POS1079 CLINICAL CHARACTERIZATION OF PRODROMAL AND VERY EARLY PSORIATIC ARTHRITIS: A SYSTEMATIC LITERATURE REVIEW FOR THE DEFINITION OF CLINICAL AND IMAGING SUSPICIOUS FEATURES FOR PROGRESSION TO PSORIATIC ARTHRITIS

Background

The transition from psoriasis (PsO) to psoriatic arthritis (PsA) is a focus of considerable scientific interest: is it possible to target pre-PsA and very early PsA, in particular for physiopathology and drug studies? Recently, a EULAR taskforce has been set up in this area (1).

Objectives

To characterize the prodromal and the very early PsA through a systematic literature review (SLR).

Methods

A SLR explored MEDLINE, EMBASE and CENTRAL, up to 22 October 2021. The objective was to identify the symptoms, objective signs, lab tests, imaging features and other characteristics of patients later diagnosed as “new onset” PsA in two key populations: 1) patients with PsO and 2) patients with early undifferentiated arthritis (UA). Studies of adult patients published in English were included, if they reported characteristics of pre-PsA or new onset PsA patients, and data were extracted by 2 readers. Meta-analysis was not done due to data heterogeneity (PsA classification criteria, outcome measures and length of observation). Results are reported semi-quantitatively.

Results

Of 31449 references, 22 studies were included of which 12 were prospective; 7 retrospective and 3 cross-sectional. Eighteen studies reported on patients with PsO (n=95828) later diagnosed as PsA (n=2136) with a mean duration of follow up of 5.2 (±3.9) years. Seven out of 18 (38.8%) studies were informative regarding the clinical features of the new onset PsA. Four studies on early UA patients (n=492) later diagnosed as PsA (n=49) were included. Progression to PsA was associated with the presence of musculoskeletal (MSK) complaints (mainly joint tenderness) and the presence of subclinical MSK inflammation detected by imaging. Peripheral oligo-arthritis was the prevalent clinical presentation of new onset PsA.

Conclusion

As expected, joint pain and imaging evidence of MSK inflammation were associated with PsA development in PsO patients. The SLR highlights the lack of robust evidence regarding data associated with the development of PsA. More prospective studies focusing on transition from PsO to PsA are needed.

Table 1.FeaturesTransition from PsO to PsA (n = 18 studies)Transition from UA to PsA (n = 4 studies)Clinical characterization of New Onset PsA (n = 5 studies)Patient reported symptomsVAS pain+++NAEntheseal pain+NAMorning stiffness+NAFatigue+NAHAQ more compromised++NAArthralgia+++NAClinical examinationJoint tenderness+++++++Swelling joints++++Entheseal tendernessMajor domain of pattern presentationPeripheral arthritis (more frequent)+++PolyarthritisMono-oligoarthritis++Inflammatory marker(s)CRP++ImagingMSK inflammation detected by imaging++++Radiographic evidence of specific damage++

Legend:

PsO = psoriasis (affecting skin); PsA = psoriatic arthritis; UA = undifferentiated inflammatory arthritis; VAS = visual-analogue scale; NA = not applicable; HAQ = health assessment questionnaire; CRP = C-reactive protein; MSK = musculoskeletal

+ = 1 study for positive association; ++ = 2 studies for positive association; +++ >= 3 studies for positive association

References

[1]https://www.eular.org/ongoing_initiatives.cfm

Disclosure of Interests

Alen Zabotti Speakers bureau: Amgen, Lilly, Janssen, Novartis, UCB, Paid instructor for: Amgen, Janssen, Grant/research support from: Novartis, Gabriele De Marco: None declared, Laure Gossec Speakers bureau: AbbVie, Amgen, BMS, Galapagos, Gilead, GSK, Janssen, Lilly, Novartis, Pfizer, Samsung Bioepis, Sanofi-Aventis, UCB, Grant/research support from: Amgen, Galapagos, Lilly, Pfizer, Sandoz, Xenofon Baraliakos: None declared, Jenny Emmel: None declared, Daniel Aletaha Speakers bureau: Abbvie, Amgen, Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Grant/research support from: Abbvie, Amgen, Lilly, Novartis, Roche, SoBi, Sanofi, Annamaria Iagnocco: None declared, Josef S. Smolen: None declared, Dennis McGonagle Speakers bureau: Janssen, Lilly, UCB, Abbvie, Pfizer, Celgene, Grant/research support from: Janssen

OP0287 IMMUNOMODULATORY THERAPIES FOR SEVERE FORMS OF COVID-19: A SYSTEMATIC LITERATURE REVIEW TO INFORM EULAR POINTS TO CONSIDER

Background:

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) pandemic is a global health problem. Beside the specific pathogenic effect of SARS-CoV-2, a deleterious aberrant non-effective host immune response plays an important role especially in severe forms of COVID-19. There is intense investigation to explore the utility of immunomodulatory drugs commonly used in the Rheumatology arena as agents that may mitigate against COVID-19 to improve disease prognosis. Rheumatologists are used to the utilization of these immune targeted therapies.

Objectives:

To summarize the available information on the use of immunomodulatory agents in severe COVID-19.

Methods:

As part of a EULAR taskforce, a systematic literature search was conducted from January 2019 up to December 11, 2020. Two reviewers independently identified eligible studies according to the PICO framework P (population): patients with SARS-CoV-2 infection; I (intervention): any immunomodulator agent/strategy; C (comparator): any comparator; O (outcome) any clinical outcome including but not limited to mortality, admission to intensive care unit and clinical improvement. Data on efficacy and safety of immunomodulatory agents utilized therapeutically in SARS-CoV-2 infection at any stage were extracted. The risk of bias was assessed using validated tools.

Results:

Of 60372 records, 401 articles were eligible for inclusion. Studies were at variable risk of bias. Randomised controlled trials (RCTs) were available for the following drugs: hydroxychloroquine (N=12), glucocorticoids (N=6), tocilizumab (N= 4), convalescent plasma (N=4), interferon beta (N=2), IVIg (N=2) and N=1 each for anakinra, baricitinib, colchicine, leflunomide, ruxolitinib, interferon kappa, and vilobelimab. For glucocorticoids, dexamethasone reduced mortality only in patients requiring respiratory support; while methylprednisolone reduced mortality in patients aged 60 years or over. Data from RCTs on tocilizumab are conflicting and definite conclusions cannot be drawn at this point in time, but recent studies suggest possible benefit in patients requiring respiratory support. Hydroxychloroquine was not beneficial at any disease stage, one RCT with anakinra was negative, one RCT with baricitinib+remdesivir was positive, and individual trials testing some other compounds provided interesting, albeit preliminary, results.

Conclusion:

Although there is emerging evidence about immunomodulatory therapies for the management of COVID-19, conclusive data is scarce with some conflicting data. Since glucocorticoids seem to improve survival in some subsets of patients, RCTs comparing glucocorticoids alone versus glucocorticoids plus anti-cytokine/immunomodulatory treatment are warranted. This SLR informed the initiative to formulate EULAR points to consider on pathophysiology and use of immunomodulatory therapies in COVID-19.

Figure 1.

Forest plots showing the risk ratio (RR) and 95% confidence interval for mortality in randomized controlled trials divided by intervention. The latest follow-up available is reported in the timing column.

Disclosure of Interests:

None declared

POS0052 PATHOPHYSIOLOGY OF ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 INFECTION: A SYSTEMATIC LITERATURE REVIEW TO INFORM EULAR POINTS TO CONSIDER

Background:

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is a global health problem. Beside the specific pathogenic effect of SARS-CoV-2, incompletely understood deleterious and aberrant host immune responses play critical roles in severe disease. Rheumatologists have the best experience of studying and treating these complicated hyperinflammatory processes.

Objectives:

To summarize the available information on pathophysiology of COVID-19.

Methods:

As part of a EULAR taskforce, two systematic literature reviews were performed one on pathophysiology and one on immunomodulatory therapies. Two reviewers independently identified eligible studies according to the following PICO framework: P (population): patients with SARS-CoV-2 infection; I (intervention): any intervention/no intervention; C (comparator): any comparator; O (outcome) any clinical or serological outcome including but not limited to immune cell phenotype and function and serum cytokine concentration. The results pertaining to pathophysiology of COVID-19 are presented here.

Results:

Of the 55496 records yielded, 85 articles were eligible for inclusion. Included studies were at variable risk of bias and exploring various aspects of disease pathogenesis from immune to non-immune cells (Table 1). Pro-inflammatory cytokines’ expression including IL-6, was increased, especially in severe COVID-19, although not as high as other states with severe systemic inflammation. Innate and adaptative immune cell compartments were differentially affected by SARS-CoV-2 infection: neutrophils displayed an immature differentiation state and also increased neutrophil extracellular traps (NETs) formation. Dendritic cell number was reduced and classical monocytes was increased although displaying a reduced expression of HLA-DR. The lymphoid compartment was also affected: lymphopenia was present with a reduced number of CD4+ and CD8+ T lymphocytes and more frequent PD1+CD8+ T cells corresponding to an exhausted phenotype. Antibody response to SARS-CoV-2 infection showed a high variability across individuals and disease spectrum. Multiparametric algorithms showed variable diagnostic performances in predicting survival, hospitalization, disease progression or severity, and mortality. Differences in SARS-CoV-2 manifestations in adults and children were highlighted.

Conclusion:

Overall, SARS-CoV-2 infection affects both innate and adaptative immune responses in a variable way, according to both disease severity and individual parameters. This SLR informs the EULAR points to consider on pathophysiology and use of immunomodulatory therapies in COVID-19.

Table 1.

Studies on SARS-CoV-2 infection pathogenesis

Research questionNCytokines profile7Immune profile18Algorithm17Children3Comorbidities1Endothelial dysfunction and platelets8Gut and microbiota3Genetics and variants8Histology7Antibodies profiles8Viral load and immune response4Interferon3Immunosenecsnce3Total90*

*Some manuscripts were including in several research questions. Total number of studies included n=85.

Disclosure of Interests:

Aurelie Najm Speakers bureau: BMS, Consultant of: BMS, Alessia Alunno: None declared, Xavier Mariette Speakers bureau: BMS, Eli Lilly, Galapagos, Gilead, GSK, Janssen, Novartis, Pfizer, Servier and UCB, Consultant of: BMS, Eli Lilly, Galapagos, Gilead, GSK, Janssen, Novartis, Pfizer, Servier and UCB, Benjamin Terrier Speakers bureau: Roche, Chugai, Vifor Pharma, GSK, AstraZeneca, Terumo BCT, LFB and Grifols, Consultant of: Roche, Chugai, Vifor Pharma, GSK, AstraZeneca, Terumo BCT, LFB and Grifols, Gabriele De Marco: None declared, Laura Mason: None declared, Jenny Emmel: None declared, Dennis McGonagle Speakers bureau: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, Consultant of: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, Pedro M Machado Speakers bureau: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, Consultant of: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB.

[The motor activity study segment as pilot study of The Child and Adolescent Health Survey]

In the Health Survey for Children and Adolescents the examination of motor activity is one aspect of physical health covered by the study. This underlines the importance of physical activity for physical development in early years. This first representative child and adolescent study for Germany intends to obtain data on motor activity and to allow for the implementation of specific intervention programmes encouraging physical activity. The specific general conditions under which the survey is conducted restrict the selection and scope of possible instruments to a minimal programme, including fitness tests, strength in combination with endurance and coordinative skills as well as flexibility. In a pilot study the suitability, feasibility and the obtained evidence of selected single motor tests were tested. This article explains the choice of instruments and methods used in the examination of physical fitness. It also discusses methodological difficulties which affect the standardisation of tests and the requirements regarding personnel. A major concern of the pilot study was the evaluation of tested instruments with regard to gender and age differences. For the main survey the following tests are recommended: coordination (balancing backwards, one-leg-footing, sideway jumping), perseverance (sit-ups, push-ups), and flexibility (trunk bending).