scores after Boolean remission were demonstrated to be significantly higher in the G-BR_IF group than in the G-IBR group. BRR was 92.6%, 92.8%, and 86.5%, while BFR was 71.3%, 71.3%, and 13.8% when indexing CDAI, SDAI, and DAS28-CRP, respectively.

CONCLUSIONS

Targeting CDAI and SDAI remission prior to Boolean remission contributes to a stable clinical course.

AB0158 PREDICT OF PROGNOSIS AT ONE YEAR AFTER THE ADMINISTRATION WITH b/tsDMARD FOR PATIENT WITH DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS

Background

Patients with difficult-to-treat rheumatoid arthritis (D2T RA) are the most serious problem in recent systemic RA treatment protocols [1].

Objectives

Prognosis after biologic or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) is beneficial when predicted in patients with D2T RA. Predictors of post b/tsDMARDs in D2T RA patients were investigated using retrospective cohort data.

Methods

RA patients more than 1 year after the start of newly administered b/tsDMARDs were recruited. The patients were divided into two groups according to the EULAR definition of D2T RA [2]. Patients who met the criteria were classified into the D2T RA group and others into the non-D2T RA group. The incidence of the clinical features described in the criteria of D2T RA and the rheumatoid disease comorbidity index (RDCI) [3] were compared between the two groups at the time of drug initiation (baseline). The primary endpoint was “Success or Failure” 1 year after baseline. Success was defined as b/tsDMARD persisted in remission as the 28 joint disease activity score with erythrocyte sedimentation rate (DAS28) ≤ 2.6, or as b/tsDMARD was discontinued upon achieving clinical remission. The Failure was defined as other decisions such as discontinuation due to failure, adverse events, or characteristic patient problems. In the discontinued cases, the monitoring value at the last observation was carried forward to 1 year.

Cox regression analysis was used to assess each variant as a potential risk factor for Failure. Receiver operating characteristic analysis (ROC) was tested on variants with significantly higher risk ratios, and Kaplan-Meier survival analysis was also tested for cut-off indices.

Results

71 cases of the D2T RA and 259 cases of the non-D2T RA group were analyzed. As shown in Table 1, the clinical characteristics of the D2T RA group were significantly worse than those of the non-D2T RA group.

Higher DAS28 had a significantly higher risk ratio for the Failure from month 3 in the D2T RA group, whereas from baseline in the non-D2T RA group (Figure 1-A). Other factors in the D2T RA group at and after baseline listed in the Table 1 had no significant risk ratios. PS-VAS and EQ5D score had significant higher risk ratios in the non-D2T RA group using univariate models, however, only DAS28 had significant higher risk ratio using multivariate model. The cut-off index (COI) and the area under the curve (AUC) using ROC for each observational period in the two groups were shown in Figure 1-B. Results of Kaplan-Meier survival analyses were shown in Figure 1-C. Hazard ratios of DAS28 > COI exceeded 2.5 even from months 3 with high sensitivity (p < 0.001) in the D2T RA group.

Conclusion

These results indicated that higher DAS 28 suggested a failure prognosis at 12 months after initiation in D2T RA and non-D2T RA patients. Even in patients with D2T RA, strict disease activity control is most important for prognostic management, with 1-year prognosis predictable in the first 3 months. However, this study is a short-term prognostic predictor, and accumulation of short-term predictions is a long-term predictor.

References

[1]Roodenrijs NMT, et al. Rheumatology (Oxford) 2021;60:3778-3788. doi:10.1093/rheumatology/keaa860

[2]Nagy G, et al. Ann Rheum Dis 2021;80:31-35.

[3]England BR, et al. Arthritis Care Res 2015;67:865-872. doi: 10.1002/acr22456.

Disclosure of Interests

None declared

AB1007 CLINICAL SIGNIFICANCE OF SERUM CREATININE-TO-CYSTATIN C RATIO AS A SURROGATE MARKER FOR INCIDENT OSTEOPOROTIC FRACTURE

Background

In a previous article, we introduced a novel index of osteoporosis that represented as T-score ≤ -2.5, which constituted the combined criteria of age, serum creatinine-to-cystatin C ratio (Cr/CysC), and tartrate-resistant acid phosphatase-5b.

Objectives

We hypothesized that serum cystine C to creatine ratio (CysC/Cr), that is the reciprocal of Cr/CysC, might function as a predictive marker of incident osteoporotic fractures in elderly population and tested this hypothesis in a retrospective cohort study.

Methods

Subjects were 50 years of age or older who had their lumbar spine and femoral neck bone mineral density (BMD) measured by dual-energy X-ray absorptiometry, and simultaneously had their CysC/Cr measured. The dates of BMD and CysC/Cr measurements were set as baseline. The primary outcomes were incidental major osteoporotic fractures (MOF), including vertebral fractures, proximal femur fractures, proximal humerus fractures, and distal radius fractures. Follow-up was continued until the first fracture occurred, was terminated at death, was lost to follow-up, or was completed. In these patients, the relationship between baseline developmental MOF and variants was investigated using Cox regression analysis. The variants were candidate risk factors for MOF for positivity and negativity. After identifying risk factors using univariate models, multivariate model was undergone in order to relative higher risk in the factors. Receivers operating characteristic analyses (ROC) were conducted in order to determine cut-off index (COI) of these factors. Kaplan-Meier survival analysis was tested in order to determine hazard ratio for presenting these risk factors.

Results

A total of 175 patients, 38 men and 137 women, were included in the dataset. The mean age at baseline was 70.2 years, ranged from 50 to 98 years, and the mean follow-up was 30.4 months. Mean BMD at baseline was 0.734 and 0.659 g/cm2 (T-score: -2.21 and -2.04) in lumbar spine and femoral neck, respectively, and mean CysC/Cr at baseline was 1.49. fall-ability, LSD, and pr-MOF, were present in, 59, 113, and 77, respectively. Administration of OPD, vitamin-D, GCS, and polypharmacy were present in 92, 170, 12, and 47, respectively (Table 1).

Table 1.

Results of receiver operation characteristics and Kaplan-Meier survival analysis for each factor

Factorcut-off indexarea under the curvep-valueHazard ratio (95%CI)p-valueCysC/Cr> 1.3450.614< 0.016.32 (2.87 – 13.92)< 0.01LSDpresent0.626< 0.013.60 (1.67 – 7.73)< 0.05Fall-abilitypresent0.703< 0.0014.83 (2.16 – 10.21)< 0.001CKDpresent0.612< 0.052.56 (1.06 – 6.20)< 0.05pr-MOFpresent0.685< 0.0014.81 (2.08 – 9.39)< 0.001

In Cox regression analysis, the presence of prevalent MOF (pr-MOF), fall-ability, lifestyle-related diseases (LSD), chronic kidney diseases (CKD) ≥ Grade3a, and higher CysC/Cr had significant higher risk ratios with univariate models. In these, the presence of LSD and fall-ability had significant higher risk ratios with multivariate model. All the binary factors had COI as the presence of each event such with 0.626, 0.703, 0.612, and 0.685 of area under the curve for LSD, Fall-ability, CKD, and pr-MOF, respectively. CysC/Cr also had COI (1.345) with 0.614 of the area under the curve.

In the Kaplan-Meier survival analysis, CysC/Cr > COI, Fall-ability, pr-MOF, LSD, CKD ≥ Grade 3 b was significantly higher in descending order of Hazard ratio (6.32, 4.83, 4.81, 3.60, 2.56, respectively) (Table 1).

Conclusion

These results suggest that CysC/Cr may be a predictor of MOF or a risk factor if it exceeds the COI. This value is the reciprocal of Cr/CysC, and if Cr/CysC reflects muscle mass, CysC/Cr is assumed to reflect low relative muscle mass. It is supposed that this is also affected by sex difference and age. There seems to be a correlation between MOF and CysC/Cr. Early measurement of CysC/Cr facilitates screening for fractures. As a result, it may be easier to implement fracture prevention programs such as drug interventions such as OPD and exercise habit guidance.

Disclosure of Interests

None declared

POS0554 CLINICAL CHARACTERISTICS OF PATIENTS WITH RHEUMATOID ARTHRITIS IN PRE-DIFFICULT-TO-TREAT STATUS

Background

Patients with rheumatoid arthritis (RA) who have a difficult-to-treat condition (D2T RA) are often a burden to both patients and rheumatologists.

Objectives

The aim of this study was to determine the risk factors for failure to treat in patients with refractory conditions and to find them relevant to prevention.

Methods

Patients with RA who were treated under treat-to-target (T2T) strategy more than one year were picked up. Their background characteristics such as sex, age, disease duration, anti-citrullinated polypeptide antibodies titer (ACPA), and disease duration, were collected, and their simplified disease activity index (SDAI) score, Health Assessment Questionnaire Disability Index (HAQ) score, pain score measured with visual analog scale (PS), EuroQol 5th-dimensions score (EQ5D) were monitored every three months. Sharp/van der Heijde score (SHS) was calculated annually.

Difficult-to-treat status was determined in according to the EULAR definition of D2T RA [1], and pre-D2T RA status was determined as follows: (Category-1) a failure history of one kind of action in biologic or targeted synthetic disease modifying anti-rheumatic drug (b/tsDMARD) and switched to another b/tsDMARD with other action mechanism or (Category-2) one or more of following status; mean SDAI score in recent three months exceeded 11 (MDA), three consecutive administration of glucocorticoid steroid no less than 7.5mg in prednisolone equivalent (GCS), rapid radiographic progression with 5 or more in SHS than last time (RRP), or decrease of EQ5D score less than -0.2 in recent 6 months (dEQ5D). Patients were recruited when Category-1 or -2 was matched in treating, and their results were determined in the last observation for each category. When second d/tsDMARD was failed until last observation in patient matched Category-1, the patient was judged as “failure”, and the other patient was judged as “success”. When Category-2 continued until last observation, the patient was judged as “failure”, and escaped from the category, the patient was judged as “success”. Risk factors for failure in background characteristics and monitored items in treating were evaluated for each category using binary logistic regression analysis.

Results

A total of 47 in Category-1 and 491 patients in Category-2 were recruited.

In Category-1 matched patients, female were 83.0% and mean age was 71.3. Mean SDAI score, HAQ score, PS, EQ5D score, and SHS at failure of b/tsDMARD (baseline) were 15.5, 0.457, 40.1, 0.811, and 72.9, respectively. Numbers of the first b/tsDMARD were 32 TNF inhibitors, 8 IL-6 inhibitors, 6 abatacepts, and 1 JAK inhibitor. Numbers of the second after the first were 13 IL-6 inhibitors and 19 JAK inhibitors after THF inhibitor, whereas 3 TNF inhibitors, 2 abatacepts, and 3 JAK inhibitors after IL-6 inhibitor failure, 1 TNF inhibitor, 1 IL-6 inhibitor, and 4 JAK inhibitors after abatacept failure, and 1 TNF inhibitor after 1 JAK inhibitor failure. In these, success counted 18 and failure counted 29. Significant risk factors for Category-1 failure were higher ACPA, higher SDAI score, higher HAQ score, and higher SHS at baseline (p<0.05). There was no significant difference between drugs.

In Category-2 matched patients, numbers of each status at first (baseline) were 455 MDAs, 20 GCSs, 17 RRPs, and 9 dEQ5Ds. Numbers in success and failure for each status at baseline were 315 and 140 for MDA, 16 and 4 for GCS, 9 and 0 for RRP, and 7 and 2 for dEQ5D, respectively. Significant risk factors for each failure status were higher mean SDAI score after baseline for MDA, higher HAQ score at baseline for GCS, and higher mean PS after baseline for dEQ5D (p<0.01).

Conclusion

Clinical background factors besides disease activity such as ACPA, HAQ score, and SHS at baseline were important for preventing fall-in D2T_RA. However, most weighted factor was disease activity control after falling in MDA status. Tight disease activity control is the overriding factor.

References

[1]Nagy G, et al. Ann Rheum Dis 2021;80:31-5.

Disclosure of Interests

None declared.

AB0383 COMPARISON OF EFFICACY AND SAFETY IN JAK INHIBITOR DUE TO A DIFFERENCE OF SELECTIVITY – TOFACITINIB vs. BARICITINIB –

Background

Each Janus Kinase Inhibitor (JAK-i) has different selectivity of JAKs, such as JAK1, JAK2, JAK3, and TIK2. However, little has been known regarding mode of action due to the selectivity difference in clinical practice for treating rheumatoid arthritis (RA).

Objectives

The aim of this study is to compare difference of efficacy and safety in two JAK-i; between tofacitinib (TOF) and baricitinib (BAR) in clinical practice using one-center retrospective cohort.

Methods

Within the case which administered TOF or BAR to the RA patient who the effect was insufficient in the existing treatment and the disease activity was over the middle disease activity using simplified disease activity index (SDAI). At the start of administration (baseline), 5 mg tablets of TOF were taken twice a day or 4 mg tablets of BAR were taken one a day. Patients were divided by drug and included their sex, age at onset, anti-cyclic citrullinated polypeptide antibodies (ACPA) titer, length of RA history at onset, Sharp/van der Heijde score (SHS) at onset, Naïve/Not Naive for biologic DMARDs or JAK-i, 28-joints disease activity score (DAS28), SDAI, Health Assessment Questionnaire Disability Index (HAQ-DI), and pain score with visual analog scale (PS-VAS). It was classified into large joint and small joint, and the point was independently scored by swelling and pressure pain by size and position in each joint. Total score of the involved joints for each part; upper-extremities, lower extremities, big joints, and small joints (UES/LES/BJS/SJS), rheumatoid factor (RF) titer, serum matrix metalloprotease-3 (MMP-3) level, serum creatinine (Cr) level, and estimated glomerular filtration rate (eGFR) of each part were measured. The mean values of each group were obtained at baseline, 1, 2, 3, 6, 9, and 12 months, and the two groups were statistically compared using the Mann-Whitney U-test. As a sub-analysis, each drug group was divided into bio or JAK-i naive, age ≥ 70 years, disease duration ≥ 10 years, SHS ≥ 100. The change of DAS28 under each 2 divided condition was compared using Mann-Whitney U-test. Similar comparison was carried out with RA patient who administered golimumab (GOL) as a control group. The significance level was less than 5%.

Continuation rate (the withdrawal after the remission introduction is put in the continuation) in 12 months after baseline was also compared.

Results

A total of 82 patients were picked up, in whom 22 TOF group, 31 BAR group, and 29 GOL group included. Both DAS28 and SDAI were consistently lower in the BAR than in the other 2 groups from 1 month after baseline. SDAI in the BAR was significantly lower than in the GOL at 3 months after the baseline. The HAQ-DI score at 6 months after baseline was significantly lower in the BAR than in the GOL. PS-VAS in the GOL was significantly higher than the other two groups at 2, 3 and 6 months after baseline. In the joint point, BJS in the BAR was significantly lower than that in the GOL at 2, 3, and 6 month after baseline. SJS in the GOL was significantly lower than that in the TOF at 6 and 12 months after baseline. There was no significant difference in MMP -3, RF, Cr and eGFR between the 3 groups in any observation month, but Cr increased after the start in the BAR group and eGFR tended to decrease.

In the sub-analysis, the decrease of DAS28 at 1 year after baseline with a history of ≥ 10 years was significantly greater than in those with a history of < 10 years in the TOF, as well as DAS28 at 1 year in those with SHS ≥ 100 decreased significantly more than that in those < 100. These phenomena was not observed in the BAR group.

The continuation rate at 12 months after the start of administration was 86.4% in the TOF, 89.3% in the BAR and 69.0% in the GOL.

Conclusion

Even JAK-i characteristics in action differs for each drug. It is needed to choose appropriate drug based on these drug characteristics.

Disclosure of Interests

None declared

AB0236 PRESENCE OF ANTI-CITRULLINATED POLYPEPTIDE ANTIBODIES DECREASES BONE MINERAL DENSITY IN BODY OF PATIENT WITH RHEUMATOID ARTHRITIS: A RETROSPECTIVE COHORT STUDY

Background

Presence of anti-citrullinated polypeptide antibodies (ACPA) is one risk factor of bone erosion of the joint in patients with rheumatoid arthritis (RA). However, bone absorption in the whole body is still not clarified in a longitudinal study.

Objectives

The aim of this study is to clarify effects of ACPA on bone mineral density (BMD) decrease using dual-energy X-ray absorptiometry (DXA) in patient with RA using retrospective longitudinal cohort study.

Methods

Patient with RA who were measured BMD in lumbar spine (LS) and total hip (TH) using dual-energy X-ray absorptiometry (DXA) at first consultation (baseline) and were treated for more than five years, were recruited. Follow-up started at BMD measurement and continued until the development of the first fracture or censoring at death, loss to follow-up or end of the study. Every patients have been followed up with monitoring of SDAI and Health Assessment Questionnaire Disability Index (HAQ) at every another to three months. Sharp/van der Heijde Score (SHS) was measured at baseline and every another year thereafter. BMD were measured every six months. Relationship between BMD and candidate risk factors including ACPA positivity and serum titer level, and other variants for BMD loss were evaluated statistically using linear regression analysis. Evaluations were performed for the absolute value of BMD and Z-score at baseline, mean value of these during follow-up, and change from baseline. Change of Z-score during follow-up was also compared between groups what classified according to ACPA positivity (ACPA positive/negative group).

Results

A total of 222 patients were recruited including 17 male (7.7%) and 205 female (92.3%). The mean age of the patients was 69.2 years old. Mean disease duration at baseline and follow-up length after baseline were 6.4 and 63.3 months, respectively. Mean SDAI score, HAQ score and SHS at baseline were 22.2, 0.516, and 6.6, respectively. The mean ACPA level and positive rate were 202.1 and 77.5%, respectively.

Higher ACPA titer level correlated significantly low BMD and Z-score in TH (p<0.05), whereas ACPA positivity significantly correlated with low Z-score in LS and TH during follow-up using univariate models (p<0.05). The ACPA positivity also correlated with decrease of Z-score in both LS and TH using univariate models (p<0.05), whereas no significant correlation demonstrated using multivariate model.

Change of Z-score in the ACPA positive group was significantly lower than in the ACPA negative group despite no significant difference of disease activity between the two groups demonstrated (p<0.05) (Table 1).

Table 1.

Comparison of the two groups

parametersACPA-positive (n=172)ACPA-negative (n=50)p-valuefemale (%)91.396.50.10at baselineage (year-old)65.471.3<0.001disease duration (months)7.74.6<0.001RF (IU/L)138.3 (197.1)21.5 (49.3)<0.001SDAI26.3 (24.0)21.0 (17.8)<0.05HAQ0.496 (0.618)0.553 (0.639)0.48SHS8.4 (8.2)3.5 (5.0)<0.001BMD in LS (g/cm2)0.825 (0.167)0.849 (0.156)0.23BMD in H (g/cm2)0.700 (0.140)0.710 (0.132)0.75Z-score in LS-0.246 (1.300)0.123 (1.392)<0.05Z-score in TH-0.062 (1.034)0.261 (1.020)<0.05at follow-upfollow-up length (months)64.865.40.65SDAI4.5 (3.1)5.1 (4.4)0.22HAQ0.495 (0.616)0.516 (0.544)0.32SHS8.1 (8.2)3.4 (4.8)<0.001BMD in LS (g/cm2)0.839 (0.171)0.870 (0.165)0.16BMD in TH (g/cm2)0.710 (0.118)0.713 (0.115)0.99Z-score in LS-0.008 (1.361)0.368 (1.426)<0.05Z-score in TH0.129 (0.902)0.396 (0.891)0.11anti-osteoporotic drug administered, ever (%)73.469.80.72GCS administered, ever (%)35.832.90.68

The values are presented as mean (SD) unless indicated otherwise.

Statistically significant within 0.05 are shown as bold styles.

Conclusion

Presence of ACPA potentially have an independent risk of BMD decrease. Its action affects regardless gender and age.

Disclosure of Interests

None declared

AB0243 ASSOCIATIONS BETWEEN JOINT DEFORMITY, DISEASE DURATION, DISEASE ACTIVITY, ACTIVITIES OF DAILY LIVING, QUALITY OF LIFE, PAIN, AND FATIGUE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Patient with rheumatoid arthritis (RA) have disease-related problems such as joint deformity, disease duration, disease activity, activities in daily life (ADL), quality of life, pain, and fatigue. All these problems correlate interactively.

Objectives

Aim of this study is to clarify association among these problems statistically using retrospective cohort data.

Methods

Patients with RA who were followed up more than three years were recruited. Their EuroQol-5th dimension (EQ5D) as an indicator of quality of life (QOL), simplified disease activity index (SDAI) as an indicator of disease activity, Health Assessment Questionnaire Disability Index (HAQ) as an indicator of ADL, pain score using visual analog scale (PS-VAS), and fatigue score using visual analog scale (FS-VAS), were monitored every three months. Sharp/van der Heijde score (SHS) as an indicator of joint deformity was calculated annually. Association among average values of these factors and patient’s sex, age, disease duration (DD), and anti-citrullinated polypeptide antibodies (ACPA) titer were evaluated using multivariate linear regression analysis. Statistical significance was set within 5%.

Results

A total of 447 patients, in whom 120 male and 327 female included, were analyzed. Mean age, disease duration, EQ5D score, SDAI score, HAQ score, SHS, PS-VAS, and FS-VAS during follow-up were 71.6-year-old, 12.9 years, 0.831, 4.26, 0.413, 46.9, 22.5, and 23.2, respectively.

EQ5D score correlated significantly with age, HAQ score, SDAI score, SHS, PS-VAS, FS-VAS, and DD using univariate models. In these, age, HAQ score, and FS-VAS correlated significantly using multivariate model (correlation coefficients (CC): 0.927). HAQ score correlated significantly with age, EQ5D score, SDAI score, SHS, PS-VAS, FS-VAS, and DD using univariate models. In these, EQ5D score, SHS, and FS-VAS correlated significantly using multivariate model (CC: 0.910). SDAI score correlated significantly with female gender, EQ5D score, HAQ score, SHS, PS-VAS, and FS-VAS using univariate models. In these, SHS and PS-VAS correlated significantly using multivariate model (CC: 0.620). SHS correlated significantly with age, female gender, EQ5D score, HAQ score, SDAI score, PS-VAS, and DD using univariate models. In these, HAQ score, SDAI score, and DD correlated significantly using multivariate model (CC: 0.685). PS-VAS correlated significantly with EQ5D, HAQ score, SDAI score, SHS, and FS-VAS using univariate models. In these, SDAI score and FS-VAS correlated significantly using multivariate model (CC: 0.732). FS-VAS correlated significantly with EQ5D score, HAQ score, SDAI score, and PS-VAS using univariate models. In these, EQ5D score, HAQ score, and PS-VAS correlated significantly using multivariate model (CC: 0.715). ACPA did not correlated with any factors significantly.

Conclusion

These results suggested that EQ5D score, namely QOL is influenced by various disease-related factors and aging, especially correlated with ADL and fatigue closely. The HAQ score, namely ADL level is influenced by fatigue level and joint deformity directly. The SDAI score, namely disease activity level correlated with pain level and joint deformity level, and correlates with the other factors indirectly. A schematic figure that represents relationships among factors were shown in Figure 1. These information would beneficial for conducting treatment protocol of RA.

Disclosure of Interests

None declared

Validity and risk of adopting PGA ≤ 2 as a remission criteria of Boolean in clinical practice in patient with rheumatoid arthritis

Validity and risk of setting patient's global assessment (PGA) ≤ 2 as a Boolean remission criteria substituting PGA ≤ 1 in treating rheumatoid arthritis (RA) was investigated. Patients were recruited from an area cohort, of whom attained Boolean remission (Boolean-1) or near remission with PGA ≤ 2 and the rest components were ≤ 1 (Boolean-2). Simplified disease activity index (SDAI) score was compared according to the criteria variations. A total of 517 patients were studied. Mean SDAI score of patients with Boolean-1 was significantly lower than that of patients with Boolean-2 at acquisition. The trend was evident in the patients who attained Boolean-1 remission. Mean SDAI score at acquisition, 6 months after, and 1 year after of patients who attained Boolean-2 first and then Boolean-1, was significantly inferior to that of patients who attained the remissions at the same time. The mean SDAI score at month 6 in the Boolean-2 was not SDAI remission at all. We concluded that setting PGA ≤ 2 as a remission criteria may not have statistical difference in disease activity from PGA ≤ 1, however, there was an determinant risk to misread that includes patient who losses clinical remission after acquisition.

Musculoskeletal ambulation disability symptom complex as a risk factor of incident bone fragility fracture

Objectives

Influence of presenting musculoskeletal ambulation disability symptom complex (MADS) on occurrence of bone fragility fracture (BFF) is investigated with retrospective cohort study.

Methods

A total of 931 subjects joined in the study. Subjects were selected as bone fragility risk positive in the fracture assessment tool questionnaire. Their assumed risk factors were harvested from the medical records and X-ray pictures. They were followed up at least 8 years consecutively, and occurrence of incident BFF was set as primary endpoint. Each assumed risk factor including MADS was evaluated using Cox regression analysis. Subjects were divided into 2 groups according to presence of MADS (G-MADS and G-noMADS). Adjusted hazard ratios between the 2 groups was evaluated using Cox regression analysis. The statistical procedures were performed before and after propensity score matching (PSM) procedures in order to make parallel with assumed risk factors.

Results

Statistically significant risk factors within 5% were prevalent vertebral body fracture, disuse, MADS, cognitive disorder, hypertension, contracture, Parkinsonism, being female sex, hyperlipidemia, insomnia, T-score in the femoral neck ≤ −2.3, chronic kidney disease ≥ stage 2, chronic obstructive pulmonary diseases, glucocorticoid steroid administrated, and osteoarthritis in order of the adjusted hazard ratios (from highest to lowest). Adjusted hazard ratios between G-MADS and G-noMADS were 2.70 and 1.83 for before and after PSM, respectively.

Conclusions

MADS demonstrated as a significant risk factor of BFF occurrence. In treating osteoporosis, fall risk should be aware of as well as bone fragility risk.

POS0439 THE INFLUENCE OF ESCALATED PGA SCORE ON DISEASE ACTIVITY, DAILY ACTIVITY, AND QUALITY OF LIFE, AND SOLUTION FOR OPTIMAL PGA LEVEL THAT DESERVES CLINICAL REMISSION IN PATIENT WITH RHEUMATOID ARTHRITIS

Background:

Patient’s global assessment (PGA) is one most difficult component as a part of disease activity index for treatment of rheumatoid arthritis (RA), that often causes an obstacle to attaining clinical remission. Moreover, PGA level affects activities in daily living.

Objectives:

The influence of escalated PGA score on disease activity, daily activity, and quality of life for patient with RA was investigated., and the optimal PGA level for both disease activity and daily activities was investigated from real world data.

Methods:

A total of 24,075 times of monitoring for RA was performed in the institute. Monitored items included TJC, SJC, PGA, EGA, CRP, and calculated values of DAS28, CDAI, SDAI, composite index of Boolean evaluation (Boolean), pain score with visual analog scale (PS-VAS), Health Assessment Questionnaire Disability Index (HAQ-DI), and quality of life score (QOLS) calculated from Euro-QOL questionnaire with 5th dimensions. Each measured item was calculated as mean value according to the PGA score, which was measured at the same time. The PGA score was classified by one increment from zero to ten. The mean values of DAS28, CDAI, SDAI, remission rate of these indices and Boolean remission rate, and mean values of PS-VAS, HAQ-DI, and QOLS were statistically evaluated.

HAQ-DI below 0.5 was determined as remission (HAQ remission). Sensitivity and specificity regarding attaining HAQ remission according to each level of PGA score were calculated, and cutoff index (COI) was determined with receiver operating characteristic (ROC) curve. For PS-VAS, sensitivity and specificity of Boolean remission regarding each level of PS-VAS after classification divided by one increment was calculated, and comparable level (PS-VAS remission) was determined with reference of the curve. ROC was performed according to PGA level, and COI was determined with a same manner.

Results:

Number of measures counted 10428, 3099, 3110, 2346, 998, 1773, 751, 703, 655, 139, and 73 for each PGA level. PGA level from 3 to 5, and 5 to 10 were put together for number adjusting.

Mean DAS28, CDAI, and SDAI demonstrated significant increase as PGA level increased, and remission rate of the all indices including Boolean demonstrated significant decrease as PGA level increases (p<0.01%). Boolean remission rate demonstrated zero percent from two, and CDAI and SDAI remission rate demonstrated zero from five, whereas DAS remission rate showed gradual decrease then zero percent was not shown in any level. Mean value of PS-VAS and HAQ-DI score demonstrated also significant decrease as PGA level increases, and QOLS demonstrated significant decrease as PGA level increases (p<0.01%). Increase of HAQ-DI score and decline of QOLS demonstrated more steep from PGA level 3, whereas no significant difference demonstrated from zero to one.

HAQ remission counted 15,703, whereas no HAQ remission counted 8,335. Using ROC, COI of the PGA level was 2.0, whereas sensitivity and specificity were 63.4% and 66.3%, respectively. The estimated PS-VAS remission level was 10mm. Optimal PGA level for PS-VAS remission was set as 1.0, and sensitivity and specificity regarding PS-VAS remission were 87.1% and 71.3%, respectively.

Conclusion:

Increase of PGA affects daily activities and quality of life. The evident level that increases deterioration risk significantly was supposed to be from 3. Optimal level of PGA score for attaining the PS-VAS remission was 1.0, whereas the optimal PGA level for HAQ-DI remission is 1.0, despite sensitivity and specificity for the HAQ remission were lower than these for the PS-VAS remission.

Disclosure of Interests:

None declared

AB0100 EVALUATION OF PGA LEVEL FOR CLINICAL REMISSION WITH BOOLEAN CRITERIA, 10MM OR 20MM?

Background:

Patient’s global assessment (PGA) is one important component of Boolean composite criteria for remission in treat with rheumatoid arthritis (RA). However, PGA no more than 10mm is sometimes obstacle to attain clinical remission. In recent few years, one opinion that PGA no more than 20mm may be comparable as no more than 10mm.

Objectives:

The aim of this study is to analyze how difference of these PGA level affect disease activity and daily activities in living, and evaluate which is optimal for the remission with Boolean remission criteria from real world setting.

Methods:

RA patients who were followed up for more than three years in the institute were picked up in the study. Each patient was monitored with tenderness joint count (TJC), swollen joint count (SJC), PGA, evaluator’s global assessment (EGA), serum C-reactive protein level (CRP), calculated disease activity score with simplified disease activity index(SDAI), Health Assessment Questionnaire Disability Index (HAQ-DI), and pain score using visual analog scale (PS-VAS) every consulted time from the first encounter (Baseline). Patients were classified according to achievement of Boolean remission criteria. Group 1: a patient group who attained Boolean remission wih TJC≦1, SJC≦1, CRP≦1mg/dl, and PGA≦1 (G-1), Group 2: a patient group who could not attained the Boolean remission used in the G-1 evaluation, but could attained another Boolean remission with TJC≦1, SJC≦1, CRP≦1mg/dl, and PGA≦2 (G-2), and Group 3: a patient group who could not attain Boolean remission for neither criterion.

Mean values of measured parameters at Baseline and after the Baseline were compared statistically with Student T-test. Mean values of the same parameters in the G-1 and G-2 at the time of attain Boolean remission for each criteria, mean values of each of these parameters thereafter, and changes of these parameters were compared statistically with Student T-test.

Results:

A total of 438 patients 385 in the G-1 group, 16 in the G-2 group, and 37 in the G-3 group, were recruited. In parameters at Baseline, level of TJC, SJC, PGA, EGA, SDAI, and HAQ-DI in the G-1 was significantly lower than in the G-3, whereas no significant differences in any parameters demonstrated between in the G-2 and G-3. Level of HAQ-DI, and PS-VAS after Baseline in the G-1 was lower than in the G-3, whereas no significant difference of these parameters after Baseline demonstrated between in the G-2 and G-3. TJC, SJC, PGA, and EGA demonstrated significant less level in the G-1 than in the other two groups. The mean SDAI score at the time of first achievement of Boolean remission in the G-1 and G-2 were 1.08 and 2.57, respectively. The mean value of SDAI score after remission in the G-1 and G-2 were 3.35 and 6.44, respectively. These values and PS-VAS including change of the SDAI score demonstrated significant difference between the two groups (p<0.01), whereas HAQ-DI in the two groups demonstrated no significant difference.

Conclusion:

These results suggested that setting PGA as no more than 10mm should be reasonable for the evaluation of clinical remission with the Boolean criteria.

Disclosure of Interests:

None declared

AB0101 THE IMPACT OF TIME SPAN TO ACHIEVE BOOLEAN REMISSION FOR MAINTAINING DISEASE ACTIVITY AFTER ACQUISITION IN RHEUMATOID ARTHRITIS PATIENT

Background:

Boolean remission criteria is one most popular and stringent criteria in treating patient with rheumatoid arthritis (RA), because it may guarantees a stable clinical course after attaining remission.

Objectives:

Impact of time span from initiation to achieving Boolean remission on maintaining disease activity, daily activities, and quality of life after attaining Boolean remission was investigated from daily clinical practice data.

Methods:

685 patients with RA since August 2010 under the T2T strategy were treated. They were monitored for their TJC, SJC, PGA, EGA, CRP, and disease activity indices such as CDAI, SDAI, DAS28, and Boolean criteria at every visit. HAQ-DI score, pain score using visual analog scale (PS-VAS), and EQ-5D were also monitored, and the quality of life score (QOLS) calculated from EQ-5D was determined at every visit from the time of diagnosis (baseline).

Of 685 patients, 465 patients had achieved Boolean remission >1 times, and were consecutively followed up for >3 years. These patients were enrolled in the study. Time span from the first visit to first Boolean remission was calculated. The relationship between the time span and each of background parameters, and the relationship between the time span and each of the mean values of the SDAI score, HAQ score, PS-VAS, SHS, and QOLS at the first Boolean remission and thereafter was evaluated statistically.

Patients were subsequently divided into the G ≤ 6 and G > 6 groups based on the achievement of first Boolean remission within two groups: time span G ≤ 6 months and G > 6 months. The two groups were compared with regard to the SDAI score, HAQ score, PS-VAS, SHS, and QOLS at first visit and at the time of first Boolean remission, and the mean values of these parameters after remission were evaluated statistically. Moreover, changes of these parameters and the mean Boolean remission rate after the first remission, and SDAI remission rate at the first Boolean remission to thereafter were compared between the two groups statistically.

Results:

Out of 465 patients, females comprised 343 (73.7%), and the mean age was 67.8 years (range, from 21–95 years). The mean disease duration at first visit was 6.1 years (range, from 1 months–45 years). The mean follow up length was 88.1 months (range: 36–122 months; median: 85 months) and mean time span from the first visit to the first Boolean remission was 8.1 months. The mean SDAI score, HAQ score, PS-VAS, and the QOLS at first visit were 13.3, 0.467, 33.2, and 0.834, respectively. Among the study parameters, PS-VAS and QOLS were significantly correlated with the time span. For parameters at the first Boolean remission, HAQ-DI score, PS-VAS, and QOLS demonstrated significant correlation with the time span, whereas SDAI, HAQ-DI score, PS-VAS, SHS, and QOLS after the Boolean remission demonstrated significant correlation with the time span.

The comparison between the G ≤ 6 and the G > 6 groups revealed that the disease duration, HAQ score, and PS-VAS at baseline in the G > 6 were significantly higher than that in the G ≤ 6 group, and QOLS in the G ≤ 6 group was significantly higher than that in the G > 6 group at baseline. Similarly, the HAQ score and PS-VAS at the first Boolean remission in the G > 6 group were significantly higher than that in the G ≤ 6 group, whereas QOLS in the G ≤ 6 group demonstrated no significant difference compared with that in the G > 6 group.

The mean value of the SDAI score after the first Boolean remission in the G > 6 group was significantly higher than that in the G ≤ 6 group. Similarly, the SDAI score, HAQ score, and PS-VAS after the first Boolean remission in the G > 6 group were also significantly higher than those in the G ≤ 6 group, and the mean value of the QOLS in the G ≤ 6 group were significantly higher than that in the G > 6 group. The Boolean remission rate and SDAI remission rate after the first Boolean remission were significantly higher in the G ≤ 6 group than those in the G > 6 group.

Conclusion:

Attaining Boolean remission ≤ 6 months for RA has significant benefit for more stable disease control, that leads good maintenance of ADL.

Disclosure of Interests:

None declared

POS0574 RELATIONSHIP BETWEEN INVOLVED JOINT FOR REGION AND MODIFIED HEALTH ASSESSMENT QUESTIONNAIRE SCORE IN JAPANESE PATIENT WITH RHEUMATOID ARTHRITIS

Objectives:

Rheumatoid arthritis (RA) is a chronic inflammatory disease that involves various joints in whole body. For evaluation of daily life activities (ADL), modified Health Assessment Questionnaire (mHAQ) is usually used. This index configures eight ADL functions these are separated by predominant extremities. This study aimed to evaluate how involved joint affect ADL predominantly in real world setting.

Methods:

A total of 24,450 times of consultation with RA patient were visited in the institute. Here, patient with RA was interviewed every another visit, and involved joint in whole body, pain score with visual analog scale (PS-VAS), and mHAQ were recorded. Involved joints were divided by four regions in accordance with joint size and part; small joint in upper extremities (US), large joint in upper extremities (UL), small joint in lower extremities (LS), and large joint in lower extremities (LL). mHAQ was also separately evaluated in accordance with predominant regions; upper extremities predominant mHAQ (mHAQ_UE), and lower extremities predominant mHAQ (mHAQ_LE). Adding to these parameters, as an index for disease activity monitoring, components of the simplified disease activity index score (SDAI) was also recorded. Relationship between mHAQ for each predominant extremities, and these parameters and sex, age, disease duration of RA, anti-cyclic citrullinated polypeptide antibodies (ACPA), rheumatoid factor (RF), and Sharp/van der Heijde score (SHS), were statistically evaluated using linear regression analysis.

Results:

mHAQ_UE significantly correlated with age, ACPA and RF titre, SHS, tenderness joint count (TJC), patient’s global assessment (PGA), evaluator’s global assessment (EGA), C-reactive protein (CRP), US, UL, LL, and PS-vas, whereas mHAQ-LE significantly correlated with all parameters that demonstrated significant correlation with mHAQ-UE and disease duration. mHAQ also correlated with all parameters those that demonstrated significant correlation with mHAQ-LE. Interestingly, all of mHAQ-UE, mHAQ-LE, and mHAQ did not correlated significantly with swollen joint count (SJC) and LS.

Conclusion:

mHAQ is influenced by various factors, however, SJC and involvement of small joint in lower extremities did not affect mHAQ.

Disclosure of Interests:

None declared

AB0102 EVALUATOR’S GLOBAL ASSESSMENT REFLECTS DISEASE ACTIVITY BUT NOT LINEARLY CORRELATES WITH DAILY ACTIVITY OR QUALITY OF LIFE COMPARED TO PATIENT’ GLOBAL ASSESSMENT

Background:

Evaluator’s global assessment (EGA) is the one component of indexed disease activity evaluation assessed by the rheumatologist for treatment of rheumatoid arthritis (RA). It does not included in the Boolean remission criteria nor 28-joints disease activity score (DAS28), however it is widely recognized among rheumatologist as an only comprehensive and objective assessment parameter.

Objectives:

The aim of this study is to evaluate how EGA correlates with other components and the influence of EGA on disease activity and daily activity, and quality of life.

Methods:

A total of 24,075 times of monitoring out of 683 RA patients who were followed up for more than three consecutive years was performed. Contents of monitoring included tenderness joint count (TJC), swollen joint count (SJC), patient’s global assessment (PGA), EGA, C-reactive protein (CRP), and calculated values of DAS28, SDAI, composite index of Boolean evaluation, pain score with visual analog scale (PS-VAS), Health Assessment Questionnaire Disability Index (HAQ-DI), and quality of life score (QOLS) calculated from Euro-QOL questionnaire with 5th dimensions. Each measurement was classified with the EGA score divided by one increment from zero to ten. Mean values of DAS28, CDAI, SDAI, remission rate of these indices and Boolean remission rate, and mean values of PS-VAS, HAQ-DI, and QOLS were statistically evaluated. Results were compared to the results that was analyzed in according to the PGA score substituted with the EGA score.

Moreover, EGA at the time of Boolean remission of the patients who achieved Boolean remission at least once during treating were picked up. Patients were classified according to the EGA level with 0.5 increment from zero. Mean value of TJC, SJC, PGA, EGA, SDAI, Boolean remission rate, HAQ-DI, and PS-VAS after attaining Boolean remission were compared statistically.

Results:

Number of measures counted 15424, 2001, 3688, 1731, 664, 293, 144, 88, 29, 2, and 11 for each level of EGA. The EGA score tended to concentrate more in zero to two in comparing to the PGA score. Mean DAS28, CDAI, and SDAI demonstrated significant increase as the EGA level increased, and remission rate of the all indices including Boolean demonstrated significant decrease as the EGA level increases (p<0.01%). CDAI, SDAI, and Boolean remission rate demonstrated zero percent from two. Mean value of PS-VAS and HAQ-DI score demonstrated also significant decrease as the EGA level increases, and QOLS demonstrated significant decrease as the EGA level increases (p<0.01%). However, these tendency showed more irregular compared to that analyzed with the PGA score. Correlation coefficients with regarding to the EGA score was always less than that with regarding to the PGA score.

In the patients who achieved Boolean remission, EGA levels were divided with 294 with zero (G-0) and 118 with 0.5 (G-.5), whereas 71 could not achieve Boolean remission. Average TJC (p<0.05), SJC (p<0.001), EGA (p<0.001), CRP (p<0.05), and SDAI (p<0.01) level in the G-0 group demonstrated significant less than in the G-.5 group, whereas PGA, Boolean remission rate, HAQ-DI, and PS-VAS demonstrated no significant difference in between the two groups.

Conclusion:

It is more reliable to estimate daily activity and quality of life from the PGA score than to estimate from the EGA score. EGA correlates with SJC and CRP more strongly than with TJC and CRP. EGA does not reflect HAQ-DI and PS-VAS.

Disclosure of Interests:

None declared

AB0606 IMPACT OF ABDOMINAL AORTIC CALCIFICATION AND SERUM CREATININE-TO-CYSTATIN C RATIO TO BONE FRAGILITY FRACTURE

Background:

Relationship between bone fragility fracture (BFF) and abdominal aortic calcification (AAC) has been discussed in recent decade.

Objectives:

Now we investigated the relationship between the two and a new factor of BFF: serum creatinine-to cystatin C ratio (Cr/CysC).

Methods:

A total of nine-hundred and thirty one osteoporotic patients were recruited. Diagnosis of osteoporosis was indexed by the criteria of Japanese Primary Osteoporosis Diagnostic Criteria. Patient’s lumbar spine X-ray pictures were taken and dual-energy X-ray absorptiometry (DXA) of lumbar spine and hip joint were tested at the same time, and all of them were followed us for more than one year up to nine years with at least an administration of vitamin D. Anti-osteoporotic drugs were administrated for 660 patients.

Vertebral compression fracture (VF) and AAC were evaluated with lateral view of X-ray picture. VF was classified in accordance with Semi-quantified method (SQ), and AAC was classified as follows: Grade0; No calcification, Grade1; Partial calcification not continued over one vertebral height, Grade2; Calcification continuous over one vertebral height. BFF history of the patients except of VF was harvested from the medical record and with interview. Patients’ background at first measurement were measured and Cr/CysC was calculated as well. Prevalence of BFF at the baseline for each grade with SQ was compared according to the grade of AAC. Background factors including bone mineral densities (BMD) of the lumbar spine and hip joint measured using DXA were compared for each AAC grade.

Occurrence of BFF was picked up during following up (BFF_F/U) of the patients. Prevalence of BFF_F/U for each ACC grade was statistically compared, and relationship between BFF_F/U and factors at the baseline was statistically evaluated.

Results:

A total of 219 of Grade0, 428 of Grade1, and 278 of Grade2 were recruited. Prevalence of BFF at baseline for each VF group was 182, 16, 9, and 12 for Grade0, 138, 98, 122, and 70 for Grade1, and 53, 45, 82, and 144 for Grade2, with Grade-0, Grade-1, Grade-2, and Grade-3 by SQ, respectively (p<0.01). Factors that demonstrated significant correlation with occurrence of BFF were sex, age, BMD of the lumbar spine and the hip joint, and Cr/CysC with univariate mode binary logistic regression anaysis. However, Cr/CysC did not demonstrate significant correlation using multivariate model.

Occurrence of BFF_F/U for each AAC group was 26, 90, and 82 for Grade0, Grade1, and Grade2, respectively (p<0.01). The only factor that demonstrated significantly correlated with occurrence of BFF_F/U was Cr/CysC in the Grade1 and the Grade2 of the AAC classification.

Conclusion:

ACC grade significantly correlates with occurrence of BFF. Cr/CysC also significantly correlates with occurrence of BFF after follow up under presence of AAC.

Disclosure of Interests:

None declared.

Cortical thickness relative to the transverse diameter of third metacarpal bone reflects bone mineral density in patients with rheumatoid arthritis

OBJECTIVE

Rheumatoid arthritis (RA) is accompanied by potential risk of bone mineral loss. In this study, we developed a screening index for the osteoporosis related level of bone mineral density loss for RA patients as a substitute to the dual-energy X-ray absorptiometry (DXA) method.

METHODS

X-ray pictures of both sides of the hand were taken in order to evaluate Sharp/van der Heijde Scores (SHSs). This score was calculated for RA patients at the first consultation and routinely thereafter. We measured cortical thickness and the transverse diameter of the mid-portion of the metacarpal bone of the right middle finger with the same radiograph. Cortical Thickness Ratio (CTR) was then calculated as cortical thickness relative to the transverse diameter. Bone mineral density (BMD) of the lumbar spine (LS) and femoral neck (FN) was measured at the same time. The relationship between BMD and CTR was evaluated using multivariate linear regression analysis. Clinical backgrounds and disease indices were also evaluated. The cut-off index (COI) of the CTR for osteoporosis criteria that represented with a T-score < -2.5 for both bones was calculated using the Receivers Operation Characteristics technique.

RESULTS

In 300 subjects, the CTR demonstrated significant correlation with BMD in both bones (p < 0.01). The COI was determined to be 0.25 and the odds ratio was 4.19 and 4.90 for the LS and FN, respectively.

CONCLUSION

Our findings indicated that the CTR correlated with BMD. This index may represent a promising screening tool for the judgment of osteoporosis in RA patients.

Screening osteoporotic femoral neck without measuring bone mineral density with the use of tartrate resistant acid phosphatase-5b and serum-creatinine-to-cystatin C ratio in Japanese postmenopausal women

BACKGROUND

Screening osteoporosis in Japanese postmenopausal women is an important subject for preventing bone fragility fracture (BFF). Measuring bone mineral density (BMD) is included in the criteria for osteoporosis diagnosis. However, it has not gained popularity.

METHODS

BMD of lumbar spine (LS) and femoral neck (FN) were measured, the serum creatinine-to-cystatin C ratio (Cr/CysC), tartrate-resistant acid phosphatase-5b (TRACP-5b), body mass index (BMI) were also simultaneously measured. These subjects had no potential secondary osteoporosis factors or concomitant drug administration for osteoporosis (pSubjects; primary subjects). Best subsets regression analysis (BeStR) was evaluated for determining the statistically significant factors, and multivariate regression analysis (MLR) was used to assess the correlation of these factors with BMD at each part. Relationship between osteoporotic criteria whether T score≤-2.5 and each factor was also evaluated at each part with binary logistic regression analysis (BLR). Cut-off index (COI) at each part was determined, and sensitivity and specificity were evaluated in pSubjects and in subjects with whom potential secondary osteoporosis factors were included (sSubjects).

RESULTS

BMI and Cr/CysC had a significant influence on BMD at the LS with BeStR, whereas only BMI demonstrated significant correlation with BMD both with MLR and BLR, with 22.7 of COI and sensitivity and specificity of 48.7% and 94.7%, respectively, in pSubjects with 60 and 49.1% and 87.5%, respectively, in sSubjects with 83. At the FN, Cr/CysC, BMI, and TRACP-5b significantly influenced BMD, whereas all these factors demonstrated significant correlation with BMD. Cr/CysC and TRACP-5b demonstrated significant correlation with T score≤-2.5 in BLR. With COI that was made in combination with these factors and subjects' age, sensitivity and specificity were 67.7% and 82.4%, respectively, in pSubjects and 55.8% and 82.8%, respectively, in sSubjects.

CONCLUSIONS

These results suggested that BMI, TRACP-5b, and Cr/CysC may be realistic surrogate markers for screening osteoporosis in Japanese postmenopausal women.

Clinical Characteristics of frailty in Japanese Rheumatoid Arthritis Patients

OBJECTIVE

The relationship between clinical characteristics and frailty was investigated in rheumatoid arthritis (RA) patients >40 years old.

METHODS

RA patients followed for >1 year were interviewed and diagnosed as frail according to a 5-item frailty score index: (1) weight loss >2 kg within 6 months (WL); (2) slower gait speed (GS); (3) exercise less than once per week (EX); (4) decline in short-term memory (SM); and (5) general fatigue in the past 2 weeks (GF). The relationship between frailty status and background parameters was evaluated.

RESULTS

Among 739 subjects, frail patients comprised 221, pre-frail patients comprised 203, and robust comprised 315. The most common symptom in the Frailty group was GS, followed by SM, GF, EX, and WL, whereas the most common symptom in the Pre-frailty group was GS followed by SM, GF, WL, and EX. Frailty was significantly correlated with aging. Elderly onset rheumatoid arthritis, disease activity, serum C-reactive protein concentration, degree of joint deformity, activities in daily living (ADL), dementia treated, and glucocorticoid steroid administration demonstrated significant correlations with frailty status, although all factors also demonstrated significant correlation with aging. In addition, the EuroQol score (EQ5D) was significantly correlated with both aging and frailty.

CONCLUSION

The results suggest that a remission state for disease activity, ADL, and dementia is correlated with frailty. The most common and primary symptom is GS. Elderly RA patients require careful attention for symptoms of frailty, which may damage the EQ5D score, specifically, the quality of life for RA patients.

Rheumatoid arthritis in tight disease control is no longer risk of bone mineral density loss

Objectives

Rheumatoid arthritis (RA) is an independent risk factor of osteoporosis. However, if disease activity is successfully controlled using the treat-to-target (T2T) strategy, the risk of bone mineral density (BMD) loss can be diminished. We evaluated if RA is a risk factor even when the T2T is applied in clinical cases.

Methods

From September 2017 to August 2019, 741 patients were examined using dual-energy X-ray absorptiometry; of these, 279 were diagnosed with RA who attained clinical remission within 6 months (RA-rem) and 53 could not attain clinical remission (RA-nonrem), while 409 were not diagnosed with RA (non-RA). The following characteristics between RA-rem and non-RA were matched using the propensity score matching (PSM) technique: age, sex, past bone fragility fracture experience, osteoporosis drug intervention ratio, glucocorticoid administration ratio, mean dose, Barthel Index score, body mass index, serum-creatinine-to-cystatin C ratio, and the number of comorbidities. The BMDs and changes of the lumbar spine, femoral neck, total hip, and greater trochanter were statistically compared between the RA-rem and the non-RA after PSM, and between RA-nonrem and RA-rem after PSM using the Mann-Whitney U test.

Results

In total, 107 patients of RA-rem and 108 of non-RA were recruited. BMDs and changes of every part demonstrated no significant differences between the 2 groups. BMDs in every part of RA-rem after PSM were significantly greater than those in every part of RA-nonrem, while no significant difference in change during follow-up.

Conclusions

If disease activity is controlled in clinical remission, RA will not contribute to BMD reduction.

AB0271 EFFECTIVENESS OF DULOXETINE FOR RELIEF OF THE REMNANT PAIN OF RHEUMATOID ARTHRITIS PATIENT WHOSE DISEASE ACTIVITY IS REMISSION

Background:

Pain control in rheumatoid arthritis (RA) patient is an important matter. When pain remains even disease activity is remission, it causes deterioration of activity in daily living (ADL) in past research. In other words, pain affects ADL independently from disease activity, namely the Health Assessment Questionnaire (HAQ) score, a most popular index of ADL for patient with RA[1]. Thus, burden of remnant pain despite clinical remission in RA is serious and pending subject.

Duloxetine, a potent reuptake inhibitor of serotonin and norepinephrine, is developed for the treatment of major depressive disorder [2]. It’s effectiveness for pain relief with osteoarthritis is also widely accepted. This drug should be effective not only for chronic pain due to osteoarthritis, but also due to RA. However, effectiveness of duloxetine for remnant pain relief in patient with RA in clinical remission is still unclear.

Objectives:

In this study, effectiveness of duloxetine for the remnant pain despite clinical remission in patient with RA was statistically evaluated.

Methods:

RA patients whose pain score with visual analog scale (PS-VAS) >30mm despite Clinical Disease Activity Score (CDAI) is <2.8, were picked up for the study. These patients were divided into groups whether duloxetine was administrated (a group without duloxetine: G-C; a group with duloxetine: G-D).

PS-VAS, C-reactive protein, CDAI and simplified disease activity index (SDAI), modified Health Assessment Questionnaire (mHAQ), and QOL value which is calculated from Euro-QOL 5-Dimensions (EQ-5D) were measured at the initiation of duloxetine in the G-D and at the first CDAI remission attained in the G-C, and at week 12 thereafter. Change of these indices were compared with One sample T-test for each group. Patient’s global assessment (PGA) at baseline compared to the other components of CDAI was evaluated for each group statistically with One-tailed T-test. Differences between the two groups at each moment were statistically evaluated with Mann-Whitney U-test. Statistical significance was set less than 1%. All statistical analyses were performed using StatPlus:mac®(AnalystSoft Inc., Walnut, CA, USA).

Results:

A total of three hundred and six patients were recruited. G-D counted sixty-eight with 18 males and 50 females, while G-C counted 238 with 57 males and 181 females. Average age were 71.3 and 71.5 for G-D and G-C, respectively, with 53.6 months for time span from baseline to initiation in the G-D. 80.8% of the patients in G-D sustained to administrate duloxetine. PGA was 0.6 and 0.5 for G-D and G-C respectively, while the other component of CDAI were below 0.3 in average for both groups and these values were significantly lower than the PGA score in both groups. PS-VAS was 46.4 and 44.0, and significantly decreased to 26.1 and 36.0 in average for G-D and G-C respectively at week 12 when compared to baseline. Reversely, the CDAI score was significantly elevated significantly from 1.16 and 1.19 to 3.25 and 4.34 for G-D and G-C respectively. PGA also significantly increased to 1.5 and 2.4 for G-D and G-C respectively. CRP and the SDAI score also demonstrated same trend significantly as the CDAI score for both groups. mHAQ decreased significantly from 0.430 and 0.495 to 0.393 and 0.487 for G-D and G-C respectively. QOL value increased from 0.800 and 0.817 to 0.811 and 0.840 for G-D and G-C respectively, however no statistical significance demonstrated in both groups.

Conclusion:

Duloxetine has been suggested to have effectiveness for the pain relief, for improvement of ADL, and for the contribution to QOL maintenance, however, no effect of disease activity control is expected.

References:

[1]Yoshii I, Chijiwa T, Sawada N. Influence of pain score measured by a visual analog scale (PS-VAS) on the Health Assessment Questionnaire Disability Index and 28-joint Disease Activity Index with C-reactive protein in rheumatoid arthritis patients. Int J Rheum Dis 2018;21:1955-61.

[2]Knadler MP, Lobo E, Chappell J, Bergstrom R. Duloxetine. Clin Pharmacokinet 2011;50:281-94.

Disclosure of Interests:

None declared

AB0916 FACTORS THAT DEMONSTRATED SIGNIFICANT CORRELATION WITH BONE MINERAL DENSITY GAIN WITH DENOSUMAB ADMINISTRATION FOR PATIENT WITH RHEUMATOID ARTHRITIS

Background:

Denosumab, a monoclonal antibody of receptor activator of NF-κB ligand promotes a strong action for bone mineral density (BMD) gain. This agent is often used for patient with rheumatoid arthritis (RA) because of its strong anti-osteoclastogenesis action, with that joint structural damage is induced. However, factors what affects BMD gain for patient with RA is still unclear.

Objectives:

Factors that may affect BMD gain for patient with RA is evaluated statistically.

Methods:

Patients with RA to whom denosumab is administrated consecutively three shots or more were picked up. BMD in lumbar spine (LS) and femoral neck (FN) measured with dual-energy X-ray absorptiometry was routinely measured at the initial administration (BL). BMDs were measured every six months when another denosumab is administrated. Change of BMD for each bone was calculated. Patient’s age at BL, at onset of RA, disease duration, sex, anti-cyclic citrullinated polypeptide antibodies (ACPA), whether denosumab is naïve, body mass index (BMI) at BL were harvested. BMD in each bone, serum tartrate resistant acid phosphatase 5b (TRACP5b), total type one procollagen-N-peptide (P1NP), calcium (Ca), creatinine (Cr), cystatin C (CysC), estimated glomerular filtration ratio based on CysC (eGFR), serum Cr-to-CysC ratio (Cr/CysC), and Barthel Index, were measured at BL and every six months thereafter. Relationship between BMD gain from BL to second administration and such like factors at BL were evaluated with linear regression analysis at first with univariate model and then multivariate model with factors that demonstrated statistical significance within 5%. Binary logistic regression analysis for these factors was also performed according to BMD gain. These procedures were performed as a same manner regarding with BMD gain from BL to third administration.

Results:

A total of 397 patients with 43 males (10.4%) and 354 females (89.6%) were recruited. Average age was 81.3 and average disease duration of RA was 6.9years. 227 patients (57.4%) was denosumab naïve, and prior to BL, 170 patients were already administered with alendronate in 26, risedronate in 26, minodronate in 23, ibandronate in 12, raloxifene in 39, bazedoxifene in 7, teriparatide in 36.

BMD gain in LS from BL to the second administration demonstrated significant correlation with age and TRACP5b at BL with univariate model, and only aging correlated significant negative correlation with BMD gain with multivariate model. In binary logistic regression analysis, aging demonstrated no significant regression with BMD gain. From BL to third administration, BMD gain also demonstrated significant correlation with aging, but no correlation with TRACP5b, but Cr/CysC at BL. These two factors also demonstrated significant correlation with BMD gain in LS, in these aging demonstrated negative and Cr/CysC demonstrated positive correlation. Cr/CysC demonstrated significant regression with BMD gain in LS from BL to the third with binary logistic regression analysis.

BMD gain in FN from BL to the second demonstrated significant correlation with age, BMD in FN at BL, and ACPA with univariate model, and all of the three demonstrated significant correlation with BMD gain with multivariate model. However, no factors demonstrated significant regression with BMD gain with binary logistic regression analysis. From BL to third administration, BMD gain in FN demonstrated significant correlation with aging and BMD in FN at BL. However, BMD in FN at BL demonstrated the only factor to correlate with BMD gain in FN. BMD in FN at BL demonstrated significant regression with BMD gain in FN from BL to the third with binary logistic regression analysis.

Conclusion:

These results suggested that BMD gain in LS and FN was affected by different factors. These results may be helpful reference in choosing denosumab against osteoporosis in RA patient.

Disclosure of Interests:

None declared

AB0232 PAIN SCORE WITH VISUAL ANALOG SCALE OF 30MM OR MORE IS A RISK FACTOR OF WORSENING CLINICAL DISEASE ACTIVITY INDEX (CDAI) AT THREE MONTHS AFTER ATTAINING CDAI REMISSION IN PATIENT WITH RHEUMATOID ARTHRITIS

Background:

In treating with rheumatoid arthritis (RA), it is needless to say essential treatment goal with first priority. On the other hand, patient’s pain influences on clinical indices deeply, however, pain score is not been regarded as most important despite that correlates with patient reported outcome.

Objectives:

Clinical significance of remnant pain score for clinical outcome although attaining remission in clinical disease activity index (CDAI) statistically.

Methods:

RA patient who have attained remission with CDAI were picked up. These patients were divided into two groups whether CDAI at three month after the first CDAI remission attained; namely CDAI-R or CDAI-F. Background data such as sex, age at onset, age, anti-cyclic citrullinated polypeptide antibodies (ACPA), rheumatoid factor (RF), Sharp/van der Heijde Score (SHS), clinical disease activity score (CDAI), C-reactive protein (CRP), modified Health Assessment Questionnaire score (mHAQ), and pain score with visual analog scale (PS-VAS) at first consultation, time span from the first consultation to first CDAI remission were compared between the two groups using Mann-Whitney U-test. CDAI, CRP, mHAQ, PS-VAS, and QOL value calculated from EuroQOL-5 dimension questionnaire (EQ-5D) at the time of CDAI were also statistically compared with Mann-Whitney U-test. Parameters that demonstrated statistical significance within 5% were picked up, and odds ratio for CDAI remission were calculated with binary logistic regression analysis. Moreover, parameters that demonstrated statistical significance with p-value within 5% were evaluated with receiver’s observational characteristics (ROC) analysis, and cut-off index (COI) was calculated.

Results:

A total of 907 patients with 594 CDAI-R and 313 CAI-F were recruied. Demographic characteristics of the two groups were shown in Table 1. SHS at first consultation and time span from first consultation to CDAI remission attained demonstrated significantly less in the CDAI-R than the CDAI-F group, while the other parameters demonstrated no significant difference. CRP, CDAI, mHAQ, PS-VAS, and QOL at CDAI remission demonstrated significant difference between the CDAI-R and CDAI-F groups. With binary logistic regression analysis, CRP, CDAI, and PS-VAS demonstrated significant regression for CDAI-R with 1.68, 0.71, and 0.78 in odds ratio, respectively. COI for CDAI remission was 0.4, 1.0, and 30 for CRP (p=2.4 x 10-4), CDAI (p=3.0 x 10-32), and PS-VAS (p=2.4 x 10-4), respectively.

Conclusion:

PS-VAS at the moment of CDAI remission is suggested to be predictive factor for sustaining CDAI remission at three months thereafter as well as CRP value and the CDAI score.

Table 1.

Demographic characteristics of the two groups

CDAI-RCDAI-Fp-valuecases594313sex430 (72.4%)313 (80.2%)5.7 x 10-2age at onset62.260.91.8 x 10-1age at FC65.865.14.7 x 10-1ACPA at FC209.3 (83.9%)227.9 (86.7%)7.2 x 10-2RF at FC83.8 (92.2%)92.3 (86.1%)5.6 x 10-2SHS at FC41.966.96.0 x 19-5CDAI at FC10.711.15.5 x 10-2CRP at FC1.31.61.2 x 10-1mHAQ at FC0.4390.4753.2 x 10-1PS-VAS at FC32.634.92.1 x 10-1time span3.74.56.4 x 10-4

Abbreviations: FC, first consultation; ACPA, anti-cyclic citrullinated polypeptide-antibodies; RF, rheumatoid factor; SHS, Sharp/van der eijde Score; CDAI, clinical disease activity index; CRP, C-reacive protein; mHAQ, modified Health Assessment Questionnaire; PS-VAS, pain score with visual analog scale; time span, time span from FC to date first CDAI remission attained.

Disclosure of Interests:

None declared

OP0295 CORRELATION BETWEEN CORTICAL THICKNESS RELATIVE TO TRANSVERSE DIAMETER ON MID-PORTION OF THIRD METACARPAL BONE AND BONE MINERAL DENSITY IN LUMBAR SPINE AND FEMORAL NECK FOR PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Rheumatoid arthritis (RA) is a determinant risk factor of osteoporosis. BMD is clearly defined as diagnosis criteria of osteoporosis in Japan; that is less than -2.5 with T-score measured with dual-energy X-ray absorptiometry (DXA). The marker of T-score <-2.5 is widely used worldwide; however, the testing system is very expensive, preventing its extensive adoption.

Objectives:

We tried to evaluate BMD not measuring with DXA, but the other method that substituting DXA with another X-ray picture of hand that is routinely taken for Sharp/van der Heijde score (SHS) calculation.

Methods:

Patient with RA, who met the American College of Rheumatology/European League Against Rheumatism classification criteria, visited our institute has been routinely calculated SHS in taking X-ray pictures of bilateral hands and feet at first consultation. Cortical thickness was calculated from mid-portion of third metacarpal bone in X-ray picture that was taken for the calculation of SHS as taking cancellous bone diameter of the third metacarpal bone from transverse diameter at the same point. We set Cortical Thickness Ratio (CTR) as cortical thickness relative to transverse thickness (Figure 1). BMD measurements at the lumbar spine (LS) and femoral neck (FN) were obtained, and BMD values are presented as g/cm2and T-score showing dissociation of the BMD compared with the mean BMD in healthy 30-year-old of the same sex with standard deviation was also presented. Patient with RA who underwent SHS calculation and BMD measurement at first consultation was picked up for the study. Relationship between BMD and the other parameters such as sex (male/female), age, disease duration (years), ACPA titer, RF titer, body mass index (BMI), CTR, the HAQ score, DAS28-CRP, SHS, PS-VAS, tartrate-resistant acid phosphatase-5b value (TRACP-5b), previous treatment for osteoporosis and RA before initial consultation (pTx_OP and pTx_RA) (Yes/No) at initial consultation was evaluated with linear regression analysis.

T-score<-2.5 was statistically evaluated with binary regression analysis for the parameters that demonstrated significant correlation in multivariate linear regression analysis.

Then, Cut-off index (COI) of CTR for the BMD represented with T-score <-2.5 for both of LS and FN was evaluated with Receivers Operation Characteristics technique (ROC). Sensitivity, specificity, area under curve, odds ratio with 95% confidence interval (95%CI) for T-score <-2.5 was also calculated.

Results:

A total of 300 patients were picked up for the study. BMDs were 0.867 and 0.682 with 0.203 and 0.143 for standard deviations, that means T-score was -1.93 and -1.86 with 1.64 and 1.15 for standard deviations in LS and FN, respectively. Mean transverse width of third metacarpal bone was 7.3 mm and thickness of the cortex was 2.00 mm, so CTR was 0.279 in average and 0.124 for standard deviation.

In linear regression analysis, BMD in LS demonstrated significant correlation with sex, CTR, and DAS28-CRP, while BMD in FN demonstrated significant correlation with sex, age, and CTR.

In binary regression analysis, CTR and DAS28-CRP demonstrated significant positive correlation with T-score <-2.5 in LS, while age and CTR demonstrated significant correlation in FN.

In ROC, cut-off index of CTR was 0.25 in both of LS and FN, and sensitivities demonstrated 67.9% and 76.1%, and specificity demonstrated 83.0% and 81.6% in LS and FN, respectively. Area under curve was 0.78 and 0.81 with 4.17 (95%CI: 2.51 – 6.92) and 4.90 (95%CI: 2.75 – 8.73) of odds ratios for LS and FN, respectively (Figure 2).

Conclusion:

Results of this cross-sectional study encourages our hypothesis that thickness of cortical bone relative to full thickness in the long bone reflects BMD. CTR correlated with BMD in both of LS and FN. CTR of third metacarpal bone was suggested that has close correlation with BMD in both LS and FN. CTR could be strong candidate marker for screening of osteoporosis in patient with RA with the index less than 0.25.

Disclosure of Interests:

None declared

SAT0486 BONE MINERAL DENSITY IN PATIENT WITH SHRUNKEN PORE SYNDROME IS SIGNIFICANTLY LOWER THAN THAT IN PATIENT WITHOUT, HOWEVER SERUM PARATHYROID HORMONE DOES NOT CORRELATED MUCH WITH IT

Background:

Shrunken pore syndrome (SPS), defined by cystatin C (CysC) based estimated glomerular filtration rate (eGFRCysC) < 60% of creatinine (Cr) based eGFR (eGFRCr) in the absence of extrarenal influences on the plasma levels of CysC or Cr, is associated with a higher increase in mortality. SPS often causes reduced bone mineral density (BMD).

Objectives:

In this study, relationship between BMD and SPS was investigated.

Methods:

Patient with rheumatic diseases who were measured BMD with dual-energy X-ray absorptiometry and at the same time, CysC and Cr were also measured, were picked up. eGFRCysCand eGFRCr,were calculated, and a patient group with SPS were recruited. Relationship between serum PTH and CysC, or Cr was evaluated with univariate linear regression analysis. Between the SPS groups and the other patient group, statistical difference was evaluated regarding sex, age, Cr, CysC, serum Cr-CysC ratio (Cr/CysC), serum calcium corrected with albumin (Ca), creatinine phosphokinase (CPK), parathyroid hormone (PTH), eGFRCysC, eGFRCr,, BMD in the lumbar spine (BMD_LS) and femoral neck (BMD_FN) were evaluated with Mann-Whitney U-test. Relationship between BMD for each bone and sex, age, CPK, PTH, Cr/CysC, eGFRCysC, and being SPS was statistically evaluated with multivariate linear regression analysis. Furtherly, sensitivity and specificity regarding being SPS for T-score < -2.5, that is defined as diagnosis criteria of osteoporosis calculated from BMD, was evaluated with chi square test.

Results:

A total of 819 participants with 75 males and 744 females joined. Patient with SPS counted 31 and without SPS counted 782. Underlying diseases are shown in Table 1. Average age, CysC, Cr, PTH, eGFRCr,and eGFRCysCwere 76.5, 1.18, 0.76, 42.1, 66.2 and 59.0, respectively. PTH significantly correlated with CyC (p=0.015), but not correlated with Cr (p=0.079). SPS demonstrated significantly higher ratio for being male (P<1.0x10-10), higher age (p=1.07x10-3), higher titer of CysC (p=5.5x10-10), lower titer of CPK (p=1.5x10-4), lower Cr/CysC (P<1.0x10-10), lower eGFRCysC(p=2.8x10-7), BMD_LS (P<1.0x10-10) and BMD_FN (P<1.0x10-10), however no significant difference demonstrated for Cr (2.4x10-1), PTH (p=1.7x10-1) and Ca (p=6.3x10-1). BMD_LS demonstrated significant positive correlation with CPK (p=2.6x10-4), and negative correlation with being female (p=4.9x10-7), age (p=2.1x10-3), PTH (p=2.2x10-2), eGFRCysC(p=2.5x10-9) and being SPS (p=4.9x10-3), while BMD-FN demonstrated significant positive correlation with Cr/CysC (p=7.3x10-4), and negative correlation with being female (p=1.5x10-6), age (p=4.9x10-8) and being SPS (7.3x10-3). Sensitivity and specificity of T-score < -2.5 in the LS regarding SPS was 50.0% and 74.0% (p=6.9x10-3), while in the FN 67.9% and 61.7% (p=1.7x10-3), respectively.

Table 1.

Number of patients who were picked up in the study Abbreviations: RA, rheumatoid arthritis; PsA, psoriatic arthritis; AJA, Sjoren Syndrome; SLE, systemic lupus erythematosus; PPP, pustulosis palmaris et plantaris; AS, ankylosing spondylitis; SSc, systemic sclerosis; UA, ulcerative colitis; PM/DM, polymyositis/dermatomyositis; MCTD, mixed connective tissue disease; FMF, Familial Medditeranean fever; PAN, polyarteritis nodosa.

DiseasesNumber of patientRA512PsA110SJS67SLE66PPP17AS16SSc13UA11Behcet8PM/DM3MCTD2FMF2PAN1total828

Conclusion:

These results suggested that SPS has serious potential risk of osteoporosis. BMD_LS loss may correlate elevation of PTH due to filtration disorder, however BMD_FN loss is not affected. Split of Cr and CysC is more important.

Disclosure of Interests:

None declared

AB0233 ATTAINING CDAI REMISSION IS THE FIRST GATEWAY TO ATTAIN BOOLEAN REMISSION

Background:

Boolean remission is most stringent but most comparable remission status for the patient with rheumatoid arthritis (RA). Clinical remission evaluated with clinical disease activity index (CDAI) is also one of the most popular index for evaluation of RA treatment. These two criteria often overlap, but some are split.

Objectives:

Clinical significance of attaining CDAI remission before attaining Boolean remission was investigated.

Methods:

Patient with RA were treated in the institute since August 2010 under treat to target (T2T) strategy. In accordance with T2T, RA patients were monitored from the first consultation with parameter such as tenderness joint count (TJC), swollen joint count (SJC), patient’s global assessment (PGA), evaluator’s global assessment (EGA), C-reactive protein (CRP), modified Health Assessment Questionnaire (mHAQ), pain scale with visual analog scale (PS-VAS), and EuroQOL 5-dimension (EQ-5D). CDAI and Boolean are also evaluated at the same time. Radiographs of bilateral hands and feet are taken once a year from the first consultation, and the Sharp/van der Heijde Score (SHS) is measured.

In patients, a group who attained CDAI remission prior to attaining Boolean remission (CDAI-R), a group who could not attain CDAI remission previously than attaining Boolean remission (CDAI-F), and a group who could not attain Boolean remission despite attaining CDAI remission (Boolean-F) were picked up and divided according to change of disease activity. Among these three groups, mean age, sex, education level, job style, anti-cyclic citrullinated polypeptide antibodies (ACPA), rheumatoid factor (RF), the CDAI score, the HAQ score, PS-VAS and quality of life index (QOL) calculated from EQ-5D were compared with each other using Mann-Whitney U-test. Boolean remission attaining rate whether CDAI remission attained was compared with chi square test.

Results:

Patient group configured with 255 of CDAI-R, 160 of CDAI-F, and 28 of Boolean-F. Patient who could not attain none of CDAI nor Boolean remission counted 175. In background factors at baseline, mean age, the HAQ score, and SHS of the Boolean-F were significantly older than the other groups. In the two groups of CDAI-R and CDAI-F, 28-joints disease activity score with C-reactive protein (DAS28-CRP), CDAI and PS-VAS in the CDAI-R were significantly lower than in the CDAI-F, similarly, DAS28-CRP, the CDAI score, the HAQ score, PS-VAS and QOL after Boolean remission attain were significantly higher in the CDAI-F than the CDAI-R. Sensitivity of Boolean remission when attaining CDAI remission previously before Boolean remission is 93.4%, and specificity was 52.2% (p<1.0x10-30).

Conclusion:

Attaining CDAI remission previously is extremely important, both for attaining Boolean remission and more stable clinical course after attaining Boolean remission. CDAI remission could be the first gateway to send sustainable QOL course.

Disclosure of Interests:

None declared

Clinical characteristics of osteoporotic second hip fracture: From the data of Clinical Pathway with Regional Alliance in rural region in Japan

BACKGROUND

Second osteoporotic fracture of the hip is a serious comorbidity that can directly cause mortality. Preventing its occurrence is particularly important in Japan, given its rapidly aging society. Here, the clinical characteristics of such recurrence were evaluated using the data of the Clinical Pathway with Regional Alliance (CPRA).

METHODS

CPRA for hip fracture started in 2007 and has allowed intranet-based data sharing since July 2011. Data from this alliance, such as number of second cases, duration from initial fracture, Functional Impairment Measure (FIM), revised Hasegawa Dementia Scale (HDS-R) score, muscle force and range of motion of hip joint, and gait status (GS) were collected and statistically evaluated.

RESULTS

Overall, 45 of 1118 cases (2.68/100 person-years) developed a second fracture. The mean interval from initial to second fracture was 13.3 months. Thirty of these cases (66.7%, 1.79/100 person-years) occurred within 1 year from initial fracture (G < 1Y). The second fracture tended to be associated with worse parameter values than initial fracture, especially for GS. FIM score for cognitive function, HDS-R score, and GS at acute fracture in the G < 1Y group were significantly lower than in the initial fracture patient group (Initial). The withdrawal rate was also significantly higher than for Initial, whereas deaths and serious comorbidities were also much more numerous.

CONCLUSIONS

Osteoporotic second hip fracture is a severe issue, and its prognosis is remarkably poor. The majority of these cases may occur within 1 year from the initial fracture. Dementia severity correlates with such recurrence within 1 year.

Validity of adopting a Health Assessment Questionnaire Disability Index less than 0.5 as a target in elderly rheumatoid arthritis patients

OBJECTIVES

The effect of age on the Health Assessment Questionnaire Disability Index (HAQ-DI) scores of rheumatoid arthritis (RA) patients and the validity of adopting HAQ-DI < 0.5 as the target for functional remission and comprehensive disease control (CDC) under a treat-to-target (T2T) treatment strategy were investigated.

METHOD

A total of 441 RA patients with > 3-year treatment under T2T were evaluated. The relationships between the HAQ-DI score at follow-up (HAQ) and 28-joint Disease Activity Score with C-reactive protein, Sharp/van der Heijde Score, age at follow-up, and HAQ-DI at baseline were statistically evaluated with best subset regression analysis in groups separated according to age and the EULAR response. CDC status was evaluated with a chi-square test.

RESULTS

The HAQ score significantly correlated with all indices in the group ≥ 65 years old (G-O) and in the group with good or moderate EULAR responses (p < 0.01). No significant correlation was observed in the group < 65 years old (G-Y) or in the group with no EULAR response. The CDC ratio was not significantly different between the age groups, whereas the HAQ failure ratio was significantly greater in G-O than in G-Y (p < 0.01). No significant difference was found between the EULAR response groups.

CONCLUSIONS

The HAQ score is influenced by age in patients > 65 years. T2T is appropriate for attaining good disease activity control but does not always lead to functional remission in these patients. The HAQ score < 0.5 is not an appropriate target for functional remission according to the CDC criteria for elderly patients.Key Points• ADL in elderly RA patient aged ≥ 65 years declines corresponding to his/her aging.• Functional remission for elderly RA patients is not the same as that for young RA patients.• The HAQ score < 0.5 in elderly RA patient is not an appropriate target for CDC.

Influence of pain score measured by a visual analog scale (PS-VAS) on the Health Assessment Questionnaire Disability Index and 28-joint Disease Activity Index with C-reactive protein in rheumatoid arthritis patients

BACKGROUND

Pain is a serious burden for rheumatoid arthritis (RA) patients. However, the effect on Health Assessment Questionnaire Disability Index (HAQ-DI) and 28-joint Disease Activity Score (DAS28) has not been presented. The aim of this study is to evaluate them in a case series.

METHODS

Three hundred and eighty-two RA patients who were treated for more than 5 years were studied. The parameters assessed included average value of the DAS28 with C-reactive protein (DAS28-CRP), the HAQ-DI score, the Sharp/van der Heijde Score (SvdHS), age, and the pain score measured by a visual analog scale (PS-VAS). Relationships among these factors and the relationships between the HAQ-DI score and the other factors, and the relationships between the change in HAQ-DI scores and the changes in other factors were evaluated statistically with multivariate linear regression analysis. The effect of PS-VAS on HAQ-DI was compared with that of DAS28-CRP on the overlapping data of each parameter.

RESULTS

HAQ-DI demonstrated significant positive correlations with all parameters. However, PS-VAS demonstrated a stronger effect than DAS28-CRP, also demonstrated without overlapping data. After minimizing the effects of DAS28-CRP, age and SvdHS, there was a significant correlation between HAQ-DI and PS-VAS in all analyses. The change in HAQ-DI demonstrated a significant correlation with the change in PS-VAS.

CONCLUSIONS

These results suggested that HAQ-DI is deeply influenced by PS-VAS. The effect of DAS28-CRP overlapped with the effect of PS-VAS in a major way. Pain control for RA patients is the most important factor contributing to activities of daily living, as well as disease activity control.

Relationship between dementia degree and gait ability after surgery of proximal femoral fracture: Review from Clinical Pathway with Regional Alliance data of rural region in Japan

BACKGROUND

Proximal femoral fracture (PFF) is one of the most serious injury-related problems in developed countries. Functional prognosis after operation for PFF is unsatisfactory, as a considerable number of patients cannot perform similar gait function before fracture. Postoperative gait function is a key in performing activities of daily living (ADL). It is well known that PFF patients with dementia result in worse prognosis compared to without dementia. It is believed that dementia affects gait function after operation. However, it is still unclear whether lost function recovers after dementia level improves.

METHODS

Relationship between ADL and dementia of PFF patients after surgery was investigated using data of Clinical Pathway with Regional Alliance system. Functional Independence Measurement (FIM), revised version of Hasegawa's Dementia Scale (HDS-R), motivation for rehabilitation (MR), and gait status (GS) measured in acute and recovery institute (A-I and R-I) of 266 patients were analyzed with linear regression analysis. Degrees of patients' dementia were classified into three groups with HDS-R for ten points increment partition, and their average FIM and GS in R-I for groups were compared statistically with ANOVA. FIM gain and GS gain from A-I to R-I were compared statistically with chi-square test.

RESULTS

FIM and HDS-R demonstrated significant regression with each of all other parameters (p < 0.01) for both A-I and R-I. The group with lowest HDS-R score demonstrated significant lower FIM gain and lower GS gain than groups with higher scores (p < 0.01). However, patients who demonstrated improvement in HDS-R at R-I demonstrated significant better GS gain (p < 0.05) even in the group with lowest HDS-R at A-I.

CONCLUSIONS

These results show that there is a very close correlation between patients' gait function and dementia and that it is necessary to control a patient's status not only for physical condition but also for mental status after PFF operation.