Comparing Prevalence of Sarcopenia Using Twelve Sarcopenia Definitions in a Large Multinational European Population of Community-Dwelling Older Adults

OBJECTIVES

Multinational prevalence data on sarcopenia among generally healthy older adults is limited. The aim of the study was to assess prevalence of sarcopenia in the DO-HEALTH European trial based on twelve current sarcopenia definitions.

SETTING AND PARTICIPANTS

This is an analysis of the DO-HEALTH study including 1495 of 2157 community-dwelling participants age 70+ years from Germany, France, Portugal, and Switzerland with complete measurements of the sarcopenia toolbox including muscle mass by DXA, grip strength, and gait speed.

MEASUREMENTS

The twelve sarcopenia definitions applied were Asian Working Group on Sarcopenia (AWGS1), AWGS2, Baumgartner, Delmonico, European Working Group on Sarcopenia in Older People (EWGSOP1), EWGSOP2, EWGSOP2-lower extremities, Foundation for the National Institutes of Health (FNIH1), FNIH2, International Working Group on Sarcopenia in Older People (IWGS), Morley, and Sarcopenia Definitions and Outcomes Consortium (SDOC).

RESULTS

Mean age was 74.9 years (SD 4.4); 63.3% were women. Sarcopenia prevalence ranged between 0.7% using the EWGSOP2 or AWGS2 definition, up to 16.8% using the Delmonico definition. Overall, most sarcopenia definitions, including Delmonico (16.8%), Baumgartner (12.8%), FNIH1(10.5%), IWGS (3.6%), EWGSOP1 (3.4%), SDOC (2.0%), Morley (1.3%), and AWGS1 (1.1%) tended to be higher than the prevalence based on EWGSOP2 (0.7%). In contrast, the definitions AWGS2 (0.7%), EWGSOP2-LE (1.1%), FNIH2 (1.0%) - all based on muscle mass and muscle strength - showed similar lower prevalence as EWGSOP2 (0.7%). Moreover, most sarcopenia definitions did not overlap on identifying sarcopenia on an individual participant-level.

CONCLUSION

In this multinational European trial of community-dwelling older adults we found major discordances of sarcopenia prevalence both on a population- and on a participant- level between various sarcopenia definitions. Our findings suggest that the concept of sarcopenia may need to be rethought to reliably and validly identify people with impaired muscle health.

AB1357 THE BEST CUT-OFF POINT FOR MEDIAN NERVE CROSS SECTIONAL AREA AT THE LEVEL OF PISIFORM BONE

Background

Carpal tunnel syndrome (CTS) is a focal neuropathy caused by compression of the median nerve (MN) at the wrist. Electromyography (EMG) is the gold standard for the diagnosis of CTS. Currently, the ultrasound (US) is frequently used as an initial screening exam by measuring the cross-sectional area (CSA) of the MN. The cut-off point of the CSA at the pisiform bone level to define CTS remains controversial with previous studies reporting values between 6.5mm2 and 15mm2 (1).

Objectives

The aim of this study is to determine the best cut-off point of the CSA for the diagnosis of CTS.

Methods

Cross-sectional study at a Tertiary Rheumatology Department including patients aged ≥ 18 years with symptoms compatible with CTS. Sociodemographic and clinical data, visual analogue scale for pain (VAS), Boston Questionnaire (BQ), and the results of EMG and US performed in each patient were collected. The EMG was performed according to the standardized protocol (sensory conduction velocity, sensory amplitude, distal sensory and motor latency), and the patients were categorized in 4 groups: normal, mild, moderate, and severe. A rheumatologist with expertise in imaging performed all the US evaluations by means of a 6–18-MHz (Siemens ACUSON S 2000) linear array transducer. The largest CSA of the MN was measured at the level of the pisiform bone. Receiver operating characteristic (ROC) curve was used to determine optimal cut-off values of the CSA taking the EMG result as the gold-standard. One-way ANOVA test was used to compare CSA between the 4 EMG groups.

Results

Fifty patients were included, 90% were female, mean age was 52.1 ± 10.8 years and median duration of symptoms was 28.0 (IQR 23.0-31.0) months. The mean VAS was 4.2 ± 2.9. In the BQ there was a mean symptom severity score of 2.4 ± 0.6 and a mean functional status score of 2.0 ± 0.9. One-way ANOVA showed that mean CSA values were significantly different in the 4 groups of patients. The Ryan-Einot-Gabriel-Welsch post hoc analysis showed that only the mean CSA of patients with severe STC is different from the remaining groups defined by EMG results. The best cut-off point for CSA at the pisiforme bone level for CTS diagnosis was 6.6 mm2 with a sensitivity and specificity of 92.9% and 75.0% (AUC=0.9, P<0.001). The positive and negative predictive values were 95.1% and 66.7%, respectively. For severe CTS diagnosis the best cut-off point for CSA was 12.3mm2 with a sensitivity of 82.4% and a specificity of 72.7% (AUC=0.8, P<0.001). The positive and negative predictive values were 60.9% and 88.9%, respectively.

Conclusion

In our study we found that the best cut-off point of the CSA was 6.6mm2 for distinguishing patients with/without CTS based on EMG alterations, with a high sensitivity and moderate specificity. This is a lower cut-off value than usually used in clinical practice and could be explained by small sample and the greater number of patients with mild and moderate STC on EMG.

References

[1]McDonagh C, Alexander M, Kane D. The role of ultrasound in the diagnosis and management of carpal tunnel syndrome: A new paradigm. Rheumatology (Oxford, England). 2014;54.

Disclosure of Interests

None declared

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

Background

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

Objectives

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

Methods

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

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

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

Results

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

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

Conclusion

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

References

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

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

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

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

Acknowledgements

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

Disclosure of Interests

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

POS0564 SHOULD WE USE PHYSICIAN’S GLOBAL TO DEFINE REMISSION IN RHEUMATOID ARTHRITIS AND CONSIDER A SEPARATE PATIENT-CENTRED TARGET?

Background

The definitions of remission play a crucial role in the treat-to-target strategy in rheumatoid arthritis.The patient’s and physician’s global assessment (PGA|PhGA) of disease activity are considered in current definitions, but PGA has been criticized for its poor relationship with actual disease activity. This leads to a considerable risk of overtreatment in patients who are otherwise in remission but fail this target solely because of PGA: PGA-near-remission. A dual-target strategy, excluding PGA from the definition of biological remission and the creation of a second target focused on disease impact has been proposed.1 Another proposal is to substitute PGA by PhGA with the purpose of strengthening the definition with a fourth variable capable of conveying relevant unaccounted factors, such as comorbidity.2

Objectives

To assess the relationship of PGA and PhGA with objective measures of disease activity (DAS3v) and their impact upon near-remission and risk of overtreatment.

Methods

This is a cross-sectional analysis of data from RAID.PT, an observational, prospective and multicenter study, including adult patients fulfilling RA classification criteria. Tender (TJC28) and swollen (SJC28) 28 joint counts, C-Reactive Protein (CRP), Pain score, Health Assessment Questionnaire (HAQ), the Rheumatoid Arthritis Impact of Disease (RAID) total score, Hospital Anxiety and Depression Scale (HADS) scores, PGA and PhGA were collected. Disease Activity Score (DAS28-3v-CRP) was calculated and taken as the reference measure of current disease activity. Correlation between PGA and PhGA with other continuous variables was evaluated through Pearson´s Correlation Coefficient and variables with p<0.10 in univariate analysis were included in multivariable linear regression models.

Results

We included 299 patients, 81.3% women, mean age of 57.4±12.0 years and disease duration 9.4±9.5 years. Average DAS28-3v-PCR 2.4 (±1.9).

DAS3v-CRP is the strongest factor associated with PhGA, explaining 45% of its variance. Inversely, it only explains 2% of the variance of PGA, which is more affected by disease impact.

In this clinical cohort, 13% of patients were in full Boolean remission and 41% in PGA-near-remission. Only 49 of 123 patients in the latter group had a PhGA >1.

Considering PhGA instead of PGA in the Boolean definition of remission would increase the proportion of remission from 13 to 37.5% of the whole cohort.

Table 1.

Factors Associated with PGA and PhGA in multivariate regression analysis

PGAPhGA(β, 95% CI)(β, 95% CI)(β, 95% CI)ΔR2ΔR2DAS28-3v-CRP3.7 (1.9-5.5)10.9 (9.4 to12.5)0.020.45RAID7.7 (6.7-8.8)3.4 (2.5 to 4.3)0.610.09HAQ5.6 (1.0-8.1)-3.4 (-6.4 to -0.4)0.010.01R20.64*0.55*

DAS28-3v-CRP: Disease Activity Score-3 variables C-Reactive Protein. PGA: Patient global assessment; PhGA: Physician Global Assessment; HAQ (health assessment questionnaire); RAID: Rheumatoid Arthritis Impact Disease score. ΔR2 change of R2associated with the inclusion of the variable in the model. *p<0,01

Conclusion

PhGA is a closer representation of actual disease activity than PGA, thus providing a more valid basis for treatment decisions aimed at disease activity. These observations support the substitution of PGA by PhGA in the Boolean definition of remission as it would strengthen the representation of disease activity and significantly reduce the risk of overtreatment in comparison to current definitions. The consequences of this change upon the prediction of long-term function and structural stability warrant evaluation. The patient’s perspective will remain central to disease management in the form of a distinct target.

References

[1]Ferreira et al. Ann Rheum Dis 2019 Oct;78(10):e109.doi: 10.1136/annrheumdis-2018-214199

[2]Pazmino et al. J Rheumatol. 2021 Feb;48(2):174-178.doi: 10.3899/jrheum.200758

Disclosure of Interests

None declared.

POS0861 ANTI-Ku ANTIBODY SYNDROME: IS IT A DISTINCT CLINICAL ENTITY? A CLUSTER ANALYSIS OF 75 PATIENTS

Background

Anti-Ku antibodies are rare among patients with Connective Tissue Diseases (CTD) (1). Their potential role as a disease biomarker is not well established.

Objectives

To identify subgroups of anti-Ku positive patients according to their spectrum of anti-nuclear antibody (ANA) specificities and analyze their clinical and analytical features.

Methods

Multicenter, cross-sectional study of anti-Ku positive patients, irrespective of their diagnosis, followed at eight Rheumatology outpatient clinics. Patients were spontaneously identified according to the local work-out for suspected autoimmune diseases. Anti-Ku and other ANA specificities were determined at each hospital’s Immunology lab according to the local methodology and strategy to decide on which auto-antibodies to check when faced with a positive ANA immunofluorescence. Clinical, analytical and treatment cumulative features were identified following a dedicated structured questionnaire. Hierarchical cluster analysis (method: between-groups linkage, squared Euclidian distance) for ANA specificity variables was performed to identify subgroups.

Results

Seventy-five anti-Ku positive patients were included (female: 73.3%, mean age at diagnosis: 50.5±17.9 years, mean disease duration: 4.7±5.4 years). Their clinical diagnosis were undifferentiated connective tissue disease (UCTD) (21.3%), systemic lupus erythematosus (17.3%), Sjögren’s syndrome (16.0%), inflammatory myositis (14.7%), systemic sclerosis (10.7%), overlap CTD syndrome (8.0%), other connective tissue diseases (17.3%), healthy anti-Ku carrier (17.3%).

Six autoantibody clusters were identified and included most patients (Figure 1): Cluster 1 - anti-Ku without any other ANA specificities (36.0%); cluster 2 - Anti-nor90 and anti-fibrillarin (8.0%); cluster 3 - anti-Jo1, PL-7, PL-12, and PM-Scl100 (9.3%); cluster 4 - anti-Scl70 (4.0%); cluster 5 - anti-Sm, anti-ribosome, and anti-dsDNA (13.3%); cluster 6 - anti-centromere, Th/To, PM-Scl75 (8.0%). The remaining patients were outliers (21.3%) not fitting in any cluster.

Figure 1.

Hierarchical cluster analysis of ANA specificities in anti-Ku+ patients

Detailed clinical analysis of patients in cluster 1, the most numerous, presenting anti-Ku antibodies without any other ANA specificities, the most frequent clinical manifestations were: Raynaud’s phenomenon (40.7%), arthritis (25.9%), sicca syndrome (25.9%), myositis (14.8%), and interstitial lung disease (ILD) (14.8%); 25.9% were healthy anti-Ku carriers. Patients from cluster 1 were most frequently treated with low dose glucocorticoids (51.9%), hydroxychloroquine (37.0%), or methotrexate (18.5%).

Among the whole study population (n=75), major organ involvement was present in 18.7%, with ILD in 10.7% and renal involvement in 8.0%. None of the patients in cluster 1 presented nephritis.

Conclusion

Anti-Ku positive patients without any other ANA specificities is the largest subset and may represent a distinct entity among the differentiated CTD (2). Patients with this anti-Ku syndrome may develop ILD. In addition, anti-Ku antibodies can be found in patients with a diversity of other ANA specificities and heterogeneous CTD diagnosis.

References

[1]Lakota K, et al. International cohort study of 73 anti-Ku-positive patients: association of p70/p80 anti-Ku antibodies with joint/bone features and differentiation of disease populations by using principal-components analysis. Arthritis Res Ther. 2012 Jan 6;14(1):R2. doi: 10.1186/ar3550. PMID: 22226402; PMCID: PMC3392788.

[2]Spielmann L, et al. Anti-Ku syndrome with elevated CK and anti-Ku syndrome with anti-dsDNA are two distinct entities with different outcomes. Ann Rheum Dis. 2019 Aug;78(8):1101-1106. doi: 10.1136/annrheumdis-2018-214439. Epub 2019 May 24. PMID: 31126956.

Disclosure of Interests

None declared

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

Background

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

Objectives

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

Methods

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

Table 1.

Predictor sets.

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

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

Results

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

Conclusion

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

References

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

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

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

Acknowledgements

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

Disclosure of Interests

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

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

References:

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

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

Table 1.

Comorbidities and concomitant medications at baseline in the GLORIA trial.

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

Acknowledgements:

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

Disclosure of Interests:

None declared

POS0713 PREDICTORS OF HOSPITALIZATION IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: A 10-YEAR COHORT STUDY OF 398 PATIENTS FROM A TERTIARY CENTRE

Background:

Patients with systemic lupus erythematosus (SLE) often require hospitalization. The cause of admission may vary, but active disease and infection are consistently reported as the main reasons for hospitalization and are associated with worse survival and damage accrual. Recent improvements in the standard of care, including minimization of glucocorticoid dose and more effective and safe immunosuppressive regimens, may have changed the incidence and risk factors for hospitalization due to these causes. Hence, it is useful to identify predictors of hospitalization to further reduce the risk of admission for disease activity and severe infection in patients with SLE.

Objectives:

To identify predictors of hospitalization in patients with SLE, according to the underlying cause.

Methods:

Patients with SLE fulfilling classification criteria (ACR’97 and/or SLICC), regularly followed at an academic lupus clinic from January 2009 to December 2020 and with at least two outpatient visits were included in this cohort study. Time to first hospitalization up to 120 months was identified separately for the following admission causes: (a) any cause; (b) active SLE; (c) infection. Predictors of hospitalization were sought through survival analysis, with distinct models for each of the major admission causes. Univariate analysis was performed using Kaplan-Meier curves and Log-Rank tests. Tested variables assessed at baseline included: gender; age at SLE onset; age; disease duration; SLE Disease Activity Index (SLEDAI-2K) score; ongoing antimalarial use; ongoing immunosuppressants; ongoing prednisolone daily dose; lupus nephritis up to baseline; SLICC Damage Index (SDI) score. Variables with p<0.1 were further tested in multivariate Cox regression models. Hazard ratios (HR) were determined with 95% confidence intervals (95%CI).

Results:

We included 398 patients (female: 86.2%, mean age: 41.2±15.1 years, mean disease duration: 10.1±9.2 years; previous lupus nephritis: 28.9%; mean SLEDAI-2K score: 3.4±2.7; ongoing antimalarials: 78.9%; ongoing immunosuppressant: 29.9%; ongoing prednisolone >7.5 mg/day: 17.1%; SDI score ≥1: 28.4%). During the follow-up period, 50.5%, 23.6% and 17.3% were hospitalized at least once for any cause, active SLE or infection, respectively.

In the multivariate model, significant baseline predictors for hospitalization due to active disease were (table 1): SLEDAI-2K score >5; disease duration ≤2 years; ongoing immunosuppressants; SDI score ≥1. Baseline independent predictors of hospitalization for infection included (table 1): male gender; SDI score ≥1; ongoing antimalarials were protective.

Table 1.

Predictors of hospitalization in multivariate Cox regression according to the admission cause

PredictorsHospitalization for active SLEHospitalization for infectionSLEDAI-2K score >52.43 (1.53-3.88)n.s.SLE duration ≤2 years1.70 (1.04-2.77)n.s.Ongoing immunosuppressant1.91 (1.24-2.95)n.s.SDI score ≥11.82 (1.16-2.86)2.14 (1.33-3.45)Male gendern.s.2.19 (1.23-3.89)No antimalarial treatmentn.s.2.20 (1.34-3.60)

Risk for each predictor reported as Hazard Ratio (95% Confidence Interval); n.s.: non-significant

Conclusion:

Tight control of disease activity, prevention of damage accrual, and treatment with antimalarials may contribute to minimize the risk of hospitalization for these two major causes of admission in patients with SLE.

Disclosure of Interests:

None declared

OP0293 OPTIMIZING A TOOL TO IDENTIFY LUPUS FLARES IN DAILY CLINICAL PRACTICE: SLE-DAS FLARE VERSUS SELENA FLARE INDEX

Background:

In the management of patients with Systemic Lupus Erythematosus (SLE), it is of utmost importance to accurately identify lupus flares. There is a conceptual consensus definition of lupus flares [1]; however, the instruments used to identify flares in clinical trials, such as the SELENA Flare Index (SFI) are too cumbersome to apply in daily clinical practice. The SLE disease activity score (SLE-DAS) is a validated continuous measure of disease activity with higher sensitivity to change and validity in predicting damage accrual when compared to SLEDAI-2K. SLE-DAS is quickly scored with its online calculator. An increase in SLE-DAS ≥1.72 was validated as a clinically meaningful worsening of SLE disease activity. [2]

Objectives:

To compare the performance of SLE-DAS, classic SFI (c-SFI), revised SFI (r-SFI) and SLEDAI-2K in the identification of lupus flares in a real-life clinical setting.

Methods:

We included patients with SLE fulfilling classification criteria [ACR (1997) and/or SLICC and/or EULAR/ACR], followed at an academic lupus clinic from January 2017 to June 2020, and presenting with lupus low disease activity score (LLDAS) at baseline.

Flares occurring after baseline were identified as fulfillment of the conceptual definition of flare, as assessed by the senior lupus expert at time of each outpatient visit. For each flare event, we evaluated the fulfillment of flare criteria according to c-SFI, r-SFI, SLEDAI-2K (score increase ≥4 points from baseline), and SLE-DAS (score increase ≥1.72 from baseline). As control visits without flare, we considered the first visit after baseline, where we assessed the four tools, excluding those where a flare was identified by the gold-standard expert evaluation. Sensitivity and specificity of the four flare tools were estimated and McNemar’s test applied to assess differences with the gold-standard flare definition. The inter-instrument agreement with the gold-standard was assessed through Cohen’s Kappa.

Results:

We included 297 patients (female: 86.2%; mean age: 48.9±14.6 years, mean disease duration: 12.5±9.0 years). At baseline, all patients were in LLDAS, receiving ongoing antimalarials, immunosuppressants, and/or glucocorticoids in 91.0%, 43.8% and 33.6%, respectively. During follow-up, 22.2% developed flares. The analysis included 92 flares [musculoskeletal (40.2%); renal (23.9%), mucocutaneous (18.5%), haematological (5.9%), serositis (3.3%); multisystemic (8.7%)], with increase or change of treatment in 80.4% of these episodes, and 292 visits without flare considered as control.

There was no statistically significant difference between either SLE-DAS flare or c-SFI and the gold-standard expert flare definition (p=0.41 and p=0.82, respectively), while r-SFI and SLEDAI-2K flare were different from the gold-standard (Table 1). There was a strong agreement between SLE-DAS flare, c-SFI, r-SFI and the expert definition (Cohen’s kappa, Table 1).

Table 1.

Performance of the flare tools for the gold-standard flare definition.

Sensitivity (%)Specificity (%)McNemar’s§§Kappa§SLE-DAS flare90.195.0n.s.0.836c-SFI flare91.196.5n.s.0.869r-SFI flare93.492.9p<0.010.820SLEDAI-2K flare51.698.6p<0.00010.590

§§ McNemar’s test: significant difference from gold-standard if p<0.05; § Cohen’s kappa agreement (0-1) with the gold-standard flare definition; n.s.: non-significant

Conclusion:

The c-SFI and SLE-DAS showed the best performance in identifying SLE flares. The SLE-DAS flare definition is easier to apply and hence might be considered as an optimal tool to be used in daily clinical practice.

References:

[1]Ruperto N, Hanrahan LM, Alarcón GS, et al. International consensus for a definition of disease flare in lupus. Lupus. 2011;20(5):453-62.

[2]Jesus D, Matos A, Henriques C, et al. Derivation and validation of the SLE Disease Activity Score (SLE-DAS): a new SLE continuous measure with high sensitivity for changes in disease activity. Ann Rheum Dis 2019; 78:365-71.

Disclosure of Interests:

None declared.

POS0055 SARS-COV-2 OUTBREAK IN AUTOIMMUNE DISEASES: THE EURO-COVIMID STUDY

Background:

Coronavirus disease 2019 (COVID-19), has raised several questions in patients with immune-mediated inflammatory diseases (IMID). Whether the seroprevalence and factors associated with symptomatic COVID-19 are similar in IMID patients and in the general population is still unknown.

Objectives:

To assess the serological and clinical prevalence of COVID-19 in European IMID patients, along with the factors associated with its risk and the impacts the pandemic had on the IMID management.

Methods:

Prospective multicentre cross-sectional study among patients with five IMID (i.e. systemic lupus erythematous, Sjögren’s syndrome, rheumatoid arthritis, axial spondylarthritis or giant cell arteritis) from six tertiary-referral centers from France, Germany, Italy, Portugal, Spain and United Kingdom. Demographics, comorbidities, IMID, treatments, flares and COVID-19 details were collected. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serological tests were systematically performed.

Results:

Between June 7 and December 8, 2020, 3028 patients were included (median age 58 years, 73.9% females). SARS-CoV-2 antibodies were detected in 166 (5.5%) patients. Symptomatic COVID-19 was seen in 122 patients (prevalence: 4.0%, 95% CI 3.4-4.8%); 23 (24.2%) of them were hospitalized and four (3.2%) died. In multivariate logistic regression analysis, symptomatic COVID-19 was more likely to be observed in patients with higher levels of C-reactive protein (OR: 1.18; 95% CI 1.05-1.33; p = 0.006), and increased with the number of IMID flares (OR: 1.27; 95% CI 1.02-1.58; p = 0.03). Conversely, it was less likely to occur in patients treated with biological therapy (OR: 0.51; 95% CI 0.32-0.82; p = 0.006). During the pandemic, at least one self-reported disease flare was seen in 654 (21.6%) patients. Also, 519 (20.6%) patients experienced changes in their treatment, with 125 of these (24.1%) being due to COVID-19.

Conclusion:

The SARS-CoV-2 prevalence in IMID patients over the study period seems to be similar to that of the general population1. The IMID inflammatory status seems to be independently associated with the development of COVID-19.

References:

[1]Pollán M, Pérez-Gómez B, Pastor-Barriuso R, Oteo J, Hernán MA, Pérez-Olmeda M, et al. Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study. Lancet Lond Engl. 2020 Aug 22;396(10250):535–44.

Disclosure of Interests:

None declared.

POS0105 PREDICTORS OF FLARE IN SLE PATIENTS ATTAINING LUPUS LOW DISEASE ACTIVITY STATE: A REAL-LIFE COHORT STUDY OF 292 PATIENTS WITH 36-MONTH FOLLOW-UP

Background:

Lupus Low Disease Activity State (LLDAS) is a target for management of patients with SLE, that should be maintained in the long-term by preventing flares. Stratification of flare risk would be useful to optimize management.

Objectives:

To identify predictors of flare in SLE patients attaining LLDAS.

Methods:

Patients with SLE fulfilling classification criteria [ACR (1997) and/or SLICC and/or EULAR/ACR], followed at an academic lupus clinic from January 2017 to March 2020 were eligible. Baseline for each patient was the first visit with LLDAS within the study period. Patients never fulfilling LLDAS were excluded. Flares were identified as change from baseline by 3 instruments: revised SELENA flare index (r-SFI); SLEDAI-2K; Systemic Lupus Erythematosus Disease Activity Score (SLE-DAS). Time to first flare up to 36 months was identified separately for each instrument. Predictors of flare were sought through survival analysis, with distinct models for each of the three definitions of flare. Univariate analysis was performed using Kaplan-Meir curves and Log-Rank tests. Tested variables at baseline were: gender; age at time of SLE diagnosis; disease duration; cumulative SLE organ involvement (arthritis; mucocutaneous; renal; neurologic; haematological; anti-phospholipid syndrome); cumulative immunological features (anti-dsDNA; anti-Sm; anti-RNP, anti-phospholipid antibodies; hypocomplementemia); ongoing treatment (hydroxychloroquine; prednisone; immunosuppressants). Variables with p<0.1 were further tested in multivariate Cox regression models. Hazard ratios (HR) were determined with 95% confidence intervals (95%CI).

Results:

From 322 patients in this SLE cohort, 292 (90.7%) fulfilled LLDAS and were included in the analyses (female: 87.3%; mean age: 46.2±14.5 years; previous lupus nephritis: 36.0%; receiving ongoing antimalarials, immunosuppressants, glucocorticoids: 92.8%, 34.6% and 29.8%, respectively. Over follow-up, the proportion of patients with flares according to each definition were: 28.4% (r-SFI), 24.7% (SLE-DAS) and 13.4% (SLEDAI-2K). The r-SFI flares were moderate in 28.9% and severe in 9.6% of the cases. From all patients, 54.1% maintained stable glucocorticoid-free control of the disease, without flares during follow-up. In the multivariate models, the following parameters were independent predictors of flare, as defined by any of the definitions (Table 1): anti-RNP+; oral glucocorticoids; immunosuppressants.

Conclusion:

Patients attaining LLDAS but requiring ongoing treatment with immunosuppressants and/or glucocorticoids present a higher risk of flare and thus might need a tighter clinical monitoring. Anti-RNP+ was newly identified as a potential biomarker for higher risk of flares. Glucocorticoid-free, stable low disease activity is an achievable target.

References:

[1]Mathian A, Pha M, Haroche J, Cohen-Aubart F, Hié M, Pineton de Chambrun M, et al. Withdrawal of low-dose prednisone in SLE patients with a clinically quiescent disease for more than 1 year: a randomised clinical trial. Ann Rheum Dis. 2020;79(3):339-46.

[2]Inês L, Duarte C, Silva RS, Teixeira AS, Fonseca FP, da Silva JA. Identification of clinical predictors of flare in systemic lupus erythematosus patients: a 24-month prospective cohort study. Rheumatology (Oxford). 2014;53(1):85-9.

Table 1.

Predictors of flare in multivariate Cox regression according to each of the flare definitions (r-SFI; SLE-DAS; SLEDAI-2K)

r-SFISLE-DASSLEDAI-2KAnti-RNP+2.11 (1.30-3.42)2.39 (1.44-3.95)2.22 (1.11-4.42)Immunosuppressants1.96 (1.22-3.15)2.32 (1.38-3.88)2.26 (1.12-4.54)Prednisone*1.93 (1.19-3.14)1.99 (1.18-3.35)2.17 (1.07-4.38)Blood cytopenias§2.08 (1.03-4.17)n.s.n.s.Arthritis§n.s.n.s.2.23 (1.12-4.44)

* Prednisone ≤7.5 mg/day as required by LLDAS. § Blood cytopenias; arthritis: cumulative SLE features up to baseline. Risk for each predictor reported as Hazard Ratio (95% Confidence Interval); n.s.: non-significant

Disclosure of Interests:

None declared

AB0147 OLDER AGE AT ONSET AND NOT DISEASE ACTIVITY IS ASSOCIATED WITH FUNCTIONAL DISABILITY AT RA DIAGNOSIS: RESULTS FROM AN EARLY ARTHRITIS COHORT

Background:

Rheumatoid Arthritis (RA) is a chronic inflammatory arthropathy that potentially leads to loss of function and disability early in the disease course. (1) Optimizing physical function is one of the primary goals of RA treatment (2). Several demographic, psychosocial and clinical factors may influence the impact of RA upon physical capacity, and understanding their relative contribution to disability at disease diagnosis is key to an effective treatment approach.

Objectives:

To evaluate functional disability at the time of disease diagnosis and identify its demographic and clinical correlates in an early RA cohort.

Methods:

We conducted a cross-sectional study based on a Rheumatology centre early arthritis cohort. Consecutive patients with early RA – less than 12 months duration– fulfilling ACR/EULAR 2010 and/or ACR 1987 RA classification criteria, were included. Variables were collected from patients’ registries at the first rheumatology appointment after symptom’s onset. Functional disability was assessed using the Health Assessment Questionnaire- Disability Index (HAQ-DI) (range 0 to 3, higher values indicating greater disability). Independent t-test, one way-ANOVA and Pearson’s correlation coefficient were performed to evaluate differences between groups. Variables with p<0.1 were included in a stepwise multiple linear regression analysis to assess the independent association of variables with the HAQ-DI at baseline.

Results:

We included 71 patients (63.4% female, mean age 57.2 ±2.01 years). Mean HAQ-DI score was 1.42±0.08. Sociodemographic and clinical variables are described in Table 1. There was a significant difference in HAQ-DI scores between rheumatoid factor (RF) positive (mean 1.24±0.11) and RF negative (1.61±0.113) patients. HAQ-DI was positively weakly correlated with age (r=0.48; p<0.001), CDAI (r=0.43; p=0.038), SDAI (r=0.49; p=0.015), and moderately with DAS28-3V (r=0.60; p<0.001) and DAS28-3V-CRP (r=0.60; p<0.001). The number of tender (r=0.35; p=0.024) and swollen joints (r=0.42; p= 0.005), ESR (r=0.46; p=0.001), CRP (r=0.35; p=0.018), HADS-depression (r=0.46; p=0.023) and educational level (r= -0.48; p=0.002) were also associated with HAQ-DI in univariate analyses. After multivariate regression analysis, age at disease diagnosis (β= 0.022 [95 CI 0.010 to 0.034]; p= 0.001) was the only independent predictor of HAQ-DI (R2= 0.46, p=0.001).

Table 1.

Patients’ baseline sociodemographic and clinical characteristics.

Age at diagnosis (years), mean (SD)57.2±2.01Educational level (years), mean (SD)7.37±0.59Employment: full-time, %42.4Employment: partial-time, %3.00Employment: retired, %48.4Employment: absenteeism in the last month, %1.50Unemployed, %4.50Disease duration at presentation (weeks), mean (SD)20.4±1.70Morning stiffness >30 minutes, %83.0RF positivity, %47.9ACPA positivity, %53.5Fibromyalgia, %6.60DAS28-3V, mean (SD)4.72±0.17CDAI, mean (SD)29.2±2.28SDAI, mean (SD)32.4±2.42PtGA, mean (SD)66.8±3.73PhGA, mean (SD)54.7±3.08Pain intensity (VAS), mean (SD)67.7±3.75EQ-5D score, mean (SD)0.26±0.039HADS-depression, mean (SD)7.17±0.87

Legend: ACPA- anti-citrullinated protein antibodies; ESR- erythrocyte sedimentation rate; CRP- c-reactive protein; DAS- disease activity score; CDAI- clinical disease activity score; SDAI-simplified disease activity score; PtGA/ PhGA – patient’s/physician’s global assessment of general health; VAS- visual analogic scale; EQ-5D- EuroQoL 5-Dimensional Descriptive System; HADS-Hospital Anxiety and Depression Scale.

Conclusion:

Older age at disease onset is associated with greater functional impairment at diagnosis, assessed by HAQ-DI, in this cohort of early RA patients, irrespective of disease activity and other clinical variables. This result suggests that older newly diagnosed RA patients may deserve special attention regarding physical function.

References:

[1]Wolfe F et al. Arthritis Res Ther. 2010; 12(2): R35.

[2]Smolen JS et al. Ann Rheum Dis. 2010; 69:631-637.

Disclosure of Interests:

None declared

POS0878 ULTRASOUND ASSESSMENT OF DERMAL THICKNESS AND SKIN STIFFNESS IN UNDIFFERENTIATED CONNECTIVE TISSUE DISEASE AT RISK FOR SYSTEMIC SCLEROSIS

Background:

High-frequency ultrasound (HFUS) and shear-wave elastography (SWE) allow an objective assessment of skin involvement in systemic sclerosis (SSc) patients.1 Till now it has been applied to patients with established diagnosis.2,3 However, there is no data concerning its application in Undifferentiated Connective Tissue Disease at risk for SSc (UCTD-risk-SSc), i.e., patients with Raynaud’s phenomenon and either SSc marker autoantibodies or typical capillaroscopic findings or both, not satisfying classification criteria for SSc.4

Objectives:

To compare ultrasound-dermal thickness (DT) and skin stiffness, using high-frequency ultrasound and shear-wave elastography, in UCTD-risk-SSc and healthy controls.

Methods:

Forty UCTD-risk-SSc patients and 40 age- and gender-matched healthy controls were included. Ultrasound-DT was measured using an 18MHz probe, and skin stiffness (i.e. shear-wave velocity values, SWV) using the VTIQ software with a 9MHz probe, at the 17 Rodnan skin sites. The mRSS score was, by definition, zero in all sites, both in cases and controls. Continuous data were expressed as the mean (SD), and Mann-Whitney U test was performed to compare differences between the groups, as variables were not normally distributed. Associations between variables were analysed using the Spearman’s correlation.

Results:

SWV values were significantly higher in patients with UCTD-risk-SSc compared with controls at the right and left hands, and in the right and left fingers (table 1). Higher values of ultrasound dermal-thickness were found in the fingers and hands bilaterally, although differences were only significantly at the hands, compared with healthy controls (table 1). There were no significant differences in the other Rodnan skin sites. There was no significant correlation between ultrasound-dermal thickness and stiffness at the same skin site.

Conclusion:

This study provides the first evidence suggesting that ultrasound-DT and stiffness can discriminate patients with UCTD-risk-SSc from healthy controls. Prospective studies including a larger number of patients with different subsets of UCTD-risk-SSc are needed to investigate diagnostic and prognostic value of the ultrasound parameters in this group.

References:

[1]Santiago T, et al. Arthritis Care Res (Hoboken). 2019;71:563-574.

[2]Hesselstrand R, et al. Rheumatology (Oxford). 2008;47:84-7.

[3]Flower V et al. jrheum.200234.

[4]Valentini, G., et al. Arthritis Care Res, 66: 1520-1527.

Table 1.

Clinical and ultrasound parameters in UCTD-risk-SSc and healthy control groups.

UCTD-risk-SSc (n=40)Healthy controls (n=40)p valueAge, mean (SD)51.4 (14.9)49.8 (13.9)NsFemale, n (%)36 (90.0)36 (90.0)Raynaud phenomenon, %100.0%-ANAs100.0-Anti-centromere, %60.0Anti-Scl70+, %11.5Scleroderma/non-scleroderma pattern in capillaroscopy, %5.0/95.0--Ultrasound parametersDermal thickness (mm) Dorsal hand right0.77 (0.32)0.62 (0.12)0.02 Dorsal hand left0.79 (0.39)0.62 (9.13)0.02 Proximal phalanx right0.64 (0.14)0.61 (0.11)Ns Proximal phalanx left0.66 (0.16)0.60 (0.09)NsSWV values (m/s) Dorsal hand right1.94 (0.40)1.61 (0.24)0.0001 Dorsal hand left1.82 (0.36)1.65 (0.25)0.025 Proximal phalanx right2.09 (0.60)1.68 (0.24)0.001 Proximal phalanx left2.13 (0.82)1.66 (0.27)0.004

Legend: ANA: Antinuclear antibodies; Ns: Non-significant; UCTD: Undifferentiated Connective Tissue Disease; SD: Standard Deviation

Disclosure of Interests:

None declared

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

Objective

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

Methods

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

Results

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

Conclusions

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

THU0586 ESTABLISHING THE KEY COMPONENTS OF A EULAR PORTFOLIO FOR TRAINING IN RHEUMATOLOGY: A EULAR SCHOOL OF RHEUMATOLOGY INITIATIVE

Background:

In clinical training, a portfolio is expected to stimulate learning and encourage critical reflection. Some, but not all, European countries use a portfolio in rheumatology training, and their scope varies widely. A EULAR portfolio for Rheumatology trainees could contribute to improve overall training, raise educational standards, foster the setting of common goals and harmonize rheumatology training across countries.

Objectives:

Develop key components that should be included in a EULAR portfolio of Rheumatology.

Methods:

A working group (WG) composed of 9 rheumatologists and 1 educationalist was established. A systematic literature review (SLR) was conducted in November 2018, according to the PIM structure: Population: trainees; Instrument of interest: portfolio; Measurement of properties of interest: content portfolio. A survey was disseminated among the WG group and WG members of the EMerging EUlar NETwork (EMEUNET), inquiring about the content and structure of existing national portfolios. Portfolio materials of selected countries were reviewed. Last, the WG elected the key components of the portfolio.

Results:

13/2,034 articles were included in the SLR (12 high/1 moderate risk of bias). Information on direct observation of procedural skills (DOPS) (9/13), personal reflections (8/13), learning goals (5/13) and multisource feedback (5/13) were most often included in the portfolio. Twenty-five respondents filled out the survey (response rate ≈ 50%). Reflective writing (n=7), learning goals (n=4) and feedback (n=4) were considered the most useful components of a portfolio. About half indicated that a portfolio was a bureaucratic burden; 4 respondents mentioned lack of feedback by supervisors as a barrier. Portfolio materials of 7 European countries were reviewed. Several portfolios (Germany, Italy, Greece and Spain) were logbooks, i.e. a record of clinical activities. Other portfolios (UK, Denmark, The Netherlands) also included information on workplace-based assessments, learning goals, and personal reflections. The proposed key components of the portfolio are included in Table 1.

Table 1.

Key components of the EULAR portfolio of Rheumatology.

Key componentContentCurriculum vitaePersonal record of achievements, experiences, knowledge and skillsPersonal Development PlanLearning goals and action planClinical workInformation on managing patients (e.g. rheumatoid arthritis)Skills (e.g. joint aspiration)Assessments (summative and formative)Personal reflectionsProfessional behaviourMultisource feedbackPersonal reflectionsEducationContinuing professional development, list of formal and non-formal learning activitiesAssessments (e.g. teaching assessment, evidence based medicine assignment)Personal reflectionsResearchList of abstracts, published articlesInformation on research funding, scholarships, bursaries, academic posts

Conclusion:

This initiative resulted in the establishment of a list of key components to be included in a EULAR portfolio of Rheumatology. Assessment forms for each key portfolio component are currently being developed. Portfolio implementation, particularly in countries that do not use it yet, may contribute significantly to promote a higher standard of patient care across Europe.

Disclosure of Interests:

Marloes van Onna: None declared, Sofia Ramiro Grant/research support from: MSD, Consultant of: Abbvie, Lilly, Novartis, Sanofi Genzyme, Speakers bureau: Lilly, MSD, Novartis, Catherine Haines: None declared, M. Holland-Fischer: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Jean Dudler: None declared, Christopher Edwards Grant/research support from: Abbvie, Biogen, Roche, Consultant of: Abbvie, Samsung, Speakers bureau: Abbvie, BMS, Biogen, Celgene, Fresenius, Gilead, Janssen, Lilly, Mundipharma, Pfizer, MSD, Novartis, Roche, Samsung, Sanofi, UCB,

Alessia Alunno: None declared, Elena Nikiphorou: None declared, L. Falzon: None declared, Francisca Sivera: None declared

THU0090 AGREEMENT BETWEEN REFERRING PHYSICIANS AND RHEUMATOLOGISTS AND PREDICTORS OF INFLAMMATORY ARTHRITIS: ANALYSIS BASED ON 8 YEARS OF EXPERIENCE IN AN EARLY ARTHRITIS CLINIC

Background:

Early recognition of patients with arthritis is a crucial opportunity for optimal outcome. The Early Arthritis Clinic (EAC) of our department was created in 2012 to ensure a prompt access of these patients to efficient medical care. Patients may be referred based on a set of clinical criteria with less than 12 months duration and laboratory parameters: arthritis, inflammatory arthralgias, squeeze test, morning stiffness > 30 minutes, rheumatoid factor (RF), erythrocyte sedimentation rate (ESR)>30mm/h and C-reactive-protein>0.5mg/dL (CRP).

Objectives:

To assess the level of agreement between the referring physician and the rheumatologist, regarding the presence of each of the six referral criteria and to identify predictors of inflammatory arthritis.

Methods:

Cross sectional study including patients aged ≥ 18-year-old observed in the EAC between January 2012 and October 2019. Subjects who were referred to the EAC by a rheumatologist and those without available referral letter/medical records from the first visit to the EAC were excluded. Demographic data, provenience, referral criteria (presence/absence) and the final diagnosis [presence or not of an inflammatory rheumatic disease (IRD)] were collected from medical records. For the six referral criteria, the agreement between the referring physician and the rheumatologist was assessed using the Cohen’s Kappa. The presence of each referral criteria was compared between patients with and without an IRD using χ2 tests. Variables with p<0.1 or clinically relevant were included in forward stepwise multivariable logistic regression analysis to identify possible predictors for IRD. The statistical analysis was performed using SPSS® v21 andp<0.05 was considered statistically significant.

Results:

376 patients (70% female; mean age (±SD) 56.3±16.2 years) were included. Most patients were referred from primary care (84%); the remaining 16% include those referred from emergency department and other hospital specialties. We diagnosed an inflammatory arthritis in 62% (n = 232) of the patients. Table 1 shows the level of agreement between the referring physician and the rheumatologist, regarding the presence of the referral criteria.

Table 1.

Agreement between the referring physician and the rheumatologist, regarding the presence of the referral criteria.

Referral criteriaKappapArthritis0.230.05Squeeze test0.090.04Inflammatory arthralgias0.110.04Morning stiffness0.180.04RF0.270.04ESR0.260.04CRP0.250.04ANA0.020.47

ANA- antinuclear antibodies; CRP- C-reactive-protein; ESR-erythrocyte sedimentation rate; RF-Rheumatoid factor

In univariable analysis (IRD Vs non-IRD), inflammatory arthralgias (74% Vs 93%, p=0.01), squeeze test (24% Vs 55%, p=0.01), morning stiffness (49% Vs 63%, p=0.05), ESR (63% Vs 46%, p=0.01), CRP (62% Vs 48%, p=0.04) were associated to IRD. In multivariable analysis, only ESR (OR 5.0 [95% CI 1.9-13.0], p < 0.05) and inflammatory arthralgias (OR 0.15 [95% CI 0.04-0.52], p < 0.05) remained as predictors of IRD.

Conclusion:

Agreement between the referring physicians and the rheumatologist regarding then presence/absence of the referral criteria was poor in all clinical criteria and fair in laboratory criteria. Elevated ESR was an independent predictor of IRD and the description of inflammatory arthralgias was negatively correlated with IRD. These findings suggest the need to clarify the referral criteria used and to improve education among the physicians referring patients to the EAC.

Disclosure of Interests:

Luisa Brites: None declared, LILIANA SARAIVA: None declared, Ana Rita Cunha: None declared, Helena Assunção: None declared, Tânia Santiago: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared

AB0223 PHYSICIAN’S GLOBAL ASSESSMENT OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS IS A RELIABLE AND RESPONSIVE TOOL IN CLINICAL practice

Background:

Physician’s global assessment of disease activity (PhGA) is highly influential upon treatment decisions taken by rheumatologists, surpassing the impact of DAS28. [1, 2]. However, data regarding its psychometric properties are scarce.

Objectives:

To evaluate the reliability and responsiveness of PhGA.

Methods:

We included two consecutive visits of RA patients followed in a Tertiary Rheumatology Department. Socio-demographic (age and gender) and clinical data were collected including tender (TJ28) and swollen (SJC28) joints in 28 count, C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR), Disease activity Score (DAS28-3v-CRP, DAS28-3v-ESR, DAS28-4v-CRP, DAS28-4v-ESR), PhGA and Patient Global Assessment of disease Activity (PGA) through a Visual Analogic Scale (VAS) 0-100mm. Changes (Δ) between the two visits were calculated. Only patients without missing data were included. Correlations between ΔPhGA and change of other variables were assessed using Pearson’s correlations. Reliability was evaluated through Intraclass Correlation Coefficient (ICC) between two consecutive appointments in a subgroup of patients with stable disease activity (Δ DAS28-4vESR [-0.6 to 0.6]. An ICC above 0.8 was considered indicative of excellent reliability. Sensitivity to change was assessed in the subgroup of patients who improved their disease activity at least 0.6 on DAS28-4V-ESR, through Standardized Response Mean (SRM). The respective intervals of confidence were obtained through bootstrapping procedures. SRM above 0.8 were considered large. Independent factors associated with ΔPhGA were identified through multivariate linear regression analysis. p<0.05 was considered statistically significant

Results:

121 RA patients (84.3% female and 64.0±12.6 years) were included. Δ PhGA was weakly correlated with ΔCRP (r=0.23), Δ PGA (r=0.31) and Δ pain (r=0.37). Moderate to strong correlations were observed with Δ DAS28-3V-ESR (r=0.55), Δ SJC28 (r=0.56), Δ DAS28-3V-CRP (r=0.58), Δ DAS28-3V-CRP (r=0.60), Δ TJ28 (r=0.62) and Δ DAS28-4V-CRP (r=0.63). ICC between two consecutive visits was 0.7, [95%CI:0.47-0.83] and SRM was -1.01 [95%CI:-1.26-(-0.73)]. In the multivariate regression analysis, ΔSJC28 (β=4.01; 95% CI:3.07 to 4.96) and Δ Pain (β=0.18; 95%CI: 0.07 to 0.28) remained as independent factors associated with ΔPhGA (R2:0.49, p<0.01)

Conclusion:

In this study, PhGA showed a high reliability and sensitivity to change regarding disease activity, in clinical practice. Changes in SJC had the strongest association with change in PhGA scoring, but Δ Pain was also significantly correlated (graph 1).

Figure 1.

Graph 1 – Explicative model to variations on PhGA

References:

[1]Choy T et al. Rheum (Oxford, England). 2014;53(3):482-90.

[2]Rohekar G et al. Jour Rheum. 2009;36(10):2178.

Disclosure of Interests:

LILIANA SARAIVA: None declared, Luisa Brites: None declared, Ana Rita Cunha: None declared, Helena Assunção: None declared, Ana Rita Prata: None declared, Mariana Luis: None declared, Flavio Costa: None declared, Pedro Freitas: None declared, Marlene Sousa: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared

AB0218 FUNCTIONAL DISABILITY AND PAIN BUT NOT DISEASE ACTIVITY ARE ASSOCIATED WITH POOR HEALTH-RELATED QUALITY OF LIFE IN A COHORT OF RHEUMATOID ARTHRITIS PATIENTS

Background:

Rheumatoid Arthritis (RA) is a systemic autoimmune disease that presents with joint pain and inflammation leading to significant disability and poor health-related quality of life (HRQoL) (1,2). Optimizing long-term HRQoL is the primary goal of disease management in RA (3).

Objectives:

To evaluate HRQoL and identify its influencing clinical and demographic factors in a Portuguese RA population.

Methods:

This is a cross-sectional study including consecutive patients fulfilling the ACR/EULAR 2010 and/or ACR 1987 RA classification criteria, followed at a tertiary Rheumatology Department. Sociodemographic and clinical variables were collected. HRQoL was assessed using the EuroQoL 5-Dimensional Descriptive System (EQ-5D) total score (normal range from -0.496 to 1.000, lower values indicating poorer HRQoL). Independent t-test and Pearson’s correlation coefficient were performed to evaluate EQ-5D differences between groups and examine its relationships with continuous variables, respectively. Variables with p<0.1 in univariate analysis were included in a stepwise multiple linear regression analysis to evaluate the independent association of variables with the EQ-5D score.

Results:

358 RA patients were included (80.20% female, mean age ± SD: 63.22 ± 0.66 years old). Mean EQ5D total score ±SD was 0.48 ± 0.01. Based on EQ-5D domains, 0.60% reported extreme problems with mobility, 3.40% extreme problems with self-care, 2.50% extreme problems with usual activities, 12.0% extreme pain or discomfort, and 7.30% extreme anxiety or depression symptoms (Fig. 1). There was a significant difference in EQ-5D scores between male (M=0.55, SD=0.24) and female gender (M=0.46, SD= 0.27); t (356) = -2.41, p=0.016. EQ-5D was weakly correlated with DAS-28-CRP (r=-0.32; p<0.001), moderately correlated with patient’s global assessment of disease activity (r=-0.54; p<0.001) and pain-visual analogue scale (pain-VAS) scores (r=-0.58; p<0.001) and strongly with Health Assessment Questionnaire (HAQ) score (r=-0.72; p< 0.001). After multivariate analysis, HAQ-score (β=-0.57 [95% CI -0.24 to -0.17]; p<0.001) and pain-VAS ((β=-0.25 [95% CI -0.003 to -0.002]; p<0.001) remained as independent predictors of EQ-5D (R2=0.56, p<0.001).

Conclusion:

Greater functional impairment and pain are associated with poor HRQoL in RA patients, and thus special attention must be given to treatment strategies providing the best patient-centred outcomes.

References:

[1]Yaghoubi et al. J Cardiovasc Thorac Res 2012;4(4):95–101.

[2]José E et al. Ann Rheum Dis 2018;1118–24.

[3]Smolen JS et al. Ann Rheum Dis. 2010; 69:631–637

Disclosure of Interests:

Ana Rita Prata: None declared, Helena Assunção: None declared, Mariana Luis: None declared, Luisa Brites: None declared, Flavio Costa: None declared, João Dinis de Freitas: None declared, Stefanie Silva: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared

THU0632-HPR DETERMINANTS OF HAPPINESS AND QUALITY OF LIFE IN PEOPLE WITH SYSTEMIC SCLEROSIS: A STRUCTURAL EQUATION MODELLING APPROACH

Background:

In recent years more attention has been given to patients reported outcomes (PROs). Systemic sclerosis (SSc) is no exception. As there is no effective treatment or cure to SSc, it is important to recognize the relevance to patients of the different features of the disease to improve quality and enjoyment of life: the ultimate targets of therapy. Remarkably lacking in PROs is the evaluation of the overall perspective of subjective well being, equivalent to ‘happiness’ or “positive psychological dimensions”.

Objectives:

To examine the determinants of happiness and quality of life (QoL) in patients with SSc with emphasis on disease activity, disease impact and personality traits.

Methods:

This is an observational, cross-sectional and multicenter study from six rheumatology clinics in Portugal. A total of 113 patients with SSc with a complete set of data on disease activity, disease impact, personality, quality of life and happiness were included.

Structural equation modelling (latent variable structural model) was used to estimate the association between the variables using a maximum likelihood estimation with Satorra-Bentler’s correction and performed with STATA® 15.0. Two hypotheses were pursued: H1 – Disease activity and impact of disease are negatively associated to overall QoL and happiness; H2 – ‘Positive’ personality traits are related to happiness both directly and indirectly through perceived disease impact.

Results:

Results obtained in the structural equation measurement model indicated a good fit [χ2/df=1.44; CFI=0.93; TLI=0.90; RMSEA=0.06] and supported all driving hypotheses (Figure 1). Happiness was positively related to ‘positive’ personality (β=0.45, p=0.01) and, to a lesser extent, negatively related with impact of disease (β=-0.32; p=0.01). This impact, in turn, was positively related to EUSTAR activity score (β=0.37; p<0.001) and mitigated by ‘positive’ personality traits (β=-0.57; p<0.001). Impact of disease had a much stronger relation with QoL than with happiness (β=-0.78, p<0.001). Quality of life and happiness had no statistically significant relationship.

Conclusion:

Optimization of Qol and happiness in people with SSc requires effective control of the disease process. Personality and its effects upon the patient´s perception of the disease impact, seems to play a pivotal mediating role in these relations and should deserve paramount attention if happiness and enjoyment of life is taken as the ultimate goal of health care.

Disclosure of Interests:

Tânia Santiago: None declared, Eduardo Santos: None declared, Ana Catarina Duarte: None declared, Patrícia Martins: None declared, Marlene Sousa: None declared, Franscisca Guimarães: None declared, Soraia Azevedo: None declared, Raquel Ferreira: None declared, Miguel Guerra: None declared, Ana Cordeiro Consultant of: Ana Cordeiro has acted as a consultant for Roche, Speakers bureau: Ana Cordeiro has received speaker fees from Boehringer Ingelheim, Lilly, and Vitoria, Inês Cordeiro: None declared, Sofia Pimenta: None declared, Patrícia Pinto: None declared, Maria Joao Salvador: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis

AB0179 BEYOND DISEASE ACTIVITY, PAIN, “TIME” AND “TIMING” ACCOUNT FOR DISABILITY IN PATIENTS WITH RHEUMATOID ARTHRITIS: RESULTS FROM A REAL-LIFE COHORT

Background:

Patients with rheumatoid arthritis (RA) suffer from joint pain, stiffness and fatigue and are therefore limited in their physical activities. Since functional disability is a major determinant of quality of life in patients with RA, an optimized approach should focus on the maintenance of functional ability.

Objectives:

To evaluate self-reported disability in RA patients and to identify its influencing clinical and demographic factors in a real-life cohort of patients with RA.

Methods:

Cross-sectional study of consecutive patients with RA fulfilling the ACR/EULAR 2010 and/or ACR 1987 RA classification criteria, followed in a Portuguese tertiary care centre. Variables collected included socio-demographic and clinical variables (disease duration; time from symptoms onset to diagnosis, classified as short (≤ 2 years) and long (> 2 years); time of diagnosis, categorised as <2000, 2000-2009, ≥2010); DAS28-CRP-3V and its individual components; pain assessed through visual analogue scale (0-100 mm) and self-perception of anxiety/ depression through EQ5D dimension 5. Disability was assessed through Health Assessment Questionnaire (HAQ) score and categorised as none-to-mild (<1) or moderate-to-severe (1-3). Comparison between groups was assessed through chi-square or T-student test, as adequate. Variables with p<0.1 and others clinically relevant in the researcher’s perspective were included in a multivariable logistic regression model. Previously to the analysis, all the assumptions were verified. Given the implementation of new strategies regarding diagnosis and treatment of RA in the last decade, a subgroup analysis was performed for patients with diagnosis performed after 2010).

Results:

A total of 251 patients were included (78.9% female, aged 62.0±12.1 years, disease duration 16.7±11.2 years), with a mean DAS28-CRP-3V of 2.24 ±0.87, with 65.3% being in remission or low disease activity. The mean HAQ score was 1.2±0.8. Over half of the patients (56.2%) reported moderate-to-severe disability. In the univariate analysis, moderate-to-severe disability was more frequent in female patients (60.6% vs 39.6%, p<0,006), in patients with moderate-to-severe self-perception of anxiety/depressive symptoms (67.2% vs 44.2%, p<0.001) and in patients with diagnosis before the year 2000, 2000-2009 than ≥2010 (71.4% vs 63.1% vs 36.7%; p< 0.001). In addition, patients with moderate-to-severe disability tended to be older (65.05 vs 57.98, p<0,001), to have longer disease duration (20.07 vs 12.39, p <0.001), to report more pain (VAS 58.08 vs 28.62, p<0.001) and to have higher disease activity (2.48 vs 1.95, p=0.001). In the multivariable analysis, pain (OR=1.04; 95%CI 1.03-1.06, p<0.001), disease activity (OR=1.51; 95%CI 1.01-2.26, p=0.049), and time of diagnosis (OR=0.553, 95%CI 0.38 -0.81, p=0.002) remained as independent factors associated with moderate-to-severe disability (R2: 0.40, p<0,001). In the subgroup of patients diagnosed after 2010, a longer time to diagnosis (>2 years) (OR=7.97, 95%CI 1.88-34.06; p=0.005) and pain (OR=1.05, 95%CI 1.03-1.08; p<0,001) remained as independent factors (R2= 0.44, p=<0.001).

Conclusion:

Functional disability remains a major problem in our patients with RA, despite clinical remission. Beyond non-modifiable factors, disease activity and pain are associated with higher disability. Moreover, in the subgroup of patients diagnosed after 2010 a long time to diagnosis was the major predictor of disability. However, a large variance of the reported functional disability remains unexplained. Hence, other factors should be properly evaluated in our patients in order to achieve a more holistic approach aiming at reducing functional disability.

Disclosure of Interests:

Helena Assunção: None declared, Ana Rita Prata: None declared, Mariana Luis: None declared, Luisa Brites: None declared, João Dinis de Freitas: None declared, Flavio Costa: None declared, Stefanie Silva: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared

OP0092 OPTIMIZING A DEFINITION OF LUPUS LOW DISEASE ACTIVITY STATE (LDA) FOR DAILY CLINICAL PRACTICE: SLE-DAS LDA VS LLDAS

Background:

The Lupus Low Disease Activity State (LLDAS)[1] is a proposed target for the management of Systemic Lupus Erythematosus (SLE). However, the LLDAS definition is cumbersome to apply, as it requires comparison with manifestations in the previous visit, scoring of Systemic Lupus Erythematosus disease activity index (SLEDAI), Physician Global Assessment (PGA), treatment conditions and exclusion of additional features. The SLE disease activity score (SLE-DAS)[2] is a validated continuous measure with higher sensitivity to change and validity in predicting damage accrual as compared to SLEDAI-2K. SLE-DAS is quickly quantified with its online calculator. The SLE-DAS low disease activity (SLE-DAS LDA) was recently defined [3] and it is easier to apply than the LLDAS.

Objectives:

To compare the performance of SLE-DAS and LLDAS for defining LDA state in a real-life clinical setting.

Methods:

Cross-sectional study of SLE patients fulfilling ACR’97 and/or SLICC’12 classification criteria followed at an academic lupus clinic, from January to December 2019. Fulfillment of LLDAS and SLE-DAS LDA state was verified for each patient. The SLE-DAS LDA state was defined as (1) SLE-DAS ≤3.77[3] with (2) prednisolone dose ≤7.5 mg/day. The proportion of cases in LDA state using LLDAS and SLE-DAS LDA was compared with McNemar’s test. Agreement between LLDAS and SLE-DAS LDA was tested with Cohen’s Kappa coefficient.

Results:

We included 292 patients (86.6% female, mean age: 48.7±14.4 years, mean disease duration: 14.4±9.3 years). From these, 245 (83.9%) and 248 (85%) were in LDA according to LLDAS and SLE-DAS LDA, respectively. There was no statistically significant difference between LLDAS and SLE-DAS LDA (p=0.581 regarding the identification of patients in LDA. Agreement between these two sets of criteria was almost perfect (k=0.831, p<0.01).

There were 13 discordant cases, fulfilling only the SLE-DAS LDA (n=8) or the LLDAS (n=5), and their manifestations of disease activity (excluding serologic features) are summarized in table 1.

Patients fulfilling only SLE-DAS LDANumber of casesPGA (range)Active clinical manifestations (range)SLEDAI-2K (range)SLE-DAS (range)Prednisolone (range, mg/day)60.1-0.2Leukopenia 2.2-2.7x10^9/L1-31.46-3.030-2.520.2-0.3Thrombocytopenia 71-96x10^9/L1-31.97-2.860-5Patients fulfilling only LLDASNumber of casesPGA(range)Active clinical manifestations(range)SLEDAI-2K(range)SLE-DAS(range)Prednisolone(range, mg/day)20.2-0.4Arthritis (2-4/28 swollen joints)44,41-5.310-510.5Panniculitis (face and torso)35,53010.1Generalized rash45,01510.4Leukopenia 2.1x10^9/L Thrombocytopenia 62x10^9/L24,990

Conclusion:

A LDA state, by either definition, was achieved by most patients in this real-life setting. LLDAS and SLE-DAS LDA identify almost exactly the same population. The SLE-DAS LDA definition is easier to apply and hence might be the optimal definition for use in daily clinical practice.

References:

[1]Franklyn K, Lau CS, Navarra SV, et al.Definition and initial validation of a Lupus Low Disease Activity State (LLDAS). Ann Rheum Dis 2016; 75: 1615-21.

[2]Jesus D, Matos A, Henriques C, et al.Derivation and validation of the SLE Disease Activity Score (SLE-DAS): a new SLE continuous measure with high sensitivity for changes in disease activity. Ann Rheum Dis 2019; 78: 365-71.

[3]Jesus D, Matos A, Henriques C, et al.The SLE Disease Activity Score (SLE-DAS) enables accurate definitions of SLE remission and LDA as achievable targets in disease management. Ann Rheum Dis 2019; 78: 411-2.

Disclosure of Interests:

Helena Assunção: None declared, Diogo Jesus: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Luís Inês: None declared

SAT0184 MAINTENANCE THERAPY WITH AZATHIOPRINE ASSOCIATED WITH HIGHER RISK OF FLARE IN PROLIFERATIVE LUPUS NEPHRITIS

Background:

Goals of lupus nephritis (LN) maintenance treatment include prevention of LN flares and long-term preservation of renal function, while minimizing drug iatrogenicity. There is an unmet need for identifying predictors of LN flare in order to guide optimization of maintenance immunosuppression.

Objectives:

To identify predictors of LN flare after attainment of complete renal response (CRR) in patients with proliferative LN.

Methods:

Retrospective cohort study over 36 months including patients with SLE fulfilling the ACR’97 and/or the SLICC’12 classification criteria, enrolled in the CHUC Lupus Cohort between 1999 and 2018, with a biopsy-proven proliferative LN (class III/IV) and who attained CRR (proteinuria <0.5g/day and normal renal function, according to EULAR/ERA-EDTA definition) following induction treatment. Only proteinuric flares were considered and defined as doubling of proteinuria to >1g/day. Clinical-analytic characteristics at baseline (time of first CRR attainment after induction) were compared using survival analysis for time-to-flare. Variables with p<0.10 on univariate analysis with Log-Rank tests were further evaluated as predictors with multivariate Cox proportional hazards regression models (Backward Stepwise method, Wald-based), with estimation of hazard ratios (HR) with 95% confidence intervals (95%CI).

Results:

A total of 50 patients in CRR were included in the analysis (78.4% female, age at baseline 30.0 ± 12.5 years-old). Over the follow-up period, 10 patients (20.0%) experienced a proteinuric flare, within a mean time of 29.1 months (95%CI 26.89-31.37). In univariate analysis, age <30years (p=0.020), arterial hypertension (p=0.020) and presence of anti-RNP antibody (p=0.002) at baseline were associated with higher risk of LN proteinuric flares. In multivariate analysis, age <30 years (HR 26.56; 95%CI 1.93-365.08; p=0.014), arterial hypertension (HR 8.30; 95%CI 1.21-56.92; p=0.031), use of antihypertensive antiproteinuric drugs (angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers) (HR 11.18; 95%CI 1.24-100.66; p=0.031) and maintenance therapy with azathioprine (HR 6.23; 95%CI 1.51-25.66; p=0.011) (Figure 1) were predictors of LN proteinuric flares.

Figure 1.

Conclusion:

In patients with proliferative LN, proteinuric flares are a frequent event after induction treatment leads to CRR. Younger age, arterial hypertension, use of antihypertensive drugs and use of azathioprine as maintenance therapy were risk factors for LN proteinuric flare in this cohort.

Disclosure of Interests:

Mariana Luis: None declared, Ana Rita Prata: None declared, Helena Assunção: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Luís Inês: None declared

OP0117 LONGITUDINAL CHANGE IN THE CENTRAL NERVOUS SYSTEM PAIN RESPONSE AFTER TREATMENT WITH CERTOLIZUMAB OR PLACEBO. A POST-HOC ANALYSIS FROM THE PRECEPRA TRIAL

Background:

Tumor necrosis factor inhibitors have revolutionized the treatment of rheumatoid arthritis (RA). However, only about 50% of the patients respond well to TNF inhibitors. Therefore, markers that predict response to TNF inhibitors are valuable. Previously we demonstrated that central nervous system (CNS) response to nociceptive stimuli, measured by fMRI of the brain as blood oxygen level dependent (BOLD) signals, decreases already after 24 hours of anti-TNF administration a higher pre-treatment BOLD signal volume seems to predict clinical response to treatment with certolizumabpegol (CZP)1,2. We therefore hypothesized that the baseline volume of BOLD signal in the CNS could predict anti-TNF treatment response.

Objectives:

To perform a randomized placebo controlled trial in active RA patients to test the effect of TNF inhibition on arthritis induced pain activity in the brain and to test whether patients with high-level RA-related brain activation react differently to TNF-inhibitors than patients with low-level brain activation.

Methods:

Adult RA patients fulfilling the 2010 ACR/EULAR classification criteria with a DAS28>3.2 receiving stable DMARD treatment for at least 3 months were eligible. Patients underwent the first fMRI at screening measuring BOLD signal upon MCP joint compression and were stratified into low (< 700 units) and high (>700 units) voxel counts. Then patients were randomized to CZP or placebo with a 2:1 ratio. The second and third fMRI were performed after 12 and 24 weeks, respectively. Control stimulation was done by measuring brain activation after non-painful finger tapping.

Results:

156 RA patients with moderate-to-high disease activity participated in the study. In the finger tapping control, fMRI showed no significant changes in BOLD signal in the CZP-L and CZP-H arms, but a slight but significant decrease (p=0.043) was observed. After joint compression, the CZP-L group showed significant increase in the BOLD signal volume (p=0.043) in fMRI-2 as compared to fMRI-1 with no further significant changes. In contrast, in the CZP-H group, the BOLD signal volume significantly decreased (p=0.037) in fMRI-2 and continued to decrease further, p=0.007. No significant changes were observed in the placebo arm over time.

Conclusion:

TNF inhibition improves arthritis-related brain activity in the subgroup of RA patients with high baseline BOLD activity in the fMRI.

References:

[1]Hess, A.et al.PNAS (2011).

[2]Rech, J. et al. Arthritis & Rheumatism (2013).

Fig 1.

BOLD fMRI responses to painful stimulation

Acknowledgments:

The study was supported by an unrestricted grant of UCB Biopharma SPRL Brussels, Belgium

Disclosure of Interests:

Jürgen Rech Consultant of: BMS, Celgene, Novartis, Roche, Chugai, Speakers bureau: AbbVie, Biogen, BMS, Celgene, MSD, Novartis, Roche, Chugai, Pfizer, Lilly, Koray Tascilar: None declared, Hannah Schenker: None declared, Melanie Hagen: None declared, Marina Sergeeva: None declared, Mageshwar Selvakumar: None declared, Laura Konerth: None declared, Jutta Prade: None declared, Sandra Strobelt: None declared, Verena Schönau: None declared, Larissa Valor: None declared, Axel Hueber Grant/research support from: Novartis, Lilly, Pfizer, EIT Health, EU-IMI, DFG, Universität Erlangen (EFI), Consultant of: Abbvie, BMS, Celgene, Gilead, GSK, Lilly, Novartis, Speakers bureau: GSK, Lilly, Novartis, David Simon Grant/research support from: Else Kröner-Memorial Scholarship, Novartis, Consultant of: Novartis, Lilly, Arnd Kleyer Consultant of: Lilly, Gilead, Novartis, Abbvie, Speakers bureau: Novartis, Lilly, Frank Behrens Grant/research support from: Abbvie, Pfizer, Roche, Chugai, Janssen, Consultant of: Abbvie, Pfizer, Roche, Chugai, UCB, BMS, Celgene, MSD, Novartis, Biotest, Janssen, Genzyme, Lilly; Boehringer; Sandoz, Speakers bureau: Abbvie, Pfizer, Roche, Chugai, UCB, BMS, Celgene, MSD, Novartis, Biotest, Janssen, Genzyme, Lilly; Boehringer; Sandoz, Christoph Baerwald Consultant of: CGB received speaker or consulting fees from AbbVie, Paid instructor for: CGB received speaker or consulting fees from AbbVie, Speakers bureau: CGB received speaker or consulting fees from AbbVie, Stephanie Finzel: None declared, Reinhard Voll: None declared, Eugen Feist Consultant of: Novartis, Roche, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Sanofi, Speakers bureau: Novartis, Roche, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Sanofi, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Arnd Doerfler: None declared, Nemanja Damjanov Grant/research support from: from AbbVie, Pfizer, and Roche, Consultant of: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Speakers bureau: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Andreas Hess: None declared, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB

AB0749 COMPARING PATIENT-PHYSICIAN DISCORDANCE IN RA AND PsA PATIENTS

Background:

Patient global Assessment (PGA) of disease activity is considered a key patient reported outcome in Rheumatoid Arthritis (RA) and Psoriatic Arthritis (PsA), both being included in combined indices of disease activity. However, patients and physicians frequently disagree in their assessment.

Objectives:

This study aimed at comparing the degree of this discrepancy and its determinants in RA and PsA.

Methods:

Cross sectional study including 100 patients with RA (ACR/EULAR 2010 criteria) and 100 patients with PsA with predominant peripheral joint involvement (CASPAR criteria), aged ≥18 years, randomly selected from the electronic registry Reuma.pt. Data were collected from the most recent rheumatology visit during the last year: sociodemographic data, disease duration (years), tender and swollen joint counts 0-28 (TJC and SJC), disease activity (DAS28 3V-PCR), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), patient’s pain assessment, PGA and physician global assessment (PhGA). The discrepancy between patients and physicians (ΔPPhGA) was defined as PGA minus PhGA, and a difference > |20mm| was taken as “discordance”. Categorical variables are presented as proportions and continuous variables as mean (±SD). Patient and clinical characteristics were compared between patients with RA and PsA using t- test and χ2 test, as adequate. Variables with p<0.05 or clinically relevant were included in multivariable logistic regression analysis to identify correlates for ΔPPhGA in the whole sample. A p≤0.05 was considered statistically significant.

Results:

Compared to PsA, patients with RA were more often female (90% Vs 49%,p< 0.05), older (66.7 ± 10.7 Vs 58.3 ± 12.2 years,p< 0.05) and had a shorter disease duration (18.2 ± 9.8 Vs 19.9 ± 9.7 years,p= 0.202). Regarding disease activity, the RA and PsA groups were comparable: DAS28 3V-PCR (2.3 ± 0.9 Vs 2.4 ± 1.0,p= 0.34). Patients with RA had a higher mean ΔPPhGA (30.4 ± 30.6 Vs 25.4 ± 27.5,p< 0.05), and were more frequently discordant to the physician (69% Vs 51%,p< 0.05). In univariable analysis, having RA, higher patient’s pain assessment and higher ESR were associated to patient-physician discordance. In multivariable analysis, only patient’s pain assessment (OR 1.04 [95% CI 1.03-1.06], p = 0.00) and TJC (OR 0.82 [95% CI 0.68-0.97], p = 0.02) remained as predictors of discordance.

Conclusion:

Despite comparable disease activity scores in RA and PsA patients, RA patients tend to have a worst self-perception of their disease activity compared to their physician´s. Patient’s pain assessment and TJC were the only predictors of patient-physician discordance, irrespective of the disease.

Disclosure of Interests:

Luisa Brites: None declared, LILIANA SARAIVA: None declared, Flavio Costa: None declared, João Dinis de Freitas: None declared, Mariana Luis: None declared, Ana Rita Prata: None declared, Helena Assunção: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, João Rovisco: None declared, Catia Duarte: None declared

SAT0185 PREDICTORS OF POOR RENAL OUTCOME IN PATIENTS WITH PROLIFERATIVE LUPUS NEPHRITIS: A 36-MONTHS COHORT STUDY

Background:

The EULAR/ERA-EDTA recommendations for lupus nephritis (LN) state that renal response should be achieved within 12 months following induction therapy. However, there is an unmet need for early predictors of renal outcome in order to adjust the immunosuppression regimen and optimize the renal outcome.

Objectives:

To identify predictors of poor renal outcome at baseline, 3 months and 6 months after starting induction therapy.

Methods:

Retrospective cohort study over 36 months including patients with Systemic lupus erythematosus (SLE) fulfilling the ACR’97 and/or the SLICC’12 classification criteria and with biopsy-proven proliferative LN (class III/IV), enrolled in the CHUC Lupus Cohort from 1999 to 2018. Poor renal outcome was defined as longer time to complete renal response (CRR), characterized by proteinuria <0.5g/day and normal renal function, according to EULAR/ERA-EDTA criteria. Clinical-analytical characteristics at baseline, 3 months and 6 months after starting induction treatment were compared using survival analysis for time-to-CRR. Variables with p<0.25 on univariate analysis using Log-Rank tests were further evaluated as predictors applying multivariate Cox proportional hazards regression models (Backward Stepwise method, Wald-based) with estimation of hazard ratios (HR) and 95% confidence intervals (95%CI).

Results:

56 patients were included (76.8% female, age at LN diagnosis 30.0 ± 13.2 years). Over the follow-up, 51 patients (91.1%) achieved CRR, within a median time of 6.0 months. In multivariate analysis, predictors of poor renal outcome were proteinuria >2g/day at baseline (HR 1.98; 95%CI 1.04-3.77; p=0.037) and induction therapy with pulse cyclophosphamide (CYC), as compared to mycophenolate mofetil (MMF) (HR=2.05; 95%CI 1.07-3.94; p=0.030) (Figure 1). Diabetes mellitus (HR=6.0; 95%CI 1.24-29.07; p=0.026) and negative anti-RNP antibody (HR 3.17; 95%CI 1.27-7.93; p=0.013) at baseline predicted poor renal outcome at 3 months. At this timepoint, level of proteinuria and clearance rate were not predictive of renal response. At 6 months, no predictors of LN outcome were found for those patients that did not achieve CRR up to this timepoint. Use of glucocorticoid pulses and/or antihypertensive drugs did not predict LN outcome.

Figure 1.

Conclusion:

In this SLE cohort, most patients with proliferative LN achieved CRR. Proteinuria above 2 g/day at baseline and diabetes mellitus were predictors of poor renal outcome, while positive anti-RNP was protective. Induction treatment with CYC was associated with poorer outcome as compared with MMF. Given the retrospective non-randomized nature of this study, caution is needed when drawing conclusions regarding both treatments efficacy.

Disclosure of Interests:

Mariana Luis: None declared, Ana Rita Prata: None declared, Helena Assunção: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Luís Inês: None declared

SAT0593 ANA TESTING IN THE (VERY) ELDERLY: EXPECTATION VERSUS REALITY

Background:

Antinuclear antibodies (ANA) are frequently used as a screening tool for systemic autoimmune rheumatic diseases (SARD), although they are also present in 10-15% of the adult healthy population. SARD have their peak incidence in the young/ middle-aged adult. As age progresses, the incidence of SARD decreases while the prevalence of ANA tends to increase, with some series reporting up to 30% prevalence in older ages1.

Objectives:

To determine the clinical significance and utility of ANA testing in a population over 85 years of age.

Methods:

We conducted a retrospective study of patients over the age of 85 who underwent ANA testing due to a SARD suspicion at our hospital autoimmunity laboratory, from 2011 to 2018. Justification for ANA request was collected from patient’s clinical records. Patients with pre-established diagnosis of SARD and patients with no justification given for ANA request were excluded from the analysis. ANA titer (positive ≥ 1:160) and cellular staining patterns were assessed by indirect immunofluorescence (Hep-2 cells).

Results:

Ages ranged from 85 to 98 years, with 58.8% being females. The prevalence of ANA in this population was 61.5%, mostly in lower titers (1:160 in 45.0%, 1:320 in 31.9%, 1:640 in 20.3% and 1:1280 in 2.7%). Dense fine speckled pattern was by far the most common cellular staining pattern (79.1%). A suspicion of SARD was the reported reason for ANA testing in 34,5% (n=296) of the 854 patients submitted to this test. The main clinical clues justifying SARD suspicion were: arthralgia/arthritis (11.9%), thrombocytopenia (10.0%), pancytopenia (10.0%), spotless fever (8.2%), interstitial lung disease (4.8%), pleural (6.1%) and pericardial (4.1%) effusion. Over a median follow-up of 1.0 year, 10 patients (3.4%) were diagnosed with a SARD, only one being an ANA-related disease: 5 cases of polymyalgia rheumatica, 2 cases of rheumatoid arthritis, 1 case of giant cell arteritis, 1 case of Sjogren syndrome and 1 case of sarcoidosis. In 60% of patients with a confirmed SARD, the main reason for suspicion was the presence of arthralgia/ arthritis. Positive ANA testing showed a 90.0% sensitivity and a 39.6% specificity for SARD. This translates into a positive predictive value of 5.0%.

Conclusion:

ANA are highly prevalent in elderly patients under SARD suspicion, while the incidence of SARD is very low, which explains the low positive predictive value of ANA testing. Interestingly, only one among the ten cases of SARD confirmed was indeed an ANA-related disease (Sjogren syndrome).

References:

[1]Selmi C, Ceribelli A, Generali E, et al. Serum antinuclear and extractable nuclear antigen antibody prevalence and associated morbidity and mortality in the general population over 15 years.Autoimmun Rev. 2016;15(2):162–166. doi:10.1016/j.autrev.2015.10.007

Disclosure of Interests:

Mariana Luis: None declared, Anália Carmo: None declared, Rosário Cunha: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Tânia Santiago: None declared

THU0111 PHYSICIAN’S GLOBAL ASSESSMENT OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS: WHAT DO WE REALLY MEAN?

Background:

Physician’s global assessment of disease activity (PhGA) is included in some scores of disease activity and, demonstrably, plays a major role upon treatment decisions in rheumatoid arthritis (RA) [1, 2, 3]. Therefore, understanding the reasons underlying the physician´s assessment is crucial.

Objectives:

To understand the reasons underlying the physician´s assessment.

Methods:

Cross-sectional study, including consecutive RA patients followed in a Tertiary Rheumatology Department. Socio-demographic (age and gender) and clinical data were collected through a standardized protocol, including 28 tender (TJ28) and swollen (SJC28) joints count, C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR), Disease activity Score (DAS28-4v-CRP and DAS28-4v-ESR), PhGA and Patient Global Assessment of disease Activity (PGA) through a Visual Analogic Scale (VAS) 0-100mm, Health Assessment Questionnaire (HAQ), European Quality of Life-5 Dimensions (EQ-5D) and Hospital Anxiety and Depression Scale (HADS). Correlation between PhGA and other continuous variables was evaluated through Pearson´s Correlation Coefficient and variables with p<0.05 in univariate analysis were included in multivariable linear regression (stepwise model).

Results:

392 RA patients (80.6% female, 65.3±12.6 years) were included. PhGA was weakly correlated with CRP (r=0.23), TJC28 (r=0.35), PGA (r=0.26), HAQ (r=0.31) and EQ5D (r=-0.21). Moderate correlations were observed with SJC28 (r=0.45) and DAS-4V-CRP (r=0.48). In multivariable analysis, SJC28 (β=4.14, 95%CI:3.16-5.12), CRP (β=0.22; 95%CI: 0.02-0.03), HAQ (β=4.46, 95%CI:1.50-7.42) and PGA (β=0.08; 95%CI:0.00-0.16) remained as independent correlates of PhGA (R2=0.27, p<0,05).

Conclusion:

In this study, PhGA was associated with SJC28, CRP, HAQ and PGA, suggesting that physicians adopt a comprehensive reading of the disease into account. However, a large proportion of the variance of PhGA remains unexplained. Given its driving role in treatment decisions, the need to standardize and better understand PhGA seems to deserve a closer attention.

References:

[1]Ward MM, et al. Art Car Res. 2017;69(8):1260-5.

[2]Desthieux C, et al. Art Car Res (Hoboken). 2016;68(12):1767-73.

[3]Kaneko Y, et al. Mod Rheumatol. 2018;28(6):960-7.

Disclosure of Interests:

LILIANA SARAIVA: None declared, Luisa Brites: None declared, Ana Rita Cunha: None declared, Helena Assunção: None declared, Ana Rita Prata: None declared, Mariana Luis: None declared, Flavio Costa: None declared, Pedro Freitas: None declared, Marlene Sousa: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared

SAT0050 PREDICTION OF RESPONSE TO CERTOLIZUMAB PEGOL TREATMENT BY FUNCTIONAL MRI OF THE BRAIN: AN INTERNATIONAL, MULTI-CENTER, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL (PRECEPRA)

Background:

Personalization of RA treatment is not optimal due to lack of predictors. We previously demonstrated in RA patients that central nervous system (CNS) pain response to tender joint compression, measured by using functional MRI (fMRI) of the brain rapidly wanes after 24 hours of anti-TNF administration and that a higher pre-treatment BOLD signal volume seems to predict clinical response to treatment with certolizumab-pegol (CZP)1,2. We therefore hypothesized that the CNS pain response upon compression of a painful joint could predict subsequent anti-TNF treatment response.

Objectives:

To compare disease activity after 12-weeks of CZP treatment to that of placebo in DMARD-refractory RA patients based on pre-treatment baseline CNS pain response measured using BOLD fMRI.

Methods:

Adult RA patients fulfilling the 2010 ACR/EULAR classification criteria with a DAS28>3.2 under stable DMARD treatment for at least 3 months were eligible. Patients underwent fMRI scanning of the brain at screening for stratification by CNS pain response. Whole brain BOLD-signal-voxel-count of 700 units classifying between low and high, and were randomized to CZP or placebo (2:1) The primary outcome was low disease activity (LDA, DAS28 ≤3.2) after 12 weeks of treatment.

Results:

156 RA patients, inadequate responders to csDMARD, signed the informed consent. 139 patients (46/47, 46/49 and 42/43) (99 females, 71%) with moderate-high disease activity (mean (SD) DAS-28: 4.83 (1.03)) could be included respectively and completed the 12-week study treatment. Geometric mean (SD) numbers of baseline BOLD signal positive voxels were 559 (10), 81 (12) and 2498 (3) in the 3 arms respectively. The mean DAS28 (SD) scores after 12 weeks of study treatment were Placebo: 3.89 (1.29), CZP-L: 3.42 (1.06) and CZP-H: 3.06 (1.04). LDA was achieved in 12/47 patients (25.5 %) in placebo, 22/49 (44.9%) in the CZP-L, and 25/43, (58.1%) in the CZP-H arm. The linear effect term for the ordinal study group variable supported a linear trend of increasing CZP treatment effect with increasing baseline CNS pain response. RR (95% CI) for achieving LDA with each unit increase in treatment category over placebo was 1.79 (1.24 to 2.74, p=0.003).

Conclusion:

A higher pre-treatment brain activity in response to pain measured with fMRI predicts the chance of achieving low disease activity with CZP treatment.

References:

[1] Hess, A.et al.PNAS (2011)

[2] Rech, J.et al. Arthritis & Rheumatism(2013).

Acknowledgments :

The study was supported by an unrestricted grant from UCB Biopharma SPRL, Brussels, Belgium

Disclosure of Interests:

Jürgen Rech Consultant of: BMS, Celgene, Novartis, Roche, Chugai, Speakers bureau: AbbVie, Biogen, BMS, Celgene, MSD, Novartis, Roche, Chugai, Pfizer, Lilly, Koray Tascilar: None declared, Hannah Schenker: None declared, Marina Sergeeva: None declared, Mageshwar Selvakumar: None declared, Laura Konerth: None declared, Jutta Prade: None declared, Sandra Strobelt: None declared, Melanie Hagen: None declared, Verena Schönau: None declared, Larissa Valor: None declared, Axel Hueber Grant/research support from: Novartis, Lilly, Pfizer, EIT Health, EU-IMI, DFG, Universität Erlangen (EFI), Consultant of: Abbvie, BMS, Celgene, Gilead, GSK, Lilly, Novartis, Speakers bureau: GSK, Lilly, Novartis, David Simon Grant/research support from: Else Kröner-Memorial Scholarship, Novartis, Consultant of: Novartis, Lilly, Arnd Kleyer Consultant of: Lilly, Gilead, Novartis,Abbvie, Speakers bureau: Novartis, Lilly, Frank Behrens Grant/research support from: Abbvie, Pfizer, Roche, Chugai, Janssen, Consultant of: Abbvie, Pfizer, Roche, Chugai, UCB, BMS, Celgene, MSD, Novartis, Biotest, Janssen, Genzyme, Lilly; Boehringer; Sandoz, Speakers bureau: Abbvie, Pfizer, Roche, Chugai, UCB, BMS, Celgene, MSD, Novartis, Biotest, Janssen, Genzyme, Lilly; Boehringer; Sandoz, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Christoph Baerwald Consultant of: CGB received speaker or consulting fees from AbbVie, Paid instructor for: CGB received speaker or consulting fees from AbbVie, Speakers bureau: CGB received speaker or consulting fees from AbbVie, Stephanie Finzel: None declared, Reinhard Voll: None declared, Eugen Feist Consultant of: Novartis, Roche, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Sanofi, Speakers bureau: Novartis, Roche, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Sanofi, Arnd Doerfler: None declared, Nemanja Damjanov Grant/research support from: from AbbVie, Pfizer, and Roche, Consultant of: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Speakers bureau: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Andreas Hess: None declared, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB

FRI0229 THE IMPACT OF SYSTEMIC SCLEROSIS ON BODY IMAGE PATIENTS

Background:

Satisfaction with body image has a major impact in quality of life. Systemic sclerosis (SSc) is a can result in disfiguring physical changes.

Objectives:

Our aim was to determine the impact of systemic sclerosis on body image using the Satisfaction with Appearance Scale (SWAP). (1)

Methods:

Cross-sectional study including patients satisfying the 2013 American College of Rheumatology criteria for SSc diagnosis, aged ≥ 18 years, treated in a tertiary Rheumatology Department. Demographic and clinical data were collected from Reuma.pt and clinical records. All patients provided informed consent and fulfilled SWAP questionnaire, which consists of 14 questions in 4 subscales: satisfaction with facial appearance, satisfaction with non-facial appearance, social discomfort due to appearance and perceived social impact of appearance. Patients rate each item on a numerical rating scale from 1 (strongly disagree) to 7 (strongly agree). Scores for the facial and non-facial appearance range from 0-24 and scores for the social discomfort and perceived social impact subscales range from 0-18. Total SWAP score can range from 0-84 and higher values indicate greater dissatisfaction with appearance and poorer body image. A descriptive analysis was used to summarize demographic and clinical data; categorical variables were described using frequencies; and continuous data using mean and standard deviation. Correlation between variables [Rodnan, age, disease duration, Hospital Anxiety and Depression Scale (HADS) and Short Form Health Survey (SF36)] and SWAP score was tested with Pearson or Spearman coefficient, as appropriated. Scores of SWAP and its subscales in preclinical, limited and diffuse forms of SSc were compared using ANOVA test. Analyses were performed with SPSS Statistics, V.21 andp<0.05 was considered statistically significant.

Results:

We enrolled 38 patients, 84.2% (n=32) female, with mean age 60.3±14.5 years and mean disease duration 13.3±6.5 years. All but one were caucasian. Fifty percent (n=19) had a limited form, 26.3% (n=10) had preclinical scleroderma and 23.7% (n=9) had a diffuse form of SSc. Regarding the autoantibody profile: 63.2% (n=24) had anti-centromere antibodies, 28.9% (n=11) had anti-Scl-70 antibodies, 5.3% (n=2) had anti-PM antibodies and 2.6% (n=1) had no positive antibodies. The median of Rodnan scores was 4 (IQR 0-9). The total mean SWAP score was 44.8±12.5 with worse results at “Satisfaction with facial appearance” subscale (mean score 14.4±6.1). There is no statistically significant difference in the SWAP score (or its subscales) between the three diagnosis subtypes. No statistically significant correlation was found between the total and subscale SWAP scores and any of the continuous variables considered and no statistically significant difference was found between the different forms of SSc.

Conclusion:

We found no significant differences between preclinical, limited or diffused SS. SWAP scores were not significantly correlated with the total Rodnan score, age or disease duration. Contrary to our expectations SWAP did not show any relationship with depression, anxiety (HADS) or quality of Life (SF-36) However, our sample is too small to support definite conclusions. Further studies assessing body image in SSc and its impact in quality of life are warranted to support the holistic care of these patients.

References:

[1]doi:10.3899/jrheum.141482.;

[2]10.1037/0278-6133.22.2.130;

[3]10.3899/jrheum.141482.

Disclosure of Interests:

Luisa Brites: None declared, Flavio Costa: None declared, LILIANA SARAIVA: None declared, Ana Rita Cunha: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Tânia Santiago: None declared, Maria Joao Salvador: None declared

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

Background:

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

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

Objectives:

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

Methods:

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

Results:

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

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

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

Conclusion:

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

References:

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

Disclosure of Interests:

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

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

Background:

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

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

Objectives:

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

Methods:

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

Results:

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

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

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

Conclusion:

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

Funding statement:

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

Disclosure of Interests:

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

SAT0029 PATIENT-PHYSICIAN DISCORDANCE IN ASSESSMENT OF DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS

Background:

In rheumatoid arthritis (RA), global disease activity is commonly assessed, from the patient’s and the physician’s perspective, through a 100mm VAS. Previous studies have commonly shown a considerable discrepancy between the patient’s and physician’s assessment.

Objectives:

This study aimed evaluating patient-physician discordance in the assessment of disease activity and to explore its determinants.

Methods:

Cross sectional study including RA patients (ACR/EULAR 2010 classification criteria), aged ≥ 18 years, followed in a single tertiary centre. Data were collected from the most recent evaluation including sociodemographic features, disease duration (years), disease activity (DAS 28 3V-PCR), tender and swollen joint count 0-28 (TJC and SJC), VAS-pain-patient, patient and physician global assessment (PGA and PhGA respectively), erythrocyte sedimentation rate (ESR), C-reactive protein (CPR), Health assessment questionnaire (HAQ) and EuroQol five-dimension scale (EQ5D). The discrepancy between patients and physicians (ΔPPhGA) was defined as PGA minus PhGA, and a difference > |20mm| was considered as “discordant”. A descriptive analysis was performed and variables described as proportions or means (+/- SD), as adequate. Correlation between ΔPPhGA and other variables was assessed through Pearson’s correlation and comparison between groups through t-test. Variables with p<0.05 or otherwise considered clinically relevant were included in multiple linear regression analysis to identify predictors for ΔPPhGA. A p≤0.05 was considered statistically significant.

Results:

In total, 467 patients with RA were included (81.2% female; mean age 63.9% ± 12.2 years). PGA and PhGA were discordant in 61.7% of the cases, the patient scoring higher than the physician in 95% of these cases. The proportion of concordance increased (p< 0.01) when considering only patients in remission (DAS 28 3V <2.6), (Graph 1). ΔPPhGA was moderately correlated with VAS-pain-patient (r = 0.59) and weakly correlated with SJC (r = -0.12), HAQ (r= 0.27), EQ5D (r = -0.28) and age (r = 0.21); all p<0.01. In multivariate analysis, VAS-pain-patient (β 0.74, 95% CI 0.62-0.88, p=0.00) and TJC (β 0.16, 95% CI 0.45-0.48, p=0.02) remained associated with a higher ΔPPhGA.

Conclusion:

Our study confirmed that a significant discrepancy between patients and physicians in the assessment of global disease activity is frequent in clinical practice, probably due to valorization of different parameters. This was much less pronounced among patients in remission. Higher VAS-pain-patient and TJC were independent predictors of greater discrepancy between patients and physician’s assessment.

Disclosure of Interests:

Luisa Brites: None declared, Flavio Costa: None declared, João Dinis de Freitas: None declared, Mariana Luis: None declared, Ana Rita Prata: None declared, Helena Assunção: None declared, LILIANA SARAIVA: None declared, Marlene Sousa: None declared, Ana Rita Cunha: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared

OP0218 CENTRAL NERVOUS SYSTEM PAIN RESPONSE AND COMPONENTS OF DISEASE ACTIVITY IN RA PATIENTS AFTER TREATMENT WITH CERTOLIZUMAB OR PLACEBO: A POST-HOC ANALYSIS FROM THE PRECEPRA TRIAL

Background:

We have previously observed in RA patients that central nervous system (CNS) response to compression of a painful joint, measured using functional MRI (fMRI) of the brain as the number of blood oxygen level dependent (BOLD) signal positive voxels, is rapidly ameliorated, much earlier than any clinical response with anti-TNF treatment and a high baseline CNS pain response could predict better response to certolizumab pegol (CZP) treatment. Pre-CePRA was designed and conducted to test this effect in a randomized, placebo controlled trial of CZP and showed an incremental linear trend of DAS28 low disease activity (LDA) across study groups treated with placebo, and two CZP arms stratified as low or high pre-treatment CNS pain response.

Objectives:

To explore and describe pre-treatment CNS pain response associations with post treatment course of RA disease activity components and patient-physician discrepancy in global disease assessment.

Methods:

Patients fulfilling the 2010 ACR/EULAR classification criteria with moderate-severe disease activity (DAS-28>3.2) under stable DMARD treatment were recruited. Patients underwent an fMRI scan, stratified by a whole-brain BOLD positive voxel count threshold of 700 units and randomized to treatment with CZP or placebo in a 2:1 ratio. We descriptively assessed components of RA disease activity (Table 1 + 2). We summarized the mean results and 95% confidence intervals of these measurements at study timepoints and compared the 3 study groups at week 12 using one-way ANOVA and post-hoc Tukey tests.

Results:

156 eligible patients were screened and 139 (99 females, 71%) patients with moderate-high disease activity were randomized. ANOVA and pairwise comparisons showed that PGA-VAS improvement was larger in the CZP-H group whereas more similar to that in placebo in the CZP-L group. PhysGA-VAS however was similarly reduced in both CZP groups. Patients in the CZP-L group constantly rated their pain numerically higher than physicians whereas in the CZP-H group an initially higher discrepancy numerically reduced over time.

Conclusion:

These results suggest that improved patient global disease activity assessment could be the main driver of improved DAS-28 LDA rates with CZP treatment in patients with a high CNS pain response. Our findings indicate a potential role of fMRI imaging of the brain to further understand disease activity perception in RA patients.

Figure 1.

Course of disease activity components through trial timepoints. *indicates log-transformed y axis. *#x002A; Discrepancy equals Patient global minus physician global assessment.

Disclosure of Interests:

Hannah Schenker: None declared, Jürgen Rech Consultant of: BMS, Celgene, Novartis, Roche, Chugai, Speakers bureau: AbbVie, Biogen, BMS, Celgene, MSD, Novartis, Roche, Chugai, Pfizer, Lilly, Koray Tascilar: None declared, Melanie Hagen: None declared, Verena Schönau: None declared, Marina Sergeeva: None declared, Mageshwar Selvakumar: None declared, Laura Konerth: None declared, Jutta Prade: None declared, Sandra Strobelt: None declared, Larissa Valor: None declared, Axel Hueber Grant/research support from: Novartis, Lilly, Pfizer, EIT Health, EU-IMI, DFG, Universität Erlangen (EFI), Consultant of: Abbvie, BMS, Celgene, Gilead, GSK, Lilly, Novartis, Speakers bureau: GSK, Lilly, Novartis, David Simon Grant/research support from: Else Kröner-Memorial Scholarship, Novartis, Consultant of: Novartis, Lilly, Arnd Kleyer Consultant of: Lilly, Gilead, Novartis,Abbvie, Speakers bureau: Novartis, Lilly, Frank Behrens Grant/research support from: Abbvie, Pfizer, Roche, Chugai, Janssen, Consultant of: Abbvie, Pfizer, Roche, Chugai, UCB, BMS, Celgene, MSD, Novartis, Biotest, Janssen, Genzyme, Lilly; Boehringer; Sandoz, Speakers bureau: Abbvie, Pfizer, Roche, Chugai, UCB, BMS, Celgene, MSD, Novartis, Biotest, Janssen, Genzyme, Lilly; Boehringer; Sandoz, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Christoph Baerwald Consultant of: CGB received speaker or consulting fees from AbbVie, Paid instructor for: CGB received speaker or consulting fees from AbbVie, Speakers bureau: CGB received speaker or consulting fees from AbbVie, Stephanie Finzel: None declared, Reinhard Voll: None declared, Eugen Feist Consultant of: Novartis, Roche, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Sanofi, Speakers bureau: Novartis, Roche, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Sanofi, Arnd Doerfler: None declared, Nemanja Damjanov Grant/research support from: from AbbVie, Pfizer, and Roche, Consultant of: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Speakers bureau: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Andreas Hess: None declared, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB

How much of skin improvement over time in systemic sclerosis is due to normal ageing? A prospective study with shear-wave elastography

Background

Measurement of skin involvement is essential for the diagnosis and assessment of prognosis and disease progression in systemic sclerosis (SSc). The modified Rodnan skin score (mRSS) is the gold standard measure of skin thickness, but it has been criticised for the lack of objectivity, poor inter-observer reproducibility and lack of sensitivity to change. Recently, shear-wave elastography (SWE) emerged as a promising tool for the objective and quantitative assessment of the skin in SSc patients. However, no studies have evaluated its sensitivity to change over time.

Objective

To assess changes in skin stiffness in SSc patients using SWE during a 5-year follow-up.

Methods

Skin stiffness [i.e. shear-wave velocity values (SWV) in metres per second] was assessed by SWE ultrasound (using virtual touch image quantification) at the 17 sites of the mRSS, in each participant, at baseline and follow-up. mRSS was performed at both time points. Differences between groups were analysed using the related-samples Wilcoxon signed-rank test and the Mann–Whitney U test.

Results

We included 21 patients [85.7% females; mean age 56.3 (10.4) years at baseline, 57.1% with limited SSc] and 15 healthy controls [73.3% females; mean age 53.6 (14.1) years)]. The median follow-up was 4.9 (0.4) years.

Skin stiffness decreased significantly at all Rodnan sites (p ≤ 0.001) (except in the fingers), in SSc patients, over time. The same phenomenon occurred in controls, but to a lesser degree, in terms of percentage change.

The percentage reduction in skin stiffness varied in the different Rodnan sites and in different phases of the disease. In addition, SWV values also decreased significantly in 15/16 skin sites with local normal Rodnan at baseline, whereas local Rodnan skin score only changed significantly in the upper arm (p = 0.046) and forearm (p = 0.026).

Conclusion

This study provides first-time evidence suggesting that skin SWV values are more sensitive to change over time than mRSS and reduce significantly over time in SSc and normal controls.

Psychological factors associated with response to treatment in rheumatoid arthritis

This paper presents a comprehensive review of research relating psychological domains with response to therapy in patients with rheumatoid arthritis. A holistic approach to the disease was adopted by incorporating not only disease activity but also dimensions of the impact of disease on patients' lives. Psychological distress, including depression and anxiety, is common among patients with rheumatoid arthritis and has a significant negative impact on response to therapy and on patients' abilities to cope with chronic illness. Evidence regarding the influence of positive psychological dimensions such as acceptance, optimism, and adaptive coping strategies is scarce. The mechanisms involved in these interactions are incompletely understood, although changes in neuro-endocrine-immune pathways, which are common to depression and rheumatoid arthritis, seem to play a central role. Indirect psychological influences on therapeutic efficacy and long-term effectiveness include a myriad of factors such as adherence, placebo effects, cognition, coping strategies, and family and social support. Data suggest that recognition and appropriate management of psychological distress may improve response to treatment and significantly reduce disease burden.

Characterization of damage in Portuguese lupus patients: analysis of a national lupus registry

Background: Although the survival rate has considerably improved, many patients with systemic lupus erythematosus (SLE) develop irreversible organ damage. Objectives: The objectives of this paper are to characterize cumulative damage in SLE patients and identify variables associated with its presence and severity. Methods: A cross-sectional analysis of SLE patients from the Portuguese Lupus register Reuma.pt/SLE in whom damage assessment using the SLICC/ACR-Disability Index (SDI) was available was performed. Predictor factors for damage, defined as SDI ≥ 1, were determined by logistic regression analyses. A sub-analysis of patients with severe damage (SDI ≥ 3) was also performed. Results: In total, 976 patients were included. SDI was ≥1 in 365 patients, of whom 89 had severe damage. Musculoskeletal (24.4%), neuropsychiatric (24.1%) and ocular (17.2%) domains were the most commonly affected. Older age, longer disease duration, renal involvement, presence of antiphospholipid antibodies and current therapy with steroids were independently associated with SDI ≥ 1. The subpopulation with severe damage had, in addition, a greater interval between the first manifestation attributable to SLE and the clinical diagnosis as well as and more frequently early retirement due to SLE. Conclusions: This large lupus cohort confirmed that demographic and clinical characteristics as well as medication are independently associated with damage. Additionally, premature retirement occurs more often in patients with SDI ≥ 3. Diagnosis delay might contribute to damage accrual.

EULAR evidence-based and consensus-based recommendations on the management of medium to high-dose glucocorticoid therapy in rheumatic diseases

To develop recommendations for the management of medium to high-dose (ie, >7.5 mg but ≤100 mg prednisone equivalent daily) systemic glucocorticoid (GC) therapy in rheumatic diseases. A multidisciplinary EULAR task force was formed, including rheumatic patients. After discussing the results of a general initial search on risks of GC therapy, each participant contributed 10 propositions on key clinical topics concerning the safe use of medium to high-dose GCs. The final recommendations were selected via a Delphi consensus approach. A systematic literature search of PubMed, EMBASE and Cochrane Library was used to identify evidence concerning each of the propositions. The strength of recommendation was given according to research evidence, clinical expertise and patient preference. The 10 propositions regarded patient education and informing general practitioners, preventive measures for osteoporosis, optimal GC starting dosages, risk-benefit ratio of GC treatment, GC sparing therapy, screening for comorbidity, and monitoring for adverse effects. In general, evidence supporting the recommendations proved to be surprisingly weak. One of the recommendations was rejected, because of conflicting literature data. Nine final recommendations for the management of medium to high-dose systemic GC therapy in rheumatic diseases were selected and evaluated with their strengths of recommendations. Robust evidence was often lacking; a research agenda was created.

Safety of glucocorticoids - clinical trials

Clinical trials published over the last 5 years support the main conclusion of a comprehensive review on glucocorticoid safety published in 2006: there is little if any solid evidence to support the fear that low-dose glucocorticoids are associated with significant toxicity when used appropriately in inflammatory rheumatic diseases. In fact, most of the recent randomised-controlled research underlines the influence of the underlying inflammatory process in the occurrence of 'adverse events' such as osteoporosis, fractures, hypertension and glucose intolerance. This 'confounding by indication' is inherent to the field and questions the validity of the observational data, that seems to drive currently common concepts about low-dose glucocorticoid toxicity. Decisive conclusions cannot, in any case, be achieved at this stage because the clinical trials available are of limited duration and dimension and have not been designed specifically to address toxicity. Toxicity with low-dose glucocorticoids needs to be kept under careful clinical surveillance while we expect such trials to be produced. Meanwhile, the risks of stopping these medications, even on longstanding well controlled disease, need also to be considered, as underlined by withdrawal trials recently published.

Monitoring adverse events of low-dose glucocorticoid therapy: EULAR recommendations for clinical trials and daily practice

Objective

To develop recommendations on monitoring for adverse events (AEs) of low-dose glucocorticoid (GC) therapy (≤7.5 mg prednisone or equivalent daily) in clinical trials and daily practice.

Methods

Literature was searched for articles containing information on incidence and monitoring of GC-related AEs using PubMed, EMBASE and Cochrane databases. Second, the authors searched for broad accepted guidelines on the monitoring of certain AEs (eg, WHO guidelines on screening for diabetes). Available data were summarised and discussed among experts (rheumatologists and patients) of the EULAR Task Force to decide which potential AEs should be monitored, how and at which interval.

Results

Data on monitoring proved to be scarce; most articles were focused on therapeutic effects of GCs, not on occurrence and monitoring of AEs. Most recommendations had to be based on consensus. Those for clinical trials aimed at getting insights into incidence, prevalence and clinical relevance of AEs to create a comprehensive and valid AE-profile of GC therapy. The set of AEs to monitor is therefore more extensive, and often consists of assessments at baseline and at end of trials. Recommendations for daily practice are meant to protect patients from real dangers, which can be prevented or treated. Standard care monitoring needs NOT be extended for patients on low-dose GC therapy, except for osteoporosis (follow national guidelines), and baseline assessments of ankle edema, fasting blood glucose and risk factors for glaucoma.

Conclusion

Given the incompleteness of literature data, consensus-based recommendations on monitoring for GC-related AEs were created, separately for daily practice and clinical trials.

Patient and rheumatologist perspectives on glucocorticoids: an exercise to improve the implementation of the European League Against Rheumatism (EULAR) recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases

OBJECTIVE

To explore perspectives among patients and rheumatologists on glucocorticoid (GC) therapy and European League Against Rheumatism (EULAR) recommendations on the management of systemic GC therapy in order to enhance implementation of the recommendations.

METHODS

Rheumatologists (from eight countries) and patients (from five countries) acquainted with GCs participated in separate meetings, during which positive and negative aspects of GC therapy were discussed and possible adverse events (AEs) were ranked for importance; in addition participants were asked to evaluate the published EULAR recommendations. The reports from these meetings and themes related to implementation of the recommendations were discussed during an international forum of the experts who had formulated the recommendations and patient participants.

RESULTS

In all, 140 patients (78% women; mean age 53 years; 61% patients with rheumatoid arthritis) and 110 rheumatologists (mean work experience 15 years) participated in the meetings. Osteoporosis, diabetes and cardiovascular diseases were ranked among the five most worrisome AEs by patients and rheumatologists. In both groups, there was agreement with most of the recommendations; the recommendations on GC information cards and GC use during pregnancy scored lowest. Ideas to improve implementation of the recommendations and a research agenda were generated.

CONCLUSION

The patient and rheumatologist views on GCs corresponded to a large extent, reflected by concerns in both groups about osteoporosis, diabetes and cardiovascular diseases. Specific problems with the EULAR recommendations were identified and addressed to improve their implementation. This exercise shows that patient and rheumatologist perspectives should be included early in the process of formulating recommendations.

Exuberant calcinosis and acroosteolysis. A diagnostic challenge

A case of exuberant acroosteolysis and subcutaneous tissue calcinosis in the absence of skin involvement is presented. Different hypotheses are discussed following the clinical unfolding of the case in practice.

EULAR evidence-based recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases

OBJECTIVE

To develop evidence-based recommendations for the management of systemic glucocorticoid (GC) therapy in rheumatic diseases.

METHODS

The multidisciplinary guideline development group from 11 European countries, Canada and the USA consisted of 15 rheumatologists, 1 internist, 1 rheumatologist-epidemiologist, 1 health professional, 1 patient and 1 research fellow. The Delphi method was used to agree on 10 key propositions related to the safe use of GCs. A systematic literature search of PUBMED, EMBASE, CINAHL, and Cochrane Library was then used to identify the best available research evidence to support each of the 10 propositions. The strength of recommendation was given according to research evidence, clinical expertise and perceived patient preference.

RESULTS

The 10 propositions were generated through three Delphi rounds and included patient education, risk factors, adverse effects, concomitant therapy (ie, non-steroidal anti-inflammatory drugs, gastroprotection and cyclo-oxygenase-2 selective inhibitors, calcium and vitamin D, bisphosphonates) and special safety advice (ie, adrenal insufficiency, pregnancy, growth impairment).

CONCLUSION

Ten key recommendations for the management of systemic GC-therapy were formulated using a combination of systematically retrieved research evidence and expert consensus. There are areas of importance that have little evidence (ie, dosing and tapering strategies, timing, risk factors and monitoring for adverse effects, perioperative GC-replacement) and need further research; therefore also a research agenda was composed.

EULAR evidence-based recommendations for the management of fibromyalgia syndrome

OBJECTIVE

To develop evidence-based recommendations for the management of fibromyalgia syndrome.

METHODS

A multidisciplinary task force was formed representing 11 European countries. The design of the study, including search strategy, participants, interventions, outcome measures, data collection and analytical method, was defined at the outset. A systematic review was undertaken with the keywords "fibromyalgia", "treatment or management" and "trial". Studies were excluded if they did not utilise the American College of Rheumatology classification criteria, were not clinical trials, or included patients with chronic fatigue syndrome or myalgic encephalomyelitis. Primary outcome measures were change in pain assessed by visual analogue scale and fibromyalgia impact questionnaire. The quality of the studies was categorised based on randomisation, blinding and allocation concealment. Only the highest quality studies were used to base recommendations on. When there was insufficient evidence from the literature, a Delphi process was used to provide basis for recommendation.

RESULTS

146 studies were eligible for the review. 39 pharmacological intervention studies and 59 non-pharmacological were included in the final recommendation summary tables once those of a lower quality or with insufficient data were separated. The categories of treatment identified were antidepressants, analgesics, and "other pharmacological" and exercise, cognitive behavioural therapy, education, dietary interventions and "other non-pharmacological". In many studies sample size was small and the quality of the study was insufficient for strong recommendations to be made.

CONCLUSIONS

Nine recommendations for the management of fibromyalgia syndrome were developed using a systematic review and expert consensus.

Safety of low dose glucocorticoid treatment in rheumatoid arthritis: published evidence and prospective trial data

Adverse effects of glucocorticoids have been abundantly reported. Published reports on low dose glucocorticoid treatment show that few of the commonly held beliefs about their incidence, prevalence, and impact are supported by clear scientific evidence. Safety data from recent randomised controlled clinical trials of low dose glucocorticoid treatment in RA suggest that adverse effects associated with this drug are modest, and often not statistically different from those of placebo.