Incidence and risk factors of major cardiovascular events in rheumatoid arthritis and psoriatic arthritis: A population-based cohort study

OBJECTIVE

To evaluate the incidence and risk factors of major adverse cardiovascular events (MACE) in rheumatoid arthritis (RA) and psoriatic arthritis (PsA) patients.

METHODS

A population-based retrospective cohort of RA and PsA patients was identified in a citywide database. All patients recruited from Jan 2006 to Dec 2015 were followed until the end of 2018. The outcome was the occurrence of a first MACE. Covariates of interest included traditional cardiovascular (CV) risk factors, inflammatory markers and pharmacotherapies. The independent predictors of MACE were identified by the time-dependent cox proportional hazard models.

RESULTS

A total of 13,905 patients (12,233 RA and 1,672 PsA) were recruited. After a total of 119,571 patient-years of follow-up, 934 (6.7%) patients developed a first MACE. RA and PsA patients had similar adjusted incidence (incidence rate ratio 0.96, 95 % CI 0.75-1.22, p = 0.767). After adjusting for traditional CV risk factors, the time-varying erythrocyte sedimentation (ESR) rate and C-reactive protein (CRP) levels, and the use of glucocorticoids were independently associated with higher risk of MACE in both the RA and PsA cohorts. In RA, the use of methotrexate and non-steroidal anti-inflammatory drugs (NSAIDs) were associated with fewer MACE. The use of biologic disease modifying anti-rheumatic drugs was not associated with MACE in both RA and PsA.

CONCLUSION

The incidence of MACE was similar in RA and PsA. Systemic inflammation and glucocorticoid use independently increased the risk of MACE in inflammatory arthritis, while methotrexate and NSAIDs use were protective against the development of MACE in RA.

Safety of the JAK and TNF inhibitors in rheumatoid arthritis: real world data from the Hong Kong Biologics Registry

OBJECTIVES

To compare the incidence of major adverse cardiovascular events (MACEs), cancer and infective complications in RA patients using Janus kinase (JAKis) and TNF (TNFis) inhibitors.

METHOD

A retrospective analysis of data from the Hong Kong Biologics Registry 2008-2021 was performed. RA patients who had ever used JAKis or TNFis were included. The incidence of MACEs, cancer and infections were compared between the two groups, with adjustment for confounding factors.

RESULTS

A total of 2471 courses of JAKis (n = 551) and TNFis (n = 1920) were used in 1732 RA patients (83.7% women, age 53.8 [12.5] years; follow-up 6431 patient-years). JAKi users had significantly older age, more atherosclerotic risk factors and higher frequency of past malignancies. A total of 15 and 40 MACEs developed in the JAKi and TNFi users, respectively (incidence 1.34 vs 0.75 per 100 patient-years; P = 0.22). There was no significant difference in the incidence of cancers between the two groups (0.81 [JAKi] vs 0.85 [TNFi] per 100 patient-years; P = 0.25). The adjusted hazard ratios of MACE and cancer in the JAKi users were 1.36 (95% CI: 0.62, 2.96) (P = 0.44) and 0.87 (95% CI: 0.39, 1.95) (P = 0.74), respectively. Rates of infections were significantly higher in the JAKi than TNFi users (16.3 vs 9.9 per 100 patient-years; P = 0.02), particularly herpes zoster (3.49 vs 0.94 per 100 patient-years; P < 0.001).

CONCLUSIONS

In a real-life setting, there is no increase in MACEs or cancers in users of JAKis compared with TNFis. However, the incidence of non-serious infections, including herpes zoster, was increased in users of JAKis.

Moderate and high disease activity levels increase the risk of subclinical atherosclerosis progression in early rheumatoid arthritis: a 5-year prospective study

OBJECTIVES

To elucidate the association between different disease activity levels over time on long-term vascular outcomes in patients with early rheumatoid arthritis (ERA).

METHODS

This was a 5-year prospective study. Patients with consecutive ERA without overt cardiovascular disease (CVD) were recruited to receive 1 year of tight-control treatment followed by standard-of-care management. High-resolution carotid ultrasound was assessed at baseline and year 5. The primary outcome was subclinical atherosclerosis progression (AP+), defined as the occurrence of incident plaque, increased region harbouring plaques and/or maximum carotid intima-media thickness progression ≥0.9 mm at year 5. Inflammatory burden during the follow-up period was represented by the cumulative average Disease Activity Score 28-erythrocyte sedimentation rate (ca-DAS28-ESR). Persistent low disease activity (LDA) or remission state was defined as ca-DAS28-ESR≤3.2.

RESULTS

One-hundred and four patients with ERA (age: 52±11 years, 81 (77.9%) female) were included in this analysis. Fifty-two (50%) patients achieved persistent LDA or remission and 42 patients (40.4%) had AP+. Patients in the AP+ group were older and had more traditional cardiovascular risk factors at baseline. Multivariate logistic regression analysis revealed that patients with persistent moderate or high disease activity (ca-DAS28-ESR>3.2) had a significantly increased risk of AP+ (OR 5.05, 95% CI 1.53, 16.64, p=0.008) compared with those who achieved persistent remission. The risk of AP+ was similar in patients who achieved persistent LDA and remission.

CONCLUSIONS

Achieving persistent LDA or remission may prevent progression of atherosclerosis in ERA. A treat-to-target approach aiming at sustained LDA or remission may reduce the risk of CVD by preventing AP+.

Inflammation is associated with incident hypertension in patients with axial spondyloarthritis: A longitudinal cohort study

OBJECTIVES

To elucidate the risk factors for the development of incident hypertension (IHT) in patients with axial spondyloarthritis (axSpA).

METHODS

We conducted a retrospective cohort study in axSpA patients who were recruited from 2001 to 2019 from a university clinic in Hong Kong. Patients with HT and/or anti-hypertensive drug use at baseline were excluded. They were followed until the end of 2020. The outcome was IHT, defined by a diagnosis and a prescription for an antihypertensive drug. Baseline and time-varying Cox regression analyses adjusting for age, sex, and body mass index (BMI), were used to assess the relationship between drug use, inflammatory burden, and IHT.

RESULTS

Four hundred and thirteen patients [age: 34(25-43) years, male: 319 (77.2%)] were recruited. After a median follow-up of 12 (6-17) years, 58 patients (14%) developed IHT (IHT+group). Among all the baseline variables, disease duration and delay in diagnosis were the independent predictors for IHT based on the Cox regression model. In the multivariate Cox regression analysis, baseline disease duration, delay in diagnosis and time-varying ESR levels were independent predictors associated with an increased risk of IHT. IHT risk was significantly increased in patients with disease duration >5 years. The use of anti-inflammatory drugs was not associated with the development of IHT.

CONCLUSION

Higher inflammatory burden as reflected by a longer disease duration, delay diagnosis and higher ESR levels, were predictors associated with IHT after adjusting for traditional CV risk factors. These data support routine screening for hypertension in axSpA patients, especially those with longer disease duration.

Time and dose-dependent effect of systemic glucocorticoids on major adverse cardiovascular event in patients with rheumatoid arthritis: a population-based study

OBJECTIVES

Cardiovascular event (CVE) risk in rheumatoid arthritis (RA) was increased by glucocorticoids (GC) use. Whether there is a threshold dose and duration of GC use beyond which will increase CVE rate remains controversial. We studied the time-varying effect of GC and its dose on the risk of incident major adverse cardiovascular events (MACE) in patients with RA.

METHODS

Patients with RA without MACE at baseline were recruited from a Hong Kong citywide database from 2006 to 2015 and followed till 2018. The primary outcome was the first occurrence of an MACE. Cox regression and inverse probability treatment weighting analyses with time-varying covariates were used to evaluate the association of GC and MACE, adjusting for demographics, traditional CV risk factors, inflammatory markers and the usage of antirheumatic drugs.

RESULTS

Among 12 233 RA patients with 105 826 patient-years of follow-up and a mean follow-up duration of 8.7 years, 860 (7.0%) developed MACE. In the time-varying analyses after controlling for confounding factors, a daily prednisolone dose of ≥5 mg significantly increased the risk of MACE (erythrocyte sedimentation rate model: HR 2.02, 95% CI 1.72 to 2.37; C reactive protein model: HR 1.87, 95% CI 1.60 to 2.18), while a daily dose below 5 mg was not associated with MACE risk, compared with no GC use. In patients receiving daily prednisolone ≥5 mg, the risk of incident MACE was increased by 7% per month.

CONCLUSIONS

GC was associated with a duration and dose-dependent increased risk of MACE in patients with RA. Very low dose prednisolone (<5 mg daily) did not appear to confer excessive CV risk.

Role of inflammatory burden and treatment on joint space width in psoriatic arthritis-a high-resolution peripheral quantitative computed tomography study

BACKGROUND

To investigate the relationship between disease-related parameters and joint space width (JSW) on high-resolution peripheral quantitative computed tomography (HR-pQCT) in psoriatic arthritis (PsA) patients.

METHODS

PsA patients who underwent HR-pQCT examination of the second to fourth metacarpophalangeal joint (MCPJ 2-4) were recruited in this cross-sectional study. The joint space metrics included joint space volume (JSV), mean, minimum, and maximum JSW, JSW asymmetry, and distribution. Correlation analysis and multivariable linear regression models were used to determine the association between disease-related variables and JSW.

RESULTS

Sixty-seven patients [37 (55.2%) males; median (IQR) age: 57.0 (53.0, 63.0); median disease duration: 21 (16, 28) years] were included in this analysis. Multivariable linear regression analysis demonstrated that males had larger JSV (MCPJ 2-4), mean (MCPJ 4), and maximum JSW (MCPJ 3). Longer disease duration (MCPJ 2-3) and higher ESR values (MCPJ 3) were negatively associated with mean and maximum JSW, while higher damage joint count was negatively associated with mean and minimum JSW (MCPJ 2). Use of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) was negatively associated with minimum JSW (MCPJ 3) while use of biologic DMARDs (bDMARDs) was positively associated with minimum JSW (MCPJ 2).

CONCLUSION

Higher inflammatory burden as reflected by longer disease duration, higher ESR levels, and damage joint count was negatively associated with mean, maximum, and minimum JSW, while suppression of inflammation using bDMARDs seems to limit the decline in JSW.

Urinary Long Non-Coding RNA Levels as Biomarkers of Lupus Nephritis

BACKGROUND

Emerging evidence suggests that long non-coding RNA (lncRNA) plays important roles in the regulation of gene expression. We determine the role of using urinary lncRNA as a non-invasive biomarker for lupus nephritis.

METHOD

We studied three cohorts of lupus nephritis patients (31, 78, and 12 patients, respectively) and controls (6, 7, and 24 subjects, respectively). The urinary sediment levels of specific lncRNA targets were studied using real-time quantitative polymerase chain reactions.

RESULTS

The severity of proteinuria inversely correlated with urinary maternally expressed gene 3 (MEG3) (r = -0.423, p = 0.018) and ANRIL levels (r = -0.483, p = 0.008). Urinary MEG3 level also inversely correlated with the SLEDAI score (r = -0.383, p = 0.034). Urinary cancer susceptibility candidate 2 (CASC2) levels were significantly different between histological classes of nephritis (p = 0.026) and patients with pure class V nephritis probably had the highest levels, while urinary metastasis-associated lung carcinoma transcript 1 (MALAT1) level significantly correlated with the histological activity index (r = -0.321, p = 0.004). Urinary taurine-upregulated gene 1 (TUG1) level was significantly lower in pure class V lupus nephritis than primary membranous nephropathy (p = 0.003) and minimal change nephropathy (p = 0.04), and urinary TUG1 level correlated with eGFR in class V lupus nephritis (r = 0.706, p = 0.01).

CONCLUSIONS

We identified certain urinary lncRNA targets that may help the identification of lupus nephritis and predict the histological class of nephritis. Our findings indicate that urinary lncRNA levels may be developed as biomarkers for lupus nephritis.

Reduced bone mineral density in patients with idiopathic inflammatory myopathies: a case-control study

Background

Patients with idiopathic inflammatory myopathies (IIMs) are at risk of reduced bone mineral density (BMD).

Objectives

To compare the prevalence of reduced BMD between patients with IIMs and controls and to determine its risk factors.

Design

This was a single-center case-control study.

Methods

BMD was assessed by dual-energy X-ray absorptiometry. The prevalence of reduced BMD in IIM patients and age-and sex-matched non-rheumatological controls was compared. The BMD results of female IIM were also compared to age-matched female rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) patients. Independent factors associated with reduced BMD in IIM patients were identified by multivariate analyses.

Results

A total of 230 patients (IIM: 65, non-rheumatological controls: 65, RA: 50, SLE: 50) were recruited. The mean age of IIM patients was 58.6 ± 11.0 years and 76.9% were females. Significantly, more IIM patients had reduced BMD (73.8% versus 43.1%, p = 0.043) and osteoporosis (29.2% versus 13.8%, p = 0.033) than non-rheumatological controls. Multivariate analysis confirmed that IIM was independently associated with reduced BMD (OR: 2.12, p = 0.048, 95% CI: 1.01-4.46). The prevalence of reduced BMD was not significantly different between IIM, RA, and SLE patients but the mean hip BMD was the lowest in the IIM group (0.641 ± 0.152 g/cm²versus 0.663 ± 0.102g/cm² in the RA group versus 0.708 ± 0.132 g/cm² in the SLE group, p = 0.035). Lower body mass index and more advanced age were independently associated with lower BMD in IIM patients.

Conclusion

Reduced BMD was more prevalent in IIM patients than in non-rheumatological controls. Hip BMD was lower in patients with IIMs than RA or SLE. Close monitoring and early treatment are encouraged especially in patients with risk factors.

Telemedicine for follow-up of systemic lupus erythematosus during the 2019 coronavirus pandemic: A pragmatic randomized controlled trial

INTRODUCTION

Patients with systemic lupus erythematous were vulnerable to severe coronavirus disease 2019 infection and the negative impact of disrupted healthcare delivery. Telemedicine has been a popular alternative to standard in-person care during the pandemic despite the lack of evidence.

METHODS

This was a 1-year pragmatic randomized-controlled trial. Patients followed at the lupus nephritis clinic were randomized to either telemedicine or standard follow-up in a 1:1 ratio. Patients in the telemedicine group were followed up via videoconferencing. Standard follow-up group patients continued conventional in-person outpatient care. The primary outcome of the study was the proportion of patients in low disease activity after 1 year. Secondary outcomes included cost-of-illness, safety, and various patient-reported outcomes.

RESULTS

From 6/2020 to 12/2021, 144 patients were randomized and 141 patients (telemedicine: 70, standard follow-up: 71) completed the study. At 1 year, 80.0% and 80.2% of the patients in the telemedicine group and standard follow-up group were in lupus low disease activity state or complete remission, respectively (p = 0.967). Systemic lupus erythematous disease activity indices, number of flares and frequency of follow-ups were also similar. There were no differences in the cost-of-illness, quality of life or mental health scores. However, significantly more patients in the telemedicine group (41.4% vs 5.6%; p < 0.001) required switch of mode of follow-up and higher proportion of them had hospitalization during the study period (32.9% vs 15.5%; p = 0.016). Being in the telemedicine group or not in low disease activity at baseline were the independent predictors of hospitalization (odds ratio: 2.6; 95% confidence interval: 1.1-6.1, odds ratio: 2.7, 95% confidence interval: 1.1-6.7, respectively) in the post hoc analysis.

CONCLUSIONS

In patients with systemic lupus erythematous, telemedicine predominant follow-up resulted in similar 1-year disease control compared to standard care. However, it needed to be complemented by in-person visits, especially in patients with unstable disease.

The Hong Kong Society of Rheumatology consensus recommendations for the management of gout

Gout is one of the most common noncommunicable diseases in Hong Kong. Although effective treatment options are readily available, the management of gout in Hong Kong remains suboptimal. Like other countries, the treatment goal in Hong Kong usually focuses on relieving symptoms of gout but not treating the serum urate level to target. As a result, patients with gout continue to suffer from the debilitating arthritis, as well as the renal, metabolic, and cardiovascular complications associated with gout. The Hong Kong Society of Rheumatology spearheaded the development of these consensus recommendations through a Delphi exercise that involved rheumatologists, primary care physicians, and other specialists in Hong Kong. Recommendations on acute gout management, gout prophylaxis, treatment of hyperuricemia and its precautions, co-administration of non-gout medications with urate-lowering therapy, and lifestyle advice have been included. This paper serves as a reference guide to all healthcare providers who see patients who are at risk and are known to have this chronic but treatable condition.

The temporal trend of disease burden attributable to metabolic risk factors in China, 1990-2019: An analysis of the Global Burden of Disease study

Background and aims

The disease burden attributable to metabolic risk factors is rapidly increasing in China, especially in older people. The objective of this study was to (i) estimate the pattern and trend of six metabolic risk factors and attributable causes in China from 1990 to 2019, (ii) ascertain its association with societal development, and (iii) compare the disease burden among the Group of 20 (G20) countries.

Methods

The main outcome measures were disability-adjusted life-years (DALYs) and mortality (deaths) attributable to high fasting plasma glucose (HFPG), high systolic blood pressure (HSBP), high low-density lipoprotein (HLDL) cholesterol, high body-mass index (HBMI), kidney dysfunction (KDF), and low bone mineral density (LBMD). The average annual percent change (AAPC) between 1990 and 2019 was analyzed using Joinpoint regression.

Results

For all six metabolic risk factors, the rate of DALYs and death increased with age, accelerating for individuals older than 60 and 70 for DALYs and death, respectively. The AAPC value in rate of DALYs and death were higher in male patients than in female patients across 20 age groups. A double-peak pattern was observed for AAPC in the rate of DALYs and death, peaking at age 20-49 and at age 70-95 plus. The age-standardized rate of DALYs increased for HBMI and LBMD, decreased for HFPG, HSBP, KDF, and remained stable for HLDL from 1990 to 2019. In terms of age-standardized rate of DALYs, there was an increasing trend of neoplasms and neurological disorders attributable to HFPG; diabetes and kidney diseases, neurological disorders, sense organ diseases, musculoskeletal disorders, neoplasms, cardiovascular diseases, digestive diseases to HBMI; unintentional injuries to LBMD; and musculoskeletal disorders to KDF. Among 19 countries of Group 20, in 2019, the age-standardized rate of DALYs and death were ranked fourth to sixth for HFPG, HSBP, and HLDL, but ranked 10th to 15th for LBMD, KDF, and HBMI, despite the number of DALYs and death ranked first to second for six metabolic risk factors.

Conclusions

Population aging continuously accelerates the metabolic risk factor driven disease burden in China. Comprehensive and tight control of metabolic risk factors before 20 and 70 may help to mitigate the increasing disease burden and achieve healthy aging, respectively.

High inflammatory burden predicts cardiovascular events in patients with axial spondyloarthritis: a long-term follow-up study

Background

Axial spondyloarthritis (axSpA) patients are at higher risk of cardiovascular (CV) disease (CVD) than the general population, partly due to consequences of inflammation or its treatment. But relationship between inflammation in axSpA and cardiovascular events (CVE) is unknown.

Objectives

To examine whether inflammatory burden over time can predict CVE independent of baseline CV risk factors in axSpA patients.

Design

A cohort analysis was performed in patients who had been recruited since January 2001. The primary outcome was a first CVE occurring between January 2001 and December 2020.

Methods

Three CVD risk scores were computed at baseline. The performance of the original and modified (*1.5 multiplication factor) CV risk algorithms were assessed. Time-varying Cox proportional hazard models and Kaplan-Meier survival analysis were used to assess whether inflammatory burden (Bath ankylosing spondylitis disease activity index [BASDAI] and inflammatory markers), nonsteroidal anti-inflammatory drugs (NSAIDs) and disease modifying antirheumatic drugs (DMARDs) can predict the development of first CVE.

Results

463 patients (35 [26-45] years, male: 360 [77.8%]) were recruited. After a median follow-up of 12 (7-19) years, 61 patients (13.2%) experienced a first CVE. Traditional/modified CV risk scores underestimated CV risk. Erythrocyte sedimentation rate (ESR) ⩾ 20 mm/h was associated with a significantly higher risk of CVE during follow-up (HR: 2.07, 95%CI [1.10, 3.98], p = 0.008). Active disease as indicated by a rising BASDAI also showed positive trend towards a higher risk of developing CVE over time. After adjusting for CV risk scores in the multivariable models, high ESR level (ESR ⩾ 20 mm/h) over time remained significantly associated with a higher risk of developing CV events.

Conclusion

Increased inflammatory burden as reflected by elevated ESR levels (ESR ⩾ 20) was associated with increased risk of CVE, while the use of NSAIDs and DMARDs were not.

Serum Calprotectin Level Is Independently Associated With Carotid Plaque Presence in Patients With Psoriatic Arthritis

Background

Whether calprotectin could play a role in augmenting cardiovascular (CV) risk in patients with psoriatic arthritis (PsA) remains uncertain. The aim of this study is to elucidate the association between serum calprotectin level and subclinical atherosclerosis in patient with PsA.

Method

Seventy-eight PsA patients (age: 52 ± 10 years, 41 [52.6%] male) without CV disease were recruited into this cross-sectional study. Carotid intima-media thickness (cIMT) and the presence of plaque were determined by high-resolution ultrasound. Calprotectin levels in serum were quantified by enzyme-linked immunosorbent assay. The variables associated with the presence of carotid plaque (CP) were selected from the least absolute shrinkage and selection operator (LASSO) regression analysis.

Results

29/78 (37.2%) of patient had carotid plaque (CP+ group). Serum calprotectin level was significantly higher in the CP+ group (CP− group: 564.6 [329.3–910.5] ng/ml; CP+ group: 721.3 [329.3–910.5] ng/ml, P = 0.005). Serum calprotectin level correlated with PsA disease duration (rho = 0.280, P = 0.013) and mean cIMT (rho = 0.249, P = 0.038). Using LASSO regression analysis, the levels of Ln-calprotectin (OR: 3.38, 95% CI [1.37, 9.47]; P = 0.026) and PsA disease duration (OR: 1.09, 95% CI [1.01, 1.18]; P = 0.013) were screened out from a total of 19 variables. The model in predicting the presence of CP was constructed by Ln-calprotectin and PsA disease duration with an area under the receiver-operating characteristic (ROC) curve of 0.744, (95 CI% [0.59, 0.80], P = 0.037).

Conclusion

Serum calprotectin level is associated with the presence of CP in PsA. Further studies are required to confirm whether this pathway is associated with CV events in PsA.

POS0372 USE OF TELEMEDICINE FOR FOLLOW-UP OF LUPUS NEPHRITIS IN THE COVID-19 OUTBREAK: ONE-YEAR, PRAGMATIC RANDOMISED CONTROLLED TRIAL

Background

Patients with systemic lupus erythematosus (SLE) are at increased risk of severe COVID-19 due to the underlying disease, comorbidities and use of immunosuppressants (IS). An alternative option would be to adopt telemedicine (TM) to maintain medical care while minimizing exposure. Despite being widely adopted during the pandemic, the evidence supporting the use of TM in rheumatology has been limited.

Objectives

We primarily aimed to evaluate the effectiveness to maintain disease activity control using TM delivered care compared to conventional in-person follow-up in patients with lupus nephritis (LN). The secondary objectives were to compare the patient reported outcomes, safety and cost-of-illness from the patient’s perspective between the 2 modes of health care delivery.

Methods

This was a 1-year, single-center, RCT conducted at a regional hospital in Hong Kong. From May 2020, consecutive adult patients with a SLE according to the 2019 EULAR/ACR classification criteria followed up at the LN clinic were invited to participate in the study. Participants were randomized 1:1 to either TM (TM group) or standard FU (SF group). Patients randomized to receive TM FU were scheduled for a video consultation via a commerical software ZOOM. Patients in the SF group received standard in-person outpatient care. SLE disease activity at each consultation was assessed by SLEDAI-2k and physician global assessment (PGA).

Results

A total of 144 patients with LN were randomized and 3 patients self-withdrew from the study. The mean age was 44.5±11.4 years and the median time from diagnosis to randomization was 168 months (range: 1-528). Most of the patients had class III, IV or V LN (87.2%) and were on prednisolone (89.4%, median dose 5mg daily). Many of them (68.1%) were on IS. While 66.0% of the patients were in lupus low disease activity state (LLDAS), none had disease remission. There were no baseline differences, including demographics, SLEDAI-2k (TM: 3.8±2.3, SF: 3.2±2.2, p=0.13, PGA (TM: 6.2±6.5, SF: 4.6±5.9, p=0.13) and SLE damage index (TM: 1.1±1.3, SF: 0.8±1.1, p=0.10), between the 2 groups.

At one year, 80.0% and 80.2% of the patients in the TM group and SF group were in LLDAS or remission respectively. SLE disease activity indices including SLEDAI-2k, PGA, proteinuria amount and serum anti-ds-DNA level remained similar between the 2 groups. Within the study period, 28 (40%) patients in the TM group and 21 (29.6%) patients in the SF group had disease flare (p=0.20). There were no differences in the SF-36, lupusQoL and HADS scores between the 2 groups at the end of the study. The overall patient satisfaction score was higher in the TM group with a significantly shorter waiting time before seeing doctors. At the end of the study, 67.9% of the overall participants agreed to (versus 15.0% who did not agree to) use TM as a mode of future FU.

The mean indirect costs of illness (HKD26,681 vs HKD12,016, p=0.20) and the out-of-pocket costs for health care services were similar between the 2 groups (TM: HKD13,547 vs SF: HKD12,297, p=0.83) in one year. The total number of FU was similar (TM: 6.0±2.0, SF: 5.7±1.7, p=0.40). However, significantly more patients in the TM group (29/70, 41.4% vs 4/71, 5.6%; p<0.01) requested change mode of FU. The proportion of patients requiring hospitalization during the study period was also higher in the TM group (TM: 23/70, 32.9% vs 11/71, 15.5%; p=0.02). After adjusting for age and prednisolone dosage, not being in LLDAS at baseline was the predictor of hospitalization (OR 3.4, 95%CI 1.20-9.65). None of the participants was tested positive for COVID-19.

Conclusion

TM FU resulted in similar 1-year disease activity control and better satisfaction in patients with LN compared to standard care. However, a significant proportion of patients cared by TM required in-person visits or were hospitalized. The results of the study suggest that TM delivered care could help minimizing exposure to COVID-19, but it needs to be complemented by physical visits, particularly in those with unstable disease.

Acknowledgements

We would also like to thank the University of Central Lancashire & East Lancashire Hospitals NHS Trust for granting us permission to use the LupusQoL questionnaire.

Disclosure of Interests

None declared

POS0779 STANDARDIZED MORTALITY RATIO AND RISK FACTORS FOR DEATH IN SOUTHERN CHINESE PATIENTS WITH THE ANTIPHOSPHOLIPID SYNDROME (APS)

Objectives

To report the mortality rate and risk factors for death in southern Chinese patients with the antiphospholipid syndrome (APS)

Methods

The HKAPS registry was established in early 2020 by the Hong Kong Society of Rheumatology to study the outcomes of Chinese patients with APS treated in public hospitals in Hong Kong. Patients aged ≥18 years were identified by the Hospital Authority Clinical Data retrieval system using the ICD-10 diagnostic code of APS. The medical history and APS diagnosis was verified by sub-investigators in different hospitals using the 2006 modified consensus criteria for the APS. Eligible patients were classified into definite APS or probable APS, which was further categorized into primary (without underlying rheumatic diseases) and secondary types. The treatment and outcome (recurrence and mortality) of the patients was studied by Kaplan-Meier analysis and risk factors for recurrence of thrombosis and mortality were studied by Cox regression.

Results

428 APS patients were studied - 282 fulfilled the 2006 criteria for APS while 146 patients had probable APS (anti-phospholipid [aPL] antibodies positive once or with non-criteria manifestations). All were ethnic Chinese. The mean age at diagnosis was 44.1±15.6 years and the female to male ratio was 3.4:1. APS was primary in 211 patients and secondary to concomitant rheumatic diseases in 217 patients (SLE in 89.9%). 369(86.4%) patients had thromboembolic manifestations, 85(19.9%) had obstetric morbidities and 20(4.7%) had both. In patients with secondary APS, 23% thrombotic or obstetric manifestations occurred before diagnosis of the rheumatic diseases. Lupus anticoagulant (LAC), moderate/high titers of IgG anticardiolipin and anti-β2glycoprotein-1 antibodies was present in 326(76.1%), 242(56.5%) and 29(6.7%) patients, respectively. 137(32%) patients were double positive while 19(4.4%) patient was triple positive for these aPL antibodies. Among the thromboembolic manifestations, arterial thrombosis (n=201) was more common than venous thrombosis (n=186). The following treatment regimens were used: warfarin (63.6%), aspirin plus subcutaneous heparin (6.8%), aspirin plus warfarin (3%), aspirin alone (17.8%) and direct oral anticoagulant (DOAC) (2.8%). Bleeding complications developed in 77(18%) patients.

After a mean follow-up of 8.0±14.1 years, recurrence of thromboembolic or obstetric complications occurred in 83(19.4%) and 14(3.3%) patients, respectively (1 patient had recurrence of both thrombosis and obstetric complications). Cox regression did not reveal any factors significantly associated with recurrence of thrombosis. A total of 67(15.7%) patients succumbed (median time to death 7.3 years). The causes of death were vascular in 29.9% (intracranial haemorrhage [35%], myocardial infarction [30%], limb ischemia [10%], ischemic stroke[10%], bowel ischemia[5%]) and non-vascular in 70.1% of patients (infection [59.6%], malignancy [10.6%], SLE activity [6.4%], pulmonary arterial hypertension [2.1%], organ failure [6.4%] and others). The cumulative risk of mortality over time was 6.4% at 5 years and 11.9% at 10 years. The age and sex adjusted standardized mortality ratio (SMR) of our APS patients relative to the general population was 18.2(14.2-23.0). In patients with thrombotic APS, mortality was associated with older age (≥60 years) (HR 2.57[1.34-4.95]) and the presence of LAC (HR 2.01[1.07-3.75]), adjusted for age, sex and vascular risk factors that included hypertension, diabetes mellitus, dyslipidaemia, smoking and atrial fibrillation.

Conclusion

APS in southern Chinese is relatively uncommon and most cases were associated with SLE. In contrast to the Caucasians, venous thrombosis related to APS is less frequent. Over 8 years, recurrence of thrombotic events is uncommon. The mortality of APS in our Chinese patients was increased, with older age and the presence of LAC being independent risk factors.

Disclosure of Interests

None declared

AB0761 Are we treating-to-target in spondyloarthritis (SpA)? A cross sectional analysis from the Asia Pacific League of Associations for Rheumatology (APLAR) SpA Registry

Background

Data on the extent of treat-to-target (T2T) recommendations application in SpA patients across Asia Pacific region is lacking. APLAR SpA Registry aimed to assess the utility of T2T on long term clinical outcomes, and to improve disease management and inform health care policy.

Objectives

To provide a snapshot of the registry including demographics, disease activity and medication use.

Methods

Patients fulfill the CASPAR 2006 for psoriatic arthritis (PsA) and 2009 ASAS criteria for axial spondylitis (AxSpA) were recruited. This cross sectional analysis included the first 188 patients recruited across 7 Asia Pacific regions (Hong Kong, Singapore, Korea, Thailand, India, Qatar & Pakistan).

Results

83 patients PsA and 115 AxSpA patients were included. They had moderate inflammation (DAPSA: 19.61±14.29, ASDAS: 2.32±1.07). Majority of PsA patients received conventional synthetic disease-modifying drug (csDMARDs, 81%) with relatively low prevalence of biologic DMARDs (bDMARDs) (24%). Most AxSpA patients used NSAIDs (79%) while nearly half of them received bDMARDs (49%). Other details listed in Table 1. Prevalence of bDMARDs use in our registry was lower than that from the USA (Corrona PsA Registry, 59%), Turkey & Canada (PsArt-ID, 40%) and the Netherlands AxSpA registry (56%) (1-3). Regarding T2T, 28% and 44% of PsA patient achieved minimal disease activity (MDA) and Disease Activity in Psoriatic Arthritis low disease activity (DAPSA LDA) respectively. The proportion of patients achieving target in other cohorts were 46% for MDA (PsArt-ID) and 46% for DAPSA LDA (Corrona) (1, 2). 37% and 47% of AxSpA patient achieved Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)<4 and Ankylosing Spondylitis Disease Activity Score (ASDAS) LDA. Proportion of patients achieving ASDAS LDA were similar to the Netherlands registry for patients with ASDAS LDA or BASDAI<4 (Figure 1A)(3). Patient on bDMARD were more likely to achieve treatment target (Figure 1B). There were no significant difference between socio-economic status and disease features between bDMARD user and non-user.

Table 1.

Demographics, clinical features and disease activity of patients

PsA (n=83)AxSpA (n=115)Age50.012.836.512.4Male n, %4251%8583%Asian n, %83100%10196%Disease duration, years7.17.35.27.6Any sacroiliitis n, %10299%HLA B27, positive n, %9189%Duration of early morning stiffness, min30392529Tender joint count7901Swollen joint count3400No. of dactylitis digit1100PASI4.05.0SPRACC1201BASDAI2.82.0ESR, mm/h31262016CRP, mg/L10151127HAQ-DI0.610.610.390.51DAPSA19.6114.29ASDAS CRP2.321.07

Data given in mean SD unless stated

. No. of case from Hong Kong 40; Singapore 46; Korea 24; Thailand 20, India 15; Qatar 10; Pakistan 33; HLA - human leucucyte antigen; PASI - psoriasis area and severity index; SPRACC - Spondyloarthritis Research Consortium of Canada Enthesitis Index; BASDAI - Bath Ankylosing Spondylitis Disease Activity Index; ESR - erythrocyte sedimentation rate; CRP - C-reactive protein; HAQ-DI - Health assessment questionnaire disability index; DAPSA - Disease activity in Psoriatic Arthritis; ASDAS - Ankylosing Spondylitis Disease Activity Score

Figure 1.

(A) Achievement of LDA in APLAR SpA registry and other registry and (B) use of bDMARDs among patients in APLAR SpA registry with or without achieving LDA

Conclusion

Patient using bDMARDs were more likely to achieve treatment target. We expect that when T2T is widely applied, better outcomes will be reported in future.

References

[1]Bakirci, S., et al. (2019). “What are the main barriers to achieve minimal disease activity in psoriatic arthritis in real life?” Clin Exp Rheumatol37(5): 808-812.

[2]Beckers, E., et al. (2021). “Treat-to-target in axial spondyloarthritis: an observational study in daily practice.” Rheumatology (Oxford).

[3]Ogdie, A., et al. (2021). “Effect of Multidomain Disease Presentations on Patients With Psoriatic Arthritis in the Corrona Psoriatic Arthritis/Spondyloarthritis Registry.” J Rheumatol48(5): 698-706.

Disclosure of Interests

Isaac T. Cheng: None declared, Ho SO: None declared, Ying Ying Leung Speakers bureau: received honorarium/ speaker fee from AbbVie, DKSH, Janssen, Novartis and Pfizer., Praveena Chiowchanwisawakit: None declared, Stanley Angkodjojo Speakers bureau: Boehringer Ingelheim Singapore in Nov 2021, Consultant of: Abbvie (Singapore), DKSH (Singapore) in 2021, Muhammad Ahmed Saeed: None declared, Kichul Shin: None declared, Mohit Goyal: None declared, Muhammad Haroon: None declared, Mohammed Hammoudeh Speakers bureau: Have you been paid as a speaker for (pharmaceutical) companies, Grant/research support from: participated in drug companies sponsored trials, Nallasivan Subramanian: None declared, Ho Yin Chung: None declared, James Cheng-Chung Wei: None declared, Mitsumasa Kishimoto Consultant of: MK received consulting fees and/or speaker fees from AbbVie, Amgen, Asahi-Kasei Pharma, Astellas, Ayumi Pharma, BMS, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Janssen, Kyowa Kirin, Novartis, Ono Pharma, Pfizer, Tanabe-Mitsubishi, and UCB Pharma., Lai-Shan Tam Consultant of: has acted as a consultant for Janssen, Pfizer, Sanofi, AbbVie, Boehringer Ingelheim, and Lilly, Grant/research support from: has received grant/research support from Amgen, Boehringer Ingelheim, Janssen, GSK, Novartis, and Pfizer

POS0625 VASCULAR EFFECT OF INFLAMMATORY BURDEN IN EARLY RHEUMATOID ARTHRITIS PATIENTS - A 5-YEAR PROSPECTIVE STUDY

Background

Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are associated with accelerated atherosclerosis driven by chronic Inflammation. We have previously reported that cumulative inflammatory burden, as reflected by cumulative averages of repeated measures of erythrocyte sedimentation rate (ca-ESR), was associated with increased arterial stiffness in PsA patients (1).

Objectives

To ascertain whether inflammatory burden over time is associated with long-term vascular outcome in early RA (ERA) patients.

Methods

In this 5-year prospective study, consecutive ERA patients without overt cardiovascular disease were recruited. All patients received tight-control treatment in the first year followed by stand-of-care management subsequently. Subclinical atherosclerosis and arterial stiffness progression were assessed using high-resolution carotid ultrasound (US) and brachial-ankle pulse wave velocity (PWV) respectively at baseline, year 1 and year 5. The primary outcome was subclinical atherosclerosis progression (AP+), defined as incident plaque in a segment without plaque before, or an increased number of plaques in a segment, and/or maximum carotid intima-media thickness (max cIMT) over 0.9 mm at year 5. Secondary outcome was the change in PWV over a period of 5 years. ESR level was measured during each clinic visit. Inflammatory burden was measured by cumulative averages of the area under the curve for erythrocyte sedimentation rate (ESR) over a period of 5 years.

Results

One-hundred and four ERA patients (age: 52±11 years, 81(78%) female) who completed 5 years of follow-up were included in this analysis. Significant improvement in disease activity was observed (DAS-ESR at baseline: 5.8±0.9 vs 3.2±1.2 at year 5, p<0.001). Forty-two patients (40.4%) had AP+. The AP+ group had higher ca-ESR (37.6±16.4 vs 32.0±17.1, p=0.106) and baseline Framingham risk score (FRS) (13.3±12.5 vs 5.5±6.6, p<0.001). Multivariate logistic regression analysis revealed that a higher ca-ESR was associated with AP+ (OR=1.03, 95%CI: 1.00-1.06, p=0.038) after adjustment for baseline high risk Framingham risk score (FRS≥20%) and baseline triglycerides level (Table 1). Similarly, PWV increased from 1461±285cm/s to 1559±309cm/s (p<0.001) after 5 years. Higher ca-ESR correlated with PWV progression (r=-0.211, p=0.032). Using multivariate logistic regression analysis, ca-ESR was associated with arterial stiffness progression ((β=2.94, 95%CI: 0.80 to 5.08, p=0.007) after adjusting for symptom duration, presence of rheumatoid factor and FRS.

Table 1.

Univariable analysis on baseline clinical characters and progression of subclinical atherosclerosis parameters

AP+ba PWV changeUnivariate modelMultivariate modelUnivariate modelMultivariate modelORp ValueORp Valueβp Valueβp Value95% CI95% CI95% CI95% CISymptom duration0.990.7045.620.089*0.92-1.06-0.88-12.131RF positive0.990.69284.040.068*84.250.0490.92-1.06-6.48-174.550.38-168.12Baseline Triglycerides3.190.009*3.480.008*-39.050.2661.34-7.611.38-8.76-108.25-30.14FRS, 20%5.970.031*5.650.500-164.110.013*-149.480.017*1.17-30.391.00-31.80-292.67- -35.55-1.25-10.87ca-ESR1.020.1061.030.038*3.120.005*2.780.008*1.00-1.041.00-1.060.97-5.270.73-4.82

*Statistically significant at p < 0.05.

RF positive: Rheumatoid factor positive, FRS, 20%: Framingham risk score ≥20%, caESR: cumulative average-Erythrocyte sedimentation rate.

Conclusion

Persistent inflammation was an independent predictor of subclinical atherosclerosis and arterial stiffness progression in ERA. Effective long-term suppression of inflammation is required to minimize cardiovascular risk.

References

[1]Shen J, Shang Q, Li EK, Leung Y-Y, Kun EW, Kwok L-W, et al. Cumulative inflammatory burden is independently associated with increased arterial stiffness in patients with psoriatic arthritis: a prospective study. Arthritis research & therapy. 2015;17(1):75.

Acknowledgements

I have no acknowledgments to declare.

Disclosure of Interests

None declared

POS0956 HIGH INFLAMMATORY BURDEN PREDICTS CARDIOVASCULAR EVENTS IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS: A LONG-TERM FOLLOW-UP STUDY

Background

Axial spondyloarthritis (axSpA) patients had a higher risk of cardiovascular disease (CVD) than the general population (1). It is also suggested that inflammation, rather than a particular disease, drives the increased risk of CVD (2). But the relationship between inflammation in axSpA and CVD is unknown.

Objectives

To examine whether inflammatory burden over time can predict cardiovascular events (CVE) independent of baseline CV risk factors in axial spondyloarthritis (axSpA) patients.

Methods

A cohort analysis was performed in patients who had been recruited since January 2001. The primary outcome was a first CVE occurring between January 2001 and December 2020. Three CVD risk scores were computed at baseline. The performance of the original and modified (x 1.5 multiplication factor) CV risk algorithms were assessed. Time-varying Cox proportional hazard models and Kaplan-Meier survival analysis were used to assess whether inflammatory burden (Bath ankylosing spondylitis disease activity index [BASDAI] and inflammatory markers), non-steroidal anti-inflammatory drugs (NSAIDs) and disease modifying anti-rheumatic drugs (DMARDs) can predict the development of first CVE.

Results

463 patients [35(26-45) years, male: 360(77.8%)] were recruited. After a median follow up of 12 (7-19) years, 61 patients (13.2%) experienced a first CVE. Traditional/modified CV risk scores underestimated CV risk. Erythrocyte sedimentation rate (ESR)≥20 mm/hr was associated with a significantly higher risk of CVE during follow-up [HR: 2.07, 95%CI (1.10, 3.98), p=0.008]. Active disease as indicated by a rising BASDAI also showed positive trend towards a higher risk of developing CVE over time. After adjusting for CV risk scores in the multivariable models, high ESR level (ESR≥20 mm/hr) over time remained significantly associated with a higher risk of developing CV events (Table 1a and 1b). A significant difference in the CV event-free survival between patients with ESR≥20 mm/hr and ESR<20 mm/hr was demonstrated in Figure 1.

Table 1.

Multivariable analysis with time-dependent Cox proportional hazard regression for the predictors of cardiovascular events.

Figure 1.

Kaplan-Meier survival analysis between time-varying ESR level and CVE. P=0.006 for difference in CVE-free survival rate between patients with ESR≥20mm/hr and ESR<20mm/hr during their follow-up intervals. ESR: Erythrocyte Sedimentation Rate.

Conclusion

Increased inflammatory burden as reflected by elevated ESR levels (ESR≥20) was associated with increased risk of CVE, while the use of NSAIDs and DMARDs were not.

References

[1]Exarchou, S., et al., Mortality in ankylosing spondylitis: results from a nationwide population-based study. Ann Rheum Dis, 2016. 75(8): p. 1466-72.

[2]Lauper, K., et al., Incidence and Prevalence of Major Adverse Cardiovascular Events in Rheumatoid Arthritis, Psoriatic Arthritis, and Axial Spondyloarthritis. Arthritis Care & Research, 2018. 70(12): p. 1756-1763.

Table 1a.Model 1Model 2Model 3Time-dependent HR (95%CI)p-valueTime-dependent HR (95%CI)P-valueTime-dependent HR (95%CI)P-valueESR≥202.75 (1.23, 6.14)0.014*2.74 (1.21, 6.21)0.016*2.93 (1.31, 6.57)0.009*BASDAI1.07 (0.90, 1.28)0.4551.06 (0.88, 1.28)0.5191.07 (0.89, 1.28)0.442FRS1.06 (1.03, 1.09)<0.001*QRISK31.05 (0.99, 1.11)0.132SCORE1.25 (1.09, 1.42)0.001*Table 1b.Model 1Model 2Model 3Time-dependent HR (95%CI)P-valueTime-dependent HR (95%CI)P-valueTime-dependent HR (95%CI)P-valueESR≥202.77 (1.24, 6.18)0.013*2.78 (1.23, 6.28)0.014*2.95 (1.32, 6.59)0.008*BASDAI≥41.37 (0.62, 2.99)0.4341.26 (0.58, 2.78)0.5591.42 (0.65, 3.09)0.376FRS1.06 (1.03, 1.09)<0.001*QRISK31.05 (0.99, 1.11)0.138SCORE1.24 (1.09, 1.42)0.001*

*Statistically significant at p≤0.05.

HR, hazard ratio; BASDAI: Bath Ankylosing Spondylitis Disease Activity Index; CRP: C-Reactive Protein; ESR: Erythrocyte Sedimentation Rate; FRS: Framingham Risk Score; SCORE: Systematic Coronary Risk Evaluation.

Acknowledgements

We would like to show our gratitude to all medical staffs, research assistants.

Disclosure of Interests

None declared

POS0776 IMMUNOGENICITY AND SAFETY OF INACTIVATED AND mRNA COVID-19 VACCINES IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Vaccination against SAR-CoV-2 is a new campaign and believed to be the key to end the pandemic. Currently, there are two COVID-19 vaccines with different mechanism of action available in Hong Kong - they are the inactivated virus vaccine and the mRNA-based vaccine. Both vaccines have obtained approval for emergency use by the World Health Organization (WHO) and were widely deployed globally (1). A mass voluntary vaccination program for all Hong Kong residents has started in late February, 2021 (2). However, the efficacy and safety of COVID-19 vaccines in patients with SLE is uncertain due to a complex interplay of underlying autoimmunity and immunosuppressive therapies used.

Objectives

This study was to investigate the effects of both inactivated and mRNA COVID-19 vaccines in patients with SLE.

Methods

This was a prospective, single-centre, case-control study. Patients with SLE planning to receive COVID-19 vaccines were recruited and matched 1:1 with healthy controls. The immunogenicity of the COVID-19 vaccines was assessed by a surrogate neutralization assay at 28 days after the second dose. The main outcomes included the antibody response and adverse effects comparing SLE patients and controls. Predictors of responses in SLE patients were analyzed. The change of SLE disease activity was evaluated.

Results

Sixty-five SLE patients received 2 doses of COVID-19 vaccines (Comirnaty: 38; CoronaVac: 27) were recruited. Many of them were on systemic glucocorticoids (75.8%) and immunosuppressants (54.5%). At day 28 after the second dose of vaccines, 92.3% (Comirnaty: 100%; CoronaVac: 81.5%, p=0.01) had positive neutralizing antibody. However, compared to the age, gender, vaccine type matched controls, the level of neutralizing antibody was significantly lower (p<0.001) in patients with SLE (Figure 1). The self-reported side effects of the vaccines in lupus patients were common but mild, and were more frequent in the Comirnaty group. There was no significant change in lupus disease activity up to 28 days after vaccination. The independent predictors of neutralizing antibody level included the dosage of systemic glucocorticoids, use of mycophenolate and type of vaccines (Table 1).

Table 1.

Multivariate linear regression analysis for neutralizing antibody activity

Beta95% confidence intervalP valueAge-0.022-0.425 – 0.3810.914Gender8.1625 (92.6)0.296SLEDAI-2k-1.96-4.22 – 0.310.088Prednisolone dosage-2.01-3.66 - -0.370.018Mycophenolate mofetil-15.2-24.4 - -6.00.002Type of vaccines: Comirnaty28.820.1 – 37.5<0.001Figure 1.

Distribution of neutralizing antibody levels after COVID-19 vaccines comparing (A) SLE patients and matched controls, (B) SLE patients and matched controls in two vaccine subgroups, and (C) two vaccine types in SLE patients. Data for each group are presented as box plots: central values within boxes correspond to median; the range between the lower (Q1) and upper (Q3) bounds of the boxes is the IQR. Whiskers represent scores outside IQR and ends in maximum (higher “calculated value” = Q3 + 1.5 x IQR) and minimum (lower “calculated value” = Q1 – 1.5 x IQR). Spots are outliers above the maximum or under the minimum values. Data regarding were analyzed using Mann-Whitney-U test. Dotted line denotes the cut-off level for positivity (30%).

Conclusion

COVID-19 vaccines produced satisfactory but impaired serological response in SLE patients compared to controls which was dependent on the immunosuppressive medications use and type of vaccines received. There was no new short-term safety signal noted. Booster dose is recommended.

References

[1]Wouters OJ, Shadlen KC, Salcher-Konrad M, Pollard AJ, Larson HJ, Teerawattananon Y, et al. Challenges in ensuring global access to COVID-19 vaccines: production, affordability, allocation, and deployment. Lancet. 2021;397(10278):1023-34.

[2]COVID-19 Vaccination Programme.

Disclosure of Interests

None declared

POS0323 RISK FACTORS FOR MAJOR CARDIOVASCULAR EVENTS (MACE) IN INFLAMMATORY ARTHRITIS: A TIME-DEPENDENT ANALYSIS ON INFLAMMATORY BURDEN, USE OF NSAIDs, STEROID AND DMARDs

Background

Inflammatory arthritis (IA) including rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylarthritis (AS) are associated with accelerated atherosclerosis due to systematic inflammation.

Objectives

To elucidate whether inflammatory burden (c-reactive protein [CRP] and erythrocyte sedimentation rate [ESR] levels) and drugs used to suppress inflammation (disease modifying anti-rheumatic drugs [DMARDs] and non-steroidal anti-inflammatory drugs [NSAIDs]) over time are independently associated with major cardiovascular events (MACE) in patients with IA.

Methods

A population-based cohort of IA patients were identified in the citywide Clinical Data Analysis and Reporting System (CDARS) of the Hong Kong Hospital Authority. IA patients recruited from 2006 to 2016 were followed until the end of 2018. The outcome was occurrence of a first MACE, defined as unstable angina, acute myocardial infarction, stroke/transient ischemic attack or death from cardiovascular causes. Cox proportional hazard models with time-varying CRP and ESR levels and drugs used were analyzed to identify the risk of having MACE in IA patients.

Results

A total of 17,732 (12050 RA patients, 1789 PsA patients and 3893 AS patients) patients with IA were recruited. After a mean follow-up of 8.7 ± 3.1 years, 1,069 (6.0 %) patients developed a first MACE. At baseline, the MACE group were older (68±12 vs 53±15, p<0.001), had more traditional cardiovascular risk factors, higher levels of CRP (2.7±1.5 vs 1.7±1.3, p<0.001) and ESR (57.8±32.4 vs 42.5±29.2, p<0.001), and less exposure to biologic DMARDs (bDMARDs) (1.0% vs 3.0%, p<0.001) and non-selective NSAIDs (nsNSAIDs) (63.4% vs 71.1%, p<0.001). After adjusting for age, sex, baseline cardiovascular comorbidities using multivariable Cox regression analysis, IA patients with higher inflammatory burden (as reflected by the time-varying CRP [hazard ratio {HR} 1.11, 95% confidence interval {CI} 1.10-1.12, p<0.001] and ESR levels (HR 1.02, 95% CI 1.01-1.01, p<0.001) and the use of steroid (HR 1.79-1.88) were independently associated with a higher risk of developing MACE (Table 1). In contrast, exposure to nsNSAIDs had a protective effect against MACE (HR 0.76, 95% CI 0.66-0.89, p<0.001), while bDMARDs were not associated with MACE.

Table 1.

Multivariable time-varying Cox regression models for the predictors of incidence of MACE in the IA patients (n=17732)

Model 1 †Model 2 ‡VariablesHR (95% CI)p valueHR (95% CI)p valueMale1.92 (1.65-2.23)<0.001*1.52 (1.33-1.76)<0.001*Age1.06 (1.05-1.06)<0.001*1.06 (1.05-1.06)<0.001*Disease duration1.04 (0.97-1.08)0.0561.04 (1.01-1.08)0.016*Baseline DM1.25 (0.95-1.64)0.1081.44 (1.13-1.84)0.003*Baseline HT1.77 (1.52-2.08)<0.001*1.85 (1.59-2.16)<0.001*Baseline LP1.14 (0.92-1.41)0.2321.19 (0.98-1.46)0.081Time-varying inflammatory markersESR1.02 (1.01-1.01)<0.001*CRP1.11 (1.10-1.12)<0.001*Time-varying treatmentbDMARDs0.93 (0.68-1.27)0.6570.89 (0.65-1.22)0.478CoxII0.71 (0.53-0.96)0.027*0.79 (0.59-1.04)0.104nsNSAIDs0.76 (0.66-0.89)<0.001*0.76 (0.66-0.88)<0.001*Steroids1.88 (1.63-2.17)<0.001*1.79(1.56-2.04)<0.001*

*Statistically significant at p < 0.05.

† and ‡ Adjusted for Age, Sex, Hypertension at baseline, diabetes mellitus at baseline, dyslipidemia at baseline, bDMARDs, CoxII, non-selective NSAIDs, Steroids.

CRP, C-reactive protein; ESR: Erythrocyte sedimentation rate; HT: hypertension; DM: diabetes mellitus; LP: Dyslipidemia; bDMARD, biological disease-modifying anti-rheumatic drug; COXII: cyclooxygenase -2 inhibitors; nsNSAIDs: non-selective nonsteroidal anti-inflammatory drugs.

Conclusion

Increased inflammatory burden as reflected by elevated ESR and CRP level over time, and increased exposure to steroid were independently associated with increased risk of MACE, while the risk was significantly reduced with non-selective NSAIDs use in IA patients.

Disclosure of Interests

None declared

OP0241 BONE MICROARCHITECTURE ASSESSED BY HIGH-RESOLUTION PERIPHERAL QUANTITATIVE COMPUTED TOMOGRAPHY (HR-pQCT) PREDICTS FRACTURE RISK IN PATIENTS WITH RHEUMATIC DISEASES ON GLUCOCORTICOIDS

Background

Peripheral bone micro-architectural parameters assessed by high-resolution peripheral quantitative computer tomography (HR-pQCT) were able to discriminate vertebral fracture in patients with rheumatic diseases on glucocorticoid (GC) independent of areal bone mineral density aBMD. Whether these parameters could predict future fracture remained to be determined.

Objectives

The aim of this study was to compare the differences in baseline vBMD, bone microarchitecture and estimated bone strength in these patients with and without incident fragility fracture over a period of 5 years.

Methods

This was a multi-centered, retrospective, case-controlled study. Patients with rheumatic diseases on long term GC from 7 regional hospitals who had dual-energy X-ray absorptiometry (DXA) and HR-pQCT done were invited to have a 5th year follow-up assessment. X-rays were repeated. The occurrence of new fragility fracture after 5 years was documented. The baseline clinical characteristics, aBMD, FRAX and HR-pQCT parameters in patients who experienced a new fragility fracture during the 5-year follow-up period (incident fracture group) were compared with patients who did not experience a fragility fracture (control group).

Results

A total of 140 patients were recruited. The mean age of the patients, who were mostly female (80.7%), was 58.7 ± 12.5 years at baseline. SLE and RA were the commonest diagnoses. At baseline, 45.0% and 28.6% of the patients had osteopenia or osteoporosis respectively. The baseline 10-year major osteoporotic and hip fracture risks by FRAX were 13.3% and 6.0% respectively. After 5 years, 47 (33.6%) of the patients developed new fractures. The baseline clinical characteristics of incident facture group and the control group are shown in Table 1. Patients with incident fracture were older. They also had more prevalent fracture and worse mobility. The aBMD and FRAX scores were significantly higher in the incident fracture group. When comparing the HR-pQCT parameters, the incident fracture group had significantly worse vBMD, microarchitecture and bone strength particularly over the tibia at baseline. However, the changes in these parameters were not different between the 2 groups. Multivariate regression confirmed that the baseline vBMD, microarchitectural parameters and estimated bone strength over distal tibia were independent predictors of new fractures after adjusting for age, gender as well as baseline fracture, mobility and osteoporosis status.

Table 1.

Demographic and clinical characteristics at baseline

Control groupn=93Incident fracture groupn=47pAge (years)57 ± 1262 ± 120.015Gender, n (%)Female74 (79.6%)39 (83%)0.629Disease typeSLE40 (43.5%)21 (44.7%)0.711RA19 (20.7%)12 (25.5%)Others33 (35.9%)14 (29.8%)Mobility class, n (%)Ambulatory82 (88.2%)34 (72.3%)0.046Stick-walking9 (9.7%)12 (25.5%)Chair-bound2 (2.2%)1 (2.1%)Previous fracture, n (%)10 (10.8%)12 (25.5%)0.023MedicationsCumulative prednisolone dose (g)20.4 ± 18.722.0 ± 15.50.604Ever or current anti-osteoporotic treatment, n (%)15 (16.1%)11 (23.4%)0.310aBMD (g/cm2) atFemoral neck0.66 ± 0.120.60 ± 0.120.009Lumbar spine0.86 ± 0.150.80 ± 0.160.025FRAX score (%)Major osteoporotic fracture9.9 ± 9.420.6 ± 17.3<0.001Hip fracture3.7 ± 5.610.8 ± 13.20.001HR-pQCT parameters*Distal radius:mTb.vBMD82.0 ± 45.262.6 ± 42.40.016Distal tibia:Average vBMD258 ± 70225 ± 700.010Tb. vBMD144 ± 42122 ± 400.003pTb. vBMD221 ± 52197 ± 460.010mTb.vBMD91.3 ± 37.770.0 ± 40.00.002Tb. number1.50 ± 0.281.36 ± 0.340.010Stiffness162139 ± 42623142054 ± 353750.004Est. failure load-8173 ± 2083-7200 ± 17440.004

*Only statististically significant parameters are shown

Conclusion

A significant proportion (33.6%) of patients with rheumatic diseases on long-term GC developed new fragility fracture in 5 years, which could be predicted by the worse vBMD, microarchitecture and bone strength over tibia at baseline on HR-pQCT independent of aBMD.

Disclosure of Interests

None declared

Performance of the 2017 EULAR/ACR classification criteria in anti-MDA5 associated idiopathic inflammatory myopathy

OBJECTIVE

To evaluate the performance of the 2017 EULAR/ACR classification criteria in a cohort of anti-MDA5 associated IIM patients.

METHODOLOGY

Consecutive adult patients with a clinical diagnosis of anti-MDA5 associated IIM from 10 hospitals in Hong Kong were recruited retrospectively. Clinical characteristics were collected by reviewing the electronic medical records. A commercial line-blot immunoassay was used to detect the myositis specific antibodies (MSA). Performance of the 2017 EULAR/ACR classification criteria was examined. Incorporation of the anti-MDA5 antibody in the EULAR/ACR criteria and the MSA-based criteria recently proposed by Casal-Dominguez et al. were also evaluated. Lastly, a new set of phenotypic-serological classification criteria specific for anti-MDA5 was proposed.

RESULTS

A hundred and twenty patients with anti-MDA5 associated IIM were recruited. The subgroups were exclusively DM (31.7%) and CADM (68.3%). Eight-six (71.7%) and 49 (40.8%) patients fulfilled the EULAR/ACR classification criteria and the Bohan/Peter criteria respectively. With the addition of Sontheimer's criteria for CADM, 76.7% the patients could be classified by the Bohan and Peter criteria. The sensitivity of the EULAR/ACR criteria could be improved to 98.3% if anti-MDA5 antibody was considered one of the criteria. The criteria by Casal-Dominguez et al. had 100% sensitivity in this cohort. Our newly proposed criteria for "anti-MDA5 syndrome" could also classify 97.5% of the patients.

CONCLUSIONS

Almost 30% of patients with clinical anti-MDA5 associated IIM could not be classified by the EULAR/ACR criteria. Modification of the existing criteria incorporating anti-MDA5 antibody or development of a new specific set of criteria for "anti-MDA5 syndrome" are suggested.

Immunogenicity and safety of inactivated and mRNA COVID-19 vaccines in patients with systemic lupus erythematosus

Objective:

To evaluate the effects and side effects of both inactivated and mRNA COVID-19 vaccines in patients with systemic lupus erythematosus (SLE).

Methods:

This was a prospective, single-center, observational study. Patients with SLE planning to receive COVID-19 vaccines were recruited and matched 1:1 with healthy controls. The immunogenicity of the COVID-19 vaccines was assessed by a surrogate neutralization assay at 28 days after the second dose. The main outcome was the antibody response comparing SLE patients and controls. Other outcomes included reactogenicity, disease activity and predictors of antibody responses in patients with SLE.

Results:

Sixty-five SLE patients received 2 doses of COVID-19 vaccines (Comirnaty: 38; CoronaVac: 27) were recruited. Many of them were on systemic glucocorticoids (76%) and immunosuppressants (55%). At day 28 after the second dose of vaccines, 92% (Comirnaty: 100% vs CoronaVac: 82%, p = 0.01) of the patients had positive neutralizing antibody. However, compared to the age, gender, vaccine type matched controls, the level of neutralizing antibody was significantly lower ( p < 0.001). The self-reported adverse reactions after vaccines in lupus patients were common but mild, and were more frequent in the Comirnaty group. There was no significant change in lupus disease activity up to 28 days after vaccination. The independent predictors of neutralizing antibody level included the dosage of systemic glucocorticoids, use of mycophenolate and type of vaccines.

Conclusions:

COVID-19 vaccines produced satisfactory but impaired humoral response in SLE patients compared to controls which was dependent on the immunosuppressive medications use and type of vaccines received. There was no new short-term safety signal noted. Booster dose is encouraged.

Use of telemedicine for follow-up of lupus nephritis in the COVID-19 outbreak: The 6-month results of a randomized controlled trial

Objective

This study aimed to evaluate the short-term patient satisfaction, compliance, disease control, and infection risk of telemedicine (TM) compared with standard in-person follow-up (FU) for patients with lupus nephritis (LN) during the COVID-19 pandemic.

Method

This was a single-center open-label randomized controlled study. Consecutive patients followed at the LN clinic were randomized to either TM or standard FU (SF) group in a 1:1 ratio. Patients in the TM group received FU via videoconferencing. SF group patients continued conventional in-person outpatient care. The 6-month data were compared and presented.

Results

From June to December 2020, 122 patients were randomized (TM: 60, SF: 62) and had at least 2 FUs. There were no baseline differences, including SLEDAI-2k and proportion of patients in lupus low disease activity state (LLDAS), between the two groups except a higher physician global assessment score (PGA) in the TM group. After a mean FU of 19.8 ± 4.5 weeks, the overall patient satisfaction score was higher in the TM group. More patients in the TM group had hospitalization (15/60, 25.0% vs 7/62, 11.3%; p = .049) with higher baseline PGA (OR = 1.17; 95% CI, 1.08–1.26) being the independent predictor. The proportions of patients remained in LLDAS were similar in the two groups (TM: 75.0% vs SF: 74.2%, p = .919). None of the patients had COVID-19.

Conclusions

TM FU resulted in better patient satisfaction and similar short-term disease control in patients with LN compared to standard care. However, it was associated with more hospitalizations and might need to be complemented by in-person visits especially in patients with higher PGA.

Seasonal Effect on Disease Onset and Presentation in Anti-MDA5 Positive Dermatomyositis

Objective

To investigate the seasonal variation of disease onset and presentation in an ethno-geographically homogeneous cohort of patients with anti-MDA5 positive dermatomyositis (DM).

Methods

This was a multi-centered, retrospective cohort study. Adult Chinese anti-MDA5 positive DM patients were identified from the Hong Kong Myositis Registry and the Clinical Data Analysis and Reporting System from 2015 to 2020. Equal number of IIM patients without anti-MDA5 antibody were selected as controls. Line blot immunoassay was used to detect the autoantibodies. The onset of disease, presenting clinical features and subsequent complications were analyzed for any seasonality.

Results

A total of 110 patients with anti-MDA5 positive DM were studied. The mean age at diagnosis was 53.0 ± 12.3 years and the mean follow-up duration was 20.6 ± 23.1 months. Two third of the patients (66%) had the clinically amyopathic phenotype. Most patients (86%) had interstitial lung disease (ILD) and 42% developed rapidly progressive ILD (RP-ILD). The mortality was 40% and the commonest cause was RP-ILD. Chi-square test showed significantly less patients had symptom onset in July to September. However, no particular seasonal pattern was observed in the anti-MDA5 negative IIM controls. RP-ILD occurred more frequently in patients with disease onset in October to December. Anti-MDA5 positive DM patients with disease onset in warmer months (April to September) were more likely to have clinical muscle involvement.

Conclusion

Apparent seasonal patterns were noted in our ethno-geographically identical anti-MDA5 positive DM patients, but not in IIM patients in general. Certain environmental factors, particularly infection, might be implicated.

APLAR recommendations on the practice of telemedicine in rheumatology

INTRODUCTION

The COVID-19 pandemic led to rapid and widespread adoption of telemedicine in rheumatology care. The Asia Pacific League of Associations for Rheumatology (APLAR) working group was tasked with developing evidence-based recommendations for rheumatology practice to guide maintenance of the highest possible standards of clinical care and to enable broad patient reach.

MATERIALS AND METHODS

A systematic review of English-language articles related to telehealth in rheumatology was conducted on MEDLINE/PubMed, Web Of Science and Scopus. The strength of the evidence was graded using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach as well as the Oxford Levels of Evidence. The recommendations were developed using a modified Delphi technique to establish consensus.

RESULTS

Three overarching principles and 13 recommendations were developed based on identified literature and consensus agreement. The overarching principles address telemedicine frameworks, decision-making, and modality. Recommendations 1-4 address patient suitability, triage, and when telemedicine should be offered to patients. Recommendations 5-10 cover the procedure, including the means, data safety, fail-safe mechanisms, and treat-to-target approach. Recommendations 11-13 focus on training and education related to telerheumatology.

CONCLUSION

These recommendations provide guidance for the approach and use of telemedicine in rheumatology care to guide highest possible standards of clinical care and to enable equitable patient reach. However, since evidence in telemedicine care in rheumatology is limited and emerging, most recommendations will need further consideration when more data are available.

Factors Associated With Use of Telemedicine for Follow-Up of SLE in the COVID-19 Outbreak

Objective: To investigate the factors associated with telemedicine (TM) use for follow-up of Systemic Lupus Erythematous (SLE) patients in the COVID-19 pandemic.

Methods: This was a single-centered cross-sectional study conducted in Hong Kong. Consecutive patients followed up at the lupus nephritis clinic were contacted for their preference in changing the coming consultation to TM in the form of videoconferencing. The demographic, socioeconomic, and disease data of the first 140 patients opted for TM and 140 control patients preferred to continue standard in-person follow-up were compared.

Results: The mean age of all the participants was 45.6 ± 11.8 years, and the disease duration was 15.0 ± 9.2 years. The majority of them were on prednisolone (90.0%) and immunosuppressants (67.1%). The mean SLEDAI-2k was 3.4 ± 2.4, physician global assessment (PGA) was 0.46 ± 0.62 and Systemic Lupus International Collaborating Clinics (SLICC) damage index was 0.97 ± 1.23. A significant proportion of the patients (72.1%) had 1 or more comorbidities. It was found that patients with higher mean PGA (TM: 0.54 ± 0.63 vs. control: 0.38 ± 0.59, p = 0.025) and family monthly income > USD 3,800 (TM: 36.4% vs. control: 23.6%; p = 0.028) preferred TM, while full-time employees (TM: 40.0% vs. control: 50.7%; p = 0.041) preferred in-person follow-up. These predictors remained significant in the multivariate analysis after adjusting for age and gender. No other clinical factors were found to be associated with the preference of TM follow-up.

Conclusion: When choosing the mode of care delivery between TM and physical clinic visit for patients with SLE, the physician-assessed disease activity and patient's socio-economic status appeared to be important.

Association of C-reactive protein and non-steroidal anti-inflammatory drugs with cardiovascular events in patients with psoriatic arthritis: a time-dependent Cox regression analysis

Aims:

Psoriatic arthritis (PsA) is associated with accelerated atherosclerosis due to underlying inflammation. Whether inflammatory burden and drugs used to suppress inflammation over time are associated with cardiovascular (CV) events remained unclear. This study aims to examine the time-varying effect of C-reactive protein (CRP) levels and the use of drugs, including non-steroidal anti-inflammatory drugs (NSAIDs) and disease modifying anti-rheumatic drugs, on the risk of CV events independent of traditional CV risk factors in PsA patients.

Methods:

A retrospective cohort analysis was performed in patients with PsA who were recruited from 2008 to 2015 and followed until the end of 2019. The outcome was occurrence of a first CV event. Framingham risk score (FRS) was used to quantify the traditional CV risk. Cox proportional hazard models with time-varying CRP levels and drugs used were analysed to identify the risk factors for CV events in PsA patients.

Results:

Two hundred patients with PsA [median age: 47.5 (40.0–56.0); male: 119 (59.5%)] were recruited. After a mean follow-up of 8.8 ± 3.8 years, 30 (15%) patients developed a first CV event. The multivariable Cox regression model showed that time-varying CRP level [hazard ratio (HR) 1.02, 95% confidence interval (CI) 1.00–1.04] and NSAIDs exposure (HR 0.38, 95% CI 0.15–0.96) were significantly associated with CV events after adjusting for baseline FRS (HR 5.06, 95% CI 1.84–13.92).

Conclusion:

Increased inflammatory burden as reflected by elevated CRP level was associated with increased risk of CV events, while the risk was significantly reduced with NSAIDs use in PsA patients.

POS0865 REDUCED BONE MINERAL DENSITY IN PATIENTS WITH IDIOPATHIC INFLAMMATORY MYOPATHIES: A CASE CONTROL STUDY

Background:

Idiopathic Inflammatory Myopathies (IIMs) patients are at risk of bone mineral density (BMD) loss due to systemic inflammation, use of glucocorticoids (GCs) and disability. Cross sectional study showed 70% of IIMs patients had reduced BMD but whether they were at excessive risk compared to controls were unknown.

Objectives:

To compare the prevalence of reduced BMD between IIMs patients, non-rheumatological controls, rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) patients and to determine the clinical determinants of BMD in IIMs patients.

Methods:

This was a single centre retrospective case control study. BMD at lumbar spine L1-L4 and neck of femur (NOF) were assessed by dual-energy X-ray absorptiometry (DXA) scans. The prevalence of reduced BMD and osteoporosis in Chinese IIMs patients and age-and-sex-matched non-rheumatological controls were compared. The BMD of female IIMs were then compared to age matched female RA and SLE patients in the secondary analysis. Binary logistic regression was used for adjustment of confounders. The demographics and clinical variables independently associated with BMD were determined by linear regression.

Results:

A total of 230 patients were recruited including 65 IIMs, 65 non-rheumatological controls, 50 RA and 50 SLE patients. The mean age was 58.6±10.96 years and 76.9% were female. There was no significant difference on demographics between the two groups. Almost all IIMs patients (98%) and 52% of controls had exposed to GCs (p<0.001). Significantly more IIMs patients had used immunosuppressants (92.3% vs 38.5%, p<0.001) and biologics (13.8% vs 1.5%, p=0.01). The prevalence of reduced BMD and osteoporosis were significantly higher in IIMs patients than non-rheumatological control (Reduced BMD: 73.8% vs 43.1%, p=0.043; Osteoporosis: 29.2% vs 13.8%, p=0.033) (Table 1). The mean lumbar spine and hip BMD were 0.886±0.181 g/cm2 and 0.651±0.144 g/cm2 in IIMs patients, which were significantly lower than that of the control group (0.960±0.143g/cm2, p=0.011 and 0.751±0.127g/cm2, p<0.001) (Figure 1). Multivariate analysis confirmed IIMs were associated with increased risk of reduced BMD (Odds ratio:2.118, p=0.048, 95% CI 1.005-4.461). The prevalence of reduced BMD and osteoporosis were not significantly different between IIMs, RA and SLE patients but the mean hip BMD was the lowest in the IIM group (0.641±0.152g/cm2 vs 0.663±0.102g/cm2 in the RA group vs 0.708±0.132 g/cm2 in the SLE group, p=0.035). Lower BMI (p=0.035) and more advanced age (p<0.001) were associated with lower BMD in the IIM patients.

Conclusion:

Reduced BMD was more prevalent in IIM patients than non-rheumatological controls. Lower BMI and more advanced age were associated with lower BMD. Vigilant monitoring of BMD and use of antiresorptive treatment should be considered in IIM patients.

References:

[1]Briot K, Geusens P, Em Bultink I et al. Inflammatory diseases and bone fragility. Osteoporos Int. 2017;28:3301-14.

[2]So H, Yip ML, Wong AKM. Prevalence and associated factors of reduced bone mineral density in patients with idiopathic inflammatory myopathies. Int J Rheum Dis. 2016;19:521-8.

Table 1.

Prevalence of reduced BMD in IIM patients and non-rheumatologcial controls

Myositis (n=65)Non-rheumatological controls (n=65)SignificanceOsteopenia at LS25 (38.5%)20 (30.8%)0.357Osteoporosis at LS13 (20%)6 (9.2%)0.082Osteopenia at NOF29(44.6%)26 (40%)0.542Osteoporosis at NOF12(18.5%)6 (9.2%)0.119Osteopenia overall29(44.6%)28 (43.1%)0.860Osteoporosis overall19(29.2%)9(13.8%%)0.033Reduced BMD overall48 (73.8%)37 (56.9%)0.043Occurrence of fragility fractureNone=52None=540.651Vertebral =5Vertebral=4Femoral=1Femoral=1Femoral=0Wrist=4Wrist=3Other sites=3Other sites=3

Disclosure of Interests:

None declared

POS1079 ASSOCIATION OF C-REACTIVE PROTEIN AND NON-STEROIDAL ANTI-INFLAMMATORY DRUGS WITH CARDIOVASCULAR EVENTS IN PATIENTS WITH PSORIATIC ARTHRITIS: A TIME-DEPENDENT Cox REGRESSION ANALYSIS

Background:

Psoriatic arthritis (PsA) is associated with accelerated atherosclerosis due to underlying inflammation. Whether inflammatory burden and drugs used to suppress inflammation over time are associated with cardiovascular (CV) events remains unclear.

Objectives:

This study aims to examine the time-varying effect of C-reactive protein (CRP) levels and the use of drugs including non-steroidal anti-inflammatory drugs (NSAIDs) on the risk of CV events independent of traditional CV risk factors in PsA patients.

Methods:

A retrospective cohort analysis was performed in patients with PsA who were recruited from 2008 to 2015 and followed till the end of 2019. The outcome was occurrence of a first CV event. Framingham risk score (FRS) was used to quantify the traditional CV risk. Cox proportional hazard models with time-varying CRP levels and drugs used were analyzed to identify the risk factors for CV events in PsA patients.

Results:

200 patients with PsA (median age: 47.5[40.0 – 56.0]; male: 119 [59.5%]) were recruited (Table 1. next page). After a mean follow-up of 8.8±3.8 years, 30 (15%) patients developed a first CV event. The Kaplan-Meier survival analysis indicated a significant difference in the CV event-free survival between patients with and without CRP level >3 mg/L (Figure 1A) and an inverse relationship between time-varying NSAIDs exposure and CV event-free survival (Figure 1B). The multivariable Cox regression model showed that time-varying CRP level (HR 1.02, 95% CI 1.00 to 1.04) and NSAIDs exposure (HR 0.30, 95% CI 0.15 to 0.95) were significantly associated with CV events after adjusting for baseline FRS (HR 5.04, 95% CI 1.83 to 13.85).

Table 1.

Baseline demographic and clinical characteristics, cardiovascular risk factors and treatments received.

VariablesAll patientsn=200median (IQR) or n (%)CVD -ve,n=170median (IQR)or n (%)CVD +ve,n=30median (IQR)or n (%)p-valueNSAID -ve, n=61median (IQR)or n (%)NSAID +ve, n=139median (IQR) or n (%)p-valueMale, n (%)119 (59.5%)100 (58.6%)19 (63.3%)0.22839 (63.9%)80 (57.6%)0.397Age, years47.5 (40.0 – 56.0)46.5 (37.7 – 54.0)57.0 (45.3 – 65.8)<0.001*49.0 (44.0 – 56.5)46.0 (38.0 – 54.8)0.176Disease duration, years4.3 (1.8 – 7.9)4.1 (1.7 – 7.0)6.0 (2.1 – 8.6)0.0664.6 (1.5 – 8.7)4.3 (1.9 – 7.3)0.393Diabetes, n (%)45 (22.5%)30 (17.6%)15 (50.0%)<0.001*10 (16.4%)35 (25.2%)0.171Hypertension, n (%)68 (34.0%)46 (27.1%)22 (73.3%)<0.001*21 (34.4%)47 (33.9%)0.933CRP, mg/L4.9 (1.7 – 12.6)4.2 (1.5 – 12.0)11.3 (2.4 – 19.6)0.035*5.5 (1.7 – 15.1)7.2 (1.4 – 15.8)0.770ESR, mm/hr21 (10.0 – 38.0)20 (9 – 35)31 (14 – 60)0.038*21 (7 – 33)21 (11 – 43)0.291Systolic blood pressure, mmHg125 (115 – 140)124 (115 – 137)144 (129 – 160)<0.001*123 (118 – 137)125 (115 – 141)0.889Diastolic blood pressure, mmHg78 (70 – 85)78 (70 – 84)82 (72 – 90)0.19978 (72 – 86)78 (70 – 85)0.697FRS8.4 (4.0 – 17.0)7.5 (3.3 – 14.0)19.6 (13.4 – 43.0)<0.001*7.9 (3.5 – 15.5)8.7 (4.2 – 17.1)0.885Lipid-lowering drugs, n (%)30 (15.0%)25 (14.7%)5 (16.7%)0.7829 (14.8%)21 (15.1%)0.949MTX, n (%)99 (49.5%)81 (47.6%)18 (60.0%)0.21225 (41.0%)74 (53.2%)0.111bDMARDs, n (%)17 (8.5%)13 (7.6%)4 (13.3%)0.3036 (9.8%)11 (7.9%)0.654NSAIDs, n (%)139 (69.2%)119 (70.0%)20 (66.7%)0.715N/AN/AN/ASteroid, n (%)2 (1.0%)2 (1.2%)0 (0%)1.0001 (1.6%)1 (0.7%)0.518

*statistically significant at p≤ 0.05

CVD+ve, patients who developed cardiovascular events during subsequent follow-up;

CVD-ve, patients who did not developed cardiovascular events during subsequent follow-up;

NSAIDs, nonsteroidal anti-inflammatory drugs; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; FRS, Framingham Risk Score; MTX, methotrexate; bDMARDs, biological disease-modifying antirheumatic drugs.

Conclusion:

Increased inflammatory burden as reflected by elevated CRP level was associated with increased risk of CV events, while the risk was significantly reduced with NSAIDs use in PsA patients.

Disclosure of Interests:

None declared.

POS1164 USE OF TELEMEDICINE FOR FOLLOW-UP OF SLE PATIENTS WITH NEPHRITIS IN THE COVID-19 OUTBREAK (“TeleSLE”): THE 6-MONTH RESULTS OF A RANDOMIZED CONTROLLED TRIAL

Background:

Patients with lupus nephritis (LN) might be more susceptible to COVID-19 due to the underlying disease, co-morbidities and use of immunosuppressants. We hypothesized that telemedicine (TM) could be a well-accepted mode of health-care delivery minimizing the risk of exposure to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), while maintaining disease control in these patients.

Objectives:

To evaluate the short-term patient satisfaction, compliance, disease control and infection risk of TM compared with standard in-person follow-up (FU) for patients with LN during COVID-19.

Methods:

This was a single-center randomized-controlled study. Consecutive patients followed at the LN clinic were randomized to either TM (TM group) or standard FU (SF group) in a 1:1 ratio. Patients in the TM group received scheduled follow-ups via videoconferencing. SF group patients continued conventional in-person outpatient care. The 6-month data were compared.

Results:

From June to December 2020, 122 patients were randomized (TM: 60, SF: 62) and had attended at least 2 FU visits. There were no baseline differences, including SLEDAI-2k and proportion of patients in lupus low disease activity state (LLDAS), between the 2 groups except a higher physician global assessment score (PGA) in the TM group (mean 0.67±0.69 vs 0.45±0.60, p=0.003) (Table 1). The mean FU duration was 19.8±4.5 weeks. When comparing the most recent visit, the mean waiting time between entering the clinic waiting room (virtual or real) and seeing a rheumatologist (virtual or in-person) was significantly shorter in the TM group (22.5±28.6 vs 68.9±40.7 minutes, p< 0.001) (Figure 1A). The mean overall patient satisfaction score was higher in the TM group (mean 2.19±0.61 vs 1.89±0.78, p=0.042). The results of the post-consultation satisfaction questionnaire are shown in Figure 1B. The number of visits was similar in the two groups (TM: 3.1±1.3 vs SF: 3.0±1.2, p=0.981). However, there was a trend suggesting that alternative mode of FU was requested more frequently in the TM group than the SF group (TM: 12/60, 20.0% and SF: 5/62, 8.1%; p=0.057). More patients in the TM group had hospitalization (15/60, 25.0% vs 7/62, 11.3%; p=0.049) within the FU period, which was no longer statistically significant after adjusting for the baseline PGA. The proportions of patients remained in LLDAS were similar in the 2 groups (TM: 75.0% vs SF: 74.2%, p=0.919). None of the patients had COVID-19.

Conclusion:

TM resulted in better patient satisfaction and could achieve similar disease control in patients with LN in the short-term when compared to standard care.

Table 1.

Baseline clinical data of the recruited patients and comparison between the telemedicine/standard follow-up groups

Overall (n=122)Telemedicine group (n=60)Standard follow-up group (n=62)P-valueAge in years44.4±11.544.1±11.744.7±11.50.779Gender: Female111 (91.0)55 (91.7)56 (90.3)0.796Disease duration in years15.1±9.016.2±8.714.0±9.10.115Nephritis class III, IV or V108 (88.5)54 (90.0)54 (87.1)0.42724 hour urine proteinuria in gram0.51±0.630.53±0.600.50±0.650.712Current use of prednisolone112 (91.8)57 (95.0)55 (88.7)0.323Daily prednisolone dose in mg5.51±4.215.69±4.175.34±4.290.570Use of immunosuppressant90 (73.8)46 (76.7)44 (71.0)0.474SLEDAI-2K3.65±2.334.00±2.343.30±2.290.097PGA0.56±0.650.67±0.690.45±0.600.003LLDAS78 (63.9)36 (60.0)42(67.7)0.251Remission0 (0)0 (0)0 (0)n/aPresence of comorbidity87 (71.3)40 (66.7)47 (75.8)0.264SDI0.93±1.151.08±1.280.78±0.980.243HAQ-DI0.23±0.460.25±0.470.21±0.440.571HADS:Anxiety scaleDepression scale6.07±4.125.72±4.316.20±4.195.73±3.935.93±4.095.70±4.680.7200.724

Data are reported as mean ± SD or number (%). LLDAS: lupus low disease activity state; SDI: Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index; HAQ-DI: Health Assessment Questionnaire Disability Index; and HADS: Hospital Anxiety and Depression Scale.

Disclosure of Interests:

Ho SO: None declared, Evelyn Chow: None declared, Tena K. Li: None declared, Sze-Lok Lau: None declared, Isaac T. Cheng: None declared, Cheuk-Chun Szeto: None declared, Lai-Shan Tam Grant/research support from: Grants from Novartis and Pfizer.

POS1222 FACTORS ASSOCIATED WITH USE OF TELEMEDICINE FOR FOLLOW-UP OF LUPUS NEPHRITIS IN THE COVID-19 OUTBREAK

Background:

It is important to weigh the potential risk of exposure to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during a doctor visits against the risk of missing disease controls in patients with lupus nephritis during the COVID-19. Telemedicine (TM) follow-up is a reasonable option. Despite the recent exponential increase in application worldwide, there is no study examining the clinical factors associated with the patients‘ choice of TM use in lupus nephritis.

Objectives:

In this study, we aimed to examine the clinical variables associated with a higher preference for TM follow-up in patients with lupus nephritis.

Methods:

Consecutive patients followed at the lupus nephritis clinic were contacted for their preferred mode of follow-up. The demographic, socioeconomic and clinical data of the first 140 patients opted for TM and 140 patients preferred to continue standard in-person follow-up were collected and compared.

Results:

The mean age of the 280 recruited patients was 45.6 ± 11.8 years. The mean disease duration was 15.0 ± 9.2 years. The majority of them had lupus nephritis class III, IV or V (88.2%) and were on prednisolone (90%). Three quarters of the patients (67.1%) were on immunosuppressants. The mean SLEDAI-2k was 4.06 ± 2.54, physician global assessment (PGA) 0.46 ± 0.62 and SLICC/ACR damage index 1.11 ± 1.36. A significant proportion of the patients (72.1%) had one or more comorbidities. It was found that patients with higher PGA and family monthly income (> USD3,800) preferred TM, while fulltime employees preferred in-person follow-up (Table 1). These predictors remained significant after controlling for age in the multivariate analysis with odd ratios for PGA 1.05 (95% CI 1.01-1.09), family income >USD3,800 1.90 (95% CI 1.24-3.79) and fulltime employment 0.53 (95% CI 0.32-0.88). PGA was noted to be positively correlated with the perceptions that TM reduces (r=0.13, p=0.036) and routine visit increases (r=0.12, p=0.04) the risk of COVID-19 during the outbreak.

Conclusion:

When choosing the mode of care delivery between TM and clinic visit, the patient’s disease activity as well as employment and economic status appeared to be important.

Table 1.

Demographic, socio-economic and disease data of the recruited lupus nephritis patients with comparison between the telemedicine/standard follow-up groups

Overall (n=280)Telemedicine group (n=140)Standard follow-up group (n=140)P-valueAge in years45.6±11.844.6±11.446.6±12.10.159Gender: Female256 (91.4)127 (90.7)129 (92.1)0.669Ever presence of rash170 (60.8)87 (62.1)82 (58.6)0.527Ever presence of joint pain174 (62.1)92 (65.7)82 (58.6)0.247Disease duration in months15.8±9.515.0±9.316.5±9.60.17624 hour urine proteinuria in gram0.45±0.600.50±0.630.40±0.570.176Daily prednisolone dose in mg8.82±6.15.28±4.466.35±7.370.143Use of immunosuppressant188 (67.1)96 (68.6)92 (65.7)0.611SLEDAI-2K3.39±2.353.51±2.283.26±2.410.366PGA0.46±0.620.54±0.630.38±0.590.025LLDAS196 (70)92 (0.66)104 (74.3)0.160Presence of comorbidity202 (72.1)100 (71.4)102 (72.9)0.790SDI0.97±1.230.95±1.211.00±1.260.732HAQ-DI0.20±0.400.23±0.450.18±0.340.300HADS: Anxiety scale5.93±3.985.86±4.066.00±3.910.776 Depression scale5.57±3.915.56±4.255.59±3.540.954Education level: tertiary or above122 (43.6)63 (45.0)59 (42.1)0.746Fulltime employment127 (45.4)56 (40.0)71 (50.7)0.041Occupation: professionals36 (12.9)22 (15.7)14 (10.0)0.181Monthly family income > USD3,80084 (30.0)51 (36.4)33 (23.6)0.028

Data are reported as mean ± SD or number (%). HAQ-DI: Health Assessment Questionnaire Disability Index; HADS: Hospital Anxiety and Depression Scale; PGA: physician global assessment; LLDAS: lupus low disease activity state and SDI: Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index.

Disclosure of Interests:

Ho SO: None declared, Evelyn Chow: None declared, Tena K. Li: None declared, Isaac T. Cheng: None declared, Sze-Lok Lau: None declared, Cheuk-Chun Szeto: None declared, Lai-Shan Tam Grant/research support from: Grants from Novartis and Pfizer

POS0094 EFFECTS OF RANKL INHIBITION ON PROMOTING HEALING OF BONE EROSION IN RHEUMATOID ARTHRITIS USING HR-pQCT: A 2-YEAR, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL

Background:

Partial repair of bone erosions in rheumatoid arthritis (RA) is known from high-resolution peripheral quantitative computer tomography (HR-pQCT) studies in patients with moderate to high disease activity using biologics [1]. Whether RANKL inhibition by denosumab is efficacious in healing existing erosions in RA patients with low disease activity or in remission on conventional synthetic DMARDs is uncertain.

Objectives:

To evaluate the effects of denosumab on erosion healing at 2-4 metacarpophalangeal head as determined by HR-pQCT in patients with RA with stable disease.

Methods:

This was a randomized, placebo-controlled, double-blind study. RA patients with disease activity score 28 joints (DAS28) ≤5.1 were randomized (1:1) to subcutaneous denosumab 60 mg or placebo once every six months for 24 months. The primary outcome was erosion healing at MCP 2-4 on HR-pQCT at 12 months. The effects of denosumab on erosion and joint space parameters on HR-pQCT and radiographs, disease activity and health assessment questionnaire-disability index (HAQ-DI) were also examined.

Results:

At 24 months, HR-pQCT images were analyzed in 98 patients. Baseline demographic, clinical characteristics and imaging parameters were comparable between the two treatment groups (table 1). Seventeen patients in each group (placebo group: 17/52, 32.6%; denosumab group: 17/50, 34.0%) achieved sustained low disease activity (DAS28 ≤ 3.2) throughout the 24 months. At 12 months, changes in erosion parameters on HR-pQCT were similar between the two groups. At 24 months, new erosions (19% vs 9%, p=0.009) and erosion progression (34% vs 16%, p<0.001) were more common in the placebo group than the denosumab group. Erosion healing was seen in a significantly higher proportion of patients in the denosumab group (20% vs 6%, p=0.045) at 24 months. The details of the changes in HR-pQCT erosion parameters are shown in figure 1. No significant differences in the changes in joint space parameters on HR-pQCT, van der Heijde-Sharp erosion score, DAS28 and HAQ-DI were observed between the two groups at 12 and 24 months.

Table 1.

Baseline clinical, demographic, disease activity parameters and medications

Placebo (n=55)Denosumab (n=55)Total (n=110)Age56.5 ± 7.157.2 ± 8.556.8 ± 7.8Gender (Female)47 (86)41 (75)88 (80)Disease duration (years)8.5 ± 6.87.3 ± 6.97.9 ± 6.8Rheumatoid factor positive40 (72)38 (69)78 (71)ACPA positive43 (78)44 (80)87 (79)DAS28-CRP2.43 ± 0.832.6 ± 0.922.51 ± 0.88DAS28-CRP>3.28 (15)13 (24)21 (19)HAQ-DI (0-3)0.31 ± 0.380.46 ± 0.470.39 ± 0.43csDMARDs49 (89)52 (95)101 (92)Combination csDMARDs26 (47)33 (60)59 (54)Glucocorticoids5 (10)5 (9)10 (9)vdH- Sharp erosion score10.4 ± 18.48.9 ± 13.89.6 ± 16.2vdH- Sharp JSN score12.4 ± 17.711.5 ± 17.211.9 ± 17.4Lumbar spine aBMD, g/cm20.914 ± 0.1470.930 ± 0.1430.922 ± 0.145Total hip aBMD, g/cm20.837 ± 0.1020.847 ± 0.1460.841 ± 0.125Femoral neck aBMD, g/cm20.681 ± 0.0990.695 ± 0.1280.687 ± 0.114

Data are reported as mean ± SD or number (%). ACPA: Anti-cyclic citrullinated peptide antibody; DAS28: disease activity score 28; csDMARDs: conventional synthetic disease modifying anti-rheumatic drug. HAQ-DI: health assessment questionnaire disability index; vdH- Sharp score: Van der Heijde- Sharp score; aBMD: areal bone mineral density

Conclusion:

Although no differences in erosion parameters were observed at 12 months, denosumab was more efficacious than placebo in erosion repair on HR-pQCT after 24 months.

References:

[1]Finzel S, Rech J, Schmidt S, et al. Interleukin-6 receptor blockade induces limited repair of bone erosions in rheumatoid arthritis: a micro CT study. Ann Rheum Dis 2013;72:396-400.

Figure 1.

Changes in erosion parameters by HR-pQCT. (A) Percentage of patients with overall erosion healing; (B) Outcome of individual erosion with healing, progression and new erosion detected across study period; change in (C) mean erosion volume; (D) total erosion volume; (E) erosion width; (F) erosion depth and (G) marginal osteosclerosis per patient.

Disclosure of Interests:

Ho SO: None declared, Isaac T. Cheng: None declared, Sze-Lok Lau: None declared, Evelyn Chow: None declared, Tommy Lam: None declared, Vivian W Hung: None declared, Edmund Li: None declared, James F Griffith: None declared, Vivian WY Lee: None declared, Lin Shi: None declared, Junbin Huang: None declared, Yan Kitty Kwok: None declared, Isaac C Yim: None declared, Tena K. Li: None declared, Vincent Lo: None declared, Jolly M Lee: None declared, Jack Jock Wai Lee: None declared, Ling Qin: None declared, Lai-Shan Tam Grant/research support from: Grants from Novartis and Pfizer

The Hong Kong Society of Rheumatology Consensus Recommendations for COVID-19 Vaccination in Adult Patients with Autoimmune Rheumatic Diseases

Patients with autoimmune rheumatic diseases are potentially at risk of more serious Coronavirus Disease 2019 (COVID-19) infection and increased mortality due to immunosuppressive therapies and disease-related medical comorbidities. Uncertainty about the safety and efficacy of the COVID-19 vaccines is a major deterrent for patients to participate in the vaccination program. The Hong Kong Society of Rheumatology took the lead to publish a set of consensus statements for COVID-19 vaccination in adult patients with autoimmune rheumatic diseases through a Delphi exercise that involved the senior members of the Society. This serves as a guide to rheumatologists and other specialists, nurses, healthcare professionals, and public regarding COVID-19 vaccination in autoimmune rheumatic diseases.

Effects of RANKL inhibition on promoting healing of bone erosion in rheumatoid arthritis using HR-pQCT: a 2-year, randomised, double-blind, placebo-controlled trial

OBJECTIVE

To evaluate the effects of denosumab on erosion healing at 2-4 metacarpophalangeal (MCP) head as determined by high-resolution peripheral quantitative CT (HR-pQCT) in patients with rheumatoid arthritis (RA) with stable disease.

METHODS

This was a randomised, placebo-controlled, double-blind study. Patients with RA with disease activity score 28 joints (DAS28) ≤5.1 were randomised (1:1) to subcutaneous denosumab 60 mg or placebo once every 6 months for 24 months. The primary outcome was erosion healing at MCP 2-4 on HR-pQCT at 12 months. The effects of denosumab on erosion and joint space parameters on HR-pQCT and radiographs, disease activity and health assessment questionnaire-disability index (HAQ-DI) were also examined.

RESULTS

At 24 months, HR-pQCT images were analysed in 98 patients. One-third of the patients achieved sustained low disease activity throughout the study. At 12 months, changes in erosion parameters on HR-pQCT were similar between the two groups. At 24 months, new erosions (19% vs 9%, p=0.009) and erosion progression (18% vs 8%, p=0.019) were more common in the placebo group than the denosumab group. Erosion healing was seen in a significantly higher proportion of patients in the denosumab group (20% vs 6%, p=0.045) at 24 months. No significant changes in joint space parameters on HR-pQCT, van der Heijde-Sharp erosion score, DAS28 and HAQ-DI were observed in the two groups at 12 and 24 months.

CONCLUSION

Although no differences in erosion parameters were observed at 12 months, denosumab was more efficacious than placebo in erosion repair on HR-pQCT after 24 months.

TRIAL REGISTRATION NUMBER

NCT03239080.

The Role of Imaging in Predicting the Development of Rheumatoid Arthritis

Rheumatoid arthritis (RA) remains a chronic debilitating disease with a significant negative societal impact, despite the expanding landscape of treatment options. This condition is often preceded by a phase of systemic autoimmunity with circulating autoantibodies, elevated pro-inflammatory cytokines, or subtle structural changes. The capability of identifying individuals in the preclinical phase of RA disease makes a "preventive window of opportunity" possible. Much recent work has focused on the role of imaging modalities including ultrasound (US), magnetic resonance imaging (MRI), and high-resolution peripheral quantitative computer tomography (HR-pQCT) in identifying at-risk individuals with or without early joint symptoms for the development of inflammatory arthritis. This article will review the evidence and discuss the challenges as well as opportunities of proactive risk assessment by imaging in RA.

Myositis-specific autoantibodies and their clinical associations in idiopathic inflammatory myopathies

BACKGROUND

Myositis-specific autoantibodies (MSAs) have been found to be present predominantly in patients with idiopathic inflammatory myopathies (IIMs). This study aimed to investigate the prevalence of MSAs and their associated complications in a cohort of patients with IIMs.

METHODS

This was a multicentered prospective study. Consecutive adult Chinese patients with IIMs in the regional hospitals in Hong Kong were followed up from July 2016 to January 2018. Clinical characteristics, treatment history, and disease complications were documented. A commercially available immunoblot assay was used to detect the MSAs.

RESULTS

Out of the 201 patients studied, at least one MSA was found in 63.2% of patients. The most common among the identified MSAs were the anti-melanoma differentiation-associated gene 5 antibody (anti-MDA5 Ab) and the anti-transcriptional intermediary factor 1-gamma antibody (anti-TIF1-γ Ab) (both 13.9%), followed by anti-Jo-1 antibody (12.4%). Anti-MDA5 was present exclusively in dermatomyositis (DM) and was strongly associated with digital ulcers, amyopathy, and rapidly progressive interstitial lung disease (RP-ILD). Anti-TIF1γ was strongly associated with refractory rash and malignancy. Independent risk factors of RP-ILD included anti-MDA5 (OR 14.5), clinically amyopathic DM (OR 13.9), and history of pulmonary tuberculosis (OR 12.2). Cox regression analysis showed that anti-TIF1γ (HR 3.55), DM (HR 3.82), and family history of cancer (HR 3.40) were independent predictors of malignancy.

CONCLUSIONS

MSA testing enables dividing of patients with IIMs into phenotypically homogeneous subgroups and prediction of potentially life-threatening complications.

Incidence and clinical course of COVID-19 in patients with rheumatologic diseases: A population-based study

Objectives

Patients with rheumatologic diseases might be more susceptible to COVID-19 and carry a poorer prognosis. The aim of this study is to examine the incidence and outcomes of all COVID-19 patients with rheumatologic conditions in Hong Kong.

Methods

This is a population-based retrospective study. All patients tested positive for SARS-CoV-2 by PCR with a previous diagnosis of rheumatologic diseases were reviewed. The incidence of COVID-19 in patients with rheumatologic conditions was calculated and compared to the general population in Hong Kong. Descriptive data of those rheumatologic patients with COVID-19 and the clinical course of the index infection were presented.

Results

Up till 27 May 2020, there were 1067 cases of COVID-19 diagnosed in Hong Kong which had a population of 7.5 million. Out of the 39,835 patients with underlying rheumatologic diseases, we identified 5 PCR confirmed COVID-19 cases. The estimated incidence of COVID-19 was 0.0126% patients with rheumatologic diseases, compared to 0.0142% in the general population. All 5 patients had inflammatory arthropathies. One patient was on hydroxychloroquine and sulphasalazine, and one was on methotrexate. None of the 3534 patients on b/tsDMARDs was infected. Four patients had leucopenia/lymphopenia and stool viral PCR was positive in 3 patients. All patients made uneventful recovery without complications or flare of underlying diseases.

Conclusions

We found no alarming signals of increased frequency or severity of COVID-19 in patients with rheumatologic diseases, although extrapolation of the results to other populations with different infection control strategies should be made with caution.

COVID-19 and Rheumatic Diseases: Practical Issues

On March 12, 2020, the World Health Organization (WHO) declared coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) a pandemic. The rapidly increasing number of cases and deaths have overwhelmed the health care system worldwide. We aimed to provide a narrative review on some practical issues of COVID-19 and rheumatic diseases with the limited data to the date of April 26, 2020.

AB0616 REDUCED BONE MINERAL DENSITY IN PATIENTS WITH IDIOPATHIC INFLAMMATORY MYOPATHIES: A LONGITUDINAL STUDY

Background:

Reduced bone mineral density (BMD) leads to fragility fracture which is associated with a significant morbidity and excess mortality [1,2]. Patients with idiopathic inflammatory myopathies (IIM) should be at a heightened risk of reduced BMD as a result of the systemic inflammation, reduced mobility and corticosteroid use [3]. A previous cross-sectional study demonstrated a high prevalence of osteoporosis (23.7%) and osteopenia (47.4%) in a cohort of IIM patients [4]. However, longitudinal data are lacking.

Objectives:

To assess the BMD of IIM patients longitudinally and to investigate the factors associated with accelerated bone loss.

Methods:

This is a single centered observational study. Existing adult Chinese patients with IIMs who had serial BMD measurements done were recruited. The diagnosis of IIMs was based on the Bohan and Peter’s criteria with definite or probable cases being included [5]. Patients with clinically amyopathic disease must have the typical Gottron’s papules or heliotrope rash as determined by rheumatologists or dermatologists, and with no symptoms or signs of muscle involvement according to Sontheimer [6]. BMD was measured by dual energy X-ray absorptiometry (DEXA). Clinical variables thought to be associated with bone health were documented.

Results:

All together 28 patients were studied. The mean age of the patients at disease onset was 46.1 years (S.D. 12.2). There was a female predominance (92.9%). The subgroups of IIMs were: dermatomyositis (39.3%), polymyositis (25.3%), clinically amyopathic dermatomyositis (21.4%) and immune mediated necrotising myopathy (14.3%). Only a minority of the patients smoked (7.1%) and none of them drinks regularly. About one fifth of the patients were underweight. All patients have been exposed to systemic corticosteroid, while 82.1% of them were still on it between the two scans with 32.1% even on high dose (>0.5mg prednisolone/kg/day). Three out of the 28 patients (10.7%) was found to be osteoporotic at baseline and 17 patients (60.7%) were osteopenic. Follow-up DEXAs were performed mostly 5 to 10 years after the initial scan. Despite 8 patients (28.6%) were given active anti-osteoporotic medications, the bone health deteriorated significantly. The mean baseline neck of femor BMD dropped from 0.711 to 0.657 g/cm2 (p=0.042) on follow-up, while the total lumbar BMD from 0.951 to 0.905 g/cm2 (p=0.036). The T-score in 11 patients (39.3) reached osteoporotic range at the second DEXA. Together with the patients with osteopenia, 78.6% of the IMM patients had reduced BMD at the follow-up scan. Actually, 5 patients (17.9%) already had one episode of fragility fracture. The use of high dose corticosteroid in between the 2 scans was found to be associated with a greater degree of mean BMD loss in the hip (-0.171 vs -0.007 g/cm2, p=0.007).

Conclusion:

Reduced BMD is prevalent in patients with IIM. Follow-up study revealed significant worsening of bone health. High dose corticosteroid use might be especially detrimental. Liberal assessment of BMD and use of anti-osteoporotic drugs in IIM patients are advisable. Prompt use of steroid-sparing agents to minimize steroid exposure may also be helpful.

References:

[1]Falch J, Aho H, Berglund K, et al. Hip fractures in Nordic Cities: difference in incidence. Ann Chir Gynaecol 1995;84:286-90.

[2]Dennison E, Mohammed MA, Cooper C. Epidemiology of osteoporosis. Rheum Dis Clin North Am 2006;32:617-29.

[3]Luigi S, Massimo V, Giuseppe G. Epidemiology of osteoporosis in rheumatic disease. Clin Exp Rheumatol 2006;32:631-58.

[4]So H, Yip ML, Wong KM. Prevalence and associated factors of reduced bone mineral density in patients with idiopathic inflammatory myopathies. Int J Rheum Dis 2016;19:521-8.

[5]Bohan A, Peter JB. Polymyositis and dermatomyositis. N Engl J Med 1975;292:344-7.

[6]6. Sontheimer RD. Clinically myopathic dermatomyositis: what can we now tell our patients? Arch Dermatol 2010;146:76-80.

Disclosure of Interests:

None declared

AB0610 SEASONAL VARIATION IN IDIOPATHIC INFLAMMATORY MYOPATHIES INCIDENCE AND PRESENTATION: A RETROSPECTIVE STUDY IN BEIJING AND HONG KONG

Background:

Seasonal patterns of disease onset and severity in idiopathic inflammatory myopathies (IIMs) as a whole are conflicting [1-3]. In recent years, over 10 myositis-specific antibodies (MSAs) have been identified. They are able to divide patients into homogenous subgroups and inform on prognosis [4].

Objectives:

The objective of the study was to investigate the seasonal variation of onset of IIMs characterised serologically.

Methods:

This was a multi-centred retrospective observational study. Consecutive Chinese patients with IIMs admitted to the rheumatology wards of the participating major regional hospitals in Beijing and Hong Kong from July 2013 to June 2018 were recruited. The diagnosis of IIMs was based on the Bohan and Peter’s criteria with definite or probable cases being included [5]. Patients with clinically amyopathic disease must have the typical Gottron’s papules or heliotrope rash as determined by rheumatologists or dermatologists, and with no symptoms or signs of muscle involvement according to Sontheimer [6]. Patients with juvenile myositis, inclusion body myositis, cancer-associated myositis and myositis associated with other connective tissue disease were excluded. A commercial line blot immunoassay kit (EUROLINE) was used to detect the MSAs.

Results:

All together 495 patients were studied. The mean age of the patients at disease onset was 48.1 years (S.D. 13.3). There was a female predominance (68.3%). The subgroups of IIMs were: dermatomyositis (61.0%), polymyositis (21.8%), clinically amyopathic dermatomyositis (12.9%), immune mediated necrotising myopathy (3.8%) and nonspecific myositis (0.4%). No particular seasonal pattern in disease onset was observed in IIM patients as a whole (Figure 1) or in any classical subgroups. However, significantly more patients with any one MSA had their disease started in the first half of the year (p=0.007) as shown in Figure 2. Patients with either anti-synthetase or anti-MDA5 antibodies, which are associated with interstitial lung disease, had more frequent disease onset from November to February, which might coincide with the local flu season. It was also found that MSA positivity was associated with infection of the patient (p=0.005). Further analyses showed that patients with MSAs which are typically associated with severe skin disease (MDA5, TIF1g, NXP2, SAE) had more hospitalisation from April to September where excessive sun exposure is expected. There were no major differences between the Beijing and Hong Kong subgroups.

Conclusion:

Apparent seasonal patterns were noticed in our ethno-serologically defined IIM patients. Certain environmental factors, particularly infection or UV exposure, could be potential triggers. Our findings could shed light on the identification of etiologic factors and enhance our understanding of disease pathogenesis.

References:

[1]Manta P, Kalfakis N, Vassilopoulos D. Evidence for Seasonal Variation in Polymyositis. Neuroepidemiology 1989;8:262–265.

[2]Phillips BA, Zilko PJ, Garlepp MJ, et al. Seasonal occurrence of relapses in inflammatory myopathies: a preliminary study. J Neurol 2002;249:441–4.

[3]Lefe R, Burgess S, Miller F, et al. Distinct Seasonal Pattern in The Onset of Adult Idiopathic Inflammatory Myopathy in Patients with Auto Antibodies Anti-Jo-1 and Anti-Signal Recognition particle. Arthritis and Rheumatism 1991;34(11):1391-1396.

[4]Tansley SL, Betterridge ZE, McHugh NJ. The diagnostic utility of autoantibodies in adult and juvenile myostis. Curt Opin Rheumatol 2013;25(6):772-777.

[5]Bohan A, Peter JB. Polymyositis and dermatomyositis. N Engl J Med 1975;292:344-347.

[6]Sontheimer RD. Clinically myopathic dermatomyositis: what can we now tell our patients? Arch Dermatol 2010;146(1):76-80.

Disclosure of Interests:

None declared

Comparison of single and dual latent tuberculosis screening strategies before biologic and targeted therapy in patients with rheumatic diseases: a retrospective cohort study

PURPOSE

Before biologic and targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD) treatment, latent tuberculosis infection (LTBI) screening by tuberculin skin test (TST) or interferon gamma release assay (IGRA) is recommended. However, both tests have reduced reliability in immunosuppressed patients. We investigated whether dual LTBI screening with both tests could reduce the incidence of tuberculosis.

METHODS

Consecutive patients receiving b/tsDMARDs for rheumatic diseases in a regional hospital were recruited. All patients underwent either TST/IGRA or both. They were categorised into a single or dual testing group and were followed up for at least 6 months. Isoniazid was prescribed if any one test was positive.

RESULTS

In total, 217 patients were included in this study; 121 underwent single LTBI testing and 96 underwent dual testing. Tuberculosis occurred in nine patients in the single testing group and one patient in the dual testing group (7.4% vs 1.0%, P=0.045). However, the difference was not statistically significant when follow-up duration was considered (log rank test). In total, 71 patients tested positive for LTBI with isoniazid treatment (28.9% in the single testing group and 45.8% in the dual testing group, P=0.007). Agreement between the IGRA and TST was 74.4% (Cohen's kappa=0.413); agreement was lower in patients receiving prednisolone. Infliximab use was independently associated with tuberculosis (P=0.032). Mild isoniazid-related side-effects occurred in seven patients.

CONCLUSIONS

Dual LTBI testing with both TST and IGRA is effective and safe. It might be useful for patients receiving prednisolone at the time of LTBI screening, or if infliximab therapy is anticipated.

A Case of Refractory Myositis

We report here a statin naive lady who had refractory myositis for years. The diagnosis was revised to be anti-HMGCR related immune mediated necrotizing myopathy after repeating the muscle biopsy and checking the autoantibody. This report serves as a diagnostic alert that anti-HMGCR related immune mediated necrotizing myopathy should be considered in refractory myositis cases even though there is no statin exposure history, as both the treatment and prognosis may differ.

Cyclophosphamide Versus Obinutuzumab for the Treatment of Anti-MDA5 Positive Inflammatory Myopathy with Interstitial Lung Disease: A Study Protocol and Literature Review

In patients with idiopathic inflammatory myopathy, the presence of the melanoma differentiation-associated gene 5 (MDA5) antibody carries an extremely poor prognosis as a result of the associated interstitial lung disease (ILD) that is often rapidly progressive and refractory to therapies. Management of anti-MDA5 associated ILD is a challenging task as there is a paucity of clinical data and treatment guidelines in the literature. We hereby describe a proposed protocol for a multicenter randomized controlled trial to compare the efficacy of intravenous cyclophosphamide and obinutuzumab in combination with high-dose glucocorticoids and tacrolimus in terms of mortality at six months (primary outcome). The epidemiology, pathogenesis and treatment options of anti-MDA5 associated ILD are briefly reviewed.

Rituximab for refractory rapidly progressive interstitial lung disease related to anti-MDA5 antibody-positive amyopathic dermatomyositis

To report our experience in using rituximab (RTX) for treating refractory rapidly progressive interstitial lung disease (RP-ILD) complicating anti-melanoma differentiation-associated gene 5 antibody (anti-MDA5 Ab)-positive amyopathic dermatomyositis (ADM). Medical records of four ADM patients with refractory RP-ILD treated with RTX therapy were reviewed retrospectively. All four patients were tested positive for anti-MDA5 Ab and failed to respond to high-dose systemic steroid and other intensive immunosuppressive therapies. Respiratory symptoms, lung function tests, and high-resolution computed tomography (HRCT) of the chest were compared before and after the first course of RTX. After RTX treatment, all four patients had improvement in the respiratory symptoms in terms of New York Heart Association classification. Two patients successfully had their supplementary oxygen therapy weaned off. The lung function tests were significantly better in all patients. The HRCT showed improvement in three patients while the other one remained static. The recalcitrant vasculitic rashes associated with the anti-MDA5 Ab were also better in all patients. The average daily prednisolone dose dropped from 20 to 6.25 mg post-treatment. None of the patients died throughout the follow-up period which ranged from 6 months to 2 years. However, two patients developed chest infection and one wound infection within 6 months after the RTX infusion. Our results suggest that RTX may be a useful therapy for anti-MDA5 Ab-positive ADM associated with RP-ILD. However, infection is the major risk.