CXCR2/CXCR2 Ligand Biology during Lung Transplant Ischemia-Reperfusion Injury

Lung transplantation is a therapeutic option for a number of end-stage pulmonary disorders. Early lung allograft dysfunction (ischemia-reperfusion injury) continues to be the most common cause of early mortality after lung transplantation and a significant risk factor for the development of bronchiolitis obliterans syndrome. Ischemia-reperfusion injury is characterized histopathologically by lung edema and a neutrophil predominate leukocyte extravasation. The specific mechanism(s) that recruit leukocytes to the lung during post-lung transplantation ischemia-reperfusion injury have not been fully elucidated. Because the ELR+ CXC chemokines are potent neutrophil chemoattractants, we investigated their role during post-lung transplantation ischemic-reperfusion injury. We found elevated levels of multiple ELR+ CXC chemokines in human bronchoalveolar lavage fluid from patients with ischemia-reperfusion injury. Proof of concept studies using a rat orthotopic lung transplantation model of "cold" ischemic-reperfusion injury demonstrated an increase in lung graft neutrophil sequestration and injury. In addition, lung expression of CXCL1, CXCL2/3, and their shared receptor CXCR2 paralleled lung neutrophil infiltration and injury. Importantly, inhibition of CXCR2/CXCR2 ligand interactions in vivo led to a marked reduction in lung neutrophil sequestration and graft injury. Taken together these experiments support the notion that increased expression of ELR+ CXC chemokines and their interaction with CXCR2 plays an important role in the pathogenesis of post-lung transplantation cold ischemia-reperfusion injury.

Utility of Transbronchial vs Surgical Lung Biopsy in the Diagnosis of Suspected Fibrotic Interstitial Lung Disease

BACKGROUND

Surgical lung biopsy (SLB) is invasive and not possible in all patients with undiagnosed interstitial lung disease (ILD). We hypothesized that transbronchial biopsy (TBB) findings combined with clinical and high-resolution CT (HRCT) data leads to a confident diagnosis congruent to SLB and therefore avoids the need for SLB in some patients.

METHODS

We evaluated 33 patients being investigated for suspected ILD who underwent HRCT, TBB, and SLB. First, clinicians, radiologists, and a pathologist reviewed the clinical information and HRCT and TBB findings. Clinicians were asked to provide a diagnosis and were also asked if SLB was needed for a more confident diagnosis. Subsequently, the clinical, HRCT, and SLB data were reviewed, and the same participants were asked to provide a final diagnosis. Clinician consensus and overall agreement between TBB- and SLB-based diagnoses were calculated.

RESULTS

Four patients had definite usual interstitial pneumonia (UIP) on HRCT and would not be considered for biopsy using current guidelines. Of the 29 patients without a definitive HRCT diagnosis, the clinicians felt confident of the diagnosis (ie, would not recommend SLB) in six cases. In these cases, there was 100% agreement between TBB and SLB diagnoses. UIP was the most common diagnosis (n = 3) and was associated with an HRCT diagnosis of possible UIP/nonspecific interstitial pneumonia-like. Agreement was poor (33%) between TBB and SLB diagnoses when confidence in the TBB diagnosis was low.

CONCLUSIONS

Information from TBB, when combined with clinical and HRCT data, may provide enough information to make a confident and accurate diagnosis in approximately 20% to 30% of patients with ILD.

Bronchogenic carcinoma complicating lung transplantation

BACKGROUND

Malignancy is a well-recognized complication of solid-organ transplantation. Although a variety of malignancies have been reported in lung transplant recipients, a paucity of information exists regarding the incidence and clinical course of bronchogenic carcinoma in this patient population.

METHODS

We conducted a retrospective cohort study of our lung transplant experience at the University of Pennsylvania.

RESULTS

We identified 6 patients with bronchogenic carcinoma detected at the time of, or developing after, transplantation. The incidence of bronchogenic carcinoma was 2.4%. All patients with lung cancer had a history of smoking, with an average of 79 +/- 39 pack-years. A total of 5 patients had chronic obstructive pulmonary disease, and 1 had idiopathic pulmonary fibrosis. Lung cancers were all of non-small-cell histology and first developed in native lungs. Three patients had bronchogenic carcinoma at the time of surgery. The remaining 3 patients were diagnosed between 280 and 1,982 days post-transplantation. Of the 6 patients, 4 presented with a rapid course suggestive of an infectious process. The 1- and 2-year survival rates after diagnosis were 33% and 17%, respectively.

CONCLUSION

Lung transplant recipients are at risk for harboring or developing bronchogenic carcinoma in their native lungs. Rapid progression to locally advanced or metastatic disease commonly occurs, at times mimicking an infection. Bronchogenic carcinoma should be considered in the differential diagnosis of pleuroparenchymal processes involving the native lung.

Changes in macrophage function after rituximab treatment in patients with rheumatoid arthritis

OBJECTIVE

To assess changes in macrophage phenotype and function after rituximab-induced B cell depletion in patients with rheumatoid arthritis (RA).

METHODS

10 patients with RA were treated with rituximab, achieving significant B cell depletion 4 months later. Clinical improvement, rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) antibodies, mRNA of B cell activating factor (BAFF), interleukin (IL) 10 and CD86 in human monocyte-derived macrophages (HMDMs) and tumour necrosis factor alpha (TNFalpha) secretion from cultured HMDMs were assessed at baseline and after the depletion.

RESULTS

A clinical response of American College of Rheumatology (ACR) 50% improvement was noted in six patients, and another two patients responded with moderate improvement, equivalent to ACR 20-50% improvements. RF and anti-CCP antibodies were positive at baseline in seven of ten patients. RF disappeared or declined in six patients 4 months after treatment, correlating with clinical improvement. By contrast, anti-CCP remained unchanged in six patients. After rituximab treatment, and in association with clinical improvement, BAFF, IL10 and CD86 mRNA expression in HMDM were significantly upregulated compared with values at baseline. A significant decrease in TNFalpha in the supernatant of cultured HMDM was also noted.

CONCLUSIONS

In addition to B cell depletion and attenuation in some of the specific autoantibodies, clinical improvement in rituximab-treated patients with RA occurred in association with changes in macrophage function.

Psoriatic arthritis treatment and the risk of herpes zoster

OBJECTIVES

To study the association between traditional disease-modifying antirheumatic drugs (c-DMARD) or anti-TNF-α agents and herpes zoster (HZ) in patients with psoriatic arthritis (PsA).

METHODS

A retrospective cohort study was conducted in patients with PsA between 2002 and 2013. Patients were grouped as follows: no DMARDs (Group A); c-DMARDs (Group B); anti-TNF-α agents (Group C); anti-TNF-α agents in combination with c-DMARDs (Group D). Crude incidence rates (IR) were calculated as number of HZ episodes per 1000 patient-years. A Cox regression model was used to adjust for HZ risk factors (age, gender, steroid use, Charlson Comorbidity Index score, and previous treatment) in order to estimate their contribution to the risk of the first HZ event.

RESULTS

The study included 3128 patients, mean age 50.26±14.54 years; 46.2% male. During a period of 20 096 person-years 182 HZ events were observed. The crude IR (95% CI) of HZ in the study population was 9.06 per 1000 patient-years, and in Groups A-D 7.36 (5.41 to 9.79), 9.21 (7.5 to 11.21), 8.64 (4.84 to 14.26), 17.86 (10.91 to 27.58), respectively. In a multivariate analysis, age (HR 1.01, 95% CI 1.00 to 1.02), treatment with steroids (HR 1.08, 95% CI 1.04 to 1.13), and a combination of anti-TNF-α agents and c-DMARDs (HR 2.37, 95% CI 1.32 to 4.22) were significantly associated with HZ events.

CONCLUSIONS

In our database, the risk of HZ was significantly increased with age, treatment with steroids, and combination of anti-TNF-α agents and c-DMARDs, but not with c-DMARDs or anti-TNF-α therapy alone. Time to HZ event was shorter in patients treated with anti -TNF-α agents.

The use of ultrasound for the assessment of enthesitis in patients with spondyloarthritis

Seronegative spondyloarthritis (SpA) represents a group of diseases that share certain genetic, clinical, and radiographic features. Enthesitis, inflammation at the site of tendon insertion into the bone, involving both the axial and the peripheral joints, is an important sign of SpA. Clinical diagnosis of enthesitis, however, is neither sensitive nor specific; thus, the diagnosis of enthesitis often relies on typical abnormalities in imaging studies. Due to its low costs and availability, ultrasound is emerging as the preferred technique for detection of enthesitis for both clinical and research purposes. Ultrasonographic features of enthesitis include tendon hypoechogenicity and thickening, calcifications, bone erosions, and Doppler signal. Several semi-quantitative scoring systems have been developed to quantify ultrasonographic abnormalities of the entheses. These methods have been used for early diagnosis and classification of SpA as well as for monitoring response to treatment.

Clinical features and aetiology of septic arthritis in northern Israel

OBJECTIVE

To assess the clinical features and determine the pathogens responsible for septic arthritis in patients admitted to two community hospitals in the Haifa district in northern Israel over a 17-yr period.

METHODS

A retrospective study of the hospital records of patients with septic arthritis admitted to Carmel Medical Center and Bnai Zion Medical Center in Haifa between 1987 and 2003.

RESULTS

Of 150 cases identified by discharge summary diagnostic codes, only 110 patients met criteria for the case definition of septic arthritis, and these form the basis of this report. Their mean age was 37.2 yr. Of the patients, 10.4% were recent immigrants, most of them from the former Soviet Union and from Ethiopia. Primary joint disease was reported in 21.8% of the cases, osteoarthritis being most prevalent (8.1%). Of the infected joints, 8.1% were prosthetic. Staphylococcus aureus was the most common pathogen isolated, making up 40% of all positive cultures. Streptococcal and Gram-negative bacilli were both identified in 14%. Eight patients had tuberculous arthritis (9%). Another pathogen, unusual in developed countries, was Brucella species, which was identified in 11% of the cases. Two-thirds of the patients underwent surgical joint drainage while the rest were treated solely with antibiotics.

CONCLUSIONS

The present study highlights the importance of characterizing the profile of species causing septic arthritis in specific regions, taking into account ethnic, genetic and environmental factors. In our survey population, tuberculous arthritis is a growing problem, mainly due to recent immigration waves, and brucella is an endemic and common pathogen. It is important to keep a high level of suspicion for these latter two bacteria, as they require special and unique care.

Actinomycosis of the face and neck

Cervical actinomycosis is a rare condition. During the last six years, five patients were hospitalized in our department, suffering from swelling in the region of the face and neck that was identified bacteriologically as Actinomyces israelii. Soft tumors of the head and neck that do not respond to common antibiotic therapy should arouse the suspicion of actinomycosis.

LB0003 IMMUNOGENICITY AND SAFETY OF THE BNT162b2 mRNA COVID-19 VACCINE IN ADULT PATIENTS WITH AUTOIMMUNE INFLAMMATORY RHEUMATIC DISEASES AND GENERAL POPULATION: A MULTICENTER STUDY

Background:

Vaccination represents a cornerstone in mastering the COVID-19 pandemic. Data on immunogenicity, efficacy, and safety of the novel BNT162b2 mRNA vaccine in patients with autoimmune inflammatory rheumatic diseases (AIIRD) are limited.

Objectives:

To investigate the immunogenicity, efficacy, and safety of the BNT162b2 mRNA vaccine in patients with AIIRD compared to the general population.

Methods:

A prospective multicenter study investigated immunogenicity, efficacy, and safety of the two-dose regimen BNT162b2 mRNA vaccine in adult patients with AIIRD including rheumatoid arthritis (RA), psoriatic arthritis (PsA), axial spondyloarthropathy (axSpA), systemic lupus erythematosus (SLE), connective tissues diseases (CTD), systemic vasculitides, and idiopathic inflammatory myositis (IIM), compared to control subjects without rheumatic diseases or immunosuppressive therapies. Serum IgG antibody levels against SARS-CoV-2 spike S1/S2 proteins were measured 2 - 6 weeks after the second vaccine dose. Seropositivity was defined as IgG ≥15 binding antibody units (BAU)/ml. Post-vaccination efficacy defined as post-vaccination COVID-19 infection and safety were assessed. Pre- and post- vaccination disease activity indices were assessed as appropriate for each disease.

Results:

A total of 686 AIIRD patients and 121 controls participated into the study. AIIRD patients were significantly older than controls, mean age±SD 56.76±14.88 vs 50.76±14.68, respectively, p<0.0001. A total of 95.2% (n=653) AIIRD patients were treated with immunomodulatory medications.

The seropositivity rate was 86% (n=590) in patients with AIIRD compared to 100% in controls (p <0.0001) The level of the S1/S2 antibodies was significantly reduced in AIIRD patients compared to controls (mean± SD 132.9±91.7 vs 218.6±82.06, P<0.0001). In patients with PsA, AxSpA, SLE, and LVV, the seropositive rate was above 90%. In RA, the seropositive rate was 82.1% and the lowest seropositive rate (<40%) was observed in patients with AAV and IIM.

Anti-CD20 significantly impaired the vaccine’s immunogenicity, with the lowest seropositivity rate of 39%. The use of GC, mycophenolate mofetil (MMF), and abatacept was associated with a significantly lower rate of seropositivity (Figure 1). MTX significantly reduced the seropositivity in patients treated with MTX monotherapy and in combinations with other treatments (92% and 84%, respectively), although at a lesser magnitude than anti-CD20, MMF, and abatacept. More than 97% of patients treated with anti-cytokine therapies including TNFi, interleukin-17 and interleukin-6 inhibitors had an appropriate immunogenic response when used as monotherapy. The combination of TNFi with MTX significantly reduced the rate of seropositivity to 93%, p=0.04. Age over 65 years, a diagnosis of RA, IIM, ANCA-associated vascilitis, and treatment with GC, MMF, anti-CD20, and abatacept were associated with a reduced likelihood of seropositivity.

Figure 1.

Seropositivity rate by immunosuppressive treatment.

There were no post-vaccination symptomatic cases of COVID-19 among AIIRD patients and one mild case in the control group. Major adverse events in AIIRD patients included death (n=2) several weeks after the second vaccine dose, non-disseminated herpes zoster (n=6), uveitis (n=2), and pericarditis (n=1). Post-vaccination disease activity remained stable in the majority of patients.

Conclusion:

Vaccination with the BNTb262 vaccine resulted in an adequate immunogenic response with an acceptable safety profile in the majority of patients with AIIRD. Treatment with GC, rituximab, MMF, and abatacept may impair BNT162b2-induced immunogenicity. Postponing administration of rituximab, when clinically feasible, seems to be reasonable to improve vaccine-induced immunogenicity. Holding treatment with abatacept and MMF may be considered on an individual basis.

Disclosure of Interests:

None declared

Systemic lupus erythematosus exacerbation following cessation of belimumab treatment

OBJECTIVES

Belimumab has recently been approved for the treatment of systemic lupus erythematosus (SLE) refractory to standard therapy. Following one case of an SLE flare after cessation of belimumab, we hypothesized that this might lead to a rebound phenomenon and possible exacerbation of SLE.

METHOD

Members of the Israeli Society of Rheumatology were contacted by e-mail and asked to report cases of an SLE flare following cessation of belimumab treatment.

RESULTS

Three cases of SLE patients who experienced a severe SLE flare following cessation of belimumab therapy were reported. In all cases, belimumab was given as treatment for active mucocutaneous manifestations and/or polyarthritis with improvement in all three patients, one of whom achieved disease remission. In all three cases, patients experienced a severe flare in previously uninvolved major organ systems, including one case of class IV lupus nephritis accompanied by a new-onset severe headache with elevated cerebrospinal fluid (CSF) protein and white matter lesions on brain magnetic resonance imaging (MRI), one case of severe pneumonitis and haemolytic anaemia, and one case of a systemic flare, fatigue, arthritis, and severe abdominal pain.

CONCLUSIONS

Belimumab therapy has been shown to be beneficial in the management of active SLE, mostly in patients with mucocutaneous and musculoskeletal manifestations. We suggest a possible rebound effect following cessation of belimumab that could be due to an increase in B-cell activating factor (BAFF) levels and lead to a disease flare. Future assessment of BAFF levels in patients stopping belimumab therapy and clinical correlation may support this hypothesis. Further studies are needed to confirm this observation.

Behcet disease in adult Druzes in north Israel: the influence of ethnic origin on disease expression and severity

BACKGROUND

Behcet's disease (BD) is known to vary in severity and manifestations in different populations.

OBJECTIVE

In an attempt to sort out genetic and environmental influences on disease expression, we carried out a study to assess the clinical features of BD in the adult Druze and Arab populations in north Israel, comparing 2 disparate ethnic groups of similar genetic background inhabiting the same geographic region.

METHODS

We compared 23 Druze and 30 Arab patients with BD. All patients fulfilled the classification criteria of the International Study Group for BD.

RESULTS

Manifestations were similar in 2 groups. The most frequent BD manifestations among the Druzes were recurrent oral aphthae (100%) and genital aphthae (61%) versus 100% and 53% in Arab patients, followed by inflammatory ocular involvement, 65% versus 53%, respectively. Arthritis was noted in 39% of Druze, with 27% in Arabs. Anterior uveitis occurred in 9 Druze patients (48%) and panuveitis in 4, with no case of blindness when compared with 30% with anterior uveitis, 4 with panuveitis, and 4 cases of blindness (P < 0.04) among the Arabs. One Druze BD patient had deep vein thrombosis versus 8 Arab patients (P < 0.017). No pulmonary embolism, aortic aneurysm, nor valvular involvement was documented in the Druze versus 1 case of each in Arabs. No case of neuro-Behcet was reported in Druzes versus 6 cases of neuro-Behcet among Arabs (P < 0.023). The severity score was 4.0 (SD, 1.2) in Druze and 5.8 (SD, 1.9) in Arabs (P = 0.0004). The prevalence of HLA B51 did not differ significantly between the groups.

CONCLUSION

Druze BD patients in Israel have a milder disease than do Arabs, similar to observations in familial Mediterranean fever. Druze BD patients had significantly less severe ocular disease and neurologic manifestations. Our results suggest an ethnic influence on expression of BD not related to HLA B 51.

POS1254 RISK FACTORS FOR SEVERE COVID-19 INFECTION AMONG PATIENTS WITH AUTOIMMUNE INFLAMMATORY RHEUMATIC DISEASES (AIRD) AND THE IMPACT OF VACCINATIONS - AN ISRAELI, MULTI-CENTER EXPERIENCE

Background

AIRD patients (pts) may be more susceptible to severe COVID19.

Objectives

To determine the risk factors for severe COVID19 and the effect of vaccinations among AIRD pts followed at dedicated rheumatology clinics.

Methods

At the onset of the pandemic, we established a national registry of AIRD pts, diagnosed with COVID19, based on voluntary reporting by the treating rheumatologist. 12 centers from Israel participated in the study. COVID19 was confirmed by a positive SARS CoV2 PCR. The indications for PCR testing were clinical symptoms or close contact with an infected person. Severe illness was defined by SpO2 <94% in room air, respiratory rate of >30 breaths/min, PaO2/FiO2 <300 mm Hg, or lung infiltrates >50% on imaging. The registry included demographic data, AIRD diagnosis and duration, visceral involvement, co-morbidities, immunomodulatory treatment, date of diagnosis and severity of COVID19 disease, management, complications, duration of hospitalization, the dates of the mRNA vaccinations, lab results and outcome. We analyzed data from 1.3.2020 to 30.11.2021

Results

During the study period we experienced 4 outbreaks of COVID19 infection. Initially social distancing, followed by a lockdown were imposed. The low number of cases led to relaxation of the measures. Two more severe outbreaks followed, which triggered 2 new lockdowns. The 3rd outbreak ended almost 2 months after vaccination started (BNT162b2 mRNA COVID19 vaccine). From March 1st 2020 to April 30, 2021, 298 AIRD pts (70.8% females, mean (SD) age 53.3(15.3)) with confirmed COVID19 infection were included. 43.3%(129) had visceral involvement due to the AIRD. 58.7%(175 pts) were on conventional synthetic disease modifying drugs (csDMARDs), 44.6% (133) on biologic/targeted DMARDs and 40% (120) on prednisone. Almost 2/3 of pts had at least one comorbidity.

In a multivariate logistic regression analysis age, AIRD with pulmonary involvement, diabetes and treatment with prednisone, mycophenolate mofetil or JAK inhibitors were associated with hospitalization. Older age, renal and vascular involvement due to the AIRD, and congestive heart failure were associated with higher mortality.

The 4th outbreak occurred 6 months after the introduction of vaccines, with spreading of the delta variant: 110 AIRD pts with COVID19 were recorded. Demographic data, clinical AIRD‘s characteristics, immunomodulatory treatment and comorbidities were similar to the previous outbreaks. However, during the 4th outbreak, the proportion of pts with severe COVID19, the hospitalization and mortality rate were significantly lower as compared to the first 3 outbreaks (15% vs 24%, 27% vs 53%, 6.7% vs 9.1%, respectively). Among COVID19 pts, 25% received a 3rd vaccine dose (booster), 56% contracted infection more than 5 months after the 2nd vaccine dose and 24% were unvaccinated. Most of the pts who received the booster contracted the disease within a week of vaccination. The odds ratio for hospitalization in vaccinated pts compared to unvaccinated was 0.11 (0.01 – 0.63 95% CI, p=0.041) in those vaccinated within the previous 1-5 months, and 0.38 (0.21-0.67 95% CI, p=0.001) in those vaccinated more than 6 months ago. 9 pts died, 5 were more than 6 months after the 2nd mRNA vaccine, 2 were unvaccinated and 1 patient received the booster on the same day of COVID19 diagnosis.

Conclusion

Before the vaccination campaign, the hospitalization and mortality rate in our cohort were similar to the data reported by other registries. COVID19 tends to be more severe, with increased mortality in patients with active AIIRD and visceral involvement (pulmonary, cardiac, renal), advanced age and co-morbidities. The delta outbreak occured 6 months after the implementation of vaccinations and was associated with significantly lower hospitalization and mortality rates, despite the increased aggressiveness of the variant. Vaccination of AIIRD pts with 3 doses of mRNA vaccines protects from severe COVID19 disease, hospitalization, and death.

Acknowledgements

Fadi Kharouf and Tali Eviatar had equal contribution

Disclosure of Interests

None declared

OP0219 THE ASSOCIATION OF PSORIATIC ARTHRITIS WITH ALL-CAUSE MORTALITY AND LEADING CAUSES OF DEATH IN PSORIATIC ARTHRITIS

Background:

Data on the association between PsA and mortality remains conflicting as it has been hampered by small sample size with few events and the potential for confounders of selection and severity biases from clinic-based studies.

Objectives:

To examine the association between PsA and all-cause mortality in a cohort of PsA patients and matched controls, using data from a population-based large medical record database.

Methods:

Patients with newly diagnosis of PsA between January 1st, 2003 and December 31st, 2018 from the Clalit Health database were identified. 4 controls without PsA were selected and matched to cases of PsA by age (within 1 year), sex, ethnicity (Jewish vs. non-Jewish), and index date. The two groups were followed from the index date until the first occurrence of death from any cause or end of follow-up (June 30, 2019). Data on mortality and on the immediate cause of death was based on the Notification of Death form legally required by the Israeli Ministry of the Interior for every deceased person in the country. Demographic data including age, sex, ethnicity (Jewish or Arab), and socioeconomic status (SES) at inception were retrieved from the CHS database. Data regarding tobacco use (ever), obesity, body mass index, diabetes mellitus, hyperlipidemia, hypertension, ischemic heart disease, prior cerebrovascular accident, congestive heart failure, chronic renal failure, chronic obstructive pulmonary disease, cirrhosis, prior malignancy, psoriasis, and the concomitant use of glucocorticosteroids, conventional and biologic disease-modifying anti-rheumatic drugs (cDMARDs and bDMARDs, respectively) were extracted from the database.

We estimated the attributable fraction of the various causes of death in PsA patients and compared it to the proportionate mortality rate (PMR) of the leading causes of death in Israel during 2014-2016 based on a recently published report by the Central Bureau of Statistics. Cox proportional hazard regression models were used to estimate the crude and the multivariate adjusted hazard ratio (HR) for the association between PsA and all-cause mortality, as well as for factors associated with mortality within the PsA group.

Results:

A total of 5275 PsA patients were identified between 2003 and 2018 and where matched to 21,011 controls based on age, sex, and ethnicity. The mean age was 51.7 ± 15.4 years of whom 53% were females. More individuals in the PsA group were smokers, obese, with diabetes, hypertension, and dyslipidemia, as well as with a history of ischemic heart disease, cerebrovascular disease, congestive heart failure, chronic obstructive pulmonary disease, chronic renal failure and cirrhosis than patients in the control group, and 38.2% of PsA patients were on b-DMARDS. Overall 471 (8.9%) patients died in the PsA group compared to 1,668 (7.9%) in the control group during a mean follow-up of 7.2 ± 4.4 years. The crude HR for the association of PsA and all-cause mortality was 1.16 (95% CI, 1.042-1.29). However, the association was not significant on multivariate analysis with HR of 1.096 (95% CI, 0.977-1.229).

In PsA patients, malignancy was the leading cause of death, constituting 26% of all deaths, followed by ischemic heart disease 15.8%, diabetes 6.2%, cerebrovascular diseases 5.5% and septicemia 5.5%, in keeping with the order of the leading causes of death in the general population of Israel during 2014-2016 as recently reported by the Central Bureau of Statistics.

On multivariate model Cox regression analysis, male sex, increased body mass index, increased Charlson comorbidity index scores and history of hospitalization in a year prior to death were associated with higher mortality, whereas treatment bDMARDs and cDMARDs were associated with a lower relative risk of death.

Conclusion:

No clinically relevant increase in mortality rate was observed in PsA patients from the period 2003-2018. The most common causes of specific proportionate mortality rates in our cohort were similar to those in the general population.

Disclosure of Interests:

None declared

AB0780 TREATMENT PERSISTENCE OF BIOLOGICS AMONG PATIENTS WITH PSORIATIC ARTHRITIS (PsA)

Background:

Persistence in biologic therapy in psoriatic arthritis is critical to optimize symptom remission, functional capacity and health care costs.

Objectives:

To estimate the persistence to biologic treatment prescribed to PsA patients in a real-life setting as well as factors associated with improved biologic drug survival in these patients.

Methods:

Patients with PsA from a large health care provider database with at least two consecutive dispensed prescriptions of a biologic agent indicated for PsA from January 1st, 2002 until December 31st, 2018 were identified and followed until medication stop date or the end of observation period. Patients were considered non-persistent whenever a new prescription was dispensed and a permissible gap of 6 months was exceeded prior to starting on this biologic agent from the prescription date. Treatment changes were based on physician decisions and patient preferences.

Demographic data including age, sex, BMI, ethnicity, smoking history and socioeconomic status as well as Charlson comorbidity index were retrieved. Data regarding use of steroids and non-biologic disease-modifying anti-rheumatic drugs were also extracted. Descriptive statistics, including means (standard deviations) for continuous variables and frequencies (%) for categorical variables, were used. Persistence estimates were derived using non-parametric survival analysis using Kaplan-Meier functions, with treatment discontinuations as failure events. Cox regression hazard ratio models were conducted to investigate factors associated with drug persistence.

Results:

2301 PsA patients with 2958 treatment periods were identified and included in the analyses. The mean age was 50.9±14 years of whom 54% were females, 70.4% of the study population had a BMI>25, and 36% were obese(BMI>30), 40% were current smokers, and 76% had a Charlson comorbidity index higher than 1. The most commonly prescribed drug was etanercept, followed by adalimumab, golimumab, secukinumab, ustekinumab and infliximab at 33%, 29%, 12%, 10%,8% and 8%, respectively. Only about 20% of patients remained on a particular biologic agent after 5 years, whereas about 40% persisted on therapy following 20 months of treatment. A Kaplan-Mayer survival analysis with pairwise comparisons of all treatment choices with respect to lines of therapy was conducted. When analyzing the data for all treatment periods and taking into account all lines of therapy, secukinumab had a higher persistency than adalimumab, infliximab and ustekinumab, with a Log Rank of 0.022, 0.047 and 0.001, respectively, as is shown in figure 1. Female sex and smoking were associated with lower drug persistence (HR=1.25, 95%CI 1.13-1.38 and HR=1.109, 95%CI 1.01-1.21, respectively). When analyzing the data regarding second-line biologic agents, secukinumab was found to be superior to adalimumab, etanercept, infliximab and ustekinumab but not to golimumab with a Log-Rank P value of 0.001, 0.004, 0.025 and 0.002, respectively (figure 2). On analyzing the data using only the first indicated biologic line, no superiority of any single anti-Tumor Necrosis Factor-alpha (anti-TNFα) agent was observed.

Conclusion:

In this large observational cohort, in the era of biologic therapy, a relatively low persistence was observed, with female sex and smoking having a negative impact on persistency. None of the anti-TNFα agents as first line therapy was found to be more persistent than others, while secukinumab was found to be superior to other biologics when indicated as second line of therapy.

References:

None

Figure 1.Figure 2.

Acknowledgments:

none

Disclosure of Interests:

None declared

Mortality in Israel during the Persian Gulf war--initial observations

During the 6-week-long 1991 Persian Gulf war, in which the civilian population was subjected to 18 separate missile attacks and the constant threat of nonconventional warfare, crude mortality rates in Israel were no higher than in the previous decade. Although the results are preliminary and need to undergo more sophisticated epidemiologic analysis, it appears that our population was able to tolerate the subacute period of psychological stress without excess mortality.

Behçet's disease, myelodysplastic syndrome, trisomy 8, gastroenterological involvement--an association

Only a limited number of cases of Behçet's disease and hematological malignancies have been reported in the literature. We report the case of a 45 year old female patient with Behçet's disease who developed myelodysplastic syndrome, refractory anemia with excess blasts in transformation subtype, with complex chromosomal abnormalities, including excess of chromosome 8, following several years of treatment with chlorambucil for Behçet's disease. As has been described in most such cases, gastrointestinal involvement was most prominent. This case is described and the occurrence of myelodysplastic syndrome in Behçet's disease reviewed.

POS0979 IMPROVING THE VALIDITY OF DIAGNOSTIC CODES AND POINT PREVALENCE ESTIMATION OF SPONDYLOARTHRITIS IN A LARGE POPULATION-BASED DATABASE

Background

Large population-based databases provide an opportunity to study the epidemiology of spondyloarthritis (SpA), however, strict validation procedures for case ascertainment are required (1).

Objectives

To examine the validity of the ICD-9 codes of SpA in a large population-based database and to assess whether applying a specific algorithm would improve the case ascertainment. Finally, the point prevalence of SpA in the database was estimated using the validated algorithm.

Methods

A Database of a large public health fund, which serves approximately 3.17 million enrollees older than 18 years old, was used. The database includes real-time input from pharmaceutical, medical and administrative operating systems. At first, the database was searched for all individuals who received an ICD-9 code of SpA, 720.0: 7200, 7201, 7202, 7208, 72081 and 72089. All medical records of a random sample of 169 patients were thoroughly reviewed by a rheumatologist. Based on the information available in the database, a decision was made whether SpA diagnosis was: 1) definite/probable SpA; 2) not SpA/; not enough data to verify the diagnosis of SpA. The positive predicted value (PPV) and 95% confidence interval (CI) were calculated. In order to improve the case ascertainment, a second validation process was performed using a specific algorithm. The algorithm applied was: a permanent ICD-9 code of SpA assigned by the family physician plus at least one of the following criteria: 1. At least one visit at a rheumatology clinic either in the community or at a hospital outpatient clinic; 2. A diagnosis of SpA given during a hospital admission; 3. A prescription fulfilled of an anti-Tumor Necrosis Factor agent or anti IL-17 agent. This algorithm was validated by two rheumatologists in a random sample of 182 cases. Finally, the point prevalence of SpA was estimated applying the validated algorithm.

Results

The PPV of the ICD-9 codes of SpA was 44% (95%CI 36%-52%). The specific algorithm improved the PPV to 90% (95%CI 85%-94%). The concordance between the two rheumatologists was 91.3 95%CI (85.7-94.8). On the 31/12/2021, the validated algorithm identified 2892 live SpA patients older than 18 among a population of 3,167,329 enrollees in the database, reflecting a point prevalence of 0.09%, 94 patients per 100,000. Fifty one percent of the patients were male, 49% females. The point prevalence of males was 0.096%, and females - 0.087%. On the 31/12/2021, 6% of the patients were 18-29 years old, 34% 30-44 years old and 60% older than 45.

Conclusion

A specific algorithm can accurately identify patients with SpA in this large population-based database. The estimated prevalence of SpA is 0.09%. This figure is consistent with other population-based estimates (2).

References

[1]Wang R, Ward MM. Epidemiology of axial spondyloarthritis: an update. Curr Opin Rheumatol. 2018;30(2):137-43.

[2]Stolwijk C, van Onna M, Boonen A, van Tubergen A. Global Prevalence of Spondyloarthritis: A Systematic Review and Meta-Regression Analysis. Arthritis Care Res (Hoboken). 2016;68(9):1320-31.

Disclosure of Interests

None declared

OP0177 IMMUNOGENICITY INDUCED BY TWO AND THREE DOSES OF THE BNT162B2 mRNA VACCINE IN PATIENTS WITH AUTOIMMUNE INFLAMMATORY RHEUMATIC DISEASES AND IMMUNOCOMPETENT CONTROLS: A LONGITUDINAL MULTI-CENTER STUDY

Background

Data on the kinetics of the immune response to SARS-CoV-2 vaccination in patients with autoimmune inflammatory rheumatic diseases (AIIRD) are limited.

Objectives

To evaluate the kinetics of the immune response induced by two and three doses of the BNT162b2 mRNA vaccine in adult patients with AIIRD and immunocompetent controls.

Methods

A prospective multicenter study investigated the antibody response to the BNT162b2 vaccine by serial measurement of serum anti-SARS-CoV-2 S1/S2 IgG titers at the following time points: 2-6 weeks (AIIRD n=720, controls n=122) and six months (AIIRD n=628, controls=116) after the second vaccine dose, and 2-6 weeks after the third vaccine dose (AIIRD n=169, controls n=45). A seropositive response was defined as a detectable anti-S1/S2 IgG titer ≥ 15 BAU/ml. T-cell immune response was evaluated in a sample of patients (n=28) and controls (n=9) by intracellular staining of S-stimulated CD4+ T-cells for TNFα and IFNγ production.

Results

The two-dose vaccine regimen induced a higher humoral response in controls compared to patients, as reflected by the post-vaccination seropositivity rates of 100% vs 84.72%, p<0.0001, and 96.55% vs 74.26%, p<0.0001 at 2-to-6 weeks and at 6 months, respectively. The decline of S1/S2 IgG titers within six months was similar in controls and patients. Following the 3rd vaccine, the seropositivity rate increased to 80.47% and 100% in AIIRD and control groups, p=0.0028, with a significantly higher increase of S1/S2 IgG titers in controls compared with AIIRD patients, 284.09±76.58 vs 219.39±151.55 BAU/ml, p=0.0016. At all-time points, S1/S2 IgG titers were significantly lower in AIIRD patients compared with controls (Figure 1).

We further investigated the impact of therapies on the vaccine‘s immunogenicity (Figure 1). Glucocorticoids (GC) were associated with a significantly lower seropositivity rate and lower S1/S2 IgG titers compared to controls at all time points. Monotherapy with methotrexate (MTX) was associated with a comparable to controls humoral response at all time points. Anti-cytokine biologics (TNFi, IL6i, IL17i) were associated with an initial high seropositivity rate, similar to controls, followed by a steeper decline at 6 months, 79.82% vs 96.55%, p=0.0001, and restoration of seropositivity after the 3rd vaccine dose in all patients. JAKi were associated with a mildly decreased seropositivity rate after the 2nd vaccine dose and similar to controls response after the 3rd vaccine dose. Abatacept was associated with a reduced immunogenicity after the 2nd vaccine dose, but was restored to 100% seropositivity after the 3rd vaccine dose. Rituximab (RTX) significantly blunted the humoral response at all time points, with a seropositivity rate of 42% after the 2nd vaccine dose, 29% at 6 months, and with increase to 40% after the 3rd vaccine dose. A third of the RTX-treated patients who were seronegative after two vaccine doses, seroconverted after the 3rd dose. The multivariate model for predicting the seropositive response to vaccination found that higher S1/S2 IgG titers after the 2nd vaccine dose was associated with a higher seropositivity rate following the 3rd vaccine dose, OR 1.026 (1.008-1.045), p=0.0027, and that treatment with RTX was associated with a 14.3-fold risk for a negative humoral response, p≤0.0001. Cellular immune response, evaluated mainly in RTX treated patients, was preserved prior to and after the 3rd vaccine dose and was similar to controls.

Conclusion

Over a six-month period, the two dose BNTb262 vaccination was associated with a similar extent of waning of the humoral immune response in AIIRD patients and controls. The 3rd vaccine dose restored the response in all controls and in patients treated with MTX monotherapy, anti-cytokine biologics, abatacept, and JAKi. Treatment with GC and RTX was associated with an impaired humoral response at all time points.

Acknowledgements

We would like to thank the statistician Mr Yishai Friedlander and Mr Yoram Neufeld for their valuable assistance.

Disclosure of Interests

None declared