Intravenous iloprost in systemic sclerosis and its effect in cardiopulmonary function: a retrospective observational study

OBJECTIVE

This study aims at evaluating the disease progression, specifically in terms of cardiopulmonary function, in a group of consecutively enrolled systemic sclerosis (SSc) patients treated with the approved iloprost regimen.

PATIENTS AND METHODS

A retrospective observational study was performed on 68 SSc patients treated with 5-6 infusions of iloprost per month for 6 hours per day at a dosage of 0.5-2.0 ng/kg/min through a portable syringe pump. All patients were evaluated for modified Rodnan skin score, systolic pulmonary arterial pressure, tricuspid annular plane systolic excursion, diffusing capacity of the lungs for carbon monoxide, forced vital capacity, alveolar volume, diffusing capacity of the lungs for carbon monoxide/alveolar volume, pro-brain natriuretic peptide (pBNP), New York Heart Association class, and the presence or absence of digital ulcers (DUs).

RESULTS

After a follow-up period of 9.9±2.9 years, all patients improved in frequency and severity of the Raynaud phenomenon and showed a stabilization or improvement of cardiopulmonary parameters. The pulmonary arterial pressure and pBNP improved significantly from baseline (30.91±6.4 mmHg vs. 27.36±7.1 mmHg, and 97.20±69.3 pg/ml vs. 66.65±44.3 pg/ml, respectively; p<0.0001 for both). A significant improvement was observed in the modified Rodnan skin score in 57 patients who continued the treatment during the entire follow-up (5.09±5.7 vs. 3.30±4.2, p<0.0001).

CONCLUSIONS

Despite the retrospective design and the lack of a control group, the regular and continued administration of iloprost maintained the stability of the cardiopulmonary and cutaneous parameters in SSc. It significantly reduced pBNP levels, a prognostic cardiac biomarker of SSc. Future research should be addressed to demonstrate a stronger causality of this effect.

POS1494-HPR INCIDENCE OF PSYCHIATRIC DISORDERS AND FIBROMYALGIA IN PATIENTS WITH RHEUMATOID ARTHRITIS AND PSORIATIC ARTHRITIS DURING COVID 19 PANDEMIC: THE ROLE OF TELEMEDICINE

Background

The management of patients with immuno-rheumatological diseases has profoundly changed during the COVID 19 pandemic and telemedicine has played an important role in the disease follow-up.

In addition to monitoring disease activity and any adverse events, especially infectious events, assessing the psychological situation of the patient can be fundamental in particular considering that COVID-19 has also a serious impact on mental health and it has been demonstrated a significantly higher incidence of anxiety disorders and depressive symptoms especially in younger people

Objectives

The aim of this study is to evaluate the incidence of depressive disorders, anxiety and fibromyalgia in our patients with rheumatoid arthritis and psoriatic arthritis during the lockdown period due to the COVID 19 pandemic and validate the use of telemedicine in the clinical management of these patients.

Methods

Patients affected by rheumatoid and psoriatic arthritis treated with biological disease-modifying drugs were contacted to evaluate the state of health and the presence of any adverse events and a nurse administered the clinimetric questionnaires assessment to evaluate the disease activity, the impact of rheumatic disease on the health status and the presence of anxiety, depression and fibromyalgia. In particular the following scales have been used: The Rheumatoid Arthritis Impact of Disease (RAID), the Psoriatic arthritis impact of disease (PsAID), Beck Depression Inventory BDI-II, State-Trait Anxiety Inventory (STAI) and The Fibromyalgia Rapid Screening Tool questionnaire (FIRST), The VAS scale for the assessment of pain. Patients who reported disease flare-up or adverse events underwent an outpatient visit and during visit Disease Activity Score (DAS 28) and Disease Activity Index for Psoriatic Arthritis (DAPSA) were used.

Results

171 patients with rheumatoid arthritis (RA) and 129 patients with psoriatic arthritis were enrolled. The incidence of fibromyalgia was increased in the two groups during the lockdown compared to the previous evaluations and in particular in patients with psoriatic arthritis (AR p =0.013, AP p= 0.001).Our analysis did not report significant differences between the two groups for the presence of fibromyalgia and anxiety-related disorders during lockdown, but a prevalence of depressive disorders in patients with rheumatoid arthritis was observed.During lockdown in RA patients, (n=50), no correlation was found between DAS28 and RAID score (r=0.112, p=0.438) and in PsA patients (n=34), no correlation was found between DAPSA and PSAID score (r=0.131, p=0.459) while median value of RAID was higher in STAI I and II positive and median value of PSAID was higher in STAI I and II positive. Patients positive at BDI had higher RAID score (median 6.28 vs 1.14) and PSAID (median 4.95 vs 2.85) score (Mann Whitney p<0.001 and p=0.003)

Conclusion

In conclusion, mental and physical stress during COVID-19 pandemic can greatly worsen FM symptoms and intensify the patients’ suffering without a clinical flare of the inflammatory disease for patients affected by rheumatoid arthritis.

Telemedicine has allowed us to identify patients who needed a face-to-face approach for therapeutic reevaluation even if not related to a flare of the disease.

References

[1]Coletto LA DermatolTher. 2020 Apr 14:e13415. doi: 10.1111/dth.13415.

[2]Lurie N JAMA Intern Med 2018;178:745–6

[3]Matteo Piga Seminars in Arthritis and Rheumatism 47 (2017) 121–128123

Disclosure of Interests

None declared

POS0297 EFFECTIVENESS AND SAFETY OF SECUKINUMAB IN AXIAL SPONDYLOARTHRITIS: A 24-MONTH PROSPECTIVE, MULTICENTER REAL-LIFE STUDY

Background

Axial Spondyloarthritis (axSpA) can be distinguished in radiographic axSpA (r-axSpA) and non-radiographic (nr-axSpA). Secukinumab (SEC) is a novel treatment for axSpA, but data from real-life are still missing.

Objectives

To evaluate, in a multicentric-Italian-cohort of axSpA patients on SEC followed for 24-months: a)the long-term effectiveness and safety of SEC; b)the drug-retention-rate and low-disease-activity (LDA) measured as BASDAI<4/ASDAS<2.1 and very-low-disease-activity (VLDA) measured as BASDAI<2/ASDAS<1.3; c)any differences in outcomes according to: line of biological treatment (naïve/non-naïve), gender (male/female), subtype of axSpA (r-axSpA/nr-axSpA).

Methods

Consecutive patients with active axSpA (diagnosis according Assessment of SpondyloArthritis International Society ASAS criteria), who started SEC treatment, were evaluated prospectively. Data on disease characteristics, previous/ongoing treatments and imaging were collected. Disease-activity/functional/clinical scores and biochemical values were recorded at baseline (T0), at 6 (T6), 12 (T12), and 24 (T24) months. Effectiveness was evaluated over-time with descriptive statistics; multivariate Cox and logistic regression models were used to evaluate predictors of drug-discontinuation and LDA at T6. Infections, adverse events were recorded.

Results

249 patients (47.8% male; median age 51 years) were enrolled; 40.9% had HLA-B27; 53.8% had r-axSpA and 46.2% nr-axSpA. SEC was prescribed in 28.9% naïve and in 71.1% non-naïve patients. SEC effectiveness was shown as an improvement in several outcomes, such as ASDAS [T0=3.5(2.9-4.4) vs. T24=1.9(1.2-2.4);p=0.02] and BASDAI [T0=6.5(5.0-7.5) vs. T24=2.8(1.8-4.0);p=0.03]. After 24-months of treatment, 90.7% of naïve and 75.3% of non-naïve patients achieved LDA (BASDAI<4). At T24 naïve-patients showed better physical-functioning and lower disease-activity than non-naïve (Table 1). Similarly, at T24 we observed better physical functioning and lower inflammatory activity in males vs. females and in nr-axSpA vs. r-axSpA subjects. Retention-rate at T24 was 75% in the whole population, with some difference depending on gender (log-rank 9.319; p=0.002) (Figure 1). Treatment was discontinued in 61 patients (24.5%), mainly due to primary/secondary loss of effectiveness events (20 and 24 subjects, respectively), and only 17 patients (6.8%) due to adverse events (7 for reactions at the injection site or skin manifestations, 1 for gastro-intestinal complications, 1 for relapsing uveitis, 1 for hypertransaminasemia, 4 for severe recurrent infections, 3 due to the onset of new cancer).

Table 1.

Clinical, functional, disease activity and serological parameters of naïve (n=72) and non-naïve (n=177) axSpA patients during the 24-month follow-up

T0T6T12T24BASMI [0-10], median (IQR)naïve2.0 (1.0-4.0)2.0 (0.0-3.3)1.0 (0.0-2.8)1.0 (0.0-2.0)non-naïve4.0 (1.0-7.0)4.0 (1.0-7.0)2.0 (1.0-4.0)2.0 (1.0-3.0)pp=0.03p=0.04nsnsHAQ-S [0-8], median (IQR)naïve0.8 (0.5-1.3)0.5 (0.0-1.0)0.3 (0.0-1.0)0.1 (0.0-0.5)non-naïve1.1 (0.8-1.5)1.0 (0.4-1.3)0.6 (0.4-0.9)0.7 (0.1-0.9)pp=0.04p=0.04p=0.04p=0.04ASDAS [0-6], median (IQR)naïve3.3 (2.7-3.9)2.1 (1.6-2.7)2.0 (1.2-2.8)1.3 (1.0-2.2)non-naïve3.7 (2.9-4.7)2.9 (2.0-3.7)2.1 (1.9-3.1)2.3 (1.6-2.3)pnsnsnsp=0.04ESR [0-25](mm/h), median (IQR)naïve14.0 (6.0-27.0)10.0 (4.0-19.5)8.0 (3.1-12.8)5.0 (2.0-15.0)non-naïve18.5 (10.0-31.3)15.0 (8.0-25.0)12.0 (6.0-20.0)12.0 (6.0-19.0)pp=0.04p=0.04p=0.04p=0.04

Legend: BASMI: Bath Ankylosing Spondylitis Metrology Index; HAQ: Health Assessment Questionnaire modified for spondyloarthritis; ASDAS: Ankylosing Spondylitis Disease Activity Score; ESR: erythrocyte sedimentation rate

Conclusion

In a real-life clinical-setting, SEC proved to be safe and effective in axSpA, mainly in naïve-patients, with a notable drug-retention-rate. No differences were observed between r-axSpA and nr-axSpA.

Acknowledgements

Contributing authors of the Spondyloartritis and Psoriatic Arthritis SIR Study Group “Antonio Spadaro”: Alberto Cauli, MD, PhD, Rheumatology Unit, Department of Medical Sciences, AOU and University of Cagliari, Cagliari, Sardegna, Italy; Angelo Semeraro, MD, Rheumatology Unit, Martina Franca-ASL Taranto, Puglia, Italy; Leonardo Santo, MD, Rheumatology Unit, ASL BT Andria – DSS4 Barletta, Italy, Barletta-Andria-Trani, Puglia, Italy; Emanuela Praino, MD, Rheumatology Unit, ASL BT Andria – DSS4 Barletta, Italy, Barletta-Andria-Trani, Puglia, Italy; Giorgio Amato, MD, Rheumatology Unit, A.O.U. Policlinico S. Marco, Catania, Sicilia, Italy; Nicolò Girolimetto, MD, Rheumatology Unit, Department of Internal Medicine, Azienda USL-IRCCS, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Emilia Romagna, Italy.

Disclosure of Interests

Giacomo Cozzi: None declared, Mariagrazia Lorenzin: None declared, Maria Sole Chimenti: None declared, Salvatore D’Angelo: None declared, Antonio Marchesoni: None declared, Carlo Salvarani: None declared, Ennio Lubrano: None declared, Luisa Costa: None declared, Ylenia Dal Bosco: None declared, Elena Fracassi: None declared, Augusta Ortolan: None declared, Mario Ferraioli: None declared, Antonio Carriero: None declared, elisa visalli: None declared, RICCARDO BIXIO: None declared, Francesca Desiati: None declared, ALBERTO BERGAMINI: None declared, elisa pedrollo: None declared, Andrea Doria Grant/research support from: Novartis, Abbvie, Pfizer, MSD, Janssen, Rosario Foti: None declared, Antonio Carletto: None declared, Roberta Ramonda Grant/research support from: Novartis, Abbvie, Pfizer, MSD, Janssen

POS1027 APREMILAST EFFICACY IN REAL WORLD SETTINGS: RESULTS FROM AN ITALIAN MULTI-CENTER OBSERVATIONAL STUDY

Background

Apremilast, an inhibitor of the phosphodiesterase 4, is indicated for Psoriatic Arthritis (PsA) treatment. The 3 years retention rate, an outcome indirectly related to efficacy, observed in clinical trials [1] is 55,5%. A single subsequent real world setting study [2] suggested a lower efficacy as it reported that the six months retention rate was about 57%.

Objectives

The main aim of this retrospective observational study is the assessment of apremilast 3 years retention rate in a real world PsA patients’ cohort. Moreover, the secondary objective is reporting the reasons of apremilast suspension and the most relevant factor related to treatment persistence.

Methods

In thirteen Italian rheumatological referral centers, all PsA consecutive patients who received apremilast were enrolled. Anamnestic data, treatment history and PsA disease activity (DAPSA) at baseline and after 6 and 12 months were recorded. The Kaplan-Meier curve and the Cox analysis computed the apremilast retention rate and treatment persistence-related risk factors. A p-value < 0.05 was considered statistically significant.

Results

The three-hundred-twenty-four enrolled patients (median age 60 [InterQuartile Range IQR 52-67] yrs; female prevalence 57,0%) median observation period was 17 [IQR 7-36] months (6848 patients-months). The apremilast retention rate at 6, 12 and 36 months was, respectively, 95%, 86% and 66% (Figure 1). The main discontinuation reasons were: primary inefficacy (40% of interruptions), secondary inefficacy (18%) and gastro-intestinal intolerance (17%%). The oligo-articular onset was the only factor associated to apremilast persistence (Hazard ratio 0.57 IQR 0.34-0.96). Sex, age, and sever comorbidities (cancer, chronic infections etc) were not related to treatment discontinuation. The basal DAPSA (24.1, IQR 18.5-32.0) decreased after 6 and 12 months (respectively 14.5, IQR 10.1-22.6 and 10.5, IQR 8,0-15.2). Remission or minimal disease activity (DAPSA < 15) was achieved after 12 months in 38.0% of patients.

Conclusion

Almost two third of PsA patients receiving apremilast were still in treatment after 3 years. The study’s data, confirmed its efficacy and safety profile. Apremilast appear a good treatment choice in patients with oligo articular PsA or burdened by severe comorbidities.

References

[1]Mease et al. ACR Open Rheumatology (2020)

[2]Favalli et al Clin Exp Rheum (2020)

Disclosure of Interests

Alarico Ariani Speakers bureau: Zentiva, Consultant of: Boeringher, Amgen, Bristol-Meyers-Squibb, Novartis, Sanofi, Novo Nordisk, Lilly, Janssen, Bruno Farmaceutici, Simone Parisi: None declared, Patrizia Del Medico: None declared, antonella farina: None declared, elisa visalli: None declared, Aldo Molica Colella: None declared, Federica Lumetti Consultant of: Amgen, rosalba caccavale: None declared, Palma Scolieri: None declared, Romina Andracco: None declared, Francesco Girelli: None declared, Elena Bravi: None declared, Matteo Colina: None declared, Veronica Franchina: None declared, Ilaria Platé: None declared, eleonora Di Donato Consultant of: Novartis, Giorgio Amato: None declared, Carlo Salvarani: None declared, Francesco De Lucia: None declared, Daniele Santilli Consultant of: Novartis, eugenio arrigoni: None declared, Flavio Mozzani Consultant of: Novartis, Abbvie, Rosario Foti: None declared, Gilda Sandri: None declared, Vincenzo Bruzzese: None declared, Marino Paroli: None declared, Enrico Fusaro: None declared, Andrea Becciolini: None declared

POS0634 SAFETY PROFILE OF b/tsDMARD IN RHEUMATOID ARTHRITIS PATIENTS WITH IMPAIRED GLOMERULAR FILTRATION RATE. AN ANALYSIS FROM THE GISEA REGISTRY

Background

In real-life setting, a greater number of elderly rheumatoid arthritis (RA) patients with impaired glomerular filtration rate (GFR) needs treatment with biologic or target synthetic disease-modifying anti-rheumatic drugs (b/tsDMARD) to achieve disease control and reduce NSAIDs intake. Long-term observational data from the real-life on the use of b/tsDMARD in these patients are scarce.

Objectives

The aim of this study was to evaluate the retention rate of b/tsDMARD in RA patients with impaired GFR in real-life setting.

Methods

Data of RA patients treated with at least one b/tsDMARD were retrospectively analyzed form the national Italian GISEA registry from January 2016 to December 2021. Estimated-GFR (eGFR) was calculated with the Cockcroft-Gault equation at the time of any b/tsDMARD prescription. For the purpose of this study, patients were divided in two groups, patients with impaired GFR (eGFR ≤60) and patients with normal GFR (eGFR >60). The retention rate was calculated by the Kaplan-Meier method and compared between these two groups by a log-rank test.

Results

The study population included 2443 treatment-line with b/tsDMARD from 1888 patients (female 80.4%, age 57±12 years, mean baseline CDAI 17±12, FR/ACPA+ 69.5%) who started a new b/tsDMARD. Disease characteristics are shown in Table 1. 288 treatments with b/tsDMARD were started in patients with impaired eGFR and 2155 in patients with normal eGFR. Compared to patients with eGFR >60, patients with eGFR ≤60 showed higher HAQ-DI (1.3±0.8 vs 1±0.8, p<0.001) at the start of b/tsDMARD treatment. Glucocorticoids were more prescribed in patients with impaired eGFR (80.2% vs 72.8%, p<0.01), while csDMARDs were more prescribed in association with b/tsDMARD in patients with normal eGFR (83.1% vs 76.4%, p<0.01). Of note, CTLA4-Ig treatment was more prescribed in patients with impaired eGFR (26% vs 17.1%, p<0.05), while no difference in b/tsDMARD prescription was observed for other mechanism of actions. Drug survival was similar between RA patients with impaired eGFR [58.2%, mean survival time 35 months (CI95% 31-39)]and RA patients with normal eGFR [55%, mean survival time 34.4 months (CI95% 33-36), log rank: 0.88] (Figure 1). Cox regression model adjusted for age, sex and b/tsDMARD showed no impact of eGFR on drug survival [HR: 0.9 (CI95%: 0.7-1.2).

Conclusion

Our data show that impaired eGFR seems to not influence the persistence of b/tsDMARD treatment in RA patients.

Disclosure of Interests

None declared

POS1267 LONG-TERM SURVEY STUDY OF THE IMPACT OF COVID-19 ON SYSTEMIC AUTOIMMUNE DISEASES. LOW DEATH RATE DESPITE THE INCREASED PREVALENCE OF SYMPTOMATIC INFECTION. ROLE OF PRE-EXISTING INTERSTITIAL LUNG DISEASE AND ONGOING TREATMENTS

Background

Patients with autoimmune systemic diseases (ASDs) can be counted among frail populations as regards the predisposition to COVID-19 due to the frequent visceral organ involvement and comorbidities, as well as the ongoing immunomodulating treatments.

Objectives

Our long-term multicenter telephone survey prospectively investigated the prevalence, prognostic factors, and outcomes of COVID-19 in Italian ASD patients during the first 3 pandemic waves.

Methods

A large series of 3,918 ASD patients (815 M, 3103 F; mean age 59±12SD years) was consecutively recruited at the 36 referral centers of COVID-19 & ASD Italian Study Group. In particular, ASD series encompassed the following conditions: rheumatoid arthritis (n: 981), psoriatic arthritis (n: 471), ankylosing spondylitis (n: 159), systemic sclerosis (n: 1,738), systemic lupus (172), systemic vasculitis (n: 219), and a miscellany of other ASDs (n: 178). The development of COVID-19 was recorded by means of telephone survey using standardized symptom-assessment questionnaire (1).

Results

A significantly increased prevalence of COVID-19 (8.37% vs 6.49%; p<0.0001) was observed in our ASD patients, while the cumulative death rate revealed statistically comparable to the Italian general population (3.65% vs 2.95%; p: ns). In particular, among the 328 ASD patients complicated by COVID-19, 57 (17%) needed hospitalization, while mild-moderate manifestations were observed in the large majority of individuals (83%). In addition, 12/57 hospitalized patients died due to severe interstitial pneumonia and/or cardiovascular manifestations.

Interestingly, a significantly higher COVID-19-related death rate was observed in systemic sclerosis patients compared to the Italian general population (6.29% vs 2.95%; p=0.018). Other adverse prognostic factors to develop COVID-19 were the patients’ older age, male gender, pre-existing ASD-related interstitial lung involvement, and chronic steroid treatment. Conversely, patients treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) showed a significantly lower prevalence of COVID-19 compared to those without (3.58% vs 46.99%; p=0.000), as well as the chronic administration of low dose aspirin in a subgroup of SSc patients (with 5.57% vs without 27.84%; p=0.000).

Conclusion

The cumulative impact of COVID-19 on ASD patients after the first 3 pandemic waves revealed less severe than that observed during the first phase of pandemic (1), especially with regards to the death rate that was comparable to the Italian general population in spite of the increased prevalence of complicating COVID-19 in the same ASD series.

Ongoing long-term treatments, mainly csDMARDs, might usefully contribute to generally positive outcomes of in this frail patients’ population.

Of note, a significantly increased COVID-19-related mortality was recorded in only SSc patients’ subgroup, possibly favored by pre-existing lung fibrosis. Among different ASD, SSc deserves special attention, since it shares the main pathological alterations with COVID-19, namely the interstitial lung involvement and the endothelial injury responsible for diffuse microangiopathy.

Besides SSc, the patients’ subgroups characterized by older age, chronic steroid treatment, pre-existing interstitial lung disease, and/or impaired COVID-19 vaccine response (1-3), may deserve well-designed prevention and management strategies.

References

[1]Ferri C, et al. Ann Rheum Dis. 2020 Oct 14 doi: 10.1136/annrheumdis-2020-219113.

[2]Ferri C et al. J Autoimmun. 2021 Dec;125:102744. doi: 10.1016/j.jaut.2021.102744.

[3]Visentini M et al. Ann Rheum Dis. 2021 Nov 24. doi: 10.1136/annrheumdis-2021-221248

Disclosure of Interests

None declared

AB1411 JOINT RHEUMA-DERMA CLINIC: FOUR YEARS OF EXPERIENCE AT THE SAN MARCO HOSPITAL IN CATANIA

Background

Psoriatic arthritis (PsA) affects up to one-third of patients with psoriasis. Many recent works in literature have underline that the percentage of undiagnosed PsA is still high.

A direct collaboration between dermatologists and rheumatologists appears fundamental for a better management of these patients, to reduce the risk of joint damage, disability, and comorbidities.

Objectives

The aim of this study is to highlight the benefits of a Rheuma-Derma clinic and a shared approach, focused to an early diagnosis and prompt therapeutic strategy of PsA.

Methods

Patients with psoriasis complaining joint symptoms or rheumatologic patients with cutaneous involvement, were simultaneously assessed by a dermatologist and a rheumatologist.

The collected data included demographics, clinical characteristics as joint patterns (axial/peripheral), clinimetric index evaluated (DAS28, HAQ, BASDAI, DAPSA, PASI, PGA) family history of psoriasis or PsA, BMI (Mass Body Index), psoriasis, comorbidities and Charlson Index, gastrointestinal and ophthalmic involvement, and previous and current treatments with conventional (csDMARDS) and/or biological therapy (bDMARDs).

Results

During the period from 2012 to 2016 the Rheumatology Department registered 255 of patients under biological treatment, against 374 of patients during the Rheuma-Derma Clinic (2017-2021), with an increase of 47% in number. CsDMARDs therapy counted 367 patients before the Rheuma-Derma Clinic and 539 after the shared outpatient activity, with a raise of the 46%. Globally the number of patients with the diagnosis of PsA moved from 622 to 913, reaching an increase of 47% of patients.

The joint pattern have shown a peripheral involvement in 69.3% of cases in comparison to 11% of cases with axial involvement and a mixed for the rest of population, 19.8%. In the group analyzed 539 patients were treated with csDMARDs, 76.5% methotrexate, 30.7% salazopyrine and only 6.7% with cyclosporine. 374 patients under treatment with bDMARD: the majority of patients (86.1%) were treated with TNFα inhibitors, 25.4% Secukinumab, 20.1% Ustekinumab, 16% Apremilast, 4.8% Ixekizumab, 1.1% Tofacitinib. The Charlson Comorbidity Index (CCI) assesses comorbidity level by taking into account the number, the severity of pre-defined comorbid conditions and the age of patients. It provides a weighted score in a range from 0 to 8, which can be used to predict short term and long-term outcomes such as function, hospital length of stay and mortality rates. In our study the majority of patients (27%) had a score of 2 while fortunately only 0.5% of population had a score of 8. The most frequent comorbidities registred in our cohort were hypertension (24.6%) and dyslipidemia (28.3%). Psoriasis was diagnosed in 41% of patients: in 80% of them the skin disease preceded the articular symptoms while 20% of patients developed psoriasis after the arthritis onset. History of family psoriasis was positive in 26% of patients. The nails involvement was observed only in 8% of patients, followed by gastrointestinal disorders (3%) and uveitis (7%). The value of BMI (Body Mass Index), the majority of patients (56%) have shown a normal weight, followed by over-weight patients (31.7%); only 10% of patients presented an obesity grade I and 1.1% an obesity grade II-III.

For all the clinimetric index evaluated (DAS28, HAQ, BASDAI, DAPSA, PASI, PGA), there was an improvement over the twelve months under the Reuma-Derma clinic

Conclusion

In conclusion, the diagnosis of an Early PsA is essential, as an early treatment and management can alter the natural course of PsA and prevent irreversible joint damage. Our experience proved the increased number of patients since the Rheuma-Derma Clinic have started, such as an increased number of patients under treatment, leading to a significant improvement in the quality of life of PsA and Pso patients.

References

[1]Mease PJ J Am Acad Dermatol. 2013;69:729–735.

[2]Scher JU Nat Rev Rheumatol. 2019 Mar;15(3):153-166.

[3]Radtke MA J Eur Acad Dermatol Venereol. 2009 Jun;23(6):683-91. doi: 10.1111/j.1468-3083.2009.03159.x

Disclosure of Interests

None declared

POS0640 REAL-WORLD EFFECTIVENESS AND SAFETY OF GP2015 IN PATIENTS WITH RHEUMATIC DISEASES: FINAL RESULTS OF THE COMPACT STUDY

Background

COMPACT is a non-interventional study evaluating the effectiveness and safety in patients (pts) with rheumatoid arthritis (RA), axial-spondyloarthritis (axSpA) or psoriatic arthritis (PsA) treated with GP2015 (an etanercept [ETN] biosimilar) in real-world conditions.

Objectives

We present the effectiveness and safety data from the final analysis of the COMPACT study for all patient groups.

Methods

Pts aged ≥18 years on treatment with GP2015 were enrolled. Baseline visit corresponded with date of study inclusion and not with date of GP2015 treatment start. Pts were categorised based on prior treatment status: pts on clinical remission or low disease activity under treatment with reference ETN or biosimilar ETN (initial ETN: [iETN]) and switched to GP2015 (Group A) or pts who received non-ETN targeted therapies and switched to GP2015 (Group B) or biologic-naïve pts who started GP2015 after conventional therapy failure (Group C) or DMARD-naïve pts with recent diagnosis of RA considered suitable for treatment initiation with a biologic and started on treatment with GP2015 (Group D). Effectiveness assessments included Disease Activity Score 28-joint count Erythrocyte Sedimentation Rate (DAS28-ESR) or Ankylosing Spondylitis Disease Activity Score (ASDAS) until Month 12 after enrolment (baseline) in the study.

Results

Of the 1466 pts enrolled, 572 were switched from iETN (Group A), 171 were switched from other targeted therapies (Group B), 713 were biologic-naïve (Group C), and 10 were RA DMARD-naïve (Group D). Comorbidities were more frequent in pts with RA (68.7%,) followed by pts with PsA (59.4%) and axSpA (52.1%). After 12 months of treatment with GP2015, pts with RA or PsA achieved comparable DAS28-ESR scores irrespective of whether they switched from iETN, or from other targeted therapies or were biologic-naïve. At Month 12, the mean ASDAS scores were comparable between the treatment groups in pts with axSpA (Table 1). Across all pt groups, no major differences were observed in the disease activity scores between baseline and Month 12 that may be explained by the ongoing GP2015 treatment at the time of enrolment for an observed average of 138 days. Overall, the proportion of patients with at least one adverse event (AE) and serious AE (SAE) was 47.6% and 7.7% in pts who were switched from iETN, 56.7% and 9.9% in pts switched from other targeted therapies, 56% and 8.7% in biologic-naïve pts, and 60% and 0% in DMARD-naïve pts. Rate of injection site reaction was low across the groups (Figure 1).

Table 1.

Effectiveness outcomes in patients treated with GP2015

Effectiveness outcomesGroup AGroup BGroup CGroup DOverall (A-D)RADAS28-ESR, n, mean (SD)N=295N=88N=451N=10N=844Baselinen=259n=70n=392n=8n=7292.5 (1.1)3.6 (1.3)3.3 (1.5)3.8 (1.2)3.0 (1.4)Month 12n=135n=47n=238n=2n=4222.5 (1.3)2.7 (1.0)2.8 (1.4)4.3 (2.5)2.7 (1.3)PsAN=117N=36N=135N=0N=288Baselinen=80n=30n=116-n=2262.1 (1.0)2.9 (1.6)2.9 (1.6)2.6 (1.5)Month 12n=32n=13n=60-n=1052.6 (1.9)2.6 (1.6)2.3 (1.4)2.4 (1.5)AxSpAASDAS, n, mean (SD)N=160N=47N=127N=0N=334Baselinen=77n=18n=59-n=1541.6 (0.6)1.8 (0.8)2.3 (0.9)1.9 (0.8)Month 12n=39n=8n=23-n=701.8 (0.9)1.9 (0.6)1.9 (1.0)1.8 (0.9)

N, total number of patients in the treatment group; n, number of patients with available data at each time point, SD, standard deviation

Figure 1.

Overall safety outcomes in patients treated with GP2015

Figure 1 represents the adverse events reported during GP2015 treatment.

N, total number of patients in the treatment; n, number of patients in each treatment group

Conclusion

The results show comparable disease activity scores between pts who were switched from iETN, pts switched from other targeted therapies and biologic-naïve pts after 12 months of treatment with GP2015. No impact on the effectiveness of ETN was observed in pts with RA, axSpA or PsA who switched to GP2015. No new safety signals were reported.

Disclosure of Interests

Marc Schmalzing Speakers bureau: Novartis, AbbVie, Chugai/Roche, Janssen-Cilag, Lilly, Consultant of: AstraZeneca, Chugai/Roche, Hexal/Sandoz, Gilead, AbbVie, Janssen-Cilag, Boehringer/Ingelheim, Grant/research support from: Chugai/Roche, Boehringer/Ingelheim, Celgene, Medac, Herbert Kellner: None declared, Ayman Askari: None declared, Javier de Toro Santos: None declared, JULIO CESAR VAZQUEZ PEREZ-COLEMAN Speakers bureau: Sandoz, Abbvie, Sanofi, Fresenius, Rosario Foti Speakers bureau: Abbivie, Gilead, Lilly, Pfizer, UCB, Roche, Novartis, Pfizer, UCB, Sławomir Jeka: None declared, Boulos Haraoui Consultant of: Abbvie, Amgen, Fresenius Kabi, Lilly and Pfizer, Grant/research support from: Abbvie, Amgen, Fresenius Kabi, Lilly and Pfizer, Yannick Allanore Consultant of: Sandoz Hexal, Mylan, Astra-Zeneca, Masiur Rahman Employee of: Sandoz Hexal AG, Fabricio Furlan Employee of: Sandoz Hexal AG, Sohaib HACHAICHI Employee of: Sandoz Hexal AG, Tom Sheeran Speakers bureau: Pfizer, UCB, Roche, Consultant of: Novartis, Pfizer, Grant/research support from: Novartis, UCB, Roche

RIF1 and KAP1 differentially regulate the choice of inactive versus active X chromosomes

The onset of random X chromosome inactivation in mouse requires the switch from a symmetric to an asymmetric state, where the identities of the future inactive and active X chromosomes are assigned. This process is known as X chromosome choice. Here, we show that RIF1 and KAP1 are two fundamental factors for the definition of this transcriptional asymmetry. We found that at the onset of differentiation of mouse embryonic stem cells (mESCs), biallelic up-regulation of the long non-coding RNA Tsix weakens the symmetric association of RIF1 with the Xist promoter. The Xist allele maintaining the association with RIF1 goes on to up-regulate Xist RNA expression in a RIF1-dependent manner. Conversely, the promoter that loses RIF1 gains binding of KAP1, and KAP1 is required for the increase in Tsix levels preceding the choice. We propose that the mutual exclusion of Tsix and RIF1, and of RIF1 and KAP1, at the Xist promoters establish a self-sustaining loop that transforms an initially stochastic event into a stably inherited asymmetric X-chromosome state.

Performance of transcatheter pacing system use in Relation to Patient Age

Background

Real-world safety data on the use of transcatheter pacing systems in particularly young and elderly patients is still limited.

Purpose

The aim of this analysis was to investigate the effect of age on the safety and efficacy of leadless pacemaker implant.

Methods

From May 2016 through July 2019, 577 patients were implanted with a leadless single chamber pacemaker according to current pacing indication in 15 Italian cardiologic centers. The population was divided into age quartiles for evaluation, including: 1) &lt;70 years, 2) 70–77 years, 3) 78–83 years, and 4) ≥83 years. Procedural data, complications, electrical parameters were collected at baseline and during the follow up.

Results

Procedural-related complication occurrence was very low (&lt;1.0%) and similar in the four subgroups according to age. No cardiac tamponade was reported. Among the groups, no difference was observed in procedural time, fluoroscopy time duration and electrical parameters (mean pacing impedance: 750±192 and 599±156, mean pacing threshold: 0.7±0.5 and 0.7±0.6, and mean right ventricular sensing 10.7±6.1 and 11.5±4.8 at implant and last follow up, respectively). Figure 1 showed the distribution of age in the patient population.

Conclusion

The reported data demonstrated a high degree of safety during leadless implant across all patient ages. Procedural complications and device electrical measurements were similar among the different ages.

Funding Acknowledgement

Type of funding sources: None.

AB0467 EFFECTIVENESS OF GOLIMUMAB AFTER TNF-INHIBITOR FAILURE IN PATIENTS WITH ACTIVE RHEUMATOID ARTHRITIS, PSORIATIC ARTHRITIS, OR AXIAL SPONDYLOARTHRITIS: RESULTS AT 3 MONTHS FROM THE GO-BEYOND ITALY STUDY

Background:

Golimumab showed trial efficacy in subjects with active rheumatoid arthritis (RA) previously treated with TNF-inhibitors (TNFi); no trial data are available for psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA).

Objectives:

To assess the effectiveness of golimumab after TNFi failure in patients with RA, PsA, or axSpA in a real-world setting.

Methods:

GO-BEYOND-Italy is an ongoing, multicenter, prospective, observational study of RA, PsA, or axSpA patients starting golimumab after TNFi failure. Patients were enrolled between July 2017 and December 2019, and followed for 1 year, with evaluations at 3, 6, and 12 months. This interim analysis estimates the effectiveness after 3 months of golimumab therapy. Differences from baseline were tested by paired t-tests.

Results:

193 patients were enrolled: 38 (19.7%) with RA (median age 54 years; median disease duration 9.5 years), 91 (47.2%) with PsA (median age 53 years; median disease duration 9.0 years) and 64 (33.2%) with axSpA (median age 54 years; median disease duration 7.2 years). Majority of the RA (73.7%), PsA (51.6%) and axSpA (53.1%) were females. Previous TNFi treatment included etanercept (44.6% of patients), adalimumab (42.0%), infliximab (8.8%) and certolizumab (4.7%). The main reason for switching to golimumab was loss of efficacy of TNFi (78.9% in RA, 83.5% in PsA, 75% in axSpA). Comorbidities were highly prevalent (RA 65.8%, PsA 65.9%, axSpA 75%); hypertension (31.1%), dyslipidaemia (13.5%), fibromyalgia (10.4%) were the most common ones. DAS28-CRP significantly reduced in RA and PsA (p<0.01) after 3 months of treatment. In RA, rates of DAS28-CRP remission and low disease activity (LDA) were 29.6% and 22.2%, respectively, and 65.2% of patients achieved good/moderate EULAR response. As for PsA, good/moderate EULAR response was observed in 78.8% of patients and 28% of patients achieved minimal disease activity. In axSpA, ASDAS-CRP (p<0.01), BASDAI (p<0.01) and ASAS-HI (p=0.032) significantly reduced; rates of ASDAS-CRP inactive disease and LDA were 15.2% and 26.1%, respectively; 14% of patients had a ≥50% improvement in baseline BASDAI. After 3 months of golimumab treatment, there was a decrease in the prevalence of enthesitis (32.9% to 16.5%), nail (17.6% to 12.9%) and skin psoriasis (42.4% to 34.1%) in PsA patients; the frequency of extra articular manifestations tended to decrease also in axSpA patients.

Conclusion:

Preliminary results of the GO-BEYOND-Italy study showed a good short-term effectiveness of golimumab in RA, PsA and axSpA after TNFi failure.

Table 1.

Effectiveness of golimumab at 3 months in the GO-BEYOND-Italy study

Rheumatoid arthritis (n=38)Psoriatic arthritis (n=91)Axial spondyloarthritis (n=64)DAS28-CRP, mean (SD)n=27DAS28-CRP, mean (SD)n=47ASDAS-CRP, mean (SD)n=44V0 / V14.05 (0.8) / 3.10* (1.0)V0 / V13.66 (1.0) / 2.79* (1.2)V0 / V12.86 (1.0) / 2.33* (1.0)V1: DAS28-CRP disease activity, n (%)n=27V1: EULAR response, n (%)n=33V1: ASDAS-CRP disease activity, n (%)n=46Remission8 (29.6)Good16 (48.5)Inactive disease7 (15.2)Low disease activity6 (22.2)Moderate10 (30.3)Low disease activity12 (26.1)Moderate disease activity13 (48.1)No response7 (21.2)High disease activity22 (47.8)Very high disease activity5 (10.9)V1: EULAR response, n (%)n=23V1: MDA, n (%)n=75Good7 (30.4)Yes21 (28.0)BASDAI, mean (SD)n=50Moderate8 (34.8)V0 / V15.99 (2.1) / 4.92 (2.3)*No response8 (34.8)V1: BASDAI50, n (%)7 (14.0)ASAS-HI, mean (SD)n=48V0 / V110.67 (3.8) / 9.68 (4.6)^

*p value for the difference from V0 <0.01. ^ p for the difference from V0=0.032

Abbreviations: ASDAS: Ankylosing Spondylitis Disease Activity Score; ASAS-HI: Assessment of SpondyloArthritis international society Health Index; BASDAI: Bath Ankylosing Spondylitis Disease Activity Index; CRP: C-reactive protein; DAS: disease activity score; EULAR: European League Against Rheumatism; MDA: Minimal Disease Activity; SD: standard deviation; V0: baseline; V1: 3 months evaluation.

Disclosure of Interests:

Salvatore D’Angelo Speakers bureau: AbbVie, BMS, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, UCB, Consultant of: AbbVie, BMS, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, UCB, Enrico Tirri Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer, Angela Maria Giardino Employee of: MSD Italia, Marco Matucci-Cerinic Speakers bureau: BMS, Pfizer, Actelion, Consultant of: Eli-Lilly, Celgene, Chemomab, CSL Behring, Grant/research support from: BMS, Pfizer, Celgene, CSL Behring, Lorenzo Dagna Consultant of: Abbvie, Amgen, Biogen, Bristol-Myers Squibb, Celltrion, Novartis, Pfizer, Roche, Sanofi-Genzyme, and SOBI, Leonardo Santo: None declared., francesco ciccia: None declared., Bruno Frediani: None declared., Marcello Govoni: None declared., Francesca Bobbio Pallavicini: None declared., Rosa Daniela Grembiale: None declared., Andrea Delle Sedie: None declared., Stefania Cercone Employee of: MSD Italia, RITA MULE’: None declared., Francesco Paolo Cantatore Speakers bureau: Pfizer, Sanofi Genzyme and Roche, Consultant of: Pfizer, Sanofi Genzyme and Roche outside this work., Rosario Foti: None declared., Elisa Gremese: None declared., Roberto Perricone: None declared., Fausto Salaffi: None declared., Ombretta Viapiana Speakers bureau: Novartis, UCB, Abbvie, MSD, Fresenius kabi, Gilead, Biogen, Consultant of: Novartis, Abbvie, Fresenius kabi, Gilead, Biogen, Alberto Cauli Speakers bureau: Abbvie, Alfa-Sigma, BMS, Celgene, Galapagos, Glaxo, MSD, Novartis, Janssen, Pfizer, Sanofi, UCB, Consultant of: Abbvie, Alfa-Sigma, BMS, Celgene, Galapagos, Glaxo, MSD, Novartis, Janssen, Pfizer, Sanofi, UCB, Rorberto Giacomelli: None declared., Luisa Arcarese: None declared., Giuliana Guggino Speakers bureau: Novartis, Celgene, Abbvie, Sandoz, Eli Lilly, Pfizer, Jansen, ROMUALDO RUSSO: None declared., Domenico Capocotta: None declared., Francesca Nacci: None declared., Maria Grazia Anelli: None declared., valentina picerno: None declared., Florenzo Iannone Speakers bureau: Pfizer, AbbVie, Janssen, Celgene, Novartis, MSD, BMS, UCB, Roche, Consultant of: Pfizer, AbbVie, Janssen, Celgene, Novartis, MSD, BMS, UCB, Roche outside this work.

POS1021 THE PsABio STUDY IN ITALY: A REAL-WORLD COMPARISON OF THE PERSISTENCE, EFFECTIVENESS AND SAFETY OF USTEKINUMAB AND TUMOUR NECROSIS FACTOR INHIBITORS IN PATIENTS WITH PSORIATIC ARTHRITIS

Background:

There are still unmet needs in the treatment of psoriatic arthritis (PsA), including in terms of treatment persistence, which is a function of effectiveness, safety and patient satisfaction. Ustekinumab (UST) was the first new biologic drug to be developed for the treatment of PsA after tumour necrosis factor inhibitors (TNFi).

Objectives:

To compare treatment persistence, effectiveness and safety of UST and TNFi in Italian patients within the PsABio cohort.

Methods:

PsABio (NCT02627768) is an observational study of 1st/2nd/3rd-line UST or TNFi treatment in PsA in 8 European countries. The current analysis set includes 222 eligible patients treated in 15 Italian centres, followed to Month 12 (±3 months). Treatment persistence/risk of stopping was analysed using Kaplan−Meier (KM) and Cox regression analysis. Proportions of patients reaching minimal disease activity (MDA)/very low disease activity (VLDA) and clinical Disease Activity Index for PsA (cDAPSA) low disease activity (LDA)/remission were analysed using logistic regression, including propensity score (PS) adjustment for imbalanced baseline covariates, and non-response imputation of effectiveness endpoints if treatment was stopped/switched before 1 year. Last observation carried forward data are reported.

Results:

Of patients starting UST and TNFi, 75/101 (74.3%) and 77/121 (63.6%), respectively, persisted with treatment at 1 year. The observed mean persistence was 410 days for UST and 363 days for TNFi. KM curves and PS-adjusted hazard ratios confirmed significantly higher persistence (hazard ratio [95% confidence interval (CI)]) for UST versus TNFi overall (0.46 [0.26; 0.82]; Figure 1). Persistence was also higher for UST than TNFi in patients receiving monotherapy without methotrexate (0.31 [0.15; 0.63]), in females (0.41 [0.20; 0.83]), and in patients with body mass index (BMI) <25 kg/m2 (0.34 [0.14; 0.87]) or >30 kg/m2 (0.19 [0.06; 0.54]). There was no significant difference in persistence between treatments in patients with BMI 25−30 kg/m2. While patients receiving 1st- and 3rd-line UST or TNFi showed similar risk of discontinuation (0.60 [0.27; 1.29] and 0.36 [0.10; 1.25], respectively), patients receiving 2nd-line UST showed better persistence than those receiving 2nd-line TNFi (0.33 [0.13; 0.87]). Other factors added to the PS-adjusted Cox model did not show significant effects. In patients with available follow-up data, the mean (standard deviation) baseline cDAPSA was 26.3 (15.4) for UST and 23.5 (12.3) for TNFi; at 1-year follow-up, 43.5% of UST- and 43.6% of TNFi-treated patients reached cDAPSA LDA/remission. MDA was reached in 24.2% of UST- and 28.0% of TNFi-treated patients, and VLDA in 12.5% of UST- and 10.2% of TNFi-treated patients. After PS adjustment (stoppers/switchers as non-responders), odds ratios (95% CI) at 1 year did not differ significantly between UST and TNFi groups for reaching cDAPSA LDA/remission (1.08 [0.54; 2.15]), MDA (0.96 [0.45; 2.05]) or VLDA (0.98 [0.35; 2.76]). In total, 23 (20.4%) patients reported ≥1 treatment emergent adverse event with UST and 30 (22.2%) with TNFi; 6 (5.3%) and 10 (7.4%) patients, respectively, discontinued treatment because of an adverse event.

Conclusion:

In the Italian PsABio cohort, UST had better overall persistence compared with TNFi, as well as in specific subgroups: females, patients on monotherapy without methotrexate, with BMI <25 or >30 kg/m2, and patients receiving UST as 2nd-line treatment. At 1 year, both treatments showed similar effectiveness, as measured by cDAPSA responses and MDA/VLDA achievement.

Acknowledgements:

This study was funded by Janssen. Contributing author: Prof. Piercarlo Sarzi-Puttini, ASST Fatebenefratelli-Sacco, University of Milan, Italy

Disclosure of Interests:

Elisa Gremese: None declared, Francesco Ciccia Speakers bureau: AbbVie, Abiogen, Bristol-Myers Squibb, Celgene, Janssen, Lilly, Novartis, Pfizer, Roche, Consultant of: Celgene, Janssen, Lilly, Novartis, Pfizer, Roche, Grant/research support from: Celgene, Janssen, Novartis, Pfizer, Roche, Carlo Selmi Speakers bureau: AbbVie, Alfa-Wassermann, Amgen, Biogen, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, Sanofi-Genzyme, Consultant of: AbbVie, Alfa-Wassermann, Amgen, Biogen, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Pfizer, Sanofi-Genzyme, Grant/research support from: AbbVie, Amgen, Janssen, Pfizer, Giovanna CUOMO: None declared, Rosario Foti Speakers bureau: AbbVie, Bristol-Myers Squibb, Celgene, Lilly, MSD, Janssen, Roche, Sanofi, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Lilly, MSD, Janssen, Roche, Sanofi, Marco Matucci Cerinic Speakers bureau: Actelion, Biogen, Janssen, Lilly, Consultant of: Chemomab, Grant/research support from: MSD, Fabrizio Conti Consultant of: AbbVie, Bristol-Myers Squibb, Galapagos, Lilly, Pfizer, Enrico Fusaro Speakers bureau: AbbVie, Amgen, Lilly, Grant/research support from: AbbVie, Pfizer, Giuliana Guggino Speakers bureau: AbbVie, Celgene, Novartis, Pfizer, Sandoz, Grant/research support from: Celgene, Pfizer, Florenzo Iannone Speakers bureau: AbbVie, Bristol-Myers Squibb, Celgene, Lilly, MSD, Novartis, Pfizer, Sanofi, UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Lilly, MSD, Novartis, Pfizer, Sanofi, UCB, Andrea Delle Sedie: None declared, Roberto Perricone: None declared, Luca Idolazzi Speakers bureau: AbbVie, Eli Lilly, Janssen, MSD, Novartis, Sandoz, Paolo Moscato: None declared, Elke Theander Employee of: Janssen, Wim Noel Employee of: Janssen, Paul Bergmans Shareholder of: Johnson & Johnson, Employee of: Janssen, Silvia Marelli Employee of: Janssen, Laure Gossec Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Biogen, Celgene, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, Samsung Bioepis, Sanofi-Aventis, UCB, Grant/research support from: Amgen, Galapagos, Janssen, Lilly, Pfizer, Sandoz, Sanofi, Josef S. Smolen Speakers bureau: AbbVie, Amgen, AstraZeneca, Astro, Bristol-Myers Squibb, Celgene, Celltrion, Chugai, Gilead, ILTOO, Janssen, Lilly, MSD, Novartis- Sandoz, Pfizer, Roche, Samsung, Sanofi, UCB, Grant/research support from: AbbVie, AstraZeneca, Lilly, Novartis, Roche.

POS1246 COVID-19 IN ITALIAN PATIENTS WITH RHEUMATIC AUTOIMMUNE SYSTEMIC DISEASES: RESULTS OF A NATIONWIDE SURVEY STUDY

Background:

SARS-CoV-2 infection poses a serious challenge for patients with rheumatic autoimmune systemic diseases (ASD), characterized by marked immune-system dysregulation and frequent visceral organ involvement.

Objectives:

To evaluate the impact of Covid-19 pandemic in a large series of Italian patients with ASD.

Methods:

Our multicenter telephone survey (8-week period, March-April 2020) included a large series of 2,994 patients (584 M, 2,410 F, mean age 58.9±13.4SD years) with ASD followed at 34 tertiary referral centers of 14 regions of northern, central, and southern Italian macro areas, characterized by different prevalence of SARS-CoV-2 infection. According to currently used criteria, Covid-19 was classified as definite Covid-19 (signs or symptoms of Covid-19 confirmed by positive oral/nasopharyngeal swabs at PCR testing) or highly suspected Covid-19 (signs or symptoms highly suggestive of Covid-19, but not confirmed by PCR testing due to limited availability of virological tests in that period). The results were analyzed performing the Odds Ratio by Java-Stat 2-way Contingency Table Analysis.

Results:

The main findings of the survey study revealed a significantly increased prevalence of Covid-19 in:

a.the whole series of ASD patients (definite Covid-19: 22/2994, 0.73%; p=0.0007;

definite Covid-19 plus highly suspected Covid-19: 74/2,994, 2.47%; p<0.0001) when compared to Italian general population of Covid-19 infected individuals (349/100000 = 0.34%; data from Italian Superior Institute of Health;

https://www.epicentro.iss.it/en/coronavirus/sars-cov-2-national-surveillance-system).

b.the subgroup of patients with connective tissue diseases or systemic vasculitis (n = 1,901) compared to the subgroup of inflammatory arthritis (n = 1,093), namely rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis (definite Covid-19: 19/1,901, 0.99%, vs 3/1,093, 0.27%; p=0.036; definite Covid-19 plus highly suspected Covid-19: 69/1,901, 3.6%, vs 5/1,093, 0.45%; p<0.0001)

c.the subgroup of patients with pre-existing interstitial lung involvement (n = 526) compared to those without (n = 2,468) (definite Covid-19: 10/526, 1.90%, vs 12/2,468, 0.48%; p=0.0015; definite Covid-19 plus highly suspected Covid-19: 33/526, 6.27%, vs 41/2,468, 1.66%; p<0.0001).

Of interest, the prevalence of Covid-19 did not correlate with presence/absence of different comorbidities, mainly diabetes, cardio-vascular and/or renal disorders, as well as of ongoing treatments with biological DMARDs; while patients treated with conventional DMARDs showed a significantly lower prevalence of Covid-19 compared to those without. Covid-19 was more frequently observed in the patients’ populations from northern and central compared to southern Italian macro area with lower diffusion of pandemic. Clinical manifestations of Covid-19, observed in 74 patients, were generally mild or moderate; 4/9 individuals requiring hospital admission died for severe pneumonia.

Conclusion:

The prevalence of Covid-19 observed in ASD patients during the first wave of pandemic was significantly higher than that observed in Italian general population; moreover, the actual prevalence of Covid-19 might be underestimated due to the high number of mild variants as well as the possible clinical overlapping between these two conditions. Patients with ASD should be invariably regarded as ‘frail patients’ during the pandemic course, considering the risk of worse outcome in the acute phase of Covid-19, as well as the potential long-term effects of viral infection.

The statistically significant association of Covid-19 with connective tissue diseases/systemic vasculitis, as well as with pre-existing interstitial lung involvement, suggests the presence of distinct clinico-pathological ASD subsets, characterized by markedly different patients’ vulnerability to SARS-CoV-2 infection.

Disclosure of Interests:

None declared

POS0675 THE COMPARATIVE 3-YEAR RETENTION RATE OF TARGETED-SYNTHETIC AND BIOLOGIC DRUGS FOR RHEUMATOID ARTHRITIS: REAL-LIFE DATA FROM THE ITALIAN GISEA REGISTRY

Background:

Long-term observational data on the real-life use of JAK inhibitors (JAKis) for rheumatoid arthritis (RA) and their comparison with biological drugs are still very limited. Large population-based registries have been increasingly used to investigate the performance of targeted drugs in a real-life setting.

Objectives:

The aim of this study is to evaluate and compare the 3-year retention rate of JAKis, TNF inhibitors (TNFis) and biologic drugs with other mechanisms of action (OMAs) in the large cohort of RA patients included in the Italian national GISEA registry.

Methods:

Data of all RA patients treated with targeted synthetic or biologic drugs were prospectively collected in the Italian multicentric GISEA registry. The analysis was limited to patients who started a first- or second-line targeted drug in the period after the first JAKi was marketed in Italy (1st December 2017). The 3-year retention rate was calculated by the Kaplan-Meier method and compared between different drug classes by a log-rank test. A descriptive analysis of reasons for discontinuation was performed.

Results:

The study population included 1027 RA patients (79.8% females, mean age [±SD] 56.9 [±13.5] years, mean disease duration 9.8 [±9] years, mean baseline SDAI 17.5 [±11.9], ACPA positive 67.4%, RF positive 62.7%) who received JAKis (baricitinib or tofacitinib, n=297), TNFis (n=365), or OMAs (n=365) as first or second targeted drug. Main baseline characteristics of study population were overall well balanced between treatment groups. Retention rate was numerically but not statistically higher (p=0.18) in patients treated with JAKis compared with TNFis or OMAs (80.6, 78.9 and 76.4% at 1 year and 73, 56.8 and 63.8% at 3 years, respectively) (Figure 1). Drug survival was significantly higher in patients receiving concomitant methotrexate (MTX) compared with monotherapy only in TNFis (66.8 vs 47.1%, p=0.04) but not in JAKis (76.1 vs 70.1%, p=0.54) and OMAs (66.1 vs 61.9%, p=0.41) group. Therapy was discontinued in a total of 211 patients because of ineffectiveness (n=107), adverse events (n=88), or compliance/other reasons (n=16). The most frequent reason for treatment withdrawal was ineffectiveness in both JAKis (n=30 out of 56) and TNFis (n=45 out of 74) groups, whereas OMAs were discontinued more frequently because of adverse events (n=41 out of 81).

Conclusion:

Our data confirmed in a real-life setting a favorable 3-year retention rate of all available targeted mechanisms of action for RA therapy. As expected, concomitant MTX significantly impacted persistence on therapy of TNFis only. Discontinuations of JAKis for adverse events were infrequent overall, confirming the safety profile observed in randomized clinical trials.

Figure 1.

Three-year retention rate by treatment group

Disclosure of Interests:

None declared

AB0488 SPONDYLOARTHRITIS DISEASE BURDEN AS PERCEIVED BY PATIENTS: BASELINE PATIENT-REPORTED OUTCOME DATA FROM THE ITALIAN PROSPECTIVE SIRENA STUDY

Background:

Previous studies have compared Patient-Reported Outcomes (PROs) in Spondyloarthritis (SpA); a recent one has found similarity in Psoriatic Arthritis (PsA) and axial patients1.

Objectives:

To describe PROs at SpA diagnosis (new or confirmed), by type of SpA and by gender.

Methods:

SIRENA is an Italian, prospective Registry of SpA patients diagnosed according to ASAS criteria and naïve to any DMARDs. At inclusion, patients were classified as predominant axial (AxSpA) or mainly peripheral (pSpA). PROs showed in the Table 1 were collected and analysed descriptively.

Table 1.

PhGA and PROs at diagnosis*

AxSpA*pSpAAll(n=123)Women(n=64)Men(n=58)All(n=227)Women(n=109)Men(n=118)PhGA, n1156054222105117mean (SD)50.2 (28.6)54.8 (26.7)45.0 (30.1)45.4 (25.9)49.9 (25.6)41.3 (25.6)median (min, max)52.0 (0-100)62.0 (0-100)43.5 (0-100)48.5 (0-100)50.0 (1.0-100)40.0 (0-95.0)PtGA, n1125952209102107mean (SD)56.4 (27.8)61.5 (25.8)50.3 (29.2)50.3 (26.2)56.4 (23.1)44.5 (27.7)median (min, max)63.0 (0-100)70.0 (2.0-100)50.0 (0-100)50.0 (0-100)58.5 (7.0-100)47.0 (0-100)Pain VAS score, n1136052207101106mean (SD)56.7 (28.3)61.1 (26.6)50.6 (29.1)51.9 (26.8)57.4 (25.3)46.8 (27.3)median (min, max)60.0 (0-100)69.5 (2.0-100)50.0 (0-100)53.0 (0-100)61.0 (0-100)48.5 (0-100)Sleep VAS score, n1136052211103108mean (SD)55.3 (29.3)57.4 (29.5)52.3 (29.2)44.0 (30.1)50.4 (29.8)37.9 (29.2)median (min, max)59.0 (0-100)61.5 (0-100)53.0 (0-100)44.0 (0-100)53.0 (0-100)34.0 (0-100)BASFI, n11058511336568mean (SD)4.6 (2.8)5.2 (2.6)3.9 (2.8)3.5 (2.6)4.0 (2.6)3.1 (2.4)median (min, max)5.1 (0-9.7)5.8 (0-9.4)3.6 (0-9.6)2.9 (0-10.0)3.9 (0-10.0)2.45 (0-8.9)BASDAI, n11259521397069mean (SD)5.2 (2.4)5.8 (2.3)4.5 (2.3)5.2 (2.3)5.8 (2.1)4.6 (2.3)median (min, max)5.5 (0-9.3)6.2 (0-9.3)4.5 (0.3-9.2)5.5 (0.2-10.0)6.1 (1.0-10.0)4.8 (0.2-9.2)HAQ-DI score, n109585020399104mean (SD)0.9 (0.7)1.1 (0.7)0.6 (0.6)0.7 (0.7)0.9 (0.7)0.6 (0.6)median (min, max)0.8 (0.0-2.5)1.1 (0-2.5)0.5 (0-2.3)0.6 (0.0-2.8)0.8 (0-2.8)0.4 (0-2.6)WPAI% work time missed, n4919301074562mean (SD)7.3 (21.4)4.2 (9.5)9.2 (26.3)8.8 (24.7)8.6 (25.6)8.9 (24.3)median (min, max)0 (0-100)0 (0-35.1)0 (0-100)0 (0-100)0 (0-100)0 (0-100)% impairment at work, n6733341346173mean (SD)48.2 (31.9)58.5 (26.6)38.2 (33.7)39.7 (31.4)45.4 (30.9)34.9 (31.2)median (min, max)50.0 (0-100)60.0 (0-100)25.0 (0-100)40.0 (0-100)50.0 (0-100)30.0 (0-100)% overall work impairment, n4819291064561mean (SD)44.1 (33.0)52.4 (27.9)38.7 (35.3)40.1 (33.0)45.1 (33.1)36.4 (32.7)median (min, max)45.0 (0-100)60.0 (0-100)20.0 (0-100)40.0 (0-100)50.0 (0-100)30.0 (0-100)% activity impairment, n10053461839390mean (SD)56.7 (28.6)63.4 (23.9)48.0 (31.0)48.5 (30.3)55.3 (28.7)41.4 (30.4)median (min, max)60.0 (0-100)70.0 (0-100)50.0 (0-100)50.0 (0-100)60.0 (0-100)40.0 (0-100)

* The sum does not add up to the total because of some missing values.

Results:

From 23 sites, 123 AxSpA and 227 pSpA patients were analysed. Diagnosis was new in 58% of AxSpA and 77% of pSpA. 85.5% of the pSpA had PsA, while in AxSpA the most frequent type was Ankylosing Spondylitis (48.8%). Time from symptom onset to diagnosis was higher in AxSpA than in pSpA (median 36 vs 24 months, respectively). At inclusion, composite disease activity measures showed high disease activity for AxSpA (mean ASDAS-CRP 3.1) and moderate disease activity for pSpA (mean DAS28 3.6; mean DAPSA 22.5). AxSpA patients had numerically worse values than pSpA in all the PROs collected, except for BASDAI score that was similar (mean 5.2). For both AxSpA and pSpA, all PROs were worse in women than men, except for the % of work time missed. PtGA scores were higher than PhGA, in each group and gender.

Conclusion:

At diagnosis, SpA patients perceive a slightly higher disease burden than assessed by Physicians. For PROs other than BASDAI, AxSpA reported a worse impact than pSpA. Overall, women showed a higher disease impact than men.

References:

[1]Michelsen B. et al. PLoS ONE 2015; 10(4): e0123582.

Disclosure of Interests:

Rosario Foti Speakers bureau: Speaker bureau honoraria from Eli Lilly, Sanofi, MSD, Janssen, AbbVie, Bristol-Myers Squibb, Celgene, Roche, Consultant of: Consultancy fees from Eli Lilly, Sanofi, MSD, Janssen, AbbVie, BMS, Celgene, Roche, Gabriella Cardinale: None declared., Luisa Costa: None declared., Franco Franceschini: None declared., Francesco Ciccia Speakers bureau: Speaker bureau honoraria from AbbVie, Abiogen, Bristol-Myers Squibb, Celgene, Janssen, Eli Lilly, Pfizer, Novartis, Roche, Consultant of: Consultancy fees from Novartis, Pfizer, Janssen, Eli Lilly, Roche, Celgene, Grant/research support from: Grant/research support from Pfizer, Novartis, Celgene, Janssen, Roche, Antonio Marchesoni: None declared., Giuliana Guggino Speakers bureau: Speaker bureau honoraria from Celgene, Sandoz, Pfizer, Grant/research support from: Grant/research support from Pfizer, Celgene, Maurizio Rossini: None declared., Ennio Lubrano Di Scorpaniello: None declared., Bruno Frediani: None declared., Maria Sole Chimenti: None declared., Gerolamo Bianchi: None declared., Giuseppe Galfo: None declared., Silvia Marelli Employee of: Employee of Janssen-Cilag SpA Italy, Ennio Favalli Speakers bureau: Consulting fees and/or speaking engagements from AbbVie, Bristol-Myers Squibb, Lilly, Merck Sharp & Dohme, Pfizer, Galapagos, Sanofi-Genzyme, and UCB.

POS0054 THE IMPACT AND OUTCOME OF COVID-19 ON SYSTEMIC SCLEROSIS PATIENTS FROM THE EUROPEAN SCLERODERMA TRIAL AND RESEARCH GROUP (EUSTAR)

Background:

Coronavirus disease-19 (COVID-19) has been a major clinical challenge worldwide. Sex, age and comorbidities have been associated with worse outcome in the general population. Systemic sclerosis (SSc) is a severe, autoimmune disease with frequent multi-organ involvement.

Objectives:

To assess the impact of COVID-19 and to determine factors associated with worse outcome in SSc patients from the European Scleroderma Trial and Research (EUSTAR) database.

Methods:

SSc patients from the EUSTAR database with COVID-19 were prospectively collected between 15.03.-31.12.2020. Two outcomes were chosen: (1) hospitalization; and (2) severe outcome defined as either non-invasive ventilation, mechanical ventilation/extracorporeal membrane oxygenation (ECMO) or death. General risk factors assessed were sex, age and number of comorbidities. SSc related risk factors were SSc subtype, autoantibodies, disease duration, SSc associated organ manifestations including interstitial lung disease (ILD), pulmonary arterial hypertension (PAH), cardiac, gastrointestinal (GI), and musculoskeletal involvement; digital ulcers (DU), CRP at last visit, renal disease (scleroderma renal crisis and SSc associated renal insufficiency), modified Rodnan skin score (mRSS) and immunosuppressive treatment. Descriptive statistics and logistic regression models were applied.

Results:

In total, 178 European SSc patients with COVID-19 were registered with a median observation time of 5.5 weeks (Table 1). 95 patients (53%) could recall SAR-Cov-2 contact, while 47 (26%) had no contact. 156 (88%) were symptomatic at COVID-19 onset with fever, cough, malaise and dyspnea being most prevalent. Over the disease course, 63 (36%) developed pneumonia. In total, 67/176 (38%) were hospitalized which were in 84% due to COVID-19. 41/170 (24%) had a severe outcome including 21 (12%) deaths. 128 (72%) recovered completely, while 14 (8%) complained of sequela, with 7 (50%) stating respiratory complications. Age, non-SSc comorbidities, presence of ILD, PAH and SSc associated renal or cardiac disease were numerically associated with hospitalization and severe outcome (Table 1). Univariable logistic analyses for hospitalization and severe outcome are shown in Figure 1. In multivariable logistic regression, age (OR 1.03, 95%CI 1.01-1.07, p=0.019), presence of non-SSc comorbidities (OR 2.52, 95%CI 1.16-5.47, p=0.019) and SSc-related renal disease (predicting success perfectly) were associated with hospitalization and for severe outcome age (OR 1.05, 95%CI 1.01-1.08).

Conclusion:

SSc patients at older age, with non-SSc comorbidities, SSc related renal disease or ILD are at risk of a more severe outcome and should follow precautions to avoid COVID-19 infections and need careful monitoring in case of COVID-19.

Table 1.

SSc disease characteristics of COVID-19 patients

All(n=172)Hospitalized(n=67)Severe outcome(n=41)Age at COVID-19, yrs (SD)57 (14.0)63 (13.8)65 (12.2)Male sex, n (%)38 (21)18 (27)12 (29)≥1 comorbidity, n (%)63/176 (36)37 (55)30 (58)SSc disease duration at COVID, yrs (SD)11.5 (8.8)13.3 (9.7)12.7 (10.2)Diffuse cutaneous SSc, n (%)74 (42)29 (43)19 (46)mRSS, median (IQR)5 (8)5 (9)5 (7)ILD, n (%)90/175 (51)36/65 (55)26/40 (65)PAH, n (%)21/175 (12)11/65 (17)8/40 (20)GI disease, n (%)112/176 (64)45 (67)30 (73)Cardiac disease, n (%)37/166 (22)19/59 (32)16/36 (44)Musculoskeletal disease, n (%)40/175 (23)15/65 (23)6/40 (15)Renal disease, n (%)8/175 (5)7/65 (11)5/40 (13)Ever DU, n (%)69/175 (39)27/65 (42)14/40 (35)CRP, ng/ml (SD)35/177 (20)14 (21)9 (22)Immunosuppressive treatment, n (%)104/177 (59)41/66 (62)26 (63)Figure 1.

Univariable logistic analyses for hospitalization and severe outcome

Disclosure of Interests:

Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Roche, Merck Sharp & Dohme, ARXX, Lilly and Medscape, Consultant of: Actelion, Boehringer Ingelheim, Bayer, ARXX, and Medscape

, Grant/research support from: Boehringer Ingelheim, Cathrine Brunborg: None declared, Francesca Tirelli: None declared, Patricia Carreira: None declared, Nicoletta Del Papa: None declared, Arsene Mekinian: None declared, Madelon Vonk: None declared, Alessandro Giollo: None declared, Giacomo De Luca: None declared, Maria De Santis: None declared, Corrado Campochiaro: None declared, Carina Mihai: None declared, Paolo Airò Speakers bureau: Bristol Myers Squibb, Bohringer Ingelheim, Consultant of: Bristol Myers Squibb, Bohringer Ingelheim, non-financial support from CSL Behring, SOBI, Janssen, Roche, Sanofi, Pfizer, Maria Grazia Lazzaroni: None declared, Elisabetta Zanatta: None declared, Rosario Foti: None declared, Yannick Allanore: None declared, Daniel Furst: None declared, Marco Matucci-Cerinic: None declared, Armando Gabrielli: None declared, Oliver Distler Speakers bureau: Actelion, Kymera Therapeutics, Mitsubishi Tanabe Pharma, Abbvie, Acceleron, Alexion, Amgen, AnaMar, Arxx Therapeutics, Baecon, Discovery, Blade Therapeutics, Corbus Pharmaceuticals, Drug Development International, Ltd, CSL Behring, Galapagos NV, Glenmark Pharmaceuticals, GSK, Horizon (Curzion) Pharmaceuticals, Inventiva, iQvia, Kymera Therapeutics, Lilly, Novartis, Pfizer, Topadur and UCB, Consultant of: Actelion, Kymera Therapeutics, Mitsubishi Tanabe Pharma, Abbvie, Acceleron, Alexion, Amgen, AnaMar, Arxx Therapeutics, Baecon, Discovery, Blade Therapeutics, Corbus Pharmaceuticals, Drug Development International, Ltd, CSL Behring, Galapagos NV, Glenmark Pharmaceuticals, GSK, Horizon (Curzion) Pharmaceuticals, Inventiva, iQvia, Kymera Therapeutics, Lilly, Novartis, Pfizer, Topadur and UCB, Grant/research support from: Boehringer Ingelheim.

POS0927 EFFECTIVENESS AND SAFETY OF SECUKINUMAB IN NAïVE OR TNF-INHIBITORS FAILURE AXIAL SPONDYLOARTHRITIS PATIENTS IN REAL LIFE: A 24-MONTHS PROSPECTIVE MULTICENTRIC STUDY

Background:

Axial Spondyloarthritis (axSpA) can be distinguished in radiographic axSpA (r-axSpA) and non-radiographic (nr-axSpA). Secukinumab (SEC) is a novel treatment for axSpA, but data from real-life are still missing.

Objectives:

1)to evaluate the effectiveness and safety of a wide cohort of axSpA patients on SEC followed in 8 Italian Rheumatologic centers for 24-months;2)to compare the features and disease-activity indices of SEC-treated axSpA patients subdivided in naïve biological drugs (group A) and in TNF-inhibitors failure patients (group B).

Methods:

Consecutive patients with active axSpA (diagnosis according Assessment of SpondyloArthritis International Society ASAS criteria), who started SEC treatment, were evaluated prospectively.Data on disease characteristics, previous/ongoing treatments and imaging were collected. Disease-activity/functional/clinical scores and biochemical values were recorded at baseline (T0), at 6 (T6), 12 (T12), and 24 (T24) months. Effectiveness was evaluated over-time with descriptive statistics. Anova (Kruskal Wallis) and generalized linear models were used to compare variables over-time. Infections,adverse events were collected.

Results:

One-hundred-seven patients [49.53% men; median age 49years; median treatment duration 18.5years] were enrolled;53(49.53%) had HLA-B27, 47.66% were r-axSpA and 52.34% nr-axSpA. Signs of sacroiliitis were present on MRI in 97 (90.65%) and X-rays in 51 (47.66%). SEC was prescribed as first line biologic treatment in 32 (29.9%) patients and as second or more line biological treatment in 75 (70.1%) patients (Figure 1). In all population significant decrease was achieved in:Visual Analogue Scale of pain and general-health; Leeds Enthesitis Index;Health Assessment Questionnaire modified for spondyloarthritis (HAQ-s);Bath Ankylosing Spondylitis Functional Index (BASFI);C-reactive protein. Bath Ankylosing Spondylitis Metrology Index and Erythrocyte-sedimentation-rate not significantly decreased. Effectiveness was associated to an improvement in Ankylosing Spondylitis disease activity score (ASDAS) [T0=3.4 (2.9-3.9) vs T24=1.9 (1.2-2.7);p=0.02] and in Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) [T0=6.6 (5.0-7.8) vs T24=3.2 (2.0-5.0);p=0.03].At T0 group B had a longer disease duration (p=0.04),a greater prevalence of peripheral arthritis (p=0.02),enthesitis (p=0.04) and psoriasis (p=0.05) and was mostly male (p=0.05),while no significant difference was observed for functional and disease-activity indices and signs of sacroiliitis on MRI/X-rays. At T24 group A showed better physical functioning and lower disease activity compared to group B [HAQs A vs. B=0.1(0.0-0.5) vs 0.3(0.1-0.8); BASFI A vs B=1.6(0.8-4.8) vs 4.0(2.5-4.6); BASDAI A vs B=2.2(1.0-3.8) vs 3.9(2.7-5.0);ASDAS A vs B=1.3(1.0-2.2) vs 2.1(1.6-2.9)].After T24 of treatment 70.2% of Group A and 68.4% of Group B had a low disease activity,accordingly to ASDAS<2.1. Twenty-three patients (21.5%) stopped the treatment during the follow-up mainly because of primary (7) or secondary loss of efficacy (9).Only 7 patients suspended SEC because of adverse events.A low number of episodes of mild infections (19) occurred;SEC was instead permanently discontinued in 4 cases for:oral refractory mucositis (2);recurrent aphthosis (1);recurrent broncopneumoniae (1).The retention rate at t24 was good in the whole population (73%).Survival curves for Group A and B were similar (log-rank test=0.81;p=0.69).

Conclusion:

In a real-life clinical setting,SEC was safe and effective in axSpA, as shown by a significant decrease of BASDAI and ASDAS over a 24-months follow-up.

Disclosure of Interests:

Mariagrazia Lorenzin: None declared, Augusta Ortolan: None declared, Maria Sole Chimenti: None declared, Antonio Marchesoni Grant/research support from: AM has received honoraria and speaker fees from Abbvie, Pfizer, MSD, UCB, Novartis, Janssen, Eli-Lilly., Ennio Lubrano: None declared, Leonardo Santo Speakers bureau: Speaker from Jansen, Novartis, Pfizer, UCB, MSD, Sanofi, Angelo Semeraro: None declared, Carlo Salvarani: None declared, Nicolò Girolimetto: None declared, Emanuela Praino: None declared, Giulia Lavinia Fonti: None declared, Rosario Foti: None declared, Antonio Carletto: None declared, Andrea Doria Grant/research support from: ADhas received honoraria and speaker fees from Novartis, Abbvie, Pfizer, MSD, Janssen., Roberta Ramonda Grant/research support from: RR has received honoraria and speaker fees from Novartis, Abbvie, Pfizer, MSD, Janssen.

FRI0284 EFFECTIVENESS AND SAFETY OF SECUKINUMAB IN NAÏVE OR TNF-INHIBITORS FAILURE PSORIATIC ARTHRITIS PATIENTS IN REAL LIFE: A 24-MONTHS PROSPECTIVE MULTICENTER STUDY

Background:

Secukinumab (SEC) is a novel treatment for psoriatic arthritis (PsA),but data from real life are still missing.

Objectives:

1)to evaluate the effectiveness and safety of a wide cohort of PsA patients on SEC followed in 7 Italian rheumatologic centers for 24 months;2)to compare the features and disease activity indices of SEC-treated PsA patients subdivided in naïve biological drugs (group A) and in TNF-inhibitors (TNFi) failure patients (group B).

Methods:

Consecutive patients with moderate-severe PsA,who begun SEC treatment were evaluated prospectively.Data on disease characteristics,previous and ongoing treatments,comorbidities and duration of follow-up were collected.Disease activity,functional and clinimetric scores and biochemical values were recorded at baseline (t0),at 6 (t6),12 (t12),and 24 (t24) months.Anova (Kruskal Wallis) and generalized linear models were used to compare variables over time.Infections and adverse events were also collected.

Results:

PsA345patients [38.84% men;mean age 52.9 (11.27) years] were enrolled;mean treatment duration was 18.53 (9.97) years.SEC was prescribed as first line biologic treatment in 133 (38.55%) patients and as second or more line biological treatment in 212 (61.45%) patients. Enthesitis was present as a prominent manifestation in 61.44% of patients (Figure 1).In all population significant decrease in tender/swollen joints;Visual Analogue Scale of pain (VASp) and general health (VASgh);Psoriasis Area Severity Index (PASI);Leeds Enthesitis Index (LEI);number of dactylitis;Health Assessment Questionnaire modified for spondyloarthritis (HAQ-S);Bath Ankylosing Spondylitis Disease Activity Index (BASDAI);Bath Ankylosing Spondylitis Functional Index (BASFI);C-reactive protein (CRP) was achieved.Effectiveness of all PsA patients was associated to an improvement in Ankylosing Spondylitis disease activity score (ASDAS) [t0=3.45 (0.69) vs t24=1.48 (0.23);p<0.01] and in Disease Activity in PsA (DAPSA) [t0=29.52 (12.56) vs t24=11.41 (7.63);p<0.001].At t0group Bhad a more erosive (p=0.04) and polyarticular pattern (p=0.04),a longer disease duration (p=0.001),a greater prevalence (p=0.04) of psoriasis and dactylitis (p=0.01),a higher PASI score (p=0.01),while no significant difference was observed for uveitis,inflammatory bowel diseases,enthesitis.At t24group Ashowed better physical functioning and lower disease activity compared togroup B[HAQs A vs B=0.03 (0.16) vs 0.69 (0.73);BASDAI A vs B=2.37 (0.66) vs 4.27 (2.33);ASDAS A vs B=1.4 (0.62) vs 1.99 (0.86);CRP A vs B=2.03 (1.94) vs 3.11 (1.55) mg/L;DAPSA A vs B=7.03 (3.57) vs 12.41 (8.05)].After t24 of treatment 74.6% ofGroup Aand 72.8% ofGroup Barticular had an inactive\low disease activity (MDA),accordingly to ASDAS and DAPSA respectively.Forty-three patients (12.46%) stopped the treatment during the follow-up mainly because of primary or secondary loss of efficacy (29 and 24, respectively).Only 14 patients suspended SEC because of adverse events (of which 9 for reactions at site of injection).A low number of episodes of mild infections (16) occurred;SEC was instead permanently discontinued in 7 cases for:oral refractory mucositis (3);recurrent aphthosis (2);diverticulitis (2).The retention rate at t24 was good in the whole population.Interestingly no differences were found betweenGroup AandB(p=0.815).

Conclusion:

In a real life clinical setting,SEC was safe and effective in PsA. as shown by a significant decrease of DAPSA and ASDAS over a 24-months follow up.

Disclosure of Interests:

Mariagrazia Lorenzin: None declared, Antonio Carletto: None declared, Rosario Foti Consultant of: lilly, sanofi, MSD, Janssen, Abbvie, BMS, celgene, roche, Speakers bureau: lilly, sanofi, MSD, Janssen, Abbvie, BMS, celgene, roche, Maria Sole Chimenti: None declared, Angelo Semeraro: None declared, Luisa Costa: None declared, Leonardo Santo: None declared, Elena Fracassi: None declared, Ilaria Montanari: None declared, Mara Felicetti: None declared, Giulia Lavinia Fonti: None declared, Francesco Caso: None declared, Andrea Doria Consultant of: GSK, Pfizer, Abbvie, Novartis, Ely Lilly, Speakers bureau: UCB pharma, GSK, Pfizer, Janssen, Abbvie, Novartis, Ely Lilly, BMS, Augusta Ortolan: None declared, Roberta Ramonda Speakers bureau: Novartis, Celgene, Janssen, Pfizer, Abbvie, Lilly

AB0681 COMPARISON BETWEEN DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF PREDOMINANT AXIAL VS MAINLY PERIPHERAL SPONDYLOARTHRITIS (SpA) PATIENTS, ENROLLED IN THE ONGOING SIRENA STUDY

Background:

SIRENA is an Italian, prospective Registry in Spondyloarthritis (SpA) patients, naïve to conventional, targeted and biological DMARDs. Patients are diagnosed, newly or confirmed, according to ASAS criteria and classified in subjects with predominant axial(AX) or with mainly peripheral manifestations(PER).

Objectives:

To compare descriptively AX vs PER subgroups of patients.

Methods:

Demographic data, diagnostic delay and subtypes of SpA as well as clinical features and comorbidities are collected.

Results:

282 patients were enrolled: 101 (35.8%) AX and 181 (64.2%) PER. Baseline data are shown in Table 1. There were more obese patients in AX (21.4% AX vs 16.1% PER) and more overweight ones in PER (19.4% AX vs 23.8% PER). The % of subjects with diagnostic delay was higher in AX (65.7% vs 53.9% PER) and the delay longer (mean of 73.1 months vs 47.8). In both groups, main reason of the delay was incorrect referrals (41.5% for AX and 45.3% for PER). Noteworthy the fact that in PER, the 75.7% of patients had a newly diagnosed SpA. In PER, the most frequent SpA type was PsA (82.3%), followed by undifferentiated SpA (8.8%) and enteropathic SpA (7.5%), while in AX, 49.5% were ankylosing spondylitis, 21.8% nr-ax-SpA and only 4% PsA. The majority of PER patients reported as first symptom peripheral arthritis (80/181), psoriasis (57/181) and enthesitis while in AX referred inflammatory back pain (80/101). High percentages of comorbidities were reported: psoriasis (65.8%) and cardiometabolic diseases (34.8%) were higher in PER while depression/anxiety and GI diseases were higher in AX (Table 2). At the baseline, the mean PhGA score (0-100) was 51.5 for AX and 43.8 for PER.

Conclusion:

SIRENA study highlights relevant differences in AX vs PER patients, expecially in terms of diagnostic delay, clinical presentation and comorbidities.

Table 1.MeanAX n=101MeanPER n=181Age (years)47.352.8Sex (female/male - %)50.5/49.547.5/52.5Weight (Kg)73.073.9BMI25.325.4Diagnostic Delay (yes - %)65.7%53.9%Time of delay (mean - months)71.347.8Newly SpA diagnosis (%)55.5%75.7%Table 2.A) First Symptom(more than 1 symptom referred)AX n=101N. PatientsPER n=181N. PatientsArthritis23122Enthesitis1654Dactylitis728Inflammatory Back Pain8034Psoriasis skin1057Psoriasis nails219Uveitis41IBD79B) Comorbidities(more than 1 comorbidity referred)% Patients% PatientsCardiometabolic20.8%34.8% -Hypertension19.8%30.9% -Dyslipidemia17.8%11.6% -Diabetes6.0%7.7% -MetS5.0%6.6%Psoriasis22.8%65.8%Gastrointestinal20.8 (16.9% CD)12.8 (4.4% CD)Depression/Anxiety11.9%2.2%Endocrine6.9%11.1%Osteoporosis3%5.5%Hepatic4% (3% NAFLD)4.4% (2.2% NAFLD)Infections3%3.9%Malignancies0%4.4%

Acknowledgments:

This study was sponsored by Janssen Italy.

We thank the Investigators and their staff at all of the study sites.

Disclosure of Interests:

Rosario Foti Speakers bureau: Abbvie, BMS, ROCHE, Janssen, Celgene, Gabriella Cardinale: None declared, Luisa Costa: None declared, Franco Franceschini Consultant of: Eli-Lilly, Janssen, Pfizer, Sanofi-Genzyme, UCB Pharma, GSK, Francesco Ciccia Grant/research support from: Pfizer, Novartis, Celgene, Janssen, Consultant of: Lilly, Novartis, Pfizer, Janssen, Roche, Celgene, Speakers bureau: Pfizer, Novartis, Celgene, Janssen, Roche, Abiogen, BMS, Antonio Marchesoni Speakers bureau: Abbvie, Pfizer, UCB, Novartis, Celgene, Eli Lilly, Giuliana Guggino Grant/research support from: Pfizer, Celgene, Speakers bureau: Celgene, Sandoz, Pfizer, Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB, Ennio Lubrano: None declared, Mauro Galeazzi: None declared, Mariasole Chimenti: None declared, Gerolamo Bianchi Grant/research support from: Celgene, Consultant of: Amgen, Janssen, Merck Sharp & Dohme, Novartis, UCB, Speakers bureau: Abbvie, Abiogen, Alfa-Sigma, Amgen, BMS, Celgene, Chiesi, Eli Lilly, GSK, Janssen, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi Genzyme, Servier, UCB, Giuseppe Galfo: None declared, Silvia Marelli Employee of: Janssen, Ennio Favalli Speakers bureau: BMS, Eli-Lilly, MSD, UCB, Pfizer, Sanofi-Genzyme, Novartis and Abbvie

AB0575 THE ROLE OF LONG-TERM AND INTENSIVE IV ILOPROST TREATMENT IN REDUCTION OF PULMONARY ARTERY PRESSURE AND PRO-BRAIN NATRIURETIC PEPTIDE (PBNP) IN SCLERODERMA PATIENTS

Background:

Systemic sclerosis (SSc) is a chronic immune-mediated connective tissue disease with heterogeneous organ involvement that reduces the life expectancy of this patients. In particular cardiopulmonary manifestations, such as pulmonary arterial hypertension (PAH), are currently the primary cause of death and stabilizing this condiction may represent an important therapeutic goal (1,2). An increased NT-proBNP is predictors of PAH in SSc and use this markers should result in improved PAH risk stratification (3)Some studies have suggested the role of intravenous iloprost in preventing the incidence of most severe vascular complications in long term treated patients (4).

Objectives:

The aim of our study is to evaluate the evolution of the disease, with particular focus on cardiopulmonary function, in a group of consecutive patients chronically treated with iloprost at the Rheumatology Unit of Catania Hospital, Italy, from 2006 to 2019.

Methods:

68 SSc patients (58F, 52.88 ± 12.6 years). At baseline, 67.6%, 25% and 5.9% had a limited, diffuse and early scleroderma type respectively and 20,6% had interstitial lung disease. The follow-up period of the study was of 9.9 ± 2.9 years. Iloprost was administered with a regimen of 6 infusions per month (6 hours/day, 0.5-2.0 ng/kg/min) to treat secondary Raynaud’s phenomenon (RP), diagnosed at an average age of 46.6 ± 13.7 years. We evaluated: skin score (SS), systolic pulmonary arterial pressure (PAPs), plane tricuspid annular systolic excursion (TAPSE), lung diffusing capacity of carbon monoxide (DLCO), forced vital capacity (FVC), alveolar volume (VA), DLCO/VA, pro-brain natriuretic peptide (pBNP), and NYHA class.We analyzed the patients as a whole group (68 subjects), as a group who continued the treatment (57 subjects) and as a group who stopped the treatment during the follow-up (11 patients).

Results:

After the long follow up period in the study (almost 10 years) in the whole group of patients, PAPs and pBNP showed statistically significant improvement from baseline (30.91 ± 6.4 vs 27.36 ± 7.1 and 97.20 ± 69.3 vs 66.65 ± 44.3 respectively, p < 0.0001 for both) while the other parameters showed no significant changes: SS (4.70 ± 5.3 vs 3.86 ± 4.2 mm), TAPSE (22.07 ± 2.4 vs 22.06 ± 3.8 mm), DLCO (83.68 ± 13.5 vs 77.70 ± 14.6 mmol/kPa.min), FVC (107.09 ± 14.5 vs 107.72 ± 18.7 liters), VA (91.12 ± 13 vs 90.30 ± 14.4 liters), DLCO/VA (88.48 ± 13.5 vs 89.5 ± 16.3) and NYHA class (1.0 ± 0.0 vs 1.0 ± 0.0). A subgroup analysis indicated a significant improvement in addition to PAPs and pBNP also for skin score for 57 patients who continued the treatment (5.09 ± 5.7 vs 3.30± 4.2, p < 0.0001) and a significant worsening of this parameter as early as the first year of suspension (p <0.05 year 1, p<0.01 year 2 and 3) in 11 patients who stopped the treatment.

Conclusion:

Cardiac involvement is recognised as a poor prognostic factor among systemic sclerosis (SSc) patients, significantly to mortality and N-TproBNP peptide may represent a surrogate marker for cardiac involvement in SSc, selectively identifying patients with severe impairment of cardiac function. Our intensive (6 infusions/month) and chronic regimen of iv iloprost administration seems improve the long-term evolution of disease in SSc patients, as suggested by the improvement of cardiopulmonary parameters and the significant improvement of SS.

References:

[1]Rheumatology 51, 1027-36 2) Best Pract Res Clin Rheumatol.32, 223-240 3) Arthritis Rheum. 2008 58, 284-9 4) Rheumatol Int 2012;32:1933-8.

Disclosure of Interests:

Rosario Foti Consultant of: lilly, sanofi, MSD, Janssen, Abbvie, BMS, celgene, roche, Speakers bureau: lilly, sanofi, MSD, Janssen, Abbvie, BMS, celgene, roche, elisa visalli Consultant of: lilly, sanofi, MSD, Janssen, Abbvie, BMS, celgene, roche, Speakers bureau: lilly, sanofi, MSD, Janssen, Abbvie, BMS, celgene, roche, Giorgio Amato: None declared, Alessia Benenati: None declared, Salvatore Bellofiore: None declared, Massimiliano Mule’: None declared, Marcella Di Gangi: None declared

Human pharmaceuticals in three major fish species from the Uruguay River (South America) with different feeding habits

The accumulation of 17 human pharmaceuticals (HPs) was investigated in the muscle of three fish species characteristic of the "Rio de la Plata Basin" with different feeding habits and of relevance for human consumption: Megaleporinus obtusidens, Salminus brasiliensis, and Prochilodus lineatus. Fish were sampled in fall and spring from 8 localities distributed along 500 Km of the Uruguay River. Atenolol and carbamazepine were the most frequently detected HPs (>50%), but at concentrations always below 1 μg/kg wet weight (w/w). Hydrochlorothiazide, metoprolol, venlafaxine, propranolol, codeine, and the carbamazepine metabolite, 2-hydroxycarbamazepine, were accumulated at higher levels showing maximum concentrations between 1 and 10 μg/kg (w/w), but infrequently (<50%). The other HPs were always below 1 μg/kg (w/w) and at frequencies lower than 50%. Distinctive accumulation patterns were observed among species at different trophic levels. However, biomagnification trends were not identified for any compound. The highest number and concentration of HPs were found in M. obtusidens (omnivorous), followed by P. lineatus (detritivorous), and lastly S. brasiliensis (piscivorous). The most recurrent HPs (i.e. carbamazepine and atenolol) were present in all species, but others exclusively in one. Geographical variations were only found for carbamazepine and atenolol in M. obtusidens and P. lineatus, showing higher concentrations in localities closer to the Rio de la Plata estuary. Differences in the HPs concentrations among seasons were not identified. Acceptable daily intake and predicted no effect concentrations would indicate that measured muscle concentrations in fish from the Uruguay River do not pose a serious risk for human consumption nowadays. Further studies will be necessary for assessing the potential adverse effects on studied fish species.

Nuclear Architecture Organized by Rif1 Underpins the Replication-Timing Program

DNA replication is temporally and spatially organized in all eukaryotes, yet the molecular control and biological function of the replication-timing program are unclear. Rif1 is required for normal genome-wide regulation of replication timing, but its molecular function is poorly understood. Here we show that in mouse embryonic stem cells, Rif1 coats late-replicating domains and, with Lamin B1, identifies most of the late-replicating genome. Rif1 is an essential determinant of replication timing of non-Lamin B1-bound late domains. We further demonstrate that Rif1 defines and restricts the interactions between replication-timing domains during the G1 phase, thereby revealing a function of Rif1 as organizer of nuclear architecture. Rif1 loss affects both number and replication-timing specificity of the interactions between replication-timing domains. In addition, during the S phase, Rif1 ensures that replication of interacting domains is temporally coordinated. In summary, our study identifies Rif1 as the molecular link between nuclear architecture and replication-timing establishment in mammals.

Regional differences of vitamin D deficiency in rheumatoid arthritis patients in Italy

Vitamin D deficiency is very common in patients with rheumatoid arthritis (RA). Aim of this study was to evaluate the prevalence of vitamin D deficiency among the different Italian regions and whether these variations are associated with different severity of the disease. The study includes 581 consecutive RA patients (464 women), not taking vitamin D supplements, from 22 Italian rheumatology centres uniformly distributed across Italy. Together with parameters of disease activity (disease activity score 28), functional impairment (activities of daily living and health assessment questionnaire disability index) and mean sun exposure time, all patients had serum 25-hydroxyvitamin D (25OHD) measured in a centralized laboratory. Vitamin D deficiency (25OHD level &lt;20 ng/mL) was very frequent among RA patients; its prevalence was 60%, 52% and 38% in southern, central and northern Italy, respectively. Mean disease activity and disability scores were worse in southern regions of Italy. These scores were inversely related to 25OHD levels and this correlation remained statistically significant after adjusting for both body mass index (BMI) and sun exposure time. However, disease severity remained significantly higher in southern regions versus central-northern Italy after adjustment also for serum 25OHD levels, age and BMI. In RA Italian patients there are significant regional differences in the prevalence of vitamin D deficiency explained by different BMI, and sun exposure time, and inversely associated with disease activity and disability scores.

The PML nuclear bodies-associated protein TTRAP regulates ribosome biogenesis in nucleolar cavities upon proteasome inhibition

TRAF and TNF receptor-associated protein (TTRAP) is a multifunctional protein that can act in the nucleus as a 5'-tyrosyl DNA phosphodiesterase and in the cytoplasm as a regulator of cell signaling. In this paper we show that in response to proteasome inhibition TTRAP accumulates in nucleolar cavities in a promyelocytic leukemia protein-dependent manner. In the nucleolus, TTRAP contributes to control levels of ribosomal RNA precursor and processing intermediates, and this phenotype is independent from its 5'-tyrosyl DNA phosphodiesterase activity. Our findings suggest a previously unidentified function for TTRAP and nucleolar cavities in ribosome biogenesis under stress.

Comparison of the Recent-Onset Arthritis Disability questionnaire with the Health Assessment Questionnaire disability index in patients with rheumatoid arthritis

BACKGROUND

Physical disability in patients with rheumatoid arthritis (RA) is often assessed by questionnaires. We compared the Recent-Onset Arthritis Disability (ROAD) questionnaire with the Health Assessment Questionnaire (HAQ) disability index (DI) in a cohort of RA patients. The aim of this study was to obtain information on several aspects of construct validity of these measures.

METHODS

A cross-sectional multicentre study was carried out among patients with RA who were attending hospital outpatient clinics. The patient group included 196 patients partially or not responding to disease modifying anti-rheumatic drugs. For the evaluation of the psychometric properties of the ROAD in comparison with HAQ-DI this population has been compared to another cohort of 247 outpatients with RA who were participating in a long-term observational study. All patients completed the ROAD and HAQ-DI. Additional comparator composite indices of disease activity were analysed. The ROAD structural validity was first assessed using exploratory factor analysis. Concurrent validity was analysed by Spearman's correlations and cross-tabulations. Discriminant validity to distinguish patients with active and non-active disease was assessed with receiver operating characteristic (ROC) curve analysis. For agreement analysis Bland and Altman plots were calculated.

RESULTS

Factor analysis yielded a two-factor ROAD score that accounted for 68.74% of the explained variance in the questionnaire. The first factor, namely upper extremity function/activity daily living and work (ROAD-upper) accounted for 55.6% of the explained variance. The second factor, namely lower extremity function (ROAD-lower) accounted for 13.1% of the explained variance. Significant correlations were found between the scores of the ROAD and the other clinical variables with a high ability to measure pain and disease activity, supporting the concept of convergent construct validity. The discriminatory power of both questionnaires to assess inactive and active RA patients was good, without significant difference.

CONCLUSIONS

ROAD is a good alternative to the HAQ-DI for the assessment of physical disability in RA. Use of the ROAD makes it easier and less costly to collect data and reduces the burden on RA patients and should be applied in both clinical trials and routine clinical care settings.

Characteristics of joint involvement and relationships with systemic inflammation in systemic sclerosis: results from the EULAR Scleroderma Trial and Research Group (EUSTAR) database

OBJECTIVE

To determine the prevalence of and independent factors associated with joint involvement in a large population of patients with systemic sclerosis (SSc).

METHODS

This study was cross-sectional, based on data collected on patients included in the European League Against Rheumatism (EULAR) Scleroderma Trials and Research (EUSTAR) registry. We queried this database to extract data regarding global evaluation of patients with SSc and the presence of any clinical articular involvement: synovitis (tender and swollen joints), tendon friction rubs (rubbing sensation detected as the tendon was moved), and joint contracture (stiffness of the joints that decreased their range of motion). Overall joint involvement was defined by the occurrence of synovitis and/or joint contracture and/or tendon friction rubs.

RESULTS

We recruited 7286 patients with SSc; their mean age was 56 +/- 14 years, disease duration 10 +/- 9 years, and 4210 (58%) had a limited cutaneous disease subset. Frequencies of synovitis, tendon friction rubs, and joint contractures were 16%, 11%, and 31%, respectively. Synovitis, tendon friction rubs, and joint contracture were more prevalent in patients with the diffuse cutaneous subset and were associated together and with severe vascular, muscular, renal, and interstitial lung involvement. Moreover, synovitis had the highest strength of association with elevated acute-phase reactants taken as the dependent variable.

CONCLUSION

Our results highlight the striking level of articular involvement in SSc, as evaluated by systematic examination in a large cohort of patients with SSc. Our data also show that synovitis, joint contracture, and tendon friction rubs are associated with a more severe disease and with systemic inflammation.

Parkinson disease-associated DJ-1 is required for the expression of the glial cell line-derived neurotrophic factor receptor RET in human neuroblastoma cells

Mutations in PARK7/DJ-1 are associated with autosomal recessive, early onset Parkinson disease (PD). DJ-1 is an atypical peroxiredoxin-like peroxidase that may act as a redox-dependent chaperone and a regulator of transcription. Here we show that DJ-1 plays an essential role in the expression of rearranged during transfection (RET), a receptor for the glial cell line-derived neurotrophic factor, a neuroprotective molecule for dopaminergic neurons, the main target of degeneration in PD. The inducible loss of DJ-1 triggers the establishment of hypoxia and the production of reactive oxygen species that stabilize the hypoxia-inducible factor-1alpha (HIF-1a). HIF-1a expression is required for RET down-regulation. This study establishes for the first time a molecular link between the lack of functional DJ-1 and the glial cell line-derived neurotrophic factor signaling pathway that may explain the adult-onset loss of dopaminergic neurons. Furthermore, it suggests that hypoxia may play an important role in PD.

A transcriptome analysis identifies molecular effectors of unconjugated bilirubin in human neuroblastoma SH-SY5Y cells

BACKGROUND

The deposition of unconjugated bilirubin (UCB) in selected regions of the brain results in irreversible neuronal damage, or Bilirubin Encephalopathy (BE). Although UCB impairs a large number of cellular functions in other tissues, the basic mechanisms of neurotoxicity have not yet been fully clarified. While cells can accumulate UCB by passive diffusion, cell protection may involve multiple mechanisms including the extrusion of the pigment as well as pro-survival homeostatic responses that are still unknown.

RESULTS

Transcriptome changes induced by UCB exposure in SH-SY5Y neuroblastoma cell line were examined by high density oligonucleotide microarrays. Two-hundred and thirty genes were induced after 24 hours. A Gene Ontology (GO) analysis showed that at least 50 genes were directly involved in the endoplasmic reticulum (ER) stress response. Validation of selected ER stress genes is shown by quantitative RT-PCR. Analysis of XBP1 splicing and DDIT3/CHOP subcellular localization is presented.

CONCLUSION

These results show for the first time that UCB exposure induces ER stress response as major intracellular homeostasis in surviving neuroblastoma cells in vitro.

Long-term angiographic follow-up after successful repeat balloon angioplasty for in-stent restenosis

BACKGROUND

Coronary stent implantation is associated with improved angiographic short-term and mid-term clinical outcome. However, restenosis rate still remains between 20 and 30%.

HYPOTHESIS

The purpose of the study, performed as a prospective angiographic follow-up to detect restenosis, was to evaluate the immediate and the 6-month angiographic results of repeat balloon angioplasty for in-stent restenosis.

METHODS

From April 1996 to September 1997, 335 stenting procedures performed in 327 patients underwent prospectively 6-month control angiography. Of the 96 lesions that showed in-stent restenosis (> 50% diameter stenosis) (29%), 72 underwent balloon angioplasty.

RESULTS

The primary success rate was 100%. Follow-up angiogram at a mean of 6.9 +/- 2.4 months was obtained in 54 patients. Recurrent restenosis was observed in 24 of the 55 stents (44%). Repeat intervention for diffuse and body location in-stent restenosis before repeat intervention was associated with significantly higher rates of recurrent restenosis (p < 0.001 and p < 0.05, respectively). Of the 19 patients who underwent further balloon angioplasty (100% success rate), coronary angiography was performed in 18 (95%) at a mean of 8.2 +/- 2.0 months and showed recurrent restenosis in 12 patients (67%). Further repeat intervention for diffuse and severe in-stent restenosis before the second repeat intervention was associated with significantly higher rates of further recurrent restenosis (p < 0.05 and p < 0.005, respectively).

CONCLUSIONS

Although balloon angioplasty can be safely, successfully, and repeatedly performed after stent restenosis, it carries a progressively high recurrence of angiographic restenosis rate during repeat 6-month follow-ups. The subgroup of patients with diffuse, severe, and/or body location in-stent restenosis proved to be at higher risk of recurrent restenosis.

[Recurrent new-onset uveitis in a patient with rheumatoid arthritis during anti-TNFalpha treatment]

Inflammation involving the uveal tract of the eye, termed uveitis, is frequently associated with various rheumatic disease, including seronegative spondylarthropathies, juvenile rheumatoid arthritis, Crohn's disease and Behçet's disease. Scleritis and keratitis may be associated with rheumatoid arthritis and systemic vasculitides such as Wegener's granulomatosis. Immune-mediated uveitis can have a chronic relapsing course and produce numerous possible complications, many of which can result in permanent vision loss. Treatment typically includes topical or systemic corticosteroids with cycloplegic-mydriatic drugs and/or noncorticosteroid immunosuppressants, but often there is an insufficient clinical effectiveness. Anti-TNFalpha therapy is promising in the treatment of sight threatening uveitis, particularly in patients with Behçet's disease. However, there have been also reports of new-onset uveitis during treatment of joint disease with TNFalpha inhibitors. We describe a case of new-onset uveitis in a patient with rheumatoid arthritis during therapy with etanercept at first and infliximab at last. Although we cannot exclude uveitis as linked to rheumatoid arthritis, it is unlike that the uveitis arises when the joint disease is well controlled. The hypothetical paradoxical effect of anti-TNF is here discussed.

[Buschke Scleredema, case report]

Buschke Scleredema is a rare connective tissue disorder of unknown aetiology, characterized by thickening of the dermis whose characteristics may mainly to mime systemic sclerosis, eosinophilic fasciitis and cutaneous amyloidosis. Scleredema may be associated with a history of an antecedent febrile illness, diabetes mellitus, or blood dyscrasia. Scleredema can be classified into three clinical groups; each has a different history, course, and prognosis. Each one of these share reduction in chest articular movements and limitation of limbs movements. The skin histology is characterised by thickened dermis and increased spaces between large collagen bundles due to increased deposition of mucopolysaccharide in the dermis. Differential diagnosis can be made considering the typical clinical features and the histologic peculiarity. No therapy has been found effective. The authors describe a case of Buschke Scleredema successfully treated by steroids and colchicine. Clinical evaluation of skin induration and thickness as well as ultrasonography were performed at baseline and after treatment.

Tubules are the major site of M-CSF production in experimental kidney disease: correlation with local macrophage proliferation

BACKGROUND

Local proliferation of macrophages occurs within both the glomerulus and the interstitium in severe forms of human and experimental glomerulonephritis and plays an important role in amplifying renal injury. Macrophage colony-stimulating factor (M-CSF) is thought to be the growth factor driving this local macrophage proliferation. Previous studies have found that glomeruli are the predominant source of M-CSF production. However, this is difficult to reconcile with the prominent macrophage accumulation and proliferation seen in the interstitial compartment in glomerulonephritis. To address this issue, we localized M-CSF expression in rat models of glomerular versus tubulointerstitial injury and examined its relationship to local macrophage proliferation.

METHODS

M-CSF expression (Northern blotting, in situ hybridization, immunostaining, Western blotting) and local macrophage proliferation (double immunostaining) was examined in normal rat kidney on days 1 and 14 of rat anti-glomerular basement membrane (anti-GBM) glomerulonephritis and on day 5 following unilateral ureteric obstruction.

RESULTS

M-CSF mRNA and protein expression were identified in small numbers of glomerular podocytes, approximately 25% of cortical tubules, and most medullary tubules in normal rat kidney. Northern blotting showed a significant increase in whole kidney M-CSF mRNA in rat anti-GBM glomerulonephritis. Up-regulation of glomerular and, most prominently, tubular M-CSF production was confirmed by three independent methods: in situ hybridization, immunostaining, and Western blotting. The increase in M-CSF expression colocalized with local macrophage proliferation (ED1+PCNA+ cells) in both the glomerulus and tubulointerstitium. On day 5 after ureter ligation, there was a significant increase in tubular M-CSF mRNA and protein expression in the obstructed kidney, with no change in glomerular M-CSF. In parallel with M-CSF expression, macrophage accumulation and proliferation was prominent in the interstitium, but was absent from glomeruli.

CONCLUSIONS

The tubular epithelial cell is the major site of M-CSF production within the injured kidney. Indeed, substantial macrophage accumulation and local proliferation can occur in the tubulointerstitium in the absence of glomerular inflammation. These results suggest that M-CSF production within the kidney, particularly by tubular epithelial cells, plays an important role in regulating local macrophage proliferation in experimental kidney disease.

[Aneurysms of the common trunk, anterior descending and right coronary artery in a 33 years old man with acute myocardial infarction. A case report]

Coronary artery aneurysms are often incidental findings during coronary angiography; they are mostly secondary to atherosclerosis or vasculitis, they are rarely congenital. Right coronary circumflex and anterior descending arteries are usually involved but only few cases of aneurysms of left main coronary artery are reported. A case of coronary artery aneurysms is described involving left main, right and anterior descending coronary arteries, probably secondary to atypical Kawasaki disease in a 33 years old man with acute myocardial infarction.

Accuracy of exercise testing in the assessment of the severity of myocardial ischemia as determined by means of technetium-99m tetrofosmin SPECT scintigraphy

BACKGROUND

The separation of patients with suspected or known coronary artery disease into low- and high-risk subgroups by means of noninvasive testing is highly relevant in the selection of patients who require further diagnostic or therapeutic investigation. We evaluated whether exercise electrocardiographic variables during exercise testing might be a means of predicting the severity of myocardial ischemia as assessed with myocardial scintigraphy.

METHODS AND RESULTS

We retrospectively reviewed 816 consecutive patients (mean age, 57+/-10 years) who underwent exercise technetium-99m tetrofosmin single photon emission computed tomography (SPECT) for the assessment of suspected or known coronary artery disease. Eight independent significant predictors of the extent and severity of reversible perfusion defects (ischemic perfusion score), which when integrated in a diagnostic algorithm satisfactorily discriminated patients with no reversible perfusion defects (sensitivity, 75%; specificity, 80%) and patients with severe impaired myocardial perfusion (> or =11 ischemic perfusion score; sensitivity, 77%; specificity, 82%), were identified by means of stepwise discriminant analysis. However, patients with mildly to moderately impaired myocardial perfusion (> or =21 but <11 ischemic perfusion score) were poorly discriminated (sensitivity, 50%; specificity, 78%). The set of variables that were significant (P<.0001) for prediction included sex, myocardial infarction, exercise angina, the maximal amount of ST segment depression, rate-pressure product threshold criteria, slope of ST segment depression, ST/heart rate index, and peak exercise heart rate.

CONCLUSIONS

The results of the use of clinical and electrocardiographic exercise variables satisfactorily agrees with the results from scintigraphy only for patients with no reversible perfusion defects and with severely impaired myocardial perfusion. However, it fails as an approach with universal applicability.

Up-regulation of the tumour-associated marker CD44V6 in experimental kidney disease

CD44 is an adhesion molecule involved in a wide range of cell-cell and cell-matrix interactions. The standard form of CD44 (CD44S) is a 85-90-kD glycoprotein, but alternative splicing of RNA encoding 10 variable exons (V1-V10) can give rise to many different CD44 variant protein isoforms of higher molecular weight. CD44 isoforms containing the V6 exon play a crucial role in tumour metastasis and lymphocyte activation. However, the role of CD44V6 in the kidney is unknown. The aim of this study was to examined renal CD44V6 expression in health, disease and in vitro. Immunohistochemistry staining with the V6-specific 1.1ASML antibody identified constitutive CD44V6 expression by occasional cortical tubular epithelial cells and medullary tubules in normal rat kidney. In immune-induced kidney disease (rat anti-glomerular basement membrane glomerulonephritis), there was a marked increase in CD44V6 expression by cortical tubules, particularly in areas of tubulointerstitial damage, which was associated with focal macrophage infiltration. There was also a marked increase in CD44V6 expression by damaged tubules in a model of non-immune kidney disease (unilateral ureteric obstruction). Reverse transcription-polymerase chain reaction revealed a complex pattern of CD44V6-containing mRNA isoforms in normal rat kidney. This pattern of CD44V6 splicing was essentially unaltered in disease. The NRK52E normal rat kidney tubular epithelial cell line expresses both CD44S and CD44V6. Stimulation of NRK52E cells with IL-1 or transforming growth factor-beta 1 induced a two-to-five-fold increase in the expression of both CD44S and CD44V6. Furthermore, triggering of NRK52E cells by antibodies to CD44S or CD44V6, but not isotype control antibodies, induced secretion of monocyte chemoattractant protein-1. In conclusion, this study has identified expression of the tumour-associated marker CD44V6 in tubular epithelial cells in normal and diseased rat kidney, and suggests that signalling through the CD44V6 molecule may participate in the pathogenesis of experimental kidney disease.

Diagnostic value of exercise electrocardiography for predicting a positive scintigraphic test in patients with complete right bundle branch block

BACKGROUND

The diagnostic value of exercise electrocardiography (ECG) in patients with complete right bundle block (cRBBB) remains controversial. The aim of this study was to investigate the diagnostic accuracy of exercise ECG for predicting ischemia in the presence of cRBBB.

METHODS

From a series of 1300 consecutive patients attending for exercise ECG and 99mTc-tetrofosmin single photon emission computed tomography (SPECT), we identified 38 male patients with cRBBB and 38 matched controls with normal intraventricular conduction. Patients with left ventricular hypertrophy or previous revascularization were excluded. Exercise ECG (modified Bruce protocol) was considered positive at > or = 1 mm ST horizontal or downsloping depression in > or = 2 adjacent leads. SPECT imaging at rest and post-exercise was performed at least 48 hours apart.

RESULTS

The odds ratio for ischemia comparing patients with positive and negative exercise ECGs was 11.0 (95% confidence interval 2.49-48.64, p = 0.002) in controls and 2.49 (95% confidence interval 0.64-9.08, p = 0.32) in cRBBB. The prior probability of ischemia was 0.37 in controls and 0.58 with cRBBB. The posterior probability after a positive test was 0.65 in controls and 0.68 in cRBBB. Thus, the utility of the test (posterior probability minus prior probability) was greater in controls (+0.28) than in cRBBB (+0.1). This difference was most pronounced in the anterior leads V1-V4 (controls +0.63 vs cRBBB +0.01) but less significant in the lateral leads V5-V6 (controls +0.26 vs cRBBB +0.21). Similar analysis also indicated reduced diagnostic value of negative exercise ECGs in cRBBB patients.

CONCLUSIONS

The diagnostic value of exercise ECG is reduced in patients with cRBBB, although ST-segment changes in the lateral ECG territory provide superior predictive accuracy to those in the anterior leads. The use of SPECT as a first-line investigation may be justified in patients with cRBBB.

Usefulness of platelet glycoprotein IIb/IIIa inhibitors in coronary stenting for reconstruction of complex lesions: procedural and 30 day outcome

BACKGROUND

Intracoronary stent implantation during percutaneous transluminal coronary angioplasty (PTCA) has shown favorable results, reducing acute complications associated with PTCA, such as coronary artery dissection and abrupt or threatened vessel closure. However, treatment of lesions with a complex morphology and diffuse disease, requiring long or multiple coronary stents, is still associated with a poorer outcome. We investigated the hypothesis that abciximab might lead to a different outcome in patients with complex coronary lesions, which require long or multiple stent implantation.

METHODS

One hundred and six patients were randomized to receive either a combination of abciximab (bolus and 12 hour infusion) and weight-adjusted low-dose heparin or weight-adjusted heparin alone and followed up to 30 days.

RESULTS

The procedural success rate was 100% in both groups of patients. In the control group a composite rate of major adverse events such as any death irrespective of cause, Q wave or non-Q wave myocardial infarction, acute or subacute stent thrombosis and urgent revascularization of 15.3% was shown at 30-day follow-up. The use of abciximab reduced the composite adverse event rate to 3.7% (76% absolute reduction, p < 0.05).

CONCLUSIONS

The use of abciximab during high risk stenting is safe and reduces the risk of cardiac events at 30-day follow-up as compared to standard treatment with heparin. A longer follow-up period is warranted to confirm the beneficial effects observed at 30 days with abciximab in this setting.

Accuracy of 99mTc-tetrofosmin myocardial tomography in the evaluation of coronary artery disease

BACKGROUND

Technetium 99m-labeled myocardial agents have been proposed as an alternative to thallium 201. The aim of this study was to assess retrospectively the accuracy of exercise myocardial 99mTc-tetrofosmin scintigraphy with tomographic imaging (SPECT) in a large group population in the evaluation of coronary artery disease. Furthermore we evaluated the relation between the severity of scintigraphic impaired myocardial perfusion and the angiographic coronary artery stenoses in patients without myocardial infarction and with stenosis localized exclusively in the proximal segment of the 3 main coronary arteries.

METHODS AND RESULTS

The study group consisted of 235 consecutive patients, 204 (87%) of whom were men, with a mean age of 57+/-10 years, and with suspected or known coronary artery disease, who underwent 99mTc-tetrofosmin SPECT and coronary angiography. Furthermore, 61 patients in a low-likelihood group for coronary artery disease were also studied. Significant disease was defined by > or = 50% luminal coronary artery stenosis in > or = 1 native coronary artery or major branch or in a saphenous vein graft or arterial mammary graft. The overall sensitivity was 95%, specificity was 76%, and predictive accuracy was 95%. The normalcy rate for the low-likelihood group was 93%. Sensitivity was 71% for the left anterior descending artery, 61% for the left circumflex artery, and 73% for the right coronary artery. Specificity was 94% for the left anterior descending artery, 96% for the left circumflex artery, and 91% for the right coronary artery. Predictive accuracy was 79% for the left anterior descending artery, 78% for the left circumflex artery, and 81 % for the right coronary artery. In patients without myocardial infarction linear regression analysis between scintigraphy and angiography showed a significant correlation in patients with severe proximal coronary artery stenosis (r = 0.53, P < .002), but not in those with moderate proximal stenosis (r = 0.31, P = NS).

CONCLUSIONS

This study shows that 99mTc-tetrofosmin SPECT is accurate in the detection of coronary artery disease. The relation of the severity of scintigraphic impaired myocardial perfusion and angiographic coronary artery stenosis, however, may differ significantly in patients with proximal stenosis of different severity.

[Safety, feasibility and efficacy of a new single-wire stent in the treatment of complex coronary lesions: the angiostent]

The angiostent is a single wire, flexible, highly radiopaque, balloon expandable stent. To evaluate the feasibility and safety of the deployment of this new stent, we report the clinical and procedural results of 70 procedures performed in 51 native coronary arteries of 48 patients, with objective evidence of ischemia. The target lesion was located in the left anterior descending artery in 18 (36%) cases, in the circumflex artery in 16 (31%) cases and in the right coronary artery in 17 (33%) cases. Mean reference vessel diameter was 3.2 +/- 0.4 mm and the minimal luminal diameter was 0.4 +/- 0.3 mm, with a mean diameter stenosis of 86 +/- 10%. Type B2 and C lesions were encountered in 56% of the cases. More than one angiostent was implanted in 14 vessels and multiple stenting was accomplished with the use of different stents in 8 coronary arteries. No major complications were reported. The post-procedural minimal luminal diameter was 3.2 +/- 0.4 mm with a mean diameter stenosis of 1.4 +/- 3.7%. In 25 cases (49%) major side branches raised from the stented segment and in all but one remained patent. In conclusion, the implantation of the angiostent is safe, feasible and effective, as it can be easily deployed at the lesion site, used for the treatment of complex lesions and preserves the patency of jailed side-branches.

Interleukin-10 differentially modulates MHC class II expression by mesangial cells and macrophages in vitro and in vivo

Inhibition of major histocompatibility complex (MHC) class II expression by macrophages is the primary mechanism by which interleukin-10 (IL-10) exerts immune suppression. Little, however, is known of the effects of IL-10 on other types of cells which can be induced to express MHC class II during an inflammatory response. We therefore studied the effects of IL-10 treatment on the expression of MHC class II molecules in a rat model of immunologically induced glomerulonephritis. MHC class II mRNA levels in whole kidney were increased in saline-treated (control) animals with glomerulonephritis (2.6-fold increase versus normal, P = 0.028) and this was partially inhibited by treatment with IL-10 (P = NS). Double immunostaining of tissue sections was used to compare MHC class II expression by infiltrating macrophages and resident glomerular cells. IL-10 treatment reduced the proportion of glomerular macrophages which expressed detectable MHC class II (70% reduction, P = 0.03). In contrast, IL-10 treatment was associated with an increase in the number of resident glomerular cells expressing MHC class II, particularly within mesangial areas. Therefore, the effects of IL-10 on macrophages and mesangial cells were compared in vitro. IL-10 reduced constitutive MHC class II mRNA and cell surface expression by peritoneal macrophages. In contrast, IFN-gamma-stimulated mesangial cells (1097 cell line) cultured with IL-10 for 24 hr showed increased MHC class II mRNA (26% increase) and surface expression (72% increase in percentage MHC II+ by flow cytometry, P = 0.04) as compared with cells stimulated with IFN-gamma alone. IL-10 also directly up-regulated expression of ICAM-1 by 1997 cells. In conclusion, IL-10 was found to have contrasting effects on the production and cell surface expression of MHC class II molecules by mesengial cells and by macrophages, both in vitro and in vivo. The implications of these findings for IL-10-mediated immunosuppression are discussed.