State-of-the-art evidence in the treatment of systemic sclerosis

Systemic sclerosis (SSc) is a rare autoimmune connective tissue disease with multi-organ involvement, fibrosis and vasculopathy. Treatment in SSc, including early diffuse cutaneous SSc (dcSSc) and the use of organ-specific therapies, has improved, as evident from randomized clinical trials. Treatments for early dcSSc include immunosuppressive agents such as mycophenolate mofetil, methotrexate, cyclophosphamide, rituximab and tocilizumab. Patients with rapidly progressive early dcSSc might be eligible for autologous haematopoietic stem cell transplantation, which can improve survival. Morbidity from interstitial lung disease and pulmonary arterial hypertension is improving with the use of proven therapies. Mycophenolate mofetil has surpassed cyclophosphamide as the initial treatment for SSc-interstitial lung disease. Nintedanib and possibly perfinidone can be considered in SSc pulmonary fibrosis. Pulmonary arterial hypertension is frequently treated with initial combination therapy (for example, with phosphodiesterase 5 inhibitors and endothelin receptor antagonists) and, if necessary, the addition of a prostacyclin analogue. Raynaud phenomenon and digital ulcers are treated with dihydropyridine calcium channel blockers (especially nifedipine), then phosphodiesterase 5 inhibitors or intravenous iloprost. Bosentan can reduce the development of new digital ulcers. Trial data for other manifestations are mostly lacking. Research is needed to develop targeted and highly effective treatments, best practices for organ-specific screening and early intervention, and sensitive outcome measurements.

POS1247 CLINICAL FEATURES AND OUTCOMES OF COVID-19 IN PATIENTS WITH IGG4-RELATED DISEASE. A COLLABORATIVE EUROPEAN MULTI-CENTRE STUDY

Background:

Coronavirus disease 2019 (COVID-19) is a pandemic-spread systemic infectious disease with prominent respiratory manifestations and significant associated morbidity and mortality. Elderly people are most significantly affected with mortality ranging from 2.4% (age 60-69) to 19.6% (age>80) in European Countries. The prevalence of COVID-19 and of its complications in patients with immune-mediated disorders, remains unclear. The frequency and impact of COVID-19 on patients with IgG4-related diease (IgG4-RD), many of whom are on concurrent immunosuppression has not been addressed.

Objectives:

To assess the epidemiological and clinical relevance of COVID-19 in patients with IgG4-RD.

Methods:

This is a multi-centre retrospective observational study of IgG4-RD patients from France, Italy, Spain and the United Kingdom. Demographics, comorbidities, IgG4-RD features, current and past treatment along with COVID-19-suggestive symptoms and COVID-19 diagnoses from February 2020 to January 2021 were recorded by means of direct or phone interviews. Patients with reverse-transcriptase polymerase chain reaction-confirmed (cCOVID) or presumed COVID-19 based on clinical, serological or imaging features (pCOVID) were pooled for analysis (totCOVID) and compared to patients who were not diagnosed with COVID-19. Inter-group comparison of categorical and quantitative variables were performed by using the chi-square test with Fisher’s correction and the Mann-Whitney’s test respectively. Data are expressed as median (interquartile range) unless otherwise specified.

Results:

A total of 305 patients [71% males, median age 64 (54-74) years] were studied. Pancreato-biliary disease was the most frequently observed IgG4-RD phenotype (39%). Fifty-one percent of patients were taking corticosteroids at time of interview and 30% were on biological or conventional immunosuppressants. Thirty-two totCOVID cases (23 cCOVID, nine pCOVID) were identified: 11/32 were hospitalised, two needed intensive care and four (13%; 3/4 aged >80 years) died. Having one or more infected family members was a risk factor for COVID-19 in patients with IgG4-RD (OR=19.9; p<0.001). No other demographic, clinical or treatment features associated with COVID-19. In particular there was no association between adverse outcomes with COVID-19 and higher doses of steroids (>20mg) or rituximab administration.

Conclusion:

The prevalence and course of COVID-19 in IgG4-RD patients are similar to those of the general population of the same age, with no evident impact of disease- or treatment-related factors to the basal infectious risk. Effective public health countermeasures might be beneficial for patients with IgG4RD.

References:

[1]European Centre for Disease Prevention and Control (ECDC): https://covid19-surveillance-report.ecdc.europa.eu/

[2]Yang H, Ann Rheum Dis, 2021

Disclosure of Interests:

Giuseppe Alvise Ramirez: None declared, Marco Lanzillotta: None declared, Mikael Ebbo: None declared, Andreu Fernandez-Codina Consultant of: consulting fees from Atheneum Consulting, Gaia Mancuso: None declared, Fernando Martínez-Valle: None declared, Olimpia Orozco-Galvez: None declared, Nicolas Schleinitz: None declared, Lorenzo Dagna Consultant of: Abbvie, Amgen, Biogen, BristolMyers Squibb, Celltrion, Galapagos, GlaxoSmithKline, Novartis, Pfizer, Roche, Sanofi-Genzyme, and SOBI, Grant/research support from: The Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR) received unresctricted research/educational grants from Abbvie, Bristol-Myers Squibb, Celgene, GlaxoSmithKline,Janssen, Merk Sharp & Dohme, Mundipharma Pharmaceuticals, Novartis, Pfizer, Roche, Sanofi Genzyme, and SOBI, Emma L. Culver: None declared, Emanuel Della Torre: None declared

OP0172 BRENTUXIMAB VEDONTIN FOR SKIN INVOLVEMENT IN REFRACTORY DIFFUSE CUTANEOUS SYSTEMIC SCLEROSIS, INTERIM RESULTS OF A PHASE IIB OPEN-LABEL TRIAL

Background:

Systemic sclerosis (SSc) is an autoimmune disease affecting multiple organs causing morbidity and mortality. Treatments targeting SSc skin often have limited success. The presence of CD30+ lymphocytes in skin biopsies and increased levels of serum CD30 have been reported in SSc patients1. This could constitute a new therapeutic target.

Objectives:

To explore the efficacy and safety of brentuximab vedotin, a chimeric anti-CD30 antibody drug conjugate, in patients with severe active diffuse cutaneous SSc who failed multiple treatments.

Methods:

This Phase IIb, single center, open-label, investigator-initiated trial will recruit 10 patients. Brentuximab vedotin 0.6 mg/Kg was infused intravenously every 3 weeks for 48 weeks. Inclusion criteria were age ≥18 years, meeting the 2013 ACR/EULAR SSc classification criteria, modified Rodnan skin score (mRSS) ≥15 with <5 years since the first non-Raynaud’s symptom and/or skin worsening despite immunosuppression. Patients were allowed to continue their standard of care medications for SSc except for rituximab. Patients with severe cardiac or pulmonary SSc involvement, severe infections, significant peripheral neuropathy, or active malignancy were excluded. The primary objective was a decrease in mRSS of ≥8 at 48 weeks. The main secondary endpoint was MRSS at 24 weeks. Differences were assessed by paired t tests. Data were compared to 16 age, disease duration, mRSS and past/present use of immunosuppressors-matched controls (ratio 2-3:1) from the Canadian Scleroderma Research Group (CSRG) registry.

Results:

Eight of 10 patients have been recruited to date; two are in the first 8 weeks and one was withdrawn at her request after developing influenza at week 12. Five subjects (60% female) have reached week 24, and 3 have completed 48 weeks. The mRSS is shown in Table 1. The ΔMRSS for patients treated with brentuximab between weeks 0 and 24 was 8.2 ([CI 95% 2.8, 13.6], p = 0.013) and from 0 to 48 was 15.3 ([CI 95% 8.2, 22.5], p = 0.012). Whereas, the ΔMRSS for the CSRG controls was 3.1 ([CI 95% -2, 8.2], p = 0.211) at 48 weeks. Assuming that mRSS would at least be the same from week 24 to 48 in the 2 cases who are between 24 and 48 weeks with brentuximab, we compared the 5 cases vs controls (Figure 1). ΔMRSS for Brentuximab was 12.2 ([CI 95% 5.9, 18.5], p = 0.006. No cases have developed a peripheral neuropathy and only one SAE (influenza).

Table 1.N (SD)NAgeDisease durationmRSS week 0mRSS week 24mRSS week 48mRSS week 48**Case560.2 (9.3)4.5 (2.1)33 (5.2)24.8 (6)15.7 (3)20.8 (8.3)Control1658.5 (8.3)4.9 (2.1)31.3 (5.9)N/D28.1 (7.5)28.1 (7.5)p0.7310.7750.559N/D0.0130.079

mRSS = modified Rodnan skin score, N/D = no data, ** = comparisons including 5 cases, assuming stability in MRSS from week 24 to 48 in cases 5 and 6

Figure 1.

Conclusion:

Brentuximab vedontin already achieved the primary endpoint at 24 weeks, after half of the intended recruitment sample reached this landmark. A comparison with CSRG controls showed that mRSS only decreased significantly in patients treated with brentuximab. This interim report suggests that brentuximab vedontin might effectively improve skin involvement in patients with diffuse SSc and severe skin involvement.

References:

[1]Mavalia C, Scaletti C, Romagnani P, et al. Type 2 helper T-cell predominance and high CD30 expression in systemic sclerosis. Am J Pathol. 1997;151(6):1751-8.

Acknowledgements:

We would like to acknowledge the Canadian Scleroderma Research Group, Louise Vanderhoek, Sara Macdonald Hewitt and Jillian Bylsma for their collaboration

Disclosure of Interests:

Andreu Fernandez-Codina Consultant of: Bayer, Boehringer Ingelheim, Atheneum consulting, Tatiana Nevskaya: None declared, Janet Pope Speakers bureau: Actelion, Amgen, Abbie, Bayer, Boehringer Ingelheim, BMS, Eli Lilly, Galapagos, Gilead, Janssen, Medexus, Merck, Novartis, Pfizer, Roche, Samsung, Sandoz, Sanofi, Teva, UCB., Consultant of: Actelion, Amgen, Abbie, Bayer, Boehringer Ingelheim, BMS, Eli Lilly, Galapagos, Gilead, Janssen, Medexus, Merck, Novartis, Pfizer, Roche, Samsung, Sandoz, Sanofi, Teva, UCB., Grant/research support from: Actelion, Amgen, Abbie, Bayer, Boehringer Ingelheim, BMS, Eli Lilly, Galapagos, Gilead, Janssen, Medexus, Merck, Novartis, Pfizer, Roche, Samsung, Sandoz, Sanofi, Teva, UCB.