OP0078 ALTERED IMMUNOLOGICAL CIRCADIAN RHYTHMS AND THE EFFECT OF TREATMENT WITH GLUCOCORTICOIDS ON CIRCADIAN RHYTHMS OF IMMUNE CELLS IN PATIENTS WITH RHEUMATOID ARTHRITIS: BRING BACK THE RHYTHM

Background

In rheumatoid arthritis (RA), pain, joint swelling, and stiffness follow a clear circadian pattern. Most of these symptoms are most pronounced in the early morning and primarily attributed to elevated levels of the key proinflammatory cytokines IL-6 and TNFα, which usually peak before clinical symptoms worsen (1). Synthetic glucocorticoids (GCs) are among the most prescribed drugs in the management of patients with RA. GCs have effects on almost every immune cell. GCs suppress expression of various cytokines, including IL-1β, TNFα, IL-6, and GM-CSF. Moreover, circadian rhythms of immune cells are known to be influenced by GCs. For example, GCs govern in part the rhythm of circulating CD4+ and CD8+ T cells.

Objectives

To identify circadian patterns for optimization of diagnosis and treatment strategies, we conducted a clinical study comparing healthy donors (HD) and patients with RA in terms of circadian rhythms. We examined the effect of treatment with GCs on circadian immune rhythms in patients with RA.

Methods

We recruited 12 HD and 13 patients with active RA (DAS28≥4.0) who either were (n=8) or, for comparison, were not (n=5) under current treatment with GCs. Their biological clock was synchronized for a week before the study day by a scheduled sleep and mealtime regimen. On the study day, participants were provided with regular meals, allowed to eat snacks ad libitum and carry passive activities. We collected blood samples every two hours over a period of 24 hours. The absolute number of circulating immune cells, clock gene expression, and serum cytokine levels were measured with TruCount, qPCR, and multiplex suspension assay, respectively.

Results

Peripheral regulatory T cells are circadian in HD and RA, but the number was notably reduced in RA (Table 1). CD8+ T cells, CD14+ monocytes, and CD19+ B cells lost their circadian rhythms in RA, but these rhythms were restored with GC treatment. Circulating NK and NK T cells, which are not diurnal in HD, exhibited circadian fluctuations in RA. GC treatment suppressed diurnal pathological circulation rhythms of NK and NK T cells by reducing the amplitude by half. In monocytes, BMAL1, PER1, PER2, and REVERBA are only circadian in HD. GC restored the rhythms of PER2 and REVERBA. CRY1 expression showed diurnal variation in RA, but not in HD. IL-6 exhibited a circadian pattern in both groups, and GC treatment showed no significant effects on IL-6. Serum IL-4, IL-5, and MIP3α showed circadian variation in HD only. The following cytokines were notably elevated in RA-patients: IFNγ, MIP1α, MIP1β, IL-1β, IL-2, IL-17A, and IL-21. GC reduced the expression of IL-10 significantly in RA.

Table 1.

Circadian rhythms in the cellular, gene, and protein levels in HD, RA, and RA with ongoing GC treatment

ComparisonCircadian / GC impactCirculating immune cellsClock genes in monocytesSerum cytokinesHD vs. RANon-circadian in HD and RA-CLOCK, CRY2, DBP, RORAFractaline, IFNγ, CXCL11, GM-CSF, MIP1α, MIP1β, IL-1β, IL-2, IL-4, IL-7, IL-8, IL-10, IL-12, IL-13, IL-17A, IL-21, IL-23Circadian in HD and RACD3+, CD4+, regulatory T cellsPER3IL-6Circadian in HDCD8+ T cells, CD14+ monocytes, CD19+ B cellsBMAL1,PER1, PER2, REVERBAIL-4, IL-5, MIP3αCircadian in RANK cells, NK T cellsCRY1-RA vs. GCs-treated RARestorative effect by GCCD8+ T cells, CD19+ B cellsPER2, REVERBA-Enhancing effect by GCregulatory T cellsPER3, CRY1-Dampening effect by GCNK T cells, NK cells--

Conclusion

In patients with RA, we found a certain loss of circadian rhythms and the establishment of “inflammatory” rhythms. GC treatment in patients with RA resulted in three different types of effects on circadian rhythms at immune cell level: restoration, amplification, and attenuation. In conclusion, these findings provide new insights into the pathophysiology of circadian rhythms in RA that could be used to optimize diagnosis and treatment.

References

[1]Clocking in: chronobiology in rheumatoid arthritis.Buttgereit, Frank, et al. 2015, Nature Reviews Rheumatology, Vol. 11, pp. 349–356.

Acknowledgements

We thank all participants for their contribution. We thank our clinical study team: Manuela Jakstadt, Lisa Ehlers, Alexandra Damerau, Annamarie Lang, Moritz Pfeiffenberger, Gabriela May, and Pierre-Louis Krauß.

Disclosure of Interests

None declared.

AB0400 A SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS INTO THE SUCCESS RATE OF GLUCOCORTICOID DISCONTINUATION AFTER THEIR USE AS INITIAL BRIDGING THERAPY IN RHEUMATOID ARTHRITIS PATIENTS IN OBSERVATIONAL COHORTS AND CLINICAL TRIALS

Background

Glucocorticoids (GC) are widely used for the initial treatment of rheumatoid arthritis (RA), to induce rapid suppression of inflammation and clinical symptoms and thereby limit radiographic damage progression. There are concerns that GC use in the long term is associated with a dose and duration dependent risk of serious side effects. Therefore, international guidelines have recommended to start GC when initiating a csDMARD, but to discontinue GC as rapidly as clinically feasible, preferably within 3 months (bridging therapy). In contrast, due to the concerns of GC side effects, the ACR guidelines published in 2021 conditionally recommend to start csDMARD monotherapy without GC bridging therapy.

Objectives

We aim to evaluate the success rate of GC discontinuation after using temporary GC as part of initial therapy (‘bridging’) both in observational cohorts and clinical trials in newly diagnosed RA patients.

Methods

Systematic literature searches were conducted to identify observational cohorts (scoping search) and clinical trials (in-depth search) that included RA patients who were treated with initial GC bridging therapy. GC bridging was defined as oral or intramuscular GC treatment that was discontinued within one year, alongside conventional DMARD therapy. Patient percentages still or again using GC were considered to represent the reverse of successful discontinuation. Random-effects meta-analyses were performed stratified by time point.

Results

The literature search on observational cohort studies could not identify any study answering the research question, since it remained unclear which patients had received GC as part of the initial treatment. The literature search for clinical trials identified 7160 abstracts, resulting in 10 included studies, with varying type and dose of GC and varying tapering schedules (Table 1). Of these included studies, 4 reported sufficient data on GC discontinuation or GC use after the bridging phase. The pooled proportion of patients who were still using GC was 22% (95% Confidence Interval (CI) 8; 37, based on 4 trials) at 12 months and 10% at 24 months (95% CI -1; 22, based on 2 trials) (Figure 1). Thus, the vast majority had stopped GC. Heterogeneity was substantial (I2 ≥ 65%).

Table 1.

Overview of included clinical trials.

Study (publication year)Tapering schedule (mg/day)COBRA (1997)In 7 weeks to 7.5. Stop after 28 weeks.*BeSt (2005)In 7 weeks to 7.5. Stop in 8 weeks after week 28 if DAS persistently ≤2.4IDEA (2014)N.A.COBRA-light (2015)arm 1: in 7 weeks to 7.5 arm 2: in 9 weeks to 7.5 Stop after 32 weeks if DAS<1.6.IMPROVED (2014)In 7 weeks to 7.5. Stop after 20 weeks if DAS <1.6 at 4 months.ARCTIC (2016)In 7 weeks to 0 if DAS <1.6 and no swollen joints present.tREACH (2013)In 10 weeks to 0.*CareRA (2017)- in 7 weeks to 7.5, further tapered from week 28, stop after 34 weeks.- Classic- in 6 weeks to 5, further tapered from week 28, stop after 34 weeks.- Slim- in 6 weeks to 5, further tapered from week 28, stop after 34 weeks.- Avant gardeAll if DAS28(CRP) ≤3.2.Hua et al. (2020)Tapering after 4 months to 5, stop after 6 months.*NORD-STAR (2020) - arm 1A (oral prednisolone)In 9 weeks to 5. Stop after 9 months.*

DAS=disease activity score; mg=milligram; N.A.=not applicable.

*GC tapered and stopped according to protocol, not depending on disease activity score.

Conclusion

The success rate of GC discontinuation after bridging as part of initial treatment of RA has been described in a limited number of studies. Reports on observational cohorts did not answer the research question and in clinical trials reports, GC (dis)continuation data were also scarce. However, the available data show that GC can be discontinued successfully in a large majority of patients. The paucity of data also reveals that more efforts are needed to provide data towards identifying the optimal GC bridging and discontinuation strategy, combining Treatment to Target with Starting to Stop.

Acknowledgements

We would like to thank J.W. Schoones for his help and expertise in the systematic literature search.

Disclosure of Interests

Lotte van Ouwerkerk: None declared, Andriko Palmowski: None declared, Isabell Nevins: None declared, Frank Buttgereit Consultant of: Consultant of AstraZeneca, AbbVie, Grünenthal, Horizon Pharma, Pfizer, and Roche., Grant/research support from: Grant/research support from AbbVie, Horizon Pharma, Pfizer, and Roche., Patrick Verschueren Consultant of: Was consultant for ABBVIE, BMS, Celltrion, Eli Lilly, Galapagos, Gilead, Nordic Pharma, Pfizer and UCB., Employee of: Holds the Pfizer Chair Early Rheumatoid Arthritis Management at KU Leuven., Josef Smolen: None declared, Robert B.M. Landewé Shareholder of: Shareholder of: Director of Rheumatology Consultancy BV., Consultant of: Consultant of: Honoraria from AbbVie, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Eli-Lilly, Novartis, Pfizer, UCB Pharma., Hans Bijlsma Consultant of: Consultant for Galapagos, Lilly and Sun., Grant/research support from: Received study grants from AbbVie and Roche., Andreas Kerschbaumer: None declared, Rene Westhovens Consultant of: Was consultant for Celltrion, Galapagos and Gilead., Thomas Huizinga: None declared, Cornelia Allaart Grant/research support from: Received study grants for BeSt and IMPROVED from Centocor Inc. (now Janssen) and AbbVie, respectively., Sytske Anne Bergstra Grant/research support from: Received an ASPIRE grant from Pfizer.

AB1009 EXERCISE IS ASSOCIATED WITH HIGHER BONE MINERAL DENSITY IN PATIENTS WITH POLYMYALGIA RHEUMATICA AND VASCULITIDES

Background

Exercise is an effective non-pharmaceutical intervention for osteoporosis (OP). However, it has not yet been explicitly validated whether it is associated with bone mineral density (BMD) in patients suffering from polymyalgia rheumatica (PMR) and vasculitides.

Objectives

To assess whether exercise is associated with BMD in PMR and vasculitis patients.

Methods

We evaluated baseline visits of patients enrolled in the monocentric, prospective “Rh-GIOP” cohort. Patients were included when having PMR or any kind of vasculitis. Simple and multiple linear regression models with minimum T-score (lumbar spine or hip, whichever was lowest) as the dependant variable were constructed. A dose-response analysis (frequency of exercise per week) was conducted in patients who were doing any kind of exercise. In multiple regression, we adjusted for potential confounders associated with minimum T-scores in an analysis of the overall cohort (manuscript in preparation): age, sex, menopause, body mass index, bisphosphonate use, denosumab use, current glucocorticoid dose, proton-pump inhibitor use, history of vertebral fractures, health assessment questionnaire scores, alkaline phosphatase levels, and gamma-glutamyltransferase levels. Multiple imputation by chained equations was used to handle missing data.

Results

198 patients were included. The mean age was 68 ± 11 years, 68% were females, and the most common diseases were PMR (36%), giant cell arteritis (26%), and granulomatosis with polyangiitis (17%). The mean minimum T-score was -1.74 ± 0.9. Five patients had a disease duration of less than three months. In both unadjusted (Figure 1) and adjusted analysis, exercise was positively associated with minimum T-scores (unadjusted: β = 0.36; 97.5% CI 0.09 to 0.63; p = 0.01; adjusted: β = 0.30; 0.04 to 0.56; p = 0.02). In exercising patients, there was no association between frequency and minimum T-scores (p(ANOVA) = 0.66.

Conclusion

In PMR and vasculitis, exercise is positively associated with BMD. We adjusted for several covariates, including health assessment questionnaire scores, so it is unlikely that the association between exercise and BMD is only caused because generally healthier patients have a higher likelihood of exercising. However, we found no dose-response relationship by looking at exercise frequency. This is probably due to confounding caused by different kinds of exercises. E.g., weight-bearing exercise is thought to be more effective in elevating BMD. Furthermore, our analysis might have been underpowered (too few patients) to assess differences within the group of exercising patients. Our findings underpin the general advice given to most patients suffering from low bone mass or OP irrespective of their underlying disease, which is to start or to continue exercising within the scope of personal possibilities. Of note, this study is of cross-sectional nature and must be interpreted accordingly as residual confounding cannot be fully ruled out. We plan for the future longitudinal analyses.

Figure 1. Acknowledgements

Funding Rh-GIOP is supported by a joint funding from Amgen, Biogen, BMS, Chugai, Generic Assays, GSK, Hexal, Horizon Therapeutics, Lilly, Medac, Mundipharma, Novartis, Pfizer, Roche and Sanofi.

Disclosure of Interests

Andriko Palmowski: None declared, Edgar Wiebe Grant/research support from: Travel expenses from Medac, Sandra Hermann Paid instructor for: Lecture fees from AbbVie, Burkhard Muche Speakers bureau: consultancy or speaker fees and/or conference expenses from Amgen, Gilead, Galapagos, UCB and Stadapharm, Paid instructor for: consultancy or speaker fees and/or conference expenses from Amgen, Gilead, Galapagos, UCB and Stadapharm, Consultant of: consultancy or speaker fees and/or conference expenses from Amgen, Gilead, Galapagos, UCB and Stadapharm, Frank Buttgereit Speakers bureau: consultancy fees, honoraria and travel expenses from Abbvie, AstraZeneca, Grünenthal, Pfizer, and Roche, and grant support from Abbvie, Pfizer and Roche, Paid instructor for: consultancy fees, honoraria and travel expenses from Abbvie, AstraZeneca, Grünenthal, Pfizer, and Roche, and grant support from Abbvie, Pfizer and Roche, Consultant of: consultancy fees, honoraria and travel expenses from Abbvie, AstraZeneca, Grünenthal, Pfizer, and Roche, and grant support from Abbvie, Pfizer and Roche, Grant/research support from: consultancy fees, honoraria and travel expenses from Abbvie, AstraZeneca, Grünenthal, Pfizer, and Roche, and grant support from Abbvie, Pfizer and Roche

OP0263 FAVORABLE BALANCE OF BENEFIT AND HARM OF LONG-TERM, LOW-DOSE PREDNISOLONE ADDED TO STANDARD TREATMENT IN RHEUMATOID ARTHRITIS PATIENTS AGED 65+: THE PRAGMATIC, MULTICENTER, PLACEBO- CONTROLLED GLORIA TRIAL

Background

Low-dose glucocorticoid (GC) therapy is widely used in RA but the true balance of benefit and harm is still unknown.

Objectives

We studied the effects of prednisolone (5 mg/day, 2 years) in RA patients aged 65+, requiring adjustment of antirheumatic therapy (DAS28≥2.60).

Methods

Pragmatic double-blind placebo-controlled randomized trial; all co-treatments and changes therein were allowed during the trial except long-term open label GC; Ca/D supplementation was advised in all patients. Minimal exclusion criteria were tailored to seniors.

Harm outcome: the number of patients with ≥1 serious adverse event (SAE), or ≥1 ‘other adverse event of special interest’ (other AESI). Other AESI comprised any AE (except worsening of RA) causing study discontinuation, and GC-specific events (Table 1).

Table 1.

Adverse events of special interest (AESI).*

prednisolone (n=224)placebo (n=225)Events by protocol-defined categorySAEother AESISAEother AESI Infection261241691  Urinary tract449429  Pneumonia217213  Other20581049 Cardiovascular8260 Symptomatic fracture21146 New onset  Hypertension1407  Diabetes mellitus0201  Cataract0726  Glaucoma0103 Other†43433526Total8019463140

*AESI: Comprises serious adverse events (SAE) and other AESI, defined by protocol.

†‘Other’ other AESI: non-serious AE outside of the above predefined categories, but associated with premature discontinuation.

Benefit outcomes: improvement in disease activity (DAS28) and joint damage progression (Sharp/van der Heijde).

Longitudinal mixed models analyzed the data. Given prior knowledge we report one-sided 95% confidence limit (95%CL) and statistical tests, performed only for the main outcomes.

Results

We randomized 451 RA patients in 7 EU countries, 449 received the intervention; of these 63% prednisolone vs 61% placebo patients completed 2 years of follow up. Discontinuations were similar in both groups: for AE (14%) and active disease (4%); the remainder mostly for ‘trial fatigue’ and covid-related access issues (20%). Mean time on study drug was 19 (SD 8) months.

70% of patients were female, mean age was 72 (max 88) years, RA duration 11 years; 67% were RF+, 56% ACPA+, 96% had joint damage on radiographs: mean score 20, median 8. Mean DAS28 was 4.5. Most patients (79%) were on current DMARD treatment, including 14% on biologics; 47% had previously used GC, 14% changed DMARD therapy at baseline. Patients had mean 2.1 active comorbidities, and used median 7 drugs.

Benefit: Disease activity rapidly declined to stabilize after 1 year (Figure 1), and was lower on prednisolone (adjusted mean difference in DAS28 over 2 years: 0.37, 95%CL 0.23, p<0.0001). The contrast in early (3-month) response was larger in 331 patients adherent to protocol on stable treatment: mean difference in DAS28 0.62 (95%CL 0.44), more responders on prednisolone (Figure 1). Significant time-treatment interaction in secondary analyses suggested a decrease in contrast after the first year, most likely caused by significantly more changes in DMARD treatment on placebo. Joint damage progression over 2 years was significantly lower on prednisolone: mean 0.6 (SD 1.9) v 1.8 (6.4) score points on placebo, difference 1.2 (95%CL 0.2, p=0.02).

Harm: 60% prednisolone vs 49% placebo patients experienced the harm outcome: adjusted RR 1.24, 95%CL 1.04, p=0.02; number needed to harm 9.5 (Table 1). During the study 1 vs 2 patients died, and 3 vs 0 died within 5 months of discontinuation. Per 100 patient-years, AE totaled 278 in prednisolone vs 206 in placebo patients, and the difference was most marked for infections (Table 1); these were mostly mild or moderately severe. Other GC-specific AESI were rare without relevant differences.

Conclusion

Add-on low dose prednisolone has beneficial long-term effects on disease activity and damage progression in senior RA patients on standard treatment. The tradeoff is a 24% increase in patients with mostly mild to moderate AE, suggesting a favorable balance of benefit and harm.

Acknowledgements

Trial registration: NCT02585258 (clinicaltrials.gov).

The trial is part of a larger project funded by the European Union’s Horizon 2020 research and innovation program under grant agreement No. 634886.

Apart from the listed authors and centers, the GLORIA Trial Consortium comprises:

L.M. Middelink, Middelinc BV The Netherlands, Operational Lead;

V. Dekker, Amsterdam UMC, Vrije Universiteit, Financial Lead;

Partners:

Trial operations: N. van den Bulk, CR2O BV, The Netherlands;

Study Medication (Development, Manufacturing & Supply): R.M.A. Pinto,

Bluepharma – Indústria Farmacêutica, S.A., Portugal;

Data management: L. Doerwald, Linical Netherlands BV, The Netherlands; S. Manger, Department of Epidemiology & Data Science, Amsterdam UMC, Vrije Universiteit, The Netherlands.

Adherence monitoring: J. Redol, BeyonDevices LDA, Portugal;

Safety monitoring: K. Prinsen, Clinfidence BV, The Netherlands;

Patient partner: M. Scholte-Voshaar, Stichting Tools (Tools2Use), The Netherlands.

Investigators (other recruiting centers):

T.L.T.A. Jansen, VieCuri – location Venlo, The Netherlands;

C. Codreanu, Clinical Center for Rheumatic Diseases, Bucarest, Rumania;

R.M.Zandhuis-Mooij, MSc, Gelre Ziekenhuis, Apeldoorn, The Netherlands;

E. Molenaar, Groene Hart Ziekenhuis, Gouda, The Netherlands;

J.M. van Laar, UMC Utrecht, The Netherlands;

Y.P.M. Ruiterman, Haga Ziekenhuis, Den Haag, The Netherlands;

A.E.R.C.H. Boonen, MUMC, Maastricht, The Netherlands;

M. Micaelo, Instituto Português de Reumatologia, Lisboa, Portugal;

J. Costa, Hospital de Ponte Lima, Portugal;

M. Sieburg, Rheumatologische Facharztpraxis Magdeburg, Germany;

J.P.L. Spoorenberg, UMC Groningen, The Netherlands;

U. Prothmann, Knappschaftsklinikum Saar GbmH, Puettlingen, Germany;

M.J. Saavedra, Hospital de Santa Maria, Lisboa, Portugal;

I. Silva, Hospital de Egas Moniz, Lisboa, Portugal;

M.T. Nurmohamed, Reade, Amsterdam, The Netherlands;

J.W.G. Jacobs, UMC Utrecht, The Netherlands; and

S.W. Tas, Amsterdam UMC, University of Amsterdam, The Netherlands.

Scientific Advisory Committee:

J.W.J. Bijlsma, UMC Utrecht, The Netherlands;

R. Christensen, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark;

Y.M. Smulders, Amsterdam UMC, VU University, The Netherlands; and

S.H. Ralston, University of Edinburgh, Edinburgh, UK.

Radiographic assessment:

D.M.F.M. van der Heijde (Imaging Rheumatology BV, the Netherlands)

coordinated the reading of the hand and foot x-rays.

A.F. Marsman and W.F. Lems scored the spine X-rays.

Patient panel:

C. Rusthoven and M. Bakkers, The Netherlands

E. Frazão Mateus, and G. Mendes, Portugal

C. Elling-Audersch and D. Borucki, Germany

A. Cardone, Italy

P. Corduta and O. Constantinescu, Romania

P. Richards, United Kingdom

G. Aanerud, Norway

Disclosure of Interests

Maarten Boers Consultant of: Novartis, Linda Hartman: None declared, Daniela Opris-Belinski Consultant of: Abbvie, Pfizer, MSD, Novartis, Eli Lilly, Ewo Pharma, UCB, Reinhard Bos: None declared, Marc R Kok: None declared, José Antonio P. da Silva: None declared, Eduard N. Griep: None declared, Ruth Klaasen: None declared, Cornelia Allaart: None declared, Paul Baudoin: None declared, Hennie Raterman Consultant of: Abbvie, Pfizer, MSD, Novartis, Eli Lilly, Ewo Pharma, UCB, Zoltán Szekanecz: None declared, Frank Buttgereit Consultant of: Abbvie, AstraZeneca, Gruenenthal, Horizon Therapeutics, Mundipharma, Pfizer, Roche, Pavol MASARYK: None declared, Thomas Klausch: None declared, Sabrina Paolino: None declared, Annemarie M. Schilder Consultant of: Eli Lilly, Novartis, Genzyme, WIllem Lems Consultant of: Pfizer, Galapagos, Lilly, Amgen, UCB., Maurizio Cutolo: None declared

OP0270 TAPERING OF LONG-TERM, LOW-DOSE GLUCOCORTICOIDS IN SENIOR RHEUMATOID ARTHRITIS PATIENTS: FOLLOW-UP OF THE PRAGMATIC, MULTICENTRE, PLACEBO-CONTROLLED GLORIA TRIAL

Background

Guidelines suggest glucocorticoids (GC) should be used as bridge therapy in rheumatoid arthritis (RA), but many patients are treated chronically with low doses. The effects of withdrawal in such patients has not been studied extensively.

Objectives

To study disease activity score (DAS28), disease flares and signs of adrenal insufficiency after withdrawal of blinded trial medication (prednisolone 5 mg/day or placebo for 2 years).

Methods

The 2-year, double-blind GLORIA trial evaluated the long-term benefits and harms of low dose GC added to standard care (see main GLORIA trial abstract). Senior RA patients (≥ 65 years) were randomly assigned to prednisolone 5 mg/day or placebo.

After the final trial visit study medication was linearly tapered to zero in 3 months by adding a stop day every two weeks, and patients were reassessed. Those who successfully completed the trial and did not receive open-label GC during the 4 weeks after the final trial visit were included in this follow-up study.

The primary outcome was change in DAS28 at follow-up compared to the final trial visit. Secondary outcomes included the occurrence of disease flares (DAS28 increase > 0.6 or open-label GC between week 4 and 12 of the taper phase) and signs of adrenal insufficiency, assessed by 9 items selected from the 57-symptom list from the MDHAQ questionnaire (1) and hypotension (systolic RR < 90 or diastolic RR < 60). In a subset of patients from 3 Dutch centres, cortisol and ACTH were measured in spot serum samples during the follow-up visit.

Analysis of covariance assessed the change in DAS28. Linear regression and chi-square test were used for the remaining outcomes.

Results

278 participants completed the GLORIA study, 21 received GC within 4 weeks after the end of the trial, 58 had missing data, leaving 199 patients eligible for this study.

34 patients received open label GC after 4 weeks and were excluded for the primary analysis. In the remaining 165 patients (80 prednisolone, 85 placebo), mean (SD) DAS28 was higher on placebo: 3.14 (1.04) vs 2.92 (1.13) prednisolone at the final trial visit. After tapering, disease activity increased significantly (p=0.02) in the prednisolone group to 3.18 (1.20) but was stable in placebo (3.14). The difference in the increase of DAS28 between the groups was 0.21 (95%CI –0.05;0.47; p=0.11).

For signs of adrenal insufficiency, 33 out of 165 had missing data, leaving 60 in the prednisolone group and 72 in placebo (Table 1). Mean (SD) number of signs for prednisolone was 1.1 (1.1) versus 0.9 (1.3) for placebo at final trial visit and 0.8 (1.2) versus 0.8 (1.0) at follow-up. Difference in the change of the number of signs was –0.1 (95%CI –0.4;0.3; p=0.66).

Table 1.

Adrenal insufficiency signs and symptoms.

prednisolone (n=60)placebo(n=72)end of trialchange after 3 monthsend of trialchange after 3 monthsFatigue (unusual)15113–1Appetite loss5–144Muscle weakness7–26–2Dizziness32101Stomach pain3431Muscle pain19–619–1Nausea5–322Vomiting1001Diarrhoea5–23–2Hypotension*2–14–2Sum**1.1 (1.1)–0.2 (1.3)0.9 (1.3)0.0 (1.3)

* Systolic RR < 90 or diastolic RR < 60.

**Mean (SD)

No differences were seen in ACTH or cortisol levels: mean (SD) ACTH was 5.8 (4.1) in 23 prednisolone patients, and 5.1 (3.7) in 24 placebo patients; cortisol 296 (113) v 310 (166), cortisol/ACTH 67 (40) v 77 (54). Two prednisolone and one placebo patient had cortisol levels below 80. None developed clinical hypoadrenalism during further follow-up.

199 patients qualified for the disease flares sample, 99 prednisolone and 100 placebo; 44 patients flared on prednisolone tapering vs 31 on placebo, relative risk 1.43 (95%CI 0.99; 2.07; p=0.07).

Conclusion

Tapering prednisolone moderately increases disease activity to placebo levels (mean still at low disease activity levels) and numerically increases the risk of flare without any evidence of adrenal insufficiency. This suggests that withdrawal of low dose prednisolone is feasible after 2 years of administration.

References

[1]DeWalt DA et al. Clin Exp Rheumatol. 2004;22:453-61.

Acknowledgements

The GLORIA trial is registered at clinicaltrials.gov under NCT02585258.

The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‘’Personalizing Health and Care’’, grant agreement No 634886.

Disclosure of Interests

Abdullah Almayali: None declared, Maarten Boers Consultant of: Novartis, Linda Hartman: None declared, Daniela Opris-Belinski Consultant of: Abbvie, Pfizer, MSD, Novartis, Eli Lilly, Ewo Pharma, UCB, Reinhard Bos: None declared, Marc R Kok: None declared, José Antonio P. da Silva: None declared, Eduard N. Griep: None declared, Ruth Klaasen: None declared, Cornelia Allaart: None declared, Paul Baudoin: None declared, Hennie Raterman Consultant of: AbbVie, Amgen, Celgene, Roche, Sandoz, Sanofi Genzyme and UCB, Zoltán Szekanecz: None declared, Frank Buttgereit Consultant of: Abbvie, AstraZeneca, Gruenenthal, Horizon Therapeutics, Mundipharma, Pfizer, Roche, Pavol MASARYK: None declared, WIllem Lems Consultant of: Pfizer, Galapagos, Lilly, Amgen, UCB., Maurizio Cutolo: None declared, Marieke ter Wee: None declared

POS1402 COST-EFFECTIVENESS AND COST-UTILITY OF ADD-ON, LOW-DOSE PREDNISOLONE IN RA PATIENTS AGED 65+: THE PRAGMATIC, MULTICENTER, PLACEBO-CONTROLLED GLORIA TRIAL

Background

Rheumatoid arthritis (RA) is a disease with substantial impact on quality of life, healthcare and societal costs [1]. Current treatment strategies, especially biologic drugs, result in high costs [2]. Previous studies have already found that a combination treatment strategy of disease-modifying antirheumatic drug(s) with initially medium-to-high doses of prednisolone resulted in better effects and lower costs compared to the treatment strategies without prednisolone [3, 4]. However, to our knowledge the cost-effectiveness of low-dose glucocorticoids (GCs), and that of GC overall in established RA has not been examined separately.

Objectives

To evaluate the cost-effectiveness and cost-utility of low-dose prednisolone in RA patients aged 65+.

Methods

The economic evaluation was performed as part of the placebo-controlled GLORIA trial of RA patients aged 65+ with a disease activity score in 28 joints (DAS28) ≥2.60. Eligible patients were randomized to 2 years 5 mg/day prednisolone or placebo. Patients were recruited from 28 clinical centers in seven European countries. All co-treatment, except for chronic oral GC, was allowed.

The economic evaluation had a societal perspective with a time horizon of two years. Cost data were collected with questionnaires and from recorded events, and valued with unit prices of 2017. The primary effectiveness outcome was the DAS28. For cost-utility, quality-adjusted life years (QALYs) were estimated from the EuroQol-5 Dimension (EQ-5D) questionnaire.

Standard regression models were used to estimate incremental costs and effects between the treatment groups. Bootstrapping assessed the uncertainty around the average differences in costs and health outcomes.

Results

In total, 444 of 451 randomized patients were included in the modified-intention-to-treat analysis (see main GLORIA study abstract). Patients were on average 72 years and had median 4 active comorbidities at baseline. Mean total costs over 2 years were k€10.8 in the prednisolone group, k€0.4 (95% CI –3.7; 1.9) lower than in the placebo group. Total direct medical costs were k€0.5 (95% CI –4.0; 1.5) lower in the prednisolone group. The mean number of QALYs was similar in both groups (difference 0.02 [–0.03; 0.06] in favor of prednisolone). The DAS28 was 0.38 lower in the prednisolone group than in the placebo group (0.19;0.56).

The cost-effectiveness plane shows that the majority of the bootstrapped cost-effect pairs was situated in the southwest quadrant of the plane confirming the larger effects (i.e. decrease in DAS28) and non-significant lower costs in the prednisolone group (Figure 1). The cost-utility plane shows that the number of QALYs was similar for both groups and that the bootstrapped cost-utility pairs were slightly more located in the southeast quadrant confirming a very small increase in QALYs and slightly lower costs in the prednisolone group (Figure 1).

Conclusion

With greater effectiveness at non-significantly lower costs, low-dose, add-on prednisolone is cost-effective for RA compared to placebo over two years. QALYs were equal in both groups, most likely due to the impact of multiple comorbidities.

References

[1]Kobelt G. Elsevier. 2009;83-9.

[2]Souliotis K et al. PLoS One. 2019;14:e0226287.

[3]Ter Wee MM et al. RMD Open. 2017;3:e000502.

[4]Verhoeven AC et al. Br J Rheumatol. 1998;37:1102-9.

Acknowledgements

The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‘’Personalizing Health and Care’’, grant agreement No 634886.

Disclosure of Interests

Linda Hartman: None declared, Mohamed El Alili: None declared, Maurizio Cutolo: None declared, Daniela Opris-Belinski Speakers bureau: Abbvie, Pfizer, MSD, Novartis, Eli Lilly, Ewo Pharma, UCB, José Antonio P. da Silva: None declared, Zoltán Szekanecz: None declared, Frank Buttgereit Speakers bureau: Abbvie, AstraZeneca, Gruenenthal, Horizon Therapeutics, Mundipharma, Pfizer, Roche, Pavol MASARYK: None declared, Reinhard Bos: None declared, Marc R Kok: None declared, Sabrina Paolino: None declared, Veerle M. H. Coupé: None declared, WIllem Lems Speakers bureau: Pfizer, Galapagos, Lilly, Amgen, UCB, Maarten Boers Speakers bureau: BMS, Novartis, Pfizer

POS0225 FLUIDIC SHEAR STRESS REDUCES TNFΑ-MEDIATED CARTILAGE DAMAGE IN A 3D MODEL OF DEGENERATIVE JOINT DISEASE

Background

Pathomechanisms of degenerative joint diseases such as osteoarthritis (OA) ultimately result in the breakdown of cartilage tissue. To date, the exact underlying mechanisms of both cause and progression of OA remain unclear. Therefore, developing complex and long-lasting in vitro components of a human joint including cartilage, subchondral bone, synovial membrane and tendons that simulate the 3D architecture and the metabolic, humoral and cellular interplay of the joint components is needed to study the long-lasting course of OA pathogenesis. Beside the impact of metabolic components and 3D architecture, mechanical forces are well-known to be important modulators of joint health, while aberrant forces are primary etiological factors leading to cartilage degeneration.

Objectives

Here, we aimed to (i) develop a long-lasting human in vitro 3D cartilage model using alternated perfused cultivation and (ii) simulate TNFα-mediated cartilage degradation. As a mechanical force we used the perfusion-mediated fluid shear stress (FSS) to enhance chondrogenesis and mimic FSS during joint movement.

Methods

Human bone marrow-derived mesenchymal stromal cells (MSC) were used to develop an in vitro 3D cartilage model incubated in a bioreactor with a perfusion cycle that facilitates mechanical stimulation via FSS and daily sampling. Within the bioreactor, MSC mass cultures were subjected to FSS at 10 dyn/cm2 by medium circulation three times a day for 1.5 hours. The approach of using optimized FSS rate, cycles and cultivation period of 18 days for MSC mass cultures was compared to a non-perfused control based on cell viability (live-dead- and viability-assay), apoptosis (TUNEL-assay, caspase-3/7-activity, BCL2/BAX), metabolic activity (oxygen and glucose consumption, lactate production), chondrogenic gene expression (ACAN, COMP, COL2A1, COL1A1, COL2A1/COL1A1) and matrix metalloproteinase expression (MMP-1, -3, -13).

Results

Alternate perfused long-term cultivation at 10 dyn/cm2 did not affect cell survival; it rather reduced apoptosis, did not affect oxygen consumption but reduced glucose consumption and lactate production and enhanced chondrogenic gene expression with reduced MMP13 and COMP gene expression compared with non-perfused conditions. Mimicking pathophysiology of OA we stimulated the 3D cartilage model with 100 ng/mL TNFα for 6 hours under non-perfused and perfused long-term cultivation with FSS at 10 dyn/cm2 as a mechanical stimulus. Compared to untreated perfused conditions, TNFα stimulation (i) did not affect overall cell survival but enhanced apoptosis (demonstrating efficacy of stimulation), (ii) did not affect oxygen consumption and glycolysis, and (iii) enhanced COMP and MMP1 expression as markers of matrix protein turnover. In comparison to TNFα treated cells under non-perfused conditions, TNF stimulation under perfused conditions (i) did not affect cell survival but reduced apoptosis, (ii) did not affect oxygen consumption but reduced glucose consumption and lactate production as a measure of glycolysis, and (iii) reduced the expression of IL6 and soluble amounts of IL-6 but not of TNFA whereas soluble amounts of TNFα were enhanced. Furthermore, TNFα stimulation (iv) reduced the expression of matrix degrading enzymes but (v) enhanced anabolic chondrogenic matrix proteins on mRNA.

Conclusion

In a 3D model that mimics OA, FSS as a mechanical stimulus provides a metabolic “feel-good” niche that reduces chondrocyte apoptosis, metabolic activity, and matrix metalloproteinase expression, increases matrix protein expression and protects against TNFα-mediated cartilage degradation.

Acknowledgements

This project is funded by Sanofi-Aventis Deutschland GmbH.

Disclosure of Interests

Duc Ha Do Nguyen: None declared, Christina Lubahn: None declared, Thomas Leeuw Employee of: Thomas Leeuw is a Sanofi employee and may hold shares and/or stock options in the company., Frank Buttgereit: None declared, Timo Gaber: None declared, Alexandra Damerau: None declared

LB0006 SARILUMAB IN PATIENTS WITH RELAPSING POLYMYALGIA RHEUMATICA: A PHASE 3, MULTICENTER, RANDOMIZED, DOUBLE BLIND, PLACEBO CONTROLLED TRIAL (SAPHYR)

Background

Interleukin-6 (IL-6) is elevated in patients with active polymyalgia rheumatica (PMR) and is associated with disease activity, relapse and severity. Clinical trials with IL-6 receptor (IL-6R) inhibitors in PMR showed higher remission rates and reduced glucocorticoid (GC) use vs GC alone.1-4

Objectives

The SAPHYR study (NCT03600818) assessed the efficacy and safety of sarilumab (SAR), a fully human anti IL-6Rα monoclonal antibody, with a 14 week (wk) GC taper in patients with steroid resistant active PMR who flared on ≥7.5 mg/day prednisone or equivalent.

Methods

Patients were randomized (1:1) to 52 wks of treatment with SAR 200 mg every 2 wks (Q2W) + 14 wk GC tapered regimen (SAR arm) OR placebo Q2W + 52 wk GC tapered regimen (comparator arm). The primary endpoint was the proportion of patients achieving sustained remission at wk 52, defined as disease remission by wk 12, absence of disease flare, CRP normalization from wks 12 to 52 and adherence to the per protocol GC taper from wks 12 to 52.

Results

The study was terminated early due to protracted recruitment timelines during the COVID-19 pandemic, resulting in 118 of the intended 280 patients recruited between Oct 2018 and Jul 2020, and 117 were treated (SAR n=59, comparator n=58). The demographics were balanced; patients were primarily female, Caucasian, and a median age of ~70 years (Table 1). Overall, 78 patients completed the treatment (SAR n=42; comparator n=36). Primary reasons for treatment discontinuation were adverse events (AEs; SAR n=7, comparator n=4) and lack of efficacy (SAR n=4, comparator n=9). Sustained remission rate was significantly higher in the SAR arm vs the comparator arm (28.3% vs 10.3%; P=0.0193). Results of a sensitivity analysis excluding CRP from the sustained remission definition was consistent with the primary analysis (31.7% vs 13.8%; P=0.0280). All sustained remission components favored SAR (Figure 1). Patients in the SAR arm were 44% less likely to have a flare after achieving clinical remission vs the comparator arm (16.7% vs 29.3%; HR 0.56; 95% CI 0.35–0.90; P=0.0158). The comparator arm required more additional GCs vs the SAR arm, mainly due to PMR flare (median difference in actual and expected cumulative dose 199.5 mg vs 0.0 mg; P=0.0189). The cumulative GC toxicity index scores numerically favored SAR but the difference was not statistically significant. PMR activity scores improved in the SAR arm vs the comparator arm (LS mean -15.57 vs -10.27, nominal P=0.0002). Patient reported outcomes (eg, physical and mental health component scores, disability index, etc) favored SAR (Figure 1). Incidence of treatment-emergent AEs (TEAEs) was numerically higher in the SAR arm vs the comparator arm (94.9% vs 84.5%) and included neutropenia (15.3%) and arthralgia (15.3%) in the SAR arm, and insomnia (15.5%) in the comparator arm. Conversely, the frequency of serious AEs was higher in the comparator arm vs the SAR arm (20.7% vs 13.6%). No deaths were reported.

Table 1.

Demographics and baseline characteristics

ParameterSAR + 14 wk GC taperPlacebo + 52 wk GC taper(n=60)(n=58)Age, median years (range)69 (51–88)70 (52–88)Sex (female), n (%)45 (75.0)37 (63.8)Race, n (%) Caucasian50 (83.3)48 (82.8) Asian1 (1.7)2 (3.4) Not reported9 (15.0)8 (13.8)PMR duration (diagnosis date to baseline),* median days (range)292 (78–3992)310 (66–2784)Any prior disease modifying anti rheumatic drugs, n (%) Methotrexate5 (8.3)10 (17.2) Leflunomide2 (3.3)1 (1.7) Azathioprine01 (1.7) Hydroxychloroquine1 (1.7)1 (1.7) Adalimumab1 (1.7)0 Tocilizumab01 (1.7)CRP (mg/L), median (range)6.8 (0.5–38.2)5.7 (0.1–62.3)Erythrocyte sedimentation rate (mm/h), median (range)25.0 (2.0–115.0)22.0 (5.0–85.0)

*SAR n = 54; comparator n= 50.

Conclusion

SAR + 14 wk GC taper demonstrated significant efficacy vs the comparator arm in steroid refractory PMR patients, including clinically meaningful improvement in quality of life. Safety was consistent with the known safety profile of SAR.

References

[1]Mori 2016;

[2]Akiyama 2020;

[3]Lally 2016,

[4]Devauchelle Pensec 2015

Acknowledgements

Medical writing support was provided by Vijay Kadasi of Sanofi and funded by Sanofi.

Disclosure of Interests

Bhaskar Dasgupta Consultant of: Sanofi, Roche Chugai, Speakers bureau: Roche Chugai, Cipla, Grant/research support from: Sanofi, Roche, Abbvie, Sebastian Unizony Consultant of: Sanofi, Kiniksa, Janssen, Grant/research support from: Genentech, Kenneth J Warrington Paid instructor for: Chemocentryx, Grant/research support from: Eli Lilly, Kiniksa, GSK, Jennifer Sloane Lazar Employee of: Sanofi, Angeliki Giannelou Shareholder of: Regeneron, Employee of: Regeneron, Chad Nivens Shareholder of: Regeneron, Employee of: Regeneron, Bolanle Akinlade Shareholder of: Regeneron, Employee of: Regeneron, Wanling Wong Employee of: Sanofi, Yong Lin Employee of: Sanofi, Frank Buttgereit Consultant of: Sanofi, Horizon Pharma, Roche, Galapagos, Abbvie, Novartis, Grant/research support from: Sanofi, Horizon Pharma, Roche, Galapagos, Abbvie, Novartis, Valerie Devauchelle-Pensec: None declared, Andrea Rubbert-Roth Consultant of: Sanofi, Speakers bureau: Sanofi, Roche, Robert Spiera Consultant of: Sanofi, GSK, Novartis, Chemocentryx, Roche-Genetech, Abbvie, Vera, Grant/research support from: GSK, Chemocentryx, Corbus, Inflarx, Boehringer Ingelheim

POS1410 DEVELOPMENT OF PREDICTION MODELS FOR SENIOR PATIENTS WITH RHEUMATOID ARTHRITIS AND COMORBIDITIES TREATED WITH CHRONIC LOW-DOSE GLUCOCORTICOIDS IN THE GLORIA TRIAL

Background

Rheumatoid arthritis (RA) is a systemic, inflammatory disease primarily located in the joints resulting in pain, joint damage, functional disability and reduced quality of life. Treatment of RA is essential to prevent these outcomes, but the treatment itself may also result in adverse events and comorbidity [1]. Although many investigators are working on personalized medicine [2], better models to predict harm and benefit from a certain drug need to be developed before they can be used in daily clinical practice [3].

Objectives

To develop prediction models for individual patient harm and benefit outcomes in senior patients with RA and comorbidities treated with chronic low-dose glucocorticoid therapy or placebo.

Methods

In the GLORIA trial 451 RA patients aged 65+ were randomized to 2 years 5 mg/day prednisolone or placebo. Eight prediction models were developed from the dataset in a stepwise procedure. In preparation, to limit excessive statistical testing and false positive results, possible predictors were grouped into five predictor sets based on prior knowledge (Table 1). The first set of four models disregarded study treatment and examined general predictive factors. The second set of four models was similar but examined the additional role of study treatment, as main factor and as interaction factor with other predictive variables. In each set two models focused on harm (1: occurrence of ≥1 adverse event of special interest (AESI); 2: number of AESIs per year) and two on benefit (3: early clinical response–disease activity; 4: lack of joint damage progression). AESI comprised all serious adverse events, events leading to discontinuation of study treatment, and events related to glucocorticoid exposure (see main GLORIA study abstract). Linear and logistic multivariable regression methods with backward selection were used to develop the models. The final models were assessed and internally validated with bootstrapping techniques, and their performance was evaluated with model fit and discrimination measures.

Table 1.

Predictor sets.

Personal factorsDisease factorsComorbiditiesAgeDAS28Active comorbidity: cont, dich,SexRA durationGC-relatedEducationRFPrior comorbidity: cont, dich,SmokingAnti-CCPGC-relatedAlcoholDamage (cont, dich)# comorbidity medicationsBMICoping RAJoint surgeryBlood pressureImpact RA# patient symptomsMedicationHealth and daily functioning# concomitant medicationsHAQPrevious use DMARD, bDMARD, GCQoLCurrent use bDMARDVAS healthAdherenceSF36 physical, mentalSwitch antirheumatic drugs

cont=continuous; dich=dichotomous; GC=glucocorticoid.

Results

Study treatment (i.e. prednisolone) was highly predictive as a main factor in models 5-8, increasing the risk of both benefit and harm. In addition, a few additional variables were slightly (but not relevantly) predictive for the outcome in one of the models (Figure 1). Their association was much weaker than that of study treatment. In three instances, prednisolone interacted with another predictive factor (see Figure 1). The quality of the prediction models was sufficient, the performance low to moderate: explained variance: 12-15%, AUC 0.67-0.69.

Conclusion

Baseline factors are not helpful to select senior RA patients for treatment with low-dose prednisolone given their low power to predict the chance of benefit or harm.

References

[1]Smolen JS et al. Lancet. 2016;388(10055):2023-38.

[2]Huizinga TWJ. J Intern Med. 2015;277(2):178-87.

[3]De Punder YMRVR et al. Journal of Rheumatology. 2015;42(3):391-7.

Acknowledgements

The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‘’Personalizing Health and Care’’, grant agreement No 634886.

Disclosure of Interests

Linda Hartman: None declared, José Antonio P. da Silva: None declared, Frank Buttgereit Speakers bureau: Abbvie, AstraZeneca, Gruenenthal, Horizon Therapeutics, Mundipharma, Pfizer, Roche, Maurizio Cutolo: None declared, Daniela Opris-Belinski Speakers bureau: Abbvie, Pfizer, MSD, Novartis, Eli Lilly, Ewo Pharma, UCB, Zoltán Szekanecz: None declared, Pavol MASARYK: None declared, Marieke Voshaar: None declared, Martijn W. Heijmans: None declared, WIllem Lems Speakers bureau: Pfizer, Galapagos, Lilly, Amgen, UCB, Désirée van der Heijde: None declared, Maarten Boers Speakers bureau: BMS, Novartis, Pfizer

AB0040 PYRUVATE DEHYDROGENASE KINASES AS A POTENTIAL TARGET IN THE TREATMENT OF OSTEOARTHRITIS TO UNLEASH THE METABOLIC FLOW?

Background:

While osteoarthritis (OA) is the most common joint disease worldwide, rheumatoid arthritis (RA) represents the most common type of autoimmune arthritis. In both diseases, fibroblast-like synoviocytes (FLS), which maintain the structural and dynamic integrity of the joint, have been identified as key drivers of cartilage degradation. FLS can be divided into two major populations. The destructive phenotype which is restricted to the THY1- FLS of the synovial lining promotes bone erosion, while THY1+ FLS of the sublining layer drives synovitis. The FLS phenotype is shaped by glucose metabolism, which promotes disease progression in patients with synovitis. However, profound knowledge about the contribution of FLS to pathogenic mechanisms in cartilage degradation is limited.

Objectives:

Here, we present the phenotypic features of FLS obtained from patients with OA (OA-FLS) compared to bone marrow-derived mesenchymal stromal cells (MSC) on transcriptomic, proteomic and metabolic levels with the aims (i) to identify novel targets for the development of disease-modifying osteoarthritis drugs and (ii) to distinguish both cell types.

Methods:

To this end, we comprehensively compared human bone marrow-derived MSC with OA-FLS isolated from human knee joint sections. MSC and OA-FLS were characterized in detail according to their multipotency, surface marker pattern, cell viability, proliferation rate, morphology and expression of fibroblast- and metabolic-related markers using flow cytometry, immunofluorescence and SeahorseTM. More in-depth, selected gene and protein expression patterns were analyzed using qPCR and mass spectrometry.

Results:

We observed a similar phenotype of OA-FLS and MSC with regard to the minimal criteria that define a MSC phenotype. In-depth comparison of OA-FLS and MSC on proteome level revealed 598 differentially expressed proteins. We observed no differences in the expression of classical fibroblast markers such as vimentin, tenascin C and decorin as confirmed on RNA level. Remarkably, fibronectin, which is mainly produced by fibroblasts, is significantly lower expressed at both protein and RNA levels in OA-FLS together with collagen type 1 and CD106. Conversely, CD9, CD54 and fibroblast-specific protein-1 were expressed significantly higher in FLS at both levels, while hyaluronan synthase 1-3 remained unchanged. Of note, in terms of mitochondrial function, human OA-FLS show a significantly lower basal respiration and ATP production than MSC, but a comparable spare respiratory capacity and cellular mitochondrial dehydrogenase activity (NADH amount) per cell. Additionally, we identified the pyruvate dehydrogenase kinase (PDK) 3 to be highly expressed in OA-FLS, while the expression of mitochondrial ATP synthase subunits, electron transport chain complexes and glycolytic enzymes was comparable with MSC. Finally, inhibition of PDK by using DCA resulted in a significant increase in oxygen consumption rate and ATP production in OA-FLS. Thus, our data newly suggest, that PDKs may play a crucial role in the pathogenesis of OA and possibly RA.

Conclusion:

Our data provide evidence that, although the classical fibroblast markers do not discriminate between MSC and FLS, the latter demonstrate a significantly higher expression of PDKs, known to inhibit the pyruvate entry into the TCA cycle which finally limits the mitochondrial ATP production. Therefore, shifting the metabolism of FLS from glycolysis to mitochondrial respiration via inhibition of PDKs might be a novel approach in OA for the development of disease-modifying osteoarthritis drugs in order to unleash the metabolic flow.

Disclosure of Interests:

None declared

OP0312 METABOLIC REPROGRAMMING IN MEMORY CD4+ T CELLS IS ASSOCIATED WITH REACTIVE OXYGEN INDUCED IMMUNE CELL DYSFUNCTION DURING AGING

Background:

Inflamm-aging is a chronic, sterile, low-grade inflammatory status, characterized by an increase of proinflammatory cytokines which participate in the development of most age-related diseases such as cancer, Alzheimer’s disease, type 2 diabetes mellitus, stroke, cardiovascular diseases, and rheumatoid arthritis (RA). As cellular metabolism modulates T cell function, it can be assumed that metabolic changes accompany the differentiation of memory CD4+ T cells into senescent CD4+ T cell and contribute to memory CD4+ T cells dysfunction during aging.

Objectives:

Therefore, we hypothesized that metabolic reprograming in memory CD4+ T cells might represent an essential factor promoting immune cell dysfunction during aging, thereby fuelling to the pathogenesis of age-related diseases including RA

Methods:

To this end, we analysed memory CD4+ T cells isolated from PBMCs of young donors (20-32 years) and old donors (52-67 years) by using MACSTM technology. Ex vivo memory CD4+ T cells were analysed by SeahorseTM Technology to determine proton efflux rate (PER) as a measure of glycolysis (glycPER) and oxygen consumption rate (OCR) as a measure of mitochondrial respiration (mitoOCR). Cytokine expression and secretion was measured by flow cytometry and multiplex assay with and without Mitotempo an inhibitor of reactive oxygen species (ROS). Finally, TCR-stimulated memory CD4+ T cell proliferation was determined using CSFE and Ki-67 after 3 days and 4 days by flow cytometry. ROS and mitochondrial activity were analysed after 24 h using DCF-DA and CellROX Deep Red and Mitotracker by flow cytometry.

Results:

In a quiescent state, memory CD4+ T cells from elderly individuals demonstrated a decrease in basal glycolysis and compensatory glycolysis, and an increase in the ratio of basal mitochondrial oxygen consumption rate (mitoOCR) to glycolytic proton efflux rate (glycoPER) while their mitochondrial profile was equivalent to that of young donors while the amount of mitochondria was higher with no increase in steady-state ATP level. In this line and in comparison to the younger reference group, memory CD4+ T cells from aged donors presented a greater spare respiratory capacity after TCR-activation and a marked increase in intracellular ROS production. Interestingly, we did not observe an impact of aging on memory CD4+ T cell proliferation as determined by CFSE and Ki-67. Although the capacity of intracellular cytokine expression did not differ between the compared groups, the levels of secreted IFN-γ, IP-10, IL-6, IL-9, and MCAF were significantly higher in the supernatants of memory CD4+ T cells taken from aged donors but were sensitive to ROS inhibition. .

Conclusion:

These findings suggest that metabolic reprogramming in human memory CD4+ T cells during aging results in an increased expression of proinflammatory cytokines as a result of ROS production and mitochondrial dysfunction. This process may culminate in T cell dysfunction and thus contribute to the pathogenesis of inflamm-aging and the development of age-related diseases such as rheumatoid arthritis (RA).

Disclosure of Interests:

None declared.

OP0115 EFFICACY AND SAFETY OF ABBV-3373, A NOVEL ANTI-TNF GLUCOCORTICOID RECEPTOR MODULATOR ANTIBODY DRUG CONJUGATE, IN PATIENTS WITH MODERATE TO SEVERE RHEUMATOID ARTHRITIS DESPITE METHOTREXATE THERAPY: A PHASE 2A PROOF OF CONCEPT STUDY

Background:

ABBV-3373 is a novel antibody drug conjugate composed of adalimumab (ADA) linked to a proprietary and highly potent glucocorticoid receptor modulator (the anti-inflammatory payload) currently evaluated for the treatment of rheumatoid arthritis (RA).

Objectives:

To assess the efficacy and safety of ABBV-3373 vs ADA in RA patients (pts).

Methods:

This was a 24-week (wk) randomized, double-blind, double-dummy, active-controlled Phase 2a study of intravenously (IV)-administered ABBV-3373 100 mg (for 12 wks followed by placebo [PBO] for 12 wks) vs subcutaneous injections of ADA 80 mg every other wk (for 24 wks) in pts on background methotrexate. The primary endpoint was the change from baseline (BL) in DAS28(CRP) at Wk 12. Pre-planned statistical methods incorporating pre-specified historical ADA data both alone (pre-specified success criterion, 2-sided P ≤0.1) and supplemented with in-trial ADA data (pre-specified success criterion, probability >95%) were used to achieve adequate statistical power with a reduced trial size. Assay sensitivity was evaluated through construction of a synthetic PBO arm by propensity score matching, using individual pt-level PBO data from 3 recent sponsor-run trials of similar populations and trial settings. Secondary endpoints at Wk 12 included 1) mean change from BL in CDAI, SDAI, DAS28(ESR), HAQ-DI; 2) proportion of pts achieving DAS28(CRP)≤3.2, ACR20/50/70 responses, HAQ-DI≤-0.22. Continuous and categorical efficacy variables were analyzed using mixed effect model repeated measurements and Cochran-Mantel-Haenszel test, respectively; non-responder imputation was applied to missing categorical data. Treatment-emergent adverse events were summarized through Wk 12.

Results:

A total of 48 pts were randomized and treated (ABBV-3373: 31; ADA: 17); 46 pts (96%) completed 12 wks of study treatment. BL demographics and disease characteristics were indicative of established RA and similar among the 2 treatment arms and the synthetic PBO arm. ABBV-3373 demonstrated significant improvement in mean DAS28(CRP) at Wk 12 vs the pre-specified historical ADA (-2.65 vs -2.13; P=0.022) and numerically greater improvement vs the combined in-trial and historical ADA arm (-2.65 vs -2.29; probability 90%; Figure). Comparable improvements in disease activity and targets were observed for ABBV-3373 and in-trial ADA. Assay sensitivity was supported by the fact that both ABBV-3373 and ADA arms were superior to synthetic PBO (P<0.001). For secondary endpoints, greater efficacy was observed with ABBV-3373 vs historical ADA; ABBV-3373 was predicted with 79-99% probability to be better than ADA based on the combined in-trial and historical ADA data. 2 serious infections were reported with ABBV-3373 (pneumonia, upper respiratory tract infection) and none with ADA through Wk 12 (Table). 1 event of anaphylactic shock reaction was reported with ABBV-3373. After increasing the duration of IV administration from 3 min to 15-30 min, no similar events were observed.

Table 1.

Treatment Emergent Adverse Events up to Week 12

Event, n (%)ADA(N = 17)ABBV-3373(N = 31)Adverse event (AE)12 (70.6)11 (35.5)AE with reasonable possibility of being drug related$3 (17.6)2 (6.5)Severe AE01 (3.2)Serious AE04 (12.9) #AE leading to Discontinuation of Study Drug1 (5.9)1 (3.2)Serious infections02 (6.5)Opportunistic infection excluding Tuberculosis00Allergic Reactions Including Hypersensitivity, Angioedema, and Anaphylaxis2 (11.8) &1 (3.2) ^Systemic glucocorticoid events00All deaths00

$As assessed by investigator. #Serious AEs: 1 non-cardiac chest pain, 1 pneumonia, 1 upper respiratory tract disease and 1 anaphylactic shock. &1 Type I hypersensitivity, 1 Pruritus ^1 Anaphylactic shock

Conclusion:

These data demonstrate the clinical efficacy of ABBV-3373 and its potential to provide improved outcomes for RA pts compared to ADA. The safety profile of ABBV-3373 was generally similar to ADA.

Acknowledgements:

AbbVie and the authors we thank the patients, trial sites, and investigators who participated in this clinical trial. AbbVie, Inc was the trial sponsor, contributed to trial design, data collection, analysis & interpretation, and to writing, reviewing, and approval of final version. No honoraria or payments were made for authorship. The authors thank Yang Yang of AbbVie Inc for supporting the statistical analysis and data reporting. Medical writing support was provided by Ramona Vladea, PhD of AbbVie, Inc.

Disclosure of Interests:

Frank Buttgereit Consultant of: AstraZeneca, AbbVie, Grünenthal, Horizon Pharma, Pfizer, and Roche, Grant/research support from: AbbVie, Horizon Pharma, Pfizer, and Roche, Jacob Aelion Grant/research support from: AbbVie, Amgen, AstraZeneca, BMS, Celgene, Eli Lilly, Galapagos/Gilead, Genentech, GlaxoSmithKline, Horizon, Janssen, Mallinckrodt, Nektar, Nichi-Iko, Novartis, Pfizer, Regeneron, Roche, Sanofi-Aventis, Selecta, UCB, Bernadette Rojkovich: None declared, Anna Zubrzycka-Sienkiewicz Consultant of: Astellas and Roche, Grant/research support from: AbbVie, Astellas, Galapagos NV, Gilead Sciences, Janssen, Lilly, Mabion, Pfizer, Roche, and UCB SA, Timothy Radstake Shareholder of: AbbVie, Employee of: AbbVie, Su Chen Shareholder of: AbbVie, Employee of: AbbVie, Dilek Arikan Shareholder of: AbbVie, Employee of: AbbVie, Hartmut Kupper Shareholder of: AbbVie, Employee of: AbbVie, Howard Amital Consultant of: Abbvie, Janssen, Novartis, Roche, Perrigo, Pfizer, Neopharm, Elly Lilly, Gilead, Sanofi, Teva and Rafa, Grant/research support from: Yansen, Pfizer

AB0160 HIGH NUMBER OF CONCOMITANT MEDICATIONS AND COMORBIDITIES AT BASELINE IN THE GLUCOCORTICOID LOW-DOSE OUTCOME IN RHEUMATOID ARTHRITIS (GLORIA) STUDY: AN OLDER POPULATION WITH RHEUMATOID ARTHRITIS

Background:

Treatment with low-dose glucocorticoids (GCs) (≤7.5 mg prednisolone) in combination with standard care is highly effective in rheumatoid arthritis (RA), but despite 70 years of clinical experience, evidence-based information on its balance of benefit and harm is incomplete. This leads to an ongoing debate, with under- and over-use of GCs as result. The GLORIA pragmatic trial was developed to assess harm, benefit and costs of low-dose GCs added to the standard treatment of older RA patients.

Objectives:

The objective of this abstract is to document the baseline status and frequency of comorbid conditions in the GLORIA study population. The results of the unblinded data will be submitted as late-breaking abstract.

Methods:

This double-blind, randomized, placebo-controlled, multicenter trial (1) was open for patients with RA according to the 1987 or 2010 (2) criteria, age ≥65 years, and disease activity score of 28 joints (DAS28) of ≥2.6. Patients were recruited from rheumatology clinics in Germany, Hungary, Italy, The Netherlands, Portugal, Romania and Slovakia. Eligible patients were randomized to two years of treatment with daily 5 mg prednisolone or matching placebo. All other medication was allowed, except for GCs. The presented data are blinded because the database is not closed yet.

Results:

The population consists of 451 patients with mean disease duration 10.6 (Q1-Q3: 3-15) years. The majority (70%) is female, mean age is 72.5 (Q1-Q3: 68-76, range: 65-88) years, 66% were positive for rheumatoid factor and 56% for ACPA. Patients had a mean of 4.3 (SD 2.8) comorbidities besides RA (3.4 active) and therefore used multiple concomitant medications (3.9 (SD 3.4)) (Table 1). The most common comorbidities (provisional data of 161 patients with complete coding) in this older population are: vascular disorders (58%), musculoskeletal and connective tissue disorders (57%) and a history of surgical and medical procedures (45%). Patients were most frequently on beta blocking agents (22%, mainly metoprolol) and HMG CoA reductase inhibitors (20%, mainly simvastatin). Most patients also have an extensive history of anti-rheumatic treatment. At the start of the trial most patients (82%) were on cDMARD treatment; 15% were on bDMARDs/tsDMARDs. Almost half of the patients previously had been treated with GCs, with a mean duration of 3.4 years and a mean last dose of 4.6 mg/day.

Conclusion:

The baseline data shows that we have an older study population who have relatively many other comorbidities next to RA and who are almost all treated with multiple concomitant medications in addition to the study medication. Therefore, we expect to report a high adverse event rate. Research among older patients is urgently needed, but the frailty of this population as represented by the multiple comorbidities and concomitant medications have to be taken into account in the analyses and interpretation of the results.

References:

[1]Hartman L, Rasch LA, Klausch T, Bijlsma HWJ, Christensen R, Smulders YM, et al. Harm, benefit and costs associated with low-dose glucocorticoids added to the treatment strategies for rheumatoid arthritis in elderly patients (GLORIA trial): study protocol for a randomised controlled trial. Trials. 2018;19:67.

[2]Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO, et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010;62:2569-81.

Table 1.

Comorbidities and concomitant medications at baseline in the GLORIA trial.

MeanSDRangeComorbidities 4.32.8 0-15 Active 3.4 Past 1.9Concomitant medications (count) 3.93.4 0-15 Beta blocking agents (%)22 HMG CoA reductase inhibitors (%)20 Platelet aggregation inhibitors (%)16 ACE inhibitors (%)12 Angiotensin II antagonists (%)11DAS28 4.521.05DAS28CRP 4.060.97HAQ (0-3) 1.20.7RA treatmentCurrent (%)Previous (%) cDMARD8492 bDMARD/tsDMARD1522 NSAID5129 Glucocorticoids 049

Acknowledgements:

The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‘’Personalizing Health and Care’’, grant agreement No 634886.

Disclosure of Interests:

None declared

POS0654 IMPACT OF CONCOMITANT GLUCOCORTICOIDS ON THE CLINICAL EFFICACY AND SAFETY OF UPADACITINIB IN PATIENTS WITH RHEUMATOID ARTHRITIS: AN AD HOC ANALYSIS OF DATA FROM THREE PHASE 3 STUDIES

Background:

Glucocorticoid (GC) therapy has strong anti-inflammatory effects and helps slow radiographic progression in RA1; however, GCs can be associated with adverse events (AEs) such as infection, especially with long-term use and higher doses.

Objectives:

To evaluate the impact of baseline GCs on the efficacy and safety of upadacitinib (UPA) with or without concomitant conventional synthetic DMARDs (csDMARDs).

Methods:

In this ad hoc analysis of three Phase 3 studies, patients with inadequate response to MTX (MTX-IR) receiving UPA 15 mg once daily (QD) or placebo (PBO) + csDMARDs in SELECT-NEXT, and MTX-IR/MTX-naïve patients receiving UPA 15 mg QD monotherapy or MTX monotherapy in SELECT-MONOTHERAPY/SELECT-EARLY, respectively, were included. Efficacy outcomes, including measures of remission and low disease activity (LDA) determined by DAS in 28 joints using CRP (DAS28[CRP]; <2.6/≤3.2) and Clinical Disease Activity Index (CDAI; ≤2.8/≤10), were assessed and stratified by baseline GC use. Patients were permitted to receive oral GCs ≤10 mg/day (prednisone equivalent) at baseline with no adjustment permitted until Week 24/26/48. Safety was reported as number and proportion of patients with AEs. Data were analyzed descriptively with no statistical comparisons between groups or doses.

Results:

Of 1,506 patients included in the analysis, 737 (48.9%) were receiving baseline GCs (mean dose 6.2 mg/day). Baseline characteristics were broadly similar across treatment groups; SELECT-EARLY, which enrolled MTX-naïve patients, generally had the shortest duration of RA and higher CRP levels. Across UPA treatment groups, concomitant GCs generally did not influence the proportions of patients achieving remission (Figure 1). In SELECT-NEXT, clinical responses with UPA 15 mg in combination with csDMARDs were similar irrespective of concomitant GC use (Figure 1). Within SELECT-MONOTHERAPY, responses in patients receiving UPA 15 mg without concomitant csDMARDs or GCs were higher than those in patients receiving MTX alone, but were numerically lower than in those receiving UPA 15 mg with GCs (Figure 1). However, this was not observed within SELECT-EARLY, where clinical responses in patients receiving UPA 15 mg monotherapy without GCs were higher than in those patients receiving UPA 15 mg with GCs for both DAS28(CRP) <2.6 (40.6% vs 29.9%, respectively) and CDAI ≤2.8 (20.0% vs 11.6%, respectively) (Figure 1). A similar trend was observed for LDA. Serious AEs, AEs leading to discontinuation, and AEs of special interest, including infections (such as herpes zoster), were broadly similar in the UPA groups irrespective of concomitant GC use (table of safety data will be presented).

Conclusion:

UPA 15 mg in combination with csDMARDs or as monotherapy was effective in achieving remission and LDA, irrespective of concomitant GC use. Safety of UPA, including incidence of infection, appeared largely unaffected by concomitant GC use.

References:

[1]Kirwan JR, et al. Cochrane Database Syst Rev 2007;1:CD006356.

Acknowledgements:

AbbVie funded this study and participated in the study design, research, analysis, data collection, interpretation of data, reviewing, and approval of the publication. All authors had access to relevant data and participated in the drafting, review, and approval of this publication. No honoraria or payments were made for authorship. Medical writing assistance was provided by Frances Smith, PhD, of 2 the Nth, which was funded by AbbVie.

Disclosure of Interests:

Bernard Combe Speakers bureau: AbbVie, Eli Lilly, Gilead, Janssen, Merck, Novartis, Pfizer, Roche-Chugai, Sanofi, and UCB Pharma, Consultant of: AbbVie, Eli Lilly, Gilead, Janssen, Merck, Novartis, Pfizer, Roche-Chugai, Sanofi, and UCB Pharma, Frank Buttgereit Speakers bureau: AbbVie, Eli Lilly, Pfizer, and Roche, Andrew Ostor Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Gilead, Janssen, Novartis, Paradigm, Pfizer, Roche, and UCB Pharma., Ricardo Xavier Speakers bureau: AbbVie, Eli Lilly, Janssen, Novartis, Pfizer, Roche, and UCB Pharma, Consultant of: AbbVie, Eli Lilly, Janssen, Novartis, Pfizer, Roche, and UCB Pharma, Alain Saraux Speakers bureau: AbbVie, Bristol-Myers Squibb, Chugai, Eli Lilly, Nordic, Sanofi, and UCB Pharma, Consultant of: AbbVie, Bristol-Myers Squibb, Chugai, Eli Lilly, Nordic, Sanofi, and UCB Pharma, Capucine DARIDON Shareholder of: AbbVie, Employee of: AbbVie, Kirsten Famulla Shareholder of: AbbVie, Employee of: AbbVie, Yanna Song Shareholder of: AbbVie, Employee of: AbbVie, Ivan Lagunes-Galindo Shareholder of: AbbVie, Employee of: AbbVie, Gerd Rüdiger Burmester Speakers bureau: AbbVie, Eli Lilly, Gilead, Janssen, Merck, Pfizer, Roche, and UCB Pharma, Consultant of: AbbVie, Eli Lilly, Gilead, Janssen, Merck, Pfizer, Roche, and UCB Pharma

POS0665 TRAJECTORIES OF GLUCOCORTICOID-THERAPY IN EARLY RHEUMATOID ARTHRITIS: FIRST RESULTS OF A SCOPING SYSTEMATIC REVIEW AND META-ANALYSIS OF OBSERVATIONAL COHORT STUDIES

Background:

Glucocorticoids (GCs) are regularly used as a bridging therapy in early rheumatoid arthritis (eRA). As long-term treatment, especially at higher dosages, may lead to undesirable adverse events, GCs should be tapered as rapidly as clinically feasible.

Objectives:

To assess real-world trajectories of GC-therapy initiated in patients with eRA and in methotrexate-naïve RA patients.

Methods:

We conducted a scoping search in MEDLINE (via PubMed) to find articles (years 2005 – 2020) reporting on eRA (or methotrexate-naïve RA) patients from observational cohorts who start or take GCs at baseline. Articles had to describe either dosages or proportions of patients who took GCs or were able to taper GCs at two (minimum) pre-specified time points. The articles were screened by one reviewer (AP). Random-effects meta-analyses pooled results per outcome and time point if ≥3 studies were available. R software with package metafor was used for statistical analyses. A research protocol was published with protocols.io (10.17504/protocols.io.bpyfmptn).

Results:

Our highly specific search strategy yielded 165 results. Twelve articles on nine cohorts were finally included. Eight cohorts originated in Europe, one in Africa. At baseline, about half of the patients with eRA were prescribed GCs with a mean dosage of 8mg/d prednisone equivalent (fig 1

). Over time, both the proportion taking GCs and the mean dosage declined. There was substantial heterogeneity between studies.

Conclusion:

Our results indicate that GCs remain regularly used drugs in eRA patients and in methotrexate-naïve patients with RA. While about 40% of patients still receive GCs after 24 months, mean dosages were tapered to “low” dosages (≤7.5mg/d prednisone equivalent)1 in all cohorts that reported respective data. Heterogeneity might be caused by country-specific differences. Unfortunately, the validity of sensitivity analyses would be poor due to the paucity of published data regarding GC dosages and proportions of patients taking GCs in observational RA cohorts. Major limitations of this scoping review are the very specific (and consequently less sensitive) search strategy and that the screening was conducted by one reviewer only.

References:

[1]Buttgereit F, Da Silva JAP, Boers M, et al. Standardised nomenclature for glucocorticoid dosages and glucocorticoid treatment regimens: current questions and tentative answers in rheumatology. Ann Rheum Dis 2002;61(8):718-22. doi: 10.1136/ard.61.8.718.

Figure 1.

Meta-analyses of proportions taking glucocorticoids and mean dosages at baseline and 24 months. GCs: Glucocorticoids; CI: Confidence interval.

Disclosure of Interests:

None declared

AB0031 METABOLIC ADAPTATION OF HUMAN NEUTROPHILS TO GLUCOSE DEPRIVATION IS IMPAIRED WITH INCREASING AGE

Background:

Age-related impairment of classical neutrophil functions is well described (Fortin, McDonald et al. 2008). However, experimental evidence for age-related alterations of neutrophil metabolic adaptation towards nutrient deprivation -a feature of neutrophil battlefields- remains elusive. Moreover, age-related differences in neutrophil metabolic adaptation may contribute to age-related pathologies such as atherosclerosis, cancer, and autoimmune diseases including rheumatoid arthritis.

Objectives:

Therefore, we hypothesized that metabolic adaptation of human neutrophils to glucose deprivation is impaired with increasing age.

Methods:

We isolated human peripheral CD15+ neutrophils from four healthy young donors (mean age: 23.4 ± 2.7) and four healthy donors with a mean age of 58.7 ± 2.4. First, we analyzed the survival of neutrophils either stimulated with PMA or left untreated and subsequently incubated for 0 h and 6 h under varying glucose concentrations (0, 0.5, 1, 5, and 10 mM). To address this, we used 7-AAD staining and flow cytometry. Using Seahorse™ technology, we determined basal respiration, ATP-bound respiration, and maximal and spare capacity.

Results:

We show that neutrophils (purity > 95%) survived for 6 hours in vitro, independent of treatment with PMA or concentrations of glucose in the culture medium. With negligible differences between the various concentrations of glucose used, the percentage of living cells after 6 h was 95% ± 2.5 without PMA and 75% ± 4.7 with PMA stimulation. No differences were uncovered in this respect between the two age groups. However, Seahorse™ technology revealed significant differences in basal, maximal, and spare respiratory capacity. Briefly, OCR (pmol/min/cell count) with respect to basal, maximal and reserve respiratory capacity was lower in the elderly donors compared to the young donors. For instance, with a concentration of 5 mM glucose, the basal respiration (OCR) was 17 ± 0.7 in elderly donors compared to 22.5 ± 1 in young donors, while the maximal respiration was 25 ± 0.8 in elderly and 41 ± 0.6 in the young donor group. Interestingly, these differences were independent of glucose concentration in the medium.

Conclusion:

Our data show that basal metabolic parameters differ between neutrophils from young and older donors. Further experiments are needed to understand in detail the mechanisms and effects of age-related differences in metabolism on neutrophil functions.

References:

[1]Fortin, C. F., P. P. McDonald, O. Lesur and T. Fülöp, Jr. (2008). “Aging and neutrophils: there is still much to do.” Rejuvenation Res11(5): 873-882.

Disclosure of Interests:

None declared

AB0029 THE METABOLIC HIERARCHY OF IMMUNE PROCESSES IN HUMAN MONOCYTES

Background:

At sites of inflammation, monocytes carry out specific immunological functions while facing challenging bioenergetic restrictions.

Objectives:

Here, we investigated the potential of human monocytes to adapt under conditions of reduced energy supply by gradually inhibiting oxidative phosphorylation (OXPHOS) under glucose free conditions.

Methods:

We modelled this reduced energy supply with myxothiazol, an inhibitor of mitochondrial respiration, at 0, 2 and 4 pmol/106 cells to decrease mitochondrial ATP production for 0%, 25% and 66% under glucose free conditions. For the three energy levels, we assessed (i) phagocytosis of FITC-labelled E.coli using flow cytometry, (i) production of reactive oxygen species (ROS) through NADPH oxidase (NOX) as determined by VAS2870-sensitive OCR using a Clark-type electrode, (iii) ATP generation and steady state level using a Clark-type electrode and luminometric assessment (iv) expression of surface activation markers CD16, CD80, CD11b, HLA-DR and (v) production of the inflammatory cytokines IL-1β, IL-6 and TNF-α using flow cytometry in peripheral blood-derived human monocytes with and without LPS-stimulation.

Results:

As a prerequisite for our study, we demonstrate that human monocytes survived strong inhibition of mitochondrial respiration without any sign of apoptosis as determined by flow cytometry. As a result of the inhibition of OXPHOS, we demonstrate a reduction of VAS2870-sensitive OCR (ROS production through NOX), ATPase-dependent OCR and ATP steady-state levels. Focusing on immune function, we observed that phagocytosis and the production of IL-6 were the least sensitive to reduced energy supply while surface expression of CD11b, HLA-DR, production of TNF-α and IL-1β were most affected by inhibition of OXPHOS.

Conclusion:

Our data demonstrate an energy-dependent hierarchy of immune functions in monocytes, which may represent a potential therapeutic target in monocyte-mediated inflammatory diseases.

Disclosure of Interests:

None declared

Patients’ and rheumatologists’ perspectives on the efficacy and safety of low-dose glucocorticoids in rheumatoid arthritis—an international survey within the GLORIA study

Objective

To evaluate the current perspectives of patients and health professionals regarding the efficacy and safety of low-dose glucocorticoids (GCs) in RA.

Methods

Two online surveys were disseminated to patients and health professionals, in their native language, through national patient organizations and national rheumatology medical societies, respectively. SurveyMonkey®, MediGuard.org and the Glucocorticoid Low-dose Outcome in RA Study (GLORIA) website were used to offer and deliver these surveys.

Results

A total of 1221 RA patients with exposure to GCs, and 414 rheumatologists completed the surveys. Patients and rheumatologists reported high levels of agreement regarding the efficacy of low-dose GCs: at least 70% considered that they are very rapid and effective in the control of signs and symptoms of RA. However, half of the patients also reported having suffered serious adverse events with GCs, and 83% described concerns about safety. The majority of rheumatologists estimated that endocrine, ophthalmologic and cutaneous adverse events affect &gt;4% of all patients treated with low-dose GCs for 2 years, based on a heat map.

Conclusions

RA patients with self-reported exposure to GCs express high levels of satisfaction with low-dose GCs efficacy, as do rheumatologists. However, both expressed excessive concerns regarding the safety of GCs (greatly exceeding the published evidence data), which may compromise the optimal use of this medication. This study indicates that there is an unmet need for appropriately designed prospective trials that shed light on the real risk associated with low-dose GCs, as well as a need for renovated educational programs on the real benefits and harms of low-dose GCs, for both patients and physicians.

OP0300 A CROSS-SECTIONAL, MATCHED-PAIR ANALYSIS OF ACPA POSITIVE AND ACPA NEGATIVE RHEUMATOID ARTHRITIS PATIENTS COMPARING THE PREVALENCE OF OSTEOPOROSIS, FRAGILITY FRACTURES AND UNDERLYING RISK FACTORS

Background:

Rheumatoid arthritis (RA) is associated with increased systemic bone loss, leading to a high risk for fragility fractures. Especially anti-citrullinated protein antibody (ACPA) positivity is considered a risk factor for local bone erosions and systemic bone loss1.

Objectives:

The purpose of this study was to compare ACPA positive versus ACPA negative RA patients in terms of the prevalence of osteoporosis and fragility fractures and to identify differences in underlying risk factors that influence bone health.

Methods:

Rh-GIOP is an ongoing prospective observational study collecting and analyzing disease- and bone-related data from patients with chronic rheumatic diseases or psoriasis treated with glucocorticoids (GC). In this cross-sectional analysis, we performed a matched-pair analysis, matching 114 ACPA positive to 114 ACPA negative RA patients according to age (5-year-steps), sex, and body mass index (BMI, 2-unit-steps). Descriptive analyses were performed, with values displayed as mean ± standard deviation for continuous variables. Non-parametric tests were used at a two-sided significance level of 5% to compare differences in underlying and potential risk factors without adjustment for multiple testing.

Results:

At same mean age (63.9 ±10.2 years) and BMI (27.9 ±5.6kg/m2), the matched groups had a female proportion of 82.5%. APCA positive patients had a significantly longer mean disease duration (13.9 vs 9.9 years, p<0.001), a higher mean cumulative GC-dose (22.3 vs 13.2g, p<0.01) and mean duration of GC therapy (10.1 vs 6.6 years, p<0.01). There was no significant difference in the prevalence of osteoporosis as defined by dual-energy X-ray absorptiometry (DXA) (18.4 vs 20.2%), nor in the prevalence of vertebral (7.0 vs 5.3%) or non-vertebral fractures (31.6 vs 29.8%). C-reactive protein levels as a marker of disease activity were significantly higher in ACPA positive patients (mean: 8.8 vs 4.3mg/l, p= 0.02), while mean disease activity score (DAS)28 levels were slightly lower in ACPA positive patients (2.4 vs 2.7, p= 0.05). No difference in health assessment questionnaire (HAQ) score was found. RA-specific treatments were similar, especially concerning current mean daily GC-dose (6.7 vs 4.9mg/day), except for Rituximab and targeted synthetic disease modifying anti-rheumatic drugs (DMARDs) which were more commonly used in ACPA positive patients (9.6 vs 2.6%, p=0.05) and (5.3 vs 0%, p=0.029), respectively. ACPA positive patients did not differ significantly from ACPA negative patients in specific anti-osteoporotic treatment, nor in the prevalence of comorbidities or concomitant medication. There were no significant differences in bone-specific laboratory parameters.

Conclusion:

In a cross-sectional analysis of our cohort, the prevalence of osteoporosis and fragility fractures was similar between ACPA positive and ACPA negative RA patients, despite longer disease duration and GC-treatment in ACPA positive patients. This is remarkable since it implies that ACPA negative patients are at a similar risk for osteoporosis and associated fractures. Optimal management of disease activity with or without GCs may represent a mainstay in preventing disease-related comorbidities such as osteoporosis.

References:

[1]Steffen, U., Schett, G., & Bozec, A. (2019). How Autoantibodies Regulate Osteoclast Induced Bone Loss in Rheumatoid Arthritis. Frontiers in immunology, 10, 1483. doi:10.3389/fimmu.2019.01483

Disclosure of Interests:

Edgar Wiebe: None declared, Desiree Freier: None declared, Dörte Huscher: None declared, gloria dallagiacoma: None declared, Robert Biesen: None declared, Sandra Hermann: None declared, Gerd Rüdiger Burmester Consultant of: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Speakers bureau: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Frank Buttgereit Grant/research support from: Amgen, BMS, Celgene, Generic Assays, GSK, Hexal, Horizon, Lilly, medac, Mundipharma, Novartis, Pfizer, Roche, and Sanofi.

AB0767 PATIENTS WITH RHEUMATOID ARTHRITIS HAVE A LOWER BONE DENSITY THAN PATIENTS WITH PSORIATIC ARTHRITIS

Background:

Osteoporosis is a skeletal disease characterized by the loss of bone density resulting in an increased fracture risk. Female sex, advanced age, Caucasian ancestry, previous history of fractures, menopause and certain genetic factors predispose for osteoporosis. In addition, recent studies could prove that chronic inflammatory diseases such as Rheumatoid Arthritis (RA) and long-term treatment with higher doses of glucocorticoids (GCs) represent independent risk factors for the development of osteoporosis. On the other hand, the intake of vitamin D, a calcium-rich diet and physical exercise can be protective. Data describing the prevalence of osteoporosis in patients with other rheumatic diseases like psoriatic arthritis (PsA) are lacking.

Objectives:

We compared the prevalence of osteopenia and osteoporosis in patients with RA and PsA, respectively, based on data obtained from our ongoing prospective monocentric study Rh-GIOP investigating glucocorticoid (GC)-induced osteoporosis in patients with different rheumatic diseases (NCT02719314).

Methods:

Bone mineral density data measured by dual x-ray absorptiometry (DXA) in patients with PsA (n=92) were compared with data measured in 92 age- and gender-matched patients with RA. The results were analysed with respect to clinical and laboratory parameters such as data on GC treatment (frequency, duration defined as start of treatment until timepoint of measurement, actual and cumulative dose), csDMARD and bDMARD (including as well tsDMARDs) therapy, serological parameters (Vitamin D, alkaline phosphatase, calcium, inflammatory markers and rheumatoid factor) and functional status (e.g. Health Assessment Questionnaire (HAQ), sporting activities). Statistical analyses were performed descriptively using mean and standard deviation, t-tests for metric variables, and chi-square tests for nominal variables. For subgroup analyses with less than 30 patients per group, tests for non-normally distributed data were used due to the lower test power.

Results:

RA patients showed significantly lower means of bone density values (minimal T-score, p=0.03) than PsA patients leading to a higher frequency of osteopenic bone densities (p<0.005). However, no differences in the frequency of osteoporotic bone densities could be detected. PsA patients reported a significantly longer disease duration and a higher current GC dosage. In contrast, the frequency of current GC intake was higher in RA patients. Although the calcium intake was higher in the RA group, neither blood levels of calcium and vitamin D, nor the cumulative GC dose (GCCD) or duration of GC therapy could indicate a causal relationship for the differences observed in bone density values between the two groups. The frequency of csDMARD therapy did not differ significantly between PsA and RA patients while the frequency of bDMARD therapy was higher in the PsA group (p=0.04).

Conclusion:

The lower bone density in RA patients seems not to be fully explained by higher GCCD, disease duration or higher levels of inflammation. However, RA patients had a higher frequency of current GC intake. Additionally, differences in bone density between the two groups could be related to the higher number of bDMARD therapies in PsA patients, but further investigations like multivariate analyses with higher numbers of patients are necessary. Furthermore there is more need for research on possible molecular and genetic factors in PsA, which are protecting from low bone density.

Disclosure of Interests:

Desiree Freier: None declared, Edgar Wiebe: None declared, Robert Biesen: None declared, Thomas Buttgereit: None declared, Sandra Hermann: None declared, Timo Gaber: None declared, Frank Buttgereit Grant/research support from: Amgen, BMS, Celgene, Generic Assays, GSK, Hexal, Horizon, Lilly, medac, Mundipharma, Novartis, Pfizer, Roche, and Sanofi.

THU0069 MIMICKING ARTHRITIS IN VITRO TO TEST DIFFERENT TREATMENT APPROACHES

Background:

Our ultimate goal is to study potential drug candidates in an experimental setting of arthritis. Therefore, we aim to develop a valid humanin vitro3D joint model mimicking features of joint inflammation by applying inflammatory conditions namely immune cells and pro-inflammatory cytokines. Our in vitro3D joint model consists of different components including an osteogenic and chondrogenic part, the joint space filled with synovial fluid, and the synovial membrane. Developed as an alternative experimental setup to animal experiments, our 3D joint model will enable us to study efficiently the effects of potential drug candidates in a human-basedin vitromodel.

Objectives:

Here, we aimed to demonstrate the suitability of our human-basedin vitro3D osteochondral model by analyzing the influence of the main cytokines involved in the pathogenesis of RA as well as the impact of a specific therapeutic intervention.

Methods:

Based on human bone marrow-derived mesenchymal stromal cells (hMSCs), we developed 3D bone and cartilage tissue components that were characterized in detail (e.g. cell vitality, morphology, structural integrity) using histological, biochemical and molecular biological methods as well as µCT and scanning electron microscope (SEM). In brief, to establish the osteogenic component, we populated β-tricalcium phosphate (TCP) – mimicking the mineral bony part – with hMSCs, while the scaffold-free cartilage component was generated by cellular self-assembly and intermittent mechanical stimulation (fzmb GmbH). Subsequently, we co-cultivated both tissue components for three weeks to generate an interconnected 3D osteochondral model. To test the suitability, we applied a cocktail of TNFα, IL-6 and MIF using concentrations reported from RA synovial fluid alone or in combination with specific therapeutic drugs and analyzed their impact by qPCR.

Results:

We verified the osteogenic phenotype of our 3D bone tissue component by demonstrating an increase in mineralized bone volume and the induction of bone-related gene expression (RUNX2,SPP1andCOL1A1) as compared to the corresponding control. Secondly, we verified the chondrogenic phenotype of our cartilage tissue component by HE and Alcian Blue staining as well as by the reduced expression ofCOL1A1and an abundant expression ofCOL2A1. Interestingly, co-cultivation of both components for up to 3 weeks demonstrated colonization, connectivity and initial calcification implying a transitional bridging area. Cytokine stimulation with a cocktail of TNF, IL-6 and MIF leads to an upregulation of the metabolic markerLDHAand the angiogenic markerVEGFin both bone and cartilage. The inflammation markersIL8andTNFare also upregulated in both components, whileIL6is downregulated in bone compared to the unstimulated control. In addition, a cytokine-induced upregulation of matrix-metalloproteases was observed especially in the cartilage component. All these cytokine-related effects could be antagonized with a cocktail of therapeutics (milatuzumab, adalimumab and tocilizumab).

Conclusion:

The results of our study showed cytokine related effects of both tissue components, which can be therapeutically antagonized. By combining the components in a 96 well format, we aim to provide a mid-throughput system for preclinical drug testing.

Acknowledgments:

This project is funded by the Federal Ministery of Education and Research (BMBF)

Disclosure of Interests:

Alexandra Damerau: None declared, Moritz Pfeiffenberger: None declared, Annemarie Lang: None declared, Timo Gaber: None declared, Frank Buttgereit Grant/research support from: Amgen, BMS, Celgene, Generic Assays, GSK, Hexal, Horizon, Lilly, medac, Mundipharma, Novartis, Pfizer, Roche, and Sanofi.

OP0186 HYDROXYCHLOROQUINE IN PATIENTS WITH INFLAMMATORY AND EROSIVE OSTEOARTHRITIS OF THE HANDS: RESULTS OF A RANDOMIZED, DOUBLE-BLIND, PLACEBO CONTROLLED, MULTI-CENTRE, INVESTIGATOR-INITIATED TRIAL (OA TREAT)

Background:

Hand osteoarthritis (OA) is a very common condition with cartilage degradation and frequently erosive bone changes. It may be very painful and can greatly affect everyday activities. Common analgesics and NSAIDs are used for symptomatic relief but are often poorly tolerated or contraindicated especially in elderly patients. There is no effective and proven disease modifying therapy available. Previous publications and anecdotal reports suggest hydroxychloroquine (HCQ) as a possible treatment, and some physicians use HCQ off-label for the treatment of OA

Objectives:

To investigate the efficacy and safety of HCQ in patients with inflammatoryanderosive hand OA in a randomized, double-blind, placebo controlled, multi-centre, investigator-initiated trial

Methods:

Patients with inflammatory and erosive hand OA, according to the ACR criteria, with radiographically proven erosive disease were randomized 1:1 to HCQ 200-400mg per day or matching placebo (PBO) for 52 weeks. Both groups received standard therapy (stable NSAIDs). The primary endpoint was AUSCAN for pain and hand disability at week 52 (W52). A secondary endpoint was radiographic progression from baseline (BL) to W52. A multiple endpoint test and analysis of covariance was used to compare changes between groups. All analyses were conducted on an intention-to-treat base

Results:

Of 156 patients 3 were excluded and 75 were randomized to HCQ and 78 to PBO. Mean age was 52.4 (SD 8.1) in the HCQ and 50.2 (SD 6.6) years in the PBO group. 68 (90.7%) of the patients were female in the HCQ and 60 (76.9%) in the PBO group. Disease duration was 9.5 (SD 7.5) in HCQ and 10.8 (SD 8.8) years in PBO group. CRP and ESR were normal in both groups. BL pain (AUSCAN) was 31.1 (SD 8.2) and 30.7 (SD 8.9), BL function (AUSCAN) was 58.5 (SD 15.5) in HCQ and 57.8 (SD 17.1) in PBO patients. Table 1 shows clinical and functional parameters at W52. Only morning stiffness was significantly reduced in the HCQ group (p=0.001). Changes in radiographic scores did not differ significantly (p>0.05) between treatment groups. There were 7 SAE in the HCQ and 15 in the PBO group. No new safety issues were detected

Table 1.

Results of the covariance analysis (ANCOVA)-adjusted mean values and 95%-confidence intervals for primary and secondary outcomes at W52, as well as a p-value for group comparison

OutcomeAdj. Mean HCQ95%-CI HCQAdj. Mean PBO95%-CI PBOP-value HCQ x PBOAUSCAN Function48.14353.351.346.6560.36AUSCAN Pain26.723.929.426.523.929.10.92tender joint6.44.87.97.15.48.70.49swollen joint21.32.72.11.42.70.93ESR (mm/h)8.26.99.611.710.113.5<0.01HAQ0.90.810.80.70.90.46Phys. Global3.22.83.63.533.90.39Pat. Global4.53.95.15.24.65.80.14SF36 mental48.846.65150.848.752.80.22SF36 physical39.83841.639.938.241.60.95Morning Stiffness (min)30.22436.316.310.322.30.001Modif. Kallmann Score53.652.155.152.851.454.20.24

The associated BL value or, if available, a mean value from BL and screening was included in the ANCOVA model as a covariate.

Conclusion:

The OATREAT trial examined the clinical and radiological efficacy and safety of HCQ as a treatment option for inflammatory and erosive OA over 52 weeks. OATREAT is the first large randomized PBO controlled trial focusing on erosive hand OA. HCQ was no more effective than PBO for changes in pain, function and radiographic scores in the 52-week period. Overall safety findings were consistent with the known profile of HCQ. Thus, our data failed to show that HCQ is effective in patients with inflammatory, erosive hand OA

Disclosure of Interests:

Claudia Kedor Consultant of: Advisory Board for Novartis Pharma GmbH, Jacqueline Detert: None declared, Rolf Rau: None declared, Siegfried Wassenberg: None declared, Joachim Listing: None declared, Pascal Klaus Employee of: Pfizer Pharma GmbH, Tanja Braun: None declared, Walter Hermann: None declared, Stefan Weiner: None declared, Martin Bohl-Bühler: None declared, Frank Buttgereit Grant/research support from: Amgen, BMS, Celgene, Generic Assays, GSK, Hexal, Horizon, Lilly, medac, Mundipharma, Novartis, Pfizer, Roche, and Sanofi., Gerd Rüdiger Burmester Consultant of: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Speakers bureau: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma

OP0244 A PRECLINICAL TESTING TOOL: THE IN VITRO 3D FRACTURE GAP MODEL

Background:

Approximately 10% of fractures lead to significant fracture healing disorders, with a tendency to further increase due to the aging population. Of note, especially immunosuppressed patients with ongoing inflammation show difficulties in the correct course of fracture healing leading to fracture healing disorders. Most notably, invading immune cells and secreted cytokines are considered to provide an inflammatory microenvironment within the fracture gap, primarily during the initial phase of fracture healing. Current research has the focus on small animal models, facing the problem of translation towards the human system. In order to improve the therapy of fracture healing disorders, we have developed a human cell-basedin vitromodel to mimic the initial phase of fracture healing adequately. This model will be used for the development of new therapeutic strategies.

Objectives:

Our aim is to develop anin vitro3D fracture gap model (FG model) which mimics thein vivosituation in order to provide a reliable preclinical test system for fracture healing disorders.

Methods:

To assemble our FG model, we co-cultivated coagulated peripheral blood and primary human mesenchymal stromal cells (MSCs) mimicking the fracture hematoma (FH model) together with a scaffold-free bone-like construct mimicking the bony part of the fracture gap for 48 h under hypoxic conditions (n=3), in order to reflect thein vivosituation after fracture most adequately. To analyze the impact of the bone-like construct on thein vitroFH model with regard to its osteogenic induction capacity, we cultivated the fracture gap models in either medium with or without osteogenic supplements. To analyze the impact of Deferoxamine (DFO, known to foster fracture healing) on the FG model, we further treated our FG models with either 250 µmol DFO or left them untreated. After incubation and subsequent preparation of the fracture hematomas, we evaluated gene expression of osteogenic (RUNX2,SPP1), angiogenic (VEGF,IL8), inflammatory markers (IL6,IL8) and markers for the adaptation towards hypoxia (LDHA,PGK1) as well as secretion of cytokines/chemokines using quantitative PCR and multiplex suspension assay, respectively.

Results:

We found via histology that both the fracture hematoma model and the bone-like construct had close contact during the incubation, allowing the cells to interact with each other through direct cell-cell contact, signal molecules or metabolites. Additionally, we could show that the bone-like constructs induced the upregulation of osteogenic markers (RUNX2, SPP1) within the FH models irrespective of the supplementation of osteogenic supplements. Furthermore, we observed an upregulation of hypoxia-related, angiogenic and osteogenic markers (RUNX2,SPP1) under the influence of DFO, and the downregulation of inflammatory markers (IL6,IL8) as compared to the untreated control. The latter was also confirmed on protein level (e.g. IL-6 and IL-8). Within the bone-like constructs, we observed an upregulation of angiogenic markers (RNA-expression ofVEGF,IL8), even more pronounced under the treatment of DFO.

Conclusion:

In summary, our findings demonstrate that our establishedin vitroFG model provides all osteogenic cues to induce the initial bone healing process, which could be enhanced by the fracture-healing promoting substance DFO. Therefore, we conclude that our model is indeed able to mimic correctly the human fracture gap situation and is therefore suitable to study the influence and efficacy of potential therapeutics for the treatment of bone healing disorders in immunosuppressed patients with ongoing inflammation.

Disclosure of Interests:

Moritz Pfeiffenberger: None declared, Alexandra Damerau: None declared, Paula Hoff: None declared, Annemarie Lang: None declared, Frank Buttgereit Grant/research support from: Amgen, BMS, Celgene, Generic Assays, GSK, Hexal, Horizon, Lilly, medac, Mundipharma, Novartis, Pfizer, Roche, and Sanofi., Timo Gaber: None declared

SAT0450 GLUCOCORTICOID-INDUCED OSTEOPOROSIS IN PATIENTS WITH CHRONIC INFLAMMATORY RHEUMATIC DISEASES: A MULTIVARIATE LINEAR REGRESSION ANALYSIS IDENTIFYING PREDICTIVE FACTORS FOR LOW BONE MASS

Background:

Rheumatic diseases are associated with increased systemic bone loss and fracture risk related to chronic inflammation, disease-specific, general and demographic risk factors as well as treatment with glucocorticoids (GC). Yet, there is evidence that GCs may, by adequately suppressing systemic inflammation, also have a positive effect on bone mineral density (BMD) and fracture risk1.

Objectives:

The purpose of this study was to investigate the prevalence of osteoporosis and fragility fractures in patients with inflammatory rheumatic diseases and to analyze the impact that treatment with GCs, other known risk factors and preventive measures have on bone health in these patients.

Methods:

Rh-GIOP is an ongoing prospective observational study collecting and analyzing disease- and bone-related data from patients with chronic inflammatory rheumatic diseases and psoriasis treated with GCs. In this cross-sectional analysis, we evaluated the initial visit of 1091 patients. A multivariate linear regression model with known or potentially influential factors adjusted for age and sex was used to identify predictors of BMD as measured by dual-energy X-ray absorptiometry (DXA). Multiple imputation was applied for missing baseline covariate data.

Results:

In the total cohort of 1091 patients (75% female of which 87.5% were postmenopausal) with a mean age of 62.1 (±13.2) years, the prevalence of osteoporosis by DXA was 21.7%, while fragility fractures have occurred in 31.2% of the study population (6.7% vertebral, 27.7% non-vertebral). Current GC therapy was common (64.9%), with a median daily dose of 5.0mg [0.0;7.5], a mean life-time total GC dose of 17.7g (±24.6), and a mean GC therapy duration of 7.8 years (±8.5). Bisphosphonates were the most commonly used anti-osteoporotic drug (12.6%).

Multivariate analysis showed that BMD as expressed by the minimum T-Score at all measured sites was negatively associated with higher age, female sex and menopause as well as Denosumab and Bisphosphonate treatment. A positive association with BMD was found for body mass index as well as current and life-time (cumulative) GC dose. While comedication with proton-pump-inhibitors significantly predicted low bone mass, concomitant use of non-steroidal anti-inflammatory drugs showed a positive association with BMD. Of the measured bone-specific laboratory parameters, higher alkaline phosphatase levels were determinants of low DXA-values, while the association was positive for gamma-glutamyltransferase.

BMD was neither predicted by duration of GC treatment nor by treatment with disease modifying anti-rheumatic drugs.

Predictive variables for BMD differed at the respective anatomical site. While treatment with Denosumab predicted low bone mass at the lumbar spine and not at the femoral neck, the opposite was true for health assessment questionnaire (HAQ) score. Current and life-time GC-dose as well as direct sun-exposure of more than 30 minutes daily were positively associated with bone mass at the femoral sites only.

Conclusion:

This cross-sectional analysis of a prospective cohort study quantified the prevalence of osteoporosis and identified predictive variables of BMD in patients with rheumatic diseases.

Multivariate analyses corroborated low BMD to be predicted by traditional factors like age, female sex and menopause but showed current and well as life-time GC dose to be positively associated with BMD in our cohort of patients with chronic inflammatory rheumatic diseases. This suggests that optimal management of disease activity with GCs might be beneficial in order to avoid bone loss due to inflammation.

References:

[1]Güler-Yüksel et al. “Glucocorticoids, Inflammation and Bone.” Calcified Tissue International (January 08 2018).

Disclosure of Interests:

Edgar Wiebe: None declared, Desiree Freier: None declared, Dörte Huscher: None declared, Robert Biesen: None declared, Sandra Hermann: None declared, Frank Buttgereit Grant/research support from: Amgen, BMS, Celgene, Generic Assays, GSK, Hexal, Horizon, Lilly, medac, Mundipharma, Novartis, Pfizer, Roche, and Sanofi.

FRI0004 SURFACE AMP DEAMINASE 2 AS A NOVEL REGULATOR MODIFYING THE EXTRACELLULAR ATP-ADENOSINE BALANCE THAT IS DIFFERENTIALLY EXPRESSED IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Adenosine and its nucleotides represent crucial immunomodulators in the extracellular environment. ATP and ADP are released from stressed cells in states of inflammation, whereas adenosine serves as a key anti-inflammatory mediator1. The ectonucleotidases CD39 and CD73 are responsible for the sequential catabolism of ATP to adenosine via AMP, thereby promoting an anti-inflammatory milieu induced by the “adenosine halo”. Great importance has been attributed to these enzymes in the pathogenesis of autoimmune diseases such as rheumatoid arthritis (RA) and as targets in cancer therapy2 3. AMPD2 mediates AMP deamination to IMP, thus constituting an ambiguous mediator both enhancing the degradation of inflammatory ATP and reducing the formation of protective adenosine. Here, we postulate that this pathway is also present on the cell surface of immune cells and modified under inflammatory conditions.

Objectives:

Therefore, we analysed surface AMPD2 expression and its modulation on distinct cell lines and primary immune cells.

Figure 1.

Surface AMPD2 as a novel regulator of the extracellular ATP-adenosine balance.

Methods:

Firstly, AMPD2 surface expression was verified by immunoprecipitation from membrane fractions isolated from cell lines (HEK293 and HMEC1) and CD14+ monocytes analysed by western blot and mass spectrometry. In addition, surface biotinylation of the aforementioned cells was performed. Also, AMPD2 surface expression was evaluated by flow cytometry, analysing both cell lines (HEK293, HMEC1, THP1, and Jurkat) and primary human immune cells from healthy donors and patients with RA.

Secondly, co-expression of surface AMPD2, CD39 and CD73 on PBMCs was analysed by flow cytometry directly after isolation as well as after a 24h culture period. Moreover, surface expression was assessed after immunostimulation and Golgi transport inhibition.

Results:

AMPD2 surface expression was confirmed by western blot and mass spectrometry of (i) precipitated AMPD2 from membrane fractions and (ii) biotinylated surface molecules in HEK293 and HMEC1 as well as CD14+ monocytes. Surface expression was reduced after AMPD2 knockdown in HEK293. Flow cytometric analysis further verified AMPD2 surface expression and revealed a significant decrease after Golgi transport inhibition (p<0.01). TLR stimulation strongly enhanced the surface expression of AMPD2 and CD39 on monocytes (p<0.05), whereas dexamethasone at high therapeutic doses inversely affected AMPD2 surface expression on lymphocytes and monocytes (p<0.01). Analysis of AMPD2 surface expression on PBMCs from RA patients revealed higher expression levels compared to sex- and age-matched healthy controls (p<0.05).

Conclusion:

We demonstrate AMPD2 surface expression on immune cells for the first time. Hence, we reveal a novel regulator of the extracellular ATP-adenosine balance that is differentially expressed in RA patients compared to healthy controls. The extracellular conversion of AMP into IMP may constitute a shunt-like mechanism adding to the CD39-CD73 system controlling immunomodulation.

References:

[1]Regateiro FS, Cobbold SP, Waldmann H. CD73 and adenosine generation in the creation of regulatory microenvironments.Clinical and experimental immunology2013;171(1):1-7. doi: 10.1111/j.1365-2249.2012.04623.x

[2]Morandi F, Horenstein AL, Rizzo R, et al. The Role of Extracellular Adenosine Generation in the Development of Autoimmune Diseases.Mediators of inflammation2018;2018:7019398. doi: 10.1155/2018/7019398

[3]Allard B, Longhi MS, Robson SC, et al. The ectonucleotidases CD39 and CD73: Novel checkpoint inhibitor targets.Immunol Rev2017;276(1):121-44. doi: 10.1111/imr.12528

Acknowledgments:

This project is funded by an unrestricted grant by Horizon Pharma plc.

Disclosure of Interests:

Lisa Ehlers: None declared, Aditi Kuppe: None declared, Alexandra Damerau: None declared, Marieluise Kirchner: None declared, Cindy Strehl: None declared, Frank Buttgereit Grant/research support from: Amgen, BMS, Celgene, Generic Assays, GSK, Hexal, Horizon, Lilly, medac, Mundipharma, Novartis, Pfizer, Roche, and Sanofi., Timo Gaber: None declared

FRI0369 MIMICKING GLUCOCORTICOID-INDUCED OSTEOPOROSIS USING AN IN VITRO TRABECULAR HUMAN BONE MODEL

Background:

The bone matrix consists of inorganic and organic components and a variety of specialized cells such as osteoblasts, osteocytes and osteoclasts. The bone-forming osteoblasts are responsible for the production of organic matrix components; they differentiate later into osteocytes which is accompanied by matrix mineralization. Osteoclasts are multinuclear giant cells, which resorb bone. Healthy bone homeostasis is characterized by a balanced, dynamic and continuous remodeling process. Glucocorticoids (GCs) are commonly used to successfully treat patients with inflammatory rheumatic and other autoimmune diseases. However, long-term treatment with GC can potentially lead to several adverse effects such as the inhibition of osteoblast proliferation and the increase of osteoclastic activity resulting in osteoporosis.

Objectives:

Hence, the aim of our project is to i) develop anin vitrotrabecular human bone model, ii) integrate this bone model into a perfusion system to accelerate mineralization and provide biomechanical stimuli and iii) applying prednisolone to induce osteoporosis. Here we present our initial results describing the successful differentiation of osteoblasts and osteoclasts in a 3D environment, and the accomplished integration of the bone model into a perfusion system.

Methods:

In a first step, different cultivation conditions were tested to allow optimal osteogenic or osteoclastic differentiation. To this end, a) human bone marrow derived mesenchymal stromal cells (hMSCs) were treated with osteogenic medium, and b) monocytes (isolated from buffy coats) were differentiated into osteoclasts using following protocol: incubation for 3 days with 25 ng/ml M-CSF followed by an 18-day incubation with M-CSF and 50 ng/ml RANKL. Calcification of hMSCs was evaluated via Alizarin Red S staining. Osteoclasts were identified using immunofluorescence staining observing multinucleated (DAPI) giant (ß-Actin) cells with TRAP and Cathepsin K activity. Additional gene expression analyses are currently conducted using qRT-PCR and looking for osteoclast-specific genes. In parallel to the monolayer cultures, cells were transferred on β-tricalcium phosphate (βTCP) – a suitable bony-like scaffold. Furthermore, first experiments in a dynamic bioreactor platform (OSPIN GmH) were conducted to evaluate the influence of shear stress on the cells and model systems.

Results:

We have been able to populate the βTCP scaffold with monocytes, which were differentiated into osteoclasts (morphological changes) without any effect on cellular viability as measured by Live/Dead staining. The morphological changes of those osteoclasts such as formation of filopodia could be demonstrated by scanning electron microscopy. In addition, the cultivation of βTCP populated with hMSCs in a perfusion system showed the upregulation of osteogenic markers (RUNX2, OSX) on mRNA-level.

Conclusion:

These first results of our approach to develop anin vitro3D model for glucocorticoid-induced osteoporosis are promising. Our next step will be the co-cultivation of osteoblasts and osteoclasts under dynamic and optimized cultivation conditions. By combining several cell types, a suitable scaffold and biomechanical stimuli (perfusion), we aim to provide a valid testing platform to study underlying disease mechanisms and for drug development.

Acknowledgments:

The project has been funded by the Elsbeth Bonhoff Foundation.

Disclosure of Interests:

Annemarie Lang: None declared, Karoline Diesing: None declared, Alexandra Damerau: None declared, Sümeyye Uzun: None declared, Moritz Pfeiffenberger: None declared, Timo Gaber: None declared, Frank Buttgereit Grant/research support from: Amgen, BMS, Celgene, Generic Assays, GSK, Hexal, Horizon, Lilly, medac, Mundipharma, Novartis, Pfizer, Roche, and Sanofi.

SAT0372 PATIENTS WITH PSORIATIC ARTHRITIS SHOW HIGHER BONE DENSITY COMPARED TO AGE AND GENDER MATCHED PATIENTS WITH ANKYLOSING SPONDYLITIS

Background:

The prevalence of osteoporosis in inflammatory rheumatic diseases such as psoriatic arthritis (PsA) has not been sufficiently clarified yet, and the data in the literature are heterogeneous. In addition, it is still unclear to what extent patients with PsA differ in terms of bone density from patients with other forms of spondyloarthritis such as ankylosing spondylitis (AS).

Objectives:

In an interim analysis of the Rh-GIOP Study (ClinicalTrials.gov IdentifierNCT02719314), we observed that PsA patients demonstrated more frequently normal bone density than any other patient group analyzed (suffering from e.g. rheumatoid arthritis or systemic sclerosis). The main objective of this investigation was to compare bone density data from patients with PsA and AS, as both diseases belong to the spondyloarthritis group. 1100 patients with inflammatory rheumatic diseases provided the basis of Rh-GIOP, a prospective study monitoring glucocorticoid (GC)-induced osteoporosis in patients with rheumatic diseases. Rh-GIOP was established in 2015 at the Charité University Hospital. Bone mineral density data were measured by dual x-ray absorptiometry (DXA).

Methods:

92 patients with PsA (65% female) were compared with 51 patients suffering from AS (35% female). Potential risk and protective factors (e.g. data on GC treatment, anti-rheumatic therapy), laboratory parameters (e.g. Vitamin D, alkaline phosphatase, calcium and inflammatory markers) and functional status (e.g. Health Assessment Questionnaire, sporting activities, back pain) were compared between these groups. Statistical analysis was performed descriptively using mean and standard deviation, t-tests for metric variables, and chi-square tests for nominal variables. Due to the heterogeneous gender distribution, an additional statistical matching was performed to compare patients matched by age and gender.

Results:

Patients with PsA displayed significantly higher minimal T-scores than patients with AS (p=0.003) even though patients with AS were younger and more often male (p<0.001). AS patients showed a higher frequency of osteopenic bone densities (p<0.05), however, no differences in the frequency of osteoporotic bone densities were found. Body-mass-index (BMI) was significantly higher (p<0.001) in PsA patients. PsA patients demonstrated a higher frequency of csDMARD use (p<0.001). Additional analyses among PsA patients with and without csDMARDs revealed also significantly higher minimal T-scores in PsA patients taking csDMARDs (90% Methotrexate), and both groups showed the same average of age and gender distribution. Furthermore, AS patients complained significantly more often of back pain (96 % vs. 74%, p=0.001) than PsA patients. No differences in GC use or cumulative GC dose were found. All results could be confirmed when groups were matched by age and gender.

Conclusion:

Our results demonstrate that patients with PsA display higher bone density compared to age and gender matched patients with ankylosing spondylitis. Possible influencing factors could be the higher frequency of csDMARD use, higher BMI or the lower frequency of back pain in PsA patients. Multivariate tests and additional biomarker investigations in larger cohorts are necessary to corroborate these findings and to identify underlying pathogenic differences which could serve for an explanation.

Disclosure of Interests:

Desiree Freier: None declared, Edgar Wiebe: None declared, Robert Biesen: None declared, Thomas Buttgereit: None declared, Sandra Hermann: None declared, Timo Gaber: None declared, Frank Buttgereit Grant/research support from: Amgen, BMS, Celgene, Generic Assays, GSK, Hexal, Horizon, Lilly, medac, Mundipharma, Novartis, Pfizer, Roche, and Sanofi.

AB1223 RHEUMATOID ARTHRITIS PATIENTS INCLUDED IN GLUCOCORTICOID TRIALS MOSTLY RESEMBLE THOSE SEEN IN OBSERVATIONAL COHORTS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background:

Randomised controlled trials (RCTs) are considered the gold standard in clinical research. Their results, however, may not be generalizable to patients in routine care.1Together with methotrexate, glucocorticoids (GCs) constitute the mainstay of therapy for many patients with rheumatoid arthritis (RA), but it is unclear whether trial evidence is actually generalizable to real-world patients.

Objectives:

This review assesses to what extent RA patients participating in GC-RCTs differ from RA patients taking GCs in routine care.

Methods:

This study was registered with PROSPERO (CRD42019134675). MEDLINE was searched for RCTs and, as comparators, cohort studies in RA evaluating systemic GC therapy. Cohorts were not allowed to exhibit apparent selection mechanisms concerning gender or age. Random-effects meta-analyses combined descriptive baseline characteristics that may modify the benefit-risk-ratio of various RA therapeutics. Meta-analyses were stratified by study type (RCT and CS). Stratified estimates were subsequently compared.

Results:

55 RCTs and ten cohort studies (21,657 participants overall) were included. Twelve characteristics (related to general demographics and disease activity) were reported frequently enough to allow for comparative analysis. Compared to cohorts, RCT participants were younger (-4.7 [-7.2 to -2.1] years) and had somewhat higher erythrocyte sedimentation rates (12 [6 to 18] mm/h) (Table 1). In the other ten characteristics, estimates did not differ significantly. Numerically, cohort patients had more longstanding disease and slightly more favourable disease levels in core set variables. Comorbidities could not be assessed.

Table 1.

Pooled estimates

OutcomeRCTkCohortkContrast(95% CI)pGeneral demographics Age (years)54.25058.910–4.7(–7.2 to –2.1)<0.001 Female (proportion)0.70520.73100.89(0.68 to 1.16)0.38 Current or previous smokers (proportion)0.5930.5121.38(0.61 to 3.14)0.44 BMI (kg/m2)25.9525.930.0(–1.9 to 1.9)0.98 Disease duration (months)56.54385.17–28.6(–85.6 to 28.4)0.33Disease activity ESR (mm/h)40.13128.2311.8(5.7 to 18.0)<0.001 DAS5.3244.950.4(–0.1 to 0.9)0.12 RF+, (proportion)0.67320.6361.19(0.80 to 1.78)0.39 ACPA+, (proportion)0.6470.5631.38(0.64 to 3.00)0.41 HAQ1.3311.140.2(–0.1 to 0.5)0.15 Pain (0-10)5.2264.820.4(–0.8 to 1.6)0.52 Patient global assessment (0-10)5.2174.930.3(–0.9 to 1.5)0.58

Conclusion:

The results of our study suggest that evidence from RA GC-RCTs can be generalized to most patients in routine practice. We note that comorbidities – a frequent exclusion criterion for trial participation – could not be evaluated due to insufficient reporting. Our findings contrast with a similar study on RCTs investigating biologics in RA: There, trial participants were found to differ significantly in 4 out of 8 investigated baseline characteristics.2

References:

1]Palmowski A et al. Applicability of trials in rheumatoid arthritis and osteoarthritis: A systematic review and meta-analysis of trial populations showing adequate proportion of women, but underrepresentation of elderly people.Semin Arthritis Rheum2018 doi: 10.1016/j.semarthrit.2018.10.017 and

[2]Kilcher G et al. Rheumatoid arthritis patients treated in trial and real world settings: comparison of randomized trials with registries.Rheumatology (Oxford) 2017 doi: 10.1093/rheumatology/kex394

Acknowledgments:

Part of the GLORIA project and trial, funded by the EU (Horizon 2020, Grant No 634886)

Disclosure of Interests:

Andriko Palmowski: None declared, Sabrina Mai Nielsen: None declared, Thomas Buttgereit: None declared, Yannick Palmowski: None declared, Maarten Boers: None declared, Robin Christensen: None declared, Frank Buttgereit Grant/research support from: Amgen, BMS, Celgene, Generic Assays, GSK, Hexal, Horizon, Lilly, medac, Mundipharma, Novartis, Pfizer, Roche, and Sanofi.

PARE0004 PATIENT PERSPECTIVE ON THE EFFICACY AND RISKS OF GLUCOCORTICOIDS IN RHEUMATOID ARTHRITIS – AN INTERNATIONAL SURVEY OF 1344 PATIENTS

Background:

The Glucocorticoid Low-dose Outcome in Rheumatoid Arthritis Study (GLORIA) is an international investigator-initiated pragmatic randomized trial designed to study the effects of low-dose glucocorticoids (GCs) in elderly patients with Rheumatoid Arthritis (RA).

The research team is also committed to promote a better understanding of the risks and benefits of these drugs among health professionals and patients. In order to achieve these goals, it is important to assess the current ideas and concerns of patients regarding GCs.

Objectives:

To evaluate the current patient perspective on the efficacy and risks of GCs in RA patients who are or have been treated with GCs.

Methods:

Patients with RA completed an online survey (with 5 closed questions regarding efficacy and safety) presented in their native language. RA patients were recruited through a variety of patient organizations representing three continents. Patients were invited to participate through national patient organizations. In the USA, patients were also invited to participate through MediGuard.org. Participants were asked for their level of agreement on a 5-point Likert scale.

Results:

1344 RA patients with exposure to GCs, from Brazil, USA, UK, Portugal, Netherlands, Germany and 24 other countries** participated: 89% female, mean age (SD) 52 (14) years and mean disease duration 13 (11) years. The majority of participants (84%) had ≥10 years of education. The duration of GCs exposure was 1.6 (4.2) years. The majority of participants had read articles or pamphlets on the benefits or harms of GC therapy.

Regarding GCs efficacy (table 1), high levels of endorsement were found: about 2/3 of patients considered that GCs as very useful in their case, more than half considered that GCs were effective even at low doses, and agreed that GC improved RA symptoms within days.

Regarding safety (table 1), 1/3 of the participants reported having suffered some form of serious adverse events (AEs) due to GCs, and 9% perceived this as “life-threatening. Adverse events had a serious impact on quality of life, according to about 1/3 of the respondents.

Conclusion:

Patients with RA exposed to GC report a strong conviction that GCs are very useful and effective for the treatment of their RA, even at low doses. This is accompanied by an important prevalence of serious AEs. Understanding the patient perspective can improve shared decision-making between patient and rheumatologist.

References:

Funding statement:This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 634886.

Disclosure of Interests:

Tânia Santiago: None declared, Marieke Voshaar Grant/research support from: part of phd research, Speakers bureau: conducting a workshop (Pfizer), Maarten de Wit Grant/research support from: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Consultant of: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Speakers bureau: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Pedro Carvalho: None declared, Frank Buttgereit Grant/research support from: Amgen, BMS, Celgene, Generic Assays, GSK, Hexal, Horizon, Lilly, medac, Mundipharma, Novartis, Pfizer, Roche, and Sanofi., Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Actelion, Celgene, Consultant of: Bristol-Myers Squibb, Speakers bureau: Sigma-Alpha, Maarten Boers: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis

AB1335-HPR HEALTH PROFESSIONALS’ PERSPECTIVE ON THE BENEFITS AND RISKS OF LOW-DOSE GLUCOCORTICOIDS IN RHEUMATOID ARTHRITIS – AN INTERNATIONAL SURVEY OF 444 HEALTH PROFESSIONALS

Background:

The Glucocorticoid Low-dose Outcome in Rheumatoid Arthritis Study (GLORIA) is an international investigator-initiated pragmatic randomized trial designed to study the effects of low-dose glucocorticoids (GCs) in elderly patients with Rheumatoid Arthritis (RA).

The research team is also committed to promote a better understanding of the risks and benefits of these drugs among health professionals and patients. In order to achieve these goals, it is important to assess the current ideas and concerns of patients regarding GCs.

Objectives:

To evaluate the current patient perspective on the efficacy and risks of GCs in RA patients who are or have been treated with GCs.

Methods:

Patients with RA completed an online survey (with 5 closed questions regarding efficacy and safety) presented in their native language. RA patients were recruited through a variety of patient organizations representing three continents. Patients were invited to participate through national patient organizations. In the USA, patients were also invited to participate through MediGuard.org. Participants were asked for their level of agreement on a 5-point Likert scale.

Results:

1344 RA patients with exposure to GCs, from Brazil, USA, UK, Portugal, Netherlands, Germany and 24 other countries** participated: 89% female, mean age (SD) 52 (14) years and mean disease duration 13 (11) years. The majority of participants (84%) had ≥10 years of education. The duration of GCs exposure was 1.6 (4.2) years. The majority of participants had read articles or pamphlets on the benefits or harms of GC therapy.

Regarding GCs efficacy (table 1), high levels of endorsement were found: about 2/3 of patients considered that GCs as very useful in their case, more than half considered that GCs were effective even at low doses, and agreed that GC improved RA symptoms within days.

Regarding safety (table 1), 1/3 of the participants reported having suffered some form of serious adverse events (AEs) due to GCs, and 9% perceived this as “life-threatening. Adverse events had a serious impact on quality of life, according to about 1/3 of the respondents.

Conclusion:

Patients with RA exposed to GC report a strong conviction that GCs are very useful and effective for the treatment of their RA, even at low doses. This is accompanied by an important prevalence of serious AEs. Understanding the patient perspective can improve shared decision-making between patient and rheumatologist.

Funding statement:

This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 634886.

Disclosure of Interests:

Tânia Santiago: None declared, Marieke Voshaar Grant/research support from: part of phd research, Speakers bureau: conducting a workshop (Pfizer), Maarten de Wit Grant/research support from: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Consultant of: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Speakers bureau: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Pedro Carvalho: None declared, Maarten Boers: None declared, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Actelion, Celgene, Consultant of: Bristol-Myers Squibb, Speakers bureau: Sigma-Alpha, Frank Buttgereit Grant/research support from: Amgen, BMS, Celgene, Generic Assays, GSK, Hexal, Horizon, Lilly, medac, Mundipharma, Novartis, Pfizer, Roche, and Sanofi., José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis

[Oral glucocorticoids : Therapeutic use and treatment monitoring in inflammatory rheumatic diseases]

Glucocorticoids (GC) have been proven drug substances in rheumatology for more than 70 years. They act very rapidly in high doses through membrane stabilizing effects. Genomic therapeutic effects of GC even in very low doses are mainly due to inhibition of the functions of the transcription factor nuclear factor kappa B (NFkB), which promotes the synthesis of proinflammatory mediators, adhesion molecules and other regulatory proteins. Indications for the use of GC in high doses in rheumatology are always given when a life-threatening, dangerous or treatment-resistant situation is involved. Lower doses of GC, usually administered orally, are particularly used in rheumatoid arthritis, vasculitis and collagenosis. In clinical practice the general principle is to use the smallest possible effective dose of GC for the shortest possible time in order to achieve the therapeutic effect of GC without running the risk of unacceptably severe side effects.

[Controlling glucocorticoid treatment in critically ill patients with rheumatism exemplified by systemic lupus erythematosus]

BACKGROUND

Infections are one of the most common clinical problems in patients with rheumatic diseases who need to be treated with glucocorticoids in an intensive care unit. To date, there are no recommendations for the standardized control of glucocorticoid treatment in such situations.

OBJECTIVE

Based on a literature search this paper provides an overview of evidence-based and eminence-based recommendations for the control of glucocorticoid treatment under intensive care conditions using the example of systemic lupus erythematosus.

METHODS

A systematic literature search was carried out using a MeSH term search in the PubMed database.

RESULTS

Infections are one of the most common causes for the treatment of patients with rheumatic diseases in intensive care units. In the case of systemic lupus erythematosus it is particularly challenging to distinguish the infection from increased disease activity or to treat the parallel occurrence. Patients in an intensive care unit are exposed to an increased level of physical stress due to the severity of the disease, which is why special attention should be paid to symptoms of adrenocortical insufficiency. Evidence-based recommendations for prophylaxis of an adrenal crisis only exist in relation to perioperative procedures and not for the situation of severe infections.

CONCLUSION

The use of glucocorticoids in systemic lupus erythematosus is often chronic and there is an increased risk of infections. In the case of infections (or simultaneous disease flare) adequate anti-infective treatment should be administered, the treatment with glucocorticoids should be adjusted accordingly and symptoms of adrenocortical insufficiency should simultaneously be looked for.

Efficacy and safety of selective glucocorticoid receptor modulators in comparison to glucocorticoids in arthritis, a systematic review

Background

Long-term treatment with glucocorticoids (GCs) plays an important role in the management of arthritis patients, although the efficacy/safety balance is unfavorable. Alternatives with less (severe) adverse effects but with good efficacy are needed. Selective GC receptor modulators (SGRMs) are designed to engage the GC receptor with dissociative characteristics: transactivation of genes, which is mainly responsible for unwanted effects, is less strong while trans-repression of genes, reducing inflammation, is maintained. It is expected that SGRMs thus have a better efficacy/safety balance than GCs. A systematic review providing an overview of the evidence in arthritis is lacking.

Objective

To systematically review the current literature on efficacy and safety of oral SGRMs in comparison to GCs in arthritis.

Methods

A search was performed in Medline, Embase and the Cochrane Library, from inception dates of databases until May 2017. Experimental studies involving animal arthritis models or human material of arthritis patients, as well as clinical studies in arthritis patients were included, provided they reported original data. All types of arthritis were included. Data was extracted on the SGRM studied and on the GC used as reference standard; the design or setting of the study was extracted as well as the efficacy and safety results.

Results

A total of 207 articles was retrieved of which 17 articles were eligible for our analysis. Two studies concerned randomized controlled trials (RCT), five studies were pre-clinical studies using human material, and 10 studies involved pre-clinical animal models (acute and/or chronic arthritis induced in mice or rats). PF-04171327, the only compound investigated in a clinical trial setting, had a better efficacy/safety balance compared to GCs: better clinical anti-inflammatory efficacy and similar safety.

Conclusion

Studies assessing both efficacy and safety of SGRMs are scarce. There is limited evidence for dissociation of anti-inflammatory and metabolic effects of the SGRMs studied. Development of many SGRMs is haltered in a preclinical phase. One SGRM showed a better clinical efficacy/safety balance.

Immunological characterization of the early human fracture hematoma

The initial inflammatory phase of fracture healing is of great importance for the clinical outcome. We aimed to develop a detailed time-dependent analysis of the initial fracture hematoma. We analyzed the composition of immune cell subpopulations by flow cytometry and the concentration of cytokines and chemokines by bioplex in 42 samples from human fractures of long bones <72 h post-trauma. The early human fracture hematoma is characterized by maturation of granulocytes and migration of monocytes/macrophages and hematopoietic stem cells. Both T helper cells and cytotoxic T cells proliferate within the fracture hematoma and/or migrate to the fracture site. Humoral immunity characteristics comprise high concentration of pro-inflammatory cytokines such as IL-6, IL-8, IFNγ and TNFα, but also elevated concentration of anti-inflammatory cytokines, e.g., IL-1 receptor antagonist and IL-10. Furthermore, we found that cells of the fracture hematoma represent a source for key chemokines. Even under the bioenergetically restricted conditions that exist in the initial fracture hematoma, immune cells are not only present, but also survive, mature, function and migrate. They secrete a cytokine/chemokine cocktail that contributes to the onset of regeneration. We hypothesize that this specific microenvironment of the initial fracture hematoma is among the crucial factors that determine fracture healing.

[Long-term glucocorticoid therapy : Is there a safe dosage?]

Glucocorticoids have been successfully used for a long time to treat a wide range of chronic inflammatory diseases. Despite the well-accepted efficacy, possible adverse effects still provoke discussions among patients and physicians. In particular, the long-term use of glucocorticoids at higher dosages may cause unwanted adverse effects; therefore, the question arises if conditions for a safe long-term treatment regimen with these drugs can be defined. Studies specifically and comprehensively addressing this question are missing; therefore, a multidisciplinary task force comprised of medical experts and patients was formed to analyze and discuss the existing literature in order to identify conditions where long-term glucocorticoid treatment has an acceptably low level of harm. The group agreed that the actual level of harm of long-term glucocorticoid therapy depends on both drug (dose and duration) and patient-specific characteristics. The patient-specific parameters (some of which can be modified by patients and/or physicians) should always be monitored before and during treatment with glucocorticoids and optimized if necessary. A positive benefit-risk ratio can be achieved when current knowledge and existing recommendations are kept in mind and implemented in clinical practice.

Nanocoating with plant-derived pectins activates osteoblast response in vitro

A new strategy to improve osseointegration of implants is to stimulate adhesion of bone cells, bone matrix formation, and mineralization at the implant surface by modifying surface coating on the nanoscale level. Plant-derived pectins have been proposed as potential candidates for surface nanocoating of orthopedic and dental titanium implants due to 1) their osteogenic stimulation of osteoblasts to mineralize and 2) their ability to control pectin structural changes. The aim of this study was to evaluate in vitro the impact of the nanoscale plant-derived pectin Rhamnogalacturonan-I (RG-I) from potato on the osteogenic response of murine osteoblasts. RG-I from potato pulps was isolated, structurally modified, or left unmodified. Tissue culture plates were either coated with modified RG-I or unmodified RG-I or - as a control - left uncoated. The effect of nanocoating on mice osteoblast-like cells MC3T3-E1 and primary murine osteoblast with regard to proliferation, osteogenic response in terms of mineralization, and gene expression of Runt-related transcription factor 2 (Runx2), alkaline phosphate (Alpl), osteocalcin (Bglap), α-1 type I collagen (Col1a1), and receptor activator of NF-κB ligand (Rankl) were analyzed after 3, 7, 14, and 21 days, respectively. Nanocoating with pectin RG-Is increased proliferation and mineralization of MC3T3-E1 and primary osteoblast as compared to osteoblasts cultured without nanocoating. Moreover, osteogenic transcriptional response of osteoblasts was induced by nanocoating in terms of gene induction of Runx2, Alpl, Bglap, and Col1a1 in a time-dependent manner - of note - to the highest extent under the PA-coating condition. In contrast, Rankl expression was initially reduced by nanocoating in MC3T3-E1 or remained unaltered in primary osteoblast as compared to the uncoated controls. Our results showed that nanocoating of implants with modified RG-I beneficially 1) supports osteogenesis, 2) has the capacity to improve osseointegration of implants, and is therefore 3) a potential candidate for nanocoating of bone implants.

What Is the Relationship Between Morning Symptoms and Measures of Disease Activity in Patients With Rheumatoid Arthritis?

OBJECTIVE

Little is known about the relationship between morning symptoms of rheumatoid arthritis (RA) and measures of disease activity currently used to assess RA. Information available from the Circadian Administration of Prednisone in Rheumatoid Arthritis (CAPRA-2) study was used to investigate these relationships.

METHODS

CAPRA-2 included 350 patients with RA who were symptomatic despite treatment with disease-modifying antirheumatic drugs, randomized 2:1 to additional treatment with a 5-mg daily dose of delayed-release prednisone or placebo. Pearson's correlations were used to evaluate the relationships between change from baseline in symptoms (duration of morning stiffness, severity of morning stiffness, and intensity of pain on waking) and measures of disease activity (the American College of Rheumatology 20% improvement criteria [ACR20], the Disease Activity Score in 28 joints [DAS28], and the Health Assessment Questionnaire disability index). Correlations were defined as weak (<0.3), moderate (0.3-0.7), or strong (>0.7).

RESULTS

There was a strong correlation between the severity of morning stiffness and the intensity of morning pain (Pearson's correlation 0.91, P < 0.001). There was a weak correlation between the duration of morning stiffness and measures of disease activity (0.24-0.28), with moderate correlations between the severity of morning stiffness or intensity of pain on waking and DAS28 or ACR20 scores (0.44-0.48). Severity of morning stiffness showed less variability and a greater effect size than did duration of morning stiffness.

CONCLUSION

Morning symptoms and measures of disease activity show weak to moderate correlations. Severity of morning stiffness showed less variability and greater effect size than did duration of morning stiffness. These findings suggest that severity is the preferred construct to measure the impact of morning stiffness in patients with RA, information that is not fully captured in the RA core set.