Continuous passive motion in adhesive capsulitis patients with diabetes mellitus: A randomized controlled trial

BACKGROUND

The aim of this study was to clarify the effects of continuous passive motion (CPM) treatment on adhesive capsulitis (AC) in diabetes mellitus (DM) patients.

METHODS

Forty-one DM patients with AC were randomized to two treatment groups. The first group (n= 20) (CPM group) received CPM treatments; the second group (n= 21) had conventional physical therapy (CPT group), including active stretching, range of motion (ROM) and pendulum exercises. All patients received electrotherapy. After a four-week-long physical therapy program, the patients were instructed to continue with an eight-week home exercise program. The patients rated the pain they felt at night, both while at rest and in motion, in the past week using the visual analogue scale (VAS). Functional outcome evaluations were performed using the Constant Shoulder Score (CSS) and Shoulder Pain and Disability Index (SPADI). All patients were evaluated at baseline, and during the fourth and twelfth weeks of the study.

RESULTS

There were significant improvements in both groups' active and passive ROM for the shoulder, VAS measures, SPADI pain and disability scores and CSS, and excluding the active and passive internal and external rotation of shoulder increased with both treatment methods (CPM or CPT) over time (p< 0.001), however these differences were found to be prominent in patients receiving CPM therapy.

CONCLUSIONS

Both the CPM and CPT therapies seemed to be beneficial for the treatment of AC in DM patients, however CPM revealed more distinctive improvements in the function and pain levels of the AC patients.

Salivary and serum concentrations of monocyte chemoattractant protein-1, macrophage inhibitory factor, and fractalkine in relation to rheumatoid arthritis and periodontitis

BACKGROUND

Monocyte chemoattractant protein-1 (MCP-1), macrophage migration inhibitory factor (MIF), and fractalkine are chemokines that are expressed by a variety of cell types to regulate macrophage inflammatory response. The aim of the study was to examine the effects of periodontitis and rheumatoid arthritis (RA) on their serum and salivary concentrations.

METHODS

Adults with either periodontitis (P, n = 21), or with rheumatoid arthritis (RA, n = 23), or with both diseases (RA+P, n = 23) were included in the study. Systemically and periodontally healthy individuals (n = 22) served as controls. Saliva and serum samples were collected from all participants before the medical and periodontal examinations. Salivary and serum MCP-1, MIF, and fractalkine concentrations were measured by the Luminex technique. Total salivary protein levels were determined by the Bradford assay.

RESULTS

Salivary MCP-1, MIF, and fractalkine concentrations were elevated in both RA groups (RA+P and RA) in comparison with systemically healthy controls. As related to total salivary protein levels, higher MCP-1 (P = 0.003) and fractalkine (P = 0.045) concentrations were found in controls compared with the P group. In serum, MCP-1 concentrations in the RA+P group were higher (P = 0.003) than those of group P. Elevated serum fractalkine concentrations were observed in both periodontitis groups (RA+P, P = 0.014; and P, P = 0.013) compared with controls.

CONCLUSIONS

In RA, MCP-1, MIF, and fractalkine concentrations are elevated in saliva. These chemokines may disrupt oral macrophage responses and potentially take part in the interaction between periodontitis and RA.

The role of methotrexate and low-dose prednisolone on adiponectine levels and insulin resistance in patients with rheumatoid arthritis naïve to disease-modifying antirheumatic drugs

AIM

Insulin resistance (IR) plays an important role in the development of cardiovascular events in rheumatoid arthritis (RA) patients. Adiponectin influences insulin sensitivity but its impact on IR in RA patients remains unclear. The present study aims to investigate the role of methotrexate (MTX) and low doses of prednisolone (LDP) on IR and adiponectin levels in RA patients who are naïve to disease-modifying antirheumatic drugs (DMARDs), as well as determining the relationship between disease activity, acute phase response, IR and adiponectin levels in patients with RA.

METHODS

Sixty-five RA patients naïve to DMARDs and prednisolone were involved in this study. The medication for RA patients was standardized for MTX and prednisolone. Body mass index, acute phase response reactants, 28-joint-count disease activity score, fasting blood glucose, serum cholesterol levels, insulin levels and adiponectin levels were measured in all RA patients both at the baseline and 3 months after the onset of the study.

RESULTS

Adiponectin levels in the third month of the therapy with MTX and LDP were significantly increased in patients with RA (P = 0.03). Insulin resistance tended to decrease in the third month of the treatment, which achieved no statistical significance.

CONCLUSION

Increased levels of adiponectin due to MTX and LDP could be related to the decrease in homeostasis model assessment insulin resistance (HOMA-IR) in RA patients. This, in turn, could prove advantageous for cardiovascular conditions in RA.

The association between gene polymorphisms and leukocytosis with thrombotic complications in patients with essential thrombocythemia and polycythemia vera

Objective: Vascular events are a common complication in patients with polycythemia vera (PV) and essential thrombocythemia (ET). This study aimed to analyze the association between PAI-1 4G/5G and ACE I/D gene polymorphisms, and leukocytosis with thrombosis in patients with PV and ET.

Material and Methods: In total, 64 patients with ET and PV were evaluated. Arterial or venous thrombosis, such as cerebral transient ischemic attack, ischemic stroke, myocardial infarction, peripheral arterial thrombosis, deep venous thrombosis, and pulmonary embolism, were defined as a vascular event. DNA samples were screened for mutations via reverse hybridization strip assay.

Results: In terms of PAI-1 gene polymorphism, the frequency of the 4G and 5G allele was 48.5% and 51.5%, respectively. The ACE allele frequency was 51.2% and 48.8% for D and I, respectively. There wasn’t an association between occurrence of vascular events and the frequency of any allele. In terms of occurrence of vascular events, there weren’t any significance differences between the patients that were carrying the ACE D/D homozygous allele to ACE I/D and those that carried the I/I allele (P = 0.93). There wasn’t a significant difference in occurrence of vascular events between the PAI-1 5G/5G homozygote allele carriers, and the 4G/5G and 4G/4G allele carriers (P = 0.97). Vascular events were significantly more common in the patients with leukocytosis (leukocyte count >10 × 109 L–1) than in those without leukocytosis (leukocyte count ≤10 × 109 L–1) (P = 0.00). Age >60 years was also a significant risk factor for occurrence of vascular events(P = 0.008).

Conclusion: PAI-1 and ACE gene polymorphisms were not considered new risk factors for thrombosis in PV and ET patients. On the other hand, leukocytosis at diagnosis was associated with the occurrence of vascular events in the patients with ET and PV.

Budd-Chiari syndrome in Behçet's disease: a retrospective multicenter study

OBJECTIVE

To compare the clinical features, laboratory findings, and prognosis of Behçet's disease (BD) patients with and without Budd-Chiari syndrome (BCS).

METHODS

This multicenter retrospective study investigated 61 (M/F: 41/20) patients with BD, having coexistent BCS, and 169 (M/F:100/69) BD patients as the control group without BCS from 22 different centers of Turkey diagnosed between 1990 and 2017.

RESULTS

Of the total 61 BD patients with BCS, the onset of the first symptom and the median age of diagnosis were earlier in contrast to BD patients without BCS (p = 0.005 and p = 0.007). Lower extremity deep vein and inferior vena cava (IVC) thrombosis were more common in patients with BCS (all; p < 0.01) compared to the control group. Mortality was significantly higher in BD-BCS patients with IVC thrombosis than in the controls (p = 0.004). Since most of the cases in our cohort had chronic and silent form of BCS, mortality rate was 14.8%, which was on the lower range of mortality rate reported in literature (14-47%). While all BD-BCS patients received immunosuppressive (IS) agents, only half of them received additional anticoagulant treatments. Among IS agents, interferon treatment was more frequently used in this cohort (19%), compared to other series reported in literature (2.3%).

CONCLUSION

To our knowledge, this is the largest series of BD patients with BCS. Our patients had earlier disease onset and diagnosis, higher frequency of IVC thrombosis, and higher mortality rate, compared to BD patients without BCS. Mortality was significantly higher in BD-BCS patients with IVC thrombosis compared to controls. Key Points • Mortality rate is higher in BD-associated BCS patients with IVC involvement. • Chronic and silent form of BD-associated BCS has a better prognosis. • The main treatment options are corticosteroids and immunosuppressive agents, whereas anticoagulant treatment remains controversial.

Are cup-like blasts specific to AML patients with FLT3 ITD and a normal karyotype? An ALL case report and review of the literature

Cup-like morphology is defined as cup-like nuclear invagination spanning ≥25% of the nuclear diameter in >10% of blasts. Studies have shown that FLT3 ITD and normal cytology are strongly associated with cup-like morphology in acute myeloid leukemia (AML) patients. Herein we describe a patient with cup-like blasts that was diagnosed and treated for common acute lymphoblastic leukemia (ALL). In contrast to the literature, the presented case was Philadelphia chromosome positive and FLT3 ITD negative.

Preferences of inflammatory arthritis patients for biological disease-modifying antirheumatic drugs in the first 100 days of the COVID-19 pandemic

Background/aim

To evaluate treatment adherence and predictors of drug discontinuation among patients with inflammatory arthritis receiving bDMARDs within the first 100 days after the announcement of the COVID-19 pandemic.

Materials and methods

A total of 1871 patients recorded in TReasure registry for whom advanced therapy was prescribed for rheumatoid arthritis (RA) or spondyloarthritis (SpA) within the 3 months (6–9 months for rituximab) before the declaration of COVID-19 pandemic were evaluated, and 1394 (74.5%) responded to the phone survey. Patients’ data regarding demographic, clinical characteristics and disease activity before the pandemic were recorded. The patients were inquired about the diagnosis of COVID-19, the rate of continuation on bDMARDs, the reasons for treatment discontinuation, if any, and the current general disease activity (visual analog scale, [VAS]).

Results

A total of 1394 patients (493 RA [47.3% on anti-TNF] patients and 901 SpA [90.0% on anti-TNF] patients) were included in the study. Overall, 2.8% of the patients had symptoms suggesting COVID-19, and 2 (0.15%) patients had PCR-confirmed COVID-19. Overall, 18.1% of all patients (13.8% of the RA and 20.5% of the SpA; p = 0.003) discontinued their bDMARDs. In the SpA group, the patients who discontinued bDMARDs were younger (40 [21–73] vs. 44 years [20–79]; p = 0.005) and had higher general disease activity; however, no difference was relevant for RA patients.

Conclusion

Although the COVID-19 was quite uncommon in the first 100 days of the pandemic, nearly one-fifth of the patients discontinued bDMARDs within this period. The long-term effects of the pandemic should be monitored.

Clinical and laboratory factors associated with the bamboo spine in patients with axial spondyloarthritis: are there clues for the bamboo spine?

OBJECTIVES

To analyse the clinical and laboratory factors associated with bamboo spine.

METHODS

Data of patients fulfilling the 2009 ASAS classification criteria for axial spondyloarthritis, registered in the national, multicentre, longitudinal, and observational database of TReasure was analysed. Radiographs were assessed using the Bath Ankylosing Spondylitis Radiologic Index (BASRI). Data of patients with a bamboo spine (Group 1) was compared to data derived from patients with a longstanding disease of at least 15 years but no syndesmophytes (Group 2).

RESULTS

Out of the 5060 patients, 1246 had eligible radiographs. There were 111 patients (8.9%) with a bamboo spine. Male sex was more common among patients with bamboo spine. The median BMI of 27.7 (25.8-31.1) in Group1 was higher than the BMI of 25.9 (22.9-29.2) in Group 2 (p<0.001). Hip arthritis, present or documented by a physician, was more common in Group 1 [(58/108 (53.7%) vs. 35/103 (34%), p=0.004]. There was a tendency towards a more prevalent enthesitis in these patients [29.1% (25/86) vs. 15.9%(11/69), p=0.054]. HLA-B27 status did not differ between groups. Smoking was more prevalent in Group 1. Multivariate logistic regression analysis revealed that male sex, body mass index, hip arthritis, and enthesitis are associated with bamboo spine in axSpA.

CONCLUSIONS

Bamboo spine was more common in the male sex and associated with a delay in diagnosis, high BMI, hip involvement, and enthesitis. The constellation of increased body weight, hip arthritis, and enthesitis may imply that mechanical stress contributes to radiographic damage in the presence of chronic inflammation.

Exon 2: Is it the good police in familial mediterranean fever?

Objective

Familial Mediterranean fever (FMF) is the most common autoinflammatory disease. Most of the identified disease-causing mutations are located on exon 10. As the number of studies about the effect of the exonal location of the mutation and its phenotypic expression is limited, we aimed to investigate whether the exonic location of the Mediterranean fever (MEFV) mutation has an effect on the clinical manifestation in patients with FMF.

Methods

Study population was derived from the main FMF registry that included 2246 patients from 15 different rheumatology clinics. We categorized the mutations according to their exon locations and retrieved the clinical and demographic information from the database.

Results

Patients having the MEFV mutations on exon 2 or 10 (n:1526) were divided into three subgroups according to the location of the MEFV mutations: Group 1 (exon 2 mutations), Group 2 (exon 10 mutations), and Group 3 (both exon 2 and exon 10 mutations). Group 2 patients were of a significantly younger age at onset, and erysipel-like erythema, arthritis, amyloidosis, and a family history of FMF were more common in this group.

Conclusion

Patients with FMF and exon 10 mutations show more severe clinical symptoms and outcome. Exon 2 mutations tend to have a better outcome.

The dynamics of prehospital/hospital care and modes of transport during civil conflict and terrorist incidents

OBJECTIVE

Prehospital and hospital care during incidents of mass violence and civil conflict involve a number of aspects that distinguish it from care during times of peace. We aimed to analyze the dynamics and outcomes of prehospital and hospital care during ongoing conflicts.

STUDY DESIGN

Multicentric prospective observational study.

METHOD

Patients enrolled in the study, which was conducted in Turkey, were all injured in armed conflict and taken to level 1 trauma centers. On admittance, patients were requested to complete a semistructured questionnaire containing questions on patient demographics, transport type, weapons used, injury severity score (ISS), and other incident-related factors. We analyzed patient outcomes (mortality, morbidity, complications, and length of hospital stay) and transfers of patients between hospitals. The present study evaluated the cases of 390 victims enrolled over a 9-month period and followed up for 6 months.

RESULTS

The majority of patients were transported by ambulances (n = 334, 85.6%); other transport modes were helicopters (n = 32, 8.2%) and private vehicles (n = 24, 6.2%). Nearly half of patients (48.7%) did not benefit by changing hospitals. During transport to hospitals, 4.1% of the vehicles in the study were involved in accidents. Using multiple regression analysis, only ISS (odds ratio [OR]: 1.098, 95% confidence interval [CI]: 1.044-1.156) and the Glasgow Coma Scale (OR: 0.744, 95% CI: 0.639-0.866) were found to affect mortality. In Receiver-operator characteristic analysis, a cutoff value of 22.5 for ISS had a sensitivity of 100% and a specificity of 89.6% for mortality.

CONCLUSIONS

Despite lower ISS values, patient outcomes were worse in terror incidents/civil conflicts. Transport modes did not significantly affect outcomes, whereas hospital transport was found to be inefficiently used.

PsART-ID inception cohort: clinical characteristics, treatment choices and outcomes of patients with psoriatic arthritis

OBJECTIVES

Our aim is to understand clinical characteristics, real-life treatment strategies, outcomes of early PsA patients and determine the differences between the inception and established PsA cohorts.

METHODS

PsArt-ID (Psoriatic Arthritis- International Database) is a multicentre registry. From that registry, patients with a diagnosis of PsA up to 6 months were classified as the inception cohort (n==388). Two periods were identified for the established cohort: Patients with PsA diagnosis within 5-10 years (n = 328), ≥10 years (n = 326). Demographic, clinical characteristics, treatment strategies, outcomes were determined for the inception cohort and compared with the established cohorts.

RESULTS

The mean (s.d.) age of the inception cohort was 44.7 (13.3) and 167/388 (43.0%) of the patients were male. Polyarticular and mono-oligoarticular presentations were comparable in the inception and established cohorts. Axial involvement rate was higher in the cohort of patients with PsA ≥10 years compared with the inception cohort (34.8% vs 27.7%). As well as dactylitis and nail involvement (P = 0.004, P = 0.001 respectively). Both enthesitis, deformity rates were lower in the inception cohort. Overall, 13% of patients in the inception group had a deformity. MTX was the most commonly prescribed treatment for all cohorts with 10.7% of the early PsA patients were given anti-TNF agents after 16 months.

CONCLUSION

The real-life experience in PsA patients showed no significant differences in the disease pattern rates except for the axial involvement. The dactylitis, nail involvement rates had increased significantly after 10 years from the diagnosis and the enthesitis, deformity had an increasing trend over time.

The First Effect of COVID-19 Pandemic on Starting Biological Disease Modifying Anti-Rheumatic Drugs: Outcomes from the TReasure Real-Life Database

OBJECTIVE

The coronavirus disease 2019 pandemic has been resulting in increased hospital occupancy rates. Rheumatic patients cannot still reach to hospitals, or they hesitate about going to a hospital even they are able to reach. We aimed to show the effect of the first wave of coronavirus disease 2019 pandemic on the treatment of biological disease-modifying anti-rheumatic drugs in patients with rheumatoid arthritis or spondyloarthritis.

METHODS

Patients were divided into three groups as follows: pre-pandemic (Pre-p: starting on biological disease-modifying anti-rheumatic drug therapy for the first time within 6 months before March 11, 2020); post-pandemic A (Post-p A: starting on biological disease-modifying anti-rheumatic drug therapy for the first time within the first 6 months after March 11, 2020); post-pandemic B (Post-p B: starting on biological disease-modifying anti-rheumatic drug therapy for the first time within the second 6 months).

RESULTS

The number of rheumatoid arthritis patients in the Post-p A and B groups decreased by 51% and 48%, respectively, as compared to the Pre-p group similar rates of reduction were also determined in the number of spondyloarthritis patients. The rates of tofacitinib and abatacept use increased in rheumatoid arthritis patients in Post-p period.

CONCLUSION

The number of rheumatoid arthritis and spondyloarthritis patients starting on biological disease-modifying anti-rheumatic drugs for the first time decreased during the first year of the coronavirus disease 2019 pandemic.

The importance of leucine-rich α-2 glycoprotein-1 in acute calculus cholecystitis

OBJECTIVE

The aim of this prospective, single-center cohort study was to analyze serum leucine-rich α-2-glycoprotein-1 (LRG1) expression in patients with acute cholecystitis (AC) and to investigate its variation depending on symptom duration.

PATIENTS AND METHODS

Participants were divided into patients with AC and a healthy control group. At the time of diagnosis, blood samples were collected, and symptom onset times were questioned. Collected serum LRG1 levels were measured.

RESULTS

30 patients and 30 healthy volunteers were included in the study. LRG1 (p=0.008), white blood cells (WBC) (p<0.001), platelet (p=0.003), neutrophil (p<0.001), lymphocyte (p=0.001), and CRP (p=0.014) were significantly different in AC patients vs. the control group. When the correlations of serum laboratory values with the time of onset of symptoms were compared, LRG1 (p<0.001) was significantly correlated, while no significant correlation was observed in C-reactive protein (CRP) (p=0.572), WBC (p=0.155), and neutrophil (p=0.155).

CONCLUSIONS

LRG1 expression increases after 24 hours in AC patients. Due to its correlation with symptom duration, we believe it can be helpful for timing cholecystectomy.

AB0700 TOCILIZUMAB DID NOT REDUCE MORTALITY IN SEVERE COVID-19 PATIENTS BUT CAUSED THROMBOCYTOSIS

Background:

TCZ is a monoclonal antibody against Interleukin-6 receptor (IL-6R) which is used for relieving inflammation and reducing mortality in COVID-19 patients. Safety and efficacy of Tocilizumab (TCZ) in Covid-19 pneumonia is uncertain yet. In this study, we aimed to determine clinical outcomes in patients treated with TCZ.

Objectives:

In this study we aimed to share our retrospective results which we had obtained from patients with COVID-19 diagnosis received TCZ.

Methods:

We performed a retrospective case control study between May and August 2020 in Turkey. We compared outcomes in patients who received TCZ with those who did not. Death in hospital and intensive care unit (ICU) requirements were evaluated as endpoints. Demographic data, comorbidities, additional treatment, treatment side effects, laboratory and clinical results were retrospectively assessed. There are no significant differences between groups according to age, gender and Charlson Comorbidity Index (CCI).

Results:

12 (27.3%) patients died in standard group and eight (18.6%) patients died in TCZ group (p=0.150).Days of staying in the hospital were eight days in standard treatment group and 12 days in TCZ group (p=0.03). 10 of 43 patients in TCZ group were admitted to ICU. MV support was needed in 8 of these patients. 18 of 44 patients (40.9%) within the standard group were admitted to ICU and 12 patients (27.3%) were intubated (p=0.125,p=0.480). Significant IL-6 decrease was not observed post treatment in TCZ group according to pretreatment period (p=0.60). Significant decreases were examined in CRP and ferritin values through TCZ treatment. However, D-dimer and thrombocyte values increased.

Conclusion:

TCZ may not be an effective treatment for reducing ICU requirement, to prevent intubation or death, for shortening period for staying in hospital. The patients should be followed up closely for possible thrombosis because of increased D-dimer and thrombocytes with TCZ treatment.

References:

[1]Sharma A, Tiwari S, Deb MK, Marty JL. Severe acute respiratory syndrome coronavirus-2 (SARS-Cov-2): A global pandemic and treatment strategies. IntJ Antimicrob Agents. 2020 Aug; 56(2):106054.

[2]Singhal T. A rewiev of coronavirus Disease-2019(COVID-19). Indian J Pediatr. 2020 Apr;87(4):281-286.

[3]Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall R.S, Manson J.J. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet. 2020;395(10229):1033-

[4]Teijaro J.R. Cytokine storms in infectious diseases. SeminImmunopathol. 2017;39:501–503.

[5]Zhang Y, Li J, Zhan Y, Wu L, Yu X, Zhang W et al. Analysis of Serum Cytokines in Patients with Severe Acute Respiratory Syndrome. Infect Immun 2004 Aug;72(8):4410-4415.

[6]Zhang C, Wu Z, Li JW, Zhao H, Wang GQ. Cytokine release syndrome in severe COVID-19: interleukin-6 receptor antagonist tocilizumab may be the key to reduce mortality. Int J Antimicrob Agents. 2020 May; 55(5):105954.

[7]Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C et al. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med. 2020;8(4):420–2

[8]Fu B, Xu X, Wei H. Why tocilizumab could be an effective treatment for severe COVID-19? J Transl Med 18,164 (2020).

[9]Guaraldi G, Meschiari M, Cozzi-Lepri A, Milic J, Tonelli R, Menozzi M et al. Tocilizumab in patients with severe COVID-19: a retrospective cohort study. Lancet Rheumatol. 2020 Aug;2(8):e474-e484.

[10]Gupta S, Wang W, Hayek S.S, Chan L, MathewsK.S, Melamed M.L et al. Association Between Early Treatment With Tocilizumab and Mortality Among Critically Ill Patients With COVID-19. JAMA Intern Med. 2021 Jan1;181(1):41-51.

[11]Campochiaro C, Della-Torre E, Cavalli G, De Luca G, Ripa M, Boffini N et al Efficacy and safety of tocilizumab in severe COVID- 19 patients: a single-centre retrospective cohort study. Eur J Intern Med. 2020 Jun;76:43-49.

Disclosure of Interests:

None declared

AB0355 THE DIFFERENCES BETWEEN THE FIRST PREFERRED BIOLOGICAL DMARD AND THE DRUG SURVIVAL IN GERIATRIC AND YOUNGER ADULT POPULATION WITH RHEUMATOID ARTHRITIS AND PSORIATIC ARTHRITIS: TREASURE REAL-LIFE DATA

Background

Inflammatory musculoskeletal diseases are frequent in the elderly population, and this number is expected to increase significantly near future. The exclusion of older adults from the studies due to their age and comorbidities causes insufficient data about this population. Insufficient data cause clinicians to have difficulties using and selecting biological therapy in the elderly patient group. In real life, physicians’ approaches to the selection and use of biological disease modifying anti-rheumatic drugs (DMARDs) in the geriatric population with rheumatoid arthritis (RA) and psoriatic arthritis (PsA) have not been well studied.

Objectives

To compare the clinicians’ first choice of biological DMARDs in elderly and younger RA and PsA patients and investigate the drug survival of first biological DMARDs in both populations.

Methods

The traditional chronological age for the human to be classified in the geriatric population is ≥ 65 years (1). The TReasure web-based registry, created in 2017, is a multicenter observational cohort established to collect data on RA and spondyloarthritis (SpA) patients from the participating 17 rheumatology centers in different regions of Turkey. Physicians’ first choice biological and targeted synthetic DMARDs in younger and elderly patients with RA and PsA was evaluated using the descriptive statistical method. The survival of the first b/tsDMARDs was assessed using the Kaplan-Meier method.

Results

3136 RA and 738 PsA patients were evaluated. 12% of 3136 patients with RA were in the geriatric population. In patients with RA, the first choice of biologic DMARDs was adalimumab (20.6%), followed by etanercept (19.9%), and tofacitinib (13.6%) in patients < 65 years of age, while rituximab (24%) was the first choice in patients ≥ 65 years, tofacitinib (20.9%) in the second place and etanercept (13%) in the third. Of 738 PsA patients, 3% were over 65 years. Adalimumab (41.1%) was the first choice of <65 years of age, etanercept (17.6%) was the second choice, and infliximab (15.5%) was the third choice, while adalimumab (28.6%) was the first choice in patients ≥ 65 years followed by etanercept (17.9%) and certolizumab (17.9%). In RA group, drug survival was significantly higher in patients ≥ 65 years (estimated median drug survival; <65 age: 37.5 (34.1-41.1) months vs ≥65 age: 53.5 (24.9-82.2) months; log-rank p=0,016) (Figure 1). In PsA group, drug survival was significantly higher in patients < 65 years (estimated median drug survival; <65 age: 31.2 (26.4-36.1) months vs ≥65 age: 9.1 (0.4-17.7) months; log-rank p<0,001) (Figure 1).

Figure 1.

Comparison of first bDMARD retention rates between <65 years and ≥ 65 years. A: In rheumatoid arthritis patients, B: In psoriatic arthritis patients

Conclusion

With these findings, it is thought that in Turkey, the limited socioeconomic support in the geriatric patients has led physicians to prescribe treatments such as rituximab, which are administered in the hospital under the supervision of a physician, are relatively preferred in malignancies, and are considered to be relatively less risky in terms of tuberculosis. Adalimumab and etanercept were chosen in the first two lines in both geriatric and young populations in the patient group with PsA. While the drug survival was significantly higher in patients with RA geriatric age group than the younger group, in PsA in which tumor necrosis factor-alpha (TNF-α) inhibitors were chosen as initial therapy in both age groups was lower in the geriatric population.

References

[1]Kotsani et al. JCM 2021. https://doi.org/10.3390/jcm10143018

Disclosure of Interests

None declared

Why are male patients with Behçet's disease prone to thrombosis? A rotational thromboelastographic analysis

OBJECTIVES

To investigate whether there is a difference between male and female patients with Behçet's disease (BD) in terms of hypercoagulability by using modified rotational thromboelastograhic (ROTEM) analysis.

METHODS

126 BD patients (71 male, 55 female; mean age: 41±9 yrs) who met ISSG criteria for BD were included into the study. 23 patients with vasculitis (16 female, 7 male; mean age 49±16 yrs), and 25 healthy individuals (11 female, 14 male; mean age: 37±10 yrs) were included to the study as disease and healthy control (HC) group, respectively. Clotting time (CT), clot formation time (CFT) and maximum clot firmness (MCF) were determined by INTEM and EXTEM analyses. As a marker of vascular endothelial injury, along with inflammatory markers, vWFag levels were investigated in patients and HC group.

RESULTS

Extem-CFT was shorter in only vasculitic group compared to HC group. Intem-CFT was found to be shorter in BD patients and vasculitis group compared to HC. Intem-MCF was significantly longer in male BD patients than female BD patients. Extem-CFT was found to be shorter in male BD patients compared to female BD patients. Extem-MCF was statistically longer in male BD patients. In inactive male BD patients, while Intem-CFT was shorter than HC individuals, Intem-MCF and Extem-MCF were statistically longer than HC (p<0.02, p<0.03), respectively. However, no significant differences were found between inactive female BD patients and HC in terms of all ROTEM parameters.

CONCLUSIONS

These results support that male BD patients have a hypercoagulable state compared to female BD patients, which may explain why male patients are prone to thrombotic complications.

Predicting extra-musculoskeletal and peripheral manifestations and their role on biologic treatment in patients with axial spondyloarthritis: TReasure experience

Objectives

This study aimed to examine the frequency and associated factors of extra-musculoskeletal manifestations (EMMs) and peripheral manifestations in an axial spondyloarthritis (axSpA) cohort and their impact on the choice of first biologic treatment.

Patients and methods

A total of 1,687 patients with axSpA (978 males, 709 females; mean age: 38.5±11 years) who started their first biologic disease modifying antirheumatic drug (bDMARD) were included from a national prospective database of TReasure between its inception and 2018-2021. Demographic and clinical characteristics, disease-related features, and treatment patterns were compared between patients with and without EMMs or peripheral involvement.

Results

Of the patients, 1,283 had radiographic axSpA (r-axSpA), while 404 had nonradiographic axSpA (nr-axSpA). Acute anterior uveitis (AAU) was the most common (11.4%) EMM, and older age, female sex, human leukocyte antigen B27 (HLA-B27) positivity, and a lower Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score were associated with AAU. Female sex, methotrexate use, dactylitis, and higher Ankylosing Spondylitis Disease Activity Score (ASDAS)-serum C-reactive protein (CRP) scores were related to psoriasis (PsO). Inflammatory bowel disease (IBD) and PsO were negatively associated with HLA-B27 positivity. Enthesitis was the most frequent (28.2%) peripheral manifestations, and peripheral arthritis, dactylitis, and enthesitis were independent predictor of each other. In addition, dactylitis and peripheral arthritis were related to more frequent use of conventional disease modifying antirheumatic drugs. In addition, IBD history was associated with less frequent use of etanercept. Older age, less use of sulfasalazine, the absence of enthesitis, and lower Bath Ankylosing Spondylitis Functional Disease Index (BASFI) scores were associated with secukinumab use.

Conclusion

Acute anterior uveitis was associated with HLA-B27 positivity, while PsO or IBD were negatively associated with HLA-B27 in patients with axSpA. Peripheral manifestations appeared to be related to each other. Among EMMs, we found that only IBD had an effect on the bDMARD preference.

AB0774 Paradoxical reactions, especially psoriasis in rheumatology patients receiving biologic therapy from the Treasure database: a 5-year follow-up study

Background

Biologic agents have altered our ability to treat chronic inflammatory diseases effectively. Although paradoxical reactions (PRs) were initially described with TNF-α inhibitors, they have been reported with newly developed biologic agents or classes too (1). Due to the potential consequences of PRs, it is critical to identify and treat these drug class side effects as soon as possible.

Objectives

The aim of this study was to characterize PRs, especially psoriasis, in a large cohort of patients treated with biologic agents and to investigate their clinical implications.

Methods

TReasure database, which was launched in 2017, is a web-based prospective observational cohort comprised of patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA) from 17 centers located throughout Turkey. Characteristics of patients with PRs and clinicians’ treatment approaches and outcomes were evaluated using descriptive statistics.

Results

3147 RA and 6071 SpA patients were evaluated. 139 (1.5%) patients (40 (28.8%) with RA and 99 (71.29%) with SpA) developed a PRs (Table 1). The rate of paradoxical psoriasis was 90.6% and 9.7% of the patients had a family history of psoriasis. Females constituted 64% of the patients. The mean age was 46±12 years and the disease duration were 146±92 months. Mean time interval between the PRs and diagnosis was 99,6±86 months, whereas median 12 (1-132) months between the PRs and the biological agent. Adalimumab (30.9 %), etanercept (20.1 %), and infliximab (18.7 %) were the three most frequently used agents during the PRs. However, 8.6% of the patients developed PRs with non-TNF agents. Only seven patients (5.1%) who had PRs discontinued the drug, while 28 patients (20.6%) continued to receive the agent that caused the PRs. Majority of patients were switched to other TNF-α inhibitors (48.5%) and non-TNF agents (25.7%). When we limited our analysis to paradoxical psoriasis patients, we observed complete remission in 43.5% of patients and progression in only six (4.7 %) of patients. (Figure 1).

Table 1.

Characteristics of RA and SpA patients who developed paradoxical reactions

NPatients (N, %)Paradoxical reactions (PRs)139  Psoriasis126 (90.6%)  Uveitis6 (4.3%)  Sarcoidosis2 (1.4%)  IBD1 (0.7%) Other*4 (4.3%)Primary disease139  RA40 (28.8%)  SpA99 (71.29%)Time interval between PRs-diagnosis of RA/SpA (months)12499,6±86† 72 (3-420) ††Time interval between PRs-biological onset (months)12622±25† 12 (1-132) ††BMI, kg/m212328±5† 27,8 (17,3-49,7) ††Smokers (Current/ex)13161 (46.6%) / 10 (8.5%)Biological agents used during PRs139  TNF-α inhibitor used**127 (91.3%)  Secukinumab2 (1.4%)  Abatacept6 (4.3%)  Rituximab4 (2.9%)Biological agents used after PRs101  Etanercept31 (22.8%)  Adalimumab15 (11%)  Secukinumab12 (8.8%)  Other***43 (57.5%)

PRs: Paradoxical reactions IBD: Inflammatory bowel disease. *Drug-induced lupus:3 Vasculitis:1. ** Adalimumab: 43 (30.9%), Etanercept: 28 (20.1%), Infliximab: 26 (18.7%), Certolizumab: 20 (14.4%), Golimumab: 10 (7.2%). *** Certolizumab: 9 (6.6%), Tofacitinib: 9 (6.6%), Infliximab: 7 (5.1%), Tocilizumab: 5 (3.7%), Golimumab: 4 (2.9%), Ustekinumab: 4 (2.9%), Rituximab:3 (2.2%), Abatacept: 1 (0.7%), Anakinra: 1 (0.7%). † mean ± standard deviation. †† median (min-max)

Conclusion

Clinicians should be aware that PRs may develop with biologic agents other than TNF-α inhibitors. Additionally, it is important to keep in mind that the development time of PRs could be variable. The mechanism(s) behind PRs remain unknown, and there is no currently available diagnostic or therapeutic protocol (2). The decision whether to continue or discontinue biologic agents should be individualized. We found that the majority of patients can be managed without discontinuing biologic agents. Finally, we believe that the experience of our large cohort can help physicians in clinical practice where sufficient protocol is lacking.

References

[1]Lluís Puig. Curr Probl Dermatol. 2018; 53:49-63.

[2]Michael J Murphy. J Am Acad Dermatol. S0190-9622(20)33154-6.

Disclosure of Interests

None declared