BCD020 rituximab bioanalog compared to standard treatment in juvenile systemic lupus erythematosus: The data of 12 months case-control study

BACKGROUND

Systemic lupus erythematosus (SLE) is the most frequent and serious systemic connective tissue disease. Nowadays there is no clear guidance on its treatment in childhood. There are a lot of negative effects of standard-of-care treatment (SOCT), including steroid toxicity. Rituximab (RTX) is the biological B-lymphocyte-depleting agent suggested as a basic therapy in pediatric SLE.

AIM

To compare the benefits of RTX above SOCT.

METHODS

The data from case histories of 79 children from the Saint-Petersburg State Pediatric Medical University from 2012 to 2022 years, were analyzed. The diagnosis of SLE was established with SLICC criteria. We compared the outcomes of treatment of SLE in children treated with and without RTX. Laboratory data, doses of glucocorticosteroids, disease activity measured with SELENA-SLEDAI, and organ damage were assessed at the time of initiation of therapy and one year later.

RESULTS

Patients, treated with RTX initially had a higher degree of disease activity with prevalence of central nervous system and kidney involvement, compared to patients with SOCT. One year later the disease characteristics became similar between groups with a more marked reduction of disease activity (SELENA-SLEDAI activity index) in the children who received RTX [-19 points (17; 23) since baseline] compared to children with SOCT [-10 (5; 15.5) points since baseline, P = 0.001], the number of patients with active lupus nephritis, and daily proteinuria. During RTX therapy, infectious diseases had three patients; one patient developed a bi-cytopenia.

CONCLUSION

RTX can be considered as the option in the treatment of severe forms of SLE, due to its ability to arrest disease activity compared to SOCT.

POS1299 RISK FACTORS OF TOTAL HIP ARTHROPLASTY IN JUVENILE ARTHRITIS WITH HIP INVOLVEMENT

Background:

Hip osteoarthritis (HOA) is a severe outcome of juvenile idiopathic arthritis (JIA) itself and also can be result of corticosteroid (CS) treatment, if it was used. Total hip arthroplasty (THA) is the last step in JIA treatment and indicates ineffectiveness of conservative treatment.

Objectives:

We aimed to evaluate risk factors which lead to THA in JIA patients with HOA.

Methods:

753 patients aged 2-17 years were included in our retrospective study during the last 10 years. Diagnosis was made according to ILAR criteria. Clinical, laboratory and radial examinations were evaluated. Diagnosis of HOA was made on MRI, CT and planar radiograms and confirmed by morphological examination of removed femoral heads.

Results:

Total 153/753 (20.3%) patients with JIA had hip involvement. HOA developed in 48/153 (31.4%) of JIA patients and 16/48 (33.3%) of them had THA was undergone. Prevalence of HOA and THA (%) in JIA subtypes: in polyarticular (5/32 (15.6%) and 8/16 (50%), systemic (6/32 (18.7%) and 5/16 (31.2%)), enthesitis-related (19/32 (59.4%) and 3/16 (18.8%)) and psoriatic (2/32 (6.7%) and 0/16) subtypes respectively, р=0,0000001. Patients who underwent THA initially had higher level of inflammation: elevated ESR (33 vs 5 mm/h, p=0.002) and CRP (14.7 vs 1.9 mg/l, p=0.03), more active joint, and especially involvement of joints of upper limbs: elbows (p=0.004) and proximal interphalangeal joints (p=0.001), arthritis of subtalar joint (p=0.02). Delayed biologic treatment (7.5 vs 3.4 years, p=0.043) and delayed achievement of remission (9.2 vs 5.6 years, p=0.047) were main predictors of THA. Patients with HOA without biologics had increased cumulative probability of THA: HR=1.99 (1.01; 3.98), p=0.049 (Figure 1). Patients with THA received corticosteroids (93.7 vs 50%, p=0.003) more often including high dose pulse-therapy regimes, but differences in the cumulative doses were not observed (5000 vs 4500 mg, p=0.54) between groups, CS administration was independent risk factor of HOA and THA.

Figure 1.

Cumulative probability of THA in JIA patients with hip osteoarthritis.

Conclusion:

the main risk factors of THA are systemic and polyarticular course because of their activity, systemic CS and delayed biologic treatment. Corticosteroids should be avoided in those group of patients because of risk of avascular pathway HOA formation.

This work supported by the Russian Foundation for Basic Research (grant № 18-515-57001).

Table 1.

The features of JIA patients with hip osteoarthritis depending on

JIA featuresTHA, (n=16)HOA without THA, (n=32)pTime to THA, years5.2 (3.6; 10.2)4.6 (2.2; 8.7)0.4Onset age, years7.95 (3.5; 11.1)8.3 (4.3; 13.1)0.5JIA duration, years8.5 (6.5; 13.2)5.43 (2.8; 11.1)0.07Polyarticular JIA, n (%)8 (50.0)5 (15.6)0.037Systemic JIA, n (%)5 (31.3)6 (7.0)0.037ANA, n (%)3/8 (37.5)5/16 (31.3)0.760HLA B27, n (%)3/6 (50)9/19 (47.4)0.911RF, n (%)0/9 (0)1/15 (6.7)0.429Uveitis, n (%)1/16 (6.3)3/24 (12.5)0.519ESR, mm/h33 (13; 54)5 (3; 27)0.002CRP, mg/l14.7 (2.9; 72.3)1.9 (0.3; 12.7)0.03Active joints, n21.5 (8.5; 52.5)9 (5; 16)0.02Elbows, n (%)11 (68.7)8 (25.0)0.004Proximal interphalangeal joints, n (%)10 (62.5)5 (15.6)0.001Subtalar, n(%)4 (25.0)1 (3.1)0.02Pulse-therapy GCS, n(%)11 (68.7)10 (31.3)0.014Cumulative GCS dose, mg5000 (3000; 14000)4500 (500; 20000)0.54Time to biologic, years7.6 (4.3; 11.4)3.4 (1.9; 8.6)0.04Achievement of remission, years9.2 (6.6; 15.4)5.6 (3.3; 11.4)0.047

Disclosure of Interests:

None declared

AB0748 ARE ANY DIFFERENCES BETWEEN JIA - ASSOCIATED UVEITIS, DEVELOPED BEFORE AND AFTER JOINT MANIFESTATION

Background:

Uveitis is the most common extra-articular manifestation of juvenile idiopathic arthritis (JIA). Usually uveitis developed during first two years after arthritis occurred [1]. In the previous studies was shown the shorter time interval between arthritis and uveitis the severe uveitis course was observed [2]. Information about course of uveitis developed before arthritis is scarce.

Objectives:

We aimed to evaluate the clinical features and therapy of JIA-associated uveitis, which developed before and after joint manifestation.

Methods:

In the retrospective study 191 pediatric autoimmune uveitis included. The onset age ranged from 1 to 17 years. We evaluated differences in clinical, laboratorial and treatment differences between groups, i) where uveitis developed before (n=58) and ii) after (n=133) arthritis. Chronic autoimmune uveitis without joint manifestations was excluded.

Results:

Uveitits before arthritis developed in 58 (30.4%) cases. Patients whom uveitis developed before arthritis had were elder and characterized equal gender involvement, rare ANA positivity, and rare use of immunosupression, e.g. corticosteroids, biologics and methotrexate, due to treatment by ophthalmologist predominantly. Patients developed uveitis before arthritis received biologics earlier due to severity of uveitis (LogRank test, p=0.016, HR=1.97 (95%CI: 1.3; 3.1, p=0.004). Data are in the Table 1 and Figure 1.

Conclusion:

Patients with JIA associated uveitis with initial ocular presentation demonstrated more severe course and delayed diagnostics and treatment due to lack of contacts with pediatric rheumatologist. Cooperation between ophthalmologist and pediatric rheumatologist is strictly required in all cases with chronic anterior uveitis.

Table 1.Table 1.ParameterUveitis before arthritis (n=58)Uveitis after arthritis (n=133)pSex, female32 (55,2)97 (72,9)0.016Onset age, years6.7 (4.6; 10.2)3.2 (2; 6.1)0.000001JIA categoryOligoarthritis41 (70.7)84 (63.6)0.174Polyarthritis9 (15.5)36 (27.3)Enthesytis-related arthritis8 (13.8)12 (9.1)Type of uveitisAnterior44 (75.9)111 (84.1)0.315Peripheral3 (5.2)2 (1.5)Posterior3 (5.2)3 (2.3)Panuveitis8 (13.8)16 (12.1)Unilateral uveitis, n (%)19 (32.8)48 (36.1)0.632ANA posititivity, n (%)25/54 (46.3)72/110 (65.5)0.019HLA B27 positivity, n (%)8/35 (22.9)13/62 (21.0)0.828Methotrexate, n (%)3 (5.2)57/132 (43.2)0.0000001Systemic corticosteroids, n (%)3 (5.2)44/131 (33.6)0.00003Biologic, n (%)26 (44.8)88 (66.2)0.006ESR, mm/h19.0 (4.0; 25.0)23 (15.0; 32.0)0.095CRP, mg/l97.0 (0.1; 107.5)8.1 (0.9; 57.4)0.493Time between arthritis and uveitis, years2.7 (0.9; 4.3)4.0 (2.0; 7.1)0.016Time before biologic, years2.5 (0.9; 3.5)1.3 (0.5; 5.0)0.462

This work supported by the Russian Foundation for Basic Research (grant № 18-515-57001).

References:

[1]Verazza S, et al. Pediatr Rheumatol Online J 2008;6(Suppl 1):77.

[2]Zannin ME, et al. Acta Ophthalmol 2012;90:91-5.

Disclosure of Interests:

None declared

Figure 1.

POS1310 CANAKINUMAB IS A RESCUE TREATMENT FOR MACROPHAGE ACTIVATION SYNDROME IN PATIENTS WITH SYSTEMIC ONSET JUVENILE IDIOPATHIC ARTHRITIS: SINGLE CENTER EXPERIENCE

Background:

Macrophage activation syndrome (MAS) is a severe life-threatening complication of the systemic-onset juvenile idiopathic arthritis (soJIA). The treatment options included high-dose of the corticosteroids (CS), cyclosporine A (CsA), intravenous immunoglobulin (IVIG) and biologics, predominantly IL-1 antagonist – anakinra. In Russia anakinra has not approved yet, so canakinumab (CAN) is a single anti-IL-1 option, available in Russia.

Objectives:

To evaluate the safety and efficacy of canakinumab in patients with severe MAS in soJIA, who failed the previous treatment.

Methods:

In the retrospective case series study were included 9 soJIA patients (4 boys and 5 girls) with severe MAS, resistant to combination of high-dose CS, IVIG and CsA.

Results:

All patients had a MAS during the onset of JIA. The main clinical features of disease onset included: fever 9 (100%), active arthritis 5 (56%), pleuritis 7 (78%), pericarditis – 5 (56%), peritonitis 2 (22%), rash 6 (67%), hepatomegaly 9 (100%), splenomegaly 9 (100%), lymphadenopathy 7 (78%), bleeding 4 (44%), CNS involvement – 3 (33%). Initial treatment included high doses CS 8 (89%), oral CS 9 (100%), methotrexate 5 (56%), tocilizumab 4 (44%), and canakinumab 5 (56%), CsA 4 (44%), IVIG 6 (67%). TCZ was discontinued due to infusion reaction (n=2), TCZ inefficacy (n=3) and presence of MAS in all patients (n=5). In children whom TCZ was switched on CAN we used the standard dose of CAN 4 mg/kg, but if MAS occurred on the CAN we temporally increased the doses since 8 to 25 mg/kg (300 mg). In all cases MAS episodes were successfully resolved during CAN treatment. In 5 (56%) MAS had repeated course during the CAN which lead to temporally increasing the doses of CAN (pt3, pt5, pt8, pt 9) or required to increase immunosupression with abatacept or tofacitinib. Three patients with repeated MAS developed interstitial lung disease (ILD). Two patients who successfully resolved MAS after CAN had relapses of arthritis and switched CAN to TCZ.

IDSexJIA onset, yRepeated MASInitial biologicMAS on CANExperience of increased CAN dosesOutcomesCurrent treatment1F7.7NTCZNNRemissionCAN2F11.5NCANNNsoJIA flare, ILDTCZ3F7.9YCANYYRemissionCAN4F3.4NTCZNYRemission, ILDCAN, CS, MMF5M0.8YTCZYYRemission, ILDCAN, abatacept, CsA, CS6M14.2YCANNNRemissionTCZ7M1.1YCANNNRemissionN8М1.3NCANYYRemissionCAN every 12 months9F9.1NTCZYYMinimal disease activityCAN, tofacitinib

Footnotes: CAN – canakinumab, CS – corticosteroids, CsA – cyclosporine A, ID – identification, ILD – interstitial lung disease, F – females, M – males, N- no, TCZ – tocilizumab, Y – yes.

Conclusion:

Canakinumab is an effective rescue treatment either soJIA either MAS. In patients with MAS developed on CAN required the temporal increasing of the doses.

Funding statement:

This work was supported by the Russian Foundation for Basic Research (grant № 18-515-57001).

Disclosure of Interests:

None declared

Development and initial validation of a composite disease activity score for systemic juvenile idiopathic arthritis

OBJECTIVE

To develop a composite disease activity score for systemic JIA (sJIA) and to provide preliminary evidence of its validity.

METHODS

The systemic Juvenile Arthritis Disease Activity Score (sJADAS) was constructed by adding to the four items of the original JADAS a fifth item that aimed to quantify the activity of systemic features. Validation analyses were conducted on patients with definite or probable/possible sJIA enrolled at first visit or at the time of a flare, who had active systemic manifestations, which should include fever. Patients were reassessed 2 weeks to 3 months after baseline. Three versions were examined, including ESR, CRP or no acute-phase reactant.

RESULTS

A total of 163 patients were included at 30 centres in 10 countries. The sJADAS was found to be feasible and to possess face and content validity, good construct validity, satisfactory internal consistency (Cronbach's alpha 0.64-0.65), fair ability to discriminate between patients with different disease activity states and between those whose parents were satisfied or not satisfied with illness outcome (P < 0.0001 for both), and strong responsiveness to change over time (standardized response mean 2.04-2.58). Overall, these properties were found to be better than those of the original JADAS and of DAS for RA and of Puchot score for adult-onset Still's disease.

CONCLUSION

The sJADAS showed good measurement properties and is therefore a valid instrument for the assessment of disease activity in children with sJIA. The performance of the new tool should be further examined in other patient cohorts that are evaluated prospectively.

SAT0493 CLINICAL PROFILE OF JIA PATIENTS WITH THE CERVICAL SPINE INVOLVEMENT: A SINGLE CENTER RETROSPECTIVE CONTINUOUS STUDY

Background:

JIA is the most common chronic condition in pediatric rheumatology. The cervical spine (CS) involvement is associated with severe disease activity and disability and has been recognized as a factor of a poor prognosis. Data about the CS involvement is contradictory due to silent CS involvement in some patients.

Objectives:

the aim of our study was to provide a clinical profile of the patients with the CS involvement.

Methods:

753 patients for last 10 years with JIA were analyzed. Patients were divided depending on the CS involvement, which was confirmed by clinical (pain, LOM) and radiological features (effusion in the CS joints). We evaluated active joints and routine tests, such as CRP, ESR, ANA-positivity and HLA B27

Results:

The CS involvement was in 101 patients (13.4%). The data are in the table. The CS involvement was more frequently associated with joints of upper body, such as TMJ (23.7% vs 2.9%, p=0.000001), shoulder (29.7% vs 2.9%, p=0.000001), elbow (34.2% vs 12.2%, p=0.000001), wrist (61.4% vs 21.8%, p=0.0000001), MCP (43.6% vs 18.4%, p=0.0000001), PIP (52.5% vs 21.3%, p=0.0000001), DIP (23.8% vs 7.1%, p=0.0000001) and hip (44.6% vs 16.6%, p=0.0000001), and ankle (60.4% vs 40.2%, p=0.0001) from lower body.

ParametersCS, yes (n=101)CS, no (n=652)pFemale, n (%)69 (68.3)388 (59.5)0.092ANA-positivity, n (%)22/57 (38.6)190/403 (47.2)0.226HLA B27-positivity, n (%)12/33 (36.4)88/275 (32.0)0.613Onset age, years5.3 (2.7-10.1)6.1 (3.0- 10.4)0.241ESR, mm/h12.0 (5.0-31.0)7.0 (3.0- 18.0)0.0006CRP, mg/l3.9 (0.0- 20.0)1.1 (0.0-9.2)0.002Active joints, n (%)16.0 (9.0-28.0)5.0 (3.0-10.0)0.000000Time before remission, years2.9 (1.5-5.1)2.2 (1.1-4.6)0.046OligoarthritisPolyarthritisPsoriatic arthritisEnthesitis-related arthritisSystemic arthritis5 (5.0)48 (48.0)7 (7.0)22 (21.8)19 (18.9)199 (30.5)217 (33.3)33 (5.1)164 (25.2)39 (6.0)0.0000001Uveitis, n (%)9/76 (11.9)107/444 (24.1)0,018Oral glucocorticosteroids, n (%)37 (36.7)115/651 (17.7)0.00001Biologic, n (%)68 (67.3)283 (43.4)0.000007Remission, n (%)57 (56.4)428 (65.6)0.072Flare, n (%)10 (9.9)128/651 (19.7)0.018

Conclusion:

The main risk factors of CS involvement in JIA were polyarthicular and systemic arthritis, high inflammatory activity and involvement of joints of upper body. Patients with CS involvement required more often biologics.

Disclosure of Interests:

None declared

THU0511 THE RISK FACTORS OF HIP OSTEOARTHRITIS IN JIA PATIENTS: THE DATA FROM A SINGLE CENTER RETROSPECTIVE CONTINUOUS STUDY

Background:

Hip osteoarthritis (HOA) is a severe irreversible complication of patients with juvenile idiopathic arthritis (JIA) leads to intensive pain, disability and required total hip arthroplasty (THA) in childhood or in the young adults.

Objectives:

the aim of our study was to evaluate risk factors of HOA in JIA patients.

Methods:

we analyzed 753 patients with JIA for last 10 years. In each patient we observed if the HOA developed or no. We evaluated the main clinical JIA measurements, such a JIA category, CRP, ESR, WBC, PLT, active joints, initial or delayed hip involvement, ANA, HLA B27, onset age, JIA duration, time before HOA and before THA, bone metabolic markers, treatment, particularly glucocorticosteroids (GCS), their cumulative doses, route of administration (oral, intra-articular, pulse therapy). HOA was confirmed with radiological assessment (MRI and CT). For comparison analysis used nonparamentric statistics. Each possible variable was evaluated with univariate regression analysis and further multiple regression analysis was applied.

Results:

the comparative study between 2 groups shown in the table 1. HOA was detected in 48 (6.4%), in oligoarthritis-0%, in polyarthritis - 4.9%, in psoriatic arthritis - 5.0%, in enthesitis-related arthritis -11.8%, in systemic arthritis 19% (p=0.0000001), THA was performed in 16 (2.1%). Hip involvement at onset of JIA was similar in both groups (49.5% vs 41.7%, p=0.367).

Table 1.

Characteristics of JIA patients, depends on HOA development.

ParameterHOA (n=48)No HOA (n=705)pOnset age, y8.0 (4.0; 12.5)5.9 (3.0; 10.7)0.045HLA B27, n (%)13/25 (52.0)88/283 (31.1)0.033JIA duration, y7.5 (3.2; 12.1)4.2 (1.8; 7.2)0.00007CRP, mg\l2.8 (0.8; 20.9)1.3 (0; 7.1)0.006Active joints, n11.0 (6.0; 27.0)6.0 (3.0; 12.0)0.000001Oral GCS, n(%)21 (43.8)131/704 (18.6)0.00003GCS pulse-therapy, n (%)21 (43.8)114/702 (16.2)0.000002GCS, cumulative doses, mg5000 (3000; 16000)2000 (1000; 4000)0.001Biologics, n (%)43 (89.6)308 (43.7)0.0000001Remission, n (%)24 (50.0)461 (65.4)0.03Time, before remission, y7.4 (3.9; 12.3)3.0 (1.4; 6.2)0.0000001Alkaline phosphatase, U\l129.3 (84; 244)223 (147; 386)0.00001Delayed hip involvement, n (%)28 (58.3)24/87 (27.6)0.00004

We calculated cut-off and OR of variables, associated with HOA development (table 2). After selection of 26 clinically meaningful and statistical significant risk factors only 22 pass the univariate regression analysis. In multiple regression analysis the main independent risk factors of HOA development were: HLA b27 (p=0.001), oral GCS/pulse therapy GCS (p=0.03) and alkaline phosphatase≤165 U/l (p=0.00006).

Table 2.

Cutt-offs, odds ratio for HOA risk factors in JIA patients.

ParameterSeSpOR (95%CI)pActive joints > 489,642,06,2 (2,4-15,9)0,000002Alkaline phosphatase ≤ 165 U/l65,970,84,7 (2,4-9,2)0,000001GCS > 2700 mg82,658,16,6 (2,1-20,6)0,0004Time before remission>5 years66,778,97,5 (3,1-18,0)0,0000001Time before biologics >7,8 years44,286,75,2 (2,6-10,2)0,0000001

Conclusion:

the main risk factors of HOA were increased inflammatory activity, systemic arthritis, HLA B27, systemic corticosteroids, delayed remission and biologics, decreased bone metabolism. Delayed hip involvement underline the possible non-inflammatory mechanism of HOA, such as avascular necrosis.

Disclosure of Interests:

None declared