Subclinical synovitis impact on the progression of lupus joint disease: A 10-year longitudinal multicenter study

OBJECTIVE

To determine the effect of subclinical synovitis on the progression of joint disease in a cohort of patients with systemic lupus erythematosus over a mean follow-up of 10 years.

METHODS

A longitudinal follow-up of 96 patients diagnosed with lupus was performed. All patients were considered clinically free of joint disease or with minimal joint impairment at baseline and were studied through ultrasound study of their dominant hand to assess the prevalence of subclinical synovitis. Now, over 10 years after we contacted them and reviewed their evolution to determine the impact of had or had not been diagnosed with subclinical synovitis in their current joint condition.

RESULTS

Thirty-one of the 91 reached patients developed clinical progression in their joint manifestations (at least one ordinal degree of worsening). Of these, 23 (74,9%) had demonstrated subclinical synovitis at baseline. In the group of patients who did not progress clinically, 46 (76,6%) did not have this finding at the start of follow-up (p < .01, OR 9,44 95%CI 3,46-25,74). The patients in whom clinical progression was demonstrated had worse combined ultrasound scores than the rest of the patients: 6,41 SD 1,45 vs. 1,15 SD 0,97 (p < .01).

CONCLUSIONS

The finding of subclinical synovitis in patients with systemic lupus erythematosus is associated with the development of joint disease progression both clinically and ultrasonographically.

Ultrasound changes following controlled mechanical stress in synovial tissue in the hands of healthy individuals

OBJECTIVE

The physiological response of the synovium to acute mechanical stress has not been extensively studied. This response is interesting in terms of the morphological changes it can cause as any such changes should be taken into account during ultrasound examinations. The purpose of this study was to assess the extent of changes in ultrasound images of the synovial joint in the hands of healthy individuals after controlled mechanical stress.

METHOD

We included 110 healthy volunteers on whom we carried out two ultrasound examinations of the non-dominant hand: one at baseline and the other after controlled handgrip exercise at 70% of the maximum voluntary contraction.

RESULTS

The synovitis scores at baseline and after exercise were 0.472±0.798 and 0.772±1.162 t(109)=-3.791, respectively; p < 0.001. We observed no tenosynovitis in 88.2% of the participants at baseline, while after exercise the percentage fell to 70.9%; x2 (1, N=110) =10.0851, p = 0.0014.

CONCLUSION

We conclude that synovitis and tenosynovitis are inducible by physical exercise and are detectable on ultrasound. This should be taken into account during ultrasound examinations for suspicion or follow-up of inflammatory rheumatism.

No radiographic sacroiliitis progression was observed in patients with early spondyloarthritis at 6 years: results of the Esperanza multicentric prospective cohort

Objective

To estimate the 6-year radiographic progression of sacroiliitis in patients with early spondyloarthritis (SpA).

Patients and methods

Sacroiliac joint (SIJ) radiographs (baseline and 6 years) of 94 patients with recent-onset SpA from the Esperanza cohort were scored, blindly and in a random order, by nine readers. The modified New York criteria were used to define the presence of sacroiliitis. As the gold standard for radiographic (r) sacroiliitis, the categorical opinion of at least five readers was used. Progression was defined as the shift from non-radiographic (nr) to r-sacroiliitis.

Results

In the 94 SIJ radiographs (baseline and 6 years), 78/94 (83%) pairs of radiographs had not changed from baseline to 6 years. Sacroiliitis was present in 20 patients at baseline (21.3%) and in 18 (19.2%) patients at 6 years; 11 patients had sacroiliitis at both the baseline and final visits; 9 patients changed from baseline r-sacroiliitis to nr-sacroiliitis at 6 years, and 7 changed from baseline nr-sacroiliitis to r-sacroiliitis at 6 years. The mean continuous change score (range: −8 to +8) was 2.80 at baseline and 2.55 at 6 years (mean net progression of −0.25). The reliability of the readers was fair (mean inter-reader kappa of 0.375 (0.146–0.652) and mean agreement of 73.7% (58.7–90%)).

Conclusion

In the early SpA Esperanza cohort, progression from nr-axSpA to r-axSpA over 6 years was not observed, although the SIJ radiographs scoring has limitations to detect low levels of radiographic progression.

POS1275 PERITENON THICKENING IS ASSOCIATED WITH THE INTENSITY OF MANUAL SPORTS ACTIVITY

Background:

Peritenon enlargement has been considered as a specific ultrasound finding associated with psoriatic arthritis based on studies in patients. Recent observations in athletes have demonstrated the existence of this finding although its relationship with the type of physical activity performed has not been determined.

Objectives:

To determine to what extent manual physical activity is associated with the prevalence of peritenon thickening in the fingers of healthy athletic subjects.

Methods:

Thirty-five healthy young male volunteers were recruited from a local sports centre in the community of Madrid. All of them performed sports activities with their hands for more than 12 hours a week.A digital dynamometer was used to determine the flexion strength of the fingers of the dominant hand. A single observer performed an ultrasound scan of this hand to determine the presence or absence of a hypoechoic image surrounding the extensor digitorum tendon of the 2nd, 3rd, 4th and 5th fingers, according to previous definitions. Mean flexion strengths were compared with the number of positive ultrasound findings.

Results:

Fifteen volunteers (mean age 24.3 years, BMI 24.4) did not present peritenon enlargement (42.8%). The mean ± standard deviation of the fingers flexor strength according to the number of peritenon enlargement detected were 43.5 ± 6.2, 49.2 ± 3.8, 53.2 ± 1.64 and 63.0 ± 4.83 Kg for volunteers with none, 1, 2, 3 and 4 peritenon enlargements, respectively. (ANOVA P<0.001; Pearson’s coefficient 0.827, P<0.001). Correlation between BMI, body fat percentage or training hours per week and the number of peritenon enlargement detected was not demonstrated.

Conclusion:

Peritenon enlargement, also knew as peritenon tendon inflammation, is detectable by ultrasound scan in healthy subjects and it seems to be associated to the physical activity intensity, indirectly measured by the flexor strength of the fingers.

References:

[1]Gutierrez et al. Ann Rheum Dis. 2011;70:1111-4

[2]Zabotti et al. Clin Exp Rheumatol. 2016;34:459-65

[3]Husic et al. Ann Rheum Dis. 2014;73:1529-36

Disclosure of Interests:

None declared

AB0779 DOES DACTYLITIS/ENTESITIS PREDICT THE RESPONSE TO A SPECIFIC BIOLOGICAL TREATMENT IN PSORIATIC ARTHRITIS?

Background:

Spondylarthritis are diseases with a pathophysiological focus in enthesis with a different extent of synovial component. In the event of therapeutic failure with DMARDs, the clinician may consider biological therapy with anti-TNF drugs or other targets such as IL23 Despite this, most patients receive first-line anti-TNFs. Given that IL19 and IL23 activity is recognized at the level of the enthesis.

Objectives:

To evaluate whether the presence of dactylitis/entesitis could be useful in the choice of a particular biological therapy.

Methods:

A secondary analysis of a previous study was performed based on an electronic survey completed by patients with PsoA and distributed among members of the patient association “Acción Psoriasis”. Records from 191 respondents who had received at least one biological therapy were included. Patients were grouped according to the presence or absence of dactylitis or enthesitis. The rate of need to progress to the next therapeutic biologic line was compared.

Results:

61 patients reported dactylitis and 155 enthesitis. Distribution of treatments in patients with dactylitis: 33 patients received an anti-TNF-alpha, 11 Secukinumab and 12 Ustekinumab. 15 patients in the group receiving an anti-TNF-alpha had to substitute another treatment within 2 years (45.4%). 3 patients in each of the remaining groups had to substitute treatment within 2 years (27.2% and 25%, respectively). Compared to those receiving anti-TNF-alpha therapy, patients treated with Secukinumab or Ustekinumab had greater therapeutic persistence at 2 years (P<0.001, in both cases). Distribution of treatments in patients with enthesitis (not including dactylitis): 115 received an antiTNF-alpha, 25 received Secukinumab and 18 received Ustekinumab. 38 patients who received an anti-TNF-alpha had to substitute it within 2 years (24.5%). 4 patients who received Secukinumab and 3 who received Ustekinumab had to substitute their treatments in less than 2 years (16% and 16.6%, respectively). Compared to patients receiving anti-TNF-alpha therapy, patients treated with Secukinumab and Ustekinumab had a higher proportion of therapeutic persistence at 2 years (P<0.05 for both cases).

Conclusion:

The presence of dactylitis more than enthesitis, is associated with a higher proportion of therapeutic persistence in those patients treated with anti-IL17 or anti-IL23 therapies. Although there are multiple factors that condition the choice of biological therapies in patients with PsoA, the presence of enthesitis and dactilitis (understood as polyenthesitis) should be considered among the most important ones.

Disclosure of Interests:

None declared

THU0169 COMPARISON OF THE SYNOVIAL RESPONSE TO MECHANICAL STRESS AMONG PATIENTS WITH RHEUMATOID ARTHRITIS IN CLINICAL REMISSION ON METHOTREXATE OR ANTI-TNF

Background:

Physiologically, the joint synovium responds to physical activity according to the frequency and intensity of the efforts, producing slight effusion without detectable hyperemia. In patients with RA in remission, a similar response can be expected, since it is understood that the immune-mediated inflammatory component has been controlled physiopathologically. Our interest is to determine whether once clinical remission has been reached, treatment with MTX or antiTNF produces the same normalization of the synovial behaviour. Our interest is to determine whether once clinical remission has been reached, treatment with MTX or antiTNF produces the same normalization of the synovial behavior.

Objectives:

The aim of the present study is to compare the synovial response to mechanical stress of patients with Rheumatoid Arthritis (RA) in remission treated with Methotrexate (MTX) or Etanercept (ETN).

Methods:

Descriptive observational study. We included patients with RA in remission (DAS28<2.6) for at least 6 months on MTX or MTX and anti-TNF-alpha therapy (ETN). An ultrasound examination protocol was developed for the 2nd, 3rd and 4th MCP and non-dominant hand carpus for gray scale (GS) and power Doppler signal detection (sPD) according to EULAR/OMERACT definitions. Two ultrasound examinations were performed on each patient, before and 24 hours after starting a manual digital flexure exercise program against resistance measured by a handheld dynamometer CAMRY™ model EH101-17. Total synovitis scores in EG (0-12) and sPD (0-12) were compared.

Results:

We included 37 patients on MTX treatment (median dose 15mg/week, range 7.5-25mg/week) and 16 patients on ETN treatment (median dose 50mg/week, range 25-50 mg/week). The baseline ultrasound score in the MTX treatment group was 1.6 SD 1.4 in EG and 2.2 SD 0.5 in PDs. After carrying out the controlled dynamometric effort, the score was 2.4 SD 1.9 in GS and 4.4 SD 1.5 in PDs (P<0.05 and P<0.001, respectively). In patients treated with TNEs, the basal score in GS was 1.3 SD 0.6 in GS and 0.6 SD 0.3 in PDs. After the controlled dynamometric effort, the score was 1.8 DE 0.9 in EG and 0.7 DE 0.4 in PDs (P=0.07 and P<0.001, respectively). In the group of patients treated with MTX, four subjects reported joint tenderness after physical effort.

Conclusion:

Our observations are congruent with previous experiences in which it has been observed that physical stress translates into synovial changes detectable by ultrasonographic studies. Our results, although modest in patient volume, suggest that TNF-alpha activity is crucial in the development and maintenance of exercise-induced hyperemia. The clinical significance of our observation may be useful as a tool to predict the response to anti-TNF therapy in patients with RA, however specific methodological designs are needed for such associations.

Disclosure of Interests:

None declared

FRI0324 NO RADIOGRAPHIC SACROILIITIS PROGRESSION OVER 6 YEARS IN PATIENTS WITH EARLY SPONDYLOARTHRITIS FROM THE ESPERANZA COHORT

Background:

Longitudinal studies about the change from non-radiographic axial Spondyloarthritis (nr-axSpA) to r-axSpA (radiographic axial Spondyloarthritis) are scarce but show a 9-10% progression rate over 2 years (1-2) and a 24% progression rate over 10 years in another study (3). However, in early cohorts such as DESIR, this only represents a 5% over 5 years (4).

Objectives:

The aim of this study was to know the rate of progression from nr-axSpA to r-axSpA over 6 years in the early Esperanza cohort.

Methods:

This study included 94 patients of the Spanish early spondyloarthritis (SpA) Esperanza cohort, 60 fulfilled the ASAS classification criteria for SpA. Every patient had a baseline and a six years sacroiliac X-ray. Nine readers, blinded for the diagnosis, participated in the reliability exercise, all of them experienced rheumatologists and members of the Spanish spondyloarthritis working group (GRESSER). Patients with SpA were classified as having r-axSpA, at baseline or after 6 years of follow-up, if they fulfilled the radiographic item of the modified New York criteria (mNY) (presence of radiographic changes in the sacroiliac joints -SIJ- of at least grade II bilaterally or grade III or IV unilaterally). The gold standard of SIJ X-Ray was the categorical opinion of at least five of the expert readers. For the statistical analysis, the Chi-square and Kappa tests were performed.

Results:

Demographic data of the SpA patients were: mean age 33.4±7.5 years; 37 (61.7%) male; mean CRP 6.4±6.5 mg/dl and ESR 10.3±10.6. Present smokers 30.6%; and past smokers 16.3%. HLA-B27 (+) 56.7%. Regarding the presence of X-Ray sacroilitis: 20 patients had baseline sacroilitis and 18 at the final visit; 11 had sacroiliitis at both baseline and final visits; 9 patients changed from baseline sacroiliitis to no-sacroiliitis and 7 changed from baseline no-sacroiliitis to sacroiliitis at the 6 year visit. The reliability of the readers was fair with a mean inter-reader kappa test of 0.375 (range 0.146 - 0.652) and a mean agreement of 73.7% (range 58.7% - 90%).

Conclusion:

In this group of patients with early SpA no progression from nr-axSpA to r-axSpA over 6 years was observed. It appears that early diagnosis and standard treatment seem to reduce SIJ radiographic progression.

References:

[1]Poddubnyy D, Rudwaleit M, Haibel H, et al. Rates and predictors of radiographic sacroiliitis progression over 2 years in patients with axial spondyloarthritis. Ann Rheum Dis 2011;70:1369–74.

[2]Sampaio-Barros PD, Conde RA, Donadi EA, et al. Undifferentiated spondyloarthropathies in Brazilians: importance of HLA-B27 and the B7-CREG alleles in characterization and disease progression. J Rheumatol 2003;30:2632–7.

[3]Sampaio-Barros PD, Bortoluzzo AB, Conde RA, et al. Undifferentiated spondyloarthritis: a longterm followup. J Rheumatol 2010;37:1195–9.

[4]Dougados M, et al. Ann Rheum Dis 2017;76:1823–1828.

Disclosure of Interests:

Carolina Tornero: None declared, María del Carmen Castro Villegas: None declared, Xavier Juanola-Roura: None declared, Maria Luz García-Vivar: None declared, Cristina Fernández-Carballido Consultant of: Yes, I have received fees for scientific advice (Abbvie, Celgene, Janssen, Lilly and Novartis), Speakers bureau: Yes, I have received fees as a speaker (Abbvie, Celgene, Janssen, Lilly, MSD, Novartis), Jose Francisco Garcia LLorente: None declared, Beatriz Joven-Ibáñez Speakers bureau: Abbvie, Celgene, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, E. Galindez: None declared, Claudia Urrego-Laurín: None declared, 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)

SAT0396 INFLUENCE OF SMOKING AND OBESITY ON THERAPEUTIC RESPONSE IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS: A SYSTEMATIC LITERATURE REVIEW

Background:

Biological therapies have substantially improved the prognosis of patients with Spondyloarthritis (SpA). However, a satisfactory clinical response is not achieved in all patients and it is essential for the clinician to identify all those factors that predict treatment response. Although they are supposed as unfavorable and potentially avoidable factors, the influence of smoking and obesity as predictors of treatment response in SpA is unknown.

Objectives:

To determine if smoking and obesity are factors of worse therapeutic response in patients with axial spondyloarthritis (axSpA).

Methods:

Systematic review of the literature in MEDLINE and EMBASE until June 30, 2019 based on the PICO design method. Population (P): patients with axSpA. Intervention (I): smoking or obesity. Comparator (C): non-smokers and normal weight. Outcome (O): any of the response criteria currently validated for axSpA. A specific excel form was used for data collection, EndNote software for the management and organization of papers and the Oxford 2009 level for evidence evaluation.

Results:

1873 citations were recovered, 46 studies were selected for full-text review and 12 for data extraction: 6 for smoking and 6 for obesity. The design of all studies was observational and longitudinal with data from national registries except one cross-sectional. In total, these studies included 5291 patients (3917 patients for smoking and 1333 patients for obesity), all treated with a TNF inhibitor (iTNF). The Oxford level of evidence for all studies was 2b except the cross-sectional study, which was 4. Regarding smoking, the evidence found is not consistent. Two of the studies concluded an unfavorable effect on the response to the iTNF (Glintborg and Ciurea) but the remaining 4 studies found no differences in the clinical response to iTNF (Zhao), the cause of discontinuity of the iTNF (Zhao, Hernandez) or quality of life indexes (Kydd). For obesity, the evidence is more consistent, so that 5 of the 6 studies observed a negative influence on the therapeutic response to iTNF (Ottaviani, Gremese, Micheroli, Hernández-Breijo and Rosas).

Conclusion:

According to scientific evidence in patients with axSpA, obesity is associated with a worse therapeutic response to iTNF. However, this negative effect is not clearly evidenced for smoking.

Disclosure of Interests:

Pablo Zurita-Prada: None declared, Claudia Urrego-Laurín: None declared, Carlos Guillén-Astete: None declared, Victoria Navarro-Compán Consultant of: Abbvie, Lilly, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Lilly, Novartis, Pfizer, UCB

SAT0369 SPINAL RADIOGRAPHIC PROGRESSION IN EARLY SPONDYLOARTHRITIS: SIX-YEAR RESULTS FROM THE ESPERANZA COHORT

Background:

There are few studies focused on the development of structural damage over time in patients with early SpA

Objectives:

The aim of this study is to analyze the mSASSS radiographic progression of spine in patients with early spondyloarthritis (SpA) in the Esperanza cohort.

Methods:

In this longitudinal study, 49 patients of the Spanish early spondyloarthritis (SpA) Esperanza cohort were included. Every patient had a baseline and a six years lateral X-Ray of the cervical and lumbar of spine. The assessment of spine structural damage was done by the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). Nine readers, blinded for the diagnosis, participated in the reliability exercise, all of them experienced rheumatologists and members of the Spanish spondyloarthritis working group (GRESSER). The mSASSS progression and development of new syndesmophytes was analyzed. The gold standard of every elemental lesion of the mSASSS and the total mSASSS score was the agreement achieved by the independent categorical opinion of at least five of the nine readers. For reliability, intraclass correlation coefficient (ICC) two-way mixed, absolute agreement was used.

Results:

Forty-nine patients were included, 69 % were males and 49%, HLA B27 positive. Mean ± SD baseline ESR, CRP, BASDAI, BASFI and mSASSS were 10.7±11.7, 5.4±7.1, 3.7±2.5, 2.1±2.0 and 0.326±0.85, respectively. Inter-reader ICC reliability of the 9 readers was 0.812 (CI 95%; 0.764-0.857). The mSASSS score at the six-year visit was 0.67 ± 1.6: thirty-nine patients did not present any changes in this score at the end of the follow-up, two patients had Δ mSASSS of – 1 and eight patients, an increase in this score (four patients, +1; three patients, +2 and one patient, +9 points).

At baseline, five patients presented one syndesmophyte; at the six-year visit, seven had one syndesmophyte; one patient, two syndesmophytes and another one, one bone bridge. Only 2/5 patients (40%) with syndesmophytes at baseline showed an increase in Δ mSASSS; the two patients with a Δ mSASSS of -1 did not have syndesmophytes at baseline. Five out of eight patients (62.5%) with an increase of the Δ mSASSS presented this lesion at the six-year visit but only two of them showed syndesmophytes at baseline. On the other hand, two of the three patients who showed an increase of the ΔmSASSS without syndesmophytes at baseline presented an erosion in the anterior vertebral corner and the patient with the bone bridge had a previous syndesmophyte. Our results indicate that in early SpA much of the progression appears in patients without previous syndesmophytes.

Conclusion:

Spinal radiographic progression was very low in our early SpA cohort, with a mean progression of 0.3 mSASSS units. Only eight patients (16.3%) presented spinal structural progression, most of them not showing syndesmophytes at baseline. It is reasonable to consider that an early diagnosis and monitoring could result in a low radiographic progression.

Disclosure of Interests:

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), Jose Francisco Garcia LLorente: None declared, Claudia Urrego-Laurín: None declared, Maria Luz García-Vivar: None declared, Cristina Fernández-Carballido Consultant of: Yes, I have received fees for scientific advice (Abbvie, Celgene, Janssen, Lilly and Novartis), Speakers bureau: Yes, I have received fees as a speaker (Abbvie, Celgene, Janssen, Lilly, MSD, Novartis), María del Carmen Castro Villegas: None declared, Beatriz Joven-Ibáñez Speakers bureau: Abbvie, Celgene, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Xavier Juanola-Roura: None declared, Carolina Tornero: None declared, E. Galindez: None declared

Relationship between anthropometric variables and the cross-sectional area of the median nerve by ultrasound assessment in healthy subjects

OBJECTIVE

Ultrasound study of the wrist in patients with suspected entrapment syndrome has severe limitations due to the variability of what is considered normal for the cross-sectional area of the median nerve and where to proceed to measure it. We aim to determine the extent to which different anthropometric variables influence the median nerve area in subjects without carpal tunnel syndrome.

METHODS

We conducted an observational study based on a multivariate linear regression analysis using as a dependent variable the area of the median nerve cut at two specific points in the wrist of healthy subjects. The independent variables were sex, age, height, weight, body mass index, finger flexor strength, and carpal circumference.

MAJOR RESULTS

The measurements of the median nerve cross-sectional area were normalized using a quadratic fixing procedure. Of all the variables included in the linear regression analysis, only carpal circumference and sex (0: female, 1: male) contributed significantly in the final model using the wrist crease as the measurement point (Constant B=-209.45, carpal circumference coefficient=21.07, sex coefficient 10.87). At four centimeters distal to the carpal fold, the model included the same variables (Constant B=-221.84, carpal circumference coefficient=24.01, and sex coefficient=11.41).

CONCLUSION

Both the wrist circumference and the sex are variables that should be considered to determine cut-off points of normality in future validation studies about the cross-sectional area of the median nerve.