Is sarcopenia a real concern in ankylosing spondylitis? A systematic literature review

PURPOSE

Sarcopenia is a condition defined as loss of muscle mass and strength, associated with poor functional performance and disability. Sarcopenia can be exacerbated or worsened in presence of inflammation, sedentary lifestyle and cytokine imbalance, thus it frequently occurs in people affected by rheumatic diseases. This systematic literature review aims to explore the association between sarcopenia and spondyloarthritis (SpA) and its most frequent manifestation, i.e. ankylosing spondylitis (AS).

METHODS

The Scopus, PubMed, and Web of Science databases were searched for articles on muscle mass, muscle strength and axial SpA, from any date to November 2023. Only studies written in English were considered. The methodological quality of the studies included in the review was evaluated using the Newcastle-Ottawa Scales for observational studies and for case-control studies.

RESULTS

190 papers were retrieved from the searches, 14 of which met the inclusion criteria. Rather than diagnosis of sarcopenia, pre-sarcopenia or probable sarcopenia were frequent in people with AS, with a great reduction especially of muscle strength. The pre-sarcopenia status appears to be related to high AS disease activity, suggesting that chronic inflammation resulting in pain, less movement and decreased physical activity could play a role in the muscle heath of AS patients.

CONCLUSIONS

Our review confirms the existence of an association between AS and loss of muscle strength-likely sarcopenia-already at a young age. Preventive and early strategies should be adopted to ensure successful aging for individuals with AS.

Which extra-renal flare is 'difficult to treat' in systemic lupus erythematosus? A one-year longitudinal study comparing traditional and machine learning approaches

OBJECTIVES

To describe phenotypes and outcomes of extra-renal flares in SLE, to identify clusters of extra-renal flares based on baseline features, and to develop a machine learning (ML) tool capable of predicting 'difficult to treat' (D2T) flares.

METHODS

Extra-renal flares that occurred in our cohort over the last five years with at least one year of follow-up were included. Baseline clinical variables were described and flares assigned to clusters. Attainment of remission and low disease activity state (LLDAS) at 12 months were compared. Flares were then considered 'D2T' in case of non-attainment of LLDAS at 6 and 12 months. Baseline features were used to train a ML model able to predict future D2T-flares, at admission. Traditional approaches were then compared with informatic techniques.

RESULTS

Among 420 SLE patients of the cohort, 114 flares occurred between 2015 and 2021; 79 extra-renal flares, predominantly mucocutaneous (24.1%) and musculoskeletal (45.6%), were considered. After 12 months, 79.4% and 49.4% were in LLDAS and in remission, respectively, while 17 flares were classified as D2T (21.5%); D2T flares received a higher cumulative and daily dose of glucocorticoids. Among the clusters, cluster 'D' (mild-moderate flares with mucocutaneous manifestations in patients with history of skin involvement) was associated with the lowest rate of remission. Among clinical data, not being on LLDAS at 3 months was the unique independent predictor of D2T flares.

CONCLUSIONS

Our clusterization well separates extra-renal flares according to their baseline features and may propose a new identification standard. D2T flares, especially refractory skin manifestations, are frequent in SLE and represent an unmet need in the management of the disease as they are associated with higher glucocorticoid (GC) dosage and risk of damage accrual. Our ML model could help in the early identification of D2T flares, flagging them to elevate the attention threshold at admission.

A strategy towards disentangling treatment refractory from misdiagnosed axial Spondyloarthritis

Axial spondyloarthritis (axSpA) encompasses radiographic axial SpA (r-axSpA), formally designated as ankylosing spondylitis (AS) and non-radiographic axial SpA (nr-axSpA). The advent of MRI permitted the description of the "pre-radiographic" (nr-AxSpA) stage characterized by bone marrow oedema lesions, histologically an osteitis, not yet visible on X-rays. Most subjects with a diagnosis of nr-axSpA do not progress to r-axSpA and the risk of misdiagnosis of nr-axSpA is considerable because back pain related to malalignment, degenerative conditions or biomechanical stress including intense exercise may lead to positive MRI scans. Even when nr-axSpA or r-axSpA are accurately diagnosed only about 40-50% achieve the ASAS40 responses with licensed therapies. It is likely that spinal enthesitis/osteitis leading to structural damage and associated damage contributes to post inflammatory disc territory secondary pain responses. Things are complicated as the concept of refractory axSpA itself is not well defined since there is no gold standard test to capture the full burden of inflammatory disease and, in any event, MRI has not been systematically applied. Nevertheless, there is sufficient evidence to borrow from the refractory rheumatoid arthritis field to propose two types of refractory axial SpA- a persistent inflammatory refractory ax-SpA (PIRaxSpA) and non-inflammatory refractory ax-SpA (NIRaxSpA). Both axSpA refractoriness and misdiagnosis need careful considerations when evaluating treatment failure. The immunological basis for axSpA immunotherapeutics non-responses is still rudimentary beyond the knowledge of HLA-B27 positivity status, CRP elevation, and MRI bone oedema that represents osteitis being equated with responder status.

Comorbidities in the Spondyloarthritis GISEA Cohort: an average treatment effect analysis on patients treated with bDMARDs

OBJECTIVES

We aimed to investigate the effectiveness of tumour necrosis factor inhibitors (TNFi), anti-interleukin-17 or interleukin-12/23 monoclonal antibodies (anti-IL) on comorbidities in a cohort of patients with spondyloarthritis (SpA), using an average treatment effect (ATE) analysis.

METHODS

SpA patients from the multicentre Italian GISEA Registry were divided into groups according to pharmacological exposure: no treatment (G0), TNFi (G1) and non-responders to TNFi switched to anti-IL (G2). In each group, we recorded the prevalence and incidence of infectious, cardiopulmonary, endocrinological, gastrointestinal, oncologic, renal and neurologic comorbidities. Each comorbidity was then fitted for ATE and baseline features were evaluated for importance.

RESULTS

The main findings of this study comprising 4458 SpA patients relate to cancer, other gastrointestinal diseases (OGID) and fibromyalgia. ATE showed no increased risk of solid cancer in G1 (0.42 95% CI 0.20-0.85) and G2 (0.26 95% CI 0.08-0.71) vs. G0, with significantly higher incidence in G0 (14.07/1000 patient-years, p=0.0001). Conversely, a significantly higher risk of OGID and fibromyalgia was found in G1 (1.56 95% CI 1.06-2.33; 1.69 95% CI 1.05-2.68, respectively) and G2 (1.91 95% CI 1.05-3.24; 2.13 95% CI 1.14-3.41, respectively) vs. G0. No treatment risk reduction was observed in haematological malignancies, cardiovascular events and endocrinological comorbidities.

CONCLUSIONS

Overall, our study confirms the safety of TNFi and anti-IL in SpA patients, albeit with some caveats pertaining to solid cancers, OGID and fibromyalgia. Furthermore, taking into consideration causality with observational data may yield more reliable and relevant clinical information.

Treat-to-target in real-life psoriatic arthritis patients: achieving minimal disease activity with bDMARDs/tsDMARDs and potential barriers

OBJECTIVE

(1) to describe the frequency of minimal disease activity (MDA) in a real-life psoriatic arthritis (PsA) cohort, (2) to longitudinally explore predictors of MDA; (3) to examine frequency and predictors of low disease activity (LDA) in patients with axial involvement (axPsA).

METHODS

consecutive PsA patients in stable biological/targeted-synthetic Disease-Modifying Anti-Rheumatic Drugs (bDMARDs/tDMARDs) who attended our center were enrolled. Disease activity indices, including MDA and ankylosing spondylitis disease activity score-LDA (ASDAS-LDA) for axPsA, were evaluated at baseline and every 6 months, up to 36 months or bDMARDs/tsDMARDs discontinuation. Patients' history, BMI, comorbidities - including osteoarthritis (OA) and fibromyalgia - were collected. Variables were compared between patients who achieved sustained MDA and those who did not. Multivariable generalized estimating equation (GEE) models were built to identify predictors of MDA and ASDAS-LDA over time. Data were expressed as beta coefficient (95%CI).

RESULTS

104 patients were enrolled, 54% males, mean age 55.7 years; 52% had axPsA. Across all evaluations, 52-61% reached MDA, and 17-24% achieved ASDAS-LDA. AxPsA, fibromyalgia, OA and BMI≥35 were less frequently observed in patients with sustained MDA. The GEE model confirmed the following factors were significantly and independently associated with MDA: age (Beta=-0.05), bDMARDs/tsDMARDs duration (Beta=+0.31), axPsA (Beta=-1.07), fibromyalgia (Beta=-3.35), OA (Beta=-1.87), BMI≥35 (Beta=-2.53). Age (Beta=-0.01), fibromyalgia (Beta=-2.03) and OA (Beta=-1.30) were also independently associated with ASDAS-LDA.

CONCLUSIONS

MDA is an attainable target in real-life. AxPsA represents a difficult-to-treat subset. Sustained MDA depends on disease features (axPsA) as well as patients' characteristics (e.g. age, bDMARDs/tDMARDs duration, comorbidities).

Relationship between sex and clinical and imaging features of early axial spondyloarthritis: results from a 48 month follow-up (Italian arm of the SPondyloArthritis Caught Early (SPACE) study)

OBJECTIVES

To assess the association between sex and clinical and disease activity indices, and X-rays and magnetic resonance imaging (MRI) features, in early-stage axial spondyloarthritis (axSpA).

METHOD

Baseline data analysis was conducted on the Italian SPACE cohort, including patients with chronic back pain (duration ≥ 3 months and ≤ 2 years; onset < 45 years). Patients underwent MRI and X-rays of the sacroiliac joints (SIJs) to establish the diagnosis of axSpA, according to Assessment of SpondyloArthritis international Society criteria and physician's judgement. Clinical features, disease activity and functional indices, and images were collected at baseline and yearly during 48 months. Spinal and SIJ X-rays and MRI images were scored by two readers following Spondyloarthritis Research Consortium of Canada (SPARCC), modified Stoke Ankylosing Spondylitis Spinal Score, and modified New York criteria. Characteristics of axSpA patients according to sex (male/female) were compared over time using descriptive statistics.

RESULTS

Ninety-one patients had axSpA (83.5% non-radiographic; 16.5% radiographic); 47.3% were male. Males were younger, with shorter duration of axial symptoms, and more frequently had HLA-B27 positivity, radiographic sacroiliitis with a bilateral/symmetric pattern, and more signs of spondylitis. Females more frequently showed peripheral/entheseal involvement and the non-radiographic phenotype. Males showed increased pelvic/spinal radiographic progression and more often had active sacroiliitis on MRI. Although the frequency of inflammatory corner lesions did not differ between males and females, localization varied, with more cervical/thoracic MRI-spine lesions in females and more lumbar lesions in males. We observed a significant downward trend of SPARCC SIJ/spine scores in all patients, irrespective of sex. More fat lesions were observed on MRI-spine in females and on MRI-SIJ in males.

CONCLUSION

Sex was associated with distinct axSpA features: females showed low-grade radiographic sacroiliitis and spinal progression, and a higher prevalence of cervical and thoracic spine MRI signs.

The impact of SARS-CoV-2 infection and vaccination on inflammatory arthritis: a cohort study

Objectives

To investigate the effects of SARS-CoV-2 infection, as well as short- (within 48 hours) and long-term (within 30 days) adverse events (AEs) of SARS-CoV-2 vaccines, including arthritis flares in a large cohort of patients with inflammatory arthritis (IA).

Methods

A retrospective cohort study comprising 362 patients: 94 (26%) rheumatoid arthritis, 158 (43.6%) psoriatic arthritis and 110 (30.4%) ankylosing spondylitis; and 165 healthy controls (HC) to ascertain the prevalence and severity of SARS-CoV-2 infection in patients with IA, the rate of AEs associated with SARS-CoV-2 vaccines and disease flares within a month of the vaccination. All patients provided informed consent and data about SARS-CoV-2 infection and/or vaccination status.

Results

One-hundred-seventeen (32.3%) patients and 39 (23.6%) HC were affected by SARS-CoV-2 infection. Forty (34.2%) patients experienced an IA flare within one month of infection, of whom 3 (7.5%) needed to switch therapy. The prevalence of SARS-CoV-2 infection, disease severity, and hospitalization rate were not significantly different. At least one shot of SARS-CoV-2 vaccine was administered in 331 (91.4%) patients and 147 (89.1%) HC. Within 48 hours, 102 (30.8%) patients developed vaccine-related AEs; 52 (15.7%) patients with >1 vaccine dose experienced an IA flare-up, of whom 12 (23.1%) needed to switch therapy.

Conclusions

A significantly higher rate of IA flare was observed among patients who contracted SARS-CoV-2 infection vs. those without infection. Patients with IA experienced flares after SARS-CoV-2 vaccination, though it was not statistically significant.

Spondyloarthritis with inflammatory bowel disease: the latest on biologic and targeted therapies

Spondyloarthritis (SpA) encompasses a heterogeneous group of chronic inflammatory diseases that can affect both axial and peripheral joints, tendons and entheses. Among the extra-articular manifestations, inflammatory bowel disease (IBD) is associated with considerable morbidity and effects on quality of life. In everyday clinical practice, treatment of these conditions requires a close collaboration between gastroenterologists and rheumatologists to enable early detection of joint and intestinal manifestations during follow-up and to choose the most effective therapeutic regimen, implementing precision medicine for each patient's subtype of SpA and IBD. The biggest issue in this field is the dearth of drugs that are approved for both diseases, as only TNF inhibitors are currently approved for the treatment of full-spectrum SpA-IBD. Janus tyrosine kinase inhibitors are among the most promising drugs for the treatment of peripheral and axial SpA, as well as for intestinal manifestations. Other therapies such as inhibitors of IL-23 and IL-17, phosphodiesterase 4 inhibitor, α4β7 integrin blockers and faecal microbiota transplantation seem to only be able to control some disease domains, or require further studies. Given the growing interest in the development of novel drugs to treat both conditions, it is important to understand the current state of the art and the unmet needs in the management of SpA-IBD.

Fetuin-A: A Novel Biomarker of Bone Damage in Early Axial Spondyloarthritis. Results of an Interim Analysis of the SPACE Study

Our study aimed to evaluate the association between fetuin-A levels and the presence of radiographic sacroiliitis and syndesmophytes in patients with early axial spondyloarthritis (axSpA) and to identify potential predictors of radiographic damage in the sacroiliac joints (SIJs) after 24 months. Patients diagnosed with axSpA in the Italian cohort of the SpondyloArthritis-Caught-Early (SPACE) study were included. Physical examinations, laboratory tests (including fetuin-A), SIJ,+ and spinal X-rays and MRIs at T0 (diagnosis) and at T24 were considered. Radiographic damage in the SIJs was defined according to the modified New York criteria (mNY). Fifty-seven patients were included in this analysis (41.2% male, median (interquartile range), chronic back pain [CBP] duration of 12 (8-18) months). Fetuin-A levels were significantly lower in patients with radiographic sacroiliitis compared to those without at T0 (207.9 (181.7-215.9) vs. 239.9 (217.9-286.9), respectively, p < 0.001) and at T24 (207.6 (182.5-246.5) vs. 261.1 (210.2-286.6) µg/mL, p = 0.03). At T0, fetuin-A levels were significantly higher in non-smokers, in patients with heel enthesitis and in those with a family history of axSpA; fetuin-A levels at T24 were higher in females, in patients with higher ESR or CRP at T0 and in those with radiographic sacroiliitis at T0. Fetuin-A levels at T0 were independently negatively associated with the likelihood of radiographic sacroiliitis (OR = 0.9 per 10-unit increase (95% CI 0.8, 0.999), p = 0.048); but not with the presence of syndesmophytes. After adjustment for confounders, fetuin-A levels at T0 and T24 were also negatively associated with mNY at T0 (β -0.5, p < 0.001) and at T24 (β -0.3, p < 0.001), respectively. Among other variables at T0, fetuin-A levels did not achieve statistical significance in predicting mNY at T24. Fetuin-A levels were negatively associated with radiographic damage of the SIJs, but not of the spine, in early axSpA and after 2 years of follow-up. Our findings suggest that fetuin-A levels may serve as a biomarker to identify patients with a higher risk of developing severe disease and early structural damage.

POS0364 UNMET NEEDS IN THE TREATMENT OF EXTRA-RENAL FLARES IN SLE PATIENTS: REAL LIFE EXPERIENCE VS ARTIFICIAL APPROACH

Background

Systemic lupus erythematosus (SLE) is a heterogeneous disease which can affect various organs and is characterized by different clinical phenotypes. While the treatment of renal involvement is quite standardized, the therapeutic approach to extra-renal manifestations is subjected to a degree of variability.

Objectives

1. To describe extra-renal disease flares in terms of clinical phenotype and outcomes in SLE patients 2. To compare data from a real-life setting with a machine learning (ML) approach.

Methods

This study is a retrospective analysis of data from a monocentric cohort of SLE patients who experienced a disease flare between 2015 and 2020. Each flare was followed for one year and was classified according to the organ involvement and categorized according to the BILAG definition of flare. At baseline and at 3,6,12 months the following variables were collected: disease activity (SELENA-SLEDAI score), ongoing therapy and disease state (DORIA definition of remission). Demographic data and previous organ involvement were retrieved from clinical charts. Flares’ features at baseline and during follow up were analyzed in terms of explained variance across the dataset’s Principal Components and clustered with a hierarchical unsupervised learning approach. A ML model based on neural networks was built to early detect flares’ therapeutic difficulty: it was validated after data augmentation to satisfy statistical requirements during the training phase.

Results

66 extra-renal flares were investigated (Table 1); 5 flares (7.5%) were treated with glucocorticoid (GC) pulses and 61 (92.5%) with oral GC therapy, while an immunosuppressive (IS) treatment was prescribed in 44 flares (66.7%). The remission rate at 12 months for the whole group was 50%, with musculo-skeletal (MS) flares, mucocutaneous (MC) flares and others (neuropsychiatric, cardiopulmonary, constitutional, haematologic) that was respectively 63.6%, 31.3% and 41.2%, showing lower rate of remission for MC flares. In 12 months, 17 flares (25.8%) did not respond to treatment (non-responders), requiring an increase in the dose of GC or the introduction of a new IS therapy. Using a machine learning approach, we were able to identify 4 flare clusters, grouping flares in relation to phenotypic characteristics (Figure 1), and recognized statistically relevant features for patients’ stratification (cluster 1“flare in systemic disease with high activity”, cluster 2 “outcast flares”, cluster 3 “flare in polymorphic disease with mild activity” and cluster 4 “recurrent skin flares”). Interestingly, cluster 4 (recurrent skin flares) was associated with the lowest rate of remission at 12 months with respect to clusters 1, 2, and 3 (33% vs 40%, 76.5% and 56% respectively). Moreover the neural network model correctly predicts difficult to treat flares in up to 80% of the cases

Table 1.WHOLE GROUPMUSKELMUCOCUTCONSTITUTIONALCARDIOPULMHAEMATOLNEUROpNUMBER (%)6633 (50)16 (24.2)7 (10.6)4 (6.1)5 (7.6)1 (1.5)SLEDAI at baseline median (IQR)7 (4-29)8 (6-10)5.5 (4-10)5 (4-9)9 (4.5-12)5 (5-6)29 (29-29)SLEDAI 12 mos median (IQR)2 (0-20)0.5 (0-4)3 (0-4)3 (2 – 4)0 (0-0)2 (0-3)14 (14 – 14)REMISSION 12 mos number (%)33 (50)21 (63.6)5 (31.3)4 (57.1)2 (40)2 (40%)1 (100)0.217NON RESPONSE 12 mos number (%)17 (25.8)8 (25)5 (31.3)2 (28.6)1 (20)1 (20%)1 (100)0.467Figure 1.

Flare clusters.

Conclusion

These data suggest that, in a real-life setting, the clinical response rate to therapy of patients with an extra-renal flare is not satisfactory, thus identifying an unmet need in the treatment of SLE and highlighting the absence of a standard treatment. Both the real-life data and the machine learning approach identify flares with MC manifestations as the most difficult to treat with the lower rate of remission after one year. Further prospective studies are necessary to improve the neural network model; ML techniques could help in the early identification of difficult to treat flares to be candidates for new and more aggressive therapeutic strategies for extra-renal manifestations.

Disclosure of Interests

None declared

AB0423 STRATEGIES FOR GLUCOCORTICOID TREATMENT IN SYSTEMIC LUPUS ERYTHEMATOSUS FLARES: A REAL-LIFE EXPERIENCE

Background

Glucocorticoids (GC) are a cornerstone for the treatment of Systemic Lupus Erythematosus (SLE) manifestations but there is still open debate concerning their optimal therapeutic employment.

Objectives

To describe and compare the GC therapeutic strategies used in a real-life setting for the initial treatment of SLE flares.

Methods

This study is a retrospective analysis of data from a monocentric cohort of SLE patients who registered a disease flare between 2015 and 2020. Flares were first categorized in “pulse-treated” (PT) and “non pulse-treated” (NPT). PT flares were then divided into “low-dose regimen” (250 mg iv 6MP for 3 consecutive days or less) and “high-dose regimen” (more than 250 mg iv 6MP for 3 days). GC daily and cumulative 6MP doses, rate of remission and relapse were evaluated at 3, 6 and 12 months.

Results

101 flares were analyzed (30 PT and 71 NPT). PT flares were more severe in terms of median SLEDAI (PT 16(12-22) vs NPT 8(5-10) p=0,00) and BILAG score index (BILAG A PT 71% vs NPT 30% p=0,001). PT patients received significantly higher GC doses at 1 month (PT median cumulative dose 1372 IQR 1028 – 3076 mg of 6MP vs NPT median 160 IQR 120-288 mg of 6MP, p=0,000), 6 months (PT median cumulative dose 2964 IQR 2294 – 4305 mg of 6MP vs NPT 880 IQR 720 – 1284 mg of 6MP, p=0,000) and 12 months (PT median cumulative dose 3510 IQR 3014-5025 vs NPT median cumulative dose 1571 IQR 1098 – 2122 mg of 6MP, p=0,000). Characteristics of flares that were treated with low-dose (N=19) or high-dose (N=11) pulse regimen are summarized in Table 1. As expected, the “low-dose regimen” subgroup received lower cumulative GC dosage over time. However, no statistically significant differences were found neither in term of disease severity at baseline nor in term of disease activity, remission rates or new flares over time.

Table 1.

Comparison between low-dose pulse regimen and high-dose pulse regimen in terms of cumulative GC dose and outcome in the first year after a SLE flare

Median GC doses (6MP)Low-dose regimenN=19 (63,33%)High-dose regimenN=11 (36,67%)P value Median SLEDAI16 (12 -20)18 (8-24)0,6186BILAG score (A, B, C)A=14, B=4, C=1A=10, B=1, C=00,488Cum. dose 1 mo1350 (1028 – 1534)1752 (960 – 2356)0,126Cum. dose 3 mos1858 (1604 – 2463)2784 (2184 – 3240)0,040Cum. dose 6 mos2450 (2218 – 3586)3456 (2906 – 4380)0,029Cumulative doses 12 mos3150 (2851 - 4448)4246 (3591 – 5772)0,011Remission 3 mos no – (%)2 (10%)0 (0%)0,265Remission 6 mos no – (%)8 (42%)1 (9%)0,057Remission 12 mos no – (%)12 (63%)5 (45%)0,346Median SLEDAI 3 mos4 (2 – 9)9 (4 – 12)0,138Median SLEDAI 6 mos3 (0 - 4)4 (0 – 9)0,154Median SLEDAI 12 mos2 (0 – 5)2 (0 – 12)0,363New flares 6 mos no – (%)2 (10%)1 (9%)0,900New flares 12 mos no – (%)2 (10%)2 (18%)0,552

GC=glucocorticoids, 6MP=6-methylprednisolone, no=number, Cum.=cumulative, mos=months

Conclusion

These data suggest that in a real-life setting, pulse GC therapy is preferred over oral administration for severe SLE flares and entails administration of high cumulative doses of GC. However, the experience outlined suggests that the low-dose pulse regimen is as effective in remission induction of severe flares as the high-dose regimen, allowing significant GC sparing. Since the cumulative GC dose is a known strong predictor of organ damage, strategies aimed to minimize the GC dosage should be encouraged.

Disclosure of Interests

None declared

AB1410 IMPACT OF COVID-19 PANDEMIC ON HEALTHCARE RESOURCE USE AND CLINICAL OUTCOMES IN A COHORT OF PATIENTS WITH SYSTEMIC AUTOIMMUNE DISEASES- AN INTERIM ANALYSIS FROM THE PER-MAS PROJECT

Background

Management of the health emergency caused by COVID-19 pandemic majorly disrupted the delivery of healthcare services to patients with chronic conditions like Systemic Autoimmune Diseases (SAD), both because resources were mainly channeled towards the care of infected patients, but also because patients tended to avoid seeking medical care for fear of becoming infected. PER-MAS is a 2-year project aimed at assessing the clinical, psychopathological, and socio-economic impact of COVID-19 in a cohort of patients with SAD.

Objectives

To assess the impact of COVID-19 pandemic on drug withdrawal, disease flares and hospitalizations for disease exacerbation in a cohort of patients with SAD through an interim analysis of data from the PER-MAS project.

Methods

A sample of 214 consecutive patients was recruited in a reference center for rare and complex autoimmune diseases from April 2021 to January 2022. Inclusion criteria were definite diagnosis of SAD (Connective Tissue Disease (CTD), Inflammatory Arthritis (IA) or Vasculitis), regular follow-up and at least 2 years of disease. Patients were asked to fill out an extensive self-administered questionnaire on disease activity and healthcare resource use during the pandemic (March 2020-moment of assessment). Pre-pandemic (March 2019-February 2020) and early pandemic (March 2020-February 2021) clinical data were recorded through retrospective chart review and patient interview.

Results

At enrolment, 119 patients were affected by CTDs (55.6%), 71 by IA (33.18%), 24 by vasculitis (11.21%), with mean age 50.44± 12.97, and mean disease duration 11.17 ± 8.94. 30.37% took steroids, 39.7% hydroxychloroquine, 61.68% DMARDs, and 9.3% vasoactive drugs.

Overall, disease course was similar in pre-pandemic and early pandemic phase: in the first period, rheumatologic condition was stable in 57.35% of patients, persistently active in 27.3% and 35.61% had ≥ 1 episode of disease exacerbation (mean 0.665±1.15, range 0-6); in the second period, 60.56% of patients was stable, 24.88% persistently active, and 39.44% had ≥1 exacerbation (mean 0.49 ±0.77, range 0-4). Mean number of visits (2.56±2.57 and 2.61±2.79), hospitalizations (0.168±0.698 and 0.14±0.473, p=0.6), number of patients with outpatient visits=0 (7.47 vs 7%), and number of patients with ≥ 1 hospital admission (10.28 vs 11.6%) were also similar, while the number of patients with hospital admissions for disease exacerbation was significantly higher in the second period (6.1 vs 11.21%, p=0.001).

170 patients completed the survey: from March 2020 to enrolment, 18.2% suspended ≥1 anti-rheumatic drug (6.25% of them for fear of contracting COVID-19 disease, 15.6% for difficulty in obtaining medications), 20% self-managed ≥ 1 disease exacerbation, and 40% had ≥ 1 telemedicine consult. From March to July 2020, 41.76% had their visit rescheduled (35.23% for hospital access restrictions, 5.3% for travel restrictions, 1.17% for fear). Conversely, only 14.7% of patients had their visit rescheduled (8.23% for hospital access restrictions, 4.7% for other reasons) from July 2020 to enrolment.

Conclusion

In the early pandemic phase, overall disease course was similar to the pre-pandemic phase, but we observed an increase in the number of patients with ≥ 1 hospitalization for disease. Moreover, despite our efforts, patients reported a non-negligible rate of drug discontinuation for non-medical indication and difficulty to get access to rheumatologic consultation, highlighting the need of alternative organizational models in case of future pandemics.

Acknowledgements

Giulia Sacco for helping in patient recruitment and data management.

Disclosure of Interests

Francesca Trentin: None declared, Giovanni Fulvio: None declared, Gianni Andreozzi: None declared, Cosimo Cigolini: None declared, Mattia Da Rio: None declared, Valerio Dell’Oste: None declared, Elena Elefante: None declared, Federico Fattorini: None declared, Silvia Fonzetti: None declared, Valentina Lorenzoni: None declared, Michele Maffi: None declared, Inmaculada Concepción Navarro García: None declared, Ilaria Palla: None declared, Virginia Pedrinelli: None declared, Laura Scagnellato: None declared, Davide Schilirò: None declared, Anastasiya Valevich: None declared, Andrea Gaglioti: None declared, Claudia Carmassi: None declared, Chiara Tani: None declared, Liliana Dell’Osso: None declared, Giuseppe Turchetti: None declared, Marta Mosca Speakers bureau: Lilly, Astra Zeneca, GSK, Consultant of: Lilly, Astra Zeneca, GSK

OP0197 POST-TRAUMATIC STRESS DISORDER AND SYMPTOMS IN PATIENTS WITH RHEUMATIC AND MUSCULOSKELETAL DISEASES DURING THE COVID-19 PANDEMIC: PRELIMINARY RESULTS FROM THE PERMAS STUDY

Background

The COVID-19 pandemic, with its uncertainties, fears of contagion, mass lockdowns and containment measures, has dramatically impacted on people’s everyday lives leading to an increased risk of mental disorders, particularly Post-Traumatic Stress Disorder (PTSD). Despite evidence in general population and healthcare workers1,2, scant data emerged on vulnerable populations, such as of patients with chronic illness, particularly rheumatic and musculoskeletal diseases (RMDs)3,4, who also underwent difficulties in the management and treatment of their disorders.

Objectives

To assess PTSD and post-traumatic stress symptoms in a sample of patients with RMDs, during the COVID-19 pandemic in Italy.

Methods

PERMAS is a monocentric prospective observational study led by the Rheumatology Unit, the Psychiatric Clinic and the Institute of Management of the School of Advanced Studies. Patients with a RMD diagnosis, were consecutively enrolled from May 2021 to January 2022. During the visit, sociodemographic characteristics and psychopathological data were collected through online survey, whereas clinical data were collected by physician. The survey included the Trauma and Loss Spectrum- Self Report (TALS-SR) and the Impact of Event Scale- Revised (IES-R), aimed to assess symptomatological PTSD and post-traumatic stress symptoms related to the impact of the COVID-19 pandemic.

Results

A total of 194 eligible patients, with a mean age of 50.3±12.17 years, was included: 142 (73.19%) were females; 112 (57.74%) patients reported connective tissue diseases (CTD), 63 (32.47%) arthritis and 19 (9.8%) vasculitis. A total of 33 (17%) subjects reported a symptomatological PTSD by means of the TALS-SR. The prevalence of Partial PTSD (defined by at least 2 out of the 4 criteria for DSM-5 diagnosis of the disorder) was 56.7%, with significant higher rates among females (90, 81.8%) with respect to males (20, 18.2%) (p=.013). Accordingly, a IES-R mean total score of 21.90 ±15.98 was found in the total sample and a gender difference emerged, with higher mean scores among females rather than males (23.42 ±16.26 vs 21.90 ±15.98, p=.031).

Conclusion

The present findings point out high prevalence rates of symptomatological PTSD among patients suffering from RMDs, highlighting the potentially traumatic burden of the COVID-19 pandemic in this particular population, especially among females, suggesting the need of further investigations to address tailored prevention and intervention strategies.

References

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Disclosure of Interests

Giovanni Fulvio: None declared, Virginia Pedrinelli: None declared, Gianni Andreozzi: None declared, Francesca Trentin: None declared, Sara Fantasia: None declared, Silvia Fonzetti: None declared, Chiara Fustini: None declared, Mattia Da Rio: None declared, Gabriele Cappellato: None declared, Cosimo Cigolini: None declared, Davide Schilirò: None declared, Michele Maffi: None declared, Laura Scagnellato: None declared, Anastasiya Valevich: None declared, Federico Fattorini: None declared, Inmaculada Concepción Navarro García: None declared, Ilaria Palla: None declared, Valentina Lorenzoni: None declared, Andrea Gaglioti: None declared, Claudia Carmassi: None declared, Chiara Tani: None declared, Giuseppe Turchetti: None declared, Liliana Dell’Osso: None declared, Marta Mosca Speakers bureau: Lillly, Astra Zeneca, GSK, Consultant of: Lillly, Astra Zeneca, GSK