AB0965 Serial serology testing in patients with psoriatic arthritis- Should it be done?

Background

The diagnosis of psoriatic arthritis (PsA) is largely based on clinical phenotype due to the heterogeneity of the presenting features, which can include synovio-entheseal disease, dactylitis, skin and nail disease, uveitis and axial involvement. (1)

In contrast to rheumatoid arthritis (RA), PsA is a seronegative inflammatory arthropathy. Rheumatoid factor (RF) and Anti-CCP antibodies are usually absent in PsA, and if patients do have positive serological findings for RF or CCP, the titres tend to be low. (2)

Seronegativity for RF has a significantly high discriminant value in the Classification Criteria for Psoriatic arthritis (CASPAR), such that a negative RF forms one of the five possible criteria; thus serological testing is often done once at the initial diagnostic appointment. (3)

A previous study in the context of RA has shown that there is a tendency for repeated serological testing with as much as 70% of patients having RF tested more than once.(4) Repeated testing amounts to additional expense and is rarely needed in PsA.

The literature on the frequency of repeated serology testing in PsA patients is absent.

Objectives

To determine how often was serology for RF and anti-CCP antibodies repeated in a PsA cohort.

Methods

A cohort of consecutive patients attending the rheumatology clinic at our centre with a diagnosis of PsA were included.

We reviewed the laboratory results of individual patients to determine how many times each patient had been tested for RF and anti-CCP antibodies.

Results

118 patients with a diagnosis of PsA were included. 117 patients had RF antibody testing at least once and all 118 patients had a minimum of one anti-CCP antibody test.

59/117 (50.4%) patients had RF checked more than once and 28/117 (23.9%) had testing at least 3 times. 3 patients had an initial positive RF which was negative on subsequent testing.

Anti-CCP antibody was checked on all 118 patients. 41/118 (34.7%) patients had anti-CCP checked more than once and 13/118 (11.0%) patients had testing at least 2 times. One patient had an initial equivocal anti-CCP antibody titre which was subsequently negative on repeat testing.

Conclusion

As opposed to RA, PsA has not been associated with the presence of circulating antibodies. The presence or absence of RF in PsA patients has for long been a subject of debate. (3)

In cases of peripheral polyarticular PsA, which may be difficult to distinguish from RA, serological testing can be useful to identify RA. However, studies have found that RF can be present in 5-13% of PsA patients. (5)

In the context of RA, serological conversion from negative to positive is infrequent and repeat testing is not recommended. (6)

Over half of the patients in our PsA cohort had repeated RF testing. Certainly this is unlikely to be helpful or cost effective and serial serology measurements in PsA patients should be avoided.

References

[1]Veale DJ, Fearon U. The pathogenesis of psoriatic arthritis. The Lancet. 2018;391(10136):2273-84.

[2]Merola JF, Espinoza LR, Fleischmann R. Distinguishing rheumatoid arthritis from psoriatic arthritis. RMD Open. 2018;4(2):e000656.

[3]Veale DJ, Fearon U. What makes psoriatic and rheumatoid arthritis so different? RMD Open. 2015;1(1):e000025-e.

[4]Orr C, Young F, Veale DJ. AB0243 How Often Are Serology Tests Repeated in RA Patients, and What Are the Merits? Annals of the Rheumatic Diseases. 2015;74(Suppl 2):972.

[5]Punzi L, Podswiadek M, Oliviero F, Lonigro A, Modesti V, Ramonda R, et al. Laboratory findings in psoriatic arthritis. Reumatismo. 2007;59 Suppl 1:52-5.

[6]Reid AB, Wiese M, McWilliams L, Metcalf R, Hall C, Lee A, et al. Repeat serological testing for anti-citrullinated peptide antibody after commencement of therapy is not helpful in patients with seronegative rheumatoid arthritis. Internal Medicine Journal. 2020;50(7):818-22.

Disclosure of Interests

None declared

AB0903 Dual Immunomodulatory Therapies in Psoriatic Disease

Background

Since the advent of numerous biologic therapies and small molecular drugs targeting specific cytokines and signalling pathways; the management of patients with psoriatic arthritis (PsA) has significantly improved. However, at least 40% of PsA patients exhibit an incomplete or failure to respond to these treatments.

While the outcomes of patients with psoriasis (Pso) has dramatically improved with monoclonal antibody therapies targeting IL-23 and IL-17A; achieving a measurable low disease activity state such as minimal disease activity (MDA) for musculoskeletal manifestations of psoriatic disease is infrequent. Given the complex and heterogeneity of signalling pathways, cytokines and cell types resulting in synovio-entheseal disease in PsA; new treatment strategies must be evaluated to induce deep and sustainable clinical responses in all the phenotypic domains of psoriatic disease (cutaneous, synovium, entheseal and axial). (1)

In patients who do not achieve remission in all clinical domains on a biologic monotherapy or combination of a biologic therapy with an oral synthetic agent; dual targeted anti-cytokines strategies or combined biologic with a targeted oral small molecule are a possible treatment option.

Objectives

To describe a series of four patients with recalcitrant psoriatic disease and failure to respond to previous treatment regimens who were successfully treated with dual immunomodulatory therapies.

Methods

Patients on dual immunomodulatory therapies attending our department were prospectively followed and clinical response monitored.

Results:

Table 1.Age/genderDiagnosisprior therapiescombination therapydoseadverse eventsCase 149/ MalePsA + PsOMethotrexate, adalimumab, etanercept, infliximab, golimumab, certolizumab, ustekinumab, secukinumab, ixekizumabBaracitinib + infliximab4mg OD + 5mg/kg Q8WNoneCase 251/ MalePsA + PsOMethotrexate, etanercept, adalimumab, ustekinumab, infliximab, secukinumab, apremilast, ixekizumab, brodalumab, guselkumabAdalimumab + guselkumab40mg QoW +100mg Q8WNoneCase 351/ FemalePsA + PsOMethotrexate, sulphasalazine, etarnercept, certolizumab, leflunomide, infliximab, adalimumab, secukinumab, ustekinumab, tofacitinib, abatacept, baracitinibAdalimumab + tofacinitib40mg QoW + 5mg BDNoneCase 439/ MalePsA +PsOMethotrexate, etanercept, ustekinumab, adalimumab, secukinumab, ixekizumab, sulphasalazineIxekizumab + baracitinib80mg Q4W+ 4mg ODNoneFigure 1.

Mini-Arthroscopy of left knee for Case 3 prior to starting dual immunomodulator therapy.

(A) Macroscopic aspects of synovitis (B) Synovium vascularization

Conclusion

Multiple pathways and mediators are responsible for the initiation of and sustained joint inflammation and damage seen in PsA. A phase II trial of ABT-122, a biologic engineered to target both TNF and IL-17A showed statistically significant superior efficacy outcomes at multiple time points based on ACR50, ACR70 and psoriasis outcome measures (PASI75/PASI90) when compared to adalimumab, with similar safety profile.(2)

Safety concerns such as infectious risks are important considerations with such strategies; however, the targeted second-generation anti-cytokine biologics and targeted JAK-I have exhibited improved safety profiles.(3) In our small case series, patients have not, to date, experienced adverse events of combination therapy.

References

[1]Haberman RH, Castillo R, Scher JU. Induction of remission in biologic-naive, severe psoriasis and PsA with dual anti-cytokine combination. Rheumatology. 2021;60(7):e225-e6.

[2]Mease PJ, Genovese MC, Weinblatt ME, Peloso PM, Chen K, Othman AA, et al. Phase II Study of ABT-122, a Tumor Necrosis Factor– and Interleukin-17A–Targeted Dual Variable Domain Immunoglobulin, in Patients With Psoriatic Arthritis With an Inadequate Response to Methotrexate. Arthritis & Rheumatology. 2018;70(11):1778-89.

[3]Scher JU, Ogdie A, Merola JF, Ritchlin C. Moving the Goalpost Toward Remission: The Case for Combination Immunomodulatory Therapies in Psoriatic Arthritis. Arthritis & Rheumatology. 2021;73(9):1574-8.

Disclosure of Interests

None declared

Dynamic voltage attenuation identifies atrial fibrosis in a rabbit model: simultaneous assessment with optical mapping and contact electrogram mapping

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation. Academy of Medical Sciences.

Background

Bipolar voltage amplitude is a widely-used clinical parameter in atrial electrophysiology procedures. However, voltage amplitude is variable, and it has been shown that increasing activation rate decreases bipolar voltage amplitude in patients with atrial fibrillation. It is not known whether such voltage attenuation is a marker of the presence of atrial fibrosis which could therefore be used to improve intra-procedural assessment of atrial cardiomyopathy.

Purpose

We sought to investigate the effect of increasing activation rate on bipolar voltage amplitude in both healthy and fibrotic left atrial tissue.

Methods

10 New Zealand Rabbits were fed a high cholesterol diet (0.75%) for a period of 12 weeks to create an atrial fibrosis model. 10 Animals were fed normal chow. After terminal anaesthesia the heart was excised, and optical and voltage mapping of the excised left atrial tissue was performed. Blebbistatin was used to maintain cardiac stasis and the voltage sensitive dye RH237 was used for optical mapping. Voltage and optical recordings were made during pacing was from 3 different directions at rates from 2-6Hz and at 3 sites across the atrial tissue. Voltage amplitude was recorded as the mean amplitude over 10 beats during steady-state pacing. Optical recordings were used to measure conduction velocity and action potential characteristics. Only pacing runs showing 1:1 conduction were included in analysis. Atrial fibrosis was assessed using Masson’s Trichrome staining.

Results

The degree of atrial fibrosis was significantly greater in the atrial fibrosis model compared to healthy controls (15±3.24% vs. 9.74±4.98%, p=0.0069). Median voltage at base rate pacing of 2Hz was not significantly different between control and fibrotic atria (11.63mV, IQR 6.35mV vs. 10.3mV, IQR 6.81mV, p=0.71, respectively). Median voltage was significantly lower at 6Hz than at 2Hz in the control group (9.84mV, IQR 6.87mV, p=0.046). The degree of voltage attenuation between study groups was not significantly different between when pacing at 3hz or 4hz, whereas pacing at 5Hz and 6Hz showed significantly greater attenuation in fibrotic atria. At 5Hz the median reduction in amplitude from baseline in control vs fibrotic atria was 0.88mV, IQR 2.36mV vs 1.92mV, IQR 1.63mV (p=0.031). At 6 Hz the median reduction was 0.94mV, IQR 1.69mV vs 2.68mV, IQR 1.11mV, p=0.013 in control and fibrotic groups respectively.

Discussion

High cholesterol diet increased atrial fibrosis in a rabbit model. Bipolar voltage amplitude attenuation occurred in both control and fibrotic atria however the degree of voltage attenuation was significantly greater in fibrotic atria. These findings support the further evaluation of dynamic voltage attenuation for intraprocedural identification of atrial fibrosis.

Atrial tissue characterisation using electroanatomic voltage mapping and cardiac magnetic resonance imaging

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Background

Atrial voltage mapping and atrial cardiac magnetic resonance imaging are two contemporary methods for quantification of atrial fibrosis. However, the absence of a gold standard for measuring atrial fibrosis has precluded their direct comparison. Nevertheless, understanding the relative performance of voltage mapping and atrial late gadolinium enhancement for identification of atrial cardiomyopathy remains critical to correctly targeting clinical application of these techniques.

Purpose

To assess the relative performance of electroanatomic voltage mapping and atrial late gadolinium enhancement imaging using three surrogate markers chosen to distinguish pre-procedural utility (progression to recurrent atrial fibrillation following ablation) from potential utility for providing atrial fibrillation mechanistic insights (paroxysmal vs. persistent status of atrial fibrillation and relationship with co-morbidities associated with atrial fibrillation).

Methods

123 patients underwent atrial late gadolinium enhancement imaging and electroanatomic voltage mapping prior to atrial fibrillation ablation. Atrial late gadolinium enhancement imaging was assessed with CEMRG software and electroanatomic voltage mapping processed with OpenEP software using previously published thresholds. Low voltage tissue was defined at (1) <0.5mV, (2) <1.17mV, and (3) <1.3mV. Atrial fibrosis using late gadolinium enhancement was defined using four thresholds (1) signal intensity >3.3 standard deviations above the blood pool mean; (2) image intensity ratio (IIR) 1.2x blood pool mean; (3) IIR 1.32x blood pool mean; and (4) IIR 0.97x blood pool mean.

Results

Patients with persistent atrial fibrillation and those with CHA2DS2VaSc >2 had increased low voltage area for each of the thresholds tested, but there was no increase in atrial late gadolinium enhancement area at any of the imaging thresholds tested.

Increased atrial fibrosis using IIR>0.97 was independently associated with recurrence of atrial fibrillation (OR 1.05 (CI 1.01-1.09), p=0.009) in both univariate and multivariate analysis. Low voltage area <1.13mV and low voltage area <1.17mV were associated with increased risk of recurrence (OR 1.02 (CI 1.01-1.04), p=0.01, and OR 1.03 (CI 1.01-1.04), p=0.009) in univariate analysis but neither voltage threshold remained statistically significant in multivariate analysis controlling for clinical variables.

Conclusion

Increased fibrosis burden measured with atrial magnetic resonance imaging, but not with low voltage area, is independently associated with recurrence of atrial fibrillation following catheter ablation. However, increased low voltage area measured with electroanatomic mapping is associated with persistent atrial fibrillation status and CHADS2VaSc score. These findings support the use of magnetic resonance imaging for pre-procedure assessment and the use of electroanatomic mapping for intraprocedural mechanism-based assessment of atrial cardiomyopathy.

POS1216 SYMPTOM RATES, ATTITUDES AND MEDICATION ADHERENCE OF RHEUMATIC AND MUSCULOSKELETAL DISEASE PATIENTS DURING THE SARS-CoV2 PANDEMIC

Background:

SARS-CoV2 has caused over two million deaths globally. The relationship between rheumatic and musculoskeletal disease (RMDs), immunosuppressive medications and COVID-19 is unclear.

Objectives:

This study explores the rates of COVID-19 symptoms and positive tests, DMARD adherence and attitudes to virtual clinics. amongst RMD patients.

Methods:

An online population survey was disseminated via the Arthritis Ireland website and social media channels.

Results:

There were 1381 respondents with RMD, 74.8% were on immunosuppressive medication. COVID-19 symptoms were reported by 3.7% of respondents of which 0.46% tested positive, no different from the general population at that timepoint. The frequency of COVID-19 symptoms was higher for respondents with spondyloarthropathy [odds ratio (OR) 2.06, 95% CI: 1.14, 3.70] and lower in those on immunosuppressive medication (OR 0.48, 95% CI: 0.27, 0.88), and those compliant with health authority (HSE) guidance (OR 0.47, 95% CI: 0.25, 0.89). Adherence to RMD medications was reported in 84.1%, with 57.1% using health authority guidelines for information on medication use. Importantly, adherence rates were higher amongst those who cited guidelines (89.3% vs 79.9%, P <0.001), and conversely lower in those with COVID-19 symptoms (64.0% vs 85.1%, P =0.009). Finally, the use of virtual clinics was supported by 70.4% of respondents.

Conclusion:

The rate of COVID-19 positivity in RMD patients was similar to the general population. COVID-19 symptoms were lower amongst respondents on immunosuppressive medication and those adherent to medication guidelines. Respondents were supportive of HSE advice and virtual rheumatology clinics.

Disclosure of Interests:

Kieran Murray Grant/research support from: Bresnihan Molloy and Newman fellowships, Sean Quinn: None declared, Matthew Turk: None declared, Anna O’Rourke: None declared, Eamonn Molloy: None declared, Lorraine O’Neill: None declared, Anne Barbara Mongey: None declared, Ursula Fearon: None declared, Douglas Veale: None declared.

POS0964 CHARACTERISTICS AND BURDEN OF DISEASE IN PATIENTS WITH RADIOGRAPHIC VERSUS NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS IN THE ANKYLOSING SPONDYLITIS REGISTRY OF IRELAND COHORT

Background:

Axial spondyloarthritis (axSpA) is an umbrella term for types of inflammatory arthritis that primarily affect the spine and the sacroiliac joints. It is comprised of patients with both radiographic (r-axSpA) and non-radiographic features (nr-axSpA). R-axSpA was historically known as Ankylosing Spondylitis. Previous studies have shown the burden of disease to be largely similar in patients with radiographic versus non-radiographic axial spondyloarthritis in cohorts both in the US and Europe [1]. The Ankylosing Spondylitis Registry of Ireland (ASRI) was formed with the objective to measure the burden of axial spondyloarthritis in the population and identify early predictors of a poor outcome. All patients in the registry are 18 years or older and meet Assessment of Spondyloarthritis International Society (ASAS) criteria for a diagnosis of SpA.

Objectives:

To compare the characteristics and burden of disease in patients with radiographic versus non-radiographic axial spondyloarthritis in the ASRI cohort.

Methods:

Patients with radiographic axial spondyloarthritis (r-axSpA) were defined as those with x-ray evidence of sacroiliitis. Patients with non-radiographic axial spondyloarthritis (nr-axSpA) were defined as having MRI evidence of sacroiliitis but no x-ray evidence of sacroiliitis. A standardised clinical assessment was performed on each patient and structured interviews provided patient-reported data. For each patient the following scores were captured: Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Health Assessment Questionnaire (HAQ) assesses the self-reported functional status for performing activities of daily living, and the Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire. Categorical variables were summarized as percentages with frequency counts, and continuous variables with a mean and standard deviation. Statistical comparisons between subgroups were evaluated using 2 sample t-tests for continuous variables and chi-square tests for categorical variables.

Results:

764 patients were available for analysis. Analysis of radiographic status showed 88.1% (n=673) of patients with r-axSpA and 11.9% (n=91) with nr-axSpA. Patients with nr-axSpA were younger (41.3 vs. 46.6 years, p<0.01), had shorter disease duration (14.8 vs. 20.2 years, p<0.01), lower proportion of males (66.6% vs. 78.4%, p=0.02) with lower rates of HLA-B27 positivity (73.6% vs. 90.5%, p<0.01). The nr-axSpA group had lower BASDAI (3.37 vs. 4.05, p=0.01), BASFI (2.46 vs. 3.88, p<0.01), BASMI (2.33 vs. 4.34, p<0.01), ASQoL (5.2 vs. 6.67, p=0.02), and HAQ scores (0.38 vs. 0.57, p<0.01). There were no significant differences in the prevalence of extra-articular manifestations.

Conclusion:

This study provides evidence that the burden of disease is less in patients with non-radiographic axial spondyloarthritis than radiographic axial spondyloarthritis, as demonstrated by better BASDAI, BASFI, BASMI, HAQ and ASQoL scores.

References:

[1]López-Medina C, et al. Characteristics and burden of disease in patients with radiographic and non-radiographic axial Spondyloarthritis: a comparison by systematic literature review and meta-analysis. RMD Open, 2019. 5(2) p1108.

Table 1.r-axSpAnr-axSpAp valuen67391Age (years)46.6 (+/-12.4)41.3 (+/-12.4)<0.01Disease duration (years)20.2 (+/-12.4)14.8 (+/-11.7)<0.01Delay to diagnosis (years)8.41 (+/-8.6)6.34 (+/-7.2)0.03Males78.8% (528)65.9% (60)0.02Females21.5% (145)34.1% (31)0.02HLA-B27+90.50%(440 of 486 available results)73.60%(53 of 72 available results)<0.01BASDAI4.05 (+/-2.39)3.37 (+/-2.31)0.01BASFI3.88 (+/-3.00)2.46 (+/-2.39)<0.01BASMI4.34 (+/-2.08)2.33 (+/-1.42)<0.01ASQoL6.67 (+/-5.55)5.2 (+/-5.53)0.02HAQ0.57 (+/-0.54)0.38 (+/-0.44)<0.01Psoriasis17.8% (120)15.4% (14)0.31IBD11% (74)8.8% (8)0.58Uveitis33.9% (228)34.1% (31)0.54

Disclosure of Interests:

Sean Quinn: None declared, Sinead Maguire: None declared, Finbar Barry O’Shea: None declared, Lorraine O’Neill: None declared, Eamonn Molloy: None declared, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Phil Gallagher: None declared, Douglas Veale Speakers bureau: AbbVie, BMS, Celgene, Pfizer, MSD, Roche, Consultant of: AbbVie, Actelion, BMS, Novartis, Pfizer, MSD, Roche, Regeneron/Sanofi, Grant/research support from: AbbVie, Pfizer, MSD, Novartis, Roche, Janssen.