Differences between radiographic and non-radiographic axial spondyloarthritis patients in a Mexican cohort

To compare the demographic, clinical, and laboratory characteristics, disease onset, and clinical features of radiographic axial Spondyloarthritis (r-axSpA) and non-radiographic axial Spondyloarthritis (nr-axSpA) patients. All patients who attended outpatient spondylarthritis (SpA) clinics at Hospital General de Mexico and the Instituto Nacional de la Nutrición from 1998 to 2005 and met the rheumatologist diagnostic criteria for SpA were selected. Then the SpA patients were classified by European Spondyloarthropathy Study Group criteria (ESSG). We selected SpA patients with axial presentation as axial SpA (axSpA), and they were classified as r-axSpA if they met modified New York (mNY) criteria for sacroiliitis and as nr-axSpA if they did not meet mNY criteria; to compared clinical, demographic, and laboratory test between the subgroups. It included 148 SpA patients; 55 (37.2%) patients had r-axSpA, and 70 (47.3%) had nr-axSpA. The nr-axSpA patients had a lower proportion of males (58.6% vs 78.2%, P < 0.05), lower HLA-B27 frequency (54.3%. vs. 92.7%, P < 0.05), were older at disease onset (21 vs 16 years; P < 0.01) and had a higher frequency of infections at disease onset (9.1% vs 32.9, P < 0.05) than r-axSpA. BASFI (2.9 vs 4.8; P < 0.0001), Dougados functional index (7 vs. 14; P < 0.05), and BASDAI (4.1 vs. 5.2; P < 0.001) were lower in patients with nr-axSpA than r-axSpA, respectively. The factors that most influenced the presentation of r-axSpA were history of uveitis (OR 14, 95% CI 2.3-85), HLA-B27 (OR 7.97, 95% CI, 2.96-122), male sex (OR 6.16, 95% CI, 1.47-25.7), axial enthesopathy count (OR 1.17 95% CI, 1.03-1.33). This study provides insight into the differences between nr-axSpA and r-axSpA in Mexico. Patients with r-axSpA were mainly male, with a younger presentation age, a higher prevalence of HLA-B27, more history of uveitis, fewer episodes of dactylitis, more axial enthesopathy, and higher disease activity than nr-axSpA.

The role of γδ T cells in the immunopathogenesis of inflammatory diseases: from basic biology to therapeutic targeting

The γδ T cells are lymphocytes with an innate-like phenotype that can distribute to different tissues to reside and participate in homeostatic functions such as pathogen defense, tissue modeling, and response to stress. These cells originate during fetal development and migrate to the tissues in a TCR chain-dependent manner. Their unique manner to respond to danger signals facilitates the initiation of cytokine-mediated diseases such as spondyloarthritis and psoriasis, which are immune-mediated diseases with a very strong link with mucosal disturbances, either in the skin or the gut. In spondyloarthritis, γδ T cells are one of the main sources of IL-17 and, therefore, the main drivers of inflammation and probably new bone formation. Remarkably, this population can be the bridge between gut and joint inflammation.

Levofloxacin induces differential effects in the transcriptome between the gut, peripheral and axial joints in the Spondyloarthritis DBA/1 mice: Improvement of intestinal dysbiosis and the overall inflammatory process

To analyze the effect of levofloxacin-induced intestinal microbiota modifications on intestinal, joint, and systemic inflammation in the DBA/1 mice with spontaneous arthritis. The study included two groups of mice, one of which received levofloxacin. The composition and structure of the microbiota were determined in the mice's stool using 16S rRNA sequencing; the differential taxa and metabolic pathway between mice treated with levofloxacin and control mice were also defied. The effect of levofloxacin was evaluated in the intestines, hind paws, and spines of mice through DNA microarray transcriptome and histopathological analyses; systemic inflammation was measured by flow cytometry. Levofloxacin decreased the pro-inflammatory bacteria, including Prevotellaceae, Odoribacter, and Blautia, and increased the anti-inflammatory Muribaculaceae in mice's stool. Histological analysis confirmed the intestinal inflammation in control mice, while in levofloxacin-treated mice, inflammation was reduced; in the hind paws and spines, levofloxacin also decreased the inflammation. Microarray showed the downregulation of genes and signaling pathways relevant in spondyloarthritis, including several cytokines and chemokines. Levofloxacin-treated mice showed differential transcriptomic profiles between peripheral and axial joints and intestines. Levofloxacin decreased the expression of TNF-α, IL-23a, and JAK3 in the three tissues, but IL-17 behaved differently in the intestine and the joints. Serum TNF-α was also reduced in levofloxacin-treated mice. Our results suggest that the microbiota modification aimed at reducing pro-inflammatory and increasing anti-inflammatory bacteria could potentially be a coadjuvant in treating inflammatory arthropathies.

A randomized, double-blind, placebo-controlled 12-week trial of infliximab in patients with juvenile-onset spondyloarthritis

Objective

To assess the efficacy and safety of infliximab versus placebo in the treatment of patients with juvenile-onset spondyloarthritis (JoSpA).

Methods

Phase III, randomized, double-blind, placebo-controlled trial of 12 weeks that included patients ≤ 18 years old with JoSpA not responding to nonsteroidal anti-inflammatory drugs, sulfasalazine, or methotrexate. Patients were randomly assigned 1:1 to the infusion of infliximab 5mg/kg or placebo; completers entered then an open-label extension (OLE) period of 42 weeks. The primary endpoint was the number of active joints. Secondary outcomes included the assessment of disease activity, tender entheses, spinal mobility, serum C-reactive protein (CRP), the Bath Ankylosing Spondylitis Disease Activity and Functional Index, and the Childhood Health Assessment Questionnaire (CHAQ).

Results

We randomized 12 patients to infliximab and 14 to placebo. No significant differences were found between groups at baseline. At week 12, the mean number of active joints was 1.4 (SD 2.4) in the infliximab group and 4.1 (SD 3.0) in the placebo group (p = 0.0002). A repeated-measures mixed model analysis that included all endpoints in the study demonstrated sustained favourable outcomes of infliximab for active joints, tender joints, swollen joints, and tender enthesis counts, as well as for CHAQ and CRP (p < 0.01). Adverse events were more frequent in the infliximab group, including infections and infusion reactions, but none of them was serious.

Conclusion

Infliximab is efficacious for patients with JoSpA with an inadequate response to conventional treatment. No serious adverse events with the use of infliximab were observed.

POS0173 DATA-DRIVEN MRI DEFINITIONS FOR ACTIVE AND STRUCTURAL SACROILIAC JOINT LESIONS IN JUVENILE SPONDYLOARTHRITIS TYPICAL OF AXIAL DISEASE

Background

For classification in juvenile spondyloarthritis (JSpA), it is important to develop cut-offs for active and structural lesions typical of axial disease on MRI that are readily and consistently interpreted. Since the maturing sacroiliac joint (SIJ) looks different from the adult SIJ, the criteria developed for positive MRI in adults may not be applicable in JSpA.

Objectives

As part of a study developing classification criteria for axial disease in JSpA, we aimed to determine quantitative SIJ imaging lesion cut-offs for inflammatory and structural lesions typical of axial JSpA using majority imaging expert decision as the reference criterion.

Methods

Subjects were a retrospective cohort of children with SpA who met the provisional Pediatric Rheumatology International Trials Organization criteria for enthesitis/spondylitis-related juvenile idiopathic arthritis or had a rheumatologist JSpA diagnosis. All subjects had symptom onset prior to age 18 years and underwent MRI as part of a diagnostic evaluation for axial disease. To enable SIJ quadrant-based scoring, all MRIs included semi-coronal slices through the cartilaginous part of the joint on fluid sensitive sequences and on T1-weighted sequences for the assessment of inflammation and structural lesions, respectively. MRIs were reviewed by 6 musculoskeletal imaging experts who were blinded to clinical details. MRI evaluation of the SIJ was based on standardized lesion definitions that were decided by consensus of the central imaging team and represented a mix of definitions from ASAS and the Juvenile Arthritis MRI Score Outcome Measures in Rheumatology working group. Using a web-based interface, raters globally assessed the presence or absence of lesions typical of axial SpA and performed SIJ quadrant or joint based scoring. Lesion scores were generated by averaging the scores of all raters. Sensitivity and specificity of lesion cut-offs were calculated using rater majority (≥4/6 raters) on a global assessment of the presence/absence of active or structural lesions typical of axial SpA with high confidence (confidence of ±3 or stronger on confidence scale from -5, “Definitely No”, to +5, “Definitely Yes”) as the reference standard.

Results

Imaging from 243 subjects, 61% male, median age 14.9 years, had sequences available for detailed MRI scoring. Active inflammatory lesion typical of axial disease in JSpA was defined as bone marrow edema (BME) in at least 3 SIJ quadrants (sensitivity 98.6%, specificity 96.5%). For structural lesion typical of axial JSpA, the optimal cut-off was erosion in at least 3 quadrants or at least one of the following lesions in at least 2 SIJ quadrants: sclerosis, fat lesion, backfill, ankylosis (sensitivity 98.6%, specificity 95.5%).

Conclusion

We propose data-driven cut-offs for active inflammatory and structural lesions on MRI typical of axial disease in JSpA that have high specificity and sensitivity using central imaging global assessment as the reference standard.

Table 1.

Performance of cut-offs for inflammatory and structural lesions of axial disease

Cut-offs for number of SIJ quadrants (any location)Sensitivity (95% CI)Specificity (95% CI)Definite active lesionBME score ≥2100 (95.0-100)93.5 (88.7-96.7)BME score ≥398.6 (92.5-100)96.5 (92.5-98.7)BME, same location on ≥3 consecutive slices88.6 (78.7-94.9)98.8 (95.8-99.9)Definite structural lesionErosion ≥295.7 (88-99.1)96.8 (92.7-99)Erosion, same location on ≥2 consecutive slices94.3 (86-98.4)98.1 (94.5-99.6)Erosion ≥391.4 (82.3-96.8)98.7 (95.4-99.8)Sclerosis ≥262.9 (50.5-74.1)98.1 (94.5-99.6)Fat lesion ≥222.9 (13.7-34.4%)98.7 (95.4-99.8%)Backfill ≥220 (11.4-31.3)100 (97.7-100)Ankylosis ≥21.3 (0.2-4.7)100 (94.9-100)ANY of the following in ≥2 SIJ quadrants: erosion, sclerosis, fat lesion, backfill, ankylosis98.6 (92.3-100)93.6 (88.5-96.9)Erosion ≥3 quadrants OR ≥2 quadrants of at least one of the following lesions: sclerosis, fat, backfill, ankylosis98.6 (92.3-100.0)95.5 (91.0-98.2)

Disclosure of Interests

Pamela F. Weiss Consultant of: Pfizer

Novartis

Biogen

Lilly

(All <$5K in the past fiscal year), Timothy G. Brandon: None declared, Amita Aggarwal: None declared, Ruben Burgos-Vargas Speakers bureau: Not in the last three years.

Novartis, Consultant of: Not in the last four years.

BMS, Lilly, Novartis, Robert A. Colbert: None declared, Gerd Horneff Speakers bureau: Pfizer, Novartis, Janssen, Chugai, Abbvie, Grant/research support from: Pfizer, Novartis, MSD, Chugai, Roche, Abbvie, Rik Joos Speakers bureau: Galapagos, Pfizer, AbbVie, Novartis, Amgen, BMS, Lilly, Grant/research support from: Pfizer, AbbVie, Roche, Ronald Laxer Consultant of: Abbvie, Novartis, Sobi, Sanofi, Eli Lilly Canada, Eli Lilly, Kirsten Minden Speakers bureau: Pfizer, Novartis, Consultant of: Pfizer, Novartis, Angelo Ravelli Speakers bureau: Abbvie, Novartis, SOBI, Angelini, Reckitt-Benkiser, Roche, Pfizer, Alexion, Grant/research support from: Novartis, Pfizer, Nicolino Ruperto Speakers bureau: NR has received honoraria for consultancies or speaker bureaus from the following pharmaceutical companies in the past 3 years: 2 Bridge, Amgen, AstraZeneca, Aurinia, Bayer, Brystol Myers and Squibb, Celgene, inMed, Cambridge Healthcare Research, Domain Therapeutic, EMD Serono, Glaxo Smith Kline, Idorsia, Janssen, Eli Lilly, Novartis, Pfizer, Sobi, UCB., Consultant of: NR has received honoraria for consultancies or speaker bureaus from the following pharmaceutical companies in the past 3 years: 2 Bridge, Amgen, AstraZeneca, Aurinia, Bayer, Brystol Myers and Squibb, Celgene, inMed, Cambridge Healthcare Research, Domain Therapeutic, EMD Serono, Glaxo Smith Kline, Idorsia, Janssen, Eli Lilly, Novartis, Pfizer, Sobi, UCB., Grant/research support from: The IRCCS Istituto Giannina Gaslini (IGG), where NR works as full-time public employee has received contributions from the following industries in the last 3 years: Bristol Myers and Squibb, Eli-Lilly, F Hoffmann-La Roche, Novartis, Pfizer, Sobi. This funding has been reinvested for the research activities of the hospital in a fully independent manner, without any commitment with third parties., Judith Smith Consultant of: Consulting panel of pediatric rheumatologists identifying issues in juvenile spondyloarthritis for Novartis. Paid < $5000, Matthew L. Stoll Consultant of: Currently consulting for Novartis, Shirley ML Tse: None declared, Filip van den Bosch Speakers bureau: Abbvie, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, UCB, Paid instructor for: Amgen, Eli Lilly, Consultant of: Abbvie, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, UCB, Robert G Lambert Paid instructor for: Novartis, Consultant of: CARE Arthritis, Calyx, Image Analysis Group, Novartis, David M. Biko Employee of: Merck (1998-2000), Nancy A. Chauvin Employee of: Forest Pharmaceuticals - Research scientist (1996) and Novartis - Pharmaceutical sales representative (1997), Michael L. Francavilla: None declared, Jacob L Jaremko: None declared, Nele Herregods: None declared, Ozgur Kasapcopur Speakers bureau: Pfizer, Abbvie, Novartis and Roche, Mehmet YILDIZ: None declared, Alison M. Hendry: None declared, Walter P Maksymowych Speakers bureau: Abbvie, Eli-Lilly, Janssen, Novartis, Pfizer, UCB Pharma, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, UCB Pharma, Grant/research support from: Abbvie, Novartis, Pfizer

POS0340 PREDICTORS OF CLINICAL RESPONSE TO ABATACEPT IN CHILDREN WITH POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS

Background

For children with polyarticular juvenile idiopathic arthritis (pJIA) and inadequate response or intolerance to initial treatment with MTX, treatment options include abatacept.1 Abatacept, a selective T-cell co-stimulation modulator, has a distinct mechanism of action from other current treatments for rheumatic diseases,2 and factors predicting clinical response can help determine optimal treatment strategy. Two phase 3 studies demonstrated the efficacy and safety of IV and SC abatacept in patients with pJIA and an inadequate response to other DMARDs.2,3

Objectives

To determine baseline and post-baseline factors that may predict a clinical response in children and adolescents with pJIA treated with abatacept for 2 years.

Methods

Baseline demographic and disease characteristics and post-baseline factors (50% and 70% improvement in ACR criteria [ACR50, ACR70] at days 57 and 85) were analyzed using data from 2 phase 3 studies of abatacept in patients with JIA aged 2–17 years (SC administration) and 6–17 years (IV administration). Efficacy endpoints were Juvenile Arthritis Disease Activity Score in 10 joints based on CRP (JADAS10-CRP) inactive disease (ID; score of ≤ 2.7),4 and remission, defined as 6 consecutive months of post-baseline JADAS10-CRP ID. Data were analyzed over the entire 2-year study period. The earliest time point at which patients achieved these outcomes was reported. The aforementioned study factors were subjected to a time-to-event analysis, including Cox proportional hazards univariate regression analysis and Cox proportional hazards multivariate regression analysis using stepwise regression; results of the multivariate analysis are reported. Kaplan–Meier analysis was used to estimate time to achieve clinical response. Receiver operating characteristic curves were used to determine threshold values for continuous variables.

Results

Overall, 347 patients were included in the analysis (SC, n = 219; IV, n = 128; 73.8% female; mean [SD] age, 11.3 [4.0] years). Following abatacept treatment, both time to JADAS10-CRP ID and time to JADAS10-CRP remission were predicted (nominal P ≤ 0.05) by age (≤ 11 years: hazard ratio [HR], 1.52 [95% CI, 1.14–2.02] and ≤ 10 years: HR, 1.73 [95% CI, 1.20–2.48], respectively), high-sensitivity CRP (hsCRP; ≤ 0.6 mg/dL: HR, 1.67 [95% CI, 1.22–2.28] and ≤ 0.21 mg/dL: HR, 1.67 [95% CI, 1.15–2.42], respectively), Parent/Patient Global Assessment of well-being (≤ 35.86: HR, 1.88 [95% CI, 1.41–2.51] and ≤ 43.16: HR, 2.05 [95% CI, 1.35–3.10], respectively), and Childhood HAQ-DI (CHAQ-DI; ≤ 1.63: HR, 2.23 [95% CI, 1.47–3.39] and ≤ 0.75: HR, 1.84 [95% CI, 1.24–2.73], respectively) (remission data shown in Figure 1). Disease duration ≤ 2 years from baseline (HR, 1.66 [95% CI, 1.25–2.21]) and SC route of administration (HR, 2.05 [95% CI, 1.45–2.91]) also predicted ID. Among the post-baseline factors, ACR50 at days 57 and 85 predicted both ID (HR, 1.57 [95% CI, 1.04–2.36] and HR, 1.88 [95% CI, 1.41–2.51], respectively) and remission (HR, 1.96 [95% CI, 1.11–3.45] and HR, 3.05 [95% CI, 1.47–6.34], respectively); ACR70 at day 57 also predicted ID (data not shown). Patients with predictive factors for age, hsCRP, Parent/Patient Global Assessment of well-being, and CHAQ-DI, and with lower disease activity achieved ID and/or remission earlier than patients with high disease activity.

Conclusion

We identified baseline and post-baseline factors that predicted JADAS10-CRP ID and remission in patients with pJIA treated with abatacept for 2 years. Screening of abatacept-treated patients with pJIA for such factors may help predict earlier achievement of ID and/or remission.

References

[1]Ringold S, et al. Arthritis Rheumatol 2019;71:846–63.

[2]Brunner HI, et al. Arthritis Rheumatol 2018;70:1144–54.

[3]Ruperto N, et al. Lancet 2008;372:383–91.

[4]Trincianti C, et al. Arthritis Rheumatol 2021;73:1966–75.

Acknowledgements

This study was sponsored by Bristol Myers Squibb. Writing and editorial assistance were provided by Candice Judith Dcosta, MSc, of Caudex, funded by Bristol Myers Squibb. We would like to acknowledge Mara Becker, Duke Clinical Research Institute, Durham, NC, USA, for her contribution to the study analysis.

Disclosure of Interests

Nicolino Ruperto Speakers bureau: Honoraria for consultancies or speaker bureaus from the following pharmaceutical companies in the past 3 years: 2 Bridge, Amgen, AstraZeneca, Aurinia, Bayer, Brystol Myers Squibb, Cambridge Healthcare Research, Celgene, Domain Therapeutic, Eli Lilly, EMD Serono, GlaxoSmithKline, Idorsia, inMed, Janssen, Novartis, Pfizer, Sobi, UCB, Consultant of: Honoraria for consultancies or speaker bureaus from the following pharmaceutical companies in the past 3 years: 2 Bridge, Amgen, AstraZeneca, Aurinia, Bayer, Brystol Myers Squibb, Cambridge Healthcare Research, Celgene, Domain Therapeutic, Eli Lilly, EMD Serono, GlaxoSmithKline, Idorsia, inMed, Janssen, Novartis, Pfizer, Sobi, UCB, Hermine Brunner Speakers bureau: GlaxoSmithKline, Novartis, Pfizer, Consultant of: AbbVie, AstraZeneca-Medimmune, Biogen, Boehringer, Bristol Myers Squibb, Celgene, Cerocor, Eli Lilly, EMD Serono, F. Hoffmann-La Roche, GlaxoSmithKline, Idorsia, Janssen, Merck, Novartis, R-Pharm, Sanofi, Grant/research support from: The Cincinnati Children’s Hospital, where HIB works as a full-time public employee, has received contributions from the following industries in the past 3 years: Bristol Myers Squibb, F. Hoffmann-La Roche, Janssen, Novartis, and Pfizer. This funding has been reinvested for the research activities of the hospital in a fully independent manner, without any commitment to third parties, Alberto Berman Grant/research support from: AbbVie, Amgen, Bristol Myers Squibb, Lilly, Novartis, Pfizer, Roche, Francisco Avila Zapata: None declared, Gerd Horneff Speakers bureau: AbbVie, Chugai, Janssen, Novartis, Pfizer, Grant/research support from: AbbVie, Chugai, MSD, Novartis, Pfizer, Roche, Linda Wagner-Weiner Grant/research support from: Abbott, Bristol Myers Squibb, Merck, Pfizer, UCB, Alexander Belot Speakers bureau: Chugai, GlaxoSmithKline, Novartis, Roche (punctual scientific intervention), Grant/research support from: Boehringer Ingelheim, Merck (joint research project), Ruben Burgos-Vargas: None declared, Maria Luz Gámir Gámir: None declared, Claudia Goldenstein-Schainberg Speakers bureau: AbbVie, Janssen, Novartis, Consultant of: AbbVie, Janssen, Novartis, Maria T. Terreri: None declared, Margarita Askelson Consultant of: Acerta Pharma, Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Robert Wong Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Alberto Martini Consultant of: AbbVie, Eli Lilly, EMD Serono, Idorsia, Janssen, Novartis, Pfizer, Daniel J Lovell Consultant of: AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Hoffman LaRoche, Novartis, UBC (all contracts with employer, CCHMC), Grant/research support from: Bristol Myers Squibb, Janssen, Pfizer, Roche (all contracts with employer, CCHMC); NIH grants: NIAMS, NICHD

Recommendations of the Mexican College of Rheumatology for the management of psoriatic arthritis

Psoriatic arthritis is a chronic systemic inflammatory disease that affects the skin, musculoskeletal structures and other organs and systems compromising functionality, quality of life and reducing the life expectancy of patients. It is a complex disease that requires specialist and timely care and management. The alternatives for treating the manifestations of psoriatic arthritis have increased and the effect of the different agents on specific manifestations has been clarified in recent studies. Therefore, we should incorporate the available evidence to build a strategy for the treatment of these patients. The Mexican College of Rheumatology selected a committee to evaluate these different alternatives and make recommendations.

METHODS

The study group included 16 rheumatologists and 3 certified dermatologists, selected from different health institutions and regions of the country. An executive committee was formed to coordinate the meetings and a committee of experts selected the literature search criteria, prepared the research questions, rated the quality of the evidence, and produced the recommendations in the different disease domains based on the GRADE methodology.

RESULTS

24 updated recommendations were generated for the treatment of patients with psoriatic arthritis. The recommendations establish the role of the drugs currently available in our country. The importance of adequate disease control is emphasized, individualizing the level of involvement of each patient in each of the six domains potentially affected by the disease. In addition, the sequence in the choice of treatments available for each domain is established, based on their efficacy, safety profile and accessibility.

CONCLUSIONS

With this consensus document, it will be possible to improve the care of patients with psoriatic arthritis. The recommendations were generated based on the best available information and in consideration of the Mexican health system.

Gout during the SARS-CoV-2 pandemic: increased flares, urate levels and functional improvement

Introduction

Gout is the most common inflammatory arthritis, but was not considered in most COVID-19 and rheumatic diseases reports. Our aim was to describe changes in clinical data, treatment, function and quality of life for gout patients during COVID-19 pandemic.

Methods

Prospective, descriptive and analytical study of 101 consecutive gout (ACR/EULAR 2015) patients from our clinic evaluated during pandemic by phone call (n=52) or phone call + face-to-face (n=68) that accepted to participate. Variables are demographics, clinical and treatment data, HAQ, EQ5D questionnaires and COVID-19-related data. Patients were divided in two groups: flare (n=36) or intercritical gout (n=65) also; available pre-pandemic data was obtained from 71 patients. Statistical analyses are X², paired t-test and Wilcoxon test.

Results

Included gout patients were males (95.8%), mean (SD) age 54.7 (10.7) years and disease duration 16.4 (9.8) years; 90% received allopurinol, 50% colchicine as prophylaxis and 25% suspended ≥ 1 medication. Comparison of pre-pandemic vs pandemic data showed > flares (4.4% vs 36%, p=0.01), more flares in the last 6 months: 0.31 (0.75) vs 1.71 (3.1), (p=0.004 and > urate levels: 5.6 (1.7)vs 6.7 (2.2) mg/dL, p=0.016. Unexpectedly, function and quality-of-life scores improved: HAQ score 0.65 (2.16) vs 0.12 (0.17), p= 0.001. Seven patients were COVID-19-confirmed cases; they had significantly more flares, higher urate levels and lower allopurinol doses and two died.

Conclusions

In gout patients, flares were 9 times more frequent during pandemic also, they had increased urate levels but led to an unexpected improvement in HAQ and functionality scores. Resilience and lifestyle changes in gout during COVID-19 pandemic require further studies.

Key Points • COVID-19 pandemic is associated with 4 times more flares in gout patients. • Increased flares were also seen in previously well-controlled gout patients. • Increased serum urate levels were also found in gout patients during pandemic. • In our gout clinic, 8/101 patients were diagnosed as COVID-19+, and two of them died.

Inflammatory Foot Involvement in Spondyloarthritis: From Tarsitis to Ankylosing Tarsitis

Spondyloarthritis (SpA) is a group that includes a wide spectrum of clinically similar diseases manifested by oligoarticular arthritis and axial or peripheral ankylosis. Although axial SpA is predominant in Caucasians and adult-onset patients, juvenile-onset and Latin American patients are characterized by severe peripheral arthritis and particularly foot involvement. The peripheral involvement of SpA can vary from tarsal arthritis to the most severe form named ankylosing tarsitis (AT). Although the cause and etiopathogenesis of axSpA are often studied, the specific characteristics of pSpA are unknown. Several animal models of SpA develop initial tarsitis and foot ankylosis as the main signs, emphasizing the role of foot inflammation in the overall SpA spectrum. In this review, we attempt to highlight the clinical characteristics of foot involvement in SpA and update the knowledge regarding its pathogenesis, focusing on animal models and the role of mechanical forces in inflammation.

POS1149 CARDIOVASCULAR RISK STATUS AND OBESITY IN GOUT COMPARED TO HEALTHY MEXICAN SUBJECTS: A CASE-CONTROLS STUDY WITH A PROPENSITY SCORE-MATCHED ANALYSIS

Background:

Atherosclerotic cardiovascular diseases (ASCVD), metabolic syndrome and hyperuricemia due to an increment in their incidence world-wide, but information regarding the 10-year estimated risk in gout vs. healthy subjects is scarce.

Objectives:

To assess baseline the 10-year cardiovascular risk and high-risk status in gout patients compared to healthy controls.

Methods:

Data from 494 gout paired to controls in a ratio of 1:1 matched with age, sex and body mass index (BMI) and stratified by normal (≤ 24.9 Kg/m2), overweight (25 - 29.9 Kg/m2) and obese (≥30 Kg/m2). Controls were asymptomatic subjects attending a preventive clinic in Mexico City. We used the Framingham Risk Score for Coronary Heart Disease (FRS-CHD) and the 2013 American College of Cardiology/American Heart Association (2013 ACC/AHA). Additionally, high risk status was defined according to pre-defined cutoff points for FRS-CHD (≥ 20%) and ACC/AHA 2013 (≥7.5%).

Results:

Data from 494 gout and 494 controls. Gout patients were male 97.4%, 47 (SD ± 13) years, mean BMI of 28.4 (SD ± 4.31) Kg/m2. Age, sex, and BMI and subgroups were equilibrated (p=NS). Gout patients had higher 10-year estimated risk vs. controls nevertheless, only FRS-CHD reached statistically significant difference with 9.38 vs. 7.5 ± 5.74 (p<0.001); For 2013 ACC/AHA 4.94 ± 6.16 vs. 5.23 ± 6.78, (p=0.49). Further stratification by BMI groups revealed that subjects with gout in normal and overweight categories were had higher risk vs. controls with FRS-CHD score of 8.86 ± 8.05 vs. 6.53 ± 6.41 (p=0.03) and 9.37 ± 7.72 vs. 7.89 ± 5.58 (p=0.01), respectively. No differences for 2013 ACC/AHA in global and BMI-stratified comparisons. Proportion of high-risk subjects were similar in both groups regardless of BMI category: for FRS-CHD 7.5 vs 4.7% (p=0.06) and 2013 ACC/AHA with 21.5 vs. 17.8% (p=0.14).

Conclusion:

Normal BMI or overweight Mexican patients with gout may be at higher 10-year estimated cardiovascular risk compared to matched age, gender and BMI healthy controls. Obese gout subjects are at high risk with non-statistical significance scores for FRS-CHD or 2013 ACC/AHA compared to controls.

References:

[1]Acosta-Cázares B, Escobedo-de la Peña J. High burden of cardiovascular disease risk factors in Mexico: An epidemic of ischemic heart disease that may be on its way?. American Heart Journal. 2010;160:230-6.

[2]Sánchez Rodríguez A, Moreno-Del Castillo C, Prado Anaya CA et al. ESTIMATED 10-YEAR CARDIOVASCULAR RISK WITH FRAMINGHAM RISK AND 2013 ACC/AHA IN GOUT AND HEALTHY MEXICAN SUBJECTS: A CASE-CONTROL STUDY WITH A PROPENSITY SCORE-MATCHED ANALYSIS J Clin Rheumatol: 2019;25:S1–S96.

[3]Bevis M, Blagojevic-Bucknall M, Mallen C, Hider S, Roddy E. Comorbidity cluster in people with gout: an observational cohort study with linked medial record review. Rheumatology (Oxford). 2018 Apr 17.

[4]Andrés M, Bernal JA, Sivera F, Quilis N, Carmona L, Vela P, Pascual E. Cardiovascular risk of patients with gout seen at rheumatology clinics following a structured assessment. Ann Rheum Dis. 2017;76:1263-8.

Disclosure of Interests:

None declared.

POS0197 RESPONSIVENESS OF ULTRASOUND SYNOVITIS AND CLINICAL OUTCOMES IN PSORIATIC ARTHRITIS TREATED WITH SECUKINUMAB: DATA FROM THE ULTIMATE TRIAL

Background:

Power Doppler ultrasonography is a sensitive imaging tool to assess synovitis in psoriatic arthritis (PsA).1,2 ULTIMATE (NCT02662985) is the first large, randomised, double-blind placebo-controlled phase IIIb study in PsA, using ultrasound to evaluate early response to secukinumab on synovitis. The use of the standardised and reliable global EULAR-OMERACT composite ultrasound synovitis score at patient level (GLOESS) as the primary endpoint showed the early and significant benefit of secukinumab vs. placebo on synovitis at week 12.3

Objectives:

To investigate the responsiveness and discriminative validity of GLOESS compared to clinical outcomes on joints at week 12 and report ultrasound and clinical efficacy data up to week 24.

Methods:

This is a 52-week study with a 12-week double-blind, placebo-controlled period followed by 12-week open-label (OL) and 6-month OL extension. All placebo patients were switched to secukinumab (300 or 150 mg) at week 12.3 Discriminative validity of GLOESS was analysed post-hoc: within-group responsiveness was assessed by comparing its standardised response mean (SRM) to that of core set of ACR response in the initial secukinumab group over 12 and 24 weeks. Mean change from baseline up to week 12 of GLOESS was determined with mixed-effect model repeated measures analysis (MMRM) and from week 12-24 as observed. 24 week efficacy outcomes included ACR responses, HAQ-DI, PASI response and resolution of dactylitis. These outcomes were exploratory and reported either according to non-responder imputation (ACR response), or as observed (HAQ-DI, PASI response and resolution of dactylitis).

Results:

Of 166 patients enrolled, a total of 155 patients (93%) completed 24 weeks of treatment (secukinumab, 79 patients 95%; placebo, 76 patients 92%). Mean change from baseline to week 24 in GLOESS was similar in the initial secukinumab and placebo-secukinumab groups. A continued improvement in GLOESS was observed in the secukinumab group, with catch-up improvement in the placebo group after switch to active therapy (Figure 1). Both SRM of GLOESS and ACR core components over 12 and 24 weeks were high (Table 1). Similar clinical response rates were reported for clinical joint count, skin, dactylitis and function at week 24 in secukinumab and placebo switchers groups (Table 1).

Conclusion:

These analyses highlight the responsiveness and high discriminative validity of GLOESS in PsA, resembling that of key clinical PsA manifestations and physical function.

References:

[1]D’Agostino MA and Coates LC. J Rheumatol. 2019;46:337–9.

[2]Uson J, et al. Rheumatol Clin. 2018;14:27–35.

[3]D’Agostino MA, et al. Arthritis Rheumatol. 2020;72 (suppl 10).

Figure 1.

Mean change from baseline in GLOESS by treatment through Week 24

Table 1.

Responsiveness of GLOESS - analysed by standardised response mean and efficacy outcomes at week 24

Standardised response mean(Initial secukinumab)Efficacy of secukinumabWeek0–12(N = 83)Week0–24(N = 83)Responders(%)Secukinumabweek 0–24(N = 83)Placebo switchersweek 12–24(N = 83)GLOESS1.051.06ACR208774Tender joint count1.031.35ACR506449Swollen joint count0.911.18ACR703423Patient global assessment of disease activity1.371.55HAQ-DI*8063Physician global assessment of disease activity1.592.39PASI 75†7259Pain1.321.53PASI 90†6245HAQ-DI score1.321.32Resolutionof dactylitis (LDI=0)6759

*HAQ-DI response is defined as an improvement of at least 0.35 score points compared to baseline (change ≤ −0.35)

†N value for PASI response in secukinumab and placebo groups are 36 and 33; respectively. PASI response was calculated for patients with BSA ≥ 3 %.

BSA, Body Surface Area; LDI, Leeds Dactylitis Index

Disclosure of Interests:

Maarten Boers Consultant of: BMS, Novartis, Pfizer, GSK, Philip G Conaghan Speakers bureau: AbbVie, AstraZeneca, BMS, Eli Lilly, Galapagos, Gilead, Novartis and Pfizer, Consultant of: AbbVie, AstraZeneca, BMS, Eli Lilly, Galapagos, Gilead, Novartis and Pfizer, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, Peter Mandl Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, MSD, Novartis, Roche and UCB, Grant/research support from: AbbVie, BMS, Celgene, Janssen, Eli Lilly, MSD, Novartis, Roche and UCB, Esperanza Naredo Speakers bureau: AbbVie, Roche, BMS, Pfizer, UCB, Eli Lilly, Novartis, Janssen, and Celgene, Consultant of: AbbVie, Novartis and BMS, Grant/research support from: Eli Lilly, Filip van den Bosch Speakers bureau: AbbVie, Celgene, Janssen, Eli Lilly, Galapagos, Merck, Novartis, Pfizer, and UCB Pharma, Consultant of: AbbVie, Celgene, Janssen, Eli Lilly, Galapagos, Merck, Novartis, Pfizer, and UCB Pharma, Ruben Burgos-Vargas: None declared, Anne-Marie Duggan Employee of: Novartis, Punit Goyanka Employee of: Novartis, Corine Gaillez Shareholder of: Novartis and BMS, Employee of: Novartis, Maria-Antonietta D’Agostino Speakers bureau: Sanofi, Novartis, BMS, Janssen, Celgene, Roche, AbbVie, UCB, and Eli Lilly, Consultant of: Sanofi, Novartis, BMS, Janssen, Celgene, Roche, AbbVie, UCB, and Eli Lilly

OP0047 IDENTIFICATION OF CLINICAL PHENOTYPES IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS, PERIPHERAL SPONDYLOARTHRITIS AND PSORIATIC ARTHRITIS ACCORDING TO PERIPHERAL MUSCULOSKELETAL MANIFESTATIONS: A CLUSTER ANALYSIS IN THE INTERNATIONAL ASAS-PERSPA STUDY

Background:

Patients with a diagnosis of Spondyloarthritis (SpA) and Psoriatic Arthritis (PsA) may have predominant axial or peripheral symptoms, and the frequency and distribution of these symptoms may determine the clinical diagnosis by the rheumatologist (“clinical clusters”). Clustering analysis represents an unsupervised exploratory analysis which tries to identify homogeneous groups of cases (“statistical clusters”) without prior information about the membership for any of the cases.

Objectives:

To identify “statistical clusters” of peripheral involvement according to the specific location of these symptoms in the whole spectrum of SpA and PsA (without prior information about the diagnosis of the patients), and to evaluate whether these “statistical clusters” are in agreement with the “clinical clusters”.

Methods:

Cross-sectional and multicentre study with 24 participating countries. Consecutive patients considered by their treating rheumatologist as suffering from either PsA, axial SpA (axSpA) or peripheral SpA (pSpA) were enrolled. Four different cluster analyses were conducted: the first one using information about the specific location from all the peripheral musculoskeletal manifestations (i.e., peripheral arthritis, enthesitis and dactylitis), and thereafter a cluster analysis for each peripheral manifestation individually. Multiple correspondence analyses and k-means clustering methods were used. Distribution of peripheral manifestations and clinical characteristics were compared across the different clusters.

Results:

4465 patients were included in the analysis. Two clusters were found with regard to the location of all the peripheral manifestations (Fig. 1). Cluster 1 showed a low prevalence of peripheral manifestations in comparison with cluster 2; however, when peripheral involvement appeared in cluster 1, this was mostly represented by arthritis of hip, knee and ankle, as well as enthesitis of the heel. Patients from cluster 1 showed a higher prevalence of males (63% vs 44%), HLA-B27 positivity (69% vs 38%) and axial involvement (80% vs 52%), as well as more frequent diagnosis of axSpA (66% vs 21%) and more frequently fulfilling the ASAS axSpA criteria (69% vs. 41%). Patients from cluster 2 showed a higher prevalence of psoriasis (63% vs 25%), a more frequent diagnosis of PsA (61% vs 19%), and they fulfilled more frequently the peripheral ASAS (26% vs 11%) and the CASPAR criteria (57% vs 19%).

Figure 1.

Distribution of the peripheral involvement across clusters

Three clusters were found with regard to the location of the peripheral arthritis. Clusters 2 and 3 showed a high prevalence of peripheral joint disease, although this was located more predominantly in the lower limbs in cluster 2, and in the upper limbs in cluster 3. Cluster 1 showed a higher prevalence of males, HLA-B27 positivity, axial involvement, a lower presence of psoriasis, a more frequent diagnosis of axSpA and fulfilling the ASAS axSpA criteria in comparison with clusters 2 and 3, respectively. Clusters 2 and 3 showed a higher prevalence of enthesitis and dactylitis in comparison with cluster 1, a more frequent diagnosis of PsA and fulfillment of the CASPAR criteria.

Information about the location of enthesitis exhibited three groups: cluster 1 showed a very low prevalence of enthesitis, while cluster 2 and 3 showed a high prevalence of enthesitis, with a predominant involvement of axial enthesis in cluster 2 and peripheral enthesitis in cluster 3.

Finally, the analysis of dactylitis also exhibited three clusters that showed a very low prevalence of dactylitis, predominantly toes and predominantly fingers involvement, respectively.

Conclusion:

These results suggest the presence of heterogeneous patterns of peripheral involvement in SpA and PsA patients without clearly defined groups, confirming the clear overlap of these peripheral manifestations across the different underlying diagnoses.

Acknowledgements:

This study was conducted under the umbrella of ASAS with unrestricted grant of Abbvie, Pfizer, Lilly, Novartis, UCB, Janssen and Merck.

Disclosure of Interests:

None declared

Recommendations of the Mexican College of Rheumatology for the management of psoriatic arthritis

Psoriatic arthritis is a chronic systemic inflammatory disease that affects the skin, musculoskeletal structures and other organs and systems compromising functionality, quality of life and reducing the life expectancy of patients. It is a complex disease that requires specialist and timely care and management. The alternatives for treating the manifestations of psoriatic arthritis have increased and the effect of the different agents on specific manifestations has been clarified in recent studies. Therefore, we should incorporate the available evidence to build a strategy for the treatment of these patients. The Mexican College of Rheumatology selected a committee to evaluate these different alternatives and make recommendations.

METHODS

The study group included 16 rheumatologists and 3 certified dermatologists, selected from different health institutions and regions of the country. An executive committee was formed to coordinate the meetings and a committee of experts selected the literature search criteria, prepared the research questions, rated the quality of the evidence, and produced the recommendations in the different disease domains based on the GRADE methodology.

RESULTS

24 updated recommendations were generated for the treatment of patients with psoriatic arthritis. The recommendations establish the role of the drugs currently available in our country. The importance of adequate disease control is emphasized, individualizing the level of involvement of each patient in each of the six domains potentially affected by the disease. In addition, the sequence in the choice of treatments available for each domain is established, based on their efficacy, safety profile and accessibility.

CONCLUSIONS

With this consensus document, it will be possible to improve the care of patients with psoriatic arthritis. The recommendations were generated based on the best available information and in consideration of the Mexican health system.

Syndemic and syndemogenesis of low back pain in Latin-American population: a network and cluster analysis

INTRODUCTION

Although low back pain (LBP) is a high-impact health condition, its burden has not been examined from the syndemic perspective.

OBJECTIVE

To compare and assess clinical, socioeconomic, and geographic factors associated with LBP prevalence in low-income and upper-middle-income countries using syndemic and syndemogenesis frameworks based on network and cluster analyses.

METHODS

Analyses were performed by adopting network and cluster design, whereby interrelations among the individual and social variables and their combinations were established. The required data was sourced from the databases pertaining to the six Latin-American countries.

RESULTS

Database searches yielded a sample of 55,724 individuals (mean age 43.38 years, SD = 17.93), 24.12% of whom were indigenous, and 60.61% were women. The diagnosed with LBP comprised 6.59% of the total population. Network analysis showed higher relationship individuals' variables such as comorbidities, unhealthy habits, low educational level, living in rural areas, and indigenous status were found to be significantly associated with LBP. Cluster analysis showed significant association between LBP prevalence and social variables (e.g. Gender inequality Index, Human Development Index, Income Inequality).

CONCLUSIONS

LBP is a highly prevalent condition in Latin-American populations with a high impact on the quality of life of young adults. It is particularly debilitating for women, indigenous individuals, and those with low educational level, and is further exacerbated by the presence of comorbidities, especially those in the mental health domain. Thus, the study findings demonstrate that syndemic and syndemogenesis have the potential to widen the health inequities stemming from LBP in vulnerable populations. Key points • Syndemic and syndemogenesis evidence health disparities in Latin-American populations, documenting the complexity of suffering from a disease such as low back pain that is associated with comorbidities, unhealthy habits, and the social and regional context where they live. • The use of network and cluster analyses are useful tools for documenting the complexity and the multifaceted impact in health in large populations as well as the differences between countries. • The variability and impact of socioeconomic indicators (e.g., Gini index) related to low back pain and comorbidities could be felt through the use of cluster analysis, which generates evidence of regional inequality in Latin America. • Populations can be studied from different models (network and cluster analysis) and grouping, presenting new interpretations beyond geographical groupings, such as syndemic and inequity in health.

Differential expression of TLR2 and TLR4 in α4β7-positive leukocytes of patients with axial spondyloarthritis

OBJECTIVES

Expression of α4β7 integrin can identify gut-homing immune cells. This study aimed to determine the expression of Toll-like receptor 2 (TLR2) and TLR4 in α4β7-positive leukocytes of patients with axial SpA (axSpA).

METHODS

We analysed the frequencies of α4β7-positive T cells, Tγδ cells and monocytes in 14 patients with axSpA and 14 healthy controls, together with the expression of TLR2 and TLR4 by flow cytometry. Also, the concentration of faecal calprotectin was measured in all patients and controls.

RESULTS

We found significantly higher percentages of α4β7-positive T (P = 0.026) and Tγδ cells (P = 0.0118) in the patients with axSpA than in controls; these cells showed differential expression of TLR2 and TLR4 when compared with α4β7-negative cells. Such differences were not correlated with disease activity or faecal calprotectin concentration.

CONCLUSION

There is an increase in circulating α4β7-positive T and Tγδ cells in patients with axSpA. These cells differentially express TLR2 and TLR4.

Peripheral neuropathies in rheumatic diseases: More diverse and frequent than expected. A cross-sectional study

BACKGROUND/OBJECTIVE

Peripheral neuropathies (PN) are heterogeneous nerve disorders; frequently rheumatic patients have neuropathic symptoms. In some rheumatic diseases (RD) PN are secondary to nerve compression while others are related to metabolic abnormalities, inflammation or vasculitis. Our aim was to explore the frequency of neuropathic symptoms with three neuropathy questionnaires (NQ) and nerve conduction studies (NCS) in RD.

METHODS

This is a cross-sectional study in patients with any RD attending for the first time to a rheumatology outpatient clinic. We included all patients who accepted to participate and who answered three NQ and received a physical evaluation. Twenty patients were randomly selected to perform NCS and 10 healthy subjects were included as controls. The topographic diagnoses were: mononeuropathy, multiplex mononeuropathy, and/or polyneuropathy.

STATISTICAL ANALYSIS

descriptive statistics (mean, median, standard deviation, interquartile range and frequency, odds ratios and Pearson correlation test).

RESULTS

One hundred patients and 10 healthy subjects were included. Sixty-nine were female, mean age 40.6 ± 15.7 years. Rheumatic diagnoses were: systemic lupus erythematosus (26%), rheumatoid arthritis (16%), gout (14%), and osteoarthritis (11%). Fifty-two patients had neuropathic signs during physical examination and 67% had positive questionnaires with variable scores among several RD. Abnormal NCS was reported in 14 patients (70%): 6 (42.8%) median nerve mononeuropathies, 4 (28.5%) multiplex mononeuropathies and 4 (28.5%) polyneuropathies. None of the healthy subjects had neuropathy (NQ, physical evaluation, or NCS). Risk of being NCS positive is higher when the patients were NQ positive.

CONCLUSION

PN has variable distribution and high frequency in patients with RD; NQ+ increases the risk of presenting NCS+ for PN.

Extension Study of PF-05280586, a Potential Rituximab Biosimilar, Versus Rituximab in Subjects With Active Rheumatoid Arthritis

OBJECTIVE

This extension study provided continued treatment to subjects with active rheumatoid arthritis who had participated for ≥16 weeks in a pharmacokinetic similarity study of PF-05280586 (potential rituximab biosimilar). Objectives were to evaluate overall pharmacokinetics, pharmacodynamics, immunogenicity, safety, and tolerability of PF-05280586 after transition from rituximab reference products to PF-05280586, and follow-up of biomarker and efficacy assessments.

METHODS

Subjects were offered ≤3 additional courses of treatment of PF-05280586, with or without a single transition from rituximab in Europe (rituximab-EU; MabThera) or the US (rituximab-US; Rituxan) to PF-05280586. Each course comprised 2 intravenous infusions (1,000 mg on days 1 and 15, separated by 24 weeks [± 8 weeks]).

RESULTS

Of 220 subjects in the parent study, 185 were randomized and included in this study. There were no notable differences in drug concentrations between groups or across courses, with little variation in depletion of CD19+ B cells between groups, and no apparent relationship between infusion-related reactions and antidrug antibodies with or without single transition from rituximab reference products to PF-05280586. Long-term safety and tolerability of PF-05280586 was acceptable in all groups for up to 96 weeks, with a low incidence of treatment-emergent adverse events independent of single drug transition. The percentage of subjects with a low disease activity score and disease activity score remission was similar across groups for all time points, and responses were sustained until end of study.

CONCLUSION

This study demonstrated acceptable safety, tolerability, and immunogenicity, with or without single transition from rituximab reference products to PF-05280586, without increased immunogenicity on single transition.

Are Target Urate and Remission Possible in Severe Gout? A Five-year Cohort Study

OBJECTIVE

Determine the proportion of patients achieving target serum urate (SU), defined as < 6 mg/dl for patients with non-severe gout and < 5 mg/dl for patients with severe gout, as well as the proportion of patients achieving remission after 5 years of followup.

METHODS

Patients from the Gout Study Group (GRESGO) cohort were evaluated at 6-month intervals. Demographic and clinical data were obtained at baseline. Visits included assessments of serum urate, flares, tophus burden, health-related quality of life using the EQ-5D, activity limitations using the Health Assessment Questionnaire adapted for gout, and pain level and patient's global assessment using visual analog scales. Treatment for gout and associated diseases was prescribed according to guidelines and available drugs.

RESULTS

Of 500 patients studied, 221 had severe gout (44%) and 279 had non-severe gout (56%) at baseline. No significant differences were observed across the study in percentages of severe gout versus non-severe gout patients achieving SU 6 mg/dl or 5 mg/dl. The highest proportion of patients achieving target SU (50-70%) and remission (39%) were found after 3-4 years of followup. In the fifth year, these proportions decreased and 28% of the patients were in remission, but only 40 patients remained in the study. None of the patients with severe gout achieved remission.

CONCLUSION

In patients with severe gout, target SU was hard to achieve and remission was not possible. The main obstacles for target SU and gout remission include poor medication adherence, persistent tophi, and loss to followup.

Assessment of SpondyloArthritis International Society (ASAS) Consensus on Spanish Nomenclature for Spondyloarthritis

OBJECTIVE

To develop a consensus to standardize the use of Spanish terms, abbreviations and acronyms in the field of spondyloarthritis (SpA).

METHODS

An international task force comprising all native Spanish-speaking Assessment of SpondyloArthritis International Society (ASAS) members, the executive committee of Grupo para el estudio de la Espondiloartritis de la Sociedad Española de Reumatología (GRESSER), two methodologists, two linguists from the Real Academia Nacional de Medicina de España (RANM) and two patients from the Spanish Coordinator of Spondylitis Associations (CEADE) was established. A literature review was performed to identify the conflicting terms/abbreviations/acronyms in SpA. This review examined written sources in Spanish including manuscripts, ICF and ICD, guidelines, recommendations and consensuses. This was followed by a nominal group meeting and a three-round Delphi. The recommendations from the RANM based on the Panhispanic dictionary were followed throughout the process.

RESULTS

Consensus was reached for 46 terms, abbreviations or acronyms related to the field of SpA. A Spanish translation was accepted for 6 terms and 6 abbreviations to name or classify the disease, and for 6 terms and 4 abbreviations related to SpA. It was agreed not to translate 15 acronyms into Spanish. However, when mentioning them, it was recommended to follow this structure: type of acronym in Spanish and acronym and expanded form in English. With regard to 7 terms or abbreviations attached to acronyms, it was agreed to translate only the expanded form and a translation was also selected for each of them.

CONCLUSIONS

Through this standardization, it is expected to establish a common use of the Spanish nomenclature for SpA. The implementation of this consensus across the community will be of substantial benefit, avoiding misunderstandings and time-consuming processes.

Stress proteins in the pathogenesis of spondyloarthritis

Spondyloarthritis is an autoinflammatory rheumatic disease in which arthritis and osteoproliferation lead the patients who suffer from it to chronic disability. This disease is associated with the expression of class I MHC molecule HLA-B27, which tends to be misfolded in the endoplasmic reticulum and, therefore, expressed in aberrant forms. This phenomena lead to endoplasmic reticulum stress, which in time, evokes a whole response to cellular injury. Under these conditions, the molecules involved in restoring cell homeostasis play a key role. Such is the case of the "heat-shock proteins", which usually regulate protein folding, but also have important immunomodulatory functions, as well as some roles in tissue modeling. In this review, we attempt to summarize the involvement of cell stress and heat-shock proteins in the homeostatic disturbances and pathological conditions associated with this disease.

Prevalence of Comorbidities and Risk Factors for Comorbidities in Patients with Spondyloarthritis in Latin America: A Comparative Study with the General Population and Data from the ASAS-COMOSPA Study

Objective.

Increased risk of comorbidities has been reported in spondyloarthritis (SpA). The objective of this study was to determine the prevalence and risk of developing comorbidities in patients with SpA in 3 Latin American (LA) countries, and to compare that prevalence with the general population.

Methods.

Data were analyzed from 390 patients with SpA enrolled in the Assessment of SpondyloArthritis international Society of Comorbidities in SpA study from Argentina, Colombia, and Mexico. Age- and sex-standardized prevalence (95% CI) was estimated for arterial hypertension (AHT), tuberculosis (TB), and malignancies. Age- and sex-specific data from the general population were obtained from the Cardiovascular Risk Factor Multiple Evaluation in Latin America (CARMELA) study for AHT, the Global TB report, and the GLOBOCAN project for malignancies. Data analyzed for AHT were confined to Colombia and Mexico. The prevalence in patients with SpA was compared with the prevalence in the general population per age- and sex-specific stratum, resulting in standardized risk ratios (SRR).

Results.

In total, 64% of the patients with SpA were male, with a mean age of 45 years (SD 14.7). The most common comorbidities in the 3 LA countries were AHT (25.3%, 95% CI 21.2–30.0), hypercholesterolemia (21.5%, 95% CI 17.6–26.0), and osteoporosis (9.4%, 95% CI 6.8–12.9). AHT prevalence in Colombia and Mexico was 21.4% (95% CI 15.4–28.9) and was higher than the general population (12.5%, 95% CI 11.4–13.7), resulting in an SRR of 1.5. TB prevalence in the 3 LA countries was 3.3% (95% CI 1.8–5.7), which was significantly higher than in the general population (0.32%), leading to an SRR of 10.3. The prevalence of malignancies was not increased.

Conclusion.

Patients with SpA in LA are at increased risk of AHT and TB in comparison to the general population. While this sample of patients may not be entirely representative of the patient population in each country, a systematic evaluation of these comorbidities in all patients with SpA still may help to monitor these conditions better.

Gender differences among patients with primary ankylosing spondylitis and spondylitis associated with psoriasis and inflammatory bowel disease in an iberoamerican spondyloarthritis cohort

The aim of the study was to compare clinical manifestations, disease activity, functional capacity, spinal mobility, and radiological findings between men and women from a multicenter, multiethnic Ibero-American cohort of patients with Spondyloarthritis (SpA).This observational cross-section study included 1264 consecutive SpA patients who fulfilled the modified New York criteria for ankylosing spondylitis (AS). Demographic, clinical, and radiologic data were evaluated. Categorical data were compared by X or Fisher's exact tests and continuous variables by ANOVA with post-hoc tests.Primary AS was diagnosed in 1072 patients, psoriatic spondylitis in 147, and spondylitis associated to inflammatory bowel disease (IBD) in 45 patients. Overall, male patients were significantly younger, had longer diagnostic delay, lower disease activity, worse spinal mobility, better quality of life, and more severe radiologic damage. Dactylitis and enthesitis, as well as swollen joint count, were significantly more common among women. In primary AS, there was a marked male predominance (76.2%). Among patients with psoriatic spondylitis, male predominance was lower (57.8%), but was also associated with worse spinal mobility and more severe radiologic damage. In the total population, male patients with primary AS referred higher permanent work disability (13.2% vs 6.9%; P < 0.05), although no difference was observed in psoriatic or IBD spondylitis according to the gender.Among Ibero-American SpA patients, there are some differences in clinical and radiological manifestations, men showing more structural damage, whereas women more active disease. These data suggest that the phenotype of SpA differs between genders. This can influence the subsequent diagnostic approach and therapeutic decisions.

Measuring impairments of functioning and health in patients with axial spondyloarthritis by using the ASAS Health Index and the Environmental Item Set: translation and cross-cultural adaptation into 15 languages

Introduction

The Assessments of SpondyloArthritis international society Health Index (ASAS HI) measures functioning and health in patients with spondyloarthritis (SpA) across 17 aspects of health and 9 environmental factors (EF). The objective was to translate and adapt the original English version of the ASAS HI, including the EF Item Set, cross-culturally into 15 languages.

Methods

Translation and cross-cultural adaptation has been carried out following the forward–backward procedure. In the cognitive debriefing, 10 patients/country across a broad spectrum of sociodemographic background, were included.

Results

The ASAS HI and the EF Item Set were translated into Arabic, Chinese, Croatian, Dutch, French, German, Greek, Hungarian, Italian, Korean, Portuguese, Russian, Spanish, Thai and Turkish. Some difficulties were experienced with translation of the contextual factors indicating that these concepts may be more culturally-dependent. A total of 215 patients with axial SpA across 23 countries (62.3% men, mean (SD) age 42.4 (13.9) years) participated in the field test. Cognitive debriefing showed that items of the ASAS HI and EF Item Set are clear, relevant and comprehensive. All versions were accepted with minor modifications with respect to item wording and response option. The wording of three items had to be adapted to improve clarity. As a result of cognitive debriefing, a new response option ‘not applicable’ was added to two items of the ASAS HI to improve appropriateness.

Discussion

This study showed that the items of the ASAS HI including the EFs were readily adaptable throughout all countries, indicating that the concepts covered were comprehensive, clear and meaningful in different cultures.

If three of my brothers have ankylosing spondylitis, why does the doctor say it is not necessarily hereditary? The meaning of risk in multiplex case families with ankylosing spondylitis

OBJECTIVE

To investigate how patients with ankylosing spondylitis and their relatives in multiplex case families understand concepts of familial aggregation, heredity and risk perceptions, and its impact on decision-making.

METHODS

This is a multimethod clinical investigation using field research style in 34 individuals from 10 families with ≥2 members with ankylosing spondylitis covering a wide spectrum of disease severity, educational level, and economical status. The narratives of patients and their relatives were obtained using clinical information, unstructured observation, and personal interviews, which were then transcribed verbatim, coded, and analyzed by three investigators. The interpretation of the textual data was based on two analysis styles, immersion/crystallization and interpretative grounded theory.

RESULTS

We identified four broad interrelated interpretive units in patient and relatives narratives: (1) familial interpretation of the disease, (2) genetic risk, (3) decision-making based on risk, and (4) patient-family/physician discourse contradiction on the meaning of heredity.

CONCLUSIONS

Patient's and their relatives interpretation of familial aggregation, HLAB27, heredity, and risk perception in relation with ankylosing spondylitis involves four broad interpretive units spanning from clinical symptoms to heredity and decisions made accordingly. Their thoughts and consequent decisions are often in contradiction with the medical knowledge on the role of genetic factors in ankylosing spondylitis.

A Randomized, Double-Blind, Placebo-Controlled Multicenter Study of Adalimumab in Pediatric Patients With Enthesitis-Related Arthritis

Objective

Enthesitis‐related arthritis (ERA) is a juvenile idiopathic arthritis (JIA) category, primarily affecting entheses and peripheral joints. This study evaluated efficacy, safety, and pharmacokinetics of adalimumab versus placebo in patients with ERA.

Methods

This is a phase III, multicenter, randomized double‐blind study in patients ages ≥6 to <18 years with ERA treated with adalimumab (24 mg/m², maximum dose 40 mg every other week) or placebo for 12 weeks, followed by up to 192 weeks of open‐label adalimumab. The primary end point was percent change from baseline in number of active joints with arthritis (AJC) at week 12. Samples were collected to determine adalimumab serum concentrations. Adverse events (AEs) were assessed throughout the study.

Results

Forty‐six patients were randomized (31 adalimumab/15 placebo). At baseline, mean age was 12.9 years, mean duration of ERA symptoms was 2.6 years, mean AJC was 7.8, and mean enthesitis count was 8.1. Mean percent change from baseline in AJC at week 12 was greater in the adalimumab group versus placebo (−62.6% versus −11.6%; P = 0.039). Most secondary variables favored adalimumab versus placebo at week 12. Treatment response further increased with continued adalimumab therapy through week 52. Mean steady‐state adalimumab serum concentrations were 7.5–11.8 μg/ml, similar to patients age ≥2 years with polyarticular JIA. AE rates were similar between placebo and adalimumab: any AE (53.3% versus 67.7%), serious AEs (0% versus 3.2%), and infectious AEs (20.0% versus 29.0%).

Conclusion

Adalimumab reduced signs and symptoms of ERA at week 12, with improvement sustained through week 52. The safety profile was consistent with previous adalimumab studies.

Function of Treg Cells Decreased in Patients With Systemic Lupus Erythematosus Due To the Effect of Prolactin

Prolactin has different functions, including cytokine secretion and inhibition of the suppressor effect of regulatory T (Treg) cells in healthy individuals. Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by defects in the functions of B, T, and Treg cells. Prolactin plays an important role in the physiopathology of SLE. Our objective was to establish the participation of prolactin in the regulation of the immune response mediated by Treg cells from patients with SLE. CD4CD25CD127 cells were purified using magnetic beads and the relative expression of prolactin receptor was measured. The functional activity was evaluated by proliferation assay and cytokine secretion in activated cells, in the presence and absence of prolactin. We found that both percentage and function of Treg cells decrease in SLE patients compared to healthy individuals with statistical significance. The prolactin receptor is constitutively expressed on Treg and effector T (Teff) cells in SLE patients, and this expression is higher than in healthy individuals. The expression of this receptor differs in inactive and active patients: in the former, the expression is higher in Treg cells than in Teff cells, similar to healthy individuals, whereas there is no difference in the expression between Treg and Teff cells from active patients. In Treg:Teff cell cocultures, addition of prolactin decreases the suppressor effect exerted by Treg cells and increases IFNγ secretion. Our results suggest that prolactin plays an important role in the activation of the disease in inactive patients by decreasing the suppressor function exerted by Treg cells over Teff cells, thereby favoring an inflammatory microenvironment.

Defining active sacroiliitis on MRI for classification of axial spondyloarthritis: update by the ASAS MRI working group

Objectives

To review and update the existing definition of a positive MRI for classification of axial spondyloarthritis (SpA).

Methods

The Assessment in SpondyloArthritis International Society (ASAS) MRI working group conducted a consensus exercise to review the definition of a positive MRI for inclusion in the ASAS classification criteria of axial SpA. Existing definitions and new data relevant to the MRI diagnosis and classification of sacroiliitis and spondylitis in axial SpA, published since the ASAS definition first appeared in print in 2009, were reviewed and discussed. The precise wording of the existing definition was examined in detail and the data and a draft proposal were presented to and voted on by the ASAS membership.

Results

The clear presence of bone marrow oedema on MRI in subchondral bone is still considered to be the defining observation that determines the presence of active sacroiliitis. Structural damage lesions seen on MRI may contribute to a decision by the observer that inflammatory lesions are genuinely due to SpA but are not required to meet the definition. The existing definition was clarified adding guidelines and images to assist in the application of the definition.

Conclusion

The definition of a positive MRI for classification of axial SpA should continue to primarily depend on the imaging features of ‘active sacroiliitis’ until more data are available regarding MRI features of structural damage in the sacroiliac joint and MRI features in the spine and their utility when used for classification purposes.

A Prospective Follow-Up of Adipocytokines in Cohort Patients With Gout: Association With Metabolic Syndrome But Not With Clinical Inflammatory Findings: Strobe-Compliant Article

The aim of this study was to determine the levels of leptin (Lep) and adiponectin (AdipoQ) in patients with gout and its relationship with joint inflammatory data and/or with metabolic syndrome (MetS) variables, during 1 year follow-up.Forty-one patients (40 males) with gout diagnosis, attending for the first time to a rheumatology department, were included. Evaluations were performed baseline, at 6 and 12 months. Variables included the following: demographic, clinical and laboratory data related to gout and associated diseases. Lep and AdipoQ determinations by the ELISA method were performed in frozen serum from each visit. The pharmacological and no-pharmacological treatment for gout and associated diseases was individualized for each patient according to published guidelines. Statistical analysis included Mann-Whitney U test, Fisher test, x, ANOVA, Cochran Q, Pearson and Spearman correlation tests, as well as linear regression.In the baseline evaluation, 29.2% had MetS (hypertriglyceridemia 66%, hypertension 44% and obesity 37%); patients with MetS had higher C reactive protein (CRP) levels [34.1 ± 28.6 vs. 12.2 ± 11.2 mg/dL, P = 0.033]. Although not significant, also had higher Lep and lower AdipoQ levels (3.2 ± 3.0 vs. 1.9 ± 1.2 ng/mL, P = 0.142 and 40.5 ± 26.8 vs. 38.0 ± 24.9 ng/mL, P = 0.877, respectively). During follow-up, our patients had significant improvement in serum uric acid (sUA) levels and variables evaluating pain and joint swelling (P ≤ 0.05). Metabolic abnormalities tended to persist or even worsen during the monitoring period: significant increase in total cholesterol (P = 0.004), tendency to higher triglycerides (P = 0.883) and slight improvement in glycaemia (P = 0.052). Lep values increased significantly during follow-up (P = 0.001) while AdipoQ levels diminished slightly (P = 0.317). Neither Lep nor AdipoQ values showed important correlation (r > 0.5) with metabolic variables or joint swelling.This study suggests that in patients with gout, concentrations of Lep and AdipoQ are more in line with the metabolic state than with clinical disease activity.

Bone Lineage Proteins in the Entheses of the Midfoot in Patients with Spondyloarthritis

Objective.

Patients with juvenile-onset spondyloarthritis (SpA) may develop ankylosis of the midfoot resembling the spinal changes seen in patients with ankylosing spondylitis (AS). The study of the histopathology of the feet of patients with tarsitis could help us understand the pathogenesis of bone formation in affected structures in the SpA. The objective of our study was to describe the histopathologic characteristics of the midfoot in patients with tarsitis associated with SpA.

Methods.

We obtained synovial sheaths, entheses, and bone samples from 20 patients with SpA with midfoot pain/tenderness and swelling. Tissue samples underwent H&E staining; immunohistochemistry for CD3, CD4, CD8, CD68, and CD20 cell identification; and immunofluorescence for bone lineage proteins, including osteocalcin, osteopontin, parathyroid hormone-related protein, bone sialoprotein, and alkaline phosphatase.

Results.

Slight edema and hyalinization were found in some tendon sheaths, and few inflammatory cells were detected in the entheses. In bones, we found some changes suggesting osteoproliferation, including endochondral and intramembranous ossification, but no inflammatory cells. In entheses showing bone proliferation, we detected osteocalcin and osteopontin in cells with a fibroblast-mesenchymal phenotype, suggesting the induction of entheseal cells toward an osteoblast phenotype.

Conclusion.

Osteoproliferation and abnormal expression of bone lineage proteins, but no inflammatory infiltration, characterize midfoot involvement in patients with SpA. In this sense, tarsitis (or ankylosing tarsitis) resembles the involvement of the spine in patients with AS. Ossification may be in part explained by the differentiation of mesenchymal entheseal cells toward the osteoblastic lineage.

Long-term outcome of anti-tumor necrosis factor alpha blockade in the treatment of juvenile spondyloarthritis

OBJECTIVES

A significant proportion of patients with juvenile spondyloarthritis (JSpA) are refractory to treatment with established medications. The objective of this study was to assess long-term efficacy of treatment with anti-TNF agents in patients with JSpA.

METHODS

An observational study of 16 patients with JSpA from 3 centres treated with infliximab (n=10) and etanercept (n=6) was performed, with a median follow-up period of 7.2 years. Prospective data was collected according to a standardized protocol. Outcomes examined were TEC, TAJC, markers of inflammation (ESR, CRP), functional assessments (C-HAQ, BASDAI, BASFI), and ongoing requirement for anti-TNF treatment.

RESULTS

13/16 patients (83%) had achieved clinical remission 6 months into the treatment. Improvement was sustained over time, with a median TAJC and TEC of 0 at any time point after 6 weeks. 6/16 patients (38%) showed a flare of arthritis after a median of 3.5 years. Two patients with hip disease prior to treatment required an arthroplasty 3 and 8 years post anti-TNF initiation. Patients showed progression of sacroiliitis with median modified New York score of 1 (range 0-3) at time of diagnosis and 3 (range 0-4) at last follow-up (p=0.002). Median BASDAI at last follow up was 1.6, median BASFI 3.1. Two patients developed transient reactions (one generalised, one local); no patient developed other adverse effects during the study.

CONCLUSIONS

Anti-TNF treatment in JSpA refractory to standard treatment results in good long-term disease control except for pre-existing hip disease. However, radiographic evidence suggests inferior efficacy for control of sacroiliac joint disease.

Multinational evidence-based recommendations for the diagnosis and management of gout: integrating systematic literature review and expert opinion of a broad panel of rheumatologists in the 3e initiative

We aimed to develop evidence-based multinational recommendations for the diagnosis and management of gout. Using a formal voting process, a panel of 78 international rheumatologists developed 10 key clinical questions pertinent to the diagnosis and management of gout. Each question was investigated with a systematic literature review. Medline, Embase, Cochrane CENTRAL and abstracts from 2010-2011 European League Against Rheumatism and American College of Rheumatology meetings were searched in each review. Relevant studies were independently reviewed by two individuals for data extraction and synthesis and risk of bias assessment. Using this evidence, rheumatologists from 14 countries (Europe, South America and Australasia) developed national recommendations. After rounds of discussion and voting, multinational recommendations were formulated. Each recommendation was graded according to the level of evidence. Agreement and potential impact on clinical practice were assessed. Combining evidence and clinical expertise, 10 recommendations were produced. One recommendation referred to the diagnosis of gout, two referred to cardiovascular and renal comorbidities, six focused on different aspects of the management of gout (including drug treatment and monitoring), and the last recommendation referred to the management of asymptomatic hyperuricaemia. The level of agreement with the recommendations ranged from 8.1 to 9.2 (mean 8.7) on a 1-10 scale, with 10 representing full agreement. Ten recommendations on the diagnosis and management of gout were established. They are evidence-based and supported by a large panel of rheumatologists from 14 countries, enhancing their utility in clinical practice.