Automated measurement of unsaturated iron binding capacity is an effective screening strategy for C282Y homozygous haemochromatosis

BACKGROUND

C282Y hereditary haemochromatosis is an appropriate condition for population screening. Transferrin saturation, the best screening test to date, is relatively expensive, labour intensive, and cannot be automated. Unsaturated iron binding capacity is a surrogate marker of transferrin saturation and its measurement can be automated.

AIMS

To evaluate a screening strategy for C282Y hereditary haemochromatosis in a tertiary hospital environment based on unsaturated iron binding capacity as the initial screening test.

METHODS

Measurement of unsaturated iron binding capacity was adapted to the main laboratory analyser. An unsaturated iron binding capacity of less than 30 micromol/l was identified as an appropriate decision point and 5182 consecutive subjects were screened over 28 consecutive days.

RESULTS

Of those screened, 697 had an unsaturated iron binding capacity less than 30 micromol/l. Of these, transferrin saturation was greater than 40% in 294. A total of 227 were able to be genotyped for the C282Y mutation. Nine subjects homozygous for C282Y were identified. Based on full cost recovery, affected persons were identified at a cost of Aus$2268.77 per case (approximately US$1496).

CONCLUSION

Automated measurement of unsaturated iron binding capacity enables a cost effective, large scale population screening programme for C282Y hereditary haemochromatosis to be developed.

Quality of life and patient-perceived symptoms in patients with psoriasis undergoing proactive or reactive management with the fixed-dose combination Cal/BD foam: A post-hoc analysis of PSO-LONG

Background

Psoriasis has important physical and psychosocial effects that extend beyond the skin. Understanding the impact of treatment on health‐related quality of life (HRQoL) and patient‐perceived symptom severity in psoriasis is key to clinical decision‐making.

Objectives

This post hoc analysis of the PSO‐LONG trial data assessed the impact of long‐term proactive or reactive management with fixed‐dose combination calcipotriene 50 µg/g and betamethasone dipropionate 0.5 mg/g (Cal/BD) foam on patient‐reported outcomes (PROs) in patients with psoriasis vulgaris.

Methods

Five hundred and twenty‐one patients from the Phase 3, randomized, double‐blind PSO‐LONG trial were included. An initial 4‐week, open‐label phase of fixed‐dose combination Cal/BD foam once daily (QD) was followed by a 52‐week maintenance phase, at the start of which patients were randomized to a proactive management arm (Cal/BD foam twice weekly) or reactive management arm (vehicle foam twice weekly). Patient‐perceived symptom severity and HRQoL were assessed using the Psoriasis Symptom Inventory (PSI), the Dermatology Life Quality Index (DLQI) and the EuroQol‐5D for psoriasis (EQ‐5D‐5L‐PSO).

Results

Statistically and clinically significant improvements were observed across all PRO measures. The mean difference (standard deviation) from baseline to Week 4 was −8.97 (6.18) for PSI, −6.02 (5.46) for DLQI and 0.11 (0.15) for EQ‐5D‐5L‐PSO scores. During maintenance, patients receiving reactive management had significantly higher DLQI (15% [p = 0.007]) and PSI (15% [p = 0.0128]) and a numerically lower EQ‐5D‐5L‐PSO mean area under the curve score than patients receiving proactive management (1% [p = 0.0842]).

Conclusions

Cal/BD foam significantly improved DLQI, EQ‐5D‐5L‐PSO and PSI scores during the open‐label and maintenance phases. Patients assigned to proactive management had significantly better DLQI and PSI scores and numerically better EQ‐5D‐5L‐PSO versus reactive management. Additionally, baseline flare was associated with worse PROs than the start of a relapse, and patients starting a relapse also had worse PROs than patients in remission.

AB0573 DUPILUMAB-INDUCED ENTHESITIS/ARTHRITIS IN PATIENTS WITH ATOPIC DERMATITIS: A RETROSPECTIVE OBSERVATIONAL STUDY

Background:

Atopic dermatitis (AD) is a common skin condition with a prevalence of 2–10% in adults1. IL-4 and IL-13 play a key role in the pathogenesis. Dupilumab, a human IgG4 monoclonal antibody binding the alpha subunit of the IL-4 receptor, blocking IL-4 and IL-13 signaling, has important efficacy in this difficult to treat disease. We first reported a musculoskeletal (MSK) adverse effect of enthesis/arthritis developing in 3 patients in 20192.

Objectives:

To report the ongoing experience at our centre of this new clinical paradigm, incidence and patient progress including clinical presentation, imaging and management.

Methods:

Clinical and radiological data was collected from electronic case records of all cases presenting with features of enthesitis/arthritis between October 2018 and January 2021.

Results:

Since initiation of dupilumab at GSTT, approximately 400 adults with moderate-to-severe AD have received at least one dose. Of these, 23 patients (14 men, 9 women) had the clinical syndrome of inflammatory enthesitis/tenosynovitis/arthritis. Nine patients had both enthesitis and arthritis, 10 enthesitis, 3 enthesitis and tenosynovitis and 1 arthritis only. Four of these also reported new onset inflammatory back pain symptoms. None had a preceding history of arthritis or enthesitis. Median onset of symptoms following initiation of dupilumab was 4 months. However, onset of symptoms ranged between 2 weeks and 48 months. Imaging (US/MRI) was performed in 18 patients, 11 with Doppler US positive enthesitis confirming clinical findings. Most common sites were lateral epicondyles, achilles and patella tendons. Two patients with more disabling symptoms had MRI confirmed gluteus medius and hamstring enthesitis and arthritis. Spine and SI joint MRI in 4 patients was negative. Most patients had normal inflammatory markers except 2; CRP 117, ESR 96 and CRP 13, ESR 10. All patients had very good AD response to dupilumab, average EASI score before and after Dupilumab was 21 and 4.2 respectively. One patient developed skin manifestations of guttate psoriasis, with subsequent disabling arthritis/enthesitis. Due to the life-changing beneficial effect of dupilumab therapy most patients did not want to stop therapy. We used NSAID therapy, etoricoxib/celecoxib/naproxen for symptom relief which was usually partly effective allowing continuation of dupilumab treatment in most. Five patients with severe MSK symptoms stopped Dupilumab completely. Some patients temporarily paused therapy but re-started as their AD became worse, often changing from the usual 2 weekly to 4 weekly dosing. Most patients continuing dupilumab had persistent MSK symptoms. Four patients who stopped dupilumab were treated with baricitinib, which has potential efficacy for both MSK symptoms and AD. Two did not tolerate it and remained on NSAID therapy.

Conclusion:

These data further characterize a new syndrome of enthesitis and/or arthritis induced by Dupilumab. In those with mild MSK symptoms use of NSAIDs allows continuation of full-dose dupilumab, in moderate cases reducing dupilumab dose frequency plus NSAID therapy maintains function. Most patients had on-going MSK symptoms. In more severe cases JAKi therapy may be an effective strategy. Our initial hypothesis that inhibition of IL-4/13 by dupilumab triggers an IL-17/23/TNF-mediated inflammatory MSK syndrome in some patients is supported by a recent in vitro study3.

References:

[1]Beck L et al. Dupilumab Treatment in Adults with Moderate-to-Severe Atopic Dermatitis. July 10, 2014. N Engl J Med 2014; 371:130-139

[2]Willsmore ZN et al. Development of inflammatory arthritis and enthesitis in patients on dupilumab: a case series. Br J Dermatol 2019; 0. doi:10.1111/bjd.18031.

[3]Bridegwood C et al. Regulation of entheseal IL-23 expression by IL-4 and IL-13 as an explanation for arthropathy development under dupilumab therapy. Rheumatology (Oxford). 2020 Nov 30:keaa568. doi: 10.1093/rheumatology/keaa568

Disclosure of Interests:

Joseph Nathan: None declared., Catherine Hughes Speakers bureau: Presented for Abbvie, Samir Patel: None declared., Libin Mathew: None declared., Catherine Smith Grant/research support from: Grants/research support; Professor Smith is a PI/CoPI on a number of commercially supported studie (Abbvie, Janssen, Leo, Sanofi)., Andrew Pink Paid instructor for: Speaker or advisor to Lilly, Abbvie, Sanofi, Leo, Almirall, Novartis, Janssen, UCB, Galderma, BMS, La-Roche Posay, Richard Woolf: None declared., Bina Menon Speakers bureau: Presented for Abbvie, L Bruce Kirkham Grant/research support from: Professor Kirkham has received honoraria and/or research funding from AbbVie, Eli Lilly, Gilead, Janssen, Novartis, Pfizer and UCB.

SAT0376 DOES SUPPRESSION OF IL-4 AND IL-13 LEAD TO THE DEVELOPMENT OF NEW ONSET SPONDYLO-ARTHRITIS IN SUSCEPTIBLE PATIENTS?

Background:

Enthesitis is a key feature of peripheral Spondyloarthritis (SpA). Several pro-inflammatory cytokines including Interleukin-17 and Interleukin-23 are found within the enthesis (1). Dupilumab is a recombinant human monoclonal antibody that inhibits signalling of Interleukin-4 and Interleukin-13, approved for use in patients with moderate- to –severe atopic eczema. Here we describe a cohort of patients with severe atopic eczema who have developed a new peripheral SpA/ enthesitis after receiving Dupilumab.

Objectives:

To describe the clinical and imaging details of this cohort.

Methods:

All patients in St John’s Institute of Dermatology who exhibited new arthralgias on Dupilumab therapy were referred for assessment in Guy’s Rheumatology Department. These patients had a focussed history, examination, ultrasound and/or MRI of affected joints and entheseal sites.

Results:

To date we have seen 12 patients with a history of new inflammatory peripheral SpA type symptoms following onset of Dupilumab therapy. There were 7 males and 5 females all of whom have longstanding severe atopic Eczema. All patients had raised baseline IgE levels of mainly >10000. All patients exhibited a positive response to Dupilumab with a marked improvement in eczema as measured by the EASI score. All patients had normal inflammatory markers and negative immunological screening bloods. Musculoskeletal symptom onset was between 2 and 20 weeks after starting treatment. Typically, these patients had inflammatory symptoms affecting both the small joints and the entheseal sites. 2/12 patients developed inflammatory sounding spinal pain. 2/12 patients had ultrasound evidence of arthritis. 11/12 patients had radiological findings of enthesitis as seen on MRI or ultrasound (power doppler ultrasound signal). 9/12 patients were treated with non-steroidal anti-inflammatories with variable improvement.1 patient required no treatment and 1 patient received low dose prednisolone.

Conclusion:

In our centre approximately 200 patients have received Dupilumab. These musculoskeletal findings have not been reported previously in clinical trials. We hypothesise that the profound inhibition of IL- 4/13 may allow an inflammatory response at the enthesis presenting with a peripheral SpA pattern. IL-4 has been shown to suppress delayed type hypersensitivity reactions (DTHRs) and psoriasis in both human and mice studies (2). These findings and the demonstratation that IL-23 transcription and secretion can be suppressed by IL-4 with resultant reduction in Th17 function (3) may be key factors as to why a SpA type response is seen in certain subjects.

References:

[1]Bridgewood et al. Immunol Rev 2020 [Epub]

[2]Ghoreschi et al. Nat Med. 2003;9:40-6.

[3]Guenova et al. PNAS. 2015;112:2163-8.

Disclosure of Interests:

Catherine Hughes Speakers bureau: Lilly, Bina Menon Speakers bureau: Novartis, Richard Woolf: None declared, Zena Willsmore: None declared, Catherine Smith: None declared, Andrew Pink: None declared, L Bruce Kirkham Grant/research support from: Eli Lilly Novartis, Consultant of: Eli Lilly Gilead Janssen Novartis