Treatment for Rheumatoid Arthritis Associated With Alterations in the Gastrointestinal Microbiota

OBJECTIVE

Emerging research suggests that rheumatoid arthritis (RA) is associated with intestinal dysbiosis. This prospective pilot study evaluates changes in intestinal microbial composition in patients with RA initiating treatment with either methotrexate (MTX) or a tumor necrosis factor inhibitor (TNFi).

METHODS

Consecutive patients, fulfilling the 2010 American College of Rheumatology/EULAR classification criteria for RA, who started treatment with either MTX or TNFi delivered a stool sample upon initiation of immunosuppression and 3 months later. A 16S ribosomal RNA gene-based validated microbiota test (GA-map Dysbiosis Index Score [DIS], Genetic Analysis, Oslo, Norway) was used to evaluate for the presence and degree of dysbiosis. Fecal levels of Prevotella copri (P. copri) were analyzed by custom-made quantitative polymerase chain reaction. Changes in microbial composition were analyzed in relation to changes in disease activity, as measured by the disease activity score based on 28-joint counts, using C-reactive protein.

RESULTS

At baseline, dysbiosis was present in 33 of 50 (66%) participants and more common in participants with more than 2 years of disease duration (P = 0.019). At the 3-month follow-up, 27 of 50 (54%) were good treatment responders and the DIS had improved in 14 of 50 (28%). Participants initiating TNFi more often exhibited improvement in the DIS compared with those initiating MTX (P = 0.031). P. copri was identified in 32 of 50 (64%) at baseline. An improvement in disease activity score based on 28-joint counts, using C-reactive protein was associated with a simultaneous decrease in P. copri abundance (rs = 0.30, P = 0.036).

CONCLUSION

This study affirms that dysbiosis is a feature of RA. Although patients were not randomized to MTX or TNFi, the findings suggest that specific therapies may differentially modulate the gastrointestinal microbiota in RA. The association between P. copri and treatment response requires further study.

Patient-reported outcomes in axial spondyloarthritis and psoriatic arthritis patients treated with secukinumab for 24 months in daily clinical practice

OBJECTIVES

In patients with axial spondyloarthritis (axSpA) or psoriatic arthritis (PsA) initiating secukinumab, we aimed to assess and compare the proportion of patients achieving 6-, 12- and 24-month patient-reported outcomes (PRO) remission and the 24-month retention rates.

PATIENTS AND METHODS

Patients with axSpA or PsA from 16 European registries, who initiated secukinumab in routine care were included. PRO remission rates were defined as pain, fatigue, Patient Global Assessment (PGA) ≤2 (Numeric Rating Scale (NRS) 0-10) and Health Assessment Questionnaire (HAQ) ≤0.5, for both axSpA and PsA, and were calculated as crude values and adjusted for drug adherence (LUNDEX). Comparisons of axSpA and PsA remission rates were performed using logistic regression analyses (unadjusted and adjusted for multiple confounders). Kaplan-Meier plots with log-rank test and Cox regression analyses were conducted to assess and compare secukinumab retention rates.

RESULTS

We included 3087 axSpA and 3246 PsA patients initiating secukinumab. Crude pain, fatigue, PGA and HAQ remission rates were higher in axSpA than in PsA patients, whereas LUNDEX-adjusted remission rates were similar. No differences were found between the patient groups after adjustment for confounders. The 24-month retention rates were similar in axSpA vs. PsA in fully adjusted analyses (HR [95 %CI] = 0.92 [0.84-1.02]).

CONCLUSION

In this large European real-world study of axSpA and PsA patients treated with secukinumab, we demonstrate for the first time a comparable effectiveness in PRO remission and treatment retention rates between these two conditions when adjusted for confounders.

Persistent pain and its predictors after starting anti-tumour necrosis factor therapy in psoriatic arthritis: what is the role of inflammation control?

OBJECTIVE

While considerable focus has been placed on pain due to inflammation in psoriatic arthritis (PsA), less is reported on pain despite inflammation control. Here, we aimed to investigate the occurrence/predictors of persistent pain, including non-inflammatory components, after starting anti-tumour necrosis factor (anti-TNF) therapy.

METHOD

Bionaïve PsA patients starting a first anti-TNF therapy 2004-2010 were identified (South Swedish Arthritis Treatment Group register; N = 351). Outcomes included unacceptable pain [visual analogue scale (VAS) pain > 40 mm], and unacceptable pain despite inflammation control (refractory pain; VAS pain > 40 mm + C-reactive protein < 10 mg/L + ≤ 1 swollen joint of 28), assessed at 0, 3, 6, and 12 months. Baseline predictors were estimated by logistic regression.

RESULTS

Upon starting anti-TNF therapy, 85% of patients reported unacceptable pain, falling to 43% at 3 months and then remaining stable. After 12 months, refractory pain constituted 63% of all unacceptable pain. Higher baseline VAS pain/global, worse physical function and lower health-related quality-of-life were associated with a higher risk of unacceptable/refractory pain at 12 months. More swollen joints and higher evaluator's global assessment were associated with a lower risk of 12-month refractory pain.

CONCLUSIONS

A substantial proportion of PsA patients reported unacceptable pain throughout the first anti-TNF treatment year. At 12 months, refractory pain constituted about two-thirds of this remaining pain load. More objective signs of inflammation at anti-TNF initiation were associated with less future refractory pain. This highlights insufficient effect of biologics in patients with inflammation-independent pain, warranting alternative treatments.

Joint tenderness at 3 months follow-up better predicts long-term pain than baseline characteristics in early rheumatoid arthritis patients

OBJECTIVE

To investigate pain course over time and to identify baseline and 3-month predictors of unacceptable pain with or without low inflammation in early RA.

METHODS

A cohort of 275 patients with early RA, recruited in 2012-2016, was investigated and followed for 2 years. Pain was assessed using a visual analogue scale (VAS; 0-100 mm). Unacceptable pain was defined as VAS pain >40, and low inflammation as CRP <10 mg/l. Baseline and 3-month predictors of unacceptable pain were evaluated using logistic regression analysis.

RESULTS

After 2 years, 32% of patients reported unacceptable pain. Among those, 81% had low inflammation. Unacceptable pain, and unacceptable pain with low inflammation, at 1 and 2 years was significantly associated with several factors at 3 months, but not at baseline. Three-month predictors of these pain states at 1 and 2 years were higher scores for pain, patient global assessment, and the health assessment questionnaire, and more extensive joint tenderness compared with the number of swollen joints. No significant associations were found for objective inflammatory measures.

CONCLUSION

A substantial proportion of patients had unacceptable pain with low inflammation after 2 years. Three months after diagnosis seems to be a good time-point for assessing the risk of long-term pain. The associations between patient reported outcomes and pain, and the lack of association with objective inflammatory measures, supports the uncoupling between pain and inflammation in RA. Having many tender joints, but more limited synovitis, may be predictive of long-term pain despite low inflammation in early RA.

Identifying Predictors of First-Line Subcutaneous TNF-Inhibitor Persistence in Patients with Inflammatory Arthritis: A Decision Tree Analysis by Indication

INTRODUCTION

Treatment persistence is a proxy for efficacy, safety and patient satisfaction, and a switch in treatment or treatment discontinuation has been associated with increased indirect and direct costs in inflammatory arthritis (IA). Hence, there are both clinical and economic incentives for the identification of factors associated with treatment persistence. Until now, studies have mainly leveraged traditional regression analysis, but it has been suggested that novel approaches, such as statistical learning techniques, may improve our understanding of factors related to treatment persistence. Therefore, we set up a study using nationwide Swedish high-coverage administrative register data with the objective to identify patient groups with distinct persistence of subcutaneous tumor necrosis factor inhibitor (SC-TNFi) treatment in IA, using recursive partitioning, a statistical learning algorithm.

METHODS

IA was defined as a diagnosis of rheumatic arthritis (RA), ankylosing spondylitis/unspecified spondyloarthritis (AS/uSpA) or psoriatic arthritis (PsA). Adult swedish biologic-naïve patients with IA initiating biologic treatment with a SC-TNFi (adalimumab, etanercept, certolizumab or golimumab) between May 6, 2010, and December 31, 2017. Treatment persistence of SC-TNFi was derived based on prescription data and a defined standard daily dose. Patient characteristics, including age, sex, number of health care contacts, comorbidities and treatment, were collected at treatment initiation and 12 months before treatment initiation. Based on these characteristics, we used recursive partitioning in a conditional inference framework to identify patient groups with distinct SC-TNFi treatment persistence by IA diagnosis.

RESULTS

A total of 13,913 patients were included. Approximately 50% had RA, while 27% and 23% had AS/uSpA and PsA, respectively. The recursive partitioning algorithm identified sex and treatment as factors associated with SC-TNFi treatment persistence in PsA and AS/uSpA. Time on treatment in the groups with the lowest treatment persistence was similar across all three indications (9.5-11.3 months), whereas there was more variation in time on treatment across the groups with the highest treatment persistence (18.4-48.9 months).

CONCLUSIONS

Women have low SC-TNFi treatment persistence in PsA and AS/uSpA whereas male sex and golimumab are associated with high treatment persistence in these indications. The factors associated with treatment persistence in RA were less distinct but may comprise disease activity and concurrent conventional systemic disease-modifying anti-rheumatic drug (DMARD) treatment.

Methotrexate treatment in early psoriatic arthritis in comparison to rheumatoid arthritis: an observational nationwide study

INTRODUCTION

We aimed to compare the proportions of patients with newly diagnosed psoriatic arthritis (PsA) and rheumatoid arthritis (RA) remaining on methotrexate (regardless of other disease-modifying antirheumatic drug (DMARD)-changes), and proportions not having started another DMARD (regardless of methotrexate discontinuation), within 2 years of starting methotrexate, as well as methotrexate effectiveness.

METHODS

Patients with DMARD-naïve, newly diagnosed PsA, starting methotrexate 2011-2019, were identified from high-quality national Swedish registers and matched 1:1 to comparable patients with RA. Proportions remaining on methotrexate and not starting another DMARD were calculated. For patients with disease activity data at baseline and 6 months, response to methotrexate monotherapy was compared through logistic regression, applying non-responder imputation.

RESULTS

In total, 3642/3642 patients with PsA/RA were included. Baseline patient-reported pain and global health were similar, whereas patients with RA had higher 28-joint scores and evaluator-assessed disease activity. Two years after methotrexate start, 71% of PsA vs 76% of patients with RA remained on methotrexate, 66% vs 60% had not started any other DMARD, and 77% vs 74% had not started specifically a biological or targeted synthetic DMARD. At 6 months, the proportions of patients with PsA versus RA achieving pain-scores ≤15 mm were 26% vs 36%; global health ≤20 mm: 32% vs 42%; evaluator-assessed 'remission': 20% vs 27%, with corresponding adjusted ORs (PsA vs RA) of 0.63 (95% CI 0.47 to 0.85); 0.57 (95% CI 0.42 to 0.76) and 0.54 (95% CI 0.39 to 0.75).

DISCUSSION

In Swedish clinical practice, methotrexate use is similar in PsA and RA, both regarding initiation of other DMARDs and methotrexate retention. On a group level, disease activity improved during methotrexate monotherapy in both diseases, although more so in RA.

Radiographic damage in early rheumatoid arthritis is associated with increased disability but not with pain-a 5-year follow-up study

OBJECTIVES

To evaluate how radiographic damage, overall and measured as joint space narrowing score (JSNS) and erosion score (ES), as well as other clinical and laboratory measures, relate to disability and pain in early rheumatoid arthritis (RA).

METHODS

An inception cohort of 233 patients with early RA, recruited in 1995-2005, was followed for 5 years. Disability was assessed with the Health Assessment Questionnaire (HAQ), and pain with a visual analogue scale (VAS; 0-100 mm). Radiographs of hands and feet were evaluated using the Sharp-van der Heijde score (SHS), including JSNS and ES. The relation for radiographic scores and other clinical parameters with pain and HAQ were evaluated cross-sectionally by multivariate linear regression analysis and over time using generalized estimating equations.

RESULTS

ES was significantly associated with HAQ cross-sectionally at inclusion, after 2 and after 5 years, and over time. Associations for HAQ with SHS and JSNS were weaker and less consistent compared with those for ES. There was no association between radiographic scores and pain at any visit. Both HAQ and pain were associated with parameters of disease activity. The strongest cross-sectional associations were found for the number of tender joints (adjusted p<0.001 at all visits).

CONCLUSION

Joint damage was associated with disability already in early RA. Erosions of hands and feet appear to have a greater influence on disability compared with joint space narrowing early in the disease. Pain was associated with other factors than joint destruction in early RA, in particular joint tenderness-suggesting an impact of pain sensitization.

Characteristics associated with poor COVID-19 outcomes in people with psoriasis, psoriatic arthritis and axial spondyloarthritis: data from the COVID-19 PsoProtect and Global Rheumatology Alliance physician-reported registries

OBJECTIVES

To investigate factors associated with severe COVID-19 in people with psoriasis (PsO), psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA).

METHODS

Demographic data, clinical characteristics and COVID-19 outcome severity of adults with PsO, PsA and axSpA were obtained from two international physician-reported registries. A three-point ordinal COVID-19 severity scale was defined: no hospitalisation, hospitalisation (and no death) and death. ORs were estimated using multivariable ordinal logistic regression.

RESULTS

Of 5045 cases, 18.3% had PsO, 45.5% PsA and 36.3% axSpA. Most (83.6%) were not hospitalised, 14.6% were hospitalised and 1.8% died. Older age was non-linearly associated with COVID-19 severity. Male sex (OR 1.54, 95% CI 1.30 to 1.83), cardiovascular, respiratory, renal, metabolic and cancer comorbidities (ORs 1.25-2.89), moderate/high disease activity and/or glucocorticoid use (ORs 1.39-2.23, vs remission/low disease activity and no glucocorticoids) were associated with increased odds of severe COVID-19. Later pandemic time periods (ORs 0.42-0.52, vs until 15 June 2020), PsO (OR 0.49, 95% CI 0.37 to 0.65, vs PsA) and baseline exposure to TNFi, IL17i and IL-23i/IL-12+23i (OR 0.57, 95% CI 0.44 to 0.73; OR 0.62, 95% CI 0.45 to 0.87; OR 0.67, 95% CI 0.45 to 0.98; respectively; vs no disease-modifying antirheumatic drug) were associated with reduced odds of severe COVID-19.

CONCLUSION

Older age, male sex, comorbidity burden, higher disease activity and glucocorticoid intake were associated with more severe COVID-19. Later pandemic time periods, PsO and exposure to TNFi, IL17i and IL-23i/IL-12+23i were associated with less severe COVID-19. These findings will enable risk stratification and inform management decisions for patients with PsO, PsA and axSpA during COVID-19 waves or similar future respiratory pandemics.

Cost-effectiveness analysis of bimekizumab for the treatment of active psoriatic arthritis in Sweden

AIMS

To evaluate the cost-effectiveness of bimekizumab, an inhibitor of IL-17F and IL-17A, against biologic and targeted synthetic disease-modifying antirheumatic drugs (DMARD) for psoriatic arthritis (PsA) from the Swedish healthcare system perspective.

MATERIALS AND METHODS

A Markov model was developed to simulate the clinical pathway of biologic [b] DMARD-naïve or tumor necrosis factor inhibitor experienced [TNFi-exp] PsA patients over a lifetime horizon. Treatment response was incorporated as achievement of the American College of Rheumatology 50% (ACR50) and Psoriasis Area and Severity Index 75% (PASI75) response, and changes in the Health Assessment Questionnaire-Disability Index (HAQ-DI) score. The efficacy of bimekizumab was obtained from the BE OPTIMAL (bDMARD-naïve) and BE COMPLETE (TNFi-experienced) trials while a network meta-analysis (NMA) informed the efficacy of the comparators. Resource use and drug costs were obtained from published studies and databases of drug retail prices in Sweden. A willingness-to-pay threshold of €50,000 per quality-adjusted life year (QALY) was applied.

RESULTS

In bDMARD-naïve patients, bimekizumab achieved greater QALYs (14.08) than with all comparators except infliximab (14.22), dominated guselkumab every 4 and 8 weeks, ixekizumab, secukinumab 300 mg, ustekinumab 45 mg and 90 mg, and was cost-effective against risankizumab, tofacitinib, upadacitinib and TNFis, except adalimumab biosimilar. In TNFi-experienced patients, bimekizumab led to greater QALYs (13.56) than all comparators except certolizumab pegol (13.84), and dominated ixekizumab and secukinumab 300 mg while being cost-effective against all other IL-17A-, IL-23- and JAK inhibitors.

LIMITATIONS

An NMA informed the comparative effectiveness estimates. Given gaps in evidence of disease management and indirect costs specific to HAQ-DI scores, and sequential clinical trial evidence in PsA, non-PsA cost data from similar joint conditions were used, and one line of active treatment followed by best supportive care was assumed.

CONCLUSIONS

Bimekizumab was cost-effective against most available treatments for PsA in Sweden, irrespective of prior TNFi exposure.

Elevated fecal levels of the inflammatory biomarker calprotectin in early systemic sclerosis

Knowledge on gastrointestinal manifestations in early systemic sclerosis (SSc) is limited. We have investigated gastrointestinal inflammation in SSc at the time of diagnosis using the inflammatory biomarker Fecal calprotectin (F-cal). Consecutive patients with suspected SSc were characterized in relation to the 2013 classification criteria for SSc and classified as SSc or SSc-like disease. F-cal levels were measured with a polyclonal ELISA (Calpro A/S, Lysaker, Norway) and levels above 50 µg/g were considered elevated. F-cal levels were compared to those of control subjects without rheumatic disease. Of 137 patients with suspected SSc, 92 were classified as SSc and 45 as SSc-like disease. Median (interquartile range) disease duration among the SSc participants was 2.5 (1.2, 4.6) years. A substantial proportion of participants classified as SSc (35/92, 38%) and SSc-like disease (14/45, 31%) exhibited elevated F-cal compared to the control group (3/41, 7.3%; p < 0.001 and p = 0.007, respectively). Elevated F-cal was associated with proton pump inhibitor usage (OR 7.14; 95% CI 2.56-29.93; p < 0.001). We conclude that elevated F-cal is present in a subgroup of patients with SSc at the time of diagnosis, suggesting that that GI inflammation may be present in this patient group early in the disease course. F-cal did not exhibit potential to differentiate SSc from SSc-like disease.

How good is the agreement between clinical diagnoses and classification criteria fulfilment in axial spondyloarthritis? Results from the SPARTAKUS cohort

OBJECTIVES

To study the agreement between clinical axial spondyloarthritis (axSpA) diagnoses and fulfilment of the Assessment of SpondyloArthritis international Society (ASAS) axSpA and modified New York (mNY) classification criteria, and to compare disease/health status between axSpA subtypes.

METHOD

Patients with prevalent, clinical axSpA attending a rheumatology clinic were enrolled in a cross-sectional study. Assessments included physical evaluation, laboratory testing, questionnaires, and appropriate imaging, allowing classification. Standard axSpA outcome measures were compared between patients fulfilling mNY/radiographic versus non-radiographic axSpA (r-axSpA/nr-axSpA) criteria.

RESULTS

Of 239 consecutively included patients, 141 fulfilled ASAS r-axSpA and/or mNY criteria, while 57 fulfilled nr-axSpA criteria. The agreement between r-axSpA and mNY criteria fulfilment was 94%. The positive predictive value (PPV) of a clinical ankylosing spondylitis (AS) diagnosis for mNY criteria fulfilment was 71%; the PPV of an undifferentiated axSpA (u-axSpA) diagnosis for fulfilment of nr-axSpA criteria was 30% and 40% for mNY criteria. Patients with r-axSpA/AS were older, more often men, and had longer disease duration, more uveitis, and worse spinal mobility than nr-axSpA patients, who had more enthesitis and dactylitis.

CONCLUSION

We found an overall good concordance between clinical axSpA diagnoses and classification criteria fulfilment, with 83% fulfilling ASAS axSpA and/or mNY criteria. Regarding axSpA subtypes, the concordance was weaker, and although the ICD-10 code for AS correctly identified patients meeting mNY criteria in 71% of cases, one-third of mNY-positive patients lacked an AS diagnosis. Moreover, clinical u-axSpA diagnoses could not serve as a proxy to identify nr-axSpA, highlighting the importance of thorough classification in research on axSpA subtypes.

OP0302 IS INCREASED RISK OF UROLITHIASIS IN AXIAL SPONDYLOARTHRITIS DRIVEN BY GUT INFLAMMATION? RESULTS FROM THE SPARTAKUS COHORT

Background

A nationwide, Swedish study found a doubled urolithiasis risk in ankylosing spondylitis (AS) compared to population controls.[1] Inflammatory bowel disease (IBD) is a known risk factor for urolithiasis, e.g. via enteric hyperoxaluria causing calcium oxalate stones.[2] With microscopic gut inflammation in around 50% of axial spondyloarthritis (axSpA) patients,[3] and overt IBD in 5-10%, gut inflammation may also drive the increased urolithiasis risk in axSpA.

Objectives

To study whether axSpA patients with a history of urolithiasis have an increased prevalence of comorbid IBD or display elevated biomarkers of gut inflammation/pathology.

Methods

AxSpA patients in the population-based SPARTAKUS cohort study in southern Sweden (non-radiographic axSpA [nr-axSpA] n=86, ASAS criteria; AS n=168, modified New York criteria) self-reported their history of prior urolithiasis (no/yes). Faecal (F) calprotectin and ASCA (anti-Saccharomyces cerevisiae antibodies) in serum were measured by commercially available ELISAs (Calpro AS; ORGENTEC Diagnostika). For a subgroup of patients (n=164), presence of gut dysbiosis was also assessed by the GA-Map Dysbiosis Test (Genetic Analysis). Demographics, disease/treatment characteristics, comorbid IBD and the gastrointestinal biomarkers (F-calprotectin/ASCA/dysbiosis) were compared between patients with versus without prior urolithiasis. Finally, the same biomarkers were also compared between patients with versus without urolithiasis history, after exclusion of subjects with known IBD.

Results

Urolithiasis history was reported by 13% (n=33) of the axSpA patients, and comorbid IBD was significantly more common in this group (27% versus 6.8%, p<0.001; Table 1). F-calprotectin levels were also significantly higher among patients with prior urolithiasis, as was presence of gut dysbiosis (Table 1). ASCA seropositivity did not differ between the groups. Moreover, prior urolithiasis was associated with longer disease duration and AS-phenotype. After exclusion of cases with comorbid IBD, urolithiasis history was reported by 10% (24 of 230 patients). F-calprotectin elevation ≥100 mg/kg remained significantly associated with urolithiasis history also in this population, while only being numerically increased when assessed as a continuous variable (p=0.053; Figure 1). Gut dysbiosis also remained associated with prior urolithiasis in the non-IBD population (56% [9 of 16 patients with prior urolithiasis] versus 30% [40 of 132 patients without], p=0.037), whereas ASCA status did not differ between the groups (data not shown).

Table 1.Urolithiasis historyNo, n=221Yes, n=33Male sex115 (52%)23 (70%)Age, years50 (13)59 (12)*Disease duration, years25 (14)31 (14)*AS (versus nr-axSpA)141 (64%)27 (82%)*Inflammatory bowel disease15 (6.8%)9 (27%)*ASAS 3-month NSAID score31 (40)37 (48)Ongoing bDMARD therapy87 (39%)16 (49%)bDMARD therapy ever113 (51%)20 (61%)ASDAS-CRP1.8 (1.0)1.9 (0.8)BASFI2.0 (2.1)2.7 (2.6)BASMI2.9 (1.5)4.3 (2.1)*F-Calprotectin, mg/kg*# Mean (SD)58 (97)115 (176) Median (IQR)29 (49)39 (152)F-Calprotectin ≥100 mg/kg28 (14%)10 (32%)*ASCA IgA ≥10 U/ml12 (5.7%)4 (13%)ASCA IgG ≥10 U/ml45 (21%)10 (33%)Gut dysbiosis†45 (32%)17 (71%)*

Mean (SD) or n (%) if not otherwise stated. † GA-Map Dysbiosis Test, dysbiosis index ≥3. * p<0.05 by Chi2-test or Student t-test, as appropriate. # Log10-transformed values compared. Missing ≤13%, except for gut dysbiosis available in 140/24 patients without/with urolithiasis history.

Conclusion

The current results lend support to the hypothesis that the increased urolithiasis risk in axSpA may be driven by gut inflammation/pathology. Prospective studies are, however, needed to assess the causality.

References

[1]Jakobsen AK, et al. PLoS One. 2014;9:e113602.

[2]Corica D, et al. J Crohns Colitis. 2016;10:226-35.

[3]Van Praet L, et al. Ann Rheum Dis. 2013;72:414-7.

Disclosure of Interests

Johan K Wallman Consultant of: AbbVie, Amgen, Celgene, Eli Lilly, Novartis, Grant/research support from: AbbVie, Amgen, Eli Lilly, Novartis, Pfizer, Elisabeth Mogard Consultant of: Novartis, Jonas Sagard: None declared, Lars Erik Kristensen Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen Pharmaceuticals, Merck Sharp & Dohme, Novartis, Pfizer, UCB Pharma, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen Pharmaceuticals, Merck Sharp & Dohme, Novartis, Pfizer, UCB Pharma, Elisabet Lindqvist: None declared, Tor Olofsson Consultant of: Eli Lilly, Merck Sharp & Dohme

AB0662 Elevated fecal calprotectin in early systemic sclerosis

Background

Gastrointestinal (GI) morbidity is prevalent in systemic sclerosis (SSc), causing a reduction in quality of life and increased mortality, but has been difficult to assess objectively [1]. Elevated levels of fecal calprotectin (F-cal), a biomarker of GI inflammation, has previously been observed in patients with SSc [2]. F-cal has not been explored in early SSc and its diagnostic potential in the classification of SSc has not been studied.

Objectives

Our objectives were; 1) study F-cal levels in early SSc; 2) investigate the discriminatory power of F-cal; 3) explore F-cal in relation to GI features of SSc.

Methods

Consecutive referred patients with suspected new-onset SSc without concurrent non-SSc GI disease were invited to this study. Patients were classified as SSc if meeting ACR-EULAR criteria, or SSc mimickers if they did not. GI symptoms and use of NSAID or PPI was noted. F-cal was measured and levels >50ug/g were classified as elevated. F-cal was also measured in age- and sex matched controls without rheumatological disease.

Results

Of 137 patients, 92 were classified as SSc and 45 as SSc mimickers. Elevated F-cal was significantly more common in SSc patients compared to the control group (38% vs 7.3%; p < 0.001) but not compared to the SSc mimicker patients (38% vs 31%; p = 0.427). The median F-cal level was higher in SSc patients compared to controls (35 µg/g vs ≤30 µg/g; p ≤ 0.001) but not compared to the SSc mimicker patients (35 µg/g vs ≤30 µg/g; p = 0.248). Elevated F-cal was not associated with any GI symptoms. Elevated F-cal was more common in patients who used PPI (OR 7.14; 95% CI 2.56-29.93; p < 0.001).

Conclusion

In this study, we demonstrate that elevated levels of F-cal are prevalent already in the early stages of SSc. These results are in line with previous data suggesting that GI involvement may be present in early SSc.

Table 1.

Frequency of GI features and association to F-cal elevation (n = 92)

GI features (n, %)Normal F-cal, n = 57Elevated F-cal, n = 35Odds Ratio (95% CI)Dysphagia19 (35%)12 (34%)0.99 (0.41-2.41)Reflux symptoms33 (59%)23 (68%)1.46 (0.60-3.56)Fecal incontinence9 (16%)3 (8.6%)0.50 (0.08-2.22)Patient-reported involuntary weightloss11 (20%)8 (23%)1.21 (0.43-3.39)Dilated esophagus on HRCT8 (16%)8 (28%)1.95 (0.64-5.94)NSAID use12 (21%)6 (17%)0.78 (0.26-2.30)PPI use23 (40%)29 (83%)7.14 (2.56-19.93)Figure 1.

F-cal measurements by group. Median value represented by horizontal bar.

References

[1]Frantz C et al. Impaired quality of life in systemic sclerosis and patient perception of the disease: A large international survey. Semin Arthritis Rheum 2016;46:115-23.

[2]Marie I et al. Fecal calprotectin in systemic sclerosis and review of the literature. Autoimmun Rev 2015;14:547-54.

Acknowledgements

This study was funded by the Anna-Greta Crafoord Foundation, the Swedish Rheumatism Association, Stiftelsen Ulla och Roland Gustafssons Donationsfond.

Disclosure of Interests

Viggo Hamberg: None declared, Johan K Wallman Consultant of: Consultant of AbbVie, Amgen, Celgene, Eli Lilly, Novartis., Grant/research support from: Research support from AbbVie, Amgen, Eli Lilly, Novartis, Pfizer., Elisabeth Mogard Consultant of: Consultant of Novartis, Elisabet Lindqvist: None declared, Tor Olofsson Consultant of: has performed consulting tasks for Merck Sharp & Dohme and for Eli Lilly, Kristofer Andréasson: None declared

POS0547 THE ADVANTAGE OF TIGHT CONTROL AND TREAT TO TARGET IN NEW-ONSET RA PATIENTS IN DAILY RHEUMATOLOGY PRACTICE: RESULTS FROM A CONTEMPORARY UNIVERSITY CLINIC INCEPTION COHORT

Background

Since 2018, all patients with new-onset rheumatoid arthritis (RA) at the Department of Rheumatology, Skane University Hospital, Lund, Sweden, are offered to participate in a ”tight control” and ”treat to target” (TC+T2T) follow-up strategy. This strategy includes regular follow-up visits to a rheumatologist (at diagnosis and 3, 6, 12, 18, 24 months) plus physical/telephone consultations with a rheumatology nurse between physician visits, both with disease activity assessments and, if needed, adjustment/intensification of anti-rheumatic treatment aiming for remission.

Objectives

To explore the possible advantages of integrating this TC+T2T strategy over routine care, aiming more systematically for remission (DAS28<2,6 or CDAI≤2,8), in clinical practice of new-onset RA.

Methods

Patients followed by the TC+T2T strategy were compared to new-onset RA patients followed according to routine care at the same department and during the same period. Data on disease and treatment characteristics, as well as outcome measures during follow-up were retrieved from the Swedish Rheumatology Quality register (SRQ). In total, 156 patients with at least 3 months follow-up between 2018 and 2021 were included; 95 followed according to the TC+T2T strategy and 61 according to routine care. Percentage females/mean age at onset/mean symptom duration at diagnosis were 79%/57 years/4 months (TC+T2T) and 62%/62 years/7 months (routine care). The change in DAS28 and CDAI from baseline to 12 months follow-up were compared between the two strategies by linear regression analyses, adjusted for sex, age, symptom duration, and DAS28 or CDAI, respectively, at baseline. In addition, changes in patient-reported outcomes (fatigue, pain and HAQ) are calculated.

Results

Disease and treatment characteristics at inclusion (diagnosis) are summarized in the Table 1.

Table 1.TC+T2T group (n=95)Controls (n=61)Swollen 28 joint count,6,6 (4)5,1 (5)Tender 28 join count8,2 (5)6,2 (6)ESR48,1 (29)37,7 (25)CRP21,3 (29)16,9 (23)DAS285,5 (1)4,6 (1)CDAI24,5 (11)18,3 (11)HAQ1,01 (0,6)0,98 (0,7)Fatigue (VAS)50,1 (29)46,6 (30)Pain (VAS)57,9 (24)47,3(30)ACPA positive (%)77%53%Radiographic changes in hands or feet at inclusion (%)12%18%Smoker (%)16%7%Methotrexate started at inclusion (%)78%85 %Prednisolone started at inclusion (%)100%97%

Mean and standard deviation (SD) if not otherwise stated.

The TC+T2T strategy resulted in greater improvements in DAS28 and CDAI scores from inclusion to 12 months follow up (p=0,025 and p=0,026; respectively; Figure 1). Beyond improvements in DAS28 and CDAI, a significant decrease in patient-reported outcomes (fatigue and pain) during 12 months from diagnosis was observed (Figure 1).

Conclusion

Compared to routine rheumatology practice, the implementation of a ”tight control” and ”treat to target” strategy resulted in a greater improvement in disease activity and an early and sustained improvement in patient-reported outcomes. Our results suggest that this type of strategy should be integrated into daily clinical practice of new-onset RA.

Disclosure of Interests

Jon Thorkell Einarsson: None declared, Katarina Friberger Pajalic: None declared, Caroline Bengtsson: None declared, Elisabeth Mogard: None declared, Elisabet Lindqvist: None declared, Carmen Roseman: None declared, Olafur Palsson: None declared, Johan K Wallman Consultant of: Consultant of AbbVie, Amgen, Celgene, Eli Lilly, Novartis, Grant/research support from: Research support from AbbVie, Amgen, Eli Lilly, Novartis, Pfizer.

Tor Olofsson Consultant of: consultant of MSD, Meliha C Kapetanovic Consultant of: Abbvie, Pfizer, GSK, Grant/research support from: unrestricted grants from Pfizer and Roche.

POS0983 LIFESTYLE IN AXIAL SPONDYLOARTHRITIS - COMPARISONS BETWEEN PATIENTS AND CONTROLS, AXIAL SPONDYLOARTHRITIS SUBTYPES, MALE AND FEMALE PATIENTS, AND ITS ASSOCIATION WITH DISEASE AND HEALTH OUTCOMES. RESULTS FROM THE SPARTAKUS COHORT

Background

Healthy lifestyle behaviours are associated with better health outcomes and quality of life in the general population (1, 2). In patients with axial spondyloarthritis (axSpA), however, little is known regarding multiple lifestyle behaviours and their associations with disease and health outcomes.

Objectives

To study lifestyle behaviours in patients with axSpA in relation to healthy controls, between axSpA subtypes and male and female patients, respectively, and to assess how the presence of two or more unhealthy lifestyle factors associate with disease and health outcomes.

Methods

We performed a cross-sectional study of 250 well-characterized axSpA patients (167 with radiographic axSpA [r-axSpA; ASAS and/or modified New York criteria], 83 with non-radiographic axSpA [nr-axSpA; ASAS criteria]) and 48 controls (frequency-matched to the patients for age and sex), participating in the population-based SPARTAKUS study in southern Sweden. Self-reported data on smoking, alcohol use, physical activity, dietary habits, and objectively measured body mass index (BMI), respectively, for all subjects was categorized as fulfilling national recommendations or not (healthy/unhealthy), and summarized in an index (0-5, indicating the number of unhealthy lifestyle factors). The index was also dichotomized into 0-1 vs. 2-5 unhealthy lifestyle factors. Comparisons between patients and controls, axSpA subtypes (r-axSpA vs. nr-axSpA), and between male and female patients were performed by Student’s t-test/Chi-square test, as appropriate. Linear regression analyses were used to explore associations between having ≥2 unhealthy lifestyle factors (yes/no) and disease and health outcomes.

Results

Characteristics and lifestyle factors for axSpA patients and controls are presented in the Table 1. Reporting ≥2 unhealthy lifestyle factors was more common in axSpA patients than controls (35% vs. 19%, p=0.029), while no difference was found between the axSpA subtypes (Figure 1 a and b). Male patients more often reported several unhealthy lifestyle factors than female patients (Figure 1 c), with more frequent unhealthy alcohol use (19% vs. 9%, p=0.023) and overweight/obesity; BMI ≥25 (63% vs. 50%, p=0.043), while smoking, physical activity, and dietary habits were similar. In addition, older patients displayed more unhealthy lifestyle factors (Figure 1 d). Having ≥2 unhealthy lifestyle factors was associated with worse disease activity (ASDAS-CRP) (β-est [95% CI]) (0.34 [0.11: 0.58]), physical function (BASFI) (0.73 [0.18; 1.28]), pain (1.03 [0.39; 1.67]), fatigue (0.95 [0.24; 1.66]), and quality of life (EQ-5D) (-0.09 [-0.15; -0.02]) in axSpA patients, adjusted for age, sex, and axSpA subtype (all p≤0.010)

Table 1.

Characteristics and lifestyle factors

r-axSpA/nr-axSpA combined n = 250Controls n =48Female sex116 (46%)24 (48%)Age, years51 (13)51 (14)Symptom duration, years7.7 (7.6)N/AASDAS-CRP1.8 (0.9)N/ABASFI2.0 (2.2)N/ABASMI3.0 (1.6)N/ANRS patients’ global health3.1 (2.5)1.1 (1.1)*NRS pain3.1 (2.5)1.5 (1.6)*NRS fatigue3.5 (2.8)2.2 (2.0)*EQ-5D utility0.72 (0.24)0.90 (0.12)*Ongoing csDMARD54 (22%)N/AOngoing bDMARD103 (41%)N/AOngoing glucocorticoids18 (7%)N/ASmoking, not fulfil rec.31 (12%)2 (4%)Alcohol, not fulfil rec.35 (14%)5 (10%)Physical activity, not fulfil rec.72 (29%)8 (17%)Dietary habits, not fulfil rec.35 (14%)5 (10%)BMI, not fulfil rec.142 (57%)15 (31%)*

Mean (SD) or n (%). * p<0.05 by Chi2-test or Student t-test, as appropriate. Missing data: ≤ 2%.

Conclusion

Unhealthy lifestyle behaviours were more common in axSpA patients than controls, and in male axSpA patients compared to females. Having two or more unhealthy lifestyle factors was associated with worse disease activity, physical function, pain, fatigue, and quality of life in the axSpA patients.

References

[1]Aleksandrova K, et al. BMC Medicine. 2014;12:168

[2]Lacombe J, et al. BMC Public Health. 2019;19:900

Disclosure of Interests

Elisabeth Mogard Consultant of: Novartis, Tor Olofsson Consultant of: Eli Lilly, Merck Sharp & Dohme, Ann Bremander: None declared, Jonas Sagard: None declared, Johan K Wallman Consultant of: AbbVie, Amgen, Celgene, Eli Lilly, Novartis, Grant/research support from: AbbVie, Amgen, Eli Lilly, Novartis, Pfizer, Elisabet Lindqvist: None declared

POS0073 COMPARISON OF TIME FROM METHOTREXATE INITIATION TO START OF A b/tsDMARD IN PSORIATIC ARTHRITIS VERSUS RHEUMATOID ARTHRITIS. A NATIONWIDE REGISTER-BASED STUDY

Background

In Sweden, methotrexate (MTX) is recommended as first-line DMARD for both psoriatic arthritis (PsA) and rheumatoid arthritis (RA). Whereas in RA the use of MTX monotherapy is supported by efficacy data from randomized trials, in PsA no clear efficacy has been demonstrated in placebo-controlled trials. Therefore, the use of MTX in PsA is mostly based on clinical experience and results from studies not primarily designed to evaluate MTX efficacy.

Objectives

To compare time from MTX initiation until start of a biological or targeted synthetic DMARD (b/tsDMARD), as marker of insufficient MTX response, in previously DMARD-naïve, incident cases with PsA and matched, corresponding, reference subjects with RA.

Methods

Patients with PsA, having collected a prescription of MTX as their first ever DMARD any time between 2011 through 2018, and with a first ever PsA diagnosis in the Swedish National Patient Register within two years prior to this date, were included. Each individual was required to have a visit in rheumatology, but no visit in dermatology, within 6 weeks prior to MTX initiation, to ensure that PsA rather than psoriasis was the main reason for MTX treatment. For each individual with PsA, a corresponding individual with incident RA was identified, matched on sex, age, and year of MTX initiation. Only PsA cases with an identified RA comparator were included. All individuals with a diagnosis indicating axial spondyloarthritis prior to MTX start were excluded. The data were enriched through linkage to other national registers.

Follow-up was defined as the time from MTX initiation until start of any b/tsDMARD. Censoring was performed at the first of death, migration or 31 Dec 2020. Time until start of a b/tsDMARD was compared for PsA and RA through crude survival curves and conditional Cox-regression, crude and adjusted for comorbidity, level of education and patient global health.

Results

3098 patients with PsA, and their individually matched RA comparators were included. At initiation of MTX, PsA cases had a mean 28-joint disease activity score (DAS28) of 4.0 and RA-controls of 4.6, while patient-reported global health was 51 (of 100) for both groups and number of swollen joints (28-joint count) 4.0 for PsA and 6.8 for RA, Table 1. The comorbidity burden was similar at baseline.

Table 1.

Characteristics of PsA cases and matched RA controls at start of MTX.

Psoriatic arthritis N=3098Rheumatoid arthritis N=3098Age, mean (sd)55 (14)55 (14)Sex, male49%49%Length of education, yrs <1020%24% 10-1251%49% >1228%26%Diabetes1, 27.4%6.7%Myocardial infarction11.3%1.8%Malignancy14.7%5.0%Congestive heart disease10.2%0.2%Chronic lung disease11.6%2.2%Use of anti-depressive drugs1, 315.4%11.4%DAS28-CRP, mean (sd)44.0 (1.1)4.6 (1.2)Patient global, mean (sd) 451 (23)51 (23)CRP, median (IQR) 47 (14)10 (21)Tender joint count (28), mean (sd) 45.2 (4.9)7.0 (5.7)Swollen joint count (28), mean (sd) 44.0 (4.1)6.8 (5.2)

1) Diagnosis within 5 years. 2) Also identified by collecting ≥1 prescription of anti-diabetics in 1 year. 3) Identified by collecting ≥1 prescription within 1 year before methotrexate start. 4) Data on disease activity variables available for 28-36% of PsA and 56-62% of RA.

During a mean follow-up of 4.5 and 4.4 years, 34% and 33% of PsA and RA patients, respectively, started a b/tsDMARD, of whom 63% and 84% had also used ≥1 non-MTX conventional synthetic DMARD before the b/tsDMARD initiation. The crude survival curves for time from MTX initiation until start of a b/tsDMARD were identical for PsA and RA, Figure 1A. The adjusted HR for starting a b/tsDMARD in PsA compared with RA was 0.99 (95% CI 0.90-1.09). No calendar time trends were observed (Figure 1B and C).

Conclusion

In this study, the risk of escalating treatment from MTX, by adding or switching to a b/tsDMARD, was identical in PsA cases and matched RA controls. This supports a good response to MTX in PsA, similar to that in RA. Due to the matching, neither the results from the PsA nor the RA populations may be fully generalizable.

Disclosure of Interests

Ulf Lindström: None declared, Daniela Di Giuseppe: None declared, Sofia Exarchou Consultant of: AbbVie, Amgen, Janssen, Novartis, Grant/research support from: AbbVie, Amgen, Eli Lilly, Novartis, Pfizer, Gerd-Marie Alenius: None declared, Tor Olofsson Consultant of: Merck Sharp & Dohme, Eva Klingberg: None declared, Lennart T.H. Jacobsson Speakers bureau: Janssen, Eli Lilly, Novartis, Consultant of: Janssen, Eli Lilly, Novartis, Johan Askling Grant/research support from: Abbvie, Astra-Zeneca, BMS, Eli Lilly, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB., Johan K Wallman Consultant of: AbbVie, Amgen, Celgene, Eli Lilly, Novartis, Grant/research support from: AbbVie, Amgen, Eli Lilly, Novartis, Pfizer

OP0249 CHARACTERISTICS ASSOCIATED WITH POOR COVID-19 OUTCOMES IN PEOPLE WITH PSORIASIS AND SPONDYLOARTHRITIS: DATA FROM THE COVID-19 PsoProtect AND GLOBAL RHEUMATOLOGY ALLIANCE PHYSICIAN-REPORTED REGISTRIES

Background

Some factors associated with severe COVID-19 outcomes have been identified in patients with psoriasis (PsO) and inflammatory/autoimmune rheumatic diseases, namely older age, male sex, comorbidity burden, higher disease activity, and certain medications such as rituximab. However, information about specificities of patients with PsO, psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), including disease modifying anti-rheumatic drugs (DMARDs) specifically licensed for these conditions, such as IL-17 inhibitors (IL-17i), IL-23/IL-12 + 23 inhibitors (IL-23/IL-12 + 23i), and apremilast, is lacking.

Objectives

To determine characteristics associated with severe COVID-19 outcomes in people with PsO, PsA and axSpA.

Methods

This study was a pooled analysis of data from two physician-reported registries: the Psoriasis Patient Registry for Outcomes, Therapy and Epidemiology of COVID-19 Infection (PsoProtect), comprising patients with PsO/PsA, and the COVID-19 Global Rheumatology Alliance (GRA) registry, comprising patients with PsA/axSpA. Data from the beginning of the pandemic up to 25 October, 2021 were included. An ordinal severity outcome was defined as: 1) not hospitalised, 2) hospitalised without death, and 3) death. A multivariable ordinal logistic regression model was constructed to assess the relationship between COVID-19 severity and demographic characteristics (age, sex, time period of infection), comorbidities (hypertension, other cardiovascular disease [CVD], chronic obstructive lung disease [COPD], asthma, other chronic lung disease, chronic kidney disease, cancer, smoking, obesity, diabetes mellitus [DM]), rheumatic/skin disease (PsO, PsA, axSpA), physician-reported disease activity, and medication exposure (methotrexate, leflunomide, sulfasalazine, TNFi, IL17i, IL-23/IL-12 + 23i, Janus kinase inhibitors (JAKi), apremilast, glucocorticoids [GC] and NSAIDs). Age-adjustment was performed employing four-knot restricted cubic splines. Country-adjustment was performed using random effects.

Results

A total of 5008 individuals with PsO (n=921), PsA (n=2263) and axSpA (n=1824) were included. Mean age was 50 years (SD 13.5) and 51.8% were male. Hospitalisation (without death) was observed in 14.6% of cases and 1.8% died. In the multivariable model, the following variables were associated with severe COVID-19 outcomes: older age (Figure 1), male sex (OR 1.53, 95%CI 1.29-1.82), CVD (hypertension alone: 1.26, 1.02-1.56; other CVD alone: 1.89, 1.22-2.94; vs no hypertension and no other CVD), COPD or asthma (1.75, 1.32-2.32), other lung disease (2.56, 1.66-3.97), chronic kidney disease (2.32, 1.50-3.59), obesity and DM (obesity alone: 1.36, 1.07-1.71; DM alone: 1.85, 1.39-2.47; obesity and DM: 1.89, 1.34-2.67; vs no obesity and no DM), higher disease activity and GC intake (remission/low disease activity and GC intake: 1.96, 1.36-2.82; moderate/severe disease activity and no GC intake: 1.35, 1.05-1.72; moderate/severe disease activity and GC intake 2.30, 1.41-3.74; vs remission/low disease activity and no GC intake). Conversely, the following variables were associated with less severe COVID-19 outcomes: time period after 15 June 2020 (16 June 2020-31 December 2020: 0.42, 0.34-0.51; 1 January 2021 onwards: 0.52, 0.41-0.67; vs time period until 15 June 2020), a diagnosis of PsO (without arthritis) (0.49, 0.37-0.65; vs PsA), and exposure to TNFi (0.58, 0.45-0.75; vs no DMARDs), IL17i (0.63, 0.45-0.88; vs no DMARDs), IL-23/IL-12 + 23i (0.68, 0.46-0.997; vs no DMARDs) and NSAIDs (0.77, 0.60-0.98; vs no NSAIDs).

Conclusion

More severe COVID-19 outcomes in PsO, PsA and axSpA are largely driven by demographic factors (age, sex), comorbidities, and active disease. None of the DMARDs typically used in PsO, PsA and axSpA, were associated with severe COVID-19 outcomes, including IL-17i, IL-23/IL-12 + 23i, JAKi and apremilast.

Acknowledgements

We thank all the contributors to the COVID-19 PsoProtect, GRA and EULAR Registries.

Disclosure of Interests

None declared

Gut dysbiosis associated with worse disease activity and physical function in axial spondyloarthritis

Background

Based on clinical and genetic associations, axial spondyloarthritis (axSpA) and inflammatory bowel disease (IBD) are suspected to have a linked pathogenesis. Gut dysbiosis, intrinsic to IBD, has also been observed in axSpA. It is, however, not established to what degree gut dysbiosis is associated with axSpA disease severity.

The objective of this study was to compare gut dysbiosis frequency between controls, non-radiographic axial spondyloarthritis (nr-axSpA), and ankylosing spondylitis (AS) patients and investigate whether gut dysbiosis is cross-sectionally associated with axSpA disease activity, physical function, mobility, or pain.

Methods

Gut dysbiosis was assessed by 16SrRNA analysis of feces from 44/88 nr-axSpA/AS patients (ASAS/mNY criteria) without inflammatory bowel disease (IBD) and 46 controls without IBD or rheumatic disease. The GA-map™ Dysbiosis Test was used, grading gut microbiota aberrations on a 1-5 scale, where ≥3 denotes dysbiosis. Proportions with dysbiosis were compared between the groups. Furthermore, standard axSpA measures of disease activity, function, mobility, and pain were compared between patients (nr-axSpA and AS combined) with and without dysbiosis, univariately, and adjusted for relevant confounders (ANCOVA).

Results

Gut dysbiosis was more frequent in AS than controls (36% versus 17%, p=0.023), while nr-axSpA (25% dysbiosis) did not differ significantly from either AS or controls. Univariately, most axSpA measures were significantly worse in patients with dysbiosis versus those without: ASDAS-CRP between-group difference 0.6 (95% CI 0.2–0.9); BASDAI 1.6 (0.8–2.4); evaluator’s global disease activity assessment (Likert scale 0–4) 0.3 (0.1–0.5), BASFI 1.5 (0.6–2.4), and VAS pain (cm) 1.3 (0.4–2.2). Differences remained significant after adjustment for demographics, lifestyle factors, treatments, gut inflammation (fecal calprotectin ≥50 mg/kg), and gut symptoms, except for VAS pain. BASMI and CRP were not associated with dysbiosis.

Conclusion

Gut dysbiosis, more frequent in AS patients than controls, is associated with worse axSpA disease activity and physical function, seemingly irrespective of both gut inflammation and treatments. This provides further evidence for an important link between disturbances in gastrointestinal homeostasis and axSpA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02733-w.

Pain Over Two Years After Start of Biologic Versus Conventional Combination Treatment in Early Rheumatoid Arthritis: Results From a Swedish Randomized Controlled Trial

OBJECTIVE

To compare the pain course between methotrexate (MTX)-refractory early rheumatoid arthritis (RA) patients randomized to infliximab (IFX) versus sulfasalazine (SSZ) plus hydroxychloroquine (HCQ).

METHODS

The randomized, controlled, open-label Swedish Pharmacotherapy (SWEFOT) trial enrolled new-onset RA patients from October 2002 to December 2005. After 3 months of receiving MTX, patients not reaching low disease activity (Disease Activity Score in 28 joints score ≤3.2) were randomized to adding IFX (n = 128) or SSZ plus HCQ (n = 130) and followed for 21 months. Here, outcomes included area under the curve (AUC) for visual analog scale (VAS) scores for pain, unacceptable pain (VAS pain score >40 mm [range 0-100]), and unacceptable pain despite inflammation control (refractory pain; VAS pain score >40 plus C-reactive protein level <10 mg/liter). Between-group differences were analyzed with multivariate regression models.

RESULTS

Overall, 50% of randomized patients (n = 258) in the crude setting reported unacceptable pain at randomization, declining to 29% at 21 months (P < 0.001), when refractory pain constituted 82% of all unacceptable pain. Comparing randomized arms (intent-to-treat analysis), the AUC for VAS pain was lower in the MTX plus IFX group (P = 0.01), and at 21 months, 32% of patients receiving MTX plus IFX and 45% receiving MTX plus SSZ plus HCQ had unacceptable pain (adjusted relative risk 0.68 [95% confidence interval 0.51, 0.90]; P = 0.008). Regarding refractory pain, no between-group differences were observed.

CONCLUSION

Despite active combination treatment, almost one-third of new-onset RA patients reported unacceptable pain after 21 months, and refractory pain constituted more than 4/5 of this pain load. Adding IFX versus SSZ plus HCQ to MTX reduced both cumulative pain and unacceptable pain at 21 months, suggesting less long-term pain for the biologic therapy. These results display insufficient effects of current treatment strategies on inflammation-independent pain components, warranting alternative approaches in affected patients.

Anterior uveitis in patients with spondyloarthritis treated with secukinumab or tumour necrosis factor inhibitors in routine care: does the choice of biological therapy matter?

BACKGROUND

The effect of interleukin 17-inhibitors on anterior uveitis (AU) in spondyloarthritis (SpA) is poorly understood. This study aimed to compare the risk of AU during treatment with secukinumab versus tumour necrosis factor inhibitors (TNFi).

METHODS

Patients with SpA starting secukinumab or a TNFi 2015 through 2018 were identified in the Swedish Rheumatology Quality Register. Occurrence of AU was identified based on diagnosis codes in outpatient ophthalmology care in the National Patient Register. The main outcomes were crude rates of AU-diagnoses per 100 patient-years, and adjusted HRs for AU, during treatment, in patients without AU during the year before treatment start (in order to reduce confounding by indication). HRs were adjusted for age, sex, history of AU and patient global assessment of disease activity.

RESULTS

Based on 4851 treatment starts (456 secukinumab; 4395 any TNFi), the rate of AU-diagnoses per 100 patient-years was 6.8 (95% CI 5.2 to 8.7) for secukinumab. Among the TNFi, the rate varied from 2.9 (95% CI 2.1 to 3.7) for infliximab and 4.0 (95% CI 3.3 to 4.9) for adalimumab to 7.5 (95% CI 6.7 to 8.4) for etanercept. The adjusted HRs for first AU (adalimumab as reference) were: secukinumab 2.32 (95% CI 1.16 to 4.63), infliximab 0.99 (95% CI 0.49 to 1.96), etanercept 1.82 (95% CI 1.13 to 2.93), golimumab 1.59 (95% CI 0.90 to 2.80) and certolizumab 1.12 (95% CI 0.44 to 2.83). Sensitivity analyses confirmed the pattern of higher AU rates with secukinumab and etanercept versus monoclonal TNFi.

CONCLUSION

As used in clinical practice in SpA, secukinumab appears to be associated with a higher risk of AU, compared with the monoclonal TNFi and a similar risk compared with etanercept.

Predictors of unacceptable pain with and without low inflammation over 5 years in early rheumatoid arthritis-an inception cohort study

Objectives

Pain is a major symptom in patients with rheumatoid arthritis (RA). In early RA, pain is usually due to synovitis, but can also persist despite effective anti-inflammatory treatment. The objective of this study was to investigate the pain course over time and predictors of unacceptable pain and unacceptable pain with low inflammation, in patients with early RA.

Methods

An inception cohort of 232 patients with early RA, recruited in 1995–2005, was followed in a structured programme for 5 years. Pain was assessed using a visual analogue scale (VAS; 0–100). Unacceptable pain was defined as VAS pain > 40 based on the patient acceptable symptom state (PASS) and low inflammation as CRP < 10 mg/l. Baseline predictors of unacceptable pain were evaluated using logistic regression analysis.

Results

Pain improved significantly during the first 6 months, but then remained basically unchanged. Thirty-four per cent of the patients had unacceptable pain 5 years after inclusion. Baseline predictors of unacceptable pain after 5 years were lower swollen joint counts [odds ratio (OR) 0.71 per standard deviation (95% confidence interval (CI) 0.51–0.99)] and higher VAS for pain and global assessment of disease activity. Unacceptable pain with low inflammation after 5 years was negatively associated with anti-CCP antibodies [OR 0.50 (95% CI 0.22–0.98)].

Conclusion

Over one third of the patients had unacceptable pain 5 years after inclusion. Lower swollen joint count was associated with unacceptable pain at 5 years. The results may be explained by the positive effects of treatment on pain related to inflammation. Non-inflammatory long-lasting pain appears to be a greater problem in anti-CCP-negative patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-021-02550-7.

POS0237 GUT DYSBIOSIS LINKED TO WORSE DISEASE STATUS IN AXIAL SPONDYLOARTHRITIS

Background:

Based on clinical and genetic associations, axial spondyloarthritis (axSpA) and inflammatory bowel disease (IBD) are suspected to have a linked pathogenesis. Gut dysbiosis, intrinsic to IBD, has also been observed in axSpA. It is, however, not established to what degree gut dysbiosis is associated with axSpA disease severity.

Objectives:

To compare presence and degree of gut dysbiosis between axSpA patients and controls, and to explore whether gut dysbiosis is associated with axSpA disease activity, function and pain.

Methods:

The GA-map Dysbiosis Test (Genetic Analysis, Oslo, Norway) was used to identify and grade gut dysbiosis based on faecal samples from 44 non-radiographic axSpA (nr-axSpA; ASAS criteria) and 88 ankylosing spondylitis (AS; modified New York criteria) patients without IBD, consecutively enrolled in a population-based cohort study, and from 46 controls without rheumatic disease or IBD (frequency-matched to the patients for age/sex). The GA-map Dysbiosis Test is a validated method grading microbiota aberration on a 1-5 scale (Dysbiosis Index, DI), where ≥3 denotes dysbiosis. Analysis of covariance (ANCOVA) was used to compare DI between axSpA patients (nr-axSpA and AS combined) and controls, adjusted for age, sex, body mass index (BMI) and smoking. Within the axSpA group, disease activity (ASDAS-CRP; BASDAI), function (BASFI) and pain (VAS pain) were compared between patients with various DI levels by One-way analysis of variance (ANOVA) or Kruskal-Wallis test, as appropriate. Finally, axSpA patients were subdivided by presence of dysbiosis (DI ≥3 vs. <3) followed by comparison of ASDAS-CRP, BASDAI, BASFI, VAS pain and Evaluator´s global assessment of disease activity (EvalGlobal; 0-4: remission-maximal) by ANCOVA. Analyses were conducted unadjusted and adjusted for age, sex, BMI, smoking, axSpA subtype, gut inflammation (faecal calprotectin ≥50 mg/kg), irritable bowel syndrome symptoms (ROME III criteria), ASAS 3-month NSAID score and cs/bDMARD treatment.

Results:

Characteristics of the patients/controls are shown in the Table 1. Gut dysbiosis (DI≥3) was observed in 33% of axSpA patients and 17% of controls. DI was significantly higher among the patients (β-estimate [bootstrapped 95%CI] for the between-group difference: 0.34 [0.04-0.65]; p=0.027). In the axSpA group, higher DI was associated with worse scores in all assessed outcomes (Figure 1, panel A). Moreover, presence of dysbiosis (DI≥3) was associated with worse ASDAS-CRP, BASDAI, BASFI, VAS pain and EvalGlobal (Figure 1, panel B; EvalGlobal not shown in the Figure: unadjusted β [bootstrapped 95%CI]: 0.32 [0.09-0.55], adjusted: 0.28 [0.03-0.52] for patients with DI ≥3 vs. <3), with between-group differences remaining significant after adjustment, except for ASDAS-CRP (p=0.079) and VAS pain (p=0.064).

Table 1.All patients n=132Nr-axSpAn=44ASn=88Controlsn=46Male sex, n (%)72 (55)17 (39)55 (63)23 (50)Age, y53 (13)48 (12)55 (13)51 (14)Symptom duration, y26 (14)21 (11)28 (14)Body mass index, kg/m227 (4.3)27 (4.2)27 (4.3)25 (3.3)Smoking ever, n (%)43 (33)9 (20)34 (39)13 (28)CRP, mg/L3.7 (5.3)2.3 (2.4)4.3 (6.1)F-Calprotectin ≥50 mg/kg, n (%)46 (35)12 (27)34 (39)Evaluator´s global, 0-4, median (IQR)1 (0-1)1 (0-1)1 (0-1)ASDAS-CRP1.8 (0.9)1.9 (0.9)1.8 (0.9)BASDAI3.1 (2.2)3.3 (1.9)3.0 (2.4)BASFI2.0 (2.1)2.0 (1.7)2.1 (2.2)VAS pain, cm3.3 (2.5)3.4 (2.2)3.2 (2.7)IBS symptoms, n (%)43 (33)15 (34)28 (32)ASAS 3-month NSAID score37 (44)36 (44)37 (44)Ongoing csDMARD, n (%)24 (18)9 (20)15 (17)Ongoing bDMARD, n (%)56 (42)19 (43)37 (42)

Mean (SD) unless otherwise specified. y, years; IBS, irritable bowel syndrome

Conclusion:

Gut dysbiosis, present to a higher degree in axSpA patients than controls, is associated with worse axSpA disease activity and function. These associations appear independent of gut inflammation and both NSAID and immunomodulatory treatment. This provides further evidence for an important link between disturbances in gastrointestinal homeostasis and axSpA manifestations, and implies that gut dysbiosis may be a novel biomarker for severe disease.

Disclosure of Interests:

Jonas Sagard: None declared, Tor Olofsson Consultant of: Eli Lilly, Merck Sharp & Dohme, Elisabeth Mogard: None declared, Jan Marsal Consultant of: AbbVie, Bristol-Myers Squibb, EuroDiagnostica, Ferring, Hospira, Janssen-Cilag, Merck, Sharp & Dohme (MSD), Otsuka, Pfizer, Sandoz, Takeda, Tillotts, UCB Pharma, Grant/research support from: AbbVie, Ferring, and Pfizer, Kristofer Andréasson: None declared, Mats Geijer Speakers bureau: UCB Pharma, AbbVie, Novartis, Pfizer, Lars Erik Kristensen Speakers bureau: Pfizer, AbbVie, Amgen, UCB, Celegene, BMS, MSD, Novartis, Eli Lilly, Janssen pharmaceuticals, Consultant of: Pfizer, AbbVie, Amgen, UCB, Celegene, BMS, MSD, Novartis, Eli Lilly, Janssen pharmaceuticals, Elisabet Lindqvist: None declared, Johan K Wallman Consultant of: Celgene, Eli Lilly, Novartis

Chronic Pain and Assessment of Pain Sensitivity in Patients With Axial Spondyloarthritis: Results From the SPARTAKUS Cohort

OBJECTIVE

To study differences in pain reports between patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (nr-axSpA), and to assess how pain sensitivity measures associate with disease and health outcomes.

METHODS

Consecutive patients with axial SpA (axSpA) were enrolled in the population-based SPARTAKUS cohort (2015-2017) and classified as AS (n = 120) or nr-axSpA (n = 55). Pain was assessed with questionnaires (intensity/duration/distribution) and computerized cuff pressure algometry to measure pain sensitivity (pain threshold/pain tolerance/temporal summation of pain). Linear regression models were used to compare pain measures between patients with AS and nr-axSpA, and to assess associations between pain sensitivity measures and disease and health outcomes.

RESULTS

Of 175 patients with axSpA, 43% reported chronic widespread pain, with no significant differences in any questionnaire-derived or algometry-assessed pain measures between patients with AS and nr-axSpA. Lower pain tolerance was associated with longer symptom duration, worse Ankylosing Spondylitis Disease Activity Score using C-reactive protein (ASDAS-CRP), Bath Ankylosing Spondylitis Functional Index, and Bath Ankylosing Spondylitis Metrology Index (BASMI), more pain regions, unacceptable pain, worse Maastricht AS Enthesitis Score (MASES), fatigue, anxiety, and health-related quality of life. Further, lower pain threshold was associated with worse ASDAS-CRP and MASES, whereas higher temporal summation was associated with longer symptom duration, unacceptable pain, and worse BASMI.

CONCLUSION

Chronic pain is common in axSpA, with no observed differences in any pain measures between patients with AS and nr-axSpA. Further, higher pain sensitivity is associated with having worse disease and health outcomes. The results indicate that patients with AS and nr-axSpA, in line with most clinical characteristics, have a similar pain burden, and they highlight large unmet needs regarding individualized pain management, regardless of axSpA subgroup.

OP0014 COMPARISON OF ANTERIOR UVEITIS OCCURRENCE DURING TREATMENT WITH SECUKINUMAB, ADALIMUMAB, INFLIXIMAB AND ETANERCEPT IN SPONDYLOARTHRITIS

Background:

Randomized controlled trials indicate that compared to tumor necrosis factor inhibitors (TNFi), secukinumab (SEC) has similar efficacy regarding axial inflammation in spondyloarthritis (SpA), better efficacy regarding cutaneous psoriasis, but is inferior in inflammatory bowel disease (IBD). However, the efficacy of SEC compared to TNFi in anterior uveitis (AU) has not been extensively studied.

Objectives:

To compare the occurrence of AU in patients with SpA treated with SEC, adalimumab (ADA), infliximab (IFX) or etanercept (ETN), in clinical practice.

Methods:

Patients with ankylosing spondylitis or undifferentiated SpA starting either SEC, ADA, IFX or ETN, in 2015 through 2017, were identified in the Swedish Rheumatology Quality register, and were linked to the national patient register for identification of AU. AU-flares were defined as the number of visits with an AU diagnosis, separated by a ≥60 days penalty interval, within ophthalmology outpatient care, during the respective bDMARD treatment.

Follow-up started at the bDMARD initiation, and ended at the first of Dec 31st2017, death, emigration or discontinuation date of the bDMARD.

To assess and accommodate treatment channeling, crude incidence rates for AU-flares were determined (A) for all bDMARD treatment starts, (B) excluding patients with an AU diagnosis during the year prior to the bDMARD start, and (C) in addition, excluding all first line bDMARD treatment starts.

Hazard ratios (HR) for time until a first on-treatment AU diagnosis were estimated using Cox regression (ADA=reference), adjusted for sex, age, and any history of AU, and estimating robust confidence intervals to account for the individuals contributing multiple lines of treatment.

Results:

In total, 2,684 patients (52% women) contributed 3,255 treatment initiations. SEC was less frequently used as first line bDMARD and there was channeling of patients with previous AU, towards treatment with ADA, and away from ETN (Table 1). Further, AU occurred almost exclusively in patients with a pre-treatment history of AU (data not shown).

Table 1.AnalysisTreat-ment starts, NPrevious AU1Age at treat-ment start, mean (sd)N Previous bDMARD, medianHR (95% CI) for first AU-diagnosisAU flares, NFollow-up2, yearsA. All treatment starts, N=3255SEC33321%48 (13)22.0 (1.2-3.3)52241ADA87234%44 (12)1Ref175973IFX71421%43 (14)00.9 (0.6-1.4)68677ETN133617%44 (14)00.9 (0.7-1.3)1021290B. Excluding patients with prior AU within 1 year before treatment start, N=2907SEC30413%47 (13)23.1 (1.4-7.3)10212ADA71119%44 (13)1Ref18792IFX63311%43 (14)01.0 (0.4-2.3)8599ETN125912%44 (14)01.8 (1.0-3.4)431204C. Excluding patients with prior AU within 1 year before treatment start and first line bDMARD, N=1288SEC28414%48 (13)22.5 (1.0-6.2)10198ADA37418%45 (13)1Ref11384IFX18512%45 (14)21.3 (0.4-4.0)4166ETN44517%47 (14)11.9 (0.9-4.0)23439

1) Anterior uveitis between 2001 and treatment start; 2) Total follow-up time for analyses of incidence rate.

The incidence rates of AU-flares were higher for SEC and ETN compared to ADA and IFX, in the analyses (B, C) accommodating for channeling, figure 1.

Compared to ADA, the adjusted HRs of a first on-treatment AU-diagnosis were also higher for SEC and ETA, Table 1.

Conclusion:

In clinical practice, SEC and ETN are associated with a higher incidence of AU than ADA and INF, suggesting a poorer protective effect of SEC and ETN against AU. These preliminary results should be interpreted in light of pronounced treatment channeling, which was only partly accommodated for.

Disclosure of Interests:

Ulf Lindström: None declared, Karin Bengtsson: None declared, Tor Olofsson: None declared, Daniela Di Giuseppe: None declared, Bente Glintborg Grant/research support from: Grants from Pfizer, Biogen and Abbvie, Helena Forsblad-d’Elia Grant/research support from: Unrestricted grant from Novartis., Consultant of: Advisory Board Fees from Sandoz, Novartis, and Abbvie, Lennart T.H. Jacobsson Consultant of: AbbVie, Eli Lilly, Janssen, Novartis and Pfizer, Johan Askling Grant/research support from: JA acts or has acted as PI for agreements between Karolinska Institutet and the following entities, mainly in the context of the ARTIS national safety monitoring programme of immunomodulators in rheumatology: Abbvie, BMS, Eli Lilly, Merck, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB Pharma

Prime-boost vaccination strategy enhances immunogenicity compared to single pneumococcal conjugate vaccination in patients receiving conventional DMARDs, to some extent in abatacept but not in rituximab-treated patients

OBJECTIVE

To explore whether a prime-boost vaccination strategy, i.e., a dose of pneumococcal conjugate vaccine (PCV) and a dose of 23-valent polysaccharide vaccine (PPV23), enhances antibody response compared to single PCV dose in patients with inflammatory rheumatic diseases treated with different immunosuppressive drugs and controls.

METHODS

Patients receiving rituximab (n = 30), abatacept (n = 23), monotherapy with conventional disease-modifying antirheumatic drugs (cDMARDs, methotrexate/azathioprine/mycophenolate mofetil, n = 27), and controls (n = 28) were immunized with a dose PCV followed by PPV23 after ≥ 8 weeks. Specific antibodies to 12 serotypes included in both vaccines were determined using a multiplex microsphere immunoassay in blood samples before and 4-8 weeks after each vaccination. Positive antibody response was defined as ≥ 2-fold increase from pre- to postvaccination serotype-specific IgG concentration and putative protective level as IgG ≥ 1.3 μg/mL. The number of serotypes with positive antibody response and IgG ≥ 1.3 μg/mL, respectively, after PCV and PCV + PPV23 were compared within each treatment group and to controls. Opsonophagocytic activity (OPA) assay was performed for serotypes 6B and 23F.

RESULTS

Compared to single-dose PCV, prime-boost vaccination increased the number of serotypes with positive antibody response in patients with abatacept, cDMARDs, and controls (p = 0.02, p = 0.01, and p = 0.01), but not in patients on rituximab. After PCV + PPV23, the number of serotypes with positive antibody response was significantly lower in all treatment groups compared to controls but lowest in rituximab, followed by the abatacept and cDMARD group (p < 0.001). Compared to PCV alone, the number of serotypes with putative protective levels after PCV + PPV23 increased significantly only in patients in cDMARDs (p = 0.03) and controls (p = 0.001). Rituximab treatment was associated with large reduction (coefficient - 8.6, p < 0.001) and abatacept or cDMARD with moderate reductions (coefficients - 1.9 and - 1.8, p = 0.005, and p < 0.001) in the number of serotypes with positive antibody response to PCV + PPV23 (multivariate linear regression model). OPA was reduced in rituximab (Pn6B and Pn23F, p < 0.001), abatacept (Pn23F, p = 0.02), and cDMARD groups (Pn6B, p = 0.02) compared to controls.

CONCLUSIONS

Prime-boost strategy enhances immunogenicity compared to single pneumococcal conjugate vaccination in patients with inflammatory rheumatic diseases receiving cDMARDs, to some extent in abatacept but not in patients on rituximab. Pneumococcal vaccination should be encouraged before the initiation of treatment with rituximab.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03762824. Registered on 4 December 2018, retrospectively registered.

Consultation prevalence among children, adolescents and young adults with pain conditions: A description of age- and gender differences

BACKGROUND

Pain is a common complaint presented in healthcare, but most epidemiological pain research has focused either on single pain conditions or on the adult population. The aim of this study was to investigate the 2017 consultation prevalence of a wide range of pain conditions in the general population of young people.

METHODS

We used the Skåne Healthcare Register, covering prospectively collected data on all healthcare delivered (primary and secondary care) to the population in the region of Skåne, southern Sweden (population 2017 n = 1,344,689). For individuals aged 1-24 in 2017 (n = 373,178), we calculated the consultation prevalence, stratified by sex and age, and the standardised morbidity ratio (SMR) to assess overall healthcare consultation.

RESULTS

A total of 58,981 (15.8%) individuals consulted at least once for any of the predefined pain conditions. Of these, 13.5% (n = 7,996) consulted four or more times for pain. Abdominal pain, joint pain/myalgia, headache and back/neck pain were the most common complaints. Overall, females had higher consultation prevalence than males: 17.6% versus 14.1% (p < .0001). SMR was 1.82 (95% CI = 1.74-1.87) for females with pain and 1.51 (95% CI = 1.42-1.56) for males with pain. Consultation prevalence increased with age, but this pattern varied between sex and pain condition.

CONCLUSIONS

Among individuals under the age of 25, a significant proportion consult for pain already in early ages, and they also have high healthcare consultation rates for conditions other than pain. The even higher consultation rates among young females need additional attention, both in the clinic and in research.

SIGNIFICANCE

We present comprehensive 1-year healthcare consultation prevalence data covering all levels of care. A significant proportion of children, adolescents and young adults consult for different pain conditions at multiple occasions warranting greater clinical awareness.

Patient-Reported Outcomes Are More Important Than Objective Inflammatory Markers for Sick Leave in Biologics-Treated Patients With Rheumatoid Arthritis

OBJECTIVE

To study the impact of common noncomposite disease activity measures on sick leave in biologics-treated patients with rheumatoid arthritis (RA).

METHODS

Data from study visits by biologics-treated RA patients of working age (<65 years) in the observational South Swedish Arthritis Treatment Group Register between 2005 and 2011, were included (5,118 visits by 941 patients). We performed association analyses between various noncomposite disease activity measures at each visit and the number of days of sick leave during the subsequent month; this information was retrieved from the Social Insurance Agency. Adjusted separate generalized estimating equation regression models were used, and analyses were stratified according to sick leave status for the month preceding each visit (no, partial, or full sick leave). Results are presented as standardized beta coefficients for comparability.

RESULTS

Among modifiable noncomposite disease activity measures, patient's assessment of pain and disease activity scored on a visual analog scale (VAS) were most strongly associated with subsequent sick leave, irrespective of baseline sick leave status. Generally, measures that were more objective (swollen joint count, erythrocyte sedimentation rate, and C-reactive protein) had less impact on sick leave compared with variables that were more subjective (patient's pain and global scores on a VAS, evaluator's global assessment of disease activity on a 5-grade Likert scale, and tender joint count).

CONCLUSION

Measures of disease activity that are more subjective have a greater impact on sick leave in biologics-treated patients with RA compared with variables that are more objective, suggesting a stronger focus on subjective measures when targeting work loss or intervening to reduce it.

Biological treatment of ankylosing spondylitis: a nationwide study of treatment trajectories on a patient level in clinical practice

BACKGROUND

There is substantial evidence that patients with ankylosing spondylitis (AS) have high response rates to tumour necrosis factor inhibitors (TNFi), a low likelihood of successful treatment termination, but yet a limited drug retention. Whereas several reports have assessed drug retention rates for TNFi in AS, there are few, if any, studies investigating the actual treatment trajectories on a patient level, including subsequent therapy changes and dose reductions, of individual patients. The aim of this study was to describe 5-year treatment trajectories in patients with ankylosing spondylitis (AS) starting a first TNFi.

METHODS

Bio-naïve patients with AS starting a TNFi in 2006-2015 were identified in the nationwide Swedish Rheumatology Quality register and followed until 31 December 2015. All changes in their anti-rheumatic treatment during follow-up were recorded. To further increase precision, these data were complimented by information on the amount of prescribed subcutaneous TNFi collected from pharmacies during each year, retrieved from the Swedish Prescribed Drug Register.

RESULTS

Two thousand five hundred ninety patients started a first TNFi 2006-2015, and after 1 year, 74% remained on their first TNFi. However, after 5 years, this figure was only 46%, although at that time 63% were still on treatment with any biologic, while 30% had no anti-rheumatic treatment at all. After discontinuing the first TNFi, 46% switched directly to a second TNFi, but the drug retention for the second and third TNFi grew successively shorter compared to that for the first TNFi. In contrast, patients remaining on treatment with their first subcutaneous TNFi gradually reduced the dose, so that during the fifth year of treatment only 66% had collected ≥ 75% of the defined daily doses for that year.

CONCLUSION

Less than half of patients with AS will remain on their first TNFi after 5 years, but most are still on a biologic. While patients remaining on treatment with their first TNFi appear to be able to reduce the dose over time, a large proportion cycle through several biologics, and 1/3 have no anti-rheumatic treatment after 5 years. This indicates the importance of thorough follow-up programs as well as a need for alternative therapeutic options.

Impact of extra-articular spondyloarthritis manifestations and comorbidities on drug retention of a first TNF-inhibitor in ankylosing spondylitis: a population-based nationwide study

Objectives

To assess the impact of extra-articular spondyloarthritis (SpA) manifestations (anterior uveitis, psoriasis and inflammatory bowel disease (IBD)), and of comorbidities, on tumour necrosis factor alpha inhibitor (TNFi) drug retention in ankylosing spondylitis (AS).

Methods

We identified all bio-naïve patients with AS starting a first ever TNFi July 2006 to December 2015 from the Swedish Rheumatology Quality register and followed these from treatment start through December 2015. We determined the presence of extra-articular SpA-manifestations, comorbidities (cardiovascular disease, affective disease, diabetes, malignancies, chronic lung disease and kidney disease) and socioeconomic status before TNFi start, through linkage to five other national registers, and calculated, for each factor, crude and adjusted HRs for discontinuing the TNFi.

Results

2577 patients with AS (71% men) started a first TNFi during the study period. 27% had a history of anterior uveitis, 6% psoriasis and 7% IBD. Anterior uveitis was associated with a superior TNFi drug retention (HR 0.72; 0.62 to 0.83), psoriasis with an inferior (HR 1.48; 1.18 to 1.86), whereas IBD did not affect TNFi drug retention. The effect of the SpA manifestations on TNFi drug retention was of a similar magnitude to that of the comorbidities.

Conclusions

In AS, anterior uveitis and psoriasis, but not IBD, affect TNFi drug retention. Possible explanations include differential effects of TNFi on these extra-articular SpA manifestations, or inherent differences in AS, associated with the inflammatory phenotype. Further, comorbidities and socioeconomy affect TNFi drug retention to a similar magnitude as the SpA manifestations, and should, as such, receive due attention in clinical practice.

Work disability in non-radiographic axial spondyloarthritis patients before and after start of anti-TNF therapy: a population-based regional cohort study from southern Sweden

Objective

The aim was to assess work-loss days before and after commencement of anti-TNF treatment in patients with non-radiographic axial spondylarthritis (nr-axSpA).

Methods

Bionaïve nr-axSpA patients (n = 75), aged 17-62 years, fulfilling the Assessment of SpondyloArthritis international Society criteria for axial spondyloarthritis and starting anti-TNF treatment during 2004-11, were retrieved from the observational South Swedish Arthritis Treatment Group study. Patient information was linked to Swedish Social Insurance Agency data on sick leave and disability pension from 1 year before to 2 years after anti-TNF initiation. Matched population references were included for comparison and to adjust for secular trends.

Results

The nr-axSpA patients had a median age of 35 years and disease duration of 6 years at the start of treatment. During the 2 years after anti-TNF initiation, mean work-loss days (including both sick leave and disability pension) in the nr-axSpA group decreased significantly from 3.4 to 1.9 times more than among the population references. The effect was seen on sick leave, whereas disability pension levels remained similar in both groups throughout.

Conclusion

Anti-TNF therapy in nr-axSpA was associated with a significant and sustained improvement of work disability over 2 years. However, the proportion of work-loss days remained almost twice as high as in the general population at the end of follow-up.

Predictors of work disability after start of anti-TNF therapy in a national cohort of Swedish patients with rheumatoid arthritis: does early anti-TNF therapy bring patients back to work?

OBJECTIVES

To examine predictors of work ability gain and loss after anti-tumour necrosis factor (TNF) start, respectively, in working-age patients with rheumatoid arthritis (RA) with a special focus on disease duration.

METHODS

Patients with RA, aged 19-62 years, starting their first TNF inhibitor 2006-2009 with full work ability (0 sick leave/disability pension days during 3 months before bio-start; n=1048) or no work ability (90 days; n=753) were identified in the Swedish biologics register (Anti-Rheumatic Treatment In Sweden, ARTIS) and sick leave/disability pension days retrieved from the Social Insurance Agency. Outcome was defined as work ability gain ≥50% for patients without work ability at bio-start and work ability loss ≥50% for patients with full work ability, and survival analyses conducted. Baseline predictors including disease duration, age, sex, education level, employment, Health Assessment Questionnaire, Disease Activity Score 28 and relevant comorbidities were estimated using Cox regression.

RESULTS

During 3 years after anti-TNF start, the probability of regaining work ability for totally work-disabled patients was 35% for those with disease duration <5 years and 14% for disease duration ≥5 years (adjusted HR 2.1 (95% CI 1.4 to 3.2)). For patients with full work ability at bio-start, disease duration did not predict work ability loss. Baseline disability pension was also a strong predictor of work ability gain after treatment start.

CONCLUSIONS

A substantial proportion of work-disabled patients with RA who start anti-TNF therapy regain work ability. Those initiating treatment within 5 years of symptom onset have a more than doubled 3-year probability of regaining work ability compared with later treatment starts. This effect seems largely due to the impact of disease duration on disability pension status.

Costs in Relation to Disability, Disease Activity, and Health-related Quality of Life in Rheumatoid Arthritis: Observational Data from Southern Sweden

Objective.

To compare how costs relate to disability, disease activity, and health-related quality of life (HRQOL) in rheumatoid arthritis (RA).

Methods.

Antitumor necrosis factor (anti-TNF)-treated patients with RA in southern Sweden (n = 2341) were monitored 2005–2010. Health Assessment Questionnaire (HAQ), 28-joint Disease Activity Score (DAS28), and EQ-5D scores were linked to register-derived costs of antirheumatic drugs (excluding anti-TNF agents), patient care, and work loss from 30 days before to 30 days after each visit (n = 13,289). Associations of HAQ/DAS28/EQ-5D to healthcare (patient care and drugs) and work loss costs (patients < 65 yrs) were studied in separate regression models, comparing standardized β coefficients by nonparametric bootstrapping to assess which measure best reflects costs. Analyses were conducted based on both individual means (linear regression, comparing between-patient associations) and by generalized estimating equations (GEE), using all observations to also account for within-patient associations of HAQ/DAS28/EQ-5D to costs.

Results.

Regardless of the methodology (linear or GEE regression), HAQ was most closely related to both cost types, while work loss costs were also more closely associated with EQ-5D than DAS28. The results of the linear models for healthcare costs were standardized β = 0.21 (95% CI 0.15–0.27), 0.16 (0.11–0.21), and –0.15 (−0.21 to −0.10) for HAQ/DAS28/EQ-5D, respectively (p < 0.05 for HAQ vs DAS28/EQ-5D). For work loss costs, the results were standardized β = 0.43 (95% CI 0.39–0.48), 0.27 (0.23–0.32), and −0.34 (−0.38 to −0.29) for HAQ/DAS28/EQ-5D, respectively (p < 0.05 for HAQ vs DAS28/EQ-5D and for EQ-5D vs DAS28).

Conclusion.

Overall, HAQ disability is a better marker of RA costs than DAS28 or EQ-5D HRQOL.

Does disease activity at start of biologic therapy influence work-loss in RA patients?

OBJECTIVE

To compare work-loss in RA patients starting their first biologic with high vs moderate disease activity.

METHODS

We identified all RA patients aged 20-63 years in the Swedish Biologics Register who started their first biologic 2007-09 with high disease activity (DAS28 >5.1; n = 868) or moderate disease activity (DAS28 3.2-5.1; n = 854). Work days lost, defined as sick leave and disability pension days from the Swedish Social Insurance Agency, were assessed over 5 years after first bio-start. We estimated between-group mean differences adjusted for age, sex, calendar year, education level, disease duration, comorbidities and work-loss the month before bio-start.

RESULTS

During 5 years after anti-TNF start, mean monthly work days lost declined from 16.0 to 9.2 (42%; P < 0.001) in patients with high disease activity at baseline and from 12.0 to 7.2 (40%; P < 0.001) in patients with moderate disease activity, with no between-group difference (adjusted mean difference 0.81; 95% CI - 0.44, 2.05). Accumulated 5-year work-loss was, however, higher in the high activity group (724 vs 548 days; adjusted mean difference 70; 95% CI 20, 120), but after stratification on baseline disability pension status, no differences in accumulated work-loss were detected.

CONCLUSION

Substantial work-loss was seen in both patients with high and patients with moderate disease activity at anti-TNF start, with a 5-year decline in mean monthly work days lost by ∼40% in both groups and no between-group difference. Accumulated work-loss over 5 years was higher in the high-activity group, which may be explained by differences in baseline disability pension status.

The radical-binding lipocalin A1M binds to a Complex I subunit and protects mitochondrial structure and function

AIMS

During cell death, energy-consuming cell degradation and recycling programs are performed. Maintenance of energy delivery during cell death is therefore crucial, but the mechanisms to keep the mitochondrial functions intact during these processes are poorly understood. We have investigated the hypothesis that the heme- and radical-binding ubiquitous protein α1-microglobulin (A1M) is involved in protection of the mitochondria against oxidative insult during cell death.

RESULTS

Using blood cells, keratinocytes, and liver cells, we show that A1M binds with high affinity to apoptosis-induced cells and is localized to mitochondria. The mitochondrial Complex I subunit NDUFAB1 was identified as a major molecular target of the A1M binding. Furthermore, A1M was shown to inhibit the swelling of mitochondria, and to reverse the severely abrogated ATP-production of mitochondria when exposed to heme and reactive oxygen species (ROS).

INNOVATION

Import of the radical- and heme-binding protein A1M from the extracellular compartment confers protection of the mitochondrial structure and function during cellular insult.

CONCLUSION

A1M binds to a subunit of Complex I and has a role in assisting the mitochondria to maintain its energy delivery during cell death. A1M may also, at the same time, counteract and eliminate the ROS generated by the mitochondrial respiration to prevent oxidative damage to surrounding healthy tissue.

The p53 target gene TRIM22 directly or indirectly interacts with the translation initiation factor eIF4E and inhibits the binding of eIF4E to eIF4G

Background information

The interferon (IFN)‐inducible protein TRIM22 (Staf50) is a member of the tripartite motif protein family and has been suggested a role in the regulation of viral replication as well as of protein ubiquitylation. In addition, we have previously shown that TRIM22 is a direct target gene for the tumour suppressor p53. Consistently, over‐expression of TRIM22 inhibits the clonogenic growth of monoblastic U937 cells, suggesting anti‐proliferative or cell death‐inducing effects.

Results

Here, we demonstrate that TRIM22 directly or indirectly interacts with the eukaryotic translation initiation factor (eIF)4E, and inhibits the binding of eIF4E to eIF4G, thus disturbing the assembly of the eIF4F complex, which is necessary for cap‐dependent translation. Furthermore, TRIM22 exerts a repressive effect on luciferase reporter protein levels and to some extent on radiolabelled methionine incorporation. Even though all nuclear mRNAs are capped, some are more dependent on eIF4F than others for translation. The translation of one of these mRNAs, IRF‐7C, was indeed found to be repressed in the presence of TRIM22.

Conclusions

Our data suggest TRIM22 to repress protein translation preferably of some specific mRNAs. Taken together, we show that TRIM22 represses translation by inhibiting the binding of eIF4E to eIF4G, suggesting a mechanism for regulation of protein translation, which may be of importance in response to p53 and/or IFN signalling.

PROX1 is a predictor of survival for gliomas WHO grade II

Background:

The clinical course of World Health Organisation grade II gliomas remains variable and their time point of transformation into a more malignant phenotype is unpredictable. Identification of biological markers that can predict prognosis in individual patients is of great clinical value. PROX1 is a transcription factor that has a critical role in the development of various organs. PROX1 has been ascribed both oncogenic and tumour suppressive functions in human cancers. We have recently shown that PROX1 may act as a diagnostic marker for high-grade gliomas. The aim of this study was to address the prognostic value of PROX1 in grade II gliomas.

Methods:

A total of 116 samples were evaluated for the presence of PROX1 protein. The number of immunopositive cells was used as a variable in survival analysis, together with established prognostic factors for this patient group.

Results:

Higher PROX1 protein was associated with poor outcome. In the multivariate analysis, PROX1 was identified as an independent factor for survival (P=0.024), together with the presence of mutated isocitrate dehydrogenase 1 R132H protein, and with combined losses of chromosomal arms 1p/19q in oligodendrocytic tumours.

Conclusion:

PROX1 is a novel predictor of survival for grade II gliomas.

Abstract LB-366: Patient-derived EBV-immortalized B-lymphocytes are a dominant contaminant of in vitro cultured human neuroblastoma tumor-initiating cells isolated from bone marrow

Neuroblastoma is one of the most common solid tumors of infancy and is believed to originate from immature sympathetic nervous system progenitor cells. Tumor stem cells from different cancer forms have during the last decade been isolated and propagated in vitro in stem cell-promoting medium. These cells have given the opportunity to study the population within the tumor that is believed to be responsible for relapse and metastatic disease. Three years ago, putative neuroblastoma tumor-initiating cells (TICs) were isolated from bone marrow of patients with high stage disease. Several findings concerning these cells have been difficult to explain in a neuroblastoma context, i.e. that initially only cells from MYCN non-amplified tumors could be established as proliferating cultures in vitro, that they have a B-cell phenotype with VDJ rearrangement as presented at the 2010 Advances in Neuroblastoma Research (ANR) meeting, and as presented here, that they lack genomic imbalances and fail to recapitulate neuroblastoma morphology when xenografted. We show that these widely studied patient-derived TIC cultures (NB12, NB88 and NB122R), also at low passages, are highly contaminated by proliferating cells of a B-lymphocyte phenotype, with the absolute majority of cells expressing multiple B-cell antigens while lacking expression of neuroblastoma-associated markers. We further show that these lymphoblastoid cells are Epstein-Barr virus (EBV)-infected with robust expression of the two EBV nuclear antigens EBNA2 and EBNA3A. In addition, orthotopic and subcutaneous TIC-derived xenograft tumors all have EBNA2 and B-cell marker CD19 positive cells at a high frequency. Published and unpublished results based on the use of the proposed TIC lines as a model for neuroblastoma development should be considered with caution, as these lines, at least with time in culture, mainly consist of EBV-transformed B-lymphoblastoid cells.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr LB-366. doi:10.1158/1538-7445.AM2011-LB-366

Abstract 3085: The IFN inducible p53 target gene TRIM22 binds to the translation initation factor eIF4E and represses translation through disturbing the assembly of the eIF4F complex

TRIM22 (Staf50) is an interferon (IFN)-inducible protein as well as a p53 target gene. It belongs to the TRIM (TRIpartite Motif) family proteins, characterized of a conserved tripartite motif consisting of a RING finger, B-box and a coiled-coil domain. The TRIM family includes more than 70 proteins, involved in various biological processes; e.g. apoptosis and cell proliferation. Consistently, several TRIM family members are involved in cancer. TRIM22 has been suggested to be an antiviral protein, capable of restricting HIV-, hepatitis B- and encephalomyocarditis replication. The molecular mechanisms for TRIM22 are unclear, but the antiviral activity may be dependent on the ubiquitylation capacity of TRIM22. We have previously shown it to suppress the clonogenic growth of leukemic U-937 cells, suggesting anti-proliferative or cell death-inducing effects. Now, we demonstrate that TRIM22 binds to the translation initiation factor eIF4E, and inhibits the binding of eIF4E to eIF4G, thus disturbing the assembly of the eIF4F complex, vital for cap dependent translation of mRNA. As a consequence, TRIM22 represses translation, as shown by decreased reporter protein levels, as well as global protein synthesis. Pulse-chase and cycloheximide experiments reveal that the repressive effects on the reporter protein is not due to increased protein degradation. Taken together, our data show TRIM22 to repress the binding of eIF4E to eIF4G, suggesting a novel translation regulating mechanism, possibly mediated in response to p53 and/or IFN signaling.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 3085. doi:10.1158/1538-7445.AM2011-3085

Minimal residual disease assessment in childhood acute lymphoblastic leukaemia: a Swedish multi-centre study comparing real-time polymerase chain reaction and multicolour flow cytometry

Minimal residual disease (MRD) assessment is a powerful prognostic factor for determining the risk of relapse in childhood acute lymphoblastic leukaemia (ALL). In this Swedish multi-centre study of childhood ALL diagnosed between 2002 and 2006, the MRD levels were analysed in 726 follow-up samples in 228 children using real-time quantitative polymerase chain reaction (RQ-PCR) of rearranged immunoglobulin/T-cell receptor genes and multicolour flow cytometry (FCM). Using an MRD threshold of 0·1%, which was the sensitivity level reached in all analyses, the concordance between RQ-PCR and FCM MRD values at day 29 was 84%. In B-cell precursor ALL, an MRD level of ≥0·1% at day 29 predicted a higher risk of bone marrow relapse (BMR) with both methods, although FCM was a better discriminator. However, considering the higher median MRD values achieved with RQ-PCR, a higher MRD cut-off (≥0·2%) improved the predictive capacity of RQ-PCR. In T-ALL, RQ-PCR was notably superior to FCM in predicting risk of BMR. That notwithstanding, MRD levels of ≥0·1%, detected by either method at day 29, could not predict isolated extramedullary relapse. In conclusion, the concordance between RQ-PCR and FCM was high and hence both methods are valuable clinical tools for identifying childhood ALL cases with increased risk of BMR.