Colchicine-responsive chronic recurrent multifocal osteomyelitis associated with familial Mediterranean fever in the presence of MEFV mutation: A case report

A 38-year-old female was referred with a history of fever, polyarthralgia, and bone pain. She was diagnosed with chronic recurrent multifocal osteomyelitis based on imaging and biopsy findings. Non-steroidal anti-inflammatory drugs and bisphosphonate caused no improvement. Then, she developed recurrent diarrhoea and abdominal pain. Genetic testing revealed MEFV mutation. Based on the symptoms and genetic mutation results that emerged during the course of these events, she was diagnosed with familial Mediterranean fever. All symptoms, including bone pain, improved with daily colchicine administration. This case was considered familial Mediterranean fever complicated with a clinical diagnosis of chronic recurrent multifocal osteomyelitis, which is included in the spectrum of pyrine autoinflammatory diseases. Considering this case, patients with chronic recurrent multifocal osteomyelitis with MEFV gene variants may respond to colchicine.

Immunological disease activity parameters at conception are risk factors for preterm birth and low birth weight in patients with systemic lupus erythematosus

OBJECTIVE

This study aimed to identify which disease activity parameters may be risk factors for preterm birth (PB) and low birth weight (LBW) in patients with systemic lupus erythematosus (SLE). We also analyzed the extent to which these parameters affected PB and LBW.

METHODS

We collected the SLE Disease Activity Index (SLEDAI), the rate of lupus low disease activity state (LLDAS) attainment, complement levels, and the titer of anti-double stranded DNA (dsDNA) antibody as disease activity parameters. We retrospectively analyzed the associations of these parameters with PB and LBW.

RESULTS

Sixty pregnancies were included in this study. C3 levels and anti-dsDNA antibody titers at conception were strongly associated with PB (p = 0.03 and p = 0.01, respectively), whereas C3 and CH50 levels were associated with LBW (p = 0.02 and p = 0.03, respectively). A logistic regression analysis showed that the cutoff values of C3 and anti-dsDNA antibody for PB were 62.0 mg/dl and 5.4 IU/ml, respectively. The cutoff values of C3 and CH50 for LBW were 87.0 mg/dl and 41.8 U/ml, respectively. The risk of PB or LBW was increased when divided by the cutoff value, and the combination of these cutoff values showed a significantly higher risk of PB and LBW (p = 0.01 and p < 0.01, respectively).

CONCLUSIONS

PB and LBW are strongly associated with disease activity parameters in patients with SLE. Therefore, strictly monitoring and controlling these disease activity parameters, with or without clinical manifestation, is important for women who want to become mothers.

Pregnancy course and outcomes of patients with polymyositis and dermatomyositis (PM/DM) managed in a single center

We aimed to determine the association between disease activity during pregnancy and pregnancy outcomes of women with polymyositis and dermatomyositis (PM/DM). Patients with PM/DM who were managed from pregnancy to delivery at Kagawa University Hospital from March 2006 to May 2021 were enrolled. Clinical data were retrospectively analyzed to evaluate the association between disease activity during pregnancy and pregnancy outcomes. Eight pregnancies in 5 women with PM/DM were analyzed. The mean age at conception was 28.3 ± 3.8 years, and mean disease duration was 6.3 ± 3.2 years. Four patients required an increased glucocorticoid dosage because of worsening disease activity (sustained elevation of creatine phosphokinase [CPK] concentration). Two patients who continuously received immunosuppressive drugs from conception to delivery showed no increase in disease activity and did not need increased glucocorticoid dosages. The pregnancy outcomes were 1 spontaneous abortion and 7 live births. The mean gestation length was 35.3 ± 5.2 weeks, and mean birthweight was 2297.7 ± 1041.4 g. Five adverse pregnancy outcomes (APOs) occurred (2 preterm births and 4 low birthweights); most of these cases had sustained elevation of CPK concentration and increased glucocorticoid dosages. No APOs occurred in the 2 patients who received continuous immunosuppressive medication. Continued use of pregnancy-compatible medications and control of disease activity with lower glucocorticoid dosages in pregnancies with PM/DM may be important to achieve good pregnancy outcomes.

Humoral immune response against BNT162b2 mRNA COVID-19 vaccine in patients with rheumatic disease undergoing immunosuppressive therapy: A Japanese monocentric study

We investigated serum total antibody titers against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein receptor-binding domain after BNT162b2 mRNA vaccination against coronavirus disease 2019 (COVID-19) in Japanese patients taking various immunosuppressive medications for rheumatic disease. In 212 outpatients with rheumatic diseases at Kagawa University Hospital and 43 healthy volunteers (controls), all of whom had received 2 doses of BNT162b2 vaccine, serum antibody titers of SARS-CoV-2 spike protein were analyzed at least 14 days after the second dose. Many of the patients were taking immunosuppressive agents to manage their rheumatic disease. The antibody titers against SARS-CoV-2 spike protein in these patients were significantly lower than those in controls. The analysis of therapeutic agents revealed that the antibody titers in patients treated with rituximab were much lower than those in controls. In patients treated with tacrolimus, baricitinib, azathioprine, mycophenolate mofetil, abatacept, tumor necrosis factor inhibitors, cyclosporine, interleukin-6 inhibitors, methotrexate, or glucocorticoids, antibody titers were moderately lower than those of controls. Interleukin-17 and interleukin-23 inhibitors did not impair the humoral response. In addition, the combination of methotrexate with various immunosuppressive agents reduced titers, although not significantly. In Japanese patients with rheumatic disease, many immunosuppressants impaired the immune response to the BNT162b2 vaccine. The degree of decline in antibody titers differed according to immunosuppressant. When used concomitantly with other immunosuppressants, methotrexate may impair the immune response to the BNT162b2 vaccine. However, immunomodulatory treatments such as interleukin-17 and -23 inhibitors may not attenuate this response in patients with rheumatic disease.

Systemic lupus erythematosus with various clinical manifestations in a patient with hereditary angioedema: a case report

Background

Hereditary angioedema (HAE) is an inherited disease characterized by recurrent angioedema without urticaria or pruritus. The most common types of HAE are caused by deficiency or dysfunction in C1 esterase inhibitor (C1-INH-HAE). The association between C1-INH-HAE and systemic lupus erythematosus (SLE) is known; however, variations in the underlying pathophysiology, disease course, and treatment in this population remain incompletely understood.

Case presentation

A 31-year-old Japanese woman with a prior diagnosis of HAE type 1 based on the episodes of recurrent angioedema, low C1 inhibitor antigen levels and function, and family history presented with new complaints of malar rash, alopecia, and arthralgias in her hands and elbows. She later developed fever, oral ulcers, lupus retinopathy, a discoid rash localized to her chest, and malar rash. Investigations revealed positive antinuclear antibody, leukopenia, thrombocytopenia, hypocomplementemia, and nephritis. Based on these findings, she was diagnosed with SLE according to the 2019 European League Against Rheumatism/American College of Rheumatology classification criteria. There did not appear to be a correlation between HAE disease activity and the timing of presentation with SLE, because HAE disease activity had been stable. The patient was able to achieve and maintain remission with immunosuppressive therapy including prednisolone, hydroxychloroquine, and tacrolimus.

Conclusions

Our patient presented with a variety of symptoms, including fever and cytopenia in addition to mucocutaneous, joint, ocular, and renal lesions. It is important to better characterize the clinical characteristics of SLE in patients with C1-INH-HAE, and to clarify the mechanisms of SLE in this population.

Supplemental hydroxychloroquine therapy regulates adipokines in patients with systemic lupus erythematosus with stable disease

BACKGROUND

In patients with systemic lupus erythematosus (SLE), a higher frequency of atherosclerotic lesions is associated with poor prognosis. Hydroxychloroquine (HCQ) has been reported to improve the lifespan and the prognosis of dyslipidaemia in patients with SLE, but the mechanism is unclear. We investigated the effect of supplemental HCQ treatment on the levels of serum cytokines associated with atherosclerosis in patients with stable SLE.

METHODS

Patients with SLE who received supplemental HCQ and maintained low disease activity between January 2016 and September 2020 were included in this study. Disease activity was assessed using Safety of Estrogens in Lupus National Assessment-SLE Disease Activity Index, Cutaneous Lupus Erythematous Disease Area and Severity Index, and Lupus Low Disease Activity State. Serum complement titres, anti-dsDNA antibodies, and serum cytokines (adiponectin, resistin, and leptin) were analyzed before and after HCQ treatment.

RESULTS

Forty-one patients (4 males and 37 females, mean age 41.3 ± 13.2 years) were included. Serum adiponectin levels were significantly increased after 3 months of HCQ treatment compared to baseline, and serum resistin levels were significantly reduced. The change in serum resistin level after HCQ administration was correlated with a significant reduction in serum TNF-α, interleukin (IL)-6, IL-8, and IL-1RA levels.

CONCLUSIONS

Supplemental HCQ treatment in patients with SLE improved adipokine levels. HCQ may improve prognosis by controlling disease activity in SLE and reducing risk factors for atherosclerosis. Key Points • Hydroxychloroquine has been reported to improve the prognosis of dyslipidaemia in patients with SLE, but the underlying mechanism is unclear. • In this study, hydroxychloroquine improved adipokine levels in patients with SLE, implicating adipokines as a potential mechanism underlying the benefit of hydroxychloroquine on dyslipidaemia. • Supplemental hydroxychloroquine should be considered in patients with SLE harboring lipid abnormalities and risk factors for atherosclerosis.

Immunogenicity against the BNT162b2 mRNA COVID-19 Vaccine in Rheumatic Disease Patients Receiving Immunosuppressive Therapy

Objective To investigate the serum total antibody (immunoglobulin M and immunoglobulin G) titre against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein receptor-binding domain following BNT162b2 messenger ribonucleic acid (mRNA) coronavirus disease 2019 (COVID-19) vaccination in Japanese rheumatic disease patients undergoing immunosuppressive therapy. Methods The serum antibody titre against SARS-CoV-2 spike protein was analysed in 123 outpatients with rheumatic diseases at Kagawa University Hospital and 43 healthy volunteers who had received 2 doses of the BNT162b2 mRNA vaccine with at least 14 days elapsing since the second dose. Results The antibody titre in rheumatic disease patients was significantly lower than that in healthy subjects (p<0.0001). The antibody titres of the 41 patients who received biologics or Janus kinase inhibitors and the 47 patients who received conventional immunosuppressive agents were significantly lower than those of the 35 patients who did not receive immunosuppressive agents (p<0.0001 and p<0.0001, respectively). In addition, the mean antibody titre of the 43 patients on methotrexate was significantly lower than that of the 80 patients not on methotrexate (p=0.0017). Conclusion Immunogenicity to the BNT162b2 mRNA COVID-19 vaccine in rheumatic disease patients was found to be reduced under immunosuppressive treatment. In particular, methotrexate seems to be associated with a decreased antibody response.

AB0313 CLINICAL FEATURE OF 100 CASES OF METHOTREXATE ASSOCIATED LYMPHOPROLIFERATIVE DISORDERS WITH RA PATIENT

Background

Lymphoproliferative disorders (LPDs), including malignant lymphoma, are known to occur in RA patients treated with disease modified antirheumatic drugs (DMARDs). In particular, LPD associated with methotrexate (MTX)-treated RA is often referred to as MTX-associated LPD (MTX-LPD). MTX-LPD have various clinical feature and histological findings1). We have accumulated MTX-LPD cases in patients with rheumatoid arthritis (MTX-RA-LPD).

Objectives

We clarified the clinical characteristics of MTX-RA-LPD. In addition, we examine the prognosis of MTX-LPD in RA patients.

Methods

We enrolled 100 RA patients who diagnosed MTX-LPD from 2005 to 2021. We collected as follow data based on clinical reports retrospectively; 1) age, 2) gender, 3) duration from RA onset to LPD onset, 4) total dose of MTX, 5) duration of MTX administration, 6) presence of extranodal lesion 7) histological findings, 8) treatment for LPD, 9) 5-year survival rate.

Results

The mean age of 100 MTX-RA-LPD patients (M:F=30:70) were 66.7 ± 10.7 years old, and the duration from RA onset to LPD onset were 25.2 ± 11.0 years. The total dose of MTX and duration of MTX administration were over 2,600mg and over 5 years, respectively. The extranodal lesions were found in 51%, and diffuse large B cell lymphoma was the most common histological findings. Spontaneous regression was observed in 68%. The 5-year survival rate of MTX-RA-LPD was as high as over 85%.

Conclusion

The clinical features of MTX-RA-LPD were similar to those previous reports. Furthermore, we suggested a good prognosis for MTX-RA-LPD.

References

[1]Harigai M. Lymphoproliferative disorders in patients with rheumatoid arthritis in the era of widespread use of methotrexate: A review of the literature and current perspective. Mod Rheumatol. 2018 Jan;28(1):1-8.

Disclosure of Interests

None declared

POS1220 HUMORAL IMMUNE RESPONSE AGAINST BNT162b2 mRNA COVID-19 VACCINE IN JAPANESE RHEUMATIC DISEASE PATIENTS RECEIVING IMMUNOSUPPRESSIVE THERAPY: A MONOCENTRIC STUDY

Background

Patients with immune-mediated inflammatory diseases are inherently susceptible to infections and are at high risk of developing COVID-19. COVID-19 vaccination in patients with rheumatoid and musculoskeletal disease (RMD) is strongly recommended [1]. BNT162b2 is the most used COVID-19 vaccine in Japan. The safety and efficacy of this vaccine has been demonstrated in the general population [2], but patients receiving immunosuppressive therapy were excluded from the study. Although data on the immunogenicity of COVID-19 vaccine in the immunocompromised adult population is rapidly increasing, the immunogenicity of mRNA COVID-19 vaccine in RMD patients receiving medication has been reported in various and still inadequate ways. Furthermore, the immunogenicity of mRNA COVID-19 vaccine may vary depending on the medication. In addition, most of these data were reported from Western countries, and data on Japanese patients with RMD are limited.

Objectives

To investigate serum antibody titre against SARS-CoV-2 spike protein following BNT162b2 vaccination in Japanese RMD patients on various immunomodulatory treatment.

Methods

Two hundred and twelve RMD outpatients undergoing treatment at Kagawa University Hospital and 43 healthy volunteers, who had received two doses of BNT162b2, were included in the study. Serum sample was collected at least 14 days after the second dose. Antibody titer against SARS-CoV-2 spike protein in serum was measured by ELISA (Elecsys Anti-SARS-CoV-2 S RUO). We analyzed the relationship between clinical characteristics, including the type of disease and treatment of RMD, and antibody titer against SARS-CoV-2 spike protein.

Results

The antibody titer against SARS-CoV-2 spike protein in RMD patients was significantly lower than that in healthy subjects. In the analysis with therapeutic agents, the mean antibody titer in RMD patients treated with rituximab (RTX) was much lower than that in healthy controls. Patients treated with baricitinib, azathioprine, mycophenolate mofetil, abatacept, TNF inhibitors, cyclosporine, IL-6 inhibitors, methotrexate (MTX), or glucocorticoids (GC) had only moderately lower antibody titers. Patients treated with tacrolimus, an immunosuppressive drug commonly used for treatment in Japan, showed a slight decrease in antibody titer, but the difference was not significant compared with healthy subjects. IL-17 and IL-23 inhibitors did not impair the humoral response. In addition, the combination of MTX with various immunosuppressive agents reduced titers, although this was not statistically significant.

Conclusion

Many of the immunosuppressants impaired the immunogenicity to BNT162b2 in Japanese RMD patients. The degree of decline of antibody titers differed according to immunosuppressant. MTX potentially impairs the immunogenicity of BNT162b2 also in the case of concomitant use with other immunosuppressant.

References

[1]Curtis JR, et al. American College of Rheumatology Guidance for COVID-19 Vaccination in Patients With Rheumatic and Musculoskeletal Diseases: Version 3. Arthritis Rheumatol. 2021;73:e60-e75.

[2]Polack FP, et al. Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine. N Engl J Med. 2020;383:2603–15.

Figure 1.

RMD diagnosis of study patients, n

Table 1.

Serum antibody titre against SARS-CoV-2 spike protein according to the use of immunosuppressive treatments in comparison with controls

Immunosuppressive treatments, nSerum antibody titre, mean±SD, U/mLP valueControl, n=43939 ± 973-Patients with RMD, n=212572 ± 9500.023Without immunosuppressant, n=271074 ± 7580.485IL-17 or IL-23 inhibitors, n=71653 ± 24710.035Tacrolimus, n=32614 ± 9200.095GC, n=103481 ± 9270.009MTX, n=78310 ± 493<0.001IL-6 inhibitors, n=10303 ± 2010.030Cyclosporine, n=8261 ± 2280.035TNF inhibitors, n=26201 ± 252<0.001Abatacept, n=10186 ± 3200.010Mycophenolate mofetil, n=11183 ± 3570.007Azathioprine, n=13150 ± 1590.003Baricitinib, n=6101 ± 970.021RTX, n=620 ± 320.012

Disclosure of Interests

None declared

POS1362 THE EFFICACY AND CYTOKINE PROFILES DURING TREATMENT WITH APREMILAST IN PATIENTS WITH BEHÇET ‘S DISEASE

Background

Apremilast has been shown to be effective in patients with Behçet’s disease (BD) in domains other than oral ulcers; however, its long-term efficacy is yet to be determined. Although serum cytokine modulation by increasing intracellular cAMP levels has been suggested as a mechanism for the efficacy of apremilast on skin areas of psoriasis [1], the relationship between efficacy and cytokine on various domains in BD has not been fully investigated.

Objectives

This study aims to evaluate the long-term clinical efficacy of apremilast in BD and its effect on serum cytokines.

Methods

In this study, patients with BD who received apremilast for active oral ulcers were included. For 12 months, the improvement rates of oral and genital ulcers, skin lesions, and arthritis were assessed every three months. Serum levels of cytokines, including interferon-gamma (IFN-γ), interleukin 10 (IL-10), and IL-17A were determined using Simple Plex (Protein Simple, CA, USA) at baseline and three months after apremilast treatment. Other cytokines, including tumor necrosis factor-alpha (TNF-a), IL-6, IL-8, and IL-23, were also measured in serum using a multiplex immunoassay (Luminex Assay, R&D Systems).

Results

Fifteen patients were included in this study. Table 1 shows the characteristics of the patients who participated in this study. Oral ulcers disappeared in 66.7% and 92.3% of the patients after 3 and 6 months of apremilast treatment, respectively. Genital ulcers disappeared in all patients after 6 months of apremilast treatment and were maintained for 12 months. The efficacy of apremilast in oral ulcers could be divided between two groups: 8 patients in the oral ulcer remission group (OU-R group) whose oral ulcers completely disappeared after 3 months of apremilast administration and persisted for 1 year, and 7 patients in the oral ulcer non-remission group (OU-NR group) whose oral ulcers persisted after 3 months of apremilast treatment. Genital ulcers improved more rapidly in the OU-R group than in the OU-NR group, and completely disappeared within 3 months. Skin and joint lesions generally improved after 6 months, but recurred after 9 months.

Table 1.

Baseline characteristics of the studied patients with Behçet’s disease

CharacteristicsN = 15Age (years), mean ± SD46.7 ± 13.0Sex (female), n (%)11 (73.3)Disease duration (years), mean ± SD10.4 ± 8.8Active Behçet’s disease manifestation at the time of enrollment, n (%) Oral ulcer15 (100) Genital ulcer5 (33.3) Skin lesion (erythema nodosum or pustules)10 (66.7) Arthralgia9 (60.0) Arthritis5 (33.3) Ocular involvement0 (0) Gastrointestinal involvement1 (6.7) Neurological involvement0 (0) Vascular involvement0 (0)

SD, standard deviation; n, number.

Serum cytokines could be analyzed in seven of the 15 cases. There was no significant association between serum baseline cytokine levels and the presence of lesions or severity of disease. Compared to baseline, TNF-α and IL-23 levels were significantly lower after apremilast treatment and IFN-γ levels were trending upwards; however, IL-6, IL-8, and IL-10 levels showed no constant trend (TNF-α and IL-23: p <0.05, IFN-γ: p = 0.078). In addition, the rate of decrease in serum IL-6, IL-10, and IL-23 levels was significantly greater in the OU-R group than in the OU-NR group (Figure 1). However, the rate of change in serum cytokines was not associated with efficacy of apremilast for skin lesions, arthralgia, or arthritis.

Figure 1.

The rate of change in serum interleukin (IL)-6, IL-10, and IL-23 levels up to 3 months after apremilast treatment in the oral ulcer remission group and the oral ulcer non-remission group.

Conclusion

Apremilast has shown long-term efficacy in the treatment of oral and genital ulcers in patients with BD. The efficacy of apremilast against oral ulcers in BD may be attributed to its modulatory effect on serum cytokines as previously reported. Future exploratory studies for biomarkers associated with the presence of efficacy against genital ulcer and arthritis are needed.

References

[1]Gottlieb AB, Matheson RT, Menter AM, et al. J Drugs Dermatol. 2013;12:888-97.

Disclosure of Interests

None declared

AB0442 EVEN IN SYSTEMIC LUPUS ERYTHEMATOSUS THAT HAS ACHIEVED SUSTAINED LLDAS, ADDITIONAL ADMINISTRATION OF HYDROXYCHLOROQUINE SHOULD BE CONSIDERED

Background

Hydroxychloroquine (HCQ) therapy is recommended as a baseline treatment for all patients with systemic lupus erythematosus (SLE) due to its various benefits (1). However, it is not clear to what extent HCQ contributes to improvement in SLE patients with stable disease activity. It has also been reported that HCQ is effective in improving the prognosis of life caused by atherosclerotic lesions in SLE, but the mechanism of this effect has not been fully elucidated.

Objectives

The purpose of this study was to determine the benefit of additional HCQ administration in SLE with controlled disease activity, who achieved the sustained LLDAS.

Methods

The study included patients with SLE who started additional HCQ treatment between January 2016 and December 2019 at our institution, those who sustained LLDAS achievement for at least 3 months prior to starting HCQ treatment. These patients did not change their immunosuppressant and glucocorticoid regimens for more than three months after starting HCQ. The effect of HCQ was assessed at the beginning and 3 months after administration. The disease activity was measured by SELENA-SLEDAI, SLE-DAS, and immunoserological parameters including serum complement levels and anti-DNA antibodies. The factors that are known to associated with pathogenesis of atherosclerosis, such as serum TNF-α, IL-6, IL-8, MCP-1, adiponectin, leptin, resistin, S100A8, and S100A9, were measured by ELISA.

Results

Of the 110 SLE patients who received additional HCQ at our institution, 27 patients who had achieved LLDAS from at least 3 months prior to HCQ administration were included in this study. Patient characteristics are represented in Table 1. SLEDAI scores, SLE-DAS scores and serum anti-dsDNA antibodies were observed to be significantly reduced after HCQ treatment compared to baseline. After 3 months of HCQ treatment, serum lipid markers such as triglyceride (TG), low-density lipoprotein (LDL) cholesterol and atherosclerotic index, which are associated with the development of atherosclerosis, were significantly reduced compared to baseline (TG, LDL and atherosclerotic index: p<0.05). Cytokines such as TNF-α, IL-6, MCP-1, S100A8, S100A9, leptin, and resistin were found to be significantly decreased, and serum adiponectin was significantly increased. (TNF-α, IL-6, MCP-1, leptin: p < 0.05. S100A8, S100A9, adiponectin, resistin: p < 0.0001, Figure 1).

Table 1.

Characteristics of patients with SLE enrolled in this study.

CharacteristicsN = 27Female, no. (%)24 (88.9)Age, years, mean ± SD44.4 ± 11.6Disease duration, years, mean ± SD18.3 ± 12.2BMI, mean ± SD21.9 ± 3.0Concomitant immunosuppressive treatmentsPrednisone, no. (%)n = 23Median dosage, mg/day#5 (3.0–5.0)Triglyceride, mg/dL#102 (73–149)High-density lipoprotein cholesterol, mg/dL#59 (43–66.5)Low-density lipoprotein cholesterol, mg/dL#108 (96–122)Arteriosclerotic index#2 (1.7–2.5)Disease activitySLEDAI score#4 (2–4)SLE-DAS score#2.076 (1.12–3.50)Anti-dsDNA antibody, IU/ml#5.2 (5–15.6)dsDNA positive, no. (%)10 (37.0)C3, mg/dL#76 (61–100)C4, mg/dL#14 (10–22)CH50, U/mL#34.1 (29.7–39.6)

#Nonparametric distributions were represented as median (interquartile range). Anti-dsDNA positive means that anti-dsDNA titer increases to >12 IU/mL.

Figure 1.

Serum cytokine levels before and after hydroxychloroquine treatment

Serum levels of the indicated cytokines and factors were measured at baseline and after 3 months (3M) of treatment with HCQ. The gray lines show the values for individual patients, and the thick red line shows the average value. P-values were determined using the Wilcoxon signed-rank test. A p-value of less than 0.05 was considered statistically significant.

Conclusion

The addition of HCQ medication to SLE patients who achieve the clinical therapeutic goal of LLDAS without HCQ may prevent progression of atherosclerosis in addition to further reducing disease activity.

References

[1]Fanouriakis A, Kostopoulou M, Alunno A, et al. Ann Rheum Dis. 2019;78:736-745.

Disclosure of Interests

None declared

POS0915 MYOSITIS-SPECIFIC AND ASSOCIETED ANTIBODIES, ESPECIALLY ANTI-ARS ANTIBODIES AND ANTI-Ro52 ANTIBODY MAY PREDICT THE CHARACTERISTICS AND FIBROSING PROGRESS OF INTERSTITIAL LUNG DISEASE WITH DERMATOMYOSITIS / POLYMYOSITIS

Background

Myositis-associated antibodies (MAA) and myositis-specific antibodies (MSA) have been associated with clinical manifestations of dermatomyositis and polyneuropathy, including interstitial lung disease (ILD), myopathy, malignancy, arthritis, and skin rashes. Among them, anti-ARS and anti-MDA5 antibodies are strongly associated with complications of ILD that are associated with life expectancy. It has been reported that anti-Ro52 antibody affects severity of myositis and ILD. (1) Based on these findings, it is possible that autoantibodies possessing features of ILD associated with dermatomyositis and polymyositis may be predictive.

Objectives

The purpose of this study is to clarify the relationship between MSA/MAA and clinical features of ILD complicated by dermatomyositis and polymyositis.

Methods

We retrospectively analyzed IIMs patients diagnosed according to Peter & Bohan’s diagnostic criteria in our hospital from 2011 to 2018. The presence of 14 MSA / MAA (Jo1, PL12, PL7, EJ, OJ, KS, Mi2, MDA5, TIF1γ, SRP, PM-Scl70, 100, Ku, Ro52) was measured using ELISA (MESACUP, MBL, Japan) and line blot (EUROLINE myositis profile3, EUROimmun, Germany). Clinical characteristics, including HRCT imaging findings, were extracted from medical records. HRCT imaging findings were analyzed by multiple radiologists. The association between the extracted clinical features and the MSA / MAA held was analyzed.

Results

Seventy-eight cases of IIM were included in the analysis. The frequency of ILD complications was 53/78 (68%), and 60% of ILD complications were ARS antibody positive. The complication rate of ILD in MDA5- and ARS-positive cases was 100% (3/3 cases) and 94% (32/34 cases), respectively. These MDA5- and ARS-positive patients with ILD had rapidly progressive ILD. One of the three MDA5 antibody-positive RPILD cases died, but none of the four ARS antibody-positive RPILD cases died. However, in patients with multiple MSA or MAA including ARS, three case had rapidly progressive ILD, and none died. n the analysis of the presence of Ro52 antibody, it was detected in 46% (36 cases) of all cases, but in 74% of anti-ARS antibody positive cases.

In the analysis of ILD patterns by radiologists using HRCT, fibrosing NSIP (fNSIP), fibrosing OP (fOP), and UIP were the most frequent in that order. analysis of the association between ILD patterns and MSA / MAA showed that there was no MSA / MAA associated with each ILD pattern. No MSA/MAA was found to be associated with each ILD pattern. ARS antibody-associated ILD, the most common type of ILD, had a worse prognosis than other MSA / MAA positive ILD. Death due to ILD was observed in 5 patients (PL7: 3cases, PL12: 1case, PM-Scl75: 1case). Oxygen was required for ILD progression in 3 Jo1-positive patients, 1 PL7-positive patients, and 1 PL12-positive patient, respectively. The frequency of UIP, which is considered to have a poor prognosis in other rheumatic diseases, was higher in patients with anti-ARS and anti-Ro52 antibodies.

Conclusion

The prognosis of anti-ARS antibody-positive lLD associated with dermatomyositis and polymyositis was associated with fibrosis by analysis of HRCT patterns, and the prognosis was confirmed to be poor.In addition, the UIP pattern, which is strongly associated with fibrosis, was found to be associated with anti-Ro52 antibody. In the treatment of ILD, which is strongly associated with the prognosis of dermatomyositis and polymyositis, it may be necessary to consider antifibrotic treatment for patients with anti-ARS antibody and anti-Ro52 antibody positivity.

References

[1]Tamara Vojinovic et al. Predictive Features and Clinical Presentation of Interstitial Lung Disease in Inflammatory Myositis. Clinical Reviews in Allergy & Immunology (2021) 60:87–94

Disclosure of Interests

None declared

AB0438 EFFICACY OF BELIMUMAB TREATMENT FOR SYSTEMIC LUPUS ERYTHEMATOSUS AT OUR HOSPITAL

Background

Belimumab (BEL), a monoclonal antibody against the soluble counterpart of B-cell activating factor (BAFF) has been recommended to be added in patients with SLE who do not respond adequately to standard therapy [1]. In addition to antibody production, belimumab may also affect other functions of B cells, such as antigen presentation and excretion of inflammatory cytokines. Belimumab may also have an effect on immune cells other than B cells, as they express BAFF receptors. These facts suggest that BEL administration in SLE may have an effect on various pathological conditions including cytokine production, not just antibody production. However, there are few reports on whether cytokine production is actually related to the efficacy of BEL administration in SLE.

Objectives

The purpose of this study was to determine the efficacy of BEL administration in patients with SLE and its effect on cytokines.

Methods

Patients with SLE who were started on BEL between December 2018 and December 2021 at our institution were included in this study. We retrospectively analyzed the reasons for additional BEL administration, adverse events, disease activity indicators (SLE Disease Activity Index (SLEDAI)-2K, lupus low disease activity state (LLDAS) achievement rate, anti-dsDNA antibody titer, serum complement titer, and treatment agents including glucocorticoid dose. Serum cytokine (interferon-alpha, interleukin (IL)-6, IL-10, and IL-17A) levels were measured using ELISA at the start of BEL administration, 3 months, and 6 months later.

Results

Five cases of SLE were included in the study. Four of the five patients were female, with a mean age of 51.4±9.6 years and a mean duration of disease of 17.4±10.0 years.

The reasons for additional BEL administration were glucocorticoid reduction in five patients, refractory pericarditis in one patient, skin rash and arthritis in two patients, and immunological activity in two patients. Four of the five patients had decreased renal function below eGFR50 at the baseline. Concomitant medications at the time of BEL induction included steroids in five patients (mean prednisolone dose 12.2±12.2 mg/day), hydroxychloroquine in three patients, mycophenolate mofetil in three patients, tacrolimus in one patient, and methotrexate in one patient. The mean disease activity before the introduction of BEL was SLEDAI 4±4, and LLDAS was achieved in three patients.

Twelve weeks after the start of BEL treatment, two patients had improved SLEDAI, including one patient who achieved LLDAS.

Immunological activity parameters improved in one of the two patients.

However, two patients flared after BEL administration and were treated with increased glucocorticoid doses.

One patient with SLE on hemodialysis had thrombocytopenia, an adverse event that may have been related to belimumab treatment.

Conclusion

At our institution, BEL was additionally administered to SLE patients with refractory disease and was effective; with the exception of one case. Serum cytokine analysis before and after BEL treatment will be included in the discussion.

References

[1]Fanouriakis A, Kostopoulou M, Alunno A, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann. Rheum. Dis. 2019;78:736–745.

[2]Parodis I, Åkerström E, Sjöwall C, et al. Autoantibody and Cytokine Profiles during Treatment with Belimumab in Patients with Systemic Lupus Erythematosus. Int J Mol Sci. 2020;21:3463.

Disclosure of Interests

None declared

AB0397 DISEASE ACTIVITY OF RHEUMATOID ARTHRITIS WERE SIGNIFICANTLY DECREASED BY SWITCHING JAK INHIBITOR TO ANOTHER JAK INHIBITOR

Background

With the availability of multiple Jak inhibitors (JAKi) for treatment, patients with RA who have had inadequate response to conventional therapies, including biologics, can now achieve favorable outcomes such as remission and low disease activity.

However, it is also true that no single JAKi therapy is effective for all RA.

Some RA treatment guidelines recommend a switch strategy from current JAKi to other JAKi or biologics in patients with inadequate response to JAKi therapy [1].

There is insufficient evidence to support the efficacy of switching to another JAKi in patients with inadequate JAKi response (JAKi-IR).

Objectives

The aim of this study is to clarify the effectiveness of the strategy of controlling disease activity by switching to other JAKi in RA cases with JAKi-IR and to analyze the effect on serum cytokines related to the pathogenesis of RA.

Methods

RA patients who switched to other JAKi during treatment with JAKi between September 2017 and January 2022 were included in this retrospective study.

The clinical characteristics of the included RA patients were collected from their medical records.

The efficacy of the JAKi switch strategy was assessed by changes in composite measure scores of disease activity, including DAS28-CRP, SDAI, and CDAI, at 4 and 12 weeks after the switch.

In addition, changes of serum cytokines associated with RA pathogenesis (IL-6, TNF-α) were measured and analyzed by ELISA (Simple Plex, Protein Simple).

Results

Twenty-nine RA patients who received the JAKi switch treatment strategy were included in the analysis. The clinical characteristics of the included patients are shown in Table 1. All patients were receiving JAKi due to inadequate response to biologics. JAKi were switched to control disease activity including 3 cases (10%) who achieved temporary remission.

Table 1.

Baseline characteristics of the 29 patients enrolled this study

Clinical characteristicsn=29Age57 [48.0-66.0]Sex (F/M)22/7 (75.9)Disease duration, years13 [8.6-18.8]RF positive26 (89.7)ACPA positive, (n=22)20(90.0)Concomitant medicationsMethotrexate, dose(mg/week)10 (34.5), 8.0 [6.0-10.5]Corticosteroid, dose(mg/day)17 (59.0), 4.0 [2.0-5.0]Disease activity  DAS28-CRP3.77 [3.2-4.6]  SDAI15.5 [9.8-21.1]  CDAI14.5 [9.5-20.0]Patient global assessment of disease activity (mm)40 [25-58]Provider global assessment of disease activity (mm)32 [15-40]CRP (mg/dl)0.9 [0.1-1.7]TJC/SJC4 [2-5], 2[2-5]Date are n (%) or median [IQR].

Figure 1 shows the effect of the JAKi switch strategy on the disease activity category.

Evaluation using SDAI showed that 65% of patients achieved the immediate treatment goal of low disease activity at 4 weeks after switch, and 69% of patients maintained this goal at 12 weeks. SDAI remission was also observed in 17% of patients at 4 weeks and 31% at 12 weeks, demonstrating the efficacy of the JAKi switch strategy. The efficacy of the JAKi switch strategy was also observed in other measures of disease activity.

Changes in serum cytokines (IL-6, TNF-α) associated with disease activity in RA before and after JAKi switch were analyzed in 10 patients. Regardless of the type of JAKi, serum IL-6 was decreased by JAKi switch in most cases at 12weeks (average change of serum IL-6: -27.25pg/ml).

However, no trend was observed for changes in serum TNF- disease acti（average change of serum TNF-ed for change）.

There was no clear association between changes in these two cytokines and the efficacy of the JAKi switch strategy.

Conclusion

The composite disease activity index showed that about 60% of JAKi-IR patients achieved low disease activity, one of the treatment goals, at 4 weeks after switching to JAKi, and the effect was maintained up to 12 weeks. This effect did not appear to be related to the type of JAKi.

The effects of biologic therapy on serum cytokines associated with RA activity differed from the effects of the JAKi switch strategy.

References

[1]György Nagy, et al. EULAR points to consider for the management of difficult-to-treat rheumatoid arthritis. Annals of the Rheumatic Diseases 2022;81:20-33.

Disclosure of Interests

None declared

AB0689 Clinical courses and pregnancy outcomes of eight cases complicated with Polymyositis/Dermatomyositis (PM/DM) in single center

Background

Pregnancies complicated by a number of rheumatic diseases are known to be at high risk for the occurrence of adverse pregnancy outcomes (APOs). There have been several reports on the risk of APOs in systemic lupus erythematosus and rheumatoid arthritis, but few reports on polymyositis (PM)/dermatomyositis (DM) pregnancies. There are also insufficient reports on changes in the activity of PM/DM during pregnancy. Based on the findings reported in other rheumatic diseases, it is suggested that increased activity during pregnancy is associated with APOs in PM/DM (1-3).

However, the risk factors for pregnancy outcome in pregnancies complicated by PM/DM, including the presence or absence of worsening of disease activity, have not been clarified.

Objectives

The purpose of this study was to analyze a case series of PM/DM complicated pregnancies in a single center to determine the changes in disease activity during pregnancy and pregnancy outcomes.

Methods

PM/DM patients who were managed from pregnancy to delivery at Kagawa University Hospital from March 2006 to May 2021 were included in this study. Clinical indices including duration of illness, disease activity, and treatment were extracted from medical records and retrospectively analyzed for association with pregnancy outcome.

Results

Eight PM/DM pregnancies were included in the analysis. The mean age at delivery was 28.3±3.8 years and the mean duration of disease was 6.3±3.2 years.

Treatment at the time of pregnancy included glucocorticoids (GC) in 7 cases and immunosuppressive drugs in 5 cases.

Creatinine phosphokinase (CK) levels were normal in all patients at the time of pregnancy, but increased during pregnancy in 4 (50%) patients. These 4 patients with elevated CK required treatment with increasing doses of GC, and the mean GC dose during pregnancy was 10.9 ± 6.0 mg/day.

Table 1 shows the pregnancy outcomes of the 8 patients. There was one spontaneous abortion and seven live births. Among the live births, 2 were preterm and 4 were low birth weight. The mean gestational age at delivery was 35.3±5.2 weeks and the mean birth weight was 2297.7±1041.4g.

Table 1.

Pregnancy outcomes of eight cases

Case no.OutcomeMode of deliveryGestational age at delivery (weeks)Birth weight of the newborn (grams)Adverse pregnancy outcomes1Live birthCesarean section26590Preterm birth, LFD, HELLP syndrome2Spontaneous abortion3Live birthTransvaginal delivery301,299Preterm birth, LBW4Live birthCesarean section382,765Hypertensive disorder5Live birthTransvaginal delivery373,290−6Live birthTransvaginal delivery372,492LBW7Live birthTransvaginal delivery393,456−8Live birthTransvaginal delivery402,192LBW7 live births 1 abortion35.3±5.22,297.7±1,041.4

The birth outcomes of the 2 patients who received continuous immunosuppressive therapy were full-term and normal weight infants. APOs, such as preterm delivery and low birth weight, occurred in cases with increased CK levels and increased GC doses.

Conclusion

In pregnancies of PM/DM patients, pregnancy outcome was less than favorable.

An association between disease activity and the development of APOs during pregnancy in PM/DM was suggested. An association was also suggested between GC dose and the risk of developing APOs.

As in other rheumatic disease pregnancies, continued use of pregnancy-appropriate immunosuppressive drugs and control of disease activity with lower glucocorticoid doses in PM/DM pregnancies may be important to achieve good pregnancy outcomes.

References

[1]Nagy-Vincze M, Vencovsky J, Lundberg IE, Danko K (2014) Pregnancy outcome in idiopathic inflammatory myopathy patients in a multicenter study. J Rheumatol 41:2492-2494.

[2]Zhong Z, Lin F, Yang J, Zhang F, Zeng X, You X (2017) Pregnancy in polymyositis or dermatomyositis: retrospective results from tertiary centre in China. Rheumatology (Oxford) 56:1272-1275.

[3]Kolstad KD, Fiorentino D, Li S, Chakravarty EF, Chung L (2018) Pregnancy outcomes in adult patients with dermatomyositis and polymyositis. Semin Arthritis Rheum 47:865-869.

Disclosure of Interests

None declared

AB0497 IMMUNOLOGICAL DISEASE ACTIVITY PARAMETERS AT CONCEPTION ARE RISK FACTORS FOR PRETERM BIRTH AND LOW BIRTH WEIGHT IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Women with systemic lupus erythematosus (SLE) are known to have more difficulty in achieving a successful pregnancy than healthy women. They have a higher risk for adverse pregnancy outcomes (APOs) including preterm birth (PB), low birth weight (LBW). (1,2). Many reports revealed that these APOs are related to uncontrolled high disease activity (3,4). Therefore, it is important for SLE women who hope to conceive to control disease activity strictly. However, it is not clear to what extent disease activity should be strictly controlled, including serum parameters such as complement levels and anti-dsDNA antibodies.

Objectives

The purpose of this study was to determine whether disease activity parameters at conception could be a risk factor for PB or LBW among APOs in patients with SLE.

Methods

Disease activity parameters including SLEDAI score, LLDAS achievement rate, serum complement levels (C3, C4, CH50), and anti-dsDNA antibody titer were retrospectively collected from medical records. We then collected information related to each APOs (PB and LBW), and analyzed the association with disease activity parameters.

Results

The subjects were 60 pregnancies of 45 patients. As for a comprehensive disease activity index at conception, SLEDAI score or the rate of LLDAS achievement became risk factors for PB (both of p<0.01, Table 1), and SLEDAI score was also a risk factor for LBW (P=0.04, Table 1). Analysis of immunological disease activity parameters showed that low C3 or high titer of anti-dsDNA antibody were risk factors for PB (P=0.03 and 0.01, respectively, Table 1). In the logistic regression analysis of PB, the cut-off levels of C3 and anti-dsDNA antibody were 62 mg/dl and 5.4 IU/ml, respectively (Figure 1 [1]-A, [1]-D). The risk of PB was significantly higher in the cases with low serum C3 and high anti-dsDNA antibody titer at conception (P=0.02).Similarly, low C3 or CH50 were risk factors for LBW (P=0.02 and 0.03, respectively, Table 1). Logistic regression analysis for LBW showed the cut-off level of C3 as 87 mg/dl, and CH50 as 41.8 IU/ml (Figure 1 [2]-A, [2]-C). Cases with low C3 and low CH50 were at higher risk for LBW (P=0.03).

Table 1.

Association between disease activity parameters and PB or LBW

Preterm birth (PB)Low birth weight (LBW)PB (+)(n = 14)PB (-)(n = 46)P valueLBW (+)(n = 23)LBW (-)(n = 37)P value Achievement of LLDAS, n (%)##5 (41.7)30 (71.4)0.0912 (63.2)23 (65.7)1.00 Achievement of LLDAS without a glucocorticoid dose, n (%)##5 (41.7)37 (88.1)< 0.01*13 (68.4)29 (82.9)0.31 SLEDAI score#3.5±2.91.1±1.3<0.01*2.3±2.11.3±2.00.04* C3, mg/dl#77.3±19.094.7±21.20.03*80.5±16.396.7±22.70.02* C4, mg/dl#16.1±9.019.2±6.30.1617.6±6.319.1±7.40.56 CH50, IU/ml#37.3±10.641.1±8.50.1736.5±6.642.2±9.70.03* Anti-dsDNA antibody, IU/ml#32.5±68.55.5±11.10.01*20.7±55.87.0±12.20.34

(Values are presented as mean ± standard deviation or number (%). #Wilcoxon rank sum test; ##Fisher’s exact test; *P < 0.05.)

Figure 1.

Logistic regression analysis of cut-off value of PB and LBW for C3, C4, CH50 and anti-dsDNA antibody.

(ROC curves based on logistic regression analysis of cut-off levels for disease activity parameters, including C3, C4, CH50, and anti-dsDNA antibody titer. [1] showed ROC curves for PB, and [2] showed those for LBW.)

Conclusion

We revealed that disease activity parameters of SLE at coception are strongly associated with negative pregnancy outcomes; PB and LBW. These include low serum C3 and CH50 levels and high anti-dsDNA antibody titers. In particular, low serum complement is a risk factor for both PB and LBW. Therefore, it is important to strictly control these disease activity parameters at conception in women with SLE.

References

[1]Clowse ME, Jamison M, Myers E, James AH. Am J Obstet Gynecol. 2008;199:127.e1-6.

[2]Bundhun PK, Soogund MZ, Huang F. J Autoimmun. 2017;79:17-27.

[3]Deguchi M, Maesawa Y, Kubota S, Morizane M, Tanimura K, Ebina Y, et al. J Reprod Immunol. 2018;125:39-44.

[4]Clowse ME, Magder LS, Petri M. J Rheumatol. 2011;38:1012-6.

Disclosure of Interests

None declared

Preterm birth is strongly affected by the glucocorticoid dose during pregnancy in women complicated by systemic lupus erythematosus

BACKGROUND

This study aimed to investigate the effect of glucocorticoid doses on adverse pregnancy outcomes (APOs) in women complicated by systemic lupus erythematosus (SLE).

METHODS

We investigated 74 pregnancies complicated by SLE or SLE-dominant mixed connective tissue disease. The pregnancies were managed from conception to delivery in our institution. We retrospectively evaluated whether the mean glucocorticoid dose during pregnancy is associated with APOs, including preterm birth (PB), low birth weight (LBW), and light-for-date (LFD). We also calculated the cut-off dose of glucocorticoid that affected APOs.

RESULTS

All APOs occurred in 35 (50.7%) patients, with 14 cases of PB, 23 cases of LBW, and 10 cases of LFD. Patients with all APOs or PB had a higher dose of glucocorticoid during pregnancy than patients without all APOs or with full-term birth (P = 0.03, P <  0.01, respectively). Logistic regression analysis for all APOs and PB showed that the cut-off values of the mean glucocorticoid dose were 6.5 and 10.0 mg/day, respectively. Patients who delivered LBW or LFD newborns showed no significant difference in the glucocorticoid dose used during pregnancy than patients without LBW or LFD newborns. Patients who delivered LBW newborns were more likely to have used glucocorticoids during pregnancy (P <  0.01).

CONCLUSIONS

In pregnancies complicated by SLE, a relatively lower dose of glucocorticoid than previously reported is significantly related to APOs, especially PB. Therefore, the disease activity of patients with SLE should be managed with the appropriate lower dose of glucocorticoid during pregnancy.

Effects of dietary supplementation with lactosucrose (4G-beta-D-galactosylsucrose) on cecal flora, cecal metabolites, and performance in broiler chickens

The effects of dietary lactosucrose on cecal flora, cecal metabolites, and performance were studied in eight 20-d-old and eight 62-d-old broiler chickens fed a basal diet (control) or a diet with .15% lactosucrose added. On Day 20 of age, the frequency of occurrence of lecithinase-negative clostridia were decreased (P < .05) by lactosucrose consumption. On Day 62 of age, the numbers of bifidobacteria were increased (P < .05) by lactosucrose consumption, but the counts of lecithinase-positive clostridia, including Clostridium perfringens, bacteriodaceae, and staphylococci, total anaerobic bacteria, and the frequency of occurrence of pseudomonads were decreased (P < .05). No detectable change was observed in counts of other organisms throughout the experimental period. Cecal concentration of ammonia (P < .01), phenol (P < .05), and cresol (P < .05) were decreased on Day 62 of lactosucrose consumption. Acetic acid and butyric acid were increased (P < .01 and P < .05, respectively) on Day 62 of lactosucrose consumption. Environmental ammonia and odor of chicken ceca were greatly reduced by lactosucrose consumption.