Pathogenic mechanisms involving the interplay between adipose tissue and autoantibodies in Rheumatoid arthritis

We aimed to evaluate the association between adipose tissue (AT) dysfunction, autoimmunity, and disease activity in rheumatoid arthritis (RA). A cross-sectional study including 150 RA patients and 50 healthy donors and longitudinal study with 122 RA patients treated with anti-tumor necrosis factor (TNF)-α, anti-interleukin 6 receptor (IL6R) or anti-CD20 therapies for 6 months were carried out. In vitro experiments with human AT and adipocyte and macrophage cell lines were performed. A collagen-induced arthritis mouse model was developed. The insulin resistance and the altered adipocytokine profile were associated with disease activity, the presence of anti-citrullinated proteins anti-bodies (ACPAs), and worse response to therapy in RA. AT in the context of arthritis is characterized by an inflammatory state alongside the infiltration of macrophages and B/plasmatic cells, where ACPAs can have a direct impact, inducing inflammation and insulin resistance in macrophages and promoting a defective adipocyte differentiation, partially restored by biologicals.

•

IR is related to disease activity, inflammation, and autoimmunity in RA patients

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IR state and adipocytokines might be associated with a worse response to biologics

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Visfatin could be used as a potential biomarker of subclinical atherosclerosis

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ACPAs might directly impact adipose tissue

POS0647 DOES TNF INHIBITOR MOLECULAR STRUCTURE MATTER? ANALYSIS OF IMPACT OF BASELINE RHEUMATOID FACTOR TITERS ON DRUG LEVELS IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Elevated rheumatoid factor (RF) in patients with rheumatoid arthritis (RA) is associated with higher disease activity and increased risk for disease progression1.

Recent publications indicate significantly lower efficacy of TNF inhibitors (TNFi) in RA patients with high RF levels compared with low/negative RF subgroup2,3. Fab therapy with Certolizumab pegol (CZP), a PEGylated, Fc-free monoclonal antibody (mAb), has shown comparable efficacy and consistent serum levels irrespective of baseline RF4.

RF binds the Fc region of IgG1, the subtype used to engineer the majority of mAbs5. Formation of large immune complexes may likely explain the inceased clearance of mAbs in patients with high RF titers and reported reduced TNFi efficacy.

Objectives

We aimed to evaluate in clinical practice whether RF levels in RA patients influence serum drug levels of 3 TNFi with different molecular structures.

Methods

We evaluated retrospectively a cohort of RA patients from La Paz University Hospital (RA-Paz Registry, 1999-2019) treated with Infliximab (IFX), Adalimumab (ADA) or CZP. Clinical and demographic data were collected at baseline (T0) and after 6 months (T6) of treatment. RF titers and serum drug levels were measured at T0 and T6 using nephelometry and ELISA respectively. Association between baseline RF titers and drug levels was assessed using non-parametric test (Mann-Whitney).

Results

168 patients were evaluated: 90 received IFX, 48 ADA and 32 CZP. Characteristics at T0 are shown in Table 1. All patients had active disease at baseline and 76% were RF positive: ADA subgroup had lower percentage of positive RF than IFX and CZP subgroups. Patients were stratified into quartiles based on baseline RF titers: low (20-57 IU/ml), medium (57-380 IU/ml), high (>380 IU/ml) and seronegative (<20 IU/ml).

Table 1.

Baseline characteristics.

CharacteristicsTotal (n=168)IFX (n=90)ADL (n=48)CZP (n=32)p valueAge, years*55.5(45.3-66)57(46-65)50(42-64)61(47-70)0.08Body mass index, Kg/m2*24.5(21.7-29)24.2(21.8-27.7)24.7(21.5-30.3)24.6(22.2-30.3)0.3Male, n(%)28(17%)14(15%)9(19%)5(17%)0.2Disease duration, years*8.7(4.5-14.3)8.4 (4.4-14.3)8.8 (3.9-16)9.7(5-12)0.06Smoking status, n(%)0.03Currently/ex-smoker66(39%)29(32%)22(48%)16(57%)Non-smoker96(57%)61(68%)24(52%)12(43%)RF, n(%)128(76%)75(83%)28(58%)25(81%)0.002ACPA, n(%)134(80%)73(81%)35(73%)27(84%)0.3DAS28**5.1(1.3)5.4(1.3)4.5(1.3)4.9(1.3)0.002CRP levels*7.8(3-21.8)10.3(3.2-25.2)5.1(1.4-10.1)7.8(2.3-18.2)0.1Prior bDMARDs, n(%)26(15%)10 (11%)10 (21%)6(20%)0.2Monotherapy, n(%)16(10%)8(9%)8(17%)00.2csDMARDS, n(%)152(90%)82(91%)82(91%)32(100%)Methotrexate, n(%)112(67%)64(78%)33(83%)17(53%)0.2Other csDMARDs, n(%)24(24%)18(22%)7(18%)15(50%)0.0008Prednisone, n(%)85(51%)49(54%)21(44%)16(50%)0.6

*Median and interquartile range;**mean and standard deviation

Drug levels of IFX and ADA at T6 were significantly lower in those patients who had higher RF titers at T0 compared to seronegative. In contrast, CZP levels remained stable irrespectively of baseline RF titers, without significant differences among quartiles (Figure 1).

Conclusion

Higher baseline RF titers are associated with lower IFX and ADA levels at T6 in a cohort of RA patients. A concentration-response association has been clearly established for TNFi, and baseline RF levels appear to influence drug levels.

Reduced immune complexes formation with CZP may result in a limited impact of baseline RF titers on drug levels.

References

[1]Aletaha D. Arthritis Res Ther2015;17(1):229.

[2]Bobbio-Pallavicini F. Ann Rheum Dis 2007;66(3):302–7.

[3]Potter C. Ann Rheum Dis 2009;68(1):69–74.

[4]Tanaka Y. APLAR 2020. Oral Communication.

[5]Levy RA. Immunotherapy 2016;8(12):1427-1436.

Acknowledgements

This study was funded by an anrestricted reserch grant from UCB pharma.

Disclosure of Interests

ANA MARTÍNEZ-FEITO: None declared, Borja Hernández-Breijo: None declared, Marta Novella-Navarro Grant/research support from: UCB, Alejandro Villalba: None declared, Diana Peiteado: None declared, Pilar Nozal: None declared, DORA PASCUAL-SALCEDO Speakers bureau: Abbvie, Pfizer, Novartis, Takeda, Menarini and MSD., Grant/research support from: Abbvie, Pfizer, Novartis, Takeda, Menarini and MSD., Alejandro Balsa Speakers bureau: Pfizer, AbbVie, Galapagos, Lilly, Gilead, UCB, Nordic, Sandoz, Consultant of: Galapagos, Pfizer, AbbVie, Lilly, UCB, Nordic, Grant/research support from: Pfizer, Abbvie, UCB, Chamaida Plasencia Speakers bureau: Abbvie, Pfizer, UCB, Sandoz, Sanofi, Biogen, Lilly, Roche and Novartis, Grant/research support from: Abbvie, Pfizer, UCB, Sandoz, Sanofi, Biogen, Lilly, Roche and Novartis

AB1469 SPANISH TRANSLATION AND CROSS-CULTURAL ADAPTATION OF THE mSQUASH

Background

Regular physical activity is recommended for all patients in the ASAS/EULAR recommendations for the management of axial spondyloarthritis (axSpA). However, there is a lack of outcome measures that assess the amount and type of physical activity in patients with axSpA. For this matter, the modified Short QUestionnaire to Assess Health enhancing physical activity (mSQUASH) was developed and validated, originally in Dutch1.

Objectives

To translate and cross-culturally adapt the mSQUASH into Spanish and to test the equivalence of the translated version in patients with axSpA.

Methods

The mSQUASH was translated into Spanish and then back-translated into Dutch, following forward-backward procedure as described by Beaton2 (Figure 1). Two bi-lingual translators (native speakers for European Spanish) produced independent forward translations of the item content, response options, and instructions of the mSQUASH into Spanish. Both versions were harmonized in a meeting among the Spanish translators, a methodologist and a rheumatologist into a consensual version. Another translator (native speaker for Dutch), blinded for the original version, back translated the synthesized version into Dutch. An expert committee, including all translators, one methodologist and a rheumatologist, reached consensus on discrepancies, ensuring equivalence between the Dutch and Spanish versions, and developed a pre-final version of the Spanish mSQUASH. The field test with cognitive debriefing involved a sample of 10 patients with axSpA covering the full spectrum of the disease -radiographic axSpA (r-axSpA) and non-radiographic axSpA (nr-axSpA)- with different gender, age, disease duration, and educational background. Each patient was interviewed to check understandability, interpretation and cultural relevance of the translation.

Figure 1.

Cross-cultural adaptation of the mSQUASH

Results

The translation process of the mSQUASH was completed without major complications following the forward-backward procedure. The first translation needed several iterations due to small discrepancies in the wording. Back-translation was performed without difficulties, and the expert committee agreed upon a final version of the questionnaire. A total of 10 patients with axSpA participated in the field test (Table 1). Seven were male, mean age (SD) was 38.9 (14.4) years; 6 patients had r-axSpA, 9 were HLA-B27+. Cognitive debriefing showed the Spanish questionnaire to be, relevant, understandable and comprehensive. The preliminary version was accepted with minor modifications. As a result of the interviews, minor spelling errors were corrected, and the wording of the response categories was homogenized (“despacio/ligero”). Besides, the term “colegio”- translated literally from the Dutch “school”- was found not comprehensive enough to reflect possibilities on education (i.e. it does not include university), so it was adapted to “el lugar de estudio”.

Table 1.

Patients’ characteristics

#GenderAgeWorking statusEducationaxSpA subtypeDisease durationHLA-B27DrugBASDAI1Male63WorkingUniversityr-axSpA35 y+NSAIDs2.32Male24StudentSecondaryr-axSpA6 y+NSAIDs03Male37WorkingUniversityr-axSpA5 y+ADA2.54Male66RetiredUniversityr-axSpA23 y+IFN3.15Male29WorkingUniversityr-axSpA11 y+ADA06Female26WorkingUniversitynr-axSpA2 y+NSAIDs-7Male24StudentUniversitynr-axSpA1 y+ETA4.58Male35WorkingUniversityr-axSpA12 y+GOL09Female40WorkingSecondarynr-axSpA4 y+NSAIDs-10Female45UnemployedPrimarynr-axSpA9 y-GOL8.2

Conclusion

The resulting Spanish version of the mSQUASH showed good linguistic and face validity according to the field test, revealing potential for use in both clinical practice and research settings. In order to conclude the cross-cultural adaptation of the mSQUASH into Spanish, the next step is the assessment of psychometric properties of the Spanish version.

References

[1]Beaton DE, et al. Spine. 2000; 25:3186-91

[2]Carbo et al. Semin Arthritis Rheum. 2021; 51:719-27

Disclosure of Interests

Diego Benavent Speakers bureau: Jannsen, Roche, Grant/research support from: Novartis, Andrea Jochems: None declared, DORA PASCUAL-SALCEDO Speakers bureau: Pfizer, Menarini, Takeda, Abvvie., Grant/research support from: Pfizer, Menarini, Takeda, Abvvie., Gijs Jochems: None declared, Chamaida Plasencia Speakers bureau: Pfizer, Abbvie, Lilly, Sandoz, Sanofi, Biogen, Roche and Novartis, Grant/research support from: Pfizer and Abbvie, Sofia Ramiro Speakers bureau: Eli Lilly, MSD, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, UCB, Sanofi, Grant/research support from: AbbVie, Galapagos, Novartis, Pfizer, UCB, Suzanne Arends: None declared, Anneke Spoorenberg Consultant of: AbbVie, Novartis, Pfizer; UCB, Lilly, Grant/research support from: AbbVie, Pfizer, Alejandro Balsa Speakers bureau: Pfizer, Abbvie, Lilly, Galapagos, BMS, Sandoz, Nordic Pharma, Gebro, Roche, Sanofi, UCB, Consultant of: Pfizer, Abbvie, Lilly, Galapagos, BMS, Nordic Pharma, Sanofi, UCB, Grant/research support from: Pfizer, Abbvie, BMS, Nordic Pharma, Gebro, Roche, UCB, Victoria Navarro-Compán Speakers bureau: AbbVie, Eli Lilly, Janssen, MSD, Novartis, Pfizer, UCB Pharma, Consultant of: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, UCB Pharma, Grant/research support from: AbbVie and Novartis

POS0907 ASSOCIATION BETWEEN DISEASE ACTIVITY AND DAMAGE IN IDIOPATHIC INFLAMMATORY MYOPATHIES. DIFFERENCES BETWEEN INCIDENT AND PREVALENT CASES

Background

There are different measures and tools validated to evaluate disease activity and damage in idiopathic inflammatory myopathies (IIM). Disease activity and damage in patients with early diagnosis is not still well defined.

Objectives

To analyze disease activity outcomes and their association with damage in IIM differentiating between incident and prevalent cases.

Methods

Multicenter cross-sectional study of a cohort of patients included in the Spanish Registry of patients with IIM (Myo-Spain)(1). Patients were classified as incident cohort (time between diagnosis and study initiation ≤ 12 months) or prevalent cohort (> 12 months). Activity and damage data were collected at the initial visit. Differences between both groups were tested by Chi-square, Student’s t and Mann-Whitney tests. Spearman’s correlation coefficients (Rho) were used to analyze correlations between disease activity and damage measures (weak ≥ 0.2 - <0.3; moderate ≥ 0.3 <0.7; strong ≥ 0.7).

Results

We included 139 (67.63% women) and 417 patients (74.34% women) with a mean age at diagnosis of 54 and 48 years in the incident and prevalent cohort, respectively. Patients in the incident cohort had significantly higher disease activity measures: myositis disease activity assessment visual analogue scale (MYOACT) total, extramuscular activity of MYOACT, physician global activity (PhGA), patient global activity (PGA), manual muscle testing (MMT)8, CK, and HAQ (p < 0.001).The organ systems with the bigger differences between the incident and the prevalent cohort were skin and constitutional (p<0.001). No significant differences were found respect to physician global damage (PhGD), patient global damage (PGD) and myositis damage index (MDI), between both cohorts (p > 0.2). Correlations between disease activity and damage measures are showed in the Table 1. The main differences found between both cohorts were the correlations of PhGA, CK, PGD and MDI with other measures of disease activity.

Table 1.

Correlations between disease activity and damage measures

Incident cohortPrevalent cohortMYOACT totalExtramuscular activity of MYOACTPhGAMMT- 8MYOACT totalExtramuscular activity of MYOACTPhGAMMT- 8Extramuscular activity of MYOACTRho0.7610.673-0.1660.77710.764-0.214P-value<0.001<0.001<0.0010.065<0.001<0.001<0.001<0.001PhGARho0.8230.6731-0.50.7790.7641-0.301P-value<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001PGARho0.6670.5440.679-0.4340.5850.5280.623-0.345P-value<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001MMT-8Rho-0.471-0.166-0.51-0.383-0.214-0.3011P-value<0.0010.065<0.001<0.001<0.001<0.001<0.001<0.001CKRho0.221-0.0860.234-0.4380.07-0.0240.112-0.11P-value0.0140.3510.008<0.0010.1780.6480.0290.034HAQRho0.4860.3380.528-0.490.3860.2480.384-0.505P-value<0.001<0.001<0.001<0.001<0.001<0.001<0.001<0.001PhGDRho0.3670.310.448-0.3050.5730.4920.598-0.334P-value<0.0010.001<0.0010.001<0.001<0.001<0.001<0.001PGDRho0.2930.1630.354-0.2950.4680.4080.476-0.347P-value0.0030.102<0.0010.002<0.001<0.001<0.001<0.001MDIRho0.3980.2790.388-0.2320.5790.4770.545-0.343P-value<0.0010.006<0.0010.026<0.001<0.001<0.001<0.001

Myositis disease activity assessment visual analogue scale (MYOACT), physician global activity (PhGA), patient globalactivity (PGA), manual muscle testing (MMT)8, health assessment questionnaire (HAQ), physician global damage(PhGD), patient global damage (PGD), myositis damage index (MDI).

Conclusion

Incident cases had higher disease activity. In those in whom damage was detected, no differences were found in damage measures with prevalent cases. The correlation between the different measures of activity and damage was slightly better in prevalent patients.

References

[1]Cobo-Ibáñez T, et al. Myo-Spain: Spanish Registry of patients with idiopathic inflammatory myopathy. Methodology. Reumatol Clin (Engl Ed). 2021 Aug 13:S2173-5743(21)00156-8.

Acknowledgements

To Nuria Montero for her contribution to data monitoring, and Francisco Javier Prado-Galbarro for his contribution to data analysis.

Disclosure of Interests

None declared

POS0264 CHARACTERIZATION OF THE IMMUNE RESPONSE IN PATIENTS WITH INFLAMMATORY IMMUNE-MEDIATED DISEASES ON IMMUNOSUPPRESSIVE TREATMENT AFTER ONE MONTH OF SARS-CoV-2 VACCINATION

Background

The relevance of studying immune response after SARS-CoV-2 vaccination in patients with inflammatory immune-mediated diseases (IMIDs) represents a deep concern regarding the risk estimation and management of patients with these diseases on immunomodulatory drugs. It is well known that certain treatments as anti CD20 therapies results in a diminished immunogenicity against common vaccines but it is a scarce data regarding the cellular protection obtained upon vaccination between patients with different IMID and between different treatments.

Objectives

To compare a potential detriment on cellular and antibody-mediated protection upon SARS-CoV-2 vaccination in patients with IMIDs treated with immunosuppressive drugs.

Methods

We recruited 73 patients with rheumatoid arthritis-RA-(n=49), spondylarthritis-SpA-(n=19), inflammatory bowel disease-IBD-(n=5), idiopathic juvenile arthritis-IJA- (n=2) and heterogenous group composed of sclerodermia, lupus, uveitis…(n=6). They were treated mainly with rituximab (n=27), TNFi (n=37) or JAKi (n=3). We collected data of age,sex, csDMARDs, previous SARS-CoV-2 infection, last RTX infusion and prednisone use.

After one month of vaccination, we assessed the humoral response performing the Thermo Scientific EliA SARS-CoV-2-Sp1 IgG Test (positivity cut-off >0.70 IU/ml) which was also compared with the data with of 35 healthy controls. In addition, in 40 patients who had serum antibody levels under 100UI/ml, we analysed the cellular response by the use of the QuantiFERON SARS-CoV-2 Starter Pack (Quiagen). A cut-off value of 0.15 IU/ml discriminate between positive or negative cell-mediated immune responses. We compared differences among the different IMIDs and between the different immunosuppressive treatments through non-parametric test (p<0.05)

Results

Regarding demographic characteristics of patients, older patients (>56 years) and female sex were factors which were associated with low titles of serum antibodies.

Anti-spike IgG antibodies were present in an 86% of the IMIDs patients and in 100% healthy controls with significant different IgG titre (median [IQR]): 51[11-184] vs 700[440-940]; p<0.0001.

The differences between (median [IQR]) serum antibody levels were statistically different between IMID type: 33[1-138] in RA vs 94[34-191] in SpA vs 204[187-204] in IBD vs 133[61-204] in IJA vs 13[1.5-31.8] in the rest; p=0.04. Remarkably, patients with IBD who had the highest antibodies titles were the youngest compared with the other patients.

Target of the therapy played also an important role in serum antibody levels being these: 3.6 [0.7-51] in RTX patients vs 156 [45-204] in TNFi vs 40 [18-58] in JAKi patients; p<0.0001. In those patients who the last infusion of rituximab was, at least, one year before vaccination presented CD19+ B cells detected by flow cytometry and anti-spike IgG antibodies as well.

Cell-mediated responses to SARS-CoV-2 were positive in 33% of IMIDs patients, indeterminated in 3% and negative in 65% of the patients. Strikingly, out of the 33% positive patients, 85% were treated with RTX. A 61% of the RTX patients had inducible cell-mediated responses vs 14% of the patients treated with TNFi; p<0.01. On the other hand, there were not differences in cell-mediated responses between positive and negative antibody patients.

Conclusion

Titres of serum antibodies against spike protein of SARS-CoV-2 were lower in IMIDs patients than in controls. Patients with RTX had lower rates of positivity humoral response as well as lower serum titles than patients treated with other therapies regardless the patients ‘age. Neverthless, in those patients in whom RTX infusion was delayed because of vaccination they conserved a humoral response.

On the other hand, more patients treated with RTX had inducible cell-mediated responses compared with patients with TNFi.

Disclosure of Interests

ANA MARTÍNEZ-FEITO: None declared, Pilar Nozal: None declared, Marta Novella-Navarro: None declared, Elisa Fernández-Fernández: None declared, Lucia del pino molina: None declared, Milagros Casas Temprano: None declared, Ibtissam Akatbach Bousaid: None declared, Maria Dolores Martin Arranz: None declared, Alejandro Balsa Speakers bureau: Pfizer,Abbvie,Lilly, Galapos,BMS, Sandoz,Nordic,Gebro,Roche, UCB, Consultant of: Pfizer,Abbvie,Lilly, Galapos,BMS, Sandoz,Nordic, Sanofi,UCB, Grant/research support from: Pfizer,Abbvie,BMS,Nordic,Gebro,Roche, UCB, Chamaida Plasencia Grant/research support from: Abbvie, Pfizer, UCB, Sandoz, Sanofi, Biogen, Lilly, Roche and Novartis

AB1472 TRANSLATION AND CROSS-CULTURAL ADAPTATION OF THE CORS INTO SPANISH

Background

Rheumatic diseases substantially affect the lives of patients, with complex associations between disease severity and self-perceived health status. In this regard, the Coping with Rheumatic Stressors (CORS) questionnaire was developed to measure how patients with rheumatoid arthritis cope with stressors such as pain or dependence. There is no validated instrument to measure coping in axial spondyloarthritis (axSpA) and therefore the adaptation of the CORS would be of great value.

Objectives

To cross-culturally adapt the CORS into Spanish and to test the conceptual equivalence of the translated version in patients with axSpA.

Methods

A translation of the CORS into Spanish was performed, followed by a back-translation into Dutch, following forward-backward procedure as described by Beaton1(Figure 1). Two bi-lingual translators (native speakers for Spanish), one of them informed of the content of the questionnaire and the other not informed, produced independent forward translations of the item content, response options, and instructions of the CORS into Spanish. Both versions were harmonized in a consensual version. Another translator (native speaker for Dutch), not informed of the concepts used in the questionnaire, back translated the synthesized version into Dutch. An expert committee including all translators, one methodologist and a rheumatologist, held a meeting and reached consensus on discrepancies to develop a pre-final version of the Spanish CORS. The field test with cognitive debriefing involved a sample of 10 patients with axSpA covering the full spectrum of the disease and with different sociodemographic backgrounds.

Figure 1.

Cross-cultural adaptation of the CORS

Results

The translation process of the CORS was completed following the forward-backward procedure, after discussion of the discrepancies throughout the process. The first translation was done without major complications. However, several discrepancies appeared in the back-translation, in which there were minor modifications in the wording in one response option (“muchas veces” to “muy a menudo”) and 15 questionnaire items. As an example, “Ik ga de deur uit”, literally meaning “I go out by the door”, was initially translated as such (“salgo por la puerta”); however, it conceptually represents “I go away”, and it was adapted like this (“me voy a la calle”). Thus, a pre-final consensus version of the CORS was agreed by the expert committee. This pre-final version was field tested in 10 patients with axSpA: mean age (SD) was 38.9 (14.4) years, 7 patients were male, 6 had radiographic axSpA, and 9 were HLA-B27+. The Spanish questionnaire appeared clear and understandable to all patients. However, some minor modifications were proposed in some items (Table 1). As a result of the cognitive debriefing, two changes were implemented (one instruction and one item), whereas two other suggestions did not lead to any change due to minor wording discrepancies with similar conceptual equivalence. The final version of the Spanish CORS is shown at shorturl.at/cimC6.

Table 1.

Cognitive debriefing queries and decisions from the expert committee

Original Dutch itemSpanish translation pre-final# Patient queriesQueriesFinal version(….) aan te geven hoe vaak u het beschreven gedrag uitvoert.(…) indique cuán a menudo usted ha llevado a cabo dicho comportamiento.1Literal discrepancies(…) indique la frecuencia con que usted ha tenido dicho comportamiento.Ik rust op tijd uitMe voy a tiempo a descansar1Literal discrepanciesNo changesIk probeer er het beste van te makenIntento aprovechar al máximo1Literal discrepanciesNo changesIk houd rekening met anderenTengo en cuenta a los demás2Meaning doubtsTengo en consideración a los que me ayudan/cuidan

Conclusion

The Spanish version of the CORS showed good cross-cultural validity and good face validity in patients with axSpA according to the field test. Before the Spanish CORS is implemented, further validation is in progress to test the psychometric properties of the instrument.

References

[1]Beaton DE, et al. Spine. 2000; 25:3186-91

Disclosure of Interests

Diego Benavent Speakers bureau: Jannsen, Roche, Grant/research support from: Novartis, Andrea Jochems: None declared, DORA PASCUAL-SALCEDO Speakers bureau: Pfizer, Menarini, Takeda, Abvvie., Grant/research support from: Pfizer, Menarini, Takeda, Abvvie., Gijs Jochems: None declared, Chamaida Plasencia Speakers bureau: Pfizer, Abvvie, Lilly, Sandoz, Sanofi, Biogen, Roche, Novartis., Grant/research support from: Pfizer, Abvvie., Sofia Ramiro Speakers bureau: Eli Lilly, MSD, Novartis, UC, Consultant of: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, UCB, Sanofi, Grant/research support from: AbbVie, Galapagos, Novartis, Pfizer, UCB, Wim van Lankveld: None declared, Alejandro Balsa Speakers bureau: Pfizer, Abbvie, Lilly, Galapagos, BMS, Sandoz, Nordic Pharma, Gebro, Roche, Sanofi, UCB, Consultant of: Pfizer, Abbvie, Lilly, Galapagos, BMS, Nordic Pharma, Sanofi, UCB, Grant/research support from: Pfizer, Abbvie, BMS, Nordic Pharma, Gebro, Roche, UCB, Victoria Navarro-Compán Speakers bureau: AbbVie, Eli Lilly, Janssen, MSD, Novartis, Pfizer, UCB Pharma, Consultant of: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, UCB Pharma, Grant/research support from: AbbVie and Novartis

POS0374 MONITORING CHRONIC INFLAMMATORY MUSCULOSKELETAL DISEASES WITH A PRECISION DIGITAL COMPANION PLATFORM(TM)–RESULTS OF THE DIGIREUMA FEASIBILITY STUDY

Background

Patients with rheumatic and musculoskeletal diseases (RMDs) require a tailored follow-up that is limited by the capacity of healthcare professionals. Innovative tools need to be implemented effectively in the clinical care of patients with RMDs.

Objectives

To test the feasibility of a Precision Digital Companion Platform™ for real-time monitoring of disease outcomes in patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA).

Methods

Digireuma was a prospective study including patients with RA and SpA, using the digital Precision Digital Companion Platform, Adhera for Rheumatology (ISRCTN11896540). During a follow-up of 3 months, patients were asked to report disease specific electronic patient reported outcomes (ePROs) on a regular basis in the mobile solution. Two rheumatologists monitored these ePROs and, patients were contacted for online or face-to-face interventions when deemed necessary by clinicians (Figure 1). Assessment measures included patient global assessment (PGA) of disease activity, tender joint count (TJC), swollen joint count (SJC), Health Assessment Questionnaire (HAQ) and pain visual analogue scale (VAS), for patients with RA; VAS, PGA, TJC, SJC, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI) and ASAS Health Index (ASAS-HI), for patients with SpA. In addition, flares, changes in medication and recent infections were asked. Usability of the digital solution was measured by the Net-Promoter Score (NPS).

Figure 1.

Digital monitoring in the study powered by Adhera for Rheumatology. Screenshots in top depict the mobile interface (left) and clinical web application (right)

Results

Forty-six patients were recruited of whom 22 had RA and 24 SpA. Mean age was 48 ± 12 and 42 ± 9 years in the RA and SpA groups, respectively. 18/22 (82%) patients with RA and 9/24 (38%) with SpA were female. Among the total included patients, 41 (89%) completed the onboarding (18/22 (82%) RA, 23/24 (96%) SpA) and 37 (80%) submitted at least one entry. In the RA group who completed the onboarding (n=18) there were a total of 4019 total interactions (2178 questionnaire items, 648 accesses to educational units, 105 quizzes, 1088 rated messages), while patients with SpA (n=23) had a total of 3160 interactions (1637 questionnaire items, 684 accesses to educational units, 77 quizzes, 762 rated messages). ePROs measurements completion rates for RA and SpA patients that completed any data during follow-up are shown in Table 1. Patients with RA completed a median of 9.5 ePROs during follow-up, whereas patients with SpA completed a median of 3. Regarding alerts, 15 patients generated a total of 26 alerts, of which 24 were flares (10 RA, 14 SpA) and 2 were problems with the medication (1 RA, 1 SpA). 18 (69%) of the alerts were managed remotely, 5 (19%) required a face-to-face intervention and in 3 (12%) patients did not respond before the consultation. Regarding usability and patient satisfaction, 14 patients provided feedback. According to the NPS, 9/14 were considered promoters, 4/14 passives and 1/14 detractor. The overall rating of these 14 patients for the app was 4.3 out of 5 stars.

Table 1.

Onboarded patient engagement with regards to e-PROs

Rheumatoid Arthritis (n=18)PGATJCSJCVASHAQTotalePROs completed1.5 (0.25, 3)2 (0.25, 3)2 (0.25, 3)2 (0, 3)2 (1, 3)9.5 (4.3, 15.8)Patients with ≥ 1 entry13 (72.2)13 (72.2)13 (72.2)12 (66.7)16 (88.9)16 (88.9)Spondyloarthritis (n=23)PGATJCSJCBASDAIASAS-HITotalePROs completed1 (0,3)1 (0,3)1 (0,3)1 (0,2)1 (0,2)3 (1, 12)Patients with ≥ 1 entry16 (69.5)16 (69.5)16 (69.5)14 (60.8)14 (60.8)21 (91.3)

Follow-up period was 3 months. Results are expressed in median (Q1, Q3) and n (%)

Conclusion

This study shows that the use of a digital health solution is feasible in clinical practice. Based on these preliminary results, the next step will be to further implement the Precision Digital Companion Platform, Adhera for Rheumatology, in a multicentric setting to analyze the added value for monitoring patients.

Acknowledgements

This study was funded with an unrestricted grant from Abbvie.

Disclosure of Interests

Diego Benavent Speakers bureau: Jannsen, Roche, Grant/research support from: Novartis, Abbvie, Francisco J. Núñez-Benjumea Employee of: AdheraHealth Inc, Luis Fernández-Luque Employee of: AdheraHealth Inc, Victoria Navarro-Compán Speakers bureau: AbbVie, Eli Lilly, Janssen, MSD, Novartis, Pfizer, UCB Pharma, Consultant of: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, UCB Pharma, Grant/research support from: AbbVie and Novartis, María Sanz: None declared, Enrique Calvo Aranda Speakers bureau: Abbvie, LETICIA LOJO: None declared, Alejandro Balsa Speakers bureau: Pfizer, Abbvie, Lilly, Galapagos, BMS, Sandoz, Nordic Pharma, Gebro, Roche, Sanofi, UCB, Consultant of: Pfizer, Abbvie, Lilly, Galapagos, BMS, Nordic Pharma, Sanofi, UCB, Grant/research support from: Pfizer, Abbvie, BMS, Nordic Pharma, Gebro, Roche, UCB, Chamaida Plasencia Speakers bureau: Pfizer, Abbvie, Lilly, Sandoz, Sanofi, Biogen, Roche, Novartis, Grant/research support from: Pfizer y Abbvie

AB0376 DIFFERENCES IN IMMUNOGLOBULIN LEVELS IN PATIENTS WITH ANCA-ASSOCIATED VASCULITIS AND RHEUMATOID ARTHRITIS TREATED WITH RITUXIMAB

Background

Hypogammaglobulinemia (HGGS) is one of the adverse effects of Rituximab (RTX), a chimeric monoclonal antibody directed against the CD20 receptor, frequently observed in ANCA-associated vasculitis (AAV) patients.

Objectives

To study the characteristics of patients with AAV on RTX treatment and to analyze the factors associated with HGGS, as well as to compare them with patients with rheumatoid arthritis (RA) on the same treatment.

Methods

Retrospective descriptive study of patients with a diagnosis of AAV or RA treated with RTX who had immunoglobulin levels prior to treatment and after each cycle were included. Demographic, clinical and analytical variables were analyzed. Patients who developed HGGS versus those who did not were compared using Student’s t and Mann-Whitney U for continuous variables and chi-square for categorical variables.

Results

Ninety-five patients were included, 19 (20%) with AAV and 76 (80%) with RA. Of the 34 (35.8%) who developed HGGS, 19 had RA (25%) and 15 AAV (79%) (p<0.001). The 6 patients who presented with severe HGGS (IgG<500) belonged to the AAV group.

The overall sample was divided into patients with HGGS and patients without (Table 1). Significant differences were obtained in relation to diagnosis (p<0.001), age at diagnosis and at the start of treatment, being higher in patients with HGGS (p 0.005 and p 0.001) and years of disease evolution (p 0.036). Patients with HGGS had a lower mean baseline IgG (p<0.001). The HGGS group had more severe infections (infections requiring admission) (p 0.005) and the time from RTX administration to the development of infection was shorter in this group (p 0.017). The frequency of abdominal infection was higher in the HGGS group (p 0.050), and there were no significant differences with the other types of infection.

Table 1.Total sample (n= 95)HGGS IgG (n= 34)No HGGS IgG (n= 61)PWomen n/N(%)70/95(73.7)23/34(67.6)47/61(77)0.318Age (m±SD)64±1268±1062±120.005Age at start of treatment (m±SD)57±1262±1054±120.001Years of evolution (m±SD)11±98±912±100.036RA n/N(%)76/95(80)19/34(55.9)57/61(93.4)<0.001AAV n/N(%)19/95(20)15/34(44.1)4/61(6.6)<0.001Glomerular filtration rate <60 n/N(%)7/91(7.7)4/34(11.8)3/61(4.9)0.164GCS AD in the previous year (m±SD)2918±31023265±30502690±31550.238GC AD during treatment (m±SD)4656±177132889±27785576±217750.271Total GC AD (m±SD)56411±326716117050±4841865879±60890.159CFM AD (m±SD)0.51±2.251.1±3.10.2±1.50.032Baseline IgG (m±SD)1107±340933±3461203±297<0.001Infection n/N(%)58/95(61.1)23/34(67.6)35/61(57.3)0.325Severe infection n/N(%)19/95(20)12/34(35.3)7/61(11.5)0.005Time to infection (months)(m±SD)43±4330±3657±450.017Exitus n/N(%)8/95(8.4)2/34(5.9)6/61(9.9)0.270

Conclusion

A significantly higher percentage of HGGS is observed in patients with AAV treated with RTX compared to patients with RA. The development of HGGS seems to be influenced by age at diagnosis and at the start of treatment, years of disease evolution and low levels of IgGs prior to the start of treatment. In addition, there is a higher frequency of severe infections in the HGGS group. Studies with larger sample sizes are needed to confirm these results.

References

[1]Roberts DM, Jones RB, Smith RM, Alberici F, Kumaratne DS, Burns S, Jayne DR. Rituximab-associated hypogammaglobulinemia: incidence, predictors and outcomes in patients with multi-system autoimmune disease. J Autoimmun. 2015 Feb;57:60-5. doi: 10.1016/j.jaut.2014.11.009.

Disclosure of Interests

None declared

AB0367 THE PARADIGM OF DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS: SUBTYPES AND EARLY IDENTIFICATION

Background

Difficult-to-treat rheumatoid arthritis (D2TRA)1 is an emerging concern for rheumatologists. Multiple failures to biologic or targeted specific disease modifying antirheumatic drugs (b/tsDMARDs) may be due to multi-drug inefficacy or difficulties in the optimum management of treatments due to adverse events, comorbidities, poor adherence, among others. In a previous study2 we identified that younger patients with erosive disease and especially the early absence of clinical response to the first b/tsDMARDs were associated to multiple drug inefficacy but it is worth knowing whether these factors are the same for those patients who receive multiple b/tsDMARDs due to causes other than inefficacy.

Objectives

i) To describe the characteristics of a cohort of D2TRA patients in clinical practice. ii) To analyze the differences between D2TRA due to inefficacy vs D2TRA to other causes. iii) To compare the different subtypes of D2TRA with non-D2TRA.

Methods

This study involved patients with D2TRA from La Paz Hospital and Clìnic Hospital between 2000 and 2021. D2TRA group included patients who had received ≥2b/tsDMARDs due to inefficacy (D2TRA-inefficacy) or due to: adverse events, poor adherence, contraindications, comorbidities, drug-intolerance etc. (D2TRA-other causes). Patients who achieved low disease activity or remission (by DAS28) with the 1st bDMARD and remained with the same drug for at least 5 years were non-D2TRA patients. For all patients, demographic, clinical characteristics and laboratory parameters were assessed at baseline visit (prior to start the 1st b/tsDMARD) and after 6 months. Descriptive analysis was performed and bivariate logistic regression models were assembled. P<0.05 was considered statistically significant. Odds Ratio (OR) and Confidence Intervals (CI) were calculated. IBM SPSS 21.0

Results

In total, 253 patients were included, 131 were non-D2TRA and 122 D2TRA [86 (70.5%) D2TRA-inefficacy and 36 (29.5%) D2TRA-other causes]. Comparison between both groups of D2TRA patients: no differences in gender, age at b/tsDMARD starting or age at RA diagnosis were found and neither between socioeconomic status, frequency of anxiety-depression or other comorbidities. Patients D2TRA-other causes had less extra-articular manifestations than D2TRA-inefficacy (8.3% vs 26.7%; p=0.02); lower values of DAS28 at starting 1st b/tsDMARD (4.9±1.4 vs 5.7±1.2; p=0.01), and also at 6 months of treatment (3.5±1.5 vs 4.5±1.5; p=0.02) than those with D2TRA-inefficacy. 2) Comparison between Non-D2TRA patients and D2TRA-other causes: no differences in sociodemographic characteristics were found and neither differences in baseline disease activity, only differences in DAS28 at 6 months were observed, being higher D2TRA-other causes than in non-D2TRA (3.54±1.54 vs 2.93±0.99; p=0.03). Bivariate analysis only showed that high DAS28-6m was slightly associated with D2TRA-other causes (OR=1.45 CI95% 1.11-2.16).

Conclusion

In this cohort, around 3 out of 10 D2TRA patients dropped out multiple b/tsDMARDs for reasons other than inefficacy In contrast to D2TRA-inefficacy, patients with D2TRA-other causes are indistinguishable from non-D2TRA patients at baseline, indicating that patients with D2TRA-other causes does not seem predictable in the early stages of treatment with b/tsDMARDs, unlike what occurs with multidrug ineficacy.

References

[1]Nagy G. et al. Ann Rheum Dis 2020

[2]Novella-Navarro M. et al. Arthitis Res Ther 2020.

Disclosure of Interests

Marta Novella-Navarro: None declared, Virginia Ruiz: None declared, Gabriela Torres Ortiz: None declared, Chafik Alejandro Chacur: None declared, Carolina Tornero: None declared, Alejandro Villalba: None declared, Raimón Sanmartí Grant/research support from: Abbvie, BMS, Gebro-Pharma, Lilly, MSD, Pfizer, Sanofi and Roche, Chamaida Plasencia Speakers bureau: Pfizer, Lilly, Sandoz, Abbvie,Biogen, Roche, Sanofi, Novartis, Grant/research support from: Pfizer, Abbvie, Alejandro Balsa Speakers bureau: Pfizer, Abbvie, Lilly, Galapagos, BMS, Sandoz, Nordic, Gebro, Roche, UCB, Consultant of: Pfizer, Abbvie, Lilly, Galapagos, BMS, Nordic, Sanofi, UCB, Grant/research support from: Pfiser, Abbvie, BMS, Nordic, Gebro, Roche, UCB

POS0327 IRISIN: A NEW MARKER OF SUBCLINICAL ATHEROSCLEROSIS, CARDIOVASCULAR RISK AND DISEASE ACTIVITY IN AXIAL SPONDYLOARTHRITIS?

Background

Axial spondyloarthritis (axSpA) is an inflammatory disease with detrimental effects on the health status of the individuals affected by this condition [1]. axSpA patients also exhibit high cardiovascular (CV) risk, mainly due to accelerated atherosclerosis [2]. Interestingly, the adipomyokine irisin was described to play a beneficial role in several physiological and pathophysiological processes such as inflammation, angiogenesis, oxidative stress, as well as lipid and bone metabolism [3]. However, studies on the role of irisin in CV risk in the setting of axSpA or in the pathogenesis of axSpA are limited [4].

Objectives

In this study we evaluated the role of irisin as a genetic and serological biomarker of subclinical atherosclerosis and CV risk in a large cohort of patients with axSpA. We also assessed its role as a marker of axSpA susceptibility and severity.

Methods

725 patients who fulfilled the Assessment of SpondyloArthritis international Society classification criteria for axSpA were included in this study [5]. In these patients, the presence of subclinical atherosclerosis (plaques and/or abnormal carotid intima-media thickness values) was assessed by carotid ultrasound. Four irisin polymorphisms (rs16835198 G/T, rs3480 A/G, rs726344 G/A and rs1570569 G/T) were genotyped by TaqMan probes in all the patients and in 656 age, sex and ethnically-matched healthy controls. Additionally, serum irisin levels were determined by ELISA in all the patients. All analyses were performed using STATA v.11.1 statistical software, adjusting for potential confounding factors. The strength of associations is indicated as odds ratios (OR) [95% confidence intervals].

Results

Low levels of serum irisin were linked to the presence of plaques (p=0.002) and with atherogenic index values indicative of an adverse lipid profile (p=0.01). Serum irisin levels also negatively correlated with visual analogue scale (VAS) patient, VAS physician and Bath Ankylosing Spondylitis Metrology Index (BASMI) values (p<0.05). Moreover, the presence of sacroiliitis was related to lower serum irisin levels (p<0.001). Furthermore, the minor alleles of rs3480 (G) and rs1570569 (T) were associated with higher values of Ankylosing Spondylitis Disease Activity Score (ASDAS) in axSpA patients (p≤0.01 in both cases). In this line, the frequency of the minor allele of rs1570569 (T) was higher in patients with ASDAS values >2.1 (indicative of high disease activity) (OR: 1.46 [1.08-1.97], p=0.01), while the minor allele of rs16835198 (T) was less frequent in this group of patients (OR: 0.73 [0.57-0.92], p=0.01).

Conclusion

Low serum irisin levels could be indicators of the presence of subclinical atherosclerosis, high CV risk and more severe disease in axSpA patients. In addition, irisin may also constitute a genetic biomarker of disease activity in axSpA.

References

[1]Packham J. Rheumatology (Oxford). 2018;57(6):vi29-vi34.

[2]Szabo SM, et al. Arthritis Rheum. 2011;63(11):3294–304.

[3]Korta P, et al. Medicina (Kaunas). 2019;55(8):485.

[4]Nam B, et al. Ann Rheum Dis. 2020;79:1358.

[5]Sieper J, et al. Ann Rheum Dis. 2009;68(2):ii1–44.

Acknowledgements

This work was partially supported by grants from Instituto de Investigación Sanitaria IDIVAL (NVAL17/10), from the `Asociación Cántabra de Reumatología’ awarded to FG. FG and JR-G are beneficiaries of a grant funded by `Instituto de Salud Carlos III´ (ISCIII) (PI20/00059). SR-M is supported by funds of the RETICS Program (RD16/0012/0009) from ISCIII, co-funded by the European Regional Development Fund. VP-C is supported by a pre-doctoral grant from IDIVAL (PREVAL18/01). RL-M is a recipient of a Miguel Servet type I programme fellowship from ISCIII, co-funded by the European Social Fund, `Investing in your future´ (grant CP16/00033).

Disclosure of Interests

Sara Remuzgo-Martínez: None declared, Javier Rueda-Gotor: None declared, Verónica Pulito-Cueto: None declared, Raquel López-Mejías: None declared, Alfonso Corrales: None declared, Leticia Lera-Gómez: None declared, Raquel Pérez-Fernández: None declared, Virginia Portilla: None declared, Iñigo Gonzalez-Mazon: None declared, Ricardo Blanco Speakers bureau: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen and MSD, Consultant of: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen and MSD, Grant/research support from: Abbvie, MSD and Roche, Rosa Expósito: None declared, Cristina Mata: None declared, Javier Llorca: None declared, Vanessa Hernández-Hernández: None declared, Carlos Rodríguez-Lozano: None declared, Nuria Barbarroja Puerto: None declared, Rafaela Ortega Castro: None declared, Esther F. Vicente-Rabaneda: None declared, Cristina Fernández-Carballido: None declared, Maria Paz Martínez-Vidal: None declared, David Castro-Corredor: None declared, Joaquín Anino-Fernández: None declared, Diana Peiteado: None declared, Chamaida Plasencia: None declared, E Galindez: None declared, María L. García Vivar: None declared, Nuria Vegas-Revenga: None declared, Irati Urionaguena: None declared, Oreste Gualillo: None declared, Juan Carlos Quevedo-Abeledo: None declared, Santos Castañeda: None declared, Iván Ferraz-Amaro: None declared, Miguel A González-Gay Speakers bureau: Abbvie, Pfizer, Roche, Sanofi, Lilly, Celgene, MSD, GSK, Grant/research support from: Abbvie, MSD, Janssen, Roche, Fernanda Genre: None declared

POS1407 COMPARISON OF CAROTID SUBCLINICAL ATHEROSCLEROSIS AND STRUCTURAL DAMAGE IN AXIAL SPONDYLITIS WITH AND WITHOUT CONCOMITANT INFLAMMATORY BOWEL DISEASE. A MULTICENTER STUDY WITH 886 PATIENTS. . A MULTICENTER STUDY WITH 886 PATIENTS

Background:

The prevalence of inflammatory bowel disease (IBD) in ankylosing spondylitis (AS) has been reported to range between 6%-15%. As occurs with axial spondyloarthrtitis (axSpA), patients with IBD have an increased risk of cardiovascular (CV) events because of a process of accelerated atherosclerosis1. However, it is unknown whether the presence of IBD confers an increased cardiovascular CV risk in patients with axSpA.

Objectives:

To compare the atherosclerotic burden, CV events, CV risk factors and disease related factors including structural damage in axSpA patients with and without IBD.

Methods:

Cross-sectional analysis of the AtheSpAin cohort, a Spanish multicenter cohort designed for the study of atherosclerosis in axSpA, comparing axSpA patients with and without concomitant IBD. Background information on CV and disease-related factors was reviewed. Data on CV risk and disease status at the time of the study were also obtained, including the structural damage assessed by the presence of syndesmophytes, the severity of the sacroiliitis (defined as grade 3 or 4 according to New York criteria), and the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS). Carotid ultrasound (US) was performed in all patients at the time of the study, including measurement of carotid intima-media wall thickness (cIMT) and plaque detection according to the Mannhein consensus criteria.

Results:

A set of 886 axSpA patients were included. 829 (93.6%) of them had no concomitant IBD, which was present in 57 (6.4%) patients. Age, sex and AS/nr-axSpA ratio were comparable in both groups (Table 1. next page). Patients with IBD were characterised by a lower prevalence of HLA B27 (46% vs 72%, p=0.01) and a higher presence of concomitant psoriasis (21% vs 10%, p=0.01)

Regarding peripheral disease (history of synovitis, enthesitis, dactylitis) and hip involvement, no differences were found between both groups. There were either no differences in the structural damage found in patients with and without IBD (Table 1. next page).

With respect to the management of the disease, prednisone (21% vs 13%, p = 0.03), DMARDs (54% vs 35%, p = 0.01) and anti-TNFα therapy (54% vs 31%, p = 0.00) were more commonly used in the group with IBD, while treatment with NSAIDs was more frequent in patients without IBD (81% vs 70%, p = 0.04).

Regarding CV risk features, smoking was more frequent in patients without IBD (34% vs 21%, p = 0.045) (Table 1. next page). No differences were observed neither in the lipid profile or blood pressure at the time of the study, nor in the prevalence of CV events (5% vs 4%, p=0.99) (Table 1) and the subclinical atherogenic burden assessed both by the presence of carotid plaques (31% vs 37%, p=0.45) and the cIMT (645 ± 147 mm vs 636 ± 112 mm, p = 0.64) (Table 1. next page).

Conclusion:

The presence of IBD does not confer additional CV risk to axSpA. In our series, patients with axSpA and IBD showed a lower frequency of HLA B27 and a higher prevalence of psoriasis.

Table 1.axSpA without IBD (n=829)axSpA with IBD (n=57)pMen/Women, n272/55715/420.33Mean age (years) ±SD at the time of study49 ± 1349 ± 100.99AS/nr-AxSpa656/17345/120.97History of CV risk factors Current smoker285 (34)12 (21)0.045 Obesitty Dyslipemia280 (34)16 (28)0.42 Hypertension223 (27)16 (28)0.79 Diabetes Mellitus60 (7)4 (7)0.99 Chronic Kidney Disease20 (2)2 (4)0.65History of cardiovascular events, n (%)40 (5)2 (4)0.99Structural damage at the time of studyPresence of syndesmophytes, n (%)307 (37%)23 (49%)0.66mSASSS5 (1-15)6 (3-23)0.64Severe sacroiliitis (grade 3,4), n (%)436 (53)34 (60)0.42CV data at the time of studyCarotid plaques261 (31)21 (37)0.45IMT (mm)645 ± 147636 ± 1120.64IMT >= 0.9 mm46 (6)0 (0)0.066

Abbreviations: AS = ankylosing spondylitis. AxSpA= axial spondylitis. CV = cardiovascular. IBD = Inflammatory bowel disease. IMT = intima-media wall thickness. Nr-axSpA = no-radiographic axial spondylitis.

Disclosure of Interests:

None declared

AB0500 IMPACT OF COVID-19 PANDEMIC IN OVERALL HEALTH AND FUNCTIONING IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS: RESULTS FROM THE REUMAVID STUDY (PHASE 1)

Background:

Evidence on the impact of the COVID-19 pandemic on the overall health and functioning in patients with axial spondyloarthritis (axSpA) is scarce.

Objectives:

To analyse the impact of the COVID-19 pandemic on the overall health and functioning in patients with axSpA.

Methods:

Data from axSpA patients participating in the first phase of the REUMAVID study were analysed. REUMAVID is a cross-sectional, observational study collecting data through an online questionnaire of unselected patients with rheumatic and musculoskeletal diseases (RMDs), recruited by patient organizations. The survey was disseminated during the beginning of the COVID-19 pandemic (April-July 2020) in seven European countries (Cyprus, France, Greece, Italy, Portugal, Spain, and the United Kingdom). Patients with axSpA who completed the ASAS health index (ASAS-HI) questionnaire were included in this analysis. Descriptive analyses were used to present socio-demographic and clinical characteristics, as well as daily habits. Overall health and functioning were defined according to the ASAS-HI (0-17), as follows: good health (ASAS-HI ≤5), acceptable health (ASAS-HI 6-11), and poor health (ASAS-HI ≥12). As secondary outcomes, well-being (WHO-5), self-perceived health status, and HADS for anxiety and depression were assessed.

Results:

Out of 670 axSpA patients, 587 (87.6%) completed ASAS-HI. Of these, 70.4% were female, 72.6% were married or in a relationship, 46.7% had university studies and 37.6% were currently employed. Mean age was 49.9±12.8 years and mean BMI was 26.7±5.5. Regarding extraarticular manifestations, 13.6% had psoriasis, 12.1% inflammatory bowel disease and 18.7% uveitis. Before the COVID-19 pandemic, 50.9% were receiving biological drugs, 46.3% NSAIDs, 26.4% painkillers, 24.7% conventional DMARDs, and 11.9% oral corticosteroids. According to the ASAS-HI, 19.6 % of patients were classified as having poor health, with the most affected aspects being pain (92.0%), movement (86.5%), maintenance of body position (80.6%), energy (79.0%) and sleep (75.3%). Regarding self-perceived health status, 14% reported their health status as “bad” or “very bad”, and 46.8% reported worsening health during the pandemic (Table 1). A distribution of the results of the total ASAS-HI scores can be seen in Figure 1.

Table 1.

Overall health and well-being, disease activity, and mental health.

Primary Outcome (ASAS-HI)Mean ± SD orn (%)ASAS-HI (0-17), n=5878.0 (±3.9)ASAS-HI <5 (good health)159 (27.1) 5-12 (acceptable health)313 (53.3) ≥12 (poor health)115 (19.6)Secondary OutcomesWHO-5 WHO-5, (0-100), n=58446.3 (±23.1) WHO- 5 Poor wellbeing WHO- ≤50330 (56.5)Self-perceived health status, n=585 Very good33 (5.6) Good214 (36.6) Fair256 (43.8) Bad69 (11.8) Very bad13 (2.2)Change in health status during lockdown, n=587 Much worse than before54 (9.2) Moderately worse220 (37.6) Same as before270 (46.0) Moderately better35 (6.0) Much better than before6 (1.0)HADSHADS Anxiety (0-21), n=5878.4 (±4.1)HADS Anxiety No case (0-7)248 (42.7) Borderline case (8-10)151 (26.0) Case (11-21)182 (31.3) HADS Depression (0-21), n=5877.0 (±4.3)HADS Depression No case (0-7)329 (56.6) Borderline case (8-10)134 (23.1) Case (11-21)118 (20.3)Figure 1.

Distribution of the result of ASAS-HI scores (N= 587)

Conclusion:

One out of five patients with axSpA reported poor health and functioning according to the ASAS-HI, and almost half of patients reported worsening self-perceived health status during the first wave of the COVID-19 pandemic.

Keywords: COVID-19, axial spondyloarthritis, ASAS-HI, health

Disclosure of Interests:

Diego Benavent Grant/research support from: Abbvie, Novartis and Roche, Marco Garrido-Cumbrera: None declared., Chamaida Plasencia Grant/research support from: Pfizer, Sanofi, Novartis, Roche and Lilly, Laura Christen Employee of: Novartis Pharma AG, Helena Marzo-Ortega Grant/research support from: Abbvie, Celgene, Janssen, Elli-Lilly, Novartis, Pfizer, UCB and Takeda Pharmaceutical Company, José Correa-Fernández: None declared., Pedro Plazuelo-Ramos: None declared., Dale Webb: None declared., Victoria Navarro-Compán Grant/research support from: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche, UCB.

POS0623 CYTOKINE PRODUCTION BY BLOOD LYMPHOCYTES DEFINES A PROFILE ASSOCIATED WITH NON-REMISSION IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH TNF INHIBITORS

Background:

In clinical practice no more than 50% of the patients treated with TNF inhibitors (TNFi) achieve remission (REM). Previous investigations suggested that peripheral blood mononuclear cells (PBMC) may be markers associated with the TNFi treatment success1.

Objectives:

This study aims to analyse the intracellular cytokine production by PBMC and its association with REM achievement after 6 months (m) of TNFi treatment in patients with RA.

Methods:

This was a prospective study including 62 patients with RA starting the 1st TNFi. PBMC were isolated from patients at baseline and after 6m of treatment with TNFi and cryopreserved until studied. In vitro stimulation and intracellular cytokine production by PBMC was performed as follow: in the presence of 2µg/mL brefeldin and 2µmol/L monensin monocytes were stimulated with 20ng/mL LPS during 4h whereas lymphocytes were stimulated with 50ng/mL phorbol 12-myristate 13-acetate and 750ng/mL ionomycin for 4h at 37°C. To identify IL10-producing B cells, PBMC were pre-incubated with 3µg/mL of CpG oligonucleotide during 20h at 37°C prior to stimulation. Intracellular cytokine production (TNFα, IL6, GM-CSF, IL10) by the different cell subsets (monocytes, CD4+ and CD8+ T cells, naïve and memory B cells) was analysed by flow-cytometry. Clinical activity at baseline and after 6m was assessed by DAS28-ESR. REM was defined as DAS28≤2.6 at 6m. The association between cytokine production by each PBMC subset and REM was analysed through univariable and multivariable logistic regression models. Receiving operating curve (ROC) analysis was used to select the optimal ratio of cytokine production associated with REM status.

Results:

After 6m of TNFi treatment, 30 (48%) patients achieved REM. No significant differences between REM and non-REM groups were observed for patients’ characteristics at baseline except for DAS28, which was lower in the REM group (non-REM: 5.4±0.9; REM: 4.3±0.9; p<0.0001) (Table 1). Therefore, further analyses were adjusted by baseline DAS28. A lower ratio between calculated with the IL10 and TNFα production by B cells and by CD4+ T cells (IL10 B/TNF CD4) at 6m was found for non-REM patients (non-REM: 0.31 vs REM: 0.54; p=0.007). Based on a ROC analysis, we found that a (IL10 B/TNF CD4)<0.54 at 6 m was significantly associated with a higher probability of non-REM at 6 months (OR: 5.0; 95% CI: 1.1-21.7) (Figure 1).

Table 1.

Baseline predictors of reduction of disease activity at 12 months from start of abatacept. Linear regression.

Baseline patients’ characteristicsTotal patients (n=62)DAS28>2.6(n=32; 52%)DAS28≤2.6(n=30; 48%)p-valueAge (years)53±1253±1352±100.8Female55 (89)30 (94)25 (83)0.2Disease duration (years)8 (4-11)8 (4-12)7 (3-11)0.7RF positive49 (79)23 (72)26 (87)0.1ACPA positive54 (87)26 (81)28 (93)0.2Smoking habit (n=55)0.2Non-smokers26 (47)16 (55)10 (38) Smoker29 (53)13 (45)16 (51)Body mass index (kg/m2)25.9±5.625.8±5.726.0±5.60.9DAS284.9±1.05.4±0.94.3±0.9<0.0001Concomitant csDMARDs60 (97)32 (100)28 (93)0.3MTX [±OD]46 (74)26 (81)20 (67)0.3Only OD14 (23)6 (19)8 (26)0.3Prednisone36 (58)19 (59)17 (57)0.9

Conclusion:

Our results show that the proinflammatory IL10 B/TNF CD4 ratio is associated with non-REM status. It could be useful to analyse the success of TNFi treatment in patients with RA.

References:

[1]Rodríguez-Martín E, et al. Front Immunol. 2020; 11: 1913.

Acknowledgements:

ISCIII (PI16/00474; PI16/01092)

Disclosure of Interests:

Borja Hernández-Breijo: None declared, Eulalia Rodríguez-Martín: None declared, Carlota García-Hoz: None declared, Victoria Navarro-Compán Speakers bureau: Abbvie, Janssen, Lilly, MSD, Novartis, Pfizer and UCB, Grant/research support from: Abbvie, Janssen, Lilly, MSD, Novartis, Pfizer and UCB, Cristina Sobrino: None declared, ANA MARTÍNEZ-FEITO: None declared, Israel Nieto-Gañán: None declared, Javier Bachiller-Corral Speakers bureau: Abbvie, MSD, BMS and Roche, Grant/research support from: Pfizer, Paloma Lapuente-Suanzes: None declared, Gemma Bonilla: None declared, Cristina Pijoán-Moratalla: None declared, Mónica Vázquez: None declared, Alejandro Balsa Speakers bureau: Abbvie, BMS, Nordic, Novartis, Pfizer, Sandoz, Sanofi, Roche and UCB, DORA PASCUAL-SALCEDO: None declared, Luisa María Villar: None declared, Chamaida Plasencia Speakers bureau: AbbVie, Lilly, Novartis, Pfizer, Sanofi, Biogen and UCB

POS0977 CARDIOVASCULAR AND DISEASE RELATED FEATURES IN AXIAL SPONDYLITIS WITH AND WITHOUT CONCOMITANT PSORIASIS. A MULTICENTER STUDY WITH 882 PATIENTS

Background:

Patients with axial spondyloarthritis (axSpA) may present with concomitant psoriasis (Ps) in approximately 10% of cases. As with axSpA, Ps is also associated with an accelerated atherosclerosis process1. However, it is unknown whether the presence of Ps confers an increased cardiovascular (CV) risk in patients with axSpA.

Objectives:

To compare factors related to the disease, CV risk factors, atherosclerotic burden, and CV events in patients with axSpA with and without Ps.

Methods:

Cross-sectional analysis of the AtheSpAin cohort, a Spanish multicenter cohort designed for the study of atherosclerosis in axSpA. We compared axSpA patients with and without concomitant psoriasis, focusing mainly on CV risk characteristics. Background information on CV risk factors, CV events, and disease-related factors was reviewed, and data on maximum body index, blood pressure, lipid profile, and disease status at the time of the study were also obtained. Carotid ultrasound (US) was performed in all patients at the time of the study, including measurement of carotid intima-media wall thickness (cIMT) and plaque detection according to the Mannhein consensus criteria.

Results:

A set of 882 axSpA patients were included. 786 (89.1%) of them had no concomitant Ps, which was present in 96 (10.9%) patients. Although the mean age was similar, male sex was more prevalent in axSpA patients with Ps (79.1% Vs 66.5%, p=0.01) (Table 1).

Furthermore, it was found that axSpA with Ps had a more frequent history of synovitis (50% vs 33%, p = 0.001), dactylitis (13% vs 6%, p = 0.011) and concomitant inflammatory bowel disease (13% vs 6%, p = 0.01). AxSpA patients with Ps had a non-significant trend towards a higher prevalence of asymmetric sacroiliitis (23 vs 16%, p = 0.064) and had a lower frequency of positive HLA-B27 status (56% vs 72%, p = 0.003). Regarding the management of the disease, prednisone (23% vs 12%, p = 0.02), methotrexate (30% vs 15%, p = 0.000) and anti-TNFα therapy (50% vs 34%, p = 0.002) were more commonly used in the group with Ps.

Regarding CV risk characteristics, no differences were observed either in the prevalence of traditional CV risk factors (Table 1), nor in the total serum level, HDL and LDL, blood pressure and body mass index at that time of the study. However, axSpA patients with Ps showed a higher prevalence of CV events (9% vs 4%, p = 0.05), including ischemic heart disease (6% vs 3%, p = 0.042) and ischemic stroke (4% vs 1%, p = 0.016) (Table 1). The subclinical atherogenic burden was also more severe in the group with Ps, with a higher prevalence of carotid plaques (39% vs 31%, p = 0.098), and higher values of cIMT (0.664 ± 0.170 mm vs 0.642 ± 0.142 mm, p = 0.16), although the differences did not reach statistical significance.

Table 1.

Main sociodemographic and cardiovascular differences among axSpA patients with and without psoriasis.

axSpA without psoriasis (n=786)axSpA with psoriasis (n=96)pMen/Women, n523/26876/200.010Mean age (years) ±SD at the time of study49 ± 1349 ± 130.81AS/nr-AxSpa625/16677/190.79History of CV risk factors Current smokers267 (34)30 (31)0.60 Obesitty174 (22)26 (27)0.29 Dyslipidemia262 (33)35 (36)0.48 Hypertension211 (27)28 (29)0.57 Diabetes Mellitus56 (7)8 (8)0.65 Chronic Kidney Disease19 (2)3 (3)0.72History of cardiovascular events, n (%)33 (4)9 (9)0.023 Ischemic heart disease20 (3)6 (6)0.042 Congestive heart failure2 (0)1 (1)0.29 Ischemic stroke6 (1)4 (4)0.016 Peripheral artery disease6 (1)0 (0)0.99CV data at the time of studyCarotid plaques244 (31)38 (39)0.098IMT mm0.642 ± 0.1420.664 ± 0.1700.16IMT >= 900 mm40 (5)6 (6)0.66

Abbreviations: AS = ankylosing spondylitis. AxSpA= axial spondylitis. CV = cardiovascular. IMT = intima-media wall thickness. Nr-axSpA = no-radiographic axial spondylitis.

Conclusion:

The presence of Ps may confer additional CV risk to axSpA patients and is associated with particular disease related factors.

References:

[1]Fang N, Jiang M, Fan Y. Association Between Psoriasis and Subclinical Atherosclerosis: A Meta-Analysis. Medicine (Baltimore). 2016;95(20):e3576.

Disclosure of Interests:

None declared.

AB0070 ROLE OF VASPIN IN ATHEROSCLEROTIC DISEASE AND CARDIOVASCULAR RISK IN AXIAL SPONDYLOARTHRITIS

Background:

Vaspin is a novel anti-inflammatory adipokine associated with cardiovascular (CV) disease and inflammation in chronic inflammatory conditions different from axial spondyloarthritis (axSpA).1 Given the high incidence of CV disease (mainly due to accelerated atherosclerosis) exhibited by axSpA patients,2 we wondered if vaspin could also be a key molecule in this process. However, data on the role of vaspin regarding atherosclerotic disease in the context of axSpA is scarce.3

Objectives:

To evaluate the implication of vaspin, at the genetic and serological level, in subclinical atherosclerosis and CV risk in axSpA.

Methods:

510 patients who fulfilled the ASAS criteria for axSpA4 were included in this study. Carotid ultrasound (US) was performed to evaluate the presence of subclinical atherosclerosis. Three vaspin gene variants (rs2236242 T/A, rs7159023 G/A and rs35262691 T/C) were genotyped by TaqMan probes. Serum vaspin levels were assessed by Enzyme-Linked ImmunoSorbent Assay. Analysis was performed using a statistical software.

Results:

Serum vaspin levels were significantly higher in female patients than in males and also in obese patients when compared to those with normal weight (p<0.05). At the genetic level, we disclosed that the minor allele of rs2236242 (A) was associated with lower serum vaspin levels in axSpA, while the rs7159023 minor allele (A) was linked to higher serum levels (p<0.05). When the three polymorphisms assessed were combined conforming haplotypes, we disclosed that the TGC haplotype related to high serum levels of vaspin (p=0.01). However, no statistically significant association was observed between vaspin and markers of subclinical atherosclerosis, both at the genetic and serological level.

Conclusion:

Our results revealed that vaspin is linked to CV risk factors that may influence on the atherosclerotic process in axSpA. Additionally, we disclosed that serum vaspin concentration is genetically modulated in a large cohort of patients with axSpA.

References:

[1]Adv Exp Med Biol. 2019;1111:159-88.

[2]Front Med (Lausanne). 2018;5:62.

[3]Braz J Med Biol Res. 2016;49(7):e5231.

[4]Ann Rheum Dis. 2009;68(2):ii1-44.

Acknowledgements:

Personal funds: RL-M: Miguel Servet type I CP16/00033 (ISCIII-ESF); SR-M: RD16/0012/0009 (ISCIII-ERDF); VP-C: PREVAL18/01 (IDIVAL); LL-G: INNVAL20/06 (IDIVAL).

Disclosure of Interests:

Javier Rueda-Gotor: None declared, Raquel López-Mejías: None declared, Sara Remuzgo-Martínez: None declared, Verónica Pulito Cueto: None declared, Alfonso Corrales: None declared, Leticia Lera-Gómez: None declared, Virginia Portilla: None declared, Iñigo González-Mazón: None declared, Ricardo Blanco Speakers bureau: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen and MSD, Consultant of: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen and MSD, Grant/research support from: Abbvie, MSD and Roche, Rosa Expósito: None declared, Cristina Mata: None declared, Javier Llorca: None declared, Vanessa Hernández-Hernández: None declared, Carlos Rodríguez-Lozano: None declared, Nuria Barbarroja Puerto: None declared, Rafaela Ortega Castro: None declared, Noelia García Castañeda: None declared, Cristina Fernández-Carballido: None declared, Maria Paz Martínez-Vidal: None declared, David Castro-Corredor: None declared, Joaquín Anino-Fernández: None declared, Diana Peiteado: None declared, Chamaida Plasencia: None declared, E Galindez: None declared, María L. García Vivar: None declared, Oreste Gualillo: None declared, Juan Carlos Quevedo-Abeledo: None declared, Santos Castañeda: None declared, Iván Ferraz-Amaro: None declared, Miguel A González-Gay Speakers bureau: Pfizer, Abbvie, MSD, Grant/research support from: Pfizer, Abbvie, MSD, Fernanda Genre: None declared

POS0617 ANTI INFLIXIMAB ANTIBODIES DETECTED BY A DRUG TOLERANT ASSAY ARE FREQUENT BUT, IN MANY CASES, WITHOUT RELEVANT CLINICAL SIGNIFICANCE

Background:

Infliximab (Ifx) has proven effective in treating rheumatoid arthritis (RA) and spondyloarthropathies (SpA), although around 40% of cases fails, mainly due to immunogenicity. Formation of immunocomplexes between antibodies to Ifx (ATI) and Ifx can increase drug clearance, leading to treatment failure. Standard ELISA assays which are drug -sensitive are frequently used, being able to detect only free ATI. Interest in drug-tolerant assays to measure total ATI (free and complexed) is increasing.

Objectives:

To compare the development of ATI using both drug-tolerant and drug-sensitive assays at early stages of Ifx therapy. To analyse the relationship of ATI detected by both assays with the drop-out of treatment.

Methods:

This is a prospective observational study including 45 patients with RA and 61 with axial-SpA treated with standard doses of Ifx (3mg/kg and 5mg/kg, respectively) enrolled at Biological Therapy Unit of Hospital La Paz. Serum samples were obtained at 2, 6, 12 and 22 weeks (W) after Ifx initiation. The data about discontinuation for inefficacy was obtained from the database. ATI presence was evaluated by a drug-sensitive in-house two-site (bridging) ELISA (bELISA) and a drug-tolerant commercial ELISA assay (Immundiagnostik®,IDK). All comparisons were performed throughout non-parametrical test. In SpA group, due to the low number of ATI+ patients at W12 by bELISA the statistical analysis to compare both assays were not performed.

Results:

ATI detection by both assays at early stages (≤22 W) of treatment is shown in Table 1a. ATI were always detected earlier by IDK than bELISA and also in RA than in SpA patients probably reflecting the effect of lower Ifx doses. Three out of 106 (3%) vs 0 (0%) patients had ATI at W 2 and 62 (58%) vs 20 (18%) patients at W22, by IDK and bELISA, respectively.

Table 1.

Patient characteristics of all included patients

W2W6W12W22ARSpAARSpAARSpAARSpAa) ATI+ patients (n, %) at early stagesbELISA003(7%)010(22%)1(2%)13(29%)7(12%)IDK1(2%)2(3%)7(16%)2(3%)16(36%)16(26%)28(62%)34(56%)b) Patients who discontinued (n, %) Ifx therapy considering ATI status at early stagesbELISA+9(90%)*1(100%)*12(92%)4(57%)bELISA-23(66%) 22(37%)20(63%)19(35%)IDK+15(94%)*7(44%)24(86%)13(38%)IDK-17(59%)11(24%)13(77%)10(27%)

*p<0.05 comparing between ATI+ vs ATI- in each assay.

Once ATIs appeared, regardless both methods, they persisted throughout the follow-up, indicating that immunogenicity was not transient.

At W22, only 13/28 (46%) and 7/34 (21%) patients with ATI detected by IDK were also positive by bELISA in RA and SpA, respectively.

ATI levels by IDK were higher in ATI+ by bELISA than in ATI- patients at early stages: ATI levels by IDK at W12: 91[74-348] ng/ml ATI+ vs 21.7[15-59.5] ng/ml ATI- (p<0.01) and at W22: 132 [89-372] ng/ml ATI+ vs 23[13-66] ng/ml ATI- (p<0.001). However, only in 4% (2/45) patients with RA and in 13% (8/61) patients with SpA the detection by IDK was earlier than by bELISA at W12.

Free IFX in serum was not detected in bELISA ATI+ patients. In IDK ATI+ patients low circulating Ifx levels were present as compare to ATI- since W6 to the end of follow-up (p<0.01).

More ATI+ patients dropped out Ifx at W12 and W22 regardless de assay (Table 1.b), being statistically significant for both assays in patients with RA and only for bELISA in patients with SpA.

Conclusion:

ATI measured by a drug-tolerant assay are always detected earlier than ATI detected by bELISA, indicating that immunogenicity, at least with Ifx, is usually an early event. High levels of ATI by IDK are associated with an earlier detection by bELISA in case of RA patients. ATI detected only by drug tolerant assays are associated with low levels of circulating Ifx but not with a complete drug neutralization and may do not have clinical relevance compared to ATI detected by bELISA. Many patients have low levels of ATI which can only be detected by drug tolerant assays after long-term of follow-up.

The reasons why ATI levels rise rapidly in some patients while in others remain low are currently unknown but may be relevant if the clinical effect of immunogenicity is to be minimized.

Acknowledgements:

We are grateful to all the rheumatologists and nurses of the Daycare Department for Biologics and to the laboratory technicians of the Immunological Unit

Disclosure of Interests:

ANA MARTÍNEZ-FEITO: None declared, Borja Hernández-Breijo: None declared, Marta Novella-Navarro: None declared, Victoria Navarro-Compán Grant/research support from: AbbVie, Janssen, Lilly, Novartis, Pfizer, and UCB, Cristina Diego: None declared, Irene Monjo: None declared, Laura Nuño: None declared, Alejandro Villalva: None declared, Diana Peiteado: None declared, DORA PASCUAL-SALCEDO: None declared, Pilar Nozal: None declared, Alejandro Balsa Grant/research support from: Abbvie, Pfizer, Novartis, Roche.Amgen, Sandoz, Lilly, UCB. Personal fees and non- financial support from BMS. Grants, personal fees and non- financial support from Nordic., Chamaida Plasencia Grant/research support from: AbbVie, Lilly, Novartis, Pfizer,Sanofi, Biogen and UCB.

AB0149 CHARACTERISATION OF RHEUMATOID ARTHRITIS PROGRESSION IN AN EARLY UNDIFFERENTIATED ARTHRITIS COHORT

Background:

Since the publication of 2010 ACR/ELUAR classification criteria for Rheumatoid Arthritis (RA), identification of patients with RA at early stages of the disease has improved. Nevertheless, up to 56% of patients are diagnosed with undifferentiated arthritis (UA) at the first visit to Rheumatology Departments, of which about 20-30% will progress to RA. For this reason, Early Arthritis Clinics (EAC) have been progressively implemented in Rheumatology departments in order to identify and have a tight follow-up of these patients.

Objectives:

a) To analyze the progression rate from UA to RA in a cohort of EAC. b) To identify differences in clinical features at baseline that characterize the progression to RA of these patients.

Methods:

Prospective study from a cohort of EAC between 2010 and 2018. Patients diagnosed with UA at first consultation were included and with a follow-up of 2-years. Final diagnosis was assessed at the end of study period defining two groups: RA progression (RA-group) vs no progression (non-RA-group).Baseline characteristics were recorded for both groups: sex, age, smoking habit, duration of symptoms, morning stiffness, tender joint count (TJC), swollen joint count (SJC), Rheumatoid Factor (RF), Anti-Citrullinated-Peptide-Antibodies (ACPA), DAS-28, erythrocyte sedimentation rate (ESR), C-Reactive Protein (CRP), Pain visual analogue scale (VAS). Differences in sociodemographic, clinical and serological features between groups were analyzed using T-test, chi-square test and U-Mann Whitney depending on the nature of variables.

Results:

A total of 228 patients with UA were included, of which 54 (23,3%) progressed to RA (patients characteristics are shown in table 1). Regarding serological characterization, we found that in our cohort, 44.4% of patients who developed RA had FR and ACPA positivity, 13% RF positive, 7.4% ACPA positive. In contrast 35% patients were seronegative. From non-RA group, 73% of patients were seronegative, 18% RF positive, 4.5% ACPA positive and 4.5% double positive.

Table 1.VariableTotal (n=228)RA (n=54)Non-RA (n=174)p-valueFemale sex n(%)165 (71.7)42 (77.8)121 (69.5)0.31*Age (mean SD)51.47 (16.46)52.9 (16.15)51.26 (16.61)0.53§Smoking habit n (%)0.12*-smokers49 (21.2)14 (25.9)33 (19)-exsmokers52 (22.5)15 (27.8)37 (21.3)-non-smokers113 (48.9)19 (35.2)93 (53.4)Duration of symptoms (weeks) (median IQR)8 (4-19)12 (8-24)8 (4-16)0.006¶Morning stiffnes >60min n (%)53 (22.9)15 (27.8)38 (21.8)0.26*Patient health assessment (meadian IQR)39 (16-68)58 (22-75)34 (14-64)0.01¶Pain (VAS) (median IQR)45 (18-68.2)54 (30-71)39 (14.5-67.5)0.02¶Tender Joint Count (median IQR)2 (1-6)4 (1-9)2 (1-6)0.04¶Swollen Joint Count (median IQR)2 (1-4)3 (1-6)2 (1-4)0.01¶Baseline DAS28 (mean SD)3.97 (1.39)4.44 (1.54)3.82 (1.33)0.006§HAQ (median IQR)0.75 (0.25-1.5)1.12 (0.37-1.56)0.62 (0.12-1.37)0.06¶CRP(mean SD)2.2 (8.01)1.39 (3.25)2.3 (8.9)0.44§ESR (mean SD)23.74 (19.5)24.62 (16.22)22.8 (19.3)0.54§RF n (%)70 (30.3)31 (57.4)39 (22.4)<0.001*ACPA n (%)44 (19)28 (51.9)16 (9.2)<0.001*

No differences between age at onset, sex an smoking habit were found. Duration of symptoms until first visit to Rheumatology Department was longer RA-group. Regarding joint involvement, TCJ and SCJ were higher in RA-group at baseline and also VAS pain and patients´global health assessment.

Conclusion:

One out of four patients diagnosed with early UA are at risk of RA development within the following 2 years. This fact implies that these patients benefit from EAC in order to have a tight control of the disease and have the chance of starting treatment as soon as possible.

References:

Combe B et al. 2016 update of the EULAR recommendations for the management of early arthritis. Ann Rheum Dis 2017;76:948-959.

van Steenbergen HW et al. Preventing progression from arthralgia to arthritis: targeting the right patients. Nat Rev Rheumatol. 2018 Jan;14(1):32-41.

Disclosure of Interests:

None declared

POS0969 UNVEILING AXIAL INVOLVEMENT IN PSORIATIC ARTHRITIS: AN ANCILLARY ANALYSIS OF THE ASAS-perSpA STUDY

Background:

Heterogeneity in psoriatic arthritis (PsA) is a current matter of discussion, especially concerning axial involvement.

Objectives:

To determine the profile of axial PsA (axPsA) in a worldwide setting. Secondly, to identify predictive factors associated with the development of axial involvement in patients with PsA.

Methods:

Data from 3684 patients with axial spondyloarthritis (axSpA) or PsA from the ASAS-PerSpA study were analysed. The ASAS-PerSpA is an observational, cross-sectional study that recruited consecutive patients with SpA from 68 centers worldwide. For this analysis, 367 PsA patients ever presenting axial involvement according to their rheumatologist were defined as axPsA and compared with 2651 axSpA patients, using logistic regression to later identify predictive factors for rheumatologist diagnosis of axPsA. In addition, the axPsA patients were also compared with 666 PsA patients without axial involvement (pPsA) and the characteristics associated with axial manifestations were determined by logistic regression analysis.

Results:

Among all patients, 2651 were identified as axSpA and 1033 patients as PsA. Among those with axial involvement, 2651 were identified as axSpA (100% of axSpA) and 367 as axPsA (35.5 % of PsA). In comparison with axSpA, axPsA patients were less frequently males, older, less frequently HLA-B27 positive and had a higher body mass index (Table 1). Additionally, while patients with axPsA had more peripheral manifestations and psoriasis, concomitant IBD and uveitis were higher in axSpA. In the multivariable analysis, older age at diagnosis (OR= 1.04), peripheral arthritis (OR= 7.32) and dactylitis (OR= 2.82) were significantly associated with a diagnosis of axPsA. However, uveitis (OR= 0.22), IBD (OR= 0.12) or HLA*B27 carriership (OR= 0.26) were inversely associated with axPsA diagnosis as compared to axSpA. Furthermore, axial involvement in patients with PsA was significantly associated with male gender (OR= 1.68), elevated CRP (OR= 2.87), and the absence of psoriasis (OR= 0.33).

Conclusion:

In this worldwide setting, axPsA was defined by rheumatologists as a unique phenotype, with disease features lying between axSpA and pure pPsA. Male gender, elevated CRP and the absence of psoriasis were associated with axial involvement in patients with PsA.

Table 1.

Demographic and disease characteristics of patients with axial involvement included in the ASAS PerSpA study. Results shown as absolute numbers (percentages) or as the mean ± standard deviation

axSpAn= 2651axPsAn= 367p-valueSex (male)1816 (68.5) 196 (53.4)<0.001Age at study visit42.1(13.0)50.0 (12.7)<0.001Body Mass Index25.9 (5.1)27.4 (5.7)<0.001Family history of SpA944 (35.6)135 (36.8)0.684Past history or current symptoms of back pain2625 (99.0)358 (97.5)0.04Inflammatory back pain (ASAS definition), n/N(%)2500/2632 (94.9)317/362 (87.6)<0.001Sacroiliitis on imaging, n/N (%) by: xRay mNY criteria1997/2586 (77.2)185/298 (62.1)<0.001 MRI-SIJ, ASAS definition1449/1757 (82.4)141/225 (62.6)<0.001 mNY criteria or ASAS definition2446/2634 (92.9)243/339 (71.7)<0.001HLA B27 positive1674 /2126 (78.7)54/182 (29.6)<0.001Elevated CRP (>5 mg/dL)1863/2569 (72.5)274/356 (76.9)0.2Classification criteria ASAS criteria2339 (88.2)185 (50.4)<0.001 CASPAR criteria123 (4.6)274 (74.4)<0.001Peripheral Arthritis946 (35.7)318 (86.6)<0.001Enthesitis1086 (41.0)198 (54.0)<0.001Dactylitis155 (5.8)125 (34.1)<0.001Psoriasis185 (7.0)324 (88.3)<0.001IBD129 (4.9)3 (0.8)<0.001Uveitis576(21.7)13 (3.5)<0.001csDMARD (ever)1359 (51.3)339 (92.4)<0.001bDMARD (ever)1585 (59.8)263 (71.7)<0.001Specific drug for axial involvementNSAIDs2465 (98.6)317 (96.1)0.002csDMARD828 (33.1)187 (56.7)<0.001bDMARD1288 (51.5)180 (54.4)0.32

axSpA: axial spondyloarthritis; axPsA: axial psoriatic arthritis; IBD: Inflammatory Bowel Disease; CRP: C-Reactive Protein; mNY: modified New York; csDMARDs: conventional synthetic DMARDs; bDMARDs: biological DMARDs; NSAID: Non-steroidal anti-inflammatory drugs

Disclosure of Interests:

Diego Benavent: None declared, Chamaida Plasencia: None declared, Denis Poddubnyy: None declared, Mitsumasa Kishimoto Consultant of: AbbVie, Amgen-Astellas BioPharma, Asahi-Kasei Pharma, Astellas, Ayumi Pharma, BMS, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Janssen, Kyowa Kirin, Novartis, Ono Pharma, Pfizer, Tanabe-Mitsubishi, Teijin Pharma, and UCB Pharma., Fabian Proft Grant/research support from: AbbVie, AMGEN, BMS, Celgene, MSD, Novartis, Pfizer, Roche, UCB, Haruki Sawada: None declared, Clementina López-Medina: None declared, Maxime Dougados: None declared, Victoria Navarro-Compán: None declared.

Doppler enthesitis: a potential useful outcome in the assessment of axial spondyloarthritis and psoriatic arthritis

OBJECTIVE

To analyse the frequency of power Doppler (PD) enthesitis in active axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) patients and its potential usefulness in clinical practice.

METHODS

A prospective multicentre cross-sectional study in patients with axSpA and PsA with active disease was undertaken. Patients underwent bilateral ultrasound (US) examination of the peripheral entheses according to the Madrid Sonographic Enthesis Index (MASEI). The MASEI and Outcome Measures in Rheumatology (OMERACT) PD enthesitis definitions were checked. An inter-reader analysis of recorded videos was performed to determine reliability.

RESULTS

Sixty-four consecutive patients were included. The mean DAS28 (3.9 ± 1.3) for peripheral involvement, mean BASDAI (5.6 ± 2.2) for axial involvement, and CRP values (10 ± 10.9) reflected moderate-high disease activity at baseline. The mean global MASEI score was 29.4 (± 11.4), and 55 patients (86%) scored ≥ 18 (proposed cut-off point to diagnose SpA). At the patient level, abnormal US findings consistent with at least one enthesis showing a PD signal were observed in 52 (81.3%) patients using the MASEI PD definition and 48 (75%) using the OMERACT PD definition, without significant variation between axSpA and PsA. The inter-reader reliability was excellent (kappa = 0.92 for MASEI PD and 0.86 for OMERACT PD).

CONCLUSIONS

PD enthesitis was found in the majority of patients with active axSpA and PsA, independent of axial or peripheral affectation. Both MASEI and OMERACT PD definitions were useful in detecting active enthesitis. These findings support the usefulness of a PD US evaluation of entheses in the assessment of axSpA and PsA. Key Points • PD enthesitis is a very common finding in patients with active axSpA and PsA • Both MASEI and OMERACT PD definitions are useful to detect active enthesitis • US enthesitis may reveal information in axSpA and PsA.

AB0670 AXIAL MANIFESTATIONS IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS AND PSORIATIC ARTHRITIS: ARE THEY SIMILAR?

Background:

Spondyloarthritis (SpA) is a group of heterogeneous diseases that includes axial SpA (axSpA), such as ankylosing spondylitis and axial non-radiographic SpA, and Psoriatic Arthritis (PsA) with peripheral and/or axial involvement (axPsA). Currently, it is not well known if the characteristics and burden of the disease in patients with axPsA are similar to that of patients with axSpA.

Objectives:

To compare the demographic, clinical and structural features between patients with axSpA and axPsA.

Methods:

Data from an observational prospective cohort including all patients with SpA initiating biological therapy because of predominant axial manifestations from 2002-2019 in a university hospital were analyzed. AxSpA and axPsA were defined in clinical practice according to the prescribing rheumatologist, based on clinical features and complementary examinations. Demographic information, laboratory tests, disease presentation, sacroiliitis according to modified New York criteria in the pelvis X-ray, disease activity indexes (ASDAS and BASDAI) and concomitant treatment before starting biological drug were collected from the electronic medical record and biologic database. In the statistical analysis, chi square or the exact Fisher’s test was used for categorical and t-student or U-Mann Whitney for continuous variables, according to the distribution of the data. Then, the association between demographic and clinical features and each disease was analysed using univariable and multivariable logistic regression models.

Results:

Out of 352 included patients, 287 (81.5%) had axSpA, and 65 had axPsA (18.5%). Baseline characteristics are shown in Table 1. Mean baseline ASDAS was 3.3±0.9 and 3.1±1.0 for axSpA and axPsA, respectively. Biological therapies initiated can be seen in Figure 1. No significant differences at baseline were observed between axSpA and axPsA for most of the characteristics including: gender, age at diagnosis, age at starting biologic, disease duration before biologic, smoking habit, CRP, disease activity, enthesitis, dactylitis, inflammatory bowel disease (IBD), patient global assessment and sulfasalazine use. However, there were differences between diseases in some relevant characteristics. AxSpA patients had less peripheral involvement (41.5 vs. 78.5 %, p=0.004), more uveitis (15.3 vs. 3.1 %, p=0.03) and were more frequently HLA-B*27 positive (72.3 vs 34.1 %, p<0.001), in comparison to axPsA patients. They also had better physician global assessments (PhGA) (37.4 vs 44.4, p=0.02), and a higher grade of radiographic sacroiilitis. AxSpA patients used less global baseline concomitant therapy (p=0.001), methotrexate (p<0.001) and prednisone (p<0.01), whereas they used more sulfasalazine (p=0.003) than axPsA patients in our cohort. After running multivariate analyses, the absence of peripheral manifestations (OR=4.7; p<0.001) and the positivity of HLA-B27 (OR=5.4; p<0.001) were independently associated with axSpA.

Table 1. Baseline stratified characteristics. Results are shown as absolute numbers (percentages) or mean ± standard deviation.

Conclusion:

Despite being spondyloartrithis with many common traits, axSpA and axPsA present some differences in clinical practice. Whereas axSpA patients are more frequently HLA-B27 positive, axPsA have more peripheral involvement. These differences in clinical presentation between both diseases may contribute to variances in therapeutic management, such as increased use of baseline concomitant therapy in axPsA patients who initiate biological therapy.

Figure 1.

Biological therapies initiated in axSpA and axPsA

Disclosure of Interests:

Diego Benavent: None declared, Victoria Navarro-Compán Consultant of: Abbvie, Lilly, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Lilly, Novartis, Pfizer, UCB, Chamaida Plasencia: None declared, Diana Peiteado: None declared, Alejandro Villalva: None declared, Alejandro Balsa Grant/research support from: BMS, Roche, Consultant of: AbbVie, Gilead, Lilly, Pfizer, UCB, Sanofi, Sandoz, Speakers bureau: AbbVie, Lilly, Sanofi, Novartis, Pfizer, UCB, Roche, Nordic, Sandoz

FRI0086 DISEASE ACTIVITY MEASURES AND OTHER POTENTIAL PREDICTORS OF SUCCESSFUL TNF INHIBITORS TAPERING IN RA PATIENTS

Background:

Biologic therapy (BT) resulted in a substantial improvement of outcomes in Rheumatoid Arthritis (RA). However, it is also associated with higher costs, adverse events and patient´s request to dose reduction and drug holidays. Although clinical practice guidelines suggest consider tapering biologics after sustained remission, the optimal approach for de-escalation remains unknown.

Objectives:

i) to identify potential features associated with long-term successful TNF inhibitors (TNFi) tapering (Tap) in RA patients (pts), including the possible predictive value of different disease activity measures (DAS28, SDAI, CDAI). ii) to describe long-term outcome in relation to dose reduction of BT.

Methods:

Observational prospective study of 91 RA pts who started a first TNFi between 2000-2014 and in whom tapering (dose down-titrated or interval widen) was applied after achieving sustained remission/Low disease activity. Demographic, clinical and analytical data were collected at biologic initiation. Disease activity was measured using DAS28, SDAI and CDAI at de-escalation start and at 6 (6 m), 12 (12 m), 18 (18 m) and 24 months (24 m) follow-up. Tap failure (primary outcome) was defined as reinstatement of full dose, escalation to the previous dose level or discontinuation due to secondary inefficacy. Tap status (Tap failure/success) was also assessed at each studied time point. Mann–Whitney U test and Fisher’s exact test were used to test statistical differences. Logistic regression analysis was used to identify predictors of tap failure at 12 and 24 m.

Results:

Of the 91 cases included (mean age 53 ±12.5 years, 74% women), eleven (12%) experienced Tap failure at the 12 m mark. At 24 m, 18 pts (20%) failed to taper, while 74 (80%) succeeded. At 12 and 24 m no significant differences were found in baseline and pre-Tap characteristics between those who experienced tap failure and those who succeeded (Table 1). In the univariate analysis, at the 12 m mark, there were no factors related to tapering; however, at 24 m, a longer time from TNFi start to achievement of remission was identified as a predictor of Tap failure (OR=1.64, p=0.02); this feature remained associated with failed Tap at 24 m in the multivariate analysis (OR=1.75, p=0.02). Neither of the three disease activity indices measured at Tap initiation predicted long-term tap failure.

Conclusion:

In our cohort of RA patients on tapered TNFi, time from TNFi start to achievement of remission seemed to determine successful tapering of biological treatment. However, disease activity scores measured at dose reduction initiation were not predictive of successful de-escalation strategies.

table

tableBaseline CharacteristicsPts who presented a tap failure at 24 m(n=18)Pts who presented a successful tap at 24 m (n=73)Totalpopulation(n=91)P valueAge at TNFi start (years)48.4 (13.2)54 (12.1)53 (12.5)P=0.06Sex (female) n (%)13 (72)54 (74)67 (74)P=1.00Non smokers, n (%)7 (41)41 (58)48 (54)P=0.28BMI, m (SD)25.3 (4.8)25.5 (4.2)25.5 (4.3)P=0.75RF +, n (%)15 (83)59 (81)74 (81)P=1.00CCP, + n (%)13 (72)58 (82)71 (80)P=0.51Monotherapy, n (%)3 (17)8 (11)11 (12)P=0.45Disease duration, m (SD)8.8 (6.6)10.2 (7.1)9.9 (7)P=0.36DAS28 at TNFi start, m (SD)4.7 (1.3)4.7 (1.1)4.7 (1.2)P=0.71CDAI at TNFi start, m (SD)25.2 (23.5)22.5 (12.3)23.1 (15.1)P=0.64SDAI at TNFi start, m (SD)23.4 (13.7)22.1 (12.4)22.3 (12.6)P=0.9Pre-Tap Characteristics:DAS28 at Tap initiation, m (SD)2.3 (0.7)2.4 (0.7)2.4 (0.7)P=0.83CDAI at Tap initiation, m (SD)3.6 (3)3.5 (4.2)3.5 (4)P=0.47SDAI at Tap initiation, m (SD)4.4 (3)3.8 (4.2)3.9 (3.9)P=0.17Time from TNFi start to achievement of remission1.9 (1.6)1.1 (1)1.3 (1.2)P=0.08Time from achievement of remission to tapering2.2 (2.5)2.5 (2.6)2.4 (2.5)P=0.46

m, mean; SD, standard deviation

Acknowledgments:

We are grateful to all of the rheumatologists and nurses at the Daycare Department for Biologicals and the patients who participated in the registry

Disclosure of Interests:

Patricia Bogas: None declared, Chamaida Plasencia: None declared, Francisco Guiñazú: None declared, Marta Novella-Navarro: None declared, Victoria Navarro-Compán Consultant of: Abbvie, Lilly, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Lilly, Novartis, Pfizer, UCB, Karen Nathalie Franco Gomez: None declared, Irene Monjo: None declared, Alejandro Balsa Grant/research support from: BMS, Roche, Consultant of: AbbVie, Gilead, Lilly, Pfizer, UCB, Sanofi, Sandoz, Speakers bureau: AbbVie, Lilly, Sanofi, Novartis, Pfizer, UCB, Roche, Nordic, Sandoz

AB0526 DIFFERENCES IN IMMUNOGLOBULIN LEVELS IN PATIENTS WITH ANCA-ASSOCIATED VASCULITIS AND RHEUMATOID ARTHRITIS TREATED WITH RITUXIMAB

Background:

Rituximab (RTX) is a chimeric monoclonal antibody against CD20 receptor, used in the treatment of rheumatic diseases. Hypogammaglobulinemia has been described as an adverse event. It has been reported that hypogammaglobulinemia is more frequent in patients with ANCA-associated vasculitis (AAV).

Objectives:

To study the basal characteristics of patients with AAV and rheumatoid arthritis (RA) in treatment with RTX and to analyze the risk factors of hypogammaglobulinemia.

Methods:

Retrospective observational study of patients treated with RTX. Patients diagnosed with AAV and RA with immunoglobulin levels prior to treatment and after each cycle were included. Clinical and demographic variables were analyzed. Both populations were compared using t-Student for continuous and chi-squared for categorical variables. The influence of the basal characteristics of the patients was analyzed using univariate and multivariate logistic regression models.

Results:

Among the 86 included patients, 10 (11.6%) had AAV and 76 (88.4%) RA. Patient’s characteristics stratified by disease are included in Table 1.

Table 1.

Characteristics of patients treated with RTX, according to their underlying disease.

Overall sample n=86ARn=76VAAn=10pAge at diagnosis, yearsm±SD57 ± 1256 ± 1263 ± 110,11Disease progression, yearsm±SD11,5 ± 913 ± 91 ± 1< 0,001Femalen/N (%)66/86 (76,6)60/76 (78,9)6/10 (60)0,18IGG <725 prior to initiation of treatmentn/N (%)10/86 (11,6)4/76 (5,3)6/10 (60)< 0,001IgG < 600n/N (%)12/86 (14)4/76 (5,3)8/10 (80)<0,001IgG <400n/N (%)2/86 (2,3)02/10 (20)<0,001IgM Hipogamaglobulinemian/N (%)26/86 (30,2)17/76 (22,4)9/10 (90)<0,001Pretreatment with non-antiTNF biologicsn/N (%)25/86 (29,1)24/76 (31,6)1/10 (10)0,15Pretreatment with antiTNFn/N (%)60/86 (69,8)59/76 (77,6)1/10 (10)<0,001Pretreatment with FAMESn/N (%)80/86 (93)72/74 (94,7)8/10 (80)0,08Pre-treatment with JAK inhibitorsn/N (%)11/86 (12,8)11/76 (14,5)00,19Cyclophosphamide pretreatmentn/N (%)3/86 (3,5)03/10 (30)< 0,001Infectionsn/N (%)21/86 (24,4)15/76 (19,7)6/10 (60)0,02Severe infectionn/N (%)7/86 (4,6)1/76 (1,3)3/10 (30)< 0,001Cumulative dose of steroids one year priorm±SD2923 ± 30032227 ± 18986199 ± 4621< 0,001Cumulative dose of steroids during treatmentm±SD2626 ± 23532303 ± 19135668 ± 39970,002

The overall sample was divided into two groups, patients who developed hypogammaglobulinemia and patients who did not. Of the 12 patients who developed hypogammaglobulinemia, 4 had RA and 8 AAV (p<0.001). In the univariate analysis, patients who developed hypogammaglobulinemia presented higher age at diagnosis (61 ± 15 vs 43 ± 11 years, OR=1.14 p<0.001), shorter time of disease progression (4.9 ± 8 vs 12.6 ± 9 years, OR=0.86 p0.02) and lower gammaglobulin rates at baseline (744 ± 504 vs 1145 ± 295 OR=0.16 p0.006). There were more severe infections in the group of patients with hypogammaglobulinemia than in the group without it (1/4 [25%] vs 1/74 [1.4%], OR=0.42 p<0.001). Patients with hypogammaglobulinemia received a higher cumulative dose of steroids during treatment (OR=1,000 p 0.019). Within the RA group, patients with hypogammaglobulinemia also received a higher cumulative dose of steroids (p 0.009).

In the multivariate study, only age at the beginning of treatment (OR=1.1 p=0.020) remained a risk factor for the appearance of hypogammaglobulinemia.

Conclusion:

A significantly higher percentage of hypogammaglobulinemia is observed in patients with AAV treated with Rituximab, compared to patients with RA. The development of hypogammaglobulinemia seems to be influenced by age at diagnosis, years of disease progression, IgG levels prior to initiation of treatment and a higher cumulative dose of glucocorticoids (targeted in both the overall sample and the RA group). In addition, there is a higher frequency of severe infections in the hypogammaglobulinemia group. Studies with larger sample sizes are needed to confirm these results.

Disclosure of Interests:

María Sanz: None declared, Gemma Bonilla: None declared, Diana Peiteado: None declared, Diego Benavent: None declared, Chamaida Plasencia: None declared, Laura Nuño: None declared, Irene Monjo: None declared, Alejandro Villalva: None declared, Alejandro Balsa Grant/research support from: BMS, Roche, Consultant of: AbbVie, Gilead, Lilly, Pfizer, UCB, Sanofi, Sandoz, Speakers bureau: AbbVie, Lilly, Sanofi, Novartis, Pfizer, UCB, Roche, Nordic, Sandoz

AB0646 IS IT FEASIBLE TO ACHIEVE RECOMMENDED THERAPEUTICAL TARGET IN PATIENTS WITH AXIAL SPONDYLARTHRITIS IN CLINICAL PRACTICE? DATA FROM THE SpA-Paz COHORT

Background:

Current ASAS/EULAR recommendations for the management of patients with axial spondylarthritis (axSpA) establish that the therapeutic goal to achieve in clinical practice is remission, defined as the absence of both clinical and laboratory disease activity evaluated by BASDAI&CRP or preferably ASDAS and if this is not possible, low disease activity may be an alternative. Recently, ASDAS nomenclature has been modified, calling now low disease activity to what was previously called moderate activity. To this day we do not know if this target is feasible in clinical practice.

Objectives:

To analyze the frequency of patients with axSpA achieving maintained remission (R) or low disease activity (LDA) after receiving biological therapy. Secondary objectives included: i) to assess if the activity index used influences the frequency of maintained R/LDA, ii) analyze the prognostic factors for achieving maintained R/LDA.

Methods:

An observational, longitudinal study of a prospective cohort (SpA-Paz) including all patients with axSpA who initiated their first biological treatment between the years 2003-2017. Demographic, clinical and analytical data were collected at the beginning of treatment and clinical disease activity measured by BASDAI&CRP and ASDAS every 6 months for 2 years. Maintained R was defined as (BASDAI<2 & normal CRP and/or ASDAS <1.3) and maintained LDA (BASDAI <4 & normal CRP and/or ASDAS <2.1) on at least 3 consecutive visits. Statistical analysis: i) measures of central tendency and dispersion for quantitative variables and frequencies for qualitative variables; ii) univariate and multivariate analysis of binomial logistic regression model and calculation of OR and 95% CI.

Results:

Out of 186 patients with axSpA who started treatment during the study period, 63% were men with a mean age of 54 ± 14.1 years. 75.3% of the patients had radiographic axSpA and 74.7% were HLA-B27 positive. Other baseline characteristics (not shown due to space restrictions). Overall, 80% of the patients achieved ASDAS R/LDA (R36%/LDA44%) in at least one of the visits after 2 years of follow-up, but only 40% (R27%/LDA13%) fulfilled the maintained ASDAS R/LDA state. On the other hand, 73% of patients were classified as BASDAI&CRP R/LDA (R31%/LDA42%) in at least one of the visits, but only 31% (R21%/LDA10%) obtained the maintained BASDAI&CRP R/LDA state. In the multivariate analysis, we observed an independent statistically significant association with male sex (OR=3.19; 95% CI=1.46-6.99), younger age at the beginning of the biological treatment (OR=0.97; 95% CI=0.95-0.99) and the use of methotrexate (OR=3.07; 95% CI=1.39-6.78) in patients who achieved maintained BASDAI&CRP R/LDA and with male sex (OR=4.01; 95% CI=1.83-8.77), younger age at the beginning of the biological therapy (OR=0.96; 95% CI=0.94-0.99) and HLA B27 presence (OR=4.30; 95% CI=1.68-11.01) in patients who achieved maintained ASDAS R/LDA.

Conclusion:

Although the majority of patients with axSpA who initiate biological therapy achieve the recommended therapeutic goal in the first two years of treatment, the percentage of patients who manage to maintain the R/LDA status is limited. In our study, maintained R was more frequent than maintained LDA, being somewhat higher when measured by ASDAS. This fact may suggest that patients who achieve maintained R have a greater inhibition of their inflammatory activity and, therefore, it remains in time. Male sex and younger age at the beginning of the biological therapy were the main baseline predictors for achieving maintained R/LDA.

Graphics:

Disclosure of Interests:

Karen Nathalie Franco Gomez: None declared, Chamaida Plasencia: None declared, Marta Novella-Navarro: None declared, Diego Benavent: None declared, Patricia Bogas: None declared, Romina Nieto: None declared, Irene Monjo: None declared, Laura Nuño: None declared, Alejandro Villalva: None declared, Diana Peiteado Grant/research support from: AbbVie, Lilly, MSD, and Roche, Speakers bureau: AbbVie, Roche, and MSD, Alejandro Balsa Grant/research support from: BMS, Roche, Consultant of: AbbVie, Gilead, Lilly, Pfizer, UCB, Sanofi, Sandoz, Speakers bureau: AbbVie, Lilly, Sanofi, Novartis, Pfizer, UCB, Roche, Nordic, Sandoz, Victoria Navarro-Compán Consultant of: Abbvie, Lilly, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Lilly, Novartis, Pfizer, UCB

AB0925 MULTIPLE FRACTURES DUE TO IRON-INDUCED AND FGF23-MEDIATED HYPOPHOSPHATAEMIC OSTEOMALACIA: AN UNKNOWN ADVERSE EFFECT

Background:

The use of a specific and widely used type of intravenous ferrotherapy, ferric carboxymaltose (FCM), has been linked to the development of an asymptomatic and transient hypophosphataemia. However, in recent years it has been published that it can generate a severe hypophosphataemic osteomalacia (HPO) mediated by fibroblast growth factor 23 (FGF23) that is associated with high morbidity1. It is a potentially serious adverse effect whose prevalence is unknown and that clinicians may know little about.

Objectives:

To know the clinical and biochemical characteristics of this adverse effect and make it visible in the medical community.

Methods:

Observational descriptive study of three cases of patients assessed in the Rheumatology department of our hospital who were referred for study of recurrent fractures and diagnosed of FGF23-mediated HPO due to FCM. Demographic, clinical and laboratory data of the patients are described.

Results:

The clinical and laboratory characteristics of the patients are shown in table 1. All patients presented clinical and biochemical features compatible with FGF23-mediated HPO (mean of FGF levels 240 kRU/L, NR 0-145). All had multiple insufficiency fractures (Fx) and/or avascular necrosis (AN), with hip involvement in all 3 cases. Other causes of HPO were ruled out in all of them using PET18F-FDG, octreotide scintigraphy, abdominal magnetic resonance and PET68Ga-DOTATOC, and a genetic study of hypophosphataemic rickets was also performed in case 1. In all patients FCM was discontinued and phosphate levels were progressively normalized allowing the withdrawal of oral phosphate and calcitriol replacement therapy. After metabolic normalization, none presented new Fx or AN.

Table 1.

Clinical and biochemical characteristics of the patients

Case 1Case 2Case 3Age (years)a367543Medical historyCrohn’s disease (CD), right hemicolectomy. CD-associated spondyloarthritisSmall bowel angiodysplasiasAntisintetase syndrome. Uterine fibroids.Cause of anemiaGastrointestinal bleeding and malabsorptionGastrointestinal bleedingGynecological bleedingFe-CBX start date10/201008/201302/2018Fe-CBX discontinuation date10/201811/201806/2018Total time Fe-CBX (months)96634FracturesAN: left calcaneus posterior tuberosity, astragaline dome, right femoral headFx: left talus, tibial pylon, tibia-astragaline and ischiopubial branch; right 2nd metatarsal, distal tibia, posterior tuberosity of calcaneusFx both femoral necks and right sacral wingAN both femoral headsBone densitometryLS: Z-score-2.4FN: Z-score -2.4LS: Z-score -0.5FN: Z-score -1.3Phosphate, mg/dL (NR 2.5-4.5)a1.81.61.3Calcium, mg/dL (NR 8.6-10.2)a9.18.39.01,25(OH)zD3, ng/ml (NR 30-100)a54127PTH, pg/ml (NR 12-65)a71223104AP, UI/L (NR 46-116)a11314086Ph-exc, mg/24h (NR 400-1300)a16091630489TPR, % (NR 73-87)a58.350.270.7FGF-23, kRU/L (NR 0-145)a183335201Time to normalizationb1048

aDuring treatment with FCM.bOf serum phosphate levels since FCM discontinuation in months. LS: Lumbar spine. FN: Femoral neck. NR: Normality range..PTH: Parathyroid hormone. AP: Alkaline phosphatase. Ph-exc: 24-hour urine phosphate excretion. Ph-cl: phosphate clearance. TPR: Tubular phosphate reabsorption. Data highlighted in bold indicate altered values.

Conclusion:

Treatment with FCM can cause severe FGF23-mediated HPO, multiple fractures and a great decrease in the quality of life. Since it can be potentially serious and easily reversible, it is important to favor the dissemination of these new cases and the knowledge of this disease. The need to monitor phosphate and/or FGF23 levels in patients receiving this intravenous iron therapy should be evaluated.

References:

[1]Bishay RH, Ganda K, Seibel MJ. Long-term iron polymaltose infusions associated with hypophosphataemic osteomalacia: a report of two cases and review of the literature. Ther Adv Endocrinol Metab. 2017;8(1-2):14–19. doi:10.1177/2042018816678363

Disclosure of Interests:

Elisa Fernández: None declared, Carolina Tornero: None declared, Victoria Navarro-Compán Consultant of: Abbvie, Lilly, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Lilly, Novartis, Pfizer, UCB, Gemma Bonilla: None declared, Chamaida Plasencia: None declared, Alejandro Balsa Grant/research support from: BMS, Roche, Consultant of: AbbVie, Gilead, Lilly, Pfizer, UCB, Sanofi, Sandoz, Speakers bureau: AbbVie, Lilly, Sanofi, Novartis, Pfizer, UCB, Roche, Nordic, Sandoz, Pilar Aguado: None declared

AB1116 DOPPLER EVALUATION OF ENTHESITIS SEEMS TO BE A RELEVANT OUTCOME IN THE ASSESSMENT OF ACTIVITY IN SPONDYLOARTHRITIS AND PSORIATIC ARTHRITIS

Background:

The assessment of activity in spondyloarthritis (SpA) and psoriatic arthritis (PsA) involves several domains, including enthesitis. Clinical enthesitis evaluation has shown low sensitivity, specificity and reliability. Ultrasound (US) examination of enthesitis can be an accurate and objective way to evaluate this domain, supporting its inclusion in the assessment of the global state of the disease

Objectives:

The main objective of this study is to analyze de prevalence of Doppler enthesitis in active SpA and PsA patients and to evaluate its association with the disease activity at patient level prior to start a biological therapy

Methods:

A prospective multicenter cross-sectional study in patients with SpA and PsA with active disease (defined as patients who were going to start or switch biological therapy according to physician criteria and in agreement with clinical guidelines) was undertaken. Basal assessment included clinical features, physical examination and laboratory tests. Patients underwent bilateral US examination of peripheral entheses according to the MAdrid Sonographic Enthesitis Index (MASEI). MASEI and Outcome Measures in Rheumatology (OMERACT) enthesitis Power Doppler (PD) definitions were checked. Each enthesis was scanned in two planes: longitudinal and transverse, and 5 second videos were recorded for reliability. An inter-reader analysis by three readers was performed at each included center. For statistical analysis Mann-WhitneyU and Kruskal-Wallis tests were used. Intraclass correlation coefficient (ICC) and kappa test were used for reliability

Results:

64 consecutive patients were included, of whom 19(29.7%) were ankylosing spondylitis (AS), 7(10.9%), non-radiographic axial spondyloarthritis (nr-axSpA) and 38(59.4%) PsA patients. Mean age was 52.4±12.5 years and 36(56.3%) were males. Mean DAS28 (3.6±1.3) for peripheral involvement, mean BASDAI (5.6±2.2) for axial involvement, and CRP values (10±10.9) reflect moderate-high disease activity at baseline. Demographic, clinical and MASEI baseline characteristics are shown in Table 1. Mean global MASEI score was 29.4 (±11.4) and 55 patients (86%) scored ≥18 (proposed cut-off point to diagnose SpA). At the patient level, abnormal US findings consistent with at least one enthesis showing PD signal were observed in 52(81.3%) of patients using MASEI PD and 48(75%) using OMERACT PD definition without significant variation among the different SpA subtypes (p=0.8 and p=0.6, respectively). The inter-reader reliability among the two cohorts from each center performed by three readers was high (ICC cohort 1:0.92; cohort 2:0.85) and inter three readers kappa was good (0.92 and 0.86 for Doppler MASEI and Doppler OMERACT respectively).

Table 1.

Baseline characteristics of SpA and PsA patients

Totaln= 64ASn=19 (29.7%)PsAn=38 (59.4%)nr-axSpAn=7 (10.9%)pAge52.4±12.550.3±14.554.6±11.646.3±9.90.2Sex (Male)36 (56.3%)10 (52.6%)23 (60.5%)3 (42.9%)0.6CRP (mg/L)10±10.913.7±11.49±10.96.8±9.10.3VSG (mm/h)17.3±1512.6±7.520.6±1811.9±40.4DAS28 n= 403.6±1.33.1±1.13.9±1.33.2±1.40.2BASDAI n=235.6±2.25.3±2.55.4±0.86.9±0.90.2MASES n=261.1±1.51.1±1.6-1.1±1.30.9MASEI29.4±11.429.1±930±12.826.7±10.40.9MASEI score ≥1855 (85.9%)18 (94.7%)32(84.2%)5(71.4%)0.3Mean number of enthesis with PD OMERACT1.6±1.41.7±1.31.5±1.51.6±1.70.6Mean number enthesis with PD MASEI2.1±1.71.9±1.42.2±1.81.7±1.70.8PD OMERACT ≥148 (75%)15(78.9%)28(73.7%)5(71.4%)0.9PD MASEI ≥152 (81.3%)15(78.9%)32(84.2%)5(71.4%)0.7

Conclusion:

PD enthesitis is found in the vast majority of patients with active SpA and PsA, independent of SpA subtype. MASEI PD might have some advantages versus OMERACT PD definition to detect active enthesitis. These findings support the usefulness of PD US in the assessment of activity in SpA and PsA at patient level.

Disclosure of Interests:

Juan Molina Collada: None declared, Cristina Macía-Villa: None declared, Chamaida Plasencia: None declared, Jose-Maria Alvaro-Gracia Grant/research support from: Abbvie, Elli-Lilly, MSD, Novartis, Pfizer, Consultant of: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Paid instructor for: Elli-Lilly, Pfizer, Roche, Speakers bureau: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, Gedeon Richter, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Eugenio de Miguel Grant/research support from: Yes (Abbvie, Novartis, Pfizer), Consultant of: Yes (Abbvie, Novartis, Pfizer), Paid instructor for: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi), Speakers bureau: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi)

AB0741 IS THE THERAPEUTIC TARGET ACHIEVEMENT INCREASING OVER TIME IN PATIENTS WITH PSORIATIC ARTHRITIS STARTING BIOLOGICAL THERAPY? DATA FROM 15 YEARS

Background:

Treatment in Psoriatic Arthritis (PsA) has undergone a major revolution in recent years, with the development of new targets and molecules. Despite these advances, data from clinical practice demonstrating a change in management success are scarce.

Objectives:

To evaluate if the proportion of patients (pts) with PsA maintaining an acceptable medium-term control of the disease activity after starting a first biologic agent is increasing over time.

Methods:

Prospective cohort including 101 patients (pts) with PsA starting a 1st biologic (TNF inhibitor, anti-IL 17 inhibitor) in a tertiary hospital between 2002-2018. Demographic, clinical and laboratory data were collected at the beginning of treatment. Disease activity indexes (ASDAS for axPsA and DAPSA for pPsA) were collected before starting biologic, six and twelve months later (baseline, 6m and 12m visit, respectively). Low disease activity (LDA) was defined as ASDAS < 2.1 (axPsA) and DAPSA ≤14 (pPsA). Three groups were established according to biologic initiation date: period 1 (p1) (between 2002-2007), (p2) 2008-2013 and (p3) 2014-2018. Each period had a minimum follow-up of 1 year for every patient. For each interval, the percentage of pts achieving persistent (at both follow-up visits) LDA was determined, as a marker of acceptable medium-term control of the disease. All collected variables were compared between groups by ANOVA and Chi-Squared test.

Results:

Out of the 101 pts initiating biological therapy, 46 % were males and 57 % had peripheral PsA. At the biologic treatment start, mean ± SD age was 48.5 ± 12 years and disease duration was 9.9 ± 10 years. Biological therapies initiated included etanercept in 38 % of pts, infliximab in 24 %, adalimumab in 25 %, golimumab in 7 %, secukinumab in 3 % and certolizumab in 3 %.

Stratified by time intervals, 36 (35.6%) pts started in p1, 36 (35.6%) in p2 and 29 (28.8%) in p3. Baseline characteristics of pts by periods are shown in Table 1. For patients in p3, compared to the previous intervals, a significant lower CRP (p=0.03) and ESR (p=0.004) were found at baseline, whereas there were no significant differences on baseline disease activity indices. Fifty-one (50%) pts achieved persistent-LDA after one year of starting biologic. Figure 1 reports the total number of patients that were in LDA in all the visits in the 1styear, stratified per period of time and predominant manifestation. A lower percentage of patients in LDA (33% in p1 vs, 67% in p2 vs 52% in p3, p = 0.02) was found in the first interval, in comparison to the most recent periods. The difference in response between p2 and p3 is mainly due to the group of patients with pPsA, whereas the improvement in the group of patients with axPsA remains constant in both periods.

Table 1.

Baseline patient’s characteristics by periods of time

Figure 1.

Patients achieving persistent-LDA during the 1styear of biological therapy, stratified by period of time and by disease.* Statistically significant difference with respect to p1.

Conclusion:

The percentage of pts with PsA achieving LDA status after one year of initiating a biological therapy has substantially increased over time. A lower threshold of inflammation at biological therapy start and a broader spectrum of therapies might explain this better management on PsA.

Disclosure of Interests:

Diego Benavent: None declared, Victoria Navarro-Compán Consultant of: Abbvie, Lilly, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Lilly, Novartis, Pfizer, UCB, Irene Monjo: None declared, Marta Novella-Navarro: None declared, Alejandro Balsa Grant/research support from: BMS, Roche, Consultant of: AbbVie, Gilead, Lilly, Pfizer, UCB, Sanofi, Sandoz, Speakers bureau: AbbVie, Lilly, Sanofi, Novartis, Pfizer, UCB, Roche, Nordic, Sandoz, Chamaida Plasencia: None declared

FRI0294 MUSCULOSKELETAL MANIFESTATIONS IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE TREATED WITH VEDOLIZUMAB

Background:

Musculoskeletal manifestations (MEM) are frequent extraintestinal symptoms in patients suffering from inflammatory bowel disease (IBD), affecting up to 40% of them. Tumor necrosis factor inhibitors (TNFi) are effective in both IBD and IBD-related spondylarthritis (SpA). Additionally, vedolizumab (VDZ), an α4β7 integrin inhibitor with selective action on intestinal tissue, has been recently proposed as 1st line treatment on TNFi refractory IBD. The effectiveness of VDZ in MEM has not been properly evaluated but even exacerbation of previously diagnosed SpA has been described.

Objectives:

The main objective is to analyse the occurrence of articular exacerbations in patients with IBD-related SpA treated with VDZ. The secondary objective is to analyse the new-onset MEM in IBD patients treated with VDZ.

Methods:

Descriptive study of a retrospective cohort of every adult with IBD (Crohn’s disease -CD- and ulcerative colitis -UC-) patients starting treatment with VDZ in a tertiary hospital. All data were collected as a collaboration between the Rheumatology and Gastroenterology Departments, through revision of the clinical history and databases from both departments. In patients previously diagnosed of SpA exacerbation was assessed, defined as a clinical worsening causing a treatment modification. The patients with new-onset MEM were classified as: i) nonspecific arthralgia (NsA), not suggestive of SpA; and ii) SpA according to ASAS criteria. A statistical analysis was performed using frequency charts

Results:

A total of 61 patients were included, 55.7% women and with an mean (SD) age of 50 (17) years. The proportion of UC and CD was similar (49% and 51%, respectively). Among the patients studied, 12 (19.7%) had a diagnosis of IBD-related SpA and 3 (25%) of them suffered articular exacerbation of SpA within 3,5 and 6 months of treatment. On the other hand, 9 (14.7%) patients showed new-onset MEM, 3 (33%) of them showed symptoms and clinical and/or radiological findings compatible with axial SpA. In 2 of the cases a treatment with a cDMARD was used and the other one required a combination therapy between iTNF and VDZ. The remaining 6 (67%) patients were classified as NsA and inflammatory arthritis was discarded. Table 1 shows the demographic and clinical characteristics of patients included in the analysis.

Table 1.

Demographic, clinical characteristics and symptoms onset in patients included in the study.

Total (n=61)Diagnosed SpA (n=12New-Onset MEM (n=9)Stable (n=9)Exacerbation (n=3New-onset SpA (n=3)NsA (n=6)Age (years), mean ± SD50 ± 1755 ± 1950 ± 7.538 ± 1350 ± 14Gener (female), n (%)34 (55.7%)6 (66.7%)3 (100%)1 (33.3%)3 (50%)BMI (Kg/m2), mean ± SD24.7 ± 4.327.5 ± 5.528.3 ± 3.930.2 ± 0.524.3 ± 4.6Smoking habit (smokers), n (%)11 (18%)1 (11.1%)0 (0%)2 (66.7%)0 (0%)CD diagnosis, n (%)31 (50.8%)2 (22.2%)1 (33.3%)3 (100%)2 (33.3%)UC diagnosis, n (%)30 (49.2%)7 (77.8%)2 (66.7%)0 (0%)4 (66.7%)IBD follow-up, (years) mean ± SD11 ± 9.610.6 ± 102 (1-29) *12 ± 6.89.8 ± 4.6bDMARD naïve, n (%)7 (11.5%)2 (22.2%)0 (0%)0 (0%)0 (0%)

*shown as median (range).

Conclusion:

Switching TNFi treatment to VDZ in patients with IBD-related SpA was found to be associated with articular exacerbation of SpA in 1 out of 4 patients within the first 5 months. New-onset MEM is also observed in up to 15% of patients with IBD treated with VDZ. A multidisciplinary assessment of these patients is necessary in order to achieve a proper management of their diseases.

Disclosure of Interests:

Pablo Rodríguez-Merlos: None declared, MARIA ANGELES RUIZ- RAMIREZ: None declared, Chamaida Plasencia: None declared, Victoria Navarro-Compán Consultant of: Abbvie, Lilly, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Lilly, Novartis, Pfizer, UCB, Cristina Suarez-Ferrer: None declared, Eduardo Martin-Arranz: None declared, Maria Dolores Martín Arranz: None declared, Diana Peiteado: None declared, Gemma Bonilla: None declared, María Sánchez Azofra: None declared, Joaquín Poza Cordón: None declared, Karen Nathalie Franco Gomez: None declared, Alejandro Balsa Grant/research support from: BMS, Roche, Consultant of: AbbVie, Gilead, Lilly, Pfizer, UCB, Sanofi, Sandoz, Speakers bureau: AbbVie, Lilly, Sanofi, Novartis, Pfizer, UCB, Roche, Nordic, Sandoz

AB0313 CLINICAL PREDICTORS OF MULTIPLE FAILURES TO BIOLOGICAL THERAPY IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Biological therapies have improved the clinical course and quality of life of Rheumatoid Arthritis (RA) patients. Despite the availability and effectiveness of these treatments, some patients present multiple failures to biologic disease-modifying anti-rheumatic drugs (bDMARDs), constituting a challenge to clinicians.

Objectives:

To determine the frequency of multiple failure to bDMARDs in RA patients and to identify baseline/early features as possible predictors of multiple failure.

Methods:

This case-control study involved subjects with RA1,2treated with bDMARDs from the RA-Registry at La Paz Hospital between 2000 and 2019. Patients who presented insufficient response to >3 different bDMARDs or >2 bDMARDs with different mechanism of action were considered Multi-refractory (MR-patients). Patients who achieved low disease activity or remission (by DAS-28) with the first bDMARD and maintained it in a follow-up period of at least 5 years were considered non-refractory(NR-patients).For all patients, demographic, clinical characteristics and laboratory parameters were assessed in the database at baseline visit, just prior to start bDMARD for first time and at 6-months visit.

Descriptive analysis was performed, and using the “refractory status” as the dependent variable, multiple bivariate logistic regression models were performed to identify which variables should be considered in the multivariate analyses. P<0.05 was considered statistically significant. Odds Ratio (OR) and Confidence Intervals (CI) were calculated. IBM SPSS 21.0

Results:

In total, 402 RA patients who had ever received bDMARD treatment were identified. According to pre-established inclusion criteria, 112 patients were included: 41MR-patients(10%) and 71NR-patients(18%). No differences in gender, age or age at RA diagnosis were found between both groups. Global time on bDMARD treatment was longer inMR-patients(11.7 vs 9.7 years, p=0.01) and survival on first bDMARD was 4.1±3.4 years, which was decreasing with the successive treatments. InMR-patients, shorter disease duration between RA diagnosis and starting bDMARD (6.9 vs 10.0; p=0.04) and higher number of previous cDMARDs were observed. Also presence of erosions and extra-articular manifestations were more frequent inMR-patients (58.5% vs 25.4%, p=0.03 and 29.3% vs 12.7%, p<0.001).

Results of variables included in bivariate and multivariate analyses are shown in Table 1. Finally, factors associated with multi-bDMARDs refractoriness in the multivariate analysis were presence of erosions, earlier age at bDMARD start, higher baseline DAS-28 and especially ΔDAS< 1.2 in the first 6 months of treatment (OR 11.12; 95% CI 3.34-26.82).

Table 1.VARIABLEBivariateOR (95%CI)MultivariateOR (95%CI)Age at diagnosis0.99 (0.96-1.0)-Sex (Female)1.67 (0.58-4.73)5.94 (0.92-38.20)Age at bDMARD treatment0.97 (0.93-1.00)0.95 (0.90-0.99)Time between diagnosis and bDMARD0.94 (0.89-1.00)-Body mass index1.01 (0.94-1.09)-Erosions (ref yes)4.07 (1.79-9.26)3.26 (1.18-9.00)Extraarticular manifestations (ref yes)2.81 (1.0-7.52)2.14 (0.59-7.78)Metothrexate (ref yes)1.83 (0.66-5.10)-Previous cDMARDs3.54 (2.05-6.1)-CRP baseline1.02 (0.99-1.05)-DAS28 baseline1.77 (1.2-2.6)2.29 (1.39-3.76)ΔDAS-28 (ref <1.2)0.22 (0.09-0.52)11.12 (3.34-26.82)HAQ baseline1.13 (1.03-1.23)1.09 (0.92-1.29)

Conclusion:

In our cohort,10%of patients with RA were observed to have multi-refractoriness to bDMARDs. This study also identified baseline and early clinical characteristics of patients as predictors of multi-refractoriness, especially absence of clinical response during the first 6 months on a first bDMARD.

References:

[1]Arnett FC. Arthritis Rheum 1988;31:315-24.2Aletaha D. Arthritis Rheum. 2010;62:2569-81

Disclosure of Interests:

Marta Novella-Navarro: None declared, Chamaida Plasencia: None declared, Carolina Tornero: None declared, Karen Nathalie Franco Gomez: None declared, Irene Monjo: None declared, Victoria Navarro-Compán Consultant of: Abbvie, Lilly, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Lilly, Novartis, Pfizer, UCB, Diana Peiteado: None declared, Alejandro Balsa Grant/research support from: BMS, Roche, Consultant of: AbbVie, Gilead, Lilly, Pfizer, UCB, Sanofi, Sandoz, Speakers bureau: AbbVie, Lilly, Sanofi, Novartis, Pfizer, UCB, Roche, Nordic, Sandoz

AB0701 ANTERIOR UVEITIS AND HLA B27, ARE THERE ANY CLINICAL OR THERAPEUTIC DIFFERENCES IN PATIENTS WITH POSITIVE HLA B27 VERSUS THOSE WITH HLA B27 NEGATIVE?

Background:

Anterior uveitis is the most frequent form of presentation of uveitis. An important part of patients do not associate extraocular manifestations, so more information about the clinical profile is needed to optimize therapeutic decisions.

Objectives:

To describe the clinical profile of patients with anterior uveitis related and not related to the antigen HLA-B27. Compare both groups to establish differences.

Methods:

Retrospective cohort study. Consecutive patients diagnosed with non-infectious anterior uveitis, assessed in the multidisciplinary uveitis unit of the Infanta Leonor University Hospital (Madrid) from its establishment in October 2017 to December 2019, were included. To compare categorical variables Chi square was used and the test of Fisher; and Student’s T or Mann-Whitney U test for continuous variables. Finally, a multivariate analysis was performed to established differences between the two groups. A value of p <0.05 was considered statistically significant.

Results:

62 patients with anterior uveitis, 26 (42%) with HLA B27 positive and 36 (58%) with HLA B27 negative were included. There were no differences between the two groups regarding sex. Differences were found in the mean age at diagnosis, 35 + -9.6 in the HLA B27 positive group vs 47 + -14.9 in the HLA B27 negative group (p 0.01). The time since uveítis diagnosis was longer in the HLA B27 positive group: 7.08 years (3.45-11.79) versus 2.41 years (1.66-3) in the HLA B27 negative group (p 0.000). Regarding the etiology, the majority of patients in the HLA B27 negative group had a diagnosis of idiopathic anterior uveitis (72.2%), and 53.8% of the patients in the HLA B27 positive group were diagnosed with spondyloarthritis (p 0.000). There were no significant differences in the number of patients that require systemic treatment. There were no differences regarding oral corticosteroids intake, with very few patients needing it (2 patients in the HLA B27 positive group and 5 patients in the HLA B27 negative group (p 0.699). The percentage of patients who needed to start an immunosuppressive treatment were similar between the two groups, 6 patients (23.1%) in the HLA B27 positive group and 11 patients (30.6%) in the HLA B27 negative group (p 0.717) No significant differences could be detected between groups in the multivariate analysis in terms of laterality, clinical course, treatment with immunosuppressants or development of complications.

Conclusion:

In our cohort patients with HLA B27 positive debut at an earlier age. There were no differences between both groups in laterality, course of uveitis, systemic treatment or ocular complications.

Disclosure of Interests:

None declared

SAT0084 SERUM ADIPOKINES PROFILE IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH TNF-INHIBITORS

Background:

In recent years, the relationship between obesity and autoimmune diseases has taken interest, since adipose tissue has been identified as an endocrine organ that secretes cytokines (adipokines), among which leptin stands out as a soluble pro-inflammatory mediator associated with the body mass index (BMI).

Objectives:

The main objectives of this study are: i) to analyse the influence of BMI on clinical response in Rheumatoid Arthritis (RA) patients who initiate TNF-inhibitor (TNFi) therapy; ii) to analyse the differences in the serum profile of adipokines (leptin and adiponectin) according to BMI and their association with response to treatment.

Methods:

Observational study of a prospective cohort of 73 RA patients who initiated biological treatment with TNFi from the Complex Therapy Unit (CTU) of our Hospital. Patients were classified according to their BMI in normal-weight (BMI<25) and overweight/obesity (O/O) (IMC≥25). Demographic, clinical and laboratory variables were collected at baseline and at 6 months. Our outcome measures were DAS28-VSG remission (DAS28<2.6) at 6 months after TNFi initiation. Serum leptin and adiponectin levels were measured by Enzyme-Linked Immuno Sorbent Assay (ELISA) at baseline and 6 months. A descriptive sample analysis comparing the characteristics of both patient subgroups was performed using Chi-square, T-test for independent samples and U-Mann Whitney. Likewise, a bivariate analysis was carried out by means of binary logistic regression to assess the probable association of the parameters studied with remission.

Results:

Of the 73 patients studied, 51% were classified in O/O group. The O/O patients presented higher levels of baseline CRP (16.69±6.16 vs 8.74±3.81, p=0.01). No statistically significant differences were observed in the remaining variables (sex, age at the beginning of the TNFi, disease duration, baseline DAS-28), as well as therapeutic variables (use of previous DMARDs and doses of methotrexate and/or steroids). Patients with overweight/obesity presented higher DAS28-ESR values at 6 months of treatment (3.59±1.14 vs 2.93±1.27, p=0.02) and achieved remission less frequently (18.9% vs 48.6%, p=0.007). Serum leptin levels were significantly higher in O/O patients, both baseline (29.39±21.50 vs 13.49±8.78, p<0.001) and 6 months (33.06±22.03 vs 14.77±9.50, p<0.001) after TNFi initiation. In addition, O/O patients were less likely to reach remission at 6 months than normal-weight patients. [OR= 4.04 IC95% (1.40-11.64); p=0.009]. Lower frequency of remission was associated to greater leptin levels at 6 months [OR=0.94 CI95% (0.90-098); p=0.012]. No differences in serum adiponectin were found between both subgroups of patients.

Conclusion:

In this RA patient cohort, overweight/obesity is associated with i) a reduced response to TNFi therapy and ii) a lower short-term remission rate. Within the adipokine profile, leptin seems to play a relevant role in the maintenance of pro-inflammatory activity with a negative influence on the response to TNFi therapy in O/O patients.

References:

[1] Versini M. et al. Autoimmun Rev. 2014; 13, 981-1000

[2] Toussirot E et al. Life Sci. 2015;140: 29-36.

Disclosure of Interests:

Marta Novella-Navarro: None declared, Borja Hernández-Breijo: None declared, Fernanda Genre: None declared, Leticia Lera-Gómez: None declared, Verónica Pulito-Cueto: None declared, Laura Nuño: None declared, Alejandro Villalba: None declared, Alejandro Balsa Grant/research support from: BMS, Roche, Consultant of: AbbVie, Gilead, Lilly, Pfizer, UCB, Sanofi, Sandoz, Speakers bureau: AbbVie, Lilly, Sanofi, Novartis, Pfizer, UCB, Roche, Nordic, Sandoz, Chamaida Plasencia: None declared

SAT0366 CLINICAL RESPONSE TO BIOLOGIC DMARDS IN AXIAL SPONDYLOARTHRITIS AND AXIAL PSORIATIC ARTHRITIS. DIFFERENT DISEASES, SAME OUTCOMES?

Background:

Patients with psoriatic arthritis may present predominant axial involvement. Currently, it is unclear whether these patients should be considered as axial spondyloarthritis (axSpA) with psoriasis or psoriatic arthritis with axial involvement –also known as axial PsA (axPsA). Data comparing medium-term treatment response to biological drugs in axSpA and axPsA would add relevant information to answer this question.

Objectives:

To compare the clinical response and predictor factors after one year of biological therapy in patients with axSpA and axPsA.

Methods:

One-year follow-up data from all patients (pts) with axSpA or axPsA (defined by the treating rheumatologist) included in a prospective cohort of pts receiving biological therapy from la Paz University Hospital between 2002 and 2019 were analysed. Demographic information, laboratory tests, concomitant treatments and disease status were collected at baseline. Clinical disease activity was measured by PhGA and ASDAS criteria at baseline, 6 and 12 months. According to ASDAS, disease activity was defined as: inactive disease (ID) (ASDAS <1.3), low disease activity (LDA) (ASDAS 1.3-2.1), high disease activity (HDA) (ASDAS 2.1-3.5) and very high disease activity (VHDA) (ASDAS >3.5). Clinical important improvement and major improvement were defined by ASDAS (delta-ASDAS ≥ 1.1 and ≥ 2.0, respectively). According to PhGA, disease activity was assorted by consensus of 3 expert rheumatologists in: ID with PhGA<5, LDA with PhGA 5-30, HDA with PhGA >30-60 and VHDA with PhGA >60. Clinical improvement by PhGA was defined as an improvement of 30 % compared to baseline. In the statistical analysis, the frequency of pts achieving each clinical activity status and clinical improvement at 6m and 12m were compared using Fisher test, separately for axSpA and axPsA. Baseline predictor factors for achieving clinical response and clinical improvement were identified using univariable and multivariable binary regression.

Results:

Out of 352 included pts, 287 (81.5%) had axSpA and 65 (18.5%) axPsA. Sixty percent were males, 158 (45%) smokers, with mean (SD) baseline disease activity of ASDAS (bASDAS): 3.3 (0.9) and PhGA: 39.1 (21.5). Biological therapies initiated included TNF inhibitors in 93.8 % and secukinumab in 6.2%. In comparison to axPsA, pts with axSpA were more HLA B27 positive (p<0.001) and had better PhGA at baseline (p=0.02). They also had more uveitis (p=0.03) and were more radiographically affected (p<0.001).

Response rates at 6m and 12m in both diseases according to ASDAS are shown in Figure 1, and to PhGA in Figure 2. Both diseases presented a similar clinical response, and no statistically significant differences were observed for any disease activity interval between them for ASDAS or PhGA. There were no differences between both diseases on clinical improvement, regardless the type of measurement.

Figure 1.

Response rates (in percentage) by ASDAS at 6m and 12m in axSpA and PsA

In the group of axSpA, the univariate analysis observed that LDA (by ASDAS) at 12m was associated with bASDAS (OR=0.67, p=0.02), male gender (OR=2.8, p=0.001) and HLA B27 positive (OR=2.3, p=0.01). In the multivariate analysis, these variables remained significantly associated with LDA (bASDAS: OR= 0.67; p<0.05; male gender: OR=2.7, p<0.01; and HLA B27 positivity OR=2.6, p<0.01). In the group of axPsA, the univariate analysis showed a tendency that male pts achieved LDA more frequently at 6m (OR=3.0, p=0.05) and at 12m (OR=2.75, p=0.09). In the multivariable analyses, none of the factors was significantly associated neither with clinical improvement nor with LDA in pts with axPsA.

Conclusion:

In clinical practice, pts with axSpA and axPsA present a similar clinical response to biological therapy within the first year of treatment. Male pts seem to have better medium-term outcomes in both diseases, and HLA B27 pts respond better in axSpA.

Disclosure of Interests:

Diego Benavent: None declared, Chamaida Plasencia: None declared, Karen Nathalie Franco Gomez: None declared, Laura Nuño: None declared, Alejandro Balsa Grant/research support from: BMS, Roche, Consultant of: AbbVie, Gilead, Lilly, Pfizer, UCB, Sanofi, Sandoz, Speakers bureau: AbbVie, Lilly, Sanofi, Novartis, Pfizer, UCB, Roche, Nordic, Sandoz, Victoria Navarro-Compán Consultant of: Abbvie, Lilly, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Lilly, Novartis, Pfizer, UCB

SAT0566 ULTRASOUND DOPPLER MASEI SHOWS SENSITIVITY TO CHANGE AFTER BIOLOGICAL THERAPY IN SPONDYLOARTHRITIS AND PSORIATIC ARTHRITIS PATIENTS

Background:

The assessment of activity in spondyloarthritis (SpA) and psoriatic arthritis (PsA) involves several domains, including enthesitis. Clinical enthesitis has shown low sensitivity, specificity and reliability. The MAdrid Sonographic Enthesitis Index (MASEI) is a feasible and reliable ultrasound score, but its responsiveness to treatment has not yet been evaluated.

Objectives:

The main objective of this study was to investigate the sensitivity to change of MASEI in active SpA and PsA patients.

Methods:

Longitudinal study in patients with SpA and PsA with active disease (defined as patients who were going to start or switch biologic disease modifying antirheumatic drugs (bDMARD) therapy according to physician criteria and in agreement with clinical guidelines). MASEI evaluation was performed at baseline, 3- and 6-months visits. MASEI and Outcome Measures in Rheumatology (OMERACT) enthesitis Power Doppler (PD) definitions were checked. Each enthesis was scanned in both the longitudinal and transverse planes, and 5 second videos were recorded for reliability. An inter-reader analysis by three readers was performed. For statistical analysis t-Student test was used to determine changes between visits and kappa test was used for reliability.

Results:

A total of 72 US evaluations of 25 patients were included, of whom 13(52%) were ankylosing spondylitis (AS) patients, 9(36%) PsA, and 3(12%) non radiographic axial spondyloarthritis (nr-axSpA). Mean age was 51.2±14.1 years and 13(52%) were females. Mean DAS28 (3.5±1.2) for peripheral involvement, mean BASDAI (5.8±2) for axial involvement, and CRP values (13.1±13.6) reflect moderate-high disease activity at baseline. US parameters at baseline and at the 3- and 6-month follow-up visits are shown in Table 1. Global MASEI score was responsive at the 3- and 6-month follow-up visit (-4.9 and -5.7, respectively) (p<0.05) and both MASEI and OMERACT PDUS definitions of active enthesitis improved significantly at 3- (-0.6 and -1.1) and 6-month follow-up visits (-0.7 and -1.1) (p<0.05). Reliability of PD MASEI definition among the three readers was excellent (kappa = 0.918).

Table 1.

MASEI evaluation at baseline, 3- and 6-month follow-up visits

ParameterBaselinen=253 monthsn=25Pa6 monthsn=22PaMASEI score28±9.323.2±7.60.00224.7±8.10.01PD US MASEI score1.8 ±1.31.1±1.10.0461±0.90.004PD US OMERACT score1.6±1.20.9±0.90.0240.8±0.90.006

at-Student test for comparison to baseline

Conclusion:

MASEI score significantly improves at 3 and 6 months of follow up in patients under bDMARD treatment and both MASEI and OMERACT Doppler definitions of active enthesitis reflects treatment response. These findings support the usefulness of PD US in the assessment of bDMARD treatment response in SpA and PsA.

Disclosure of Interests:

Juan Molina Collada: None declared, Cristina Macía-Villa: None declared, Chamaida Plasencia: None declared, Jose-Maria Alvaro-Gracia Grant/research support from: Abbvie, Elli-Lilly, MSD, Novartis, Pfizer, Consultant of: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Paid instructor for: Elli-Lilly, Pfizer, Roche, Speakers bureau: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, Gedeon Richter, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Eugenio de Miguel Grant/research support from: Yes (Abbvie, Novartis, Pfizer), Consultant of: Yes (Abbvie, Novartis, Pfizer), Paid instructor for: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi), Speakers bureau: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi)

AB0476 GIANT CELL ARTERITIS: A DISEASE WITH DIFFERENT SUBSETS

Background:

Giant cell arteritis (GCA) is the most common form of autoimmune vasculitis in the elderly. Some evidence indicates that GCA is a heterogeneous disease in terms of symptoms, immune pathology and response to treatment1.

Objectives:

To analyze whether the identification by image of cranial vessels (VC) or large vessels (VG) involvement allows to characterize different clinical subsets of the disease.

Methods:

Descriptive observational study of the last 87 consecutive patients with a new diagnosis of GCA in our hospital. All patients had a CV and LV CDUS exam that included axillary, subclavian, vertebral and carotid arteries or a Positron Emission Tomography (PET-CT). The OMERACT (Outcome Measures in Rheumatology) definitions of halo sign were used for ultrasound diagnosis and IMT limits were established as ≥ 0.34 mm for superficial temporal arteries and ≥ 1 mm for axillary, subclavian and carotid arteries; a clear halo sign was used in the vertebral arteries. The radiologist’s report and the liver/vascular wall index were used for the definition of positive PET-CT. The medical records of these patients were reviewed and their demographic, clinical and laboratory data were compared between the different patterns of GCA. The statistical significance limit was set at P < 0.05. Statistical analyses were performed by using SPSS version 25.

Results:

Out of 198 patients with suspected GCA who underwent a CDUS or PET-CT between November 2016 and November 2019, 87 were diagnosed of GCA. Three different patterns were detected: 44 patients (50.6%) had an exclusive cranial pattern, 31 (35.6%) had a mixed pattern with involvement of both CV and LV and 12 (13.8%) had an exclusive large vessel pattern. The differences between these 3 subsets are shown in table 1. Patients with a LV pattern had more fever and polymyalgia rheumatica than patients with CV involvement and fewer ischemic visual disturbances than those with mixed pattern, reaching statistical significance. In addition, they tended to have fewer other ischemic symptoms (headache, jaw claudication) and more general symptoms than patterns with CV involvement. Regarding laboratory values, the erythrocyte sedimentation rate was significantly higher in the exclusive CV involvement group and lower in those with only LV involvement.

Table 1.

Characteristics of the patients with the different patterns

Cranial pattern (n = 44; 50.6%)Mixed pattern(n = 31; 35.6%)Large vessel pattern(n = 12; 13.8%)p-valueAge, years (mean, SD)78 ± 776 ± 774 ± 110.291Male sex12 (27.3%)14 (45.2%)5 (41.6%)0.252ESR, mm/h (mean, SD)78.7 ± 33.763.9 ± 33.052.1 ± 33.50.031*CRP, mg/L (mean, SD)55.8 ± 46.668.3 ± 63.685.9 ± 89.30.801Headache36 (81.8%)25 (80.6%)8 (66.6%)0.704Jaw claudication12 (27.3%)5 (16.1%)1 (8.3%)0.249Ischemic visual disturbances9 (20.4%)11 (35.5%)0 (0%)0.041#PMR18 (40.9%)13 (41.9%)8 (66.6%)0,018*0,029#General symptoms17 (38.6%)13 (41.9%)8 (66.6%)0.132Fever5 (11.4%)3 (9.7%)6 (50%)0.005*#

SD: standard deviation. ESR: erythrocyte sedimentation rate. CRP: C reactive protein. PMR: polymyalgia rheumatica.

*Statistically significant difference between cranial pattern and large vessel pattern.

#Statistically significant difference between mixed pattern and large vessel pattern.

Conclusion:

Imaging in GCA allow us to establish different patterns of involvement (cranial, mixed, large vessel) that correspond to different clinical subsets. The patients with LV subset debut with a lower ESR and have more fever and polymyalgia rheumatica and less ischemic symptoms.

References:

[1]van der Geest KSM, Sandovici M, van Sleen Y, et al. Review: What Is the Current Evidence for Disease Subsets in Giant Cell Arteritis?. Arthritis Rheumatol. 2018;70(9):1366–1376. doi:10.1002/art.40520

Disclosure of Interests: :

Elisa Fernández: None declared, Irene Monjo: None declared, Gemma Bonilla: None declared, Diana Peiteado: None declared, Chamaida Plasencia: None declared, Alejandro Balsa Grant/research support from: BMS, Roche, Consultant of: AbbVie, Gilead, Lilly, Pfizer, UCB, Sanofi, Sandoz, Speakers bureau: AbbVie, Lilly, Sanofi, Novartis, Pfizer, UCB, Roche, Nordic, Sandoz, Eugenio de Miguel Grant/research support from: Yes (Abbvie, Novartis, Pfizer), Consultant of: Yes (Abbvie, Novartis, Pfizer), Paid instructor for: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi), Speakers bureau: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi)

FRI0582 GM-CSF PRODUCED BY CD4+ T CELLS AS A MARKER OF CLINICAL REMISSION IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH TNF INHIBITORS

Background:

According to the EULAR recommendations, the therapeutic target in patients with RA should be remission (REM). However, no more than 50% of the patients treated with TNF inhibitors (TNFi) attains this outcome. Previous investigations suggested the peripheral blood mononuclear cells (PBMC) as markers associated with the TNFi treatment success1,2. Granulocyte-monocyte colony-stimulating factor (GM-CSF) plays a relevant role in the pathogenesis of rheumatoid arthritis (RA) because it promotes the macrophage differentiation, survival and activation3.

Objectives:

To analyse the intracellular cytokine production by PBMC and its association with REM attainment after 6 months (m) of TNFi treatment in patients with RA.

Methods:

This was a prospective bi-center pilot study including 36 patients with RA. PBMC were isolated from patients at baseline and after 6m of treatment with TNFi and cryopreserved until studied. Intracellular cytokine production by PBMC was stimulated in the presence of 2µg/mL brefeldin as follow: monocytes were stimulated with 20ng/mL LPS during 4h; and simultaneously lymphocytes were stimulated with 50ng/mL phorbol 12-myristate 13-acetate (PMA) and 750ng/mL ionomycin during 4h at 37°C. To identify IL-10-producing B cells, PBMC were pre-incubated with 3µg/mL of CpG oligonucleotide during 20h at 37°C prior to stimulation in presence of 2µmol/L monensin. Intracellular cytokine production (TNFα, IL6, GM-CSF, IL10) by the different cell subsets (monocytes, CD4+and CD8+T cells, naïve and memory B cells) was analysed by flow-cytometry. Clinical activity at baseline and after 6m was assessed by DAS28. REM was defined as DAS28≤2.6 at 6m. The association between REM and the change in cytokine production (Δ, 6m-0m) by each PBMC subset was analysed through univariable and multivariable logistic regression models.

Results:

Seventy-eight percent of the patients were female. After 6m of TNFi treatment, 47% patients attained REM. Univariable analyses was performed to investigate the association between REM and the baseline variables. Male sex (OR: 12.6; 95% CI: 1.35-117.57; p=0.03) and having lower baseline DAS28 (OR: 0.4; 95% CI: 0.19-0.85; p=0.02) were independently associated with attaining REM after 6m of TNFi. In the multivariable analysis, only being male (OR: 19.7; 95% CI: 1.4-273.9; p=0.03) remained independently associated with REM after 6m of treatment. Therefore, further analyses were adjusted by sex. Decreased production of GM-CSF by CD4+T cells percentage was found after 6m of TNFi treatment in REM patients (0m: 6.07%; 6m: 3.87%; p=0.007) while no-REM patients did not show differences with the baseline (0m: 3.70%; 6m: 3.75%; p=0.9). The decrease was significantly associated with attaining REM (OR: 0.56; 95% CI: 0.33-0.95; p: 0.03). No significant association was found between any other analysed intracellular cytokine produced by the different PBMC subsets and REM.

Conclusion:

GM-CSF intracellular production by CD4+T cells was significantly decreased by TNFi treatment only in patients who attained REM. Therefore, our results suggest that GM-CSF production by CD4+T cells may be a useful marker of REM to TNFi in RA.

References:

[1] Sobrino C, et al. Ann Rheum Dis. 2019; 78 (S2): A1665.

[2] Hernández-Breijo B, et al. Ann Rheum Dis. 2019; 78 (S2): A711.

[3] Avci AB, et al. Clin Exp Rheumatol. 2016; 34 (S98), 39-44.

Figure. 1:

Association between the change in intracellular cytokine production (Δ, 6m-0m) by each PBMC subset and REM. Adjusted logistic regression analyses were performed for each cytokine.

Acknowledgments:

ISCIII (PI16/00474; PI16/01092)

Disclosure of Interests:

Borja Hernández-Breijo: None declared, Chamaida Plasencia: None declared, Carlota García-Hoz: None declared, Cristina Sobrino: None declared, Victoria Navarro-Compán Consultant of: Abbvie, Lilly, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Lilly, Novartis, Pfizer, UCB, ANA MARTÍNEZ-FEITO: None declared, Israel Nieto-Gañán: None declared, Paloma Lapuente-Suanzes: None declared, Javier Bachiller-Corral: None declared, Gemma Bonilla: None declared, Cristina Pijoan Moratalla: None declared, Garbiñe Roy: None declared, Mónica Vázquez Díaz: None declared, Alejandro Balsa Grant/research support from: BMS, Roche, Consultant of: AbbVie, Gilead, Lilly, Pfizer, UCB, Sanofi, Sandoz, Speakers bureau: AbbVie, Lilly, Sanofi, Novartis, Pfizer, UCB, Roche, Nordic, Sandoz, Luisa María Villar: None declared, DORA PASCUAL-SALCEDO Grant/research support from: Pfizer, Novartis & Progenika, Speakers bureau: Pfizer, Merck, Novartis, Takeda, Menarini & Grifols, Eulalia Rodríguez-Martín: None declared

False positives in the ultrasound diagnosis of giant cell arteritis: some diseases can also show the halo sign

Objectives

To describe the frequency and causes for the presence of a halo sign on the ultrasound of patients without a diagnosis of GCA.

Methods

In total, 305 patients with temporal artery colour Doppler ultrasound showing the presence of halo sign (intima-media thickness ≥0.34 mm for temporal arteries [TAs] and ≥1 mm for axillary arteries) were included, and their medical records were reviewed. The clinical diagnosis based on the evolution of the patient over at least one year was established as the definitive diagnosis.

Results

Fourteen of the 305 (4.6%) patients included showed presence of the halo sign without final diagnosis of GCA: 12 patients in the TAs (86%), and two patients with isolated AAs involvement (14%). Their diagnoses were PMR (n = 4, 29%); atherosclerosis (n = 3, 21%); and non-Hodgkin lymphoma type T, osteomyelitis of the skull base, primary amyloidosis associated with multiple myeloma, granulomatosis with polyangiitis, neurosyphilis, urinary sepsis and narrow-angle glaucoma (n = 1 each, 7%).

Conclusion

The percentage of halo signs on the ultrasound of patients without GCA is low, but it does exist. There are conditions that may also show the halo sign (true positive halo sign), and we must know these and always correlate the ultrasound findings with the patient’s clinic records.

Cost evolution of biological drugs in rheumatoid arthritis patients in a tertiary hospital: Influential factors on price

OBJECTIVE

To assess the evolution of cost per patient/year and the cost per patient/year/drug in patients with rheumatoid arthritis (RA) receiving biological treatments. To analyze and quantify the factors influencing this evolution, such as the optimization of the biological drugs, the use of biosimilars, and official discounts and discounts obtained after negotiated procedures. In addition, to assess specific clinical parameters of disease activity in these patients.

METHODS

Retrospective, observational study conducted in a Spanish tertiary hospital. Adult patients diagnosed with RA under treatment from 2009 to 2017 were included.

RESULTS

320, 270 and 389 patients were included in 2009, 2013 and 2017, respectively. The patient/year cost decreased from 10,789€ in 2009, 7491€ in 2013 to 7116€ in 2017. In 2017, due to the established competition, discounts of 14% and 29.5% were achieved on etanercept and its biosimilar; 11.5%, 17.8%, 17.9%, 17.3% on adalimumab, certolizumab, golimumab and tocilizumab IV respectively, and 24.6% and 43.1% on infliximab and its biosimilar. The percentage of patients optimized in 2017 was 35.2%. The annual saving in 2017 was 1,288,535€ (830,000€ due to dose optimization and/or administration regimens, 249,666€ corresponding to 7.5% of the official discount and 208,868€ after negotiated procedures).

CONCLUSION

The annual cost per patient in RA decreased considerably due to different factors, such as discounts on the purchase of drugs due to official discounts and negotiated procedures, together with the optimization of therapies, the latter being the factor that contributed most to this decrease.

Cost evolution of biological agents for the treatment of spondyloarthritis in a tertiary hospital: influential factors in price

Background Spending on biological agents has risen dramatically due to the high cost of the drugs and the increased prevalence of spondyloarthritis. Objective To evaluate the annual cost per patient and cost for each biological drug for treating patients with spondyloarthritis from 2009 to 2016, and to calculate factors that affect treatment cost, such as optimizing therapies by monitoring drug serum levels, the use of biosimilar-TNF inhibitors, and official discounts or negotiated rebates in biologicals acquired by the pharmacy department. Method Retrospective, observational study in a Spanish tertiary hospital. Main outcome Annual cost per patient and per drug. Factors that influenced the costs and socio-demographic parameters and disease activity. Results A total of 129, 215, and 224 patients were treated in 2009, 2013, and 2016, respectively. The annual cost per patient decreased: EUR11,604 in 2009, EUR8513 in 2013, and EUR7464 in 2016. The introduction of new drugs drives economic competition, leading to total savings per drug, with discounts reaching 5.8, 12.4, 16.7, 17.7, 13.7, and 24.8% for original infliximab, etanercept, adalimumab, ertolizumab, golimumab, and secukinumab, respectively, while rebates for biosimilar infliximab reached 31.90% in 2016. The number of patients with optimized therapies reached 47.5% in 2016, which led to cost savings of EUR798,614, in addition to savings from official discounts and rebates of EUR252,706 and savings from optimized therapies of EUR545,908 in 2016. Conclusion The cost of biological treatments declined after official discounts, negotiated rebates, and optimized therapies, leading to a significant decrease in the annual cost per patient. The greatest contribution to economic savings in biological therapy according to our study was biological therapy optimization.

Infusion reactions during infliximab treatment are not associated with IgE anti-infliximab antibodies

OBJECTIVES

Controversy exists on the role of IgE antidrug antibodies (IgE-ADA) in infusion reactions (IR) on infliximab treatment, partly due to the lack of a positive control used for assay validation. We sought to (1) develop a robust assay to measure IgE-ADA, including a positive control, (2) determine the association between IgE-ADA and IR and (3) determine the incidence of IgE-ADA in infliximab treated patients.

METHODS

A recombinant human IgE anti-infliximab monoclonal antibody was developed as standard and positive control. With this antibody, we set up a novel robust assay to measure IgE-ADA. IgE-ADA was determined in three retrospective cohorts (n=159) containing IR+ (n=37) and IR- (n=39), and longitudinal sera of 83 spondyloarthritis.

RESULTS

IgE-ADA was found in 0/39 IR-, whereas 4/37 (11%) IR+ showed low levels (0.1-0.3 IU/mL, below the 0.35 IU/mL threshold associated with elevated risk of allergic symptoms). All patients who were IgE-ADA positive also had (very) high IgG-ADA levels. The incidence of IgE-ADA in patients with infliximab-treated spondyloarthritis was estimated at less than approximately 1%.

CONCLUSIONS

IgE-ADA is rarely detected in infliximab-treated patients. Moreover, the absence of IgE-ADA in the majority of IR+ patients suggests that IgE-ADA is not associated with infusion reactions.

Comparing a tapering strategy to the standard dosing regimen of TNF inhibitors in rheumatoid arthritis patients with low disease activity

OBJECTIVES

The aim of this study is to compare clinical outcomes, incidence of flares and administered drug reduction between rheumatoid arthritis (RA) patients under TNF inhibitors (TNFi) tapering strategy and RA patients on standard regimen.

METHODS

Two groups of RA patients on TNFi with DAS28<3.2 were compared: the tapering group (TG: 67 pts from Spain) and the control group with standard therapy regimen (CG: 77 pts from the Netherlands). DAS28 was measured at different time points: visit 0 (prior starting TNFi), visit 1 (prior to start tapering in TG and with DAS28<3.2 in TG and CG), visit 2 (6 months after visit 1), visit 3 (1 year after visit 1), visit 4 (the last visit available after visit 1) and visit-flare (visit with the worst flare between visit 1 and visit 4).

RESULTS

Despite the reduction of administered drug at visit 4 in the TG (interval elongation of 32.8% in infliximab, 52.9% in adalimumab and 52.6% in etanercept), the DAS28 remained similar between groups at the end of the study (DAS28: 2.7±0.9 in TG vs. 2.5±1 in CG, p=0.1). No differences were seen in the number of patients with flares [26/67 (38.9%) in the TG vs. 30/77 (39%) in the CG, p=0.324] and only nineteen out of 136 patients (14%) had anti-drug antibodies at the end of the study.

CONCLUSIONS

The tapering strategy of TNFi in RA patients result in a reduction of the drug administered, while the disease control is not worse than patients on the standard regimen.