POS0865 THE EFFECT OF SILVER FIBER GLOVES ON RAYNAUD’S PHENOMENON IN PATIENTS WITH SYSTEMIC SCLEROSIS: A DOUBLE-BLIND RANDOMIZED CROSS-OVER TRIAL

Background

Over 90% of patients with systemic sclerosis (SSc) experience Raynaud’s phenomenon (RP), which strongly influences quality of life. Therapeutic options of RP include drug treatment and general lifestyle measures such as smoking cessation and avoiding cold by wearing warm clothes and gloves including electrically heated gloves or silver fiber gloves. Clinical observations suggest an additional benefit of silver fiber gloves compared to normal gloves. Silver is thought to help by reflecting heat back into the hands allowing less heat to escape and has an antimicrobial effect. Despite its generalized use among SSc patients, no objective evidence regarding its superiority for RP over normal gloves exists.

Objectives

To evaluate the added value of 8% silver fiber gloves compared to normal gloves in the treatment of patients with RP secondary to SSc.

Methods

This was a multicenter double-blind randomized cross-over trial in which 85 SSc patients were randomized in two sequences: 8% silver fiber gloves in period 1 and normal gloves in period 2 or vice versa; each period lasted six weeks. To reduce bias of interindividual differences and external factors (e.g. temperature), a cross-over design was performed in the Netherlands during the winter months. The primary outcome was the triweekly Raynaud Condition Score (RCS), a scale from 1 (no symptoms) to 10 (extreme symptoms). A linear mixed model was used with RCS as dependent and type of gloves as independent variable, adjusted for baseline RCS. Secondary outcome measures included number of RP attacks, RP attack duration, Health Assessment Questionnaire (HAQ-DI) and vascular complications. Secondary outcomes were also analyzed with linear mixed models. All analyses were performed and interpreted before unblinding.

Results

The 85 included SSc patients had a mean age of 60 (SD:12), 80% were female, 60% had limited cutaneous SSc and 67% used vasoactive medication. Ten patients prematurely ended the study due to various reasons, most notable: allergic reaction to gloves (n=2). At baseline, mean RCS was 6.43 (SD 1.6), with silver fiber gloves the mean RCS decreased to 3.91 (SD 2.3) and with normal gloves to 3.90 (SD 2.3) (Figure 1). No statistically significant difference in RCS during follow-up was observed between the silver fiber gloves and normal gloves (β 0.067, 95% CI -0.006 to 0.19), meaning that on the 1-10 scale, silver fibre gloves gave only a 0.067 higher RCS compared to normal gloves (Table 1). For all other secondary outcome measures, we did not find a statistically significant difference between silver fiber gloves and normal gloves, except for the HAQ (β 0.036, 95% CI 0.026 to 0.046; Table 1), which is not clinically relevant. One vascular complication occurred in the silver fiber gloves, compared to three vascular in the normal gloves, which was not statistically significant different (OR:3.2, 95% CI 0.32 to 31.1).

Table 1.

Primary and secondary efficacy outcomes

β95% confidence intervalPrimary outcomeRaynaud Condition Score0.067-0.0059; 0.194Secondary outcomesRaynaud attacks frequency-0.480-1.215; 0.255Raynaud attacks duration39.80-36.051; 115.654VAS warmth hands-0.086-0.212; 0.041Impact Raynaud0.088-0.035; 0.211HAQ_DI0.0360.026; 0.046

VAS: visual analogue scale; HAQ: Health Assessment Questionnaire

The reference category was Normal gloves.

Linear mixed models were performed with the primary and secondary outcomes as dependent variables, the type of gloves as independent variable, adjusted for baseline Raynaud Condition Score.

Figure 1.

Raynaud Condition Score during the study period

Conclusion

This trial shows that wearing any type of glove decreases the RP burden in SSc patients, but no additional benefit from gloves containing 8% silver fibers compared to normal gloves could be demonstrated. Potentially, less vascular complications may arise in SSc patients wearing silver fiber gloves. Further confirmation of this potential benefit is necessary.

Acknowledgements

The authors would like to thank all participants of this study and Skafit for providing the gloves.

Disclosure of Interests

None declared

POS0916 A 10-YEAR JOURNEY OF CARING FOR PATIENTS WITH SYSTEMIC SCLEROSIS: FOLLOW-UP DATA ON DISEASE DURATION OF THE LEIDEN CCISS COHORT

Background

Combined Care in Systemic Sclerosis (CCISS) is a prospective cohort of patients referred to Leiden University Medical Center for Raynaud’s Phenomenon (RP), a suspicion of systemic sclerosis (SSc) or a connective tissue disease. This cohort is characterized by its standardized and extensive annual follow-up. Since initiation of the cohort in 2009, diagnostic criteria for SSc have been updated leading to a higher sensitivity for early SSc (ACR 2013 criteria). A recent Dutch study showed that there is a gap to time of diagnosis between men and women, despite of overall increase of SSc awareness (PMID: 31539063).

Objectives

To determine whether 1. time between first disease symptoms and diagnosis has changed over time, and 2. disease characteristics of SSc at first presentation in an expert clinic have changed over time for the total cohort, and between male and female patients.

Methods

Patients included in the CCISS cohort undergo annual evaluation and clinical, laboratory, and imaging variables are systematically recorded. For this study, patients fulfilling the ACR/EULAR 2013 SSc criteria were included, and categorized into three groups based on the cohort entrance year: 1) 2010 – 2013, 2) 2014 – 2017, and 3) 2018 – 2021. SSc patients with a baseline visit in 2009 (n=65) were excluded as these patients were often not newly referred. Disease duration was defined by months since first RP, since first non-RP symptom and months between first date of diagnosis by a physician and first non-RP symptom. Disease characteristics included presence of interstitial lung disease (ILD), pulmonary arterial hypertension, digital ulcers (DU), diffuse cutaneous SSc, anti-topoisomerase and anticentromere antibodies. At baseline, disease duration and disease characteristics were compared between the three groups using appropriate tests. In addition, disease duration was compared between males and females in the three groups.

Results

In total, 643 SSc patients were included of whom 229 (36%) had their baseline visit from 2010 until 2013, 207 (32%) from 2014 until 2017, and 207 (32%) from 2018 until 2021.

The proportion of female patients was significantly higher in the 2010 – 2013 group compared to the 2014 – 2017 and 2018 – 2021 group (Table 1). Over time, disease duration defined by RP duration and non-RP duration decreased as well as time between diagnosis and first non-RP symptom (Table 1). The proportion of patients presenting with ILD and DU was highest in the first group (Table 1).

Table 1.2010 - 2013 N=2292014- 2017 N=2072018 – 2021 N=207P-valueBASELINEAge, mean (SD)53 (15)57 (14)55 (14)0.003Female, %8676750.010RP duration, months (IQR)122 (46 – 240)93 (20 – 202)67 (20 – 210)0.003Non RP duration, months (IQR)43 (16 – 227)20 (5 – 112)17 (6 – 54)<0.001Diagnosis duration, months (IQR)116 (80 - 177)65 (45 – 105)25 (5 – 45)<0.001ΔRP and Non-RP, months (IQR)24 (0 – 99)18 (0 – 118)22 (0 – 120)0.337Anti-centromere antibodies, %3843490.092Anti-topoisomerase antibodies, %2424180.259Diffuse cutaneous SSc, %1923160.073Interstitial lung disease, %433131<0.001Pulmonary arterial hypertension, %3240.746Digital ulcers, %2013110.041

In both male and female SSc patients, disease duration and time between diagnosis and first non-RP decreased over time with a longer time in females for all durations which was significantly different for time between first RP and non-RP in 2014-2017 and 2018-2021 (Figure 1). For the 2018 – 2021 group, duration since diagnosis for female was 26 (4 - 46) and male 17 months (7 – 39; p=0.355), and time between RP and non-RP for female 24 (0 - 168) and male 12 months (0 – 48; p=0.029).

Figure 1.

Conclusion

Over time, we observe a decrease in disease duration and in SSc patients presenting with ILD or DU at cohort entrance. Our results indicate increased awareness of early SSc and identification of SSc patients before severe complications have occurred. At the same time our results show the urge for specific attention to improve timely diagnosis in female SSc patients.

Disclosure of Interests

None declared

The effect of silver fibre gloves on Raynaud's phenomenon in patients with systemic sclerosis: a double-blind randomized crossover trial

OBJECTIVES

Silver fibre gloves transport heat from the palm to the fingers, possibly reducing the burden of RP in SSc patients. We aim to evaluate the clinical efficiency of this intervention.

METHODS

A multicentre, double-blind, randomized trial was performed, accounting for interindividual differences and external factors using a crossover design. Patients were randomized in two groups: group 1 wore 8% silver fibre gloves in period 1 and normal gloves in period 2 and group 2 vice versa. Each period lasted 6 weeks. The primary outcome was the Raynaud Condition Score (RCS) over time (minimal clinical important difference 1.4), assessed three times per week using an online questionnaire. Secondary outcomes included vascular complications and Scleroderma-Health Assessment Questionnaire (SHAQ). Outcomes were evaluated before unblinding using linear mixed models.

RESULTS

A total of 85 SSc patients were included, with 76 completing the study. The mean RCS during 2 weeks before the study (i.e. without gloves) was 6.4 (s.d. 1.6). Both with silver fibre gloves and normal gloves the mean RCS decreased to 3.9 (s.d. 2.3) with a similar course over time. There was no difference in mean RCS over time between the type of gloves [β = 0.067 (95% CI -0.006, 0.19)]. Of secondary outcomes, total SHAQ [β = 0.036 (95% CI 0.026, 0.046)] was slightly higher with silver fibre gloves, which is clinically irrelevant. Three patients developed new digital ulcers with normal gloves vs one patient with silver fibre gloves [odds ratio 3.2 (95% CI 0.32, 31.1)].

CONCLUSIONS

Wearing gloves in SSc patients clearly decreases the RP burden. Our results do not support the hypothesis that increased heat transport of 8% silver fibre gloves is associated with less disease burden as measured in this study by the RCS compared with normal gloves.

CLINICAL TRIAL REGISTRATION NUMBER

Netherlands Trial register (https://www.trialregister.nl/) NL7904.

Predictive factors for treatment-related mortality and major adverse events after autologous haematopoietic stem cell transplantation for systemic sclerosis: results of a long-term follow-up multicentre study

BACKGROUND

Autologous haematopoietic stem cell transplantation (HSCT) improves survival in systemic sclerosis (SSc) with poor prognosis, but is hampered by treatment-related mortality (TRM).

OBJECTIVE

To evaluate event-free survival (EFS), TRM, response to treatment, disease progression and patient characteristics associated with events.

METHODS

All patients treated with HSCT for SSc in The Netherlands until 2017 (n=92) were included. Data on skin involvement (modified Rodnan skin score (mRSS), pulmonary function (forced vital capacity (FVC) and diffusion capacity of the lungs for carbon monoxide (DLCO)), extent of interstitial lung disease on high-resolution CT using Goh scores and left ventricular ejection fraction (LVEF) were collected at baseline, 1, 2 and 5 years. Occurrence of events, defined as death or major organ failure, were collected until 2019. As control, a comparison between patients treated with cyclophosphamide (CYC) and patients with HSCT who participated in the Autologous Stem Cell Transplantation International Scleroderma (ASTIS) trial was performed.

RESULTS

Median follow-up was 4.6 years. EFS estimates at 5, 10 and 15 years were 78%, 76% and 66%, respectively. Twenty deaths occurred. Mean FVC, DLCO, mRSS and Goh scores all improved significantly. Disease progression occurred in 22 patients. Frequency of TRM decreased over time and occurred more often in males. Events were independently associated with male sex, LVEF <50% and older age. In ASTIS, patients treated with HSCT (n=23) 7 events occurred versus 13 in the CYC group (n=22).

CONCLUSION

Our data confirm long-term efficacy of HSCT in improving survival, skin and lung involvement in SSc. Male sex, lower LVEF and older age at baseline were identified as risk factors for events.

Circulating calprotectin (S100A8/A9) is higher in rheumatoid arthritis patients that relapse within 12 months of tapering anti-rheumatic drugs

Objective

To investigate whether calprotectin (S100A8/A9 or MRP8/14), an inflammatory complex released by monocytes, could indicate residual subclinical inflammation in rheumatoid arthritis (RA) patients who are in stable remission on disease-modifying anti-rheumatic drugs (DMARDs) and serve as a marker for disease flare after DMARD tapering.

Methods

We used data from two trials. Patients from the IMPROVED study had early (< 2 years) RA, and when they achieved disease activity score remission (DAS44 < 1.6), they stopped methotrexate to attempt drug-free remission. Patients from the RETRO study had established RA in stable remission (DAS28 < 2.6) and either tapered by 50% or stopped (biological or conventional) DMARDs. Circulating calprotectin at the tapering time point was determined by ELISA, and its predictive value for flare (loss of remission) within 12 months of DMARD tapering/stopping was determined.

Results

In both IMPROVED (n = 104) and RETRO (n = 57), patients that flared within 12 months had higher calprotectin at the moment of DMARD tapering/stopping. Twofold higher calprotectin at the moment of DMARD tapering/stopping was associated with an increased risk (odds ratio) of flare of 1.07 (95% CI 0.98–1.18, p = 0.14) in the IMPROVED and 3.62 (95% CI 1.76–7.46, p < 0.001) in the RETRO. Correcting for clinical predictors of flare (DAS at study inclusion, anti-CCP2 positivity, gender) did not change these estimates. The area under the receiver operating curve of calprotectin levels for predicting flare within 12 months was 0.63 (95% CIs 0.51–0.76) in the IMPROVED study and 0.80 (95% CIs 0.69 to 0.92) in the RETRO study.

Conclusion

Circulating calprotectin levels in RA patients in remission on DMARDs are higher in patients that will flare upon DMARD tapering/stopping. Since the differences between the cohorts precluded definitive conclusions, more research is needed to determine whether calprotectin has prognostic value in predicting flare after attempting drug tapering in RA.

Trial registration

IMPROVED, ISRCTN11916566. RETRO, 2009-015740-42.

Rituximab in early systemic sclerosis

OBJECTIVES

(1) Hypothesis testing of the potency of rituximab (RTX) in preventing fibrotic complications and (2) assessing acceptability and feasibility of RTX in early systemic sclerosis (SSc).

METHODS

A small, 24-month, randomised, double-blind, placebo-controlled, single-centre trial in patients with SSc diagnosed <2 years was conducted. Patients received RTX or placebo infusions at t=0, t=15 days and t=6 months. Patients were clinically evaluated every 3 months, with lung function tests and high-resolution CT every other visit. Skin biopsies were taken at baseline and month 3. Immunophenotyping of peripheral blood mononuclear cells was performed at every visit, except at months 9 and 18. Adverse events, course of skin and pulmonary involvement and B cell populations in skin and peripheral blood were evaluated.

RESULTS

In total 16, patients (rituximab n=8, placebo n=8) were included. Twelve patients had diffuse cutaneous SSc. Eighty-eight adverse events (RTX n=53, placebo n=35, p=0.22) and 11 serious adverse events (RTX n=7, placebo n=4, p=0.36) occurred. No unexpected RTX-related events were observed. Mean skin score over time did not differ between the groups. Over time, forced vital capacity and extent of lung involvement slightly improved with RTX, but this difference was insignificant. In peripheral blood B cells depletion was demonstrated.

CONCLUSIONS

No unexpected safety issues were observed with RTX in early SSc. Although this small trial could not confirm or reject potential efficacy of RTX in these patients, future placebo-controlled trials are warranted, specifically in the subgroup of patients with pulmonary involvement.

TRIAL REGISTRATION NUMBER

EudraCT 2008-07180-16; Results.

The educational needs of people with systemic sclerosis: a cross-sectional study using the Dutch version of the Educational Needs Assessment Tool (D-ENAT)

The Dutch Educational Needs Assessment Tool (D-ENAT) systematically assesses educational needs of patients with rheumatic diseases. The present study aims to describe the educational needs of Dutch patients with systemic sclerosis (SSc). The D-ENAT was sent to 155 SSc patients registered at the outpatient clinic of a university hospital. The D-ENAT consists of 39 items in seven domains. “Each domain has different number of items therefore we normalized each domain score: (domain score/maximum) × 100) and expressed in percentage to enable comparisons between domains.” A total D-ENAT score (0–156) is calculated by summing all 39 items. In addition, age, disease duration, gender, educational level, present information need (yes/no) and information need (1–4; wanting to know nothing–everything) were recorded. Univariate regression analysis was used to examine factors associated with the D-ENAT scores. The response rate was 103 out of 155 (66 %). The mean % of educational needs scores (0–100 %; lowest–highest) were 49 % for “D-ENAT total score,” 46 % for “Managing pain,” 41 % for “Movement,” 43 % for “Feelings,” 59 % for “Disease process,” 44 % for “Treatments from health professionals,” 61 % for “Self-help measures” and 51 % for “Support systems.” No associations between the D-ENAT total score and age, disease duration, gender and educational level were found. The D-ENAT demonstrated its ability to identify educational needs of Dutch SSc patients. SSc patients demonstrated substantial educational needs, especially in the domains: “Disease process” and “Self-help measures.” The validity and practical applicability of the D-ENAT to make an inventory of SSc patients’ educational needs require further investigation.