AB0584 MANAGEMENT OF REFERRALS, TREATMENT STRATEGY, AND RESEARCH CHALLENGES IN POLYMYALGIA RHEUMATICA AMONGST RHEUMATOLOGISTS WORLDWIDE: A QUESTIONNAIRE BASED STUDY

Background

Polymyalgia rheumatica (PMR) is diagnosed and treated by both general practitioners (GP) and rheumatologists. How rheumatologists around the world manage the referral process of patients with PMR from GP’s has not been described. EULAR/ACR guidelines recommend initial prednisolone doses between 12.5 and 25 mg, but it is unknown if guidelines are followed in daily clinical practice1. In addition, the understanding of challenges for recruitment to clinical trials in PMR is currently limited.

Objectives

This study aims to describe the management of referrals, treatment strategy, and recruitment to clinical trials in PMR among rheumatologists worldwide.

Methods

An English language questionnaire was drafted by a working group of rheumatologists and GP’s from 6 different countries. Questions concerned: 1: respondent, 2: referrals, 3: prednisolone, and 4: barriers to research. Questionnaires were distributed to rheumatologists via members of the International PMR/GCA study group. Answers were collected via an online survey tool (Redcap), from 2nd of November 2021 to 27th of January 2022. Countries were grouped by income and geographical region based on the World bank classifications. Data were weighted by number of inhabitants in a country, based on the United Nations age specific population count, divided by number of respondents in a country. Countries with more than 20 respondents were included.

Results

Results from 27 countries were analysed including 1000 responders in total (Figure 1). There was large variation in time from referral to first assessment, initial dose of prednisolone was high, duration of treatment was relatively short, and a large proportion of patients with newly diagnosed PMR received prednisolone prior to rheumatological evaluation (Table 1). Concerning the 15% of respondents who performed research in PMR, 52% had participated in clinical trials and 56% of the responders experienced difficulties with recruitment.

Table 1.

Characteristics of reponders, referrals, and treatment.

Geographical regionIncomeThe worldEurope and Central AsiaNorth AmericaLatin AmericaEast Asia and PacificSouth AsiaMiddle East and AfricaHigh- income countriesLow- and middle- income countriesRespondersResponders (n), Completed questionnaire (total)875 (1000)294 (304)78 (81)136 (152)53 (53)53 (72)261 (338)446 (458)429 (542)Experience as rheumatologist (years)11 (6-20)12 (6-20)7 (4-20)11 (6-23)21 (10-30)7 (4-10)9 (5-18)11 (5-22)8 (5-12)ReferralsGP’s can discuss patients prior to referral, %647979575860677461Referred patients seen (%)100 (90-100)100 (90-100)100 (100-100)100 (100-100)100 (95-100)100 (100-100)100 (60-100)100 (100-100)100 (90-100)Evaluation > 2 weeks after referral, %26498060216185815PrednisoloneStarted prior to rheumatological evaluation (%)50 (20-50)60 (30-80)70 (50-80)50 (10-50)30 (20-50)50 (20-80)20 (0-50)50 (30-80)50 (10-70)Initial dose (mg)20 (15-40)20 (15-20)20 (15-20)20 (20-40)15 (15-15)20 (15-40)20 (15-40)15 (15-20)20 (15-40)Initial dose > 25 mg, %32964104143642Duration of treatment (months)12 (6-12)12 (12-18)12 (10-18)6 (3-12)18 (12-18)12 (6-12)6 (3-12)12 (12-18)9 (6-12)

Data presented as weighted median (interquartile range) unless otherwise stated.

GP: general practitioner

Conclusion

This is the first description of current practice in managing referrals and treatment of PMR by rheumatologists worldwide. In general, median treatment duration was according to EULAR/ACR guidelines, but initial dose of prednisolone was often higher than recommended in many parts of the world. PMR patients were often seen more than two weeks after referral, and treatment had started prior to first rheumatological evaluation.

References

[1]Dejaco C, Singh YP, Perel P, et al. 2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Annals of the rheumatic diseases 2015; 74(10): 1799-807.

Acknowledgements

This study was endorsed by the international PMR/GCA study group.

Disclosure of Interests

Agnete Overgaard Donskov: None declared, Sarah Mackie: None declared, Ellen-Margrethe Hauge Speakers bureau: AbbVie, Sanofi, Sobi, MSD, UCB, Consultant of: AbbVie, Sanofi, Sobi, MSD, UCB, Grant/research support from: Novo Nordic Foundation, Danish Rheumatism Association, Danish Regions Medicine Grants, Roche, Novartis, Celgene, MSD, Pfizer, Roche, Sobi, CARLOS TORO GUTIÉRREZ: None declared, Ib Hansen: None declared, Andrea Hemmig: None declared, Aatke van der Maas: None declared, Tamer A Gheita: None declared, Berit Dalsgaard NIelsen Paid instructor for: Roche, Karen Douglas: None declared, Richard Conway Speakers bureau: Janssen, Roche, Sanofi, Abbvie,, Elena Rezus: None declared, Bhaskar Dasgupta: None declared, Sara Monti: None declared, Eric Matteson Consultant of: Boehringer-Ingelheim,, Grant/research support from: Boehringer Ingelheim,, Sebastian E. Sattui Grant/research support from: AstraZeneca, Mark Matza: None declared, Vanessa Ocampo Speakers bureau: Abbvie, Andrea Bran: None declared, Simone Appenzeller Grant/research support from: GSK, Annelise Goecke Speakers bureau: Abbvie, Boehringer Ingelheim, Recalcine. Consultant Abbvie, Boehringer Ingelheim, NELLY COLMAN MC LEOD Speakers bureau: Laboratorios FAPASA (Farmacéutica Paraguay), Helen Keen Speakers bureau: Roche, Abbvie, Masataka Kuwana: None declared, Latika Gupta: None declared, Babur Salim: None declared, Ghita Harifi Speakers bureau: Abvie, Johnson and johnson, Lilly, Novartis, Mariama Erraoui: None declared, Nelly Ziade Speakers bureau: Abbvie, Eli Lilly, Janssen, Pfizer, Pierre Fabre, Roche, Novartis, Sanofi-Aventis, Paid instructor for: Abbvie, Eli Lilly, Sanofi-Aventis, Pfizer, Janssen, Novartis., Consultant of: Abbvie, Eli Lilly, Janssen, Pfizer, Roche, Novartis, Sandoz, Grant/research support from: Abbvie, Celgene - Algorithm, Bristol-Myers Squibb - NewBridge, Pfizer, Nizar Abdulateef Al-Ani: None declared, Adeola Ajibade: None declared, Johannes Knitza: None declared, Line Frølund: None declared, Max Yates: None declared, Victor Pimentel-Quiroz: None declared, Andre Lyrio: None declared, Maria Sandovici: None declared, Kornelis van der Geest Speakers bureau: Roche, Toby Helliwell Grant/research support from: Valneva, Elisabeth Brouwer Speakers bureau: Roche, Christian Dejaco Speakers bureau: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer, Roche, Galapagos and Sanofi, Consultant of: Abbvie, Eli Lilly, Janssen, Roche, Galapagos and Sanofi, Kresten Keller: None declared

SAT0004 INCREASED M1 INFLAMMATORY PHENOTYPE OF CIRCULATING MONOCYTES IS ASSOCIATED WITH HISTORY OF CARDIOVASCULAR EVENTS IN RA PATIENTS

Background:

Cardiovascular (CV) Disease is the main cause of death in Rheumatoid Arthritis (RA). Current tools like Framingham or European SCORE underestimate CV risk in RA patients. Efforts to improve the assessment including RA biomarkers (disease activity) have been only partially successful. There is a need for better biomarkers to identify AR patients at high risk for CV disease. Monocytes have an important role in plaque development. Monocytes differentiates into 2 main phenotypes M1 and M2 (1). In RA and in post-MI patients M1 monocytes are expanded (2). mTORC influences monocyte phenotypein vitroand has been associated with development of atheromatous plaque (3).

Objectives:

To evaluate the phenotype of circulating monocyte in RA patient with or without previous CV events (RA-CV(-)RA-CV(+)), and its possible association with mTORC activity.

Methods:

9 RA-CV(+)patients aged between 18 and 65 yo with RA (EULAR/ACR 2010 criteria), were paired with RA-CV(-)patients. 6 healthy individuals (HI) were also studied. Pairing criteria were classic CV risk factors (AHA 2018), sex, age, years since RA diagnosis, comorbidities, number of DMARDs previously used and use of bDMARDS. M1 and M2 circulating Monocytes were evaluated in PBMC obtained from patients and controls by flow cytometry analysis. Intracellular inflammatory cytokines (IL1, Il6) and phosphorylated S6R (P-S6R) as a measure of mTORC activation was also evaluated. M1 was defined as CD14+HLA-DR+CCR2+ and M2 CD14+CD163+CCR2-. DAS28-RCP, DAS28-ESR and Lipid profile was also measured. The differences among groups was analysed using Mann–Whitney U nonparametric. The relationship between variables with Spearman rank correlation test.

Results:

There were no differences in demographic, RA characteristic and CV risk factors between RA-CV (+) and RA-CV (-) patients. Male/Female 4/5, age 62±3 and 63±2 respectively. HI were younger than RA patients (32.5±7). CV events were 8 patients with MI and one Stroke. DAS28-RCP was 2.96±0.23 and 2.88±0.43 respectively. One patient in each group had failed to more than 2 sDMARDs and one in each group was receiving bDMARD. M1 circulating monocytes were expanded in RA as compared to HI. This difference was at RA-CV (+) expense. RA monocytes had higher Intracellular levels of IL-1b and IL-6 as compared to HI. M1 from RA-CV (+) had higher intracellular levels of IL-1b and IL-6 than RA-CV (-). M1 monocytes have higher levels of inflammatory cytokines than M2. P-S6R protein, (mTORC activation), was higher in RA patients than HI. The highest levels of P-S6R was observed in M1 monocytes from RA-CV(+) population.

FIGURE 1.

Circulating monocytes phenotype, intracellular cytokines and phosphorylated S6R in HI and RA-CV (+), RA-CV (-) and the combined RA patients. A) *=0,02; B) *=0,016; C) ****=0,0001, **=0,002; D) ****=0,0001, ***=0,0008, **=0,001, *=0,01; E) ****0,0001, **=0,002; F) ****=0,0001, **=0,001, **=0,003.

Conclusion:

RA-CV+ patients, have a significantly higher number of pro-inflammatory circulating monocytes, using a multiparametric classification method. These monocytes also express higher levels of inflammatory cytokines and higher activation of mTORC, which also participate in the development of atheromatous plaque, suggesting that these monocytes could be a key element in the non-clarified-yet, excess of CV risk of RA patients.

References:

[1] Fukui S, et al. M1 and M2 Monocytes in Rheumatoid Arthritis: A Contribution of Imbalance of M1/M2 Monocytes to Osteoclastogenesis. Front Immunol. 2017;8:1958.2. Zhuang J, et al. Comparison of circulating dendritic cell and monocyte subsets at different stages of atherosclerosis: insights from optical coherence tomography. BMC Cardiovasc Disord. 2017 Oct 18;17(1):270.

Disclosure of Interests:

None declared

AB0554 CONCORDANCE IN THE CLASSIFICATION CRITERIA IN A PATIENT COHORT WITH IDIOPATHIC INFLAMMATORY MYOPATHIES (IIM)

Background:

Differents classifications criteria for IIM exist. New classification criteria are superior to previous in capturing different subgroups of IIM.

Objectives:

To compare the concordance and disparity of Bohan and Peter and EULAR/ACR 2017 classification criteria at the level of diagnostic certainty, in a group of chilean patients with IIM.

Methods:

40 adults patients with IIM (27 Dermatomyositis (DM) and 13 Polimyositis (PM)), according Bohan and Peter criteria were analized. The patients were reclassified with EULAR/ACR criteria. The level of diagnostic certainty (definitive, probable and possible) was registered for both Classification Criteria. The concordance and disparity between criteria was evaluated. Concordance and disparity analysis were made considering the strict agreement between level of certainty of both criteria, using Cohen´s Kappa coefficient. The analysis was done for the complete cohort and for separated groups.

Patients with discordance belonging to the same subgroup were evaluated using contingency tables. The direction of the change (gain or lost of certainty) and the relation with diagnostic subgroup was also analized. Descriptive statistics is expressed as diagnostic categories, number of patients and rates.

Results:

For the complete cohort and for DM and PM groups the concordance was low. For 27 patients with DM, the observed concordance rate was 63% (16 definitives, 1 probable). The observed disparity rate was 37%. The direction of the change was gain of one level of certainty in 14.5% and two levels in 22.2% of patients applying EULAR/ACR criteria compared to Bohan y Peter criteria. For 13 pacients with PM, the observed concordance rate was 46% (3 definitives and 3 probables). The observed disparity rate was 54%. The direction of the change was loss of certainty. The loss of certainty was one level in 85,7% (one patient change from probable to posible). Only one patiente had gain of certainty of one level (14.3%).

Conclusion:

The strict concordance between both classification criteria was low. The observed concordances were better in patients with DM that PM. The disparities involved gain of level of diagnostic certainty in DM patients, while in PM patients there was mostly lost of level of certainty.

References:

[1]Bohan A, Peter JB. Polymyositis and dermatomyositis (first of two parts). NEJM 1975;292:344-7.

[2]Bohan A, Peter JB. Polymyositis and dermatomyositis (second of two parts). NEJM 1975;292:403-7.

[3]2017 European League Against Rheumatism/American Colllege of Rheumatology Classification Criteria for Adult and Juvenile Idiopathic Inflammatory Myopathies and Their major Subgroups. Arthritis Rheum 2017;0:1-12.

Disclosure of Interests: :

None declared

Increased Na,K,Cl cotransporter and Na, K-ATPase activity of vascular tissue in two-kidney Goldblatt hypertension

The properties of the Na/K pump and Na,K,Cl cotransporter were studied in vascular tissue of two-kidney Goldblatt hypertensive rats. These transport systems were measured as ouabain-sensitive and bumetanide-sensitive 86Rb/K uptake in aortic rings, left ventricular muscle and soleus skeletal muscle fibers of control and hypertensive Sprague-Dawley rats. A dramatic increment in Na/K pump activity was observed in intact aortic rings from the hypertensive group. The same was true for the Na,K,Cl cotransporter. The transport parameters related to the left ventricular muscle and soleus skeletal muscle were not significantly altered in the hypertensive rats. Measurements of the catalytic isoforms of the Na+, K(+)-ATPase in the aortic rings indicated that both isoforms (alpha 1 and alpha 2) were elevated in the same proportion in the hypertensive rats. The results also indicate that the endothelium plays an important role in both transport systems: in the absence of endothelium, a much lower 86Rb/K uptake was observed than in intact aortic rings, either from control or hypertensive vascular tissue. Nevertheless, when the 86Rb/K transport activity was measured in denuded aortic rings, a significantly higher ouabain and bumetanide sensitive 86Rb/K uptake was also observed in the hypertensive rats. These data also show no alteration in the endothelium of the hypertensive rats as compared to control animals. The presence of endothelium had a more striking effect on the alpha 2 catalytic isoform activity than on the alpha 1 isoform. We conclude that there is a significant increment in the Na/K pump and Na,K,Cl cotransporter in two kidney-Goldblatt hypertension, that is specific for vascular smooth muscle.

[Comparison of the efficacy of intraarticular and intraarterial injections of two betamethasone preparations in patients with osteoarthritis or epicondilytis]

BACKGROUND

Local infiltration with corticoids is a simple therapy for rheumatic disorders devoid of systemic adverse reactions.

AIM

To compare the efficacy of two betametasone preparations from two different pharmaceutical laboratories in the treatment of patients with osteoarthritis or epicondylitis.

PATIENTS AND METHODS

Fourty patients with knee osteoarthritis and 12 patients with epicondylitis were studied. Using a double blind protocol, one of the two betametasone preparations was used for local infiltration of the lesions. The change in a global score of clinical variables including pain and disability was assessed after 30 days of the infiltration.

RESULTS

In patients with osteoarthritis, the global score decreased significantly with both preparations, but no differences were observed between preparations (7.3 +/- 1.8 to 3.9 +/- 2.3 with preparation A and 7.8 +/- 1.9 to 3.6 +/- 2.3 with preparation B). In patients with epicondylitis, pain was also significantly reduced but no differences between preparations was observed (7 +/- 2.1 to 1.4 +/- 2.5 for preparation A and 4.6 +/- 2.8 to 1.2 +/- 1.6 for preparation B).

CONCLUSIONS

Local infiltration with both betametasone preparations was equally effective in the treatment of patients with knee osteoarthritis or epicondilytis.