Can the Dose of Belimumab be Reduced in Patients with Systemic Lupus Erythematosus?

OBJECTIVES

The aims of this study were to investigate the prevalence of dose reduction in patients with SLE treated with belimumab (BEL) in Spain, analyze treatment modalities, and determine impact on control of disease activity.

METHODS

Retrospective longitudinal and multicentre study of SLE patients treated with BEL. Data on disease activity, treatments and outcomes were recorded before and after reduction (6-12 months), and they were compared.

RESULTS

A total of 324 patients were included. The dose was reduced in 29 patients (8.9%). The dosing interval was increased in 9 patients receiving subcutaneous BEL and in 6 patients receiving intravenous BEL. The dose per administration was reduced in 16 patients.Pre-reduction status was remission (2021 DORIS) in 15/26 patients (57.7%) and LLDAS in 23/26 patients (88.5%). After reduction, 2/24 patients (8.3%) and 3/22 patients (13.6%) lost remission at 6 months and 12 months, respectively (not statistically significant [NS]). As for LLDAS, 2/23 patients (8.7%) and 2/21 patients (9.5%) lost their status at 6 and 12 months, respectively (NS). Significantly fewer patients were taking glucocorticoids (GCs) at their 12-month visit, although the median dose of GCs was higher at the 12-month visit (5 [0.62-8.75] vs 2.5 [0-5] at baseline).

CONCLUSION

Doses of BEL can be reduced with no relevant changes in disease activity-at least in the short term-in a significant percentage of patients, and most maintain the reduced dose. However, increased clinical or serologic activity may be observed in some patients. Consequently, tighter post-reduction follow-up is advisable.

FANCJ promotes PARP1 activity during DNA replication that is essential in BRCA1 deficient cells

The effectiveness of poly (ADP-ribose) polymerase inhibitors (PARPi) in creating single-stranded DNA gaps and inducing sensitivity requires the FANCJ DNA helicase. Yet, how FANCJ relates to PARP1 inhibition or trapping, which contribute to PARPi toxicity, remains unclear. Here, we find PARPi effectiveness hinges on S-phase PARP1 activity, which is reduced in FANCJ deficient cells as G-quadruplexes sequester PARP1 and MSH2. Additionally, loss of the FANCJ-MLH1 interaction diminishes PARP1 activity; however, depleting MSH2 reinstates PARPi sensitivity and gaps. Indicating sequestered and trapped PARP1 are distinct, FANCJ loss increases PARPi resistance in cells susceptible to PARP1 trapping. However, with BRCA1 deficiency, the loss of FANCJ mirrors PARP1 loss or inhibition, with the detrimental commonality being loss of S-phase PARP1 activity. These insights underline the crucial role of PARP1 activity during DNA replication in BRCA1 deficient cells and emphasize the importance of understanding drug mechanisms for enhancing therapeutic response.

FANCJ promotes PARP1 activity during DNA replication that is essential in BRCA1 deficient cells

Single-stranded DNA gaps are postulated to be fundamental to the mechanism of anti-cancer drugs. Gaining insights into their induction could therefore be pivotal for advancing therapeutic strategies. For poly (ADP-ribose) polymerase inhibitors (PARPi) to be effective, the presence of FANCJ helicase is required. However, the relationship between FANCJ dependent gaps and PARP1 catalytic inhibition or trapping-both linked to PARPi toxicity in BRCA deficient cells-is yet to be elucidated. Here, we find that the efficacy of PARPi is contingent on S-phase PARP1 activity, which is compromised in FANCJ deficient cells because PARP1, along with MSH2, is "sequestered" by G-quadruplexes. PARP1's replication activity is also diminished in cells missing a FANCJ-MLH1 interaction, but in such cells, depleting MSH2 can release sequestered PARP1, restoring PARPi-induced gaps and sensitivity. Our observations indicate that sequestered and trapped PARP1 are different chromatin-bound forms, with FANCJ loss increasing PARPi resistance in cells susceptible to canonical PARP1 trapping. However, in BRCA1 null cells, the loss of FANCJ mirrors the effects of PARP1 loss or inhibition, with the common detrimental factor being the loss of PARP1 activity during DNA replication, not trapping. These insights underline the crucial role of PARP1 activity during DNA replication in BRCA deficient cells and emphasize the importance of understanding drug mechanisms for enhancing precision medicine.

Modified Chevrel technique for abdominal closure in critically ill patients with abdominal hypertension and limited options for closure

Abdominal compartment syndrome is a potentially life-threatening condition seen in critically ill patients, and most often caused by acute pancreatitis, postoperative abdominal vascular thrombosis or mesenteric ischemia. A decompressive laparotomy is sometimes required, often resulting in hernias, and subsequent definitive wall closure is challenging.

AIM

This study aims to describe short term results after a modified Chevrel technique for midline laparotomies in patients witch abdominal hypertension.

MATERIALS AND METHODS

We performed a modified Chevrel as an abdominal closure technique in 9 patients between January 2016 and January 2022. All patients presented varying degrees of abdominal hypertension.

RESULTS

Nine patients were treated with new technique (6 male and 3 female), all of whom had conditions that precluded unfolding the contralateral side as a means for closure. The reasons for this were diverse, including presence of ileostomies, intraabdominal drainages, Kher tubes or an inverted T scar from previous transplant. The use of mesh was initially dismissed in 8 of the patients (88,9%) because they required subsequent abdominal surgeries or active infection. None of the patients developed a hernia, although two died 6 months after the procedure. Only one patient developed bulging. A decrease in intrabdominal pressure was achieved in all patients.

CONCLUSION

The modified Chevrel technique can be used as a closure option for midline laparotomies in cases where the entire abdominal wall cannot be used.

Activity of imipenem/relebactam against Enterobacterales and Pseudomonas aeruginosa in Spain. SMART 2016-2020

OBJECTIVE

To determine susceptibility to the novel β-lactam/β-lactamase inhibitor combination imipenem/relebactam in clinical isolates recovered from intra-abdominal (IAI), urinary (UTI), respiratory (RTI) and bloodstream (BSI) infections in the SMART (Study for Monitoring Antimicrobial Resistance Trends) study in SPAIN during 2016 - 2020.

METHODS

Broth microdilution MICs for imipenem/relebactam and comparators were determined by a central laboratory against isolates of Enterobacterales and Pseudomonas aeruginosa. MICs were interpreted using EUCAST-2021 breakpoints.

RESULTS

In total, 5,210 Enterobacterales and 1,418 P. aeruginosa clinical isolates were analyzed. Imipenem/relebactam inhibited 98.8% of Enterobacterales. Distinguishing by source of infection susceptibility was 99.1% in BSI, 99.2% in IAI, 97.9% in RTI, and 99.2% in UTI. Of intensive care unit isolates (ICU) 97.4% were susceptible and of non-ICU isolates 99.2% were susceptible. In Enterobacterales, activity against Class A, Class B and Class D carbapenemases was 96.2%, 15.4% and 73.2%, respectively. In P. aeruginosa, imipenem/relebactam was active in 92.2% of isolates. By source of infection it was 94.8% in BSI, 92.9% in IAI, 91.7% in RTI, and 93.1% in UTI. An 88.7% of ICU isolates and 93.6% of non-ICU isolates were susceptible to imipenem/relebactam. Imipenem/relebactam remained active against P. aeruginosa ceftazidime-resistant (76.3%), cefepime-resistant (73.6%), imipenem-resistant (71.5%) and piperacillin-resistant (78.7%) isolates. Of all multidrug-resistant or difficult-to-treat resistance P. aeruginosa isolates, 75.1% and 46.2%, respectively, were susceptible to imipenem/relebactam.

CONCLUSIONS

Imipenem/relebactam showed high rates of susceptibility in Enterobacterales and P. aeruginosa isolates from different sources of infection as well as depending on patients' location (ICU or non-ICU scenarios).

POS0796 TREATMENT, ADVERSE EVENTS AND FOLLOW UP IN PATIENTS WITH GIANT CELL ARTERITIS IN THE ARTESER MULTICENTER STUDY

Background

Glucocorticoids (GC) are the mainstay therapy in Giant Cell Arteritis (GCA), initially at high doses (40-60 mg/day) followed by gradual glucocorticoid tapering. This treatment, especially in older patients, is associated with numerous adverse effects (AE). In addition, there are frequent relapses. Therefore, conventional synthetic immunosuppressants such as methotrexate (MTX), leflunomide, azathioprine, cyclophosphamide or mycophenolate, have been used with controversial results. Studies with biological immunosuppressants, such as TNFi have been ineffective; in contrast, tocilizumab (TCZ) has obtained positive results and was approved for the treatment of GCA.

Objectives

In the ARTESER study we describe a) treatment with GC, synthetic or biological immunosuppressants; b) AE of CG; and c) evolution.

Methods

ARTESER is a retrospective observational study sponsored by the Spanish Society of Rheumatology. 26 Spanish centers participated and all new patients diagnosed with GCA from June 1, 2013 to March 29, 2019 were included. Data on GC and immunosuppressants were collected at the beginning and during the follow-up of GCA patients. For the calculation of the cumulative dose of GC, an application was developed that, by including the periods of time, dose and type of GC received during follow-up, performs the automatic calculation in mg of prednisone.

Results

Of the 1675 patients included, GC treatment was adequately recorded in 1650 patients (Table 1). All received oral treatment, being prednisone the most frequently drug used (N=1602, 97.09%). In addition, 426 (25.82%) patients received at least one iv pulse of methylprednisolone, being the 1000 mg regimen the most frequent (n=217; 50.9%). The total mean duration of GC treatment was 22.65 months. The mean cumulative dose per patient at the end of follow-up was 8514.98 mg of prednisone.

Table 1.

Corticosteroid treatment and immunosuppressive treatment

Patients taking oral corticosteroid1650 Prednisone, n (%)1602 (97.09) Methylprednisolone, n (%)164 (9.94) Deflazacort, n (%)64 (3.88)Patients receiving intravenous corticosteroid, n (%)426 (25.82)Mean duration of steroid treatment, mean (SD)22.65 (17.36)Mean cumulative dose at the end of follow-up per patient, mg of prednisone, mean (SD)8514.98 (6570.21)Methotrexate at diagnosis*, n (%)165 (9.9)Leflunomide at diagnosis*, n (%)2 (0.1)Azathioprine at diagnosis*, n (%)3 (0.2)Cyclophosphamide at diagnosis*, n (%)7 (0.4)Mycophenolate at diagnosis*, n (%)1 (0.1)Tocilizumab at diagnosis*, n (%)22 (1.3)Methotrexate during follow-up, n (%)532 (31.8)Leflunomide during follow-up, n (%)19 (1.2)Azathioprine during follow-up, n (%)26 (1.5)Cyclophosphamide during follow-up, n (%)10 (0.6)Mycophenolate during follow-up, n (%)10 (0.6)Tocilizumab during follow-up, n (%)153 (9.1)

The most widely used immunosuppressant was MTX both at diagnosis (n=165; 9.9%) and during follow-up (n=532; 31.8%), followed by TCZ, at diagnosis (22; 1.3%) and at follow-up (153; 9.1%).

AE with GC were described in 393 patients (23.8%), highlighting serious infections (n=67; 10.03%) followed by diabetes mellitus (n=63; 9.43%), steroid myopathy (n=53; 7.9%), vertebral fractures (n=47; 7.04%), non-vertebral fractures (n=36; 5.39%), heart failure (n=36; 5.39%), arterial hypertension (n=34; 5.09%) and neuropsychiatric alterations (n=27; 4.04%).

During the follow-up, 334 (19.9%) patients had relapses, 532 (31.8%) were hospitalized on some occasion, and 142 patients (8.48%) died. The main cause of death were infections (n=44; 30.99%), neoplasms (n=23; 16.2%), cardiovascular (n=15; 10.56%), and cerebrovascular (n=10; 7.04%).

Conclusion

The main treatment for GCA was oral GC, which were required for almost two years on average, in a quarter of patients associated with IV pulses. The cumulative steroid dose was high as well as the side effects. MTX was the most widely used immunosuppressant and TCZ was prescribed in 10%. Relapses and admissions at the hospital were relatively frequent.

Acknowledgements

This study has been funded by ROCHE Farma. The funder has not participated in the design, analysis, or interpretation of the results

Disclosure of Interests

None declared

Assessment of optimal thresholds for ventricular scar substrate characterization using the high density grid multipolar mapping catheter

Funding Acknowledgements

Type of funding sources: None.

Background

Voltage thresholds for ventricular scar definition are based on historic data collected using catheters with widely spaced bipoles in the absence of contact force. Modern multipolar mapping catheters employ smaller electrodes and interelectrode spacing that theoretically allows for mapping with increased resolution and reduced far-field electrogram (EGM) component. Despite the advancement in technology, historic cut-offs of <0.5mV for dense scar and 0.5-1.5mV for scar borderzone continue to be used in contemporary electrophysiology.

Purpose

We aimed to assess the optimal voltage cut-offs for ventricular scar substrate characterization using the HD Grid multipolar mapping catheter. Voltage cut-offs were assessed against cardiac MRI derived scar. We compared optimal voltage cut-offs using conventional bipolar sampling, the Best Duplicate Algorithm and with the HD wave solution plus best duplicate algorithm on.

Methods

A multicentre study of twenty patients undergoing VT ablation was conducted. Substrate mapping was performed using the high-density HD-grid multipolar mapping catheter. Bipolar voltage maps were co-registered with cardiac MRI obtained prior to the procedure to assess the voltage characteristics of scar defined by cardiac MRI (CMR) (Figure 1). Pre-procedure contrast enhanced CMR data were analysed using ADAS software (Galgo medical). Data points were collected in regions of scar during (1) HD wave mapping with best duplicate algorithm on(Waveon), (2) Mapping with HD wave off and best duplicate on (Waveoff) and (3) with conventional bipolar mapping (Alloff).

Results

The median bipolar voltage for regions of dense CMR scar using (Waveon) HD wave solution and best duplicate algorithm was 0.27mV (IQR 0.14 – 0.46). The median voltage with (Waveoff) HD wave off was 0.29mV (0.15 – 0.45). The median voltage with (Alloff) HD wave off and best duplicate off was 0.32mV (0.19 – 0.5). ROC analysis using AUC suggested the optimal cut-off for endocardial dense scar using (Waveon) HD wave mapping and best duplicate algorithm was 0.30mV (sensitivity: 69.6%, specificity: 60.74%), (Waveoff) cut-off with the best duplicate and without the HD wave mapping was 0.34mV (sensitivity: 69.78%, specificity: 64.46%) and (Alloff) without wave mapping or best duplication was 0.36mV (sensitivity: 84%, specificity: 52%) Figure 2.

Conclusion

Ventricular substrate characterization with newer mapping technology using narrow electrode spacing and smaller electrode size suggests that traditional voltage cut-offs may need revision for delineation of scar characteristics. Additionally, the ability to repeat sample in a region to obtain the best signal (Best Duplicate), and the ability to obviate the effect of wavefront direction using the HD wave solution omnipolar technology, may further increase the fidelity of scar characterization. This has important implications for mapping VT and characterizing channels in order to identify VT circuits.

Replication gaps are a key determinant of PARP inhibitor synthetic lethality with BRCA deficiency

Mutations in BRCA1 or BRCA2 (BRCA) is synthetic lethal with poly(ADP-ribose) polymerase inhibitors (PARPi). Lethality is thought to derive from DNA double-stranded breaks (DSBs) necessitating BRCA function in homologous recombination (HR) and/or fork protection (FP). Here, we report instead that toxicity derives from replication gaps. BRCA1- or FANCJ-deficient cells, with common repair defects but distinct PARPi responses, reveal gaps as a distinguishing factor. We further uncouple HR, FP, and fork speed from PARPi response. Instead, gaps characterize BRCA-deficient cells, are diminished upon resistance, restored upon resensitization, and, when exposed, augment PARPi toxicity. Unchallenged BRCA1-deficient cells have elevated poly(ADP-ribose) and chromatin-associated PARP1, but aberrantly low XRCC1 consistent with defects in backup Okazaki fragment processing (OFP). 53BP1 loss resuscitates OFP by restoring XRCC1-LIG3 that suppresses the sensitivity of BRCA1-deficient cells to drugs targeting OFP or generating gaps. We highlight gaps as a determinant of PARPi toxicity changing the paradigm for synthetic lethal interactions.

POS0579 LOCAL ADAPTATION OF RECOMMENDATION-BASED MATERIALS FOR SHARED DECISION-MAKING AND MANAGEMENT OF COMORBIDITY IN RHEUMATOID ARTHRITIS

Background:

Evolving the management of rheumatoid arthritis (eRA) is a European-wide educational initiative aiming to support improved patient care through practical and educational tools addressing specific unmet needs. The aims of the eRA program were: (1) To identify priority unmet needs with the greatest impact on disease outcomes; (2) To develop practical, educational and guidance tools in line with EULAR recommendations to address identified unmet needs; and (3) To improve RA management and patient care.

Objectives:

To describe the process by which local adaptations were made of materials derived from evidence-based recommendations in a training programme in rheumatoid arthritis (RA).

Methods:

A multidisciplinary Steering Committee (17 members, 12 countries) identified unmet needs within the management of RA and prioritised those with the greatest impact on patient outcomes. Practical educational tools addressing priority needs were then developed for dissemination and implementation by the rheumatology community across Europe, including shared decision making practises and a checklist for managing comorbidity in RA, among others. These materials were evaluated in detailed and discussed in small regional groups by practicing rheumatologists. Voting, open discussions and recommendations were extracted from the meetings.

Results:

Thirty-five Spanish rheumatologists from diverse geographic regions discussed a comorbidity checklist and a shared decision making tool. The results of the local meetings were synthesised as (1) a judicious commitment to check agreed comorbidities, and (2) a list of barriers and facilitators for the implementation of shared decision making at the local settings. With regards to ways to implement the agreed list and periodicity, two issues standed-out: (1) patient education and (2) the need of easy access to information and the use of local organisational systems in place. With respect to shared decision-making, issues raised included messages for self-awareness, challenges, and practical facilitators.

Conclusion:

Discussion, adaptation, and planning are needed before implementing any evidence-based recommendation and materials if we want to achieve a successful implementation. Further studies should demonstrate whether this initiative was successful in achieving the goals of improved patient care. Our experience could be used as a guidance or example for implementation elsewhere.

Disclosure of Interests:

None declared

POS0627 SHORT-TERM EFFECT OF ANTI-IL-6 THERAPY ON ADIPONECTIN SERUM LEVELS IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Adiponectin is an adipokine with anti-inflammatory, anti-atherosclerotic and cardioprotective effects that also contributes to the pathogenesis of metabolic syndrome (MetS) [1]. MetS is frequently observed in patients with rheumatoid arthritis (RA), increasing the risk of cardiovascular (CV) morbidity and mortality in these patients [1-3]. A recent study of our group disclosed a short-term effect of anti-IL-6 therapy on serum levels of leptin (another adipokine with pro-inflammatory functions, related with MetS and CV disease) in RA patients [4]. Accordingly, it is plausible to think that such treatment may also have an effect in adiponectin levels.

Objectives:

To determine the short-term effect of the anti-IL-6 receptor tocilizumab (TCZ) administration on circulating adiponectin serum levels in patients with RA, as well as the potential association of adiponectin with demographic and clinical features of these patients.

Methods:

50 consecutive Spanish patients undergoing periodic treatment with TCZ who fulfilled the 2010 classification criteria for RA [5] were recruited. Adiponectin serum levels were assessed in samples obtained immediately prior to (pre-infusion) and 60 minutes after the end of a TCZ intravenous infusion (post-infusion) by a commercial Enzyme-Linked ImmunoSorbent Assay (ELISA) kit.

Results:

Similar serum levels of adiponectin were found following the TCZ infusion (mean ± standard deviation: 23.01 ± 18.58 µg/mL versus 22.35 ± 17.84 µg/mL, pre- and post-infusion, respectively, p=0.69). Additionally, there was a negative correlation between adiponectin basal levels and body mass index (r=-0.45, p<0.01), insulin (r=-0.33, p=0.02), insulin/glucose index (r=-0.32, p=0.03) and C-peptide levels (r=-0.32, p=0.03) of RA patients, whereas a strong positive correlation was observed with HDL-cholesterol levels (r=0.51, p<0.01). Moreover, basal levels of adiponectin were significantly lower in obese patients when compared to those with normal weight (p=0.03).

Conclusion:

Our study suggests that anti-IL-6 therapy has no short-term effect on adiponectin serum levels in patients with RA. Furthermore, our results support that low adiponectin levels are associated with MetS features and, therefore, with CV disease in RA.

References:

[1]Biochem Pharmacol. 2019;165:196-206; [2] Clin Exp Rheumatol. 2008;26:596-603; [3] Mediators Inflamm. 2013;2013:710928; [4] Clin Exp Rheumatol 2020;38:1201-1205; [5] Arthritis Rheum. 2010;62:2569-2581.

Acknowledgements:

Personal funds:

SR-M: RD16/0012/0009 (ISCIII-ERDF); VP-C: PREVAL 18/01 (IDIVAL); OG: GPC IN607B2019/10 (GAIN); RL-M: Miguel Servet type I programme CP16/00033 (ISCIII-ESF).

Disclosure of Interests:

Sara Remuzgo-Martínez: None declared, Verónica Pulito-Cueto: None declared, Fernanda Genre: None declared, Jaime Calvo: None declared, Elena Aurrecoechea: None declared, Irene Llorente: None declared, Ana Triguero-Martinez: None declared, Ricardo Blanco Speakers bureau: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen and MSD, Consultant of: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen and MSD, Grant/research support from: Abbvie, MSD and Roche, Javier Llorca: None declared, M E Ruiz: None declared, Natalia Rivera: None declared, Oreste Gualillo: None declared, Raquel López-Mejías: None declared, Santos Castañeda: None declared, Miguel A González-Gay Speakers bureau: Pfizer, Abbvie, MSD, Grant/research support from: Pfizer, Abbvie, MSD.

Stimulated whole salivary flow rate: The most appropriate technique for assessing salivary flow in Sjögren syndrome

BACKGROUND

We sought to determine the most appropriate method for measuring salivary flow to aid the diagnosis of Sjögren's syndrome (SS). Specifically, we compared the unstimulated whole salivary flow rate (UWSFR) with the stimulated whole salivary flow rate (SWSFR).

MATERIAL AND METHODS

This case-control study comprised one group of 103 patients with SS and a control group of 50 healthy people. We measured the UWSFR and SWSFR in both groups according to the guidelines established by Navacet [1993].

RESULTS

The UWSFR and SWSFR were significantly lower in the patient group compared with the controls (p < 0.01). Among the participants in the patient group, we found a decreased UWSFR in 84 individuals (81.5%) and a decreased SWSFR in 90 individuals (87.4%). We encountered difficulties obtaining saliva in 37 (35.9%) patients during the UWSFR test, and in 12 (11.7%) patients during the SWSFR test. There was no significant statistical difference in the UWSFR or SWSFR between patients with primary and secondary SS.

CONCLUSIONS

Compared with the UWSFR, the SWSFR is a more suitable and effective method for measuring salivary flow in patients with SS, as well as for qualitative analysis of the obtained saliva.

Description of Influenza B in seasonal epidemic in Cantabria during the beginning of the pandemia due to SARS-CoV-2

Introduction. Co-circulation of the two Influenza B lineages hinders forecast of strain to include in trivalent vaccine. Autonomous Communities such as Cantabria continue without supplying tetravalent vaccine. The aim of this study was to analyse epidemiological characteristics of influenza type B in Cantabria (2019-2020 season) as well as to establish the predominant lineage and its relation to the recommended vaccine. Methods. Retrospective study whereby flu diagnosis and lineage analysis were determined by RT-PCR. Results. All samples belonged to the Victoria lineage. Most prevalent viral co-infection was due to SARS-CoV-2. The population affected by influenza B was mainly paediatric and non-vaccinated patients more frequently required hospital admittance. Conclusions. Influenza type B has a higher incidence in the paediatric population and type A affects more the adult population. Only 28.8% of patients with Influenza B that presented with some underlying condition or risk factor were vaccinated. This shows the need to increase coverage with tetravalent vaccines in order to reduce the burden of disease associated with the Influenza B virus.

Carex divisa, una nueva ciperácea naturalizada en Chile

Carex divisa se registra por primera vez en Chile. Se incluye una discusión taxonómica para su apropiada determinación.

THU0579 “EVOLVING THE MANAGEMENT OF RA” PROGRAMME: EDUCATIONAL TOOLS TO SUPPORT DAILY PRACTICE

Background:

The eRA (evolving the management of RA) programme was initiated in Europe to provide practical educational tools that address unmet needs in the management of rheumatoid arthritis (RA). Several eRA tools – covering early access to care, management of comorbidities, treat-to-target strategies, and patient empowerment – are available to the rheumatology community. Through ongoing activities, the eRA Steering Committee (SC) identified a need for tools on non-pharmacological management of RA.

Objectives:

To improve accessibility to eRA tools for rheumatology professionals; to review the evidence base of non-pharmacological interventions to create new eRA resources that may support management decisions.

Methods:

A web platform providing information on eRA programme and tools was developed in 2019. The platform collects survey-based metrics to quantify perception of eRA and use of eRA tools in clinical practice. Platform and tools are translated to further support access and use across Europe.

To address unmet needs in non-pharmacological patient management, the eRA SC reviewed the core literature on agreed priority interventions, including physical activity, diet, patient education and self-management, psychosocial interventions, occupational therapy and orthotics, hand exercises, and hydrotherapy/balneotherapy. Available evidence for each intervention was assessed and graded according to the Oxford Centre for Evidence-based Medicine Levels of Evidence.

Results:

The eRA web platform is now live in 3 countries (www.evolvingthemanagementofRA.com), hosting translated copies of the eRA tools, with additional countries launching throughout 2020.

From a review of core literature on non-pharmacological interventions, the eRA SC determined that strong evidence exists to support use of physical activity, patient education and self-management, psychosocial interventions, and occupational therapy and orthotics. Evidence was lacking or conflicting for diet and nutrition, hand exercises, and balneotherapy/hydrotherapy. A set of educational slides was produced by the eRA SC to summarise the evidence (Fig. 1) and provide top-line guidance on use of interventions in practice that should engage relevant members of the multi-disciplinary team. These slides are available through eRA dissemination activities.

Conclusion:

The eRA programme content is now freely available to health care professionals in several countries on a web platform, supported by translations of the eRA tools. An additional slide set on non-pharmacological management serves to further increase the practical guidance of this programme’s educational offering.

Acknowledgments:

The eRA programme is funded by Sanofi Genzyme. Programme direction and content creation are driven by an independent Steering Committee

Disclosure of Interests:

Gerd Rüdiger Burmester Consultant of: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Speakers bureau: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Jose-Maria Alvaro-Gracia Grant/research support from: Abbvie, Elli-Lilly, MSD, Novartis, Pfizer, Consultant of: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Paid instructor for: Elli-Lilly, Pfizer, Roche, Speakers bureau: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, Gedeon Richter, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Neil Betteridge Consultant of: Amgen, Eli Lilly and Company, Grunenthal, GSK, Sanofi Genzyme, Jaime Calvo Grant/research support from: Lilly, UCB, Consultant of: Abbvie, Jansen, Celgene, Bernard Combe Grant/research support from: Novartis, Pfizer, Roche-Chugai, Consultant of: AbbVie; Gilead Sciences, Inc.; Janssen; Eli Lilly and Company; Pfizer; Roche-Chugai; Sanofi, Speakers bureau: Bristol-Myers Squibb; Gilead Sciences, Inc.; Eli Lilly and Company; Merck Sharp & Dohme; Pfizer; Roche-Chugai; UCB, Patrick Durez Speakers bureau: AbbVie, Bristol-Myers Squibb, Celltrion, Eli Lilly, Pfizer, Sanofi, Ricardo J. O. Ferreira Grant/research support from: Abbvie, Consultant of: Sanofi Genzyme, Amgen, MSD, Paid instructor for: UCB, Bruno Fautrel Grant/research support from: AbbVie, Lilly, MSD, Pfizer, Consultant of: AbbVie, Biogen, BMS, Boehringer Ingelheim, Celgene, Lilly, Janssen, Medac MSD France, Nordic Pharma, Novartis, Pfizer, Roche, Sanofi Aventis, SOBI and UCB, Annamaria Iagnocco Grant/research support from: Abbvie, MSD and Alfasigma, Consultant of: AbbVie, Abiogen, Alfasigma, Biogen, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Sanofi and Sanofi Genzyme, Speakers bureau: AbbVie, Alfasigma, BMS, Eli-Lilly, Janssen, MSD, Novartis, Sanofi, Carlomaurizio Montecucco: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Sofia Ramiro Grant/research support from: MSD, Consultant of: Abbvie, Lilly, Novartis, Sanofi Genzyme, Speakers bureau: Lilly, MSD, Novartis, Andrea Rubbert-Roth Consultant of: Abbvie, BMS, Chugai, Pfizer, Roche, Janssen, Lilly, Sanofi, Amgen, Novartis, Tanja Stamm Grant/research support from: AbbVie, Roche, Consultant of: AbbVie, Sanofi Genzyme, Speakers bureau: AbbVie, Roche, Sanofi, Zoltán Szekanecz Grant/research support from: Pfizer, UCB, Consultant of: Sanofi, MSD, Abbvie, Pfizer, Roche, Novertis, Lilly, Gedeon Richter, Amgen, Peter C. Taylor Grant/research support from: Celgene, Eli Lilly and Company, Galapagos, and Gilead, Consultant of: AbbVie, Biogen, Eli Lilly and Company, Fresenius, Galapagos, Gilead, GlaxoSmithKline, Janssen, Nordic Pharma, Pfizer Roche, and UCB, Mart van de Laar Consultant of: Sanofi Genzyme, Speakers bureau: Sanofi Genzyme

AB0698 REAL CLINICAL PRACTICE IN THE CONTROL OF REPORTED OUTCOMES BY THE PATIENT (PROS) DIAGNOSED WITH PSORIATIC ARTHRITIS AND/OR ANKYLOSING SPONDYLITIS WHO BEGIN TREATMENT WITH SECUKINUMAB. A PROSPECTIVE MULTICENTRIC STUDY

Background:

Objectives:

Analyse the effect of secukinumab in terms of the patient´s own variables, specifically: fatigue, sleep, pain and quality of life in patients with psoriatic arthritis or spondyloarthritis.

Methods:

A multicentric longtitudinal observational prospective study was carried out at 6 months in patients who begin treatment with secukinumab. At the start and after 6 months the following data was collected on the outcome: pain through an visual analogue scale (VAS), fatigue using the FACIT-fatigue scale, sleeping problems using the insomnia severity index (ISI) and quality of life with the EuroQol-3L-5D and the PsAQoL.

The sample can be described in terms of the distribution of the variables through measures of central tendency.It was analysed if the change after 6 months was statistically relevant using Student´s t-test for paired data in the case of FACIT, VAS, PsAQoL and ISI and chi-squared for the dimensions of the EQ-5D. The size of the effect of each of the measurements taken was calculated using Cohen’s D. the results are given grouped by disease and globally. The analysis was carried out using Stata v12 (College Station Tx, USA)

Results:

In table 1, the changes in the scales of normal distribution can be seen. Apart from general VAS, all the scales experience significant relevant changes. The PROs preferred by the patient with the best therapeutic response is the quality of sleep. The adjustment of the regression models does not produce changes in the results, apart from small adjustments to the condidence intervals (final column table 1). The subdomain in which the most significant change in the EQ-5D is produced is in that of pain and discomfort.

Conclusion:

After 6 months patients who begin treatment with secukinumab, present with improvements in all sizes of the effects of the treatment in the various studied scales. The improvement achieves global and generalised statistical significance after 6 months of study. The greatest effect is on sleep, quality of life and fatigue.

The measurements of the outcomes reported by the patients are a clinical value added to our objective evaluations of the health and activity of the disease, and allow us, in a more integrated and comprehensive manner, to undertake a more exact and close evaluation of their state of health and wellbeing.

Disclosure of Interests:

JUAN JOSE LERMA: None declared, Antonio Gracia: None declared, Antonio Perez: None declared, Amalia Rueda: None declared, Clara Molina: None declared, M. Dolores Pastor: None declared, Isabel Balaguer Trull: None declared, Inmaculada Valiente: None declared, Cristina Campos Fernández: None declared, Javier Calvo: None declared, Loreto Carmona Grant/research support from: Novartis Farmaceutica, SA, Pfizer, S.L.U., Merck Sharp & Dohme España, S.A., Roche Farma, S.A, Sanofi Aventis, AbbVie Spain, S.L.U., and Laboratorios Gebro Pharma, SA (All trhough institution)

OP0002 INCIDENCE OF FIRST CARDIOVASCULAR EVENT IN SPANISH PATIENTS WITH CHRONIC INFLAMMATORY RHEUMATIC DISEASES: PROSPECTIVE DATA FROM THE CARMA PROJECT AFTER 5 YEARS OF FOLLOW-UP

Objectives:

To determine the incidence and risk factors implicated in the development of first cardiovascular (CV) event (CVE) in patients with chronic inflammatory rheumatic diseases (CIRD) attending Spanish rheumatology clinics after 5 years of follow-up

Methods:

Analysis of data of patients included in an observational prospective study [CARdiovascular in rheuMAtology (CARMA) project] after 5 years of follow-up. The study includes a cohort of 2234 patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA), and another cohort of matched individuals (n=677) without CIRD from 67 hospitals in Spain. Cumulative incidence per 1000 patients of CVE was estimated in both cohorts at 5 years from the start. Weibull proportional hazard model was used to calculate the Hazard Ratio (HR) and 95% confidence intervals (CI) of the risk factors involved in the development of CV events. Losses to follow-up and their causes were also analyzed.

Results:

The total number patient who completed the follow-up visit at 5 years was 2.382 (81.9%). Fifteen patients died due to CVE and sixty due to non-CVE. The patients with CIRD showed higher cardiovascular cumulative incidence (40.5; 95% CI: 36.2-44.8) than controls (28.3; 95% CI: 21.8-34.8). The higher risk of developing a first CVE during the 5 years of follow-up was seen in patients with AS (HR: 4.60; 95% CI: 1.32-15.99; p=0.02), those with older age (HR:1.09; 95% CI: 1.05-1.13; p<0.001), higher systolic blood pressure (HR: 2.64; 95% CI: 1.32-5.25; p=0.006), and those with longer duration of the rheumatic disease (HR: 1.07; 95% CI: 1.03-1.12; p=0.002). In contrast, woman gender was a protective factor (HR: 0.45; 95% CI: 0.21-0.99; p=0.047).

Conclusion:

Patients with AS prospectively followed-up at rheumatology outpatient clinics showed higher risk of developing a first CVE than those without CIRD. Besides traditional CV disease risk factors, a longer time course of the disease is a risk factor for the development of CV disease in patients with CIRD.

Acknowledgments:

This project has been supported by an unrestricted grant from Abbvie, Spain. The design, analysis, interpretation of results and preparation of the manuscript has been done independently of Abbvie.

Disclosure of Interests:

Maria Auxiliadora Martin-Martinez: None declared, Santos Castañeda: None declared, Fernando Sánchez-Alonso: None declared, Carmen García Gomez: None declared, Carlos Gonzalez Juanatey: None declared, Maria Angeles Belmonte: None declared, Jesús Tornero: None declared, José Santos Rey: None declared, CARMEN OLGA SANCHEZ GONZALEZ: None declared, Estefanía Quesada-Masachs: None declared, MARIA DELPUERTO MORENO GIL: None declared, Tatiana Cobo-Ibáñez: None declared, Jose Antonio Pinto Tasende: None declared, Jesús Babío: None declared, Gemma Bonilla: None declared, Antonio Juan Mas: None declared, Javier Manero: None declared, Montserrat Romera: None declared, Javier Bachiller-Corral: None declared, Eugenio Chamizo Carmona: None declared, Javier Calvo: None declared, Raimon Sanmarti: None declared, Maria Celia Erausquin: None declared, Rosario Garcia de Vicuna Grant/research support from: BMS, Lilly, MSD, Novartis, Roche, Consultant of: Abbvie, Biogen, BMS, Celltrion, Gebro, Lilly, Mylan, Pfizer, Sandoz, Sanofi, Paid instructor for: Lilly, Speakers bureau: BMS, Lilly, Pfizer, Sandoz, Sanofi, Carmen Barbadillo: None declared, Sergio Ros Exposito: None declared, Javier del Pino Grant/research support from: Roche, Bristol, Consultant of: Gedeon, MARIA JOSE GONZALEZ: None declared, José Manuel Pina Salvador: None declared, Javier Llorca: None declared, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD

FRI0481 HEMOPHAGOCYTIC SECONDARY SYNDROME. DIFFERENCES BETWEEN AUTOIMMUNE AND HEMATO-ONCOLOGICAL ETIOLOGIES

Background:

The Hemophagocytic Syndrome (HPS) is has been classified into 2 groups: primary and secondary. The secondary form is mainly associated with hemato-oncological diseases (HOD) and autoimmune diseases (AID). The present work aims to obtain clinical and analytical data that can guide us to an etiological diagnosis.

Objectives:

To describe and identify the differences between HPS secondary to AID and HOD during their admission to a tertiary hospital between 2005 and 2019.

Methods:

This is a retrospective observational study. We include patient meeting the diagnostic criteria for HLH proposed by Henter JI. (1), or who presented haemophagocytic cells (HC) in the bone marrow biopsy (BMB), or who had HPS in the hospital discharge report. Demographic, clinical, analytical, etiological, underlying disorders and prognosis variables were collected. Continuous variables are described with the mean or median according to the degree of normality. Kruskal Wallis, Fisher test and Mann-Whitney U test were used for the bivariate analysis, and also a multivariate logistic regression analysis was performed.

Results:

We found 30 patients with secondary HPS, 22 of which corresponded to the AID [Systemic Lupus Erythematosus (n=5), Adult Still’s Disease (n=3), Rheumatoid arthritis (n=1) and IgG4 Sclerosing Disease (n=1)] and HOD [Non-Hodgkin’s Lymphoma (n=3), Myelodysplastic syndrome (n=3), Acute leukemia (n=3), Extranodal NK cell lymphoma (n=1), Multiple Myeloma (n=1) and probable lymphoproliferative process (n=1)]. The coincidence of an infectious disease with HPS was observed in 8 of the 22 cases [AID: 5 cases (2Cytomegalovirus, 2 viral respiratory infections and 1 bacterial infection) and HOD: 3 cases (2Epstein Barr virusand 1 bacterial infection)]. In two patients with HPS secondary to HOD (acute leukemia), allogeneic transplantation was associated as a possible trigger. In a patient with myelodysplastic syndrome, HPS was associated with the development of graft versus host disease. The age at diagnosis was lower in the AID [40 (26.5 - 56.3); p 0.001]. The HOD had more severe cytopenias [platelets 4500 (650 - 15,750; p 0.009), leukocytes 2050 (20 - 728; p 0.0001) and neutrophils 0 (0 - 280; p 0.002)]. Overall mortality (n=30 patients) was 43.3% (HOD: 66.7%; p 0.029) (table 1). In the final multivariate model according to AID and HOD, the following independent associations were observed: age (p 0.002), platelets (p 0.031), GOT (p 0.012), GPT (p 0.015), total proteins (p 0.007) and mortality (p 0.007).

Table 1.

Characteristics and comparative analysis of HPS secondary to AID and HOD

TotalAIDHODn301012*p<0,05Age(x± s)55,5±18,34026,5-56,36857,5-73,80,001Gender, male1446,7%330%975%0,084Spenomegaly1653,3%550%866,7%0,666Hepatomegaly1033,3%440%433,3%1,000Hb (g/dL)7,16,4-7,97,26,6-8,46,55,9-7,30,05Pt (x109/L)13 5005 000-52 50031 65011 000-100 2504 500650-15 7500,004Leu (x109/L)1 250238-3 1531 9851 350-3 38218520 – 7280,000Neu (x109/L)6150-1 550948633-1 80800-2800,001Fb (mg/dL) (n=24)171111-35821290-450167114-3541,00Fer (ng/mL) (n=28)15 3305 434-38 28414 2634 254-14 26316 7968 287 - 56 9690,314Tg (mmol/L)341226-438411,5234-572321233,8-403,80,314GOT (U/L)13978-406457289-1 14010671-1930,003GPT (U/L)16246-388432174-59910954-2630,017T.P. (n=29)4,8±,1,045,04,5-5,84,33,9-4,50,003Hospital stay35,520,0-60,830,59,5-53,361,529,3-93,30,036Hospital stay pre-dx16,58,5-29,8105,0-16,52610-390,038Mortality1343,3%110%866,7%0,011

Hb: hemoglobin, Pt: platelets, Leu; leukocytes, Neu, neutrophils, Fb: fibrinogen, Fer: ferritin, Tg: triglycerides, GOT: aspartate aminotransferase, GPT: alanine aminotransferase, T.P.: total proteins, pre-dx: prior to the diagnosis of HPS according to BMO. *Analysis between AID and HOD.

Conclusion:

The HOD presented higher mortality and severe cytopenias. The AID presented a higher elevation of transaminases and better prognosis.

References:

[1]Henter JI, et al. HLH-2004: Diagnostic and therapeutic guidelines for HLH.Pediatr Blood Cancer. 2007;48:124.

Disclosure of Interests:

César Antonio Egües Dubuc: None declared, Andrea De Diego: None declared, Patricia Cabrera Miranda: None declared, Nerea Alcorta Lorenzo: None declared, Jesús Alejandro Valero Jaimes: None declared, Jose Ramon Furundarena Salsamendi: None declared, Luis Maria Lopez Dominguez: None declared, Jorge Jesús Cancio Fanlo: None declared, Olga Maiz-Alonso: None declared, Esther Uriarte Isacelaya: None declared, Jaime Calvo Grant/research support from: Lilly, UCB, Consultant of: Abbvie, Jansen, Celgene, Joaquin Maria Belzunegui Otano: None declared

FRI0487 APREMILAST IN MONOTHERAPY OR COMBINED IN NON-ULCER MANIFESTATIONS OF BEHÇET’S DISEASE. NATIONAL MULTICENTER STUDY OF 34 REFRACTORY CASES OF CLINICAL PRACTICE

Background:

Apremilast (APR) has demonstrated efficacy in orogenital ulcers of Behçet´s disease (BD). Response of other clinical manifestations remains unknown.

Objectives:

To assess the efficacy and safety of APR in monotherapy or combined with disease-modifying anti-rheumatic drugs (DMARDs) in non-aphthous ulcers of BD.

Methods:

National multicenter open-label study on 34 BD patients treated with APR at maintained standard dose of 30 mg twice daily.

Results:

From a cohort of 51 patients with APR by refractory orogenital ulcers of BD, we selected 34 (24 women/10 men, mean age 43.8±14.3 years), cases with another clinical manifestation/s.

Excluding CTs, colchicine or NSAIDs, APR was given in monotherapy (n=21) or combined with conventional and/or biologic DMARDs in 13 cases (5 methotrexate, 3 azathioprine, 3 hydroxychloroquine, 1 sulfasalazine, 1 dapsone, 2 tocilizumab, 1 IFX). Other active manifestations present at APR onset were: arthralgia/arthritis (16, true arthritis in 5), folliculitis/pseudofolliculitis (14), erythema nodosum (3), furunculosis (2), paradoxical psoriasis by TNFi (2), intestinal ileitis (2), deep venous thrombosis (2), leg ulcers (1), erythematosus and scaly skin lesions (1), fever (1), unilateral anterior uveitis (1) and neurobehçet (1).

After a median follow-up of 6 [3-12] months, folliculitis and ileitis improved, neurobehçet remained stable and musculoskeletal manifestations evolved in a variable way.(TABLE)

TABLE.

Conclusion:

In addition of orogenital ulcers, APR in monotherapy or combined, seems to be useful in skin manifestations of BD

Disclosure of Interests:

Alba Herrero Morant: None declared, Belen Atienza Mateo: None declared, J. Loricera: None declared, Vanesa Calvo del Rio Grant/research support from: MSD and Roche, Speakers bureau: Abbott, Lilly, Celgene, Grünenthal, UCB Pharma, José Luis Martín-Varillas Grant/research support from: AbbVie, Pfizer, Janssen and Celgene, Speakers bureau: Pfizer and Lilly, Gerard Espinosa: None declared, Jenaro Graña: None declared, Clara Moriano: None declared, Trinidad Pérez Sandoval: None declared, Manuel Martín Martínez: None declared, Elvira Diez: None declared, María Dolores García-Armario: None declared, Esperanza Martínez: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, Patricia Moya Alvarado: None declared, Francisca Sivera: None declared, Jaime Calvo Grant/research support from: Lilly, UCB, Consultant of: Abbvie, Jansen, Celgene, Isabel de la Morena: None declared, Francisco Ortiz Sanjuán: None declared, José Andrés Román Ivorra: None declared, Ana Pérez Gómez: None declared, Alejandro Olive: None declared, Carolina Díez: None declared, Juan José Alegre: None declared, D Ybáñez-García Speakers bureau: Lilly, Roche, Sanofi, Ángels Martínez-Ferrer: None declared, Javier Narvaez: None declared, Ignasi Figueras: None declared, Ana Isabel Turrión: None declared, Susana Romero-Yuste: None declared, Pilar Trénor: None declared, Soledad Ojeda Speakers bureau: AMGEN, LILLY, GEBRO, Miguel Á. González-Gay Grant/research support from: AbbVie, MSD and Roche, Speakers bureau: AbbVie, MSD and Roche, Ricardo Blanco Grant/research support from: Abbvie, MSD and Roche, Consultant of: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen and MSD, Speakers bureau: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen, Lilly and MSD

THU0307 RESPONSE OF BEHÇET’S REFRACTORY ORAL AND/OR GENITAL ULCERS TO APREMILAST IN COMBINATION VS MONOTHERAPY. NATIONAL MULTICENTER STUDY OF 51 CASES OF CLINICAL PRACTICE

Background:

Apremilast (APR) has demonstrated efficacy in the treatment of oral and/or genital aphthous ulcers in Behçet´s disease (BD). Combination of APR to other disease-modifying anti-rheumatic drugs (DMARDs) has not been assessed.

Objectives:

To compare the efficacy and safety of APR in monotherapy or combined with DMARDs in refractory BD.

Methods:

National multicenter open-label study on 51 BD patients with oral and/or genital ulcers refractory to conventional treatment.

Results:

We included 51 patients (35 women/16 men), mean age 44.7±13.2 years. Before APR, all patients had received several systemic conventional drugs. The main clinical symptoms for starting APR were oral (n=19) and genital (2) aphthous ulcers or both (30).

Excluding corticosteroids, colchicine or NSAIDs, APR was given at standard dose of 30 mg twice daily in monotherapy (n=31), or combined with conventional DMARDs in 16 cases (6 azathioprine, 5 methotrexate, 4 hydroxychloroquine, 4 sulfasalazine, 1 dapsone) or with biologic DMARDs in 4 (2 tocilizumab, 1 adalimumab, 1 infliximab). There were not found statistically significant differences in demographic features, previous therapy, clinical manifestations or reported adverse effects.

After a median follow-up of 6 [3-12] months, most of the patients experienced improvement of the orogenital ulcers in both groups (89.8% in the first 2 weeks), without statistically significant differences.(TABLE)

Conclusion:

APR leads to a rapid and maintained improvement in most patients with refractory BD orogenital ulcers. APR seems as effective and safe in monotherapy as combined.

TABLE:Week 1-2Week 4Month 6Month 12Month 24Outcome of oral and/or genital ulcers n, (%)Cn=19Mn=30Cn=19Mn=26Cn=12Mn=17Cn=7Mn=6Cn=1Mn=1 Complete resolution8 (42.1)11 (36.7)12 (63.2)20 (77)7 (58.4)14 (82.4)3 (42.8)3 (50)1 (100)1 (100) Partial resolution9 (47.4)16 (53.4)7 (36.8)3 (11.5)5 (41.6)2 (11.7)4 (57.2)3 (50)00 No response2 (10.5)3 (9.9)03 (11.5)01 (5.9)0000p value0.90.10.10.80.7

Abbreviations: C= combined; M= monotherapy; n= available data.

Disclosure of Interests:

Alba Herrero Morant: None declared, Belen Atienza Mateo: None declared, J. Loricera: None declared, Vanesa Calvo del Rio Grant/research support from: MSD and Roche, Speakers bureau: Abbott, Lilly, Celgene, Grünenthal, UCB Pharma, José Luis Martín-Varillas Grant/research support from: AbbVie, Pfizer, Janssen and Celgene, Speakers bureau: Pfizer and Lilly, Jenaro Graña: None declared, Gerard Espinosa: None declared, Clara Moriano: None declared, Trinidad Pérez Sandoval: None declared, Manuel Martín Martínez: None declared, Elvira Diez: None declared, María Dolores García-Armario: None declared, Esperanza Martínez: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, Patricia Moya Alvarado: None declared, Francisca Sivera: None declared, Jaime Calvo Grant/research support from: Lilly, UCB, Consultant of: Abbvie, Jansen, Celgene, Isabel de la Morena: None declared, Francisco Ortiz Sanjuán: None declared, José Andrés Román Ivorra: None declared, Ana Pérez Gómez: None declared, Sergi Heredia: None declared, Alejandro Olive: None declared, Águeda Prior: None declared, Carolina Díez: None declared, Juanjo J Alegre-Sancho Consultant of: UCB, Roche, Sanofi, Boehringer, Celltrion, Paid instructor for: GSK, Speakers bureau: MSD, GSK, Lilly, Sanofi, Roche, UCB, Actelion, Pfizer, Abbvie, Novartis, D Ybáñez-García Speakers bureau: Lilly, Roche, Sanofi, Ángels Martínez-Ferrer: None declared, J. Narváez: None declared, Ignasi Figueras: None declared, Ana Isabel Turrión: None declared, Susana Romero-Yuste: None declared, Pilar Trénor: None declared, Soledad Ojeda Speakers bureau: AMGEN, LILLY, GEBRO, Miguel Á. González-Gay Grant/research support from: AbbVie, MSD and Roche, Speakers bureau: AbbVie, MSD and Roche, Ricardo Blanco Grant/research support from: Abbvie, MSD and Roche, Consultant of: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen and MSD, Speakers bureau: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen, Lilly and MSD

OP0262-HPR COST OF ILLNESS IN PATIENTS WITH PSORIASIS AND PSORIATIC ARTHRITIS. COEPSO STUDY

Background:

Psoriasis (Ps) and psoriatic arthritis (PsA) have a major impact on patients’ health-related quality of life. Cost of illness of patients with Ps, PsA and both diseases (PsA+Ps) is an important subject as they are associated with a substantial economic impact, with implications from a health management perspective.

Objectives:

To describe the economic burden of direct non-healthcare and indirect resources of patients with Ps, PsA and PsA+Ps in Spain.

Methods:

COEPSO (“Evaluation of Costs in patients with Psoriatic Disease”) was an observational, retrospective, cross-sectional study performed in 22 Spanish centers (17 Dermatology and 14 Rheumatology Services), from February 2017 to February 2018, including moderate to severe Ps and PsA patients (with or without Ps), naive to biologics. Direct non-healthcare (social services, home care, physical adaptations, private health and non-health professionals, non-reimbursed and non-pharmaceutical therapies), indirect (loss of productivity) and total costs (direct non-healthcare and indirect costs) related to the disease during the previous year to the study were obtained. Unitary costs (€, 2018) were calculated: out-of-pocket costs were specified directly by patients and loss of productivity costs by means of average salaries based on occupation specified by patients. The information was collected through a case report form filled out by the investigators and a telephone survey administered to the patients.

Results:

A total of 318 patients were included (196 Ps; 43 PsA and 79 PsA+Ps), mean age 48.7 years and 51.3% males. Metabolic syndrome was the most frequent comorbidity in all groups. The average annual total cost per patient was 1,042.71€ (SD 3,817.55), 1,137.84€ (SD 3,070.39) and 1,830.26€ (SD 5,835.81) for Ps, PsA and PsA+Ps, respectively. The average annual direct non-healthcare cost per patient was 749.57€ (SD 2,393.77), 750.50€ (SD 1,641.82) and 1,247.56€ (SD 4,467.19) for Ps, PsA and PsA+Ps, respectively. The average annual indirect cost per patient was 293.14€ (SD 2,855.27), 387.35€ (SD 2,409.63) and 582.71€ (SD 3,842.12) for Ps, PsA and PsA+Ps, respectively.

Patients with combined PsA+Ps had higher annual total cost (direct non-healthcare and indirect costs) than patients with only one of these manifestations separately (75.5% and 60.9% above patients with Ps and PsA, respectively). Total costs in patients with Ps and PsA were similar. Direct non-healthcare costs represent between 66.0% (patients with PsA) to 71.9% (patients with Ps) of total cost. Indirect costs represent between 28.1% (patients with Ps) to 34.0% (patients with PsA) of total cost.

Conclusion:

PsA and Ps have proved to be diseases with a high economic burden, and the total costs were mainly driven by direct non-healthcare costs. Moreover, although annual total costs in patients with PsA were similar to those of Ps patients, the combination of both manifestations yielded the highest costs suggesting the importance of the increased disease load.

Disclosure of Interests:

Santos Castañeda: None declared, Esther Vicente Speakers bureau: BMS, Roche., Mar Llamas Velasco: None declared, Javier Sanchez Perez: None declared, José Pardo: None declared, Rita Cabeza-Martínez: None declared, Mercedes Miranda-Fontes: None declared, Juan Márquez: None declared, Jaime Calvo Grant/research support from: Lilly, UCB, Consultant of: Abbvie, Jansen, Celgene, susana armesto: None declared, Isabel Belinchón: None declared, Alejandro Gómez: None declared, María Dolores Miranda: None declared, Silvia Martinez Pardo: None declared, Leticia Merino-Meléndez: None declared, Miguel Angel Casado Consultant of: UCB Pharma, María Yébenes: None declared, Araceli Casado: None declared

SAT0516 CLINICAL CHARACTERISTICS AND PROGNOSTIC FACTORS IN PATIENTS WITH SECONDARY HEMOPHAGOCYTIC SYNDROME

Background:

The Hemophagocytic Syndrome (HPS) had a mortality rate between 20% and 90%. The mortality of HPS secondary to autoimmune diseases (AID) is lower than hemato-oncological diseases (HOD). In general, the HOD, thrombocytopenia, age, and a prolongation of prothrombin are considered to be an adverse prognostic factor.(1)

Objectives:

To describe and identify differences between patients who survived and did not survive to HPS during hospital admission to a tertiary hospital between 2005 and 2019.

Methods:

This is a retrospective observational study. All patients who met the diagnostic criteria for LHH were included, or who presented haemophagocytic cells in the bone marrow biopsy, or who had diagnosis of HPS in the hospital discharge report.(2) Demographic, clinical, analytical, etiological, underlying disorder and prognosis variables were collected. Continuous variables are described with the mean or median according to the degree of normality. Kruskal Wallis, Fisher test and Mann-Whitney U test were used for the bivariate analysis, and also a multivariate logistic regression analysis was performed.

Results:

Thirty patients with HPS were included. They were distributed in 5 subgroups (Table 1). Overall mortality was 43.3%, statistically significant higher in the HOD [8 patients (66.7%); p 0.029]. Also, they were divided into 2 groups (survivor vs. non-survivor; Table 2). In the multivariate model the age and INR prolongation were confirmed to be independently associated with the outcome of mortality.

Table 1.

Etiology of HPS

Etiologyn = 30MortalityAID10n = 1 Systemic lupus erythematosus51 Adult Still’s Disease3No Rheumatoid arthritis1No Sclerosing Disease IgG41NoHOD12n = 8* Non-Hodgkin’s lymphoma31 Myelodysplastic syndrome32 Acute leukemia33 Extranodal NK cell lymphoma11 Multiple Myeloma1No Probable lymphoproliferative process11Infectious diseases2n = 1 Pneumocystis carinii in patient with H.I.V.11 Campylobacter yeyuni1NoGlyoblastoma multiforme with temozolomida1n = 0HPS without defined aetiology53

HIV: Human Immunodeficiency Virus, NK: Natural Killer. *p = 0,029

Table 2.

Characteristics and differences between survivor and non-survivor groups

TotalNon-survivorsurvivorn301317p<0,05Age55,5±18,36858,2-74,54034-570,043Women1653,3%761,5%947,1%1,00Comorbidities (≥ 2)516,7%215,4%317,6%1,000Hospital stay35,520-60,82915,5-39138-170,563Splenomegaly1653,3%753,8%952,9%1,000Hepatomegaly1033,3%538,5%529,4%0,705Hb (g/dL)7,16,4-7,9710%6,2-7,87,16,6-7,80,094Pt (x109/L)13 5005 000-52 50016 00011 000-44 00012 0005 000-99 0000,281Pt≤ 100 0002583,3%13100%1270,6%0,052Leu (x109/L)1 250238-3 1531 300150-3 9401 400200-3 3400,457Neu (x109/L)6150-1 5501 29020-3 3006500-1 4000,805Fb (mg/dL) (n=24)171111-358167,00106-253169,00103-4510,796Fer (ng/mL) (n=28)15 3305 434-38 28429 0635 728-74 60413 2258 287-28 7290,108Tg (mmol/L)341226-438254,00184-382471,00341-6040,053GOT (U/L)13977,5-406,3133,00101-513179,00101-512,50,483GPT (U/L)16246-389109,0041-333199,0099-2980,198INR (n=29)1,51,1-1,92,11,2-3,71,51,1-1,60,028

Hb: Hemoglobin, Pt: platelets, Leu: leukocytes, Neu: neutrophils, Fb: fibrinogen, Fer: ferritin, Tg: triglycerides, GOT: aspartate aminotransferase, GPT: alanine aminotransferase

Conclusion:

The HOD presented higher mortality. The non-survivor group presented a longer INR prolongation and a higher age at the time of diagnosis.

References:

[1]Parikh SA. Prog. factors and outcomes of adults with HLH. Mayo Clin Proc. 2014;89:484–492.

[2]Henter JI. HLH-2004: Diag. and therapeutic guidelines for HLH.Pediatr Blood Cancer. 2007;48:124.

Disclosure of Interests:

César Antonio Egües Dubuc: None declared, Andrea De Diego: None declared, Patricia Cabrera Miranda: None declared, Nerea Alcorta Lorenzo: None declared, Jesús Alejandro Valero Jaimes: None declared, Jose Ramon Furundarena Salsamendi: None declared, Olga Maiz-Alonso: None declared, Luis Maria Lopez Dominguez: None declared, Esther Uriarte Isacelaya: None declared, Jorge Jesús Cancio Fanlo: None declared, Jaime Calvo Grant/research support from: Lilly, UCB, Consultant of: Abbvie, Jansen, Celgene, Joaquin Maria Belzunegui Otano: None declared

Prospective multicentre study of rectal carriage of multidrug-resistant Enterobacteriaceae among health-care workers in Spain

OBJECTIVES

To investigate the rectal carriage of multidrug-resistant Enterobacteriaceae (colistin-resistant, extended-spectrum β-lactamase (ESBL) -producers and/or carbapenemase-producers) among health-care workers (HCWs) from six Spanish hospitals.

METHODS

Rectal swabs from 258 HCWs, employed in intensive care units, haematology wards and clinical microbiology laboratories from six hospitals in northern Spain were studied. They were cultured in selective media for Gram-negative resistant bacteria. Detection of antimicrobial resistance genes and multilocus sequence typing were performed by PCR and further sequencing. A questionnaire including data related to risk factors of colonization/infection by resistant bacteria (age, gender, chronic diseases, immunosuppressive therapies, invasive procedures or antimicrobial treatments) was given to each participant.

RESULTS

No carbapenemase-producing Enterobacteriaceae were recovered. However, 8/258 HCWs (3.1%) were positive for ESBL-producing isolates. This rate was not higher than the colonization rate previously reported in Spain for healthy people in the community. Five isolates showed high-level resistance to colistin (MICs ranging from 8 to 128 mg/L) but all of them were negative for the mcr genes tested. No statistically significant risk factors for gut colonization by ESBL-producing or colistin-resistant Enterobacteriaceae were identified among the HCWs participating in the study.

CONCLUSIONS

Our data suggest that working in hospitals does not represent a risk for rectal carriage of multidrug-resistant Enterobacteriaceae.

[Dual trigger with gonadotropin-releasing hormone agonist and hCG to improve oocyte maturation rate]

OBJECTIVE

This study investigates dual trigger with GnRHa and hCG as a potential treatment in patients with a history of ≥25 % immature oocytes retrieved in IVF/ICSI cycles.

METHODS

This is a retrospective case-control study performed between October 2008 and December 2017. Forty-seven patients who experienced high oocyte immaturity rate (≥25 %) during their first IVF/ICSI cycle (analyzed as control group) and received a dual trigger for their subsequent cycle, were involved. During dual trigger cycles, patients received antagonist protocol and ovulation triggering using triptorelin 0.2mg and hCG. Primary endpoint was maturation rate (MR). Secondary endpoints were fertilization, D2 top quality embryo (TQE) rates, clinical pregnancy rate per fresh embryo transfer and cumulative clinical pregnancy rate per couple.

RESULTS

A significant increase in MR was achieved in case of dual trigger (71.0 %) when compared to control group (47.8 %; P<0.0001). Moreover, cumulative clinical pregnancy rate yielded 46.8 % in dual trigger group, which was statistically higher than 27.6 % obtained in control group (P=0.05). However, fertilization, D2 TQE rates and clinical pregnancy rates/transfer were statistically similar when compared between the two groups.

CONCLUSION

Dual trigger seems efficient for managing patients with high oocyte immaturity rate.

Opposing Roles of FANCJ and HLTF Protect Forks and Restrain Replication during Stress

The DNA helicase FANCJ is mutated in hereditary breast and ovarian cancer and Fanconi anemia (FA). Nevertheless, how loss of FANCJ translates to disease pathogenesis remains unclear. We addressed this question by analyzing proteins associated with replication forks in cells with or without FANCJ. We demonstrate that FANCJ-knockout (FANCJ-KO) cells have alterations in the replisome that are consistent with enhanced replication stress, including an aberrant accumulation of the fork remodeling factor helicase-like transcription factor (HLTF). Correspondingly, HLTF contributes to fork degradation in FANCJ-KO cells. Unexpectedly, the unrestrained DNA synthesis that characterizes HLTF-deficient cells is FANCJ dependent and correlates with S1 nuclease sensitivity and fork degradation. These results suggest that FANCJ and HLTF promote replication fork integrity, in part by counteracting each other to keep fork remodeling and elongation in check. Indicating one protein compensates for loss of the other, loss of both HLTF and FANCJ causes a more severe replication stress response.

Defective glucose and lipid metabolism in rheumatoid arthritis is determined by chronic inflammation in metabolic tissues

BACKGROUND

Rheumatoid arthritis (RA) patients are at increased risk of insulin resistance (IR); however, the specific mechanisms mediating this association are currently unknown.

OBJECTIVE

To investigate whether the inflammatory activity associated with RA accounts for the observed defective glucose metabolism and lipid metabolism in these patients.

METHODS

We followed two main strategies: (i) extensive metabolic profiling of a RA cohort of 100 patients and 50 healthy control subjects and (ii) mechanistic studies carried out in both a collagen-induced arthritis mouse model and 3T3-L1 adipocytes treated with conditioned serum from RA patients.

RESULTS

Following the exclusion of obese and diabetic subjects, data from RA patients demonstrated a strong link between the degree of systemic inflammation and the development of IR. These results were strengthened by the observation that induction of arthritis in mice resulted in a global inflammatory state characterized by defective carbohydrate and lipid metabolism in different tissues. Adipose tissue was most susceptible to the RA-induced metabolic alterations. These metabolic effects were confirmed in adipocytes treated with serum from RA patients.

CONCLUSIONS

Our results show that the metabolic disturbances associated with RA depend on the degree of inflammation and identify inflammation of adipose tissue as the initial target leading to IR and the associated molecular disorders of carbohydrate and lipid homeostasis. Thus, we anticipate that therapeutic strategies based on tighter control of inflammation and flares could provide promising approaches to normalize and/or prevent metabolic alterations associated with RA.

Morbidly Obese Patients Awaiting Liver Transplantation-Sleeve Gastrectomy: Safety and Efficacy From a Liver Transplant Unit Experience

BACKGROUND

The prevalence of obesity has increased dramatically, even in the population awaiting a liver transplantation. Despite their associated complications, we cannot consider morbid obesity any longer as an absolute contraindication to liver transplantation. Dietary approaches alone are usually completely ineffective. Bariatric surgery is the gold-standard treatment for morbid obesity and can be performed before, during, or after transplantation.

MATERIALS AND METHODS

At our Liver Transplantation Unit, a single surgeon performed a sleeve gastrectomy in 8 patients with liver cirrhosis due to nonalcoholic steatohepatitis, alcohol, or HCV. The Child score was A in 6 patients and B in the remaining 2 patients. Two of our patients had portal hypertension with mild esophageal varices. The procedure was performed laparoscopically in 7 cases (87.5%); in the other case, it was performed by open approach due to portal hypertension and according to patient preferences.

RESULTS

Patients showed no postoperative morbidity or mortality. The mean postoperative body mass index of our patients was 37.4, 33.3, and 30.3 kg/m² at 3, 6, and 12 months after surgery, respectively. The mean percentage excess weight loss of our patients was 42.9%, 62.2%, and 76.3% at 3, 6, and 12 months. Two of the patients have already undergone a successful liver transplant.

CONCLUSION

Bariatric surgery in selected patients with compensated cirrhosis and without significative portal hypertension is reasonable. There are not clear guidelines on the use of bariatric surgery in patients with cirrhosis. In our experience, the sleeve gastrectomy is safe and effective in the treatment of patients with compensated cirrhosis; in a short time, the sleeve gastrectomy can improve candidacy in morbidly obese patients awaiting transplantation.

Variability in biological behaviour, pathogenicity, protectotype and induction of virus neutralizing antibodies by different vaccination programmes to infectious bronchitis virus genotype Q1 strains from Chile

In the period from July 2008 to 2010, a disease episode resulting in serious economic losses in the major production area of the Chilean poultry industry was reported. These losses were associated with respiratory problems, increase of condemnations, drops in egg production and nephritis in breeders, laying hens and broilers due to infections with infectious bronchitis virus (IBV). Twenty-five IBV isolates were genotyped and four strains were selected for further testing by pathotyping and protectotyping. Twenty-four IBV isolates were of the Q1 genotype. The experiments also included comparing the ability of six vaccination programmes to induce virus neutralizing antibodies (VNA) in layers against four selected Chilean strains. Despite the high genetic homology in the S1 gene between the four strains, the heterogeneity in biological behaviour of these different Q1 strains was substantial. These differences were seen in embryonated eggs, in cell culture, in pathogenicity and in level of cross-protection by IBV Massachusetts (Mass) vaccination. This variability underlines the importance of testing more than one strain per serotype or genotype to determine the characteristics of a certain serotype of genotype. The combination of Mass and 793B vaccine provided a high level of protection to the respiratory tract and the kidney for each strain tested in the young birds. The combination of broad live priming using Mass and 793B vaccines and boosting with multiple inactivated IBV antigens induced the highest level of VNA against Q1 strains, which might be indicative for higher levels of protection against Q1 challenge in laying birds.

European Society of Coloproctology consensus on the surgical management of intestinal failure in adults

Intestinal failure (IF) is a debilitating condition of inadequate nutrition due to an anatomical and/or physiological deficit of the intestine. Surgical management of patients with acute and chronic IF requires expertise to deal with technical challenges and make correct decisions. Dedicated IF units have expertise in patient selection, operative risk assessment and multidisciplinary support such as nutritional input and interventional radiology, which dramatically improve the morbidity and mortality of this complex condition and can beneficially affect the continuing dependence on parenteral nutritional support. Currently there is little guidance to bridge the gap between general surgeons and specialist IF surgeons. Fifteen European experts took part in a consensus process to develop guidance to support surgeons in the management of patients with IF. Based on a systematic literature review, statements were prepared for a modified Delphi process. The evidence for each statement was graded using Oxford Centre for Evidence-Based Medicine Levels of Evidence. The current paper contains the statements reflecting the position and practice of leading European experts in IF encompassing the general definition of IF surgery and organization of an IF unit, strategies to prevent IF, management of acute IF, management of wound, fistula and stoma, rehabilitation, intestinal and abdominal reconstruction, criteria for referral to a specialist unit and intestinal transplantation.

[Role of bacteriobilia in postoperative complications]

OBJECTIVE

At present there is a controversy regarding the impact of positive bile cultures on morbidity and mortality rates, and on the incidence of readmissions in patients with biliar disease. The aim of this study was to evaluate the role of bacteriobilia in postoperatory infections, mortality or readmissions in these patients.

METHODS

The information was obtained from all patients with bile cultures admitted to Hospital Universitario Marqués de Valdecilla (Santander, Spain) from January to December 2011. Clinical, epidemiological and microbiological data and laboratory findings were analyzed. The patients were followed for two years.

RESULTS

One hundred and fifty-two patients (65% men) were included. Mean age was 67 years (SD= 15 years). The most frequent diagnoses were acute cholecystitis (79%) and cholangitis (8%). Laparoscopic cholecystectomy was performed in 42% of patients, open cholecystectomy in 45% and percutaneous cholecystostomy in 8%. Bacteriobilia was present in 83 patients (55%). The most frecuent microorganisms isolated were Escherichia coli (31%), Enterococcus faecium (13%) and Klebsiella pneumoniae (13%). The initial antimicrobial agent was a carbapenem in 62 patients (44%) and piperacillin-tazobactam in 28 (18%). There were 39 postoperative infections (26%), 21 readmissions (14%) and 17 patients died during admission (11%). The presence of microorganisms in bile cultures was not a statistically significant predictor of neither complications nor readmissions.

CONCLUSIONS

Intra-operative bile cultures would allow guide early appropriate antibiotic treatment use in case of infection, or empiric antimicrobial therapy, however there was no correlation between bacteriobilia and postoperative infections, length of stay, mortality or readmissions.

[Fertility preservation in women of the childbearing age: Indications and strategies]

Advances on cryopreservation techniques now allow considering oocyte, embryo or ovarian tissue freezing for female fertility preservation. Originally developed for patients suffering from cancer, fertility preservation has rapidly invaded others medical fields, and represents now the standard of care for all young patient diagnosed with a disease that could impair fertility or having to receive possibly gonadotoxic treatment. As a result, autoimmune diseases, some genetic pathologies or iterative pelvic surgeries, at risk of premature ovarian failure, have become common indications of fertility preservation. In addition, the social egg freezing aiming at preventing the age-related fertility decline is still debated in France, although authorized in numerous countries. This review will discuss the different strategies of fertility preservation in young girls and women of reproductive age, regarding different medical or non-medical indications.

Medication-related osteonecrosis of the jaw associated with bisphosphonates and denosumab in osteoporosis

OBJECTIVE

To describe the clinical characteristics and evolution of our series of medication-related osteonecrosis of the jaws (MRONJ) associated with denosumab in osteoporotic patients.

MATERIAL AND METHODS

We present 10 new cases of MRONJ in patients receiving denosumab for osteoporosis. We describe the mean doses of denosumab, previous bisphosphonate intake, and the clinical characteristics associated with the osteonecrosis, such as local contributing factors, symptoms, and evolution after treatment.

RESULTS

The mean number of denosumab doses was 3.4 ± 2.2. In 90% of patients, there was a prior history of oral bisphosphonate intake, with a mean duration of 46.78 ± 25.11 months. The most common local factor was dental extraction (6 cases; 60%), and most cases had necrotic bone exposure (9/10, 90%). Sclerosis of the bone was the most common radiographic finding. Stage 1 was the most common ONM stage, found in 80%. 'Cure' after conservative treatments was obtained in 71.4%.

CONCLUSIONS

Most of our cases were in the early stages of MRONJ, and the success rate after conservative treatment was high.

Tenofovir/entecavir monotherapy after hepatitis B immunoglobulin withdrawal is safe and effective in the prevention of hepatitis B in liver transplant recipients

BACKGROUND AND AIMS

Combination of hepatitis B immunoglobulin (HBIG) and a nucleos(t)ide analog (NA) is considered the standard of care for prophylaxis of hepatitis B virus (HBV) recurrence after liver transplantation (LT). However, use of lifelong HBIG has significant limitations. We evaluated the efficacy and safety of entecavir (ETV) or tenofovir disoproxil fumarate (TDF) after withdrawal of HBIG in patients who had been under HBIG-regimen prophylaxis post LT.

METHODS

Patients at low risk of recurrence were eligible for HBIG discontinuation (fulminant HBV hepatitis, co-infection with hepatitis D virus, and hepatitis B e antigen-negative cirrhotic patients with HBV DNA levels <300 copies/mL). All patients had received HBIG, with or without NA, for at least 12 months after LT. After HBIG discontinuation, they continued with ETV or TDF monotherapy. Patients were followed up with HBV serum markers and evaluation of renal function.

RESULTS

Between September 2011 and June 2014, 58 liver transplant recipients were converted to TDF (31, 53%) or ETV (27, 47%). Mean follow-up after conversion was 28 ± 5 months (range 13-36 months). Five patients (8.6%) developed detectable hepatitis B surface antigen at 7, 9, 13, 15, and 22 months after HBIG discontinuation. However, in every case seroconversion was transitory, serum HBV DNA was undetectable, with no clinical manifestations of HBV recurrence. No adverse effects were observed or dose reductions required associated with ETV or TDF.

CONCLUSIONS

Maintenance therapy with newer NAs, after discontinuation of HBIG prophylaxis, was safe and effective, with a low rate of serological recurrence and no evident clinical, biochemical, or virological consequences.